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Anaesthesia Mccqe Review

This upload for knowledge refreshing for your preparation, folks!



What is pain?
The conscious experience of an unpleasant
sensory or emotional experience associated with
actual or potential tissue damage.
What is nociception?
the process of neurotransmission, originating from
sensory receptors (nociceptors) which transmits
and processes information related to tissue
damage.
What is hyperalgesia? an exaggerated response to a noxious stimulus.
What is allodynia?
a pain response to a non-noxious stimulus (such as
a gentle touch.)
What is peripheral sensitisation?
sensitization of C & A nociceptors, predominantly
induced by inflammatory mediators released by
tissue damage such that their response threshold is
lowered and/or they produce a greater response to
the same stimulus.
What is central sensitisation?
The enhanced excitability of spinal nociceptive
neurons to result in a hypersensitive and
hyperactive nociceptive transmission system. Can
be short lived, associated with transient changes in
neurotransmitter activity, or long-lived, associated
with phenotypic changes in these central neurons.
What is analgesia? The absence of pain sensation.
What is distress? Physical and emotional / mental strain or stress.
What is somatic pain?
Somatic pain is easily localized and so often
described as acute, aching, stabbing or throbbing.
Somatic pain includes cutaneous pain after an
operation. Somatic pain can be further classified as
superficial (skin) or deep (joints, muscle, or
periosteum) in origin.
What is peripheral pain?
Either visceral (thoracic/abdominal) or somatic
(joints, muscles, or periosteum.) Visceral pain is
poorly localized and frequently described as
cramping or gnawing. May be also reffered pain to
cutaneous sites far from site of injury.
What is neuropathic pain?
The result of trauma, inflammation, or sensitization
of peripheral nerves or spinal cord. Neuropathic
pain is described as burning, lacerating, and
intermittent, and is often poorly responsive to
treatment.
What is idiopathic pain?
Persistent pain in the absence of an identifiable
organic substrate. Idiopathic pain is often excessive
and associated with emotional stress or behavioral
abnormalities.
What are the physiological signs of pain?
Inc blood pressure, inc heart rate, inc peripheral
vasoconstriction - identifiable by pale mucus
membranes, inc respiratory rate, possible muscle
splinting, inc catabolic processing, dec food / water
intake, dec voiding
What is multimodal analgesia?
The simultaneous administration of a combination
of analgesic agents (opiods, NSAIDs, and alpha2-
agonists) with different modes of action and
different side effects which may act synergistically
and achieve optimal analgesia with less risk/side
effects than large doses of a single drug.
What is pre-emptive analgesia?
Administration of an analgesic agent prior to
noxious stimulation.
How do anaesthetics affect fluid deficits?
"Decompensate" - ie, incapacitate compensatory
mechanisms, depress cardiac output, derange
blood-gases, exacerbate pH changes, impair renal
function, increase respiratory water losses (low
FiH2O); also, surgery imposed H2O deprivation,
3rd space losses, gross haemorrhage, evaporation
from wound, blood sequestration in tissues then
removed (ex spay), urinary losses.
Define the term: hypotonic. Water lost in excess of electrolytes (pure water).
What are the clinical signs of hypotonic /free water
loss? How can they be corrected?
Skin tenting, tachycardia, hypotension
Succinylcholine
1. Type of agent
2. Mechanism of action
3. Indications
4. Speed of onset and clearance
5. Side effects
6. Contraindications
1. a depolarizing paralytic anesthetic.
2. Binds to muscarinic (organs) and nicotinic
(muscles) receptors, causing depolarization of
muscles (fasciculations) and blocks ACh.
3.RSI, Converting from a laryngeal mask to ETT,
short procedure, Risk of aspiration, laryngospasm.
4. Onset = 30 sec. Duration 5-10min.
5.Malignant hyperthermia. Plasma Cholinesterase
deficiency = paralysis upon waking. Hyperkalemia.
Muscarinic = Bradycardia, dysrythmia, sinus arrest.
Increased ICP, IOP and Gastric pressure.
Fasciculations and post-op myalgia
6. History of MH, PCD. Hyperkalemia, Allergy.
myotonia. Caution in eye injury, myasthenia gravis.
What type of paralytic is succinylcholine? How
does it work?
A depolarizing paralytic. It binds to the nicotinic
receptor, causes prolonged muscle depolarization
and fasciculations then paralyzes the muscle. Then
it remains in the receptor and is slowly degraded.
Not degraded by acetylcholinesterase.
Propofol
1. type of drug
2. Mechanism of action (2)
2. uses (3)
3. Side effects (6)
1. A sedative hypnotic and amnesic with muscle
relaxant properties. It is not an analgesic and thus
fentanyl is also used. It's the white drug.

2. Potentiates GABA and blocks sodium channels.

3. Used for Rapid Sequence Induction RSI,
procedural sedation and as a general anaesthetic.

SIDE EFFECTS
1. Increased ICP,
2. increased IOP,
3. decreased RR,
4. decreased BP,
5. decreased HR
6. Apnea
Midazolam
1. Mechanism of action
2. Uses
3. Side effects
4. Reversal
1. Benzo that potentiates GABA, decreasing CNS
neuron activity. Sedative, hypnotic, anxiolytic and
amnesic properties.
2. Ultra-short acting benzo - used for procedural
sedation, prior to induction
3. Confusion, somnolence, bradycardia,
hypotension
4. Overdose reversed by flumazenil.
How is benzodiazepine overdose treated? Flumazenil
Morphine
1. Mechanism of action
2. Uses
3. Side effects intraoperatively
4. Reversal of overdose
1. binding to and activating the -opioid receptors
in the central nervous system. Endogenous opioids
include endorphins, enkephalins, dynorphins also
bind to the -opioid receptor.
2. Analgesic with long acting properties compared
with fentanyl which is quite short.
3. Hypotension & bradycardia. Also causes nausea
and constipation.
4. Intraoperatively use phenylephrine
(norepinephrine) to increase BP. In overdose use
Narcan (Naloxone) but watch for rebound pain.
Rocuronium
1. Mechanism of action
2. Uses
3. Length of activity
3. Side effects
4. Reversal
1. Non-depolarizing muscle relaxant. Competitively
antagonizes acetylcholine nicotinic receptors and
prevents muscular contraction. Does not cause
fasciculations like succinylcholine.

2. Used as a paralytic and muscle relaxant for
intubation and mechanical ventilation and to
prevent laryngospasm.

3. Takes effect in 1-2 minutes (2-3 x longer than
succ), but can use higher dose for RSI. Lasts
longer - 20-30 minutes.

4. No risk of Malignant hyperthermia. Prolonged
Apnea and paralysis without reversal.

5. Reversed with a Neostigmine and Glycopyrrolate
cocktail.
Sevoflurane
1. Mechanism of action
2. Use
3. Side effects
4. Reversal
1. An ether which is a sedative, hypnotic and
amnesic with mild muscle relaxant properties.
2. Used as an inhaled volatile anesthetic for the
induction and maintenance of general anesthesia.
3. Rare cause of malignant hyperthermia. Apnea.
4. Reversed with high flow O2 to wash out lungs.
Phenylephrine
1. Mechanism of action
2. Use
3. Side effects
1. A vasopressor which is a pure alpha agonist. A
weak form of norepinephrine. Causes constriction
of blood vessels to increase preload without
affecting HR or contractility.
2. Used to increase BP. Increase preload and
afterload.
3. Compensatory decrease in heart rate. Due to the
increased preload and BP, heart slows down.
Ephedrine
1. Mechanism of action
2. Use
3. Side effects
1. Ephedrine is a sympathomimetic amine & weak
form of epinephrine. Vasopressor and inotrope.
Acts on alpha and beta receptors. Causes blood
vessel constriction (alpha = preload and afterload)
and increased cardiac heart rate and contractility
(beta).
2. Used to counteract blood loss and morphine
induced hypotension and bradycardia.
3. Hypertension, arrythmias, confusion and
agitation, sweating.
Neostigmine and Physostigmine
1. Mechanism of action
2. Uses
1. a parasympathomimetic, specifically, a reversible
cholinesterase inhibitor. By interfering with the
breakdown of acetylcholine, neostigmine indirectly
stimulates both nicotinic and muscarinic receptors.
Unlike physostigmine, neostigmine has a
quarternary nitrogen; hence, it is more polar and
does not enter the CNS. its effect on skeletal
muscle is greater than that of physostigmine, and it
can stimulate contractility before it paralyzes.
2. improve muscle tone in people with myasthenia
gravis and routinely, in anesthesia at the end of an
operation, to reverse the effects of non-depolarizing
muscle relaxants such as rocuronium and
vecuronium when preparing to extubate. Used in
combo with glycopyrrolate.
Glycopyrrolate
1. Mechanism of action
2. Uses
1. Muscarinic anticholinergic with no central effects
2. used as a preoperative medication to reduce
salivary, tracheobronchial, and pharyngeal
secretions, as well as decreasing the acidity of
gastric secretion. It is also used in conjunction with
neostigmine, a neuromuscular blocking reversal
agent, to prevent neostigmine's muscarinic effects
such as bradycardia.
Odansatron / Granisetron
1. Mechanism of action
2. Uses
3. Dose
Granisetron is a serotonin 5-HT3 receptor
antagonist that acts at the nausea and vomiting
centre via antagonizing vagus nerve receptors in
the medulla oblongata..

