Apex Unit 12 Miscellaneous Topics Flashcards
Match each chemical bond with its definition.
Ionic bond + Complete transfer of valence electrons
Covalent + Equal sharing of valence electrons
Polar covalent + Unequal sharing of valence electrons
Which law is represented by the image? p1 + p2 + p3 =
Dalton
Henry
Graham
Charles
Dalton
Dalton’s law of partial pressures says that the total pressure is equal to the sum of the partial pressures exerted by each gas in the mixture.
P total = P1 + P2 + P3…
Click on the part of the oxygen delivery equation that exemplifies Henry’s law.
DO2 = CO x [(1.34 x Hgb x SpO2) + (PaO2 x 0.003)] x 10
Pao2 x .003
Henry’s law: At a constant temperature, the amount of gas that dissolves in solution is directly proportional to the partial pressure of that gas over the solution.
Henry’s law applied to oxygen solubility:
DO2 = CO x [(1.34 x Hgb x SpO2) + (PaO2 x 0.003)] x 10
Multiplying the PaO2 by oxygen’s solubility coefficient (0.003) allows us to calculate how much oxygen is dissolved in the blood.
Match each gas law with its equation.
Boyle’s law + P1 x V1 = P2 x V2
Charles’s law + (V1 / T1) = (V2 / T2)
Gay-Lussac’s law + (P1 / T1) = (P2 / T2)
During laminar flow, quadrupling the radius will cause flow to increase by a factor of:
256
The Poiseuille Equation describes the laminar flow of fluid through a tube, where flow equals:
(Pi x Radius ^4 x Pressure difference) / (8 x viscosity x length)
As you can see, the radius of the tube exhibits the greatest impact on flow.
R = 1^4: 1 x 1 x 1 x 1 = 1 R = 2^4: 2 x 2 x 2 x 2 = 16 R = 3^4: 3 x 3 x 3 x 3 = 81 R = 4^4: 4 x 4 x 4 x 4 = 256
Reynold’s number is the LOWEST in the:
medium-sized bronchi.
terminal bronchioles.
glottis.
carina.
Terminal bronchioles
There are 3 types of flow, and Reynold’s number helps us predict what type of flow will occur in a particular situation.
Laminar (Re < 2,000) Turbulent (Re > 4,000) Transitional (Re = 2,000 - 4,000) Gas flow through the terminal bronchioles is laminar.
Flow through the glottis, carina, and medium-sized airways is turbulent
When applied to the left ventricle, which variables are included in the law of Laplace? (Select 2.)
Diameter
Wall tension
Wall thickness
Transmural pressure
Wall tension
Wall thickness
In spheres and cylinders, the law of Laplace illustrates the relationship between the wall tension, internal pressure, and radius.
The equation is a bit different for spheres vs. cylinders.
When applied to the left ventricle, we usually want to understand wall tension. This is the equation that we use:
Wall Tension = (LV Pressure x Radius) / (LV Wall Thickness x 2)
*We use the radius (not diameter) and internal pressure (not transmural pressure).
The risk of ionizing radiation exposure to the anesthesia provider is:
directly proportional to the square of the distance of the source.
directly proportional to the cubed radius of the distance from the source.
inversely proportional to the square of the distance of the source.
inversely proportional to the cubed radius of the distance from the source.
Inversely proportional to the square of the distance from the source
Understanding the inverse square law helps us reduce our exposure to ionization radiation inside and outside of the operating room.
The risk of ionizing radiation exposure to the anesthesia provider is inversely proportional to the square of the distance from the source. It will make more sense on the next page. We promise.
The number of calories required to convert one gram of liquid to vapor without a temperature change in the liquid is called the:
critical temperature.
latent heat of vaporization.
specific heat.
boiling point.
Latent heat of vaporization
Latent heat of vaporization is the number of calories required to convert one gram of liquid to vapor without a temperature change in the liquid.
Boiling point is the temperature at which a liquid’s vapor pressure equals atmospheric pressure.
Specific heat the amount of heat required to increase the temperature of one gram of a substance by one degree C.
Critical temperature is the highest temperature where a gas can exist as a liquid. Said another way, it is the temperature above which a gas cannot be liquefied regardless of the pressure applied to it.
How many centimeters of water is equal to 1 mmHg?
(Round to the hundredths place)
1.36 ( We accepted 1.34 - 1.36)
You should understand how to convert pressure to different units, specifically mmHg to cm H2O and vice versa’
1 mmHg = 1.36 cm H2O
We believe that Nagelhout has a small error, so we accepted the calculation using the numbers in that text. It says that standard atmospheric pressure = 1020 cm H2O, however we think a better answer is 1033 cm H2O.
What is the BEST method of minimizing intraoperative heat loss?
Forced air warmer
Fluid warmer
Circulating water mattress
Warm blankets
Forced air warmer
The four mechanisms of heat transfer (in order of importance) include:
Radiation > Convection > Evaporation > Conduction
The forced air warmer is arguably the most effective single method of perioperative warming, however any combination that prevents hypothermia is acceptable.
Which temperature monitoring site offers the BEST combination of accuracy and safety over an extended period of time?
Rectal
Tympanic membrane
Esophageal
Pulmonary artery
Esophageal
Esophageal temperature monitoring provides a good estimation of core temperature with minimal risk.
Rectal temperature monitoring produces less consistent results.
Tympanic membrane temperature monitoring is reliable when used correctly, however it can’t be used for continuous monitoring and there is a risk of tympanic membrane injury.
Pulmonary artery temperature monitoring accurately reflects core temperature, however it is invasive.
Anesthetic considerations for removal of vocal cord papilloma with a carbon dioxide laser include:
adding saline instead of air to the cuff of the endotracheal tube.
reducing the FiO2 by adding nitrous oxide.
applying reflective tape to a red rubber endotracheal tube.
using amber goggles.
Adding saline to the cuff of the endotracheal tube
Adding saline to the cuff of the endotracheal tube provides two benefits: 1) It acts as a heat sink for the thermal energy produced by the laser and 2) If the laser breaks the balloon, then the surgeon will see the saline in the surgical field. Adding dye to the saline makes this more obvious.
When a laser is in use, air should be blended with oxygen to maintain an FiO2 < 30 percent. Nitrous oxide supports combustion and should be avoided.
When a CO2 laser is used, the eyes are protected by clear lenses (not amber).
While reflective tape can be used to reduce the flammability of conventional endotracheal tubes, it is best to use a laser resistant endotracheal tube.
Calculate the 24-hr fluid requirement for a 70 kg adult with a new burn that consumes 50 percent of his total body surface area.
(Enter your answer as a whole number in mL)
7,000 - 14,000 mL/24 hr period
There are 2 commonly used formulas to calculate fluid requirements for the acutely burned patient. These include the Parkland and Modified Brooke formulas. We accepted responses and everything in-between.
Modified Brooke Formula: 2 mL x % TBSA burned x kg (body weight)
Parkland Formula: 4 mL x % TBSA burned x kg (body weight)
2 mL x 70kg x 50 = 7,000 mL
4 mL x 70kg x 50 = 14,000 mL
Choose the statement that BEST describes the anesthetic considerations for the patient undergoing electroconvulsive therapy.
There is an initial increase in sympathetic tone followed by an increase in parasympathetic tone.
Pregnancy is an absolute contraindication.
Lithium shortens the duration of action of succinylcholine.
Hypocarbia increases the seizure duration.
Hypocarbia increases seizure duration
Hypocarbia increases seizure duration, making this a useful modality prior to the ECT procedure.
The seizure caused by ECT results in a profound hemodynamic response. Initially there is a surge in PNS activity, and this is followed by an increase in SNS activity (not the other way around).
Pregnancy is a relative contraindication (not absolute).
Lithium prolongs (not reduces) the duration of action of both succinylcholine AND nondepolarizing NMBs.
Match each drug-induced hyperthermic syndrome with its antidote.
Neuroleptic malignant syndrome + Bromocriptine
Serotonin syndrome + Cyproheptadine
Anticholinergic syndrome + Physostigmine
NMS is caused by dopamine depletion in the basal ganglia and hypothalamus. The DA concentration is restored with bromocriptine.
Serotonin syndrome occurs when there’s excess 5-HT activity in the CNS and PNS. Cyproheptadine is a 5-HT antagonist that reverses the effects of excess serotonin.
Anticholinergic poisoning is the result of excessive Ach blockade in the CNS and PNS. Physostigmine is the only cholinesterase inhibitor that lacks a quaternary ammonium, so it diffuses into the CNS and increases the Ach concentration.
Identify the statement that BEST represents the anesthetic considerations for ophthalmic surgery.
Intraocular perfusion pressure equals MAP - CVP.
Nitrous oxide is contraindicated for 10 days after a sulfur hexafluoride bubble is placed.
Hypocarbia increases intraocular pressure.
Aqueous humor is reabsorbed by the ciliary process.
Nitrous oxide is contraindicated for 10 days after a SF6 bubble is placed
Aqueous humor is produced (not reabsorbed) by the ciliary process. It is reabsorbed in the canal of Schlemm.
Intraocular perfusion pressure = MAP - IOP (not MAP - CVP).
Hypercarbia (not hypocarbia) increases IOP.
A transverse abdominal plane block would be useful for all of the following procedures EXCEPT:
inguinal hernia repair.
cystoscopy.
kidney transplant.
appendectomy.
Cystoscopy
The TAP block is a peripheral nerve block that targets the anterior and lateral abdominal wall. It reduces opioid requirements in patients undergoing general, GYN, and urologic surgeries involving the T9-L1 distribution.
Since the patient undergoing cystoscopy won’t receive an abdominal incision, he won’t benefit from a TAP block.
Match each term with its definition.
Algogenic + A stimulus that is normally expected to produce pain
Allodynia + Pain due to a stimulus that does not normally produce pain
Hyperalgesia + Exaggerated pain response to a painful stimulus
Neuralgia + Pain localized to a dermatome
Match each antibiotic with its drug class.
Cefazolin + Beta-lactam
Gentamycin + Aminoglycoside
Levofloxacin + Fluoroquinolone
Match each disease with the appropriate safety precautions.
Influenza + Droplet Precautions
Mycobacterium tuberculosis + Airborne Precautions
Methicillin-resistant staphylococcus aureus + Contact Precautions
Which procedure places health care workers at the HIGHEST risk of developing a positive skin TB test?
Cataract removal
Open reduction internal fixation of a femur
Video assisted thoracoscopic surgery
Bronchoscopy
Bronchoscopy
TB is transmitted via small (1-5 um) aerosolized droplets These are released into the environment when a person with TB coughs, sneezes, or even talks. Therefore, any procedure involving the airway is inherently associated with a higher risk of transmitting TB.
Bronchoscopy is associated with the highest risk of skin test conversion in health care personnel. Endotracheal intubation is the second highest risk procedure.
To reduce the risk of transmission, the infected patient and all health care workers must wear tight fitting N95 masks.
Anaphylaxis causes degranulation of: (Select 2.)
monocytes.
mast cells.
neutrophils.
basophils
Basophils
Mast cells
Degranulation is a fancy way of saying that a cell releases cytotoxic contents from its storage vesicles. These chemicals play a critical role in the immunologic response.
