Pediatrics

You desire to place an LMA in a 2.7 kg neonate. What is the correct size LMA to use? a. 1 b. 1.5 c. 2 d. 2.5 e. LMAs are contraindicated in this small a neonate

A. 1 The size 1 LMA is designed for use in patients with a weight of less than 5 kg. The cuff volume should be from 2 to 5 mL of air. The LMA is placed and cuff inflated upon feeling the resistance of the upper esophageal sphincter. When inflated, the cuff creates a seal in the pharynx that permits ventilation without a large gas leak when peak pressures are kept below 15 cmH2O. The LMA is also included in the difficult airway algorithm for patients who are unable to be intubated or in whom bag-mask ventilation is difficult. Although each LMA has the correct weight printed on the package it is still imperative to know the correct sizes for each patient because of emergency situations.

What is the maximum FiO2 that can be administered to the mother without increasing risk of retinopathy of prematurity in utero? Select one: a. 1 b. 0.8 c. 0.6 d. 0.4 e. 0.21

A. 1 fetal PaO2 never exceeds 60 mmHg even if the maternal PaO2 is increased to 600 mmHg

Which of the following heart rates is considered abnormal in a resting 2 month old? Select one: a. 90 BPM b. 100 BPM c. 120 BPM d. 180 BPM e. 210 BPM

A. 90 BPM Normal HR in this age group is 100-220 BPM in an awake resting infant ages 1 week to 3 months. A heart rate of 90, though not critical would be considered bradycardia. Between the ages of 3 months until 2 years of age a HR from 80-150 can be expected. From ages 2-10 heart rate is 70-110. After 10 years of age normal resting heart rate more closely approximates that of adults.

Which of the following findings is NOT associated with pyloric stenosis? Select one: a. Bilious vomiting b. Olive-sized abdominal mass c. Metabolic alkalosis d. Hypokalemia e. Severe dehydration

A. Bilious vomiting Non-billous vomiting is the typical presenting sign of pyloric stenosis, with a typical occurrence between 2 to 8 weeks of age. It is the most common cause of intestinal obstruction in the pediatric population. On physical exam, an olive-sized mass is seen in the upper abdomen. It is caused by hyperplasia of the muscular layers of the pylorus, causing a gastric outlet obstruction. Vomiting leads to hypovolemia and a hypochloremic, hypokalemic metabolic alkalosis. The hypochloremic hypokalemic metabolic alkalosis is caused by repeated vomiting causing loss of chloride and hydrogen ions, as well as loss of sodium and potassium. The metabolic alkalosis occurs as vomiting does not cause the loss of alkaline intestinal secretions (below the level of the obstruction which is at the pylorus). Increased bicarbonate levels are then seen in the kidney, overwhelming the kidney's ability to reabsorb bicarbonate. The bicarbonate then travels to the distal tubule, causing excretion of aldosterone and further reabsorption of sodium and excretion of potassium. Dehydration is treated with fluid bolus of .45% NaCl with or without D5. Potassium chloride (2-4 mEq per 100 mL of IV fluid) may also be added. A serum chloride of greater than 90 mEq/L is typically adequate for surgery. Prior to surgery, aspiration of the infant's stomach may be undertaken to remove residual gastric fluid or barium if barium studies have been done.

Choose the normal set of vital signs for a 2 month old: a. HR 120, BP 70/50, Respiratory rate 40 b. HR 100, BP 70/40, Respiratory rate 50 c. HR 180, BP 50/35, Respiratory rate 30 d. HR 150, BP 50/35, Respiratory rate 35 e. HR 120, BP 70/50, Respiratory rate 20

A. HR 120, BP 70/50, Respiratory rate 40

Choose the normal set of vital signs for a 4 year old: a. HR 80, BP 100/70, Respiratory rate 22 b. HR 50, BP 100/60, Respiratory rate 14 c. HR 120, BP 120/70, Respiratory rate 30 d. HR 75, BP 85/60, Respiratory rate 20 e. HR 75, BP 90/60, Respiratory rate 16

A. HR 80, BP 100/70, Respiratory rate 22 A 4 year old patient should have a heart rate of between 65-110 beats per minute, a systolic blood pressure of between 95-110 mmHg, a diastolic pressure of between 60-75 mmHg, and a respiratory rate of 20-25 breaths per minute.

Where does hemoglobin F lie compared to adult hemoglobin on oxyhemoglobin dissociation curve? Select one: a. Left b. Right

A. Left Fetal hemoglobin (HbF) lies to the left of HbA, a shift that allows fetal hemoglobin to have a higher affinity for oxygen compared to HbA. At birth the P50 is 18-20 mmHg, and in the adult is 27 mmHg.

Infants have decreased NPO times due to the risk of developing hypoglycemia. What makes the neonatal population more prone to developing hypoglycemia? a. Low glycogen stores b. Increased brown fat metabolism c. Large body surface area with high thermogenesis d. Immature renal tubules causing loss of glucose molecules e. Increased insulin production compared to adults

A. Low glycogen stores Infants are born with low glycogen stores, and thus are more prone to dangerous low blood sugars.

Which of the following blades is the most appropriate for performing direct laryngoscopy on a premature neonate? Select one: a. Miller 0 b. Miller 1 c. Miller 2 d. Macintosh 1 e. Macintosh 2

A. Miller 0 Premature neonates should use a Miller 0. Term neonates should use a miller 0 to 1. A Miller 1 is useful until around age 2 yrs, when a Miller 2 or Macintosh 2 should be used. After 6 years old, a Macintosh 3 should be used (Miller 2 still fine).

For pediatric dental procedures, what is the best method of providing for airway control? a. Nasal RAE b. Oral RAE c. Standard oral endotracheal tube d. LMA e. Mask ventilation

A. Nasal RAE For pediatric dental procedures, nasotracheal intubation with a nasal RAE is often used. Complications include bacteremia, dislodgement of adenoidal tissue, and traumatic injury. Fiberoptic intubation may be required for facial or maxillary trauma, Pierre Robin syndrome, or Treacher Collins syndrome as they may have cleft palates or severe dental problems. If there is presence of basal skull fracture or other contraindication oral intubation may be used.

What is the reason that a premature neonate has impaired temperature regulation? a. Premature infants have limited brown fat metabolism for nonshivering thermogenesis. b. Premature infants have increased glucose stores, and thus do not metabolize fat that would generate heat c. A smaller surface area to weight ratio, increasing radiant heat losses d. Decreased norepinephrine stores do not allow for nonshivering thermogenesis e. Premature infants have decreased norepinephrine stores, preventing adequate vasoconstriction to reduce heat loss

A. Premature infants have limited brown fat metabolism for nonshivering thermogenesis Neonates and premature infants have decreased brown fat stores, and thus have impaired ability to regulate their own temperature. Brown fat is highly vascularized and is innervated with beta sympathetic receptors. Stress created by a cold environment increases sympathetic nervous activity and the release of norepinephrine, causing a breakdown of brown fat and release of heat through increased metabolism. In addition one quarter of the cardiac output may be sent to brown fat to directly warm blood. Decreased norepinephrine stores are not the reason for decreased nonshivering thermogenesis. During normal nonshivering thermogenesis, the following occurs: when norepinephrine release is stimulated by sympathetic activity, free fatty acids and glycerol are released from triglycerides. The increase in oxygen consumption due to increased metabolism allows an infant to double the normal thermogenic rate. A larger surface to weight ratio will increase radiant heat losses, thus making the choice about a smaller surface area to weight ratio incorrect.

