Hall

Anesthesia
A Comprehensive Review
FIFTH E DITION
Brian A. Hall, MD
Assistant Professor of Anesth esiology, College of Med icine, May o Clinic,
Roch ester, Minnesota
Robert C. Chantigian, MD
Associate Professor of Anesth esiology, College of Med icine, May o Clinic,
Roch ester, Minnesota
Table of Contents
Cove r ima ge
Title pa ge
Copyright
Pre fa ce
Contributors
Cre dits
Bibliogra phy
Acknowle dgme nts

Part 1. Basic Sciences
Cha pte r 1. Ane sthe sia Equipme nt a nd Physics

Anesthesia Equipment and Physics
Cha pte r 2. Re spira tory Physiology a nd Critica l Ca re Me dicine
Respiratory Physiology and Critical Care Medicine
Cha pte r 3. Pha rma cology a nd Pha rma cokine tics of Intra ve nous
Drugs
Pharmacology and Pharmacokinetics of Intravenous Drugs
Cha pte r 4. Pha rma cology a nd Pha rma cokine tics of Vola tile
Ane sthe tics
Pharmacology and Pharmacokinetics of Volatile Anesthetics
Part 2. Clinical Sciences
Cha pte r 5. Blood Products, Tra nsfusion, a nd Fluid The ra py

Blood Products, Transfusion, and Fluid Therapy
Cha pte r 6. Ge ne ra l Ane sthe sia

General Anesthesia
Cha pte r 7. Pe dia tric Physiology a nd Ane sthe sia

Pediatric Physiology and Anesthesia
Cha pte r 8. Obste tric Physiology a nd Ane sthe sia

Obstetric Physiology and Anesthesia
Cha pte r 9. Ne urologic Physiology a nd Ane sthe sia

Neurologic Physiology and Anesthesia
Cha pte r 10. Ana tomy, Re giona l Ane sthe sia , a nd Pa in Ma na ge me nt
Anatomy, Regional Anesthesia, and Pain Management
Cha pte r 11. Ca rdiova scula r Physiology a nd Ane sthe sia

Cardiovascular Physiology and Anesthesia
Inde x
Copyright
1600 John F. Ke nne dy Blvd.

Ste 1800
Phila de lphia , PA 19103-2899
ANESTHESIA: A COMPREHENSIVE REVIEW, FIFTH
EDITION ISBN: 978-0-323-28662-6

Copyright © 2015, 2010, 2003, 1997, 1992 by Mayo Foundation for
Medical Education and Research, Published by Elsevier Inc. All rights
reserved.
No pa rt of this publica tion ma y be re produce d or tra nsmitte d in a ny

form or by a ny me a ns, e le ctronic or me cha nica l, including
photocopying, re cording, or a ny informa tion stora ge a nd re trie va l
syste m, without pe rmission in writing from the publishe r. De ta ils
on how to se e k pe rmission, furthe r informa tion a bout the
Publishe r ’s pe rmissions policie s a nd our a rra nge me nts with
orga niza tions such a s the Copyright Cle a ra nce Ce nte r a nd the
Copyright Lice nsing Age ncy, ca n be found a t our we bsite :
www.e lse vie r.com/pe rmissions.
This book a nd the individua l contributions conta ine d in it a re

prote cte d unde r copyright by the Publishe r (othe r tha n a s ma y be
note d he re in).
Notices
Knowle dge a nd be st pra ctice in this fie ld a re consta ntly
cha nging. As ne w re se a rch a nd e xpe rie nce broa de n our
unde rsta nding, cha nge s in re se a rch me thods, profe ssiona l
pra ctice s, or me dica l tre a tme nt ma y be come ne ce ssa ry.
Pra ctitione rs a nd re se a rche rs must a lwa ys re ly on the ir own

e xpe rie nce a nd knowle dge in e va lua ting a nd using a ny
informa tion, me thods, compounds, or e xpe rime nts de scribe d
he re in. In using such informa tion or me thods the y should be
mindful of the ir own sa fe ty a nd the sa fe ty of othe rs, including
pa rtie s for whom the y ha ve a profe ssiona l re sponsibility.
W ith re spe ct to a ny drug or pha rma ce utica l products ide ntifie d,

re a de rs a re a dvise d to che ck the most curre nt informa tion
provide d (i) on proce dure s fe a ture d or (ii) by the ma nufa cture r
of e a ch product to be a dministe re d, to ve rify the re comme nde d
dose or formula , the me thod a nd dura tion of a dministra tion,
a nd contra indica tions. It is the re sponsibility of pra ctitione rs,
re lying on the ir own e xpe rie nce a nd knowle dge of the ir
pa tie nts, to ma ke dia gnose s, to de te rmine dosa ge s a nd the be st
tre a tme nt for e a ch individua l pa tie nt, a nd to ta ke a ll
a ppropria te sa fe ty pre ca utions.
To the fulle st e xte nt of the la w, ne ithe r the Publishe r nor the

a uthors, contributors, or e ditors, a ssume a ny lia bility for a ny
injury a nd/or da ma ge to pe rsons or prope rty a s a ma tte r of
products lia bility, ne glige nce or othe rwise , or from a ny use or
ope ra tion of a ny me thods, products, instructions, or ide a s
conta ine d in the ma te ria l he re in.
Library of Congress Cataloging-in-Publication Data

Ha ll, Bria n A., a uthor.
Ane sthe sia : a compre he nsive re vie w / Bria n A. Ha ll, Robe rt C.
Cha ntigia n. -- Fifth e dition.
p. ; cm.
Include s bibliogra phica l re fe re nce s a nd inde x.
ISBN 978-0-323-28662-6 (pbk. : a lk. pa pe r)
I. Cha ntigia n, Robe rt C., a uthor. II. Title .
[DNLM: 1.Ane sthe sia --Exa mina tion Que stions.W O 218.2]
RD82.3
617.9’6076--dc23
2014034662
Ex ecutive Content Strategist: W illia m Schmitt