2. Antiemetic
a. Chemotherapy
b. Anaesthetic induced Post-op nausea and
vomiting prophylaxis.
c. Bowel surgery and radiation releases 5HT3 and
it is effective.

3. 1mg IV q8h. Best given intraoperatively 1mg po
bid.
Metochlopramide (Maxaran)
1. Mechanism of action
2. Uses
1. Dopamine antagonist. Powerful antiemetic and
gastric motility agent.
2. Used for post op nausea, chemo induced
nausea and after bowel surgery to promote gut
motility. Also used in combo with Ketorolac
(Toradol) for migraine headaches.
Ketorolac (Toradol)
1. Mechanism of action
2. Uses
3. Contraindications
1. Potent NSAID - can only use for a max of 5
days. Anti-inflammatory, anti-pyretic, analgesic.
competitive blocking of the enzyme
cyclooxygenase (COX). Like most NSAIDs,
ketorolac is a non-selective COX inhibitor.
2. Migraine headaches. Post operative pain.
3. NSAID and ASA allergy. Renal disease
(constricts afferent arteriole).

Name the structures.

Diagram of renal corpuscle structure:

A Renal corpuscle
B Proximal tubule
C Distal convoluted tubule
D Juxtaglomerular apparatus
1. Basement membrane (Basal lamina)
2. Bowman's capsule parietal layer
3. Bowman's capsule visceral layer
3a. Pedicels (podocytes)
3b. Podocyte


4. Bowman's space (urinary space)
5a. Mesangium Intraglomerular cell
5b. Mesangium Extraglomerular cell
6. Granular cells (Juxtaglomerular cells)
7. Macula densa
8. Myocytes (smooth muscle)
9. Afferent arteriole
10. Glomerulus Capillaries
11. Efferent arteriole
Prochlorperazine (Stemetil)
Prochlorperazine (marketed under the names
Compazine, Stemzine, Buccastem, Stemetil and
Phenotil) is a drug that belongs to the
phenothiazine class of antipsychotic agents that
are used for the treatment of nausea and vertigo. It
is also a highly-potent typical antipsychotic, 10 to
20 times more potent than chlorpromazine.
Droperidol
1. Action and use
2. Side effects
1. antidopaminergic drug used as an antiemetic
and antipsychotic.
2. QT prolongation and torsades de pointes. The
evidence for this is disputed, with 9 reported cases
of torsades in 30 years and all of those having
received doses in excess of 5 mg.[3] QT
prolongation is a dose-related effect,[4] and it
appears that droperidol is not a significant risk in
low doses.
Diphenhydramine (Benadryl)
1. Mechanism of action
2. Systemic effects - 2
3. Uses - 3
1. A - Blocks histamine at H1 receptor sites.

2 A - increase of vascular smooth muscle
contraction, thus reducing the redness,
hyperthermia and edema that occurs during an
inflammatory reaction. B - Blocking the H1 receptor
on peripheral nociceptors also decreases
sensitization and reduces itching.

3. A - Antiemetic, nausea and vomiting. B -
Antihistamine for allergic reactions. C -
extrapyramidal side effects of typical
antipsychotics, such as the tremors that haloperidol
can cause.
Hydromorphone (Dilaudid)
1. Mechanism of action
2. Uses
3. Side effects
4. Reversal
1. u-opioid receptor agonist. 5-10 times stronger
than morphine. Where morphine is given in doses
of 5-10mg post-op, hydromorphone is given in
doses of 0.5-2mg.
2. Faster acting than morphine, good for PCA over
several days. Also produces fewer active
metabolites, thus less side effects.
3. Fewer side effects than morphine. Resp
depression, hypotension, Nausea, vomiting,
constipation, sedation, dependece, itching,
redness.
4. Reversed with naloxone (narcan)
Fentanyl
1. Mechanism of action
2. Uses
3. Side effects
4. Dose
1. synthetic primary -opioid agonist. 100 times
more potent than morphine.
2. administered in combination with a
benzodiazepine, such as midazolam, for procedural
sedation, anesthesia and analgesia.
3. Resp depression, hypotension, nausea,
vomiting, itching, redness.
4. Dose - 3-10 ug/kg
Define anesthesia.
Lack of awareness or sensation. Can be a
spectrum from local anaesthesia, conscious
sedation with analgesia to general anesthesia.
Atropine
1. Mechanism of action
2. Uses
3. Side effects
1. Anticholinergic - Competitive antagonist for the
muscarinic acetylcholine receptor.
Lowers parasympathetic activity

2 -
a. Cycloplegic / Mydriatic
b. Bradycardia, asystole and pulseless electrical
activity (PEA) - usual dosage = 0.5 to 1 mg IV push
every three to five minutes
3. Ventricular fibrillation, supraventricular or
ventricular tachycardia, dizziness, nausea, blurred
vision, loss of balance, dilated pupils, photophobia,
and, possibly, notably in the elderly confusion and
delerium.
1. Signs of atropine overdose.
2. Antidote
1. Ventricular fibrillation, supraventricular or
ventricular tachycardia, dizziness, nausea, blurred
vision, loss of balance, dilated pupils, photophobia,
and, possibly, notably in the elderly, extreme
confusion, extreme dissociative hallucinations, and
excitation
2. The antidote to atropine is physostigmine or
pilocarpine.
Preload
1. Define
2. Ways that you can increase preload in
anaesthesia
3. Ways you can decrease preload
1. the pressure stretching the left ventricle after
atrial contraction and passive filling. May also be
called end-diastolic volume.
2. INcreased with epinephrine- ephedrine (a + B
agonist) and norepi - phenylephrine (a agonist).
Increased blood volume.
3. Decreased with PEEP (increased intrathoracic
pressure) + anaesthetics (relax vessels).
Afterload
1. Define
2. Ways that you can increase afterload in
anaesthesia
3. Ways you can decrease afterload.
1. the tension produced by the left ventricle in order
to contract. against systemic resistance.
2. Epinephrine and ephedrine increase preload and
afterload (+ rate + contractility). Phenylephrine
increase preload and afterload. Trendelenberg
position (drop head) increases afterload.
3. Decrease with Nitroglycerine, Nitrates, CCB,
Beta-blockers.
What drugs can be used to alter heart contractility?
1. Increase - ephedrine and epinephrine.
Dopamine, dobutamine, calcium, digoxin
2. Decrease - CCB
What drugs can be used to alter heart rhythm?
1. CCB
2. Digoxin
How do calcium channel blockers work?
Calcium channel blockers work by blocking
voltage-gated calcium channels (VGCCs) in
cardiac muscle and blood vessels. This decreases
intracellular calcium leading to a reduction in
muscle contraction. In the heart, a decrease in
calcium available for each beat results in a
decrease in cardiac contractility. In blood vessels, a
decrease in calcium results in less contraction of
the vascular smooth muscle and therefore an
increase in arterial diameter (CCB's do not work on
venous smooth muscle), a phenomenon called
vasodilation. Vasodilation decreases total
peripheral resistance, while a decrease in cardiac
contractility decreases cardiac output. Since blood
pressure is determined by cardiac output and
peripheral resistance, blood pressure drops.
Digoxin:
Describe the two ways it acts on the heart.
1. A decrease of conduction of electrical impulses
through the AV node, making it a commonly used
antiarrhythmic agent in controlling the heart rate
during atrial fibrillation or atrial flutter.
2. An increase of force of contraction via inhibition
of the Na+/K+ ATPase pump. This results in
increased Ca+ in the sarcoplasmic reticulum. Thus
less frequent and more powerful contractions.
What factors do you want to consider on an
anaesthetic history?
1. Difficult intubation + why
2. Neck or Oralaryngeal trauma
3. Medications and drugs
4. Smoking
5. Post-op nausea and vomiting and history of
motion sickness
6. Allergies to meds and anaesthetics
7. Personal/Family history of Malignant
hyperthermia and Plasma Cholinesteras Deficiency
8. Poor response to codeine - they also won't
respond well to Ketorolac (Tramadol)
What other drug will not work well for a patient with
a history of poor response to codeine?
Ketorolac (Tramadol)
What are the 2 most common reasons for delayed
discharge after surgery?
1. Post-op nausea and vomiting
2. Pain
How common is post-op nausea and vomiting? About 25% of pts.
Which factors predispose to post-op nausea and
vomiting?
Prototype - young female non-smoker with history
of motion sickness who gets opioids
intraopertively.
1. Female
2. Non-smoker
3. History of PONV or motion sickness
4. Opioids
5. Prolonged surgery
When should you consider prophylaxis for nausea
& vomiting (PONV)?