Comparing sevoflurane to halothane used in the pediatric population, which of the following statements is incorrect? a. Sevoflurane causes less myocardial oxygen consumption b. Sevoflurane causes less decrease in cardiac output c. Sevoflurane causes less decrease in myocardial contractility d. Sevoflurane causes less decrease in heart rate e. Sevoflurane causes less incidence of dysrhythmias

A. Sevoflurane causes less myocardial oxygen consumption Myocardial oxygen consumption is unchanged with either agent. Sevoflurane is superior to halothane for several reasons. Sevoflurane causes less of a decrease in heart rate, less decrease in myocardial contractility, and less drop in cardiac output compared to halothane. Dysrhythmias are also less common with sevoflurane than with halothane. Halothane causes more hypotension and bradycardia as it diminishes baroreceptor reflexes.

A one day old infant is diagnosed with a congenital heart lesion which is known to lead to pulmonary hypertension and right ventricle dilation. In addition to her primary cardiac defect, there is a patent ductus arteriosus which is intentionally not being treated or closed. This infant's condition is called: a. Total anomalous pulmonary venous return b. Hypoplastic left heart syndrome c. Tricuspid atresia d. Truncus arteriosus e. Tetralogy of Fallot

A. Total anomalous pulmonary venous return Total anomalous pulmonary venous return is a rare congenital defect wherein the pulmonary veins return blood to the right atrium, causing all pulmonary venous (oxygenated) blood to return to the right atrium. The blood is then sent to the right ventricle (along with normally returning blood) and then into the pulmonary circulation. This causes a great volume overload of the right ventricle and leads to a dilated right ventricle along with increased pulmonary artery pressure. Eventually pulmonary hypertension becomes severe and causes significant right to left shunting, leading to hypoxemia and its associated conditions - acidosis, hypotension, cardiac dysrhythmias, and hemodynamic instabilities. In order to maintain life and systemic circulation, there must be an atrial right-to-left shunt in the form of a patent foramen ovale or atrial septal defect.

What is the best position for transport of the pediatric patient after emergence from general anesthesia? Select one: a. Lateral b. Supine c. Prone

A. lateral The lateral position is preferred as it helps to maintain upper airway air flow, decreases collapse of the airway and decreases the risk of aspiration. Extension of the neck and holding up the chin also can help maintain a patent airway.

A pediatric patient undergoing which of the following surgeries is most likely to suffer from vomiting in the recovery room? Select one: a. Strabismus correction b. Tonsillectomy c. Myringotomy tube placement d. Tracheoesophageal fistula repair e. Ventriculoperitoneal shunt placement

A. strabismus correction Strabismus surgery is the most common ocular surgery of pediatrics. Nausea and vomiting are seen 50% to 80% of the time without treatment, making prophylaxis a must in these surgeries. Strabismus is a misalignment of the eyes, which if not corrected will lead to life long problems with vision and learning. Strabismus is more common in patients with trisomy 21 (Down syndrome), hydrocephalus, or cerebral palsy, each of which have their own anesthetic considerations. Ondansetron produces excellent results without sedation or other side effects. Droperidol is a good choice for prophylaxis but can cause sedation.

What is a correct formula for determining the depth (in centimeters) of an endotracheal tube in a premature or newborn infant? Select one: a. Weight in kilograms plus 6 b. 2 + age/12 c. 4 + age/4 d. Weight in kilograms plus 2 e. No such formula exists for neonates

A. weight in kg plus 6 Weight in kilograms plus 6 allows an estimate for endotracheal tube depth after ET placement for a pediatric patient or tube ID x 3. Tube ID x 3 can be used for all tube sizes and is much easier to use when in the OR.

You wish to infuse phenylephrine into a 20 kg patient. Which of the following rates would be efficacious to administer this drug? Select one: a. 0.05 mcg/kg/min b. 0.1 mcg/kg/min c. 1 mcg/kg/min d. 2 mcg/kg/min e. 4 mcg/kg/min

B. 0.1 mcg/kg/min For a simple injection of phenylephrine, the dose can range from 1-10 mcg/kg although you should start with the lower side of dosing initially if possible. For an infusion, the dosing should be titrated to effect from 0.1-0.5 mcg/kg/min.

Which of the following is the most common cause of pediatric bradycardia? a. Succinylcholine b. Hypothermia c. Hypoxia d. Overly deep volatile anesthetic level e. Hyperkalemia

C. Hypoxia Hypoxia is the most common cause of bradycardia in the pediatric population. Other causes of bradycardia in the pediatric population include vagal stimulation, hypothermia, depression from anesthetic agent, and succinylcholine administration.

A child presenting for sphincterotomy to treat a chronic anal fissure is in the preoperative area. His mom notes that he is very anxious and requests some medicine to "calm him down." As you wish to administer this patient midazolam, what is an appropriate oral dose of this medication? a. 1 mg/kg b. 0.5 mg/kg c. 0.04 mg/kg d. .2 mg/kg e. .1 mg/kg

B. 0.5 mg/kg Midazolam 0.5 mg/kg is commonly used in pediatric settings to provide anxiolysis and sedation prior to procedures. Only 50% of PO administered midazolam reaches systemic circulation due to the first pass effect. It should be given 30 minutes prior to the procedure to enable sufficient time for action. Alternatively, IM or IV midazolam 0.1-0.2 mg/kg may be given. Intranasal midazolam, 0.2 to 0.5 mg/kg, has been used successfully in this population as well. Interestingly, intranasal midazolam has found success in prehospital and emergency settings for treatment of acute seizures when IV access has not been obtained (adult dose usually 5 mg intranasal). 1 mg/kg of midazolam may be given PO, but is a higher dose that may increase recovery times.

How long should a 4 month old infant be kept NPO from clear liquids prior to surgery? a. 1 hour b. 2 hours c. 4 hours d. 6 hours e. 8 hours

B. 2 hours NPO guidelines can be stated as follows: Less than 6 months old - clear liquids 2 hours, breast milk 4 hours, formula 6 hours. 6-36 months old - clear liquids 2 hours, breast milk 4 hours, solids/formula 6 hours. Greater than 36 months old clear liquids 2 hours, solids 8 hours. Reasoning behind the shorter NPO times in the younger patient is the smaller glycogen stores and increased likelihood of hypoglycemia developing. In patients with an increased risk of aspiration, a longer NPO period may be desired. This includes children with pyloric stenosis, ileus, GERD, or diabetic ketoacidosis. In these patients metoclopramide, H2 blockers, and antacids may be administered prior to surgery.

