*part Ii All Saqs

Front 1

(Oct-2012 Q5) You are asked to assess a 4 year old child who is scheduled for a strabismus correction as a day case procedure. 1. What are the issues relevant to anaesthesia (70%). 2. What would prevent you from discharging this patient home after surgery? (30%).

Back 1

a)
Patient Fx
- may have associated syndrome, and potentially epilepsy, cardiac anomalies, etc.
- may be associated with condition with difficult intubation (mucopolysaccharidosis)
- 4yo child, who may be anxious (with parents), need to consider premedication, and parental presence on induction, as well as IV vs Gas induction if patient cooperative
- any other risk fx for PONV? (past hx or family hx, age >3)

Anaesthetic Fx
- Remote airway access, use of LMA vs ETT in this situation
- potentially stimulating procedure, so need adequate depth, and intraop analgesia
- postop analgesia can be by surgical LA infiltration
- risk of oculocardiac reflex (bradycardia), and need for treatment
- high risk of PONV, due to type of surgery, duration of surgery, and age of child (~55% risk, as per SAMBA guidelines). Therefore antiemetic prophylaxis is vital (ie, dexamethasone 0.1mg/kg, ondansetron 0.1mg/kg), +/- TIVA and No N2O.
- potential for emergence delerium

Surgical Fx
- need for adequate conditions (depth, still)
- stimulating, PONV

b)
Pt must meet criteria for discharge from day surgery as per ANZCA professional document. These include Pt/Social Fx.
Social
- has to have responsible/mature parents/carers that understand discharge instructions
- lives within 60 mins of medical care
- has telephone

Patient
- low risk of airway, bleeding probs (in this situation)
- analgesia ok
- PONV controlled
- alimentation (has at least tolerated fluids)
- passed urine?
- mobilised (if usually applies to child, not necessarily relevant to paed practice).

Front 2

(Apr-2009 Q13) Outline the steps you would take to ensure the safe introduction of elective paediatric surgery at your local private hospital.

Back 2

Requires a multi-disciplinary approach, with surgical, anaesthetic, nursing and administrative involvement.
- consultation with appropriate regulatory authorities (levels of government)
- committee of above groups to commence planning, implementation, and SCOPE of practice
- write protocols for care
* day surgery as per ANZCA guidelines (ie, considering age, ASA, etc)
* other day surgery protocols
* protocols for ALS, pain, PONV, discharge for Paed patients
- consideration of facilities for paed pts / parents
* pre-admission, consultation rooms, PACU, wards
- someone to advise on and be responsible for paed equipment
* airway
*breathing circuits
* IV's, BP cuffs, fluids, drugs
- ensuring staff (surgeons, anaesthetists, nurses, anaesthetic assistants) are credentialled and appropriately trained for paeds, and trained as per ANZCA guidelines
- liason and consultation with tertiary facility, specifically for advice/transfer of patients unable to be cared for in private facility
- graded implementation, and ongoing audit/review to improve

Front 3

(Oct-2008 Q7) A 6yo girl with severe spastic cerebral palsy presents for orthopaedic surgery to correct lower limb deformities. Outline the implications of cerebral palsy for anaesthesia management for this operation.

Back 3

CP is a non-progressive disorder of motor and posture resulting from a cerebral insult pre/peri/post-natally or even during infancy. May be spastic, dyskinetic, ataxic or mixed.

Implications
- A
Risk of aspiration on induction due to high frequency of GORD. RSI uncommonly used however, due to difficulties with pre-induction IV access and cooperation.
- B
possible chronic aspiration, poor cough, restrictive lung disease due to chest wall spasticity / SCOLIOSIS. Means ETT likely required for airway protection, suction, and care with oversedation/opioids in postoperative period due to risk of sedation/respiratory depression
- C
Risk of blood loss from osteotomies, need to monitor blood loss and fluid resuscitate
- D
may have cognitive impairment, amking periop communication difficult (ie, induction, emergence, and postop pain assessment).
potentially painful procedure, and may not be able to use PCA if CI.
- E
"large neonate", with thin skin, and potential for periop hypothermia (which may cause poor wound healing, coagulopathy, and slow emergence/sedation). Need to keep warm with FAW, warm fluids, etc.
- F
sensitivity to opioids/sedatives
painful operation, so useful to use regional technique such as epidural (with LA +/- fentanyl +/- clonidine, run at 0.1-0.2ml/kg/hr).
G - GORD and risk aspiration mentioned. risk of PONV after surgery (esp opioids and duration).
J - risk of contractures, and pressure areas with difficult positioning/padding/IV access

