Quizzezzzzz Flashcards

Question

What is the upper limit of pressure in cm H2O for the adjustable pressure-limiting (APL) valve?

Answer 1

70-80 cm H2O

Answer 2

35-75 L/min

Answer 3

Humidification and heating of inspiratory gases may be most important for small pediatric patients and older patients with severe underlying lung pathology.

Answer 4

Pressure regulators, oxygen supply failure protective devices, flow valves and flow meters, vaporizers and common (fresh) gas outlet.

Answer 5

Inspired oxygen analysis

Answer 6

The SPDD model is the supply, processing, delivery, and disposal model. The Supply phase in the SPDD model involves pipeline systems and gas cylinders that deliver medical gases to the anesthesia workstation. The pipeline supply system provides a steady and regulated supply of oxygen, nitrous oxide, and air to the anesthesia machine. If the pipelines fail, emergency E-cylinders are required, and the tanks should be checked before the start of any case.

Answer 7

-To supply fresh gas to the oxygen flow meter -To drive ventilator bellows -to activate low pressure oxygen alarms -activates fail safe mechanisms -supply oxygen to the oxygen flush system

Answer 8

Reduce occurrences of hypothermia due to increased heat conservation and prevents smaller tracheal tube plugging via dried secretions.

Answer 9

-The flush valve should only be used cautiously when the patient is connected to the breathing circuit as it can cause barotrauma. Do not use during inhalation phase. -It can result in backflow of gases into the low-pressure circuit, diluting anesthetic concentrations.

Answer 10

143 minutes ## Footnote tank capacity (L) / service pressure (psig) = contents remaining (L) / current tank pressure (psig). current tank pressure (psig) * tank capacity (L) / service pressure (psig) = contents remaining (L) 1300psig * 625L / 1900psig = 428L 428L / (3L/minutes) = 143 minutes

Answer 11

-The negative pressure relief valve is malfunctioning An active scavenging system relies on suction to remove waste gas. A negative pressure relief valve opens to draw in room air when suction is excessive in a closed interface scavenging system. This prevents excessive suction, which could expose the breathing circuit to negative pressure and hypoxia when emptying gas from the breathing circuit. Failure in the negative pressure relief valve causes the scavenger to remove gas from the circuit system, requiring a high fresh gas flow to maintain adequate circuit volume.

Answer 12

Breathing circuit with a compliance of 6mL/cm H2O, Fresh gas flows of 5L/min and Gas compression.

Answer 13

Avoids direct airway connection, making it useful for pediatric induction.

Answer 14

-Minimal operating room and environmental pollution -Low resistance (less than the endotracheal tube; not as low as in nonrebreathing circuits) -Constant inspired concentrations -Conservation of respiratory tract heat and humidity

Answer 15

In a circle system, CO₂ absorbent granules remove exhaled CO₂. If the absorbent becomes exhausted, CO₂ is no longer effectively removed, leading to rebreathing of CO₂ and increased inspired CO₂. Additionally, faulty unidirectional valves can cause exhaled CO₂-rich gas to bypass the absorber and mix with fresh gas, further increasing inspired CO₂.

Answer 16

A. Pneumothorax B. Decreased pulmonary compliance C. Surgery requiring peritoneal gas insufflation Answer: a, b, c

Answer 17

Between the inspiratory valve and the absorber, to prevent dilution of fresh gas.

Answer 18

A preset inspiratory pressure must be reached.

Answer 19

Answer: A. Fresh gas inlet inside the breathing tube

Answer 20

Answer: B Bronchospasm Peak inspiratory pressure (PIP) is generated during the inspiratory cycle and provides an indication of dynamic compliance. Plateau pressure is measured during an inspiratory pause and is an indicator of static compliance. An increase in peak inspiratory pressure without an increase in plateau pressure can indicate an increase in airway resistance. Secretions, bronchospasm, a kinked endotracheal tube, and foreign body aspiration are all potential causes of increased PIP without an increase in plateau pressure.

Answer 21

C. Check the y-piece and other common locations for disconnections.

Answer 22

FiO2 reaches 30-40% ## Footnote Rationale: Across the clinical range of tidal volume and respiratory rate, an oxygen flow rate of 1 L/min gives a FiO2 of 30-40%.

Answer 23

When 50%-70% of granules have changed color ## Footnote Rationale: According to Butterworth et al. (2022), absorbent should be replaced when 50% to 70% has changed color.

Answer 24

C. Peak inspiratory pressure ## Footnote Rational: Peak inspiratory pressure is the highest circuit pressure generated during an inspiratory cycle.

Answer 25

Desflurane

Answer 26

Dynamic compliance is indicated by PIP where PP is static compliance

Answer 27

Tidal volume is the amount of air moving into and out of the lungs with each breath.

Answer 28

An increase in tidal volume can cause an increase in both peak inspiratory pressure and plateau pressure.

Answer 29

PEEP refers to the positive pressure maintained in the airways at the end of exhalation.

Answer 30

Desflurane ## Footnote Carbon monoxide is produced by desflurane, much more than isoflurane, when these agents are in contact with absorbent granules.

