The American Board of Anesthesiology Practice Examination Questions

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PRACTICE SET #1:
Session 1
A 52 y.o., 130 kg, 5’8” man (BSA 2.5 m2) is scheduled for quadruple coronary artery bypass grafting and mitral valve
replacement.
HPI: Patient suffered an acute myocardial infarction complicated by chronic heart failure and post-infarct mitral
insufficiency 5 days ago. Cardiac catheterization revealed multivessel coronary artery disease and an
ejection fraction of 30%. Two-dimensional echocardiography demonstrated 3 to 4+ mitral regurgitation.
Cardiac function is supported by infusion of dobutamine and intraaortic balloon counterpulsation.
PMH: Underwent successful balloon angioplasty of the LAD 2 years ago. Left ventricular ejection fraction at that
time was 60%. He also has hypertension; Type II diabetes mellitus; hypercholesterolemia; and reflux
esophagitis.
MEDS: Metformin, nitroglycerin, metoprolol, pravachol and omeprazole. Dobutamine and heparin infusions.
PHYS Augmented BP 85/55 (mean 68); HR 106; RR 22; T 37°C.

EXAM: Airway: normal
Chest: auscultation reveals bibasilar rales and an S3 gallop with a 3/6 systolic murmur radiating to the
axilla.
CXR: Enlarged cardiac silhouette, mild pulmonary edema. Intraaortic balloon pump tip noted in proximal descending
aorta.
ECG: Sinus tachycardia, inferior Q waves with anterolateral ST depression.
LABS: Hgb 13.5 gm/dl; glucose 150 mg/dl; serum K+ 3.3 mEq/L; ABG on 50% O2 by mask; PaO2 71; PaCO2 33;
pH 7.43; creatinine 1.8 mg/dl.
Patient arrives in the OR with unchanged vital signs but with increasing chest pain. Two peripheral IVs, an arterial
catheter and a pulmonary artery catheter are in place.
The American Board of Anesthesiology, Inc. Practice Examination Questions 5/11 Page 1 of 24
PRACTICE SET #1:
Session 1 - Continued
A. INTRA-OPERATIVE MANAGEMENT
1. Induction: Does history of obesity or reflux esophagitis influence your induction technique? How? Choice of
muscle relaxant? Would you expect induction with fentanyl and midazolam to decrease systemic BP? Why/why
not? Can it be prevented? How? In spite of best attempts, BP falls to 80/40 with induction and ST segment
depressions become more marked. Of concern? Why? Rx? Volume? To what end point? Phenylephrine? Would
approach change if PAP increased to 70/40? How?
2. Anesthetic maintenance: Is isoflurane an appropriate choice for maintenance? Why/why not? Is myocardial
depression with isoflurane an issue with this pt? Explain. Would sevoflurane be different? Your choice for
maintenance? Why? Compare fentanyl to sufentanil as maintenance opioids. Implications of these opioids for
postop emergence? Extubation?
3. Anticoagulation: Pt receives heparin prior to going onto bypass with no change in his ACT. DDx. Further
evaluation necessary? Rx? Add’l heparin? FFP? Why? Goal for ACT before institution of CPB?
4. Low CI post CPB: After CPB, the pt’s CI is 1.6, PAP is 75/35, and BP is 80/40 with high dose epinephrine
infusing and IABP at 1:1. DDx? Do you need add’l info? SVR is high. How will it impact Rx? Role of
phosphodiesterase inhibitors?
B. POST-OPERATIVE CARE
1. Postop ventilatory support: Pt received 28 micrograms/kg of fentanyl intraop. Assume cardiac index now 2.0
L/min/m2. Is he candidate for early extubation following ICU admission? Why/why not? Is SIMV a useful
weaning mode for this pt? Why/why not? Pressure-support ventilation? Why/why not?
2. Coagulopathy: Over first 2 hrs, 450 ml of chest tube drainage is measured. Possible causes of bleeding? PT
measured at 17 seconds (INR 1.8) and platelet count 95,000. Could these explain the bleeding? Any other tests
indicated? Assuming normal ACT at end of surgery, why might PT now be prolonged? Your Rx? Is a platelet
transfusion indicated? Why/why not? Hct is 27. Is transfusion of PRBC indicated?
3. Cardiac tamponade: At 6 hrs postop, CVP 22; PA 46/25; cardiac index 1.5; and minimal UO. DDx? Further
diagnostic studies helpful? Which? Clots now noted in chest tubes without drainage. Tamponade suspected, with
mediastinal exploration planned shortly. Your immediate priorities in ICU? Is diuretic indicated? Why/why not?
How will you maintain CO until OR?
4. Hyperglycemia: Assume tamponade resolved. Blood sugar measured at 460 mg/dl. Is this a concern? Why? Pt not
responding to sliding insulin scale ordered by surgeon. Why not? Alternative therapy? Is insulin infusion
indicated? How Rx? Goals for blood glucose levels? Why?
5. Vocal cord paralysis: POD#2. Pt extubated and hoarseness noted. Possible etiologies? Indirect laryngoscopy
reveals paralyzed left vocal cord. Could this have a surgical etiology? Why/why not? Mechanism(s) of injury if
related to anesthesia? What should be done?
6. Intraop recall: Pt informs you that he heard conversations during surgery. Request add’l info? He denies pain
during episodes of awareness but admits to being very anxious and frightened since surgery. What will you tell
him? Could you have prevented this problem? Change anesthetic next time?
C. ADDITIONAL TOPICS
1. Pre-eclampsia: A 28 y.o., 85 kg, G3P2 woman in term labor is scheduled for emergent C-section for late fetal
heart rate decelerations. She has pregnancy-induced hypertension with proteinuria and edema. HR 84; BP 190/110.
Anesthetic concerns? Lab tests? If coags and PLTs normal, could you proceed with epidural or spinal? Hydrate
and/or treat BP before anesthesia? Would you start MgSO4? Why? How? What would you use for aspiration
prophylaxis? Defend choices.
2. Pediatric pain mgmt: A 10 y.o. girl with cystic fibrosis is scheduled to undergo a fundoplication and gastrostomy
tube placement for the mgmt of gastroesophageal reflux and malnutrition. Vital capacity is 75% predicted and
stable. How will you Rx her pain postop? (systemic opioids, local anesthetic infiltration, NSAIDs, regional block?)
Would epidural analgesia be a good choice in this child? Advantages? Would her malnutrition affect your choice
of analgesia? How?
3. Hypothermia: A 68 y.o. man is emerging from isoflurane/N2O/vecuronium anesthesia following abdominal
surgery. Esophageal T 34ºC. Risks of hypothermia? Why for each? What is adequate Temp end point? Forced-air
hose apparently disconnected intraop from lower body warming blanket causing a second-degree burn to inner
thigh. How explain to family?
PRACTICE SET #1:
Session 2
A 30 y.o., 65 kg, 181 cm man requires right knee arthroscopy. He became lightheaded and fainted briefly while playing soccer,
falling and injuring his knee. He has been taking ibuprofen for pain. Prior surgery associated with severe postop nausea and
vomiting (PONV). Older sibling required unanticipated intensive care after strabismus surgery as a child and records are
unavailable. BP 120/60; P 55; RR 16; T 37°C.
A. PRE-OPERATIVE EVALUATION
1. Preop evaluation: Is it important to know why he fainted? Why/why not? Possible causes? ECG shows prolonged
QT. Concerned? Further evaluation needed? Why/why not? Impact of this finding on preop evaluation? Impact on
anesthetic mgmt?
2. Abnormal family anesthetic history: What is your interpretation of older sibling’s experience after strabismus
surgery? How would you investigate the possible susceptibility to MH? Implications for current case? If CK level
normal and prior anesthetics tolerated without hyperthermia, are precautions necessary? Why/why not?
3. NPO timing and PONV prophylaxis: Significance of prior PONV with anesthesia on this anesthetic? Pt inquires
why N/V occurred after prior anesthetics. Your response? Possible anesthetic strategy to prevent? Role of N 2O in
PONV? Possible pharmacologic strategy to prevent?
4. Preinduction/preemptive analgesia: Pt is outpatient. What can be done pre-incision to reduce postop pain? Role of
pre-incision NSAID’s, local anesthetic infiltration, or regional anesthesia to decrease postop opioid requirement?
What will you do?
B. INTRA-OPERATIVE MANAGEMENT (Assume standard monitors.)

1. Regional anesthesia vs. monitored anesthesia care: Pt requests not to have GA. Can arthroscopy be accomplished
with MAC? What must surgeon do? Can tourniquet discomfort be blocked or attenuated during MAC? How? Pt
requests epidural anesthetic. Any advantage(s) over SAB? Explain. What nerve block(s) is/are alternative(s) to
SAB/epidural? Advantages over neuraxial blocks?
2. Seizure following epidural attempt: During injection of epidural with lidocaine, pt has grand mal seizure. Immediate
treatment priorities? Discuss. Must pt be intubated? Why/why not? Is cardiac toxicity to be expected? Compare
lidocaine, bupivacaine and ropivacaine in this context.
3. GA/ unable to intubate: Assume seizure very brief with no loss of respiration and SpO2 100% throughout.
Appropriate to proceed with GA? Why/why not? Assume GA planned from start with decision to intubate. Despite
normal appearing airway preop, unable to intubate but easy to ventilate. Will you wake the pt up? Your plan? Explain.
4. Arrhythmia following intubation attempts: LMA successfully inserted, but pt now having ventricular bigeminy.
Why is this occurring? Your therapy? If lidocaine bolus successful, but bigeminy recurs, what will you do? Explain.
5. Malignant hyperthermia: Despite spontaneous ventilation and avoidance of volatile anesthetics, hyperpnoea and
tachycardia near the end of the procedure. DDx? EtCO2 rises rapidly and MH tentatively diagnosed. Your treatment
priorities at this time? When is dantrolene indicated? Explain. With LMA, should you attempt to hyperventilate?
Why? Any dangers? Further airway mgmt?
6. Advice to family members: Assume MH crisis resolved and pt is stable in ICU. What do you recommend to family
members? Muscle biopsies? Why/why not?
1. Anterior mediastinal mass: A 32 y.o. woman has a large anterior mediastinal mass. She was unable to lie flat for
a CT scan. GA needed for a sternotomy, biopsy and possible resection of the mass. Concerns? Other evaluation
needed? Echo shows significant right ventricular and atrial compression. Awake intubation? Pt unable to tolerate
fiberoptic attempts. What will you do now? Is mask induction with volatile agent appropriate? Controlled vs.
spontaneous ventilation? Why? Indications for cardiopulmonary bypass?
2. Upper extremity regional: A 24 y.o. man sawed off two fingers and needs urgent reimplantation of the digits. If
regional anesthesia, what technique (interscalene, supraclavicular, axillary)? What local? Why? Catheter
technique? Advantages/disadvantages? What analgesia postop? Surgeon requests stellate ganglion block. Your
response? Stellate ganglion block done and slight shortness of breath develops. Explain.
3. PACU: You are PACU Medical Director and the Patient Relations Office wants unlimited visitors for PACU pts.
Your response? What visitation policy is reasonable for safe pt care? Pediatric vs. adult differ? Why? How? Would
outpatients differ from inpatients? What types of pts would benefit from having a family member or visitor in
PACU? Defend your decisions.
PRACTICE SET #2:
Session 1
A 74 y.o., 85 kg, 5’6” man is brought to the operating room for removal of an infected aortobifemoral graft and
insertion of a right axillofemoral graft.
HPI: The patient has been febrile for 3 days and blood cultures are positive for staphylococcus aureus.
PMH: He has a history of peripheral vascular and coronary artery disease with a myocardial infarction at age 57.
Four months ago he underwent placement of the aortobifemoral graft complicated by wound dehiscence.
His hypertension has been well controlled, and he has a history of atrial fibrillation in the past. Type II
diabetes mellitus had been treated with oral hypoglycemics. He has not smoked cigarettes for the last 15
years. He currently has no symptoms of angina, congestive heart failure or pulmonary disease. He drinks
socially and is allergic to sulfa drugs and meperidine.
MEDS: Atenolol, vancomycin, and digoxin. Sliding scale insulin during this hospitalization for the infected graft.
PHYS BP 150/95; HR 90; RR 20; T 39.1ºC.

