SAQ Past Paediatric Anaesthesia

ANZCA Final SAQs with answers

18A01 (24.9%) Describe your assessment of a

four-year-old child who has been rescued
from a house fire.
Features suggestive of inhalational injury: Orofacial burns, Singed eyebrows / hair, Soot in
nasal passages, Swollen uvula, Voice changes/hoarseness, Stridor, Coughing up soot,
Respiratory distress, Hypoxaemia/hypercarbia, Confusion/agitation/decreased GCS, 

Investigations: Arterial blood gases – Pa02, lactate, carboxyhaemoglobin level 

Nasendoscopy – nasopharyngeal oedema and swelling of cords; soot, mucosal pallor or

erythema

Chest xray may show atelectasis, pulmonary oedema 

This question was answered poorly mainly because inadequate or irrelevant information was
provided. The question asked for assessment however many candidates wasted time by
writing about management. A borderline answer required demonstration to the examiner of
an understanding of why airway assessment is critical, in particular a propensity for
catastrophic deterioration. It needed to include assessment of inhalational injury, potential
for carbon monoxide poisoning and level of consciousness. Assessment of the extent of the
burn and pain was often overlooked.

Structure 

 Assess for Key Issues

 airway involvement 
 inhalational injury or CO poisoning 
 concurrent blunt trauma
 need for fluid resuscitation
 secondary injury / physiologic derangement (ARDS, shock)
 need for transfer
 History
 Mechanism
 Entrapment – strongly predictive of inhalational injury
 Materials producing noxious gases – chemical
inhalational injury?
 Explosions or blasts – ?blunt trauma 
  AMPLE history
 Exam 
 APLS primary survey – ABCDE
 Investigations

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Normal Values
Age Pulse rate Sys BP MABP Respiratory rate

<1 yr 100-160 70-85 45-60 30-60

1-2 yr 90-150 80-95 50-70 25-40

2-5 yr 80-140 80-100 50-70 25-35

6-12 yr 70-120 90-110 60-90 15-30

>12 yr 60-100 100-120 60-90 12-16

Airway – Assess for airway burns

 Features suggestive of airway burns

 Soot around mouth and nose
 Facial burns, singed nasal hairs 
 Swollen uvula
 Coughing up soot
 Hoarse voice
 Stridor
 Brassy cough
 Nasendoscopy
 Assess oropharynx
 Visualise vocal chords – assess for 
 Oedema
 Mucosal pallor or erythema
 Signs indicating injury and potential for further swelling
 Early intervention if suspect airway burns
 Potential to deteriorate from oedema causing airway obstruction
 Cervical spine control during airway maneuvres 

Breathing – Assess for pulmonary injury from inhalation

  Respiratory rate and pattern
 Normal RR 25-35
 Respiratory distress, accessory muscle use
 Listen to and percuss chest
 Consider pneumothorax if associated trauma
 O2 Saturation, PaO2, PaCO2 
 Circumferential burns
 Chest excursion, tidal volumes
 Carbon monoxide
 Transcutaneous
 ABG
 Aa Gradient to assess degree lung injury
 Chest XR
 Atelectasis
 Consolidation 

Circulation – Assess degree of shock, Need for resuscitation

 Heart rate and blood pressure 

 Normal HR 80-140
 Normal SBP 80-100 MAP 50-70
 Systolic hypotension  <78 (70 + (age in years x 2)
 Central and peripheral capillary refill
 Urine output 1-1.5ml/kg/hr = 16-24ml/hr (assuming 16kg)
 ABG – pH, lactate

Disability – Pain and Level of consciousness, head injury

 Level of consciousness – AVPU / GCS

 Confusion / Agitation
 Decreased by CO poisoning, severe airway obstruction or
respiratory failure or concurrent blunt trauma 
 Assess pain – likely if significant burns
 Early effective analgesia
 Rapid acting opiates
 Intranasal fentanyl
 IV morphine
 May require intubation to facilitate sedation/analgesia if extensive
resuscitation and analgesia requirement 
 Check blood glucose

Exposure – Thickness and extent of burns, look for trauma

 Assess % body surface area of at least superficial dermal burns (exclude

superficial epidermal)
 Modified rule of 9s in children
 Paediatric burn chart or app
 Patient palmar surface area ~ 1% TBSA 
 Parklands formula for fluid 
  Special areas – will need referral to specialist centres
 Hands, feet
 Face
 Perineum
 Circumferential 
 Temperature
 Potential to get cold quickly
 Extrication time
 Vasodilatation from burns
 Examine whole body for trauma / other injuries
 Distracting burns may reduce voluntary reporting
 Check Weight for drug calculations
 Estimated Weight  (Age x 2) +8 = 16kg
 Check against recent known weight, Broselow tape

Fluids – Fluid Status and electrolytes

 Assess degree of dehydration

 Mucous membranes
 Heart rate
 Capillary refilll
 Urine output
 Calculate fluid requirements
 Based on weight and % BSA of burns
 Parkland’s = 3-4mL/kg/%BSA, use 4 if delayed
resuscitation, electrical burns, or inhalational injury 
 Titrate to UO >1mL/kg/hr 
 Add replacement to maintenance
 Check electrolytes
 Na, K, U, Cr
 Check CK
 Look for rhabdomyolysis

GI – nutrition

 Check blood glucose

 Ask about fasting and last meal

Renal

 Check urine for Hb and myoglobin

 if positive, increase UO to 2ml/kg/hr, alkalinise urine with sodium
bicarbonate IV, and promote diuresis with mannitol added to
Hartmann’s 

Haematology

 Check Hb
  Send G&S if major burns, large blood loss with escharotomy/debridement  

Infection

 Check WCC

Treatment so far?

 O2, IV access, fluid resus (if significant, this may predispose to ARDS),
cooling, covering of burns, analgesia 

17B11 (40.5%) Describe the anatomy relevant

to performing a caudal block in a two-year-
old male. 
This question highlighted candidates’ weakness of anatomy related to regional techniques
which is a core area. Answers often included only surface anatomy. Reference needed to be
made to identifying surface landmarks, including the sacral cornu as well as the contents of
caudal canal.

Structure – Description,  Surface anatomy, Boundaries / relations, Contents, Approach

 Description
 Caudal is injection of local anaesthetic into sacral canal through
the sacral hiatus
 Sacral canal is continuation of lumbar spinal canal 
 LA here produces block of sacral and lumbar nerve roots
 ideal for perineal surgery or other surgery below umbilicus
 Up to lower thoracic levels if sufficient volume – less reliable
 Boundaries / relations,
 Access to sacral canal is via sacral hiatus
 U shaped aperture at caudal end of sacral canal 
 Due to incomplete fusion of fourth / fifth sacra
vertebral arches
 Triangular shaped, formed by two sacral cornuae and
lower part of 4th sacral vertebra 
 Sacral cornuae = 5th sacral inferior
articular processes
 Covered by sacrococcygeal membrane/ligament 
 Extension of ligamentum flavum 
 Sacral bony anatomy more easily palpable, less inter
individual variation, and sacrococcygeal membrane
softer in young children than in adults, increasing
success of accessing space 
 Surface anatomy
 Identify PSIS
  Draw equilateral triangle with base as line between
PSISs
 Sacral hiatus is at apex (caudal to base)
 Natal cleft doesn’t always correspond to midline
 Natal cleft and perineum are nearby
 increased risk infection if
catheter technique used 
 Contents of sacral canal
 Continuation of epidural space
 Cauda equina nerve roots (lumbosacral nerve roots)
 Spinal meninges (dural sac terminates at S3-4 in young children,
cf S2 in adults, so needle must be advanced as little as possible, or
risk dural puncture and/or intradural injection)
 Epidural fat (less dense than adults, facilitating spread, allowing
more reliable block and more cranial level of block from a caudal
injection than adults)
 Epidural venous plexus (situated anterolaterally in canal, so needle
angle should be flattened on passing through SC membrane, to
avoid intravascular needle placement)
   Approach
 Position
 Lateral position, (Or can do prone position)
 upper hip flexed 90 degrees
 lower one to 45 degrees
 Technique
 Identify sacral hiatus between sacral cornuae
 Needle technique
 Aim for proximal hiatus
 Epidural puncture at most
proximal hiatus
 needle inserted just below
spinous process of S4 
 needle inclined caudally, 60* angle from
skin 
 Needle passes through
 Skin – risk of introducing
dermoid cyst, so use cannula
over needle technique, or nick
skin with sharp needle first 
 Subcutaneous tissue
 sacrococcygeal membrane 
 flatten angle, enter caudal canal, then
advance only minimally (1-3mm)
 Aspirate and inject pre-calculated dose of LA /
Adjunct
 Bupivicaine 2.5mg/ml
 0.5ml/kg – sacral dermatomes
 1ml/kg – sacral and lumbar
dermatomes
 1.25ml/kg – mid thoracic
  Needle malplacement may be
 Subcutaneous 
 Intra dural / subarachnoid
 Intra vascular
 Sub periosteal / intra osseous 
 May perforate rectum 

17A10 (70.8%) Outline the advantages and

disadvantages of using the paediatric circle
system and the Jackson-Rees modification of
Ayre’s T-piece (Mapleson F) for anaesthesia in
a 15 kg child.
The candidate needed to demonstrate an adequate understanding of each system including
resistance, dead space and fresh gas flows.

