SEE EXAM Anesthesia QOD Diagram | Quizlet

An action potential characterized by a spike followed by a plateau phase is seen in:

A. peripheral sensory nerve cells

B. peripheral motor nerve cells

C. striated skeletal muscle cells

D. cardiac muscle cells

cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.

pg. 345

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During mediastinoscopy the risk of air embolization is greatest:

A. when the patient is supine

B. during spontaneous ventilation

C. immediately after closure of the incision

D. in the postoperative period

B. during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989

Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The formation of metanephrine is the result of:

catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to vanillymandelic acid (VMA).

pg. 868

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A decrease in pseudocholinesterase activity has been associated with the use of: (Select 3)

pancuronium

esmolol

droperidol

vecuronium

metoclopramide

magnesium sulfate

dantrolene

rocuronium

A decrease in pseudocholinesterase activity has been associated with the use of:

pancuronium, esmolol, metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, phenelzine, cyclophosphamide, metoclopramide, esmolol, pancuronium and oral contraceptives. Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

pg. 207

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is:

745 - 750 psig

Nitrous oxide has a critical temperature of 37C. This allow nitrous oxide to exist as a liquid at room temperature. Full E-cylinders of nitrous oxide contain approximately 1590 L at a pressure of 745 psig. A sixty minute delivery of 3 L/min would result in a 180 L consumption, and this would be inadequate to consume all the liquid nitrous oxide in the tank. As a result, there would be no change in tank pressure.

pg. 622

Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Autonomic hyperreflexia:

A. is common with cord lesions below T8

B. can precipitate pulmonary edema

C. is not effectively prevented by regional anesthesia

D. can be prevented with adequate intraoperative sedation

B. can precipitate pulmonary edema

Autonomic hyperreflexia should be suspected in patients with lesions above T5-8. Regional anesthesia and deep general anesthesia are effective in preventing autonomic hyperreflexia. Surgical stimulation in these patients without adequate anesthesia can result in pulmonary edema, myocardial ischemia and cerebral hemorrhage.

pg. 927

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

In the CVP trace below, the v wave is caused by:

A. atrial contraction

B. ventricular contraction

C. atrial filling

D. opening of the tricuspid valve

C. atrial filling

In the normal CVP tracing, the a wave is due to atrial systole. The c wave coincides with ventricular contraction. The v wave is the result of atrial filling prior to the opening of the tricuspid valve. The x descent is thought to be due to the pulling down of the atrium by ventricular contraction. The y descent corresponds to the opening of the tricuspid valve.

pp. 298-300

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The primary causative factor in the development of persistent pulmonary hypertension (PPH) in the neonate is:

A. cystic fibrosis

B. pregnancy-induced hypertension

C. hypoxemia

D. right-to-left shunting through a patent ductus arteriosus

C. hypoxemia

Hypoxia or acidosis during the early neonatal period may predispose the infant to return to fetal circulation. This serious condition, previously known as persistent fetal circulation (PFC), is currently known as persistent pulmonary hypertension (PPH). Hypoxemia and/or acidosis promotes an increase in pulmonary vascular resistance which ultimately causes right to left shunting through the ductus arteriosus, foramen ovale, or both. Shunting causes continued hypoxemia, leading to a continued increase in pulmonary vascular resistance, and a vicious cycle ensues. Primary causes of hypoxemia in the neonate include pneumonia and meconium aspiration.

pp. 1163-1164

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Deleterious effects of hypothermia include: (Select 2)

A. impaired renal function

B. right shift of the hemoglobin-oxygen saturation curve

C. irreversible platelet dysfunction

D. increased incidence of wound infection

E. increased postoperative protein anabolism

A. impaired renal function,

D. increased incidence of wound infection

increased PVR

left shift of the hemoglobin-oxygen saturation curve

reversible platelet dysfunction

postoperative protein catabolism

altered mental status

impaired renal function

decreased drug metabolism

poor wound healing

increased incidence of infection

cardiac arrhythmias

pp. 1235-1236

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

You are managing anemia in a 3-day-old neonate. Which of the following most accurately reflects the hemoglobin equivalent for tissue delivery in the neonate, infant, and adult?

A. Neonate: 10 g/dl; Infant 14 g/dl; Adult 8 g/dl

B. Neonate: 14 g/dl; Infant 10 g/dl; Adult 8 g/dl

C. Neonate: 8 g/dl; Infant 10 g/dl; Adult 14 g/dl

D. Neonate: 14 g/dl; Infant 8 g/dl; Adult 10 g/dl

Dr. Motoyama described a hemoglobin requirement for equivalent tissue oxygen delivery for neonates, infants and adults based on the oxygen affinity of hemoglobin. The hemoglobin required to transport an equivalent amount of oxygen is:

D. 14-15 g/dl for the neonate, 8 g/dl for the infant, and 10 g/dl for the adult

Prior to pneumonectomy, split lung function testing is indicated in the patient with:

A. an FEV1 of 2.2 L

B. a PaCO2 of 49 mm Hg on room air

C. a PaO2 of 54 mm Hg on room air

D. a maximum VO2 of 21 mL/kg/min

B. a PaCO2 of 49 mm Hg on room air

Split lung function testing is indicated in patients requiring pneumonectomy, but not meeting the recommended laboratory criteria. Current recommendations for patients requiring pneumonectomy are:

PaCO2 < 45 mm Hg

FEV1 > 2 L

Predicted postop FEV1 > 800 mL

Maximum VO2 > 15 mL/kg/min

FEV1/FVC > 50% of predicted

pp. 663-665

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An infant had a patent ductus arteriosus closed and is recovering in the NICU. You note that the patient has new-onset stridor and hoarseness. Which of the following is the MOST likely cause of this finding?

A. Surgical dissection causing recurrent laryngeal nerve injury

B. Hypocalcemia after transfusion of packed red blood cells

C. Laryngospasm after deep extubation

D. Incorrectly sized endotracheal tube

The incidence of recurrent laryngeal nerve injury with standard PDA ligation is reported to be 4.2% by Fan et al. while other authors indicate 2.5% using VATS clipping. Symptoms attributable to vocal cord paralysis regress in most cases and usually less than 1% of patients have lasting dysfunction. Clip entrapment of the nerve has been cited to be the mechanism of injury, but it may be that trauma induced by traction (or thermal injury by electrocautery) may better explain the observed clinical outcome. Zbar et al. reports a series of PDAs treated using open thoracotomy and indicates an incidence of recurrent laryngeal nerve injury of 22.7% in extremely low-weight babies, confirming the importance of the issue in premature infants. Decreased incidence of this complication appears to have been achieved with VATS and may be a consequence of improved vision from the video camera image.

The lumbar plexus is derived from which of the following?

A. Dorsal rami of L1-4

B. Ventral rami of L1-4 and variable contributions from T12 and L5

C. Dorsal rami of L1-4 and variable contributions from S1-2 and L5

D. Ventral rami of L1-4 and variable contributions

B. Ventral (anterior) rami of L1-4 and variable contributions from T12 and L5

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:

A. genioglossus muscle

B. longitudinal muscle of the tongue

C. palatoglossus muscle

D. styloglossus muscle

A. genioglossus muscle

The genioglossus muscle allows the tongue to be protruded and kept away from the posterior pharynx. It is innervated by the hypoglossal nerve. The palatoglossus muscle elevates the tongue and depresses the soft palate. The styloglossus muscle elevates and retracts the tongue. The superior longitudinal muscle of the tongue is an intrinsic muscle of the tongue that elevates the tip.