EXAM: He is alert and oriented.
Airway: exam is normal (Mallampati Class I).
Lungs: clear, regular rhythm without murmur or gallops noted.
Abdomen: soft with slight pulsations.
CXR: Normal
ECG: NSR with 1° AV block; old inferior wall myocardial infarction; no acute changes.
LABS: ABG: PaO2 79; PaCO2 35; pH 7.39 on room air; K+ 3.9 mEq/L; BUN 15 mg/dl; creatinine 1.0 mg/dl;
glucose 108 mg/dl; Hgb 12.8 gm/dl; WBC 12,400.
Patient is in the operating room with a 16g IV, arterial and pulmonary artery catheters in place. He did not receive any
of his usual cardiac medications preoperatively.
PRACTICE SET #2:
1. Induction/aspiration/bronchospasm: Should this pt receive beta blockers prior to induction? Why/why not? If so,
to what end point? Is thiopental appropriate for induction? Why/why not? If not, your choice? After induction,
difficult to ventilate pt with a mask. How to proceed? SpO2 is falling. Administer muscle relaxant? If so, which?
Place an LMA? Proceed with laryngoscopy? ETT in place, but ventilation does not improve. With auscultation of
the chest extensive wheezing is heard throughout the lung fields. Rx? Gastric contents noted in the ETT. Should
surgery be cancelled?
2. Renal preservation: The endotracheal tube was placed without aspiration/bronchospasm and the surgeon
anticipates prolonged cross clamp time. What precautions would you take to ensure maintenance of optimal renal
function? Explain. Is there a role for mannitol? Furosemide? Dopamine? Fenoldopam?
3. Aortic cross clamp/myocardial ischemia: As the aorta is cross-clamped, the pt’s MAP increases from 85 to 105
mmHg and ST segment depression is noted in lead V5. What is the significance? How will you proceed? Rationale.
Could this have been avoided? Would TEE have been helpful?
4. Septic shock with graft manipulation: As the graft is being removed, the pt’s MAP decreases to 60 mmHg and
HR increases to >90 bpm. What is the likely etiology? The PA catheter reveals a PCWP of 8 mmHg; CI of 3.4
L/min/m2; and SVRI of 275 dynes/sec/cm-5/m2. Interpret. What is your Rx plan? Pharmacologic agents? Choice of
fluids? End point of fluid administration. Why?
1. Bleeding/coagulopathy: Immediately postop, the pt is noted to be bleeding from his wounds and catheter insertion
sites. Discuss your evaluation. Assuming heparin was administered and reversed with protamine intraop, how
would you differentiate residual heparin vs. DIC? If DIC, how would you Rx? Why?
2. Low UO: 40 ml UO in 1st hr after admission to the ICU; then 5 ml/hr. DDx? Rx necessary? Other info needed?
Cardiac index is 2 L/min/m2. Response? Administer add’l intravenous fluid? When to use a diuretic? Which one?
3. Hypoperfusion of hand: 12 hrs postop his left hand is dusky distal to radial arterial catheter. You are the first to
be called. Discuss your evaluation. Rx?
4. Respiratory/ARDS post-sepsis: 36 hrs postop pt is receiving epinephrine to support BP with PCWP 16 mmHg; CI
3.5 L/min/m2; and MAP 68 mmHg with PaO2 65 mmHg on FiO2 0.6. How will you manage his ventilation? What
tidal volume? Rationale? Is PIP a concern? Use PEEP? Why/why not? How would you determine the best PEEP
level? What are consequences of increasing PEEP? Can you compensate for the hemodynamic effects of
increasing PEEP? Where would you keep PaCO2?
5. Recurrent atrial fibrillation: You are called due to sudden onset of irregular HR at 160 bpm. BP is 85/40. DDx?
Assume Afib. Rx? Esmolol? Phenylephrine? Would verapamil have a role here? No response to therapy and BP is
now 70/30. Is cardioversion indicated? What might be etiology of recurrent a-fib? Suppose K+ is 3.0 mEq/L. Any
relationship? Explain.
6. Postop ileus requiring total parenteral nutrition: POD#5. Pt is weaning from ventilatory support, but has a
persistent ileus. Should nutritional support be instituted? Why/why not? If so, how? Why? Does TPN affect
ventilator weaning? Pt now on TPN needs reoperation. What are anesthetic implications of TPN? If D/C’d acutely
during surgery, how would you manage glucose?
1. Anesthesia for the pre-term infant: An 8 wk old, 2.7 kg boy requires bilateral inguinal herniorrhaphies. He was
born at 28 wks gestation and is now stable after an initial 2 wks in the neonatal ICU for mgmt of respiratory
distress. Can this be done as an outpatient? Compare advantages and risks of regional anesthesia vs. GA. Your
choice? How will you manage intraop oxygen supplementation? How will you monitor this infant postop? Would
your approach to postop pain control be different from a full term child?
2. Airway tumor: A 69 y.o. woman with severe COPD is scheduled for laser excision of a large subglottic mass
which is causing symptomatic stridor with increased respiratory rate. How evaluate? Surgeon suggests
tracheostomy under local anesthesia, then GA. Agree? Pt anxious, refuses local. Your response/alternative
approach? During sedation (or mask/LMA) with local infiltration for initial tracheostomy, airway obstructs. How
will you Rx? Surgeon is having trouble with exposure and bleeding. Your next step?
3. Radiology anaphylaxis: Called emergently to angiography suite because pt suddenly unresponsive. How
evaluate? SBP 56 and HR 129. DDx (cardiac, PE, septic shock, anaphylaxis., other)? More info necessary? If yes,
what? Assume anaphylaxis. Rx? Epinephrine? Norepinephrine? Intubate? Why/why not?
PRACTICE SET #2:
Session 2
A 42 y.o., 5’3”, 105 kg woman is scheduled for a tonsillectomy. Asthma treated with albuterol inhaler prn. Mild hypertension
treated with hydrochlorothiazide. She snores loudly. Treated with antibiotics for the last 7 days for recurrent tonsillitis. She
takes an ‘herbal’ medicine for depression and sleeping problems. Allergic to aspirin. P 80;; BP 165/90;; RR 20; T 37.5 C; Hgb
14 gm/dl; K 3.3 mEq/l. On physical exam, some scattered expiratory wheezes and a Mallampati Class 3 airway.
A. PREOP EVALUATION
1. Medication issues: If St. John’s wort, delay surgery? Why/why not? With use of an herbal medicine, should PT, aPTT ,
and INR be drawn? Why/why not? Significance of allergy to aspirin? Stop HCTZ preop? Why? Will hypokalemia lead to
any problems? How avoid? Correct? How?
2. Asthma: Could her tonsils contribute to her wheezing? PFTs? Why/which? ABG? Delay surgery until wheezing
disappears? How decide? Add ipratropium? Add IV corticosteroids? Why/why not?
3. Sleep apnea: What is the significance of ‘snoring’? Possible obstructive sleep apnea. Will tonsillectomy fix? Make sure
tracheostomy mentioned in surgical consent? Why/why not? Is she likely to have pulmonary hypertension? Consequences?
4. Hypertension: Is hypertension related to BP cuff application or obesity-related upper arm anatomy? How determine? If BP
190/100, proceed? If no, why not? If yes, Rx before induction? Why/why not? Asthma history affect choice of
antihypertensive? Why? Require arterial line? Unable to place despite multiple attempts. Cancel vs. proceed.
B. INTRAOPERATIVE MANAGEMENT (Assume peripheral IV and left radial arterial line.)

1. Anesthesia induction: Awake intubation vs. IV induction? Assume awake and pt becomes very uncooperative. How
respond? If IV induction, compare ketamine, propofol, and thiopental. Your choice? Why? During induction, pt becomes
difficult to ventilate. Interpretation? Mgmt? What if laryngospasm? Two attempts at ETT placement fail due to difficult
visualization. Mgmt? Surgeon willing to perform surgery with LMA in place. Agree? How proceed? SpO2 75% and
decreasing. HR 45; BP 70/40. Rx?
2. Anesthesia maintenance: (Assume successful intubation.) Does concern regarding sleep apnea influence your choice of
maintenance agents? Why? TIVA vs. inhaled? Ketorolac (ASA allergy)? Opioids (fentanyl vs. remifentanil)? Why/why
not? Are nondepolarizing muscle relaxants necessary? Why/why not?
3. Hyperglycemia: Blood glucose after induction 180? Rx? Why/why not? What if 230? Effect of Rx on K+? Administer K+?
4. Bradycardia: HR drops suddenly to 40 bpm. How assess? No P waves seen, regular rhythm. DDx? BP 64/44; SPO2 99.
Could surgical traction cause? No effect. Give glycopyrrolate? Atropine? Isoproterenol? If no effect, pace? How?
5. Surgical bleeding: 30 minutes later, surgeon complains of oozing. Order PLTs or FFP? Likely to be venous or arterial?
Related to positioning? Role hypertension? Optimal BP to minimize bleeding? If EBL is 1500 mL, txn indicated? Hgb 10.
Why/why not? What if blood unavailable? Choice of fluids? How evaluate efficacy of resuscitation?
6. Extubation: Extubation criteria in this pt? Special precautions? Pt is clenching teeth and occluding ETT. How proceed?
1. Placenta previa: A 29 y.o. woman at 37 wks gestation has been in labor with placenta previa and vaginal bleeding
for 3 hrs. Fetal monitor has reassuring pattern. Urgent C-section planned. Regional anesthesia acceptable? Your
choice? Why? Pt develops significant bleeding from placenta previa. BP 68/44 despite fluids/ephedrine. Mgmt?
Criteria for transfusion of PRBC? If type and cross not completed, administer O negative blood? Type specific?
2. Myasthenia gravis: A 38 y.o. woman with myasthenia gravis on pyridostigmine 60 mg qid for emergent
appendectomy. Asks if spinal better choice than GA. Your response? She prefers to be awake. Can you
accommodate? Epidural vs. spinal? Difference regional anesthesia with myasthenia vs. regional anesthesia and no
myasthenia? Epidural inadequate. She feels incisional pain. Mgmt? IV vs. epidural fentanyl. IV ketamine? Assume
needs GA. How is GA plan affected by myasthenia? Colleague says to avoid all NMB except succinylcholine.
Agree? Why/why not?
3. Regional anesthesia/local anesthetic toxicity: A 35 y.o. laborer requires elective tendon release for trigger finger
and surgeon requests IV regional block. What local anesthetic will you use for a 60 min operation? Assume Bier
Block with lidocaine. 15 min after injection, tourniquet suddenly releases. Immediate mgmt? Grand mal seizure
occurs. Mgmt? Midazolam? Thiopental? Intubation required? Proceed with surgery?
PRACTICE SET #3:
Session 1
A 4 y.o., 22 kg, 3’11” boy is brought to the operating room for an urgent craniotomy.
HPI: The child fell down a flight of stairs and briefly lost consciousness. When the paramedics arrived, he was
found to be lethargic with regular spontaneous respirations. A 22 gauge IV catheter was started in the field.
No other injuries were noted.
PMH: Full term, normal, spontaneous, vaginal delivery with 1 and 5 minute Apgar scores of 9 and 10. He is an
active child without any medical conditions known to his parents. He ate a sandwich four hours ago.
PHYS BP 85/50; HR 50; RR 10; T 38.6 C; O2 Sat 90%.