 Ayres T-Piece (Mapleson E)

 Original T-piece by Phillip Ayre in 1937 for children 
 Ventilation by occlusion of the open ended tube
 Fresh gas entering at a right angle to the tube.
 Jackson Rees Modification
 Modified by Jackson Rees in 1950’s
 Adding an open-ended 500 ml bag
 allow respiratory monitoring and/or assistance, 
 and parallel entry of the fresh gas line at the patient connection.

 Advantages
 light weight
 low resistance – no valves
 low dead space especially during spontaneous ventilation
 good ‘feel’ of the lungs – qualitative assessment of lung
compliance and tidal volumes 
 can be used for spont, assisted, and controlled ventilation
 Dynamic ability to add PEEP/PIP/CPAP
 Disadvantages
 High FGF required
 2-3x minute volume for spontaneous ventilation, 1L +
0.2L/kg in controlled, dependent on respiratory pattern 
 Not suitable over 20kg
 Minimum 3L/min, can be adjusted to achieve FiCO2
<4-5mmHg and normocapnia 
 Much less efficient than a circle system
 Dry unwarmed fresh gases unless humidified or partial rebreathing
 Barotrauma possible
 Scavenging difficult – theatre and environmental pollution
  Can’t be used for controlled ventilation with some modern
machines
 End tidal gas sampling may be inaccurate 

 Paediatric circle
 15mm hose
 For children over 5 kg
 Advantages
 Closed system
 Less pollution
 Cost efficient
 Conserves warmth and moisture
 Lower dead space than adult circle
 Disadvantages
 Increased resistance to breathing

Breathing
Paediatric Circle Mapleson F
System

15mm tubingOne way valvesCO2 T piece15mm tubingOpen ended

Description absorberVentilator or 500ml 500ml bagFresh gas at patient
bagAPL valve connection

Low flow anaesthesiaReduced

costRecycling of volatileLess Light weightPortableLow
Advantages greenhouse gasScavenging built resistanceNo valvesGood ‘feel’ of
inReduced staff exposure to compliance
volatiles

Only for patients >5kgIncreased

Lower efficienyStaff exposure to
resistance vs MpFLess
volatilesBarotrauma possible if
portableIncreased weight of
occlude bagScavenging difficult
circuit – potential for dislodging
(new circuits with scavenging
airway device Less subjective
attached to expiratory valve exist,
assessment of respiratory system
Disadvantages but this adds resistance and
complianceHand assistance more
weight)Mechanical ventilation
difficultLess precise pressure
problematic with modern
adjustment with APLCompliance
machinesSafety issue switching
of circuit may -> inaccurate tidal
circuits to establish mechanical
volume measurement and/or
ventilation
delivery 
15B06 (68.3%) A three-year-old child requires
an adenotonsillectomy for obstructive sleep
apnoea. Outline and justify your peri-
operative management plan.
Examiner’s Report

A borderline candidate should make some mention of the following areas.

• Assessment of severity of sleep apnoea including complications

• Intra-op – shared airway, sensible airway plan, issue with sedative premeds

• Post-op – monitoring and care, appropriate analgesic consideration, e.g. opioid sensitivity

NEW ZEALAND GUIDELINES FOR THE ASSESSMENT OF SLEEP-DISORDERED

BREATHING IN CHILDHOOD

BJA ED Obstructive sleep apnoea in children: perioperative considerations

Pre-Op

 Assessment of severity of OSA and presence of central apnoeas

 More severe OSA at risk of postoperative respiratory problems
 History
 Standard anaesthetic assessment
 Airway assessment
 Identify potential difficult
intubation
 Pertinent as mask ventilation
likely to be more difficult
 Cooperative / interactiveness of child
 Balance risks vs benefits of gas
induction vs IV induction 
 Assess need for pre medication
 Avoid
premedication if
possible 
 Increase
d risk of
complica
tions /
respirato
ry
 obstructi
on
 If required, give in
monitored area, eg
PACU
 Focussed sleep history
 Screening tool for OSA – BEARS
 Bedtime issues
 Excessive daytime sleepiness / disruptive
symptoms
 Awakenings at night
 Regularity and duration of sleep
 Snoring / Disordered Breathing
 Structured Questionnaire
 Chervin Paediatric Sleep Questionnaire 22
 Score of >0.33 (yes/no)
Indicates OSA
 Sensitivity 81% Specificity
87% for AHI>5
 History or exam features of associated
diseases/syndromes
 Trisomy 21
 Obesity
 Cleft palate
 Other craniofacial anomalies
 Neuromuscular disorders
 History or exam or investigation findings of
complications
 Behavioural, developmental, learning
difficulties
 Hypertension
 Polycythaemia
 ECG – RV strain
 Echo
 For Severe and Very Severe
OSA
 Risk of Pulmonary
Htn and Rt heart
complications
 High risk conditions for incomplete resolution of OSA,
 High Pre-operative AHI
 Downs syndrome
 Prader Willi Syndrome
 Neurologic conditions
 Myelomeningocoele
 Postoperative respiratory problems
 As above plus
 Spina Bifida
 Achondroplasia
 Mucopolyaccharidosis
  Cerebral Palsy
 Laryngomalacia
 Pierre Robin Sequence
 Previous palatal surgery
 Prematurity
 Obesity
 Investigations
 Polysomnography (PSG) (key definitions here)
 AHI >10  – severe OSA
 Nadir<80%
 All patients with another high risk feature need formal
PSG studies prior to tonsillectomy
 Current treatment for OSA
 Mandibular advancement devices
 CPAP
 HFNC
 Nasal steroids
 Previous surgery
 Scheduling
 schedule procedure for earlier in the day – increased recovery time
before night.

Intraop

 Avoid premedication if possible 

 Increased risk of complications / respiratory obstruction
 IV induction preferable
 Pre-oxygenation
 Reduced time to definitive airway
 Inhalational induction (less preferable) 
 Anticipate difficulty
 Obstruction
 Difficult BMV
 Early OPA
 Opiates
 Increased sensitivity to opiates
 Use short acting eg fentanyl
 Titrate to RR
 Muscle relaxants
 Aid placement of ETT, but probably not ability to face mask
ventilate 
 But then unable to titrate opioids to respiratory rate, and need
reversal 
 Can use ultra short acting opioid and propofol to achieve
incubating conditions in most young children 
 Airway
 ETT
 Protect airway from soiling
 Ventilation
 Aim to establish spontaneous ventilation
  Titrate opiate to respiratory rate
 Analgesia
 Multimodal analgesia
 Reduce opiate requierments
 NSAID
 Paracetamol
 LA to tonsil bed 
 Antiemetic
 High risk procedure for PONV
 Dexamethasone
 Also reduce swelling and associated obstruction
 Also opioid sparing
 And one other eg ondansetron 
 Extubation
 Awake extubation
 Risk of obstruction with deep extubation
 Ensure airway clear of blood including nasopharynx 
 Deep extubation
 Advanced technique
 Minimises coughing and compromising haemostasis 
 But may cough on emergence in PACU anyway 
 Need to be available until airway reflexes return

Post Op

 Regular analgesia
 Paracetamol
 NSAID
 PRN Opiate – up to 0.1mg/kg oral morphine
 Post op admission
 Criteria for overnight admission post tonsillectomy

 Age   years
 Severe OSA
 OAHI > 10/hr
 O2 Sat Nadir <80%
 Mcgill oximetry score >3 
 3 or more SaO2 <85%
 Hypoventilation
 Elevated CO2
 Significant comorbidities
 Downs syndrome
 Craniofacial anomalies
 Neuromuscular disease
 Especially hypotonia
 Cardiac problems
 Pulmonary hypertension
 Obesity (Weight >95th centile, BMI >30kg/M2)
 Failure to thrive
 Ex-Premature infants 
  PCA <55 weeks
 Current increased WOB from lung problems
 Indication for HDU/ICU monitoring post tonsillectomy, in
hospital with onsite ICU
 2 or more risk factors
 E.g. age<3 plus comorbidity
 Children with very severe OSA
 OAHI > 30 per hour
 NO2 sats Nadir <70%
 Mcgill oximetry score >4
 3 or more SaO2 <80%

14B01 (45.8%) An 8 week old baby is scheduled for an inguinal hernia repair on your list at a
local general hospital tomorrow. 
Examiners’ Report:

6 Key components of an answer for this question requires candidates to. Make comments
about appropriateness of baby, its gestational age and “normality”, whether the facility has
the facilities / equipment to provide care for such an infant, decision, based on PS 29 and the
local departments adaptation of that in terms of age / size limits, staff experience and
training, equipment and facilities and transfer arrangements if needed

a) Outline the important issues when

providing anaesthesia care for this baby.
(70%) *
(Not certain if they want you to focus on more management overview vs how would you
anaesthetise)

Anaesthesia for Infants undergoing inguinal hernia repair

 Minimum requirements set out in ANZCA Professional Statement PS29

 Age of Patient – Specialist anaesthetist experience
 Trained and Current experience with this age group
 Staff in theatre and ward 
 Trained in care of this age group
 Equipment and Facilities
 Specific to this age group
 Anaesthesia delivery system
 Monitoring
 Preop
 Preoperative visit
 History
 Gestational Age
 Post conceptual age
  Ex-Premature <37wks GA
52wks PCA
 Increased risk postoperative
apnoea
 Neonatal complications
 Neurologic conditions
 Respiratory conditions
 Lung injury
 Consent with parents
 Risks of anaesthesia
 Fasting 
 as outlined in PS07 and European
consensus statement on fasting
endorsed endorsed by SPANZA
 Avoid prolonged fasting 
 neonates increased risk
hypoglycaemia
 Formula 6 hrs
 Breast milk 3 hrs
 Clear Fluids up to 1
hr
 Intraop
 Patient
 Airway
 Large head prominent occiput
 Neutral position for
management
 Shoulder roll
 Floppy epiglottis
 Straight blade available
 Short trachea
 Care with depth of ETT
insertion
 Cricoid narrowest point
 Care with sizing of ETT
 Pronounced reflexes
 Anticipate laryngospasm
 Respiratory
 Immature alveolar development
 Open lung ventilation
 PEEP to maintain FRC
 Fixed tidal volume
 Adjust respiratory rate to meet
MV requirements
 Cardiovascular
 May have patent intracardiac
communications
 Risk of shunt
 Avoid rises in PVR
 Avoid hypoxia
  Avoid hypercapnia
 Renal
 High renal vascular resistance
 Low GFR
 Reduced ability to excrete
excess water
 Limit fasting times
 Consider dextrose
infusion preop
 Limit
transepidermal loss
 Balanced solution
replacement fluid
 GI / Hepatic / Metabolic
 Limited glycogen stores
 Monitor blood glucose levels
 Dextrose for premature infants
 Immature oxidative systems
 Risk of oxygen toxicity
 Avoid hyperoxia esp
in premature infants
 Temperature
 Prone to hypothermia
 Warm environment
 Warm gases
 Monitor temperature
 Surgical
 Laparoscopic or open
 Laparoscopic
 Aspiration risk
 Cuffed ETT
 CO2 
 Monitor ETCO2
 Monitor Arterial
CO2
 Intracardiac connections
 Risk of shunt
 Risk of paradoxical
emboli
 Anaesthetic
 Regional or GA
 Spinal anaesthetic
 L4/5
 GA
 Induction
 Inhalational vs IV
 Emergence
 Emergence delirium 
 Postop
 Analgesia
  Paracetamol
 Caudal
 Monitoring
 Overnight monitoring for apnoeas
 High risk patients
 Ex-Prem PCA<52 weeks

BJAed Anaesthesia for neonates and infants

European consensus statement on fasting in paediatric patients – Endorsement by SPANZA

b) Justify your decision to proceed with

surgery at the local general hospital. (30%)
 Providing able to meet requirements set out in ANZCA Professional
Statement PS29
 Staff
 Age of Patient 
 Specialist anaesthetist experience
 Trained and Current experience
with this age group
 Second anaesthetist available
 Staff in theatre, PACU and ward 
 Trained in care of this age
group
 Surgeons
 Trained and current with this
age group
 Patient
 Age and ASA as defined by local policy
 At least ASA 2 or below
 Referral to specialist centres for
 ASA 3 to specialist
centres
 Patients with
complex medical
issues
 Ex-prem patients at
high risk of post-op
apnoea
 <44
weeks
PCA
 A
ll
p
a
 ti
e
n
ts
 44-58
weeks
PCA 
 w
it
h
p
o
o
r
p
o
st
n
a
t
a
l
h
is
t
o
r
y
 Neuro
musc
ular
diseas
e
 Curre
nt
infecti
on
 Chron
ic
lung
diseas
e
 Equipment and Facilities
 Specific to this age group
 Airway equipment
 IV equipment
 Anaesthesia delivery system
 Monitoring
 Operating room
  Able to be warmed to appropriate
temperature
 Parents able to be present for induciton
oand recovery with escort

 No neonatal patients (<28 days age), ex prems with PCA <52 weeks, no
infants with history of apnoeic episodes
 No children with complex medical issues or ASA III

ANZCA PS29 – Care of children in healthcare  facilities without dedicated paediatric

facilities

ANCA PS18  – Monitoring during anaesthesia 

14A01 (23.3%) Outline the advantages and

disadvantages of using the paediatric circle
system and the Jackson-Rees modification of
Ayre’s T- piece (Mapleson F) for anaesthesia
in a 15 kg child
Examiner’s Report

Key components of an answer for this question required candidates to

Demonstrate adequate understanding of each system. Should mention:

Resistance – valves; Dead space; Fresh gas flows

Better candidate will mention: Humidification, scavenging, weight/bulk, provide more

detailed understanding / explanation and point out there is less difference between
contemporary systems
Breathing
Paediatric Circle Mapleson F
System

15mm tubingOne way valvesCO2

T piece15mm tubingOpen ended 500ml bagFresh
Description absorberVentilator or 500ml bagAPL
gas at patient connection
valve

Advantages Reduced costRecycling of Light weightPortableLow resistanceNo

volatileLess greenhouse
 gasScavenging built inReduced staff
exposure to volatilesDecreased heat valvesGood ‘feel’ of compliance
lossDecreased water loss

Lower efficienyStaff exposure to

Only for patients >5kgIncreased
volatilesBarotrauma possible if occlude
resistance vs MpFLess portableLess
bagScavenging difficultMechanical ventilation
Disadvantages ‘feel’Hand assistance more
problematic with modern machinesSafety issue
difficultLess precise pressure
switching circuits to establish mechanical
adjustment with APL
ventilation

13B10 (57.7%) A 7-year-old nonverbal girl

with severe spastic cerebral palsy is scheduled
for cystoscopy.  Describe the important
features of cerebral palsy relevant to planning
anaesthesia for this procedure. (70%)
Key components of an answer for this question related to:

a. mentioning that CP covers a spectrum of motor, sensory and intellectual impairments of

varying severity and the effects across the varying systems of relevance to anaesthesia and
surgery; CNS, GIT, MSS, Resp, drug issues

b. a brief list of relevant advantages and disadvantages of inhalational technique.

Cerebral Palsy Definition

 Disease characterised by neurological injury and impairment

 Occurring in the prenatal, perinatal or postnatal period
 Impairment of varying degree
 Motor
 Sensory
 Intellectual
 Non progressive 
 Incidence 1:500 births
 More common in premature infants
 ‘Congenital’ – apparent at birth, due antental factors 
 ‘Acquired’ – developing in 1st 2 years 
 ‘Idiopathic’ – no apparent aetiology, 30% of cases

Features Relevant to Anaesthesia

 Wide spectrum of impact on physiology
 Motor
 abnormalities of tone, movement, and posture
 Subtypes – spastic, ataxia, dyskinetic
 Sensory and intellectual impairment
 Varied degrees of impairment
 Assessment of individual patient
 Tailored care to degree of impairment
 Institutionalized patient
 May have distress related to past experiences with HCPs
 Aim to reduce problems for future contact with HCPs
 Reduce stressful events
 Parents/carers often are expert in child’s care 
 Check what has been done previously – old notes invaluable 
 Systems
 CNS
 Epilepsy
 Anti-Epilepsy medications
 Enzyme induction
 Post-op drowsiness
 MAC reduction
 Communication
 Intellectual impairment
 behavioral and emotional disorders
 visual and hearing impairment
 speech disorders.
 AIRWAY
 Aspiration risk
 Sialorrhea
 Consider pre op antisialogogue 
 Poor secretion clearance
 Airway management implications
 Contractures
 Difficulty positioning
 RS
 Chronic lung disease
 Multiple aetiology
 Restrictive lung disease 
 Scoliosis
 Chronic infections
 Sialorrhea
 Poor secretion
clearance
 Respiratory muscle hypotonia
 Increased postoperative respiratory
complications
 Chronic hypoxia and hypercapnia
 CVS
 RV impairment 
 Pulmonary hypertension
  Chronic hypoxia
 Risk of worsening with 
 Hypoxia
 Hypercarbia
 GIT
 Aspiration risk
 Gastro Oesophageal Reflux
 Abnormal LOS tone
 Nutritional impairment
 Often PEG fed
 Risk of pressure areas
 May be on ketogenic diet
 Avoid Hartmann’s 
 MSK
 Difficulty positioning
 Multiple issues
 Spasticity
 Scoliosis
 Fixed flexion deformities
 Risk of nerve injuries
 Risk of pressure injury
 Risk of fractures
 Osteopenia from disuse and malnutrition
 Vulnerable to fracture from minor forces
 Muscle contraction poor
 Increased bleeding when incised
 Heat loss rapid
 Low body fat
 SKIN
 Thin skin
 Difficult IV access
 Risk of pressure injury
 HOMEOSTASIS
 Risk of perioperative hypothermia – ‘the oversize
neonate’
 Low  BMI, low adipose tissue
 impaired hypothalamic regulation
 Glucose
 Impaired homeostasis 
 Measure regularly in long procedures 
 PAIN
 very common in children with CP
 often underdiagnosed
 Difficult to assess, enlist help of
parent/carer 
 Use regional anaesthesia/analgesia where possible
 Multi modal analgesia 
 If pain post op, consider opioid infusion rather than
PCA
 Pain post op may be due to muscle spasms, triggered