44-year-old man presents to the emergency room with a table saw injury to the left hand. The surgeon plans to explore the wound and possibly repair tendon and vascular injuries. The estimated operative duration is between 1-5 hours and an axilla block with bupivacaine is planned as the primary anesthetic technique. The patient has a seizure with the inejction of bupivacaine. Which of the following should be your FIRST therapeutic action?

A. Administer a short-acting muscle relaxant to stop muscle contractions

B. Administer intra-lipid

C. Administer lidocaine to prevent cardiac arrhythmias

D. Administer oxygen and ensure a patent airway

D. Administer oxygen and ensure a patent airway

The treatment of local anesthetic toxicity is similar to the management of other medical emergencies and focuses on airway, breathing and circulation. Ensuring adequate oxygenation and ventilation is paramount to avoid progressive acidosis

Compared to "plain" local anesthetic without epinephrine, a pre-mixed local anesthetic with epinephrine solution is MOST associated with which of the following?

A. Little effect on peak plasma levels

B. Decreased sensory block

C. Increased onset time

D. Decreased cardiac output

Commercially prepared solutions with epinephrine have a lower pH than those in which it is freshly added. A lower pH results in a higher percentage of ionized drug molecules. It is the non-ionized form that easily crosses the lipid membrane; therefore the onset will be delayed.

During fetal monitoring, Type III decelerations are thought to be related to:

A. head compression

B. umbilical cord compression

C. uteroplacental insufficiency

D. placental abruption

B (umbilical cord compression

Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

pg. 1167

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinic)

Which of the following statements regarding the addition of clonidine to an epidural infusion is MOST correct?

A. Clonidine is an alpha-2-receptor antagonist

B. Clonidine effect in peripheral nerve blocks is primarily centrally mediated

C. Clonidine prolongs the sensory block when added to intermediate local anesthetics

D. Commonly reported side effects include tachycardia and hypertension

C. Clonidine prolongs the sensory block when added to intermediate local anesthetics

Clonidine is an alpha-2-agonist. It has been found to prolong the sensory block primarily when combined with intermediate local anesthetics although it may also have some effect when combined with longer-acting local anesthetics. The exact mechanism is unclear but appears to be peripherally mediated and dose-dependent. Side effects include bradycardia, hypotension, and sedation.

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:

A. hypernatremia

B. hyperglycemia

C. difficulty with intubation and airway management

D. increased blood viscosity due to elevated hematocrit

C (Anesthetic complications associated with hypothyroidism include: difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

pp. 875-876

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

After an accidental needle stick with a contaminated needle, which of the following viruses carries the HIGHEST risk of transmission?

A. HIV

B. Hepatitis A

C. Hepatitis B

D. Hepatitis C

Hepatitis B carries the greatest risk of transmission, with 37 to 62% of exposed workers eventually showing seroconversion and 22 to 31% showing clinical hepatitis B infection. The hepatitis C transmission rate has been reported at 1.8%, but newer, larger surveys have shown only a 0.5% transmission rate. The overall risk of HIV infection after percutaneous exposure to HIV-infected material in the health care setting is 0.3%. Hepatitis B prophylaxis Current CDC guidelines call for the administration of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine. While the efficacy of the combination has not been evaluated in the needlestick injury setting, it has been shown to be the most efficacious approach in the perinatal setting. The approach has no contraindications during pregnancy and lactation. Hepatitis C prophylaxis CDC guidelines acknowledge that there is no active post-exposure prophylaxis for HCV. There is some evidence that treatment with interferon alfa-2b may be beneficial preventing chronic hepatitis. HIV prophylaxis CDC guidelines generally recommend a post-exposure prophylaxis protocol with 3 or more antiviral drugs, when it is known that the donor was HIV positive; however, when the viral load was low and none of the above noted risk factors are met, the CDC protocol utilizes 2 antiviral drugs.

Which of the following is MOST often associated with carbon monoxide poisoning?

A. Salicylate poisoning

B. Cyanide toxicity

C. Ethanol toxicity

D. Acetaminophen toxicity

Carbon monoxide binds to hemoglobin and prevents the delivery of O2 to tissues. Conventional two-wavelength pulse oximeter cannot discriminate between Hgb-CO and HgbO2. The half-life of carboxyhemoglobin (Hb-CO) in a patient breathing room air is approximately 300 minutes; this decreases to 90 minutes with high-flow oxygen via a nonrebreathing mask. Thus, the most important interventions in the management of a CO-poisoned patient are prompt removal from the source of CO and institution of high-flow oxygen by facemask. For patients suffering from CO poisoning after smoke inhalation, it is important to consider concomitant cyanide toxicity, which can further impair tissue oxygen utilization and exacerbate cellular hypoxia. Cyanide toxicity should be considered in anyone who rapidly loses consciousness after ingestion or inhalation (it is common in indoor fire victims due to combustion of plastics). The symptoms are those of hypoxia (headache, lethargy, seizures, coma but without cyanosis). Cyanide inhibits cytochrome oxidase in the electron transport chain which prevents the offloading of electrons from NADH to oxygen which prevents ATP production → anaerobic metabolism → lactic acidosis all in spite of normal PaO2. Manage with 100% O2 and give any or all of amyl nitrate, sodium nitrate, and/or sodium thiosulfate. The nitrates generate methemoglobin which has a greater affinity for cyanide than does cytochrome oxidase.

Which of the following monitoring modality is MOST important in the setting of tricyclic antidepressant (TCA) poisoning?

A. Pulse oximetry

B. Electrocardiogram

C. Blood pressure

D. PaCO2

TCA overdose can lead to lethargy, delirium, coma, and seizures. Tachycardia and hypotension may also develop. Attempt gastric lavage if history suggests recent large ingestion (10-20 mg/kg) and use activated charcoal. The ECG tracing is crucial in the management of TCA overdose. Give sodium bicarbonate if QRS duration > 100 ms (1-2 meq/kg bolus) and convert from bolus to infusion when the QRS complex narrows (targeting a pH of 7.5 to 7.55). If the pH becomes too alkaline but QRS complex widens then given 3% hypertonic saline to antagonize sodium channel blockade associated with TCAs. Use norepinephrine if vasopressors are necessary. Seizures need to be rapidly controlled with GABA agonists (benzos, propofol) b/c associated metabolic acidosis will rapidly worsen toxicity; don't give phenytoin which is a type IA anti-arrhythmic.

A 59-year-old man presents with nausea, diaphoresis, and bradycardia. His blood pressure is 80/40 mmHg, HR 45 bpm. A transthoracic echocardiogram reveals global left ventricular hypokinesis with bulging of the interventricular septum into the left ventricle, mild mitral regurgitation, and moderate tricuspid regurgitation. Which coronary artery do you MOST expect to be occluded?

A. First diagonal artery

B. Left anterior descending artery

C. Left circumflex artery

D. Right coronary artery

The symptoms of this patient as well as the echocardiogram findings indicate right ventricular ischemia. Patients typically often present with symptoms, such as nausea, vomiting, diaphoresis and bradycardia, and may not have the typical chest pain or pressure symptoms. An inferior wall myocardial infarction (right coronary artery distribution in 85% of patients) may manifest as complete heart block due to damage to the AV node. The SA node is fed by the RCA in 55% of population and left circumflex artery in 45% of population.

