Anesthesia QOD

Autonomic hyperreflexia:

A. is common with cord lesions below T8
B. can precipitate pulmonary edema
C. is not effectively prevented by regional anesthesia
D. can be prevented with adequate intraoperative sedation

Autonomic hyperreflexia:

can precipitate pulmonary edema

Autonomic hyperreflexia should be suspected in patients with lesions above T5-8. Regional anesthesia and deep general anesthesia are effective in preventing autonomic hyperreflexia. Surgical stimulation in these patients without adequate anesthesia can result in pulmonary edema, myocardial ischemia and cerebral hemorrhage.

pg. 927
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

During mediastinoscopy the risk of air embolization is greatest:

A. when the patient is supine
B. during spontaneous ventilation
C. immediately after closure of the incision
D. in the postoperative period

during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

An action potential characterized by a spike followed by a plateau phase is seen in:

A. peripheral sensory nerve cells
B. peripheral motor nerve cells
C. striated skeletal muscle cells
D. cardiac muscle cells

cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.

pg. 345
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The formation of metanephrine is the result of:
catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to vanillymandelic acid (VMA).

pg. 868
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is:
745 – 750 PSIg

Nitrous oxide has a critical temperature of 37oC. This allow nitrous oxide to exist as a liquid at room temperature. Full E-cylinders of nitrous oxide contain approximately 1590 L at a pressure of 745 psig. A sixty minute delivery of 3 L/min would result in a 180 L consumption, and this would be inadequate to consume all the liquid nitrous oxide in the tank. As a result, there would be no change in tank pressure.

pg. 622
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

A decrease in pseudocholinesterase activity has been associated with the use of: (Select 3)

pancuronium
esmolol
droperidol
vecuronium
metoclopramide
magnesium sulfate
dantrolene
rocuronium

A decrease in pseudocholinesterase activity has been associated with the use of:

pancuronium, esmolol, metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, phenelzine, cyclophosphamide, metoclopramide, esmolol, pancuronium and oral contraceptives. Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

A. echinacea
B. valerian
C. ginkgo
D. ephedra

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

pg. 346t
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.
pg. 585
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pulmonary complications from advanced hepatic disease with cirrhosis include:

A. an obstructive ventilatory defect
B. respiratory acidosis
C. increased intrapulmonary shunting
D. increased functional residual capacity

Pulmonary complications from advanced hepatic disease with cirrhosis include:

increased intrapulmonary shunting

Pulmonary manifestations associated with cirrhosis include: increased intrapulmonary shunting, decreased FRC, pleural effusions, restrictive ventilatory defect and respiratory alkalosis.

pg. 774
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

A. echinacea
B. valerian
C. ginkgo
D. ephedra

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

pg. 346t
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.
pg. 585
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013

A decrease in pseudocholinesterase activity has been associated with the use of: (Select 3)

A. pancuronium
B. esmolol
C. droperidol
D. vecuronium
E. metoclopramide
F. magnesium sulfate
G. dantrolene
H. rocuronium
response is incorrect.

A decrease in pseudocholinesterase activity has been associated with the use of:

pancuronium, esmolol, metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, phenelzine, cyclophosphamide, metoclopramide, esmolol, pancuronium and oral contraceptives. Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is:
745 – 750 psig

Nitrous oxide has a critical temperature of 37C. This allow nitrous oxide to exist as a liquid at room temperature. Full E-cylinders of nitrous oxide contain approximately 1590 L at a pressure of 745 psig. A sixty minute delivery of 3 L/min would result in a 180 L consumption, and this would be inadequate to consume all the liquid nitrous oxide in the tank. As a result, there would be no change in tank pressure.

pg. 622
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The formation of metanephrine is the result of:
catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to vanillymandelic acid (VMA).

pg. 868
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An action potential characterized by a spike followed by a plateau phase is seen in:

A. peripheral sensory nerve cells
B. peripheral motor nerve cells
C. striated skeletal muscle cells
D. cardiac muscle cells

cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.

pg. 345
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During mediastinoscopy the risk of air embolization is greatest:

A. when the patient is supine
B. during spontaneous ventilation
C. immediately after closure of the incision
D. in the postoperative period

B. during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Autonomic hyperreflexia:

A. is common with cord lesions below T8
B. can precipitate pulmonary edema
C. is not effectively prevented by regional anesthesia
D. can be prevented with adequate intraoperative sedation

B. can precipitate pulmonary edema

Autonomic hyperreflexia should be suspected in patients with lesions above T5-8. Regional anesthesia and deep general anesthesia are effective in preventing autonomic hyperreflexia. Surgical stimulation in these patients without adequate anesthesia can result in pulmonary edema, myocardial ischemia and cerebral hemorrhage.

pg. 927
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

In the CVP trace below, the v wave is caused by:

A. atrial contraction
B. ventricular contraction
C. atrial filling
D. opening of the tricuspid valve

C. atrial filling

In the normal CVP tracing, the a wave is due to atrial systole. The c wave coincides with ventricular contraction. The v wave is the result of atrial filling prior to the opening of the tricuspid valve. The x descent is thought to be due to the pulling down of the atrium by ventricular contraction. The y descent corresponds to the opening of the tricuspid valve.

pp. 298-300
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The primary causative factor in the development of persistent pulmonary hypertension (PPH) in the neonate is:

A. cystic fibrosis
B. pregnancy-induced hypertension
C. hypoxemia
D. right-to-left shunting through a patent ductus arteriosus

C. hypoxemia

Hypoxia or acidosis during the early neonatal period may predispose the infant to return to fetal circulation. This serious condition, previously known as persistent fetal circulation (PFC), is currently known as persistent pulmonary hypertension (PPH). Hypoxemia and/or acidosis promotes an increase in pulmonary vascular resistance which ultimately causes right to left shunting through the ductus arteriosus, foramen ovale, or both. Shunting causes continued hypoxemia, leading to a continued increase in pulmonary vascular resistance, and a vicious cycle ensues. Primary causes of hypoxemia in the neonate include pneumonia and meconium aspiration.

pp. 1163-1164
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Deleterious effects of hypothermia include: (Select 2)

A. impaired renal function
B. right shift of the hemoglobin-oxygen saturation curve
C. irreversible platelet dysfunction
D. increased incidence of wound infection
E. increased postoperative protein anabolism

A. impaired renal function,
D. increased incidence of wound infection

increased PVR
left shift of the hemoglobin-oxygen saturation curve
reversible platelet dysfunction
postoperative protein catabolism
altered mental status
impaired renal function
decreased drug metabolism
poor wound healing
increased incidence of infection
cardiac arrhythmias
pp. 1235-1236
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

You are managing anemia in a 3-day-old neonate. Which of the following most accurately reflects the hemoglobin equivalent for tissue delivery in the neonate, infant, and adult?

A. Neonate: 10 g/dl; Infant 14 g/dl; Adult 8 g/dl
B. Neonate: 14 g/dl; Infant 10 g/dl; Adult 8 g/dl
C. Neonate: 8 g/dl; Infant 10 g/dl; Adult 14 g/dl
D. Neonate: 14 g/dl; Infant 8 g/dl; Adult 10 g/dl

Dr. Motoyama described a hemoglobin requirement for equivalent tissue oxygen delivery for neonates, infants and adults based on the oxygen affinity of hemoglobin. The hemoglobin required to transport an equivalent amount of oxygen is:

D. 14-15 g/dl for the neonate, 8 g/dl for the infant, and 10 g/dl for the adult

Prior to pneumonectomy, split lung function testing is indicated in the patient with:

A. an FEV1 of 2.2 L
B. a PaCO2 of 49 mm Hg on room air
C. a PaO2 of 54 mm Hg on room air
D. a maximum VO2 of 21 mL/kg/min

B. a PaCO2 of 49 mm Hg on room air

Split lung function testing is indicated in patients requiring pneumonectomy, but not meeting the recommended laboratory criteria. Current recommendations for patients requiring pneumonectomy are:

PaCO2 < 45 mm Hg FEV1 > 2 L
Predicted postop FEV1 > 800 mL
Maximum VO2 > 15 mL/kg/min
FEV1/FVC > 50% of predicted
pp. 663-665
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An infant had a patent ductus arteriosus closed and is recovering in the NICU. You note that the patient has new-onset stridor and hoarseness. Which of the following is the MOST likely cause of this finding?

A. Surgical dissection causing recurrent laryngeal nerve injury
B. Hypocalcemia after transfusion of packed red blood cells
C. Laryngospasm after deep extubation
D. Incorrectly sized endotracheal tube

The incidence of recurrent laryngeal nerve injury with standard PDA ligation is reported to be 4.2% by Fan et al. while other authors indicate 2.5% using VATS clipping. Symptoms attributable to vocal cord paralysis regress in most cases and usually less than 1% of patients have lasting dysfunction. Clip entrapment of the nerve has been cited to be the mechanism of injury, but it may be that trauma induced by traction (or thermal injury by electrocautery) may better explain the observed clinical outcome. Zbar et al. reports a series of PDAs treated using open thoracotomy and indicates an incidence of recurrent laryngeal nerve injury of 22.7% in extremely low-weight babies, confirming the importance of the issue in premature infants. Decreased incidence of this complication appears to have been achieved with VATS and may be a consequence of improved vision from the video camera image.

The lumbar plexus is derived from which of the following?

A. Dorsal rami of L1-4
B. Ventral rami of L1-4 and variable contributions from T12 and L5
C. Dorsal rami of L1-4 and variable contributions from S1-2 and L5
D. Ventral rami of L1-4 and variable contributions

The lumbar plexus is derived from the anterior (ventral) primary rami of lumbar nerves L1-L4 with variable contributions from the 12th thoracic and 5th lumbar nerves.

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:

A. genioglossus muscle
B. longitudinal muscle of the tongue
C. palatoglossus muscle
D. styloglossus muscle

genioglossus

The genioglossus muscle
allows the tongue to be protruded and kept away from the posterior pharynx. It is innervated by the hypoglossal nerve. The palatoglossus muscle elevates the tongue and depresses the soft palate. The styloglossus muscle elevates and retracts the tongue. The superior longitudinal muscle of the tongue is an intrinsic muscle of the tongue that elevates the tip.

44-year-old man presents to the emergency room with a table saw injury to the left hand. The surgeon plans to explore the wound and possibly repair tendon and vascular injuries. The estimated operative duration is between 1-5 hours and an axilla block with bupivacaine is planned as the primary anesthetic technique. The patient has a seizure with the inejction of bupivacaine. Which of the following should be your FIRST therapeutic action?

A. Administer a short-acting muscle relaxant to stop muscle contractions
B. Administer intra-lipid
C. Administer lidocaine to prevent cardiac arrhythmias
D. Administer oxygen and ensure a patent airway

The treatment of local anesthetic toxicity is similar to the management of other medical emergencies and focuses on airway, breathing and circulation. Ensuring adequate oxygenation and ventilation is paramount to avoid progressive acidosis

Compared to “plain” local anesthetic without epinephrine, a pre-mixed local anesthetic with epinephrine solution is MOST associated with which of the following?

A. Little effect on peak plasma levels
B. Decreased sensory block
C. Increased onset time
D. Decreased cardiac output

Commercially prepared solutions with epinephrine have a lower pH than those in which it is freshly added. A lower pH results in a higher percentage of ionized drug molecules. It is the non-ionized form that easily crosses the lipid membrane; therefore the onset will be delayed.

During fetal monitoring, Type III decelerations are thought to be related to:

A. head compression
B. umbilical cord compression
C. uteroplacental insufficiency
D. placental abruption

B (umbilical cord compression

Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

pg. 1167
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinic)

Which of the following statements regarding the addition of clonidine to an epidural infusion is MOST correct?

A. Clonidine is an alpha-2-receptor antagonist
B. Clonidine effect in peripheral nerve blocks is primarily centrally mediated
C. Clonidine prolongs the sensory block when added to intermediate local anesthetics
D. Commonly reported side effects include tachycardia and hypertension

Clonidine is an alpha-2-agonist. It has been found to prolong the sensory block primarily when combined with intermediate local anesthetics although it may also have some effect when combined with longer-acting local anesthetics. The exact mechanism is unclear but appears to be peripherally mediated and dose-dependent. Side effects include bradycardia, hypotension, and sedation.

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:

A. hypernatremia
B. hyperglycemia
C. difficulty with intubation and airway management
D. increased blood viscosity due to elevated hematocrit

C (Anesthetic complications associated with hypothyroidism include: difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

pp. 875-876
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

After an accidental needle stick with a contaminated needle, which of the following viruses carries the HIGHEST risk of transmission?

A. HIV
B. Hepatitis A
C. Hepatitis B
D. Hepatitis C

Hepatitis B carries the greatest risk of transmission, with 37 to 62% of exposed workers eventually showing seroconversion and 22 to 31% showing clinical hepatitis B infection. The hepatitis C transmission rate has been reported at 1.8%, but newer, larger surveys have shown only a 0.5% transmission rate. The overall risk of HIV infection after percutaneous exposure to HIV-infected material in the health care setting is 0.3%. Hepatitis B prophylaxis Current CDC guidelines call for the administration of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine. While the efficacy of the combination has not been evaluated in the needlestick injury setting, it has been shown to be the most efficacious approach in the perinatal setting. The approach has no contraindications during pregnancy and lactation. Hepatitis C prophylaxis CDC guidelines acknowledge that there is no active post-exposure prophylaxis for HCV. There is some evidence that treatment with interferon alfa-2b may be beneficial preventing chronic hepatitis. HIV prophylaxis CDC guidelines generally recommend a post-exposure prophylaxis protocol with 3 or more antiviral drugs, when it is known that the donor was HIV positive; however, when the viral load was low and none of the above noted risk factors are met, the CDC protocol utilizes 2 antiviral drugs.

Which of the following is MOST often associated with carbon monoxide poisoning?

A. Salicylate poisoning
B. Cyanide toxicity
C. Ethanol toxicity
D. Acetaminophen toxicity

Carbon monoxide binds to hemoglobin and prevents the delivery of O2 to tissues. Conventional two-wavelength pulse oximeter cannot discriminate between Hgb-CO and HgbO2. The half-life of carboxyhemoglobin (Hb-CO) in a patient breathing room air is approximately 300 minutes; this decreases to 90 minutes with high-flow oxygen via a nonrebreathing mask. Thus, the most important interventions in the management of a CO-poisoned patient are prompt removal from the source of CO and institution of high-flow oxygen by facemask. For patients suffering from CO poisoning after smoke inhalation, it is important to consider concomitant cyanide toxicity, which can further impair tissue oxygen utilization and exacerbate cellular hypoxia. Cyanide toxicity should be considered in anyone who rapidly loses consciousness after ingestion or inhalation (it is common in indoor fire victims due to combustion of plastics). The symptoms are those of hypoxia (headache, lethargy, seizures, coma but without cyanosis). Cyanide inhibits cytochrome oxidase in the electron transport chain which prevents the offloading of electrons from NADH to oxygen which prevents ATP production ? anaerobic metabolism ? lactic acidosis all in spite of normal PaO2. Manage with 100% O2 and give any or all of amyl nitrate, sodium nitrate, and/or sodium thiosulfate. The nitrates generate methemoglobin which has a greater affinity for cyanide than does cytochrome oxidase.

Which of the following monitoring modality is MOST important in the setting of tricyclic antidepressant (TCA) poisoning?

A. Pulse oximetry
B. Electrocardiogram
C. Blood pressure
D. PaCO2

TCA overdose can lead to lethargy, delirium, coma, and seizures. Tachycardia and hypotension may also develop. Attempt gastric lavage if history suggests recent large ingestion (10-20 mg/kg) and use activated charcoal. The ECG tracing is crucial in the management of TCA overdose. Give sodium bicarbonate if QRS duration > 100 ms (1-2 meq/kg bolus) and convert from bolus to infusion when the QRS complex narrows (targeting a pH of 7.5 to 7.55). If the pH becomes too alkaline but QRS complex widens then given 3% hypertonic saline to antagonize sodium channel blockade associated with TCAs. Use norepinephrine if vasopressors are necessary. Seizures need to be rapidly controlled with GABA agonists (benzos, propofol) b/c associated metabolic acidosis will rapidly worsen toxicity; don’t give phenytoin which is a type IA anti-arrhythmic.

A 59-year-old man presents with nausea, diaphoresis, and bradycardia. His blood pressure is 80/40 mmHg, HR 45 bpm. A transthoracic echocardiogram reveals global left ventricular hypokinesis with bulging of the interventricular septum into the left ventricle, mild mitral regurgitation, and moderate tricuspid regurgitation. Which coronary artery do you MOST expect to be occluded?

A. First diagonal artery
B. Left anterior descending artery
C. Left circumflex artery
D. Right coronary artery

The symptoms of this patient as well as the echocardiogram findings indicate right ventricular ischemia. Patients typically often present with symptoms, such as nausea, vomiting, diaphoresis and bradycardia, and may not have the typical chest pain or pressure symptoms. An inferior wall myocardial infarction (right coronary artery distribution in 85% of patients) may manifest as complete heart block due to damage to the AV node. The SA node is fed by the RCA in 55% of population and left circumflex artery in 45% of population.

The most severe transfusion reactions are due to:
ABO incompatibility

The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis.

pg. 1172
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 55-year-old woman with a history of congenital long QT syndrome is undergoing a hysteroscopy for abnormal uterine bleeding. She had uneventful induction of general anesthesia but after paracervical block with lidocaine develops ventricular tachycardia with morphological appearance of torsades de pointe. Which of the following medications should be AVOIDED in the treatment of her arrhythmia?

A. Amiodarone
B. Calcium chloride
C. Esmolol
D. Magnesium sulfate

Congenital long QT syndrome may occur in conjunction with other hereditary syndromes, such as Jervell, Lange-Nielsen or Romano-Ward syndrome, or acquired as a result of pharmacologic or metabolic etiologies. It is an issue of cellular repolarization which precipitates tachyarrhythmias, most commonly polymorphic ventricular tachycardia or torsades de pointe. There are multiple subtypes that affect both potassium and/or sodium channels. The arrhythmias may be precipitated by sympathetic activation, auditory stimuli or at rest. Family history may be positive for sudden cardiac death and the ECG significant for prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves. Treatment includes magnesium for arrhythmias, possible permanent pacemaker, or beta blockers for subtypes 1 and 2, but amiodarone is considered contraindicated as it prolongs the QT interval.

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by:

A. placing the grounding pad near the pacemaker
B. using infrequent bursts of longer duration
C. the use of a bipolar cautery
D. reducing the surface area of the return electrode

the use of a bipolar cautery

Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.

pg. 403
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 75-year-old man is undergoing a mitral valve replacement via cardiopulmonary bypass. The perfusionist is running bypass flows at > 2.5 liters/minute/m2. Which of the following is the MOST likely adverse consequence of undergoing cardiopulmonary bypass at increased flow rates?

A. Increased trauma to blood elements
B. Increased hypothermia
C. Decreased blood flow to the brain
D. Decreased myocardial blood flow

Cardiopulmonary bypass (CPB) does the work of the heart and lungs in order to isolate those organs from blood flow such that surgery on the heart can occur in a relatively bloodless fashion. Thus, the CPB circuit must oxygenate and ventilate the blood and then deliver the oxygenated blood back to the body and end organs. It has long been debated whether maximal blood flow or pressure is more important in perfusion and homeostasis of the end organs during bypass. Maximizing blood flow (generally considered to be flow at a cardiac index of > 2 liters/minute/meter2) has been shown to increase hematologic trauma, increase the magnitude of the stress or inflammatory response, cause strain on suture lines, increase shunting of blood through the pulmonary system, increase washout of cardioplegia and not necessarily lead to improved regional blood flow. The CPB machine can change total flow, but it cannot adjust regional flows to the various end organ systems. Changes in blood pressure are currently thought to be most effective for allowing adjustments to regional flow in organ systems as the organs retain their regional vascular resistance capabilities. Thus conduct of CPB with an optimal pressure (and potentially lower flows) may allow the individual organs to regionally modulate their own flows.

postretrobulbar block apnea syndrome is associated with:
unconsciousness

The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.

pg. 766
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Physiologic effects of electroconvulsive therapy (ECT) include an:

A. initial sympathetic response with sustained tachycardia
B. initial sympathetic discharge followed by a sustained parasympathetic response
C. initial parasympathetic discharge followed by a sustained sympathetic response
D. initial parasympathetic response with sustained bradycardia

C (initial parasympathetic discharge followed by a sustained sympathetic response

An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased secretions can occur, which is then followed by hypertension and tachycardia. Patients scheduled for ECT are routinely given anticholinergic medication preoperatively.

pg. 1277
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:

A. T4 – T8
b. T8 – L2
c. L2 – L4
d. L4 – S1

arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from: T8 – L2

A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable origin from aorta, arising between T5 – T8 in 15%, between T9 – T12 in 60% and between L1 – L2 in 25% of individuals.

pg. 480
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Which of the following respiratory parameters remains UNCHANGED in pregnancy?

a. Functional residual capacity (FRC)
b. Inspiratory reserve volume (IRV)
c. Total lung capacity (TLC)
d. Expiratory reserve volume (ERV)

b (IRV

Compression of the lungs by the gravid uterus causes multiple changes in lung volumes. The diaphragm is elevated from upward pressure from the uterus, resulting in decreased TLC, FRC, ERV, and residual volume. Tidal volumes increase to increase minute ventilation, and by extension inspiratory capacity increases as well. Parameters that stay roughly constant in pregnancy vital capacity and inspiratory reserve volume. There is a small (~5%) reduction in total lung capacity. Thus, the loss of FRC caused by the elevation of the diaphragm does not reduce the volumes that the patient is actively breathing.)

Correct location of the catheter tip of a central venous line is in the:

a. superior vena cava
b. right atrium
c. right ventricle
d. pulmonary artery

superior vena cava

The CVP catheter tip should not be allowed to migrate into the heart chamber to avoid arrhythmias and perforatio

Which of the following is MOST true regarding acetaminophen poisoning?

a. 5% of acetaminophen is excreted in the urine
b. Acetaminophen is responsible for at least 90% of acute hepatic failure in the US
c. Acetaminophen is a central COX-1 inhibitor
d. The majority of acetaminophen is oxidized to NAPQI (which is detoxified by glutathione)

There were 100,000 reported exposures to acetaminophen in 2005, 333 of which were fatal and 3310 considered significant. Acetaminophen is a central COX-2 and prostaglandin synthase inhibitor and is responsible for 51% of all acute hepatic failure in the US. 90% of ingested acetaminophen is conjugated with glucuronide or sulfate, 5-15% is oxidized to NAPQI (by cytochrome P450) which is toxic and is detoxified by glutathione, and 5% eliminated unchanged in urine. If sulfate becomes saturated, NAPQI can no longer be detoxified by glutathione and it reaches toxic levels in the liver. Stage I acetaminophen toxicity: asymptomatic Stage II acetaminophen toxicity: hepatitis-like findings (AST/ALT, INR) Stage III acetaminophen toxicity: peak hepatotoxicity at 72-96 hours Stage IV acetaminophen toxicity: hepatic recovery (does not always occur) N-acetylcysteine (augments glutathione reserves) @ 140 mg/kg loading dose PO or 150 mg/kg IV (preferable) followed by repeated (smaller) doses every 4 hours. Because NAC is so effective, charcoal is not needed unless co-ingestion is suspected.

During pregnancy, the minimum alveolar concentration (MAC):

a. decreases until the 20th week
b. increases until the 20th week
c. decreases throughout the pregnancy
d. increases throughout the pregnancy

decreases throughout the pregnancy

The MAC progressively decreases during pregnancy, at term by as much as 40%. MAC returns to normal by the third day after delivery.

pg. 826
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Which of the following is NOT a contraindication to activated charcoal in the setting of suspected aspirin poisoning?

a.Bowel obstruction
b. Bowel perforation
c. Inability to protect airway
d. Two hours since ingestion

AC is absolutely contraindicated in patients with bowel obstruction or perforation and those with an unprotected airway.

While benefit from GI decontamination is most likely when it can be performed within one hour of poison ingestion, because it is relatively harmless (if contraindications are not present), giving it within two hours of ingestion is reasonable (at this time mean drug absorption may still be reduced by ~ 30%). That said, since most adults do not present to emergency departments until a mean of three to four hours after a toxic ingestion, when much of the ingested material has already been absorbed, GI decontamination is unlikely to affect these patients. The potential for benefit from GI decontamination after one hour cannot, however, be excluded Activated charcoal (AC) is the preferred means of gastrointestinal (GI) decontamination following a toxic ingestion. AC is an insoluble, non-absorbable, inert, fine carbon powder produced by the pyrolysis of organic material and then treated with steam and acid. AC has an extensive network of carbon moieties (e.g., carbonyl, hydroxyl) that are capable of binding (adsorbing) and trapping chemicals within minutes of contact, thereby preventing intestinal absorption and subsequent toxicity. The recommended dose of activated charcoal is 1 g/kg of the patient’s total body weight. An AC-to-intoxicant weight ratio of at least 10:1 is desirable. The usual single adult dose is 25 to 100 g mixed with water and administered as a slurry by mouth or nasogastric tube. Doses larger than 100 g are not recommended in obtunded patients due to the increased risk of vomiting and aspiration. The commercial product should be vigorously shaken prior to administration to resuspend all AC. If available, superactivated charcoal may be preferable in massive ingestions because it allows smaller but equally effective doses to be administered. Pooled data from controlled human volunteer studies reveal that mean drug absorption is reduced by 52%, 38%, 34%, and 21% when AC is given at 30, 60, 120, and 180 minutes, respectively. AC is absolutely contraindicated in patients with bowel obstruction or perforation and those with an unprotected airway. AC should not be given to patients with a depressed level of consciousness until the airway is secured by tracheal intubation.

During surgical repair of a detached retina, 1 mL of sulfur hexafluoride is injected into the posterior chamber. If the patient is receiving 4% desflurane and a 2:1 ratio of N2O and O2, the pressure-volume relationship of the bubble will approximately:

a. decrease by one third
b. remain the same
c. double
d. triple

triple

A sulfur hexafluoride gas bubble is sometimes used to support the retina after detachment. Diffusion of nitrous oxide into the bubble will cause expansion as nitrous oxide equilibrates with the gas bubble. A sixty-seven percent nitrous oxide concentration will cause the bubble to triple in its pressure-volume relationship in about 30 minutes and may double the intraocular pressure (IOP). In addition, when nitrous oxide is discontinued, the bubble will return to normal size, causing a fall in IOP and possible extension of the retinal tear. For these reasons, it is recommended that nitrous oxide be discontinued at least 15 minutes prior to the injection of a posterior chamber bubble.

pg. 762
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

At approximately what level or above will a patient with spinal cord injury be at GREATEST risk for autonomic hyperreflexia?

a. C8
b. T4
c. T7
d. T10

c. T7

A spinal cord injury at or above T7 (T5-T8, depending on reference) predisposes a patient to autonomic hyperreflexia. Autonomic hyperreflexia is typically first seen within four to six months of spinal cord injury and can continue to occur for years. With a stimulus below the level of the spinal cord injury lesion, intact lower motor neurons send an impulse up the spinal cord. However, this impulse is interrupted at the site of the spinal cord injury and unable to reach the cerebral cortex. This leads to an impaired feedback loop. However, the ascending signal reaches the thoracic sympathetic splanchnic nerves resulting in hypertension. This hypertension is recognized by the carotid sinus and aortic arch baroreceptors leading to a parasympathetic reflexive bradycardic response via the vagus nerve. No autonomic nervous system changes occur below the level of spinal cord injury since these signal pathways are also interrupted.

Which muscle is the only abductor of the vocal cords?

a. Cricothyroid muscle
b. Thyroarytenoid muscle
c. Posterior cricoarytenoid muscle
d. Lateral cricoarytenoid muscle

This is a challenging question that few people answer correctly! Most anesthesiologists do not understand the muscles anatomy of the larynx. The only abductor (“opener”) of the vocal cords is the posterior cricoarytenoid muscle. All muscles of the larynx apart from the cricothyroid muscle are innervated by the recurrent laryngeal nerve; therefore, the only abductor muscle of the vocal cords is innervated by the recurrent laryngeal nerve. If both recurrent laryngeal nerves were severed during an operation such as a thyroidectomy, you would expect severe airway obstruction.

Correct statements regarding cerebral metabolism include:

a. the brain can only utilize glucose as an energy source
b. forty percent of brain glucose consumption is anaerobically metabolized
c. hyperglycemia can reduce the damage from focal hypoxic injury
d. the adult brain consumes approximately 50 ml/min of oxygen

d. the adult brain consumes approximately 50 ml/min of oxygen

(The adult brain consumes about 20% of the total body oxygen (50 ml/min). Neuronal cells normally utilize glucose as their energy source, but can also utilize ketone bodies and lactate. Hyperglycemia has been shown to worsen global and focal hypoxic brain injury.)

Which nerve provides sensory innervation to the base of the tongue, epiglottis, aryepiglottic folds, and arytenoids?

a. Internal branch of superior laryngeal nerve
b. Recurrent laryngeal nerve
c. External branch of superior laryngeal nerve
d. Glossopharyngeal nerve

a. internal branch of the superior laryngeal

nerve provides sensory innervation to the larynx above the level of the vocal cords. The superior laryngeal nerve is a branch of the vagus nerve. The glossopharyngeal nerve provides sensory innervation to the pharynx. The recurrent laryngeal nerve provides sensory innervation to the larynx below the level of the vocal cords. The recurrent laryngeal nerve is a branch of the vagus nerve.

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include:

a. a nitroglycerine infusion
b. inotropic support
c. afterload reduction
d. maintenance of adequate preload

d. (maintenance of adequate preload

In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable.

pp. 1083-1084
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

You have designed a study that compares average postoperative opioid consumption after three different anesthetic techniques. After informed consent, 120 patients undergoing total knee arthroplasty will be randomly assigned to one of the three groups. Which of the following statistical tests can be BEST used to compare the means of three groups?

a. Chi-square
b. One-way ANOVA
c. Paired t-test
d. Unpaired t-test

One-Way Analysis of Variance (ANOVA)

simultaneously compares the differences among population means of more than two independent groups for a one-factor experiment. Chi-square test for categorical variables determines whether there is a difference in the population proportions between two or more groups. The unpaired t-test compares the population means between two independent (and normally distributed) groups. The paired t-test examines repeated measurements obtained from the same set of individuals. The objective of the analysis is to show that any differences between two measurements of the same individuals are due to different treatment conditions. This approach is based on the theory that the same individuals will behave alike if they are treated alike and is frequently used in crossover studies.

Which of the following symptoms would be MOST expected in a 64-year-old man with an acute right anterior cerebral artery (ACA) stroke?

a. Left leg weakness ****
b. Left hand weakness
c. Left CN VII palsy
d. Hoarseness

a. Left leg weakness

The left and right anterior cerebral arteries (ACA) supply blood to most medial portions of the frontal lobes and superior medial parietal lobes. This portion of the brain supplies innervation primarily to the lower extremities, most of the corpus callosum, the anterior portions of the basal ganglia and internal capsule, and the olfactory bulb and tract. Thus, patients with an acute ACA stroke classically present with hemiparesis or hemiplegia of the contralateral lower limbs and pelvic floor musculature. Patients may also develop an apraxia (secondary to involvement of the corpus callosum), anosmia (secondary to involvement of the olfactory bulb and tract), and urinary incontinence

Venous irritation associated with the injection of diazepam and lorazepam is secondary to:

a. the high degree of water solubility of these agents
b. the presence of propylene glycol as a solvent
c. the presence of metabisulfite as a preservative
d. the low pH of these agents

b. the presence of propylene glycol as a solvent

The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation.

pg. 488

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Which of the following positions is associated with the LOWEST risk of ventilator associated pneumonia?

a. Prone
b. Supine head up
c. Supine head down
d. Supine flat

b. Supine head up

In a retrospective review of 109 mechanically ventilated patients, Kollef found an increased risk of pneumonia in supine patients (adjusted odds ratio 2.9). A randomized trial of 50 patients suggested that gastroesophageal reflux (detected with scintigraphy) was more likely in supine patients as compared to semi-recumbent. Another randomized controlled trial of semi-recumbent versus supine positioning in mechanically ventilated patients was stopped early because of an increased risk of both clinically suspected (34% vs. 8%, p = 0.003) and microbiologically confirmed (23% vs. 5%, p = 0.016) pneumonia in supine patients

Topically applied ophthalmic medications are absorbed:
a. as quickly as intravenous administration
b. more quickly than subcutaneous administration
c. only minutely, with insignificant clinical effect
d. directly into the central nervous system through the optic nerve foramen
B (more quickly than subcutaneous administration

Topically applied ophthalmic medications are absorbed at a rate intermediate between intravenous and subcutaneous injection. Children and the elderly are at particular risk for the toxic effects of topically applied medications.

pg. 762
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 70-year-old man is undergoing a left hip hemiarthroplasty for a hip fracture. As the prosthesis is cemented in place, his blood pressure decreases to 70/50 mmHg, his end tidal CO2 decreases from 35 mmHg to 16 mmHg, and his SpO2 decreases from 99% to 88%. Which of the following is the MOST likely explanation for these hemodynamic changes?

a. Anaphylaxis
b. Fat emboli
c. Mucous plug
d. Myocardial ischemia

b. fat emboli

Patients undergoing hip surgery with bone reaming and cementation of prosthesis are at risk for bone cement implantation syndrome. There is no formal definition but its clinical features include hypoxia and hypotension in mild forms and in more severe presentations it may include progression to cardiac arrhythmias, increased pulmonary vascular resistance and cardiac arrest. The process of reaming and cementation allows excessively high intramedullary pressures to develop, and this may produce embolization of cement particles, bone marrow and bone particles, air, clot and/or fat. The clinical presentation appears just like a pulmonary embolus, with hypotension, hypoxia, reduction in end tidal CO2 early in the course of the embolus.

A 65-year-old woman with severe mitral regurgitation presents for mitral valve repair. She develops hypotension after the induction of general anesthesia. Vital signs include BP 78/40 mmHg, HR 84 bpm, and SpO2 98%. Which of the following drugs will MOST effectively treat her hypotension without worsening her mitral regurgitation?

a. Ephedrine
b. Atropine
c. Vasopressin
d. Phenylephrine

a. Ephedrine

Hemodynamic goals for patients with mitral regurgitation include maintenance of sinus rhythm and a relative tachycardia in order to minimize regurgitation. Interventions that increase left ventricular afterload should be avoided in order to promote forward systemic cardiac output and reduce mitral regurgitation. Preload should be judiciously maintained but arbitrary fluid boluses should be avoided as excessive volume administration can worsen ventricular distention and mitral regurgitation. Left ventricular contractility should be maintained. Mitral regurgitation may occur as a result of chronic coronary artery disease and ischemia of the left ventricle, in addition to papillary muscle dysfunction due to ischemia. There are two papillary muscles in the left ventricle that connect the left ventricular walls to the mitral valve apparatus via the chordae tendinae. The posterior papillary muscle derives its blood supply from the posterior descending artery and the anterior papillary muscle receives blood supply from both the left anterior descending artery and the circumflex coronary artery. Thus, the posterior papillary muscle is most vulnerable to ischemia. With ischemia of the inferior left ventricular wall due to occlusion of the posterior descending artery, the posterior papillary muscle becomes dysfunctional. If the ischemia continues, the posterior papillary muscle may rupture, ultimately leading to acute mitral regurgitation. ?

