Anaesthesia Q Review 2014

8/11/2019 Anaesthesia Q Review 2014

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Anaesthesia Mccqe ReviewThis upload for knowledge refreshing for your preparation, folks

What is pain?

The conscious experience of an unpleasant

sensory or emotional experience associated withactual or potential tissue damage.

What is nociception?

the process of neurotransmission, originating fromsensory receptors (nociceptors) which transmitsand processes information related to tissuedamage.

What is hyperalgesia? an exaggerated response to a noxious stimulus.

What is allodynia?a pain response to a non-noxious stimulus (such asa gentle touch.)

What is peripheral sensitisation?

sensitization of C & A nociceptors, predominantlyinduced by inflammatory mediators released bytissue damage such that their response threshold islowered and/or they produce a greater response tothe same stimulus.

What is central sensitisation?

The enhanced excitability of spinal nociceptiveneurons to result in a hypersensitive andhyperactive nociceptive transmission system. Canbe short lived, associated with transient changes inneurotransmitter activity, or long-lived, associated

with phenotypic changes in these central neurons.

What is analgesia? The absence of pain sensation.

What is distress? Physical and emotional / mental strain or stress.

What is somatic pain?

Somatic pain is easily localized and so oftendescribed as acute, aching, stabbing or throbbing.Somatic pain includes cutaneous pain after anoperation. Somatic pain can be further classified assuperficial (skin) or deep (joints, muscle, or

periosteum) in origin.

What is peripheral pain?

Either visceral (thoracic/abdominal) or somatic(joints, muscles, or periosteum.) Visceral pain ispoorly localized and frequently described ascramping or gnawing. May be also reffered pain tocutaneous sites far from site of injury.


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What is neuropathic pain?

The result of trauma, inflammation, or sensitizationof peripheral nerves or spinal cord. Neuropathicpain is described as burning, lacerating, andintermittent, and is often poorly responsive totreatment.

What is idiopathic pain?

Persistent pain in the absence of an identifiableorganic substrate. Idiopathic pain is often excessiveand associated with emotional stress or behavioralabnormalities.

What are the physiological signs of pain?

Inc blood pressure, inc heart rate, inc peripheralvasoconstriction - identifiable by pale mucusmembranes, inc respiratory rate, possible musclesplinting, inc catabolic processing, dec food / waterintake, dec voiding

What is multimodal analgesia?

The simultaneous administration of a combinationof analgesic agents (opiods, NSAIDs, and alpha2-agonists) with different modes of action anddifferent side effects which may act synergisticallyand achieve optimal analgesia with less risk/sideeffects than large doses of a single drug.

What is pre-emptive analgesia?Administration of an analgesic agent prior tonoxious stimulation.

How do anaesthetics affect fluid deficits?

"Decompensate" - ie, incapacitate compensatorymechanisms, depress cardiac output, derangeblood-gases, exacerbate pH changes, impair renalfunction, increase respiratory water losses (lowFiH2O); also, surgery imposed H2O deprivation,3rd space losses, gross haemorrhage, evaporationfrom wound, blood sequestration in tissues thenremoved (ex spay), urinary losses.

Define the term: hypotonic. Water lost in excess of electrolytes (pure water).

What are the clinical signs of hypotonic /free waterloss? How can they be corrected?

Skin tenting, tachycardia, hypotension

Succinylcholine1. Type of agent

2. Mechanism of action3. Indications

4. Speed of onset and clearance5. Side effects

6. Contraindications

1. a depolarizing paralytic anesthetic.2. Binds to muscarinic (organs) and nicotinic(muscles) receptors, causing depolarization ofmuscles (fasciculations) and blocks ACh.3.RSI, Converting from a laryngeal mask to ETT,short procedure, Risk of aspiration, laryngospasm.4. Onset = 30 sec. Duration 5-10min.5.Malignant hyperthermia. Plasma Cholinesterasedeficiency = paralysis upon waking. Hyperkalemia.


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Muscarinic = Bradycardia, dysrythmia, sinus arrest.Increased ICP, IOP and Gastric pressure.Fasciculations and post-op myalgia6. History of MH, PCD. Hyperkalemia, Allergy.myotonia. Caution in eye injury, myasthenia gravis.

What type of paralytic is succinylcholine? Howdoes it work?

A depolarizing paralytic. It binds to the nicotinicreceptor, causes prolonged muscle depolarizationand fasciculations then paralyzes the muscle. Thenit remains in the receptor and is slowly degraded.Not degraded by acetylcholinesterase.

Propofol1. type of drug2. Mechanism of action (2)

2. uses (3)3. Side effects (6)

1. A sedative hypnotic and amnesic with musclerelaxant properties. It is not an analgesic and thusfentanyl is also used. It's the white drug.

2. Potentiates GABA and blocks sodium channels.

3. Used for Rapid Sequence Induction RSI,procedural sedation and as a general anaesthetic.

SIDE EFFECTS1. Increased ICP,2. increased IOP,3. decreased RR,4. decreased BP,5. decreased HR6. Apnea

Midazolam1. Mechanism of action

2. Uses3. Side effects

4. Reversal

1. Benzo that potentiates GABA, decreasing CNSneuron activity. Sedative, hypnotic, anxiolytic andamnesic properties.2. Ultra-short acting benzo - used for proceduralsedation, prior to induction3. Confusion, somnolence, bradycardia,hypotension4. Overdose reversed by flumazenil.

How is benzodiazepine overdose treated? Flumazenil

Morphine1. Mechanism of action

2. Uses3. Side effects intraoperatively

4. Reversal of overdose

1. binding to and activating the -opioid receptorsin the central nervous system. Endogenous opioidsinclude endorphins, enkephalins, dynorphins also

bind to the -opioid receptor.2. Analgesic with long acting properties comparedwith fentanyl which is quite short.3. Hypotension & bradycardia. Also causes nauseaand constipation.4. Intraoperatively use phenylephrine(norepinephrine) to increase BP. In overdose useNarcan (Naloxone) but watch for rebound pain.


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Rocuronium1. Mechanism of action

2. Uses3. Length of activity

3. Side effects4. Reversal

1. Non-depolarizing muscle relaxant. Competitivelyantagonizes acetylcholine nicotinic receptors andprevents muscular contraction. Does not causefasciculations like succinylcholine.

2. Used as a paralytic and muscle relaxant for

intubation and mechanical ventilation and toprevent laryngospasm.

3. Takes effect in 1-2 minutes (2-3 x longer thansucc), but can use higher dose for RSI. Lastslonger - 20-30 minutes.

4. No risk of Malignant hyperthermia. ProlongedApnea and paralysis without reversal.

5. Reversed with a Neostigmine and Glycopyrrolatecocktail.

Sevoflurane1. Mechanism of action

2. Use3. Side effects

4. Reversal

1. An ether which is a sedative, hypnotic andamnesic with mild muscle relaxant properties.2. Used as an inhaled volatile anesthetic for theinduction and maintenance of general anesthesia.3. Rare cause of malignant hyperthermia. Apnea.4. Reversed with high flow O2 to wash out lungs.

Phenylephrine1. Mechanism of action

2. Use

3. Side effects

1. A vasopressor which is a pure alpha agonist. Aweak form of norepinephrine. Causes constrictionof blood vessels to increase preload withoutaffecting HR or contractility.2. Used to increase BP. Increase preload and

afterload.3. Compensatory decrease in heart rate. Due to theincreased preload and BP, heart slows down.

Ephedrine1. Mechanism of action

2. Use3. Side effects

1. Ephedrine is a sympathomimetic amine & weakform of epinephrine. Vasopressor and inotrope.Acts on alpha and beta receptors. Causes bloodvessel constriction (alpha = preload and afterload)and increased cardiac heart rate and contractility(beta).2. Used to counteract blood loss and morphineinduced hypotension and bradycardia.3. Hypertension, arrythmias, confusion and

agitation, sweating.

Neostigmine and Physostigmine1. Mechanism of action

2. Uses

1. a parasympathomimetic, specifically, a reversiblecholinesterase inhibitor. By interfering with thebreakdown of acetylcholine, neostigmine indirectlystimulates both nicotinic and muscarinic receptors.Unlike physostigmine, neostigmine has aquarternary nitrogen; hence, it is more polar and


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does not enter the CNS. its effect on skeletalmuscle is greater than that of physostigmine, and itcan stimulate contractility before it paralyzes.2. improve muscle tone in people with myastheniagravis and routinely, in anesthesia at the end of anoperation, to reverse the effects of non-depolarizing

muscle relaxants such as rocuronium andvecuronium when preparing to extubate. Used incombo with glycopyrrolate.