Answer 31

Answer: 23L of CO2 per 100g of soda lime ## Footnote Soda lime contains hydroxide salts that neutralize carbonic acid formed with the reaction of carbon dioxide and water.

Answer 32

Correct Answer: D) Using sharp bends ## Footnote Resistance can be reduced by decreasing the length of the circuit, increasing the diameter, maintaining laminar flow, and eliminating valves.

Answer 33

Correct answer: Pressure-controlled ventilation

Answer 34

Answer: A) The negative pressure relief valve is malfunctioning ## Footnote A negative pressure relief valve opens to draw in room air when suction is excessive, preventing hypoxia.

Answer 35

To prevent the delivery of these gases in the absence of oxygen.

Answer 36

By using a proportioning safety device that proportionately reduces the pressure of nitrous oxide and other gases.

Answer 37

To activate alarm sounds when inlet gas pressure drops below a threshold value (usually 20–30 psig).

Answer 38

Because the flow rate across a constriction depends on the gas's viscosity and density.

Answer 39

Because the partial pressure of the anesthetic agent remains largely unchanged with altitude changes.

Answer 40

To monitor the oxygen partial pressure and ensure patient safety.

Answer 41

It maintains appropriate circuit pressure to prevent excessive buildup during ventilation.

Answer 42

Turn on the backup oxygen cylinder, disconnect the pipeline, verify the rise in FiO2.

Answer 43

The Tec 6 is a heated, dual-circuit injector vaporizer that adds vapor to the fresh gas without direct contact.

Answer 44

Proportioning systems maintain at least a 23% to 25% oxygen concentration in the final breathing mixture.

Answer 45

To reduce the risk of hypoventilation in anesthetized or unconscious patients.

Answer 46

Suitable for children weighing 10 to 20 kg; comparable to nonrebreathing circuit in maintaining blood gas values in infants as low as 6 kg.

Answer 47

To prevent misconnections between breathing and scavenger hoses.

Answer 48

Synchronized Intermittent Mandatory Ventilation (SIMV) ## Footnote SIMV allows spontaneous breathing while providing support to maintain normocapnia and reduce ventilator dyssynchrony.

Answer 49

The bag inflates during inspiration and deflates during expiration. ## Footnote A rapid deflation of the manual breathing bag indicates a disconnect in the system.

Answer 50

Failure to ventilate due to disconnection in the breathing circuit.

Answer 51

They provide better control of inspired gas concentration and depth of anesthesia.

Answer 52

Application of high fresh gas flows to prevent rebreathing.

Answer 53

Peak inspiratory pressure.

Answer 54

The DAS emphasizes the use of a supraglottic airway after failed intubation, while the ASA promotes bag-mask ventilation.

Answer 55

Fiberoptic intubation.

Answer 56

The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords.

Answer 57

Cricoid pressure is applied to occlude the esophagus, while BURP is applied to optimize vocal cord visualization.

Answer 58

During deep anesthesia or when the patient awakens.

Answer 59

Unilateral damage results in hoarseness but is unlikely to cause respiratory distress.

Answer 60

All of these answers are possible correct actions.

Answer 61

Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve. ## Footnote Treatment includes gentle positive pressure ventilation and intravenous lidocaine.

Answer 62

Cricoid cartilage.

Answer 63

Class III.

Answer 64

Cricoid pressure.

Answer 65

A. Less dental trauma C. Does not require neck mobility ## Footnote Unlike endotracheal tubes, LMAs do not require the use of a rigid laryngoscope blade, which is a primary cause of dental trauma during intubation. LMAs can also be inserted with minimal head and neck movement, making them useful in cases with limited neck mobility.

Answer 66

C. History of previous difficult intubation ## Footnote A prior history of a difficult airway is one of the strongest predictors of future difficulties in airway management.

Answer 67

Persistent end-tidal carbon dioxide ## Footnote Other traditional methods of confirming ETT placement lack specificity and can be misleading.

Answer 68

Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures

Answer 69

B. Arytenoid D. Corniculate E. Cuneiform ## Footnote The larynx is composed of nine cartilages: thyroid, cricoid, epiglottic, and (in pairs) arytenoid, corniculate, and cuneiform.

Answer 70

Office-based anesthesia occurs in a private practice setting, while NORA takes place in remote hospital locations. ## Footnote Office-based anesthesia refers to anesthetic care provided in a practitioner’s office, often for procedures like cosmetic or dental surgeries. In contrast, NORA takes place in remote hospital locations such as MRI suites and endoscopy units.

Answer 71

The risk of obstructive sleep apnea ## Footnote The STOP-Bang questionnaire is a validated screening tool designed to assess a patient's risk of having OSA based on symptoms and physical characteristics.

Answer 72

Neck circumference 35 kg/m² ## Footnote The STOP-Bang questionnaire includes neck circumference >40 cm as a risk factor for OSA.

Answer 73

Total intravenous anesthesia (TIVA) with propofol ## Footnote TIVA with propofol is associated with a lower risk of PONV compared to inhalational anesthesia.

