Quizzezzzzz Flashcards
What anesthetic agent was first documented as being used for surgical anesthesia in 1846?
Ether
What is the significance of the critical temperature of a compressed gas?
The critical temperature of a compressed gas is the temperature at which the gas cannot be compressed into a liquid if the temperature of the gas is above the critical point regardless of how much pressure is used.
According to the textbook, what color-coding scheme safety standards are used to identify oxygen in North America?
Green
In what year was the American Association of Nurse Anesthetists founded?
1931
When should you avoid use of the oxygen flush valve?
During inspiration
Gases that must pass through safety devices before reaching their flow control valve in an anesthesia machine?
Nitrous oxide, air and helium
In the United States of America, what color is used to represent a cylinder of Nitrous Oxide (N2O)?
Blue
In the event of the anesthesia machine experiencing a maximum supply pressure of 95-110 psi for a specific gas, what safety mechanisms would alleviate elevated pressures with single-stage pressure regulation?
Opening of a high-pressure relief valve for the supplied gas
What is the purpose of the oxygen supply failure protection device on anesthesia machines?
Prevent the delivery of a hypoxic gas mixture by sensing oxygen pressure and regulating the flow of other gases..
Which gas cylinders have a size opening and thread pattern similar to oxygen cylinders, making accidental interchange possible?
Carbon Dioxide
What maximum pressure is an N2O (Nitrous Oxide) E-cylinder pressurized to?
745 psi
What gases, commonly seen on anesthesia machines and used in operating rooms, exist in its gaseous form at room temperature inside standard cylinders?
Oxygen and Medical Air
How much more likely are reported adverse outcomes to be caused by misuse of anesthesia gas delivery systems than by equipment failure or malfunction?
3 Times
What safety system uses each gas’s specific pin and hole configurations to prevent incorrect cylinder attachment?
The pin index safety system (PISS)
What is the only reliable way to determine the residual volume of nitrous oxide in a cylinder?
Weigh the cylinder
At a consumption rate of 3 L/min, how long will a half-full oxygen E-cylinder last?
110 minutes
Time (minutes)= Volume (liters)/ Flow rate (L/min)
Full E-cylinder contains 660 L of oxygen.
Half a cylinder would be 330 L/ 3L/min=110/mins
Regarding the pipeline pressure delivering the gases to the anesthesia machine by the diameter-index safety system (DISS), what is the approximate pipeline pressure in pounds per square inch gauge (PSIG)?
50 psig
What safety features on a modern anesthesia machine prevents the simultaneous activation of multiple vaporizers?
Interlocking or exclusion device
The oxygen/nitrous oxide ratio controller is a safety feature of the anesthesia machine and ensures what minimum oxygen concentration?
25%
When is the Adjustable Pressure-Limiting (APL) valve usually fully open?
Spontaneous ventilation
What are the three types of oxygen analyzers?
Polarographic (Clark electrode), galvanic (fuel cell) and paramagnetic
Which anesthetic gas has the highest vapor pressure and lowest boiling point?
Desflurane
Causes of flow meter malfunction?
Flowmeters can malfunction when there is debris in the flow tube, a misalignment of the vertical tube, and a float that is sticking or concealed at the top of the tube. The inner tube of the flowmeter should be coated with a conductive substance in order to reduce the effect of static electricity.
On modern anesthesia machines, where is the location of the oxygen flowmeter, and why?
Farthest to the right; This prevents hypoxia if there is a leak from another flowmeter located upstream.
What is the upper limit of pressure in cm H2O for the adjustable pressure-limiting (APL) valve?
70-80 cm H2O
How fast does Oxygen flow when the Oxygen flush valve is activated?
35-75 L/min
Which patients will benefit the most from humidifying and heating inspiratory gases during general anesthesia?
Humidification and heating of inspiratory gases may be most important for small pediatric patients and older patients with severe underlying lung pathology.
What are the components of the flow control circuits in an anesthesia machine?
Pressure regulators, oxygen supply failure protective devices, flow valves and flow meters, vaporizers and common (fresh) gas outlet.
What is the only system that determines the presence of oxygen in the pipeline or cylinder?
Inspired oxygen analysis
Which component of the SPDD model ensures the provision of gases like oxygen and nitrous oxide to the anesthesia machine?
The SPDD model is the supply, processing, delivery, and disposal model. The Supply phase in the SPDD model involves pipeline systems and gas cylinders that deliver medical gases to the anesthesia workstation. The pipeline supply system provides a steady and regulated supply of oxygen, nitrous oxide, and air to the anesthesia machine. If the pipelines fail, emergency E-cylinders are required, and the tanks should be checked before the start of any case.
What is the purpose of oxygen in the anesthesia workstation?
-To supply fresh gas to the oxygen flow meter
-To drive ventilator bellows
-to activate low pressure oxygen alarms
-activates fail safe mechanisms
-supply oxygen to the oxygen flush system
Why are active humidifiers valuable in pediatric anesthesia applications?
Reduce occurrences of hypothermia due to increased heat conservation and prevents smaller tracheal tube plugging via dried secretions.
What are the risks of using the oxygen flush valve?
-The flush valve should only be used cautiously when the patient is connected to the breathing circuit as it can cause barotrauma. Do not use during inhalation phase.
-It can result in backflow of gases into the low-pressure circuit, diluting anesthetic concentrations.
The emergency oxygen tank is being used due to a significant drop in pipeline pressure. The pressure of the E-cylinder oxygen tank reads 1300 psig. The flow is set to 3L/min. How long will the tank last at this flow rate?
143 minutes
tank capacity (L) / service pressure (psig) = contents remaining (L) / current tank pressure (psig).
current tank pressure (psig) * tank capacity (L) / service pressure (psig) = contents remaining (L)
1300psig * 625L / 1900psig = 428L
428L / (3L/minutes) = 143 minutes
During a surgical case, you notice that the reservoir bag in the scavenging system is completely collapsed, and the anesthesia circuit’s fresh gas flow must be significantly increased to maintain proper ventilation in your circuit. What is the most likely cause?
-The negative pressure relief valve is malfunctioning
An active scavenging system relies on suction to remove waste gas. A negative pressure relief valve opens to draw in room air when suction is excessive in a closed interface scavenging system. This prevents excessive suction, which could expose the breathing circuit to negative pressure and hypoxia when emptying gas from the breathing circuit. Failure in the negative pressure relief valve causes the scavenger to remove gas from the circuit system, requiring a high fresh gas flow to maintain adequate circuit volume.
What are potential causes for discrepancies in set tidal volume and achieved tidal volume with volume-controlled ventilation?
Breathing circuit with a compliance of 6mL/cm H2O, Fresh gas flows of 5L/min and Gas compression.
What is a key advantage of insufflation in anesthesia?
Avoids direct airway connection, making it useful for pediatric induction.
What are some advantages of the circle system in anesthesia?
-Minimal operating room and environmental pollution
-Low resistance (less than the endotracheal tube; not as low as in nonrebreathing circuits)
-Constant inspired concentrations
-Conservation of respiratory tract heat and humidity
What are some reasons that would cause increased inspired CO₂ in a circle system?
In a circle system, CO₂ absorbent granules remove exhaled CO₂. If the absorbent becomes exhausted, CO₂ is no longer effectively removed, leading to rebreathing of CO₂ and increased inspired CO₂.
Additionally, faulty unidirectional valves can cause exhaled CO₂-rich gas to bypass the absorber and mix with fresh gas, further increasing inspired CO₂.
Which of the following are factors that might increase the peak inspiratory pressure (PIP) AND the plateau pressure (PP) on a respiration waveform?
A. Pneumothorax
B. Decreased pulmonary compliance
C. Surgery requiring peritoneal gas insufflation
Answer: a, b, c
Where should the fresh gas inlet be positioned in the circle system, and why?
Between the inspiratory valve and the absorber, to prevent dilution of fresh gas.
What factor primarily influences the transition from inspiration to expiration in a pressure-cycled ventilator?
A preset inspiratory pressure must be reached.
Which of the following is NOT a component of the circle system?
A. Fresh gas inlet inside the breathing tube
B. Y-connector
C. Reservoir bag
D. APL valve
Answer: A. Fresh gas inlet inside the breathing tube
Which of the following conditions would increase peak inspiratory pressure without affecting plateau pressure?
A. Pulmonary Edema
B. Bronchospasm
C. Increased TV
D. Decreased Pulmonary Compliance
Answer: B Bronchospasm
Peak inspiratory pressure (PIP) is generated during the inspiratory cycle and provides an indication of dynamic compliance. Plateau pressure is measured during an inspiratory pause and is an indicator of static compliance. An increase in peak inspiratory pressure without an increase in plateau pressure can indicate an increase in airway resistance. Secretions, bronchospasm, a kinked endotracheal tube, and foreign body aspiration are all potential causes of increased PIP without an increase in plateau pressure.
You are providing anesthesia without complications up to this point in the procedure. Suddenly, low-pressure alarms begin to sound, and the patient’s breath sounds are absent. What should be the first course of action?
