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W olters Kluwer
Health

L ippincott’s
ANESTHESIA
REVIEW:
1,001
QUESTIONS AND ANSWERS

L ippincott’s
ANESTHESIA
REVIEW:
1,001
QUESTIONS AND ANSWERS
Paul Sikka, MD, PhD
Department of Anesthesia and
Perioperative Medicine
Signature Healthcare Brockton Hospital,
Brockton, Massachusetts
Affiliate of Beth Israel Deaconess Medical
Center, Boston, Massachusetts (Former
Faculty—Brigham and Women’s Hospital,
Harvard Medical School)

Edward A. Bittner, MD, PhD, FCCP, FCCM
Program Director, Critical Care Medicine-Anesthesiology
Fellowship, Associate
Director, Surgical Intensive Care Unit,
Assistant Professor of Anaesthesia,
Harvard Medical School, Massachusetts
General Hospital, Department of
Anesthesia, Critical Care, and Pain
Medicine, Boston, Massachusetts

Thomas M. Halaszynski, DMD, MD, MBA
Associate Professor of Anesthesiology,
Director of Regional Anesthesia/
Acute Pain Medicine, Department of
Anesthesiology, Yale University School of
Medicine, Yale New Haven Hospital, New
Haven, Connecticut

T hoha M. Pham, MD
Associate Clinical Professor, University

of California, San Francisco (UCSF),
Department of Anesthesia and
Perioperative Care, San Francisco, California

Ashish C. Sinha, MD, PhD, DABA
Vice Chairman, Anesthesiology &
Critical Care, Drexel University College
of Medicine, Hahnemann University
Hospital, Philadelphia, Pennsylvania

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98765432 1

Library of Congress Cataloging-in-Publication Data

Sikka, Paul, author.
Lippincott’s anesthesia review : 1001 questions and answers / Paul Sikka, Edward Bittner, Thomas Halaszynski, Thoha Pham, Ashish
Sinha.
p. ; cm.
Anesthesia review
E-ISBN: 978-1-4698-3101-5
I. Bittner, Edward A., 1967- author. II. Halaszynski, Thomas, author. III. Pham, Thoha, author. IV. Sinha, Ashish, author. V. Title. VI. Title:
Anesthesia review.
[DNLM: 1. Anesthesia--Examination Questions. 2. Anesthetics—Examination Questions. WO 218.2]
RD82.3
617.9'6076—dc23

2014019574

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CONTRIBUTORS

Mian Ahmad, MD
D e p a r tm e n t o f A n e s th e s io lo g y a n d P e r io p e r a tiv e M e d ic in e , D r e x e l U n iv e r s ity C o lle g e o f M e d ic in e ,
P h ila d e lp h ia , P e n n s y lv a n ia

Sheri M. Berg, MD
I n s tru c to r, D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e , a n d P a in M e d ic in e , M a s s a c h u s e tts G e n e r a l
H o s p ita l, B o s to n , M a s s a c h u s e tts

Edward A. Bittner, MD, PhD, FCCP, FCCM
P r o g r a m D ir e c to r , C r itic a l C a r e M e d ic in e - A n e s th e s io lo g y F e llo w s h ip , A s s o c ia te D ir e c to r , S u r g ic a l
In te n s iv e C a r e U n it, A s s is ta n t P r o f e s s o r o f A n a e s th e s ia , H a r v a r d M e d ic a l S c h o o l, M a s s a c h u s e tts
G e n e r a l H o s p ita l, D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e , a n d P a in M e d ic in e , B o s to n ,
M a s s a c h u s e tts

Yuriy S. Bronshteyn, MD
S u r g ic a l C r itic a l C a r e F e llo w , M a s s a c h u s e tts G e n e r a l H o s p ita l, D e p a r tm e n t o f A n e s th e s ia , C r itic a l
C a r e , a n d P a in M e d ic in e , B o s to n , M a s s a c h u s e tts

Thomas M. Halaszynski, DMD, MD, MBA
A s s o c ia te P r o f e s s o r o f A n e s th e s io lo g y , D ir e c to r o f R e g io n a l A n e s th e s ia /A c u te P a in M e d ic in e ,
D e p a r tm e n t o f A n e s th e s io lo g y , Y a le U n iv e r s ity S c h o o l o f M e d ic in e , Y a le N e w H a v e n H o s p ita l,
N e w H a v e n , C o n n e c tic u t

D arrin J. H yatt, MD
A n e s th e s ia C h ie f R e s id e n t, D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e , a n d P a in M e d ic in e , M a s s a c h u s e tts
G e n e r a l H o s p ita l, B o s to n , M a s s a c h u s e tts

Daniel W. Johnson, MD
A s s is ta n t P r o f e s s o r , F e llo w s h ip D ir e c to r , C r itic a l C a r e A n e s th e s io lo g y , D e p a r tm e n t o f
A n e s th e s io lo g y , U n iv e r s ity o f N e b r a s k a M e d ic a l C e n te r, O m a h a , N e b r a s k a

Rebecca Kalman, MD
C lin ic a l I n s tr u c to r in A n e s th e s ia , M a s s a c h u s e tts G e n e r a l H o s p ita l, B o s to n , M a s s a c h u s e tts

Jean Kwo, MD
A n e s th e s io lo g is t, D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e , a n d P a in M e d ic in e , M a s s a c h u s e tts G e n e r a l
H o s p ita l, A s s is ta n t P r o f e s s o r o f A n a e s th e s ia , H a r v a r d M e d ic a l S c h o o l, B o s to n , M a s s a c h u s e tts

Jinlei Li, MD
A s s is ta n t P r o f e s s o r o f A n e s th e s io lo g y , Y a le U n iv e r s ity S c h o o l o f M e d ic in e , Y a le N e w H a v e n
H o s p ita l, N e w H a v e n , C o n n e c tic u t

Dipty Mangla, MD
S ta ff A n e s th e s io lo g is t, C u m b e r la n d P a in M a n a g e m e n t, C u m b e r la n d , M a r y la n d

Ala Nozari, MD
A s s is ta n t P r o f e s s o r , D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e , a n d P a in M e d ic in e , M a s s a c h u s e tts
G e n e r a l H o s p ita l, B o s to n , M a s s a c h u s e tts

Thoha M. Pham, MD
A s s o c ia te C lin ic a l P r o f e s s o r , U n iv e r s ity o f C a lif o r n ia , S a n F r a n c is c o (U C S F ), D e p a r tm e n t o f
A n e s th e s ia a n d P e r io p e r a tiv e C a r e , S a n F r a n c is c o , C a l if o r n ia

Manish Purohit, MD
D e p a r tm e n t o f A n e s th e s io lo g y a n d P e r io p e r a tiv e M e d ic in e , D r e x e l U n iv e r s ity C o lle g e o f M e d ic in e ,
P h ila d e lp h ia , P e n n s y lv a n ia

Paul Sikka, MD, PhD
D e p a r tm e n t o f A n e s th e s ia a n d P e r io p e r a tiv e M e d ic in e , S ig n a tu r e H e a lth c a r e B r o c k to n H o s p ita l,
B r o c k to n , M a s s a c h u s e tts , A f f ilia te o f B e th I s r a e l D e a c o n e s s M e d ic a l C e n te r, B o s to n , M a s s a c h u s e tts
( F o r m e r F a c u lty — B r ig h a m a n d W o m e n ’s H o s p ita l, H a r v a r d M e d ic a l S c h o o l)

Ashish C. Sinha, MD, PhD, DABA
V ic e C h a ir m a n , A n e s th e s io lo g y & C r itic a l C a r e , D r e x e l U n iv e r s ity C o lle g e o f M e d ic in e , H a h n e m a n n
U n iv e r s ity H o s p ita l, P h ila d e lp h ia , P e n n s y lv a n ia

Preet Mohinder Singh, MD
D e p a r tm e n t o f A n e s th e s ia , A ll In d ia In s titu te o f M e d ic a l S c ie n c e s , N e w D e lh i, In d ia

David L. Stahl, MD
C lin ic a l F e llo w , D e p a r tm e n t o f A n e s th e s ia , C r itic a l C a r e a n d P a in M e d ic in e , M a s s a c h u s e tts G e n e r a l
H o s p ita l, B o s to n , M a s s a c h u s e tts

Deppu Ushakumari, MD
D e p a r tm e n t o f A n e s th e s io lo g y a n d P e r io p e r a tiv e M e d ic in e , D r e x e l U n iv e r s ity C o lle g e o f M e d ic in e ,
P h ila d e lp h ia , P e n n s y lv a n ia

W e w o u ld a ls o lik e to th a n k o u r f a m ilie s f o r th e ir s u p p o r t w h ile w e p r e p a r e d th is m a n u s c r ip t. p r o o f r e a d e r s ( in c lu d in g S h ilp a S h a h .c o m . T h e b o o k is d e s ig n e d to r a p id ly r e v ie w a n e s th e s io l o g y to h e lp r e s id e n ts p a s s th e w r itte n e x a m in a tio n s ta k e n d u r in g a n d a fte r re s id e n c y .001 Questions and Answers. PREFACE T h e p r a c tic e o f a n e s th e s io l o g y r e q u ir e s a s o lid f o u n d a tio n o f k n o w le d g e . a n d th e te a m a t L ip p in c o tt W illia m s & W ilk in s . T h e b o o k is b r o a d l y d iv id e d in to 21 c h a p te rs to c o v e r a lm o s t a ll r e le v a n t to p ic s te ste d . p le a s e c o n ta c t u s b y e m a il: A n e s 1 0 0 1 @ o u tlo o k . F o r a n y c o n s tr u c tiv e s u g g e s tio n s . E a c h q u e s tio n is f o ll o w e d b y f o u r p o s s ib le a n s w e rs . a m o n g w h ic h o n e is th e b e s t o r m o s t lik e ly a n s w e r. The Editors . T h e e d ito r s a c k n o w le d g e th e w o r k o f a ll w h o h a v e g iv e n th e ir v a lu a b le tim e a n d e f f o r t to c o m p le te th is b o o k . T h e s e in c lu d e a ll a u th o r s . M D ). It is w ith e x tr e m e p le a s u r e th a t w e in tr o d u c e Lippincott’s Anesthesia Review: 1. W e h o p e th a t th is r e v ie w b o o k p r o v e s to b e a v a lu a b le e d u c a tio n a l r e s o u r c e f o r a n e s th e s ia r e s id e n ts a n d y o u n g p r a c titio n e r s to h e lp th e m p a s s th e b o a r d s .

Pain Management THOMAS HALASZYN SKI 10. Anesthesia Machine PAUL SIKKA 4. MANISH PUROHIT. Spinal and Epidural Anesthesia THOMAS HALASZYN SKI 8. Anesthetic Pharmacology MIAN AHMAD AND ASHISH SINHA 7. Patient Monitoring DARREN HYATT. Orthopedic Anesthesia THOMAS HALASZYN SKI 11. ALA NOZARI. Airway Management YURIY BRONSHTEYN AND EDWARD BITTNER 3. Peripheral Nerve Blocks THOMAS HALASZYN SKI 9. ASHISH SINHA. AND PAUL SIKKA 2. Cardiovascular Anesthesia DEPPU USHAKUMARI AND ASHISH SINHA . CONTENTS Contributors Preface 1. AND EDWARD BITTNER 5. Fluid Management and Blood Transfusion REBECCA KALMAN AND EDWARD BITTNER 6. Perioperative Evaluation and Management PREET SINGH.

Critical Care DAVID STAHL. Liver. and Throat Surgery THOHA PHAM 17 . Postoperative Anesthesia Care SHERI BERG AND EDWARD BITTNER 21 . and Renal Diseases THOHA PHAM 15 .12 . Ophthalmic. Neuroanesthesia DIPTY MANGLA AND ASHISH SINHA 14 . Pediatric Anesthesia DIPTY MANGLA AND ASHISH SINHA 19 . Miscellaneous Topics PAUL SIKKA AND THOMAS HALASZYN SKI . Gastrointestinal. DANIEL JOHNSON. Nose. AND EDWARD BITTNER 20 . Ear. Thoracic Anesthesia DEPPU USHAKUMARI AND ASHISH SINHA 13 . Obstetric Anesthesia THOHA PHAM 18 . Endocrine Diseases JEAN KWO AND EDWARD BITTNER 16 .

.

Male. Aprepitant C. Patients with achalasia cardia for esophageal myotomy D. Palonosetron B. Famotidine. Female. Which of the following drugs antagonizes substance P in the central nervous system and is used as premedication to prevent postoperative nausea and vomiting? A. when used for stress ulcer prophylaxis. Ondansetron B. Scopolamine patch C. 70 years old 2. Ashish Sinha. Which of the following drugs is least likely to be effective for prophylaxis for postoperative nausea and vomiting? A. Patients with replaced mitral valve on warfarin B. Aprepitant D. Smoker. Metoclopramide 3. Which of the following predictors is likely to be associated with lower incidence of perioperative nausea and vomiting? A. Manish Purohit. Metoclopramide D. Patient with a blood pressure of 160/96 mm Hg D. 35 years old B. Preoperative application of scopolamine patch to prevent postoperative nausea and vomiting should be avoided in A. Patients with a history of coronary stenting on aspirin 4. Patients with idiopathic thrombocytopenic purpura (ITP) for splenectomy C. must be avoided preoperatively in which of the following patients? A. and Paul Sikka 1. Prochlorperazine 5.Perioperative Evaluation and Management Preet Singh. Female gender . 20 years old C.

Haloperidol 7. he is less likely to have significant cardiopulmonary ailment during surgery? A. he is asked about his level of physical activity. A 65-year-old male with a history of hypertension and diabetes presents to emergency department with altered sensation with a likely subdural hematoma. Within 60 minutes prior to incision D. Patients with a history of smoking D. Within 30 minutes prior to incision C. In preoperative assessment of patients. If he is capable of performing at least which of the following activities independently. physical activity is graded in terms of metabolic equivalents (METs).5 mL/kg/min D. 5. Vancomycin. except A. as a component of perioperative antimicrobial prophylaxis for surgery. as a component of perioperative antimicrobial prophylaxis for surgery. To assess his cardiorespiratory status. All of the following have an antiemetic action. Use of fentanyl for pain relief C. Within 60 minutes prior to incision D. must begin within what time before incision? A. Walk to washroom on level floor B. Propofol C. The value that corresponds to oxygen consumption of 1 MET in an adult is A. Climb a flight of stairs 10. Simultaneously with incision B. 3. Patients undergoing laparoscopic surgery 6. Simultaneously with incision B. Within 120 minutes prior to incision 8. B. Etomidate D. Walk one block D. Promethazine B. Within 120 minutes prior to incision 9. Cefazolin. Within 30 minutes prior to incision C. 7 mL/kg/min C. Play the accordion C. must begin within what time before incision? A. 2 mL/kg/min B.5 mL/kg/min .

Which of the following perioperative factors in patients undergoing dialysis prior to surgery predicts the possibility of hypotension (due to increased volume removed)? A. Fresh-frozen plasma (FFP) B. Injectable vitamin K C. As per American Society of Regional Anesthesia (ASRA) guidelines. Obesity B. Which of the following induction agents will cause the least respiratory depression? . A 70-year-old male. Factor VIII concentrate 13. Change in serum sodium B. Change in pH after dialysis 17. anticoagulation produced by warfarin can be reversed by using A. at least 24 hours 12. Aspirin D.11. Enlarged tonsils D. 1 to 1. Neuraxial block is not contraindicated for patients on which of the following drugs? A. History of recurrent diarrhea B. Prothrombin complex concentrate D. Warfarin B. Low-molecular-weight heparin C. is scheduled for an elective surgery. except A. A patient with a history of severe asthma is scheduled for an appendectomy. Female gender 15. at least 12 hours D. For emergent surgery.5 hours B. History of recurrent constipation D. History of urinary retention 16. 2 to 4 hours C. Short neck C. intravenous infusion of unfractionated heparin should be stopped how long prior to a planned epidural? A. Which of the following is not a sign of autonomic diabetic neuropathy? A. All of the following are risk factors for obstructive sleep apnea. Change in serum potassium D. Clopidogrel 14. who is diabetic for the last 20 years. History of postural hypotension C. Change in body weight C.

A. Just prior to induction of anesthesia in the operating room 23. Ketamine B. Additive B. During preoperative anesthetic evaluation C. Direct procedural costs 22. At the same time that a surgeon obtains consent for the surgical procedure D. Competitively antagonistic D. Effect of combined administration of midazolam and fentanyl is A. An optimal preoperative evaluation is designed A. Droperidol C. Glycopyrrolate 19. an anesthesia provider must obtain informed and preferably written consent A. Synergistic C. To screen for and properly manage comorbid conditions B. Patient morbidity C. To assess the risk of anesthesia and surgery and lower it . except A. Just prior to transferring the patient to the operating room for surgery B. None of the above 20. Dexamethasone B. aPTT C. Aprepitant D. Case cancellations B. Propofol C. Preoperative anxiety D. Noncompetitively antagonistic 21. ACT D. Etomidate D. Thiopental 18. Preoperative anesthetic evaluation is likely to bring down the incidence of all the following. For elective procedures. Which of the following drugs can significantly prolong the QT interval on the ECG? A. Which of the following tests is used to confirm coagulation after stopping low-molecular- weight heparin (LMWH)? A. PT B.

a controlled hypertensive patient with no target end-organ damage scheduled for elective surgery will be classified as A. Toddler for tonsillectomy C. Clopidogrel C. As per ASA classification. General or regional anesthesia B. except A. A healthy pregnant patient in labor has which of the following ASA classifications? A. Brain tumor patients D. ASA IV . Uncontrolled hypertensive B. must be avoided in which of the following patients? A. All the above 24. III D. IV 26. C. I B. as premedication. Monitored anesthesia care D. ASA III B. Warfarin D. ASA VI 29. ASA III D. Sedatives. As per the American Society of Regional Anesthesia (ASRA) guidelines. Conscious sedation C. Surgical procedure 25. ASA classification for risk stratification is validated for predicting preoperative morbidity associated with the following. Aspirin B. Low-molecular-weight heparin 28. Patients with alcohol abuse 27. ASA II C. A brain-dead organ donor undergoing laparotomy for “kidney harvesting” will be classified as an A. which of the following drugs can be continued preoperatively in patients planned for neuraxial blockade for an elective procedure? A. To identify patients who may require special anesthetic techniques or postoperative care D. II C. ASA I B.

ASA IV C. who is to undergo a laparoscopic cholecystectomy. Due to decreased effort tolerance and a significant blockade of left anterior descending coronary artery onstress thallium. Percutaneous coronary stenting—bare-metallic stent C. A patient with a history of uncontrolled hypertension. ASA V 32. 10 days 33. ASA IV D. ASA III B. 3 days C. A 26-year-old female. ASA V D. Just prior to surgery. ASA VI 30. Percutaneous coronary stenting—drug-eluting stent D. ASA II B. C. He is on warfarin since the time of valve replacement. she is diagnosed to have atrial fibrillation (AF) with no hemodynamic instability. A 65-year-old male with a history of mitral valve replacement 2 years back presents for a knee replacement. The first step in preparation for surgery is A. Coronary artery bypass graft (CABG) B. Percutaneous balloon dilatation . ASA V D. Plan for therapy postdelivery 34. the ideal time to stop his warfarin prior to surgery would be A. A 72-year-old patient with a history of hypertension and angina at moderate activity is to undergo a laparoscopic cholecystectomy. will be classified as an A. ASA III C. Antiarrhythmic medication D. diabetes. A moribund patient who is not expected to survive without the operation is categorized as an A. Perform an echocardiogram to rule out left-atrial clot B. ASA VI 31. As per ASRA guidelines. with a history of rheumatic mitral stenosis. Synchronized DC cardioversion under sedation C. Which of the following procedures performed prior to the elective surgery is least likely to delay the laparoscopic surgery? A. and angina. 12 hours B. a preprocedure coronary intervention is planned. 5 days D. is scheduled for an elective cesarean section at 38 weeks of gestation.

The most significant risk factor for developing pulmonary complications is A. No waiting. Hypocoagulable state B. Hyper proteinemia D. 2 hours C. 6 months 39. since it is a child B. The child had formula milk 2 hours ago. Which of the following is not seen as a result of primary renal disease in patients with chronic renal failure? A. Hypercoagulable state C. A 2-year-old child is to undergo a tonsillectomy.0 B. Ketamine C. Anemia 36. Droperidol B. As per ASA guidelines.35. Smoking 40. optimal NPO status would be to wait another_____before proceeding to surgery: A. Sevoflurane D. A 45-year-old patient is scheduled for an abdominal hysterectomy. Etomidate 38. 1. Presence of respiratory infection C. Presence of obstructive sleep apnea D.4 D.6 . Site of surgery (abdominal/thoracic) B. She states that her aunt had a severe reaction to anesthesia and was in the ICU for 1 week. 1. You would avoid which of the following drugs for her general anesthesia? A. 6 weeks C. 4 hours D. Elective surgery should be postponed after a myocardial infarction for at least A.2 C. 30 days B. 1. 1. 6 hours 37. 3 months D. Maximum international normalized ratio (INR) before proceeding for elective surgery should be A.

Which of the following tests is likely to detect clinically relevant bleeding tendency most efficiently? A. Right ulnar nerve-innervated muscles B. the patient should be monitored for which electrolyte? A. A 32-year-old patient after being involved in a road traffic accident due to alcohol intoxication is taken to the operating room for open fracture reduction of an ankle fracture. which of the following is not a major clinical risk predictor in a patient with cardiac disease scheduled for noncardiac surgery? . Improvement of ciliary function B. Decrease in mucous production C. Potassium B. Left ulnar nerve-innervated muscles D. Decrease in airway irritability D. He is now scheduled for laparoscopic cholecystectomy under general anesthesia. you notice that the patient is wheezing. Lower C. Thromboelastogram (TEG) 46. Prothrombin time C. His blood alcohol level is above the legal limit. Right posterior tibial nerve-innervated muscles C. Compared to a patient who is not intoxicated with alcohol. Sodium D. Calcium C. Decrease in level of carboxyhemoglobin 45. Left facial nerve 42. you would expect the minimum alveolar concentration (MAC) of sevoflurane to be A. Unpredictable due to pharmacodynamic variations 43. Equal D. As per AHA guidelines. Which of the following sites should be preferably used to monitor the train of four muscle twitches for estimating neuromuscular blockade? A. Chloride 44. Smoking cessation for 24 hours before a scheduled surgery will lead to A.41. On physical examination. A 55-year-old patient with a history of asthma and heart failure is to undergo a hernia repair. Activated partial thromboplastin time B. A 73-year-old patient has residual weakness on the right arm and leg following a stroke 5 years ago. Activated clotting time D. Higher B. Following treatment with albuterol.

Dry mouth C. Desflurane D. Sevoflurane 51. The inhalation agent of choice in a 2-year-old child for ophthalmologic surgery is A. Tachycardia 48. Lowers pulmonary vascular resistance C. Precipitates vitamin B12 deficiency anemia . Which of the following occurs during the preoxygenation of a patient? A. Halothane B. Increase in closing capacity of lungs 50. Useful in preventing postoperative nausea 49. Which of the following is true of nitrous oxide? A. A. Can cause extrapyramidal side effects D. Sevoflurane D. when given preoperatively. Recent myocardial infarction B. Decreases lower esophageal sphincter tone B. Increase in functional residual capacity B. except A. Bronchoconstriction D. Presence of congestive cardiac failure D. Isoflurane C. Suppresses EEG pattern in the cerebral cortex D. Uncontrolled systolic hypertension 47. Denitrogenation C. Delays gastric emptying C. Desflurane C. Increase in CO2 clearance from lungs D. Skin flushing B. Halothane B. Nitrous oxide 52. Which of the following agents is associated with the highest incidence of hepatitis postoperatively? A. Acts on central nervous system GABA receptors B. Which of the following is true about metoclopramide? A. can cause all of the following. Symptomatic mitral stenosis C. Glycopyrrolate.

Succinylcholine is contraindicated in a patient with A. Inhibition of dopamine activity C. Peripheral neuropathy D. Continuing of which of the following antihypertensive drugs. Congestive heart failure C. Inhibition of glutamate release D. preoperatively. Alfentanil D. Depressant effect on the chemoreceptor trigger zone B. Hydrochlorothiazide D. in the geriatric age group. Furosemide 57. Patient with full stomach 56. can be associated with profound hypotension on induction of general anesthesia? A. Duchene muscular dystrophy C.53. Which of the following findings in the preoperative evaluation cannot be attributed to obesity with obstructive sleep apnea (OSA) in a patient planned for bariatric surgery? A. Dementia 58. Sufentanil C. Diazepam 55. Chronic renal failure B. Which of the following is the preferred intravenous agent of induction of anesthesia for maintaining spontaneous breathing and airway tone? A. Remifentanil . Midazolam B. All of the following medications can be administered via an epidural anesthesia. except A. All of the above 54. Propofol C. A 75-year-old patient with a history of hypertension is to undergo laparoscopic colectomy for carcinoma colon. Pulmonary artery hypertension B. The antiemetic effect of propofol is thought to occur due to A. Angiotensin-converting-enzyme (ACE) inhibitors C. Myasthenia gravis D. Ketamine D. Fentanyl B. Metoprolol B.

59. Abrupt stoppage of total parenteral nutrition (TPN) would most likely cause A. Shoulder arthroscopy B. Sickle cell crisis C. Laparoscopic surgery C. Hypertension B. May produce sedation B. Adds to the analgesia D. Strabismus repair D. Malignant hypertension B. Antagonist at 5-HT3 receptors 60. All of the following surgeries are associated with an increased risk of postoperative nausea and vomiting. Which of the following statements is false regarding scopolamine patch applied preoperatively? A. Serotonin B. Antagonist at 5-HT2 receptors C. Addisonian crisis D. Agonist at 5-HT2 receptors B. Muscarinic D. Hypertension and bradycardia D. Overdose with dexmedetomidine results in A. Decreases the risk of nausea C. Dopamine C. Ondansetron causes its antiemetic effect by acting as an A. Bradycardia C. Tympanoplasty 65. except A. Acetylcholine 64. Abrupt withdrawal of steroids can lead to A. Hypotension and bradycardia 62. Psychosis 63. Promethazine primarily inhibits which of the following receptors? A. Agonist at 5-HT3 receptors D. Hypoglycemia . Inhibits muscarinic receptors 61.

B. Diarrhea B. A 42-year-old patient is scheduled for a hernia repair under general anesthesia. Which of the following antibiotics can prolong the action of neuromuscular-blocking drugs? A. 7 C. except A. 10 D. Penicillin C. In general. alprazolam. His medications include fluoxetine. Order a lithium blood level D. Estrogen in birth control pills increases the perioperative risk of A. A 34-year-old patient is to undergo an appendectomy under general anesthesia. he appears confused. and lithium for bipolar disorder. Cephalexin 69. herbal medications should be stopped before surgery for at least_____days: A. Myocardial infarction 70. Hyperglycemia C. Levofloxacin D. his blood pressure drops to 72/36 mm Hg and a medication is administered. Thromboembolism C. His blood pressure suddenly increases to 220/120 mm Hg. 14 68. Lowers lower esophageal sphincter tone 67. Stroke D. 3 B. Consult a psychiatrist 71. Proceed with the case C. Hyperphosphatemia D. Sedation B. Ephedrine . Hypophosphatemia 66. Tachycardia C. has tremors. Your next step would be to A. Gentamicin B. Antisialagogue effect D. The most likely medicine that was administered is A. In the preoperative area. He is taking a monoamine oxidase inhibitor (MAOI) for depression. Intraoperatively. Cancel the case B. and is ataxic. Glycopyrrolate causes all of the following.

and the blood pressure drops to 78/42 mm Hg. Subarachnoid injection B. the patient starts to wheeze and develops tachycardia. An axillary nerve block would not produce loss of sensation of the A. Your next step would be to administer A. Ulnar nerve blockade 77. A patient is administered cephalexin preoperatively. Phenylephrine C. Patient with an insulin pump should continue the insulin at their basal rate 73. Hyperkalemia B. Hypocalcemia 74. The entire forearm D. Air embolism 75. B. Hypokalemia C. Lateral aspect of the forearm B. Patients should continue their oral hypoglycemic agents the morning of the surgery C. Cardiac arrhythmias D. Medial aspect of the forearm C. All of the following may occur with an interscalene block. Epinephrine D. Median nerve blockade D. The most common complication of inserting a central venous catheter is A. Norepinephrine 72. Digoxin toxicity is most likely exacerbated by A. Finger-stick blood glucose should be tested before taking the patient to the operating room D. Oxygen 76. except A. Ephedrine B. Radial nerve blockade C. Thrombosis C. Hypercalcemia D. Carotid artery puncture B. None of the above . Phenylephrine D. Within 5 minutes of starting the antibiotic. Meperidine C. All of the following are true about diabetic patients. Patients should take half or one-third of their insulin dose the morning of the surgery B. except A.

All of the following nerves are blocked by an ankle block. Nitroglycerin 82. More common after using a laryngeal mask airway C. Anterior tibial 80. History of diabetes B. Posterior to the femoral artery D. History of hypertension C. Sore throat is A. except A. Which of the following is the best agent to treat these symptoms? A. Warfarin C. A patient with hypertrophic obstructive cardiomyopathy (HOCM) presents with dyspnea and angina on exertion. More common after using an endotracheal tube B. Anterior to the femoral artery C. More common after using an oral airway 81. Aspirin D. Morphine D. John wort (Hypericum perforatum) potentiates the effects of A.78. Lateral to the femoral artery 79. Hydrochlorothiazide B. Clopidogrel 83. Age D. Metoprolol C. Similar incidence with either endotracheal tube or a laryngeal mask airway D. Sural B. The femoral nerve lies A. St. Medial to the femoral artery B. Superficial peroneal C. Heparin B. A patient with Parkinson disease undergoes a general anesthetic. Your plan to treat his nausea would include all of the following. Dexamethasone . Deep peroneal D. The most powerful predictor of atrial fibrillation post-cardiac surgery is A. Time on bypass 84. except A.

Establish airway and give 100% O2 via a face mask D. Administer epinephrine . Prolonged QTc C. 50% D. U wave D. Dobutamine C. Class 3a D. Octreotide B. Soon after injecting 20 mL of 0. You are performing an interscalene brachial plexus block on an awake 40-year-old patient who is healthy with no significant medical history. Class 1 B. Administer intralipid B. Class 3b 86. Administer midazolam or propofol to control the seizure C. A 46-year-old lady is seen at the preoperative assessment clinic. The drug of choice to treat intraoperative hypotension is A. His New York Heart Association classification is A. Scopolamine patch C. and loses consciousness. Prolonged PR interval B. She is taking 180 mg/day methadone. B. Your first step in management is A. Milrinone D. 30% B. Tented T-waves 88.25% bupivacaine the patient becomes agitated. has a seizure. Metoclopramide D. He is able to take a shower but gets dyspneic on mowing the lawn. You are about to anesthetize a 55-year-old man who is undergoing liver resection for removal of metastatic carcinoid tumor. The most likely change to be found in her preoperative ECG is A. 50% C. Ondansetron 85. 70% 87. A 65-year-old patient is being treated for congestive cardiac failure. The percentage of postdural puncture headaches that would resolve spontaneously by 1 week is approximately A. Vasopressin 89. Class 2 C.

Patients with dilated cardiomyopathy exhibit all of the following. 24 weeks D. and a pulse rate of 96 beats/min. Glucose D. Afterload should be maximized C. Left ventricular hypertrophy 91. Which of the following organs is least tolerant of ischemia for removal for transplantation? A. Dobutamine C. except A. The best agent to treat the hypotension is A. Heart D.90. You have administered a patient 1. Decreased myocardial contractility B. Pancreas 93.2 mg/kg of rocuronium to do an intubation. 8 mg/kg D. Noradrenaline D. 4 mg/kg C. 2 mg/kg B. a blood pressure of 80/40 mm Hg. The dosage you would use is A. Dopamine B. At what gestational age should you monitor fetal heart rate? A. 28 weeks . 18 weeks C. Increased preload D. After 4 days. 16 weeks B. Phosphate C. she develops dyspnea and is found to have cardiac failure. A pregnant lady is to undergo general anesthesia for acute appendicitis. You are unable to intubate or ventilate the patient and decide to reverse the patient’s paralysis with sugammadex. Epinephrine 92. Potassium B. Cornea B. A septic patient has a central venous pressure of 10 mm Hg. A young female patient with anorexia nervosa has just started eating again. Which of the following is most important to correct? A. 16 mg/kg 94. Sodium 95. Kidney E.

monitoring of somatosensory-evoked potentials indicates monitoring of A. High volatility 102. Age >60 years B. Which of the following is contraindicated to use during pregnancy? A. The desflurane vaporizer is heated because of desflurane’s A. Hydralazine 100. Calcitonin C. All of the following help increase the excretion of calcium. IV crystalloids 99. FEV <25% D. Which of the following is the most effective way to reduce renal failure in a patient having an abdominal aortic aneurysm repair? . 96. Thyromental distance 97. A patient with a history of chronic obstructive pulmonary disease presents for lung volume- reduction surgery. Which of the following is the best predictor of a difficult intubation in a morbidly obese patient? A. Enalapril C. Bisphosphonates B. except A. Spinothalamic tract 101. Dorsal column D. Aspirin B. Furosemide D. Body mass index C. During scoliosis surgery. Anterior horn B. Mallampati score D. Chronic asthma C. Metoprolol D. High minimum alveolar concentration D. High boiling point C. Which of the following is a contraindication for surgery? A. Anterior corticospinal tract C. High vapor pressure B. Evidence of bullous disease 98. Pretracheal tissue volume B.

F lu id b o lu s a fte r a o r tic c la m p r e le a s e C. M in im iz a tio n o f c r o s s . F lu id b o lu s p r i o r to a o r tic c la m p in g B. A d m in is tr a tio n o f m a n n ito l D.A.c la m p tim e .

a p p lic a tio n o f s c o p o la m in e p a tc h s h o u ld b e a v o id e d in th e e ld e r ly . m id d le . is o f te n a p p lie d a s a tr a n s d e r m a l p a tc h p r e o p e r a t iv e ly f o r th e p r e v e n tio n o f p o s to p e r a tiv e n a u s e a a n d v o m itin g . D. S u r g e r ie s lik e la p a r o s c o p y . C. h a lo p e r id o l. lik e a tr o p in e . m e to c lo p r a m id e is a n a n tid o p a m in e r g ic a g e n t. a n a n tic h o lin e r g ic d r u g . e s p e c ia lly in th e e ld e r ly .e a r s u r g e r y . P -L a c ta m a n tib io tic s m u s t b e g iv e n w ith in 6 0 m in u te s p r i o r to in c is io n . D. p o s to p e r a tiv e u s e o f o p io id s . T h e A p fe l s c o r e c a n b e u s e d to p r e d ic t p a tie n ts w ith a h ig h r i s k f o r p e r io p e r a tiv e n a u s e a a n d v o m itin g (P O N V ). CHAPTER 1 ANSWERS 1. B. 8. T h e la tte r tw o a r e u s u a lly u s e d f o r th e tr e a tm e n t o f r e f r a c t o r y P O N V . th u s h a s n o r e la tio n to p e r io p e r a tiv e b le e d in g d u e to p la te le t p a th o lo g y . A ll th e o th e r a g e n ts h a v e p r o v e n b e n e f it in p r e v e n tin g p o s to p e r a tiv e n a u s e a a n d v o m itin g . 7. a n d p r o p o f o l a ll a r e u s e d in th e tr e a tm e n t o f P O N V . H e n c e . V a n c o m y c in a n d f l u o r o q u in o lo n e s r e q u i r e a d m in is tr a tio n w ith in 1 2 0 m in u te s p r i o r to in c is io n . D. s u c h p r e m e d ic a tio n s h o u ld b e a v o id e d . . a n d p r o c h l o r p e r a z i n e is a d o p a m in e (D 2) r e c e p to r a n ta g o n is t ( a n tip s y c h o tic d r u g ) w ith a d d itio n a l a n tie m e tic a c tiv ity . E to m id a te a d m in is tr a tio n c a n c a u s e a n in c r e a s e in th e in c id e n c e o f p e r io p e r a tiv e n a u s e a a n d v o m itin g (P O N V ).H T 3 a n ta g o n is t. F a m o tid in e is k n o w n to c a u s e th r o m b o c y to p e n ia ( b o th q u a n tita tiv e a n d q u a lita tiv e p la te le t d y s f u n c tio n ) . P -L a c ta m a n tib io tic s m u s t b e g iv e n w ith in 6 0 m in u te s p r i o r to in c is io n . P a tie n ts w ith IT P a lr e a d y h a v e l o w p la te le ts . P a lo n o s e t r o n is a 5 . M e to c lo p r a m id e is a p r o k in e tic a g e n t a n d h e lp s to in c r e a s e g a s tr ic m o tility . 6. s c o p o la m in e p a s s e s th r o u g h th e b l o o d . P r o m e th a z in e . 3. S c o p o la m in e . W a r f a r in d o e s n o t a f f e c t p la te le t f u n c tio n o r n u m b e r. h o w e v e r. A p r e p ita n t is a n N K 1 r e c e p to r a n ta g o n is t th a t a n ta g o n iz e s th e a c tio n o f s u b s ta n c e P in th e c e n tr a l n e r v o u s s y s te m to p r e v e n t n a u s e a a n d v o m itin g . T r e a tm e n t o f s c o p o la m in e . V a n c o m y c in a n d f l u o r o q u in o lo n e s r e q u i r e a d m in is tr a tio n w ith in 1 2 0 m in u te s p r i o r to in c is io n . C. B. a n d u n lik e g ly c o p y r r o la te . T h e A S A d o e s n o t r e c o m m e n d p r e o p e r a t iv e a d m in is tr a tio n o f m e to c lo p r a m id e f o r p r e v e n tio n o f p o s to p e r a tiv e n a u s e a a n d v o m itin g .b r a i n b a r r i e r a n d c a n c a u s e c o n f u s io n . th u s .in d u c e d c o n f u s io n m a y r e q u i r e a d m in is tr a tio n o f p h y s o s tig m in e . It in c lu d e s f o u r f a c to r s : f e m a le g e n d e r . 5. a n d p r e v io u s P O N V o r m o tio n s ic k n e s s in th e p a tie n ts ’ h is to r y . H o w e v e r. n o n s m o k in g . it is a n in d e p e n d e n t r i s k f a c to r f o r b le e d in g . a n d s tr a b is m u s s u r g e r y a r e a s s o c ia te d w ith a h ig h e r r i s k o f PO N V . 2. C. 4.

A s p e r A S R A g u id e lin e s 2 0 1 0 . T h is is to p r e v e n t th e p o te n tia l f o r m a ti o n o f a n e p id u r a l h e m a to m a . te n n is . G . P. to ile t) • 4 M E T s — c a n w a lk u p a f li g h t o f s te p s o r a h ill • 4 to 10 M E T s — c a n d o h e a v y h o u s e h o ld w o r k ( s c r u b b in g f l o o r s . s k iin g ) 11. s n o r in g . h ig h b l o o d p r e s s u r e . T h e a s s e s s m e n t o f p r e o p e r a t iv e p r e d ic ta b ility f o r o b s tr u c tiv e s le e p a p n e a c a n b e d o n e b y u s in g th e “ S T O P . e x c e p t c h o ic e D . P e a k a c tio n o f in je c ta b le v ita m in K ta k e s u p to 6 to 12 h o u r s . d r e s s in g . k e ta m in e c a u s e s a n in c r e a s e in s e c r e tio n s . K e ta m in e c a u s e s th e le a s t r e s p i r a t o r y d e p r e s s io n a m o n g th e in tr a v e n o u s in d u c tio n a g e n ts . B. 17. E f f o r t to le r a n c e o f a r o u n d 4 M E T s ( m e ta b o lic e q u iv a le n t o f ta s k s ) o r m o r e is s u g g e s te d to b e a g o o d p r e d ic to r f o r p o s to p e r a tiv e c a r d io p u lm o n a r y o u tc o m e . A . h e p a r in in f u s io n s h o u ld b e s to p p e d a t le a s t 2 to 4 h o u r s b e f o r e p la c in g a n e p id u r a l. f o r e m e r g e n t s u r g e r y th e fa s te s t m e th o d is th e a d m in is tr a tio n o f f r e s h . it m a y b e b e n e f ic ia l a s a n in d u c tio n a g e n t in p a tie n ts w ith s e v e r e a s th m a . a r e s ig n s o f d ia b e tic a u to n o m ic n e u ro p a th y . a n d m a y p r o d u c e e m e r g e n c e d e lir iu m (v iv id d r e a m s ) . T h e r e f o r e . . 10. A s p e r th e A H A /A C C S c ie n tific S ta te m e n t. tu m o r s o f th e u p p e r a irw a y . a s p ir in in ta k e b y th e p a tie n t is n o m o r e c o n s id e r e d a s a c o n tr a in d ic a tio n to p e r f o r m i n g a n e u r a x ia l b lo c k . B . A ll. m a le g e n d e r . C. T h u s . B.B A N G ” q u e s tio n n a ir e . O . In th is s c o r in g . N . e x c e p t c h o ic e D . B M I > 3 5 k g / m 2. T h e s e a c tiv itie s a r e c la s s if ie d a s p e r p h y s ic a l s tr a in in v o lv e d . T . lif tin g h e a v y f u r n itu r e ) • > 1 0 M E T s — c a n p a r tic ip a te in s tr e n u o u s s p o r ts (s w im m in g . w h ic h c a n le a d to p o o r c o m p e n s a tio n o f h y p o te n s io n in p a tie n ts u n d e r g o in g s u r g e r y . A s p e r A S R A g u id e lin e s (2 0 1 0 ). M E T s c a n b e a s s e s s e d a s f o llo w s : • 1 M E T — c a n ta k e c a r e o f s e lf (e a tin g . A. D. C. b a s k e tb a ll. a h ig h w e ig h t lo s s c a n p r e d ic t h ig h e r c ir c u l a t o r y v o lu m e lo s t. a n d n o t f e m a le g e n d e r . D.5 to th e o x y g e n c o n s u m p tio n (m L O 2/k g /m in ) . P r e tr e a tm e n t w ith g ly c o p y r r o la te a n d m id a z o la m a lle v ia te s th e s e e ffe c ts o f k e ta m in e .d e p e n d e n t r e s p i r a t o r y d e p r e s s io n . O n e m e ta b o lic e q u iv a le n t is d e f in e d a s th e a m o u n t o f o x y g e n c o n s u m e d a t re s t. D. U r in a r y r e te n tio n a t th is a g e is m o r e lik e ly d u e to p r o s ta te h y p e r tr o p h y . H o w e v e r. 12.5 m L O 2/k g /m in . T h e o th e r in d u c tio n a g e n ts c a u s e d o s e . n e c k c ir c u m f e r e n c e > 4 0 c m . o r f a c io m a x illa r y a b n o r m a litie s . r e v e r s a l o f w a r f a r i n c a n b e a c h ie v e d b y u s in g a ll. W e ig h t lo s s d u e to d ia ly s is is a ttrib u te d to a c tu a l v o lu m e ( u ltr a f iltr a te ) r e m o v e d f r o m th e b o d y . T h e e n e r g y c o s t o f a n y a c tiv ity c a n b e d e te r m in e d b y m u ltip ly in g 3.f r o z e n p la s m a . A. u p p e r a ir w a y a n a to m ic a l a b n o r m a litie s th a t in c r e a s e th e l i k e lih o o d o f o b s tr u c tio n a r e to n s illa r h y p e r tr o p h y . 14. m a le g e n d e r ) . 13. a n d is e q u a l to 3. 16. 15. is c la s s if ie d a s a r i s k f a c to r (S . o b s e r v e d f o r a p n e a d u r in g s le e p . a g e > 5 0 y e a r s . H o w e v e r. In a d d itio n to th e q u e s tio n n a ir e .9. tir e d d u r in g d a y tim e .

A. T h e g o a ls o f p r e a n e s th e tic e v a lu a tio n in c lu d e a ll th o s e lis te d in th e q u e s tio n . D.r e la te d a n x ie ty ). w h ic h c a n c a u s e h y p e r c a r b i a a n d a n in c r e a s e in in tr a c r a n ia l p r e s s u r e . D. A t p re s e n t. 24. P a tie n ts s h o u ld h a v e a p r e o p e r a t iv e E C G . T h is is o n e o f th e p r im e a im s th a t n e e d to b e f u lf ille d a s a c o m p o n e n t o f p r e o p e r a t iv e a n e s th e tic e v a lu a tio n . B. p o s to p e r a tiv e ly . A n a n e s th e s ia c o n s e n t s h o u ld b e o b ta in e d d u r in g p r e a n e s th e tic e v a lu a tio n . s e d a tiv e s c a n le a d to d e p r e s s io n o f r e s p i r a t o r y d r iv e . B. 20. a s it r e c o g n iz e s p a tie n t c o m o r b id iti e s . D. o b ta in in g in f o r m e d c o n s e n t.b a s e d m o r b i d ity r a th e r th a n ty p e o f s u r g e r y . 27. S e d a tiv e s ty p ic a lly a lle v ia te a n x ie ty in h y p e r te n s iv e p a tie n ts ( p r e v e n tin g b l o o d p r e s s u r e e le v a tio n s d u e to s u r g e r y . w h e n e v e r p o s s ib le . H e a lth y p r e g n a n t p a tie n ts in la b o r a r e c la s s if ie d a s a n A S A II. p r e o p e r a t iv e e v a lu a tio n is v ita l. In a d d itio n . n o c o n v e n tio n a l te s t (P T .w e ig h t h e p a r in in th e r a p e u tic d o s e s m u s t . P r e o p e r a tiv e e v a lu a tio n e v e n tu a lly lo w e r s in d ir e c t c o s ts th a t m a y b e in c u r r e d to tr e a t th e w o r s e n i n g a lim e n t. w a r f a r i n m u s t b e s to p p e d a t le a s t 5 d a y s p r i o r a n d c l o p i d o g r e l 7 to 10 d a y s p r i o r to e le c tiv e s u r g e r y . P r e o p e r a tiv e e v a lu a tio n in f a c t in c lu d e s a b a tte r y o f te sts a n d a d d s a d d itio n a l c o s ts to th e to ta l p e r io p e r a tiv e c o s ts . 25. P a tie n ts w ith c o n tr o lle d d ia b e te s o r e s s e n tia l h y p e r te n s io n a r e s till c la s s if ie d a s a n A S A II. th e ir e ffe c ts a r e g e n e r a lly c o n s id e r e d to b e s y n e r g is tic . P a tie n ts r e c e iv in g b o th th e s e d r u g s m a y b e p r o n e to g r e a te r s e d a tio n a n d r e s p i r a t o r y d e p r e s s io n th a n w h e n r e c e iv in g th e d r u g a lo n e . C. o r c o m m it to o th e r p r e v e n tiv e c a r e . B. 22.18. A S A c la s s if ic a tio n d o e s n o t in c lu d e th e n a tu r e o f p r o c e d u r e in p r e d ic tin g p e r io p e r a tiv e m o r b i d ity a n d m o r ta lity .F a c to r X a e s tim a tio n m a y b e u s e d in s p e c if ic p a tie n ts to m o n ito r th e c o a g u la tiv e e ffe c ts o f L M W H . b e f o r e d is c h a r g in g th e p a tie n t. D r o p e r id o l c a n c a u s e a s ig n if ic a n t p r o l o n g a t i o n o f th e Q T in te r v a l o n th e E C G . o th e r ta r g e ts o f p r e a n e s th e tic e v a lu a tio n in c lu d e e d u c a tio n o f p a tie n ts a n d f a m ilie s a b o u t a n e s th e s ia a n d th e a n e s th e s io l o g is t’s r o le . A s th e s e d r u g s a c t o n d if f e r e n t r e c e p to r s . It o n ly in c lu d e s p a tie n t. A n ti. m o tiv a tio n o f p a tie n ts to s to p s m o k in g a n d lo s e w e ig h t. B. p a tie n t a n x ie ty is u s u a lly lo w e r e d a s th e r is k s a n d p r o c e d u r e a r e e x p la in e d to th e p a tie n t. 21. D. 26. H o w e v e r. P T T ) c a n b e u s e d to q u a n tif y th e c lin ic a l e ffe c ts o f L M W H o n th e c o a g u la tio n s y s te m . a n d E C G m o n ito r in g s h o u ld b e c o n tin u e d p o s to p e r a ti v e ly f o r a t le a s t 2 h o u r s . A s p e r A S R A g u id e lin e s . 23. in p a tie n ts w ith c h r o n ic a lc o h o l a b u s e . P r e s e n c e o f p r e e c la m p s ia w ill s te p u p th e c la s s if ic a tio n to a n A S A III. w h ic h c a n w o r s e n p e r io p e r a tiv e l y a n d c a u s e in c r e a s e d p a tie n t m o r b id ity . 19. D u r in g p r e o p e r a t iv e in te r a c tio n .m o le c u la r . L o w . In n e u r o s u r g i c a l p a tie n ts . a n d in c h ild r e n to m a in ta in c o o p e r a tio n f o r in d u c tio n o f a n e s th e s ia .

h y p e r te n s iv e w ith o u t c o r o n a r y a r te r y d is e a s e o r a n g in a ) a s a n A S A II. le ft- a tr ia l c lo ts m u s t b e r u le d o u t. 30. th e p a tie n t s h o u ld b e a d v is e d to u n d e r g o b a llo o n d ila ta tio n a n d th e n d e la y th e e le c tiv e p r o c e d u r e f o r 2 to 3 w e e k s th e re a f te r . b e s to p p e d a t le a s t 2 4 h o u r s p r io r . F o r a d r u g . D. A n IN R o f 1. . C. B. C. 33. A n e m ia is a r e s u lt o f d e c r e a s e d e r y th r o p o ie tin p r o d u c tio n a n d is o f te n la b e le d a s “ a n e m ia o f c h r o n ic d is e a s e . it is a d v is e d to a v o id e le c tiv e s u r g e r y f o r a y e a r (to c o n tin u e d u a l a n tip la te le t m e d ic a tio n ) . A s p e r A S A g u id e lin e s . c e n tr a l n e u r a x ia l b lo c k a d e is s till d e b a te d in th e s e p a tie n ts . th e s e p a tie n ts r e q u i r e s u r g e r y d e s p ite b e in g r e a l l y s ic k .e lu tin g ste n t. a n d w h e n b e in g u s e d in p r o p h y la c tic d o s e s . O n c e th e p a tie n t’s a c tiv ity is lim ite d d u e to th e d is e a s e . th e s u r g ic a l c o r r e c t i o n o f th e u n d e r ly in g p a th o lo g y (th a t m a y h a v e le d to m u l tio r g a n in v o lv e m e n t) m a y b e th e o n ly o p tio n o f im p r o v in g th e ir c h a n c e s o f s u r v iv a l. P e r f o r m i n g la p a r o s c o p ic s u r g e r y p o s t.e. O n th e d a y o f th e s u r g e r y . w ith a n a c u te k id n e y in ju r y . 31.C A B G s u r g e r y is h ig h ly ris k y . S o w h e n s u r g e r y n e e d s to b e p la n n e d in th e n e a r fu tu r e . M o s t o fte n . w o u ld b e a n e x a m p le . W a r f a r in s h o u ld b e s to p p e d a t le a s t 5 d a y s p r i o r to s u r g e r y . A S A c la s s if ie s a n y m e d ic a l c o m o r b id ity w ith o u t f u n c tio n a l lim ita tio n (i.4 o r le s s is d e s ir a b le to p e r f o r m th e s u r g e r y . C. a n d th e r e f o r e . th e c h a n c e s o f s u r v iv a l m a y n o t im p r o v e . th e p r o t h r o m b i n tim e ( in te r n a tio n a l n o r m a liz e d r a tio o r IN R ) is c h e c k e d . B y d e f in itio n . it is r e c o m m e n d e d to w a it a t le a s t 6 h o u r s a fte r in g e s t io n o f n o n h u m a n m ilk b e f o r e p e r f o r m i n g a n e le c tiv e o p e r a tio n in a c h ild . 32. 29. th e p a tie n t is th e n c a te g o r iz e d a s a n A S A III.m e ta ll ic sten t. A S A III is a p a tie n t w ith s e v e r e s y s te m ic d is e a s e th a t is a c o n s ta n t th r e a t to lif e ( f u n c tio n a lity in c a p a c ita te d ) . 28. C. A s p ir in u s e is n o m o r e c o n s id e r e d a s a c o n tr a in d ic a tio n to p e r f o r m i n g a n e u r a x ia l b lo c k . A h e m o d y n a m ic a lly u n s ta b le p a tie n t s e c o n d a r y to p e r f o r a t i o n p e r ito n itis . it is a d v is e d to a v o id e le c tiv e s u r g e r y f o r a b o u t 4 w e e k s . B e f o r e a n y r a te /r h y th m c o n tr o l in p a tie n ts lik e ly to h a v e A F f o r m o r e th a n 4 8 h o u r s . 34. B y d e f in itio n . A lth o u g h th e p a tie n t m a y b e e x tr e m e ly s ic k . R e n a l f a ilu r e c a n in d u c e p la te le t d y s fu n c tio n . T h e y a ls o h a v e c o a g u la tio n f a c to r a b n o r m a litie s th a t m a y p r e d is p o s e th e m to d e e p v e in th r o m b o s is .” 36. D. B. 35. A. u n til th e p e r f o r a t i o n p e r ito n itis is s u r g ic a ll y tre a te d . it m u s t b e s to p p e d a t le a s t 12 h o u r s p r i o r to a n e le c tiv e s u r g e r y r e q u i r i n g c e n tr a l n e u r a x ia l b lo c k a d e . a n d f o r a b a r e . A n u n d ia g n o s e d c lo t c a n le a d to c a ta s tr o p h ic e m b o lic co n seq u en ces. s u c h p a tie n ts a r e c a te g o r iz e d a s A S A C la s s V I..

h y p o th e r m ia . a n d p o s tu r a l d r a in a g e o f m u c u s a n d s e c r e tio n s .5 % b e tw e e n 3 a n d 6 m o n th s . 43. F o r e x a m p le . B. f u r th e r d e ta ils s h o u ld b e o b ta in e d f r o m th e h is to r y . R e d u c e d le v e ls o f C O H b in c r e a s e s le v e ls o f o x y g e n a te d H b . B. a n d 2 % a fte r 6 m o n th s o f a m y o c a r d ia l in f a r c tio n . a n x io ly tic s . 41. th e p a tie n t s h o u ld b e a s s u m e d to b e p r o n e to d e v e lo p in g M H . D e la y e d b e n e f its ( c e s s a tio n m o r e th a n 8 w e e k s ) a r e k n o w n to im p r o v e a ir w a y i m m u n o lo g i c a n d c i l i a r y fu n c tio n . C. m o r i b u n d /s ic k p a tie n ts . C h r o n ic a lc o h o l a b u s e .f r o z e n p la s m a . R is k o f r e i n f a r c t i o n is a p p r o x im a te ly 5 . S in c e h e r a u n t h a d a s e v e r e r e a c tio n to a n e s th e s ia . w h ic h d e c r e a s e s th e r i s k o f m y o c a r d ia l is c h e m ia a n d p e r io p e r a tiv e c a r d ia c m o r b id ity . 2 . T E G h a s th e h ig h e s t p o s itiv e p r e d ic tiv e v a lu e f o r d ia g n o s i n g a b le e d in g te n d e n c y . T h u s . V o la tile a g e n ts a n d s u c c in y lc h o lin e s h o u ld b e a v o id e d in th is p a tie n t. it is r e c o m m e n d e d th a t a n IN R v a lu e o f 1. th u s c a u s in g h y p o k a le m ia . T h e r e f o r e . C. m u s c le tw itc h m o n ito r in g s h o u ld b e d o n e o n th e n o n a f f e c te d s ite s to c o r r e c t l y m o n ito r th e d e g r e e o f n e u r o m u s c u la r b lo c k a d e . D. T h e r e is n o s p e c if ic v a lu e o f IN R b e f o r e a p a tie n t is ta k e n to th e O R f o r e le c tiv e s u r g e r y . T h e p a r a ly z e d m u s c le s d u e to c e n tr a l d e n e r v a tio n e v e n tu a lly d e v e lo p a tro p h y . th e IN R c a n b e n o r m a liz e d b y in f u s in g f r e s h . a lc o h o l in to x ic a tio n . 42.5 % f o r s u r g e r i e s b e tw e e n 0 a n d 3 m o n th s . A m o n g a ll th e s e te sts. w h ic h r e m a in r e s is ta n t to th e e ffe c ts o f n e u r o m u s c u la r b lo c k a d e f o r v a r y in g d e g r e e s . A. In c a s e o f e m e r g e n c y . 45. 39. th e o th e r te sts w ill b e d e r a n g e d in a p a tie n t w ith .4 o r le s s s h o u ld b e a im e d f o r b e f o r e ta k in g th e p a tie n t to th e O R f o r e le c tiv e s u r g e r y . M H h a s a g e n e tic c o m p o n e n t. A s s u c h . a n d r u n s in f a m ilie s . T h is in c lu d e s p u lm o n a r y to ile t: c h e s t p h y s io th e r a p y /e x e r c is e s . T h is p r in c ip le is s o m e tim e s u s e d in th e tr e a tm e n t o f p a tie n ts w ith h y p e r k a le m ia . S m o k in g c e s s a tio n f o r 2 4 h o u r s b e f o r e s u r g e r y r e d u c e s c a r b o x y h e m o g lo b i n (C O H b ) le v e ls . E x tr a ju n c tio n a l r e c e p to r s a r e th e n s y n th e s iz e d a t th e m u s c le s ite s . E le c tiv e s u r g e r y s h o u ld b e p o s tp o n e d f o r a t le a s t 6 w e e k s a fte r a m y o c a r d ia l in f a r c tio n . M A C ty p ic a lly is f o u n d to b e lo w e r f o r p a tie n ts o n s e d a tiv e s . e x tr e m e s o f a g e . H o w e v e r. in c r e a s e s M A C . T h e m o s t s ig n if ic a n t r i s k f a c to r f o r d e v e lo p in g p u lm o n a r y c o m p lic a tio n s is th e u p p e r a b d o m in a l o r th o r a c ic s ite o f s u r g e r y . 40. V o la tile in h a la tio n a g e n ts a n d s u c c in y lc h o lin e a r e c o n s id e r e d t r i g g e r s f o r m a lig n a n t h y p e r th e r m ia (M H ) r e a c tio n . D e r a n g e d v a lu e s f r o m o th e r te sts lis te d h a v e n o t s h o w n to a lw a y s c o r r e la te w e ll w ith b le e d in g te n d e n c y . a ll p a tie n ts u n d e r g o in g s u c h s u r g e r i e s s h o u ld b e o p tim a lly p r e p a r e d f o r th e s u r g e r y . If a n y d o u b t a b o u t th e h is to r y . D. a n d p a tie n ts w ith o b tu n d e d c o n s c io u s n e s s .37. A. th e s e p a r a ly z e d m u s c le s g iv e a n e x a g g e r a te d r e s p o n s e o n d ir e c t s tim u la tio n w ith a n e r v e s tim u la to r . 44. C. 38. A ll p 2 a g o n is ts a r e k n o w n to c a u s e in te r n a liz a tio n o f p o ta s s iu m ( f r o m p la s m a to c e ll). h o w e v e r.

lik e e x tr a p y r a m id a l s id e e ffe c ts . It b lo c k s th e d o p a m in e r g ic r e c e p to r s to c a u s e p a r k in s o n is m . C. P r e o x y g e n a tio n o f lu n g s p r i m a r i l y a c ts to in c r e a s e s a f e a p n e a tim e b y d e n itr o g e n a tin g f u n c tio n a l r e s id u a l c a p a c ity (F R C ) a n d in c r e a s in g d is s o lv e d o x y g e n c o n te n t in th e b lo o d . c a n c a u s e tw o s u b ty p e s o f h e p a titis (ty p e 1 is im m u n o g e n ic — m ild — a n d ty p e 2 is d u e to d ir e c t e f f e c t o f h a lo th a n e o n liv e r c e lls ) . it h a s n o e f f e c t o n F R C o r o n c lo s in g v o lu m e /c a p a c ity . s e p s is b u t m a y n o t s h o w a c lin ic a ll y r e le v a n t b le e d in g te n d e n c y . A. It c a n b e u s u a lly c o n tr o lle d w ith in tr a o p e r a tiv e a n tih y p e r te n s iv e m e d ic a tio n s w ith o u t e v id e n c e o f s ig n if ic a n t a d v e r s e o u tc o m e s . N itr o u s o x id e is k n o w n to in h ib it th e e n z y m e “ m e th io n in e s y n th a s e . 47. D. 51. 48. H a lo th a n e . It d o e s n o t a lte r a n y p h y s ic a l m e a s u r e m e n ts o f lu n g s . D. S e v o f lu r a n e h a s l a r g e l y r e p la c e d h a lo th a n e d u e to a b e tte r s a f e ty p r o f ile . N itr o u s o x id e is a ls o k n o w n to a c t o n N M D A r e c e p to r s a n d a ls o in c r e a s e p u lm o n a r y v a s c u la r r e s is ta n c e . D. b u t m a y n o t a c tu a lly w o r k f o r n a u s e a ( v o m itin g r a th e r th a n n a u s e a is p r e v e n te d ) . P r o p o f o l. 53. 52. is u s e d in r e f r a c t o r y c a s e s o f P O N V a n d in l o w d o s e s . A ll th e o th e r c h o ic e s a r e a s a r e s u lt o f d ir e c t c o n s e q u e n c e o f c h o lin e r g ic b lo c k a d e . e s p e c ia lly o n r e p e a te d a d m in is tr a tio n . 50. 49. B. K e ta m in e p r e s e r v e s s p o n ta n e o u s r e s p i r a t i o n a n d a ir w a y to n e w ith o u t c a u s in g a p n e a a t in d u c tio n d o s e s . p r e v e n tin g v o m itin g . 46. c a u s in g p e r n ic io u s m e g a l o b la s tic a n e m ia . 54. M e to c lo p r a m id e is a p r o k in e tic a g e n t th a t e n h a n c e s g a s tr ic c le a r a n c e a n d in c r e a s e s lo w e r e s o p h a g e a l s p h in c te r to n e . G ly c o p y r r o la te is a s y n th e tic q u a te r n a r y a m in e w ith a n tim u s c a r in ic p r o p e r tie s a n d n o c e n tr a l s id e e ffe c ts l ik e s e d a tio n . C. A ll th e o th e r c h o ic e s n e e d e v a lu a tio n /o p tim iz a tio n p r i o r to e le c tiv e n o n c a r d ia c s u r g e r y .” in h ib itin g D N A s y n th e s is a n d p r e c ip ita tin g B 12 d e fic ie n c y . U n c o n tr o lle d s y s to lic h y p e r te n s io n w ith o u t t a r g e t e n d . B o th h a lo th a n e a n d s e v o f lu r a n e h a v e b e e n u s e d f o r in h a la tio n in d u c tio n in th e p e d ia tr ic p o p u la tio n . C. . P r o p o f o l a n d b e n z o d ia z e p in e s a r e a s s o c ia te d w ith r e s p i r a t o r y d e p r e s s io n a t in d u c tio n d o s e s a n d c a u s e a p n e a . C. A ll th e m e c h a n is m s h a v e b e e n p r o p o s e d f o r p r o p o f o l in p r e v e n tin g n a u s e a a n d v o m itin g in th e p o s to p e r a tiv e p e r i o d (P O N V ). th a t is . T h e in c id e n c e o f h a lo th a n e h e p a titis is a r o u n d 1 in 1 0 . w h e n u s e d .0 0 0 to 1 in 3 5 .o r g a n d a m a g e is a m in o r p r e d i c t o r / r i s k fa c to r. a n d h a s e m e r g e d a s th e in d u c tio n a g e n t o f c h o ic e in p e d ia tr ic p o p u la tio n .0 0 0 h a lo th a n e a n e s th e tic s .

r e la te d c o m p lic a tio n n o t a s s o c ia te d d ir e c tly w ith o b e s ity . 60. 59. T h e la tte r c a u s e s h y p o th a la m ic . e s p e c ia lly in th e g e r ia tr ic a g e g r o u p . T h u s . B. 61. M u ltip le s tu d ie s h a v e s h o w n p r o p e n s ity o f A C E in h ib ito r s to p r e c ip ita te p r o f o u n d h y p o te n s io n a t in d u c tio n o f g e n e r a l a n e s th e s ia . It d o e s n o t p r o d u c e a n a lg e s ia . O b e s e p a tie n ts a r e a ls o k n o w n to h a v e a h ig h e r in c id e n c e o f c a r d ia c p r o b le m s . h y p o te n s io n . A.H T 3 r e c e p to r s . F a c to r s th a t a r e a s s o c ia te d w ith a n in c r e a s e d r i s k o f p o s to p e r a tiv e n a u s e a a n d v o m itin g . A C E in h ib ito r s s h o u ld b e w ith h e ld o n th e d a y o f th e s u r g e r y . D. It h a s a n tid o p a m in e r g ic a c tiv ity . 64.55. R a r e ly r e p o r te d s id e e ffe c ts o f th e s e a g e n ts in c lu d e Q T p r o lo n g a tio n . w h ic h c a n c a u s e d ir e c t n e u r o to x ic ity . C o m p r e s s io n n e u r o p a th ie s a r e a ls o c o m m o n in th is s u b p o p u la tio n . 57. in c lu d in g a d ila te d h e a r t a n d h e a r t f a ilu r e . e s p e c ia lly in th e e ld e r ly a n d f o r m a jo r s u r g e r ie s . H e n c e .a .n e r v o u s . a n d h e a d a c h e . 58. S u c c in y lc h o lin e s h o u ld n o t b e u s e d in p a tie n ts w ith a h is to r y o f m u s c u la r d y s tr o p h y o r p a tie n ts w ith a h is to r y o f m a lig n a n t h y p e r th e r m ia . D.a d r e n e r g i c a c tiv ity .b r a i n b a r r i e r a n d c a u s e s e d a tio n a n d c o n f u s io n . 56. w ith a b o u t e ig h t tim e s g r e a te r a f f in ity f o r th e r e c e p to r th a n c lo n id in e . P r o m e th a z in e is c o m m o n ly u s e d a s a n a n tie m e tic . e v e n tu a lly le a d in g to p u lm o n a r y a r te r y h y p e r te n s io n . A d d is o n ia n c r is is o r a c u te a d r e n a l in s u f f ic ie n c y d u r in g th e p e r io p e r a tiv e p e r i o d o c c u r s in p a tie n ts w ith k n o w n a d r e n a l in s u f f ic ie n c y o r in th o s e r e c e iv in g c h r o n ic s te r o id th e ra p y . D e m e n tia is a c e n tr a l. D.p itu ita r y a x is s u p p r e s s io n . a n d in a d d itio n a ls o h a s a n tih is ta m in ic a n d a n t i . T r e a tm e n t c o n s is ts o f a d m in is tr a tio n o f h y d r o c o r tis o n e a n d c o r r e c t i o n o f a s s o c ia te d d e r a n g e m e n ts . C. S c o p o la m in e is a n a n tim u s c a r in ic d r u g th a t c a n c r o s s th e b l o o d . M y a s th e n ia g r a v is p a tie n ts m a y s h o w r e s is ta n c e to P h a s e I b lo c k o f s u c c in y lc h o lin e . C o n tin u o u s in f u s io n is m o r e lik e ly to r e s u lt in h y p o te n s io n a n d b r a d y c a r d ia . 63. In p a tie n ts w ith fu ll s to m a c h . e s p e c ia lly in th e e ld e r ly . B. D e x m e d e to m id in e is a n a 2 r e c e p to r a g o n is t. D. O n d a n s e tr o n e x e r ts its a n tie m e tic e f f e c t b y a c tin g a s a n a n ta g o n is t o n th e 5 . s u c c in y lc h o lin e is u s e d in “ r a p id s e q u e n c e in tu b a tio n ” to p r e v e n t a s p ir a tio n . w h ic h le a d s to in c r e a s e d p u lm o n a r y v a s c u la r r e s is ta n c e . D r u g s in th e s a m e c a te g o r y in c lu d e p a lo n o s e tr o n a n d g r a n is e tr o n . 62. B.s y s te m . C. it is r e c o m m e n d e d th a t r e m if e n ta n il p r e p a r a t io n s b e n o t u s e d f o r c e n tr a l n e u r a x ia l b lo c k a d e . R e m if e n ta n il p r e p a r a t io n s a v a ila b le in th e m a r k e t h a v e g ly c in e a s th e p r e s e r v a tiv e . M o r b id ly o b e s e p a tie n ts w ith O S A a r e o f te n s u b je c t to p e r s is te n t h y p o x ia . P a tie n ts w ith a d r e n a l in s u f f ic ie n c y m a y p r e s e n t w ith r e f r a c t o r y s h o c k w ith e le c tr o ly te a n d g lu c o s e a b n o r m a litie s .

E s tr o g e n in ta k e c a n le a d to a h y p e r c o a g u la b le sta te . B. m y o c lo n ic tw itc h e s . n a u s e a . n o n s m o k in g . a c u te o r c h r o n ic . 65. B e c a u s e o f its n a r r o w th e r a p e u tic in d e x . 71. a n d d e a th . w h ic h p r e v e n ts it f r o m c r o s s in g th e b l o o d . e tc. p a in . C h r o n ic lith iu m in to x ic a tio n o c c u r s in th o s e p a tie n ts o n lo n g . a n d g a s tr ic d is te n tio n .b r a i n b a r r i e r . P a tie n ts u n d e r tr e a tm e n t w ith M A O Is h a v e a n in c r e a s e d a v a ila b ility o f e n d o g e n o u s n o r e p in e p h r in e . r e n a l in s u f f ic ie n c y . v o m itin g .a c tin g d r u g s u c h a s e p h e d r in e c a n le a d to a n e x a g g e r a te d r e s p o n s e . C. d r o w s in e s s . B. T h e r e f o r e . s e iz u r e s . lo w e r e x tr e m ity p a r a ly s is . A. d y s a r th r ia . p la te le t d y s fu n c tio n . 68. lith iu m d o s in g r e q u ir e s c o n s ta n t s u r v e illa n c e w ith m o n ito r in g o f le v e ls a n d d o s a g e a d ju s tm e n t. T h r e e ty p e s o f lith iu m in to x ic a tio n c a n o c c u r — a c u te . in c lu d e p r e v io u s h is to r y o f p o s to p e r a tiv e n a u s e a a n d v o m itin g . A b r u p t w ith d r a w a l o f T P N w ill m o s t c o m m o n ly r e s u lt in h y p o g ly c e m ia d u e to th e h ig h c ir c u la tin g in s u lin le v e ls . a n d f la t o r in v e r te d T -w a v e s o n E C G • S e v e re to x ic ity : m a y b e lif e . c a u s e s d r y n e s s o f s e c r e tio n s .t e r m lith iu m th e ra p y . p r e d is p o s in g w o m e n to t h r o m b o e m b o li c e v e n ts . O th e r r i s k f a c to r s f o r th r o m b o e m b o li s m in c lu d e m a jo r s u r g e r y . T h is m a y p r o l o n g n e u r o m u s c u la r b lo c k a d e a s s o c ia te d w ith n o n d e p o la r iz i n g m u s c le r e la x a n ts . G ly c o p y r r o la te in c r e a s e s th e h e a r t ra te . a n d lo w e r s th e lo w e r e s o p h a g e a l s p h in c te r to n e . H y p o te n s io n in th e s e p a tie n ts is b e tte r m a n a g e d w ith a d ir e c t. in c r e a s in g a g e . in c r e a s e d d e e p te n d o n r e f le x e s . a n d d ia r r h e a • M o d e r a te to x ic ity : m a n if e s ts a s c o n f u s io n . It m a y p r e s e n t w ith g r o s s l y im p a ir e d c o n s c io u s n e s s . T h e la tte r m a y p r e d is p o s e a p a tie n t to p u lm o n a r y a s p ir a ti o n o f g a s tr ic c o n te n ts . 67. m u s c le w e a k n e s s . c o m a . P a tie n ts ta k in g h e r b a l m e d ic a tio n s f o r th e ir a lle g e d b e n e f its a r e o f te n u n a w a r e o f th e ir p o te n tia l s id e e ffe c ts ( b le e d in g te n d e n c y .a c tin g d r u g s u c h a s p h e n y le p h r in e . A. o b e s ity . m u ltip le tr a u m a (h ip f r a c tu r e ) . A. . a n d c h r o n ic . c a r d ia c o r r e s p i r a t o r y f a ilu r e . 70. G ly c o p y r r o la te is a n a n tic h o lin e r g ic d r u g w ith a q u a te r n a r y a m m o n iu m s tr u c tu r e . c o a r s e h a n d tr e m o r . tr e a tm e n t w ith a n in d ir e c t. T h e r e f o r e . p r e s e n c e o f c e n tr a l v e n o u s lin e s . la p a r o s c o p ic s u r g e r y . A. it h a s n o c e n tr a l n e r v o u s s y s te m e ffe c ts (s e d a tio n ) .th r e a te n in g . n y s ta g m u s . a n d a w id e v a r ie ty o f h e m a t o lo g ic c o n d itio n s ( in h e r ite d o r a c q u ir e d ) . G e n ta m ic in is a n a m in o g ly c o s id e a n tib io tic th a t b lo c k s a c e ty lc h o lin e r e le a s e f r o m th e p r e s y n a p tic te r m in a ls a n d r e d u c e s p o s ts y n a p tic r e s p o n s iv e n e s s . a ta x ia . M o s t m e d ic a tio n s m u s t b e s to p p e d f o r a t le a s t 7 d a y s p r i o r to s u r g e r y . 66.). • M ild to x ic ity : m a n if e s ts a s le th a r g y . e y e o r e a r s u r g e r y . a n e s th e tic d r u g s . 69. p r o l o n g e d im m o b ility . f e m a le g e n d e r . s y n c o p e .

a n a p h y la c tic s h o c k is th e m o s t c o n s is te n t d ia g n o s is a n d n e e d s to b e tr e a te d w ith e p in e p h r in e f ir s t. U s in g lid o c a in e j e l l y to lu b r ic a te th e e n d o tr a c h e a l tu b e . A. A. 79. T h e f e m o r a l n e r v e lie s la te r a l to th e f e m o r a l a rte ry . L a r y n g o p h a r y n g iti s is m o r e c o m m o n a fte r a n e n d o tr a c h e a l in tu b a tio n th a n w h e n u s in g a la r y n g e a l m a s k a irw a y . a n d th e r a d ia l n e r v e s . 78. s m a lle r c u f f s iz e s (le s s a r e a o f c o n ta c t w ith tr a c h e a l m u c o s a ) . r e c u r r e n t la r y n g e a l n e r v e b lo c k . 77. P a tie n ts ta k in g o r a l h y p o g ly c e m ic a g e n ts m a y e x p e r ie n c e d e la y e d h y p o g ly c e m ia in th e a b s e n c e o f c a l o r i c in ta k e in th e in tr a o p e r a tiv e a n d p o s to p e r a tiv e p e r io d s . P a tie n ts o n a n in s u lin p u m p s h o u ld c o n tin u e th e in s u lin a t th e b a s a l ra te .72. h y p o k a le m ia . th e g u id e w ir e o r th e tip o f th e c a th e te r e n te r s th e r i g h t a tr iu m a n d m a y r e s u lt in a n a r r h y th m ia . 76. C. C o m p lic a tio n s o f a n in te r s c a le n e b lo c k in c lu d e s te lla te g a n g lio n b lo c k . a n d l o w p r e s s u r e in th e tr a c h e a l c u f f d e c r e a s e th e in c id e n c e o f p o s to p e r a tiv e s o r e th r o a t. H o r n e r s y n d r o m e . w h ic h m u s t b e b lo c k e d s e p a r a te ly (d e e p in je c tio n in to th e c o r a c o b r a c h ia lis m u s c le ) . p h r e n ic n e r v e b lo c k . d is tu r b e d c o l o r v is io n ( y e llo w o r g r e e n h a lo s a r o u n d o b je c ts ) . w h ic h is la te r a l to th e f e m o r a l v e in (V A N — v e in . a p r o l o n g e d P R in te r v a l. C. D. S ig n s a n d s y m p to m s o f d ig o x in to x ic ity in c lu d e d r o w s in e s s o r c o n f u s io n . T h e u ln a r n e r v e is f r e q u e n tly s p a r e d w ith a n in te r s c a le n e b lo c k . m e tf o r m in s h o u ld b e s to p p e d a t le a s t 4 8 h o u r s b e f o r e s u r g e r y a s it m a y p r e c ip ita te th e d e v e lo p m e n t o f la c tic a c id o s is d u r in g s u r g e r y . A n a x illa r y n e r v e b lo c k p r o d u c e s b lo c k a d e o f th e m e d ia n . n e r v e . p a tie n ts s h o u ld b e a d v is e d n o t to ta k e o r a l h y p o g ly c e m ic a g e n ts th e m o r n i n g o f th e s u r g e r y . It c a u s e s c a lc iu m io n s to e n te r th e c e lls . v e r te b r a l a r te r y in je c tio n . S e n s a tio n to th e la te r a l a s p e c t o f th e f o r e a r m is p r o v id e d b y th e m u s c u lo c u ta n e o u s n e r v e . n a u s e a /v o m itin g . a n d c a r d ia c d y s r h y th m ia s . e p id u r a l/s u b a r a c h n o id /s u b d u r a l in je c tio n . T h u s . 75. D u r in g c e n tr a l lin e in s e r tio n . lo s s o f a p p e tite . B. a rte ry . a n d p n e u m o th o r a x . th e s a p h e n o u s n e r v e . a n d th e s u p e r f ic ia l p e r o n e a l n e rv e . T h e a n k le b lo c k b lo c k s th e d e e p p e r o n e a l n e r v e . w ill e x a c e r b a te d ig ita lis to x ic ity . w h ic h r e tu r n s to s in u s r h y th m w h e n th e g u id e w ir e /c a th e te r tip is w ith d r a w n o u t o f th e h e a rt. a n d d e p e n d s o n o p e r a to r e x p e r ie n c e (le s s tr a u m a ) . a g ita tio n . B a s e d o n th e p a tie n t’s p r e s e n ta tio n . B. th e p o s t e r i o r tib ia l n e r v e . 74. U s e o f s m a lle r e n d o tr a c h e a l tu b e s . d ia r r h e a . In a d d itio n . o r a n a c c e le r a te d ju n c tio n a l rh y th m . th e s u r a l n e r v e . C h a r a c te r is tic E K G c h a n g e s in c lu d e b r a d y c a r d ia . u ln a r. A n tib io tic a lle r g ie s m a y r e s u lt in a n a n a p h y la c tic o r a n a p h y la c to id r e a c tio n . b u t c a u s e s a n e t K+ lo s s f r o m th e c e ll. T h e in c id e n c e o f s o r e th r o a t c a n v a r y f r o m 1 5 % to 4 0 % . D. D. 73. 80. w h ic h r e v e r s e s m o s t o f th e m a n if e s ta tio n s o f a n a p h y la x is . m o r e so th a n h y p e r c a lc e m ia . H e n c e . D ig o x in is a n in o tr o p e th a t b lo c k s th e N a+ /K + A T P a s e p u m p o n th e m y o c a r d ia l c e ll. m e d ia l to la te r a l) .

Class IV: Patients with cardiac disease resulting in inability to carry on any Symptoms of heart failure or the anginal syndrome may be present ev< physical activity without discomfort. p o s tu r a l in s ta b ility . Table 1-1 Functional capacity: How a patient with cardiac disease feels during physical activity Class I: Patients with cardiac disease but resulting in no limitation of physical Ordinary physical activity does not cause undue fatigue. w ith m o r e s tr e n u o u s a c tiv ity .r o l l i n g r e s tin g tr e m o r . 83. In H O C M . B. Table 1-2 Objective assessment Class A: No objective evidence of cardiovascular disease. disease. discomfort increases. T h is p a tie n t is a s y m p to m a tic a t r e s t a n d c a n g o a b o u t h is a c tiv itie s o f d a ily liv in g w ith o u t is s u e s . Class B: Objective evidence of minimal cardiovascular Mild symptoms and slight limitation during ordinary activity. h e b e c o m e s d y s p n e ic . B. disease. M e to c lo p r a m id e (a n d d r o p e r i d o l ) h a s s ig n if ic a n t a n tid o p a m in e r g ic p r o p e r tie s a n d s h o u ld b e a v o id e d in th e s e p a tie n ts in th e tr e a tm e n t o f n a u s e a a n d v o m itin g . dyspnea. No symptoms and no limitation in ordinary physical activity. r e s u ltin g in b r a d y k in e s ia . Class D: Objective evidence of severe cardiovascular Severe limitations. C. palpitation. o b s tr u c tio n o f th e v e n tr ic u la r o u tf lo w tr a c t c a n o c c u r f r o m s y s to lic a n te r io r m o tio n o f th e m itr a l v a lv e a g a in s t th e h y p e r tr o p h ie d s e p tu m .b lo c k e r s ( m e to p r o l o l) o r c a lc iu m c h a n n e l b lo c k e r s . Comfortable only at rest. b e 2 (T a b le s 1-1 a n d 1 -2 ). 85. or anginal pain. D. Experiences symptoms even while at rest. w h ic h c a n b e o b ta in e d b y u s in g P . 81. ( r a th e r th a n lu b r ic a tin g je lly ) in c r e a s e s th e in c id e n c e o f s o r e th r o a t. H o w e v e r. J o h n w o r t m a y b e u s e d to in c r e a s e th e e f f e c t o f c l o p i d o g r e l in h y p o r e s p o n d e r s . 84. T h e N e w Y o rk H e a r t A s s o c ia tio n c la s s if ic a tio n f o r h e a r t f a ilu r e is b a s e d o n b o th a f u n c tio n a l a n d o b je c tiv e a s s e s s m e n t o f th e p a tie n t’s c a p a b ilitie s a n d s y m p to m s . a n d p i l l . Class C: Objective evidence of moderately severe Marked limitation in activity due to symptoms. Class III: Patients with cardiac disease resulting in marked limitation of They are comfortable at rest. In p a tie n ts w ith a s e v e r e H O C M . St. even during less-than-ordinary activity cardiovascular disease. Comfortable at rest. Less-than-ordinary activity causes fatig physical activity. Class II: Patients with cardiac disease resulting in slight limitation of physical They are comfortable at rest. M o s t c a s e s o f s o r e th r o a t r e s o lv e s p o n ta n e o u s ly . . St. rest.a n d C Y P 3 A 4 in d u c e r . < activity. 82. It r e d u c e s th e e f f e c t o f w a r f a r i n a n d h e p a r in . J o h n w o r t is a c o m m o n ly u s e d h e r b a l m e d ic a tio n th a t is a C Y P 2 C 1 9 . H is c la s s if ic a tio n w o u ld . palpitation. A s c l o p i d o g r e l is a c tiv a te d b y th e c y to c h r o m e P 4 5 0 s y s te m . A d v a n c e d a g e is th e m o s t im p o r ta n t p r e d ic to r o f a tr ia l f i b r illa tio n n o t o n ly in p a tie n ts f o ll o w i n g c a r d ia c s u r g e r y b u t a ls o in th e g e n e r a l p o p u la tio n . Ordinary physical activity results in fati activity. dyspnea. or anginal pain. P a r k in s o n d is e a s e is c h a r a c te r iz e d b y a lo s s o f d o p a m in e in th e n ig r o s tr i a tu m . or anginal pain. If any physical activity is undertaken. m y o c a r d ia l d e p r e s s io n is b e n e f ic ia l. th e r e f o r e . w ith little e f f e c t o n a s p ir in . palpitation. C. r ig id ity .

92. . H o w e v e r.m o d e r a te P D P H is u s u a lly tr e a te d c o n s e r v a tiv e ly (f lu id s . d o p a m in e m a y p r o m o t e f u r th e r tis s u e a c id o s is in th e s p la n c h n ic c ir c u la tio n . B.2 m g /k g . th e d o s e is 2 m g /k g . a f te r lo a d s h o u ld b e m in im iz e d to m a in ta in s tr o k e v o lu m e . th e F D A in 2 0 0 6 is s u e d a b la c k b o x w a r n in g f o r a ll p r a c titio n e r s .d e p e n d e n t m a n n e r a n d c a n b e u s e d in th e e v e n t o f f a ile d in tu b a tio n . v e c u r o n iu m . W h e n th e b lo c k a d e is d e e p e r. th a t is . T h e h e a r t. 94. 93. 91. In th e e v e n t o f a p o s td u r a l p u n c tu r e h e a d a c h e (P D P H ). a n a lg e s ic s ) . M ild . T r e a tm e n t f o r th is p a tie n t is to f i r s t e s ta b lis h a n a ir w a y (A B C s) a n d th e n tr e a t th e s e iz u r e . I n je c tio n o f l a r g e a m o u n t o f lo c a l a n e s th e tic in to th e v e r te b r a l a r te r y o r in to th e s u b a r a c h n o id o r s u b d u r a l s p a c e r e s u ltin g in a s e iz u r e is a w e ll. 7 2 % in 7 d a y s . 89. th e d o s e m u s t b e in c r e a s e d . a n d p a n c u r o n iu m . T h u s . D. r e d u c in g th e is c h e m ic tim e o f d o n o r h e a r ts w ill d e c r e a s e m o r b i d ity a n d c o s ts o f c a r d ia c tr a n s p la n ta tio n s . a d o s e o f 8 m g /k g o f s u g a m m a d e x w ill e f f e c tiv e ly r e v e r s e r o c u r o n i u m g iv e n a t 0 .6 m g /k g . a n d 8 5 % w ith in 6 w e e k s . A. If th e d o s e o f r o c u r o n i u m g iv e n is 1. C. B.86. w ith tw o tw itc h e s . b r o n c h o s p a s m . 90. 5 3 % o f h e a d a c h e s r e s o lv e in 4 d a y s. C. th u s m a k in g it th e d r u g o f c h o ic e f o r th is s c e n a r io . b e c a u s e o f its h ig h o x y g e n r e q u ir e m e n ts .k n o w n c o m p lic a tio n o f th e in te r s c a le n e b lo c k . th e in c r e a s e d r e le a s e o f p a n c r e a tic in s u lin le a d s to a n a n a b o lic s ta te a n d a n in tr a c e llu la r s h if t o f p h o s p h a te . B. F o r n o r m a l r e v e r s a l. S u g a m m a d e x r e v e r s e s n e u r o m u s c u la r b lo c k a d e b y n o n d e p o la r iz i n g m u s c le r e la x a n ts b y d ir e c tly b in d in g to r o c u r o n iu m . W ith p r o l o n g e d p e r io d s o f s ta r v a tio n f o ll o w e d b y r e in tr o d u c tio n o f e n te r a l o r p a r e n te r a l n u tr itio n . H y p e r k a le m ic c r y s ta ll o id c a r d io p le g i a a t 4 ° C f o r a m a x im u m o f 4 h o u r s is u s e d to p r e s e r v e th e h e a r t. S e v e re P D P H m a y r e q u i r e a n e p id u r a l b l o o d p a tc h . w h e r e a s n o r e p in e p h r in e d o e s n o t. a n d v e n tr ic u la r ta c h y c a r d ia . a n d p o ta s s iu m . P a tie n ts w h o r e c e iv e d o c tr e o tid e e x p e r ie n c e d n o s ig n if ic a n t in tr a o p e r a tiv e c o m p lic a tio n s . F o llo w in g a r a s h o f s u d d e n d e a th s in p a tie n ts ta k in g m e th a d o n e . h y p o te n s io n . S u r g e r y f o r c a r c in o id tu m o r d e b u lk in g o r r e s e c tio n m a y p r e c ip ita te a c a r c in o id c r is is in th e p a tie n t c o n s is tin g o f f lu s h in g . c a f f e in e d r in k s . 88. D. O f th e s e d e r a n g e m e n ts . In s e p tic s h o c k . b o th d o p a m in e a n d n o r e p in e p h r in e c a n b e u s e d to tr e a t p e r s is te n t h y p o te n s io n . a c id o s is . P a tie n ts w ith d ila te d c a r d io m y o p a th y a r e e x tr e m e ly s e n s itiv e to c h a n g e s in a f te r lo a d . R e v e r s a l o f n e u r o m u s c u la r b lo c k a d e is a c h ie v e d in a d o s e . B. is th e le a s t to le r a n t o f is c h e m ia . r e v e r s a l w ith s u g a m m a d e x r e q u ir e s a d o s e o f 16 m g /k g . 87. T h e r e f o r e . s p e c if ic a lly d e ta ilin g th e h ig h r i s k o f p r o l o n g e d Q T s y n d r o m e a n d s u d d e n d e a th in p a tie n ts p r e s c r i b e d th is m e d ic a tio n . w ith o u t a n y s id e e ffe c ts . W h e n r e v e r s i n g f o ll o w i n g a f a ile d in tu b a tio n . m a g n e s iu m .

in c lu d in g c a r d ia c f a ilu r e .8 L o r < 4 0 % o f p r e d ic te d p o s to p e r a tiv e ly • F E V i/F V C < 5 0 % p r e d ic te d • M a x im u m b r e a th in g c a p a c ity < 5 0 % o f p r e d ic te d • M a x im u m V O 2 < 1 0 m L /k g /m in 98. m a n n ito l. B ip h o s p h o n a te s d o n o t a f f e c t th e e x c r e tio n o f c a lc iu m . It b o ils a t ju s t 2 2 . A. U s in g r o u tin e p u lm o n a r y f u n c tio n te sts. T h e r e f o r e . 101. c r i t e r i a h a v e b e e n e s ta b lis h e d f o r h ig h . a n g io te n s in . a m in o g ly c o s id e a n tib io tic s ) . T h e fe tu s b e c o m e s v ia b le a t th is g e s ta tio n a g e . r e c o v e r y . p u lm o n a r y . In p u lm o n a r y r e s e c tio n s . T h e b e s t p r e d ic to r o f d if f ic u lty is a s h o r t. A. a d e q u a te f lu id r e s u s c ita tio n . if p o s s ib le . a n d m u s c u lo s k e le ta l s y s te m s . C. 97.8 ° C c o m p a r e d w ith s e v o f lu r a n e a t 5 8 . f e n o ld o p a m . • P a C O 2 > 4 5 m m H g o r P a O 2 < 5 0 m m H g o n r o o m a ir • FE V <25% • F E V i < 2 L p r e o p e r a t iv e ly o r < 0 . p r e o p e r a t iv e im p a ir m e n t is d ir e c tly r e la te d to o p e r a tiv e r is k . th e d e s f lu r a n e v a p o r iz e r is h e a te d to 3 9 ° C a n d p r e s s u r i z e d a t 2 a tm . 96. h y p o p h o s p h a te m ia le a d s to th e m o s t s e v e r e c o n d itio n s .r i s k p a tie n ts . L o o p d iu r e tic s ( f u r o s e m id e ) . a f f e c tin g th e c a r d ia c .e n z y m e in h ib ito r s .5 °C .c o n v e r tin g . F e ta l h e a r t r a te a n d u te r in e m o n ito r in g s h o u ld b e p e r f o r m e d d u r in g in d u c tio n .e v o k e d p o te n tia ls a r e u s u a lly m o n ito r e d o n th e p o s t e r i o r tib ia l n e r v e s o f th e le g s d u r in g s p in a l s u r g e r y a n d a r e u s e d to a s s e s s th e in te g r ity o f th e d o r s a l c o lu m n s o f th e s p in a l c o r d .4 % . d o p a m in e . a n d . 100.5 °C o r is o f lu r a n e a t 4 8 . C. 102. T h e m a in s ta y o f r e n a l p r e s e r v a tio n is b y r e d u c in g a o r tic c r o s s ­ c la m p in g tim e . B is p h o s p h o n a te s a r e u s e d in th e tr e a tm e n t o f o s t e o p o r o s i s a s th e y in h ib it o s te o c la s tic r e s o r p t i o n o f b o n e . C. B. S o m a to s e n s o r y . h o w e v e r. 99. th e r e is n o c o n c r e te e v id e n c e to s u p p o r t th e ir u s e . o f w h ic h 0 . 95. T h e in c id e n c e o f r e n a l f a ilu r e a fte r a b d o m in a l a o r tic a n e u r y s m s u r g e r y is 5 .6 % r e q u ir e s h e m o d ia ly s is . th ic k n e c k ( p r e tr a c h e a l tis s u e v o lu m e ) a n d a h is to r y o f o b s tr u c tiv e s le e p apnea. a n d A -a c e ty lc y s te in e a r e p r o p o s e d r e n a l p r o te c tiv e a g e n ts . T h e m a in is s u e w ith d e s f lu r a n e is th a t it h a s a h ig h s a tu r a te d v a p o r p r e s s u r e a t r o o m te m p e r a tu r e (6 6 9 m m H g a t 2 0 ° C ). A. d u r in g th e s u r g e r y in a n y p r e g n a n c y o f m o r e th a n 2 4 w e e k s ’ g e s ta tio n . a n d a v o id a n c e o f n e p h r o to x in s ( n o n s te r o id a l a n ti­ in f l a m m a to r y d r u g s . e m e r g e n c e . r e n a l. D. . E n a la p r il e x p o s u r e d u r in g th e f i r s t tr im e s te r o f p r e g n a n c y h a s b e e n a s s o c ia te d w ith m u ltip le fe ta l d e fe c ts . A ir w a y m a n a g e m e n t in o b e s e p a tie n ts b e g in s f i r s t w ith a n a d e q u a te p h y s ic a l e x a m a s th e s e p a tie n ts a r e m o r e lik e ly to b e b o th m o r e d if f ic u lt to v e n tila te a n d to in tu b a te .

.

Narrowest segment of a neonate’s upper airway occurs at the level of the vocal cords D. Airway management in Klippel-Feil syndrome is most likely to be challenging because of A. Vocal cords D. Subglottic stenosis D. Airway obstruction in Pierre Robin syndrome most likely occurs A. Hyoid bone B. At the level of the glottis C. Cervical spine fusion 5. Neonate’s larynx is located more superiorly in the neck B. Thyroid cartilage C. Subglottic region 3. Between the tongue and pharyngeal wall B. Laryngoscopy is often challenging in Turner syndrome because of a high frequency of laryngeal distortion B. Micrognathia B. Airway management in Treacher Collins syndrome is complicated by a high incidence of cervical spine instability C. At the bronchial level 4. Intubation in patients with Goldenhar syndrome is often challenging due to a high rate of . In the subglottic trachea D. A major difference between the adult and neonatal airway is that the A. Neonate’s epiglottis is angled more superiorly C. Neonate is at lower risk of postextubation stridor compared to the adult 2. Macroglossia C. The narrowest segment of a 14-day-old child’s upper airway is located at the A. One of the following statements regarding airway management in patients with congenital syndromes is most accurate: A.Airway Management Yuriy Bronshteyn 1.

5-mm cuffed endotracheal tube. The tube cuff should be deflated until a leak is present starting at 15 cm H2O of positive pressure C. when inflated. Hypercapnia C. At the completion of the operation. The tube cuff should be deflated and the tube withdrawn until ventilator peak pressures decrease 9. subglottic stenosis D. A 4-year-old boy with autism and failure-to-thrive undergoes a gastrostomy tube placement. The tube is secured with the 15-cm mark at the patient’s gumline. Increased peak inspiratory pressures D. No change in anesthetic care is indicated B. Continue current management B. Airway management of patients with trisomy 21 is complicated by a high incidence of cervical spine instability 6. and the patient is placed on volume-control ventilation. Replace the ETT with a 4.0-mm cuffed ETT 7. The anesthesiologist then inserts an appropriately sized oropharyngeal airway and places a face mask connected to the ventilator . Auscultation reveals equal breath sounds bilaterally. The most likely first sign of a right main stem intubation is A. Manual ventilation produces an air leak in the oropharynx beginning at a peak pressure of 20 cm H2O. Arterial desaturation B. Hypotension 8.5-mm uncuffed endotracheal tube (ETT). is palpable below the cricoid cartilage D. Replace the ETT with a larger-sized uncuffed tube D. The best next step in the anesthetic management is to A. The anesthesiologist extubates the patient and immediately shuts off the volatile agent. His airway was managed uneventfully with mask ventilation followed by direct laryngoscopy and intubation with a 4. The tube cuff should be deflated and the tube advanced until the cuff. the patient remains unresponsive but is breathing spontaneously and has a mild gag response to oral suctioning. The next best step in management is A. A 6-year-old patient scheduled for laparoscopic bilateral inguinal hernia repair undergoes inhalational induction and intubation with a 5. The tube is taped 14 cm at the gumline. A healthy 2-year-old male is scheduled to undergo a laparoscopic inguinal hernia repair.0-mm cuffed endotracheal tube. Inflation of the pilot balloon results in palpation of the inflated tube cuff just above the cricoid cartilage. A 4-year-old patient scheduled for laparoscopic gastrostomy tube placement undergoes induction of general anesthesia and endotracheal intubation with a 4. Replace the ETT with a smaller-sized uncuffed tube C. A leak test reveals leak of air into the oropharynx at a positive pressure of 20 cm H2O.

The superior surface of the epiglottis is innervated by the A. Pulmonary edema D. Recurrent laryngeal nerve C. Croup 11. Facial nerve C.0 mm C.0 mm B. 6. jaw thrust. the patient will most likely experience A. Auscultation over the sternal notch reveals no air movement. In order to anesthetize the posterior third of the tongue. 3.0 mm 12. Internal branch of the superior laryngeal nerve D. the anesthesiologist should perform a nerve block of the . the anesthesiologist elects to perform an awake fiberoptic intubation. circuit over the patient’s face. An appropriately-sized cuffed endotracheal tube for this patient will have an internal diameter of A. Despite providing a chin lift. The pulse oximeter reading then rapidly drops to 70% from 100%. The next best step in management is A. allowing the patient to breathe 100% oxygen. Due to concern for challenging laryngoscopy. A 2-year-old child weighing 13 kg is scheduled for inguinal hernia repair. Tactile sensation from the anterior third of the tongue is carried by fibers of the A. if the patient’s postextubation condition is left untreated. Aspiration B. A 48-year-old female patient with temporomandibular joint dysfunction and associated limited mouth opening is scheduled for a thyroidectomy for goiter. Hypoglossal nerve 14. Administration of albuterol B. the anesthesiologist notes that the ventilator shows no end-tidal carbon dioxide. 4. 5. In the scenario above. She is at the 55th percentile for height for her age. External branch of the superior laryngeal nerve 13. Administration of succinylcholine 10.0 mm D. and positive-pressure breaths. Bronchospasm C. Insertion of a nasal trumpet C. Trigeminal nerve B. Glossopharyngeal nerve D. Endotracheal reintubation D. Hypoglossal nerve B.

A. A 65-year-old woman undergoes a thyroidectomy for papillary thyroid cancer. Auscultation reveals lack of breath sounds over the chest. Cranial nerve VII C. the local anesthetic should be injected into one of the following areas: A. the anesthesiologist elects to perform an awake oral fiberoptic intubation. A patient who suffers acute. Through the cricothyroid membrane 17. The surgeon suggests a bilateral block of both the internal and external branches of the patient’s superior laryngeal nerve. No symptoms B. Improvement of the patient’s respiratory distress and no change in her aphonia C. which is involved in laryngospasm. No change in the patient’s respiratory distress and no change in her aphonia 19. which slightly improve the patient’s oxygenation and ventilation. Stridor D. There is no evidence of a surgical site hematoma. A 48-year-old woman with temporomandibular joint dysfunction and limited mouth opening is scheduled for thyroidectomy for goiter. the anesthesiologist should perform a bilateral block of the . primarily involves the A. Immediately after emergence and extubation. Cranial nerve V B. Cranial nerve IX D. No change in the patient’s respiratory distress and improvement of her aphonia D. To reliably blunt the afferent limb of the cough reflex. she is aphonic and has minimal chest movement. The base of the anterior tonsillar pillar B. Aspiration 16. Medial to the lesser cornu of the hyoid bone C. If performed this block would likely result in A. Worsening of the patient’s respiratory distress and no change in her aphonia B. The anesthesiologist provides a jaw thrust and positive-pressure breaths. Hoarseness C. Recurrent laryngeal nerve D. Superior to the superior cornu of the thyroid cartilage D. Cranial nerve XII 15. Due to concern for a difficult laryngoscopy. Hypoglossal nerve C. The efferent limb of the glottic closure reflex. despite spontaneously moving her limbs and head. Glossopharyngeal nerve 18. To anesthetize the supraglottic laryngeal mucosa. Internal branch of the superior laryngeal nerve B. bilateral denervation of the external branch of the superior laryngeal nerve will most likely present with A.

One of the following statements regarding the innervation of airway structures is most correct: A. A 25-year-old passenger ejected out of a motorcycle now with Glasgow Coma Scale of 13 and some periorbital bruising B. Several hours after undergoing repair of an ascending aortic dissection. Vocal cords in a fully abducted position B. A nasal trumpet would be most appropriate for management of anesthetic-induced upper airway obstruction in one of the following patients: A. Awake fiberoptic laryngoscopy would most likely show the following during inspiration: A. An awake tracheostomy would be facilitated by a regional block of the A. Vocal cords in a fully adducted position C. The afferent limb of the gag reflex is primarily carried by fibers of the recurrent laryngeal nerve B. a 65-year-old male patient is extubated in the intensive care unit. awake laryngoscopy would most likely reveal A. Glossopharyngeal nerve C. otherwise healthy except for gestational thrombocytopenia. . A 32-year-old term parturient. Left vocal cord in an abducted position and right vocal cord fully adducted 22. Vocal cords in a partially adducted position with 2 to 3 mm of space between them D. Glossopharyngeal nerve and external branch of the superior laryngeal nerve D. Tactile sensation from the posterior one-third of the tongue is carried by the hypoglossal nerve 24. Glossopharyngeal nerve and internal branch of the superior laryngeal nerve C. Trigeminal nerve block would facilitate awake nasotracheal intubation C. Fully adducted vocal cords B. Left vocal cord in an adducted position and right vocal cord fully abducted D. bilateral transection of cranial nerve X. A. Superior laryngeal nerve D. Trigeminal nerve B. All of the arch vessels were preserved during the operation. If an adult patient were to suffer an acute. After extubation. Fully abducted vocal cords C. Recurrent laryngeal nerve 23. Internal and external branches of the superior laryngeal nerve 20. Superior laryngeal nerve and the recurrent laryngeal nerve B. The superior surface of the epiglottis is primarily innervated by the glossopharyngeal nerve D. Vocal cords oscillating between adducted and abducted position 21. the patient’s voice is noted to be hoarse.

A 55-year-old woman with severe anxiety and rheumatoid arthritis is scheduled for thyroidectomy for medullary thyroid cancer. Cancel the case 26. Induction of general anesthesia followed by fiberoptic bronchoscopy B. A 45-year-old female with temporomandibular joint syndrome and breast cancer scheduled for bilateral mastectomy D. one of the following patients would be the best candidate for “deep extubation”: . An elderly patient with restrictive lung disease scheduled for inguinal hernia repair C.5 fingerbreadths. a 2 fingerbreadth mouth opening. After rapid sequence induction of general anesthesia. An obese patient with acute appendicitis who. cannot be intubated B. and neck range-of-motion at the atlanto-occipital joint of about 70 degrees. Transtracheal jet ventilation does not require a patent natural airway B. A full-term parturient brought to the OR for emergent cesarean section because of fetal bradycardia 28. After undergoing an uneventful operation. fixed. Induction of general anesthesia followed by rigid bronchoscopy C. Use of a laryngeal mask airway would be most appropriate for airway management in the following patient: A. An obese male patient with a hiatal hernia and GERD scheduled for umbilical hernia repair D. Induction of general anesthesia followed by laryngeal mask airway placement D. Her airway exam in the upright position is notable for a nonvisible uvula with the tongue protruded. The trachea cannot be palpated. The patient is highly anxious and tells you that under no circumstance will she let you insert a “breathing tube inside my airway while I’m awake. and nonmobile mass that appears to be contiguous with the thyroid gland when the patient swallows. A 65-year-old male with a mechanical mitral valve on therapeutic anticoagulation undergoing emergent coronary catheterization for unstable angina 25. Examination of her neck reveals an enlarged. who requires emergent cesarean section under general anesthesia C. Ventilation through a surgical cricothyrotomy allows both inhalation and exhalation to occur C. a patient is unable to be intubated. after rapid sequence induction. Subsequent attempts at ventilation by face mask and a supraglottic airway device are also unsuccessful. One of the following statements regarding transtracheal jet ventilation and surgical cricothyrotomy in this situation is most correct: A. a thyromental distance of 2. The development of laryngospasm during ventilation through a cricothyrotomy would rapidly cause pulmonary overinflation and barotrauma D. Transtracheal jet ventilation can be continued for a longer period of time than can ventilation via a cricothyrotomy 27.” The next best step in anesthetic management is A.

T h e f l o w . F ig u r e 2 -1 C D. A 6 5 .o ld f e m a le w ith c o r o n a r y a r te r y d is e a s e w h o h a s ju s t u n d e r g o n e a to ta l h ip a r th r o p la s ty u n d e r g e n e r a l a n e s th e s ia 29.y e a r . A n o th e r w is e h e a lth y p a tie n t w ith a h is to r y o f d a y tim e s le e p in e s s a n d s n o r in g f r o m la r y n g e a l p a p illo m a to s is u n d e r g o e s p o ly s o m n o g r a p h y a n d s p ir o m e tr y . H ig h a r c h e d p a la te D.o ld p a tie n t w ith s c o li o s is w h o h a s j u s t u n d e r g o n e a 6 .h o u r p o s te r io r th o r a c o lu m b a r s p in a l in s tr u m e n ta tio n a n d f u s io n D. A 6 4 .y e a r . T h y r o m e n ta l d is ta n c e le s s th a n 3 f in g e r b r e a d th s C.v o l u m e l o o p th a t w o u ld b e m o s t c o n s is te n t w ith th is p a tie n t’s c o n d itio n is F igu re 2-1 A. A.y e a r . In a b ility to b r in g m a n d ib u la r in c is o r s a n te r io r to th e m a x illa r y in c is o r s 30. L im ite d m o u th o p e n in g B. w h ic h s h o w s d y n a m ic in s p i r a t o r y o b s tr u c tio n .y e a r .o ld m a n w ith g a s tr o e s o p h a g e a l r e f lu x w h o h a s j u s t u n d e r g o n e a n in g u in a l h e r n ia r e p a ir C. A n 1 8 . F ig u r e 2 -1 A B. F ig u r e 2 -1 B C. F ig u r e 2 -1 D .o ld w o m a n w ith a s th m a w h o h a s j u s t u n d e r g o n e a n e x p l o r a t o r y l a p a r o to m y f o r s m a ll b o w e l o b s tr u c tio n B. A 2 3 . O n e o f th e f o ll o w i n g is a p r i m a r y r i s k f a c to r f o r d if f ic u lt m a s k v e n tila tio n : A.