What is the estimated anatomic dead space in a 18 kg child? Select one: a. 18 mL b. 36 mL c. 72 mL d. 90 mL e. 180 mL

B. 36 mL Anatomic dead space is estimated as 2 mL/kg, though a more exact estimate may be based on the individual's height, 105 + 5 for every inch over 5 feet for females and 106 + 6 for males. 105 + 5 and 106 + 6 is the same formula for Ideal Body Weight, thus your ideal body weight is about the same as your anatomic dead space.

A stable newborn of about 3 days age is thought to have a meconium ileus. Non-surgical therapies have failed, and decision is made to proceed to surgery. In spite of the NPO order the mother felt it was unsafe for the baby to go so long without eating and has fed the baby a breast milk meal prior to arrival in the OR. How long must the baby remain fasting prior to an elective procedure? Select one: a. 2 hours b. 4 hours c. 6 hours d. 8 hours e. There is no NPO requirement for breast milk feeding

B. 4 hours

What is the narrowest part of a pediatric airway? a. Hyoid bone b. Cricoid cartilage c. Glottis d. Thyroid cartilage e. Trachea

B. Cricoid cartilage The narrowest part of the pediatric airway is the cricoid cartilage (subglottic cricoid ring). Other things unique to the pediatric airway are the funnel-shaped larynx and the glottic opening is located at the C3-C4 level. Their airways also are more anterior and cephelad, and the epiglottis is shorter and more angled. The larynx is also more superior in the neck. The narrowest part of the adult airway is the vocal cords.

Choose the normal set of vital signs for a 10 month old: a. HR 60, BP 100/60, Respiratory rate 20 b. HR 100, BP 90/60, Respiratory rate 30 c. HR 140, BP 90/60, Respiratory rate 18 d. HR 120, BP 110/70, Respiratory rate 25 e. HR 120, BP 110/70, Respiratory rate 16

B. HR 100, BP 90/60, Respiratory rate 30

A 12 year old patient presents to your operating room for an emergent procedure. During your history the parent of the child informs you that a 2nd degree relative of the child was told that he may be allergic to some anesthetic compounds, but they cannot remember what the reaction was. You are suspicious that they may be referring to malignant hyperthermia. Which of the following combination of signs would most strongly indicate possible impending malignant hyperthermia? Select one: a. Masseter muscle spasm, temp 38.0?, pCO2 of 35mm Hg, heart rate 95 b. Heart rate of 110, Respiratory rate of 28, darkening urine, masseter rigidity, muscle rigidity c. CK levels of 200 mg/dl in the serum, masseter spasm, transient nonsustained V-tach, d. Blood Glucose > 400mg/dl, pH 7.20, increased serum ketones, darkening urine e. Heart rate 160, pCO2 29, PO2 of 39, SBP 65, Temp 42 C, elevated CK, Cola colored urine,

B. Heart rate of 110, Respiratory rate of 28, darkening urine, masseter rigidity, muscle rigidity

Choose the the procedure below that doesn't typically require vascular access? a. Ventral hernia repair b. Myringotomy c. Tonsillectomy d. Adenoidectomy e. Meatoplasty

B. Myringotomy Due to the speed of the procedure and lack of significant pain, intravenous access is typically not required of myringotomy patients. A mask induction with nitrous oxide, sevoflurane, and oxygen may be undertaken. Intranasal Fentanyl 1 mcg/kg, Acetaminophen 15 mg/kg (rectal, intravenous or oral) may be used for analgesia, or ketorolac 1 mg/kg IM (if greater than 2 yrs of age). Children requiring myringotomy often may have obstructive sleep apnea, and some may require CPAP if obstruction is significant after the case.

A 4 year old patient should have a heart rate of between 65-110 beats per minute, a systolic blood pressure of between 95-110 mmHg, a diastolic pressure of between 60-75 mmHg, and a respiratory rate of 20-25 breaths per minute. a. 12 hours after birth b. 24 hours after birth c. 1 week after birth d. 4 weeks after birth e. 1 year after birth

C. 1 week after birth Neonates in the first week of life have glomerular filtration rates (GFR) and renal plasma flows of only 25% of normal adult values. Urine output is important to monitor during surgery as urine output can give the provider an idea of intravascular volume status and cardiac output. But in the neonate that is younger than 1 week, the urine output is not a reliable indicator of cardiac output or volume status. The neonatal distal tubule is not very responsive to aldosterone, and the kidney has a very limited ability to concentrate urine during this time. At the end of the first week, the ability to reabsorb sodium becomes similar to the ability of the adult kidney.

Which of the following is a correct hourly maintenance rate for a 9 kg patient? Select one: a. 9 mL b. 18 mL c. 36 mL d. 72 mL e. 90 mL

C. 36 mL 36 mL per hour. Basal rates are calculated as follows: From 0 to 10 kg: 4 mL/kg per hour. From 10 to 20 kg: 40 mL + 2 mL/kg per hour above 10 kg. For greater than 20 kg: 60 mL + 1 mL/kg per hour above 20 kg. This is otherwise stated as the 4/2/1 rule (4 mL/kg for first 10 kg, 2 mL/kg above this for the second 10 kg, and 1 mL/kg extra for every kilogram above 20 kg). For each 1 degree Celsius increase in body temperature, an 10 increase in fluid requirement occurs. Fluid deficits should be replaced 50% in first hour, 25% in the second and third hours and the basal rate maintained afterwards. This deficit replacement may be carried into postoperative period. Third space losses for small surgeries can be calculated as 1-3 mL/kg per hour, but neonates with severe peritonitis or gastroschisis may need 25 to 100 mL/kg per hour for replacement of third space losses.

How long should a 3 month old infant be kept NPO from breast milk prior to surgery? a. 1 hour b. 2 hours c. 4 hours d. 6 hours e. 8 hours

C. 4 hours Breast milk should be withheld at least 4 hours prior to surgery.

A 10 month old with chromosomal trisomy 21 is having surgical repair to treat his Hirschprung's disease. Which of the following concerns is NOT likely to be present in a patient with chromosomal trisomy 21? a. Endocardial Cushion Defects b. Atlanto-Axial instability c. Hyperthyroidism d. Macroglossia e. Narrow hypopharynx

C. Hyperthyroidism Patients with Down syndrome may have the following anesthesia relevant abnormalities: endocardial cushion defects, atlanto-axial instability, hypothyroidism, macroglossia, narrow hypopharynx, subglottic stenosis, choanal atresia, obesity. Although hyperthyroidism does occur at a greater rate than the general population, they are far more prevalent to have a hypothyroid function.