A. Check settings of fresh gas flow, scavenger, and ventilator
B. Ventilate manually using the anesthesia breathing circuit
C. Check the y-piece and other common locations for disconnections.
D. Disconnect the patient from the circuit, provide IV anesthetics, and ventilate the patient with the Ambubag
E. Troubleshoot the anesthesia machine
C. Check the y-piece and other common locations for disconnections.
In draw-over anesthesia, what happens when oxygen is supplied at 1 L/min?
FiO2 reaches 30-40%
Rationale: Across the clinical range of tidal volume and respiratory rate, an oxygen flow rate of 1 L/min gives a FiO2 of 30-40%.
When should you change your CO2 absorber canister?
When 50%-70% of granules have changed color
Rationale: According to Butterworth et al. (2022), absorbent should be replaced when 50% to 70% has changed color.
Which of the following is the highest circuit pressure generated during an inspiratory cycle during mechanical ventilation?
A. Plateau Pressure
B. Tidal Volume
C. Peak Inspiratory Pressure
D. Positive end-expiratory pressure
C. Peak inspiratory pressure
Rational: Peak inspiratory pressure is the highest circuit pressure generated during an inspiratory cycle.
Which inhaled anesthetic agents produce the highest amount of carbon monoxide when in contact with CO₂ absorbent granules?
Desflurane
What is the indication of dynamic compliance?
Dynamic compliance is indicated by PIP where PP is static compliance
What is tidal volume?
Tidal volume is the amount of air moving into and out of the lungs with each breath.
What can an increase in tidal volume cause?
An increase in tidal volume can cause an increase in both peak inspiratory pressure and plateau pressure.
What does PEEP refer to?
PEEP refers to the positive pressure maintained in the airways at the end of exhalation.
Which inhaled anesthetic agent produces the highest amount of carbon monoxide when in contact with CO₂ absorbent granules?
Desflurane
Carbon monoxide is produced by desflurane, much more than isoflurane, when these agents are in contact with absorbent granules.
How much carbon dioxide is soda lime capable of absorbing?
Answer: 23L of CO2 per 100g of soda lime
Soda lime contains hydroxide salts that neutralize carbonic acid formed with the reaction of carbon dioxide and water.
Which of the following will NOT decrease resistance within the circle system?
A. Increasing the diameter of the circuit
B. Maintaining Laminar Flow
C. Eliminating valves
D. Using sharp bends
Correct Answer: D) Using sharp bends
Resistance can be reduced by decreasing the length of the circuit, increasing the diameter, maintaining laminar flow, and eliminating valves.
What ventilation mode is described as having peak inspiratory pressure limited and cycle controlled by time?
Correct answer: Pressure-controlled ventilation
During a surgical case, you notice that the reservoir bag in the scavenging system is completely collapsed, and the anesthesia circuit’s fresh gas flow must be significantly increased to maintain proper ventilation in your circuit. What is the most likely cause?
A. The negative pressure relief valve is malfunctioning
B. The positive pressure relief valve is malfunctioning
C. This is an open scavenging system, and gases are entrained from excessive suction
D. The scavenging system is passive and its valve is not working properly
Answer: A) The negative pressure relief valve is malfunctioning
A negative pressure relief valve opens to draw in room air when suction is excessive, preventing hypoxia.
Why do nitrous oxide and other gases pass through safety devices before reaching their flow control valves?
To prevent the delivery of these gases in the absence of oxygen.
How do modern anesthesia machines ensure patient safety in the event of an oxygen supply failure?
By using a proportioning safety device that proportionately reduces the pressure of nitrous oxide and other gases.
What is the primary function of the oxygen supply low-pressure sensor in anesthesia machines?
To activate alarm sounds when inlet gas pressure drops below a threshold value (usually 20–30 psig).
Why are flowmeters in anesthesia machines calibrated for specific gases?
Because the flow rate across a constriction depends on the gas’s viscosity and density.
Why does the use of a variable-bypass vaporizer not require adjustment of the selected anesthetic concentration at different altitudes?
Because the partial pressure of the anesthetic agent remains largely unchanged with altitude changes.
Why is it essential to have an oxygen analyzer with a low-level alarm integrated into the breathing circuit?
To monitor the oxygen partial pressure and ensure patient safety.
What is the critical role of the Adjustable Pressure-Limiting (APL) valve in anesthesia machines?
It maintains appropriate circuit pressure to prevent excessive buildup during ventilation.
What is the correct sequence of actions if the pipeline pressure fails during the use of an anesthesia workstation?
Turn on the backup oxygen cylinder, disconnect the pipeline, verify the rise in FiO2.
How does the Tec 6 vaporizer differ from variable-bypass vaporizers?
The Tec 6 is a heated, dual-circuit injector vaporizer that adds vapor to the fresh gas without direct contact.
Why are proportioning systems important in anesthesia workstations?
Proportioning systems maintain at least a 23% to 25% oxygen concentration in the final breathing mixture.
What is the primary reason for minimizing resistance in anesthesia breathing circuits?
To reduce the risk of hypoventilation in anesthetized or unconscious patients.
What is the minimum weight range for a child to be suitable for a pediatric circle anesthesia breathing circuit?
Suitable for children weighing 10 to 20 kg; comparable to nonrebreathing circuit in maintaining blood gas values in infants as low as 6 kg.
Why is the standardized diameter of breathing hoses in the circle system important?
To prevent misconnections between breathing and scavenger hoses.
Which ventilation mode is most suitable for supporting normocapnia and minimizing ventilator dyssynchrony during general anesthesia with LMA?
Synchronized Intermittent Mandatory Ventilation (SIMV)
SIMV allows spontaneous breathing while providing support to maintain normocapnia and reduce ventilator dyssynchrony.
What observation can be made about the manual breathing bag’s movement during mechanical ventilation with fresh gas decoupling?
The bag inflates during inspiration and deflates during expiration.
A rapid deflation of the manual breathing bag indicates a disconnect in the system.
What is the most common preventable equipment-related cause of mishaps in anesthesia ventilation?
Failure to ventilate due to disconnection in the breathing circuit.
What is a key advantage of the Mapleson breathing systems over insufflation and draw-over systems?
They provide better control of inspired gas concentration and depth of anesthesia.
How do Mapleson circuits reduce CO2 rebreathing?
Application of high fresh gas flows to prevent rebreathing.
What is the highest circuit pressure generated during an inspiratory cycle during mechanical ventilation?
Peak inspiratory pressure.
What is one difference between the DAS and ASA guidelines for difficult airways/intubation?
The DAS emphasizes the use of a supraglottic airway after failed intubation, while the ASA promotes bag-mask ventilation.
What is the safest intubation technique for a patient with suspected cervical spine injury?
Fiberoptic intubation.
Which statement is correct regarding the function of the superior laryngeal nerve (SLN)?
The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords.
How do cricoid pressure and the BURP maneuver differ during laryngoscopy?
Cricoid pressure is applied to occlude the esophagus, while BURP is applied to optimize vocal cord visualization.
When is the safest time to extubate a patient after surgery?
During deep anesthesia or when the patient awakens.
What describes the effects of unilateral recurrent laryngeal nerve (RNL) injury?
Unilateral damage results in hoarseness but is unlikely to cause respiratory distress.
What should a CRNA do after successfully placing a laryngeal mask airway following unsuccessful intubation attempts?
A. Wake the patient up
B. Intubate trachea via the supraglottic airway device (SAD)
C. Proceed without intubating the trachea (ventilate using LMA)
D. Perform a tracheostomy or cricothyroidotomy
E. All of these answers are possible correct actions
All of these answers are possible correct actions.
What is the most likely cause of laryngospasm in a freshly extubated patient?
Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve.
Treatment includes gentle positive pressure ventilation and intravenous lidocaine.
Which anatomical structure separates the upper airway from the lower airway?
Cricoid cartilage.
Which Mallampati classification correlates to only visualizing the soft and hard palate?
Class III.
What is a way to prevent gastric aspiration for a patient who received rapid-sequence induction?
Cricoid pressure.
What are some advantages of laryngeal mask airways (LMAs) when compared with tracheal intubation? (Pick 2)
A. Less dental trauma
B. Decreased risk of gastrointestinal aspiration
C. Does not require neck mobility
D. Decreased risk of gastrointestinal aspiration C leak and pollution
A. Less dental trauma
C. Does not require neck mobility
Unlike endotracheal tubes, LMAs do not require the use of a rigid laryngoscope blade, which is a primary cause of dental trauma during intubation. LMAs can also be inserted with minimal head and neck movement, making them useful in cases with limited neck mobility.
Which of the following is the most reliable predictor of a difficult airway?
A. Thyromental distance less than 6 cm
B. Thyromental distance less than 6 cm
C. History of previous difficult intubation
D. Prescence of facial hair
C. History of previous difficult intubation
A prior history of a difficult airway is one of the strongest predictors of future difficulties in airway management.
What is the most reliable indicator that the endotracheal tube has not inadvertently been placed in the esophagus?
Persistent end-tidal carbon dioxide
Other traditional methods of confirming ETT placement lack specificity and can be misleading.
Which clinical signs can provide clues to the diagnosis of bronchial intubation?
Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures
Which cartilages of the larynx are paired? (Pick 3)
A. Thyroid
B. Arytenoid
C. Cricoid
D. Corniculate
E. Cuneiform
F. Epiglottic
B. Arytenoid
D. Corniculate
E. Cuneiform
The larynx is composed of nine cartilages: thyroid, cricoid, epiglottic, and (in pairs) arytenoid, corniculate, and cuneiform.
