Flashcards in Practice Exam 1 Deck (125):
The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
15 - 25%
Passive flow accounts for about 75 - 85% of ventricular filling. The remaining 15 - 25% occurs as a result of atrial contraction, which is lost during atrial fibrillation.
In the parturient, early decelerations signify:
-vagal stimulation from head compression
-impending emergency Cesarean delivery
vagal stimulation from head compression
Early decelerations are normal and common. The deceleration pattern matches the contraction with the most deceleration occurring at the peak of the contraction. The FHR rarely goes below 100 beats per minute. The cause of these decelerations is head compression during uterine contractions.
In the diagram below, anesthesia of the 5th digit of the hand can be produced by blocking:
The ulnar nerve is represented by 'D', and supplies sensory innervation to medial part of the 4th and entire 5th digits. 'A' is the axillary nerve, 'B' is the radial nerve and 'C' is the median nerve
Proper induction technique for the infant with tracheoesophageal fistula would include:
-preoxygenation with 100% and PPV
-ketamine 2 mg/kg
-inhalation induction in the sitting position
Awake intubation offers the greatest degree of safety and does not risk insufflation of the stomach.
An acute increase in PaCO2 from 40 mmHg to 80 mmHg will cause an increase in cerebral blood flow of approximately:
85 - 100%
Increasing CO2 causes cerebral vasodilatation and increased cerebral blood flow. Within a range of 20 - 80 mmHg the increase in blood flow is linear. Therefore, doubling the CO2 causes a nearly 100% increase in cerebral blood flow.
Which of the following cardiac malformations is associated with Tetralogy of Fallot?
-Left ventricular hypertrophy
Tetralogy of Fallot has four key features. A ventricular septal defect and pulmonic stenosis are the most important. Also, the aorta lies directly over (overrides) the ventricular septal defect and the right ventricle is hypertrophic.
The release of catecholamines from the adrenal medulla is under the control of the autonomic nervous system. The neurotransmitter controlling the release is:
Preganglionic fibers pass directly into the adrenal medulla without synapsing in a ganglion. Acetylcholine is the neurotransmitter causing the release of catecholamines from the adrenal medulla.
The most common cause of postpartum hemorrhage is:
Which of the following has been associated with causing the release of antidiuretic hormone (ADH)?
-Decreased plasma sodium
-Decreased serum osmolality
-Positive pressure ventilation
Positive pressure ventilation
Positive pressure ventilation has been associated with the release of ADH. Decreased serum osmolality and decreased sodium will decrease ADH production. Diabetes insipidus is a disease of decreased ADH production.
Initial closure of the ductus arteriosus following umbilical cord clamping is the result of:
-a rise in arterial oxygen concentration
-a decrease in placental prostaglandin secretion
-a sudden increase in infant's SVR
a rise in arterial oxygen concentration
The ductus provides shunting of blood flow from the left pulmonary artery to the aorta just beyond the origin of the left subclavian artery. The high levels of oxygen which it is exposed to after birth causes it to close.
Manual compression of the reservoir bag is an example of:
With temperature constant, the volume of a gas is inversely proportional to pressure: V is proportional to 1/P or VP = constant. As the gas in the reservoir bag is compressed, the pressure rises and gas is transferred to the patient.
Anesthesia of the epiglottis can be produced by local anesthetic block of the:
-recurrent laryngeal nerve
-external branch of the superior laryngeal nerve
-internal branch of the superior laryngeal nerve
internal branch of the superior laryngeal nerve
Stimulation of the baroreceptors results in:
-increased sympathetic tone
-increased myocardial contractility
-increased vagal tone
-increased heart rate
increased vagal tone
The baroreceptors, located in the carotid sinus and aortic arch, respond to stretching from elevated mean blood pressure. When stimulated, the baroreceptors reduce sympathetic tone, inotropy, chronotropy, and SVR, as well as increase vagal tone to further reduce heart rate.
Hydrophobic heat and moisture exchangers:
-use a membrane lacking pleating or pores
-are efficient bacterial and viral filters
-have improved performance when used in high ambient temperatures
-are more effect at temperature and heat conservation as compared to hygroscopic heat and moisture exchangers
are efficient bacterial and viral filters
Most heat and moisture exchangers (HME) are of one of two types, hydrophobic or hygroscopic. Hydrophobic HMEs use a pleated hydrophobic membrane with small surface pores. They provide moderately good inspired humidity, but performance may be impaired by high ambient temperatures. Hydrophobic HMEs are also efficient bacterial and viral filters.
The anesthetic incidence of MH in children is approximately one patient in:
15000 - 20000 patients
The incidence of MH is 1:15,000 - 20,000 anesthetics in children and 1:40,000 anesthetics in adults.
The output of a variable-bypass vaporizer, set to deliver 2% is shown below. Possible causes for the variation of the delivered output from the vaporizer include:
a change in the composition of the fresh gas flow
Changes in fresh gas composition can have an effect on vaporizer output. This is the result of uptake and subsequent release of an introduced gas by the liquid volatile agent in the vaporizer. Temperature changes normally encountered in the operating room do not cause a clinically significant change in vaporizer output.
In the evaluation of the patient with pheochromocytoma, 24-hour urine assessment of the metabolic end-products of catecholamines is diagnostic. The major metabolic end-product of catecholamine metabolism is:
vanillylmandelic acid (VMA)
Vanillylmandelic acid (VMA) is excreted in the urine and constitutes about 85% of the metabolites of catecholamines.
In the anesthesia machine, components of the low-pressure system include the: (Select 2)
-oxygen failure safety device
-oxygen pressure alarm
The anesthesia machine can be broadly divided into 3 systems. The low-pressure system contains the flowmeters, the vaporizers, any ancillary oxygen flowmeter and the common gas outlet.
A 36-year-old female presents for a laparoscopic cholecystectomy. Her past medical history is significant for glucose-6-phosphate-dehydrogenase deficiency. Her anesthetic management would include the avoidance of:
In patients with G-6-PD deficiency, drugs that can oxidize hemoglobin to methemoglobin should be avoided. These include: prilocaine, nitroprusside, methylene blue, penicillin, sufonamides, quinidine, and doxorubicin.