Answer 74

Minimizing supplemental oxygen delivery and avoiding oxygen buildup under drapes ## Footnote An oxygen-rich environment increases the risk of surgical fires, particularly in head and neck procedures.

Answer 75

9 ## Footnote A score of ≥9 is required for PACU discharge.

Answer 76

The ability to rescue patients who transition to a deeper level of sedation than intended.

Answer 77

General anesthesia with endotracheal intubation may be required due to compromised airway access. ## Footnote ERCP is performed with the patient in positions that can compromise airway access.

Answer 78

Sevoflurane ## Footnote Volatile anesthetics such as sevoflurane may have negative effects on assisted reproductive technology (ART) outcomes.

Answer 79

SVT ## Footnote SVT is a supraventricular arrhythmia often symptomatic due to poor cardiac reserve.

Answer 80

A) Atrioesophageal fistula, D) Atrial perforation leading to cardiac tamponade, E) Phrenic nerve injury ## Footnote Major complications from ablations include atrioesophageal fistula, atrial perforation, and phrenic nerve injury.

Answer 81

A) Nausea and vomiting, C) Crying, D) Bleeding ## Footnote Postoperative nausea and vomiting, crying, and bleeding are common complications in pediatric dental anesthesia.

Answer 82

a. Patient takes oral medications with water two hours prior to procedure ## Footnote ECT fasting guidelines state that patients must fast from solid foods for six hours and abstain from water for 2 hours prior to ECT.

Answer 83

C. Metformin, because of the risk of lactic acidosis.

Answer 84

Zone II ## Footnote Zone II is the area where patients are greeted and movement is supervised by MRI personnel.

Answer 85

Children under 5 years of age ## Footnote Children under 5 years of age are at the greatest risk for adverse events, particularly respiratory events

Answer 86

D. Morphine ## Footnote Morphine has been shown to adversely affect fertilization outcomes.

Answer 87

A. Utilization of multiple anesthetic agents, D. Procedural duration is greater than one hour

Answer 88

C. Antiplatelet therapy in patients with stents should only be discontinued after discussion between the patient, cardiologist, and surgeon. ## Footnote Patients with cardiac stents are typically on antiplatelet therapy, which should not be discontinued without coordination between the surgeon, cardiologist, and anesthesiologist due to the risk of discontinuation of antiplatelet therapy and the necessity of surgery.

Answer 89

B. 6 ## Footnote The Modified Aldrete score looks at Activity, Respiration, Circulation, Consciousness, and O2 Saturation. The patient had scores totaling 6 based on the assessment criteria.

Answer 90

B) Inadequately controlled pain D) Postoperative nausea and vomiting ## Footnote The two most frequent causes of unplanned hospital admission from ASCs and office surgery practices are due to inadequately controlled pain and postoperative nausea and vomiting.

Answer 91

Left lateral decubitus position ## Footnote Patients are usually asked to assume a left lateral decubitus position for the colonoscopy procedure.

Answer 92

C. A 55 y/o male with a BMI of 38 kg/m2 who reports lethargy and snoring frequently during the night ## Footnote Option C had five risk factors for OSA, making it the highest risk among the choices.

Answer 93

B) It targets different pain pathways to produce a synergistic effect at lower analgesic doses. ## Footnote Multimodal analgesia targets different pain pathways to produce a synergistic effect, enhancing pain control while minimizing the required doses of individual analgesics.

Answer 94

C. After the blood pressure cuff is applied and inflated on the lower extremity ## Footnote A blood pressure cuff is inflated to isolate the extremity before administering succinylcholine to observe motor seizure activity.

Answer 95

B. Total intravenous anesthesia (TIVA) to optimize hemodynamic stability and reduce PONV ## Footnote TIVA is preferred during RFCA due to the potential for hemodynamic instability and interference with inhaled anesthetics.

Answer 96

Labetolol ## Footnote Labetolol blocks both beta and alpha receptors, allowing for vasodilation in addition to reducing cardiac rate and contractility.

Answer 97

B & D ## Footnote Myocardial depressant characteristics of Ketamine can become unmasked in patients with depleted catecholamine stores and autonomic nervous system dysfunction.

Answer 98

Desflurane ## Footnote Desflurane is known to be a respiratory irritant, especially during mask inductions.

Answer 99

C & D Rational: Scopolamine patch has an onset of 4 hours and minimum duration of 24 hours. It works by blocking transmission of cholinergic impulses from vestibular nuclei to higher centers in the CNS and from the reticular formation to the vomiting center. It is chosen for PDNV due to its long duration. While Ondansetron and Palonosetron belong to the same class, Palonosetron is a second-generation serotonin antagonist and has a long half-life of 44 hours, which makes it effective for PDNV. Ondansetron and Metoclopramide are not used for PDNV due to their short durations of action.

Answer 100

C) A 28-year-old female taking hormonal contraceptives for birth control. ## Footnote Sugammadex can bind to and reduce the effectiveness of hormonal contraceptives.

