Pediatric Anesthesia

Questions

DIRECTIONS (Questions 310-396): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

310. Preoperative evaluation of a 4-year-old boy for myringotomy and placement of tympanostomy tubes is concerning for possible difficulty with airway management. Physical exam reveals micrognathia, glossoptosis, and cleft palate. What is the most likely diagnosis?

(A) Beckwith Syndrome

(B) Goldenhar Syndrome

(D) Treacher Collins Syndrome

(E) Trisomy 21

311. A 2-year-old child is rushed to the trauma room for a laparotomy after sustaining multiple injuries in a motor vehicle accident. The child arrives intubated and pharmacologically paralyzed. The child is tachycardic, mildly hypotensive, and hypothermic. All of the following may be consequences of unintended, intraoperative hypothermia EXCEPT

(A) decreased oxygen consumption

(B) increased metabolic rate

(D) pulmonary hypertension

(E) hypoglycemia

312. A newborn infant born at 33 weeks gestational age presents for gastroschisis repair. In preparing medications for this patient, all of the following are considerations that will affect your medication selection EXCEPT

(A) increased ventilatory depression from maternally administered opioids

(B) immature blood brain barrier

(D) increased sensitivity to CNS toxicity of lidocaine

(E) immature enzyme systems for drug metabolism

313. A 3-week-old infant, born at 38 weeks gestational age, weighing 4 kg, presents for a Ladd’s procedure. In order to request the appropriate amount of blood, you would like to know the allowable blood loss for this patient. What is the blood volume of this patient?

(A) 160 mL

(B) 200 mL

(D) 280 mL

(E) 320 mL

314. A 6-year-old boy presents to the holding area for elective repair of an inguinal hernia. He is a mild asthmatic and has not taken any daily asthma medications for 5 weeks. He is currently wheezing throughout on physical exam. You inform the mother that you will

(A) proceed with surgery without treatment

(B) postpone until tomorrow after 2 doses of montelukast

(D) proceed with surgery after albuterol

(E) perform surgery with sedation and analgesia with local infiltration

315. A 2-year-old child has suffered extensive burns to his head, neck, and torso. What percentage of his body has been affected?

(A) 30% of total surface area

(B) 35% of total surface area

(D) 45% of total surface area

(E) 50% of total surface area

316. A neonate presents with respiratory distress, a scaphoid abdomen, and absent breath sounds on the left side of the chest. The incidence of this congenital lesion is 1 in 2000-5000 live births. Which one of the following statements is true?

(A) Mortality in infants with this lesion is 50-70%.

(B) 70% of all lesions involve the foramen of Bochdalek.

(D) 30% of infants with this lesion have an accompanying congenital cardiac lesion.

(E) Approximately 5% of infants with this lesion present with symptoms of bowel obstruction.

317. A 3-month-old African-American baby is scheduled for elective repair of an inguinal hernia. He has an older brother with sickle cell anemia, but he has not had any diagnostic tests for sickle cell anemia. His hematocrit is 30%. This baby

(A) almost certainly has sickle cell anemia

(B) should receive a preoperative transfusion

(D) may undergo anesthesia safely without further testing

(E) has a 50% chance of having sickle cell anemia

318. A 10-day-old infant, born at 27 weeks gestational age, weighing 1,100 g at birth, is noted to have clinical signs and symptoms of peritonitis and intestinal obstruction. The patient has had increasing oxygen requirements over the past 48 h, and has been becoming progressively more tachypneic. The patient is also thrombocytopenic, and has developed metabolic and respiratory acidosis. Which one of the following statements is true of this patient’s likely diagnosis?

(A) It is an anomaly found predominantly in premature infants.

(B) Umbilical artery catheterization should be performed in order to monitor hematologic and metabolic abnormalities.

(D) Cardiovascular collapse usually occurs early in the course of the illness.

(E) Metabolic abnormalities include hypoglycemia resulting from intestinal malabsorption.

319. A 4-year-old child requires postoperative intubation and sedation in the PICU. It is expected that the child will remain intubated for more than 1-2 d. Which one of the following is the least desirable medication to use for sedation for this period of time?