Lab values expected to be elevated in a patient with chronic renal failure include:
-plasma carbon dioxide content
Platelet count may be normal to low in the chronic renal failure patient but an increase in bleeding time is noted secondary to platelet dysfunction, specifically from a decrease in platelet aggregation and adhesion.
Determinants of the vapor pressure of volatile anesthetic agents include:
-density of the vaporized agent
Vapor pressure (VP) is independent of atmospheric pressure or altitude. VP depends only on the physical characteristics of the liquid and its temperature. VP increases with increases in temperature.
Halogenation of volatile anesthetic agents:
-results in the formation of an ether
-involves the substitution of iodine for hydrogen
Halogenation refers to the substitution of a halogen atom in place of a hydrogen atom. Although iodine is a halogen, the atom is too big for use in volatile anesthetics. Halogenation decreases flammability and increases anesthetic potency.
The train-of-four tracing below was obtained after the administration of:
Characteristics of depolarizing blockade include: decreased twitch height, absence of fade, and minimal reduction in twitch height (T4:T1 > 0.7).
Of the following organs, the most likely to be injured during extracorporeal shockwave lithotripsy is:
During ESWL, repetitive high energy sound waves are aimed at the nephrolithiasis, causing it to fragment. Because tissue has the same acoustic density as water, damage does not generally occur. However, tissue destruction can occur if the waves are focused at air-tissue interfaces such as in the lung and the intestine.
During intraoral laser surgery, ignition of the endotracheal tube occurs. By dragging & reordering the selections in yellow, match & place in correct order the steps that should be taken.
-Extinguish with saline
-Remove burning material
-Stop gas flow
Remove burning material---Step 1
-Stop gas flow---Step 2
-Extinguish with saline---Step 3
-Mask ventilate---Step 4
The greatest decreases in hepatic blood flow occur with:
-proximity of the operative site to the liver
proximity of the operative site to the liver
Inhaled anesthetics and regional anesthesia reduce hepatic blood flow by approximately 20-30%; halothane > isoflurane. Surgical procedures near the liver can reduce HBF up to 60%.
Signs consistent with cardiogenic shock include:
-increased pulmonary artery occlusion pressure
-decreased systemic vascular resistance
-increased cardiac index
-decreased myocardial oxygen demand
-redistribution of the blood volume away from the heart and lungs
increased pulmonary artery occlusion pressure, venous congestion
Characteristics of cardiogenic shock include increased PAOP, low CI, and increased SVR. Also present are venous congestion, reflex vasoconstriction and a redistribution of blood volume toward the heart and lungs.
Correct statements concerning the geriatric patient include:
-hypothalamic temperature centers remain essentially intact
-body fat decreases with increasing age
-a glomerular filtration rate of 70 mL/min may be within normal limits
-physiologic dead space is decreased in the elderly patient
a glomerular filtration rate of 70 mL/min may be within normal limits
Renal blood flow and GFR decrease by between 1-2% per year after the age of 25 years. (Normal GFR is 125 mL/min.) Aging impairs central temperature regulation. Body fat content and physiologic dead space increase with age.
Major criteria for the diagnosis of fat embolism syndrome include: (Select 3)
-retinal fat emboli
-urinary fat globules
-increased erythrocyte sedimentation rate
hypoxemia, cerebral changes, axillary/subconjunctival petechiae
Major diagnostic criteria for fat embolism include axillary/subconjunctival petechiae, hypoxemia, CNS depression and pulmonary edema.
Conditions commonly associated with painless vaginal bleeding include:
Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy. It is one of the leading causes of painless vaginal bleeding in the second and third trimesters.
A 32-year-old male develops polyuria in the post-operative period following a transphenoidal resection of a pituitary adenoma. Laboratory data includes a urine sodium concentration of 11 mEq/liter and a serum sodium concentration of 145 mEq/liter. The appropriate treatment is:
-administration of ACTH
-administration of hydrocortisone
-administration of DDAVP
-administration of an insulin infusion
administration of DDAVP
Injury to the pituitary gland during transphenoidal surgery can produce deficiencies in any of the hormones from either the anterior or posterior pituitary. In this patient with polyuria with dilute urine in the face of an elevated serum sodium, diabetes insipidus is the most likely diagnosis.
The normal alveolar-to-arterial (A-a) partial pressure gradient for a 70-year-old is approximately:
The normal A-a partial pressure gradient for oxygen increases from 8 mm Hg at age 20 years to approximately 20 mm Hg at age 70 years.
An estimate of the A-a gradient can be made using:
A-a gradient = (Age +4) / 4
The function of the regulator in line with the input from the oxygen e-cylinders is to:
-reduce variable high pressure input to constant low pressure output
-reduce constant high pressure input to variable low pressure output
-reduce the pressure from the e-cylinders to match the pressure from the wall outlet
-prevent retrograde filling of any other attached oxygen cylinders
reduce variable high pressure input to constant low pressure output
Pressure regulators reduce variable high pressure input to constant low pressure output. The pressure from the cylinders is reduced to below that of the wall outlet gas supplies so that the wall outlets are preferentially used if both sources are available.
As the volume of distribution at steady state of a drug increases:
Half-life = (0.693)(volume of distribution)/clearance. Increases in volume of distribution increase half-life, while increases in clearance decrease half-life.
You are asked to evaluate an 86-year-old man following an inguinal hernia repair performed with monitored anesthesia care and minimal sedation. The rhythm strip below is obtained. The most appropriate therapy is:
Second degree heart block, type 2 is characterized by constant P-P and R-R intervals prior to the dropped QRS complex. Acute onset second degree heart block, type 2 is usually associated with MI and can rapidly progress to 3rd degree block. Atropine is characteristically not effective and pacing is indicated.
You are asked to evaluate a 37-year-old, 180-kilogram male scheduled for gastric banding. During examination of the airway you are able to visualize the hard palate, soft palate and base of the uvula. The corresponding Mallampati classification is:
Visualized oral structures in the Mallampati classification are:
I - soft palate, fauces, uvula, tonsillar pillars
II - soft palate, fauces, uvula
III - soft palate, base of uvula
IV - hard palate only.
A list of adrenergic agonists is shown below. By dragging & reordering the selections in yellow, match the agonist of with its corresponding receptor.