Glycopyrrolate1. Mechanism of action

2. Uses

1. Muscarinic anticholinergic with no central effects2. used as a preoperative medication to reducesalivary, tracheobronchial, and pharyngealsecretions, as well as decreasing the acidity ofgastric secretion. It is also used in conjunction withneostigmine, a neuromuscular blocking reversalagent, to prevent neostigmine's muscarinic effectssuch as bradycardia.

Odansatron / Granisetron1. Mechanism of action

2. Uses3. Dose

Granisetron is a serotonin 5-HT3 receptorantagonist that acts at the nausea and vomitingcentre via antagonizing vagus nerve receptors inthe medulla oblongata..

2. Antiemetica. Chemotherapyb. Anaesthetic induced Post-op nausea andvomiting prophylaxis.c. Bowel surgery and radiation releases 5HT3 andit is effective.

3. 1mg IV q8h. Best given intraoperatively 1mg pobid.

Metochlopramide (Maxaran)1. Mechanism of action

2. Uses

1. Dopamine antagonist. Powerful antiemetic andgastric motility agent.2. Used for post op nausea, chemo inducednausea and after bowel surgery to promote gutmotility. Also used in combo with Ketorolac(Toradol) for migraine headaches.

Ketorolac (Toradol)1. Mechanism of action2. Uses

3. Contraindications

1. Potent NSAID - can only use for a max of 5days. Anti-inflammatory, anti-pyretic, analgesic.

competitive blocking of the enzymecyclooxygenase (COX). Like most NSAIDs,ketorolac is a non-selective COX inhibitor.2. Migraine headaches. Post operative pain.3. NSAID and ASA allergy. Renal disease(constricts afferent arteriole).


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Name the structures.

Diagram of renal corpuscle structure:

ARenal corpuscleBProximal tubuleCDistal convoluted tubuleDJuxtaglomerular apparatus1. Basement membrane (Basal lamina)2. Bowman's capsuleparietal layer3. Bowman's capsulevisceral layer3a. Pedicels (podocytes)3b. Podocyte

4. Bowman's space (urinary space)5a. MesangiumIntraglomerular cell5b. MesangiumExtraglomerular cell6. Granular cells (Juxtaglomerular cells)7. Macula densa8. Myocytes (smooth muscle)9. Afferent arteriole10. Glomerulus Capillaries

11. Efferent arteriole

Prochlorperazine (Stemetil)

Prochlorperazine (marketed under the namesCompazine, Stemzine, Buccastem, Stemetil andPhenotil) is a drug that belongs to thephenothiazine class of antipsychotic agents thatare used for the treatment of nausea and vertigo. Itis also a highly-potent typical antipsychotic, 10 to20 times more potent than chlorpromazine.

Droperidol1. Action and use

2. Side effects

1. antidopaminergic drug used as an antiemeticand antipsychotic.

2. QT prolongation and torsades de pointes. Theevidence for this is disputed, with 9 reported casesof torsades in 30 years and all of those havingreceived doses in excess of 5 mg.[3] QTprolongation is a dose-related effect,[4] and itappears that droperidol is not a significant risk inlow doses.


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Diphenhydramine (Benadryl)

1. Mechanism of action2. Systemic effects - 2

3. Uses - 3

1. A - Blocks histamine at H1 receptor sites.

2 A - increase of vascular smooth musclecontraction, thus reducing the redness,hyperthermia and edema that occurs during aninflammatory reaction. B - Blocking the H1 receptor

on peripheral nociceptors also decreasessensitization and reduces itching.

3. A - Antiemetic, nausea and vomiting. B -Antihistamine for allergic reactions. C -extrapyramidal side effects of typicalantipsychotics, such as the tremors that haloperidolcan cause.

Hydromorphone (Dilaudid)1. Mechanism of action


4. Reversal

1. u-opioid receptor agonist. 5-10 times strongerthan morphine. Where morphine is given in dosesof 5-10mg post-op, hydromorphone is given in

doses of 0.5-2mg.2. Faster acting than morphine, good for PCA overseveral days. Also produces fewer activemetabolites, thus less side effects.3. Fewer side effects than morphine. Respdepression, hypotension, Nausea, vomiting,constipation, sedation, dependece, itching,redness.4. Reversed with naloxone (narcan)

Fentanyl1. Mechanism of action


4. Dose

1. synthetic primary -opioid agonist. 100 timesmore potent than morphine.2. administered in combination with a

benzodiazepine, such as midazolam, for proceduralsedation, anesthesia and analgesia.3. Resp depression, hypotension, nausea,vomiting, itching, redness.4. Dose - 3-10 ug/kg

Define anesthesia.Lack of awareness or sensation. Can be aspectrum from local anaesthesia, conscioussedation with analgesia to general anesthesia.

Atropine1. Mechanism of action


1. Anticholinergic - Competitive antagonist for themuscarinic acetylcholine receptor.

Lowers parasympathetic activity

2 -a. Cycloplegic / Mydriaticb. Bradycardia, asystole and pulseless electricalactivity (PEA) - usual dosage = 0.5 to 1 mg IV pushevery three to five minutes3. Ventricular fibrillation, supraventricular orventricular tachycardia, dizziness, nausea, blurred


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vision, loss of balance, dilated pupils, photophobia,and, possibly, notably in the elderly confusion anddelerium.

1. Signs of atropine overdose.2. Antidote

1. Ventricular fibrillation, supraventricular or

ventricular tachycardia, dizziness, nausea, blurredvision, loss of balance, dilated pupils, photophobia,and, possibly, notably in the elderly, extremeconfusion, extreme dissociative hallucinations, andexcitation2. The antidote to atropine is physostigmine orpilocarpine.

Preload1. Define

2. Ways that you can increase preload in

anaesthesia3. Ways you can decrease preload

1. the pressure stretching the left ventricle afteratrial contraction and passive filling. May also becalled end-diastolic volume.2. INcreased with epinephrine- ephedrine (a + Bagonist) and norepi - phenylephrine (a agonist).

Increased blood volume.3. Decreased with PEEP (increased intrathoracicpressure) + anaesthetics (relax vessels).

Afterload1. Define

2. Ways that you can increase afterload inanaesthesia

3. Ways you can decrease afterload.

1. the tension produced by the left ventricle in orderto contract. against systemic resistance.2. Epinephrine and ephedrine increase preload andafterload (+ rate + contractility). Phenylephrineincrease preload and afterload. Trendelenbergposition (drop head) increases afterload.3. Decrease with Nitroglycerine, Nitrates, CCB,Beta-blockers.

What drugs can be used to alter heart contractility?1. Increase - ephedrine and epinephrine.Dopamine, dobutamine, calcium, digoxin2. Decrease - CCB

What drugs can be used to alter heart rhythm?1. CCB2. Digoxin

How do calcium channel blockers work?

Calcium channel blockers work by blockingvoltage-gated calcium channels (VGCCs) incardiac muscle and blood vessels. This decreasesintracellular calcium leading to a reduction in

muscle contraction. In the heart, a decrease incalcium available for each beat results in adecrease in cardiac contractility. In blood vessels, adecrease in calcium results in less contraction ofthe vascular smooth muscle and therefore anincrease in arterial diameter (CCB's do not work onvenous smooth muscle), a phenomenon calledvasodilation. Vasodilation decreases totalperipheral resistance, while a decrease in cardiac


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contractility decreases cardiac output. Since bloodpressure is determined by cardiac output andperipheral resistance, blood pressure drops.

Digoxin:Describe the two ways it acts on the heart.

1. A decrease of conduction of electrical impulses

through the AV node, making it a commonly usedantiarrhythmic agent in controlling the heart rateduring atrial fibrillation or atrial flutter.2. An increase of force of contraction via inhibitionof the Na+/K+ ATPase pump. This results inincreased Ca+ in the sarcoplasmic reticulum. Thusless frequent and more powerful contractions.

What factors do you want to consider on ananaesthetic history?

1. Difficult intubation + why2. Neck or Oralaryngeal trauma3. Medications and drugs4. Smoking5. Post-op nausea and vomiting and history of

motion sickness6. Allergies to meds and anaesthetics7. Personal/Family history of Malignanthyperthermia and Plasma Cholinesteras Deficiency8. Poor response to codeine - they also won'trespond well to Ketorolac (Tramadol)

What other drug will not work well for a patient witha history of poor response to codeine?