How does office-based anesthesia differ from NORA?
Office-based anesthesia occurs in a private practice setting, while NORA takes place in remote hospital locations.
Office-based anesthesia refers to anesthetic care provided in a practitioner’s office, often for procedures like cosmetic or dental surgeries. In contrast, NORA takes place in remote hospital locations such as MRI suites and endoscopy units.
What does the STOP-Bang questionnaire assess?
The risk of obstructive sleep apnea
The STOP-Bang questionnaire is a validated screening tool designed to assess a patient’s risk of having OSA based on symptoms and physical characteristics.
According to the STOP-Bang questionnaire, which patient characteristic is NOT a risk factor for OSA?
A. Snoring
B. Age > 50 years
C. Neck circumference 35 cm
D. Hypertension
Neck circumference 35 kg/m²
The STOP-Bang questionnaire includes neck circumference >40 cm as a risk factor for OSA.
Which anesthetic technique is most likely to reduce the risk of postoperative nausea and vomiting (PONV) in ambulatory surgery patients?
Total intravenous anesthesia (TIVA) with propofol
TIVA with propofol is associated with a lower risk of PONV compared to inhalational anesthesia.
What intraoperative measure should be taken to minimize the risk of an operating room fire during head and neck surgery?
Minimizing supplemental oxygen delivery and avoiding oxygen buildup under drapes
An oxygen-rich environment increases the risk of surgical fires, particularly in head and neck procedures.
What is the minimum modified Aldrete score required for a patient to be considered ready for discharge from the postanesthesia care unit (PACU)?
9
A score of ≥9 is required for PACU discharge.
What is a critical competency for providers administering moderate or deep sedation?
The ability to rescue patients who transition to a deeper level of sedation than intended.
Which anesthetic considerations is MOST important when performing an ERCP?
General anesthesia with endotracheal intubation may be required due to compromised airway access.
ERCP is performed with the patient in positions that can compromise airway access.
Which anesthetic agents should be AVOIDED during oocyte retrieval due to potential adverse effects on ART outcomes?
Sevoflurane
Volatile anesthetics such as sevoflurane may have negative effects on assisted reproductive technology (ART) outcomes.
What is the most common tachyarrhythmia seen in children?
SVT
SVT is a supraventricular arrhythmia often symptomatic due to poor cardiac reserve.
What is the optimal shock dose for initial cardioversion of A-flutter and other supraventricular tachycardia?
50-100 J.
During the anesthetization of a patient with atrial fibrillation undergoing an ablation procedure, the anesthetist must remain vigilant for which major complications? (Select all that apply)
A) Atrioesophageal fistula
B) Vagus nerve injury
C) Hemorrhage
D) Atrial perforation leading to cardiac tamponade
E) Phrenic nerve injury
A) Atrioesophageal fistula, D) Atrial perforation leading to cardiac tamponade, E) Phrenic nerve injury
Major complications from ablations include atrioesophageal fistula, atrial perforation, and phrenic nerve injury.
Which are the most frequent postoperative complications in pediatric dental patients? (Select all that apply)
A. Nausea and vomiting
B. Hypothermia
C. Crying
D. Bleeding
A) Nausea and vomiting, C) Crying, D) Bleeding
Postoperative nausea and vomiting, crying, and bleeding are common complications in pediatric dental anesthesia.
Which of the following is acceptable according to fasting guidelines for a patient prior to electroconvulsive therapy (ECT)?
A. Patient takes oral medications with water two hours prior to procedure
B. Patient has breakfast three hours prior to procedure
C. Patient eats a midnight snack the night before his procedure at 0500
D. Patient has a glass of water before getting in the car to drive 30 minutes to the procedure
a. Patient takes oral medications with water two hours prior to procedure
ECT fasting guidelines state that patients must fast from solid foods for six hours and abstain from water for 2 hours prior to ECT.
What medication should be held when a patient is undergoing a CT scan with IV contrast, and why?
A. Propofol, because it reacts with the IV contrast.
B. Zofran, because it will cause worse nausea and vomiting
C. Metformin, because of the risk of lactic acidosis.
D. No medications need to be held with IV contrast use.
C. Metformin, because of the risk of lactic acidosis.
Which MRI Suite Zone is described as the area where patients are greeted and histories obtained?
Zone II
Zone II is the area where patients are greeted and movement is supervised by MRI personnel.
Which age group in the pediatric population has the greatest risk of adverse events during anesthesia?
Children under 5 years of age
Children under 5 years of age are at the greatest risk for adverse events, particularly respiratory events
Which anesthetics may cause problems with In vitro fertilization procedures and should be avoided?
A. Fentanyl
B. Remifentanil
C. Alfentanil
D. Morphine
D. Morphine
Morphine has been shown to adversely affect fertilization outcomes.
Which factors can increase the risk of adverse effects during anesthetic care in pediatric patients? (Select two)
A. Utilization of multiple anesthetic agents
B. Assessment of any recent upper respiratory tract infections
C. Absence of nitrous oxide usage in combination with other sedatives
D. Procedural duration is greater than one hour
A. Utilization of multiple anesthetic agents, D. Procedural duration is greater than one hour
Which statement regarding perioperative management of cardiac patients is correct?
A. Beta blockers should be discontinued perioperatively to prevent bradycardia.
B. Angiotensin-converting enzyme inhibitors should always be discontinued due to the risk of intraoperative hypotension.
C. Antiplatelet therapy in patients with stents should only be discontinued after discussion between the patient, cardiologist, and surgeon.
D. Pacemakers do not require any special considerations during ambulatory procedures.
C. Antiplatelet therapy in patients with stents should only be discontinued after discussion between the patient, cardiologist, and surgeon.
Patients with cardiac stents are typically on antiplatelet therapy, which should not be discontinued without coordination between the surgeon, cardiologist, and anesthesiologist due to the risk of discontinuation of antiplatelet therapy and the necessity of surgery.
In the PACU, A patient has the following clinical presentation: Dyspnea with shallow breathing, 3L Nasal Canula with O2 Saturation of 91%, Blood pressure 10 mmHg lower than preanesthetic level, opens eyes to voice and is able to move only their hands/arms to command. What would the Modified Aldrete score be for this patient?
B. 6
The Modified Aldrete score looks at Activity, Respiration, Circulation, Consciousness, and O2 Saturation. The patient had scores totaling 6 based on the assessment criteria.
What are the two most frequent causes of unplanned hospital admission from ambulatory surgery centers? (select 2)
A. Surgical site infections
B. Inadequately controlled pain
C. Delayed wound healing
D. Postoperative nausea and vomiting
B) Inadequately controlled pain
D) Postoperative nausea and vomiting
The two most frequent causes of unplanned hospital admission from ASCs and office surgery practices are due to inadequately controlled pain and postoperative nausea and vomiting.
What position should the patient be in during a colonoscopy?
Left lateral decubitus position
Patients are usually asked to assume a left lateral decubitus position for the colonoscopy procedure.
Which patient is at the highest risk for obstructive sleep apnea (OSA)?
A. A 23 y/o female with a BMI of 23 kg/m2
B. A 60 y/o male with a BMI of 28 and neck circumference of 30 cm
C. A 55 y/o male with a BMI of 38 kg/m2 who reports lethargy and snoring frequently during the night
D. A 70 y/o female with a BMI of 25 kg/m2 being treated for HTN
C. A 55 y/o male with a BMI of 38 kg/m2 who reports lethargy and snoring frequently during the night
Option C had five risk factors for OSA, making it the highest risk among the choices.
What is the primary advantage of multimodal analgesia in postoperative pain management?
A) It relies solely on opioids for pain control.
B) It targets different pain pathways to produce a synergistic effect at lower analgesic doses.
C) It is only effective for major surgical procedures.
D) It eliminates the need for pharmacologic interventions in pain management.
B) It targets different pain pathways to produce a synergistic effect at lower analgesic doses.
Multimodal analgesia targets different pain pathways to produce a synergistic effect, enhancing pain control while minimizing the required doses of individual analgesics.
When is the appropriate time to administer succinylcholine during electroconvulsive therapy (ECT)?
A. Before applying the blood pressure cuff to the lower extremity
B. Immediately after induction, but before applying the blood pressure cuff
C. After the blood pressure cuff is applied and inflated on the lower extremity
D. After the seizure has been induced to prevent excessive muscle contractions
C. After the blood pressure cuff is applied and inflated on the lower extremity
A blood pressure cuff is inflated to isolate the extremity before administering succinylcholine to observe motor seizure activity.
What is the most often used anesthetic plan for a patient undergoing radiofrequency catheter ablation (RFCA) using general anesthesia?
A. Inhaled volatile anesthetics with antiemetics to reduce postop nausea and vomiting (PONV)
B. Total intravenous anesthesia (TIVA) to optimize hemodynamic stability during pulmonary artery occlusion and reduce PONV
C. A balanced combination of volatile anesthetic and intravenous anesthetic to maintain appropriate anesthetic depth while optimizing hemodynamic stability and reduction of PONV
D. A balance of volatile anesthetic and opioid to decrease the chance of hemodynamic instability during the case
B. Total intravenous anesthesia (TIVA) to optimize hemodynamic stability and reduce PONV
TIVA is preferred during RFCA due to the potential for hemodynamic instability and interference with inhaled anesthetics.