Answer 101

C. Tylenol ## Footnote Tylenol is used to treat mild pain, while the other medications listed are used for greater pain.

Answer 102

A. Depressed ventilatory response to CO2 ## Footnote Benzodiazepines lower the hypercapnic drive by blunting the central chemoreceptors' response to increased CO2 levels.

Answer 103

D) Sufentanil ## Footnote Sufentanil is the most potent of the phenylpiperidines and is used for profound analgesia.

Answer 104

B) The liver produces plasma cholinesterase, responsible for hydrolyzing succinylcholine. ## Footnote Succinylcholine is degraded via hydrolysis by plasma cholinesterase produced by the liver.

Answer 105

A) A patient with severe asthma ## Footnote Ketamine is a potent bronchodilator, making it ideal for patients with reactive airway disease.

Answer 106

A. Nitrous Oxide C. Ketamine ## Footnote Nitrous Oxide and Ketamine function as NMDA receptor antagonists.

Answer 107

D) Propofol is a profound respiratory depressant and can cause apnea following an induction dose. ## Footnote Propofol typically causes apnea after an induction dose.

Answer 108

Dexmedetomidine (Precedex) & Clonidine (Catapres) ## Footnote Clonidine decreases blood pressure by agonizing peripheral presynaptic alpha 2 receptors and central alpha 2 receptors. Dexmedetomidine provides dose-dependent sedation, analgesia, sympatholysis, and anxiolysis without significant respiratory depression.

Answer 109

Neostigmine increases endogenous acetylcholine around the cholinoreceptors. Neostigmine inhibits acetylcholinesterase, which increases acetylcholine levels at the neuromuscular junction. This can cause bradycardia, arrhythmias, bronchoconstriction, and hypersalivation, so anticholinergics (glycopyrrolate or atropine) are given to counteract these effects. Sugammadex is a modified y-cyclodextrin that works by encapsulating and forming very tight water-soluble complexes at a 1:1 ratio with steroidal neuromuscular blocking drugs, therefore, it does not affect ACh levels and does not require an anticholinergic.

Answer 110

Morphine ## Footnote Morphine can cause significant histamine release, leading to vasodilation, hypotension, and pruritus.

Answer 111

All of the above are true of ketamine. ## Footnote Ketamine provides dissociative sedation and analgesia, increases blood pressure and heart rate, and can be administered IV, IM, and orally.

Answer 112

80-85% block.

Answer 113

Clindamycin.

Answer 114

2–4 mg/kg IV.

Answer 115

Propofol decreases blood pressure, cardiac output, and systemic vascular resistance more than etomidate.

Answer 116

Hypotension and bradycardia.

Answer 117

Morphine's active metabolite, M6G, may produce prolonged effects due to its more potent effect within the CNS compared to the parent drug.

Answer 118

Atopic or asthmatic patients, the elderly, or patients with renal or GI dysfunction or bleeding disorders.

Answer 119

Acetaminophen.

Answer 120

Use an alternative contraceptive for at least one week.

Answer 121

30–60 sec.

Answer 122

Minimum Alveolar Concentration.

Answer 123

By priming rocuronium, which involves giving 10% of the calculated dose before inducing anesthesia and then giving the remaining dose 1 to 3 minutes after the patient is anesthetized.

Answer 124

A 55-year-old patient with known coronary heart disease undergoing a laparoscopic cholecystectomy. Feedback General Feedback Routine testing with a 12-lead ECG is recommended only for patients with known coronary heart disease or other significant structural heart disease. While some facilities may use age-specific criteria, the presence of known heart disease provides a clearer indication. Routine ECGs are generally not recommended for low-risk surgeries in asymptomatic patients.

Answer 125

Lower patient satisfaction, less trust, and stronger negative emotional responses. General Feedback The survey revealed that "not disclosing information was associated with lower patient satisfaction, less trust, and stronger negative emotional responses".

Answer 126

A subparalytic dose of intravenous Succinylcholine. General Feedback The text states that if a jaw thrust maneuver with CPAP is ineffective in treating laryngospasm, a subparalytic dose of intravenous succinylcholine (0.1-1 mg/kg) or 4 mg/kg intramuscularly) may be given by the anesthesia provider.

Answer 127

Recent myocardial infarction within 30 days General Feedback A recent MI (within 30 days) is a major risk factor for perioperative reinfarction and mortality. Elective surgery should be postponed until at least 60 days post-MI to minimize risk.

Answer 128

Inhibition of neurotransmitter reuptake; discontinue at least 7 days before surgery. General Feedback According to Table 20.3, St. John's Wort has the relevant pharmacologic effect of inhibition of neurotransmitter reuptake. The table recommends discontinuing its use at least 7 days before surgery.

Answer 129

Loss of pharyngeal muscle tone in a sedated or obtunded patient. General Feedback The text indicates that the most common cause of airway obstruction in the immediate postoperative phase is the loss of pharyngeal muscle tone in a sedated or obtunded patient. While the tongue causing obstruction is mentioned, it is described as what happens due to this loss of muscle tone.

Answer 130

Atelectasis General Feedback The text explicitly states that atelectasis is the most common cause of postoperative arterial hypoxemia.