Content Developm ent Manager: Ka tie De Fra nce sco
Publish ing Services Manager: Pa tricia Ta nnia n
Senior Project Manager: Kristine Fe e he rty
Design Direction: Bria n Sa lisbury
Printe d in the Unite d Sta te s of Ame rica
La st digit is the print numbe r: 9 8 7 6 5 4 3 2 1

Preface
The ha lf-life for knowle dge a nd huma n discove ry is shorte r now
tha n a ny time in the history of the mode rn world. Ne w discove rie s
in scie nce a nd ne w de ve lopme nts in te chnology occur da ily.
Me dicine in ge ne ra l a nd a ne sthe siology in pa rticula r a re no
e xce ptions. Ma ny a ne sthe tic drugs a nd te chnique s, once he ld a s
sta te -of-the -a rt, a re now re le ga te d to the pa st. Some of the se we re
curre nt for a pe riod of only 1 or 2 ye a rs. The a uthors ha ve re move d
ma te ria l from the pre vious e dition tha t is not use ful in the pre se nt
da y, with a fe w e xce ptions inte nde d to de monstra te a spe cific
historic le a rning point.
The contributors ha ve strive d to provide a le a rning tool for
pra ctitione rs just e nte ring the spe cia lty a s we ll a s a re vie w source
for those with more e xpe rie nce . Que stion difficulty ra nge s from
ba sic, e ntry le ve l conce pts to more a dva nce d a nd cha lle nging
proble ms.
Ea ch que stion ha s be e n ve tte d by two or more re vie we rs in the
va rious a ne sthe tic subspe cia ltie s. All ma te ria l ha s be e n che cke d
for a ccura cy a nd re le va nce . Simila r to the pre vious e ditions, the
fifth e dition is not inte nde d a s a substitute for te xtbooks, but ra the r
a s a guide to dire ct use rs to a re a s ne e ding furthe r study. It is hope d
tha t the re a de r will find this re vie w thought provoking a nd
va lua ble .
Brian A. Hall, MD
Contributors
Kendra Grim, MD, Assista nt Profe ssor of Ane sthe siology, Colle ge
of Me dicine , Ma yo Clinic, Roche ste r, Minne sota
Dawit T. Haile, MD, Assista nt Profe ssor of Ane sthe siology,

Colle ge of Me dicine , Ma yo Clinic, Roche ste r, Minne sota
Keith A. Jones, MD, Profe ssor a nd Cha irma n, De pa rtme nt of

Ane sthe siology, Unive rsity of Ala ba ma School of Me dicine ,
Birmingha m, Ala ba ma
Kent Rehfeldt, MD, Assista nt Profe ssor of Ane sthe siology,