-Phenylephrine -beta(non selective)
-Dexmedetomidine -alpha 1
-Isoproterenol -alpha 2
-Terbutaline -beta 2
-Phenylephrine alpha 1
-Isoproterenol -beta(non selective)
-Terbutaline -beta 2
Hemodynamic signs commonly seen in the patient with end stage liver disease include:
-increased cardiac output
-increased systemic vascular resistance
increased cardiac output
Patients with cirrhosis and ESLD often exhibit low SBPs (90 - 110 mmHg) , low PaO2 (
A 56-year-old man is being treated with sodium nitroprusside for control of elevated blood pressure following a craniotomy. He has been treated for the previous 36 hours and the current rate of infusion is 10 micrograms/kg/min. His blood pressure is 165/96 and pulse rate is 115/min. Additional findings you would expect include:
-elevated methemoglobin levels
-increased mixed venous oxygen content
-decreased oxygen saturation as measured by pulse oximetery
tachyphylaxis, metabolic acidosis, increased mixed venous oxygen content
Cyanide intoxication must be suspected when the dose of nitroprusside exceeds 1 mg/kg over a 2-hour period or 0.5mg/kg/hour over 24 hours. Metabolic acidosis, elevated mixed venous oxygen saturation, and tachyphylaxis would indicate toxicity.
The pressure in an e-cylinder of oxygen is found to be 500 psi. If an anesthetic is being delivered using 2 L/min of oxygen flow, the cylinder will last approximately:
80 - 90 minutes
The contents of the oxygen e-cylinder can be estimated by the following formula:
Capacity (L) / Service Pressure = Contents Remaining (L) / Gauge Pressure:
660 L / 1900 psi = Contents Remaining / 500 psi
Contents Remaining = 174 L; @ 2 L/min consumption = 87 minutes of use
Depression of the oxygen flush button delivers approximately:
35 - 75 L/min
Depression of the flush button delivers 35 - 75 L/min at up to 60 psi. Extreme caution is necessary when the oxygen flush is used, so as to avoid barotrauma.
Difficult airway management and intubation is associated with: (choose 3)
Treacher-Collins syndrome, Pierre-Robin syndrome, Klippel-Feil syndrome
Treacher-Collins syndrome consists of mandibulofacial dysostosis. Pierre-Robin syndrome consists of micrognathia and glossoptosis. Klippel-Feil syndrome is characterized by cervical fusion and immobility. All can result in difficulty with airway management and intubation.
In the geriatric patient, a significant prolongation of the elimination half-life is seen with:
Aging increases the volume of distribution for all benzodiazepines, which prolongs their elimination half-lives. Diazepam's elimination half life may approach 36 - 72 hours. Elderly patients also exhibit enhanced sensitivity to benzodiazepines, which may lead to prolonged postoperative confusion.
The upward slope of Phase III of the capnogram below is secondary to:
-obstructive airway disease
-restrictive airway disease
-exhaled gas from lung units with lower V/Q ratios
-exhaled gas from lung units with higher V/Q ratios
exhaled gas from lung units with lower V/Q ratios
On the capnogram, Phase I is the inspiratory baseline and represents fresh gas from the anesthesia machine. Phase II, or the expiratory upstroke is CO2-rich alveolar gas. Phase III is the expiratory plateau and has an upward slope as lung units with lower V/Q ratios have time to empty. Finally, Phase IV is the inspiratory downstroke as the flow of fresh gas rapidly washes the CO2 away.
An ultrasound of the right ilioinguinal region is shown below. The femoral nerve is best represented by:
In the figure above, A represents the iliopsoas muscle, B represents the femoral nerve, C represents the femoral artery and D represents the femoral vein.
Common postoperative complications following carotid endarterectomy include:
-glossopharyngeal nerve injury
Between 10% - 66% of patients will experience postoperative hypertension following CEA. The cause appears to involve alteration of the carotid sinus baroreceptors. Other common complications include MI and CVA. Hypotension and bradyarrhythmias are much less common. Esophageal perforation as a complication is rare.
You are evaluating a patient for resection of a mandibular tumor under general anesthesia with controlled hypotension. Possible postoperative complications you would inform the patient of include:
-pericarditis with effusion
renal failure, myocardial infarction, blindness
Complications from controlled hypotension include: hemiplegia, CVA, ATN, MI, cardiac arrest, hepatic necrosis, and blindness.
During repair of an ascending aortic arch aneurysm, deep hypothermic cardiac arrest is needed. It is recommended that the patient be cooled to:
15 - 22 degrees C.
Cerebral perfusion must be temporarily interrupted during aortic arch repair. Deep hypothermic cardiac arrest (DHCA) is the most important therapeutic intervention to prevent cerebral ischemia. During DHCA, nasopharyngeal temperatures are measured and the patient is cooled to 15 - 22o C. Arrest periods of up to 25 minutes are generally considered safe.
The primary cause of maternal mortality in patients with pregnancy-induced hypertension is:
-congestive heart failure
All types of cardiovascular complications can be seen with PIH, however intracerebral hemorrhage is the most common cause of mortality.
During the administration of an intravenous regional block, a double tourniquet is commonly used to:
-increase systemic redistribution of the anesthetic
-increase local anesthetic tissue penetration beneath the tourniquet
-reduce the incidence of tourniquet pain
-allow the use of concentrated local anesthetic solutions
reduce the incidence of tourniquet pain
It is common for tourniquet pain to develop in patients receiving an IV block after about 25 - 30 minutes. If a double tourniquet is used, the distal tourniquet can be inflated and the proximal tourniquet deflated allowing an additional 15 - 20 minutes of relief from the tourniquet pain.
A 46-year-old female is scheduled for laparoscopic cholecystectomy. During the preoperative evaluation, the patient admits to having taken "Phen-Fen" over a 5-month period for weight control when she was 36 years of age. You should specifically inquire about:
-valvular heart disease
valvular heart disease
Although never approved for use, the combination of dexfenfluramine and phentermine, "Phen-Fen", was used for short-term weight control. It was later found that Phen-Fen was associated with valve disease.
At which stage of gestation is maternal CO the greatest?