Ulnar nerve injury:

a. results in wrist drop and loss of sensation in the web space between the thumb and index finger
b. occurs more frequently in males
c. manifests itself in the immediate postoperative period
d. is most commonly seen in the patient with a BMI of less than 18
response is incorrect.

b. occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:
1) male sex – various reports suggest that 70 – 90% of patients with postoperative ulnar neuropathy are men
2) high body mass index – BMI > or = 38
3) prolonged postoperative bed rest.
Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury.

pp. 809-810
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

What features BEST distinguish heparin induced thrombocytopenia and thrombocytopenia induced by other drugs?

a. Drug induced thrombocytopenia results in mild thrombocytopenia
b. Heparin induced thrombocytopenia results in severe thrombocytopenia with mucocutaneous bleeding
c. Drug induced thrombocytopenia results in significant arterial thrombosis
d. Heparin induced thrombocytopenia results in moderate thrombocytopenia with venous thrombosis

d. Heparin induced thrombocytopenia results in moderate thrombocytopenia with venous thrombosis

Drug induced thrombocytopenia (from drugs like quinine or vancomycin) results in severe levels of thrombocytopenia, on the order of 10 X 10^9. Mucocutaneous bleeding is a commonly observed feature. In contrast, heparin induced thrombocytopenia results in mild-moderate thrombocytopenia with platelet counts around 50-60 X 10^9 and coexistent thrombosis

The timing of heparin induced thrombocytopenia is BEST described by which of the following?

a. Immediate upon heparin administration
b. Within 24 hours of heparin administration
c. From 5 to 14 days after heparin administration
d. Greater than 2 weeks after heparin administration

c. From 5 to 14 days after heparin administration

Approximately 70% of the cases of heparin induced thrombocytopenia occur between 5 days to 2 weeks after heparin administration. Rapid onset (within 24 hours of heparin administration) and delayed onset are both comparatively rare.

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to:
a. 0.5 ppm
b. 5 ppm
c. 25 ppm
d. 50 ppm
c (25 ppm

NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used).

pp. 652-654
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Terbutaline is often administered to treat preterm labor or to stop tetanic uterine contractions that interfere with fetal oxygenation. Which of the following is MOST likely a maternal side effect of terbutaline administered under these circumstances?
?
A. ?Bradycardia
?B. ?Hypokalemia
?C. ?Hypoglycemia
?D. ?Hypertension
Terbutaline is a beta-adrenergic receptor agonist. Its maternal side effects can be categorized as follows: (1) Cardiopulmonary (pulmonary edema, myocardial ischemia, hypotension, tachycardia); (2) Metabolic (hyperglycemia, hyperinsulinemia, hypokalemia, antidiuresis, altered thyroid function) and; (3) others (tremors, palpitations, nervousness, N/V, fever, hallucinations). The fetal side effects include tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, and myocardial ischemia. Potential neonatal side effects include: tachycardia, hypoglycemia, hypocalcemia, hyperbilirubinemia, hypotension, intraventricular hemorrhage. Contraindications to terbutaline administration in the parturient include: maternal cardiac dysrhythmias, poorly controlled DM, and poorly controlled thyroid disease.

?Concerning preoperative informed consent:

a. it should disclose only life-threatening complications
b. charges of assault and battery are possible if it is not obtained
c. oral consent is insufficient
d. it is not necessary if the procedure is done in an office setting

charges of assault and battery are possible if it is not obtained

Any procedure performed without the patient’s consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.

pp. 29-30

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.?

?Magnesium sulfate therapy is the gold standard for seizure prophylaxis in the setting of preeclampsia. Which of the following is the MOST likely side effect of magnesium?

a. Decreased motor endplate sensitivity to acetylcholine
b. Development of coagulopathy
c. Increased systemic vascular resistance
d. Inhibition of acetylcholinesterase
?

a. Decreased motor endplate sensitivity to acetylcholine

Magnesium is a divalent cation that competes with calcium and inhibits many calcium-dependent processes. With regard to muscle relaxation, it is known to: (1) antagonize calcium either at the motor end plate or cell membrane, reducing calcium influx into the myocyte; (2) Compete with calcium for low-affinity calcium binding sites on the outside of the SR membrane and prevent the rise in free intracellular calcium concentration; and (3) Attenuate the: release of acetylcholine at neuromuscular junction, sensitivity of the motor endplate to acetylcholine, and excitability of the muscle membrane. Implications for and potential interactions with anesthesia care are many. Magnesium may increase the likelihood of hypotension with epidural use (studies with gravid ewes demonstrated reduced maternal MAP, but not uterine blood flow or fetal oxygenation during epidural). Magnesium can potentiate the effects of both depolarizing and non-depolarizing muscle relaxants (probably not as much with depolarizing), increasing potency and duration (clinically it is still advised to use the same intubating dose as potentiation can be variable; and smaller maintenance doses). Magnesium can trigger hypotension, especially with concurrent use calcium entry-blocking agents (nifedipine). Sedation is very commonplace with therapeutic levels of serum magnesium; a 20% decrease in MAC can be seen with serum magnesium levels 7-11 mg/dL Magnesium can hypothetically affect any calcium-dependent process, but inhibition of coagulation due specifically to isolated magnesium use is not thought to be clinically significant.

Correct statements concerning the use of benzodiazepines in the elderly include:

a. volume of distribution is increased
b. reduced pharmacodynamic sensitivity is observed
c. the elimination half-life of diazepam, but not midazolam, is increased
d. all of the above

a (volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased.

pg. 895
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

30-year-old woman undergoes a right frontal craniotomy for resection of a low grade glioma. She is given dexamethasone and levetiracetam. Mannitol (1 g/kg) and hyperventilation are used to provide brain bulk reduction. Her sodium drops acutely from 139 meq/L preoperatively to 125 meq/L intraoperatively. Serum osmolality is 310. What is the MOST appropriate management?

a. Conivaptan
b. Furosemide diuresis
c. Hypertonic saline
d. No intervention is required

d. No intervention is required

The administration of mannitol results in the shift of water from the intracellular compartments (and to a small degree from the extracellular fluid compartment) into the intravascular compartment. The resulting rapid expansion of the intravascular water can result in hyponatremia and hypokalemia. In this case, blood osmolality is 310 mOsm supporting the diagnosis of dilutional hyponatremia resulting mannitol. This will resolve when the mannitol clears.

In the midesophageal long axis view at approximately 110-130 degree multiplane angle, which of the left ventricular walls can be BEST assessed for function and regional wall motion abnormalities?

a. Anteroseptal and inferolateral
b. Anterior and lateral
c. Inferior and apical
d. Anterolateral and posteroseptal

The aortic valve is an anterior structure and the left ventricular wall seen closest to the aortic valve is anterior in location. In the midesophageal long axis view at about 120 degrees, part of the right ventricle is seen as well thus the wall closest to the aortic valve is the anteroseptal wall (on the same side as the aortic valve and LVOT). The wall opposite of this in this view is the inferolateral LV wall.

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:

a. 20 cmH2O
b. 50 cmH2O
c. 25 psi
d. 50 psi

d (50 psi

After proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi.

pg. 1237
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of:

a. midazolam
b. rocuronium
c. fentanyl
d. succinylcholine

c (fentanyl

Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug.

Download CoreNotes

pg. 185
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is LEAST likely to be observed in an infant presenting with pyloric stenosis?

a. Hypernatremia
b. Hypochloremia
c. Hypokalemia
d. Metabolic alkalosis

d. Metabolic alkalosis

In pyloric stenosis, the loss of gastric acid leads to a metabolic alkalosis and depletion of sodium, potassium, and chloride. Hypernatremia is not typically observed.

A baby is born at 39 weeks gestation with congenital diaphragmatic hernia. The baby is cyanotic and limp. He has a slow, irregular respiratory pattern and appears to be grimacing. His heart rate is 120 bpm at the one-minute of life. Which APGAR score correctly corresponds with these findings?

a. 3
b. 4
c. 5
d. 6

b. 4

APGAR stands for Appearance, Pulse, Grimace, Activity, and Respirations. Each of the 5 signs is assigned a value from 0 to 2 with a total greater than 7 considered normal. In this question, the baby is cyanotic with a pulse greater than 100, he is grimacing, he has no tone, and he has irregular respirations.

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of:

a. isoflurane
b. sevoflurane
c. desflurane
d. nitrous oxide

desflurane

Volatile agents decrease the nondepolarizer dosage requirements. The degree of the augmentation of blockade depends on the inhalational agent, with desflurane > sevoflurane > isoflurane > nitrous oxide.

pg. 213
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

portal hypertension is defined as sustained portal vein pressure greater than:

a. 5 mm Hg
b. 10 mm Hg
c. 20 mm Hg
d. 25 mm Hg

a (5 mm Hg

Portal hypertension is defined as a sustained portal vein pressure of *5 mm Hg or greater above hepatic vein pressure*. This leads to the formation of portal-systemic collateral venous channels.

pg. 1299
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

The highest incidence of muscle pain following the use of succinylcholine is seen in:

a. infants
b. octogenarians
c. outpatients
d. pregnant patients

outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

pg. 532
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:

a. 20 – 30 mm Hg
b. 35 – 45 mm Hg
c. 50 – 60 mm Hg
d. 90 – 100 mm

50 – 60 mm Hg

Healthy young individuals tolerate mean arterial pressures as low as 50 – 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 – 30% below baseline.

pg. 262
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

a. internal laryngeal nerve
b. external laryngeal nerve
c. recurrent laryngeal nerve
d. glossopharyngeal nerve

recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea.

pg. 310
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of:

a. isoflurane
b. desflurane
c. sevoflurane
d. nitrous oxide

d (nitrous oxide

By irreversibly oxidizing the cobalt atom in vitamin B12, nitrous oxide inhibits vitamin B12 dependent enzymes. These enzymes include methionine synthetase and thymidylate synthetase. As a result of these enzyme inhibitions, prolonged exposure to nitrous oxide has been associated with bone marrow depression, megaloblastic anemia, peripheral neuropathy and teratogenicity.

pg. 471
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 4-year-old boy presents with the acute onset of inspiratory stridor and a barking cough after waking in the middle of the night. The child is febrile, sounds noticeably hoarse, and cries loudly when handled by medical personnel. The patient’s parents report that the child has had a “cold for a couple of days.” What is the MOST likely infectious etiology of this child’s disease?

a. Haemophilus influenzae
b. Influenza A
c. Parainfluenza virus
d. Streptococcus pyogenes

Parainfluenza virus

This patient has croup, which is caused by the Parainfluenza virus about 75% of the time. Epiglottis, typically associated with Haemophilus influenzae, type B, is not typically characterized by a barking cough. Classically, patients are anxious, toxic, and have severe dyspnea

Basal metabolic oxygen consumption in a 20-kg patient is approximately:
95 ml/min

(Basal metabolic oxygen consumption can be estimated using the following formula:

VO2 = 10*Kg^3/4

pg. 175
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.)

The administration of propofol (2 mg/kg) to an otherwise healthy adult for the induction of anesthesia is most commonly associated with which one of the following hemodynamic changes?

a. Decreased afterload
b. Decreased contractility
c. Decreased heart rate
d. Decreased preload

decreased afterload,

The administration of propofol is associated with dose-dependent decreases in afterload, with possible decreases in contractility at high doses (although some studies suggest that within the range commonly used, myocardial function is preserved). Preload is also decreased; however, decreases in afterload are thought to be more important.

Physiologic derangements seen in the patient with scleroderma include: (Select 3)

a. pulmonary hypertension
b. esophageal dysmotility
c. excessive oral secretions and salivation
d. myocardial fibrosis
e. hypotension
f. spastic quadraparesis

a, b, d (pulmonary hypertension, esophageal dysmotility, myocardial fibrosis

(Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs. Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration. Systemic hypertension from renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement.

pg. 636
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

During the transfusion of one unit of FFP, an 8-year-old girl develops severe systemic hypotension, bronchospasm, and urticaria. Which of the following diseases would be MOST likely the cause of this reaction?

a. Celiac disease
b. Cystic fibrosis
c. Hemophilia A
d. Selective IgA deficiency

selective IgA deficiency

Patients with selective IgA deficiency may present with severe reactions including anaphylaxis to blood transfusions or intravenous immunoglobulin due to the presence of IgA in these blood products. Selective IgA deficiency is the single most common cause of anaphylaxis after transfusion

The maximum recommended occupational whole-body exposure to radiation is:

a. 1 rem/year
b. 5 rem/year
c. 10 rem/year
d. 20 rem/year

5 rem/year

The intraoperative use of imaging equipment exposes anesthesia providers to ionizing radiation. The maximum recommended whole-body exposure to radiation is 5 rem/year.

pg. 65
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Examples of Type IV hypersensitivity reactions include:

a. contact dermatitis
b. hemolytic transfusion reactions
c. anaphylaxis
d. angioedema

a (contact dermatitis

Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis.

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pg. 292
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Negative consequences of positive pressure ventilation for patients with pericardial tamponade include which of the following?

a. Increased right ventricular preload
b. Increased systemic vascular resistance leading to an increase in myocardial oxygen consumption
c. Increased left ventricular filling due to interventricular septal shift
d. Increased pulmonary vascular resistance due to increased airway pressures

Increased pulmonary vascular resistance due to increased airway pressures

Average blood loss during a vaginal delivery is:

a. 100 – 200 ml
b. 400 – 500 ml
c. 700 – 800 ml
d. 1000 – 1500 ml

b (400 – 500 ml

At term, blood volume has increased by 1000 – 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 – 500 ml, compared with 800 – 1000 ml for cesarean section.

pg. 827
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Nerves blocked with a fascia iliaca block include the:

a. sciatic nerve
b. femoral nerve
c. pudendal nerves
d. anterior tibial nerve

a (femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

pp. 1003-1004
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Sickle hemoglobin: (Select 2)

a. has a lower P50 than hemoglobin A
b. releases oxygen less readily than hemoglobin A
c. is present in about 30% of African Americans
d. readily polymerizes and precipitates in the red cell
e. results from a single amino acid substitution on the ?-chain
f. has decreased solubility as compared to hemoglobin A

d, f (readily polymerizes and precipitates in the red cell,
has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an *elevated P50* (31 mm Hg) [decreased affinity] as compared to hemoglobin A (27 mm Hg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the *?-chain*.

pg. 1177
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Laminar flow in the airway occurs in the: (Select 2)

a. trachea
b. main stem bronchi
c. terminal bronchiole
d. 3rd generation bronchus
e. respiratory bronchioles

C, E (terminal bronchiole, respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow.

pp. 498-499
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

After inducing general anesthesia, a morbidly obese patient is intubated and ventilated with volume-control ventilation in the supine position with 8 cc/kg tidal volume. Which of the following would you MOST expect from this ventilation strategy?

a. Decreased pulmonary vascular resistance
b. Decreased ventilation of nondependent alveoli
c. Increased ventilation of nondependent alveoli
d. Increased perfusion of nondependent alveoli

Increased ventilation of nondependent alveoli

In the upright position with spontaneous ventilation in normal patients, ventilation and perfusion will be as normally matched as possible, with most ventilation and perfusion in the lung bases or dependent portions of the lungs. After induction of general anesthesia, neuromuscular relaxation and supine positioning, functional residual capacity decreases and ventilation becomes distributed to the more nondependent alveoli whereas perfusion is maintained in the dependent areas of the lung. The effect is exaggerated in obese patients.

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

a. increased carbon dioxide levels
b. increased 2,3-DPG levels
c. increased pH
d. the presence of fetal hemoglobin
e. increased body temperature
f. the presence of hemoglobin-S

increased pH, presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus.

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pp. 603-604
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The addition of bicarbonate to a local anesthetic solution:

a. delays the onset of blockade
b. increases the concentration of the nonionic form of the local anesthetic
c. causes a fall in the pH of the solution
d. should only be done when using bupivacaine

increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on the penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8.

pg. 963
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Fondaparinux achieves its anticoagulant effect through:

a. factor Xa inhibition
b. activation of antithombin III
c. direct thrombin inhibition
d. inhibition of vitamin K-dependent coagulation factor production

a. factor Xa inhibition

(Fondaparinux is a factor Xa inhibitor. No reversal agent is available if emergency surgery is necessary.

pp. 439-440
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 201)

Which of the following is NOT an absolute contraindications to Ramipril?

a. Hereditary angioedema
b. Pregnancy
c. Renal artery stenosis
d. Sulfonamide allergy

d. Sulfonamide allergy
(
Ramipril is an ACE-inhibitor (ACE-I). ACE-Is are contraindicated in patients with a history of angioneurotic edema, even if angioedema is not due to an ACE-I or C1 esterase deficiency. The use of ACE-Is during pregnancy is associated with serious complications in the fetus, including congenital malformations and intrauterine fetal demise. Patients with renal artery stenosis can develop serious hypotension when treated with an ACE-I. While captopril contains a sulfhydryl group, there is not thought to be cross-reactivity with sulfonamides. Regardless, ramipril may be safely administered to patients with a history of allergy to sulfonamides.)

3 month-old infant presents to the hospital febrile, lethargic, and tachypneic. Upon questioning, the infant’s parents indicate that the infant had been treated for colic with a combination of aspirin and a bismuth subsalicylate solution for the past several weeks. Salicylate toxicity is suspected. An arterial blood gas would MOST likely show which of the following abnormalities?

a. Primary metabolic acidosis with respiratory compensation
b. Primary metabolic alkalosis with respiratory compensation
c. Primary respiratory acidosis with metabolic compensation
d. Primary respiratory alkalosis with metabolic compensation

a. (Primary metabolic acidosis with respiratory compensation

This infant is suffering from severe salicylate toxicity. Patients taking large doses of bismuth subsalicylate solutions often do not realize that these drugs contain high concentrations of salicylate. Bismuth subsalicylate has an aspirin equivalency conversion factor of 0.479 (approximately half the strength of aspirin). Salicylate toxicity occurs as a result of salicylate’s interference with both Kreb’s cycle enzymes and, at high level, uncoupling of oxidative phosphorylation. This results in a primary metabolic acidosis, to which most patients will develop a respiratory compensation.)

Which nerve innervates the only abductor muscle of the vocal cords?

a.Internal branch of superior laryngeal nerve
b. Recurrent laryngeal nerve
c. External branch of superior laryngeal nerve
d. Glossopharyngeal nerve

b. (Recurrent laryngeal nerve

The only abductor of the vocal cords is the posterior cricoarytenoid muscle. All muscles of the larynx apart from the cricothyroid muscle are innervated by the recurrent laryngeal nerve. Therefore, the only abductor muscle of the vocal cords is innervated by the recurrent laryngeal nerve. If both recurrent laryngeal nerves were severed during an operation such as a thyroidectomy, you would expect severe airway obstruction.)

A fresh E-cylinder of oxygen:

a.contains more liters of gas than an E-cylinder of nitrous oxide
b. contains about 90% liquid oxygen and 10% oxygen as a gas
c. contains about 660 liters of oxygen
d. has a lower pressure than the pipeline oxygen supply

c (contains about 660 liters of oxygen

A fresh E-cylinder of oxygen contains about 660 liters of oxygen and is pressurized to 1900 psi.

pg. 8
Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.)

Which of the following statements regarding the pharmacology of heparin is MOST correct?

a. Warfarin increases the synthesis of endogenous heparin
b. Low Molecular Weight Heparin preferentially inhibits Factor Xa
c. Heparin is a highly sulfated protein molecule with negative charge
d. Protamine reverses heparin action as a competitive antagonist on the receptor binding site

b. (Low Molecular Weight Heparin preferentially inhibits Factor Xa

Heparin is a carbohydrate containing glucuronic acid residues. It has negatively charged sulfate groups “two per uronic acid residue”making it one of the strongest acids found in living things. The major inhibitor of thrombin, factors IXa, and factor Xa is AT III. UFH accelerates the formation of the thrombin-AT complex by 2000-fold and accelerates formation of the factor Xa-AT complex by 1200-fold. In contrast, LMWH fragments preferentially inhibit factor Xa. Protamine is a positively charged polypeptide that combines with the negatively charged heparin to form stable complexes resulting in neutralization of heparin activity. Warfarin acts as an anticoagulant by inhibiting vitamin K epoxide reductase.)

The elimination half-life of intravenously administered oxytocin in the parturient is approximately:

a. 30 to 120 seconds
b. 3 to 5 minutes
c. 10 to 15 minutes
d. 20 to 30 minutes

b (3 to 5 minutes

Both endogenous and intravenously administered oxytocin have short elimination half-lives of about 3 to 5 minutes. As a result, oxytocin must be administered as a continuous infusion for the induction of labor.

pg. 835
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The criteria for systemic inflammatory response syndrome includes which of the following parameters?

a. Temperature, blood pressure, respiratory rate or PaCO2, white blood cell count
b. Temperature, heart rate, respiratory rate or PaCO2, urine output
c. Temperature, heart rate, respiratory rate or PaCO2, white blood cell count
d. Temperature, blood pressure, respiratory rate or PaCO2, urine output

c. (Temperature, heart rate, respiratory rate or PaCO2, white blood cell count

The systemic inflammatory response syndrome is defined by the presence of 2 or more of the following parameters: body temperature greater than 38°C or less than 36°C, heart rate greater than 90 bpm, respiratory rate greater than 20 breaths per min or PaCO2 less than 32 mmHg, and leukocytosis greater than 12,000/mm3 or less than 4000/mm3.)

In the fetus, the percentage of cardiac output directed to the placenta is approximately:

a. 10%
b. 25%
c. 50%
d. 100%

c. (50%

In the fetus, the lungs receive little blood flow. The placenta receives nearly one-half of the fetal cardiac output and is responsible for respiratory gas exchange.

pg. 836

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

FOUR DAYS AFTER AN URETERAL STENT PLACEMENT, AN 87-YEAR-OLD WOMAN BECOMES INCREASINGLY CONFUSED. VITAL SIGNS INCLUDE T 38.9°C, BP 100/60 MMHG (MAP 73), HR 103 BPM, RESPIRATORY RATE 16 /MIN, SPO2 96% ON ROOM AIR. WHITE BLOOD CELL COUNT IS 16,000 ?L-1, CREATININE IS 2.2 MG/DL (UP FROM 0.8 MG/DL BASELINE), AND LACTATE IS 3 MMOL/L. URINALYSIS SHOWS LEUKOCYTES AND POSITIVE NITRITE; A URINE CULTURE IS PENDING. WHICH OF THE FOLLOWING IS THIS PATIENT’S MOST APPROPRIATE SEPSIS CLASSIFICATION?

a. Sepsis
b. Severe sepsis
c. Sepsis-induced hypotension
d. Septic shock

b. Severe sepsis
(
According to the 2012 International Guidelines for Management of Severe Sepsis and Septic Shock, sepsis is defined as the probable or known presence of an infection together with systemic manifestations of infection. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion. Sepsis-induced hypotension is defined as a systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mmHg or systolic blood pressure decrease > 40 mmHg or less than two standard deviations below normal for age in the absence of other causes of hypotension. Septic shock is sepsis-induced hypotension that persists despite adequate fluid resuscitation. Any of the following signs of organ dysfunction or tissue hypoperfusion thought to be due to the infection would lead to a severe sepsis classification: Sepsis-induced hypotension Lactate above upper limits laboratory normal Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source Creatinine > 2.0 mg/dL (176.8 ?mol/L) Bilirubin > 2 mg/dL (34.2 ?mol/L) Platelet count < 100,000 ?L Coagulopathy (international normalized ratio > 1.5)

At the neuromuscular junction, acetylcholine receptor binding sites are found on the:

a. ?-subunits
b. ?-subunits
c. ?-subunits
d. ? -subunits

a. (?-subunits

Each acetylcholine (ACh) receptor in the neuromuscular junction consists of 5 protein subunits. Only the ?-subunits are capable of binding ACh molecules. If both binding sites are occupied, the channel briefly opens. The ?-subunits are also the site of action of neuromuscular blockers.

pg. 527
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013)

50 year-old man was diagnosed with hypertension and his primary care physician started him on hydrochlorothiazide for blood pressure control. He presents for elective laparoscopic cholecystectomy. Which of the following electrolyte disturbances is MOST common in patients taking hydrochlorothiazide?

a. Increased calcium
b. Increased magnesium
c. Increased potassium
d. Increased sodium

a. (Increased calcium

Hydrochlorothiazide (HCTZ) is a sulfonamide derivative in the thiazide class of diuretics. It is often used as a first line treatment for hypertension. It blocks the sodium chloride transporter in the distal convoluted tubule of the kidney. Thus, HCTZ causes a natriuresis along with chloride loss. Other effects include reductions in potassium and magnesium. HCTZ increases calcium due to reabsorption of calcium also at the distal convoluted tubule. Glucose levels can rise if potassium is supplemented with use of HCTZ. In addition, LDL cholesterol, total cholesterol and triglycerides also increase.)

Absolute contraindications to electroconvulsive therapy (ECT) include:

a. congestive heart failure
b. pregnancy
c. myocardial infarction 5 months prior to therapy
d. increased intracranial pressure

d (increased intracranial pressure

Absolute contraindications to ECT include recent MI (usually < 3 months), recent stroke (< 1 month), intracranial mass, or increased ICP from any cause. Relative contraindications include angina, CHF, significant pulmonary disease, bone fractures, osteoporosis, pregnancy, glaucoma and retinal detachment. pg. 628 Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

69 year-old woman presents for combined mitral valve repair and aortic valve replacement after CABG 10 years ago. She is deemed to be high risk for bleeding after cardiopulmonary bypass and during the postoperative period in the ICU. You plan to administer tranexamic acid prior to commencement of cardiopulmonary bypass. Which of the following BEST describes the mechanism of tranexamic acid?

a. Activates platelets
b. Improves fibrin concentration
c. Increases thrombin
d. Inhibits activation of plasmin

d. (Inhibits activation of plasmin

Prohemostatic interventions for patients having cardiac surgery at high risk of bleeding are very important and attack the coagulation cascade at many different points. Tranexamic acid, epsilon aminocaproic acid and aprotinin (no longer used in the US due to safety concerns) work by inhibiting conversion of plasminogen to plasmin and plasmin release. Thus they have an anti-fibrinolytic effect and attempt to preserve clot formation (reduce inappropriate breakdown of thrombus). Other treatments used include DDAVP which increases the release of von Willebrand factor from the endothelium in order to increase platelet activation; prothrombin complex concentrates and recombinant factor VIIa which increase thrombin formation (and thus improve clot formation); and fibrinogen concentrates or cryoprecipitate which increases fibrinogen and thus the fibrin component of clot formation.)

Which of the following anti-platelet agents works by inhibiting platelet activation via an adenosine diphosphate-dependent mechanism?

a. Aspirin
b. Clopidogrel
c. Dipyridamole
d. Tirofiban

b. (Clopidogrel

Aspirin permanently inactivates the cyclooxygenase enzyme to reduce thromboxane A2-induced activation of platelets. Clopidogrel is one of the thienopyridines which functions via irreversibly inhibiting ADP-induced platelet aggregation. Other medications in this class include prasugrel, ticlopidine (both irreversible) and cangrelor and ticagrelor (both reversible). Dipyridamole is a phosphodiesterase inhibitor which achieves its antiplatelet effect through increased cyclic AMP which blocks the uptake of adenosine, thus reducing the amount of adenosine at the platelet vascular interface or via direct stimulation of prostacyclin release from the endothelium. Tirofiban is in the class of antiplatelet agents which block platelet activation via glycoprotein IIb/IIIa inhibition.)

An 85-year-old man is in atrial fibrillation in the intensive care unit after aortic valve replacement. Amiodarone 150 mg is administered by intravenous bolus injection. Which of the following BEST describes that mechanism of amiodarone?

a. Blocks cardiac sodium channels
b. Prolongs repolarization
c. Shortens the QT interval
d. Slows conduction at the AV node

b. (Prolongs repolarization

Amiodarone is a Class III antiarrhythmic agent and is used to treat both atrial and ventricular arrhythmias. It prolongs repolarization and lengthens the cardiac action potential, provides negative chronotropy in nodal tissue, blocks cardiac potassium and calcium channels. This slows conduction at the SA node. It does also have a negative inotropic effect and causes significant peripheral vasodilation. The two main side effects from administration of amiodarone are bradycardia and hypotension. These can be lessened by slowing the rate of administration, providing a fluid bolus, supporting with a vasopressor during the infusion or temporary pacing if the bradycardia is profound.)

58-year-old man is admitted with chest pain, ST elevation in ECG leads II, III and aVF, and increased cardiac troponin levels. His echocardiogram shows regional wall motion abnormalities in the inferior wall. Which of the following medications should be initiated within 24 hours after admission to improve his survival following his myocardial infarction?

a.Hydrochlorothiazide
b. Losartan
c. Metoprolol
d. Ramipril

d. (Ramipril

For patients who have sustained a myocardial infarction, there are numerous studies that show a survival benefit for starting angiotensin converting enzyme (ACE) inhibitor medications within 24 hours after MI. Beta blockers are important in care of the patient with myocardial ischemia in order to reduce heart rate (decrease demand and increase supply). ACE inhibitors and angiotensin receptor blockers work by inhibiting the renin-angiotensin aldosterone system and are theorized to help prevent or slow ventricular remodeling after MI, which allows for improvement in ejection fraction.)

Dextran 40 has been shown to improve microcirculation by:

a. reducing blood density
b. increasing blood density
c. decreasing blood viscosity
d. increasing blood viscosity

c. (decreasing blood viscosity

Dextran 40 has been shown to improve microcirculation presumably by decreasing blood viscosity thereby improving laminar flow in the microcirculatory beds. Both Dextran 40 and Dextran 70 possess antiplatelet effects and may interfere with blood typing.

pg. 1165
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is MOST correct regarding the treatment of known venous thromboembolism with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH)?

a. LMWH more efficacious but with more side effects
b. LMWH more efficacious and with fewer side effects ****
c. UFH more efficacious but with more side effects
d. UFH more efficacious and with fewer side effects

b. (LMWH more efficacious and with fewer side effects

While it has been firmly established the LMWH is superior to UFH for the prevention of VTI, it appears that if venous thromboembolism does develop, fixed dose LMWH is more effective and safer than UFH (based on 23 studies including 9587 patients) for the treatment of VTE. These data suggest statistically significant reductions in thrombotic complications, more frequent reduction in thrombus size, fewer major hemorrhages, and lower mortality.)

Maternal mortality associated with amniotic fluid embolization is:

a. 10 – 15%
b. 20 – 25%
c. 40 – 45%
d. greater than 50%

d. (greater than 50%

Amniotic fluid embolism is rare with a occurrence of about 1:20,000. However, it carries a very high mortality; some studies quoting as much as 86%. Mortality within the first hour after onset is about 50%.

pg. 867
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: (Select 3)

a. hypotension secondary to cement monomer absorption
b. hypoxemia secondary to air embolization
c. hypoxemia secondary to fat embolization
d. hypocarbia
e. decreased pulmonary artery pressure
f. increased end-tidal carbon dioxide

A, B, C (hypotension secondary to cement monomer absorption, hypoxemia secondary to air embolization, hypoxemia secondary to fat embolization

During hip replacement surgery, hypotension associated with the use of acrylic bone cement has been attributed to absorption of methyl methacrylate monomer, embolization of air and bone marrow, lysis of red cells and marrow and conversion of methyl methacrylate to methacrylic acid. Hypoxemia is common. Embolic events cause an increase in dead space with a reduction in ETCO2 with an increase in PaCO2.

pg. 1454
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

The lumbar plexus is derived from which of the following?

a.Dorsal rami of L1-4
b. Ventral rami of L1-4 and variable contributions from T12 and L5
c. Dorsal rami of L1-4 and variable contributions from S1-2 and L5
d. Ventral rami of L1-4 and variable contributions

b. (

The lumbar plexus is derived from the anterior (ventral) primary rami of lumbar nerves L1-L4 with variable contributions from the 12th thoracic and 5th lumbar nerves.)

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:

a. genioglossus muscle
b. longitudinal muscle of the tongue
c. palatoglossus muscle
d. styloglossus muscle

a. (genioglossus muscle

The genioglossus muscle allows the tongue to be protruded and kept away from the posterior pharynx. It is innervated by the hypoglossal nerve. The palatoglossus muscle elevates the tongue and depresses the soft palate. The styloglossus muscle elevates and retracts the tongue. The superior longitudinal muscle of the tongue is an intrinsic muscle of the tongue that elevates the tip.

pg. 314
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

44-year-old man presents to the emergency room with a table saw injury to the left hand. The surgeon plans to explore the wound and possibly repair tendon and vascular injuries. The estimated operative duration is between 1-5 hours and an axilla block with bupivacaine is planned as the primary anesthetic technique. The patient has a seizure with the inejction of bupivacaine. Which of the following should be your FIRST therapeutic action?

a. Administer a short-acting muscle relaxant to stop muscle contractions
b. Administer intra-lipid
c. Administer lidocaine to prevent cardiac arrhythmias
d. Administer oxygen and ensure a patent airway

d. (Administer oxygen and ensure a patent airway

The treatment of local anesthetic toxicity is similar to the management of other medical emergencies and focuses on airway, breathing and circulation. Ensuring adequate oxygenation and ventilation is paramount to avoid progressive acidosis)

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:

a. hypernatremia
b. hyperglycemia
c. difficulty with intubation and airway management
d. increased blood viscosity due to elevated hematocrit

c. (difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

pp. 875-876
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Compared to “plain” local anesthetic without epinephrine, a pre-mixed local anesthetic with epinephrine solution is MOST associated with which of the following?

a. Little effect on peak plasma levels
b. Decreased sensory block
c. Increased onset time
d. Decreased cardiac output

c. (Increased onset time

Commercially prepared solutions with epinephrine have a lower pH than those in which it is freshly added. A lower pH results in a higher percentage of ionized drug molecules. It is the non-ionized form that easily crosses the lipid membrane; therefore the onset will be delayed. )

During fetal monitoring, Type III decelerations are thought to be related to:

a. head compression
b. umbilical cord compression
c. uteroplacental insufficiency
d. placental abruption

b. (umbilical cord compression

Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

pg. 1167
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinic)

Which of the following statements regarding the addition of clonidine to an epidural infusion is MOST correct?

a. Clonidine is an alpha-2-receptor antagonist
b. Clonidine effect in peripheral nerve blocks is primarily centrally mediated
c. Clonidine prolongs the sensory block when added to intermediate local anesthetics
d. Commonly reported side effects include tachycardia and hypertension

c. (Clonidine prolongs the sensory block when added to intermediate local anesthetics

Clonidine is an alpha-2-agonist. It has been found to prolong the sensory block primarily when combined with intermediate local anesthetics although it may also have some effect when combined with longer-acting local anesthetics. The exact mechanism is unclear but appears to be peripherally mediated and dose-dependent. Side effects include bradycardia, hypotension, and sedation.)

Ninety percent of congenital diaphragmatic hernias occur:

a. through the left posterolateral foramen
b. through the right posterolateral foramen
c. through the anterior foramen
d. along the inferior vena cava

a (through the left posterolateral foramen

Left-sided herniation through the posterolateral foramen of Bochdalek accounts for 90% of diaphragmatic hernias. Hypoxia, scaphoid abdomen and evidence of bowel in the thorax are the hallmarks of diaphragmatic herniation. Peak airway pressures should not exceed 30 cm H2O to minimize the risk of pneumothorax during surgical correction.

pg. 899
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The perception of an ordinarily non-noxious stimulus as pain is referred to as:

a. allodynia
b. anesthesia dolorosa
c. dysesthesia
d. hyperalgesia

a (allodynia

Allodynia is the perception of non-noxious stimuli as pain. Dysesthesia is an unpleasant sensation without a stimulus. Hyperesthesia is an increased response to a mild stimulus. Anesthesia dolorosa is pain in an area that lacks sensation.

pp. 1649-1650

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

After an accidental needle stick with a contaminated needle, which of the following viruses carries the HIGHEST risk of transmission?

a. HIV
b. Hepatitis A
c. Hepatitis B
d. Hepatitis C

c. (Hep B

Hepatitis B carries the greatest risk of transmission, with 37 to 62% of exposed workers eventually showing seroconversion and 22 to 31% showing clinical hepatitis B infection. The hepatitis C transmission rate has been reported at 1.8%, but newer, larger surveys have shown only a 0.5% transmission rate. The overall risk of HIV infection after percutaneous exposure to HIV-infected material in the health care setting is 0.3%. Hepatitis B prophylaxis Current CDC guidelines call for the administration of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine. While the efficacy of the combination has not been evaluated in the needlestick injury setting, it has been shown to be the most efficacious approach in the perinatal setting. The approach has no contraindications during pregnancy and lactation. Hepatitis C prophylaxis CDC guidelines acknowledge that there is no active post-exposure prophylaxis for HCV. There is some evidence that treatment with interferon alfa-2b may be beneficial preventing chronic hepatitis. HIV prophylaxis CDC guidelines generally recommend a post-exposure prophylaxis protocol with 3 or more antiviral drugs, when it is known that the donor was HIV positive; however, when the viral load was low and none of the above noted risk factors are met, the CDC protocol utilizes 2 antiviral drugs.)