C. T homas Wass, MD, Associa te Profe ssor of Ane sthe siology,

Francis X. Whalen, MD, Assista nt Profe ssor of Ane sthe siology,

De pa rtme nt of Ane sthe siology a nd Critica l Ca re Me dicine , Colle ge
of Me dicine , Ma yo Clinic, Roche ste r, Minne sota
Credits
Figure 1-1, page 4
From va n Ge nde ringe n HR e t a l: Compute r-a ssiste d ca pnogra m
a na lysis, J Clin Monit 3:194-200, 1987, with kind pe rmission of
Kluwe r Aca de mic Publishe rs.
Figure 1-2, page 8
From Ma rk JB: Atlas of Card iovascular Monitoring, Ne w York,
Churchill Livingstone , 1998, Figure 9-4.
Figure 1-3, page 9
Modifie d from W illis BA, Pe nde r JW, Ma ple son W W : Re bre a thing
in a T-pie ce : volunte e r a nd the ore tica l studie s of Ja ckson-Re e s
modifica tion of Ayre ’s T-pie ce during sponta ne ous re spira tion, Br J
Anaesth 47:1239–1246, 1975. © The Boa rd of Ma na ge me nt a nd
Truste e s of the British Journa l of Ana e sthe sia . Re produce d by
pe rmission of Oxford Unive rsity Pre ss/British Journa l of
Ana e sthe sia .
Figure 1-5, page 11
Re printe d with pe rmission from Andre ws JJ: Unde rsta nding
a ne sthe sia ma chine s. In: 1988 Review Course Lectures, Cle ve la nd,
Inte rna tiona l Ane sthe sia Re se a rch Socie ty, 1988, p 78.
Figure 1-6, page 13
Modifie d from Ame rica n Socie ty of Ane sthe siologists (ASA): Ch eck-
out: A Guid e for Preoperative Inspection of an Anesth esia Mach ine, Pa rk
Ridge , IL, ASA, 1987. A copy of the full te xt ca n be obta ine d from the
ASA a t 520 N. Northwe st Highwa y, Pa rk Ridge , IL, 60068-2573.
Figure 1-7, page 16
From Andre ws JJ: Unde rsta nding your a ne sthe sia ma chine a nd
ve ntila tor. In: 1989 Review Course Lectures, Cle ve la nd, Inte rna tiona l
Ane sthe sia Re se a rch Socie ty, 1989, p 59.
Figure 1-9, page 21
Courte sy Dra e ge r Me dica l, Inc., Te lford, Pe nnsylva nia .
Figure 1-10, page 22
From Aza r I, Eise nkra ft JB: Wa ste a ne sthe tic ga s spilla ge a nd
sca ve nging syste ms. In Ehre nwe rth J, Eise nkra ft JB, e ditors:
Anesth esia Eq uipm ent: Principles and Applications, St Louis, Mosby,
1993, p 128.
Table 1-1, page 12
From Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2011, p 201, Ta ble 15-2.
Table 1-6, page 27
Da ta from Ehre nwe rth J, Eise nkra ft JB, Be rry JM: Anesth esia
Eq uipm ent: Principles and Applications, e d 2, Phila de lphia , Sa unde rs,
2013.
Figure 2-1, page 30
From Mille r RD: Miller’s Anesth esia, e d 7, Phila de lphia , Sa unde rs,
2011, Figure 15-4. Courte sy the e ditor of the BMJ se rie s: Re spira tory
Me a sure me nt.
From Stoe lting RK: Ph arm acology and Ph y siology in Anesth etic
Practice, e d 3, Phila de lphia , Lippincott W illia ms & W ilkins, 1999.
From Stoe lting RK, Die rdorf SF: Anesth esia and Co-Ex isting Disease,
e d 4, Ne w York, Churchill Livingstone , 2002.
Figure 3-1, page 71
2011, Figure 10-3.
Table 3-1, page 62
2011, p 151, Ta ble 12-6.
Table 3-2, page 64
2011, p 76, Ta ble 7-3.
Table 3-3, page 65
Practice, e d 4, Phila de lphia , Lippincott W illia ms & W ilkins, 2006, p
293.
Table 3-4, page 67
2011, p 882, Ta ble 29-11.
Table 3-5, page 73
Practice, e d 4, Phila de lphia , Lippincott W illia ms & W ilkins, p 462.
Table 3-6, page 77
From Stoe lting RK, Mille r RD: Basics of Anesth esia, e d 5,
Phila de lphia , Churchill Livingstone , 2006, p 1794.
Table 3-7, page 84
From Hine s RL: Stoelting’s Anesth esia and Co-Ex isting Disease, e d 5,
Phila de lphia , Sa unde rs, 2008, p 371.
Figure 4-2, page 93
Modifie d from She ffe r L, Ste ffe nson JL, Birch AA: Nitrous oxide -
induce d diffusion hypoxia in pa tie nts bre a thing sponta ne ously,
Anesth esiology 37:436-439, 1972.
Figure 4-3, page 98
2005, Figure 5-2. Da ta from Ya suda N e t a l: Kine tics of de sflura ne ,
isoflura ne , a nd ha lotha ne in huma ns, Anesth esiology 74:489-498,
1991; a nd Ya suda N e t a l: Compa rison of kine tics of se voflura ne
a nd isoflura ne in huma ns, Anesth Analg 73:316–324, 1991.
Modifie d from Ege r EI II, Ba hlma n SH, Munson ES: Effe ct of a ge on
the ra te of incre a se of a lve ola r a ne sthe tic conce ntra tion,
Anesth esiology 35:365–372, 1971.
From Ca ha la n MK: Hem od y nam ic Effects of Inh aled Anesth etics.
Review Courses, Cle ve la nd, Inte rna tiona l Ane sthe sia Re se a rch
Socie ty, 1996, pp 14-18.
Table 4-4, page 103
From Stoe lting RK, Mille r RD: Basics of Anesth esia, e d 4, Ne w York,
Churchill Livingstone , 2000, p 26.
Table 5-2, page 116
2011, Ta ble 55-6.
Courte sy Philippe R. Housma ns, MD, PhD, Ma yo Clinic.
Table 6-2, page 142
Da ta from Ka ttwinke l J e t a l: Ne ona ta l re suscita tion: 2010
Ame rica n He a rt Associa tion Guide line s for Ca rdiopulmona ry
Re suscita tion a nd Eme rge ncy Ca rdiova scula r Ca re , Ped iatrics
126:e 1400–e 1413, 2010.
Modifie d from Gross RE: Th e Surgery of Infancy and Ch ild h ood ,
Phila de lphia , Sa unde rs, 1953.
From Da vis PJ: Sm ith ’s Anesth esia for Infants and Ch ild ren, e d 8,
Phila de lphia , Sa unde rs, 2011, Figure 16-3.
From Cote CI, Le rma n J, Todre s ID: A Practice of Anesth esia for
Infants and Ch ild ren, e d 4, Phila de lphia , Sa unde rs, 2008.
Table 7-1, page 165
Da ta from Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia ,
Sa unde rs, 2011, pp 548–550.
Table 7-3, page 177
From Da vis PJ e t a l: Sm ith ’s Anesth esia for Infants and Ch ild ren, e d
8, Phila de lphia , Sa unde rs, 2011, pp 288-289.
From Be ne de tti TJ: Obste tric he morrha ge . In Ga bbe SG, Nie byl
JR, Simpson JL, e ditors: Obstetrics: Norm al and Problem Pregnancies,
e d 3, Ne w York, Churchill Livingstone , 1996, p 511.
Table 8-3, page 203
From Che stnut DH e t a l: Ch estnut’s Obstetric Anesth esia: Principles
and Practice, e d 4, Phila de lphia , Mosby, 2009, pp 161–162.
From Mille r RD: Anesth esia, e d 3, Ne w York, Churchill
Livingstone , 1990, p 1745.
2011, p 2014, Figure 63-11.
Modifie d from He bl J: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, Ne w York, Oxford Unive rsity
Pre ss, 2010, Figure 12A.
By pe rmission of Ma yo Founda tion for Me dica l Educa tion a nd
Re se a rch.
