ABSITE Review Questions Anesthesia
Troublesome PONV can prolong recovery room stay and hospitalization and is one of the most common causes of hospital admission following ambulatory surgery. The intentional dilution of blood volume often is referred to as. Acute normovolemic hemodilution ANH anemia. Acute hypovolemic normodilution AHN anemia. Hypercoagulable hemodilution HH anemia. None of the above. The intentional dilution of blood volume often is referred to as acute normovolemic hemodilution ANH anemia. ANH is a technique in which whole blood is removed from a patient, while the circulating blood volume is maintained with acellular fluid.
Blood is collected via central lines with simultaneous infusion of crystalloid or colloid solutions.
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Collected blood is reinfused after major blood loss has ceased, or sooner, if indicated. Blood units are reinfused in the reverse order of collection. Under conditions of ANH, the increased plasma compartment becomes an important source of O 2 , which is delivered to Please enter User Name Password Error: Please enter Password Forgot Username? Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! Otherwise it is hidden from view. About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.
Sign in via OpenAthens. Sign in via Shibboleth. Clinical Sports Medicine Collection. Search Advanced search allows to you precisely focus your query. Search within a content type, and even narrow to one or more resources. If loading fails, click here to try again. A year-old male is seen in preoperative testing in preparation for left shoulder arthroplasty the following day. The patient has a history of congestive heart failure and is currently on metoprolol, digoxin, and furosemide. Which one of the following plans would be the most appropriate plan to proceed?
Proceed to surgery and administer an additional dose of furosemide intraoperatively. Proceed to surgery and use a regional anesthetic. Cancel the case and refer the patient for cardiac catheterization. Recent weight gain, fatigue, orthopnea, complaints of dyspnea, peripheral edema, and hospitalizations are all significant.
Decompensated heart failure is considered a high risk cardiac condition, and elective surgery should be postponed. The patient does not appear to be optimally managed, and this elective surgery should be postponed. Medical therapy including beta blockers, nitrates, digoxin, and diuretics needs to be optimized and continued preoperatively. The decision to selectively continue or discontinue these drugs depends on the patient's volume and hemodynamic status, the anticipated surgery, and the degree of cardiac dysfunction.
Echocardiography is helpful to provide an objective measure of the left ventricular ejection fraction, ventricular performance, and diastolic function if not previously performed but not essential to be repeated preoperatively.
Similarly, invasive testing such as cardiac catheterization is not indicated. Regardless of the anesthetic technique planned, unless it is truly an emergency and life-preserving, surgery should be postponed in patients with decompensated or untreated heart failure. A year-old female with no past surgical history receives a lumbar epidural for labor pain at the maternity ward. The local anesthetic initially given through the epidural has a very short duration of action matched with a concentration dependent quick onset and is metabolized rapidly by plasma esterases.
The combination of low pH, sodium bisulfite preservative, and inadvertent intrathecal dosing has been associated with prolonged motor and sensory deficits when using which one of the following local anesthetics? Chloroprocaine The local anesthetic described in the question is chloroprocaine. This ester-type local anesthetic is hydrolyzed very quickly by plasma esterases, and its rapid onset is due to the large concentration that can be safely administered.
Although current preparations of this medication no longer contain sodium bisulfite, this preservative, along with high concentrations of the drug, given intrathecally has been associated with neurotoxicity. Ropivacaine is an amide local anesthetic that has a greater tendency to block A-delta and C fibers — hence limiting motor block when used in the epidural space.
Bupivacaine is an amide local anesthetic that has been implicated for its cardiovascular toxicity.
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Mepivacaine is an amide local anesthetic that has been associated with transient neurological symptoms when given intrathecally. Cocaine is a local anesthetic that is known to cause vasoconstriction at all concentrations due to its inhibition of norepinephrine reuptake. Benzocaine is a local anesthetic that has been associated with methemoglobinemia when given in high concentrations. A year-old female presents for assessment prior to exploratory laparotomy and small bowel resection for a suspected malignancy in two weeks. She has a history of CAD status post bare metal stents inserted 45 days ago, well controlled type I diabetes mellitus, hypertension, porcine mitral valve replacement 8 years ago, and migraines.
She denies any chest pain or dyspnea currently. Her medications include aspirin, metoprolol, lisinopril, clopidogrel, regular insulin, and topiramate. Which one of the following plans is the most appropriate preoperative recommendation? The procedure should be postponed for at least one year given her recent percutaneous coronary intervention. The metoprolol can be discontinued prior to surgery, because her heart rate is well controlled. Prophylaxis against infective endocarditis will be required. Cardiac catheterization is recommended prior to surgery to evaluate patency of existing stents.
She may proceed with the scheduled surgery after clopidogrel has been stopped for 7 days; aspirin should be continued throughout the perioperative period. She may proceed with the scheduled surgery after clopidogrel has been stopped for seven days; aspirin should be continued throughout the perioperative period Several cohort studies have examined the benefit of percutaneous coronary intervention PCI before noncardiac surgery.