A 15 kg patient with 2 hours of NPO requires fluid replacement. Ignoring surgical losses, how much crystalloid should be administered in the second hour after the first administration of fluids? Select one: a. 25 mL b. 50 mL c. 75 mL d. 100 mL e. 200 mL

C. 75 mL 75 mL should be administered. Basal rates are calculated as follows: From 0 to 10 kg: 4 mL/kg per hour. From 10 to 20 kg: 40 mL + 2 mL/kg per hour above 10 kg. For greater than 20 kg: 60 mL + 1 mL/kg per hour above 20 kg. This is otherwise stated as the 4/2/1 rule (4 mL/kg for first 10 kg, 2 mL/kg above this for the second 10 kg, and 1 mL/kg extra for every kilogram above 20 kg). Insensible fluid losses include respiratory and evaporative from the skin, and premature infants have highly permeable skin that can cause 3 times the normal fluid loss as seen in full term infants Fluid deficits should be replaced 50% in first hour, 25% in the second and third hours and the basal rate maintained afterwards. This deficit replacement may be carried into postoperative period. Third space losses for small surgeries can be calculated as 1-3 mL/kg per hour, but neonates with severe peritonitis or gastroschisis may need 25 to 100 mL/kg per hour for replacement of third space losses. In this case, the basal rate for the patient is 50 mL per hour. In addition to the basal rate, there is a 2 hour NPO deficit (2 x 50 mL equals a 100 mL deficit). Half of this deficit should be administered over the first hour, so in the first hour you add 50 mL plus 50 mL (basal rate plus half of your NPO deficit). The next two hours would be 75 mL per hour ( basal rate plus 25%, so 50 mL plus 25 mL). After this, the standard hourly maintenance should be used (ignoring any additional you wish to add due to surgical losses).

What is the cause of the leftward shift of the oxyhemoglobin dissociation curve in the fetus? a. Decreased levels of HbF b. Increased levels of HbA c. Decreased levels 2,3-DPG d. Decreased iron stores e. Decreased levels of ATP

C. Decreased levels 2,3-DPG Fetal hemoglobin (HbF) lies to the left of HbA. This leftward shift of fetal hemoglobin is due to decreased interaction with 2,3-DPG. Maternal hemoglobin represented as HbA has normal interaction with 2,3-DPG which allows it to off load oxygen. With little to no interaction of HbF with 2,3-DGP this makes HbF have a higher affinity of oxygen compared to HbA. The higher affinity of HbF and the offloading ability of HbA promotes Fetal Hemoglobin saturation with a P50 of 18-20 mmHg vs HbA P50 of 27 mmHg. Basically, HbF has a higher affinity for oxygen so that a lower partial pressure will result in 50% saturation of HbF.

Which of the following is not generally found in a patient with Treacher Collins Syndrome? a. Downward slanting palpebral fissures b. Receded chin c. Mental retardation d. Hypoplastic zygoma e. Malformed ear pinnae

C. Mental retardation Mental retardation is not found as a feature of Treacher Collins syndrome. Most patients with Treacher Collins syndrome and mental retardation are developmentally delayed due to hearing loss. Downward slanting palpebral fissures are a classic and striking feature of Treacher Collins syndrome. A receded chin and depressed cheekbones are seen in this syndrome. The mouth tends to be turned down. Retrognathism that can be seen in this syndrome is a concern to anesthesia professionals, but some milder cases may only have mild physical abnormalities. The pinnae are frequently malformed and may appear crumpled in a forward direction. External auditory canal stenosis or atresia can be seen, along with numerous other auditory physical abnormalities leading to conductive hearing loss. Hypoplastic zygoma and supraorbital rims are seen in Treacher Collins. Although a patient with Treacher Collins has a normal size nose, the hypoplastic facial features make the nose appear to be larger than normal.

The reason pediatric patients have a faster rate of inhalational induction than adults, is that pediatric patients have a: a. Larger FRC b. Larger deadspace c. Preferential blood flow to vessel rich organs d. Larger relative dead space to tidal volume ratio e. Greater cardiac output

C. Preferential blood flow to vessel rich organs Inhalation induction in children is faster due to decreased FRC, less deadspace, increased respiratory rate and preferential blood flow to blood vessel rich organs.

A 4 month old presents for elective surgery and you have discovered that the patient had a clear liquid meal 3 hours prior to arrival in the operating room in spite of NPO after midnight orders. The surgeon wishes to proceed with surgery that day due to scheduling concerns. What should be done? Select one: a. Delay the surgery until the next day. b. Wait an additional one hour to allow gastric emptying c. Proceed with surgery d. Premedicate with metoclopramide and procede with induction e. Aspirate stomach contents via NGT then procede with surgery.

C. Proceed with surgery NPO guidelines for clear liquid diets require only 2 hrs of NPO status prior to elective procedures. There are no contraindications in this patients history to proceeding with surgery. The length of time NPO status should be maintained in infants and children depends largely on their diet with fat content of the last meal eaten being the greatest determining factor of NPO duration. Fat is a major determinant in gastric emptying as such times vary from clear liquids to breast milk, to formula to solid food. For an infant under 6 months of age on breast milk 4 hrs time NPO is acceptable. 2hrs for clear liquids, 6hrs for formula and 8hrs for solid foods if applicable.

Neonates have what amount of oxygen consumption, as compared to adults? a. Same amount b. 3 times lower consumption c. 5 times lower consumption d. 3 times higher consumption e. 5 times higher consumption

D. 3 times higher consumption Oxygen consumption on a mg/kg basis decreases as age increases. In the neonate, oxygen consumption is 2 to 3 times as high as is in adults. Oxygen consumption is twice as high in infants as in adults. Neonates average 6-8 mg/kg/min, infants at 5 mg/kg/min, children at 4 mg/kg/min, and adults at 3 mg/kg/min.

A 40 kg patient with 8 hours of NPO requires fluid replacement. Ignoring surgical losses, how much crystalloid should be administered in the first hour? a. 40 mL b. 80 mL c. 240 mL d. 400 mL e. 640 mL

D. 400 mL 400 mL should be administered in the first hour. Basal rates are calculated as follows: From 0 to 10 kg: 4 mL/kg per hour. From 10 to 20 kg: 40 mL + 2 mL/kg per hour above 10 kg. For greater than 20 kg: 60 mL + 1 mL/kg per hour above 20 kg. This is otherwise stated as the 4/2/1 rule (4 mL/kg for first 10 kg, 2 mL/kg above this for the second 10 kg, and 1 mL/kg extra for every kilogram above 20 kg). Fluid deficits should be replaced 50% in first hour, 25% in the second and third hours and the basal rate maintained afterwards. This deficit replacement may be carried into postoperative period. Third space losses for small surgeries can be calculated as 1-3 mL/kg per hour, but neonates with severe peritonitis or gastroschisis may need 25 to 100 mL/kg per hour for replacement of third space losses. In this case, the basal rate for the patient is 80 mL per hour. In addition to the basal rate, there is an 8 hour NPO deficit (8 x 80 mL equals a 640 mL deficit). Half of this deficit should be administered over the first hour, so in the first hour you add 80 mL plus 320 mL (basal rate plus half of your NPO deficit). The next two hours would be 240 mL per hour ( basal rate plus 25%, so 80 mL plus 320 mL). After this, the standard hourly maintenance should be used (ignoring any additional you wish to add due to surgical losses).

