Module: ASA Monitoring Standards and ASA

Sedation Guidelines
Slides (3-11)

Monitoring Standards and Sedation

• It is important to distinguish between
“monitored anesthesia care” and
“sedation/analgesia”
ANESTHESIA PROCEDURES, METHODS,
• In October 2004, the American Society of
& TECHNIQUES IV
Anesthesiologists (ASA) approved:
Jerrold Lerman, MD • Sedation/ analgesia is the term currently used
Clinical Professor of Anesthesiology by the ASA in their recently published Practice
John R. Oishei Children’s Hospital, Guidelines for Sedation and Analgesia by Non-
Jacobs School of Medicine and Biomedical Anesthesiologists
Sciences, • Monitored anesthesia care implies the potential
Buffalo, NY for a deeper level of sedation than that
jerrold.lerman@gmail.com provided by sedation/analgesia and is always
administered by an anesthesiologist provider
The standards for preoperative evaluation,
Question Based Learning
intraoperative monitoring, and the continuous
Lecture Modules presence of a member of the anesthesia care
team, and so forth, are no different from those
• American Society of Anesthesiologists (ASA)
for general or regional anesthesia
Monitoring Standards and ASA Sedation
ASA position statement that defines monitored
Guidelines
anesthesia care as follows
• Selected Complications of Anesthesia
• Monitored anesthesia care is a specific
anesthesia service for a diagnostic or
therapeutic procedure. Indications for
monitored anesthesia care include the nature
of the procedure, the patient's clinical
condition, and/or the potential need to convert
to a general or regional anesthetic
• Monitored anesthesia care includes all aspects
of anesthesia care, the anesthesiologist
provides or medically directs a number of
specific services
– Diagnosis and treatment of clinical problems
– Support of vital functions
– Administration of all medications needed
– Psychological support and physical comfort
– Provision of other medical services as needed
to complete the procedure safely