How?
When there are 2 or more risk factors.
1. Female
2. Non-smoker
3. History of PONV, motion sickness
4. Opioids during surgery?

Prophylaxis = Odansitron / Granisetron (5HT3
antagonist), dimenhydramine, droperidol
What intraopertive drugs can increase the risk of
Post-op Nausea Vomiting?
Nitrous oxide, inhaled anaesthetics (sevoflurane
etc.), opioids, neostigmine
What is a 5HT3 antagonist?
Use?
Examples?
1. Antagonize a the 5HT3 subtype of serotonin
receptor found in terminals of the vagus nerve
which stimulates the nausea and vomiting center in
medulla oblongata.
2. Used to control chemo induced N+V and PONV.
3. Odansetron and Granisetron
List 5 side effects that may occur with the
intravenous administration of 1 mg/kg of
succinylcholine. (Do not include malignant
hyperthermia trigger)
Hyperkalemia
Sustained contraction in myotonia
Cholingergic: Sinus bradycardia, increased
secretions
Fasciculations, myalgia
Increased IOP, ICP, intragastric pressure
What 2 structures obstruct the airway in an
unconscious patient who is supine.
Tongue, epiglottis
With just your hands, how should you open the
airway in an unconscious patient who
i) has a suspected C-spine injury

ii) has no suspected C-spine injury.
1. Jaw thrust
2. Sniffing position - Head tilt & Chin lift
List 2 devices that can be placed blindly that can
assist you in opening the airway.
Nasopharyngeal airway, oropharangeal airway
What concentration of oxygen should be given to
all patients who present with apnea?
100%
What piece of oxygen therapy equipment will you
use to deliver this concentration of oxygen to all
patients who present with apnea?
Ambu bag and mask with 100% O2
Where can this piece of equipment be found on
most nursing wards?
crash cart, on the wall
List 5 usual steps taken in examining a patients
airway to determine the ease of intubating
conditions for oral intubation, and note for each
what constitutes a normal or abnormal finding:
1. TMJ mobility: condyle should be able to move 1
cm anteriorly

2. mouth opening: > 2 fingers

3. thrymental distance: > 6.5 cm

4. cervical spine mobility: flexion and extension
without discomfort

5. Mallampati = visability of hypopharyngeal
structures: full view of uvula, tonsillar pillars, tonsils,
posterior pharyngeal wall, soft palare and tongue
A 65-year old man presents to your family practice
office for a preoperative assessment before a
proposed ventral hernia repair. He is a known
hypertensive and has been treated with Metoprolol
50 mg bid and Hydrochlorothiazide 50 mg a day.
His blood pressure today is 180/110 mm Hg.

A. What are 4 specific questions you would ask him
on history related to his hypertension? (4)
Duration

Usual BP

Hx of MI,

Stroke, kidney damage
A 65-year old man presents to your family practice
office for a preoperative assessment before a
proposed ventral hernia repair. He is a known
hypertensive and has been treated with Metoprolol
50 mg bid and Hydrochlorothiazide 50 mg a day.
His blood pressure today is 180/110 mm Hg.
B. What 3 physical findings are crucial to determine
with regards to his cardiovascular "fitness" for
elective surgery?
S4, retinal changes, renal bruit
A 65-year old man presents to your family practice
office for a preoperative assessment before a
proposed ventral hernia repair. He is a known
hypertensive and has been treated with Metoprolol
50 mg bid and Hydrochlorothiazide 50 mg a day.
His blood pressure today is 180/110 mm Hg.

What 3 investigations are strongly indicated in this
patient related to the information given? (3)
Echo, ekg, creatinine
You are seeing a 32 year old woman in the holding
area outside the operating room immediately prior
to her scheduled laparoscopic cholecystectomy.
She tells you that she has had a cold for 2 days.

What 5 items elucidated on either history, physical
examination or laboratory data would cause you to
postpone this elective procedure?
Increased WBC

Adventitious lung sounds

Absent breath sounds/dullness

Fever

New productive cough
A 44 year old morbidly obese (200 kg) man
presents for an emergency appendectomy.

List 5 important problems associated with morbid
obesity that puts these patients at an increased risk
for anaesthesia and surgery. (10)
Aspiration

Possible difficult intubation

Decreased FRC reduced lung space to
preoxygenate means less time to intubate before
patient desturates

Difficult bag mask ventilation

Increased positive pressures required for
ventilation
A 75-year-old man presents for a total hip
replacement. He is given a general anaesthetic.
The drugs used for induction are sodium thiopental
250 mg, fentanyl 250 micrograms and
succinylcholine 100 mg. Anaesthesia is maintained
with isoflurane 0.2-0.8%, nitrous oxide 60%,
rocuronium increments and morphine increments.

His usual blood pressure is 150/85 mm Hg. One
and one-half hours after induction, his blood
pressure drops to 90/60.

List 5 reasons for intraoperative hypotension in this
man: briefly discuss how each of these items
actually causes the blood pressure to fall. (10)
1. isoflurane = myocardial depression =
hypotension

2. nitrous oxide = myocardial depression =
hypotension

3. morphine = release histamine = vasodilation
hypotension

4. blood loss = hypovolemia hypotension

5. positive pressure ventilation = IVC compression
= decreased venous return = decreased preload =
hypotension
List 5 potential complications from the use of non-
steroidal anti-imflammatory drugs i.e NSAIDS. (10)
AIN, fluid retention, allergy, gastritis/GI bleed,
hypertension, bone marrow suppression (platelet
dysfunction), worse CHF
What is the aortocaval syndrome? Compression of IVC and/or aorta by gravid uterus.
List three ways to decrease the effects associated
with aortocaval syndrome.
1. Lie patient on left side, 2. Right hip wedge, 3.
Avoid supine position
List 4 potential complications of single unit blood
transfusion and 6 potential complications related to
multiple unit blood transfusion. (10)
Single: Immune, nonhemolytic: 1. immediate
hemolytic reaction, 2. delayed hemolytic reaction 3.
infection, 4. allergic reaction

Multiple: 1. hyperkalemia, 2. dilutional
coagulopathy, 3. dilutional thrombocytopenia,
4. circulatory overload, 5. citrate toxicity
(hypocalcemia), 6. iron overload
List 5 ways in which you could distinguish between
a neuromuscular block associated with a 1-mg/kg
dose of succinylcholine and one associated with a
non-depolarizing muscle relaxant (Rocuronium).
Succinylcholine = time to block < 1 min, no fade
with tetanus, not reversible, TOF ratio > 0.4

Non-depolarizing (Rocuronium) = > 2 mins, fades
with tetanus, positive post tetanic facilitation,
reversible, TOF ratio < 0.7
List 5 ABSOLUTE contraindications to the
administration of either succinylcholine or a non-
depolarizing relaxant. (Do not give the
1. allergy to medication

2. unable to secure airway
contraindications to succinylcholine, rather
GENERAL absolute contraindications to muscle
relaxation with either type of drug. Assume the
patient has a functioning intravenous in situ) (5)

3. lack of resuscitative equipment

4. lack of anaethesia medications

5. unable to bag mask ventilate
Name 2 situations, 1 in the operating room and 1
outside the operating room setting where a
laryngeal mask might be used. (2)
Surgery where intubation not required:
1. No risk of aspiration
2. Short procedure
3. Non-obese, not pregnant, no ascites

OUTSIDE OR
Emergent - can't intubate, can't ventilate.
Inadequate seal (e.g. beard) with face mask
List 6 contraindications to the elective use of a
laryngeal mask in the operating room. (6)
need PPV, risk of aspiration, pharyngeal pathology,
limited mouth opening, cervical vertebra/laryngeal
cartilage #, spontaneous breathing, trendelenberg
positioning
What size laryngeal mask would be used for an
average female (1) and an average male (1)? (2)
females 3, males 4
35-year old man is having an inguinal hernia repair
under general endotracheal anesthesia. He is a
previously healthy man with no cardiorespiratory
problem. He is intubated with a 8.0mm
endotracheal tube and his lungs are being
ventilated with a tidal volume of 500 cc at a
respiratory rate of 10 breaths/minute. His
intraoperative course has been uneventful since
the induction of anesthesia, 1 hour ago. Over the
course of 15 minutes, his oxygen saturation, which
had been stable at 98% has fallen to 90%. BP is
120/80 and heart rate is 110 bpm. List 5 possible
causes of this problem and for each problem, list
one therapeutic intervention to improve the
situation. (10)
Endobronchial intubation: pull back tube