A 5 year old male presents for pre-operative evaluation for a possible adenoidectomy. His mother states that he snores at night and seems to be tired all the time during the day. Which of the following findings is not associated with this child's clinical condition? Select one: a. Hypercarbia b. Hypoxia c. Cor pulmonale d. Pulmonary hypertension e. Decreased catecholamines

D. Decreased catecholamines Increased, not decreased, circulating catecholamines are seen in this condition.

What landmark should be felt for prior to administering a caudal anesthetic? Select one: a. Femoral triangle b. Umbilicus c. Anterior superior illiac spine d. Sacral cornua e. Illiac crest

D. Sacral cornua The landmarks felt are the sacral cornua and sacral hiatus. The sacral canal is the terminal part of the dural sac, ending between S1 and S3. Five sacral nerves and the coccygeal nerves form the cauda equina. The sacral epidural veins end at S4 typically but may course through the canal placing them at risk from catheter or needle puncture during caudal anesthetic procedures. The filum terminale is the final part of the spinal cord but does not contain nerves - it exits out of the sacral hiatus. To place a single shot caudal, a short beveled needle with a stylet or a 22 gauge blunt catheter may be used. The child is placed in the later position with hips flexed. The landmarks felt are the sacral cornua and sacral hiatus. The sacral hiatus is an indentation felt just inferior to the cornua and at midline. The needle is placed at a 45 degree angle aiming cephalad toward the sacral hiatus, entering the epidural space with a "pop" felt as there is entry through the sacrococygeal ligament. Prior to injection of local anesthetic, aspiration is important to look for CSF and blood. Injection should be easy and resistance not felt.

Which of the following cardiac defects is most likely to allow a venous air bubble to enter systemic circulation? a. Ventricular septal defect b. Patent Ductus Arteriosus c. Atrial Septal Defect d. Tetralogy of Fallot e. Patent Foramen Ovale

D. Tetralogy of Fallot Tetralogy of Fallot is comprised of 4 main identifying characteristics 1) VSD, 2) Pulmonary artery stenosis, 3) abnormal aorta overriding the right ventricle, 4) Right ventricular hypertrophy. The combination of a pulmonary outflow tract obstruction along with VSD causes a repeated right to left shunt from venous to arterial circulation which may allow venous air to enter arterial circulation. Of the remaining choices PFO and ASD can both cause right to left shunting, but usually during transient elevations of right atrial pressure such as during valsalva maneuver. The lack of constant right to left blood flow makes this less likely. Both VSD and PDA are left to right shunts making paradoxical air embolus unlikely.

Choose the correct blood volume estimate for a preterm infant: Select one: a. 60 mL/kg b. 70 mL/kg c. 80 mL/kg d. 90 mL/kg e. 100 mL/kg

E. 100 mL/kg Premie- 100cc/kg Full Term Neonate-90cc/kg Infant-80cc/kg Child-75cc/kg Adult Male-75cc/kg Adult Female-65cc/kg

A premature infant born at 32 weeks post-conception is scheduled to undergo general anesthesia. At how many weeks will this infant no longer need prolonged observation after general anesthesia is administered? a. 37 weeks b. 42 weeks c. 48 weeks d. 52 weeks e. 60 weeks

E. 60 weeks For premature infants postconception age requiring observation is 55-60 weeks and for full term infants it is 45 weeks of age, but can vary from institution to institution. Apnea of prematurity is defined as a cessation of breathing for 20 seconds or for less than 20 seconds associated with bradycardia, cyanogen, or pallor. Apnea may be classified as central, obstructive, or a mix of the two. Central apnea is defined as apnea in which there is no effort at respiration due to neurological cause. Obstructive apnea is when there is an effort at respiration but air is unable to flow due to an obstructive process. Some patients may have both and is referred to as "mixed." A separate condition called "periodic breathing" is a condition unique to neonates and preterm infants, where pauses of breathing that are 5 to 10 seconds in length occur in a repeated fashion - this is not apnea of prematurity by definition. Increased risk of apnea of prematurity is seen up to 55-60 weeks post-conceptual age (not from date of birth, but of conception). General anesthesia increases this risk. After undergoing general anesthesia, these patients should be admitted and observed for at least 12 hours without signs of apnea before discharge. In actuality, the greatest risk is in premature infants with a history of apnea and who are less than 44 weeks in age, but the boards typically ask at what post conceptual age there ceases to be an increased risk (which is 60 weeks).

Which of the following is not characteristic of Hemolytic Uremic Syndrome (HUS)? a. Hemolytic anemia b. Thrombocytopenia c. Acute renal failure d. Elevated liver enzymes e. Congestive heart failure

E. Congestive heart failure Congestive heart failure is not associated with HUS. Hemolytic Uremic Syndrome is one of many thrombocytopenic syndromes. It is characterized by a dropping platelet count, hemolytic anemia and acute renal failure (Uremia). Elevated liver enzymes are frequently seen as is central nervous system involvement with seizures, coma, and stroke. It is preceded in 90% of cases by a diarrheal illness, usually caused by an enterohemorrhagic strain of shiga toxin producing E-coli.

A 18 month old child has undergone surgery for removal of adenoids and tonsils secondary to obstructive sleep apnea. After thorough suctioning, you remove the endotracheal tube deep and prepare to take the child to postoperative recovery. Twenty seconds after extubation, you note the patient is not moving air and is having retractions while attempting to breathe. You reposition the child's head and perform a chin lift, but still do not feel any movement of air. The child's intravenous line is still intact and flowing well. The most appropriate treatment at this time is: a. Atropine 0.15 mg/kg b. Succinylcholine 4 mg/kg IM c. Succinylcholine 1 mg/kg IV d. Propofol 2 mg/kg IV e. Continuous positive airway pressure

E. Continuous positive airway pressure Treatment of pediatric laryngospasm should begin with continuous positive airway pressure up to 40 cmH2O along with jaw thrust. The incidence of laryngospasm in children under 9 years is around 2%, but when a recent upper respiratory infection exists the incidence is up to 10%. Tracheal instrumentation or intubation causes an increased risk of laryngospasm, particularly with a recent infection or reactive airway, compared to the use of an LMA or facemask. Laryngospasm is actually a prolonged a stronger than typical response of the glottic protective reflex, causing the false cords and epiglottic body to come together. This serious condition will not allow air to pass, and can cause rapid deterioration of the fetus. Treatment of pediatric laryngospasm should begin with continuous positive airway pressure up to 40 cmH2O along with jaw thrust. Propofol or Succinylcholine is next indicated if laryngospasm does not break. Most pediatric anesthesia providers prefer propofol over succinylcholine due to complications that can occur with succinylcholine. Dosing for succinylcholine is 0.25-1 mg/kg IV or 4 mg/kg IM as is typically given. Atropine (0.01-0.02 mg/kg with a minimum dose of 0.1 mg) should be given at the same time as dangerous bradycardia can result with administration of succinylcholine in the Pediatric population. Propofol 1 mg/kg should be enough to break the spasm without the need for coadministration of atropine.