Ketorolac (Tramadol)

What are the 2 most common reasons for delayeddischarge after surgery?

1. Post-op nausea and vomiting2. Pain

How common is post-op nausea and vomiting? About 25% of pts.

Which factors predispose to post-op nausea andvomiting?

Prototype - young female non-smoker with historyof motion sickness who gets opioidsintraopertively.1. Female2. Non-smoker3. History of PONV or motion sickness4. Opioids5. Prolonged surgery

When should you consider prophylaxis for nausea& vomiting (PONV)?

How?

When there are 2 or more risk factors.1. Female2. Non-smoker3. History of PONV, motion sickness4. Opioids during surgery?

Prophylaxis = Odansitron / Granisetron (5HT3antagonist), dimenhydramine, droperidol


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What intraopertive drugs can increase the risk ofPost-op Nausea Vomiting?

Nitrous oxide, inhaled anaesthetics (sevofluraneetc.), opioids, neostigmine

What is a 5HT3 antagonist?Use?

Examples?

1. Antagonize a the 5HT3 subtype of serotoninreceptor found in terminals of the vagus nerve

which stimulates the nausea and vomiting center inmedulla oblongata.2. Used to control chemo induced N+V and PONV.3. Odansetron and Granisetron

List 5 side effects that may occur with theintravenous administration of 1 mg/kg of

succinylcholine. (Do not include malignanthyperthermia trigger)

HyperkalemiaSustained contraction in myotoniaCholingergic: Sinus bradycardia, increasedsecretionsFasciculations, myalgiaIncreased IOP, ICP, intragastric pressure

What 2 structures obstruct the airway in anunconscious patient who is supine. Tongue, epiglottis

With just your hands, how should you open theairway in an unconscious patient who

i) has a suspected C-spine injury

ii) has no suspected C-spine injury.

1. Jaw thrust2. Sniffing position - Head tilt & Chin lift

List 2 devices that can be placed blindly that canassist you in opening the airway.

Nasopharyngeal airway, oropharangeal airway

What concentration of oxygen should be given toall patients who present with apnea?

100%

What piece of oxygen therapy equipment will youuse to deliver this concentration of oxygen to all

patients who present with apnea?Ambu bag and mask with 100% O2

Where can this piece of equipment be found onmost nursing wards?

crash cart, on the wall

List 5 usual steps taken in examining a patientsairway to determine the ease of intubating

conditions for oral intubation, and note for eachwhat constitutes a normal or abnormal finding:

1. TMJ mobility: condyle should be able to move 1cm anteriorly

2. mouth opening: > 2 fingers

3. thrymental distance: > 6.5 cm

4. cervical spine mobility: flexion and extensionwithout discomfort


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5. Mallampati = visability of hypopharyngealstructures: full view of uvula, tonsillar pillars, tonsils,posterior pharyngeal wall, soft palare and tongue

A 65-year old man presents to your family practice

office for a preoperative assessment before aproposed ventral hernia repair. He is a known

hypertensive and has been treated with Metoprolol50 mg bid and Hydrochlorothiazide 50 mg a day.

His blood pressure today is 180/110 mm Hg.

A. What are 4 specific questions you would ask himon history related to his hypertension? (4)

Duration

Usual BP

Hx of MI,

Stroke, kidney damage

A 65-year old man presents to your family practiceoffice for a preoperative assessment before aproposed ventral hernia repair. He is a known

hypertensive and has been treated with Metoprolol

50 mg bid and Hydrochlorothiazide 50 mg a day.His blood pressure today is 180/110 mm Hg.

B. What 3 physical findings are crucial to determinewith regards to his cardiovascular "fitness" for

elective surgery?

S4, retinal changes, renal bruit

A 65-year old man presents to your family practiceoffice for a preoperative assessment before aproposed ventral hernia repair. He is a known

hypertensive and has been treated with Metoprolol50 mg bid and Hydrochlorothiazide 50 mg a day.

His blood pressure today is 180/110 mm Hg.

What 3 investigations are strongly indicated in thispatient related to the information given? (3)

Echo, ekg, creatinine

You are seeing a 32 year old woman in the holdingarea outside the operating room immediately priorto her scheduled laparoscopic cholecystectomy.

She tells you that she has had a cold for 2 days.

What 5 items elucidated on either history, physicalexamination or laboratory data would cause you to

postpone this elective procedure?

Increased WBC

Adventitious lung sounds

Absent breath sounds/dullness

Fever

New productive cough

A 44 year old morbidly obese (200 kg) manpresents for an emergency appendectomy.

List 5 important problems associated with morbidobesity that puts these patients at an increased risk

for anaesthesia and surgery. (10)

Aspiration

Possible difficult intubation

Decreased FRCreduced lung space topreoxygenate means less time to intubate beforepatient desturates


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Difficult bag mask ventilation

Increased positive pressures required forventilation

A 75-year-old man presents for a total hipreplacement. He is given a general anaesthetic.

The drugs used for induction are sodium thiopental250 mg, fentanyl 250 micrograms and

succinylcholine 100 mg. Anaesthesia is maintainedwith isoflurane 0.2-0.8%, nitrous oxide 60%,

rocuronium increments and morphine increments.

His usual blood pressure is 150/85 mm Hg. Oneand one-half hours after induction, his blood

pressure drops to 90/60.

List 5 reasons for intraoperative hypotension in thisman: briefly discuss how each of these itemsactually causes the blood pressure to fall. (10)

1. isoflurane = myocardial depression =hypotension

2. nitrous oxide = myocardial depression =hypotension

3. morphine = release histamine = vasodilationhypotension

4. blood loss = hypovolemia hypotension

5. positive pressure ventilation = IVC compression

= decreased venous return = decreased preload =hypotension

List 5 potential complications from the use of non-steroidal anti-imflammatory drugs i.e NSAIDS. (10)

AIN, fluid retention, allergy, gastritis/GI bleed,hypertension, bone marrow suppression (plateletdysfunction), worse CHF

What is the aortocaval syndrome? Compression of IVC and/or aorta by gravid uterus.

List three ways to decrease the effects associatedwith aortocaval syndrome.

1. Lie patient on left side, 2. Right hip wedge, 3.Avoid supine position

List 4 potential complications of single unit bloodtransfusion and 6 potential complications related to

multiple unit blood transfusion. (10)

Single: Immune, nonhemolytic: 1. immediatehemolytic reaction, 2. delayed hemolytic reaction 3.infection, 4. allergic reaction

Multiple: 1. hyperkalemia, 2. dilutionalcoagulopathy, 3. dilutional thrombocytopenia,4. circulatory overload, 5. citrate toxicity(hypocalcemia), 6. iron overload

List 5 ways in which you could distinguish between

a neuromuscular block associated with a 1-mg/kgdose of succinylcholine and one associated with anon-depolarizing muscle relaxant (Rocuronium).

Succinylcholine = time to block < 1 min, no fadewith tetanus, not reversible, TOF ratio > 0.4

Non-depolarizing (Rocuronium) = > 2 mins, fadeswith tetanus, positive post tetanic facilitation,reversible, TOF ratio < 0.7

List 5 ABSOLUTE contraindications to theadministration of either succinylcholine or a non-

depolarizing relaxant. (Do not give the

1. allergy to medication

2. unable to secure airway


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contraindications to succinylcholine, ratherGENERAL absolute contraindications to musclerelaxation with either type of drug. Assume thepatient has a functioning intravenous in situ) (5)

3. lack of resuscitative equipment

4. lack of anaethesia medications

5. unable to bag mask ventilate

Name 2 situations, 1 in the operating room and 1outside the operating room setting where a

laryngeal mask might be used. (2)

Surgery where intubation not required:1. No risk of aspiration2. Short procedure3. Non-obese, not pregnant, no ascites

OUTSIDE OREmergent - can't intubate, can't ventilate.Inadequate seal (e.g. beard) with face mask

List 6 contraindications to the elective use of a

laryngeal mask in the operating room. (6)

need PPV, risk of aspiration, pharyngeal pathology,limited mouth opening, cervical vertebra/laryngeal

cartilage #, spontaneous breathing, trendelenbergpositioning

What size laryngeal mask would be used for anaverage female (1) and an average male (1)? (2)

females 3, males 4

35-year old man is having an inguinal hernia repairunder general endotracheal anesthesia. He is apreviously healthy man with no cardiorespiratory

problem. He is intubated with a 8.0mmendotracheal tube and his lungs are beingventilated with a tidal volume of 500 cc at a

respiratory rate of 10 breaths/minute. Hisintraoperative course has been uneventful sincethe induction of anesthesia, 1 hour ago. Over the

course of 15 minutes, his oxygen saturation, whichhad been stable at 98% has fallen to 90%. BP is120/80 and heart rate is 110 bpm. List 5 possiblecauses of this problem and for each problem, list

one therapeutic intervention to improve thesituation. (10)

Endobronchial intubation: pull back tube

Tube disconnected: check tubing

Patient biting down on tube: relaxation, insertoropharyngeal airway

Secretions blocking tube: suction

PE/Atelectasis = increase PEEP to reduceatelectasis

Name 5 SPECIFIC preoperative investigations thatan anaesthetist would consider important

information in the assessment of a patient suffering

from severe chronic obstructive lung disease whois scheduled for an elective ventral hernia repair.