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 1
Distribution is a violation of copyright laws.
Monitoring Standards and Sedation cont’d
ASA position statement that defines monitored
anesthesia care as follows cont’d
• Monitored anesthesia care may include varying
levels of sedation, analgesia, and anxiolysis as
necessary. The provider may have to convert to
general anesthesia. If the patient loses
consciousness and the ability to respond
purposefully, the anesthesia care is a general
anesthetic, irrespective of whether airway
instrumentation is required
• Monitored anesthesia care should be subject to
the same level of payment as general or
regional anesthesia
• ASA states that all institutional regulations
pertaining to anesthesia services shall be
observed, and all the usual services performed
by the anesthesiologist shall be furnished,
including but not limited to
– Usual non-invasive cardiocirculatory and
respiratory monitoring
– Oxygen administration, when indicated
– Administration of sedatives, tranquilizers,
antiemetics, narcotics, other analgesics,
beta-blockers, vasopressors, bronchodilators,
antihypertensives, or other pharmacologic
therapy as may be required in the judgment
of the anesthesiologist
• Controversy exists regarding the level of
training required for non-anesthesiologists to
be credentialed to provide moderate and deep
sedation
• The ASA released a statement in October 2005,
amended in October 2006, suggesting a
framework for granting privileges that will help
ensure competence of individuals who
administer or supervise the administration of
moderate sedation
• In 2005 and 06, ASA recommended complete
formal training in
– (1) the safe administration of sedative and
analgesic drugs used to establish a level of
moderate sedation, and
– (2) rescue of patients who exhibit adverse
physiologic consequences of a deeper-than-
intended level of sedation
Notes:
Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV
This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384
Distribution is a violation of copyright laws.
Monitoring Standards and Sedation cont’d
• Because of the significant risk that patients who
receive deep sedation may enter a state of
general anesthesia, privileges to administer
deep sedation should be granted only to
practitioners who are qualified to administer
general anesthesia or to appropriately
supervised anesthesia professionals
Question: Standard II of the ASA’s Standards for
basic anesthetic monitoring requires all of the
following except which one?
A. Physical presence of an anesthesia care
provider
B. An oxygen analyzer with a low FiO 2 alarm
C. A means for measuring patient
temperature
D. A device to signal disconnection from the
mechanical ventilator
Monitoring Standards and Sedation
• Standards for basic anesthetic monitoring have
been established by the ASA. Since 1986, these
standards have emphasized the importance of
regular and frequent measurements,
integration of clinical judgment and experience,
and the potential for extenuating circumstances
that can influence the applicability or accuracy
of monitoring systems
• Standard I requires qualified personnel to be
present in the operating room during general
anesthesia, regional anesthesia, and monitored
anesthesia care to monitor the patient
continuously and modify anesthesia care based
on clinical observations and the responses of
the patient to dynamic changes resulting from
surgery or drug therapy
• Standard II focuses attention on oxygenation,
ventilation, circulation, and temperature
– Using an oxygen analyzer with a
low concentration-limit alarm during GA
– Quantitatively assessing blood oxygenation
during any anesthesia care
– Continuously ensuring the adequacy of
ventilation by physical diagnostic techniques