Which Beta blocker has additional alpha blocking properties?
Labetolol
Labetolol blocks both beta and alpha receptors, allowing for vasodilation in addition to reducing cardiac rate and contractility.
Which patients would direct myocardial depressant effects be more apparent with higher dose Ketamine administration? Select two.
A. 27-year-old male trauma patient
B. 57-year-old female in severe end-stage septic shock
C. 46-year-old woman with a small bowel obstruction
D.24-year-old male with a spinal cord transection
B & D
Myocardial depressant characteristics of Ketamine can become unmasked in patients with depleted catecholamine stores and autonomic nervous system dysfunction.
Which inhalation anesthetic is known for causing airway irritation?
Desflurane
Desflurane is known to be a respiratory irritant, especially during mask inductions.
Which antiemetics are effective for postdischarge nausea and vomiting (PDNV)? (select 2)
A. Ondansetron (Zofran)
B. Metoclopramide (Reglan)
C. Scopolamine transdermal
D. Palonosetron (Aloxi)
C & D
Rational: Scopolamine patch has an onset of 4 hours and minimum duration of 24 hours. It works by blocking transmission of cholinergic impulses from vestibular nuclei to higher centers in the CNS and from the reticular formation to the vomiting center. It is chosen for PDNV due to its long duration. While Ondansetron and Palonosetron belong to the same class, Palonosetron is a second-generation serotonin antagonist and has a long half-life of 44 hours, which makes it effective for PDNV. Ondansetron and Metoclopramide are not used for PDNV due to their short durations of action.
Which patient requires additional education regarding sugammadex administration for surgery?
A) A 32-year-old male with a history of hypertension controlled with lisinopril.
B) A 45-year-old female with a history of asthma using albuterol as needed.
C) A 28-year-old female taking hormonal contraceptives for birth control.
D) A 60-year-old male with type 2 diabetes managed with metformin.
C) A 28-year-old female taking hormonal contraceptives for birth control.
Sugammadex can bind to and reduce the effectiveness of hormonal contraceptives.
Which of the following treats mild pain?
A. Ketorolac
B. Hydromorphone
C. Tylenol
D. Fentanyl
C. Tylenol
Tylenol is used to treat mild pain, while the other medications listed are used for greater pain.
What is the primary concern regarding the respiratory effects of benzodiazepines?
A. Depressed ventilatory response to CO2
B. Increased airway resistance
C. Increased airway resistance
D. Benzodiazepines have no respiratory effects
A. Depressed ventilatory response to CO2
Benzodiazepines lower the hypercapnic drive by blunting the central chemoreceptors’ response to increased CO2 levels.
Which opioid has the highest potency compared to morphine?
A) Hydromorphone
B) Meperidine
C) Fentanyl
D) Sufentanil
D) Sufentanil
Sufentanil is the most potent of the phenylpiperidines and is used for profound analgesia.
What describes the role of the liver in the metabolism of succinylcholine?
A) The liver directly metabolizes succinylcholine via cytochrome P450 enzymes.
B) The liver produces plasma cholinesterase, responsible for hydrolyzing succinylcholine.
C) Succinylcholine undergoes first-pass metabolism in the liver, reducing its bioavailability.
D) Succinylcholine skips the liver and is entirely excreted unchanged by the kidneys.
B) The liver produces plasma cholinesterase, responsible for hydrolyzing succinylcholine.
Succinylcholine is degraded via hydrolysis by plasma cholinesterase produced by the liver.
Which patient would most benefit from ketamine induction?
A) A patient with severe asthma
B) A patient with uncontrolled hypertension
C) A patient with schizophrenia
D) A patient with a full stomach at risk for aspiration
A) A patient with severe asthma
Ketamine is a potent bronchodilator, making it ideal for patients with reactive airway disease.
Which drugs are NMDA receptor antagonists? (Select 2)
A. Nitrous Oxide
B. Propofol
C. Ketamine
D. Etomidate
A. Nitrous Oxide
C. Ketamine
Nitrous Oxide and Ketamine function as NMDA receptor antagonists.
Which statement about propofol is correct?
A) Propofol is a respiratory stimulant and enhances the response to hypercarbia.
B) Propofol-induced depression of upper airway reflexes is less than that of thiopental.
C) Propofol can be administered for sedation by any healthcare personnel without specific training.
D) Propofol is a profound respiratory depressant and can cause apnea following an induction dose.
D) Propofol is a profound respiratory depressant and can cause apnea following an induction dose.
Propofol typically causes apnea after an induction dose.
Which drugs are alpha 2 agonists?
A. Carvedilol
B. Dexmedetomidine
C. Prazosin
D. Clonidine
E. Labetalol
Dexmedetomidine (Precedex) & Clonidine (Catapres)
Clonidine decreases blood pressure by agonizing peripheral presynaptic alpha 2 receptors and central alpha 2 receptors. Dexmedetomidine provides dose-dependent sedation, analgesia, sympatholysis, and anxiolysis without significant respiratory depression.
Which of the following best explains why neostigmine requires an anticholinergic agent for co-administration, while sugammadex does not?
A. Neostigmine directly stimulates the vagus nerve; therefore, it requires counteraction.
B. Sugammadex binds to muscarinic receptors and prevents parasympathetic effects.
C. Sugammadex increases acetylcholine breakdown, which counteracts muscarinic effects.
D. Neostigmine increases endogenous acetylcholine around the cholinoreceptors.
Neostigmine increases endogenous acetylcholine around the cholinoreceptors.
Neostigmine inhibits acetylcholinesterase, which increases acetylcholine levels at the neuromuscular junction. This can cause bradycardia, arrhythmias, bronchoconstriction, and hypersalivation, so anticholinergics (glycopyrrolate or atropine) are given to counteract these effects. Sugammadex is a modified y-cyclodextrin that works by encapsulating and forming very tight water-soluble complexes at a 1:1 ratio with steroidal neuromuscular blocking drugs, therefore, it does not affect ACh levels and does not require an anticholinergic.
Which opioid is most likely to cause histamine release leading to hypotension and pruritus?
Morphine
Morphine can cause significant histamine release, leading to vasodilation, hypotension, and pruritus.
What are the characteristics of ketamine?
A. Ketamine provides dissociative sedation AND analgesia
B. Ketamine increases blood pressure and heart rate
C. Ketamine is an NMDA receptor antagonist
D. Ketamine can be administered IV, IM, and orally.
E. All of the above are true of ketamine
All of the above are true of ketamine.
Ketamine provides dissociative sedation and analgesia, increases blood pressure and heart rate, and can be administered IV, IM, and orally.
What percentage of neuromuscular blockade corresponds with the absence of twitches T3 and T4?
80-85% block.
What is the best alternative to cefazolin for perioperative prophylaxis in patients with severe penicillin allergy?
Clindamycin.
What is the correct induction dose of ketamine?
2–4 mg/kg IV.
How does propofol affect blood pressure compared to etomidate?
Propofol decreases blood pressure, cardiac output, and systemic vascular resistance more than etomidate.
What are the most frequent cardiovascular adverse effects of dexmedetomidine?
Hypotension and bradycardia.
What is a unique consideration for morphine use in patients with renal failure?
Morphine’s active metabolite, M6G, may produce prolonged effects due to its more potent effect within the CNS compared to the parent drug.
For which patient populations is Ketorolac contraindicated?
Atopic or asthmatic patients, the elderly, or patients with renal or GI dysfunction or bleeding disorders.
Which of the following is NOT an NSAID?
A. ASA
B. Ibuprofen
C. Tylenol
D. Ketorolac
Acetaminophen.
What postoperative counseling should a patient receive after receiving sugammadex?
Use an alternative contraceptive for at least one week.
What is the onset time for succinylcholine?
30–60 sec.
What does MAC stand for in the context of inhaled anesthetics?
Minimum Alveolar Concentration.
How can an anesthesia provider accelerate the onset of Rocuronium during rapid sequence intubation?
By priming rocuronium, which involves giving 10% of the calculated dose before inducing anesthesia and then giving the remaining dose 1 to 3 minutes after the patient is anesthetized.
In which of the following scenarios would routine preoperative 12-lead electrocardiography (ECG) be MOST clearly indicated according to the provided sources?
A. A 55-year-old patient with known coronary heart disease undergoing a laparoscopic cholecystectomy.
B. A healthy 45-year-old patient undergoing elective cataract surgery
C. An asymptomatic 70-year-old patient scheduled for a minor dermatological procedure.
D. A 30-year-old pregnant patient with no known medical conditions scheduled for an elective cesarean section.
A 55-year-old patient with known coronary heart disease undergoing a laparoscopic cholecystectomy.
Feedback
General Feedback
Routine testing with a 12-lead ECG is recommended only for patients with known coronary heart disease or other significant structural heart disease. While some facilities may use age-specific criteria, the presence of known heart disease provides a clearer indication. Routine ECGs are generally not recommended for low-risk surgeries in asymptomatic patients.