(5)

Hgb, PaO2, PaCO2, HCO3, PFTs, CXR, EKG

Name 5 SPECIFIC preoperative investigations thatan anaesthetist would consider important

information in the assessment of a patient sufferingfrom severe chronic obstructive lung disease who

1. ABG: hypoxemia, acidosis and appropriatecompensation

2. CXR: hyperflation and evidence of any cardiac


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is scheduled for an elective ventral hernia repairand give a BRIEF reason as to the importance for

each individual investigation.

failure or pulmonary infection

3. CBC: any additional pulmonary infection

4. PFT: extent of obstruction

5. ECG: cardiac failure

List 5 classes of drugs that a patient may be askedto discontinue prior to elective surgery. (10)

1. oral hypoglycemics

2. anticoagulants

3. antiplatelets

4. insulin

5. antidepressants

A 75-year-old man undergoing a laparotomy for abowel obstruction has received a general

anaesthetic. He is intubated and ventilated and hasbeen paralyzed with rocuronium. Anesthesia ismaintained with 70% nitrous oxide, 30% oxygen

and 1% isoflurane. He has a history ofhypertension for which he takes Vasotec. One hourafter the surgery began, his blood pressure, which

had been stable, drops to 80/40 mm Hg.

A. List 5 actions you would take at this point.

1. verify monitors connected properly

2. crystalloid infusion - Ringer's Lactate

3. decrease nitrous oxide = will increase BP

4. decrease isoflurane = will increase peripheralresistance

5. consider phenylephrine - will increase peripheralresistance without increasing heart rate andcontractility.

List 5 common causes of intraoperativehypotension. (5)

1. inhalational anesthesia

2. opiods

3. hemorrhage

4. loss of fluids

5. positive airway ventilation causing IVCcompression

A previously healthy 32-year-old man has

undergone an open reduction and internal fixationof a tibial fracture following an injury incurred in afootball game. He weighs 90 kg and has no history

of abnormal bleeding or bruising. He is currentlytaking ranitidine 150 mg once daily for a duodenal

ulcer and is asymptomatic. He has no knownallergies. In the Post Anaesthetic Care Unit(PACU), he is complaining of severe pain.

Morphine 1-3 mg IV


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A. In the PACU, what medication and dose wouldyou use to start treating his pain? (3)

What THREE specific methods of anaesthesia canbe used for a Caesarean section. (3)

Epidural, spinal, GA

List 4 common side effects of opioid medications.

1. histamine release leading to hypotension

2. constipation

3. respiratory depression

4. nausea/vomitting

A previously healthy 32-year-old man hasundergone an open reduction and internal fixationof a tibial fracture following an injury incurred in a

football game. He weighs 90 kg and has no historyof abnormal bleeding or bruising. He is currentlytaking ranitidine 150 mg once daily for a duodenal

ulcer and is asymptomatic. He has no knownallergies. In the Post Anaesthetic Care Unit(PACU), he is complaining of severe pain.

After 1 hour and a large dose of morphine he is stillin pain. What alternate therapy could you offer

him?

(3) PCA Using hydromorphone

What THREE specific methods of anaesthesia canbe used for a Caesarean section. List two

significant disadvantages of each technique. (6)

1. epidural: block sympathetic nerves and worsenhypotension, slower onset

2. spinal: block sympathetic nerves and worsenhypotension, one dose only, motor block, duralpuncture headache

3. general: technique difficult due to upper airwayedema, maternal drugs transfer to neonate causingneonatal depression and requiring resuscitation

What type of anaesthesia would most likely begiven to a patient requiring EMERGENCY

Caesarean section for an acute haemorrhagesecondary to an abruptio placenta? (1)

insufficient time to establish regional anaesthesia.Thus rapid sequence general anesthesia.

List 2 common uses for propofol. (2) 1. induction, 2. maintenance anesthesia

List 5 important physiological effects of anintravenous induction dose of propofol. (5)

1. decreased ICP, 2. increased IOP, 3. decreasedRR, 4. decreased BP, 5. decreased CO

Pain on injection may occur with propofol. List 3 1. mix in small dose of lidocaine, 2. administer


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ways you might avoid or decrease the incidence ofthis side effect? (3)

through a fast flowing iv catheter,

3. adminster through a more proximal iv catheter

What are the five minimum pieces of equipment

required to intubate? (5)1. suction, 2. O2, 3. laryngoscopy, 4. ETT, 5. stylet

A 24 year old previously healthy male is brought byambulance to the emergency department. He has

taken an unknown quantity of an unknown drug. Heis unconscious and breathing at a rate of 5 per

minute. His saturation on room air is 88%. He hasno gag reflex and the casualty officer would like

you to intubate him. He has not sustained acervical spine injury. Assuming that all the

equipment you need is ready, describe the fivesteps you would follow to perform the intubation.

(5)

1. position patient2. open mouth3. laryngoscopy4. insert ETT though vocal cords, removelaryngoscope5. confirm ETT placement

Name 3 ways to confirm placement of an ETT.

1. Chest wall rising with ventillation2. Air entry heard by stethoscope at bilaterally atthe mid-axillary line3. End tidal CO2 30-40mmHg

List 5 GENERAL causes of hypoxaemia. (10) (Donot give specific examples i.e. pulmonary

embolus).

1. decreased FIO22. decreased alveolar ventilation3. increased shunting4. increased dead space ventilation5. decreased diffusion6. poor placement of ETT

A 60 year old woman with insulin-dependentdiabetes presents to the preoperative consultation

clinic having been scheduled for a total kneearthroplasty in 2 weeks time.

A. What 6 specific questions related to her diabeteswould be important to ask to assess her fitness for

anaesthesia and surgery? (6)

B. What 4 specific tests would you orderpreoperatively? (4)

1. how long?2. end organ damage?3. monitor blood glucose regularly?4. adequate control?5. admissions to hospital for hypo orhyperglycemia?6. other CAD risk factors?

1. blood glucose, 2. ECG, 3. lytes and creatinine, 4.urinalysis

A 50 year old man takes beta blockers and Ca2+channel blockers for stable angina. He is comingfor elective surgery in one week. What should you

tell him about his medications and eating anddrinking before his operation? (3)

B) What are 2 reasons that we have patients fastbefore elective surgery? (2)

A- 1. take B-blockers and CCB at usual time withsips of water2. no solids at least 8 hrs prior3. no fluids at least 4 hrs prior

B - 1. decrease gastric volume, 2. decrease gastricacidity

C - (1) aspiration


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C) What immediate outcome may occur undergeneral anaesthesia in a patient who has a full

stomach?

D - What is a potential consequence of thisoutcome?