Answer 131

Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%. General Feedback Three readily identifiable findings that indicate poor ventricular function are a cardiac index of less than 2.2 L/m2, a left ventricular end-diastolic pressure of greater than 18 mm Hg, and an EF of less than 40%. Taking note of ischemia-induced dysfunction of the papillary muscles can help in avoiding later confusion about the configuration of the pulmonary wedge pressure waveform and the significance of intraoperative changes in wedge pressure. Wall motion abnormalities should be noted. Areas of akinesis (no movement during systole) usually represent nonviable regions of myocardium and are relatively fixed deficits.

Answer 132

The patient admits to sometimes having a drink first thing in the morning. General Feedback The CAGE mnemonic includes the question, "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?". A patient reporting more than two positive responses to the CAGE questions is at high risk for an alcohol problem. The other options are not part of the standard CAGE questionnaire.

Answer 133

Correct Answer: D) Increased in both sympathetic and parasympathetic response Abstinence syndrome typically exhibits increased sympathetic and parasympathetic responses resulting in hypertension, tachycardia, abdominal cramping and diarrhea, tremors, anxiety, irritability, lacrimation, mydriasis, algid sweat, and yawning.

Answer 134

Answer: B) Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%. Rationale: Three readily identifiable findings that indicate poor ventricular function are a cardiac index of less than 2.2 L/m2, a left ventricular end-diastolic pressure of greater than 18 mm Hg, and an EF of less than 40%. Taking note of ischemia-induced dysfunction of the papillary muscles can help in avoiding later confusion about the configuration of the pulmonary wedge pressure waveform and the significance of intraoperative changes in wedge pressure. Wall motion abnormalities should be noted. Areas of akinesis (no movement during systole) usually represent nonviable regions of myocardium and are relatively fixed deficits.

Answer 135

Answer: B. A 45-year-old nonsmoker female with a history of motion sickness undergoing breast surgery Rationale: Risk factors for PONV include female gender, history of PONV or motion sickness, nonsmoking status, use of volatile anesthetics, age less than 50, and opioid administration. The answer is B since this female in question has more risk factors than the 70-year-old female. Females experience PONV two to three times more often than males. Anxiety, obesity, use of a nasogastric tube, history of migraines, and supplemental oxygen are not risk factors of PONV and have been disproven or are not clinically relevant as predictors of PONV.

Answer 136

Answer: D. Newly developed angina within the past 2 months Rationale: Stable angina is defined as substernal discomfort brought on by exertion and relieved by rest, nitroglycerin, or both within 15 minutes. Stable angina is unlikely to significantly increase the risk of perioperative MI compared to those with an absence of anginal symptoms. Unstable angina, which can be characterized as newly developed angina occuring within the past 2 months, is associated with the highest risk of perioperative MI.

Answer 137

Answer: Latex Rationale: The incidence of intraoperative latex reactions has decreased due to increased awareness, preventive measures, and the availability of nonlatex medical supplies. However, latex sensitivity still accounts for up to 20% of intraoperative anaphylactic reactions. Preoperative assessments should include screening for latex allergies and sensitivities to prevent reactions.

Answer 138

Answer: A. 400 to 500 mL Rationale: Diabetes can decrease sensation and contractility in the bladder and increase bladder capacity, which increases the development of postoperative urinary retention (POUR). A predictor of POUR is the presence of greater than 400 to 500 mL of urine in the bladder immediately after spinal anesthesia. Opioids, ketamine, general anesthetics, and NSAIDs can increase the risk of POUR.

Answer 139

Answer: C - Sevoflurane Rationale: The incidence of postoperative emergence delirium has been reported to be as high as 50-80% in pediatric cases. There are many factors associated with increased risk of emergence delirium, such as pain, separation anxiety, endotracheal tube presence, and choice of anesthetic agent . In children, sevoflurane-anesthesia has been strongly linked to high levels of emergence delirium, whereas in the adults, benzodiazepine administration has been more related to its incidence

Answer 140

Answer: C, Healthcare provider caring for the patient. Rationale: No one desires to harm patients when caring for them. After a critical incident harms a patient, the healthcare professionals involved have often demonstrated PTSD symptoms. These symptoms can result in personal distress, burnout, loss of empathy, and an increased risk of making another error. Processing the incident using six steps is imperative to continue thriving and functioning: chaos/accident response, intrusive reflections, restoring personal integrity, enduring inquisition, obtaining emotional first aid, and moving onward.

Answer 141

Correct answer: B) Induction of a catabolic state, C) Decreased peripheral glucose uptake E) Increased endogenous glucose production Rationale: “The surgical stress respoinse is characterized by neuro-endocrine, metabolic, inflammatory, and immunological changes initiated by the physiological trespass of the surgical incision and subsequent invasive procedures. The stress response can adversely affect organ function and perioperative outcomes and may include induction of a catabolic state as well as a transient, but reversible, state of insulin resistance, characterized by decreased peripheral glucose uptake and increased endogenous glucose production

Answer 142

Answer: D. Fat Free Milk Rationale: Clear liquids can be consumed up to 2 hours before a procedure. Examples of clear liquids include: water, apple juice, black coffee, black tea, clear juice drinks, clear Jell-O, clear broth, ice, popsicles, and Pedialyte. Fat free milk is not a clear liquid and must be stopped 6 hours prior to a surgical procedure.