by hypothermia, anxiety, pain
 Clonidine in epidural or continuous
regional block if severe 
 MEDICINES
 Polypharmacy
 Poor nutrition – altered protein binding
 Decreased volume of distribution – increased apparent
sensitivity to induction agents 
 Often on anticonvulsants – enzyme
inhibition/induction, also decrease MAC by up to 30%
 Sux controversial – may have immature ACh receptor
proliferation but actually probably fine
 non depolarising NMBDs less potent and shorter
duration of action
 may be offset by small volume of
distribution in low body weight and
dehydrated children 
 use neuromuscular monitoring! And ensure
complete reversal prior to extubation 

What are the advantages and disadvantages of

inhalational induction in this child? (30%)
ADVANTAGES

 Reduced distress
 IV access asleep
 Providing mask well tolerated
 Parental expectation may be for inhalational induction
 IV Access easier asleep
 Vasodilation from volatile anaesthetic

DISADVANTAGES

 Aspiration risk
 Longer induction
 Reflux risk in patients with GOR
 Laryngospasm risk 
 Longer in excitable phase
 May have reactive airways already if prone to chest infections
 Propofol decreases airway and bronchial reactivity 
 Second practitioner
 Required to place IV or hold airway during IV
 IV access
 Period without IV access
 Potential risk if airway problems before IV placed
 Staff exposure to volatiles
  Greater with inhalational induction, especially with Mapleson F
 Environmental pollution
 High gas flows with inhalational induction

13A10 (66.8%) List methods to prevent

hypothermia in paediatric patients during
anaesthesia and surgery, commenting on the
effectiveness of each.
Examiner’s Report

Key components of an answer for this question related to listing methods and giving some
information about efficacy. Modalities to be mentioned: Forced air warming Insulating layer
Warming OR Circulating water mattress IV fluid warming Humidification of gases Preop
warming, Radiant heaters

Modes of heat loss

Radiation: 40% – major component

Convection up to 30%- due to loss of heat to air immediately surrounding the body. 

Conduction: 5%- eg theatre table or cold fluids.

Evaporation 15%- eg from cleaning fluids, skin, respiratory, bowel and wound surfaces.

Respiratory 10% 
Class Method Effectiveness

Not always well tolerated by the

Active active childReduces heat loss in
Pre-warming of patient
first hour of anaesthesia due to
redistribution

Effective if large volumes or txMay

Warmed IV fluids
cool as being infused

Forced air warming Reduce both radiative and conductive

loss – major components of heat
 lossUnder and over-body warming
possibleRisk of thermal injury

Limited surface area for heat

Electric warming mattress
transferHigher risk of thermal injury

Circulating water Limited surface area for heat

mattress transferHigher risk of thermal injury

Radiant heaters Reduce radiant heat loss in neonates

Passive Minimise exposure surface and time Reduces evaporative losses

Humidification of
respiratory gases
Recirculation of  gases in Only 10 % of heat loss from respiratory
circleHeat and water
vapour from soda lime

Reducing child’s exposure to

Increased ambient
environment more effective and more
temperature and humidity
practical

Increased ambient
Reduces evaporative losses
humidity

Temperature monitoring Ideally core temp 

Checks to make sure heating equipment

Anaesthetic vigilance working properly, reducing unnecessary
exposure of child

12B05 (74.5%) You are asked to assess a 4

year old child who is scheduled for a
strabismus correction as a day case
procedure. 
Examiner Report

Key components of a response to this question related to: 1) consideration of

a. preoperative issues: history and examination (looking for causes, family history,
associated disorders, medical therapy e.g. echothiophate)

b. intraoperative: topical vasoconstrictor use, oculo-cardiac reflex and its prophylaxis and
treatment, airway management, provision of adequate surgical conditions, considerations for
analgesia, emergence delirium.

2) Section 7 of College Policy Document PS15 covers most issues relating to discharge of the
patient from a day care facility

1. What are the issues relevant to anaesthesia

(70%). 
 Pre-op
 Patient factors
 Medical history
 Associated syndromes
 Medical therapy
 Paediatric patient
 Psychological preparation for surgery
 Involvement of parents
 Minimise fasting time (PS09)
 Appropriate Staff, Equipment, facilities to
manage paediatric day case pts.
 Pre med with po paracetamol 20mg/kg
 Intra-op
 Limited access to airway
 Intubate trachea
 Oculocardiac reflex (60%)
 Communicate with surgeons (reduce retraction)
 Consider prophylaxis with glycopyrrolate / atropine
 Atropine drawn up ready 20 mcg/kg
 Consider regional block for analgesia
 Possible increased incidence of MH
 Suxamethonium to be avoided 
 20min effect on ocular muscles
 Need sufficient depth of anaesthesia for neutral gaze
 Propofol may affect eye movement less than volatiles
  High incidence of PONV
 multimodal prophylaxis
 Avoid opioids
 Consider TIVA
 Ensure euvolemia
 Day case
 Short acting sedating drugs preferable
 Post-op
 Emergence delirium risk in this age group
 Pain amenable to oral analgesia and topical eye drops
 Paracetamol
 Ibuprofen
 Consider sub-tenons block (surgically placed)

BJA Ed Anaesthesia for Paediatric Eye Surgery

Modified DIMC (Daubney Intraoperative Magic Checklist) – MAID PPICASO

 Monitoring 
 Airway 
 Induction plan
 Drugs 

 Physiological goals 
 Positioning 
 IV fluids 
 Crises / critical periods
 Analgesia plans 
 Surgical Issues
 Other

2. What would prevent you from discharging

this patient home after surgery? (30%). 
If has not met all of requirements for day stay surgery set out in ANZCA PS15

 Vital Signs 
 Stable vital signs for at least one hour
 Conscious Level 
 Conscious state that is similar to pre-anaesthesia levels.
 Pain 
 Adequate pain control, take home analgesia provided.
 Nausea 
 Manageable nausea, vomiting or dizziness.
 Fluids
 Tolerating oral fluids, passed urine.
 Bleeding 
 Minimal bleeding or wound drainage.
  Residence 
 Within 1 hour from hospital
 Supervision 
 Responsible adult available to take home
 Instructions 
 Written and verbal instructions provided to parent, safe mode of
transport arranged

Day Surgery Discharge Criteria – PS15 – V CRISP FUN

 Vital Signs 
 Stable vital signs for at least one hour
 Conscious Level 
 Conscious state that is similar to pre-anaesthesia levels.
 Residence / responsible adult
 Within 1 hour from hospital
 Instructions 
 Written and verbal instructions provided to parent, safe mode of
transport arranged
 Surgical 
 Low risk of bleeding
 Low risk airway problems
 Low risk post-op pain
 Pain 
 Adequate pain control, take home analgesia provided.

 Fluids
 Tolerating oral fluids
 Urine
 passed urine (if risk urinary retention
 Nausea
 Manageable nausea, vomiting or dizziness.

ANZCA PS15 post anaesthesia care and discharge requirements

The following criteria should be satisfied prior to patients being discharged home:

8.3.1 Stable vital signs.

8.3.2 Conscious state that is similar to pre-anaesthesia levels.

8.3.3 Mobility level that is similar to pre-anaesthesia levels with allowance for type of
surgery and/or regional anaesthesia techniques.

8.3.4 Adequate pain control.

8.3.5 Manageable nausea, vomiting or dizziness.

8.3.6 Tolerating oral fluids.

8.3.7 Minimal bleeding or wound drainage.

8.3.8 Patients at significant risk of urinary retention (central neural blockade, pelvic and
other surgery) should have passed urine.

8.3.9 Written and verbal instructions for all relevant aspects of post-anaesthesia and surgical
care have been provided to patients or their accompanying adult. It should be established
that patients and/or their responsible person understand the requirements for post
anaesthesia care and intend to comply with these requirements, particularly with regard to
public safety. A contact place and telephone number for emergency medical care should be
included.

8.3.10 Patients have received advice as to when to resume activities such as driving and
decision making.

8.3.11 Analgesia has been provided where necessary, with clear written instructions on how
and when medications should be used. Careful consideration should be given when
prescribing opioids on discharge.