A c c o r d in g to c la s s ic a l te a c h in g . th e y h a v e a h ig h in c id e n c e o f c e r v ic a l s p in e in s ta b ility .F e il. T h e s e w o m e n te n d to h a v e s h o r t n e c k s a n d s m a ll ja w s . T h e y a ls o h a v e a h ig h in c id e n c e o f s u b g lo ttic s te n o s is . D. a n d a n g le d m o r e posteriorly c o m p a r e d to th e a d u lt’s. T h e n e o n a te ’s la r y n x is lo c a te d m o r e s u p e r i o r l y in th e n e c k th a n th e a d u lt’s. A ll o f th e s e l im it th e o r o p h a r y n g e a l s p a c e . T h e s e p a tie n ts te n d to h a v e s m a ll m o u th s a n d l a r g e to n g u e . P ie r r e R o b in is a c o n g e n ita l s y n d r o m e a s s o c ia te d w ith e n la r g e d to n g u e . r e s u ltin g in lim ite d o r o p h a r y n g e a l s p a c e . A h ig h in c id e n c e o f . w h ic h r e n d e r s th e s e p a tie n ts a c h a lle n g e f o r d ir e c t la r y n g o s c o p y . T h e lo c a t io n o f th e a d u lt’s la r y n x is a t C 4 . D. T h e n e o n a te is a t g r e a te r r i s k o f p o s te x tu b a tio n s tr id o r c o m p a r e d to th e a d u lt. c o n tr ib u tin g to a ir w a y o b s tr u c tio n b e tw e e n th e to n g u e a n d p o s te r io r p h a r y n g e a l w a ll. a n d c o n g e n ita l s p in a l f u s io n c a u s in g lim ite d n e c k m o b ility . s u c h th a t e n d o tr a c h e a l tu b e s s h o u ld b e d o w n s iz e d b y 0 . w h e r e a s th e n a r r o w e s t p o r t i o n o f a n a d u lt’s u p p e r a ir w a y is a t th e le v e l o f th e v o c a l c o r d s .F e il is a c o n g e n ita l s y n d r o m e a s s o c ia te d w ith th e p h e n o ty p ic a l tr ia d o f s h o r t n e c k . R e s is ta n c e th r o u g h a c y lin d r ic a l tu b e (s u c h a s th e tr a c h e a ) is in v e r s e ly p r o p o r t i o n a l to th e r a d iu s r a is e d to th e f o u r th p o w e r ( P o is e u ille la w ).C 5 le v e l o f th e s p in e . F in a lly . 2. H o w e v e r. T h e o th e r th r e e s y n d r o m e s s h a r e a c o m m o n f e a tu r e o f m ic r o g n a th ia ( s m a ll ja w ) . a 1 -m m r e d u c tio n in tr a c h e a l d ia m e te r d u e to e d e m a r e s u lts in a m a r k e d r i s e in a ir w a y r e s is ta n c e in s m a ll c h ild r e n . L a r y n g e a l d is to r tio n ( c h o ic e A ) h a s n o t b e e n d e s c r ib e d in th is p o p u la tio n . A. th e n a r r o w e s t p o r t i o n o f a c h i l d ’s u p p e r a ir w a y is a t th e le v e l o f th e c r i c o i d c a r tila g e . a n d a t th e le v e l o f th e v o c a l c o r d s in a d u lts . s m a ll m o u th . T h u s .g . th in k K F : C e r v ic a l F u s io n . th in k P R : P o s te r io r R e s tr ic tio n b e h in d th e to n g u e . T r e a c h e r C o llin s is a r a r e s y n d r o m e c h a r a c te r iz e d b y a b n o r m a l d e v e lo p m e n t o f f a c ia l b o n e s (e . l o w p o s t e r i o r h a i r lin e . T h e y a r e p r o n e to la r y n g o s p a s m . n o t th e c r ic o id c a r tila g e . w h ic h is o n e o f th e r e a s o n s w h y s tr a ig h t b la d e s a r e m o r e p o p u la r a m o n g p e d ia tr ic a n e s th e s io lo g is ts . T h e n e o n a te ’s e p ig lo ttis is r e la tiv e ly lo n g e r . s tiffe r. A.5 m m f r o m th e c a lib e r e x p e c te d f o r a p a tie n t o f th e s a m e s iz e w ith o u t D o w n s y n d r o m e . m a x illa r y a n d m a n d ib u la r ) .. T h e c h i l d ’s a ir w a y ta k e s o n a d u lt c h a r a c te r is tic s b e tw e e n th e a g e s o f 5 a n d 10 y e a r s . in c r e a s in g th e r i s k o f n e u r o l o g i c c o m p r o m is e d u r in g n e c k m a n ip u la tio n . a n d m a n d ib u la r a n o m a lie s ty p ic a lly m a n if e s te d a s m ic r o g n a th ia . W h e n y o u s e e P ie r r e R o b in . 3. K lip p e l. w h ile th e n e o n a te ’s is a t C 3 . W h e n y o u s e e K lip p e l. F u s e d s e g m e n ts o f th e c e r v ic a l s p in e in p a tie n ts w ith th is s y n d r o m e p r o m o t e h y p e r m o b ilit y a t u n f u s e d s p in e s e g m e n ts . T u r n e r s y n d r o m e o c c u r s in f e m a le s w h o la c k a c o m p le te s e c o n d X c h r o m o s o m e ( m o n o s o m y ) . A ir w a y m a n a g e m e n t o f p a tie n ts w ith tr i s o m y 21 (D o w n s y n d r o m e ) is c o m p lic a te d b y s e v e r a l f a c to r s . 4. th e g lo ttis . 5. CHAPTER 2 ANSWERS 1. a m o r e r e c e n t b r o n c h o s c o p ic s tu d y o f a ir w a y d im e n s io n s in c h ild r e n f o u n d th a t b e tw e e n th e a g e s o f 6 m o n th s a n d 13 y e a r s . w h ic h m a y b e in c o n s e q u e n tia l in a d u lts . is th e n a r r o w e s t p o r t i o n o f th e c h i l d ’s a irw a y . T h e n a r r o w e s t p a r t o f th e u p p e r a ir w a y is a t th e le v e l o f th e c r i c o i d c a r tila g e in n e o n a te s .C 4 le v e l. T h is s tu d y d id n o t m e a s u r e a ir w a y d im e n s io n s in c h ild r e n y o u n g e r th a n 6 m o n th s . D.

9. th e f i r s t s ig n o f a n e n d o b r o n c h ia l in tu b a tio n w o u ld b e a n e le v a tio n in p e a k i n s p i r a t o r y p r e s s u r e s . h a s n o t b e e n d e s c r ib e d in th e G o ld e n h a r p o p u la tio n . a n d (2 ) s u c h a h ig h tu b e p o s itio n m a y in c r e a s e th e r i s k o f in a d v e r te n t e x tu b a tio n .c a p i l l a r y p e r f u s io n p r e s s u r e . H o w e v e r. c e r v ic a l s p in e in s ta b ility ( c h o ic e B ) h a s n o t b e e n d e s c r ib e d in th is p o p u la tio n . D.g . R e tu rn o f a g a g r e f le x is a c h a r a c te r is tic o f th is lig h te r . A f ix e d v o lu m e o f a ir m o v in g o u t o f a n e n d o b r o n c h ia l tu b e w o u ld e n c o u n te r s ig n if ic a n tly m o r e l a r g e a ir w a y r e s is ta n c e c o m p a r e d to th e s a m e v o lu m e m o v in g o u t o f a n e n d o tr a c h e a l tu b e ( r e m e m b e r : r e s is ta n c e is in v e r s e ly p r o p o r t i o n a l to r a d iu s r a is e d to th e f o u r th p o w e r ) .g . C. A h ig h in c id e n c e o f s u b g lo ttic s te n o s is ( c h o ic e D ). th e e n d o tr a c h e a l tu b e o r a n o r a l a ir w a y ) c a n r e s u lt in la r y n g o s p a s m d u r in g th e e x c ita tio n s ta g e o f a n e s th e s ia o r s o m e tim e s e v e n d u r in g a w a k e sta te s. u lc e r a tio n . C h o ic e D w o u ld lik e ly r e s u lt in th e tip o f th e e n d o tr a c h e a l tu b e m o v in g f r o m a n in tr a la r y n g e a l to a s u p r a la r y n g e a l p o s itio n . H y p e r c a p n ia ( c h o ic e B ) w o u ld e v e n tu a lly d e v e lo p in a n e n d o b r o n c h ia ll y in tu b a te d p a tie n t o n c o n tr o lle d v e n tila tio n if th e m in u te v e n tila tio n w e r e k e p t c o n s ta n t. B e c a u s e th e n o n v e n tila te d lu n g h a s s o m e r e s e r v e o f o x y g e n .. w ith r e s u ltin g in f la m m a tio n . T h u s . P e a k i n s p i r a t o r y p r e s s u r e r e s u lts f r o m th e r e s is ta n c e to f lo w o f th e l a r g e a ir w a y s a n d th e s ta tic c o m p lia n c e o f th e lu n g . e y e s . T h is is p r o b le m a tic f o r tw o r e a s o n s : (1 ) a n in f la te d c u f f in th e la r y n x m a y c a u s e la r y n g e a l in ju r y a n d p o s to p e r a tiv e r e s p i r a t o r y c o m p r o m is e ...p r e s s u r e le a k te s t p r o v id e s i n f o r m a t io n a b o u t th e tig h tn e s s o f th e s e a l f o r m e d b e tw e e n a n E T T a n d its s u r r o u n d in g m u c o s a . a lth o u g h a c o m m o n f in d in g in p a tie n ts w ith t r i s o m y 2 1 . A. T h e c u f f s h o u ld b e d e fla te d a n d th e tu b e a d v a n c e d u n til th e c u f f (w h e n in fla te d ) is p a lp a b le b e lo w th e c r i c o i d c a r tila g e . h y p e r e x c ita b le s ta g e . a n d m o u th ) a n d v e r te b r a l a n o m a lie s (e . C h o ic e B is in c o r r e c t: a c u f f in f la te d to e n a b le a ir le a k a t 2 0 to 2 5 c m H 2O o f p o s itiv e p r e s s u r e s h o u ld n o t c a u s e a ir w a y in ju r y a n d e d e m a in r o u tin e c ir c u m s ta n c e s . A p o s itiv e .c o n tr o l v e n tila tio n . T h e s c e n a r io d e s c r ib e s e x tu b a tio n o f a c h ild d u r in g a “ l i g h t ” p la n e o f a n e s th e s ia w h e n la r y n g e a l r e f le x e s a r e h y p e r s e n s itiv e . s tr id o r . S tim u la tio n o f th e la r y n g e a l m u c o s a b y s e c r e tio n s o r a f o r e i g n b o d y (e . 6.g . a n d la te r s c a r r i n g a n d s te n o s is . L a r y n g o s p a s m a n d o th e r c a u s e s o f u p p e r a ir w a y o b s tr u c tio n (e . r e s tr ic tin g v e n o u s r e tu r n . 8. If a p a tie n t is e x tu b a te d w h ile lig h tly a n e s th e tiz e d . G o ld e n h a r s y n d r o m e is m a n if e s te d b y d y s p la s tic g r o w th o f th e fa c e ( e s p e c ia lly th e e a r s . s c o li o s is ) . A le a k a t p r e s s u r e s b e lo w 2 5 c m H 2O p la c e s th e tr a c h e a l m u c o s a a t a v e r y l o w r i s k o f is c h e m ic in ju r y . c a n c a u s e m u c o s a l is c h e m ia . C. P r e s s u r e s a b o v e 3 0 c m H 2O . 7. W h e n a n e n d o tr a c h e a l tu b e m ig r a te s f r o m a n in tr a tr a c h e a l to a n e n d o b r o n c h ia l p o s itio n w h ile o n v o lu m e . th is w o u ld n o t b e a s im m e d ia te a s a r i s e in p e a k i n s p i r a t o r y p r e s s u r e s . to n g u e c o lla p s e d a g a in s t . H y p o te n s io n ( c h o ic e D ) m ig h t o c c u r if th e r i g h t lu n g is a llo w e d to h y p e r in f la te . p a s s iv e o x y g e n a tio n w o u ld d e la y o n s e t o f h y p o x e m ia b r i e f l y ( c h o ic e A ). th e f i r s t s ig n o f m i g r a t i o n is g e n e r a lly a n in c r e a s e in p e a k i n s p i r a t o r y p r e s s u r e s . th e a r t e r i o l a r . P a lp a tio n o f th e e n d o tr a c h e a l tu b e c u f f p a lp a b le a b o v e th e c r i c o i d c a r tila g e im p lie s th a t th e c u f f ’s p o s itio n is in tr a la r y n g e a l . th e r e is a n in c r e a s e d r i s k o f la r y n g o s p a s m .

e x c e p t th e c r i c o t h y r o i d m u s c le . T h e v o c a l c o r d s th e m s e lv e s r e c e iv e d u a l in n e r v a tio n f r o m b o th n e r v e s . If th e s e m e a s u r e s f a il to r e lie v e th e la r y n g o s p a s m a n d h y p o x e m ia d e v e lo p s .0 m m f o r a c u f f e d tu b e .5 m m f o r a n u n c u f f e d tu b e . C. 12. T h e h y p o g lo s s a l n e r v e ( c h o ic e A ) is a p u r e ly m o t o r n e r v e th a t in n e r v a te s th e m u s c l e s o f th e to n g u e . a s m a ll d o s e o f s u c c in y lc h o lin e (0 . T h e R L N ( c h o ic e B ) is a m ix e d m o to r a n d s e n s o r y n e r v e . In a p a tie n t w ith n o c o n tr a in d ic a tio n s .p r e s s u r e p u lm o n a r y e d e m a (a ls o c a lle d p o s to b s tr u c tiv e p u lm o n a r y e d e m a ). A b o v e th e v o c a l c o r d s . w ith p r o p o f o l o r a n o th e r g e n e r a l a n e s th e tic ) s h o u ld b r e a k th e la r y n g o s p a s m . A c o m m o n ly u s e d f o r m u l a f o r e s tim a tin g th e in te r n a l d ia m e te r o f a n uncuffed e n d o tr a c h e a l tu b e in c h ild r e n is In te rn a l d ia m e te r (in m m ) = (A g e + 1 6 )/4 T h e r e s u ltin g v a lu e s h o u ld b e r e d u c e d b y 0 . 2 . w h ile th e s e n s o r y b r a n c h in n e r v a te s th e s u b g lo ttic m u c o s a o f th e a irw a y . C. B. T h e m o to r b r a n c h in n e r v a te s a ll o f th e la r y n g e a l m u s c le s . . F o r c e f u l in s p ir a tio n a g a in s t a c lo s e d u p p e r a ir w a y g e n e r a te s a l a r g e n e g a tiv e in tr a th o r a c ic p r e s s u r e w h ic h c a n r e s u lt in p u lm o n a r y e d e m a b y in c r e a s in g c a p il la r y tr a n s m u r a l p r e s s u r e a n d /o r b y a c u te ly e le v a tin g le f t v e n tr ic u la r e n d .g . 11. T h e in te r n a l S L N b r a n c h ( c h o ic e C ) is e x c lu s iv e ly a s e n s o r y n e r v e th a t in n e r v a te s b o th th e s u p e r io r a n d i n f e r i o r s u r f a c e s o f th e e p ig lo ttis . B r o n c h o s p a s m ( c h o ic e B ) w o u ld n o t b e e x p e c te d a s a d ir e c t c o n s e q u e n c e o f p r o l o n g e d la r y n g o s p a s m .2 ). th e p o s t e r i o r p h a r y n g e a l w a ll) m a y n o t b e im m e d ia te ly d is tin g u is h a b le . th e f o r m u l a w o u ld b e r e a s o n a b le to u s e . th e in te r n a l d ia m e te r is (2 + 1 6 )/4 = 4 . w h ic h is r e d u c e d to 4 . T h e S L N h a s tw o b r a n c h e s : in te r n a l a n d e x te r n a l. th e in itia l tr e a tm e n t is id e n tic a l: a n te r io r d is p la c e m e n t o f th e m a n d ib le u s in g a c h in lif t o r j a w th r u s t c o m b in e d w ith p o s itiv e .p r e s s u r e v e n tila tio n . F o r th e p a tie n t in th is q u e s tio n . 10. It h a s tw o m a j o r b r a n c h e s th a t in n e r v a te d is tin c t p a rts o f th e a irw a y : th e s u p e r io r la r y n g e a l n e r v e (S L N ) a n d r e c u r r e n t la r y n g e a l n e r v e (R L N ).2 5 . H o w e v e r. C r o u p o r l a r y n g o tr a c h e a l b r o n c h itis ( c h o ic e D ) is a f o r m o f u p p e r a ir w a y o b s tr u c tio n th a t ty p ic a lly o c c u r s in r e s p o n s e to a v i r a l o r b a c te r ia l u p p e r r e s p i r a t o r y tr a c t in f e c tio n in c h ild r e n b e tw e e n th e a g e s o f 6 m o n th s a n d 6 y e a r s . L e ft u n tre a te d . B e lo w th e v o c a l fo ld s .0 . u p p e r a ir w a y o b s tr u c tio n in a s p o n ta n e o u s ly b r e a th in g p a tie n t c a n r e s u lt in th e d e v e lo p m e n t o f n e g a ti v e . T h e e x te r n a l b r a n c h o f th e S L N is a m o to r n e r v e th a t in n e r v a te s th e c r i c o t h y r o i d m u s c le ( F ig . A s p ir a tio n ( c h o ic e A ) w o u ld b e im p o s s i b le d u r in g la r y n g o s p a s m .5 m m w h e n u s in g a cuffed e n d o tr a c h e a l tu b e to a llo w s p a c e in th e tr a c h e a l lu m e n f o r c u f f in f la tio n . th e s e n s o r y in n e r v a tio n o f th e la r y n x is v ia th e S L N ..5 m g /k g ) o r d e e p e n in g o f th e a n e s th e tic (e . p h a r m a c o lo g i c th e r a p y s h o u ld b e in itia te d e m e r g e n tly .d ia s to lic p r e s s u r e . T h e v a g u s n e r v e p r o v id e s s e n s o r y in n e r v a tio n to th e s tr u c tu r e s o f th e a ir w a y b e g in n in g w ith th e e p ig lo ttis a n d m o v i n g c a u d a lly . s e n s o r y in n e r v a tio n o f th e a ir w a y is p r o v id e d b y b r a n c h e s o f th e r e c u r r e n t R L N . T h is c lin ic a l s c e n a r io is n o t s u g g e s tiv e o f a n in f e c tio u s e t i o l o g y f o r th e u p p e r a ir w a y o b s tr u c tio n . S in c e th is c h ild a p p e a r s to h a v e a h e ig h t a n d w e ig h t a p p r o p r ia te f o r h e r a g e .

T h e h y p o g lo s s a l n e r v e ( c h o ic e D ) is a p u r e ly m o to r n e r v e th a t in n e r v a te s th e m u s c le s o f th e to n g u e .3 ). 13.th ir d s o f th e to n g u e is p r o v id e d b y th e tr i g e m in a l n e r v e (C N V ). of SLN (SLN) Epiglottis External branch of Thyroid cartilage SLN Transverse Vocal arytenoid m. cords Cricoid Cricothyroid m. Thyrohyoid Superior Internal branch larynqeal n.th ir d o f th e to n g u e b y th e g lo s s o p h a r y n g e a l n e r v e (C N IX ). 2 . a n d f o r th e p o s te r io r th ir d o f th e to n g u e b y th e g lo s s o p h a r y n g e a l n e r v e (C N IX ). T a c tile s e n s a tio n f o r th e a n te r io r tw o . Subdivisions of the superior laryngeal nerve in the sagittal view. cartilage Trachea F igu re 2-2. G u s ta to r y (ta s te ) s e n s a tio n f o r th e a n te r io r tw o . a s m a ll p o r t i o n o f s e n s o r y in n e r v a tio n o f th e p o s te r io r to n g u e is p r o v id e d b y f ib e r s o f th e s u p e r io r la r y n g e a l n e r v e ’s in te r n a l b r a n c h ( “ s p illo v e r f i b e r s ” f r o m th a t n e r v e ’s in n e r v a tio n o f th e e p ig lo ttis ) ( F ig . A. a n d f o r th e p o s te r io r o n e .th ir d s o f th e to n g u e is p r o v id e d b y th e f a c ia l n e r v e (C N V II). T h e to n g u e h a s in n e r v a tio n f o r b o th g u s ta to r y (a k a “ ta s te ” ) a n d ta c tile ( g e n e r a l s e n s o r y ) in p u t. In a d d itio n . .

th ir d s o f th e to n g u e a n d o r a l c a v ity . B.14. It c a r r ie s ta ste s e n s a tio n f r o m th e a n te r io r tw o . T h e s u p e r io r la r y n g e a l n e r v e (S L N ) is a m ix e d m o to r a n d s e n s o r y n e r v e th a t r e c e iv e s s e n s o r y i n f o r m a t io n f r o m th e s u p r a g lo ttic la r y n x a n d p r o v id e s m o to r in n e r v a tio n to th e c r i c o t h y r o i d m u s c le . A c u te .3 ). O f n o te . T h e g l o s s o p h a r y n g e a l n e r v e (C N IX ) is a m ix e d m o to r a n d s e n s o r y n e r v e . th e g l o s s o p h a r y n g e a l n e r v e d o e s n o t p r o v id e s e n s o r y in n e r v a tio n to th e e p ig lo ttis . T h is a c tio n r a is e s th e p itc h o f s p e e c h a n d e n a b le s s in g in g . b ila te r a l d e n e r v a tio n o f th e e x te r n a l b r a n c h o f th e S L N m a y c a u s e h o a r s e n e s s a n d o th e r s u b tle v o ic e f in d in g s . Its s e n s o r y f ib e r s c a r r y i n f o r m a t io n a b o u t g e n e r a l s e n s a tio n a n d ta ste f r o m th e p o s te r io r th ir d o f th e to n g u e ( F ig . C. 15. H o w e v e r. it is p r o v id e d b y th e s u p e r io r la r y n g e a l n e r v e . T h e fa c ia l n e r v e (C N V II) ( c h o ic e B ) is a m ix e d m o to r a n d s e n s o r y n e r v e . T h e tr i g e m in a l n e r v e (C N V ) ( c h o ic e A ) c a r r ie s g e n e r a l s e n s o r y i n f o r m a t io n f r o m th e a n te r io r tw o . th e a b ility to . T h e h y p o g lo s s a l n e r v e (C N X II) ( c h o ic e D ) is a p u r e ly m o to r n e r v e th a t in n e r v a te s th e m u s c le s o f th e to n g u e . T h e c r i c o t h y r o i d m u s c le te n s e s a n d a d d u c ts th e v o c a l c o r d s .th ir d s o f th e to n g u e . 2 .

T h e e x te r n a l b r a n c h o f th e S L N is p r i m a r i l y a m o to r n e r v e th a t in n e r v a te s th e c r ic o th y r o id m u s c le . C. 2 . in c lu d in g a ll o f th e e p ig lo ttis a n d th e s u p r a g lo ttic m u c o s a . a d d u c t a n d a b d u c t th e v o c a l c o r d s w o u ld r e m a in in ta c t...4 . C h o ic e D d e s c r ib e s a tr a n s tr a c h e a l to p ic a liz a tio n o f R L N f ib e r s . T h e c r i c o t h y r o i d m u s c le is in n e r v a te d b y th e e x te r n a l ( m o t o r ) b r a n c h o f th e s u p e r io r la r y n g e a l n e r v e (S L N ). b u t n o t th e e x te r n a l “ m o t o r ” b r a n c h . C h o ic e B d o e s n o t d e s c r ib e a c lin ic a ll y r e le v a n t p r o c e d u r e (i. a ty p ic a l “ S L N b l o c k ” (i. C h o ic e A d e s c r ib e s a g lo s s o p h a r y n g e a l b lo c k . w h ile th e a f f e r e n t lim b is m e d ia te d b y th e s u p e r io r la r y n g e a l n e r v e (S L N ). 18. . T h e c r i c o t h y r o i d m u s c le c o n tr ib u te s to la r y n g o s p a s m b y le n g th e n in g . T h e R L N in n e r v a te s a ll o f th e m u s c le s o f th e la r y n x e x c e p t th e c r i c o t h y r o i d m u s c le . th e in je c tio n w o u ld b e to o m e d ia l to r e l i a b l y b lo c k th e S L N ). S e n s o r y in n e r v a tio n o f th e la r y n x a b o v e th e v o c a l c o r d s is c a r r i e d b y f ib e r s o f th e s u p e r io r la r y n g e a l n e r v e (S L N ). T h e p r e s e n ta tio n o f a c u te a p h o n ia a n d r e s p i r a t o r y d is tr e s s im m e d ia te ly a fte r th y r o id e c to m y a r e s u g g e s tiv e o f b ila te r a l in ju r y to th e r e c u r r e n t la r y n g e a l n e r v e (R L N ). P r a c tic a lly s p e a k in g . 17.e. T h e e x te r n a l b r a n c h o f th e S L N ( n o t o n e o f th e lis te d o p tio n s ) is a m o to r n e r v e th a t in n e r v a te s th e c r i c o t h y r o i d m u s c le . “ S L N b l o c k ” is lik e ly to b lo c k th e in te r n a l b r a n c h o f th e S L N . C.e. B. a r e c o g n iz e d c o m p lic a tio n o f th is s u r g e r y . B ila te r a l R L N in ju r y le a v e s th e v o c a l c o r d s te n s e d a n d c lo s e d d u e to th e u n o p p o s e d a c tio n o f th e c r i c o t h y r o i d m u s c le s . T h e S L N c a n b e b lo c k e d a s it d e s c e n d s b e tw e e n th e g r e a te r c o r n u o f th e h y o id b o n e a n d th e s u p e r io r c o r n u o f th e th y r o i d c a r tila g e . a n d th u s te n s in g th e v o c a l c o r d s . T h e e f f e r e n t lim b o f th e g lo ttic c lo s u r e r e f le x in v o lv e d in la r y n g o s p a s m is p r i m a r i l y m e d ia te d b y th e r e c u r r e n t la r y n g e a l n e r v e (R L N ). in je c tio n o f —2 m L o f lo c a l a n e s th e tic b e tw e e n th e g r e a te r c o r n u o f th e h y o id c a r tila g e a n d th e s u p e r io r c o r n u o f th e th y r o i d c a r tila g e ) is lik e ly to o n ly b lo c k th e in te r n a l ( s e n s o r y ) b r a n c h o f th is n e r v e a s o p p o s e d to th e m o to r b r a n c h ( F ig . T h e in te r n a l b r a n c h o f th e S L N p r o v id e s s e n s o r y in n e r v a tio n to th e s u p r a g lo ttic p o r t i o n o f th e la r y n x . A s s h o w n in F ig u r e 2 . 16. B lo c k a d e o f th e m o to r b r a n c h o f th e S L N s h o u ld im p r o v e th e p a tie n t’s r e s p i r a t o r y d is tr e s s b y r e la x in g th e v o c a l c o r d s b u t w o u ld h a v e n o im p a c t o n th e a p h o n ia .4 ).

of SLN (SLN) Epiglottis Externa! branch of Thyroid cartilage SLN Transverse Vocal arytenoid m. A fte r b r a n c h in g o f f th e le f t v a g u s n e r v e in th e c h e s t. b r a n c h in g p o in ts o f l a r g e a ir w a y s . cords Cricoid Cricothyroid m. a n d o th e r m a jo r i n s p i r a t o r y a n d e x p ir a to r y m u s c le s . e x te r n a l in te r c o s ta ls . la r y n x . w h ic h a r e f o u n d in th e p h a r y n x . W h e n t r i g g e r e d . e s p e c ia lly if th e p a tie n t h a s a n y c o n c u r r e n t la r y n g e a l e d e m a . cartilage Trachea Recuurent laryngeal n. POSTERIOR ANTERIOR Hyoid bone Thyrohyoid Superior Internal branch laryngeal n. im p u ls e s tr a v e l v ia th e in te r n a l b r a n c h o f th e s u p e r io r la r y n g e a l n e r v e a n d th e r e c u r r e n t la r y n g e a l n e r v e . d ia p h r a g m . C. 20. T h e le f t r e c u r r e n t la r y n g e a l n e r v e (R L N ) is p a r tic u la r ly v u ln e r a b le to in ju r y d u r in g c a r d io th o r a c ic s u r g e r i e s a n d m a n y n e c k s u r g e r i e s d u e to its a n a to m ic lo c a tio n . T h e e f f e r e n t n e u r a l p a th w a y th e n f o llo w s . C h o ic e D w o u ld b e o b s e r v e d in a p a tie n t w ith a n o r m a l la r y n x w h o is a lte r n a tin g b e tw e e n b r e a th in g a n d p h o n a tin g . w h ic h s te m f r o m th e v a g u s n e r v e . a n d m o r e d is ta l s m a lle r a ir w a y s . T h is a d d u c te d p o s itio n m a y c a u s e s tr id o r a n d r e s p i r a t o r y d is tr e s s . In c o n tr a s t. w ith r e le v a n t s ig n a ls tr a n s m itte d b a c k f r o m th e c e r e b r a l c o r te x a n d m e d u lla v ia th e v a g u s a n d s u p e r io r la r y n g e a l n e r v e s to th e g lo ttis . b ila te r a l in ju r y to th e r e c u r r e n t la r y n g e a l n e r v e (a b r a n c h o f th e v a g u s ) w o u ld le a v e th e c o r d s p a r a ly z e d in a p a r tia lly a d d u c te d p o s itio n b e c a u s e o f u n o p p o s e d a c tio n o f th e c r i c o t h y r o i d m u s c le . in c o n tr a s t. P o s to p e r a tiv e h o a r s e n e s s c a n r e s u lt f r o m in ju r y to th e m o to r n e r v e s w h ic h in n e r v a te th e la r y n x . b ila te r a l in ju r y to th e v a g u s n e r v e (C N X ) te r m in a te s a ll o f th e m o to r in n e r v a tio n to th e la r y n x . T h is is th e a f f e r e n t n e u r a l p a th w a y . 21. to th e m e d u lla o f th e b r a in . 19. T h is le a v e s th e v o c a l c o r d s in a f u lly o p e n o r a b d u c te d p o s itio n . c a r in a . A c o u g h o c c u r s th r o u g h th e s tim u la tio n o f a c o m p le x r e f le x a rc . T h e r i g h t R L N . T h is is in itia te d b y th e ir r i t a t i o n o f c o u g h r e c e p to r s . A c u te . Gross anatomic distribution of the SLN and RLN. B. th e le f t R L N p a s s e s b e tw e e n th e le f t p u lm o n a r y a r te r y a n d th e a r c h o f th e a o r ta a b o v e b e f o r e a s c e n d in g a lo n g s i d e th e tr a c h e a to th e la r y n x . A. A n a o r tic a r c h r e p a ir th a t s p a r e s th e a r c h v e s s e ls w o u ld b e m o r e lik e ly to d a m a g e th e le f t R L N th a n th e . F igu re 2-4. b r a n c h e s o f f th e r i g h t v a g u s n e r v e in th e lo w e r n e c k w h e r e it p a s s e s u n d e r th e r o o t o f th e r i g h t s u b c la v ia n a r te r y b e f o r e a s c e n d in g a lo n g s i d e th e tr a c h e a to th e la r y n x . C h o ic e A w o u ld b e o b s e r v e d d u r in g la r y n g o s p a s m . tra c h e a .

o th e r c la s s ic s ig n s o f a b a s ila r s k u ll f r a c tu r e in c lu d e le a k a g e o f b l o o d o r c e r e b r o s p in a l f lu id f r o m th e n a r e s . a n d to ta l a tla n to - o c c ip ita l r a n g e . T h is p a tie n t h a s m u ltip le r i s k f a c to r s f o r d if f ic u lt in tu b a tio n . P a tie n ts w ith in f l a m m a to r y r h e u m a to id a r th r itis (R A ) h a v e a n in c r e a s e d in c id e n c e o f te m p o r o m a n d ib u la r j o i n t d is e a s e (a n d a s s o c ia te d lim ite d m o u th o p e n in g ) a n d im m o b il e c e r v ic a l v e r te b r a ( a s s o c ia te d w ith lim ite d n e c k r a n g e .th ir d o f th e to n g u e . a n d h e m o ty m p a n u m o r b le e d in g f r o m th e e a r s . 24. A b o v e th e v o c a l c o r d s . s u c h a s la r y n g e a l r o ta tio n . 25. F o r a p a tie n t w ith te m p o r o m a n d ib u la r j o i n t d y s f u n c tio n w h o h a s n o n e o f th e a b o v e c o n tr a in d ic a tio n s ( c h o ic e C ). n o t th e g lo s s o p h a r y n g e a l ( c h o ic e C ). B.th ir d o f th e to n g u e . a p a tie n t w ith a c u te le f t R L N p a ls y w o u ld b e e x p e c te d to h a v e a n a d d u c te d le f t v o c a l c o r d a n d a n a b d u c te d r i g h t v o c a l c o r d . T h e p a tie n t’s th y r o i d m a lig n a n c y m a y r e s u lt in o th e r a ir w a y a b n o r m a litie s in c lu d in g tr a c h e a l . A c u te in ju r y to th e le f t R L N w o u ld le a v e th e le f t v o c a l c o r d s u b je c t to th e u n o p p o s e d a c tio n o f th e c r i c o t h y r o i d m u s c le (th e o n ly la r y n g e a l m u s c le N O T in n e r v a te d b y th e R L N ). T h e g l o s s o p h a r y n g e a l n e r v e ( c h o ic e B ) p r o v id e s ta c tile a n d g u s ta to r y s e n s a tio n to th e p o s t e r i o r o n e . s e n s o r y in n e r v a tio n is v ia b r a n c h e s o f th e r e c u r r e n t la r y n g e a l n e r v e (R L N ). rig h t R LN . D u r in g in s p ir a tio n .o f . T h is m u s c le s tre tc h e s a n d te n s e s th e v o c a l c o r d s . th e n a s a l tr u m p e t w o u ld b e a r e a s o n a b le w a y to b y p a s s th e p a tie n t’s lim ite d m o u th o p e n in g a n d r e lie v e u p p e r a ir w a y o b s tr u c tio n . T h e g a g r e f le x is e lic ite d p r i m a r i l y b y ta c tile s tim u la tio n o f th e p o s te r io r o n e . T h e o p h th a lm ic (V 1 ) a n d m a x illa r y (V 2 ) d iv is io n s o f th e tr i g e m in a l n e r v e (C N V ) c o n v e y s e n s o r y i n f o r m a t io n f r o m th e n a s a l m u c o s a . p a tie n ts w ith R A c a n h a v e o c c u lt a ir w a y a b n o r m a litie s n o t a p p a r e n t o n p h y s ic a l e x a m . D. a m o n g o th e r th in g s . T h e s u p e r io r s u r f a c e o f th e e p ig lo ttis is in n e r v a te d b y th e s u p e r io r la r y n g e a l n e r v e (S L N ). w ith c o a g u lo p a th y ( c h o ic e B ). a n d c e r v ic a l s p in e in s ta b ility . B lo c k a d e o f th e s e n e r v e s w o u ld f a c ilita te a w a k e n a s o tr a c h e a l in tu b a tio n . T h e a f f e r e n t lim b o f th is r e f le x is c a r r i e d b y th e g lo s s o p h a r y n g e a l n e r v e (C N IX ). T h e v o c a l c o r d s th e m s e lv e s r e c e iv e d u a l in n e r v a tio n f r o m b o th n e r v e s . B e lo w th e v o c a l c o r d s . to th e a n te r io r tw o - th ir d s o f th e to n g u e a n d th e n a s a l p a s s a g e s . th y r o m e n ta l d is ta n c e < 3 f in g e r b r e a d th s . B o th n a s o tr a c h e a l in tu b a tio n a n d n a s a l tr u m p e t in s e r tio n a r e c o n tr a in d ic a te d in p a tie n ts w ith f a c ia l o r s k u ll in ju r ie s ( c h o ic e A ). th e p a tie n t’s m e c h a n is m o f in ju r y a n d f in d in g s o f p e r io r b it a l b r u is in g s u g g e s t a n u n d e r ly in g s k u ll f r a c tu r e . In g e n e r a l. in c lu d in g th e e p ig lo ttis . th e s e n s o r y in n e r v a tio n o f th e la r y n x is v ia th e s u p e r io r la r y n g e a l n e r v e . A d d itio n a lly . In c h o ic e A . In a d d itio n to p e r io r b it a l e c c h y m o s e s .m o t io n ) . T h e tr i g e m in a l n e r v e ( c h o ic e A ) p r o v id e s ta c tile s e n s a tio n .o f .m o t i o n < 8 0 d e g r e e s . e c c h y m o s e s o n th e s k in o v e r ly in g th e m a s to id p r o c e s s . m o u th o p e n in g < 3 f in g e r b r e a d th s . C. b o th v o c a l c o r d s n o r m a l l y a b d u c t. n o t th e r e c u r r e n t la r y n g e a l n e r v e ( c h o ic e A ) o r th e h y p o g l o s s a l n e r v e ( c h o ic e D ). D u r in g in s p ir a tio n . 22. in c lu d in g M a lla m p a ti c la s s > 2. c r ic o a r y te n o id a r th r itis . th e S L N p r o v id e s s e n s o r y in n e r v a tio n to a ll s tr u c tu r e s o f th e la r y n x a b o v e th e v o c a l c o r d s . a n a c tio n th a t s h ifts th e v o c a l c o r d s to w a r d m id lin e (a d d u c tio n ). m a x im iz in g th e g lo ttic o p e n in g f o r a ir m o v e m e n t. D. a n d th o s e o n a n tic o a g u la tio n ( c h o ic e D ). N o n e o f th e c h o ic e s e x c e p t f o r th e R L N w o u ld b e s tim u la te d d u r in g a n a w a k e tr a c h e o s to m y . 23.

T h u s . T r a n s tr a c h e a l j e t v e n tila tio n r e q u ir e s th a t th e a ir w a y b e c a n n u la te d in s o m e w a y . D. w o u ld r a p id ly c a u s e p u lm o n a r y o v e r in f la tio n a n d b a r o tr a u m a . w h e n u s in g tr a n s tr a c h e a l v e n tila tio n . W e re s u c h a p a tie n t to b e in d u c e d a n d m a s k v e n tila tio n tu r n o u t to u n s u c c e s s f u l. J e t v e n tila tio n r e q u ir e s a p a th w a y f o r e x p ir e d a ir to e g r e s s o u t o f th e lu n g s .s a v in g to o l to o x y g e n a te a n d v e n tila te th e p a tie n t. c a ta s tr o p h ic s u b c u ta n e o u s e m p h y s e m a c a n r a p id ly d e v e lo p r e n d e r in g o th e r a tte m p ts at in v a s iv e a ir w a y a c c e s s im p o s s ib le . 1 4 /1 6 G ) a n d th e n a tta c h in g th e e n d o f th e c a th e te r to a j e t v e n tila to r .a b d o m in a l p r e s s u r e a s s o c ia te d w ith c o u g h in g .g . if a r a p id s e q u e n c e in d u c tio n a n d in tu b a tio n a r e u n s u c c e s s f u l. In e m e r g e n t c ir c u m s ta n c e s .. is a d e f in itiv e m e th o d o f s e c u r in g th e a ir w a y th a t c a n b e u s e d f o r u p to 72 h o u r s . A s id e f r o m its u s e a s a r e s c u e d e v ic e . d e v ia tio n a n d /o r c o m p r e s s io n . 28. a p a tie n t w ith c o r o n a r y a r te r y d is e a s e o r h e a r t f a ilu r e m a y b e n e f it f r o m d e e p e x tu b a tio n to a v o id th e s y m p a th e tic s u r g e a s s o c ia te d w ith a w a k e e x tu b a tio n a n d a p a tie n t u n d e r g o in g a b d o m in a l h e r n i a r e p a ir m a y b e n e f it f r o m d e e p e x tu b a tio n to a v o id th e in c r e a s e d in tr a . T h e “ c a n n o t in tu b a te . th e a n e s th e s io l o g is t s h o u ld c a n c e l th e o p e r a tio n a n d d is c u s s th e o p tio n s f o r a ir w a y m a n a g e m e n t w ith th e p a tie n t so th a t a m u tu a lly a c c e p ta b le p la n c a n b e re a c h e d . th e r e w o u ld b e n o r e lia b le b a c k u p m e th o d o f a ir w a y m a n a g e m e n t. A lth o u g h th e p a tie n t in c h o ic e A id e a l ly w o u ld b e tr e a te d w ith “ fu ll s to m a c h ” p r e c a u tio n s . R e la tiv e c o n tr a in d ic a tio n s to th e e le c tiv e u s e o f th e L M A in c lu d e lo w a ir w a y c o m p lia n c e ( c h o ic e s B a n d C ). H o w e v e r. in c o m p e te n c e o f th e g a s tr o e s o p h a g e a l s p h in c te r ( c h o ic e C ). W h e n th e c a th e te r m ig r a te s in to th e a n te r io r c e r v ic a l s o ft tis s u e s . o n th e o th e r h a n d . A. a s u r g ic a l c r ic o th y r o to m y p e r m its b o th in h a la tio n a n d e x h a la tio n th r o u g h th e lu m e n o f in s e r te d tu b e ( c h o ic e B ) a n d so is n o t d e p e n d e n t o n u p p e r a ir w a y p a te n c y in o r d e r to f u n c tio n s a fe ly . T r a n s tr a c h e a l je t v e n tila tio n is a te m p o r a r y w a y to p r o v id e o x y g e n a tio n u n til a d e f in itiv e a ir w a y c a n b e e s ta b lis h e d . th is m a y b e a c c o m p lis h e d b y c a n n u la tin g th e c r i c o t h y r o i d m e m b r a n e w ith a n in tr a v e n o u s c a th e te r (e . a n L M A m a y b e a lif e . D e e p e x tu b a tio n m a y b e p e r f o r m e d b e c a u s e o f p o te n tia l b e n e f it r e la te d to a p a tie n t’s m e d ic a l c o m o r b id iti e s o r f o r s u r g ic a l r e a s o n s . th e d e liv e r e d h ig h p r e s s u r e s c a n e x p e l th e c a th e te r o u t o f th e tr a c h e a . c a n n o t v e n tila te ” s c e n a r io is a n e m e r g e n c y a n d n e c e s s ita te s im m e d ia te in v a s iv e a ir w a y a c c e s s to p r e v e n t a n o x ic in ju r y . “ D e e p e x tu b a tio n ” r e f e r s to th e te c h n iq u e o f r e m o v in g th e e n d o tr a c h e a l tu b e in a p a tie n t b r e a th in g s p o n ta n e o u s ly w h o r e m a in s a n e s th e tiz e d s u c h th a t h is o r h e r p r o te c tiv e a ir w a y r e f le x e s a r e s till a b o lis h e d . F o r e x a m p le . th e L M A c a n b e u s e d a s a s u p r a g lo ttic a ir w a y f o r e le c tiv e s u r g e r y . 26. S u r g ic a l c r ic o th y r o to m y . S in c e th e p a tie n t h a s r e f u s e d th is o p tio n a n d th e c a s e is n o t u r g e n t. la r y n g o s p a s m ( c h o ic e C ). In c o n tr a s t. 27. T w o o p tio n s in c lu d e tr a n s tr a c h e a l j e t v e n tila tio n a n d s u r g ic a l c r ic o th y r o to m y . W ith p r o l o n g e d j e t v e n tila tio n . B. o r a n o th e r c a u s e o f u p p e r a ir w a y o b s tr u c tio n ( c h o ic e A ). T h e A S A D if f ic u lt A ir w a y A lg o r it h m r e c o m m e n d s u s e o f s u p r a g lo ttic d e v ic e s s u c h a s th e la r y n g e a l m a s k a ir w a y (L M A ) a s r e s c u e to o ls w h e n l a r y n g o s c o p y a n d m a s k v e n tila tio n a r e u n s u c c e s s f u l. T h e s a f e s t w a y to s e c u r e th is p a tie n t’s a ir w a y w o u ld b e a n a w a k e f ib e r o p tic in tu b a tio n . T h e s e in c lu d e . T h is te c h n iq u e d e c r e a s e s th e c h a n c e o f a p a tie n t c o u g h in g d u r in g e m e r g e n c e in r e s p o n s e to th e p r e s e n c e o f a n e n d o tr a c h e a l tu b e . a n d in p a tie n ts w ith a fu ll s to m a c h ( c h o ic e D ). d e e p e x tu b a tio n s h o u ld n o t b e a tte m p te d in p a tie n ts w ith c o n tr a in d ic a tio n s to th is te c h n iq u e .

T h e y c a n a ls o h e lp to d is tin g u is h e x tr a th o r a c ic v s . C h o ic e s A . a n e x tr a th o r a c ic o b s tr u c tio n is d r a w n in to th e p a th w a y o f a ir m o v e m e n t b y s u b a tm o s p h e r ic in tr a lu m in a l p r e s s u r e s . a b e a r d ) o r in c r e a s e s th e r e s is ta n c e to a i r f l o w b e tw e e n th e m o u th a n d la r y n x . a n d a n a c u te a n g le b e tw e e n th e m o u th a n d la r y n x .a t m o s p h e r ic in tr a lu m in a l p r e s s u r e . a n e x tr a th o r a c ic o b s tr u c tio n is s te n te d o p e n b y s u p r a . In c o n tr a s t. 30. B .g . T h e s e f a c to r s in c lu d e p r o m i n e n t m a x illa r y te e th . p a tie n ts w ith a fu ll s to m a c h ( c h o ic e s A a n d B ) a n d in p a tie n ts w h o m a y b e c h a lle n g in g to m a s k v e n tila te o r re in tu b a te . a n d M a lla m p a ti sta tu s > 3 a r e a ll f a c to r s a s s o c ia te d w ith d if f ic u lt m a s k v e n tila tio n . in tr a th o r a c ic s o u r c e s o f th e o b s tr u c tio n . m a le g e n d e r . s in c e th e e x tr a lu m in a l in tr a th o r a c ic p r e s s u r e e x c e e d s th e in tr a lu m in a l p r e s s u r e . D u r in g th e i n s p i r a t o r y p h a s e o f s p o n ta n e o u s v e n tila tio n . In c o n tr a s t.v o l u m e lo o p . C h o ic e C w o u ld f a ll in to th is la tte r c a te g o r y b e c a u s e o f th e p o te n tia l f o r a ir w a y e d e m a f r o m p r o l o n g e d p r o n e p o s itio n in g . D. F l o w . C h o ic e D r e p r e s e n ts a d y n a m ic in tr a th o r a c ic o b s tr u c tio n . a h is to r y o f s n o r in g . 29. In g e n e r a l. a n d C r e p r e s e n t r i s k f a c to r s f o r d if f ic u lt in tu b a tio n . B. a n in tr a th o r a c ic o b s tr u c tio n is s te n te d o p e n d u r in g in s p ir a tio n b y th e n e g a tiv e e x tr a lu m in a l in tr a th o r a c ic p r e s s u r e . o n e p r e s e n t d u r in g b o th in s p ir a tio n a n d e x p ir a tio n . M a s k v e n tila tio n c a n b e m a d e d if f ic u lt b y a n y th in g th a t p re v e n ts th e fa c e m a s k f r o m f o r m in g a n a d e q u a te s e a l w ith th e p a tie n t’s fa c e (e . th a t is . a h ig h ly a r c h e d o r v e r y n a r r o w p a la te . w h ic h w o u ld b e e x p e c te d in a p a tie n t w ith a s th m a o r c h r o n ic o b s tr u c tiv e p u lm o n a r y d is e a s e . E d e n tu lo u s n e s s . f a c to r s th a t m a k e it d if f ic u lt to a lig n th e o r a l a x is w ith th e la r y n g e a l a x is r e s u lt in d if f ic u lt in tu b a tio n . C h o ic e C r e p r e s e n ts a f ix e d o b s tr u c tio n . d y n a m ic c a u s e s o f a ir w a y o b s tr u c tio n . h is to r y o f n e c k r a d ia tio n .v o l u m e l o o p s c a n h e lp d if f e r e n tia te f ix e d v s . a n in tr a th o r a c ic o b s tr u c tio n is e x a c e r b a te d d u r in g e x p ir a tio n . o b e s ity . . m u ltip le a tte m p ts a t la r y n g o s c o p y . C h o ic e A r e p r e s e n ts a n o r m a l f l o w . D u r in g e x p ir a tio n in a s p o n ta n e o u s ly b r e a th in g p a tie n t..

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None of the above . Inspiratory check valve D. 50 D. Pipeline gases are supplied at pressures of about______psi: A. The oxygen-flush valve provides which of the following oxygen flows (L/min) to the common gas outlet? A. 50 D. Pin index safety system C. Have a gas flow rate which depends on viscosity at high turbulent flows C. Gas flowmeters A.Anesthesia Machine Paul Sikka 1. Have a gas flow rate which depends on density at low laminar flows D. Oxygen C. Which of the following flowmeters is situated nearest to the gas outlet? A. Are cylindrical in shape 5. 25 C. Which of the following prevents delivery of hypoxic gas mixture once the oxygen pressure falls below 25 psi? A. 75 2. Are gas-specific B. Diameter index safety system B. Air D. 40 C. Fail-safe valve 3. Nitrous oxide B. 25 B. 90 4. 10 B.

Disconnection alarm D. Is pressure-compensated D. 2 12. A standing or ascending bellow is preferred for anesthesia ventilators. Modern vaporizers are A. Is pressurized to 3 atm C. 0. 10 B. Temperature-compensated C. Variable bypass vaporizers should be located A. 25 C. 6. Filling by gravity C. Both A and B 7. All of the above 8. Collapse B.2 B. The National Institute for Occupational Safety and Health (NIOSH) recommends limiting operating-room concentration of nitrous oxide t o ______ppm: A. Capacity of an oxygen “E” cylinder is approximately______L: . The National Institute for Occupational Safety and Health (NIOSH) recommends limiting operating-room concentration of volatile inhalational agents t o ______ppm: A.5 C. Agent-specific B. 100 11. Stoppage of flowmeter gas 10. 1 D. Between the flowmeters (upstream) and the common gas outlet (downstream) C. Inside the circle system 9. 0. Is electrically heated to 39°C B. 50 D. as disconnection is indicated by A. The Tec 6 desflurane vaporizer A. Between the common gas outlet (upstream) and the flowmeters (downstream) B. Pressure-compensated D. Between the gas pipeline and the flowmeters D.

The highest content of soda lime is A. A line-isolation monitor A. heat D.Na2CO3 (or K2CO3) + 2 H2O + Energy 3. 186 B. heat B. Carbonates. Which of the following system prevents the wrong gas cylinder being attached to the anesthesia machine? A. sodium hydroxide C.CaCO3 + 2 NaOH (or KOH) . water. A. If pressure in a full nitrous oxide “E” cylinder is 745 psi at 20°C. 745 14. H2CO3 + 2 NaOH (or KOH) . End products of the reaction in a soda lime CO2 canister are A. water. Na2CO3 (or K2CO3) + Ca(OH)2 . 650 D. Silica 17. Calcium hydroxide B. Diameter index safety system B. sodium hydroxide. Carbonates. Warns that an electrical shock is imminent B. 750 13. 600 C. the pressure in a half-full cylinder will be about______psi: A. Pin index safety system C. 248 C. Gauge-safety system 15. heat 1. Sodium hydroxide D. heat. Warns of a fault between the power line and the ground C.H2CO3 2. Carbonates. 500 B. Trips the ground leakage circuit breaker 16. CO2 + H2O . Warns of the presence of two faults D. Potassium hydroxide C. Sodium hydroxide. Hanger yoke assembly system D. 372 D. water.

It would have increased by 4-fold D. It would have not changed 22. 10 19. Malfunction of which of the following valves within a circle system may cause rebreathing of carbon dioxide and could potentially result in hypercapnia? A. You are preparing to set up for anesthesia in an off-floor location in the interventional radiology suite. Incorrect statement regarding the mechanisms of an Ambu bag is A. Patient valve has low resistance to both inspiration and expiration 21. It contains a nonrebreathing valve. It would double as well B. Has decreased resistance to patient breathing D. Mapleson B . Since fresh gas flow equal to minute ventilation is sufficient to prevent rebreathing. The radiography equipment is consuming the limited space that is available in the suite. It allows for positive-pressure ventilation D.18. None of the above 23. Is less bulky B. Compared to the Mapleson A system. Has a decreased risk of disconnection C. It has been decreased to half the original volume C. 7 D. Better conserves humidity 20. which of the following Mapleson circuit breathing/ventilation systems is the most efficient for spontaneous ventilation of the patient? A. and therefore. the circle system A. same as the circle system B. It is capable of delivery of nearly a 100% O2 concentration C. Inspiratory valve B. which of the following minimal fresh gas flows (L/min) will make the CO2 absorbent unnecessary? A. Mapleson A B. 5 C. 3 B. the decision is made to double the extension tube length from the ventilator to the patient table. If you notice that the CO2 absorbent is exhausted during the surgical procedure. Both A and B D. Expiratory valve C. What is the impact on the dead-space ventilation that would have occurred secondary to doubling the extension tubing length? A.

In a CO2-absorbent canister. Compound C D. Degradation of sevoflurane by soda lime results in the production of A. the greatest amount of carbon monoxide is produced by which of the following volatile agents? A. Mapleson C D. D>B>C>A B. D>C>B>A D. Isoflurane D. which of the Mapleson systems provides for the best efficacy? A. While setting up for anesthesia delivery in an “off-floor” location and planning for controlled ventilation of an asthmatic patient. Mapleson D 24. Compound A B. Compound D 26. Compound B C. C. Halothane C. Desflurane . C>A>D>B 25. A>B>C>D C. Different semi closed anesthetic ventilation/breathing systems (classically referred to as Mapleson systems and designated A to F) are pictured below. Sevoflurane B.

CHAPTER 3 ANSWERS 1. s p e c if ic f il le r s a r e a v a ila b le f o r e a c h v o la tile a g e n t. G a s f lo w r a te d e p e n d s o n its v is c o s ity a t l o w la m in a r flo w s . A c o n s ta n t c o n c e n tr a tio n o f a g e n t is d e liv e r e d . T h is is in c o n tr a s t to c y lin d e r g a s p r e s s u r e s . w h ic h e x p a n d s /c o n tr a c ts to d e liv e r a c o n s ta n t c o n c e n tr a tio n o f v a p o r . T h e h e a tin g a n d p r e s s u r i z a tio n o p tim iz e s th e d e liv e r y o f d e s f lu r a n e . u n a f f e c te d b y te m p e r a tu r e o r f lo w ra te s . A.s a f e v a lv e a u to m a tic a lly c lo s e s n itr o u s o x id e (a n d o th e r g a s e s ) to p r e v e n t d e liv e r y o f h y p o x ic g a s m ix tu r e to th e p a tie n t. B. T o m in im iz e th is . A d e s c e n d in g b e llo w . w h ic h a r e m u c h h ig h e r . a n d a r e r e d u c e d b y p r e s s u r e r e g u l a t o r s to le s s th a n 50 p s i.c o m p e n s a te d . D. A ls o . M o d e r n v a p o r i z e r s a r e a g e n t. C. C.f lu s h v a lv e . T h is is b e c a u s e . w h ic h p r e v e n t f il lin g o n th e w r o n g a g e n t. 9. 7. T h e T e c 6 d e s f lu r a n e v a p o r iz e r is e le c tr i c a lly h e a te d to 3 9 ° C a n d p r e s s u r i z e d to 2 a tm . O n e s h o u ld b e c a r e f u l w h e n u s in g th e o x y g e n . c o n tin u e s to f ill b y g r a v ity w h e n d is c o n n e c tio n o c c u r s . A. 5. T h e o x y g e n f lo w m e te r is s itu a te d n e a r e s t to th e g a s o u tle t. A. G a s f lo w m e te r s a r e c a lib r a te d f o r a p a r tic u la r g a s . h o w e v e r. T h e h ig h f lo w o f o x y g e n is p r o v id e d d ir e c tly to th e c o m m o n g a s o u tle t. P ip e lin e g a s e s a r e s u p p lie d a t p r e s s u r e s b e tw e e n 4 5 a n d 5 5 p s i. th e o x y g e n f lo w m e te r is p o s itio n e d d o w n s tr e a m a n d n e a r e s t to th e g a s o u tle t. T h e r e f o r e . v a p o r i z e r s a r e lo c a te d o u ts id e th e c ir c le s y s te m . a n d its d e n s ity a t h ig h tu r b u le n t flo w s . . a h y p o x ic g a s m ix tu r e c a n b e d e liv e r e d to th e p a tie n t.s a f e v a lv e is d e s ig n e d to b e a c tiv a te d w h e n o x y g e n p r e s s u r e f a lls b e lo w 2 5 p s i. F lo w m e te r s a r e ta p e r e d in s h a p e . if a le a k d e v e lo p s in th e f lo w m e te r tu b e s . 4. 2. V a p o r iz e r s a r e lo c a te d b e tw e e n th e f lo w m e te r s (u p s tr e a m ) a n d th e c o m m o n g a s o u tle t ( d o w n s tr e a m ) . B. T h e o x y g e n . as h ig h g a s f lo w s a t h ig h p r e s s u r e s c a n c a u s e lu n g b a r o tr a u m a in th e p a tie n t.s p e c if ic a n d te m p e r a tu r e . w ith th e d ia m e te r th e s m a lle s t n e a r th e b o tto m o f th e tu b e . 3.f lu s h v a lv e p r o v id e s g a s f lo w a t p ip e lin e p r e s s u r e s o f a b o u t 4 5 to 5 5 p s i a t 3 5 to 7 5 L /m in . T h e f a il. T e m p e r a tu r e c o m p e n s a tio n is a c h ie v e d b y a m e ta llic s tr ip c o m p o s e d o f tw o d if f e r e n t m e ta ls . In o th e r w o r d s . T h is d e c r e a s e s th e l i k e lih o o d o f d e liv e r y o f h ig h v a p o r c o n c e n tr a tio n s w h e n u s in g th e o x y g e n .f lu s h v a lv e . 8. A n a s c e n d in g b e llo w c o lla p s e s w h e n d is c o n n e c tio n o c c u r s . b y p a s s in g th e f lo w m e te r s a n d v a p o r iz e r s . a s c e n d in g b e llo w s a r e p r e f e r r e d f o r a n e s th e s ia v e n tila to r s . T h is is d o n e b e c a u s e d e s f lu r a n e b o ils a t r o o m te m p e r a tu r e a t s e a le v e l (1 a tm ). 6. D. T h e f a il.

D. w ith o x y g e n b e in g g r e e n . C y lin d e r m a n u f a c tu r e s h a v e a d o p te d th e p in in d e x s a f e ty s y s te m . n itr o u s o x id e b e in g b lu e . a s tw o fa u lts a r e r e q u ir e d to p r o d u c e a s h o c k . th e f r e s h g a s f lo w r a te h a s to b e in c r e a s e d . w h ic h p r e v e n ts a tta c h m e n t o f w r o n g g a s c y lin d e r to th e a n e s th e s ia m a c h in e . A n in d ic a to r d y e . if n e c e s s a ry . N e w e r a n e s th e s ia m a c h in e s a llo w c h a n g in g th e C O 2.c o d e d . W a s te .f o u r t h o f th e g a s is c o n s u m e d ( a b o u t 4 0 0 L r e m a in in g ) th a t th e p r e s s u r e in th e c y lin d e r b e g in s to fa ll.s c a v e n g in g s y s te m s a r e u tiliz e d to d e c r e a s e o p e r a t i n g .r o o m p o llu tio n is im p o r ta n t to p r e v e n t h e a lth . D. w h ic h is a d d e d to p r o d u c e h a r d n e s s . 16. E n d p r o d u c ts o f th e r e a c tio n o c c u r r i n g in a s o d a lim e C O 2 c a n is te r a r e c a r b o n a te s . 13.s c a v e n g in g s y s te m s a r e u tiliz e d to d e c r e a s e o p e r a t i n g . A s in g le f a u lt d o e s n o t c a u s e a n e le c tr ic a l s h o c k .is o la tio n m o n ito r . 17. T h e d ia m e te r in d e x s a f e ty s y s te m p re v e n ts a tta c h m e n t o f th e w r o n g g a s h o s e f r o m th e w a ll s u p p ly . in d ic a te s th a t a s in g le f a u lt h a s o c c u r r e d b e tw e e n th e p o w e r lin e a n d th e g r o u n d . N itr o u s o x id e is p r e s e n t in th e c y lin d e r a s a liq u id . A d v a n ta g e s o f a c ir c le s y s te m in c lu d e th e u s e o f lo w f r e s h g a s f lo w r a te s b e c a u s e o f th e p r e s e n c e o f a C O 2. N IO S H r e c o m m e n d s lim itin g o p e r a t i n g .r o o m c o n c e n tr a tio n o f n itr o u s o x id e to 2 5 p p m . s u c h a s e th y l v io le t. a n d s ilic a .8 0 0 p s i a t 2 0 °C . th e v o lu m e r e m a in in g in th e c y lin d e r d o e s n o t r e f le c t th e p r e s s u r e in th e c y lin d e r. w a te r. A lin e . P r e s s u r e in a h a lf . M in im iz in g o p e r a t i n g . w h e n a la r m in g . O th e r c o n s titu e n ts in c lu d e s o d iu m (3 % ) a n d p o ta s s iu m h y d r o x id e (1 % ).r o o m p o llu tio n .r o o m p o llu tio n . s o d iu m h y d r o x id e ( r e g e n e r a ti o n ) . a n d a ir b e in g y e llo w .a b s o r b e n t c a n is te r. F o llo w in g a r e th e r e a c tio n s : 18. 15. A. . W a s te . B. e s p e c ia lly th e la s t e q u ip m e n t th a t w a s p lu g g e d in . B.r o o m p o llu tio n is im p o r ta n t to p r e v e n t h e a lth . T h e e m p ty w e ig h t o f th e c y lin d e r is s ta m p e d o n th e c y lin d e r. th e e q u ip m e n t s h o u ld b e c h e c k e d .r e la te d e ffe c ts in h e a lt h ­ c a r e p r o v id e r s . T h e c a p a c ity o f a n “ E ” c y lin d e r o f o x y g e n is a b o u t 6 2 5 to 7 0 0 L . C.f u ll “ E ” c y lin d e r o f n itr o u s o x id e w ill s till b e 7 4 5 p s i. T h e r e f o r e . T h e h ig h e s t c o n te n t o f s o d a lim e is c a lc iu m h y d r o x id e (7 5 % ). H a n g e r y o k e a s s e m b ly is th e m e th o d o f a tta c h m e n t o f g a s c y lin d e r s to th e a n e s th e s ia m a c h in e . D. th e r e lia b le w a y to d e te r m in e th e r e m a in in g n itr o u s o x id e in th e c y lin d e r is to w e ig h th e c y lin d e r. C y lin d e r s a r e c o lo r . if th e C O 2 a b s o r b e n t is e x h a u s te d d u r in g a s u r g ic a l p r o c e d u r e . A m in im u m f r e s h g a s f lo w r a te o f 5 L /m in w ill m a k e th e u s e o f th e a b s o r b e n t u n n e c e s s a ry .r o o m c o n c e n tr a tio n o f v o la tile a g e n ts to 2 p p m . T h e p r e s s u r e in a fu ll c y lin d e r is a b o u t 1 . a n d th e r e f o r e . C a p a c ity o f a n “ E c y lin d e r ” o f n itr o u s is a b o u t 1 5 9 0 L . It is n o t u n til th r e e . M in im iz in g o p e r a t i n g . A s s o o n a s th e a la r m is tr i g g e r e d .a b s o r b e n t c a n is te r d u r in g th e s u r g ic a l p r o c e d u r e .r e la te d e ffe c ts in h e a lth ­ c a r e p r o v id e r s . B. is a d d e d to in d ic a te th e d e g r e e o f e x h a u s tio n . N IO S H r e c o m m e n d s lim itin g o p e r a t i n g .10. w a te r (2 0 % ). 11. a n d h e a t. H o w e v e r. 12. 14. B.

w h ic h c a n in c r e a s e c a r b o x y h e m o g lo b i n b l o o d c o n c e n tr a tio n . A. D is a d v a n ta g e s o f c ir c le s y s te m in c lu d e g r e a te r s iz e . 22.r o o m p o llu tio n . . W ith th e u s e o f s u c h v a lv e s .m a s k u n its h a v e n o n r e b r e a th in g v a lv e s . A. b u t c a n b e c o m e o b s tr u c te d b y e x h a le d m o is tu r e . a n d in c r e a s e d r e s is ta n c e to p a tie n t b r e a th in g . A. D u r in g s p o n ta n e o u s v e n tila tio n /b r e a th in g o f th e p a tie n t. h ig h c o n c e n tr a tio n s o f v o la tile a g e n t.a b s o r b e n t c a n is te r. c o n s e r v a tio n o f h e a t a n d h u m id ity . A d v a n ta g e s o f th e c ir c le s y s te m in c lu d e e c o n o m y ( lo w f r e s h g a s f lo w ra te s .s p a c e v e n tila tio n is lim ite d only to th a t v o lu m e d is ta l to Y -p ie c e ( in c lu d in g th e e n d o tr a c h e a l tu b e ). A m b u b a g s h a v e a r e s e r v o i r s y s te m to p r e v e n t r o o m a ir e n tr a p m e n t a n d a r e a b le to d e liv e r n e a r ly 1 0 0 % o x y g e n . w h e r e i n s p i r a t o r y a n d e x p ir a to r y g a s e s m i x a n d c o n v e r g e .19. D e s f lu r a n e p r o d u c e s th e h ig h e s t a m o u n t o f c a r b o n m o n o x id e in th e C O 2. a n d a d r y a b s o r b e n t. u s in g h ig h c o n c e n tr a tio n s o f s e v o f lu r a n e . a s its f r e s h g a s f lo w d r iv e s e x p ir e d a ir a w a y f r o m th e p a tie n t a n d to w a r d th e e x p ir a to r y /e x h a u s t v a lv e . d e c r e a s e d p o r ta b ility . D. P r o d u c ti o n o f c a r b o n m o n o x id e is in c r e a s e d b y u s in g l o w f r e s h g a s f lo w r a te s . r e g a r d l e s s o f th e le n g th o f tu b in g p r o x im a l to th e Y -p ie c e (to th e a n e s th e s ia m a c h in e ). th e v o lu m e o f d e a d . d e c r e a s e d u s e o f v o la tile a g e n ts ). a n d d e c r e a s e d o p e r a t i n g . 26. 20. O n e a d v a n ta g e o f th e c ir c le s y s te m v e n tila tio n w h e n c o m p a r e d to th e M a p le s o n s y s te m is th e p r e s e n c e o f u n id ir e c tio n a l v a lv e s ( in s p ir a to r y a n d e x p ir a to r y v a lv e s ) . T h e M a p le s o n D c ir c u it is m o s t e f f ic ie n t d u r in g c o n tr o lle d v e n tila tio n . n e ith e r th e M a p le s o n ( o n ly h a s a d ju s ta b le p r e s s u r e . T h e e f f ic ie n c y o f M a p le s o n s y s te m s d r o p s f r o m D > B > C > A f o r c o n tr o lle d v e n tila tio n .li m itin g v a lv e ) n o r th e c ir c le s y s te m ( o n ly h a s u n id ir e c tio n a l v a lv e s a n d d o e s a llo w r e b r e a t h in g ) h a s th is c o m p o n e n t. C.p r e s s u r e v e n tila tio n a s th e in ta k e v a lv e c lo s e s d u r in g b a g c o m p r e s s io n . 25. th e M a p le s o n c ir c u it p r o v id i n g f o r th e m o s t e f f ic a c y r a n g e s f r o m A > D > C > B (in th e o r d e r o f d e c r e a s in g e f f ic ie n c y ) . a n d f o r lo n g h o u r s (> 6 h o u r s ) . r e s u ltin g in th e p r o d u c tio n o f a p o te n tia lly n e p h r o to x ic c o m p o u n d A . 21. A. C o m p o u n d A p r o d u c tio n is in c r e a s e d b y u s in g l o w f r e s h g a s f lo w ra te s . D. 24. D. S e v o f lu r a n e is d e g r a d e d b y s o d a lim e . M a lf u n c tio n in e ith e r o f th e u n id ir e c tio n a l v a lv e s w ith in a c ir c le s y s te m c o u ld r e s u lt in th e a c c u m u la tio n a n d e v e n tu a l C O 2 r e b r e a th in g th a t m a y r e s u lt in h y p e r c a p n ia . W h ile r e s u s c ita tio n d e v ic e s s u c h a s A m b u b a g s o r b a g . T h e p a tie n t v a lv e h a s l o w r e s is ta n c e . 23. in c r e a s e d r i s k o f d is c o n n e c tio n . A m b u r e s u s c ita tio n b a g s d o a llo w f o r p o s itiv e .

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Continuous visual display of an ECG D. Positive electrode on the right arm and the negative electrode on the left arm D. Current ASA standards require that during anesthesia. you are looking for signs of ischemia. and AvF D. and Edward Bittner 1. III. Negative electrode on the right arm and the positive electrode on the left leg C. except A. Ala Nozari. Positive electrode on the right arm and the negative electrode on the left leg B. systemic blood pressure and heart rate be evaluated at least every A. A peripheral nerve stimulator 2. Use of lead V5 alone on ECG results in the detection o f _____(%) of ischemic episodes: A. and are most interested in leads A.Patient Monitoring Darren Hyatt. To help encourage universal quality and safety practices. During reperfusion. 35 B. 7 minutes D. V4—V6 C. 5 minutes C. I and AvL 5. Lead II of an ECG is represented by placing the A. An oxygen analyzer B. the surgeon informs you that he is worried about damage to the right coronary artery in a patient with a right-dominant coronary system. During the course of a complicated cardiac case. Negative electrode on the right arm and the positive electrode on the left arm 4. 55 . V1-V3 B. 3 minutes B. the ASA has adopted and mandates the use of all the following monitors during general anesthesia. II. 10 minutes 3. Capnography C.

None of the above . Diastolic or mean arterial blood pressure 8. The diastolic blood pressure recorded with an automated blood pressure cuff using the oscillometric method will be A. Phase 5 10. Phase 2 C. Phase 3 D. the diastolic blood pressure is measured at the onset of A. Incorrectly overestimate the true blood pressure C. Approximately 10 mm Hg higher when compared to direct arterial measurement B. Equal to direct arterial measurement D. Approximately 10 mm Hg lower when compared to direct arterial measurement C. C. A noninvasive blood pressure cuff can be used to monitor perfusion pressures C. Systolic blood pressure B. it is important to remember that you will not be able to measure the A. When performing the oscillometric method to measure blood pressure. Not give an incorrect blood pressure. for example. You are told during pass-off that the patient’s blood pressures have consistently been 90/50 mm Hg. You notice the blood pressure cuff on the left arm is one or two sizes small and barely stays on the patient. When measuring blood pressure manually and listening for Korotkoff sounds. While on CPB A. Phase 1 B. A blood pressure cuff that is too small will A. You are preparing for an emergent mitral valve repair that will need to be done on cardiopulmonary bypass (CPB). but will be uncomfortable in an awake patient 7. when you do not have a stethoscope or automated blood pressure cuff. Incorrectly underestimate the true blood pressure B. Random and unreliable 9. 95 6. Randomly both over. An arterial line can be used to measure perfusion pressures D. A pulse oximeter can be used to monitor oxygen saturation B.and underestimate the true blood pressure D. Mean arterial pressure D. 75 D. Diastolic blood pressure C. You are taking over a case from another anesthesia provider with a patient in the beach chair position and a history of moderate carotid artery disease.

22 mm Hg lower than the actual pressure D. 30 mm Hg lower than the actual pressure B. A wave B. Ease of compressibility if a hematoma or laceration develops B. the A. 0.01% 12. you notice that the arterial monitor transducer has slipped off its stand and is hanging approximately 30 cm lower than where it was originally leveled. An important consideration in using the subclavian approach for central venous access includes the A. Systolic blood pressures are generally higher and diastolic blood pressures are generally lower in which of the following conditions? A. 1% C. 22 mm Hg higher than the actual pressure 15. The incidence of distal ischemia resulting from arterial cannulation is less than A. While taking care of a patient. 30 mm Hg higher than the actual pressure C. Increased risk of damaging the brachial plexus when compared to internal jugular approach 16. Cannulation of ulnar artery is commonly associated with damage to the median nerve C. When considering the advantages and disadvantages of different sites for arterial cannulation such as radial. The further you are from the heart when using a direct arterial measurement B. C wave C. When using an automated noninvasive blood pressure cuff compared to a direct arterial measurement D. Lower risk of pneumothorax when compared to internal jugular approach C. ulnar. 0. brachial. Ability of the vessel to remain patent in the setting of hypovolemia D. V wave . Radial artery provides the principal source of blood to the hand B. 10% B.11. This would correspond to a blood pressure reading that is A. and dorsalis pedis. When interpreting a CVP waveform. the end of systole best coincides with the A. Cannulation of the femoral artery risks local and retroperitoneal hematoma 13. Dorsalis pedis artery is commonly used during emergencies and low-flow states D.1% D. When recording from an over dampened arterial tracing 14. The closer you are to the heart when using a direct arterial measurement C. femoral.

15% 21. and needs to emergently come to the operating room with minimal to no time for fluid resuscitation. you are watching the pressure tracing. After placing a central line. the beginning of systole is best represented by the A. If an echocardiogram was then obtained. The risk of complication from pulmonary artery catheter placement is less than A. After placing a central line in an unstable patient in the ICU. V wave D. D. The patient is unstable. as well as universally elevated filling pressures. When interpreting a CVP waveform. C wave C. as . Insertion of a pulmonary artery catheter can be beneficial in the management of all of the following cases. A wave B. Helping to determine cardiogenic versus noncardiogenic pulmonary edema B. Significant tricuspid regurgitation C. X decent 18. Following response to therapy in an unstable septic patient using mixed venous oxygen tension 22. If you were to then do an echocardiogram. you might expect to find A. 0.05% B. Following the response to therapy in a patient with severe pulmonary hypertension D. Significant tricuspid regurgitation C. 5% D. Cardiac tamponade B. you notice loss of the Y descent on the CVP tracing. you might expect to find which of the following? A. Atrial fibrillation D. except A. X decent 17. AV dissociation 20. you notice the initial CVP tracing shows very prominent C-V waves. AV dissociation 19. Cardiac tamponade B.5% C. Following cardiac output in an unstable patient with acute-onset tricuspid regurgitation C. 0. You receive a patient from the emergency department with multiple stab wounds to the upper abdomen. During placement of a pulmonary artery catheter. Descending thoracic aortic dissection D.

Start an infusion of epinephrine 26. 40 mm Hg C. 25 mm Hg B. 25 to 35 cm C. 75 mm Hg 25. Of the options listed below. the most beneficial intervention at this time would be to A. The tip of a pulmonary artery catheter typically enters the pulmonary artery at approximately A. Cardiac output is found to be markedly decreased with low central venous. Pulmonary artery D. Start an infusion of milrinone D. Typical mixed venous oxygen tension in a healthy adult is A. while central venous and pulmonary artery pressures are markedly increased. A t th e p o in t in d ic a te d b y th e a r r o w . pulmonary artery. Of the options listed below. 15 to 25 cm B. Right ventricle C. 45 to 55 cm 24. th e c a th e te r tip is lo c a te d in th e A. Right atrium B. 55 mm Hg D. A pulmonary artery catheter is placed to help guide management of hypotension. A pulmonary artery catheter is placed to help guide management of an obese patient with a known history of poorly controlled obstructive sleep apnea who is admitted with refractory hypotension. Systemic vascular resistance is moderately elevated. and pulmonary artery occlusion pressures. Cardiac output and pulmonary artery occlusion pressures are markedly decreased. Administer volume B. s h o w n . the most beneficial intervention at this time would be to . 35 to 45 cm D. Begin diuresis C. Wedge position 23.

When evaluating regurgitant lesions with transesophageal echocardiography. 1800 and 2100 29.4 and 6. Serious complications with transesophageal echocardiography (TEE).1% C. 40 and 50 C.01% B. 4. The cardiac index in a healthy adult ranges between______L/min/m2: A. B e g in d iu r e s is C. Pulse-wave Doppler C. 900 and 1500 D. Normal systemic vascular resistance ranges between______ (dynes)(s)/cm5: A. 900 and 1500 D. such as oral or pharyngeal injury or esophageal rupture. S ta rt a n in f u s io n o f m ilr in o n e D.0 30. S ta rt a n in f u s io n o f e p in e p h r in e 27. Normal pulmonary vascular resistance ranges between______(dynes)(s)/cm5: A. 10% 31. 0.2 and 4. have an incidence as high as A.8 and 1. the Nyquist limit should be set between______cm/s: A.2 D. When evaluating flow at a specific point during echocardiography.0 C.4 and 2. A. 60 and 70 32.2 B. Continuous-wave Doppler B. 1800 and 2100 28. 1. 300 and 600 C. Color Doppler . 50 and 60 D. 50 and 150 B. A d m in is te r v o lu m e B. you would use A. 50 and 150 B. 30 and 40 B. 2. 0. 300 and 600 C. 1% D. 0.

A patient with methemoglobinemia will have a pulse oximetry reading that A. the surgeon expresses concern of damage to the anterior spinal artery. P u ls e -w a v e o r c o n tin u o u s . Converges around a saturation of 85% B. 660 and 940 C. 540 and 780 B. An insufficient depth of anesthesia D. Damage to the anterior spinal artery B. Varies widely 36. Somatosensory-evoked potentials D. The monitoring that would be helpful to determine viability of the anterior spinal cord intraoperatively would include A. Low blood flow 35. Converges around a saturation of 65% C. For the removal of a complex spinal cord tumor. A patient with carboxyhemoglobin will have a pulse oximetry reading that A. 720 and 960 D. Pulse oximetry illuminates tissue samples with two wavelengths of light in order to calculate oxygen saturation. Severe acidosis D. Electroencephalography B. Intravenous bolus of methylene blue B. D. Bispectral index or Sedline monitoring 38. Intravenous bolus of heparin C. Converges around a saturation of 45% D. The accuracy of pulse oximetry can be significantly reduced by all of the following. 480 and 720 34. Varies widely 37. Converges around a saturation of 45% D. These wavelengths a re ______nm: A. Damage to the posterior spinal arteries C. except A. Motor-evoked potentials C. Converges around a saturation of 85% B.w a v e D o p p le r 33. The inadvertent administration of a neuromuscular blocking agent . A sudden drop in somatosensory-evoked potentials (SSEPs) would cause you to be worried about A. Converges around a saturation of 65% C.

the patient begins to cough. A. Hyperventilating the patient C. Amplitude and latency to decrease B. Cooling the patient D. the segment correlating with inspiration is represented by points A. the segment that correlates with the exhalation of anatomic dead space F igu re 4-2. A to C C.39. While monitoring somatosensory-evoked potentials. Of the options listed below. During cervical spine surgery for the resection of an intradural mass. Hemodilution 42. Midazolam D. the most likely medication to have caused this increase in amplitude would be A. an increase in amplitude is noted. With respect to somatosensory-evoked potential (SSEP) monitoring. A to B B. Propofol C. C to D D. Amplitude and latency to increase C. In the capnogram below. The concentration of isoflurane is subsequently increased. Amplitude to increase and latency to decrease 40. D to E 43. Sevoflurane 41. 4-2). Amplitude to decrease and latency to increase D. A to B . If somatosensory-evoked potentials change significantly. In the capnogram (Fig. Increasing blood pressure B. Etomidate B. you would expect A. the anesthesia provider should consider A.

Conduction B. A to C C. Up to the discretion of the anesthesia provider . Approximately 30 minutes after the induction of general anesthesia in a healthy adult patient. D to E 44. however not required for sedation D. Redistribution D. Radiation 47. Never required. Esophageal intubation D. C to D D. Esophageal intubation C. you notice that core body temperature has dropped by a full degree Celsius. temperature monitoring is A. Convection C. Endobronchial intubation B. Always required B. Bronchospasm D. According to the American Society of Anesthesiologists. Required for all general anesthetics. Bronchospasm or airway obstruction C. The capnograph depicted in Figure 4-3 is most likely a result of A. except A. This is most likely due to A. B. Pulmonary embolism 45. Pulmonary embolism B. Capnography can help detect all of the following. Elimination of neuromuscular blockers 46. but recommended C.

25% B. W ith f o u r tw itc h e s o n tr a in o f f o u r s tim u la tio n s . R e c tu m 50. 90% . e x c e p t A. y o u n o tic e th e p a tie n t h a s r e g a in e d f o u r tw itc h e s u s in g tr a in o f f o u r s tim u la tio n s . N a so p h a rn y x D. I n c r e a s in g s u r g ic a l s ite in f e c tio n s C. 50% C. c o r e te m p e r a tu r e is b e s t m e a s u r e d v ia th e A. O f th e o p tio n s lis te d b e lo w . I m p a ir m e n t o f p la te le t f u n c tio n D. I n c r e a s in g th e d u r a tio n o f a c tio n o f m u s c le r e la x a n ts 49. T y m p a n ic m e m b r a n e B. 75% D. W h ile m o n ito r in g a p a tie n t f o r r e tu r n o f n e u r o m u s c u la r f u n c tio n a fte r u s in g r o c u r o n iu m . D e tr im e n ta l e ffe c ts o f h y p o th e r m ia in c lu d e a ll o f th e f o ll o w i n g . D u r in g a c o m p le x m itr a l v a lv e r e p la c e m e n t.48. it is d e te r m in e d th a t th e p a tie n t w ill b e n e f it f r o m b r i e f p r o te c tiv e h y p o th e r m ia . I n c r e a s in g c e r e b r a l o x y g e n c o n s u m p tio n B. B la d d e r C. th e p a tie n t m a y s till h a v e b lo c k a g e o f a c e ty lc h o lin e r e c e p to r s o f u p to A.

A p r o p e r ly . T h is i n f e r i o r d is tr ib u tio n is r e p r e s e n te d b y le a d s II. a n d u p to 9 6 % w ith th e a d d itio n o f le a d s II and V 4. D. 3. 5. a v is u a l d is p la y o f a n E C G . a n o x y g e n a n a ly z e r in th e b r e a th in g s y s te m . 6. C. th e c u r r e n t s ta n d a r d o f c a r e is to m e a s u r e s y s te m ic b lo o d p r e s s u r e a n d h e a r t r a te e v e r y 5 m in u te s a t a m in im u m .d o m in a n t (th e p o s te r io r d e s c e n d in g a r te r y is s u p p lie d b y th e r i g h t c o r o n a r y a r te r y in a r ig h t . It is n o t p o s s ib le to m e a s u r e a d ia s to lic b l o o d p r e s s u r e w ith th e o s c il lo m e t r ic m e th o d . A s th e c u f f c o n tin u e s to b e d e fla te d . a n d is r e p r e s e n te d r o u g h l y b y le a d s V 1 . w h ic h is u p to th e j u d g m e n t o f th e a n e s th e s ia p r o v id e r . a n d is r e p r e s e n te d b y I. B.V 4 .a c c u r a te p r e s s u r e . T h e u s e o f th e V 5 le a d r e s u lts in th e d e te c tio n o f 7 5 % o f is c h e m ic e p is o d e s .d o m in a n t s y s te m ). . w h ic h r e p r e s e n ts th e s y s to lic b l o o d p r e s s u r e . W h e n u s in g th e o s c il lo m e t r ic m e th o d to m e a s u r e b l o o d p r e s s u r e . s y s te m ic b l o o d p r e s s u r e a n d h e a r t r a te m o n ito r in g . th e c u f f is in f la te d u n til n o o s c illa tio n s o n th e s p h y g m o m a n o m e te r a r e s e e n . T h e a n te r io r w a ll is s u p p lie d b y th e le f t a n te r io r d e s c e n d in g a rte ry . T h e u n d e r s ta n d in g o f c o r o n a r y a n a to m y a n d r e g i o n s o f is c h e m ia o n a n E C G is f u n d a m e n ta l. C. L e a d III c o r r e la te s w ith th e p la c e m e n t o f th e n e g a tiv e e le c tr o d e o n th e le f t a r m a n d th e p o s itiv e e le c tr o d e o n th e le f t le g . B. B. T h e r i g h t c o r o n a r y a r te r y p r o v id e s p e r f u s io n to th e i n f e r i o r o f th e h e a r t in a p p r o x im a te ly 8 0 % o f p a tie n ts w h o a r e c o n s id e r e d to b e r ig h t . 2.s iz e d n o n in v a s iv e b l o o d p r e s s u r e c u f f s h o u ld e n c o m p a s s 4 0 % o f th e c ir c u m f e r e n c e o f th e a r m . a n d A vF. s in c e s h e a lr e a d y h a s a h is to r y o f c a r o tid a r te r y d is e a s e a n d is in th e b e a c h c h a ir p o s itio n . B.th a n . and V 6. T h e la te r a l w a ll o f th e h e a r t is s u p p lie d p r i m a r i l y b y th e le f t c ir c u m f le x a rte ry . T h e c u f f is th e n s lo w ly d e f la te d u n til o s c illa tio n s a r e s e e n . a n d te m p e r a tu r e m o n ito r in g (w h e n c lin ic a ll y in d ic a te d ) f o r a ll c a s e s . A v L . V 5 . T h is c a n b e in c r e a s e d to 9 0 % w ith th e a d d itio n o f th e V 4 le a d . 4. w h e r e a s a c u f f th a t is to o l a r g e w ill r e s u lt in a lo w e r . D u r in g th e d e liv e r y o f a n e s th e s ia . T h e c lin ic a l s c e n a r io a n d p h a s e o f th e o p e r a tio n m a y m a n d a te m o r e f r e q u e n t m o n ito r in g . T h is p o in t o f m a x im a l o s c il la ti o n r e p r e s e n ts th e m e a n a r te r ia l p r e s s u r e . A c u f f th a t is to o s m a ll w ill r e s u lt in a r e a d in g th a t is in c o r r e c t l y h ig h . d is c o n n e c t a la r m s . A S A s ta n d a r d s m a n d a te th e u s e o f p u ls e o x im e tr y . III. L e a d I c o r r e la te s w ith th e p la c e m e n t o f th e n e g a tiv e e le c tr o d e o n th e r i g h t a r m a n d th e p o s itiv e e le c tr o d e o n th e le f t a r m . T h e u s e o f a p e r ip h e r a l n e r v e s tim u la to r is n o t a m a n d a te d m o n ito r . CHAPTER 4 ANSWERS 1. y o u n o te th e p o in t w h e r e m a x im a l o s c illa tio n s o c c u r . 7. L e a d II c o r r e la te s w ith th e p la c e m e n t o f th e n e g a tiv e e le c tr o d e o n th e r i g h t a r m a n d th e p o s itiv e e le c tr o d e o n th e le f t le g . T h is is p a r tic u la r ly w o r r i s o m e in th is p a tie n t w h e n c o n s id e r in g h e r c e r e b r a l p e r f u s io n p r e s s u r e . c a p n o g r a p h y .

T h e D IN A M A P (d e v ic e f o r in d ir e c t n o n in v a s iv e a u to m a tic m e a n a r te r ia l p r e s s u r e ) m e th o d f o r m e a s u r in g b l o o d p r e s s u r e u s e s a n a u to m a te d c u f f th a t m e a s u r e s o s c il lo m e t r ic v a r ia tio n s w ith r e d u c tio n in c u f f p r e s s u r e to c a lc u la te s y s to lic . C a n n u la tio n o f th e f e m o r a l a r te r y r is k s b o th lo c a l a n d r e t r o p e r ito n e a l h e m a to m a . P h a s e 5 o c c u r s a t th e c u f f p r e s s u r e a t w h ic h th e s o u n d f i r s t d is a p p e a r s . 12. A. d o r s a lis p e d is . D. P h a s e s 2 a n d 3 h a v e n o c lin ic a l s ig n if ic a n c e . A n o v e r d a m p e n e d a r te r ia l lin e tr a c in g w ill te n d to r e d u c e s y s to lic p r e s s u r e s a n d in c r e a s e d ia s to lic p r e s s u r e s . A n o n in v a s iv e a u to m a te d b l o o d p r e s s u r e c u f f w ill te n d to c o r r e la te w ith s y s to lic a r te r ia l b l o o d p r e s s u r e s . H o w e v e r. in f e c tio n . 9. c a n r e l i a b l y m e a s u r e m e a n a r te r ia l p r e s s u r e . w h e r e p u ls a tile f lo w is m in im a l. 10. a n d v e n o u s to a r te r ia l e x tr a c o r p o r e a l m e m b r a n e o x y g e n a tio n d e v ic e s . H e n c e r a d ia l a r te r y c a n n u la tio n is m u c h m o r e c o m m o n ly u s e d f o r in v a s iv e b l o o d p r e s s u r e m o n ito r in g . w h e n w id e s w in g s in B P a r e e x p e c te d . w h e r e a s s y s to lic a n d m e a n p r e s s u r e s te n d to c o r r e la te w e ll. th e d o r s a lis p e d is w ill r e c o r d h ig h e r s y s to lic a n d lo w e r d ia s to lic p r e s s u r e s c o m p a r e d to th e f e m o r a l lin e . D o r s a l is p e d is a r te r y c a n n u la tio n . C. a n d w h e n th e r e is n e e d f o r m u ltip le a r te r ia l b l o o d g a s m e a s u r e m e n ts . In c a s e s w h e r e P h a s e 5 d o e s n o t o c c u r (th e s o u n d n e v e r f u lly d is a p p e a r s ) . th e m e a n a r te r ia l p r e s s u r e s w ill b e a p p r o x im a te ly th e s a m e . b u t th e d ia s to lic p r e s s u r e w ill b e a p p r o x im a te ly 10 m m H g lo w e r w h e n m e a s u r e d v ia th e d ir e c t in v a s iv e a r te r ia l m o n ito r . s in c e it is a l a r g e v e s s e l a n d c a n s till b e id e n tif ie d in lo w f lo w s ta te s . d ia s to lic m e a s u r e m e n ts w ith D IN A M A P a r e a b o u t 10 m m H g h ig h e r w ith a u to m a te d a s o p p o s e d to d ir e c t a r te r ia l m e a s u r e m e n t. a n d is d e s c r ib e d in 5 p h a s e s o f s o u n d . w h e n c o m p a r in g a d o r s a lis p e d is a r te r ia l m e a s u r e m e n t to a f e m o r a l a r te r ia l m e a s u r e m e n t. C o m m o n in d ic a tio n s f o r d ir e c t b l o o d p r e s s u r e m o n ito r in g in c lu d e c a r d io p u lm o n a r y b y p a s s . a n d is th e p h a s e r e c o m m e n d e d b y th e A m e r ic a n H e a r t A s s o c ia tio n to c o r r e s p o n d m o s t r e l i a b l y w ith th e d ia s to lic h e a r t s o u n d . a n d f e m o r a l a r te r ie s . a n d d ia s to lic p r e s s u r e s . a n d h e m o r r h a g e . b r a c h ia l. a x illa r y . .1 % ). T h e s e m o n ito r s w ill n o t b e e f f e c tiv e d u r in g C P B w h e n b l o o d f lo w is a r tif i c ia lly s u s ta in e d w ith a m o r e c o n tin u o u s flo w . T h e u ln a r a r te r y is th e p r in c ip a l s o u r c e o f b l o o d f lo w to th e h a n d . T h is c a n a ls o b e th e c a s e w ith s o m e p a tie n ts o n le f t v e n tr ic u la r a s s is t d e v ic e s . 11. S y s to lic b l o o d p r e s s u r e s a r e g e n e r a lly h ig h e r a n d d ia s to lic b l o o d p r e s s u r e s a r e g e n e r a lly lo w e r th e f u r th e r y o u a r e f r o m th e h e a r t w h e n u s in g d ir e c t in v a s iv e a r te r ia l m e a s u r e m e n t. P h a s e 1 h e r a ld s th e o n s e t o f th e f i r s t s o u n d h e a r d a n d c o r r e la te s w ith th e s y s to lic b l o o d p r e s s u r e . P h a s e 4 is th e n u s e d to r e p r e s e n t th e d ia s to lic b l o o d p r e s s u r e . C a n n u la tio n o f th e b r a c h ia l a r te r y r is k s d a m a g e to th e m e d ia n n e r v e . T h e f e m o r a l a r te r y is o f te n u s e d in e m e r g e n c ie s . m e a n . C. w h ile n o t id e a l s in c e it is fa r f r o m th e c e n tr a l c ir c u la tio n .8. In g e n e r a l. w h e n r i g o r o u s c o n tr o l o f B P is n e c e s s a ry . B o th p u ls e o x im e tr y a n d n o n in v a s iv e b l o o d p r e s s u r e c u ffs r e q u i r e p u ls a tile b l o o d f lo w in o r d e r to o b ta in m e a s u r e m e n ts . C o m p lic a tio n s f r o m a r te r ia l c a n n u la tio n in c lu d e d is ta l is c h e m ia (< 0 . D. A. C o m m o n s ite s f o r c a n n u la tio n in c lu d e r a d ia l. 13. K o r o tk o f f s o u n d s a r e u s e d to in te r p r e t b l o o d p r e s s u r e w h e n u s in g a s te th o s c o p e a n d a n o n in v a s iv e b l o o d p r e s s u r e c u ff. F o r e x a m p le . a n d is d e s c r ib e d a s a th u m p in g o r m u tin g o f th e s o u n d j u s t b e f o r e d ia s to le .

T h e s u b c la v ia n a p p r o a c h h a s th e b e n e f it o f a ls o h a v in g g o o d la n d m a r k s . a n d th e Y d e s c e n t o c c u r s w h e n th e tr ic u s p id v a lv e o p e n s a n d th e a tr iu m s ta rts to e m p ty . th e C w a v e r e p r e s e n ts b u lg in g o f th e tr ic u s p id v a lv e in to th e a tr iu m d u r in g th e b e g in n in g o f s y s to le . C. b u t it c a n b e m o r e d if f ic u lt to th r e a d a c a th e te r c e n tr a lly . B. th e V w a v e r e p r e s e n ts f illin g o f th e a tr iu m w h ile th e tr ic u s p id v a lv e is c lo s e d . a n d r i s k o f p n e u m o th o r a x w ith lo w e r p la c e m e n ts . D. F o r e v e r y 3 0 c m in h e ig h t th a t a tr a n s d u c e r is m o v e d u p a n d d o w n . th e X d e c e n t o c c u r s d u r in g s y s to le a n d c o r r e s p o n d s to a tr ia l r e la x a tio n . a n d th e c o n v e n ie n c e o f b e in g e a s ily a c c e s s ib le a t th e h e a d o f th e b e d . th e r e is a c o r r e s p o n d i n g c h a n g e o f 22 m m H g in th e b l o o d p r e s s u r e r e a d in g (1 c m H 2O = 0 . th e A w a v e r e p r e s e n ts a tr ia l c o n tr a c tio n . a n d c a n b e d if f ic u lt to c o m p r e s s if a h e m a to m a o r la c e r a tio n o c c u r s . 15.4 . 16. T h e e x te r n a l ju g u l a r v e in c a n a ls o b e c a n n u la te d . th e V w a v e r e p r e s e n ts f illin g o f th e a tr iu m w h ile th e tr ic u s p id v a lv e is c lo s e d . T h e le f t in te r n a l j u g u l a r v e in c a r r ie s th e a d d e d r i s k o f d a m a g e to th e th o r a c ic d u c t. a s w e ll a s r e m a in in g r e la tiv e ly p a te n t in a h y p o v o le m ic p a tie n t. D u r in g s y s to le in a p a tie n t w ith tr ic u s p id r e g u r g ita tio n . R is k s a n d b e n e f its o f d if f e r e n t c e n tr a l c a n n u la tio n s ite s a r e im p o r ta n t f o r a n a n e s th e s ia p r o v id e r to u n d e rs ta n d . T h e s u b c la v ia n h o w e v e r d o e s c a r r y th e h ig h e s t r i s k o f p n e u m o th o r a x . T h e in te r n a l ju g u l a r a p p r o a c h h a s g o o d la n d m a r k s . th e A w a v e r e p r e s e n ts a tr ia l c o n tr a c tio n .14. tr a u m a to th e b r a c h ia l p le x u s .7 4 m m H g ). a n d th e Y d e s c e n t o c c u r s w h e n th e tr ic u s p id v a lv e o p e n s a n d th e a tr iu m s ta rts to e m p ty . C. p r e d ic ta b le a n a to m y . D is a d v a n ta g e s in c lu d e r i s k o f c a r o tid a r te r y p u n c tu re . 17. th e X d e c e n t o c c u r s d u r in g s y s to le a n d c o r r e s p o n d s to a tr ia l r e la x a tio n . th e C w a v e r e p r e s e n ts b u lg in g o f th e tr ic u s p id v a lv e in to th e a tr iu m d u r in g th e b e g in n in g o f s y s to le . B. In th e C V P w a v e f o r m d e p ic te d in F ig u r e 4 . p a r t o f th e e je c te d v o lu m e flo w s . In th e C V P w a v e f o r m d e p ic te d b e lo w . 18. a n d c a n b e m o r e d if f ic u lt to p a s s a p u lm o n a r y a r te r y c a th e te r w h e n n e e d e d . a n d its s u p e r f ic ia l lo c a t io n m a k e s it a n e a s y ta rg e t.

a s w e ll a s lo s s o f th e Y d e s c e n t. b u t o n ly if th e y in v o lv e th e a o r tic r o o t a n d th e n e x te n d in to th e p e r ic a r d iu m . e le v a te d a lv e o la r p r e s s u r e s . It w o u ld b e h ig h ly u n lik e ly to h a v e e le v a te d f illin g p r e s s u r e s in a b le e d in g tr a u m a p a tie n t w h o h a s n o t y e t b e e n r e s u s c ita te d . p u lm o n a r y th r o m b o e m b o li s m o r a ir e m b o lis m . it is im p o r ta n t to k n o w s o m e o f th e lim ita tio n s o f a p u lm o n a r y a r te r y c a th e te r b e f o r e s u b je c tin g a p a tie n t to r is k s . In p a tie n ts w ith a tr ia l f ib r illa tio n . a n d s e p s is . c a th e te r k n o ttin g . a s y s to lic s te p -u p is s e e n w h e n e n te r in g th e r i g h t v e n tr ic le . a d ia s to lic s te p -u p w h e n e n te r in g th e p u lm o n a r y a rte ry . A p u lm o n a r y a r te r y c a th e te r is p la c e d w h ile m o n ito r in g th e p r e s s u r e c h a n g e s m e a s u r e d a t th e tip o f th e c a th e te r. O th e r c o m m o n e r r o r s in m e a s u r e m e n t th a t a r e n o t p a tie n t d e p e n d e n t c a n in c lu d e a n in a c c u r a te v o lu m e o r te m p e r a tu r e o f th e in je c ta te s o lu tio n . In a d d itio n to u n iv e r s a l c o m p lic a tio n s a s s o c ia te d w ith c e n tr a l lin e p la c e m e n t. F o r e x a m p le . w h ic h r e p r e s e n t a tr ia l c o n tr a c tio n a g a in s t a c lo s e d tr ic u s p id v a lv e . . W ith A V d is s o c ia tio n . th e r e w ill b e e le v a te d p r e s s u r e s th r o u g h o u t th e e n tir e w a v e f o r m . A s w e ll a s k n o w in g s o m e v a lu a b le in d ic a tio n s . B. In s te a d o f s e e in g a s m a ll C w a v e th a t n o r m a l l y r e p r e s e n ts th e b u lg in g o f th e tr ic u s p id v a lv e . p u lm o n a r y a r te r y r u p tu r e . T h is r e t r o g r a d e b l o o d f lo w w o u ld c o n tin u e t h r o u g h o u t th e s y s to le . 21. s in c e th e r e is n o l o n g e r a u n if o r m a tr ia l c o n tr a c tio n . A s th e c a th e te r is a d v a n c e d . le f t a tr ia l m y x o m a s . th e r e w ill b e a lo s s o f th e A w a v e . d e v e lo p m e n t o f c o m p le te h e a r t b lo c k in a p a tie n t w ith p r e e x is tin g le f t b u n d le b r a n c h b lo c k . b a c te r e m ia . A. s in c e f il lin g p r e s s u r e s e le v a te to c o m p e n s a te a n d im p r o v e v e n tr ic u la r f illin g . a n d a r e tu r n to a tr a d itio n a l C V P w a v e f o r m w h e n e n te r in g th e w e d g e p o s itio n . B. th e r e f o r e . e n d o c a r d itis . 19. s o m e o f th e c o m p lic a tio n s c a n c a r r y s e v e r e m o r b i d ity a n d m o r t a lit y r is k s . th e r e a r e l a r g e a n d e x a g g e r a te d A w a v e s ( o f te n c a lle d “ c a n n o n ” A w a v e s ). S e e th e a n s w e r e x p la n a tio n o f Q u e s tio n 18. s in c e th is is a s y s to lic c o m p o n e n t o f th e C V P tra c e . p u lm o n a r y v e n o u s o b s tr u c tio n . W h ile th e in c id e n c e o f c o m p lic a tio n s is in f r e q u e n t. T h e f i r s t s e c tio n s h o w s a tr a d itio n a l C V P w a v e f o r m m e a s u r e d in th e r i g h t a tr iu m . a n d d e c r e a s e d le f t v e n tr ic u la r c o m p lia n c e . 20. a m u c h l a r g e r C w a v e w o u ld b e s e e n a s b l o o d f lo w s r e t r o g r a d e in to th e r i g h t a tr iu m a n d to w a r d th e tr a n s d u c e r . 22. s o m e a d d itio n a l p u lm o n a r y a r te r y c a th e te r c o m p lic a tio n s in c lu d e d y s r h y th m ia s ( m o s t c o m m o n ) . b a c k w a r d in to th e a tr iu m . B. A o r tic d is s e c tio n s c a n c a u s e c a r d ia c ta m p o n a d e . th e m e a s u r e m e n t o f c a r d ia c o u tp u t in p a tie n ts w ith tr ic u s p id r e g u r g i t a t i o n o r v e n tr ic u la r s e p ta l d e fe c ts is in a c c u r a te d u e to d ilu tio n o f th e in je c ta te . a n d w o u ld . a ls o in c r e a s e th e V w a v e s iz e . P u lm o n a r y a r te r y o c c lu s io n p r e s s u r e c a n a ls o in a c c u r a te ly r e p r e s e n t le f t v e n tr ic u la r e n d d ia s to lic p r e s s u r e in p a tie n ts w ith m itr a l s te n o s is . a n d a n o v e r a ll in c r e a s e in th e C w a v e s iz e . c a r d ia c v a lv e in ju r y . D u r in g c a r d ia c ta m p o n a d e .

a n d p u lm o n a r y a r te r y o c c lu s io n p r e s s u r e s s u p p o r t th e d ia g n o s is o f h y p o v o le m ia . I n te r p r e tin g p h y s io lo g ic d a ta f r o m a p u lm o n a r y a r te r y c a th e te r a n d g u id in g th e r a p y r e q u ir e s h a v in g a n in tim a te k n o w le d g e o f b a s e lin e v a lu e s . 30. s in c e it is m o r e r e lia b le w ith e x tr e m e s o f h e ig h t. 26.2 a n d 4 . 24. T y p ic a l m ix e d v e n o u s o x y g e n te n s io n in a h e a lth y a d u lt is 4 0 m m H g . In th e c lin ic a l s c e n a r io . O n a v e r a g e .2 L / m in /m 2. e s o p h a g e a l p e r f o r a tio n . A. e s o p h a g e a l s tr ic tu r e . S tr ic t c o n tr a in d ic a tio n s to T E E in c lu d e b u t a r e n o t lim ite d to e s o p h a g e a l s p a s m . n o r m a l p h y s io lo g ic v a s c u la r r e s is ta n c e f a lls b e tw e e n 9 0 0 a n d 1 5 0 0 ( d y n e s ) ( s ) /c m 5. 25. C. 28. T h e tip o f th e p u lm o n a r y a r te r y c a th e te r ty p ic a lly e n te r s th e p u lm o n a r y a r te r y a t a r o u n d 3 5 to 4 5 c m . y ie ld in g a s a tu r a tio n o f a p p r o x im a te ly 7 5 % . T h e p a tie n t’s h is to r y a n d c lin ic a l s c e n a r io s u g g e s t r i g h t h e a r t f a ilu r e d u e to p u lm o n a r y h y p e r te n s io n . C. e s p e c ia lly w ith p a tie n ts a t th e e x tr e m e s o f h e ig h t. R e d u c tio n in o x y g e n d e liv e r y c a n b e d u e to a r e d u c tio n in o x y g e n c o n te n t p e r d e c ilite r le a v in g th e le f t v e n tr ic le . a n d . A. C. 29. C a r d ia c in d e x is o f te n u s e d o v e r c a r d ia c o u tp u t in e s tim a tin g c a r d ia c fu n c tio n .0 0 0 p a tie n ts . s u c h a s d u r in g v i g o r o u s e x e r c is e o r s e p s is . l o w c e n tr a l v e n o u s . I n c r e a s e d o x y g e n c o n s u m p tio n ( lo w m ix e d v e n o u s o x y g e n ) o c c u r s d u r in g p e r io d s o f e le v a te d m e ta b o lic s ta te s . 27. M ix e d v e n o u s o x y g e n te n s io n c a n p r o v id e v a lu a b le i n f o r m a t io n o n th e b a la n c e b e tw e e n o x y g e n c o n s u m p tio n a n d d e liv e ry . B. S e r io u s c o m p lic a tio n s w ith T E E h a v e b e e n r e p o r te d in a p p r o x im a te ly 0 . B. N o r m a l c a r d ia c in d e x in a h e a lth y a d u lt r a n g e s b e tw e e n 2.1 % o f c a s e s . e s o p h a g e a l la c e r a tio n .23. N o r m a l p u lm o n a r y v a s c u la r r e s is ta n c e r a n g e s b e tw e e n a p p r o x im a te ly 5 0 a n d 1 5 0 (d y n e s ) ( s ) /c m 5. I n c r e a s in g in tr a v a s c u la r v o lu m e w o u ld b e th e m o s t b e n e f ic ia l in te r v e n tio n a t th is tim e . T h is c a n v a r y f r o m p a tie n t to p a tie n t. C. o r a p p r o x im a te ly 1 in 1 . M ilr in o n e m a y b e b e n e f ic ia l in d e c r e a s in g p u lm o n a r y v a s c u la r r e s is ta n c e a s w e ll a s in c r e a s in g c a r d ia c o u tp u t. p u lm o n a r y a rte ry . o r a r e d u c tio n in o v e r a ll c a r d ia c o u tp u t.

w a v e D o p p le r is u s e d to e x a m in e r e g u r g i t a n t le s io n s . a n d c a n v a r y w id e ly in s a tu r a tio n r e a d in g s . P u ls e -w a v e D o p p le r is u s e d to c a p tu r e f lo w a t a s p e c if ic p o in t. a n d s e ttin g th e l im it to h ig h c o u ld r e s u lt in u n d e r e s tim a tin g th e r e g u r g i t a n t le s io n . o n th e o th e r h a n d . S e ttin g th e l im it to l o w c o u ld r e s u lt in o v e r e s tim a tin g th e r e g u r g i t a n t le s io n . B. C o lo r . D u r in g p u ls e . 37. a n d c a n v a r y w id e ly in s a tu r a tio n r e a d in g s . R e la tiv e c o n tr a in d ic a tio n s in c lu d e b u t a r e n o t lim ite d to u p p e r G I b le e d . B. T h e s e w a v e le n g th s a r e 6 6 0 n m o f r e d lig h t (w e ll a b s o r b e d b y o x y g e n a te d h e m o g lo b in ) a n d 9 4 0 n m o f in f r a r e d lig h t (w e ll a b s o r b e d b y d e o x y g e n a te d h e m o g lo b in ) . 32. b u t n o t in f r a r e d lig h t. lo o k in g f o r d e c r e a s e d c e r e b r a l . I n tr a v e n o u s h e p a r in b o lu s is n o t k n o w n to d is to r t th e a c c u r a c y o f p u ls e o x im e try . a tla n to a x ia l d is e a s e . te n d s to c a u s e s a tu r a tio n s to c o n v e r g e a r o u n d 6 5 % . o n th e o th e r h a n d . a c o m m o n d y e u s e d d u r in g s u r g e r y . 31. T h e c u r r e n t g u id e lin e s r e c o m m e n d a N y q u is t l im it o f 5 0 to 6 0 c m /s w h e n e v a lu a tin g r e g u r g i t a n t le s io n s . te n d s to c a u s e s a tu r a tio n s to c o n v e r g e a r o u n d 6 5 % . S e n s o r y tra c ts . M e th e m o g lo b in e m ia a b s o r b s b o th w a v e le n g th s o f lig h t a n d te n d s to c o n v e r g e a r o u n d a s a tu r a tio n o f 8 5 % .w a v e D o p p le r. M e th y le n e b lu e . C a r b o x y h e m o g l o b in o n ly a b s o r b s r e d lig h t. d y s p h a g ia o r o d y n o p h a g ia . th e e x a c t lo c a t io n o f th e s ig n a l c a n n o t b e d e te r m in e d . C. M e th e m o g lo b in e m ia a b s o r b s b o th w a v e le n g th s o f lig h t a n d te n d s to c o n v e r g e a r o u n d a s a tu r a tio n o f 8 5 % . E l e c tr o e n c e p h a lo g r a p h y is c o m m o n ly u s e d to m e a s u r e c e r e b r a l a c tiv ity d u r in g n e u r o v a s c u la r s u r g e r ie s . a n d th e lo c a t io n o f th e s ig n a l c a n b e c a lc u la te d . a n d a lte r e d r e la tio n s h ip s in th e h e m o g lo b in d is s o c ia tio n c u r v e ( s e v e r e a c id o s is ) . a c o m m o n d y e u s e d d u r in g s u r g e r y . h o w e v e r. d y e s s u c h a s m e th y le n e b lu e a n d in d ig o c a r m in e .w a v e D o p p le r.e v o k e d p o te n tia ls . M a n y d if f e r e n t c lin ic a l s itu a tio n s w ill c a u s e p u ls e o x im e tr y to r e a d in c h a r a c te r is tic p a tte rn s . C a r b o x y h e m o g l o b in o n ly a b s o r b s r e d lig h t. C o n tin u o u s . 33. T h e c o r tic o s p i n a l tra c ts r e s p o n s ib le f o r m o to r f u n c tio n tr a v e l a lo n g th e a n te r io r s p in a l c o r d . 36. a n d c a n b e m o n ito r e d u s in g m o to r . T h is a llo w s th e e c h o m a c h in e to d e te c t h ig h e r v e lo c itie s a n d e n e r g y s h ifts . e s o p h a g e a l d iv e r tic u lu m . a m b ie n t lig h t. M a n y d if f e r e n t c lin ic a l s itu a tio n s w ill c a u s e p u ls e o x im e tr y to r e a d in c h a r a c te r is tic p a tte rn s . A. b u t n o t in f r a r e d lig h t. P u ls e o x im e tr y u s e s tw o w a v e le n g th s o f lig h t to c a lc u la te o x y g e n s a tu r a tio n .e v o k e d p o te n tia ls . a s in g le c r y s ta l is u s e d to b o th e m it a n d r e c e iv e u ltr a s o u n d e n e r g y . m e d ia s tin a l r a d ia tio n . d y s f u n c tio n a l h e m o g lo b in m o le c u le s . B. p a tie n t m o v e m e n t. u s e s tw o s e p a r a te c r y s ta ls to s e n d a n d r e c e iv e u ltr a s o u n d e n e r g y . T h e s e in c lu d e b u t a r e n o t lim ite d to lo w b l o o d f lo w c o n d itio n s . s u c h a s c a r o tid e n d a r te r e c to m ie s . a n d c a n b e m o n ito r e d u s in g s o m a t o s e n s o r y . 35. B. T h e a c c u r a c y o f p u ls e o x im e tr y c a n b e a ffe c te d b y m a n y f a c to r s . D. M e th y le n e b lu e . l a r g e d ia p h r a g m a tic h e r n ia s . 34. tr a v e l a lo n g th e p o s te r io r s p in a l c o r d . a n d d if f ic u lt in tu b a tio n d u e to p o s s ib il ity o f u n in te n tio n a l e x tu b a tio n w ith p r o b e m a n ip u la tio n .