-Immediately following delivery
Immediately following delivery
During the first trimester cardiac output is 30-40% higher than in the non-pregnant state. Steady rises are seen, from an average of 6.7 L/minute at 8 - 11 weeks to about 8.7 L/minute flow at 36 - 39 weeks.
During labor, further increases are seen with pain in response to increased catecholamine secretion. Also during labor, there is an increase in intravascular volume by 300 - 500 ml of blood from the contracting uterus to the venous system. Following delivery, this autotransfusion compensates for the blood losses and tends to further increase cardiac output by 50% of pre-delivery values.
A 37-year-old patient with a history of regional enteritis is undergoing a small bowel resection. During the resection the surgeon expresses difficulty with the anastomosis because of increased bowel activity. Appropriate therapy would include the administration of:
-positive end expiratory pressure
Activity of the bowel is under the control of the autonomic nervous system, with the parasympathetic system causing increased activity. Anticholinergic agents, such as glycopyrrolate and atropine, will decrease bowel motility.
Ventilatory and blood gas results that suggest a patient is a suitable candidate for pneumonectomy include a:
-PaCO2 of 48 mmHg
-maximum VO2 of 21 mL/kg/min
-FEV1/FVC of 45%
-PaO2 of 61 mmHg
maximum VO2 of 21 mL/kg/min
Emergent control of the airway using the Seldinger catheter/wire/dilator technique is best accomplished at:
The cricothyroid membrane is located inferiorly to the thyroid cartilage and is the area of choice for the emergent placement of a surgical airway.
Carbon monoxide poisoning has been reported when delivering inhaled anesthesia with:
-a freshly changed sodalite absorber
-Amsorb Plus used as the carbon dioxide absorbent
-desiccated carbon dioxide absorbent
desflurane, desiccated carbon dioxide absorbent
Although CO production has been shown to occur with all volatile agents, the greatest amount of production is with desflurane. This usually occurs on Monday morning after fresh gas flow has thoroughly dried the soda lime over the weekend. The new absorbent, Amsorb Plus, does not cause the production of carbon monoxide or compound A.
Proper placement of a laryngeal mask airway will result in:
-a leak with positive pressure ventilation exceeding 15 cm H2O
-an intracuff pressure greater than 60 cm H2O
-the tip of the mask resting against the upper esophageal sphincter
-the sides of the mask resting against the pyriform fossae
-the aperture of the mask aligned with the rim glottis
-reliable occlusion of the esophageal inlet
the tip of the mask resting against the upper esophageal sphincter, the sides of the mask resting against the pyriform fossae, the aperture of the mask aligned with the rima glottis
The properly inserted LMA should lie with the mask tip resting against the upper esophageal sphincter, the sides facing the pyriform fossae, and the upper border under the base of the tongue. The epiglottis may point up, down, or lie in the bowl of the mask. Mask inflation causes the whole device to move upward slightly and brings the glottic and LMA apertures in line with each other. The seal created by the LMA should allow positive pressure ventilation up to 20 cm H2O. Intracuff pressure should never exceed 60 cm H2O.
In the anesthetized patient, the most commonly injured peripheral nerve is the:
-common peroneal nerve
The most common peripheral nerve injury is ulnar neuropathy. Persistent ulnar neuropathy occurs in approximately 1:2,700 patients.
Cardiopulmonary effects of peritoneal insufflation for laparoscopic surgery include increased:
-venous return to the heart
-systemic vascular resistance
systemic vascular resistance, atelectasis, intrapulmonary shunting
Cardiopulmonary consequences to peritoneal insufflation include reduced venous return, increased SVR, decreased CO with increased PAOP (especially in ASA III - IV patients), increased atelectasis, decreased FRC and increased intrapulmonary shunting.
The greatest risk of intraoperative recall and awareness occurs during general anesthesia for:
-acute trauma patients
-total joint replacement
acute trauma patients
As a result of the minimal anesthesia often given to acutely traumatized patients, the incidence of awareness is over 43%. The incidence of awareness for cardiac surgery and C-section is 1.5% and 0.4% respectively.
Near-infrared spectroscopy is:
-effective in assessing intracranial hemoglobin oxygen concentration
-effective in assessing cerebral electrical activity
-accomplished by placing a probe through a small burr hole
-unable to assess intracranial blood volume
effective in assessing intracranial hemoglobin oxygen concentration
NIRS is a method of analyzing brain hemodynamics, especially hemoglobin oxygenation and blood volumes. NIRS can better penetrate deep into thick tissues, allowing noninvasive physiologic interpretation of oxygenation by evaluating the transmission and absorption of infrared light in the hemoglobin in brain tissue.
In the United States, the incidence of intraoperative awareness is approximately:
0.1 - 0.4%
Using the figure below, the transition between dead space gas and alveolar gas is best represented by:
(Make your selection by clicking on the appropriate part of the figure)
Phase II, the expiratory upstroke, begins at the end of the Phase I, the inspiratory baseline, and ends at Phase III, the expiratory plateau. It is in Phase II that the transition from dead space gas and alveolar gas occurs.
In the burn patient, the dosing requirement of nondepolarizing neuromuscular blockers is:
-decreased because of decreased extracellular fluid volume
-decreased because of decreased receptor sensitivity to acetylcholine
-increased because of decreased extracellular fluid volume
-increased because of the presence of exntrajunctional receptors
increased because of the presence of exntrajunctional receptors
Burn patients and patients with lower motor neuron injury develop extrajunctional receptors. These receptors are very sensitive to succinylcholine and resistant to nondepolarizing blockers.
Signs and symptoms commonly associated with epiglottitis include:
-barking cough with stridor
-abdominal distention and pain
-low grade fever
Common signs and symptoms of epiglottitis include: acute onset of fever, dysphagia, dyspnea, drooling, muffled voice, and preference for the sitting position with head leaning forward.
The fetal tracing below is associated with:
-maternal atropine administration
This tracing is of late decelerations, which is associated with uteroplacental insufficiency. It is believed that the reduction in fetal heart rate is the result of fetal myocardial ischemia and characteristically occurs 20-30 seconds after the start of the uterine contraction. With early decelerations the heart rate slows with the beginning of the uterine contraction and is secondary to increased vagal tone from head compression. Variable decelerations are secondary to cord compression.
The most commonly occurring type of tracheo-esophageal fistula is:
TE-fistula type IIIB accounts for 87% of the TE fistulas seen.