8.3.12 Advice has been provided on resumption of other regular medications.

8.3.13 Discharge has been authorised by a member of the medical team or trained nurse
after discharge criteria have been satisfied.

8.3.14 A responsible adult is available to transport the patient and must accompany the
patient home in a suitable vehicle. A train, tram, or bus is not suitable. For some patients it
may be important to have an adult escort as well as the vehicle driver. A responsible person
should be available to stay at least overnight following discharge from the unit. This person
must be physically and mentally able to make decisions for the patient’s welfare when
necessary.

8.3.15 If the patient is to be transferred to an inpatient facility, the anaesthetist and/or the
surgeon will be responsible for the patient until care has been transferred to another medical
officer in accordance with PS53 Statement on the Handover Responsibilities of the
Anaesthetist.

12B09 (72.5%) A 3-year-old presents to the

emergency department with a recent onset of
stridor. 
Examiner’s Report
72.5% of candidates passed this question. Key components of a response to this question
included:

Differential diagnoses

– supraglottic,glottic or subglottic origin of stridor

Differentiating between causes

– History of exacerbating factors of existing pathology, Sx of systemic illness, trauma or

possibility of foreign body – Examination: body position, signs suggestive of sepsis, timing
of stridor, response to therapy

– Ix: radiological (and its limitations) or consideration of GA for direct inspection or to

facilitate radiology.

(Consider a table with DD and Differentiating features)

List the differential diagnoses (30%)

Surgical Sieve

 Infection
 Croup 
 Viral Infection
 laryngotracheobronchitis
 Parainfluenza virus
 80% of stridor in children
 Onset
 2-3 days into URTI
 Features
 Inspiratory stridor and cough
 Epiglottitis 
 Bacterial infection
 Haemophilus Influenza B
 Epiglottis, aryepiglottis, arytenoids
 Onset
 Fulminant (abrupt) onset
 Features
 Toxic appearance of child
 Bacterial tracheitis
 Bacterial infection
 S aureus/ haemophilus
 Onset
 2-3 days into URTI
 Rapid progression
 Features
 High fever

Secretions

Retrosternal pain

 Retropharyngeal abscess
 Bacterial infection
 Staphylococci
 Streptococci
 Features
 Neck swelling
 Pain
 Dysphagia
 Trismus
 Mechanical
 Foreign body aspiration
 Features
 Sudden onset
 History of inhalation
 Neoplasm
 Mediastinal Mass
 Likely to be more gradual onset

Level of lesion

 Above the cords – Inspiratory Stridor

 Croup
 Epiglottitis
 At the level of the cords – Biphasic Stridor
 Foreign body
 Cord Lesion
 RLN Lesion
 Tracheomalacia
 Intrathoracic – Expiratory Stridor
 Foreign body
 Asthma
 Croup (severe)
 Mediastinal mass

Croup Score – Mild croup, 0–3; moderate croup, 4–6 (transfer to HDU); severe croup, 7–10
(patient requires tracheal intubation)
Score  0  1  2 

Breath sounds  Normal  Harsh, wheeze  Delayed 

Stridor  None  Inspiratory  Inspiratory and expiratory 

 Cough  None  Hoarse cry  Bark 

Flaring, suprasternal Flaring, suprasternal and intercostal

Recession/flaring  None 
recession  recession 

Cyanosis  None  In air  In oxygen 40% 

 Supraglottic (extrathoracic) – Inspiration

 Infection
 Retropharyngeal abscess/ quinsy
 Epiglottitis
 Mechanical
 Foreign body
 Subglottic (intrathoracic) – Expiration
 Inflammation
 Asthma
 Infection
 Croup (laryngotracheobronchitis)
 Inspiratory stridor and cough
 80% of stridor in children
 Bacterial tracheitis
 S aureus/ haemophilus
 Bronchiolitis
 Mechanical
 Foreign body
 Mediastinal masses/ thyroid
 Glottic – Biphasic
 Infection
 Croup (laryngotracheobronchitis)
 Inspiratory stridor and cough
 80% of stridor in children
 Mechanical
 Foreign body
 Cord lesion
 Laryngomalacia (inspiratory)
 RLN palsy

How do you differentiate between the

potential causes of this stridor? (70%)
H-E-I

History
  Diagnosis guided heavily by history
 Previous episodes
 Possibility of foreign body 
 playing with lego, parent lost their marbles
 Past medical history
 Tracheomalacia more likely in neonate
 Vaccination history (HIB, pertussis)
 Recent contact with other ill people
 Timing
 Onset
 Preceding URTI
 Rapid vs Gradual
 Exacerbating factors 
 Position – variable severity with mediastinal mass
 Systemic illness
 Fever
 Trauma
 Laryngeal injury

Examination

 Stridor
Inspiratory, expiratory, biphasic
Continuous / intermittent
Characteristic features
 Eg barking cough in croup
 Signs suggestive of sepsis
 Fever
 Secretions
 inability to swallow secretions, drooling
 More common in epiglottitis
 Voice changes
 Vocal cord involvement
 Response to therapy 
 eg adrenaline neb

Investigations

 Care with any procedure that may distress child

 may precipitate complete airway closure
 Radiological (and its limitations) 
 CXR
 insp and  expiratory (may be difficult to get child to
comply)
 Lateral neck XR
 Look for swelling consistent with retropharyngeal
abscess
 CT – high radiation, needs GA
 Consideration of GA for direct inspection or to facilitate radiology
  FNE – poorly tolerated awake
 Blood tests
 To look for infective cause
 CRP
 CBC
 Viral Swabs
 Parinfluenzas

911B08 (76%) A child with active upper

respiratory tract infection presents for general
anaesthesia. 
76% of candidates passed this question

Key components of a response to this question included:

Factors which increase adverse respiratory events:

– different airway instrumentation devices

– age, prematurity

– history (bronchial reactivity, patient symptoms and signs, parental smoking or other
exposure) – surgical intervention, airway manipulation

Risk reduction:

– methods to decrease secretions: mechanical, pharmacological – airway device choice and

use

– monitoring

a. Outline the factors that increase the rate of

adverse respiratory events during
anaesthesia. (50%)
PAS

 Patient 
 from the APRICOT Study
 Patient
 Age
  Especially <1 year
 Airway sensitivity
 URTI in past 2 weeks
 Wheezing in past 12 months
 Asthma Diagnosis
 Passive smoking
 Environmental sensitivity
 Atopy
 Physical condition
 Prematurity
 Fever
 Snoring
 ASA >1
 Anaesthetic
 Years of experience of most senior
anaesthetist
 Anaesthesia team
 GA > Sedation
 Inhalational induction
 Airway instrumentation
 ETT
 SGA
 Surgical
 ENT surgery
 Surgical vs non-surgical proceure

Operative
Low Age >5
Risk

Mild Proceed with

Clear dischargeClear chestNot unwell
URTI surgery

Severe Fever >38 CCopious secretionNasal congestionChest Delay 2-4

High
URTI SignsConstitutional change ‘not theirself weeks

Age <1 yr with any URTI1-5 yrs with above features

Risk passive smokinghistory of snoringprematurity <37

factors wksETT requiredENT surgery

High risk History Severe URTI history not their-self’not eating

 Risk factors passive smokinghistory of snoringprematurity <37 wks

Age <1 year

Examination General Looks unwellHR > 140Temp >38C

ENT Copious secretionsNasal congestion

RESP RR > 35Sp02 <98%Respiratory distressChest signs

b. How can you reduce the risk of an adverse

event occurring? (50%)
P-A-S

 Risk Reduction
 Pre-op
 Assessment – Indications to delay
 Postpone if severe URTI
 Systemically unwell 
 Fever
 Postpone if > 2 other risk factors and
mod/severe URTI
 Prematurity
 Asthma
 ENT surgury
 Age <1 year
 Treatment
 Bronchodilators
 Salbutamol
 Intra-op
 Senior paediatric anaesthetist to perform case
 Secretion reduction
 Glycopyrrolate
 Hyoscine
 Sensitivity reduction
 Pharmacological
 Analgesia
 Propofol
 IV Lidocaine
 Avoid desflurane
 Physical
  Airway instrumentation
 Mask > SGA > ETT
 Consider deep removal airway
device (risk benefit)
 Reduces
laryngospasm
 Induction method
 IV preferred vs Inhalational
 Propofol induction agent
 Post-op
 Deep extubation (consider)
 Postoperative apnoea monitoring

11A09 (67%) You hear a cardiac murmur in a

two-year-old child presenting for elective
minor surgery. 
Examiner’s report – Key components of a response to this question included:

• Innocent (soft/early systolic/postural change)with examples

• Pathological(loud/diastolic/pansystolic/continuous)with examples

• Inclusion of other standard cardiovascular examination features

• Evaluation by history & investigations

• Context: innocent murmurs occur in up to 70% of younger children. Innocent murmurs

should not require

echocardiography, referral to a cardiologist, or cancellation of minor surgery

• Murmurs with pathological characteristics (historical or clinical) should be further

evaluated

Well-structured answers used comparison tables and flow charts to demonstrate pathways of
decision-making (with examples) that led to conclusions regarding evaluation.