EXAM: Heart: normal
Lungs: normal.
Abdomen: soft and abdominal ultrasound scan is negative for blood.
Child has a large scalp laceration and a depressed skull deformity over the left frontoparietal area.
No bruises or skeletal deformities are noted.
He is spontaneously moving all four extremities.
LABS: Hgb 11 gm/dl; K+ 4.2 mEq/L; normal PT, aPTT and platelet count.
CT
SCAN: Depressed left parietal skull fracture with an underlying subdural hematoma and slight midline shift of the
ventricles. The cervical spine shows no evidence of fracture.
He arrives in the operating room very lethargic with a 22 g IV in place.
PRACTICE SET #3:
1. Induction of anesthesia: Is an awake intubation indicated? The IV is noted to be infiltrated. Consider inducing
with sevoflurane by mask? Why/why not? Effects of IV vs. inhalation induction on ICP and CBF. IV started. Is
RSI of anesthesia required? Why/why not? If so, which muscle relaxant would you use? Why? Is the use of
succinylcholine contraindicated in this case?
2. Maintenance of anesthesia: Will you use N2O? Why/why not? Avoid inhalational anesthetics? Effects of CO2 on
ICP? How will you maintain anesthesia in this pt? Why? Optimal PaCO2 with vs. without inhalational agents? BP
goals during maintenance of anesthesia? Why?
3. Sudden hypotension: During the craniotomy, BP suddenly decreases to 50/30 and ETCO2 decreases to 21 mmHg.
DDx? Is air embolism possible in this supine child? Surgeon states that the sagittal sinus is bleeding rapidly. Rx?
Discontinue nitrous oxide? Discontinue volatile anesthetics? Insert a CVP catheter? Trendelenberg position?
Increase intravenous fluid administration? Other Rx? When would you consider blood transfusion?
4. Difficult ventilation: 30 min into surgery, PIP increases from 20 to 35 cm H2O as SpO2 decreases from 98 to 90%.
DDx? Rx? Breath sounds are decreased on left. Do CXR? Rx? What if SpO2 is 80%?
1. Ventilatory support: Will you plan to extubate this child at the conclusion of surgery? Why/why not? If not, when
would you extubate? In addition to neurologic status, what other factors are important? Why for each (e.g., VC,
NIF, PaO2/FiO2 ratio)?
2. Sedation on ventilator: Assume you decide to leave the child intubated. How will you sedate him? Opioids?
Propofol? Dexmedetomidine? Use muscle relaxants? Why/why not? How would you manage “neuro checks” with
sedation and ongoing mechanical ventilation?
3. Hypoxemia: Shortly after admission to ICU, SpO2 is 90%. How will you evaluate? Pink fluid noted in ET tube.
DDx? Rx? Pathophysiology of neurogenic pulmonary edema?
4. Polyuria: 8 hrs after ICU admission, pt has UO 250 ml/hr. DDx? How will you assess? Would FeNa be useful?
Why? Plasma sodium is 152 and urine osm is 180. Dx? DI? Rx? What type of crystalloid should he receive?
Should glucose be given?
5. Assessment of neurological status: Is ICP monitoring indicated postop? Why/why not? ICP is increased to 30
mmHg. Why might this occur? Rx? Diuretics? Hyperventilation? Steroids? Deepening level of sedation?
Barbiturate coma? Why/why not? If concerned about brain death would an EEG be indicated? How do you assess
a pt for brain death (e.g., apnea test, CBF, BAERs)?
6. ARDS: POD#3. Progressive hypoxemia develops and CXR reveals white-out bilaterally. How evaluate? Rx? Are
high tidal volume and high PEEP indicated? Why/why not?
1. Vaginal delivery following previous C-section: A 38 y.o., G2P1 full term parturient is in active labor. She is
scheduled to deliver vaginally although her first pregnancy resulted in a C-section 6 yrs ago for fetal distress.
Should an epidural anesthetic be administered for labor analgesia? Why? What, if any, are the potential hazards in
this pt? Monitoring? Discuss. Epidural top-up results in late decelerations. What will you do? Why?
2. Cardioversion: A 77 y.o. man with COPD and a history of CHF and successful PTCA is admitted for increasing
dyspnea. ECG reveals atrial flutter (ventricular rate 140), and cardioversion is planned. Cardiologist requests
propofol. Need more info? BP 90/62. Last ate 12 hrs ago. GA OK? How will you manage the airway (e.g., ETT vs.
LMA vs. mask)? Rx different if BP 70/40?
3. Chronic post-thoracotomy pain: 10 wks after thoracotomy for lung cancer a 67 y.o. male has severe left chest
wall pain unrelieved with oral oxycodone. Evaluation? Mgmt? How to Dx neuroma vs. metastatic disease vs.
other? Gabapentin useful? Amitriptyline? Clonidine? Intercostal n blocks? Cryotherapy? Implantable intrathecal
morphine pump?
PRACTICE SET #3:
Session 2
A 64 y.o., 110 kg, 5’8” man is scheduled for resection of a suprarenal abdominal aortic aneurysm diagnosed by
ultrasound. Past medical history includes hypertension treated with enalapril and chronic obstructive pulmonary
disease after 80 pack years of cigarettes. BP 188/105; HR 85; ECG: sinus rhythm; left bundle branch block; T-wave
inversion in the inferior leads. Hct 45; SpO2 92%.
1. Evaluation of cardiac risk: Is a stress test indicated in this pt? Why/why not? What stress test would you choose?
Why? Consider transthoracic echo only? Go straight to cardiac cath?
2. Pulmonary evaluation: How will you evaluate pulmonary status? Pt has bilateral expiratory wheezes. ABG? pH
7.38; PaO2 60; PaCO2 46. Interpretation? Need PFTs? Which ones? Why? Postpone surgery to obtain? Will you
prescribe any pulmonary Rx? Why/why not?
3. Preop control of hypertension: Is BP adequately controlled? Will you postpone surgery to control? Why/why
not? Is premeds indicated? What are you treating? Anxiety? BP? Use prophylactic beta-adrenergic blockers?
Why/why not? To what end point? Does COPD impact decision? Cardioselective beta-blocker?
4. Renal function: How will you evaluate renal function preop? BUN? Creatinine? Why for each? Assume
creatinine 2.5 mg/dl. How will you proceed?
B. INTRA-OPERATIVE MANAGEMENT
1. Invasive monitoring vs. TEE: Assume LVEF is 35%. Is a PA catheter or TEE indicated for hemodynamic
monitoring? Advantage/disadvantage for each? During placement of 8 Fr catheter, carotid artery is entered. What
will you do? Does LBBB cause concern in placing PA catheter? Any special precautions needed?
2. Epidural/general: Will you use epidural anesthesia in this pt? Why/why not? Assume you plan combined
technique. You get wet tap. Will you convert to continuous spinal or go to another level? Reason for choice?
Assume no wet tap. Will you use epidural catheter intraop? Opioids? Local anesthetics? Why for each?
3. Induction of anesthesia: How will you induce GA in this pt? With induction, his BP falls to 80/40. Is this of
concern? Why/why not? Rx? With what? Why? Pt develops PVCs. Rx? In spite of therapy, he develops VTach.
Rx?
4. Mgmt of cross clamp period/renal protection: Surgeon is preparing to cross clamp aorta. Do you give mannitol
prior to cross clamp for renal protection? Why/why not? Lasix? Fenoldopam? No UO during cross clamp. What
will you do? Are loop diuretics indicated? Why/why not?
5. Myocardial ischemia: Clamp is applied. BP 200/100. How will you Rx? PA 55/30; PAOP 30; CI 1.3 l/min/m2.
Rx? Use vasodilator? Which one? Add dopamine? Dobutamine? Is nitroglycerin indicated? Why/why not? Could
you have prevented these hemodynamic changes prior to placement of the cross clamp?
6. Extubation vs. postop intubation: Assume intraop course was uneventful. Will you extubate pt in the OR?
Why/why not? Does presence of epidural impact decision? Why? If ABG postop is pH 7.30; PaO 2 76; PaCO2 54
on 30% oxygen, can the pt be extubated? What further info do you need? What extubation criteria will you use in
this pt? How are they different than in a pt undergoing a laparoscopic cholecystectomy? With no pulmonary
disease?
1. Retinal detachment: A 59 y.o. woman needs urgent retinal detachment repair. NPO for 10 hrs. GA vs. retrobulbar
block? Advantages/disadvantages for this procedure? If GA chosen, is LMA acceptable? Why? Succinylcholine
OK for intubation? Why? Retrobulbar block is given and pt immediately becomes apneic, what might have
happened? What will you do?
2. Liver disease: A 38 y.o. woman with hepatitis C and end-stage liver disease needs multiple tooth extractions.
What lab tests do you need? Why? INR 1.5, aPTT normal. Would you delay surgery? What blood products/drugs
should be available? Is activated Factor VIIa a reasonable choice? Why/why not? What should be given? Can this
be done as an ambulatory procedure?
3. Myasthenia gravis: A 25 y.o. woman with myasthenia gravis is to have a thymectomy via a transthoracic
approach. Periop mgmt of her prednisone and pyridostigmine? How manage muscle relaxants during induction and
maintenance of anesthesia? Pt is weak postop. Differentiate myasthenia vs. cholinergic crisis. If latter, how Rx?
PRACTICE SET #4:
Session 1
A 22 y.o., 60 kg, 5’4” tall parturient is brought to the operating room for an emergent cesarean section.
HPI: The patient is a primigravida with a normal pregnancy until 2 weeks ago at 36 weeks gestation. At that
time she was noted to have become hypertensive and developed peripheral edema. She was treated with
bed rest. She was admitted 3 hours ago with vaginal bleeding and abdominal pain.
On admission her vital signs were P 96; BP 170/100; RR 22; T 38°C. She was noted to have ankle edema
and 3+ patellar reflexes. She denied headache or visual disturbances. Initial management included a
loading dose of intravenous MgSO4 followed by an infusion plus 5 mg of intravenous hydralazine.
Bleeding has increased and late decelerations in fetal heart rhythm have developed.
PMH: Pre-pregnancy medical and surgical history is negative. She is allergic to codeine, penicillin and aspirin.
She denies smoking, alcohol use or use of illicit drugs.
PHYS P 111; BP 105/85; RR 26; T 38°C.