Basophil and mast cell degranulation can be stopped with epinephrine (beta-2 receptor stimulation). This is one of the several reasons we give epinephrine during anaphylaxis. More on this in a bit…
Match each type of hypersensitivity reaction with its BEST example.
Type I + Anaphylaxis
Type II + ABO incompatibility
Type III + Serum sickness after snake bite
Type IV + Graft-vs-host reaction
Match each chemotherapeutic agent with its unique side effect.
Cisplatin + Renal toxicity
Bleomycin + Pulmonary toxicity
Doxorubicin + Cardiac toxicity
Match each gastrointestinal hormone with its unique characteristic.
Gastrin + Associated with Zollinger-Ellison syndrome
Somatostatin + Treatment for carcinoid tumor
Cholecystokinin + Produces gallbladder pain after a fatty meal
Which agent primarily targets the chemoreceptor trigger zone?
Scopolamine
Hydroxyzine
Ondansetron
Dexamethasone
Ondansetron
Ondansetron is a 5-HT3 receptor antagonist. It treats PONV by antagonizing serotonin receptors in two places:
Chemoreceptor trigger zone (area postrema)
Peripheral receptors in the GI tract and vagus nerve
Scopolamine (M1 antagonist) and hydroxyzine (H1 antagonist) primarily target the vestibular apparatus in the inner ear.
Dexamethasone binds to intracellular steroid receptors, however its exact site of action is unknown.
Deflation of the pneumatic tourniquet during orthopedic surgery is expected to increase:
mixed venous oxygen saturation.
end-tidal carbon dioxide.
blood pH.
blood pressure.
End-tidal carbon dioxide
The pneumatic tourniquet is used to reduce blood loss during extremity surgery. Cells distal to the tourniquet shift to anaerobic metabolism, and metabolic byproducts accumulate as long as the tourniquet is inflated.
Releasing the tourniquet produces transient changes that include:
Increased EtCO2 Decreased core body temperature Decreased blood pressure Decreased SvO2 (SaO2 is usually normal) Metabolic acidosis
All of the following are associated with Samter’s triad EXCEPT:
nasal polyps.
allergic rhinitis.
bronchospasm.
hypertension.
Hypertension
Aspirin exacerbated respiratory disease (Samter’s triad) refers to the combination of asthma, allergic rhinitis, and nasal polyps. These patients can develop life threatening bronchospasm following aspirin administration.
Match each herbal medication with its unique characteristic.
Licorice + May mimic Conn's syndrome Valerian + Decreases MAC St. John's Wort + Serotonin syndrome with MAOIs Garlic + Increases bleeding
Herbal medications have perioperative implications including effects on bleeding, synergism with other agents, cardiovascular instability, and metabolic derangements. We’ll cover the essentials on the next page.
Match each regulatory agency with the standards it sets.
Food and Drug Administration + Food and drugs
United States Department of Transportation + Compressed gas cylinders
Occupational Safety and Health Administration + Acceptable occupational exposure to volatile anesthetics
American Society for Testing and Materials + Required components of the anesthesia machine
All of the following are assessed by the modified Aldrete scoring system EXCEPT:
postoperative nausea and vomiting.
level of consciousness.
oxygen saturation.
quality of respiration.
Postoperative nausea and vomiting
The modified Aldrete scoring system is used to quantify readiness for discharge from the PACU. It assesses five areas: Activity Respiration Circulation Consciousness Oxygen saturation
PONV is not assessed by the modified Aldrete scoring system.
How many calories are required to produce one gram of body fat?
4
7
9
11
Nine
Each gram of fat provides nine calories. If unused, the body will store these excess calories as adipose.
By comparison, a gram of carbohydrate provides four calories and a gram of protein provides four calories.
A patient weighs 176 pounds and stands 74 inches tall. Calculate this patient’s body mass index.
(Round your answer to the nearest hundredth)
22.59 or 22.64 kg/m2
We accepted a range to account for different ways of calculating BMI.
- Convert weight from pounds to kilograms. (Conversion = lbs / 2.2)
176 lbs / 2.2 = 80 kg - Convert height from inches to centimeters. (Conversion = in x 2.54)
74 inches x 2.54 = 187.96 cm - Convert centimeters to meters. (Conversion = cm / 100)
187.96 cm / 100 = 1.8796 m
- BMI = kg / m squared
80 kg / 1.8796 m squared = 80 / 3.53289616 = 22.64
Calculate the ideal body weight for a woman who is 5 feet 3 inches tall.
(Enter your answer in kg and round your answer to the nearest whole number)
52 – 58
The ideal body weight for this patient is 55 kg.
IBW men (kg) = Height (cm) - 100 IBW women (kg) = Height (cm) - 105
We understand there are some other formulas for the IBW calculation, so we accepted a range of answers (52 – 58).
Which factors are reduced by obesity? (Select 2.) Closing volume Vital capacity Residual volume Expiratory reserve volume
Vital capacity
Expiratory reserve volume
Obesity creates a restrictive ventilatory defect. In effect, this compresses the lungs and reduces lung volumes.
FRC decreases (ERV decreases and RV remains constant).
Closing volume is increased.
Vital capacity is decreased.
What is the optimal tidal volume for a patient with class III obesity?
6 – 8 mL/kg ideal body weight
6 – 8 mL/kg total body weight
10 – 12 mL/kg ideal body weight
10 – 12 mL/kg total body weight
6 – 8 mL/kg ideal body weight
The lungs do NOT grow in proportion to body mass, so the morbidly obese patient should receive a tidal volume 6 – 8 mL/kg of ideal body weight.
A higher respiratory rate may be required to maintain PaCO2.
Higher tidal volumes only minimally increase PaO2 and may cause shear stress on the lungs.
Considerations for the cardiovascular effects of morbid obesity include: (Select 2.)
tachycardia.
diastolic dysfunction.
increased venous return.
increased EKG voltage.
Diastolic dysfunction
Increased venous return
The expansion of intravascular blood volume is one of the key changes that lead to the cardiovascular complications of obesity.
Increased circulating volume augments venous return (preload) and consequently myocardial wall stress. The heart compensates by becoming thicker, however this occurs at the expense of myocardial relaxation. This causes diastolic dysfunction.
Heart rate is usually unchanged (not increased) in the obese patient. An increased stroke volume is responsible for the increased cardiac output.
The EKG voltage is typically reduced (not increased) because the fat mass increases the distance between the heart and the skin leads.
In the obese patient, which factors are expected to increase? (Select 2.)
Volume of distribution of hydrophilic drugs
Volume of distribution of lipophilic drugs
MAC
Circulation time
Volume of distribution of lipophilic drugs
Volume of distribution of hydrophilic drugs
This one may be a bit tricky, but it builds on several important concepts from the last question.
The Vd of lipophilic drugs is increased due to a larger fat mass.
The Vd of hydrophilic drugs is increased due to a larger muscle mass and blood volume.
A higher cardiac output hastens IV drug delivery to the site of action. This shortens circulation time.
MAC is unchanged.
Select the drug whose initial dose should be based on total body weight. (Select 2.)
Midazolam
Remifentanil
Succinylcholine
Propofol
Succinylcholine
Midazolam
The initial doses of succinylcholine and midazolam should be based on total body weight.
The initial doses of propofol and remifentanil should be based on lean body weight.
Before moving to the next page, can you think of why this is?
All of the following muscles dilate the upper airway EXCEPT the:
hyoid muscles.
tensor palatine.
genioglossus.
thyroarytenoid.
Thyroarytenoid
There are three sets of muscles that dilate the upper airway. You should know the primary function for each one.
Tensor palatine (opens nasopharynx) Genioglossus (opens oropharynx) Hyoid muscles (opens hypopharynx) The thyroarytenoid muscles relax the vocal cords.
Which apnea/hypopnea index score is consistent with mild obstructive apnea?
3
12
25
40
12
The apnea/hypopnea index helps quantify the severity of OSA. This value is derived by the number episodes of apnea and hypopnea divided by the total hours of sleep.
Mild = 5 – 15 episodes/hr Moderate = 15 – 30 episodes/hr Severe = > 30 episodes/hr
In the Charles Dickens novel “The Pickwick Papers”, the errand boy named Joe suffers from what ailment?
Virchow’s triad
Obesity hypoventilation syndrome
Metabolic syndrome
Bulimia
Obesity hypoventilation syndrome
Okay, maybe this question is unfair for those of you who don’t read classic British literature. Who has time for that?
Having said this, you should be able to deduce the answer from the title, “The Pickwick Papers.” Pickwick…Pickwickian syndrome…another name for obesity hypoventilation syndrome…you get the idea.
What is the MOST sensitive sign of an anastomotic leak following gastric bypass?
Unexplained tachycardia
Abdominal pain
Shoulder pain
Fever
Unexplained tachycardia
Unexplained tachycardia is the most sensitive sign of an anatomic leak following gastric bypass.
Abdominal pain, shoulder pain, and fever are additional signs of an anastomotic leak, however they are not the most sensitive.
Match each appetite suppressant with its drug class
Ma huang + Ephedra alkaloid
Phentermine + Norepinephrine reuptake inhibitor
Sibutramine + Norepinephrine and serotonin reuptake inhibitor
Orlistat + Lipase inhibitor
The Trendelenburg position: (Select 2.)
moves the diaphragm caudad.
increases functional residual capacity.
increases the risk of endobronchial intubation.
reduces pulmonary compliance.
Reduces pulmonary compliance
Increases the risk of endobronchial intubation
Just as gravity affects the distribution of blood volume in the anesthetized patient, it also affects the position of the abdominal viscera.
When the patient is placed into the Trendelenburg position, the abdominal viscera shift toward the thorax. This has several consequences:
The diaphragm moves cephalad (not caudad).
FRC is reduced (not increased).
Pulmonary compliance is decreased.
The risk of endobronchial intubation is increased.
The surgical team is positioning a patient for a robotic assisted laparoscopic radical prostatectomy. What is the BEST position to protect the brachial plexus?
Arms tucked at sides + non-sliding mattress
Arms tucked at sides + shoulder braces placed near the acromion.
Arms abducted 90 degrees + non-sliding mattress
Arms abducted 90 degrees + shoulder braces placed at the midpoint of the clavicle
Arms tucked at side + non-sliding mattress
Surgical positioning for robotic assisted laparoscopic radical prostatectomy requires steep Trendelenburg position.
To minimize the risk of brachial plexus injury, the arms should be tucked at the patient’s sides and he should be positioned on a non-sliding mattress.
Shoulder braces increase the risk of brachial plexus injury.
A patient is unable to abduct his fifth digit after a prolonged stay in the intensive care unit. Which nerve sustained an injury?
Median
Long thoracic
Ulnar
Radial
Ulnar
The ulnar nerve is the most commonly injured peripheral nerve. Although its anatomy renders it susceptible to compression, it’s critical to understand that this isn’t the only cause of ulnar neuropathy that develops during hospitalization.
Presentation may include:
Impaired sensation of the fourth and fifth digits
Inability to ABduct or oppose the pinky finger
Chronic injury presents with claw hand (muscular atrophy)
Which nerve is MOST likely to be injured following traumatic IV insertion in the antecubital space?
Axillary
Median
Ulnar
Radial
Median
Although median nerve injury is a rare event, it can occur as a result of traumatic IV insertion at the antecubital space.