Tube disconnected: check tubing

Patient biting down on tube: relaxation, insert
oropharyngeal airway

Secretions blocking tube: suction

PE/Atelectasis = increase PEEP to reduce
atelectasis
Name 5 SPECIFIC preoperative investigations that
an anaesthetist would consider important
information in the assessment of a patient suffering
from severe chronic obstructive lung disease who
is scheduled for an elective ventral hernia repair.
(5)
Hgb, PaO2, PaCO2, HCO3, PFTs, CXR, EKG
Name 5 SPECIFIC preoperative investigations that
an anaesthetist would consider important
information in the assessment of a patient suffering
from severe chronic obstructive lung disease who
1. ABG: hypoxemia, acidosis and appropriate
compensation

2. CXR: hyperflation and evidence of any cardiac
is scheduled for an elective ventral hernia repair
and give a BRIEF reason as to the importance for
each individual investigation.
failure or pulmonary infection

3. CBC: any additional pulmonary infection

4. PFT: extent of obstruction

5. ECG: cardiac failure
List 5 classes of drugs that a patient may be asked
to discontinue prior to elective surgery. (10)
1. oral hypoglycemics

2. anticoagulants

3. antiplatelets

4. insulin

5. antidepressants
A 75-year-old man undergoing a laparotomy for a
bowel obstruction has received a general
anaesthetic. He is intubated and ventilated and has
been paralyzed with rocuronium. Anesthesia is
maintained with 70% nitrous oxide, 30% oxygen
and 1% isoflurane. He has a history of
hypertension for which he takes Vasotec. One hour
after the surgery began, his blood pressure, which
had been stable, drops to 80/40 mm Hg.

A. List 5 actions you would take at this point.
1. verify monitors connected properly

2. crystalloid infusion - Ringer's Lactate

3. decrease nitrous oxide = will increase BP

4. decrease isoflurane = will increase peripheral
resistance

5. consider phenylephrine - will increase peripheral
resistance without increasing heart rate and
contractility.
List 5 common causes of intraoperative
hypotension. (5)
1. inhalational anesthesia

2. opiods

3. hemorrhage

4. loss of fluids

5. positive airway ventilation causing IVC
compression
A previously healthy 32-year-old man has
undergone an open reduction and internal fixation
of a tibial fracture following an injury incurred in a
football game. He weighs 90 kg and has no history
of abnormal bleeding or bruising. He is currently
taking ranitidine 150 mg once daily for a duodenal
ulcer and is asymptomatic. He has no known
allergies. In the Post Anaesthetic Care Unit
(PACU), he is complaining of severe pain.

Morphine 1-3 mg IV
A. In the PACU, what medication and dose would
you use to start treating his pain? (3)
What THREE specific methods of anaesthesia can
be used for a Caesarean section. (3)
Epidural, spinal, GA
List 4 common side effects of opioid medications.
1. histamine release leading to hypotension

2. constipation

3. respiratory depression

4. nausea/vomitting
A previously healthy 32-year-old man has
undergone an open reduction and internal fixation
of a tibial fracture following an injury incurred in a
football game. He weighs 90 kg and has no history
of abnormal bleeding or bruising. He is currently
taking ranitidine 150 mg once daily for a duodenal
ulcer and is asymptomatic. He has no known
allergies. In the Post Anaesthetic Care Unit
(PACU), he is complaining of severe pain.

After 1 hour and a large dose of morphine he is still
in pain. What alternate therapy could you offer
him?
(3) PCA Using hydromorphone
What THREE specific methods of anaesthesia can
be used for a Caesarean section. List two
significant disadvantages of each technique. (6)
1. epidural: block sympathetic nerves and worsen
hypotension, slower onset

2. spinal: block sympathetic nerves and worsen
hypotension, one dose only, motor block, dural
puncture headache

3. general: technique difficult due to upper airway
edema, maternal drugs transfer to neonate causing
neonatal depression and requiring resuscitation
What type of anaesthesia would most likely be
given to a patient requiring EMERGENCY
Caesarean section for an acute haemorrhage
secondary to an abruptio placenta? (1)
insufficient time to establish regional anaesthesia.
Thus rapid sequence general anesthesia.
List 2 common uses for propofol. (2) 1. induction, 2. maintenance anesthesia
List 5 important physiological effects of an
intravenous induction dose of propofol. (5)
1. decreased ICP, 2. increased IOP, 3. decreased
RR, 4. decreased BP, 5. decreased CO
Pain on injection may occur with propofol. List 3 1. mix in small dose of lidocaine, 2. administer
ways you might avoid or decrease the incidence of
this side effect? (3)
through a fast flowing iv catheter,

3. adminster through a more proximal iv catheter
What are the five minimum pieces of equipment
required to intubate? (5)
1. suction, 2. O2, 3. laryngoscopy, 4. ETT, 5. stylet
A 24 year old previously healthy male is brought by
ambulance to the emergency department. He has
taken an unknown quantity of an unknown drug. He
is unconscious and breathing at a rate of 5 per
minute. His saturation on room air is 88%. He has
no gag reflex and the casualty officer would like
you to intubate him. He has not sustained a
cervical spine injury. Assuming that all the
equipment you need is ready, describe the five
steps you would follow to perform the intubation.
(5)
1. position patient
2. open mouth
3. laryngoscopy
4. insert ETT though vocal cords, remove
laryngoscope
5. confirm ETT placement
Name 3 ways to confirm placement of an ETT.
1. Chest wall rising with ventillation
2. Air entry heard by stethoscope at bilaterally at
the mid-axillary line
3. End tidal CO2 30-40mmHg
List 5 GENERAL causes of hypoxaemia. (10) (Do
not give specific examples i.e. pulmonary
embolus).
1. decreased FIO2
2. decreased alveolar ventilation
3. increased shunting
4. increased dead space ventilation
5. decreased diffusion
6. poor placement of ETT
A 60 year old woman with insulin-dependent
diabetes presents to the preoperative consultation
clinic having been scheduled for a total knee
arthroplasty in 2 weeks time.
A. What 6 specific questions related to her diabetes
would be important to ask to assess her fitness for
anaesthesia and surgery? (6)

B. What 4 specific tests would you order
preoperatively? (4)
1. how long?
2. end organ damage?
3. monitor blood glucose regularly?
4. adequate control?
5. admissions to hospital for hypo or
hyperglycemia?
6. other CAD risk factors?

1. blood glucose, 2. ECG, 3. lytes and creatinine, 4.
urinalysis
A 50 year old man takes beta blockers and Ca2+
channel blockers for stable angina. He is coming
for elective surgery in one week. What should you
tell him about his medications and eating and
drinking before his operation? (3)

B) What are 2 reasons that we have patients fast
before elective surgery? (2)

A- 1. take B-blockers and CCB at usual time with
sips of water
2. no solids at least 8 hrs prior
3. no fluids at least 4 hrs prior

B - 1. decrease gastric volume, 2. decrease gastric
acidity

C - (1) aspiration
C) What immediate outcome may occur under
general anaesthesia in a patient who has a full
stomach?

D - What is a potential consequence of this
outcome?

E - What 3 reasons contribute to these outcomes?
(3)

D - (1) pneumonitis, atelectasis, ARDS, abscess

E - volume, acidity, particulate matter


190 Cards in this Set
Front

Back
Many unnecessary blood tests are ordered
prior to surgery. List 5 pieces of information
learned from the patients history that would
cause you to order preoperative coagulation
studies. (10)
1. on anticoagulants, 2. liver disease, 3. known factor
deficiency, 4. family history of factor deficiency
5. surgery involving lots of blood loss
A. You are called to the postanaesthetic care
unit to see a patient who has a saturation of
80%. She has been in the PACU for 20
minutes after having had a total abdominal
hysterectomy. She is otherwise healthy. Her
blood pressure is 120/80 mm Hg and her heart
rate is 120 bpm. Describe in point form
EXACTLY what your management of this
situation would be. (5)

B. What are five GENERAL potential causes of
her tachycardia? (5)
A - 1. assess airway, secure airway
2. assess need for ventilation
3. increase O2
4. look for acute blood loss, stop
5. fluid resuscitation
6. Control pain
7. Empty bladder

B - Hypovolemia, pain, arrhythmia, full bladder, anxiety,
anemia, drugs (e.g. atropine, pancuronium)
You are called to the floor to see a patient who
the nurse believes has had a narcotic
overdose. He has been on the ward for 2 hours
having just had an open reduction and internal
fixation of a femoral fracture. He is on PCA
which his wife has been using regularly on his
behalf.
A. What would be your management of the
situation at this point? (2)

B. If the patient is rousable and maintains his
airway, what would you do in this case? (5)
A - Assess responsiveness, resp rate, heart rate,
pupils, educate patient and wife

B - reduce PCA infusion rate, hold bolus doses for now,
reassess frequently

C - 1. assess and secure airway
2. give O2
3. give small incremental doses of 40 mcg naloxone

C. If the patient is difficult to rouse, snores and
has a respiratory rate of 8 per minute, and a
saturation of 80% on room air with a stable BP
and Heart rate, what would you do? (3)
List 5 options for pain relief during labour. (5)
Lamaze, epidural, NO, pudendal block, opioids
B. For each of the options for pain relief during
labour listed above; give 1 advantage and 1
disadvantage for each. (5)
Lamaze: gives woman control, not great analgesia
Epidural: good analgesia, hypotension
NO: easy, does not relieve pain completely
Spinal: good analgesia, motor blockade
Opioids: easy, maternal/neonatal depression
You are called to the recovery room (PACU) to
see a patient who has just arrived after having
had a laparoscopic cholecystectomy. The
patient was awake, alert, extubated and
breathing spontaneously. The nurse has just
given a gram of Ancef intravenously at the
surgeons request. The nurse tells you that the
patient is having an allergic reaction.

