1. All of the following
statements regarding pain neurophysiology are true except:
A.
A-d
fibers are associated with sharp localized pain, whereas C fibers are associated
with dull diffuse pain
B.
Substance P, a peripheral pain
transmitter can increase the responsiveness of peripheral nociceptors to pain
C.
The underlying principle of
transcutaneous electrical nerve stimulation (TENS) is such that large diameter
peripheral nerves are stimulated, effectively blocking nociceptive information
from the periphery
D.
The neuroanatomic pathways for
pain transmission develop at 4 months of age
E. Pain may be relieved by altering the patient’s emotional responses to
it
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2. Which of the
following statements is true regarding opioids and opioid receptors:
A. The opioids most commonly used in the management of pain are kappa
agonists
B.
The receptor
m1
involves respiratory depression and the m2
receptor involves supraspinal analgesia
C. m2
receptor
stimulation causes tachycardia
D.
The
m2
receptors
are more abundant at birth and may account for the increased risk of opioid-induced
respiratory depression in infants
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3. Match the pain
receptor with its anticipated effect or prototype agonist:
A.
m
receptor
B.
k
receptor
C.
d
receptor
D.
s
receptor
____
1.
Dysphoria/hallucinations
____
2.
Inhibition of antidiuretic hormone release
____
3.
Inhibits GI motility
____
4.
Phencyclidine
____
5.
Methadone
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4. Match the opioid
receptor with its effect:
A.
Seizures in the newborn
B.
Catastrophic interaction with MAO inhibitors
C.
Chest wall and glottic rigidity
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here for answer
5. Which of the
following statements is true regarding the commonly used m-agonist
drugs:
A.
Meperidine produces tachycardia
B.
Morphine causes histamine release
C.
Fentanyl minimizes hemodynamic effects
D.
Codeine can only be administered orally
E.
All of the above
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6. Which of the
following statements is true regarding fentanyl:
A.
Fentanyl is less potent than morphine
B.
Fentanyl is largely devoid of hypnotic and sedative activity
C.
Sufentanil is less potent than fentanyl
D.
Fentanyl binds weakly to the plasma protein a-1
acid glycoprotein
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7. Which of the
following statements is true regarding meperidine:
A.
Is 10 times more potent than morphine
B.
Effectively stops shivering at low doses
C.
The metabolite normeperidine prevents central nervous system excitation
D.
May be used safely in combination with MAO inhibitors
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8. Which of the
following statements is true regarding methadone:
A.
The half life is approximately 19 hours
B.
Clonidine may be used concomitantly to treat opiate withdrawal
C.
It has excellent gastrointestinal tract bio-availability
D.
All of the above
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9. Which of the
following is true regarding hydromorphone:
A.
Rapid onset with 4-6 hour duration
B.
More potent than morphine
C.
Less sedating than morphine
D.
All of the above
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10. Which of the following is/are
true regarding intrathecal and epidural opioid analgesia:
A.
Morphine will have a greater latency and duration of action than
fentanyl
B.
Hydrophilic agents produce more
segmental analgesia with less rostral spread than lipid-soluble agents
C. Both light touch and proprioception are preserved
D.
All of the above
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11. All of the following statements
are true regarding naloxone except:
A. It is an opioid antagonist
B.
Very small doses may alleviate
the respiratory depression effect of opioids without affecting their analgesic
effects
C.
It is rapidly metabolized in the liver
D. Produces sedation in patients who have not received opioids
E.
May induce withdrawal symptoms in chronic opioid abusers
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12. All of the following statements
regarding ketamine are true except:
A.
Loss of consciousness is heralded by nystagmus
B.
Nightmares are more common in children than adults
C.
Cerebral metabolism and cerebral blood flow increase
D.
Mean arterial pressure, heart rate and cardiac output increase
E.
Profound hypotension may occur in patients with depleted catecholamine
stores
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13. Select whether the following
statements are true or false regarding ketamine:
____
It is a ventilatory depressant
____
Laryngeal reflexes are generally lost
____
Increases pulmonary compliance
____
Highly lipid soluble
____
Redistribution explains its short duration of action
____
Reduction in liver blood flow prolongs half life
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14. Which of the following statements
is/are true regarding local anesthetics:
A.