(A) Midazolam

(B) Morphine

(D) Propofol

(E) Dexmedetomidine

320. A 4-day-old, full term neonate presents for repair of imperforate anus. The baby has no other abnormalities. All of the following are true regarding transitional circulation in this patient EXCEPT

(A) the patient’s pulmonary vascular resistance has decreased relative to the pressures in utero

(B) the patient’s pressures on the left side of the heart have increased relative to the pressures in utero

(D) mechanical closure of the ductus arteriosus has occurred in this patient

(E) events during anesthesia may cause a return to fetal circulation

321. A 1-month-old infant, born at 35 weeks gestational age, presents for inguinal hernia repair. The patient no longer requires oxygen and no longer demonstrates episodes of apnea and bradycardia. A spinal anesthetic is performed with tetracaine and then the patient is positioned for surgery. During positioning the patient’s legs are inadvertently raised up above the patient’s torso. What is the most likely clinical sign that will be seen in the patient?

(A) A decrease in oxygen saturation

(B) Agitation or irritability

(D) An increase in heart rate

(E) Loss of consciousness

322. A 2-year-old child (weight 13 kg) is scheduled for circumcision. The most suitable dose of local anesthetic for a dorsal penile block is

(A) bupivacaine 0.25% 8 mL

(B) lidocaine 1% 8 mL

(D) bupivacaine 0.25% 15 mL

(E) bupivacaine 0.125% 15 mL

323. Preoperative assessment of a healthy pediatric patient shows the patient to be normotensive with a blood pressure of 82/54. What is the likely age of this patient?

(A) full term neonate

(B) 4 months

(D) 12 months

(E) 18 months

324. A 3-year-old healthy child presents preoperatively for elective repair of an umbilical hernia. The mother informs you that the child had 4 ounces of apple juice 2 h ago. You recommend

(A) to cancel surgery

(B) to delay surgery by 2 h

(D) to delay surgery by 6 h

(E) to proceed with surgery now

325. In the delivery room, after birth, an infant is noted at 1 min to be blue, motionless and unresponsive, with minimal respiratory effort, and heart rate of 70 bpm. At 5 min after birth, the infant is centrally pink with blue extremities, demonstrates some flexion at the hips and slight grimacing to stimulation, still has minimal respiratory effort, and a heart rate of 80 bpm. Initial resuscitation should include all of the following EXCEPT

(A) oxygen

(B) radiant heat

(D) glucose

(E) bicarbonate

326. A newborn has Apgar scores of 4 and 5 at 1 and 5 min, respectively, and requires resuscitation, including intubation, after birth. Which one of the following is the most significant factor associated with lack of closure of the ductus arteriosus in this patient?

(A) Increased PaCO₂

(B) Decreased PaCO₂

(D) Decreased PaO₂

(E) Increased pulmonary artery pressure

327. A 5-month-old infant is anesthetized for correction of an eye condition. Immediately after intubation, bilateral breath sounds and chest excursion are noted and there is 100% oxygen saturation with an FIO₂ of 0.5. After positioning for surgery, the oxygen saturation is noted to have dropped to 94%, no other changes having been made. The most likely cause for this fall in oxygen saturation is

(A) a kinked endotracheal tube

(B) bronchospasm

(D) inspissated secretions plugging the tube

(E) anesthesia machine failure

328. A 20-month-old child presents for removal of a swallowed foreign body. The child is crying intermittently, and is reluctant to separate from his father for any length of time. The child is drooling significantly and appears unable to swallow his secretions, but is not in respiratory distress. He complains of a sore throat. Which one of the following is the most appropriate premedication and route for this patient?

(A) Oral midazolam

(B) Nasal midazolam

(D) Oral fentanyl

(E) Oral ketamine

329. A neonate is noted to have a murmur. The patient is not cyanotic, but is noted to have dyspnea, tachypnea, and diaphoresis with eating. What is the most likely congenital cardiac defect?

(A) Atrial septal defect

(B) Ventricular septal defect

(D) Coarctation of the aorta

(E) Transposition of the great arteries

330. An infant is undergoing general anesthesia for pyloromyotomy. A rapid sequence induction was performed with propofol and succinylcholine. Anesthesia was maintained with sevoflurane in oxygen and air. After induction the patient was noted to be tachycardic. During the surgery, the patient is noted to become more tachycardic with a rise in end tidal CO₂, and an increase in temperature as measured with nasopharyngeal temperature probe. You are concerned that this could be malignant hyperthermia. Of the following signs and symptoms, which one is the most common first sign of malignant hyperthermia?

(A) Cyanosis

(B) Dark-colored urine

(D) Arrhythmia

(E) Hot circle absorber

331. An 11-month-old, 10-kg infant presents for hypospadias repair. The child is otherwise healthy. An LMA is placed after induction and the patient is then ventilated with tidal volumes of 80 mL. What percentage of that volume is respiratory dead space in this patient?