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be:

a. between 300 and 400
b. between 200 and 300
c. between 100 and 200
d. less than 100

d (less than 100

RSBI is frequently used to help predict who can be successfully weaned from mechanical ventilation. With the patient breathing spontaneously, the ventilatory rate is divided by the tidal volume (liters). Successful extubation can be predicted by an RSBI of less than 100.

Crawford, J, Otero, R. “Rapid shallow breathing index a key predictor for noninvasive ventilation.” URL: http://ccforum.com/content/11/S2/P169, March, 2007.

pg. 1297
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is MOST often associated with carbon monoxide poisoning?

a. Salicylate poisoning
b. Cyanide toxicity
c. Ethanol toxicity
d. Acetaminophen toxicity

c. Cyanide toxicity

Carbon monoxide binds to hemoglobin and prevents the delivery of O2 to tissues. Conventional two-wavelength pulse oximeter cannot discriminate between Hgb-CO and HgbO2. The half-life of carboxyhemoglobin (Hb-CO) in a patient breathing room air is approximately 300 minutes; this decreases to 90 minutes with high-flow oxygen via a nonrebreathing mask. Thus, the most important interventions in the management of a CO-poisoned patient are prompt removal from the source of CO and institution of high-flow oxygen by facemask. For patients suffering from CO poisoning after smoke inhalation, it is important to consider concomitant cyanide toxicity, which can further impair tissue oxygen utilization and exacerbate cellular hypoxia. Cyanide toxicity should be considered in anyone who rapidly loses consciousness after ingestion or inhalation (it is common in indoor fire victims due to combustion of plastics). The symptoms are those of hypoxia (headache, lethargy, seizures, coma but without cyanosis). Cyanide inhibits cytochrome oxidase in the electron transport chain which prevents the offloading of electrons from NADH to oxygen which prevents ATP production ? anaerobic metabolism ? lactic acidosis all in spite of normal PaO2. Manage with 100% O2 and give any or all of amyl nitrate, sodium nitrate, and/or sodium thiosulfate. The nitrates generate methemoglobin which has a greater affinity for cyanide than does cytochrome oxidase.)

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above:

a. 5 mm Hg
b. 15 mm Hg
c. 25 mm Hg
d. 30 mm Hg

b (15 mm Hg

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above 15 mm Hg. Uncompensated increases in tissue or fluid within the rigid intracranial vault produce the sustained pressure elevations.

pp. 871-874
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Which of the following monitoring modality is MOST important in the setting of tricyclic antidepressant (TCA) poisoning?

a. Pulse oximetry
b. Electrocardiogram
c. Blood pressure
d. PaCO2

b. (Electrocardiogram

TCA overdose can lead to lethargy, delirium, coma, and seizures. Tachycardia and hypotension may also develop. Attempt gastric lavage if history suggests recent large ingestion (10-20 mg/kg) and use activated charcoal. The ECG tracing is crucial in the management of TCA overdose. Give sodium bicarbonate if QRS duration > 100 ms (1-2 meq/kg bolus) and convert from bolus to infusion when the QRS complex narrows (targeting a pH of 7.5 to 7.55). If the pH becomes too alkaline but QRS complex widens then given 3% hypertonic saline to antagonize sodium channel blockade associated with TCAs. Use norepinephrine if vasopressors are necessary. Seizures need to be rapidly controlled with GABA agonists (benzos, propofol) b/c associated metabolic acidosis will rapidly worsen toxicity; don’t give phenytoin which is a type IA anti-arrhythmic.)

A 59-year-old man presents with nausea, diaphoresis, and bradycardia. His blood pressure is 80/40 mmHg, HR 45 bpm. A transthoracic echocardiogram reveals global left ventricular hypokinesis with bulging of the interventricular septum into the left ventricle, mild mitral regurgitation, and moderate tricuspid regurgitation. Which coronary artery do you MOST expect to be occluded?

a. First diagonal artery
b. Left anterior descending artery
c. Left circumflex artery
d. Right coronary artery

d. (Right coronary artery

The symptoms of this patient as well as the echocardiogram findings indicate right ventricular ischemia. Patients typically often present with symptoms, such as nausea, vomiting, diaphoresis and bradycardia, and may not have the typical chest pain or pressure symptoms. An inferior wall myocardial infarction (right coronary artery distribution in 85% of patients) may manifest as complete heart block due to damage to the AV node. The SA node is fed by the RCA in 55% of population and left circumflex artery in 45% of population.)

The most severe transfusion reactions are due to:
ABO incompatibility

The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis.

pg. 1172
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

APGAR stands for
Appearance, Pulse, Grimace, Activity, and Respirations. Each of the 5 signs is assigned a value from 0 to 2 with a total greater than 7 considered normal. In this question, the baby is cyanotic with a pulse greater than 100, he is grimacing, he has no tone, and he has irregular respirations.

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of:

a. isoflurane
b. sevoflurane
c. desflurane
d. nitrous oxide

c. (desflurane

Volatile agents decrease the nondepolarizer dosage requirements. The degree of the augmentation of blockade depends on the inhalational agent, with desflurane > sevoflurane > isoflurane > nitrous oxide.

pg. 213
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

At approximately what carboxyhemoglobin level will a patient start to display mild signs and symptoms (headache, nausea and vomiting) of carbon monoxide toxicity?

a. 5%
b. 10%
c. 15%
d. 25%

b. (15%
A nonsmoker has a carboxyhemoglobin level < 5% whereas a smoker may have a carboxyhemoglobin level of 4-9%. Symptoms such as headache, dizziness, nausea, and vomiting may occur at a carboxyhemoglobin level of 15-20%.)

The highest incidence of muscle pain following the use of succinylcholine is seen in:
a. infants
b. octogenarians
c. outpatients
d. pregnant patients
c. (outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

pg. 532
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:
a. 20 – 30 mm Hg
b. 35 – 45 mm Hg
c. 50 – 60 mm Hg
d. 90 – 100 mm
c. (50 – 60 mm Hg

Healthy young individuals tolerate mean arterial pressures as low as 50 – 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 – 30% below baseline.

pg. 262
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Basal metabolic oxygen consumption in a 20-kg patient is approximately:
(numerical answer)
95 ml/min

Basal metabolic oxygen consumption can be estimated using the following formula:

VO2 = 10*Kg^3/4

pg. 175
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.)

A 4-year-old boy presents with the acute onset of inspiratory stridor and a barking cough after waking in the middle of the night. The child is febrile, sounds noticeably hoarse, and cries loudly when handled by medical personnel. The patient’s parents report that the child has had a “cold for a couple of days.” What is the MOST likely infectious etiology of this child’s disease?

a. Haemophilus influenzae
b. Influenza A
c. Parainfluenza virus
d. Streptococcus pyogenes

c. (Parainfluenza virus

This patient has croup, which is caused by the Parainfluenza virus about 75% of the time. Epiglottis, typically associated with Haemophilus influenzae, type B, is not typically characterized by a barking cough. Classically, patients are anxious, toxic, and have severe dyspnea)

Physiologic derangements seen in the patient with scleroderma include: (Select 3)

a. pulmonary hypertension
b. esophageal dysmotility
c. excessive oral secretions and salivation
d. myocardial fibrosis
e. hypotension
f. spastic quadraparesis

a, b, d. (pulmonary hypertension, esophageal dysmotility, myocardial fibrosis

Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs. Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration. Systemic hypertension from renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement.

pg. 636
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

During the transfusion of one unit of FFP, an 8-year-old girl develops severe systemic hypotension, bronchospasm, and urticaria. Which of the following diseases would be MOST likely the cause of this reaction?

a. Celiac disease
b. Cystic fibrosis
c. Hemophilia A
d. Selective IgA deficiency

d. (Selective IgA deficiency

Patients with selective IgA deficiency may present with severe reactions including anaphylaxis to blood transfusions or intravenous immunoglobulin due to the presence of IgA in these blood products. Selective IgA deficiency is the single most common cause of anaphylaxis after transfusion.)

The maximum recommended occupational whole-body exposure to radiation is:

a. 1 rem/year
b. 5 rem/year
c. 10 rem/year
d. 20 rem/year

b. (5 rem/year

The intraoperative use of imaging equipment exposes anesthesia providers to ionizing radiation. The maximum recommended whole-body exposure to radiation is 5 rem/year.

pg. 65
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Examples of Type IV hypersensitivity reactions include:

a. contact dermatitis
b. hemolytic transfusion reactions
c. anaphylaxis
d. angioedema

a. (contact dermatitis

Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis.

Download CoreNotes

pg. 292
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Comparing the incidence of post-dural puncture headache (PDPH) between pencil point spinal needles and cutting bevel spinal needles, which of the following is MOST correct?

a. The incidence is the same
b. The incidence is lower with pencil point needles
c. The incidence is lower with cutting bevel spinal needles
d. The incidence is the same but only if the cutting bevel spinal needles are 27 gauge or smaller

b (The incidence is lower with pencil point needles

A cutting bevel leaves a different type of “hole” in the dura than a pencil point needle. A pencil point needle makes a tiny hole in the dura that then spreads to the size of the needle being used. The effective size of the dural hole is much smaller than the needle size and dural fibers are stretched rather than cut. A cutting bevel needle leaves a hole equal in size to the diameter of the needle and dural fibers have been cut rather than stretched. This results in a lower incidence of PDPH with pencil point needles.)

nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is:

a. phenoxybenzamine
b. doxazosin
c. propranolol
d. terazosin

a (phenoxybenzamine

Phenoxybenzamine is a nonselective ?-antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and terazosin are selective ?1-antagonists. Propranolol is a nonselective ?-antagonist. In the preparation of patients with pheochromocytoma, ?-blockade and intravascular volume replacement must precede ?-blockade, so as to prevent the possibility of unopposed ?-stimulation.

pg. 192
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Sickle hemoglobin: (Select 2)

a.has a lower P50 than hemoglobin A
b. releases oxygen less readily than hemoglobin A
c. is present in about 30% of African Americans
d. readily polymerizes and precipitates in the red cell
e. results from a single amino acid substitution on the ?-chain
f. has decreased solubility as compared to hemoglobin A

d, f. (readily polymerizes and precipitates in the red cell, has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50 (31 mm Hg) as compared to hemoglobin A (27 mm Hg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the ?-chain.

pg. 1177
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

a. increased carbon dioxide levels
b. increased 2,3-DPG levels
c. increased pH
d. the presence of fetal hemoglobin
e. increased body temperature
f. the presence of hemoglobin-S

c, d. (increased pH, presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus.

pp. 603-604
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of:

a 13 – 15
b. 9 – 12
c. 6 – 9
d. less than 6

b (9 – 12

According to the Modified Glasgow Coma scale, mild head injury is associated with a score of 13 – 15, moderate head injury is associated with a score of 9 – 12, and severe head injury is associated with a score of less than 8.

pg. 923
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case?

a. Check oxygen cylinder supply
b. Check the carbon dioxide absorber
c. Performance of a machine low-pressure leak test
d. Calibration of the oxygen monitor

b (Check the carbon dioxide absorber

Verification of the adequacy of the carbon dioxide absorber is suggested prior to every case. If the same anesthesia machine is being used by the same provider, E-cylinder pressure checks, machine low-pressure leak testing and calibration of the oxygen sensor need not be repeated after an initial check.

pp. 84-85
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following proteins is LEAST likely to be down-regulated in the setting of sepsis?

a. Activated protein C
b. Endothelial protein C receptor (EPCR)
c. Glycoprotein Ib (GP1B)
d. Thrombomodulin
e. Protein S

c. (Glycoprotein Ib (GP1B)

The hematologic and inflammatory systems are closely related. This relationship can be deduced from experience (i.e., septic patient developing multiple coagulopathies and in some instances disseminated intravascular coagulation [DIC]) and also makes teleological sense (most infectious insults are accompanied by tissue trauma, at least in the natural environment). The relationship is not fully understood but it appears that sepsis leads to the downregulation of thrombomodulin, endothelial protein C receptor (EPCR), activated protein C, and protein S, all of which are anti-coagulant proteins.

A 27-year-old construction worker presents to the ER after traumatic amputation of the 4th and 5th digits by a table saw. An ultrasound-guided axillary block with 30 cc of 0.5% bupivacaine is performed as the primary anesthetic for digital re-attachment. After 90 minutes of tourniquet inflation, the patient reports severe tourniquet pain. What nerve is MOST likely responsible for this pain?

a. Axillary nerve
b. Intercostobrachial nerve
c. Medial antebrachial cutaneous nerve
d. Lateral antebrachial cutaneous nerve

b. (Intercostobrachial nerve

The cutaneous innervation of the medial arm and axilla is derived from the intercostobrachial (ICB) nerve, a branch on the second thoracic nerve root. The ICB nerve is blocked by a subcutaneous skin wheal in the medial aspect of the arm near the axilla. Failure to block the ICB nerve can result in significant tourniquet pain, especially during long-duration tourniquet use.)

When performing an ultrasound-guided supraclavicular block, what is the MOST appropriate needle and probe orientation?

a. In-plane, anteromedial to posterolateral
b. In-plane, posterolateral to anteromedial
c. Out-of-plane, anteromedial to posterolateral
d. Out-of-plane, posterolateral to anteromedial

b. (In-plane, posterolateral to anteromedial

The safety of the ultrasound-guided supraclavicular block is based on the anesthesiologist visualizing the needle tip at all times during the block. This can only be reliably accomplished using an in-plane needle approach. In order to reliably block the ulnar nerve, local anesthetic needs to be deposited between the subclavian artery and the first rib. This is most easily accomplished using a posterolateral to anteromedial needle approach.)

An increase in intraocular pressure has been associated with: (select 3)

a. nitrous oxide administration
b. succinylcholine administration
c. opioid administration
d. hyperventilation
e. laryngoscopy
f. hypoxemia
g. sevoflurane administration

b, e, f (succinylcholine administration, hypoxemia, laryngoscopy

Succinylcholine increases intraocular pressure by 5 – 10 mm Hg for 5 – 10 minutes after administration. This increase is primarily the result of *prolonged contracture* of the extraocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetic agents and opioids have been associated with a reduction in intraocular pressure. *Hypoxemia, hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation* have all been shown to increase IOP.

pp. 760-761
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 46-year-old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately:

a. 2%
b. 5%
c. 10%
d. 25%

c (10%

Patients with acute hepatitis should have elective surgery postponed until the acute hepatitis has resolved. Studies indicate increased perioperative morbidity (12%) and mortality (10% with laparotomy) during acute hepatitis.

pp. 1315-1316
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Changes found in banked blood include: (Select 2)

a. increased levels of 2,3-DPG
b. a left shift of the hemoglobin dissociation curve
c. decreased levels of potassium
d. formation of microaggregates
e. alkalosis secondary to the presence of citrate
f. increased intracellular ATP stores
e. thrombocytosis

b, d (a left shift of the hemoglobin dissociation curve, formation of microaggregates

Changes occurring in banked blood include:

Depletion of 2,3-DPG
Depletion of intracellular ATP
Oxidative damage
Increased adhesion to vascular endothelium
Altered cell morphology
Accumulation of microaggregates
Hyperkalemia (as high as 17.2 mEq/L)
Absence of platelets (after 2 days of storage)
Hemolysis
Accumulation of proinflammatory products
pg. 396
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

Pulmonary changes associated with Duchenne’s muscular dystrophy include:

a. a restrictive ventilatory defect
b. an obstructive ventilatory defect
c. decreased pulmonary artery pressures
d. increased residual volume

a (a restrictive ventilatory defect

The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilatory defect in patients with Duchenne’s muscular dystrophy. Pulmonary hypertension is also commonly seen.

pg. 753
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is MOST accurate with regard to total circulating blood volume in the parturient?

a. It is increased by up to 45% over pre-pregnancy values
b. It doubles during the first two trimesters and remains constant throughout the third trimester
c. It increases by 10% over pre-pregnancy values
d. It decreases slightly during the first trimester

a. (It is increased by up to 45% over pre-pregnancy values

Due to changes is osmoregulation and the renin-angiotensin system during pregnancy leading to salt retention, circulating blood volume is increased by up to 45% in the full-term parturient. This leads to a total body water volume of about 8.5 L. These changes begin early in the first trimester. Red cell volume increases by only 30% in pregnancy, leading to “physiologic anemia” of pregnancy.)

Which of the following should be MOST suspected in a laboring parturient who experiences sudden hypotension and abdominal pain accompanied by fetal bradycardia?

a. Progression from first to second stage of labor
b. Placenta previa
c. Placenta accreta
d. Uterine rupture

d. (Uterine rupture

Uterine rupture may present with nonspecific signs but almost always includes fetal bradycardia. Maternal hypotension along with loss of function of uterine pressure monitors often occurs as well. Risk factors for uterine rupture include uterine scar (such as from prior cesarean delivery), trauma, aggressive use of oxytocin during labor, and excessive uterine manipulation. Incidence of uterine rupture during vaginal birth after cesarean delivery (VBAC) is approximately 1%. The American Congress of Obstetricians and Gynecologists (ACOG) recommends that at any facility where patients undergo trial of labor after cesarean (TOLAC), a physician capable of monitoring labor and performing emergent cesarean deliveries and an anesthesiologist must be immediately available. Serious maternal morbidity or mortality is as high as 10-25% with uterine rupture. Treatment includes emergent laparotomy.)

During an anterior-posterior spinal fusion, in a 70-kg patient, the laboratory reports an intraoperative hematocrit of 21% with a hemoglobin of 7g/dL. Two units of packed red blood cells are administered over the course of 30 minutes. Upon completion of the transfusion, the anticipated hematocrit will be approximately:

(numerical answer)

25 – 27%

A commonly used rule of thumb states that each unit of PRBCs increases the hemoglobin 1 g/dL and the hematocrit 2% to 3%.

pg. 396
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
( numerical answer)
3.0 – 4.4 kg

Using cricoid yolk studies, the optimum force necessary to effectively occlude the esophagus without obstruction of the trachea is between 30 and 44 Newtons (3.0 – 4.4 kg). It is recommended that 2 kg of force be applied prior to loss of consciousness and that pressure be increased to 4 kg of force after loss of consciousness.

pg. 449
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: (Select 2)

a. high-frequency oscillation
b. inverse I:E ratio ventilation
c. airway pressure release ventilation
d. differential lung ventilation
e. high-frequency positive-pressure ventilation
f. pressure support ventilation

a, e (*high-frequency* oscillation, *high-frequency* positive-pressure ventilation

High-frequency oscillation (HFO) creates a to-and-fro gas movement in the airway at rates of 180 – 3000 times/min. High frequency positive-pressure ventilation is delivered at a rate of 60 – 120 breaths/min. Tidal volume is at or below anatomic dead space. High-frequency ventilation techniques may be useful in cases of bronchopleural and tracheoesophageal fistulas.

pg. 1062
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 59-year-old woman with end-stage renal disease on hemodialysis has prolonged ventilatory depression after the administration of morphine. Which of the following is MOST likely responsible for the patient’s ventilatory depression?

a. Morphine-3-glucuronide accumulation
b. Morphine-6-glucuronide accumulation
c. Increased mu-receptor affinity
d. Increased volume of distribution

b. (Morphine-6-glucuronide accumulation

Morphine can be metabolized to both morphine-3-glucuronide and morphine-6-glucuronide, both of which are excreted by the kidney and thus may accumulate in renal failure. Morphine-3-glucuronide is largely inactive, although high serum levels may be associated with seizures. Conversely, morphine-6-glucuronide is an active metabolite and likely contributes to much of the analgesia associated with morphine. Patients with renal failure do not have altered mu-receptor affinity. The volume of distribution is increased in patients with renal failure; however, this increase is not responsible for prolonged ventilatory depression.)

??The essential component of cardioplegia solutions is:

a. mannitol
b. magnesium
c. potassium
d. corticosteroid

c (potassium

High concentrations of potassium (20 – 30 mEq/L) are used in cardioplegia solutions. These solutions result in an increase in extracellular potassium and *reduce transmembrane potential*. This progressively interferes with the normal sodium currents of depolarization and eventually the *sodium channels are completely inactivated*.

pg. 519
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?The 2013 SCCM guidelines on delirium recommend which of the following as the first line pharmacologic treatment of delirium?

a. Benzodiazepines
b. Opioids
c. Haloperidol
d. Quetiapine
e. None of the above

e. (None of the above there is no pharma Rec previous Rec was Haldol. )

?The formation clinically significant amounts of carbon monoxide has been associated with:

a. the use of a non-rebreathing circuit
b. the use of fresh carbon dioxide absorber
c. the use of desflurane
d. expiratory valve incompetence

c (the use of desflurane

The formation of CO depends on the use of a volatile agent containing a difluoromethoxy moiety (desflurane, isoflurane, enflurane). This moiety can react with desiccated base (baralime or sodalime) to form CO. Fresh absorber has sufficient water to prevent the reaction. Clinically, CO intoxication occurs after a weekend when the flow of dry oxygen in the machine has desiccated the absorber and desflurane is being used.

pp. 471-472
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.
Anesthesiology. 89(4):929-941, October 1998. Baxter, Pamela J. PhD; Garton, Kyle BS; Kharasch, Evan D. MD, PhD)

?The duration of which of the following neuromuscular blockers is MOST prolonged in patients with dialysis-dependent renal failure?

a. Cisatracurium
b. Pancuronium
c. Succinylcholine
d. Rocuronium

b.
(Of the drugs listed, pancuronium is the neuromuscular blocker most dependent upon renal elimination for the termination of its effects. Indeed, as much as 40% of an injected dose of pancuronium is recovered in urine as unchanged and as much as 25% may be recovered as 3-hydroxy metabolite, which is a potent neuromuscular blocker (about 50% as potent as pancuronium). Thus, the duration of action of pancuronium is prolonged in patients with renal failure. Cisatracurium is not metabolized but rather cleared by Hofmann degradation. Succinylcholine is metabolized by pseudocholinesterase. Rocuronium is primarily eliminated by the liver; however, a small decrease in clearance among patients with end-stage renal disease can be demonstrated.)

?A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mm Hg, the expected PaCO2 at the end of the apneic period would be:
67 to 74 mm Hg

The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10 – 20 minutes in most patients. Arterial PaCO2 rises 6 mm Hg in the first minute followed by a rise of 3 – 4 mm Hg during each subsequent minute. In this patient this will produce a 27 – 34 mm Hg increase, resulting in a PaCO2 of 67 to 74 mm Hg.

pg. 561
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?After being injured in a motor vehicle accident, a 35-year-old previously healthy woman is intubated and mechanically ventilated in the ICU. Her respiratory quotient is calculated to 0.97. This suggests that her primary metabolic fuel is MOST likely to be:

a. Carbohydrate
b. Fat
c. Protein
d. None of the above

a. (Carbohydrate

Respiratory quotient (RQ) is the ratio of CO2 eliminated/O2 consumed. Under most conditions, the RQ ranges from 0.7 to 1.0. A RQ of 1.0 suggests pure carbohydrate metabolism whereas as RQ of 0.7 suggests pure fat metabolism. When proteins are metabolized, the RQ is approximately 0.8 (or slightly higher). This patient has a RQ of 0.97, which suggests that carbohydrate is her primary metabolic fuel.)

?The largest fraction of carbon dioxide in the blood is in the form of:

a. carbamino compounds
b. bicarbonate
c. dissolved gas
d. carboxyhemoglobin

b (bicarbonate

Nearly 90% of carbon dioxide in the blood is in the form of bicarbonate.

pg. 605
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?When given in equipotent doses, which of the following opioids would have the GREATEST spread when given in the epidural space?

a. Hydromorphone
b. Fentanyl
c. Morphine
d. Sufentanil

c. (morphine

In general terms, when administered in the epidural space, the “spread” of an opioid is directly proportional to its hydrophilicity. The more hydrophilic the opioid, the greater the spread; the more lipophilic the opioid, the lesser the spread. Of the opioids listed, morphine is the most hydrophilic and would thus be expected to have the greatest spread when administered in the epidural space.)

?The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately:
(numerical answer)
20 – 25

(Dichotomous division, each branch dividing into two smaller branches, of the tracheobronchial tree is estimated to involve 20 – 25 divisions.

pg. 593
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier)

?A 52-year-old man with a large meningioma presents for craniotomy and resection of his tumor. Which of the following agents is MOST likely to increase ICP in this patient?

a. 1 mg/kg lidocaine IV
b. 2 mg/kg propofol IV
c. 8% sevoflurane mask induction
d. 10 mg/kg vecuronium IV

c. (8% sevoflurane mask induction

All intravenous induction agents (except ketamine) decrease the cerebral metabolic rate (CMR) and thus decrease cerebral blood flow and intracranial pressure (ICP) through CMR-CBF coupling. Intravenous lidocaine has a negligible effect on ICP, although it can attenuate the increase in ICP that may occur with laryngoscopy. Vecuronium, like most non-depolarizing neuromuscular blockers, has a negligible effect on ICP. It should be noted that pancuronium can increase ICP in patients with space-occupying lesions. All potent volatile anesthetics are direct cerebral vasodilators and can thus increase ICP, especially in patients with space-occupying lesions and altered intracranial elastance.)

?Which of the following syndromes is MOST closely associated with Pierre Robin Sequence?

a. Apert
b. Crouzon
c. Goldenhar
d. Stickler

d (Stickler

Pierre Robin sequence (PRS) has a variable presentation. It may be isolated and not associated with a syndrome or it may be associated with a syndrome. The most common syndromes associated with PRS are Stickler, Treacher-Collins, Velocardiofacial, and fetal alcohol syndrome. Goldenhar is a craniofacial anomaly with hypoplasia of one half of the facial skeleton but it is not associated with PRS. Apert and Crouzon are both syndromes with craniosynostosis (abnormal fusion of one or more of the craniofacial sutures) but they are also not associated with PRS.)

Pierre Robin sequence (PRS) is characterized by:
1) Small mandible (micrognathia);
2) Posterior displacement of the tongue (glossoptosis); and,
3) Airway obstruction. It is often, but not always associated with a cleft lip and/or palate.

Pierre Robin is called a “sequence” (as opposed to a “syndrome”) because everything occurs as a result of mandibular undergrowth in utero. Pierre Robin sequence may occur in isolation, but is often associated with an underlying disorder. The most common syndromes associated with PRS are Stickler syndrome, velocardiofacial syndrome, and Treacher-Collins syndrome. Stickler syndrome is a connective tissue disorder caused by abnormal collagen types II and IX and has autosomal dominant inheritance. It is characterized by “flat” facial appearance with a small nose secondary to midface hypertrophy. Also, extreme myopia and prominent eyes, glaucoma, hearing loss, arthritis, and other problems.

?Neuroleptic malignant syndrome:

a. can be precipitated with the use of metoclopramide
b. carries a mortality of over 80%
c. can be treated with physostigmine administration
d. can be diagnosed with muscle biopsy

a (can be precipitated with the use of metoclopramide

Neuroleptic malignant syndrome is a rare complication of antipsychotic therapy. *Meperidine* and *metoclopramide* can also precipitate the disorder which appears to be secondary to dopamine blockade in the basal ganglia. The disease has many characteristics in common with MH including increased temperature, metabolic derangement and hyperthermia. The mortality is 20 – 30%. *Treatment* with *dantrolene* and *dopamine agonist, bromocripitine*, appears effective.

pg. 626
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?the following statements regarding informed consent and peripheral nerve blockade is MOST correct?

a. Physicians are required by law to discuss any complications occurring with frequencies > 1:10,000
b. In practice, physicians’ discussions of risks and benefits are often inconsistent with the literature
c. Peripheral nerve injury is the only mandatory element of informed consent discussions prior to regional anesthesia
d. Preoperative anxiety on the part of the patient is an acceptable reason to omit discussions of risks and benefits of regional anesthesia

a. (Physicians are required by law to discuss any complications occurring with frequencies > 1:10,000)

?A 36-year-old female is scheduled for an elective cholecystectomy. Her past medical history is significant for depression treated with phenelzine (Nardil). Her anesthetic plan should include: (Select 2)

a. discontinuation of phenelzine for at least 2 weeks prior to surgery
b. the avoidance of indirect acting vasopressors
c. the avoidance of propofol
d. the avoidance of meperidine
e. the avoidance of nitrous oxide
f. the avoidance of volatile anesthetics

b, d (the avoidance of meperidine, the avoidance of indirect acting vasopressors

*Phenelzine is a monamine oxidase (MAO) inhibitor.* The practice of discontinuing MAO inhibitors prior to surgery is no longer recommended. The use of meperidine in patients receiving MAO inhibitors has been associated with hypertensive crisis and should be avoided. Additionally, indirect acting vasopressors have also been associated with hypertensive crisis and direct acting vasopressors should be used to treat hypotension.

pg. 625
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?Following an interscalene block, a patient undergoing right wrist surgery reports pain along the ulnar aspect of distal forearm. The MOST likely explanation for this is inadequate spread of local anesthetic to which of the following nerve roots?

a. C3-C4 nerve roots
b. C5-C6 nerve roots
c. C6-C7 nerve roots
d. C8-T1 nerve roots

d. (C8-T1 nerve roots

The C8-T1 nerve roots join the brachial plexus more caudally and so are frequently spared during interscalene blockade. Thus interscalene may not be appropriate for procedures of the distal, ulnar aspects of the upper extremity.)

?Renal blood flow: (Select 2)

a. is largely determined by renal oxygen consumption
b. accounts for 20 – 25% of the cardiac output
c. is distributed mostly to juxtamedullary nephrons
d. can be directed away from cortical nephrons by sympathetic stimulation
e. is not autoregulated

b, d. (accounts for 20 – 25% of the cardiac output, can be directed away from cortical nephrons by sympathetic stimulation

The kidneys are the only organ for which oxygen consumption is determined by blood flow; the reverse is true in other organs. The kidneys receive 20 – 25% of the cardiac output with only 10 – 15% going to the juxtamedullary nephrons and 80% going to cortical nephrons. However, blood flow can be redirected to juxtamedullary nephrons by increased levels of catecholamines and angiotensin II. Autoregulation of RBF occurs between mean arterial pressures of 80 – 180 mm Hg.

pp. 639-641
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?After ?completing a transarterial axillary block, a patient reports continued sensation over the lateral aspect of the distal forearm. Which of area has MOST likely failed to come in contact with local anesthetic?

a. Area posterior to the axillary artery
b. Area anterior to the axillary artery
c. Area in the coracobrachialis muscle
d. Area under the skin in the medial aspect of the upper arm

b. (Area anterior to the axillary artery

The sensory nerve of the lateral aspect of the forearm is the lateral antebrachial cutaneous nerve, which is a terminal branch of the musculocutaneous nerve. The musculocutaneous nerve runs in the body of the coracobrachialis muscle in the axilla.)

?An Axillary block is performed at which level of the brachial plexus?

a. Trunks
b. Divisions
c. Cords
d. Branches

d. (The axillary block is performed at the level of the terminal branches)

?The body mass index (BMI) associated with morbid obesity is:

a. > 30
b. > 35
c. > 40
d. > 45

c (> 40

(Overweight and obesity are classified using the BMI. Overweight is defined as a BMI > 24, obesity as a BMI > 30, morbid obesity as a BMI > 40, super obesity as a BMI > 50 and super-super obesity as a BMI > 60. BMI is calculated with the following formula:

BMI = Weight (kg) / Height (meters)2

pg. 1050
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier,)

?A year-old, 94-kg man underwent ultrasound-guided supraclavicular blockade for a 3-hour right wrist surgery. 40 ml of 0.5% bupivacaine was injected under ultrasound visualization. In the recovery room, the patient reports that his breathing “does not feel normal” and you also notice that his pupil diameter is unequal with the right pupil being smaller. Vital signs include: HR 70 bpm, BP 119/70 mmHg, SpO2 98% on room air. Which of the following is the MOST appropriate next step?

a. Initiate an intralipid infusion
b. Obtain an upright chest X-ray
c. Perform a needle decompression
d. Reassure the patient that he is fine

d. (Reassure the patient that he is fine

Although pneumothorax is possible during ultrasound supraclavicular blockade, it is a very rare occurrence. Using a traditional landmark-based supraclavicular block technique, it is estimated that pneumothorax occurred in 0.5% to 5% of patients. The rate is likely significantly lower under ultrasound guidance. The most common side effects during supraclavicular block are Horner’s syndrome (ipsilateral eye ptosis, miosis and anhydrosis) and phrenic nerve blockade. These are estimated to occur in 30% to 50% of supraclavicular blocks and are more likely when local anesthetic volumes >20 ml are used.)

?The dibucaine number:

a. is normally less than 60%
b. is a quantitative assessment of pseudocholinesterase activity
c. is inversely proportional to pseudocholinesterase function
d. reflects inhibition of pseudocholinesterase by dibucaine

d (reflects inhibition of pseudocholinesterase by dibucaine

Dibucaine, a local anesthetic, inhibits normal pseudocholinesterase. Homozygous patients with abnormal pseudocholinesterase characteristically have a dibucaine number of about 20%, heterozygous patients have numbers of 40 – 60% and normal patients usually have a dibucaine number of 80%. The dibucaine number is proportional to pseudocholinesterase function, but is independent of the amount of the enzyme.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?formula for systemic vascular resistance (SVR)?

a. [80*(MAP — CVP)]/CO
b. [80*(MAP — PCWP)]/CO
c. [80*(PAmean — PCWP)]/CO
d. [80*(PAmean — CVP)]/CO

a. ([80*(MAP — CVP)]/CO

The basic principle of calculating resistance is derived from Ohm’s Law: I = V/R Ohm’s Law states that the current or flow between two points is directly proportional to the potential difference across the two points, divided by the resistance. Thus, cardiac output (flow) will be proportional to the difference in pressure (MAP – CVP), divided by the systemic vascular resistance (SVR). This yields: CO = (MAP – CVP)/SVR Thus: SVR = (MAP — CVP)]/CO SVR is typically multiplied by 80 to yield an answer in dynes*sec/cm5. Normal systemic vascular resistance is 800-1500 dynes*sec/cm5)

?35-year-old patient with severe acute inflammatory demyelinating polyneuropathy (AIDP or Guillain-Barre Syndrome) becomes bradycardic during endotracheal tube suctioning. Which of the following is the MOST likely cause and MOST appropriate treatment?

a. Pulmonary embolus; heparin
b. Dysautonomia; transvenous pacing
c. Mucous plugging; bronchoscopy
d. Acute right coronary artery infarction with conduction abnormalities; PTCA

b.
(Dysautonomia is common in severe Guillain-Barre Syndrome. GBS is treated with plasmapheresis or intravenous immunoglobulin initially and then the care becomes supportive. In the setting of severe dysautonomia causing asystole, transvenous pacing may be required. Isoproterenol infusion (or another appropriate chronotrope) can be tried, as can prophylactic atropine prior to patient care maneuvers that would stimulate a vagal response (suctioning, turning, etc.). As a reminder, succinylcholine is contraindicated in this patient population.)

?A 20-year-old woman is admitted to the ICU with refractory status epilepticus (new onset refractory status epilepticus [NORSE]). Treatment with levetiracetam and a midazolam infusion at 0.5mg/kg/hr is initiated. Continuous EEG reveals no seizures. A brain MRI with and without contrast is normal. Which of the following diagnostic tests is MOST appropriate at this time?

a. CT perfusion study to obtain quantitative cerebral blood flow measurements
b. Somatosensory and motor evoked potential studies
c. Lumbar puncture for cerebrospinal fluid analysis
d. Transcranial Doppler examination to rule out vasospasm

c. (LP

In a patient with new onset seizures, a central nervous system infection must be ruled out immediately so that any appropriate antimicrobial therapy can be started. CSF analysis for cell count, protein, glucose, gram stain, and culture is the basic approach. PCR analysis for herpes simplex virus (HSV) should be performed. In immunocompromised patients, such as those with HIV disease, other viral and opportunistic infections must be considered. Finally, in young patients with new onset refractory status epilepticus, autoimmune encephalitis must be strongly considered and aggressively evaluated and treated.)

