Induction Techniques in Children — MCQs

10 questions

Which of the following is the induction anesthesia of choice in the pediatric age group?

The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

Propofol and thiopentone are:

Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:

During rapid sequence intubation in a child after taking brief history and clinical examination next step is:

The best inhalational agent of choice for induction of anesthesia in a six-year-old child who refuses IV access is –

What is the MOST clinically significant anatomical difference between pediatric and adult airways?

A 6 month old child is suffering from patent ductus arteriosus (PDA) with congestive cardiac failure. Ligation of ductus arteriosus was decided for surgical management. The most appropriate inhalational anaesthetic agent of choice with minimal haemodynamic alteration for induction of anaesthesia is –

Induction agent of choice in a child with cyanotic heart disease is

Q10

A patient with mitral stenosis is having surgery tomorrow. There is some liver compromise. Which of the following inhalational agents is preferred?

Induction Techniques in Children Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is the induction anesthesia of choice in the pediatric age group?

A. A. Sevoflurane (Correct Answer)
B. B. Desflurane
C. C. Halothane
D. D. Isoflurane

Explanation: ***A. Sevoflurane*** - **Sevoflurane** is an inhalation anesthetic widely preferred for **pediatric induction** due to its rapid onset and non-pungent odor, which makes it well-tolerated by children. - Its low blood-gas partition coefficient allows for swift changes in anesthetic depth and rapid emergence. *B. Desflurane* - **Desflurane** has a **pungent odor** and is known to cause airway irritation, making it unsuitable for inhalational induction in children. - Its rapid onset and offset are beneficial, but its irritant properties limit its use for induction, especially in younger patients. *C. Halothane* - **Halothane** was previously used for pediatric induction but has largely been replaced due to its association with **hepatotoxicity** and cardiac arrhythmias. - It also has a slower onset and offset compared to newer agents like sevoflurane. *D. Isoflurane* - **Isoflurane** has a **pungent odor** and can cause airway irritation, making it less suitable for inhalational induction in children compared to sevoflurane. - While effective for maintenance, its irritant properties make for a less smooth and potentially distressing induction experience for pediatric patients.

Question 2: The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

A. Oxygen saturation
B. Torso
C. Verbal response (Correct Answer)
D. Cry

Explanation: ***Verbal response*** - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is designed for children **under one year of age**, who are typically pre-verbal. - While verbal complaints are not assessed, a child's **verbal response** (e.g., moaning, crying, or not making sounds at all) in relation to pain is a component of the scale, contributing to the interpretation of their comfort level. *Oxygen saturation* - **Physiological parameters** like oxygen saturation are typically not part of behavioral pain scales like CHEOPS, which focus on observable behaviors. - While low oxygen saturation can indicate distress, it is not a direct measure of pain for this scale. *Torso* - The CHEOPS scale assesses **pain-related behaviors** of extremities (e.g., legs, arms) and facial expressions, but does not specifically include observations of the "torso" as a separate category. - Behaviors like stiffening or arching of the torso might be implicitly considered under overall body tension, but it’s not a distinct domain. *Cry* - The **quality and intensity of crying** is a primary behavioral indicator of pain in pre-verbal infants and is a significant component of many pediatric pain scales, including CHEOPS. - A child's cry, along with other behaviors, helps differentiate between various levels of discomfort or pain.

Question 3: Propofol and thiopentone are:

A. Anesthesia maintenance agents
B. Anesthesia reversal agents
C. Local anesthetics
D. Anesthesia induction agents (Correct Answer)

Explanation: ***Anesthesia induction agents*** - Propofol and thiopentone are **intravenous anesthetic agents** primarily used to rapidly induce a state of unconsciousness for surgery and other medical procedures. - They produce a **quick onset of action** allowing for a smooth and controlled intubation if needed, initiating the anesthetic process. *Anesthesia maintenance agents* - While propofol can be used for maintenance as a continuous infusion, its primary role, as well as that of thiopentone, is **induction due to their rapid onset and short duration** when given as a bolus. - Anesthesia maintenance typically involves volatile anesthetics (e.g., sevoflurane, isoflurane) or continuous infusions of drugs like propofol or remifentanil. *Anesthesia reversal agents* - Reversal agents are used to **counteract the effects of muscle relaxants** (e.g., neostigmine, sugammadex) or benzodiazepines (e.g., flumazenil) used during anesthesia. - Propofol and thiopentone do not have a role in reversing general anesthesia; their effects simply wear off as they are metabolized. *Local anesthetics* - Local anesthetics (e.g., lidocaine, bupivacaine) block nerve conduction in a **specific region of the body** without affecting consciousness. - Propofol and thiopentone are **general anesthetics** that induce a state of unconsciousness, affecting the entire central nervous system.