There are two types – amides and esters, which are both weak bases
B.
The non-ionized (base) form crosses the nerve membrane
C.
Acidosis and hypercapnea increase their toxicity
D.
Because of the lower Cm (minimum
concentration necessary to block a nerve impulse), less local anesthetic is
necessary to block pain than produce paralysis
E.
All of the above
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15. Rank
the following in order from highest to lowest regarding absorption of anesthetic
administration—1=highest, 5=lowest:
____
Distal peripheral
____
Caudal/epidural
____
Brachial plexus
____
Subcutaneous
____
Intercostal/intratracheal
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here for answer
16. All of the following regarding
benzodiazepines are true except:
A.
GABA is the major neuro-inhibitory neuro-transmitter within the brain
B.
Binding to a sites facilitates binding to b sites which causes hyperpolarization
C.
Tidal volume is decreased
D.
Produces preload and afterload reduction
E.
Midazolam increases coronary
sinus blood flow and myocardial oxygen consumption
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17. Benzodiazepines can effectively treat anxiety in children.
Select whether the following statements are true or false:
____
Midazolam is 4 times more potent than diazepam
____
Midazolam is painful when administered intravenously
____
When midazolam is used > 7
days and acutely stopped, withdrawal symptoms may be present
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18. Match the following barbiturate
with its associated effect:
A.
Pentobarbital
B.
Thiopental
____ 1.
Effect terminated by redistribution from the brain to other body
compartments
____ 2.
Sleep induced in 10-15 minutes
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19. Select whether the following
statement is true or false:
____ The incident rate of cardiac arrest with anesthesia in children is 1:700
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20. Match
the American Society of Anesthesiology physical status classification with the
appropriate descriptor:
A.
Class I
B.
Class II
C.
Class III
D.
Class IV
E.
Class V
____
1.
Moribund patient with little chance of survival
____
2.
Severe systemic disease
____
3.
No organic, physiologic, biochemical, or psychiatric disturbance
____
4.
Mild-moderate systemic disturbance
____
5.
Severe systemic disorder which is life-threatening and not always
correctable by the operative procedure
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21. Which of the following drugs
stimulate histamine release:
A.
Morphine
B.
Protamine
C.
Barbiturates
D.
Latex
E.
All of the above
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22. Select whether the following
statements are true or false regarding inhalational anesthetics:
____
Most common pediatric
inhalational anesthesia involves halothane, enflurane and isoflurane usually in
conjunction with and oxygen/nitrous oxide mixture
____
Minute ventilation and inspired
concentration determine rate of removal of the agent from the alveolus
____ Nitrous oxide achieves steady state within 5-10 minutes
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23. All of the following statements
regarding succinylcholine are true except:
A.
Intragastric, intraocular, and intracranial pressure are increased
B.
Metabolism is by plasma and hepatic pseudocholinesterase
C.
Hepatic dysfunction, hypermagnesemia, and pregnancy prolong emergence
D.
Severe bradycardia may occur
E.
A decrease in potassium accompanies administration
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24. Which
of the following statements is/are true regarding non-depolarizing neuromuscular
blockers:
A. They represent false neurotransmitters
B. Residual effects can be
characterized by an unsustained response to a tetanic stimulation of 50Hz at 2.5
seconds.
C. Hypokalemia, respiratory
acidosis, hypermagnesemia, and a decreased body temperature can result in
failure to reverse their effects.
D. Calcium channel blockers,
nitroglycerin and high dose corticosteroids potentiate their neuromuscular
blockade
E. All of the above
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Answers
1.
D Neuroanatomic pathways are present at birth they do not develop at 4
months of age. All of the other
statements are correct. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1548-1550)
2.
D The m
receptor agonists are the most commonly used opioids for analgesia. The m1
receptor is the subtype that provides supraspinal analgesia.
The m2
receptor produces respiratory depression, inhibition of
gastrointestinal motility, and spinal analgesia. Furthermore, the m2
receptors cause bradycardia and sedation. Newborns may be
sensitive to an age-related receptor phenomenon that leads to opiate induced
respiratory depression. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1552-1554)
3.
