Board Question 1

Front 1

What happens to flow and what happens to resistance when the radius of a tube increases? When
radius of a tube decreases?

Back 1

When the radius of a tube increases, resistance to flow decreases and flow increases. Conversely,
when the radius of a tube decreases, resistance to flow increases and flow decreases.

Front 2

If flow through a tube is laminar (streamlined), explain how resistance and flow are changed if radius
is: doubled, halved, tripled, or reduced to one-third of its original value.

Back 2

According to poiseuilles law, when radius is doubled, resistand is decreased to 1/16th of its original
value and flow is increased 16 fold. When radius is halved, resistance is increased 16 fold and flow is
decreased to 1/16th of its original value. When radius is tripled, resistance is decreased to 1/81 of its
original value and flow is increased 81 fold. When radius is decreased to 1/3rd of its original value,
resistance is increased 81 fold and flow is decreased to 1/81 of its original value.

Front 3

Assuming laminar flow through a tube, how much does flow through a tube decrease if the radius of
the tube decreases to one-third of its original value? Whose law applies?

Back 3

If the radius of a tube decreases to one-third of its original size, flow will decrease to 1/81 of its
original value. Flow is proportinal to the radius to the fourth power. 1/3^4=1/81 Poiseuilles law applies.
NOTE also that if radius is halved, flow is reduced to 1/16th of its original value. If radius is doubled,
flow increases 16 fold. If radius is tripled, flow increases 81 fold.

Front 4

The bourdon gauge on an E cylinder of oxygen show 800psi. If you turned on the cylinder with flow
at 4 liters per minute, how many hours will elapse before the tank is empty?

Back 4

A full oxygen cylinder has a pressure of 2200 psi and will release approximately 660 liters of oxygen.
The amount of oxygen remaining in the cylinder is 800/2200 times 660 liters = 240 liters. 240 divided by
4 l/min = 60 minutes or one hour

Front 5

You are running 2 liters of oxygen and 4 liters of nitrogen at an altitude where the atmospheric
pressure is 630 mmHg. What is the partial pressure of oxygen going to the patient?

Back 5

Total flow is 6 liters, so the flow of oxygen is 2/6th or 1/3rd of the total. The partial pressure of
oxygen is 1/3 * 660 mmHg = 210 mmHg

Front 6

Identify 4 CV changes that occur with aging.

Back 6

1) CO decreases 1% per year (50% decrease in 80 year old) 2) myocardial stiffness increases
(compliance decreases) 3) systemic blood pressure increases 4) the baroreceptor reflex is attenuated
(less effective)

Front 7

Elderly patients have changes in autonomic function referrred to as physiologic beta blockade. Why
do elderly patients have a reduced response to beta agonists?

Back 7

elderly patients, despite having higher levels of circulating norepinephrine, have reduced
chronotropic and inotropic (contractility) response to beta agonists. Possible explanations for the
decreases responsiveness to beta agonists include: 1)a reduced number of beta receptors 2) abnormal
receptor affinity for beta agonists 3) reduced cAMP production after activation of the beta receptors

Front 8

For each of the herbals give the most common uses for them.

Back 8

ginseng - energy and vitality ginkgo - enhance or preserve memory garlic - decrease cholesterol,
decrease blood pressure, stimulate GI function, physical strength, and energy glucosamine -
osteoarthritis and joint mobility St. John's Wort - depression and mood elevation Echinacea - reduce
cold and flu symptoms, enhance immune function lecithin - prevent hardening of arteries, improve
brain function, treatment of chronic fatigue syndrome chondroitin - osteoarthritis and joint mobility,
usually in combination with glucosamine creatine - build muscle and enhance ATP stores in muscle Saw
Palmetto - treat enlargement of the prostrate (BPH) in stages 1 and 2 Ephedra - stimulant and a weight
loss supplement Kava Kava - anxiolytic valerian - immune function stimulant, antiinflammatory,
antibacterial for urinary tract infection and upper respiratory infection

Front 9

Why do geriatric patients have a decreases response to beta antagonists?

Back 9

In the geriatric paitent, the beta receptor has a reduced affinity for beta adrenergic receptor
antagonists. Beta adrenergic receptor agonists also show a reduced affinity for the beta adrenergic
receptor in the elderly.

Front 10

Why is the elimination of midazolam prolonged in the elderly?

Back 10

decreased hepatic blood flow and possibly decreases in hepatic metabolism (decreased clearance)
may cause as much as a doubling of the elimination half time in the elderly (stoelting). Recall that half
time of elimination increases if clearance decreases and/or volume of distro increases. NOTE: there
may be controversy on this issue. Barasch states that age has relatively little influence on the elimination
half time of versed.

Front 11

The elimination half-life of IV anesthetics is generally increased in elderly patients for what three
reasons?

Back 11

1) decreased hepatic metabolism develops either b/c of decreased hepatic enzyme levels or reduced
hepatic circulation 2) plasma binding of drugs in the elderly is often decreased, giving rise to a larger
volume of dist. and a longer half life 3) there is an increase in the percentage of fat which increases the
volume of distribution and prolongs the half-life of lipid soluble drugs

Front 12

What is the most common side-effect of administration of spinal opioids?

Back 12

Pruritus

Front 13

You plan to give an epidural opioid as a bolus in preservative free normal saline for postop pain in the
patient who has had a thoracic incision. What are some choices?

Back 13

Morphine (1-5 mg) may be best because it provides greater dermatomal spread. Lipophilic opioids
including fentanyl (50-100 ug), sufentanil (10-60ug), meperidine(25-100ug) and hydromorphone (0.5 - 2
mg) should generally only be used when the catheter tip is close to the incisional dermatome.
Morphine for epidural bolus administration is mixed in 10 ml of preservative free normal saline. NOTE:
different textbooks have slightly different dosing ranges for the opioids specified.

Front 14

You wish to decrease the concentration of epidural opioid to reduce systemic side effects, so you
plan to mix a local anesthetic with the opioid. What local anesthetic do you choose?

Back 14

Marcaine (.0625 - .125%) combined with morphine (.1mg/ml) or fentanyl (5ug/ml) provided excellent
analgesia.

Front 15

You will give a local anesthetic and an opioid in your epidural. Your goal is to produce analgesia while
permitting the patient to walk (ambulate). Which of the following combos would you use? a) 1% lido
with 2ug/ml fentanyl, 1% lidocaine with 50ug/ml morphine b) .5% marcaine with 5ug/ml fentanyl c)
.1% ropivicaine with 25 ug/ml dilaudid d) 1.5% mepivacaine with 25 ug/ml dilaudid

Back 15

c) The dose of local anesthetic should be reduced when used in combo with an opioid. For example
the dose of marcaine when used with morphine .1mg/ml or fentanyl 5 ug/ml is .0625-.125%. The
concentration of marcaine, lidocaine, and mepivacaine in the question equal or exceed the
recommended concentrations when local anesthetic is used alone. The local anesthetic concentration
that is less than the recommended concentration when given alone is ropivicaine. The dose of dilaudid
may be a little low (50-100 ug/ml is appropriate when used with a local anesthetic).

Front 16

What local anesthetic would you use for postop or post trauma care if you goal was to provide pain
relief while permitting the patient to ambulate?

Back 16

Either .25% marcaine or .2% ropivicaine is recommended for sensory analgesia with little motor
blockade.

Front 17

What local anesthetics are appropriate for providing analgesia to your obstetric patient without
causing motor blockade?

