Resident’s Name:______________________________________________________
Pediatric Sedation Elective
PROBLEM BASED EXAMINATION
1) A 22 month old, former 35 week premie, is scheduled for an MRI scan as part of the work-up
for new-onset seizures. The family had a previous child who died in the hospital as a neonate
secondary to complex congenital heart disease. This child has had a normal echocardiogram and
had several episodes of reactive airway disease over the past winter which were treated with
albuterol.
A. The risk of any anesthetic/sedation is related to:
1. Patient co-morbidities
2. Duration and complexity of the procedure
3. Current health status (asthma flair-up, upper respiratory tract infection, etc)
4. Patient age
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
B. List at least 6 patient-related factors which increase the risk of complications
during procedural anesthesia/sedation:
___________________________________________
___________________________________________
___________________________________________
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C.. A reasonable presedation laboratory screening protocol might include:
A. An echocardiogram in all patients less than 1 year old
B. A preoperative hematocrit in patients whose procedure or personal history
predict a risk of blood loss or anemia
C. A complete blood count (CBC), chemistry panel and urinalysis in all
pediatric patients
D. An HIV test in all sexually active patients
E. A chest x-ray in all patients with a history of reactive airway disease
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SINGLE BEST ANSWER
D. True statements about blanket preoperative/presedation screening include:
1. Preoperative screening tests may be very expensive
2. Surgery or diagnostic procedures may be delayed
3. False-positive tests may need to be pursued further
4. Blanket preoperative screening is associated with improved perioperative
outcome
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
E. Define the American Society of Anesthesiologists (ASA) physical status
classification system:
Class I-
Class II-
Class III-
Class IV-
Class V-
F. When deciding what level of sedation/anesthesia is appropriate for a particular
procedure, factors to take into account include all of the following EXCEPT:
A. Age and temperament of the child
B. Presence or absence of a student observer
C. Type of procedure and amount of pain involved
D. Amount of immobility required
E. Patient and parental anxiety level
_______
SINGLE BEST ANSWER
G. A presedation screening history should include (list at least six things):
___________________________________________
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___________________________________________
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H. A presedation screening physical exam should include (list at least six things):
___________________________________________
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I. The parents state that they “do not want their child sedated for the MRI scan”.
Non-pharmacologic interventions include:
1. Parental presence
2. Child life involvement to facilitate a non-threatening and age-appropriate approach
to the child
3. Relaxation-imagery and distraction techniques
4. Promising the patient that the procedure will not be scary
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
2) A 3 year old boy is scheduled for a bone scan under sedation. He is otherwise healthy, of
normal weight and has a normal airway exam. His parents state that he hasn’t eaten since the
previous evening and that he had some sips of Gatorade three hours prior to arriving at the
hospital for his bone scan. He receives a mask induction with nitrous oxide and sevoflurane in
oxygen, followed by propofol continuous sedation. He maintains a natural airway and receives
supplemental oxygen via a Hudson mask.
A. NPO guidelines can be more liberal (ie, allow food and drink closer to the time of
the procedure) for patients scheduled for sedation vs. those scheduled for general
anesthesia.
A. TRUE
B. FALSE
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SINGLE BEST ANSWER
B. True statements about NPO standards include:
1. NPO standards have recently been relaxed to allow ingestion of solid food
until 4 hours prior to elective anesthesia/sedation
2. NPO standards have recently been relaxed to allow ingestion of clear liquids
until 2 hours prior to elective anesthesia/sedation
3. High risk patients (hiatal hernia, GERD) are no longer at risk for perioperative
aspiration if they have been NPO for at least 6 hours
4. Emergency patients are almost always treated as having a “full” stomach
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
C. LPCH’s current NPO policy is:
Ingested Material
Minimum Fasting Period (hours)
D. “Clear” liquids include:
1. Water
2. Juice without pulp
3. Ginger Ale
4. Coffee with milk
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
E. Prolonged preoperative fasting in infants can lead to:
1. Hypoglycemia
2. Irritability
3. Dehydration
4. Crouzon syndrome
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
At the end of the procedure, while emerging from sedation, the patient vomits. His pharynx is
suctioned thoroughly and he is placed on his side until his airway reflexes are fully intact. He
exhibits no respiratory distress, and his room air saturation is 98%. When you questioning the
family further about his NPO status, his six year old sister states that on the way to the hospital
her brother ate two chicken nuggets and several French fries which he found lodged in the
backseat of the car.