The text discusses the importance of open disclosure following a critical incident. According to the survey of adults, what was associated with a lack of disclosure from healthcare providers?
A. A perception that healthcare providers were effectively managing the situation.
B. A decreased likelihood of patients and families pursuing legal action.
C. Increased patient satisfaction and trust in their providers.
D.Lower patient satisfaction, less trust, and stronger negative emotional responses.
Lower patient satisfaction, less trust, and stronger negative emotional responses.
General Feedback
The survey revealed that “not disclosing information was associated with lower patient satisfaction, less trust, and stronger negative emotional responses”.
When treating laryngospasm, and initial interventions of jaw thrust and CPAP are ineffective, what is the next pharmacological intervention suggested by the text?
A. Propofol bolus.
B.Intravenous Lidocaine.
C. Rocuronium induction dose bolus intramuscularly.
D. A subparalytic dose of intravenous Succinylcholine.
A subparalytic dose of intravenous Succinylcholine.
General Feedback
The text states that if a jaw thrust maneuver with CPAP is ineffective in treating laryngospasm, a subparalytic dose of intravenous succinylcholine (0.1-1 mg/kg) or 4 mg/kg intramuscularly) may be given by the anesthesia provider.
Which of the following is a high-risk cardiac condition requiring elective surgery delay until further evaluation or treatment is completed?
A. Stable angina
B. Recent myocardial infarction within 30 days
C. Controlled atrial fibrillation
D. Stage 1 hypertension
Recent myocardial infarction within 30 days
General Feedback
A recent MI (within 30 days) is a major risk factor for perioperative reinfarction and mortality. Elective surgery should be postponed until at least 60 days post-MI to minimize risk.
A patient taking St. John’s Wort reports for preoperative assessment. What is the PRIMARY perioperative concern associated with this herbal supplement, and what is the recommended discontinuation time prior to surgery?
A. Increased risk of bleeding; discontinue at least 36 hours before surgery.
B. Inhibition of neurotransmitter reuptake; discontinue at least 7 days before surgery.
C. Inhibition of neurotransmitter reuptake; discontinue at least 7 days before surgery.
D. Risk of myocardial ischemia and stroke; no specific discontinuation data provided.
Inhibition of neurotransmitter reuptake; discontinue at least 7 days before surgery.
General Feedback
According to Table 20.3, St. John’s Wort has the relevant pharmacologic effect of inhibition of neurotransmitter reuptake. The table recommends discontinuing its use at least 7 days before surgery.
What is the most common cause of airway obstruction in the immediate postoperative phase?
A. The tongue falling back and occluding the pharynx.
B. Loss of pharyngeal muscle tone in a sedated or obtunded patient.
C. Swelling secondary to surgical manipulation or edema.
D. Laryngeal obstruction due to laryngospasm.
Loss of pharyngeal muscle tone in a sedated or obtunded patient.
Loss of pharyngeal muscle tone in a sedated or obtunded patient.
General Feedback
The text indicates that the most common cause of airway obstruction in the immediate postoperative phase is the loss of pharyngeal muscle tone in a sedated or obtunded patient. While the tongue causing obstruction is mentioned, it is described as what happens due to this loss of muscle tone.
What is the most common cause of postoperative arterial hypoxemia?
A. Aspiration
B. Atelectasis
C. Forgetting to turn on the oxygen
D. Pulmonary edema
Atelectasis
General Feedback
The text explicitly states that atelectasis is the most common cause of postoperative arterial hypoxemia.
Which of the following findings indicate poor ventricular function?
A. Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
B. Cardiac index < 2.5 L/min/m², left ventricular end-diastolic pressure < 12 mm Hg, and ejection fraction (EF) > 50%.
C. Cardiac index > 2.5 L/min/m², left ventricular end-diastolic pressure < 12 mm Hg, and ejection fraction (EF) > 50%.
D. Pulmonary wedge pressure waveform is not influenced by ischemia-induced papillary muscle dysfunction.
Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
General Feedback
Three readily identifiable findings that indicate poor ventricular function are a cardiac index of less than 2.2 L/m2, a left ventricular end-diastolic pressure of greater than 18 mm Hg, and an EF of less than 40%. Taking note of ischemia-induced dysfunction of the papillary muscles can help in avoiding later confusion about the configuration of the pulmonary wedge pressure waveform and the significance of intraoperative changes in wedge pressure. Wall motion abnormalities should be noted. Areas of akinesis (no movement during systole) usually represent nonviable regions of myocardium and are relatively fixed deficits.
A patient with a history of heavy alcohol use is undergoing preoperative evaluation. Which of the following findings on questioning would indicate the HIGHEST risk for problematic alcohol consumption based on the CAGE mnemonic?
A. The patient feels they should reduce their intake of sugary drinks.
B. The patient’s spouse has expressed concern about their driving.
C. The patient reports feeling guilty about forgetting appointments.
D. The patient admits to sometimes having a drink first thing in the morning.
The patient admits to sometimes having a drink first thing in the morning.
General Feedback
The CAGE mnemonic includes the question, “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?”. A patient reporting more than two positive responses to the CAGE questions is at high risk for an alcohol problem. The other options are not part of the standard CAGE questionnaire.
In a patient with a recent history of illicit drug use, abstinence syndrome typically exhibits as:
A) An increase in sympathetic response
B) An increase in parasympathetic response
C) A decrease in parasympathetic response
D) An increase in both sympathetic and parasympathetic response.
Correct Answer:
D) Increased in both sympathetic and parasympathetic response
Abstinence syndrome typically exhibits increased sympathetic and parasympathetic responses resulting in hypertension, tachycardia, abdominal cramping and diarrhea, tremors, anxiety, irritability, lacrimation, mydriasis, algid sweat, and yawning.
Which of the following findings indicate poor ventricular function?
A) Cardiac index > 2.5 L/min/m², left ventricular end-diastolic pressure < 12 mm Hg, and ejection fraction (EF) > 50%.
B) Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
C) Presence of ischemia-induced hypokinesis, which always indicates nonviable myocardium.
D) Pulmonary wedge pressure waveform is not influenced by ischemia-induced papillary muscle dysfunction.
Answer: B) Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
Rationale: Three readily identifiable findings that indicate poor ventricular function are a cardiac index of less than 2.2 L/m2, a left ventricular end-diastolic pressure of greater than 18 mm Hg, and an EF of less than 40%. Taking note of ischemia-induced dysfunction of the papillary muscles can help in avoiding later confusion about the configuration of the pulmonary wedge pressure waveform and the significance of intraoperative changes in wedge pressure. Wall motion abnormalities should be noted. Areas of akinesis (no movement during systole) usually represent nonviable regions of myocardium and are relatively fixed deficits.
Which of the following patients is at the highest risk for postoperative nausea and vomiting (PONV)?
A. A 65-year-old male with a history of smoking undergoing bowel resection and has an NG tube
B. A 45-year-old nonsmoker female with a history of motion sickness undergoing breast surgery
C. A 30-year-old male with no history of motion sickness undergoing knee arthroscopy
D. A 70-year-old female undergoing cataract surgery under local anesthesia and mild sedation
Answer: B. A 45-year-old nonsmoker female with a history of motion sickness undergoing breast surgery
Rationale: Risk factors for PONV include female gender, history of PONV or motion sickness, nonsmoking status, use of volatile anesthetics, age less than 50, and opioid administration. The answer is B since this female in question has more risk factors than the 70-year-old female. Females experience PONV two to three times more often than males. Anxiety, obesity, use of a nasogastric tube, history of migraines, and supplemental oxygen are not risk factors of PONV and have been disproven or are not clinically relevant as predictors of PONV.
Which of the following is associated with the highest risk for perioperative MI?
A. Substernal discomfort brought on by exertion
B. Blood pressure of 130/80
C. Angina relieved by nitroglycerin in less than 15 minutes
D. Newly developed angina within the past 2 months
Answer: D. Newly developed angina within the past 2 months
Rationale: Stable angina is defined as substernal discomfort brought on by exertion and relieved by rest, nitroglycerin, or both within 15 minutes. Stable angina is unlikely to significantly increase the risk of perioperative MI compared to those with an absence of anginal symptoms. Unstable angina, which can be characterized as newly developed angina occuring within the past 2 months, is associated with the highest risk of perioperative MI.
Which of the following has been attributed to approximately 20% of intraoperative anaphylactic reactions?
A. Latex
B. Antibiotics
C. Opioids
D. Propofol
Answer: Latex
Rationale: The incidence of intraoperative latex reactions has decreased due to increased awareness, preventive measures, and the availability of nonlatex medical supplies. However, latex sensitivity still accounts for up to 20% of intraoperative anaphylactic reactions. Preoperative assessments should include screening for latex allergies and sensitivities to prevent reactions.
Urinary output and voiding are essential monitoring assessments for post-spinal and epidural anesthesia. Diabetic patients can develop postoperative urinary retention (POUR). What is the amount in the bladder immediately after spinal anesthesia that indicates a predictor of POUR?
