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Principles of Anesthesia > Exam 2 questions > Flashcards

Exam 2 questions Flashcards

1
Q

A patient with cirrhosis is undergoing an elective cholecystectomy. Preoperative labs show INR 2.2, Platelets 78,000, Albumin 2.5 g/dL, and AST/ALT ratio >2. What is your primary concern before induction?

A

Elevated INR and low platelets cause an increased risk of bleeding especially if varices are present.

Low albumin will have less protein binding and increased free drug with risk of toxicity so less anesthetic dose will be needed. Albumin infusion will be beneficial.

Cirrhosis patients often have portal HTN so be cautious with use of PEEP on ventilator. Increased PEEP = increased portal HTN. (slide 6 & 9)

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2
Q

Which of the following anesthetic agents is preferred in a patient with severe hepatic dysfunction?

A

Isoflurane for anesthetic gas (slide 16).

Induction with Propofol or Etomidate at reduced doses. (pg. 356).

Remifentanil is opioid of choice per Palmer (slide 5).

NMBs: Cisatracurium & Succinylcholine. (p. 356).

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3
Q

You are managing a patient with hepatic encephalopathy undergoing an emergent procedure. What drug would you avoid preventing worsening encephalopathy?

A

Avoid Sedatives, Opioids, & Anesthetic Drugs (p. 355).

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4
Q

In a patient with cirrhosis and portal hypertension, which sign would most likely indicate worsening liver disease?

A

Portal HTN >6 mmHg, decreased albumin and prolonged PT, increased LFTs and ALP. (slide 9).
Varices, splenomegaly, ascites (slide 11).
Increased MELD Score (p. 253).
Table 17.5: hepatic encephalopathy, hepatorenal and hepatopulmonary syndrome.

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5
Q

A patient with liver disease is scheduled for surgery. His labs include INR 2.4, Platelets 65,000, and low albumin. What intervention is most appropriate preoperatively?

A

Give FFP or Vitamin K to correct coagulation abnormalities as well as albumin replacement since hypoalbuminemia will cause prolonged anesthetic effects. (Slide 6).

To optimize preoperatively, the patient may need an Echo with EF. Draw a BMP to assess creatinine, glucose, and electrolytes (slide 15).

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6
Q

Which factors do NOT reduce hepatic blood flow during anesthesia?

A

Isoflurane, Normocapnia, Regional anesthesia & PEEP < 5. (slide 16).

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7
Q

A chronic alcoholic patient has increased MAC requirements for volatile anesthetics. What is the primary mechanism behind this?

A

Accelerated metabolism of drugs (slide 17).

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8
Q

A patient with alcoholic cirrhosis is found to have spontaneous bacterial peritonitis (SBP) and severe ascites. Which anesthetic management strategy is most appropriate?

A

Initiation of Antibiotic Therapy (p. 354).

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9
Q

Which statement is TRUE regarding the use of volatile anesthetics in patients with liver disease?

A

Volatiles reduce hepatic blood flow (slide 22). However, Isoflurane preserves hepatic blood flow the best (slide 16).

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10
Q

A patient develops delirium tremens (DT) three days after admission. Which treatment is most appropriate?

A

Diazepam and beta-blockers (slide 19).

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11
Q

During surgery on a cirrhotic patient, what is the best method to avoid reducing hepatic blood flow?

A

Maintain CO/Avoid HoTN and normocapnia. Use Isoflurane. Keep Peep < 5 and decrease SNS stimulation (slide 20).

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12
Q

Which of the following patients is at the highest risk for hepatic encephalopathy during surgery?

A

TIPS procedure (slide 14). GI bleed, infection and portosystemic shunts (p. 355).

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13
Q

In managing a patient with alcohol withdrawal syndrome, which drug combination is most appropriate?

A

Benzodiazepines, Beta-blockers and alpha 2 agonists (slide 19 & p. 622).

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14
Q

A patient with known cirrhosis presents with the following labs: AST 220, ALT 195, INR 1.8, Platelets 85,000, Bilirubin 3.4 mg/dL. What is the most concerning complication to manage perioperatively?

A

bleeding risk

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15
Q

Which intervention is appropriate for a patient with hepatic encephalopathy undergoing general anesthesia?

A

Maybe do a regional PNB to cut back on anesthetics? Use smaller doses of propofol or etomidate. (p. 356). Correct electrolyte disturbances (p. 355).