Question 4: Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:

A. Extended ramping
B. Avoid cricoid pressure (Correct Answer)
C. Rapid sequence induction
D. Avoid preoxygenation

Explanation: ***Avoid cricoid pressure*** - While **cricoid pressure** (Sellick's maneuver) is used to prevent **aspiration** by compressing the esophagus, its effectiveness in **obese patients** is highly debated and often hindered by excess neck tissue. - In obese patients, cricoid pressure can actually worsen the view during laryngoscopy, making intubation more difficult and potentially causing airway trauma. *Extended ramping* - **Ramping** the patient, where the head and shoulders are elevated, is crucial in **obese patients** to align the **oral, pharyngeal, and laryngeal axes**. - This position improves the view during laryngoscopy and facilitates successful intubation by effectively displacing excess tissue. *Rapid sequence induction* - **Rapid sequence induction (RSI)** is often indicated in **obese patients** undergoing emergency surgery due to their increased risk of **gastric reflux** and **pulmonary aspiration**. - RSI involves administering a sedative and a paralytic agent in rapid succession, followed immediately by intubation, to minimize the time the airway is unprotected. *Avoid preoxygenation* - **Preoxygenation** is essential in **obese patients** to maximize their **oxygen reserves** before intubation. - Obese patients have reduced **functional residual capacity (FRC)** and increased **oxygen consumption**, making them desaturate rapidly during apnea, so preoxygenation significantly prolongs safe apnea time.

Question 5: During rapid sequence intubation in a child after taking brief history and clinical examination next step is:

A. Administer oxygen (Correct Answer)
B. Analgesic injection with Fentanyl
C. Preanaesthetic medication with atropine and lignocaine
D. IV anesthetic Diazepam/Ketamine

Explanation: ***Administer oxygen*** - Pre-oxygenation with 100% oxygen is critical before **rapid sequence intubation (RSI)** to maximize **oxygen reserves** and extend the safe apnea time. - This step helps prevent **hypoxemia** during the intubation procedure, especially in children who have lower functional residual capacity. *Analgesic injection with Fentanyl* - While fentanyl is often used in RSI for its **analgesic** and **sedative properties**, it typically follows pre-oxygenation and is administered as part of the **induction phase**, often concurrently with a paralytic. - Administering fentanyl alone without prior oxygenation or other induction agents would not be the immediate next step in a structured RSI protocol. *Preanaesthetic medication with atropine and lignocaine* - **Atropine** may be used in children to prevent **bradycardia** during intubation, particularly in infants, but it's not the immediate next step after initial assessment; pre-oxygenation is more critical. - **Lidocaine** can be used to blunt the sympathetic response to intubation or to suppress cough, but it's not universally required and comes after pre-oxygenation and other induction medications. *IV anesthetic Diazepam/Ketamine* - **Diazepam** and **ketamine** are **induction agents** that cause sedation and loss of consciousness, but they are administered after pre-oxygenation and often just before the paralytic agent. - Administering an induction agent without adequate pre-oxygenation would increase the risk of **hypoxemia** during the subsequent apnea.

Question 6: The best inhalational agent of choice for induction of anesthesia in a six-year-old child who refuses IV access is –

A. Sevoflurane (Correct Answer)
B. Methoxyflurane
C. Desflurane
D. Isoflurane

Explanation: ***Sevoflurane*** - **Sevoflurane** has a **low pungency** and a **rapid onset** due to its low blood/gas solubility, making it ideal for inhalational inductions in children who are often uncooperative with IV access. - Its pleasant odor and non-irritating properties minimize coughing and breath-holding, ensuring a smooth and quick induction. *Methoxyflurane* - **Methoxyflurane** is **nephrotoxic** and has a very slow onset, making it unsuitable for rapid inhalational induction, especially in children where kidney function can be more sensitive. - Due to its significant side effects and slow induction profile, it is rarely used today for general anesthesia. *Desflurane* - **Desflurane** has a very **pungent odor** and a high incidence of airway irritation, including coughing and breath-holding, which makes it a poor choice for gas induction, particularly in children. - Although it has a rapid onset due to very low blood/gas solubility, its irritating properties outweigh this benefit for pediatric inhalational induction. *Isoflurane* - **Isoflurane** is also highly **pungent** and associated with significant airway irritation, making it uncomfortable for inhaled induction and poorly tolerated by children. - It has a slower onset compared to sevoflurane and desflurane, further diminishing its suitability for uneventful inhalational induction in pediatric patients.

Question 7: What is the MOST clinically significant anatomical difference between pediatric and adult airways?

A. Funnel-shaped vs cylindrical airway shape
B. Proportionally larger tongue
C. Larynx in higher position
D. Narrowest part is cricoid cartilage (Correct Answer)

Explanation: ***Narrowest part is cricoid cartilage*** - In **pediatric airways**, the **cricoid cartilage** is the narrowest point, making it the **most critical consideration** for endotracheal tube sizing and intubation. - This contrasts with adults where the **glottic opening** (vocal cords) is typically the narrowest. - This difference is **clinically crucial** as it determines tube selection, risk of subglottic stenosis, and why uncuffed tubes were traditionally preferred in children. *Proportionally larger tongue* - Pediatric patients indeed have a **proportionally larger tongue** relative to their oral cavity, which can contribute to airway obstruction [1]. - While this is a true anatomical difference, it is **less critical** for intubation decisions than the cricoid narrowing. *Funnel-shaped vs cylindrical airway shape* - Pediatric airways are **funnel-shaped** with narrowing at the cricoid, whereas adult airways are more **cylindrical**. - This morphological difference is a **consequence** of the cricoid being the narrowest point, not a separate primary consideration. *Larynx in higher position* - The **larynx** in infants and young children is positioned more **superiorly** (C3-C4 vs C4-C6 in adults). - While this affects intubation technique and angle, it is **less directly relevant** to airway sizing than the cricoid narrowing.