EXAM: She is fully awake and oriented. Airway is Mallampati Class II.
Chest auscultation is clear. Cardiac exam is normal. Reflexes are 2+.
XRAY: Vascular congestion without cardiomegaly
LABS: Hgb 9.5 gms/dl; urinalysis shows 2+ protein; electrolytes, coagulation studies and Mg level are pending.
On arrival in the operating room, she is complaining of mild difficulty in breathing and SpO2 of 91% on room air. A Foley
catheter has been in place for 2 hours, with 15 ml of output. Two units of packed cells were ordered 45 minutes ago. She
had wanted an epidural for expected vaginal delivery.
PRACTICE SET #4:
1. Monitoring: Does pt require any invasive hemodynamic monitors? Which? Why? Would you delay case to place
invasive monitors? Why? What are advantages/disadvantages of a PA catheter? Under what circumstances would
you use it in this case? Why?
2. Choice of anesthesia: Would you use a regional technique for this procedure? Why/why not? You decide on GA.
How will you secure airway? Rationale? Is thiopental contraindicated? Why? What induction agents would you
use? Why?
3. Oxygenation: 10 min after incision, and 8 min after delivery of fetus, SpO2 decreases from 99% to 91% over 30
seconds while pt is receiving 50% oxygen with N2O. How will you proceed? Why? What might be cause? How will
you determine cause? What to expect if amniotic embolus? How manage? Explain.
4. Low urine output: Despite 500 mL of LR, U.O continues low (< 10 mL in 30 min). DDx? How assess if
prerenal? Urine electrolytes helpful? FeNa is 3%. Interpretation? Treatment? Furosemide? Mannitol?
1. Muscle relaxation: At end of procedure, train-of-four is 0/4. The pt received succinylcholine for intubation, and
vecuronium during procedure. Will you reverse? Why/why not? If so, how? Why? What are the risks, if any, of
reversal? Would you consider administering calcium? Why/why not? What might be implications of MgSO 4
therapy?
2. Respiration: Following intraop desaturation the pt required FiO2 1.0 and PEEP 7.5 cm H2O to maintain 89% SpO2.
What should be postop plans for ventilatory mgmt? Why? Would you order pressure support? Benefits?
3. Coagulation: Postop coagulation tests reveal a prothrombin time of 17.2 seconds (INR 2.2), partial thromboplastin
time 44 seconds and 95,000 platelets. Do you need further studies? Why? What is likely cause(s)? How will you
differentiate? Assume DIC. How will you treat? Rationale?
4. Sedation and pain control: Pt is in the ICU and is restless and agitated. How will you proceed? Why? What will
you use to sedate? Why? Provide analgesia? Why? With what? Why?
5. Nutrition: When to provide nutrition? How? Why? What are implications of nutritional formulae to respiratory
function and ability to discontinue ventilator support?
6. ARDS: POD#2. Pt develops increasing hypoxemia and diffuse pulmonary infiltrates. How do you differentiate
cause of infiltrates? If ARDS likely, what is cause? How will you treat? Why? What is role/benefit of permissive
hypercapnia? Discuss. When might you select pressure control ventilation? Why?
1. Eye surgery: An 83 y.o. man is scheduled for monitored anesthesia care for cataract removal and placement of
intraocular lens. History of hypertension, DM, and MI 10 yrs ago. How to sedate for regional block? Is peribulbar
better choice than retrobulbar block? Immediately after placement of block, pt is unconscious/apneic. How to
determine etiology? Mgmt? Following stabilization, surgery proceeds. Pt becomes agitated during lens placement.
How to manage? Is GA indicated?
2. Intensive care: A 60 y.o. man is being treated in the ICU for RML and RLL pneumonia secondary to aspiration
during emergence from GA. ABG (FiO2 1.0): pH 7.32; PaCO2 30 mmHg; PaO2 60 mmHg. How would you
improve his oxygenation? How do you decide which level of PEEP is best for pt? Which ventilator mode would
you choose? Why? Will change from supine to prone position change PaO2? Why? If this pt requires 10 days of
ventilator care, should he have a tracheostomy? Why?
3. Postdural puncture headache: A 35 y.o. man complains of postural headache one day after knee surgery with
epidural anesthesia complicated by accidental dural puncture. How would you evaluate? Rx? What if there was no
evidence of accidental dural puncture? What if he has a fever and nuchal rigidity? When is a blood patch
appropriate? What if the pt was known to be HIV positive?
PRACTICE SET #4:
Session 2
A 67 y.o., 58 kg, 5’2” woman has new onset, frequent, transient ischemic attacks and is scheduled for an urgent right
carotid endarterectomy. She has a history of an MI 3 years ago, hypertension, recent onset fatigue and weight gain. She
has smoked 2 packs per day for 30 years and has a chronic productive cough. Medications: metoprolol, low molecular
weight heparin SQ twice a day. BP 150/110; HR 48; RR 12; T 36.3°C; Hgb 14.5 gm/dl; EKG: SB; Q waves in II, III
and AVF; thyroid stimulating hormone markedly elevated.
A. PREOP EVALUATION
1. Hypertension: Is her BP adequately controlled? If you wish to lower, how? To what end point? Why? Should
surgery be delayed for BP control? How long? Any risks? Why?
2. Thyroid function: Is further workup of her thyroid function necessary? Why/why not? If so, which test(s)? Why?
Recommend preop Rx? Explain. Any risks? How do you assure adequate end point is achieved?
3. Cardiac disease: Is further evaluation of the pt’s cardiac function necessary? Why/why not? If EKG is unchanged
from previous studies, any add’l tests required? ECHO? Dipyridamole thallium? How would the results impact
your periop Rx? Should her metoprolol be continued preop?
4. Pulmonary evaluation: Is this pt’s cough of concern? Why? Should it be treated preop? How? Does she require a
preop CXR? Why/why not? Are other evaluations of her respiratory status necessary? If so, which test(s)? ABG?
PFTs? How would the results change your anesthetic Rx? Why? D/C cigarettes preop?
B. INTRAOPERATIVE MANAGEMENT
1. Anesthetic choice: Would you recommend regional or GA? Why? Risks/benefits of each? Assume pt prefers GA.
How will you induce and maintain anesthesia? Thiopental or propofol for induction? Why? If neither, your choice?
Why? How low would you allow the BP to fall during induction? Why did you choose this end point? Is a fentanyl
infusion appropriate for maintenance of anesthesia? Why/why not? Your preference?
2. Neurologic monitoring: Is it necessary to monitor the adequacy of cerebral perfusion? If so, how? EEG? SSEP?
Transcranial doppler? Stump pressure? Advantages/disadvantages of each? If evidence of decreased perfusion,
what will you do? Why?
3. Bradycardia/hypotension: 10 min after incision, HR falls to 30 and BP to 90/50. Of concern? Why? DDx? Rx?
Bradycardia recurs as surgeon begins to operate again. What can be done to allow surgery to proceed? Surgeon
continues to operate and pt becomes asystolic. Rx? No immediate response with stopping surgery. Glycopyrrolate?
Atropine? Ephedrine? Epi? Chest compressions?
4. Hypertension/ischemia: With placement of the carotid cross clamp, pt’s BP increases to 220/120 and the EKG
demonstrates ST segment elevation in V5. DDx? Rx? Remove the cross clamp? Beta blockers? Nitrates? BP is not
responsive to initial Rx and pt begins to have PVCs. Rx?
5. Neuroprotection: Assume no ischemia. What will you do, if anything, to protect the brain while the carotid is
cross-clamped? Does administration of a barbiturate offer any advantage over isoflurane? What is your target BP
during cross clamp? Explain. If BP low, how will you elevate?
6. Failed emergence: Despite discontinuation of all anesthetics for 20 min, pt remains unresponsive. DDx?
Evaluation? Rx? Naloxone? Flumazenil? Physostigmine? Neostigmine? Special tests or studies if no effect?
1. Obstetric anesthesia: You are called to see a 20 y.o., G1P0 for acute respiratory distress. She is at 33 weeks
gestation, has no previous medical problems, and is receiving IV terbutaline for pre-term labor. DDx? Pulmonary
embolus vs. anxiety vs. pulmonary edema? Her oxygen saturation is 85% on mask O2. How would you Rx
assuming pulmonary edema caused by the tocolytic? (Diuretics, morphine, esmolol)? Fetal distress ensues and the
pt requires emergent C-section. Regional anesthesia vs. GA? Why?
2. Air embolism: You are called to assist a colleague who believes he has accidentally infused a large amount of air
into a pt via a rapid infusion device. Pt has become hypotensive suddenly. How would you establish the diagnosis?
What monitors might help? TEE? What therapy would you initiate? Is this reportable? To whom? What would you
tell the surgeon, pt and the family? What safety methods are used in rapid infusion devices to reduce this risk?
3. Nutrition: A 58 y.o. man with alcoholic cirrhosis presents for a colostomy revision. How will you assess his preop
liver function? History? PE? Lab studies? What? Why? If preop albumin is 2.4, should surgery be delayed for
nutritional improvement? Why? Would ascites affect your decision? Why? If you planned for nutritional
supplementation, IV or enteral? Why? Would the pt’s ammonia level give you any info on hepatic function? How
would you manage an elevated ammonia? How would an elevated ammonia affect his response to GA?
PRACTICE SET #5:
Session 1
A 46 y.o., 71 kg, 5’8” man is brought to the operating room for a laparoscopic cholecystectomy.
HPI: Recurrent right upper quadrant abdominal pain for 8 months.
PMH: He has had Type I diabetes mellitus since age 10. Complications include retinopathy, neuropathy, and end
stage renal disease on hemodialysis. He had a non-ST segment elevation myocardial infarction 3 years ago
and was treated for congestive heart failure. His last hemodialysis was the day before surgery.
MEDS: NPH insulin 20 units q AM, 7 units q PM; amlodipine; erythropoietin.
PHYS BP 160/100; HR 80; RR 16; T 37°C.