E - What 3 reasons contribute to these outcomes?(3)

D - (1) pneumonitis, atelectasis, ARDS, abscess

E - volume, acidity, particulate matter

190 Cards in this Set

Front

Back

Many unnecessary blood tests are orderedprior to surgery. List 5 pieces of informationlearned from the patients history that wouldcause you to order preoperative coagulation

studies. (10)

1. on anticoagulants, 2. liver disease, 3. known factordeficiency, 4. family history of factor deficiency5. surgery involving lots of blood loss

A. You are called to the postanaesthetic careunit to see a patient who has a saturation of

80%. She has been in the PACU for 20minutes after having had a total abdominal

hysterectomy. She is otherwise healthy. Herblood pressure is 120/80 mm Hg and her heart

rate is 120 bpm. Describe in point formEXACTLY what your management of this

situation would be. (5)

B. What are five GENERAL potential causes ofher tachycardia? (5)

A - 1. assess airway, secure airway2. assess need for ventilation3. increase O2

4. look for acute blood loss, stop5. fluid resuscitation6. Control pain7. Empty bladder

B - Hypovolemia, pain, arrhythmia, full bladder, anxiety,anemia, drugs (e.g. atropine, pancuronium)

You are called to the floor to see a patient whothe nurse believes has had a narcotic

overdose. He has been on the ward for 2 hourshaving just had an open reduction and internal

fixation of a femoral fracture. He is on PCAwhich his wife has been using regularly on his

behalf.A. What would be your management of the

situation at this point? (2)

B. If the patient is rousable and maintains hisairway, what would you do in this case? (5)

A - Assess responsiveness, resp rate, heart rate,pupils, educate patient and wife

B - reduce PCA infusion rate, hold bolus doses for now,reassess frequently

C - 1. assess and secure airway2. give O23. give small incremental doses of 40 mcg naloxone


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C. If the patient is difficult to rouse, snores and

has a respiratory rate of 8 per minute, and asaturation of 80% on room air with a stable BP

and Heart rate, what would you do? (3)

List 5 options for pain relief during labour. (5)Lamaze, epidural, NO, pudendal block, opioidsB. For each of the options for pain relief during

labour listed above; give 1 advantage and 1disadvantage for each. (5)

Lamaze: gives woman control, not great analgesiaEpidural: good analgesia, hypotensionNO: easy, does not relieve pain completelySpinal: good analgesia, motor blockadeOpioids: easy, maternal/neonatal depression

You are called to the recovery room (PACU) tosee a patient who has just arrived after having

had a laparoscopic cholecystectomy. Thepatient was awake, alert, extubated and

breathing spontaneously. The nurse has justgiven a gram of Ancef intravenously at the

surgeons request. The nurse tells you that thepatient is having an allergic reaction.

A) What 5 signs and/or symptoms might thepatient be experiencing to support this

diagnosis? (5)

B) What 5 steps MUST be taken to treat thispatient? (Be specific) (5)

A - rash, stridor, tachycardia, hypotension,

bronchospasm, urticaria

B - 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrineiv, 4. N/S, 5. benadryl 50 mg iv 6. Ranitidine

A. What two genetic disorders related toanaesthesia might be elicited by asking a

patient about their family history ofanaesthetics? What investigations can be done

to determine if the disorder has beentransmitted to the patient? (4)

B. What would be the symptoms that mightoccur, related to each disorder, if a patientreceived a general anaesthetic without any

precautions against the above problems? (6)(Separate the symptoms according to the

disorder.)

A - Cholinesterase deficiency: genotyping

MH: muscle biopsy

B - Cholinesterase deficiency: prolonged paralysisMH: - hypermetabolic state (increased temp, increasedO2 consumption, resp acidosis, tachypnea,tachycardia)- muscle rigidity- rhabdomyolysis- renal failure

With respect to the following drugs:

A. What is the usual initial dose of epinephrineused in a cardiac arrest situation? (1)

B. What is the optimal route of administration ofepinephrine in the above situation? (1)

C. What is the dose of lidocaine used forventricular dysrhythmias?

A - 1mg IV push q3-5 min

B - IV push q3-5 minC - 1-1.5 mg/kg pushD - 400mg/7=57E - 5 mcgF - Decrease systemic absorption, higher threshold foranesthetic, longer duration of epiduralG - 0.5-1.0mgH - 300mg - IV lidocaine 1% = 10mg/ml. 1.5% lidocaine= 15mg/ml


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D. What is the weight of a patient to whom theadministration of 20 ml of 2% lidocaine with

epinephrine would be a maximum?

E. What dose of epinephrine is contained in 1cc of a 1:200,000 solution? (1)

F. List 3 advantages of mixing epinephrine inlocal anaesthetic solutions (3)

G. What dosage of atropine should be given toa patient with a bradyarrhythmia who is

hypotensive? (1)

H. 20ml of 1.5% lidocaine is equivalent to howmany milligrams?

List 5 maneuvers that can be used to open the

airway and permit ventilation in an unconsciouspatient that you are unable to ventilate with abag and mask alone. (10)

1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insertoral airway, 5. remove any foreign object

. List 4 methods to absolutely confirm that anendotracheal tube is situated in the trachea.

(10)

See it go through cords, bronchoscope, capnograph,CXR

You are seeing a 30 year old woman in yourfamily practice office as part of a work-up for

infertility. She has had asthma for the past tenyears and uses a Ventolin inhaler on a prnbasis. Over the past three weeks, she has

been using the Ventolin more than usual andhas been waking up at night coughing. On

physical examination she has bilateralwheezes that do not clear with cough. She is

scheduled to have a diagnostic laparoscopy inone weeks time.

A. What are four therapeutic modalities thatmay be used to improve her condition? (8)

B. When you see her again on the day prior tosurgery, her condition is unchanged. What

would you do at this point? (2)

A - 1. addition of inhaled steroid, 2. addition of inhaledLABA, 3. addition of oral steroid, 4. smoking cessation

B - Cancel and optimize?

A 65 year old man with untreated hypertensionpresents to the emergency department,

complaining of severe abdominal pain. He hasbeen seen by general surgery and has anincarcerated inguinal hernia that required

EMERGENCY surgery. His blood pressure isnow 200/120 mm Hg. List five IMPORTANT

and specific anaesthetic considerations of this

A - GERD/hiatus hernia, not NPO, pregnant,overdose/LOC, delayed emptying

B - 1. NPO (8 hrs for food, 4 hrs for clear fluids)2. H2-antagonists to decrease acidity (eg. Na citrate)3. increase gastric emptying (eg. metoclorpropamide)4. NG tube to empty stomach5. extubate awake on side


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patient undergoing this procedure.

A. Give 5 indications for performing a rapidsequence induction. (5)

B. Besides performing a rapid sequence

induction, how can we minimize the risk ofaspiration? (5)

A - Describe the ACLS protocol forsymptomatic Bradycardia.

B - What should be done if the abovemeasures fail?

Pacing Always Ends Danger

Pacing **TCP Immediately prepare for transcutaneouspacing (TCP) with serious circulatory compromise dueto bradycardia (especially high-degree blocks) or ifatopine failed to increase rate.

Consider medications while pacing is readied.Always - Atropine = 1st-line drug, 0.5 mg IV/IO q3-5

min. (max. 3mg)

Ends - Epinephrine 2-10 g/min 2nd-line drugs toconsider if atropine and/or TCP are ineffective. Use withextreme caution.Danger - Dopamine - 2-10 g/kg/min

B - Search for other causes -

What are the ACLS DDx for a problem searchwhen interventions fail to correct cardiac

abnormalities.

6H's and 5T's

HypoxiaHypoglycemia

Hypo/HyperkalemiaHypocalcemiaHypovolemiaHypothermiaHyperacidemia

Thrombus - MI/PETension PneumoTamponade

How should you treat symptomatichyperkalemia?

Sodium bicarbonate, calcium chloride, albuterolnebulizer, insulin/glucose, dialysis, diuresis, Kayexalate

What features would you see with a patientwho is crashing and has cardiac tamponade?

What is the treatment?

No pulse w/ CPR, JVD, narrow pulse pressure prior toarrest.

Tx - Pericardiocentesis.

Why do you give Fentanyl intraoperativelydespite the patient being unconscious?

Despite unconsciousness, incision and intubation willresult in a pronounced sympathetic drive at level of


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What about when harvesting organs from a

brain dead patient?

spinal cord.

You must control pain and hemodynamics even on abrain dead patient.

What are contraindications to inhaledanaesthetics?

What are your options?

Hx of Malignant HyperthermiaCardiopulmonary procedures that bypass heart andlungsNeck Surgery preventing access

Options are to use local, regional or TIVA GA (propofol,thiopental or Ketamine )

How are exhaled anaesthetics such assevoflurane and isoflurane cleared from the

body?

By inhalation - thus you need to increase the O2 whenpreparing for extubation.

An 82 year old male is scheduled for electiverepair of a AAA. What factors will affect his

perioperative plan and outcome?

Elderly - Requires lower MAC, less opioids, increasedrisk of delirium, more pronounced hemodynamicchanges, less pulmonary reserve for intubation.

Vascular surgery = >5% mortality.