The most severe transfusion reactions are due to:

ABO incompatibility

The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis.

pg. 1172

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 55-year-old woman with a history of congenital long QT syndrome is undergoing a hysteroscopy for abnormal uterine bleeding. She had uneventful induction of general anesthesia but after paracervical block with lidocaine develops ventricular tachycardia with morphological appearance of torsades de pointe. Which of the following medications should be AVOIDED in the treatment of her arrhythmia?

A. Amiodarone

B. Calcium chloride

C. Esmolol

D. Magnesium sulfate

A. Amiodarone

Congenital long QT syndrome may occur in conjunction with other hereditary syndromes, such as Jervell, Lange-Nielsen or Romano-Ward syndrome, or acquired as a result of pharmacologic or metabolic etiologies. It is an issue of cellular repolarization which precipitates tachyarrhythmias, most commonly polymorphic ventricular tachycardia or torsades de pointe. There are multiple subtypes that affect both potassium and/or sodium channels. The arrhythmias may be precipitated by sympathetic activation, auditory stimuli or at rest. Family history may be positive for sudden cardiac death and the ECG significant for prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves. Treatment includes magnesium for arrhythmias, possible permanent pacemaker, or beta blockers for subtypes 1 and 2, but amiodarone is considered contraindicated as it prolongs the QT interval.

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by:

A. placing the grounding pad near the pacemaker

B. using infrequent bursts of longer duration

C. the use of a bipolar cautery

D. reducing the surface area of the return electrode

the use of a bipolar cautery

Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.

pg. 403

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 75-year-old man is undergoing a mitral valve replacement via cardiopulmonary bypass. The perfusionist is running bypass flows at > 2.5 liters/minute/m2. Which of the following is the MOST likely adverse consequence of undergoing cardiopulmonary bypass at increased flow rates?

A. Increased trauma to blood elements

B. Increased hypothermia

C. Decreased blood flow to the brain

D. Decreased myocardial blood flow

A. Increased trauma to blood elements

Cardiopulmonary bypass (CPB) does the work of the heart and lungs in order to isolate those organs from blood flow such that surgery on the heart can occur in a relatively bloodless fashion. Thus, the CPB circuit must oxygenate and ventilate the blood and then deliver the oxygenated blood back to the body and end organs. It has long been debated whether maximal blood flow or pressure is more important in perfusion and homeostasis of the end organs during bypass. Maximizing blood flow (CI > 2 liters/minute/meter2) has been shown to increase hematologic trauma, increase the magnitude of the stress or inflammatory response, cause strain on suture lines, increase shunting of blood through the pulmonary system, increase washout of cardioplegia and not necessarily lead to improved regional blood flow. The CPB machine can change total flow, but it cannot adjust regional flows to the various end organ systems. Changes in blood pressure are currently thought to be most effective for allowing adjustments to regional flow in organ systems as the organs retain their regional vascular resistance capabilities. Thus conduct of CPB with an optimal pressure (and potentially lower flows) may allow the individual organs to regionally modulate their own flows.

postretrobulbar block apnea syndrome is associated with:

unconsciousness

The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.

pg. 766

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Physiologic effects of electroconvulsive therapy (ECT) include an:

A. initial sympathetic response with sustained tachycardia

B. initial sympathetic discharge followed by a sustained parasympathetic response

C. initial parasympathetic discharge followed by a sustained sympathetic response

D. initial parasympathetic response with sustained bradycardia

C (initial parasympathetic discharge followed by a sustained sympathetic response

An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased secretions can occur, which is then followed by hypertension and tachycardia. Patients scheduled for ECT are routinely given anticholinergic medication preoperatively.

pg. 1277

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.)

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:

A. T4 - T8

b. T8 - L2

c. L2 - L4

d. L4 - S1

arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from: T8 - L2

A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable origin from aorta, arising between T5 - T8 in 15%, between T9 - T12 in 60% and between L1 - L2 in 25% of individuals.

pg. 480

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Which of the following respiratory parameters remains UNCHANGED in pregnancy?

a. Functional residual capacity (FRC)

b. Inspiratory reserve volume (IRV)

c. Total lung capacity (TLC)

d. Expiratory reserve volume (ERV)

b (IRV

Compression of the lungs by the gravid uterus causes multiple changes in lung volumes. The diaphragm is elevated from upward pressure from the uterus, resulting in decreased TLC, FRC, ERV, and residual volume. Tidal volumes increase to increase minute ventilation, and by extension inspiratory capacity increases as well. Parameters that stay roughly constant in pregnancy vital capacity and inspiratory reserve volume. There is a small (~5%) reduction in total lung capacity. Thus, the loss of FRC caused by the elevation of the diaphragm does not reduce the volumes that the patient is actively breathing.)

Correct location of the catheter tip of a central venous line is in the:

a. superior vena cava

b. right atrium

c. right ventricle

d. pulmonary artery

superior vena cava

The CVP catheter tip should not be allowed to migrate into the heart chamber to avoid arrhythmias and perforatio

Which of the following is MOST true regarding acetaminophen poisoning?

a. 5% of acetaminophen is excreted in the urine

b. Acetaminophen is responsible for at least 90% of acute hepatic failure in the US

c. Acetaminophen is a central COX-1 inhibitor

d. The majority of acetaminophen is oxidized to NAPQI (which is detoxified by glutathione)

There were 100,000 reported exposures to acetaminophen in 2005, 333 of which were fatal and 3310 considered significant. Acetaminophen is a central COX-2 and prostaglandin synthase inhibitor and is responsible for 51% of all acute hepatic failure in the US. 90% of ingested acetaminophen is conjugated with glucuronide or sulfate, 5-15% is oxidized to NAPQI (by cytochrome P450) which is toxic and is detoxified by glutathione, and 5% eliminated unchanged in urine. If sulfate becomes saturated, NAPQI can no longer be detoxified by glutathione and it reaches toxic levels in the liver. Stage I acetaminophen toxicity: asymptomatic Stage II acetaminophen toxicity: hepatitis-like findings (AST/ALT, INR) Stage III acetaminophen toxicity: peak hepatotoxicity at 72-96 hours Stage IV acetaminophen toxicity: hepatic recovery (does not always occur) N-acetylcysteine (augments glutathione reserves) @ 140 mg/kg loading dose PO or 150 mg/kg IV (preferable) followed by repeated (smaller) doses every 4 hours. Because NAC is so effective, charcoal is not needed unless co-ingestion is suspected.

During pregnancy, the minimum alveolar concentration (MAC):

a. decreases until the 20th week

b. increases until the 20th week

c. decreases throughout the pregnancy

d. increases throughout the pregnancy

decreases throughout the pregnancy

The MAC progressively decreases during pregnancy, at term by as much as 40%. MAC returns to normal by the third day after delivery.

pg. 826

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Which of the following is NOT a contraindication to activated charcoal in the setting of suspected aspirin poisoning?

a.Bowel obstruction

b. Bowel perforation

c. Inability to protect airway

d. Two hours since ingestion

AC is absolutely contraindicated in patients with bowel obstruction or perforation and those with an unprotected airway.