EXAM: He is a thin male in no distress.
Legally blind.
There is a functioning arteriovenous graft in the left arm.
CXR: Slightly enlarged heart, otherwise no active disease.
ECG: Normal sinus rhythm, low voltage.
ECHO: No valvular abnormalities. Ejection fraction 45%.
LABS: Na+ 138 mEq/L; K+ 5.3 mEq/L; Hgb 8.9 gm/dl. Finger stick capillary blood glucose in the holding area is
200 mg/dl.
The patient arrives in the operating room after having received his usual morning medications. An 18g peripheral IV
and standard monitors are in place.
PRACTICE SET #5:
1. Induction/maintenance: Will this pt respond to a propofol induction differently than a 20 y.o. athlete? Discuss
reasons (diabetic autonomic neuropathy, cardiac status, ESRD). Your choice of induction agent(s) and reasons. Is
N2O appropriate? Why/why not? Your choice of maintenance technique and reasons?
2. Hypotension/bradycardia with pneumoperitoneum: After CO2 insufflation, BP is 70/40. Possible causes? How
will you determine? If HR decreases to 40 as BP falls, what may be occurring? What will you do? Should surgeon
evacuate the gas from the peritoneal cavity? Why/why not?
3. Venous gas embolism: BP and ETCO2 noted to precipitously drop toward end of procedure. Possible causes?
Assume venous gas embolism with CO2. Your response(s). Explain choices. If BP still very low, what will you do?
Endpoints of successful therapy? Continue case? Why/why not?
4. Difficult cholangiogram: Surgeon cannot adequately pass cholangiogram catheter to inject dye into common bile
duct. Other than stone in common duct, what may be cause? If not a stone, what may be done to assist surgeon
(naloxone, glucagon)? Are there differential effects on the Oddi’s sphincter with various opioids? Explain. Clinical
implications?
1. Respiratory failure: Pt unable to achieve spontaneous tidal volume greater than 150 ml. Causes? Possibly related
to renal failure or cardiac status? How can you differentiate cause? Your plan for postop ventilation? Explain.
Colleague suggests pressure support ventilation. Agree? Why/why not?
2. T wave inversion on ECG: 1 hr after entry to ICU, BP 160/100; HR 100; and T wave inversion noted in II, III and
AVF. Can this be something other than myocardial ischemia? How will you clinically assess pt at this time? How
do you rule out an evolving MI? Assume ischemia. What Rx options at this time (aspirin, beta blockade,
thrombolytics, interventional approach)? Defend choice(s).
3. Pain mgmt: Assume pt still intubated and receiving mechanical ventilation but also breathing spontaneously. He
indicates abdominal pain at trocar sites. Is IV morphine contraindicated with ongoing wean from mechanical
ventilation? Why/why not? Is PCA an appropriate choice? Why/why not? Your choice with reason(s).
4. Hyperglycemia: Blood sugar in ICU noted to be 350 mg/dl. How would you manage? Why? Different options?
Target for blood sugar? Why?
5. Hyperkalemia: Serum potassium measured at 6.2 mEq/L. Why might pt’s potassium rise from preop level (5.3
mEq/L)? Does this level require Rx? Why/why not? If pt is anuric, how can serum potassium be lowered safely
and quickly? Danger(s) if not lowered? While treating, pt becomes asystolic. Rx?
6. Jaundice: POD#1. Pt extubated. Pod#2. Pt has jaundice. Possible causes? How will you confirm etiology?
Surgeon asks if jaundice related to anesthetic. Your response?
1. Cardiac surgery: A 25 y.o., obese woman is scheduled for urgent mitral valve replacement. Mitral valve was
replaced 5 yrs ago and she now has worsening dyspnea and orthopnea. Echo reveals a thrombus above and below
stenotic bioprosthetic valve (PAP 70 mmHg). How to induce anesthesia? Why? Fentanyl, propofol and
cisatracurium appropriate for induction? Why/why not? Your choice? After valve replacement, PA pressures
remain elevated (CI decreased). Describe Rx approach.
2. Hemophilia: After a fall, a 28 y.o. man with hemophilia A has a mandibular fracture with normal vital signs
except for HR 105. Surgeon requests nasotracheal intubation for repair. How will you proceed? Awake fiberoptic?
Need coag tests first? Which? ACT vs. PT vs. aPTT? APTT is 42 sec. Delay surgery? Why? Best options for
increasing factor VIII levels (human or recombinant concentrates, cryoprecipitate, FFP)? What about
desmopressin? Target plasma level before surgery?
3. Sedation guidelines: You are the anesthesia representative at a meeting of departments to discuss moderate and
deep sedation guidelines for your hospital. The endoscopy group states they are doing fine and do not need your
input. Your reply? Should only anesthesiologists administer propofol? Concerns? Does the level of monitoring
have to be the same irrespective of location? How will you train personnel?
PRACTICE SET #5:
Session 2
A 25 y.o., 65 kg, 5’1/2” woman with myasthenia gravis is scheduled for decompression of the orbit to relieve a
compressive optic neuropathy sustained in a motor vehicle crash 4 hours previously. Medications: pyridostigmine 30
mg qid; prednisone 10 mg every other day; ranitidine 150 mg at bedtime. BP 128/86; HR 98; RR 24; T 38.6°C; Hgb
11.6 gm/dl.
A. PREOP EVALUATION
1. Myasthenia gravis: What is the role of pyridostigmine in treating myasthenia? Are there adverse side effects?
Explain. Should she receive pyridostigmine before surgery? What are implications of myasthenia for anesthetic
Rx? How will you evaluate disease status? Implications of prednisone?
2. Preop fever: Is this pt’s temperature of concern? Why/why not? Is further evaluation required? If so, which tests?
Should surgery be delayed until results of the work up are available? Should she receive antipyretics? Why/why
not? Empiric antibiotics?
3. Raised intraocular pressure: What are considerations related to anesthesia regarding eye injury? How can you
assess implications? If assume increased IOP, what preop measures are helpful? What will you do?
4. Full stomach: The pt states that she hasn’t eaten for several hrs. Is she at risk for regurgitation and aspiration?
Why/why not? What meds would you choose for aspiration prophylaxis? Sodium citrate? Metoclopramide?
Ranitidine? Why? When should the meds be administered?
1. Anesthetic induction/intubation: Assuming all monitors are in place, what agents will you select to induce
anesthesia? Why for each? Is rapid sequence induction indicated? Should succinylcholine be used? Why/why not?
If yes, how to attenuate an increase in IOP? If not, then what relaxant? Why? How does myasthenia influence your
choice/dose of relaxant?
2. Anesthetic maintenance: Will you maintain anesthesia with a volatile anesthetic? Why/why not? Effect on
intraocular pressure? Which opioids, if any, will you use as part of your anesthetic maintenance? Would
remifentanil be preferable to fentanyl?
3. Hypoxemia/ventilator dysfunction: 10 mins after intubation, you note progressive decrease in SpO2 to 88%. Rx?
Evaluation? You note exhaled tidal volume using anesthesia ventilator to be 200 ml. Could hypoventilation cause
this degree of hypoxemia? How? Does FiO2 impact? What would you do? No wheezing. No cuff leak. Tube and
circuit OK. Attempts to increase tidal volume with ventilator are unsuccessful. How will you proceed? SpO2
decreases further to 70%.
4. Neuromuscular monitoring/mgmt of reversal: What is the expected influence of myasthenia on monitoring of
neuromuscular block? Discuss effect of myasthenia on tetanic stimulation and train-of-four. How will you reverse
residual block of relaxants if used? Why? Any concerns regarding administration of an anticholinesterase to this
pt? What is a cholinergic crisis? Rx?
5. Delayed emergence: All anesthetics have been discontinued and the pt is not breathing and is not responsive 15
mins following the conclusion of surgery. DDx? Evaluation? How proceed?
6. Pain mgmt: Assume an uneventful emergence from anesthesia and extubation. How will you Rx postop pain in this
pt? Opioids? NSAIDs? Which? Why? The pt remains uncomfortable in spite of your initial therapy. What will you
give next? Why? Is your decision influenced by her myasthenia? How?
1. Pediatric eye injury: A 5 y.o., 20 kg boy is admitted to the ER with a metal fragment penetrating the corner of his
left eye. What are the important anesthetic considerations if globe open? If globe closed? How would you induce
anesthesia? Rationale. No IV is present and pt is anxious and uncooperative. How would you modify approach, if
at all? If calm with parents present, allow them in OR for induction? Adult circle system or Bain circuit? Why?
Advantages/disadvantages of other systems?
2. Pain mgmt: A 52 y.o. diabetic woman about to undergo a left above-knee amputation for tumor is extremely
concerned about postop pain. What analgesic modalities are available to her? What would you recommend? Why?
Can phantom limb pain be prevented? Explain.
3. Ethics: A 55 y.o. man with amyotrophic lateral sclerosis presents for percutaneous endoscopic gastrostomy with a
“Do Not Resuscitate” order on the chart. What are the guidelines for “Do Not Resuscitate” orders in your OR?
After administration of midazolam and fentanyl, he experiences a respiratory arrest. Rx?
PRACTICE SET #6:
Session 1
A 53 y.o., 70 kg, 5’5” woman is brought to the operating room for an exploratory laparotomy and repair of lacerated
tendons in her right hand.
HPI: Patient was a passenger in a motor vehicle crash. She was returning home from a dinner party. She presented in
the ER with a sore neck, abdominal pain and multiple lacerations in her right hand. She did not lose
consciousness at the scene of the accident.
PMH: Patient has a history of hypertension. Patient denies any history of chest pain, but leads a sedentary lifestyle.
She has been told that she has a “fat” neck but denies any history of thyroid disease.
She smokes one pack of cigarettes per day (for the past 15 years) and drinks socially.
No known allergies.
Current medications: Lisinopril 20 mg daily, multivitamins.
PHYS BP 110/70; P 115; RR 22; T 36.6 C.