Front 4

(May-2008 Q8) You are asked to provide assistance to resuscitate a baby. One minute after birth the baby is apnoeic, grey/blue all over, floppy and unresponsive to stimulation, with a pulse felt at the umbilical stump of 60/min. What is this baby's APGAR score? Describe your resuscitation of the baby.

Back 4

The APGAR is 1. APGAR score is calculated at 1 and 5 minutes, and uses
* Colour
* Tone
* Resp effort
* HR
* "Reflex irratibility"
To give score out of 10.

The resuscitation of this neonate should follow neonatal resusc guidelines, and follow an A, B, C approach.

1) Is baby TERM, CRYING/BREATHING, and has TONE? THen goes straight to mum. If not, needs further ax.
1st 30 secs is to stimulate, dry, etc, and ax HR/Resp effort.
*A
Airway should be cleared
* B
PPV should be instituted if no resp effort +/- HR<100.
CPAP is gasping/poor resp effort. And sats monitoring.
* C
if initial HR < 60, chest compressions should be commenced (rate 3:1 breath), with 2 fingers.

2) after 1 min, if HR < 100, then ventilation should be corrected to ensure adequacy (ie, OPA, higher pressures, even intubation).
if HR < 60, start compressions.

If starting compressions, IV access should be attempted.
- fluid 10ml/kg
- adrenaline 10mcg/kg (0.1ml of 1:10,000)
100% oxygen should be given at this stage.

If term, neonate is likely to require a 3-3.5 ETT, and is approx 3-3.5kg.

further care involves checking for pneumothorax, hypovolemia, or other abnormalities.

post- resuscitation care should continue in NICU or SCN (depending on resusc needed), and family should be informed.

Front 5

(May-2008 Q11) You are the anaesthetist at a childrens' hospital. A 3yo schedules for dental restoration and extractions is found to have a systolic murmur during your preoperative assessment on the day of surgery. They have been on a waiting list for 6 months and have had a dental abscess that settled with antibiotics. Describe how you would evaluate the significance of this murmur and how this decision would affect your decision to proceed or not with surgery.

Back 5

only 1% of murmurs are from CHD. The aim is to differentiate from the children with CHD that need evaluation and treatment prior to elective surgery, from those with innocent murmurs.

Evaluate by Hx, Ex, Ix and Consultation.

- Hx
"well" child, any comorbidities or syndromic, recurrent chest infections
hx of poor feeding, FTT, poor ability to keep up with peers in terms of playing/exercise
hx of blue spells, squatting
family hx of cardiac conditions (ie, HOCM)

-Ex
general appearance, cyanosis (sats)
pulses (4 limbs - coarctation)
signs of heart failure (lung creps, hepatomegaly, oedema)
Murmur
* timing (late systolic, pansystolic bad)
* quality (loud, harsh)

- Ix
ECG. look for signs of LVH or RVH
*RVH R wave V1 > 3.5 sqrs (<5yo) with upgoing TW
*LVH R wave in V5,6 > 8 sqrs!
*VE's
TTE if in tertiary centre with easy access to cardiology, especially if any concerning signs.

If patient does not have any comorbidities or concerning features on Hx/Ex/Ix, then would be suitable to go ahead with procedure, and initiate referral for follow-up with cardiologist.

If any signs of concern, and available - cardiology consult prior to surgery on DOS, or cancellation, with appropriate referral. This would have to be discussed properly with parents.

If antibiotic prophylaxis came into it - I would personally not be thinking of proceeding, as this implies you think it is some sort of CHD.

Front 6

(May-2007 Q4)A 2 year old child has burns to lower body from immersion into a hot bath. Describe your assessment and management of pain and fluid requirements in the first 2 hours following injury.