D, B, A, D, A The m2
receptor inhibits gastrointestinal motility. Methadone, morphine,
fentanyl and meperidine are agonists for the m
receptor. The k
receptor inhibits antidiuretic hormone release.
The d
receptor produces analgesia, respiratory depression, euphoria and physical
dependence. The psychotomimetic effects that are observed with some opiates
including dysphoria and hallucinations are associated with the s
receptor. Phencyclidine is an
agonist for the s
receptor. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1552-1554; Tables 46.2
and 46.3)
4.
B, C, A Neonatal seizures can occur
with the use of morphine at commonly prescribed doses.
Meperidine is also associated with seizure activity.
This, however, can occur in any age group and is related to the buildup
of the toxic metabolite normeperidine. The serotonin syndrome occurs following
the use of serotomimetic agents of which meperidine is included.
When used alone or in combination with monoamine oxidase inhibitors a
symptom complex characterized by myoclonus, rigidity, hyperreflexia, shivering,
confusion, agitation, restlessness, coma, autonomic instability, low-grade
fever, nausea, diarrhea, diaphoresis, flushing, and rarely, rhabdomyolysis and
death can occur. The development of
chest wall rigidity is a side effect associated with the rapid administration of
fentanyl. This effect can be
treated with the administration of either a neuromuscular blocker or naloxone.
(Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 1554-1559; Bodner RA, et
al. Neurology 1995; 45:219-23)
5.
E All of the statements regarding the m
receptor agonist drugs are true. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1552-1560)
6.
B Fentanyl is approximately 100 times more potent than morphine and is
largely devoid of hypnotic or sedative activity. Sufentanyl is approximately 10 times more potent than
fentanyl. Alfentanil is
approximately 10 times less potent than fentanyl.
The a-1
acid glycoprotein is an acute phase protein that inhibits platelet aggregation,
and phagocytosis, and may help to regulate collagen fiber formation in healing.
Fentanyl is tightly bound to alpha-1 glycoprotein. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1557-1558; Fuhrman BP, Pediatric Critical Care, 2nd Edition; p 807;
Wilson AS, et al. Anesth Analg 1997; 84: 315-8)
7.
B Meperidine is 10 times less potent than morphine.
It is unique among the opioids in its ability to stop shivering from
amphotericin, blood products, anesthetics and hypothermia.
The metabolite normeperidine causes central nervous system excitation and
seizures. See response to Question 4 regarding the interaction of meperidine and
MAO inhibitors. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1558-1559; Bodner RA, et
al. Neurology 1995; 45:219-23)
8.
D Methadone has a half-life of approximately 19 hours.
Clonidine is useful as an adjunct to treat opioid withdrawal. The
bioavailability of methadone from the gastrointestinal tract is excellent.
It is estimated at 80-90%. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1559)
9.
D Hydromorphone has a rapid onset of action with a 4-6 hour duration.
It is 6-7 times more potent than morphine and 10 times more lipid
soluble. Its half-life is 3-4
hours. Hydromorphone is far less
sedating than morphine and associated with fewer systemic side effects. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; p 1559)
10.
D Lipid solubility affects the transition of opioid analgesics from the
aqueous side of the cerebrospinal fluid to the lipid phase of the underlying
neuraxis where the receptors are located. Hydrophilic agents like morphine have a greater latency and
duration of action than the more lipid soluble agent fentanyl.
However, the lipid soluble agents produce more segmental analgesia
associated with less rostral spread than the less lipid soluble agonists.
Spinal opiates produce analgesia without altering autonomic or
neuromuscular function. In
addition, both light touch and proprioception are preserved. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1561-1562)
11.
D Naloxone is a non-selective, opioid antagonist that works in small
doses to alleviate the respiratory depression associated with opioids without
affecting the analgesic properties. It
is rapidly metabolized in the liver. Naloxone
has no effect on the mental status of patients who have not received opioids.
(Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 1562-1563)
12.
B Vertical or horizontal nystagmus heralds the onset of the loss of
consciousness after ketamine administration.
Ketamine is an excitatory hallucinogen that produces a coupled increase
in both cerebral metabolism and blood flow.
This has the effect of raising intracranial pressure.