(A) 5%

(B) 10%

(D) 30%

(E) 40%

332. Your institution is evaluating various pediatric warming devices in order to choose the most effective for use in your operating room. Which one of the following statements is true of the available pediatric warming devices?

(A) When using radiant warmers, core temperature should be measured to prevent skin burns.

(B) Circulating water blankets are not very useful in children smaller than 10 kg due to the decreasing ratio of body surface area to body mass.

(D) Use of heat moisture exchangers is an efficient way to increase a child’s body temperature.

(E) Circulating water blankets work by convection and therefore, they should not be directly in contact with the skin.

333. A healthy 5-month-old presents for repair of an umbilical hernia. Induction of anesthesia is uneventful and surgical preparation and draping are completed. At incision it is noted that the patient’s temperature is 34.9°C. The patient had a normal temperature in the preoperative area. The most important factor in the operating room contributing to the patient’s current temperature is which one of the following?

(A) Body temperature on arrival to the operating room

(B) Room temperature

(D) Use of cold fluids

(E) Temperature of prep solutions

334. A neonate presents for repair of an inguinal hernia. The plan is for a spinal anesthetic. The parents are agreeable to a spinal but are concerned about injury to the infant’s spinal cord. You explain to the parents the technique for spinal in a neonate and how to minimize the chance of injury to the spinal cord, emphasizing that the conus medullaris is located at which one of the following levels in the neonate?

(A) First lumbar vertebra

(B) Second lumbar vertebra

(D) Fourth lumbar vertebra

(E) Fifth lumbar vertebra

335. A 4-year-old previously healthy child presents for repair of a femur fracture. The plan is for an inhalational induction followed by placement of a peripheral IV and then intubation. Which one of the following is the most appropriate size uncuffed endotracheal tube for this child?

(A) 3.5 mm

(B) 4.0 mm

(D) 5.0 mm

(E) 5.5 mm

336. An 18-month-old child presents for repair of tetralogy of Fallot. During the procedure, prior to cardiopulmonary bypass, the child’s blood pressure is noted to decrease over several minutes from 88/57 to 76/41. All of the following are true EXCEPT

(A) the patient’s Spo₂ will likely decrease with this decrease in blood pressure

(B) phenylephrine is a useful medication to increase blood pressure in this patient

(D) if the blood pressure continues to fall, the surgeon should be asked to apply pressure to the aorta.

(E) ephedrine is not a useful medication to increase blood pressure in this patient

337. A child is admitted with an incarcerated inguinal hernia. The child has nasal congestion and discharge, with a productive cough. The child is afebrile and lung sounds are clear to auscultation bilaterally. Which one of the following is the most appropriate way to proceed?

(A) The surgery should be cancelled.

(B) The surgery should be allowed to proceed, but the child should not be intubated.

(D) The surgery should proceed with careful monitoring.

(E) The patient should be operated on only under spinal anesthesia.

338. A neonate presents for repair of myelomeningocele. The neonate was born full term. All of the following are true regarding anesthetic technique and surgery for this patient EXCEPT

(A) supine position should be avoided and therefore the patient should be intubated in the lateral position

(B) succinylcholine may be used safely in this patient

(D) spinal anesthesia is a possible technique for this patient

(E) this patient will likely need a ventriculoperitoneal shunt

339. A 6-year-old, 24-kg child presents for a cyst removal. The child has been NPO since midnight and it is now 0800. What is this child’s approximate fluid requirement for the fasting deficit?

(A) 190 mL

(B) 240 mL

(D) 510 mL

(E) 580 mL

340. A 12-year-old patient with sickle cell disease presents for an exploratory laparoscopy and possible laparotomy. The patient is otherwise healthy and has not had a vaso-occlusive crisis in several months. Preparation of this patient for surgery should include all of the following EXCEPT

(A) transfuse to a hemoglobin level of 15 g/dL

(B) treat infection

(D) provide good pulmonary care

(E) avoid stasis of blood flow

341. A 6-week-old baby born at 34 weeks gestation presents in the holding area for elective repair of an inguinal hernia. The parents believe that they will be taking their child home today after surgery. You inform them

(A) they may take their child home today

(B) the child may have to stay for several hours

(D) the child will be admitted for 23 h of apnea monitoring

(E) the child will need apnea monitoring at home tonight

342. A 7-year-old, 35-kg girl is scheduled for excision of a large intraabdominal mass. Her starting hematocrit is 36% and the minimally acceptable hematocrit is 24%. How much blood could the patient lose before transfusion is necessary?