A 3 year old patient is extubated after undergoing repair of a ventral hernia. Vital signs have been stable and oxygen saturation is at 99% on blow-by oxygen, but you note harsh stridorous breath sounds. You have attempted a jaw thrust and chin lift maneuver but the stridor still remains. Air movement is adequate at this time and the child is not in significant distress. What is the most beneficial treatment indicated at this time? Select one: a. Corticosteroids b. Reintubation c. Albuterol nebulizer d. Ipratropium nebulizer e. Racemic epinephrine nebulizer

E. Racemic epinephrine nebulizer Post intubation stridor may be seen in any patient but is more common in patients less than 4 years of age. The treatment is with racemic epinephrine, and albuterol may not be effective. Stridor is most often caused by an ET tube that is too tight fitting and is used for positive pressure ventilation. A too tight fitting ET tube is determined by having a cuff leak at greater than 30 cmH2O (ideal leak pressure is 15-20 cmH2O). Other things that can lead to post intubation stridor are repeated or traumatic intubations, duration of intubation, and surgery involving the head or neck. Racemic epinephrine is dosed as 0.5 mL of a 2.25% solution, diluted in 3-5 mL of normal saline. It is administered nebulized over 5 - 10 minutes. Racemic epinephrine provides for vasoconstriction of the respiratory mucosal vasculature, shrinking the swollen mucosa. Rebound swelling is common and thus patients requiring treatment should be observed for at least several hours after treatment. Corticosteroids may be beneficial but take at least hours for effect to begin. Steroids do reduce the incidence of postintubation stridor in children who have been intubated for 48 hours.

Which of the following is a correct formula for determining pediatric ET tube size? Select one: a. 4 + age/4 b. 2 + age/12 c. 12 + age/2 d. 12 + age/4 e. 4 + age/2

a. 4 + age/4

A 6 month old child requiring hernia repair presents for surgery. The child was 3 weeks premature but has had a noneventful upbringing besides some lower than typical weight gain. He is also on metoclopramide for reflux disease. Vital signs are stable, and a mask induction is begun in routine fashion followed by propofol and succinylcholine. Intubation is performed with a grade I view, and a non-cuffed ETT is successfully placed. Sevoflurane is currently at 3.2% end tidal, and oxygen saturation is 98%. While securing the ETT, you note the pulse oximeter fails to read a waveform. You assess for a blood pressure and none is noted, and now note a pulseless wide complex tachycardia. CPR is initiated and epinephrine is given at 0.1 mg/kg IV. What further intervention should be immediately given in this situation that is likely to be efficacious? Select one: a. Calcium chloride b. Potassium chloride c. Amiodarone d. Epinephrine drip e. Synchronized cardioversion

a. Calcium chloride Calcium chloride should be given to treat presumed hyperkalemia. There have been rare cases of sudden cardiac arrest and ventricular dyshythmias following the use of succinylcholine, and this is a reason succinylcholine is often avoided in the pediatric population unless absolutely required. This frequently presents as peaked T waves (from hyperkalemia) followed by ventricular tachycardia or cardiac arrest. It most frequently has occurred in male patients 8 years old or younger, but occasionally in the older population. This syndrome is secondary to succinylcholine triggering rhabdomyolysis resulting in hyperkalemia. Interventions include normal pedatric advanced life support treatment (in this case CPR, epinephrine, and defibrillation), but also adds presumptive treatment of hyperkalemia (insulin and glucose, bicarbonate, hyperventilation, and calcium). In an otherwise healthy pediatric patient that goes into cardiac arrest after induction, presumptively add calcium to your immediate ACLS treatment - do not wait for confirmation with lab tests, as standard resuscitation without calcium or hyperkalemic treatment is unlikely to be successful.

Surgical repair of which of the following conditions requires the greatest amount of volume replacement? Select one: a. Gastroschisis b. Omphalocele c. Pyloric stenosis d. Congenital diaphragmatic hernia e. Transposition of the great vessels

a. Gastroschisis Of these conditions, gastroschisis requires the greatest amount of volume replacement. Third space losses for small surgeries can be calculated as 1-3 mL/kg per hour, but neonates with gastroschisis may need 25 to 100 mL/kg per hour for replacement of third space losses. Providing at IV therapy from 2 - 4 times the typical hourly maintenance dose provides for adequate hydration despite large third space losses, along with the losses of proteins and the presence of ischemia. Failure to provide adequate fluid resuscitation will lead to a metabolic acidosis subsequent to poor perfusion, and hypovolemic shock may ensue.

In the infant population, changes in which of the following is the major regulator of cardiac output? Select one: a. Heart rate b. Afterload c. Preload d. Contractility e. Stroke volume

a. Heart rate

What is the correct dosing for pediatric morphine? Select one: a. 0.01-0.05 mg/kg b. 0.05-0.1 mg/kg c. 0.2-0.5 mg/kg d. 0.5-1 mg/kg e. 1-2 mg/kg

b. 0.05-0.1 mg/kg

What is an efficacious dose of ephedrine for the treatment of hypotension in the pediatric patient? Select one: a. 0.01 mg/kg b. 0.1 mg/kg c. 0.05 mg/kg d. 0.5 mg/kg e. 1 mg/kg

b. 0.1 mg/kg For treatment of hypotension with ephedrine, the dose is 0.02 - 0.2 mg/kg.

Pyloric stenosis is most likely to be diagnosed at what age range? Select one: a. 0-2 weeks b. 2-8 weeks c. 10-12 weeks d. 12-24 weeks e. 24 weeks -1 year

b. 2-8 weeks

Choose the correct blood volume estimate for a 1 year old child? Select one: a. 60 mL/kg b. 75 mL/kg c. 80 mL/kg d. 90 mL/kg e. 110 mL/kg

b. 75 mL/kg

A 5 month old infant suffering from tetralogy of Fallot is administered an inhalation induction with sevoflurane. After administration of propofol and placement of an uncuffed endotracheal tube, the oxygen saturation is noted to be at 58% despite an FiO2 of .94 and what appears to be adequate ventilation. Endotracheal tube placement has been confirmed and end tidal CO2 is present. Which of the following is the most appropriate treatment at this time? Select one: a. Decrease FiO2 b. Administer phenylephrine c. Increase ventilatory rate d. Administer epinephrine e. Administer indomethacin

b. Administer phenylephrine Phenylephrine may be used to treat hypotension and hypoxia seen in tetralogy of Fallot patients, also known as Tet spells.