during all anesthesia care. Identification of
expired carbon dioxide is performed unless
nullified by the type of patient, procedure, or
equipment
2
Monitoring Standards and Sedation cont’d
– Quantitative monitoring of tidal volume and
capnography is strongly encouraged in
patients undergoing general anesthesia
– When administering regional anesthesia or
monitored anesthesia care,
sufficient ventilation should be assessed by
qualitative clinical signs and/or monitoring of
exhaled carbon dioxide
– Ensuring correct placement of a tracheal
tube or laryngeal mask airway (LMA) requires
clinical assessment and qualitative
identification of carbon dioxide in the expired
gas. During general anesthesia, capnography
and end-tidal carbon dioxide analysis is
performed
– When using a mechanical ventilator, there
should be a device that is able to detect
a disconnection of any part of the breathing
system
– The adequacy of circulation should be
monitored by the continuous display of
the EKG, and by determining the
arterial blood pressure and heart rate at least
at 5 min intervals. During general anesthesia,
circulatory function is to be continually
evaluated by the quality of the pulse, either
electronically or by palpation or auscultation
– During all anesthetics, the means for
continuously measuring the
patient's temperature must be available.
When changes in body temperature are
intended or anticipated, temperature should
be continuously measured and recorded on
the anesthesia record
Module: Selected Complications of
Anesthesia
Slides (12-45)
Question: Which of the following would produce
the worst impact on the ability to spontaneously
ventilate?
A. Bilateral sentinel lymph node (SLN) injury
B. Unilateral Recurrent laryngeal nerve
(RLN) injury
C. Bilateral RLN injury
D. Bilateral Vagus nerve injury
Airway Injury
• Unilateral denervation of a cricothyroid muscle
causes very subtle clinical findings
• Bilateral palsy of the SLN may result
in hoarseness or easy tiring of the voice, but
airway control is not jeopardized
• Bilateral injury to the vagus nerve affects both
the superior and the recurrent laryngeal nerves.
Thus, bilateral vagal denervation
produces flaccid, midpositioned vocal cords
similar to those seen after administration of
succinylcholine. Although phonation is severely
impaired in these patients, airway control
is rarely a problem
• Unilateral paralysis of a RLN results in paralysis
of the ipsilateral VC, causing a deterioration in
voice quality
• Acute bilateral recurrent laryngeal nerve palsy
can result in stridor and respiratory distress
because of the remaining unopposed tension
of the cricothyroid muscles
• Airway problems are less frequent
in chronic bilateral recurrent laryngeal nerve
loss because of the development of
various compensatory mechanisms (e.g.,
atrophy of the laryngeal musculature)

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 3
Distribution is a violation of copyright laws.
Airway Injury cont’d

Anterior Ethmoid N
Sphenopalatine N
(V1)
(V2)

Lingual N
(V3)
CN 9

SLN (Int)

RLN

Question: Compared with high-pressure/low- Airway

volume cuffs, endotracheal tubes (ETTs) with • There are two major types of cuffs: high
low-pressure/high volume cuffs are more likely pressure (low volume) and low pressure (high
to cause all of the following except which one? volume)
A. Passive aspiration • High-pressure cuffs are associated with
B. Sore throat more ischemic damage to the tracheal mucosa
C. Mucosal damage and are less suitable for intubations of long
D. Spontaneous extubation duration
• Low-pressure cuffs may increase the likelihood
of sore throat (larger mucosal contact
area), aspiration, spontaneous extubation,
and difficult insertion (because of the floppy
cuff)