A) What 5 signs and/or symptoms might the
patient be experiencing to support this
diagnosis? (5)

B) What 5 steps MUST be taken to treat this
patient? (Be specific) (5)
A - rash, stridor, tachycardia, hypotension,
bronchospasm, urticaria

B - 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrine
iv, 4. N/S, 5. benadryl 50 mg iv 6. Ranitidine
A. What two genetic disorders related to
anaesthesia might be elicited by asking a
patient about their family history of
anaesthetics? What investigations can be done
to determine if the disorder has been
transmitted to the patient? (4)

B. What would be the symptoms that might
occur, related to each disorder, if a patient
received a general anaesthetic without any
precautions against the above problems? (6)
(Separate the symptoms according to the
disorder.)
A - Cholinesterase deficiency: genotyping
MH: muscle biopsy

B - Cholinesterase deficiency: prolonged paralysis
MH: - hypermetabolic state (increased temp, increased
O2 consumption, resp acidosis, tachypnea,
tachycardia)
- muscle rigidity
- rhabdomyolysis
- renal failure
With respect to the following drugs:
A. What is the usual initial dose of epinephrine
used in a cardiac arrest situation? (1)

B. What is the optimal route of administration of
epinephrine in the above situation? (1)

C. What is the dose of lidocaine used for
ventricular dysrhythmias?

A - 1mg IV push q3-5 min
B - IV push q3-5 min
C - 1-1.5 mg/kg push
D - 400mg/7=57
E - 5 mcg
F - Decrease systemic absorption, higher threshold for
anesthetic, longer duration of epidural
G - 0.5-1.0mg
H - 300mg - IV lidocaine 1% = 10mg/ml. 1.5% lidocaine
= 15mg/ml
D. What is the weight of a patient to whom the
administration of 20 ml of 2% lidocaine with
epinephrine would be a maximum?

E. What dose of epinephrine is contained in 1
cc of a 1:200,000 solution? (1)

F. List 3 advantages of mixing epinephrine in
local anaesthetic solutions (3)

G. What dosage of atropine should be given to
a patient with a bradyarrhythmia who is
hypotensive? (1)

H. 20ml of 1.5% lidocaine is equivalent to how
many milligrams?
List 5 maneuvers that can be used to open the
airway and permit ventilation in an unconscious
patient that you are unable to ventilate with a
bag and mask alone. (10)
1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insert
oral airway, 5. remove any foreign object
. List 4 methods to absolutely confirm that an
endotracheal tube is situated in the trachea.
(10)
See it go through cords, bronchoscope, capnograph,
CXR
You are seeing a 30 year old woman in your
family practice office as part of a work-up for
infertility. She has had asthma for the past ten
years and uses a Ventolin inhaler on a prn
basis. Over the past three weeks, she has
been using the Ventolin more than usual and
has been waking up at night coughing. On
physical examination she has bilateral
wheezes that do not clear with cough. She is
scheduled to have a diagnostic laparoscopy in
one weeks time.
A. What are four therapeutic modalities that
may be used to improve her condition? (8)

B. When you see her again on the day prior to
surgery, her condition is unchanged. What
would you do at this point? (2)
A - 1. addition of inhaled steroid, 2. addition of inhaled
LABA, 3. addition of oral steroid, 4. smoking cessation

B - Cancel and optimize?
A 65 year old man with untreated hypertension
presents to the emergency department,
complaining of severe abdominal pain. He has
been seen by general surgery and has an
incarcerated inguinal hernia that required
EMERGENCY surgery. His blood pressure is
now 200/120 mm Hg. List five IMPORTANT
and specific anaesthetic considerations of this
A - GERD/hiatus hernia, not NPO, pregnant,
overdose/LOC, delayed emptying

B - 1. NPO (8 hrs for food, 4 hrs for clear fluids)
2. H2-antagonists to decrease acidity (eg. Na citrate)
3. increase gastric emptying (eg. metoclorpropamide)
4. NG tube to empty stomach
5. extubate awake on side
patient undergoing this procedure.

A. Give 5 indications for performing a rapid
sequence induction. (5)

B. Besides performing a rapid sequence
induction, how can we minimize the risk of
aspiration? (5)
A - Describe the ACLS protocol for
symptomatic Bradycardia.

B - What should be done if the above
measures fail?
Pacing Always Ends Danger

Pacing **TCP Immediately prepare for transcutaneous
pacing (TCP) with serious circulatory compromise due
to bradycardia (especially high-degree blocks) or if
atopine failed to increase rate.

Consider medications while pacing is readied.
Always - Atropine = 1st-line drug, 0.5 mg IV/IO q3-5
min. (max. 3mg)

Ends - Epinephrine 2-10 g/min 2nd-line drugs to
consider if atropine and/or TCP are ineffective. Use with
extreme caution.
Danger - Dopamine - 2-10 g/kg/min

B - Search for other causes -
What are the ACLS DDx for a problem search
when interventions fail to correct cardiac
abnormalities.
6H's and 5T's

Hypoxia
Hypoglycemia
Hypo/Hyperkalemia
Hypocalcemia
Hypovolemia
Hypothermia
Hyperacidemia

Thrombus - MI/PE
Tension Pneumo
Tamponade
How should you treat symptomatic
hyperkalemia?
Sodium bicarbonate, calcium chloride, albuterol
nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate
What features would you see with a patient
who is crashing and has cardiac tamponade?

What is the treatment?
No pulse w/ CPR, JVD, narrow pulse pressure prior to
arrest.

Tx - Pericardiocentesis.
Why do you give Fentanyl intraoperatively
despite the patient being unconscious?
Despite unconsciousness, incision and intubation will
result in a pronounced sympathetic drive at level of

What about when harvesting organs from a
brain dead patient?
spinal cord.

You must control pain and hemodynamics even on a
brain dead patient.
What are contraindications to inhaled
anaesthetics?

What are your options?
Hx of Malignant Hyperthermia
Cardiopulmonary procedures that bypass heart and
lungs
Neck Surgery preventing access

Options are to use local, regional or TIVA GA (propofol,
thiopental or Ketamine )
How are exhaled anaesthetics such as
sevoflurane and isoflurane cleared from the
body?
By inhalation - thus you need to increase the O2 when
preparing for extubation.
An 82 year old male is scheduled for elective
repair of a AAA. What factors will affect his
perioperative plan and outcome?
Elderly - Requires lower MAC, less opioids, increased
risk of delirium, more pronounced hemodynamic
changes, less pulmonary reserve for intubation.

Vascular surgery = >5% mortality.
Describe the primary and secondary ABCDs.
Primary = BLS protocol, Airway with head tilt, Breathing
with bag, Chest compressions, Defibrillation.

Secondary = ETT, Breathing monitors, Circulatory IV
and Meds, Differential Dx = PATCH4 MDS
How should you manage an unstable VT or VF
tachycardia without pulses?

ACLS Pulseless arrest algorythm
1. 5 cycles of CPR followed by Synchronized
cardioversion for all unstable VT and VF tachycardias.
Followed by 5 cycles of CPR. Give Epinephrine. 5
cycles CPR. Check rhythm.

2. Do secondary survey - PATCH4 MDS if no response
to measures.
How should you manage an unstable PEA and
Asystole tachycardia without pulses?

ACLS Pulseless Arrest Algorythm
5 cycles of CPR. IV epinephrine 1 mg every 3-5 min. 5
cycles of CPR. Atropine 1mg IV. 5 cycles of CPR.
Check rhythm.

Do secondary survey - PATCH4 MDS if no response to
measures.
How should tachycardia with pulses be
managed.

ACLS Tachycardia Algorythm
1. Unstable? Immediate synchronized cardioversion.

2. Stable?
Narrow QRS = Vagal manoevre, Adenosine,
Converts = SVT Tx recurrence with Beta blocker
(metoprolol) or diltiazem

Does not convert = A Fib or Flutter - Diltiazem oe Beta-
blocker (metoprolol).

Wide QRS = Amiodarone and Cardioversion
How should Bradycardia be approached within
the ACLS algorythm?
1. HR <60 and adequate perfusion = monitor with ECG,
IV access, O2, oximetry, ABG, Lytes.