Answer 143

Answer: C Rationale: Risk factors associated with an increased risk of PONV include female gender, age <50 years, history of PONV, history of motion sickness, and a nonsmoker.

Answer 144

Answer: A, D, & E Rationale: Risk factors for awareness include: female sex, age (younger adults but not children), obesity, clinician experience, previous awareness, after normal hours operation, emergency procedure, type of surgery (obstetric, cardiac, thoracic), and use of nondepolarizing relaxants.

Answer 145

Answer: B. Proceed with surgery; findings are not contraindications Rationale: While hypoxemia (PaO₂ <60), SpO₂ of less than 90%, and hypercarbia (PaCO₂ >45) increase perioperative risk, they are not absolute contraindications for non-cardiac surgery. These values are expected in many patients with moderate to severe COPD. The key is to optimize the patient preoperatively, not necessarily delay or cancel.

Answer 146

Answer: a., c., d. Rationale: Tactics to decrease pulmonary complications in chronic bronchitis populations include respiratory maneuvers, smoking cessation, treatment of pulmonary infections with antibiotics, expectorants, chest physiotherapy, good nutrition, and weight reduction. It is not recommended to administer prophylactic antibiotics to "sterilize" the sputum as this may initiate growth of a resistant bacterial strain that would further complicate respiratory management

Answer 147

Correct Answer: A & D Rationale Signs and symptoms associated with upper respiratory tract infections include sore throat, reddened pharyngeal and oropharyngeal mucus membranes, increased secretions, fever, sneezing, rhinorrhea, and bulging or tender eardrums (Elisha et al., 2023). Conversely, lower respiratory tract infections present signs and symptoms more precisely associated with the lower airway anatomy, such as pulmonary congestion on a chest radiograph and the auscultation of rales in the lung fields

Answer 148

Answer: D Rationale: The recommended dose of hydrocortisone for a patient with known or suspected adrenal insufficiency undergoing moderate surgery (lower extremity revascularization, total joint replacement) is their preoperative corticosteroid dose + 50 - 75 mg of hydrocortisone. The dose for minor surgeries (inguinal hernia repair) is their preoperative corticosteroid dose + 25 mg hydrocortisone. The dose for major surgery (cardiac surgery, aortic aneurysm repair) is their preoperative corticosteroid dose + 100 - 150 mg of hydrocortisone every 8 hours for 48-72 hours. However, if the total dose per day exceeds 100 mg, a steroid such as methylprednisolone should be considered instead. 4 mg of methylprednisolone = 20 mg hydrocortisone.

Answer 149

Answer: C) Serum potassium Rational: Preoperative measurement of serum potassium concentration is recommended within 6 to 8 hours of surgery regardless of whether dialysis is performed, because unexpected hyperkalemia with its adverse cardiac effects is known to occur rapidly. If serum potassium level exceeds 5.5 mEq/L and congestive heart failure is apparent, elective surgery should be delayed until after dialysis. If postponement is not an option due to emergency surgery, measures to reduce the serum potassium concentration should be initiated.

Answer 150

Correct Answer: C. Recent myocardial infarction within 30 days Rationale: A recent MI (within 30 days) is a major risk factor for perioperative reinfarction and mortality. Elective surgery should be postponed until at least 60 days post-MI to minimize risk.

Answer 151

The patient is able to lift their head and move two extremities voluntarily but has shallow respirations. Rationale: Incomplete reversal of neuromuscular relaxation can lead to hypoventilation. The text emphasizes the use of objective monitoring measures like train-of-four ratio <0.90 to determine the depth of residual blockade. Shallow respirations in conjunction with a low train-of-four ratio strongly suggest inadequate reversal.

Answer 152

C. Potassium Potassium is the key determinant of intracellular osmotic pressure, whereas sodium dominates extracellular osmotic regulation. This balance is critical for cell volume and function.

Answer 153

A. Maintains the potassium gradient across cell membranes The Na⁺/K⁺-ATPase actively transports sodium out of and potassium into cells, maintaining intracellular potassium concentration and contributing to osmotic balance and resting membrane potential. It's vital for cellular function.

Answer 154

Correct Answer: Intravenous calcium Symptomatic hypocalcemia is a medical emergency that necessitates immediate treatment with intravenous calcium to stabilize the cardiac and neuromuscular systems. Oral supplementation is too slow, and while magnesium may correct hypomagnesemia-associated hypocalcemia, it is not the first-line treatment. Diuretics and saline are used for hypercalcemia management, not hypocalcemia.

Answer 155

D. SIADH SIADH is the most common cause of hyponatremia and is characterized by excessive release of ADH, leading to water retention and dilutional hyponatremia. The other conditions may affect sodium balance but are far less common.