EXAM: Alert, oriented x 3.
Chest: auscultation clear with distant breath sounds.
Cardiac: exam normal.
Airway: soft cervical collar in place. Mallampati 2. Normal mouth opening. Enlarged thyroid (goiter) with
slight deviation of trachea to left. No difficulty swallowing or breathing.
Abdomen: tender to palpation.
Right upper extremity is bandaged.
Normal neurologic examination
LABS: Hgb 11.8 gm/dl; normal electrolytes and coagulation profile
ECG: Sinus tachycardia with non specific ST-T wave changes.
CXR: No active disease, slight deviation of trachea to the left, no cardiomegaly, poor inspiratory effort.
CERVICAL SPINE
XRAY: No evidence of fracture or subluxation, slight deviation of trachea to the left. Neck has not been “cleared” by a
neurosurgeon.
CT
ABDOMEN: Small amount of free fluid in the abdomen, possible splenic laceration.
Patient arrives in the operating room at 1 AM, anxious, with two large bore IVs.
PRACTICE SET #6:
Session 1
A. INTRAOPERATIVE MANAGEMENT
1. Airway mgmt: Airway concerns? How will you secure airway? Awake fiberoptic? Bronchoscope breaks during use and
back-up scope out for repair. Alternative approach? Blind nasal awake vs. rapid sequence vs. inhalation induction?
Defend choice. Unable to visualize glottic opening with direct laryngoscopy. What now? Intubating LMA?
2. Hypoxemia: Assume intubated on 3rd attempt. SpO2 after intubation 99% but decreases to 88% over next 5 min. DDx?
How determine? Suppose PAW increasing and ETCO2 decreasing. Decreased/absent BS over left chest? How respond?
Chest tube?
3. Hypertension and tachycardia: 30 min after incision, BP 190/100; P 130. DDx? Light anesthesia vs. thyroid storm vs.
MH vs. other? How decide? Which clinical signs/symptoms/tests? ABG pH 7.35; PaO2 110 (FiO2 0.4); PaCO2 47. Rules
out MH? Empty vaporizer or flowmeter leak? Pt has received 10 mcg/kg fentanyl and respiratory monitor says 2.0 MAC
end-tidal desflurane? Rules out light anesthesia? Desflurane be the cause?
4. Hemorrhage: Loses 1 liter blood within a few min upon mobilization of spleen. BP 60/40. Phenylephrine infusion to
maintain BP during volume restoration? Transfuse without Hct determination? Why/why not? Blood bank reports
antibodies during type and cross. Check Hct? Hct 22. Transfuse O neg or type specific RBCs despite antibodies?
Why/why not? Continue resuscitation with crystalloid? Colloid? Hetastarch? Rationale? EKG shows 3 mm ST
depression. Influence mgmt?
B. POSTOPERATIVE CARE
1. Hypothermia: Pt is brought to PACU intubated, breathing spontaneously. T 34.5oC? Concerns? Adverse effects of
hypothermia? How Rx? Is warming IV fluids effective? Why not? Shivering? Suppress? Why? How?
2. Extubation criteria: Extubation criteria in this pt? Does presence of goiter influence? Why/why not? If no goiter, are
criteria same as after elective abdominal procedure? Impact of difficult airway? Fluid resuscitation? NPO status? Temp?
Despite hypothermia pt is awake, obeying commands, and coughing on ETT. Extubate? Why/why not? If no, sedate?
How?
3. Pain mgmt: After extubation pt complains of severe pain in the operated (right) hand. Brachial plexus block
appropriate? Why/why not? If yes, single shot or continuous? Which local anesthetics? Add adjuvants?
Advantages/disadvantages? Can she give informed consent if immediately postop or recent sedative infusion? Can block
contribute to injury? How? If no block, how will you approach pain mgmt? PCA? NSAIDs? Which? Why?
4. Myocardial ischemia: While preparing to transfer pt, ICU nurse notices depressed ST segments with occasional PVCs
on ECG. BP 180/95; P 85; Sat 95% on nasal O2 3L/min. How will you manage? Pt complains of chest discomfort. DDx?
How evaluate? Rx? If HR control relieves symptoms, continue transfer? Wait until troponin level obtained? What if BP
90/50?
5. Awareness: Pt says she remembers conversations in OR. Possible? How follow-up? If establish OR not ICU is time of
awareness, Rx? Is this malpractice? Was this avoidable? What if occurred during hemorrhagic shock?
6. Hepatic dysfunction: POD #2. Pt is jaundiced. What lab tests do you require to evaluate? Why? Pt asks if due to
anesthetic. Response? Due to blood txn? What will you tell the pt regarding her expected clinical course?
1. Amniotic fluid embolus: A 29 y.o., G3P2 complains of dyspnea just after baby delivered via C-section under epidural
anesthesia. Evaluation? SpO2 falling quickly and BP trending downward. How Dx amniotic fluid embolus? If suspect,
mgmt? Is immediate intubation mandatory? Justify approach. If amniotic fluid embolus, why is pt hypotensive?
Coagulopathy likely? Are serial coagulation tests indicated? Fibrinolysis documented. Give epsilon-aminocaproic acid?
2. ECT and neuroleptic malignant syndrome: A 36 y.o. man admitted 1 wk ago with paranoid delusions. He developed
febrile response when treated with haloperidol. Now receiving midazolam to control agitation. Scheduled for ECT
(worsening psychosis). Special precautions required because of febrile rxn? Dantrolene? Affect choice of induction
agent? Affect choice of muscle relaxant? Why? Discontinue midazolam prior to the scheduled ECT? If so, how much
before? Why? If not, why not? Effect on seizure threshold?
3. OR environment: A scrub nurse asks if her headaches and dizziness could be the result of anesthetic gases in the OR.
What would you tell her? How does one test for trace anesthetic gases? How often should the ORs be tested? Who should
do the testing? What are acceptable levels for nitrous oxide? Isoflurane? Sevoflurane? What are the possible effects of
elevated levels?
PRACTICE SET #6:
Session 2
An 8 y.o., 35 kg girl is scheduled to undergo biopsy of an anterior mediastinal mass via mediastinoscopy with possible right
anterior thoracotomy. Mother reports difficulty in IV access and in breathing tube placement when she had tonsillectomy last year.
Both are very anxious. Mother wants to be present during induction. You are seeing patient for first time in holding area just prior
to scheduled surgery. BP 90/60; P 126; RR 22.
A. PREOP EVALUATION
1. Mandatory diagnostic studies: CXR obtained. If pt sleeps comfortably lying flat, any add’l studies needed? What if pt
dyspneic sitting and worse supine? CT scan? Flow-volume loop? Why? Awake bronchoscopy useful? How evaluate
adequacy of upper airway? Mallampati score useful in children? Postpone case until previous anesthetic record available?
Assume anesthesia record describes stormy induction with laryngospasm but intubation on first attempt.
2. SpO2 87% on RA: DDx? How evaluate? During tonsillectomy admission, all SpO2 determinations were 99%. No
improvement with increased FiO2. Explain. Prior to coming to OR EMLA cream liberally applied to multiple potential
IV access sites and to both wrists for arterial in access. Significant? Response? How Dx and Rx methemoglobinemia?
3. IV and arterial line: Plan IV access and a-line insertion prior to induction. Sedate in holding area vs. OR? Is ketamine
reasonable choice? If not, what? As obtain IV access, send lab tests? Which/why? Hgb 9.0 g/dl. Further work up?
Transfuse preop? Why/why not? ABG: pH 7.33; PaO2 80; PaCO2 50. Interpret. Concern?
4. Parental presence for induction: Agree to mother’s presence for IV access? A-line placement? Induction? If yes, rules
for when to leave? Concerns about difficult induction? If no, how deal with child’s and parent’s anxiety and concerns?
B. INTRAOPERATIVE MANAGEMENT (Arterial line and IV in place.)

1. Induction and airway: How secure airway? Awake (D.L. vs. fiberoptic vs. blind) vs. inhalation induction vs. IV
induction. Justify approach. Does plan account for both upper airway and mediastinal mass? Which is more important
consideration? Unique precautions needed before proceed (cricothyrotomy/tracheostomy setups, surgeon scrubbed,
bypass)? If inhalation induction, deep inhalation vs. muscle relaxant-assisted intubation? Why? Appropriate agent?
2. Elevated PAW and decreased SpO2: After intubation, peak PAW elevated with positive pressure ventilation. SpO2 falls to
90%. DDx? How proceed? Manipulation of ETT does not improve SpO2. Next steps? SpO2 now 82%. Control ventilation
or allow resumption of spontaneous ventilation? Emergent thoracotomy? CPB/ECMO?
3. Coagulopathy/PLT reaction: SpO2 normalizes with spontaneous ventilation. During mediastinoscopy, bleeding
necessitates thoracotomy. Transfusion trigger? Assume required 2 units PRBCs. Diffuse oozing at surgical sites. Give
PLTs? FFP? Need lab tests before Rx? Assume preop PLT count 89,000/mm3 and now 32,000. Mgmt? 10 min after
starting PLT txn, T 39oC. Evaluation? Mgmt? Stop PLT txn? If so, how correct bleeding?
4. Paroxysmal SVT: After resuscitation, paroxysmal SVT occurs. How differentiate from sinus tachycardia? How Rx?
Justify. Does age influence Rx? How minimize chance of recurrence? Further evaluation?
5. Oliguria: UO less than 0.5 mL/kg/hr for past 2 hrs. Acceptable? Why/why not? ADH response to stress of surgery?
Appropriate to give furosemide without urine Na+ measurement? If intravascular volume adequate, is it necessary to treat
UO? How decide? Roles for furosemide, dopamine, fenoldapam? Explain.
6. Anesthetic complication: Hand on the side of arterial line and an IV is swollen and blanched. DDx? How evaluate?
Doppler? Where? Why? Tissue pressure? How proceed? What will you tell the child’s mother?
1. Transsphenoidal hypophysectomy: A 58 y.o. man with acromegaly is scheduled for a transsphenoidal hypophysectomy.
Are endocrine tests indicated preop? Why? How will results impact anesthetic plan? How manage if he has adrenal
suppression? Administer steroids? When? Which? Induction/intubation plan? At end of the procedure, UO increases to
400 ml/hr. DDx? How can you confirm Dx of DI? Necessary to do so before initiating Rx? Which Rx? DDAVP? What
IV fluids?
2. Regional postop analgesia: A 68 y.o. woman requests regional analgesia following total knee arthroplasty. Surgeon
plans to start low molecular weight heparin 12 hrs postop. Can you accommodate her request? Epidural vs. continuous
femoral catheter? Rationale? Timing of removal? Need coag studies before removal? Why?
3. Carotid endarterectomy: A 74 y.o. man with severe carotid stenosis and frequent TIAs for carotid endarterectomy.
General vs. regional? Your choice? Why? If regional, is both a deep and superficial cervical plexus block necessary?
Why/why not? Assume GA. Is CNS monitoring necessary? Why/why not? If so, how? Any special measures for cerebral
protection?
PRACTICE SET #7:
Session 1
A 62 y.o., 130 kg, 5’8’’ tall man is brought to the operating room for an emergent evacuation of a subdural hematoma.
HPI: Patient was riding a motorcycle without a helmet when he was thrown off in an accident 2 hours previously. He
was found by the paramedics to be responsive to verbal commands. P 78; BP 160/110; RR 22. An IV was started
and the patient transferred to the emergency room complaining of a headache and foot pain. A head CT scan
demonstrates a right subdural hematoma with a 1 cm midline shift. He has a left ankle fracture and received 10
mg of morphine in the emergency room.
PMH: History of hypertension and myocardial infarction 3 years previously, after which he had a coronary artery stent
placed. No further symptoms of angina. He has no allergies. He has smoked 1 pack per day of cigarettes for 45
years and has a chronic productive cough. He drinks 2-4 beers per day and denies other drug use.
MEDS: Metoprolol and hydrochlorothiazide.
PHYS P 62; BP 170/115; RR 16; T 35.2 C; SpO2 93% on 4 L/min O2 by nasal prongs.
EXAM: Obese male in hard cervical collar with a full beard.
Lethargic, but when aroused, responds to verbal commands.
Airway: Mallampati 3 with poor dentition and alcohol on the breath.
Chest: Auscultation reveals scattered inspiratory rhonchi and faint expiratory wheezes.
XRAY: CXR reveals normal mediastinum, without PTX or infiltrates.