Back 17

0.125%-0.5% marcaine, 0.2% ropivicaine, or 1% lidocaine (with epinephrine) produce analgesia with
minimal motor blockade. 1% mepivicaine also produces sensory block with minimal motor block.

Front 18

Describe nociceptive pain

Back 18

There are two general categories of pain, nociceptive and neuropathic. Nociceptive pain is pain
associated with the stimulation of specific nociceptors (pain receptors). Nociceptive pain may be either
somatic or visceral. Somatic pain refers to pain that is well localized, sharp in nature, and generally
hurts in the area of stimulus. Visceral pain is diffuse, can be referred to another area, and is often
discribed as dull and vague in nature. Pain originating from cutaneous nociceptors is carried by Adelta
and C fibers. Nociceptive pain is "physiological" pain. Nociception is the process of transduction,
transmission, perception, and modulation of pain. Main point: Nociceptive pain arises when tissue
trauma stimulates somatic or visceral pain receptors called nociceptors.

Front 19

Descrive neuropathic pain.

Back 19

There are two general categories of pain, nociceptive and neuropathic. Neuropathic pain is caused by
abnormal processing of painful stimuli. Neuropathic pain may occur after injury to neural tissue
secondary to systemic disease, infection, trauma, ischemia, deficiencies in metabolism or nutrition, or
exposure to environment toxins or neurotoxic medications. Some common examples of neuropathic
pain syndromes include diabetic neuropathy, postherpetic neuralgia, immunodeficiency syndrome
(AIDS) neuropathy, phantom limb pain, and carpal tunnel syndrome. In summary, neuropathic pain initiated or caused by a primary lesion or dysfunction in the nervous system. Neuropathic pain is
"pathophysiological" pain.

Front 20

Transcutaneous electrical nerve stimulation (TENS) works on which of the two general types of pain,
nociceptive or neuropathic?

Back 20

TENS has a role in patients with neuropathic pain.

Front 21

By what route is most heat lost in the burn patient? How much heat is lost by this route?

Back 21

Most heat is lost by evaporation. 0.58 kilocalories (580 calories) of heat is lost for each gram of H2O
that evaporates.

Front 22

Why do burn injuries, paraplegia or upper motor neuron injuries intensify the succinylcholineinduced
release of K from skeletal muscles?

Back 22

Denervation for any reason results in a proliferation of extrajunctional receptors, which open in
response to succinycholine. The depolarization causes the release of potassium from skeletal muscle.
NOTE: extrajunctional means away from the myoneural junction, or away from the motor end-plate.

Front 23

Why are patients with third degree burns resistant to the actions of non depolarizing agents?

Back 23

The number of cholinergic nicotinic receptors (referred to as an extrajunctional proliferation of Ach
receptors) is greatly increased in these patients.

Front 24

What is the legal term for administration of an anesthetic to an unwilling patient?

Back 24

Battery. Rendering anesthesia to a patient who does not consent constitutes assault and battery.

Front 25

During a general anesthetic for an elective breast biopsy, you realize that there was no anesthesia
consent obtained. You can now be charged with what?

Back 25

Battery. Battery is the unauthorized touching of person. This usually results in anesthesia and
surgery when a procedure is performed without appropriate consent.

Front 26

If the anesthesiologist is independent and the CRNA is a hospital employee, who is responsible for the
CRNA, the anesthesiologist or the hospital?

Back 26

The borrowed servant rule pertains to situations in which an employer loans an employee to another
employer. An anesthesiologist who supervises an CRNA is liable for the nurse anesthetist's negligences,
even if the CRNA is an employee of the hospital.

Front 27

The patient with spina bifida has a known allergy to latex. The CRNA does nothing to prevent contact
of the patient with latex. What is the legal problem faced by the CRNA?

Back 27

Negligence, this is the failure to use reasonable care which is that level of care recognized as
acceptable and appropriate given the circumstance.

Front 28

Informed consent should inform the patient about what?

Back 28

The patient is informed of the contemplated procedure, including its reasonably anticipated risks and
complications, its possible benefits, and the therapeutic alternatives. If more than one type of
anesthetic is contemplated, then explain both, including risks. HINT: Informed consent does not
necessarily involve a description of the treatment or management of complications.

Front 29

What is the goal of traditional quality assurance programs? What are the three steps in a quality
assurance program?

Back 29

The goal of traditional quality assurance programs identifying deviations from the norm (outliers or
"bad apples"). Quality assurance programs: 1) define the norm (standard of care), 2) determine
whether adverse events were caused by deviations from the norm, and 3) prevent the occurrence of
adverse events. NOTE: the first step in a quality assurance program is to define the norm, or set the
standards. Quality assurance has been superceded by quality improvement.

Front 30

In the quality improvement process, indicators are used to measure the performance of functions,
processes and outcomes of an anesthesia department over time. Do incident reports provide indicators
of the QI process? Are lawsuits used as indicators?

Back 30

Incident reports may help provide indicators of the QI process, but law suits are not indicators

Front 31

Quality improvement measuring over time performance function and outcomes is what: an indicator,
a goal, a criteria, a standard, and occurrence?

Back 31

Measuring over time performance function and outcomes is an indicator. An indicator is a tool used
to measure, over time, the performance of functions, processes, and outcomes of an organization.

Front 32

What are 11 complications of steep trendelenberg position?

Back 32

hypotension, blood loss and hypovolemia, VAE (entrainment of air in pelvic or abdominal veins),
ocular complications (retinal detachment or cerebral edema), venous thrombosis, endotracheal tube
migration into brochus, atelectasis, neuropathy (brachial plexus dysfunction and several others),
arthralgia, finger injuries, regurgitation.

Front 33

What is the most likely reason a patient who undergoes a nonophthalmic procedure develops
blindness postop?

Back 33

Optic nerve and retinal ischemia. The perfusion of the optic nerve and retina can be seriously
compromised because of eye compression, which can occlude the central retinal artery and decrease
retinal perfusion. Eye compression may occur in the down eye in the lateral or the prone position.
Systemic hypotension may als contribute to postop blindness. The decrease in retinal perfusion
pressure produces retinal ischemia.

Front 34

What two sites are to be avoided when obtaining arterial blood gases in the neonate? Why?

Back 34

ABG samples are usually NOT obtained from the brachial or femoral arteries. Obtaining from brachial
artery has been assoc with nerve damage. Obtaining from femoral artery assoc with femoral head
necrosis and limb shortening

Front 35

Does hypothyroidism alter MAC?

Back 35

NO However, recovery from anesthesia may be delayed r/t hypothermia, respiratory depression and
slowed drug biotransformation

Front 36

Your patient is on CPB. During the rewarming phase, tha MAP increases to 90 mmHg. The bypass
flow is 50ml/kg/min. How should the elevated BP be treated?

Back 36

The blood pressure can be lowered by administering a vasodilator or administering an inhalational
agent. Because the increased SVR is usually due to inadequate anesthesia during rewarming, a volatile
agent is preferable to a vasodilator in patients with good ventricular function. In cases of poor
ventricular function, inhalational agents are avoided because of the potential myocardial depression
after CPB. The pump flow is not excessive (at normothermia pump flow should be between 50 and 70
ml/kg/min), so you would not try to lower blood pressure by turning down the pump flow.

Front 37

Give the normal values for parameters measured with dynamic spirometry.