Which nerve is MOST likely to be injured by an IV pole that presses against the dorsolateral aspect of the humerus?
Ulnar
Axillary
Median
Radial
Radial
The radial nerve passes along the spiral groove at the lateral aspect of
the humerus (about 3 fingerbreadths above the lateral epicondyle).
It can be injured by: External compression by an IV pole Excessive cycling of the NIBP cuff Upper extremity tourniquet Sheets that are too tight (if the arms are tucked)
A patient developed foot drop following vaginal hysterectomy. She was positioned in candy cane stirrups. Which nerve was injured?
Saphenous
Femoral
Common peroneal
Obturator
Common peroneal
The common peroneal nerve is highly susceptible to injury when the patient is placed in stirrups. This nerve wraps around the fibular head, and it can be compressed when the lateral aspect of the leg leans against the stirrup bar.
Presentation of common peroneal nerve injury:
Foot drop
Inability to evert the foot
Inability to extend the toes dorsally
Which complications are MOST commonly associated with the sitting position? (Select 2.)
Tracheobronchial compression
Paradoxical air embolism
Midcervical tetraplegia
Lower extremity compartment syndrome
Midcervical tetraplegia
Paradoxical air embolism
Midcervical tetraplegia is associated with hyperflexion of the neck (chin to chest). Ischemia occurs as a result of stretching and/or compression of the midcervical spinal cord (usually C5). This complication is most common in the sitting position.
Although the sitting position is most commonly associated with venous air entrainment, this complication can occur in any position that produces a pressure gradient between the atmosphere and the veins at the surgical site.
A nurse anesthetist in middle management submits written complaints to a state board about several other nurse anesthetists that are false and defamatory. Which AANA document could be applied to this situation?
Practice Standards
Position Statements
Code of Ethics
Practice Guidelines
Code of Ethics
The AANA Code of Ethics dictates the principles of conduct and professional integrity that guide the decision making and behavior of nurse anesthetists. This document speaks to the anesthetist’s responsibilities as a professional, which holds the individual CRNA accountable for his or her own actions and judgments, regardless of institutional policy or physician orders.
As a professional, the CRNA is held individually accountable for his or her “conduct in maintaining the dignity and integrity of the profession” and “does not knowingly engage in deception in any form.”
The specific act committed by the CRNA in this question is called libel.
The use of unnecessary invasive preoperative testing is most likely to put the provider in violation of the principle of:
justice.
beneficence.
respect for autonomy.
nonmaleficence.
Nonmaleficence
Nonmaleficence asserts that a provider has an obligation not to inflict hurt or harm—in other words, the Hippocratic oath primum non nocere (first do no harm). There is no distinction between intentional or unintentional harm.
The use of unnecessary preoperative testing can put the provider in violation of the principle of nonmaleficence.
Informed consent for anesthesia should include a discussion of which topics? (Select 2.)
Agreement to undergo the scheduled surgery/procedure
Description of the recommended type of anesthetic
Patient preferences, questions, and fears
Risks and benefits of each type of appropriate anesthetic
Risks and benefits of each type of appropriate anesthetic
Patient preferences, questions, and fears
Informed consent conversations should include a discussion of all available and appropriate anesthetic choices for both the particular surgery/procedure and relevant comorbidities.
The preoperative consent process should allow for open sharing of information regarding anesthetic care and focused on the patient’s concerns, needs, and questions. It is recommended that the anesthesia consent process and paperwork should be separate and apart from the surgical consent process; further, the only appropriate person to conduct the anesthesia informed consent is the anesthesia provider.
What must the anesthesia provider do to obtain informed consent for epidural placement in a parturient who just received 50 mg of meperidine?
Review the efficacy of current pain management.
Determine that the patient has sufficient capacity.
Document the patient’s dilation, effacement, and station.
Perform detailed obstetrical history and physical exam.
Determine that patient has sufficient capacity
Despite the pain and distress that may accompany active labor, research has shown that most women retain the ability to understand, assimilate information, and make decisions. However, capacity is one of the elements of consent and should be ascertained as part of the informed consent process (review the last page if this doesn’t make sense).
It should go without saying that a current H&P, labor progress, and the effectiveness of current analgesia are all important parts of the pre-anesthetic evaluation process.
A terminal cancer patient with a “do not resuscitate” order presents for a port-a-cath placement. Which standard of nurse anesthesia practice has the most immediate relevance to the anesthetist’s preoperative activities?
Standard 4 on informed consent and related anesthesia services
Standard 13 on wellness
Standard 3 on plan for anesthetic care
Standard 2 on thorough preoperative assessment and evaluation
Standard four on informed consent and related anesthesia services
Reconsideration of a pre-existing advanced directive is a critical component of the informed consent process, because some events that may occur are responses to the anesthetic and are not part of the terminal disease process. Advance directives should not be routinely suspended perioperatively, but require a detailed discussion as noted in this lesson.
Identify the standards of care that have been published by the American Association of Nurse Anesthetists. (Select 3.)
Transfer of Care Chronic Pain Management Wellness Mass Casualty Incident Preparedness Latex Allergy Management Infection Control and Prevention
Wellness
Infection Control and Prevention
Transfer of Care
Only three of the answer choices are standards published by the AANA (listed above).
These standards represent the expected behaviors that must be demonstrated in a professional practice and that “must” be adhered to. These are the standards against which the delivered care is compared in the event of a lawsuit. Failure to adhere to these standards will provide prima facie evidence of negligence.
The AANA publications on latex allergy, chronic pain, and mass casualty incident management are practice guidelines—suggestions that “should” be adhered to but that do not rise to the level of standards.
You are four hours into a complex case and are relieved by another anesthesia provider. You are late to an appointment and give only a cursory report that results in a missed repeat antibiotic dose. The patient ultimately develops sepsis intraoperatively that results in an unexpected 3-day ICU stay. Which two causes of action against you might apply to this scenario? (Select 2.)
Abandonment
Malpractice violation of the AANA standards of care
Loss of chance of survival
Vicarious liability for relieving anesthetist
Malpractice violation of the AANA standards of care
Abandonment
Standard 11 relates to the accurate reporting of a patient’s condition which is defined as, “ Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care.”
A plaintiff attorney may also claim abandonment—the transfer of care, although to a qualified provider, was incomplete in not addressing the requirement for a repeat dose of antibiotic. Thus, the duty to the patient was abandoned.
Vicarious liability and loss of chance of survival will be defined shortly.
Which law ensures public access to emergency services regardless of their ability to pay?
Affordable Care Act
Health Information Technology for Economic and Clinical Health Act
Health Insurance Portability and Accountability Act
Emergency in Medical Treatment and Active Labor Act
Emergency in Medical Treatment and Active Labor Act
There are 6 federal laws that significantly affect health care practice in the United States. Deciphering these laws and their acronyms is the object of Parts I and II of the next lessons.
Match each drug to its schedule based on the Controlled Substances Act.
Schedule I + Heroin
Schedule II + Cocaine
Schedule III + Ketamine
Schedule IV + Tramadol
When a patient experiences a serious anesthetic complication, what information is most appropriate to offer to the patient’s relatives?
Disclose nothing until you are certain of the patient’s outcome
Describe the facts of the event while also expressing regret
Tell the family that risk management will contact them
Provide the names and roles of the party or parties at fault
Describe the facts of the event while also expressing regret
It is now generally accepted that the relationship between the anesthesia provider and the patient-family should be based on honesty and trust. Disclosure of actual events early reinforces this relationship of trust. Disclosure of facts does not pose any greater threat to the providers because the patient and family will inevitably discover them in the future.
There is evidence that the “disclosure, apology, and offer” approach to adverse events versus the “deny and defend” approach reduces claims, settlement amounts, and defense costs. All providers should ensure that they are aware of their institutional or group policies as well as state law on these matters.
“Proof” in a juried malpractice case must include which components? (Select 2.)
Absolute certainty that the provider was negligent
The highest standards of care were not followed
Evidence of duty, breach, cause, and harm
More likely than not that negligence occurred
Evidence of duty, breach, cause, and harm
More likely than not that negligence occurred
A claim of malpractice must prove that the defendant had a duty to the patient, the defendant breached their duty, a causal relationship exists between the defendant’s acts and the patients’ injury, and damages resulted from the breach.
With this in mind, absolute certainty of malpractice is NOT required. A jury may find for the plaintiff if they believe that the probability of causal injury is greater than 50%. Further, the defense need only prove an acceptable, not the highest, standard of care was provided.
Rank the causes of anesthesia-related lawsuits from most common to least common.
(1 is the most common, and 4 is the least common)
1 + Death
2 + Nerve damage
3 + Permanent brain damage
4 + Awareness
A 13-year old Jehovah’s witness with a Cobb angle of 50°presents for an elective spinal fusion. The parents are adamant that they do NOT want the child transfused. What is the best approach for discussing the possible need for intraoperative transfusion?
Tell the parents they will be reported to Child Protective Services if they refuse.
Delay surgery until the child is mature enough to join in the decision-making process.
Get a court order for transfusion despite the parent’s wishes.
Agree, then perform an emergency transfusion if the need arises
Delay surgery until the child is mature enough to join in the decision-making process.
In elective cases, it is appropriate to wait for the pediatric patient to reach a sufficient age and maturity, and then allow them to participate in the decision-making process.
Which two statements represent norms in a culture of safety? (Select 2.)
Providers are rewarded for erring on the side of caution even if wrong.
A steep hierarchy exists so that junior personnel are excluded.
Explicit communication is frequent and ambiguity is challenged.
Workflow efficiency overrides patient safety concerns.
Providers are rewarded for erring on the side of caution even if wrong.
Explicit communication is frequent and ambiguity is challenged.
Workplace culture can make or break efforts to improve patient care and increase patient safety.
A culture of safety is cultivated in several ways, which we’ll discuss on the next page.
Which skill is central to and most essential for effective crisis resource management?
Communication
Task management
Situation awareness
Decision making
Communication
In an anesthetic crisis, effective response and management is dependent upon non-technical skills. Crisis resource management (CRM) uses a simple model in which effective communication is the “glue” that holds all the other components together.
What proportion of anesthesia mishaps are estimated to occur as a result of human error?
30%
50%
70%
90%
70%
The 70% human error rate is comparable to our parallel professionals—aviators—in terms of the high cognitive demands, multitasking, and the need for constant vigilance.
Work in both professions challenges individuals both physiologically and mentally; for this reason, maintenance of personal health and wellness is absolutely required.
The most effective method of maintaining vigilance during an anesthesia workday is to:
get a consistent 8 hours of sleep each night.
have a 60-minute workout right before bedtime.
use a peripheral nerve stimulator on yourself when sleepy.
ingest caffeinated beverages every 3 hours.
Get a consistent 8 hours of sleep each night
As noted in the previous lesson, sleep debt will accumulate until the debt is directly paid. No countermeasures can reduce sleep debt; however helpful guidelines for managing fatigue at work are next!
What is the annual OSHA limit for workplace exposure to ionizing radiation in a 38-year old provider? (Enter your answer in rem)
5 rem
The OSHA limit for occupational exposure to ionizing radiation is 5 rem annually, with a lifetime limit of (N-18) x 5 rem, N= age in years.