It is im p o r ta n t to r e m e m b e r th a t c a p n o g r a p h y w ill s h o w a n o r m a l c a p n o g r a p h a n d e n d -tid a l C O 2 im m e d ia te ly f o ll o w i n g e n d o b r o n c h ia l in tu b a tio n . 41. a n d o c c u r s w h e n a p a tie n t b e g in s to a tte m p t in s p ir a tio n d u r in g th e e x p ir a to r y p h a s e o f m e c h a n ic a l v e n tila tio n . H a lo g e n a te d a n e s th e tic s a s w e ll a s n itr o u s o x id e ( e s p e c ia lly w h e n c o m b in e d to g e th e r ) c a n d e c r e a s e a m p litu d e a n d in c r e a s e la te n c y . D. . C to D r e f le c ts th e e x h a la tio n o f a lv e o la r g a s . A. M id a z o la m h a s b e e n s h o w n to d e c r e a s e a m p litu d e . a n d D to E r e p r e s e n ts th e b e g in n in g o f in s p ir a tio n . o r to u s e a to ta l in tr a v e n o u s te c h n iq u e w h e n m o n ito r in g S S E P s. A. S S E P s m o n ito r th e p o s t e r i o r s p in a l c o lu m n . 38. it is r e c o m m e n d e d to m in im iz e th e u s e o f v o la tile a n e s th e tic s to b e lo w 1 M A C . 45. A lig h t p la n e o f a n e s th e s ia w o u ld n o t c a u s e a d r o p in S S E P s. F o r th is r e a s o n . w ith p o in t D c o r r e la tin g w ith e n d -tid a l c a r b o n d io x id e . a n d h y p e r th e r m ia . A s d is c u s s e d in th e p r e v io u s q u e s tio n . B to C o c c u r s d u r in g m ix in g o f e x h a le d d e a d s p a c e a n d a lv e o la r g a s . L a te n c y c a n b e in c r e a s e d d u r in g h y p o th e r m ia . a n d c a n s o m e tim e s b e d r a m a tic . C to D r e f le c ts th e e x h a la tio n o f a lv e o la r g a s . C.e v o k e d p o te n tia ls . n o r w o u ld th e a d m in is tr a tio n o f a n e u r o m u s c u la r b lo c k in g a g e n t (th e la tte r w o u ld h in d e r th e u s e o f m o to r . as c h a n g e s in p h y s i o l o g y c a n a ls o a lte r la te n c y a n d a m p litu d e . s e v o f lu r a n e w o u ld b e e x p e c te d to d e c r e a s e a m p litu d e a n d in c r e a s e la te n c y o f S S E P s. T h is is o n e o f th e in d ic a tio n s th a t n e u r o m u s c u la r f u n c tio n is r e tu r n in g . w ith p o in t D c o r r e la tin g w ith e n d -tid a l c a r b o n d io x id e . 44. h y p o x ia . A to B o c c u r s d u r in g e x h a la tio n o f a n a to m ic d e a d s p a c e . M e d ic a tio n s a r e n o t th e o n ly v a r ia b le s th a t a f f e c t s o m a t o s e n s o r y . h y p o c a r b ia . b l o o d flo w .e v o k e d p o te n tia ls ) . B to C o c c u r s d u r in g m ix in g o f e x h a le d d e a d s p a c e a n d a lv e o la r g a s . w h ic h w o u ld b e a ffe c te d b y d a m a g e to th e p o s te r io r s p in a l a r te r ie s o r c o m p r e s s io n o f th e p o s t e r i o r s p in a l c o r d . a n d th is s h o u ld b e k e p t in m in d w h e n u s e d f o r p r e m e d ic a tio n . T h e c la s s ic im a g e a b o v e is c o m m o n ly r e f e r r e d to a s a c u r a r e c le ft. A. B is p e c tr a l in d e x o r S e d lin e m o n ito r in g is s o m e w h a t c o n tr o v e r s ia l.e v o k e d p o te n tia ls (S S E P s ). 39. A m p litu d e d e c r e a s e s d u r in g e p is o d e s o f h y p o te n s io n . A. A n e s th e s ia p r o v i d e r s m u s t b e v ig ila n t to a lw a y s lis te n f o r b ila te r a l b r e a th s o u n d s a n d o b s e r v e b ila te r a l c h e s t r i s e to c o n f ir m tr a c h e a l in tu b a tio n . E to m id a te is k n o w n to in c r e a s e th e a m p litu d e o f s o m a t o s e n s o r y . a n d D to E r e p r e s e n ts th e b e g in n in g o f in s p ir a tio n . A to B o c c u r s d u r in g e x h a la tio n o f a n a to m ic d e a d s p a c e . 43. 42. P r o p o f o l is c o n s id e r e d to h a v e m in im a l to n o e f f e c t o n a m p litu d e . a n d h e m o d ilu tio n /a n e m ia . 40. D. B. a n d is c o m m o n ly u s e d a s a n in f u s io n f o r th e m a in te n a n c e o f a n e s th e s ia w h e n m o n ito r in g S S E P s. b u t is u s e d to m o n ito r th e a d e q u a c y o f d e p th o f a n e s th e s ia .

T h e c u r r e n t r e c o m m e n d a tio n s f r o m th e A m e r ic a n S o c ie ty o f A n e s th e s io lo g is ts s ta te th a t te m p e r a tu r e m o n ito r in g is r e q u ir e d “w h e n c lin ic a ll y s ig n if ic a n t c h a n g e s in b o d y te m p e r a tu r e a r e in te n d e d . 49. A d e q u a te r e v e r s a l ( n e o s t i g m i n e . c o n v e c tio n . in c lu d in g in c r e a s e d o x y g e n u tiliz a tio n th r o u g h s h iv e r in g . a n tic ip a te d . R e c ta l te m p e r a tu r e s o v e r a ll te n d to b e a p o o r s u b s titu te . d e c r e a s e s b y a p p r o x im a te ly 7 % p e r d e g r e e C e ls iu s d e c r e a s e in te m p e r a tu r e . h o w e v e r. in fa n ts . s till u p to 7 5 % to 8 0 % o f a c e ty lc h o lin e r e c e p to r s m a y b e b lo c k e d . d e la y e d w o u n d h e a lin g a n d in c r e a s in g s u r g ic a l s ite in f e c tio n s . im p a ir e d p la te le t f u n c tio n a n d c o a g u la tio n . o c c u r (a s o p p o s e d to r e d is tr ib u tio n ) . a n d c lin ic a l s ig n s f o r r e tu r n o f n e u r o m u s c u la r f u n c tio n s h o u ld b e u s e d to g a u g e r e a d in e s s f o r e x tu b a tio n . o r s u s p e c te d . s u c h a s c o n d u c tio n . U n c o n tr o lle d h y p o th e r m ia h a s m a n y d e tr im e n ta l e ffe c ts . N u m e r o u s s ite s c a n b e u s e d to m o n ito r te m p e r a tu r e in th e o p e r a tin g r o o m . A t th e p o in t th e f o u r th tw itc h r e a p p e a r s . f o ll o w e d b y b la d d e r te m p e r a tu r e s . A. a n d p a tie n ts w ith a u to n o m ic d y s fu n c tio n . ty m p a n ic m e m b r a n e ( p e r f u s e d b y c a r o tid a r te r y ) a n d p u lm o n a r y a r te r y m e a s u r e m e n ts te n d to b e th e b e s t r e f le c to r s o f c o r e te m p e r a tu r e . w h ile a x illa r y a n d s k in te m p e r a tu r e s a r e h ig h ly p r o n e to e r r o r .5 °C a fte r th e in d u c tio n o f g e n e r a l a n e s th e s ia . C. D. it is a ls o im p o r ta n t to c o n s id e r a t r i s k p o p u la tio n s s u c h a s th e e ld e r ly . C. c o r e te m p e r a tu r e d e c lin e s b y a p p r o x im a te ly 1 to 1 . 48. a s w e ll a s p o te n tia l f o r s e r io u s d y s r h y th m ia s . r a d ia tio n .” In a d d itio n to c o n s id e r in g th e s u r g ic a l p r o c e d u r e . 50. O n a v e r a g e . 47.46. U n d e r s ta n d in g th e lim ita tio n s o f n e u r o m u s c u la r tw itc h m o n ito r in g d e v ic e s is fu n d a m e n ta l f o r a n a n e s th e s ia p r o v id e r . b u r n p a tie n ts . A.g l y c o p y r r o l a t e ) s h o u ld b e g iv e n . . a n d e v a p o r a tio n . O f th e m o s t c o m m o n . T h is in itia l d r o p in c o r e b o d y te m p e r a tu r e is p r i m a r i l y d u e to r e d is tr ib u tio n ( c o r e to p e r ip h e r y ) f r o m th e v a s o d ila tin g p r o p e r tie s o f m a n y a n e s th e tic s . C e r e b r a l o x y g e n c o n s u m p tio n . T e m p e r a tu r e m a y c o n tin u e to d r o p a s p r o c e s s e s o f h e a t lo s s .

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a CVP of 10 mm Hg should be considered elevated 3. Is converted to bicarbonate by the liver C.Fluid Management and Blood Transfusion Rebecca Kalman and Edward Bittner 1. Causes a hyperchloremic metabolic acidosis 4. the lactate in lactated Ringer solution A. Urine osmolality < 300 mOsm/kg D. Normal saline C. Dextran 40 may improve blood flow through the microcirculation B. Progressive metabolic acidosis B. Regarding central venous pressure (CVP) monitoring A. All of the following statements regarding dextran solutions are true. Is rapidly bound by albumin D. CVP monitoring is never indicated in patients with normal cardiac and pulmonary function D. Dextrans may have antiplatelet effects C. Urinary specific gravity > 1. D5 normal saline D. Lactated Ringer B. except A. Low values of <5 mm Hg may be considered normal in the absence of other signs of hypovolemia B. In healthy patients.010 C. except A. except A. Causes a lactic acidosis B. CVP readings can be interpreted independently of the clinical setting C. In a patient with right ventricular dysfunction. D5^ normal saline 5. Dextran 40 is a better volume expander than dextran 70 . Large-volume infusions of dextrans have been associated with renal failure D. Urine sodium < 10 mEq/L 2. All of the following fluids are generally considered to be isotonic. All of the following are signs of dehydration.

Low levels of 2. A leftward shift of the oxyhemoglobin dissociation curve may be related to A. “third spacing. 5% to 10% C. Recipient cells are mixed with donor serum C. 50% to 70% D. None of the above 10. None of the above 9. 6. Which of the following statements is true regarding fluid loss? A. Donor cells are mixed with recipient serum B. Traumatized. Contains all of the clotting factors except factor VIII B. Misidentification of the patient. Cellular dysfunction as a result of hypoxia usually produces a decrease in intracellular fluid volume 7. An error during type and crossmatch C. Both A and B D. Defective blood filter 12. Which of the following statements regarding fresh-frozen plasma (FFP) is correct? A. Evidence for the fact that leukocyte-containing blood products appear to be immunosuppressive includes all of the following. <1% B. >80% 8. An error during type and screen B. Internal redistribution of fluids. or infected tissues can only sequester minimal amounts of fluid in the interstitial space D. Hypothermia resulting from transfusion of blood C. Is contraindicated in the case of isolated-factor deficiencies 11. Carries the same infection risk as a unit of whole blood D. inflamed. blood specimen. except . Substantial evaporative losses can be associated with large wounds and are directly proportionate to the surface area exposed B. or transfusion unit D.3-DPG in packed red blood cells B.” cannot cause massive fluid shifts C. Donor serum is tested against red cells of known antigenic composition D. In a conventional crossmatch A. Should not be used in patients with antithrombin III deficiency C. The probability of developing anti-D antibodies after a single exposure to the Rh antigen is A. The most common cause of an acute hemolytic transfusion reaction is A.

Hespan D. A hyperchloremic-induced nongap metabolic acidosis C. Fresh-frozen plasma C. Packed red blood cells B. Platelets D. Packed red blood cells 17. Lactated Ringer solution B. PlasmaLyte C. Reaction-free C. A metabolic alkalosis B. None of the above 16. An anion gap lactic acidosis D. Bacterial infection due to a contaminated blood product is most likely with transfusion of A. 60 to 80 days D. The storage time for packed red blood cells at temperatures of 1 to 6°C is A. Nontoxic B. 120 days 18. Have the ability to remain in the intravascular space for a relatively long amount of time 15. 21 to 35 days C. Cryoprecipitate 14. Transfusion of allogeneic leukocytes can activate latent viruses in a recipient D. Preoperative blood transfusions appear to improve graft survival in renal transplant patients B. except A. A. All of the following solutions contain potassium. All of the following qualities are advantages of crystalloid solutions. Administration of large volumes of normal saline can lead to A. except A. Which of the following statements regarding transfusion of packed red blood cells is most correct? A. Recurrence of malignant growths may be more likely in patients who receive a blood transfusion during surgery C. Blood transfusion may decrease the incidence of serious infection following surgery or trauma 13. Relatively inexpensive D. The hematocrit of 1 unit is usually 30% to 40% . 7 to 10 days B.

A s o a k e d “ l a p ” p a d c a n h o ld 10 to 15 m L o f b lo o d 21. A lle r g ic B. R e g a r d in g a s s e s s m e n t o f s u r g ic a l b l o o d lo s s A. T h e u s e o f i r r i g a t i n g s o lu tio n s d o e s n o t c o m p lic a te a s s e s s m e n t o f b l o o d lo s s D. N one 24. D e x tr o s e . A n a p h y la c to id D. P h o s p h a te C. P r e d e p o s ite d d o n a tio n B. T r a n s f u s io n o f a s in g le u n it w ill in c r e a s e a n a d u lt’s h e m o g lo b in c o n c e n tr a tio n a b o u t 4 g /d L C. e x c e p t A. B o th a n ti-A a n d a n ti-B D. e x c e p t A. th e p r e s e r v a tiv e C P D A -1 is c o m m o n ly a d d e d . B lo o d p r o d u c ts a r e te s te d f o r a ll o f th e f o ll o w i n g . U r tic a r ia l 22. N o r m o v o le m ic h e m o d ilu tio n D. B o th s u r g e o n s a n d a n e s th e s io lo g is ts te n d to u n d e r e s tim a te b l o o d lo s s B. C itra te B. H IV C.d i r e c te d tr a n s f u s io n 23. M e a s u r e m e n t o f b l o o d in th e s u r g ic a l s u c tio n c o n ta in e r is a ll th a t is n e c e s s a r y to e s tim a te b l o o d lo s s C. B. e x c e p t A. M a y c a u s e c lo ttin g if th e tr a n s f u s e d p a c k e d r e d b l o o d c e lls a r e m ix e d w ith la c ta te d R in g e r s o lu tio n D. D o n o r . I n tr a o p e r a tiv e b l o o d s a lv a g e C. A n ti-B C. T h is c o n ta in s a ll o f th e f o ll o w i n g . T h e m o s t c o m m o n n o n h e m o ly tic r e a c tio n to tr a n s f u s io n o f b l o o d p r o d u c ts is A. A fte r b l o o d is c o lle c te d . H e p a titis C B. F e b r ile C. H e r p e s v ir u s 20. T h e ir p r in c ip le u s e a s th a t o f a v o lu m e e x p a n d e r 19. A n ti-A B. A p a tie n t w ith ty p e O b l o o d w ill h a v e w h ic h o f th e f o ll o w i n g p la s m a a n tib o d ie s ? A. T y p e s o f a u to lo g o u s b l o o d tr a n s f u s io n in c lu d e a ll o f th e f o ll o w i n g . W e s t N ile v ir u s D.

50 mL/h B. A medical student asks you if “young” blood is better for critically ill patients.” All of the following are potential contributors to his coagulopathy. Hypoventilation 26. 4 units of fresh-frozen plasma. A 50-year-old patient with coronary artery disease undergoing an open femoral popliteal bypass procedure. A neonate undergoing congenital diaphragmatic hernia repair D. 35-kg patient is A. A 51-year-old patient was an unrestrained driver in a motor vehicle crash in which he sustained multiple traumatic injuries. who is hypothermic and has received greater than 2 blood volumes of transfusion C. The estimated maintenance fluid requirement for a 9-year-old. A 70-year-old patient with chronic renal failure is in the operating room undergoing a kidney transplant. A patient with end-stage liver disease undergoing a complicated open shunt procedure. Which of the following patients is least likely to need calcium supplementation due to citrate- induced hypocalcemia related to blood transfusion? A. Under-resuscitation C. Uremia C. Blood from younger donors has lower risk of immunosuppression than blood donated by the elderly C. 75 mL/h C. A 30-year-old trauma patient receiving massive blood transfusion through a rapid transfuser at a rate of 75 mL/min B. and 6 units of platelets. His arterial blood gas reveals a metabolic alkalosis. The surgeons still complain that the patient “won’t clot. D. Older blood has a lower potassium content . who has received 3 units of packed red blood cells 29. The most likely explanation for this finding is A. 100 mL/h D. Fresher blood has better ability to deliver oxygen to tissues B. Temperature of 34. Dilutional thrombocytopenia D. Metabolism of citrate to bicarbonate B. Potassium 25. Which of the following statements regarding “young” blood is most correct? A. Fibrinogen level of 250 mg/dL 27. There has been more blood loss than expected.9°C B. He is on mechanical ventilation. and has received 8 units of packed red blood cells. Continued bleeding D. 20 mL/h 28. except A. and he has received 6 units of packed red blood cells and 3 units of fresh-frozen plasma.

T h e b l o o d b a n k n o tif ie s y o u th a t th e p a tie n t’s b l o o d ty p e is A . O . D. th e r e w a s n o tim e f o r b l o o d ty p in g a n d s h e h a s r e c e iv e d 3 u n its o f O .o ld f e m a le tr a u m a p a tie n t w h o w a s e m e r g e n tl y tr a n s p o r te d to th e o p e r a tin g r o o m f o r c o n tr o l o f m a s s iv e b le e d in g . Y o u a r e c a r in g f o r a n 1 8 .n e g a tiv e R B C s D.y e a r . A . R hoG A M . If th e p a tie n t r e q u ir e s f u r th e r tr a n s f u s io n .p o s itiv e . w h ic h o f th e f o ll o w i n g s h o u ld b e a d m in is te r e d ? A. D u e to th e a c u te n e s s o f th e p a tie n t’s b le e d in g . F r e s h e r b l o o d c a n b e tr a n s f u s e d m o r e r a p id ly th a n o ld e r b lo o d 30.p o s itiv e R B C s B. A -n e g a tiv e R B C s C.n e g a tiv e p a c k e d r e d b lo o d c e lls .

U r in e s o d iu m w ill b e lo w . a n d th u s . A. CHAPTER 5 ANSWERS 1. a lth o u g h th e y a r e s u b tly d if f e r e n t. la s ts lo n g e r . a n d is a b e tte r v o lu m e e x p a n d e r. O s m o la r ity is th e n u m b e r o f o s m o le s o r m o le s o f s o lu te p e r lite r o f s o lu tio n . S u b s ta n tia l e v a p o r a tiv e lo s s e s c a n b e a s s o c ia te d w ith l a r g e w o u n d s a n d a r e d ir e c tly . B. L a c ta te is n o t b o u n d b y a lb u m in . T h is te r m is s o m e tim e s u s e d in te r c h a n g e a b ly w ith o s m o la r ity . D e x tra n 4 0 a p p e a r s to im p r o v e b l o o d f lo w th r o u g h th e m i c r o c ir c u la tio n .0 0 0 . A n in tr a v e n o u s s o l u t i o n ’s e f f e c t o n f lu id m o v e m e n t d e p e n d s in p a r t o n its to n ic ity . I n f u s io n o f l a r g e v o lu m e o f d e x tr a n (> 2 0 m L /k g /d a y ) h a s b e e n a s s o c ia te d w ith r e n a l f a ilu r e . p la c e m e n t o f a C V P m o n ito r m a y b e in d ic a te d . In h e a lth y p a tie n ts th e la c ta te in la c ta te d R in g e r s s o lu tio n is r a p id ly c o n v e r te d to b ic a r b o n a te b y th e liv e r a n d d o e s n o t c a u s e a la c tic a c id o s is . F o r s u r g ic a l c a s e s d u r in g w h ic h l a r g e f lu id s h ifts a r e e x p e c te d . a n d a n a to m y c a n a f f e c t th e v a lu e s . d e x tr a n 7 0 h a s a m o le c u la r w e ig h t o f 7 0 . 3. p a tie n t p o s itio n . 2. P a tie n ts w ith c o m p r o m is e d r i g h t v e n tr ic u la r f u n c tio n g e n e r a lly h a v e h ig h C V P s.0 0 0 . C. a C V P o f 10 m m H g s h o u ld b e c o n s id e r e d n o r m a l to lo w d e p e n d in g o n th e d e g r e e o f d y s fu n c tio n . a n d th e r e f o r e . A. U r in e o s m o la lity is ty p ic a lly g r e a te r th a n 4 5 0 m O s m /k g in th is s e ttin g . 6. p a tie n ts w ith n o r m a l r e n a l f u n c tio n w ill r e ta in s o d iu m a n d p r o d u c e a c o n c e n tr a te d u r in e . F a c to r s s u c h as u n d e r ly in g c a r d io p u lm o n a r y d is e a s e . C V P m e a s u r e m e n ts m u s t b e e v a lu a te d in c o n te x t o f th e c lin ic a l s e ttin g . D. th e la tte r is b r o k e n d o w n m o r e s lo w ly . A h y p o to n ic s o lu tio n h a s lo w e r o s m o l a r i t y (< 2 5 0 ). A d m in is tr a tio n o f a l a r g e v o lu m e o f n o r m a l s a lin e c a n c a u s e a h y p e r c h lo r e m ic m e ta b o lic a c id o s is . a n d a h y p e r to n ic s o lu tio n h a s h ig h e r o s m o l a r i t y (> 3 5 0 ) (T a b le 5 -1 ). Table 5-1 Osmolarity and tonicity of commonly used crystalloid solutions F lu id M o s m /L T o n ic it y Lactated Ringers 273 Isotonic Normal saline 305 Isotonic D5 normal saline 586 Hypertonic D5M normal saline 355 Isotonic 5. A C V P o f < 5 m m H g c a n b e n o r m a l in a h e a lth y p a tie n t w ith o u t s ig n s o f h y p o v o le m ia . 4. C. a n d s p e c if ic g r a v ity w ill b e h ig h . T o n ic ity is th e e f f e c tiv e o s m o la lity a n d is e q u a l to th e s u m o f th e c o n c e n tr a tio n s o f th e s o lu te s w h ic h h a v e th e c a p a c ity to e x e r t a n o s m o tic f o r c e a c r o s s th e m e m b r a n e . W h ile d e x tr a n 4 0 h a s a m o le c u la r w e ig h t o f 4 0 . a n d a ll d e x tra n s m a y h a v e a n tip la te le t e ffe c ts . A s o lu tio n is is o to n ic if its to n ic ity f a lls w ith in ( o r n e a r ) th e n o r m a l r a n g e f o r b l o o d s e r u m — f r o m 2 7 5 to 2 9 5 m O s m /k g . W h e n d e h y d ra te d .

w h e r e d o n o r c e lls a r e m ix e d w ith th e r e c i p i e n t ’s s e r u m .1 ) . c a u s in g d e c r e a s e d o x y g e n u n lo a d in g to th e tis s u e s . T h i r d s p a c in g c a n c a u s e m a s s iv e f lu id s h ifts . a n d tr a u m a tiz e d . T h is h a s th r e e p u r p o s e s : (1 ) c o n f ir m s A B O /R h ty p in g . th e R h sta tu s is r o u ti n e ly d e te r m in e d in b l o o d d o n o r s . T h e R h b l o o d g r o u p is s e c o n d in im p o r ta n c e o n ly to th e A B O b l o o d g r o u p in th e f ie ld o f tr a n s f u s io n m e d ic in e . C. b e in g th e m a in c a u s e o f h e m o ly tic d is e a s e o f th e n e w b o r n . . T h e le v e l o f 2 . T h e s ig n if ic a n c e o f th e R h b l o o d g r o u p is r e la te d to th e f a c t th a t th e R h a n tig e n (D a n tig e n ) is h ig h ly im m u n o g e n ic . F o r th is r e a s o n . C e llu la r d y s f u n c tio n a s a r e s u lt o f h y p o x ia u s u a lly p r o d u c e s a n in c r e a s e in in tr a c e l lu la r f lu id v o lu m e . 7. A c r o s s m a tc h m im ic s a tr a n s f u s io n . 5 . 9.to . (2 ) d e te c ts r e c ip ie n t a n tib o d ie s to o th e r b l o o d g r o u p s y s te m s . A. 8. tr a n s f u s io n r e c ip ie n ts . in d iv id u a ls w h o d o n o t p r o d u c e th e D a n tig e n w ill p r o d u c e a n ti-D if th e y e n c o u n te r th e D a n tig e n w h e n tr a n s f u s e d w ith R B C s (c a u s in g a h e m o ly tic tr a n s f u s io n r e a c tio n ) . C.3 -D P G in s to r e d b l o o d is re d u c e d . C h o ic e C d e s c r ib e s a n a n tib o d y s c r e e n . H y p o th e r m ia a ls o c a u s e s a le f tw a r d s h if t o f th e o x y h e m o g lo b in d is s o c ia tio n c u r v e ( F ig . o r in f e c te d tis s u e c a n s e q u e s te r l a r g e a m o u n ts o f flu id . In th e c a s e o f th e D a n tig e n . a n d m o th e r s . a n d (3 ) d e te c ts a n tib o d ie s in l o w tite r s o r th o s e th a t d o n o t a g g lu tin a te e a s ily . p r o p o r tio n a t e to th e s u r f a c e a r e a e x p o s e d . in f la m e d . It h a s r e m a in e d o f p r i m a r y im p o r ta n c e in o b s te tr ic s .b e .

f a c to r d e f ic ie n c ie s .0 0 0 tr a n s f u s io n s . C.t e r m p r o g n o s i s in c a n c e r s u r g e r y is u n c le a r. c h ills . 12. A ll c o a g u la tio n f a c to r s .w e i g h t s u b s ta n c e s th a t r e m a in in th e in tr a v a s c u la r s p a c e l o n g e r th a n c r y s ta llo id s . b u t h a v e fe w e r r is k s th a n b l o o d p r o d u c ts . 11. w h ic h p r o b a b ly a c c o u n ts f o r th e g r e a te r r i s k o f b a c te r ia l g r o w th th a n w ith o th e r b l o o d p r o d u c ts . A c u te r e n a l f a ilu r e r e f le c ts p r e c ip ita tio n o f s tr o m a l a n d lip id c o n te n ts ( n o t f r e e h e m o g lo b in ) o f h e m o ly z e d e r y th r o c y te s in d is ta l r e n a l tu b u le s .9 % N a C l) is s lig h tly h y p e r to n ic a n d c o n ta in s m o r e c h lo r id e th a n e x tr a c e llu la r f lu id .r e la te d s e p s is c a n b e fa ta l a n d o c c u r s a s f r e q u e n tly a s 1 in 5 . B. T h e im m e d ia te s ig n s o f a c u te h e m o ly tic tr a n s f u s io n r e a c tio n s in c lu d e lu m b a r a n d s u b s te r n a l p a in .r e la te d fa ta litie s in th e U n ite d S ta te s is b a c te r ia l c o n ta m in a tio n . th e in itia l v o lu m e o f d is tr ib u tio n is e q u iv a le n t to th e p la s m a v o lu m e . a n d in e x p e n s iv e . P la te le t. 14. B lo o d tr a n s f u s io n s u p p r e s s e s c e ll. 15. P la te le ts a r e s to r e d a t 2 0 to 2 4 ° C in s te a d o f 4 °C .a n i o n g a p m e ta b o lic a c id o s is . C o llo id s o lu tio n s a r e c o m p o s e d o f l a r g e . a n d th e m o s t c o m m o n c a u s e is m is id e n tif ic a tio n o f th e p a tie n t. T h e s y n th e tic c o llo id s a n d p r o c e s s e d a lb u m in h a v e m in im a l o r n o r is k s o f in f e c tio n .m o l e c u l a r .10. 13. P r e o p e r a tiv e b l o o d tr a n s f u s io n s a p p e a r to im p r o v e g r a f t s u r v iv a l in r e n a l tr a n s p la n t p a tie n ts . F F P is a ls o in d ic a te d in a n tith r o m b in III d e f ic ie n c y a n d is o la te d . o r tr a n s f u s io n u n it ( c le r ic a l e r r o r ) . A d v a n ta g e s o f c r y s ta ll o id s o lu tio n s a r e th a t th e y a r e n o n to x ic . e x c e p t p la te le ts . H e m o ly tic r e a c tio n s o c c u r w h e n th e w r o n g b l o o d ty p e is a d m in is te r e d to a p a tie n t. D. w h ic h e x p la in s th e u s e o f th is c o m p o n e n t in th e tr e a tm e n t o f h e m o r r h a g e . A d m in is tr a tio n o f l a r g e v o lu m e s o f n o r m a l s a lin e s o lu tio n c a n le a d to a h y p e r c h lo r e m ic n o n . r e a c tio n . a n d h y p o te n s io n . T h e a p p e a r a n c e o f f r e e h e m o g lo b in in p la s m a o r u r in e is p r e s u m p tiv e e v id e n c e o f a h e m o ly tic r e a c tio n . C o llo id s a r e m o r e e x p e n s iv e th a n c r y s ta llo id s . T h e a s s o c ia tio n w ith lo n g . w h ic h m a y p la c e s u r g ic a l p a tie n ts a t r i s k f o r p o s to p e r a tiv e in f e c tio n . w h ic h is m o s t lik e ly to o c c u r in p la te le t c o n c e n tr a te s .in d u c e d s e p s is . f lu s h in g o f th e s k in .f r e e . a n d ty p ic a lly . D. A c u te h e m o ly tic tr a n s f u s io n r e a c tio n s a r e u s u a lly d u e to A B O b l o o d in c o m p a tib ility . b l o o d s p e c im e n .a s s o c ia te d v ir u s e s . N o r m a l s a lin e (0 . A n y p a tie n t in w h o m a f e v e r d e v e lo p s w ith in 6 h o u r s o f r e c e iv in g p la te le t c o n c e n tr a te s s h o u ld b e c o n s id e r e d to b e p o s s ib ly m a n if e s tin g p la te le t. A d m in is tr a tio n o f l a r g e a m o u n ts o f la c ta te d R in g e r s o lu tio n m a y r e s u lt in a m e ta b o lic a lk a lo s is b e c a u s e o f in c r e a s e d b ic a r b o n a te p r o d u c tio n f r o m th e m e ta b o lis m o f la c ta te . . C. F F P is th e f lu id p o r t i o n o b ta in e d f r o m a s in g le u n it o f w h o le b l o o d th a t is f r o z e n w ith in 6 h o u r s o f c o lle c tio n . C. a r e p r e s e n t in FFP. b u t th e r e is a s u g g e s tio n o f a c o r r e l a t i o n b e tw e e n tu m o r r e c u r r e n c e a n d b l o o d tr a n s f u s io n s .m e d ia te d im m u n ity . d y s p n e a . R e m o v in g m o s t o f th e w h ite b l o o d c e lls f r o m b l o o d a n d p la te le ts ( le u k o r e d u c tio n ) r e d u c e s th e in c id e n c e o f n o n h e m o ly tic f e b r ile tr a n s f u s io n r e a c tio n s a n d th e tr a n s m is s io n o f le u k o c y te . fe v e r. O n e o f th e le a d in g c a u s e s o f tr a n s f u s io n . a n d e m p ir ic a l a n tib io tic th e r a p y s h o u ld b e in s titu te d . A tr a n s f u s io n o f F F P c a r r ie s th e s a m e r i s k o f in f e c tio n a s tr a n s f u s in g a w h o le b lo o d .

C h a n g e s th a t o c c u r in b l o o d d u r in g s to r a g e r e f le c t th e le n g th o f s to r a g e a n d th e ty p e o f p r e s e r v a tiv e u s e d . C. d e p e n d in g o n th e s to r a g e m e d iu m . A s o a k e d “ l a p ” p a d c a n h o ld u p to 1 0 0 to 1 5 0 m L o f b lo o d . th e m o s t im p o r ta n t o n e is im p r o v e d m e th o d s f o r te s tin g o f d o n o r b lo o d . B. A lth o u g h tr a n s f u s io n o f p a c k e d r e d b l o o d c e lls in c r e a s e s in tr a v a s c u la r f lu id v o lu m e . a n d tr a n s f u s e d b a c k to th e p a tie n t. B lo o d s a lv a g e r e f e r s to th e c o lle c tio n o f s h e d b l o o d in tr a o p e r a tiv e ly . A lth o u g h m a n y f a c to r s a c c o u n t f o r th e m a r k e d d e c r e a s e d in c id e n c e o f tr a n s m is s io n o f in f e c tio u s a g e n ts v ia b l o o d tr a n s f u s io n . r o u ti n e ly r e c e iv e n o r m a l s a lin e b e c a u s e it c o n ta in s n o p o ta s s iu m .5 % to 1 % o f tr a n s f u s io n s . D. a n d o c c u lt b le e d in g u n d e r th e d r a p e s m u s t b e a c c o u n te d fo r . 17. . b l o o d is r e m o v e d j u s t p r i o r to s u r g e r y a n d r e p la c e d w ith c r y s ta ll o id o r c o llo id . T h e p a tie n t’s te m p e r a tu r e r a r e l y in c r e a s e s a b o v e 3 8 °C . HIV. P a tie n ts u n d e r g o in g e le c tiv e p r o c e d u r e s w ith a h ig h p r o b a b ility o f b lo o d tr a n s f u s io n c a n d o n a te th e ir o w n b l o o d 4 to 5 w e e k s p r i o r to s u r g e r y . M a n y p a tie n ts w ith h y p e r k a le m ia . n o n e m e r g e n c y tr a n s f u s io n . T r a n s f u s io n o f a s in g le u n it w ill in c r e a s e a n a d u lt’s h e m o g lo b in c o n c e n tr a tio n b y a b o u t 1 g /d L . T h e s to r a g e tim e (7 0 % v ia b ility o f tr a n s f u s e d e r y th r o c y te s 2 4 h o u r s a fte r tr a n s f u s io n ) is 21 to 3 5 d a y s . a n d th e c o n d itio n is tr e a te d b y s lo w in g th e in f u s io n a n d a d m in is te r in g a n tip y r e tic s . T h e h e m a t o c r i t o f 1 u n it o f p a c k e d r e d b l o o d c e lls is 7 0 % to 8 0 % . a n d th e n b e g iv e n b a c k to th e p a tie n t a fte r b l o o d lo s s . A d ir e c te d ( o r d e s ig n a te d ) b l o o d d o n a tio n is o n e in w h ic h a p a tie n t s e le c ts h is /h e r o w n b l o o d d o n o r ( s ) f o r a n a n tic ip a te d . F e b r ile r e a c tio n s a r e th e m o s t c o m m o n a d v e r s e n o n h e m o ly tic r e a c tio n a n d o c c u r w ith 0 . B lo o d l o s t in s p o n g e s . 21. M e a s u r e m e n t o f b l o o d in th e s u r g ic a l s u c tio n c o n ta in e r is o n ly o n e c o m p o n e n t o f e s tim a tin g b l o o d l o s s . T h e o th e r o p tio n s a r e a ll fa ls e . T h e b l o o d is s to r e d f o r u p to 6 h o u r s . C. in c lu d in g p a tie n ts w ith r e n a l f a ilu r e . a n d th is is r e f e r r e d to a s a p r e d e p o s ite d d o n a tio n . 18. T h e o b je c tiv e in tr a n s f u s io n o f p a c k e d r e d b l o o d c e lls is to in c r e a s e th e b l o o d ’s o x y g e n .16. B o th s u r g e o n s a n d a n e s th e s io lo g is ts te n d to u n d e r e s tim a te b l o o d lo s s . a n d W e s t N ile v ir u s a r e te s te d b y n u c le ic a c id te c h n o lo g y . h e p a titis C .c a r r y in g c a p a c ity . w a s h e d . T h e d o n o r is ty p ic a lly a f r ie n d o r r e la tiv e to th e p a tie n t. w h ic h is th e n c o n c e n tr a te d . H e s p a n is c o l l o i d c o n ta in in g s ta r c h a n d s a lin e . “ l a p ” p a d s . S e v e re f e b r ile r e a c tio n s a c c o m p a n ie d b y c h ills a n d s h iv e r in g m a y r e q u i r e d is c o n tin u a tio n o f th e b l o o d tr a n s f u s io n . T h e u s e o f i r r i g a t i n g s o lu tio n s o f te n c o m p lic a te s th e a s s e s s m e n t o f b l o o d lo s s . C u rre n tly . 22. D. T h e in c id e n c e o f in f e c tio n f r o m b l o o d tr a n s f u s io n s h a s m a r k e d ly d e c r e a s e d . A ll o f th e o th e r o p tio n s c o n ta in p o ta s s iu m . M ix in g o f p a c k e d r e d b l o o d c e lls w ith la c ta te d R in g e r s o lu tio n c a n c a u s e c lo ttin g a s th e c itr a te in th e b l o o d p r o d u c t c a n b in d w ith c a lc iu m in th e la c ta te d R in g e r. T h e m o s t lik e ly c a u s e is a n in te r a c tio n b e tw e e n th e r e c i p i e n t ’s a n tib o d ie s a n d th e a n tig e n p r e s e n t o n th e le u k o c y te s o f p la te le ts o f th e d o n o r . th e y s h o u ld n o t b e u s e d r o u ti n e ly f o r th is p u r p o s e g iv e n th e r is k s a s s o c ia te d w ith tr a n s f u s io n . A. 20. B. 19. F o r n o r m o v o l e m i c h e m o d ilu tio n .

T h e s e a n tib o d ie s a r e c a p a b le o f c a u s in g r a p id in tr a v a s c u la r d e s tr u c tio n o f e r y th r o c y te s th a t c o n ta in th e c o r r e s p o n d i n g a n tig e n s . B. B . a r b i t r a r y a d m in is tr a tio n o f c a lc iu m in th e a b s e n c e o f o b je c tiv e e v id e n c e o f h y p o c a lc e m ia is n o t in d ic a te d .v o lu m e tr a n s f u s io n . s to r e d < 1 4 d a y s ) is a s s o c ia te d w ith b e tte r o u tc o m e s in c lu d in g d e c r e a s e d m o r t a lit y r a te a n d fe w e r p o s to p e r a tiv e c o m p lic a tio n s .” 75 m L /h w o u ld b e th e m a in te n a n c e ra te . U n d e r .d ip h o s p h o g ly c e r a te c o n c e n tr a tio n s a r e b e tte r m a in ta in e d w ith f r e s h e r b lo o d ) . It c o n ta in s c itr a te a s a n a n tic o a g u la n t. T h e p o ta s s iu m f o u n d in b lo o d c o m e s f r o m th e b r e a k d o w n o f r e d b l o o d c e lls . 30.e. O . p h o s p h a te a s a b u f f e r . A f i b r i n o g e n g r e a te r th a n 1 5 0 m g /d L s h o u ld b e a d e q u a te f o r c lo ttin g . R h ) o n th e m e m b r a n e s o f e r y th r o c y te s . 27.o c c u r r in g a n tib o d ie s (a n ti-B . e s p e c ia lly w ith m a jo r s u r g e r y . C. a n d a d e n in e n e e d e d f o r th e m a in te n a n c e o f r e d c e ll A T P le v e ls . d e x tr o s e a s a r e d b l o o d c e ll e n e r g y s o u r c e . T h e c itr a te in th e b l o o d p r e s e r v a tiv e is m e ta b o liz e d to b ic a r b o n a te b y th e liv e r a n d c a n c a u s e a m e ta b o lic a lk a lo s is f o ll o w i n g a l a r g e . H y p o c a lc e m ia a s a r e s u lt o f c itr a te b in d in g o f c a lc iu m is r a r e b e c a u s e o f m o b iliz a tio n o f c a lc iu m s to r e s f r o m th e b o n e . 25.3 . a n ti-A ) a r e f o r m e d w h e n e v e r e r y th r o c y te m e m b r a n e s la c k A o r B a n tig e n s ( o r b o th ). D. A.23.. s o m e e v id e n c e s u g g e s ts th a t a d m in is tr a tio n o f y o u n g e r b l o o d (i. o r (3 ) th e p a tie n t is a n e o n a te . a n d d ilu tio n f r o m m a s s iv e tr a n s f u s io n a r e a ll p o te n tia l r e a s o n s f o r c o a g u lo p a th y in th is p a tie n t. C P D A -1 is th e m o s t c o m m o n ly a d d e d p r e s e r v a tiv e a d d e d to b l o o d p r o d u c ts . E v e n if th e p a tie n t’s b l o o d ty p e b e c o m e s k n o w n a n d a v a ila b le . 29. S u p p le m e n ta l c a lc iu m m a y b e n e e d e d w h e n (1 ) th e r a te o f b l o o d in f u s io n is m o r e r a p id th a n 50 m L /m in . 24. (2 ) h y p o th e r m ia o r liv e r d is e a s e in te r f e r e s w ith th e m e ta b o lis m o f c itra te . D. M o r e re c e n tly . a fte r 2 u n its o f ty p e O . A c c o r d in g to th e “ 4 -2 -1 r u l e . R o u tin e ty p in g o f b l o o d is p e r f o r m e d to id e n tif y th e a n tig e n s (A . In a n e m e r g e n c y s itu a tio n th a t r e q u ir e s tr a n s f u s io n b e f o r e ty p e a n d c o m p a tib ility te s tin g c a n b e p e r f o r m e d . a n d th e a b ility o f th e liv e r to r a p id ly m e ta b o liz e c itr a te to b ic a r b o n a te . Table 5-2 Formula for calculation of maintenance fluid requirement W e ig h t u p to 10 kg 4 m L /k g /h 11-20 kg Add 2 mL/kg/h 21 kg and above Add 1 mL/kg/h 28. C. 26. T h e r e f o r e . w h e r e a s h y p o v e n tila tio n c a u s e s a r e s p i r a t o r y a c id o s is . u r e m ia . A. F r e s h e r b l o o d (< 5 d a y s o f s to r a g e ) h a s b e e n r e c o m m e n d e d f o r c r itic a lly ill p a tie n ts in a n e f f o r t to im p r o v e th e d e liv e r y o f o x y g e n ( 2 . H y p o th e r m ia . T h is is c a lc u la te d as 4 0 + 2 0 + 15 = 75 m L /h (T a b le 5 -2 ).n e g a tiv e p a c k e d r e d b l o o d . N a tu r a lly .r e s u s c ita tio n a n d b le e d in g a r e lik e ly to c a u s e a m e ta b o lic a c id o s is . D.n e g a tiv e p a c k e d r e d b l o o d c e lls m a y b e a d m in is te r e d .

c e lls h a v e b e e n tr a n s f u s e d . R h o G A M is n o t in d ic a te d s in c e th e p a tie n t’s b l o o d ty p e is R h + .n e g a tiv e b lo o d . s u b s e q u e n t tr a n s f u s io n s s h o u ld c o n tin u e w ith O . .

.

When asked to describe the symptoms of her allergy to a local anesthetic that a 26-year-old female had at the dentist’s office. except A. except A. the capacity of the liver to metabolize the drug is the rate-limiting step C. In general. Methylparaben reaction B. All of the following drugs increase cardiac output. Epinephrine in the local anesthetic 3. and flushing. Para-aminobenzoic acid allergy D. This reaction is most likely caused by A. For drugs with high extraction ratio. Isoproterenol 4. palpitations. Mean arterial blood pressure . norepinephrine causes increase in all of the following. Epinephrine C. Correct statement about metabolism of drugs by the liver is A. All of the following drugs increase the mean arterial blood pressure. Norepinephrine 5. Dopamine B.Anesthetic Pharmacology Mian Ahmad and Ashish Sinha 1. Norepinephrine C. the patient describes a feeling of light-headedness. Vasovagal reaction C. Removal of the drug from the blood by hepatic clearance is directly proportional to hepatic blood flow and intrinsic clearance 2. liver blood flow is the rate-limiting step in their metabolism B. Dopamine B. Cytochrome P450 system is highly drug-specific D. Dobutamine D. Epinephrine D. except A. For drugs with low extraction ratio.

He has a history of hypertension. More depression of respiratory drive B. Anxiety 7. Cardiac dysrhythmias D. Stimulation of a 2 receptors causes A. Epinephrine B. Methylprednisolone B. Intraoperative hypotension develops secondary to injury to inferior epigastric artery. and depression. Bradycardia C. etomidate causes A. Heart rate C. Which of the following medications is relatively contraindicated to treat this hypotension? A. Treatment of hypertension in preeclampsia C. Compared with propofol. Less nausea B. Hypertension secondary to clonidine withdrawal 8. Salivation D. More depression of airway reflexes C. His medication list includes lisinopril. B. The best initial treatment for anaphylaxis during general anesthesia is A. More bronchodilation D. Hypertensive emergencies after cardiac surgery involving second-degree heat block D. diabetes. Treatment of hypertension in aortic dissection B. ketamine causes A. Hypertension B. Epinephrine 9. Greater myoclonic activity D. Greater histamine release 10. Labetalol is relatively contraindicated for A. Famotidine C. Less analgesia 11. A 65-year-old African American patient is undergoing laparoscopic repair of inguinal hernia under general anesthesia. hydrochlorothiazide. Increased seizure threshold C. Compared with thiopental. and phenelzine. Diphenhydramine D. metformin. Norepinephrine . Systemic vascular resistance 6.

It reverses opioid-induced respiratory depression 13. Increased nonionized lidocaine concentration B. Which of the statements among the following is true? A. Ropivacaine is an S-enantiomer of bupivacaine . Increased ionized lidocaine concentration C. Ropivacaine causes more motor than sensory block C. It causes hypertension and tachycardia C. Transcutaneous D. Lidocaine B. It has a shorter duration of action than midazolam D. Oral B. It binds irreversibly with benzodiazepine receptor B. Ephedrine D. Ropivacaine is more potent than bupivacaine B. except A. Decreased extracellular pH D. Which of the following local anesthetics is an ester? A. Hypertension C. Bupivacaine causes more vasoconstriction than ropivacaine D. Increased intracellular pH 15. Transnasal 14. Cocaine 17. more rapid onset of action of lidocaine occurs because of A. C. Pinpoint pupils D. True statement regarding flumazenil is A. When sodium bicarbonate is added to lidocaine. Prilocaine C. Midazolam can be administered through all of the following routes. Hypothermia 16. Mepivacaine D. Sublingual C. Phenylephrine 12. Which of the following findings suggests current use of cocaine in a patient undergoing preoperative evaluation? A. Bradycardia B.

It is th e ir c h a r g e d f o r m th a t in te r a c ts w ith th e r e c e p to r D. w h ic h a r e tr e a te d w ith n itr o g l y c e r i n e w ith n o e ffe c t.y e a r . B u p iv a c a in e C. H is h e a r t r a te is 1 2 3 /m in . L o c a l a n e s th e tic s c a u s e th e ir e ffe c ts b y A.o b s tr u c te d h e r n ia . Lidocaine 60 to 120 minutes B. A lte r in g th e r e s tin g m e m b r a n e p o te n tia l C. A d m in is tr a tio n o f e s m o l o l D. Mepivacaine 120 to 240 minutes C. A d m in is tr a tio n o f h y d r a la z in e B. A n E K G s h o w s S T -T w a v e c h a n g e s . b lo o d p r e s s u r e is 2 0 0 /1 0 0 m m H g . W h ic h o f th e f o ll o w i n g s ta te m e n ts a b o u t th e lo c a l a n e s th e tic s is f a ls e ? A. L id o c a in e . M a y b e d if f e r e n t in in v iv o o r in v itr o s y s te m s 22. Ropivacaine 120 to 180 minutes D. A p p lic a tio n o f a w a r m in g b la n k e t 19. L ip id s o lu b ility o f lo c a l a n e s th e tic s A. D e c r e a s in g th e r a te o f d e p o la r iz a tio n 21. In c r e a s e s a s th e f r a c tio n o f u n io n iz e d f o r m o f th e lo c a l a n e s th e tic in c r e a s e s D. I n c r e a s in g th e r a te o f d e p o la r iz a tio n D. W h ic h is th e c o r r e c t e x p e c te d d u r a tio n o f a n e s th e s ia a fte r in f i ltr a tio n w ith th e f o ll o w i n g lo c a l a n e s th e tic s ? A. I n c r e a s in g th e th r e s h o ld p o te n tia l B. T h e y c o n ta in e ith e r e s te r o r a m id e lin k a g e C. T h e y a re w eak b ases B. In c r e a s e s a s th e f r a c tio n o f io n iz e d f o r m o f th e lo c a l a n e s th e tic in c r e a s e s C. Bupivacaine 120 to 180 minutes 23. W h ic h o f th e f o ll o w i n g is th e m o s t a p p r o p r ia te n e x t s te p ? A. A d m in is tr a tio n o f n itr o p r u s s id e C.o ld p a tie n t is s h iv e r in g a n d h a s c h e s t p a in in th e r e c o v e r y r o o m f o llo w in g e x p l o r a t o r y l a p a r o to m y f o r a r u p tu r e . R o p iv a c a in e B. U s e o f w h ic h o f th e f o ll o w i n g lo c a l a n e s th e tic s f o r s p in a l a n e s th e s ia is c o n tr o v e r s ia l? A. T h e y b in d th e r e c e p to r in s id e th e c e ll 20. G e n e r a lly c o r r e la te s d ir e c tly w ith th e tim e to o n s e t o f a c tio n B. A 7 5 . T e tr a c a in e D. a n d S p o 2 is 9 7 % o n 2 L o f o x y g e n v ia n a s a l c a n n u la .18.

Highly ionized 28. Loss of consciousness means that patient has developed cardiac arrest D. The seizure threshold is increased by the administration of thiopental D. Highly protein bound B. except A. 20% to 30% . Seizure may have been caused by injection of the local anesthetic into cervical nerve root 25. 24. Repeated attempts at aspiration would have prevented this complication B. In general.The following three questions belong to this clinical situation: During placement of an interscalene block utilizing 0. Which of the following statements regarding local anesthetic toxicity is correct? A. The neonate does not show any sign of muscle relaxation because rocuronium is A. decreased local anesthetic protein-binding decreases potential CNS toxicity 26. Cerebral palsy 29. Addition of epinephrine to the local anesthetic may have helped to prevent this complication C. “Unaffected by ion trapping” C. Lipid soluble D. Burn injury B. All of the following can lead to hyperkalemic response to the administration of succinylcholine. Which of the following statements is false? A. Loss of consciousness may be secondary to high epidural anesthesia C. The dibucaine number in a patient having heterozygous type of plasma cholinesterase will be A. Spinal cord injury C. Seizure is a sign of neurotoxicity from high dose of local anesthetic B. Seizure may have happened secondary to the injection of local anesthetic into vertebral artery B. Amiodarone is the first line of treatment for cardiovascular toxicity caused by bupivacaine 27. Which of the following statements is false? A. a 62-year-old patient suddenly starts experiencing seizures and loses consciousness. During induction of anesthesia for cesarean delivery in a 22-year-old female. Prolonged ICU stay D. Loss of consciousness is a sign of low-dose local anesthetic neurotoxicity C.5% bupivacaine. Loss of consciousness may be secondary to high spinal anesthesia D. rocuronium is inadvertently substituted for succinylcholine.

Cisatracurium 0. Physostigmine B.07 mg/kg C. Succinylcholine 0. Vecuronium 0. Bradycardia D.2 ms long D. The correct recommended intubating dose among the following muscle relaxants is A. Glycopyrrolate 33. Pancuronium 0. Which of the following antibiotics augments the action of nondepolarizing muscle relaxants? A. 60% to 80% D. Succinylcholine C. 30% to 40% C. Neostigmine C.08 to 0.2 ms) high-frequency stimulations separated by a 30-ms interval and followed 1 second later by two or three additional impulses 35.5 to 0. Pancuronium 31. Cephalosporin C. Rocuronium B. except A.5 to 0. B. Which of the following muscle relaxants is eliminated mostly by the kidneys? A. Train of four: A series of four twitches in 2 seconds (2-Hz frequency). Erythromycin D. Tetany: A sustained stimulus of 50 to100 Hz. Twitch: A single pulse 0. Which of the following drugs is able to cross the blood-brain barrier? A. Increased bowel motility C. Excessive salivation B.5 second in duration C.07 mg/kg D. All of the following are side effects of anticholinesterase drugs.05 to 0. each 0.1 mg/kg B. Which of the following characteristics of electrical stimulation is the correct representation of the stimulus generated by the nerve stimulator used for monitoring the neuromuscular blockade? A.8 mg/kg 32. Pyridostigmine D. usually lasting 2 seconds B. Penicillin B. Double-burst stimulation: Three short (0. Vecuronium D. Streptomycin . 50% to 60% 30. Bronchodilation 34.

Phenylephrine D. Metoprolol B.36. Which of the following medications should be discontinued before the elective surgery? A. Administration of magnesium sulfate for preeclampsia results in a decreased dose requirement for each of the following. Glycopyrrolate C. a-Adrenergic D. except A. Desflurane D. Dopamine C. Which of the following medications is associated with extrapyramidal effects? A. Famotidine 40. Metoclopramide D. Tolerance to the antihypertensive effect of nitroprusside D. Which of the following is the most appropriate initial treatment? A. Metabolic acidosis B. Which of the following is not seen in acute cyanide poisoning? A. Lidocaine . Rocuronium C. Cardiac arrhythmias C. Succinylcholine B. Glutamate 38. Atorvastatin D. Mechanism of action of droperidol involves antagonism at all of the following receptors. Decreased mixed venous oxygen saturation 39. Ranitidine 41. a 56-year-old patient with severe mitral stenosis and a normal ejection fraction develops a blood pressure of 70/35 mm Hg with a heart rate of 90 bpm. Milrinone 37. except A. Immediately after induction of general anesthesia for hip replacement surgery. Dobutamine B. Midazolam B. Monoamine oxidase inhibitors C. Serotonin B. Epinephrine C.

4 7 B. E p h e d r in e B. T h e u s e o f n e o s tig m in e to r e v e r s e r e s id u a l n e u r o m u s c u la r b lo c k m a y s lo w th e m e ta b o lis m o f w h ic h o f th e f o ll o w i n g d r u g s a d m in is te r e d s u b s e q u e n tly ? A.o ld p a tie n t w ith h is to r y o f h y p e r tr o p h ic s u b a o r tic c a r d io m y o p a th y b e c o m e s h y p o te n s iv e .y e a r . C is a tr a c u r iu m C. M o r p h in e . N itr o u s o x id e 0 . D a ily in g e s t io n o f a s p ir in 47. P a n c u r o n iu m D. e x c e p t A. I s o f lu r a n e B. B e n e fits o f e p in e p h r in e 1 :2 0 0 .0 0 0 a d d e d to lid o c a in e f o r a n e p id u r a l in je c tio n in c lu d e a ll o f th e f o ll o w i n g . A 4 5 . N itr o g l y c e r in e C. N itr o g l y c e r in e 46. D ig o x in D. A c tiv e p e p tic u lc e r d is e a s e D. S u c c in y lc h o lin e 45. P r o p h y la c tic tr e a tm e n t o f h y p o te n s io n a s s o c ia te d w ith th e b o lu s a d m in is tr a tio n o f lid o c a in e D. W h ic h o f th e f o ll o w i n g c h o ic e s is c o r r e c t r e g a r d i n g th e b l o o d g a s p a r titio n c o e f f ic ie n t? A. a p a tie n t a n e s th e tiz e d w ith is o f lu r a n e .4 D. F a c to r V III d e f ic ie n c y C. B e tte r q u a lity o f b lo c k C. P h e n y le p h r in e D. th e r e b y d e c r e a s in g p r o b a b ility o f lo c a l a n e s th e tic to x ic ity 43. D e s f lu r a n e 0 . fe n ta n y l. T h e d r u g m o s t lik e ly to h e lp h im a c u te ly is A.6 2 C. R e n a l in s u f f ic ie n c y B. a n d n itr o u s o x id e d e v e lo p s a c u te p u lm o n a r y e d e m a . R o c u r o n iu m B.42. P r o l o n g a t i o n o f d u r a tio n o f a c tio n o f lid o c a in e B. W h ic h o f th e f o ll o w i n g d r u g s is most a p p r o p r ia te f o r tr e a tm e n t o f h y p o te n s io n ? A. F a c to r s th a t c o n tr a in d ic a te k e to r o la c a d m in is tr a tio n in c lu d e a ll o f th e f o ll o w i n g e x c e p t A. A m r in o n e C.8 5 44. I s o f lu r a n e 2. A fte r r e c e iv in g m a s s iv e b l o o d tr a n s f u s io n . S e v o f lu r a n e 0 . D e la y e d a b s o r p tio n in to s y s te m ic c ir c u la tio n .

It does not cross the placenta 50. Meperidine C. Elimination half-life is longer than most of the ^-receptor opioids B. Metoclopramide C. MAC of the drug 54. Less protein-binding D. Which of the following agents would be least likely to further lengthen the QT interval? A. Compared with sufentanil. Higher pKa B. An inhaled anesthetic has blood/gas partition coefficient of 14. A 22-year-old college athlete with a history of prolonged QT syndrome presents for an inguinal hernia repair. alfentanil is characterized by A. More rapid onset of analgesia C. Addition of fentanyl to epidural bupivacaine will cause A. Which of the following statements concerning naloxone is true? A. Increased sensory block 52. Increased vagal activity D. Morphine D. Succinylcholine D.8. Which of the following drugs is most likely to cause tachycardia? A. It has mixed agonist-antagonist activity C. Larger unionized fraction at physiologic pH C. Propofol 49.48. No change in duration of analgesia B. Ondansetron B. Nitroprusside therapy for hypertension should be discontinued in the presence of . Sufentanil 51. Recovery time primarily depends on A. Greater lipid solubility 53. It relieves opioid-induced spasm of the sphincter of Oddi D. Fentanyl B. Oil/gas solubility of the agent B. Cardiac output C. Duration of administration D.

Cardiopulmonary resuscitation is started. Ephedrine C. Undergoes slower hepatic metabolism 58. A 24-year-old man is apprehensive of general anesthesia and prefers a regional anesthetic. Epinephrine D. Acute myocardial infarction B. midazolam (Versed) A. Thiopental B. Renal failure 55. Has a larger volume of distribution D. A. he suddenly loses consciousness. Prevented by pretreatment with magnesium B. Increasing metabolic acidosis C. Partially reversed by calcium 57. Metabolizes succinylcholine by Hofmann elimination . Mitral regurgitation D. The next most appropriate intervention is administration of A. Isoflurane D. The drug that causes dose-dependent EEG evidence of both central nervous system excitation and depression is A. Potentiated by anticholinesterases C. Compared with lorazepam (Ativan). Resists dibucaine inhibition more than atypical pseudocholinesterase D. Is antagonized by acetyl cholinesterase C. Atropine B. Normal pseudocholinesterase A. The effect of gentamycin at the neuromuscular junction is A. Decreased by depolarizing relaxants D. There is profound hypotension with systolic blood pressure of 44 mm Hg and a heart rate of 28 bpm. Midazolam 59. Has a shorter elimination half-life B. Has more rapid clearance C. During the procedure. Decision is made to conduct spinal anesthesia for the repair of inguinal hernia along with midazolam and fentanyl to allay anxiety. Is produced primarily at nerve terminals B. Lidocaine C. Flumazenil 56.

A 28-year-old burn patient needs daily wound debridement. Which of the following drugs decreases lower esophageal sphincter tone? A. Glycopyrrolate C.60. During liver transplant surgery D. Mepivacaine D. Succinylcholine B. In older than in younger patients C. Bupivacaine B. A 76-year-old man with history of hypertension and cancer of the colon had colectomy under . Contraction of smooth muscle of the gallbladder B. Neostigmine 64. Opioid analgesics cause all of the following effects except A. Which of the following best explains this phenomenon? A. In kidney failure 63. An increased proportion of succinylcholine reaches the neuromuscular junction 61. Eutectic mixture of local anesthetics (EMLA cream) is sometimes used to numb the skin before attempting an intravenous access in pediatric patients. Midazolam 65. Delayed gastric emptying 62. Depress cellular immunity D. Lidocaine C. Hepatic clearance of succinylcholine is reduced C. Etomidate D. Nitrous oxide B. Which of the following local anesthetics is combined with prilocaine to produce this cream? A. Which of the following agents is not appropriate to provide a short duration of anesthesia? A. Metoclopramide D. Ketamine C. Diffusion away from the neuromuscular junction is slow B. In men compared to women B. Ropivacaine 66. Contraction of detrusor muscle of the urinary bladder C. Opioids may have more pronounced action in all of the following except A. Succinylmonocholine induces neuromuscular block D. Succinylcholine has prolonged action in patients carrying homozygous pseudocholinesterase.

Butorphanol B. Replacing 10 mg of morphine with 30 mg of ketorolac can increase the risk of A. He is receiving an epidural infusion of fentanyl at the rate of 100 micro symbol g/h. Respiratory depression B. Nalbuphine C. Isoflurane D. Buprenorphine D. Nausea B. Hypotension 67. Use of which of the following drugs will cause acute withdrawal symptoms? A. Chronic anemia with hemoglobin of 7. Bleeding 70. Thiopental 69. Analgesia C. A 45-year-old woman has been using heroin for last 20 years. Which of the following may help in mapping of a seizure focus under general anesthesia by enhancing the EEG activity or inducing the seizure? A. general anesthesia 24 hours ago.5 gm/dL D. Which of the following anesthetic agents is contraindicated for use in patients with intermittent porphyria? A. Which of the following is least likely? A. Pruritus C. Thiopental B. Respiratory alkalosis C. Diazepam D. Hypothermia to 34°C 71. Nausea D. Etomidate C. Ketamine administered in anesthetic doses . Naltrexone 72. Respiratory depression D. Isoflurane 68. Chronic alcohol use B. Ketamine B. Ketamine C. The minimum anesthesia concentration (MAC) of desflurane is decreased by A.

Which of the following drugs is the most appropriate agent for acute treatment of hypertension in a preeclamptic patient? A. which of the following agents is most appropriate to treat an acute episode of cyanosis in a child with tetralogy of Fallot? A. Propofol for induction D. Rebound hypertension is most likely after sudden discontinuation of which of the following classes of antihypertensive drugs? . Intrathecal opioids B. Labetalol C. Phenylephrine D. Causes respiratory depression C. Lisinopril D. Which of the following is contraindicated in a patient with Guillain-Barre syndrome? A. Absence of fade of single twitch 75. Atropine B. Absence of fade on tetanic stimulation at 50 Hz D. 100% oxygen 78. Ketamine for induction C. Double-burst ratio of 1 B. Is metabolized by the liver D. A. Magnesium B. Which of the following provides the best estimate of complete reversal of neuromuscular blockade? A. Nitroglycerine 74. Train-of-four-ratio of 1 C. Which of the following drugs is the most appropriate for management of anesthesia in a patient who needs emergency surgery and admits to using cocaine in last 3 hours? A. Increases bronchomotor tone 73. Decreases intracranial pressure B. Epinephrine C. Labetalol before induction B. Nondepolarizing muscle relaxant C. During general anesthesia. Succinylcholine 76. Epidural local anesthetics D. Ephedrine for treatment of hypotension 77.

Metoclopramide (Reglan) D. Vasodilation B. Lipid solubility 84. Calcium channel modulation 83. Which of the following drugs is most likely to be the cause of these symptoms? A. Promethazine (Phenergan) B. Granisetron (Kytril) 80. pKa C. a-Agonist D. NMDA receptor inhibition C. Sodium channel blockade D. A. Most of the administered dose is excreted unchanged by the kidney 82. Angiotensin-converting enzyme inhibitors 79. Calcium channel blockers C. Thiazide diuretics B. Primary site of action is GABA receptor D. A 65-year-old man has nausea and vomiting in the post-anesthesia care unit. Protein-binding D. It is extensively bound to plasma protein C. He develops involuntary facial movements. It increases frequency of excitatory spikes on the EEG more than thiopental D. It causes cerebral vasodilatation C. It is water soluble at an acidic pH and lipid soluble at physiologic pH B. difficulty swallowing. and torticollis. Which of the following statements about etomidate is most likely true? A. Kidney is the primary route of elimination 81. Which of the following properties of local anesthetics is most likely a primary determinant of potency? A. It causes significant dose-dependent respiratory depression B. Which of the following statements about etomidate is most likely true? A. It may be used as an infusion for sedation in the ICU . Which of the following statements about ketamine is true? A. The MOST likely analgesic mechanism of action of gabapentin for neuropathic pain is A. needing antiemetic therapy. Diphenhydramine (Benadryl) C. Antagonism at the GABA receptor B. Tolerance may develop after repeated administration B.

Which of the following medications is most appropriate to treat his condition? A. On examination. Which of the following statements about clopidogrel is most likely true? A. A patient has a history of an allergic reaction to a local anesthetic but does not recall the name. He is agitated and confused. Sodium channel blockade 89. The American Society for Regional Anesthesia recommends that clopidogrel be stopped 3 days before neuraxial anesthesia B. it is noted that he has been taking clopidogrel for a coronary artery stent that was inserted 2 years ago. C. It is related to propofol in its chemical structure D. Which of the following local anesthetics will most likely be the cause of a true allergic reaction? A. Inhibition of G-protein-coupled receptors B. Edrophonium . A 45-year-old farmer is brought into the emergency room. Neostigmine B. Which of the following statements about ketamine is most likely true? A. Clopidogrel is associated with pancytopenia D. Awakening from induction dose is secondary to very rapid liver metabolism 85. Anesthetic plan includes placement of an epidural catheter for postoperative pain relief. Anticholinergic poisoning is suspected. he has dry skin with fever and rapid heart rate. Which of the following is most likely the (analgesic) mechanism of action of lidocaine when used for neuropathic pain? A. Ketamine decreases the duration of action of nondepolarizing neuromuscular-blocking drugs C. Ketamine decreases the cortical amplitude of somatosensory-evoked potentials 87. Lidocaine C. Ketamine is a direct myocardial depressant D. A 64-year-old man is scheduled for an open abdominal aortic aneurysm surgery. Bupivacaine 88. A single dose of clopidogrel may have a clinically significant effect on platelet function C. Pyridostigmine C. On review of his medication list. Inhibition of platelet function by clopidogrel is reversible 86. Calcium channel blockade D. Antagonism of NMDA receptors C. Analgesic efficacy of epidural ketamine is equivalent to epidural morphine B. Procaine B. Mepivacaine D.

Atropine and neostigmine D. Glycopyrrolate and neostigmine 95. Neostigmine administration C. Which of the following statements about dexmedetomidine is most likely true? A. Clindamycin C. The patient is now bradycardic. Hypothermia 94. Rapid redistribution B. The shorter duration of action of remifentanil compared with fentanyl is primarily due to its A. It can increase opioid-induced rigidity C. Carbamazepine B. Rocuronium was used as muscle relaxant. D. and a combination of anticholinergic and anticholinesterase was used for reversal of muscle-relaxant action. It has no effect on systemic vascular resistance 93. Which of the following medications will prolong the neuromuscular blockade produced by vecuronium? A. Which of the following can precipitate an episode of myotonia in a patient with myotonic dystrophy? A. Nondepolarizing neuromuscular-blocker administration D. Which of the . Glycopyrrolate and edrophonium C. A 50-year-old woman had cholecystectomy done under general anesthesia. Cause of obstruction is found to be an ileal carcinoid tumor. the patient develops bronchospasm. Atropine and edrophonium B. and the peak airway pressure increases from 24 to 45 cm of H2O. Metabolism by esterases D. Quinidine D. Hepatic extraction ratio 92. Lidocaine administration B. Suddenly. Physostigmine 90. Renal elimination C. A 68-year-old man is undergoing exploratory laparotomy for intestinal obstruction. It has more a 2 selectivity than clonidine B. Verapamil 91. The combination of reversal agents most likely to cause the bradycardia is A. Context-sensitive half time increases markedly after prolonged infusion of dexmedeto midine D.

H e is n o r m o c a r b ic . w h ic h n e e d s e x p l o r a t o r y la p a r o to m y f o r r e l i e f o f in te s tin a l o b s tr u c tio n . A p a tie n t is u n d e r g o in g r e s e c tio n o f a s u p r a te n to r ia l b r a i n tu m o r . A d e c r e a s e d d o s e o f th is a g e n t is r e c o m m e n d e d in p a tie n ts w ith h y p o v o le m ic s h o c k p r i m a r i l y because A. S e v o f lu r a n e C. A d m in is tr a tio n o f w h ic h o f th e f o ll o w i n g is m o s t lik e ly to d e c r e a s e c e r e b r a l b l o o d v o lu m e ? . A 7 5 . C a r d ia c m u s c a r in i c r e c e p to r s C. a n d h is m e a n b l o o d p r e s s u r e is 70 m m H g .A d r e n e r g ic r e c e p to r s B. T a c h y c a r d ia is a n e a r ly s ig n o f th is s y n d r o m e D. f o ll o w i n g is th e b e s t tr e a tm e n t f o r th e b r o n c h o s p a s m in th is s itu a tio n ? A. G l y c o p y r r o la te B. C a r d ia c d y s f u n c tio n is v e r y c o m m o n in th is c o n d itio n 100. K e ta m in e D. T h e p a tie n t’s s y s to lic b l o o d p r e s s u r e is 7 8 m m H g a n d h e a r t r a te is 112 b p m . I s o p r o te r e n o l 99.y e a r . In o r d e r to c o u n te r a c t th e b r a d y c a r d i a c a u s e d b y fe n ta n y l.o ld w o m a n is s c h e d u le d f o r m itr a l v a lv e r e p a ir . T h io p e n ta l is s e le c te d a s th e in d u c tio n a g e n t f o r g e n e r a l a n e s th e s ia .o ld b o y h a s s e v e r e g a s tr o e n te r itis w ith n a u s e a . H ig h . p a n c u r o n iu m is a d m in is te r e d . D e x a m e th a s o n e B. C e n tra l v a g a l n u c le i 98. A C T s c a n o f th e a b d o m e n s h o w s in tu s s u s c e p tio n s . A 1 5 . a n d d ia r r h e a f o r la s t 3 d a y s . A tr o p in e D. D e liv e r y o f th e d r u g to th e b r a i n is in c r e a s e d B. S o m a to s ta tin 96. ^ . T h io p e n ta l is a m y o c a r d ia l d e p r e s s a n t D. P h e n y le p h r in e C.y e a r . T h io p e n ta l is a v a s o d ila to r 97. W h ic h o f th e f o ll o w i n g m e d ic a tio n s w o u ld b e most a p p r o p r ia te to tr e a t s y m p to m a tic b r a d y c a r d i a 1 m o n th a fte r c a r d ia c tra n s p la n t? A. W h ic h o f th e f o ll o w i n g s ta te m e n ts a b o u t p r o p o f o l in f u s io n s y n d r o m e is most lik e ly fa ls e ? A.d o s e fe n ta n y l is u s e d to in d u c e a n e s th e s ia . H e p a tic c le a r a n c e is d e c r e a s e d C. M o r ta lity r a te in a n e s ta b lis h e d c a s e is v e r y h ig h B. C a r o tid b a r o r e c e p t o r s D. R h a b d o m y o ly s is is o n e o f th e d ia g n o s tic c r ite r ia C. v o m itin g . P a n c u r o n iu m b lo c k s th e b r a d y c a r d i a c a u s e d b y fe n ta n y l b y a c tin g o n w h ic h o f th e f o ll o w i n g ? A.

O p io id s C.b l o c k in g d r u g s B. N e u r o m u s c u la r . T h io p e n ta l 2 m g /k g D. P h e n y to in 15 m g /k g 101. D e s f lu r a n e a t 1 M A C C. R a d io c o n tr a s t d y e s . A n tib io tic s D. N itr o u s o x id e a t 0 . W h ic h o f th e f o ll o w i n g c la s s e s o f d r u g s is m o s t lik e ly to b e r e s p o n s ib le f o r a n a n a p h y la c tic r e a c tio n d u r in g g e n e r a l a n e s th e s ia ? A. A.5 m in im u m a lv e o la r c o n c e n tr a tio n (M A C ) B.

V a s o v a g a l r e s p o n s e u s u a lly m a n if e s ts a s p a le s k in w ith v e r y l o w h e a r t r a te a n d b l o o d p r e s s u r e . o p tio n s f o r s a f e d e liv e r y o f a n e s th e s ia c a n g e t c h a lle n g in g . C y to c h r o m e P 4 5 0 s y s te m c a n m e ta b o liz e a w id e v a r ie ty o f d r u g s b y a s in g le g r o u p o f e n z y m e s . E f f e c t o f s y m p a th o m im e tic d r u g s o n th e m e a n a r te r ia l b l o o d p r e s s u r e is m e d ia te d th r o u g h th e ir e f f e c t o n th e a d r e n e r g i c r e c e p to r s th e y s tim u la te . b u t n o r e p in e p h r in e a ls o h a s a v e r y s tr o n g e f f e c t o n a ! r e c e p to r s . Q u e s tio n in g th e m a b o u t it is im p o r ta n t. D. a m e ta b o lite o f e s te r lo c a l a n e s th e tic s . C le a r a n c e o f d r u g s th a t a r e m a in ly m e ta b o liz e d in th e liv e r is a f u n c tio n o f th e a m o u n t o f d r u g b r o u g h t in to th e liv e r b y its b l o o d f lo w m u ltip lie d b y a b ility o f th e h e p a to c y te s to c le a r th e b l o o d o f th a t d r u g . it is th e in tr in s ic a b ility o f th e liv e r to c le a r th e b l o o d o f th is d r u g th a t d e te r m in e s a lf e n ta n i l’s c le a r a n c e . If la b e le d a s a n a l l e r g i c r e a c tio n . M a n y p a tie n ts b e lie v e th a t th e y a r e a l l e r g i c to lo c a l a n e s th e tic . In s te a d .h e a d e d n e s s . D. U ltim a te e f f e c t is g e n e r a te d th r o u g h c o m p le x in te r a c tio n o f d if f e r e n t f a c to r s b a s e d o n b a s e lin e s y m p a th e tic to n e . s h e a ls o h a d f lu s h in g a n d p a lp ita tio n w h ic h is n o t c o n s is te n t w ith v a s o v a g a l r e a c tio n . T r u e ty p e 1 a l l e r g i c r e a c tio n w ith lo c a l a n e s th e tic is e x tr e m e ly r a r e b u t w ill p r e s e n t a s a n a p h y la x is w ith h y p o te n s io n a n d r e s p i r a t o r y s y m p to m s . D. o th e r w is e . c a u s in g v a s o d ila ta tio n a n d d e c r e a s in g th e s y s te m ic v a s c u la r r e s is ta n c e . In a n e m e r g e n t s itu a tio n w h e r e a s p in a l a n e s th e tic c o u ld h a v e b e e n p o s s ib le . a n d d iz z in e s s . o n th e o th e r h a n d . 2.a m in o b e n z o ic a c id . M o s t o f th e a lle r g ic r e a c tio n s o b s e r v e d w ith lo c a l a n e s th e tic s a r e n o t d u e to th e lo c a l a n e s th e tic m o le c u le b u t e ith e r to p a r a . th u s in c r e a s in g c a r d ia c c o n tra c tility . it c a n c a u s e tr a n s ie n t ta c h y c a r d ia a n d h y p e r te n s io n th a t p a tie n t m a y d e s c r ib e a s p a lp ita tio n s . It is im p o r ta n t to e lu c id a te th e r e a l a lle r g ic r e a c tio n f o r a n e le c tiv e c a s e b y s u b je c tin g th e p a tie n t to a l l e r g y te s tin g . 4. A lfe n ta n il. L id o c a in e a n d p r o p r a n o l o l a r e e x a m p le s o f th is k in d o f c le a r a n c e . it a ls o s tim u la te s P! r e c e p to r s in b ig v a s c u la r b e d s lik e m u s c le . f lu s h in g . D. w h ic h a r e b o th p r e s e r v a tiv e s . D e n tists u s u a lly a d d e p in e p h r in e to th e lo c a l a n e s th e tic to d e c r e a s e th e b le e d in g a s s o c ia te d w ith th e d e n ta l p r o c e d u r e . th u s in c r e a s in g a f te r lo a d to s u c h a d e g r e e th a t c a r d ia c o u tp u t m a y a c tu a lly d e c r e a s e a fte r a d m in is tr a tio n o f th is . p a tie n t’s v o lu m e s ta tu s. A lth o u g h i s o p r o t e r e n o l in c r e a s e s c o n tr a c tility th r o u g h its a c tio n o n P2 r e c e p to r s . S o d e s p ite in c r e a s in g c o n tr a c tility o f th e h e a r t a n d in c r e a s in g th e c a r d ia c o u tp u t. a n d c o n d itio n o f th e h e a r t. a n d liv e r b l o o d f lo w d o e s n o t r e a l l y a f f e c t its c le a r a n c e . F o r d r u g s th a t h a v e a h ig h e x tr a c tio n r a tio . If a n y e p in e p h r in e g e ts a c c e s s to th e v a s c u la r s y s te m . O th e r m e d ic a tio n s in c r e a s e th e m e a n a r te r ia l b lo o d p r e s s u r e b y th e ir e f f e c t o n a ! a n d P! r e c e p to r s . th e liv e r r e m o v e s th e e n tir e d r u g e n te r in g th e liv e r in o n e p a s s . A ll o f th e s e c a te c h o la m in e s c a u s e s tim u la tio n o f P! r e c e p to r s . th e m e a n a r te r ia l b l o o d p r e s s u r e c a n d e c r e a s e w ith a d m in is tr a tio n o f th is d r u g . h a s a l o w e x tr a c tio n r a tio . it m a y l im it a n e s th e tic o p tio n s f o r th e p a tie n t in th e fu tu r e . CHAPTER 6 ANSWERS 1. S k in te s tin g is n o t in d ic a te d b e c a u s e o f th e r is k s in v o lv e d . o r to m e th y lp a r a b e n a n d m e ta b is u lp h ite . S e r u m te s tin g is a v a ila b le . 3. o n e m a y h a v e to u tiliz e g e n e r a l a n e s th e s ia a n d r i s k a ir w a y c o m p lic a tio n s . A lth o u g h th is p a tie n t d id h a v e lig h t.

C a r d ia c o u tp u t = S y s te m ic b l o o d p r e s s u r e /S y s te m ic v a s c u la r r e s is ta n c e A c c o r d in g to th is f o r m u la . In th e p a st. C. B. L a b e ta lo l is a c o m p e titiv e a n ta g o n is t a t th e a ! a n d P a d r e n e r g i c r e c e p to r s . H y p o te n s io n a n d b r a d y c a r d i a a r e s id e e ffe c ts th a t s o m e tim e s l im it th e u s e o f m e d ic a tio n s lik e c lo n id in e a n d d e x m e d e to m id in e . a n d its lo n g . It d o e s in c r e a s e th e l i k e lih o o d o f c a r d ia c d y s r h y th m ia s in th e p r e s e n c e o f s o m e o ld e r a n e s th e tic s lik e h a lo th a n e a s w e ll a s in h y p o x ia a n d h y p e r c a r b ia .t e r m a d m in is tr a tio n le a d s to u p r e g u la tio n o f a d r e n e r g i c r e c e p to r s . H 1. c a r d ia c o u tp u t in c r e a s e s w ith th e ir a d m in is tr a tio n .b lo c k e r s a r e a ls o in d ic a te d in th e tr e a tm e n t o f a n a p h y la x is a n d h e lp m itig a te th e e ffe c ts o f ty p e 1 a n tig e n a n tib o d y r e a c tio n o n m a s t c e lls . s y s te m ic v a s c u la r r e s is ta n c e (S V R ) is i n v e r s e ly r e la te d to c a r d ia c o u tp u t. th u s d e c r e a s in g s y m p a th e tic a c tiv ity . 5. A b n o r m a litie s o f c a r d ia c c o n d u c tio n s y s te m a r e a r e la tiv e c o n tr a in d ic a tio n to th e a d m in is tr a tio n o f la b e ta lo l a s it m a y w o r s e n th e d e g r e e o f c o n d u c tio n b lo c k a d e . a n in c r e a s e in th e S V R m a y d e c r e a s e th e c a r d ia c o u tp u t. e p in e p h r in e is c o n s id e r e d to b e th e d r u g o f c h o ic e a n d is in d ic a te d a s th e f i r s t lin e o f tre a tm e n t. 8. A lth o u g h a ll o f th e s e m e d ic a tio n s m a y b e u s e f u l in th e e v e n t o f a n a p h y la x is d u r in g a g e n e r a l a n e s th e tic . It is a p a r tic u la r ly u s e f u l d r u g in h y p e r te n s iv e p a tie n t w ith d ia g n o s is o f a o r tic d is s e c tio n a s it d e c r e a s e s th e s h e e r f o r c e a c r o s s th e d is s e c tio n . so it is u s e d in o b s te tr ic p a tie n ts w ith p r e e c la m p s ia to c o n tr o l th e ir b lo o d p r e s s u r e . th u s d e c r e a s in g th e a c tiv ity o f th e s y m p a th e tic n e r v o u s s y s te m . D r y m o u th m a y a ls o r e s u lt f r o m th e u s e o f d e x m e d e to m id in e . C lo n id in e is a s tim u la n t o f a 2 r e c e p to r s . It is a u s e f u l a g e n t in th e p e r io p e r a tiv e p e r i o d b e c a u s e v a s o d ila ta tio n c a u s e d b y a ! b lo c k a d e is n o t a c c o m p a n ie d w ith ta c h y c a r d ia w ith its a tte n d a n t r is k s . a n d th u s . a n d th u s o n s y s te m ic m e a n a r te r ia l b l o o d p r e s s u r e m a y b e so p r o n o u n c e d th a t th e r e m a y b e a d e c r e a s e in h e a r t r a te s e c o n d a r y to b a r o r e c e p t o r r e s p o n s e . b u t a p p lic a tio n s b a s e d o n th e ir s e d a tiv e . d ru g . It d o e s n o t c r o s s th e p la c e n ta a n d d o e s n o t d e c r e a s e th e u te r in e b l o o d f lo w e v e n w h e n p a tie n t is h y p o te n s iv e . 7.b lo c k e r a n ta g o n is t is v e r y h e lp f u l in c o n tr o llin g th e m a n if e s ta tio n s o f th is o v e ra c tiv ity .a n d H 2. th e s e d r u g s w e r e u s e d m a in ly a s a n tih y p e r te n s iv e s . Its P2 a c tio n h e lp s tr e a t b r o n c h o c o n s tr ic ti o n w h ile P1 a c tio n h e lp s s u p p o r t th e c a r d ia c o u tp u t. a n d a n a lg e s ic p r o p e r tie s a r e b e c o m in g i n c r e a s in g ly c o m m o n . S tim u la tio n o f a 2 r e c e p to r s c a u s e s in h ib itio n o f r e le a s e o f n o r e p in e p h r in e . a n x io ly tic . 6. D o s e d e p e n d s o n th e s e v e r ity o f th e r e a c tio n a n d m a y b e a n y w h e r e f r o m 10 |ig to 1 m g if c a r d ia c a r r e s t d e v e lo p s . D. Its a ! a c tio n c o u n te r a c ts th e s e v e r e v a s o d ila ta tio n . B. O th e r d r u g s h a v e m o r e e f f e c t o n c a r d ia c c o n tr a c tility th a n o n S V R . S u d d e n w ith d r a w a l o f th is m e d ic a tio n le a d s to o v e r a c tiv ity o f th e s y m p a th e tic s y s te m a n d a P . th u s . E f f e c t o f n o r e p in e p h r in e is o n a ! r e c e p to r s a n d s y s te m ic v a s c u la r r e s is ta n c e . w h ic h is th e h a llm a r k o f th is c o n d itio n .

w h ic h h a s b e e n s h o w n to r e le a s e h is ta m in e in v itr o . In s h a r p c o n tr a s t to o th e r a n e s th e tic a g e n ts . b u t th e ir a c tio n s a r e n e ith e r a s r a p id n o r a s p r o f o u n d a s e p in e p h r in e . 13. a n e n z y m e th a t m e ta b o liz e s c a te c h o la m in e s . b u t in tr a n a s a l r o u te u tiliz in g m u c o s a l a to m iz a tio n d e v ic e m a y b e u s e f u l to tr e a t s e iz u r e a c tiv ity . a n d is th u s u s e f u l in c a s e s o f e le c tr o c o n v u ls iv e th e r a p y f o r s e v e r e d e p r e s s io n . C. C. It is a n e x c e lle n t b r o n c h o d ila to r a n d a n a lg e s ic . so r e p e a te d d o s e s o r in f u s io n is r e q u i r e d if r e c u r r e n c e o f s e d a tio n is d e s ir e d . if an y . b u t b e c a u s e o f s im ila r ity in th e c h e m ic a l s tr u c tu r e . o n th e o th e r h a n d . P h e n e lz in e in h ib its m o n o a m in e o x id a s e . so is n o t u s e f u l to r e v e r s e r e s p i r a t o r y d e p r e s s io n c a u s e d b y n a r c o tic o v e r d o s e . a n d e to m id a te . S te r o id s s ta b iliz e th e c e ll m e m b r a n e s o f m a s t c e lls a n d e o s in o p h ils . S p o n ta n e o u s m o v e m e n ts c h a r a c te r iz e d as m y o c lo n u s o c c u r in m o r e th a n 5 0 % o f p a tie n ts r e c e iv in g e to m id a te a n d m a y b e a s s o c ia te d w ith s e iz u r e . th u s d e c r e a s in g th e in te n s ity o f th e im m u n o lo g i c r e s p o n s e . m a y b e a n ti. In s te a d o f a c tin g d ir e c tly o n th e r e tic u la r . M id a z o la m o r a l s u s p e n s io n is u s e d r o u ti n e ly in p e d ia tr ic a n e s th e s ia . In th e s a m e v e in . a n d th e r e is little e v id e n c e to s u p p o r t th e u s e o f s te r o id s f o r th e a c u te tr e a tm e n t o f a n a p h y la x is . E to m id a te a c tu a lly c a u s e s a d e c r e a s e in th e s e iz u r e th r e s h o ld . F lu m a z e n il is u s e f u l a s a s p e c if ic r e v e r s a l a g e n t f o r b e n z o d ia z e p in e o v e r d o s e . T h io p e n ta l. 11. it in c r e a s e s b l o o d p r e s s u r e . 12. R e v e r s a l o f b e n z o d ia z e p in e a c tio n d o e s n o t le a d to c a r d io v a s c u la r s id e e ffe c ts o r e v id e n c e o f a c u te s tr e s s r e s p o n s e . c a u s in g v a s c u la r d ila ta tio n a n d in c r e a s e d c a p il la r y p e r m e a b ility . its e f f e c t o n th e v e n tila to r d r iv e a n d a ir w a y r e f le x e s is m in im a l. A n o th e r s id e e f f e c t is a n in c r e a s e d in c id e n c e o f n a u s e a a n d v o m itin g in th e p o s to p e r a tiv e p e r io d . I n d ir e c t a c tio n in v o lv e s r e le a s e o f e x a g g e r a te d a m o u n ts o f n o r e p in e p h r in e f r o m th e a d r e n e r g i c n e u r o n s le a d in g to c a ta s tr o p h ic in c r e a s e in b lo o d p r e s s u r e . it c a u s e s d is s o c ia tio n o f th a la m u s (w h ic h r e la y s s e n s o r y i n f o r m a t io n f r o m th e R E S to c e r e b r a l c o r te x ) f r o m th e lim b ic c o r te x (w h ic h is in v o lv e d w ith th e a w a r e n e s s o f s e n s a tio n ) . it a c ts a s a c o m p e titiv e a n ta g o n is t in th e p r e s e n c e o f a g o n is t a t th e r e c e p to r s ite . p r o p o f o l . th is d r u g c a n b e g iv e n v ia m a n y r o u te s . It d o e s n o t h a v e a n y e f f e c t o n o p io id r e c e p to r . E x p o s u r e o f th e a c id ic m id a z o la m p r e p a r a t io n to th e p h y s io lo g ic p H o f b l o o d c a u s e s a c h a n g e in th e r i n g s tr u c tu r e th a t r e n d e r s th e . M o r e d ir e c t. K e ta m in e d if f e r s f r o m o th e r in d u c tio n a g e n ts u s e d in c o n te m p o r a r y p r a c tic e o f a n e s th e s ia in m a n y im p o r ta n t w a y s . D u r a tio n o f a c tio n is s h o r t ( 6 0 .a n a lg e s ic . B io a v a ila b ility o f s u b lin g u a l m id a z o la m is m u c h b e tte r th a n o r a l l y a d m in is te r e d d r u g . B. C. a llo w in g th e ir le v e ls to b u ild u p in th e a d r e n e r g i c n e u r o n s . 9. h e a r t ra te .a c tin g m e d ic a tio n lik e p h e n y le p h r in e is a b e tte r c h o ic e in a p a tie n t u s in g m o n o a m in e o x id a s e in h ib ito r s . E p h e d r in e h a s b o th d ir e c t a n d in d ir e c t a c tio n s o n a d r e n e r g i c s y s te m . b u t th e ir a c tio n ta k e s 4 to 6 h o u r s to d e v e lo p . A lth o u g h m o s t c o m m o n r o u te o f a d m in is tr a tio n o f m id a z o la m in a n e s th e s ia is in tr a v e n o u s . I n tr a m u s c u la r in je c tio n c a n b e p a in f u l. A. a n d c a r d ia c o u tp u t b y c e n tr a l s tim u la tio n o f s y m p a th e tic s y s te m a n d in h ib itio n o f u p ta k e o f n o r e p in e p h r in e .a c tiv a tin g s y s te m (R E S ). a n d o th e r m e d ia to r s .lik e a c tiv ity o n th e E E G . 10. It d o e s n o t c a u s e h is ta m in e r e le a s e in c o n tr a s t to th io p e n ta l. It h a s m in im a l in tr in s ic a c tiv ity o n th is r e c e p to r .9 0 m in u te s ).

A p p lic a tio n o f w a r m in g b la n k e t m a y b e e f f e c tiv e if p a tie n t is h y p o th e r m ic . D e p e n d in g o n th e a m o u n t in je c te d . if an y . e x c e p t c o c a in e . 14. A m id e lo c a l a n e s th e tic s a r e m e ta b o liz e d b y liv e r . 18. a n d in d iv id u a ls k n o w n to h a v e a l l e r g y to th is s u b s ta n c e s h o u ld n o t b e g iv e n e s te r k in d o f lo c a l a n e s th e tic . E n a n tio m e r s a r e s t e r e o is o m e r s th a t e x is t a s m i r r o r im a g e s . th u s d e c r e a s in g th e o x y g e n d e m a n d . B. R o p iv a c a in e is le s s lip id s o lu b le . p u p illa r y d ila ta tio n . w h ic h h a s a c h e m ic a l s tr u c tu r e s im ila r to th a t o f P A B A . C. p r o m o t in g m o r e r a p id o n s e t o f its a c tio n .b lo c k e r th a t w ill d e c r e a s e th e h e a r t r a te a n d m y o c a r d ia l . A. c a u s in g ta c h y c a r d ia .b r a i n b a r r i e r . A ll o f th e lo c a l a n e s th e tic s in c lu d e d in th is q u e s tio n h a v e a m id e s tr u c tu r e in th e ir m o le c u le . D. m a k in g it d if f ic u lt f o r th e m to c r o s s th e c e ll m e m b r a n e . T h e y a r e m e ta b o liz e d to p a r a . b u t e ffe c t o n th e in tr a c e l lu la r p H is m in im a l. h y p e r te n s io n .e n a n tio m e r o f m e p iv a c a in e a n d b u p iv a c a in e . E s m o lo l is a s h o r t. S h iv e r in g in c r e a s e s o x y g e n d e m a n d a n d n e e d s to b e tr e a te d p r o m p tly . th e s e n s o r y b lo c k is m o r e th a n th e m o to r b lo c k . E s te r lo c a l a n e s th e tic s a r e m e ta b o liz e d b y p la s m a c h o lin e s te r a s e . b u t it m a y ta k e a w h ile f o r th e b o d y te m p e r a tu r e to im p r o v e .a c tin g P . E n a n tio m e r s h a v e id e n tic a l p h y s ic a l p r o p e r tie s e x c e p t f o r th e d ir e c tio n o f th e r o ta tio n o f th e p la n e o f th e p o la r iz e d lig h t. th u s d e la y in g th e ir lo c a l a n e s th e tic a c tio n . th u s d e c r e a s in g th e r a te o f a b s o r p tio n in to s y s te m ic c ir c u la tio n . S a m e is tr u e f o r n itr o p r u s s id e .a m in o b e n z o ic a c id (P A B A ). a n d in c r e a s e d s k in te m p e r a tu r e . E s m o lo l w ill d e c r e a s e b o th th e h e a r t r a te a n d b l o o d p r e s s u r e r a p id ly . d r u g m o r e lip id s o lu b le . T h e r e is n o p r e p a r a t io n a v a ila b le f o r tr a n s c u ta n e o u s d e liv e r y o f th is d r u g in c o m p a r is o n to fe n ta n y l. C o m m e r c ia l m u ltid o s e p r e p a r a t io n s o f a m id e s o f te n c o n ta in m e th y lp a r a b e n . H y d r a la z in e w ill d e c r e a s e th e b l o o d p r e s s u r e b u t m a y m a k e th e ta c h y c a r d ia w o r s e .r e c o m m e n d e d d o s e is u s e d . T h e r e a r e im p o r ta n t d if f e r e n c e s b e tw e e n th e tw o c la s s e s o f lo c a l a n e s th e tic s . T h is p r e s e r v a tiv e m a y b e r e s p o n s ib le f o r m o s t o f th e r a r e a l l e r g i c r e s p o n s e s to a m id e a g e n ts . D. It m a y n o t b e e f f e c tiv e in th is p a tie n t if h is te m p e r a tu r e is n o r m a l a n d if th e m e c h a n is m o f s h iv e r in g in v o lv e s in h ib itio n o f t h e r m o r e g u l a t o r y m e c h a n is m s o f th e b o d y b y th e r e s id u a l a n e s th e tic . F o r a g iv e n d o s e .m a x im u m . O x y g e n d e m a n d o f th e m y o c a r d iu m in c r e a s e s w ith in c r e a s e in h e a r t r a te a n d b l o o d p r e s s u r e . A d d itio n o f s o d iu m b ic a r b o n a te p r o m o t e s n o n io n iz e d f r a c tio n o f lo c a l a n e s th e tic . a n d so p a tie n ts w ith a ty p ic a l v a r ie ty o f e n z y m e is lia b le to d e v e lo p lo c a l a n e s th e tic to x ic ity b e c a u s e o f s lo w m e ta b o lis m . th e lo c a l p H m a y in c r e a s e .th a n . C o c a in e in h ib its r e u p ta k e o f c a te c h o la m in e s in to p r e g a n g l i o n i c n e r v e te r m in a l. R o p iv a c a in e is a n S . a n d d e c r e a s e d liv e r b l o o d f lo w o r h is to r y o f liv e r f a ilu r e m a y le a d to to x ic ity e v e n w h e n le s s . P a r t o f th e r e a s o n r o p iv a c a in e m a y b e le s s c a r d io to x ic th a n b u p iv a c a in e is th a t it c a u s e s v a s o c o n s tr ic tio n in th e tis s u e s . 16. a n d th u s le s s p o te n t th a n b u p iv a c a in e . it h a s a s y m p a th o m im e tic e ffe c t. th u s s p e e d in g its p a s s a g e a c r o s s th e b l o o d . S in c e lo c a l a n e s th e tic s a r e w e a k b a s e s . C h r o n ic u s e m a y le a d to c a r d io m y o p a th y a n d d e p le tio n o f c a te c h o la m in e s to r e s w ith u n p r e d ic ta b le m a n if e s ta tio n s d u r in g a n e s th e s ia . th e y e x is t l a r g e l y in th e io n ic f o r m . 17. 15.

T h e e f f e c t a c tu a lly m a y v a r y e v e n in d if f e r e n t a r e a s o f th e b o d y lik e e p id u r a l s p a c e v s . h ig h e r th e lip id s o lu b ility a n d h ig h e r th e p o te n c y . F o r e x a m p le . W h e n a n im p u ls e r e a c h e s th e c e ll. T h e y d o n o t c h a n g e th e th r e s h o ld p o te n tia l o r r e s tin g m e m b r a n e p o te n tia l p e r se. p e r ip h e r a l n e r v e b lo c k b e c a u s e o f s e c o n d a r y e ffe c ts s u c h a s th e in h e r e n t v a s o a c tiv e p r o p e r tie s o f th e a n e s th e tic . I o n iz a tio n m a k e s it m o r e r e s is ta n t to e n te r th e c e ll a n d d e c r e a s e s its p o te n c y . D. D.v e n tr ic u la r m y o c a r d iu m g e ts its oxygen. it in c r e a s e s th e in f l o w o f s o d iu m in to th e c e ll. If th is c h a n g e is e n o u g h to r e a c h a c r itic a l le v e l c a lle d th e th r e s h o ld p o te n tia l. A. D u r a tio n o f a n e s th e s ia a fte r in f i ltr a tio n is m u c h le s s th a n a fte r a n e r v e b lo c k . It is im p o r ta n t to a p p r e c ia te th a t m e a s u r e s o f a n e s th e tic a c tiv ity m a y b e a ffe c te d b y th e in v itr o a n d in v iv o s y s te m in w h ic h th e s e e ffe c ts a r e d e te r m in e d . h ig h e r th e p r o p o r t i o n o f n e u tr a l b a s e o r th e u n io n iz e d f o r m . p a in s o m e tim e s is so s e v e r e th a t it m a y e x c e e d th e p a in o f s u r g e r y a n d m a y n e c e s s ita te r e a d m is s io n in to th e h o s p ita l. 19. D. 22. g e n e r a lly w a te r o r b u f f e r e d s o lu tio n . T h is is s u e . A n e s th e s ia a fte r r o p iv a c a in e a n d b u p iv a c a in e la s ts 4 to 8 h o u r s . In c id e n c e o f T N S is r e la tiv e ly h ig h w ith u p to o n e . T h is e f f e c t is p r i m a r i l y m e d ia te d b y in te r a c tio n w ith s p e c if ic r e c e p to r s th a t a r e w ith in th e in n e r v e s tib u le o f th e s o d iu m i o n c h a n n e l. L o c a l a n e s th e tic s d e c r e a s e th e r a te o f d e p o la r iz a tio n o f th e c e ll m e m b r a n e w h e n a n e r v e im p u ls e a r r iv e s a n d c h a n g e s th e r e s tin g m e m b r a n e p o te n tia l o f th e n e u r o n . It w a s c o m m o n ly u s e d f o r s p in a l a n e s th e s ia u n til r e p o r ts o f tr a n s ie n t n e u r o l o g i c s y m p to m s (T N S ) s ta r te d a p p e a r in g in th e lite r a tu r e . 23.9 0 m V in s id e th e c e ll. L o c a l a n e s th e tic s e x e r t th e ir e le c tr o p h y s io lo g ic e ffe c ts b y b lo c k in g s o d iu m io n c o n d u c ta n c e . th e im p u ls e d ie s d o w n . It is o r d i n a r i l y e x p r e s s e d a s a p a r titio n c o e f f ic ie n t. te tr a c a in e is 2 0 tim e s m o r e p o te n t th a n b u p iv a c a in e w h e n s tu d ie d in is o la te d n e r v e tis s u e b u t h a s e q u iv a le n t p o te n c y c o m p a r e d w ith b u p iv a c a in e w h e n te s te d in in ta c t in v iv o s y s te m s . I m p r o v e d h e a r t r a te w ill a ls o h e lp w ith im p r o v e d s u p p ly o f o x y g e n to th e m y o c a r d iu m b y in c r e a s in g th e d ia s to lic tim e d u r in g w h ic h m o s t o f th e le f t. c a u s in g th is p o te n tia l to m o v e to w a r d a p o s itiv e v a lu e . 21. o th e r w is e . w h ic h is d e te r m in e d b y c o m p a r in g th e s o lu b ility in a q u e o u s p h a s e . 20. c o n tr a c tility th r o u g h its in h ib itio n o f ^ r e c e p to r s . U s e o f m a n y lo c a l a n e s th e tic s f o r s p in a l a n e s th e s ia is s till e v o lv in g . L o c a l a n e s th e tic s d e c r e a s e th e r a te o f c h a n g e o f th is p o te n tia l so th a t it d o e s n o t r e a c h th e th r e s h o ld le v e l.th ir d o f p a tie n ts c o m p la in in g o f p a in a n d d y s e s th e s ia 12 to 2 4 h o u r s a fte r th e s u r g e r y . a n a c tio n p o te n tia l is g e n e r a te d . N o r m a lly . L ip id s o lu b ility o f a lo c a l a n e s th e tic is d ir e c tly p r o p o r t i o n a l to its p o te n c y . w h ile lid o c a in e is e f f e c tiv e o n ly f r o m 1 to 2 h o u r s . M e p iv a c a in e is in b e tw e e n w ith d u r a tio n o f a c tio n f r o m 9 0 to 1 8 0 m in u te s . A lth o u g h s y m p to m s a r e tra n s ie n t. S in c e th e s ite o f a c tio n o f th e a n e s th e tic m o le c u le is in s id e th e n e r v e c e ll. L id o c a in e w a s in tr o d u c e d in to c lin ic a l p r a c tic e in 1 9 4 6 . C. I n f iltr a tio n o f lo c a l a n e s th e tic in p e r ip h e r a l tis s u e s is d if f e r e n t f r o m in je c tio n in to a n e r v e s h e a th f o r a p e r ip h e r a l n e r v e b lo c k . th u s d e c r e a s in g th e m y o c a r d ia l o x y g e n d e m a n d . th is p o te n tia l is .

b u t it m a y a ls o b e s e c o n d a r y to h ig h . a n d . H ig h e r p r o t e i n ­ b in d in g d e c r e a s e s th e c h a n c e o f n e u r o to x ic ity b y d e c r e a s in g th e f r e e f r a c tio n o f th e d r u g a v a ila b le f o r a b s o r p tio n in to th e c ir c u la tio n . s y m p to m s a r e u s u a lly m ild e r to b e g in a n d e s c a la te f in a lly to th e s e iz u r e le v e l. D. m e ta llic ta ste in th e m o u th . th e m a jo r d a n g e r is c a r d io to x ic ity th a t is m a d e m u c h w o r s e a n d is e x tr e m e ly d if f ic u lt to tr e a t in th e p r e s e n c e o f a c id o s is . h a s r a is e d q u e s tio n s r e g a r d i n g th e a d v is a b ility o f c o n tin u e d u s e o f lid o c a in e f o r s p in a l a n e s th e s ia . 26. 25. a n d g o o d b a s ic a n d a d v a n c e d lif e s u p p o r t a r e e x tr e m e ly e s s e n tia l a s b u p iv a c a in e to x ic ity is a d v e r s e ly a f f e c te d b y h y p e r c a r b ia . th u s k e e p in g th e m a x im u m s e r u m c o n c e n tr a tio n lo w e r. F r e q u e n t a tte m p ts a t a s p ir a ti o n a r e r e c o m m e n d e d w h e n e v e r l a r g e d o s e a n d v o lu m e o f lo c a l a n e s th e tic is in je c te d f o r e p id u r a l o r p e r ip h e r a l n e r v e b lo c k to a v o id in je c tin g th e lo c a l a n e s th e tic in th e v a s c u la r o r in tr a th e c a l s p a c e . It is im p o r ta n t to c o n tr o l th e s e iz u r e b e c a u s e in te n s e m u s c u la r a c tiv ity in c r e a s e s o x y g e n u tiliz a tio n a n d c a r b o n d io x id e p r o d u c tio n . s e iz u r e m a y r e s u lt d u e to e x c ita tio n o f s o m e f o c u s in th e c e n tr a l n e r v o u s s y s te m . N e r v e r o o t s in th is r e g i o n a r e v e r y s u p e r f ic ia l a n d if a l o n g e r n e e d le is u s e d . A d d itio n o f a d ilu te c o n c e n tr a tio n o f e p in e p h r in e to lo c a l a n e s th e tic is h e lp f u l a s it m a y a le r t th e p r a c titio n e r to in a d v e r te n t v a s c u la r in je c tio n o f th e lo c a l a n e s th e tic b y in c r e a s e in th e h e a r t ra te .5 m L /k g b o lu s . T r e a tm e n t is s u p p o r tiv e . It is r e c o m m e n d e d to a v o id p e r f o r m a n c e o f a n e r v e b lo c k u n d e r g e n e r a l a n e s th e s ia so th a t p a tie n t c o u ld p o in t to th is. E a r ly s y m p to m s o f lo c a l a n e s th e tic to x ic ity m a y m a n if e s t a s c i r c u m o r a l n u m b n e s s . b u t n o w 2 0 % in tr a lip i d h a s r e p la c e d th is d r u g .2 5 m L /k g /m in f o r th e n e x t 10 m in u te s . f o ll o w e d b y 0 . v e n tila tio n . n o t a s e iz u r e . C a s e s o f lo c a l a n e s th e tic to x ic ity h a v e b e e n r e p o r te d e v e n w h e n a s p ir a ti o n w a s n e g a tiv e f o r b l o o d o r C SF. S e iz u r e is n o t a p r e s e n ta tio n o f h ig h e p id u r a l o r in tr a th e c a l in je c tio n . If th e d o s e o f b u p iv a c a in e th a t g a in e d a c c e s s to v a s c u la r s y s te m is h ig h . 24. R e c o m m e n d e d d o s a g e f o r c a r d io v a s c u la r c o lla p s e s e c o n d a r y to b u p iv a c a in e to x ic ity is 1. D. S p e c ific tr e a tm e n t f o r th e s e iz u r e is e ith e r b e n z o d ia z e p in e o r b a r b itu r a te s th a t in c r e a s e th e s e iz u r e th r e s h o ld . A. a c id o s is . a n d th e r e b y a v o id a n c e o f n e r v e in ju r y . r e s p i r a t o r y d is tr e s s f o ll o w e d b y c a r d io v a s c u la r c o lla p s e d e p e n d in g o n th e d o s e in je c te d . o r h ig h n e u r a x ia l a n e s th e s ia . r e s p i r a t o r y a r r e s t. c a u s in g b o th m e ta b o lic a s w e ll a s r e s p i r a t o r y a c id o s is . F u r th e r in c r e a s e in th e s e le v e ls le a d s to d e p r e s s io n o f th e n e r v o u s s y s te m m a n if e s tin g as l e th a r g y a n d c o m a . It a ls o h e lp s d e la y th e s y s te m ic a b s o r p tio n o f lo c a l a n e s th e tic . It is r e c o m m e n d e d th a t th e n e e d le u s e d f o r in te r s c a le n e b lo c k s h o u ld b e o f a p p r o p r ia te le n g th f o r th e g iv e n p a tie n t. It is p o s s ib le th a t lo s s o f c o n s c io u s n e s s is s e c o n d a r y to c a r d ia c a r r e s t. a n d tr e m o r s .d o s e C N S to x ic ity . T h is u s u a lly p r e s e n ts a s c a ta s tr o p h ic h y p o te n s io n . a m e d ia lly d ir e c te d n e e d le m a y e n d u p in e ith e r e p id u r a l o r in tr a th e c a l s p a c e le a d in g to h ig h e p id u r a l o r in tr a th e c a l b lo c k r e s p e c tiv e ly . If c e n tr a l n e r v o u s s y s te m to x ic ity w a s to h a p p e n f r o m s lo w a b s o r p tio n o f lo c a l a n e s th e tic o r in je c tio n in to a v e in . A s th e s e r u m le v e ls o f th e lo c a l a n e s th e tic in c r e a s e fu r th e r . O x y g e n a tio n . D ir e c t in je c tio n in to a n e r v e u s u a lly c a u s e s a s h o o tin g p a in a lo n g th e le n g th o f th e n e r v e w ith in v o lu n ta r y w ith d r a w a l o f th e lim b in a n a w a k e p a tie n t. A m io d a r o n e w a s th e d r u g o f c h o ic e to tr e a t c a r d io v a s c u la r to x ic ity o f b u p iv a c a in e in th e p a st.