Cervical spine x-rays do not show any fracture or dislocation, but the neck has not been “cleared” yet.
ECG: LVH. Q waves in II, III, and AVF.
LABS: Hgb 14.9 gm/dl; K+ 3.0 mEq/L; glucose 195 mg/dl.
He arrives in the operating room with two 16-gauge upper extremity IVs, right radial arterial line, and a Foley catheter. He
has received 2 liters of normal saline and 100 gm of mannitol in the emergency room.
PRACTICE SET #7:
1. Anesthetic induction: Awake intubation vs. RSI? Why? If awake, nasal or oral? Pro/con? Significant bleeding if attempt
nasal. How respond? If oral, how avoid MI and increased ICP? During attempted awake intubation, the pt becomes
agitated and uncooperative. Response? More sedation? Induce anesthesia? Why/why not? How would you secure airway
if anesthesia is induced? What if cords not seen during laryngoscopy? Can’t intubate. Mask ventilation becoming
increasingly difficult. How proceed? SpO2 90% and falling. What next? If ventilation is possible with an LMA can
surgery be done without intubating the pt? Tracheostomy?
2. Brain swelling: After removal of bone flap, surgeon complains dura is very tight. How Rx? Hyperventilation limits?
Add’l mannitol? Furosemide? Why/why not? Thiopental? Discontinue the N2O begun after intubation? If pt was
receiving isoflurane, convert to propofol/remifentanil? Why/why not?
3. VAE: During evacuation of hematoma, BP decreases to 75/50; HR increases to 105. DDx? ETCO 2 decreased to 18. Air
embolus? How manage? Is phenylephrine the best choice to raise BP? Why/why not? What else would you do?
4. Bleeding/coagulopathy: Blood loss 1 liter. Choice of fluid replacement? Why? Criteria for txn? The blood loss
continues. Now generalized microvascular bleeding. How evaluate? When would you give PLTs? FFP? Cryoprecipitate?
Base on clinical signs or lab tests? Consider DDAVP? Cryoprecipitate? Amicar? Why/why not?
1. Postop ventilation: Extubation postop vs. mechanical ventilation? How decide? Type of ventilation. Ventilator settings?
Why? Any indication for pressure support ventilation? Why/why not? Pulmonologist suggests permissive hypercapnia.
Your response and why? If PaO2 90; FiO2 1.0, add PEEP? Why/why not?
2. Bronchospasm: 30 min after arrival in ICU, peak PAW increases to 65 cm H2O. DDx? How evaluate? Bilateral wheezing
is heard. SpO2 75% on FiO2, 1.0. DDx? COPD vs. pulmonary edema? How Rx? What if albuterol fails? Epinephrine?
How administer? Ketamine? Ipratropium? Steroids?
3. Diabetes insipidus: UO 3 liters/2 hrs in ICU. DDx? Delayed response to mannitol effect vs. hyperglycemia vs. DI? If
DI, how would you Rx? How would you replace fluids?
4. Seizure: 4 hrs postop pt has grand mal seizure. DDx? Lab tests (electrolytes, ABG, glucose)? Administer muscle
relaxant? Why/why not? Is lorazepam or propofol a better choice to stop the seizure? Why? Administer phenytoin?
Why/why not?
5. Hyperglycemia: After seizure, glucose 295 mg/dl. Concerns? How Rx? Target? Insulin infusion appropriate? Why/why
not? Should K+ be administered? Change mgmt if pt has metabolic acidosis?
6. Atrial fibrillation: 8 hrs postop the pt develops tachycardia with P 140. DDx? Evaluation? Serial enzymes? Electrolytes?
Repeat glucose? Assume Afib. Treat if BP 134/80? How? Different if BP 70/50? Settings to perform cardioversion?
What if that fails?
1. Congenital heart disease: A 4 y.o. girl with a moderate ventricular septal defect and L → R shunt presents for repair of
an open femur fracture. NPO for 8 hrs. Insist on an IV prior to induction? What if received opioids? All attempts at IV
access unsuccessful. Proceed with inhalation induction? Other options (IM, intraosseous)? Risks? Your response? The pt
turns blue after intubation, SpO2 60% despite 100% FiO2. Could shunt reverse? Rx? Phenylephine? Resume spontaneous
ventilation?
2. Regional anesthesia in HSV: A 32 y.o., G1P0 female at term gestation is scheduled for elective C-section. She takes
acyclovir for a herpes simplex infection. Is regional anesthesia contraindicated in this pt? What if not taking acyclovir?
What if no apparent genital lesions? Why/why not? Options if no regional anesthesia?
3. Cancer pain mgmt in pt with H/O substance abuse: A 41 y.o. man S/P extensive perineal surgery for anal carcinoma.
Prescribed short acting opioid analgesics one mo prior to surgery for pain control. Admits to using cocaine and marijuana
in the past but not in last 3 yrs. Options for postop pain control in this pt? Epidural analgesia? IV PCA? Upon discharge,
pt still requires opioid analgesics for pain control. How distinguish opioid requirements for pain from addiction? What is
opioid tolerance? Physical dependence?
PRACTICE SET #7:
Session 2 -
A 58 y.o., 90 kg, 178 cm man is scheduled for femoral popliteal bypass. He has Type II diabetes mellitus and controlled
hypertension. A myocardial infarction was diagnosed 4 years ago. Medications include Humulin, hydrochlorothiazide, and
enalapril. ECG: sinus rhythm, poor R wave progression, occasional premature ventricular contraction. BP 140/75; P 76; RR
16; T 37° C; Hgb 13 gm/dl; Na+ 138 mEq/L; K+ 3.1 mEq/L.
1. Cardiac evaluation: How would you evaluate his cardiac status? Would you order a stress test? What kind? How do you
interpret his ECG? (Significance of PVC’s, poor R wave progression?) Why is he receiving enalapril? Should this be
given the day of surgery? Would you give prophylactic B-blockade to a pt of this type? What are the indications?
2. Diabetes mgmt: How would you evaluate his diabetic status? What would you consider to be an acceptable blood
glucose level? Problems of hyperglycemia? Acute vs. chronic? How would you manage his insulin the day of surgery?
How would you monitor glucose levels during the case?
3. Hypokalemia: Potential problems resulting from low K+? Is 3.1 an acceptable value? Methods of increasing K+ if you
believe this is necessary? Other than brisk diuresis, what common interventions are likely to further reduce K+ in the OR?
4. Risks of anesthesia: What ASA physical status would you assign? Specific risks/problems this man’s pathophysiology
present to you? Do you anticipate an ICU stay postop? How would you explain reasons for this possibility to the family
preop?
B. INTRA-OPERATIVE MANAGEMENT
1. Choice of anesthetic technique: The pt asks your opinion regarding the anesthetic technique. Compare GA vs. regional
anesthesia. What do you recommend? Why? If regional selected, would you do a spinal or an epidural? Why? Is an
epidural safe if the surgeons sometimes give low-dose (3-5000 units) heparin during the grafting?
2. Monitoring: Would you place an arterial line? What if Allen’s test reveals compromised ulnar flow? Justify. Which
ECG leads would you select? Why? Is a central line or a pulmonary artery catheter indicated? Why/why not? What are
potential indicators of hypoglycemia during GA?
3. High spinal: You select spinal anesthesia. A few minutes after placing the block, pt becomes agitated, whispers that he
cannot breathe and his BP is 70/40 mmHg. What is going on? What will you do? Would you place an endotracheal tube?
Why/why not?
4. Supraventricular dysrhythmia: Assume an endotracheal tube proves necessary to accomplish adequate ventilation.
Immediately post-ET placement, his pulse rate increases to 150 bpm. Dx? Etiology? Concerns? How will you treat?
5. Hypotension/wheezing after protamine: Later in the case, the surgeon requests you to give IV protamine. After doing
so, BP decreases to 80/40 and pt begins to wheeze. What is happening? How does protamine cause this type of problem?
How will you treat? How might you have prevented the problem?
6. Hypoxemia prior to extubation: At the end of surgery, you note that his SaO2 is 86%. Significance? Possible causes?
How would you differentiate? What parameters do you use in determining whether it is appropriate to extubate a pt?
Assume diagnosis of opioid effect. How would you manage? Is naloxone indicated? Why/why not? Risks?
1. Epidural analgesia after AAA surgery: A 55 y.o. man with CAD and COPD undergoes AAA repair. Place epidural
preop for postop analgesia? Why/why not? Thoracic vs. lumbar? Test catheter before start infusion? Is infusion of
0.125% bupivacaine with 0.005% morphine at 8 mL/hr reasonable? Require SpO2 monitor postop?
2. Pacemaker malfunction: An 82 y.o. man was resuscitated yesterday when he suddenly developed atrial flutter with no
ventricular response. A temporary transvenous pacemaker is in place pacing with a ventricular rate of 90. As you see him
prior to placement of a permanent pacemaker he develops a paroxysm of coughing and the pacemaker stops capturing.
What has likely happened? What will you do assuming no underlying ventricular complexes? Rationale.
3. Radiology anaphylaxis: Called emergently to angiography suite because pt suddenly unresponsive. How evaluate? SBP
56 and HR 129. DDx (cardiac, PE, septic shock, anaphylaxis., other)? More info necessary? If yes, what? Assume
anaphylaxis. Rx? Epinephrine? Norepinephrine? Intubate? Why/why not?
PRACTICE SET #8:
Session 1
A 66 .y.o., 76 kg man is scheduled for radical prostatectomy.
HPI: Patient noted the onset of progressively worsening difficulty with urination. He consulted his urologist who
subsequently biopsied him for a suspicious prostatic nodule. His metastatic work up is negative.
PMH: Significant for a myocardial infraction 8 months ago, which was complicated by CHF. His current anginal
pattern is stable. The patient has excellent exercise tolerance, walking up to two miles per day without difficulty.
An echocardiogram performed three days ago revealed an ejection fraction of 45%. BNP level 225 pg/mL
(normal < 100 pg/mL).
MEDS: Atenolol, ACE inhibitor, aspirin 81 mg, and sublingual NTG. He has not used nitroglycerine in more than 3
months. He has a 30 pack/year tobacco history, but has not smoked in 20 years. He also states he had hepatitis at
age 37.
PHYS P 65; BP 140/80; RR 16; T 36.1°C.