Back 37

For a healthy 70 kg male, normal dynamic spirometry values are: 1) FVC = 5.0 L, 2) FEV1 = 4.0 L, 3)
FEV1/FVC = 0.75-0.85, and 4) FEF25-75% = 4.7 L/sec = 280 L/min FEF25-75% is also termed MMEF and
MMFR

Front 38

How does amrinone work? What are two CV actions of amrinone?

Back 38

Amrinone is a PDE-I. PDE is the enzyme that breaks down cAMP. By inhibiting PDE, cAMP
accumulates in cardiac and vascular smooth muscle cells. Amrinone improves CO because it has a
positive inotropic effect (increases contractility) and also because it is a vasodilator, and it decreases

Front 39

List three herbal therapies that would cause concern for anemia and warrant a preop CBC or H/H?

Back 39

garlic, ginseng, ginkgo. Garlic is associated with increased bleeding diathesia and gingko with
unexpected spontaneous bleeding. HINT: remember the Gs for bleeding and coagulation issues.

Front 40

Which alternative/herbal medicine may create a syndrome of hyperaldosteronism characterized by
hypernatremia, hypertension, hypokalemia, and suppression of the renin-angiotensin system?

Back 40

Licorice (glycyrrhiz glabra) ingestion may create hyperaldosteronism syndrome. Glycyrrhetininic acid
inhibits 11 beta-hydroxysteroid dehydrogenase leading to excess glucocorticoids which bind to
mineralcorticoid receptors, producing a mineralcorticoid response. Discontinue the herbal medicine at
least 2 weeks before elective surgery.

Front 41

Identify the herbal medicines and supplements that inhibit PLT aggregation.

Back 41

Garlic, evening primrose, fish oils, and DHEA are known to inhibit platelet aggregation. Request PT,
INR, PLTs, and H/H during preop eval.

Front 42

List the herbal medicines and supplements that may alter coagulation homeostasis and/or bleeding
time.

Back 42

The following herbals and supplements may alter coagulation status and/or bleeding time, especially
when used concomitantly with warfarin: gingko, garlic, dong quai, danshen, feverfew, ginger, DHEA,
androstenedione, and glucosamine sulfate.

Front 43

Which herbal medicine inhibits thromboxane synthase and thus has synergistic effects with other
antiplatelet agents?

Back 43

ginger inhibits TXA synthase and may potentiate other antiplatelet agents, increasing the risk of
bleeding and coag disorders

Front 44

One herbal medicine may oppose heparin or warfarin anticoagulation therapy. Which herbal is this
and what periop risks are associated with a large dose of this herbal medicine?

Back 44

goldenseal (hydrastis canadensis), sold as an antidiarrhetic, an anti-inflammatory,and hemostatic
agent, may oppose the anticoagulant effects of heparin and warfarin. An unusually large dose of
goldenseal can cause a labile blood pressure, cardiac inotropy, CNS stimulation, muscle spasms,
decreased seizure threshold, and respiratory distress

Front 45

State four anesthetic concerns for the patient taking ginger as an herbal supplement.

Back 45

1) interaction with antiplatelet agents possibly leading to coag disorders and increased risk of
bleeding 2) potentiation of barbs 3) prolonged sleep time 4) increased GI motility, decreasing the risk
of aspiration

Front 46

Which herbal medicines and supplements increase the risk of intraoperative hemodynamic
instability? Which tests would you request as part of the preop work up?

Back 46

Intraop hemodynamic instability is possible with use of garlic, ginseng, feverfew, ephedra, dandelion,
licorice and saw palmetto. At minimum, request lytes and check blood pressure and HR as indicators of
volume status.

Front 47

Identify the 2 best selling herbals that might cause hypoglycemia.

Back 47

garlic - especially when taken concomitantly with chlorpropamide ginseng - especially if taken with
oral hypoglycemics

Front 48

The pt presents with hypertension, tachycardia, agitation, and restlessness. Pt history reveals current
treatment with prozac and they also report taking "some herbal for depression". What syndrome does
this pt exhibit and which herbal medicine has potentiated this syndrome?

Back 48

A serotonin-like syndrome St. John's Wort can potentiate this syndromes?

Front 49

What drugs should be avoided or may have altered dosing requirements in the pt taking St. Johns'
Wort? List an describe 2 reasons (mechanisms) for why these drugs should be avoided or may require
altered dosing..

Back 49

Avoid MAO-Is and SSRIs Consider increasing the dosing of digitalis, theophylline, BDZs, beta-blockers,
CCBs, cyclosporins, and warfarin The rationale is as follows: 1) St. Johns wort inhibits serotonin, NE, and
DA reuptake by neurons, thus avoid MAO-I and SSRI 2) St. John's Wort induces P450 thus decreasing
bioavailability of many drugs metabolized by the P450, including those previously listed.

Front 50

Preop eval of a male pt reveals he is taking saw palmetto as a natural remedy for a mild case of BPH.
Which class of drugs may interact with saw palmetto to cause urinary retention?

Back 50

anticholinergics in combo with saw palmetto may cause urinary retention.

Front 51

During the preop workup, the patient states an allergy to soy and soy products. What is the
anesthetic implication?

Back 51

Propofol should be avoided as soybean oil is used as a component of popofol emulsion.

Front 52

A young, otherwise healthy patient presents for an emergency appendectomy. Preop assessment
reveals that they routinely take a dietary supplement to lose weight and reduce body fat. What herbal
is most likely this supplement and what are the anesthetic concerns for this pt?

Back 52

Ephedra is the most common ingredient in weight loss supplements. These supplements usually
include a number of ephedrine alkaloids, including pseudoephedrine, thus ephedra exerts its effects by
increasing sympathetic stimulation. The anesthetic concerns are chiefly CV and neuro. Hypertension,
myocarditis, myocaridal infarction, and angina are of concern with the major CV concern being lethal
cardiac dysrhythmia, as ephedra may interact with PIAs to promote dysrhythmias. Severe intraop
hypotension should be treated with a direct acting agent (phenylephrine) b/c of tachyphylaxis to
ephedrine. Neuro concerns for the patient taking ephedra are increased risk of hemorrhagic or ischemic
stroke, subarachnoid hemorrhage, and seizures.

Front 53

6 herbal medications may alter the sedative and hypnotic effects of anesthetics, identify these 6
herbals and describe the sedative and hypnotic alterations each may cause

Back 53

ginger - may potentiate barb effects and prolong sleep time ginkgo - may decreased the effects of IV
barbs St. John's wort - may prolong the sedative effects of anesthesia Melatonin - may enhance BDZ
activity Kava - may potentiate barbs and BDZ Valerian - is synergistic with barbs, narcotics, hypnotics,
and BDZs, sedatives effects of narcotics are unpredictable, may decreasd MAC and may have delayed
emergence with delirium.

Front 54

As a rule of thumb how long should most herbals be d/c prior to surgery?

Back 54

2 weeks NOTE: some sources state to d/c St Johns wort and ginseng for 7 days. The exception is
ephedra (24-36 hours)

Front 55

Identify the common herbal medicines and supplements that, at this time, have no known direct
anesthetic concerns.

Back 55

echinacea, saw palmetto, chondroitin sulfate, cranberry, creatine NOTE: be sure to review and
understand the preop concerns for these herbals and supplements. Also, consider ABX in the patient
taking cranberry as they are probably treating or trying to prevent a urinary tract infection

Front 56

Rank the following routes of drug administration from greatest to least with regards to peak plasma
concentration. Subcutaneous, IV, caudal, epidural, intratracheal

Back 56

IV intrat>caudal epidural>subcutaneous

Front 57

Besides children with spina bifida, what 4 groups of people appear to be at increased risk for latex
allergy?