Describe the primary and secondary ABCDs.

Primary = BLS protocol, Airway with head tilt, Breathingwith bag, Chest compressions, Defibrillation.

Secondary = ETT, Breathing monitors, Circulatory IVand Meds, Differential Dx = PATCH4 MDS

How should you manage an unstable VT or VFtachycardia without pulses?

ACLS Pulseless arrest algorythm

1. 5 cycles of CPR followed by Synchronizedcardioversion for all unstable VT and VF tachycardias.Followed by 5 cycles of CPR. Give Epinephrine. 5cycles CPR. Check rhythm.

2. Do secondary survey - PATCH4 MDS if no responseto measures.

How should you manage an unstable PEA andAsystole tachycardia without pulses?

ACLS Pulseless Arrest Algorythm

5 cycles of CPR. IV epinephrine 1 mg every 3-5 min. 5cycles of CPR. Atropine 1mg IV. 5 cycles of CPR.Check rhythm.

Do secondary survey - PATCH4 MDS if no response to

measures.

How should tachycardia with pulses bemanaged.

ACLS Tachycardia Algorythm

1. Unstable? Immediate synchronized cardioversion.

2. Stable?Narrow QRS = Vagal manoevre, Adenosine,Converts = SVT Tx recurrence with Beta blocker(metoprolol) or diltiazem


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Does not convert = A Fib or Flutter - Diltiazem oe Beta-blocker (metoprolol).

Wide QRS = Amiodarone and Cardioversion

How should Bradycardia be approached withinthe ACLS algorythm?

1. HR


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List 5 GENERAL causes of hypoxaemia. (10)(Do not give specific examples i.e. pulmonary

embolus)

1. decreased FIO22. decreased alveolar ventilation3. increased shunting4. increased dead space ventilation5. decreased diffusion

A. You are called to the postanaesthetic careunit to see a patient who has a saturation of

80%. She has been in the PACU for 20minutes after having had a total abdominal

hysterectomy. She is otherwise healthy. Herblood pressure is 120/80 mm Hg and her heart

rate is 120 bpm. Describe in point formEXACTLY what your management of this

situation would be. (5)

B. What are five GENERAL potential causes ofher tachycardia? (5)

A. 1. assess airway, secure airway2. assess need for ventilation3. increase O24. look for acute blood loss, stop5. fluid resuscitation

B. Hypovolemia, pain, arrhythmia, full bladder, anxiety,anemia, drugs (e.g. atropine, pancuronium)

You are called to the floor to see a patient whothe nurse believes has had a narcotic

overdose. He has been on the ward for 2 hourshaving just had an open reduction and internal

fixation of a femoral fracture. He is on PCAwhich his wife has been using regularly on his

behalf.A. What would be your management of the

situation at this point? (2)

B. If the patient is rousable and maintains hisairway, what would you do in this case? (5)

C. If the patient is difficult to rouse, snores andhas a respiratory rate of 8 per minute, and a

saturation of 80% on room air with a stable BPand Heart rate, what would you do? (3)

A. Assess responsiveness, resp rate, heart rate, pupils,educate patient and wife

B. reduce PCA infusion rate, hold bolus doses for now,reassess frequently

C. 1. assess and secure airway2. give O2

3. give small incremental doses of 40 mcg naloxone

List 5 options for pain relief during labour andgive 1 advantage and 1 disadvantage for each.

(5)

Lamaze: gives woman control, not great analgesiaEpidural: good analgesia, hypotensionNO: easy, does not relieve pain completelySpinal: good analgesia, motor blockadeOpioids: easy, maternal/neonatal depression

You are called to the recovery room (PACU) tosee a patient who has just arrived after havinghad a laparoscopic cholecystectomy. Thepatient was awake, alert, extubated and

breathing spontaneously. The nurse has justgiven a gram of Ancef intravenously at the

surgeons request. The nurse tells you that thepatient is having an allergic reaction.

A) What 5 signs and/or symptoms might the

A. rash, stridor, tachycardia, hypotension,bronchospasm, urticaria

B. 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrineiv, 4. N/S, 5. benadryl 50 mg iv


24/33

patient be experiencing to support thisdiagnosis? (5)

B) What 5 steps MUST be taken to treat thispatient? (Be specific) (5)

What two genetic disorders related toanaesthesia might be elicited by asking a

patient about their family history ofanaesthetics? What investigations can be doneto determine if the disorder has bee transmitted

to the patient? (4)

B. What would be the symptoms that mightoccur, related to each disorder, if a patientreceived a general anaesthetic without any

precautions against the above problems? (6)(Separate the symptoms according to the

disorder.)

A. Cholinesterase deficiency: genotypingMH: muscle biopsy

B. Cholinesterase deficiency: prolonged paralysisMH: - hypermetabolic state (increased temp, increasedO2 consumption, resp acidosis, tachypnea,tachycardia)- muscle rigidity- rhabdomyolysis

A. What is the usual initial dose of epinephrineused in a cardiac arrest situation? (1)

1mgB. What is the optimal route of administration of

epinephrine in the above situation? (1)IV push

C. What is the dose of lidocaine used forventricular dysrhythmias? (1)

1-1.5 mg/kg pushD. What is the weight of a patient to whom the

administration of 20 ml of 2% lidocaine with

epinephrine would be a maximum? (1)400mg/7=57

E. What dose of epinephrine is contained in 1cc of a 1:200,000 solution? (1)

5 mcgF. List 3 advantages of mixing epinephrine in

local anaesthetic solutions (3)Decrease systemic absorption, higher

threshold for anesthetic, longer duration ofepidural

G. What dosage of atropine should be given toa patient with a bradyarrhythmia who is

hypotensive? (1)

0.5-1.0mgH. 20ml of 1.5% lidocaine is equivalent to howmany milligrams? (1)

300mg

A. 1mgB. IV pushC. 1-1.5 mg/kg pushD. 400mg/7=57E. 5 mcgF. Decrease systemic absorption, higher threshold foranesthetic, longer duration of epiduralG. 0.5-1.0mgH. 300mg

List 5 maneuvers that can be used to open theairway and permit ventilation in an unconscious

patient that you are unable to ventilate with abag and mask alone. (10)

1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insertoral airway, 5. remove any foreign object


25/33

List 4 methods to absolutely confirm that anendotracheal tube is situated in the trachea.

(10)

See it go through cords, bronchoscope, capnograph,CXR

You are seeing a 30 year old woman in your

family practice office as part of a work-up forinfertility. She has had asthma for the past ten

years and uses a Ventolin inhaler on a prnbasis. Over the past three weeks, she has

been using the Ventolin more than usual andhas been waking up at night coughing. On

physical examination she has bilateralwheezes that do not clear with cough. She is

scheduled to have a diagnostic laparoscopy inone weeks time.

A. What are four therapeutic modalities thatmay be used to improve her condition? (8)

B. When you see her again on the day prior tosurgery, her condition is unchanged. Whatwould you do at this point? (2)

A. 1. addition of inhaled steroid, 2. addition of inhaledLABA, 3. addition of oral steroid, 4. smoking cessation

B. Cancel and optimize

Give 5 indications for performing a rapidsequence induction. (5)

B. Besides performing a rapid sequenceinduction, how can we minimize the risk of

aspiration? (5)

A. GERD/hiatus hernia, not NPO, pregnant,overdose/LOC, delayed emptying,

B. 1. NPO (8 hrs for food, 4 hrs for clear fluids)2. H2-antagonists to decrease acidity (eg. Na citrate)3. increase gastric emptying (eg. metoclorpropamide)4. NG tube to empty stomach5. extubate awake on side

You are attending a breech delivery (in aperipheral hospital) with the staff obstetrician. It

is a very difficult delivery complicated bytrapping of the after-coming head. When the

baby is finally delivered, it is limp and blue. Theobstetrician is attending to the mother who is

having a brisk postpartum haemorrhage.A. The babys heart rate is 50 bpm. What

resuscitative efforts should be done now? List8 steps/actions in the management of this

situation (8)

B. At 6 minutes of life, the heart rate is 120

bpm, respirations are slow and irregular. Thebaby is limp, does not respond to stimulationbut is centrally pink with blue hands and feet.