EXAM: His airway appears normal.
He has no evidence of organomegaly or peripheral edema.
EKG: Left bundle branch block.
LABS: Hgb 14.5 gm/dl, normal electrolytes, albumin, liver function tests, and coagulation studies.
He arrives in the operating room at 0900 with a functioning peripheral IV and left subclavian CVP in place, having taken his
normal morning atenolol and ACE inhibitor.
PRACTICE SET #8:
Session 1
1. Anesthetic selection: Pt requests epidural analgesia postop. Combined epidural-general vs. general with PCA?
Advantages/disadvantages of each. How decide? Assume agree to epidural. During placement, wet tap. How respond?
Epidural in place. Advantages/disadvantages to local anesthetic before/after induction? Preemptive analgesia? Affect on
MAC? Is propofol-fentanyl-rocuronium a reasonable induction sequence? If no, why not? Your choice? Why? What is most
likely problem with it? How will you avoid hypotension?
2. Unexpected difficult intubation: Easy mask ventilation but unable to visualize glottic opening after 4 laryngoscopies, the
last a recognized esophageal intubation. SpO2 100%. What next? LMA? What kind? LMA well positioned. Controlled
ventilation through LMA acceptable for surgery? Why/why not? Do fiberoptic intubation through mask/LMA? Assume ETT
placed.
3. Venous VAE: 1 hr into procedure (prostate open), BP acutely drops to 70/40? DDx? Does ETCO 2 18 affect your Dx /
urgency to Rx? Hypovolemia vs. PTX vs. VAE. TEE helpful? If VAE, how Rx?
4. Non-surgical bleeding: (Assume no VAE.) 90 min into procedure, surgeon complains of a slow, generalized ooze in the
field. How proceed? What lab studies would you order to evaluate? Why? Does thrombin time help assess his coagulopathy?
Fibrinogen? Why/why not? Does history of hepatitis impact periop mgmt of this situation? Administer aminocaproic acid?
DDAVP? Why/why not? FFP? How decide?
1. Extubation and hypothermia: At the end of the procedure, T 34.7°C. Would you extubate? What if pt follows commands
and coughing on ETT? Why/why not? Risks/benefits? If the pt did not have CAD, would you extubate? At what T would
extubation be acceptable? Why? How rewarm?
2. Hypertension: Shortly after extubation, pt’s BP is noted to be 180/110. Better coronary perfusion than if normal BP?
Why/why not? Treat BP? If yes, how? End point? If not, when? Why? Is metoprolol indicated (HR 50)? Why/why not?
NTG? Hydralazine?
3. Postop chest pain: The pt is transferred to step down unit following 2 hrs in PACU. 8 hrs later he complains of chest pain. Is
this ischemia (demand/supply imbalance) or infarction (unstable plaque)? Continuum? How Dx? Does LBBB affect ability to
use ECG? What would you do while awaiting definitive tests? Why? Would a PA catheter assist with mgmt? TEE? How
treat pain?
4. Postop surgical pain: POD #1. Pt has incisional pain (8/10). If epidural in place, how respond? If IV PCA with morphine
sulfate, how respond? Is goal pain score of 3/10? What if pt comfortable with score of 5/10? Would administration of a
COX-2 inhibitor be beneficial? Ketorolac? Administer subarachnoid morphine sulphate? Why/why not?
5. Jaundice: POD#5. Pt’s wife tells surgeon that she thinks his “eyes are yellow.” Response? What would you tell the pt and
his family? Does this require further evaluation? Related to the anesthetic?
6. Nerve injury: Prior to hospital discharge, the pt notifies the surgeon that he is experiencing neck pain and bilateral shoulder
and biceps pain. The surgeon asks you to evaluate the pt. What would you do? Why? The pt wants to know if this is
secondary to the anesthetic. What would you tell them? Why? What evaluation is indicated? Why? CT scan? MRI? Would
you get a neurologic consultation? Is EMG indicated?
1. Ventilatory equipment: A 28 y.o. man with a mental disability is having an MRI of the abdomen under GA with a circle
system. The anesthesia machine is outside the MRI room and 4 lengths of anesthesia hose have been connected together.
Does this change the mechanical dead space of the system? The compression volume? What is the significance of changes in
compression volume? Is it necessary to, and how would you compensate for, these changes? Is it necessary to use high gas
flows in this situation? Why/why not?
2. Pediatric airway mgmt: A 2 y.o. child with full stomach requires emergent I + D of retropharyngeal abscess. T 40ºC and pt
is drooling, stridorous and combative. IV catheter is infiltrated. IV mandatory for induction? Why? If yes, IM ketamine with
atropine acceptable to achieve IV? How secure airway? Awake intubation vs. inhalation induction vs. RSI? Defend. If
complete airway obstruction occurs prior to securing airway, describe mgmt.
3. Chronic post-thoracotomy pain: 10 wks after thoracotomy for lung cancer a 67 y.o. male has severe left chest wall pain
unrelieved with oral oxycodone. Evaluation? Mgmt? How to Dx neuroma from metastatic disease from other? Gabapentin
useful? Amitriptyline? Clonidine? Intercostal n. blocks? Cryotherapy? Implantable intrathecal morphine pump?
PRACTICE SET #8:
Session 2
A 25 y.o, 5’6”, 70 kg, G1P0 at 31 weeks gestation presents for drainage of subdural hematoma. She was in a motor vehicle
accident, is sleepy but oriented, and has a mild left hemiparesis. Her pregnancy has been complicated by pregnancy-induced
diabetes. Allergies: PCN (itching). Past medical history is otherwise unremarkable. PE: Multiple head lacerations. Temp
36 C; BP 200/100; HR 60; RR 33; glucose 350; Hgb 9.0gm/d. CT scan: right sided subdural hematoma.
A. PREOP EVALUATION
1 Hemodynamics: Should the pt’s BP be treated? Why? How does hypertension affect fetal/placental circulation? Acute vs.
chronic? If treated, what agents? End point of Rx? How will lowering it impact CBF?
2 Diabetes: Should the pt’s blood sugar be lowered prior to surgery? Why? Effects of hyperglycemia on fetus? Acute vs.
chronic. Effects on injured brain? If treated, infusion vs. bolus insulin? Goals? Risks?
3 Fetal monitoring: Is fetal monitoring needed periop? Why? Will its presence change your Rx? Would you recommend
tocolytic therapy preop? Why? If so, would MgSO4 be an appropriate choice? Terbutaline? What will you tell the pt and
her family regarding the effects of anesthesia and surgery on premature labor?
4 Transfusion: Type and crossmatch not yet completed. Would you delay surgery until blood available? What if blood
bank detects antibodies that make crossmatch difficult? Type specific blood or O-neg blood OK? Assume pt is O+. Is
Rhogam (RhD immune globulin) needed?
1. Induction: Is RSI indicated? How will you avoid increases in ICP during induction? Thiopental? Etomidate? Your
choice? Will you administer opioids in addition? Lidocaine? Benzodiazepines? Is sux contraindicated? Why? Other
choices for muscle relaxant? BP 250/120; HR 120 after intubation. Is Rx required? With what?
2. Aspiration: During induction/intubation, pt aspirates. SpO2 is 90% on FiO2 1.0. Rx? Suctioning? Steroids? Antibiotics?
PEEP? Impact on maintenance of anesthesia? Is isoflurane/N2O appropriate? Your preference? Would TIVA be
preferable? Why? Risk/benefits in pregnancy? Effect on brain volume? Uterine tone? Fetus?
3. Brain edema: Assume uneventful intubation. Surgeon notes very tight brain upon dural exposure. How to manage? Will
you hyperventilate the pt? Why? Concerns regarding hyperventilation? Safe target for PaCO 2? Is mannitol indicated?
Why? Hypothermia beneficial? Effect on fetus?
4. Hemorrhage: Uncontrolled blood loss during evacuation of hematoma. Response? Crystalloid? If yes, which? Why?
Colloid? If yes, which? Pressors? Which? BP 110/70; HR 110 with therapy. Is transfusion required? When will you
transfuse? BP 70/40; HR 130. Rx? Should deliberate hypotension be used to help control bleeding? Why?
5. Allergy: Pt stabilizes but you notice pt is covered with a rash. Is Rx necessary? Diffuse wheezing noted. DDx? Rx? HR
increases to 140, no change in BP. What now? Different Rx if BP is 65/30? Epinephrine? Phenylephrine?
Diphenhydramine? Steroids?
6. Fetal compromise: Assume fetal monitoring intraop. Persistent late decelerations noted toward the completion of surgery.
Rx? Obstetrician in room recommends emergent Caesarian delivery. Colleague present to care for mother. After delivery,
the baby is limp and cyanotic. HR 60 bpm. Rx? Intubate? No response. Cardiac massage? No response? What drugs
would you choose? How to administer?
1. Pheochromocytoma: A 48 y.o. woman requires resection of a pheochromocytoma. What are the anesthetic
considerations? What pre-op preparation is required prior to elective resection? How do you determine when this Rx has
been adequate? Rx of BP 70/40 post-induction? Rx of intraop BP 190/110? After resection, BP 60/40 unresponsive to
fluids. DDx? Rx?
2. Cervical plexus block: A 79 y.o. man is scheduled for a right carotid endarterectomy. He wishes to be awake during the
procedure. Reasonable request? Advantages? How would you accomplish this? Deep vs. superficial cervical plexus
blocks. Landmarks? During the endarterectomy, pt complains of pain in the incision and surgeon injects local anesthesia
to supplement block. Immediately after injection, pt has a generalized tonic/clonic seizure. Etiology? Rx? Must you
intubate? Should surgeon continue with the case? Why?
3. Latex allergy: A 26 y.o. woman is scheduled for diagnostic laparoscopy as an outpatient. During preop questioning she
describes a history of itching of her hands when she uses household rubber gloves. Is allergy testing required? Why/why not?
Appropriateness of procedure as an outpatient? Preop Rx? Impact on your anesthetic plan? How? Why? Intraop, in spite of
precautions, airway pressures rise. Rx?

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Phone: (866) 999-7501 | Fax: (866) 999-7503 | Website: www.theABA.org

PRACTICE SET #1:

PHYS Augmented BP 85/55 (mean 68); HR 106; RR 22; T 37°C.

ECG: Sinus tachycardia, inferior Q waves with anterolateral ST depression.

B. INTRA-OPERATIVE MANAGEMENT (Assume standard monitors.)

PHYS BP 150/95; HR 90; RR 20; T 39.1ºC.

B. INTRAOPERATIVE MANAGEMENT (Assume peripheral IV and left radial arterial line.)

PHYS BP 85/50; HR 50; RR 10; T 38.6 C; O2 Sat 90%.

He arrives in the operating room very lethargic with a 22 g IV in place.

PHYS P 111; BP 105/85; RR 26; T 38°C.

XRAY: Vascular congestion without cardiomegaly

HPI: Recurrent right upper quadrant abdominal pain for 8 months.

MEDS: NPH insulin 20 units q AM, 7 units q PM; amlodipine; erythropoietin.

PHYS BP 160/100; HR 80; RR 16; T 37°C.

CXR: Slightly enlarged heart, otherwise no active disease.

ECG: Normal sinus rhythm, low voltage.

ECHO: No valvular abnormalities. Ejection fraction 45%.

PHYS BP 110/70; P 115; RR 22; T 36.6 C.

LABS: Hgb 11.8 gm/dl; normal electrolytes and coagulation profile

ECG: Sinus tachycardia with non specific ST-T wave changes.

B. INTRAOPERATIVE MANAGEMENT (Arterial line and IV in place.)

MEDS: Metoprolol and hydrochlorothiazide.

XRAY: CXR reveals normal mediastinum, without PTX or infiltrates.

ECG: LVH. Q waves in II, III, and AVF.

LABS: Hgb 14.9 gm/dl; K+ 3.0 mEq/L; glucose 195 mg/dl.

PHYS P 65; BP 140/80; RR 16; T 36.1°C.

EKG: Left bundle branch block.

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