In this provider, the lifetime limit will be reached at 100 rem.
Match the term with its definition.
Tolerance + Markedly diminished effects of the same drug amount
Impairment + An inability to engage in activities of daily living
Withdrawal + Physical and emotional responses to very low drug levels
All of the following signs or symptoms are characteristic of substance abuse EXCEPT:
difficult to locate after breaks.
intense emotional response to a medical error.
frequent requests to work late or take call.
emotionally labile and moody.
Intense emotional response to a medical error
It’s important to recognize that just because a person exhibits signs and symptoms of substance abuse disorder, doesn’t mean that it’s the only explanation for this behavior. For instance, someone could work a lot of overtime as she saves for a down payment on a home or someone else might be emotionally labile and moody because he’s going through a divorce.
Having said this, we must be aware of these changes in our co-workers. Furthermore, the more signs or symptoms someone demonstrates, the more we should pay attention.
An intense emotional response to a medical error is a natural (and expected) human response in even the healthiest of individuals.
Identify the major goals of the Institute for Healthcare Improvement Triple Aim’s broad conceptual approach to improving health outcomes. (Select 3.)
Improve population health Provide holistic care Avoid waste of supplies Improve patient experience Build an engaged leadership Reduce per capita costs
Improve patient experience
Improve population health
Reduce per capita costs
The “Triple Aim” is a conceptual approach to improving the US health care system “aiming” at three primary areas: care, health, and cost.
Care involves improving patient experience and includes both delivered healthcare quality and patient satisfaction.
Improving overall population health affects both individual health and reduces the societal burden of a chronically ill population
Reduced per capita costs references the fact that the US has the most expensive healthcare system in the developed world while also being ranked among the worst for efficiency, equity, and outcomes.
What is the STRONGEST type of molecular bond?
Ionic
Covalent
Hydrogen
Van der Waals
Covalent
The atom is the building block of matter, and 2 or more atoms bonded together is called a molecule.
Molecular bonding occurs when valence electrons of one atom interact with the valence electrons of another atom.
There are 4 types of atomic bonds you should know:
1. Ionic bond:
Involves the complete transfer of valence electron(s) from one atom to another. This creates ions.
2. Covalent bond:
Involves the sharing of electrons.
3. Polar covalent bond:
Involves the sharing of electrons, but the electrons tend to remain closer to one of the atoms (creates a partial negative charge) and further away from another atom (creates a partial positive charge).
- Van der Waals forces:
Van der Waals’ forces describe a very weak intermolecular force that holds molecules of the same type together.
Electrons (and their negative charges) orbiting a molecule are in constant motion. This creates temporary partial (+) and (-) charges at different parts of the molecule at any given time. The net result is that electron rich areas of one molecule will be attracted to electron poor areas of another molecule.
Recap: Molecular bonds in decreasing order of strength:
Covalent > Ionic > Polar covalent > Van der Waals
At sea level, the agent monitor measures the end-tidal desflurane as 38 mmHg. Convert this to volumes percent.
(Enter your answer as a whole number)
Five percent
Dalton’s law of partial pressures says that the total pressure is equal to the sum of the partial pressures exerted by each gas in the mixture.
P total = P1 + P2 + P3…
The question asked you to convert the partial pressure of desflurane to volumes percent. Here’s the equation:
Volumes percent = (Partial pressure / Total pressure) x 100
Et Des = 38 mmHg
P atm = 760 mmHg
(38 mmHg / 760 mmHg) x 100 = 5%
At sea level, the agent monitor measures the end-tidal sevoflurane as three percent. Convert this to mmHg.
(Round your answer to the tenths place)
22.8 mmHg
The question is just like the last one, but we’re going the other direction. Here’s how to convert volumes percent to partial pressure:
Partial pressure = Volumes percent x Total pressure
Vol% sevo = 3%
P atm = 760 mmHg
3% x 760 mmHg = 22.8
Instead of a volatile agent, you might be asked about carbon dioxide or any other gas. The concept is the same no matter what gas you’re asked about.
If the atmospheric pressure is 650 mmHg and you are delivering oxygen at 1 L/min and nitrous oxide at 2 L/min, what is the partial pressure of nitrous oxide that is delivered to the patient?
(Enter your answer as mmHg, and round to the nearest whole number)
433 mmHg (we also accepted 429 and 436 mmHg)
This is another application of Dalton’s law.
O2 FGF = 1 L/min (this is 1/3 of total FGF)
N2O FGF = 2 L/min (this is 2/3 of total FGF)
P atm = 650 mmHg (this is the same as P total)
If the total FGF is 3 L/min and N2O is 2 L/min, then the FiN2O is 66% or 2/3. Next, you need to multiply the total pressure (P atm) by 2/3 to arrive at the correct answer.
N2O at 2 L/min x (2/3 x 650 mmHg) = 433 mmHg
If you used 0.66, then the correct answer is 429.
If you used 0.67, then the correct answer is 436.
Overpressurizing the vaporizer is an example of:
Dalton’s law.
Graham’s law.
Henry’s law.
Fick’s law.
Henry’s Law
Henry’s Law states that the amount of gas that dissolves in solution is directly proportional to the partial pressure of that gas over the solution.
If we significantly increase the concentration of volatile anesthetic at the alveolocapillary interface, we can hasten its transfer into the bloodstream and ultimately the brain. This technique is called “overpressurizing” the vaporizer.
Which law states that pressure is directly proportional to temperature when the volume is held constant?
Henry
Boyle
Charles
Gay-Lussac
gay lussac
You’re expected to understand which variables remain constant in each gas law, and the mnemonic “Paid TV Can Be Great” can help you.
The top row of boxes contains the variables and the bottom row contains the gas laws. The red variable directly above each gas law is NOT included in that law, while the green variables are included in that particular law.
Gay-Lussac’s law says that pressure and temperature are directly proportional when the volume is held constant.
A gas occupies a volume of 500 mL at a pressure of 700 mmHg. What will the pressure be if the volume becomes 300 mL?
(Enter your answer as a whole number)
1167 mmHg
This is an application of Boyle’s law: P1 x V1 = P2 x V2
P1 = 700 mmHg V1 = 500 mL P2 = X V2 = 300 mL Here's the calculation: (700 mmHg x 500 mL) = (X mmHg x 300 mL) X = 1167 mmHg As a secondary way to check your calculation, you should conceptually determine the directional change of the unknown variable. If the direction of change doesn't match your prediction, then you'll want to double-check your equation and/or calculation.
Match each gas law to the clinical example that exemplifies it.
Boyle’s law + Diaphragm contraction increases tidal volume
Charles’s law + An LMA cuff ruptures when placed in an autoclave
Gay-Lussac’s law + Oxygen tank explodes in a heated environment
Boyle’s law (P x V = constant):
Diaphragm contraction increases tidal volume
Pneumatic bellows
Squeezing an ambu bag
Using the bourdon pressure gauge to calculate how much O2 is left in a cylinder (assumes a given flow rate).
Charles’s law (V / T = constant):
LMA cuff ruptures when placed in an autoclave
Gay-Lussac’s law (P / T = constant):
Oxygen tank explodes in a heated environment
At sea level, the Bourdon pressure gauge on an oxygen tank reads 0 mmHg. What is the pressure inside the oxygen tank?
(Enter your answer in mmHg)
760 mmHg
This question wasn’t designed to trick you, but rather we want to make sure that you understand a few critical concepts.
- The Bourdon pressure gauge measures tank pressure relative to atmospheric pressure. Therefore, if the gauge reads 0 mmHg, the pressure in the tank is actually the same as atmospheric pressure (760 mmHg at sea level).
- And this brings us to our next point. Gas moves according to a pressure gradient. If the pressure inside the tank is 760 mmHg and the atmospheric pressure is also 760 mmHg, the small volume of gas that remains in the tank will remain inside the tank since there is no driving pressure to push it out (760 mmHg - 760 mmHg = 0).
During laminar flow, doubling the radius will cause flow to increase by a factor of:
16
The Poiseuille equation describes the laminar flow through a tube.
Q = π R^4 ∆P / 8 η l
Flow = 3.14 x Radius ^4 x Pressure difference / 8 x viscosity x length
As you can see, the radius of the tube exhibits the greatest impact on flow.
R = 1^4: 1 x 1 x 1 x 1 = 1 R = 2^4: 2 x 2 x 2 x 2 = 16 R = 3^4: 3 x 3 x 3 x 3 = 81
Selecting an 8.0 endotracheal tube instead of a 6.0 endotracheal tube for a morbidly obese patient demonstrates an understanding of:
Henry’s law.
Bernoulli’s principle.
Poiseuille’s law.
Laplace’s law.
Poiseuille’s law
Poiseuille’s law describes the variables that govern laminar flow.
Q = πr^4 ∆P / 8ηl
Flow is directly proportional to:
Driving pressure
Radius^4 (increasing R is the best way to improve flow)
Flow is inversely proportional to: Viscosity Length of the tube If we apply these concepts to the question, then we can see that flow is increased when a wider endotracheal tube is s
Reynold’s number is inversely proportional to:
viscosity.
mass.
density.
velocity.
Viscosity
Reynold’s number helps us predict the type of flow that will occur in a given location.
Re = (fluid velocity x fluid density x tube diameter) / (fluid viscosity)
Laminar: Re < 2,000
Transitional: Re = 2,000 - 4,000
Turbulent: Re = > 4,000
Laminar flow is more dependent on fluid viscosity.
Turbulent flow is more dependent on fluid density.
Using a helium-oxygen mixture in the patient with status asthmaticus demonstrates an understanding of:
Laplace’s law.
Reynolds number.
Bernoulli’s principal.
Vander Waal’s forces.
Reynold’s number
Because turbulent flow is primarily dependent on gas density, we can improve flow by having the patient inhale a lower density gas. An oxygen/helium mixture (Heliox) decreases Reynold’s number and can improve airflow when airway resistance is high.
A helium/oxygen mixture is also useful for the patient with epiglottitis.
Helium does NOT improve flow if it is already laminar
Which laws are illustrated in the Fick equation? (Select 2.)
Dalton
Reynolds
Henry
Graham
Henry
Graham
Fick’s law of diffusion describes the transfer rate of gas through a tissue medium.
The rate of transfer is DIRECTLY proportional to:
Partial pressure difference (driving force)
Diffusion coefficient (solubility)
Membrane surface area
The rate of transfer is INVERSELY proportional to:
Membrane thickness
Molecular weight
Applications of the Fick equation:
Diffusion hypoxia
A patient with COPD has a reduced alveolar surface area, and therefore has a slower rate of inhalation induction
Calculation of cardiac output
Henry’s law and Graham’s law are incorporated into the Fick equation.
Henry’s law states that the amount of gas that dissolves in solution is directly proportional to the partial pressure of that gas over the solution.
Graham’s law states that the rate of gas diffusion is inversely proportional to the square root of its molecular weight.
Which concept BEST explains why a patient with systemic hypertension develops left ventricular hypertrophy?
Boyle’s law
Joule-Thompson effect
Bernoulli’s principal
Law of Laplace
Law of Laplace
The ventricle develops wall tension to overcome afterload, and we can apply the law of Laplace to give us deeper insight into this process.