In c lin ic a l te r m s . C h o ic e o f th e m u s c le r e la x a n t f o r a n y g iv e n a n e s th e tic d e p e n d s o n m a n y f a c to r s lik e d u r a tio n o f s u r g ic a l p r o c e d u r e . a n d p la c e n ta . c o n c o m ita n t u s e o f d r u g s th a t in f lu e n c e th e m u s c le r e la x a ti o n lik e m a g n e s iu m o r c a lc iu m c h a n n e ls b lo c k e r s . w ith d u r a tio n r a n g in g f r o m 5 to 10 m in u te s w ith n o r m a l e n z y m e to 6 0 to 1 8 0 m in u te s f o r p a tie n ts h a v in g h o m o z y g o u s a ty p ic a l v a r ie ty o f e n z y m e . p r e s e n c e o f a s s o c ia te d c o n d itio n s lik e h y p o th e r m ia . A lth o u g h s m a lle r d o s e s c a n b e e ffe c tiv e .b r a i n b a r r i e r .2 5 % ) . h y p o x ia . D. 28. d u r a tio n o f a c tio n .b l o c k in g d r u g s (N M B D s ) a r e h ig h ly c h a r g e d m o le c u le s b e c a u s e o f th e p r e s e n c e o f a q u a te r n a r y a m m o n iu m g r o u p in th e ir s tr u c tu r e . A s d is c u s s e d in th e p r e v io u s q u e s tio n . D. c o n s e n s u s is th a t it is s a f e to u s e s u c c in y lc h o lin e f o r th e s e p a tie n ts if a ir w a y m a n a g e m e n t w ill b e f a c ilita te d b y its u s e . 27. N e u r o m u s c u la r . a n d th e ir u s e in p a tie n ts w ith r e n a l f a ilu r e m a y le a d to p r o l o n g e d n e u r o m u s c u la r b lo c k a d e . w h ile a ty p ic a l h o m o z y g o u s ty p e is m in im a lly in h ib ite d (2 0 % ). th is le a d s to p r o l o n g e d p a r a ly s is f o ll o w i n g a d m in is tr a tio n o f s u c c in y lc h o lin e . A d m in is tr a tio n o f th e s e d r u g s th u s d o e s n o t p r o d u c e c e n tr a l n e r v o u s s y s te m e ffe c ts . a n d 8 0 % o f its a d m in is te r e d d o s e is e x c r e te d b y th e k id n e y . O n s e t a n d d u r a tio n o f a c tio n a r e l a r g e l y d e p e n d e n t o n th e d o s e a d m in is te r e d . a lo c a l a n e s th e tic . 31. T h is m a k e s th e m p o o r l y lip id s o lu b le so th a t th e y d o n o t c r o s s b i o l o g i c m e m b r a n e s lik e b l o o d . B. th e d u r a tio n o f a c tio n d e p e n d s o n th e d o s e . to in h ib it th e a c tiv ity o f th is e n z y m e . In s o m e p a tie n ts . p a tie n t m a y b e s u s c e p tib le to h y p e r k a le m i a a fte r th e a d m in is tr a tio n o f s u c c in y lc h o lin e a n d is d e p e n d e n t o n d e v e lo p m e n t o f e x tr a ju n c tio n a l a ty p ic a l r e c e p to r s .a c tin g n e u r o m u s c u la r b lo c k e r s a r e e x c r e te d b y th e k id n e y . T h is c a n le a d to s e r io u s c a r d ia c a r r h y th m ia s a n d e v e n c a r d ia c a r r e s t. r o u te o f e lim in a tio n . r e n a l tu b u la r e p ith e liu m . r e n a l tu b u la r r e a b s o r p t i o n is m in im a l. A. a n d m a te r n a l a d m in is tr a tio n d o e s n o t a d v e r s e ly a f f e c t th e fe tu s . D ia g n o s is o f p r e s e n c e o f a ty p ic a l e n z y m e c a n b e m a d e b y m e a s u r in g th e a b ility o f d ib u c a in e . th e r e c o m m e n d e d in tu b a tin g d o s e is u s u a lly tw o to f o u r tim e s . D. r e q u i r e d s p e e d o f o n s e t. O u t o f th e s e f a c to r s . p o ta s s iu m le v e ls m a y e x c e e d 10 m E q /L . s u c c in y lc h o lin e is m e ta b o liz e d b y th e p la s m a c h o lin e s te r a s e a n d o n ly a f r a c tio n o f th e a d m in is te r e d d o s e r e a c h e s th e n e u r o m u s c u la r ju n c tio n . c o m o r b id iti e s o f th e p a tie n t. a n d th e p r e s e n c e o f h e p a tic o r r e n a l d is e a s e . A ty p ic a l p la s m a c h o lin e s te r a s e la c k s th e a b ility to h y d r o ly z e e s te r b o n d s in d r u g s s u c h as s u c c in y lc h o lin e a n d r e m if e n ta n il. In te rm e d ia te a c tin g n e u r o m u s c u la r b lo c k e r s lik e r o c u r o n i u m a n d v e c u r o n iu m u n d e r g o p r i m a r i l y h e p a tic m e ta b o lis m a n d b i l i a r y e x c r e tio n w ith m in im a l r e n a l e x c r e tio n ( 1 0 % . A n o r m a l e n z y m e g e ts in h ib ite d th e m o s t (8 0 % ). Is s u e o f i o n tr a p p in g c a n o n ly d e v e lo p if a d r u g g e ts tr a p p e d in th e a c id ic e n v ir o n m e n t o f fe ta l b l o o d a fte r it h a s c r o s s e d th e p la c e n ta . A n y tim e p r o l o n g e d s k e le ta l m u s c le in a c tiv ity o r e x te n s iv e m u s c le d a m a g e e x is ts . 30.a c tin g a g e n ts . P a n c u r o n iu m is o n e o f th e s e lo n g . H e te r o z y g o u s v a r ie ty h a s le s s e r in h ib itio n . A lth o u g h c e r e b r a l p a ls y s e e m s to b e a m u s c u la r p r o b le m . T h e d u r a tio n o f s u s c e p tib ility to th e h y p e r k a le m ic r e s p o n s e to s u c c in y lc h o lin e is u n k n o w n b u t p r o b a b ly d e c r e a s e s a fte r 3 to 6 m o n th s o f d e n e r v a tio n in ju r y . M a n y o f th e lo n g . a n d a s s o c ia te d s id e e ffe c ts lik e ta c h y c a r d ia o r h y p e r k a le m ia . 29.

C h o lin e r g ic a c tiv ity m a y a ls o le a d to b r o n c h o s p a s m a n d n o t b r o n c h o d ila tio n . S tr e p to m y c in b e lo n g s to a m in o g ly c o s id e . U s in g a n a n tic h o lin e s te r a s e w ith o n ly p e r ip h e r a l a c tio n th u s m a k e s s e n s e b e c a u s e c e n tr a l n e r v o u s s y s te m s id e e ffe c ts o f a d r u g lik e p h y s o s tig m in e c a n b e a v o id e d . m a n if e s tin g in c r e a s e d c h o lin e r g ic a c tio n s in th e b o d y . 32. s e c o n d a r y to in c r e a s e d p e r is ta ls is o f th e b o w e l. h ig h e r th a n E D 95. m a y le a d to c a r d ia c s ta n d s till.b u r s t s tim u la tio n . m a y c r o s s th e b l o o d .r e la x a n t e f f e c t in n o r m a l d o s e s . a n d te tr a c y c lin e a r e d e v o id o f n e u r o m u s c u la r e ffe c ts . w ith th e ir q u a te r n a r y a m m o n iu m s tr u c tu r e a n d c o n s e q u e n t in a b ility to c r o s s th e b l o o d . D is r u p tio n o f g a s tr o in te s tin a l a n a s to m o s is is a n o th e r c o n s id e r a tio n . is d e la y e d . D. w h ile d e p o la r iz i n g m u s c le r e la x a n ts a n ta g o n iz e th e e ffe c ts o f th e s e d r u g s . a r e th u s p r e f e r r e d a g e n ts to r e v e r s e th e a c tio n s o f N M B D s th a n p h y s o s tig m in e w h ic h c r o s s e s th a t b a r r i e r r e a d ily . h a s q u a te r n a r y s tr u c tu r e a n d la c k s c e n tr a l n e r v o u s s y s te m e ffe c ts a n d h a s l a r g e l y r e p la c e d a tr o p in e f o r b lo c k in g th e a d v e r s e m u s c a r in i c e ffe c ts . A n tic h o lin e s te r a s e s a r e u s e d to r e v e r s e th e e ffe c ts o f n o n d e p o la r iz i n g n e u r o m u s c u la r - b lo c k in g a g e n ts (N M B D s ).b r a i n b a r r i e r . 34. if n o t a n ta g o n iz e d b y c o n c o m ita n t a d m in is tr a tio n o f a c h o lin e r g ic a g e n t. A tr o p in e a n d s c o p o la m in e . e r y th r o m y c in . N e o s tig m in e a n d p y r id o s tig m in e . A d e p o la r iz i n g b lo c k is c h a r a c te r iz e d b y a b s e n c e o f fa d e b u t ta k e s o n c h a r a c te r is tic s o f a n o n d e p o la r iz i n g b lo c k if e n o u g h d e p o la r iz i n g a g e n t is a d m in is te r e d . a p r e r e q u is ite b e f o r e a r e v e r s a l a g e n t c a n b e a d m in is te r e d . O n e o f th e c o n s id e r a tio n s is th e a b ility o f th e s e le c te d d r u g to c r o s s th e b l o o d . A m in o g ly c o s id e a n tib io tic s p o te n tia te th e e ffe c ts o f N D M R s. c e p h a lo s p o r in s .b r a i n b a r r i e r a n d m a y c a u s e c e n tr a l n e r v o u s s y s te m e ffe c ts . C. T h e s e e ffe c ts c a n b e v e r y p r o n o u n c e d in e ld e r ly p a tie n ts . I n tr a v e n o u s a n e s th e tic a g e n ts d o n o t h a v e a n y a p p r e c ia b le m u s c le . o n ly th e c h a r a c te r is tic o f tr a in o f f o u r is c o r r e c t . A d m in is tr a tio n o f a n tic h o lin e s te r a s e a g e n t le a d s to a c c u m u la tio n o f a c e ty lc h o lin e . A n tis ia la g o g u e a c tio n s o f th e s e a g e n ts a r e a ls o h e lp f u l in r e d u c in g th e e x c e s s iv e s a liv a tio n in d u c e d b y p a r a s y m p a th e tic o v e r a c tiv ity o f a c e ty lc h o lin e g e n e r a te d b y in h ib itio n o f c h o lin e s te r a s e . le a d in g to c o n f u s io n a n d a g ita tio n in th e r e c o v e r y r o o m . S a m e p r in c ip le a p p lie s to a n tic h o lin e r g ic a g e n ts th a t a r e a d m in is te r e d a lo n g w ith a n tic h o lin e s te r a s e d r u g to c o u n te r a c t th e s u r g e o f a c e ty lc h o lin e c a u s in g b r a d y c a r d ia . M a n y p h y s io lo g ic f a c to r s a n d a n e s th e tic a n d n o n a n e s th e tic d r u g s in te r a c t w ith n o n d e p o la r iz i n g m u s c le r e la x a n ts (N D M R s ).b r a i n b a r r i e r . V o la tile a n d lo c a l a n e s th e tic s p o te n tia te . o n th e o th e r h a n d . T h is p r o v id e s a h ig h e r in c id e n c e o f b e tte r a n d e a r lie r in tu b a tin g c o n d itio n s th a n w o u ld b e p o s s ib le w ith E D 95. V a g a l s tim u la tio n c a u s e s b r a d y c a r d i a a n d . 33. w ith th e ir t e r tia r y c h a r a c te r . S e le c tio n o f th e s e d r u g s d e p e n d s o n m a n y f a c to r s . G ly c o p y r r o la te . H ig h e r d o s e s d o le a d to l o n g e r d u r a tio n o f a c tio n so th a t th e r e tu r n o f th e f i r s t tw itc h o n tr a in o f fo u r . A. A s N M B D s d o n o t c r o s s th e b l o o d .b r a i n b a r r i e r . 35. Im p u ls e s g e n e r a te d b y th e n e r v e s tim u la to r a r e s ta n d a r d iz e d to e n s u r e u n if o r m ity o f m o n ito r in g . A lth o u g h th is m o d e is u s e d m o r e o f te n in m o d e r n c lin ic a l p r a c tic e o f a n e s th e s ia . in f a c t th e a b s e n c e o f fa d e — a h a llm a r k o f n o n d e p o la r iz i n g b lo c k — is a m o r e r e lia b le in d ic a to r o f r e v e r s a l o f n e u r o m u s c u la r b lo c k a d e w ith te ta n ic o r d o u b le . O u t o f th e d if f e r e n t p a tte rn s d e s c r ib e d in th e q u e s tio n . th e r e is n o e f f e c t o n th e c e n tr a l n e r v o u s s y s te m . D. w h ile p e n ic illin .

m e ta b o lic a c id o s is . C. n o r e p in e p h r in e . W h e n th e r a te o f S N P in f u s io n e x c e e d s th a t o r w h e n s u lf u r d o n o r s a n d m e th e m o g lo b in a r e e x h a u s te d . o c u l o g y r i c c r is is .in d u c e d d e c r e a s e in h e a r t ra te . A d m in is tr a tio n o f d r o p e r i d o l m a y le a d to h y p o te n s io n in a h y p o v o le m ic p a tie n t.v e n tr ic u la r f il lin g p r e s s u r e . I n c r e a s in g a f te r lo a d w ith p h e n y le p h r in e w ill d e c r e a s e a b n o r m a l tr a n s m itr a l v a lv u la r p r e s s u r e g r a d ie n t th a t w ill h e lp w ith r e s t o r a t i o n o f p e r f u s io n p r e s s u r e . d r o p e r i d o l h a s f a lle n in to d is f a v o r a s a s o le p r e m e d ic a tio n . c y a n id e to x ic ity m a y d e v e lo p . It a ffe c ts m a n y r e c e p to r s in th e c e n tr a l n e r v o u s s y s te m . a n d in c r e a s e d o x y g e n s a tu r a tio n o f v e n o u s b l o o d b e c a u s e o f in a b ility o f th e c e lls to e x tr a c t o x y g e n f r o m a r te r ia l b lo o d . T h e n e t e f f e c t is a p p e a r a n c e o f tr a n q u ility a n d s e d a tio n in p a tie n ts p r e m e d ic a te d w ith th is d r u g . P r i o r to u s e o f d r o p e r id o l. d r o p e r i d o l c a u s e s a b lo c k a d e . A d m in is tr a tio n o f p h e n y le p h r in e w ill c a u s e v e n o c o n s tr ic tio n th r o u g h s tim u la tio n o f a ! r e c e p to r s a n d in c r e a s e th e le f t. In th e p r e s e n c e o f n o r m a l e je c tio n f r a c tio n . w h ic h m a y m a n if e s t a s to r t ic o ll is . . h a lo p e r id o l. I n c r e a s e in b l o o d p r e s s u r e w ill c a u s e b a r o r e c e p to r . a n d in th e p r e s e n c e o f Q T in te r v a l b e in g m o r e th a n 4 4 0 m s in m e n a n d m o r e th a n 4 5 0 m s in w o m e n .b r a i n b a r r i e r m a y le a d to e x tr a p y r a m id a l s y m p to m s . I n c r e a s e in th e h e a r t r a te is v e r y p o o r l y to le r a te d a s th e v e n tr ic u la r f il lin g is im p a ir e d b e c a u s e o f d e c r e a s e d d ia s to lic tim e . b u t th e y a r e o f te n e x tr e m e ly a p p r e h e n s iv e a n d f e a r f u l. e p in e p h r in e . a n d b e c a u s e o f th is . a n d th u s a u g m e n ts th e e ffe c ts o f N D M R s. th e U S F o o d a n d D r u g A d m in is tr a tio n h a s a s s o c ia te d a b la c k b o x w a r n in g w ith d r o p e r id o l. d r o p e r i d o l s h o u ld n o t b e g iv e n . L is t o f d r u g s th a t c a n p r e c ip ita te th e s e s y m p to m s is lo n g . F o r th is r e a s o n . 37. m e to c lo p r a m id e . th u s in c r e a s in g th e c a r d ia c o u tp u t a n d b l o o d p r e s s u r e . a n d p r o m e th a z in e . F o r tu n a te ly .v e n tr ic u la r f illin g . T h e la tte r e f f e c t e x p la in s its a b ility to c o u n te r a c t n a u s e a a n d v o m itin g . it is r e a d ily tr e a te d b y a d m in is tr a tio n o f d ip h e n h y d r a m in e . a u g m e n ta tio n o f c a r d ia c c o n tr a c tility w ith a d m in is tr a tio n o f m ilr in o n e . 39. D. im p r o v in g th e le f t. M id a z o la m is a ls o h e lp f u l in tr e a tin g th is c o n d itio n . A h e a lth y a d u lt c a n e lim in a te c y a n id e v ia th e liv e r a t a r a te e q u iv a le n t to c y a n id e p r o d u c tio n d u r in g s o d iu m n i tr o p r u s s id e (S N P ) in f u s io n a t th e r a te o f 2 |ig /k g /m in . A p a r t f r o m th a t it a ls o in te r f e r e s w ith tr a n s m is s io n m e d ia te d b y s e r o to n in . a 12 le a d s h o u ld b e r e c o r d e d . D o p a m in e is a m a jo r n e u r o tr a n s m itte r in e x tr a p y r a m id a l s y s te m . c a r d ia c a r r h y th m ia s m a y d e v e lo p . T h is m a y c a u s e tis s u e a n o x ia . a n d G A B A . a llo w in g m o r e tim e in d ia s to le . D. 36. fa m ily . D r u g s th a t a n ta g o n iz e d o p a m in e a n d a r e a b le to c r o s s th e b l o o d . F r e e c y a n id e r a d ic a l b in d s w ith in a c tiv e tis s u e c y to c h r o m e o x id a s e a n d p r e v e n t o x id a tiv e p h o s p h o r y la tio n . b u t im p o r ta n t o n e s in th e p e r io p e r a tiv e p e r i o d a r e d r o p e r id o l. 38. o r d o b u ta m in e m a y n o t b e n e e d e d . C y a n id e to x ic ity m u s t b e s u s p e c te d e a r lie r th a n th a t s ta g e in a n y p a tie n t w h o d e v e lo p s r e s is ta n c e to th e h y p o te n s iv e a c tio n o f a m a x im u m d o s e o f SN P. I n d u c tio n o f a n e s th e s ia in a p a tie n t w ith s e v e r e v a lv u la r s te n o s is c a n le a d to d e c r e a s e d v e n tr ic u la r f illin g s e c o n d a r y to v a s o d ila ta tio n a n d d e c r e a s e d v e n o u s r e tu r n . It m a y a ls o c a u s e p r o l o n g a t i o n o f Q T in te r v a l a n d to r s a d e s d e p o in te s . in c lu d in g d o p a m in e r e c e p to r s in th e c a u d a te n u c le u s a n d th e m e d u lla r y c h e m o r e c e p to r t r i g g e r z o n e . a n d a g ita tio n . D r o p e r id o l is a b u ty r o p h e n o n e a n d is s tr u c tu r a lly r e la te d to h a lo p e r id o l. C. U ltim a te ly . P e r ip h e r a lly .

R e c o m m e n d a tio n is to s to p th e s e a g e n ts a t le a s t 2 w e e k s b e f o r e th e p la n n e d s u r g e r y . N itr o u s o x id e . M o s t h o s p ita ls h a v e p o lic ie s to e n s u r e th a t p a tie n ts u s in g lo n g . b lo o d . D o s e o f m a g n e s iu m s u lfa te u s e d to tr e a t p r e e c la m p s ia is h ig h a n d c a n i n te r f e r e w ith th e e ffe c ts o f m a n y m e d ic a tio n s u s e d in a n e s th e s ia . D. c h o le s te r o l. a n d th e a b ility o f th e p a tie n t to b r e a th e s p o n ta n e o u s ly th e e n d o f g e n e r a l a n e s th e tic w h e r e m u s c le r e la x a n t w a s u s e d n e e d s to b e a s s e s s e d v e r y c a r e f u lly . B. In o th e r w o r d s . A ll o f th e m e d ic a tio n s m e n tio n e d in th e q u e s tio n s h o u ld b e c o n tin u e d in th e p e r io p e r a tiv e p e r io d . d e c r e a s in g th e c h a n c e o f lo c a l a n e s th e tic to x ic ity a s w e ll a s p r o l o n g a t i o n o f th e b lo c k b y a llo w in g th e lid o c a in e to w o r k l o n g e r o n th e n e u r o n a l tis s u e . M a g n e s iu m d o e s n o t a f f e c t th e d o s e o f lo c a l a n e s th e tic . L o c a l v a s o c o n s tr ic tio n b y e p in e p h r in e s lo w s d o w n th e s y s te m ic a b s o r p tio n o f lid o c a in e . S im ila r ly . b e in g a le s s p o te n t a n e s th e tic w ith a M A C o f 1 0 4 . T h e r e is s tr o n g e v id e n c e to c o n tin u e th e u s e o f P . T h e r e la tiv e s o lu b ility o f a n a n e s th e tic in a ir. T h e a b s o r p tio n o f th e e p in e p h r in e f r o m th e e p id u r a l s p a c e in to s y s te m ic c ir c u la t io n is to o s lo w f o r it to c o u n te r a c t th e h y p o te n s io n w h ic h is c a u s e d b y a b o lu s o f lid o c a in e . m o r e r a p id r i s e o f a lv e o la r p r e s s u r e is tr a n s la te d in to fa s te r a n e s th e tic in d u c tio n . A n o th e r f a c to r th a t p la y s a r o l e in th is r e g a r d is th e c o n c e n tr a tio n e ffe c t.4 2 . . S in c e it is th e a lv e o la r p a r tia l p r e s s u r e th a t d e te r m in e s th e p a r tia l p r e s s u r e in th e b r a in . h ig h e r th e r a te o f e q u ilib r a tio n . S in c e th is c a n c a u s e p r o b le m in a p a tie n t w h o is d e p e n d e n t o n th is m e d ic a tio n .l o w e r in g a g e n ts . 41. 43. a n d H 2. It d e c r e a s e s th e M A C o f v o la tile a n e s th e tic s a n d p o te n tia te s th e m u s c le r e la x a ti o n c a u s e d b y b o th d e p o la r iz i n g a s w e ll a s th e n o n d e p o la r iz i n g m u s c le r e la x a n ts . U s e o f in d ir e c t. 42.b lo c k e r s r e c e iv e th e m in th e p e r io p e r a tiv e p e r io d . B y d e c r e a s in g th e m e ta b o lis m o f c a te c h o la m in e s . th e s e m e d ic a tio n s c a u s e a n in c r e a s e in th e a m o u n t o f n o r e p in e p h r in e a v a ila b le at th e p r e s y n a p tic a d r e n e r g i c n e r v e e n d in g . C. th e r e is e v id e n c e th a t p e r io p e r a tiv e c o n tin u e d u s e o f s ta tin s le a d s to b e tte r o u tc o m e s .4 6 c o m p a r e d w ith d e s f lu r a n e w ith p a r titio n c o e f f ic ie n t o f 0 . T h e d o s e s o f th e s e a g e n ts n e e d to b e r e d u c e d . 40. th e r a te o f r i s e o f a lv e o la r c o n c e n tr a tio n . A.b lo c k e r s .t e r m P . except m o n o a m in e o x id a s e in h ib ito r s . T h e m a s s iv e in f l o w ( h ig h e r c o n c e n tr a tio n ) o f n itr o u s o x id e le a d s to h ig h e r r a te o f r i s e o f a lv e o la r c o n c e n tr a tio n (F A ) o f w ith a b l o o d g a s p a r titio n c o e f f ic ie n t o f 0 . th is g r o u p o f m e d ic a tio n is f a llin g o u t o f f a v o r. L o w e r th e p a r titio n c o e f f ic ie n t. is a d m in is te r e d in m u c h l a r g e r q u a n titie s to in d u c e a n e s th e s ia th a n a p o te n t a g e n t lik e s e v o f lu r a n e .a c tin g s y m p a th o m im e tic d r u g lik e e p h e d r in e to tr e a t h y p o te n s io n w ill le a d to e x a g g e r a te d r e s p o n s e w ith s e v e r e d e g r e e o f h y p e r te n s io n a n d c a r d ia c a r r h y th m ia s . a n d tis s u e s is e x p r e s s e d a s p a r titio n c o e f f ic ie n ts . w ill b e h ig h e r th a n a n a n e s th e tic w ith h ig h e r p a r titio n c o e f f ic ie n t. a n d th u s a lv e o la r p a r tia l p r e s s u r e . E p in e p h r in e im p r o v e s th e q u a lity o f b lo c k b y a c tin g o n th e a n a lg e s ic a d r e n e r g i c r e c e p to r s in th e s p in a l c o r d . le a d in g to lo w e r s e r u m le v e ls . F a m o tid in e a n d g ly c o p y r r o la te a r e n o t a s s o c ia te d w ith a n y e x tr a p y r a m id a l e ffe c ts .b lo c k e r s . E a c h e f f ic ie n t is th e r a tio o f th e c o n c e n tr a tio n o f th e a n e s th e tic g a s in e a c h o f th e tw o p h a s e s at e q u ilib r iu m . f o r a n a n e s th e tic w ith a lo w e r a lv e o la r to b l o o d p a r titio n c o e f f ic ie n t.

U n fo rtu n a te ly . It a ls o d e c r e a s e s th e h e a r t ra te . R e s to r a tio n o f th e a f te r lo a d w ith a d m in is tr a tio n o f p h e n y le p h r in e r e v e r s e s th is e ffe c t. th u s u n lo a d in g th e c e n tr a l c o m p a r tm e n t a n d a llo w in g th e p u lm o n a r y e d e m a f lu id to b e r e a b s o r b e d in to th e c ir c u la tio n . it is r e c o m m e n d e d th a t th is d r u g b e a v o id e d in p a tie n ts w ith c o n g e n ita l p r o l o n g e d Q T s y n d r o m e . N e o s tig m in e d o e s n o t i n te r f e r e w ith a n y o f th e s e p r o c e s s e s . 46. D.v e n tr ic u la r o u tf lo w o b s tr u c tio n is d y n a m ic in s te a d o f b e in g fix e d . In th is s itu a tio n . S u c c in y lc h o lin e a d m in is tr a tio n c a n p r o l o n g Q T in te r v a l p o s s ib ly f r o m p o ta s s iu m e f f lu x a n d b y its e ffe c t o n th e a u to n o m ic n e r v o u s s y s te m . O n d a n s e tr o n h a s b e e n s h o w n to in c r e a s e th e Q T in te r v a l. I n h ib itio n o f p r o s ta g la n d i n w h ic h is p a r t o f its a n a lg e s ic m e c h a n is m o f a c tio n le a d s to a f f e r e n t a r t e r i o l a r c o n s tr ic tio n . N itr o g l y c e r in e m a y w o r s e n th e h y p o te n s i o n a n d m a y n o t b e a g o o d c h o ic e f o r a h y p o te n s iv e p a tie n t. . a d m in is tr a tio n o f s u c c in y lc h o lin e a fte r th e u s e o f n e o s tig m in e f o r r e v e r s a l o f n e u r o m u s c u la r b lo c k a d e m a y le a d to lo n g e r . 45. It w a s th e s o le n o n s te r o id a l a n ti.v e n tr ic u la r p e r f u s io n to ta k e p la c e d u r in g th e d ia s to le . in c r e a s in g th e o b s tr u c tio n .44. T h i r ty m i l l i g r a m s o f k e to r o la c is e q u iv a le n t in p o te n c y to 1 0 0 m g o f m e p e r id in e o r 10 m g o f m o r p h in e . n itr o g ly c e r in e w ill b e m o r e h e lp f u l in th is s itu a tio n . T h is r e s p o n s e is c o m p a r a b le to th a t o c c u r r i n g w ith d r o p e r i d o l . a llo w in g m o r e tim e f o r le f t. w h ic h is a v e r y p o te n t v a s o d il a to r in c r e a s in g th e v e n o u s c a p a c ita n c e .in f la m m a to r y d r u g a v a ila b le in in tr a v e n o u s f o r m p r i o r to th e a v a ila b ility o f IV ib u p r o f e n . P r o p o f o l. B. A s th e c lin ic a l s itu a tio n s e e m s to in d ic a te th e n e e d f o r a n a g e n t th a t is p o te n t a n d e x tr e m e ly fa s t in its o n s e t o f a c tio n . A lth o u g h th e r e is n o c le a r a s s o c ia tio n b e tw e e n to r s a d e s d e p o in te s a n d th is d r u g . c o n tin u e to m e c h a n ic a lly v e n tila te th e p a tie n t u n til th e p a tie n t m e e ts e x tu b a tio n c r ite r ia . c is a tr a c u r iu m v ia H o f m a n n e lim in a tio n a n d p a n c u r o n iu m v ia k id n e y . N e o s tig m in e c a u s e s in h ib itio n o f p la s m a c h o lin e s te r a s e . D e c r e a s e d a f te r lo a d u n d e r g e n e r a l a n e s th e s ia c a u s e s th e g r a d ie n t b e tw e e n th e le f t.e x p e c te d d u r a tio n o f a c tio n o f s u c c in y lc h o lin e . R o c u r o n iu m is m a in ly m e ta b o liz e d b y liv e r a n d e x c r e te d in to b ile . h a s b e e n s h o w n to b e s a f e in p a tie n ts w ith th is c o n d itio n a n d m a y a c tu a lly d e c r e a s e th e Q T in te r v a l in c r e a s e in d u c e d b y s e v o f lu r a n e . C. T h is a c tio n o f n itr o g l y c e r i n e h e lp s r e lo c a te th e in tr a v a s c u la r v o lu m e in to p e r ip h e r a l c o m p a r tm e n t.th a n . 47. 48. le a d in g to c o lla p s e o f th e le f t. P a tie n ts w ith h y p e r tr o p h ic c a r d io m y o p a th y b e h a v e a s if th e y h a v e a o r tic s te n o s is e x c e p t th a t th e le f t. E p h e d r in e w ill in c r e a s e th e h e a r t r a te a s w e ll a s c a r d ia c c o n tra c tility . it h a s m a n y s id e e ffe c ts th a t l im it its u s e in th e p e r io p e r a tiv e p e r io d .in f la m m a to r y a c tio n . th u s m a k in g th e s itu a tio n w o r s e a s d e s c r ib e d a b o v e .v e n tr ic u la r p r e s s u r e a n d th e a o r tic p r e s s u r e to in c r e a s e . D. N itr o g l y c e r in e is c o n v e r te d in to n itr ic o x id e .v e n tr ic u la r o u tf lo w tra c t. M e to c lo p r a m id e h a s a s im ila r e ffe c t. A m r in o n e w ill a c tu a lly in c r e a s e th e c o n tr a c tility w h ile r e d u c in g th e a f te r lo a d : b o th e ffe c ts b e in g u n d e s ir a b le in th is c lin ic a l s itu a tio n . o n th e o th e r h a n d . a n d d e c r e a s in g th e c a r d ia c o u tp u t. D e c r e a s in g th e c a r d ia c c o n tr a c tility m a y a ls o b e h e lp f u l a s th a t w ill p r e v e n t th e o p p o s in g w a lls o f th e o u tf lo w tra c t to c o m e to g e th e r r e lie v in g th e o b s tr u c tio n . K e to r o la c is a v a lu a b le n o n s te r o id a l a n a lg e s ic w ith m o d e s t a n ti. D. A s s u c c in y lc h o lin e is m e ta b o liz e d b y th is e n z y m e .

N a lo x o n e e a s ily c r o s s e s th e p la c e n ta . S in c e e p id u r a l b u p iv a c a in e h a s a l o n g e r d u r a tio n o f a c tio n th a n e p id u r a l fe n ta n y l. it h a s in tr in s ic a tr o p in e lik e a c tiv ity th a t m a y c a u s e ta c h y c a r d ia a fte r its a d m in is tr a tio n . D e g r e e o f a n a lg e s ia is e n h a n c e d b y a d d itio n o f fe n ta n y l to e p id u r a l lo c a l a n e s th e tic . E p id u r a l fe n ta n y l h a s n o e f f e c t o n th e v a g u s n e r v e . w h ile lip id s o lu b ility is m u c h le s s . S o r e n a r c o t iz a tio n is a p o s s ib ility . it m a y le a d to d e c r e a s e d b l o o d p r e s s u r e a n d b a r o r e c e p to r . F o r th is r e a s o n .49. s u fe n ta n il (8 . 2 0 % . S a m e is tr u e f o r m itr a l r e g u r g ita tio n . H ig h e r o i l/g a s p a r titio n c o e f f ic ie n t m e a n s h ig h e r p r o p o r t i o n o f in h a le d a g e n t is in s o lu b le f o r m in b l o o d b e f o r e e n o u g h p a r tia l p r e s s u r e is a c h ie v e d a t th e a lv e o la r . to a n e s th e tiz e th e p a tie n t. a n d in fa c t. S o its p e n e tr a tio n in to b r a i n is m u c h fa s te r th a n s u fe n ta n il. P r o l o n g e d a d m in is tr a tio n . 52. A c u te m y o c a r d i a l i n f a r c tio n is n o t a c o n tr a in d ic a tio n in its e lf o f n i tr o p r u s s id e th e r a p y a s lo n g a s it is n e e d e d to tr e a t h ig h b l o o d p r e s s u r e . B. U n fo rtu n a te ly .in d u c e d s p a s m o f th e s p h in c te r o f O d d i. 54. R e n a l f a ilu r e m a y in c r e a s e th e a v a ila b ility o f s u lfa te io n .5 ) v s . n i tr o p r u s s id e m a y b e h e lp f u l a s it m a y in c r e a s e th e c a r d ia c o u tp u t in th is c o n d itio n b y d e c r e a s in g th e a f te r lo a d . T h is is e x p la in e d b y th e lo w e r p K a o f a lf e n ta n il (6 . b u t its e f f e c t w ill b e s m a lle r th a n th e e f f e c t o f d u r a tio n o f a d m in is tr a tio n . a d m in is tr a tio n o f n a lo x o n e to a n o p io id . A lfe n ta n il h a s a fa s t o n s e t o f a c tio n c o m p a r e d w ith s u fe n ta n il b e c a u s e o f a v e r y h ig h p r o p o r t i o n o f it b e in g u n io n iz e d a t p h y s io lo g ic p H : 9 0 % v s .4 5 m in u te s ) th a n m o s t c o m m o n ly u s e d o p io id s . T h is e f f e c t is m e d ia te d th r o u g h c e n tr a l n e r v o u s s y s te m . le a d in g to lo w e r to ta l v o lu m e o f d is tr ib u tio n . w h ic h a llo w s p r o d u c tio n o f m o r e th io s u lf a te to a c t a s a d o n o r a n d th u s c o n v e r t c y a n id e to th io c y a n a te . b u t th e e f f e c t o n th e s e n s o r y a n d m o to r b lo c k is n o t a u g m e n te d . M o r p h in e c a u s e s v a s o d ila ta tio n .b in d in g is c o m p a r a b le to s u fe n ta n il. th e d u r a tio n o f b lo c k m a y n o t b e p r o lo n g e d . 51. N a lo x o n e is a n o n s e le c tiv e o p io id a n ta g o n is t a t a ll th r e e ^ . S a m e p r o c e s s is r e v e r s e d a t th e tim e o f a w a k e n in g . h a lf . a n d f in a lly in th e b r a in . a n d in th e p r e s e n c e o f p r e e x is tin g h y p o v o le m ia . H a llm a r k o f n i tr o p r u s s id e p o is o n in g is in c r e a s in g m e ta b o lic a c id o s is s e c o n d a r y to im p a ir e d o x id a tiv e p h o s p h o r y la tio n in th e c e ll b e c a u s e o f a c c u m u la tio n o f c y a n id e io n s . B.in d u c e d ta c h y c a r d ia . M e p e r id in e is a n e x c e p tio n . C. D. C. B. O p io id r e c e p to r s a r e f o u n d in s id e s u b s ta n tia g e la tin o s a in th e s p in a l c o r d . so m u c h a n e s th e tic is f o u n d in th e tis s u e s in a s o lu b le f o r m th a t a ll o th e r f a c to r s b e c o m e m u c h le s s im p o r ta n t a s d e te r m in a n ts o f r e c o v e r y tim e . A d d itio n o f fe n ta n y l to lo c a l a n e s th e tic in je c te d in th e e p id u r a l s p a c e d e c r e a s e s th e o n s e t o f a n a lg e s ia tim e .li f e is s h o r te r ( 3 0 . W ith in c r e a s e d tim e o f a d m in is tr a tio n . T h e y a ls o h a v e d ir e c t e f f e c t o n th e c a r d ia c p a c e m a k e r c e lls . H ig h e r c a r d ia c o u tp u t m a y s lo w d o w n th e r e c o v e r y tim e . Its p r o te in .0 ). 50. O p io id s u s u a lly c a u s e b r a d y c a r d ia . M A C o f th e d r u g in its e lf d o e s n o t d e te r m in e th e tim e o f in d u c tio n o r re c o v e ry . 53. It is u s e f u l in th e tr e a tm e n t o f o p io id . It d o e s n o t s e e m to h a v e a n y a g o n is t a c tiv ity a t th e o p io id r e c e p to r s .r e c e p to r s .d e p e n d e n t p a r tu r ie n t m a y p r o d u c e a c u te w ith d r a w a l in th e n e o n a te .

b lo c k in g a g e n ts ’ a c tio n a n d so a c ts s y n e r g is ti c a lly to p r o l o n g th e n e u r o m u s c u la r b lo c k a d e .d e p e n d e n t c h a n g e s in th e E E G .4 h o u r s ) . 55.in d u c e d e n h a n c e m e n t o f n e u r o m u s c u la r b lo c k a d e p r o d u c e d b y n o n d e p o la r iz i n g n e u r o m u s c u la r . o n th e o th e r h a n d . P e r io d s o f e le c tr ic a l s ile n c e b e g in to o c c u p y a g r e a te r p o r t i o n o f th e tim e as d e p th in c r e a s e s ( b u r s t s u p p r e s s io n ) . B u t s in c e c a lc iu m a ls o s ta b iliz e s th e p o s tju n c tio n a l m e m b r a n e to th e e f f e c t o f a c e ty lc h o lin e . it c a u s e s r e s tle s s n e s s . a n d a t le a s t t e m p o r a r i l y r e v e r s e s th e ir e f f e c t o n e n h a n c e m e n t o f n e u r o m u s c u la r . L id o c a in e . c h e s t c o m p r e s s io n s a lo n g w ith a d m in is tr a tio n o f e p in e p h r in e m a y b e th e b e s t c o u r s e o f a c tio n . I n c r e a s in g d e p th o f a n e s th e s ia w ith is o f lu r a n e f r o m th e a w a k e s ta te is c h a r a c te r iz e d b y in c r e a s e d a m p litu d e a n d s y n c h r o n y . V o la tile a n e s th e tic s c a u s e c h a r a c te r is tic d o s e . It is f o u n d in p la s m a a n d m o s t tis s u e s b u t n o t in r e d b l o o d c e lls . s o m e tim e s th e e f f e c t o f c a lc iu m o n a n ta g o n is m o f a n tib io tic . A n tic h o lin e s te r a s e s in c r e a s e th e a m o u n t o f a c e ty lc h o lin e a v a ila b le a t th e n e u r o m u s c u la r ju n c tio n b y in h ib itin g th e e n z y m e th a t m e ta b o liz e s it. th e c le a r a n c e o f m id a z o la m is s ix to e ig h t tim e s th a t o f lo r a z e p a m . T h e m e c h a n is m is p o o r l y u n d e r s to o d .b lo c k in g a g e n ts is th e in h ib itio n o f r e le a s e o f a c e ty lc h o lin e a t th e p r e ju n c tio n a l s ite . P r o p o s e d m e c h a n is m in c lu d e s p r e e x is tin g h y p o v o le m ia . tin n itu s . A t a lo w e r s e r u m le v e l. S im ila r ly . S p in a l a n e s th e s ia is r a r e l y a s s o c ia te d w ith d r a m a tic d r o p o f h e a r t r a te a n d b l o o d p r e s s u r e in y o u n g in d iv id u a ls . A s a r e s u lt. C. th e e lim in a tio n h a lf . If th e r e is n o p u ls e . 56.b lo c k in g a g e n ts is u n p r e d ic ta b le . In th e c lin ic a l s c e n a r io d e s c r ib e d . 59.0 0 0 . L a r g e r d o s e s in h ib it b o th in h ib ito r y a n d e x c ita to r y n e u r o n s . L o r a z e p a m is c o n ju g a te d in th e liv e r w ith g lu c u r o n ic a c id to p r o d u c e in a c tiv e m e ta b o lite s . M id a z o la m a n d th io p e n ta l b o th in c r e a s e th e in h ib ito r y a c tio n o f G A B A r e c e p to r a n d s lo w d o w n th e E E G . le a d in g to c e n tr a l n e r v o u s s y s te m d e p r e s s io n a n d com a. o r a h ig h s p in a l w ith in h ib itio n o f c a r d i o a c c e l e r a t o r y s y m p a th e tic n e r v e s a r is in g f r o m T 1 to T 4 s e g m e n ts o f th e s p in a l c o r d .in d u c e d n e u r o m u s c u la r b lo c k a d e e n h a n c e s th e w e a k n e s s p r o d u c e d b y a m in o g ly c o s id e a n tib io tic s . a n d v e r tig o c u lm in a tin g in t o n i c . B. a tr o p in e in its e lf m a y n o t b e a b le to c o r r e c t th e h e m o d y n a m ic s . u n r e c o g n iz e d h y p o x e m ia s e c o n d a r y to s e d a tio n . A. B. h a s a b ip h a s ic a c tio n .li f e o f lo r a z e p a m is m u c h l o n g e r ( 1 0 . b u t th is p r o c e s s is m u c h s lo w e r th a n th e m e ta b o lis m o f m id a z o la m . 57. P r o p o s e d m e c h a n is m o f a c tio n o f th e s e a n tib io tic s in c a u s in g th e p o te n tia tio n o f a c tio n o f n e u r o m u s c u la r . 58. P la s m a p s e u d o c h o lin e s te r a s e o r n o n s p e c if ic c h o lin e s te r a s e is a n e n z y m e w ith m o le c u la r w e ig h t o f 3 2 0 . C a lc iu m a n ta g o n iz e s th is a c tio n o f a n tib io tic s . w h ic h r e f le c ts in h ib itio n o f c o r tic a l in h ib ito r y n e u r o n s .2 0 h o u r s ) c o m p a r e d w ith m id a z o la m ( 1 . G e n ta m y c in is a n a m in o g ly c o s id e a n tib io tic th a t e n h a n c e s n e u r o m u s c u la r b lo c k a d e a c tio n o f m u s c le r e la x a n ts u s e d in a n e s th e s ia . tr e m o r . M a g n e s iu m in its e lf p o te n tia te s n e u r o m u s c u la r . a n d th e s itu a tio n s c a ll f o r in itia tio n o f m e a s u r e s r e q u ir e d in a d v a n c e d c a r d ia c lif e s u p p o r t. S u c c in y lc h o lin e . V o lu m e o f d is tr ib u tio n o f lo r a z e p a m is c o m p a r a b le to m id a z o la m . D. It d e g r a d e s .b lo c k in g a c tio n o f th e s e a n tib io tic s .c l o n i c s e iz u r e . o f h ig h d o s e s o f n i tr o p r u s s id e m a y le a d to th io c y a n a te a c c u m u la tio n a n d to x ic ity .

O ld e r in d iv id u a ls a r e a ls o m o r e p r o n e to th e s e d a tiv e e ffe c t o f o p io id d r u g s c o m p a r e d w ith y o u n g e r in d iv id u a ls . B. a lth o u g h p s e u d o c h o lin e s te r a s e is p r o d u c e d in th e liv e r . c a u s in g u n e x p e c te d v e n tila to r y d e p r e s s a n t e ffe c ts f r o m e v e n a s m a ll d o s e o f m o r p h in e . b i l i a r y c o lic .in d u c e d n e u r o m u s c u la r b lo c k w ill o c c u r b e c a u s e a n in c r e a s e d p r o p o r t i o n o f s u c c in y lc h o lin e r e a c h e s th e n e u r o m u s c u la r ju n c tio n . th e to n e o f th e b la d d e r s p h in c te r is e n h a n c e d . A s u b s ta n tia l p o r t i o n o f th e n e u r o g e n ic to n e in th e h u m a n s is d u e to c h o lin e r g ic in n e r v a tio n v ia th e v a g u s n e r v e .in d u c e d a u g m e n ta tio n o f d e tr u s o r to n e . a n d w ith d r a w a l f r o m o p io id s c a n a ls o in c r e a s e th e d e g r e e o f im m u n o s u p p r e s s io n . w h e n in a n h e p a tic p h a s e . D if f u s io n a w a y f r o m th e n e u r o m u s c u la r ju n c tio n s ta y s th e s a m e w h e th e r th e p a tie n t h a s n o r m a l o r a ty p ic a l e n z y m e a n d d o e s n o t c o n tr ib u te m u c h to th e c e s s a tio n o f a c tio n o f s u c c in y lc h o lin e . S u c c in y lc h o lin e is n o t m e ta b o liz e d in th e liv e r . B. 61. C h r o n ic r a th e r th a n a c u te u s e o f o p io id s is a s s o c ia te d w ith im m u n o s u p p r e s s io n . It is p r i m a r i l y p r o d u c e d in th e liv e r . b u t. a n d p o s ts y n a p tic n e u r o tr a n s m itte r is . th is m e ta b o lis m is s lo w .6 . S o th e d ib u c a in e n u m b e r is a g o o d e s tim a tio n o f th e d e g r e e o f q u a lita tiv e a b n o r m a lity o f th e e n z y m e . a n d d e la y e d g a s tr ic e m p ty in g . T h is p r o c e s s is so f a s t th a t o n ly 5 % o f in je c te d s u c c in y lc h o lin e r e a c h e s th e n e u r o m u s c u la r ju n c tio n . U r in a r y u r g e n c y is p r o d u c e d b y o p io id . N o r m a l p la s m a p s e u d o c h o lin e s te r a s e d o e s n o t r e s i s t d ib u c a in e in h ib itio n . It c a u s e s c o n tr a c tio n o f th e s m o o th m u s c le o f th e g a s tr o in te s tin a l tra c t. a c e ty lc h o lin e r e le a s e d a t th e n e u r o m u s c u la r ju n c tio n .s ta g e liv e r d is e a s e m a y d e c r e a s e p la s m a c h o lin e s te r a s e a c tiv ity . F ir s t s te p c o n v e r ts s u c c in y lc h o lin e to s u c c in y lm o n o c h o lin e . c a u s in g u r i n a r y r e te n tio n . A. 60. M o r p h in e . L iv e r d is e a s e h a s to b e s e v e r e b e f o r e d e c r e a s e s in p la s m a p s e u d o c h o lin e s te r a s e p r o d u c tio n s u f f ic ie n t to p r o l o n g s u c c in y lc h o lin e . 62.s u lf a te m a y a c c u m u la te in c a s e s o f r e n a l f a ilu r e . c a u s in g v a r ie ty o f s id e e ffe c ts lik e c o n s tip a tio n . D. so e n d . A c e ty lc h o lin e s te r a s e s a n ta g o n iz e th is e n z y m e . O p io id s a lte r th e d e v e lo p m e n t. d if f e r e n tia tio n . A s m e n tio n e d in th e p r e v io u s d is c u s s io n p s e u d o c h o lin e s te r a s e m e ta b o liz e s th e in je c te d s u c c in y lc h o lin e b e f o r e it r e a c h e s n e u r o m u s c u la r ju n c tio n . a n d g r e a te r q u a n tity o f s u c c in y lc h o lin e r e a c h e s n e u r o m u s c u la r ju n c tio n . th e lo w e r e s o p h a g e a l s p h in c te r is a p p r o x im a te ly 4 c m lo n g . le a d in g to p r o l o n g e d a p n e a . M e ta b o lis m o f s u c c in y lc h o lin e b y p s e u d o c h o lin e s te r a s e is a tw o -s te p p r o c e s s o f h y d r o ly s is . T h e p r e s y n a p tic n e u r o tr a n s m itte r is a c e ty lc h o lin e . M o r p h in e e x h ib its g r e a te r a n a lg e s ic p o te n c y a n d s lo w e r o n s e t o f a c tio n in w o m e n th a n m e n . a n d th e s e c o n d s te p to s u c c in ic a c id . f o ll o w i n g th e s ta n d a r d d o s e o f s u c c in y lc h o lin e . L iv e r d is e a s e d o e s n o t s e e m to a f f e c t th e s e n s itiv ity o f th e in d iv id u a l to o p io id a d m in is tr a tio n e x c e p t d u r in g liv e r tr a n s p la n t s u r g e r y . In th e p r e s e n c e if a ty p ic a l p s e u d o c h o lin e s te r a s e . M u s c le to n e in th e lo w e r e s o p h a g e a l s p h in c te r is th e r e s u lt o f n e u r o g e n ic a n d m y o g e n ic m e c h a n is m s . th e e f f e c t o f o p io id s m a y b e e n h a n c e d . w h ile th e a b n o r m a l o n e d o e s . I n c r e a s e d b i l i a r y p r e s s u r e o c c u r s w h e n th e g a llb la d d e r c o n tr a c ts a g a in s t a c lo s e d o r n a r r o w e d s p h in c te r o f O d d i. a n d f u n c tio n o f im m u n e c e lls . L o w e r e s o p h a g e a l s p h in c te r m e c h a n is m c o n s is ts o f th e in tr in s ic to n e o f th e in tr in s ic s m o o th m u s c le o f th e d is ta l e s o p h a g u s a n d th e s k e le ta l m u s c le o f th e d ia p h r a g m . 63. a t th e s a m e tim e . U n d e r n o r m a l c ir c u m s ta n c e s . E ffe c ts o f n a r c o tic s o n s m o o th m u s c le s a r e v a r ia b le in d if f e r e n t a r e a s o f th e b o d y .

A ll o f th e a g e n ts m e n tio n e d in th is q u e s tio n c a n b e u s e d to a n e s th e tiz e a p a tie n t f o r a s h o r t d u r a tio n o f tim e o n f r e q u e n t b a s is e x c e p t f o r e to m id a te a s its a d r e n a l s u p p r e s s iv e a c tio n w ill im p a ir th e a b ility o f th e p a tie n t to m o u n t a s tr e s s r e s p o n s e . a n d . w h ic h th is p a tie n t w ill n e e d o n a n o n g o in g b a s is . k e ta m in e c a n b e h e lp f u l in th is r e g a r d . D. S o m e a n e s th e tic a g e n ts a r e k n o w n to in c r e a s e th e s e iz u r e a c tiv ity a n d c a n b e u tiliz e d f o r th a t p u r p o s e . N e o s tig m in e a ls o in c r e a s e s th is s p h i n c t e r ’s to n e b y in c r e a s in g th e c o n c e n tr a tio n o f a c e ty lc h o lin e . r e la x e s th e s m o o th m u s c le o f th is s p h in c te r. I n d u c ib le o n e s a r e th o s e th a t a r e t r i g g e r e d b y a n e x o g e n o u s f a c to r lik e a d m in is tr a tio n o f a d r u g . a n d c y to c h r o m e s . s k in th ic k n e s s . F o r a n e s th e s io lo g is ts . 68. M e to c lo p r a m id e a ls o in c r e a s e s lo w e r e s o p h a g e a l s p h in c te r to n e a n d is h e lp f u l in tr e a tin g th e s y m p to m s o f g a s tr o e s o p h a g e a l r e f lu x a n d a s s o c ia te d e s o p h a g itis . E M L A c r e a m is a e u te c tic m ix tu r e o f lid o c a in e (2 . E u te c tic m ix tu r e is a c o m b in a tio n o f tw o s u b s ta n c e s w h o s e m e ltin g p o in t is lo w e r th a n th a t o f e ith e r o f th e c o n s titu e n ts . S o m e p a tie n ts m a y d is lik e th e tin g lin g f e e lin g th a t is p r o d u c e d b y th is d r u g .in d u c in g d r u g s . S ig n s a n d s y m p to m s d e p e n d . B. S id e e ffe c ts in c lu d e s k in b la n c h in g . F iv e p e r c e n t E M L A c r e a m is a p p lie d to d r y in ta c t s k in a n d c o v e r e d w ith a n o c c lu s iv e d r e s s in g f o r a t le a s t a n h o u r . m e th o h e x ita l. S u c c in y lc h o lin e in c r e a s e s i n tr a g a s t r ic a n d lo w e r s e s o p h a g e a l p r e s s u r e s . m y o g lo b in . e ry th e m a . n itr ic o x id e . T h e n o r m a l lo w e r e s o p h a g e a l s p h in c te r p r e s s u r e is 10 to 3 0 m m H g a t e n d e x h a la tio n . H y p o te n s io n is h ig h ly u n lik e ly w ith e p id u r a l fe n ta n y l a d m in is tr a tio n . 64. as th e r e is n o in h ib itio n o f s y m p a th e tic s y s te m . to s o m e d e g r e e . It p r o v id e s to p ic a l a n e s th e s ia f o r 1 to 2 h o u r s . d e r m a l b l o o d flo w . C. 67. E to m id a te . It s h o u ld n o t b e a p p lie d to b r o k e n s k in o r m u c o u s m e m b r a n e s . A ll th e p o r p h y r ia s r e s u lt f r o m a d e f e c t in h e m e s y n th e s is .5 % ) a n d p r il o c a in e (2 . a n d to ta l d o s e a d m in is te r e d . G ly c o p y r r o la te . H e m e is a n e s s e n tia l c o m p o n e n t o f h e m o g lo b in . B. a n d r e s p i r a t o r y d e p r e s s io n . T h e la s t s id e e f f e c t is s e c o n d a r y to m e ta b o lis m o f p r il o c a in e O . E p id u r a l o p io id s c a n c a u s e n a u s e a . p o r p h y r i a c a n b e d iv id e d in to in d u c ib le a n d n o n in d u c ib le . c o m p o u n d s in v o lv e d in th e tr a n s p o r t a n d a c tiv a tio n o f o x y g e n a n d th e e le c tr o n tr a n s p o r t c h a in . B ig g e s t a d v a n ta g e o f th e s e a g e n ts o v e r e p id u r a l a d m in is tr a tio n o f lo c a l a n e s th e tic s is th e h e m o d y n a m ic s ta b ility . p r u r itu s . A n e s th e s io lo g is t is s o m e tim e s a s k e d in th e s e c a s e s to h e lp lo c a te th e f o c u s th r o u g h e n h a n c in g th e E E G a c tiv ity o r a c tu a lly in d u c in g th e s e iz u r e d u r in g th e a n e s th e tic . D r u g s th a t in d u c e c y to c h r o m e e n z y m e s lik e b a r b itu r a te s a n d p h e n y to in c a n p r e c ip ita te a n e p is o d e o f p o r p h y r ia . O th e r a n e s th e tic s a c tu a lly in c r e a s e th e s e iz u r e th r e s h o ld a n d m a k e it d if f ic u lt f o r th e s u r g e o n to f in d th e a r e a o f in te re s t. 66. a n d m e th e m o g lo b in e m ia . e d e m a .5 % ) w ith a m e ltin g p o in t o f 1 8 0 ° C so th a t th e m ix tu r e is a n o i l y liq u id a t b o d y te m p e r a tu r e . o n th e o th e r h a n d . T h e a m o u n t o f d r u g a b s o r b e d d e p e n d s o n a p p lic a tio n tim e . 65. I n tr a c ta b le s e iz u r e s a r e s o m e tim e s tr e a te d w ith e x c is io n o f th e s e iz u r e f o c u s in th e b r a in . D. th a t is .to lu id in e a n d m a y b e m o r e c o m m o n if th e p a tie n t is c o n c u r r e n t ly ta k in g s u lf o n a m id e s a n d o th e r m e th e m o g lo b in . o ld e r in h a le d a n e s th e tic e n f lu r a n e .

It is r e a d ily m e ta b o liz e d in th e liv e r b y th e c y to c h r o m e P 4 5 0 s y s te m o f e n z y m e s to f o r m n o r k e ta m in e . T h e v e n tila to r y r e s p o n s e to c a r b o n d io x id e is m a in ta in e d . p s y c h ia tr ic d is tu r b a n c e s .in f la m m a to r y a n a lg e s ic th a t is a v a ila b le in p a r e n te r a l f o r m . R e s p ir a to r y a lk a lo s is d o e s n o t s e e m to h a v e a n y e ffe c t. D. K e ta m in e c a u s e s m in im a l to n o r e s p i r a t o r y d e p r e s s io n w h e n u s e d to in d u c e g e n e r a l a n e s th e s ia . in s o m e c a s e s . d ia r r h e a . K e to r o la c 3 0 m g p r o d u c e s e q u iv a le n t a n a lg e s ia c o m p a r e d w ith 10 m g o f m o r p h in e . U s e o f n a ltr e x o n e in th is p a tie n t w h o h a s b e e n u s in g h e r o i n f o r s u c h a lo n g tim e w ill p re c ip ita te w ith d r a w a l s y m p to m s . A d m in is tr a tio n o f th is m e d ic a tio n w ill h e lp a v o id s id e e ffe c ts th a t a r e a s s o c ia te d w ith th e u s e o f m o r p h in e . r u n n y n o s e . ta c h y c a r d ia .a n t a g o n i s t a t d if f e r e n t o p io id r e c e p to r s e x c e p t n a ltr e x o n e . C. it is a u s e f u l d r u g in p a tie n ts w h o h a v e p a in s e c o n d a r y to b i l i a r y s p a s m . v o m itin g . a n d th e PaCO2 is u n lik e ly to in c r e a s e m o r e th a n 3 m m H g . o n th e ty p e o f p o r p h y r ia . D. a n d . P e r io p e r a tiv e ly . a n d in c r e a s e d te m p e r a tu r e . D if f e r e n t d r u g s a n d p h y s io lo g ic a n d p a th o lo g ic sta te s c a n a f f e c t th e M A C o f a n a n e s th e tic . S e v e r ity a n d d u r a tio n o f th e s e s y m p to m s v a ry . b u t a n e s th e s io l o g is t is u s u a lly in v o lv e d in a c a s e w h e r e p a tie n t is b r o u g h t to th e o p e r a tin g r o o m f o r e x p l o r a t o r y l a p a r o to m y s e c o n d a r y to n a u s e a . a n d p a tie n ts p r o n e to h a v e in c r e a s e d in tr a c r a n ia l p r e s s u r e (IC P ) m a y s h o w a s u s ta in e d r i s e in IC P a fte r in d u c tio n o f a n e s th e s ia w ith k e ta m in e d e s p ite n o r m o c a p n ia . b u t it s e e m s to d o so o n ly if h e m o g lo b in le v e l is b e lo w 5 g m /d L . It is a p o te n t v a s o d il a to r o f c e r e b r a l v e s s e ls . w h ic h in c lu d e b o d y a c h e s . q u a d r ip le g ia . d is tu r b a n c e s o f a u to n o m ic s y s te m a n d e le c tr o ly te im b a la n c e a r e c o m m o n a n d n e e d to b e a d d r e s s e d .f if th to o n e . w h ic h is o n e . C h r o n ic a n e m ia d e c r e a s e s M A C . A ll o f th e d r u g s m e n tio n e d in th e q u e s tio n a r e a g o n i s t . K e ta m in e h a s b r o n c h o d ila to r a c tiv ity a n d is a t le a s t a s e f f e c tiv e a s h a lo th a n e in p r e v e n tin g e x p e r im e n ta lly in d u c e d b r o n c h o s p a s m in d o g s . w h ile a c u te in to x ic a tio n d e c r e a s e s it. a n d p a tie n t m a y th e n d e v e lo p o th e r s ig n s o f p o r p h y r i a p o s to p e r a ti v e ly lik e n e u r o l o g i c s ig n s o f h e m ip le g ia . h ig h b l o o d p r e s s u r e . M A C is d e f in e d a s th e d o s e o f a n a n e s th e tic a t w h ic h 5 0 % o f p a tie n ts d o n o t m o v e in r e s p o n s e to a s u r g ic a l in c is io n . K e to r o la c is a n o n s te r o id a l a n ti. S in c e it is d e v o id o f a c tio n o n th e s p h in c te r o f O d d i. D. n itr o u s o x id e . it d o e s c a r r y th e s id e e f f e c t o f in h ib itio n o f p la te le t f u n c tio n a n d in c r e a s in g th e c h a n c e o f b le e d in g p o s to p e r a tiv e ly . 69. H y p o th e r m ia d e c r e a s e s th e M A C . w h ic h is a p u r e a n ta g o n is t. 70. N o o r g a n i c c a u s e o f th e s e s y m p to m s is fo u n d . e x c e s s iv e te a r in g a n d s a liv a tio n . a n d o p io id s a r e a ll s a f e to u s e in th e s e p a tie n ts . 71. 72. s u c h a s n a u s e a a n d r e s p i r a t o r y d e p r e s s io n . E lic ita tio n o f f a m ily h is to r y a n d p a s t h is to r y o f s im ila r e p is o d e s c a n h e lp w ith th e d ia g n o s is . in d u c tio n a g e n ts o th e r th a n b a r b itu r a te s . w h ile h y p e r th e r m ia in c r e a s e s it. . In h a le d a n e s th e tic s . a n d p a in in th e a b d o m e n . a n d a lte r a tio n o f c o n s c io u s n e s s o r p a in .in f la m m a to r y d r u g . C h r o n ic a lc o h o l u s e in c r e a s e s th e M A C . L ik e a n y o th e r n o n s te r o id a l a n ti.th ir d as p o te n t a s k e ta m in e . It h a s b e e n u s e d in s u b a n e s th e tic d o s e s to tr e a t b r o n c h o s p a s m in th e o p e r a tin g r o o m a n d IC U . m o o d s w in g s .

T h is s h o r tc o m in g m a y b e o v e r c o m e . B.o f .4 o r g r e a te r .f o u r fa d e w h e n a c tu a l t r a in . 75.o f .f r e q u e n c y s tim u la tio n . G u i l l a i n .m u s c le r e la x a n t a n d h e lp s w ith c o n tr o l o f h ig h b lo o d p r e s s u r e b u t in its e lf is n o t g o o d e n o u g h to c o n tr o l th e e le v a tio n o f b l o o d p r e s s u r e in p r e e c la m p s ia . C. m e a n in g th e r e b y th a t r e s id u a l p a r a ly s is m a y g o u n d e te c te d . D. H ig h e r th e f r e q u e n c y . T h e r e s p o n s e o f th e n e r v e to e le c tr ic a l s tim u la tio n d e p e n d s o n th r e e f a c to r s : th e c u r r e n t a p p lie d . .73.te ta n ic f a c ilita tio n w ith h ig h . a p o te n t v a s o d il a to r o f r e s is ta n c e a n d c a p a c ita n c e v e s s e ls w ith a n im m e d ia te b u t e v a n e s c e n t a c tio n . th e d u r a tio n o f th e c u r r e n t. n o fa d e is p r e s e n t a n d th e r e s p o n s e is s u s ta in e d . T h e s e f a c to r s c a n b e m o d if ie d in d if f e r e n t w a y s to ta k e a d v a n ta g e o f th e c h a r a c te r is tic f e a tu r e s o f th e n o n d e p o la r iz i n g n e u r o m u s c u la r b lo c k a d e : fa d e a n d p o s t. 76. Its in f u s io n c a n b e titr a te d to e ffe c t. It is a n a u to im m u n e d is e a s e t r i g g e r e d b y b a c te r ia l o r v i r a l in f e c tio n . If th e c ir c u m s ta n c e s a llo w . w h ic h is c o n tr a in d ic a te d d u r in g p r e g n a n c y b e c a u s e o f th e r i s k o f fe ta l a b n o r m a litie s . N itr o p r u s s id e .c o n v e r tin g e n z y m e in h ib ito r . b u t its c o n c o m ita n t b lo c k a d e o f P r e c e p to r s m a y p o s e p r o b le m . is u s e f u l in p r e v e n tin g d a n g e r o u s e le v a tio n s in s y s te m ic a n d p u lm o n a r y a r te r y b l o o d p r e s s u r e d u r in g la r y n g o s c o p y . th e m e c h a n ic a l r e s p o n s e o f th e m u s c le is th e f u s io n o f in d iv id u a l tw itc h r e s p o n s e s . to s o m e e x te n t b y a p p ly in g tw o s h o r t te ta n ic s tim u la tio n s ( th r e e im p u ls e s a t 5 0 H z. L a b e ta lo l a n d h y d r a la z in e c a n b e u s e d to p r o v id e a l o n g e r la s tin g c o n tr o l o f b l o o d p r e s s u r e b u t m a y n o t b e fa s t e n o u g h in th e ir a c tio n to c o n tr o l a s u d d e n a c u te r i s e o f b lo o d p r e s s u r e th a t is a s s o c ia te d w ith th is c o n d itio n . w ith tr a in o f f o u r w h e n 2 -H z s tim u la tio n is u s e d . m o r e u s e f u l it is to d e te c t r e s id u a l b lo c k a d e . P a r a ly s is le a d s to p r o l i f e r a t i o n o f e x tr a ju n c tio n a l a c e ty lc h o lin e r e c e p to r s w ith r i s k o f h y p e r k a le m ia if s u c c in y lc h o lin e is u s e d . 74. U s e o f th e s e a g e n ts a lth o u g h is n o t c o n tr a in d ic a te d a s lo n g as c a u tio n is p r a c tic e d in a s s u r in g r e tu r n o f n o r m a l m u s c u la r p o w e r a t th e e n d o f th e p r o c e d u r e b e f o r e e x tu b a tio n is p e r f o r m e d . a n d th e p o s itio n o f th e e le c tr o d e s . I r r e s p e c tiv e o f th e e x p e r ie n c e . in tr a th e c a l o p io id s a n d e p id u r a l lo c a l a n e s th e tic s m a y a c tu a lly b e a b e tte r w a y to p r o v id e a n e s th e s ia f o r th e s e p a tie n ts . O n th e o th e r h a n d . th e m e c h a n ic a l o r e le c tr ic a l r e s p o n s e d e c r e a s e s little a fte r th e f o u r th s tim u lu s . a n d is id e a l f o r tr e a tm e n t o f h y p e r te n s iv e e m e r g e n c ie s . D u r in g n o n d e p o la r iz i n g b lo c k . B. M a g n e s iu m is p r i m a r y th e r a p y to p r e v e n t s e iz u r e s in th is c o n d itio n . P r o b le m w ith tr a in o f f o u r is th e d if f ic u lty to e v a lu a te b y v is u a l o r ta c tile m e a n s th e d if f e r e n c e b e tw e e n th e h e ig h t o f f i r s t a n d th e f o u r th tw itc h . It is a s m o o th . In th e a b s e n c e o f n e u r o m u s c u la r - b lo c k in g d r u g s . B lo c k a d e o f a r e c e p to r s b y la b e ta lo l m a y b e h e lp f u l u n d e r th is c o n d itio n . S y m p a th e tic s tim u la tio n a t th e tim e o f in tu b a tio n m a y c a u s e a n e x a g g e r a te d s y m p a th e tic r e s p o n s e a n d n e e d s to b e c o n s id e r e d in th is s itu a tio n . s e p a r a te d b y 7 5 0 m s ). a n d th e d e g r e e o f fa d e is s im ila r to th a t f o u n d a t 5 0 H z. L i s in o p r il is a n a n g io te n s in .f o u r r a tio is 0 . T r e a tm e n t o f h y p e r te n s io n in a p r e e c la m p tic p a tie n t a im s a t d e c r e a s in g th e r i s k o f c e r e b r a l h e m o r r h a g e w h ile m a in ta in in g a n d e v e n im p r o v in g tis s u e p e r f u s io n . th e r e s p o n s e a c h ie v e s a p e a k a n d th e n fa d e s . a lth o u g h s o m e tim e s th e r e m a y b e fa d e a fte r s tim u la tio n w ith 1 0 0 H z in th e a b s e n c e o f a n e u r o m u s c u la r b lo c k .B a r r e s y n d r o m e is th e m o s t c o m m o n c a u s e o f a c u te f la c c id p a r a ly s is . T h e s e p a tie n ts m a y s h o w a r a n g e o f s e n s itiv ity to n o n d e p o la r iz i n g m u s c le r e la x a n ts f r o m e x tr e m e s e n s itiv ity to r e s is ta n c e . it is d if f ic u lt f o r a n e s th e s io lo g is ts to d e te c t tr a in . W h e n s tim u la tio n is a p p lie d a t a f r e q u e n c y o f > 3 0 H z. a n d b y e v a lu a tin g th e r a tio o f th e s e c o n d to th e f i r s t r e s p o n s e .

r e c e p to r a n ta g o n is ts h a v e b e c o m e th e m o s t f r e q u e n tly a d m in is te r e d p r o p h y la x is a n d tr e a tm e n t f o r P O N V d u e to th e ir e ffic a c y . A d if f e r e n tia l d ia g n o s is in a p a tie n t w ith h y p e r te n s io n in th e r e c o v e r y r o o m s h o u ld a lw a y s in c lu d e p o s s ib il ity o f r e b o u n d h y p e r te n s io n s e c o n d a r y to o m is s i o n o f a d o s e o f a n a a g o n is t lik e c lo n id in e . m a y le a d to s e v e r e r e b o u n d h y p e r te n s io n . O th e r o p tio n s a ls o m a y h e lp tr e a t th e p r i m a r y p r o b le m . A s m e n tio n e d e a r lie r . th e in c id e n c e is m u c h lo w e r th a n w ith m e to c lo p r a m id e .b lo c k e r a g e n t.le f t s h u n t b e c a u s e o f d e c r e a s e d s y s te m ic v a s c u la r r e s is ta n c e . E f f o r ts to tr e a t it s o m e tim e s le a d to tr o u b l e s o m e s id e e ffe c ts w h ic h l o o k a la r m in g a t th e tim e o f p r e s e n ta tio n b u t a r e e a s y to tre a t. D y s to n ic r e a c tio n s .H T 3. a lth o u g h h y p o te n s io n d u r in g a n e s th e s ia a s s o c ia te d w ith p e r io p e r a tiv e u s e o f d r u g s c a u s in g a n g io te n s in . C lo n id in e h a s b e e n in c lin ic a l u s e f o r o v e r tw o d e c a d e s n o w . in c lu d in g ta r d iv e d y s k in e s ia .c o n v e r tin g e n z y m e b lo c k a d e c a n b e d if f ic u lt to m a n a g e . c a lle d “ te t s p e ll s . a s it w ill in c r e a s e th e s y s te m ic v a s c u la r r e s is ta n c e th r o u g h its a c tio n o n a ! r e c e p to r s .r e c e p to r a n ta g o n is t s im ila r to o n d a n s e tr o n . In te n s e in c r e a s e in th e a f te r lo a d s e c o n d a r y to e x a g g e r a te d r e le a s e o f n o r e p in e p h r in e m a y n o t b e to le r a te d b y th e h e a r t th a t is in h ib ite d b y la b e ta lo l. th u s m a k in g it a c c u m u la te in th e s e n e r v e e n d in g s . a n d it is a p p r o p r ia te f o r u s e in th is c a s e . o r a l d o s e r e q u ir e s r e p e a te d d o s e s .to . m o r e o x y g e n w ill b e a v a ila b le to th e p e r ip h e r a l tis s u e s im p r o v in g th e c y a n o s is .” b y s q u a ttin g d o w n . 78. th u s d e c r e a s in g th e s h u n t. a r e s o m e o f th e m a n if e s ta tio n s o f th is p s e u d o p a r k in s o n ia n s y n d r o m e . C. C h ild r e n w ith th is c o n d itio n le a r n to tr e a t th e s e e p is o d e s . It is a v e r y p o te n t a n tih y p e r te n s iv e a n d is v e r y u s e f u l to c o n tr o l h ig h b l o o d p r e s s u r e in s o m e p a tie n ts w ith a v e r y r e s is ta n t k in d o f d is e a s e . P o s to p e r a tiv e n a u s e a a n d v o m itin g (P O N V ) is o n e o f th e m o s t d is lik e d s id e e ffe c ts o f a n e s th e s ia a n d s u r g e r y . A s k e ta m in e c a n s tim u la te s y m p a th e tic d is c h a r g e . D ir e c t v a s o d il a to r s lik e n itr o g ly c e r in e a n d n i tr o p r u s s id e a r e m o r e s u ita b le f o r th is s itu a tio n th a n a n o n s e le c tiv e P . T h e 5- H T 3. P r o p o f o l d o e s n o t h a v e a n y s u c h a c tio n . a n d o m is s i o n o f a d o s e . c o c a in e in h ib its r e u p ta k e o f n o r e p in e p h r in e in to th e p r e s y n a p tic n e r v e . C e n tra l n e r v o u s s y m p to m s o c c u r in le s s th a n 8 % o f p a tie n ts tr e a te d w ith th is g r o u p o f d r u g s . t o r t ic o ll is ( c o m m o n ly c a lle d o c u l o g y r i c c r is is ) . P h e n y le p h r in e m a y b e a n a p p r o p r ia te a g e n t f o r th is s itu a tio n . g a s tr o in te s tin a l p r o k in e tic s . a n d lith iu m a r e s o m e o f th e e tio lo g ic a g e n ts . O x y g e n in th is s itu a tio n m a y n o t b e h e lp f u l a s n o t e n o u g h o f th e b l o o d is f lo w in g th r o u g h th e lu n g s . a s w ill h a p p e n if a lo n g s u r g ic a l p r o c e d u r e w a s s c h e d u le d . A lth o u g h p r o m e th a z in e c a n c a u s e th e s e r e a c tio n s . B u ty r o p h e n o n e s . it is n o t a n a p p r o p r ia te in d u c tio n a g e n t f o r th is p a tie n t. a n d e x c e s s iv e s a liv a tio n . I n tr a v e n o u s d ip h e n h y d r a m in e p r o v id e s e x c e lle n t r e l i e f . G r a n is e tr o n is a 5 . A v a ila b ility o f tr a n s c u ta n e o u s p a tc h h a s h e lp e d d e c r e a s e th is p r o b le m . 79. C. th u s in c r e a s in g th e ir s y s te m ic v a s c u la r r e s is ta n c e a n d v e n o u s r e tu r n to th e h e a rt. A s m o r e b l o o d f lo w s th r o u g h th e lu n g s b e f o r e r e tu r n in g to th e h e a r t. U n fo rtu n a te ly . 77. O th e r a n tih y p e r te n s iv e a g e n ts m e n tio n e d in th e q u e s tio n d o n o t le a d to r e b o u n d h y p e r te n s io n . E p h e d r in e m a y a ls o in c r e a s e th e r e le a s e o f n o r e p in e p h r in e f r o m th e s to r e d s ite a n d c a u s e p r o f o u n d h y p e r te n s io n a n d c a r d ia c d y s r h y th m ia s . d y s p h a g ia . C. p h e n o th ia z in e s . A n a c u te o f e p is o d e o f c y a n o s is in a c h ild w ith h is to r y o f te tr a lo g y o f F a llo t s ig n if ie s m o r e r ig h t .

In c o m p a r is o n to th io p e n ta l it in c r e a s e s th e e x c ita to r y s p ik e s o n th e E E G a n d is a g o o d a g e n t f o r a n e s th e s ia f o r e le c tr o c o n v u ls iv e th e r a p y a n d m a p p in g f o r s e iz u r e f o c u s if E E G a c tiv ity n e e d s to b e f a c ilita te d . T h is is n o t th e o n ly d e te r m in a n t o f th e o n s e t o f a c tio n . G a b a p e n tin ’s r o l e in tr e a tm e n t o f n e u r o p a th ic p a in h a s n o t b e e n lin k e d w ith a n y in te r a c tio n w ith s o d iu m c h a n n e l. It e x e r ts its p r i m a r y a n e s th e tic a n d a n a lg e s ic a c tio n th r o u g h N M D A r e c e p to r . P r o te in . r e d u c in g its d u r a tio n o f a c tio n a t th e s ite o f in je c tio n c o m p a r e d to a lo c a l a n e s th e tic w h ic h c a u s e s v a s o c o n s tr ic tio n . a n d a d r u g w ith a h ig h e r a f f in ity f o r p r o te in w ill la tc h o n to th e s e r e c e p to r s l o n g e r th a n a d r u g w ith le s s a f f in ity f o r p r o te in . T h is p h e n o m e n o n c o u ld p a r tly b e e x p la in e d b y th e f a c t th a t c h r o n ic a d m in is tr a tio n o f k e ta m in e s tim u la te s th e liv e r e n z y m e s th a t m e ta b o liz e it.s o lu b le lo c a l a n e s th e tic s lik e lid o c a in e . lo c a l a n e s th e tic s w ith a p K a f a r th e r f r o m th e p h y s io lo g ic p H h a v e m o r e o f th e d r u g in io n iz e d ( c h a r g e d ) f o r m d e la y in g th e ir o n s e t o f a c tio n . D. 81.7. a n d v e r y little o f th e p a r e n t m o le c u le is f o u n d in th e u r in e . A s it is th e u n c h a r g e d f o r m th a t c r o s s e s th e n e u r o n a l m e m b r a n e . R e p e a te d a d m in is tr a tio n o f k e ta m in e m a y n e c e s s ita te in c r e a s e d d o s e to a c h ie v e th e s a m e e ffe c t. m o r e lip id . 83. A s a r e s u lt. E to m id a te c a n n o t b e u s e d a s a n in f u s io n b e c a u s e o f its s u p p r e s s iv e a c tio n o n th e a d r e n a l g la n d . d e c r e a s in g n e u r o n a l tr a n s m is s io n r e s p o n s ib le f o r c a u s in g p a in . .lin e tr e a tm e n t f o r n e u r o p a th ic p a in . w h ile p K a d e te r m in e s th e o n s e t o f a c tio n . D. A. In s te a d . th o u g h c h l o r o p r o c a i n e h a s a v e r y s h o r t o n s e t o f a c tio n d e s p ite h a v in g a p K a o f 8. G a b a p e n tin h a s b e c o m e a f ir s t. It is n o t s ig n if ic a n tly b o u n d to p la s m a p r o te in s a n d th u s is r e a d ily a v a ila b le f o r d is tr ib u tio n in to th e tis s u e s . 80. P r i m a r y s ite o f m e ta b o lis m o f k e ta m in e is liv e r . it w o u ld b e a n id e a l s e d a tiv e a g e n t f o r p r o c e d u r e th a t n e e d s m o d e r a te s e d a tio n a s it d o e s n o t d e p r e s s r e s p i r a t i o n e v e n w h e n u s e d in in d u c tio n d o s e s .g a t e d c a lc iu m c h a n n e ls w h ic h g e t a c tiv a te d in a n in ju r e d n e r v e .b in d in g o f th e lo c a l a n e s th e tic d e te r m in e s its d u r a tio n o f a c tio n a s th e r e c e p to r s a r e p r o te in s . 82. C. It is a p o te n t c e r e b r a l v a s o c o n s tr ic to r a n d c a u s e s d e c r e a s e in c e r e b r a l m e ta b o lis m a s w e ll a s c e r e b r a l b l o o d flo w . G a b a p e n tin h a s n o t b e e n f o u n d to in te r a c t d ir e c tly w ith N M D A r e c e p to r .b in d in g . A n a d m in is te r e d d o s e o f e to m id a te is a lm o s t c o m p le te ly m e ta b o liz e d b y th e liv e r. T h e p H a t w h ic h th e c h a r g e d a n d u n c h a r g e d f o r m s o f th e d r u g e x is t in e q u a l c o n c e n tr a tio n is p K a . In h ib itio n o f th is c h a n n e l le a d s to d e c r e a s e d in f lu x o f c a lc iu m in to th e n e r v e c e ll. a lth o u g h it is f o u n d to in te r a c t w ith m a n y o th e r r e c e p to r s in th e c e n tr a l n e r v o u s s y s te m . o f th e s e n e u r o l o g i c s y m p to m s . o th e r w is e .s o lu b le lo c a l a n e s th e tic s lik e te tr a c a in e a n d b u p iv a c a in e a r e m o r e p o te n t ( n e e d in g le s s d o s e ) th a n le s s lip id . In tr in s ic p r o p e r t y o f a d r u g to c a u s e v a s o d ila ta tio n c a u s e s th e d r u g to g e t a b s o r b e d in th e s y s te m ic c ir c u la tio n . R e a s o n is th a t th e q u a n tity o f th e d r u g in je c te d is so h ig h w ith c h l o r o p r o c a i n e th a t m o r e o f its m o le c u le s a r e a v a ila b le in its u n c h a r g e d f o r m d e s p ite th e l o w p e r c e n ta g e o f th e d r u g f o u n d in u n c h a r g e d f o r m . L ip id s o lu b ility o f a lo c a l a n e s th e tic is m o s t c lo s e ly r e la te d to its p o te n c y . T h is a c tio n is n o t m e d ia te d th r o u g h G A B A r e c e p to r s a s w o u ld b e e x p e c te d f r o m th e n a m e . it m o d u la te s v o lta g e .

S o r e c o m m e n d a tio n f r o m A S R A is to a v o id p e r f o r m i n g a n e u r a x ia l b lo c k f o r 7 d a y s e v e n if o n ly a s in g le th e r a p e u tic d o s e o f c l o p i d o g r e l w a s u s e d b y th e p a tie n t. it is n o t u s e f u l f o r s e d a tio n o f th e p a tie n ts in th e IC U b e c a u s e o f its a c tio n o n a d r e n a l g la n d s . P r o c a in e is th e o n ly e s te r lo c a l a n e s th e tic a m o n g th e c h o ic e s g iv e n in th is q u e s tio n . 88. N M D A r e c e p to r s h a v e b e e n d o c u m e n te d in th e s p in a l c o r d . th a t is . e x c e p t th a t it c h a n g e s its c h a r a c te r is tic s in th e b o d y a n d b e c o m e s lip id s o lu b le o n e x p o s u r e to p h y s io lo g ic p H . A lth o u g h lid o c a in e h a s b e e n f o u n d to in h ib it N M D A r e c e p to r in s u p r a c lin ic a l le v e ls . U n lik e p r o p o f o l . A lth o u g h in v iv o k e ta m in e h a s b e e n s h o w n to m a in ta in th e s tr o k e v o lu m e . S o th e m e c h a n is m o f its a n a lg e s ic a c tio n m a y b e m o r e c o m p lic a te d th a n s im p le b lo c k a d e o f s o d iu m c h a n n e l. A. E v e n a s in g le d o s e m a y le a d to a p r o l o n g e d d e p r e s s a n t e f f e c t ( 4 .c o u p l e d r e c e p to r s . In v iv o f in d in g is e x p la in e d b y th e a b ility o f k e ta m in e to s tim u la te s y m p a th e tic s y s te m . b u t is m o r e c o m m o n w ith e s te r lo c a l a n e s th e tic s c o m p a r e d w ith a m id e lo c a l a n e s th e tic s . w h ic h is u p to 7 d a y s . It in h ib its 1 1 . a lr e a d y u s in g m a x im u m s y m p a th e tic a c tiv ity to m a in ta in h is o r h e r c a r d ia c o u tp u t. A ll o th e r s a r e a m id e s . a n d w h o m ig h t r e q u i r e a n in ta c t c o r tis o l r e s p o n s e . 87.8 h o u r s ) o n th e a d r e n a l g la n d . T r u e a l l e r g i c r e a c tio n to a lo c a l a n e s th e tic is v e r y r a r e . L iv e r m e ta b o lis m o f e to m id a te is v e r y c o m p le te b u t n o t fa s t e n o u g h th a t th a t a c tio n w ill le a d to a w a k e n in g f r o m a n in d u c tio n d o s e o f th is a g e n t.p r o t e i n . L ik e o th e r in d u c tio n a g e n ts . a n d so it d o e s n o t d e c r e a s e th e d u r a tio n o f a c tio n o f n o n d e p o la r iz i n g n e u r o m u s c u la r . 85. a g g r e g a tio n . k e ta m in e m a in ta in s th e m u s c le to n e th e m o s t. th u s c a u s in g in h ib itio n o f c o n v e r s io n o f c h o le s te r o l to c o r tis o l. C lo p id o g r e l m o d if ie s th e A D P r e c e p to r ir r e v e r s ib ly . C. A lth o u g h p r i m a r y m e c h a n is m o f its a n a lg e s ic a c tio n m a y b e th r o u g h b lo c k a d e o f th e s o d iu m c h a n n e l. P a tie n ts e x p e r ie n c in g s e p s is o r h e m o r r h a g e . A. w h ic h c o u n te r a c ts its m y o c a r d ia l d e p r e s s a n t a c tio n . it is v e r y d is s im ila r in its c h e m ic a l s tr u c tu r e to e to m id a te . . in th a t it is w a te r s o lu b le in a c id ic f o r m a n d w o u ld b e u s e le s s a s a n in d u c tio n a g e n t.h y d r o x y la s e . It r e s e m b le s m id a z o la m in its p h a r m a c o k in e tic s . w o u ld b e a t r i s k if e to m id a te is a d m in is te r e d to th e m . L id o c a in e h a s b e e n in u s e f o r tr e a tin g a m y r i a d o f p a in c o n d itio n s in v o lv in g n e u r o p a th ic p a in . C lo p id o g r e l b in d s to A D P r e c e p to r s o n th e s u r f a c e o f p la te le ts . T h is a c tio n le a d s to in h ib itio n o f a c tiv a tio n .^ . E to m id a te is a c a r b o x y la te d im id a z o le . C lo p id o g r e l m a y c a u s e n e u tr o p e n ia . 86. r e s u ltin g in its in h ib itio n f o r th e lif e tim e o f th e p la te le t. K e ta m in e d o e s n o t d e c r e a s e th e a m p litu d e o f th e c o r tic a l s e n s o r y . a c tiv a tio n o f th is r e c e p to r w o u ld n o t le a d to a n a lg e s ia . th r o m b o tic th r o m b o c y to p e n ic p u r p u r a . a w a k e n in g f r o m a n in d u c tio n d o s e o f e to m id a te is s e c o n d a r y to r e d is tr ib u tio n o f th e d r u g .e v o k e d p o te n tia ls .84. S o it is p r o b a b ly f r o m p r o c a in e . it a c ts o n m a n y o th e r c h a n n e ls in c lu d in g c a lc iu m a n d G . a n d e p id u r a l k e ta m in e d o e s h a v e s o m e a n a lg e s ic a c tio n b u t m u c h le s s th a n m o r p h in e . in v itr o s tu d ie s w ith is o la te d m y o c a r d ia l c e ll s h o w th a t k e ta m in e le a d s to d e c r e a s e in th e f o r c e o f c o n tr a c tio n o f m y o c a r d ia l c e ll. T h is a c tio n o f k e ta m in e c a n g e t u n m a s k e d in a p a tie n t w ith c h r o n ic c o n g e s tiv e h e a r t f a ilu r e . A. O f a ll th e a n e s th e tic s a v a ila b le . a n d h e p a tic d y s f u n c tio n b u t h a s n o t b e e n a s s o c ia te d w ith p a n c y to p e n ia . A s p r o p o f o l is a s u b s titu te d is o p r o p y l p h e n o l. A. a n d d e g r a n u la ti o n o f p la te le ts .b lo c k in g a g e n ts .

D e x m e d e to m id in e d e c r e a s e s s y s te m ic v a s c u la r r e s is ta n c e . It is n o t a s s o c ia te d w ith p r o l o n g e d a c tio n o f n e u r o m u s c u la r . its u s e f o r r e v e r s a l o f m u s c le r e la x a n ts is n o t in d ic a te d . M y o to n ic d y s tr o p h y is th e m o s t c o m m o n f o r m . D. it is p r u d e n t to a v o id u s in g l o n g e r .b lo c k in g a g e n ts . N e o s tig m in e . M a n y p h y s io lo g ic f a c to r s a n d m e d ic a tio n s a r e a s s o c ia te d w ith p o te n tia tio n o f a c tio n o f n e u r o m u s c u la r b lo c k e r s .89. 91. So o n c e tr i g g e r e d . B e lla d o n n a a lk a lo id s f o u n d in th e n a tu r e s o m e tim e s le a d to m a n if e s ta tio n s o f a n tic h o lin e r g ic s y n d r o m e . S u c c in y lc h o lin e c a n c a u s e s e v e r e h y p e r k a le m ia a n d is c o n tr a in d ic a te d in th is c o n d itio n . P h y s o s tig m in e b e in g a t e r tia r y c o m p o u n d is a b le to c r o s s th is b a r r i e r a n d is a b le to a n ta g o n iz e th e c e n tr a l a c tio n s o f th e s e a n tic h o lin e r g ic a g e n ts . N o n d e p o la r iz in g m u s c le r e la x a n ts m a y n o t b e a b le to r e v e r s e th is s p a s m .b lo c k in g a g e n ts . a n d e d r o p h o n iu m h a v e q u a te r n a r y a m m o n iu m i o n in th e ir c h e m ic a l s tr u c tu r e . m u s c le s f a il to r e la x . F o r th a t r e a s o n .in d u c e d r i g i d i t y is n o t w e ll s tu d ie d . a s it is s o m e tim e s u s e d in in te n s iv e c a r e u n it s e ttin g . A s n e o s tig m in e c a n a ls o t r i g g e r m y o to n ic e p is o d e . D. so p r e c a u tio n s n e e d to b e ta k e n to a v o id it d u r in g .a c tin g n o n d e p o la r iz i n g a g e n ts th a t m a y r e q u ir e r e v e r s a l a g e n ts . E lim in a tio n h a lf . Its e ffe c t in o p io id . n o ta b ly a m in o g ly c o s id e s . T h e r e is n o a c c u m u la tio n o f th e d r u g in p a tie n ts w ith r e n a l f a ilu r e . C lo n id in e b e lo n g s to th e s a m e g r o u p o f m e d ic in e s . T h is m e ta b o lis m is so r a p id th a t a c tio n o f r e m if e n ta n il is te r m in a te d w ith o u t th e n e e d f o r r e d is tr ib u tio n o r h e p a tic e x tr a c tio n . M y o to n ia is c h a r a c te r iz e d b y c o n tin u e d in v o lu n ta r y c o n tr a c tio n o f a g r o u p o f m u s c le s . C a lc iu m c h a n n e l b lo c k e r s lik e v e r a p a m il le a d to d e c r e a s e d s a r c o p la s m ic c o n c e n tr a tio n o f c a lc iu m . M a n y a n tib io tic s . C a r b a m a z e p in e w a s o r i g i n a l l y u s e d a s a n tic o n v u ls a n t b u t h a s b e e n f o u n d to b e u s e f u l in m a n y o th e r c o n d itio n s . 92. it s e e m s th a t m a n if e s ta tio n s o f C N S in v o lv e m e n t a r e o b v io u s . R e m if e n ta n il is m e ta b o liz e d b y n o n s p e c if ic e s te r a s e s f o u n d in b l o o d a n d tis s u e s . a n d th a t is o n e o f its m e c h a n is m b y w h ic h it m a y c a u s e a d e c r e a s e in b l o o d p r e s s u r e . b u t c lin d a m y c in is s a f e to u s e a n d h a s n o t b e e n s h o w n to h a v e a n y d e le te r io u s e ffe c t w h e n u s e d c o n c o m ita n tly w ith d r u g s lik e v e c u r o n iu m . b u t if it u s e d f o r l o n g e r tim e . D e x m e d e to m id in e is a n a 2.li f e (6 m in u te s ) is n o t p r o l o n g e d e v e n a fte r a p r o l o n g e d in f u s io n . H y p o th e r m ia c a n t r i g g e r th is c o n d itio n . th e s e d a tiv e a c tio n m a y ta k e a lo n g tim e to d is s ip a te . 10 h o u r s . D e c a y tim e o f th e s e r u m le v e ls o f d e x m e d e to m id in e a fte r a s h o r t d u r a tio n o f in f u s io n is v e r y fa st. w h ic h a c ts c e n tr a lly to in h ib it s y m p a th e tic n e r v o u s s y s te m a c tiv ity . 93. p r o l o n g th e a c tio n s o f th e s e d r u g s . C. w h ic h m a y p o te n tia te th e m u s c le w e a k n e s s a s w e ll as p r o l o n g th e d u r a tio n o f a c tio n o f n e u r o m u s c u la r . m a k in g th e m u n a b le to c r o s s th e b l o o d . H y p o th e r m ia d u r in g c a r d ia c b y p a s s d o e s p r o l o n g its e lim in a tio n tim e u p to 2 0 % . F a c to r s th a t n e e d to b e ta k e n in to c o n s id e r a tio n f o r tr e a tm e n t o f th is c o n d itio n in c lu d e w h e th e r th e r e is C N S in v o lv e m e n t o r n o t. D e x m e d e to m id in e a c tu a lly s o m e tim e s is u s e d to tre a t s p a s m o b s e r v e d in c e r e b r a l p a ls y p a tie n ts .a g o n is t. p y r id o s tig m in e .b r a i n b a r r i e r . f o r e x a m p le . D. 90. In th is c a s e . C.

M e c h a n is m o f th is a c tio n in c lu d e s b a r b itu r a te . w h e r e th is e f f e c t is n o t a s p r e d ic ta b le . 94. . S ig n s a n d s y m p to m s d u r in g a n e s th e s ia m a y in c lu d e f lu s h in g o f h e a d . D e x a m e th a s o n e is n o t in d ic a te d f o r th e a c u te tr e a tm e n t o f b r o n c h o s p a s m . O ld e r a n tic h o lin e s te r a s e a g e n t e d r o p h o n iu m c a u s e s th e c h o lin e s te r a s e a c tiv ity to in c r e a s e in c a r d ia c m u s c a r in i c r e c e p to r s . F in d in g th e b e s t c o m b in a tio n o f th e s e a g e n ts is o f g r e a t im p o r ta n c e to a n a n e s th e s io lo g is t. A s y n th e tic a n a lo g u e : o c tr e o tid e is u s e d m o r e o f te n in c o n te m p o r a r y p r a c tic e . a n d h y p o o r h y p e r te n s io n . w h ile n e o s tig m in e a n d g ly c o p y r r o la te a r e s lo w e r in o n s e t. A d m in is tr a tio n o f a n tic h o lin e s te r a s e a g e n ts to r e v e r s e th e a c tio n o f n o n d e p o la r iz i n g a g e n t a llo w s th e a c e ty lc h o lin e le v e ls to b u ild u p n o t o n ly in n e u r o m u s c u la r ju n c tio n o f th e s k e le ta l m u s c le b u t a ls o a t th e le v e l o f m u s c a r in i c r e c e p to r s . K e ta m in e is n o t in d ic a te d in th is c o n d itio n . M a n y c a r c in o id tu m o r s c o n ta in s o m a to s ta tin r e c e p to r s : a g a s tr o in te s tin a l r e g u l a t o r y p e p tid e th a t r e d u c e s th e p r o d u c tio n a n d r e le a s e o f g a s tr o p a n c r e a tic h o r m o n e . 96.in d u c e d d e p r e s s io n o f th e m e d u lla r y v a s o m o t o r c e n te r a n d d e c r e a s e d C N S o u tf lo w f r o m th e C N S . a s g ly c o p y r r o la te w ill ta k e m u c h l o n g e r a n d m a y n o t r e v e r s e a ll o f th e c h o lin e r g ic e f f e c t p r o d u c e d b y e d r o p h o n iu m . C a r c in o i d s y n d r o m e c a n b e p r e c ip ita te d in th e o p e r a tin g r o o m w h e n th e c a r c in o id tu m o r is m a n ip u la te d b y th e s u r g e o n . T h is m a y c a u s e c a ta s tr o p h ic d r o p in b l o o d p r e s s u r e . It is r e c o m m e n d e d to b e s ta r te d 2 w e e k s p r i o r to th e s c h e d u le d s u r g e r y a n d c o n tin u e d in th e p o s to p e r a tiv e p e r io d . A n o th e r f a c to r to c o n s id e r is th e o n s e t o f a c tio n o f th e s e d r u g s . S o m a to s ta tin in f u s io n c a n a v o id a n d tr e a t th e m a n if e s ta tio n o f th is s y n d r o m e in th e p e r io p e r a tiv e p e r io d . a s its o n s e t o f a c tio n m e a s u r e s in h o u r s a n d n o t in m in u te s .m e d ia te d re sp o n se s. T h io p e n ta l d o e s h a v e n e g a tiv e i n o tr o p ic e ffe c ts o n th e h e a r t. D. C a u s e is th e r e le a s e o f m a s s iv e a m o u n t o f h o r m o n e s m a d e b y th e c a r c in o id tu m o r in to th e s y s te m ic c ir c u la tio n . a n d u p p e r th o r a x .in d u c e d b r a d y c a r d i a is e f f e c tiv e ly p r e v e n te d b y a d m in is tr a tio n o f a n tic h o lin e r g ic a g e n t c o m p a r e d w ith e d r o p h o n iu m . b r o n c h o s p a s m . M e ta b o lis m o f th io p e n ta l b y th e liv e r is s lo w a n d d o e s n o t c o n tr ib u te a p p r e c ia b ly to th e te r m in a tio n o f e f f e c t o f th is d r u g . if g ly c o p y r r o la te is in je c te d to c o u n te r a c t th e c h o lin e r g ic r e s p o n s e in d u c e d b y e d r o p h o n iu m . C. th e c h a n c e o f d e v e lo p m e n t o f b r a d y c a r d i a is g r e a te s t w ith th is c o m b in a tio n . T h is p a tie n t s e e m s to b e in h y p o v o le m ic s h o c k . w h ic h th is p a tie n t m a y n o t b e a b le to to le r a te . D e s p ite th a t f in d in g . T h a t le a d s to th e p r o b le m o f b r a d y c a r d i a if n o t e f f e c tiv e ly c o u n te r b a la n c e d b y a d m in is tr a tio n o f a n a n tic h o lin e r g ic a g e n t. n e c k . B o d y ’s r e s p o n s e to s u c h a s ta te is to r e d i r e c t th e in tr a v a s c u la r v o lu m e to v ita l o r g a n s lik e b r a i n a n d h e a r t b y c a u s in g p e r ip h e r a l v a s o c o n s tr ic tio n th r o u g h a c tiv a tio n o f th e s y m p a th e tic s y s te m . A s a r e s u lt. a n y a n e s th e tic . 95. T h io p e n ta l is a k n o w n v a s o d ila to r . n e o s tig m in e . S e v o f lu r a n e is h e lp f u l to tr e a t b r o n c h o s p a s m a c u te ly b u t is n o t s p e c if ic f o r th is c o n d itio n a n d m a y n o t b e p o te n t e n o u g h to tr e a t b r o n c h o s p a s m in d u c e d b y th e s e h o r m o n e s . D. B e s t tr e a tm e n t to r e lie v e th e s p a s m is to in je c t lo c a l a n e s th e tic in to th e m u s c le .a c tin g . a s it m a y in c r e a s e th e s y m p a th e tic n e r v o u s s y s te m d is c h a r g e a n d w o r s e n th e s itu a tio n . T h is v a s o d ila ta tio n w ill c a u s e p e r ip h e r a l p o o lin g o f b lo o d . a lth o u g h th is e f f e c t is n o r m a l l y m a s k e d b y b a r o r e c e p to r . w h ile n e o s tig m in e w a s f o u n d to h a v e a d d itio n a l d ir e c t a c tio n o n th e s e c a r d ia c r e c e p to r s . A tr o p in e a n d e d r o p h o n iu m a r e v e r y fa s t.

P a n c u r o n iu m a n d a n o ld e r n o n d e p o la r iz i n g m u s c le . P r o p o f o l in f u s io n s y n d r o m e w a s f i r s t d e s c r ib e d in p e d ia tr ic in te n s iv e c a r e u n its . 99. d o n o r s in o a t r ia l (S A ) n o d e is s e v e r e d o f its a u to n o m ic n e r v o u s s y s te m c o n n e c tio n s .h e a r t b lo c k is v e r y c o m m o n . T o s o m e e x te n t. In c a s e o f r e g u r g i t a n t le s io n s .r e la x a n t g a lla m in e w e r e u s e d f o r th is p u r p o s e .97. T h is c o u p lin g e f f e c t is p r e s e r v e d d u r in g a n e s th e s ia . C a r o tid b a r o r e c e p t o r s a n d [3 a d r e n e r g i c r e c e p to r a r e n o t in v o lv e d in in d u c tio n o f ta c h y c a r d ia n o tic e d a fte r a d m in is tr a tio n o f p a n c u r o n iu m . H ig h . D if f e r e n t s u r g ic a l te c h n iq u e s a r e u s e d to s u tu r e th e d o n o r h e a r t to th e c u f f o f th e r e c ip ie n t h e a r t. E a r li e s t s ig n o f s y n d r o m e is m e ta b o lic a c id o s is b e c a u s e o f im p a ir m e n t o x id a tiv e p h o s p h o r y la tio n in th e m ito c h o n d r ia . D. th e ir s tim u la tio n w ith p h e n y le p h r in e is n o t a s s o c ia te d w ith c h r o n o t r o p i c e ffe c ts . O n th e o th e r h a n d . E f f e c t o f p a n c u r o n iu m o n th e h e a r t r a te is e lic ite d a t th e le v e l o f s in o a t r ia l n o d e b y b lo c k a d e o f th e m u s c a r in ic r e c e p to r s . A t 1. it is a c e r e b r a l v a s o d il a to r w ith p o te n tia l o f in c r e a s in g th e c e r e b r a l b l o o d f lo w a n d in tr a c r a n ia l p r e s s u r e . a ll o f th e d r u g s th a t u s e S A n o d e a n d n o r m a l c o n d u c tio n s y s te m o f th e h e a r t to p r o d u c e th e ir c a r d ia c e ffe c ts f a il to p r o d u c e th e ir e ffe c ts in a tr a n s p la n te d h e a rt. e f f e c t o f fe n ta n y l th a t c a u s e d b r a d y c a r d i a w a s m o r e th r o u g h c e n tr a l n u c le i o f th e v a g u s n e r v e . In a n y c a s e . D. a n d f r e e m y o g l o b i n p r e c ip ita te s in th e r e n a l tu b u le s . A s a r e s u lt. w h ic h h a s m a n y . w h ic h m a n if e s ts e a r ly o n a s b r a d y c a r d ia . in e x c e s s o f 8 0 % . P a tie n ts w ith v a lv u la r h e a r t d is e a s e a r e s o m e tim e s e x tr e m e ly s e n s itiv e to a b r u p t c h a n g e s in th e h e a r t ra te . th e m o r t a lit y r a te is e x tr e m e ly h ig h . b u t q u ite a f e w a d u lt c a s e s h a v e b e e n r e p o r t e d n o w . 100. G e n e r a lly . In o r d e r to c o u n te r a c t th is b r a d y c a r d i a a c tio n o f th e fe n ta n y l. th e o v e r a ll e f f e c t o f d e s f lu r a n e is c e r e b r a l v a s o d ila ta tio n a n d in c r e a s e d b l o o d flo w . th is m a y b e d e s ir a b le in a p a tie n t w ith s te n o tic v a lv u la r le s io n .5 M A C .s p e c if ic a c tio n o n c e r e b r a l v a s c u la tu r e . T h is v a r ia tio n is d if f e r e n t f o r d if f e r e n t in h a la tio n a l a g e n ts a n d a ls o a t d if f e r e n t d o s e s o f th e s a m e a g e n t. a n a e r o b ic m e ta b o lis m . A lth o u g h oq r e c e p to r s a r e f o u n d in th e h e a r t. I s o p r o te r e n o l b e in g a d ir e c t P! s tim u la n t is th e d r u g o f c h o ic e to tr e a t a n e p is o d e o f b r a d y c a r d i a u n d e r th e s e c ir c u m s ta n c e s . c e r e b r a l b l o o d f lo w is r e la te d to c e r e b r a l m e ta b o lic r a te w ith f a c to r s th a t d e c r e a s e c e r e b r a l m e ta b o lic r a te d e c r e a s e th e c e r e b r a l b l o o d flo w . 98. A lth o u g h n itr o u s o x id e h a s b e e n s h o w n to h a v e s p e c ie s . C. a n d a c c u m u la tio n o f la c tic a c id . s o m e a n e s th e s io lo g is ts lik e to u s e a m u s c le r e la x a n t th a t c a u s e s ta c h y c a r d ia . In a n e s ta b lis h e d c a s e . R h a b d o m y o ly s is is a h a llm a r k o f th is c o n d itio n . C. C a r d ia c d y s f u n c tio n is a ls o a n e a r ly s ig n .d o s e fe n ta n y l h a s b e e n s h o w n to c a u s e b r a d y c a r d i a th r o u g h its e f f e c t o n th e v a g u s n e r v e . th is m a y le a d to c r itic a l d e c r e a s e in c a r d ia c o u tp u t. it is c le a r th a t in h u m a n s . H ig h e r c u m u la tiv e d o s e o f p r o p o f o l o v e r a r e la tiv e ly l o n g e r p e r i o d o f tim e s e e m s to b e a s s o c ia te d w ith h ig h e r in c id e n c e o f th is c o n d itio n . a n d r i g h t . le a d in g to k id n e y f a ilu r e . P h e n y to in is a n a n tic o n v u ls a n t. b u t th e d e g r e e o f th e c o u p lin g m a y b e a lte r e d b y a n e s th e tic a g e n ts w h e r e in h a la tio n a l a g e n ts h a v e r e la tiv e ly h ig h e r c e r e b r a l b l o o d f lo w f o r a n y d e g r e e o f c e r e b r a l m e ta b o lic ra te . T h is h a s le d to a d r o p in th e p o p u la r ity o f th is d r u g in th e p e d ia tr ic in te n s iv e c a r e s e ttin g . O n ly d r u g s th a t a r e a b le to d ir e c d y s tim u la te th e a d r e n e r g i c r e c e p to r s f o u n d in th e m y o c a r d iu m a r e u s e f u l in tr e a tin g b r a d y c a r d i a in a tr a n s p la n te d h e a r t.

A n a p h y la c tic r e a c tio n d u r in g a n e s th e s ia is e s tim a te d to o c c u r b e tw e e n 1 in 5 . L a te x . P e n to th a l d e c r e a s e s c e r e b r a l m e ta b o lic r a te a n d is k n o w n to p r e s e r v e th e n o r m a l c o u p lin g b e tw e e n th e m e ta b o lis m a n d b l o o d flo w . a n tib io tic s . 101.0 0 0 a n d 1 in 2 5 .b l o c k in g d r u g s s e e m to b e th e m o s t c o m m o n a g e n ts c a u s in g th is r e a c tio n . . N e u r o m u s c u la r . A. c e n tr a l n e r v o u s s y s te m e ffe c ts b u t h a s n o t b e e n s h o w n to b e a c e r e b r a l v a s o d ila to r . O p io id s e x tr e m e ly r a r e l y c a u s e a n a p h y la c tic r e a c tio n s . In c id e n c e is fa r to o lo w to d e te r m in e th e r e la tiv e f r e q u e n c y o f o c c u r r e n c e w ith in d iv id u a l n e u r o m u s c u la r b lo c k e r .0 0 0 c a s e s . S o a d m in is tr a tio n o f th is a g e n t w ill d e c r e a s e th e c e r e b r a l b l o o d flo w . a n d in d u c tio n a g e n ts a r e m u c h le s s c o m m o n e tio lo g ic a g e n ts in a n e s th e s ia .

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Supraspinous ligament D. T4 D. the epidural needle penetrates all the following anatomical layers. Ligamentum flavum B. Amniotic fluid embolus 3. Contraindication(s) for neuraxial blockade include(s) A. During epidural placement using a midline approach. At what level do you anticipate the block will reach to provide adequate pain control? A. T2 B. A spinal neuraxial anesthetic was given 20 minutes earlier to a 28-year-old G3P2 parturient scheduled for repeat cesarean section. You have just administered a bolus of 2% lidocaine (25 mL) through an epidural catheter that has been working well for labor analgesia in preparation for emergency cesarean section for fetal distress in an otherwise-healthy 35-year-old woman. T3 C. The most likely cause is A. Existing severe hypotension D. Intraspinous ligament . Anaphylactic reaction to lidocaine B. Severe bleeding tendency C. Shortly after administration of lidocaine. Alcohol swab exam revealed that she has lost temperature sensation up to T2 level. Subarachnoid membrane C. except A. and you notice that her heart rate has decreased from 99 to 38 bpm.Spinal and Epidural Anesthesia Thomas Halaszynski 1. Pneumothorax C. the patient complains of nausea. All of the above 4. Epidural level is higher than T4 D. Severe aortic stenosis B. T5 2.

The anterior spinal artery supplies the anterior two-thirds of the spinal cord. epinephrine can A. Lidocaine injection (3 mL of 1.5%) intravascularly will induce local anesthetic toxicity such as perioral numbness B. Adult spinal cord ends at L2 B. Intrathecal injection of lidocaine can cause a low-level spinal anesthesia with some degree of motor block D. Blood supply to the spinal cord is from a single anterior spinal artery and two posterior spinal arteries B. except A. Leads to earlier return of GI function C. Nerve roots C. Major benefits of a neuraxial block in a Whipple procedure include all the following. Decrease the peak plasma levels of local anesthetic concentration D. The dural sac and subarachnoid space in adults end at S1 D. Intrathecal injection of epinephrine will result in a high spinal C. except A. Anterior spinal artery originates from the vertebral artery D. Reduces the risk of pulmonary embolism or deep-vein thrombosis 6. Decreases the risk of urinary retention D. All of above . Improve the quality of blockade C. As an adjuvant in epidural anesthesia. Spinal cord B. 5. Intravascular injection of epinephrine (typically 15 |ig/3 mL) can cause hypertension more than tachycardia 10. Epidural space D. Blood supply to the human spinal cord includes all of the following. Spinal cord in children ends at L3 C. The dural sac and subarachnoid space in children end at S2 7. Decreases the incidence of atelectasis B. Subarachnoid space 9. Lidocaine and epinephrine are commonly used together when testing epidural anesthesia because A. Prolong duration of blockade B. The principal site of action of local anesthetics placed into the epidural space is the A. and the posterior spinal arteries supply the posterior one-third C. Posterior spinal artery originates from the posterior cerebral artery 8. The correct statement for human neuraxial anatomy is A.