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16
Q

What is the most appropriate anesthetic strategy for a patient with ascites?

A

Increased risk of reflux and aspiration -> ramp up on intubation & do RSI. (slide 21).

Have decreased oncotic pressure ->give albumin and decrease anesthetic doses. (slide 11)

Reduced pulmonary compliance -> Use Pressure control (slide 12)

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17
Q

A cirrhotic patient with portal hypertension develops esophageal varices. Which of the following would help reduce the risk of variceal bleeding during anesthesia?

A

Keep PEEP < 5, Avoid esophageal instrumentation (slide 4). Nonselective beta blockers (nadalol, propranolol) reduce portal HTN (p. 354).

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18
Q

A patient with cirrhosis and refractory ascites is undergoing paracentesis. Which anesthetic consideration is most important during the procedure?

A

Maintain intravascular volume with colloids like albumin due to risk of HoTN? Not in PPT or book.

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19
Q

You are preparing to induce anesthesia in a patient with liver cirrhosis. What is the best anesthetic induction agent to use?

A

Propofol or Etomidate (p. 356).

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20
Q

Which clinical sign or symptom would most likely indicate that a cirrhotic patient is developing hepatic encephalopathy?

A

Asterixis (p. 355).

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21
Q

A patient with advanced liver disease has developed hepatorenal syndrome. What is the best strategy for managing this complication during anesthesia?

A

Administration of albumin, midodrine, & octreotide (p. 355 & slide 28).

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22
Q

A patient with alcoholic cirrhosis presents with the following labs: ALT 45, AST 150, INR 1.6, albumin 2.8 g/dL. What does the AST/ALT ratio suggest?

A

AST/ALT ratio > 2 suggests alcoholic liver disease (slide 6 & p. 351).

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23
Q

A patient with liver failure requires mechanical ventilation. How should positive pressure ventilation (PPV) be managed to minimize adverse effects on hepatic perfusion?

A

Avoid PEEP or PEEP < 5 to prevent increases in portal HTN (slide 16).

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24
Q

A patient with chronic alcohol use is undergoing anesthesia for an elective procedure. What is the most appropriate anesthesia consideration for this patient?

A

Chronic alcohol abuse will have an Increased MAC requiring more anesthesia. (slide 17)