What Apgar score corresponds with thesefindings? (2)

A.1. open airway (infant supine or on side)2. suction mouth then nose3. 100% O24. keep neonate warm and dry5. physical stimulation (slapping soles of feet, rubbingback)6. PPV if apnea, HR


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A 24 year old previously healthy male isbrought by ambulance to the emergency

department. He has taken an unknown quantityof an unknown drug. He is unconscious and

breathing at a rate of 5 per minute. Hissaturation on room air is 88%. He has no gag

reflex and the casualty officer would like you tointubate him. He has not sustained a cervicalspine injury. Assuming that all the equipmentyou need is ready, describe the five steps you

would follow to perform the intubation. (5)

1. position patient in sniffing position2. open mouth and check for obstructions, dentition3. laryngoscopy, exposing the vocal cords

4. insert ETT though vocal cords, remove laryngoscope5. confirm ETT placement with stethoscope, end-tidalCO2, condensation or bronchoscope confirmation.

Name 5 ways that you can confirm placementof an ETT tube.

1. Visualize placement with naked eye or glidescope.2. Bronchoscopy down tube3. Auscultate lungs for breath sounds4. End Tidal CO25. Condensation on ETT6. Compliance of manual bag with ventillation and chest

expansion7. CXR

Describe the sniffing position for placement ofan ETT. Why important?

Flexion of C6-C7 and Extension of C1-C2.

Aligns Oral, pharyngeal and laryngeal axis.

List 5 problems associated with the use ofintramuscular narcotics ordered on a prn basis

for postoperative pain. (10)

Inadequate analgesia, increased side-effects, delays torelief, large variability in different patients in maximumlevels, wide fluctuations, painful injections

A 20 year old male is scheduled for removal of

impacted wisdom teeth under generalanaesthesia. During a pre-op assessment, he

states that his first cousin had an unusualreaction under anaesthesia and subsequently

had a positive biopsy for malignanthyperthermia. Neither of his parents has had a

general anaesthetic.A. What 2 anaesthetic agents should be

avoided in this patient? (4)

B. List five signs of a malignant hyperthermiareaction. (5)

C. What is the drug of choice and dose fortreating malignant hyperthermia? (1)

A. succinylcholine, inhalational agents

B. Hyperthermia, muscle rigidity, hypertension,tachycardia, tachypnea, cyanosis

C. dantrolene (2 mg/kg)

List four GENERAL indications forendotracheal intubation (NOT restricted to the

operating room setting). (10)

Five P's1. Protect airway - aspiration2. Pharm - administer medications NAVEL (naloxone,atropine, ventolin, epinephrine, lidocaine)


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3. Pulmonary toilet - to remove tracheobronchialsecretions and prevent ARDS and Atelectasis4. Positive pressure ventilation - hypoventilation,apnea, hypoxia, status asthmaticus5. Patency - decreased LOC, facial fractures, edema

A 65-year old man is referred to your internalmedicine office with the following story: He has

had stable class I angina for four years, forwhich he is taking Vasotec and sublingual

nitroglycerine prn. Recently, he hasexperienced some angina at rest and at night

and an episode a week ago lasted half an hourand did not respond to nitroglycerine. He hasbenign prostatic hypertrophy and is scheduled

for surgery (transurethral resection of theprostate) in two weeks time.

A. What are three specific concerns regarding

this mans story? (6)

B. List 4 items in your plan of action at thistime. (4)

A. 1. night symptoms, 2. angina at rest, 3. notresponsive to NTG

B. Go to ER, ECG, troponins, stress test, Echo, cath

At the end of a 2-hour laparoscopiccholecystectomy, all inhalation anaestheticsare turned off and the patient is ventilatedthrough the endotracheal tube with 100%

oxygen. After 10 minutes, the patient, who isstill intubated, has not begun to breathe

spontaneously. Blood pressure is 120/80 mmHg, heart rate 98 bpm. Anaesthesia was

induced with propofol and fentanyl. Intubationwas facilitated by 100 mg of intravenous

succinylcholine. Maintenance of anaesthesiainvolved the use of incremental doses ofrocuronium, morphine, nitrous oxide andisoflurane. List 5 common and important

potential causes of this patients postoperativeapnea. (10)

1. rocuronium, 2. morphine, 3. nitrous oxide, 4.

isoflurane, 5. succinylcholine

A 83 year old man with a history ofhypertension is undergoing emergency surgery

for an incarcerated inguinal hernia. Shortlyafter induction of the general anesthesia with

fentanyl 50 micrograms, propofol 160 mg androcuronium 50 mg, Nitrous oxide 70% andoxygen 30% and Isoflurane 1%, his blood

pressure which had been 150/90 mm Hg onadmission to the OR is now 80/60 with a heart

rate of 120 bpm.A. What might be the cause of this fall in blood

pressure? (5)

A. 1. fentanyl, 2. propofol, 3. nitrous oxide, 4.

isoflurane, 5. decreased sympathetics after removal ofpainful stimulus

B. 1. crystalloids, 2. phenylephrine (increases BPwithout increasing HR), 3. decrease nitrous oxide4. decrease isoflurane, 5. monitor


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B. What would you do? (5)

Name 5 conditions that are associated withdifficult VENTILATION.

BONES.Beard, Obeses, No teeth, Elderly, Snoring (Sleepapnea).

Name 6 conditions associated with a difficultINTUBATION and 1 reason why for each.

1. Obesity - extra tissue collapses airway2. Pregnancy - edematous tissues3. Scleroderma - connective tissue leads to lowcompliance in pharynx.4. Arthritis - Osteo and Rheum - c-spine instability, TMJstiffness, atlanto-axial instability5. Acromegaly - big tongue, thick throat6. Congenital anomolies.

List 4 MAJOR side effects related to the use ofNSAIDS. (8)

B. What is the mechanism of action that leadsto the adverse effects? (2)

A. 1. bleeding, 2. renal failure, 3. worsens CHF, 4.PUD

B. 1. platelet inhibition, 2. prostaglandin synthesisinhibition

List 5 advantages of the use of patient-controlled analgesia over intramuscular

injections of narcotics. (10)

Quicker onsetNo painful injectionsAble to adjust to patient variabil ityAble to adjust as pain needs change overtimeReduce side-effectsMore effective analgesia

You have just positioned a patient supine afteradministering a spinal anesthetic with

hyperbaric bupivacaine for an elective repeatcesarean section. The patients blood pressurewas 110/65 preoperatively and is now 88/45.

A. List 2 reasons why her blood pressure hasdropped. (2)

B. What is your immediate management? (3)

C. List three signs or symptoms that she mightexperience while her blood pressure is 88/45.

(2.5)

D. List three other signs or symptoms that she

might experience while her blood pressure is88/45. (2.5)

E. List the 5 components of the Apgar score.(2.5)

A. Aortocaval, sympathetic nerve block from spinalanesthesia

B. 1. position patient on left side, 2. O2, 3. IVcrystalloids

C. lightheadedness, palpitations, visual changes,

D. 1. tachycardia, 2. tachypnea, 3. presyncope

E. Activity, Pulse, Grimmace, Appearance, Respirations1-3.

A previously healthy 18 year old male wasstabbed in the back at an after hours club. He

A. ABCs, IV, O2 monitor, Cardiac monitor


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comes to the ER with a single wound 2 cm inlength, 5 cm below the left scapula and 15 cmleft of the midline. He is awake and alert, BP

110/50 mm Hg, SpO2 97%.A. What immediate steps should be taken in

the management of this patient? (3)

10 minutes later he is pale, diaphoretic: BP70/40 mm Hg, HR 130 bpm. SpO2 88%B. What are 3 LIKELY possibilities for the

above changes. (3)

C. What treatment measures would youinstitute at this point? (2)

He stabilises for 1 hour, then again getshypotensive. His repeat Hb is 45. You now

decide to give him a blood transfusion

immediately. Unfortunately the blood bank saysit will be 30 min. before fully cross matched

blood is available.