(A) 250 mL

(B) 450 mL

(D) 950 mL

(E) 1100 mL

343. A 3-year-old child presents emergently for repair of an incarcerated inguinal hernia. The patient was recently diagnosed with hypothyroidism and started treatment less than one week ago. All of the following may be encountered in this patient while undergoing anesthesia EXCEPT

(A) hypothermia

(B) hypoventilation

(D) small mouth and large tongue

(E) hyperkinetic myocardium

344. A 7-year-old patient with Down syndrome is admitted for dental extractions. Additional medical history includes well-controlled asthma. The patient had myringotomy and ear tubes in the past without problems. In providing anesthesia for this patient, which one of the following is true?

(A) Atropine should be avoided.

(B) Opioids should be avoided.

(D) Intubation should be avoided.

(E) Neuromuscular blockers should be avoided.

345. A 5-year-old boy is admitted with an open eye secondary to severe globe laceration. He had eaten 1 h before his accident. General anesthesia is required for the repair. The intubation should be accomplished

(A) by an awake intubation

(B) after injection of 100 mg of succinylcholine

(D) after vecuronium administration

(E) after inhalation induction with sevoflurane

346. A 1-day-old child presents with coughing and choking at his first feed. Following investigation, a diagnosis of tracheoesophageal fistula (TEF) is made. Which one of the following statements is true?

(A) Esophageal atresia is associated with tracheoesophageal fistula in 10% of cases.

(B) Air leak through the fistula is minimized with paralysis.

(D) Sump suction is maintained in the esophageal pouch to lessen the risk of aspiration.

(E) 10% of infants with TEF have the associated anomalies of VATER syndrome.

347. Nonanesthetized newborns and infants rely on nonshivering thermogenesis to help maintain body temperature. All of the following are true of nonshivering thermogenesis EXCEPT

(A) it refers to the increased metabolism of brown fat

(B) brown fat is highly vascularized and contains an abundance of mitochondria

(D) brown fat comprises 25% of the infant’s total body weight

348. A neonate develops respiratory distress soon after birth. A chest radiograph demonstrates hyperinflation of the left lung, with herniation across the midline and mediastinal shift, and atelectasis of the right lung. Which one of the following statements is true?

(A) The right lower lobe is most commonly affected in patients with this congenital malformation.

(B) Neonates with this congenital malformation usually present with cardiovascular collapse due to mediastinal shift.

(D) Neonates with this congenital malformation should be treated with assisted ventilation as soon as possible in order to improve gas exchange.

(E) Differential diagnosis of this congenital malformation includes congenital cystic lesions and congenital diaphragmatic hernia.

349. A full term neonate is scheduled for inguinal hernia repair. The anesthetic plan is for spinal anesthesia. Which one of the following statements is true of spinal anesthesia in the neonate?

(A) It is suitable as the sole technique of anesthesia for procedures lasting 2 h or more.

(B) The apex of the conus medullaris is usually at L2-L3.

(D) Tetracaine 0.4 mg/kg is a suitable dose for subarachnoid block.

350. A newborn, born at 31 weeks gestational age, develops nasal flaring, chest retractions, and grunting soon after birth. Chest radiograph demonstrates diffuse atelectasis. The most likely diagnosis is

(A) bronchopulmonary dysplasia

(B) patent ductus arteriosus

(D) hyaline membrane disease

(E) tracheoesophageal fistula

351. A 32-year-old woman with recently diagnosed preeclampsia delivers a baby at 39 weeks gestational age. During labor and delivery, it was noted that the amniotic fluid was heavily stained with meconium. Apgar scores for this neonate are 7 and 8 at 1 and 5 min, respectively. Which one of the following statements is true?

(A) This neonate will most likely develop respiratory difficulties in the first few days of life.

(B) This neonate has a very high risk for developing radiographic evidence of pneumothorax.

(D) Absence of meconium in the mouth and pharynx precludes the presence of meconium in the trachea.

(E) Meconium is an indication of fetal distress.

352. A neonate, who was born at 36 weeks gestational age with gastroschisis and has undergone staged reduction of the defect, presents for final closure in the operating room. When planning for fluid management for this patient, all of the following are important considerations for this patient EXCEPT

(A) maturation of renal function is more rapid in full term compared to preterm infants

(B) the glomerular filtration rate of this patient is less than 20% of the adult value

(D) the glomerular filtration rate reaches the adult value by about 1-2 years of age

(E) potassium excretion is much less efficient in neonates compared to adults

353. A 4-year-old child is brought to the emergency department at 1 a.m. She was put to bed in apparently good health, but awoke four hours later crying and having difficulty breathing. Physical examination reveals that the child is flushed, drooling, sitting upright, and has severe inspiratory stridor. Which one of the following statements is true?