Wall Tension = (LV Pressure x Radius) / (LV Wall Thickness x 2)
From this equation you can see that wall tension (wall stress) is reduced by: ↓ Intraventricular pressure ↓ Radius ↑ Wall thickness
The law of Laplace also helps us understand why the patient with systemic hypertension compensates with left ventricular hypertrophy - A thicker left ventricle reduces wall stress.
What is the minimum recommended distance from an ionizing radiation source?
(Enter your answer in feet)
Six feet
Radiation exposure obeys the inverse square law, which says the amount of exposure is inversely proportional to the square of the distance of the source.
Intensity = 1 / Distance ^2
The minimum recommended distance from an ionizing radiation source is 6 feet.
Which gas can be compressed into a liquid at room temperature?
Air
Carbon dioxide
Nitrogen
Oxygen
Carbon dioxide
We’re sure that nitrous oxide immediately came to mind. Remember, you won’t always see the obvious answer on boards.
Critical temperature is the highest temperature where a gas can exist as a liquid. Said another way, it is the temperature above which a gas cannot be liquefied regardless of the pressure applied to it.
The critical temperature for carbon dioxide is 31 C, which explains why it primarily exists as a liquid inside the cylinder (Room temperature is about 20 C). Conversely, the critical temperature of oxygen is -119 C, so it exists as a gas inside the cylinder.
Critical temperatures of common gases (highest to lowest):
Nitrous oxide = 36.5 C (liquid in the cylinder at room temp)
Carbon dioxide = 31 C (liquid in the cylinder at room temp)
Oxygen = -119 C
Air = -140 C
Nitrogen = -147 C
Vapor pressure is primarily dependent on:
molecular weight.
temperature.
volume.
altitude
Temperature
In a closed container, molecules from a volatile liquid escape the liquid phase and enter the gas phase. The molecules in the gas phase exert a pressure on the walls of the container. This is called vapor pressure.
Vapor pressure is primarily dependent on the liquid’s temperature:
↑ Temp → ↑ VP
↓ Temp → ↓ VP
At body temperature, the vapor pressure of water is 47 mmHg. This is why you see this number subtracted in the alveolar gas equation.
Altitude does NOT affect vapor pressure.
An oxygen cylinder feels cool to the touch after it is opened. Which phenomenon BEST describes this process?
Adiabatic process
Joule-Thompson effect
Critical pressure
Latent heat of vaporization
Joule-Thompson effect
The Joule-Thompson effect says that a gas stored at high pressure that is suddenly released escapes from its container into a vacuum. It quickly loses speed as well as a significant amount of kinetic energy, resulting in a fall in temperature. This explains why an oxygen cylinder that is opened quickly feels cool to the touch (Joule is cool). Conversely, rapid compression of a gas intensifies its kinetic energy, causing the temperature to rise.
Adiabatic process describes a process that occurs without gain or loss of energy (heat). For example, a very rapid expansion or compression of a gas where there is no transfer of energy is an example of an adiabatic process.
Convert 38.3 degrees Celsius to Fahrenheit.
(Round your answer to the nearest tenth)
100.9 F
Converting between Celsius and Fahrenheit requires a conversion factor (5/9 or 1.8). To review the “why” you may wish to revisit the Chemistry & Physics Tutorial.
Celsius = (F – 32) x 5/9
Fahrenheit = (C x 1.8) + 32
Question: Convert 38.3 C to Fahrenheit.
F = (38.3 x 1.8) + 32 = 68.94 + 32 = 100.94 F
Convert 10 mmHg to centimeters of water.
(Round your answer to the nearest tenth)
13.6 mmHg
You should be able to covert to the common units of pressure. All of the following are equal:
1 atm = 1 bar = 760 mmHg = 760 torr = 100 kPa = 1033 cm H2O
To solve the calculation, you’ll need to convert mmHg to cm H2O then multiply by 10 mmHg.
(1033 cm H2O / 760 mmHg) x 10 mmHg = 13.6 cm H2O
What is the MOST significant source of heat loss in the operating room?
Conduction
Evaporation
Radiation
Convection
Radiation
Radiation is the #1 source of heat loss.
Radiation > Convection > Evaporation > Conduction
Where in the esophagus should the esophageal temperature probe be placed?
Proximal half
Proximal quarter
Distal half
Distal quarter
Distal quarter
The esophageal temperature probe should be placed in the distal 1/3 - 1/4 of the esophagus (38 - 42 cm past the incisors).
If the probe is placed too proximal, the cooling effect of inspiratory gas falsely decreases the temperature measurement.
If the probe is placed in the stomach, heat created by liver metabolism falsely increases the temperature measurement.
For every degree below normal body temperature, oxygen consumption is reduced by:
(Enter your answer as a percent)
5 - 7 percent
Oxygen consumption is reduced by 5 - 7% for every 1 degree C reduction in body temperature.
Induced hypothermia may be useful during: Cerebral ischemia (stroke) Cerebral aneurysm clipping Traumatic brain injury Cardiopulmonary bypass Cardiac arrest Aortic cross clamping Carotid endarterectomy
Identify the statements that BEST represent an understanding of fire safety during laser surgery on the airway. (Select 2.)
The cuff is the most vulnerable component of the endotracheal tube.
Laser resistant endotracheal tubes have laser resistant cuffs.
Laser reflective tape is the safest way to protect the endotracheal tube.
Polyvinyl chloride endotracheal tubes are flammable.
Polyvinyl chloride endotracheal tubes are flammable
The cuff is the most vulnerable component of the endotracheal tube
Why are the other answers wrong?
Laser resistant tubes do NOT have laser resistant cuffs!
Laser reflective tape is no longer advised. It’s smarter to use a laser resistant ETT
Abdominal compartment syndrome is diagnosed when intraabdominal pressure exceeds:
(Enter your answer as mmHg)
20 mmHg
Abdominal compartment syndrome is defined as intraabdominal pressure > 20 mmHg (transduction of bladder pressure) and evidence of organ dysfunction (hemodynamic instability, oliguria, increased PIP).
This condition is usually the result of aggressive fluid resuscitation.
Treatment includes neuromuscular blockade, sedation, diuresis, and abdominal decompression via laparotomy.
Expected findings during the tonic phase of electroconvulsive therapy include:
increased intraocular pressure.
hypertension
increased cerebral blood flow.
bradycardia.
Bradycardia
The seizure produced by ECT causes a predictable physiologic response.
Tonic phase: Increased PNS tone (bradycardia, hypotension)
Clonic phase: Increased SNS tone (increased CBF, ICP, HR, BP, and IOP)
Identify the statements that BEST describe neuroleptic malignant syndrome. (Select 2.)
Hyperthermia is a sign.
It has a fast onset.
There is a genetic link.
Dantrolene is a treatment.
Hyperthermia is a sign
Dantrolene is a treatment
You must be able to compare and contrast neuroleptic malignant syndrome and malignant hyperthermia.
Key facts about NMS:
No genetic link.
Slower onset (24 - 72 hours).
Is caused by dopamine antagonists and antipsychotic drugs.
Presents with muscle rigidity, hyperthermia, and tachycardia (like MH).
Is treated with dantrolene (like MH) or bromocriptine (not like MH).
Match each antidepressant with its drug class.
Amitriptyline + Tricyclic antidepressant
Venlafaxine + Selective norepinephrine reuptake inhibitor
Citalopram + Selective serotonin reuptake inhibitor
Antidepressants are used in the treatment of chronic pain.
Pain modulation occurs in the spinal cord. In the setting of central sensitization, the efficacy of the descending inhibitory pain pathway is impaired. Recall that this pathway uses norepinephrine and serotonin as inhibitory transmitters, so it makes sense that antidepressants that increase the concentrations of these neurotransmitters can treat chronic pain.
Match each regional anesthesia technique with its MOST appropriate indication.
Celiac plexus block + Liver cancer
Superior hypogastric block + Uterine cancer
Thoracic paravertebral block + Breast cancer
Thoracic paravertebral block:
Local anesthetic injected into the paravertebral space (a potential space) targets the ventral ramus of the spinal nerve as it exits the vertebral foramen.
Used for post-op pain relief following mastectomy.
Celiac plexus block:
The celiac plexus innervates the upper abdominal viscera (except the left side of the colon).
Used for cancer pain involving the upper abdominal organs.
Superior hypogastric plexus block:
The superior hypogastric plexus innervates the pelvic organs.
Used for cancer pain involving the pelvic organs.
A patient has a confirmed history of an IgE mediated immune reaction to penicillin. Today he presents for a total knee replacement. Select the MOST appropriate prophylactic antibiotic for this patient.
Metronidazole
Ampicillin
Gentamycin
Vancomycin
Vancomycin
Previous literature suggested a high rate of cross-reactivity between PCN and cephalosporins (up to 10 percent).
These numbers are grossly overstated (due to contamination during the manufacturing process). The likelihood of cross-reactivity is based on the R1 side chain, and the true rate is < 1%. Third and fourth generation cephalosporins are associated with the lowest rate of cross-reactivity (very rare).
If a patient reports an allergy to PCN, then s/he may receive a cephalosporin if the reaction:
Was NOT IgE mediated (anaphylaxis, bronchospasm, urticaria).
Did NOT produce exfoliative dermatitis (Stevens-Johnson syndrome).
If the patient experienced any of these complications, then vancomycin or clindamycin are acceptable alternatives.
The primary defect associated with Creutzfeldt-Jakob disease is:
hepatitis.
glucose intolerance.
encephalopathy.
heart failure.
Encephalopathy
Prion disease can lead to encephalopathy and dementia. Creutzfeldt-Jakob disease is the classic example. Etiologies include:
Consumption of contaminated animal protein
Contaminated implants (corneal or dural tissue)
Cadaveric pituitary hormone supplementation
A patient develops urticaria, flushing, and hypotension. This patient MOST likely exposed to:
contrast media.
cefazolin.
latex.
succinylcholine
Succinylcholine
The most common causes of perioperative anaphylaxis are: #1 Neuromuscular blockers (succinylcholine is most common) #2 Latex #3 Antibiotics (beta-lactams are most common)
FiO2 should be maintained < 30% in patients who are receiving:
vincristine.
bleomycin.
doxorubicin.
cisplatin.
Bleomycin
Bleomycin is associated with pulmonary toxicity. To prevent complications (pulmonary fibrosis), FiO2 should be maintained < to 30 percent.
Doxorubicin is associated with cardiotoxicity.
Vincristine is associated with peripheral neuropathy.
Cisplatin is associated with acoustic nerve injury and nephrotoxicity
Gastric barrier pressure is increased by:
pregnancy.
metoclopramide.
cricoid pressure.
glycopyrrolate.
Metoclopramide
Gastric barrier pressure is the difference of lower esophageal sphincter pressure and intragastric pressure. A lower gastric barrier pressure is associated with a greater likelihood of gastroesophageal reflux.
Metoclopramide increases barrier pressure as a function of increased LES tone.
Barrier pressure is reduced by glycopyrrolate, pregnancy, and cricoid pressure
Risk factors that contribute to PONV include: (Select 3.)
old age. long surgical duration. previous episodes of PONV. laparoscopic procedures. male gender. smoking history.