(a) What are the features of the murmur that

would differentiate an innocent from a
pathological murmur? (50%)
  7 S’s of innocent murmurs
 Sensitive ie positional
 Short duration
 Single (no click or gallop)
 Small (focal distribution, non radiating)
 Soft eg 2/6 no thrill
 Sweet not harsh
 Systolic (diastolic is concerning)

 Features
 Symptoms
 Timing
 Quality
 Precordial thrill
 Variation with positioning
 Age
 Associated syndromes
 Behavioural
 Innocent Murmurs
 Asymptomatic
 Early systolic or continuous murmur
 Blowing, Musical, Vibratorty murmur
 No precordial thrill
 No Variation with posture
 Pathological Murmurs
 Symptomatic
 DIastolic, Pansystolic or late systolic
 Variable, Harsh

Differentiating Features
Murmur  Innocent  Pathological 

Cardiac symptoms  Asymptomatic  Symptomatic 

Early systolic or continuous (venous

Timing  Diastolic, pansystolic, or late systolic 
hum) 

Quality of murmur  Blowing/ musical/ vibratory  Variable/harsh 

Precordial thrill  Never  Sometimes 

Variation with Often  Rarely (HOCM murmur increases on

 posture  standing) 

(b) How would you evaluate this child’s fitness

for anaesthesia from the cardiac perspective?
(50%)
BJAed Dilemmas in Paediatric Anaesthesia

H–E–I

 History
 Age
Under 1 year
 Associated syndromes
 Downs
 CHARGE
 VATER
 Turners
 DiGeorge
 Behaviour
 Decreased exercise tolerance
 Squatting
 Syncope
 Examination
 Inspection
 Cyanosis
 Clubbing
 Palpation
 Precordium
 Thrills
 Pulses (all 4 limbs)
 Rate, Rhythm
 Equality
 Delay
 Abdomen
 Hepatomegaly
 Ascites
 Auscultation of murmur
 Location
 Quality
 Timing
 Duration
 Intensity
 Variation with posture
 Investigation
 ECG
  Ventricular hypertrophy
 Left Axis deviation
 Echo
 Evaluation for structural defects

 High Risk of mortality

 Cyanosis
 Young age
 Complex cardiac defects
 Poor general health
 Current treatment for heart failure
 Referral to specialist centre
 Pulmonary hypertension
 Coronary artery abnormalities
 New onset arrhythmias
 Ventricular failure
 Obstructive valvular disease
 Post corrective surgery
 No increased risk
 If well compensated

10A09 (61.4% ) a. Describe the factors that

influence emergence delirium in children.
(50%)
Examiner’s Report

of candidates passed this question. The following were key components of an answer
required to pass this question:

Part A:

Factors can be divided into anaesthetic (eg short acting rapid offset inhalational agents),
surgical (eg possible increase with surgery around the head and neck) and patient-related
(eg peak age group 2-5 years old) The incidence is reported to be lower with total
intravenous anaesthesia, and a propofol bolus at the end of surgery has been reported to be
preventative. The use intraoperatively of ketamine, fentanyl, clonidine or dexmedetomidine
may also be preventative, but not midazolam.

BJA 2017 Article

Definitions

 DSM IV and V condition;5,9,10

 disturbance in immediate post-anaesthesia period of
  a child’s awareness of and attention to his/her
environment with 
 disorientation and perceptual alterations including
 hypersensitivity to stimuli and 
 hyperactive motor behaviour
 Paul’s notes
 Emergence delirium is a transient state of marked irritation and
dissociation 
 after the discontinuation of anaesthesia in some
patients 
 which does not respond to consoling measures. 
 It is most likely to occur in paediatric patients between
2 and 5 yrs of age 
 undergoing relatively painful procedures 
 under inhalational anaesthesia.
 Vopel-Lewis et al 2003
 Emergence agitation characterized by

 non-purposeful movement, 
 restlessness, 
 thrashing, 
 incoherence, 
 Inconsolability
 unresponsiveness 

Factors (PAS – PIP)

 Patient
 Age 
 Peak incidence 2-5
 Anxiety
Parental anxiety

Patient pre-operative anxiety

 Pre-existing behaviours
 Pre-disposing to anxiety
 Temperament
 Sociability
 Cognitive skills
 Interactions with healthcare providers
 Negative interactions pre-anaesthesia
 Increases risk EA
 Negative behaviour at induction
 Increases risk EA
 Anaesthetic- 

 Pre operative
 Psychological
 Behavioural management to decrease pre op anxiety
 Parental presence at induction/distraction
techniques(cartoons/video goggles)
  Interventions
 ADVANCE,
 Anxiety re- duction,
 Distraction on the day of
surgery, 
 Video modelling and education
before the day of the operation, 
 Adding parents to the child’s
surgical experience, 
 No excessive reassurance, 
 Coaching of parents by staff
 Exposure/shaping of the child
via mask practice.
 After a 30 min average time commitment
of the health- care staff via videotape,
pamphlets, and a kit for practising mask
induction, the children exhibited less ED
than those with midazolam premedication
or parent-present induction
 Premed
 Consider anxiolytic pre med
 Parent- education and reassurance 
 Fasting
 Avoid excessive fasting
 Premedication/intra op- 
 A2 agonist administered at any point 
 clonidine oral 4-5mcg/kg, IN 4mcg/kg. Iv intraop
2mcg/kg
 Dexmed 1-2mcg/kg IN(RCT trial) 45min prior and
may be superior to clonidine. Iv intraop 2mcg/kg iv
then .7mcg/kg/hour -More effective than a narcotic.
Other option of 0.3mcg/kg iv pre emergence rather
than propofol
 Oral gabapentin pre med 15mg/kg
 BZD effective if reduce anxiety pre med
 ???Pre op oral Melatonin 0.4mg/kg reduced ED from
25–>4%. 2009 study. 
 Ketamine 1mg/kg iv or pre med 6mg/kg orally 
 Intraoperative
 Induction
 Increased with with inhalational induction
 Maintenance
 Increased risk with Sevofluorane
 short acting rapid offset volatile anaesthetic
 Increased risk with Sevofluorane
 Pharm prophylaxis 
 Clonidine see above
 Propofol 1mg/kg
 Dexmed see above
 Ketamine 
 MgSo4 post induction 30mg/kg iv then 10mg/kg/hour 

 Minimise pain/Multimodal- fentanyl, paracetamol, NSAIDs
 tonsillectomy 2.5mcg/kg fent 
 Anaesthetic Agent
 Sevo > Des
 TIVA
 Post operative
 Reduce stimuli if possible
 Noise, 
 Light
 Handling
 Surgical
 Surgery around head
 ENT
 Head and neck 

b. How would you manage emergence

delirium in a 3 year old child having had
myringotomy tubes inserted under general
anaesthesia? (50%)
Examiner’s Report Part B:

Although difficult, an attempt should be made to eliminate causes of emergence agitation

such as pain, hunger, thirst, hypo or hyperthermia, anxiety or hypoxia

Take steps to prevent the child from injuring themselves

Reduce stimuli if possible, such as noise, light and handling

Reassure the parents of self-limiting nature and good prognosis of the condition

If severe, consider rescue medication with propofol, dexmedetomidine, fentanyl or clonidine

(including doses)

Comments about how this question was answered:

A brief definition or description of emergence delirium was not asked for, but enabled the
examiner to be clear that the candidate was describing the correct condition. Good
candidates differentiated the condition from other causes of agitation during emergence from
anaesthesia Good candidates also described how they would assess the child in recovery to
exclude these other causes and described both general and specific measures to manage both
the child and the parents Many candidates described factors that affect behaviour at
induction, rather than emergence In part B, preoperative and intraoperative management
was often discussed, even though postoperative management had been asked for. It was
common to incorrectly state that emergence delirium is affected by the length of anaesthesia,
or by the use or absence of nitrous oxide, or that it can be successfully treated with
midazolam

Management of delerium

 Patient Safety
 Assessment
 History and assessment of patient
 Check anaesthetic chart (procedure, medication given-
prophylaxis)
 Assessment
 Features helpful in differentiating ED from Pain
 No eye contact
 no purposeful action
 no awareness of surroundings
 Features unreliable in differentiating ED from Pain
 Inconsolability
 restlessness 
 Scoring 
 PAED score- emergence delerium scoring system.