While benefit from GI decontamination is most likely when it can be performed within one hour of poison ingestion, because it is relatively harmless (if contraindications are not present), giving it within two hours of ingestion is reasonable (at this time mean drug absorption may still be reduced by ~ 30%). That said, since most adults do not present to emergency departments until a mean of three to four hours after a toxic ingestion, when much of the ingested material has already been absorbed, GI decontamination is unlikely to affect these patients. The potential for benefit from GI decontamination after one hour cannot, however, be excluded Activated charcoal (AC) is the preferred means of gastrointestinal (GI) decontamination following a toxic ingestion. AC is an insoluble, non-absorbable, inert, fine carbon powder produced by the pyrolysis of organic material and then treated with steam and acid. AC has an extensive network of carbon moieties (e.g., carbonyl, hydroxyl) that are capable of binding (adsorbing) and trapping chemicals within minutes of contact, thereby preventing intestinal absorption and subsequent toxicity. The recommended dose of activated charcoal is 1 g/kg of the patient's total body weight. An AC-to-intoxicant weight ratio of at least 10:1 is desirable. The usual single adult dose is 25 to 100 g mixed with water and administered as a slurry by mouth or nasogastric tube. Doses larger than 100 g are not recommended in obtunded patients due to the increased risk of vomiting and aspiration. The commercial product should be vigorously shaken prior to administration to resuspend all AC. If available, superactivated charcoal may be preferable in massive ingestions because it allows smaller but equally effective doses to be administered. Pooled data from controlled human volunteer studies reveal that mean drug absorption is reduced by 52%, 38%, 34%, and 21% when AC is given at 30, 60, 120, and 180 minutes, respectively. AC is absolutely contraindicated in patients with bowel obstruction or perforation and those with an unprotected airway. AC should not be given to patients with a depressed level of consciousness until the airway is secured by tracheal intubation.

During surgical repair of a detached retina, 1 mL of sulfur hexafluoride is injected into the posterior chamber. If the patient is receiving 4% desflurane and a 2:1 ratio of N2O and O2, the pressure-volume relationship of the bubble will approximately:

a. decrease by one third

b. remain the same

c. double

d. triple

triple

A sulfur hexafluoride gas bubble is sometimes used to support the retina after detachment. Diffusion of nitrous oxide into the bubble will cause expansion as nitrous oxide equilibrates with the gas bubble. A sixty-seven percent nitrous oxide concentration will cause the bubble to triple in its pressure-volume relationship in about 30 minutes and may double the intraocular pressure (IOP). In addition, when nitrous oxide is discontinued, the bubble will return to normal size, causing a fall in IOP and possible extension of the retinal tear. For these reasons, it is recommended that nitrous oxide be discontinued at least 15 minutes prior to the injection of a posterior chamber bubble.

pg. 762

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

At approximately what level or above will a patient with spinal cord injury be at GREATEST risk for autonomic hyperreflexia?

a. C8

b. T4

c. T7

d. T10

c. T7

A spinal cord injury at or above T7 (T5-T8, depending on reference) predisposes a patient to autonomic hyperreflexia. Autonomic hyperreflexia is typically first seen within four to six months of spinal cord injury and can continue to occur for years. With a stimulus below the level of the spinal cord injury lesion, intact lower motor neurons send an impulse up the spinal cord. However, this impulse is interrupted at the site of the spinal cord injury and unable to reach the cerebral cortex. This leads to an impaired feedback loop. However, the ascending signal reaches the thoracic sympathetic splanchnic nerves resulting in hypertension. This hypertension is recognized by the carotid sinus and aortic arch baroreceptors leading to a parasympathetic reflexive bradycardic response via the vagus nerve. No autonomic nervous system changes occur below the level of spinal cord injury since these signal pathways are also interrupted.

Which muscle is the only abductor of the vocal cords?

a. Cricothyroid muscle

b. Thyroarytenoid muscle

c. Posterior cricoarytenoid muscle

d. Lateral cricoarytenoid muscle

This is a challenging question that few people answer correctly! Most anesthesiologists do not understand the muscles anatomy of the larynx. The only abductor ("opener") of the vocal cords is the posterior cricoarytenoid muscle. All muscles of the larynx apart from the cricothyroid muscle are innervated by the recurrent laryngeal nerve; therefore, the only abductor muscle of the vocal cords is innervated by the recurrent laryngeal nerve. If both recurrent laryngeal nerves were severed during an operation such as a thyroidectomy, you would expect severe airway obstruction.

Correct statements regarding cerebral metabolism include:

a. the brain can only utilize glucose as an energy source

b. forty percent of brain glucose consumption is anaerobically metabolized

c. hyperglycemia can reduce the damage from focal hypoxic injury

d. the adult brain consumes approximately 50 ml/min of oxygen

d. the adult brain consumes approximately 50 ml/min of oxygen

(The adult brain consumes about 20% of the total body oxygen (50 ml/min). Neuronal cells normally utilize glucose as their energy source, but can also utilize ketone bodies and lactate. Hyperglycemia has been shown to worsen global and focal hypoxic brain injury.)

Which nerve provides sensory innervation to the base of the tongue, epiglottis, aryepiglottic folds, and arytenoids?

a. Internal branch of superior laryngeal nerve

b. Recurrent laryngeal nerve

c. External branch of superior laryngeal nerve

d. Glossopharyngeal nerve

a. internal branch of the superior laryngeal

nerve provides sensory innervation to the larynx above the level of the vocal cords. The superior laryngeal nerve is a branch of the vagus nerve. The glossopharyngeal nerve provides sensory innervation to the pharynx. The recurrent laryngeal nerve provides sensory innervation to the larynx below the level of the vocal cords. The recurrent laryngeal nerve is a branch of the vagus nerve.

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include:

a. a nitroglycerine infusion

b. inotropic support

c. afterload reduction

d. maintenance of adequate preload

d. (maintenance of adequate preload

In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable.

pp. 1083-1084

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

You have designed a study that compares average postoperative opioid consumption after three different anesthetic techniques. After informed consent, 120 patients undergoing total knee arthroplasty will be randomly assigned to one of the three groups. Which of the following statistical tests can be BEST used to compare the means of three groups?

a. Chi-square

b. One-way ANOVA

c. Paired t-test

d. Unpaired t-test

One-Way Analysis of Variance (ANOVA)

simultaneously compares the differences among population means of more than two independent groups for a one-factor experiment. Chi-square test for categorical variables determines whether there is a difference in the population proportions between two or more groups. The unpaired t-test compares the population means between two independent (and normally distributed) groups. The paired t-test examines repeated measurements obtained from the same set of individuals. The objective of the analysis is to show that any differences between two measurements of the same individuals are due to different treatment conditions. This approach is based on the theory that the same individuals will behave alike if they are treated alike and is frequently used in crossover studies.