Back 57

Multiple surgical procedures healthcare workers or others frequently exposed to latex atopic
individuals with hx of allergy Individuals with allergy to food (avocados, bananas, chestnuts, and stone
fruits)

Front 58

What is the function of the purkinje system? How is this function accomplished?

Back 58

the purkinje system synchronizes right and left ventricular contractions. This occurs b/c the fibers
allow very rapid transmission of the cardiac impulses from the AV node to the ventricles.

Front 59

Compared with cardiac fibers conduct muscle cells and junctional tissue (SA and AV nodes), how fast
do purkinje fibers conduct impulses?

Back 59

Purkinje fibers are large-diameter fibers that transmit impulses at a velocity 6 times that of cardiac
muscle cells and 150 times that of nodal tissue (SA and AV nodes)

Front 60

A pt in MH crisis has PVCs. What is the antiarrhythmic drug of choice?

Back 60

Procainamide, 15mg/kg IV

Front 61

The pt has AIP, or variegate porphyria (south africa). Other than barbs, list ten drugs that are
considered high risk for precipitating an acute attack

Back 61

Drugs other than barbs that are considered high risk and are thus unsafe for pts with AIP
are: etomidate, enflurane, nifedipine, sufonamides, toradol, pentozacine, phenytoin, hydralazine,
mepivicaine, and lidocaine.

Front 62

What is the fastest way to correct hyperkalemia?

Back 62

Sodium Bicarbonate, .5 to 1.0 meq/kg IV, drives potassium into cells in approximately 5 minutes.
Glucose-insulin infusion will promote SUSTAINED transfer of potassium into cells, decreasing serum
potassium concentration by 1.5 to 2.5 meq/l in approximately 30-60 minutes. B2 agonists will reduce
serum potassium levels by 1 meq/l within 30 minutes and its effects last up to 2 hours

Front 63

What is the FIRST treatment for marked hyperkalemia with widened QRS complexes and peaked T
waves? In which patients must this treatment be used cautiously?

Back 63

Cardiac membrane hyperexcitability due to hyperkalemia is rapidly offset by an infusion of calcium (5-
10 ml of 10% calcium gluconate or 3-5 ml of 10% calcium chloride). The effects are rapid (1-2 minutes),
but short-lived (15-20 minutes) so the underlying hyperkalemia must be treated. Use calcium cautiously
in the patient taking digoxin, since calcium potentiates digoxin toxicity.

Front 64

What antiemetic might be used to treat postop nausea in the parkinson's patient?

Back 64

zofran would be the appropriate antiemetic for the patient with parkinson's disease.

Front 65

A heroin addict is taking methadone to help break the addiction presents for surgery, what is your
anesthetic concern?

Back 65

Withdrawal produced by drug cessation is a concern in the patient who is taking methadone or who is
dependent on other opioids. Avoid using an opioid agonist-anagonist, such as nalbuphine or stadol,
preop.

Front 66

What is the terminal branch of the femoral nerve?

Back 66

the saphenous nerve

Front 67

What single nerve block is best of ACL repair?

Back 67

femoral nerve block alone is sufficient for ACL repair and is an effective adjunct to general anesthesia
for knee joint surgery.

Front 68

In addition to the femoral nerve, what three other nerves may be blocked for surgery on or above the
knee?

Back 68

The sciatic, lateral femoral cutaneous, and the obturator

Front 69

a routine antenatal ultrasound reveals polyhydramnios in the pregnant pt. What is polyhydramnios
and what are the implications for the fetus?

Back 69

polyhydramnios occurs when the infant fails to swallow and absorb amniotic fluid in normal amounts.
The most common causes are GI obstruction and neurologic problems. Esophageal atresia, as seen in
TEF is of greatest concern for the infant. If polyhydramnios is present check for TEF by passing a NGT shortly after delivery. NOTE: polyhydramnios also appears antenatally in 30% of CDH cases. If both
answers appear choose TEF as best answer

Front 70

Which type of shock is most frequent in pediatric pts?

Back 70

Hypovolemic shock, often due to blood loss from trauma is the most common in children. Appreciate
that compensatory mechanisms (vasoconstriction and tachycardia) in children are very efficient at
maintaining perfusion; children may lose as much as 1/4 of their blood bolume without significant CV
changes in the supine position. Hypovolemic shock due to plasma loss can be seen with burns and
peritonitis, and may be a component of septic shock

Front 71

What is the best fluid replacement for the pediatric patient in hypovolemic shock?

Back 71

Crystalloid solutions (I.E. LR) are effective in the initial treatment of hypovolemic shock in pediatric
patients. Crystalloids administered early in the management of hypovolemic shock will prevent renal
failure and also prevent renal collapse. If indicated blood should be transfused as soon as crossmatching
has been done.

Front 72

What is the minimum HgB acceptable for elective surgery?

Back 72

In pts without systemic disease, hemoglobin levels of 7g/dl are acceptable for proceeding with
elective surgery. NOTE: this represents a departure from the traditional level of 10, and is due in large
part to the concern over blood-borne infections.

Front 73

How many days prior to surgery should MAO-I be discontinued?

Back 73

14-21 days before elective surgery. However, current clinical opinion favors continuing MAO-I
therapy up to the time of surgery to avoid the risks of enduring 2-3 weeks of refractory depression. If
MAO-I therapy is continued up until time of surgery, avoid drugs with substantial sympathetic effects.

Front 74

What lab test is the best measure of end stage hepatorenal failure?

Back 74

Urine sodium concentration (UNa) < 10 meq/l is indicative of end stage hepatorenal failure.

Front 75

The pt has a PCWP of 18 mmHg, SBP of 85 mmHg, CI of 1.5. What is the most appropriate course of
action for this patient?

Back 75

PCWP is high, SBP is low, and CI is low In spite of low SBP the pt has an adequate blood volume,
indicated by the PCWP. Therefor, an inotrope such as dobutamine, amrinone, or NE is indicated to
"push the volume" forward.

Front 76

A neonate is undergoing a surgical procedure with the use of spinal blockade. What would indicate a
high or total spinal?

Back 76

Decreasing oxygen saturation is the earliest sign of a high or total spinal in the neonate. A high or
total spinal, produced either with a primary spinal technique or secondary to an attempted epidural,
presents as respiratory insufficiency rather than hypotension owing to the relatively immature nervous
system in the neonate. With an immature sympathetic nervous system, the CV parameters are
remarkably stable in the neonate with a high or total spinal.

Front 77

: The pt has a PCWP of 18 mmHg, SBP of 85 mmHg, CI of 1.5. What is the most appropriate course of
action for this patient?

Back 77

PCWP is high, SBP is low, and CI is low In spite of low SBP the pt has an adequate blood volume,
indicated by the PCWP. Therefor, an inotrope such as dobutamine, amrinone, or NE is indicated to
"push the volume" forward.

Front 78

Where is the epidural space b/w the ligamentum flavum and the dura mater the largest?

Back 78

largest at L2-L3, approximately 4-6mm

Front 79

In 1990, the food and drug administration instituted the safe medical device act. What does this act
require?