F. Aspiration of gastric contents is a potentially fatal complication of procedural
sedation.
A. TRUE
B. FALSE
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SINGLE BEST ANSWER
G. Conditions that increase the risk of periprocedural aspiration of gastric contents
include:
1. Recent ingestion of food
2. Hiatal hernia
3. Gastroesophageal reflux disease (GERD)
4. Obesity
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
H. Severity of aspiration is related to:
1. Presence of particulate matter
2. Volume of the aspirate
3. Acidity of the aspirate
4. Glucose content of the aspirate
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
3) A 6 month old, 6.4 kg child with new onset seizures is scheduled for an MRI scan of the brain.
He receives 480 mg (~75 mg/kg) of chloral hydrate PO, and begins to fall asleep. An IV is
placed because he will need IV contrast. About halfway through the procedure he gets restless
and the scan is interrupted. The patient is given 0.3 mg (~0.05mg/kg) of midazolam IV, settles
down and scanning resumes. Several minutes later it is noted that the patient’s oxygen saturation
is 72%. The patient is pulled out of the scanner and noted to be apneic.
A. Define the following terms which are currently in use to describe sedation/anesthesia
in pediatric patients:
Minimal sedation (anxiolysis)-
Moderate sedation (conscious sedation)-
Deep sedation-
General anesthesia-
B. True statements about sedation in children include all of the following EXCEPT:
1. Rescue equipment, including size-appropriate equipment and drugs to
resuscitate a nonbreathing and/or unconscious child, must be immediately
accessible.
2. The intensity of monitoring is determined by the expected level of sedation
3. Sedation personnel and monitoring equipment should always be capable of
caring for a patient at least one level beyond the intended level of sedation.
4. Sedation/general anesthesia is a continuum, rather than a set of distinct phases
5. Progression through the phases of sedation/general anesthesia is linear, so it is
easy to predict when a patient will enter another phase
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SINGLE BEST ANSWER
C. The risk that a patient will become more sedated than intended is increased:
1. In younger patients
2. In sicker patients
3. When pharmacologic agents are mixed
4. In red-headed patients
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
D. Patients receiving minimal sedation (anxiolysis)
1. Have intact airway reflexes
2. May have mildly impaired cognitive function
3. Should not require monitoring beyond a pulse oximeter and/or direct
observation
4. Are not known to progress to a level of moderate sedation (conscious
sedation)
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
E. Patients receiving moderate sedation (conscious sedation)
1. Should be able to maintain a patent airway
2. Do not need to be monitored in a suitably equipped recovery facility after the
procedure is completed, as is done with patients who have received deep
sedation
3. May progress into a state of deep sedation and obtundation
4. Require monitoring with pulse oximeter only
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
F. Patients receiving deep sedation
1. Incur risks similar to those undergoing general anesthesia
2. Must receive continuous monitoring of oxygen saturation and heart rate,
intermittent recording of respiratory rate and blood pressure, and
consideration of the use of a capnograph
3. Must be monitored in a PACU-like setting post-procedure
4. Should have an intravenous line placed before or shortly after induction
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
4) A 5 year old, 22 kg, boy with Treacher Collins syndrome and an abdominal mass presents for
an MRI scan of the abdomen which will require that the patient’s breathing be suspended
intermittently. He has never had an anesthetic previously. He has an IV in place. At induction he
receives 20 mg lidocaine, 80 mg propofol and 20 mg rocuronium IV. Neither the glottis nor the
epiglottis are visualized with a Mac 2 blade. The patient is difficult to ventilate using a face
mask.
A. Name at least six things which might predict a difficult intubation
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B.
Describe the Mallampati airway classification system:
Class I-
Class II-
Class III-
Class IV-
C. Patients who are difficult to intubate are also usually impossible to ventilate via face
mask.