Data has suggested a notably lower rate of cardiac complications in patients who underwent PCI at least 90 days before noncardiac surgery. PCI using coronary stenting poses several intraoperative issues including myocardial infarctions, major bleeding episodes, and deaths. More events have been shown to occur when noncardiac surgery in performed within 2 weeks of PCI. The recommendation is thus that elective noncardiac surgery after PCI, with or without stent placement, should be delayed for 4 to 6 weeks.
Drug-eluting stents represent a greater challenge during the perioperative period. Reports suggest that drug eluting stents may present an additional risk over a prolonged period up to 12 months. New guidelines suggest continuing aspirin therapy in all patients with a coronary stent and discontinuing clopidogrel for as short an interval as possible for patients with bare metal stents in place less than 30 days or drug-eluting stents for less than 1 year.
Beta blockers should be used in patients previously taking beta blockers and those with a positive stress test undergoing major vascular surgery. Cardiac catheterization procedures are not recommended to evaluate stent patency without a clear indication and may lead to stent displacement.
A year-old, otherwise healthy man pulled from his burning home is intubated in the field and transported via helicopter to the intensive care unit, where aggressive fluid resuscitation is initiated. Initiate total parenteral nutrition due to the possibility of post-burn ileus.
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Wait at least 48 hours before initiating enteral nutrition to allow for mobilization of third spaced fluid. Initiate enteral feedings with a high protein, high carbohydrate formula. Wait until the patient is extubated to begin oral feedings with clear liquids, advancing his diet as tolerated. Initiate enteral feedings with a high protein, high carbohydrate formula The hypermetabolic response to severe burns resembles the stress response to other surgical or traumatic injuries but to a particularly heightened magnitude. A year-old man with a history of coronary artery disease is undergoing a craniotomy for resection of meningioma in the seated position.
One hour into the surgery, the patient coughs. He immediately becomes hypotensive and hypoxemic. Ventilation has become difficult, with the patient exhibiting high peak pressures. Which one of the following mechanisms is the most likely cause of these symptoms? Air embolism Patients who undergo surgery in the seated position are at increased risk of developing air emboli because the surgical field is elevated with respect to the heart.
On admission, laboratory investigation revealed a hour urine protein of 7g. Shortly after admission, there was an abrupt fetal heart rate deceleration for 8 minutes and an emergent cesarean section was called. Cefazolin was administered prior to skin incision.
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The patient was maintained on propofol and remifentanil infusion and surgery proceeded uneventfully for a total of 45 minutes. Uterine tone was maintained on oxytocin. At the end of surgery, a train of 4 revealed no twitches. Which one of the following medications could potentiate the neuromuscular blocking effect of rocuronium?
Magnesium Magnesium enhances neuromuscular blockade produced by nondepolarizing neuromuscular-blocking drugs and, to a lesser extent, enhances neuromuscular blockade produced by succinylcholine. Patients treated chronically with anticonvulsants phenytoin, carbamazepine are relatively resistant to some pancuronium, vecuronium, rocuronium, cisatracurium, pipecuronium, doxacurium.
Antibiotics devoid of neuromuscular-blocking effects are the penicillins and cephalosporins. Nifedipine and remifentanil have not been shown to have any interactions with neuromuscular blocking agents. A 3-year-old healthy child is undergoing strabismus repair surgery under general anesthesia with a laryngeal mask airway.
Ten minutes into the surgery, the surgeon applies traction to the medial rectus muscle; asystole ensues and a code blue was called. Traction was stopped immediately and there was an abrupt return of spontaneous rhythm. Which of the 2 cranial nerves are most likely responsible for the intraoperative asystole? V and X Traction on the extraocular muscles or pressure on the globe causes bradycardia, atrioventricular block, ventricular ectopy, or asystole. Miller's Anesthesia 7th edition, page A G8P4 parturient with known placenta previa is undergoing her fourth repeat cesarean delivery under combined spinal-epidural anesthesia.
Soon after delivery of the fetus, an occult placenta accreta was diagnosed. Approximately 3 L of blood were lost rapidly from the uterus over 10 minutes and a decision was made to proceed with a hysterectomy. A total of 8 units of packed red blood cells and 8 units of fresh frozen plasma were rapidly transfused. Surgical bleeding was controlled with clamping of the uterine arteries but an ongoing oozing of blood was noted from the incision sites. Laboratory investigation revealed a hematocrit of 0. Which one of the following steps would be the most appropriate next step in the management of this patient?
Administer platelets and apply forced air warmer. Administer platelets and cryoprecipitate This is an example of disseminated intravascular coagulopathy DIC from massive transfusion. Miller's Anesthesia 7th edition, pages An emergent page is received to come to the post-anesthesia recovery unit to see a year-old woman status post-hysterectomy under general anesthesia for endometrial adenomyosis. She had a history of insulin-dependent diabetes, unstable angina and IgA deficiency.