From Ra j PP: Practical Managem ent of Pain, e d 2, St Louis, Mosby,
1992, p 785.
From Cousins MJ, Bride nba ugh PO: Neural Blockad e in Clinical
Anesth esia and Managem ent of Pain, e d 2, Phila de lphia , JB Lippincott,
1988, pp 255–263.
Modifie d from He bl J: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, Ne w York, Oxford Unive rsity
Pre ss, 2010, Figure 12B.
From Ma rk JB: Atlas of Card iovascular Monitoring, Ne w York,
Churchill Livingstone , 1998.
From Ja ckson JM, Thoma s SJ, Lowe nste in E: Ane sthe tic
ma na ge me nt of pa tie nts with va lvula r he a rt dise a se , Sem in Anesth
1:244, 1982.
From Morga n GE, Mikha il MS: Clinical Anesth esiology, Ea st
Norwa lk, NJ, Apple ton & La nge , 1992, p 301.
From Spie ss BD, Iva nkovich AD: Thromboe la stogra phy:
ca rdiopulmona ry bypa ss. In: Effective Hem ostasis in Card iac Surgery,
Phila de lphia , Sa unde rs, 1988, p 165.
Figure 78-12.
From Stoe lting RK, Die rdorf SF: Anesth esia and Co-Ex isting Disease,
e d 4, Ne w York, Churchill Livingstone , 2002.
Bibliography
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: executive summary: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg. 2008;106:685–712.
American College of Obstetricians and Gynecologists. Task force on hypertension of
pregnancy. November 2013 Available at. http://www.acog.org/Resources-And-
Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-
Pregnancy Accessed August 18, 2014.
American Heart Association. American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Science. Circulation. 2010;122:S639–S946.
American Heart Association and American Academy of Pediatrics: Textbook of Neonatal
Resuscitation. Elk Grove Village, IL: American Academy of Pediatrics; 2011.
American Society of Regional Anesthesia and Pain Medicine. Checklist for treatment of
local anesthetic systemic toxicity Available at. http://www.asra.com/checklist-for-
local-anesthetic-toxicity-treatment-1-18-12.pdf Accessed August 18, 2014.
Barash P.G, Cullen B.F, Stoelting R.K. Clinical Anesthesia. ed 7. Philadelphia: Lippincott
Williams & Wilkins; 2013.
Baum V.C, O’Flaherty J.E. Anesthesia for Genetic, Metabolic, and Dysmorphic Syndromes of
Childhood. ed 2. Philadelphia: Lippincott Williams & Wilkins; 2007.
Brown D.L. Atlas of Regional Anesthesia. ed 3. Philadelphia: Lippincott Williams &
Wilkins; 2008.
Brunner J.M.R, Leonard P.F. Electricity, Safety, and the Patient. Chicago: Year Book Medical
Publishers; 1989.
Brunton L, Chabner B, Knollman B. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. ed 12. New York: McGraw-Hill; 2011.
Butterworth J.F, Mackey D.C, Wasnick J.D. Morgan & Mikhail’s Clinical Anesthesiology. ed
5. New York: Lange Medical Books/McGraw-Hill; 2013.
Chestnut D.H, et al. Chestnut’s Obstetric Anesthesia: Principles and Practice. ed
5. Philadelphia: Mosby; 2014.
Clemente C.D. Anatomy: A Regional Atlas of the Human Body. ed 3. Baltimore: Urban and
Schwarzenberg; 1987.
Coté C.J, et al. A Practice of Anesthesia for Infants and Children. ed
3. Philadelphia: Saunders; 2001.
Cottrell J.E, Smith D.S. Anesthesia and Neurosurgery. ed 4. St Louis: Mosby; 2001.
Cousins M.J, Bridenbaugh P.O. Neural Blockade in Clinical Anesthesia and Management of
Pain. ed 3. Philadelphia: Lippincott-Raven; 1998.
Cunningham F.G, et al. Williams Obstetrics. ed 22. New York: McGraw-Hill; 2005.
Davis P.J, Cladis F.P, Motoyama E.K. Smith’s Anesthesia for Infants and Children. ed
8. Philadelphia: Mosby; 2011.
Eger E.I II: Anesthetic Uptake and Action. Baltimore: Lippincott Williams & Wilkins; 1974.
Ehrenwerth J, Eisenkraft J.B. Anesthesia Equipment: Principles and Applications. St
Louis: Mosby; 1993.
Eisenkraft J.B. Potential for barotrauma or hypoventilation with the Drager AV-E
ventilator. J Clin Anesth. 1989;1:452–456.
Evers A.S, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical
Practice. Philadelphia: Churchill Livingstone; 2004.
Faust R.J, Cucchiara R.F, Rose S.H. Anesthesiology Review. ed 3. New York: Churchill
Livingstone; 2001.
Fleisher L.A. Anesthesia and Uncommon Diseases. ed 5. Philadelphia: Saunders; 2006.
Fleisher L.A. Anesthesia and Uncommon Diseases. ed 6. Philadelphia: Saunders; 2012.
Flick R.P, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary
referral center. A study of 92,881 patients. Anesthesiology. 2007;106:226–237.
Flick R.P, et al. Risk factors for laryngospasm in children during general anesthesia. Paediatr
Anaesth. 2008;18:289–296.
Gabbe S.G, Niebyl J.R, Simpson J.L. Obstetrics: Normal and Problem Pregnancies. ed 4. New
York: Churchill Livingstone; 2001.
Grines C.L, et al. Prevention of premature discontinuation of dual antiplatelet therapy in
patients with coronary artery stents: a science advisory from the American Heart
Association, American College of Cardiology, Society for Cardiovascular Angiography
and Interventions, American College of Surgeons, and American Dental Association,
with representation from the American College of Physicians. J Am Coll
Cardiol. 2007;49:734–739.
Groudine S.B, et al. New York state guidelines on the topical use of phenylephrine in the
operating room. Anesthesiology. 2000;92:859–864.
Hardman J.G, Limbird L.E, Gimman A.G. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. ed 10. New York: McGraw-Hill; 2001.
Harmening D.M. Modern Blood Banking and Transfusion Practices. ed 5. Philadelphia: FA
Davis; 2005.
Hebl J.R. The importance and implications of aseptic techniques during regional
anesthesia. Reg Anesth Pain Med. 2006;31:311–323.
Hebl J.R. Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-Guided Nerve Blockade. New
York: Oxford University Press; 2010.
Hebl J.R, Neal J.M. Infections complications: a new practice advisory. Reg Anesth Pain
Med. 2006;31:289–290.
Hemmings HC. J.r, Egan T.D. Pharmacology and Physiology for Anesthesia: Foundations and
Clinical Application. Philadelphia: Saunders; 2013.
Hensley FA. J.r, Martin D.E, Gravlee G.P. A Practical Approach to Cardiac Anesthesia. ed
4. Philadelphia: Lippincott Williams & Wilkins; 2007.
Hines R.L, Marschall K.E. Stoelting’s Anesthesia and Co-Existing Disease. ed