Back 79

It requires that hospitals report instances in which medical devices cause or contribute to death,
serious illness, or serious injury. The act also requires any medical personnel who become aware of
the problem to remove the equipment from patient contact and to report the problem to their
supervisors.

Front 80

The Safe medical device act of 1990 requries reporting to whom and by when?

Back 80

The incident report must be made by the hospital risk manager to the FDA within 10 days of the
incident

Front 81

Who is primarily affected by duschenne's MD?

Back 81

It is an X-linked recessive disorder, thus affecting males almost exclusively. The incidence is about 1-3
cases per 10,000 live male births and most commonly presents b/w 3-5 years of age.

Front 82

List the top 6 surgeries in the geriatric population, from most to least frequent

Back 82

1) orthopedic
2) opthalmologic
3) gastrointestinal
4) urological
5) vascular
6) gynecologic

Front 83

A neonate diagnosed with pyloric stenosis presents with a Na of 120, Cl of 84, and a respiratory rate
of 16. What is the course of action for this patient?

Back 83

Pyloric stenosis is characterized by persistent vomiting which depletes sodium, potassium, chloride,
and hydrogen ions causing hypochloremic metabolic acidosis. In this particular presentation, the
disturbances are moderately severe and the patient should be given IV 5 percent dextrose in 0.45
percent normal saline with 20-40 meq/l potassium chloride administered at a rate of 10 ml/kg/hr. Avoid
LR because lactate is metabolized to bicarbonate.

Front 84

What is thoracic outlet syndrome? What are the implications of this syndrome with regard to patient
positioning?

Back 84

Thoracic outlet syndrome results from compression of the brachial plexus and subclavian artery at the
thoracic outlet between the first rib and the clavicle or between the anterior and middle scalene
muscles. Patients usually complain of weakness, numbness, or paraesthesias in the affected upper
extremity after working with the arms overhead. All patients schedules for surgery in a pronated
position should be assessed for these symptoms. If the patient reports any of the symptoms of thoracic
outlet syndrome, the arms should be placed along the trunk during surgery.

Front 85

What are possible surgical interventions for thoracic outlet syndrome?
What are six complications of
this procedure?

Back 85

Resection of the first rib, resection of a cervical rib, partial resection of the scalene muscles, or
removal of anomalous fibrous bands Complications include: pneumothorax, brachial neuralgia, pleural
effusion, temporal phrneic nerve palsy, injury to the subclavian artery, injury to the long thoracic and T1
nerve roots

Front 86

Why are infants more prone to airway obstruction?

Back 86

Infants have a proportionately larger tongue than adults.

Front 87

Describe the anatomic r/t of the median, ulnar, and radial nerves to the axillary artery.

Back 87

The median nerve lies anterior (superior) to the axillary artery, the ulnar nerve is medial and slightly
posterior (inferior) to the artery, and the radial nerve is posterior and slightly lateral to the artery.

Front 88

Which nerve is most commonly blocked with at transarterial approach to an axillary block?

Back 88

the radial nerve

Front 89

List three types of patients who are poor candidates for office based surgery.

Back 89

1) recent CV event
2) obese
3) suffer medical conditions that would interfere with recovery

Front 90

Which blood component, FFP or cryo, has more fibrinogen in it?

Back 90

Cryoprecipitate is a concentrated source of I, VIII, XIII, and VWF

Front 91

How much will one unit of PLT increase the count in a 70 kg pt?

Back 91

5,000-10,000

Front 92

Which periop period is most often associated with severe HTN?
What percentage of pts experienced severe hypertension during this period?

Back 92

Severe HTN is most often associated with induction and endotracheal intubation. Up to 25% of
patients will exhibit severe HTN during induction and endotracheal intubation

Front 93

What "criteria based" recovery standard is an acceptable alternative to the Aldrete score? Describe
this criteria based scoring system.

Back 93

The post anesthetic discharge scoring system (PADDS) has been developed base on five criteria: vital
signs, activity and mental status, pain and nausea, surgical bleeding, and intake and output. As with the
aldrete system, a score of 9-10 is required for discharge to home.

Front 94

Where are pulse oximeters placed on the neonate to monitor preductal and postductal oxygenation?

Back 94

Preductal - right hand or finger Postductal - left foot or toe

Front 95

What is the purpose of a preductal pulse oximeter in the neonatal patient undergoing cardiac
surgery?

Back 95

It is a better index of neonatal cerebral oxygenation than are those taken at a postductal location.
The right to left shunt at the ductus arteriosis persists for some time after birth and this shunt may
affect oxygen saturation readings, thus preductal placement of the pulse oximeter is preferred. A
postductal pulse oximeter may be used in addition to the preductal pulse oximeter to quantitate the
severity of the right to left shunt.

Front 96

Identify the best area to draw ABGs from the neonate?

Back 96

Radial artery, this reflects preductal oxygenation

Front 97

How would you expect a pt with small cell carcinoma to respond to NDMBs and DMBs?

Back 97

NDMBs - increased sensitivity DMBs - increased sensitivity

Front 98

What is the anesthetic concern for the pediatric pt undergoing repair of a ventricular septal defect
without significant pulm HTN? With Pulm HTN

Back 98

Without - avoid arrhythmias, RV dysfunction, pulmonary vascular obstructive disease, and paradoxical
embolus. With - the pt with unrepaired VSD and irreversible PulmHTN often displays right to left
shunting through VSD (eisenmenger's physiology). Manipulations that may increase PVR can cause
rapid deterioration and include hypoxia, hypercarbia, acidosis, hypothermia, atelectasis, sympathetic
stimulation and polycythemia. Early closure of VSD before 1 year old results in normal ventricular
function and ejection fraction.

Front 99

Which blood substitute can alter serum amylase levels?

Back 99

Hespan (hetastarch), may cause serum macroamylasemia following transfusion. Large molecules of
hespan must be broken down by serum amylase before being removed from the circulation by renal
excretion and redistribution. Serum amylase levels can be increased for up to 5 days following hespan.

Front 100

Describe the physiological anemia of the neonate and pediatric patient. How is this altered in the
preterm infant?

Back 100

Normal HgB concentrations progressively falls during the 9th to 12th week to reach a minimum of 10-
11 g/dl, with a Hct of 33%. After the third month (12 weeks) the Hgb levels stabilize at 11.5 - 12 g/dl
until about 2 years of age. After 2 y/o the Hgb levels gradual increase to reach adult levels of 14-15.5
g/dl by puberty. In preterm infants, the decrease in Hgb levels is greater and earlier, reaching the
minimum HgB of 8g/dl by 4-8 weeks. At about 1 yr old, the preterm and full term infants' Hgb leverls
are comparable, and preterm infants following the same progression reachin normal adult levels at
puberty.

Front 101

Describe the preop fasting guidelines for children.

Back 101

<6months - restrict solids for 4 hours and clears for 2 hours 6-36 months - solids 6 hours and clears 3
hours > 36 months - 8/3 NOTE: advise restriction of clear fluids for 2 hours, breast milk for 4 hours,
formula or light meals for 6 hours, and fatty solid meals for 8 hours. The pattern is to start NPO at 2
hours for clear liquids and add 2 hours for each increasingly "fatty" meal.

Front 102

At what age is BMR normally the highest?