In the geriatric patient, the most rapid increase in lung capacity is seen in:
-functional residual capacity
-total lung capacity
In the elderly patient, airway collapse increases residual volume and closing capacity. Closing capacity exceeds functional residual capacity, resulting in a ventilation/perfusion mismatch. VC and TLC both decrease with aging.
A 22-year-old female presents to the OR with a ruptured ectopic pregnancy. Her medical history is remarkable for major depressive disorder. Her medications include phenelzine and prenatal vitamins. Intraoperatively, agents that should be avoided include:
Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI). A serious reaction between MAOI's and meperidine has been reported, which may result in the development of hyperthermia, seizures, and coma.
The laboratory test most reflective of the glomerular filtration rate is:
-urine protein content
Creatinine clearance is the most reliable measurement for accurate assessment of the GFR.
A 6-year-old, 25 kg male is undergoing a tonsillectomy. With currently used surgical techniques, the expected blood loss would be approximately:
The average blood loss during tonsillectomy is 4 mL/kg. This constitutes over 5% of the total blood volume.
The most common complication associated with mediastinoscopy is:
-phrenic nerve injury
-recurrent laryngeal nerve injury
Hemorrhage is the most common complication of mediastinoscopy occurring in about 0.77% of cases.
In the figure below, the LMA-ProSeal is best represented by:
(Make your selection by clicking on the appropriate part of the figure)
The LMA-ProSeal has four main parts: cuff, inflation line, airway tube and drain tube. The drain tube is parallel and lateral to the airway tube and allows gasses to escape from the stomach. In addition, the drain tube allows access to the esophagus and stomach.
Transient blindness after transurethral resection of the prostate has been associated with the use of:
-distilled water irrigation
Visual disturbances including blindness have been reported after the use of glycine irrigation during TURP.
A 46-year-old female becomes extremely bradycardic during a blepharoplasty. The most appropriate initial intervention would be:
-the administration of 0.4 mg of atropine IV
-infiltration of the orbit with local anesthetic
-to ask the surgeon to cease surgical stimulation
to ask the surgeon to cease surgical stimulation
The oculocardiac reflex consists of a trigeminal (V) afferent and vagal (X) efferent pathways (A.K.A."the five and dime reflex"). It occurs from traction of the extra ocular muscles and/or pressure on the periorbital area. It may elicit a wide variety of cardiac dysrhythmias including bradycardia, ventricular ectopy, V-fib, and sinus arrest. Primary management consists of immediate notification of the surgeon and temporary cessation of surgical stimulation.
A list of lung volumes & capacities in the average adult is shown below. By dragging & reordering the selections in yellow, match the volume of gas with its corresponding lung volume/capacity.
-total lung capacity
5800 mL TLC
4500 mL VC
2300 mL FRC
1200 mL RV
Regional anesthetic techniques best avoided in patients receiving positive pressure ventilation include:
-stellate ganglion block
-lumbar paravertebral block
Needle location required to achieve an interpleural block puts the patient at high risk for pneumothorax if positive pressure ventilation is being delivered.
The most effective intervention in preventing maternal hypotension is:
-supine positioning with left uterine displacement
-phenylephrine 100 mcg IV
-ephedrine 10 mg IV
-one liter IV fluid bolus with normal saline
supine positioning with left uterine displacement
An 80-year-old patient becomes hypotensive the after administration of an intrathecal dose of 12 milligrams of tetracaine. Ephedrine 10 mg IV is administered with little effect on the BP. Possible reasons for this would include:
-inadequate dose of ephedrine
-resistance to beta adrenergic agents seen in the elderly population
-inappropriately large dose of tetracaine
-decreased plasma norepinephrine seen in the elderly population
resistance to beta adrenergic agents seen in the elderly population
Elderly patients exhibit decreasing responses to beta-adrenergic agents due to what is known as an endogenous beta-blockade. Circulating norepinephrine levels are increased in the elderly. Ephedrine 10 mg IV and tetracaine 12 mg intrathecally are commonly employed doses.
Common findings in patients with hepatorenal syndrome include:
-a recent history of aggressive IV fluid therapy
-low urine sodium content
-markedly reduced urine output
-irreversible renal failure
low urine sodium content
Hepatorenal syndrome is seen in patients with end-stage liver disease and portal hypertension. The syndrome is commonly associated with a preceding event that reduced plasma volume, eg. diuresis or GI bleed. Urine volume is only slightly diminished however, urine sodium falls to nearly zero. Histologically, the kidneys are intact and function normally if transplanted.
The most common viral disease from blood transfusion is:
The rate of viral transmission of cytomegalovirus is reported to be 1- 3%. Hepatitis B transmission is approximately 1:366,500; the rate of infection with hepatitis C is approximately 1:1,657,700; and, the rate of infection with HIV is approximately 1:1,860,800 Since routine screening of donors for HIV, the incidence of HIV infection from blood transfusion has fallen to about 5 cases per year.
A 48-year-old, 71 kg woman is scheduled for a hysterectomy. Her preoperative hematocrit was found to be 40%. The day following surgery, her hematocrit is 30%. Her estimated blood loss is
1200 - 1500 mL
Estimated blood volume for a 71 kg female = (71 kg x 70 mL/kg blood volume)
EBL = (Kg x EBV/Kg) x (HCT(start) - HCT(final)) / HCT(average)
EBL = (71 x 70) x (40 - 30)/35
EBL = 1420 mL
The cell type primarily responsible for surfactant production is:
-capillary endothelial cells
-alveolar epithelial cells Type I
-alveolar epithelial cells Type II
alveolar epithelial cells Type II
Surfactant is produced by Type II alveolar epithelial cells. These cells also secrete cytokines and contribute to pulmonary inflammation.
Neuroleptic malignant syndrome:
-has not been associated with metoclopramide administration
-can be effectively treated with dantrolene
-has a mortality rate of 5 - 10%
-is easily differentiated from malignant hyperthermia
can be effectively treated with dantrolene
Neuroleptic malignant syndrome is a rare complication of antipsychotic therapy which may mimic MH. It has a mortality rate of 20 - 30% Muscle rigidity, hyperthermia, rhabdomyolysis, ANS instability, and altered consciousness may be noted. It may be precipitated by metoclopramide and meperidine. Treatment with dantrolene appears to be effective.