6. Philadelphia: Churchill Livingstone; 2012.
Horlocker T.T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic
therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-
Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64–101.
Johnston R.R, Eger EI. I.I, Wilson C. A comparative interaction of epinephrine with
enflurane, isoflurane and halothane in man. Anesth Analg. 1976;55:709–712.
Kahn R.A, et al. Intraoperative echocardiography. In: Kaplan J.A, ed. Essentials of Cardiac
Anesthesia. Philadelphia: Saunders; 2008.
Kaplan J.A. Kaplan’s Cardiac Anesthesia. ed 4. Philadelphia: Saunders; 1999.
Kaplan J.A, Reich D.L, Savino J.S. Kaplan’s Cardiac Anesthesia. ed
6. Philadelphia: Saunders; 2011.
Kasper D.L, et al. Harrison’s Principles of Internal Medicine. ed 16. New York: McGraw-
Hill; 2005.
Kattwinkel J, et al. Textbook of Neonatal Resuscitation. ed 5. Elk Grove Village, IL: American
Academy of Pediatrics and American Heart Association; 2006.
Lobato E.B, Gravenstein N, Kirby R.R. Complications in
Anesthesiology. Philadelphia: Lippincott Williams & Wilkins; 2008.
Loeser J.D. Bonica’s Management of Pain. ed 3. Philadelphia: Lippincott Williams &
Wilkins; 2001.
Longnecker D.E, Tinker J.H, Morgan GEJ.r. Principles and Practice of Anesthesiology. ed 2. St
Louis: Mosby; 1998.
Miller R.D. Basics of Anesthesia. ed 6. Philadelphia: Saunders; 2011.
Miller R.D, et al. Miller’s Anesthesia. ed 6. Philadelphia: Churchill Livingstone; 2005.
Miller R.D, et al. Miller’s Anesthesia. ed 7. Philadelphia: Churchill Livingstone; 2010.
Navarro R, et al. Humans anesthetized with sevoflurane or isoflurane have similar
arrhythmic response to epinephrine. Anesthesiology. 1994;80:545–549.
Neal J.M, et al. Upper extremity regional anesthesia: essentials of our current
understanding, 2008. Reg Anesth Pain Med. 2009;34:134–170.
Netter F.H. Atlas of Human Anatomy. Summit, NJ: Ciba-Geigy; 1989.
O’Grady N.P, et al. Guidelines for the prevention of intravascular catheter-related
infections. Centers for Disease Control and Prevention. MMWR Recomm
Rep. 2002;51(RR-10):1–29.
Orient J.M. Sapira’s Art and Science of Bedside Diagnosis. ed 4. Philadelphia: Lippincott
Williams & Wilkins; 2010.
Perlman J.M, et al. Part 11: neonatal resuscitation: 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation. 2010;122:S516–S538.
Physicians’ Desk Reference 2014. ed 68. Montvale, NJ: PDR Network; 2014.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce
the risk of pulmonary aspiration: application to healthy patients undergoing elective
procedures: a report by the American Society of Anesthesiologists Task Force on
Preoperative Fasting. Anesthesiology. 1999;90:896–905.
Raj P.P. Practical Management of Pain. ed 3. St Louis: Mosby; 2000.
Shott S.R. Down syndrome: analysis of airway size and a guide for appropriate
intubation. Laryngoscope. 2000;110:585–592.
Southorn P, et al. Reducing the potential morbidity of an unintentional spinal anaesthetic
by aspirating cerebrospinal fluid. Br J Anaesth. 1996;76:467–469.
Stoelting R.K, Dierdorf S.F. Anesthesia and Co-Existing Disease. ed 4. New York: Churchill
Livingstone; 2002.
Stoelting R.K, Hillier S.C. Pharmacology and Physiology in Anesthetic Practice. ed
Suresh M.S, et al. Shnider and Levinson’s Anesthesia for Obstetrics. ed
Thomas S.J, Kramer J.L. Manual of Cardiac Anesthesia. ed 2. Philadelphia: Churchill
Livingstone; 1993.
U.S. Food and Drug Administration. Fatalities reported to FDA following blood collection
and transfusion: annual summary for fiscal year. 2012 Available
at. http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/Tran
August 18, 2014.
Wedel D.J. Orthopedic Anesthesia. New York: Churchill Livingstone; 1993.
West J.B. Respiratory Physiology. ed 6. Philadelphia: Lippincott Williams & Wilkins; 1999.
Wilson W, et al. Prevention of infective endocarditis: guidelines from the American Heart
Association: a guideline from the American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease
in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular
Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group. Circulation. 2007;115:1736–1754.
Acknowledgments
The va rie ty a nd qua ntity of ma te ria l in the fifth e dition of Anesth esia:
A Com preh ensive Review a re va st. Effort ha s be e n ta ke n to e nsure
re le va nce a nd a ccura cy of e a ch ste m. The que stions ha ve be e n
re fe re nce d to the most re ce nt e ditions of a ne sthe sia te xtbooks or
journa l publica tions. Se ve ra l individua ls contribute d by sugge sting
ide a s for que stions or by ve tting one or more ite ms. The a uthors
wish to e xpre ss the ir gra titude to Drs. Ma rtin Abe l, J.P. Abe nste in,
Dorothe e Bre me rich, Da vid Da nie lson, Niki Die tz, Ja son Eldridge ,
Tra cy Ha rrison, W illia m La nie r, Ja me s Lynch, W illia m Ma ue rma nn,
Bria n McGlinch, Jura j Sprung, De nise We de l, a nd Roge r W hite , a s
we ll a s Robin Ha rdt, CRNA, a nd Ta ra Ha ll, RRT.
Se ve ra l Ma yo Clinic a ne sthe sia re side nts contribute d to this work
by che cking te xtbook re fe re nce s a nd cita tions a nd by proofre a ding
the cha pte rs be fore production. The a uthors wish to tha nk Drs.
Arnole y (Arne y) Abce jo, Je nnife r Ba rtlotti Te le sz, Se ri Ca rne y, Rya n
Hofe r, Erin Holl, Ke lly La rson, La ure n Lica tino, Emily Sha rpe ,
Thoma s Ste wa rt, Lore n Thompson, Cha nning Twyne r, Luke Va n
Alstine , Pa ul Wa rne r, a nd C.M. Armste a d-W illia ms. Additiona l he lp
with gra mma r a nd synta x, a s we ll a s typing a nd e diting, wa s
provide d by Ka re n Da nie lson, Ha rve y Johnson, a nd Lia na Johnson.
The de sign, pre pa ra tion, a nd production of the fina l ma nuscript
could not ha ve be e n a ccomplishe d without the he lp of ma ny skillful
pe ople a t Else vie r. Spe cia l tha nks to W illia m R. Schmitt, Exe cutive
Conte nt Stra te gist, a s we ll a s Ka thryn De Fra nce sco, Conte nt
De ve lopme nt Ma na ge r, a nd Kristine Fe e he rty, Se nior Proje ct
Ma na ge r.
Brian A. Hall, MD
PA R T 1
Basic Sciences
OUTLI NE
Chapter 1. Anesthesia Equipment and Physics

