Advanced | Intraoperative or Perioperative Disease States Flashcards
A ASA 1 28 year old male attends for inguinal hernia repair under general anaesthesia. He is administered propofol 180mg morphine 8mg rocuronium 50mg cephazolin 2g. Post induction he develops an erythematous rash on his chest and arms, swelling of his lips and face, tachycardia and severe hypotension. Preliminary blood results revealed:
Tryptase 321 mcg/L at 1 hour
Tryptase 58 mcg/L at 3 hours
IgE is normal
Morphine RAST is elevated
The most likely diagnosis is:
A. IgE mediated morphine allergy
B. IgE mediated rocuronium allergy
C. Morphine induced histamine
release
D. IgE mediated cefazolin allergy
E. Mastocytosis
B. IgE mediated rocuronium allergy
A 2 year old with leukemia is scheduled for intrathecal chemotherapy. She have had previous history of post procedure nausea and vomiting. Which of the following prophylactic drug can potentially lead to tumor lysis syndrome?
A. Haloperidol
B. Dexamethasone
C. Ondansetron
D. Promethazine
E. Metaclopramide
B. Dexamethasone
A 22 year old male sustained a complete spinal cord injury at T1 four weeks ago. Which of the following is least consistent with acute hyperreflexia?
A. Profound hypotension
B. AF
C. Lightheadedness
D. Piloerection below T1
A. Profound hypotension
Typically, Acute Autonomic Dysreflexia presents with hypertension.
You see a flash of fire from the endotracheal tube of a patient undergoing carbon dioxide laser excision of laryngeal polyps. The immediate response should be to:
(A) discontinue the fresh gas flow
(B) increase the nitrous oxide concentration
(C) spray water down the endoscope
(D) insert wet pads into the pharynx
(E) remove the endotracheal tube
(E) remove the endotracheal tube
During isoflurane anesthesia, a 45-year-old patient with chronic asthma has wheezing, prolonged expiration, sinus tachycardia of 120 bpm, and premature ventricular contractions. Preoperative medication included cromolyn and theophylline (serum level 20 jag/ml). The most appropriate treatment is to administer:
(A) albuterol aerosol
(B) aminophylline by intravenous infusion
(C) cromolyn aerosol
(D) halothane
(E) hydrocortisone by intravenous bolus
(A) albuterol aerosol
Is this light anesthesia?
The initial reduction in core temperature during general anesthesia is caused by:
(A) ablation of thermoregulatory vasoconstriction
(B) conductive heat loss
(C) evaporative heat loss in the respiratory tract
(D) neuromuscular blockade
(E) redistribution of heat from the core to the periphery
(E) redistribution of heat from the core to the periphery
With acute carbon monoxide poisoning:
(A) P50 is decreased
(B) Pa02 is decreased
(C) arterial oxygen saturation is increased
(D) oxygen-carrying capacity of blood is normal
(E) 2,3-diphosphoglycerate concentration in erythrocytes is increased
(A) P50 is decreased
Explain.:)
Four days after subarachnoid hemorrhage and surgical clipping of a cerebral aneurysm, a patient develops cerebral artery vasospasm. Appropriate treatment includes each of the following EXCEPT
(A) administration of nimodipine
(B) controlled hypertension
(C) hemodilution to hematocrit of 33%
(D) hyperventilation to PaC02 of 25 to 30 mmHg
(E) increasing preload
(D) hyperventilation to PaC02 of 25 to 30 mmHg
Which of the following is the MOST common cause of blindness with prone position?
A. Corneal abrasion
B. Central retinal artery occlusion
C. Ischemic optic neuropathy
D. Occipital cortex stroke
C. Ischemic optic neuropathy
In a patient with adult respiratory distress syndrome who is being mechanically ventilated, which of the following findings indicates the most severe disease?
(A) Decreased functional residual capacity
(B) Decreased lung compliance
(C) Hypercarbia
(D) Hypoxemia
(E) Increased dead space
(C) Hypercarbia
Which of the following fluids will restore circulating blood volume with the smallest infused volume?
(A) Albumin 25%
(B) Dextrose 5% in saline solution 0.45%
(C) Hydroxyethyl starch 6%
(D) Lactated Ringer’s solution
(E) Type-specific whole blood
(A) Albumin 25%
In an adult undergoing laparotomy, which of the following is the most effective means of maintaining body temperature during the first hour of anesthesia?