(A) The most likely diagnosis is acute laryngotracheobronchitis.

(B) A possible diagnosis is croup.

(D) The child should be taken straight to the operating room for intubation/emergency tracheostomy.

(E) It is important to place an IV prior to induction in this patient.

354. A neonate undergoes inhalation induction with 7% sevoflurane. A peripheral IV is placed and the patient is then intubated. Soon after induction and intubation the patient is noted to be mildly hypotensive. The hypotension may be explained by the fact that the cardiac output

(A) may decrease significantly because of decreases in stroke volume

(B) is not very sensitive to changes in afterload

(D) is reflected by a rightward shift of the cardiac function curve as compared to the adult

(E) may decrease significantly due to decreases in heart rate

355. A full term neonate presents for bilateral inguinal hernia repair. General anesthesia with an endotracheal tube is planned. All of the following are true of this patient’s airway EXCEPT

(A) a 3.0-mm endotracheal tube is a suitable first choice for this patient

(B) pressures of 30 cm H₂O are usually required for adequate IPPV

(D) positive pressure ventilation should be conducted at a rate of about 30-60 breaths per minute

(E) the narrowest part of this patient’s airway is at the cricoid ring

356. A newborn presents for repair of omphalocele. All of the following are true of this defect EXCEPT

(A) it is a central midline defect

(B) it is a congenital defect originating in the first trimester of pregnancy

(D) it is associated with a high incidence of congenital abnormalities

(E) the herniated bowel is covered by the amnion

357. A newborn presents for repair of myelomeningocele. During maintenance of anesthesia, end tidal isoflurane is 0.9%. A colleague offering you a break comments on the end tidal isoflurane and expresses concern that the patient is not receiving adequate anesthesia. You explain that the concentration is adequate for the patient for all of the following reasons EXCEPT

(A) neonates have an immature nervous system

(B) neonates have an immature blood–brain barrier

(D) neonates have elevated blood levels of β-endorphin

(E) neonates have immature liver function

358. A 10-month-old with septic arthritis presents for placement of a central venous catheter for a course of antibiotics. The patient has a peripheral IV in place. The patient is preoxygenated, undergoes IV induction followed by intubation. During intubation it is noted that the Spo₂ decreases from 100% to 86%. The reason for this rapid desaturation compared with adults is due to which one of the following?

(A) High respiratory rate

(B) High oxygen consumption

(D) Small expiratory reserve volume

(E) Small tidal volume (TV)

DIRECTIONS: Use the following scenario to answer Questions 359-360: A 2-year-old child presents for repair of a ventricular septal defect. Preoperative evaluation reveals congestive heart failure, failure to thrive, and a pulmonary:systemic flow ratio greater than 2:1.

359. Which one of the following is the most appropriate induction technique?

(A) Halothane dialed to 6% on the vaporizer in 100% oxygen.

(B) Sevoflurane dialed to 6% on the vaporizer in 100% oxygen

(D) Ketamine 2 mg/kg with fentanyl 2 mcg/kg

360. If shunt reversal occurs intraoperatively, which one of the following is an appropriate treatment?

(A) Ketamine

(B) α-adrenoceptor agonists

(D) High inhaled concentrations of volatile anesthetics

361. In a full term, 4-kg neonate, which one of the following is true regarding body fluid?

(A) Total body water (TBW) constitutes approximately 3 kg of this patient’s weight.

(B) Extracellular fluid (ECF) accounts for approximately 2.5 kg of this patient’s weight.

(D) Intracellular fluid accounts for approximately 2.5 kg of this patient’s weight.

362. Fetal circulation is characterized by right to left shunting across the ductus arteriosus and the foramen ovale. Fetal circulation progresses to transitional circulation with birth that is characterized by which one of the following?

(A) Complete closure of the ductus arteriosus

(B) Complete closure of the foramen ovale

(D) Decreased systemic vascular resistance

363. A 3-week-old neonate, born at 32 weeks gestational age presents for exploratory laparotomy for likely bowel obstruction. During the procedure vecuronium is used for muscle relaxation. After the initial dose of vecuronium given at induction, the patient was noted to be breathing spontaneously during preparation and draping for surgery. An additional dose of vecuronium was given prior to the start of surgery, and it was noted that the patient did not recover from this dose as rapidly as from the initial dose. Which one of the following explains the reason for the prolonged recovery from the second dose of muscle relaxant?