Individual components summedGreater score correlates with

PAED Score
severity

1. The child makes eye contact with the 4=not at all3=just a little2=quite a bit; 1=very
caregiver much0=extremely

4=not at all3=just a little2=quite a bit; 1=very

2. The child’s actions are purposeful
much0=extremely

3. The child is aware of his/her 4=not at all3=just a little2=quite a bit; 1=very

surroundings much0=extremely

0=not at all; 1=just a little; 2=quite a bit; 3=very

4. The child is restless
much;4=extremely

5. The child is inconsolable 0=not at all; 1=just a little; 2=quite a bit; 3=very
 much;4=extremely

 Treatment
 Non pharmacological
 Identify and address other causes of agitation
 Pain
 Hunger
 Thirst
 Hypo or hyperthermia
 Anxiety
 Hypoxia
 Reduce stimuli if possible
 Noise, 
 Light
 Handling
 Pharmacological interventions-
 rescue medication if severe
 Fentanyl
 IV 0.5mcg/kg
 IN 1.5mcg/kg 
 Clonidine 
 IV 0.5mcg/kg
 IN 4mcg/kg
 Propofol 
 IV 0.5-1mg/kg
 Dexmedetomidine 
 IN 2mcg/kg
 Midazolam 
 NOT effective
 Midazolam not a treatment for
ED- can be used preop for
anxiolysis but 14% of patients
may have the opposite effect
(extreme distress)

09B12 You are asked to give a practical

tutorial on paediatric airway management to
Emergency Department registrars at a large
hospital. 
What are the important aspects of paediatric
airway management that you would present to
them?
Examiner’s Report

The following were key components of an answer required to pass this question.

• The anatomical and physiological airway characteristics in children

• Assessing the airway in a child

• Basic airway manoeuvres

• Airway equipment including guedel airways, LMA, nasopharyngeal airways

• Intubating equipment and technique in paediatric resuscitation

• Airway procedures including the surgical airway in a child

• Common paediatric airway scenarios 

Comments about how this question was answered:

• Many candidates focused inappropriately on airway management during induction of

anaesthesia

• Some candidates focused only on endotracheal intubation

• Good answers used examples of common airway emergencies to illustrate their points

• The anatomical and physiological differences between children and adults was well
described

• Surgical airway options were frequently omitted

 Calculations
 ETT size
 0-2 years
 Newborn <3kg 3.0mm
 Newborn 3.5mm
 4 months 4.0mm
 12-16 months 4.5mm
 Over 2 years Age/4+3.5 (cuffed ETT)
 Anatomy and physiology – paediatric vs adult airway
 Prone to laryngospasm
 Increased sensitivity of airway reflexes
 Shorter desaturation time
 Reduced FRC
 Increased metabolic rate
 Head positioning
 Larger head and occiput compared to the adult which
can cause flexion of the head and potential obstruction
to the airway when the child is supine(mainly as a
infant and the first year of life)
 Don’t need to use a pillow in younger children- keep
head neutral
 Drug dosing
 Dosing by weight mg/kg
 Narrowest point of airway
 Level of cricoid
 Laryngoscopy
 Anterior larynx may make intubation more difficult→
towel roll under the shoulder of an infant may bring
the glottis into view 
 Large floppy epiglottis may obstruct the view –
>frequently use straight blades
 Risk of endobronchial intubation
 Shorter distance from cord to carina / RULB
 Assessment 
 Congenital syndromes
 Specific to presenting condition
 Airway swelling
 Burns
 Facial trauma
 Teeth
 More likely to have loose teeth
 Equipment 
 Mask sizing 
 Guedel sizing
 Laryngeal Mask 
 Specific laryngoscopes
 Straight blade
 Curved of appropriate size
 ETT sizing 
 Basic airway manoeuvres 
 Supporting the airway
 Open the airway
 head in a neutral position
 Chin lift/jaw thrust
 Easy to obstruct
 fingers on mandible not on soft
tissues
 Oropharyngeal airway
 Sizing
Insertion technique in child
 Nasopharyngeal airway
 Sizing
 Insertion technique
 ETT insertion
 Laryngoscopy
 Common scenarios
 Obtunded child / low GCS
 Burns
 Foreign body
 Epiglottitis/Stridor 
 Resp/Cardiac arrest
 Seizures
 Facial trauma
 Airway management planning
 Human Factors
 Team work
 Decision making
 Resource management
 Communication
 Rescue devices and adjuncts
 LMA
 Bougie
 CICO
 FONA

09A13 (13.9%) Outline the steps you would

take to ensure the safe introduction of elective
paediatric surgery at your local private
hospital.
ANZCA PS29 – Care of children in healthcare  facilities without dedicated paediatric
facilities

ANCA PS18  – Monitoring during anaesthesia

 Process guiding introduction

 MDT group involving stakeholders
 Surgeons
 Anaesthetists
 Theatre nurses
 Ward Nurses
 Theatre managers
 Ward Managers
 Seek advice
  Specialist centre
 Guidelines
 Research for local/national/ANZCA/college/
international guidelines
 Timeline with key steps
 Discussion of scope
 Definition of physical and resource requirements
 Outline of required processes to be defined
 Policy development
 Process development
 Education plan
 Quality Improvement
 Involve other organisation
 Specialist children’s hospital for referral
 Other local hospitals
 Authorities
 Local, state, national
 Formulate local protocols
 Specific issues identified in ANZCA professional document 29
 Age of patient
 Specified age at which restrictions come
into effect
 ASA of patient
 Guidance on what ASA pts will care for
 Guidance on which pts to discuss / refer to
tertiary hospital
 Staff training and experience
 Specialist anaesthetists
 Training in the care of infants
 Regulate clinical exposure to
maintain competence at age
level
 Second anaesthetist requirement
 ASA 3 patients
 Perioperative Staff
 Anaesthesia assistant/nursing
staff/recovery staff 
 trained to care for children
 Equipment and facilities
 Anaesthesia equipment specific to
paediatric patients
 Airway
 Ventilator, circuits
 Cannulas
 Fluids, infusion pumps
 drugs
 Climate control and equipment 
 designed to meet the special
needs of small children
  Maintain body temp throughout
the perioperative period.
 Monitoring equipment 
 suitable for use with infants and
children.
 (ANZCA PS18)
 Ward facilities
 Dedicated ward facilities for
paediatric patients and available
resus equipment 
 An area where the parents and
child can be seen privately in
the perioperative phase
 Transfer to a specialist centre
 Guidance on who to transfer to specialist
children’s hospital
 Liaison with a specific specialist children’s
hospital for definitive advice and referral
 Specific groups for referral / transfer to
specialist children’s hospital
 Neonates (<28 weeks)
 Ex-Premature infants (GA <37
weeks) with PCA<52 weeks
 infants (need post-
op monitoring as
increased risk
apnoea)
 Infants with history of apnoeic
episodes
 Infants with complex medical or
surgical problems ASA 3 or
greater
 Patient Selection
 Patient selection for a non specialist private
hospital. 
 Only children above age 1 
 ASA 1 and 2. If 
 ASA 3 or above would need a
second anaesthetic involved and
discussion with a paediatric
specialist centre. 
 Process development
 Referral
 Admission
 Perioperative
 Discharge
 Readmission
 Education plan 
 All staff
 Ward
  Theatre
 Medical 
 AHP
 Nursing

08B07 (31.5%) 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.
Examiner’s Report

Candidates who classified implications under comprehensive headings performed much

better than those who gave random lists which frequently missed entire areas of clinical
relevance.

Effects on the respiratory system (aspiration, recurrent phenomena, restrictive lung disease,
upper airway obstruction, sensitivity to opiates) were answered well. The issues of
contractures causing problems with positioning, padding and intravenous access were also
well covered. Concurrent epilepsy and the implications of medication were well mentioned
but unfortunately reference to temperature control (both central control and operative loss)
and treatment of temperature was not. The implications of the surgery itself being prolonged,
painful and potentially bloody (osteotomies) were seldom mentioned. Not one candidate
mentioned possible SPICA plastering at the end of the case and the potential hazards this
entailed.

Although the words “good analgesia” and “regional techniques” were often used there was
little expansion of this and even less mention of doses employed caveats or clinical
limitations. The monitoring of patients postoperatively with respect pain management,
respiratory depression, physiotherapy or higher nursing requirements was almost
nonexistent. Only 3 candidates mentioned treatment for postoperative nausea and vomiting
whereas nearly all mentioned the relevance of severe gastroesophageal reflux and
aspiration. Some mandated the use of antacid therapies but then chose to sedate the patient
and then do a gaseous induction. Techniques vary amongst anaesthetists and precise
methods were not required only a discussion of implications.

At least 80% of candidates incorrectly said that suxamethonium was contraindicated and
associated with a dangerous potassium rise! Also venous thromboembolism prophylaxis is
not indicated in this operation at this age.