(A) Increasing ambient temperature
(B) Using a warming blanket
(C) Warming inspired gases
(D) Warming intravenous fluids
(E) Warming irrigating fluids
(A) Increasing ambient temperature
A 40-year-old woman with chronic renal failure is undergoing revision of an arteriovenous shunt with general anesthesia. The capnographic waveform was obtained during spontaneous ventilation 20 minutes after administration of succinylcholine and tracheal intubation. Which of the following is the most likely cause of these findings?
(A) Leaking endotracheal cuff
(B) Channeling of soda lime
(C) Light anesthesia
(D) Metabolic acidosis
(E) Residual neuromuscular block
(B) Channeling of soda lime
A 75-year-old man is confused, restless, and disoriented two days after an aortic aneurysm repair. Serum sodium concentration is 112 mEq/L, serum osmolality is low, and urine is hypertonic. The most appropriate treatment is:
(A) restriction of fluid intake
(B) administration of isotonic saline solution
(C) administration of hypertonic (3%) saline solution
(D) administration of spironolactone
(E) infusion of mannitol 25 g
(C) administration of hypertonic (3%) saline solution
What is the hallmark of SIADH?
- The Syndrome of Inappropriate Secretion Anti-Diuretic Hormone (SIADH) is characterized by excessive ADH secreted from the posterior pituitary (neurohypophysis) leading to free water retention and excretion of concentrated urine. Despite volume expansion, **there is no edema in SIADH **due to natriuresis secondary to atrial natriuretic peptide (ANP) release, inhibition of the renin-angiotensin-aldosterone system, and decrease in proximal tubular sodium absorption.
This results in a** euvolemic hypotonic hyponatremia.** Although it is the most common cause of euvolemic hyponatremia, SIADH remains a diagnosis of exclusion after other causes of hypotonic hyponatremia have been ruled out. After careful history is taken, work up of hyponatremia involves assessing serum osmolality (normal 275-290 mosm/kg), extracellular fluid volume status (vital signs including orthostatic blood pressure, JVP, skin turgor, mucous membranes, peripheral edema, BUN, Creatinine, uric acid), and urine sodium concentration.
- Serum sodium concentration in SIADH is typically > 40 mEq/L and serum osmolality is low (<280 mosmol/kg) with a **high urine osmolality** (> 300 mosmol/kg) and UNa>20mEq/L.
A 3-year-old boy is scheduled for an elective outpatient right inguinal hernia repair. The patient is very anxious but has no other medical history and has never received general anesthesia. Family history is positive for malignant hyperthermia (MH) in his father. The MOST appropriate anesthetic management for this patient would be:
A. Preoperative dantrolene administration
B. Spinal anesthesia
C. General anesthesia using propofol and nitrous oxide
D. Preoperative MH molecular genetic testing
C. General anesthesia using propofol and nitrous oxide
A 40-year-old male is admitted to the Post-Anesthesia Care Unit (PACU) immediately following surgery. General anesthesia with Total Intravenous Anesthesia (TIVA) and a strong opioid were used during the procedure. If the patient exhibits signs of opioid-induced respiratory depression, Naloxone would be the primary treatment to reverse the overdose. Which of the following statements is NOT accurate regarding the reversal of opioid-induced respiratory depression?
A. Respiratory depression from opioids occurs at higher receptor occupancy rates than analgesia
B. Naloxone causes a parallel leftward shift of the opioid dose–response relationship
C. Naloxone antagonizes all the pharmacologic effects of opioids
D. The rate of decay of naloxone in plasma is relatively fast resulting in “renarcotization” when used to reverse opioid with a longer plasma half-life than naloxone
B. Naloxone causes a parallel leftward shift of the opioid dose–response relationship
- It should be a parallel RIGHTWARD shift of the opioid dose–response relationship
- All the other statements are accurate.
Barash | 9th edit
A 20-year-old male is admitted to the Post-Anesthesia Care Unit (PACU) immediately following surgery. General anesthesia with Total Intravenous Anesthesia (TIVA) and Remifentanil was used during the procedure. The patient was extubated with stable vitals noted. At the PACU, the patient exhibits signs of opioid-induced respiratory depression but with a relatively hemodynamic stability. If Naloxone is to be used, which will MOST likely restore a spontaneous breathing?
A. 80 ug IV as a starting IV bolus
B. 10 ug IV as a starting bolus
C. cumulative IV bolus dose of more than 400 ug
D. All of the above
A. 80 ug IV as a starting IV bolus
- opioid concentrations are often just above the threshold for respiratory depression, and intravenous titration of naloxone 40 to 80 μg bolus doses to cumulative doses of less than 400 μg is often sufficient to restore spontaneous breathing.