She had an intraoperative blood loss of 2 L and was just starting to receive blood transfusion when the patient complained of chest pain, dyspnea, severe itching and dizziness. The transfusion was stopped and epinephrine and hydrocortisone were administered to the patient with resolution of the symptoms. Transfuse 4 units of cross-matched blood immediately. Request 4 units of leukoreduced packed red cells. Request 4 units of cytomegalovirus CMV negative packed. Hold transfusion and administer IV fluids, mannitol and lasix to force diuresis. Request 4 units of washed packed red cells This is an anaphylactic reaction caused by the transfusion of IgA to a patient who is IgA deficient and has formed anti-IgA.
A year-old woman with history of acute intermittent porphyria is scheduled to undergo a bilateral tubal ligation under general anesthesia. Which one of the following medications should be avoided in this patient? Thiopental Acute intermittent porphyria is a rare disorder of heme synthesis in which the precursors to heme synthesis, porphyrins, accumulate and lead to neurological manifestations.
You have not finished your quiz. If you leave this page, your progress will be lost. A year-old man undergoes total knee arthroplasty under epidural anesthesia. He complains of persistent back pain at the epidural site that begins on postoperative day 3 and continues to worsen. The pain was initially localized, but now radiates down his right thigh to his knee, stopping there. He does not complain of any sensory deficits or have any bladder or bowel incontinence. Which one of the following diagnoses is the most probable?
Direct neurotoxic effect of local anesthetic. Epidural abscess The clinical scenario described in the stem is most suggestive of an epidural abscess. This is a rare but dreaded complication of epidural anesthesia that usually manifests as localized back pain that worsens and develops radicular changes. Epidural abscesses have a median onset of days. The patient goes on to develop sensory and motor deficits and eventually paralysis if untreated. Direct neurotoxic effect of local anesthetics is less often seen with conventional concentrations of local anesthetics and does not follow this timeline.
Epidural hematoma proceeds more rapidly to produce sensory and motor deficits within hours. Anterior spinal artery syndrome is predominantly characterized by motor changes. There is no associated pain. A year-old female is undergoing repair of a laceration of the third toe under ankle block. Which one of the following anatomic landmarks is appropriate for performing an ankle block?
It can be blocked by subcutaneous infiltration of local anesthetic between the medial malleolus and the extensor hallucis longus tendon. The posterior tibial nerve is blocked by deep infiltration of local anesthetic between the posterior tibial artery and the medial malleolus, not between the lateral malleolus and the tendocalcaneus.
This nerve does not supply the web space between the first and second digits or the lateral fifth digit. It can be blocked by subcutaneous infiltration of local anesthetic between the lateral malleolus and the extensor digitorum longus or anterior border of the medial malleolus , not between the tendons of the anterior tibial and extensor hallucis longus muscle. The nerve is blocked by identifying the groove between the extensor hallucis longus and the extensor digitorum longus tendons, 2 cm distal to the intermalleolar line, and infiltrating the local anesthetic, just lateral to the dorsalis pedis artery pulse.
The nerve is blocked by local anesthetic infiltration between the lateral malleolus and the tendocalcaneus, not between medial malleolus and tendocalcaneus. In essence, the ankle block can be achieved by local anesthetic infiltration in a ring- n like fashion at the ankle level. A 4-year-old boy must undergo surgery for repair of an open eye injury secondary to globe laceration.
He ate 2 hours prior to his accident. General anesthesia is required for repair. Which one of the following anesthetic techniques is appropriate for securing the airway? Intubation after deep inhalational induction. Slow, controlled intravenous IV induction with propofol and vecuronium. Rapid, sequence IV induction with propofol and succinylcholine. Rapid, sequence IV induction with propofol and rocuronium. Rapid, sequence IV induction with propofol and rocuronium The child has a full stomach and is at risk for aspiration.
Succinylcholine is the drug of choice to use for rapid sequence induction in the setting where aspiration is a risk as succinylcholine facilitates tracheal intubation within 30 seconds as compared to other muscle relaxants. Succinylcholine use is a relative contraindication in this case since this is an open globe injury. There is a risk of expulsion of the contents of the globe secondary to an increase in the intraocular pressure caused by succinylcholine induced muscle fasciculations.
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The safer approach is to perform rapid sequence induction with propofol and a large-dose of rocuronium which provides optimal intubating conditions within 60 to 90 seconds without the risk of expulsion of the contents of the globe. In addition, the FDA has published a warning for the risk of cardiac arrest from hyperkalemic rhabdomyolysis in children administered succinylcholine, especially males, 8 years of age or younger.
These were healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy. Awake intubation with topical anesthesia of the airway is optimal and safe in an adult, but a 4-year-old child would not be as cooperative enough for this approach.