Pediatric Anesthesia Practice Questions

Q: What is the anesthetic of choice in a child with cyanotic heart disease?

Ketamine. **Explanation:** The primary goal in the anesthetic management of cyanotic heart disease (e.g., Tetralogy of Fallot) is to prevent or minimize **right-to-left (R-L) shunting**. R-L shunting is exacerbated by a decrease in **Systemic Vascular Resistance (SVR)** or an increase in Pulmonary Vascular Resistance (PVR). **Why Ketamine is the Correct Choice:** Ketamine is the induction agent of choice because it stimulates the sympathetic nervous system, leading to an **increase in SVR**. By maintaining or increasing systemic pressure relative to pulmonary pressure, Ketamine helps reduce the R-L shunt, thereby maintaining or improving arterial oxygen saturation. It also maintains functional residual capacity and has minimal impact on airway resistance. **Why Other Options are Incorrect:** * **Propofol & Thiopentone:** Both are potent vasodilators that significantly **decrease SVR**. A drop in SVR worsens the R-L shunt, leading to a "Tet spell" or profound cyanosis and cardiovascular collapse. * **Sevoflurane:** While commonly used for pediatric induction, volatile anesthetics cause dose-dependent vasodilation (decreasing SVR) and can depress myocardial contractility, which is less ideal than Ketamine in unstable cyanotic patients. **High-Yield Clinical Pearls for NEET-PG:** * **The Goal:** Maintain high SVR and low PVR. * **Tetralogy of Fallot (TOF):** Avoid drugs that cause histamine release (like Morphine or Atracurium) as they can drop SVR. * **Premedication:** Adequate sedation is crucial to prevent crying/struggling, which increases PVR and triggers cyanotic spells. * **Fluid Status:** Maintain adequate preload; dehydration worsens shunting.

Q: Which of the following is NOT a risk factor associated with post-operative nausea and vomiting following strabismus surgery?

Age less than 3 years. **Explanation:** Post-operative nausea and vomiting (PONV) is a common complication in pediatric anesthesia, particularly following **strabismus surgery**, which carries a high incidence (up to 40-80%) due to the **oculo-emetic reflex**. **Why Option A is the Correct Answer:** Age is a significant predictor of PONV, but the risk is **lower in children under 3 years old**. The incidence of PONV increases as children age, peaking just before puberty (around age 6–12), and then gradually declines in adulthood. Therefore, being less than 3 years old is actually a "protective" factor rather than a risk factor. **Analysis of Incorrect Options:** * **B. Duration of anesthesia >30 minutes:** Prolonged exposure to volatile anesthetics and opioids increases the risk of PONV. In pediatrics, every 30-minute increase in duration significantly raises the baseline risk. * **C. History of PONV:** A personal or first-degree family history of PONV is one of the strongest predictors of post-operative emetic episodes. * **D. History of motion sickness:** There is a strong correlation between motion sickness and PONV, as both involve similar pathways in the vestibular system and the chemoreceptor trigger zone (CTZ). **High-Yield Clinical Pearls for NEET-PG:** * **Strabismus Surgery:** Known as the "emetogenic" surgery of childhood. * **Oculo-cardiac Reflex (OCR):** Triggered by traction on extraocular muscles (medial rectus most common). It causes bradycardia (Afferent: Trigeminal nerve; Efferent: Vagus nerve). * **Prevention:** Total Intravenous Anesthesia (TIVA) with Propofol and avoiding nitrous oxide or opioids can reduce PONV risk. * **Vomiting vs. Age:** PONV is rare in infants (<1 year), increases in toddlers, and peaks in school-aged children.

Q: Which of the following are advantages of endotracheal intubation, in a child requiring pediatric advanced life support? I. Inspiratory time can be controlled II. Positive end-expiratory pressure can be provided III. Peak expiratory pressure can be controlled IV. Reduced risk of aspiration of gastric contents Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - Endotracheal intubation allows for precise control of **inspiratory time**, optimizing ventilation for the child's respiratory mechanics. - It enables the application of **positive end-expiratory pressure (PEEP)**, which helps maintain alveolar patency and improves oxygenation. - An endotracheal tube provides a sealed airway, significantly **reducing the risk of aspiration** of gastric contents into the lungs. *II, III and IV* - While PEEP can be provided and aspiration risk is reduced, endotracheal intubation primarily controls **peak inspiratory pressure**, not peak expiratory pressure. - **Peak expiratory pressure** is usually determined by the patient's lung mechanics and the ventilator's exhalation valve settings, not directly controlled by the tube. *I, III and IV* - Endotracheal intubation allows control of inspiratory time and reduces aspiration risk, but it does not directly control **peak expiratory pressure**. - **Peak expiratory pressure** is largely a function of the patient's lung recoil and airway resistance during exhalation. *I, II and III* - Although inspiratory time can be controlled and PEEP can be provided, **peak expiratory pressure** is not a primary parameter controlled by endotracheal intubation. - The main benefits revolve around controlled ventilation and airway protection, not active control over **peak expiratory pressure**.