Long surgical duration
Laparoscopic procedures
Previous episodes of PONV
Patient risk factors:
Female gender (effects of progesterone and/or estrogen on CTZ)
Nonsmoker
History of motion sickness
Previous episodes of PONV
Age is loosely associated (youth > old age)
Surgical risk factors:
Long surgical duration (more time for lipophilic drugs to accumulate) GYN procedures Laparoscopy Breast Plastics Ear Eye Anesthetic risk factors: Halogenated anesthetics Nitrous oxide (> 50%) Opioids Etomidate Neostigmine
Match each antiemetic to its drug class.
Aprepitant + Neurokinin-1 antagonist
Promethazine + Phenothiazine
Droperidol + Butyrophenone
Granisetron + 5-HT3 antagonist
Neurokinin-1 antagonists:
Receptor: NK-1
Ligand: substance P
Example: aprepitant
Phenothiazines: Receptors: H1 and M1 Ligands: histamine and acetylcholine Examples: promethazine, prochlorperazine, chlorpromazine Butyrophenones: Receptor: D2 Ligand: Dopamine Examples: droperidol, haloperidol 5-HT3 antagonists: Receptor: 5-HT3 Ligand: serotonin Examples: granisetron, ondansetron, dolasetron
Which of the following reduce gastroesophageal barrier pressure? (Select 2.)
Metoclopramide
Pregnancy
Glycopyrrolate
Succinylcholine
Glycopyrrolate
Pregnancy
The likelihood of gastroesophageal reflux is determined by barrier pressure. The higher the barrier pressure, the lower the likelihood of reflex.
Barrier pressure = Lower esophageal sphincter pressure - Intragastric pressure
Barrier pressure is reduced by:
Decreased LES tone
Increased intragastric pressure
Anticholinergics reduce barrier pressure. This effect lasts ~ 60 minutes with glycopyrrolate and ~ 40 minutes with atropine.
Pregnancy reduces barrier pressure. This is probably a combined effect of progesterone (chemical change) and increased abdominal and gastric pressures caused by the gravid uterus.
Metoclopramide increases barrier pressure by increasing lower esophageal sphincter tone. It also increases gastric motility, making it a useful option for patients presenting for cesarean delivery.
Succinylcholine increases LES tone but it also increases intragastric pressure. These cancel each other out, which is why succinylcholine has no effect on barrier pressure.
What is the MOST common side effect associated with ondansetron?
Sedation
QTc prolongation
Headache
Extrapyramidal effects
Headache
Ondansetron is a 5-HT3 receptor antagonist. It does not interact with histamine, dopamine, cholinergic, or NK-1 receptors.
Headache and diarrhea are the most common side effects associated with ondansetron.
5-HT3 antagonists (including ondansetron) cause QTc prolongation, however this is not the most common side effect. Droperidol also prolongs the QTc.
Extrapyramidal symptoms can occur with metoclopramide and droperidol since these drugs antagonize dopamine in the CNS.
Which drugs are BEST suited for the patient with motion induced nausea? (Select 2.)
Scopolamine
Dimenhydrinate
Dexamethasone
Ondansetron
Scopolamine
Dimenhydrinate
Motion induced nausea is the result of muscarinic receptor stimulation (M1) in the vestibular system of the inner ear. Therefore, drugs that antagonize the M1 receptor (scopolamine and dimenhydrinate) provide relief, while those that target other receptors (ondansetron - 5-HT3 antagonist) and dexamethasone (intracellular steroid receptors) are not helpful for this population.
Dimenhydrinate (Dramamine) antagonizes H1 and M1 receptors in the vestibular system.
All of the following receptors are located in the chemoreceptor trigger zone EXCEPT:
M1.
5-HT3.
D2.
NK-1.
M1
The vomiting center is located in the nucleus tractus solitarius, (medulla). It receives and integrates input from the chemoreceptor trigger zone, vestibular system, and GI tract. The cerebral cortex also provides afferent input.
The chemoreceptor trigger zone (CTZ) resides in the area postrema at the caudal end of the forth ventricle. The blood-brain barrier is poorly developed here, so the CTZ is sensitive to nausea-inducing chemicals and toxins in the systemic circulation. Neurotransmission between the CTZ and the vomiting center involves:
Serotonin (5-HT3 receptor)
Dopamine (D2 receptor)
Substance P (NK-1 receptor)
There are no muscarinic receptors in the CTZ
The vestibular system is stimulated by acetylcholine (M1 receptor) and histamine (H1 receptor).
The GI tract uses serotonin (5-HT3 receptor) and substance P (NK-1 receptor) to communicate with the vomiting center.
Aprepitant is a:
5-HT3 receptor antagonist.
NK-1 receptor antagonist.
H1 receptor antagonist.
opioid receptor antagonist:
NK-1 receptor antagonist
NK-1 receptors are located in the GI tract and the vomiting center in the brain.
Substance P is the ligand for the NK-1 receptor.
Aprepitant:
Has no sedative qualities.
Does not prolong the QTc.
Is available in a PO formulation.
5-HT3 receptor antagonists reduce postoperative nausea and vomiting by their effects on the: (Select 2.)
vestibular system.
lower esophageal sphincter.
vagus nerve.
nucleus tractus solitarius.
Vagus nerve
Nucleus tractus solitarius
5-HT3 receptor antagonists treat PONV in the peripheral and central nervous systems.
They act peripherally by blocking 5-HT3 receptors on vagal afferents from the stomach and small intestine.
They act centrally by blocking 5-HT3 receptors in the chemoreceptor trigger zone.
5-HT3 receptors are not located on the lower esophageal sphincter or the vestibular system.
The transdermal scopolamine patch:
delivers 5 mg/hr.
is effective for up to 48 hours.
is best applied before the induction of anesthesia.
has a similar side effect profile to the intravenous formulation.
Is best applied before the induction of anesthesia
The transdermal scopolamine patch is placed in the postauricular area (behind the ear).
It is best applied before > 4 hours prior to the induction of anesthesia.
It delivers a dose of 5 mcg/hr for ~ 72 hours. Because this is a smaller dose than the intravenous formulation, it’s not associated with the same side effect profile (anticholinergic effects).
If the patient removes the patch and then touches his or her eye, it will cause mydriasis (pupil dilation). While it’s only temporary, it’s an inconvenience for the patient.
What is the MAXIMUM daily dose for acetaminophen?
(Enter your answer in grams)
4 g
Acetaminophen is a centrally acting, non-NSAID analgesic.
The exact mechanism of action is unclear, however it’s been suggested that it inhibits prostaglandin synthesis (COX-3 inhibition?). Additionally, analgesia may be produced by activating the descending inhibitory pain pathway in the spinal cord.
Acetaminophen is the most common cause of liver failure in the US. The max dose is 4 g per day.
A patient weighs 176 pounds and is 74 inches tall. How would you categorize this patient’s body habitus?
Under weight
Normal
Overweight
Obese
Normal
BMI = Weight in Kgs / Height in meters squared
This patient is of normal weight. His BMI is 23 Kg/m2.
Underweight: < 18.5 Normal (IBW): 18.5 – 24.9 Overweight: 25 – 29.9 Class I Obesity: 30 – 34.9 Class II Obesity: 35 – 39.9 Obesity class III (severe/morbid): > 40
Which of the following are associated with obesity? (Select 3.)
Increased total body water Increased cardiac output Increased renal clearance Increased blood volume Decreased lean body weight Decreased volume of distribution of lipid soluble drugs
Increased cardiac output
Increased blood volume
Increased renal clearance
Obesity is associated with an increased: Blood volume Cardiac output Renal clearance Vd lipid soluble drugs
Obesity is associated with a decreased: Total body water Pulmonary function Obesity is associated with altered: Plasma protein binding Liver function
Lean body weight is used to calculate the loading dose for: (Select 2.)
remifentanil.
midazolam.
succinylcholine.
propofol.
Remifentanil
Propofol
While it’s true that opioids are highly lipophilic and have large volumes of distribution, the behavior of remifentanil is unique. Since it is rapidly cleared by non-specific plasma esterases (not pseudocholinesterase), it behaves like it’s a low Vd drug. For this reason it is dosed on lean body weight (LBW = IBW x 1.3).
The loading dose for propofol is based on LBW. It’s termination of action is due to redistribution from the plasma into the peripheral compartment (not clearance).
Even though succinylcholine is a water soluble drug, the loading dose is based on TBW. This is a clear exception to the rule for water soluble drugs, and we all know that the NCE likes to test the exceptions! Shortly stated, the combination of increased plasma volume (↑ Vd) and increased pseudocholinesterase activity (↑ clearance) necessitates that a higher dose is used to achieve adequate muscle relaxation for tracheal intubation.
The texts seem to agree that midazolam should be administered based on TBW, citing a large central volume of distribution. Dosing in this way prolongs the elimination t1/2. Clinically this may result in over sedation in a population already sensitive to respiratory depressant drugs.
What is the estimated blood volume of the patient with class III obesity?
40 mL/kg
50 mL/kg
60 mL/kg
70 mL/kg
50 mL/kg
Although the total blood volume is increased in the morbidly obese patient, the percentage of total blood volume relative to the patient’s weight is actually decreased.
Adipose isn’t as vascular as lean tissue, so it contributes less total body water on a per weight basis. The patient with a normal BMI has a TBW of 60%, while the patient with class III obesity has a TBW of ~ 40 percent.
The patient with a normal BMI has an EBV of 70 mL/kg. The patient with class III obesity has an EBV of 45 - 55 mL/kg.
For this reason, fluid management should be based on lean body weight (IBW x 1.3). To complicate matters further, these patients commonly have diastolic dysfunction, making volume overload and pulmonary edema more likely.
In the obese patient, how much does FRC decrease in the supine position after induction of anesthesia?
20%
30%
40%
50%
50 percent
We all know that FRC decreases after induction of anesthesia.
When a normal weight patient is in the supine position, FRC falls by 20 percent.
When an obese patient is in the supine position, FRC can fall by as much as 50 percent!
This contributes to a shorter time period between apnea and arterial desaturation. This situation is made even worse because the obese patient also has a higher oxygen consumption.
Obstructive sleep apnea is associated with cessation of airflow for more than:
10 seconds.
15 seconds.
20 seconds.
25 seconds.
10 seconds
Obstructive sleep apnea is defined as the cessation of airflow for at least 10 seconds (apnea), with 5 or more unsuccessful efforts to breathe (obstruction), and a drop of at least 4% SaO2 during sleep
Hypopnea describes a smaller than normal minute ventilation and is associated with some amount of arterial saturation
Strategies for mechanical ventilation in the morbidly obese patient include all of the following EXCEPT:
recruitment maneuver to peak pressure of 40 cm H2O.
permissive hypercapnia.
tidal volume 7 mL/kg total body weight.
CPAP during anesthetic induction.
Tidal volume 7 mL/kg total body weight
Just because a patient’s body habitus expands, does not mean that their lungs get bigger! For this reason, tidal volume is set at 6 - 8 mL/kg of ideal body weight (not total body weight).
Anesthetic induction reduces FRC upwards of 50 percent! V/Q mismatch widens the A-a gradient and decreases SaO2. You may be tempted to use 100% FiO2, however this contributes to absorption atelectasis. Alveolar recruitment reverses atelectasis and reduces the need for a high FiO2. First we need to re-expand atelectatic alveoli with several vital capacity breaths (inhale to peak pressure of 40 cm H2O). And to keep these alveoli open, we apply PEEP 5 - 10 cmH2O.