?20-year-old woman is admitted to the ICU, intubated, with refractory status epilepticus (new onset refractory status epilepticus [NORSE]). A non-contrast head CT is normal. Treatment with levetiracetam 1000 mg every 12 hours and a midazolam infusion at 0.5 mg/kg/hr. The patient has intermittent facial blinking movements and stereotyped grimacing. What is the MOST appropriate next step in her management?

a. Add phenytoin
b. Add a ketamine infusion
c. Continuous EEG monitoring
d. Continue current therapy

c. (Continuous EEG monitoring

In this setting, you must determine whether the cerebral seizure activity has stopped. The patient’s movements could be from ongoing seizures but could also be from non-epileptic subcortical or brainstem myoclonic movements. EEG monitoring is indicated.)

?Effects of lidocaine include:

a. increased intracranial pressure
b. increased refractory period of cardiac muscle
c. decreased fibrinolysis
d. myonecrosis

d. (myonecrosis

Intravenous lidocaine decreases cerebral blood flow unless seizure activity develops. Lidocaine decreases the refractory period of cardiac muscle and decreases platelet aggregation while enhancing fibrinolysis. Local anesthetics have been shown to cause lytic degeneration and necrosis of muscle fibers when directly injected into the muscle (trigger point injections).

pp. 270-274
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?Which of the following confirmatory tests is mandatory when declaring brain death?

a. Cerebral angiography demonstrating no cerebral blood flow
b. EEG demonstrating electrocerebral silence
c. TCD demonstrating loss of cerebral blood flow
d. None of the above

d. (none of the above

Brain death is a clinical diagnosis and confirmatory testing is not mandatory. Patients must have the following: 1) Have an appropriate clinical scenario and imaging findings; 2) Free of neuromuscular blockers and drugs that depress the central nervous system; 3) Normothermic; 4) Clinical neurologic examination demonstrating unresponsive coma and absence of cranial nerve reflexes; 5) Apnea testing demonstrating no spontaneous respirations in the presence of a PCO2 >60mmHg)

?The elimination half-life of a drug:

a. is inversely proportional to the clearance
b. is inversely proportional to the volume of distribution
c. is directly proportional to clearance
d. is shortest in drugs that are rapidly redistributed

A (is inversely proportional to the clearance

The elimination half-life of a drug is proportional to the volume of distribution and inversely proportional to the rate of clearance.

pg. 165
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

?A patient with severe traumatic brain injury has been in the ICU for five days. He is comatose. He has been treated with pentobarbital for ICP control and continuous EEG monitoring shows burst suppression, with approximately 1 second of activity every 10 seconds (90% suppression ratio). He develops copious urine output accompanied by rising serum sodium levels. What is the MOST likely cause of this and what is the treatment?

a. Brain death; withdrawal of life support
b. Intracranial hypertension; mannitol
c. Pentobarbital; vasopressin infusion
d. Pentobarbital; normal saline infusion

c. (Pentobarbital; vasopressin infusion

In this scenario, the patient has developed central diabetes insipidus (DI). This could be caused by either pentobarbital-induced neurohypophysis dysfunction or to hypothalamic-pituitary infarction from cessation of cerebral blood flow (i.e., brain death). Brain death is less likely given the persistence of burst activity on the EEG. The DI must be treated with vasopressin infusion (or ddAVP [desmopressin]). Cerebral blood flow evaluation with a modality such as transcranial Doppler (TCD) is reasonable to rule out critical or total cessation of cerebral blood flow. Euvolemia must be maintained.

An otherwise healthy 61-year-old woman is in the operating room for the placement of an intramedullary rod after a femur fracture 2 days ago. During reaming, her SpO2 falls from 98% to 85% on FiO2 0.5, she develops sinus tachycardia to 120 bpm and her blood pressure is currently 65/40 mmHg. Which of the following would you MOST expect to see on an intraoperative transesophageal echocardiogram?

a. Anterolateral regional wall dyskinesis
b. Global left ventricular hypokinesis
c. Patent foramen ovale
d. Right ventricular dilation

d. (RV dilation

A history of trauma to long bones or an orthopedic procedure with intramedullary reaming of the bone may result in fat embolism syndrome. In a patient under general anesthesia, the signs are few but include hypoxia, increased A-a gradient, tachycardia, and a petechial rash on the upper body. If the fat embolism is large enough, fat, blood components and bony particles travel via the venous system to the right side of the heart and become lodged in the pulmonary arteries, causing increased afterload against which the right ventricle must pump. The right ventricle acutely dilates and fails as it is accustomed to performing low pressure, volume work. This causes the interventricular septum to bulge into the left ventricle and reduce the stroke volume being pumped to the systemic circulation (thus reducing arterial systemic blood pressure). It is not uncommon, if a patient has a patent foramen ovale (PFO), for debris to cross from right to left via the opening, but a PFO is not specific to fat embolism syndrome. Hypokinesis and dyskinesis of parts of the left ventricle occur with myocardial ischemia, which is not usually part of the initial response to fat embolism.)

The formation of active metabolites has NOT been associated with the use of:

a. vecuronium
b. rocuronium
c. pancuronium
d. succinylcholine

b. (rocuronium

The 3-OH metabolites of both vecuronium and pancuronium possess about 50% of the neuromuscular blocking activity of parent compound. Succinylcholine is metabolized to choline, succinic acid and succinylmonocholine. Succinylmonocholine also has some neuromuscular blocking activity. A small amount of rocuronium is metabolized to the 17-OH compound, which lacks activity. Most rocuronium is excreted by the kidneys and liver as intact drug.

pg. 535-538
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Which of the following neurotransmitters is MOST commonly used by preganglionic sympathetic neurons at sympathetic ganglia?

a. Acetylcholine
b. Dopamine
c. Epinephrine
d. Norepinephrine

a. (ACh

Both sympathetic and parasympathetic PREganglionic neurons are cholinergic and thus release acetylcholine as the neurotransmitter. Most POSTganglionic sympathetic neurons are adrenergic and release norepinephrine; however, some are cholinergic such as the nerves that innervate sweat glands. Most POSTganglionic parasympathetic neurons are and thus release acetylcholine.)

The area of myocardium most vulnerable to ischemia is the:

a. left ventricular epicardium
b. right ventricular epicardium
c. left ventricular subendocardium
d. right ventricular subendocardium

c. (left ventricular subendocardium

The subendocardium of the left ventricle is most vulnerable to ischemia since this is an area of greater systolic shortening. In addition, left ventricular subendocardium perfusion is almost entirely restricted to diastole, in contrast to the subendocardium of the right ventricle that receives most of its perfusion during systole.

pg. 244
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

63-year-old woman with a six-month history of headache and visual disturbances is diagnosed with a non-functioning pituitary macroadenoma. Serum levels of which following hormones is MOST likely to be elevated in this patient?

a. Adrenocorticotropic hormone (ACTH)
b. Growth hormone (GH)
c. Prolactin
d. Thyroid-stimulating hormone (TSH)

c. (Prolactin

The mass effects of an expanding pituitary tumor are well-characterized. Many patients complain of a headache. Patients with macroadenomas may complain of visual loss (classically temporal or bitemporal hemianopsia) from compression of the optic chiasm. Compression of the normal pituitary gland by the tumor can cause anterior pituitary compression and dysfunction, resulting in hypopituitarism and low levels of ACTH, TSH, GH, luteinizing hormone (LH), and follicle stimulating hormone (FSH). Patients may become hyperprolactinemic secondary to a loss of tonic inhibition of prolactin secretion. )

During the delivery of an inhalation anesthetic using 6.5% desflurane in oxygen, nitrous oxide is introduced into the gas mixture. The effect of the addition of nitrous oxide on the concentration of desflurane delivered is:

a. to cause an increase in desflurane concentration
b. to cause a decrease in desflurane concentration
c. to cause no change in desflurane concentration
d. variable, depending on the ambient atmospheric pressure

b. (to cause a decrease in desflurane concentration

When a carrier gas other than 100% oxygen is used, a clear trend toward reduction in the desflurane vaporizer output is seen. This effect is thought to be secondary to the change in gas viscosity that occurs with the introduction of nitrous oxide and is most pronounced at low-flow rates. A reduction of as much as 20% may be produced.

pg. 669
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Which of the following is LEAST likely to be a risk factor for the development of postherpetic neuralgia?

a. Age > 60 years
b. Corticosteroid administration
c. Female sex
d. Severe acute pain

b (Corticosteroid administration

Advanced age has consistently been demonstrated to be associated with an increased risk of postherpetic neuralgia. Postherpetic neuralgia is more frequently observed in women and Jung et al. found female sex to be strongly associated with postherpetic neuralgia. Patients with more severe acute pain have an increased risk to develop postherpetic neuralgia. Corticosteroids may be added to antiviral therapy during the acute phase and may reduce acute pain; however, the impact of corticosteroids on the incidence of postherpetic neuralgia remains uncertain.)

In the adrenal gland, mineralocorticoids are secreted by the:

a. zona reticularis
b. zona glomerulosa
c. zona fasciculata
d. adrenal medula

b. (zona glomerulosa

The zona glomerulosa chiefly secrets mineralocorticoids. The zona reticularis is responsible for secreting sex hormones. Finally, the zona fasciulata secretes glucocorticoids. The adrenal medula secretes catecholamines, mainly epinephrine.

pg. 772
Yao, FS, Fontes, ML, Malhotra, V. Yao and Artusio’s Anesthesiology. Philadelphia: Lippincott Williams & Wilkins, 2008.)

Renal effects of nitrous oxide include:

a. decreased renal blood flow secondary to decreased cardiac output
b. decreased renal blood flow secondary to increased renal vascular resistance
c. increased renal blood flow secondary to sympathetic stimulation
d. increased glomerular filtration with increased reabsorption

b (decreased renal blood flow secondary to increased renal vascular resistance

Nitrous oxide appears to decrease renal blood flow by increasing renal vascular resistance. This results in decreased glomerular filtration and decreased urine output.

pg. 167
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?Sinus tachycardia typically shortens which phase of diastole the most?

a. Atrial systole
b. Diastasis (slow filling)
c. Early inflow (rapid filling)
d. Isovolemic relaxation

b. (diastasis

The length of diastasis is dependent most upon heart rate. At rates higher than 100 beats per minute, it is almost completely abolished when looking at mitral inflow velocities using Doppler echocardiography.)

?Which of the following is MOST correct regarding the neonatal airway?

a. The epiglottis is typically more broad and rigid compared to an adult
b. The larynx is described as funnel-shaped
c. The position of the larynx is typically more caudad than an adult
d. The tongue occupies more space in the adult relative to a neonate

b. (The larynx is described as funnel-shaped

The neonatal larynx is typically described as located more cephalad compared to an adult (c3-4, versus c5-6). Neonatal tongues are relatively larger and their epiglottis is “omega-shaped” and floppier compared to those of adults. The neonatal airway has been described as “funnel-shaped” compared to the “column-shaped” airway of an adult and although its narrowest portion has classically been described as being at the cricoid cartilage, this concept has been recently challenged.)

?Closing capacity is defined as:

a. closing volume + expiratory reserve volume
b. functional residual capacity – residual volume
c. closing volume + residual volume
d. residual volume + expiratory reserve volume

c. (closing volume + residual volume

Closing capacity is the lung volume at which airways begin to close and is defined as the closing volume + residual volume.

pg. 497
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

?You are taking care of a 3 kg neonate having an inguinal hernia repair. The NICU has started intravenous fluids at 12 ml/hr. What would be the MOST appropriate intravenous fluid for maintenance fluid management this patient?

a. Lactated Ringer’s
b. D 2.5%
c. D 5%
d. D 10%

d. D10%

(Preoperatively, most newborns receive an IV infusion containing 5% to 10% dextrose. In general, an infusion rate for dextrose of 4 to 7 mg/kg per minute maintains normoglycemia in both full-term and preterm infants. This neonate requires 1080 mg/hr dextrose (6 mg/kg/min x 3 kg x 60 min= 1080 mg/hr). 10% dextrose contains 100 mg/ml of glucose. 10% dextrose at 4 mL/kg per hour equals 1200 mg/hr of dextrose. Occasionally administering this amount of glucose produces hyperglycemia, and the infused concentration of glucose must be reduced, usually to 2.5% dextrose.)

?Postintubation croup:

a. is secondary to inflammation of subglottic structures
b. is less common when cuffed endotracheal tubes are used
c. occurs most frequently in infants less than 4 months of age
d. is most often seen immediately

a. (is secondary to inflammation of subglottic structures

Postintubation croup usually occurs at the level of the cricoid, since this is the narrowest part of the pediatric airway. Croup is less common with endotracheal tubes that are uncuffed and small enough to allow a gas leak at 10 – 25 cm H2O. Postintubation croup is associated with early childhood (1 – 4 years). Unlike laryngospasm, postintubation croup is seen some time after extubation, usually within 3 hours.

pp. 463-464
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 1231
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

?An euvolemic 20 kg 4-year-old boy presents emergently to the operating room with a small bowel perforation. The procedure is performed with a laparotomy and there is minimal blood loss. Assuming there was no preoperative fluid deficit, what would be the MOST appropriate volume of intravenous fluid administration during the surgical procedure?

a. 60 ml/hr
b. 120 ml/hr
c. 180 ml/hr
d. 360 ml/hr

a. (60 ml/hr

This patient’s fluid requirements include the preoperative deficit, maintenance rate, blood loss, and third space volume loss. This is emergency surgery so there is little to no preoperative deficit. His maintenance requirement is based on the 4-2-1 rule: (4 cc/kg/hr x 1st 10 kg) + (2 cc/kg/hr x 2nd 10 kg) = 40 + 20 = 60 ml/hr. He has peritonitis from his ruptured appendicitis and likely has increased third space fluid loss. These losses may be in the range of 5-10 ml/kg/hr. For this patient, 100-200 cc/hr will most likely cover his third space losses. There is minimal blood. The total fluid requirement for this patient, for this procedure, is approximately 160-260 ml/hr.)

Prior to pneumonectomy, split lung function testing is indicated in the patient with:

a. an FEV1 of 2.2 L
b. a PaCO2 of 49 mm Hg on room air
c. a PaO2 of 54 mm Hg on room air
d. a maximum VO2 of 21 mL/kg/min

b. (a PaCO2 of 49 mm Hg on room air

Split lung function testing is indicated in patients requiring pneumonectomy, but not meeting the recomme
nded laboratory criteria. Current recommendations for patients requiring pneumonectomy are:

PaCO2 < 45 mm Hg FEV1 > 2 L
Predicted postop FEV1 > 800 mL
Maximum VO2 > 15 mL/kg/min
FEV1/FVC > 50% of predicted

pp. 663-665
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?You are managing anemia in a 3-day-old neonate. Which of the following most accurately reflects the hemoglobin equivalent for tissue delivery in the neonate, infant, and adult?

a. Neonate: 10 g/dl; Infant 14 g/dl; Adult 8 g/dl
b. Neonate: 14 g/dl; Infant 10 g/dl; Adult 8 g/dl
c. Neonate: 8 g/dl; Infant 10 g/dl; Adult 14 g/dl
d. Neonate: 14 g/dl; Infant 8 g/dl; Adult 10 g/dl

d. (Neonate: 14 g/dl; Infant 8 g/dl; Adult 10 g/dl

Dr. Motoyama described a hemoglobin requirement for equivalent tissue oxygen delivery for neonates, infants and adults based on the oxygen affinity of hemoglobin. The hemoglobin required to transport an equivalent amount of oxygen is 14-15 g/dl for the neonate, 8 g/dl for the infant, and 10 g/dl for the adult)

Deleterious effects of hypothermia include: (Select 2)

a. impaired renal function
b. right shift of the hemoglobin-oxygen saturation curve
c. irreversible platelet dysfunction
d. increased incidence of wound infection
e. increased postoperative protein anabolism

a,d, (impaired renal function, increased incidence of wound infection

Deleterious effects of hypothermia include:

increased PVR
left shift of the hemoglobin-oxygen saturation curve
reversible platelet dysfunction
postoperative protein catabolism
altered mental status
impaired renal function
decreased drug metabolism
poor wound healing
increased incidence of infection
cardiac arrhythmias

pp. 1235-1236
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?The primary causative factor in the development of persistent pulmonary hypertension (PPH) in the neonate is:

a. cystic fibrosis
b. pregnancy-induced hypertension
c. hypoxemia
d. right-to-left shunting through a patent e. ductus arteriosus

c. (hypoxemia

Hypoxia or acidosis during the early neonatal period may predispose the infant to return to fetal circulation. This serious condition, previously known as persistent fetal circulation (PFC), is currently known as persistent pulmonary hypertension (PPH). Hypoxemia and/or acidosis promotes an increase in pulmonary vascular resistance which ultimately causes right to left shunting through the ductus arteriosus, foramen ovale, or both. Shunting causes continued hypoxemia, leading to a continued increase in pulmonary vascular resistance, and a vicious cycle ensues. Primary causes of hypoxemia in the neonate include pneumonia and meconium aspiration.

pp. 1163-1164
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

In the CVP trace below, the v wave is caused by:

a. atrial contraction
b. ventricular contraction
c. atrial filling
d. opening of the tricuspid valve

c. (atrial filling

In the normal CVP tracing, the a wave is due to atrial systole. The c wave coincides with ventricular contraction. The v wave is the result of atrial filling prior to the opening of the tricuspid valve. The x descent is thought to be due to the pulling down of the atrium by ventricular contraction. The y descent corresponds to the opening of the tricuspid valve.

pp. 298-300
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Interpleural analgesia can be accomplished by placing local anesthetic:

a. along the cephalad border of the T6 rib
b. immediately deep to the parietal pleura
c. immediately deep to the visceral pleura
d. superficial to the internal intercostal muscle

b (immediately deep to the parietal pleura

Interpleural analgesia is accomplished by placing an catheter between the parietal and visceral pleura. A loss-of-resistance technique is most commonly used at the T6 to T8 intercostal spaces, or the catheter can be placed under direct vision by the surgeon. Pneumothorax is a significant complication if the needle or catheter penetrates the visceral pleura.

pg. 1069
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Autonomic hyperreflexia:

a. is common with cord lesions below T8
b. can precipitate pulmonary edema
c. is not effectively prevented by regional anesthesia
d. can be prevented with adequate intraoperative sedation

b (can precipitate pulmonary edema

Autonomic hyperreflexia should be suspected in patients with lesions above T5-8. Regional anesthesia and deep general anesthesia are effective in preventing autonomic hyperreflexia. Surgical stimulation in these patients without adequate anesthesia can result in pulmonary edema, myocardial ischemia and cerebral hemorrhage.

pg. 927
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?During mediastinoscopy the risk of air embolization is greatest:

a. when the patient is supine
b. during spontaneous ventilation
c. immediately after closure of the incision
d. in the postoperative period

b. (during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

An action potential characterized by a spike followed by a plateau phase is seen in:

a. peripheral sensory nerve cells
b. peripheral motor nerve cells
c. striated skeletal muscle cells
d. cardiac muscle cells

d. (cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.

pg. 345
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The formation of metanephrine is the result of:
catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to vanillymandelic acid (VMA).

pg. 868
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is:

(numerical answer)

745 – 750 psig

Nitrous oxide has a critical temperature of 37oC. This allow nitrous oxide to exist as a liquid at room temperature. Full E-cylinders of nitrous oxide contain approximately 1590 L at a pressure of 745 psig. A sixty minute delivery of 3 L/min would result in a 180 L consumption, and this would be inadequate to consume all the liquid nitrous oxide in the tank. As a result, there would be no change in tank pressure.

pg. 622
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

A decrease in pseudocholinesterase activity has been associated with the use of: (Select 3)

a. pancuronium
b. esmolol
c. droperidol
d. vecuronium
e. metoclopramide
f. magnesium sulfate
g. dantrolene
h. rocuronium

response is incorrect.

A decrease in pseudocholinesterase activity has been associated with the use of:

a,b,e. (pancuronium, esmolol, metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, phenelzine, cyclophosphamide, metoclopramide, esmolol, pancuronium and oral contraceptives. Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

a. echinacea
b. valerian
c. ginkgo
d. ephedra

b. (valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

pg. 346t
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 585
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Pulmonary complications from advanced hepatic disease with cirrhosis include:

a. an obstructive ventilatory defect
b. respiratory acidosis
c. increased intrapulmonary shunting
d. increased functional residual capacity

c. (increased intrapulmonary shunting

Pulmonary manifestations associated with cirrhosis include: increased intrapulmonary shunting, decreased FRC, pleural effusions, restrictive ventilatory defect and respiratory alkalosis.

pg. 774
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

?Sympathetic blockade during acute herpes zoster has been shown to:

a. increase analgesic requirements
b. reduce the incidence of postherpetic neuralgia
c. increase the need for corticosteroid therapy
d. be an effective treatment for patients who have had postherpetic neuralgia for a number of years

b (reduce the incidence of postherpetic neuralgia

Sympathetic blockade within 2 months of the onset of herpes zoster has been shown to significantly reduce analgesic requirements and reduce the incidence of postherpetic neuralgia. Once the neuralgia is established however, blocks are usually ineffective.

pp. 1540-1541
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

pg. 407
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.)

Hypoxemia during one-lung anesthesia is most effectively treated by:

a. PEEP applied to the ventilated lung
b. continuous oxygen insufflation to the collapsed lung
c. changing tidal volume and rate
d. periodic inflation of the collapsed lung

d. (periodic inflation of the collapsed lung

The application of PEEP to the ventilated lung, changes in the ventilatory parameters and oxygen insufflation to the collapsed lung may offer marginal improvement in oxygenation. However, periodic inflation of the collapsed lung with oxygen, early ligation of the ipsilateral pulmonary artery and CPAP to the collapsed lung offer consistently effective improvement in oxygenation.

pp. 678-679
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Carbonic anhydrase inhibitors are used in the treatment of:

a. acute glaucoma
b. renal tubular acidosis
c. diarrhea induced acidosis
d. acidosis resulting from hypoventilation

a (acute glaucoma

Carbonic anhydrase inhibitors decrease the ability of the kidneys to reabsorb bicarbonate, resulting a hyperchloremic acidosis. As a result, carbonic anhydrase inhibitors would be avoided in patients with acidosis, especially a normal-anionic-gap acidosis. Because bicarbonate is filtered by the ciliary process in the formation of aqueous humor, carbonic anhydrase inhibitors reduce the formation of aqueous humor and can be used to decrease intraocular pressure.

pg. 1211
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Causes of normal-anion-gap acidosis include:

a. renal failure
b. starvation
c. diarrhea
d. lactic acidosis

c. (diarrhea

Normal-anion-gap acidosis is also called hyperchloremic acidosis and results from the selective loss of bicarbonate anion or the introduction of large amounts of chloride anion. Common causes include: diarrhea, hypoaldosteronism, renal tubular acidosis and increased intake of chloride containing acids sometimes found in hyperalimentation.

pg. 461
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

The recommended maximum leakage current allowed in operating room equipment is:

a. 5 ?A
b. 10 ?A
c. 1 mA
d. 5 mA

b (10 ?A

10 ?A has been established as the recommended maximum allowable leakage current. This amount of current is below the threshold of perception (1mA) as well as below the threshold for risk of microshock.

pg. 192
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Pancreatic somatostatin producing cells in the Islets of Langerhans are:

a. alpha cells
b. beta cells
c. gamma cells
d. delta cells

d (delta cells

The Islets of Langerhans are comprised of four cell types: alpha cells producing glucagon, beta cells producing insulin, delta cells producing somatostatin and PP cells producing pancreatic polypeptide.

pg. 789
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Pancreas.” URL: http://en.wikipedia.org/wiki/pancreas)

Hormones released by the neurohypophysis are (two)?
oxytocin, arginine vasopressin

The neurohypophysis is another term for the posterior pituitary gland. The hormones of the neurohypophysis, oxytocin and arginine vasopressin (vasopressin, ADH), are synthesized in the hypothalamus and stored in the posterior pituitary. Stimulus for the release of arginine vasopressin arises from osmoreceptors in the hypothalamus that sense an increase in plasma osmolality.

pp. 843, 846-847
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The most consistent clinical manifestation of aspiration pneumonitis is:
arterial hypoxemia

Inhaled gastric fluid is rapidly distributed throughout the lungs, leading to destruction of surfactant-producing cells, damage to the pulmonary capillary endothelium and resultant atelectasis and pulmonary edema. Arterial hypoxemia is the most consistent clinical finding associated with aspiration pneumonitis. Tachypnea, bronchospasm and pulmonary vasoconstriction with secondary pulmonary hypertension may also be present.

pg. 640
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

As compared with plasma osmolality, hypertonic crystalloid solutions include:

a. D5 0.45NS
b. LR
c. D50.25NS

a. (D5 0.45NS

Normal plasma osmolality ranges between 280 – 290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOSm /L respectively. D5 0.45NS is hypertonic with a tonicity of 406 – 432 mOsm/L.

pg. 392
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

T or F: the supine position decreases physiologic dead space.
T
(
Dead space is comprised of gases in non-respiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). The sum of the two is known as physiologic dead space. Certain factors affect dead space. The supine position is known to decrease dead space, whereas anticholinergics, ?2-sympathomimetics, advancing age and COPD all increase dead space.

pg. 599
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 363
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

T or F

The incidence of headache with inadvertent dural puncture during epidural anesthesia is decreased with the use of fluid, instead of air, for loss of resistance.

T (

The use of fluid instead of air has been associated with a significant reduction in the incidence of postdural puncture headache (PDPH). Other factors associated with a reduced incidence of PDPH are: increasing age, insertion of the bevel aligned parallel to the long axis of the meninges and the use of smaller needles. There is no evidence that keeping the patient supine reduces the incidence of PDPH.

pg. 926
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A decrease in cholinesterase activity has been associated with:
a. obesity
b. thyrotoxicosis
c. alcoholism
d. burns
d (burns

Burns, liver disease, 3rd trimester of pregnancy, carcinoma, renal failure and collagen diseases as well as certain drug therapy have been associated with a decrease in cholinesterase activity. Increased cholinesterase activity has been associated with obesity, alcoholism, thyrotoxicosis, nephrosis, psoriasis and electro-convulsive therapy.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The rate of seroconversion after exposure of mucous membranes to HIV-infected blood is approximately:

a. 0.3%
b. 0.03%
c. 0.9%
d. 0.09%

d. (0.09%

Percutaneous exposure (needle stick) carries a risk of HIV-seroconversion of approximately 0.3% or about 1:300. Mucous membrane exposure carries a risk of approximately 0.09% or about 1:1100.

pg. 77
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

An 82-year-old female arrives to the OR for open reduction of a left intratrochanteric fracture. Significant past medical history includes hypertension, moderate aortic stenosis and dementia. The most appropriate anesthetic technique for this patient is:

a. Neuraxial
b. TIVA
c. Balanced
d. opioid-based

d. (opioid-based general anesthesia

In patients with mild to moderate aortic stenosis, a primarily opioid-based technique results in minimal cardiac depression, less tachycardia and suppression of the sympathetic response to surgical stimulation. These are all desired effects as HTN and tachycardia may precipitate ischemia in these patients. Spinal or epidural anesthesia as well as a volatile-agent-based anesthesia can cause a fall in afterload with resulting severe hypotension.

pp. 501-502
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

A fresh E-cylinder of oxygen contains how many liters of oxygen?
A fresh E-cylinder of oxygen contains about 660 liters of oxygen and is pressurized to 1900 psi.

pg. 8
Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.)

Local anesthetic solutions that are isobaric with the cerebrospinal fluid include: (Select 2)

a.tetracaine 0.5% in 5% dextrose
b. bupivacaine 0.75% in normal saline
c. procaine 10% in sterile water
d. lidocaine 2% in normal saline
e. bupivacaine 0.3% in sterile water
f. lidocaine 5% in 7.5% dextrose

b, d (
Local anesthetic solutions that are isobaric with the cerebrospinal fluid include: bupivacaine 0.75% in normal saline, lidocaine 2% in saline

Hyperbaric
Tetracaine: 0.5% in 5% dextrose
Bupivacaine: 0.75% in 8.5% dextrose
Lidocaine: 5% in 7.5% dextrose
Procaine: 10% in water

Isobaric
Tetracaine: 0.5% in saline
Bupivacaine: 0.75% in saline
Bupivacaine: 0.5% in saline
Lidocaine: 2% in saline

Hyporbaric
Tetracaine: 0.2% in water
Bupivacaine: 0.3% in in water
Lidocaine: 0.5% in in water

pp. 916-917
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

In a 6-year-old, the appropriate length of an endotracheal tube from distal tip to incisors is:
15 – 16.5 cm

Several formulas exist to estimate the length of ETT insertion in patients aged 2 to 12 years. One of the most frequently used is:

Age/2 +12

pp. 1201-1202
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

MAC-BAR is the:
partial pressure of an anesthetic at which autonomic blockade occurs

(MAC-BAR is the minimum alveolar concentration that blocks autonomic reflexes. MAC-BAR is considerably greater than MAC, particularly in the absence of opioids. It has been estimated that MAC-BAR is approximately 50% above standard MAC.

pg. 458
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

The speed in an inhalation induction is slowed by right-to-left shunting. The change in the rate of induction is LEAST pronounced when using:
isoflurane

(With right-to-left shunting there is slowing of an inhalation induction. This effect is less pronounced with agents with high blood/gas solubilities.

pg. 455
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A decrease in cholinesterase activity has been associated with:
a. obesity
b. thyrotoxicosis
c. alcoholism
d. burns
d. (burns

Burns, liver disease, 3rd trimester of pregnancy, carcinoma, renal failure and collagen diseases as well as certain drug therapy have been associated with a decrease in cholinesterase activity. Increased cholinesterase activity has been associated with obesity, alcoholism, thyrotoxicosis, nephrosis, psoriasis and electro-convulsive therapy.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

After a CABG, a 65-year-old man is hypotensive upon weaning from cardiopulmonary bypass. The surgeon is considering insertion of an intraaortic balloon pump for counterpulsation. Which of the following represents the MOST significant contraindication to placement of an intraaortic balloon pump?

a. Aneurysm of left ventricle
b. Aortic atheroma
c. Aortic regurgitation
d. Aortic stenosis

c. (AR

Intraaortic balloon counterpulsation has been used for many years for patients with left ventricular failure. Indications for its use have grown in recent years. Still, it is most commonly used for patients in cardiogenic shock, post-myocardial infarction, severe myocarditis, cardiomyopathy, unstable angina refractory to medications, high grade left main coronary artery disease, failure to wean adequately from cardiopulmonary bypass, low cardiac output syndrome and as a short-term bridge to heart transplant. There are relatively few contraindications, including severe aortic regurgitation (AR) as the balloon inflates during diastole and would worsen AR and not improve coronary flow during diastole. Aortic dissection (difficult to place balloon in true lumen of aorta) and severe aortoiliac occlusive disease or peripheral vascular disease (high risk of limb ischemia) are also contraindications.)

?A 60-year-old man is undergoing a Type A aortic dissection repair under deep hypothermic circulatory arrest. His current temperature is 24°C and his uncorrected ABG shows pH 7.40, PaCO2 40 mmHg and PaO2 250 mmHg. Which of the following changes would you MOST expect If you were to adjust his ABG to his core body temperature of 24°C?

a. PaCO2 increased, PaO2 increased
b. PaCO2 decreased, PaO2 decreased
c. PaCO2 increased, PaO2 decreased
d. PaCO2 decreased, PaO2 increased

b. (PaCO2 decreased, PaO2 decreased

As temperature of blood decreases, the solubility of gases increases such that the partial pressure of CO2 and O2 decrease. Thus, a respiratory alkalosis develops as temperature decreases. The ABG appears normal at the temperature at which it is measured (37 °C) on the ABG machine; however, when corrected the patient’s core temperature of 24°C he will have a respiratory alkalosis with PaCO2 and PaO2 that are decreased compared to the normal.)

?Actuation of the oxygen flush valve delivers 100% oxygen at a rate of:

a. 10 – 20 L/min
b. 20 – 30 L/min
c. 35 – 75 L/min
d. 80 – 100 L/min

c. (35 – 75 L/min

The oxygen flush valve delivers 100% oxygen at a rate of 35 – 75 L/min with a pressure of 40 – 60 psi.

pg. 64
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The incidence of headache with inadvertent dural puncture during epidural anesthesia is decreased:

A. with decreasing age
B. By keeping the patient supine for more than 12 hours following puncture
C. with the use of fluid, instead of air, for loss of resistance
D. by inserting the needle with the bevel aligned perpendicular to the long axis

C. (with the use of fluid, instead of air, for loss of resistance

The use of fluid instead of air has been associated with a significant reduction in the incidence of postdural puncture headache (PDPH). Other factors associated with a reduced incidence of PDPH are: increasing age, insertion of the bevel aligned parallel to the long axis of the meninges and the use of smaller needles. There is no evidence that keeping the patient supine reduces the incidence of PDPH.

pg. 926
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

55 year-old man presents with chest pain, hypotension, and cardiogenic shock. He has sustained an acute inferior wall myocardial infarction complicated by a papillary muscle rupture. Which of the following associated findings is MOST consistent with his clinical presentation?

A. Dilated left atrium
B. Dilated right atrium
C. Mitral regurgitation
D. Tricuspid regurgitation

C. (MR
Rupture of a papillary muscle is a rare but often devastating consequence of acute myocardial infarction. It is rare that the anterolateral papillary muscle will rupture due to a dual blood supply from branches of both the left anterior descending (first diagonal) and the left circumflex (first obtuse marginal) arteries. In the case of an inferior wall myocardial infarction, the posteromedial papillary muscle has higher risk of rupture due to its single blood supply from the right coronary artery. Papillary muscle rupture is associated with severe acute mitral regurgitation and because it happens acutely there is not enough time for the left atrium to dilate in order to compensate for the increased left atrial pressure and mitral regurgitant flow.)

Factors decreasing physiologic dead space include:

A. the supine position
B. anticholinergic agents
C. increasing age
D. emphysema

A. (the supine position

Dead space is comprised of gases in non-respiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). The sum of the two is known as physiologic dead space. Certain factors affect dead space. The supine position is known to decrease dead space, whereas anticholinergics, ?2-sympathomimetics, advancing age and COPD all increase dead space.

pg. 599
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 363
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Which of the following is the LARGEST branch of the lumbar plexus?

A. Femoral nerve
B. Lateral femoral cutaneous
C. Sciatic nerve
D. Obturator nerve

A. (femoral nerve is the largest branch of the lumbar plexus and arises from the posterior division of the ventral rami of L2-L4.)

Which of the following is the LARGEST branch of the lumbar plexus?

A. Femoral nerve
B. Lateral femoral cutaneous
C. Sciatic nerve
D. Obturator nerve

A. (femoral nerve is the largest branch of the lumbar plexus and arises from the posterior division of the ventral rami of L2-L4.)

As compared with plasma osmolality, hypertonic crystalloid solutions include:
A. D5W
B. Ringer’s lactate
C. D5 0.25NS
D. D5 0.45 NS
D. (D5 0.45NS

Normal plasma osmolality ranges between 280 – 290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOSm /L respectively. D5 0.45NS is hypertonic with a tonicity of 406 – 432 mOsm/L.

pg. 392
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Which of the following BEST estimates the incidence of epidural spread following a lumbar plexus (psoas) block ?

A. 0.1%
B. 1%
C. 16%
D. 54%

C. (16%
Epidural spread following a lumbar plexus block is not uncommon. The incidence of epidural spread has been reported to range from 1.8%-16%.)

As compared with plasma osmolality, hypertonic crystalloid solutions include:
A. D5W
B. Ringer’s lactate
C. D5 0.25NS
D. D5 0.45 NS
D. (D5 0.45NS

Normal plasma osmolality ranges between 280 – 290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOSm /L respectively. D5 0.45NS is hypertonic with a tonicity of 406 – 432 mOsm/L.

pg. 392
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Selective adrenergic stimulation of the ?2-receptor results in:
A. increased heart rate
B. increased insulin secretion
C. detrusor muscle contraction
D. pupillary constriction
B (increased insulin secretion

?2-receptor stimulation results in: increased insulin secretion, bronchodilation, increased salivary gland secretion, decreased upper GI motility, gluconeogenesis, pupillary dilation and detrusor muscle relaxation. Increased heart rate is a result of ?1-receptor stimulation. Pupillary constriction (miosis) is the result of parasympathetic stimulation.

pg. 187
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Which of the following is LEAST likely a potential complication of lumbar plexus block?