A 56-year-old, 100-kg male is scheduled for appendectomy. During rapid-sequence induction, difficulty is encountered with endotracheal tube placement with subsequent oxyhemoglobin desaturation. The most appropriate action would be:
-positive pressure pressure with up to 50 cm H2O
-positive pressure pressure with up to 25 cm H2O
positive pressure with up to 25 cm H2O pressure
Difficulties encountered during rapid-sequence induction that result in desaturation may be resolved with gentle positive pressure ventilation with continued cricoid pressure. Positive-pressure ventilation should not exceed 25 cm H2O to minimize the risk of gastric distention and regurgitation.
The plasma of stored blood experiences an increase in:
-factors V and VIII
Calcium, pH, factors V and VIII, and 2,3-DPG all decrease in the plasma of stored blood. Potassium, lactate, microaggregates and hemoglobin all increase in the plasma of stored blood.
The potency of a local anesthetic agent is best correlated with the:
-pH of the agent
-pKa of the agent
-protein binding of the agent
-lipid solubility of the agent
lipid solubility of the agent
Potency is related to hydrophobicity and physiochemical properties of the agent. In general, more potent agents are more lipid soluble.
Hypotension may be seen during rapid infusion of packed red cells as a result of acutely depressed:
When large volumes of stored blood (more than one blood volume) are administered rapidly, the citrate can cause a temporary reduction in ionized calcium levels resulting in hypotension.
A list of pain syndromes is shown below. By dragging & reordering the selections in yellow, match the pain syndrome with its corresponding clinical characteristic.
-Preceding Nerve Injury
-Trigger Point Present
Complex regional pain syndrome type I (CRPS I) is gradual in onset with characteristics that include: burning pain, decreased range of motion, hyperpathia, antecedent injury with little correlation to the severity of symptoms, and relief with adrenergic blockade. CRPS II has identical signs & symptoms, but is usually acute in onset, following a proximal nerve injury.
A 6-year-old is scheduled for tonsillectomy under general anesthesia. In preparation for the anesthetic the circuit is to be primed with 50% nitrous oxide, 50% oxygen and 4% sevoflurane. To prime the circuit, the flows are set to 2 L/m nitrous oxide, 2 L/m oxygen and 4% sevoflurane. If the volume of the circuit is 4 liters, the time needed to prime the circuit to achieve 95% of the desired anesthetic concentration is:
To determine the time necessary to prime the circuit, the time constant (τ) must be determined. τ = Volume/Flow. Since the volume = 4 L and the flow is 4 L/m the time constant is 1 minute. Each time constant changes the concentration in the circuit by 63.2%. Therefore, after 1 time constant, 63.2% of the desired concentration is obtained; after 2 time constants, 86.5% of the desired concentration is obtained; and after 3 time constants, 95% of the desired concentration is achieved.
As compared to the normal ventricular flow-volume loop (purple), the left ventricular flow-volume loop shown in yellow is indicative of:
This loop demonstrates increased LV pressures and prolonged LV ejection.
Ten milliliters of blood with a saturation of 75% is mixed with ten milliliters of blood with a saturation of 25%. The resultant PaO2 of the mixture is approximately:
26 - 27 mmHg
The mixture will have a saturation of 50%. This corresponds to the P50, which is 26 - 27 mmHg.
A 18-year-old female is scheduled for spinal fusion for the management of scoliosis. Monitoring will include both somato-sensory and motor evoked potential monitoring. Regarding motor evoked potential monitoring:
-it is much more resistant to the effects of general anesthesia than somatosensory evoked potential monitoring
-clinical decision making is done on amplitude changes alone
-deep neuromuscular blockade is possible during the case
-magnetic stimulation is most commonly used while the patient is receiving general anesthesia
clinical decision making is done on amplitude changes alone
Motor and sensory evoked potential monitoring are complimentary, allowing assessment of both ascending and descending pathways. Motor evoked potentials (MEP) must be produced with electrical stimulation, since magnetic stimulation is not effective while the patient is under general anesthesia. MEPs are very sensitive to the effects of inhalational anesthetics and most centers use only intravenous anesthetic techniques. In addition, latency of response has little value in clinical decision making, and signal amplitude alone is used to assess the descending pathways.
The use of acrylic bone cement has been associated with intraoperative hypotension. This is the result of:
-an allergic response to the bone cement
-vagal stimulation secondary to circulating red cell lysis
-absorption of methyl methacrylate monomer
-absorption of methacrylate acid
-sympathetic stimulation secondary to polymerized cement
-embolization of air and bone marrow
absorption of methyl methacrylate monomer, absorption of methacrylate acid, embolization of air and bone marrow
The use of bone cement is associated with hypotension secondary to absorption of the volatile methyl methacrylate monomer, embolization of air and bone marrow, lysis of cells and marrow by the exothermic reaction of the cement, and the conversion of methyl methacrylate to methacrylic acid.
During the preoperative evaluation of a 68-year-old woman you discover that she was treated with doxorubicin for carcinoma of the breast 5 years ago. Important additional information you would obtain includes:
-a history of pulmonary fibrosis
-a history of cardiomyopathy
-a history of peripheral neuropathy
-a history of acute loss of vision
a history of cardiomyopathy
Late toxicity from doxorubicin involves cardiomyopathy and is seen with doses that exceed 550 mg/m2.
A 49-year-old woman is scheduled for a right mastectomy with axillary node dissection. Your anesthesia plan would include the avoidance of:
-deep neuromuscular blockade
deep neuromuscular blockade
During axillary node dissection, identification of the long thoracic and thoracodorsal nerves may be necessary. This is most effectively done with nerve stimulation and thus contraindicates the use of deep neuromuscular blockade during the case.
During an inhalation induction, 2 MAC of volatile anesthetic agent is being delivered. The longest induction time will be achieved with:
Isoflurane has the highest blood/gas solubility of all of the inhalation agents listed. (isoflurane 1.4, N2O 0.47, desflurane 0.42, sevoflurane 0.65). Lower blood/gas solubility corresponds directly to quicker inhalation induction times because the agent is taken up by the blood less avidly and the alveolar concentration of the agent rises more quickly.