Patient position at the time and immediately following injection D. Factors that can affect the level of an epidural anesthetic include A. Patient weight 15. Radiculopathy B.5% dextrose was injected intrathecally after being mixed with CSF.5 mL of 5% preservative-free lidocaine in 7. Factors influencing the level of spinal anesthesia achieved include all of the following. amount of local anesthetic injected.11. B and C 12. Complications from neuraxial blockade may include all of the following. High spinal anesthesia 17. Patient age. Arachnoiditis D. amount of local anesthetic injected. Neuraxial block complications using local anesthetics alone include all of the following. Bupivacaine 13. Urinary retention C. except A. . except A. patient position D. Drug dose B. Addition of sodium bicarbonate to epidural local anesthetics may accelerate the onset of blockade with all of the local anesthetics. Chloroprocaine C. Patient age C. A total of 1. Volume of anesthetic solution injected D. except A. Patient weight. amount of local anesthetic injected. Patient gender 14. patient position B. Postoperative cognitive dysfunction D. Needle direction C. except A. Constipation 16. Baricity of anesthetic solution B. All of the following factors may influence the spinal level achieved during spinal anesthesia. Anterior spinal artery syndrome C. patient position C. Post-dural puncture headache B. Spinal anesthesia was performed on a 25-year-old healthy male for ureter stent placement. except A. Lidocaine B. There was evidence of free CSF flow before and after injection. Mepivacaine D. Patient height.

P reg n an cy B. Y o u a r e c o n s u lte d a s to w h e n a p a tie n t w o u ld b e a n a p p r o p r ia te c a n d id a te f o r a n e u r a x ia l b lo c k f o ll o w i n g a d m in is tr a tio n o f th e f o ll o w i n g a n tic o a g u la n t m e d ic a tio n s ( p a tie n t d o e s n o t h a v e a n y o th e r c o a g u lo p a th ie s . A th o r a c ic e p id u r a l a n e s th e s ia w a s p e r f o r m e d u s in g a te s t d o s e o f 1 . R a d ic u lo p a th y 18. T h e m o s t lik e ly d ia g n o s is is A. Y o u p e r f o r m e d a n e p id u r a l a n e s th e tic f o r a n e le c tiv e o p e n . S p in a l a b s c e s s C. F e m a le g e n d e r 21. F o u r h o u r s a fte r e p id u r a l p la c e m e n t 20. a n d d o e s n o t ta k e o th e r m e d ic a tio n s th a t c o u ld in f lu e n c e c o a g u la tio n ) . L a s t d o s e o f c l o p i d o g r e l (P la v ix ) th is m o r n i n g C. E ld e r ly D.5 % lid o c a in e w ith 1 :2 0 0 .y e a r . T h e s u r g e r y w a s p e r f o r m e d in th e lith o to m y p o s itio n a n d w a s u n e v e n tf u l. e x c e p t A. D e x m e d e to m id in e D. L a s t d o s e o f e p tifib a tid e ( I n te g r ilin ) 12 h o u r s a g o 19. A h ig h e r . O n e h o u r a fte r e p id u r a l p la c e m e n t C.th a n . Y o u a r e a s k e d to a d v is e th e s u r g e o n w h e n it w o u ld b e c o n s id e r e d s a f e to a d m in is te r in tr a o p e r a tiv e in tr a v e n o u s h e p a r in : A.a n e s th e s ia c a r e u n it. T r a n s ie n t n e u r o l o g i c a l s y m p to m s D. C o m m o n ly u s e d s p in a l a n e s th e s ia a d ju v a n ts in c lu d e a ll th e f o ll o w i n g . A s c ite s C.0 0 0 e p in e p h r in e in je c te d th r o u g h th e e p id u r a l T u o h y n e e d le th a t r e s u lte d in n o e v id e n c e o f a d v e r s e s e q u e la e . N o t a t a ll B. S p in a l h e m a to m a B. M o r p h in e B. T w o h o u r s a fte r e p id u r a l p la c e m e n t D. L a s t d o s e o f tic lo p id in e (T ic lid ) 7 d a y s a g o B. L a s t d o s e o f a b c ix im a b ( R e o P r o ) 2 4 h o u r s a g o D. C lo n id in e C.o ld f e m a le w ith o v a r ia n c a n c e r is s c h e d u le d f o r to ta l a b d o m in a l h y s te r e c to m y /b ila te r a l s a lp in g o o o p h o r e c to m y a n d tu m o r d e b u lk in g . T h e m o s t c o r r e c t s ta te m e n t is A.a b d o m in a l a n e u r y s m r e p a ir . e x c e p t A. A n e u r o e x a m w a s n e g a tiv e f o r s e n s o r y a n d m o to r d e fic its . A 7 5 . b u t th e p a tie n t c o m p la in e d o f s e v e r e b u tto c k p a in in th e p o s t.e x p e c te d s p in a l le v e l a c h ie v e d o r g r e a te r d e r m a to m a l s p r e a d o f lo c a l a n e s th e tic c a n b e a s s o c ia te d w ith a ll o f th e f o ll o w i n g c lin ic a l s itu a tio n s . A n . E p h e d r in e 22.

The most likely diagnosis is A. and feeling faint. epidural catheter was then threaded through the needle followed by evidence of negative aspiration through the catheter. High epidural anesthesia C. You quickly administer a total of 20 mL 0. 5 mL B. A caudal anesthesia catheter should be positioned without penetrating the sacrococcygeal ligament D. tinnitus. the patient complains of shortness of breath. 20 mL D. Support the airway with 100% oxygen C.5% bupivacaine was administered through the epidural catheter. but still able to move all of her extremities. Administer an intralipid bolus and continuous infusion 24. You just placed a thoracic epidural in a morbidly obese female (5’1” and 350 lb). 10 mL C. You have just placed a lumbar epidural for labor analgesia at L3-L4 interspace in a 34-year-old G2P1 woman of 39 weeks’ gestation. Her HR has decreased from a baseline of 98 to 41 bpm. except A. Local anesthetic systemic toxicity (LAST) B. and her systolic blood pressure has decreased from a baseline of 140s to 70s mm Hg. The younger the child. The correct statement regarding caudal anesthesia is A.5% bupivacaine through the epidural catheter. Total spinal anesthesia D. the less likely you are to experience an intrathecal injection 26. bilateral arm weakness. The patient maintained spontaneous breathing throughout with an oxygen saturation (Spo2) of 95%. 30 mL 25. Administer intravenous epinephrine according to ACLS protocols D. Caudal anesthesia is essentially sacral epidural anesthesia B. Anaphylactic reaction 23. A total of 10 mL 0. As you reposition the patient from the sitting to the supine position. The minimum amount of 2% lidocaine you would need to administer through the epidural catheter in order to achieve a T4 level is A. All of the following local anesthetic systemic toxicity (LAST) treatment measures should be performed when caring for a patient who may be experiencing toxicity. The most likely cause is . and nausea. you are called for an emergency cesarean section on the woman. the patient became agitated and complained of lightheadedness. Two hours later. The patient is 6-feet tall and weighs 300 pounds. Her BP decreased from 150/70 to 100/45 mm Hg and her HR decreased from 85 to 55 bpm. Thirty seconds later. Stop epidural medication administration B. Caudal anesthesia can only be performed in pediatric population C.

and increased fluid intake. During performance of lumbar epidural anesthesia for labor analgesia. Epinephrine 29. Phrenic nerve palsy when the neuraxial level reaches T3-T5 B. Atropine C. The CSF study proved negative for meningitis. Bed rest B. Patient is experiencing an anxiety attack C. Accidental intravascular injection of local anesthetic B. Repeat the CSF study as one set of negative results is not definitive B. described as constant. nonsteroidal anti­ inflammatory drugs. Medullary hypoperfusion D. The ER physician also indicated that the patient presented to the ER 2 days prior with fever. Congestive heart failure 28. The next method of treatment you would suggest is A. Recommend performing an epidural blood patch D. A high epidural block D. you experience free- flowing cerebrospinal fluid (CSF) from the advancing 17G Tuohy epidural needle. In the situation of a high spinal anesthetic. Anaphylactic reaction to local anesthetic or latex 27. along with diplopia. caffeine. Recommend opioids for treatment of the headache C. which of the following drug is pharmacodynamically considered the least useful in controlling hypotension A. The epidural needle is removed and a second attempt is successfully performed with an epidural catheter placed at a different level. Increase caffeine intake D. Which of the following you would not recommend for the patient to practice in the next 72 hours? A. Ephedrine B. Fluid restriction C. but now the patient has returned to the ER with complaints of a severe headache that has failed therapies of bed rest. Local anesthetic systemic toxicity C. The most likely reason for dyspnea in a patient experiencing the effects of a high neuraxial blockade is A. chills. A. You are consulted by an emergency room (ER) physician to evaluate a patient experiencing a severe and bilateral retro-orbital headache. Phenylephrine D. Continue with daily stool softener 30. Continue with conservative therapy as it will eventually prevail . and photophobia when a diagnostic lumbar puncture was performed with a 20G needle.

L 5 le v e l w ith 3 m L o f 5 % lid o c a in e . S u r g ic a l c o m p lic a tio n . D e r m a to m e le v e l o f a n e s th e s ia a c h ie v e d w ith a s p in a l a n e s th e tic is o f te n m o r e p r e d ic ta b le th a n f o ll o w i n g a n e p id u r a l b lo c k a d e B. I n c o r r e c t s ta te m e n t r e g a r d i n g n e u r a x ia l b lo c k a d e is A. B ic e p s f e m o r is w e a k n e s s 33. Y o u a r e c a lle d to s e e a 7 6 .L 4 lu m b a r e p id u r a l p la c e d 3 d a y s p r i o r f o r p o s to p e r a tiv e a n a lg e s ia f o r a c o le c to m y . y o u s u s p e c t a p o te n tia l in ju r y to th e c o n u s m e d u lla r is . T h o r a c i c e p id u r a l a n e s th e s ia h a s a n in c r e a s e d r i s k o f u r i n a r y r e te n tio n c o m p a r e d to lu m b a r e p id u r a l a n e s th e s ia w h e n th e s a m e v o lu m e o f lo c a l a n e s th e tic is a d m in is te r e d 32.L 5 le v e l) w ith e v id e n c e o f p o s itiv e b l o o d a s p ir a tio n . U r in a r y in c o n tin e n c e B. T h e e p id u r a l p la c e m e n t w a s tr a u m a tic o n th e f i r s t a tte m p t (a t L 4 . L o c a l a n e s th e tic s a d m in is te r e d d u r in g e p id u r a l a n e s th e s ia a r e ty p ic a lly m o r e v o lu m e - d e p e n d e n t. c o n s u lt o r th o p e d ic s D. S a d d le a n e s th e s ia C. W h ic h o f th e f o ll o w i n g s y m p to m s is least lik e ly to b e a s s o c ia te d w ith c a u d a e q u in a s y n d r o m e ? A.y e a r . T h e m o s t lik e ly d ia g n o s is a n d o p tim a l m a n a g e m e n t is A. S p in a l a n e s th e s ia c a n m o r e r a p id ly a n d c o n s is te n tly p r o d u c e d e n s e r m o to r b lo c k a d e th a n e p id u r a l a n e s th e s ia C.d e p e n d e n t D. Q u a d r ic e p s w e a k n e s s D. a n d d u r in g s p in a l a n e s th e s ia a r e m o r e c o n c e n tr a tio n . F o llo w in g p e r f o r m a n c e o f s p in a l a n e s th e s ia a t th e L 4 . B r e a k th r o u g h p a in in a p a tie n t w h o is c o n f u s e d .o ld f e m a le w h o h a d a L 3 . c o n s u lt n e u r o l o g y f o r s u g g e s tio n s . T h e p a tie n t is n o w c o m p la in in g o f n e w o n s e t b a c k p a in w ith r a d ia tio n to th e r i g h t lo w e r e x tr e m ity a n d r i g h t k n e e w e a k n e s s th a t w a s c o n f ir m e d b y p h y s ic a l e x a m . tr e a t w ith a d d itio n a l p a in m e d ic a tio n s B. S ta t M R I o f th e b a c k to r u le o u t n e u r a x ia l h e m a to m a C. S y m p to m a tic s p in a l s te n o s is .31.

N e u r a x ia l b lo c k s a r e a s s o c ia te d w ith a s y m p a th e c to m y a n d c a n th e r e f o r e w o r s e n e x is tin g h y p o te n s io n a n d h y p o v o le m ia .r i s k p a tie n t p o p u la tio n s . th e r i s k o f b le e d in g is s ig n if ic a n tly h ig h e r in p a tie n ts w ith a k n o w n c o a g u lo p a th y . T o p e r f o r m a s p in a l a n e s th e s ia . 5. a n d r e d u c e c o n d itio n s f o r a h y p e r c o a g u la tio n s ta te p e r io p e r a tiv e ly . In s p in a l a n d e p id u r a l a n e s th e s ia . C.th ir d . N e u r a x ia l b lo c k is a g r e a t a lte r n a tiv e to g e n e r a l a n e s th e s ia f o r m a n y s u r g ic a l p r o c e d u r e s b e lo w th e d ia p h r a g m a n d a n e x c e lle n t c h o ic e f o r p o s to p e r a tiv e p a in c o n tr o l. d if f e r e n tia l b lo c k a d e is f r e q u e n tly r e p o r te d to o b s e r v e th e “ tw o s e g m e n ts r u l e . 2. N e u r a x ia l b lo c k s in u p p e r a b d o m in a l a n d th o r a c ic p r o c e d u r e s o f f e r a d v a n ta g e s o f d e c r e a s e d p u lm o n a r y a n d c a r d ia c c o m p lic a tio n s in h ig h . a n x ie ty o n p h y s ic a l e x a m a n d r e p o r t s y m p to m s s u c h a s n a u s e a . a n d th e p o s t e r i o r s p in a l a r te r y a r is e s f r o m th e p o s t e r i o r i n f e r i o r c e r e b e lla r a rte ry . p r o m o t e p e r is ta ls is . a n d th e p o s te r io r s p in a l a r te r ie s s u p p ly th e p o s te r io r o n e . B. a n d lig a m e n t fla v u m . H o w e v e r. A lth o u g h s p in a l/e p id u r a l h e m a to m a is r a r e y e t p o s s ib le . s u b c u ta n e o u s tis s u e . h y p o te n s io n . CHAPTER 7 ANSWERS 1. 4. A l a r g e lo c a l a n e s th e tic b o lu s to a p a r tu r ie n t w ith a n a n tic ip a te d e p id u r a l s p a c e r e d u c e d in s iz e s e c o n d a r y to e n g o r g e d e p id u r a l v e in s a n d e n la r g e d u te r u s c a n c a u s e a h ig h e r le v e l o f e p id u r a l b lo c k a d e th a n a n tic ip a te d . 3. in tr a s p in o u s lig a m e n t. v o m itin g . H y p o te n s io n in c o m b in a tio n w ith a o r tic a n d /o r m itr a l v a lv e s te n o s is m a y n o t b e v e r y w e ll to le r a te d . C. T h e a n te r io r s p in a l a r te r y is b r a n c h e d f r o m th e v e r te b r a l a rte ry . a n d a r o u n d L 3 in c h ild r e n . If th e b lo c k le v e l r e a c h e s h ig h e r th a n T 4 a n d in f lu e n c e s T 1 - T 4 ( c a r d ia c a c c e le r a to r f ib e r s ) . th e n e e d le g o e s d e e p e r to p e n e tr a te th e d u r a a n d f r e q u e n tly th e s u b a r a c h n o id m e m b r a n e . u r i n a r y r e te n tio n is o n e o f th e p o te n tia l m a jo r s id e e ffe c ts a s s o c ia te d w ith n e u r a x ia l b lo c k a d e . th e r e a r e c o n d itio n s w h e r e n e u r a x ia l b lo c k n e e d s to b e u s e d w ith c a u tio n .th ir d s o f th e s p in a l c o r d . T o p e r f o r m a n e p id u r a l b lo c k . in c lu d in g s k in . T h e d u r a l s a c a n d s u b a r a c h n o id s p a c e s e n d a t S2 in a d u lts a n d S 3 in c h ild r e n . a n d h e a d a c h e .” n a m e ly . In th is s p in a l b lo c k . D. T h e s p in a l c o r d ty p ic a lly e n d s a r o u n d L 1 in a d u lts . 6. H o w e v e r. a n d e v e n p a r e s th e s ia in th e u p p e r e x tr e m itie s . a lc o h o l s w a b te s te d th e le v e l o f s e n s o r y /s y m p a th e tic b lo c k a d e . D. B. C. a n d s e n s o r y b lo c k is tw o s e g m e n ts h ig h e r th a n m o to r b lo c k . . 7. p a tie n ts m a y h a v e b r a d y c a r d ia . T h is is th e r e a s o n w h y n e u r a x ia l b lo c k s a r e p e r f o r m e d b e lo w th e s e le v e ls a n d c a r r y a lo w e r r i s k o f d ir e c t s p in a l c o r d in ju r y . B lo o d s u p p ly to th e s p in a l c o r d is b y o n e a n te r io r s p in a l a r te r y a n d tw o p o s te r io r s p in a l a r te r ie s . th e n e e d le p a s s e s th r o u g h s e v e r a l la y e r s . T h e a n te r io r s p in a l a r te r y s u p p lie s th e a n te r io r tw o . s y m p a th e tic b lo c k is tw o s e g m e n ts h ig h e r th a n s e n s o r y b lo c k . s u p r a s p in o u s lig a m e n t.

10.5 % lid o c a in e w ith 1 :2 0 0 . I n tr a v a s c u la r in je c tio n o f e p in e p h r in e (1 5 |ig ) c a n r e s u lt in a tr a n s ie n t in c r e a s e in h e a r t r a te o f 2 0 % o r h ig h e r . It is c u r r e n tly b e lie v e d th a t b o d y w e ig h t a lo n e d o e s n o t in f lu e n c e th e le v e l o f a n e p id u r a l b lo c k ( a lth o u g h e x tr e m e o b e s ity m a y ). a r a c h n o id itis . d e la y s lo c a l a n e s th e tic in tr a v a s c u la r a b s o r p tio n . d r u g d o s e u s e d . 13. B. p a tie n t h e ig h t. s o d iu m b ic a r b o n a te is n o t u s e d w ith b u p iv a c a in e a s it c a n p re c ip ita te in s o lu tio n s o f a p H a b o v e 6. p a tie n t a g e a n d s p in e a n a to m y . A d d itio n a lly . M a jo r f a c to r s in f lu e n c in g th e le v e l o f s p in a l a n e s th e s ia in c lu d e s b a r ic ity o f lo c a l a n e s th e tic s o lu tio n . h ig h /to ta l s p in a l a n e s th e s ia . p a tie n t p o s itio n im m e d ia te ly f o ll o w i n g s p in a l b lo c k p la c e m e n t. p H o f th e C SF. e p id u r a l h e m a to m a . p o s t . p a r a p le g ia . a n d d e c r e a s e s p e a k p la s m a lo c a l a n e s th e tic c o n c e n tr a tio n ( s ) .8. n e e d le o r i f i c e d ir e c tio n . c a r d ia c a r r e s t. r a d ic u lo p a th y . P o te n tia l c o m p lic a tio n s o f n e u r a x ia l b lo c k a d e c a n b e d iv e r s e a n d r a n g e f r o m d e a th .8. d r u g v o lu m e u s e d . p a tie n t h e ig h t. n e e d le o r i f i c e d ir e c tio n . P a tie n t h e ig h t ( v e r te b r a l le v e ls c o v e r e d d e c r e a s e w ith h e ig h t) a n d a g e ( v e r te b r a l le v e ls c o v e r e d in c r e a s e w ith a g e ) a lo n g w ith lo c a l a n e s th e tic v o lu m e (a b o u t 1 to 2 m L lo c a l a n e s th e tic m e d ic a tio n p e r s e g m e n t) a n d p a tie n t p o s itio n ( th e o r y o f g r a v ity ) c a n p la y s ig n if ic a n t r o le s . D. e p id u r a l a b s c e s s . a n te r io r s p in a l a r te r y s y n d r o m e .0 0 0 e p in e p h r in e is c o m m o n ly u s e d w h e n te s tin g f o r e p id u r a l a n e s th e s ia to r u le o u t in tr a th e c a l ( lid o c a in e c a n r e s u lt in s p in a l b lo c k a d e ) a n d /o r in tr a v a s c u la r in je c tio n . D. 11. e p in e p h r in e in th e d o s e o f 5 |ig /m L w ill im p r o v e th e q u a lity o f a n e p id u r a l a n e s th e tic . D. th e c o m p lic a tio n r a te s a r e ty p ic a lly l o w a n d m a y e v e n im p r o v e b o w e l f u n c tio n a n d d e c r e a s e c o n s tip a tio n . 14. 16. D. A d d itio n o f a b a s e w ith a c id ic lo c a l a n e s th e tic m e d ic a tio n s w ill in c r e a s e th e a m o u n t o f u n c h a r g e d lo c a l a n e s th e tic m o le c u le s in je c te d a n d c a n th e r e f o r e in c r e a s e d if f u s io n o f lo c a l a n e s th e tic m o le c u le s th r o u g h th e lip id la y e r o f th e c e ll m e m b r a n e . s e iz u r e s . d r u g v o lu m e u s e d . w ith in 3 0 s e c o n d s o f in je c tio n a n d w ith o u t e v id e n c e o f a B P c h a n g e . e p in e p h r in e c a n a ls o p r o l o n g b lo c k a d e d u r a tio n . a n d p a tie n ts b e in g p r e g n a n t. C o m p lic a tio n s f r o m n e u r a x ia l b lo c k a d e c a n b e d iv e r s e a n d r a n g e f r o m d e a th . M a jo r f a c to r s in f lu e n c in g th e le v e l o f s p in a l a n e s th e s ia in c lu d e s b a r ic ity o f lo c a l a n e s th e tic s o lu tio n . a n d u r i n a r y r e te n tio n . a n d p a tie n ts b e in g p r e g n a n t. 9. s ite o f in je c tio n . c a r d ia c . 15. C. D u r in g e p id u r a l a n e s th e s ia . D. C. L o c a l a n e s th e tic s a c t o n n e r v e r o o t s in th e s u b a r a c h n o id s p a c e in th e c a s e o f a s p in a l b lo c k a d e a n d o n th e n e r v e r o o t s in th e e p id u r a l s p a c e in th e c a s e o f e p id u r a l a n e s th e s ia . H o w e v e r. H o w e v e r. 12. p a tie n t a g e a n d s p in e a n a to m y . p a tie n t p o s itio n im m e d ia te ly f o ll o w i n g s p in a l b lo c k p la c e m e n t. b a c k p a in . D. s ite o f in je c tio n . p H o f th e C SF. d r u g d o s e u s e d .d u r a l p u n c tu r e h e a d a c h e . A to ta l o f 3 m L o f 1 . M a jo r s ite o f a c tio n o f n e u r a x ia l b lo c k a d e ta k e s p la c e o n th e n e r v e r o o ts .

p a r a p le g ia . 21. a n d c a n b e a s s o c ia te d w ith a n e x a g g e r a te d s p r e a d o f n e u r a x ia l lo c a l a n e s th e tic ( v o lu m e a n d a m o u n t o f lo c a l a n e s th e tic in je c te d r e m a in c o n s ta n t). 18. a s c ite s . S y s te m ic h e p a r in a d m in is tr a tio n c a n b e c o n s id e r e d s a f e if g iv e n 1 h o u r o r l o n g e r f o ll o w i n g n e u r a x ia l b lo c k a d e a c c o r d in g to th e A S R A g u id e lin e s . a ! a g o n is t s u c h a s e p in e p h r in e a n d a 2 a g o n is ts s u c h as c lo n id in e /d e x m e d e to m id in e .c la im s d a ta b a s e . a r r e s t. a r a c h n o id itis . S u b c u ta n e o u s h e p a r in p r o p h y la x is a t o n c e o r tw ic e d a ily is n o t a c o n tr a in d ic a tio n to n e u r a x ia l a n e s th e s ia p la c e m e n t o r p r i o r to e p id u r a l c a th e te r r e m o v a l. A lth o u g h tr a n s ie n t n e u r o l o g i c a l s y m p to m s a r e u s u a lly s e lf . 24. 19. A d ju v a n ts a d d e d to n e u r a x ia l lo c a l a n e s th e tic s m a y im p r o v e q u a lity a n d /o r p r o l o n g th e d u r a tio n o f s p in a l a n e s th e s ia . a n te r io r s p in a l a r te r y s y n d r o m e . S o m e c o m m o n ly u s e d a g e n ts in c lu d e th e f o llo w in g : o p io id s s u c h a s m o r p h i n e a n d fe n ta n y l. B. In itia l v e r te b r a l le v e l a c h ie v e d w ith e p id u r a l a n e s th e s ia c a n b e v a r ia b le a n d is n o t as p r e d ic ta b le a s s p in a l a n e s th e s ia . 23. C. th e r e f o r e .lim itin g . b a c k p a in . In L A S T m a n a g e m e n t. a n d th e e ld e r ly . A d m in is tr a tio n o f e p in e p h r in e a s w e ll v a s o p r e s s i n in th e tr e a tm e n t o f L A S T s h o u ld b e a v o id e d a s it h a s n o t b e e n s h o w n to b e a s s o c ia te d w ith im p r o v e d p a tie n t o u tc o m e s . p o s t . r a d ic u lo p a th y . B. L A S T is m o r e c o m m o n th a n w h a t is b e in g f o r m a l l y r e p o r te d . 22.a c tin g v a s o p r e s s o r s a d d e d to lo c a l a n e s th e tic m ix tu r e s h a v e n o t b e e n s h o w n to b e e ffe c tiv e . H o w e v e r. e p id u r a l h e m a to m a . h ig h /to ta l s p in a l a n e s th e s ia . . A. I n d ir e c t. s e iz u r e s . D. a b c ix im a b ( R e o P r o ) 4 8 h o u r s . a n d e p tifib a tid e ( I n te g r ilin ) 8 h o u r s . l a r g e a b d o m in a l tu m o r . A c c o r d in g to th e A S R A g u id e lin e s .d u r a l p u n c tu r e h e a d a c h e . F a c to r s a s s o c ia te d w ith a d e c r e a s e d C S F v o lu m e in c lu d e p re g n a n c y . 17. c o m p lic a tio n r a te s a r e l o w a n d p a tie n ts d o n o t ty p ic a lly e x p e r ie n c e d e lir iu m u n le s s s y s te m ic o p io id a n a lg e s ic s h a v e b e e n u s e d . D. T h e g e n e r a lly a c c e p te d r u le is th a t 1 to 2 m L o f a n a p p r o p r ia te ly s e le c te d lo c a l a n e s th e tic s h o u ld b e a d m in is te r e d f o r e a c h v e r te b r a l le v e l o f a n e s th e s ia d e s ir e d in a d u lts . P e r f o r m i n g a te s t d o s e w ith e p in e p h r in e a n d a s p ir a ti o n is n o t a lw a y s 1 0 0 % e ffe c tiv e . D. w a itin g p e r i o d f o r th e c o m m o n ly u s e d a n tip la te le t a g e n ts a r e a s f o llo w s : tic lo p id in e (T ic lid ) 1 4 d a y s . A c c o r d in g to A S A c lo s e d . 20. T h e e t i o l o g y is m o s tly lik e ly d u e to th e h ig h c o n c e n tr a tio n o f lid o c a in e . a n d e p id u r a l a b s c e s s . S m a ll a n d in c r e m e n ta l d o s in g o f e p id u r a l m e d ic a tio n s s h o u ld a lw a y s b e c o n s id e r e d as a n o th e r s a f e ty m e a s u r e to d e c r e a s e th e r is k . c l o p i d o g r e l (P la v ix ) 7 d a y s . C. 5 % lid o c a in e is n o w a v o id e d in s p in a l a n e s th e s ia w h e n p o s s ib le . it c a n b e b o th e r s o m e to p a tie n ts . s te p s ta k e n to w a r d a d v a n c e d lif e s u p p o r t s till n e e d to b e f o llo w e d d e s p ite e v id e n c e th a t in tr a lip i d a d m in is tr a tio n is th e d e f in itiv e tre a tm e n t.

a p o s t . C. In p a tie n ts w h o m a y e x p e r ie n c e a “w e t ta p ” d u r in g p la c e m e n t o f a n e p id u r a l. O p io id s c a n a ls o a d v e r s e ly a f f e c t b la d d e r fu n c tio n . T h e r e f o r e . C a u d a l a n e s th e s ia c a n a ls o b e u s e d in a d u lts . m o s t c lin ic ia n s m a y c h o o s e to p e r f o r m a n e p id u r a l b l o o d p a tc h ( if n o c o n tr a in d ic a tio n s ) w ith 15 to 2 0 m L o f a u to lo g o u s b lo o d . a ir w a y s u p p o r t is n e e d e d a n d a g g r e s s iv e c o n tr o l o f h y p o te n s io n is im p o r ta n t in th e m a n a g e m e n t o f h ig h n e u r a x ia l b lo c k a d e e ffe c ts . th e c a r d ia c a c c e le r a to r f ib e r s w e r e a ffe c te d . D. in c lu d in g c a f fe in e .25. D u r in g n e u r a x ia l b lo c k a d e . 32. H y p o te n s io n a s s o c ia te d w ith a h ig h s p in a l m a y b e w o r s e n e d a s a r e s u lt o f e ffe c ts o n th e c a r d ia c a c c e le r a to r f ib e r s a t th e T 1 . 29. A. 28. W ith in th e s a c r a l c a n a l.th a n . f o o d d ie t lo w in f ib e r a n d s to o l s o f te n e r s a r e e n c o u r a g e d to p r e v e n t s tr a in in g . e s p e c ia lly in s h o r t a n d o b e s e p a tie n ts c a n p r e d is p o s e th e m to h ig h e r .in d u c e d b r a in . If th e r e is in s u f f ic ie n t o r n o e v id e n c e o f s y m p to m a tic im p r o v e m e n t a fte r 2 4 to 4 8 h o u r s . C. C a u d a l a n e s th e s ia n e e d le /c a th e te r p la c e m e n t m u s t p e n e tr a te th e s a c r o c o c c y g e a l lig a m e n t in o r d e r to e n te r th e c a u d a l s p a c e . c o u ld b e e x p la in e d b y th e c a u d a e q u in a s y n d r o m e ( in n e r v a te d b y th e s a c r a l p le x u s ) . c a n b e u s e d to tr e a t s e v e r e b r a d y c a r d i a in th e m a n a g e m e n t o f a h ig h n e u r a x ia l b lo c k a s s o c ia te d w ith a d e c r e a s in g h e a r t ra te . c o n s e r v a tiv e th e r a p y s h o u ld in c lu d e b e d r e s t a n d p le n ty o f f lu id in ta k e . A ll o f th e a b o v e d r u g s . C. 27. In th is p a r tic u la r s itu a tio n . C. a lu m b a r e p id u r a l a n e s th e tic h a s a h ig h e r r i s k o f b la d d e r r e f le x in h ib itio n a n d u r i n a r y r e te n tio n th a n a th o r a c ic e p id u r a l. 26. T h e r e f o r e . a n d th e r e f o r e . u r i n a r y r e te n tio n is m o s t o f te n d u e to th e lo c a l a n e s th e tic e ffe c ts o n th e S 2 . A lth o u g h p h r e n ic n e r v e p a ls y m a y c o n tr ib u te to p a tie n t’s e x p e r ie n c e s o f s h o r tn e s s o f b r e a th a n d a p n e a .s te m h y p o p e r f u s io n .a n tic ip a te d le v e ls o f n e u r a x ia l a n e s th e s ia .S 4 n e r v e r o o ts . a v a s o p r e s s o r th a t c a n s im u lta n e o u s ly in c r e a s e b o th H R a n d B P w o u ld b e th e m o s t id e a l m e d ic a tio n to a d m in is te r . A ll o f a b o v e s y m p to m s . T h e r e f o r e . th e d u r a l s a c s to p s a t th e f i r s t s a c r a l v e r te b r a in a d u lts a n d a p p r o x im a te ly a r o u n d th e th ir d s a c r a l v e r te b r a in in fa n ts . Q u a d r ic e p s m u s c le s a r e in n e r v a te d b y lu m b a r p le x u s a n d lu m b a r n e r v e r o o t s a n d a r e r a r e l y in v o lv e d in th e . w ith th e e x c e p tio n o f th e q u a d r ic e p s m u s c le s . th e p a tie n t e x p e r ie n c e d b r a d y c a r d i a a n d h y p o te n s io n . b u t m a y b e m o r e d if f ic u lt to p e r f o r m d u e to c a lc if ic a tio n o f th e s a c r o c o c c y g e a l lig a m e n t. th e r i s k o f s p in a l a n e s th e s ia is h ig h e r in y o u n g e r c h ild r e n . C. e x c e p t p h e n y le p h r in e . B. C a u d a l a n e s th e s ia is a ty p e o f e p id u r a l a n e s th e s ia p e r f o r m e d in th e s a c r a l r e g i o n j u s t as lu m b a r e p id u r a l a n e s th e s ia is p e r f o r m e d in th e lu m b a r r e g i o n . R a p id in je c tio n o f l a r g e v o lu m e s o f lo c a l a n e s th e tic s e ith e r e p id u r a lly o r in tr a th e c a lly . 30. C a u d a e q u in a s y n d r o m e is u s u a lly s e c o n d a r y to n e u r o to x ic e ffe c ts f r o m lo c a l a n e s th e tic s o n th e s a c r a l n e r v e r o o ts .T 4 le v e ls . th e r e f o r e . 31.d u r a l p u n c tu r e h e a d a c h e is ty p ic a lly tr e a te d c o n s e r v a tiv e ly . th e m o s t lik e ly r e a s o n f o r d y s p n e a f o ll o w i n g a h ig h n e u r a x ia l b lo c k a d e is p e r s is te n t h y p o te n s io n . In itia lly .

cauda equine syndrome. Epidural hematoma may present with back pain. . 33. focal neurological deficits. B. emergent intervention needs to be taken to confirm diagnosis and then to perform an emergency decompression as soon as possible to avoid permanent spinal cord/nerve roots injury. and bowel and bladder dysfunction. If a neuraxial hematoma is suspected.

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Administer supplemental oxygen B. An inter scalene brachial plexus block plus an intercostal brachial nerve block B. Patients who may not provide absolute cooperation during nerve block placement (mental retardation) without administration of sedation B. Given that the surgeon plans to use a forearm tourniquet.Peripheral Nerve Blocks Thomas Halaszynski 1. Medical history is significant for chronic obstructive pulmonary disease dependent on 2 L of oxygen. A supraclavicular approach to the brachial plexus plus an intercostal brachial nerve block C. Superficial cervical plexus blockade plus an intercostal brachial nerve block 2. the regional anesthesia technique that would be most appropriate for this patient is A. Patient refusal C. Apply standard ASA monitors C. Ulnar nerve C. Lateral brachial cutaneous nerve D. except A. An 85-year-old male is scheduled for a right distal radius and ulnar open reduction interior fixation at the wrist. Contraindications to safely perform peripheral regional anesthesia include all of the following. except A. Evidence of infection at injection site 4. access and/or use of all of the following should be considered mandatory. Medial brachial cutaneous nerve 3. except A. Severe coagulopathy while anticipating a deep nerve plexus blockade D. While performing an axillary brachial plexus block. Access to resuscitation medications and equipment . hypertension. and coronary artery disease with a stent inserted one year ago. diabetes mellitus. While performing a peripheral nerve block in an awake patient. Musculocutaneous nerve B. all of the following nerves are spared. An infraclavicular block of the brachial plexus at the cords plus an intercostal brachial nerve block D.

Immediate access to a mechanical ventilator 5. Which of the following nerves is typically spared during performance of an interscalene brachial plexus block? A. Roots . Median B. Performing an infraclavicular approach for brachial plexus blockade would deposit local anesthetics at which of the following anatomical levels of the plexus? A. Musculocutaneous D. Ulnar and axillary nerve branches D. Suprascapular and supraclavicular nerve branches 9. A supraclavicular block of the brachial plexus does not provide consistent surgical anesthesia for shoulder surgery secondary to potential sparing of which of the following nerve branches of the brachial plexus? A. Axillary and suprascapular nerve branches C. Higher frequency ultrasound probes are used for deeper penetration B. Trunks B. Musculocutaneous and axillary nerve branches B. Liner array probes are typically used for imaging deeper anatomical structures D. Cerebrovascular accident (CVA) 8. and pupillary constriction. High-frequency ultrasound probes provide for higher image resolution C. Ulnar 7. redness of the conjunctiva. The most likely diagnosis is A. Divisions C. The curvilinear probe is designed to best image superficial structures 6. you are called to the recovery room (post-anesthesia care unit) 3 hours later to evaluate the patient. Following successful performance of a right interscalene block for surgical rotator cuff repair in a 27-year-old patient with no other medical issues. D. Cords D. Subdural injection of local anesthetic C. Horner syndrome D. The patient’s symptoms include drooping of the right eyelid. The most correct statement regarding the appropriate use of ultrasound equipment during performance of regional anesthesia is A. Axillary C. Spinal anesthesia B.

10. Median B. your needle tip is imaged inferior to the pulsating axillary artery. A supraclavicular approach for brachial plexus blockade would deposit local anesthetics at which of the following anatomical levels of the plexus? A. Median nerve B. Radial C. Radial 14. The needle tip is closest to which of the following brachial plexus . Musculocutaneous D. Ulnar C. While performing an ultrasound-guided axillary nerve block along with a nerve stimulator. Ulnar B. You also see pronation of the patient’s forearm. and you observe supination of the forearm. Roots 11. and you see evidence of flexion of fourth and fifth digits. During placement of an ultrasound-guided and nerve stimulator-assisted axillary nerve block. Anatomical location of the musculocutaneous nerve in the upper forearm is most frequently found within which of the following muscles? A. The stimulating needle tip is in closest proximity to which of the following peripheral nerve branches of the brachial plexus? A. Brachialis 13. When performing an axillary block of the brachial plexus for distal upper extremity surgery. Axillary nerve C. the image of your needle tip is seen posterior to axillary artery. The needle tip is in closest proximity to which of the following branches of the brachial plexus? A. Branches B. While performing an axillary nerve block by both ultrasound guidance and nerve-stimulator assistance. Trunks/Divisions C. Biceps brachii C. Cords D. Interscalene nerve 15. which of the following nerves most often needs to be targeted separately? A. Coracobrachialis D. Triceps brachii B. Musculocutaneous D. Musculocutaneous nerve D. your needle tip is imaged superiorly to the axillary artery. Median 12.

Triceps brachii nerve C. Radial nerve 17. The patient was sedated with 2 mg of midazolam upon arrival to the OR. You are called to the post-anesthesia care unit 2 hours later because the patient is complaining of pain on the back of the wrist. Radial nerve 16. Anaphylaxis to midazolam B. Interscalene nerve 18. weight. Ten minutes following the local anesthetic placement. A properly performed lumbar plexus block will result in blockade of all the following nerve branches. Musculocutaneous nerve D. 6 ft. You successfully perform a right supraclavicular nerve block for a right wrist open reduction interior fixation. you notice that the elbow begins to flex. At the surgeon’s request. which extends distal to the index. Ulnar C. The most likely nerve branch that is being stimulated is A. After performing an axillary peripheral nerve block. Femoral nerve B. You have just successfully performed a Bier block using 50 mL 0. n e rv e b ra n c h e s? A. Infraclavicular nerve B. and ring fingers on the dorsal surface of the hand. Median nerve B. 200 lb). Lateral femoral cutaneous nerve . your ultrasound probe moves to scan laterally and you see what appears to be an oval and hyperechoic nerve structure within the belly of the coracobrachialis muscle. You consent the patient to perform a terminal branch nerve block to supplement the initial block. Median nerve B. except A. The patient soon becomes agitated. the nurse releases the tourniquet that was placed on the upper arm. middle. and you notice twitching of the patient’s arms and legs.5% lidocaine for carpal tunnel release surgery in a 45-year-old male (height. Radial nerve C. Local anesthetic systemic toxicity (LAST) 19. When the needle tip is advanced closer to this structure and the nerve stimulator is activated. New-onset seizure disorder C. Intercostal brachial nerve D. the surgeon indicates that the surgery is finished. Allergic reaction to the local anesthetic D. The most likely diagnosis is A. The nerve that would be needed to be blocked is A. Infraclavicular nerve D.

Sciatic nerve injury 23. You are consulted on an ASA IV patient for a right-ankle surgery. Which of the following nerves will need to be blocked in order to provide for complete anesthesia during performance of foot and ankle surgery? A. Femoral nerve block alone D. the patient complains of lateral thigh pain. Sciatic nerve block alone C. Local anesthetic systemic toxicity D. Lateral femoral cutaneous nerve B. and obturator nerve blocks 24. The surgeon is requesting for a peripheral nerve block that will provide for surgical anesthesia. but do not repeat the block as there exists a high risk of nerve injury 22. Sciatic. Sciatic nerve C. Spinal anesthesia C. No. All of the following nerves provide sensory innervation to the foot. The patient has a known history of difficult intubation and status post-spinal fusion surgery. the pain is due to a failed femoral block. No. Was the femoral nerve block a failure and what would be the most appropriate action? A. Retroperitoneal hematoma B. C. Obturator nerve 21. the pain expressed is not located within the distribution of the femoral nerve. Three hours postsurgery in the recovery room. You have just performed a femoral nerve block in preparation for a tibial plateau fracture repair using 20 mL 0. Lateral femoral cutaneous nerve D. supplement with a lateral femoral cutaneous nerve block D. Yes. Electrical nerve stimulation of which of the following nerves will produce quadriceps muscle contraction? A. femoral. Yes. Obturator nerve D. repeat the femoral nerve block as the effectiveness of the local anesthetic has worn off after 4 hours C. A properly placed psoas compartment block or posterior lumbar plexus block can be associated with any of the following complications. Both sciatic and femoral nerve blockade B. except A. except A. Sural nerve . repeat the femoral nerve block due to a failed block B. Femoral nerve B. Sciatic nerve 20.5% ropivacaine.

Internal oblique and transversus abdominis muscles C. S u p e r f ic ia l p e r o n e a l n e r v e 25. The most correct statement concerning a unilateral paravertebral block is A. C. D eep p e ro n e a l n e rv e D. It is the sensory terminal branch of the femoral nerve D. It is the motor terminal branch of the femoral nerve C. The nerve on the lateral side is the common posterior tibial nerve. One potential complication includes liver injury D. and the nerve on the medial side is the tibial nerve (combined nerve is the sciatic nerve) B. Such a block may be associated with epidural spread of local anesthetic 26. Such a block is always associated with a similar degree of sympathectomy as with an epidural block B. Unilateral TAP blocks never cross over the midline 27. The correct identity of the two nerve branches is A. you are able to identify the popliteal artery adjacent to two hyperechoic nerve structures that appear to become one nerve structure upon proximal movement of the ultrasound probe placed within the popliteal fossa. Rectus abdominis and external oblique muscles 28. The most incorrect statement regarding transversus abdominis plane (TAP) block is A. and the nerve on the medial side is the superficial peroneal nerve (combined nerve is the femoral nerve) 29. External oblique and internal oblique muscles B. Transversus abdominis and external oblique muscles D. The most appropriate statement regarding the function of the saphenous nerve is A. While performing the popliteal approach for a sciatic nerve block under ultrasound guidance. The nerve on the lateral side is the common tibial nerve. When performing a transversus abdominis plane (TAP) block. Such a block is often associated with a higher serum level of local anesthetic than that achieved with an intercostal nerve block due to high vascularity C. It is a sensory terminal branch of the sciatic nerve . It serves as both a motor nerve and a sensory nerve B. and nerve on the medial is the superficial peroneal nerve (combined nerve is the sciatic nerve) D. the goal is to deposit/inject local anesthetic between which of the following two muscle layers? A. TAP blocks can often alleviate both somatic and visceral pain C. The nerve on the lateral side is the common peroneal nerve. and nerve on the medial side is the deep peroneal nerve (combined nerve is the femoral nerve) C. TAP blocks can provide analgesia following hernia repair surgeries B. The nerve on the lateral side is the sciatic nerve. It is not likely to be associated with a pneumothorax D.

A 45-year-old healthy male is scheduled for bilateral elbow open reduction interior fixation secondary to a motor vehicle accident. In the operating room. The regional anesthetic technique that will provide her the most optimal perioperative pain management is A. The most likely diagnosis is . and the oxygen saturation decreases from 100% to 85%. Thirty minutes after incision. hand. Successful bilateral supraclavicular blocks were planned and performed under ultrasound guidance. A sciatic nerve block and a spinal 34. A femoral and proximal sciatic nerve block C. Dysfunction of the diaphragm (diaphragm palsy) C. and is status post L1-L5 vertebral fusion. Both a femoral and popliteal sciatic nerve block D. Endotracheal intubation to provide respiratory support D. obesity. Aspiration pneumonia 32. An interscalene block will typically deposit the local anesthetic between which of the following two muscles? A. A 65-year-old female is scheduled for a right total shoulder replacement. The most appropriate treatment for the patient in the above scenario is A. Sternocleidomastoid and anterior scalene muscles 31. the patient is experiencing progressive respiratory depression. Flumazenil to antagonize midazolam (oversedation) C. A femoral nerve block and an epidural B. the patient is receiving 25 |ig/kg/min of a propofol infusion and oxygen via a non-rebreather bag. Antibiotics to treat aspiration pneumonia 33. but no opioids. An MRI shows a diffuse swelling of the brachial plexus at the level of the cords. Anterior and middle scalene muscles B. A 56-year-old woman is scheduled for a right total knee replacement. The most likely diagnosis is A. Methylene blue due to local anesthetic systemic toxicity B. One week later. including the wrist.30. you perform a right interscalene nerve block and place a catheter for continuous local anesthetic infiltration planned for 3 days.5% ropivacaine injected for each block on each side. the patient complains of persistent parasthesia of the entire right arm. Local anesthetic systemic toxicity (LAST) B. Middle and posterior scalene muscles C. and all fingers (from the shoulder to the fingers). She has a medical history of hypertension. diabetes mellitus. Methemoglobinemia D. Under ultrasound guidance. The patient also received 2 mg of midazolam. Anterior and posterior scalene muscles D. with 20 mL 0.

Direct nerve injury/trauma from the block needle used B. The foot is supplied mainly by which of the following nerve(s)? A. Ropivacaine D. Local anesthetic toxicity of the brachial plexus at the level of the roots/trunks 35. Posterior thigh and majority of the leg below the knee C. Medical history of the patient includes alcohol abuse and panic attacks. Sciatic nerve B. Lower extremity below the knee B. The most appropriate nerve block for pain management in a patient scheduled for a total hip replacement is A. Medial and posterior thigh D. Lidocaine B. Obturator and tibial nerves C. Femoral and lateral femoral cutaneous nerve block 38. Irritation of the brachial plexus at the level of the branches from the continuous peripheral nerve catheter C. Mepivacaine 37. Medial leg below the knee 40. After the surgery in the post-anesthesia care unit. Bupivacaine C. Surgical trauma/manipulation of the brachial plexus at the level of the cords D. Anterior and medial thigh C. You perform a right-side T3-T5 paravertebral blockade for a patient who is to undergo a right mastectomy with axillary lymph node dissection. Lumbar plexus block C. Almost the entire ankle 39. Femoral nerve block B. Saphenous and common peroneal nerves 36. Femoral and obturator nerve block D. Femoral and lateral femoral cutaneous nerves D. Sciatic nerve blockade provides sensory loss of the A. Anterior and lateral thigh B. The femoral nerve provides sensory innervation to the A. the patient complains . A. Posterior and medial thigh D. The following local anesthetic medication is associated with the highest risk for cardiovascular collapse in the event of local anesthetic systemic toxicity (LAST) A.

th e p a tie n t c o m p la in s th a t s h e h a s n o s e n s a tio n f r o m th e r i g h t e lb o w to th e tip s o f a ll h e r f in g e r s . T h e m o s t lik e ly d ia g n o s is is A. a n d u ln a r p e r ip h e r a l n e r v e s C. a n d u ln a r p e r ip h e r a l n e r v e s B. u ln a r. V ita l s ig n s r e m a in s ta b le a lo n g w ith s tr o n g a n d e q u a l u p p e r e x tr e m ity b ila te r a l p u ls e s . L e v e l o f th e d iv is io n s a n d ta r g e tin g th e s u p r a c la v ic u la r . S id e e f f e c ts /c o m p lic a tio n s o f th e p a r a v e r t e b r a l b lo c k o n th e b r a c h ia l p le x u s D. it s h o u ld h a v e b e e n p la c e d a t th e T 6 le v e l C. E ig h te e n h o u r s p o s to p e r a tiv e ly . T h e p a tie n t is e x p e r ie n c in g w ith d r a w a l f r o m a lc o h o l C. o f a n e w . T h e b lo c k le v e l w a s to o h ig h . P r o l o n g e d e f f e c t o f th e lo c a l a n e s th e tic s e c o n d a r y to th e p a tie n t’s r e n a l f a ilu r e D. 10 m L o f 0 . L e v e l o f th e b r a n c h e s a n d ta r g e tin g th e r a d ia l.p a r t i a l h e p a te c to m y . N e u r o to x ic ity o f th e tr u n k s /d iv is io n s o f th e b r a c h ia l p le x u s s e c o n d a r y to th e r o p iv a c a in e B. th e p a tie n t c o m p la in s o f 7 /1 0 p a in .2 % r o p iv a c a in e is a d m in is te r e d th r o u g h e a c h c a th e te r. T h e m o s t lik e ly e t i o l o g y is A. In te r s c a le n e a n d a x illa r y a p p r o a c h e s . N e r v e in ju r y s e c o n d a r y to th e r e g i o n a l b lo c k n e e d le u s e d C.5 % r o p iv a c a in e . m e d ia n . P o s s ib le s u r g e r y . T h e b lo c k le v e l is to o lo w . a n d r a d ia l p e r ip h e r a l n e rv e s D. b u t s h e c a n m o v e a ll o f h e r f in g e r s n o r m a lly . th e g o a l is to d e p o s it lo c a l a n e s th e tic m e d ic a tio n s a t w h a t lo c a t io n o f th e b r a c h ia l p le x u s a n d to ta r g e t w h ic h s p e c if ic n e r v e s tr u c tu r e s ? A.f r e e c o n d itio n is A.r e la te d in ju r y a t th e e lb o w th a t m a y w a r r a n t a n e l e c tr o p h y s io lo g y s tu d y 43. th e p a tie n t in d ic a te s th a t th e p a in h a s d e c r e a s e d to 4 /1 0 . a n d r a d ia l p e r ip h e r a l n e r v e s 44. A p a tie n t is to u n d e r g o s u r g e r y to c r e a te a n a r te r io v e n o u s f is tu la f o r h e m o d ia ly s is o n th e a n te c u b ita l a r e a o f th e r i g h t u p p e r e x tre m ity . T h e lo c a l a n e s th e tic v o lu m e a d m in is te r e d is to o s m a ll 42. T w e n ty m in u te s la te r. T h e m o s t lik e ly a s p e c t o f p a r a v e r t e b r a l b lo c k a d e th a t c a n a c c o u n t f o r th e r e a s o n w h y th e p a tie n t d id n o t a c h ie v e a p a in .a r m p a r e s th e s ia . L e v e l o f th e c o r d s a n d ta r g e tin g th e in f r a c la v ic u la r . P a tie n t is h a v in g a p a n ic a tta c k 41. L e v e l o f th e tr u n k s a n d ta r g e tin g th e in te r s c a le n e . P a r a v e r te b r a l b lo c k a d e a n a lg e s ia p r o v id e s f o r m o s tly s o m a tic b lo c k a d e a n d d o e s n o t p r o v id e f o r c o m p le te c o v e r a g e o f v is c e r a l p a in D. S u r g e r y . T h r e e d a y s f o ll o w i n g th e s u r g e r y .r e la t e d b r a c h ia l p le x u s n e r v e in ju r y a n d /o r p o s itio n a l in ju r y B. it s h o u ld h a v e b e e n p la c e d a t th e T 1 0 le v e l B. W h ic h o f th e f o ll o w i n g a p p r o a c h e s to b lo c k a d e o f th e b r a c h ia l p le x u s is a s s o c ia te d w ith th e h ig h e s t in c id e n c e o f a p n e u m o th o r a x ? A. Y o u s u c c e s s f u lly p e r f o r m a n d p la c e a b ila te r a l T 8 c o n tin u o u s p a r a v e r t e b r a l b lo c k c a th e te rs f o r a n o p e n . Y o u p e r f o r m a r i g h t s u p r a c la v ic u la r b lo c k u n e v e n tf u lly u s in g 2 0 m L 0 .s ta g e r e n a l d is e a s e . W h ile p e r f o r m i n g a n a x illa r y b r a c h ia l p le x u s b lo c k a d e . r a d ia l. T h e p a tie n t h a s a m e d ic a l h is to r y s ig n if ic a n t f o r h y p e r te n s io n a n d e n d . m e d ia n . T o im p r o v e p o s to p e r a tiv e a n a lg e s ia .o n s e t r i g h t .

The most likely diagnosis is A. Ketamine C. Dexamethasone D. The block needle needs to be repositioned more medially. Venous bleeding into the paravertebral space resulting in large volumes of local anesthetic absorption from the paravertebral blocks . except A. The stimulating block needle tip is in the correct position.2% ropivacaine administered through each catheter (following evidence of negative aspiration). Infraclavicular and axillary approaches D. Sartorius muscle twitch indicates that the needle tip is in the correct location. The trauma team in the ICU did not want a thoracic epidural placed on a trauma patient with bilateral rib fractures secondary to concerns about the potential hemodynamic instability that may result. Axillary and interscalene approaches 45. While performing a femoral nerve block guided with a nerve stimulator. and the block needle needs to be readjusted (twitch may not be from stimulation of the femoral nerve) prior to local anesthetic injection C. Epinephrine B. but you need to get closer to the nerve as 0.2 mA. Local anesthetic toxicity as the paravertebral space is very vascular C. both right T7 and left T5 continuous paravertebral catheters were successfully placed for this patient under ultrasound guidance. you observe a strong sartorius muscle twitch that disappears at 0.2 mA stimulus is too high D. the systolic blood pressure dropped by 50 mm Hg. Clonidine 46. All of the following medication adjuvants can be used in combination with local anesthetic solutions during performance of a peripheral nerve blockade to extend the duration/effectiveness of nerve blockade. B. Possible epidural spread of local anesthetics from either one or both the paravertebral catheters D. What does this mean and how should you proceed further? A. and the local anesthetic can be injected B. Therefore. Performance of paravertebral blockade creates identical concerns about potential hemodynamic compromise as do thoracic epidural blocks B. Supraclavicular and interscalene approaches C. and a paresthesia must be elicited prior to local anesthetic injection 47. The needle tip is likely superficial to the femoral nerve. Twenty minutes following the administration of 10 mL of 0.

H ig h . a lo n g w ith a r e d u c e d in c id e n c e o f a d v e r s e e ffe c ts o n th e p h r e n ic n e r v e . L o w . R e g io n a l a n e s th e s ia s h o u ld b e a d m in is te r e d in a m o n ito r e d lo c a t io n w h e r e s ta n d a r d A S A m o n ito r s .f r e q u e n c y u ltr a s o u n d p r o b e s a r e ty p ic a lly m a n u f a c tu r e d w ith a lin e r p r o b e d e s ig n a n d p r o v id e h ig h im a g e r e s o lu tio n u s e d f o r s u p e r f ic ia l a n a to m ic a l s tr u c tu r e s . b u t is u s e d f o r v is u a liz in g d e e p e r a n a to m ic a l s tr u c tu r e s s e c o n d a r y to b e tte r p e n e tr a tio n . 4.b e n e f it a n a ly s is n e e d s to b e c a r e f u l ly c o n s id e r e d . . B. CHAPTER 8 ANSWERS 1. p e r f o r m i n g e ith e r a n in te r s c a le n e o r s u p r a c la v ic u la r b lo c k o f th e b r a c h ia l p le x u s s h o u ld b e a p p r o a c h e d w ith c a u tio n s e c o n d a r y to th e in c r e a s e d r i s k o f a n ip s ila te r a l p h r e n ic n e r v e p a ls y . D.to .f r e q u e n c y u ltr a s o u n d p r o b e e q u ip m e n t is ty p ic a lly p r o d u c e d w ith a c u r v ilin e a r p r o b e d e s ig n a n d r e v e a ls a lo w e r im a g e r e s o lu tio n . b u t it is n o t a n a b s o lu te c o n tr a in d ic a tio n to p e r f o r m i n g r e g i o n a l a n e s th e s ia . C. 6. P a tie n t r e f u s a l is a n a b s o lu te c o n tr a in d ic a tio n f o ll o w i n g in f o r m e d c o n s e n t. P r o p e r l y p e r f o r m e d in te r s c a le n e a p p r o a c h to b r a c h ia l p le x u s b lo c k a d e c a n p r o v id e f o r a d e n s e b lo c k a d e o f th e C 5 - C 7 n e r v e r o o ts /tr u n k s a n d le s s c o n s is te n t b lo c k a d e o f th e C 8 . E v id e n c e o f a n tic ip a te d in je c tio n . D. im m e d ia te a c c e s s to a f u n c tio n in g a n e s th e s ia v e n tila to r is n o t a lw a y s n e c e s s a ry . S u p p le m e n ta l o x y g e n a lo n g w ith r e s u s c ita tiv e m e d ic a tio n s a n d e q u ip m e n t s h o u ld b e r e a d ily a c c e s s ib le a n d im m e d ia te ly a v a ila b le . T h e la te r a l b r a c h ia l c u ta n e o u s n e r v e is a b r a n c h o f m u s c u lo c u ta n e o u s n e rv e . 2.T 1 n e r v e r o o ts /tr u n k s . B o th in f r a c la v ic u l a r a n d a x illa r y a p p r o a c h e s to th e b r a c h ia l p le x u s w o u ld b e a p p r o p r ia te f o r w r is t s u r g e r y . th e s e n e r v e b r a n c h e s n e e d to b e b lo c k e d s e p a r a te ly if th e y in n e r v a te th e p la n n e d s u r g ic a l a r e a .s ite in f e c tio n a n d s e v e r e c o a g u lo p a th y a r e c o n s id e r e d r e la tiv e c o n tr a in d ic a tio n s . A. H o w e v e r. T h e r e f o r e . T h e m u s c u lo c u ta n e o u s a n d m e d ia l b r a c h ia l c u ta n e o u s n e r v e s b r a n c h f r o m th e b r a c h ia l p le x u s a t a m o r e p r o x im a l lo c a t io n th a n c a n b e c o n s is te n tly a n e s th e tiz e d w ith a n a x illa r y n e r v e b lo c k a p p r o a c h o f th e b r a c h ia l p le x u s . 3. T h e u ln a r n e r v e b r a n c h o r ig i n a te s f r o m th e C 8 . B.T 1 n e r v e r o o ts . I n te r c o s to b r a c h ia l n e r v e b lo c k a d e is a d d e d to c o v e r th e T 2 d e r m a to m e d is tr ib u tio n th a t is n o t in c lu d e d in a p r o p e r l y p e r f o r m e d b r a c h ia l p le x u s b lo c k a n d w ill c o n tr ib u te to a lle v ia tin g to u r n iq u e t d i s c o m f o r t in th e m e d ia l p o r t i o n o f th e u p p e r a rm . P la c e m e n t o f a n in te r s c a le n e b lo c k f o r w r is t s u r g e r y m a y a ls o n o t b e o p tim a l a s it m a y n o t e f f e c tiv e ly b lo c k th e u ln a r n e r v e d is tr ib u tio n to th e w r is t. 5. T h e r e f o r e .C 4 ) w ill n o t e f f e c tiv e ly p r o v id e a n e s th e s ia /a n a lg e s ia to th e w r is t. a n d r is k . In a p a tie n t w ith s e v e r e p u lm o n a r y c o m p r o m is e . a n in te r s c a le n e a p p r o a c h to b lo c k a d e o f th e b r a c h ia l p le x u s f o r d is ta l u p p e r e x tr e m ity s u r g ic a l p r o c e d u r e s m a y n o t b e th e m o s t id e a l a p p r o a c h . A s u p e r f ic ia l c e r v ic a l p le x u s b lo c k ( C 1 . N o n ­ c o o p e r a tiv e p a tie n ts c a n o f te n p o s e a n in c r e a s e d r i s k to p a tie n t/o p e r a to r sa fe ty .

A t th e in f r a c la v ic u l a r le v e l. D e s p ite s o m e a n a to m ic a l v a r ia tio n s w ith in th e n e r v e . 8. a n d a n h id r o s is ) c a n b e c o m m o n ly s e e n f o ll o w i n g a n in te r s c a le n e b lo c k . C. th u m b o p p o s itio n . a s u p r a c la v ic u la r b lo c k c a n b e u s e d f o r p o s to p e r a tiv e a n a lg e s ia . a n d f o r e a r m p r o n a tio n . 13. It p r o v id e s a n e s th e s ia o f th e b r a c h ia l p le x u s d is ta l to th e r o o t s a n d p r o x im a l to th e c o r d s o f th e p le x u s . A lth o u g h s o m e a n a to m ic a l v a r ia tio n c a n b e f o u n d w ith th e b r a c h ia l p le x u s a t th e le v e l o f th e a x illa . In p a tie n ts w h e r e a C V A m a y a ls o b e w ith in th e d if f e r e n tia l d ia g n o s is . A. a n d th u m b a d d u c tio n . b u t th e u ln a r n e r v e is f r e q u e n tly p o s itio n e d in f e r i o r to th e a x illa r y a rte ry . a n d p o s te r io r c o rd s. th e m u s c u lo c u ta n e o u s n e r v e m u s t b e ta r g e te d s e p a r a te ly w h e n p e r f o r m i n g a n a x illa r y b lo c k o f th e b r a c h ia l p le x u s f o r d is ta l u p p e r e x tr e m ity s u r g e r y . 12. A H o r n e r s y n d r o m e ( m io s is . S u p r a c la v ic u la r b lo c k a d e o f th e b r a c h ia l p le x u s is o f te n r e f e r r e d to a s th e “ s p in a l a n e s th e s ia ” o f th e u p p e r e x tre m ity .h u m e r u s . C. T h e m e d ia n n e r v e is m o s t f r e q u e n tly p o s itio n e d s u p e r io r to th e a x illa r y a r te r y (w ith s o m e a n a to m ic a l v a r ia tio n s ) . p to s is . 15. S p a r in g o f u ln a r n e r v e d u r in g a s u p r a c la v ic u la r b lo c k m a y a ls o o c c u r th a t w o u ld n o t p r o v id e e f f e c tiv e a n e s th e s ia f o r p r o c e d u r e s d is ta l to th e m id . T h is s y n d r o m e is o f te n d u e to p r o x im a l tr a c k in g o f lo c a l a n e s th e tic a n d b lo c k a d e o f th e s y m p a th e tic f ib e r s to th e c e r v ic o th o r a c ic g a n g lio n . B. T h e r e f o r e . T h e m u s c u lo c u ta n e o u s n e r v e ty p ic a lly b r a n c h e s o f f m o r e p r o x im a l to th e a x illa r y a p p r o a c h o f b r a c h ia l p le x u s b lo c k a d e a n d is f r e q u e n tly n o t a d e q u a te ly a n e s th e tiz e d w ith a tr a d itio n a l a x illa r y b lo c k o f th e p le x u s ( lo c a l a n e s th e tic s a r e d e p o s ite d a r o u n d th e a x illa r y a r te r y ) . S o m e a n a to m ic a l v a r ia tio n c a n e x ist. b u t m a y n o t b e id e a l f o r s u r g ic a l a n e s th e s ia d u r in g in v a s iv e s h o u ld e r p r o c e d u r e s . C. a t h o r o u g h h is to r y a n d n e u r a l e x a m s h o u ld a lw a y s b e in c lu d e d . th e b r a c h ia l p le x u s f o r m s th r e e c o r d s in r e la tio n to a x illa r y a r te r y a n d n a m e d a c c o r d in g to th e ir p o s itio n a r o u n d th e a r te r y : m e d ia l. 11. B.b r a n c h d is tr ib u tio n o f th e b r a c h ia l . 9.tim e u ltr a s o u n d g u id a n c e . A s u p r a c la v ic u la r a p p r o a c h to b r a c h ia l p le x u s b lo c k a d e d o e s n o t c o n s is te n tly a n d r e lia b ly p r o v id e a n e s th e s ia /a n a lg e s ia to th e a x illa r y a n d s u p r a s c a p u la r n e r v e b r a n c h e s . T h e r e h a s b e e n a n in c r e a s e d p r a c tic e o f p e r f o r m i n g th e s u p r a c la v ic u la r a p p r o a c h to b lo c k a d e o f th e b r a c h ia l p le x u s s e c o n d a r y to th e in tr o d u c tio n o f u ltr a s o u n d in to c lin ic a l p r a c tic e a s a n e s th e s io lo g is ts c a n n o w a p p r e c ia te a d e c r e a s e d in c id e n c e o f p n e u m o th o r a x u n d e r r e a l. c r e a tin g w r is t f le x io n . 10. S tim u la tio n o f th e m e d ia n n e r v e w ill c a u s e m u s c le s tim u la tio n . f le x io n o f th e f o u r th a n d fif th d ig its . B. 7. th e m u s c u lo c u ta n e o u s n e r v e is m o s t c o m m o n ly p o s itio n e d w ith in th e c o r a c o b r a c h ia lis m u s c le o r b e tw e e n th e b e llie s o f th e b ic e p s a n d c o r a c o b r a c h ia lis m u s c le s . 14. C. la te r a l. D. T h e r e f o r e . S tim u la tio n o f th e u ln a r n e r v e w ill c a u s e w r is t f le x io n .

c a u tio u s . D. 20. s a p h e n o u s n e r v e . 19. b e lo w th e k n e e ). T h e f e m o r a l n e r v e p r o v id e s m o to r s u p p ly to th e q u a d r ic e p s m u s c le s a n d s e n s o r y s u p p ly to p o r t i o n o f th e m e d ia l th ig h . A lu m b a r p le x u s b lo c k is c o n s id e r e d a d e e p b lo c k a n d h a s b e e n d e s c r ib e d a s a n a d v a n c e d b lo c k in r e g i o n a l a n e s th e s ia . F o r c o m p le te s u r g ic a l a n e s th e s ia o f th e f o o t a n d a n k le . T h e r e f o r e . E v e n a fte r 15 to 2 0 m in u te s h a s e la p s e d . 18. a n d r e n a l in ju r y (w ith p o te n tia l f o r s u b s e q u e n t h e m a to m a ) . a n d o b tu r a to r n e r v e s . A B ie r b lo c k c a n p r o v id e s u r g ic a l a n e s th e s ia f o r s h o r t p r o c e d u r e s o f th e e x tre m ity . S o m e p o te n tia l c o m p lic a tio n s in c lu d e r e t r o p e r ito n e a l h e m a to m a . T h e ty p ic a l a p p r o a c h f o r lu m b a r p le x u s b lo c k a d e s h o u ld n o t c a u s e in ju r y to th e s c ia tic n e r v e u n le s s a n i m p r o p e r l y p la c e d o r m is d ir e c te d r e g i o n a l b lo c k n e e d le is p o s itio n e d to o c a u d a d th a t c o u ld th e n r e s u lt in in ju r y to s a c r a l p le x u s a n d th e s c ia tic n e rv e . p le x u s a r o u n d th e a x illa r y a rte ry . In o r d e r to p r e v e n t o r r e d u c e th e in c id e n c e o f L A S T . T h e s e n s o r y d is tr ib u tio n o n th e d o r s a l s u r f a c e o f th e h a n d d e s c r ib e d in th e q u e s tio n m a tc h e s th e in n e r v a tio n p r o v id e d b y th e r a d ia l n e r v e . H o w e v e r. C. D. S c ia tic n e r v e o r ig i n a te s f r o m th e s a c r a l p le x u s a n d is n o t p a r t o f th e lu m b e r p le x u s . 21. la te r a l f e m o r a l c u ta n e o u s . b o th s c ia tic a n d f e m o r a l/s a p h e n o u s . b u t c a n b e b lo c k e d s e p a r a te ly if /w h e n n e e d e d . 17. th e to u r n iq u e t n e e d s to r e m a in in f la te d a n d in p o s itio n f o r a m in im u m o f 15 to 2 0 m in u te s e v e n if th e s u r g ic a l p r o c e d u r e f in is h e s e a rly . T h e f e m o r a l n e r v e d o e s n o t h a v e a n y m o to r c o m p o n e n ts b e lo w th e k n e e ( o n ly a s e n s o r y b r a n c h . 22. T h e la te r a l f e m o r a l c u ta n e o u s n e r v e s u p p lie s th e la te r a l p o r t i o n o f th e th ig h . lo c a l a n e s th e tic s y s te m ic to x ic ity . th e r a d ia l n e r v e is m o s t f r e q u e n tly p o s itio n e d p o s t e r i o r to a x illa r y a rte ry . D. p a tie n ts m a y c o m p la in o f to u r n iq u e t p a in th a t c a n b e c o m e e v id e n t a s e a r ly a s 2 0 m in u te s f o ll o w i n g b lo c k p e r f o r m a n c e . in te rm itte n t. S tim u la to r o f r a d ia l n e r v e w ill in d u c e d ig it/w r is t/ e lb o w e x te n s io n a n d f o r e a r m s u p in a tio n . A. 16. L A S T c a n o c c u r w h e n a l a r g e v o lu m e o f lo c a l a n e s th e tic is a b s o r b e d in to o r d ir e c tly in je c te d in to th e s y s te m ic c ir c u la tio n . C. T h e th r e e m a jo r n e r v e b r a n c h e s o f th e lu m b a r p le x u s th a t a r e a f f e c te d b y s u c h a b lo c k in c lu d e f e m o r a l. B lo c k a d e o f th e la te r a l f e m o r a l c u ta n e o u s n e r v e is n o t a lw a y s c o n s is te n tly b lo c k e d w ith f e m o r a l n e r v e b lo c k a p p r o a c h . a n d s lo w r e le a s e o f to u r n iq u e t is re c o m m e n d e d . B. in tr a th e c a l a n d /o r e p id u r a l in je c tio n s o f lo c a l a n e s th e tic s . S tim u la tio n o f th e m u s c u lo c u ta n e o u s n e r v e w ill c h a r a c te r is tic a lly c a u s e e lb o w f le x io n . M u s c u lo c u ta n e o u s n e r v e is f r e q u e n tly f o u n d w ith in c o r a c o b r a c h ia lis m u s c le a n d /o r b e tw e e n th e b ic e p s a n d c o r a c o b r a c h ia lis m u s c le s . 23. a te r m in a l n e r v e b lo c k a n y w h e r e a lo n g th e d is tr ib u tio n o f th e r a d ia l n e r v e p r o x im a l to th e w r is t w o u ld b e a n a p p r o p r ia te p la c e to s u p p le m e n t th e in itia l b r a c h ia l p le x u s b lo c k . la s tin g 6 0 m in u te s o r le s s . A.

26. H o w e v e r. B. n a m e ly . a n d g e n ito f e m o r a l n e r v e s a r e ta r g e te d w h e n p e r f o r m i n g a T A P b lo c k . B. v is c e r a l p a in . T h e s e n e r v e s h a v e a ty p ic a l d is tr ib u tio n b e tw e e n th e in te r n a l o b liq u e a n d tr a n s v e r s u s a b d o m in is m u s c le s . b u t is m o s t o f te n a n a c u te e v e n t f r o m s y s te m ic a d m in is tr a tio n . 28. T h e b r a c h ia l p le x u s n e r v e r o o t / t r u n k is u s u a lly p o s itio n e d b e tw e e n th e a n te r io r a n d m id d le s c a le n e m u s c le s . 24. D. ilio in g u i n a l (L 1 ). p e r f o r m i n g b ila te r a l T A P b lo c k s a r e o f te n n e e d e d . e s p e c ia lly w h e n p la c in g b ila te r a l p a r a v e r t e b r a l b lo c k s . a n d i l i o h y p o g a s tr ic (L 1 ). F o r m id lin e v e n tr a l h e r n ia s u r g e r y . 27. it is c o m m o n ly r e f e r r e d to a s a n in te r s c a le n e b lo c k . A. 25. a n d p o s te r io r tib ia l n e rv e . o n e o f th e m a jo r c o n c e r n s f o r p o te n tia l c o m p lic a tio n s is d e v e lo p m e n t o f a p n e u m o th o r a x . s a p h e n o u s n e r v e . th e s a p h e n o u s n e r v e is p r e f e r e n tia lly b lo c k e d to a v o id m o to r b lo c k a d e o f th e a n te r io r q u a d m u s c le s th a t c a n r e s u lt f r o m p e r f o r m a n c e o f a f e m o r a l n e r v e b lo c k ( in c r e a s e d r i s k o f f a ll). C. T h e s u b c o s ta l (T 1 2 ). M e th e m o g lo b in e m ia c a n h a p p e n in p a tie n ts w ith c e r ta in lo c a l a n e s th e tic s . A. T h e s a p h e n o u s n e r v e is a te r m in a l s e n s o r y n e r v e b r a n c h o f th e f e m o r a l n e r v e w ith N O m o to r c o m p o n e n ts . th e s u p e r f ic ia l a n d d e e p p e r o n e a l n e r v e . T h e s c ia tic n e r v e is m o s t o p tim a lly b lo c k e d w ith lo c a l a n e s th e tic a t th e u n io n ( b if u r c a tio n ) o f th e s e tw o n e r v e s th a t f r e q u e n tly b e c o m e o n e n e r v e s tr u c tu r e a p p r o x im a te ly 7 to 10 c m p r o x im a l to th e p o p lite a l c r e a s e . a n d p a r a v e r t e b r a l b lo c k s c a n b e a s s o c ia te d w ith v a r ia b le d e g r e e s o f lo c a l a n e s th e tic e p id u r a l s p re a d . A d v a n ta g e s o f p r o p e r l y p la c e d p a r a v e r t e b r a l n e r v e b lo c k s in c lu d e r e d u c e d d e g r e e s o f lo c a l a n e s th e tic . A. T h e o b tu r a to r n e r v e d o e s n o t p r o v id e s e n s o r y o r m o to r n e r v e d is tr ib u tio n to f o o t o r a n k le . W h e n lo c a l a n e s th e tic s a r e p la c e d b e tw e e n th e s e tw o m u s c le b u n d le s . L A S T c a n o c c u r f r o m a d m in is tr a tio n o f to x ic d o s e s o f a n y lo c a l a n e s th e tic . B ila te r a l s u p r a c la v ic u la r b lo c k a d e c a n s ig n if ic a n tly in c r e a s e th e r i s k o f s y m p to m a tic p h r e n ic n e r v e p a ls y . n e r v e s n e e d to b e a n e s th e tiz e d /b lo c k e d . . T A P b lo c k s d o n o t c o v e r c ra p p y . b u t u s u a lly n o t f r o m r o p iv a c a in e a d m in is tr a tio n .in d u c e d s y m p a th e c to m y c o m p a r e d to e p id u r a l o r s p in a l a n e s th e s ia a n d a lo w e r r i s k o f lo c a l a n e s th e tic s y s te m ic to x ic ity a s c o m p a r e d w ith in te r c o s ta l n e r v e b lo c k s . P o p lite a l a p p r o a c h to th e s c ia tic n e r v e b lo c k is ty p ic a lly p e r f o r m e d a t th e s ite o f b if u r c a tio n o f th e tib ia l ( m e d ia l p o s itio n ) a n d c o m m o n p e r o n e a l ( la te r a l p o s itio n ) n e r v e s . 29. U n d e r c e r ta in c lin ic a l s itu a tio n s . A n a n k le b lo c k c a n b e p e r f o r m e d b y p r o v id i n g a n e s th e s ia a n d b lo c k in g th e fiv e n e r v e s th a t in n e r v a te th e f o o t. T A P b lo c k s c a n p r o v id e a n a lg e s ia f o r p e r ip h e r a l s o m a tic p a in o f th e a b d o m e n a n d c a n b e a s s o c ia te d w ith a l o w y e t p o te n tia l r i s k o f b o w e l p e r f o r a t i o n a n d liv e r in ju r y . B. 31. s u r a l n e r v e . 30.

39. 36. it o f te n te n d s to in v o lv e m o r e is o la te d n e r v e r o o ts /tr u n k s o f th e b r a c h ia l p le x u s f r o m th e in te r s c a le n e a p p r o a c h r a th e r th a n d if f u s e in f lu e n c e s a t m o r e d is ta l le v e ls o f th e p le x u s . N e r v e . 35. a n d m e d ia l s id e o f th e lo w e r e x tr e m ity b e lo w th e k n e e . 38. B. o b tu r a to r . 37. A n a p p r o p r ia te o p tio n w o u ld b e to in tu b a te th e p a tie n t a n d p r o v id e a n y n e c e s s a r y s e d a tio n a n d th e n e x tu b a tio n u p o n e v id e n c e o f r e c o v e r y o f d ia p h r a g m fu n c tio n . B u p iv a c a in e is b e s t k n o w n f o r its h ig h c a r d io v a s c u la r to x ic ity . C. e x c e p t f o r th e m e d ic a l lo w e r le g . S c ia tic n e r v e b lo c k a d e p r o v id e s s e n s o r y lo s s to th e p o s t e r i o r th ig h b y b lo c k in g th e p o s te r io r c u ta n e o u s n e r v e a lo n g w ith e v e r y th in g b e lo w th e k n e e . A. T h e w itn e s s e d r e s p i r a t o r y d e p r e s s io n is m o s t lik e ly d u e to d ia p h r a g m p a ls y a n d th e u r g e n t n e e d f o r v e n tila tio n a s s is ta n c e u n til r e s o l u t i o n o f p h r e n ic n e r v e d y s fu n c tio n . 34. B. S h o u ld e r s u r g e r y is o n e o f th e u p p e r e x tr e m ity p r o c e d u r e s th a t c a n o f te n b e a s s o c ia te d w ith n e r v e in ju r ie s s e c o n d a r y to p a tie n t p a th o lo g y . T h e o th e r lis te d lo c a l a n e s th e tic m e d ic a tio n s te n d to h a v e n e u r o l o g i c a l to x ic ity p r i o r to p r o g r e s s i n g to w a r d c a r d io v a s c u la r c o lla p s e . T h e s e p e r ip h e r a l r e g i o n a l te c h n iq u e s c a n b e p a r tic u la r ly u s e f u l in p a tie n ts w ith d if f ic u lty o r c o n tr a in d ic a tio n s to n e u r a x ia l b lo c k a d e . b r a c h ia l p le x u s n e r v e s tr e tc h in g o r c o m p r e s s io n . etc. B. B. w h ic h is in n e r v a te d b y th e s a p h e n o u s n e rv e . a lth o u g h a n y o f th e lo c a l a n e s th e tic m e d ic a tio n s lis te d a b o v e c a n r e s u lt in L A S T .32. F e m o r a l a n d p r o x im a l s c ia tic n e r v e b lo c k to g e th e r c a n o f te n p r o v id e f o r e x c e lle n t p e r io p e r a tiv e p a in c o n tr o l a n d c a n f a c ilita te p h y s ic a l th e r a p y w ith a r e d u c e d in c id e n c e o f in te r f e r e n c e w ith a m b u la tio n . A p r o p e r l y p la c e d a n d f u n c tio n in g lu m b a r p le x u s b lo c k a d e /c a th e te r w ill c o v e r th e f e m o r a l. a n d la te r a l f e m o r a l c u ta n e o u s n e r v e a n d o f te n p r o v id e s f o r b e tte r p a in c o n tr o l o f th e h ip in c o n ju n c tio n w ith a s c ia tic /s a c r a l n e r v e p le x u s b lo c k . . B.c o n d u c tio n s tu d ie s a n d E M G s h o u ld b e c o n s id e r e d r a th e r th a n m e r e ly d e lin e a tin g a n e t i o l o g y o f th e in ju r y . O n e o f th e r e p o r te d a d v a n ta g e s o f r o p iv a c a in e o v e r b u p iv a c a in e is its r e la tiv e ly lo w e r e d in c id e n c e o f c a r d io v a s c u la r to x ic ity . C. A f e m o r a l b lo c k f o r h ip s u r g ic a l p r o c e d u r e s h a v e in tr in s ic lim ita tio n s a s d o e s n o t c o m p le te ly c o v e r A L L d e r m a to m e d is tr ib u tio n s o f th e h ip . T h e f e m o r a l n e r v e p r o v id e s s e n s o r y in n e r v a tio n to th e a n te r io r a n d m e d ia l th ig h a b o v e th e k n e e . s u r g ic a l tra u m a . s u r g ic a l m a n ip u la tio n ( s ) . T h e s c ia tic n e r v e s u p p lie s a ll o f th e m o to r in n e r v a tio n a n d th e m a j o r i t y o f th e s e n s o r y in n e r v a tio n to th e lo w e r e x tr e m itie s b e lo w k n e e e x c e p t th e m e d ia l s id e o f th e lo w e r e x tr e m ity th a t is in n e r v a te d b y th e s a p h e n o u s n e rv e . If s u c h a n in ju r y w a s d u e to p e r f o r m a n c e o f th e p e r ip h e r a l n e r v e b lo c k a n d /o r c a th e te r p la c e m e n t. S u r g ic a l c o m p lic a tio n s o f th e b r a c h ia l p le x u s o f te n te n d to b e m o r e d if f u s e a n d le s s s e le c tiv e . T h e f e m o r a l n e r v e in n e r v a te s a n d s u p p lie s m o to r c o n tr o l o f th e a n te r io r q u a d r ic e p s m u s c le s a b o v e th e k n e e a n d n o m o to r in n e r v a tio n b e lo w th e k n e e . 33.

h e p a te c to m y p a tie n ts n e e d a d d itio n a l p a in . A. th e b r a c h ia l p le x u s s h o u ld n o t b e a ffe c te d ( C 4 . a lo n g w ith e p h e d r in e . T h e f e m o r a l n e r v e is u s u a lly p o s itio n e d m o r e la te r a l a n d d e e p e r to th is s m a ll b r a n c h th a t o r ig i n a te s f r o m th e f e m o r a l n e r v e w h ic h in n e r v a te s th e s a r to r iu s m u s c le . C. w h e n b ila te r a l p a r a v e r t e b r a l b lo c k s a r e p e r f o r m e d . e x c e p t k e ta m in e . T h e m o s t lik e ly c a u s e is s e c o n d a r y to a x illa r y ly m p h n o d e d i s s e c tio n . th e r e f o r e . If th e n e u r o l o g i c in ju r y w e r e d u e to c o m p lic a tio n s f r o m p la c e m e n t o f a s i n g le . 47. A p o te n tia l a d v a n ta g e o f p a r a v e r t e b r a l b lo c k a d e c o m p a r e d to n e u r a x ia l b lo c k a d e is a r e d u c e d in c id e n c e o f c r e a tin g a n in te n s e s y m p a th e c to m y r e s u ltin g in h e m o d y n a m ic c o m p r o m is e .g u id e d r e g i o n a l a n e s th e s ia . th e p o te n tia l e x is ts th a t e p id u r a l s p r e a d c o u ld b e s ig n if ic a n t. S u p r a c la v ic u la r a p p r o a c h to b lo c k a d e o f th e b r a c h ia l p le x u s c a r r ie s a h ig h r i s k o f p n e u m o th o r a x f o ll o w e d b y th e in te r s c a le n e a p p r o a c h . P e r ip h e r a l n e r v e b lo c k in ju r ie s f r o m a s u p r a c la v ic u la r b lo c k w o u ld b e m o r e lik e ly to r e s u lt in e v id e n c e o f a n in ju r y p a tte r n is o la te d to th e tr u n k s o r d iv is io n s o f th e b r a c h ia l p le x u s . K e ta m in e . r e s u ltin g in a n o b s e r v a tio n o f a m o d e r a te B P d e c r e a s e . 43.m a n a g e m e n t m o d a litie s s u c h as o p io id s .s h o t s u p r a c la v ic u la r b lo c k a d e o r lo c a l a n e s th e tic u s e d d u r in g b lo c k p la c e m e n t. 45. N e u r o lo g ic in ju r ie s s e c o n d a r y to p o s itio n a l. 44. . D. 41. B.in je c te d lo c a l a n e s th e tic . is c h e m ic in ju r y o f te n c re a te s a m o r e d if f u s e ty p e o f a n in ju r y p a tte r n s im ila r to th e o n e d e s c r ib e d in th e q u e s tio n .40. a n d u ln a r n e r v e s . th e n th e s e ty p e s o f in ju r ie s w o u ld te n d to h a v e a m o r e is o la te d p a tte rn . B. H o w e v e r. C. W ith o u t a n y a d ju v a n t. s p e c if ic a lly th e r a d ia l. 46. A x illa r y b lo c k is ty p ic a lly p e r f o r m e d a t th e le v e l o f th e in d iv id u a l p e r ip h e r a l n e r v e b r a n c h e s o f th e b r a c h ia l p le x u s . c o m p r e s s io n a l. r o p iv a c a in e b lo c k w ill n o t la s t a s lo n g a s 72 h o u r s . th e r e f o r e . a n d th e p a tie n t w o u ld ty p ic a lly r e v e a l s y m p to m s a b o v e e lb o w a s w e ll. T h is p n e u m o th o r a x r i s k h a s d e c r e a s e d a n d is b e lie v e d to b e s e c o n d a r y to th e m o r e f r e q u e n t u s e o f u ltr a s o u n d .T 1 ) b y th e p a r a v e r t e b r a l. 42.in d u c e d p a in w ith little v is c e r a l p a in c o v e r a g e . S a r to r iu s m u s c le tw itc h c o u ld b e s e c o n d a r y to s tim u la tio n o f a s m a ll b r a n c h f r o m th e f e m o r a l n e r v e th a t in n e r v a te s th e s a r to r iu s m u s c le o r s e c o n d a r y to d ir e c t m u s c le s tim u la tio n .T 5 . a r e c o m m o n ly u s e d in p e r ip h e r a l n e r v e b lo c k s to im p r o v e th e d e n s ity a n d p r o l o n g th e d u r a tio n o f n e r v e b lo c k a d e e ffic a c y .r e la te d b r a c h ia l p le x u s in ju r y . w h e n m ix e d w ith lo c a l a n e s th e tic s d u r in g a p e r ip h e r a l n e r v e b lo c k h a s b e e n s tu d ie d in a n im a l m o d e ls a n d w a s d e e m e d to o f f e r little to n o a d d itio n a l b e n e f its o r s y n e r g is tic e ffe c ts . A ll o f th e a b o v e a d ju v a n t m e d ic a tio n s . T h e le v e l o f p a r a v e r t e b r a l b lo c k s w a s a t T 3 . P a r a v e r te b r a l b lo c k a d e p r o v id e s m o s tly f o r s o m a tic . A. B. m e d ia n . N o w th e s u p r a c la v ic u la r a p p r o a c h to b lo c k a d e o f th e b r a c h ia l p le x u s is c o m m o n ly p e r f o r m e d w ith u ltr a s o u n d g u id a n c e .

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Inflammatory D. 1 to 2 months D. Indirect effect of decreasing opioid-related side effects D. All of the above 3.Pain Management Thomas Halaszynski 1. Type(s) of symptomatic pain conditions that best describes “chronic” pain often includes A. Can improve wound healing 4. Decreases opioid requirements B. Neuropathic or nociceptive pain D. some of the potential advantages include all of the following. 3 to 4 weeks C. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as part of “multimodal” analgesic therapy. 1 to 2 weeks B. Somatic or visceral pain 5. Can decrease postoperative pain intensity C. Neuroendocrine B. 6 to 12 months 2. At what levels does the modulation of pain by electrical stimulation result in the activation of inhibitory fibers? A. At what time frame following the postsurgical period does persistent postsurgical pain become defined as being “chronic pain”? A. Spinal cord level alone . Nociceptive pain alone C. Nociceptor level alone B. except A. Both surgical trauma and anesthetic administration techniques can modulate which of the following human stress responses? A. Metabolic C. Neuropathic pain alone B.

Which of the following can best explain the block failure? A. All of the above 6. Chronic pain indications for insertion of a spinal cord stimulator include all of the following. Dysesthesia is an abnormal sensation with or without a stimulus B. Neuralgia is due to abnormality in nerve roots D. Hypalgesia D. C. Anesthesia dolorosa C. Paresthesia is abnormal sensation without a stimulus C. skin temperature in the left arm rises from 33 to 36. Phantom pain B. Pain-carrying fibers originated from inferior cervical ganglion D.5°C. Second-order wide dynamic range neurons B. Hyperalgesia B. left eye papillary constriction. Hyperesthesia is an abnormal sensation of exaggerated response to mild stimulation 11. Complex regional pain syndrome C. Compartment syndrome pain 9. Pain-carrying fibers originated from second thoracic ganglion 8. Spinal cord reflexes D. All of the above 7. A 26-year-old female undergoes a left stellate ganglion block for treatment of complex regional pain syndrome of the left hand. Incorrect statement related to the definition of an abnormal sensation is A. Allodynia 10. The term used to best describe the PAIN condition “perception toward ordinary non-noxious stimulus as being painful” is A. Dorsal horn neuron C. Twenty minutes after the block is placed. The pain is not relieved. Only within the brain D. Chronic visceral pelvic pain D. Which of the following clinical diagnoses best describes deafferentation pain? . and drooping of the eyelid are observed. Activation of which of the following mechanisms and/or pathways best describes “central sensitization” at the level of the spinal cord? A. Venous engorgement of the left arm and hand. Pain-carrying fibers originated from right stellate ganglion B. except A. Pain-carrying fibers originated from middle cervical ganglion C.

except A. Glossopharyngeal nerve D. Facial nerve B. A. Postherpetic neuralgia D. Vagal nerve 13. Gasserian ganglion block is most commonly used for neuropathic pain located in which of the following nerve distributions? A. It is associated with Lewis’ triple response C. Adenosine C. It is increased by application of capsaicin 16. Complex regional pain syndrome B. Hypertension and tachycardia . except A. Major excitatory neurotransmitters responsible for pain modulation include all the following. Types of pain disorders that are commonly treated using “sympathetic blockade” include all of the following. Diabetic neuropathy 12. Substance P B. Phantom limb pain C. It is caused by neurogenic inflammation B. Amputation C. Aspartate 14. Neuropathic pain D. Herniated disk B. except A. except A. Norepinephrine B. Trigeminal nerve C. Systemic responses of the human body that can develop secondary to symptoms of acute pain include all of the following. Calcitonin gene-related peptide 15. All the following are inhibitory neurotransmitters in the pain pathway. Serotonin D. Acute pain due to pelvic exenteration 17. It is increased by injection of local anesthetics D. Somatostatin D. Glutamate C. Incorrect statement regarding secondary hyperalgesia is A.

No other pathologies can explain or contribute to the pain D. the patient complains of right fourth and fifth digit numbness and minor pain. Median nerve B. Degenerative disk disease C. Systemic diseases such as connective tissue disease may cause myofascial pain D. and alcohol abuse presents to the operating room for a right-elbow open reduction internal fixation. secondary to a motor vehicle accident that occurred 24 hours ago. On postoperative day 1. The diagnosis of fibromyalgia includes all of the following. A 56-year-old patient with a past medical history of hypertension. Pain lasts more than 3 months C. Patient may have several trigger points producing pain upon stimulation C. except A. Frequent association with psychiatric diagnosis 22. Sciatic nerve D. Minor pain B. stiffness. Incorrect statement regarding myofascial pain is A. diabetes. Increased peristalsis 18. A diagnosis of cubital tunnel syndrome has been made. Femoral and saphenous nerves B. Common causes for lower back pain include all of the following. Myofascial syndromes D. The nerve most likely to be involved is A. spasm) B. Urinary retention D. Obturator and femoral nerves 19. Ilioinguinal nerve C. A 56-year-old man presented to his primary care physician with a complaint of right buttock and right leg pain along with numbness and tingling sensations. Increased work of breathing C. Myofascial pain is associated with muscle discomfort (pain. Ulnar nerve C. Lumbosacral strain B. Musculocutaneous nerve 20. Myofascial pain is never associated with autonomic dysfunctions 21. The nerve(s) responsible for this diagnosis is/are A. Fibromyalgia syndrome 23. except A. A 68-year-old male presents to his primary care physician’s office with a major complain of . Radial nerve D. B. weakness. He was subsequently diagnosed with a piriformis syndrome (trapped nerve).

L5-S1 24. Incorrect statement regarding treatment of complex regional pain syndrome (CRPS) is . Spinal cord stimulator is not an effective therapy 28. Quadriceps femoris muscle weakness C. except A. It is only associated with major injuries (never from minor procedures) D. Pain is sympathetically mediated 26. It is not associated with evidence of skin color. Pathological features of complex regional pain syndrome include all the following. Facet syndrome is characterized by all the following. It is most optimally treated with multimodal therapies C. Neuropathic pain can be associated with hyperpathia 27. It is not associated with low back pain or multiple sclerosis C. and temperature changes 29. It is often associated with documented nerve injury C. Regarding the treatment of neuropathic pain. It includes pain associated with stroke. Disk herniation at L4-L5 of the vertebral column often presents with all of the following clinical symptoms. Posterior-lateral thigh pain D. Diminished dorsiflexion of the foot B. The patient’s physical examination reveals decreased plantar flexion of the foot. Incorrect statement regarding neuropathic pain is A. spinal cord injury. L2-L3 B. Pain relieved by an intra-articular injection of the zygapophyseal joints C. It is sympathetically mediated B. the correct statement is A. Dorsal foot pain between first and second toes 25. and diabetic neuropathy B. Pain can be exacerbated by overextension and lateral rotation of back D. L4-L5 D. An MRI will most commonly show a herniated disk at A. Neuropathic pain can be paroxysmal D. L3-L4 C. Narcotics is the most effective and “first-line” treatment option B. except A. back pain radiating into the gluteal region and pain in the distribution of the plantar surface of the foot on the same side. except A. Sympathetic blockade will eliminate all neuropathic pain D. hair. Pain relieved by local anesthetic injection of the medial branches of the posterior rami of spinal nerves B.

If n o t tr e a te d p r o p e r l y a n d in a tim e ly f a s h io n . C o n s tip a tio n a n d u r i n a r y r e te n tio n C. P a tie n ts n e e d to r e f r a i n f r o m p h y s ic a l th e r a p y u n til th e p a in s y n d r o m e is r e s o lv e d 30. e x c e p t A. R e tr o p e r ito n e a l h e m o r r h a g e . P o s tu r a l h y p o te n s io n a n d lig h th e a d e d n e s s B. P o s s ib le c o m p lic a tio n s to d is c lo s e w h e n o b ta in in g a n a n e s th e s ia c o n s e n t f r o m a p a tie n t p r i o r to p e r f o r m a n c e o f a c e lia c p le x u s b lo c k in c lu d e a ll o f th e f o ll o w i n g . C R P S c a n r e s u lt in f u n c tio n a l d is a b ility D. E f f ic a c io u s tr e a tm e n t w ith m u ltim o d a l th e r a p y e a r ly in th e d ia g n o s is (w ith in 1 m o n th o f s y m p to m ) is m o s t e ffe c tiv e B. It r e s p o n d s w e ll to s y m p a th e tic b lo c k a d e C. V e n a c a v a a n d a o r tic v a s c u la r in ju r y D. A.

a c h in g . tin g lin g . It c a n o c c u r a t th e n o c ic e p to r le v e l p e r ip h e r a lly o r c e n tr a lly e ith e r in th e s p in a l c o r d o r in s u p r a s p in a l s tr u c tu r e s . b u t a ls o s e v e r a l p o te n tia l s id e e ffe c ts th a t th e p r a c titio n e r m u s t r e m a in c o g n iz a n t o f s u c h a s r i s k o f g a s tr o in te s tin a l b le e d in g . m a s te c to m y . V is c e r a l p a in o r ig i n a te s in th e in te r n a l o r g a n s y s te m (s ) o f th e b o d y . T h e s e f a c to r s c a n b e f u r th e r m o d if ie d b y p a tie n t.” 2. a n d is d e s c r ib e d a s d u ll. N S A ID s h a v e n o t o n ly m a n y o f th e a b o v e . D e e p s o m a tic p a in is in itia te d b y s tim u la tio n o f n o c ic e p to r s in lig a m e n ts . th o r a c o to m y . th o u g h s o m e o th e r in v e s tig a to r s h a v e p la c e d th e tr a n s itio n f r o m a c u te to c h r o n ic p a in a t 12 m o n th s . te n d o n s . M o d u la tio n o f p a in c a n h a p p e n c e n tr a lly o r p e r ip h e r a lly . A p o p u la r a lte r n a tiv e d e f in itio n o f c h r o n ic p a in in v o lv in g n o a r b i t r a r i l y fix e d d u r a tio n s is “ p a in th a t e x te n d s b e y o n d th e e x p e c te d p e r i o d o f h e a lin g . P e r ip h e r a l n e u r o p a th ic p a in is o f te n d e s c r ib e d a s b u r n in g . e le c tr ic a l. C h r o n ic p a in is m o s t o f te n d e f in e d a s n e u r o p a th ic a n d /o r n o c ic e p tiv e in n a tu re . s u r g ic a l te c h n iq u e ( o p e n v s . N o c ic e p tiv e p a in is d iv id e d in to s u p e r f ic ia l o r d e e p . 4. p o o r l y . C h r o n ic p a in m a y b e d iv id e d in to n o c ic e p tiv e p a in — c a u s e d b y a c tiv a tio n o f n o c ic e p to r s — a n d n e u r o p a th ic p a in — c a u s e d b y d a m a g e to o r m a lf u n c tio n o f th e n e r v o u s s y s te m . la p a r o s c o p y ) .id e n tif ie d a d v a n ta g e s . w h e r e th e s e n s a tio n is lo c a te d in a n a r e a d is ta n t f r o m th e s ite o f p a th o lo g y o r in ju r y . r e g io n a l) . C. a n d in g u in a l h e r n ia r e p a ir . A c u te p a in w ill ty p ic a lly la s t le s s th a n 3 0 d a y s . s u r g ic a l h is to r y . D. a n d s e v e r a l v is c e r a l r e g i o n s c a n p r o d u c e “ r e f e r r e d ” p a in w h e n d a m a g e d o r in f la m e d . a n d s u b a c u te p a in la s ts f r o m 1 to 6 m o n th s . b u t o f te n is d if f ic u lt to lo c a te . r e n a l in ju r y . T h e in c id e n c e o f p e r s is te n t p o s ts u r g ic a l p a in c a n o fte n e x c e e d a n in c id e n c e o f 3 0 % a fte r c e r ta in h i g h . V is c e r a l p a in m a y b e w e ll. C h r o n ic p a in is d e f in e d a s p a in th a t h a s la s te d l o n g e r th a n 3 to 6 m o n th s . P e r s is te n t p o s ts u r g ic a l p a in is d e f in e d a s c h r o n ic p a in th a t c o n tin u e s b e y o n d th e u s u a l r e c o v e r y p e r i o d o f 1 to 2 m o n th s f o ll o w i n g s u r g e r y (w e ll p a s t th e n o r m a l c o n v a le s c e n c e p e r io d e x p e c te d f o r a p a r tic u la r /s p e c if ic s u r g ic a l p r o c e d u r e ) . D. CHAPTER 9 ANSWERS 1.s p e c if ic c o n tr ib u tio n s s u c h as a n x ie ty /d e p r e s s io n . c h r o n ic p a in to m o r e th a n 6 m o n th s d u r a tio n . M a n y p e r io p e r a tiv e f a c to r s c a n p r o d u c e s ig n if ic a n t in f lu e n c e to w a r d a m p lif y in g o r d e c r e a s in g th e s u r g ic a l s tr e s s r e s p o n s e ( s ) s u c h a s n e u r o e n d o c r i n e .lo c a liz e d . 5. b o n e s . b l o o d v e s s e ls .r i s k / s u r g i c a l l y in v a s iv e p r o c e d u r e s s u c h as a m p u ta tio n s . a n d th e p o te n tia l to im p a ir w o u n d h e a lin g . a n d a n e s th e tic te c h n iq u e s ( g e n e r a l v s . m u c h o f th e i n f o r m a t io n f r o m th e n o c ic e p tiv e a f f e r e n t f ib e r s r e s u lts f r o m e x c ita to r y d is c h a r g e s o f m u ltir e c e p tiv e n e u r o n s .l o c a l i z e d p a in . T h e s e m o d u la tio n e ffe c ts c a n b e e ith e r in h ib itiv e o r fa c ilita tiv e . D. 3. P a in i n f o r m a t io n in th e c e n tr a l n e r v o u s s y s te m is c o n tr o lle d b y a s c e n d in g a n d d e s c e n d in g in h ib ito r y p a th w a y s (u s in g e n d o g e n o u s o p io id s o r o th e r e n d o g e n o u s . m e ta b o lic . a n d m u s c le s . a n d in f l a m m a to r y c h a n g e s . S u p e r f ic ia l p a in is in itia te d b y a c tiv a tio n o f n o c ic e p to r s in th e s k in o r s u p e r f ic ia l tis s u e s . In th e b r a i n a n d th e s p in a l c o r d . s ta b b in g . a n d d e e p p a in in to d e e p s o m a tic a n d v is c e r a l p a in . N e u r o p a th ic p a in is d iv id e d in to p e r ip h e r a l (w ith in th e p e r ip h e r a l n e r v o u s s y s te m ) a n d c e n tr a l ( o r ig in a t in g f r o m th e b r a in /s p in a l c o r d ) . a n d /o r p in s a n d n e e d le s s e n s a tio n ( s ) . C.

C e n tra l s e n s itiz a tio n is r e s p o n s ib le f o r h y p e r a lg e s ia a n d th e r e a r e th r e e m e c h a n is m s th a t h a v e b e e n id e n tif ie d a t th e le v e l o f s p in a l c o r d : (1 ) w in d u p o f s e c o n d . a p o w e r f u l in h ib itio n o f p a in . D. p h a n to m lim b p a in .o r d e r w id e d y n a m ic r a n g e n e u r o n s . S te lla te g a n g lio n is lo c a te d a t th e le v e l o f C 7 ( s e v e n th c e r v ic a l v e r te b r a ) . H y p e r a lg e s ia is a n e x a g g e r a te d r e s p o n s e to n o x io u s s tim u li. D. T h e s te lla te g a n g lio n ( c e r v ic o th o r a c ic g a n g lio n o r i n f e r i o r c e r v ic a l g a n g lio n ) is a s y m p a th e tic g a n g lio n f o r m e d b y th e f u s io n o f th e i n f e r i o r c e r v ic a l a n d f ir s t th o r a c ic g a n g lio n . c a u s e d b y in c r e a s e s in m e m b r a n e e x c ita b ility a n d s y n a p tic e f f ic a c y as w e ll a s r e d u c e d in h ib itio n a n d is a m a n if e s ta tio n o f th e p la s tic ity o f th e s o m a t o s e n s o r y n e r v o u s s y s te m in r e s p o n s e to a c tiv ity . s u b s ta n c e s ). a n d (3 ) h y p e r e x c ita b ility o f f le x io n r e f le x e s . C o m p a r tm e n t s y n d r o m e p a in o fte n r e q u ir e s u r g e n t e v a lu a tio n a n d p o s s ib le n e e d f o r e m e r g e n c y f a s c io to m y . w e tn e s s . D. C. S p in a l c o r d s tim u la tio n is m o s t e f f e c tiv e f o r n e u r o p a th ic p a in . in tr a th e c a l/e p id u r a l in je c tio n . 10. a n te r io r to th e tr a n s v e r s e p r o c e s s o f C 7 . b r a c h ia l p le x u s in v o lv e m e n t. a n d v is c e r a l p a in . H o w e v e r. p r ic k lin g . T h is s e n s a tio n is a ls o in f lu e n c e d b y e m o tio n a l state. a n d o s te o m y e litis o r m e d ia s tin itis ( r a r e ly ) . A llo d y n ia is d e f in e d a s p a in d u e to a s tim u lu s th a t d o e s n o t n o r m a l l y p r o v o k e p a in . P a r e s th e s ia is a b n o r m a l s e n s a tio n w ith o u t a s tim u lu s w ith a s e n s a tio n o f tin g lin g . lo c a l a n e s th e tic s s p r e a d to r e c u r r e n t la r y n g e a l n e r v e . p e r ip h e r a l n e u r o p a th ie s . o r s e v e r e . H y p a lg e s ia e q u a ls r e d u c e d s e n s itiv ity to p a in . A n e s th e s ia d o l o r o s a is p a in in a r e a th a t h a s n o s e n s a tio n . s u p e r io r to th e n e c k o f th e f i r s t r ib . in c lu d in g m o s t o f te n th e m o u th . s c a lp . a c h in g . D. p n e u m o th o r a x .r e la te d i n f o r m a t io n o c c u r s in th e s p in a l c o r d . is p a in fe lt in a n a r e a ( u s u a lly o f th e fa c e ) th a t is c o m p le te ly n u m b to to u c h w ith th e p a in d e s c r ib e d a s c o n s ta n t. in f la m m a tio n . a n d p in s a n d n e e d le s . b le e d in g . In a d d itio n . a n d a d d itio n a l a p p lic a tio n s in c lu d e u s e in s o m e m o to r d is o r d e r s . a n d j u s t b e lo w th e s u b c la v ia n a rte ry . p a in is a c o m p le x p e r c e p tio n th a t is in f lu e n c e d a ls o b y p r i o r e x p e r ie n c e a n d b y th e c o n te x t w ith in w h ic h th e n o x io u s s tim u lu s o c c u r s . . a n e x tr e m e a n d e x a g g e r a te d r e a c tio n to a s tim u lu s w h ic h is n o r m a l l y p a in f u l. 6. s k in . 7. C e n tra l s e n s itiz a tio n is a n e n h a n c e m e n t in th e f u n c tio n o f n e u r o n s a n d c ir c u its in n o c ic e p tiv e p a th w a y s . (2 ) d o r s a l h o r n n e u r o n r e c e p to r f ie ld e x p a n s io n . o r le g s . th e o p p o s ite o f h y p e r a lg e s ia . D y s e s th e s ia is c a u s e d b y le s io n s o f th e n e r v o u s s y s te m ( p e r ip h e r a l o r c e n tr a l) a n d in v o lv e s s e n s a tio n s ( s p o n ta n e o u s o r e v o k e d ) s u c h as b u r n in g . T h e s e in h ib ito r y s y s te m s c a n b e a c tiv a te d b y b r a i n s tim u la tio n a n d p e r ip h e r a l n e r v e s tim u la tio n . a b n o r m a l s e n s e o f to u c h a n d o f te n p r e s e n ts a s p a in ( m a y a ls o p r e s e n t a s a n in a p p r o p r ia te . is c h e m ic p a in d u e to p e r ip h e r a l v a s c u la r d is e a s e . o f w h ic h s o m e c o m m o n in d ic a tio n s in c lu d e s y m p a th e tic a lly m e d ia te d p a in . tic k lin g . C o m p lic a tio n s o f s te lla te b lo c k in c lu d e in tr a v a s c u la r in je c tio n . D y s e s th e s ia is a n a b n o r m a l s e n s a tio n w ith o r w ith o u t a s tim u lu s a n d is d e f in e d a s a n u n p le a s a n t. T e m p e r a tu r e o r p h y s ic a l s tim u li c a n p r o v o k e a llo d y n ia (w h ic h m a y fe e l lik e a b u r n in g s e n s a tio n ) a n d c a n o f te n o c c u r a fte r in ju r y . A s p in a l c o r d s tim u la to r is a d e v ic e u s e d to e x e r t p u ls e d e le c tr ic a l s ig n a ls to th e s p in a l c o r d to c o n tr o l c h r o n ic p a in . e le c tr ic s h o c k . b u t n o t d is c o m f o r tin g . a n d n e u r a l in ju r y . b u r n in g . 9. s e n s a tio n ) . 8. D y s e s th e s ia c a n in c lu d e s e n s a tio n s in a n y b o d ily tis s u e . itc h in g .