(A) Blood brain barrier

(B) Volume of distribution

(D) Metabolism

(E) α₁-acid glycoprotein concentrations

364. A 5-week-old, 4-kg infant presents for open pyloromyotomy. Electrolyte abnormalities were corrected preoperatively. The patient was born full term and is otherwise healthy. General anesthesia is induced with propofol 15 mg and rocuronium 6 mg. No opioid is administered and the surgeon injects local anesthesia at the incision site. At the conclusion of the case, neostigmine 0.1 mg and glycopyrrolate 0.02 mg are administered. The patient is awake, but appears weak and with spontaneous breathing has tidal volumes of 6-8 mL. All of the following could explain this patient’s persistent weakness EXCEPT

(A) musculature is poorly developed

(B) muscle mass is less

(D) total body water is greater

(E) inadequate dose of neostigmine

365. At the conclusion of a gastroschisis repair, arrangements are made to transport the patient, intubated, to the ICU. The surgeon requests that the patient remains paralyzed and that you continue with controlled ventilation. Which one of the following is the best circuit to use for transport of this patient to the ICU?

(A) Mapleson A

(B) Mapleson B

(D) Mapleson D

(E) Mapleson E

366. During resuscitation of a newborn with an Apgar score of 2 at 2 min, sodium bicarbonate is administered. All of the following are potential side effects of sodium bicarbonate EXCEPT

(A) metabolic alkalosis

(B) hypernatremia

(D) hyperglycemia

(E) hyperosmolality

367. You are called to help evaluate a neonate who has presented to the emergency department with respiratory distress. The child is breathing >50 breaths per min and has sternal and subcostal retractions. All of the following contribute to increased work of breathing in this neonate EXCEPT

(A) overcoming elastic forces

(B) overcoming resistive forces

(D) increased respiratory rate

(E) radius of the infant’s airway

368. During anesthesia for a previously healthy infant having a spica cast placed, you note that the patient periodically has mild desaturations that respond well to recruitment maneuvers. Which one of the following best explains why infants are prone to airway collapse and atelectasis?

(A) Closing capacity is greater than functional residual capacity.

(B) Closing capacity is greater than residual volume.

(D) Closing capacity is greater than expiratory reserve volume.

(E) Closing capacity is greater than vital capacity.

369. An infant presents for emergent repair of coarctation of the aorta. The infant was born full term, had no problems after delivery and went home on day 2 of life. All of the following are associated with coarctation of the aorta EXCEPT

(A) ventricular septal defect

(B) bicuspid aortic valve

(D) mitral valve abnormalities

(E) pulmonic stenosis

370. A 4-year-old child with a history of upper airway obstruction undergoes tonsillectomy and adenoidectomy. The child is otherwise healthy. The surgery and anesthesia are uneventful and the patient is extubated easily and without complication in the operating room at the conclusion of surgery. In recovery, the patient is noted to have symptoms consistent with postintubation laryngeal edema. The treatment for this should include all of the following EXCEPT

(A) inhalation of mist

(B) parenteral glucocorticoids

(D) sedation

(E) head up position

371. A 4-week-old, 4-kg child presents with several days of nonbilious, projectile vomiting and inability to tolerate feeds. The child was born full term, had no problems after birth and went home on day 2 of life. The patient has had decreased urine output and a metabolic panel demonstrates multiple metabolic derangements. The next step in management is

(A) proceed to the operating room for emergent repair of the lesion

(B) start an IV and give 20 mL/kg of lactated Ringer solution, then proceed to the operating room for repair of the lesion

(D) admit the patient to the floor, start IV hydration, and check a metabolic panel several hours later

(E) administer an antiemetic such as ondansetron

DIRECTIONS: Use the following scenario to answer Questions 372-373: A 4-year-old child presents to the emergency department with acute onset of a high fever, sore throat, stridor, dysphagia, and drooling. The patient is sitting up and appears anxious.

372. The most likely diagnosis is

(A) laryngotracheobronchitis

(B) epiglottitis

(D) laryngeal papillomatosis

373. Treatment includes all of the following EXCEPT

(A) humidified oxygen

(B) glucocorticoids

(D) intubation

(E) hydration

374. A 14-year-old girl presents to the emergency department with wheezing and hemoptysis. A history reveals solvent abuse. All of the following are possible physiological derangements in this patient due to solvent abuse EXCEPT

(A) hepatic dysfunction

(B) peripheral neuropathy

(D) neutropenia

(E) methemoglobinemia

375. A 20-month-old child with a ventricular septal defect presents with dyspnea, tachypnea, and decreased activity tolerance. The patient is tachycardic with Spo₂ of 90-93%. All of the following are mechanisms that may explain this patient’s presentation EXCEPT

(A) decreased pulmonary vascular resistance

(B) obstruction of the left main stem bronchus by the left atrium

(D) increased interstitial and alveolar lung water

(E) elevated left atrial pressure

376. A neonate with a diagnosis of Pierre Robin syndrome presents for anesthesia. Which one of the following preoperative evaluations is indicated in this patient in the setting of this syndrome?