Which of the following symptoms would be MOST expected in a 64-year-old man with an acute right anterior cerebral artery (ACA) stroke?

a. Left leg weakness ****

b. Left hand weakness

c. Left CN VII palsy

d. Hoarseness

a. Left leg weakness

The left and right anterior cerebral arteries (ACA) supply blood to most medial portions of the frontal lobes and superior medial parietal lobes. This portion of the brain supplies innervation primarily to the lower extremities, most of the corpus callosum, the anterior portions of the basal ganglia and internal capsule, and the olfactory bulb and tract. Thus, patients with an acute ACA stroke classically present with hemiparesis or hemiplegia of the contralateral lower limbs and pelvic floor musculature. Patients may also develop an apraxia (secondary to involvement of the corpus callosum), anosmia (secondary to involvement of the olfactory bulb and tract), and urinary incontinence

Venous irritation associated with the injection of diazepam and lorazepam is secondary to:

a. the high degree of water solubility of these agents

b. the presence of propylene glycol as a solvent

c. the presence of metabisulfite as a preservative

d. the low pH of these agents

b. the presence of propylene glycol as a solvent

The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation.

pg. 488

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Which of the following positions is associated with the LOWEST risk of ventilator associated pneumonia?

a. Prone

b. Supine head up

c. Supine head down

d. Supine flat

b. Supine head up

In a retrospective review of 109 mechanically ventilated patients, Kollef found an increased risk of pneumonia in supine patients (adjusted odds ratio 2.9). A randomized trial of 50 patients suggested that gastroesophageal reflux (detected with scintigraphy) was more likely in supine patients as compared to semi-recumbent. Another randomized controlled trial of semi-recumbent versus supine positioning in mechanically ventilated patients was stopped early because of an increased risk of both clinically suspected (34% vs. 8%, p = 0.003) and microbiologically confirmed (23% vs. 5%, p = 0.016) pneumonia in supine patients

Topically applied ophthalmic medications are absorbed:

a. as quickly as intravenous administration

b. more quickly than subcutaneous administration

c. only minutely, with insignificant clinical effect

d. directly into the central nervous system through the optic nerve foramen

B (more quickly than subcutaneous administration

Topically applied ophthalmic medications are absorbed at a rate intermediate between intravenous and subcutaneous injection. Children and the elderly are at particular risk for the toxic effects of topically applied medications.

pg. 762

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

A 70-year-old man is undergoing a left hip hemiarthroplasty for a hip fracture. As the prosthesis is cemented in place, his blood pressure decreases to 70/50 mmHg, his end tidal CO2 decreases from 35 mmHg to 16 mmHg, and his SpO2 decreases from 99% to 88%. Which of the following is the MOST likely explanation for these hemodynamic changes?

a. Anaphylaxis

b. Fat emboli

c. Mucous plug

d. Myocardial ischemia

b. fat emboli

Patients undergoing hip surgery with bone reaming and cementation of prosthesis are at risk for bone cement implantation syndrome. There is no formal definition but its clinical features include hypoxia and hypotension in mild forms and in more severe presentations it may include progression to cardiac arrhythmias, increased pulmonary vascular resistance and cardiac arrest. The process of reaming and cementation allows excessively high intramedullary pressures to develop, and this may produce embolization of cement particles, bone marrow and bone particles, air, clot and/or fat. The clinical presentation appears just like a pulmonary embolus, with hypotension, hypoxia, reduction in end tidal CO2 early in the course of the embolus.

A 65-year-old woman with severe mitral regurgitation presents for mitral valve repair. She develops hypotension after the induction of general anesthesia. Vital signs include BP 78/40 mmHg, HR 84 bpm, and SpO2 98%. Which of the following drugs will MOST effectively treat her hypotension without worsening her mitral regurgitation?

a. Ephedrine

b. Atropine

c. Vasopressin

d. Phenylephrine

a. Ephedrine

Hemodynamic goals for patients with mitral regurgitation include maintenance of sinus rhythm and a relative tachycardia in order to minimize regurgitation. Interventions that increase left ventricular afterload should be avoided in order to promote forward systemic cardiac output and reduce mitral regurgitation. Preload should be judiciously maintained but arbitrary fluid boluses should be avoided as excessive volume administration can worsen ventricular distention and mitral regurgitation. Left ventricular contractility should be maintained. Mitral regurgitation may occur as a result of chronic coronary artery disease and ischemia of the left ventricle, in addition to papillary muscle dysfunction due to ischemia. There are two papillary muscles in the left ventricle that connect the left ventricular walls to the mitral valve apparatus via the chordae tendinae. The posterior papillary muscle derives its blood supply from the posterior descending artery and the anterior papillary muscle receives blood supply from both the left anterior descending artery and the circumflex coronary artery. Thus, the posterior papillary muscle is most vulnerable to ischemia. With ischemia of the inferior left ventricular wall due to occlusion of the posterior descending artery, the posterior papillary muscle becomes dysfunctional. If the ischemia continues, the posterior papillary muscle may rupture, ultimately leading to acute mitral regurgitation. ​

Ulnar nerve injury:

a. results in wrist drop and loss of sensation in the web space between the thumb and index finger

b. occurs more frequently in males

c. manifests itself in the immediate postoperative period

d. is most commonly seen in the patient with a BMI of less than 18

response is incorrect.

b. occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:

1) male sex - various reports suggest that 70 - 90% of patients with postoperative ulnar neuropathy are men

2) high body mass index - BMI > or = 38

3) prolonged postoperative bed rest.

Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury.

pp. 809-810

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

What features BEST distinguish heparin induced thrombocytopenia and thrombocytopenia induced by other drugs?

a. Drug induced thrombocytopenia results in mild thrombocytopenia

b. Heparin induced thrombocytopenia results in severe thrombocytopenia with mucocutaneous bleeding

c. Drug induced thrombocytopenia results in significant arterial thrombosis

d. Heparin induced thrombocytopenia results in moderate thrombocytopenia with venous thrombosis

d. Heparin induced thrombocytopenia results in moderate thrombocytopenia with venous thrombosis

Drug induced thrombocytopenia (from drugs like quinine or vancomycin) results in severe levels of thrombocytopenia, on the order of 10 X 10^9. Mucocutaneous bleeding is a commonly observed feature. In contrast, heparin induced thrombocytopenia results in mild-moderate thrombocytopenia with platelet counts around 50-60 X 10^9 and coexistent thrombosis

The timing of heparin induced thrombocytopenia is BEST described by which of the following?

a. Immediate upon heparin administration

b. Within 24 hours of heparin administration

c. From 5 to 14 days after heparin administration

d. Greater than 2 weeks after heparin administration

c. From 5 to 14 days after heparin administration

Approximately 70% of the cases of heparin induced thrombocytopenia occur between 5 days to 2 weeks after heparin administration. Rapid onset (within 24 hours of heparin administration) and delayed onset are both comparatively rare.

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to:

a. 0.5 ppm

b. 5 ppm

c. 25 ppm

d. 50 ppm

c (25 ppm

NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used).

pp. 652-654

Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Terbutaline is often administered to treat preterm labor or to stop tetanic uterine contractions that interfere with fetal oxygenation. Which of the following is MOST likely a maternal side effect of terbutaline administered under these circumstances?