Ketamine also increases mean arterial blood pressure, heart rate and
cardiac output through an increase in plasma catecholamine levels.
If a patient is catecholamine deficient, profound hypotension or death
may occur. Nightmares occur as a
side effect in about 10% of adult patients and 5% of pediatric patients. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1563-1564)
13.
T, F, T, T, T, T
Ketamine is a
ventilatory depressant that reduces the ventilatory response to carbon dioxide.
Laryngeal reflexes remain intact but this does not preclude the potential
for aspiration. Ketamine increases
pulmonary compliance by direct action on bronchial smooth muscle and indirectly
by increasing plasma catecholamine levels.
The drug is highly lipid soluble. Its
redistribution rather than biotransformation or elimination is responsible for
its short half-life. Reduction in
liver blood flow leads to a prolongation of the serum half-life of ketamine.
(Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 1563-1564)
14.
E The local anesthetics are of two types, amides and esters, which are
both weak bases that block nerve conduction at the sodium channel when they are
in their ionized form. In order to
gain access to the channel, the drug must cross the membrane.
It does this in its ionized form. The
minimum concentration (Cm) of a local anesthetic is the concentration necessary
to block nerve impulse conduction. Unmyelinated
nerve fibers carry nociceptive information and have a lower Cm than heavily
myelinated fibers. Less local
anesthetic is necessary to block the transmission of pain than is necessary to
produce muscle paralysis. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1565-1567)
15.
4,
2, 3, 5, 1 The absorption of local anesthetic is dependent on the site of the
block. The order of absorption from
highest to lowest is intercostal, intrathecal, > caudal/epidural >
brachial plexus > distal peripheral > subcutaneous. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1566)
16.
E GABA is the major inhibitory neurotransmitter in the brain.
Glycine is an inhibitory neurotransmitter in the spinal cord and
brainstem. The GABA receptor has
two alpha and two beta subunits. Binding
of benzodiazepines to the alpha subunits of the GABA receptor facilitates
binding to the beta-receptors and promotes membrane hyperpolarization and
resistance to neuronal excitation. The
benzodiazepines can blunt or abolish the respiratory responses to hypercarbia
and hypoxia. They produce hypoventilation by reducing tidal volume.
The benzodiazepines produce minimal cardiac affects.
However, they do reduce preload and afterload.
They increase, rather than decrease coronary sinus blood flow and
myocardial oxygen consumption. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1573-1574)
17.
T, F, T Midazolam is 4 times more potent than diazepam and can be painlessly
administered. When used for
continuous sedation, usually for more than a week, dependence and withdrawal may
occur when the drug is stopped. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1574-1576)
18.
B, A Recovery from the effects of thiopental and methohexital are a result
of drug redistribution and not biotransformation or elimination.
Pentobarbital is used to induce sleep.
It acts within 10-15 minutes of an intravenous or intramuscular injection
and lasts approximately 2-6 hours. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1576)
19.
T The incidence of cardiac arrest associated with anesthesia is 1:600
for infants, 1:700 for children, and 1:2500 for adults, respectively. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; p 1577)
20.
E, C, A, B, D The preoperative
assessment of surgical risk or postoperative complications has been classified
according to the American Society of Anesthesiologists.
The classification ranges from Class 1 to Class 5.
As the patient’s physiologic dysfunction worsens; a higher Class is
attained. This higher Class has an increased risk of anesthetic related
complications and death. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1577;
Table 46.12)
21.
E
All of the agents listed stimulate histamine release. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; p1577)
22.
T, F, T The inhalational agents mentioned are commonly used in pediatric
anesthesia. The rate of delivery of
the agent to the alveolus is the function of minute ventilation and inspired
concentration, but the rate of removal is dependent upon cardiac output and the
solubility of the agent. Nitrous
oxide is relatively insoluble and can achieve steady state within 5-10 minutes.
Halothane requires 15-20 minutes to achieve steady state. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; pp 1579-1583)
23.
E Hyperkalemia is associated with the administration of succinylcholine
not hypokalemia. All of the other
statements are true regarding succinylcholine. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1584-1585)
24.
E All of the statements regarding non-depolarizing neuromuscular
blockers are true. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1584-1587)