Which of the following electrolyte disturbances is most likely to be seen in premature infants? Select one: a. Hypokalemia b. Hyponatremia c. Hypercalcemia d. Hyperphosphatemia e. Hypernatremia

b. Hyponatremia Hyponatremia and hyperkalemia are seen most commonly. Hyponatremia is seen as immature renal functionality causes more sodium excretion than in the mature population. There is less sodium reabsorption in the proximal tubule, and the distal tubule is less responsive to the aldosterone's sodium retaining action due to immature kidney function. Low glomerular filtration rates seen in infants can also lead to hyponatremia if large volumes of hypotonic fluids are given, as there is limited fluid excretion. Hyponatremia can lead to conduction and neurological disturbances, and up to 1 in 3 preterm infants will have a sodium of less than 130 mEq/L. Hyperkalemia is seen as infants have less ability to excrete potassium, also due to the distal tubule's lack of responsiveness to aldosterone. Preterm and term infants have an infinite ability to dilute urine, but a poor ability to concentrate urine. Hypocalcemia and metabolic acidoses is more common in preterm infants as well.

Choose the correct statement regarding lung compliance in the infant as compared to the adult: Select one: a. Infants have higher elastic recoil than adults b. Infants lungs are more compliant than adult lungs c. Outward recoil is greater than inward recoil in the infant d. Elastic fibers are more functional in the infant than in the adult e. Decreased chest wall compliance leads to an increased relative FRC in the infant

b. Infants lungs are more compliant than adult lungs

At what age in your pediatric patient population are children most anemic physiologically? Select one: a. 1-2 weeks after birth b. 1 month c. 2 to 3 months d. 6 months e. 1 year

c. 2 to 3 months

How many teeth are considered deciduous? Select one: a. 16 b. 18 c. 20 d. 24 e. 32

c. 20 Primary dentition (deciduous teeth) totals 20 teeth

Which of the following is a correct hourly maintenance rate for an 18 kg patient? Select one: a. 18 mL b. 36 mL c. 56 mL d. 76 mL e. 152 mL

c. 56 mL 56 mL per hour. Basal rates are calculated as follows: From 0 to 10 kg: 4 mL/kg per hour. From 10 to 20 kg: 40 mL + 2 mL/kg per hour above 10 kg. For greater than 20 kg: 60 mL + 1 mL/kg per hour above 20 kg. This is otherwise stated as the 4/2/1 rule (4 mL/kg for first 10 kg, 2 mL/kg above this for the second 10 kg, and 1 mL/kg extra for every kilogram above 20 kg). For each 1 degree Celsius increase in body temperature, an 10 increase in fluid requirement occurs. Fluid deficits should be replaced 50% in first hour, 25% in the second and third hours and the basal rate maintained afterwards. This deficit replacement may be carried into postoperative period. Third space losses for small surgeries can be calculated as 1-3 mL/kg per hour, but neonates with severe peritonitis or gastroschisis may need 25 to 100 mL/kg per hour for replacement of third space losses.

Which of the following is a correct hourly maintenance rate for a 25 kg patient? Select one: a. 25 mL b. 50 mL c. 65 mL d. 70 mL e. 130 mL

c. 65 mL For any patient greater than 20 kgs, simply take their weight in kilograms plus 40 and that will give you the maintenance in mL per hour. In this example the patient is 25 kg so 25 + 40= maintenance of 65 mL/hr

Choose the physical finding NOT seen in congenital diaphragmatic hernia patients: Select one: a. Scaphoid abdomen b. Barrel shaped chest c. Olive-sized mass near the epigastrium d. Dyspnea e. Cyanosis

c. Olive-sized mass near the epigastrium

In order to prevent retinopathy of prematurity, it is best to use the lowest FiO2 possible until what post conceptual age? Select one: a. 38 weeks b. 40 weeks c. 42 weeks d. 44 weeks e. 60 weeks

d. 44 weeks Concerns about the development of retinopathy of prematurity makes it prudent to limit increases in FiO2 to any infants less than 44 weeks in post-conceptual age.

How long should a 2 year old child be kept NPO from solid foods prior to surgery? Select one: a. 1 hour b. 2 hours c. 4 hours d. 6 hours e. 8 hours

d. 6 hours NPO guidelines can be stated as follows: Less than 6 months old - clear liquids 2 hours, breast milk 4 hours, formula 6 hours. 6-36 months old - clear liquids 2 hours, breast milk 4 hours, solids/formula 6 hours. Greater than 36 months old - clear liquids 2 hours, solids 8 hours. Reasoning behind the shorter NPO times in the younger patient is the smaller glycogen stores and increased likelihood of hypoglycemia developing. In patients with an increased risk of aspiration, a longer NPO period may be desired. This includes children with pyloric stenosis, ileus, GERD, or diabetic ketoacidosis. In these patients metoclopramide, H2 blockers, and antacids may be administered prior to surgery.

What airway abnormality is not found in a patient with Pierre Robin syndrome? Select one: a. Cleft palate b. Glossoptosis c. Hearing loss d. Downward sloping palpebral fissues e. Micrognathia

d. Downward sloping palpebral fissues Downward sloping palpebral fissures are seen in Treacher-Collins syndrome (mandibulofacial dysostosis), not in Pierre Robin syndrome. Micrognathia is the most commonly found physical characteristic seen in Pierre Robin syndrome. This is seen in 90% of patients. Micrognathia contributes to causing severe respiratory and feeding difficulties in the very young. The inferior dental arch is retracted about 1 cm behind the superior arch. The mandible also has a small body. Mandibular hypoplasia, however, usually resolves by around age 6. Glossoptosis is noted in 3 out of 4 patients. Macroglossia, however, is only seen in 10% of patients. Glossoptosis combined with other physical findings can cause severe respiratory and feeding difficulties. Obstructive sleep apnea is seen in some patients with Pierre Robin syndrome. Cleft palate incidence varies greatly from 20-90% and is usually in a U shape. Hearing loss is seen in 75% of these patients as well, usually conductive.

Which of the following is not a concern in a 16 month old female with Down syndrome? Select one: a. Macroglossia b. Congenital heart disease c. Cervical spine laxity d. Enlarged upper face and nose e. Subglottic stenosis

d. Enlarged upper face and nose Down syndrome patients have a smaller nose and upper face, not enlarged.Down syndrome is the most common cause of mental disability and retardation. It is caused by an extra 21 chromosome, called trisomy 21. Macroglossia is a common difficulty found in providing anesthesia to Down syndrome patients. Around 40% of Down syndrome patients have endocardial cushion defect, making it the most common cardiac defect. Ventricular septum defect is the next most common, and one in three have multiple cardiac defects. Cervical spine laxity is of great concern, as hyperextension of the neck has led to atlanto-axial subluxation and injury. Care must be taken to maintain neutrality of the neck as much as reasonably possible. Signs of subluxation include extremity weakness, neck pain, and paralysis. Patients with Down syndrome will possibly have a narrowed airway, and a standard-for-age sized ET tube may be too tight for your patient. In addition, care must be taken in management to avoid making pre-existing stenosis worse. Asymptomatic subglottic stenosis is particularly easy to miss and should be considered when making your anesthetic plan.