N e u r a l g ia f a lls in to tw o c a te g o r ie s : c e n tr a l n e u r a lg ia (th e c a u s e o f th e p a in is lo c a te d in th e s p in a l c o r d o r b r a in ) a n d p e r ip h e r a l n e u r a lg ia . th e z o n e o f in ju r y ( in c r e a s e d p a in s e n s itiv ity o u ts id e o f th e a r e a o f in ju r y o r in f la m m a tio n ) . a n d e n d o r p h in a r e a m o n g th e m a jo r in h ib ito r y m e d ia to r s o f p a in . N o r e p in e p h r in e ..t e r m p h y s ic a l e ffe c t. a n d s e n s itiz a tio n to n o x io u s s tim u li.g . 15. c a lc ito n in g e n e . T h e m a n if e s ta tio n o f a p a r e s th e s ia m a y b e tr a n s ie n t o r c h r o n ic . a n d s e r o to n in a r e a m o n g th e m a jo r in h ib ito r y n e u r o tr a n s m itte r s in th e p a in c a s c a d e . T h e d u r a l p o u c h th a t lie s j u s t b e h in d th e g a n g lio n is c a lle d th e tr i g e m in a l c is te r n a n d c o n ta in s c e r e b r o s p in a l f lu id . T h e y e n te r a r e c e s s c a lle d M e c k e l c a v e . o r b u r n in g o f a p e r s o n ’s s k in w ith n o a p p a r e n t l o n g . C.” N e u r a lg ia is p a in s e n s a tio n in th e d is tr ib u tio n o f a n e r v e o r a g r o u p o f n e r v e s ( r a d ic u lo p a th y is p a in s e c o n d a r y to n e r v e r o o t s p a th o lo g ie s ) . T h e g a s s e r ia n g a n g lio n is f o r m e d f r o m tw o r o o t s th a t e x it th e v e n tr a l s u r f a c e o f th e b r a in s te m a t th e m id p o n tin e le v e l. tis s u e e d e m a . 14. T h e g a s s e r ia n g a n g lio n c o n ta in s th e c e ll b o d ie s o f s e n s o r y f ib e r s o f tr i g e m in a l n e r v e . a n d A T P a r e a m o n g th e m a jo r e x c ita to r y m o le c u le s r e s p o n s ib le f o r p a in m o d u la tio n . w h ic h is f o r m e d b y a n in v a g in a tio n o f th e s u r r o u n d in g d u r a m a te r in to th e m id d le c r a n ia l f o s s a . g lu ta m a te . S u b s ta n c e P. th e m a x illa r y (V 2 ). a n d th e s e r o o t s p a s s in a f o r w a r d a n d la te r a l d ir e c tio n in th e p o s te r io r c r a n ia l f o s s a a c r o s s th e b o r d e r o f th e p e tr o u s b o n e . A s m a ll m o to r r o o t jo i n s th e m a n d ib u la r d iv is io n a s it e x its th e c r a n ia l c a v ity v ia th e f o r a m e n o v a le . a ls o k n o w n a s n e u r o g e n ic in f la m m a tio n . B. a d e n o s in e . 12. in a n im a l e x p e r im e n ts . It is th e in te r r u p t io n o r d e s tr u c tio n o f th e a f f e r e n t c o n n e c tio n s o f n e r v e c e lls (e .r e la te d p e p tid e is a n e x c ita to r y n e u r o tr a n s m itte r .s h a p e d . d e a f f e r e n ta tio n d e m o n s tr a te s th e s p o n ta n e ity o f l o c o m o t o r m o v e m e n t b y th e f r e e in g o f a m o to r n e r v e f r o m s e n s o r y c o m p o n e n ts ) . a c e ty lc h o lin e . w ith th e th r e e s e n s o r y d iv is io n s — th e o p h th a lm ic (V 1 ). S o m a to s ta tin . L o c a l a n e s th e tic s in je c tio n o r c a p s a ic in to p ic a l a p p lic a tio n c a n . T h e g a s s e r ia n g a n g lio n is c a n o e . T h e m o s t f a m ilia r k in d o f p a r e s th e s ia is th e s e n s a tio n k n o w n a s “ p in s a n d n e e d le s ” o r o f a lim b “ f a llin g a s le e p . D. p r ic k in g . T h is p r o c e d u r e c a lle d a g a s s e r ia n g a n g lio n b lo c k to tr e a t f a c ia l p a in is w h e r e a s m a ll a m o u n t o f lo c a l a n e s th e tic (w ith o r w ith o u t s te r o id ) is in je c te d o n to th e p a r t o f th e n e r v e s u p p ly to th e fa c e c a lle d th e g a s s e r ia n g a n g lio n ( lo c a te d to th e b a c k o f th e fa c e b e tw e e n th e e a r a n d e y e s o c k e t). is a s s o c ia te d w ith lo c a l r e d n e s s . H o w e v e r. A. a s p a rta te . 11. B. D e a f f e r e n ta tio n p a in is a ty p e o f n e u r o p a th ic p a in th a t is a s s o c ia te d w ith lo s s o f s e n s o r y in p u t f r o m th e p e r ip h e r y to th e c e n tr a l n e r v o u s s y s te m . a n d th e m a n d ib u la r (V 3 )— e x itin g th e a n te r io r c o n v e x a s p e c t o f th e g a n g lio n . S e c o n d a r y h y p e r a lg e s ia is d e f in e d a s a n in c r e a s e in p a in s e n s itiv ity w h e n a n o x io u s s tim u lu s is d e liv e r e d to a r e g i o n s u r r o u n d in g . S e c o n d a r y h y p e r a lg e s ia . 13. N e u r a l g ia is p a in in o n e o r m o r e n e r v e s c a u s e d b y a c h a n g e in n e u r o l o g i c a l s tr u c tu r e o r f u n c tio n o f th e n e r v e s r a th e r th a n b y e x c ita tio n o f h e a lth y p a in r e c e p to r s . s u c h a s p h a n to m lim b p a in . b u t n o t in c lu d in g . H y p e r e s th e s ia is e x a g g e r a te d r e s p o n s e to m ild s tim u la tio n o r a c o n d itio n th a t in v o lv e s a n a b n o r m a l in c r e a s e in s e n s itiv ity to s tim u li o f th e s e n s e .

v a s o c o n s tr ic tio n ) . a n d a s s o c ia te d w ith a u to n o m ic d y s f u n c tio n (e . p a in . C. M y o f a s c ia l p a in n e e d s to b e r u le d o u t in p a tie n ts w ith c h r o n ic lo w e r b a c k p a in as t r i g g e r p o in ts in q u a d ra tu s lu m b o r u m . a n d j o i n t s tiffn e s s . C u b ita l tu n n e l s y n d r o m e is a c o n d itio n b r o u g h t o n b y in c r e a s e d p r e s s u r e o n th e u ln a r n e r v e at th e e lb o w . 19. 21. a llo d y n ia a n d p in p r ic k ) . M y o f a s c ia l p a in s y n d r o m e s a r e a s s o c ia te d w ith m u s c le s y m p to m s s u c h a s s p a s m . C e r ta in c h r o n ic p a in c o n d itio n s a r e s y m p a th e tic a lly m a in ta in e d a n d w ill r e s p o n d to s y m p a th e tic b lo c k a d e . P o o r p o s tu r e a n d e m o tio n a l d is tu r b a n c e s m ig h t a ls o in s tig a te o r c o n tr ib u te to m y o f a s c ia l p a in . P i r i f o r m i s s y n d r o m e is a n e u r o m u s c u la r d is o r d e r th a t o c c u r s w h e n th e s c ia tic n e r v e is c o m p r e s s e d o r o th e r w is e ir r ita te d b y th e p i r i f o r m i s m u s c le . S o m e s y s te m ic d is e a s e s s u c h a s c o n n e c tiv e tis s u e d is e a s e c a n c a u s e m y o f a s c ia l p a in . ty p ic a lly a g a in s t m e d ia l e p ic o n d y le w h e r e th e u ln a r n e r v e p a s s e s . T h e d ia g n o s is o f m y o f a s c ia l p a in is b y th e p a in a n d e x is te n c e o f t r i g g e r p o in ts . b u t b e lie v e d to in v o lv e p s y c h o lo g ic a l. s u c h a s c o m p le x r e g i o n a l p a in s y n d r o m e . is ty p ic a lly n o t m e d ia te d s y m p a th e tic a lly a n d d o e s n o t u s u a lly r e s p o n d w e ll to a s y m p a th e c to m y . a n d th e te n d in o u s a r c h j o i n i n g th e h u m e r a l a n d u ln a r h e a d s o f th e f le x o r c a r p i u ln a r is . O th e r s y m p to m s c a n in c lu d e d e b ilita tin g fa tig u e . b u t m a y c o n tin u e o n a n d b e c o m e la te n t a n d a c tiv a te d a t a la te r tim e . w h ic h in c lu d e h y p e r te n s io n .g . w e a k n e s s . O n e o f th e m a n y r e a s o n s a c u te p a in n e e d s to b e m a n a g e d p r o p e r l y is its s y s te m ic e ffe c ts .g . 20. a n d tr i g e m in a l n e u r a lg ia . a n d in c r e a s e d m in u te v e n tila tio n . T h is c a n o c c u r d u e to c h r o n ic c o m p r e s s io n o f th is n e r v e . 16. S e c o n d a r y h y p e r a lg e s ia is d u e to c e n tr a l n e u r o n s e n s itiz a tio n a n d r e q u ir e s c o n tin u o u s n o c ic e p to r in p u t f r o m th e z o n e o f p r i m a r y h y p e r a lg e s ia f o r its m a in te n a n c e . tin g lin g . D. a c u te p a in s e c o n d a r y to p e lv ic e x e n te r a tio n s u r g e r y . D. Its e x a c t c a u s e is u n k n o w n . A. D. a n d e n v ir o n m e n ta l f a c to r s . d im in is h th e s e r e a c tio n s . F ib r o m y a lg ia s y m p to m s a r e n o t r e s tr ic te d to p a in . a n d s tiffn e s s . s le e p d is tu r b a n c e s . T h e c u b ita l tu n n e l is a c h a n n e l th a t a llo w s th e u ln a r n e r v e to tr a v e l o v e r th e e lb o w a n d is b o r d e r e d b y th e m e d ia l e p ic o n d y le o f th e h u m e r u s .. T h e t r i g g e r p o in ts c a n s p o n ta n e o u s ly r e s o lv e . p o s itio n a l o r d u e to in a p p r o p r ia te c a s t/s p lin t p la c e m e n t. a n d g lu te u s m e d iu s m u s c le s c a n b e th e c a u s e f o r it. F ib r o m y a lg ia is c h a r a c te r iz e d b y c h r o n ic w id e s p r e a d p a in a n d a llo d y n ia (a h e ig h te n e d a n d p a in f u l r e s p o n s e to p r e s s u r e ) . 18. p o s th e r p e tic n e u r a lg ia . a lth o u g h v e r y d if f ic u lt to tre a t. S e c o n d a r y h y p e r a lg e s ia im p lie s o n ly m e c h a n ic a l h y p e r a lg e s ia (e . th e o l e c r a n o n p r o c e s s o f th e u ln a . H o w e v e r. T h e s c ia tic n e r v e c a n b e tr a p p e d a t th e s c ia tic n o tc h a n d c a u s e im p in g e m e n t s y n d r o m e s (b u tto c k s a n d le g p a in ). c a u s in g p a in . T h e A m e r ic a n C o lle g e o f R h e u m a to lo g y d ia g n o s is c r i t e r i o n in d ic a te s th a t th e p a in b e a t le a s t . c a n p r o m o t e ile u s a n d u r i n a r y r e te n tio n . g e n e tic . a lo n g w ith th e r e le a s e o f c a ta b o lic h o r m o n e s .. B. a n d n u m b n e s s in th e b u tto c k s a n d a lo n g th e p a th o f th e s c ia tic n e r v e d e s c e n d in g d o w n th e p o s te r io r lo w e r th ig h a n d in to th e le g . S e c o n d a r y h y p e r a lg e s ia is a c e n tr a lly m e d ia te d c o n d itio n th a t m a y o c c u r d u e to in ju r y o r d is e a s e in a n a r e a o f th e b o d y . n e u r o b i o l o g i c a l . 17. p h a n to m lim b p a in . ta c h y c a r d ia .

N e u r o p a th ic p a in is p a in c a u s e d b y d a m a g e o r d is e a s e th a t a ffe c ts th e s o m a t o s e n s o r y s y s te m . F a c e t jo in ts a r e f o r m e d b y th e s u p e r io r a n d i n f e r i o r p r o c e s s e s o f e a c h v e r te b r a . F a c e t s y n d r o m e s y m p to m s m a y w o r s e n b y h y p e r e x te n s io n o r la te r a l r o ta tio n o f th e b a c k . f r o m C 2 to S 1 ) c a u s e b a c k p a in .. a n d k n e e . 23. s tr o k e . B. m e d ia l d o r s u m o f th e f o o t. T h e s e in c lu d e a n tic o n v u ls a n ts . a n d u n d e r s u r f a c e o f th e f o o t. .S 1 is th e m o s t c o m m o n lo c a t io n o f v e r te b r a l d is k p a th o lo g y p r e s e n tin g a s b a c k p a in (a ffe c ts th e S1 n e r v e r o o t) . b u r n in g . C o n f ir m a tiv e te s t is p a in r e l i e f o f f e r e d b y in tr a . N e u r o p a th ic p a in c a n b e v e r y d if f ic u lt to tr e a t e f f e c tiv e ly a n d o f te n r e q u ir e s m u ltip le th e r a p e u tic m o d a litie s f o r tre a tm e n t.L 5 is a v e r y c o m m o n lo c a t io n f o r s u c h p a th o lo g y a n d a ffe c ts th e L 5 n e r v e r o o t. 24. th ig h .a r ti c u la r in je c tio n o f lo c a l a n e s th e tic s o r b lo c k a d e o f th e p o s t e r i o r r a m u s m e d ia l n e r v e b r a n c h . L u m b o s a c r a l s tra in . N e u r o p a th ic p a in is o f te n d e s c r ib e d a s “w a x a n d w a n e ” ty p e s o f p a in s y m p to m s (e . p o s th e r p e tic n e u r a lg ia . m o d e r a te to s e v e r e in s c a le : W id e s p r e a d P a in In d e x (W P I) s c o r e o f 7 o r h ig h e r a n d th e S y m p to m S e v e r ity (S S ) s c a le s c o r e o f 5 o r h ig h e r . p a r tic u la r ly b e tw e e n th e f i r s t a n d s e c o n d to e s ) . a n d m iln a c ip r a n (S a v e lla ) to id e n tif y a f e w o p tio n s . 22. c a n c e r p a in . a n d m y o f a s c ia l s y n d r o m e s a r e th e m o s t c o m m o n c a u s e s .L 4 . D is k h e r n ia tio n a t L 4 . a n d f i b r o m y a l g i a is n o t ty p ic a lly a s s o c ia te d w ith a d ia g n o s is o f lo w e r b a c k p a in . 26. P h y s ic a l e x a m in a tio n w ill a ls o id e n tif y a d im in is h e d p la n ta r f le x io n o f th e a n k le o n th e a f f e c te d s id e . la te r a l d o r s u m .f iv e p e r c e n t o f f a c e t s y n d r o m e c a s e s o c c u r in c e r v ic a l v e r te b r a e . A llo d y n ia o r h y p e r a lg e s ia c a n o f te n b e a s s o c ia te d w ith n e u r o p a th ic p a in . T r e a tm e n t in c lu d e s p r e g a b a lin ( L y ric a ) . F if ty . N e u r o p a th ic p a in a lo n g w ith c o m p o n e n ts o f n e u r o p a th ic p a in c a n b e a s s o c ia te d w ith s e v e r a l c h r o n ic d is e a s e s s u c h a s d ia b e te s . C h r o n ic lo w e r b a c k p a in is o n e o f th e to p r e a s o n s f o r p h y s ic ia n o f f ic e v is its a n d a ls o o n e o f th e g r e a te s t r e a s o n s f o r w o r k a b s e n c e . F a c e t s y n d r o m e is a s y n d r o m e in w h ic h th e z y g a p o p h y s e a l jo in ts ( s y n o v ia l d ia r th r o s e s . B. P a tie n ts o f te n h a v e a s s o c ia te d g lu te a l p a in a n d n u m b n e s s a lo n g w ith p a in /p a r e s th e s ia in th e p o s t e r i o r th ig h . D. o r lo w b a c k p a in . P a tie n ts m a y p r e s e n t w ith p a in a n d p a r e s th e s ia a n y w h e r e a lo n g th e d e r m a to m e d is tr ib u tio n o f th e L 5 n e r v e r o o t ( la te r a l th ig h . c o m e s a n d g o e s ) . a n te r o la te r a l c a lf. D is k h e r n ia tio n a t L 5 .g . d e g e n e r a tiv e d is k d is e a s e . It is c h a r a c te r iz e d b y n e a r m id lin e p a in th a t m a y r a d ia te to th e g lu te a l r e g i o n . 25. a n d e le c tr ic a l. T h e s y m p to m s o f q u a d r ic e p s f e m o r is m u s c le w e a k n e s s w o u ld b e s e c o n d a r y to p a th o lo g y o f n e r v e r o o t s L 2 . a n tid e p re s s a n ts . A n o th e r c a te g o r y o f c r i t e r i a to d ia g n o s e f i b r o m y a l g i a in c lu d e s a W P I o f 3 to 6 a lo n g w ith a n SS s c a le s c o r e o f 9 o r h ig h e r . T h e o th e r tw o c r i t e r i a f o r d ia g n o s is in c lu d e c h r o n ic c o n d itio n s a n d a b s e n c e o f o th e r c o e x is tin g c h r o n ic p a in d is o r d e r s . 27. p o s te r o la t e r a l c a lf. B a c k p a in s e c o n d a r y to d e g e n e r a tiv e c h a n g e s in th e f a c e t ( z y g a p o p h y s e a l) jo in ts is a ls o c a lle d f a c e t s y n d r o m e . B. a n d 3 1 % in th e lu m b a r a r e a . D. F a c e t s y n d r o m e c a n p r o g r e s s to s p in a l o s te o a r th r itis . d u lo x e tin e (C y m b a lta ). D. a s d e s c r ib e d b y p a tie n ts . s p in a l c o r d p a th o lo g y . m u ltip le s c le r o s is . w h ic h is k n o w n a s s p o n d y lo s is .

a n d s e x u a l d y s fu n c tio n .a d r e n e r g ic a g o n is ts . P h y s ic a l th e r a p y ty p ic a lly c o n s is ts o f a c tiv e m o v e m e n t w ith o u t w e ig h ts a n d d e s e n s itiz a tio n th e ra p y . in ju r y to th e k id n e y s o r p a n c r e a s . 30. W h e n th e a u to n o m ic n e r v o u s s y s te m is in v o lv e d . is a c h r o n ic s y s te m ic d is e a s e c h a r a c te r iz e d b y s e v e r e p a in . B o th th e v e n a c a v a a n d th e a o r ta a r e in c lo s e p r o x im ity a n d s u s c e p tib le to in tr a v a s c u la r in ju r y /in je c tio n . S y m p a th e tic b lo c k s a s w e ll a s s p in a l c o r d s tim u la tio n w o r k f o r c e r ta in p a tie n ts r e s is ta n t to p h a r m a c o lo g i c a l in te r v e n tio n s . T h e in c id e n c e o f a c u r e is a b o u t 9 0 % w ith e f f e c tiv e m u ltim o d a l th e r a p y in itia te d w ith in 1 m o n th o f s y m p to m s . a n d n a ils . o r r e f le x n e u r o v a s c u la r d y s tr o p h y o r a m p lif ie d m u s c u lo s k e le ta l p a in s y n d r o m e . M o to r s tr e n g th a n d r a n g e o f m o tio n o f th e e x tr e m ity m a y a ls o b e a ffe c te d . c o lo r . D. to p ic a l a g e n ts . 28. 29. P h y s ic a l th e r a p y p la y s a c e n tr a l r o l e in th e m u ltim o d a l tr e a tm e n t o f C R P S . P o te n tia l c o m p lic a tio n s o f a c e lia c p le x u s b lo c k in c lu d e p o s tu r a l h y p o te n s io n f r o m th e v is c e r a l s y m p a th e c to m y a n d v a s o d il a tio n d u e to th e lo c a l a n e s th e tic in je c tio n . If n o t tr e a te d in tim e ly f a s h io n . w ith th e u s e o f d if f e r e n t ty p e s o f m e d ic a tio n s c o m b in e d w ith d is tin c t p h y s ic a l th e r a p ie s . B. C R P S c a n r e s u lt in f u n c tio n a l d is a b ility . a lo n g w ith tr o p h ic c h a n g e s o f th e s k in . T h e g e n e r a l s tr a te g y in C R P S tr e a tm e n t is o f te n m u ltid is c ip lin a r y . a n tia r r h y th m ic s . a 2. T h e v is c e r a l s y m p a th e tic c h a in is in c lo s e p r o x im ity . r e t r o p e r ito n e a l h e m o r r h a g e . C R P S c a n b e a s s o c ia te d w ith e ith e r m in o r o r m a jo r s u r g ic a l p r o c e d u r e s o r in ju r ie s . O th e r p o te n tia l c o m p lic a tio n s in c lu d e a p n e u m o th o r a x . a d d itio n a l s ig n s a n d s y m p to m s c a n in c lu d e s w e a tin g ( s u d o m o to r c h a n g e s ) . a n d b lo c k a d e m a y r e s u lt in u n o p p o s e d p a r a s y m p a th e tic a c tiv ity th a t m a y le a d to in c r e a s e d g a s tr o in te s tin a l m o tility a n d d ia r r h e a . D. C R P S is e x p e c te d to w o r s e n o v e r tim e . C R P S ty p e 2 is a s s o c ia te d w ith d o c u m e n te d n e r v e d a m a g e /in ju r y . a n d a n a lg e s ic s ( n o n s te r o id a l a n ti­ in f l a m m a to r y d r u g s a n d o p io id s ) . C o m p le x r e g i o n a l p a in s y n d r o m e (C R P S ). a n d c h a n g e s in th e s k in . . S o m e f o r m s o f C R P S a r e s y m p a th e tic a lly m a in ta in e d a n d a r e th e r e f o r e r e s p o n s iv e to s y m p a th e tic b lo c k a d e . T h e r a p y is f a c ilita te d w ith s y m p a th e tic b lo c k a d e o r in tr a v e n o u s r e g i o n a l b lo c k s . a n d s k in te m p e r a tu r e c h a n g e s . h a ir. f o r m e r l y c a lle d r e f le x s y m p a th e tic d y s tr o p h y o r c a u s a lg ia . b u t n o t C R P S ty p e 1. s w e llin g .

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Neuraxial anesthesia may decrease platelet reactivity D. and conjunctiva along with decreased breath sounds to auscultation. Decreased pulmonary shunt 2. he has become progressively more short of breath. Neuraxial anesthesia may reduce blood loss C. Potential complications of use of a pneumatic tourniquet include all of the following. The surgeon is performing a right total knee arthroplasty under a combined spinal-epidural anesthetic. A compression nerve injury C. Tourniquet pain that is relieved by performing a peripheral nerve block B. Cardiac arrhythmias D. Increased work of breathing and hypercapnia C. In the last 24 hours. Physical exam reveals petechiae on the anterior chest wall. Cognitive dysfunction B. except A. Hypertension B. Neuraxial anesthesia may increase activity of both factor VIII and von Willebrand factor . requiring 100% Fi o 2 to maintain an oxygen saturation in the high 80s and is now becoming more confused and disoriented. The most likely clinical side effect that may occur is A. Incorrect statement regarding neuraxial anesthesia and deep-vein thrombosis/pulmonary embolism (DVT/PE) in orthopedic surgical procedures is A. The surgical team is providing you with information that within the next 15 minutes they plan to place bone cement (polymethylmethacrylate) to anchor the prosthesis. Undiagnosed pneumothorax D. arms. The most likely diagnosis is A. Development of arterial thromboembolism D. Neuraxial anesthesia may reduce thromboembolic complications B. Pulmonary embolism 3. Congestive heart failure 4.Orthopedic Anesthesia Thomas Halaszynski 1. A 20-year-old male (status post car accident) sustained a right femur and pelvic fracture 2 days prior. Pulmonary fat embolism C.

diabetes. Lateral view: flexion of the cervical spine B. except for A. and would like to know for what time interval once-daily prophylactic low-molecular-weight heparin (LMWH) should be held prior to performing the epidural procedure: A. The RA is affecting the upper extremities bilaterally and the cervical spine. you are assessing a 58-year-old female with a medical history significant for hypertension.5. Statin medication use that patient started 2 weeks prior D. In the postanesthesia care unit. Thrombin inhibitors (desirudin. Prolonged tourniquet inflation time C. where the final total tourniquet time was 3 hours 15 minutes. on postoperative day 2. 4 hours and no absolute contraindication to placement of a catheter B. 12 hours and no absolute contraindication to placement of a catheter D. All of the above 8. On postoperative day 1. Therapeutic dosing of low-molecular-weight heparin (LMWH) D. but her RA symptoms are well-controlled with methotrexate. He is now consulting you for an epidural catheter placement for postoperative pain control. the patient showed no signs of any peripheral nerve injury of the left lower extremity. Lateral view: both flexion and extension of the cervical spine 7. you discovered that the patient required hemodialysis secondary to rhabdomyolysis. and rheumatoid arthritis (RA). No radiographs are indicated since the patient is asymptomatic D. and Argatroban) C. lepirudin. In the anesthesia preadmission testing clinic. The radiographs that should be ordered to rule out atlantoaxial instability are A. Concurrent administration of all of the following anticoagulants and thrombolytic therapy should be avoided when planning for neuraxial blockade. 6 hours and a relative contraindication to place a catheter C. bivalirudin. an orthopedic surgeon has consulted you about his total knee arthroplasty patient who is in severe pain and has failed a regimen of patient-controlled analgesia using morphine.000 U or less 9. Which of the following could be responsible for the rhabdomyolysis? A. Subcutaneous heparin daily dose of 10. Fibrinolytic and thrombolytic therapy B. Intertrochanteric > base of femoral neck > subcapital . Compartment syndrome B. She is now presenting for an elective total hip arthroplasty. The most correct statement regarding blood loss that may occur in a patient with a hip fracture is A. 24 hours and absolute contraindication to place a catheter 6. However. You were involved in a complicated left lower leg procedure (open reduced internal fixation of proximal tibia-fibula fracture repair). Lateral view: extension of the cervical spine C. fibromyalgia.

12 hours D. and 2 U packed red blood cells). and creatinine of 1. All of the following should be considered in the perioperative pain management regimen for this patient.5 mL 0. Add ketorolac 30 mg every 6 hours as needed for 14 days 13. You perform a spinal anesthetic using 1. 3 days B. 1 L albumin. diabetes (IDDM). tobacco abuse. All of the above 12. Arterial blood gas results reveal an Hct of 23% that responds to a crystalloid fluid bolus and blood transfusion (2 L crystalloids. The patient stated she has 7/10 pain daily. Subcapital > base of femoral neck > transcervical 10. You are administering anesthesia for a cervical spine procedure. A 68-year-old female (5’1” and 250 lb) with a medical history of chronic lower back pain and radiculopathy in the lumbar 4 to sacral 1 vertebral levels presents for anterior and posterior fusion. B. blood urea nitrogen of 25 mg/dL. Her home medications include methadone 75 mg daily. A 56-year-old female with medical history significant for obesity (BMI 50). Your anesthetic plan includes avoidance of long-acting muscle relaxants in addition to avoiding the use of A. Pulmonary embolism C.0 mg/dL. Vasodilation caused by monomer of the bone cement D. A 76-year-old female is to undergo a right femoral neck fracture repair. and asthma is scheduled for bilateral hip replacement surgery. Preoperative laboratory results show a hematocrit (Hct) of 45%. 24 hours 11. Immediately following application of cement for the second hip.5% bupivacaine mixed with 100 |ig of preservative-free morphine. Hypovolemia and/or low Hct B. Subtrochanteric > subcapital > transcervical D. Transcervical > base of femoral neck > subcapital C. How long should the patient be monitored for postoperative apnea/hypoventilation secondary to the intrathecal morphine administration? A. Consider transversus abdominis plane (TAP) block for the anterior abdomen D. Continue with daily methadone B. a fentanyl patch (50 |ig/h). and lisinopril 10 mg daily. oxycodone 10 mg every 3 hours as needed. the patient became hypotension with sinus tachycardia. The possible cause(s) for the hypotension is/are A. and the surgeon has indicated that she plans to monitor somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs). except A. Consider a perioperative ketamine infusion C. hypertension. 1 MAC or higher of sevoflurane as needed for maintenance anesthesia . 48 hours C.

B. and vomiting C. The patient may experience all the following subsequent to tourniquet release. Arrhythmia secondary to increased total serum calcium 18. and surgery lasting greater than 6 hours represent the highest risk D. The arms are kept at less than 90 degrees of extension and flexion 16. Hypotension and tachycardia B. greater than 1 L intraoperative blood loss. The abdomen must always be supported (never permitted to hang freely) D. Femoral nerve block when combined with a sciatic nerve block can provide adequate . except A. Hemodilution B. The eyes must be free of pressure and checked periodically C. nausea. Ischemic optic neuropathy accounts for the highest incidence of POVL B. Is associated with reduced incidence of urinary retention D. All of the following statements when positioning patients for spine surgery in the prone position are true. After 180 minutes of tourniquet time during a difficult right total knee arthroplasty in a patient under sedation and intraoperative anesthesia provided by a combined spinal-epidural. D e x m e d e to m id in e to s m o o th o u t th e a n e s th e tic d e liv e r y 14. Controlled hypotension C. Aprotinin 15. The most incorrect statement regarding placement of a femoral perineural catheter for pain management during unilateral knee replacement surgery is that a femoral nerve block when compared to neuraxial blockade A. POVL due to central retinal artery occlusion (CRAO) tends to be bilateral 17. AH of the following can be used to assist in reducing the amount of perioperative surgical blood loss in an orthopedic procedures. The neck should be in neutral position (without hyperextension or hyperflexion) B. the tourniquet is released and surgical closure is started. Tranexamic acid D. Provides equipotent analgesia B. Ischemic optic neuropathy is associated with decreased ocular perfusion pressure C. Prone positioning. Arrhythmia secondary to increased serum potassium D. Is associated with reduced incidence of pruritus. H a lf M A C o f n itr o u s o x id e to s u p p le m e n t th e in h a la tio n a g e n t C. except A. C o n tin u o u s p r o p o f o l in f u s io n a s a n e s th e s ia m a in te n a n c e D. except A. The most incorrect statement regarding postoperative vision loss (POVL) that may occur during prone positioning in spine surgery patients is A. Transient increase of end-tidal carbon dioxide C.

a n d a r e c e n t tr a n s ie n t is c h e m ic a tta c k .o ld f e m a le is s c h e d u le d f o r a r i g h t to ta l s h o u ld e r r e p la c e m e n t in th e b e a c h c h a ir p o s itio n . A ll o f th e a b o v e . I s c h e m ia in d u c e d b y h y p o p e r f u s io n C.e v o k e d p o te n tia ls (S S E P s ) is /a r e A. L e v e l o f s h o u ld e r to m e a s u r e a d e q u a te s h o u ld e r p e r f u s io n 20. T h e s u r g e o n is r e q u e s tin g a h y p o te n s iv e te c h n iq u e to r e d u c e in tr a o p e r a tiv e b l o o d lo s s . W h e r e is th e m o s t o p tim a l lo c a t io n to p la c e th e a r te r ia l lin e tr a n s d u c e r ? A. A 5 6 .y e a r . L e v e l o f th e e x te r n a l m e a tu s to m o n ito r b r a i n s te m p e r f u s io n D. S p in a l c o r d in ju r y B. I n tr a o p e r a tiv e b le e d in g D. M e d ic a l h is to r y is s ig n if ic a n t f o r h y p e r te n s io n . d ia b e te s . a n a lg e s ia f o r k n e e s u r g e r y 19. W h ic h o f th e f o ll o w i n g s u r g ic a l c o n d itio n s m a y n e g a tiv e ly in f lu e n c e c h a n g e s o n s o m a t o s e n s o r y . T h e a n e s th e tic a g e n t( s ) th a t c a n c a u s e a d v e r s e c h a n g e s o n th e w a v e f o r m s w h e n m o n ito r in g s o m a t o s e n s o r y . A L L o f th e a b o v e 21. T h e le v e l o f th e h e a r t a s th is is th e c la s s ic w a y o f m e a s u r in g B. H ig h c o n c e n tr a tio n s o f in h a la tio n a l a g e n ts ( r e d u c e s w a v e f o r m a m p litu d e ) B.e v o k e d p o te n tia ls (S S E P s ) w a v e f o r m s ? A. 1 M A C o f n itr o u s o x id e ( r e d u c e s w a v e f o r m a m p litu d e ) C. I n tr a v e n o u s a n e s th e s ia w ith k e ta m in e ( e x a g g e r a te s w a v e f o r m s ) D. T h e le v e l o f th e s te r n u m to m e a s u r e a d e q u a te p e r f u s io n to th e b r a in C.

S u c h a c o n d itio n m a y a ls o o c c u r f o ll o w i n g c a r d io p u lm o n a r y r e s u s c ita tio n .b o n e a n d /o r p e lv ic f r a c tu r e in ju r ie s . a n d d e c r e a s e d c a r d ia c o u tp u t. d e c r e a s e d p la te le t a c tiv ity .d a ily d o s a g e o f L M W H f o r p r o p h y la x is . a n d r h a b d o m y o ly s is . p a r e n ta l fe e d in g w ith lip id in f u s io n . in tu b a tio n s h o u ld b e p e r f o r m e d w ith in lin e s ta b iliz a tio n u tiliz in g v id e o o r f ib e r o p tic l a r y n g o s c o p y to m in im iz e e x c e s s iv e h e a d a n d n e c k m o v e m e n t in o r d e r to r e d u c e th e in c id e n c e o f c e r v ic a l s p in a l c o r d /n e r v e r o o t in ju r y . T h e c la s s ic a l tr ia d in c lu d e s d y s p n e a . w h ic h m a y m a k e th e m m o r e p r o n e to r h a b d o m y o ly s is . M u ltip le c a u s e s c a n b e p r e s e n t s im u lta n e o u s ly in o n e in d iv id u a l. 2. It is s u g g e s te d th a t to u r n iq u e t tim e s u s u a lly b e k e p t to 2 h o u r s o r le s s to d e c r e a s e th e r i s k o f n e r v e in ju r y . D. U s e o f a c o m p r e s s io n to u r n iq u e t o n u p p e r a n d lo w e r e x tr e m itie s c a n f a c ilita te s u r g e r y a n d d e c r e a s e b l o o d lo s s . im m u n e th e ra p y . 3.h o u r tim e d e la y s h o u ld o c c u r b e f o r e a d m in is te r in g th e n e x t d o s e o f d a ily p r o p h y la c tic L M W H . m e d ic a tio n s s u c h a s s ta tin s . R h a b d o m y o ly s is c a n b e in d u c e d b y s e v e r a l c o n d itio n s in c lu d in g c o m p a r tm e n t s y n d r o m e . B. R a d io g r a p h s o f b o th f le x io n a n d e x te n s io n w ith la te r a l v ie w s o f th e c e r v ic a l s p in e a r e n e c e s s a r y to r u le o u t a tla n to a x ia l in s ta b ility . . M e ta b o lic a lte r a tio n s u p o n to u r n iq u e t r e le a s e . C. If a tla n to a x ia l in s ta b ility is p re s e n t. CHAPTER 10 ANSWERS 1. A v e n o u s fa t e m b o lis m w ill ty p ic a lly p r e s e n t its e lf w ith in 72 h o u r s f o ll o w i n g lo n g . 5. a n d m a lig n a n t h y p e r th e r m ia . u s u a lly h e r e d ita r y in n a tu re . a r te r ia l th r o m b o e m b o li s m . 4. a n d lip o s u c tio n s u r g e r y . D. p r o l o n g e d to u r n iq u e t in f la tio n tim e . 6. 7. A n y f o r m o f m u s c le d a m a g e o f s u f f ic ie n t s e v e r ity c a n c a u s e r h a b d o m y o ly s is . b u t it c a n r e s u lt in c o m p lic a tio n s a n d c a n n o t b e a p p lie d f o r p r o l o n g e d p e r io d s . D. U s e o f s u c h d e v ic e s c a n b e a s s o c ia te d w ith is c h e m ic p a in th a t is n o t ty p ic a lly o r c o m p le te ly r e lie v e d b y p e r f o r m i n g p e r ip h e r a l n e r v e b lo c k s o f th e e x tre m ity . a n d a tte n u a tio n o f s tr e s s h o r m o n e r e s p o n s e s . C. is c h e m ia . p u lm o n a r y h y p e r te n s io n . a n d p e te c h ia e . S o m e p a tie n ts m a y h a v e a n u n d e r ly in g m u s c le c o n d itio n . d e c r e a s e d f a c to r V III a n d v o n W ille b r a n d f a c to r a c tiv ity . a 4 . c o n f u s io n . A d v a n ta g e s o f n e u r a x ia l a n e s th e s ia in o r th o p e d ic s u r g e r y m a y in c lu d e r e d u c e d in c id e n c e o f D V T a n d P E f o r m a tio n . a n d p u lm o n a r y e m b o lis m a r e o th e r p o te n tia l c o m p lic a tio n s . A d v a n c e d R A c a n a f f e c t th e c e r v ic a l s p in e s u c h th a t p a tie n ts m a y r e q u i r e tr e a tm e n t in c lu d in g s te r o id s . h y p o te n s io n . A. c a r d ia c a r r h y th m ia s ( p o s s ib ly h e a r t b lo c k o r e v e n s in u s a r r e s t) . b o th e p id u r a l a n d s p in a l n e u r a x ia l te c h n iq u e s m a y b e p e r f o r m e d ( o r n e u r a x ia l c a th e te rs p la c e d o r r e m o v e d ) 10 to 12 h o u r s f o ll o w i n g th e p r e v io u s d o s e o f L M W H . a n d /o r m e th o tr e x a te . F o r p a tie n ts r e c e iv in g o n c e . w h ic h c o u ld le a d to r e n a l f a ilu r e . P la c e m e n t o f b o n e c e m e n t ( b o n e c e m e n t im p la n ta tio n s y n d r o m e ) c a n r e s u lt in a n y c o m b in a tio n o f a d v e r s e e v e n ts in c lu d in g h y p o x ia . In a d d itio n .

10. 11. th r o m b o ly tic s . m e a s u r in g a n H c t m a y n o t a c c u r a te ly r e f le c t th e tr u e v a lu e a s e q u ilib r iu m ta k e s s o m e tim e to s h o w th e tr u e H c t. a s th e c a p s u le d e c r e a s e s b l o o d lo s s b y a c tin g lik e a to u r n iq u e t. w h ic h c a n f u r th e r c o n tr ib u te to th e lo w b l o o d p r e s s u r e . a n d /o r d ir e c t p e r im e d u lla r y v a s c u la r c h a n n e ls . so a r e th e r e f o r e d is c o u r a g e d . C e m e n t p la c e m e n t h a s b e e n a s s o c ia te d w ith p u lm o n a r y e m b o lis m a n d p u lm o n a r y h y p e r te n s io n . In a c u te b le e d in g . C h r o n ic p a in is o f te n a c o m m o n o c c u r r e n c e in p a tie n ts p r e s e n te d f o r s p in e /b a c k s u r g e r ie s . o r th e r a p e u tic L M W H p r e s e n t a n u n a c c e p ta b le r i s k f o r s p in a l a n d /o r e p id u r a l h e m a to m a d e v e lo p m e n t w ith o u t s u f f ic ie n t tim e la p s e b e tw e e n a d m in is tr a tio n o f s u c h m e d ic a tio n s a n d n e u r a x ia l te c h n iq u e s . 9. In g e n e r a l. in tr a c a p s u la r (s u b c a p ita l.in f la m m a to r y d r u g s a t l o w d o s e s in s p in e s u r g e r ie s . A.8. E v id e n c e s u p p o r ts th e u s e o f n o n s te r o id a l a n ti. e s p e c ia lly in th e s itu a tio n o f b ila te r a l h ip r e p la c e m e n t. a n d th e s e c o n d p e a k c o u ld h a p p e n a s la te a s 2 4 h o u r s la te r. tr a n s c e r v ic a l) f r a c tu r e s h a v e b e e n a s s o c ia te d w ith le s s b l o o d lo s s th a n e x tr a c a p s u la r (b a s e o f th e f e m o r a l n e c k . 13. D. K e ta m in e (G A B A a g o n is t) is e f f e c tiv e in c h r o n ic p a in p a tie n ts . In a d d itio n .0 0 0 U tid is n o t k n o w n to b e a c c e p te d in c lin ic a l p r a c tic e in c o n ju n c tio n w ith n e u r a x ia l b lo c k a d e . b o n e c e m e n t c a n c a u s e v a s o d ila tio n . A. in te r tr o c h a n te r ic . H ig h c o n c e n tr a tio n s o f p o te n t in h a la tio n a l a g e n ts (s u c h a s d e s f lu r a n e a n d s e v o f lu r a n e ) m a y in c r e a s e n e u r o m o n i t o r i n g la te n c y a n d d e c r e a s e a m p litu d e o f th e S S E P a n d M EP. D. b u t h ig h e r c o n c e n tr a tio n s h a v e b e e n a s s o c ia te d w ith a r a te o f n o n u n io n . A s a g e n e r a l r u le . In tr a th e c a l m o r p h i n e c a n d e p r e s s v e n tila tio n a n d C O 2 r e s p o n s iv e n e s s th a t c a n la s t f o r u p to 2 4 h o u r s . It is a c o m m o n p r a c tic e to c o n tin u e m e th a d o n e if p a tie n ts a r e a lr e a d y ta k in g s u c h m e d ic a tio n s a n d to c o n s id e r s ta r tin g m e th a d o n e in p a tie n ts w ith u n c o n tr o lle d p o s to p e r a tiv e p a in . 12. A c c o r d in g to th e A m e r ic a n S o c ie ty o f R e g io n a l A n e s th e s ia a n d P a in M e d ic in e a n tic o a g u la tio n g u id e lin e s . T h e p h y s io lo g ic a n d p h a r m a c o lo g i c m e c h a n is m s o f th is in c lu d e v a s c u la r o p io id u p ta k e b y th e e p id u r a l o r s u b a r a c h n o id v e n o u s p le x u s e s . f o n d a p a r in u x . s u b tr o c h a n te r ic ) f r a c tu r e s . b l o o d lo s s f r o m a s u b tr o c h a n te r ic a n d in te r tr o c h a n te r ic > b a s e o f f e m o r a l n e c k > tr a n s c e r v ic a l a n d s u b c a p ita l. d ir e c t th r o m b in in h ib ito r s . D. B lo o d lo s s in a p a tie n t s e c o n d a r y to a h ip f r a c tu r e c a n b e s ig n if ic a n t. A m u ltim o d a l th e r a p e u tic p a in m a n a g e m e n t s tr a te g y a im e d a t d if f e r e n t p a in c a s c a d e p a th w a y s is f r e q u e n tly u tiliz e d . M a x im u m a d m in is tr a tio n o f s u b c u ta n e o u s h e p a r in o f 5 . H e p a r in a d m in is tr a tio n o f 5 . m e d ic a tio n s s u c h a s a n tip la te le t a g e n ts (P la v ix . D. T A P b lo c k a d e w ith lo c a l a n e s th e tic s c a n p r o v id e e f f e c tiv e s o m a tic p a in r e l i e f o f th e a n te r io r a b d o m e n th a t w ill h e lp in th e tr e a tm e n t o f in c is io n a l p a in . r o s t r a l s p r e a d o f th e a q u e o u s c e r e b r o s p in a l f lu id to th e b r a in s te m .0 0 0 U b id is e s tim a te d to b e s a f e w ith e p id u r a l a n d s p in a l a n e s th e s ia . . T h e f i r s t p e a k e f f e c t o c c u r s a b o u t 6 to 8 h o u r s p o s t in je c tio n . T o ta l h ip a r th r o p la s ty s u r g e r y c a n b e c h a r a c te r iz e d b y s ig n if ic a n t b l o o d lo s s . a n d s o m e a n e s th e s io lo g is ts p la n to u tiliz e c e ll s a v e r s a n d /o r p e r f o r m h y p o te n s iv e te c h n iq u e s to m in im iz e f u r th e r b l o o d lo s s . B lo o d lo s s f r o m a h ip f r a c tu r e d e p e n d s o n th e a c tu a l lo c a t io n o f th e f r a c tu r e . a n d in tr a v e n o u s g ly c o p r o te in Ilb /IIIa in h ib ito r s ) .

14. in h a la tio n a g e n ts c a n b e u s e d f o r in tr a o p e r a tiv e m a in te n a n c e a n e s th e s ia .f r e e . P r o n e p o s itio n in g o f p a tie n ts n e e d s to b e c a r e f u l ly e x e c u te d . Is c h e m ic o p tic n e u r o p a th y is a m a jo r c a u s e o f p e r io p e r a tiv e P O V L a c c o r d i n g l y to th e v is io n lo s s r e g i s t r y c o lle c te d b y th e A S A . 15. R e le a s e o f a to u r n iq u e t u s e d o n a n e x tr e m ity d u r in g s u r g e r y is o f te n a s s o c ia te d w ith th e r e le a s e o f m e ta b o lic ( a c id o tic ) b y . O P P = M A P . D. a n d e p in e p h r in e a t w o u n d site . k e ta m in e . C R A O a c c o u n ts f o r a s m a ll p e r c e n ta g e o f p a tie n ts w h o e x p e r ie n c e v is io n d y s f u n c tio n a c c o r d in g to th e v is io n lo s s r e g is tr y . P h a r m a c o lo g ic a lly . A p r o tin in h a s b e e n a s s o c ia te d w ith a 5 0 % in c r e a s e o f c a r d ia c s id e e ffe c ts ( m y o c a r d ia l in f a r c tio n /c o n g e s tiv e h e a r t f a ilu r e ) . in c r e a s e (d o u b le ) o f th e r i s k o f s tr o k e . th e r e f o r e . u s e o f c e ll s a v e r. T h e s e IV a n e s th e tic s in c lu d e p r o p o f o l . b u t a r e u s e d a t le s s th a n o n e fu ll M A C c o n c e n tr a tio n . 17. D. T h e r e f o r e . e s p e c ia lly d u r in g s p in e s u r g e r i e s ( p r o l o n g e d p r o c e d u r e s ) a n d in p a tie n ts w h o h a v e o th e r a s s o c ia te d c o m o r b id iti e s s u c h a s r h e u m a to id a r th r itis a n d a n k y lo s in g s p o n d y litis . a u to lo g o u s b l o o d d o n a tio n p r e o p e r a tiv e ly . a n d o p io id s in d e p e n d e n tly a n d in v a r io u s c o m b in a tio n s . b e n z o d ia z e p in e s . it te n d s to b e m o s tly u n ila te r a l.p r o d u c ts m a y b e e n o u g h to r e s u lt in h y p o te n s io n a n d c a r d ia c a r r h y th m i a th a t m a y r e q u i r e v o lu m e r e s u s c ita tio n a n d /o r p h a r m a c o lo g i c s u p p o r t. e to m id a te . p a r tic u la r ly w ith p a tie n ts in a h e a d . S p in e s u r g e r y c a n b e a s s o c ia te d w ith s ig n if ic a n t b l o o d lo s s . In r a r e in s ta n c e s . a s th e y a r e m o r e c o m p a tib le w ith S S E P a n d M E P n e u r o m o n i t o r i n g ( s o m e e x p e c te d . O p io id s h a v e th e le a s t p o te n tia l to i n te r f e r e S S E P a n d M E P n e u r o m o n ito r in g . a n tif ib r in o ly tic s s u c h a s tr a n e x a m ic a c id a n d e . I n tr a v e n o u s (IV ) a n e s th e tic s a r e m o r e c o m m o n ly u s e d f o r m a in te n a n c e o f a n e s th e s ia . S u r g ic a l a n d a n e s th e tic te c h n iq u e s th a t h a v e b e e n d e v e lo p e d to c o n tr o l p e r io p e r a tiv e b l o o d lo s s in c lu d e h e m o d ilu tio n . d e x m e d e to m id in e .p r o d u c ts f r o m th e is c h e m ic lim b th a t a r e d u m p e d in to th e s y s te m ic c ir c u la tio n . C. a n d h ig h e r d e a th r a te s ( in c r e a s e d m o r ta lity ) . a n d e y e s a n d n o s e s h o u ld b e p a d d e d a n d c h e c k e d p e r i o d i c a l l y to e n s u r e th a t th e y a r e p r e s s u r e . T r a n e x a m ic a c id is a s y n th e tic d e r iv a tiv e o f th e a m in o a c id ly s in e .d o w n p o s itio n w h e r e e d e m a c a n d e v e lo p in th e o r b i t th a t w ill in c r e a s e v e n o u s p r e s s u r e . D. th e in c r e a s e d s y s te m ic m e ta b o lic b y . T h e n e c k a n d a r m s s h o u ld b e k e p t p o s itio n e d in a n a n a to m ic a lly n e u tr a l p o s itio n . th e h y p e r k a le m ia m a y n e e d to b e tr e a te d ( s o d iu m b ic a r b o n a te o r c a lc iu m ) . C R A O m a y b e e m b o lic in n a tu r e o r th e r e s u lt o f d ir e c t p r e s s u r e o n th e e y e b a ll.a m in o c a p r o ic a c id h a v e b e e n u s e d w ith s o m e e ffic a c y . T h e a b d o m e n n e e d s to r e m a in f r e e to a v o id in c r e a s e d v e n o u s p r e s s u r e (a s s is ts in r e d u c in g in c r e a s e d v e n o u s b le e d in g ) a n d to r e d u c e th e in c id e n c e o f a b d o m in a l c o m p a r tm e n t s y n d r o m e th a t c a n d e v e lo p d u r in g p r o l o n g e d d u r a tio n o f s u r g ic a l in te r v e n tio n a n d a g g r e s s iv e flu id a d m in is tr a tio n . 16. a n d it is u s e d to tr e a t o r p r e v e n t e x c e s s iv e b l o o d lo s s d u r in g s u r g e r y a n d in v a r io u s o th e r m e d ic a l c o n d itio n s . T h e e n d o tr a c h e a l tu b e n e e d s to b e p r o p e r l y s e c u r e d . b u t to le r a b le c h a n g e s o n e ith e r la te n c y a n d /o r a m p litu d e ). .IO P. A n y in c r e a s e o f in tr a o c u la r p r e s s u r e (IO P ) o r d e c r e a s e o n m e a n a r te r ia l p r e s s u r e (M A P ) w ill a f f e c t o c u la r p e r f u s io n p r e s s u r e (O P P ). In p a tie n ts w ith p o o r p r e o p e r a t iv e f u n c tio n a l sta tu s o r th o s e th a t m a y e x p e r ie n c e s ig n if ic a n t in tr a o p e r a tiv e b l o o d lo s s .

u r i n a r y r e te n tio n . If a c o n tr o lle d h y p o te n s io n te c h n iq u e is c h o s e n . 19. a n d a r te r ia l b l o o d p r e s s u r e m a y a ls o in f lu e n c e th e S S E P tr a c in g . a n d b r a i n is c h e m ia . F o r b ila te r a l k n e e r e p la c e m e n t s u r g e r y . C. s tr o k e . a p e r ip h e r a l n e r v e b lo c k u s in g a f e m o r a l p e r in e u r a l c a th e te r d o e s n o t h a v e s e v e r a l o f th e ty p ic a l s id e e ffe c ts th a t c a n b e a s s o c ia te d w ith n e u r a x ia l b lo c k a d e . te m p e r a tu r e . C O 2. D ir e c t tr a u m a . In a d d itio n to s e v e r a l a n e s th e tic c o n s id e r a tio n s ( f r o m a n e s th e tic a g e n t c h o ic e to te c h n iq u e s u s e d ) . e ith e r b ila te r a l f e m o r a l c a th e te rs o r lu m b a r e p id u r a l c a th e te r m a y b e a r e a s o n a b le o p tio n . is c h e m ia .. 21. In a d d itio n . S e v e r a l o th e r p e r io p e r a tiv e v a r ia b le s s u c h a s h e m o g lo b in c o n c e n tr a tio n . D. . D u r in g u n ila te r a l k n e e r e p la c e m e n t s u r g e r y . s u c h a s m o r e in te n s e s y m p a th e c to m y . s p in a l c o r d is c h e m ia c h a n g e s s e c o n d a r y to d e c r e a s e d b l o o d s u p p ly . a n d /o r v e s s e l in ju r y ( s tr e tc h in g /p r e s s u r e ) m a y ta k e a s m u c h a s a h a lf a n h o u r to m a n if e s t its e lf. e x te r n a l m e a tu s o f th e e a r ). o r o r th o s ta tic h y p o te n s io n a n d lig h th e a d e d n e s s . th e p o s to p e r a tiv e p a in d u r in g to ta l k n e e a r th r o p la s ty is lo c a te d o n th e a n te r io r k n e e th a t c a n b e e q u a lly c o n tr o lle d b y e ith e r lu m b a r e p id u r a l o r f e m o r a l n e r v e b lo c k a lo n e .e. p r o p e r l y f u n c tio n in g lu m b a r e p id u r a l a n d f e m o r a l p e r in e u r a l c a th e te rs c a n p r o v id e e q u iv a le n t p e r io p e r a tiv e a n a lg e s ia . H o w e v e r. T h e r e a r e a h o s t o f r e a s o n s c a u s in g n e g a tiv e S S E P . T h e b e a c h c h a ir p o s itio n m a y b e a s s o c ia te d w ith d e c r e a s e s in c e r e b r a l p e r f u s io n le a d in g to th e p o te n tia l f o r in c r e a s e d r i s k o f b lin d n e s s . S h o u ld e r o p e r a tio n s m a y b e p e r f o r m e d in e ith e r a s ittin g ( “b e a c h c h a i r ” ) o r th e la te r a l d e c u b itu s p o s itio n . S e v e r a l s tu d ie s h a v e s h o w n th a t p a tie n ts w ith r e g i o n a l a n e s th e s ia /a n a lg e s ia ( f e m o r a l c a th e te r p a tie n ts m a y m e e t d is c h a r g e c r i t e r i o n e a r lie r ) m a y s h o w e a r lie r im p r o v e d o u tc o m e s .18. D. 20. p r u r itu s (w h e n o p io id s a r e m ix e d w ith lo c a l a n e s th e tic s ). C o n s id e r in g v a r ia tio n s o f s u r g ic a l te c h n iq u e . a n a r te r ia l tr a n s d u c e r s h o u ld b e p o s itio n e d m o s t p r e f e r a b l y a t th e le v e l o f th e b r a i n s te m (i.tra c in g c h a n g e s . n a u s e a a n d v o m itin g . M o s t o f th e c u r r e n tly u s e d a n e s th e tic a g e n ts m a y h a v e s o m e e f f e c ts /n e g a tiv e in f lu e n c e o n S S E P ( d if f e r e n c e s m a y b e m in o r o r m a jo r c h a n g e s ) . a n d p r e s s u r e to th e s p in a l c o r d a r e c a p a b le o f in d u c in g a c u te c h a n g e s o n SS E P. th e r e a r e s u r g ic a l te c h n iq u e s a n d c o n s id e r a tio n s th a t c a n in f lu e n c e SS E P. D.

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Cardiovascular Anesthesia Deppu Ushakumari and Ashish Sinha 1. S A n o d e a n d AV n o d e s u p p r e s s io n b y h a lo th a n e f o ll o w e d b y a n tic h o lin e r g ic a c tio n o f a tr o p in e D. A 2 . a n d y o u d e c id e to a d m in is te r a tr o p in e 0 . T h e y a f f e c t o n ly L -ty p e c a lc iu m c h a n n e ls . S lo w m o v e m e n t o f p o ta s s iu m o u t o f th e c e ll B. T h e m e c h a n is m s o f d e p r e s s io n o f c a r d ia c c o n tr a c tility b y v o la tile a n e s th e tic s in c lu d e a ll th e f o ll o w i n g .o ld b o y is in d u c e d w ith h a lo th a n e . B u p iv a c a in e b in d s in a c tiv a te d s lo w s o d iu m c h a n n e ls a n d d is s o c ia te s f r o m th e m s lo w ly D. y o u n o tic e th a t th e p a tie n t is h a v in g a ju n c tio n a l ta c h y c a r d ia . S A n o d e a n d AV n o d e s u p p r e s s io n b y h a lo th a n e f o ll o w e d b y p a r o x y s m a l ta c h y c a r d ic a c tio n o f a tr o p in e 3.4 m g in tr a v e n o u s ly . B u p iv a c a in e b in d s in a c tiv a te d f a s t s o d iu m c h a n n e ls a n d d is s o c ia te s f r o m th e m s lo w ly B. S in o a tr ia l (S A ) n o d e s u p p r e s s io n b y h a lo th a n e f o ll o w e d b y a n tic h o lin e r g ic a c tio n o f a tr o p in e B. S lo w m o v e m e n t o f c a lc iu m o u t o f th e c e ll D. B u p iv a c a in e b in d s a c tiv a te d s lo w s o d iu m c h a n n e ls a n d d is s o c ia te s f r o m th e m s lo w ly 4. W h ic h o f th e f o ll o w i n g b e s t d e s c r ib e s th e m e c h a n is m o f c a r d ia c to x ic ity o f b u p iv a c a in e ? A. W h ic h o f th e f o ll o w i n g m o s t a c c u r a te ly d e s c r ib e s th e s e q u e n c e o f e v e n ts ? A. S ig n if ic a n t in tr a v e n o u s a b s o r p tio n /in a d v e r te n t in tr a v e n o u s in je c tio n o f b u p iv a c a in e c a n c a u s e p r o f o u n d b r a d y c a r d i a a n d s in u s n o d e a r r e s t. W h ic h o f th e f o ll o w i n g is r e s p o n s ib le f o r th e p la te a u p h a s e o f c a r d ia c a c tio n p o te n tia l? A. A tr io v e n tr i c u la r (A V ) n o d e s u p p r e s s io n b y h a lo th a n e f o ll o w e d b y a n tic h o lin e r g ic a c tio n o f a tr o p in e C. B u p iv a c a in e b in d s a c tiv a te d f a s t s o d iu m c h a n n e ls a n d d is s o c ia te s f r o m th e m s lo w ly C. e x c e p t A. B o th A a n d C 2.y e a r . I m m e d ia te ly th e r e a f te r . S lo w m o v e m e n t o f c a lc iu m in to th e c e ll C. T h e p a tie n t s u d d e n ly g e ts b r a d y c a r d ic .in h a la tio n in d u c tio n . T h e y d e c r e a s e th e e n tr y o f c a lc iu m in to c e lls d u r in g d e p o la r iz a tio n B.

a n d H b = 1 4 g /d L .y e a r .o ld h e a lth y m a le v o lu n te e r is u n d e r g o in g c a r d ia c f u n c tio n te sts a s p a r t o f a p h y s i o l o g y e x p e r im e n t.v a lv e a r e a o f 1. A 5 5 . W h ic h o f th e f o ll o w i n g is th e b e s t d e te r m in a tio n o f th e a d e q u a c y o f h is c a r d ia c o u tp u t? A.o ld p a tie n t w ith m itr a l. B P = 1 2 4 /7 4 m m H g .y e a r . W h ic h o f th e f o ll o w i n g p a tie n ts w ill b e a ffe c te d th e m o s t f r o m lo s s o f a tr ia l c o n tr ib u tio n to p r e lo a d ? A. T h e m e c h a n is m o f “ x ” d e s c e n t ( d e s c e n t b e tw e e n C a n d V w a v e s ) in th e f o ll o w i n g r i g h t a tr ia l tr a c in g ( F ig 1 1 -1 ) is A. C a r d ia c o u tp u t 8.o ld p a tie n t w ith s e v e r e a o r tic s te n o s is w h o w e n t in to r e c e n t o n s e t a tr ia l f ib r illa tio n D. C a r d ia c o u tp u t 8. S v o 2 o f 7 5 % f r o m a p u lm o n a r y a r te r y (P A ) c a th e te r 7. A 3 8 . H is v ita l s ig n s a r e H R = 6 2 b p m . T h e y a lte r k in e tic s o f c a lc iu m r e le a s e D. R e la x a tio n o f a tr iu m a fte r a tr ia l s y s to le D. r e s p i r a t o r y r a te = 12 b r e a th s /m in . D e c lin e in a tr ia l p r e s s u r e a s th e A V v a lv e s o p e n 6. A 6 5 .o ld p a tie n t w ith a c u te r ig h t . P u llin g d o w n o f th e a tr iu m b y v e n tr ic u la r c o n tr a c tio n C.y e a r . S p o 2 = 1 0 0 % o n r o o m a ir.1 L /m in b y th e r m o d ilu t io n te c h n iq u e C. T h e y d e c r e a s e th e s e n s itiv ity o f c o n tr a c tile p r o te in s to c a lc iu m 5.o ld p a tie n t w ith s e v e r e a o r tic r e g u r g i t a t i o n w h o w e n t in to r e c e n t o n s e t a tr ia l f ib r illa tio n B. D o w n w a r d m o v e m e n t o f th e a tr io v e n tr ic u la r (A V ) v a lv e c u s p s a fte r v e n tr ic u la r c o n tr a c tio n B.1 L /m in b y F ic k m e th o d D. C a r d ia c in d e x 4 .y e a r . A n 8 0 .0 L / m in /m 2 B.v e n t r ic u la r m y o c a r d ia l in f a r c tio n . A 3 5 . C.0 c m 2 w h o w e n t in to r e c e n t o n s e t a tr ia l f ib r illa tio n C.y e a r .

S in o a tr ia l n o d e 13. W h ic h o f th e f o ll o w i n g f o r m u la e e x p la in s th e h y p e r tr o p h y o f h e a r t in r e s p o n s e to p r e s s u r e o r v o lu m e lo a d s (P. in tr a v e n tr ic u la r p r e s s u r e . B a r o r e c e p to r r e f le x is in e f f e c tiv e f o r lo n g . PT = Rt 9. E le c tr ic a l a c tiv ity B. V o lu m e w o r k C. P o s te r io r p a p illa r y m u s c le D. W h ic h o f th e f o ll o w i n g ty p e s o f m y o c a r d ia l w o r k n e e d s th e h ig h e s t o x y g e n r e q u ir e m e n t? A. L e ft a n te r io r d e s c e n d in g a r te r y B. w a ll th ic k n e s s . v e n tr ic u la r r a d iu s . R e n a l r e g u la tio n o f B P is m o r e p o w e r f u l C. A tr io v e n tr ic u la r n o d e C. R e n in a n g io te n s in a ld o s t e r o n e s y s te m ta k e s o v e r th e c o n tr o l B. B u n d le o f H is B. D o s e o f h e p a r in ( U /k g ) a d m in is te r e d f o r c a r d io p u lm o n a r y b y p a s s is ( a p p r o x im a te ly ) A. T = 2 P /R t C. W h ic h o f th e f o ll o w i n g in h a la tio n a l a g e n ts c a u s e s th e le a s t c o r o n a r y v a s o d ila tio n ? A. P o s te r io r d e s c e n d in g a r te r y 11. 8. T . 1 0 0 to 2 0 0 B. c ir c u m f e r e n tia l s tr e s s ) ? A. A ll o f th e a b o v e 12. B a s a l r e q u ir e m e n t 14. P = 2 T t/R B. t. 4 0 0 to 5 0 0 10. H a lo th a n e . T h e s in o a t r ia l a n d th e a tr io v e n tr ic u la r (A V ) n o d e s a r e s u p p lie d in m a j o r i t y o f th e in d iv id u a ls b y A. O f a d a p ta tio n to c h a n g e s in B P o v e r 1 to 2 d a y s D. W h ic h o f th e f o ll o w i n g p o r ti o n s o f m y o c a r d iu m h a s a d u a l b l o o d s u p p ly ? A. R ig h t c o r o n a r y a r te r y C. P ressu re w o rk D. 2 0 0 to 3 0 0 C. 3 0 0 to 4 0 0 D.t e r m b l o o d p r e s s u r e (B P ) c o n tr o l b e c a u s e A. C ir c u m f le x a r te r y D. R . T = 2 R /P t D.

0 . V e ra p a m il C.y e a r . M e to p r o lo l . it a c ts o n ly o n th e a tr io v e n tr ic u la r (A V ) node 20. V e ra p a m il m a y d e c r e a s e a n e s th e tic r e q u ir e m e n ts D. D o p a m in e 18. E m e r g e n c y a p p e n d e c to m y B. F e m o ra l-p o p lite a l b y p a ss s u rg e ry D. C C B s p o te n tia te b o th d e p o la r iz i n g a n d n o n d e p o la r iz i n g n e u r o m u s c u la r b lo c k e r s B. A 6 7 . D ih y d r o p y r id in e s D. W h ic h o f th e f o ll o w i n g s u r g e r i e s c a r r ie s th e h ig h e s t c a r d io v a s c u la r r is k ? A. T h e p a tie n t m e n tio n e d a b o v e d e v e lo p s s e v e r e h y p o te n s io n im m e d ia te ly a fte r in tu b a tio n . W h ic h o f th e f o ll o w i n g a g e n ts is m o s t s u ite d to b r in g th e b l o o d p r e s s u r e b a c k to n o r m a l v a lu e s ? A.b lo c k e r s is m o s t s u ite d f o r a p a tie n t w ith b r o n c h o s p a s tic d is e a s e ? A. I s o f lu r a n e C.5 m g /k g in tr a v e n o u s ly D. S e v o f lu r a n e 15. E p in e p h r in e D. E p h e d r in e B.B lo c k e r s 19. V e ra p a m il h a s n o e f f e c t o n c a r d ia c c o n tr a c tility . P h e n y le p h r in e C. A d m in is te r in g to p ic a l a ir w a y a n e s th e s ia C. W h ic h o f th e f o ll o w i n g s ta te m e n ts a b o u t c a lc iu m c h a n n e l b lo c k e r s (C C B s ) is n o t tru e ? A. W h ic h o f th e f o ll o w i n g te c h n iq u e s is n o t s u ite d f o r a tte n u a tin g th e h y p e r te n s iv e r e s p o n s e to in tu b a tio n ? A. A d m in is te r in g 3 |ig /k g o f fe n ta n y l in tr a v e n o u s ly B. I n g u in a l h e r n ia r e p a ir 16. A d m in is te r in g lid o c a in e 0 . W h ic h o f th e f o ll o w i n g a n tia n g in a l a g e n ts h a s th e h ig h e s t c o r o n a r y v a s o d ila tin g p o te n tia l? A. C C B s p o te n tia te th e c ir c u l a t o r y e ffe c ts o f v o la tile a n e s th e tic a g e n ts C.o ld p a tie n t w ith u n c o n tr o lle d h y p e r te n s io n p r e s e n ts f o r a n e le c tiv e d ia ly s is a c c e s s c r e a tio n . D e s f lu r a n e D. A d m in is te r in g e s m o l o l 1 m g /k g in tr a v e n o u s ly 17. N itra te s B. C a r o tid e n d a r te r e c to m y C. B. W h ic h o f th e f o ll o w i n g 0 . P ro p ra n o lo l B.

II D. W h ic h o f th e f o ll o w i n g is n o t tr u e a b o u t s y s te m ic h y p o th e r m ia d u r in g c a r d io p u lm o n a r y b y p a s s (C P B )? A. V5 B.w a ll m y o c a r d ia l is c h e m ia ? A. D r o p e r id o l is a d m in is te r e d to th e p a tie n t f o r p r e v e n tio n o f p o s to p e r a tiv e n a u s e a . S u r g ic a l e le c tr o c a u te r y m a y c a u s e a p r o b le m w ith a n a u to m a te d im p la n ta b le c a r d io v e r te r d e f ib r il la to r (A IC D ) b y a ll th e f o ll o w i n g m e c h a n is m s . P r o f o u n d h y p o th e r m ia to te m p e r a tu r e s o f 15 to 1 8 °C a llo w s to ta l c ir c u l a t o r y a r r e s t f o r u p to 6 0 m in u te s . A 2 4 . A IC D in te r p r e tin g a c a u te r y c u r r e n t a s v e n tr ic u la r f ib r illa tio n B. V4 C. M e ta b o lic o x y g e n r e q u ir e m e n ts a r e u s u a lly h a lv e d f o r e v e r y o f 1 0 °C r e d u c tio n in te m p e r a tu r e D. A c e b u to lo l D.r e s p o n s iv e s e n s o r D. S u s ta in e d d e c r e a s e (> 1 0 m m H g ) in s y s to lic b l o o d p r e s s u r e d u r in g e x e r c is e B. B is o p r o l o l 21. D iltia z e m 22. V2 25. W h ic h o f th e f o ll o w i n g E C G le a d s is m o s t s e n s itiv e to d e te c t a n a n te r io r . A m io d a r o n e B. A 1 -m m u p s lo p in g o f S T s e g m e n t 23. C. e x c e p t A. C a u te r y c u r r e n t g e n e r a tin g to o m u c h h e a t a t th e lo c a t io n o f A IC D a n d c a u s in g b u r n s 24. C o r e b o d y te m p e r a tu r e is u s u a lly r e d u c e d to 2 0 to 3 2 ° C C.v e n tr ic u la r ta c h y c a r d ia . In h ib itio n o f p a c e m a k e r f u n c tio n d u e to c a u te r y a r tif a c t C. P a c in g D. W h ic h o f th e f o ll o w i n g d r u g s /th e r a p ie s is b e s t f o r th e p a tie n t a t th is p o in t? A. I n c r e a s e d p a c in g r a te d u e to a c tiv a tio n o f a r a te . P e r s is te n c e o f S T -s e g m e n t d e p r e s s io n a fte r e x e r c is in g f o r 5 m in u te s o r l o n g e r D. L id o c a in e C. W h ic h o f th e f o ll o w i n g f a c to r s is n o t a s s o c ia te d w ith s e v e r e m u ltiv e s s e l d is e a s e d u r in g e x e r c is e e le c tr o c a r d io g r a p h y ? A. f o ll o w i n g w h ic h th e p a tie n t g o e s in to p o ly m o r p h ic . I n te n tio n a l h y p o th e r m ia is a lw a y s u s e d f o ll o w i n g th e in itia tio n o f C P B B. F a ilu r e to r e a c h a m a x im u m h e a r t r a te g r e a te r th a n 7 0 % o f p r e d ic te d C.o ld f e m a le p a tie n t w ith a p r e o p e r a t iv e Q T c in te r v a l o f 5 5 0 m s is u n d e r g o in g b r e a s t s u r g e r y u n d e r g e n e r a l a n e s th e s ia .y e a r .

I n tr a v e n o u s f lu id a d m in is tr a tio n w ill n o t h e lp c o r r e c t th is c h a n g e C. M y o c a r d ia l d e p r e s s io n 30. M id e s o p h a g e a l s e c o n d .c h a m b e r v ie w 29.o ld m a le is u n d e r g o in g c o r o n a r y a r te r y b y p a s s g r a f tin g (C A B G ).d o s e o p io id in d u c tio n in c lu d e a ll th e f o ll o w i n g . Arterial diastolic pressure left-ventricular end diastolic pressure B. P a tie n ts w h o h a d p r i o r e x p o s u r e to a p r o tin in D. a n d y o u s h o u ld a s k f o r b l o o d to b e tr a n s f u s e d D. W h ic h o f th e f o ll o w i n g v ie w s o f tr a n s e s o p h a g e a l e c h o c a r d i o g r a p h (T E E ) is m o s t s u ite d to v is u a liz e b l o o d s u p p ly o f a ll th e s e g m e n ts o f th e h e a r t? A. Arterial systolic pressure left-ventricular end systolic pressure 28. Arterial diastolic pressure left-ventricular end systolic pressure C. J e h o v a h w itn e s s e s B. C o r o n a r y p e r f u s io n p r e s s u r e is A. H ig h in c id e n c e o f r e c a ll d u r in g s u r g e r y C. I r r e v e r s ib le c o a g u lo p a th y C. It im p lie s im m in e n t r i s k o f d e a th .y e a r . P a tie n ts o n c o m b in e d c l o p i d o g r e l (P la v ix ) a n d a s p ir in th e r a p y 32. P la te le t d y s f u n c tio n B. P r o l o n g e d p o s to p e r a tiv e r e s p i r a t o r y d e p r e s s io n B. D is a d v a n ta g e s o f h ig h . A fte r th e c h e s t is o p e n e d . P o s s ib le im p a ir m e n t o f im m u n e r e s p o n s e D. M id e s o p h a g e a l th ir d .26. e x c e p t A. A 6 6 . R e d o s u r g e r ie s C. T r a n s g a s tr ic m id s h o r t a x is v ie w D. a p r o g r e s s i v e d e c lin e in c a r d ia c o u tp u t is n o tic e d . W h ic h o f th e f o ll o w i n g s ta te m e n ts is f a ls e r e g a r d i n g p la c e m e n t o f v e n o u s c a n n u la s f o r c a r d io p u lm o n a r y b y p a s s (C P B )? .c h a m b e r v ie w B. T h e m o s t a c c u r a te s ta te m e n t r e g a r d i n g th e c h a n g e is A.c h a m b e r v ie w C. A p r o tin in th e r a p y s h o u ld b e c o n s id e r e d f o r a ll o f th e f o ll o w i n g p a tie n ts . P o te n tia tio n o f c itr a te to x ic ity D. Arterial systolic pressure left-ventricular end diastolic pressure D. It is n o r m a l in d e e p ly a n e s th e tiz e d p a tie n ts B. It is c a u s e d b y s u r g e o n lif tin g th e h e a r t. D e p r e s s io n o f m y o c a r d ia l c o n tr a c tility 27. A d v e r s e e ffe c ts o f h y p o th e r m ia in c lu d e a ll th e f o ll o w i n g . e s p e c ia lly if it is n o t a c c o m p a n ie d b y a d r o p in b lo o d p re s su re 31. e x c e p t A. e x c e p t A. M id e s o p h a g e a l f o u r th .

le f t s h u n t le a d in g to h y p o x e m ia B. H e lp s to in c r e a s e v e n o u s r e tu r n v ia th e v e n o u s o u tf lo w c a n n u la D. It is n o r m a l. V e n o u s c a n n u la in s e r tio n f r e q u e n tly p r e c ip ita te s a tr ia l o r v e n tr ic u la r a r r h y th m ia s C. It is u s u a lly c a u s e d b y a n a ir l o c k in th e a r te r ia l c a n n u la D. D is c o n tin u in g v e n tila tio n p r e m a tu r e ly b e f o r e fu ll f lo w is a c h ie v e d o n c a r d io p u lm o n a r y b y p a s s (C P B ) c a u s e s A. Im p lie s lig h t a n e s th e s ia B.lin e v e n o u s o x y g e n s a tu r a tio n m o n ito r 35. A d m in is te r m id a z o la m to p r e v e n t a w a r e n e s s 34.w a r m in g d e v ic e d u r in g th e s u r g e r y 38. A r ig h t . M a n u a l v is u a liz a tio n D. V e n o u s c a n n u la s a r e in s e r te d b e f o r e a o r tic c a n n u la p la c e m e n t B. L o w u r in e o u tp u t D. W h ic h o f th e f o ll o w i n g is th e m o s t s e n s itiv e to d e te c t a ir b u b b le s a t th e te r m in a tio n o f c a r d io p u lm o n a r y b y p a s s (C P B )? A. N e c e s s ita te s c o o lin g th e o p e r a tin g r o o m D. F o llo w in g in itia tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ) f o r a o r tic v a lv e r e p la c e m e n t. a n d n o a c tio n is n e e d e d B. V e n o u s c a n n u la s c a n c a u s e s u p e r io r v e n a c a v a s y n d r o m e 33. In c re a se d d ead sp ace C. V e n o u s c a n n u la s c a n im p e d e v e n o u s r e tu r n to th e h e a r t D. P r o g r e s s i v e m e ta b o lic a lk a lo s is C. T h e m o s t a p p r o p r ia te n e x t s te p is A. S vo2 >80% B. Is a h y p o th a la m ic r e s p o n s e to p e r f u s io n w ith b l o o d th a t is o f te n a t 3 9 °C C.to . A id s th e s u r g e o n to v is u a liz e a n d c a n n u la te th e c o r o n a r y s in u s 36. W h ic h o f th e f o ll o w i n g is n o t a n in d ic a tio n o f lo w f lo w r a te s u n d e r c a r d io p u lm o n a r y b y p a s s (C P B )? A. P u m p f lo w s h o u ld b e d e c r e a s e d to d e c r e a s e th e b l o o d p r e s s u r e C. E p ia o r tic e c h o c a r d io g r a p h y 37. D o p p le r u l tr a s o n o g r a p h y C. S w e a tin g d u r in g th e r e w a r m in g p h a s e o f te r m in a tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ) A. H y p o x e m ia n o tic e d o n a n in . A. T r a n s e s o p h a g e a l e c h o c a r d io g r a p h y (T E E ) B. y o u n o tic e th e m e a n a r te r ia l p r e s s u r e (M A P ) c o n s is te n tly a b o v e 1 0 0 m m H g . U s e o f c o r r e c t e d g a s te n s io n s d u r in g h y p o th e r m ia . C a n b e p r e v e n te d b y u s in g a f o r c e d a ir .

C o r e b o d y te m p e r a tu r e o f a t le a s t 3 4 ° C B. A 6 8 .a o r ti c b a l l o o n p u m p (IA B P ) C. Is c a lle d p H -s ta t m a n a g e m e n t B. P r e s e r v e s c e r e b r a l a u to r e g u la t io n C. S ta b le h e a r t r h y th m o r p a c e r r h y th m C. G e n e r a l g u id e lin e s f o r s e p a r a tio n f r o m c a r d io p u lm o n a r y b y p a s s (C P B ) in c lu d e a ll th e f o ll o w i n g . I n c r e a s in g th e h e m a to c r it 43.o ld p a tie n t w ith a n in f e c te d p r o s th e tic a o r tic v a lv e u n d e r w e n t a v a lv e r e p la c e m e n t. a n d s y s te m ic v a s c u la r r e s is ta n c e (S V R ) a r e lo w . P o s t . S y n c h r o n iz e d w ith th e r i s e o f a o r tic p u ls e 42. p u lm o n a r y c a p il la r y w e d g e p r e s s u r e (P C W P ).b a s e r e a c tio n B.c a r d i o p u l m o n a r y b y p a s s (C P B ). A d d in g a p u lm o n a r y v a s o d il a to r D. H e a r t r a te a r o u n d 8 0 to 1 0 0 b p m D. J u s t b e f o r e th e d ic r o tic n o tc h B. S p e e d s th e r e w a r m in g p r o c e s s a n d d e c r e a s e s l a r g e te m p e r a tu r e g r a d ie n ts C.y e a r . w h ile th e c a r d ia c o u tp u t (C O ) is h ig h . It is r e m o v e d b y th e k id n e y s D. A. T im in g o f in f la tio n o f a n in tr a . J u s t a fte r th e d ic r o tic n o tc h C. A d e q u a te v e n tila tio n w ith 1 0 0 % O 2 41. A s s o o n a s th e d o w n w a r d s lo p e o f a o r tic p u ls e b e g in s D. It is r e m o v e d b y th e r e tic u lo e n d o th e lia l s y s te m C. A d d in g in tr a . Is a n o ld te c h n iq u e th a t p r o d u c e s u n n e c e s s a r y h e m o d y n a m ic c h a n g e s D. w h ic h o f th e f o ll o w i n g is th e fa te o f th e h e p a r i n . D ila te s th e c o r o n a r y v e s s e ls a n d h e lp s im p r o v e c o r o n a r y f lo w B. h is c e n tr a l v e n o u s p r e s s u r e (C V P ). T h e n e x t s te p in m a n a g e m e n t o f th is p a tie n t is A. I m p r o v e s r e n a l b l o o d f lo w 40. A d d in g a n in o tr o p e B. T h e o n ly p r o d u c t r e m a in in g w ill b e w a te r s in c e it is a n a c id . Is d o n e b y a d d in g s o d iu m b ic a r b o n a te to th e v e n o u s r e s e r v o i r 39. I n f u s io n o f n itr o g l y c e r i n a t th e te r m in a tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ) A. A fte r n e u tr a liz in g h e p a r in . It is e x c r e te d u n c h a n g e d v ia g a s tr o in te s tin a l (G I) tr a c t 44. e x c e p t A. H e p a r in r e b o u n d a fte r te r m in a tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ) is d u e to . I m p r o v e s m y o c a r d ia l p r e s e r v a tio n D.p r o t a m i n e r e a c tio n p r o d u c t? A.a o r ti c b a l l o o n p u m p (IA B P ) s h o u ld b e A.

A. e x c e p t A. T is s u e c r o s s m a tc h in g 49. A b o litio n o f X d e s c e n t B. In th e f i r s t f e w p o s to p e r a tiv e h o u r s a fte r a n o p e n h e a r t s u r g e r y . F a c to r V III C. B o th A a n d B a r e fa ls e . it is d u e to in a d e q u a te p r o ta m in e d o s in g 45. F a c to r V II B. D D A V P ( d e s m o p r e s s in ) a d m in is tr a tio n c a n in c r e a s e th e a c tiv ity o f a ll th e f o ll o w i n g f a c to r s . v o n W ille b r a n d f a c to r 46. e x c e p t A.g r o u p ty p in g C. in c o n tr a s t to a c u te ta m p o n a d e B. A B O b l o o d . I n c r e a s e d d ia s to lic f il lin g d o e s n o t o c c u r . T h e Y d e s c e n t is a b s e n t in C V P w a v e f o r m C. T r y in g f o r a n e a r ly e x tu b a tio n D. M a in ta in in g e u th e r m ia 47. In c o n s tr ic tiv e p e r ic a r d itis . D r o p in p u lm o n a r y v a s c u la r r e s is ta n c e (P V R ) C. R e d is tr ib u tio n o f h e p a r in to c e n tr a l c o m p a r tm e n t C.r e c i p i e n t c o m p a tib ility in c a r d ia c tr a n s p la n ta tio n is b a s e d o n a ll. A b o litio n o f Y d e s c e n t C. C V w a v e fo rm D. D r o p in s y s te m ic v a s c u la r r e s is ta n c e (S V R ) B. D if f u s e T -w a v e a b n o r m a litie s a r e a r a r e s ig n . except A. P u ls u s p a r a d o x u s is u n c o m m o n D. C y to m e g a lo v ir u s s e r o l o g y D. T h e c e n tr a l v e n o u s p r e s s u r e (C V P ) w a v e f o r m in c a r d ia c ta m p o n a d e is c h a r a c te r iz e d b y A. B e tte r r i g h t c o r o n a r y p e r f u s io n 48. D o n o r . R e d is tr ib u tio n o f p r o ta m in e to p e r ip h e r a l c o m p a r tm e n ts B. B o th A a n d B a r e tru e D. F a c to r X II D. In h a le d n itr ic o x id e (N O ) a t 6 0 p p m h a s a ll o f th e f o ll o w i n g e ffe c ts . I m p r o v e m e n t in c a r d ia c o u tp u t D. H e a r t s iz e B. M a in ta in in g a d e q u a te u r in e o u tp u t C. A. M o n ito r in g f o r e x c e s s iv e p o s to p e r a tiv e b le e d in g B. th e e m p h a s is is o n A. T a ll C w a v e s 50.

T a c h y c a r d ia (> 1 0 5 b p m ) f o r 5 m in u te s in th e p o s to p e r a tiv e p e r i o d c a n in c r e a s e th e r i s k o f d e a th b y 1 0 . E c h o c a r d io g r a p h y w a ll. P e r io p e r a tiv e r i s k r e d u c tio n w ith P . A 2 5 . y o u n o tic e a h e a r t r a te o f 1 2 0 b p m a n d b l o o d p r e s s u r e o f 6 0 /4 0 m m H g . N o r m a l m ix e d v e n o u s o x y g e n te n s io n i s _______ ( m m H g ): A. P e r io p e r a tiv e P .b lo c k e r s a n d c lo n id in e is i n f e r i o r to r i s k s tr a tif ic a tio n w ith in v a s iv e te s tin g . 560 54. 40 C. P u lm o n a r y c a p il la r y w e d g e p r e s s u r e (P C W P ) d o e s n o t c o r r e s p o n d to th e le f t. Y o u s u s p e c t th e p a tie n t h a s id io p a th ic h y p e r tr o p h ic s u b a o r tic s te n o s is . U s e o f e s m o l o l b o lu s e s in tr a o p e r a tiv e ly to k e e p th e h e a r t r a te < 8 0 b p m 55. 45 D. a n d c o r o n a r y a r te r y b y p a s s g r a f tin g (C A B G ) D. W h ic h o f th e f o ll o w i n g m a n e u v e r s is m o s t lik e ly to h e lp th is p a tie n t’s h e m o d y n a m ic s ? A.a tr ia l m y x o m a 53. B o th A a n d B D. A d m in is te r in g a b o lu s o f 1 L o f n o r m a l s a lin e a n d e s m o l o l 10 m g IV C. A d m in is te r in g v e r a p a m il 5 m g IV im m e d ia te ly D. W h ic h o f th e f o ll o w i n g is th e m o s t e f f e c tiv e m e a n s o f p r e d ic tin g a p e r io p e r a tiv e c a r d ia c e v e n t? A. M o s t p e r io p e r a tiv e M Is o c c u r in th e f i r s t 4 8 to 72 h o u r s p o s to p e r a tiv e ly B. a n g io p la s ty . A 1 -m in u te e p is o d e o f 1 -m m S T -s e g m e n t e le v a tio n o r d e p r e s s io n o n th e E C G in c r e a s e s th e r i s k f o r c a r d ia c e v e n ts b y 1 0 .51.o ld m a le w ith a f a m ily h is to r y o f s u d d e n c a r d ia c d e a th s is u n d e r g o in g a la p a r o s c o p ic a p p e n d e c to m y . L e f t.m o tio n a b n o r m a litie s .f o ld 56. 75 B.e x p i r a t o r y p r e s s u r e (P E E P ) D. M itra l s te n o s is B. T r ic u s p id r e g u r g i t a t i o n C.y e a r . A d m in is te r in g a b o lu s o f n o r m a l s a lin e a n d p h e n y le p h r in e 1 0 0 |ig IV 52. w ith a n o r m a l c a p n o g r a m .f o ld C. e x c e p t A. I m m e d ia te ly a fte r in d u c tio n a n d in tu b a tio n . L o w e r in g th e h e a d e n d o f th e b e d a n d a d m in is te r in g 10 m g o f e p h e d r in e IV B. W h ic h o f th e f o ll o w i n g s ta te m e n ts is f a ls e r e g a r d i n g p e r io p e r a tiv e m y o c a r d ia l i n f a r c tio n (M I)? A. T h e o n ly c lin ic a ll y p r o v e n m e th o d to r e d u c e th e r i s k o f p e r io p e r a tiv e m y o c a r d ia l in f a r c tio n (M I) a n d a s s o c ia te d d e a th is A. V e ry h ig h p o s itiv e e n d .b lo c k e r th e r a p y B.v e n tr ic u la r e n d d ia s to lic p r e s s u r e (L V E D P ) in a ll o f th e f o ll o w i n g s itu a tio n s . P e r io p e r a tiv e c lo n id in e th e r a p y C.

M in im iz e d r u g . W h ic h o f th e f o ll o w i n g e v e n ts is n o t lik e ly to a d v e r s e ly a f f e c t h e m o d y n a m ic s in a p a tie n t w ith m itr a l. T a k e p la c e d u r in g th e a s c e n d in g lim b o f th e T w a v e ( R . E c h o c a r d io g r a p h y e je c tio n f r a c tio n C. A v o id s u d d e n d e c r e a s e s in s y s te m ic v a s c u la r r e s is ta n c e (S V R ) C.r e g u r g i t a n t f lo w 60. P r o p h y la c tic a d m in is tr a tio n o f in tr a v e n o u s v a s o c o n s tr ic to r p h e n y le p h r in e C.o n . A v o id s u d d e n d e c r e a s e s in h e a r t r a te B. V e n tric u la r p r e m a tu r e b e a ts (V P C s ) c a n b e tr e a te d w ith lid o c a in e ( 1 . A v a ila b ility o f e le c tr ic a l c a r d i o v e r s i o n w h ile th e p a tie n ts a r e u n d e r g o in g s u r g ic a l p ro c e d u re s 61. A r e f r e q u e n t ( m o r e th a n s ix p r e m a tu r e b e a ts /m in ) B.in d u c e d m y o c a r d ia l d e p r e s s io n D. W h ic h o f th e f o ll o w i n g is m o s t e f f e c tiv e m e th o d o f p r e v e n tin g th e h e m o d y n a m ic c h a n g e s a s s o c ia te d w ith in tu b a tio n ? A. E s m o lo l 1 m g /k g IV b e f o r e in tu b a tio n C. A v o id a n c e o f d r u g s th a t p r o l o n g th e Q T in te r v a l D.B lo c k e r s B. 0 .T p h e n o m e n o n ) . H e a d -u p p o s itio n o f th e p a tie n t D. A v o id a n c e o f s u d d e n in c r e a s e s in s y s te m ic v a s c u la r r e s is ta n c e (S V R ) 62. T r e a tm e n t o f p a tie n ts w ith p r o l o n g e d Q T in te r v a l in c lu d e a ll.th a lliu m s c in tig r a p h y D. R ig h t s te lla te g a n g lio n b lo c k C. A n e s th e tic c o n s id e r a tio n s in p a tie n ts w ith a o r tic s te n o s is in c lu d e a ll. B.v a lv e p r o la p s e ? A. M o n ito r th e m a g n itu d e o f th e C w a v e o f C V P a s a r e f le c tio n o f m i t r a l . I n tr a . B r ie f l a r y n g o s c o p y (< 1 5 s e c o n d s ) B. S y m p a th e tic s tim u la tio n B. A r e m u ltif o c a l C. e x c e p t A. D ip y r id a m o le . D e c r e a s e d s y s te m ic v a s c u la r r e s is ta n c e C. D e e p e n th e a n e s th e s ia w ith p r o p o f o l 1 m g /k g 58. L id o c a in e 2 m g /k g b e f o r e in tu b a tio n D. A v o id a n c e o f e x tr e m e b r a d y c a r d i a o r ta c h y c a r d ia D.2 m g /k g IV ) w h e n th e y A. A n e s th e tic c o n s id e r a tio n s in a p a tie n t w ith m itr a l r e g u r g i t a t i o n in c lu d e a ll th e f o ll o w i n g .a r te r ia l b l o o d p r e s s u r e m o n ito r in g B. e x c e p t A. I n c r e a s e d p u lm o n a r y v a s c u la r r e s is ta n c e 59. C a r e f u l p r e o p e r a t iv e e v a lu a tio n 57. e x c e p t A.

A ll o f th e a b o v e 63. W h ic h o f th e f o ll o w i n g s ta te m e n ts is f a ls e r e g a r d i n g m a n a g e m e n t o f a p a tie n t w ith a n a u to m a te d im p la n ta b le c a r d io v e r te r d e f ib r il la to r (A IC D )? A. I n c r e a s e in s y s te m ic b l o o d p r e s s u r e d u e to in c r e a s e d in tr a p e r ic a r d ia l p r e s s u r e f r o m a c c u m u la tio n o f f lu id in th e p e r ic a r d ia l s p a c e D.W h i t e (W P W ) s y n d r o m e ? A.f ille d tu b in g b e tw e e n th e r o l l e r a n d c u r v e d m e ta l b a c k p la te a n d h e n c e a v o id a ir . K e ta m in e B. R e t r o g r a d e f lo w th r o u g h th e a o r tic v a lv e c o u ld c a u s e le f t. Y o u th in k th is is a w r o n g d e c is io n . a n d y o u r a r g u m e n ts in c lu d e a ll th e f o ll o w i n g . T h e s u r g e o n d e c id e s n o t to v e n t th e le f t v e n tr ic le . V e n tin g c a n b e d o n e th r o u g h a p u lm o n a r y v e n o u s d r a in C. D e c r e a s e in s tr o k e v o lu m e C. e x c e p t A. T h e m a g n e t m o d e m a y p r o d u c e a s y n c h r o n o u s p a c in g a t 9 9 b p m 65.d e p e n d e n t.o ld p a tie n t w ith a h is to r y o f m o d e r a te a o r tic r e g u r g i t a t i o n is u n d e r g o in g a c o r o n a r y a r te r y b y p a s s g r a f tin g (C A B G ). S y s to lic d y s fu n c tio n . C a r d ia c ta m p o n a d e is c h a r a c te r iz e d b y A. A n 8 1 .y e a r . T h e y a r e a f te r lo a d . e x c e p t A.v e n tr ic u la r d is te n s io n D. D ig ita lis 64. W h ic h o f th e f o ll o w i n g d r u g s n e e d s n o t b e a v o id e d in th e a n e s th e tic m a n a g e m e n t o f a p a tie n t w ith W o l f f . S u c c in y lc h o lin e D.P a r k i n s o n . V e n tin g c a n b e d o n e th r o u g h a d r a in p la c e d f r o m th e r i g h t s u p e r io r p u lm o n a r y v e in in to th e le f t v e n tr ic le B. C e n tr if u g a l p u m p s a r e s u p e r io r to r o l l e r p u m p s b e c a u s e o f a ll. B ip o la r e le c tr o c a u te r y m a y b e u s e d o v e r u n ip o la r e le c tr o c a u te r y to r e d u c e in te r f e r e n c e b e tw e e n e le c tr o s u r g ic a l c a u te r y a n d th e p a c e m a k e r D. T h e “ m a g n e t m o d e ” is a lw a y s s a fe B. T h e g r o u n d p la te s h o u ld b e p la c e d a s fa r a s p o s s ib le f r o m th e p u ls e g e n e r a to r C. V e n tin g d o n e b y a s p ir a tin g f r o m th e a n te g r a d e c a r d io p le g i a lin e p la c e d in th e p r o x im a l a s c e n d in g a o r ta w ill n o t b e h e lp f u l 67. is th e p r i m a r y p r o b le m 66. R o lle r p u m p s c o m p r e s s th e f lu i d . D. T h e y a r e le s s tr a u m a tic to b l o o d c e lls B. a n d n o t d ia s to lic d y s fu n c tio n . a n d a v o id th e r i s k o f lin e r u p tu r e w ith c la m p in g o f th e a r te r ia l in f l o w c ir c u it D. P a n c u r o n iu m C. T h e y d o n o t p u m p a ir b u b b le s s e c o n d a r y to a ir b e in g le s s d e n s e th a n b l o o d C. I n c r e a s e in d ia s to lic f illin g o f th e v e n tr ic le s B.

Further decrease the patient’s temperature D. The most appropriate management is to A. During cardiopulmonary bypass (CPB). Hypothermia B. Regarding the maintenance of blood pressure during cardiopulmonary bypass (CPB). Pao2 decreases from 90 to 70 mm Hg at an Fio 2 of 0. Rewarming D. Bronchial mucus plugging C. the hematocrit is 20%.7.68. During total cardiopulmonary bypass. Left-ventricular failure D. Light anesthesia 72. and mechanically ventilated. and the uncorrected Paco2 is 60 mm Hg. peak inspiratory pressure measured proxim ally in the ventilator circuit increases from 40 to 66 cm H2O. Over the next 3 hours. endotracheally intubated. Which of the follow ing is the most likely case of these changes? A. If the pressure in the coronary sinus catheter is 40 to 60 mm Hg during a 200-mL/min infusion. Pressures less than 40 mm Hg are avoided if possible in adults C. the catheter is correctly positioned . Administer packed red blood cells to increase hematocrit to 25% C. Pressures higher than 90 mm Hg are used during rewarming D. and plateau pressure remains unchanged at 30 cm H2O. the temperature corrected Paco2 is 50 mm Hg. Administer additional opioid B. The most likely cause is A. the catheter is not in the coronary sinus but is most likely in the pulmonary artery B. If the pressure at the distal tip of the coronary sinus catheter during cardioplegia administration at 200 mL/min is equal to central venous pressure. While monitoring coronary sinus pressure during retrograde cardioplegia. Adult respiratory distress syndrome (ARDS) B. while higher pressures may improve cerebral blood flo w but cause more emboli B. Tension pneumothorax 70. A. metabolic acidosis and decreasing mixed venous oxygen saturation are noted. the nasopharyngeal temperature is 28°C. Lower blood pressures may reduce cerebral blood flo w and reduce emboli load to the brain. a 62-year-old man remains sedated. Increase fresh-gas flo w to the oxygenator 69. Hypoperfusion C. which of the follow ing is false? A. the coronary sinus catheter is in the left ventricle C. Pressures up to 90 mm Hg may be used in patients with cerebral vascular disease 71. Two days after coronary artery bypass grafting. If the pressure is very high (>100 mm Hg).

D. C a r d ia c ta m p o n a d e D. A 5 7 . H ig h p u lm o n a r y v a s c u la r r e s is ta n c e D.v e n tr ic u la r d y s f u n c tio n C. A d d itio n a l s u p p le m e n ta l a n e s th e tic s a n d m u s c le r e la x a n ts s h o u ld b e a d m in is te r e d A. 2 m L /1 0 0 g /m in B. R ig h t. L o w s y s te m ic v a s c u la r r e s is ta n c e (S V R ) C. L e f t. 0 . In th e e a r ly p e r i o d a fte r c o n c lu s io n o f C P B 75.y e a r . B o th A a n d B D. A fte r te r m in a tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ).o ld m a le is u n d e r g o in g c o r o n a r y a r te r y b y p a s s g r a f tin g ( le f t in te r n a l m a m m a r y a r te r y to le f t a n te r io r d e s c e n d in g a r te r y ) . T h e e le c tr o m e c h a n ic a lly q u ie t h e a r t a t 2 2 ° C c o n s u m e s o x y g e n a t a r a te o f A.3 m L /1 0 0 g /m in D. T h e m o s t c o m m o n h e m o d y n a m ic a b n o r m a lity a fte r c a r d io p u lm o n a r y b y p a s s (C P B ) is A. L o w h e a r t r a te 76. T h e m o s t lik e ly r e a s o n f o r th e f in d in g is A. d e liv e r y o f c a r d io p le g i a to th e le f t v e n tr ic le w ill b e c o m p r o m is e d a n d r e s u lt in le f t.v e n tr ic u la r d y s f u n c tio n 73. 0. A t r e w a r m in g C. A t in s titu tio n o f c a r d io p u lm o n a r y b y p a s s (C P B ) B. L o w c a r d ia c o u tp u t B. y o u n o tic e a p r o m i n e n t V w a v e in th e p u lm o n a r y a r te r y o c c lu s io n p r e s s u r e (P A O P ) tr a c in g .1 m L /1 0 0 g /m in 74. P o s te r io r p a p illa r y m u s c le d y s f u n c tio n . 8 m L /1 0 0 g /m in C.v e n tr ic u la r d y s f u n c tio n B. If th e c a th e te r is p la c e d to o d is ta lly .

3 s e c o n d s ) is d u e to o p e n in g o f s lo w e r c a lc iu m c h a n n e ls . S o th e n e x t tis s u e in th e c o n d u c tin g p a th w a y ( ju n c tio n a l p a c e m a k e r s ) ta k e s o v e r a n d p r o d u c e s ju n c tio n a l rh y th m . T h e s p ik e p o r t i o n o f th is a c tio n p o te n tia l is p r o d u c e d b y o p e n in g o f fa s t s o d iu m c h a n n e ls a lo n g w ith a d e c r e a s e d p e r m e a b il ity to p o ta s s iu m a n d th e p la te a u p o r t i o n ( 0 . T h is r e s to r e s th e r e s tin g .m e m b r a n e p o te n tia l. T h e n o r m a l v e n tr ic u la r c e l l . Its e ffe c ts c a n b e s in u s b r a d y c a r d ia . th e s o d iu m a n d c a lc iu m c h a n n e ls c lo s e a n d th e m e m b r a n e p e r m e a b il ity to p o ta s s iu m is r e s to r e d .r e s t i n g m e m b r a n e p o te n tia l is . S p o n ta n e o u s ly d e p o la r iz i n g c e lls . d o so p r i m a r i l y b y in tr in s ic s lo w le a k a g e o f c a lc iu m in to c e lls a id e d b y le a k y N a c h a n n e ls m o v in g N a+ in (T a b le 1 1 -1 ). T h e th e r a p e u tic e ffe c ts o f l o w c o n c e n tr a tio n s o f lid o c a in e tu r n to x ic a t h ig h e r c o n c e n tr a tio n s — th e y b in d to f a s t N a c h a n n e ls a n d d e p r e s s c o n d u c tio n . th e y d e p r e s s th e a u to m a tic ity o f h e a r t b y its e f f e c t o n s in o a t r ia l n o d e . w h ic h c a u s e to x ic ity b y its e f f e c t o n P u r k in je f ib e r s a n d v e n tr ic u la r m u s c le . A c tio n p o te n tia l ( d e p o la r iz a tio n ) o c c u r s w h e n c e ll m e m b r a n e b e c o m e s le s s n e g a tiv e a n d c r o s s e s a th r e s h o ld v a lu e . T h e c a r d ia c a c tio n p o te n tia l is s lig h tly d if f e r e n t f r o m n e u r o n a l a c tio n p o te n tia l in th a t it h a s a c h a r a c te r is tic s p ik e a n d p la te a u a p p e a r a n c e . If w e in c r e a s e th e c o n c e n tr a tio n fu r th e r .2 . a n d p r o l o n g th e d u r a tio n o f P u r k in je f i b e r . Table 11-1 A C T I O N P O T E N T IA L P H A S E NAM E N E T IO N M O V E M E N T 0 Rapid upstroke Na+ in (relative impermeability to K+) 1 Early rapid repolarization K+ out (increased permeability to K+ transien 2 Plateau (a part of repolarization) Ca++ in 3 Final repolarization K+ out of cells 4 Resting-membrane potential Na+ in and K+ out 2. T h is is v e r y d if f e r e n t f r o m th e m o r e p o te n t lo c a l a n e s th e tic s lik e b u p iv a c a in e a n d r o p iv a c a in e . s in u s n o d e a r r e s t.9 0 m V . N a . B y g iv in g a n a n tic h o lin e r g ic .K A T P a s e b o u n d to th e m e m b r a n e is r e s p o n s ib le f o r c o n c e n tr a tin g K+ i n t r a c e l lu la r ly a n d in e x c h a n g e f o r N a a n d m a in ta in in g th is r e s tin g . O p io id s d e p r e s s c a r d ia c c o n d u c tio n .8 0 to . B u p iv a c a in e b in d s in a c tiv a te d fa s t s o d iu m c h a n n e ls a n d d is s o c ia te s f r o m th e m s lo w ly . CHAPTER 11 ANSWERS 1. o r m a lig n a n t v e n tr ic u la r a r r h y th m ia .0 .a c t i o n p o te n tia l. A fte r d e p o la r iz a tio n . w e s tim u la te d th e c o n d u c tio n s y s te m o f th e h e a r t. A r r h y t h m o g e n ic ity b y in h a la tio n a l a g e n ts is d u e to p o te n tia tio n o f a c tio n o f c a te c h o la m in e s .m e m b r a n e p o te n tia l to its b a s e lin e . r e s p o n s ib le f o r th e m y o c a r d ia l rh y th m . H a lo th a n e a n d is o f lu r a n e d e p r e s s S A n o d e a u to m a tic ity a n d m a k e A V n o d e r e f r a c to r y . in c r e a s e A V n o d e r e f r a c to r in e s s . s o m e tim e s a s h ig h a s + 2 0 m v . . 3. W h ile th e d e p r e s s io n o f S A a n d A V n o d e s b y in h a la tio n a l a g e n ts is w e ll k n o w n . a n d th e d ir e c t d e p r e s s io n o f c a lc iu m c h a n n e ls r e n d e r s s o m e a n tia r r h y th m ic e ffe c t. A. th e e f f e c t o f in h a la tio n a l a g e n ts o n P u r k in je f ib e r s a n d v e n tr ic u la r m y o c a r d iu m is u n p r e d ic ta b le w ith r e p o r ts o f b o th a r r h y th m ia . b u t S A a n d AV n o d e s h a v e b e e n s u p p r e s s e d b y th e in h a la tio n a l a g e n t. B.in d u c in g a n d a n tia r r h y th m ic e ffe c ts . T h is d e p o la r iz a tio n r a is e s th e m e m b r a n e p o te n tia l o f th e m y o c a r d ia l c e ll. A.

5 to 4 .4. S V is th e s tr o k e v o lu m e (th e v o lu m e p u m p e d p e r c o n tr a c tio n ) . A ll a n e s th e tic a g e n ts c a n d e p r e s s cardiac contractility. a n d d e s f lu r a n e . B S A is u s u a lly o b ta in e d f r o m n o m o g r a m s b a s e d o n h e ig h t a n d w e ig h t.2 L / m in /m 2. A b e tte r e s tim a te o f v e n tr ic u la r p e r f o r m a n c e c a n b e o b ta in e d if w e s u b je c t th e v e n tr ic le s to s o m e s tr e s s lik e e x e r c is e . c. s e v o f lu r a n e . C a r d ia c o u tp u t is d e f in e d a s th e v o lu m e o f b l o o d p u m p e d b y th e h e a r t p e r m in u te . A t v e r y h ig h h e a r t r a te s (> 1 2 0 b p m ) in a d u lts . th e r e is a w id e r a n g e f o r C I a n d th e p a tie n t s h o u ld h a v e a g r o s s v e n tr ic u la r im p a ir m e n t p r i o r to it b e in g e v id e n t o n C I. B. D. w h e r e C O is th e c a r d ia c o u tp u t. a n d d e c r e a s in g th e s e n s itiv ity o f c o n tr a c tile p r o te in s to c a lc iu m . e x c e p t in c r itic a lly ill p a tie n ts w ith d e p le te d c a te c h o la m in e s . V e n tric u la r f il lin g is in f lu e n c e d b y b o th h e a r t r a te a n d rh y th m . a n d H R is h e a r t ra te . N o r m a l C I is 2.d e p e n d e n t f a s h io n . C.in d u c tio n a g e n t k e ta m in e : a g e n t w ith n o s ig n if ic a n t m y o c a r d ia l d e p r e s s io n . C O = S V x H R . B u p iv a c a in e . m e a s u r e m e n t o f m ix e d v e n o u s o x y g e n te n s io n ( o r s a tu r a tio n ) is th e b e s t d e te r m in a tio n o f th e a d e q u a c y o f c a r d ia c o u tp u t. 7. A s y o u c a n s e e .v e n tr ic u la r f il lin g is s ig n if ic a n tly im p a ir e d b y th e s h e e r d e c r e a s e in d u r a tio n o f . L o c a l a n e s th e tic a g e n ts : r e d u c e c a lc iu m in f lu x a n d r e le a s e in a d o s e . te tr a c a in e . S in c e th e tim e s p e n t in d ia s to le is h ig h e r th a n th e tim e s p e n t in s y s to le . a n d r o p iv a c a in e c a u s e g r e a te r d e p r e s s io n th a n lid o c a in e a n d c h lo r o p r o c a in e . a wave atrial contraction c wave cusps bulging into the right atrium x descent atrial relaxation during ventricular systole v wave venous filling of the right atrium y descent atrial emptying when tricuspid valve opens 6. w h e r e it a c ts a s a d ir e c t m y o c a r d ia l d e p re s s a n t. th e le f t. th e r i g h t a n d le f t v e n tr ic le s h a v e th e s a m e o u tp u t.a n d L -ty p e c a lc iu m c h a n n e ls . F a c to r s th a t c a n w o r s e n th is c a r d ia c d e p r e s s io n in c lu d e h y p o c a lc e m ia . M ix e d v e n o u s o x y g e n s a tu r a tio n is id e a l ly o b ta in e d f r o m a PA c a th e te r. a n y in c r e a s e in h e a r t r a te h a s m o r e e f f e c t o n th e d ia s to lic f illin g tim e m o r e th a n th e s y s to lic e je c tio n tim e . T h is w ill r e v e a l u n d e r ly in g in a b ility o f th e h e a r t to d e liv e r a d e q u a te o x y g e n to th e tis s u e s a n d c a n b e n o te d a s a f a llin g m ix e d v e n o u s o x y g e n s a tu r a tio n . a - a d r e n e r g i c b lo c k a d e . T h is o c c u r s b y a lte r a tio n s in th e in tr a c e llu la r c o n c e n tr a tio n o f c a lc iu m a s f o llo w s : I n h a la tio n a l a g e n ts : d e c r e a s in g th e e n tr y o f c a lc iu m in to c e lls b y a f f e c tin g b o th T . V e n tric u la r s y s to lic f u n c tio n is d o c u m e n te d m o s t c o m m o n ly a s c a r d ia c o u tp u t o r e je c tio n f r a c tio n . N itr o u s o x id e : r e d u c e s th e in tr a c e llu la r c a lc iu m c o n c e n tr a tio n ( d o s e -d e p e n d e n t). a lte r in g th e k in e tic s o f c a lc iu m r e le a s e a n d u p ta k e in to th e s a r c o p la s m ic r e tic u lu m . T h e C V P w a v e f o r m c o n s is ts o f th r e e p o s itiv e w a v e f o r m s c a lle d a. C. In a d e q u a te tis s u e p e r f u s io n r e la tiv e to d e m a n d is c a u s in g th e d r o p in m ix e d v e n o u s s a tu r a tio n . T h is c a n b e a v o id e d b y u s in g c a r d ia c in d e x : C I = C O /B S A . 5. T h e s e e ffe c ts a r e m o r e a p p a r e n t w ith h a lo th a n e th a n w ith m o d e r n in h a la tio n a l a g e n ts lik e is o f lu r a n e . T h u s . a n d c a lc iu m c h a n n e l b lo c k e r s . w h e r e C I is th e c a r d ia c in d e x a n d B S A is th e to ta l b o d y s u r f a c e a r e a . I n tr a v e n o u s . a n d v a n d tw o n e g a tiv e s lo p e s c a lle d th e x a n d y d e p r e s s io n s . N o r m a lly . in th e a b s e n c e o f h y p o x ia o r s e v e r e a n e m ia . V a ria tio n s in b o d y s iz e c a n le a d to a m b ig u ity if w e j u s t u s e c a r d ia c o u tp u t a s a m e a s u r e .