2. HR <60 and poor perfusion = Prepare
transcutaneous pacing, consider atropine 1mg IV,
epinephrine 1mg IV if no response, continue pacing.
Search for causes - PATCH4 MDS
A 50 year old man takes beta blockers and
Ca2+ channel blockers for stable angina. He is
coming for elective surgery in one week. What
should you tell him about his medications and
eating and drinking before his operation? (3)
1. take B-blockers and CCB at usual time with sips of
water
2. no solids at least 8 hrs prior
3. no fluids at least 4 hrs prior
B) What are 2 reasons that we have patients
fast before elective surgery? (2)
1. decrease gastric volume, 2. decrease gastric acidity
What immediate outcome may occur under
general anaesthesia in a patient who has a full
stomach?

What is a potential consequence of this
outcome?

What 3 reasons contribute to these outcomes?
(3)
(1) aspiration

(1) pneumonitis, atelectasis, ARDS, abscess

volume, acidity, particulate matter
Many unnecessary blood tests are ordered
prior to surgery. List 5 pieces of information
learned from the patients history that would
cause you to order preoperative coagulation
studies. (10)
1. on anticoagulants, 2. liver disease, 3. known factor
deficiency, 4. family history of factor deficiency
5. surgery involving lots of blood loss
A 60 year old woman with insulin-dependent
diabetes presents to the preoperative
consultation clinic having been scheduled for a
total knee arthroplasty in 2 weeks time.

A. What 6 specific questions related to her
diabetes would be important to ask to assess
her fitness for anaesthesia and surgery? (6)

B. What 4 specific tests would you order
preoperatively? (4)
1. how long?
2. end organ damage?
3. monitor blood glucose regularly?
4. adequate control?
5. admissions to hospital for hypo or hyperglycemia?
6. other CAD risk factors?

1. blood glucose, 2. ECG, 3. lytes and creatinine, 4.
urinalysis
List 5 GENERAL causes of hypoxaemia. (10)
(Do not give specific examples i.e. pulmonary
embolus)
1. decreased FIO2
2. decreased alveolar ventilation
3. increased shunting
4. increased dead space ventilation
5. decreased diffusion
A. You are called to the postanaesthetic care
unit to see a patient who has a saturation of
80%. She has been in the PACU for 20
minutes after having had a total abdominal
hysterectomy. She is otherwise healthy. Her
blood pressure is 120/80 mm Hg and her heart
rate is 120 bpm. Describe in point form
EXACTLY what your management of this
situation would be. (5)

B. What are five GENERAL potential causes of
her tachycardia? (5)
A. 1. assess airway, secure airway
2. assess need for ventilation
3. increase O2
4. look for acute blood loss, stop
5. fluid resuscitation

B. Hypovolemia, pain, arrhythmia, full bladder, anxiety,
anemia, drugs (e.g. atropine, pancuronium)
You are called to the floor to see a patient who
the nurse believes has had a narcotic
overdose. He has been on the ward for 2 hours
having just had an open reduction and internal
fixation of a femoral fracture. He is on PCA
which his wife has been using regularly on his
behalf.
A. What would be your management of the
situation at this point? (2)

B. If the patient is rousable and maintains his
airway, what would you do in this case? (5)

C. If the patient is difficult to rouse, snores and
has a respiratory rate of 8 per minute, and a
saturation of 80% on room air with a stable BP
and Heart rate, what would you do? (3)
A. Assess responsiveness, resp rate, heart rate, pupils,
educate patient and wife

B. reduce PCA infusion rate, hold bolus doses for now,
reassess frequently

C. 1. assess and secure airway
2. give O2
3. give small incremental doses of 40 mcg naloxone
List 5 options for pain relief during labour and
give 1 advantage and 1 disadvantage for each.
(5)
Lamaze: gives woman control, not great analgesia
Epidural: good analgesia, hypotension
NO: easy, does not relieve pain completely
Spinal: good analgesia, motor blockade
Opioids: easy, maternal/neonatal depression
You are called to the recovery room (PACU) to
see a patient who has just arrived after having
had a laparoscopic cholecystectomy. The
patient was awake, alert, extubated and
breathing spontaneously. The nurse has just
given a gram of Ancef intravenously at the
surgeons request. The nurse tells you that the
patient is having an allergic reaction.
A) What 5 signs and/or symptoms might the
A. rash, stridor, tachycardia, hypotension,
bronchospasm, urticaria

B. 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrine
iv, 4. N/S, 5. benadryl 50 mg iv
patient be experiencing to support this
diagnosis? (5)

B) What 5 steps MUST be taken to treat this
patient? (Be specific) (5)
What two genetic disorders related to
anaesthesia might be elicited by asking a
patient about their family history of
anaesthetics? What investigations can be done
to determine if the disorder has bee transmitted
to the patient? (4)

B. What would be the symptoms that might
occur, related to each disorder, if a patient
received a general anaesthetic without any
precautions against the above problems? (6)
(Separate the symptoms according to the
disorder.)
A. Cholinesterase deficiency: genotyping
MH: muscle biopsy

B. Cholinesterase deficiency: prolonged paralysis
MH: - hypermetabolic state (increased temp, increased
O2 consumption, resp acidosis, tachypnea,
tachycardia)
- muscle rigidity
- rhabdomyolysis
A. What is the usual initial dose of epinephrine
used in a cardiac arrest situation? (1)
1mg
B. What is the optimal route of administration of
epinephrine in the above situation? (1)
IV push
C. What is the dose of lidocaine used for
ventricular dysrhythmias? (1)
1-1.5 mg/kg push
D. What is the weight of a patient to whom the
administration of 20 ml of 2% lidocaine with
epinephrine would be a maximum? (1)
400mg/7=57
E. What dose of epinephrine is contained in 1
cc of a 1:200,000 solution? (1)
5 mcg
F. List 3 advantages of mixing epinephrine in
local anaesthetic solutions (3)
Decrease systemic absorption, higher
threshold for anesthetic, longer duration of
epidural
G. What dosage of atropine should be given to
a patient with a bradyarrhythmia who is
hypotensive? (1)
0.5-1.0mg
H. 20ml of 1.5% lidocaine is equivalent to how
many milligrams? (1)
300mg
A. 1mg
B. IV push
C. 1-1.5 mg/kg push
D. 400mg/7=57
E. 5 mcg
F. Decrease systemic absorption, higher threshold for
anesthetic, longer duration of epidural
G. 0.5-1.0mg
H. 300mg
List 5 maneuvers that can be used to open the
airway and permit ventilation in an unconscious
patient that you are unable to ventilate with a
bag and mask alone. (10)
1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insert
oral airway, 5. remove any foreign object
List 4 methods to absolutely confirm that an
endotracheal tube is situated in the trachea.
(10)
See it go through cords, bronchoscope, capnograph,
CXR
You are seeing a 30 year old woman in your
family practice office as part of a work-up for
infertility. She has had asthma for the past ten
years and uses a Ventolin inhaler on a prn
basis. Over the past three weeks, she has
been using the Ventolin more than usual and
has been waking up at night coughing. On
physical examination she has bilateral
wheezes that do not clear with cough. She is
scheduled to have a diagnostic laparoscopy in
one weeks time.
A. What are four therapeutic modalities that
may be used to improve her condition? (8)

B. When you see her again on the day prior to
surgery, her condition is unchanged. What
would you do at this point? (2)
A. 1. addition of inhaled steroid, 2. addition of inhaled
LABA, 3. addition of oral steroid, 4. smoking cessation

B. Cancel and optimize
Give 5 indications for performing a rapid
sequence induction. (5)

B. Besides performing a rapid sequence
induction, how can we minimize the risk of
aspiration? (5)
A. GERD/hiatus hernia, not NPO, pregnant,
overdose/LOC, delayed emptying,

B. 1. NPO (8 hrs for food, 4 hrs for clear fluids)
2. H2-antagonists to decrease acidity (eg. Na citrate)
3. increase gastric emptying (eg. metoclorpropamide)
4. NG tube to empty stomach
5. extubate awake on side
You are attending a breech delivery (in a
peripheral hospital) with the staff obstetrician. It
is a very difficult delivery complicated by
trapping of the after-coming head. When the
baby is finally delivered, it is limp and blue. The
obstetrician is attending to the mother who is
having a brisk postpartum haemorrhage.
A. The babys heart rate is 50 bpm. What
resuscitative efforts should be done now? List
8 steps/actions in the management of this
situation (8)