Q: The size of endotracheal tube in a child < 6 years old is calculated using which formula?

(Age ÷ 4) + 3.5. ***(Age ÷ 4) + 3.5*** - This formula is for calculating the appropriate **uncuffed endotracheal tube (ETT) size** for children 1-10 years old. - For children less than 6 years old, an **uncuffed ETT** is often preferred to reduce the risk of subglottic stenosis. *(Age ÷ 4) - 4.5* - This formula is incorrect for determining ETT size in children. - Subtracting 4.5 would result in an ETT size that is usually too small for the child. *(Age ÷ 4) + 4.5* - This formula is incorrect for determining ETT size in children. - Adding 4.5 would result in an ETT size that is usually too large, increasing the risk of tracheal injury. *(Age ÷ 4) + 2.5* - This formula is incorrect for determining ETT size in children. - Adding 2.5 would result in an ETT size that may be too small or too snug, potentially leading to increased work of breathing or airway obstruction.

Q: 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 –

Sevoflurane. ***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.

Q: A 5 year old healthy child is undergoing strabismus surgery with a Laryngeal mask airway in place. Thirty minutes into the procedure, his heart rate is 60 bpm, blood pressure is 90/60 mmHg, and oximeter shows 98% saturation. The next step in management is

Inform surgeon, administer atropine. ***Inform surgeon, administer atropine*** - **Oculocardiac reflex** is a common complication during strabismus surgery, characterized by bradycardia, hypotension, and arrhythmias. The significant drop in heart rate (60 bpm in a 5-year-old child) and mild hypotension suggest this reflex. - The standard management for an oculocardiac reflex involves informing the surgeon to temporarily cease manipulation of the extraocular muscles and administering an **anticholinergic drug** like atropine to counteract the vagal stimulation. *Replace the LMA with endotracheal tube* - The patient's oxygen saturation of 98% indicates adequate ventilation and oxygenation with the LMA, so there is no immediate need for **airway intervention**. - Replacing the LMA with an endotracheal tube is a more invasive procedure and would not directly address the underlying cause of bradycardia, which is likely due to the oculocardiac reflex. *Nothing, this is normal for this child* - A heart rate of 60 bpm is **significantly low** for a 5-year-old child under anesthesia, as the expected heart rate for this age group is typically much higher (around 80-120 bpm). - Ignoring this bradycardia could lead to further compromise in **cardiac output** and tissue perfusion if not addressed promptly. *Increase FiO2 to 1.0* - The current oxygen saturation of 98% indicates **adequate oxygenation**, so increasing the FiO2 would not address the bradycardia or hypotension. - While maintaining good oxygenation is important, this step would not resolve the primary issue of an **oculocardiac reflex** causing vagal stimulation.

Q: Infants require which of the following regarding anesthetic agents?

Higher amount of anaesthetic agent. ***Higher amount of anaesthetic agent*** - Infants generally have a **larger volume of distribution** for many drugs due to a higher proportion of total body water and lower fat content, necessitating higher doses per kilogram. - Their **metabolic pathways** and **organ function** (especially hepatic and renal) are immature, which can affect clearance and drug half-life, but often the initial dosing might be higher due to distribution differences. *Equal amount as in adults* - This is incorrect as infants have significant physiological differences compared to adults, particularly in **drug distribution**, **metabolism**, and **excretion**. - Dosing anesthetics based on adult equivalents would likely lead to **underdosing** or **overdosing** due to these differences. *Least amount of anaesthetic agent* - While some medications may require lower doses in neonates due to immature metabolic pathways, many anesthetic agents, particularly those with a high volume of distribution, may require **higher doses per kilogram** to achieve the desired effect. - The concept of "least amount" is overly simplistic and does not account for the **pharmacokinetic differences** in infants. *None of the options* - This is incorrect because one of the provided options accurately reflects the general requirement for anesthetic agents in infants.

Q: Which of the following is a pleasant anaesthetic agent preferred for inhalation mask anaesthesia in children?

Sevoflurane. ***Sevoflurane*** - Sevoflurane is known for its **low pungency and sweet smell**, making it well-tolerated by children for mask induction. - It has a **rapid onset and offset** due to its low blood-gas solubility, allowing for quick control of anesthesia depth. *Isoflurane* - Isoflurane has a **pungent odor** and is irritating to the airway, often causing coughing and laryngospasm during mask induction. - It is typically not the preferred choice for **inhalation induction in pediatric patients** due to these airway irritant properties. *Desflurane* - Desflurane is highly **pungent and irritating to the airway**, causing a high incidence of coughing, breath-holding, and laryngospasm. - Its use for mask induction, especially in children, is **contraindicated** due to severe airway irritation. *Enflurane* - Enflurane has a **pungent odor** and can be irritating to the airway, similar to isoflurane. - It is also associated with a higher risk of **seizure activity** at deeper anesthetic depths, limiting its use in pediatric patients.