A. TRUE
B. FALSE
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SINGLE BEST ANSWER
D. What steps can be taken to improve ventilation by face mask in this patient?
1.
2.
3.
E. Once adequate ventilation by face mask has been established for this patient, describe
the management options which exist for this patient. (Refer to the ASA difficult
airway algorithm).
F. The laryngeal mask airway (LMA)
1. Cannot be used in patients who are latex allergic
2. Comes in a variety of sizes and styles
3. Forms a high pressure seal around the entrance to the larynx and prevents aspiration
of gastric contents
4. Can be used in the emergency establishment of an airway
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
G. Tracheal intubation may be confirmed by
1. Auscultation of bilateral breath sounds
2. Detection of end-tidal CO2
3. Fiberoptic bronchoscopy
4. SpO2 of 100%
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
H. Complications of direct laryngoscopy and intubation include
1. Esophageal intubation
2. Dental damage
3. Endobronchial intubation
4. Increased intracranial pressure
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
I. After multiple attempts by multiple people using multiple techniques, the above patient was
finally intubated fiberoptically through an LMA. He was transported to the MRI scanner and
the scan was completed uneventfully. True statements about extubation of this patient
include:
1. Before removing this patient’s ETT, the cuff should be deflated to check for a gas
leak around the ETT
2. Consideration should be given to delaying extubation until airway edema has
resolved
3. Consideration should be given to removing this patient’s ETT over a fiberoptic scope,
ETT tube changer, or jet stylet.
4. This patient should be extubated “deep” (while still deeply anesthetized) to prevent
coughing, breath-holding and laryngospasm.
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
5) An 8 month old infant is scheduled for a nuclear medicine scan with sedation. He is a former
full term infant who is otherwise healthy. He has no IV access.
A. Initially, you consider using chloral hydrate for this child. True statements about
chloral hydrate include:
1. In most patients, airway reflexes and respiratory drive are well maintained during
chloral hydrate sedation
2. The dose of chloral hydrate is 50-100mg/kg, with a maximum dose of 2gm
3. Care should be taken in administering chloral hydrate to developmentally delayed
children (who may have an exaggerated or dysphoric reaction) or to patients with
potential upper airway obstruction (enlarged tonsils, OSA, laryngomalacia)
4. Chloral hydrate works by inducing a dissociative state between the cortex and the
limbic system
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
B. Reasons that chloral hydrate might be a good choice in this patient include:
1. Chloral hydrate is administered PO or PR, so it is a good choice in patients without
IV access
2. Chloral hydrate provides no analgesia, so it is a good choice in diagnostic, nonpainful procedures such as this one
3. Chloral hydrate works best in patients less than three years of age (about a 90%
efficacy rate in this age group)
4. Chloral hydrate is a short acting drug- patients awaken very quickly- so it is a good
choice for this relatively short procedure
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
C. You learn that the patient will need an IV placed prior to the nuclear medicine scan so
that a radionucleotide tracer can be injected prior to the scan. You would like to use
EMLA cream before placing the IV.
1. EMLA stands for “Eutectic Mixture of Local Anesthetics”, and contains the
local anesthetics lidocaine and prilocaine
2. EMLA has a quick onset of action, allowing an IV to be started 3-5 minutes
after the cream has been placed
3. EMLA has been associated with methemoglobinemia
4. EMLA cream can be used safely on mucous membranes, open skin and in
neonates (infants less than one month of age)
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
D. Since the patient now has an IV in place, you decide instead to use midazolam for
sedation. Benzodiazepines can be used for:
1. Anxiolysis
2. Sedation
3. Amnesia
4. The control of seizures
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
E. Midazolam can be administered
1. Orally, rectally
2. Intranasally
3. Intravenously
4. Intramuscularly
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
F. True statements about midazolam include:
1. Midazolam is a GABAA receptor agonist
2. Midazolam has a longer ½ life than diazepam
3. Midazolam is rapidly metabolized by hydroxylation
4. After administration, midazolam is not detected in the brain or CSF
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
G. True statements about oral midazolam include:
1. An advantage of using oral midazolam is that there are no first-pass hepatic
effects
2. Oral midazolam has a pleasant and easily tolerated taste
3. The onset of sedation after the administration of oral midazolam is usually 2-3
minutes
4. Oral midazolam is typically administered in doses ranging from 0.5-1.0 mg/kg
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
H. True statements about intravenous midazolam include:
1.