Answer 156

B. Decreased PaCO₂ and increased pH Respiratory alkalosis results from hyperventilation, which decreases PaCO₂ and increases blood pH. The other options describe different acid-base disturbances.

Answer 157

A. Limit correction to no more than 0.5–1.5 mEq/L per hour Osmotic demyelination syndrome is a severe risk of correcting chronic hyponatremia too quickly. Recommended correction rates are 0.5–1.5 mEq/L per hour depending on severity and should not exceed 8–10 mEq/L in 24 hours. Rapid normalization is dangerous and should be avoided.

Answer 158

B. Hyperkalemia Hyperkalemia above 6 mEq/L poses a high risk for cardiac arrhythmias and cardiac arrest, especially with EKG changes. Urgent intervention is required to stabilize cardiac membranes and reduce serum potassium.

Answer 159

B. Isotonic Crystalloids Isotonic crystalloids like Lactated Ringer’s or PlasmaLyte are typically used for initial volume resuscitation due to their distribution within the extracellular compartment. Colloids are reserved for specific indications and hypertonic fluids are rarely first-line.

Answer 160

B. SVV SVV and pulse pressure variation (PPV) are dynamic indicators that reflect preload responsiveness in mechanically ventilated patients, helping guide fluid therapy more effectively than static measures like CVP.

Answer 161

B. ABO incompatibility ABO incompatibility can lead to acute hemolytic reactions, which are the most severe and potentially fatal transfusion complications. While other reactions can be serious, they are typically less immediately life-threatening.

Answer 162

A & D Cell salvage techniques are utilized to reduce the amount of allogenic red blood cell transfusions in cases with high expected blood loss (>500mL) (Elisha et al., 2023, p. 404). These practices are also beneficial in maintaining hemodynamic stability in patients who do not consent to allogenic blood transfusion, such as Jehovah’s Witnesses (Elisha et al., 2023, p. 404). Relative contraindications to cell salvage techniques include the contamination of the surgical field by malignant tumor cells and possible exposure of bowel contents

Answer 163

B. Severe hypoalbuminemia C. Massive third spacing E. Buying time before blood availability Rationale: Colloids are reserved for specific situations such as oncotic pressure loss, significant fluid shifts, or immediate volume expansion while awaiting blood products. Crystalloids are generally reserved for burns and sepsis.

Answer 164

B and C Rationale: Hypocalcemia should be diagnosed based upon the ionized plasma calcium concentration. If hypocalcemia is present based upon this, common causes include hypoparathyroidism, vitamin d deficiency, hyperphosphatemia, precipitation of calcium, and chelation of calcium. Thiazide diuretic administration, and hyperparathyroidism are common causes of hypercalcemia.

Answer 165

A, B and D Rationale: Chloride sensitive mechanisms of metabolic alkalosis include conditions that deplete extracellular fluid. In response to fluid depletion, the renal tubules reabsorb Na+; when not enough chloride anions are present to accompany the Na+, H+ ions must be excreted to maintain electrical neutrality. Urine chloride concentrations are typically low (<10mEq/L). Conditions can can lead to this fall into three categories: Gastrointestinal, renal, and sweat. While diuretic therapy is the most common cause, other triggers include vomiting (gastrointestinal) and cystic fibrosis (sweat). Hyperaldosteronism falls into the "chloride resistant" category, causing metabolic alkalosis by way of promoting sodium retention and K+ and H+ excretion. In this instance, urine chloride is typically elevated (>20 mEq/L).

Answer 166

D The relationship between LVEDV and myocardial contractility is the basis of the Frank-Starling mechanism. This mechanism describes how increasing LVEDV (ventricular stretch) will increase myocardial contractility, which increases the force of contraction. It all has to do with sliding filament theory. As the sarcomeres lengthen from stretching, more actin overlaps myosin, creating more cross-bridges. The number of cross-bridges dictates the force of contraction. However, the force of contraction will decrease if the ventricle is stretched past a certain point because the myosin and actin filaments are only so long. Too much stretch ultimately causes less myosin and actin to overlap. This reduces the number of cross-bridges to form, causing a weaker contraction. The Frank-Starling mechanism explains why giving fluid volume for hypovolemia increases cardiac output, but too much volume (fluid overload) is counterproductive.

Answer 167

C) 10–15 mmol/L in 24 hours Once the patient is clinically stable, Na+ administration should be slowed to raise serum Na+ not more than 10 to 15 mmol/L in 24 hours.