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25
Which of the following would be an appropriate preoperative intervention for a cirrhotic patient with a platelet count of 45,000 and an INR of 1.9 undergoing elective surgery?
Platelet infusion and FFP/Vitamin K (slide 6 he mentions INR)
26
A patient with a history of cirrhosis is experiencing confusion, tremors, and agitation. Labs show elevated ammonia levels. Which treatment should be initiated?
Lactulose (Slide 5)
27
Which of the following volatile anesthetics should be avoided in a patient with liver disease due to its known hepatotoxic effects?
Halothane (slide 13).
28
A patient presents for surgery with ascites, jaundice, and caput medusae. What is the most likely diagnosis?
Cirrhosis—symptoms of cirrhosis are fatigue, malaise, palmar erythema, spider telangiectasis, caput medusae, ascites (more specific and suggestive of liver dysfunction), portal HTN, decreased albumin, prolonged PT increase AST and ALT (slide 9 liver ppt)
29
A patient with severe liver disease is on beta-blockers to manage portal hypertension. Which anesthetic consideration is essential for this patient?
Optimize the patient preop, cardiac clearance, assess coag status, renal function, electrolytes, albumin levels. Continue beta blockers, maintain IV fluid volume and urine output (slide 15 liver ppt)
30
A patient with liver cirrhosis is scheduled for surgery. Labs show low albumin, elevated AST/ALT, and high bilirubin. Which anesthetic drug is most appropriate for induction?
Propofol is acceptable for induction as its metabolism is not significantly altered in liver disease (Slide 22). Pg 356 in the book says Propofol or Etomidate with a decreased dose –Destenee
31
A cirrhotic patient is undergoing surgery. Which intervention is most appropriate to minimize the risk of bleeding?
Assess coags/risk of thrombocytopenia, no instrumentation in the esophagus bc bleeding varices cause 1/3 of cirrhosis deaths (mentioned liver is where coag factors are made, maybe need to give vitamin K, and really emphasized nothing in the esophagus) ppt 9-15
32
During anesthesia management of a patient with acute pancreatitis, what is the main concern when using mechanical ventilation?
ARDS is seen in 20% of patients so use low tidal volumes and higher PEEP? (p. 372). Increased abdominal pressure will make it harder to ventilate. (slide 47). Not really sure what they want here.
33
Which electrolyte imbalance is commonly seen in patients with acute pancreatitis and may cause life-threatening cardiac arrhythmias during anesthesia?
Hypocalcemia (Ranson criteria has low calcium as a criterion on pg 372). Sydney says she talked with JP and he says also hypokalemia..
34
What is the primary goal when managing a patient with acute liver failure undergoing surgery?
Correct coagulation abnormalities with FFP, Avoid HoTN (slide 25)
35
Which condition is a contraindication for liver transplantation due to its associated high perioperative mortality?
Severe pulmonary HTN (PAP> 50 or > 35 with CO < 6). -slide 27
36
Why should NSAIDs be avoided in patients with liver disease during anesthesia management?
The effect on renal blood flow & need for hepatic metabolism (slide 22)
37
What is the most appropriate induction technique for a patient with a full stomach, experiencing vomiting, and diagnosed with ileus?
RSI with NGT placement before. (slide 42)
38
In managing anesthesia for a patient with GERD, what should be the preoperative medication plan to minimize the risk of aspiration?
Bicitra, Alka-Seltza Gold, Pepcid, Zantac (given within 20 mins of surgery) -Slide 41
39
Which electrolytes should be carefully monitored and corrected preoperatively in patients with acute pancreatitis to prevent respiratory muscle weakness and ventilatory failure?
Calcium p.372
40
Why is regional anesthesia contraindicated in patients with significant coagulopathies related to liver disease?
Risk of spinal hematoma (slide 16)
41
Which symptom is most suggestive of a CO2 embolism during laparoscopic surgery, and what is the immediate intervention?
Rapid loss of EtCO2. Immediately decrease insufflation and place in left lateral Trendelenburg (slide 36).
42
In a patient with acute liver failure, which coagulation test is the most reliable marker of liver synthetic function?
PT/INR (slide 6)
43
Which anesthetic agent should be avoided in patients with a history of carcinoid syndrome due to its potential to release histamine?
Succinylcholine, Mivacurium, Atracurium, Tubocurarine, Epinephrine, Norepi, Dopamine, Isoproterenol, Thiopental (p. 371 Table 18.8) His PPT says Roc/Vec which is wrong…..
44
Why should volatile anesthetics be used cautiously in patients with acute liver failure?
Volatiles reduce hepatic blood blow (slide 22)
45
Which of the following is the primary adverse effect of anemia?
Decrease in oxygen-carrying capacity (slide 2)
46
Which compensation mechanism initially occurs in response to anemia?