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 4
Distribution is a violation of copyright laws.
Airway
TRUE or FALSE
• Laryngeal trauma is more likely to occur during
routine (non-difficult) tracheal intubation
compared with difficult laryngoscopies
TRUE
• The ASA Closed Claims Database reveals that
claims for laryngeal injury during DL arise more
often in “easy” as opposed to difficult
laryngoscopies
• In the ASA Closed Claim Database, 87 instances
of laryngeal trauma were recorded (out of 4460
cases). Of these, 80% occurred during routine
(easy) tracheal intubation, in which no injury
was suspected
Question: During deliberate hypothermia,
temperature measurement at which of the
following sites will MOST likely lag behind the
true core body temperature?
A. Middle ear
B. Esophagus
C. Bladder
D. Nasopharynx
Hypothermia
• Both general and regional anesthesia inhibit
afferent and efferent control of
thermoregulation
• Heat losses may result from radiation,
convection, evaporation, and conduction,
– Radiation refers to the infrared rays
emanating from all objects above absolute
temperature
– Convection refers to the transfer of heat
from air passing by objects
– Evaporation represents the heat loss that
results when water vaporizes
– Conduction refers to the transfer of heat
from contact with objects
• Perioperative hypothermia predisposes patients
to  in metabolic rate (shivering) and cardiac
work,  in drug metabolism and cutaneous
blood flow, and impairs coagulation
Notes:
Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV
This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384
Distribution is a violation of copyright laws.
Question: Which of the following patients is
LEAST likely to exhibit a decrease in body
temperature?
A. A patient in spontaneous labor receiving
epidural anesthesia for 8 hr
B. A patient undergoing a appendectomy
under general anesthesia for 1 hr
C. A patient undergoing abdominoplasty
under monitored anesthesia care for 1 hr
D. A patient undergoing spinal anesthesia
for a 30 min knee arthroscopy
Hypothermia
• Hyperthermia frequently complicates epidural
analgesia for labor and delivery
– It is more likely during prolonged labor (i.e.,
>8 hrs)
–  Body temperature in laboring and
postoperative patients is presumably true
fever (i.e., a regulated increase in core
temperature) resulting from infection or
inflammation
– The conventional assumption is that
hyperthermia is caused by the technique,
although no convincing mechanism has been
proposed
• It is worth remembering, though, that pain
in “control” patients is usually treated with
opioids—which themselves attenuate
fever. Fever associated with infection or
tissue injury might then be suppressed by
the low doses of opioids that are usually
given to the “control” patients while being
expressed normally in patients given
epidural analgesia The extent to which this
mechanism contributes remains to be
determined and has been disputed, but no
convincing alternative explanation has
been advanced
• Even during cardiopulmonary bypass, the core
temperature–monitoring sites (e.g., tympanic
membrane, nasopharynx, pulmonary artery,
and esophagus) remain useful
• In contrast, rectal temperatures lag behind
those measured in core sites. Consequently,
rectal temperature is considered an
“intermediate” temperature in deliberately
5
 cooled patients
Hypothermia cont’d
• During cardiac surgery, bladder temperature is
equal to rectal temperature (and therefore
intermediate) when urine flow is low, but it is
equal to pulmonary artery temperature (and
thus core) when flow is high
– Because bladder temperature is strongly
influenced by urine flow, it may be difficult to
interpret in these patients. Adequacy of
rewarming is best evaluated by considering
both “core” and “intermediate”
temperatures
• Core temperature usually decreases 0.5°C to
1.5°C in the first 30 mins after induction of
anesthesia
• Core temperature perturbations during the first
30 mins of anesthesia are thus difficult to
interpret, and measurements are not usually
required
• Body temperature should, however, be
monitored in patients undergoing general
anesthesia exceeding 30 mins in duration and in
all patients whose surgery lasts longer than 1 hr
• The ASA standards require only that “every
patient receiving anesthesia shall have
temperature monitored when clinically
significant changes in body temperature are
intended, anticipated, or suspected.” For office-
based sedation, regional anesthesia, or general
anesthesia, the ASA also requires that “the
body temperature of pediatric patient shall be
measured continuously”
Ocular Complications
• The most common ocular complication of
general anesthesia is corneal abrasion
• A variety of mechanisms can result in corneal
abrasion, including
– Damage caused by the anesthetic mask
– Surgical drapes, and spillage of solutions
– During intubation of the trachea, the end of
plastic watch bands or hospital identification
cards clipped to the laryngoscopist's vest
pocket can injure the cornea
– Ocular injury may also occur from loss of pain
sensation, obtundation of protective corneal
reflexes, and decreased tear production
Notes:
Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV
This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384
Distribution is a violation of copyright laws.
during anesthesia
Ocular Complications
• Therefore, it may be prudent to tape the eyelids
closed immediately after induction, and during
mask ventilation and laryngoscopy
• In addition to taping the eyelids closed,
applying protective goggles and instilling
petroleum-based ointments into the
conjunctival sac may provide protection
– Disadvantages of ointments include
occasional allergic reactions
– Flammability, which may make their use
undesirable during surgery around the face
and contraindicated during laser surgery and
blurred vision in the early postoperative
period
– The blurring and foreign-body sensation
associated with ointments may
actually increase the incidence of
postoperative corneal abrasions if they
trigger excessive rubbing of the eyes while
the patient is still emerging from anesthesia
• Patients with corneal abrasion usually complain
of a foreign-body sensation, pain, tearing, and
photophobia
• The pain is typically exacerbated by blinking and
ocular movement
• It is wise to have an ophthalmologic
consultation immediately
• Treatment typically consists of the prophylactic
application of antibiotic ointment and patching
the injured eye shut
• Although permanent sequelae are possible,
healing usually occurs within 24 hr
• Because of a perceived increase in the
incidence of postoperative visual loss since the
mid-1990s, the Committee on Professional
Liability of the ASA established the
Postoperative Visual Loss Database on July 1,
1999, to better identify associated risk factors
so these tragic complications might be
prevented in the future
• The incidence of postoperative vision loss after
spine surgery in the prone position (posterior
ischemic optic neuropathy) up to 1%: assoc’d
with males, hypotension, anemia, >6 h surgery,
increased venous/eyeball pressure, less colloids
Source: Goepfert CE, et al. Curr Opin Anaesth 2010:23;582.
6