A. Intrathecal or epidural spread of local anesthetics
B. Foot drop 3 days after catheter removal
C. Local anesthetic toxicity due to intravascular injection of local anesthetic
D. Retroperitoneal hematoma in the setting of anticoagulation

B (Foot drop 3 days after catheter removal

Injury to the sciatic nerve would be a very unlikely complication of psoas blockade. With variable incidence, the other complications listed have been well documented.)

Pathophysiologic changes associated with hypercortisolism include: (Select 2)
A. hyperkalemia
B. plasma volume depletion
C. metabolic alkalosis
D. hypoglycemia
E. hypotension
F. osteoporosis
G. hyponatremia
C, F (metabolic alkalosis, osteoporosis

The clinical picture of hypercortisolism includes central obesity, hypertension, glucose intolerance, weakness, bruising and osteoporosis. Mineralocorticoid effects include fluid retention and hypokalemic alkalosis.

pg. 865
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

You are in the maintenance phase of a 6-hour anesthetic for craniotomy for the resection of a craniopharyngioma. Urine output abruptly increases to over 1 liter/hour. What is the most appropriate next step in this patient’s management?

A. Maintain euvolemia and watch the base deficit
B. Maintain euvolemia and check serial serum sodium levels
C. Reduce fluid administration to reduce urine output
D. Target hypervolemia by keeping ahead of urine output

B (Maintain euvolemia and check serial serum sodium levels

In this scenario, the anesthesiologist must be concerned about central diabetes insipidus. Euvolemia must be maintained and serum sodium followed (generally every 30-60 min) to look for rising sodium levels.)

The most consistent clinical manifestation of aspiration pneumonitis is:
A. bronchospasm
B. arterial hypoxemia
C. pulmonary vasoconstriction
D. tachypnea
B (arterial hypoxemia

Inhaled gastric fluid is rapidly distributed throughout the lungs, leading to destruction of surfactant-producing cells, damage to the pulmonary capillary endothelium and resultant atelectasis and pulmonary edema. Arterial hypoxemia is the most consistent clinical finding associated with aspiration pneumonitis. Tachypnea, bronchospasm and pulmonary vasoconstriction with secondary pulmonary hypertension may also be present.

pg. 640
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

A patient with a cerebral tumor and seizure disorder is being treated with phenobarbital for seizure prophylaxis. Which of the following is the MOST likely anesthetic implication of chronic phenobarbital?

A. Etomidate is contraindicated
B. Propofol is contraindicated
C. Slower metabolism of hepatically metabolized drugs
D. Rapid metabolism of hepatically metabolized drugs

D (Rapid metabolism of hepatically metabolized drugs
Phenobarbital, primidone (which is converted to phenobarbital), phenytoin, and carbamazepine are potent hepatic enzyme inducers. The most noticeable effect is the short duration of clinical effect with the aminosteroid neuromuscular blocking agents (i.e., vecuronium, rocuronium)

A full-term, 4.2 kg neonate is scheduled for a thoracotomy for resection of congenital lobar emphysema. The infant’s starting hematocrit is 48%. Estimated allowable blood loss to maintain a hematocrit at or above 38% is:

numerical answer

70 – 110 mL

The full-term neonate has approximately 85 ml/kg total blood volume. Therefore:
4.2 kg x 85 ml/kg = 357 ml (blood volume)
MABL = Blood Volume x (HCT(starting) – HCT(final)) / HCT(average)
357 ml x (48 – 38) / 43 = 83 mL

Please note that multiple formulas exist for the calculation of allowable blood loss, which may yield varying results.

pp. 1165, 1171
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A 55-year-old man is admitted with progressively worsening headache. Non-contrast head CT suggests cerebral venous sinus thrombosis and the diagnosis is confirmed by CT venography. He is treated with intravenous heparin but becomes more somnolent. Which of the following is the MOST appropriate management at this time?

A. Add argatroban (direct thrombin inhibitor)
B. Repeat head CT and send for endovascular therapy
C. Add a glycoprotein IIb/IIIa inhibitor
D. Increase heparin infusion to target a higher PTT

B (
This patient has progressive neurologic decline despite therapeutic anticoagulation. Venous infarctions, which can frequently become hemorrhagic, are common. Repeating the head CT to rule out intra-cerebral hemorrhage (most commonly from venous infarction) and/or large ischemic infarction is the most appropriate immediate step. There is no high level evidence to guide subsequent therapeutic decisions. Most neurointensivists and neurointerventionalists would opt for endovascular therapy (catheter directed thrombolysis and/or mechanical clot disruption) in this setting.)

Hormones released by the neurohypophysis include: (Select 2)
A. thryotropin
B. growth hormone
C. arginine vasopressin
D. adrenocorticotropic hormone
E. follicle stimulating hormone
F. oxytocin
G. prolactin
H. luteinizing hormone
C, F (oxytocin, arginine vasopressin

The neurohypophysis is another term for the posterior pituitary gland. The hormones of the neurohypophysis, oxytocin and arginine vasopressin (vasopressin, ADH), are synthesized in the hypothalamus and stored in the posterior pituitary. Stimulus for the release of arginine vasopressin arises from osmoreceptors in the hypothalamus that sense an increase in plasma osmolality.

pp. 843, 846-847
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

During a craniotomy, a patient develops intraoperative diabetes insipidus. Which of the following is the MOST likely cause of central diabetes insipidus and what is the MOST appropriate treatment?

A. Medullary compression; vasopressin
B. Pontine injury; vasopressin
C. Hypertonic saline; diuresis
D. Hypophyseal injury; vasopressin

D (Hypophyseal injury; vasopressin. Central diabetes insipidus is due to injury to the neurohypophysis and subsequent reduction in vasopressin secretion. Clinically, patients have high volume dilute urine with a rising serum sodium. Patients with chronic untreated diabetes insipidus must drink large volumes of liquid to compensate. Treatment is generally with nasal ddAVP. Acute diabetes insipidus in the operating room or ICU is usually initially treated with intravenous vasopressin or ddAVP.)

Pancreatic somatostatin producing cells in the Islets of Langerhans are:
A. alpha cells
B. beta cells
C. gamma cells
D. delta cells
D. (delta cells

The Islets of Langerhans are comprised of four cell types: alpha cells producing glucagon, beta cells producing insulin, delta cells producing somatostatin and PP cells producing pancreatic polypeptide.

pg. 789
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Pancreas.” URL: http://en.wikipedia.org/wiki/pancreas)

hours after total thyroidectomy, a patient is found to be obtunded and cyanotic. The patient’s SpO2 is 70%. What is the MOST likely etiology of this clinical deterioration?

A. Acute hypocalcemia
B. Bilateral recurrent laryngeal nerve injury
C. Postoperative hematoma
D. Tracheomalacia

C (Postoperative hematoma compressive hematoma is the most common cause of airway obstruction 24 hours after thyroidectomy. Acute hypocalcemia typically manifests 24 to 48 hours postoperatively with laryngeal stridor and airway obstruction. Prior to stridor, the patient may complain of a tingling sensation in the lips and fingers. If recurrent laryngeal nerve damage occurs, it is more likely to be unilateral and present with hoarseness. If both recurrent laryngeal nerves were severed, severe airway obstruction occurs immediately. Hematoma is the most common cause of airway obstruction within 24 hours of a thyroidectomy. The definitive treatment of a hematoma is opening the surgical incision to evacuate the hematoma and relieve the airway obstruction.)

Pancreatic somatostatin producing cells in the Islets of Langerhans are:
A. alpha cells
B. beta cells
C. gamma cells
D. delta cells
D. (delta cells

The Islets of Langerhans are comprised of four cell types: alpha cells producing glucagon, beta cells producing insulin, delta cells producing somatostatin and PP cells producing pancreatic polypeptide.

pg. 789
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Pancreas.” URL: http://en.wikipedia.org/wiki/pancreas)

10 hours after total thyroidectomy, a patient is found to be obtunded and cyanotic. The patient’s SpO2 is 70%. What is the MOST likely etiology of this clinical deterioration?

A. Acute hypocalcemia
B. Bilateral recurrent laryngeal nerve injury
C. Postoperative hematoma
D. Tracheomalacia

C (Postoperative hematoma compressive hematoma is the most common cause of airway obstruction 24 hours after thyroidectomy. Acute hypocalcemia typically manifests 24 to 48 hours postoperatively with laryngeal stridor and airway obstruction. Prior to stridor, the patient may complain of a tingling sensation in the lips and fingers. If recurrent laryngeal nerve damage occurs, it is more likely to be unilateral and present with hoarseness. If both recurrent laryngeal nerves were severed, severe airway obstruction occurs immediately. Hematoma is the most common cause of airway obstruction within 24 hours of a thyroidectomy. The definitive treatment of a hematoma is opening the surgical incision to evacuate the hematoma and relieve the airway obstruction.)

Congenital heart diseases associate with right-to-left shunting include: (Select 3)
A. tricuspid atresia
B. hypoplastic left heart syndrome
C. aortopulmonary window
D. patent ductus arteriosus
E. tetralogy of Fallot
F. subvalvular aortic stenosis
G. ventricular septal defects
H. atrial septal defect
A, b, E (tricuspid atresia, hypoplastic left heart syndrome, tetralogy of Fallot

Right-to-left shunting (cyanotic) heart disease is associated with: Tetrology of Fallot, pulmonary atresia, triscupid atresia, transposition of the great vessels, truncus arteriosus, single ventricle, double-outlet ventricle, total anomalous pulmonary venous return and hypoplastic left heart.
With tricuspid atresia, blood can flow out of the right atrium only via a patent foramen ovale (PFO). A PDA or VSD is necessary for the blood to flow from the left ventricle to the pulmonary circulation.

pg. 1181
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Causes of normal-anion-gap acidosis include:
A. renal failure
B. starvation
C. diarrhea
D. lactic acidosis
C (diarrhea

Normal-anion-gap acidosis is also called hyperchloremic acidosis and results from the selective loss of bicarbonate anion or the introduction of large amounts of chloride anion. Common causes include: diarrhea, hypoaldosteronism, renal tubular acidosis and increased intake of chloride containing acids sometimes found in hyperalimentation.

pg. 461
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Which of the following is the narrowest portion of the pediatric airway?

A. Cricoid ring
B. Glottic opening
C. Nasal opening
D. Posterior pharynx

B (glottis opening
This is a challenging question that few people answer correctly! Most anesthesiologists think that the narrowest part of the pediatric airways is the cricoid ring, which is no longer thought to be true. Classically, the cricoid ring has been described as the narrowest part of the pediatric airway. Recent studies by Litman and Dalal measured airway dimensions in anesthetized children. They have shown that the glottic opening is the narrowest part of the pediatric airway, like the adult. Nevertheless, the cricoid ring is fixed, non-distensible, and prone to edema formation with a large endotracheal tube. A small change in airway diameter from edema contributes significantly to airway resistance in a pediatric (small) airway.)

Causes of normal-anion-gap acidosis include:
A. renal failure
B. starvation
C. diarrhea
D. lactic acidosis
C (diarrhea

Normal-anion-gap acidosis is also called hyperchloremic acidosis and results from the selective loss of bicarbonate anion or the introduction of large amounts of chloride anion. Common causes include: diarrhea, hypoaldosteronism, renal tubular acidosis and increased intake of chloride containing acids sometimes found in hyperalimentation.

pg. 461
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Carbonic anhydrase inhibitors are used in the treatment of:
A. acute glaucoma
B. renal tubular acidosis
C. diarrhea induced acidosis
D. acidosis resulting from hypoventilation
A (acute glaucoma

Carbonic anhydrase inhibitors decrease the ability of the kidneys to reabsorb bicarbonate, resulting a hyperchloremic acidosis. As a result, carbonic anhydrase inhibitors would be avoided in patients with acidosis, especially a normal-anionic-gap acidosis. Because bicarbonate is filtered by the ciliary process in the formation of aqueous humor, carbonic anhydrase inhibitors reduce the formation of aqueous humor and can be used to decrease intraocular pressure.

pg. 1211
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

What is the MOST likely position of the larynx in a normal full term infant?

A. C2-C3
B. C3-C4
C. C4-C5
D. C5-C6

B ( C3-C4
position of the larynx in the full term infant is C3-C4. The position in the preterm neonate is even more cephalad at C3. The position in the adult is C4-C5.)

Hypoxemia during one-lung anesthesia is most effectively treated by:
A. PEEP applied to the ventilated lung
B. continuous oxygen insufflation to the collapsed lung
C. changing tidal volume and rate
D. periodic inflation of the collapsed lung
D (periodic inflation of the collapsed lung

The application of PEEP to the ventilated lung, changes in the ventilatory parameters and oxygen insufflation to the collapsed lung may offer marginal improvement in oxygenation. However, periodic inflation of the collapsed lung with oxygen, early ligation of the ipsilateral pulmonary artery and CPAP to the collapsed lung offer consistently effective improvement in oxygenation.

pp. 678-679
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

You are caring for a neonate with congenital diaphragmatic hernia and pulmonary hypertension. She is intubated and receiving inhaled nitric oxide (iNO). iNO reduces pulmonary vascular resistance by activating protein kinase G via cyclic GMP. This reduces which of the following intracellular ions?

A. Calcium
B. Magnesium
C. Potassium
D. Sodium

A ( calcium
iNO activates guanylate cyclase. This in turn converts GTP to cGMP. cGMP activates protein kinase G which decreases intracellular calcium by decreasing Ca++ entry into the muscle cell and by decreasing the release of Ca++ from the sarcoplasmic reticulum. The reduced concentration of calcium decreases Ca++ activated phosphorylation of myosin.)

Hypoxemia during one-lung anesthesia is most effectively treated by:
A. PEEP applied to the ventilated lung
B. continuous oxygen insufflation to the collapsed lung
C. changing tidal volume and rate
D. periodic inflation of the collapsed lung
D (periodic inflation of the collapsed lung

The application of PEEP to the ventilated lung, changes in the ventilatory parameters and oxygen insufflation to the collapsed lung may offer marginal improvement in oxygenation. However, periodic inflation of the collapsed lung with oxygen, early ligation of the ipsilateral pulmonary artery and CPAP to the collapsed lung offer consistently effective improvement in oxygenation.

pp. 678-679
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

You are caring for a neonate with congenital diaphragmatic hernia and pulmonary hypertension. She is intubated and receiving inhaled nitric oxide (iNO). iNO reduces pulmonary vascular resistance by activating protein kinase G via cyclic GMP. This reduces which of the following intracellular ions?

A. Calcium
B. Magnesium
C. Potassium
D. Sodium

A ( calcium
iNO activates guanylate cyclase. This in turn converts GTP to cGMP. cGMP activates protein kinase G which decreases intracellular calcium by decreasing Ca++ entry into the muscle cell and by decreasing the release of Ca++ from the sarcoplasmic reticulum. The reduced concentration of calcium decreases Ca++ activated phosphorylation of myosin.)

Branches of the femoral nerve anesthetized during an ankle block include the:
A. deep peroneal nerve
B. sural nerve
C. saphenous nerve
D. posterior tibial nerve
C (saphenous nerve

The saphenous nerve is the only branch of the femoral nerve innervating the foot. The four remaining nerves innervating the foot, the deep peroneal nerve, the posterior tibial nerve, the sural nerve and the superficial peroneal nerve, are all branches of the sciatic nerve.

pp. 1123-1124
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Branches of the femoral nerve anesthetized during an ankle block include the:
A. deep peroneal nerve
B. sural nerve
C. saphenous nerve
D. posterior tibial nerve
C (saphenous nerve

The saphenous nerve is the only branch of the femoral nerve innervating the foot. The four remaining nerves innervating the foot, the deep peroneal nerve, the posterior tibial nerve, the sural nerve and the superficial peroneal nerve, are all branches of the sciatic nerve.

pp. 1123-1124
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Pulmonary complications from advanced hepatic disease with cirrhosis include:
A. an obstructive ventilatory defect
B. respiratory acidosis
C. increased intrapulmonary shunting
D. increased functional residual capacity
C (increased intrapulmonary shunting

Pulmonary manifestations associated with cirrhosis include: increased intrapulmonary shunting, decreased FRC, pleural effusions, restrictive ventilatory defect and respiratory alkalosis.

pg. 774
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

In which of the following cardiac conditions would a patient presenting in shock be LEAST likely to benefit from intra-aortic balloon pump (IABP) placement?

A. A ruptured papillary muscle from a recent myocardial infarction
B. A low ejection fraction of 10% secondary to ischemic cardiomyopathy
C. Aortic valve endocarditis resulting in severe aortic insufficiency
D. Severe aortic stenosis and congestive heart failure

C ( Aortic valve endocarditis resulting in severe aortic insufficiency

A patient with severe aortic insufficiency should not have an IABP placed since it would worsen the amount of blood regurgitated into the left ventricle and likely lead to left ventricular distension. Since the IABP improves coronary perfusion pressure and unloads the left ventricle, the other conditions would benefit from IABP placement.)

Assuming no other clinical risk factors, which of the following conditions should MOST be evaluated and treated prior to a 65-year-old patient undergoing elective hip replacement?

A. Moderate mitral regurgitation resulting from a myocardial infarction 6 months ago
B. New asymptomatic atrial fibrillation with a heart rate of 120
C. NYHA class III heart failure symptoms that have been present for the last year
D. An uncomplicated myocardial infarction 2 months ago

B (New asymptomatic atrial fibrillation with a heart rate of 120

New onset atrial fibrillation with an uncontrolled heart rate is an active cardiac condition (significant arrhythmia) that should delay elective surgery until further workup is performed and the ventricular rate better controlled. Mild or moderate valvular disease, old myocardial infarctions (>30 days out), and controlled heart failure should be appropriately managed, but do not require delay of surgery for further work-up.)

Which of the following is MOST likely to INCREASE a patient’s mixed venous oxygen saturation?

A Administering a beta-blocker
B Inducing general anesthesia with a muscle relaxant
C Reducing the FiO2 so that the patient’s SpO2 decreases 100% to 95%
D Removing 2 units of blood during acute normovolemic hemodilution (ANH)

B (Inducing general anesthesia with a muscle relaxant

SvO2 = SaO2 — [(VO2)/(Hbg x 1.36 x Q)], where SvO2 is mixed venous oxygen saturation, SaO2 is arterial oxygen saturation, VO2 is oxygen consumption, Hgb is hemoglobin, and Q is cardiac output. General anesthesia with a muscle relaxant would be expected to decrease VO2, thereby increasing SvO2. (Granted, this assumes the patient does not arrest during induction.) Administering beta blockers would be expected to decrease cardiac output and therefore lower SvO2. Lowering a patient’s hemoglobin with ANH would be expected to decrease SvO2, as would decreasing their SpO2.)

Which of the following is MOST likely to INCREASE a patient’s mixed venous oxygen saturation?

A Administering a beta-blocker
B Inducing general anesthesia with a muscle relaxant
C Reducing the FiO2 so that the patient’s SpO2 decreases 100% to 95%
D Removing 2 units of blood during acute normovolemic hemodilution (ANH)

B (Inducing general anesthesia with a muscle relaxant

SvO2 = SaO2 — [(VO2)/(Hbg x 1.36 x Q)], where SvO2 is mixed venous oxygen saturation, SaO2 is arterial oxygen saturation, VO2 is oxygen consumption, Hgb is hemoglobin, and Q is cardiac output. General anesthesia with a muscle relaxant would be expected to decrease VO2, thereby increasing SvO2. (Granted, this assumes the patient does not arrest during induction.) Administering beta blockers would be expected to decrease cardiac output and therefore lower SvO2. Lowering a patient’s hemoglobin with ANH would be expected to decrease SvO2, as would decreasing their SpO2.)

In critically ill patients that require mechanical ventilation in the ICU, early tracheostomy after 4 days of mechanical ventilation compared to late tracheostomy after 10 days of mechanical ventilation is MOST associated with which of the following?

A. Lower mortality
B. Higher mortality
C. No difference in mortality
D. No difference in mortality but more ventilator days

C
(No difference in mortality
A previously utilized rule of thumb suggested that after 1 week of intubation, if extubation does not appear likely within a week, place the tracheostomy (because the clinical course at one week seems to be predictive of final outcome [1]). The TracMan trial randomized 909 patients to early tracheostomy (within 4 days) or late tracheostomy (after 10 days if still indicated) and found no difference in the primary outcome (30-day mortality) or other secondary outcomes [2].)

50 year-old woman is undergoing a mitral valve repair. She has been taking garlic prior to surgery as an herbal supplement to reduce blood pressure and improve her overall health. She has significant mediastinal blood loss after separation from bypass. Which of the following effects can MOST be attributed to garlic?

A. Increased fibrinolysis
B. Increased consumption of coagulation factors
C. Inhibition of the prothrombinase complex
D. Inhibition of platelet aggregation

C (Inhibition of the prothrombinase complex
The use of herbals has increased but herbal medicines are not regulated by the FDA. This makes it difficult to know what exact substances patients are ingesting and there are a multitude of side effects that can result from herbals. Garlic is used by some to treat hypertension and to reduce lipids, but the organosulfur compound irreversibly inhibits platelet aggregation. The effects of garlic require 7 days of discontinuation prior to surgery to reduce postoperative bleeding. Ginkgo causes milder bleeding than garlic and its effects are attributed to inhibition of platelet activating factor. Ginkgo should be stopped 36 hours prior to surgery. Ginseng can inhibit platelet aggregation as well and should be stopped 7 days prior to surgery.)

An 80-year-old man has been in the ICU for 12 hours following an aortic valve replacement and has been on nitroprusside for control of hypertension. Which of the following is MOST responsible for the toxicity caused by nitroprusside?

A. Accumulation of thiosulfate and cyanide
B. Formation of cyanmethemoglobin
C. Inactivation of cytochrome oxidase
D. Production of thiocyanate

C (Inactivation of cytochrome oxidase

After nitroprusside enters red blood cells, electron transfer occurs and the compound dissolves into 5 cyanide ions and a nitroso group. The cyanide ions can undergo 3 different reactions: forming cyanmethemoglobin; binding with thiosulfate; or interacting directly with cytochrome oxidase. The inactivation of cytochrome oxidase is responsible for the uncoupling of mitochondrial oxidative phosphorylation and shift from aerobic to anaerobic metabolism. This causes production of lactic acid and the symptoms of cyanide toxicity including metabolic acidosis, arrhythmias, tachycardia, hypertension, neurologic dysfunction (confusion) and increased mixed venous oxygen content. One other key sign of cyanide toxicity is tachyphylaxis or the resistance to the effects of nitroprusside to reduce blood pressure.)

A 79-year-old patient suffers an ascending aortic dissection and presents with acute pericardial tamponade physiology. The patient demonstrates pulsus paradoxus on his arterial waveform tracing. What physiologic event MOST accounts for this pulsus paradoxus?

a. Increased systemic vascular resistance
b. Reduced diastolic filling
c. Shift of interventricular septum
d. Tachycardia

c (Shift of interventricular septum
In acute tamponade physiology, the pericardial sac does not have time to stretch to accept increased fluid thus the effusion reaches a critical volume early and causes reduction in filling of the cardiac chambers with increased intracavitary pressures. This drastically reduces preload and cardiac output. Venous return is normally biphasic but becomes confined to systole in severe tamponade and ceases during diastole when intrapericardial pressures are maximal. During inspiration there is increased right-sided filling, which causes the interventricular septum to shift toward the left side of the heart. This causes reduction in blood pressure during inspiration and the septum shifts back during expiration and thus blood pressure goes up during the expiratory phase.)

Which of the following MOST accurately reflects changes in lung volumes during pregnancy?

a. Decrease in functional residual capacity (FRC)
b. Decrease in vital capacity (VC)
c. Increased expiratory reserve volume (ERV)
d. Increased residual volume (RV)

a
(Decrease in functional residual capacity (FRC)

During pregnancy, enlargement of the uterus forces the diaphragm cephalad, resulting in decreased residual volume and expiratory reserve volume. The decrease in RV and ERV create an approximately 20% decrease in FRC at term. Vital capacity does not change during pregnancy. Total lung capacity may decrease by as much as 5%.)

During mediastinoscopy the risk of air embolization is greatest:
a. when the patient is supine
b. during spontaneous ventilation
c. immediately after closure of the incision
d. in the postoperative period
b
(during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

In planning for the intubation of the full-term parturient patient who requires general anesthesia, which of the following is MOST correct?

a. Enlarged tracheal caliber due to changes in cartilage composition at term may necessitate selected of a larger ETT
b. Capillary engorgement of mucosal lining of the upper airway, including vocal cords and arytenoids, leads to tissue edema and may necessitate selection of smaller ETT
c. Pre-oxygenation for a full one minute should precede induction of general anesthesia
d. Anesthetic requirements may be greater

b
(Capillary engorgement of mucosal lining of the upper airway, including vocal cords and arytenoids, leads to tissue edema and may necessitate selection of smaller ETT

There are many changes of the upper airway during pregnancy. Capillary engorgement in the mucosal lining of the upper respiratory tract leads to tissue edema in normal full-term pregnant patient resulting in smaller caliber upper airway. Edema at the level of the arytenoids and vocal cords may necessitate selection of a smaller ETT (6.0 or 6.5mm). Additionally, increased tissue friability can be expected and extra care should be taken during any instrumentation of the mouth or upper airway, such as suctioning, placement of an oral airway or direct laryngoscopy. Active pushing leading to venous engorgement can exacerbate tissue edema along with the above-described changes. Given the decrease in functional residual capacity and increased oxygen consumption during pregnancy, pre-oxygenation for at least three minutes is recommended prior to induction of general anesthesia. Anesthetic requirements are decreased in pregnancy and thus MAC is decreased.)

During placement of a lumbar epidural using a midline approach, the needle passes through the: (Select 3)
a. interspinous ligament
b. anterior longitudinal ligament
c. intervertebral disk
d. supraspinous ligament
e. ligamentum flavum
f. facet joint
a, d, e
(supraspinous ligament, interspinous ligament, ligamentum flavum

Passing anteriorly from the skin to the epidural space are the following structures: skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum.

pp. 941-942
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following can be MOST expected from mask ventilation of the full-term parturient?

a. Easier due to increased neck range of motion
b. Easier due to increased chest wall compliance
c. More difficult secondary to upper airway edema
d. More difficult secondary to left uterine displacement positioning

c
(More difficult secondary to upper airway edema

Anesthesiologists need to account for the changes of the upper airway during pregnancy and plan accordingly. Capillary engorgement in the mucosal lining of the upper respiratory tract leads to tissue edema in a normal full-term pregnant patient resulting in smaller caliber upper airway. Increased tissue friability can be expected and extra care should be taken during any instrumentation of the mouth or upper airway, such as suctioning, placement of an oral airway or direct laryngoscopy. Active pushing leading to venous engorgement can exacerbate tissue edema along with the above-described changes. Weight gain during pregnancy can also make mask ventilation more challenging.)

A patient with a creatinine of 1.6 mg/dL is receiving IV magnesium for preeclampsia. The patient develops a widened QRS complex. After cessation of magnesium administration, which of the following is the MOST appropriate therapy?

a. Calcium chloride
b. Glucagon
c. Kayexalate
d. Propranolol

a (Calcium chloride
This preeclamptic patient, who was receiving magnesium for seizure prophylaxis, presumably developed worsening renal function as a complication of her preeclampsia. Since magnesium is cleared renally, her serum magnesium levels rapidly increased, leading to magnesium toxicity. Normal serum levels of magnesium are 1.2-2.0 mEq/L and therapeutic range is 4-8 mEq/L. ECG changes including prolonged PR intervals and widened QRS complexes can develop at serum levels of 5-10 mEq/L, with loss of deep tendon reflexes being another telltale sign of magnesium toxicity. Calcium chloride (500mg) or calcium gluconate (1g) are the antidotes for magnesium toxicity, via competitive inhibition of divalent cations. Miller RD, Pardo M. Basics of Anesthesia, 6th ed. Philadelphia, PA: Elsevier Saunders; 2011.)

Which of the following is NOT an initial consideration for a reversible cause of cardiac arrest according to the 2010 ACLS guidelines?

a. Hypoglycemia
b. Hypokalemia
c. Hypothermia
d. Hypovolemia

a (Hypoglycemia
ACLS recommends consideration of the “Hs and Ts” as possible reversible causes of cardiac arrest. The “Hs” include hypovolemia, hypo/hyperkalemia, hydrogen ion (acidosis), hypothermia, and hypoxia.)

You are called to intubate a patient in the emergency department who was found pulseless in front of the hospital. Which of the following is MOST correct regarding the use of cricoid pressure during endotracheal intubation in this scenario?

a. Cricoid pressure should be used only if the victim is unconscious
b. The routine use of cricoid pressure is not recommended
c. Cricoid pressure should be used if the patient has food contents in mouth at the time of intubation
d. Cricoid pressure should only be applied by trained personnel

b (The routine use of cricoid pressure is not recommended
Per the 2010 ACLS Guidelines: “…Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation. Seven randomized studies showed that cricoid pressure can delay or prevent the placement of an advanced airway and that some aspiration can still occur despite application of cricoid pressure. In addition, it is difficult to appropriately train rescuers in use of the maneuver. Therefore, the routine use of cricoid pressure in cardiac arrest is not recommended.”)

Electrocardiographic changes seen with hypokalemia include:
a. peaked T waves
b. increasingly prominent U waves
c. shortened PR interval with P wave inversion
d. decreased QRS amplitude
b (increasingly prominent U waves

Electrocardiographic changes seen with hypokalemia include:

T wave flattening/inversion
ST segment depression
increased P wave amplitude
prolongation of the P-R interval
increasingly prominent U waves
pg. 378, 1712
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

pg. 1125
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following has been MOST extensively compared to ScvO2 as an optimal therapeutic end point in the management of sepsis?

a. Corrected flow time (FTc)
b. Lactate clearance
c. Nitrogen balance
d. Pulse pressure variation (PPV)

b (Lactate clearance

Lactate clearance has been suggested by some investigators to have several advantages over ScvO2 as a therapeutic end point in the treatment of sepsis. These include decreased cost, lack of need for an invasive catheter, and increased sensitivity for malperfusion. Because of this, several studies have compared lactate clearance to ScvO2 in the setting of sepsis. The largest, the LACTATES trial, included 300 patients and concluded that “management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality.” Based on this, the 2012 Surviving Sepsis guidelines state “We recommend the protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L) . . . We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (grade 2C).”)

Question of the Day
A 32-year-old woman with renal failure is administered 5L of 0.9% Normal Saline during a kidney transplant. An ABG reveals a pH of 7.20 with pCO2 38 mmHg and PaO2 103 mmHg. Which of the following laboratory results MOST strongly suggests a hyperchloremic metabolic acidosis?

A. Anion gap of 14 mEq/L
B. Anion gap of 20 mEq/L
C. Strong ion difference of +20
D. Strong ion difference of +50

This is a challenging question that few people answer correctly! Most anesthesiologists do not understand the utility of the strong ion difference in a hyperchloremic metabolic acidosis. Hyperchloremic metabolic acidosis is a “non-gap acidosis” and presents with a normal anion gap. The ion gap is calculated by: Anion Gap = ([Na+] + [K+]) – ([Cl-] + [HCO3-]) The normal range for anion gap is 8 — 12 mEq/L. Causes of elevated anion gap acidosis classically include “MULE-PAK” items (Methanol, Uremia, Lactate, Ethylene Glycol, Paraldehyde, ASA, Ketoacidosis). A patient with a hyperchloremic metabolic acidosis should not have an anion gap greater than 12. The strong ion difference (SID) is estimated by: /n SID = ([Na+] + [K+] + [Ca2+] + [Mg2+]) — ([Cl-] + [lactate-] + [SO42-]) A normal SID value is approximately +40. A patient with a hyperchloremic metabolic acidosis should have a strong ion difference of less than 40.l

Postintubation croup:
a. is secondary to inflammation of subglottic structures
b. is less common when cuffed endotracheal tubes are used
c. occurs most frequently in infants less than 4 months of age
d. is most often seen immediately upon extubation
a (is secondary to inflammation of subglottic structures

Postintubation croup usually occurs at the level of the cricoid, since this is the narrowest part of the pediatric airway. Croup is less common with endotracheal tubes that are uncuffed and small enough to allow a gas leak at 10 – 25 cm H2O. Postintubation croup is associated with early childhood (1 – 4 years). Unlike laryngospasm, postintubation croup is seen some time after extubation, usually within 3 hours.

pp. 463-464
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 1231
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

Which of the following is LEAST consistent with a Phase II block after succinylcholine?

A. Fade with tetanic stimulation
B. Post-tetanic potentiation
C. Train-of-four ratio of 1.0
D. Total dose of succinylcholine >4 mg/kg

C. (Train-of-four ratio of 1.0
Phase II block is typically encountered after a large dose of succinylcholine (i.e., a large single dose, repeated doses, or a continuous infusion) where the total amount is greater than 4 mg/kg. Repeated stimulus of the acetylcholine receptor results in desensitization at the nerve terminal and the myocyte becomes less sensitive to acetylcholine, with prolonged neuromuscular blockade. Thus, with nerve stimulation, a Phase II block will have the features of a non-depolarizing block: Fade with tetanic stimulation; Post-tetanic potentiation; and a Train-of-four ratio of less than 0.4.)

Submit

Closing capacity is defined as:
A. closing volume + expiratory reserve volume
B. functional residual capacity – residual volume
C. closing volume + residual volume
D. residual volume + expiratory reserve volume

C (closing volume + residual volume

Closing capacity is the lung volume at which airways begin to close and is defined as the closing volume + residual volume.

pg. 497
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Dantrolene: (Select 2)
a. depends on an extracellular mechanism to achieve muscle relaxation
b. inhibits calcium ion release from the sarcoplasmic reticulum
c. can also be used in the treatment of thyroid storm
d. therapy should not be repeated after an MH episode has terminated
e. has a half-life of approximately 12 hours
b, c (inhibits calcium ion release from the sarcoplasmic reticulum, can be used in the treatment of thyroid storm

Dantrolene binds with the Ryr1 receptor and inhibits calcium ion release from the sarcoplasmic reticulum. Dantrolene’s effects are intracellular and may result in muscle weakness and ventilatory insufficiency. The half-life of dantrolene is approximately 6 hours. Dantrolene has also been used to treat neuroleptic malignant syndrome and thyroid storm.

pp. 1188, 1190
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 52-year-old man with a parathyroid adenoma presents for surgical resection. Which of the following ECG changes are MOST consistent with hypercalcemia?

a. Peaked P-wave
b. Peaked T-wave
c. Short PR interval
d. Short QT interval

d (Short QT interval
The most common ECG change in hypercalcemia is a short QT interval. Peaked T-waves are most commonly encountered in hyperkalemia. A short PR interval may indicate a preexcitation syndrome via an accessory pathway that leads to early activation of the ventricles, such as Wolff-Parkinson-White syndrome. A large or peaked P-wave (>2.5mm) can be encountered in hypokalemia. A large P-wave can also indicate right atrial enlargement.)