Question 8: A 6 month old child is suffering from patent ductus arteriosus (PDA) with congestive cardiac failure. Ligation of ductus arteriosus was decided for surgical management. The most appropriate inhalational anaesthetic agent of choice with minimal haemodynamic alteration for induction of anaesthesia is –

A. Sevoflurane (Correct Answer)
B. Isoflurane
C. Enflurane
D. Halothane

Explanation: ***Sevoflurane*** - **Sevoflurane** is the preferred inhalational anesthetic for induction in pediatric patients, especially those with cardiovascular compromise, due to its **less pungent odor**, leading to smoother induction and minimal airway irritation. - It maintains **hemodynamic stability** better than other volatile agents at equipotent doses, making it suitable for children with congenital heart defects like PDA. *Isoflurane* - **Isoflurane** has a more **pungent odor** than sevoflurane, making it less suitable for mask induction in pediatric patients due to potential airway irritation and resistance. - While it offers good hemodynamic stability, its higher pungency can lead to coughing or laryngospasm during induction, which is undesirable in a child with cardiac compromise. *Enflurane* - **Enflurane** is now largely replaced by newer agents like sevoflurane and isoflurane due to its potential to cause **seizures** and myocardial depression, especially at higher concentrations. - It also carries a risk of inducing **nephrotoxicity** due to fluoride metabolism and is associated with more significant hemodynamic alterations compared to sevoflurane. *Halothane* - **Halothane** is associated with significant **myocardial depression**, leading to reduced cardiac output and hypotension, which is particularly detrimental in a child with congestive cardiac failure due to PDA. - It also has a risk of causing **halothane hepatitis**, a rare but severe liver toxicity, making it a less safe option compared to modern inhalational agents.

Question 9: Induction agent of choice in a child with cyanotic heart disease is

A. Thiopentone
B. Ketamine (Correct Answer)
C. Halothane
D. Midazolam

Explanation: ***Ketamine*** - **Ketamine** is preferred in cyanotic heart disease because it generally maintains or even **increases systemic vascular resistance** and **blood pressure**, which helps maintain systemic-pulmonary shunting and reduces right-to-left shunting. - It also has a **sympathomimetic effect**, supporting myocardial contractility and heart rate, which is beneficial in patients with compromised cardiac function. *Thiopentone* - **Thiopentone** can cause **myocardial depression** and **vasodilation**, leading to a decrease in systemic vascular resistance. - This reduction in SVR can exacerbate **right-to-left shunting** in cyanotic heart disease, worsening hypoxemia. *Halothane* - **Halothane** is a potent **myocardial depressant** and causes significant **peripheral vasodilation**, leading to decreased blood pressure and systemic vascular resistance. - These effects can lead to a severe decrease in **pulmonary blood flow** and an increase in **right-to-left shunting**, worsening cyanosis and hypoxemia. *Midazolam* - **Midazolam** is a benzodiazepine primarily used for **sedation** and anxiolysis, not as a primary induction agent in critically ill children. - While it has minimal effects on cardiac output at typical doses, it lacks the favorable hemodynamic profile of ketamine for maintaining **organ perfusion** and preventing increased right-to-left shunting in cyanotic heart disease.

Question 10: A patient with mitral stenosis is having surgery tomorrow. There is some liver compromise. Which of the following inhalational agents is preferred?

A. Enflurane
B. Xenon
C. Sevoflurane (Correct Answer)
D. Halothane

Explanation: ***Sevoflurane*** - **Sevoflurane** is preferred due to its **minimal hepatic metabolism** and rapid elimination, making it a safer option in patients with **liver compromise**. - It maintains **cardiovascular stability**, which is beneficial in mitral stenosis and avoids the arrhythmogenic potential seen with other agents. *Enflurane* - **Enflurane** is extensively metabolized in the liver, leading to the production of inorganic fluoride ions, which can cause **renal toxicity**. - It can also induce a decrease in **hepatic blood flow**, exacerbating existing liver compromise. *Xenon* - While **Xenon** has excellent cardiovascular stability and minimal metabolism, its **high cost** and **limited availability** make it an impractical choice for routine use. - Its anesthetic potency is relatively low, requiring **higher concentrations** for surgical anesthesia. *Halothane* - **Halothane** is associated with a significant risk of **halothane-induced hepatitis** due to its extensive hepatic metabolism and the production of toxic metabolites. - It can also cause **cardiac depression** and **arrhythmias**, which are undesirable in patients with mitral stenosis.

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