Back 102

peaks somewhere b/w 6-12 months old. In a full term infant, BMR rises progressively during the first
10 days of life. After the first few weeks of life, BMR decreases nearly linearly throughout life. However,
if you look at caloric requirements, infants under 1 y/o require about 100 cal/kg/day, whereas older
infants require 75 cal/kg/day, and adults require 35 cal/kg/day

Front 103

If a pregnant patient is placed on 100% oxygen, by how much will fetal O2 change?

Back 103

Maternal PO2 will rise from 90 to 500 mmHg, which is an increase of about 1 mmol in arterial oxygen
content. Becaus increasing FIO2 will not cause uterine blood flow to increase, uterine venous oxygen
content should also increase by 1 mmol. Therefore, uterine venous PO2 will increase by about 10
mmHg (11.5 mmHg, to be exact). Since uterine venous PO2 is the primary determinant of umbilical
venous PO2, the fetal PO2 will increase by about 10 mmHg.

Front 104

Which organ (non surgical) is of greatest preoperative concern in the geriatric patient?

Back 104

The cardiovascular system is of greatest preoperative concern in the geriatric patient. Nearly one-half
of the geriatric population has HTN, with or without significant CAD. Other organ systems of concern, in
decreasing frequency of concern, are renal, hepatic, pulmonary, and multi-organ disease.­

Front 105

What is the most specific test of renal failure in the geriatric patient?

Back 105

Serum creatinine clearance (24 hour) is specific and reliable for assessing GFR in all patients. Because
serum creatinine concentrations are dependent upon many factors (e.g. degree of skeletal muscle
atrophy), creatinine clearance is a better indicator of general kidney function and GFR. Creatinine
clearance decreases with age such that creatine clearance is about 70 ml/min at 70 years old. NOTE:
BUN is a late and less reliable indicator of renal function

Front 106

Discuss 5 physiologic factors that may alter SEPs.
Which factor(s) has the most effect, and
which has the least effect?

Back 106

Five physiologic factors which may alter sensory evoked potentials are: 1) temperature 2)
hypotension 3) hypoxia 4) hypocarbia 5) isovolemic hemodilution SPECIFIC DETAILS: 1) hypothermia
will increase latency and decrease amplitude of SEPs (latency increases by 1 ms for each 1 degree celsius
decrease in temperature) and hyperthermia will decrease amplitude by up to 15%. Miller states that
SEPs are lost at 42 degrees Celsius. 2) With a MAP less than 40 mmHg, there is a progressive decrease in
amplitude of SEPs. 3) A decrease in SEP amplitude is seen with hypoxia, probably due to alterations in
blood flow. 4) With an ETCO2<25 mmHg, SEP latency increases. 5) With isovolemic hemodilution, SEP
latency does not increase until the Hct is less than 15%, and SEP amplitude does not decrease until the
Hct is less than 7%. Determining which factors affect SEPs most and least is tricky. Based upon the data,
we believe that altered temperature affects SEPs the most, whereas hemodilution affects SEPs the least
(based upon the dramatic alterations necessary to cause teh alterations). NOTE: read the question
carefully and hope there is an obvious answer.

Front 107

What laboratory value will exclude CO2 retention from a diagnosis?

Back 107

Normal bicarbonate values will rule out CO2 rentention. For every 10 mmHg increase in PCO2, serum
bicarb will increase by 1 mmol/L.

Front 108

What are 5 major anesthetic concerns for the pregnant patient scheduled for nonobstetric surgery?

Back 108

1) maternal safety
2) fetal well-being
3)avoid or prevent PTL
4) fetal and uterine monitoring
5)maintaining uteroplacental perfusion

Front 109

What are your concerns for the fetus in or after nonobstetric surgery in the pregnant pt?

Back 109

Perinatal mortality is a common complication from elective surgery in the pregnant patient and your
concern for the fetus includes possible teratogenic effects of anesthetic agents, intrauterine fetal
asphyxia, and PTL (rare according to Kirby). Nitrous oxide has been associated with inhibition of DNA
synthesis - avoid nitrous if possible. Maternal diazepam administration is associated with cleft lip/palate
- avoid BDZs if possible. There is an increased risk of SAB if elective surgery is done duringthe first or
second trimester (most organogenesis occurs in the first trimester)

Front 110

What is the best stimulation pattern to determine fade during neuromuscular block?

Back 110

DBS appears to be the best test to determine fade in neuromuscular block. In DBS 3,3 - two trains of
3 impulses at 50 hz separated by 750 ms are given. The response to DBS is easier to detect MANUALLY,
correlates well with TOF, and the DBS response may reappear earlier than TOF during intense
neuromuscular blockade.

Front 111

Discuss the tests to determine the adequacy of neuromuscular block reversal. Which test is the best
indicator of neuromuscular blockade reversal?

Back 111

Traditional tests to determine the adequacy of neuromuscular block reversal have included 1) TOF >
.7, 2) head lift for 5 seconds, 3) adequate tidal volume and/or vital capacity, 4) NIF of -50 cm H20, and 5)
hand grip strength Of these test adequate tidal volumes and/or vital capacity are the least sensitive
tests of adequate NMB reversal (70-80% receptor block remains). The other tests are considered
roughly equivalent in their ability to determine reversal of NMB % receptors block). Recent research
and the NEW CRITERION is TOF>0.8-0.9 to exclude clinically significant neuromuscular block

Front 112

What tests of neuromuscular block correlate well with TOF > 0.8-0.9?

Back 112

Two tests seem to correlate well: 1) DBS and holding a tongue blade between the teeth. DBS
appears to provide a better tactile response to fade, and the DBS 3,3 pattern seems to be a more
reliable assessment of muscle relaxant reversal (Duke). The ability to hold a tongue blade b/w the teeth
correlates with a TOF >0.86 and thus is an excellent assessment of adequate neuromuscular block
reversal. NOTE: a TOF > 0.9 cannot be determined by feel; it must be quantitated by mechano-,
electro-, or acceleromyography.

Front 113

What is an emancipated minor?

Back 113

A minor (under 18) who has been given the global rights to make their own health care decisions.

Front 114

What qualification may enable a minor to receive the status of emancipated minor?

Back 114

Pts under 18 y/o may be awarded the status of emancipated minor if they are: 1) married, 2) are a
parent, 3) in the military, and 4) economically independent.

Front 115

State the "major minor doctrine"

Back 115

applies to a minor who has decision making capacity and is legally and ethically capable of giving
informed consent in specific situations as determined by the court

Front 116

What are common contaminants of medical gas lines?
What contaminant is most common?

Back 116

Oil, water, bacteria, particulate matter, and residual sterilizing solutions.
Water is the most common

Front 117

State 3 anesthetic concerns for the pt with hypothyroidism.

Back 117

1) susceptible to the hypotensive effects of anesthetic agents
2) have significantly impaired
ventilatory responses to hypoxia and hypercarbia
3) are particularly susceptible to intraoperative
hypothermia.

Front 118

How would you manage intubation of a patient with an obstructive tumor in the upper airway?

Back 118

The optimal decision for the safety of the patient with an upper airway tumor is to intubate with FOB
before induction of anesthesia. "If there is any doubt about the ability to intubate an anesthetized pt,
awake intubatio is mandated" (Kirby). An additional concern involves the friability of the tumor. If the
patient has received radiation treatment to the tumor, the obstructing mass may be stiff and friable, and
furthermore, temporomandibular joint mobility may be compromised. In this case, a tracheostomy is
preferable as attempts at intubation risk serious hemorrhage and edema which may lead to complete
obstruction of the airway.