The intravenous administration of acetylcholine would result in:
-decreased insulin secretion
-relaxation of the urinary bladder sphincter
-decreased detrusor muscle tone
relaxation of the urinary sphincter
Acetylcholine (ACh) is the chief neurotransmitter of the parasympathetic nervous system therefore, its effects are synonymous with PNS effects. ACh causes a relaxation of the bladder sphincter with an attendant contraction of the detrusor muscle, causing micturition. Insulin secretion is increased, and miosis is noted from contraction of the iris sphincter.
The most important factor determining the spread of local anesthetic in the subarachnoid space is:
-baricity relative to the patient position
-rate of speed of injection
-height of the patient
-volume of anesthetic injected
baricity relative to the patient position
Baricity of the local anesthetic solution relative to patient position appears to be the most important factor in determining spread within the subarachnoid space.
The effects of adding 1 mEq of sodium bicarbonate to 10 milliliters of local anesthetic solution include:
-a decrease in the intensity of the block
-an increase in pain at the injection site
-a decrease in onset time
-a decrease in duration of the block
a decrease in onset time
Alkalinization of local anesthetic solutions speeds the onset and improves the quality of the block by increasing the amount of free base available. Interestingly, alkalinization also decreases pain during subcutaneous infiltration.
In the figure below, the Mapleson D circuit is best represented by:
(Make your selection by clicking on the appropriate part of the figure)
The Mapleson D circuit, shown below, is a non-rebreathing circuit. Carbon dioxide elimination is dependent on fresh gas flow. The circuit is much more efficient during controlled ventilation, requiring approximately 70 - 100 mL/kg/min of fresh gas flow for adequate carbon dioxide elimination. During spontaneous ventilation, 100 - 300 mL/kg/min is recommended.
During a radical prostatectomy in a 68-year-old, occasional ventricular ectopy is noted and the following tracing from the pulmonary artery catheter is obtained. The most appropriate therapy would be:
-administration of lidocaine 100 mg IV
-advancement of the pulmonary artery catheter
-25% increase in tidal volume
-increase anesthetic depth
advancement of the pulmonary artery catheter
This trace shows a diastolic pressure of zero suggesting that the tip of the PA catheter is in the right ventricle. The ectopy implies that the catheter tip is causing RV wall irritation. The most appropriate therapy would be to properly locate the catheter by advancement.
A 17-year-old female is scheduled for a nasal septoplasty under general anesthesia. She has no significant past medical history. Appropriate preoperative testing would include:
-hemoglobin and hematocrit
-glucose and electrolytes
-no preop testing required
no preoperative testing is required
No preoperative testing is required. Preoperative pregnancy testing remains a subject of controversy with current practice varying among practitioners and centers.
Despite the proper function of the fail-safe valve and oxygen proportioning system, a hypoxic mixture may be delivered if:
-the wrong gas is in the oxygen pipeline
-the pressure in the oxygen supply line falls below 25 psi
-there is a leak in the oxygen supply line
-there is a leak downstream from the fail-safe valve
-helium is being administered as a third gas
-oxygen flow exceeds minute ventilation
the wrong gas is in the oxygen pipeline, there is a leak downstream from the fail-safe valve, helium is being administered
Circumstances under which the hypoxic guard systems can permit the formation of a hypoxic mixture include: wrong gas in the oxygen pipeline, defective pneumatics or mechanics, leaks downstream of the flow control devices and the administration of a third gas such as helium.
Reduction in plasma concentration through non-specific blood and tissue esterases is seen with the use of:
Unlike the other opioids, which depend on redistribution for the reduction of plasma concentration, remifentanil owes its very short half-life to rapid hydrolysis by tissue and plasma esterases.
In the geriatric patient:
-the dosage requirement of local anesthetic is reduced
-the MAC of general anesthetics is increased
-spinal anesthesia has a shorter duration of action
-epidural anesthesia has a longer duration of action
the dosage requirement of local anesthetics is reduced
Both the dosage requirements for local anesthetics and the MAC of general anesthetics are reduced in the elderly. Epidural anesthesia results in a greater cephalad spread but a shorter duration of action; spinal anesthetics have a longer duration of action.
Within the anesthesia machine, nitrous oxide and oxygen are interfaced mechanically, pneumatically or electronically, so that the minimum oxygen concentration at the common gas outlet is approximately:
23 - 25%
Manufacturers equip anesthesia workstations with N2O/O2-proportioning systems designed to prevent creation and delivery of a hypoxic mixture when nitrous oxide is administered. Nitrous oxide and oxygen are interfaced mechanically and/or pneumatically, or electronically (on the GE Aisys Carestation), so that the minimum oxygen concentration at the common gas outlet is between 23% and 25% depending on the manufacturer.
Components of the intermediate-pressure system of the anesthesia machine include:
-the yoke block with check valves
-the cylinder pressure regulators
-the flush valve
-the flowmeter tubes
the flush valve
Components of the intermediate-pressure system include the: pipeline inlets and gauges, ventilator power inlet, oxygen pressure-failure devices, flowmeter valve and the flush valve.
After induction of a 73-year-old female scheduled for a right mastectomy, the rhythm below is noted. The patient's past medical history is significant only for insulin-dependent diabetes mellitus for the past 25 years. The most appropriate course of action at this time is:
-administir digoxin 0.5 mg
-postpone surgery and obtain a cardiac evaluation
-adminstir verapamil to control heart rate
postpone surgery and obtain a cardiac evaluation
The rhythm strip shows atrial fibrillation. New onset atrial fibrillation requires a search for the precipitating cause and often signifies an acute disease process or cardiac ischemia.
Acute and life-threatening increases in serum potassium can be seen after succinylcholine administration in patients: (select 3)
-with chronic renal failure
-with extensive burns
-with muscular dystrophy
-that have received succinylcholine in the previous 10 minutes
-with lower motor neuron disease
-demonstrating a phase II block
-with abnormal pseudocholinesterase
with extensive burns, with muscular dystrophy, with lower motor neuron disease
Serum potassium increases 0.5 mEq/l from succinylcholine administration in normal individuals. However, patients with denervation injuries, such as burns, crush injuries and lower motor neuron diseases, can have exaggerated increases in serum potassium levels that can be life-threatening. Renal failure does not predispose to exaggerated increases in serum potassium. The diagnosis of muscular dystrophy is sometimes precipitated by a hyperkalemic event following succinylcholine administration.