2.
3.
4.
_______
It burns on administration
It is easily titrated
It has analgesic properties
The usual dose is 0.05- 0.1 mg/kg
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
You give the patient 0.1mg/kg midazolam intravenously. He quiets down and the scan resumes.
Shortly afterwards you note that his respiratory rate has fallen from 26/min to 6/min. His oxygen
saturation is 98%. After assuring that his airway is patent, you decide to administer flumazenil.
I. True statements about flumazenil include all of the following EXCEPT:
A. Flumazenil is a GABAA receptor agonist
B. The dose of flumazenil is 0.02 mg/kg intravenously, which may be repeated
every minute as needed up to a maximum of 1.0 mg
C. The onset of action of flumazenil is approximately one minute
D. Side effects of flumazenil include crying, agitation, headache, dizziness and
nausea/vomiting
E. After receiving flumazenil, patients should be observed for at least 50 minutes
to be certain that the patient does not become resedated.
_______
SINGLE BEST ANSWER
6) A 12 year old girl is scheduled for excision of a mole from her thigh. The surgeons are
concerned about injecting local anesthetic into the surgical site because the patient describes an
“allergic reaction” to “novocain”, which she received once at the dentist’s office.
A. Considerations in a patient with a “novocain” allergy include:
1. “Novocain” is frequently used by patients to refer to all local anesthetic agents
(LAs), but novocain (procaine) is rarely used clinically today
2. Most “allergic” reactions to local anesthetics are actually vasovagal reactions
to the injection of the LA, tachycardia and/or hypertension secondary to
systemic absorption of the epinephrine in the LA solution, or the effect of high
blood levels of LAs, rather than a true allergy
3. True allergic reactions to local anesthetics usually occur with the ester type
LAs, not the amide type LAs.
4. Allergic reactions to the preservative (methylparaben) in LAs are more
common than allergic reactions to local anesthetics themselves.
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
B. Local anesthetic agents are weak bases, consisting of a lipophilic group (usually a benzene
ring) linked to a hydrophilic group (usually a tertiary amine) through an _____________ or
_____________ linkage.
C. A 1% solution of local anesthetic has _________mg/ml of local anesthetic.
D. Briefly describe the mechanism of action of local anesthetic agents:
E. List at least three ester type local anesthetic agents and at least three amide type local
anesthetic agents:
Ester type local anesthetic agents
Amide type local anesthetic agents
F. Ester-type local anesthetics are predominantly metabolized by:
G. Amide-type local anesthetics are predominantly metabolized by:
H. True statements include all of the following EXCEPT:
A. Acidic pH will hasten the onset of the local anesthetic block
B. Myelinated nerves are more easily blocked than non-myelinated nerves,
because blockade need only occur at the nodes of Ranvier
C. With careful choice of local anesthetic agent, dose, and concentration, a
selective block may be obtained (eg block of pain and temperature sensation
in the absence of significant motor blockade)
D. Local anesthetic molecules must traverse the neural cell membrane in order to
bind to the sodium channels and produce their effect
E. In general, thinner nerve fibers are more easily blocked than thick nerve fibers
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SINGLE BEST ANSWER
I. Epinephrine is often added to local anesthetics to:
1. Decrease systemic absorption via vasoconstriction, and therefore enhance
neuronal uptake
2. Prolong the duration of action
3. Limit the toxic side effects of local anesthetics
4. Pretreat local anesthetic toxicity
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
J. Local anesthetic blockade of peripheral nerves usually progresses in the following order:
A. Autonomics temperature motor pain proprioception
B. Autonomics temperature pain proprioception motor
C. Motor proprioception pain temperature autonomics
D. Temperature pain proprioception motor autonomics
E. Motor temperature pain proprioception autonomics
_______
SINGLE BEST ANSWER
K. Signs and symptoms of local anesthetic toxicity include the following:
1.
2.
3.