Ocular Complications
• Although the multifactorial pathophysiology
of anterior ischemic optic neuropathy has not
been completely established, it is believed to
involve temporary hypoperfusion or non-
perfusion of the vessels supplying the anterior
portion of the optic
– Coexisting systemic disease, especially
involving the cardiovascular system and (to a
lesser extent) the endocrine system, is
common in patients in whom anterior
ischemic optic neuropathy develops. Male
gender also strongly predominates. Other
risk factors for postoperative anterior
ischemic optic neuropathy include coronary
artery bypass graft (CABG) and other
thoracovascular operations, as well as spinal
surgery
– Other possible risk factors are increased
intraocular pressure (IOP) or orbital venous
pressure. Anterior ischemic optic neuropathy
is not usually caused by emboli because
emboli preferentially lodge in the central
retinal artery rather than in the short
posterior ciliary arteries that supply the
anterior optic nerve
– Pts typically have painless visual loss that
may not be noted until the first
postoperative day (or possibly later), an
afferent pupillary defect, and optic disc
edema or pallor. MRI or CT initially shows
enlargement of the optic nerve
– Therapy includes intravenous acetazolamide,
furosemide, mannitol, and steroids
• The posterior optic nerve has a less luxuriant
blood supply than the anterior optic nerve
– In contrast to anterior ischemic optic
neuropathy, relatively few cases have been
reported after CABG, and posterior ischemic
optic neuropathy appears to be less related
to coexisting cardiovascular disease. As with
anterior ischemic optic neuropathy, male
patients outnumber female patients four to
one
– Posterior ischemic optic neuropathy is
produced by reduced oxygen delivery to the
retrolaminar part of the optic nerve. Most
Notes:
Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV
This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384
Distribution is a violation of copyright laws.
likely, compression of the pial vessels
Ocular Complications cont’d
– Typical findings include an afferent pupillary
defect or nonreactive pupil. Disc edema is
not a feature of posterior ischemic optic
neuropathy because of its retro-orbital
position. CT scan in the early postoperative
period may reveal enlargement of the
intraorbital portion of the optic nerve.
Bilateral blindness is more common with
posterior ischemic optic neuropathy than
with anterior ischemic optic neuropathy,
possibly indicating involvement of the optic
chiasm
– A review of the first 6 yrs of cases submitted
to the ASA Postoperative Visual Loss Registry
found that spine surgery patients at greatest
risk for ischemic optic neuropathy and visual
compromise include those with predisposing
patient-specific factors, surgery exceeding 6
hrs.’ duration, and blood loss of more than a
liter
Question: Which of the following statements
regarding ulnar neuropathy (UN) is considered
false?
A. High body mass index (BMI) is a risk factor
for UN
B. There exists a high frequency of patients
who complain of UN that have
contralateral ulnar nerve conduction
deficits
C. The majority of complaints of UN will
occur in the first 12 postoperative hr
D. Prevalence in men greater than women
7
 References for Difficult Intubation
Ulnar Neuropathy
• Shiga T, Wajima Z, Inoue T et al: Predicting
• Typically, anesthesia-related ulnar nerve injury
Difficult Intubation in Apparently Normal
is thought to be associated with external nerve
Patients: A Meta-analysis of Bedside Screening
compression caused by malpositioning.
Test Performance. Anesthesiology 2005; 103:
Although this implication may be true for some
429.
patients, three findings suggest that other
• El-Ganzouri AR, McCarthy RJ, Tuman KJ et al:
factors may contribute
Preoperative airway assessment: predictive
– First, patient characteristics (e.g., male sex,
value of a multivariate risk index. Anesth Analg
high body mass index [>38], and prolonged
1996; 82: 1197.
postoperative bed rest) are associated with
• Wilson ME, Spiegelhalter D, Robertson J et al:
these ulnar neuropathies. Various reports
Predicting difficult intubation. Br J Anaesth
suggest that 70% to 90% of patients who
1988; 61: 211.
have this problem are men
• Naguib M, Malabarey T, AlSatli RA et al:
– Second, many patients with perioperative
Predictive models for difficult laryngoscopy. A
ulnar neuropathies have a high frequency of
clinical, radiologic and three dimensional
contralateral ulnar nerve conduction
computer imaging study. Can J Anesth 1999; 46:
dysfunction. This finding suggests that many
748.
of these patients likely have asymptomatic
• American Society of Anesthesiologists Task
but abnormal ulnar nerves before their
Force on Management of the Difficult
anesthetics, and these abnormal nerves may
Airway: Practice guidelines for management of
become symptomatic during the
the difficult
perioperative period
airway. Anesthesiology 2003; 98:1269-1277.An
– Finally, many patients do not notice or
updated report by the American Society of
complain of ulnar nerve symptoms until >48
Anesthesiologists Task Force on Management
hrs after their surgical procedures. A
of the Difficult Airway.
prospective study of ulnar neuropathy in
• Karkouti K, Rose DK, Wigglesworth D, Cohen
1,502 surgical patients found that none
MM: Predicting difficult intubation: A
of the patients had symptoms of the
multivariable analysis. Can J
neuropathy during the first 2 postoperative
Anaesth 2000; 47:730-739.
days
• Rosenstock C, Gillesberg I, Gatke MR, et
• Why are men more likely to have this
al: Inter-observer agreement of tests used for
complication?
prediction of difficult laryngoscopy/tracheal
– First, two anatomic differences may increase
intubation. Acta Anaesthesiol
the chance of ulnar nerve compression in the
Scand 2005; 49:1057-1062.
region of the elbow. The tubercle of the
• Rose DK, Cohen MM: The airway: Problems and
coronoid process is approximately 1.5 times
predictions in 18,500 patients. Can J
larger in men than women. In addition, there
Anaesth 1994; 41:372-383.
is less adipose tissue over the medial aspect
• Lee A, Fan LT, Gin T, et al: A systematic review
of the elbow of men compared with women
(meta-analysis) of the accuracy of the
of similar body fat composition
Mallampati tests to predict the difficult
– Second, men may be more likely to have a
airway. Anesth Analg 2006; 102:1867-1878.
well-developed cubital tunnel retinaculum
than women, and the retinaculum is thicker