Upon the diagnosis of malignant hyperthermia, the following steps should be taken. By dragging & reordering the selections in yellow, place the steps in the correct order of implementation.
-Hyperventilation with O2
Treatment of MH should be initiated with the discontinuation of all volatile anesthetics (and succinylcholine), followed by hyperventilation with oxygen. Intravenous administration of dantrolene should commence and be titrated to heart rate, ETCO2 and temperature. Active cooling and treatment of metabolic derangement should then be undertaken.
Reactants involved in the absorption of CO2 by soda lime include: (select 3)
calcium hydroxide, water, carbonic acid
The absorption of carbon dioxide by sodalime occurs in a 3-step reaction. Carbon dioxide combines with water to form carbonic acid. Carbonic acid reacts with sodium hydroxide to form sodium carbonate and water. Finally, calcium hydroxide reacts with sodium carbonate to produce calcium carbonate and regenerate sodium hydroxide.
Therapeutic goals of the application of positive end-expiratory pressure to patients receiving mechanical ventilation are to:
-increase lung water
-achieve adequate PaO2 with an FiO2 of less than 0.5
-decrease functional residual capacity
-increase closing capacity
achieve adequate PaO2 with an FiO2 of less than 0.5
The therapeutic goals of PEEP are to reduce lung water and improve oxygenation while lowering the FiO2. PEEP also increases FRC.
A list of the oil:gas coefficients of the inhaled agents is shown below. By dragging & reordering the selections in yellow, match the inhaled agent with its corresponding oil:gas coefficient.
The oil:gas coefficient correlates directly with the potency and inversely with the MAC of the inhaled agent. Therefore, the agents with the lowest MAC have the highest oil:gas coefficients.
Laryngoscopy and oral endotracheal intubation:
-reliably prevent gastric aspiration
-reduce anatomic dead space by 50%
-cause stimulation of cranial nerve IX resulting in bradycardia
-are contraindicated in the patient with a CSF leak due to head trauma
reduce anatomic dead space by 50%
Endotracheal intubation reduces anatomic dead space by 50%. Although endotracheal intubation helps to prevent gastric aspiration, it is not absolutely guaranteed. Bradycardia during laryngoscopy is a result of stimulation of cranial nerve X. Nasal intubation is contraindicated in the patient with CSF leak 2o head trauma.
Perioperative hypothermia predisposes patients to:(select 2)
-decreased metabolic rate
-decreased cardiac work
-decreased cutaneous blood flow
-decreased incidence of postoperative wound infection
impaired coagulation, decreased cutaneous blood flow
Perioperative hypothermia predisposes the patient to increased metabolic rate from shivering as well as increased cardiac work and increased rates of wound infection. Cutaneous blood flow is decreased as a result of vasoconstriction and redirection of blood flow away from the skin. Impaired coagulation has also been demonstrated in hypothermic patients.
The most sensitive monitor for the detection of venous air embolism is the:
-detection of end-tidal nitrogen
-pulmonary artery catheter
-end tidal CO2 monitor
Monitors for the detection of venous air embolization in order of decreasing sensitivity are: TEE, Doppler, PA catheter, end-tidal carbon dioxide, and end-tidal nitrogen.
Antibiotics associated with an increase in nondepolarizing neuromuscular blockade include:
Aminoglycosides, polymyxins and lincosamides (clindamycin & lincomycin) are all associated with increasing the depth of neuromuscular blockade.
Compensatory mechanisms that increase oxygen delivery in patients with chronic anemia include:
-decreased RBC 2,3-diphosphoglycerate
-decreased plasma volume
-decreased blood viscosity
decreased blood viscosity
Cardiac output, 2,3-DPG levels, P-50, and plasma volume are all increased to improve tissue oxygen delivery. However, plasma viscosity is decreased and this allows for a further increase in cardiac output and blood flow.
Anesthetic agents that should be avoided in patients receiving intravitreal sulfur hexafluoride for mechanical support of the retina include:
Intraocular sulfur hexafluoride is used to support the retina in cases of retinal detachment. Because of its solubility, nitrous oxide may significantly increase the size/pressure of the bubble and should be avoided.
-requires a large surgical incision with the patient in the prone position
-is intended to improve the strength of the vertebral body
-is used in the treatment of the piriformis syndrome
-is effective in relieving the symptoms of thoracic outlet syndrome
is intended to improve the strength of the vertebral body
Kyphoplasty and vertebroplasty lead to restoration of some of the decreased vertebral height, improve strength of the vertebral body, and decrease stress placed on the adjacent vertebrae in patients with vertebral compression fractures. Kyphoplasty differs from vertebroplasty in that kyphoplasty involves the percutaneous introduction of a balloon into the vertebral body, inflation of the balloon, then filling the balloon with methacrylate cement that is more viscous than that used for vertebroplasty.
In an adult patient, nasal cannula with an oxygen flow rate of 6 L/min will produce an FiO2 of approximately:
39 - 44%
Nasal cannula produce FiO2 ranges based upon oxygen flow rates, nasopharyngeal volume, and the patient's inspiratory flow rate. Approximations of the FiO2 are:
1 L/min - 0.21-0.24
2 L/min - 0.23-0.28
3 L/min - 0.27-0.34
4 L/min - 0.31-0.38
5-6 L/min - 0.39-0.44
According to the ASA's Difficult Airway Algorithm, the initial appropriate maneuver in the "can't intubate/can't ventilate" scenario after induction of general anesthesia is:
-secure an immediate surgical airway
-laryngoscopy by alternate caregiver
-administer additional neuromuscular blockade
If initial attempts at intubation are unsuccessful and face mask ventilation is inadequate, consider/attempt an LMA is the next maneuver on the ASA's Difficult Airway Algorithm.
The cerebral metabolic rate of oxygen consumption may be increased by the use of:
Ketamine has been shown to increase the CMRO2. Reductions in CMRO2 can be achieved with barbiturates, desflurane and isoflurane, all of which can produce a profound reduction in cerebral electrical activity.