Back 6

- May or may not have significant burns (ie, superficial vs deep) from this injury, and may be different depending on accidental vs NAI
- Need to make an Ax of burn size and severity
* Rule of 9's vs 1% palm, vs Paed burns charts
*significant burns > 10% BSA in children require fluids (partial/full) and require t/f to specialist facility, or full thickness > 5% any age.
*signficant burns involving perineum, joints, circumferential burns on limbs/torso, inhalational injury, face/eyes/ears/hands/feet

- fluid requirements are as per % burn (parkland formula), maintenance requirements, and assessed by urine output adequacy.
- RCH formula,
*3ml/%BSA/kg crystalloid/albumin over 24 hrs since burn (1/2 in 1st 8 hrs).
*normal maintenance also added to this
*urine output > 0.75ml/kg/hr
*2nd 24 hrs usually involves about 1/2 the "resuscitation" amount.

Pain
- should ideally be observed with objective measurement tool (such as FLACC - Facial expression, Leg movement, Activity, Crying, Consolability)
- requires titration of IV opioid if significant burn injury, and care must be taken as potentially hypovolemic (could titrate 0.1-0.2mg/kg morphine in 10 ml syringe, and give 1-2ml at a time).

Front 7

(Sep-2006 Q10) Discuss in detail the technique of rapid sequence induction with cricoid pressure in a child. Include the reasons for your choice of relaxant.

Back 7

detail any technique that is safe. Particular attention to problems with RSI in a child. Aim is rapid airway securing, and avoidance of aspiration.

- IV access! potentially the most difficult with an uncooperative/distressed child, and would depend on indication for RSI on how long this is attempted.
- Pre-oxygenation. again depends on cooperation. May be difficult in anxious, may not get good pre-O2 if screaming!
- Dose, depends on age, size, medical stability. Would tend to use 3-5mg propofol, and suxamethonium 2mg/kg, depending on medical status/hx. atropine if < 12 months for sux bradycardia.
- discuss parental presence on induction
- use of atracurium if medical status requires
- depending on age, may elect to gently BMV with cricoid to maintain oxygenation (rapid destauration in smaller child due to physiology)
- choice of uncuffed vs cuffed tube (would choose cuffed given only want 1 go, and best airway protection).

Reasons for sux
- most rapid onset drug, best intubating conditions quickest, although rocuronium is close in high dose
- likely to wear off quickly for spontaneous ventilation
- has some risks - but benefits in true emergency outweigh these in my opinion.

Front 8

(Sep-2005 Q1) What are the indications for tracheal intubation in a 3 year old who presents with "croup"? Describe your technique for intubation.

Back 8

Croup is a laryngotracheobronchitis, usually caused by a virus. It presents between 6/12 and 6 years, peaking around 2-3yo. about 0.5-1% require intubation.

Indications based on clinical ax
Hx
- rapid onset
- other medical comorbidities
Ex
- resp distress, exhaustion
- lethargic
- sitting up, drooling, unable to lie flat
- cyanosis / hypoxaemia (late)

failure to respond to medical treatment.

Intubation technique
- parental presence, try not to upset child, no IV, etc
- gas induction with 100% O2 /Sevo, in position child is comfortable
- experienced paed anaesthetist in room, in contorl of airway
- ENT surgeon on standby in case of loss of airway
- IV access when deep enough (assessed by clinical and MAC)
- view of larynx should not be difficult, but passing of ETT may be, choose 0.5-1 size smaller than expected, if possible croup tube (longer) and nasal intubation (required for ICU if possible). Unlikely to be leak.
- commence sedation, discontinue anaesthetic and ensure appropriate treatment with steroids +/- antibiotics.

Front 9

(May-2004 Q12) Working in a small obstetric unit you are asked to attend at the birth of a child where there is meconium stained liquor. How will you manage the infant's resuscitation?

Back 9

See Q4 for neonatal resuscitation.

Main thing here is to determine whether the child is flat or whether they are thriving. If flat, then they need to have trachea suctioned (via ETT) prior to any resuscitation. If not, they do not require suctioning.

Are they TERM, TONED, and CRYING? They can go straight to mother.

Front 10

(May-2004 Q13) Describe the characteristics of a ventilator suitable for neonates.

Back 10

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