T h e A V n o d e is s u p p lie d b y th e r i g h t c o r o n a r y a r te r y in 8 5 % o f in d iv id u a ls . s o m e tim e s c a lle d th e H e r in g n e r v e . 11. C.w a ll te n s io n c a n b e c a lc u la te d b y L a p la c e la w : C ir c u m f e r e n tia l s tr e s s = in tr a v e n tr ic u la r p r e s s u r e x v e n tr ic u la r r a d iu s /2 x w a ll th ic k n e s s T h is r e la tio n s h ip is a p p lic a b le to s p h e r ic a l s tr u c tu r e s . d ia s to le . T h e r i g h t c o r o n a r y a r te r y (R C A ) n o r m a l l y s u p p lie s th e r ig h t a tr iu m . A n y c o n d itio n th a t a ffe c ts th e a tr ia l c o n tr a c tio n . 12. T h e a f f e r e n t p a th w a y f o r b a r o r e c e p t o r r e f le x f r o m th e a o r tic r e c e p to r s tr a v e ls a lo n g th e v a g u s n e r v e . a n d th e i n f e r i o r w a ll o f th e le ft v e n tr ic le . a n d b y th e c ir c u m f le x a r te r y in 1 5 % o f in d iv id u a ls . a n y in c r e a s e in th ic k n e s s ( h y p e r tr o p h y ) d e c r e a s e s th e w a ll te n s io n . T h is is c a lle d th e b a r o r e c e p t o r r e f le x . 8. lik e a tr ia l f ib r illa tio n /f lu tte r . H o w e v e r. b u t c a n b e a p p lie d to le f t v e n tr ic le as w e ll. 10. H o w e v e r. C. th e P D A . T h e d o s e is g iv e n to a c h ie v e a n a c tiv a te d c lo ttin g tim e o f 4 0 0 to 4 5 0 s e c o n d s . R e c o m m e n d e d d o s e o f h e p a r in b e f o r e in itia tio n o f c a r d io p u lm o n a r y b y p a s s is 3 0 0 to 4 0 0 U /k g . It c a n b e d e n o te d b y th e v e n tr ic u la r . T h e y a r e lo c a te d at th e b if u r c a tio n o f th e c o m m o n c a r o tid a n d in th e a o r tic a rc h .w a ll te n s io n d u r in g s y s to le o r im p e d a n c e o f th e a r te r ia l tre e . T h is is a p r o te c tiv e m e c h a n is m s e e n in p a tie n ts w ith lo n g . A f te r lo a d is th e f o r c e a g a in s t w h ic h v e n tr ic le is p u s h in g th e b l o o d o u t. A. w ill n e g a te th is c o n tr ib u tio n a n d c a n h a v e s ig n if ic a n t h e m o d y n a m ic c o n s e q u e n c e s in s o m e p a tie n ts . r e a d a p ta tio n to c h a n g e s in a c u te b l o o d p r e s s u r e o c c u r s o v e r th e c o u r s e o f 1 to 2 d a y s . A ll v o la tile a n e s th e tic s d e p r e s s th e n o r m a l b a r o r e c e p t o r r e s p o n s e . B a r o r e c e p to r s h a v e a n im p o r ta n t r o l e in a c u te r e g u la tio n o f b l o o d p r e s s u r e . V e n tr ic u la r . o r a lte r s th e tim in g o f a tr ia l k ic k . T h e a f f e r e n t p a th w a y f o r th e b a r o r e c e p t o r r e f le x is v ia a b r a n c h o f th e g lo s s o p h a r y n g e a l n e r v e . T h e S A n o d e is s u p p lie d b y th e r i g h t c o r o n a r y a r te r y in 6 0 % o f in d iv id u a ls . a n d b y th e le f t a n te r io r d e s c e n d in g a r te r y in 4 0 % o f th e in d iv id u a ls . a tr ia l c o n tr a c tio n (k ic k ) c o n tr ib u te s a b o u t 2 0 % to 3 0 % o f th e v e n tr ic u la r f illin g in a n o r m a l h e a r t.t e r m b l o o d p r e s s u r e c o n tr o l. w h ic h h a s a d u a l b lo o d s u p p ly d e r iv e d f r o m th e p o s te r io r d e s c e n d in g a r te r y (P D A ) a n d th e le f t a n te r io r d e s c e n d in g (L A D ) a rte ry . m a k in g th is r e f le x in e f f e c tiv e f o r l o n g . B. A. T h e a tr ia l c o n tr ib u tio n to v e n tr ic u la r f illin g is m o r e im p o r ta n t in p a tie n ts w ith r e d u c e d v e n tr ic u la r c o m p lia n c e w h o d e p e n d o n a c tiv e f illin g w ith a tr ia l c o n tr a c tio n th a n p a s s iv e f il lin g o f th e v e n tr ic le f o r a d e q u a te p r e lo a d . B lo o d s u p p ly to th e h e a r t is f r o m th e r i g h t a n d le f t c o r o n a r y a r te r ie s . w h ic h s u p p lie s p a rt o f th e . A n y in c r e a s e in v e n tr ic u la r r a d iu s a s in a d ila tio n in c r e a s e s th e w a ll te n s io n .s ta n d in g h y p e r te n s io n o r a o r tic s te n o s is in a n a tte m p t to d e c r e a s e th e w a ll te n s io n . th e r e b y in h ib itin g s y s te m ic v a s o c o n s tr ic tio n . le s s so w ith is o f lu r a n e a n d d e s f lu r a n e . In a d d itio n . T h e b u n d le o f H is is th e o n ly p a r t o f th e c a r d ia c c o n d u c tin g s y s te m . 9. C h a n g e s in b l o o d p r e s s u r e c a u s e d b y a c u te e v e n ts lik e c h a n g e in p o s tu r e a r e m in im iz e d p r i m a r i l y b y th e c a r o tid b a r o r e c e p t o r b e tw e e n m e a n a r te r ia l p r e s s u r e s o f 8 0 a n d 1 6 0 m m H g . T h e s e r e c e p to r s s e n s e a n in c r e a s e in b l o o d p r e s s u r e a n d e n h a n c e th e v a g a l to n e . In 8 5 % o f p e r s o n s . w h ic h is a p r o la p s e d e llip s o id . m o s t o f th e r ig h t v e n tr ic le .

F a c to r s in f lu e n c in g th e s u p p ly a n d d e m a n d a r e lis te d in T a b le 1 1-2.d e p e n d e n t a b o litio n o f a u to r e g u la t io n m a y b e g r e a te s t w ith is o f lu r a n e . T h e ir e f f e c t o n c o r o n a r y b l o o d f lo w is v a r ia b le a n d d e p e n d s o n a n in te r p la y b e tw e e n th e ir e f f e c t o n b l o o d p r e s s u r e . a n d th e ir d ir e c t v a s o d ila tin g p r o p e r tie s . it m a y in v o lv e a c tiv a tio n o f A T P -s e n s itiv e K+ c h a n n e ls a n d s tim u la tio n o f a d e n o s in e ( A 1) r e c e p to r s . H ig h (reported cardiac risk often greater than 5%) Emergent major operations. 15. in te r v e n tr ic u la r s e p tu m a n d i n f e r i o r w a ll. A lth o u g h th e m e c h a n is m is n o t c le a r. a s h a lo th a n e p r i m a r i l y a ffe c ts l a r g e c o r o n a r y v e s s e ls a n d is o f lu r a n e a ffe c ts m o s tly s m a lle r v e s s e ls . w ith o n ly 1 % o f th e s u p p lie d o x y g e n b e in g u s e d f o r e le c tr ic a l a c tiv ity . T h e le f t c o r o n a r y a r te r y n o r m a l l y s u p p lie s th e le f t a tr iu m a n d m o s t o f th e in te r v e n tr ic u la r s e p tu m a n d le f t v e n tr ic le . m e ta b o lic o x y g e n r e q u ir e m e n ts o f th e m y o c a r d iu m . a n d th e s e p e o p le a r e s a id to h a v e a r ig h t .v e n tr ic u la r w a ll. D. D o s e .d o m in a n t c ir c u la tio n . Table 11-2 M Y O C A R D IA L O X Y G E N S U P P L Y M Y O C A R D IA L O X Y G E N D E M A N D Heart rate Diastolic time Basal requirements Aortic diastolic blood pressure Heart rate Coronary perfusion pressure Wall tension Ventricular end diastolic pressure Preload Arterial oxygen content and tension Afterload Hemoglobin concentration Contractility Coronary vessel diameter 14.r i s k s u r g e r i e s h a v in g < 1 % r i s k (T a b le 1 1 -3 ). in te r m e d ia te .d o m in a n t c ir c u la tio n . Table 11-3 Cardiac Risk Stratification for Noncardiac Surgical Procedures. In th e r e m a in in g 1 5 % o f p e r s o n s . A c c o r d in g to A C C /A H A g u id e lin e s f o r n o n c a r d ia c s u r g e r y in c a r d ia c p a tie n ts . P r e s s u r e w o r k u s e s m o s t o f th e o x y g e n . H a lo th a n e a n d is o f lu r a n e s ta n d a p a rt. a s it c a n n o t c o m p e n s a te f o r r e d u c tio n in f lo w b y in c r e a s in g o x y g e n e x tr a c tio n . A u to n o m ic a lly m e d ia te d v a s o d il a tio n is s ig n if ic a n t f o r d e s f lu r a n e . H a lo g e n a te d a n e s th e tic a g e n ts a r e in h e r e n t v a s o d il a to r s . It e x tra c ts 6 5 % o f th e o x y g e n in a r te r ia l b lo o d . th e P D A a r is e s f r o m th e le f t c o r o n a r y a r te r y a n d is a p p r o p r ia te ly la b e le d le f t. H e n c e . C. a r is e s f r o m th e R C A . S u r g e r ie s c a n b e c la s s if ie d in to h ig h . a n d l o w r i s k w ith h ig h . A u to r e g u la to r y n a tu r e o f th e m y o c a r d iu m m a k e s th e m y o c a r d ia l o x y g e n d e m a n d a n im p o r ta n t d e te r m in a n t o f m y o c a r d ia l b l o o d flo w . T h e le f t m a in c o r o n a r y a r te r y d iv id e s in to th e L A D a r te r y a n d th e c ir c u m f le x (C X ) a rte ry . C o r o n a r y s in u s o x y g e n s a tu r a tio n is u s u a lly 3 0 % .r i s k s u r g e r i e s h a v in g > 5 % r i s k a n d l o w . a n d th e C X a r te r y s u p p lie s th e la te r a l w a ll. particularly in the elderly Aortic and other major vascular surgery . c o m p a r e d w ith 2 5 % in m o s t o th e r tis s u e s . a n y d r o p in m y o c a r d ia l o x y g e n s u p p ly is d e le te r io u s . 13. C. T h e m y o c a r d iu m a ls o h a s a v e r y h ig h e x tr a c tio n r a tio . 6 5 % . T h e L A D a r te r y s u p p lie s th e s e p tu m a n d a n te r io r le f t. v o lu m e w o r k = 1 5 % . f o ll o w e d b y b a s a l r e q u ir e m e n ts = 2 0 5 . S e v o f lu r a n e a p p e a r s to la c k c o r o n a r y v a s o d ila tin g p r o p e r tie s .

2 5 to 50 |ig . f o ll o w i n g in d u c tio n in p a tie n ts w ith u n c o n tr o lle d h y p e r te n s io n p r e o p e r a tiv e ly . s m a ll d o s e s o f e p h e d r in e ( 5 . P .f r e e lid o c a in e a t 1. 17. D ir e c t a 1 a g o n is ts lik e p h e n y le p h r in e a r e p r e f e r a b le to in d ir e c t s y m p a th o m im e tic s lik e e p h e d r in e to tr e a t h y p o te n s io n . B u t th is c o m e s a t th e p r ic e o f h y p o te n s io n . C h r o n ic h y p e r te n s iv e p a tie n ts s h o w w id e f lu c tu a tio n s in b l o o d p r e s s u r e o n in d u c tio n ( h y p o te n s io n ) a n d in tu b a tio n ( h y p e r te n s io n ) . in tr a v e n o u s p r e s e r v a tiv e .B lo c k e r s h o w e v e r h a v e n o v a s o d il a to r y a c tio n o n c o r o n a r y b lo o d v e s s e ls .1 0 m g ) o r e v e n e p in e p h r in e ( 2 . D ih y d r o p y r id in e .a c tin g o p io id s lik e fe n ta n y l 2.b lo c k e r s lik e e s m o l o l 0 . W e c a n s ta r t w ith s m a ll d o s e s o f p h e n y le p h r in e . I n tu b a tio n p e r f o r m e d u n d e r d e e p a n e s th e s ia is a ls o s h o w n n o t to p r o d u c e s ig n if ic a n t r i s e in b l o o d p r e s s u r e . C C B s h a v e s ig n if ic a n t a n e s th e tic im p lic a tio n s . s h o r t. B o th d e p o la r iz i n g a n d n o n d e p o la r iz i n g n e u r o m u s c u la r .5 to 5 |ig /k g . In p a tie n ts w h o a r e o n a n g io te n s in .5 m g /k g h a v e a ll b e e n s h o w n to b e e f f e c tiv e in a tte n u a tin g th e h y p e r te n s iv e re s p o n se . D u r a tio n o f l a r y n g o s c o p y < 1 5 s e c o n d s h a s b e e n s h o w n to p r e v e n t th is h y p e r te n s iv e r e s p o n s e to in tu b a tio n . C a te c h o la m in e s — b o th e n d o g e n o u s a n d e x o g e n o u s — c a n p r o d u c e e x a g g e r a te d h y p e r te n s iv e r e s p o n s e in th e s e p a tie n ts . C. n im o d ip in e ) is m u c h g r e a te r th a n th o s e b y v e r a p a m il a n d d iltia z e m . 19.5 m g /k g . th e r e f r a c t o r y h y p o te n s io n m a y r e s p o n d o n ly to v a s o p r e s s in . p r o v id e d th e h e a r t r a te is n o t to o lo w .r e c e p to r b lo c k e r p r e o p e r a tiv e ly . V e ra p a m il m a y a ls o m o d e s tly d e c r e a s e a n e s th e tic r e q u ir e m e n ts . B o th v e r a p a m il a n d d iltia z e m c a n p o te n tia te c a r d ia c d e p r e s s io n a n d in h ib it c o n d u c tio n in th e A V n o d e c a u s e d b y v o la tile a n e s th e tic s . C C B s a ls o p o te n tia te th e c ir c u la t o r y e ffe c ts o f v o la tile a g e n ts a n d m a y c a u s e m o r e h y p o te n s io n . D. Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss I n t e r m e d ia t e (reported cardiac risk generally less than 5%) Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery L ow (reported cardiac risk generally less than 1%) Endoscopic procedures Superficial procedure Cataract surgery Breast surgery 16. f o r e x a m p le . 18.5 |ig ) m a y b e u s e d . A v o id in g h ig h h e a r t r a te s a n d p r o l o n g e d h y p e r te n s io n h a s b e e n s h o w n to d e c r e a s e c a r d io v a s c u la r m o r b id ity . n ic a r d ip in e . P . T h e y e v e n e x c e e d n itr a te s in th e ir v a s o d il a to r y p o te n tia l.3 to 1. C. T h e r e a r e s e v e r a l te c h n iq u e s th a t c a n b e u s e d to p r e v e n t s u d d e n s p ik e s in b l o o d p r e s s u r e o n in tu b a tio n .b lo c k in g a g e n ts a r e p o te n tia te d b y C C B s. If th e h e a r t r a te is lo w . T o p ic a l a ir w a y a n e s th e s ia . B. C o r o n a r y v a s o d il a tio n p o te n tia l o f d ih y d r o p y r id in e s ( n if e d ip in e .

w h ic h c a n le a d to v e n tr ic u la r f ib r illa tio n . a n d th is m a y b e a c tiv a te d b y a c a u te r y d e v ic e . 20. 22. r e s e ttin g o f th e d e v ic e to b a c k u p m o d e . p r o v id e a u n iq u e a d v a n ta g e in p a tie n ts w ith b r o n c h o s p a s tic a ir w a y d is e a s e . If th e r e is n o tim e to r e p r o g r a m th e d e v ic e p r i o r to s u r g e r y . C a r d io s e le c tiv ity o f a g e n ts lik e m e t o p r o l o l is d o s e . S e v e re m u ltiv e s s e l d is e a s e c a n b e d e te c te d u s in g e x e r c is e E K G if th e p a tie n t ( d e v e lo p s ) • C a n n o t a tta in a m a x im u m H R > 7 0 % o f p r e d ic te d • D y s r h y th m ia s a t a lo w e r H R • S u s ta in e d f a ll in s y s to lic b l o o d p r e s s u r e d u r in g e x e r c is e (> 1 0 m m H g ) • S T d e p r e s s io n > 2 m m . lik e a c e b u to lo l. H o w e v e r. E le c tiv e s u r g e r y s h o u ld b e p o s tp o n e d u n til d r u g to x ic ity a n d e le c tr o ly te im b a la n c e s a r e e x c lu d e d .b lo c k in g a c tio n a t h ig h e r d o s e s . 21. E v e n th e ^ . p la c e m e n t o f e le c tr ic a l r e tu r n p a d fa r a w a y f r o m th e d e v ic e . D. P o ly m o r p h ic ta c h y a r r h y th m ia s w ith a lo n g Q T in te r v a l a r e u s u a lly tr e a te d w ith in tr a v e n o u s m a g n e s iu m o r b y p a c in g .v a lv e p r o la p s e . o r p h e n o th ia z in e s ) . T h is is b e c a u s e th e y d o n o t r e s p o n d to c o n v e n tio n a l a n tia r r h y th m ic s .d e p e n d e n t ^ . T h is is in a d d itio n to c o n f ir m i n g th a t th e p a c e m a k e r w a s i n te r r o g a te d f o r f u n c tio n a lity w ith in th e la s t y e a r a n d A IC D w a s in te r r o g a te d in th e la s t 6 m o n th s . in te r f e r in g w ith its p a c e m a k e r c a p a b ility . P a tie n ts w ith c o n g e n ita l p r o l o n g a t i o n g e n e r a lly r e s p o n d to P . C. S o m e A IC D s a r e p r o g r a m m e d w ith a r a te .r e s p o n s iv e fu n c tio n . e ith e r h o r iz o n ta l o r d o w n s lo p in g • S T d e p r e s s io n a t a v e r y l o w w o r k lo a d • S T d e p r e s s io n s u s ta in e d e v e n a fte r th e e x e r c is e is > 5 m in 23. u s in g e le c tr o c a u te r y in s m a ll b u r s ts a r e s o m e . d r u g to x ic ity ( a n tia r r h y th m ic a g e n ts .r e c e p t o r . a n tid e p r e s s a n ts . P r o l o n g e d Q T in te r v a l is d u e to n o n u n if o r m p r o l o n g a t i o n o f v e n tr ic u la r r e p o la r iz a ti o n . a u to n o m ic d y s fu n c tio n . T h e o ld a d a g e o f “ p u t a m a g n e t o n i t ” is b a s e d o n th e f a c t th a t a n tita c h y c a r d ia f u n c tio n in s o m e ( o ld e r ) p a c e m a k e r s w a s tu r n e d o f f b y th e a p p lic a tio n o f a m a g n e t. th is is n o t tr u e f o r m o s t o f th e n e w e r A IC D s. E l e c tr o s u r g ic a l in te r f e r e n c e c a n b e c a u s e d b y th e d e v ic e in te r p r e tin g th e c u r r e n t a s v e n tr ic u la r f i b r illa tio n a n d f ir in g . a c o n g e n ita l a b n o r m a lity . o r. m itr a l. le s s c o m m o n ly . a ls o k n o w n a s to r s a d e d e p o in te s o r tw is tin g p o in ts . P r o l o n g e d Q T in te r v a l p r e d is p o s e s p a tie n ts to v e n tr ic u la r a r r h y th m ia s . P r o l o n g e d Q T in te r v a l (Q T c > 0 . p a r tic u la r ly p o ly m o r p h ic . T h is p r e d is p o s e s p a tie n ts to r e e n tr y p h e n o m e n a a n d r e s u lts in v e n tr ic u la r ta c h y c a r d ia o r f ib r illa tio n .s p e c i f i c ) .4 4 s e c o n d ) c a n b e c a u s e d b y m y o c a r d ia l is c h e m ia . C.s te lla te - g a n g lio n b lo c k a d e h a s a ls o b e e n tr ie d a n d h a s s o m e s u c c e s s in th e s e p a tie n ts s u g g e s tin g th a t th is m a y b e d u e to a n a u to n o m ic im b a la n c e . e le c tr o ly te a b n o r m a litie s ( h y p o k a le m ia o r h y p o m a g n e s e m ia ) . u s e o f a b ip o la r c a u te ry . L e ft.v e n tr ic u la r ta c h y c a r d ia .a d r e n e r g ic b lo c k in g a g e n ts . Id e a lly . P .s p e c i f i c a g e n ts c a n h a v e s o m e P2. S u r g ic a l e le c tr o c a u te r y in te r f e r e n c e w ith A IC D s a n d p a c e m a k e r d e v ic e s a r e w e ll k n o w n . th e m a n u f a c t u r e r ’s r e p r e s e n ta tiv e o r c a r d i o l o g y s h o u ld b e c o n ta c te d to f in d o u t if th e d e v ic e c o u ld b e r e p r o g r a m m e d to h a v e th e a n tita c h y c a r d ia f u n c tio n o f f p r i o r to th e s u r g e r y .B lo c k e rs w ith in tr in s ic s y m p a th o m im e tic a c tiv ity . d e r iv a tiv e s p o te n tia te s y s te m ic v a s o d il a tio n u n d e r a n e s th e s ia .r e c e p t o r . D.

II. In a d d itio n . C o r o n a r y p e r f u s io n p r e s s u r e is d e te r m in e d b y th e d if f e r e n c e b e tw e e n th e a r te r ia l d ia s to lic p r e s s u r e a n d th e le f t. d e c r e a s e d s y s to lic f u n c tio n o f m y o c a r d iu m . w h ile th e r i g h t v e n tr ic le is p e r f u s e d b o th d u r in g d ia s to le a n d s y s to le . a n d r e d u c tio n in s e r u m .io n iz e d c a lc iu m d u e to c itr a te to x ic ity . L e a d s II a n d V 5 a r e th e tw o m o s t c o m m o n ly u s e d le a d s . U s u a lly tw o le a d s a r e m o n ito r e d s im u lta n e o u s ly in p e r io p e r a tiv e p e r io d . a n d V 3 le a d s .w a ll is c h e m ia . V 5 is th e m o s t u s e f u l le a d . M o d if ie d V 5 le a d is v e r y u s e f u l w h e n o n ly o n e c h a n n e l c a n b e m o n ito r e d ( th r e e le a d s a p p lie d w ith le f t. T h e s e n s itiv ity o f th e i n tr a o p e r a tiv e /p e r io p e r a ti v e E C G in d e te c tin g is c h e m ia is d ir e c tly p r o p o r t i o n a l to th e n u m b e r o f le a d s m o n ito r e d .w a l l is c h e m ia . w h ile le a d V 5 is u s e f u l f o r d e te c tin g la te r a l. H o w e v e r. N o r m a l c o r o n a r y b l o o d f lo w a t r e s t is a b o u t 2 5 0 m L /m in . In o r d e r o f d e c r e a s in g s e n s itiv ity . it is n o t a lw a y s r e q u ir e d . L e a d II h e lp s to d e te c t a r r h y th m ia s a n d i n f e r i o r . T h e le f t v e n tr ic le is p e r f u s e d d u r in g d ia s to le . T h e a d v e r s e e ffe c ts o f h y p o th e r m ia a r e a r r h y th m ia s . . S o m e p r o c e d u r e s n e e d a c o m p le te c ir c u l a t o r y s ta n d s till— c a lle d c i r c u l a t o r y a r r e s t — a n d d e e p h y p o th e r m ia is e m p lo y e d f o r s u c h p r o c e d u r e s — c o o lin g to 15 to 1 8 °C a llo w s a n a r r e s t tim e o f a r o u n d 6 0 m in u te s .a r m le a d a t V 5 p o s itio n a n d m o n ito r in g le a d I).p a p ill a r y ( m i d s h o r t a x is ) v ie w p r o v id e s a s n a p s h o t o f a ll th e d if f e r e n t b l o o d v e s s e ls s u p p ly in g th e h e a r t ( F ig 1 1 -2 ). A n in c r e a s e in h e a r t r a te r e d u c e s c o r o n a r y p e r f u s io n b e c a u s e o f a s h o r te r d ia s to le . T h is is b a s e d o n th e p r in c ip le th a t m e ta b o lic o x y g e n r e q u ir e m e n ts c a n b e h a lv e d w ith e a c h r e d u c tio n o f 1 0 °C in b o d y te m p e r a tu r e . 26. m e th o d s to d e c r e a s e s u c h a n in te r f e r e n c e . 27. p la te le t d y s fu n c tio n . c o a g u lo p a th y . V 5 is f o ll o w e d b y V 4 . T r a n s g a s tr ic m id . 24. V 2 . P o s te r io r w a ll c a n b e m o n ito r e d u s in g a n e s o p h a g e a l le a d .v e n tr ic u la r e n d d ia s to lic p r e s s u r e . It is a c o m m o n p r a c tic e to c o o l th e b o d y to a c o r e b o d y te m p e r a tu r e o f 2 0 to 3 2 °C f o ll o w i n g C P B s ta rt. A. 28. E v e r y e f f o r t s h o u ld b e m a d e to r e p r o g r a m th e d e v ic e to its o r i g i n a l s e ttin g p r i o r to d is c h a r g e o f th e p a tie n t f r o m th e p o s ta n e s th e s ia c a r e u n it. A. A. 25. B. a ll s u c h p a tie n ts s h o u ld h a v e tr a n s c u ta n e o u s p a d s o n a n d a d e f ib r il la to r /p a c e r s h o u ld b e a v a ila b le in th e r o o m . T h is te m p e r a tu r e is b r o u g h t b a c k to a c c e p ta b le le v e ls ( w h e r e a r r h y th m ia s a r e lo w e r ) a t th e e n d o f C P B — a p h a s e c a lle d r e w a r m in g . C.

P u r e h ig h . A n o th e r c o m m o n r e s p o n s e s e e n d u r in g s te r n a l r e tr a c tio n a n d p e r ic a r d ie c to m y is b r a d y c a r d i a a n d h y p o te n s io n d u e to e x a g g e r a te d v a g a l r e s p o n s e . a n in h ib ito r o f s e r in e p r o te a s e s .b lo c k e r s . T h e m a in d is a d v a n ta g e s o f h ig h .d o s e o p i o i d te c h n iq u e in c lu d e p r o l o n g e d p o s to p e r a tiv e r e s p i r a t o r y d e p r e s s io n ( e a r ly e x tu b a tio n is b e c o m in g a v e r y c o m m o n tr e n d in c o r o n a r y a r te r y b y p a s s g r a f tin g s u r g e r ie s ) . 29.v e n tr ic u la r fu n c tio n . 30. A p r o g r e s s i v e d e c lin e in c a r d ia c o u tp u t is s o m e tim e s s e e n a fte r th e c h e s t is o p e n e d . s u c h as p la s m in . A p r o tin in . Shernan SK. 31.g .1 0 0 ^ g /k g o r s u f e n ta n il 1 5 . k a llik r e in . In: Savage RM. b r a d y c a r d ia . 2011: 86. Vezina DP. It h a s b e e n s h o w n to d e c r e a s e b l o o d . eds. e x a g g e r a te d h y p e r te n s iv e r e s p o n s e to s tim u la tio n lik e s te r n o to m y in a p a tie n t w ith g o o d le f t. C. p o s to p e r a tiv e ile u s . H e n c e a IV flu id b o lu s m a y h e lp . a n d i m p a ir e d im m u n ity . a ls o h e lp s to p r e s e r v e p la te le t a g g r e g a t i o n a n d a d h e s iv e n e s s .r e c e p to r .b l o c k a d e u s e . A.F igu re 11-2. a n d c a lc iu m c h a n n e l b lo c k e r s . Philadelphia. a n d tr y p s in . c h e s t-w a ll r ig id ity . P . F a c to r s p o te n tia tin g s u c h a r e s p o n s e in c lu d e d e e p a n e s th e s ia a n d p r e o p e r a t iv e a n g io te n s in ..d o s e o p i o i d a n e s th e s ia (e . D. T h is is a ttrib u te d to th e lo s s o f n e g a tiv e in tr a th o r a c ic p r e s s u r e a n d d e c r e a s e d p r e lo a d . 2nd ed. Aronson S. h ig h in c id e n c e o f p a tie n t a w a r e n e s s /r e c a ll. It w a s u s e f u l a t a tim e in a n e s th e s ia w h e n th e o n ly in h a le d a g e n ts a v a ila b le p r o d u c e d u n a c c e p ta b le m y o c a r d ia l d e p r e s s io n . T h is is p o te n tia te d b y h y p o x ia .2 5 ^ g /k g ) h a s f a lle n o u t o f v o g u e in c a r d ia c a n e s th e s ia p r a c tic e . PA: Lippincott Williams & Wilkins. Comprehensive Textbook of Perioperative Transesophageal Echocardiography. fe n ta n y l 5 0 . Shin JJ.Reused with permission from Shanewise JS. et al. Comprehensive and abbreviated intraoperative TEE examination.

r e c e n t a d m in is tr a tio n o f g ly c o p r o te in Ilb /IIIa in h ib ito r s ( a b c ix im a b [R e o P r o ] . 33. A b r u p t h e m o d ilu tio n .6 0 m L /k g /m in ) a n d m e a n a r te r ia l p r e s s u r e s b e tw e e n 50 a n d 8 0 m m H g a r e c o m m o n ly u s e d . r e p e a t e x p o s u r e to a p r o tin in h a s b e e n s h o w n to c a u s e a lle r g ic r e a c tio n s . o r b y im m e d ia te a n tic o a g u la tio n a n d in itia tio n o f b y p a s s d e p e n d in g o n th e a m o u n t o f h e m o d y n a m ic c o m p r o m is e . s to p p in g th e s u r g ic a l s tim u lu s is a ll th a t is n e e d e d . M A P is p r o p o r t i o n a l to p u m p flo w . B. P u m p f lo w s o f 2 to 2. S u p e r io r v e n a c a v a s y n d r o m e c a n b e c a u s e d b y a m a lp o s itio n e d v e n o u s c a n n u la s c a n b e i n te r f e r in g w ith v e n o u s d r a in a g e f r o m th e h e a d a n d n e c k .tr a n s d u c e r e r r o r m a y a ll c a u s e h y p o te n s io n . p a tie n ts w ith c o a g u lo p a th ie s . a s m e a n b l o o d p r e s s u r e s a s l o w a s 3 0 m m H g m a y s till p r o v id e a d e q u a te c e r e b r a l b l o o d flo w . M A P is p r o p o r t i o n a l to S V R . S V R . P r e m a tu r e a tr ia l c o n tr a c tio n s a n d tr a n s ie n t b u r s ts o f a s u p r a v e n tr ic u la r ta c h y c a r d ia a r e c o m m o n . P o o r v e n o u s r e tu r n . F lo w r e q u ir e m e n ts a r e g e n e r a lly lo w e r d u r in g d e e p h y p o th e r m ia ( 2 0 . w h ic h m a y in c lu d e a n a p h y la x is . w h ic h r e d u c e s b lo o d v is c o s ity a n d e f f e c tiv e ly lo w e r s s y s te m ic v a s c u la r r e s is ta n c e (S V R ). H y p e r te n s io n is s a id to e x is t o n p u m p w h e n M A P s e x c e e d 1 0 0 m m H g . p u m p f lo w is g r a d u a lly in c r e a s e d to 2 to 2. a n d m e a n s y s te m ic a r te r ia l b l o o d p r e s s u r e m a y b e c o n c e p tu a liz e d a s f o llo w s : M A P = P u m p f lo w x S V R W ith a c o n s ta n t S V R . tr a n s e s o p h a g e a l e c h o c a r d i o g r a p h e v a lu a tio n is v e r y u s e f u l in s u c h a s itu a tio n to l o o k f o r u n r e c o g n iz e d a o r tic d is s e c tio n . S V R c a n b e in c r e a s e d w ith a a g o n is ts lik e p h e n y le p h r in e . V e n o u s c a n n u la tio n u s u a lly c a u s e s h e m o d y n a m ic c h a n g e s . m a y b e r e s p o n s ib le f o r th is d r o p . T h e r e la tio n s h ip b e tw e e n p u m p flo w . o r tir o f ib a n [ A g g ra s ta t]. S o m e tim e s . P a tie n ts o n a c o m b in a tio n o f a s p ir in a n d A D P - r e c e p to r a n ta g o n is t a r e a t h ig h r i s k o f b le e d in g a n d m a y b e n e f it f r o m a p r o tin in . J e h o v a h ’s w itn e s s e s . o r p r e s s u r e . a n d w e h a v e a n a c c e s s to p r o v id e r a p id in f u s io n th r o u g h th e a o r tic c a n n u la if n e c e s s a r y . In itia l m e a n s y s te m ic a r te r ia l ( r a d ia l) p r e s s u r e s o f 3 0 to 4 0 m m H g a r e n o t u n u s u a l. T h e e f f e c t is p a r tia lly c o m p e n s a te d b y s u b s e q u e n t h y p o th e r m ia . C P B m u s t b e t e m p o r a r i l y s to p p e d u n til th e a o r ta is r e c a n n u la te d d is ta lly to p r e v e n t f u r th e r e x te n s io n o f a d is s e c tio n fla p w ith g r a v e c o n s e q u e n c e s . S im ila r ly . lo s s a n d tr a n s f u s io n r e q u ir e m e n ts a n d s h o u ld b e c o n s id e r e d in r e d o s u r g e r ie s . a n d p a tie n ts w ith lo n g p u m p r u n s . T h e e v e n ts o c c u r r i n g in s e q u e n c e a fte r h e p a r in iz a tio n a r e a o r tic c a n n u la tio n f o ll o w e d b y v e n o u s c a n n u la tio n .5 L / m in /m 2 ( 5 0 . e le c tr ic a lly . H ig h s y s te m ic a r te r ia l p r e s s u r e s (> 1 5 0 m m H g ) a r e a ls o d e le te r io u s b e c a u s e th e y p r o m o t e a o r tic d is s e c tio n o r a c e r e b r o v a s c u la r a c c id e n t in a d d itio n to in c r e a s in g th e s u r g ic a l b le e d in g . p u m p m a lf u n c tio n .2 5 ° C ) . A. If d is s e c tio n is p re s e n t. w h ic h te n d s to r a is e b lo o d v is c o s ity a g a in . A o r tic c a n n u la m is d ir e c te d to w a r d th e in n o m in a te a r te r y m a y b e a c a u s e f o r f a ls e h y p e r te n s io n w h e n r i g h t r a d ia l a r te r y is u s e d f o r m o n ito r in g . a t a n y g iv e n p u m p flo w . A fte r in itia tio n o f C P B . A d is a s tr o u s s c e n a r io is a p e r s is te n t a n d e x c e s s iv e d e c r e a s e in M A P (< 3 0 m m H g ). H o w e v e r. e p tifib a tid e [I n te g r ilin ]. S u s ta in e d a r r h y th m ia s m u s t b e tre a te d p h a r m a c o lo g i c a lly . V e n o u s c a n n u la tio n a ls o f r e q u e n tly p r e c ip ita te s a r r h y th m ia s .5 L / m in /m 2 a n d M A P s a r e m o n ito r e d . It is c o m m o n to s e e a n in itia l f a ll in BP. 32. a n d th is is tr e a te d b y .

e s p e c ia lly w ith in th e le f t v e n tr ic le . w h ic h c a n p r o m o t e h y p o x e m ia . B u t m o s t m a c h in e s d o n o t p r o v id e a g lu c o s e m o n ito r . T h is d o e s n o t r e q u i r e a d d itio n o f C O 2 a n d h a s b e e n s h o w n to p r e s e r v e c e r e b r a l a u to r e g u la t io n a n d im p r o v e m y o c a r d ia l p r e s e r v a tio n . a n d o x y g e n . a n d th e n a r r o w o p e n in g o f th e a o r tic c a n n u la . p H -s ta t m a n a g e m e n t r e f e r s to th e p r a c tic e o f t e m p e r a t u r e . T h e in c id e n c e o f a w a r e n e s s /r e c a ll is h ig h d u r in g r e w a r m in g b e c a u s e th e in h a la tio n a l a g e n t d e liv e r e d v ia th e o x y g e n a to r is tu r n e d o f f j u s t p r i o r to te r m in a tio n o f C P B to a v o id r e s id u a l m y o c a r d ia l d e p r e s s io n . A.c la m p e d n u m e r o u s tim e s a n d in p e r c u ta n e o u s tr a n s c a th e te r a o r tic v a lv e r e p la c e m e n ts . 35. c a u s e d b y th e p r e s s u r e d r o p a c r o s s th e a r te r ia l filte r .c o r r e c tin g g a s te n s io n s b y a d d in g C O 2 a n d m a in ta in in g a “ n o r m a l ” C O 2 te n s io n o f 4 0 m m H g a n d a p H o f 7 .to . if p u m p f lo w is a lr e a d y lo w . S w e a tin g d u r in g r e w a r m in g is a h y p o th a la m ic r e s p o n s e to p e r f u s io n w ith b lo o d . a n d h y p o g ly c e m ia is s till a th re a t. B. d u r in g th e r e w a r m in g p h a s e . d e c r e a s in g p u m p f lo w o r d e e p e n in g a n e s th e s ia u s in g is o f lu r a n e a t th e o x y g e n a to r in f l o w g a s . F o llo w in g in s titu tio n o f fu ll C P B . T E E is v e r y u s e f u l in d e te c tin g p o c k e ts o f a ir. r e f e r s to th e u s e o f u n c o r r e c t e d g a s te n s io n s d u r in g h y p o th e r m ia .d o w n p o s itio n . a n d in . In a d e q u a te tis s u e p e r f u s io n c a u s e d b y in a d e q u a te f lo w r a te s is e v id e n c e d b y l o w v e n o u s o x y g e n s a tu r a tio n s (< 7 0 % ).4 0 d u r in g h y p o th e r m ia . v e n tila tio n c a n b e d is c o n tin u e d . I n . v e n tr ic u la r e je c tio n m a y c o n tin u e f o r a b r i e f p e r i o d o f tim e . a n d v e n tin g b e f o r e a n d d u r in g in itia l c a r d ia c e je c tio n . o r l o w u r i n a r y o u tp u t.in te r v a ls . A t p h y s io lo g ic p H .le f t s h u n t. in a d d itio n to f illin g u p th e h e a r t w ith v e n t in p la c e . a . p r o g r e s s i v e m e ta b o lic a c id o s is . T h e e x te n t o f h y p o x e m ia d e p e n d s o n th e r e la tiv e r a tio o f r e m a in in g p u lm o n a r y b l o o d f lo w to p u m p flo w . 37. 38. b l o o d ( p e r f u s a te a n d v e n o u s ) a n d m y o c a r d ia l te m p e r a tu r e s . o n th e o th e r h a n d .lin e ( a r te r ia l a n d v e n o u s ) o x y g e n s a tu r a tio n s . B u t th e r i s k o f a th e r o m a to u s e m b o li s till p e r s is ts a n d is w o r s e in c a s e s w h e r e a o r ta w a s m a n ip u la te d e x te n s iv e ly . m a y n e c e s s ita te a v a s o d il a to r lik e n itr o p r u s s id e . B e f o r e d is c o n tin u in g v e n tila tio n a fte r in itia tio n o f C P B .a ir in g is f a c ilita te d b y h e a d . th e . a r te r ia l in f l o w lin e p r e s s u r e is a lm o s t a lw a y s h ig h e r th a n th e s y s te m ic a r te r ia l p r e s s u r e r e c o r d e d f r o m a r a d ia l a r te r y o r e v e n a n a o r tic c a th e te r. M o n ito r in g d u r in g C P B is u s u a lly d o n e b y th e p e r f u s io n is ts . S o m e tim e s . v e n o u s r e s e r v o i r le v e l. B. a h y p e r te n s io n is r e f r a c t o r y to th e s e m a n e u v e r s o r. B lo o d g a s te n s io n s a n d p H a r e c o n f ir m e d b y d ir e c t m e a s u r e m e n ts p e r io d ic a l ly — 3 0 m in u te . T h e y m o n ito r th e p u m p f lo w ra te . 36. D e . E p ia o r tic e c h o c a r d io g r a p h y is th e m o s t s e n s itiv e a n d s p e c if ic te c h n iq u e to d e te c t a ir b u b b le s a t th e te r m in a tio n o f C P B . it is a g o o d p r a c tic e to c o n f ir m w h e th e r fu ll f lo w h a s b e e n a tta in e d w ith th e p e r f u s io n is t.lin e p H . th e a r te r ia l tu b in g . c r o s s . D u r in g b y p a s s . w h ic h is o f te n a t 3 9 °C . D. 34. p r o v id e d th e r e is n o h y p o x e m ia .te n s io n s e n s o r s a r e a ls o a v a ila b le in n e w e r b y p a s s m a c h in e s . C O 2 te n s io n . It is im p o r ta n t to r e m e m b e r to a d m in is te r a n e s th e tic a g e n ts . a n d s o m e tim e s a d d itio n a l m u s c le r e la x a n ts . N e w e r d e v ic e s w ith b a s k e ts to c a tc h s u c h e m b o li h a v e p r o v e n to b e v e r y u s e f u l.S ta t m a n a g e m e n t. A. D is c o n tin u in g v e n tila tio n p r e m a tu r e ly c a u s e s a n y r e m a in in g p u lm o n a r y b l o o d f lo w to a c t a s a r ig h t . O n c e th e h e a r t s to p s e je c tin g b lo o d . a r te r ia l in f l o w lin e p r e s s u r e .

f illin g p r e s s u r e s . th e d e f la tio n s h o u ld b e tim e d j u s t p r i o r to L V e je c tio n to p r o d u c e a n o p tim a l r e d u c tio n in a f te r lo a d . I n f la tio n to o la te in th e d ia s to lic p h a s e w ill r e d u c e d ia s to lic a u g m e n ta tio n a n d m y o c a r d ia l s u p p ly . u s u a lly c o n f ir m e d w ith tr a n s e s o p h a g e a l e c h o c a r d io g r a p h /f lu o r o s c o p y . P C W P s u g g e s tiv e o f lo w .s ta t is m o r e c o m m o n ly u s e d in a d u lt c a r d ia c s u r g e r y .1 0 0 b p m ) E = E p in e p h r in e — in o t r o p e s / v a s o p r e s s o r s u s e d a s n e e d e d . B. D. 42. in d ic a tin g th a t h e is h y p o v o le m ic . B.v e n tr ic u la r (L V ) v o lu m e . IA B P is s o m e tim e s u s e d to f a c ilita te w e a n in g th e p a tie n t o f f c a r d io p u lm o n a r y b y p a s s . p H -s ta t m a n a g e m e n t is c o m m o n ly u s e d in p e d ia tr ic c a r d ia c s u r g e r y . a n d p a tie n t m a y b e c o m e h y p o th e r m ic a g a in .h e a rt f a ilu r e (L H F ) w ill h a v e a h ig h P C W P a n d p u lm o n a r y a r te r y p r e s s u r e . B u t th e r e s t o f th e c lin ic a l p ic tu r e o f l o w S V R a n d h ig h C O is s t r o n g l y s u g g e s tiv e o f a h y p e r d y n a m ic c i r c u l a t o r y s ta te ( v a s o d ila te d ) . 40. T im in g a n d lo c a t io n o f a n IA B P a r e c r itic a l f o r o p tim a l f u n c tio n in g . R ig h t. p a c in g n e e d e d s o m e tim e s ( 8 0 . T h is p r o v id e s a s y s to lic a u g m e n ta tio n o f b l o o d p r e s s u r e in a d d itio n to im p r o v in g m y o c a r d ia l o x y g e n s u p p ly d u r in g d ia s to le . L e ft. B o th L H F a n d R H F w ill h a v e lo w C O . T h e lo c a t io n o f th e tip o f th e IA B P s h o u ld b e j u s t d is ta l to th e ta k e o f f o f th e le f t. w o r s e n a o r tic r e g u r g i t a t i o n a n d le f t. . b u t a . E p in e p h r in e m a y in c r e a s e m y o c a r d ia l O 2 n e e d F = F lu id s — f o r r a p id v o lu m e r e s u s c ita tio n G = G o o d c o n tr a c tility b y d ir e c t v is u a l iz a tio n /tr a n s e s o p h a g e a l e c h o c a r d io g r a m H = H y p o th e r m ia is a v o id e d . T h e tr e a tm e n t in s u c h a s c e n a r io w ill b e to in c r e a s e th e h e m a to c r it. S im ila r ly . > 3 7 ° C is a im e d I = In v a s iv e m o n ito r s r e c a lib r a te d 41. If th e p a tie n t h a d a d e c r e a s e d c a r d ia c o u tp u t. Id e a l in f l a tio n o f th e b a l l o o n s h o u ld b e ju s t a fte r th e d ic r o tic n o tc h ( c lo s u r e o f a o r tic v a lv e ) .h e a r t f a ilu r e (R H F ) w ill h a v e a h ig h C V P a n d n o r m a l o r lo w P C W P . 39. A. I n f la tio n w h ile th e a o r tic v a lv e is s till o p e n c a n in c r e a s e a f te r lo a d . T im in g is u s u a lly s y n c h r o n iz e d w ith E K G /a r te r ia l p u ls e . th e tr e a tm e n t w o u ld b e to a d m in is te r v o lu m e /c r y s ta ll o id s . T h e b o d y e q u ilib r a te s th is g r a d ie n t f o ll o w i n g s e p a r a tio n f r o m C P B .p e r f u s e d o r g a n s a n d p e r ip h e r a l v a s o c o n s tr ic te d tis s u e s .s u b c la v ia n a rte ry . S e p a r a tio n f r o m C P B c a n b e g u id e d b y a m n e m o n ic : A = A ir w a y — o x y g e n a tio n a n d v e n tila tio n w ith 1 0 0 % o x y g e n B = B lo o d g a s — c o r r e c t e le c tr o ly te a b n o r m a litie s / h e m o g lo b i n C = C o a g u la tio n — r e v e r s e h e p a r in w ith p r o ta m in e D = D y s r h y th m ia s — s in u s r h y th m is g o o d . h is tid in e r e s id u e s o f in tr a c e l lu la r p r o te in s p la y a m a jo r r o l e in m a in ta in in g e le c tr ic a l n e u tra lity . T h is p a tie n t h a s a l o w C V P. It a ls o r e s u lts in l a r g e te m p e r a tu r e g r a d ie n ts b e tw e e n w e ll. M e th o d s u s e d to s p e e d th e r e w a r m in g p r o c e s s in c lu d e in f u s io n o f a v a s o d il a to r d r u g ( n it r o p r u s s id e o r n i tr o g ly c e r in ) a n d a llo w in g s o m e p u ls a tile f lo w ( v e n tr ic u la r e je c tio n ) . R a p id r e w a r m in g c a n r e le a s e g a s b u b b le s th a t w e r e d is s o lv e d r a p id ly b a c k in to th e b l o o d s tr e a m .

v e n t r ic u la r (R V ) f a ilu r e s e c o n d a r y to p u lm o n a r y h y p e r te n s io n . A v e r y d e a d ly s ite f o r p o s to p e r a tiv e m o n ito r in g is in to th e p e r ic a r d iu m c a u s in g c a r d ia c ta m p o n a d e . A fte r th e f i r s t 2 h o u r s . p r o ta m in e is th e n g iv e n in a r a tio o f 1 to 1. D D A V P. o r n e w ly a c q u ir e d d e fe c ts m a y b e r e s p o n s ib le .a o r ti c b a l l o o n p u m p .p r o t a m i n e c o n c e n tr a tio n m is m a tc h a n d c a n b e c a u s e d b y a r e d is tr ib u tio n e ith e r o f p r o ta m in e to p e r ip h e r a l c o m p a r tm e n ts o r o f p e r ip h e r a lly b o u n d h e p a r in to th e c e n tr a l c o m p a r tm e n t. a s e c o n d d o s e is u s u a lly n o t e ffe c tiv e . I m m e d ia te ly f o ll o w i n g c a r d ia c s u r g e r y . 45. a t th e s a m e tim e r e ta in in g th e th e r a p e u tic p o te n tia l o f d e c r e a s in g p u lm o n a r y h y p e r te n s io n . N O is a p o te n t v a s o d ila to r . 0 . h y p o th e r m ia . s o m e tim e s . T im in g o f p r o ta m in e a d m in is tr a tio n s h o u ld b e d e te r m in e d b y c lo s e c o m m u n ic a tio n w ith th e s u r g e o n . D D A V P fa c ilita te s th e ir r e le a s e f r o m th e v a s c u la r e n d o th e liu m . p r e o p e r a t iv e c o a g u la tio n d e fe c ts . C o a g u lo p a th y o f te n f o llo w s lo n g b y p a s s p e r io d s (> 2 h o u r s ) a n d is d u e to m u ltif a c to r i a l c a u s e s : s u r g ic a l b le e d in g s ite s .2 |i g /k g /m in a r e v e r y . T h is is u s u a lly s ig n a le d b y e q u a liz a tio n o f d ia s to lic p r e s s u r e s a n d h e m o d y n a m ic c o m p r o m is e a n d n e e d s im m e d ia te s u r g ic a l in te r v e n tio n . B.43. th r o m b o c y to p e n ia . T o o e a r ly a d m in is tr a tio n m a y le a d to c lo t f o r m a ti o n in th e c a r d io p u lm o n a r y b y p a s s c ir c u it. c o m f o r ta b le p a tie n t. S e d a tio n u s in g p r o p o f o l/f e n ta n y l /titr a te d d o s e s o f m o r p h in e /d e x m e d e to m id in e is u s e d in d if f e r e n t in s titu tio n s to e n s u r e a c a lm . b u t th e y p r o d u c e d r o p in s y s te m ic b l o o d p r e s s u r e . 47. R e h e p a r in iz a tio n ( h e p a r in r e b o u n d ) a fte r a p p a r e n t a d e q u a te r e v e r s a l is d u e to a r e la tiv e h e p a r i n . in a d e q u a te r e v e r s a l o f h e p a r in . P r o ta m in e b in d s a n d e f f e c tiv e ly in a c tiv a te s h e p a r in b e c a u s e th e p o s itiv e c h a r g e o f p r o ta m in e n e u tr a liz e s th e n e g a tiv e c h a r g e o f h e p a r in . a n y d r a in a g e f r o m c h e s t tu b e > 1 0 0 m L /h o u r s h o u ld b e c lo s e ly o b s e r v e d . 46. P r o ta m in e d o s in g is b a s e d o n th e a m o u n t o f h e p a r in in itia lly r e q u ir e d to p r o d u c e th e d e s ir e d a c tiv a te d c lo ttin g tim e . D D A V P is v e r y u s e f u l in r e v e r s i n g q u a lita tiv e p la te le t d e fe c ts . H y p o th e r m ia (< 3 5 ° C ) o f te n e x a c e r b a te s s u c h b le e d in g p r o b le m s . a d d itio n a l d o s e s o f p r o ta m in e ( 2 5 . T h e e le c tr i c a lly n e u tr a l h e p a r in ­ p r o ta m in e c o m p le x e s a r e r e m o v e d b y th e r e tic u lo e n d o th e lia l s y s te m . C. V a s o d ila to r s lik e n itr o g l y c e r i n w ill a ls o d e c r e a s e th e P V R . C h e s t-tu b e d r a in a g e m o r e th a n 10 m L /k g /h o u r in th e f i r s t 2 h o u r s o f te n r a is e s a r e d f la g a n d p r o m p ts c o a g u la tio n s tu d ie s a n d s o m e tim e s r e q u i r e c h e s t r e e x p lo r a tio n . w h ic h c ir c u m v e n ts th e u n w a n te d s id e e f f e c t o f d e c r e a s e d S V R a n d s y s te m ic b l o o d p r e s s u r e .5 0 m g ) m a y b e n e c e s s a ry . r e h e p a r in iz a tio n .3 m g p e r 1 0 0 U o f h e p a r in .3 |ig /k g ( in tr a v e n o u s ly o v e r 2 0 m in u te s ). w h ic h w o r k s b y in c r e a s in g th e p e r f u s io n to th e r i g h t s id e o f th e h e a r t. In h a le d p r o s ta g la n d i n E 1 ( P G E 1) is a ls o v e r y s p e c if ic in d e c r e a s in g P V R w ith o u t a f f e c tin g S V R . A d v a n c e d R V f a ilu r e m a y n e c e s s ita te a R V . T h e a c tiv a te d c lo ttin g tim e s h o u ld r e tu r n to b a s e lin e f o ll o w i n g r e v e r s a l o f h e p a r in w ith p r o ta m in e . p la te le t d y s fu n c tio n . I n o d ila to r s lik e d o p a m in e a n d m i l r in o n e m a y h e lp in s itu a tio n s w ith r ig h t . c a n in c r e a s e th e a c tiv ity o f f a c to r s V III a n d X II a n d th e v o n W ille b r a n d fa c to r.a s s is t d e v ic e o r a n in tr a . b u t is n o t r e c o m m e n d e d f o r r o u tin e u s e . A. w h ic h c a n b e g iv e n a s in h a le d n itr ic o x id e .r e s p o n s e c u r v e a n d th e e s tim a tio n o f h e p a r in c o n c e n tr a tio n u s in g s p e c ia l m o n ito r s (H e p c o n ) .0 1 to 0. th e e m p h a s is is o n m a in ta in in g h e m o d y n a m ic s ta b ility a n d m o n ito r in g f o r e x c e s s iv e p e r io p e r a tiv e b le e d in g . H e n c e . In h a le d N O a t 10 to 6 0 p p m a n d P G E 1 a t 0 . A. A n o th e r a p p r o a c h c a lc u la te s th e p r o ta m in e d o s e b a s e d o n th e h e p a r in d o s e . 44. A.

w h e r e a s v e n o c o n s tr ic tio n a u g m e n ts th e v e n o u s r e tu r n to th e h e a r t.s ta g e h e a r t d is e a s e p a tie n ts h a v e a n o p tio n to g e t a d e s tin a tio n v e n tr ic u la r .v e n t r ic u la r f a ilu r e . D r u g s w ith p- a g o n is t a c tiv ity a r e n o t lik e ly to b e u s e d to tr e a t h y p o te n s io n b e c a u s e a n y in c r e a s e in c a r d ia c . a n d E K G m a y s h o w a tr ia l f ib r illa tio n . C. T h e g o a l d u r in g m a n a g e m e n t o f a n e s th e s ia f o r p a tie n ts w ith h y p e r tr o p h ic c a r d io m y o p a th y is to d e c r e a s e th e p r e s s u r e g r a d ie n t a c r o s s th e le f t.p r e s s u r e to p o s itiv e . a n d c y to m e g a lo v ir u s s e r o l o g y a r e u s e d f o r d o n o r . f ib r o tic . H ig h p u lm o n a r y v a s c u la r r e s is ta n c e > 6 to 8 W o o d u n its (1 W o o d u n it = 8 0 d y n [ m id d o t] s /c m 5) is a p r e d ic to r o f r ig h t . T h is is in c o n tr a s t to c a r d ia c ta m p o n a d e . S u r v iv a l r a te s a fte r c a r d ia c tr a n s p la n ta tio n a r e u s u a lly h ig h a t a 5 -y e a r s u r v iv a l r a te o f 6 0 % to 9 0 % .r e c i p i e n t c o m p a tib ility te s tin g . a s c ite s . D o n o r o r g a n s f r o m p a tie n ts w ith h e p a titis B o r C o r H IV in f e c tio n a r e e x c lu d e d . T h e ir p o s itio n in th e tr a n s p la n t lis t is h ig h e r if th e y a r e u n lik e ly to s u r v iv e th e n e x t 6 to 12 m o n th s . th e c o n tr ib u tio n f r o m s tr o k e v o lu m e is v e r y lim ite d . H o w e v e r. T h e a d h e r e n t p a r ie ta l p e r ic a r d iu m a llo w s th e h e a r t to f ill o n ly to a f ix e d v o lu m e . C a r d ia c ta m p o n a d e is c h a r a c te r iz e d b y e q u a liz a tio n o f d ia s to lic p r e s s u r e s th r o u g h o u t th e h e a r t: L A P = R A P = L V E D P = R V E D P. T h is p r o d u c e s a r e d u c e d s tr o k e v o lu m e a n d h ig h c e n tr a l v e n o u s p r e s s u r e . C h e s t X . l o w Q R S v o lta g e .l u n g tr a n s p la n ta tio n . w h ic h h a s a h ig h e a r ly p o s to p e r a tiv e m o r ta lity . 50. tis s u e c r o s s m a tc h in g is g e n e r a lly n o t p e r f o r m e d . in th e p r e s e n c e o f im p a ir e d e m p ty in g . a n d th e s e p a tie n ts c o m p e n s a te b y h a v in g ta c h y c a r d ia a n d a n in c r e a s e in c o n tra c tility . w h ic h is a llo c a te d f r o m a s e p a r a te lis t. c o n d u c tio n b lo c k s . B. E n d . F illin g d u r in g e a r ly d ia s to le is ty p ic a lly a c c e n tu a te d a n d m a n if e s te d b y a p r o m i n e n t y d e s c e n t o n th e C V P w a v e f o r m . T h e y s till q u a lif y f o r a c o m b in e d h e a r t . P a th o p h y s io lo g y c o n s is ts o f a th ic k e n e d . T h is p a th o p h y s i o lo g y is r e s p o n s ib le f o r K u s s m a u l s ig n — p a r a d o x ic a l r i s e in v e n o u s p r e s s u r e d u r in g in s p ir a tio n . w h ic h c a u s e s a f illin g d e fe c t. th e x d e s c e n t ( s y s to lic . 49. A B O b l o o d - g r o u p ty p in g . T h e y d o n o t to le r a te th e s w itc h f r o m n e g a ti v e . D.p r e s s u r e b r e a th in g . I n tr a o p e r a tiv e h y p o te n s io n is g e n e r a lly tr e a te d w ith in tr a v e n o u s f lu id s o r a n a a g o n is t s u c h a s p h e n y le p h r in e . i r r e v e r s i b l e p u lm o n a r y v a s c u la r d is e a s e is c o n s id e r e d a c o n tr a in d ic a tio n to o r th o t o p ic c a r d ia c tr a n s p la n ta tio n .a tr ia l f il lin g ) is n o r m a l o r e v e n a c c e n tu a te d . 51.v e n tr ic u la r o u tf lo w o b s tr u c tio n .v e n tr ic u la r o u tf lo w o b s tr u c tio n . e f f e c tiv e p u lm o n a r y v a s o d il a to r s . A r te r ia l v a s o c o n s tr ic tio n ( in c r e a s e d s y s te m ic v a s c u la r r e s is ta n c e ) s u p p o r ts s y s te m ic b l o o d p r e s s u r e . T h is is p a r tic u la r ly im p o r ta n t to th e a n e s th e s io l o g is t w h ile in d u c in g g e n e r a l a n e s th e s ia in s u c h p a tie n ts . C h a r a c te r is tic C V P w a v e f o r m in c a r d ia c ta m p o n a d e is d e s c r ib e d a s im p a ir m e n t o f b o th d ia s to lic f il lin g a n d a tr ia l e m p ty in g a b o lis h e s th e y d e s c e n t. D. D e c r e a s e s in m y o c a r d ia l c o n tr a c tility a n d in c r e a s e s in p r e lo a d ( v e n tr ic u la r v o lu m e ) a n d a f te r lo a d w ill d e c r e a s e th e m a g n itu d e o f le f t. a n d a b n o r m a l liv e r fu n c tio n . T h e e x te r n a l c o m p r e s s io n o n th e c o lla p s ib le c h a m b e r s p r e v e n ts e m p ty in g . H o w e v e r.r a y m a y s h o w s o m e p e r ic a r d ia l c a lc if ic a tio n s .a s s is t d e v ic e th e r a p y o r g e t a c a r d ia c tr a n s p la n ta tio n . T h e C V P w a v e f o r m is c h a r a c te r is tic in c a r d ia c ta m p o n a d e . 48. H e n c e . S iz e . a n d d if f u s e T -w a v e a b n o r m a litie s . C lin ic a l s ig n s in c lu d e r a is e d j u g u l a r v e n o u s p r e s s u r e . h e p a to m e g a ly . a n d o f te n c a lc if ie d p e r ic a r d iu m s e c o n d a r y to a c u te o r r e c u r r e n t p e r ic a r d itis . C o n s tr ic tiv e p e r ic a r d itis is c h a r a c te r iz e d b y a s tif f p e r ic a r d iu m th a t lim its d ia s to lic f illin g o f th e h e a r t.

statin. and type of anesthesia used (general anesthesia vs. site of procedure for procedures <3 hour. B. such as nitroprusside or nitroglycerin. A reduction in delivery (decreased cardiac output) or an increase in consumption (increased BMR) can both cause a reduction in Pvo2. P-Blockers started 7 to 30 days prior to surgery and continued for 30 days postoperatively reduce the risk of cardiac m orbidity (M I or cardiac death) by 90%. It is a good measure of tissue oxygen supply relative to its demand. P-Blockers. strict hemodynamic control using an intra-arterial catheter and prompt pharmacologic intervention or fluid infusion to treat physiologic hemodynamic alterations from the normal range may decrease the risk of perioperative cardiac m orbidity in high-risk patients. with many false positives and negatives: PCWP > LVEDP • PEEP/positive-pressure ventilation • Increased intrathoracic pressure • Left-atrial pathology— myxoma • Mitral-valve pathology— stenosis/regurgitation • Pulmonary hypertension • Chronic obstructive pulmonary disease LVEDP > PCWP • LVEDP >25 mm Hg • Premature mitral-valve closure (usually an aortic regurgitation jet causing this) • Left-ventricular diastolic dysfunction (left-ventricular hypertrophy/ischemia) 53. Intraoperatively. 55. and statins. C. Ideally. Statin therapy with fluvastatin for 30 days before and after surgery. angioplasty. Normal Pvo2 is about 40 mm Hg. B. should be used with caution because decreases in systemic vascular resistance can increase left-ventricular outflow obstruction. C. Site of previous MI. Vasodilators. this sample is drawn from the tip of a pulmonary artery catheter. an increased delivered concentration of isoflurane or sevoflurane can be used. PCWP is an indirect measure of LVEDP. and aspirin have all been . Mixed venous oxygen tension refers to the oxygen tension in a venous sample with blood mixed from both inferior vena cava and superior vena cava. 54. clonidine. Perioperative clonidine administration reduces the 30-day and 2-year mortality risks. with a saturation of 75%. Only three pharmacologic measures have been proven to produce a decrease in cardiovascular m orbidity and mortality: P-blockers. Perioperative risk-reduction therapy with medications is superior to risk stratification with invasive testing. reduces risk of M I and death by an additional 50%. If started just prior to surgery and continued for 7 days. it w ill still confer a reduction in mortality risk by 50%. contractility or heart rate could increase left-ventricular outflow obstruction. clonidine. history of coronary artery bypass grafting. in addition to P-blockade. When hypertension occurs. regional) have no influence on perioperative myocardial reinfarction. 52. and CABG.

and aspirin may be superior to invasive approach with angioplasty and/or CABG. D. The ACC/AHA guidelines have not been shown to actually reduce perioperative risk.5 mg/kg and fentanyl 2 to 5 |ig/kg. especially thoracic and upper abdominal. Barlow syndrome. Risk stratification based on preoperative history and physical examination followed by some series of tests (if deemed necessary) predicts perioperative cardiac morbidity and mortality risk. The American College of Cardiology (ACC) and American Heart Association (AHA) have developed a protocol entitled ACC/AHA Guideline Perioperative Cardiovascular Evaluation for Noncardiac Surgery. A. D. A single 1-minute episode of myocardial ischemia detected by 1-mm ST-segment elevation or depression increases the risk of cardiac events 10-fold and the risk for death 2­ fold. The risks of interventional procedures like angiography and an intracoronary stent or even coronary artery bypass graft (CABG) surgery adds to the already- existing risk of the proposed surgical procedure and does not reduce total risk. refers to mitral valve. 56. 57. It is an abnormality of the mitral-valve structure (suspected to be myxomatous in origin) that permits prolapse of the mitral valve into the left atrium during left-ventricular systole. Invasive testing adds little information. Thus.5 mg/kg IV) or topically (2 mg/kg) on the airway. as it is sometimes called. However. used for this. Any condition that increases cardiac emptying can accentuate this prolapse: (1) sympathetic nervous system stimulation. Lidocaine can be given IV (1. Tachycardia for 5 minutes above 120 bpm in the postoperative period can increase the risk of mortality 10 times. brief duration of laryngoscopy seems to be the most effective method in avoiding the sympathetic response to intubation. clonidine. D. elective surgery. The incidence of perioperative myocardial reinfarction does not stabilize at 5% to 6% until 6 months after the prior myocardial infarction. However. Adequate preload and a sudden prolonged decrease in systemic vascular resistance must be avoided during induction of anesthesia in these patients to prevent the worsening of prolapse. and (3) performance of surgery with patients in the head-up or sitting position all of these conditions predispose to increased cardiac emptying. However. Anesthetic considerations in patients with regurgitant lesions: . Other pharmacologic options include esmolol 0. recently this has reduced to 6 to 8 weeks follow ing the ACC/AHA guidelines. Perioperative medical optimization of the patient with P-adrenergic blockers. 58. Careful preoperative evaluation is the most effective method of predicting a perioperative cardiac event. (2) decreased systemic vascular resistance. which can be used to produce a change in outcome. The combined risk of two procedures exceeds that of the original operation. or other major procedures used to be delayed for a period of 2 to 6 months after a myocardial infarction. the risk of myocardial infarction remains increased for several months after surgery. statins. addition of other drugs should be considered. Deep anesthesia and brief duration of direct laryngoscopy (<15 seconds) is important in minimizing the hemodynamic changes associated with intubation. 59. If you anticipate a longer intubation or if the patient has uncontrolled hypertension preoperatively. Perioperative myocardial reinfarctions occur most frequently in the first 48 to 72 hours postoperatively.

mechanical irritation of the ventricles) if possible and correct it. hypertension. WPW syndrome is characterized by a short PR interval (less than 120 ms).3% of the general population. The primary goal with VPCs should be to identify any underlying cause (myocardial ischemia. 63. The composite of cardiac impulses conducted by normal and accessory pathways is the reason for 5 wave and wide QRS complex. syncope. Unstable ventricular arrhythmias need electrical cardioversion. (2) the absence of a P wave preceding the QRS complex. Anesthetic management in the presence of a preexcitation syndrome is to avoid increase in . VPCs are recognized on the ECG by (1) premature occurrence. D. C. D. Anesthetic considerations in patients with aortic stenosis: • Maintaining a high SVR • Optimal preload • Avoiding extreme fluctuations in HR (60-80 bpm is ideal) • Avoiding arrhythmias • Rapid availability of a agonists to counter the drop in SVR with induction • Accurate BP measurements preferably with an intra-arterial catheter 62. The short PR interval is due to conduction along the bundle of Kent. (3) a wide and often bizarre QRS complex. • Keep the heart rate high— decreases the duration of systole • Keep SVR high • Avoid decrease in myocardial contractility • V wave is a reflection of mitral-regurgitant flow 60. and sudden death due to delayed repolarization. (2) are multifocal. Common congenital syndromes associated with these conditions are Jervell and Lange-Nielsen syndrome (with deafness) and Romano Ward syndrome (no deafness). Care should also be taken to avoid the drugs that prolong the QT interval like phenothiazines. Atrial arrhythmias like paroxysmal atrial tachycardia (most frequent) and supraventricular may lead to hemodynamic collapse in patients with WPW syndrome. (4) an inverted T wave. a wide QRS complex. or (4) take place during the ascending lim b of the T wave (R-on-T phenomenon) that corresponds to the relative refractory period of the ventricle. Any condition that increases the heart rate predisposes these patients to arrhythmias— avoidance of sympathetic stimulation during anesthetic induction is vital. If the patient is hemodynamically stable. Left-stellate ganglion block has been shown to have some therapeutic benefit. with an incidence of approximately 0. B. (3) occur in salvos of three or more. suggesting an autonomic nervous system imbalance as possible etiology for this syndrome. which does not have a physiologic delay like conduction across the atrioventricular node. arterial hypoxemia. and 5 wave in EKG. VPCs can be treated with lidocaine (1 to 2 mg/kg IV) when they (1) are frequent (more than six premature beats/min). hypokalemia. these patients can be treated with p- blockers. QTc >440 ms in EKG is considered a predisposing factor for ventricular dysrhythmias. hypercarbia. 61. WPW is the most common preexcitation syndrome. and (5) a compensatory pause that follows the premature beat.

adenosine or procainamide w ill be a good choice to treat the arrhythmia. A ll cardiac antidysrhythmic drugs should be continued throughout the perioperative period. However. Magnet mode for many pacemakers (not AICDs) is asynchronous at 99 bpm. This can be avoided (1) by a drain placed from the right superior pulmonary vein into the left ventricle. 65.” The specific magnet mode for a patient’s device should be identified by interrogation prior to surgical procedures as some magnet modes change with device state or are programmable. Hence. which in turn results in activation of the sympathetic nervous system (tachycardia. The goal is to keep the ventricle from overdistention when it is not pumping. and (3) decreases in systemic blood pressure due to increased intrapericardial pressure from accumulation of fluid in the pericardial space. propranolol. sympathetic nervous system activity events (anxiety) or drugs (anticholinergics. the regurgitant flo w from the aorta w ill keep distending the left ventricle. D. Asynchronous pacing at such a low heart rate with the sensing function o ff may lead to R-on-T phenomenon if the patient has a spontaneous heart rate above 50 bpm. The centrifugal pump has three . Cardiac tamponade is characterized by (1) decreases in diastolic fillin g of the ventricles. in some devices. B. The bypass pump serves to pump the oxygenated blood back to the arterial side of the patient. Inadequate ventricular fillin g leads to a decreased stroke volume. 67. (2) by aspirating from the antegrade cardioplegia line placed in the proximal ascending aorta. (2) decreases in stroke volume. or esmolol) can be used to avoid tachycardia during induction of anesthesia. A. They are of two types: centrifugal and roller pump. 64. These patients need to be kept “ fu ll and fast” as the right-sided fillin g occurs only when central venous pressure exceeds the right-ventricular end diastolic pressure. is now programmable and does not always default to asynchronous pacing. vasoconstriction) in attempts to maintain the cardiac output. resulting in an increase in ventricular response rate during this dysrhythmia and should be avoided. it should not be considered “ safe. Electrosurgical cautery is interpreted as spontaneous cardiac activity by the artificial cardiac pacemaker when the ground plate for electrocautery is placed too near the pulse generator or with use of a unipolar cautery. Digitalis and verapamil may decrease the refractory period of accessory pathways responsible for atrial fibrillation. Histamine-releasing agents like mivacurium/atracurium are also preferably avoided. especially the newer AICDs. D. Other techniques to improve safety include using a bipolar cautery. metoprolol. or (3) via a pulmonary venous drain. For this reason. the magnet mode shifts to asynchronous at 50 bpm at the end of battery life. The magnet mode of many implanted devices. the electrical return plate (wrongly called ground plate) should be placed as far as possible from the pulse generator. and placement of external pads prior to the beginning of the case. ketamine. If the aortic valve is not competent. 66. Intravenous P-blockers (atenolol. Ketamine with its sympathomimetic property w ill be a poor choice for induction. impairing perfusion and myocardial preservation. Venting of blood returning via the Thebesian or bronchial veins may also be necessary. pancuronium) that might predispose to tachydysrhythmias. In case of a sudden onset of tachycardia.

D. and usual flows for normothermia or m ild hypothermia aim for a cardiac index between 2 and 4 L/min/m 2. Use of a agonists to keep the mean arterial pressure may aid the cerebral perfusion. Since the patient is on cardiopulmonary bypass. Paco2 is a balance of CO2 production and removal. This patient has a drop in Pao2 from 90 to 70 mm Hg despite having a Fio 2 of 70. etc. they can cause tube rupture with arterial inflo w clamping. This is very important for tissues with high oxygen consumption like myocardium and brain. 70. The clinical scenario described can result from both tension pneumothorax and bronchial mucous plugging. VCO2/VA In the equation. But the fact that it occurred after 2 days of mechanical ventilation and without any change in the hemodynamic status makes bronchial mucous plugging the most likely cause.000 to 4. V C o 2 is carbon dioxide production. the patient has an increased CO2 in the blood (irrespective of temperature correction). C. 69. 68.000 rpm that use blood viscosity to pump blood. do not pump air bubbles secondary to air being less dense than blood. Roller pumps generate flo w by compression of fluid-filled tubing between the roller and curved metal back plate and can pump air. None of the other options has any role in C o 2 production or elimination during cardiopulmonary bypass.863) that corrects units. The drop in mean arterial pressure at the beginning of CPB is caused by a sharp decrease in systemic vascular resistance caused by the drop in hematocrit caused by the priming solution on pump. The flo w is determined by a dial on the cardiopulmonary bypass machine. and VA is alveolar ventilation. carotid stenosis. avoiding the risk of line rupture with clamping of the arterial inflo w circuit. Paco2 increases. In the clinical scenario described. Pressures less than 40 mm Hg are avoided if possible in adults. Paco2 decreases. Along with the relative hypoxemia. The resulting Paco2 is expressed by the alveolar CO2 equation: Paco2 = k. he also developed an increase in peak inspiratory pressure with no change in plateau pressure. Pressures up to 80 to 90 mm Hg may be used in . If production exceeds removal. k is a constant (0. disks rotating at 3. increasing the fresh-gas flo w to the oxygenator w ill wash out more C o 2. and are afterload-dependent. Higher pressures may improve cerebral blood flow and reduce watershed infarction but higher pressures come from higher flows and more emboli per unit time. Pressures higher than 60 mm Hg are used during rewarming. Both ARDS and left-ventricular failure (pulmonary edema) w ill result in a change in lung compliance. Lower pressures may reduce cerebral blood flo w and emboli load to the brain. This drop in blood pressure along with decreased hematocrit may cause a drop in tissue oxygen delivery. B. Centrifugal pumps are less traumatic to blood cells. The correct blood pressure during bypass is often decided based on the patient’s coexisting conditions. The lack of change in plateau pressure rules out any intrinsic change in the lung compliance. If removal exceeds production. Because of their mechanism.

If the catheter is too deep. the catheter is not in the coronary sinus but is most likely in the right atrium or in the superior vena cava. Positioning of the coronary sinus catheter should be checked with transesophageal echocardiography and manual feel by the surgeon. Therefore. resulting in poor right-ventricular protection. B. such as benzodiazepines or opioids. The anatomical location of coronary sinus ostia makes it very difficult for proper visualization by the surgeon. SVR should be between 1. 74. . may be administered prophylactically. Low SVR is a very common hemodynamic abnormality after CPB. Temperature correction of Paco2 and pH is probably not necessary. A mixed venous Po 2 lower than 30 mm Hg associated with metabolic acidosis suggests inadequate tissue perfusion. At 30°C. 75. SVR is usually calculated using the formula mean arterial pressure (mm Hg) .400 prior to CPB separation. indicating adequate renal perfusion. patients with cerebral vascular disease. By this. Oxygen consumption in the fibrillating ventricle at 22°C is 2 mL/100 g/min.central venous pressure (mm Hg)/pump flo w (L/m i) x 80. Supplemental anesthetics. 73. The units of SVR are dyn s/cm5. The electromechanically quiet heart at 22°C consumes oxygen at a rate of 0. C. The effect of hemodilution on drug concentrations is likely to be offset by a decreased need for drugs during hypothermia.5 to 1 mL/kg/hr. SVR can be normalized with a vasoconstrictor prior to weaning from CPB. Volatile anesthetics delivered using vaporizers incorporated into the CPB circuit have largely negated this problem along with the use of BIS monitors. B. and an additional dose of nondepolarizing muscle relaxant. Being up against a wall produces a very high (>100 mm Hg) pressure. Monitoring of coronary sinus pressures during retrograde administration is used to assess proper catheter placement. This makes weaning from CPB very difficult. If the pressure at the distal tip of the coronary sinus catheter during cardioplegia administration at 200 mL/min is equal to central venous pressure. A. C. cardioplegia to the right ventricle w ill be compromised.200 and 1. with an output of 0.3 mL/100 g/min. we are attempting to match the vascular input impedance to the cardiac output impedance and optimizing energy transfer. This creates a high chance of patient recall/ movement. the heart muscle consumes oxygen at a rate of 8 to 10 mL/100 g/min. 72. 71. A properly placed coronary sinus catheter w ill have pressure of 40 to 60 mm Hg during a 200-mL/min infusion. anesthetic requirements seem to be minimal if the patient was adequately rearmed at the conclusion of CPB. additional anesthesia is not routinely required during rewarming at the termination of CPB. provided it is normally contracting. On the contrary. Urine output may serve as a guide to the adequacy of renal perfusion. The extra volume of crystalloid used in priming the CPB circuit may produce a sudden dilution of circulating drug concentrations.

we may be able to see a wide MR jet. with observation of an echogenic mass attached to the mitral valve or when a mobile mass is seen to prolapse into the left atrium during systole and to move back into the left ventricle during diastole. along with the posterior wall. Acute MR due to volume overload from excessive fluid administration is usually a central MR as evidenced in TEE with a distended ventricle and can be managed by decreasing the preload. usually by a single artery unlike the anterior. . The posterior papillary muscle. Acute mitral regurgitation (MR) post-CPB is often noticed as a prominent V wave in PAOP tracing. which derives its blood supply from two arteries. is entirely perfused either by the right coronary artery (RCA) or by the third obtuse marginal branch. It is usually a complication of acute mitral infarction but maybe seen at the end of CPB due to inadequate myocardial protection (warm blood in the adjacent descending aorta providing inadequate protection) during CPB or air entry into the RCA.76. If there is a transesophageal echocardiograph (TEE) in place. D.

.

A ll the above are correct 3. Elastase deficiency in the airways 2. Which of the follow ing techniques is associated with a lower complication rate related to bronchospasm in the asthmatic population? A. General anesthesia— laryngeal mask airway (LM A) C. which shows an increase of FEV: percent predicted of more than 12%. Which of the follow ing statements about this clinical scenario is most appropriate? A. Which of the follow ing is not a characteristic feature of asthma? A. Bronchial asthma— acute bronchodilator responsiveness B. Presence of wheezing on physical examination indicates that he is having a severe attack of asthma B. A 22-year-old patient with a history of moderate persistent asthma on medium-dose inhaled corticosteroids and long-acting inhaled 0-agonist presents for an emergency appendectomy.2 L in response to bronchodilators. Chronic inflammatory changes in the submucosa of the airways B. but maintaining an oxygen saturation of 99% on room air.Thoracic Anesthesia Deppu Ushakumari and Ashish Sinha 1. Regional anesthesia B. Airway hyper responsiveness C. Reversible expiratory airflow obstruction D. Increased airway resistance that occurs intraoperatively is usually due to acute exacerbation of asthma . General anesthesia— endotracheal tube (ETT) D. he is actively wheezing. and an increase in FEV1 of greater than 0. A 55-year-old male presented to you with a pulmonary function test report. Chronic obstructive pulmonary disease (COPD)— variability in airflow obstruction C. COPD— acute bronchodilator responsiveness D. Which characteristic of his respiratory illness is depicted here? A. Volatile anesthetics cause bronchodilation through catecholamine-independent mechanisms C. On clinical examination. Combined general and neuraxial anesthesia 4.

Insert an orogastric tube.5. Right heart catheterization is the gold standard for diagnosis B. Snoring . Inadequate depth of anesthesia 6. hypoxemia. D. and should be avoided in asthmatics 5. Transition to a laryngeal mask airway (LM A) under sevoflurane anesthesia and let the patient wake up with an LM A 7. the end-tidal sevoflurane concentration reads 3. Which of the follow ing is true regarding administering general anesthesia to a chronic obstructive pulmonary disease (COPD) patient? A. Acute bronchospasm B. but the anesthesia ventilator is alarming because of high peak airway pressures. Anesthetic considerations for a patient with severe pulmonary hypertension include all the following. Nitrous oxide + opioid technique is ideal B. Which of the follow ing w ill be your most likely plan of action? A. the surgeon requests you to extubate the patient fu lly awake because he found extensive intestinal adhesions and is afraid of retained gastric contents in the stomach. except A. Shut o ff the inhalational agent and use intravenous propofol to avoid transitioning through a rocky stage-2 wake up D. Mechanical causes of obstruction D. Which of the follow ing is the most likely cause? A. and hypercapnia during anesthetic management D. Cardiac output from a failing right ventricle depends on fillin g pressure from venous return and pulmonary pressure 9. Minimize tachycardia. Which of the follow ing is not a part of the “ STOP BANG” screening questionnaire for obstructive sleep apnea (OSA)? A. Anaphylactic reaction to intravenous muscle relaxant that you just administered C. empty the stomach as much as you can. Administer intravenous lidocaine to decrease the likelihood of airway stimulation and wait till the patient is fu lly awake before extubation C. A laryngeal mask airway (LM A) is more stimulating to the airway than an endotracheal tube. M ortality in pregnant patients undergoing vaginal delivery is very small as opposed to cesarean section C. Use lower breathing rates to permit more exhalation time D. Use large tidal volumes C. Correct the hypercapnia intraoperatively to help extubate early 8. At the end of the above case. and proceed with a deep extubation to avoid bronchospasm B. During the above case.

Uniform ventilation to all lobes is most likely achieved by a right-sided DLT because it has a ventilation slot in the bronchial tube D. you inflate the bronchial cuff and ventilate the left lung through the bronchial lumen without any difficulty. Measurement of tracheal width from a posteroanterior chest radiograph is of no use in selecting the size of a double-lumen tube (DLT) B. Shift of oxyhemoglobin dissociation curve to the right B. More frequent use of left-sided DLT is based on the anatomy of tracheobronchial tree C. Pulmonary capillary wedge pressure >18 mm Hg B. Then you proceed to inflate the tracheal cuff and ventilate through the tracheal lumen. except A. You notice a very high resistance to air flow. Experience of the operating surgeon D. Fiber-optic confirmation of correct DLT placement is not required if you have good clinical confirmation 14. Predicted postoperative diffusing capacity for carbon monoxide (D l c o ) >40% 12. Risk factors associated with increased perioperative m orbidity and mortality in thoracic surgery patients include all the following. Which of the follow ing is one of the benefits regarding cessation of smoking 12 to 24 hours prior to surgery? A. Extent of lung resection B. After intubation. Left DLT entered the right bronchus with the tracheal outlet in the right main stem . Which of the follow ing events is most unlikely with the said clinical picture? A. In surgical cases requiring lung isolation A. Exercise tolerance D. High blood pressure 10. V o 2 max >15 mL/kg/min D. B. The follow ing is not necessarily a part of prethoracotomy respiratory assessment A. Male sex 11. Improvement in mucociliary transport C. Decrease in sputum production D. Left DLT displaced with the bronchial cuff herniated at carina C. Observed apnea C. Left DLT too deep with the tracheal outlet into the left main-stem bronchus B. Improved small-airway function 13. A 59-year-old lady is intubated with a 37 left-sided double-lumen tube (DLT) for wedge resection of left lower lobe nodule. Predicted postoperative FEV1 >40% C. Age older than 70 years C.

DLT too far out with the bronchial lumen sitting just above the carina 15. Appropriate positioning for this surgery B. Which of the follow ing statements is false regarding ventilation/perfusion relationship in a . In which of the follow ing situations is applying continuous positive-airway pressure (CPAP) to the nondependent lung most ideal for improving oxygenation? A. Massive pulmonary hemorrhage D. Withdraw the bronchial blocker a couple of centimeters C. What would you do if you have the follow ing situation with a bronchial blocker for left lung surgery? A. Open lobectomy C. Insert the bronchial blocker a few centimeters farther down D. D. Remove the bronchial blocker and reinsert it into the left side 16. Bronchopleural fistula B. Sleeve resection 17.

Contraction of dependent hemi diaphragm is more efficient C. Dependent lung is on a more favorable part of the compliance curve D. Factors known to inhibit hypoxic pulmonary vasoconstriction (HPV) and thus worsen the alveolar-arterial oxygen gradient include all of the following. M ortality is higher for left-sided pneumonectomy D. Patient to be left intubated post operatively B. Regarding lung resection surgery. except A. Low tidal volume alarm D. which of the follow ing alarms indicates a malposition of the double-lumen tube (DLT)? A. The lower lung receives less ventilation and more perfusion than the upper lung 18. Anatomical abnormality precluding the placement of a double-lumen tube (DLT) C. Decrease the contribution of dependent lung to the tidal volume B. Move air to and fro between the dependent and the nondependent lung C. M ortality rate for pneumonectomy is 5% to 7% B. The ventilation/perfusion matching is preserved B. Nitroglycerin C. High CO2 alarm B. except A. the major effect of mediastinal shift is to A. which of the follow ing statements is false? . Hypercapnia D. lateral decubitus position during spontaneous ventilation? A. Tamponading bronchial bleeding in adult patients D. To attain better collapse of the nondependent lung 22. Which of the follow ing statements about lung resection surgery is false? A. Hypocapnia B. A 64-year-old female is undergoing a left video-assisted thoracoscopy for a suspicious pulmonary nodule. Decrease the perfusion to the dependent lung D. Compress the big veins and decrease cardiac preload 19. Low O2 alarm C. M ortality rate for lobectomy is 2% to 3% C. Most postoperative deaths result from cardiac issues 23. Pulmonary infection 20. A bronchial blocker is useful in all of the follow ing clinical situations. Unable to drive bellows alarm 21. In an open pneumothorax. Immediately after positioning the patient laterally.

Continuous inflation of oxygen into collapsed lung 27. she develops hemoptysis. Supraventricular tachycardias (SVTs) are thought to result from surgical manipulation or distension of the right atrium C. The first step recommended to improve oxygenation if a patient is exhibiting drop in oxygen saturation during one-lung ventilation is A. Postoperative hypoxemia and acidosis due to atelectasis and shallow breathing are common 24. An 80-year-old female underwent a left lower lobectomy.5% 25. Arterial Pc o 2 rises 1 to 2 mm Hg each subsequent minute after the first minute D. It is caused by excessive fluid administration in a lateral decubitus position B. A. The vital signs are stable. Desflurane end tidal 5. Apply continuous positive-airway pressure (CPAP) to the collapsed lung B. A. Which of the follow ing has the least effect on hypoxic pulmonary vasoconstriction (HPV)? A. Nitrous oxide B. It is due to volutrauma caused during one-lung ventilation 26. On postoperative day 4. In the ICU on postoperative day 2. Atelectasis causing shifting of the mediastinum to the left D. The most likely cause is A. Perioperative arrhythmias are common B. Adequate oxygenation can be maintained only for short periods of time B. A 68-year-old male patient with a lung nodule underwent a right upper lobectomy.5% C. Progressive respiratory acidosis limits the use of this technique to 10 to 20 minutes in most patients 28. During apneic oxygenation. Bronchopleural fistula on the right from inadequate surgical closure of the bronchial stump C. It increases intrapulmonary shunting C. A normal finding 29. Which of the follow ing statements is not true regarding “ lower lung syndrome” ? A. the patient develops a sudden large air leak from the chest tube associated with increasing pneumothorax and partial lung collapse. but on the chest X-ray a homogenous . Apply positive end-expiratory pressure (PEEP) to the dependent lung C. Sevoflurane end tidal 2. Incidence of arrhythmia decreases with age due to the ageing of cardiac conduction system D. Arterial Pc o 2 rises 3 to 4 mm Hg in the first minute C. Periodic inflation of the collapsed lung D. Isoflurane end tidal 1.5% D. It is gravity-dependent transudation of fluid into the dependent lung D. Bronchopleural fistula on the right from necrosis of suture line B.

These cavities allow to and fro movement of air and have a very low chance to progressively enlarge C. The cyst is compressing her remaining right lung. Assisted ventilation is not necessary immediately after induction and can be harmful 32. Progressive dyspnea B. and she is brought to the OR for an emergency pulmonary cystectomy. A 66-year-old patient with a history of severe tracheal stenosis is presenting for a tracheal resection. The greatest risk of rupture of the cavity is during preoxygenation just prior to induction B. and there is no need to do it emergently C. Dyspnea worse on sitting up and leaning forward D. In your discussion with the patient. The most common cause of death is asphyxia secondary to blood in the airway D. It is a normal finding and the homogenous opacity is due to accumulation of fluid in the left lower lobe area C. which of the follow ing statements is not appropriate about his clinical condition? A. It can be done as a semi-elective procedure. the left upper lobar orifice is closed. Right radial artery blood pressure monitoring is preferred over the left side for lower tracheal resection C. After subsequent bronchoscopy. Which of the follow ing is right regarding anesthetic management of this patient? A. Maintenance of spontaneous ventilation is desirable until a double-lumen tube (DLT) is in place D. Early extubation is not advisable at the end of the procedure for risk of rupturing the suture lines . Patient may have a history of blunt/penetrating tracheal trauma 33. Medical management has a lower mortality rate than operative management 31. Torsion of the left upper lobe as the left upper lobe expanded to occupy the left hemithorax D. Flow-volume loops aid the clinician in evaluating the severity of the lesion B. density is seen in the left lower lung area. which of the follow ing statements is correct? A. Slow-inhalation induction is not advisable and a rapid-sequence induction should be used D. A 45-year-old recent immigrant from Vietnam is admitted to the emergency department with massive hemoptysis (>600 mL in the last 24 hours). with a history of 60 pack year smoking. The most likely diagnosis is A. An 81-year-old chronic smoker. is admitted with progressive dyspnea and a huge right-sided pulmonary cyst. The most unlikely clinical finding is A. Acute herniation of the heart into the left lower lobe area B. You are called to evaluate the patient for a possible bronchial artery embolization or a rig id bronchoscopy. Operative mortality exceeds 20% B. Reexpansion edema of the left upper lobe 30. Wheezing evident on exertion C. In the anesthetic management of the above patient.

Anesthetic considerations for esophageal surgery include A. A prolonged inspiratory time is recommended for facilitating exposure of the surgical segments D. After a double-lung transplantation A. except A. Always performed with a double-lumen tube (DLT) 39. Patients with diminished left-ventricular function can be transplanted as long as they have normal right-ventricular function C. It involves positioning the patient in a lateral position to aid active suctioning of the lavage fluid 36. Which of the follow ing flow-volum e loops w ill be expected in a child with variable . except A. Respiratory pattern changes to a slow deep respiration C. It is performed under general anesthesia with lung isolation C. Pneumothorax D. Patients have a better outcome if kept intubated at the end of the surgery 40.34. Loss of lymphatic drainage predisposes to pulmonary edema B. except A. Very low risk of pulmonary aspiration B. Diaphragmatic retractors interfering with cardiac function D. Hypoxic pulmonary vasoconstriction is abolished 38. Mandatory pulmonary artery catheter monitoring C. Cough reflex is abolished above the carina D. Considerations for lung transplantation include all the following. Vagally mediated reflex bradycardia B. Complications associated with mediastinoscopy include all the following. Cor pulmonale does not necessarily require combined heart-lung transplantation B. Patients with Eisenmenger syndrome require combined heart-lung transplantation D. Cerebral ischemia C. Lung-volume-reduction surgery (LVRS) A. Thoracic duct injury 35. Has been demonstrated to have very good efficacy by the National Emphysema Treatment Trial (NETT) B. It is performed for patients who make excess quantities of surfactant and fail to clear it B. Anesthetic considerations for bronchoalveolar lavage include all the following. It is usually performed in the supine position D. Organ selection is based on size and ABO compatibility 37. Necessitates lim iting of peak inspiratory pressure to 30 cm H2O follow ing intubation C.

A 12-year-old boy with suspected lymphoma presents to you for a lymph node biopsy. He refuses to lie down. When you go to visit the patient. you notice that he has venous engorgement and edema of the head. extrathoracic obstruction? 41. The preferred management for this boy would be A. Empiric treatment with steroids and surgery under general anesthesia only after the airway compromise is alleviated D. Get a chest X-ray and rule out mediastinal compression prior to any active management . and arms. and is tachycardiac and tachypneic. Preferably biopsy the lymph node under local anesthesia so that the patient can be sent for radiotherapy immediately after a tissue diagnosis C. Safest thing w ill be to secure the airway immediately by using rapid-sequence induction B. neck.

history of previous intubations for asthma. regional anesthesia is superior to general anesthesia with an LMA. inhaled bronchodilator therapy immediately prior to induction. Mechanical causes of . anesthesia should be augmented with an intravenous anesthetic such as propofol. airway manipulation only after deep anesthetic plane. Acute bronchospasm causes expiratory wheezing. Sudden severe bronchospasm can present as high airway pressures with absence of breath sounds and very high resistance to mechanical ventilation. musical wheezes are characteristic of asthma. If a general anesthetic technique is pursued. reversible expiratory airflow obstruction. and they act through catecholamine-independent mechanisms. COPD patients do respond to bronchodilators but not to the same extent. which is better than general anesthesia with ETT. and patient preference. D. Early stages of asthma are diagnosed by decreased mid expiratory flo w rates (effort independent) and decreased FEV1 and by its reversibility. General anesthesia through a LM A is less stimulating to the airway than through an endotracheal tube.2 L suggest acute bronchodilator responsiveness and variability in airflow obstruction. Sudden bronchospasm in response to external/internal stimuli and response to bronchodilators like P2-agonists are important distinguishing features of asthma. C. dependence on inhaled bronchodilators. and chronic inflammation. The goal in any such circumstance is to decrease airway manipulation and stimulation. A more than 12% increase in predicted FEV1 and an absolute increase in FEV1 of more than 0. History and physical examination can suggest presence of severe asthma if the patient has had repeated intubations for asthma. Mechanical causes of obstruction such as a kinked endotracheal tube or a mucous plug can also present a similar clinical picture and are more common. Spirometry is the only objective method to quantify the severity of obstruction. 5. increased peak inspiratory pressure or decreased tidal volume (depending on the mode of ventilation). B. CHAPTER 12 ANSWERS 1. The reversibility of this magnitude is almost always indicative of bronchial asthma. and a characteristic upslope of the capnogram. Volatile anesthetics are potent bronchodilators. they are not specific and they have no correlation with the severity of obstruction. Any airway stimulation can cause severe reflex bronchoconstriction and bronchospasm in severely asthmatic patients with hyperactive airways. They are rarely used as second- line agents in cases of bronchospasm refractory to medical therapy. A. Elastase deficiency in the airways is a feature of emphysema. Response to a bronchodilator drug resulting in relief of airway obstruction is highly suggestive of bronchial asthma. If bronchospasm is suspected. use of non-histamine-releasing drugs. Asthma is a type of reactive airway disease characterized by hyperresponsive airways. Even though high-pitched. 3. 2. A. and use of intravenous lidocaine prior to intubation have all been proven to be useful. The choice of anesthetic technique is often influenced by the severity of asthma. 4. In a severely asthmatic patient.

pain. light anesthesia. This can be done by using a normal tidal volume and a slow respiratory rate and an I:E ratio of >1:3. However. intravenous administration of lidocaine (1. When extubation is delayed for reasons of patient safety. inadequate left-ventricular fillin g . (presence of gastric contents in a case with acute appendicitis). 7. obstruction such as a kinked endotracheal tube or a mucous plug can also present a similar clinical picture and are more common. an intravenous anesthetic agent is very helpful to deepen the plane of anesthesia as the delivery of inhaled anesthetic agents may not be effective. dysrhythmias. B. Careful patient selection is very important. high Paco2 levels w ill increase pulmonary artery pressure. Thus. Right-sided heart catheterization is the gold standard for diagnosing and quantifying the degree of pulmonary hypertension. B.5-2 mg/kg bolus) may decrease the likelihood of airway irritation and bronchospasm. hypothermia. Cardiac output from a failing right ventricle depends on the fillin g pressure from venous return and pulmonary pressure. which may be poorly tolerated in patients with a compromised right-ventricular function and cor pulmonale. hypercarbia. Care should be taken to avoid hyperventilation and creation of a respiratory alkalosis as these patients tolerate marked hypercapnia secondary to hypoventilation. The ability of N2O to diffuse into closed air spaces may lead to the enlargement of an emphysematous bulla or a pneumothorax and possibly rupture. Care should be taken to avoid all the factors that increase pulmonary vascular resistance in a patient with severe pulmonary hypertension presenting for surgery. Pulmonary hypertension is defined as an increase in mean pulmonary artery pressure above 25 mm Hg at rest or 30 mm Hg with exercise in the presence or absence of an elevated pulmonary capillary wedge pressure. Use of nitrous oxide (N2O) is normally safe but not strictly necessary. After clearing out the secretions from the oropharynx and the endotracheal tube. Pulmonary hypertension in pregnant patients has a . A patient who has adequate return of neuromuscular function and has a regular spontaneous breathing pattern with adequate tidal volumes can be considered a candidate for deep extubation. and eventually biventricular failure. Progressive right-ventricular dilation and hypertrophy in response to an increased afterload generated by chronic pulmonary hypertension w ill eventually lead to right-ventricular systolic dysfunction. extubation is performed under a deep plane of anesthesia and ventilation continued by a mask/LMA. 6. and it should not be considered in those at increased risk for aspiration of gastric content and if the necessary airway management skills are not immediately available. The interventricular septal bulge decreases left-ventricular cavity fillin g . extubation can be performed after the patient is awake and follow ing commands if airway irritation can be avoided. A ir trapping and development of auto positive end-expiratory pressure can be decreased by providing a prolonged expiratory time. and maintaining adequate cardiac output. 8. Balanced anesthesia using an inhaled anesthetic and opioid is a safe choice for anesthesia for a COPD patient. C. This includes avoiding hypoxia. When troubleshooting such a scenario. further worsening the left- ventricular failure. Bronchodilation using inhaled P2-agonists and pulmonary toilet through blind suctioning or fiberoptic bronchoscopy may facilitate safe extubation of the trachea.

cardiopulmonary reserve. D. However. The choices B. obesity. The extent of lung resection (pneumonectomy > lobectomy > wedge resection). A. and more than 4 weeks in patients undergoing pulmonary surgery. 11. Smoking can affect the pulmonary system in multiple ways— increase in airway irrita b ility and secretions. MVV. Pao2 >60. pulmonary function tests— ppoFEV1. 6-minute walk test. even 12 to 24 hours of cessation may be beneficial because it decreases the level of carboxyhemoglobin and it shifts . There is a high risk for OSA if >3 yes to the below questions. and inexperience of the operating surgeon are risk factors associated with increased perioperative m orbidity and mortality rates. In patients with anatomically resectable lung cancer. hypertension. and a fam ily history of OSA are risk factors for OSA. or a female with a neck circumference greater than 16 inches. S (snore) Have you been told that you snore? T (tired) Are you often tired during the day? O (obstruction) Do you know if you stop breathing or has anyone witnessed you stop breathing while you are asleep? P (pressure) Do you have high blood pressure or on medication to control high blood pressure? B (BMI) Is your body mass index greater than 28? A (age) Are you 50 years old or older? N (neck) Are you a male with a neck circumference greater than 17 inches. The prethoracotomy respiratory assessment has been labeled as a three-legged stool that incorporates assessment of respiratory mechanics. and increased incidence of postoperative pulmonary complications. A. Snoring. high mortality rate up to 50% for vaginal delivery and even higher for cesarean delivery. the cardiopulmonary reserve measurements show Vo2 max >15 mL/kg/min. C. C. age older than 70 years. and D are the most valid tests out of the “ three­ legged stool. 9. G (gender) Are you a male? 10. lung perfusion scanning. Any patient presenting for elective surgeries with a history of smoking should be advised smoking cessation regardless of the time available prior to surgery.” 12. The follow ing findings are considered favorable: respiratory mechanics assessment demonstrates ppoFEV1 >40%. daytime sleepiness. Patients are more receptive toward interventions immediately prior to surgery and this provides a good teachable moment. PacO2 <45 mm Hg. and FVC. and assessment of lung parenchymal function shows ppoDLCO >40%. Prolonged abstinence (8-12 weeks) is required to improve mucociliary transport and small-airway function and decrease sputum production. RV/TLC. The incidence of postoperative pulmonary complications decreases with abstinence from cigarette smoking for more than 8 weeks in patients undergoing coronary artery bypass surgery. stair climb >2 flights. and exercise testing to measure maximum oxygen consumption (Vo2max)— may predict postoperative pulmonary function and outcome. and lung parenchymal function. decreased mucociliary transport. exercise Spo2 <4%.

But a general guideline is a woman shorter than 160 cm should be intubated with a 35-Fr tube. This tube size of 37 Fr may be too big for this lady. The angle between the right main bronchus and trachea is 25 degrees at the level of carina. This finding can be confirmed with fiberoptic bronchoscopy. Because of these reasons. Uniform ventilation to all lobes can be achieved more easily with a left-sided DLT than a right-sided one. wider. B. In addition to physical examination. a left-sided DLT is most commonly used. failure to ventilate suggests that something is occluding the tracheal lumen (the bronchial cuff in this situation). a woman taller than 160 cm should be intubated with a 37-Fr tube. The ventilated gas coming out of tracheal lumen is being trapped between the tracheal and the bronchial balloons. However. Thus. fiberoptic assessment should be done to confirm proper position of a left-sided DLT because the malposition incidence if confirmed with auscultation alone is considered to be 20% to 48%. The right upper lobe bronchus takes o ff at an acute angle from the point of origin of the right primary bronchus and is easily occluded if the ventilation port on the right-sided DLT is not aligned properly. it could be that the DLT is too far into the left bronchus with the tracheal lumen opening into the left main stem. after inflating the tracheal cuff (with the bronchial cuff already inflated).68 of tracheal diameter). the unoccluded outflow tract of the bronchial lumen made it easy to ventilate. There is a good correlation between tracheal and bronchial width (bronchial diameter is predicted to be 0. When we inflated the bronchial cuff and attempted ventilation. 14. . the oxyhemoglobin dissociation curve to the right. If with the same clinical picture. Measurement of tracheal width from a posteroanterior chest roentgenogram can help select the size of a left-sided DLT. C. and the tube needs to be repositioned with bronchial cuff in the left main-stem bronchus. 13. The presence of breath sounds only on the right side with both the cuffs inflated suggests that the bronchial lumen is patent and ventilating the right side. and a man shorter than 170 cm should be intubated with a 39-Fr tube. and more in line with the trachea. you are hearing breath sounds only on the left side with both the cuffs inflated. It is also possible that the bronchial cuff is barely into the left main stem with a herniated bronchial cuff preventing the inflation of right-sided lung via the tracheal lumen. There is no single predictor that can accurately predict the appropriate size of a DLT. and a man taller than 170 cm should be intubated with a 41-Fr tube. right main bronchus is shorter. but the left main bronchus takes o ff at an acute angle of 45 degrees.

Figure 12-4A is a bronchial blocker for a left-sided lung surgery placed deeply into the left main-stem bronchus. and the balloon of the bronchial blocker is occluding the right upper lobe takeoff. . the bronchial blocker should be withdrawn a couple of centimeters to a level just below the carina. B.15. For both situations. Figure 12-4B is a bronchial blocker advanced too far into the right main stem.

F igu re 12-4. .

sleeve resection. or massive pulmonary hemorrhage. 17. A slow inflation of 2 L/min of oxygen into the nonventilated lung for 2 seconds and repeated every 10 seconds for 5 minutes or until the saturation rises to 98% has been shown to improve oxygenation during one-lung ventilation. This should be done prior to application of PEEP to the dependent lung. Difficulties with oxygenation are fa irly common during one-lung ventilation. various techniques that can be tried to improve the oxygenation include increasing Fio 2 to 1. D. However. bronchopleural fistula. CPAP applied to the operative lung may be disadvantageous in some cases like thoracoscopy. This low level of CPAP results in minimal lung inflation and generally does not interfere with surgery. ventilation/perfusion matching is preserved because the lower lung receives more perfusion due to gravity and more ventilation due to better contraction of the dependent hemidiaphragm.16. intermittent two-lung ventilation. B. The dependent hemidiaphragm gets a better displacement from a higher position in the chest. the most effective method is the application of 5 to 10 cm H2O CPAP to the nondependent lung. The dependent . During spontaneous ventilation in lateral decubitus position. applying positive end-expiratory pressure (PEEP) to the dependent lung. If the Spo2 is below acceptable range.

HPV is a protective mechanism by which body shunts away blood from a nonventilated lung. This results in an ineffective respiratory exchange. lung has a better compliance as well— this improves ventilation. C. The reverse happens on expiration. 19. Factors . It plays a significant role in maintaining oxygenation during one-lung ventilation. 18. The relatively higher pressure on the nondependent side causes a downward shift of the mediastinum during inspiration. but the major effect is by decreasing the contribution of the dependent lung to the tidal volume. A. and the mediastinum shifts upward. Inspiration in a lateral position during spontaneous ventilation causes more negative pleural pressure on the dependent side of the open pneumothorax.

This is attributed to the greater loss of lung tissue. inhibiting HPV include infection. Halogenated agents generally have minimal effects on HPV in doses <1 minimum alveolar . C. D. or too far into the left primary bronchus. If it is in the trachea. the inflated bronchial cuff is preventing any ventilated gas from going past it. at the same time leaving enough for residual postoperative pulmonary function. 20. Left-sided DLTs are most commonly used in clinical practice. They are passed through a single-lumen endotracheal tube under fiberoptic guidance and the balloon is inflated within the bronchus of the operative side. low Paco2. Pulmonary complications after surgery can be decreased by preoperative incentive spirometry. bronchodilator therapy. pulmonary hyper/hypotension. placement of a DLT is difficult and bronchial blockers are used for lung isolation. 22. and pharmacological agents like vasodilators— nitroglycerin and nitroprusside. and limited pulmonary reserve are among the various choices the surgeons can make. into the right main-stem bronchus. Wedge resections for peripheral lesions. C. The cuff of the bronchial blocker is a high-pressure-low-volume cuff. Perioperative arrhythmias are fa irly common after thoracic surgery— atrial fibrillations/SVTs and PVCs are all seen and are thought to be a result of the surgical manipulation of the heart and distension of the right atrium as a result of decreased pulmonary vascular bed. and inhalational anesthetic agents. C. calcium channel blockers. changes in Svo2 (mixed venous oxygen saturation). The biggest problem is caused by the small size of the channel. However. The incidence of arrhythmias increases with age and with the amount of pulmonary resection. M ortality is higher for right-sided pneumonectomy than for left-sided pneumonectomy. In certain situations. Left­ sided DLT may be malpositioned back into the trachea. compared with 2% to 3% for a lobectomy. DLTs are considered to be the best lung isolation device currently in use. in patients with a history of difficult intubation bronchial blockers circumvent the need to reintubate a patient prior to transferring out of the operating room. lobectomy for bigger tumors. Low exhaled tidal volumes and poor lung compliance are the most common initial indicators. 23. 24. B. Lung cancer resection surgeries involve finding the right balance between resecting enough lung tissue to obtain a tumor-free margin. pneumonectomy for tumors involving the main bronchus. The single narrow lumen within the blocker allows the lung to deflate (though slowly) and can be used for suctioning or insufflating oxygen (below). and good pulmonary hygiene. The mortality rate for pneumonectomy is about 5% to 7%. If it is in the right side or pushed too far into the left bronchus. Any change in position of the patient after the DLTs have been placed includes a risk of malpositioning of the DLT. They are similar to Fogarty catheters and are single-lumen devices with an inflatable balloon at the tip. sleeve resections for patients with proximal lesions. P-agonists. which impairs exhalation. These two situations can be immediately relieved by deflating the bronchial cuff. the bronchial cuff may be obstructing the left upper or left lower lobe bronchus. 21.

shunting. D. Inadequate surgical closure of the bronchial stump usually presents itself with a bronchopleural fistula in the first 24 to 72 hours. concentration (MAC). and change in dependent lung minute ventilation (Vt 5 mL/kg is usually recommended but can be increased). They complement each other very well. D. Apneic oxygenation refers to insufflation of 100% oxygen at a rate greater than the oxygen consumption (>250 mL/min) while the ventilation is stopped. 26. Oxygenation can be maintained in patients with normal D l c o for more than this time interval. A. Persistent hypoxemia requires immediate return to two-lung ventilation. use of long-acting opioids should be limited during surgery to prevent excessive postoperative respiratory depression. and can be easily titrated to desired concentration and opioids have minimal hemodynamic effects as well as providing analgesia. arterial Pc o 2 rises 6 mm Hg in the first minute followed by 3 to 4 mm Hg every subsequent minute. Application of CPAP to the collapsed lung should be done before instituting PEEP to the ventilated lung. A. as the effect of PEEP depends on where the lung falls on the PEEP-PVR curve. reexpansion of the collapsed lung can result in pulmonary edema due to alteration in the pressures on either side of the Starling equation. Various interventions can be tried when it happens— some have better efficacy than the others. However. These include periodic reinflation of the collapsed lung with oxygen. and CPAP (5-10 cm H2O) to the collapsed lung causing partial reexpansion of the lung and may interfere with surgery. Other less efficacious methods that can be tried include PEEP (5-10 cm H2O) to the ventilated lung. Lower lung syndrome refers to gravity-dependent transudation of fluid into the dependent lung. Necrosis of the suture line (bronchial/parenchymal) caused by ischemia or infection usually presents . Most of the time restrictive fluid management strategy facilitated by use of blood/colloids is entertained. Progressive respiratory acidosis limits the use of this technique to 10 to 20 minutes in most patients. Bronchopleural fistula refers to a communication between the bronchial and pleural spaces. The mechanism of action of CPAP application is supposed to oxygenation as well as displacement of blood from the pulmonary vasculature into the dependent lung. 25. It presents as a sudden large air leak from the chest tube that may be associated with an increasing pneumothorax and partial lung collapse. oxygen insufflation to collapsed lung (diffusion respiration). increases ventilation-perfusion mismatch. and promotes hypoxemia. Hypoxemia is fa irly common after institution of one-lung ventilation in the lateral position. Balanced anesthetic technique using a combination of inhaled anesthetic agents and intravenous opioids is beneficial. which interferes with surgery. Anesthetic management of pulmonary resections includes very tight fluid management. During apneic oxygenation. 28. which decreases effective oxygenation. This transudation is worsened by excessive administration of intravenous crystalloids. early ligation or clamping of the ipsilateral pulmonary artery— seldom used but can be tried in pneumonectomies. The only choice with <1MAC is B. On the nondependent side. Inhalational agents allow delivery of 100% oxygen. 27. are potent bronchodilators.