Respiratory depression
from opioids occurs at higher receptor occupancy rates than analgesia. Therefore, analgesia is not compromised with careful titration of naloxone to
respiratory effect.
Barash | 9th edit
Which of the following will LEAST likely respond to an IV bolus of Naloxone in an attempt to reverse the opioid-induced respiratory depression?
A. Remifentanil
B. Buprenorphine
C. Fentanyl
D. Morphine
C. Methadone
B. Buprenorphine
The naloxone titration opioid reversal approach is adequate for most opioids, with the exception of opioids with a high affinity for the MOR, such as buprenorphine or carfentanil. In that case, a continuous naloxone infusion (2 to 4 mg/h) will cause a slow but steady resumption of breathing
activity.
Barash | 9th edit
- Buprenorphine is a partial agonist of μ receptors and shows resistance to reversal from naloxone. (Open anesthesia)
30 year old is undergoing posterior fossa surgery. After induction, the patient was positioned to a sitting/high-fowler position. Few minutes after the dura was opened, the following were noticed: Tachycardia, hypotension
rales, wheezing and ABG showing metabolic ACIDOSIS. What is the most sensitive diagnostic tool to detect the possible intraoperative event?
(A) precordial Doppler stethoscope
(B) transesophageal echocardiography
(C) end-tidal carbon dioxide measurement
(D) pulmonary artery pressure measurement
(E) central venous pressure measurement
(B) transesophageal echocardiography
Miller | 9th edit
The most likely cause of this capnographic tracing obtained just after laryngoscopy and intubation is:
(A) esophageal intubation
(B) partial obstruction of the endotracheal tube
(C) pulmonary embolus
(D) insertion of an endotracheal nasogastric tube
(E) mild bronchospasm
(A) esophageal intubation
During surgery with a carbon dioxide laser, which inhaled gas mixture is LEAST likely to promote combustion of the endotracheal tube?
(A) Oxygen 25%-helium 75%
(B) Oxygen 25%-nitrogen 75%
(C) Oxygen 25%-nitrous oxide 75%
(D) Oxygen 50%-nitrogen 50%
(E) Oxygen 50%-nitrous oxide 50%
(A) Oxygen 25%-helium 75%
Helium-Oxygen Mixtures (Heliox):
During normal inspiration, airflow is laminar in small airways and turbulent in large airways due to their irregular walls and high velocity flow. Increased turbulent flow, as in airway obstruction, leads to increased airway resistance, work of breathing, hypoxia, and hypercapnia.
During turbulent airflow, flow is inversely proportional to density; therefore, the lower the density of the gas the higher the flow rate. Helium is eight times less dense than oxygen and Heliox is three times less dense than air. Thus, when mixed with oxygen. Helium reduces the density of the gas mixture, providing increased laminar flow and leading to decreased respiratory rate, work of breathing, and resulting hypoxia/hypercapnia
When using a Venturi face mask with a reservoir bag:
(A) a known constant FiO2 is delivered
(B) the reservoir bag ensures predictable FiO2 while conserving fresh gas flow
(C) low fresh gas flows will not decrease FiO2
(D) the system prevents hypocarbia during tachypnea
(E) the system increases anatomic dead space
(B) the reservoir bag ensures predictable FiO2 while conserving fresh gas flow
During right upper lobectomy and one-lung ventilation with a double-lumen endotracheal tube, the PaO2 decreases to 40 mmHg. The PaCO2 is 39 mmHg. Which of the following is most appropriate?
(A) Confirm position of the tube with bronchoscopy
(B) Apply 5 cmH20 continuous positive airway pressure to the nondependent lung
(C) Apply 5 cmH20 positive end-expiratory pressure to the dependent lung
(D) Resume two-lung ventilation
(E) Clamp the pulmonary artery of the nondependent lung
(D) Resume two-lung ventilation
A 35-kg child requires mechanical ventilation with pure oxygen at a tidal volume of 350 ml and a rate of 20/min during a severe asthma attack. The most likely cause of severe hypotension after initiating mechanical ventilation is:
(A) hypoxic circulatory depression
(B) inadequate expiratory time
(C) increased pulmonary vascular resistance
(D) respiratory alkalosis
(E) tension pneumothorax
(B) inadequate expiratory time
During laser excision of vocal cord polyps in a 5-year-old boy, dark smoke suddenly appears in the surgical field. The trachea is intubated and anesthesia is being maintained with halothane, nitrous oxide, and oxygen. The most appropriate initial step is to
(A) change from oxygen and nitrous oxide to air
(B) fill the oropharynx with water
(C) instill water into the endotracheal tube
(D) remove the endotracheal tube
(E) ventilate with carbon dioxide
(D) remove the endotracheal tube
A 32-year-old woman is anesthetized for suboccipital craniotomy. During positioning, the capnograph shows an abrupt decrease in the slope of the expiratory upstroke. Which of the following is the most likely cause?