4.
_______
Seizure
Dizziness, tinnitus, metallic taste in the mouth, numbness of tongue or lips
Arrhythmias
Cardiovascular collapse
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
L. Signs of CNS toxicity usually precede signs of cardiovascular toxicity with local
anesthetics
A. TRUE
B. FALSE
_______
SINGLE BEST ANSWER
M. Treatment of systemic local anesthetic toxicity may include:
1. Administration of a benzodiazepine, like midazolam
2. Hyperventilation
3. Control of the airway, administration of 100% oxygen
4. Administration of intralipid
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
7) A 22 month old child is admitted to the recovery area after having a CT guided aspiration of
the left hip joint. He was sedated with ketamine and midazolam IV. He is transported to the
recovery room on supplemental oxygen. On arrival to the recovery area his oximeter is noted to
be reading 82%, and his lips are noted to be slightly blue.
A. Immediate actions include:
1. Give a detailed sign-out to the recovery personnel
2. Open the airway with a jaw thrust or chin lift
3. Draw up an appropriate dose of ondansetron, as this could be nausea
4. Assess the patient for respiratory effort
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
B. Possible causes of the patient’s desaturation include:
1. Laryngospasm
2. Upper airway obstruction
3. Hypoventilation from oversedation
4. Aspiration
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
C. Reasonable interventions include all of the following EXCEPT:
A. Suction of the oropharynx if it is noted to be full of secretions or emesis
B. Positive pressure ventilation if the patient’s respiratory effort is inadequate
C. Insertion of an oral or nasal airway if soft tissue relaxation is causing upper
airway obstruction
D. Administration of 0.1 mg/kg atropine to prophyactically treat bradycardia
E. Administration of CPAP if the airway obstruction is thought to be secondary
to laryngospasm
_______
SINGLE BEST ANSWER
After a jaw thrust opens his upper airway and stimulates him to take a few deep breaths his lips
pink up and the oximeter is now reading 100%. Moments later he is crying uncontrollably.
D. His crying could be due to:
1.
2.
3.
4.
_______
Pain
Hunger
Emergence delirium
Eosinophilic esophagitis secondary to reflux and aspiration
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
E. Emergence delirium:
1. Must be distinguished from hypoxia, hypoglycemia and/or pain
2. Occurs in about 15% of children after sedation
3. Most commonly occurs after a pure inhalational anesthetic or a ketamine
anesthetic
4. Will resolve spontaneously if untreated
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
F. True statements about the treatment of post-procedure pain include:
1. Both pain and the opioid medications used to treat pain can cause nausea
and vomiting
2. It is not necessary to monitor patients in a PACU setting if opiates are given
for emergence delirium rather than for pain
3. It is often difficult to distinguish between pain, hunger, anxiety and
emergence delirium in children
4. Most of the commonly used anti-emetics have analgesic properties
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
The patient is given 0.05 mg/kg morphine IV. After 5minutes he settles down and stops crying.
He gladly takes a popsicle. After eating about half of the popsicle, he vomits.
G. Post-procedure nausea and vomiting:
1. Can be associated with agents given for sedation
2. Can be associated with agents given for analgesia
3. Can be associated with premature introduction of oral fluids
4. Can be treated with ondansetron 0.1 mg/kg (up to 4 mg) IV
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
H. Serious complications during sedation/anesthesia occur secondary to
1. Inadequate monitoring for the level of sedation attained
2. Medication overdose
3. Inadequate skill of the practitioner performing the sedation
4. Inadequate guidelines for procedural sedation
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
I. The majority of reported serious complications during sedation/anesthesia occur in:
1. Patients with congenital heart disease
2. Patients with reactive airway disease
3. Patients with liver disease
4. Previously healthy children
_______
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
A. True statements about barbiturates include all of the following EXCEPT:
A. The longest acting of the barbiturates is methohexital, a property which is
related to the methyl group substituted at N1
B. Barbiturates depress the reticular activating system (RAS) to produce
unconsciousness
C. The duration of action of thiopental is primarily dependent on redistribution
D. In patients who are hypovolemic, the administration of an induction dose of
sodium pentothal may lead to a dramatic fall in blood pressure and cardiac
output
E. Barbiturates significantly decrease CMRO2 (cerebral metabolic rate of
oxygen) and may provide some brain protection from transient focal brain
ischemia
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B. True statements about ketamine include all of the following EXCEPT:
A. Ketamine produces so-called “dissociative anesthesia” by functionally
disconnecting the cortex from the limbic system.