Correct statements concerning the use of antidepressants in pain management include:
a. analgesic effects require a higher dose than that needed for antidepression
b. analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake
c. antidepressants are not effective in neuropathic pain
d. newer SSRIs are more effective analgesics than the older tricyclic antidepressants
b (analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake

Antidepressants demonstrate an analgesic effect at doses lower that those needed for antidepressant effect. Both actions appear secondary to the block of the reuptake of serotonin and norepinephrine. Older tricyclic antidepressants seem more effective analgesics than the newer SSRIs. Antidepressants are most useful in patients with neuropathic pain.

pg. 1055
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following sequence of events MOST commonly occurs in drowning?

a. Breath-holding, laryngospasm, involuntary ventilatory efforts, desaturation, muscular relaxation, inhalation of water, cardiac arrest
b. Breath-holding, involuntary ventilatory efforts, inhalation of water, laryngospasm, desaturation, muscular relaxation, cardiac arrest
c. Involuntary ventilatory efforts, laryngospasm, breath-holding, desaturation, muscular relaxation, inhalation of water, cardiac arrest
d. Breath-holding, laryngospasm, involuntary ventilatory efforts, muscular relaxation, inhalation of water, desaturation, cardiac arrest

a (Breath-holding, laryngospasm, involuntary ventilatory efforts, desaturation, muscular relaxation, inhalation of water, cardiac arrest

Drowning is defined as a primary respiratory impairment from submersion or immersion in a liquid medium. The process of drowning usually entails a voluntary period of breath-holding (for an average of 87 seconds), possible (but not always) swallowing of water, followed by laryngospasm as water becomes entrained into the larynx. Involuntary ventilatory efforts ensue but are ineffective in the setting of laryngospasm. Survivors report this as being the most traumatic component of the drowning process and the total duration of voluntary and involuntary breath holding lasts 1.5-2 minutes. As arterial saturation declines, laryngospasm eventually abates, at which point the subject begins to breathe in water, after which circulatory arrest quickly occurs. The organ most susceptible to injury during drowning is the brain, with brain damage occurring approximately 3 minutes after PaO2 falls below 30 mm Hg. Exceptions to this rule include trained divers and individuals immersed in cold water. Many subjects who drown do so under direct supervision (lifeguards falsely believe that the victims were “fooling around” or attend to other tasks). No individual should ever be allowed under water without making purposeful movements for more than 10 seconds. Treatment: airway management is of paramount importance and should be initiated in water if a) this is safe and b) removal from water would result in any time delay. Once ventilation has been initiated, attend to the cardiovascular system – not all patients will have systole and profound bradycardia is not uncommon. Abdominal thrusts to “remove water” have not been shown to be helpful. The major sources of morbidity and mortality are related to respiratory and CNS compromise. Post-drowning survivors should be admitted to an ICU and CPAP (or PEEP) applied. Anti-epileptics may be initiated in patients with suspected CNS injury. Infection may be an issue in standing water (Pseudomonas) and empiric antibiotic coverage may be indicated in this setting.)

What is the approximate sensitivity and specificity of the ?-D-Glucan Assay for the diagnosis of invasive fungal infection (IFE)?

a. ~ 50% sensitivity, ~ 95% specificity
b. ~ 75% sensitivity, ~ 85% specificity
c. ~ 95% sensitivity, ~ 95% specificity
d. ~ 95% sensitivity, ~ 50% specificity

b ( ~ 75% sensitivity, ~ 85% specificity
Based on a meta-analysis of 16 studies including 2979 patients, the sensitivity and specificity of ?-D-Glucan (BDG) for the detection of invasive fungal infection (IFE) is 76.8% and 85.3%, respectively. It is important to note that while -D-Glucan is a component of the cell wall of most fungi, it is not present in Zygomycetes or Cryptococci thus BDG will miss these agents. Fungi can be classified as one of three types — yeast (Candida and Cryptococcus are the most common infections), mold (Aspergillus and Rhizopus are most common), and dimorphic agents (Histoplasma capsulatum, Coccidioides immitis, and Blastomyces dermatitidis are most common). Candida is a normal component of gastrointestinal flora (and is also present on the skin) whereas other agents, which are ubiquitous in nature, are typically acquired by inhalation. It is therefore extremely difficult to distinguish between colonization and infection, and definitive diagnosis requires either histopathologic evidence or presence of fungus in a normally sterile site (hence the utility of BDG). Complicating the detection of IFE, the liver clears candida from the bloodstream so efficiently that only ~ 50% of patients with disseminated candidiasis will exhibit a positive blood culture. Furthermore, autopsy data suggest that only 15-40% of patients who have invasive candidiasis carry the diagnosis.)

A 60-year-old man with a medically refractory seizure disorder has a generalized tonic clonic seizure complicated by aspiration pneumonia. He improves and his respiratory mechanics are compatible with extubation by ICU day #6. He is awake and alert; however, he has no leak around the endotracheal tube with the cuff deflated. What is the MOST appropriate management?

a. Elective tracheostomy
b. Proceed with extubation
c. Methylprednisolone therapy prior to extubation
d. Extubate over a tube changer, to facilitate re-intubation if necessary

c (Methylprednisolone therapy prior to extubation

While many practitioners would opt for extubation in this scenario, there is high level evidence for the efficacy of methylprednisolone in reducing postextubation laryngeal edema and the incidence of re-intubation.)

Regarding motor innervation of the larynx, which of the following muscles is NOT innervated by the recurrent laryngeal nerve?

a. Cricothyroid muscle
b. Lateral cricoarytenoid muscle
c. Thyroarytenoid muscle
d. Posterior cricoarytenoid muscle

a (Cricothyroid muscle
The cricothyroid muscle is innervated by the external branch of the superior laryngeal nerve. The superior laryngeal nerve is a branch of the vagus nerve. The cricothyroid muscle is the only muscle of the larynx not innervated by the recurrent laryngeal nerve. The cricothyroid muscle is the only tensor muscle of the larynx; thus, it serves to aid phonation by increasing the pitch of the voice. The cricothyroid muscle pulls the anterior aspects of the thyroid and cricoid cartilages together to achieve this. The thyroarytenoid muscle, innervated by the recurrent laryngeal nerve, antagonizes this movement.)

A 2-day-old boy with a lumbar meningomyelocele is scheduled to undergo surgical repair. Which of the following associated anomalies are MOST likely to occur with a meningomyelocele?

a. Cleft palate
b. Chiari malformation
c. Radial anomalies
d. Renal failure

b (Chiari malformation

Infants with meningomyelocele have many associated anomalies. The most common associated anomalies include Chiari malformations. There are 4 types of Chiari malformations. The result of the Chiari malformation is downward displacement of the brainstem, cerebellar tonsils and fourth ventricle. This causes hydrocephalus, which usually requires surgical shunting. Patients can present with apnea and stridor.)

A 67-year-old man with no prior heparin exposure underwent an uneventful aortic valve replacement. Three days after surgery, the patient has an isolated and asymptomatic drop in platelet count > 50%. What is the probability of heparin-induced thrombocytopenia?

a. < 1% b. 1-5% c. 5-10% d. > 10%

a (< 1% Thrombocytopenia is common after cardiac surgery and is typically multifactorial. The most feared cause is heparin-inducted thrombocytopenia (HIT). HIT is an immune-mediated reaction involving antibodies to a heparin: PF4 complex (PF4 is a cytokine released from alpha granules of activated platelets during activation, and its physiologic role is to neutralize heparin-like molecules in the extracellular matrix). This can lead to platelet clumping and a prothrombotic state. The treatment for HIT is anticoagulation with a direct thrombin inhibitor (DTI). Warfarin is contraindicated in the setting of HIT because it can lead to coagulation ("Coumadin necrosis"). Suspicion of HIT complicates venous thromboprophylaxis because if HIT is present, heparin and low molecular weight heparin should be avoided. Thus, a four-point scoring system was developed based on the amount of thrombosis, the timing, alternative causes, and physical exam findings. In a patient with plausible other causes (i.e.., cardiopulmonary bypass) who is asymptomatic and outside the 5-10 day peak period, an isolated platelet drop of 50% or more still only carries a 0.84% chance of HIT.)

Which of the following factors is NOT part of the Child-Pugh score for chronic liver disease?

a. Ascites
b. Platelet count
c. Total bilirubin
d. Serum albumin

b (Platelet count
The Child-Pugh score was originally developed in 1964 as the Child-Turcotte score and then modified by Pugh in 1972. The score endeavors to predict mortality in patients with chronic liver disease. The score measures five favors: Bilirubin, Albumin, INR, Ascites, and Hepatic encephalopathy. The severity of liver disease is assessed by scoring each factor from 1 – 3. Patients with a total score of 5 – 6 have 100% one-year survival whereas patients with 10 or more points have 45% one-year survival. The Child-Pugh score has been largely replaced by the MELD score to stratify patients for liver transplantation. Platelet count is not part of the Child-Pugh score.)

Which of the following coagulation factors has the SHORTEST half-life?

A. Factor II
B. Factor VII
C. Factor IX
D. Factor X

B( Factor VII
Factor VII has the shortest half-life: 4-6 hours. Factor IX has a half-life of about 24 hours. Factor X has a half-life of 25-60 hours and Factor II has a half-life of 50-80 hours.)

A 55-year-old man develops refractory hypotension after a 8-hour anesthetic consisting of etomidate and sufentanil infusions. Which of the following BEST explains this patient’s hypotension?

a. Activation of GABA receptors by etomidate
b. Activation of GABA receptors by sufentanil
c. Inhibition of 11?-hydroxylase by etomidate
d. Inhibition of 11?-hydroxylase by sufentanil

c (Inhibition of 11?-hydroxylase by etomidate
Etomidate is a reversible inhibitor of 11?-hydroxylase, which is critical to adrenocortical steroid synthesis. Thus, etomidate suppresses corticosteroid synthesis and leads to primary adrenal suppression, which typically manifests as refractory hypotension. Increases in patient mortality can be observed after a single dose of etomidate, which may be related to adrenal suppression.)

A patient who smokes may have a carboxyhemoglobin level as high as which of the following?

a. 5%
b. 10%
c. 20%
d. 25%

b. (10%
A non-smoker may have a carboxyhemoglobin level of 1-3% at baseline whereas a patient who smokes may have a carboxyhemoglobin level as high as 8-10%.)

A 23-year-old critically ill woman develops MRSA ventilator-associated pneumonia. Which of the following is the MOST appropriate initial treatment?

A. Vancomycin
B. Vancomycin plus ciprofloxacin
C. Vancomycin plus gentamicin
D. Vancomycin plus tobramycin

A (Vancomycin
The overwhelming majority of data suggest that combination antibiotic therapy is not helpful in treating patients with MRSA. Ruotsalainen et al. performed a RCT of 381 patients with MRSA bacteremia and failed to demonstrate a decrease in mortality with the addition of a second agent. Most double coverage studies have used beta-lactams or aminoglycosides alone and in combination. In the Safdar study, the summary odds ratio was 0.96 for all causes (95% CI 0.70-1.32), indicating no mortality benefit with combination therapy. Considerable heterogeneity was present in the main analyses. The Heyland RCT of VAP showed no difference in 28-day mortality between the combination and monotherapy groups (relative risk = 1.05, 95% confidence interval 0.78-1.42, p = .74), although Pseudomonas and MRSA were excluded.)

An 8-year-old, obese girl with severe obstructive sleep apnea is taken to the PACU after a tonsillectomy and adenoidectomy. On arrival, she is tachycardic, dyspneic, tachypneic, and anxious. Her SpO2 is 89% despite 4L nasal cannula. Auscultation reveals occasional wheezes bilaterally. A chest radiograph reveals diffuse interstitial and alveolar infiltrates. Given these findings, which of the following is the MOST likely diagnosis?

a. Acute respiratory distress syndrome
b. Negative pressure pulmonary edema
c. Pulmonary aspiration
d. Pulmonary hemorrhage

b. (Negative pressure pulmonary edema

Postoperative complications associated with tonsillectomy include pain, nausea and vomiting, dehydration, and post-tonsillectomy hemorrhage. Acute postoperative pulmonary edema, albeit infrequent, may occur when airway obstruction from tonsillar hypertrophy is relieved. Normal pleural pressures range from -2.5 to -10 cmH2O during inspiration. In a child with tonsillar hypertrophy and airway obstruction, pleural pressures may be as negative as -30 cmH2O. This may lead to pulmonary capillary wall dysfunction. Due to the negative pressure gradient during inspiration, a concomitant increased in venous return exists, but due to the microvasculature wall disruption, transudation of fluid into the alveolar space can occur. To counterbalance this potentially deleterious condition, patients with chronic airway obstruction develop an adaptive mechanism by which they generate positive intrapleural and alveolar pressures during exhalation, decreasing pulmonary venous return. Post-tonsillectomy, the obstruction has been relieved and the adaptive mechanism has been lost. This leads to decreased airway pressures during exhalation, increased venous return, increased pulmonary hydrostatic pressure, and then pulmonary edema.)

A 75-year-old woman complains of loss of vision in one eye. She reports that she first noticed blurred vision in the right eye. This progressed to her bumping into objects on the right side. When she is asked to read, she can only read one half of sentences on a page. She has normal strength, coordination, reflexes and tone. Her cranial nerve exam shows that she cannot see a moving finger on the right field in either eye. An occlusion of which major vessel is associated with these findings?

a. Basilar artery
b. Internal carotid artery
c. Middle cerebral artery
d. Posterior cerebral artery

d (posterior cerebral artery The description of this patient suggests that she has a right visual field deficit, in both eyes, as opposed to monocular blindness (the classic “amaurosis fugax” typically due to emboli from an internal carotid artery source). Although patients may describe not being able to see out of one eye, a cursory physical exam will reveal that the eye can see, but there may be a significant field cut in both eyes. The neurological term for this sign is homonymous hemianopsia, and it is most commonly due to occipital lobe injury from a posterior cerebral artery infarction. Although field cuts can also occur with temporal or parietal lesions, there tends to be other associated findings not seen in this patient (such as neglect).

While performing an interscalene block with a nerve stimulator, the patient’s diaphragm begins to twitch. In order to successfully perform the block, the needle should be redirected in which of the following directions?

a. Advanced because the needle tip is too shallow
b. Redirected anteriorly because the needle tip is too posterior
c. Redirected posteriorly because the needle tip is too anterior
d. Withdrawn because the needle tip is too deep

c (Redirected posteriorly because the needle tip is too anterior
At the C6 level, the phrenic nerve is nearly always located immediately anterior to the superior trunk. Appropriate repositioning is in a posterior direction. Conversely, stimulation of the accessory nerve leads to movement of the trapezius muscle and indicates a need for anterior needle redirection.)

During which of the following phases does MOST left ventricular filling occur?

a. Atrial systole
b. Early diastole
c. Isovolumic relaxation
d. Ventricular systole

b (Early diastole
The left ventricle fills during diastole, when the left atrial pressure exceeds left ventricular pressure and the mitral valve opens. More than 60% of all left ventricular filling occurs during early diastole. Atrial systole is responsible for only about 15% of ventricular filling. The mitral valve is closed during isovolumic relaxation and ventricular systole and thus no ventricular filling occurs.)

Which of the following BEST explains the faster onset of alfentanil relative to an equipotent bolus of fentanyl?

a. Increased protein binding
b. Lower lipid solubility
c. Lower pKa
d. Increased clearance

c (Lower pKa
In general terms, the onset of any drug is dependent upon the drug’s ability to reach its target receptor. The most important target receptors for an opioid sit in the CNS and as a result, onset is thus dependent upon an opioid’s ability to rapidly cross the blood-brain barrier. Drugs that are small, uncharged, and highly lipid soluble are able to cross the blood-brain barrier most rapidly. Alfentanil is unique among opioids in that it has a pKa of 6.5 (as compared to fentanyl, which has a pKa of 8.0). This leads to a very high proportion of alfentanil being uncharged at physiologic pH and a rapid onset.)

Advancing the needle deeper than 2 cm during interscalene blockade is MOST associated with an increased risk of which of the following?

a. Carotid artery puncture
b. Intrathecal injection
c. Phrenic nerve blockade
d. Stimulation of the accessory nerve

b (Intrathecal injection
All of these complications have been reported from deep needle placement; however, intrathecal injection is the most significant risk. In the vast majority of patients, the brachial plexus is found 0.5 to 1.5 cm below the skin surface.)

Absolute contraindications to the use of epidural anesthesia in the parturient include: (Select 2)
a. inability of the patient to cooperate
b. herniated lumbar disc
c. multiple sclerosis
d. patient refusal
e. history of previous cesarean section
f. aortic regurgitation
a, d
(inability of the patient to cooperate, patient refusal

Absolute contraindications to epidural anesthesia/analgesia in the parturient include infection over the injection site, coagulopathy, thrombocytopenia, marked hypovolemia, true local anesthetic allergy, patient refusal and inability of the patient to cooperate. Preexisting neurological disease and back disorders are relative contraindications. Patients with aortic regurgitation usually benefit from the reduction in afterload seen after neuraxial anesthesia.

pg. 849
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A previously healthy 78-year-old woman sustains a left femur fracture and is in the operating room undergoing a left femur intramedullary rod placement. During bone reaming her blood pressure acutely drops from 130/70 mmHg to 90/45 mmHg, her heart rate increases from 80 to 115 bpm, and her SpO2 falls to 88%. Which of the following signs is MOST specific for fat embolism ?

a. Decreased hemoglobin
b. PaO2 75 mmHg on 100% oxygen
c. Petechial rash on upper body
d. Left ventricular dilation

c (Petechial rash on upper body

This scenario in the operating room is most concerning for fat embolism. In patients who are having orthopedic surgery with long bone trauma/reaming, fat embolism is very common, occurring in 3-10% of orthopedic trauma patients. Common signs under general anesthesia include hypoxia, increased alveolar-arterial oxygen gradient, tachycardia and a petechial rash on the upper portion of the body. Petechiae only occur in 20-50% of patients but are considered to be diagnostic. In general as the fat particles move to the right side of the heart they can lodge in the pulmonary vascular bed but eventually travel through the left side of the heart to the brain. They produce local ischemia and inflammation. Pulmonary compliance decreases, pulmonary arterial hypertension occurs and cardiac output declines. This leads to the picture of right-sided heart failure, whereby the right side of the heart dilates and is unable to pump blood to the left side of the heart. Thus, systemic blood pressure drops. If a TEE is available in this scenario, it would likely reveal some embolic particles in the right side of the heart and pulmonary arteries, and the right ventricle may even be dilated. The alveolar arterial oxygen gradient is a nonspecific sign that there is some type of shunt physiology ongoing. These are helpful signs but may also occur as a result of air or pulmonary thromboembolic embolism. The upper body petechial rash is considered to be diagnostic.)

Carotid bodies located at the bifurcation of the common carotid artery MOST respond to which of the following parameters to control ventilation?

a. pH
b. PaO2
c. PaCO2
d. SaO2

b (PaO2
Chemical control of ventilation occurs via the peripheral and central chemoreceptors. Peripheral chemoreceptors consist of the carotid and aortic bodies. These chemoreceptors respond primarily to a decrease in PaO2. Neural activity increases when PaO2 falls below 100 mmHg, but a substantially recognizable increase in minute ventilation may not be seen until the PaO2 drops below 65 mmHg. The carotid bodies serve to influence largely the ventilatory effects of a decrease in PaO2 by increasing respiratory rate and tidal volume. The aortic bodies predominantly affect the circulatory effects of a decrease in PaO2 by stimulating a decrease in heart rate, hypertension, increased bronchiolar tone, and increased adrenal secretion. Central chemoreceptors, on the contrary, respond primarily to a decrease in pH or an increase in PaCO2. Central chemoreceptors are located in the medulla. An increase in minute ventilation after central chemoreceptor stimulation will occur within 1-2 minutes. However, if the stimulation persists, the resultant increase in ventilation will decline over several hours.)

A 55-year-old man with colon cancer undergoes an open colectomy under general anesthesia. Which of the following is the MOST likely cause of a 1°C decrease in core temperature during the first hour of anesthesia?

a. Radiation heat loss to the operating room
b. Conductive heat loss to the operating table
c. Evaporative heat loss from surgical site
d. Redistribution of heat from the core to the periphery

d (Redistribution of heat from the core to the periphery
Under general anesthesia, core temperature characteristically decreases 1-1.5°C during the first hour. This decrease in core temperature occurs mainly as a result of the redistribution of thermal energy from the core to the periphery. Generally speaking, humans concentrate heat energy in the core and a patient’s core temperature is typically much warmer than their extremities. This is typically the result of vasoconstriction. General anesthesia results in vasodilation, which allows core heat to flow down the temperature gradient into peripheral tissues. It should be noted that the internal redistribution of thermal energy decreases core temperature but does not represent any actual heat loss. Heat loss occurs secondary to radiation, convection, and conduction, or evaporation.)

The cardiovascular effects of pancuronium are caused by: (Select 3)
a. vagal blockade
b. stimulation of cardiac muscarinic receptors
c. ganglionic stimulation
d. decreased catacholamine reuptake
e. direct myocardial stimulation
f. blockade of cardiac slow calcium channels
g. central thalamic stimulation
a, c, d (vagal blockade, ganglionic stimulation, decreased catecholamine reuptake

The cardiovascular effects of pancuronium are caused by the combination of vagal blockade and sympathetic stimulation. The latter is due to a combination of ganglionic stimulation, catecholamine release and decreased catecholamine reuptake.

pg. 537
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

pg. 217
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is the BEST option for treating hypotension related to arrhythmia during venous cannula placement prior to institution of cardiopulmonary bypass for the patient undergoing coronary artery bypass graft surgery?

a. Cardioversion
b. Discontinuation of mechanical stimulation
c. Phenylephrine
d. Volume replacement

b (Discontinuation of mechanical stimulation
For cardiopulmonary bypass to be instituted, an arterial cannula is placed in the ascending aorta and venous cannulae are placed in the right atrium to drain deoxygenated blood from the patient. This blood is directed to the bypass circuit where it is oxygenated and CO2 is eliminated. Blood is then returned to the patient via the arterial cannula in the aorta. During placement of the venous cannula in the right atrium, surgical manipulation can and often does trigger arrhythmias: the most common being atrial fibrillation. Cessation or limited mechanical stimulation is recommended if arrhythmias occur. Often, this alone corrects the problem. Other maneuvers that may be successful include giving a fluid bolus, titrating vasoactive medications and cardioversion.)

Anesthetic implications of multiple sclerosis include:

a. exacerbation induced by spinal anesthesia
b. exacerbation induced by epidural anesthesia
c. exacerbation of symptoms secondary to hypothermia
d. the presence of significant peripheral neuropathy causing severe hyperkalemia after succinylcholine administration

a (exacerbation induced by spinal anesthesia

Spinal anesthesia has been reported to cause exacerbation of the disease. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia.

pg. 619
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Which of the following antiemetics should MOST be avoided in patients undergoing assisted reproductive therapy?

a. Metoclopramide
b. Ondansetron
c. Promethazine
d. Scopolamine

a (Metoclopramide
Along with droperidol, metoclopramide should be avoided in the assisted reproductive therapy population because it can cause increased prolactin levels. High prolactin levels have been shown to impair follicle maturation and corpus luteum function, decreasing the likelihood of a successful reproductive outcome.)

According to the 2010 American Society of Regional Anesthesia (ASRA) guidelines, epidural catheter placement in obstetric patients should be delayed for at least how long after administration of a therapeutic dose of low-molecular weight heparin?

a. 6 hours
b. 12 hours
c. 24 hours
d. 48 hours

c (24 hours

Pregnancy is a state of relative hypercoagulability. Pregnant patients needing anticoagulation are often treated with low-molecular weight heparin (LMWH) due to its efficacy, maternal safety, ease of administration, and lack of placental transfer to the fetus. Anticoagulated patients are at increased risk for the development of epidural and spinal hematoma following neuraxial anesthetics. Although there is no definitive data linking absolute time since LMWH administration with the development of epidural and spinal hematoma, consensus guidelines have been created in an attempt to decrease the risk of this catastrophic complication. Patients receiving higher therapeutic doses of LMWH are at increased risk compared to patients receiving lower prophylactic doses of LMWH. ASRA guidelines state that neuraxial placement should occur no sooner than 24 hours following a therapeutic dose of LMWH. Neuraxial placement should occur no sooner than 10-12 hours following a prophylactic dose of LMWH.)

Local anesthetics with the potential to form methemoglobin include: (Select 3)
a. EMLA topical anesthetic cream
b. bupivacaine
c. benzocaine
d. ropivacaine
e. prilocaine
f. mepivacaine
a, c, e (EMLA topical anesthetic cream, prilocaine, benzocaine

EMLA cream contains both lidocaine and prilocaine. The metabolites of prilocaine can convert hemoglobin to methemoglobin. Benzocaine can also cause methemoglobinemia.

pg. 140
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Methemoglobin Risk with Benzocaine Containing Local Anesthetics”
URL: http://www.upstate.edu/uha/pharmacy/newsletters/kidstuff_06/kidstuff_05_06.pdf)

The potency of local anesthetics increases as the:

a. lipid solubility increases
b. pKa increases
c. number of double bonds in the anesthetic molecule increases
d. molecular weight decreases

a (lipid solubility increases

Local anesthetic potency correlates directly with lipid solubility. In general, lipid solubility increases with an increase in the total number of carbon atoms in the molecule and by adding a halogen to the aromatic ring.

pg. 129
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Which of the following factors is LEAST likely to be associated with uterine atony?

a. Infection
b. Polyhydramnios
c. Recent ketorolac
d. Tocolytic therapy

c (Recent ketorolac
Uterine atony is not only the leading cause of postpartum hemorrhage, but it is also the most common indication for a peripartum blood transfusion. Postpartum hemostasis involves the release of endogenous uterotonic factors, and atony results when there is failure of adequate uterus contraction after delivery. This can occur for various reasons including pre-delivery use of oxytocin (via receptor down-regulation), over-distension of the uterus due to polyhydramnios or multiple gestations, and chorioamnionitis. Tocolytic therapy relaxes uterine muscle, making it more difficult to contract after delivery. Although non-steroidal anti-inflammatory drugs irreversibly inhibit platelet function, they have minimal effect on uterine muscle tone. Mayer DC, Smith KA. Antepartum and Postpartum Hemorrhage. In: Chestnut DH, ed. Obstetric Anesthesia. 4th ed. Philadelphia: Mosby Elsevier, 2009:811-836.)

A 4-week-old infant presents with tachycardia and tachypnea and is refusing to take anything by mouth. Chest x-ray reveals congenital emphysema on the left. What would be the most likely findings on physical exam on the affected side?

a. Decreased breath sounds, hyper-inflation, hyper-resonance
b. Decreased breath sounds, hyper-inflation, hypo-resonance
c. Increased breath sounds, hyper-inflation, hyper-resonance
d. Increased breath sounds, hyper-inflation, hypo-resonance

a (Decreased breath sounds, hyper-inflation, hyper-resonance
Congenital lobar emphysema is a developmental anomaly of the lung that is characterized by hyperinflation of one or more of the pulmonary lobes. The left lung is more commonly involved and specifically the left upper lobe is the most commonly affected. Infants typically have tachypnea and increased work of breathing, and may have cyanosis. Recurrent pneumonia or poor feeding with failure to thrive are less frequent presentations that may occur in milder forms. Physical examination reveals decreased breath sounds and hyperresonance to percussion. A chest x-ray will reveal hyper-inflation)

Regarding cardiopulmonary bypass, if pump outflow is occluded, excessive pressure can build proximal to the occlusion if which kind of pump is used?

a. Roller pump
b. Centrifugal pump
c. Neither roller nor centrifugal pump
d. Either roller or centrifugal pump

a (Roller pump

During cardiopulmonary bypass, a mechanical pump is required to circulate blood through the circuit and then back to the patient. In general, 2 types of pumps are utilized for this purpose: roller pumps and centrifugal pumps. Flow of a roller pump is predictable and depends on the revolutions per minute of the pump. Although retrograde flow is not possible, if there is outflow occlusion to the pump, excessive pressure can build, causing the tubing to rupture or the tubing connections to separate. Of course, there are safety checks in place to prevent this from occurring.)

Regarding roller pumps and centrifugal pumps utilized for cardiopulmonary bypass, which of the following statements is MOST correct?

a. Retrograde flow is possible with the roller pump
b. Retrograde flow is possible with the centrifugal pump
c. Retrograde flow is not possible with either the roller pump nor the centrifugal pump
d. Retrograde flow is possible with either the roller pump or the centrifugal pump

b (Retrograde flow is possible with the centrifugal pump
The centrifugal pump is quite different than the roller pump. The centrifugal pump operates on a principle of a constrained vortex, where a rotator (impeller) is housed within a rigid container shaped like a cone. Flow depends on the pressure differential created by spinning cones within the pump. In other words, rapidly rotating cones create negative pressure (pressure drop) by the centrifugal action of the rotating core, propelling fluid forward. Flow varies depending on pump preload and afterload. Unfortunately, retrograde flow is possible, but of course, safety checks are in place to prevent this.)

When used in the ICU, dexmedetomidine has been associated with a lower risk of delirium when compared to which of the following sedating agents?

a. Opioids
b. Benzodiazepines
c. Propofol
d. Ketamine

b (Benzodiazepines
Delirium in the ICU may be to be related to benzodiazepine use. Benzodiazepine use appears to be associated with an increase in delirium when compared to dexmedetomidine – both the Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS) [Pandharipande et al.] and the Safety and Efficacy of Dexmedetomidine Compared to Midazolam (SEDCOM) [Riker et al.] studies suggest that dexmedetomidine may decrease delirium when compared to benzodiazepines.)

A 56-year-old man with a history of tobacco abuse is scheduled to undergo thoracoscopic resection of a right upper lobe mass. Which of the following benefits of smoking cessation will be MOST immediate?

a. Decreased airway secretions
b. Decreased airway reactivity
c. Decreased carboxyhemoglobin concentration
d. Decreased incidence of postoperative pneumonia

c (Decreased carboxyhemoglobin concentration
Smoking cessation results in many advantages to this patient; however, a *reduction* in significant *morbidity and mortality* does not occur for at *least eight weeks*. Indeed, surgery during the first four weeks of tobacco abstinence has been associated with increased pulmonary complications. While *acute cessation* is associated with *decreased carboxyhemoglobin levels* (and increased tissue oxygenation), airway reactivity and secretions increase.)

The effects of barbiturates on ischemic areas of the brain include:
a. vasoconstriction
b. vasodilation
c. redirection of blood flow to the ischemic areas
d. redirection of blood flow away from ischemic areas
c (redirection of blood flow to the ischemic areas

Barbiturates cause cerebral vasoconstriction in normal areas. These agents tend to redistribute blood flow to ischemic areas in what is sometimes referred to as a reverse steal phenomenon or Robin Hood effect. Ischemic areas remain maximally dilated and unaffected by the barbiturate.

pg. 485
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 24-year-old man with a history of T4 paraplegia is undergoing his first anesthetic for a urinary diversion due to a neurogenic bladder. As the surgeon makes the incision, his BP reaches 220/110 mmHg with a heart rate of 45 bpm. Which of the following is the MOST appropriate first step in treatment?

a. Atropine
b. Dantrolene
c. Fentanyl
d. Nitroprusside

D (Nitroprusside
In a patient with a history of a spinal cord lesion higher than T7, marked hypertension and bradycardia is concerning for autonomic hyperreflexia. Normally, descending inhibitory impulses travel down the spinal cord to block reflex arcs to cutaneous, visceral, or proprioceptive stimuli. This arc is disrupted in spinal cord injury and can lead to autonomic instability, most notably severe hypertension followed by a sustained vagal response including bradycardia, vasodilation, and cutaneous flushing. Treatment is supportive, including stopping the inciting stimulus (ask surgeons to pause) and lowering the blood pressure to normal levels via vasodilators and assuring adequate levels of anesthesia.)

Which of the following ligaments is traversed when using a paramedian approach to the neuraxis?

a. Interspinous ligament
b. Ligamentum flavum
c. Posterior longitudinal ligament
d. Supraspinous ligament

b (Ligamentum flavum
The supraspinous and interspinous ligaments are both midline structures and are not traversed in a paramedian approach. The only structure traversed in both midline and paramedian approaches is the ligamentum flavum. The posterior longitudinal ligament is anterior to the spinal cord and not traversed in either the paramedic or midline approaches.)

Which of the following is LEAST likely to occur following a celiac plexus block?

a. Diarrhea
b. Orthostatic hypotension
c. Retroperitoneal hemorrhage
d. Urinary incontinence

d (The celiac plexus contains preganglionic sympathetic fibers from greater and lesser splanchnic nerves and postganglionic sympathetic and preganglionic parasympathetic fibers. It provides sensory innervation and sympathetic outflow to the stomach, liver, spleen, pancreas, kidney, and GI tract up to splenic flexure. Thus, blockade of the celiac plexus results in a loss of sympathetic innervation. The loss of sympathetic outflow can result in both diarrhea and orthostatic hypotension. During performance of the block, inadvertent puncture of the aorta or vena cava can result in a retroperitoneal hemorrhage; however, this is less common. Urinary incontinence does not occur and the urinary tract is not innervated by the celiac plexus.)

Pathophysiologic changes associated with liver disease include: (Select 2)
a. increased cardiac output
b. increased systemic vascular resistance
c. increased mean blood pressure
d. sodium-losing nephropathy
e. hyperkalemia
f. arterial hypoxemia
a, f (Pathophysiologic changes associated with liver disease include (Select 2): increased cardiac output, arterial hypoxemia

Arterio-venous shunting, resulting from advanced liver disease, results in a decrease in systemic vascular resistance, a decrease in blood pressure and an increase in cardiac output. Arterial hypoxemia is common in patients with advanced liver disease and appears to be the result of ascites, hepatic hydrothorax and widespread pulmonary vasodilation.

pp. 773-774
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

An otherwise healthy 25-year-old G1P0 is taken emergently to the OR for cesarean delivery. She receives a bolus of 30 mL of 2-chloroprocaine through an existing epidural catheter. Which of the following is MOST correct regarding the use of 3% 2-chloroprocaine?

a. Its rapid onset is a result of its high pKa
b. Efficacy of epidurally administered opioids may be decreased
c. It is rapidly metabolized by the liver and kidneys
d. Fetal acidosis leads to high levels in fetal circulation

b (2-Chloroprocaine is considered a safe and favorable choice for emergent/urgent dosing of an epidural for cesarean section. It is favorable because of its rapid onset, which is independent of its pKa (*based on pKa alone, one would expect a very slow onset*). The rapid onset is thought to be *due to the high concentrations* that are used. It is safe because it is metabolized by plasma cholinesterases (it is an ester local anesthetic), so intravascular injection is clinically inconsequential. A down side of its use is its relatively short duration; repeat boluses must be given about every 30 minutes to maintain surgical anesthesia. The use of 2-chloroprocaine is associated with a decreased efficacy of subsequent epidural opioids, rather than increased efficacy.)

Enoxaparin:
a. causes less platelet inhibition than heparin
b. is easily reversed with protamine
c. has a half-life that is 35% less than that of heparin
d. effects are monitored using the INR
a (causes less platelet inhibition than heparin
Low molecular weight heparins (LMWH), such as enoxaparin, have greater activity against factor Xa than thrombin. As a result, the INR is not a reliable monitoring tool. The LMWHs cause less platelet inhibition and are associated with a lesser incidence of heparin induced thrombocytopenia.

pg. 400
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.)

A 3-month-old full term boy presents for right inguinal hernia repair. If, during placement of a caudal anesthetic, the infant were unintentionally administered 1 ml/kg 0.25% bupivacaine intravenously, what would be the MOST likely INITIAL sign of cardiac toxicity?

a. Supraventricular tachycardia
b. Sinus tachycardia
c. Ventricular tachycardia
d. Third degree heart block

c (Ventricular tachycardia
The most common arrhythmia observed with bupivacaine local anesthetic toxicity is a wide complex ventricular rhythm. In a dog model, bupivacaine lowered the ventricular tachycardia threshold and caused polymorphic ventricular tachycardia.)

Termination of the effects of succinylcholine at the neuromuscular junction occurs as a result of:
a. succinylcholine hydrolysis by acetylcholinesterase
b. diffusion of succinylcholine away from the receptors
c. succinylchoine hydrolysis by hepatic esterases
d. the competition of succinylcholine with acetylcholine
b (diffusion of succinylcholine away from the receptors

Because depolarizing muscle relaxants are not metabolized by acetylcholinesterase, they diffuse away from the neuromuscular junction and are hydrolyzed in the plasma by pseudocholinesterase.

pp. 203-204
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 75-year-old man has had an infrarenal open abdominal aortic aneurysm repair under general anesthesia. His baseline preoperative creatinine, prior to surgery, was 1.1 mg/dL. On postoperative day 2, his creatinine increases to 2.0 mg/dL with a concomitant reduction in urine output. Which of the following physiologic changes is MOST associated with a reduction in renal function after aortic aneurysm surgery?

a. Increase in renal cortical blood flow
b. Decrease in renal cortical blood flow
c. Decrease in renal vascular resistance
d. Increase in glomerular filtration rate

b (Decrease in renal cortical blood flow
The effects of the aortic cross-clamp on the kidneys are mediated by both the renin-angiotensin-aldosterone system as well as the sympathetic nervous system. There is an increase in renal vascular resistance, decrease in renal cortical blood flow and decrease in glomerular filtration rate. An infrarenal cross clamp can decrease renal blood flow by 40% whereas a thoracic level aortic clamp decreases renal blood flow by as much as 80-90%. These changes persist for a long period of time after the cross clamp is removed. In addition, the decrease in renal blood flow is not necessarily associated with decreased cardiac output or decreased mean arterial blood pressure (although those changes would certainly not improve renal function or prevent the decrement).)