Q: A 5 year old boy suffering from Duchenne muscular dystrophy has to undergo tendon lengthening procedure. The most appropriate anaesthetic would be –

Total intravenous anesthesia (TIVA) with propofol and remifentanil. ***Total intravenous anesthesia (TIVA) with propofol and remifentanil*** - **Duchenne muscular dystrophy (DMD)** patients are highly susceptible to **malignant hyperthermia** and rhabdomyolysis when exposed to volatile anesthetics (e.g., sevoflurane, isoflurane) and succinylcholine. TIVA avoids these triggers. - **Propofol** and **remifentanil** are suitable anesthetic agents for TIVA in DMD patients, providing stable anesthesia without triggering adverse muscle reactions. *Induction with inhalation sevoflurane; maintenance with isoflurane and vecuronium* - **Sevoflurane** and **isoflurane** are volatile anesthetic agents that can trigger **malignant hyperthermia** and severe rhabdomyolysis in patients with DMD due to their muscle pathology. - While vecuronium is a non-depolarizing muscle relaxant that is generally safe in DMD, the use of volatile agents makes this regimen inappropriate. *Induction with intravenous propofol and N2O; TIVA maintenance with propofol* - **Nitrous oxide (N2O)**, while not a direct trigger for malignant hyperthermia itself, is often used in conjunction with volatile anesthetics and does not significantly mitigate the risks associated with them in DMD patients. - Although propofol for induction and TIVA maintenance is appropriate, the inclusion of N2O does not improve safety in the context of DMD, and concerns about potential interactions or masking early signs of complications might arise. *Induction with intravenous thiopentone; maintenance with sevoflurane and non-depolarizing muscle relaxants* - **Thiopentone** (thiopental) is an intravenous anesthetic that is generally safe for induction in DMD patients. - However, **sevoflurane** is a volatile anesthetic that is contraindicated in DMD due to the risk of triggering **malignant hyperthermia** and severe rhabdomyolysis.

Question 1

What is the anesthetic of choice in a child with cyanotic heart disease?

Accepted Answer

Ketamine

Answer

Propofol

Answer

Thiopentone

Answer

Sevoflurane

Question 2

A child with bladder exstrophy posted for operative repair has renal failure. Which anesthetic agent should be preferred?

Accepted Answer

Vecuronium

Answer

Pancuronium

Answer

Atracurium

Answer

Rocuronium

Question 3

Which of the following is NOT a risk factor associated with post-operative nausea and vomiting following strabismus surgery?

Accepted Answer

Age less than 3 years

Answer

Duration of anesthesia greater than 30 minutes

Answer

Personal or family history of post-operative nausea and vomiting

Answer

Personal or family history of motion sickness

Question 4

Which of the following are advantages of endotracheal intubation, in a child requiring pediatric advanced life support?
I. Inspiratory time can be controlled
II. Positive end-expiratory pressure can be provided
III. Peak expiratory pressure can be controlled
IV. Reduced risk of aspiration of gastric contents

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 5

The size of endotracheal tube in a child < 6 years old is calculated using which formula?

Accepted Answer

(Age ÷ 4) + 3.5

Answer

(Age ÷ 4) - 4.5

Answer

(Age ÷ 4) + 4.5

Answer

(Age ÷ 4) + 2.5

Question 6

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 –

Accepted Answer

Sevoflurane

Answer

Isoflurane

Answer

Enflurane

Answer

Halothane

Question 7

A 5 year old healthy child is undergoing strabismus surgery with a Laryngeal mask airway in place. Thirty minutes into the procedure, his heart rate is 60 bpm, blood pressure is 90/60 mmHg, and oximeter shows 98% saturation. The next step in management is

Accepted Answer

Inform surgeon, administer atropine

Answer

Replace the LMA with endotracheal tube

Answer

Nothing, this is normal for this child

Answer

Increase FiO2 to 1.0

Question 8

Infants require which of the following regarding anesthetic agents?

Accepted Answer

Higher amount of anaesthetic agent

Answer

Equal amount as in adults

Answer

Least amount of anaesthetic agent

Answer

None of the options

Question 9

Which of the following is a pleasant anaesthetic agent preferred for inhalation mask anaesthesia in children?

Accepted Answer

Sevoflurane

Answer

isoflurane

Answer

Desflurane

Answer

Enflurane

Question 10

A 5 year old boy suffering from Duchenne muscular dystrophy has to undergo tendon lengthening procedure. The most appropriate anaesthetic would be –

Accepted Answer

Total intravenous anesthesia (TIVA) with propofol and remifentanil

Answer

Induction with inhalation sevoflurane; maintenance with isoflurane and vecuronium

Answer

Induction with intravenous propofol and N2O; TIVA maintenance with propofol

Answer

Induction with intravenous thiopentone; maintenance with sevoflurane and non-depolarizing muscle relaxants

Pediatric Anesthesia — MCQs

Pediatric Anesthesia — MCQs

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