D. What are your transfusion options at thistime? (2)

B. Tension pneumo, tamponade, hemothorax

C. Ventilate with 100% O2, fluids wide open

D. O positive, type specific

Succinylcholine is often given to patientsundergoing anaesthesia and surgery. In

otherwise healthy patients with no history ofneuromuscular diseases, allergy, personal or

family history of pseudocholinesterasedeficiency, list 5 side effects that may occur

with the intravenous administration of 1 mg/kgof succinylcholine. (Do not include malignant

hyperthermia trigger) (10)

Myalgias, hyperkalemia, bradycardia, increasedsecretions, increased ICP/IOP

A 50 year old female has undergone a totalabdominal hysterectomy. She has been fasting

since midnight. Her surgery began at 08:00and took 2 hours. The total estimated bloodloss was 500 cc. Considering all sources ofperioperative fluid loss, answer the following

question.How much fluid (i.e. Normal saline) should she

be given by the end of the case? Show howyou derived the total amount, includingformulas. She weighs 50 kg. (10)

maintenance requirement per hour: 4 ml x 10 kg + 2 mlx 10 kg + 1 ml x 30 ml = 90 ml/hfluid deficit: 90 ml/h x 10 h = 900 mlthird space losses: 6 ml/kg/h x 50 kg x 2 hr = 600 mlblood loss replacement: 500 ml x 3 = 1500 mlTOTAL: 3090 ml

What is more important, Ventilation orIntubation?

Ventilation - if you can't ventilate they die. If you can'tintubate you can still ventilate until you wake or get asurgical airway.


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A. List four devices for delivering supplementaloxygen to spontaneously-breathing (notintubated) patients. For each, give the

approximate FiO2 or range of FiO2 that can bedelivered by each: (8)

B. What device and corresponding FIO2 wouldyou select for a 60 year old obese patient withsevere COPD, a known CO2 retainer, who haspresented to the Emergency Department with

acute bronchitis, and whose PaO2 is 48(normally 55) and PaCO2 is 65 (previously

50)? His lips and nail beds are blue-tinged. (2marks):

A. Nasal Prongs =24-44%, face mask=40-60%, mask

with reservoir=60-80%, Venturi 24, 28, 31, 35, 40%

B. Venturi 24%

What is the standard medication to use in wideQRS (>0.12sec) tachycardia with pulses?

Amiodarone 150mg IV over 10 minutes. If Torsades dePointes give 1-2 mg magnesium over 30 min.

A 50 kg male has been NPO for 12 hours priorto a 3 hour laparatomy. He lost 300cc of blood.

Calculate fluid requirements.

12h NPO = 4:2:1 = 90cc/h x 12 = 10803h Surgery Maint. = 90cc/h x 3 = 270Losses @ 3:1 = 900ccThird space loss (Medium surgery) = 6cc/kg/h = 6 x 50x 3 = 900ccTotal = 3150 of Ringers (or NS).

Note: Third space loss calculationSmall surg (nose, foot, hand) = 4cc/kg/hMed. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/hBIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).

How do you calculate third space losses forsurgical procedures?

Note: Third space loss calculationSmall surg (nose, foot, hand) = 4cc/kg/hMed. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/hBIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).

Laryngospasm1. Etiology

2. When does it most commonly occur?3. Complications

4. . Tx

1. induced by secretions, inadequate anestheisa,anaphylaxis and airway manipulation.

2. Most commonly occurs in a patient who is going intoor out of paralysis during intubation or extubation.

3. Results in inability to ventilate a patient =EMERGENCY.

4. Succinylcholine to stop spasm, then ETT.

Laryngeal Mask (LMA)1. When to use

2. Sizing3. Contraindications

1. a. Great for can't intubate/ventillate.b. When not using a paralytic.c. Short procedure.d. Breathing spontaneously.


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2. Women = Size 3, Men = Size 4.

3. Succinylcholine, Sevoflurane. Full stomach,preganant, ascites, reflux.

DDx of Hypertension Intraoperatively. Give 10.Pain, hypoxia, drugs (epi, phenyl, atropine, dopamine),fluid overload, electrolytes (Ca+) Pheochromo, Thyroidstorm, Malignant Hyper, Machine not working (art linetoo low, wrong size BP cuff).

DDx of High Airway pressure with ventilation.Give 10.

Kink/Fluid in tubes, Kink in ETT, secretion/tissue inETT, ETT placed down Left bronchus, PTX,trendelenberg, obesity, ascites, surgeon leaning onpatient, bronchospasm.

Bronchospasm1. Etiology

2. Clinical signs3. Complications4. Management

Bronchospasm or a bronchial spasm is a suddenconstriction of the muscles in the walls of the

bronchioles. Often occurs at the induction stage beforepatient is fully anesthetized. It is caused by the release(degranulation) of substances from mast cells orbasophils under the influence of anaphylatoxins.Asthma, chronic bronchitis, anaphylaxis, pilocarpine(which is used to treat illness resulting from theingestion of deadly nightshade as well as other things)and beta blockers2. Prolonged expiratory phase, wheeze, hypoxia,increased airway pressures, silent chest, upsloppingCO2 tracing with ventilation.3. Hypoxia, unable to venilate, hypercarbia, respacidosis, CV collapse.4. Atropine, increase inhalation anesthetic(bronchodilator), Induction (propofol) for Statusathmaticus, salbutamol & Ipratoprium bromide by MDI,Prednisone,

1. An elderly male with pain in his left hip isscheduled for a hip arthroplasty. He requests to

have a spinal anesthetic. All are potentialcomplications of a spinal anesthetic EXCEPT:

HypotensionInfection at site

Hematoma at siteLocal anesthetic toxicity

Nausea & Vomiting

Nausea & Vomiting

2. All of the following are contraindications tospinal anesthesia EXCEPT:Raised intracranial pressure

HypovolemiaCoagulopathy

Infection at site of needle insertion

Kyphosis


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Kyphosis

3. A 24 week pregnant woman is in need of anemergency appendectomy. All are physiologic

changes in pregnancy EXCEPT:

Decreased gastroesophageal sphincter toneDecreased haemoglobin

Decreased coagulation factorsDecreased functional residual capacity

Decreased systemic vascular resistance

Decreased coagulation factors

What is the name of the curved laryngoscopeblade? Straight?

Macintosh is curved, Miller is straight

Name important measurements andclassification systems in the assessment of an

airway?

Mallampati Score, weight, head and neck movements,mouth opening, thyromental distance, jaw subluxation

How long prior to surgery is a patient able toconsume clear fluids?

2 hours

A patient who is a smoker, is obese or hascontrolled Type 2 diabetes is considered which

ASA class?2

What length of time must a patient wait post MIbefore undergoing elective surgery?

4-6 weeks

When is an ECG indicated prior to surgery? Heart disease, hypertension, diabetes, other risk factorsfor cardiac disease (may include age), subarachnoidhemorrhage, CVA, head trauma

Define MAC

The minimum alveolar concentration of an inhalationalanesthetic agent is the concentration that preventsmovement in response to standard surgical stimulus(incision) in 50% of patients

What is the proper positioning of patientsduring intubation?

The sniffing position: head bowed forward, nose in theair

What is the proper depth of endotracheal tubeplacement?

The tip 2 cm above the carina, the cuff 2 cm below thevocal cords

What medications can be given through the ETtube?

Naloxone, atropine, ventolin, epinephrine, lidocaine

What are some signs of an esophagealintubation?

ETCO2 zero or near zero, poor breath sounds onauscultation, impaired chest excursion, hypoxia


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At what SaO2 can cyanosis be detected? SaO2 = 80%

How do you calculate the fluid maintenancerequirements in an adult?

4 mL/kg/hour for the first 10 kg, 2 ml/kg/hour for thesecond 10 kg, 1 ml/kg/hour for the remaining weight

What replacement ratio must be used whenusing crystalloid to replace blood loss? Colloid?

3 mL crystalloid / 1 ml blood loss, 1 ml colloid / 1 mLblood loss

Which anesthetic drugs can trigger MalignantHyperthermia crisis?

Enflurane, halothane, isoflurane, desflurane,sevoflurane (end inane), succinylcholine,decamethonium

All of the following are contraindications tospinal anesthesia EXCEPT:

a) Raised intracranial pressureb) Hypovolemiac) Coagulopathy

d) Infection at site of needle insertione) Kyphosis

e) Kyphosis

An elderly male with pain in his left hip isscheduled for a hip arthroplasty. He requests to

have a spinal anesthetic. All are potentialcomplications of a spinal anesthetic EXCEPT:

a) Hypotensionb) Infection at site

c) Hematoma at sited) Local anesthetic toxicity

e) Nausea & Vomiting

e) Nausea & Vomiting

A 24 week pregnant woman is in need of anemergency appendectomy. All are physiologic

changes in pregnancy EXCEPT:a) Decreased gastroesophageal sphincter tone

b) Decreased haemoglobinc) Decreased coagulation factors

d) Decreased Functional Residual Capacitye) Decreased Systemic Vascular

Resistance

c) Decreased coagulation factors

Documents

Anaesthesia Q Review 2014