(A) Air embolism
(B) Incompetent expiratory valve
(C) Incomplete neuromuscular block
(D) Kinked endotracheal tube
(E) Tracheal extubation
(D) Kinked endotracheal tube
A sevoflurane vaporizer is filled with isoflurane and the vaporizer dial is set at 1%. Which of the following will occur?
(A) Less than 1% isoflurane will be delivered
(B) More than 1% isoflurane will be delivered
(C) Thymol precipitation will prevent vaporization
(D) The vaporizer bypass will not open
(E) The vaporizer will be damaged
(B) More than 1% isoflurane will be delivered
A neurologically intact 48-year-old woman is scheduled for removal of a parietal lobe arteriovenous malformation. The relative risk for complete resection is to be determined by a test occlusion of the feeding artery. Which of the following intraoperative monitoring techniques is most appropriate for this test?
(A) Brain stem auditory evoked potentials
(B) Cerebral blood flow using radioactive xenon
(C) EEG
(D) Evoked potentials elicited by stimulating the posterior tibial nerve
(E) Transcranial Doppler
(D) Evoked potentials elicited by stimulating the posterior tibial nerve
A patient is manifesting lightheadedness, tinnitus
numbness of tongue and seizures several hours after induction with femoral block and ankle block to provide anesthesia. The symptoms presented by this patient corresponds to which plasma concertation(mg/mL) of Lidocaine?
A. 15 - 25
B. > 25
C. 10 - 15
D. 5 - 10
C. 10 - 15
DICTUM:
- The effects on the CNS are determined by the plasma concentration of the local
anesthetics. - The potential for CNS toxicity correlates directly with the potency of local anesthetics.
- Situation or Disease state that can increase the RISK of CNS toxicity to local anesthetics are the following:
- decrease in protein binding
and clearance of local anesthetics - systemic acidosis,
- hypercapnia
- hypercarbia
Why does bupivacaine have a uniquely high propensity for cardiotoxicity?
READ
TRUE or FALSE
Infants younger than 6 months of age are found to be at sixfold
greater risk for LAST than older children
This is TRUE!
Also the pregnant population is relatively at high risk due to decreased protein binding, hormonal milieu, and increased cardiac output.
What is the BEST management for LAST?
The best management for LAST starts with prevention and risk reduction. (Barash claim).:)
The following will potentially INCREASE the risk of TNS EXCEPT:
A. Intrathecal lidocaine
B. Ambulatory anesthesia
C. Lithotomy position
D. Baricity
Increased risk of TNS is associated with lidocaine, the lithotomy position, and ambulatory anesthesia, but not with
baricity of solution or dose of local anesthetic.
Stoelting Pharma | 6th edit
A 15 year old patient has sudden tonic movements of the head and neck, nystagmus, and slurred speech after receiving metoclopramide for nausea after nitrous oxide-opioid anesthesia. The most appropriate pharmacologic treatment at this time is:
(A) diphenhydramine
(B) midazolam
(C) naloxone
(D) phenytoin
(E) physostigmine
(A) diphenhydramine
Metoclopramide is a D2 receptor antagonist as well as 5-HT3 antagonist and 5-HT4 agonist. Through its anti-dopaminergic and anti-serotonergic effects, it blocks the communication between the CTZ and NTS and thereby acts as an potent antiemetic. Additionally, its antagonist effect on dopamine receptors combined with its agonistic effects on 5-HT4 receptors yield increased GI motility and contractility. Given these pharmacologic effects, metoclopramide can be used as both an antiemetic and a promotility agent.
Adverse effects from metoclopramide primarily extend from its antidopaminergic actions. Similar to antipsychotics with antidopaminergic action, metoclopramide can cause extrapyramidal symptoms including acute dystonia, parkinsonism, and akathisia, as well as Neuroleptic Malignant Syndrome.