Chapter 2. Respiratory Physiology and Critical Care Medicine
Chapter 3. Pharmacology and Pharmacokinetics of Intravenous
Drugs
Chapter 4. Pharmacology and Pharmacokinetics of Volatile
Anesthetics
C H AP T E R 1
DIRECT IONS (Que stions 1 through 90): Ea ch que stion or

incomple te sta te me nt in this se ction is followe d by a nswe rs
or by comple tions of the sta te me nt, re spe ctive ly. Se le ct the
ONE BEST a nswe r or comple tion for e a ch ite m.
1. The driving force of the ve ntila tor (Da te x-Ohme da 7000, 7810,
7100, a nd 7900) on the a ne sthe sia worksta tion is a ccomplishe d with
A. Compre sse d oxyge n
B. Compre sse d a ir
C. Ele ctricity a lone
D. Ele ctricity a nd compre sse d oxyge n
2. Se le ct the corre ct sta te me nt re ga rding color Dopple r ima ging.
A. It is a form of M-mode e choca rdiogra phy
B. The te chnology is ba se d on continuous wa ve Dopple r
C. By conve ntion, motion towa rd the Dopple r is re d a nd motion
a wa y from the Dopple r is blue
D. Two ultra sound crysta ls a re use d: one for tra nsmission of the
ultra sound signa l a nd one for re ce ption of the re turning wa ve
3. W he n the pre ssure ga uge on a size “E” compre sse d-ga s cylinde r
conta ining N2O be gins to fa ll from its pre vious consta nt pre ssure of
750 psi, a pproxima te ly how ma ny lite rs of ga s will re ma in in the
cylinde r?
A. 200 L
B. 400 L
C. 600 L
D. Ca nnot be ca lcula te d
4. W ha t pe rce nt de sflura ne is pre se nt in the vaporizing ch am ber of a
de sflura ne va porize r (pre ssurize d to 1500 mm Hg a nd he a te d to 23°
C)?
A. Ne a rly 100%
B. 85%
C. 65%
D. 45%
5. If the inte rna l dia me te r of a n intra ve nous ca the te r we re double d,
flow through the ca the te r would be
A. De cre a se d by a fa ctor of 2
B. De cre a se d by a fa ctor of 4
C. Incre a se d by a fa ctor of 8
D. Incre a se d by a fa ctor of 16
6. A size “E” compre sse d-ga s cylinde r comple te ly fille d with N2O
conta ins how ma ny lite rs?
A. 1160 L
B. 1470 L
C. 1590 L
D. 1640 L
7. W hich of the following me thods ca n be use d to de te ct a ll le a ks
in the low-pre ssure circuit of a ll conte mpora ry a ne sthe sia
ma chine s?
A. Ne ga tive -pre ssure le a k te st
B. Common ga s outle t occlusion te st
C. Tra ditiona l positive -pre ssure le a k te st
D. None of the a bove
8. W hich of the following va lve s pre ve nts tra nsfilling be twe e n
compre sse d-ga s cylinde rs?
A. Fa il-sa fe va lve
B. Che ck va lve
C. Pre ssure -se nsor shutoff va lve
D. Adjusta ble pre ssure -limiting va lve
9. The e xpre ssion tha t for a fixe d ma ss of ga s a t consta nt
te mpe ra ture , the product of pre ssure a nd volume is consta nt is
known a s
A. Gra ha m’s la w
B. Cha rle s’ la w
C. Boyle ’s la w
D. Da lton’s la w
10. The pre ssure ga uge on a size “E” compre sse d-ga s cylinde r
conta ining O2 re a ds 1600 psi. How long could O2 be de live re d from
this cylinde r a t a ra te of 2 L/min?
A. 90 minute s
B. 140 minute s
C. 250 minute s
D. 320 minute s
11. A 25-ye a r-old he a lthy pa tie nt is a ne sthe tize d for a fe mora l
he rnia re pa ir. Ane sthe sia is ma inta ine d with isoflura ne a nd N2O
50% in O2, a nd the pa tie nt’s lungs a re me cha nica lly ve ntila te d.
Sudde nly, the “low-a rte ria l sa tura tion” wa rning signa l on the pulse
oxime te r give s a n a la rm. Afte r the pa tie nt is disconne cte d from the
a ne sthe sia ma chine , he unde rgoe s ve ntila tion with a n Ambu ba g
with 100% O2 without difficulty, a nd the a rte ria l sa tura tion quickly
improve s. During inspe ction of your a ne sthe sia e quipme nt, you
notice tha t the bobbin in the O2 rota me te r is not rota ting. This most
like ly indica te s
A. Flow of O2 through the O2 rota me te r
B. No flow of O2 through the O2 rota me te r
C. A le a k in the O2 rota me te r be low the bobbin
D. A le a k in the O2 rota me te r a bove the bobbin
12. The O2 pre ssure -se nsor shutoff va lve re quire s wha t O2 pre ssure
to re ma in ope n a nd a llow N2O to flow into the N2O rota me te r?
A. 10 psi
B. 30 psi
C. 50 psi
D. 100 psi
13. A 78-ye a r-old pa tie nt is a ne sthe tize d for re se ction of a live r
tumor. Afte r induction a nd tra che a l intuba tion, a 20-ga uge a rte ria l
line is pla ce d a nd conne cte d to a tra nsduce r tha t is loca te d 20 cm
be low the le ve l of the he a rt. The syste m is ze roe d a t the stopcock
loca te d a t the wrist while the pa tie nt’s a rm is stre tche d out on a n
a rm boa rd. How will the a rte ria l line pre ssure compa re with the
true blood pre ssure (BP)?
A. It will be 20 mm Hg highe r
B. It will be 15 mm Hg highe r
C. It will be the sa me
D. It will be 15 mm Hg lowe r
14. The se cond-sta ge O2 pre ssure re gula tor de live rs a consta nt O2
pre ssure to the rota me te rs of
A. 4 psi
B. 8 psi
C. 16 psi
D. 32 psi
15. The highe st tra ce conce ntra tion of N2O a llowe d in the ope ra ting
room (OR) a tmosphe re by the Na tiona l Institute for Occupa tiona l
Sa fe ty a nd He a lth (NIOSH) is
A. 1 pa rt pe r million (ppm)
B. 5 ppm
C. 25 ppm
D. 50 ppm
16. A se voflura ne va porize r will de live r a n a ccura te conce ntra tion
of a n unknown vola tile a ne sthe tic if the la tte r sha re s which
prope rty with se voflura ne ?
A. Mole cula r we ight
B. Oil/ga s pa rtition coe fficie nt
C. Va por pre ssure
D. Blood/ga s pa rtition coe fficie nt
17. A 58-ye a r-old pa tie nt ha s se ve re shortne ss of bre a th a nd