B. At 6 minutes of life, the heart rate is 120
bpm, respirations are slow and irregular. The
baby is limp, does not respond to stimulation
but is centrally pink with blue hands and feet.
What Apgar score corresponds with these
findings? (2)
A.
1. open airway (infant supine or on side)
2. suction mouth then nose
3. 100% O2
4. keep neonate warm and dry
5. physical stimulation (slapping soles of feet, rubbing
back)
6. PPV if apnea, HR <100, or central cyanosis despite
100% O2
7. chest compressions (if HR < 80 despiate PPV)
8. iv fluids (pallor despite 100% O2, weak pulse, BP <
55.30)
9. epinephrine (0.01 mg/kg) if HR still < 80 despiate
100% O2 and chest compressions

B. HR: 2, Respiration: 1, Irritability: 0, Tone: 0, Colour:
1, TOTAL: 4
What are the five minimum pieces of
equipment required to intubate? (5)
1. suction, 2. O2, 3. laryngoscopy, 4. ETT, 5. stylet
A 24 year old previously healthy male is
brought by ambulance to the emergency
department. He has taken an unknown quantity
of an unknown drug. He is unconscious and
breathing at a rate of 5 per minute. His
saturation on room air is 88%. He has no gag
reflex and the casualty officer would like you to
intubate him. He has not sustained a cervical
spine injury. Assuming that all the equipment
you need is ready, describe the five steps you
would follow to perform the intubation. (5)
1. position patient in sniffing position
2. open mouth and check for obstructions, dentition
3. laryngoscopy, exposing the vocal cords
4. insert ETT though vocal cords, remove laryngoscope
5. confirm ETT placement with stethoscope, end-tidal
CO2, condensation or bronchoscope confirmation.
Name 5 ways that you can confirm placement
of an ETT tube.
1. Visualize placement with naked eye or glidescope.
2. Bronchoscopy down tube
3. Auscultate lungs for breath sounds
4. End Tidal CO2
5. Condensation on ETT
6. Compliance of manual bag with ventillation and chest
expansion
7. CXR
Describe the sniffing position for placement of
an ETT. Why important?
Flexion of C6-C7 and Extension of C1-C2.

Aligns Oral, pharyngeal and laryngeal axis.
List 5 problems associated with the use of
intramuscular narcotics ordered on a prn basis
for postoperative pain. (10)
Inadequate analgesia, increased side-effects, delays to
relief, large variability in different patients in maximum
levels, wide fluctuations, painful injections
A 20 year old male is scheduled for removal of
impacted wisdom teeth under general
anaesthesia. During a pre-op assessment, he
states that his first cousin had an unusual
reaction under anaesthesia and subsequently
had a positive biopsy for malignant
hyperthermia. Neither of his parents has had a
general anaesthetic.
A. What 2 anaesthetic agents should be
avoided in this patient? (4)


B. List five signs of a malignant hyperthermia
reaction. (5)

C. What is the drug of choice and dose for
treating malignant hyperthermia? (1)
A. succinylcholine, inhalational agents

B. Hyperthermia, muscle rigidity, hypertension,
tachycardia, tachypnea, cyanosis

C. dantrolene (2 mg/kg)
List four GENERAL indications for
endotracheal intubation (NOT restricted to the
operating room setting). (10)
Five P's
1. Protect airway - aspiration
2. Pharm - administer medications NAVEL (naloxone,
atropine, ventolin, epinephrine, lidocaine)
3. Pulmonary toilet - to remove tracheobronchial
secretions and prevent ARDS and Atelectasis
4. Positive pressure ventilation - hypoventilation,
apnea, hypoxia, status asthmaticus
5. Patency - decreased LOC, facial fractures, edema
A 65-year old man is referred to your internal
medicine office with the following story: He has
had stable class I angina for four years, for
which he is taking Vasotec and sublingual
nitroglycerine prn. Recently, he has
experienced some angina at rest and at night
and an episode a week ago lasted half an hour
and did not respond to nitroglycerine. He has
benign prostatic hypertrophy and is scheduled
for surgery (transurethral resection of the
prostate) in two weeks time.
A. What are three specific concerns regarding
this mans story? (6)

B. List 4 items in your plan of action at this
time. (4)
A. 1. night symptoms, 2. angina at rest, 3. not
responsive to NTG

B. Go to ER, ECG, troponins, stress test, Echo, cath
At the end of a 2-hour laparoscopic
cholecystectomy, all inhalation anaesthetics
are turned off and the patient is ventilated
through the endotracheal tube with 100%
oxygen. After 10 minutes, the patient, who is
still intubated, has not begun to breathe
spontaneously. Blood pressure is 120/80 mm
Hg, heart rate 98 bpm. Anaesthesia was
induced with propofol and fentanyl. Intubation
was facilitated by 100 mg of intravenous
succinylcholine. Maintenance of anaesthesia
involved the use of incremental doses of
rocuronium, morphine, nitrous oxide and
isoflurane. List 5 common and important
potential causes of this patients postoperative
apnea. (10)
1. rocuronium, 2. morphine, 3. nitrous oxide, 4.
isoflurane, 5. succinylcholine
A 83 year old man with a history of
hypertension is undergoing emergency surgery
for an incarcerated inguinal hernia. Shortly
after induction of the general anesthesia with
fentanyl 50 micrograms, propofol 160 mg and
rocuronium 50 mg, Nitrous oxide 70% and
oxygen 30% and Isoflurane 1%, his blood
pressure which had been 150/90 mm Hg on
admission to the OR is now 80/60 with a heart
rate of 120 bpm.
A. What might be the cause of this fall in blood
pressure? (5)

A. 1. fentanyl, 2. propofol, 3. nitrous oxide, 4.
isoflurane, 5. decreased sympathetics after removal of
painful stimulus

B. 1. crystalloids, 2. phenylephrine (increases BP
without increasing HR), 3. decrease nitrous oxide
4. decrease isoflurane, 5. monitor
B. What would you do? (5)
Name 5 conditions that are associated with
difficult VENTILATION.
BONES.
Beard, Obeses, No teeth, Elderly, Snoring (Sleep
apnea).
Name 6 conditions associated with a difficult
INTUBATION and 1 reason why for each.
1. Obesity - extra tissue collapses airway
2. Pregnancy - edematous tissues
3. Scleroderma - connective tissue leads to low
compliance in pharynx.
4. Arthritis - Osteo and Rheum - c-spine instability, TMJ
stiffness, atlanto-axial instability
5. Acromegaly - big tongue, thick throat
6. Congenital anomolies.
List 4 MAJOR side effects related to the use of
NSAIDS. (8)

B. What is the mechanism of action that leads
to the adverse effects? (2)
A. 1. bleeding, 2. renal failure, 3. worsens CHF, 4.
PUD

B. 1. platelet inhibition, 2. prostaglandin synthesis
inhibition
List 5 advantages of the use of patient-
controlled analgesia over intramuscular
injections of narcotics. (10)
Quicker onset
No painful injections
Able to adjust to patient variability
Able to adjust as pain needs change overtime
Reduce side-effects
More effective analgesia
You have just positioned a patient supine after
administering a spinal anesthetic with
hyperbaric bupivacaine for an elective repeat
cesarean section. The patients blood pressure
was 110/65 preoperatively and is now 88/45.
A. List 2 reasons why her blood pressure has
dropped. (2)

B. What is your immediate management? (3)

C. List three signs or symptoms that she might
experience while her blood pressure is 88/45.
(2.5)

D. List three other signs or symptoms that she
might experience while her blood pressure is
88/45. (2.5)

E. List the 5 components of the Apgar score.
(2.5)

A. Aortocaval, sympathetic nerve block from spinal
anesthesia

B. 1. position patient on left side, 2. O2, 3. IV
crystalloids

C. lightheadedness, palpitations, visual changes,

D. 1. tachycardia, 2. tachypnea, 3. presyncope

E. Activity, Pulse, Grimmace, Appearance, Respirations
1-3.
A previously healthy 18 year old male was
stabbed in the back at an after hours club. He
A. ABCs, IV, O2 monitor, Cardiac monitor

comes to the ER with a single wound 2 cm in
length, 5 cm below the left scapula and 15 cm
left of the midline. He is awake and alert, BP
110/50 mm Hg, SpO2 97%.
A. What immediate steps should be taken in
the management of this patient? (3)

10 minutes later he is pale, diaphoretic: BP
70/40 mm Hg, HR 130 bpm. SpO2 88%
B. What are 3 LIKELY possibilities for the
above changes. (3)

C. What treatment measures would you
institute at this point? (2)


He stabilises for 1 hour, then again gets
hypotensive. His repeat Hb is 45. You now
decide to give him a blood transfusion
immediately. Unfortunately the blood bank says
it will be 30 min. before fully cross matched
blood is available.