A 70-year-old man who has just undergone an abdominal aortic aneurysm repair under halothane anesthesia develops hypertension, dyspnea, and cyanosis shortly after awakening in the recovery room. Administration of furosemide 20 mg intravenously improves the cyanosis within 10 minutes. This immediate effect of furosemide is best explained by
(A) inotropic effect from electrolyte shifts
(B) decreased preload through diuresis
(C) increased peripheral venous capacitance
(D) decreased pulmonary vascular resistance
(E) increased coronary blood flow
(C) increased peripheral venous capacitance
You are performing an interscalene nerve block using a nerve stimulator when your patient begins to hiccup. You should aim to position the tip of your needle more:
A. Anterior
B. Posterior
C. Cephalad
D. Caudal
E. Superficial
B. Posterior
Interpretation: The result of stimulation of the phrenic nerve
Problem: The needle is inserted too anterior and medial
Action: Withdraw the needle and reinsert 15 degrees posterior and lateral
- TROUBLESHOOTING needling technique in Interscalene:
When abdominal contractions/hiccups is elicited > phrenic nerve stimulation = needle too anterior.
If there is medialization of scapula > thoracodorsal nerve = needle too posterior.
In a patient with BPF, when an empyema is present in a patient who underwent pneumonectomy, the ideal approach is intubation of the trachea with:
A. RSI with depolarizing NMB agent
B. RSI with rocuronium
C. Intubating while patient is awake using a DLT while spontaneously breathing
C. Intubating while patient is awake using a DLT while spontaneously breathing
The priorities in the anesthetic management of BPF are the isolation of the affected side in terms of contamination and ventilation. The ideal approach is intubation of the trachea while the patient is awake using a DLT with the patient breathing spontaneously.
Supplemental oxygen should be
administered, and the patient should be constantly reassured.
Barash | 9th edit
Which of the following statements concerning carbon monoxide poisoning is TRUE?
(A) Diagnosis is excluded if the PaO2 is greater than 300 mmHg while breathing 100% oxygen
(B) Increased inspired oxygen concentration accelerates displacement of carbon monoxide from hemoglobin
(C) Methylene blue decreases binding of carbon monoxide to hemoglobin
(D) Pulse oximetry accurately reflects hemoglobin oxygen saturation
(E) Tissue oxygen delivery is normal
(B) Increased inspired oxygen concentration accelerates displacement of carbon monoxide from hemoglobin
Which of the following is usually absent in the event of carbon monoxide poisoning?
A. Tachypnea
B. Nausea and vomiting
C. Seizure
D. Headache
A. Tachypnea
Which of the following statements regarding carbon monoxide poisoning is TRUE?
(A) Breathing 100% oxygen at 1 atmosphere reduces the carboxyhemoglobin half-life
(B) Effective treatment includes administration of methylene blue
(C) It is commonly associated with respiratory acidosis
(D) It is incompatible with a normal Sp02 while breathing room air
(E) The oxyhemoglobin dissociation curve is shifted to the right
(A) Breathing 100% oxygen at 1 atmosphere reduces the carboxyhemoglobin half-life
A 70-kg, 77-year-old man Is undergoing left nephrectomy with nitrous oxide, oxygen, fentanyl, and midazolam anesthesia. He has a 90 pack-year history of cigarette smoking and has chronic obstructive pulmonary disease. One hour after incision, expiratory wheezing occurs and peak Inspiratory pressure increases from 35 to 65 cmH20; end-tidal PCO2 is unchanged, but SpO2 decreases from 97% to 88%. The most likely cause is
(A) endobronchial intubation
(B) overinflation of the endotracheal tube cuff
(C) pneumothorax
(D) pulmonary edema
(E) pulmonary embolism
(C) pneumothorax
A 56-year-old woman with pulmonary fibrosis is scheduled for pneumonectomy. Which of the following parameters best predicts potential postoperative functional impairment?
(A) Exercise tolerance
(B) Flow-volume loop
(C) Resting arterial blood gas values
(D) Unilateral pulmonary artery occlusion pressure
(E) Vital capacity and FEV,
(D) Unilateral pulmonary artery occlusion pressure
Compared with a person of normal weight, which of the following findings are most likely on pulmonary function testing of a patient with morbid obesity?
(FVC, FEV/FVC, FRC, A-a DO2)?
(A) Decreased, Normal, Decreased, Normal
(B) Decreased, Normal, Decreased , Increased
(C) Decreased, Normal, Normal, Increased
(D) Increased, Decreased, Normal, Increased
(E) Increased, Decreased, Decreased, Increased
(B) Decreased, Normal, Decreased , Increased
The adult oxyhemoglobin dissociation curve will resemble that of the fetus in the presence of
(A) increased 2,3-diphosphoglycerate concentration
(B) chronic anemia
(C) hyperthermia
(D) metabolic alkalemia
(E) hyperkalemia
(D) metabolic alkalemia