​

A. ​Bradycardia

​B. ​Hypokalemia

​C. ​Hypoglycemia

​D. ​Hypertension

Terbutaline is a beta-adrenergic receptor agonist. Its maternal side effects can be categorized as follows: (1) Cardiopulmonary (pulmonary edema, myocardial ischemia, hypotension, tachycardia); (2) Metabolic (hyperglycemia, hyperinsulinemia, hypokalemia, antidiuresis, altered thyroid function) and; (3) others (tremors, palpitations, nervousness, N/V, fever, hallucinations). The fetal side effects include tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, and myocardial ischemia. Potential neonatal side effects include: tachycardia, hypoglycemia, hypocalcemia, hyperbilirubinemia, hypotension, intraventricular hemorrhage. Contraindications to terbutaline administration in the parturient include: maternal cardiac dysrhythmias, poorly controlled DM, and poorly controlled thyroid disease.

​Concerning preoperative informed consent:

a. it should disclose only life-threatening complications

b. charges of assault and battery are possible if it is not obtained

c. oral consent is insufficient

d. it is not necessary if the procedure is done in an office setting

charges of assault and battery are possible if it is not obtained

Any procedure performed without the patient's consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.

pp. 29-30

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.​

​Magnesium sulfate therapy is the gold standard for seizure prophylaxis in the setting of preeclampsia. Which of the following is the MOST likely side effect of magnesium?

a. Decreased motor endplate sensitivity to acetylcholine

b. Development of coagulopathy

c. Increased systemic vascular resistance

d. Inhibition of acetylcholinesterase

​

a. Decreased motor endplate sensitivity to acetylcholine

Magnesium is a divalent cation that competes with calcium and inhibits many calcium-dependent processes. With regard to muscle relaxation, it is known to: (1) antagonize calcium either at the motor end plate or cell membrane, reducing calcium influx into the myocyte; (2) Compete with calcium for low-affinity calcium binding sites on the outside of the SR membrane and prevent the rise in free intracellular calcium concentration; and (3) Attenuate the: release of acetylcholine at neuromuscular junction, sensitivity of the motor endplate to acetylcholine, and excitability of the muscle membrane. Implications for and potential interactions with anesthesia care are many. Magnesium may increase the likelihood of hypotension with epidural use (studies with gravid ewes demonstrated reduced maternal MAP, but not uterine blood flow or fetal oxygenation during epidural). Magnesium can potentiate the effects of both depolarizing and non-depolarizing muscle relaxants (probably not as much with depolarizing), increasing potency and duration (clinically it is still advised to use the same intubating dose as potentiation can be variable; and smaller maintenance doses). Magnesium can trigger hypotension, especially with concurrent use calcium entry-blocking agents (nifedipine). Sedation is very commonplace with therapeutic levels of serum magnesium; a 20% decrease in MAC can be seen with serum magnesium levels 7-11 mg/dL Magnesium can hypothetically affect any calcium-dependent process, but inhibition of coagulation due specifically to isolated magnesium use is not thought to be clinically significant.

Correct statements concerning the use of benzodiazepines in the elderly include:

a. volume of distribution is increased

b. reduced pharmacodynamic sensitivity is observed

c. the elimination half-life of diazepam, but not midazolam, is increased

d. all of the above

a (volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased.

pg. 895

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

30-year-old woman undergoes a right frontal craniotomy for resection of a low grade glioma. She is given dexamethasone and levetiracetam. Mannitol (1 g/kg) and hyperventilation are used to provide brain bulk reduction. Her sodium drops acutely from 139 meq/L preoperatively to 125 meq/L intraoperatively. Serum osmolality is 310. What is the MOST appropriate management?

a. Conivaptan

b. Furosemide diuresis

c. Hypertonic saline

d. No intervention is required

d. No intervention is required

The administration of mannitol results in the shift of water from the intracellular compartments (and to a small degree from the extracellular fluid compartment) into the intravascular compartment. The resulting rapid expansion of the intravascular water can result in hyponatremia and hypokalemia. In this case, blood osmolality is 310 mOsm supporting the diagnosis of dilutional hyponatremia resulting mannitol. This will resolve when the mannitol clears.

In the midesophageal long axis view at approximately 110-130 degree multiplane angle, which of the left ventricular walls can be BEST assessed for function and regional wall motion abnormalities?

a. Anteroseptal and inferolateral

b. Anterior and lateral

c. Inferior and apical

d. Anterolateral and posteroseptal

The aortic valve is an anterior structure and the left ventricular wall seen closest to the aortic valve is anterior in location. In the midesophageal long axis view at about 120 degrees, part of the right ventricle is seen as well thus the wall closest to the aortic valve is the anteroseptal wall (on the same side as the aortic valve and LVOT). The wall opposite of this in this view is the inferolateral LV wall.

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:

a. 20 cmH2O

b. 50 cmH2O

c. 25 psi

d. 50 psi

d (50 psi

After proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi.

pg. 1237

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of:

a. midazolam

b. rocuronium

c. fentanyl

d. succinylcholine

c (fentanyl

Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug.

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pg. 185

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Which of the following is LEAST likely to be observed in an infant presenting with pyloric stenosis?

a. Hypernatremia

b. Hypochloremia

c. Hypokalemia

d. Metabolic alkalosis

d. Metabolic alkalosis

In pyloric stenosis, the loss of gastric acid leads to a metabolic alkalosis and depletion of sodium, potassium, and chloride. Hypernatremia is not typically observed.

A baby is born at 39 weeks gestation with congenital diaphragmatic hernia. The baby is cyanotic and limp. He has a slow, irregular respiratory pattern and appears to be grimacing. His heart rate is 120 bpm at the one-minute of life. Which APGAR score correctly corresponds with these findings?

a. 3

b. 4

c. 5

d. 6

b. 4

APGAR stands for Appearance, Pulse, Grimace, Activity, and Respirations. Each of the 5 signs is assigned a value from 0 to 2 with a total greater than 7 considered normal. In this question, the baby is cyanotic with a pulse greater than 100, he is grimacing, he has no tone, and he has irregular respirations.

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of:

a. isoflurane

b. sevoflurane

c. desflurane

d. nitrous oxide

c (desflurane

Volatile agents decrease the nondepolarizer dosage requirements. The degree of the augmentation of blockade depends on the inhalational agent, with desflurane > sevoflurane > isoflurane > nitrous oxide.

pg. 213

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

portal hypertension is defined as sustained portal vein pressure greater than:

a. 5 mm Hg

b. 10 mm Hg

c. 20 mm Hg

d. 25 mm Hg

a (5 mm Hg

Portal hypertension is defined as a sustained portal vein pressure of 5 mm Hg or greater above hepatic vein pressure. This leads to the formation of portal-systemic collateral venous channels.

pg. 1299

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.)