During induction, CPAP will prolong the time between apnea and desaturation. Permissive hypercapnia is acceptable, however this can increase pulmonary vascular resistance and right heart strain in the patient with pulmonary hypertension.
A multimodal approach to postoperative pain management in the patient undergoing Roux-en-Y gastric bypass includes all of the following EXCEPT:
ketorolac.
dexmedetomidine.
acetaminophen.
ketamine.
Ketorolac
Since opioids induce ventilatory depression, we look for non-opioid adjutants to supplement a multimodal regimen. In the postop period, opioid sparing effects can be obtained from dexmedetomidine, clonidine, acetaminophen, and low dose ketamine
Patients s/p gastric bypass should not receive ketorolac, since this drug increases the risk of GI bleeding in the postoperative period.
Which of the following physiologic parameters decreases in the obese patient?
Total body water
Cardiac output
Blood volume
Renal clearance
Total body water
Obesity is associated with an increased: Blood volume Cardiac output Renal clearance Vd lipid soluble drugs
Obesity is associated with a decreased:
Total body water
Pulmonary function
Obesity is associated with altered:
Plasma protein binding
Liver function
All of the following contribute to hypertension in the obese patient EXCEPT:
angiotensinogen.
hyperinsulinemia.
cytokines.
decreased blood viscosity.
Decreased blood viscosity
The incidence of hypertension in the obese population is twice that of those of normal weight. Blood pressure can increase 6.5 mm/Hg for every 10 percent increase of body weight.
The following contribute to the development of hypertension in the obese patient:
Increased blood viscosity
Hyperinsulinemia - Increases release of norepinephrine, cytokines, and angiotensinogen
Elevated mineralocorticoid concentrations
Abnormal sodium reabsorption
Select the MOST effective weight loss procedure for the patient with morbid obesity.
Roux-en-Y gastric bypass
Biliopancreatic diversion with duodenal switch
Gastric sleeve
Gastric banding
Roux-en-Y gastric bypass
Gastric bypass confers the highest potential for weight reduction in morbidly obese patients. Additionally, it yields the best improvement in obesity related co-morbidities.
Disadvantages include a longer hospital stay (2-3 days) as well as malabsorption related consequences including caloric deficiency, anemia, and deficiency of fat soluble vitamins (D, A, K, E). For this reason, there is a requirement of life-long nutritional support.
Gastric bypass is associated with a 2 percent rate of anastomotic leak. The most common s/sx are unexplained tachycardia (72 percent), fever (63 percent), and abdominal pain (54 percent). Patients s/p gastric bypass should not receive ketorolac, since this drug increases the risk of postop GI bleeding in this patient population.
Which bariatric procedures are more likely to cause nutritional deficiencies? (Select 2.)
Gastric banding
Roux-en-Y gastric bypass
Gastric sleeve
Biliopancreatic diversion
Roux-en-Y gastric bypass
Biliopancreatic diversion
Weight reduction surgery accomplishes its goal by:
Restricting the amount of food that can be consumed at one time (gastric band or sleeve gastrectomy).
Reducing the body’s ability to absorb nutrients (jejunoileal bypass or biliopancreatic diversion).
A combination of restriction and malabsorption (Roux-en-Y gastric bypass).
Malabsorption is caused by reducing the size of the stomach and bypassing a portion of the small intestine. The more of the intestine that is bypassed, the greater the degree of malabsorption.
Consequences of malabsorption include caloric malnutrition, anemia, and deficiency of fat-soluble vitamins (D, A, K, E). For this reason, there is a requirement of life-long nutritional support.
Which of the following complications are associated with maternal obesity? (Select 2.)
Increased risk of preterm labor
Excessive blood loss during cesarean section
Decreased duration of first stage labor
Increased incidence of type 1 diabetes
Increased risk of preterm labor
Excessive blood loss during cesarean section
Obesity increases the:
Incidence of preterm labor
Duration of the first and second stages of labor
Need for cesarean section
Risk of surgical complications (wound infection, blood loss, and venous thrombi/emboli)
Difficulty in performing neuraxial blockade
Difficulty of airway management
Incidence of false negatives when searching for fetal abnormalities via ultrasound
Incidence of macrosomia (large for gestational age)
Which surgical positions reduce cardiac output the most? (Select 2.)
Lateral decubitus
Prone
Supine
Sitting
Sitting
Prone
Gravity affects the distribution of blood volume, and the awake patient has a variety of compensatory mechanisms (SNS activation) to minimize the impact of body position changes.
General anesthesia causes vasodilation, myocardial depression, and impairs baroreceptor responsiveness. Venous return is reduced as blood pools in dependent regions in the body. Taken together, these changes, render the patient more susceptible to hemodynamic instability when placed in certain surgical positions.
For each position, think about where the lower extremities are relative to the heart. In the sitting, flexed lateral, and prone positions, the lower extremities are below the level of the heart. This explains why these positions are associated with a higher incidence of hemodynamic changes (decreased BP and CO).
While auscultating breath sounds during surgery, you only hear air movement in the right lung. Which are the MOST likely causes? (Select 2.)
Neck flexion
Trendelenburg position
Neck extension
Lateral position
Trendelenburg
Flexion of the neck
You have diagnosed an endobronchial intubation. Compared to the left mainstem bronchus, the right mainstem bronchus takes off at a less acute angle. This explains why the endotracheal tube is more likely to slip down the right side.
There are two conditions that increase the risk of this complication.
- Neck flexion - the tube goes where the nose goes.
Neck flexion makes the endotracheal tube advance. This increases the risk of endobronchial intubation.
Neck extension moves the endotracheal tube towards the vocal cords. This increases the risk of inadvertent extubation. - The position of the carina in the chest.
In the Trendelenburg position, the abdominal contents shift cephalad, moving the diaphragm and thoracic contents towards the endotracheal tube. Remember that the tube is secured in a fixed location at the mouth, so the tip of the tube isn’t going to change.
In the sitting position, what reflex has been implicated as the cause of hypotension and bradycardia in the patient with an interscalene block?
Bezold-Jarisch
Baroreceptor
Cushing
Bainbridge
Bezold-Jarish
The Bezold-Jarisch reflex can be seen in patients with an interscalene block in the sitting position (think shoulder surgery).
The BJR causes the triad of: profound hypotension, bradycardia, and coronary vasodilation.
In the setting of inadequate preload, the heart slows to allow it adequate time to fill.
This is the same reflex that’s been implicated in unexplained cardiac arrest during spinal anesthesia.
Which position is MOST likely to contribute to the development of a “mill wheel” murmur?
Supine
Prone
Sitting
Lateral decubitus
Sitting position
A “mill wheel” murmur may signal the presence of a venous air embolism.
VAE can occur anytime there is a pressure gradient between the right atrium and the veins at the operative site. This gradient is largest in the sitting position.
If you encounter a question like this and you don’t see the sitting position as an answer choice, the best approach is to consider which answer choice creates the largest pressure gradient between the veins at the operative site and the right atrium.
Paradoxical air embolism can occur when the patient has a patent foramen ovale (PFO). TEE is the gold standard for diagnosing a PFO.
During posterior spinal fusion in the prone position, chest rolls: (Select 2.)
improve venous return.
decrease pulmonary compliance.
reduce surgical blood loss.
increase central venous pressure.
Improve venous return
Reduce surgical blood loss
When you place the patient in the prone position, your primary objective is to minimize pressure on the abdomen and the vena cava. This confers several key benefits:
Improved pulmonary mechanics
Improved venous return
Decreased venous pressure
The intervertebral veins do not contain valves. Increased venous pressure is transmitted to this region and can contribute to increased surgical blood loss.
When compared to the Wilson frame and chest rolls, the Jackson table is least likely to negatively impact pulmonary mechanics (compliance is better and PIP is lower).
All of the following increase the risk of brachial plexus injury EXCEPT:
axillary roll placed caudal to the axilla.
head turned laterally + contralateral arm abduction.
arms extended over the head in the prone position.
shoulder braces.
Axillary roll placed caudal to the axilla
The brachial plexus is susceptible to stretch and compression injuries.
In the supine position, arm ABduction > 90 degrees stretches the brachial plexus around the head of the humerus. Lateral neck rotation stretches the brachial plexus on the contralateral side.
In the Trendelenburg position shoulder braces are used to prevent the patient from sliding on the OR table. The best answer is to never use shoulder braces! If they are used, they should be placed at distal end of the clavicle. Improper placement near the base of the neck or midway along the clavicle increases the risk of a compression injury.
In the prone position, the shoulders should not be allowed to sag forward and the arms should not be extended over the head.
In the lateral decubitus position, brachial plexus injury is most likely the result of excessive stretching, extension, or external rotation of the arm or posterior displacement of the shoulder. An axillary roll is placed distal to the axilla. A roll placed inside the axilla can cause neurovascular compression.
Choose the risk factors that increase the risk of perioperative ulnar neuropathy. (Select 4.)
Regional anesthesia Male gender Outpatient surgery Female gender Cardiac surgery Extremes of body habitus Prolonged hospital stay Youth
Male gender
Cardiac surgery
Extremes of body habitus
Prolonged hospital stay
These risk factors are associated with a higher risk of perioperative nerve injury:
Male gender > female gender (particularly if over 50 years of age)
Cardiac surgery (median sternotomy and sternal retraction)
Prolonged hospital stay
Extremes of body habitus
Undiagnosed preexisting ulnar neuropathy
Ulnar nerve injury is BEST prevented by:
elbow flexion.
elbow extension.
forearm pronation.
forearm supination.
Forearm supination
Forearm positioning has been implicated as a source of ulnar nerve injury. In the supine patient:
Forearm supination (palms up) is best when the arms are abducted.
The neutral position (palms in) is best when the arms are tucked at the patient’s sides. It’s also an acceptable alternative when the arms are abducted.
Forearm pronation (palms down) is avoided, as it is associated with a higher risk of ulnar injury.
Extreme elbow flexion can also contribute to ulnar neuropathy. Unfortunately, ulnar nerve injury often occurs with no perceivable cause. It may not be preventable despite your best efforts.
In the supine position, which of these positions is responsible for median nerve injury?
Forearm pronation on armboard
Forearm supination on armboard
Hyperextension of elbow
Extreme flexion of elbow
Hyperextension of elbow
Hyperextension of the elbow can stretch the median n.
Extreme flexion of the elbow can stretch the ulnar n.
The ulnar n. is also affected by forearm position. If the patient is supine:
Forearm supination is best when the arms are abducted.
The neutral position is best when the arms are tucked at the patient’s sides. It’s also an acceptable alternative when the arms are abducted.
Forearm pronation is avoided, as it is associated with a higher risk of ulnar injury.
Match each upper extremity nerve injury to its presentation.
Inability to oppose thumb
Wrist drop
Claw hand
Median
Radial
Ulnar
Radial + Wrist drop
Ulnar + Claw hand
Median + Inability to oppose thumb
Radial n. injury presents with wrist drop. This can be caused by external compression of the lower third of the arm (spiral groove at the humerus).
Ulnar n. injury presents with the inability to abduct the pinky finger. Permanent injury can cause the intrinsic muscles in the hand to atrophy, which presents as “claw hand.”