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 8
Distribution is a violation of copyright laws.
References for Difficult Ventilation
• Langeron O, Masso E, Huraux C et al: Prediction
of difficult mask ventilation. Anesthesiology
2000; 92: 1229.
• Kheterpal S, Han R, Tremper KK et al: Incidence
and predictors of difficult and impossible mask
ventilation. Anesthesiology 2006; 105: 885.
References for Preoxygenation
• Benumof JL: Preoxygenation: Best method for
both efficacy and efficiency (editorial).
Anesthesiology 1999; 91: 603.
• Jense HG, Dubin SA, Silverstein PI et al: Effect of
obesity on safe duration of apnea in
anesthetized humans. Anesth Analg 1991; 72:
89.
• Baraka AS, Taha SK, Aouad MT et al:
Preoxygenation: Comparison of maximal
breathing and tidal volume breathing
techniques. Anesthesiology 1999; 91: 612.
• Taha SK, Siddik-Sayyid SM, El Khatib MF et al:
Nasopharyngeal oxygen insufflation following
pre-oxygenation using the four deep breath
technique. Anaesthesia 2006; 61: 427.
• El-Khatib MF, Kanazi G, Baraka AS: Noninvasive
bilevel positive airway pressure for
preoxygenation of the critically ill morbidly
obese patient. Can J Anaesth 2007; 54: 744.
• Dixon BJ, Dixon JB, Carden JR et al:
Preoxygenation is more effective in the 25
degrees head-up position than in the supine
position in severely obese patients: a
randomized controlled study. Anesthesiology
2005; 102: 1110.
• Baraka AS, Hanna MT, Jabbour SI et al:
Preoxygenation of pregnant and nonpregnant
women in the head-up versus supine position.
Anesth Analg 1992; 75: 757.
Answer Key
Question: Standard II of the ASA’s Standards for
basic anesthetic monitoring requires all of the
following except which one?
A. Physical presence of an anesthesia care
provider
B. An oxygen analyzer with a low FiO 2 alarm
C. A means for measuring patient
temperature
D. A device to signal disconnection from the
mechanical ventilator
Question: Which of the following would produce
the worst impact on the ability to spontaneously
ventilate?
A. Bilateral sentinel lymph node (SLN) injury
B. Unilateral Recurrent laryngeal nerve
(RLN) injury
C. Bilateral RLN injury
D. Bilateral Vagus nerve injury
Question: Compared with high-pressure/low-
volume cuffs, endotracheal tubes (ETTs) with
low-pressure/high volume cuffs are more likely
to cause all of the following except which one?
A. Passive aspiration
B. Sore throat
C. Mucosal damage
D. Spontaneous extubation
Question: During deliberate hypothermia,
temperature measurement at which of the
following sites will MOST likely lag behind the
true core body temperature?
A. Middle ear
B. Esophagus
C. Bladder
D. Nasopharynx

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 9
Distribution is a violation of copyright laws.
Question: Which of the following patients is
LEAST likely to exhibit a decrease in body
temperature?
A. A patient in spontaneous labor receiving
epidural anesthesia for 8 hr
B. A patient undergoing an appendectomy
under general anesthesia for 1 hr
C. A patient undergoing abdominoplasty
under monitored anesthesia care for 1 hr
D. A patient undergoing spinal anesthesia
for a 30 min knee arthroscopy

Question: Which of the following statements

regarding ulnar neuropathy (UN) is considered
false?
A. High body mass index (BMI) is a risk factor
for UN
B. There exists a high frequency of patients
who complain of UN that have
contralateral ulnar nerve conduction
deficits
C. The majority of complaints of UN will
occur in the first 12 postoperative hr
D. Prevalence in men greater than women

End of Lecture

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques IV

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 10
Distribution is a violation of copyright laws.