An anesthetized child is noted to have their core temperature decrease from 37.4 degrees celcius to 35.4 degrees celcius in the first hour of surgery. What is the greatest contributing factor for this temperature change? Select one: a. Heat loss to the operating room environment b. Peripheral vasoconstriction c. Decreased brown fat metabolism d. Redistribution of blood from core to peripheral tissues e. Loss of hypothalamic functionality

d. Redistribution of blood from core to peripheral tissues During the first hour of anesthesia, heat from the central core of the body is redistributed throughout the body to peripheral tissues. Typically the patient doesn't lose much heat to the environment, but rather there is a shunting of blood from the core to periphery causing this drop in temperature. This is largely due to anesthesia induced peripheral vasodilation. The second stage continues temperature decrease but begins more of the actual heat loss - there is lessened heat production and increased heat loss to the operating room environment. This occurs over the next several hours. The third state is known as the thermal steady stage, where metabolic heat production equals heat dissipation and temperature stays unchanged. When under anesthesia, the body loses the ability to regulate temperature and temperature will fall without the normal compensatory mechanisms to prevent heat loss. Vasoconstriction and nonshivering thermogenesis are the only remaining ways to maintain normothermia. In addition, there is a decrease in metabolic heat production during anesthesia.

At pre-op for a tonsillectomy, the patient's mother is asked to give a history of her child's health. Of note, the child did not begin to ambulate until he was 20 months old and when he did he seemed to have a "waddling" gate. He also seems to fall more than she thinks he should, but doesn't seem to lose his balance or trip over anything to cause a fall. The child had previously made all normal childhood markers with no deficits. What medication should you withhold from this patient? Select one: a. Ketorolac, increased risk of nephrotic syndrome b. Meperidine, more likely to induce seizures c. Acetaminophen, increased chance of Reye's syndrome d. Succinylcholine, increased chance of hyperkalemia e. Prednisone, which may cause worsening of patient's weakness due to muscle atrophy

d. Succinylcholine, increased chance of hyperkalemia Withhold succinylcholine due to an increased chance of hyperkalemia. This patient is suffering from Duchenne's muscular dystrophy and has a classic history to suggest this. A child beginning to ambulate later than normal with a "waddling" gate, frequent falls, and otherwise normal childhood markers may lead to a clinical picture of Duchenne's muscular dystrophy. Important to anesthesia is the higher incidence of sudden rhabdomyolysis and hyperkalemia in muscular dystrophy patients. It is best to avoid succinylcholine and other triggers of malignant hyperthermia in these patients, as although these patients may develop sudden cardiac arrest and death when exposed to MH triggers they are two distinct and separate causes of injury. Propofol infusions are a good choice for an anesthetic in these patients. If a patient is given succinylcholine and suddenly enters cardiac arrest, the potential of undiscovered muscular dystrophy must be entertained. In this situation, emergency treatment of hyperkalemia must be immediately undertaken in addition to normal ACLS procedures (calcium, insulin and glucose, bicarbonate). Corticosteroids are often prescribed in this condition to decrease the rate of muscle deterioration, though it does not solve the problem by any means. Meperidine is not more likely to cause seizures in this patient population provided that renal and hepatic function is intact. Renal damage secondary to this disease may be seen, in which case meperidine should be avoided. This patient's history does not suggest a predisposition to Reye syndrome. Second, Reye's syndrome is not associated with acetaminophen, but is associated with aspirin. The etiology of Reye's syndrome is unknown but typically occurs after viral illness, and is very rare due perhaps to a decrease in aspirin use in children. It is likely that patients with Reye syndrome are born with an inborn error of metabolism that may explain the occurrence of this illness.

Which of the following factors does NOT correlate with an increased risk of anesthesia related cardiac arrest? Select one: a. Physical status ASA IV b. Emergent surgery c. Surgery on neonates d. Surgery on very elderly e. All of these increase the risk of cardiac arrest

e. All of these increase the risk of cardiac arrest actors increasing the risk of cardiac arrest includes 1 - high ASA status (IV and V have 30-300 times greater risk of cardiac arrest than lower ASA classes), 2 - extremes of age (neonates and infants, the very elderly) and 3 - emergency surgeries.

Choose the normal set of vital signs for a 4 month old: Select one: a. HR 100, BP 110/60, Respiratory rate of 30 b. HR 140, BP 80/60, Respiratory rate 40 c. HR 140, BP 70/50, Respiratory rate 30 d. HR 80, BP 110/60, Respiratory rate 20 e. HR 100, BP 80/60, Respiratory rate 35

e. HR 100, BP 80/60, Respiratory rate 35

Choose the normal set of vital signs for a 10 year old: Select one: a. HR 70, BP 100/70, Respiratory rate 10 b. HR 50, BP 120/70, Respiratory rate 20 c. HR 110, BP 130/70, Respiratory rate 16 d. HR 80, BP 100/70, Respiratory rate 28 e. HR 80, BP 110/70, Respiratory rate 18

e. HR 80, BP 110/70, Respiratory rate 18

What causes the ductus arteriosis to close? Select one: a. Increase in PaCO2 b. Decrease in PaCO2 c. Increase in PVR d. Decrease in SVR e. Increase in PaO2

e. Increase in PaO2 The increase of PaO2 causes the ductus arteriosis to close. An increase in oxygen tension decreases PVR, while increasing SVR.

Which of the following local anesthetics is found in EMLA cream? Select one: a. Bupivacaine b. Tetracaine c. Mepivacaine d. Ropivacaine e. Prilocaine

e. Prilocaine EMLA stands for a Eutetic (easily mixed) Mixture of Local Anesthetics. EMLA cream is a 1:1 mix of 2.5% lidocaine with 2.5% prilocaine. It lasts for 1-2 hours and should only be used on intact skin and not mucous membranes. After application, it may take up to an hour before adequate analgesia is obtained.

Of the following, choose the incorrect statement regarding the benefits of using a circle system with mechanical ventilation: Select one: a. Can use low gas flows b. Conserves heat c. Conserves humidity d. Conserves anesthetic agent e. System components do not add to airway resistance

e. System components do not add to airway resistance

In which of the following conditions is the patient the most likely to have a latex allergy? Select one: a. Gastroschisis b. Omphalocele c. Pyloric stenosis d. Congenital diaphragmatic hernia e. Spina bifida

e. spina bifida Children with spina bifida, congenital urologic abnormalities, or cerebral palsy with ventriculoperitoneal shunts are at greatest risk. Related to repeated exposure to rubber products during surgery and other procedures such as catheterization. Even with negative reactions to latex in past, the potential for allergic reaction always exists. Health care personnel and those with a history of atopy also are at higher risk.