A. Greater than 400 to 500 mL
B. Greater than 600 to 700 mL
C. Greater than 800 to 1000 mL
D. Greater than 200 to 300 mL
Answer: A. 400 to 500 mL
Rationale: Diabetes can decrease sensation and contractility in the bladder and increase bladder capacity, which increases the development of postoperative urinary retention (POUR). A predictor of POUR is the presence of greater than 400 to 500 mL of urine in the bladder immediately after spinal anesthesia. Opioids, ketamine, general anesthetics, and NSAIDs can increase the risk of POUR.
Which of the following anesthetic agents is most commonly associated with elevated incidences of emergence delirium in pediatric patients?
A. Midazolam
B. Dexmedetomidine
C. Sevoflurane
D. Propofol
Answer: C - Sevoflurane
Rationale: The incidence of postoperative emergence delirium has been reported to be as high as 50-80% in pediatric cases. There are many factors associated with increased risk of emergence delirium, such as pain, separation anxiety, endotracheal tube presence, and choice of anesthetic agent . In children, sevoflurane-anesthesia has been strongly linked to high levels of emergence delirium, whereas in the adults, benzodiazepine administration has been more related to its incidence
During a critical healthcare-related incident where the patient is harmed, who would be considered the second victim?
A. The family of the patient
B. The hospital shareholders
C. The healthcare provider caring for the patient
D. The local community
Answer: C, Healthcare provider caring for the patient.
Rationale: No one desires to harm patients when caring for them. After a critical incident harms a patient, the healthcare professionals involved have often demonstrated PTSD symptoms. These symptoms can result in personal distress, burnout, loss of empathy, and an increased risk of making another error. Processing the incident using six steps is imperative to continue thriving and functioning: chaos/accident response, intrusive reflections, restoring personal integrity, enduring inquisition, obtaining emotional first aid, and moving onward.
What is the “surgical stress response” characterized by? (select all that apply)
A) Temporary increase in liver enzymes
B) Induction of a catabolic state
C) Decreased peripheral glucose uptake
D) Uncontrolled postoperative pain
E) Increased endogenous glucose production
Correct answer: B) Induction of a catabolic state, C) Decreased peripheral glucose uptake E) Increased endogenous glucose production
Rationale: “The surgical stress respoinse is characterized by neuro-endocrine, metabolic, inflammatory, and immunological changes initiated by the physiological trespass of the surgical incision and subsequent invasive procedures. The stress response can adversely affect organ function and perioperative outcomes and may include induction of a catabolic state as well as a transient, but reversible, state of insulin resistance, characterized by decreased peripheral glucose uptake and increased endogenous glucose production
Which of the following is not considered an acceptable clear liquid that can be consumed up to 2 hours before a surgical procedure?
A. Beef Broth
B. Popsicle
C. Clear Jell-O
D. Fat Free Milk
Answer: D. Fat Free Milk
Rationale: Clear liquids can be consumed up to 2 hours before a procedure. Examples of clear liquids include: water, apple juice, black coffee, black tea, clear juice drinks, clear Jell-O, clear broth, ice, popsicles, and Pedialyte. Fat free milk is not a clear liquid and must be stopped 6 hours prior to a surgical procedure.
Which patient would be most likely to experience postoperative nausea and vomiting?
A. 85 year-old female with osteoporosis
B. 30 year-old male with a history of tobacco abuse
C. 28 year-old female with vertigo
D. 76 year-old male with coronary artery disease.
Answer: C
Rationale: Risk factors associated with an increased risk of PONV include female gender, age <50 years, history of PONV, history of motion sickness, and a nonsmoker.
Which of the following patients is at increased risk of awareness during surgery? Select 3
A) Female
B) Elderly
C) Smoker
D) Obese
E) Obstetric
Answer: A, D, & E
Rationale: Risk factors for awareness include: female sex, age (younger adults but not children), obesity, clinician experience, previous awareness, after normal hours operation, emergency procedure, type of surgery (obstetric, cardiac, thoracic), and use of nondepolarizing relaxants.
A patient with chronic obstructive pulmonary disease (COPD) presents for elective non-cardiac surgery. His arterial blood gas shows PaCO₂ of 50 mm Hg, PaO₂ of 57 mm Hg, and SpO₂ of 89%. Which of the following is the most appropriate next step?
A. Cancel surgery and consult pulmonary rehab
B. Proceed with surgery; findings are not contraindications
C. Intubate preoperatively and admit to ICU
D. Postpone surgery until PaCO₂ normalizes
Answer: B. Proceed with surgery; findings are not contraindications
Rationale: While hypoxemia (PaO₂ <60), SpO₂ of less than 90%, and hypercarbia (PaCO₂ >45) increase perioperative risk, they are not absolute contraindications for non-cardiac surgery. These values are expected in many patients with moderate to severe COPD. The key is to optimize the patient preoperatively, not necessarily delay or cancel.
Question: Which of of the following are effective preoperative strategies to prevent pulmonary complications in a patient with chronic bronchitis? (SATP)
a. Weight reduction
b. Prophylactic antibiotics to sterilize sputum
c. chest physiotherapy
d. Expectorants
Answer: a., c., d.
Rationale: Tactics to decrease pulmonary complications in chronic bronchitis populations include respiratory maneuvers, smoking cessation, treatment of pulmonary infections with antibiotics, expectorants, chest physiotherapy, good nutrition, and weight reduction. It is not recommended to administer prophylactic antibiotics to “sterilize” the sputum as this may initiate growth of a resistant bacterial strain that would further complicate respiratory management
Which of the following are signs of upper respiratory tract infection in pediatric patients in the preoperative period? Select two.
A. Rhinorrhea
B. Auscultation of rales
C. Pulmonary congestion evidenced on a chest radiograph
D. Bulging and tender eardrums
Correct Answer: A & D
Rationale
Signs and symptoms associated with upper respiratory tract infections include sore throat, reddened pharyngeal and oropharyngeal mucus membranes, increased secretions, fever, sneezing, rhinorrhea, and bulging or tender eardrums (Elisha et al., 2023). Conversely, lower respiratory tract infections present signs and symptoms more precisely associated with the lower airway anatomy, such as pulmonary congestion on a chest radiograph and the auscultation of rales in the lung fields
For a patient with suspected or known adrenal insufficiency undergoing total joint replacement surgery, what is the recommended perioperative dose of hydrocortisone?
A. Preoperative corticosteroid dose + 25 mg
B. Preoperative corticosteroid dose + 150 mg
C. Preoperative corticosteroid dose + 40 mg
D. Preoperative corticosteroid dose + 75 mg
Answer: D
Rationale:
The recommended dose of hydrocortisone for a patient with known or suspected adrenal insufficiency undergoing moderate surgery (lower extremity revascularization, total joint replacement) is their preoperative corticosteroid dose + 50 - 75 mg of hydrocortisone. The dose for minor surgeries (inguinal hernia repair) is their preoperative corticosteroid dose + 25 mg hydrocortisone. The dose for major surgery (cardiac surgery, aortic aneurysm repair) is their preoperative corticosteroid dose + 100 - 150 mg of hydrocortisone every 8 hours for 48-72 hours. However, if the total dose per day exceeds 100 mg, a steroid such as methylprednisolone should be considered instead. 4 mg of methylprednisolone = 20 mg hydrocortisone.
A patient with chronic kidney disease is scheduled for surgery. Which lab test should be checked within 6-8 hours before surgery to prevent cardiac risks?
A) Blood urea nitrogen (BUN)
B) Serum creatinine
C) Serum potassium
D) Complete blood count (CBC)
Answer: C) Serum potassium
Rational: Preoperative measurement of serum potassium concentration is recommended within 6 to 8 hours of surgery regardless of whether dialysis is performed, because unexpected hyperkalemia with its adverse cardiac effects is known to occur rapidly. If serum potassium level exceeds 5.5 mEq/L and congestive heart failure is apparent, elective surgery should be delayed until after dialysis. If postponement is not an option due to emergency surgery, measures to reduce the serum potassium concentration should be initiated.
Which of the following is a high-risk cardiac condition requiring elective surgery delay until further evaluation or treatment is completed?
A. Stable angina
B. Stage 1 hypertension
C. Recent myocardial infarction within 30 days
D. Controlled atrial fibrillation
Correct Answer: C. Recent myocardial infarction within 30 days
Rationale:
A recent MI (within 30 days) is a major risk factor for perioperative reinfarction and mortality. Elective surgery should be postponed until at least 60 days post-MI to minimize risk.
Which of the following assessment findings is MOST indicative of inadequate reversal of neuromuscular blockade in the PACU?
A. The patient has a heart rate of 105 bpm and a blood pressure of 142/78 mm Hg.
B. The patient is able to lift their head and move two extremities voluntarily but has shallow respirations
C. The patient has a heart rate of 55 bpm and a blood pressure of 90/60 mm Hg.
D. The patient is shivering and reports feeling cold despite a room temperature of 75°F.
The patient is able to lift their head and move two extremities voluntarily but has shallow respirations.
Rationale: Incomplete reversal of neuromuscular relaxation can lead to hypoventilation. The text emphasizes the use of objective monitoring measures like train-of-four ratio <0.90 to determine the depth of residual blockade. Shallow respirations in conjunction with a low train-of-four ratio strongly suggest inadequate reversal.
What is the primary determinant of intracellular osmotic pressure?