(A) Cardiac echo

(B) Chest x-ray

(D) MRI of the spine

(E) Lumbar puncture

377. An infant born at 29 weeks is brought to the operating room for laser treatment for retinopathy of prematurity. The infant was intubated for the first two weeks of life. Which one of the following statements about retinopathy of prematurity (ROP) is true?

(A) ROP is related to incomplete vascularization of the retina at birth.

(B) ROP is directly related to the FIO₂.

(D) ROP occurs only after exposure to hyperoxemia for at least 24 h.

(E) ROP does not occur in full term infants.

378. A 5-year-old patient exhibits symptoms of subglottic edema in the recovery area. The patient has a history of mild asthma, abdominal pain, chronic constipation, and is obese. The patient underwent an upper endoscopy and colonoscopy under general anesthesia. The patient was intubated after three attempts and the remainder of the procedure and anesthesia was uneventful. All of the following statements about subglottic edema are true EXCEPT

(A) it is more common in pediatric than adult patients

(B) it may be prevented with use of steroid cream on the endotracheal tube

(D) it is associated with changes in position during the procedure

(E) it is associated with multiple attempts at intubation

379. A 2-week-old neonate presents for repair of tracheoesophageal fistula (TEF). The patient has proximal esophageal atresia and blind pouch and a distal TEF. All of the following statements are true EXCEPT that

(A) this patient has the most common type of TEF

(B) the incidence of TEF in premature babies is higher than in term infants

(D) the congenital anomalies associated with TEF occur in 30% to 50% of patients

(E) the most common congenital defect associated with TEF is cardiac

380. A 2-year-old child presents for urgent rigid bronchoscopy for likely foreign body aspiration. The child was eating popcorn and was noted to have an episode of choking followed by intermittent coughing. The patient is currently not in any distress. On physical exam, there is diffuse wheezing over the right lung field and it is suspected that the food particle is located in the right mainstem bronchus. Which one of the following is true regarding the management of this child?

(A) After retrieval of the food particle from the right main stem bronchus, investigation of the left mainstem bronchus is still indicated in this case even if no particulate matter is found in the trachea.

(B) As the patient is not in any distress, the procedure should be postponed until the patient is appropriately fasted.

(C) Positive pressure ventilation should not be used as it may cause the foreign body to move more distally in the airway.

(D) The patient should be paralyzed during the removal of the foreign body in order to prevent coughing at that time.

(E) A propofol based total intravenous anesthetic technique should not be used as the patient may become apneic with this.

381. A 5-year-old boy with hypotonic cerebral palsy presents for gastrostomy tube revision. All of the following are complications associated with this disease EXCEPT

(A) joint contractures

(B) scoliosis

(D) epilepsy

(E) recurrent respiratory dysfunction

382. A neonate is found to have a congenital cardiac lesion. The child is cyanotic, has intracardiac shunting, but is not exhibiting signs or symptoms of congestive heart failure. Which one of the following is the most likely diagnosis for this child?

(A) Patent ductus arteriosus

(B) Total anomalous pulmonary venous drainage

(D) Ventricular septal defect

(E) Transposition of the great arteries

383. A 3-year-old child presents with acutely raised intracranial pressure from a blocked ventriculoperitoneal shunt. Surgical alleviation of the problem is planned. Which one of the following is true regarding anesthesia for this patient?

(A) Premedication with intramuscular opioids is beneficial, minimizing further increases in intracranial pressure due to agitation and induction of anesthesia.

(B) Induction of anesthesia with intravenous ketamine 0.5-1 mg/kg is a suitable technique.

(D) Concentrations of isoflurane of up to 1% result in minimal increases in cerebral blood flow.

DIRECTIONS: Use the following scenario to answer Questions 384-385: A 2-year-old child presents to the emergency department with low grade fever, cough, stridor, and dyspnea. The patient had been well until 3 d ago when she developed symptoms of an upper respiratory tract infection.