Answer 168

Correct Answer: A, D, E, F Specialized neurons in the hypothalamus are sensitive to changes in extracellular osmolality. When ECF osmolality increases, these cells shrink and cause ADH release from the posterior pituitary. ADH markedly increases water reabsorption in renal collecting tubules which reduces plasma osmolality back to normal. Conversely, a decrease in extracellular osmolality causes osmoreceptors to swell and suppresses the release of ADH. Decreased ADH secretion allows water diuresis, which increases osmolality to normal. Peak diuresis occurs once circulating ADH is metabolized (90–120 minutes). With complete suppression of ADH secretion, the kidneys can excrete up to 10 to 20 L of water per day. Carotid baroreceptors (volume receptors), as well as low-pressure volume receptors in the atria, vena cavae, and pulmonary arteries, also influence ADH release. A fall in wall tension results in a reflex increase of ADH secretion from the posterior pituitary. An increased stretch of these receptors not only suppresses ADH secretion, but the increased atrial volume receptor stretch also increases secretion of atrial natriuretic peptide (ANP; see later discussion), which promotes renal excretion of sodium and water”

Answer 169

B. 3 Liters Rationale: The fluid requirement for person who is healthy, normothermic, and has standard metabolic function is 25-35 ml/kg a day. Thus, a 100 kg patient would require 2.5 - 3.5 Liters of fluid to maintain Total Body Water Homeostasis.

Answer 170

C. Hyponatremia is the most common electrolyte abnormality in hospitalized patients.

Answer 171

Correct Answer: C. Nephrogenic DI involves impaired renal response to normal ADH levels In nephrogenic DI, ADH secretion is normal, but the kidneys fail to respond to it, and urinary concentrating ability is impaired. It can be congenital or secondary to chronic conditions, such as CKD, hypokalemia, or lithium use. Central DI is due to decreased ADH secretion, commonly resulting from brain lesions or brain death. An increase in urine osmolality following the administration of exogenous ADH confirms the diagnosis of central DI. In nephrogenic DI, the kidneys fail to produce hypertonic urine following the administration of exogenous ADH.

Answer 172

C. Optimization of the patient’s red blood cell production Addressing patient blood management (PBM) throughout the perioperative period allows practitioners to identify and treat conditions—such as anemia or coagulopathy—that increase the risk of bleeding or transfusion. The key aspects of PBM during this time include optimization of the patient’s red blood cell (RBC) production, minimization of blood loss, and treatment of anemia. These strategies help improve oxygen delivery, reduce transfusion requirements, and ultimately enhance patient outcomes.

Answer 173

Answer: B) Hypocalcemia Rational: Citrate is used as a preservative in packed red blood cells. The citrate chelates or binds calcium. During massive rapid transfusion, the excess citrate can significantly reduce the serum calcium levels, leading to acute hypocalcemia. Correction of serum calcium should be guided by ionized calcium levels.

Answer 174

C. Mild thrombocytosis without bleeding Platelet transfusion is not indicated in thrombocytosis. Examples of some indications for platelet transfusion are platelet dysfunction, thrombocytopenia, or platelet count <50 × 10⁹ cells/L with active bleeding.

Answer 175

B. Breast milk: 2 hours The preoperative fasting guidelines recommend the following fasting intervals: clear liquids 2 hours, breast milk 4 hours, infant formula/nonhuman milk/light meal 6 hours, and heavy meal (fried foods, fatty foods, meats) 8 hours. Also, supplying a carbohydrate drink (such as Gatorade) 2 hours prior to surgery has the added benefit of maintaining adequate preoperative glucose and insulin levels, thereby reducing preoperative thirst, hunger, and anxiety levels.

Answer 176

B. Hypokalemia. The ECG represents a classic presentation of hypokalemia. Assumably, the hypokalemia was brought on by a decreased dietary potassium intake and the administration of loop diuretics. Conversely, hyperkalemia is presented with a flattened P wave, widened QRS, shortened QT interval, and peaked T wave.

Answer 177

C. Hypertension TACO is estimated to occur in 1% to 4% of patients receiving a transfusion and occurs higher in those who are critically ill and in ICUs.It should be suspected in any patient experiencing respiratory distress or hypertension 6 to 12 hours after completion of a transfusion. Although hypertension is a distinguishing feature between TRALI and TACO, hypotension and shock can also occur with TACO.’’ Other findings may include hypoxia, tachycardia, widened pulse pressure, jugular vein distension, or rales/wheezing within the lungs

Answer 178

A. Hyponatremia and hyperkalemia Rationale: Medications such as ACE inhibitors, beta blockers (specifically Beta 1 receptor antagonism), ARBs, and digoxin can cause an increase in extracellular potassium. ACE inhibitors and ARBs can cause a decrease in angiotensin, and beta blockers inhibit renin release, which decreases the release of aldosterone. A decrease in aldosterone can cause hyperkalemia and hyponatremia.

Answer 179

Correct Answer: B. To utilize individual hemodynamic end points to achieve an optimal cardiac output and oxygen delivery to tissues. Perioperative goal-directed fluid therapy (GDFT) aims to optimize each individual's hemodynamic status by tailoring fluid administration to achieve specific hemodynamic end points, thus decreasing oxygen demand and optimizing cardiac output and tissue oxygenation during surgery. Administering a fixed volume of fluids has historically been used in the past, but it may have unintended physiologic consequences since it is not tailored to each individual's hemodynamic needs. Focusing solely on replacing estimated blood loss does not account for individual patient needs, and is related to the "zero balance" approach of fluid management. Minimizing vasopressor use is not the primary objective of GDFT. However, GDFT will allow the provider to determine if the patient requires fluid therapy or inotropy support.