Median n. injury presents with the inability to oppose the thumb. The most common cause is IV insertion at the antecubital site.
Scapular winging is usually the result of injury to the:
thoracodorsal nerve.
long thoracic nerve.
lateral pectoral nerve.
axillary nerve.
Long Thoracic nerve
The long thoracic nerve:
Arises from C5-C7.
Innervates the serratus anterior muscle.
Long thoracic nerve injury presents with scapular winging (dorsal protrusion of the scapula).
Match each lower extremity nerve injury to its presentation.
Foot drop
Impaired knee extension
Impaired leg adduction
Femoral
Obturator
Peroneal
Obturator + Impaired leg adduction
Femoral + Impaired knee extension
Peroneal + Foot drop
Obturator n. injury:
Most common causes: excessive traction during lower abdominal surgery, forceps delivery, and/or excessive flexion of the thigh towards the groin.
Presentation: inability to ADDuct the leg and reduced sensation over the medial aspect of the thigh.
Femoral n. injury:
Most common cause: excessive traction during lower abdominal surgery.
Presentation: impaired knee extension, impaired hip flexion, and reduced sensation over the anterior thigh and anteromedial aspect of the leg (remember the femoral n. gives rise to the saphenous n.).
Peroneal n. injury
Most common cause: external compression (head of fibula compressed against a “candy cane” stirrup).
Presentation: foot drop, inability to evert the foot, and inability to extend the toes dorsally.
Which piece of equipment is MOST likely to injure the pudendal nerve?
Jackson table
Horseshoe head rest
Orthopedic fracture table
Wilson frame
Orthopedic fracture table
The pudendal nerve can be injured by compression against a perineal post on an orthopedic table.
The Wilson frame and Jackson table are used during spinal surgery.
The horseshoe head rest stabilizes the face in the prone position. The face is pretty far from the pudendal nerve.
Which statements about the lithotomy position are true? (Select 2.)
The saphenous nerve can be damaged at the lateral aspect of the leg.
Extreme hip flexion can injure the sciatic nerve.
Both legs must be moved simultaneously to prevent hip dislocation.
The peroneal nerve can be damaged at the medial aspect of the leg.
Both legs must be moved simultaneously to prevent hip dislocation
Extreme hip flexion can injure the sciatic nerve
The lithotomy position can cause hip dislocation, spinal torsion, and back pain. Both legs should be raised and lowered together to avoid injury.
The sciatic nerve can be injured by extreme hip flexion, external rotation of the legs, and extended knees.
The common peroneal nerve can be damaged when the LATERAL aspect of the leg leans against the stirrup bar (the peroneal nerve wraps around the fibular head).
The saphenous nerve can be damaged when the MEDIAL aspect of the leg leans against the supporting cradle (the saphenous nerve resides near the tibia).
In the supine position, which nerves will MOST likely be damaged when the legs are crossed. (Select 2.)
The sural nerve of the superior leg.
The posterior tibial nerve of the superior leg.
The superficial peroneal nerve of the dependent leg.
The common peroneal nerve of the dependent leg.
The sural nerve of the superior leg
The superficial peroneal nerve of the dependent leg
Many patients have the tendency to cross their legs prior to anesthetic induction, and failing to uncross the legs can contribute to peripheral nerve injury.
The sural n. is injured in the top leg:
Pressure from the superior aspect of the dependent leg will damage the sural nerve on the underside of the superior leg.
The superficial peroneal n. is injured in the bottom leg:
Pressure from the underside of the superior leg will damage the superficial peroneal nerve of the dependent leg.
What is the MOST common cause of perioperative eye injury?
Central retinal artery occlusion
Corneal abrasion
Ischemic optic neuropathy
Enucleation
Corneal abrasion
Corneal abrasion is the most common cause of perioperative eye injury. It is usually caused by direct trauma or drying of the cornea.
Movement during eye surgery is the single most common cause of corneal abrasion.
Ischemic optic neuropathy is the most common cause of postoperative vision loss.
Central retinal artery occlusion is usually the result of direct pressure on the globe.
All of the following are risk factors for ischemic optic neuropathy EXCEPT:
surgery lasting more than 6 hours.
hypotension.
glycine toxicity.
prone position.
Glycine toxicity
Intraocular perfusion pressure = MAP - Intraocular pressure
Ischemic optic neuropathy (ION) is the result of hypoperfusion and ischemia of the optic nerve. As you can predict from the equation, the most common causes of ION are impaired perfusion and increased intraocular pressure.
Patient risk factors: male gender, obesity, diabetes, hypertension, and vascular comorbidities.
Intraoperative risk factors: prone position, spine surgery, extensive surgical times, large blood loss, and hypotension (SBP < 100 mmHg).
In patients with L-arginine deficiency, glycine toxicity tends to increase blood ammonia. This can temporarily impair vision until the blood ammonia level returns to normal.
An anesthetist’s MOST important clinical responsibility to a patient is to adhere to:
national practice standards
local standards of care.
professional association practice guidelines.
state association position statements.
National practice standards
The AANA Practice Standards are the highest standards that must be followed by all CRNAs. Practice standards are RULES that define the minimum expected actions and behaviors for providing professional services.
Practice guidelines are just that: guidance, but not rules.
Position statements reflect currently accepted beliefs on various issues, usually formulated by a committee of recognized experts.
Local standards of care—which are often used to defend untoward clinical actions—may be the lowest bar one could set for a clinical practice and are generally not considered to provide an effective legal defense.
Which types of risk must be disclosed as part of informed consent for a labor epidural? (Select 2.)
Significant effects on the fetus
Low incidence with high morbidity
Minimal morbidity and low incidence
Temporary effect with low morbidity
Low incidence with high morbidity
Significant effects on the fetus
In the parturient, you must disclose any risk with a/an:
High incidence
High morbidity
Association with adverse fetal effects
Clearly, this means you should be able to delineate these specific risks to the patient.
A preoperative patient refuses an epidural, but you feel strongly that this is the best choice for the patient. You sedate the patient and place the epidural. The patient remains sedated during the surgical procedure, and the case finishes without incident. This is an example of a/an: (Select 2.)
negligence.
res ipsa loquitur.
battery.
intentional tort.
Battery
Intentional tort
Battery (as well as assault) are intentional torts; in this case, battery occurred when the patient was touched without consent during placement of the epidural.
This unlawful act does not meet the definition of negligence since no damages occurred.
The concept of res ipsa loquitur depends upon the presence of a negligent act.
A culture of safety does NOT include:
keeping hierarchical lines of contact bidirectional.
accepting responsibility while concealing a medication error.
communicating clearly and respectfully.
asking for assistance when managing an anesthetic complication.
Accepting responsibility while concealing a medication error
Concealment or suppression of facts that are relevant to a patient’s responses or outcomes is evidence of a dysfunctional safety environment.
The use of cognitive aids during perioperative crisis management has which beneficial effect?
Decreases the risk of making drug dose errors
Reduces the need for listening to alternative views
Assists team leader in delegating tasks
Promotes the development of tunnel vision
Decreases the risk of making drug dose errors
The stress of a critical incident decreases cognitive function and impairs memory. The use of a cognitive aid provides a quick and easy reference for differential diagnosis, a reminder of best practices, and verification of proper drug doses. The use of a cognitive aid is often a task that is delegated to one of the team members, and this person relays this information to the rest of the team.
Excessive work hours are associated with: (Select 2.)
workplace hostility.
accurate self-assessment.
anxiety and depression.
enhanced situational awareness.
Workplace hostility
Anxiety and depression
Both night-shifts and double shifts contribute to extreme fatigue and chronic stress, primarily when worked on a regular basis. This can lead to a variety of psychological effects including anxiety, depression, and hostility, and may increase the risk of medical error. When fatigued, situational awareness erodes, and the ability to self-assess readiness for work falls.
If the room noise is 95 dB, then the auditory anesthesia alarms must be set to a MINIMUM of:
105 dB.
125 dB.
110 dB.
115 dB.
115 dB
In general, for accurate hearing and interpretation of audible signals in the OR, audible monitoring must be set at least 20 dB above the background noise. In this case, the required 115 dB is also the OSHA peak allowable exposure to noise in a work setting!
Noise pollution is particularly damaging to work efficiency, short-term memory, and the ability to perform psychomotor tasks. All of these issues come into play during induction and emergence, which is precisely when excessive (and typically unnecessary) OR noise is common.
Which risk factors increase the likelihood of developing a substance abuse disorder? (Select 2.)
Functional OR team dynamics
Pre-existing hormonal imbalance
Uncontrolled access to addictive drugs
Workplace production pressure
Workplace production pressure
Uncontrolled access to addictive drugs
Even the most psychologically stable anesthesia provider faces a risk for abusing substances due to easy access to highly addictive drugs (propofol, opioids) and the stress of a highly demanding profession in a financially driven employment sector.
As an aside, the only physical factor associated with substance abuse is the presence of acute or chronic pain.
What are the recommended criteria for considering re-entry to practice for an anesthetist with a substance abuse problem? (Select 2.)
Five years of monitoring with random drug testing
At least six months in recovery
A minimum of one year in recovery
One year of monitoring with random drug testing
A minimum of one year in recovery
Five years of monitoring with random drug testing
Current recommendations for re-entry to practice include abstinence-based recovery for at least one year AND at least five years of monitoring with random drug testing. These relatively long periods of guided treatment and monitoring are due to the high relapse rate and easy diversion of drugs in a typical anesthesia practice.
What is the MOST common cause of respiratory morbidity and mortality?
Esophageal intubation
Difficult intubation
Difficult extubation
Inadequate ventilation
Inadequate ventilation
Here’s the most common causes of respiratory M&M within the subset of claims for adverse respiratory events,
Inadequate ventilation = 38%
Esophageal intubation (unrecognized) = 18%
Difficult intubation = 17%
Inadequate FiO2 = 11%
Inadequate ventilation includes hypoxia, hypercarbia, or both.
Which of the following is associated with the GREATEST frequency of pain medicine malpractice claims?
Lumbar epidural steroid injection
Cervical spine injection
Implanted device
Prescription medications
Cervical spine injection
The increase in chronic pain procedures has brought about an increase in pain management related claims. Of these, cervical spine injections are associated with the highest frequency of claims, where more than 50 percent of cases resulted in permanent spine injury!
Other chronic pain claims include:
Medications 17 percent (death is the most common outcome)
Lumbar injections 17 percent
Implanted devices 16 percent
hat step should you take after being served with a lawsuit?
Avoid making notes about the case because they are discoverable
Update the anesthesia record to fix missing information
Inform others who were involved in the case
Contact your insurance carrier
Contact your insurance carrier
In the event you’re served with a lawsuit, there are several things that you should do to best protect yourself. Here’s a list of the initial actions:
Notify your insurance carrier IMMEDIATELY
Do NOT discuss the case—not even with other providers who were involved
Do NOT alter any records
Gather all records of the case (EHR, case notes, critical incident reports, billings, any correspondence about the case)
Make notes regarding all aspects of the case (if you wrote a detailed case note/incident report immediately after the event as recommended, you will have much of this already)
Cooperate with your insurer’s attorney
After this, the first thing you’ll need to do is work with your attorney to write an initial response to the summons.