A. Bicarbonate
B. Sodium
C. Potassium
D. Chloride
C. Potassium
Potassium is the key determinant of intracellular osmotic pressure, whereas sodium dominates extracellular osmotic regulation. This balance is critical for cell volume and function.
What is the function of the Na⁺/K⁺-ATPase pump in fluid and electrolyte physiology?
A. Maintains the potassium gradient across cell membranes
B. Generates intracellular hydrostatic pressure
C. Regulates bicarbonate buffering in plasma
D. Facilitates passive diffusion of potassium
A. Maintains the potassium gradient across cell membranes
The Na⁺/K⁺-ATPase actively transports sodium out of and potassium into cells, maintaining intracellular potassium concentration and contributing to osmotic balance and resting membrane potential. It’s vital for cellular function.
Which of the following is the most appropriate initial treatment for symptomatic hypocalcemia in the perioperative period?
A. IV magnesium
B. Oral calcium carbonate
C. Intravenous calcium
D. Loop diuretics and saline infusion
Correct Answer: Intravenous calcium
Symptomatic hypocalcemia is a medical emergency that necessitates immediate treatment with intravenous calcium to stabilize the cardiac and neuromuscular systems. Oral supplementation is too slow, and while magnesium may correct hypomagnesemia-associated hypocalcemia, it is not the first-line treatment. Diuretics and saline are used for hypercalcemia management, not hypocalcemia.
Which of the following is the most common cause of hyponatremia in hospitalized patients?
A. Diabetes insipidus
B. Hyperaldosteronism
C. Salt-wasting nephropathy
D. Syndrome of inappropriate antidiuretic hormone (SIADH)
D. SIADH
SIADH is the most common cause of hyponatremia and is characterized by excessive release of ADH, leading to water retention and dilutional hyponatremia. The other conditions may affect sodium balance but are far less common.
Which of the following defines respiratory alkalosis?
A. Increased plasma HCO₃⁻ and metabolic compensation
B. Decreased PaCO₂ and increased pH
C. Decreased plasma HCO₃⁻ and increased anion gap
D. Increased PaCO₂ and decreased pH
B. Decreased PaCO₂ and increased pH
Respiratory alkalosis results from hyperventilation, which decreases PaCO₂ and increases blood pH. The other options describe different acid-base disturbances.
What is the safest strategy for correcting chronic hyponatremia to prevent osmotic demyelination syndrome?
A. Limit correction to no more than 0.5–1.5 mEq/L per hour
B. Rapidly normalize sodium levels within 12 hours
C. Administer hypertonic saline until symptoms resolve
D. Increase serum sodium by 2 mEq/L per hour
A. Limit correction to no more than 0.5–1.5 mEq/L per hour
Osmotic demyelination syndrome is a severe risk of correcting chronic hyponatremia too quickly. Recommended correction rates are 0.5–1.5 mEq/L per hour depending on severity and should not exceed 8–10 mEq/L in 24 hours. Rapid normalization is dangerous and should be avoided.
Which electrolyte abnormality is most immediately life-threatening and requires urgent correction when serum levels exceed 6 mEq/L?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypercalcemia
B. Hyperkalemia
Hyperkalemia above 6 mEq/L poses a high risk for cardiac arrhythmias and cardiac arrest, especially with EKG changes. Urgent intervention is required to stabilize cardiac membranes and reduce serum potassium.
Which fluid type is most appropriate for initial volume resuscitation in hypovolemic patients undergoing surgery?
A. Dextrose 5% in water
B. Isotonic crystalloids
C. Colloid-only resuscitation
D. Hypertonic saline
B. Isotonic Crystalloids
Isotonic crystalloids like Lactated Ringer’s or PlasmaLyte are typically used for initial volume resuscitation due to their distribution within the extracellular compartment. Colloids are reserved for specific indications and hypertonic fluids are rarely first-line.
Which of the following measures is most useful for assessing real-time fluid responsiveness during surgery?
A. Urine output
B. Stroke volume variation (SVV)
C. Central venous pressure (CVP)
D. Serum lactate
B. SVV
SVV and pulse pressure variation (PPV) are dynamic indicators that reflect preload responsiveness in mechanically ventilated patients, helping guide fluid therapy more effectively than static measures like CVP.
In the context of massive transfusion protocols (MTPs), which of the following is the most life-threatening transfusion complication?
A. Graft-versus-host disease
B. ABO incompatibility
C. Transfusion-associated circulatory overload (TACO)
D. Transfusion-associated circulatory overload (TACO)
B. ABO incompatibility
ABO incompatibility can lead to acute hemolytic reactions, which are the most severe and potentially fatal transfusion complications. While other reactions can be serious, they are typically less immediately life-threatening.
Which of the following are optimal indications for cell salvage techniques, such as Cell Saver? Select two.
A. Hip replacement with an anticipated blood loss of >500mL
B. Surgical debulking of a malignant peritoneal tumor
C. Exploratory laparotomy following a gunshot wound to the abdomen
D. Jehovah’s Witness patient undergoing a spinal fusion
A & D
Cell salvage techniques are utilized to reduce the amount of allogenic red blood cell transfusions in cases with high expected blood loss (>500mL) (Elisha et al., 2023, p. 404). These practices are also beneficial in maintaining hemodynamic stability in patients who do not consent to allogenic blood transfusion, such as Jehovah’s Witnesses (Elisha et al., 2023, p. 404). Relative contraindications to cell salvage techniques include the contamination of the surgical field by malignant tumor cells and possible exposure of bowel contents
Select All That Apply (Pick 3)
Which are common indications for using colloid fluids over crystalloids?
A. Sepsis
B. Severe hypoalbuminemia
C. Massive third spacing
D. Fluid replacement under 2 liters
E. Buying time before blood availability
B. Severe hypoalbuminemia
C. Massive third spacing
E. Buying time before blood availability
Rationale: Colloids are reserved for specific situations such as oncotic pressure loss, significant fluid shifts, or immediate volume expansion while awaiting blood products. Crystalloids are generally reserved for burns and sepsis.
Which of the following are causes of hypocalcemia? [Select 2]
A. Hyperparathyroidism
B. Vitamin D deficiency
C. Hyperphosphatemia
D. Thiazide diuretic administration
B and C
Rationale: Hypocalcemia should be diagnosed based upon the ionized plasma calcium concentration. If hypocalcemia is present based upon this, common causes include hypoparathyroidism, vitamin d deficiency, hyperphosphatemia, precipitation of calcium, and chelation of calcium. Thiazide diuretic administration, and hyperparathyroidism are common causes of hypercalcemia.
Which of the following are chloride-sensitive causes for metabolic alkalosis? (SATP)
A. Vomiting
B. Diuretics
C. Hyperaldosteronism
D. Cystic fibrosis
A, B and D
Rationale: Chloride sensitive mechanisms of metabolic alkalosis include conditions that deplete extracellular fluid. In response to fluid depletion, the renal tubules reabsorb Na+; when not enough chloride anions are present to accompany the Na+, H+ ions must be excreted to maintain electrical neutrality. Urine chloride concentrations are typically low (<10mEq/L). Conditions can can lead to this fall into three categories: Gastrointestinal, renal, and sweat. While diuretic therapy is the most common cause, other triggers include vomiting (gastrointestinal) and cystic fibrosis (sweat). Hyperaldosteronism falls into the “chloride resistant” category, causing metabolic alkalosis by way of promoting sodium retention and K+ and H+ excretion. In this instance, urine chloride is typically elevated (>20 mEq/L).
Question: Which of the following relationships is the basis for the Frank-Starling mechanism?
A. Systemic vascular resistance (SVR) and left ventricular end-diastolic volume (LVEDV)
B. Cardiac output and left ventricular end-systolic volume (LVESV)
C. Myocardial contractility and systemic vascular resistance (SVR)
D. Left ventricle end-diastolic volume (LVEDV) and Myocardial contractility
D
The relationship between LVEDV and myocardial contractility is the basis of the Frank-Starling mechanism. This mechanism describes how increasing LVEDV (ventricular stretch) will increase myocardial contractility, which increases the force of contraction. It all has to do with sliding filament theory. As the sarcomeres lengthen from stretching, more actin overlaps myosin, creating more cross-bridges. The number of cross-bridges dictates the force of contraction. However, the force of contraction will decrease if the ventricle is stretched past a certain point because the myosin and actin filaments are only so long. Too much stretch ultimately causes less myosin and actin to overlap. This reduces the number of cross-bridges to form, causing a weaker contraction. The Frank-Starling mechanism explains why giving fluid volume for hypovolemia increases cardiac output, but too much volume (fluid overload) is counterproductive.
Once a patient with hyponatremia is clinically stable, what is the recommended maximum rate at which serum sodium (Na⁺) should be increased to avoid the risk of osmotic demyelination syndrome?
A) 5-8 mmol/L in 24 hours
B) 8 mmol/L in 24 hours
C) 10–15 mmol/L in 24 hours
D) 20-25 mmol/L in 24 hours
C) 10–15 mmol/L in 24 hours
Once the patient is clinically stable, Na+ administration should be slowed to raise serum Na+ not more than 10 to 15 mmol/L in 24 hours.