Front 119

Describe a 3 in 1 block and its utility.

Back 119

It is anothor, name for a lumbar plexus block. The 3 in 1 anesthetizes the femoral, obturator, and
lateral femoral cutaneous nerves. Used alone the 3 in 1 block is applicable for minor knee surgeries, and
in combo with spinal anesthesia is appropriate for major knee surgery. Potential disadvantages of a 3 in
1 block include: 1) large volumes of local anesthetic solution are required to achieve adequate spread
along the fascial plane of the plexus, 2) the block often MISSES the OBTURATOR nerve, and 3)
quadriceps weakness may limit ambulation after the procedure.

Front 120

What is the major intraoperative complication during cerebral aneurysm surgery?

Back 120

Hemorrhage (rupture)

Front 121

If a cerebral aneurysm ruptures during surgery, what is your plan?

Back 121

Requires immediate, aggressive fluid resuscitation and controlled hypotension. Controlled
(deliberate) hypotension may be achieved with nitroprusside, labetalol, propranolol, or esmolol. These
agents are preferred because they do not affect cerebral blood flow or ICP. Use dextrose free fluids
since increased neurologic defects are seen with hyperglycemia. NOTE: this is the traditional answer
found in most texts. However, these same texts are now favoring the use of a temporary clip on the
parent vessel to allow the surgeon to gain control of the ruptured vessel. If controlled hypotension was
instituted before the temporary clip was placed, restore SBP after the clipping to improve collateral
blood flow. Additionally, if the temporary clip is in place for mare than 10 minutes, STP and mild
hypothermia are often implemented for cerebral protection. Normocarbia should be maintained
whenever possible regardless of which protocol is used.

Front 122

What drugs would you administer to a PEC pt with cerebral edema prior to C/S?

Back 122

Hydralazine or labetalol are the most popular drugs to reduce hypertension in the PEC pt. CBF and
ICP are maintained with both of thies antihypertensives. Antihypertensive with reported adverse effects
during pregnancy which may be avoided include esmolol, clonidine, nifedipine, and ACE-I's.

Front 123

What standards of care apply during MAC?

Back 123

Identical standards of care apply to monitored anesthesia care and regional or general anesthesia.

Front 124

What is the single greatest danger associated with MAC?

Back 124

Lack of vigilance

Front 125

Which monitors are required during MAC of the pediatric pt?

Back 125

All standard monitors to include precordial, NIBP, temp, SPO2, ECG, and ETCO2?

Front 126

Describe the periop management of the patient with hyperparathyroidism.

Back 126

Hypercalcemia (serum [] higher than 5.5 meq/L and ionized calcium [] higher than 2.5 meq/L) is a
hallmark of patients with hyperparathyroidism. The periop goal is to correct intravascular volume and
electrolyte abnormalities. Normal saline and a loop diuretic of (usually lasix) are administered to
increase calcium excretion by means of hydration and diuresis. Periop, avoid fluids with calcium, e.g. LR.
Also, increased dosing vecuronium and probably all nondepolarizing muscle relaxants will be required.

Front 127

Which nerves are blocked in a cervical plexus block?

Back 127

The ventral rami C1-C4 form the cervical plexus. However, the first cervical nerve (C1) is a motor
nerve with no sensory distribution. Thus, both deep and superficial cervical plexus blocks anesthetize
C2-C4. The deep cervical plexus block is essentially a paravertebral block of C2-C4.

Front 128

Describe the recent modifications to the PACU aldrete score.

Back 128

The major change b/w the original and modified aldrete criteria is the change from assessing COLOR
(old) to assessing OXYGENATION (new). In the old criteria, pink = 2, pale = 1, cyanotic = 0. With the new
criteria, SPO2>92% on room air = 2, >90 % = 1, <90= 0. The other notable change is the circulation
criteria; it is fairly simple to learn. Under the new criteria, a blood pressure within 20 mmHg of normal =
2, within 20-50 mmHg = 1, and deviating >50 mmHg from normal = 0. Under the old criteria, blood
pressure within 20% of normal = 2, 20 - 50% = 1, and 50% = 0. Score of 9-10 is needed for discharge.

Front 129

During a total hip replacement procedure, what sign indicates methymethacrylate toxicity has
occurred?
What is bone cement implantation syndrome?n

Back 129

Sudden hypotension about 30-60 seconds after placing methylmethacrylate indicates toxicity.
Occasionally the hypotension may take up to 10 minutes to manifest. Two mechanisms are probably
responsible: 1) transient fat and air emboli from the bone marrow, 2) residual monomer causes
vasodilation and decreased SVR, leading to hypotension. Bone implantation syndrome occurs when
hypotension is accompained by hypoxia, dysrhythmias, pulmonary hypertension, and decreased CO.

Front 130

Identify the 5 criteria that must be met for d/c to home from office based anesthesia under the
clinical discharge criteria (CDC)

Back 130

1) stable VS 2) patient is alert and oriented 3) patient is free of nausea and/or vomiting 4) steady of
gain 5) patient has no significant bleeding.

Front 131

Given the following spirometry values, FVC = 3.1 L, FEV1 = 2.5 L, what is your diagnosis?

Back 131

This patient has a restrictive lung disease. Both values are lower than normal, but the FEV1/FVC ratio
is 0.8, which is normal. By definition, in restrictive lung disease, there is a proportional decrease in all
lung volumes, but the FEV1/FVC will be normal. HINT: be certain to evaluate the lung volumes and not
just the FEV1/FVC ratio.

Front 132

What dynamic spirometry values would place a patient in the high risk category for postop
pulmonary complications? Moderate risk?

Back 132

High - FEV1 < 1L, FVC <1.5L or 20 ml/kg, FEV1/FVC < 35% predicted or peak flow <
200L/min Moderate- FEV1 1-2L, FVC <50% predicted, FEV1/FVC >35% but less than 50%, or FEF25-75%
<50% predicted, the patient is at moderate risk for postop pulmonary complications.

Front 133

Define sentinel event.

Back 133

A sentinel event is an unexpected occurrence or variation involving serious physical or psychological
injury, or risk thereof. Sentinel means send and alarm or signal that requires immediate attention.

Front 134

What is a major problem in any QA program? How may this problem be avoided?

Back 134

The major pitfall is inconsistent reporting of data. To avoid inconsistent reporting of data, a succinct
check-off form should be used.

Front 135

A patient with known allergies is scheduled for a precedure involving injection of IV contrast dye.
What are your anesthetic concerns? What prophylactic treatments would be appropriate?

Back 135

The allergic pt is at risk for an anaphylactoid allergic reaction to the IV contrast dye (5-8% of patients
will experience an allergic reaction). Appropriate prophylaxis includes both H1 - and H2 antagonists and
a corticosteroid. A typical prophylactic regimen would be: benadryl, cimetidine (or ranitiding), and
prednisone 16-24 hours prior to the planned procedure. Adequate hydration is also warranted, as the
contrast dye usually causes substantial diuresis.

Front 136

What prophylactic measures can be taken to minimize the risk of methylmethacrylate toxicity?
If bone cement toxicity occurs, what is your first treatment?

Back 136

Strategies to minimize BCIS and toxicity include:
1) increase FIO2 prior to cementing
2) D/C nitrous prior to cementing
3) maintaining euvolemia
4) creating vent holes in the distal femur
5) high pressure
lavage of the femoral shaft to remove debris
6) using an uncemented femoral component
If toxicity occurs, ADEQUATE HYDRATION and INCREASED FIO2 will aid in the elimination of the methylmethacrylate and restore normal blood pressure.

