EDAIC Pediatric and Neonatal Anesthesia 4 — Questions and Answers
Question 1: What is the recommended glucose-containing fluid strategy for neonates undergoing major surgery?
- Give 10% dextrose as the primary intraoperative fluid
- Use isotonic balanced crystalloid for volume replacement and a separate low-rate glucose infusion (Correct answer)
- Avoid all glucose-containing fluids intraoperatively
- Use 5% dextrose in normal saline as the sole fluid
Correct answer: Use isotonic balanced crystalloid for volume replacement and a separate low-rate glucose infusion
Neonates require a background glucose infusion (4–8 mg/kg/min) to prevent hypoglycemia, while isotonic fluid is used separately for deficit and blood loss replacement.
Question 2: A child develops stridor immediately after extubation. The FIRST step in management is:
- Reintubate immediately
- Administer IV dexamethasone
- Apply 100% oxygen and CPAP/jaw thrust (Correct answer)
- Give nebulized racemic epinephrine
Correct answer: Apply 100% oxygen and CPAP/jaw thrust
Initial management of post-extubation stridor is supportive: 100% oxygen, continuous positive airway pressure, and positioning to relieve obstruction.
Question 3: What anatomical feature makes bag-mask ventilation more challenging in neonates compared to adults?
- Smaller mandible causing tongue obstruction
- Larger occiput that flexes the neck when supine (Correct answer)
- Higher laryngeal position (C3-C4) causing a sharper airway angle
- Softer tracheal cartilage prone to compression
Correct answer: Larger occiput that flexes the neck when supine
The large occiput of neonates causes neck flexion when supine, which occludes the airway; a small shoulder roll is used to achieve neutral or sniffing position.
Question 4: Which regional anesthetic technique is most appropriate for providing postoperative analgesia after lower abdominal surgery in a neonate?
- Lumbar epidural via caudal approach (Correct answer)
- Paravertebral block
- Femoral nerve block
- Transversus abdominis plane block
Correct answer: Lumbar epidural via caudal approach
Caudal epidural block via the sacral hiatus is technically simple, reliable, and the most commonly used regional technique for lower abdominal and perineal surgery in neonates.
Question 5: A 3-year-old child weighing 15 kg receives a caudal block with 0.25% bupivacaine. What is the maximum safe volume using the Armitage formula for mid-abdominal coverage?
- 0.5 mL/kg (7.5 mL)
- 1.0 mL/kg (15 mL) (Correct answer)
- 1.25 mL/kg (18.75 mL)
- 1.5 mL/kg (22.5 mL)
Correct answer: 1.0 mL/kg (15 mL)
The Armitage formula recommends 1.0 mL/kg for mid-abdominal dermatomal coverage in caudal epidural blocks in children.
Question 6: What is the primary concern with using nitrous oxide in neonates with suspected bowel obstruction?
- Increased risk of laryngospasm
- Diffusion into air-filled spaces causing bowel distension (Correct answer)
- Cardiotoxicity in the neonatal myocardium
- Impaired hypoxic pulmonary vasoconstriction
Correct answer: Diffusion into air-filled spaces causing bowel distension
Nitrous oxide diffuses into closed air-containing spaces 30 times faster than nitrogen exits, causing distension of obstructed bowel loops and worsening the surgical field.
Question 7: Which condition is most likely to cause unexpected perioperative hyperkalemia in a pediatric patient?
- Succinylcholine administration in a child with an undetected myopathy (Correct answer)
- Rapid transfusion of packed red blood cells
- Metabolic alkalosis from pyloric stenosis repair
- High-dose sevoflurane causing renal impairment
Correct answer: Succinylcholine administration in a child with an undetected myopathy
Succinylcholine can trigger massive potassium release from abnormal muscle membranes in undiagnosed myopathies, causing life-threatening hyperkalemia.
EDAIC Pediatric and Neonatal Anesthesia 4
What is the recommended glucose-containing fluid strategy for neonates undergoing major surgery?