384. The most likely diagnosis is

(A) laryngotracheobronchitis

(B) epiglottitis

(D) laryngeal papillomatosis

385. Treatment typically includes which one of the following?

(A) Humidified oxygen

(B) Glucocorticoids

(D) Intubation

386. A 4-year-old child with Down syndrome presents for tonsillectomy and adenoidectomy for upper airway obstruction. The child had a ventricular septal defect repaired in the past that was well tolerated. The patient does not have any other congenital abnormalities and neck radiographs are negative for atlantoaxial subluxation. On arrival to the operating room, the child is very agitated and crying. You induce general anesthesia with sevoflurane dialed to 8% and then establish IV access. You note that the patient’s heart rate has decreased from 140 bpm prior to induction to 102 bpm now. You administer propofol 4 mg/kg, fentanyl 1 mcg/kg, and rocuronium 0.5 mg/kg. Just after the patient has been intubated, you note that the heart rate is now 55 bpm with sinus rhythm. What is the most likely cause of this bradycardia?

(A) Propofol

(B) Fentanyl

(D) Sevoflurane

(E) Rocuronium

387. A 4-year-old child with a genetic syndrome presents for tonsillectomy for upper airway obstruction. The child has elfin facies, hypothyroidism treated with levothyroxine, neurodevelopmental delay, repaired aortic stenosis and coarctation of the aorta, and generalized muscle weakness. This child most likely has which one of the following syndromes?

(A) DiGeorge syndrome

(B) Down syndrome

(D) Trisomy 13

(E) Williams syndrome

388. A 2-year-old boy is undergoing an inguinal hernia repair. As part of the anesthetic, you have discussed a single-shot caudal injection with the parents. After an uneventful inhalation induction of general anesthesia, the patient is positioned for the caudal injection. You palpate the patient’s lower back to identify the site for injection. All of the following are landmarks that may be palpated to aid in performing a caudal injection EXCEPT

(A) posterior superior iliac spine

(B) sacrococcygeal ligament

(D) sacral cornu

(E) L4-L5 intervertebral space

389. A 5-year-old boy with cerebral palsy, a seizure disorder controlled with medication, mild asthma, and controlled gastroesophageal reflux presents for ventriculoperitoneal shunt revision. The patient is asymptomatic at this time, but increased head circumference was noted on routine exam. Regarding the anesthetic plan and medications to be used, all of the following are true for this patient EXCEPT

(A) an inhalational induction is contraindicated for this patient

(B) it is acceptable to use succinylcholine for this patient

(D) this patient will require less volatile agent than a child without cerebral palsy

390. You are planning to use normovolemic hemodilution in a 14-year-old patient who will be undergoing correction of idiopathic scoliosis. The child has a history of mild asthma, alpha-thalassemia, and has had surgery and anesthesia before without any problems. In determining weather of not it would be safe to use normovolemic hemodilution in this patient, you consider that all of the following are either relative or absolute contraindications to use of normovolemic hemodilution EXCEPT

(A) sickle cell disease

(B) sepsis

(D) moderate anemia

(E) renal insufficiency

391. You are seeing a 12-year-old girl, accompanied by her mother, preoperatively prior to her having an arthroscopy of her knee. When asking about family history of problems with anesthesia, the patient’s mother state that she has severe postoperative nausea and vomiting (PONV) after general anesthesia and she would like to know what the likelihood is that her daughter will have problems with this after her surgery today. You have a discussion with the patient and her mother about PONV. Which one of the following is true of PONV in pediatric patients?

(A) The incidence of PONV is inversely related to age.

(B) PONV is common in young children.

(D) The type of surgery does not affect the incidence of PONV in children.

(E) The type of anesthesia used does not affect the incidence of PONV in children.

392. An 11-year-old girl presents for laparoscopic cholecystectomy. She is otherwise healthy. Carbon dioxide will be used for insufflation of the abdomen to facilitate surgery. All of the following are side effects of insufflation with carbon dioxide EXCEPT

(A) 25% increase in PaCO₂

(B) increased ventilation/perfusion mismatch

(D) increased venous return

(E) increased systemic vascular resistance

DIRECTIONS (Questions 393-396): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Apert syndrome

(B) Beckwith-Wiedemann syndrome

(D) Ehlers-Danlos syndrome

(E) Gilbert syndrome

(F) Kawasaki disease

(G) Peutz-Jeghers syndrome

(H) Reiter syndrome

(I) Sjögren syndrome

(J) Stevens-Johnson syndrome

(K) Sturge-Weber syndrome

(L) Turner syndrome

(M) von Hippel-Lindau syndrome