Front 137

Where are MEPs stimulated? How are they stimulated?

Back 137

MEPs are stimulated over or in the motor region of the cerebral cortex. MEPs may be stimulated by
transcranial electrical stimulation (teMEP), transcranial magnetic stimulation, (meMEP) or by direct
stimulation of the motor cortex with an electrode.

Front 138

Where may motor evoked potentials be monitored?

Back 138

MEPs are recorded over or att:
1) spinal cord
2) peripheral nerve
3) the involved muscle
NOTE:
neither SEPs nor MEPs can be recorded at the site of stimulation

Front 139

An S3 heart sound is an indicator of what condition?

Back 139

An S3 heart sound (gallop rhythm) during mid-diastole is most often heard in the context of CHF.

Front 140

What is the postulate mechanism(s) that produces and S3 heart?

Back 140

The third heart sound is thought to reflect a flacid and inelastic condition of the heart during diastole
(Stoelting). Guyton says: "..a logical but unproven explanation of this sound (S3) is oscillation of blood
back and forth between the walls of the ventricles initiated by inrushing blood from the atria." We favor
Guyton's explanation..

Front 141

What is the r/t of the following parameters: preload, LVEDV, PAOP, LVEDP, and LADP?

Back 141

In the absence of mitral stenosis or pulmonary hypertension, PAOP = LADP = LVEDP = LVEDV =
preload. Any of the pulmonary artery catheter measurement are equivalent indirect measurements of
preload, in the absence of mitral stenosis or pulmonary hypertension.

Front 142

States Graham's Law. Give an application of Graham's law.

Back 142

Graham's law states that the rate of diffusion of a gas is inversely proportional to the square root of
its molecular weight. For example, Helium will diffuse faster than oxygen , which will diffuse faster than
nitrous oxide.

Front 143

Your patient is scheduled for bilateral total hip replacement. What is a major concern and what
indicator would require postponement of the second hip replacement after the first hip has been
replaced?

Back 143

A major concern in THR surgery is pulmonary embolism. PAP monitoring is required in this patient.
PAP monitoring reliable signals embolization by a rise in PVR (> 300 dynes*s/cm^5). A rise in PVR is
usually indicated by a rise in pulmonary pressure with no change in PAOP and a decreased CO.
(Increased PAP, Decreased CO, and no change in PAOP)

Front 144

The pregnant patient delivered baby under general anesthesia; what factors(s) correlates most with a
depressed APGAR score at one minute?

Back 144

The general anesthetic factors which most depress the APGAR score at one minute are low FIO2 and
High N2O.
Initial lower APGAR scores under general anesthesia are probably due to transient sedation rather than asphyxia. The incidence of depressed APGAR scores at one minute can be markedly
reduced by techniques that include: 1)higher FIO2, 2) reduced N2O, 3) lower dose (0.5 MAC)
halogenated agents, 4) continuous lateral tilt, and 5) expeditious delivery time. NOTE: the fears that
high maternal PO2 may cause uterine vasoconstriction are unfounded.

Front 145

Which is more important to neonatal outcome: the induction of anesthesia to delivery interval or the
uterine incision to delivery interval.

Back 145

The UTERINE INCISION TO DELIVERY interval seems to be more important to neonatal outcome than
the induction of anesthesia to delivery interval. The uterine incision to delivery interval is ideally less
than 3 minutes (180 seconds)

Front 146

What 9 CV signs indicate fetal cocaine toxicity in the newborn of a concaine addicted mother.

Back 146

1) arterial hypoxemia 2) increased BP 3) increased HR 4) increased CBF 5) reduced CO 6) reduced
SV 7) right ventricular conduction delay 8) RVH 9) ST segment and T wave changes

Front 147

What is the most common cause of thrombocytopenia in the parturient?

Back 147

PEC Others include
1) ITP,
2) gestational thrombocytopenia (up to 5% of parturients),
3) HIV positive status
4) drug induced thrombocytopenia, including cocainexes)

Front 148

Which amino acid is the immediate precursor of nitric oxide (NO)?

Back 148

Nitric Oxide is formed from L-arginine

Front 149

What enzyme family catalyzes the release of nitric oxide from L-arginine?

Back 149

The nitric oxide synthase family of enzymes catalyzes the release of NO from L-arginine.

Front 150

Describe the signal transduction pathway of nitric oxide

Back 150

NO is a short-lived gas which diffuses easily across membranes. NO stimulates the production of
cGMP by activating GC. cGMP activates PKG which ultimately decreases cytoplasmic calcium levels.

Front 151

Identify 6 metabolic or electrolyte disorders that prolong/increase nondepolarizing neuromuscular
block.

Back 151

1) respiratory acidosis 2) metabolic acidosis 3) hypothermia 4) hypokalemia 5) hypercalcemia 6)
hypermagnesemia

Front 152

Identify drugs and conditions associated with increased resistance to nondepolarizing neuromuscular
block.

Back 152

Antiepileptic drugs and patients with burns are associated with increased resistance to NDMBs.

Front 153

Describe the process that causes ventricular myocyte relaxation (lusitropy).

Back 153

Ventricular myocyte contraction requires increased intracellular calcium. Thus, for the ventricular
myocyte to relax, intracellular calcium must be reduced back to resting levels. Calcium is sequestered in
the sarcoplasmic reticulum through energy dependent processes.

Front 154

Which biotransformation reaction (acetylation, oxidation, glucuronidation, sulfonation) are NOT
MATURE in the neonate?

Back 154

Acetylation, glycination, glucuronidation NOTE: sulfonation IS MATURE at birth. By one year, all
reactions are mature.

Front 155

Why is morphine sulfate used cautiously, if at all, in the neonate?

Back 155

Hepatic conjugation of morphine is reduced and renal clearance of morphine metabolites is reduced.

Front 156

State the numeric values for absolute deadspace and shunt.

Back 156

Absolute dead space=infinity

Shunt= zero

Front 157

Which pathway, extrinsic or intrinsic, do the PT and INR assess?

Back 157

Extrinsic

Front 158

What is the most common anesthesia related complication in ambulatory surgery??'

Back 158

PONV NOTE: others in descending order are persistent hypoxemia, unresolving conduction block,
PDPH, pain, and persistent HTN

Front 159

Q: Which NSAID does not alter platelet function.

Back 159

Tylenol (Stoelting)

Front 160

What is the correct vertebral level of a properly placed CVP catheter tip?

Back 160

The tip of a properly placed CVP catheter will be at the T4-T5 interspace, above the level of the 3rd rib.

Front 161

What anesthetic agent would you avoid during retinal detachment repair?

Back 161

Avoid N2O during retinal detachment repair as the surgeon will often inject a bubble of SF6 or other perfluorocarbon.

Front 162

Name the most commonly encountered type of drug-induced hepatitis.

Back 162

Alcohol hepatitis is probably the most commonly encountered type of drug induced hepatitis.

Front 163

Describe the r/t between IOP in intraocular volume.
How is the r/t different if the globe is open?

Back 163

Increased IOP in closed globe usually means increaed volume.
With an open globe, increased IOP decreases volume

Front 164

Which electrolyte abnormality will cause MAC to increase?

To decrease?

Back 164

Hypernatremia-MAC increases

Hypercalcemia- MAC decreases