Slide 4 says “Right shift of the oxyhemoglobin dissociation curve which allows release of oxygen from HGB to tissues” but book Pg. 477 says increase in cardiac output..
47
Which factor does not directly trigger perioperative blood transfusion in anemic patients?
Hemoglobin level (slide 6)
48
Why is methylene blue contraindicated in patients with G6PD deficiency?
It can be life-threatening if given for methemoglobinemia with a G6PD deficiency because G6PD deficient RBCs can’t protect themselves from oxidative damage causing hemolysis. (P.482 and slide 10)
49
Which of the following anesthetic agents is recommended to avoid in patients with hemolytic anemia?
Isoflurane, sevoflurane, diazepam, lidocaine, prilocaine (slide 10 & P. 482). Reglan and PCN in book & Silver Nitrate on slide as well but are these really anesthetic agents?...
50
What is the most common cause of microcytic anemia?
Iron deficiency and the thalassemias (p. 479 says both but slide 27 says thalassemia)
51
Which lab test is used to evaluate the intrinsic coagulation pathway?
aPTT (slide 52)
52
What is the main cause of the shortened RBC lifespan in sickle cell disease?
In SCD a substitution of a valine for glutamic acid in the beta globin subunit occurs. In the deoxygenated state, the Hb S undergoes conformational change leading to aggregation and a shortened life span- 10-20 days. (Slide 12).
53
Which of the following is a significant risk factor for perioperative complications in patients with sickle cell disease?
Advanced age, frequent and severe recent episodes of sickling, evidence of end organ damage & concurrent infection. Also, type of surgery (p. 483)
54
Which of the following would most likely precipitate a vaso-occlusive crisis in a sickle cell patient?
The vaso-occlusive crisis is initiated or worsened by dehydration, infection, acidosis, cold, shivering, vascular stasis, hypoxemia, and stress. (Slide 15). Book on page 483 says illness, stress, and dehydration.
55
Why is pulse oximetry unreliable in patients with methemoglobinemia?
“Pulse oximetry is unreliable in this setting because most pulse oximeters can not detect methemoglobin” (pg. 486). It moves the oxyhemoglobin dissociation curve to the left, causing less oxygen to be dropped off at the tissues (p. 486).
56
What is the first line treatment for von Willebrand Disease during a bleeding episode?
DDAVP (slide 46)
57
Which lab finding is expected in a patient with hemophilia A?
Prolonged aPTT, normal PT/ bleeding time, and deficiency of Factor VIII. (p. 492 & slide 36 & 37).
58
What is the hallmark of thalassemia on a peripheral blood smear?
Hypochromic and microcytic RBCs- mean corpuscular volume < 80 fL. (p. 479)
59
Which of the following interventions would REDUCE the risk of bleeding in a patient with polycythemia undergoing surgery?
Reduce Hct to 45%, Withhold aspirin for 7 days prior to surgery, Give Desmopressin (DDAVP) and Cryoprecipitate to increase vWF. (slide 33)
60
What is the preferred anesthetic approach for a patient with sickle cell disease undergoing a major surgery?
Avoid dehydration, deoxygenation (keep O2 > 95%), hypotension, venous stasis, hypoventilation, stressors such as shivering/pain/anxiety, etc. Make sure Hct is 30% & have PRBCs on standy for exchange transfusion (slide 24).
61
Which of the following would you expect to see in a patient with folate deficiency anemia?
Megaloblastic & Macrocytic RBCs, Hx of alcoholism, Hb level 8-10, increased LDH & bilirubin, normal reticulocyte count (p. 485).
62
What is the primary cause of death in sickle cell disease patients undergoing surgery?
Acute Chest Syndrome (slide 26)
63
Which of the following laboratory findings would most likely indicate iron deficiency anemia?
Hb concentration 9-12g/dL, decrease in ferritin concentration <41ng/ml, low reticulocyte count, decreased serum iron, reduced transferrin saturation (<20%) pg 479 in book IDA is a Microcytic anemia- mean corpuscular size <80 fL, caused by chronic blood loss or nutritional deficiency (only infants/small children) pg. 479 book
64
Which patient population is at highest risk for developing vitamin B12 deficiency anemia?
Alcoholics because of poor dietary habits and alcohols interference with folate metabolism (pg 485 book, slide 29 ppt) -Elisabeth P. 485 says “developing countries where tropical and nontropical sprue are more widespread, malabsorption may increase the frequency of Vit b12 deficiency”-Destenee
65
Which of the following is the most common symptom of thrombocytopenia?
Petechial rash involving skin or mucous membranes (pg 494 book)
66
Which lab result would you expect in a patient with von Willebrand Disease?
Increased PTT with normal PT & Platelet Count (slide 46).
67
Which of the following would most likely precipitate a hemolytic crisis in a patient with G6PD deficiency?
Isoflurane, sevoflurane, diazepam, methylene blue, lidocaine, prilocaine, and silver nitrate (slide 10)
68
Which of the following is the most appropriate goal for preoperative hematocrit in a patient with thalassemia undergoing intermediate-risk surgery?