B. Although ketamine is a structural analogue of phencyclidine (PCP), it is so
much less potent that it has no “street value” and therefore is not a controlled
drug.
C. Ketamine has sympathomimetic properties. It may actually increase blood
pressure and cardiac output. It significantly increases cerebral metabolic rate,
cerebral blood flow and intracranial pressure.
D. Ketamine produces very little, if any, respiratory depression
E. Ketamine leads to excessive salivation, but luckily airway reflexes remain
largely intact
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C.
The periurethral skin tag turns out to be fairly large. You decide to administer
narcotics intraoperatively for perioperative pain relief. True statements about opioids
include all of the following EXCEPT:
A. Opioid is a broad term which includes endogenous peptides and exogenous
drugs- both naturally occurring and synthetically produced- which act at the
opioid receptor
B. There are four major types of opioid receptors: mu, kappa, delta, and sigma
C. Opioid receptor activation inhibits the presynaptic release and post-synaptic
response to excitatory neurotransmitters like substance P in the nociceptive
neurons
D. Opioids given in combination with benzodiazepines can have synergistic
(greater than additive) respiratory depressant effects
E. Although the hypoxic respiratory drive (response to PaO2) is affected by the
administration of narcotics, the respiratory response to PaCO2 is maintained.
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D.
Effects of opioids include:
1. Somnolence and/or respiratory depression
2. Dysphoria
3. Nausea and/or pruritis
4. Euphoria
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
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E.
Morphine:
1. Is metabolized via glucuronidation in the liver
2. Is typically dosed at 0.05-0.1 mg/kg IV
3. Has an active metabolite which can accumulate in renal failure, so must be
used cautiously in patients with impaired renal function
4. Is not associated with histamine release or pruritis
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
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F.
True statements about meperidine include:
1. Meperidine’s active metabolite, normeperidine, has been associated with
seizure activity
2. Meperidine is contraindicated in patients taking MAO inhibitors
3. A typical dose of meperidine is 0.5 mg/kg IV
4. Meperidine is often used IM because it is rapidly absorbed intramuscularly
and peak blood levels can be reached in about 10 minutes
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
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G.
True statements about fentanyl include:
1. A typical dose of fentanyl is 1-2 μg/ kg IV
2. Fentanyl is 100 times more potent than morphine
3. Fentanyl has been associated with stiff chest syndrome
4. Because of its poor lipid solubility and slow redistribution, fentanyl has a slow
onset and a long duration of action
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
_______
H.
Because you have administered an opioid, you double check to be sure that you
have naloxone immediately available. True statements about naloxone include:
1. Naloxone will reverse opioid-induced analgesia as well as opioid-induced
respiratory depression, so patients may experience pain after its administration
2. Naloxone administration has been associated with the development of
ventricular fibrillation and pulmonary edema
3. Naloxone administration has been associated with nausea and vomiting
4. Naloxone has a long duration of action, so the risk of re-narcotization is very
small
Answer A if 1,2,and 3 are correct. Answer B if 1 and 3 are correct. Answer C if 2 and 4
are correct. Answer D if 4 only is correct. Answer E if 1,2,3, and 4 are all correct
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I.
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In addition to the opioid, you administer ketorolac 0.5mg/kg IV. True statements
about ketorolac include all of the following EXCEPT:
A. Ketorolac potentiates opioid analgesia and can reduce opioid consumption
B. Ketorolac is a cox-2 specific inhibitor and, as such, is less likely to result in
stomach ulceration and bleeding
C. Ketorolac is the only parenterally administered NSAID currently available in
the United States
D. Ketorolac use has been associated with renal failure
E. Ketorolac should be used with caution, if at all, in patients less than a year of
age because of the lack of pharmacokinetic and toxicity information in that
age group
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