The highest incidence of muscle pain following the use of succinylcholine is seen in:

a. infants

b. octogenarians

c. outpatients

d. pregnant patients

outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

pg. 532

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:

a. 20 - 30 mm Hg

b. 35 - 45 mm Hg

c. 50 - 60 mm Hg

d. 90 - 100 mm

50 - 60 mm Hg

Healthy young individuals tolerate mean arterial pressures as low as 50 - 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 - 30% below baseline.

pg. 262

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

a. internal laryngeal nerve

b. external laryngeal nerve

c. recurrent laryngeal nerve

d. glossopharyngeal nerve

recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea.

pg. 310

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of:

a. isoflurane

b. desflurane

c. sevoflurane

d. nitrous oxide

d (nitrous oxide

By irreversibly oxidizing the cobalt atom in vitamin B12, nitrous oxide inhibits vitamin B12 dependent enzymes. These enzymes include methionine synthetase and thymidylate synthetase. As a result of these enzyme inhibitions, prolonged exposure to nitrous oxide has been associated with bone marrow depression, megaloblastic anemia, peripheral neuropathy and teratogenicity.

pg. 471

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

A 4-year-old boy presents with the acute onset of inspiratory stridor and a barking cough after waking in the middle of the night. The child is febrile, sounds noticeably hoarse, and cries loudly when handled by medical personnel. The patient's parents report that the child has had a "cold for a couple of days." What is the MOST likely infectious etiology of this child's disease?

a. Haemophilus influenzae

b. Influenza A

c. Parainfluenza virus

d. Streptococcus pyogenes

Parainfluenza virus

This patient has croup, which is caused by the Parainfluenza virus about 75% of the time. Epiglottis, typically associated with Haemophilus influenzae, type B, is not typically characterized by a barking cough. Classically, patients are anxious, toxic, and have severe dyspnea

Basal metabolic oxygen consumption in a 20-kg patient is approximately:

95 ml/min

(Basal metabolic oxygen consumption can be estimated using the following formula:

VO2 = 10*Kg^3/4

pg. 175

Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.)

The administration of propofol (2 mg/kg) to an otherwise healthy adult for the induction of anesthesia is most commonly associated with which one of the following hemodynamic changes?

a. Decreased afterload

b. Decreased contractility

c. Decreased heart rate

d. Decreased preload

decreased afterload,

The administration of propofol is associated with dose-dependent decreases in afterload, with possible decreases in contractility at high doses (although some studies suggest that within the range commonly used, myocardial function is preserved). Preload is also decreased; however, decreases in afterload are thought to be more important.

Physiologic derangements seen in the patient with scleroderma include: (Select 3)

a. pulmonary hypertension

b. esophageal dysmotility

c. excessive oral secretions and salivation

d. myocardial fibrosis

e. hypotension

f. spastic quadraparesis

a, b, d (pulmonary hypertension, esophageal dysmotility, myocardial fibrosis

(Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs. Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration. Systemic hypertension from renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement.

pg. 636

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

During the transfusion of one unit of FFP, an 8-year-old girl develops severe systemic hypotension, bronchospasm, and urticaria. Which of the following diseases would be MOST likely the cause of this reaction?

a. Celiac disease

b. Cystic fibrosis

c. Hemophilia A

d. Selective IgA deficiency

selective IgA deficiency

Patients with selective IgA deficiency may present with severe reactions including anaphylaxis to blood transfusions or intravenous immunoglobulin due to the presence of IgA in these blood products. Selective IgA deficiency is the single most common cause of anaphylaxis after transfusion

The maximum recommended occupational whole-body exposure to radiation is:

a. 1 rem/year

b. 5 rem/year

c. 10 rem/year

d. 20 rem/year

5 rem/year

The intraoperative use of imaging equipment exposes anesthesia providers to ionizing radiation. The maximum recommended whole-body exposure to radiation is 5 rem/year.

pg. 65

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Examples of Type IV hypersensitivity reactions include:

a. contact dermatitis

b. hemolytic transfusion reactions

c. anaphylaxis

d. angioedema

a (contact dermatitis

Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis.

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pg. 292

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.)

Negative consequences of positive pressure ventilation for patients with pericardial tamponade include which of the following?

a. Increased right ventricular preload

b. Increased systemic vascular resistance leading to an increase in myocardial oxygen consumption

c. Increased left ventricular filling due to interventricular septal shift

d. Increased pulmonary vascular resistance due to increased airway pressures

Increased pulmonary vascular resistance due to increased airway pressures

Average blood loss during a vaginal delivery is:

a. 100 - 200 ml

b. 400 - 500 ml

c. 700 - 800 ml

d. 1000 - 1500 ml

b (400 - 500 ml

At term, blood volume has increased by 1000 - 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 - 500 ml, compared with 800 - 1000 ml for cesarean section.

pg. 827

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Nerves blocked with a fascia iliaca block include the:

a. sciatic nerve

b. femoral nerve

c. pudendal nerves

d. anterior tibial nerve

a (femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

pp. 1003-1004

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Sickle hemoglobin: (Select 2)

a. has a lower P50 than hemoglobin A

b. releases oxygen less readily than hemoglobin A

c. is present in about 30% of African Americans

d. readily polymerizes and precipitates in the red cell

e. results from a single amino acid substitution on the α-chain

f. has decreased solubility as compared to hemoglobin A

d, f (readily polymerizes and precipitates in the red cell,

has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50 (31 mm Hg) [decreased affinity] as compared to hemoglobin A (27 mm Hg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the β-chain.

pg. 1177

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

Laminar flow in the airway occurs in the: (Select 2)

a. trachea

b. main stem bronchi

c. terminal bronchiole

d. 3rd generation bronchus

e. respiratory bronchioles

C, E (terminal bronchiole, respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow.

pp. 498-499

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

After inducing general anesthesia, a morbidly obese patient is intubated and ventilated with volume-control ventilation in the supine position with 8 cc/kg tidal volume. Which of the following would you MOST expect from this ventilation strategy?

a. Decreased pulmonary vascular resistance

b. Decreased ventilation of nondependent alveoli

c. Increased ventilation of nondependent alveoli

d. Increased perfusion of nondependent alveoli

Increased ventilation of nondependent alveoli

In the upright position with spontaneous ventilation in normal patients, ventilation and perfusion will be as normally matched as possible, with most ventilation and perfusion in the lung bases or dependent portions of the lungs. After induction of general anesthesia, neuromuscular relaxation and supine positioning, functional residual capacity decreases and ventilation becomes distributed to the more nondependent alveoli whereas perfusion is maintained in the dependent areas of the lung. The effect is exaggerated in obese patients.

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

a. increased carbon dioxide levels

b. increased 2,3-DPG levels

c. increased pH

d. the presence of fetal hemoglobin

e. increased body temperature

f. the presence of hemoglobin-S

increased pH, presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus.

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pp. 603-604

Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The addition of bicarbonate to a local anesthetic solution:

a. delays the onset of blockade

b. increases the concentration of the nonionic form of the local anesthetic

c. causes a fall in the pH of the solution

d. should only be done when using bupivacaine

increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on the penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8.

pg. 963

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Fondaparinux achieves its anticoagulant effect through:

a. factor Xa inhibition

b. activation of antithombin III

c. direct thrombin inhibition

d. inhibition of vitamin K-dependent coagulation factor production

a. factor Xa inhibition

(Fondaparinux is a factor Xa inhibitor. No reversal agent is available if emergency surgery is necessary.

pp. 439-440

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 201)

Which of the following is NOT an absolute contraindications to Ramipril?

a. Hereditary angioedema

b. Pregnancy

c. Renal artery stenosis

d. Sulfonamide allergy

d. Sulfonamide allergy

(

Ramipril is an ACE-inhibitor (ACE-I). ACE-Is are contraindicated in patients with a history of angioneurotic edema, even if angioedema is not due to an ACE-I or C1 esterase deficiency. The use of ACE-Is during pregnancy is associated with serious complications in the fetus, including congenital malformations and intrauterine fetal demise. Patients with renal artery stenosis can develop serious hypotension when treated with an ACE-I. While captopril contains a sulfhydryl group, there is not thought to be cross-reactivity with sulfonamides. Regardless, ramipril may be safely administered to patients with a history of allergy to sulfonamides.)

