1. Probable diagnosis

2. Associated congenital anomalies, any four

1. Vertebral anomalies
2. Anorectal malformations
3. Cardiac defects: VSD, ASD, TOF, PDA
4. Renal anomalies: renal agenesis, ectopic kidney, hydronephrosis
5. Limb anomalies: radial ray defect, thumb hypoplasia
6. Other associations: duodenal atresia, tracheomalacia, CHARGE syndrome.

3. Precautions during intubation, any four

1. Avoid bag-mask ventilation, if possible, because air can pass through the distal fistula into the stomach causing severe gastric distension and respiratory compromise.
2. Perform gentle intubation and maintain spontaneous ventilation until the airway is secured, especially if a difficult airway is anticipated.
3. Place the ETT tip beyond the fistula but above the carina, usually by advancing it into the right main bronchus initially and then withdrawing until bilateral air entry is heard.
4. Use minimal positive-pressure ventilation and low airway pressures.
5. Prefer preoperative rigid bronchoscopy to identify the fistula site and assess for airway anomalies.
6. Keep the infant head-up, suction the upper esophageal pouch continuously, and arrange gastric decompression when appropriate.
7. Avoid excessive manipulation and accidental esophageal intubation.

4. Any two methods to confirm correct ETT placement

1. Continuous capnography: persistent exhaled CO₂ waveform.
2. Clinical examination: equal bilateral chest rise and bilateral air entry, with no increasing abdominal distension.

1. Intraoperative bronchospasm: treatment

Immediate management

1. Call for help and give 100% oxygen.
2. Hand ventilate to assess compliance.
3. Exclude mechanical causes:
   • Endobronchial intubation
   • Kinked/obstructed ETT, secretions or mucus plug
   • Circuit obstruction
   • Pneumothorax
   • Aspiration
4. Deepen anaesthesia:
   • Propofol IV, or
   • Volatile agent such as sevoflurane.
5. Use gentle ventilation with prolonged expiratory time to avoid air trapping and auto-PEEP.

Specific treatment

1. Salbutamol/albuterol via ETT, usually 4-8 puffs with spacer; repeat as needed. Nebulization may be used in a spontaneously breathing patient.
2. Add ipratropium bromide for persistent bronchospasm.
3. If severe or refractory:
   • Epinephrine IV in titrated small doses if severe bronchospasm, hypotension, or suspected anaphylaxis.
   • Magnesium sulfate IV.
   • Ketamine IV may help due to bronchodilator action.
   • Corticosteroid such as hydrocortisone, recognizing its delayed onset.
4. If anaphylaxis is suspected: stop the triggering agent, give epinephrine, rapid IV fluid resuscitation, and manage according to the anaphylaxis protocol.

2. Laryngospasm: treatment

Immediate management

1. Call for help.
2. Remove the stimulus: stop surgery or airway stimulation; remove blood, secretions, or foreign material.
3. Give 100% oxygen with a tight-fitting face mask.
4. Perform jaw thrust and apply continuous positive airway pressure, usually 15-20 cm H₂O.
5. Suction the pharynx/glottis if blood or secretions are the precipitating cause.
6. Deepen anaesthesia with IV propofol, if IV access is present.

If spasm persists or hypoxia/bradycardia develops

1. Give succinylcholine:
   • IV: a small dose may be sufficient, commonly 0.25-0.5 mg/kg to break the spasm.
   • In severe complete spasm, use 1-2 mg/kg IV.
   • If no IV access: 4-5 mg/kg IM.
2. Ventilate with 100% oxygen after relaxation and intubate the trachea if ventilation remains inadequate or there is pulmonary aspiration/ongoing airway risk.
3. Treat associated bradycardia, especially in children, with oxygenation first and atropine if needed.
4. Observe for complications: negative-pressure pulmonary edema, aspiration, hypoxemia, and post-obstructive pulmonary edema.

• Salbutamol (albuterol) MDI 100 micrograms per puff: give 8-10 puffs through the ETT, using an MDI adapter/spacer in the breathing circuit.
• Repeat after 10 minutes if bronchospasm persists.

• Salbutamol MDI: 4-8 puffs, preferably with spacer.
• Or nebulized salbutamol: 2.5-5 mg.

• Ipratropium bromide 0.5 mg nebulized with salbutamol for persistent/severe bronchospasm.

Extubation strategy in a hypertensive and diabetic patient

Aim

Before extubation

1. Assess readiness
   • Awake, obeying commands, good muscle strength.
   • Adequate spontaneous ventilation and oxygenation.
   • Full reversal of neuromuscular block, preferably quantitative TOF ratio ≥0.9.
   • Normothermia and adequate analgesia.
2. Control haemodynamics
   • Treat pain, hypoxia, hypercarbia, bladder distension, and inadequate anaesthetic depth.
   • Continue usual antihypertensive treatment where appropriate.
   • Ensure BP and heart rate are near baseline before extubation.
3. Check glucose
   • Measure blood glucose before emergence and continue monitoring in PACU.
   • Avoid hypoglycaemia, especially after fasting and intraoperative insulin.
   • A practical perioperative target is about 140-180 mg/dL (7.8-10 mmol/L).
   • Correct significant hyperglycaemia or ketosis before elective extubation when clinically relevant.
4. Aspiration precautions
   • Diabetic autonomic neuropathy can cause gastroparesis. Therefore, avoid deep extubation if aspiration risk is present.
   • Thorough oral and pharyngeal suctioning before extubation.

Blunting the extubation response in hypertension

• Lidocaine 1-1.5 mg/kg IV, 1-2 minutes before extubation, to reduce cough.
• Esmolol 0.5-1 mg/kg IV shortly before extubation for tachycardia/hypertension. Titrate carefully.
• If hypertension persists, use titratable agents such as labetalol, nicardipine, clevidipine, or nitroglycerin, depending on the clinical setting.
• Adequate opioid analgesia in small titrated doses may reduce coughing and sympathetic stimulation, but avoid respiratory depression.
• Dexmedetomidine can be useful for smooth emergence, but monitor for bradycardia and hypotension.

Extubation

1. Give 100% oxygen and suction oral cavity/pharynx.
2. Ensure patient is fully awake with intact airway reflexes.
3. Extubate gently during a controlled, smooth phase of respiration.
4. Apply supplemental oxygen and monitor ECG, SpO₂, BP, respiratory rate, and capnography if available.
5. Observe closely in PACU for hypertension, myocardial ischemia, hypoventilation, airway obstruction, nausea/vomiting, and glucose abnormalities.

Important OSCE point