An occurrence malpractice insurance policy:
a. offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed
b. offers coverage if the policy is in place at the time the claim is filed
c. is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy
d. is the most common form of malpractice insurance in place today
a (offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed

An occurrence policy offers coverage of an incident resulting in a claim, whenever that claim might be filed. The much more common claims-made policy covers claims that are filed only while the insurance is in force. Umbrella coverage is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy.

pg. 38
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

During abdominal aortic aneurysm repair, a patient has an oximetric pulmonary artery catheter. The mixed venous oxygen saturation (SvO2) increases from 70 to 80% after the aortic cross clamp is placed. Which of the following accounts for the increase in mixed venous oxygen saturation?

a. Decreased carbon dioxide production
b. Decreased oxygen consumption
c. Increased afterload
d. Increased preload

b (Decreased oxygen consumption
During the time period of the aortic crossclamp, there is increased mixed venous oxygen saturation as there is a reduction in total body oxygen consumption and decreased total body oxygen extraction. Other factors that impact mixed venous oxygen saturation include arterial oxygen saturation, hemoglobin concentration and cardiac output. During aortic cross-clamping these variables may also change, but they likely would be responsible for decreasing the mixed venous oxygen saturation (in the case of arterial desaturation, bleeding, decreased cardiac output).)

Signs of cardiac tamponade include: (Select 2)
a. distended neck veins
b. increased QRS voltage seen on ECG
c. decreased central venous pressure
d. bradycardia
e. systemic vasoconstriction
f. an increase in systolic blood pressure during inspiration
a (distended neck veins, systemic vasoconstriction

Cardiac tamponade is indicated by the presence of neck vein distention, hypotension, muffled heart sounds (Beck’s triad) and a greater than 10 mm Hg decline in blood pressure during spontaneous inspiration (pulsus paradoxus). Tachycardia and systemic vasoconstriction are present to maintain blood pressure with the associated decreased stroke volume.

pp. 495-496
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

A 65-year-old man with a history of coronary artery disease and previous CABG has a 6 cm abdominal aortic aneurysm (AAA). He presents to the OR for elective open repair of his AAA. Which of the following medications will be MOST likely to improve his myocardial function during the aortic cross-clamping?

a. Nitroprusside
b. Phenoxybenzamine
c. Epinephrine
d. Norepinephrine

a (Nitroprusside
Principles of hemodynamic management during the period of aortic cross-clamping in patients with decreased myocardial reserve include reduction in afterload with arteriolar dilators such as nitroprusside and reduction in preload with venodilators such as nitroglycerin. Phenoxybenzamine is longer-acting, orally administered alpha-blocker which is often used in treatment of hypertension in patients with pheochromocytoma. It is not appropriate for use in AAA repair. Care should be taken with reduction in blood pressure in order prevent worsening of visceral ischemia distal to the aortic occlusion. Vasoconstrictors such as norepinephrine and epinephrine may be useful with removal of the aortic cross-clamp in low vascular resistance states. Epinephrine is not usually required as it often increases heart rate and myocardial oxygen consumption while increasing myocardial contractility. Other helpful management options after the cross clamp is removed include volume administration, treatment for hyperkalemia, acidosis and arrhythmias.)

Respiratory parameters that are increased during pregnancy include: (Select 2)
a. airway resistance
b. tidal volume
c. oxygen consumption
d. plasma bicarbonate levels
e. functional residual capacity
f. PaCO2
b, c (tidal volume, oxygen consumption

Respiratory/ventilatory effects of pregnancy include increased oxygen consumption, decreased airway resistance, decreased FRC, increased tidal volume and rate, increased PaO2, decreased PaCO2 and decreased serum bicarbonate.

pg. 1129
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.)

A 70-year-old man suffers a ruptured descending aortic aneurysm and presents for emergent open repair. Which of the following effects is MOST important after aortic cross-clamping in determining anticipated intraoperative hemodynamic changes?

a. Level of the cross clamp
b. Myocardial function
c. Presence of aortoiliac occlusive disease
d. Volume status

a (Level of the cross clamp
While all of the above answers have an effect on the patient’s hemodynamics during the time of aortic cross-clamping, the major factor that determines the consequences of aortic cross-clamping is the *level of the clamp on the aorta*. The majority of abdominal aortic aneurysmectomies are performed with an *infrarenal* cross-clamp, which produces the least effect hemodynamically. *Juxtarenal, suprarenal* and *supraceliac* clamps produce increasing hemodynamic effects, in respective order. There is arterial *hypertension ABOVE* the level of the clamp and *hypotension BELOW* the level of the clamp. A patient with *aortoiliac occlusive disease lives in a chronically “clamped” state* and has likely developed significant collateralization due to the nature of vascular disease. Those patients have the least hemodynamic change related to cross-clamping. Volume status is very important in a patient with a ruptured aneurysm, but during the cross-clamp, central venous pressure and preload are augmented usually due to blood volume redistribution from the splanchnic vascular bed. In addition, baseline myocardial function is vitally important. In patients with preserved myocardial function, aortic cross clamping is usually well tolerated, despite the increased ventricular afterload due to the clamp. In patients who have coronary artery disease, reduced coronary blood flow, aortic regurgitation or reduced myocardial reserve, placement of the aortic cross clamp may be met with decompensation, dilation and failure of the left ventricle, with resultant acute mitral regurgitation and pulmonary edema.)

Neuromuscular blocking agents that undergo metabolism through the Hofmann elimination include: (Select 2)
a. rocuronium
b. vecuronium
c. atracurium
d. doxacurium
e.cisatracurium
f. succinylcholine
c, e (atracurium, cisatracurium

Atracurium and cisatracurium are bisquaternary ammonium benzylisoquinoline compounds of intermediate duration of action. They are degraded via two metabolic pathways. One of these pathways is the Hofmann reaction, a nonenzymatic degradation with a rate that increases as temperature and/or pH increases. The second pathway is nonspecific ester hydrolysis.

pp. 535-536
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Prostaglandin E1 is MOST appropriate for which of the following congenital cardiac lesions?

a. Interrupted aortic arch
b. Patent ductus arteriosus
c. Pulmonary hypertension
d. Truncus arteriosus

a (interrupted aortic arch
Prostaglandin E1 (0.1 ug/kg/min) maintains ductal patency (and in some cases can reopen a closed duct) by directly acting on vascular smooth muscle. It is critically important in any cardiac lesion where systemic oxygen delivery is dependent on ductus flow. Interrupted aortic arch is a ductal-dependent cardiac lesion. Pulmonary hypertension may also benefit from prostaglandin but it is a different prostaglandin (E12, not E1).)

A 34-year-old female is undergoing tumescent liposuction of the abdomen and flanks. Peak serum levels of local anesthetic from the tumescent solution are most commonly seen in:
a. the first 2 hours
b. 4 to 6 hours
c. 7 to 9 hours
d. 12 to 14 hours
d (12 – 14 hours

Tumescent liposuction is commonly done with large volumes of tumescent solution consisting of normal saline with 1:1,000,000 epinephrine and 0.025 – 0.1% lidocaine. Peak serum levels of lidocaine occur 12 – 14 hours after injection and decline over the next 6 – 14 hours.

Download CoreNotes

pg. 868
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Treatment with prostaglandin E1 is initiated in a newborn with hypoplastic left heart syndrome. Which of the following is the MOST likely side effect of prostaglandin E1?

a. Apnea
b. Arrhythmias
c. Hypertension
d. Hypothermia

a (Apnea
Prostaglandin E1 (0.1 ug/kg/min) maintains ductal patency (and in some cases can reopen a closed duct) by directly acting on vascular smooth muscle. It is critically important in any cardiac lesion where systemic oxygen delivery is dependent on ductus flow. Apnea, hypotension, and fever are important side effects of prostaglandin E1.)

A person acting as an amicus curiae:
a. is not a party to the litigation
b. gives expert testimony for the defense
c. gives expert testimony for the plaintiff
d. cannot file a written brief
a (is not a party to the litigation

Amicus curiae is a phrase that literally means ‘friend of the court’ — someone who is not a party to the litigation, but who believes that the court’s decision may affect its interest. An expert, not associated with either the defendant or plaintiff may, at the court’s discretion, file a brief or give testimony to assist the court in decision making.

“Amicus curiae.” URL: http://en.wikipedia.org/wiki/Amicus_curiae

“Amicus curiae.” URL: http://www.merriam-webster.com/dictionary/amicus%20curiae)

Which of the following cardiac findings during pregnancy is MOST ABNORMAL?

a. Cardiomegaly on chest x-ray
b. Right bundle branch block
c. S4 heart sound
d. Tricuspid regurgitation

c (S4 heart sound
Cardiovascular changes in pregnancy revolve around the themes of increasing cardiac output and extension of blood flow to the placenta. Heart rate and stroke volume increase, while systemic vascular resistance decreases to reduce afterload and maintain a normal blood pressure. As a result of the increased volumes occupying the heart, a mild but normal increase in heart size can be seen and a third heart sound (S3) can be heard. Dilation of the heart can also cause new regurgitant murmurs, particularly tricuspid regurgitation, with a resulting systolic murmur. The dilation can temporarily alter conduction in the heart, leading to right-axis deviation and right bundle branch block. An S4 heart sound is almost always pathologic, and this holds true in pregnant women: it should be investigated fully if present.)

A previously healthy 32-year-old G1P0 patient at 39 weeks gestation is rushed to the operating room for cesarean delivery after fetal heart rate tracings display prolonged late decelerations. The patient is induced with propofol, intubated by rapid sequence with succinylcholine, and maintained with 1.8% isoflurane in 100% oxygen. The fetus is delivered safely, but the patient’s blood pressure is noted to be 85/40 mmHg throughout the procedure, down from a baseline of 115/60 mmHg; it responds appropriately and transiently to ephedrine and phenylephrine boluses. The heart rate range is 70-90 bpm, SpO2 is 100% and blood loss is estimated at 900 mL. What is the most likely etiology of hypotension?

a. Anesthetic overdose
b. Amniotic fluid embolism
c. Chorioamnionitis
d. Postpartum hemorrhage

a (Anesthetic overdose
Pregnant patients have decreased MAC requirements of 25-40% compared to non-pregnant women. Isoflurane at 1.8% would be a high dose even in non-pregnant patients (roughly 1.5 MAC), but adjusting for pregnancy it would be closer to 1.7- 2.0 MAC, or approximately the level at which the sympathetic system stops responding to stimuli (MAC-bar). Such hypotension should respond well to pharmacologic sympathetic stimulation with ephedrine or phenylephrine. In contrast, amniotic fluid embolism rapidly deteriorates to total cardiovascular collapse. The blood loss is typical for a cesarean delivery and since the heart rate is not increased, postpartum hemorrhage is less likely. Chorioamnionitis would likely have been present prior to induction of anesthesia, and associated with fever, tachycardia, and possibly hypotension prior to arrival in the operating room.)

Re-order the list of inhaled agents below from highest vapor pressure to lowest (Highest vapor pressure agent at top of list):

Isoflurane
Sevoflurane
Nitrous Oxide
Desflurane

Nitrous Oxide
Desflurane
Isoflurane
Sevoflurane

(At 20o C, the highest vapor pressure of the inhaled agents is possessed by nitrous oxide (38,700 mmHg), followed by desflurane (669 mmHg), isoflurane (238 mmHg) and sevoflurane (157 mm Hg).

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pg. 86
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Clinical signs of tension pneumothorax include:
a. contralateral absence of breath sounds
b. ipsilateral hyporesonance to percussion
c. neck vein distention
d. all of the above
c (neck vein distention

A tension pneumothorax develops from air entering the pleural space through a one-way valve in the lung or chest wall. Clinical signs include ipsilateral absence of breath sounds, hyperresonance to percussion, contralateral tracheal shift and distended neck veins.

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pg. 1497
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 67-year-old, 96-kg man underwent ultrasound-guided supraclavicular blockade for a 2-hour right wrist surgery. Forty ml of 0.5% bupivacaine was injected under ultrasound guidance. In the recovery room the patient reports that his breathing does not feel “normal” and you notice that his pupil diameter is unequal with the right pupil being smaller. Vital signs include HR 65 bpm, BP 117/68 mmHg, SpO2 98% on room air. Which of the following is the BEST course of action?

a. Initiate an intralipid infusion
b. Obtain an upright Chest X-Ray
c. Perform an emergent needle decompression of the right lung
d. Reassure the patient

Although pneumothorax is possible during ultrasound supraclavicular blockade, it is a very rare occurrence. With traditional landmark based supraclavicular block, it is estimated that pneumothorax occurred in 0.5% to 5%. The most common side effects during supraclavicular block are Horner’s syndrome (ipsilateral eye ptosis, miosis and anhidrosis) and phrenic nerve blockade. These occur less frequently compared to an interscalene nerve block and are estimated to occur in 30% to 50% of supraclavicular blocks and are more likely when local anesthetic volumes >20 cc are used. Reassure the patient that the symptoms will resolve as the block resolves. This is clearly not local anesthetic toxicity and therefore intralipid infusion would not be helpful.)

A 34-year-old otherwise healthy woman presents for resection of an occipital glioma in the seated position. She takes no medications. Her preoperative INR is 1.5. What is the likelihood that the transfusion of 2 units of fresh frozen plasma (FFP) would normalize her INR?

a. < 5% b. 25% c. 50% d. 75% e. >90%

a (< 5% Abdel-Wahab prospectively audited all fresh frozen plasma (FFP) transfusions for an INR of 1.1-1.85 at Massachusetts General Hospital over 13 months (324 transfusions had the necessary follow up data). Transfusion of FFP resulted in normalization of only PT-INR values in 0.8% of patients and decreased the INR halfway to normalization in 15% of patients. Interestingly, there was no significant relationship between pretransfusion INR and likelihood of achieving 50 percent correction of the INR after FFP transfusion). There was no dose-response effect, and increasing amounts of FFP did not appear to result in larger decrements in INR. Median decrease in INR was 0.07.)

A patient’s blood type is to be determined. No agglutination is seen when the patient’s blood is mixed with Anti-A antibody or Anti-B antibody. Agglutination is seen when the patient’s blood is mixed with Anti-D antibody. Which ABO blood type PRBCs would be acceptable to administer to this patient?

a. A positive
b. AB positive
c. B positive
d. O positive

d
(O positive
Many antigens are present on the surface of red blood cells. A and B antigens are capable of causing an antibody response that results in fatal intravascular hemolysis, whereas reaction of the D antigen with its antibody can cause hemolytic disease of the newborn. Red blood cells exist with one of 3 clinically important states: A antigen only, B antigen only, or neither the A or the B antigen. When a type and screen is performed, antibodies towards the A and B antigens are mixed with the patient’s blood to check for agglutination, which will occur when the patient’s blood contains the appropriate antigen. In the case above, no agglutination occurs with the mixture of either Anti-A or Anti-B antibodies to the patient’s serum, indicating that the red blood cells do not have either A or B antigen on their surfaces (type O). Agglutination does occur with Anti-D antibody, however, so the Rh type of the patient is “positive,” hence the patient is Type O positive. Because this patient has Type O positive blood, they must receive Type O blood. Because they do have the D antigen, though, they can receive either Rh positive or Rh negative blood.)

A 57-year-old woman has undergone cerebral aneurysm coil embolization under general anesthesia. She awakens but cannot move her right arm and leg and is having trouble following commands. An emergent head CT is performed. Air emboli are visible in the left middle cerebral artery territory. What is the MOST appropriate initial treatment?

a. Air aspiration
b. Hyperbaric oxygen
c. Intravenous thrombolysis (alteplase)
d. Heparin infusion

Emergent treatment for stroke secondary to air embolism is hyperbaric oxygen. Cerebral perfusion pressure should be maintained and the patient placed on 100% oxygen while awaiting hyperbaric therapy.

The hormones produced by the adrenal gland are shown below. By dragging & reordering the selections in yellow, match the hormone to the site of production in the adrenal gland.
a. Glucocorticoids 1. Adrenal Medulla
b. Mineralocorticoids 2. Zona Reticularis
c. Sex Steroids 3. Zona Glomerulosa
d. Catecholamines 4.Zona Fasciculata
a. Glucocorticoids 4.Zona Fasciculata
b. Mineralocorticoids 2. Zona Glomerulosa
c. Sex Steroids 3. Zona Reticularis
d. Catecholamines 1. Adrenal Medulla
(
pg. 772
Yao, FS, Fontes, ML, Malhotra, V. Yao and Artusio’s Anesthesiology. Philadelphia: Lippincott Williams & Wilkins, 2008.)

You are delivering a 10-hour anesthetic for craniotomy. ABG reveals pH 7.35, PCO2 25 mmHg, PO2 183 mmHg, and HCO3 17 mEq/L with base deficit -9. Other electrolytes include: Na 142 mEq/L, K 3.9 mEq/L, Cl 115 mEq/L, CO2 17 mEq/L, BUN 24 mg/dL, Cr 1.1 mg/dL. Which of the following is the MOST likely metabolic abnormality?

a. Anion-gap acidosis
b. Hyperchloremic metabolic acidosis
c. Lactic acidosis
d. Mannitol toxicity

b (Hyperchloremic metabolic acidosis

The ABG and electrolytes reveal a hyperchloremic metabolic acidosis. The anion gap is 10, which makes a lactic acidosis unlikely. Infusion of large volumes of solutions containing sodium chloride and no alkali can cause a hyperchloremic metabolic acidosis. This is due to a dilution of the preexisting bicarbonate and to decreased renal bicarbonate reabsorption as a result of volume expansion.)

A 67-year-old man with a history of coronary artery disease, diabetes and hypertension is undergoing coronary artery bypass grafting. After induction the patient becomes hypotensive with a blood pressure of 85/47 mmHg. A TEE probe is in place. Which TEE view is MOST likley to identify myocardial ischemia in regions supplied by all of the 3 main coronaries (right, left anterior descending and circumflex arteries)?

A. Mid-esophageal four chamber view
B. Mid-esophageal short axis view
C. Transgastric long axis view of the left ventricle
D. Transgastric mid-papillary short axis view

D (Transgastric mid-papillary short axis view ((TEE) is an effective tool in detecting myocardial ischemia as manifested by left ventricular systolic dysfunction. In fact, echocardiographic evidence of wall motion abnormalities has been shown to precede ECG evidence of ischemia. Furthermore TEE has also been shown to be sensitive in the detection of ischemia. The transgastric mid-papillary short axis view is recommended for monitoring of ischemia because it shows portions of the myocardium that are perfused by all three main coronary arteries: the right, left anterior descending and circumflex arteries. It should be noted that this view does have its limitations as it does not provide information about the right ventricle, or the basal or apical segments of the left ventricle.)

Factors decreasing physiologic dead space include:
A. The supine position
B. anticholinergic agents
C. increasing age
D. emphysema
A (the supine position

Dead space is comprised of gases in non-respiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). The sum of the two is known as physiologic dead space. Certain factors affect dead space. The supine position is known to decrease dead space, whereas anticholinergics, ?2-sympathomimetics, advancing age and COPD all increase dead space.

pg. 599
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 363
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.)

When used in the ICU, dexmedetomidine has been associated with a lower risk of delirium when compared to which of the following sedating agents?

A. Opioids
B. Benzodiazepines
C. Propofol
D. Ketamine

B (Benzodiazepines Delirium in the ICU may be to be related to benzodiazepine use. Benzodiazepine use appears to be associated with an increase in delirium when compared to dexmedetomidine – both the Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS) [Pandharipande et al.] and the Safety and Efficacy of Dexmedetomidine Compared to Midazolam (SEDCOM) [Riker et al.] studies suggest that dexmedetomidine may decrease delirium when compared to benzodiazepines.)

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As compared with plasma osmolality, hypertonic crystalloid solutions include:
A. D5W
B. Ringer’s lactate
C. D5 0.25NS
D. D5 0.45 NS

D (D5 0.45NS

Normal plasma osmolality ranges between 280 – 290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOSm /L respectively. D5 0.45NS is hypertonic with a tonicity of 406 – 432 mOsm/L.

pg. 392
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

A 67-year-old man with a history of coronary artery disease, diabetes and hypertension is undergoing coronary artery bypass grafting. After the induction of anesthesia, the patient becomes hypotensive with a blood pressure of 85/47 mmHg. Which of the following monitors is the MOST sensitive for detecting myocardial ischemia?

a. Central venous pressure
b. Electrocardiogram
c. Pulmonary artery occlusion pressure
d. Transesophageal echocardiography

d. (Transesophageal echocardiographyTransesophageal echocardiography (TEE) is an effective tool in detecting myocardial ischemia as manifested by left ventricular systolic dysfunction. In fact, echocardiographic evidence of wall motion abnormalities has been shown to precede ECG evidence of ischemia. Furthermore, TEE has also been shown to be sensitive in the detection of ischemia. Central venous pressure and systolic pulmonary artery pressure may change during ischemia, but neither is sensitive nor specific for ischemia.)

Systemic levels of mepivacaine would MOST likely be the greatest 10 minutes after which of the following regional techniques using an equal volume of 1.5% mepivacaine?

a. Brachial plexus
b. Caudal
c. Epidural
d. Intercostal

d (Intercostal

Systemic absorption of a local anesthetic is determined by the site of injection, the concentration and volume of local anesthetic, the addition of vasoconstricting additives, and the pharmacologic profile of local anesthetic. Generally speaking, the more vascular the region the higher the blood levels after injection. Absorption from the intercostal space is rapid, with plasma concentrations peaking as quickly. Many people use the acronym “ICE-BS” (Intercostal — Caudal — Epidural – Brachial plexus – Spinal) to remember fastest to slowest systemic absorption.)

An otherwise healthy 25-year-old man is scheduled to undergo removal of ankle hardware under general anesthesia. A popliteal nerve block is performed for postoperative analgesia via an anterior approach using nerve stimulation. Which of the following motor responses at 0.5 mA nerve stimulation is expected when the needle is appropriately near the tibial nerve?

a. Plantar flexion of ankle
b. Dorsiflexion of ankle
c. Eversion of ankle
d. Toe extension

a (Plantar flexion of ankle
The sciatic nerve splits into the *tibial* and *common peroneal* nerve around the level of the popliteal fossa. The tibial nerve goes on to innervate the *gastrocnemius* and the *soleus* muscles of the calf, which function in flexion of the foot and ankle. A motor response for the tibial nerve would therefore result in plantar flexion of the ankle and toe flexion (not extension). Stimulation of the common *peroneal nerve* results in ankle eversion and *dorsiflexion*.)

A 26-year-old woman presents for laparoscopic cholecystectomy. She has a family history of sudden death and was found to have hypertrophic cardiomyopathy (HCM). Which of the following is a MOST correct regarding hypertrophic cardiomyopathy?

a. Decreased systemic vascular resistance following induction can be beneficial since it increases cardiac output
b. Beta blockers will worsen stroke volume in HCM
c. Reverse Trendelenburg position during laparoscopy can worsen the systolic anterior motion of the mitral valve leaflet
d. The gradient across the aortic valve will be likely to be higher than the gradient across left ventricular outflow tract

c (Reverse Trendelenburg position during laparoscopy can worsen the systolic anterior motion of the mitral valve leaflet

Asymmetric left ventricular hypertrophy is characteristic of HCM, which can be diagnosed by echocardiography. Hypertrophy is more common in the upper interventricular septum, below the aortic valve leading to left ventricular outflow tract (LVOT) obstruction. High velocity blood flow across the LVOT during systole can result in venturi effect leading to suctioning of anterior mitral leaflet into LVOT (known as systolic anterior motion of mitral valve leaflet or SAM). Factors that increase the velocity of blood across LVOT such as decreased systemic vascular resistance, decreased preload, and increased myocardial contractility can result in SAM and a worsening in the LVOT obstruction. Since the obstruction is at level of the LVOT, the gradient is higher across LVOT than at the level of aortic valve. However, the obstruction is dynamic compared to a fixed obstruction such as aortic valve stenosis. The beneficial role of beta-blockers is due to the decreased heart rate with resultant prolongation of diastole and increased time for passive ventricular filling.)

Stimulation of the parasympathetic nervous system results in:
a. far vision accommodation
b. increased inotropy
c. increased insulin secretion
d. contraction of the urinary sphincter
C (increased insulin secretion

Insulin secretion is increased by stimulation of the parasympathetic nervous system through the vagus nerves.

pg. 1343
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 9-month-old infant with beta-thalassemia major was initially normal at birth with no evidence of hemolysis or anemia. The presence of which hemoglobin is the MOST likely reason for this presentation at birth?

a. Hemoglobin A
b. Hemoglobin B-thal
c. Hemoglobin F
d. Hemoglobin S

c (Hemoglobin F
Normal hemoglobin has two alpha and two beta globin protein chains. A deficiency or absence of the alpha chain results in Alpha-thalassemia and a deficiency or absence of one or more of the beta chains results in Beta-thalassemia. Newborns with Beta-thalassemia major usually are normal at birth because of the initial predominance of hemoglobin F. As this hemoglobin is replaced with defective hemoglobin, they develop anemia from hemolysis during the first year of life.)

Neuraxial anesthesia is MOST appropriate for which of the following patients?

a. A 32-year-old woman patient receiving a recombinant hirudin derivative (desirudin, lepirudin) due to previous heparin induced thrombocytopenia.
b. A 55-year-old woman undergoing total hip arthroplasty who is receiving aspirin 325mg bid
c. A 70-year-old man who had a drug-eluting stent placed 6-months ago and continues on clopidogrel therapy
d. A 75-year-old man who stopped coumadin 3 days ago and the INR is pending

b (A 55-year-old woman undergoing total hip arthroplasty who is receiving aspirin 325mg bid

Nonsteroidal anti-inflammatory drugs seem to represent no added significant risk for the development of spinal hematoma in patients having epidural or spinal anesthesia. Nonsteroidal anti-inflammatory drugs (including aspirin) do not create a level of risk that will interfere with the performance of neuraxial blocks. Caution should be used when performing neuraxial techniques in patients recently discontinued from long-term warfarin therapy. In the first 1 to 3 days after discontinuation of warfarin therapy, the coagulation status (reflected primarily by factor II and X levels) may not be adequate for hemostasis despite a decrease in the INR (indicating a return of factor VII activity). Adequate levels of II, VII, IX, and X may not be present until the INR is within reference limits. We recommend that the anticoagulant therapy must be stopped (ideally 4-5 days before the planned procedure) and the INR must be normalized before initiation of neuraxial block. On the basis of labeling and surgical reviews, the suggested time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 14 days for ticlopidine and 7 days for clopidogrel. Recombinant hirudin derivatives, including desirudin (Revasc), lepirudin (Refludan), and bivalirudin (Angiomax) inhibit both free and clot-bound thrombin. Argatroban (Acova), an l-arginine derivative, has a similar mechanism of action. These medications are indicated for the treatment and prevention of thrombosis in patients with heparin-induced thrombocytopenia and as an adjunct to angioplasty procedures. There is no “antidote”; the antithrombin effect cannot be reversed pharmacologically. Although there are no case reports of spinal hematoma related to neuraxial anesthesia among patients who have received a thrombin inhibitor, spontaneous intracranial bleeding has been reported.)

A 67-year-old, 96-kg man underwent ultrasound-guided supraclavicular blockade for a 2-hour right wrist surgery. Forty ml of 0.5% bupivacaine was injected under ultrasound guidance. In the recovery room the patient reports that his breathing does not feel “normal” and you notice that his pupil diameter is unequal with the right pupil being smaller. Vital signs include HR 65 bpm, BP 117/68 mmHg, SpO2 98% on room air. Which of the following is the BEST course of action?

a. Initiate an intralipid infusion
b. Obtain an upright Chest X-Ray
c. Perform an emergent needle decompression of the right lung
d. Reassure the patient

d (Reassure the patient

Although pneumothorax is possible during ultrasound supraclavicular blockade, it is a very rare occurrence. With traditional landmark based supraclavicular block, it is estimated that pneumothorax occurred in 0.5% to 5%. The most common side effects during supraclavicular block are Horner’s syndrome (ipsilateral eye ptosis, miosis and anhidrosis) and phrenic nerve blockade. These occur less frequently compared to an interscalene nerve block and are estimated to occur in 30% to 50% of supraclavicular blocks and are more likely when local anesthetic volumes >20 cc are used. Reassure the patient that the symptoms will resolve as the block resolves. This is clearly not local anesthetic toxicity and therefore intralipid infusion would not be helpful.)

A 28-year-old woman with a grossly infected ingrown toenail presents for debridement of the affected area. The great toe is swollen, with red streaks radiating up the foot. The orthopedic surgeon plans to inject local anesthetic directly into the infected area prior to debriding the toe. Which of the following BEST explains why the injection of local anesthetics into an abscess is LESS effective than an ankle block?

a. More highly protein bound in acidotic tissue
b. More highly ionized in acidotic tissue
c. More highly lipid soluble in acidotic tissue
d. More rapidly metabolized in acidotic tissue

b (More highly ionized in acidotic tissue

Onset of action is largely dependent on the Pka of the local anesthetic and the total dose administered. Nonionized forms of local anesthetics pass more easily through lipid bilayer; therefore, in an acidic environment there will be more local anesthetic in the ionized form and the onset will be slower and patchy.)

What is the maximal reduction in the cerebral metabolic requirement for oxygen (CMRO2) achievable exclusively through the use of high-dose barbiturates?

a. 10%
b. 25%
c. 50%
d. 75%
e. 90%

c (50%

At best, high-dose barbiturates can only reduce the CMRO2 by approximately 50%. Barbiturates, as most anesthetics, are only able to reduce that proportion of the CMRO2 that is responsible for electrical activity. As electrical activity accounts for only about 50% of the CMRO2, barbiturates can only reduce it by an equivalent amount. Further reductions in CMRO2 are really only possible with hypothermia.)

You are taking care of a 6-week-old infant with congenital lobar emphysema. He was born full term and was doing well at home until he developed respiratory distress. He is scheduled for a left upper lobe resection via a thoracotomy. He has been NPO for breast milk for 6 hours and he is now in the operating room. After the placement of standard ASA monitors, what is the MOST appropriate immediate anesthetic plan?

a. Inhalation induction, controlled ventilation, double lung ventilation
b. Inhalation induction, spontaneous ventilation, single lung ventilation
c. Intravenous induction, controlled ventilation, single lung ventilation
d. Intravenous induction, spontaneous ventilation, double lung ventilation

b (Inhalation induction, spontaneous ventilation, single lung ventilation
Congenital lobar emphysema is a developmental anomaly of the lung that is characterized by hyperinflation of one or more of the pulmonary lobes. In patients with congenital lobar emphysema, an inhalation induction that maintains spontaneous ventilation is preferred. Positive pressure ventilation may cause respiratory compromise or pneumothorax. After the induction of anesthesia the airway is secured with an endotracheal tube. Lung isolation is recommended to minimize inflation of the emphysematous lung. This can be achieved with an endobronchial intubation, bronchial blocker or a Fogarty catheter)

A 68-year-old man undergoes right colectomy for colorectal cancer. He had been taking clopidogrel, which was held for one week prior to surgery. Intraoperatively he is transfused one unit of PRBCs and one unit of platelets. On post-operative day 3, his hemoglobin drops from 10 to 8.2 mg/dL. He is hemodynamically stable and only complains of mild back pain. He is transfused 1 unit of PRBCs and follow-up Hgb is 8.4 mg/dL. What is the MOST likely cause for his anemia?

a. Dilution of blood by maintenance IV fluids
b. Inadequate surgical hemostasis exacerbated by preoperative clopidogrel
c. Carcinoma-induced coagulopathy
d. Immune-mediated reaction

d (Immune-mediated reaction

This patient most likely has a delayed antibody-mediated hemolytic transfusion reaction from the PRBCs given during his surgery. Hemolysis is the most likely cause for the patient’s anemia at this time due to lack of signs suggestive of acute blood loss. Such reactions can occur 3-21 days post-transfusion. Laboratory values such as elevated unconjugated bilirubin help lend evidence to this mechanism for his anemia.)

Which of the following factors conveys the HIGHEST risk of abnormal placentation (accreta, increta, percreta)?

a. Prior cesarean section
b. Advanced maternal age
c. Placenta previa
d. Pre-eclampsia

c (Placenta previa
This is a challenging question that few people answer correctly! Most anesthesiologists do not know that placenta previa is associated with the greatest risk of abnormal placentation. While prior cesarean section, advanced maternal age, and placenta previa ALL convey an increased risk of abnormal placentation, placenta previa carries the highest risk with an odds ratio of 51.42 (vs. 2.16 for 1 prior cesarean section, or 8.62 for ?2 prior cesarean sections, and 1.14 for age). Pre-eclampsia has been shown to correlate with abnormal placentation in certain circumstances but a true causative effect has not been specified. The combination of placenta previa in the setting of multiple prior cesarean sections markedly increases the risk of abnormal placentation.)

After the unintentional intravascular injection of bupivacaine during an attempted caudal, a 3-month-old 5 kg full term boy develops local anesthetic toxicity. Resuscitation is initiated with chest compressions, ventilation, and epinephrine. What is the MOST appropriate dose of 20% intralipid?

a. 1 ml IV bolus
b. 2.5 ml IV bolus
c. 10 ml IV bolus
d. 20 ml IV bolus

c (10 ml IV bolus
The most appropriate management is a 1.5 mL/kg bolus of 20% intralipid followed by 0.25 mL/kg/min according to Guy Weinberg [founder of LipidRescue]. In older textbooks, some authors have recommended 4 ml/kg but the dose recommended by Dr Weinberg and ASRA is 1.5 ml/kg. Propofol is NOT an appropriate substitute.)

The highest level of protein binding is seen with:
a. procaine
b. lidocaine
c. mepivacaine
d. bupivacaine
d (bupivacaine

The physicochemical property that determines the duration of action of a local anesthetic is lipid solubility, which is directly correlated with plasma protein binding. Bupivacaine and levobupivacaine have the highest degree of protein binding (97%).

pg. 269
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 56-year-old man is undergoing a right carotid endarterectomy with intraoperative EEG monitoring. Which of the following cerebral blood flow rates is associated with EEG deterioration?

a. 10-15 mL/min/100 gm
b. 15-20 mL/min/100 gm
c. 20-25 mL/min/100 gm
d. 25-30 mL/min/100 gm

b (15-20 mL/min/100 gm
EEG provides evidence of electrical activity to cortical surface cells, which is an area vulnerable to ischemia. *Regional cerebral blood flow is 50-55 mL/min/100gm* brain tissue and *ischemia begins at 18-20 mL/min/100gm* and thus *EEG deterioration* becomes evident in the range of *15-20 mL/min/100gm*. EEG signs of ischemia include slowing of the EEG in addition to amplitude reduction. In cases of severe ischemia, the EEG becomes isoelectric. There are some limitations to use of EEG to monitor neurologic status during carotid surgery and these include that deeper structures are not able to be monitored, preexisting deficits are not accounted for or may result in lack of intraoperative EEG changes. EEG changes are also affected by temperature, blood pressure, CO2 tension and anesthetic depth.)

A 9-month-old infant presents to the OR for a right inguinal hernia repair. The newborn screening was positive for beta-thalassemia major. Which of the following MOST accurately defines this condition?

A. Absence of one of the beta-globin proteins
B. Absence of both of the beta-globin protein
C. Absence of one of the alpha-globin proteins
D. AAbsence of both of the alpha-globin proteins

B (Absence of both of the beta-globin protein

Normal hemoglobin has two alpha and two beta globin protein chains. A deficiency or absence of the alpha chain results in Alpha-thalassemia and a deficiency or absence of one or more of the beta chains results in Beta-thalassemia. The beta chain requires a gene from each parent to produce the correct quality and quantity of beta globin. If the gene from one parent is missing or incomplete, the child will develop Beta-thalassemia minor. If the gene from both parents is missing, the child will develop Beta-thalassemia major or Cooley’s anemia.)