D. What are your transfusion options at this
time? (2)
B. Tension pneumo, tamponade, hemothorax

C. Ventilate with 100% O2, fluids wide open

D. O positive, type specific
Succinylcholine is often given to patients
undergoing anaesthesia and surgery. In
otherwise healthy patients with no history of
neuromuscular diseases, allergy, personal or
family history of pseudocholinesterase
deficiency, list 5 side effects that may occur
with the intravenous administration of 1 mg/kg
of succinylcholine. (Do not include malignant
hyperthermia trigger) (10)
Myalgias, hyperkalemia, bradycardia, increased
secretions, increased ICP/IOP
A 50 year old female has undergone a total
abdominal hysterectomy. She has been fasting
since midnight. Her surgery began at 08:00
and took 2 hours. The total estimated blood
loss was 500 cc. Considering all sources of
perioperative fluid loss, answer the following
question.
How much fluid (i.e. Normal saline) should she
be given by the end of the case? Show how
you derived the total amount, including
formulas. She weighs 50 kg. (10)
maintenance requirement per hour: 4 ml x 10 kg + 2 ml
x 10 kg + 1 ml x 30 ml = 90 ml/h
fluid deficit: 90 ml/h x 10 h = 900 ml
third space losses: 6 ml/kg/h x 50 kg x 2 hr = 600 ml
blood loss replacement: 500 ml x 3 = 1500 ml
TOTAL: 3090 ml
What is more important, Ventilation or
Intubation?
Ventilation - if you can't ventilate they die. If you can't
intubate you can still ventilate until you wake or get a
surgical airway.
A. List four devices for delivering supplemental
oxygen to spontaneously-breathing (not
intubated) patients. For each, give the
approximate FiO2 or range of FiO2 that can be
delivered by each: (8)

B. What device and corresponding FIO2 would
you select for a 60 year old obese patient with
severe COPD, a known CO2 retainer, who has
presented to the Emergency Department with
acute bronchitis, and whose PaO2 is 48
(normally 55) and PaCO2 is 65 (previously
50)? His lips and nail beds are blue-tinged. (2
marks):
A. Nasal Prongs =24-44%, face mask=40-60%, mask
with reservoir=60-80%, Venturi 24, 28, 31, 35, 40%

B. Venturi 24%
What is the standard medication to use in wide
QRS (>0.12sec) tachycardia with pulses?
Amiodarone 150mg IV over 10 minutes. If Torsades de
Pointes give 1-2 mg magnesium over 30 min.
A 50 kg male has been NPO for 12 hours prior
to a 3 hour laparatomy. He lost 300cc of blood.
Calculate fluid requirements.
12h NPO = 4:2:1 = 90cc/h x 12 = 1080
3h Surgery Maint. = 90cc/h x 3 = 270
Losses @ 3:1 = 900cc
Third space loss (Medium surgery) = 6cc/kg/h = 6 x 50
x 3 = 900cc
Total = 3150 of Ringers (or NS).

Note: Third space loss calculation
Small surg (nose, foot, hand) = 4cc/kg/h
Med. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/h
BIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).
How do you calculate third space losses for
surgical procedures?
Note: Third space loss calculation
Small surg (nose, foot, hand) = 4cc/kg/h
Med. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/h
BIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).
Laryngospasm
1. Etiology
2. When does it most commonly occur?
3. Complications
4. . Tx
1. induced by secretions, inadequate anestheisa,
anaphylaxis and airway manipulation.

2. Most commonly occurs in a patient who is going into
or out of paralysis during intubation or extubation.

3. Results in inability to ventilate a patient =
EMERGENCY.

4. Succinylcholine to stop spasm, then ETT.
Laryngeal Mask (LMA)
1. When to use
2. Sizing
3. Contraindications
1. a. Great for can't intubate/ventillate.
b. When not using a paralytic.
c. Short procedure.
d. Breathing spontaneously.

2. Women = Size 3, Men = Size 4.

3. Succinylcholine, Sevoflurane. Full stomach,
preganant, ascites, reflux.
DDx of Hypertension Intraoperatively. Give 10.
Pain, hypoxia, drugs (epi, phenyl, atropine, dopamine),
fluid overload, electrolytes (Ca+) Pheochromo, Thyroid
storm, Malignant Hyper, Machine not working (art line
too low, wrong size BP cuff).
DDx of High Airway pressure with ventilation.
Give 10.
Kink/Fluid in tubes, Kink in ETT, secretion/tissue in
ETT, ETT placed down Left bronchus, PTX,
trendelenberg, obesity, ascites, surgeon leaning on
patient, bronchospasm.
Bronchospasm
1. Etiology
2. Clinical signs
3. Complications
4. Management
Bronchospasm or a bronchial spasm is a sudden
constriction of the muscles in the walls of the
bronchioles. Often occurs at the induction stage before
patient is fully anesthetized. It is caused by the release
(degranulation) of substances from mast cells or
basophils under the influence of anaphylatoxins.
Asthma, chronic bronchitis, anaphylaxis, pilocarpine
(which is used to treat illness resulting from the
ingestion of deadly nightshade as well as other things)
and beta blockers
2. Prolonged expiratory phase, wheeze, hypoxia,
increased airway pressures, silent chest, upslopping
CO2 tracing with ventilation.
3. Hypoxia, unable to venilate, hypercarbia, resp
acidosis, CV collapse.
4. Atropine, increase inhalation anesthetic
(bronchodilator), Induction (propofol) for Status
athmaticus, salbutamol & Ipratoprium bromide by MDI,
Prednisone,
1. An elderly male with pain in his left hip is
scheduled for a hip arthroplasty. He requests to
have a spinal anesthetic. All are potential
complications of a spinal anesthetic EXCEPT:
Hypotension
Infection at site
Hematoma at site
Local anesthetic toxicity
Nausea & Vomiting
Nausea & Vomiting
2. All of the following are contraindications to
spinal anesthesia EXCEPT:
Raised intracranial pressure
Hypovolemia
Coagulopathy
Infection at site of needle insertion
Kyphosis
Kyphosis
3. A 24 week pregnant woman is in need of an
emergency appendectomy. All are physiologic
changes in pregnancy EXCEPT:
Decreased gastroesophageal sphincter tone
Decreased haemoglobin
Decreased coagulation factors
Decreased functional residual capacity
Decreased systemic vascular resistance
Decreased coagulation factors
What is the name of the curved laryngoscope
blade? Straight?
Macintosh is curved, Miller is straight
Name important measurements and
classification systems in the assessment of an
airway?
Mallampati Score, weight, head and neck movements,
mouth opening, thyromental distance, jaw subluxation
How long prior to surgery is a patient able to
consume clear fluids?
2 hours
A patient who is a smoker, is obese or has
controlled Type 2 diabetes is considered which
ASA class?
2
What length of time must a patient wait post MI
before undergoing elective surgery?
4-6 weeks
When is an ECG indicated prior to surgery?
Heart disease, hypertension, diabetes, other risk factors
for cardiac disease (may include age), subarachnoid
hemorrhage, CVA, head trauma
Define MAC
The minimum alveolar concentration of an inhalational
anesthetic agent is the concentration that prevents
movement in response to standard surgical stimulus
(incision) in 50% of patients
What is the proper positioning of patients
during intubation?
The sniffing position: head bowed forward, nose in the
air
What is the proper depth of endotracheal tube
placement?
The tip 2 cm above the carina, the cuff 2 cm below the
vocal cords
What medications can be given through the ET
tube?
Naloxone, atropine, ventolin, epinephrine, lidocaine
What are some signs of an esophageal
intubation?
ETCO2 zero or near zero, poor breath sounds on
auscultation, impaired chest excursion, hypoxia
At what SaO2 can cyanosis be detected? SaO2 = 80%
How do you calculate the fluid maintenance
requirements in an adult?
4 mL/kg/hour for the first 10 kg, 2 ml/kg/hour for the
second 10 kg, 1 ml/kg/hour for the remaining weight
What replacement ratio must be used when
using crystalloid to replace blood loss? Colloid?
3 mL crystalloid / 1 ml blood loss, 1 ml colloid / 1 mL
blood loss
Which anesthetic drugs can trigger Malignant
Hyperthermia crisis?
Enflurane, halothane, isoflurane, desflurane,
sevoflurane (end in ane), succinylcholine,
decamethonium
All of the following are contraindications to
spinal anesthesia EXCEPT:
a) Raised intracranial pressure
b) Hypovolemia
c) Coagulopathy
d) Infection at site of needle insertion
e) Kyphosis
e) Kyphosis
An elderly male with pain in his left hip is
scheduled for a hip arthroplasty. He requests to
have a spinal anesthetic. All are potential
complications of a spinal anesthetic EXCEPT:
a) Hypotension
b) Infection at site
c) Hematoma at site
d) Local anesthetic toxicity
e) Nausea & Vomiting
e) Nausea & Vomiting
A 24 week pregnant woman is in need of an
emergency appendectomy. All are physiologic
changes in pregnancy EXCEPT:
a) Decreased gastroesophageal sphincter tone
b) Decreased haemoglobin
c) Decreased coagulation factors
d) Decreased Functional Residual Capacity
e) Decreased Systemic Vascular
Resistance
c) Decreased coagulation factors