3 month-old infant presents to the hospital febrile, lethargic, and tachypneic. Upon questioning, the infant's parents indicate that the infant had been treated for colic with a combination of aspirin and a bismuth subsalicylate solution for the past several weeks. Salicylate toxicity is suspected. An arterial blood gas would MOST likely show which of the following abnormalities?

a. Primary metabolic acidosis with respiratory compensation

b. Primary metabolic alkalosis with respiratory compensation

c. Primary respiratory acidosis with metabolic compensation

d. Primary respiratory alkalosis with metabolic compensation

a. (Primary metabolic acidosis with respiratory compensation

This infant is suffering from severe salicylate toxicity. Patients taking large doses of bismuth subsalicylate solutions often do not realize that these drugs contain high concentrations of salicylate. Bismuth subsalicylate has an aspirin equivalency conversion factor of 0.479 (approximately half the strength of aspirin). Salicylate toxicity occurs as a result of salicylate's interference with both Kreb's cycle enzymes and, at high level, uncoupling of oxidative phosphorylation. This results in a primary metabolic acidosis, to which most patients will develop a respiratory compensation.)

Which nerve innervates the only abductor muscle of the vocal cords?

a.Internal branch of superior laryngeal nerve

b. Recurrent laryngeal nerve

c. External branch of superior laryngeal nerve

d. Glossopharyngeal nerve

b. (Recurrent laryngeal nerve

The only abductor of the vocal cords is the posterior cricoarytenoid muscle. All muscles of the larynx apart from the cricothyroid muscle are innervated by the recurrent laryngeal nerve. Therefore, the only abductor muscle of the vocal cords is innervated by the recurrent laryngeal nerve. If both recurrent laryngeal nerves were severed during an operation such as a thyroidectomy, you would expect severe airway obstruction.)

A fresh E-cylinder of oxygen:

a.contains more liters of gas than an E-cylinder of nitrous oxide

b. contains about 90% liquid oxygen and 10% oxygen as a gas

c. contains about 660 liters of oxygen

d. has a lower pressure than the pipeline oxygen supply

c (contains about 660 liters of oxygen

A fresh E-cylinder of oxygen contains about 660 liters of oxygen and is pressurized to 1900 psi.

pg. 8

Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.)

Which of the following statements regarding the pharmacology of heparin is MOST correct?

a. Warfarin increases the synthesis of endogenous heparin

b. Low Molecular Weight Heparin preferentially inhibits Factor Xa

c. Heparin is a highly sulfated protein molecule with negative charge

d. Protamine reverses heparin action as a competitive antagonist on the receptor binding site

b. (Low Molecular Weight Heparin preferentially inhibits Factor Xa

Heparin is a carbohydrate containing glucuronic acid residues. It has negatively charged sulfate groups "two per uronic acid residue"making it one of the strongest acids found in living things. The major inhibitor of thrombin, factors IXa, and factor Xa is AT III. UFH accelerates the formation of the thrombin-AT complex by 2000-fold and accelerates formation of the factor Xa-AT complex by 1200-fold. In contrast, LMWH fragments preferentially inhibit factor Xa. Protamine is a positively charged polypeptide that combines with the negatively charged heparin to form stable complexes resulting in neutralization of heparin activity. Warfarin acts as an anticoagulant by inhibiting vitamin K epoxide reductase.)

The elimination half-life of intravenously administered oxytocin in the parturient is approximately:

a. 30 to 120 seconds

b. 3 to 5 minutes

c. 10 to 15 minutes

d. 20 to 30 minutes

b (3 to 5 minutes

Both endogenous and intravenously administered oxytocin have short elimination half-lives of about 3 to 5 minutes. As a result, oxytocin must be administered as a continuous infusion for the induction of labor.

pg. 835

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

The criteria for systemic inflammatory response syndrome includes which of the following parameters?

a. Temperature, blood pressure, respiratory rate or PaCO2, white blood cell count

b. Temperature, heart rate, respiratory rate or PaCO2, urine output

c. Temperature, heart rate, respiratory rate or PaCO2, white blood cell count

d. Temperature, blood pressure, respiratory rate or PaCO2, urine output

c. (Temperature, heart rate, respiratory rate or PaCO2, white blood cell count

The systemic inflammatory response syndrome is defined by the presence of 2 or more of the following parameters: body temperature greater than 38°C or less than 36°C, heart rate greater than 90 bpm, respiratory rate greater than 20 breaths per min or PaCO2 less than 32 mmHg, and leukocytosis greater than 12,000/mm3 or less than 4000/mm3.)

In the fetus, the percentage of cardiac output directed to the placenta is approximately:

a. 10%

b. 25%

c. 50%

d. 100%

c. (50%

In the fetus, the lungs receive little blood flow. The placenta receives nearly one-half of the fetal cardiac output and is responsible for respiratory gas exchange.

pg. 836

Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.)

FOUR DAYS AFTER AN URETERAL STENT PLACEMENT, AN 87-YEAR-OLD WOMAN BECOMES INCREASINGLY CONFUSED. VITAL SIGNS INCLUDE T 38.9°C, BP 100/60 MMHG (MAP 73), HR 103 BPM, RESPIRATORY RATE 16 /MIN, SPO2 96% ON ROOM AIR. WHITE BLOOD CELL COUNT IS 16,000 ΜL-1, CREATININE IS 2.2 MG/DL (UP FROM 0.8 MG/DL BASELINE), AND LACTATE IS 3 MMOL/L. URINALYSIS SHOWS LEUKOCYTES AND POSITIVE NITRITE; A URINE CULTURE IS PENDING. WHICH OF THE FOLLOWING IS THIS PATIENT'S MOST APPROPRIATE SEPSIS CLASSIFICATION?

a. Sepsis

b. Severe sepsis

c. Sepsis-induced hypotension

d. Septic shock

b. Severe sepsis

(

According to the 2012 International Guidelines for Management of Severe Sepsis and Septic Shock, sepsis is defined as the probable or known presence of an infection together with systemic manifestations of infection. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion. Sepsis-induced hypotension is defined as a systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mmHg or systolic blood pressure decrease > 40 mmHg or less than two standard deviations below normal for age in the absence of other causes of hypotension. Septic shock is sepsis-induced hypotension that persists despite adequate fluid resuscitation. Any of the following signs of organ dysfunction or tissue hypoperfusion thought to be due to the infection would lead to a severe sepsis classification: Sepsis-induced hypotension Lactate above upper limits laboratory normal Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source Creatinine > 2.0 mg/dL (176.8 μmol/L) Bilirubin > 2 mg/dL (34.2 μmol/L) Platelet count < 100,000 μL Coagulopathy (international normalized ratio > 1.5)

At the neuromuscular junction, acetylcholine receptor binding sites are found on the:

a. α-subunits

b. β-subunits

c. δ-subunits

d. ε -subunits

a. (α-subunits

Each acetylcholine (ACh) receptor in the neuromuscular junction consists of 5 protein subunits. Only the α-subunits are capable of binding ACh molecules. If both binding sites are occupied, the channel briefly opens. The α-subunits are also the site of action of neuromuscular blockers.

pg. 527

Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013)