CLINICAL SCENARIOS

Question 1

A medianstinoscopy is most useful for _______.

Answer 1

right lung cancers

Question 2

What is the first and second most common complication during a medianstinoscopy?

Answer 2

1) hemorrhage

2) pneumothorax (primarily on right side)

Question 3

Where should a BP cuff be placed during a medianstinoscopy?

Answer 3

left arm

Question 4

Where should an a-line be placed during a medianstinoscopy?

Answer 4

right radial to assess for compression of innominate and right brachiocephalic arteries

Question 5

Where should the pulse oximeter be placed during a medianstinoscopy?

Answer 5

right hand–> to assess vascular compression

Question 6

Where is the incision made for a medianstinoscopy?

Answer 6

transverse incision just above suprasternal notch or in the 2nd or 3rd rib interspace

Question 7

What arteries may be compressed during a medianstinoscopy?

Answer 7

innominate and right brachiocephalic arteries

Question 8

What tissues can a pheochromocytoma be found in?

Answer 8

found in the abdominal cavity 95% of the time and originates in the adrenal medulla about 90% of the time

Question 9

What is the diagnostic triad for pheochromocytoma?

Answer 9

1) diaphoresis
2) tachycardia
3) headaches

Question 10

If a pheochromocytoma is not diagnosed and treated in a timely manner, the patient may die from _______. (3 main things)

Answer 10

1) CHF
2) myocardial infarction
3) intracerebral hemorrhage

Question 11

What is the treatment (pre-operative preparation) for pheochromocytoma?

Answer 11

• alpha before beta
• alpha block with phenoxybenzamine 20-30mg/day and increase to 60-250mg/day in order to control BP
• prazosin is also an alpha blocker
• beta block primarily for treatment of tachycardia
• also need to check fluid status and assess for hypovolemia prior to surgery

Question 12

What are some anesthetic considerations for pheochromocytoma surgery?

Answer 12

• DO NOT stimulate SNS
• Must have anesthesia in place before any stimulation occurs
• control tachycardia with esmolol, labetalol, and propanolol

Question 13

What is the goal of one-lung ventilation?

Answer 13

to optimize arterial oxygenation

Question 14

Name 2 absolute indications for one-lung ventilation.

Answer 14

1) prevent contamination of healthy lung

2) control distribution of ventilation

Question 15

Name 1 relative indication for one-lung ventilation.

Answer 15

1) surgical exposure

Question 16

What is the most common DLT used?

Answer 16

Robertshaw–> available in left or right and does not have a carinal hook like the Carlens (left DLT) or White tube (right sided Carlens DLT)

Question 17

What is a description of Class 1 ASA?

Answer 17

healthy patient, no organic, physiologic, biochemical, or psychiatric disturbance

Question 18

What is a description of Class 2 ASA?

Answer 18

patient with mild systemic disease (disturbance) that may or may not be related to the reason for surgery
EX) essential HTN, heart disease that only slightly limits activity, diabetes, anemia, extremes of age, morbid obesity, and chronic bronchitis

Question 19

What is a description of Class 3 ASA?

Answer 19

patient with severe systemic disease (disturbance) that limits activity but is not incapacitating and may or may not be related to the surgery
EX) heart disease that limits activity, poorly controlled essential HTN, diabetes with vascular complications, chronic pulmonary disease that limits activity, history of prior MI and angina pectoris

Question 20

What is a description of Class 4 ASA?

Answer 20

patient with an incapacitating systemic disease that is a constant threat to life with or without surgery
EX) CHF, persistent angina pectoris, any advanced kidney, liver, or pulmonary disease

Question 21

What is a description of Class 5 ASA?

Answer 21

moribund patient not expected to live 24 hours with or without surgery; submitted to surgery as resuscitative effort
EX) pulmonary embolus, cerebral trauma or ruptured AAA (uncontrolled)

Question 22

What is a description of Class 6 ASA?

Answer 22

a brain dead patient whose organs are being harvested

EX) organ donation

Question 23

What is a description of Class E ASA?

Answer 23

any patient requiring emergency surgery (not elective)

EX) appendicitis, D&C for bleeding, etc.

Question 24

A painless degeneration and atrophy of skeletal muscles (associated with mental retardation) is called ______.

Answer 24

muscular dystrophy

*hereditary disease

Question 25

What is the most common and most severe neuromuscular disease?

Answer 25

Duchenne’s muscular dystrophy

• X-linked recessive
• Early childhood

Question 26

What are some ECG changes seen with Duchenne’s muscular dystrophy?

Answer 26

prolonged QRS and PR interval; ST segment abnormalities, bundle branch block, Q waves, tall R waves

Question 27

Why should you avoid succinylcholine with patients having Duchenne’s muscular dystrophy?

Answer 27

increased incidence of malignant hyperthermia

Question 28

Should you use neuromuscular monitor with a patient having Duchenne’s muscular dystrophy?

Answer 28

neuromuscular monitoring is mandatory

Question 29

______ is characterized by random and multiple sites of demyelination of corticospinal tract neurons in the brain and spinal cord, exclusive of peripheral neurons.

Answer 29

multiple sclerosis

Question 30

What are some s\s of multiple sclerosis?

Answer 30

• visual distrubances
• ataxia
• limb paresthesia and weakness
• spastic paresis of skeletal muscles
• exacerbations and remission

Question 31

With multiple sclerosis you should avoid marked ______ changes.

Answer 31

temperature