“whe e zing.” On e xa mina tion, the pa tie nt is found to ha ve
inspira tory a nd e xpira tory stridor. Furthe r e va lua tion re ve a ls
ma rke d e xtrinsic compre ssion of the midtra che a by a tumor. The
type of a irflow a t the point of obstruction within the tra che a is
A. La mina r flow
B. Turbule nt flow
C. Undula nt flow
D. Ste notic flow
18. Conce rning the pa tie nt in Que stion 17, a dministra tion of 70%
he lium in O2 inste a d of 100% O2 will de cre a se the re sista nce to
a irflow through the ste notic re gion within the tra che a be ca use
A. He lium de cre a se s the viscosity of the ga s mixture
B. He lium de cre a se s the friction coe fficie nt of the ga s mixture
C. He lium de cre a se s the de nsity of the ga s mixture
D. He lium incre a se s the Re ynolds numbe r of the ga s mixture
19. A 56-ye a r-old pa tie nt is brought to the OR for e le ctive
re pla ce me nt of a ste notic a ortic va lve . An a wa ke 20-ga uge a rte ria l
ca the te r is pla ce d into the right ra dia l a rte ry a nd is the n conne cte d
to a tra nsduce r loca te d a t the sa me le ve l a s the pa tie nt’s le ft
ve ntricle . The e ntire syste m is ze roe d a t the tra nsduce r. Se ve ra l
se conds la te r, the pa tie nt ra ise s both a rms into the a ir until his right
wrist is 20 cm a bove his he a rt. As he is doing this the BP on the
monitor re a ds 120/80 mm Hg. W ha t would this pa tie nt’s true BP be
a t this time ?
A. 140/100 mm Hg
B. 135/95 mm Hg
C. 120/80 mm Hg
D. 105/65 mm Hg
20. An a dmixture of room a ir in the wa ste ga s disposa l syste m
during a n a ppe nde ctomy in a pa ra lyze d, me cha nica lly ve ntila te d
pa tie nt unde r ge ne ra l vola tile a ne sthe sia ca n be st be e xpla ine d by
which me cha nism of e ntry?
A. Positive -pre ssure re lie f va lve
B. Ne ga tive -pre ssure re lie f va lve
C. Soda lime ca niste r
D. Ve ntila tor be llows
21. The re la tionship be twe e n intra -a lve ola r pre ssure , surfa ce
te nsion, a nd the ra dius of a n a lve olus is de scribe d by
A. Gra ha m’s la w
B. Be e r ’s la w
C. Be rnoulli’s la w
D. La pla ce ’s la w
22. Curre ntly, the commonly use d va porize rs (e .g., GE-Da te x-
Ohme da Te c 4, Te c 5, Te c 7; Drä ge r Va por 19.n a nd 2000 se rie s) a re
de scribe d a s ha ving a ll of the following fe a ture s EXCEPT
A. Age nt spe cificity
B. Va ria ble bypa ss
C. Bubble through
D. Te mpe ra ture compe nsa te d
23. For a ny give n conce ntra tion of vola tile a ne sthe tic, the splitting
ra tio is de pe nde nt on which of the following cha ra cte ristics of tha t
vola tile a ne sthe tic?
A. Va por pre ssure
B. Mole cula r we ight
C. Spe cific he a t
D. Minimum a lve ola r conce ntra tion (MAC) a t 1 a tmosphe re
24. A me cha nica l ve ntila tor (e .g., Ohme da 7000) is se t to de live r a
tida l volume (VT) of 500 mL a t a ra te of 10 bre a ths/min a nd a n
inspira tory-to-e xpira tory (I:E) ra tio of 1:2. The fre sh ga s flow into the
bre a thing circuit is 6 L/min. In a pa tie nt with norma l tota l
pulmona ry complia nce , the a ctua l VT de live re d to the pa tie nt
would be
A. 500 mL
B. 600 mL
C. 700 mL
D. 800 mL
25. In re fe re nce to Que stion 24, if the ve ntila tor ra te we re
de cre a se d from 10 to 6 bre a ths/min, the a pproxima te VT de live re d
to the pa tie nt would be
A. 600 mL
B. 700 mL
C. 800 mL
D. 900 mL
26. A 65-ye a r-old pa tie nt is me cha nica lly ve ntila te d in the inte nsive
ca re unit (ICU) a fte r a n ope n ne phre ctomy. How fa r should the
suction ca the te r be inse rte d into the e ndotra che a l tube for
suctioning?
A. To the midle ve l of the e ndotra che a l tube
B. To the tip of the e ndotra che a l tube
C. Just proxima l to the ca rina
D. Pa st the ca rina
27. If the a ne sthe sia ma chine is discove re d Monda y morning to
ha ve run with 5 L/min of oxyge n a ll we e ke nd long, the most
re a sona ble course of a ction be fore a dministe ring the ne xt
a ne sthe tic would be to
A. Administe r 100% oxyge n for the first hour of the ne xt ca se
B. Pla ce humidifie r in line with the e xpira tory limb
C. Avoid use of se voflura ne
D. Cha nge the CO2 a bsorbe nt
28. According to NIOSH re gula tions, the highe st conce ntra tion of
vola tile a ne sthe tic conta mina tion a llowe d in the OR a tmosphe re
whe n a dministe re d in conjunction with N2O is
A. 0.5 ppm
B. 2 ppm
C. 5 ppm
D. 25 ppm
29. The de vice on a ne sthe sia ma chine s tha t most re lia bly de te cts
de live ry of hypoxic ga s mixture s is the
A. Fa il-sa fe va lve
B. O2 a na lyze r
C. Se cond-sta ge O2 pre ssure re gula tor
D. Proportion-limiting control syste m
30. A ve ntila tor pre ssure -re lie f va lve stuck in the close d position
ca n re sult in
A. Ba rotra uma
B. Hypove ntila tion
C. Hype rve ntila tion
D. Low bre a thing circuit pre ssure
31. A mixture of 1% isoflura ne , 70% N2O, a nd 30% O2 is
a dministe re d to a pa tie nt for 30 minute s. The e xpire d isoflura ne
conce ntra tion me a sure d is 1%. N2O is shut off, a nd a mixture of 30%
O2 a nd 70% N2 with 1% isoflura ne is a dministe re d. The e xpire d
isoflura ne conce ntra tion me a sure d 1 minute a fte r the sta rt of this
ne w mixture is 2.3%. The be st e xpla na tion for this obse rva tion is
A. Inte rmitte nt ba ck pre ssure (pumping e ffe ct)
B. Diffusion hypoxia
C. Conce ntra tion e ffe ct
D. Effe ct of N2O solubility in isoflura ne
32.
The ca pnogra m wa ve form a bove re pre se nts which of the