Which of the following regulate or contribute to the release of ADH and, thereby, control plasma osmolality? (select all that apply)
A. Osmoreceptors in the hypothalamus
B. The anterior pituitary
C. The renal collecting tubules
D. Carotid baroreceptors
E. The posterior pituitary
F. Low pressure volume receptors in the atria, v ena cavae, and pulmonary arteries.
Correct Answer: A, D, E, F
Specialized neurons in the hypothalamus are sensitive to changes in extracellular osmolality. When ECF osmolality increases, these cells shrink and cause ADH release from the posterior pituitary. ADH markedly increases water reabsorption in renal collecting tubules which reduces plasma osmolality back to normal. Conversely, a decrease in extracellular osmolality causes osmoreceptors to swell and suppresses the release of ADH. Decreased ADH secretion allows water diuresis, which increases osmolality to normal. Peak diuresis occurs once circulating ADH is metabolized (90–120 minutes). With complete suppression of ADH secretion, the kidneys can excrete up to 10 to 20 L of water per day. Carotid baroreceptors (volume receptors), as well as low-pressure volume receptors in the atria, vena cavae, and pulmonary arteries, also influence ADH release. A fall in wall tension results in a reflex increase of ADH secretion from the posterior pituitary. An increased stretch of these receptors not only suppresses ADH secretion, but the increased atrial volume receptor stretch also increases secretion of atrial natriuretic peptide (ANP; see later discussion), which promotes renal excretion of sodium and water”
What daily fluid volume would a 100 kg patient need in order to maintain Total Body Water homeostasis? Assume the person is healthy, normothermic, and has standard metabolic function.
A. 2 Liters
B. 3 Liters
C. 4 Liters
D. 5 Liters
B. 3 Liters
Rationale: The fluid requirement for person who is healthy, normothermic, and has standard metabolic function is 25-35 ml/kg a day. Thus, a 100 kg patient would require 2.5 - 3.5 Liters of fluid to maintain Total Body Water Homeostasis.
What is the most common electrolyte abnormality in hospitalized patients?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hyperphosphatemia
C.
Hyponatremia is the most common electrolyte abnormality in hospitalized patients.
Which of the following best distinguishes nephrogenic diabetes insipidus (DI) from central DI?
A. Nephrogenic DI often develops due to lesions in the brain
B. Central DI shows no response to antidiuretic hormone (ADH) administration
C. Nephrogenic DI involves impaired renal response to normal ADH levels
D. Central DI is commonly associated with lithium therapy
Correct Answer: C. Nephrogenic DI involves impaired renal response to normal ADH levels
In nephrogenic DI, ADH secretion is normal, but the kidneys fail to respond to it, and urinary concentrating ability is impaired. It can be congenital or secondary to chronic conditions, such as CKD, hypokalemia, or lithium use. Central DI is due to decreased ADH secretion, commonly resulting from brain lesions or brain death. An increase in urine osmolality following the administration of exogenous ADH confirms the diagnosis of central DI. In nephrogenic DI, the kidneys fail to produce hypertonic urine following the administration of exogenous ADH.
Which of the following is a key component of patient blood management (PBM) in the perioperative period?
A. Delaying anemia treatment until after surgery
B. Routine transfusion of all patients undergoing major surgery
C. Optimization of the patient’s red blood cell production
D. Ignoring mild anemia if the patient is asymptomatic
C. Optimization of the patient’s red blood cell production
Addressing patient blood management (PBM) throughout the perioperative period allows practitioners to identify and treat conditions—such as anemia or coagulopathy—that increase the risk of bleeding or transfusion. The key aspects of PBM during this time include optimization of the patient’s red blood cell (RBC) production, minimization of blood loss, and treatment of anemia. These strategies help improve oxygen delivery, reduce transfusion requirements, and ultimately enhance patient outcomes.
A trauma patient is receiving massive transfusion of packed red blood cells intraoperatively. Which electrolyte imbalance is most likely to occur due to the citrate preservative in the blood products?
A) Hyperkalemia
B) Hypocalcemia
C) Hypernatremia
D) Hypomagnesemia
Answer: B) Hypocalcemia
Rational: Citrate is used as a preservative in packed red blood cells. The citrate chelates or binds calcium. During massive rapid transfusion, the excess citrate can significantly reduce the serum calcium levels, leading to acute hypocalcemia. Correction of serum calcium should be guided by ionized calcium levels.
Which of the following is NOT a recommended indication for platelet transfusion?
A. Platelet count <10 × 10⁹ cells/L in a non-bleeding patient
B. Platelet count <50 × 10⁹ cells/L with active bleeding
C. Mild thrombocytosis without bleeding
D. Platelet dysfunction
C. Mild thrombocytosis without bleeding
Platelet transfusion is not indicated in thrombocytosis. Examples of some indications for platelet transfusion are platelet dysfunction, thrombocytopenia, or platelet count <50 × 10⁹ cells/L with active bleeding.
According to Enhanced Recover After Surgery (ERAS) protocol, which of the following is NOT correct regarding the preoperative fluid management fasting intervals?
A. Clear liquids: 2 hours
B. Breast milk: 2 hours
C. Formula/non-human milk/light meal: 6 hours
D. Heavy meal (fried foods, fatty foods, meats): 8 hours.
B. Breast milk: 2 hours
The preoperative fasting guidelines recommend the following fasting intervals: clear liquids 2 hours, breast milk 4 hours, infant formula/nonhuman milk/light meal 6 hours, and heavy meal (fried foods, fatty foods, meats) 8 hours. Also, supplying a carbohydrate drink (such as Gatorade) 2 hours prior to surgery has the added benefit of maintaining adequate preoperative glucose and insulin levels, thereby reducing preoperative thirst, hunger, and anxiety levels.
A patient presented to the emergency department 2 days prior with heart failure and fluid overload. The patient has been NPO during this time and is receiving loop diuretics to offload fluid. The patient is preparing for a heart cath when the nurse anesthetist notices the patient’s ECG: A pronounced P wave, a flattened T wave, and a prominent U wave. What condition should the CRNA suspect?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
E. Wolff-Parkinson-White Syndrome
B. Hypokalemia.
The ECG represents a classic presentation of hypokalemia. Assumably, the hypokalemia was brought on by a decreased dietary potassium intake and the administration of loop diuretics. Conversely, hyperkalemia is presented with a flattened P wave, widened QRS, shortened QT interval, and peaked T wave.
Which of the following findings is most consistent with Transfusion-Associated Circulatory Overload (TACO) rather than Transfusion-Related Acute Lung Injury (TRALI)?
A. Hypotension
B. Fever and chills
C. Hypertension
D. Acute hypoxemia within 6 hours of transfusion
C. Hypertension
TACO is estimated to occur in 1% to 4% of patients receiving a transfusion and occurs higher in those who are critically ill and in ICUs.It should be suspected in any patient experiencing respiratory distress or hypertension 6 to 12 hours after completion of a transfusion. Although hypertension is a distinguishing feature between TRALI and TACO, hypotension and shock can also occur with TACO.’’ Other findings may include hypoxia, tachycardia, widened pulse pressure, jugular vein distension, or rales/wheezing within the lungs
The anesthesia provider is looking at the patient’s history and medication list. The anesthesia provider confirmed with the nurse that the patient is taking a scheduled dose of an ACE inhibitor (lisinopril) and a Beta blocker (metoprolol) to control their blood pressure. The patient is scheduled for surgery in the next 10 hours. What electrolyte abnormality would you see in the patient if it is not corrected by goal-directed fluid therapy?
A. hyponatremia and hyperkalemia
B. hypernatremia and hypokalemia
C. hypernatremia and hyperkalemia
D. hypercalcemia and hypocalcemia
A. Hyponatremia and hyperkalemia
Rationale: Medications such as ACE inhibitors, beta blockers (specifically Beta 1 receptor antagonism), ARBs, and digoxin can cause an increase in extracellular potassium. ACE inhibitors and ARBs can cause a decrease in angiotensin, and beta blockers inhibit renin release, which decreases the release of aldosterone. A decrease in aldosterone can cause hyperkalemia and hyponatremia.
What is the ultimate goal of perioperative goal-directed fluid therapy (GDFT)?
A. To administer a fixed volume of fluids to all patients.
B. To utilize individual hemodynamic end points to achieve an optimal cardiac output and oxygen delivery to tissues.
C. To minimize the use of vasopressors during surgery, thus decreasing increased oxygen demand.
D. To aim for a “zero balance” between intake and output to minimize excess fluid administration by only replacing the estimated blood loss during surgery.
Correct Answer: B. To utilize individual hemodynamic end points to achieve an optimal cardiac output and oxygen delivery to tissues.
Perioperative goal-directed fluid therapy (GDFT) aims to optimize each individual’s hemodynamic status by tailoring fluid administration to achieve specific hemodynamic end points, thus decreasing oxygen demand and optimizing cardiac output and tissue oxygenation during surgery. Administering a fixed volume of fluids has historically been used in the past, but it may have unintended physiologic consequences since it is not tailored to each individual’s hemodynamic needs. Focusing solely on replacing estimated blood loss does not account for individual patient needs, and is related to the “zero balance” approach of fluid management. Minimizing vasopressor use is not the primary objective of GDFT. However, GDFT will allow the provider to determine if the patient requires fluid therapy or inotropy support.