Mechanisms of renal compensation during acidosis include:
a. decreased reabsorption of filtered bicarbonate
b. decreased excretion of hydrogen ions
c. increased production of ammonia
d. increased elimination of carbon dioxide
c (increased production of ammonia

The renal response to acidemia is:

increased reabsorption of bicarbonate anion
increased excretion of hydrogen ion in the form of titratable acids
increased production of ammonia

Although increased carbon dioxide elimination is a compensatory mechanism in acidemia, it is accomplished by increased alveolar ventilation.

pg. 734
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

A 57-year-old man with ESRD develops progressive bradycardia with peaked T-waves following reperfusion of the renal allograft during a kidney transplant. Which of the following is the MOST appropriate initial treatment?

a. Calcium chloride 500-1000 mg IV
b. Glucose 25-50g/Insulin 5-10 U IV
c. Hyperventilation to PaCO2 30 mmHg
d. Sodium bicarbonate 8.4 % 50 ml IV

a (Calcium chloride 500-1000 mg IV
This patient has ECG changes that suggest symptomatic hyperkalemia. All the options listed would effectively lower serum potassium. Glucose/Insulin, hyperventilation, and bicarbonate all function by shifting potassium from the extracellular space into the intracellular space. Unfortunately, each of these interventions takes time (5-10 minute minimum) to be effective. Calcium is a physiologic antagonist and can temporarily stabilize the myocardium. Calcium is effective almost immediately and thus is the initial treatment of choice in this patient.)

A 40-year-old woman with multiple sclerosis presents for a vaginal hysterectomy. Which of the following has been MOST associated with perioperative multiple sclerosis exacerbation?

a. Intraoperative hyperthermia
b. Ketorolac for perioperative analgesia
c. Neuromuscular blockade with rocuronium
d. Reversal of neuromuscular blockade with neostigmine

a (Multiple sclerosis (MS) is a *central demyelinating* neurologic disease. MS is characterized by periods of relapse and remission and variable presentation. It is said to “vary in space [affected areas] and time [relapse and remission].” Patients may be either sensitive or insensitive to neuromuscular blockade and succinylcholine may result in hyperkalemia; however, there is no evidence that neuromuscular blockade or its reversal is associated with perioperative exacerbation. Ketorolac has not been implicated in perioperative exacerbations. Hyperthermia has been associated with perioperative exacerbations and increases as little as 1C may result in disease exacerbation.)

A 67-year-old man with a history of coronary artery disease, diabetes and hypertension is undergoing coronary artery bypass grafting. After the induction of anesthesia, the patient becomes hypotensive with a blood pressure of 85/47 mmHg. Which of the following monitors is the *MOST sensitive* for detecting myocardial ischemia?

a. Central venous pressure
b. Electrocardiogram
c. Pulmonary artery occlusion pressure
d. Transesophageal echocardiography

d (Transesophageal echocardiography
Transesophageal echocardiography (TEE) is an effective tool in detecting myocardial ischemia as manifested by left ventricular systolic dysfunction. In fact, echocardiographic *evidence of wall motion abnormalities has been shown to precede ECG evidence* of ischemia. Furthermore, TEE has also been shown to be sensitive in the detection of ischemia. Central venous pressure and systolic pulmonary artery pressure may change during ischemia, but neither is sensitive nor specific for ischemia.)

A 24-year-old man with a history of T4 paraplegia is undergoing his first anesthetic for a urinary diversion due to a neurogenic bladder. As the surgeon makes the incision, his BP reaches 220/110 mmHg with a heart rate of 45 bpm. Which of the following is the MOST appropriate first step in treatment?

a. Atropine
b. Dantrolene
c. Fentanyl
d. Nitroprusside

d (Nitroprusside
In a patient with a history of a *spinal cord lesion higher than T7*, marked hypertension and bradycardia is concerning for autonomic hyperreflexia. Normally, descending inhibitory impulses travel down the spinal cord to block reflex arcs to cutaneous, visceral, or proprioceptive stimuli. This arc is disrupted in spinal cord injury and can lead to autonomic instability, most notably severe hypertension followed by a sustained vagal response including bradycardia, vasodilation, and cutaneous flushing. Treatment is supportive, including *stopping the inciting stimulus* (ask surgeons to pause) and *lowering the blood pressure* to normal levels via *vasodilators* and assuring *adequate levels of anesthesia*.)

The most common complication of thoracic paravertebral nerve block is:
a. hypotension
b. subarachnoid injection
c. pneumothorax
d. intravascular injection
c (pneumothorax

Pneumothorax is the most common complication of paravertebral block and a chest radiograph is needed upon completion of the block. Other complications include subarachnoid injection, epidural injection, intravascular injection, and hypotension.

pg. 1073
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Regional anesthesia of this area can be accomplished with a block of the:
Radial nerve

Regional anesthesia in this area can be accomplished with a block of the:
Median nerve

Regional anesthesia in this (doral) area can be accomplished with a block of the:
Ulnar nerve

Regional anesthesia in this (ventral) area can be accomplished with a block of the:
Median nerve

Regional anesthesia in this (ventral) area can be accomplished with a block of the:
Ulnar nerve

Regional anesthesia in this (ventral) area can be accomplished with a block of the:
Radial nerve

d (treatment of hypotension with phenylephrine

This pressure-volume loop is indicative of aortic stenosis. Patients with severe aortic stenosis have a fixed stroke volume, and cardiac output is rate dependent. Both tachycardia and bradycardia are poorly tolerated. Vasodilation from regional anesthesia or volatile agents may precipitate severe hypotension. Treatment of hypotension should be prompt and accomplished with small doses of an alpha-stimulant such as phenylephrine.

pp. 483, 500-502
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

Anesthetic management of the patient with the pressure-volume loop shown below (red) should include:

a. maintenance of a heart rate of < 50 b. spinal or epidural anesthesia if possible c. vasodilator therapy d. treatment of hypotension with phenylephrine

A 55-year-old previously healthy woman presents with trigeminal neuralgia. Which of the following agents is the MOST appropriate first-line pharmacologic treatment?

a. Amitriptyline
b. Carbamazepine
c. Oxycodone
d. Phenytoin

b (Carbamazepine
Trigeminal neuralgia is characterized by intense, stabbing pain in the distribution of the trigeminal nerve. The symptoms are usually unilateral. The patient may experience exacerbations with more frequent attacks, followed by remissions with fewer and less frequent attacks. Carbamazepine (Tegretol) [CNS Na-Ch blocker]is the first line treatment for trigeminal neuralgia.)

Which of the following drugs is included in Step 1 in the World Health Organization (WHO) analgesic ladder?

a. Codeine
b. Ketoprofen
c. Propoxyphene
d. Tramadol

b (Ketoprofen
The World Health Organization (WHO) analgesic ladder was established in 1986 to guide physicians developing treatment plans for cancer pain. In general terms, *Step 1 includes Non-opioid analgesics*, with or without adjuvants. *Step 2 includes “weak” opioids* (such as codeine, propoxyphene, and tramadol), with or without adjuvants. *Step 3 includes “strong” opioids* (such as morphine, fentanyl, and methadone) and non-opioids, without or without adjuvants. Ketoprofen is the only non-opioid listed.

Which of the following is LEAST likely to be a contraindication to left ventricular assist device (LVAD) placement?

a. An atrial septal defect
b. Severe aortic insufficiency
c. Severe mitral regurgitation
d. Severe mitral stenosis

This is a challenging question that few people answer correctly! Most anesthesiologists do not know contraindications to left ventricular assist device (LVAD) placement. Placement of a left ventricular assist device *(LVAD) improves forward flow* and typically reduces mitral regurgitation; therefore, this is not a contraindication to placement. Severe mitral stenosis must be corrected as it is an impediment to flow into the LVAD’s inflow cannula. An atrial septal defect (or significant PFO) could result in right to left shunting and hypoxemia. Severe aortic regurgitation would cause most of the flow out of the LVAD’s outflow cannula to go back into the left ventricle instead of systemically.)

In acute hemorrhage and resuscitation, which of the following coagulation factors is MOST likely to reach a critically low level first?

a. Factor VIII
b. Fibrinogen
c. Platelets
d. Thrombin (Factor IIa)

b (
*Fibrinogen* will reach a critical level (i.e., below 100 mg/dL) after *loss of about 1.5 blood volumes*. Other coagulation factors typically reach critical levels after about 2 to 2.5 blood volumes.)

Which of the following would be LEAST likely to decrease mixed venous oxygen saturation (SVO2)?

a. Anemia
b. Cyanide poisoning
c. Hypoxemia
d. Shivering

B (
*Cyanide poisoning* results in the cell’s *inability to utilize oxygen for ATP production*, thus the body’s oxygen consumption (VO2) is low. SVO2 is inversely related to VO2, thus SVO2 would be expected to be high in cyanide poisoning. Shivering would result in the opposite — an increase in VO2 and therefore a decrease in SVO2. Anemia and hypoxemia both result in a lower SVO2.)

A 110 kg man presents for right upper lobectomy via a thoracoscopic approach for squamous cell carcinoma located in the right upper lobe. His preoperative exam is significant for micrognathia. Which of the following characteristics of a single lumen ETT used with a bronchial blocker instead of a double lumen endobronchial tube provides the GREATEST advantage in this patient?

a. Relative ease of intubation with single lumen ETT
b. Superior and reliable lung isolation
c. Use of CPAP for operative lung
d. Decreased cost

a (Relative ease of intubation with single lumen ETT

Various techniques exist for lung isolation and one lung ventilation (OLV) during thoracoscopic lung resection. Either a double lumen endobronchial tube (DLT) or a single lumen ETT with a bronchial blocker can be successfully used to achieve OLV. Although better lung isolation is typically achieved with a DLT, single lumen ETT’s with bronchial blockers do offer some advantages. Because the airway is secured with a single lumen tube, the actual act of intubation is typically easier (note, though, that it is not necessarily easier to achieve correct positioning of the bronchial blocker for lung isolation than it is for positioning of the DLT within the tracheobronchial tree, (Bauer et al. 2001).). Additionally, single lumen ETT’s with bronchial blockers allow the isolation of individual lung segments, and should mechanical ventilation need to be continued post-operatively, tube exchange is not required. Bronchial blockers, however, are associated with a greater expense. It is not possible to apply CPAP or suction the operative lung through a bronchial blocker.)

An otherwise healthy 45-year-old woman is seen at an ambulatory surgical center for release of Dupuytren’s contracture. A brachial plexus block is performed using the axillary approach. Assuming that no other nerve blocks are performed, and that the axillary block successfully achieves a complete motor and sensory block in its intended distribution, which of the following motor responses in the blocked extremity would MOST likely still be present?

a. Wrist flexion
b. 1st-5th digit adduction
c. Forearm supination
d. Extension of the MCP joints

c (Forearm supination
At the level of the axillary artery, the brachial plexus has divided into three cords (medial, lateral, and posterior), which are named in relationship to the axillary artery. These three cords travel with the axillary artery within the axillary sheath. The musculocutaneous nerve, however, as a terminal branch of the lateral cord, travels separately and is NOT located inside the axillary sheath. Thus, it must be blocked separately from an axillary brachial plexus block. Assuming that a musculocutaneous nerve block has not been performed, we would not expect to see a motor block of the biceps muscle, and elbow flexion and forearm supination, as well as cutaneous sensation to the lateral forearm, would be intact.)

Two days after resection of a brain tumor through a right frontal craniotomy, a 70-year-old man has persistent postoperative delirium with waxing-waning mental status. His sodium is 136 mEq/L and glucose is 123 mg/dL. A head CT reveals some residual pneumocephalus but no hemorrhage. Which of the following is the MOST appropriate next step in his care?

a. Brain MRI
b. Transcranial Doppler
c. Continuous EEG monitoring
d. High flow oxygen (FiO2 1.0)

c (Continuous EEG monitoring
The basic differential diagnosis for a patient with neurologic decline post-craniotomy is the following: 1. Hemorrhage 2. Tension pneumocephalus 3. Venous or arterial stroke 4. Hydrocephalus 5. Infection (urinary, pulmonary, CNS) 6. Seizures 7. Metabolic (usually sodium abnormalities). 8. Retraction injury/surgical injury. Items 1-4 are “ruled out” with a CT scan to a large extent. Infection is a consideration and should be considered, especially if the patient is on high dose dexamethasone. Surgical injury to the brain (whether avoidable or unavoidable) is possible, but generally should not produce fluctuating encephalopathy after resection of a unilateral frontal lobe tumor. Therefore, seizure activity should be highly suspected and investigated.)

A 5 kg 3-month-old full term boy presents for right inguinal hernia repair. A caudal block is performed with 1 ml/kg 0.25% bupivacaine during sevoflurane anesthesia via an endotracheal tube. The infant’s vital signs prior to injection reveal a HR of 133 bpm, SBP 83 mmHg, upright T-waves in lead II. Which of the following is the MOST appropriate test dose of epinephrine?

a. 1 mcg
b. 2.5 mcg
c. 10 mcg
d. 25 mcg

b (2.5 mcg

The dose of epinephrine required to identify intravascular injection for pediatric regional anesthesia during inhaled anesthesia is *0.5 mcg/kg up to a max of 15 mcg*. Sethna described HR and BP changes with intravenous injections of 0.5 and 0.75 mcg/kg of epinephrine in infants greater than 3 mo. 0.5 mcg/kg was almost identical to 0.75 mcg/kg regarding heart response. SBP was more consistently elevated in patients receiving 0.75 mcg/kg of epinephrine.)

A 3-month-old full term boy presents for right inguinal hernia repair. He experiences an intravascular injection during the administration of a caudal the test dose. Atropine was administered 5 minutes prior to the test dose. What is the EARLIEST clinical marker of this intravascular injection of epinephrine?

a. HR increase greater than 10 bpm
b. HR increase greater than 20 bpm
c. SBP increase greater than 25 mmHg
d. ST segment elevation greater than 25%

a (HR increase greater than 10 bpm
The *earliest sign of intravascular injection is T wave elevation* greater than 25% (not ST segment elevation). Another very sensitive marker of intravascular injection is an elevation in HR of 10 or more bpm. Unlike adults, children are usually under anesthesia during the test dose and the sensitivity of epinephrine is reduced (especially when halothane was used) if the *standard HR response of 20 bpm* is expected. The administration of an anticholinergic and reducing the HR response to 10 bpm will increase the sensitivity of the test dose. In fact some evidence suggests that if atropine or glycopyrrolate is given prior to the test dose and a HR of 10 bpm is utilized, the sensitivity of 0.5 mcg/kg is 100%.)

Characteristics of omphalocele include: (Select 2)
a. location lateral to the umbilicus
b. lacks a hernia sac
c. results from the failure of midgut migration into the abdomen
d. nitrous oxide should be used during the repair to ensure a rapid emergence
e. association with trisomy 21
f. results from abnormal development of the right omphalomesenteric artery
c, e (association with trisomy 21, results from the failure of midgut migration into the abdomen

Gastroschisis and omphalocele are characterized by defects in the abdominal wall that allow herniation of the viscera. *Omphaoceles* occur at the *base of the umbilicus*, have a *hernia sac* and are commonly *associated with other anomalies*. In contrast, *gastroschisis* is usually *lateral to the umbilicus*, *lacks a hernia sac* and is usually an *isolated finding*. Nitrous oxide is best avoided during repair as it may result in bowel distention making closure more difficult.

pg. 901
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 70 kg adult man presents for emergent exploratory laparotomy after free air is seen on abdominal imaging. In addition, his serum sodium is 160 mEq/L. Which of the following is NOT true?

a. A relatively higher concentration of sevoflurane will be needed for adequate anesthesia
b. The fastest rate at which his sodium should be corrected is 1.5 mEq/L/h.
c. His condition would likely be worsened by administration of demeclocycline.
d. Rapid correction of his sodium level could result in permanent neurologic deficit

b (The fastest rate at which his sodium should be corrected is 1.5 mEq/L/h.
In general, plasma *sodium concentration* should not be *decreased faster than 0.5 mEq/L/h*. Rapid correction of hypernatremia can result in permanent neurologic damage, as well as seizures and brain edema. *Hypernatremia increases* the *minimum alveolar concentration* for inhaled anesthetics. *Demeclocycline* is a tetracycline antibiotic that *interferes with* the action of *ADH*. By blocking ADH at its receptor, demeclocycline impairs the ability of the kidneys to concentrate urine, and therefore may worsen hypernatremia. Because of this effect, demeclocycline is used as off label treatment for SIADH.)

A 30-year-old man with acromegaly undergoes the transsphenoidal resection of a pituitary adenoma. On postoperative day one, the patient develops a brisk diuresis. Which of the following laboratory measurements MOST supports the diagnosis of diabetes insipidus?

a. Serum sodium 145 meq/L
b. Serum sodium 135 meq/L
c. Urine osmolarity of 300 mOsm/L
d. Urine osmolarity of 450 mOsm/L

a (Serum sodium 145 meq/L
Diabetes insipidus (DI) may be pituitary (central) or nephrogenic. Pituitary DI is characterized by a relative or absolute deficiency of antidiuretic hormone (ADH). Nephrogenic DI is characterized by kidneys that do not respond normally to ADH. In the context of pituitary surgery, pituitary DI is much more common. The relative or absolute deficiency of ADH results in the failure of the distal and collecting tubules to absorb water. This results in dilute urine and, most commonly, a rising serum sodium.)

A previously healthy 29-year-old G1P0 patient is admitted with the diagnosis of preeclampsia and is treated with an intravenous infusion of magnesium sulfate. Later, her serum magnesium level is found to be 10 mEq/L. Which of the following is MOST correct regarding magnesium?

a. ECG changes associated with hypermagnesemia include prolongation of the P-R interval and widening of the QRS complex.
b. Increased levels of magnesium are associated with vasoconstriction and exacerbation of hypertension.
c. Magnesium is a substance that cannot be removed via dialysis.
d. Should she require general anesthesia, her dose of non-depolarizing muscle relaxant should be increased by 25%.

a (ECG changes associated with hypermagnesemia include prolongation of the P-R interval and widening of the QRS complex.

Pathologic increases in the levels of serum magnesium are frequently due to excessive intake (magnesium containing antacids, laxatives, or treatment during pregnancy induced hypertension and preeclampsia). Loss of deep tendon reflexes occurs at 10 mEq/L, with the risk of cardiac depression, ECG changes, and ultimately respiratory arrest increasing as levels rise. ECG changes are inconsistent, but frequently show a widening of the QRS complex and a prolongation of the P-R interval. Increased levels of magnesium are associated with a drop in SVR and hypotension, not hypertension. Magnesium interferes with the release of acetylcholine, thus potentiating neuromuscular blocking drugs so the dose would need to be decreased, not increased. Magnesium can be dialyzed if necessary.)

Disodium edetate or sodium metabisulfite is added to formulations of propofol to:
a. enhance drug solubility
b. adjust pH
c. inhibit bacterial growth
d. increase drug potency
c (inhibit bacterial growth

Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth.

pg. 186
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

According to the American College of Cardiology/American Heart Association 2009 Expert Consensus Document on pulmonary hypertension, the diagnosis of pulmonary arterial hypertension does NOT require which of the following?

a. Resting mPAP > 25mmHg
b. PVR > 3 Wood units
c. PCWP/LAP less than or equal to 15mmHg
d. Right ventricular hypertrophy

d (In order to make the diagnosis of pulmonary hypertension, the ACC/AHA expert consensus document requires right heart catheterization and confirmation of *all 3* of the following hemodynamic findings: 1) Resting *mPAP >25mmHg*; 2) *PCWP/LAP < 15 mmHg*; and 3) *PVR > 3 Woods units*. Right ventricular hypertrophy is not required.)

A 12-year-old girl presents for a posterior spine fusion. Except for idiopathic scoliosis, she is healthy and weighs 50 kg. Which of the following is the MOST appropriate dose of methadone?

a. 4 mg
b. 8 mg
c. 12 mg
d. 16 mg

Typical *pediatric* dosing of *methadone* includes a *bolus of 0.1-0.2* mg/kg followed by *0.05 mg/kg *every 6-8 hours.

Which of the following anomalies is MOST likely to be associated with congenital diaphragmatic hernia?

a. Horseshoe kidney
b. Hypoplastic left heart
c. Radial limb anomalies
d. Vertebral anomalies

b (Hypoplastic left heart
A congenital diaphragmatic hernia (CDH) is an early developmental defect that results in the extrusion of intraabdominal organs (i.e. stomach, small intestines, kidney, liver) into the thoracic cavity. Significant cardiac disease is associated with at least 10% of of patients with CDH. Survival for patients with cardiac disease is significantly lower than for patients with normal cardiac anatomy. Patients with CDH and univentricular cardiac anatomy have a poor prognosis.)

Anesthetic implications of multiple sclerosis include:
a. the postponement of elective procedures during relapse
b. exacerbation induced by peripheral nerve block
c. exacerbation of symptoms secondary to hypothermia
d. the presence of significant peripheral neuropathy causing severe hyperkalemia after succinylcholine administration
a (the postponement of elective procedures during relapse

Surgery and other physiologically stressful events should be avoided during episodes of relapse. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia.

pp. 620, 621
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

You are called to the NICU to perform an anesthetic on a 3.5 kg neonate with congenital diaphragmatic hernia. The patient is intubated with conventional mechanical ventilation. The most recent arterial blood gas reveals a pH 7.38, PaCO2 45 mmHg, PaO2 89 mmHg, HCO3 29 mEq/L, SaO2 of 97% on an FiO2 of 0.6. Peak airway pressures are 32 cmH2O with 5 cmH2O PEEP. Expiratory tidal volume is 45 ml. Which of the following is the MOST appropriate ventilatory management for this patient?

a. Decrease peak airway pressure to 25 cmH2O
b. Decrease FiO2 to 50%
c. Increase FiO2 to 90%
d. Increase PEEP to 7 cmH2O

a (Decrease peak airway pressure to 25 cmH2O

Due to the concern of aggressive ventilation on both the short-term survival as well as long-term outcomes of *congenital diaphragmatic hernia*, ventilatory strategies that employ small tidal volumes with *permissive hypercapnia* have gained widespread acceptance. Boloker, et al. suggested preservation of spontaneous ventilation, acceptance of a pre-ductal oxygen saturation of 90-95% with *>80% tolerated if the infant appears comfortable*, permissive *hypercapnia of 60-65 mmHg*, and peak *inspiratory pressures < 25 cm H20*.)

A decrease in cerebral blood flow is seen after the administration of:
a. isoflurane
b. propofol
c. desflurane
d. ketamine
b (propofol

The inhaled anesthetic agents and ketamine all increase cerebral blood flow (CBF). Benzodiazepines, etomidate, propofol and barbiturates all decrease CBF.

Download CoreNotes

pg. 701
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

The age group with the highest minimum alveolar concentration (MAC) of desflurane is:
a. 2 – 3 months
b. 1 – 2 years
c. 25 – 30 years
d. greater than 75 years
a (2 – 3 months

The two-to-three-months-of-age group represents the highest MAC requirement. MAC subsequently decreases with advancing age.

pg. 883
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

While providing anesthesia for a patient with a history of HIV on highly active antiretroviral therapy (HAART) including the drug indinavir, which of the following medications is LEAST likely to have altered metabolism?

a. Midazolam
b. Methadone
c. Diltiazem
d. Gentamicin

d (Gentamicin
HAART consists of a combination of drugs including nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors. Protease inhibitors inhibit cytochrome p450 metabolism, specifically CYP3A. Other drugs that are substrates of CYP3A include calcium channel blockers, macrolide antibiotics, barbiturates, alprazolam, midazolam, carbamazepine, azole antifungals, phenytoin, and rifampin. Gentamicin is an aminoglycoside and is not metabolized by CYP3A.)

The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
(numerical answer)
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.

pg. 287
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

A 57-year-old woman with a history of hypertension, type 2 diabetes mellitus, obesity, severe asthma, and coronary artery disease presents for elective laparoscopic cholecystectomy. The patient arrives the morning of surgery and informs the anesthesiologist that she takes a daily metoprolol but did not take it this morning. Which of the following beta-blockers would be MOST appropriate to administer to the patient prior to surgery?

a. Acebutolol
b. Nadolol
c. Pindolol
d. Timolol

a (Acebutolol

Patients with a history of known coronary artery disease who are taking a daily beta-blocker should continue the beta-blocker the day of surgery. Given that the patient has a history of severe asthma, it is most appropriate to administer a beta-1 selective beta-blocker. Of the above choices, only acebutolol is a beta-1 selective beta-blocker.

All *olols* that start *A to M are cardioselective* (beta 1). *N to Z are non-selective* (beta 1&2))

Small amounts of opioids are often used to supplement the analgesic and anesthetic effects of local anesthetics administered in the epidural space. In the obstetric patient, which of the following is the MOST common side effect of 100 mcg of epidural fentanyl?

a. Difficulty “pushing” if administered too close to delivery
b. Pruritus
c. Respiratory depression
d. Uterine atony

b (Pruritus
Intrathecal fentanyl results in profound visceral pain relief. As fentanyl is highly lipophilic, it rapidly leaves cerebrospinal fluid and penetrates the spinal cord as well as the systemic circulation. In contrast to local anesthetics, fentanyl does not contribute to motor block or difficulty pushing. Unlike the more hydrophilic morphine, fentanyl does not have significant rostral spread within the intrathecal space and is therefore not thought to contribute to maternal respiratory depression. Common side effects of intrathecal fentanyl include pruritus (especially of the nose and trunk) and nausea, although pruritus is the most common. Epidural administration of fentanyl also results in significant systemic absorption. It can cross the placenta and result in a transient decrease in fetal heart rate variability, which can make interpretation of fetal heart rate patterns challenging. It is not thought to contribute to newborn respiratory depression under normal circumstances.

Santos AC, Bucklin BA. Local Anesthetics and Opioids. In: Chestnut DH, ed. Obstetric Anesthesia. 4th ed. Philadelphia: Mosby Elsevier, 2009:247-282.)

Cholinesterase inhibitors that freely cross the blood-brain barrier include:
a. neostigmine
b. pyridostigmine
c. physostigmine
d. edrophonium
b (physostigmine

Physostigmine is a teritary amine and has a carbamate group, but no quaternary ammonium. Therefore, it is lipid soluble and is the only clinically available cholinesterase inhibitor that freely passes the blood-brain barrier.

pg. 304
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

Which of the following is MOST correct regarding the most common cause of transfusion related mortality?

a. It is due to clerical error
b. It is due to gram-negative bacteria
c. It is due to neutrophilic immune response
d. It is due to platelet-mediated response

c (It is due to neutrophilic immune response

Transfusion-related acute lung injury (TRALI) is the most common cause of transfusion-related mortality, causing more deaths than acute hemolytic reactions from ABO blood type error. Acute hemolytic reactions are most frequently due to clerical error. Infectious complications such as sepsis occur usually from bacterial infection most common after transfusion of platelets due to storage at room temperature to maintain platelet function. Gram-negative bacteria are frequent causes of transfusion-associated sepsis as well. TRALI involves an immune response of recipient antibodies directed against donor human leukocyte antigens (anti-HLA) or human neutrophil antigens (anti-HKA) and causes an influx of neutrophils into the lungs, with subsequent activation of neutrophils and release of inflammatory mediators with the development of increased pulmonary microvascular permeability. Clinically, it is indistinguishable on chest X-ray from ARDS.)

In which of the following clinical scenarios is the transfusion of cryoprecipitate LEAST appropriate?

a. A patient with ongoing blood loss and a fibrinogen 140 mg/dl
b. A trauma patient with massive hemorrhage who has received 10 units PRBCs.
c. Spontaneous bleeding in a patient with Christmas Disease (Hemophilia B)
d. Spontaneous bleeding in a patient with Hemophilia A

c (Spontaneous bleeding in a patient with Christmas Disease (Hemophilia B)

Cryoprecipitate contains factor VIII, fibrinogen, vWF, and factor XIII. It does not contain factor IX, which is the missing clotting factor in hemophilia B. Although DDAVP and factor concentrates are the preferred treatment in von Willebrand’s disease, cryopreciptate is an acceptable therapy if the others are not available. Hypofibrinogenemia and massive resuscitation which leads to relative fibrinogen deficiency and potentially worsened clinical bleeding are indications for administration of cryoprecipitate (or fibrinogen concentrates if available).)

The most frequent manifestation of sickle cell disease is:
a. pain
b. splenic sequestration
c. aplastic crisis
d. right upper quadrant syndrome
a (pain

The most frequent manifestation of sickle cell disease is pain. The pain is thought to be secondary to tissue ischemia and usually affects the back, chest, extremities and abdomen.

pg. 635
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

Label the graph of cerebral blood flow below, PaO2 and PaCO2 would best be represented by which curves: 

A
B
C
D
Label the graph of cerebral blood flow below, PaO2 and PaCO2 would best be represented by which curves:

A
B
C
D

A PaO2
B PaCO2

(Curve A best represents the effects of changing oxygen tensions on cerebral blood flow. Hypoxemia causes a significant increase in CBF to meet the brain’s metabolic demand. Hyperoxia, however, causes little change in CBF.

Curve B best represents the effects of changing carbon dioxide tensions on cerebral blood flow. Between the ranges of 20 to 80 mm Hg a linear relationship exists between PaCO2 and CBF, such that a change in PaCO2 from 30 to 60 mm Hg will double CBF.

pg. 1008
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

A 4-week-old neonate with Pierre Robin Sequence is scheduled for a direct laryngoscopy and bronchoscopy to evaluate his airway obstruction. In addition to micrognathia and airway obstruction, what additional feature defines this sequence?

a. Cleft lip
b. Craniosynostosis
c. Glossoptosis
d. Maxillary hypoplasia

c (Pierre Robin sequence (PRS) is characterized by:
1) Small mandible (*micrognathia*);
2) Posterior displacement of the tongue (*glossoptosis*); and,
3) *Airway obstruction*.

It is often, but not always associated with a cleft lip and/or palate. Pierre Robin is called a “sequence” (as opposed to a “syndrome”) because everything *occurs as a result of mandibular undergrowth* in utero. Pierre Robin sequence may occur in isolation, but is often associated with an underlying disorder. The *most common* syndromes associated with PRS are *Stickler* syndrome, *velocardiofacial* syndrome, and *Treacher-Collins* syndrome.)

In which of the following arrhythmias is synchronized electrical cardioversion LEAST likely to be effective?

a. Atrial fibrillation
b. Multifocal atrial tachycardia
c. Reentrant tachycardia
d. Ventricular fibrillation

d( Ventricular fibrillation
Synchronized electrical cardioversion is most effectively employed to convert patients with unstable supraventricular tachycardias. The electrical shock is “synchronized” with the QRS complex in order to avoid shocking the heart during the vulnerable refractory period: It avoids an “R on T” episode. During ventricular fibrillation, there is no QRS complex and thus the device would fail to discharge)

The purpose of the ductus venosus in fetal circulation is to:

a. allow umbilical vein blood to bypass the liver
b. allow umbilical artery blood to bypass the liver
c. bypass the pulmonary circulation
d. divert portal vein blood to the placenta

a (allow umbilical vein blood to bypass the liver

Up to 50% of the umbilical vein blood can pass directly into the inferior vena cava, bypassing the liver, through the ductus venosus. The remainder mixes with blood from the portal vein and passes through the liver prior to returning to the heart.

pg. 1092
Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.)

A 5-year-old with Duchenne’s muscular dystrophy presents to preoperative clinic before elective bilateral lower extremity tendon lengthening. Which of the following is the MOST important for further preoperative assessment of this child?

a. Complete Blood Count
b. Electrolyte panel
c. Electrocardiogram and echocardiogram
d. History and Physical Exam

c (Electrocardiogram and echocardiogram

Duchenne’s muscular dystrophy (DMD) is the most common and severe form of muscular dystrophy and is an X-linked recessive disease resulting in a mutation in the dystrophin gene. DMD has effects on many organ systems in addition to skeletal muscle, including the heart. Patients frequently develop a dilated cardiomyopathy from fatty infiltration of the myocardium. This may present initially on ECG as prominent Q waves, inverted T waves, or other changes. Echocardiography will show LV wall motion abnormalities as fibrosis progresses and indicates the disease is advancing. Some form of cardiac involvement is present in up to 90% of patients; therefore, a cardiac workup is most appropriate for this patient preoperatively.)

A 62-year-old otherwise healthy woman loses 1000 mL of blood rapidly during a partial hepatectomy. After adequate volume resuscitation, including the initiation of packed red blood cell transfusion, she becomes increasingly hypotensive and tachycardic. Her vital signs are BP 64/42 mmHg, HR 136 bpm, SpO2 98%, temperature 38.4°C. What is the MOST appropriate next step in management?

a. Continue packed red blood cell transfusion
b. Initiate fresh frozen plasma transfusion
c. Continue volume resuscitation with tetrastarch
d. Discontinue transfusion

d (Discontinue transfusion
This patient has signs suggestive of an acute transfusion reaction. Despite adequate volume resuscitation and control of surgical bleeding, she is hypotensive, tachycardic and febrile after the initiation of packed red blood cell transfusion. The transfusion should be discontinued and the blood sent back to the blood bank for testing. Febrile transfusion reactions occur in 0.5% of RBC transfusions and 30% of platelet transfusions and are thought to be due to recipient antibodies directed against HLA antigens on donor WBC or platelets. Cytokines released from WBC in stored blood product (especially platelets) may also be a contributing factor. Patients experiencing a febrile reaction have increase in temperature of > 1 C as well as headache and back pain (not obvious in patient under general anesthesia) in addition to signs similar to allergic reaction. The febrile reaction is usually delayed up to 2 hours after the transfusion but is treated successfully with acetaminophen and diphenhydramine. Leukoreduction helps to reduce febrile transfusion reactions. An acute hemolytic transfusion reaction is usually the result of ABO blood group incompatibility and may be fatal. Patients having acute hemolytic reaction present with fever, dyspnea, chest pain, low back pain and sudden hypotension. Under general anesthesia only hypotension and fever may be apparent. Acute renal failure may result; the transfusion should be stopped and volume resuscitation with addition of mannitol or furosemide should be considered.)

A 74-year-old man with chronic atrial fibrillation is brought to the emergency room four hours after the acute onset of left hemiparesis. A CT angiogram reveals a right middle cerebral artery (M1 segment) occlusion. He is unable to get IV t-PA within the required window and is brought to the neurointerventional suite for endovascular clot extraction. Which of the following complications is MOST associated with a general anesthetic technique for this procedure?

a. Anesthetic neurotoxicity
b. Hypotension/hypoperfusion
c. Inability to examine the patient during the procedure
d. Aspiration pneumonia and urosepsis

b (Hypotension/hypoperfusion
The use of general anesthesia for acute stroke interventions is requested by many endovascular neurosurgeons, but recent retrospective data points to an association between the use of GA and worse outcome (Froehler, 2012). Prospective studies are needed. In the interim, it appears that hypotension in the setting of GA is the most likely culprit (Davis, 2012). Other possibilities include time delay in mobilizing anesthesia resources, and/or placing a patient on a critical care treatment pathway with associated morbidities (such as ongoing intubation, ventilator associated pneumonia, etc.).)

Sinus arrhythmia:
a. is mediated through sympathetic innervation of the AV node
b. causes an increase in heart rate with inspiration
c. is indicative of SA node ischemia
d. is the primary cause of premature atrial contractions
b (causes an increase in heart rate with inspiration

Sinus arrhythmia is a cyclic variation in heart rate that corresponds to ventilation, increasing with inspiration and decreasing with expiration. Sinus arrhythmia is a normal cardiac rhythm and is due to cyclic changes in vagal tone.

pg. 1717
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Which of the following anesthetic techniques is associated with the LOWEST failure rate for spinal cord stimulator placement?

a. General anesthesia
b. Local only
c. Spinal anesthesia
d. Epidural anesthesia

c (Spinal anesthesia

Spinal cord stimulator placement often requires both extensive surgical dissection and an awake patient for intra-operative testing to optimize the surgical result. The stimulators are placed over the spinal cord in the thoracic epidural space in most cases (the spinal cord ends at L1/2 in adults). Awake spinal cord stimulator placement is associated with a much lower failure rate. Viable anesthetic approaches include spinal anesthesia, local anesthesia with conscious sedation, and thoracic epidural anesthesia (single shot).)

Of the following, the block associated with the highest blood level of local anesthetic per volume injected is the:
a. epidural block
b. spinal block
c. intercostal block
d. caudal block
c (intercostal block

Blood concentration of local anesthetic is dependent on the total volume and concentration injected. However, with the exception of airway blocks, the intercostal block results in the highest blood levels of local anesthetic per volume injected.

pg. 569
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

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