Doesn’t say a HCT but JP said Hgb 9-10 on slide 27. Also not noted in stoelting’s, hematocrit of 30% on slide 23
69
What is the primary purpose of administering DDAVP in patients with mild hemophilia A?
DDAVP will increase plasma factor VIII:C & vWF concentrations (slide 38)
70
Which of the following patients is most likely to require platelet transfusion before surgery?
Patients undergoing procedures associated with high risk for bleeding or regional/neuraxial anesthesia. Ø platelet transfusion in HIT patients
71
What is the major risk associated with polycythemia in the perioperative period?
Thromboses and hemorrhage (p. 488)
72
What is the recommended preoperative management for a patient with moderate risk for perioperative sickle cell crisis?
Preop transfusion to target HCT 30% (slide 23)
73
What is the most common cause of macrocytic anemia?
Folate and Vitamin B12 Deficiency (slide 29)
74
Which of the following is a key anesthetic consideration in a patient with thrombocytopenia?
The insulting factor must first be corrected prior to treating thrombocytopenia. Also, if severe, it may be ideal to delay surgery and stabilize coagulation.
75
What is the most common cause of lung cancer?
90% of cases related to cigarette smoking (Slide 12)
76
Which tumor suppressor gene is crucial in preventing cancer progression by monitoring DNA damage?
Slide 2/pg 586: Tumor Suppressor Genes p53 prevents cancer progression but also monitors cellular DNA replication
77
A 65-year-old female patient presents with unexplained weight loss and chronic abdominal pain. Imaging reveals a large ascending colon mass. Which of the following would be the most likely presentation of this type of cancer?
Colorectal cancer; upper socioeconomic class, direct correlation between calories consumed, high intake of animal fat, family history, IBS, and cigarette smoking > 35 years, liquid stool (slides 14-15). P. 598 says they frequently ulcerate leading to blood loss in the stool. Iron deficiency anemia common with ascending
78
Which of the following cancers is often associated with SIADH (Syndrome of Inappropriate Antidiuretic Hormone)?
Small Cell Lung Cancer, intracranial neoplasms (slide 7) but chart 28.4 on Pg. 592 says Duodenal, SCLC, lymphoma, pancreatic, prostate cancers.
79
What is the primary mechanism by which targeted chemotherapy works?
Targeted chemotherapy works by interrupting a link in carcinogenic cell proliferation. Drugs have now been developed that block growth factors, their receptors, or their associated tyrosine kinases. Cancer cells have the ability to mutate and develop resistance to targeted therapies, so targeted therapies are often used in conjunction with traditional chemotherapy. Stoeltings pg 587
80
A 58-year-old male undergoing chemotherapy for metastatic prostate cancer presents for surgery. You are concerned about his immune status post-chemotherapy. Which anesthetic management strategy is most likely to avoid suppression of the immune system?
Ø opioids or volatile anesthetics (slide 6)
81
Which of the following is a well-known side effect of bleomycin, a chemotherapeutic drug?
Bleo blebs = lung blebs, pneumos, pHTN (pg 589) + pulmonary fibrosis
82
Which chemotherapeutic agent is most associated with cardiotoxicity, especially at high cumulative doses?
Doxyrubicin (pg 588)
83
A 55-year-old woman with a history of breast cancer undergoing radiation therapy presents with dyspnea and nonproductive cough. Imaging shows interstitial lung disease. Which cancer treatment is most likely responsible?
Bleomycin (pg 595) or erlotinib (pg 588 table 28.2 says it causes interstitial lung disease)
84
What is the role of propofol in cancer surgery with regards to tumor growth?
Propofol bears a chemical resemblance to the antioxidant alpha-tocopherol and may possess anti-inflammatory and antioxidative properties that tend to inhibit neutrophil, monocyte, and macrophage activity; recent studies into propofol ester conjugates in the treatment of breast cancer, some studies show it to inhibit cellular adhesion and migration of breast cancer cells and direct cytotoxicity toward some cancer cells (Book p 583)
85
A 60-year-old male presents for elective surgery. He has a history of squamous cell carcinoma of the lung and is currently undergoing chemotherapy with cisplatin. Preoperative labs show hypomagnesemia. Which of the following is the most likely cause of this electrolyte disturbance?
Cisplatin induced nephrotoxicity causing magnesium wasting (p. 589)
86
Which of the following vaccines is considered a preventive cancer vaccine?
HPV and Hepatitis B vaccine (slide 5 and Pg. 591).
87
What is the most common site for colorectal cancer to metastasize?
Cancer generally spreads to lymph nodes and then through portal circulation to the liver (most common site of metastasis (slide 15)
88
A 50-year-old woman with metastatic breast cancer undergoing treatment with doxorubicin presents with shortness of breath and fatigue. An echocardiogram reveals reduced ejection fraction. What is the most likely diagnosis?