Cerebral Palsy
  Describes a diverse group of neurological disorders characterized by varying
degrees of sensory, motor and intellectual impairment
 It is a primary disorder of posture and movement
 Classified according to
 Extremity involved (monoplegia, hemiplegia, diplegia,
quadriplegia)
 Characteristics of the neurological dysfunction
(spastic, ataxic/hypotonic, dystonic/athetotic)

CP Feature Implication for management

MSS

Contractures, spasticity joint deformity,

Difficult positioningPressure areasDifficult IV access
scoliosis, Thin Skin

Increased blood lossConservation strategiesDiathermyCell

Poor muscle contraction on skin incision
salvageAntifibrinolyticsAutologous transfusion

Risk of hypothermiaMonitor temperature intraop. Consider

Thin skin, reduced subcutaneous fat pre op warming if possibleNeed for active warming
strategies

Can have acute withdrawal if unable to eatPain can

Antispasmodics (baclofen)
precipitate 

AchR upregulation Resistant to NDMR

CNS

Varying sensory/motor/intellectual
impairmentVisual and hearing Communication difficultyPersonalised approachInvolve
impairmentBehavioral and emotional carers / parentsDifficulty assessing pain
disorders

Epilepsy Aim to continue perioperativelyCan affect liver enzymes and

reduce MAC 30%. Can cause sedation and slower recovery
 from anaesthesiaAvoidance of seizure threshold lowering
medications ie tramadol, enflurane, pethidine  

Assessment can be difficultPain can trigger muscle

Abnormal pain perceptionPostoperative spasmsPost op analgesia should be continuous rather than on
pain management demand. May need HDU/ICU monitoring to ensure no
oversedation/complications from this. 

RS

Restrictive lung defects from scoliosiscan

lead to pulmonary hypertension, cor If significant will need higher level of monitor in HDU/ICU
pulmonale and respiratory failure post operatively 

May have chronic lung disease especially if

born premature with neonatal respiratory
distress syndrome 

Increased risk of aspiration pneumonitis

with swallowing difficulties/oesophageal Ensure fasted Protect the airway- ETT. Consideration of a
dysmotility, Decreased LOS tone and spinal RSI depending on patient cooperation/balance of risk 
deformity predisposing to GORD

Increased respiratory secretions Aspiration 

Respiratory muscle hypotonia Decrease in FRC

GI

Consider pre op antacid. ETT to protect the airwayRSI vs

GORD- risk of reflux/aspiration(see above)
gas induction with 30 degrees head up

Constipation Co-prescription of stool softeners post operatively 

PONV Prophylaxis intraop

Immunity

Decreased immunity due to poor nutrition Increased risk of post op infection/pneumonia 

2008A Q11 You are the anaesthetist at a

children’s 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.
HEI

 History
 Age (<1 year more concerning
 Associated syndromes
 Downs
 VATER
 CHARGE
 Turners
 DiGeorge
 Symptoms
 Decreased exercise tolerance cf peers
 Syncope
 Squatting
 Recurrent chest infection
  Tachpnoea
 Sweating
 Feeding difficulties
 Failure to thrive
 Hypercyanotic spells
 Funny turns and chest pain
 Family history
 Sudden death
 Examination
 Inspection
 Percordial pulsations
 Dysmorphic features
 Weight
 Signs of breathlessness
 Central cyanosis
 Palpation
 Praecordium
 Thrills
 Heaves
 Pulses
 Delay
 Radio-radioal
 Radio-femoral
 Abdomen
 Hepatomegaly
 Ascites
 Percussion
 Auscultation
 Heart sounds for intensity and chronology
 Murmur
 Location
 Timing
 Quality
 Duration
 Intensity
 Variation with posture
 Temperature
 ? endocarditis
 Investigation
 ECG
 Left Ventricular hypertrophy
 Left axis deviation
 Right Ventricular Hypertrophy
 Inflammatory markers

 Features of innocent murmur

 Timing
 Early Systolic
 Continuous
 Quality
  Soft
 Blowing
 Musical 
 Vibratory
 Thrill
 Never
 Symptoms
 Asymptomatic
 Variation with position
 Often varies with posture
 Softens when standing

 Features of pathological murmur

 Symptoms
 Symptomatic
 Quality
 Variable
 Harsh
 Precordial thrill
 Sometimes
 Timing
 Diastolic
 Pansystolic
 Late systolic

Decision to proceed with surgery

 Proceed with surgery if:

 >1 year old
 Features consistent with an innocent murmur
 No features concerning for pathological murmur
 Systemically well
 No features suggestive of endocarditis
 Otherwise, would delay and refer for further investigation before surgery

08A08 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? 
APGAR Score
 Appearance (skin colour) Blue 0 Acrocyanosis 1Pink 2

Pulse (pulse rate) Absent 0<100 1>100 2

Grimace (reflex irritability No response to stimulation 0Suction or aggressive stimulation 1Cries

grimace) with stimulation 2

Activity (activity) None 0Some flexion 1Strong tone 2

Cry (respiratory effort) None 0Weak irregular gasping 1Strong cry 2

APGAR = 1

Describe your resuscitation of the baby.

NZRC Neonatal Resuscitation Guidelines

Neonatal resucitation

 Call for help

 Keep warm and dry, ensure open airway
 Stimulate with towels
 Positive pressure ventilation
 Attach SpO2 monitor to right wrist 
 Measure pre-ductal SpO2
 If HR below 60 chest compressions
 3 compressions to 1 breath
 Venous access
 Intubation
 3.5ETT
 Volume exansion
 Adrenaline

07B12 (64%) A 3 week old male infant who

was born by uncomplicated vaginal delivery
at term presents with projectile vomiting for 2
weeks. His weight is now 2.8 kg from a birth
weight of 3.1kg. His presumed diagnosis is
pyloric stenosis. His blood chemistry results
are
Na 129 mmol/L (135-145 mmol/L ) K 3.0
mmol/L (3.5-5.5 mmol/L ) Cl 84 mmol/L (95-
110 mmol/L) HCO3 36 mmol/L (18-25 mmol/L
) Creatinine 69 μmol/L (20-75 mmol/L)
Glucose 3.0 mmol/L (2.5-5.5 mmol/L)
Explain how these abnormal results come
about.
 Metabolic alkalosis
 Persistent loss of gastric acid
 Loss of hydrogen ions and chloride ions
 Loss of sodium and potassium ions
 Rise in Bicarbonate ions
 Renal K/H exchange
 Attempt to compensate for extreme hypokalaemia
 Hypokalaemia
 Renal sodium and water loss
 Increased bicarbonate load to distal tubule
 Alkaline urine
 Renal potassium loss
 RAS activation from dehydration and stress
 Attempted sodium conservation
 Renal potassium loss
 Hyponatraemia
 Water retention from ADH secretion
 Gastric secretions sodium loss
 Renal sodium loss from bicarbonate

Describe an appropriate fluid resuscitation

regime for this infant. 
 Assess degree of dehydration
 Resuscitation
 NaCl 0.9% 20ml/kg
 Replacement of deficit
 NaCl 0.9% 
 half over 4 hours
 Remainder over 12 hours
 Maintenance 4ml/kg/hr
 Replacement of ongoing NG losses
 1 for 1 replacement of NG losses

List the laboratory criteria by which you

would consider him sufficiently resuscitated
for surgery.
 Ideal targets
 All lab markers normal
 Priorities
 Normalise serum chloride
 Serum chloride 105mmol/l
 Urine chloride 20mmol/l
 Normalise serum bicarbonate
 Indicates correction of acidosis

07A04 Describe the assessment of a two-year

old child with lower body immersion burns,
and management of pain and fluid
requirements in first two hours following
injury.
Examiner’s report

This question was slightly ambiguous. Equal marks were awarded for each of the two ways
in which it could have been answered. Nearly all candidates read the question correctly and
gave appropriate answers.

A pass mark required:

• A reasonable approximate assessment of the extent of the burn – ie depth and area (using
appropriate body surface area percentage charts modified for small children).

• An appropriate fluid regimen eg Parkland formula starting from the time of the burn, using
a balanced salt solution.
• An appropriate pain assessment (observational rather than by direct questioning at this
age) and appropriate acute pain management, recognising the need for titration of opiates in
a potentially shocked child.

Assessment

 According to EMST guidelines

 A – Assess for thermal injury
 B – Rate, adequacy, saturation, WOB
 C – BP, HR, Capillary return in unburnt and burnt limbs
 D – responsiveness with AVPU
 E – Expose and evaluate
 Assessment of the burn
 Evaluate surface area for each depth
 Age appropriate charts (lund and browder)
 Specialist referral if >5% full thickness burns
 Assessment of pain
 2 years old – won’t self report
 Observational and behavioural scales
 FLACC
 Obs HR, RR, Sweating

Management

 Management of Pain
 IV access
 Analgesia requirements high
 Paracetamol 20mg/kg loading dose (90mg/kg/day)
 Nasal Fentanyl 2 mcg/kg
 Morphine IV titrate to effect up to 0.1mg/kg
 Ketamine 0.5mg/kg
 Management of fluid requirements
 Key components
 Fluid resuscitation
 Maintenance
 Resuscitation
 If >10% BSA burns
 Parkland formula 4ml/kg x %BSA burn in 24 h
 50% fluids in first 8h
 Remaining 50% in remaining 16h
 Maintenance
 4:2:1