Herniation to the right causes severe hypotension and an elevated central venous pressure due to torsion of the vena cava. These patients present with progressive dyspnea. Pulmonary cysts or bullae are large cavitary lesions that behave as if they have a one-way valve. Whenever possible. Maintenance of spontaneous ventilation (negative inspiratory pressure) is recommended until the affected lung is isolated using a DLT or until a chest tune is placed. w ill not cause significant impairment of ventilation. The inciting factors for the mucosal damage include trauma or prolonged endotracheal intubation. C. Tracheal stenosis is narrowing of the airway as a result of tracheal mucosal damage followed by scarring. >50%. resulting in hypotension. It can also be caused by tumors— squamous or adenoid cystic carcinoma. On the other hand. D. Herniation to the left causes compression of the heart at the atrioventricular groove. Bronchial artery embolization may be attempted if the patient is hemodynamically stable. but the large dead space caused by the presence of huge cyst may result in progressive hypercarbia. >20%. aspergillomas. gets progressively large and may compress the remaining lung tissue. A potentially lethal hemoptysis with severe hemodynamic compromise necessitates emergency surgery. surgery is carried out in a semi­ elective way. Care should be taken to avoid complete positive-pressure ventilation. They are usually smaller in volume. This can be confirmed by visualizing a closed lobar orifice on bronchoscopy. 31. which drains blood flo w to that part of the lung and presents clinically as hemoptysis and radiographically as an enlarging homogenous density. Assisted ventilation is helpful in such circumstances. 32. They can be congenital or acquired as a result of emphysema. The most common cause of death is asphyxia secondary to blood in the airway. This is the classical picture of torsion of a lung lobe as it expands to f ill up the space left by resection of the other lobe. The other causes of massive hemoptysis include bronchiectasis. The dyspnea is characteristically worse on lying down and is made better by sitting up . after 72 hours. This is a rare complication. hemoptysis. medical management is associated with a much higher mortality. and trauma. an acute herniation of the heart into the operative hemithorax is associated with hemodynamic changes and a shift in the cardiac shadow on chest X-ray. 29. They may also rupture producing a tension pneumothorax. and stridor on exertion. ischemia. With the given history. foreign body in the trachea. This is caused by a large pressure difference between the two hemithoraces. the massive hemoptysis (defined as >500-600 mL of blood loss in 24 hours) is most likely infectious in origin with tuberculosis being a strong possibility. Positive-pressure ventilation results in further expansion of such cavities and increased risk of rupture along with impaired oxygenation from the affected lung. This is because the torsion results in occlusion of the pulmonary vein. and w ill close by itself after a few days— after which chest tubes can be discontinued. C. Inhalational agents can be used to facilitate this. They are usually scheduled for lung resection surgeries when they cause recurrent pneumothorax or progressive dyspnea. However. C. but small air leaks are fa irly common after segmental or lobar resection due to collateral ventilation from small channels at the sites of incomplete fissures. neoplasms. 30. and infarction. but the operative mortality is still high.

3 if the surgeon is using laser to resect the scar tissue. It is an absolute indication for lung isolation. A nonirritating inhalational agent like sevoflurane in 100% oxygen can be used along with short­ acting opioids like remifentanil. A false drop in blood pressure may be observed due to compression of the innominate artery if the arterial line is placed on the right arm. If both lungs are lavaged during the same procedure. Care should be taken to decrease the Fio 2 to below 0. There w ill be a brief period of apnea as the surgeon is anastomosing the anterior part of trachea after resection. air embolism. A. Lung isolation for unilateral bronchoalveolar lavage is obtained by a double-lumen tube . The neck is kept flexed in the postoperative period to minimize tension on the tracheal suture line. 33. and leaning forward. use of anticholinergics to prevent increased secretions. 34. Once the anastomosis is complete. D. and phrenic nerve injury. the initial endotracheal tube can be readvanced below the lesion. They undergo sequential lung lavages interspaced by a few days with the worse lung getting lavage first. airway stimulation after attaining a deep plane of anesthesia. Heliox offers a method to avoid turbulence due to its lower density. Pulmonary alveolar proteinosis is a condition in which patients produce excessive quantities of surfactant and fail to clear it. bleeding from damage to the great vessels. it significantly impairs effective oxygenation. The complications include reflex bradycardia due to vagal stimulation. D. Anesthetic considerations for tracheal resection include invasive monitoring. Flow-volume loops confirm the location of the obstruction and aid the clinician in evaluating the severity of the lesion. A spontaneously breathing patient with head end elevated is also at risk for a pneumothorax that presents postoperatively. pneumothorax. slow inhalational induction maintaining spontaneous ventilation. and early extubation. return of spontaneous ventilation. Bronchoalveolar lavage is performed in these patients for severe hypoxemia or worsening dyspnea. producing bilateral lung involvement and recurrent pneumonias. The left radial artery is preferred for lower tracheal resections because of the potential for compression of the innominate artery. Mediastinoscopy involves operating on an area covered with blood vessels and nerves. the surgeon can insert a sterile endotracheal tube into the segment of trachea below the lesion and patient can be ventilated through that. After opening the stenosed segment. post-op hoarseness due to recurrent laryngeal nerve injury. 35.

and bronchial circulation. ABO compatibility. Even though a DLT (Double lumen tube) facilitates surgical exposure. and use of transcutaneous pads for defibrillation if needed. Respiratory failure caused by cystic fibrosis. Organ selection is based on size. Although some patients develop bronchial hyperreactivity. a PAC (Pulmonary artery catheter) is used only for patients with significant cardiac disease. However. as the wait list of patients for the organs are long. Warm normal saline is infused into the lung to be treated and is drained by gravity. Anesthetic considerations in patients with esophageal disease include the risk of pulmonary aspiration. and cytomegalovirus serology matching. or abnormal sphincter function. use of a DLT. However. Hypoxic pulmonary vasoconstriction. Fluid restriction is fa irly common after lung transplantation to prevent this from happening. but the ventilation-perfusion mismatch caused by ventilating a nondependent lung which is not perfused is severe and makes this clinically impossible. Right-ventricular failure caused by increase in right-sided afterload (increased pulmonary artery resistance) may recover after isolated lung transplantation. Central respiratory pattern generated by centers in the brain stem is unaffected. These patients usually get postoperative bronchoscopy to assess bronchial suture line. normal left-ventricular function and absence of significant coronary artery disease or other serious health problems is ensured before lung transplantation. treatment continues until the fluid returning is clear (about 10-20 L). lavaging a dependent lung in a lateral position helps to minimize soiling of the nondependent lung. The procedure is normally done in the supine position. The risk of aspiration continues into the postoperative period. B. 37. Single-lung transplantation is being increasingly performed for patients with chronic obstructive pulmonary disease. However. A. It can be done using cardiopulmonary bypass or sequentially using one-lung ventilation depending on the pulmonary artery pressures and the ventricular function. bullous emphysema. mediated locally is also unaffected. under general anesthesia. altered motility. A newly transplanted lung lacks the neural innervation. or vascular diseases are usually bilateral and necessitate a double-lung transplant. as they are prone for ischemic breakdown in the absence of bronchial circulation. Invasive monitoring with arterial line and central venous pressure monitoring help guide hemodynamic management. 38. and they do not require combined heart-lung transplantation. it is not always required. loss of lymphatic drainage increases extravascular lung water and predisposes the transplanted lung to pulmonary edema. cough reflex is abolished below the carina. intravenous access sufficient for rapid fluid resuscitation. Surgeons hand can interfere with cardiac fillin g while bluntly dissecting . Patient can be extubated after carefully suctioning out both the lungs or the double-lumen tube is replaced by a single-lumen tube at the end of the procedure. A water-tight seal with the cuffs is also essential prior to the lavage. The esophageal disease process predisposes them to aspiration due to obstruction. which were present in the explanted lung. Such is not the case in patients with Eisenmenger syndrome who require combined heart-lung transplantation. lymphatic drainage. invasive monitoring. C. maintaining normothermia. 36. Substernal and diaphragmatic retractors used during the transhiatal approach to esophagectomy can interfere with cardiac function. Proper positioning of the tube by bronchoscopy is essential prior to the lavage to prevent contamination of the opposite lung.

39. Such patients usually adapt by pursed-lip breathing and terminating the expiration early before functional residual capacity falls below closing capacity (auto PEEP). It is facilitated by the large pressure drop across the airways causing a higher gradient between extra and intraluminal pressures. Elastase deficiency in emphysema causes decreased elastic support in smaller airways. This is usually produced by a mediastinal tumor causing compression of the mediastinal structures including the SVC. lim iting the degree of positive-pressure ventilation (<30 cm H2O peak inspiratory pressure). the increase in lung volume and slowing of expiration caused by such a maneuver helps to stent the airway open. This is normally beyond the 11th to 13th generation of bronchioles where cartilaginous support is absent. Equal pressure point refers to the point in the airway where intraluminal pressure and extraluminal pressure (pleural) are the same. Among the mediastinal neoplasms. Any lesion causing a compression of the superior vena cava (SVC) and impedes blood return from head and neck can cause venous engorgement and edema of the head. and early extubation. use of double-lumen tubes to allow selective ventilation and to facilitate surgery. and arms. This shifts the equal pressure point to the noncollapsible larger airways or to the mouth. prolonging the expiratory time. This is the point where dynamic airway compression can occur— this refers to the phenomenon in which collapsible membranous portion of the airway gets compressed by the extraluminal pressure generated by a forced expiration. using a lower Fio 2 to a goal Spo2 of 90%. Since the vagus runs very close to the esophagus. The airway obstruction is due to direct mechanical compression as . B. 40. suggested lack of efficacy of LVRS. The bronchoconstriction and inflammation of asthma predisposes to reversal of transmural gradients. marked vagal stimulation can result in profound bradycardia or even cardiac arrest — transcutaneous pads helps in these situations. However. a trial of usual medical therapy versus usual medical therapy plus LVRS. B. the esophagus from the posterior mediastinum. neck. 41. lymphomas are the most common causes for SVC syndrome. There has been a recent resurgence in LVRS. It can also be caused by an occlusive thrombus in the SVC. The potential for rapid massive blood loss is significant as the surgery is near the major blood vessels. But other mediastinal tumors like germ-cell tumors or pulmonary lesions with secondary lymphadenopathy may also be responsible. Obstructive airway diseases predispose the patients to dynamic airway compression. Total IV anesthesia techniques using propofol and remifentanil or inhalational agents like desflurane with short-acting neuromuscular blocking agents help facilitate early extubation. These cases are very difficult as induction of anesthesia in a supine position causes severe airway obstruction and cardiovascular collapse. Hypothermia increases coagulopathy and increases cardiac arrhythmias and should be avoided. If the patient cannot be extubated at the conclusion of the procedure. The increase in lung volume increases the intraluminal pressure and dilates the airways. the double-lumen tube is exchanged for a single-lumen tube to decrease airway resistance. Anesthetic considerations for LVRS include watching out for pneumothorax caused by a ruptured bleb. C. and the slow expiration reduces the decrease in pressure from the alveoli to the mouth because lower driving pressures are sufficient for lesser flows. even though NETT.

A CT scan/MRI w ill help diagnose the presence of tracheomalacia/erosion and the level of the lesion. If induction of general anesthesia is required in the presence of SVC syndrome. This includes radiation therapy. or dynamic inflo w obstruction in the presence of pericardial fluid. A preoperative echocardiogram can quantify the degree of compromise in cardiac function. and steroids. awake fiberoptic intubation is the preferred method and inhalational anesthetics can be used to attain a deep plane of anesthesia in a spontaneously breathing patient after intubation. chemotherapy. presence of a thrombus. A rig id bronchoscope and ability to go on cardiopulmonary bypass are other precautionary measures that can be taken. Attempts should be made to decrease the size of the mass and the degree of mediastinal compression should be made prior to elective surgery. An empiric treatment with steroids may be attempted prior to a tissue diagnosis in this 12-year old.well as mucosal edema. <CT> .

.

Mannitol B. Hyperventilation . Hypokalemia 5. Increased central venous pressure to 14 mm Hg B. central venous pressure (CVP) of 15 mm Hg.N euroanesthesia Dipty Mangla and Ashish Sinha 1. 55 C. 150 mL/100 g/min 2. 48 4. and mean arterial pressure (MAP) of 70 mm Hg w ill be A. During the procedure. Cerebral perfusion pressure (CPP) (mm Hg) in a patient with intracranial pressure (ICP) of 12 mm Hg. Bucking and coughing on endotracheal tube 3. A patient is undergoing craniotomy for subdural hematoma. 50 mL/100 g/min C. 58 B. 100 mL/100 g/min D. Total normal cerebral blood flo w (CBF) is A. except A. The factor associated with maximum increase in intracranial pressure (ICP) is A. Hypervolemia D. Ventilation with positive end-expiratory pressure (PEEP) of 5 cm H2O D. the surgeon requests lowering the intracranial pressure. Hyper car bia with Paco2 of 50 mm Hg C. Oliguria B. except A. 52 D. Treatment of a patient with mannitol can lead to all the follow ing. Hypotension C. A ll the follow ing can be used. 25 mL/100 g/min B.

The next step w ill be A. Give P-blockers C. 15 to 25 mm Hg 7. Hetastarch . Signs of air embolism in a patient include all. Administer lidocaine D. An absolute contraindication for electroconvulsive therapy (ECT) is A. Normal saline C. Pneumocephalus 11. Nitrous oxide should be avoided in patients with A. Give 100% oxygen 10. Hypertension B. except A. Dextrose 5%— normal saline D. Steroids D. Closed head injury D. A 65-year-old male is undergoing surgery for medulloblastoma in the posterior fossa of brain. 20 to 25 mm Hg D. Decreased EtCO2 9. Approximately 1 hour into surgery you notice arrhythmias on the monitors. Heart murmur C. 30 to 35 mm Hg B. Subdural hematoma B. Inform the surgeon B. Stroke 8. The desired level of Paco2 in a neurosurgical patient is A. The follow ing fluid should be avoided in a patient undergoing craniotomy A. Lactated Ringerés B. Aortic aneurysm D. Hypertension B. Pheochromocytoma C. Arrhythmia D. 25 to 30 mm Hg C. Brain tumor C. C. Furosemide 6.

A patient with spinal injury. Involves placement of catheter through inferior vena cava D. decreased amplitude 18. Level of hypothalamus B. Is unaffected by systemic hypoxia C. The effect of ischemia on somatosensory-evoked potentials (SSEPs) is A. Estimates oxygen extraction B. Increased end-tidal nitrogen D. sustained 3 hours ago. increased amplitude D. Decreased end-tidal carbon dioxide C. comes to the OR for exploratory laparotomy. Level of external auditory meatus D. M ill wheel murmur 13. Etomidate B. Administration of barbiturates B. Hypothermia for better neurologic outcome . Transesophageal echocardiogram (TEE) B. except A. decreased amplitude B. Increased latency. Monitors global oxygenation of both cerebral hemispheres 17. the transducer of arterial line should be zeroed at the A. Hyperventilation C. Level of atmosphere 16. Decreased latency. Best measure to reduce cerebral oxygen consumption includes A. Administration of opioids D.12. Level of heart C. Most sensitive method to detect air embolism is A. Rapid-sequence induction with succinylcholine B. increased amplitude C. Decreased latency. Institution of hypothermia 14. Propofol C. In a patient undergoing craniotomy. Ketamine 15. Anesthetic management of the patient includes which of the following? A. A ll of the follow ing decrease cerebral blood flo w (CBF). Thiopental D. Jugular venous oxygen saturation A. Increased latency.

Ketamine D. Phenylephrine . Stump pressure 21. A ll the follow ing can be used in anesthetic management. Succinylcholine C. It can be provoked by thermal stimulation 24. Motor-evoked potentials C. Avoiding hypothermia B. Respiratory paralysis is frequent complication B. Presence of labile autonomic nervous system C. Spinal anesthesia is safe D. Lesions below T10 is responsible for the reflex B. Exaggerated reflexes 23. It can be treated with deep general anesthetic C. The most reliable monitor for neurologic monitoring in a patient undergoing carotid endarterectomy is A. The electrophysiological monitor most resistant to anesthetic agents is A. Brain-stem auditory-evoked potentials D. Electroencephalogram B. Avoiding hyperthermia C. Propofol B. Avoiding corticosteroids 19. It is associated with vasoconstriction above the site of injury D. Jugular venous oxygen saturation C. except A. Ascending motor paralysis D. except A. C. Use of succinylcholine can result in hypokalemia 22. True statement about autonomic hyperreflexia is A. Electroencephalography 20. Awake neurologic exam D. A 16-year-old patient with acute lysergic acid diethylamide (LSD) intoxication and head injury comes to emergency room. Managing autonomic hyperreflexia D. A ll the follow ing are true for Guillain-Barre syndrome (GBS). Anesthetic management of a patient with multiple sclerosis (MS) includes A. Somatosensory-evoked potentials B.

25. A 25-year-old patient with severe depression is undergoing an electroconvulsive therapy
(ECT). The duration of seizure can be increased by
A. Hypoventilating the patient
B. Hyperventilating the patient
C. Administering succinylcholine
D. Administering rocuronium

26. A ll of the follow ing are contraindications of electroconvulsive therapy (ECT), except
A. Pacemaker
B. Recent stroke
C. Raised intracranial pressure
D. Severe osteoporosis

27. True statement regarding cerebral physiology is
A. Normal cerebral metabolic oxygen consumption is 5 mL/100g/min
B. Normal Intracranial pressure (ICP) is approximately 15 mm Hg
C. Normal cerebral blood flo w (CBF) is 50 mL/100g/min
D. Cerebral autoregulation is strictly maintained at blood pressures between 60 and 150 mm
Hg in all patients

28. True statement about cerebrospinal fluid (CSF) is
A. It is formed in the third ventricle
B. It is absorbed in arachnoid granulations present in fourth ventricle
C. Total volume of CSF is about 150 mL
D. Major mechanism of formation is by passive diffusion of ions

29. A precordial Doppler can detect a minimal o f ___mL of intracardiac air:
A. 0.1
B. 0.25
C. 0.5
D. 1

30. The only inhalational anesthetic that can cause an isoelectric EEG among the follow ing is
A. Isoflurane
B. Halothane
C. Enflurane
D. Nitrous oxide

31. Intraoperative anesthetic management of a patient undergoing cerebral aneurysm repair
includes all, except

A. Maintenance of hypotension
B. Mannitol for facilitating surgical exposure
C. Maintaining m ild hypothermia
D. Patient remaining intubated for 24 hours postoperatively

32. Which of the follow ing types of neuromonitoring can be done in a patient undergoing
transsphenoidal resection of a pituitary tumor?
A. EEG
B. Motor-evoked potentials
C. Visual-evoked potentials
D. Auditory-evoked potentials

33. The drug of choice for treating nausea and vomiting in a patient with parkinsonism would be
A. Ondansetron
B. Promethazine
C. Droperidol
D. Metoclopramide

34. A ll the follow ing anesthetic agents can cause seizurelike activity on the electroencephalogram
(EEG), except
A. Ketamine
B. Etomidate
C. Enflurane
D. Thiopental

35. The neuromuscular blocking agent relatively contraindicated in a patient with raised
intracranial pressure (ICP) is
A. Rocuronium
B. Vecuronium
C. Atracurium
D. Cisatracurium

36. The afferent input for somatosensory-evoked potentials is carried by which spinal cord tract
A. Corticospinal
B. Dorsal columns
C. Spinothalamic
D. Spinocerebellar

37. You are called to evaluate a 50-year-old patient for brain death. A ll the follow ing are criteria
for brain death, except
A. Apnea for 10 minutes

B. Absence of corneal reflex
C. Presence of spinal reflexes
D. Decerebrate posturing

38. A 30-year-old male is found unresponsive outside a supermarket. The emergency response
team finds him in ventricular fibrillation. After 10 minutes of CPR, the emergency response
team is successful in reviving the patient. In the emergency room, it is decided to cool the
patient to 34°C from 37°C. By this measure, the cerebral metabolic demand w ill decrease by
A. 12%
B. 18%
C. 24%
D. 30%

39. A ll the follow ing are relative contraindications to a sitting craniotomy, except
A. Right-to-left cardiac shunt
B. Patent foramen ovale
C. Ventriculoatrial shunt
D. Ventriculoperitoneal shunt

40. An 80-year-old female comes to the ER with closed distal radial fracture. On further
questioning, she gives a history of stroke about 2 weeks ago. How long should one wait before
it can be assumed that her risk of perioperative stroke is same as a healthy 80-year-old?
A. 6 days
B. 6 weeks
C. 6 months
D. 6 years

41. A 28-year-old male is being treated in the ICU for raised intracranial pressure (ICP). A ll the
follow ing measures can aid in decreasing ICP quickly , except
A. Corticosteroids
B. Hyperventilation to Paco2 of 30 mm Hg
C. Mannitol
D. Head elevation to 30 degrees

42. Which of the follow ing agents w ill have the least effect on somatosensory-evoked potentials
(SSEPs)?
A. Vecuronium
B. Propofol
C. Fentanyl
D. Nitrous oxide

43. Signs and symptoms of raised intracranial hypertension include all the following, except
A. Hypertension
B. Tachycardia
C. Bradycardia
D. Irregular respiration

44. Etomidate in a dose of 0.2 mg/kg can lead to all the following, except
A. Abolish ventilatory response to carbon dioxide
B. Increase amplitude and latency of somatosensory-evoked potentials (SSEPs)
C. Decrease cerebral metabolic oxygen demand
D. Decrease cerebral blood flo w (CBF)

45. The most important factor governing cerebral blood flo w (CBF) is
A. Cerebral metabolic oxygen demand
B. Paco2
C. pH
D. Cerebral perfusion pressure

46. The follow ing graph depicts the relationship between cerebral perfusion and

A. Paco2
B. Pao2
C. Mean arterial pressure
D. Cerebrospinal fluid pH

47. The follow ing graph depicts the relationship between cerebral perfusion and

A. Paco2
B. Pao2
C. Mean arterial pressure
D. Cerebrospinal fluid pH

48. A 45-year-old male is seen in the preadmission testing for pituitary adenoma resection surgery.
A ll the follow ing would be expected if this adenoma was causing acromegaly, except
A. Hypotension
B. Obstructive sleep apnea
C. D ifficult airway
D. Hyperglycemia

49. The fastest measure to decrease intracranial pressure (ICP) in a patient is
A. Mannitol
B. Dexamethasone
C. Furosemide
D. Hyperventilation

50. Therapy for cerebral vasospasm includes
A. Hypertension, hypervolemia, hemodilution
B. Normotension, euvolemia, hypocarbia
C. Hypotension, hypovolemia, hypocarbia
D. Hypertension, hypervolemia, hypocarbia

CHAPTER 13 ANSWERS

1. B. Normal total CBF is about 50 mL/100 g/min. CBF below 20 mL/100 g/min is associated
with cerebral ischemia. CBF is modulated by various factors, which include Paco2, Pao2, blood
pressure, intracranial pressure, etc.

2. D. Intracranial pressure is supratentorial CSF pressure measured in the lateral ventricles or
cerebral cortex. Normal ICP is 10 mm Hg or less. Between Paco2 values of 20 and 80 mm Hg,
CBF increases by 1 mL/100 g/min and cerebral blood volume increases by 0.05 mL/110g/min
per mm Hg increase in Paco2. Increase in CVP and adding PEEP w ill m inim ally increase ICP by
affecting venous return. Coughing and bucking can cause a much higher increase in ICP (acute
increase) than any of the above factors.

3. B. CPP = MAP - ICP or CVP, whichever is higher.
Thus, CPP = 70 - 15 = 55 mm Hg.

4. A. Mannitol, a six-carbon sugar, is the most commonly used diuretic in neuroanesthesia
practice. It is an osmotic diuretic and undergoes little or no reabsorption. It also improves renal
blood flow. Side effects include an initial increase in circulatory volume, which can cause
pulmonary edema. Diuresis attributed to mannitol can lead to hypovolemia and hypokalemia.

5. C. Treatment of intracranial hypertension includes hyperventilation to PaCO2 of 25 to 30 mm
Hg, improving CSF drainage by elevating the head by 30 degrees or surgical placement of CSF
drain, using an osmotic diuretic (mannitol), hypertonic saline, decompression craniectomy,
barbiturates, and corticosteroids. The latter have been used to decrease cerebral edema, and take
a few hours to have effect, but routine use of corticosteroids in managing intracranial
hypertension is not recommended.

6. B. PaCO2 is the most potent physiologic determinant of cerebral blood flow. Maximal
reductions in ICP can be achieved by decreasing PaCO2 to 25 to 28 mm Hg, and the reduction in
ICP lasts up to 24 to 36 hours.

7. B. ECT is commonly used for treatment of refractory major depression. It involves using
electricity to shock one or both cerebral hemispheres to induce a seizure lasting 30 to 60
seconds. Contraindications to ECT include pheochromocytoma, recent myocardial infarction
(<3 months), recent stroke (<1 month), intracranial mass or increased ICP, angina, poorly
controlled heart failure, significant pulmonary disease, bone fractures, severe osteoporosis,
pregnancy, glaucoma, and retinal detachment.

8. A. Clinical signs of venous air embolism include a decrease in end-tidal CO2, a decrease in
arterial oxygen saturation, sudden hypotension, m ill wheel murmur, and even sudden

circulatory arrest. Presence of a patent foramen ovale, which has an incidence of 20% in adults,
can lead to paradoxical air embolism, with the potential of causing coronary ischemia or a
stroke.

9. A. For posterior fossa tumor resection, the patient is frequently placed in the sitting or prone
position. Monitoring of the patient includes arterial blood pressure line, a central venous
catheter (for access, pressure monitoring, aspiration of any air— if required), and a precordial
Doppler to detect intracardiac air (venous air embolism). Operations on posterior fossa tumors
can injure vital brain-stem respiratory and circulatory nuclei, resulting in hemodynamic
fluctuations or depression of ventilation. The surgeon should be informed at the first sign of
cardiac arrhythmias.

10. D. Nitrous oxide can diffuse into closed air spaces, which may be of significant clinical
consequences. The blood/gas coefficient of nitrous oxide is 0.47, whereas that of nitrogen is
0.015. This means that nitrous oxide is about 33 times more diffusible than nitrogen. As a result,
at any given partial pressure, far more nitrous oxide can be carried into a closed gas space than
nitrogen removed. Thus, nitrous oxide can quickly expand closed gas spaces, such as middle
ear or a pneumothorax.

11. C. In a patient undergoing craniotomy, intravenous fluid replacement should be performed by
using glucose-free isotonic crystalloid or colloid solutions. Hyperglycemia is known to worsen
ischemic brain injury.

12. A. The most sensitive intraoperative monitor for detecting venous air embolism is TEE. The
second best monitor is precordial Doppler sonography, which can detect as little as 0.25 mL of
air. Changes in end-tidal respiratory gas concentrations, such as nitrogen and carbon dioxide,
and changes in pulmonary artery pressures are less sensitive. Hypotension and m ill wheel
murmur are late manifestations of venous air embolism.

13. D. Hypothermia is one of the most effective methods for protecting the brain against ischemia.
Hypothermia decreases both basal and electrical metabolic requirements throughout the brain,
unlike intravenous anesthetic agents or hyperventilation.

14. D. Propofol, barbiturates, and etomidate produce dose-dependent decreases in cerebral
metabolic rate and CBF. Ketamine is the only induction agent that dilates the cerebral
vasculature and thus increases CBF (50% to 60%).

15. C. In a seated patient, the arterial pressure in the brain differs significantly from left
ventricular pressure. Cerebral perfusion pressure is determined by setting the transducer to zero
at the level of the ear, which approximates the circle of W illis.

16. D. Jugular venous bulb oximetry involves placing a sampling catheter in the internal jugular
vein (IJV). The normal range for mixed venous oxygen saturation at IJV is 50% to 75%. It gives

an estimate of balance between oxygen supply and demand of the brain, and measures global
cerebral oxygenation (not focal).

17. D. SSEPs reflect the integrity of neuronal pathway from the peripheral nerves through the
spinal cord (dorsal columns) to the brain. SSEPs are electrical manifestations of the central
nervous system response to external stimulation. Intraoperative changes in amplitude or latency
or complete loss of waveforms are indicators of compromised sensory pathway integrity. SSEP
amplitude loss greater than 50% or a latency increase greater than 10% is considered
significant.

18. A. In the early management of acute spinal injury patients, particular emphasis should be
placed on preventing further spinal damage, which may occur during patient movement, airway
manipulation, and positioning. High-dose corticosteroids are often administered to help
improve neurological outcome. The head and neck should be stabilized using manual inline
stabilization, and awake fiberoptic intubation should be considered in high cervical injuries.
Patients with high cord transections may have impaired airway reflexes, hypotension, and
bradycardia and may be prone to hypothermia in view of generalized vasodilation.
Succinylcholine can be used safely in first 24 hours follow ing spinal injury.

19. C. Somatosensory- and motor-evoked potential monitoring is commonly used to detect
ischemia of spinal cord in spine surgeries. Brain-stem auditory-evoked responses monitor
ischemia during posterior fossa surgeries. Inhalational agents in general increase the latency
and decrease the amplitude of evoked potentials (if used at more than 0.5-0.75 MAC). The effect
of inhalational anesthetics on evoked potentials in decreasing order is visual > motor >
somatosensory > brain-stem auditory.

20. C. Awake neurological status is the most reliable method to detect cerebral ischemia. In
patients undergoing carotid endarterectomy under local anesthesia and m ild sedation, global
and focal neurological status can be continuously assessed. In patients undergoing carotid
endarterectomy under general anesthetic indirect methods to detect cerebral ischemia can be
used. These include EEG monitoring, transcranial Doppler, arteriography, and measurement of
blood flo w using xenon.

21. B. MS is characterized by progressive demyelination in the brain and spinal cord. Stress,
anesthesia, and surgery can have detrimental effects on the course of the disease. Elective
surgery should be avoided in acute relapse of MS. Regarding the effect of anesthetic technique
on MS, spinal anesthesia can exacerbate MS symptoms, epidural anesthesia usually does not
affect MS, succinylcholine should be avoided to prevent hyperkalemia, and hyperthermia
should be avoided as an increase in temperature may block nerve conduction. Advanced MS
may be associated with autonomic dysfunction.

22. D. GBS affects about 2/100,000 people. It is characterized by a sudden onset ascending motor
paralysis, areflexia, and paresthesias. Bulbar involvement with respiratory failure is a frequent

a recent stroke (<1 month). B. Succinylcholine should be avoided in these patients. In adults. It is characterized by acute generalized sympathetic hyperactivity in response to a triggering stimulus. bradycardia. In view of hypertension and tachycardia that can be caused by LSD. C. and pallor and vasoconstriction below the level of lesion. A precordial Doppler can detect as little as 0. lacrimation. The CSF is absorbed in arachnoid granulations over cerebral hemispheres. and vomiting. angina. and not passive diffusion. The triggering stimulus can be any stimulus occurring below the level of the lesion. hypertension. Propofol when used for induction in patients undergoing ECT can increase the seizure threshold and decrease the duration of the seizure. Total CBF averages 50 mL/100 g/min. bone fractures. C. B. normal CSF production is about 20 mL/hour with a total volume of 150 mL. poorly controlled congestive heart failure. CSF is formed by the choroid plexuses of cerebral lateral ventricles. Antihypertensives may have to be utilized to treat the hypertension. Contraindications to ECT include recent myocardial infarction (<3 months). Autonomic hyperreflexia is seen in patients with spinal cord injury at or above T6. 27. 24. and retinal detachment. complication. piloerection. ketamine should be avoided. mediated via the hypothalamus. 28. A precordial Doppler is the next best sensitive indicator to detect intracardiac air after a transesophageal . arrhythmias. vasodilation above the level of lesion. 25. CBF remains nearly constant between mean arterial pressures of about 60 and 160 mm Hg. severe osteoporosis. In normal individuals. include tachycardia. mydriasis. A. Spinal anesthesia (not preferred because of technical difficulty and unpredictable level) or deep general anesthesia has been used in preventing autonomic hyperreflexia. B. C. CSF formation involves active secretion of sodium in the choroid plexuses. glaucoma. Muscle relaxants do not affect the threshold or duration of the seizure. Hyperventilation and administration of caffeine or etomidate can increase seizure duration. The cerebral metabolic rate is reflected by oxygen consumption. profuse sweating. Clinical signs include severe hypertension.8 mL/100 g/min. sensory distortion. as it can cause hyperkalemia. pregnancy.25 mL of intracardiac air. which is about 3 to 3. and euphoria. significant pulmonary disease. 29. ICP by convention means supratentorial CSF pressure measured in the lateral ventricles or over the cerebral cortex. and is most commonly a distension of hollow viscera (bowel or bladder). Regional anesthesia may make GBS worse. 26. salivation. LSD is a hallucinogen and causes CNS excitation. delusions. and the normal CSF pressure is 10 mm Hg or less. 23. The cerebral autoregulation curve is shifted to right in patients with chronic arterial hypertension. Anesthetic management may be complicated by liab ility of the autonomic nervous system (hypotension or hypertension). Autonomic effects. hallucinations. an intracranial mass and raised intracranial pressure.

and oropharyngeal packing is done to prevent bleeding into the esophagus. and metoclopramide can worsen symptoms and thus these should be avoided. etomidate. Patients are intubated endotracheally (oral). Intraoperative management of cerebral aneurysms should include availability of blood. IV. 34. A. The cavernous sinus forms the lateral border of the sella turcica and includes the internal carotid artery. and a resting p ill-ro llin g tremor. Thiopental increases the threshold and decreases the duration of seizure activity. Isoflurane can produce an isoelectric EEG at 2 to 2. echocardiogram. V. Patients have bradykinesia. Additionally. Increasing sevoflurane concentration from 2 to 5 MAC changes the cortical EEG pattern from a high-amplitude slow wave to burst suppression to an isoelectric EEG interspersed with spikes. phenothiazines. D.5 MAC. The former (transsphenoidal approach) has several advantages including elimination of frontal lobe retraction. and enflurane can cause seizurelike activity on the EEG. and cranial nerves III. In a patient with increased intracranial pressure. epinephrine or cocaine may be injected submucosally to reduce bleeding. central venous pressure and arterial blood pressure monitoring. Halothane causes slowing of EEG activity with increasing concentration until 4 MAC. visual-evoked potentials may be monitored in the OR for early detection of visual pathway damage. postural instability. C. The transsphenoidal or bifrontal craniotomy approach may be used to gain access to pituitary gland. and shorter hospital stay. administration of thiopental and m ild hypothermia for cerebral protection. rigidity. Hyperventilation prior to intubation is utilized to decrease the ICP. facial masking. Somatosensory-evoked potentials are transmitted through the follow ing pathway: . Parkinson disease is a movement disorder that affects individuals 50 to 70 years of age. 30. Antidopaminergic activity associated with butyrophenones. 33. C. after which it produces uniform activity. and VI. 32. 36. Therefore. Ketamine. It is caused by progressive loss of dopamine in the nigrostriatum. Rocuronium and vecuronium are commonly used as they provide the greatest hemodynamic stability. reduced blood loss. avoidance of hypertension during induction. a nondepolarizing muscle relaxant is commonly used to facilitate controlled ventilation and tracheal intubation. mannitol after the dura is opened to help surgical exposure. elective hypotension as it decreases transmural pressure across the aneurysm (avoiding rupture). B. Seizure activity may be seen on EEG with 3% enflurane in a hypocapnic patient. microsurgical removal of small adenomas. A. venous structures. Succinylcholine and atracurium (due to associated histamine release) may increase ICP. 35. and awake extubation depending on neurological status. particularly if intubation is attempted before deep general anesthesia. while enflurane typically produces a spike and wave pattern at 2 to 3 MAC. D. 31.

sitting position should be avoided in patients with a right-to-left shunt. and pupillary changes (papilledema may be seen on fundoscopy). Regional blood flo w and metabolic rate are normal after 2 weeks follow ing a stroke. 39. or ventriculoatrial shunt. Inhalational volatile anesthetics produce an increase in latency and decrease in amplitude of evoked potentials. Propofol decreases amplitude and an increase in latency of SSEPs. Cerebral metabolic rate decreases by 6% per degree Celsius decrease in body temperature below 37°C. moderate hyperventilation (up to 24-36 hours). isoelectric EEG. most clinicians postpone elective surgery for at least 6 weeks follow ing stroke. Generally accepted clinical criteria for brain death include presence of coma. 37. Cushing triad consists of raised ICP. D. 42. vestibule-ocular. 40. Definitive treatment of intracranial hypertension is ideally directed at the underlying cause. corneal. absence of brain­ stem reflexes (papillary. absence of ventilatory effort (Paco2 >60 mm Hg). The incidence of venous air embolism in sitting craniotomies is about 20% to 40%. and take a few hours to take effect. patent foramen ovale. Thus. A. B. intractable vomiting. and bradycardia. osmotic agents and loop diuretics. Alterations in CO2 responsiveness and blood-brain barrier abnormalities require more than 4 weeks to be corrected. hypertension. Clinical signs include hypertension. 38. 44. A. and corticosteroids. Narcotics cause dose-dependent decrease in amplitude and increase in latency. B. 43. absence of motor activity. and absence of cerebral perfusion by angiography. The latter is used to decrease cerebral edema in patients with known intracranial tumors. exclusion of hypothermia or effect of sedatives. Muscle relaxants have no effect on SSEPs. hypoxia and hypercarbia. Increased intracranial pressure (ICP) can lead to altered mental status. The presence of right-to-left shunt can cause paradoxical air embolism. Etomidate decreases cerebral metabolic rate. CBF. leading to a decrease in intracranial pressure. Thus. bradycardia. Treatment modalities include fluid restriction. avoidance of hypotension. It enhances SSEP. 41. A ir embolism can have catastrophic consequences. A. Brain death is irreversible cessation of all brain activity.peripheral stimulus peripheral nerve dorsal root ganglia first-order fibers in the ipsilateral posterior column to dorsal column nuclei second-order fibers crossing to the opposite side medial lemniscus to the thalamus third-order fibers continuing to the frontoparietal sensory-motor cortex. and focal or global neurological deficits. Hence. Nitrous oxide produces a decrease in amplitude with no change in latency. a 3°C drop in temperature w ill decrease the cerebral metabolic rate by 18%. It is a sedative hypnotic but lacks analgesic properties. D. and gag/cough). irregular respiration. Ventilation is . B. such as coronary ischemia and stroke. head elevation.

Marked changes in Pao2 affect cerebral blood flo w (CBF). hypertension. motor activity of a lim b is associated with a rapid increase in regional blood flo w of the corresponding motor cortex. CO2 gas tension has the greatest influence on cerebral blood flo w (CBF). A. skeletal muscle weakness. Therapies for cerebral vasospasm include “ triple-H therapy” (hypertension/hypervolemia/hemodilution). Increased metabolic activity leads to an increase in CBF. and intra-arterial nicardipine and other vasodilators. 46. balloon angioplasty. A. However. D. On the other hand. These changes may also lead to obstructive sleep apnea. Patients also are prone to hyperglycemia. and glottic and subglottic narrowing. enlargement of tongue and epiglottis. 49. 48. For example. Vasospasm usually develops 3 to 14 days postsubarachnoid hemorrhage results in narrowing of cerebral blood vessels and decreased blood flo w distally. Induction doses usually do not result in apnea. increased ventilation-perfusion mismatch. soft. The quickest way to reduce ICP in a patient is hyperventilation. B. 50. affected to a lesser extent with etomidate when compared to barbiturates or benzodiazepines. and osteoporosis. 45. Between a Paco2 of 20 and 80 mm Hg. hyperventilation is only used as a temporizing measure only in periods of acute raised ICP. hypoxemia (Pao2<50 mm Hg) greatly increases CBF. overgrowth of mandible with increased distance from lips to vocal cords. A. The degree of vasospasm depends on the degree of initial subarachnoid hemorrhage. Hyperoxia is associated with only minimal decreases in CBF. increased lung volumes. Regional CBF parallels metabolic activity and can vary from 10 to 300 mL/100 g/min. Cerebral vasospasm occurs in about one-third of patients surviving the initial aneurysmal rupture. osteoarthritis. peripheral neuropathy. This may lead to an ischemic deficit and cerebral infarction. congestive heart failure.<CT> . CBF changes approximately 1 to 2 mL/100 g/min per mm Hg in Paco2. Reduced PaCO2 (hypocarbia) causes cerebral vasoconstriction leading to a reduction in cerebral blood flo w and cerebral blood volume. and carries a high degree of m orbidity and mortality. if left untreated. 47. A. often to a PaCO2 of 25 mm Hg. The acromegalic patient suffers from general overgrowth of skeletal. Patients may also have a difficult airway because of overgrowth of soft tissues of upper airway. although minimally. This results in coarse facial features and enlarged hands and feet. and connective tissues.

.

Each of the follow ing would be expected in an otherwise-healthy 125-kg (BM I 40 kg/m2) man undergoing open cholecystectomy. Which of the follow ing has a dual effect of increasing gastric pH. Providing warm and humidified inspired gases B. A m orbidly obese 60-year-old man with a 65-pack year history of tobacco smoking is awake after an uncomplicated general anesthetic with sevoflurane for routine endoscopy and . Use of warm irrigating fluids 2. Metoclopramide 4. Increased metabolism of volatile anesthetics D. Prochlorperazine B. Ranitidine C. Ondansetron D. Diffuse wheezing D. Hypoxemia C. A 38-year-old woman with a history of diverticulosis is scheduled for an exploratory laparotomy for lysis of adhesions. Which of the follow ing is the best way of maintaining core body temperature during the initial hour of general endotracheal anesthetic? A. Decreased metabolism of atracurium 3. and decreasing the gastric volume to minimize risks associated with aspiration? A. Hypercarbia B. Liver. Administration of warm intravenous fluids D. Increasing ambient temperature C. This finding is indicative of microatelectasis on the second postoperative day after major abdominal surgery: A. and Renal Diseases Thoha Pham 1. Tactile fremitus 5. except A. Decreased functional residual capacity B.Gastrointestinal. Increased intra-abdominal pressure and risk of reflux C.

During intubation of the trachea.30.= 18 C. The most likely finding would be A. while breathing 6 L/min of oxygen via nasal cannula. Pao2 = 80. Administer corticosteroids D. A 65-year-old patient is noted to have excessive bleeding during a colectomy with an activated clotting time (ACT) of 200 seconds. Dilutional coagulopathy .= 15 8. HCO3 . Paco2 = 45. Reintubation of the trachea C. colonoscopy screening. When she arrives preoperatively for her surgery. HCO3 . a 45-year-old man vomits a large quantity of undigested food particles. During rapid-sequence induction of anesthesia for emergent laparotomy to explore multiple stab wounds. The most unlikely reason for this oozing is A.35. Administer antibiotics 7. His rest of the vital signs are stable.= 28 D. As the fifth unit of pRBCs begins infusing. During laparotomy. Intravenous administration of doxapram D. HCO3 . Continuous positive-airway pressure 6. The most effective management at this point is A. Ventilate with positive end-expiratory pressure of 15 cm H2O C. Dilutional thrombocytopenia D. his pulse oximetry drops to 88%. Hemolytic transfusion reaction B. food particles are noted near the cords. Leukoagglutinin reaction C.40. pH = 7. Dilutional thrombocytopenia 9. patient has sudden onset of tachycardia and hypotension. Undiagnosed factor V II deficiency B. Preoperative ingestion of aspirin and ibuprofen D.45. pH = 7. Paco2 = 32. Paco2 = 30. Pao2 = 85. After instituting ventilation with 100% oxygen. Within a few minutes. a patient has required infusion of 4 L of lactated Ringer’s and 4 U of packed red blood cells (pRBCs). After 45 minutes in the recovery room (PACU). Pao2 = 85.= 24 B. The most likely cause of unexplained oozing is A. Foley bag reveals dark urine. H C o3 .000 U subcutaneously C. Pao2 = 60. A 71-year-old female develops a severe case of diarrhea with multiple loose bowel movements since awakening this morning. the most appropriate next step in this patient’s management is A. Coughing with deep breathing B. Place patient in Trendelenburg position B. pH = 7. Prior administration of heparin 5. Paco2 = 50. an arterial blood gas (ABG) is obtained. and the lungs are clear to auscultation. pH = 7.

The specific electrolyte abnormality that should be evaluated considering his TPN requirement is A. the patient fails to regain consciousness. Intraoperative effect that should be expected and monitored for is A. Azotemia B. unresponsive to conservative measures. Hyperkalemia C.Questions 10 to 12 A 26-year-old male patient with a history of severe ulcerative colitis. At the conclusion of the surgery. Dilutional anemia B. However. Potassium B. ^-Blockers should be administered only in conjunction with adequate a-blockade C. Nasal congestion is a sign of inadequate a-adrenergic block . Glucose (hypoglycemia. except A. Hyperglycemia C. Each of the follow ing statements about the preoperative management of an adrenal pheochromocytoma is true. Administration of a-blocker can decrease operative mortality D. Hyperosmolar nonketotic hyperglycemia 12. Hyperosmolar ketotic hyperglycemia D. Sepsis D. Consider that the patient opens his eyes and is extubated in the operating room. Physical exam reveals profound global weakness with absent reflexes. Glucose 13. Phosphate C. The metabolic complication of TPN (Table 14-1) that is likely is Table 14-1 Metabolic Complications of TPN. Sodium D. Hyperphosphatemia 11. He has been unable to eat for the last 2 weeks and was started on total parenteral nutrition (TPN) several days prior. Adequate blockade can be assessed by in-house blood pressures <160/90 mm Hg for 24 hours prior to surgery B. presents for elective open total abdominal colectomy with end ileostomy. 10. hyperosmolar nonketotic coma) Protein (hyperammonemia) Hypercalcemia Hypophosphatemia Essential fatty acid deficiency Vitamin toxicity A. 15 minutes after arriving to the recovery room (PACU) he is unable to maintain adequate ventilation and oxygenation.

An initial bolus of pancuronium was administered to a patient with end-stage liver disease with associated ascites for general anesthesia. Shortened duration of pancuronium action 17. hypertension. A T2 sensory level is obtained with hyperbaric bupivacaine prior to incision. The cardioaccelerator nerves are blocked C. An otherwise-healthy 38-year-old female patient is undergoing repair of a large ventral hernia under intrathecal anesthesia. except A. Intravenous vasodilator C. all values were within normal limits in this patient preoperatively. Intravenous lidocaine 15. A false statement concerning this situation includes A. Posthepatic biliary obstruction D. A 40-year-old man undergoing an open resection of a pheochromocytoma under isoflurane general endotracheal anesthesia suddenly develops tachycardia. An alcoholic 62-year-old male patient is noted to have jaundice one day after a laparoscopic cholecystectomy under halothane/fentanyl general endotracheal anesthesia. A patient with cholestasis presents for preoperative evaluation with laboratory findings revealing normal aspartate aminotransferase (serum glutamic-oxaloacetic transaminase) and prothrombin time but with a markedly elevated alkaline phosphatase. and multifactorial ventricular ectopy. Prolonged duration of succinylcholine action D. Effective cough is preserved B. B ilirubin and alkaline phosphatase are elevated. Of note. Prolonged duration of vecuronium action B. The most likely cause of his jaundice is A. Appropriate anesthetic considerations include all of the following. Switching from isoflurane to sevoflurane B. Each of the follow ing could be considered an appropriate treatment option. Which of the follow ing anesthetic scenarios should be considered? A. He w ill need a muscle relaxant for upcoming colon surgery. except A. Examination of the biceps reveals fu ll strength bilaterally D. but alanine aminotransferase (serum glutamic-pyruvic transaminase [SGPT]) and aspartate aminotransferase (serum glutamic-oxaloacetic transaminase [SGOT]) are within normal ranges. Worsening of underlying chronic liver dysfunction C. Intravenous a-blocker D. Idiopathic halothane hepatic injury B. Bupivacaine binds to the intracellular portion of sodium channels 16. Intravenous acetaminophen administration 18. Increase intubating dose of atracurium C. Increased sympathomimetic activity due to vagolysis .14.

Intense histamine release immediately after administration C. except A. HCO3 = 26 C. HCO3 = 28 .5 via face mask. His wife reports that he snores loudly every night with occurrences of breathing cessation.42. Opioid hyperalgesia C. Decreased cardiac output 21. Widened pulse pressure C. Pao2= 65. Increased cardiac output Questions 22 to 23 A 120-kg diabetic male is scheduled for emergent pinning of his mandible after a motor vehicle accident. Resting tachycardia B.37. Pao2= 67. Larger volume of distribution requiring initial larger doses D. Which of the follow ing cardiovascular abnormalities is least likely to be present in a patient with end-stage alcoholic cirrhosis A. Arterial blood gas (ABG) finding that would confirm Pickwickian syndrome is A. HCO3 = 24 B. HCO3 = 22 D. Medical history is also significant for hypertension controlled with a diuretic. On physical examination.35. Increased peripheral vascular resistance D. B.4 g/dL) with an arterial blood gas revealing a Pao2 of 65 mm Hg breathing a Fio 2 of 0. Pao2= 80. pH = 7. Paco2 = 36. Anemia D. Intrahepatic arteriovenous shunts B. Resistance to the analgesic effects of opiates 20. Resistance to the hypnotic effects of thiopental D. pH = 7. Longer duration of action requiring smaller maintenance doses 19. pH = 7. he has a large tongue and a wide neck with inadequate mouth opening revealing a Mallampati grade 4 view. Paco2 = 44. Intrapulmonary arteriovenous shunts C. Her vitals are a blood pressure of 135/60 mm Hg and a heart rate of 88 bpm. Paco2 = 44. A review of her lab findings reveal a hematocrit concentration of 36% (hemoglobin 12. Pao2= 90. Paco2 = 55. pH = 7. 22. The most likely cause of her hypoxemia is A. A chronic alcoholic patient with liver cirrhosis is likely to demonstrate all of the follow ing during administration of anesthesia. A woman with long-standing alcoholic cirrhosis (Child-Turcotte-Pugh B) presents to the emergency room for chronic shortness of breath and abdominal pain. His BMI is 38 kg/m2 with a neck circumference of 44 cm.44. A high minimum alveolar concentration (MAC) for desflurane B.

INR (international normalized ratio) C. Requires heparinization D. Hypertension 28. Platelet count is . Decreased cardiac output C. diffuse microvascular bleeding is noted in this patient who required 15 U of blood during his intraoperative course. At the end of the case as the drapes are taken down. the most accurate effect created by use of venovenous bypass (VVB) is that it A. Decreased liver metabolism 24. A patient with chronic liver disease is scheduled for a laparoscopic abdominal operation. sodium bicarbonate and calcium chloride are administered intravenously to counteract A. The risk of mortality during surgery for this patient is assessed using A. 26. Increased blood volume C. Mayo end-stage liver disease B. Increased systemic vascular resistance D. The dose of thiopental required for rapid-sequence induction would be increased . Immediately before unclamping and reperfusion of the transplanted liver. Coagulopathy B. Child-Turcotte-Pugh score C. During cross-clamping of the suprahepatic inferior vena cava (IVC). Induces urinary retention B. Ranson criteria D. as compared with what would be required at his ideal body weight. Alvarado score 25. Increased muscle mass D. Supports cardiac output 27. 23. The variable not used to calculate an MELD (model for end-stage liver disease) score to prioritize patients for liver transplantation is A. Albumin Questions 26 to 28 A 30-year-old male patient without preoperative renal dysfunction is undergoing a primary orthotopic liver transplant (OLT) for failure due to inherited a1-antitrypsin deficiency. Creatinine B. because of changes in A. Decreased basal metabolic rate B. Prevents metabolic acidosis C. Bilirubin D.

000 ng/mL. except A.000/mm3. Buprenorphine B. the risk of failure to visualize contrast material entering the duodenum during intraoperative cholangiogram is highest with the administration of A. Metoclopramide D. Arterial blood gas analysis shows Pao2 = 95 mm Hg. Hypocalcemia 30. Decreased functional residual volume C. Decreased minute volume B. Paco2 = 44 mm Hg. Decreased respiratory drive 31. Glucagon 33. He has a history of liver transplantation 2 years ago.37. otherwise feeling well. Following a gastric bypass procedure. Prolonged partial thromboplastin time D. and is complaining of continued subjective dyspnea. Nalbuphine C. Elevated serum creatinine concentration B. and serum fibrinogen concentration is 40 mg/dL. Hypoalbuminemia C. Citrate toxicity 29. During laparoscopic cholecystectomy. and pH = 7. Diltiazem B. Each of the follow ing is associated with delayed gastric emptying. Atropine C. Drugs that can decrease or reduce opioid-induced biliary spasm include all of the following. Naloxone 32. Morphine D. Disseminated intravascular coagulation (DIC) B. The most likely cause of bleeding is A. 40. Abnormal platelet function C. D-dimer is 2. except . activated partial thromboplastin time (PTT) is 54 seconds. The parameter most closely related to her increased alveolar-arterial oxygen-tension gradient is A. Depressed levels of factor V III D. a 130-kg woman is extubated and breathing spontaneously in the recovery room (PACU). prothrombin time is 18 seconds. Which of the follow ing is most likely to be present during preoperative evaluation? A. A patient presents for preoperative evaluation for upcoming surgery. She is breathing at a rate of 24 breaths/min on 10 L/min of oxygen via nasal cannula. Decreased expiratory reserve volume D.

Renal failure B. Add positive end-expiratory pressure (PEEP) B. 34. The initial step in the management of her hypoxemia is A. The exploratory surgery progresses slowly. Switch to pressure support ventilation 37. Arrhythmias . |i-Receptor agonism Questions 34 to 39 A 33-year-old otherwise-healthy female suffering from moderately severe abdominal pain of unclear etiology is set to undergo an exploratory laparoscopy. her EtCO2 begins to gradually rise. except A. Decreased systemic vascular resistance (SVR) D. The patient is placed in a steep Trendelenburg position. Gas emboli D. Reposition the patient D. requiring increasing minute ventilation. Over the next 3 hours. Celiac plexus block C. Decreased venous return C. Diabetes mellitus B. Hypothermia 36.0). Her oxygen saturation begins to gradually decline over the course of several minutes while being ventilated with 100% oxygen (Fio 2 = 1. A ll of the follow ing contribute to the degree of systemic CO2 absorption. Increased intrathoracic pressures 35. Bronchospasm C. Intra-abdominal pressures (IAP) C. Intravenous bolus of 500 mL saline C. except A. Inherent risks of abdominal laparoscopy include A. The abdominal cavity is insufflated using carbon dioxide (CO2). A. Vagotomy D. Each of the follow ing is hemodynamic change associated with hypercarbia. Increased risk of reflux and aspiration B. A ll of the follow ing are correct statements regarding pathophysiologic changes associated with creation of the pneumoperitoneum. Duration of surgery D. Solubility of the gas B. except A. Blood pressure 38.

Increase cardiac afterload C. The patient requests an epidural for perioperative pain management. followed by tracheal intubation. Use metoclopramide to decrease gastric secretions Questions 43 to 45 A 70-year-old 70-kg male with benign prostatic hypertrophy and difficulty with urination presents for a transurethral resection of his 65-g prostate (TURP). His other pertinent history includes . Tachypnea D. Hypertension B. A 50-year-old male patient is to undergo an open nephrectomy for renal carcinoma. The expected response to intubation in this patient includes A. Compression of the inferior vena cava B. Bradycardia C. This physical exam finding is inappropriately paired with the possible nerve injury resulting from ill positioning during surgery: A. except A. After a T2 sensory level is obtained. She now presents for right-knee arthroscopic anterior cruciate ligament repair and mentions significant history of postoperative nausea and vomiting (PONV). A 24-year-old female status postrecent living-related renal transplant requires chronic immunosuppression with cyclosporine and steroids to combat organ rejection. The most appropriate next step in planning her anesthetic management is A. as he is strongly intolerant to |i- agonist opiate therapy with nausea and vomiting. Too small blood pressure cuff D. Low systemic vascular resistance (SVR) 39. B. A ll of the follow ing are appropriate in the differential diagnosis for hypotension during laparoscopy. High cardiac output D. the patient is induced with propofol 200 mg and rocuronium 70 mg. Mydriasis 42. Proceed with total IV anesthesia (TIVA). Difficulty climbing stairs femoral nerve injury D. Tachycardia C. Avoid regional anesthesia C. Liberally infuse intravenous fluids D. The surgery continues on with a request to increase the pneumoperitoneum to 30 mm Hg to improve the surgical view. avoiding inhaled anesthetics B. Inability to evert the foot common peroneal nerve B. Foot drop saphenous nerve injury 41. CO2 embolism 40. Inability to stand on toes sciatic nerve C.

Hypertonic saline infusion B. The most appropriate next step in the management of his hyponatremia is A. Assuming the use of a hypotonic irrigant. Decreased risk for acute tubular necrosis C. The relatively common complication of this procedure that should be ruled out at this time is A. Fluid restriction C. The step of the epidural placement that should be avoided in this patient is A. revealing a serum sodium value of 130 mEq/L. Lithotomy position D. Venous pressure B. 43. Extraperitoneal perforation D. 47. his postoperative laboratories have returned. Metabolic alkalosis D. these factors w ill contribute to the amount of fluid absorbed by the patient. Insulin and glucose administration 46. He has a remote history of a lumbar spinal fusion with no current lumbar symptomatology. and 20 minutes later is feeling well with minimal pain complaints. Hyperkalemia Questions 47 to 51 A 38-year-old woman is set to undergo extracorporeal shock wave lithotripsy to disintegrate a painful stone trapped in her upper ureter. The patient requests a general anesthetic for the procedure and refuses spinal anesthesia. Demeclocycline administration D. Size of prostate 44. Glycine toxicity C.hypertension and hyperlipidemia. he complains of bothersome localized suprapubic pain and is requesting pain medicine. except A. The patient is administered hydromorphone intravenously. His review of systems is negative for fevers or chills. Hyponatremia B. Hypernatremia B. both well controlled. In the recovery room. Hydrostatic pressure of the irrigation infusion C. Transient bacteremia 45. At this time. Loss of resistance to air . The patient is requesting an epidural anesthetic and is choosing to be otherwise awake and cooperative with her positioning and procedure. Effects of furosemide administration in the perioperative period include A. He denies pain or discomfort anywhere else.

Once the epidural is adequately placed and the patient is immersed sitting in the water tank. Large calcified abdominal aortic aneurysm 52. Delivery of the shock wave is timed to coincide with the ventricular refractory phase B. Extracorporeal shock wave lithotripsy therapy proceeds with the shock wave synchronized with what ECG phase of the cardiac cycle? A. Positive pregnancy test D. A 26-year-old male patient with A lport syndrome requires hemodialysis (every third day) and . Decreased creatinine clearance B. The R wave D. Removal of the patient from the bath water can be accompanied by a decrease in the blood pressure 51. Lower extremity peripheral pooling 49. A ll of the follow ing are contraindications to immersion extracorporeal shock wave lithotripsy. The Q wave C. Decreased central venous pressure C. Decreased central venous pressure B. except A. Harrington rod implants B. Neuraxial anesthesia up to T2 sensory level is adequate C. Increased functional residual capacity D. The P wave B. the physiologic change that should be expected is A. Bolus dose of local anesthetics 48. Loss of resistance to hanging drop C. B. Which of the follow ing is considered the most sensitive indicator of impending traumatic renal failure? A. Decreased fractional excretion of sodium D. The S wave 50. Which of the follow ing statements would be considered false with regard to extracorporeal shock wave lithotripsy (ESWL)? A. Test dose injection D. Increased urine osmolality 53. use high tidal volumes and low respiratory rate D. Increased vital capacity C. If able to control ventilation. Abdominally placed rate-responsive cardiac pacemaker C.

His last dialysis treatment was yesterday. Hyperchloremic acidosis B. His laboratory findings reveal Urine osmolality: 550 mOsm/L Urine specific gravity: 1. Muddy casts D. Patient requests general anesthesia for this procedure. Fluid restriction B. The best option for opioid therapy in this patient is A. presents for an arteriovenous fistula creation. Hyaline casts B. Neostigmine C.5% Ratio of urine-to-plasma urea concentration: 10 55. Renal ultrasound D. Fractional excretion of sodium of 4% Questions 55 to 56 A 75-year-old patient who is awaiting urgent laparotomy has had oliguria for the past 12 hours since the onset of his acute abdominal pain last night. His medical history includes well-controlled hypertension. The potential acid-base abnormality that can occur is A. Methadone 54. Hyperkalemic acidosis D. except A. Meperidine . Fentanyl B. Metabolic alkalosis C. A 67-year-old patient with chronic renal failure presents for hip arthroscopy to address and treat his labral tears and associated hip pain.020 Urine sodium concentration: 15 mmol/L Fractional excretion of sodium: 0. Which of the follow ing drugs w ill have a prolonged duration of action? A. Foley placement 56. Urine specific gravity <1. Fluid challenge C. Each of the follow ing is associated with acute tubular necrosis.010 C. Respiratory alkalosis 57. Vital signs include a BP of 120/65 mm Hg and a HR of 72 bpm. The most appropriate treatment of his oliguria is A. Fluid resuscitation is done with 4 L of normal saline. Atracurium D.

Dextropropoxyphène D. Fentanyl .B. Codeine C.

5. B. followed by suctioning of the oropharynx. ondansetron) and D2 (dopamine) antagonism (e. gastroesophageal reflex disease. increased cardiac output). use of an incentive spirometer. Metoclopramide promotes gastrointestinal m otility without directly affecting pH itself.. A. cardiovascular (e. 3. decreased functional residual capacity). 2. which can be attenuated by increasing ambient temperature to minimize the gradient. focusing on deep breathing while encouraging coughing.g. ranitidine) can decrease gastric volume and raise pH to a level that should be protective from fatal aspiration.. Ambulation is also highly encouraged to improve lung inflation.g. . difficult airway. Atelectasis likely occurs in all patients who undergo general anesthesia. H2-blockers (e. B. as there is no evidence to support this practice. Doxapram stimulates chemoreceptors in the carotid bodies. the patient should be placed in Trendelenburg position to lim it pulmonary contamination. 5-HT3 (serotonin) receptor antagonism (e. Aspiration of acidic gastric juices poses a potential threat during induction and intubation. and adequate pain control are all measures used to expand lung volumes and promote improved oxygenation.. Given that metabolism of inhalational agents is increased over normal weight patients. Postsurgical atelectasis is treated by physiotherapy. These measures are considered first-line options for his presumed microatelectasis.g. Empirical antibiotic therapy is strongly discouraged unless it is apparent that the patient has developed a subsequent pneumonia. Perioperative m orbidity related to obesity is associated with changes in respiratory (e. cimetidine.g. A. CHAPTER 14 ANSWERS 1. higher minimum alveolar concentrations may be required. early mobilization. Initial management involves the recognition of a possible aspiration event when there are visible gastric contents in the oropharynx. and gastrointestinal (e. B. Changes of microatelectasis develop routinely and do not significantly delay discharge for most patients despite the relative state of hypoxia (decreased Pao2). in particular those postabdominal surgeries. Deep breathing.. In the smoker. Atracurium (including cis-atracurium) is metabolized via Hofmann degradation and is unaffected by the obese state. coughing w ill also clear the airways of mucous to improve aeration.g. with no effect on gastric pH or volume. 4. prochlorperazine) are useful antiemetics. Once diagnosis is suspected.. increased abdominal pressure) systems that w ill impact the delivery of anesthesia. D.g.. 6. The initial reduction in core temperature during general anesthesia is caused by redistribution of heat from the core to the periphery. An incentive spirometer is often used to promote fu ll expansion of the lungs. which in turn stimulates the respiratory center in the brain stem to increase tidal volume and respiratory rate. Corticosteroids should not be given prophylactically.

D. restore volume depletion. Factor level must be less than 5% of normal to prolong the ACT.or hyperglycemia. Pulmonary leukoagglutinin reaction is related to the presence of antileukocyte antibodies in donor plasma leading to transfusion-related acute lung injury. usually related to ABO incompatibility with associated hemoglobinuria. For those on TPN. 7. including diarrhea and intestinal fistulas. hyperglycemic coma has been reported in patients who fail to regain consciousness after anesthesia. The ACT enables one to monitor the anticoagulant effect of unfractionated heparin. Switching from isoflurane to sevoflurane is not an appropriate method to treat the catecholamine storm. effecting change in as quick as 15 to 30 minutes. A. and electrolyte abnormalities. The ACT is sensitive to a deficiency or dysfunction of all the clotting factors (except factor V II)— indicating problems with the intrinsic or common pathways. An a­ blocker. losses w ill cause a metabolic acidosis. D. and prevent surgery-induced catecholamine storm. are rich in bicarbonate and. one would expect ABG findings of a metabolic acidosis with fu ll respiratory compensation. vasodilator. as hypophosphatemia has been associated with acute respiratory failure due to profound areflexic muscle weakness. and lidocaine are appropriate options to counter the effects of catecholamine storm. A. 9. However. B. ACT prolongation can also indicate coagulation-factor deficiency. 11. 8. severe thrombocytopenia. The main goals of preoperative blockade are to normalize blood pressure and heart rate. B. the anesthesiologist must monitor blood glucose levels meticulously to avoid hypo. which can occur during direct surgical manipulation of the tumor. or severe platelet dysfunction. therefore. Gastrointestinal secretions. However. 14. 10. A sign of adequate a-blockade is the development of nasal congestion due to smooth-muscle relaxation of nasal mucosal arterioles. Ensuring the presence of normal serum phosphate levels in the patient receiving TPN is essential. An acute hemolytic transfusion reaction is associated with hemolysis of transfused blood. nonketotic. 13. B. The most critical element to safe perioperative care of the pheochromocytoma patient is adequate preoperative blockade against the effects of the circulating catecholamines. Malnourished surgical patients are at greater risk for postoperative m orbidity and mortality compared to a well-nourished patient undergoing similar operations for similar indications. A. such as greater risk of infection. hyperglycemia. 12. respiratory compensation for metabolic processes w ill occur almost immediately by increasing ventilation to blow o ff CO2 to reduce the acidosis. Therefore. . providing TPN to the malnourished patient in the perioperative period carries its own inherent risks. Hyperosmolar.

mostly independent of renal or hepatic function. 17. A surgical cause is likely if the operation involved the liver or biliary tract. The pharmacokinetics of many nondepolarizing muscle relaxants in the presence of cholestasis and obstructive jaundice may be altered. vecuronium have been demonstrated in this population. MAC is higher in infants and lower in the elderly. 16. P R E H E P A T IC IN T R A H E P A T IC P O S T H E P A T IC E tio lo g y H em o ly sis Severe a rte ria l h y p o x e m ia S tones H e m a to m a re a b s o rp tio n C irrh o sis Sepsis B iliru b in o v e rlo a d C o n g e stiv e h e a r t failu re C ancer Sepsis V iru se s D r u g -in d u c e d B iliru b in T (u n c o n ju g a te d ) T (c o n ju g a te d ) t (c o n ju g a te d ) A m in o tra n sfe ra s e s U nchanged TT U nchanged A lk a lin e p h o sp h a ta s e U n c h a n g e d U nchanged Tt P ro th r o m b in tim e U nchanged T U nchanged A lb u m in U nchanged i U nchanged 18. Cirrhotic patients w ill require a larger initial dose of pancuronium due to increased volume of distribution for this hydrophilic agent with smaller maintenance doses for prolonged duration of action. The respiratory system is usually unaffected. and. As such. Certain physiologic and pathologic states may alter MAC of inhaled anesthetics. Table 14-2 Postoperative Liver Dysfunction—Causes and Differentiation. A. B. Postoperative liver dysfunction is common. lidocaine. Subclinical hepatocellular injury can occur in up to 50% of those receiving an inhaled anesthetic with halothane. Sympathetic preganglionic fibers originate in the intermediolateral cell column of the spinal cord from T1 to L2. M ild transient increases in serum levels of liver enzymes (SGOT/SGPT) are often seen within hours of surgery. but rarely persist >2 days. . Also. Pancuronium has slight vagolytic activity resulting in increased heart rate and cardiac output. Drugs. pancuronium. 15. MAC increases with hyperthermia. B. Chronic liver disease may interfere with the metabolism of drugs due to decreased number of functional hepatocytes or decreased hepatic blood flo w that typically accompanies cirrhosis of the liver. diazepam. and cis-atracurium have theoretical advantages because their elimination occurs via plasma cholinesterases and Hofmann degradation. Succinylcholine. there are many other causes to consider. to a lesser degree. 19. alcoholism. A. but is generally m ild and asymptomatic (Table 14-2). atracurium. Prolonged elimination half-life times for morphine. Mivacurium and atracurium are associated with histamine release. respectively. leading to bradycardia and hypotension. including antibiotics. The prolonged duration of action likely results from both inhibition of hepatic uptake by the accumulated bile salts and a general deterioration of liver transport function. However. patients may feel unable to breath and are often unable to cough effectively. Though volatile anesthetics are often implicated as the cause of postoperative jaundice. high thoracic blockade up to T2 w ill block the cardioaccelerator nerves. and other metabolic or infectious causes must also be ruled out. C. as diaphragmatic breathing alone can maintain relatively normal arterial blood gases. Cardiac innervation is principally via sympathetic fibers from T1 to T4.

and thyrotoxicosis. cirrhosis. Standard technique of OLT causes changes in hemodynamics during the anhepatic phase because of cross-clamping of the suprahepatic IVC. 22. and weight seem to have little effect on MAC. 21. resulting in hypoxia and hypercarbia. Redistribution of thiopental to inactive tissue sites rather than metabolism is the most important determinant of early awakening follow ing a single intravenous injection. the most important initial test is the demonstration of elevated carbon dioxide in the blood. promoting venous return with decrease incidence of renal dysfunction. cardiac output. Cirrhosis is typically associated with several cardiovascular abnormalities including a hyperdynamic circulation characterized by increased cardiac output and decreased peripheral resistance. B. The Mayo or model for end-stage liver disease was in itia lly developed to predict death within 3 months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt procedure and was subsequently found to be useful in determining prognosis and prioritizing patients for liver transplant. MELD score = 10 x [0. 25. B. Furthermore. Alvarado score is used for appendicitis. D. namely. warm peripheries. D. a bounding pulse. Obesity hypoventilation syndrome (aka Pickwickian syndrome) is a state in which the severely overweight patient fails to breathe rapidly or deeply enough. VVB has been used to achieve hemodynamic stability by avoiding venous congestion. For dialysis-dependent patients. gender. while duration of anesthesia.957 x log e (creatinine) + log e (bilirubin) + 1. C.43 26. and arterial blood pressure. 24. height. Those with chronic liver disease are also at increased risk of arterial-venous shunting. 23. Postreperfusion syndrome is the most common hemodynamic derangement in liver . The presence of intrapulmonary shunting w ill result in hypoxemia.12 x log e (INR)] + 6. Other cardiovascular changes include a resting tachycardia. and pregnancy seem to decrease MAC. This requires either an ABG or a measurement of bicarbonate levels in venous blood. while the Ranson criteria assess pancreatitis. D. 20. Those with chronic liver disease are at increased risk of arterial-venous shunting. If Pickwickian syndrome is suspected. hypotension. and bilirubin. B. and a widened pulse pressure. hypothermia. The MELD score is a formulaic calculation utilizing three variables: creatinine. INR. Interruption of the IVC and portal vein flow causes a decrease in preload. compensated respiratory acidosis. The Child-Turcotte-Pugh score is used to predict mortality during surgery in patients with chronic liver disease. the creatinine score is automatically set to 4 mg/dL despite true serum levels. B. Expected ABG findings would reveal a chronic. 27.

in which case the visceral and liver vasodilation that occurs would be the main cause of arterial hypotension. buprenorphine) and agonist-antagonist (e. 32. prolonged prothrombin. A. platelet dysfunction. Administration of calcium chloride and sodium bicarbonate together with hyperventilation mitigates the symptoms related to the reduced cardiac output. 28. C. to create a pneumoperitoneum. compromising cardiac output further. preventing passage of contrast with fu ll ^-agonist more likely to contribute versus partial ^-agonists (e. are additional agents that can provide sphincter of Oddi relaxation. ^-Receptor agonism may contribute to sphincter of Oddi spasm. Dyspnea is a common complaint in individuals with class II or III obesity. general anesthesia with an endotracheal tube is required. and systemic vascular resistances.g. rather than direct damage to the kidney itself. and low antithrombin. thus. especially follow ing a general anesthetic. A variety of agents that can produce smooth-muscle relaxation have been used. C. or hypofibrinogenemia. nalbuphine). 33. Prophylaxis with atropine prevents bradycardia but not hypotension. Bleeding follow ing massive transfusion can occur due to hypothermia. prolonged PTT. C. Transfusion of 15 to 20 U of blood products causes dilutional thrombocytopenia contributing to the bleeding. Nitrates and calcium channel blockers have been the most extensively studied.. mean arterial pressure. The hemostatic signatures of DIC are low platelets. dilutional coagulopathy. A. hampering venous return to the heart. As such. Increase in intra-abdominal pressures w ill place the patient at a greater risk of reflux and aspiration. most commonly using CO2. Naloxone. 30. reflected as an increase in afterload for left-sided heart . fibrinolysis. associated with diaphragm elevation.. 31. Metoclopramide is a prom otility agent that enhances sphincter smooth-muscle contraction. Intrathoracic pressures are also increased. transplantation. elevated D-dimers. Sympathetic celiac plexus blockade leaves parasympathetic fibers unopposed with associated increased gastrointestinal m otility and possible diarrhea. Abdominal laparoscopy requires insufflation of the abdominal cavity. High pressures in the abdominal cavity can also compress both small and large blood vessels. Ventricular function. The likely presence of renal insufficiency is a consequence of these changes in blood flow. Increase in SVR occurs during pneumoperitoneum. low fibrinogen.g. as a ^-antagonist would alleviate any opioid-induced spasm. B. including atropine and glucagon. 29. Anticholinergics. both right and left. individuals present with a pronounced reduction in expiratory reserve volume and an increase in the alveolar-arterial oxygen gradient. C. has been shown to be normal during reperfusion. Excessive fibrinolysis and low fibrinogen are further causes of bleeding in these patients. Coagulopathy follow ing massive transfusion is a consequence of posttraumatic and surgical hemorrhage. 34. manifesting mainly as decreased heart rate. Long-standing insufficient liver function is believed to cause changes in the circulation that changes vessel tone and blood flo w in the kidneys.

an increase in CO2 partial pressures and changes in arterial blood pressure and heart rate. A blood pressure cuff that is too small for the arm w ill result in erroneously high blood pressure readings. Movement of the foot is unaffected. entering the venous system to create an “ air lock” with mechanical obstruction of the right-side chambers. high cardiac output. particularly during long surgeries under high IAP unless minute ventilation is increased. however. The effects of pneumoperitoneum include compression of the inferior vena cava resulting in poor venous return and low preload. providing a larger afterload against which the left ventricle must function. A. D. 36. The supine position under general anesthesia results in a decrease in functional residual capacity (FRC). The judicious use of PEEP can be helpful to mitigate end-expiratory alveolar collapse. High thoracic epidural blockade up to T2 blocks the cardiac accelerators. If FRC becomes less than closing capacity. Transplant recipients are always under various regimens of immunosuppression to prevent . 39. B. Manifestations while under general anesthesia include tachycardia. potential inability to control bleeding. Systemic vascular resistance increases proportionately when the intra-abdominal pressure is elevated. atelectasis. and duration of surgery. severe hypercarbia can occur despite aggressive hyperventilation. Sympathetic outflow to the pupil travels via the intermediolateral cell column at the C8 to T2 cord level and remains intact. further decreasing FRC. thus. and ventilation/perfusion mismatch can further compromise respiratory function. D. Systemic absorption of gas from pneumoperitoneum is determined by factors including solubility of the gas. CO2 laparoscopy may produce hypercarbia. Hypercarbia causes hemodynamic changes by its direct action on the cardiovascular system and indirect actions through the sympathetic nervous system. D. CO2 absorption from the peritoneal cavity can result in a state of acidosis as Paco2 rises. 40. In those with severely compromised cardiopulmonary function and restricted CO2 clearance. is associated with a few inherent dangers including gaseous embolism. Therefore. the sympathetic surge can still result in mydriasis. A. IAP. C. though relatively safe. and low SVR with flushed skin. providing adequate sympathectomy to prevent hypertension and tachycardia. airway collapse. Abdominal laparoscopy. During insufflation. chambers. Pneumoperitoneum and the Trendelenburg position shifts the diaphragm cephalad. The saphenous nerve is the largest and longest branch of the femoral nerve that supplies sensory innervation to the medial aspect of the lower leg. a gas embolus can occur. 37. 41. too much PEEP can contribute to deterioration in right-sided cardiac performance. increased arterial blood pressure. C. 35. arrhythmias. 42. 38.

There is no role for hypertonic saline in these patients. 47. Most perforations are extraperitoneal. The volume of restriction should be based on the patient’s renal diluting capacity. The tip of the resectoscope can also cause injury. in the upper abdomen. consider use of a loop diuretic (e. Perforations usually occur during difficult resections and are often made by the cutting loop or knife electrode. furosemide) to increase free water excretion in the kidneys. consider avoiding the use of loss of resistance to air for identifying the epidural space. 44. A. Many immunosuppressants are metabolized in the liver via the cytochrome P450 system such that drugs administered during anesthesia (or perioperatively) may affect blood levels including increased concentrations with cimetidine and metoclopramide and decreased levels with octreotide. calcium. organ rejection. As with many diuretics. and surgical skills of the surgeon (efficiency with time management and hemostasis). C. Another relatively common complication of TURP is perforation of the bladder. the perforation is through the wall of the bladder and thus intraperitoneal. C. Less often. the urologist may note the irregular return of irrigating fluid. Excessive use of furosemide w ill most likely lead to a metabolic alkalosis due to hypochloremia and hypokalemia.g. thus improving free water loss. With epidural anesthesia. which increases as the duration of the surgery increases. 43. The amount of fluid absorbed depends on several other factors as well. they result in pain in the periumbilical. Normally. the size of the prostate to be resected (associated with longer time required). Animal experiments have shown epidural tissue damage follow ing injection of air followed by exposure to shock waves. as air w ill provide an interface and cause dissipation of shock wave energy resulting in local tissue injury. Regional anesthesia and/or TIVA are reasonable options to minimize PONV in this patient. venous pressure (more fluid absorbed if patient is hypotensive). or referred from the diaphragm to the shoulder. as well as overdistention of the bladder with irrigation fluid. sodium. about 20 mL/min of irrigation fluid is absorbed (1-1. including loss of potassium. and in the awake patient. pain may be generalized. and magnesium. 46. For normovolemic.5 L for a normal case with resection time about 45-60 minutes). inguinal. Demeclocycline is a tetracycline antibiotic that has a secondary effect of reducing the responsiveness of the collecting tubule cells to antidiuretic hormone. In such cases. Clinically significant reductions in serum levels of these medications can be caused by dilution with massive fluid resuscitation perioperatively. Bacteremia is usually asymptomatic and easily treated with commonly used antibiotic combinations that are effective against gram-positive and gram-negative bacteria. 45. asymptomatic hyponatremic patients. furosemide can cause dehydration and electrolyte imbalance. C. blood loss (implies a large number of open veins). it is almost impossible to accurately assess the volume absorbed. as well as with cardiopulmonary bypass. If patient is unable to adhere to fluid restrictions. free water restriction is generally the treatment of choice. additionally. In clinical practice. .. or suprapubic regions. B. including the hydrostatic pressure of the irrigation infusion (determined by the height of the bag).

rapid breathing pattern. Respiratory changes with immersion up to the clavicles are significant: functional residual capacity and vital capacity are reduced by 20% to 30%. Contraindications for lithotripsy include the follow ing: pregnancy. which are directly correlated with the depth of immersion.g. including hip prostheses and even Harrington rods. atracurium. Succinylcholine. greater than . Fentanyl and methadone are also considered relatively safe in renal failure as they have no active metabolites. pulmonary blood flo w has been shown to increase. A.48. An advantage of providing a general anesthetic for ESWL is that ventilatory parameters can be controlled using high frequency and low volumes to decrease stone movement with respiration. a waste product of muscle energy metabolism. together with either general or epidural anesthesia. A. 50.. Patients with abdominally placed cardiac pacemakers should notify their doctor. 52. Orthopedic prostheses. A. Renal failure allows some protection against residual neuromuscular blockade because renal elimination half times of anticholinesterase drugs is prolonged. C. Rate-responsive pacemakers that are implanted in the abdomen may be damaged during lithotripsy. and tight abdominal straps and the hydrostatic pressure of water on the thorax impart a characteristic of shallow. Methadone has limited plasma accumulation in renal failure as it is prim arily eliminated in the feces. would tend to cause peripheral pooling and decreased venous return. is produced at a constant rate that is proportional to the muscle mass of the individual. Shock wave-induced cardiac arrhythmias occur in up to 10% to 14% of patients undergoing lithotripsy despite the fact that shock waves are purposefully synchronized with the patient’s ECG and are delivered in the refractory period of the cardiac cycle (R wave). Water immersion produces significant changes in the cardiovascular and respiratory systems. Cardiovascular changes include an increase in central blood volume. Because the body does not recycle it. 49. 53. 54. renal excretion accounts for approximately 50% of the clearance of neostigmine and approximately 75% of elimination of edrophonium and pyridostigmine. with an increase in central venous and pulmonary artery pressures. B. respectively. D. and cis-atracurium have theoretical advantages because their elimination occurs via plasma cholinesterases and Hofmann degradation. Creatinine. C. mostly independent of renal or hepatic function. Acute tubular necrosis is classified as a “ renal” (e. The sitting position. certain bleeding conditions. all of the creatinine filtered by the kidneys in a given amount of time is excreted in the urine. Creatinine clearance test evaluates how efficiently the kidneys clear creatinine from the blood. Diagnosis is made by a fractional excretion of sodium >3%. and certain skeletal deformities that prevent accurate focus of shock waves. 51. are generally not a problem as long as they can be kept out of the blast path. a large aortic aneurysm. not prerenal or postrenal) cause of acute kidney injury. making creatinine clearance a very specific measurement of kidney function. In terms of reversal agents.

metabolism. PARAM ETER P R E R E N A L F A IL U R E A C U T E T U B U L A R N E C R O S IS Urine Na+ (meq/L) <20 >40 Urine osmolality (mOsm/kg) >500 <350 FENa % <1 >2 Urea % <35 >35 Urine specific gravity >1. Hyperchloremic acidosis is a well-recognized entity as a consequence of large volume administration of some intravenous fluids. prerenal acute renal failure can cause tissue death in the kidneys and lead to intrinsic (intrarenal) acute renal failure. respectively. with no effect on pH. B.010 Urine:plasma urea ratio >10:1 <7:1 55. But if it is not reversed or treated successfully and quickly. Chronic pain is common in chronic kidney disease and most w ill rate their pain as moderate to severe. Meperidine is not recommended in renal failure due to accumulation of normeperidine. expected urine sodium concentration with low osmolality and presence of muddy casts on urinalysis. chloride levels can significantly increase. the condition often reverses itself within a couple of days after normal blood flo w to the kidneys has been restored. pointing to hypovolemia and prerenal failure (Table 14-3). adding normal saline (154 mEq Na and 154 mEq Cl) causes the chloride to increase proportionately more than the sodium. Depending on the cause. most often with a fluid challenge. A sensitive indicator of tubular function is sodium handling because the ability of an injured tubule to reabsorb sodium is impaired. D. The absorption. 56. with the appropriate selection and titration of opioids. When a patient is given normal saline (a hyperchloremic solution). If the patient has tubular damage for any reason. or an acidic environment can contribute to the formation of hyaline casts. 57. because the normal concentrations of Na+ and Cl . thereby causing a metabolic acidosis.020 <1. and renal clearance of opioids are complex in renal failure. can complicate the interpretation of these results. concentrated urine. It is the chloride anion that is the ultimate cause of the acidosis. patients with renal failure can achieve analgesia with minimal risk of adverse effects. A. Low urine flow. Table 14-3 Differentiation between Prerenal and Intrinsic Renal Failure. Morphine is not recommended for chronic use in renal insufficiency due to the rapid . However. However. The strong acid (HCl) and the strong base (NaOH) should cancel each other out. Urinalysis reveals a prerenal state. and are isotonic with plasma.in the serum are 140 and 100.9% sodium chloride solution) and colloids suspended in normal saline are often infused because they are easily available. Consider this equation: sodium chloride combines with water: NaCl + H2O HCl + NaOH. Treatment focuses on correcting the cause of the prerenal acute renal failure. the urinary sodium w ill be greater than expected. Keep in mind that the use of diuretics. Normal saline (0. which may cause seizures. whereas an intact tubule can maintain this resorptive capacity. This increase in chloride tips the acid-base balance toward HCl. however.

Codeine has been reported to cause profound renal toxicity. . which can be delayed and may occur after trivial doses. fentanyl is considered relatively safe in renal failure. Dextropropoxyphene is associated with central nervous system and cardiac toxicity and is not recommended for use in patients with renal failure. as it has no active metabolites. On the other hand.accumulation of its active nondialyzable metabolite (morphine-6-glucuronide).

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elevated T3. Pheochromocytoma. low T3. weight loss. Always requires insulin C. Pancreas tumors. low T3. low T3. Desflurane B. Affects 95% of patients with diabetes D. Elevated TSH. Low TSH. Normal TSH. Preferred anesthetic agent in a patient with hyperthyroidism includes A. Laboratory findings in primary hypothyroidism are A. Preoperative assessment of patients with diabetes mellitus should include A. medullary thyroid carcinoma.Endocrine Diseases Jean Kwo and Edward Bittner 1. pituitary adenoma C. elevated T4 B. parathyroid hyperplasia 5. Cancellation of the surgical case if HbA1c >10% 3. Is characterized by a relative lack of insulin plus resistance to endogenous insulin B. Pancreas tumors. Pulmonary function testing D. and oral hypoglycemic agents 2. 24-Hour creatinine clearance C. low T4 C. Ketamine C. Meperidine 4. Type 1 diabetes mellitus A. mucosal neuromas D. parathyroid hyperplasia B. Can be controlled with diet. pituitary adenoma. low T4 . Multiple endocrine neoplasia (MEN) I syndrome includes A. Sevoflurane D. medullary thyroid carcinoma. An assessment of functional status B. medullary thyroid carcinoma. low T4 D. Pheochromocytoma. Low TSH.

The most likely diagnosis for these signs is A. Thyroid storm B. The most likely diagnosis for these signs is A. her blood pressure drops to 80/55 mm Hg. her heart rate increases to 140 bpm. Irreversible. Pheochromocytoma 8. A 40-year-old woman with a history of Graves disease is in the recovery room after undergoing a CT scan under general anesthesia. Selective a2-receptor agonist 9. The best treatment for these symptoms is A. A reduction in functional residual capacity (FRC) C. Administration of calcium gluconate . Restrictive lung disease 7. she develops severe hypertension and tachycardia. Pheochromocytoma 10. and nephrolithiasis is undergoing a parathyroidectomy for parathyroid adenoma. palpitations. Octreotide D. Dantrolene B. Carcinoid syndrome C. 6. A 39-year-old woman with a history of headaches. and she becomes agitated and complains of difficulty breathing and feeling hot. Propylthiouracil 11. A history of obstructive sleep apnea D. nonselective a-adrenergic receptor antagonist D. hypertension. Phenoxybenzamine C. During a postoperative check on a 53-year-old patient who underwent a total thyroidectomy earlier in the day. While in the recovery room. you notice that he is stridorous and is complaining of muscle cramps. Reversible ^-receptor antagonist C. A decrease in lung compliance B. Adrenal insufficiency B. Malignant hyperthermia D. Obese patients may experience rapid oxygen desaturation during induction of general anesthesia because of A. Selective ^-receptor antagonist and a nonselective P-adrenergic receptor antagonist B. Treatment of thyroid storm includes A. Thyroid storm D. During induction. Carcinoid syndrome C. Phenoxybenzamine is a A.

Complications of cricoid pressure include A. Reintubation for airway protection D. Need to dose water-soluble drugs (e. B.g. Hypoparathyroidism D. During the preoperative evaluation of a critically ill patient with ischemic bowel scheduled for a second look laparotomy and possible abdominal closure. Perioperative instructions for glucose management should include A. Hypoventilation C. hypokalemia. Preparation for a rapid sequence induction. and insulin sliding scale. You are evaluating a 55-year-old patient with type 2 diabetes mellitus for a total knee replacement. neuromuscular-blocking agents) to actual body weight D. since she is at increased risk for aspiration of gastric contents B. More frequent administration of lipid-soluble drugs w ill be needed 14.. Need for less pressure in parturients 16. Refeeding syndrome 15. A possible cause for these electrolyte abnormalities is A. Give half of the NPH dose if morning blood glucose level is at least 150 mg/dL . Are at increased risk of left-heart failure B. Opening the neck wound C. Have the same perioperative complication rate as patients without OSA C. May have an increased likelihood of difficult intubation D. Renal failure B. Rarely require continuous positive airway pressure (CPAP) after bariatric surgery 13. A 39-year-old patient with a BMI of 45 kg/m2 is scheduled for a Roux-en-Y gastric bypass. Your perioperative concerns include A. Administration of sodium bicarbonate 12. Placing her in the reverse Trendelenburg position to reduce atelectasis in dependent areas of the lung and move the chest and breast tissue caudally to allow easier access to the mouth for endotracheal intubation C. Displacement of thoracic spine C. His diabetes is controlled on a regimen of Glucophage (metformin). and hypomagnesemia. She has a history of hypertension. Esophageal obstruction B. you notice multiple electrolyte abnormalities including hypophosphatemia. NPH insulin twice a day. Patients with obstructive sleep apnea (OSA) A. Worsening of view of airway in patients with difficult airway D.

He had a COPD exacerbation 4 months ago and was on steroids for a week at the time. Synthesize epinephrine and norepinephrine C. hypertension. Care with laryngoscopy because of risk of vertebral compression 19. Physiologic effects of chronically elevated corticosteroid levels (Cushing syndrome) include all of the following. Should be given at a dose greater than 10 times the normal daily cortisol production rate B. Hydration with normal saline and diuresis with furosemide D. You are taking care of a 67-year-old patient undergoing a parathyroidectomy. 10 to 15 B. Can cause right-sided heart failure due to tricuspid and pulmonary valve damage 18. and patients are often symptomatic with carcinoid syndrome B. Metabolic acidosis C. 75 to 100 21. Carcinoid tumors A. Give regular insulin dose according to morning blood glucose level C. except A. Hypoventilation to decrease ionized calcium level B. Should include 100 mg of cortisol. Hypotension . Starting insulin infusion with target glucose range of 81 to 108 mg/dL 17. Grow rapidly. Should not exceed 100 to 150 mg of cortisol equivalent per day C. except A. Holding metformin for 48 hours preoperatively to avoid risk of fatal lactic acidosis D. Hypotension B. Anesthetic considerations should include all of the following. Normal daily cortisol production (mg/day) in adults is A. Can cause left-sided heart failure due to mitral and aortic valve damage D. A 75-year-old patient with coronary artery disease. B. Careful titration of neuromuscular-blocking agents C. tapered over 5 to 7 days 22. and chronic obstructive pulmonary disease (COPD) is undergoing a left colectomy for cancer. 20 to 30 C. 50 to 60 D. The patient is hypercalcemic with a serum calcium of 20 mg/dL. Hypokalemia D. Clinical manifestations of mineralocorticoid excess include A. Is not necessary in this patient D. Steroid replacement A. Tetany 20.

III. Increased supraglottic soft tissue due to chronic hyperglycemia B. A 75-year-old. Patients with type 1 diabetes mellitus may be difficult to intubate because of A. Limited jo in t m obility D. Intraoperative management includes A. Hypokalemia D. His medications include insulin. Use of angiotensin-receptor blocker B. He has a history of hypertension and type 2 diabetes mellitus. and an angiotensin-receptor blocker. An association between type 1 diabetes and an anterior larynx C. a P-blocker. Magnesium sulfate infusion to treat hypertension 24. B. 110-kg patient is scheduled for a radical prostatectomy. You are taking care of a 45-year-old patient undergoing a left adrenalectomy for a pheochromocytoma. Muscle wasting C. Use of ketamine as an induction agent to counteract the effects preoperative of a- adrenergic blockade B. The most likely cause of hypotension is A. Glucophage (metformin). though the patient denies having a previous myocardial infarction. An increased incidence of obesity in patients with type 1 diabetes . Diabetic autonomic neuropathy C. Long-acting antihypertensive agents should be available to treat hypertension C. Upon induction. his blood pressure drops from 150/80 to 65/40. Myocardial ischemia 25. His preoperative ECG is significant for Q waves in leads II. Judicious fluid replacement as these patients are usually volume-overloaded D. and aVF. Volume depletion D. Glucose intolerance 23.

MEN I syndrome includes the triad of tumors of the pancreas. Hence. While the risk of complications of diabetes increases with increasing HbA1c levels. D. Ketamine. Conversely. Medullary thyroid carcinomas are a component of the MEN II endocrine syndromes. Type 2 diabetes can be controlled with diet and weight loss. B. a careful assessment of functional status and any symptoms such as increasing dyspnea on exertion and fatigue may be indicative of significant CAD. though these patients may also require insulin. D. there is insufficient evidence to recommend an upper lim it of HbA1c prior to elective surgery. of which there are several subtypes. and oral agents. which is characterized by a relative lack of insulin plus resistance to endogenous insulin. there is no evidence that a preoperative evaluation with a 24-hour creatinine clearance is helpful. 4. the goal of anesthesia is to avoid an increase in heart rate or sympathetic activation. and fentanyl and its congeners for analgesia would be favored. CHAPTER 15 ANSWERS 1. The risks associated with poor glycemic control should be balanced against the necessity for surgery. In patients with hyperthyroidism. Table 15-1 T h y r o id d iso r d e r TSH T3 T4 P rim ary h ypothyroidism T 4 4 Secondary* h ypothyroidism 4 4 4 P rim ary hyp erth y ro id ism 4 t 4 Secondary* h y p erthyroidism t t t Subclinical hypothyroidism T N orm al N orm al Subclinical h y perthyroidism 4 N orm al N orm al Sick euthyroid N o rm al 4 4 . 3. when practical. Most patients carrying the diagnoses of diabetes (95%) have type 2 diabetes. desflurane. Diabetes is a well-recognized risk factor for coronary artery disease (CAD). While diabetes is a leading cause of renal failure. 5. Type 1 diabetes mellitus results from the autoimmune destruction of insulin-producing p cells of the pancreas and thus these patients always need insulin to prevent hyperglycemic ketoacidosis and other complications. and parathyroid glands and is inherited as an autosomal-dominant trait. and meperidine cause sympathetic stimulation and tachycardia. and there is evidence that higher HbA1c levels are associated with adverse outcomes follow ing a variety of surgical procedures. Sevoflurane for anesthesia. 2. A. Cardiac autonomic neuropathy may mask angina pectoris and obscure the presence of CAD. C. Regional anesthesia. anesthetics and techniques that reduce or blunt sympathetic activity are preferred. Complications of diabetes result largely from microangiopathy and macroangiopathy. might also be efficacious in avoiding sympathetic activation. pituitary.

and lung volumes suggestive of restrictive lung disease. selective a!- receptor antagonist that is an alternative to phenoxybenzamine for treatment of pheochromocytoma. Doxazosin is a reversible. but it should be given only after the loading dose of . altered mental status. Thyroid storm is a medical emergency and if untreated. C. decreased pulmonary compliance. Starting P-blockade first w ill lead to unopposed a stimulation causing further increase in the blood pressure. hydration. It can be precipitated by surgery. Unlike malignant hyperthermia. Propranolol has the additional benefit of inhibiting the peripheral conversion of T4-T3. The FRC is the reservoir of oxygen during the apneic state associated with the induction of general anesthesia. and hypertension. diaphoresis. Thyroid storm is a state of severe hypermetabolism induced by excessive release of thyroid hormones. which pushes the diaphragm cephalad causing an increase in pulmonary blood volume. Total pulmonary compliance decreases due to a decrease in both chest-wall compliance and lung compliance. while lung compliance decreases because of the increased abdominal mass. the reduction of FRC associated with obesity results in greater oxygen desaturation during the induction of general anesthesia. Propylthiouracil and methimazole inhibit the synthesis of T4 by blocking the organification of tyrosine residues. medullary thyroid carcinoma. there is a shift in this balance due to adipose tissue in the chest wall and abdomen. The FRC of the lung is the volume of air present in the lungs at the end of passive expiration and reflects a balance between the elastic recoil of the lungs and the pleural pressure. Thyroid storm is characterized by fever. often fatal. anticholinergic. D. hypertension. Symptoms associated with pheochromocytoma include paroxysmal headache. Thus. stress. In patients with pheochromocytoma. and parathyroid adenoma. Chest-wall compliance decreases because of excessive adipose tissue over the thorax. Phenoxybenzamine is an irreversible. nonselective a-adrenergic receptor antagonist used preoperatively for adrenergic blockade in patients with pheochromocytomas. presenting most often in the postanesthesia care unit or in the immediate postoperative period (24 hours). 7. D. resulting in a decreased FRC. amiodarone. Obesity is associated with obstructive sleep apnea. and adrenergic drugs such as pseudoephedrine. an elevated creatinine kinase. 8. infection. With obesity. 9. thereby reducing sympathetic activity. 6. A. and iodinated contrast media. Pheochromocytoma is a catecholamine-secreting tumor and is part of the multiple endocrine neoplasia (MEN) type II syndrome. a-blockade is always started prior to P-blockade. which consists of pheochromocytoma. and palpitations. Clinical signs of the optimal dose of phenoxybenzamine are a stuffy nose and slight dizziness due to postural hypotension. Supportive treatment includes cooling. tachycardia. it is not associated with muscle rigidity. While inadequate anesthesia and thyroid storm may result in intraoperative hypertension and tachycardia. Iodide blocks the release of preformed thyroid hormones. and drugs including chemotherapeutic agents. Hypertension may be followed by congestive heart failure that is associated with hypotension and shock. or acidosis. It blocks both the postsynaptic a! and presynaptic a2 receptors in the nervous system. B. 10. the most likely diagnosis is pheochromocytoma. and P-blockers to control heart rate.

B. Refeeding syndrome can occur in malnourished patients who are acutely fed (either enterally or parenterally). respiratory failure. A. increases time to oxygen desaturation after preoxygenation. difficult endotracheal intubation. large tongue. it is unlikely to cause muscle cramps. and thus. Supine positioning and sedative agents make the upper airway even more prone to obstruction. For lipid-soluble drugs. Nondiabetic obese patients are not at increased risk of aspiration of gastric contents. hypertension. Stridor due to bilateral vocal cord paralysis is evident immediately on extubation and would require reintubation to establish a patent airway. 13. Preoperative preparation is essential for caring for the obese patient. Obese patients have a smaller volume of distribution for water-soluble drugs. dosing of these drugs should be based on ideal body weight to avoid overdosing. maintenance doses should be administered less frequently. Thus. since the upper airway abnormalities associated with OSA (increased neck circumference. Treatment consists of normalizing the serum calcium level with intravenous calcium. OSA is associated with increased perioperative complications including cardiac arrhythmias. 12. Hypercapnia associated with severe OSA can lead to right-heart failure. and moves the chest and abdominal tissue caudally to allow easier access to the mouth for endotracheal intubation. Placement of the patient in the reverse Trendelenburg position during intubation is advantageous because it reduces atelectasis. and appropriate dosing of medications. patients with OSA may require CPAP in the immediate postoperative period. as they may have smaller gastric fluid volumes at higher pH than do lean nondiabetic patients. 14. Hypophosphatemia is the hallmark biochemical feature of refeeding syndrome. It is caused by increased adenosine triphosphate production and metabolic rate. Patients with OSA may have an increased likelihood of difficult intubation. Sodium bicarbonate would cause a metabolic alkalosis and potentially worsen symptoms of hypocalcemia by decreasing ionized calcium levels. tetany. Thus. decreased cross-sectional area of the upper airway) may also predispose to difficult intubation. myocardial ischemia. weakness. . and stridor. C. antithyroid medication to prevent the utilization of iodine in the synthesis of new thyroid hormones. D. and stroke. However. While a neck hematoma can cause airway compromise due to compression. Perioperative concerns include difficult intravenous access. Larger fat stores provide an increased volume of distribution for lipid-soluble drugs. especially in males and patients with a higher Mallampati score. laryngospasm. obesity may increase the risk of a difficult laryngeal intubation. Administration of cortisol is also recommended to prevent complications from potential coexisting adrenal insufficiency. while a loading dose should be based on actual body weight. and can result in muscle cramps. Hypoparathyroidism resulting from the unintentional removal of the parathyroid glands is a potential complication of thyroidectomy. Low blood calcium levels interfere with normal muscle contraction and nerve conduction. 11. positioning. Other metabolic and electrolyte disturbances may include abnormal sodium and fluid balance. clearance w ill be slower because of the larger volume of distribution. possible need for arterial blood pressure monitoring.

The NICE-SUGAR trial in critically ill patients showed an increased mortality and increased incidence of severe hypoglycemia in patients randomized to intensive glucose control (target glucose range 81-108 mg/dL). thiamine deficiency. The most common perioperative management regimen consists of giving the patient a fraction (usually half) of the morning intermediate-acting insulin dose. A. The primary goal of intraoperative blood sugar management is to avoid hypoglycemia. and changes in glucose. and bronchoconstriction. Short-acting insulin preparations are held because of an increased risk of hypoglycemia and their short duration of action. Patients are symptomatic if they have tumors arising outside of the hepatic portal venous system or when liver metastatic disease has compromised hepatic synthetic function. patients with difficult airways. hypokalemia. If hypoglycemia is a concern. However. Cricoid pressure can be associated with several complications. and when there is difficulty palpating the cricoid cartilage. Carcinoid tumors are slow-growing tumors that secrete serotonin. hypomagnesemia. D. an infusion of dextrose may be started. and fat metabolism. Refeeding syndrome can be avoided by slowly increasing the nutritional intake toward caloric goals. most patients with carcinoid tumors are not symptomatic because the liver detoxifies the excess serotonin. premeal glucose targets should generally be <140 mg/dL and random blood glucose values should be <180 mg/dL. patients with cervical injury. children. Preoperative echocardiography should be considered in patients with carcinoid syndrome. Metformin has a duration of action of 6 to 24 hours (up to 48 hours with the extended release formulation). 18. 17. The technique involves the application of backward pressure on the cricoid cartilage to occlude the esophagus and thus prevents the aspiration of gastric contents during induction of anesthesia. Excess serotonin secretion can result in carcinoid syndrome. C. The sclerosing effect of serotonin on the tricuspid and pulmonary valves can result in right-heart failure. flushing. These complications are more likely in the elderly. The optimal level of glucose control in the perioperative setting remains controversial. more recent data suggest that this risk is low. pregnant women. While it was previously recommended that metformin be discontinued 48 hours preoperatively to avoid risk of fatal lactic acidosis. 16. Patients with a serum calcium >14 mg/dL should be managed with saline and diuresis to decrease their calcium level. kallikrein. However. which is characterized by diarrhea. strong downward pressure can also displace an unstable cervical spine and worsen visualization of the airway by occluding the glottis. For noncritically ill patients treated with insulin. Neuromuscular-blocking agents should be titrated carefully as severe hypercalcemia can result in muscle weakness. In contrast. The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) recommend keeping blood glucose between 140 and 180 mg/dL in critically ill patients. parturients may need more pressure to effectively occlude the esophagus. and histamine. palpitations. A. The left heart is generally not affected because of lung metabolism of serotonin. 15. protein. Prolonged hypercalcemia can result in osteoporosis and risk of vertebral compression fractures with laryngoscopy and bone fractures .

Involvement of the temporomandibular jo in t and the cervical spine can . This risk is increased by concomitant use of P- blockers.g. 25. hypertension. longstanding diabetes. Hypersecretion of aldosterone results in increased sodium reabsorption in the distal renal tubule in exchange for potassium and hydrogen ions. beginning at the time of surgery and taper the replacement over 48 to 72 hours. 22. hypertension may still occur. weight gain. Hypoventilation should be avoided as acidosis increases ionized calcium levels. Despite adequate preoperative a. Limited jo in t m obility syndrome is due to glycosylation of tissue proteins due to chronic hyperglycemia. 24. 21. during transport. and thus are more likely to have hemodynamic instability and even sudden cardiac death. hypokalemia. glucose intolerance. Diabetic patients with hypertension. hypokalemia. This results in fluid retention. and angiotensin-receptor blockers. C. metabolic alkalosis. It is characterized by hand stiffness. easily titrated agents such as nitroprusside or nicardipine. C. This may increase to over 300 mg under conditions of stress. One recommended approach is to give a dose between 1 and 5 times the daily cortisol production (no more than 100 to 150 mg of cortisol equivalent) per day.. spine) may be involved. The dose of steroids needed is controversial though. Intraoperative management of pheochromocytoma resection includes avoidance of drugs (e. the most likely cause in this patient is diabetic autonomic neuropathy.and ^-blockade. though other joints (wrists. Patients with autonomic neuropathy are unable to compensate for intravascular volume changes with an increased heart rate. 20. angiotensin-converting enzyme inhibitors. ephedrine) or techniques that may stimulate the sympathetic nervous system. A. coronary artery disease. D. B. and muscle weakness. While all of the above may cause hypotension on induction of anesthesia. hypertension. Patients with pheochromocytomas are often hypovolemic and become hypotensive. Magnesium infusions have been shown useful in managing hypertension by inhibiting catecholamine release and by altering adrenergic receptor response. and hypoglycemic (lack of catecholamine-induced glucose synthesis) after tumor ligation and resection. hypercoagulability. Adults normally secrete 20 to 30 mg of cortisol daily. Phentolamine may also be useful because it blocks a-adrenergic receptors. 23. Cushing syndrome is characterized by muscle weakness/wasting. These patients should receive perioperative steroid replacement therapy. Patients who have received the equivalent of 5 mg of prednisone or more for a period of more than 2 weeks within the previous 3 months may not be able to respond appropriately to surgical stress due to adrenal suppression. 19. elbows. B. C. Intubation should be performed after a deep level of anesthesia is achieved and hypoventilation should be avoided. feet. and old age are more likely to have autonomic dysfunction. and osteoporosis. ketamine. These should be treated with short-acting.

result in difficult endotracheal intubation. .

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Nitrous oxide B. Increase in PacO2 w ill increase IOP 5. A ll of the follow ing w ill serve to decrease intraocular pressure (IOP). Increase in Pao2 w ill decrease IOP C. Nose. Ear. except A. Morphine D. 25 D. Correct consequence of respiratory variables on intraocular pressure (IOP) is A. Trabecular network C. Acidosis C. Drainage of aqueous humor occurs at all of these sites. except A. The normal intraocular pressure (IOP) is _______(mm Hg): A. Tear ducts 3. Vecuronium . Canal of Schlemm B. 10 C. The most accurate statement regarding absorption of topically administered ophthalmic drugs is that they are absorbed A. Decrease in Paco2 w ill increase IOP D. Episcleral venous system D. Similar to oral absorption D. Slower than subcutaneous absorption B.Ophthalmic. 5 B. Faster that intravenous absorption C. 30 4. Decrease in Pao2 w ill decrease IOP B. and Throat Surgery Thoha Pham 1. Slower than intravenous absorption 2.

An air bubble is injected into the posterior chamber at the conclusion of retinal surgery (pneumatic retinopexy) to facilitate anatomically correct healing. Hypokalemic metabolic acidosis C. except A. Nondepolarizing relaxant C. Ensure adequate muscle relaxation D. sulfur hexafluoride (SF6) bubble injected follow ing vitreous surgery A. . Atropine-resistant bradycardia 9. except A. Following an uneventful inhaled induction with sevoflurane. Increases in intraocular pressure (IOP) follow ing succinylcholine administration for tracheal intubation can be minimized by all of the following. The most appropriate anesthetic management. Is contraindicated in outpatient surgery Questions 11 to 14 A 22-month-old 14. Lidocaine 7. Compared with air. Patient denies other medical issues. Is more soluble in blood than nitrogen C. patient was given 20 mg of succinylcholine prior to intubation. Masseter spasm was noted moments later. Potential anesthetic considerations as a result of eye drops include all of the following. is A. She states that she uses eye drops to treat glaucoma. peripheral IV was obtained. Detachment of extraocular muscles from the globe D. ^-Adrenergic blocker B. Increase depth of anesthesia B. Myoclonus 8. Is inert and w ill not expand D. The ocular effects of ketamine includes A. Has a longer duration of action B. Pupillary constriction B. 6. however states that she frequently has acid reflux. but does not know exact names.5-kg “ preemie” is undergoing strabismus repair under general endotracheal anesthetic (GETA). Hyperchloremic metabolic acidosis B. Prolonged neuromuscular block with succinylcholine D. Discontinue nitrous oxide (N2O) C. An 82-year-old female patient who resides in a nursing home facility presents for breast biopsy. before the air bubble is injected. Decrease in intraocular pressure D. and by oversight. Hyperventilate the patient 10. Blepharospasm C.

Suppressed by general anesthesia 16. At the conclusion of the surgery.11. Lim iting opioids D. Phenylephrine 14. Vagus nerve trigeminal nerve D. Incidence is increased in the setting of hypercarbia C. Trigeminal nerve B. Hypotension C. Propofol infusion C. Optic nerve vagus nerve C. respectively. Intensity increases with repeated stimulation D. Vagus nerve C. patient’s heart rate plummets from 110 bpm down to 55 bpm. Deep extubation 15. The most appropriate first step in the management of this hemodynamic instability is A. A ll of the follow ing anatomic structures may participate in triggering an acute and abrupt bradycardia during ophthalmic surgery. Optic nerve . Trigeminal nerve vagus nerve B. It does not occur in enucleated patients B. The true statement regarding an oculocardiac reflex is A. The pairing that accurately reflects the afferent and efferent limbs. Globe D. Trochlear Nerve optic nerve 13. postoperative na