Chronic heart failure 2/2 cardiomyopathy from cardiotoxicity related to doxorubicin use
89
What role does VEGF (vascular endothelial growth factor) play in cancer development?
VEGF is involved in growth and differentiation of normal cells, but they get overexpressed or mutated on cancer cells. When they bind to receptors on cell membranes it induces a cascade of signal transduction events that activate tyrosine kinase. Drugs are being targeted to block these growth factors -> apoptosis (p. 587).
90
A 68-year-old man with a history of prostate cancer is scheduled for robotic prostatectomy. He has received androgen deprivation therapy. During the procedure, his position is steep Trendelenburg, and the surgery is expected to last 4 hours. Which of the following anesthetic considerations is the most relevant for this patient?
Slide 18 is eventually going to talk about it- P. 609 says to pay attention to padding pressure points to limit the risk of nerve injuries, pneumoperitoneum will decrease pulm compliance and FRC, Increased SVR/MAP/CVP/ICP, risk of laryngeal edema and post-op visual loss.
91
Which of the following anesthetic strategies is associated with better immune preservation in cancer surgery?
Use neuraxial & Regional anesthesia, if possible, decrease opioid and volatile anesthetic use as they are immunosuppressants (p. 596 & slide 6)
92
What is the primary purpose of sentinel lymph node biopsy in breast cancer surgery?
Sentinel node mapping injects a radioactive tracker into the area around the breast tumor and it tracks rapidly to the dominant axillary lymph node. If the sentinel node is tumor free the remaining lymph nodes are also likely to be tumor free and further axillary surgery can be avoided (Book pg. 600)
93
A 55-year-old female is undergoing chemotherapy with cisplatin for ovarian cancer. She presents to the emergency room with confusion and lethargy. Blood tests reveal hyponatremia. Which of the following is the most likely cause of her symptoms?
SIADH? P. 592
94
Which of the following is the most common paraneoplastic syndrome associated with small cell lung cancer?
Lambert Eaton Syndrome, SIADH or Cushing Syndrome? p. 592-3
95
What is the principal factor that increases the risk of breast cancer?
The principle risk factors for development of breast cancer are increasing age (75% of cases occur in patients >50 years) and a family history (first degree relative diagnosed before 50 of breast cancer increases risk 3-4x (book pg 600)
96
A 63-year-old male with prostate cancer presents with back pain and difficulty walking. Imaging reveals bone metastases. What is the most likely cause of his symptoms?
Spinal Cord Compression p. 594
97
What is the mechanism of action for trastuzumab in breast cancer treatment?
Monoclonal antibody binding to HER2 protein to stop proliferation, bonding, cell signaling and causes apoptosis (Took Eli’s word for it coming from Stoelting Pharmacology since it was not in slide of book).
98
A 40-year-old female with BRCA1 mutation presents for a bilateral mastectomy. Which of the following is true regarding her risk of developing breast and ovarian cancer?
BRCA1 is an inherited autosomal dominant mutation, 1st degree relative with breast cancer diagnosed before 50 increases breast cancer risk 3-4x (book pg 600)
99
Which of the following types of anesthesia is associated with reduced opioid consumption and potentially improved outcomes in cancer surgery?
Regional Anesthesia (slide 26)
100
A 55-year-old male is undergoing surgery for colorectal cancer. He has a history of chronic large bowel obstruction. Which of the following should be considered when managing his anesthesia?
There should not be an increased risk of aspiration during induction. However, distention could interfere with adequate ventilation and oxygenation. (Slide 16).
101
What is the most common treatment modality for well-differentiated prostate cancer in younger patients (<65 years)?
Prostatectomy or Radiation (slide 17)
102
A 72-year-old woman with a history of breast cancer treated with radiation presents for elective surgery. Her preoperative evaluation shows normal cardiac function. During surgery, she develops hypotension and jugular venous distension. What is the most likely cause?
Myocardial/Myocardial fibrosis is caused from radiation to the mediastinum. (p. 589). Fibrosis would decrease contractility so it would increase CVP ->JVD.
103
What is the main role of monoclonal antibodies like bevacizumab in cancer therapy?
They act on extracellular receptors such as EGF and VEGF, as well as small molecules that penetrate cell membranes & block intracellular signaling pathways (p. 587).
104
A 65-year-old male with lung cancer is scheduled for mediastinoscopy. Which of the following is a potential intraoperative complication related to this procedure?
Hemorrhage and pneumothorax are the most frequently encountered side effects (slide 13)

Principles of Anesthesia (5 decks)

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