following situa tions?
A. Kinke d e ndotra che a l tube
B. Bronchospa sm
C. Incompe te nt inspira tory va lve
D. Incompe te nt e xpira tory va lve
33. Se le ct the FALSE sta te me nt.
A. If a Ma gill force ps is use d for a na sotra che a l intuba tion, the
right na re s is pre fe ra ble for inse rtion of the na sotra che a l tube
B. Exte nsion of the ne ck ca n conve rt a n e ndotra che a l intuba tion
to a n e ndobronchia l intuba tion
C. Bucking signifie s the re turn of the coughing re fle x
D. Postintuba tion pha ryngitis is more like ly to occur in fe ma le
pa tie nts
34. Ga s from a n N2O compre sse d-ga s cylinde r e nte rs the
a ne sthe sia ma chine through a pre ssure re gula tor tha t re duce s the
pre ssure to
A. 60 psi
B. 45 psi
C. 30 psi
D. 15 psi
35. Eye prote ction for OR sta ff is ne e de d whe n la se r surge ry is
pe rforme d. Cle a r wra pa round goggle s or gla sse s a re a de qua te
with which kind of la se r?
A. Argon la se r
B. Nd:YAG (ne odymium:yttrium-a luminum-ga rne t) la se r
C. CO2 la se r
36. W hich of the following syste ms pre ve nts a tta chme nt of ga s-
a dministe ring e quipme nt to the wrong type of ga s line ?
A. Pin inde x sa fe ty syste m
B. Dia me te r inde x sa fe ty syste m
C. Fa il-sa fe syste m
D. Proportion-limiting control syste m
37. A pa tie nt with a ortic ste nosis is sche dule d for la pa roscopic
chole cyste ctomy. Pre ope ra tive e choca rdiogra phy de monstra te d a
pe a k ve locity of 4 m/se c a cross the a ortic va lve . If he r BP wa s
130/80 mm Hg, wha t wa s the pe a k pre ssure in the le ft ve ntricle ?
A. 145 mm Hg
B. 160 mm Hg
C. 194 mm Hg
D. 225 mm Hg
38. The dia l of a n isoflura ne -spe cific, va ria ble bypa ss, te mpe ra ture -
compe nsa te d, flowove r, out-of-circuit va porize r (i.e ., mode rn
va porize r) is se t on 2%, a nd the infra re d spe ctrome te r me a sure s 2%
isoflura ne va por from the common ga s outle t. The flowme te r is se t
a t a ra te of 700 mL/min during this me a sure me nt. The output
me a sure me nts a re re pe a te d with the flowme te r se t a t 100 mL/min
a nd 15 L/min (va por dia l still se t on 2%). How will the se two
me a sure me nts compa re with the first me a sure me nt ta ke n?
A. Output will be le ss tha n 2% in both ca se s
B. Output will be gre a te r tha n 2% in both ca se s
C. Output will be 2% a t 100 mL/min O2 flow a nd le ss tha n 2% a t
15 L/min flow
D. Output will be le ss tha n 2% a t 100 mL/min a nd 2% a t 15 L/min
39. W hich of the following would re sult in the gre a te st de cre a se in
the a rte ria l he moglobin sa tura tion (SpO2) va lue me a sure d by the
dua l-wa ve le ngth pulse oxime te r?
A. Intra ve nous inje ction of indigo ca rmine
B. Intra ve nous inje ction of indocya nine gre e n
C. Intra ve nous inje ction of me thyle ne blue
D. Ele va tion of bilirubin
40. Ea ch of the following sta te me nts conce rning none le ctronic
conve ntiona l flowme te rs (a lso ca lle d rota me te rs) is true EXCEPT
A. Rota tion of the bobbin within the Thorpe tube is importa nt for
a ccura te function
B. The Thorpe tube incre a se s in dia me te r from bottom to top
C. Its a ccura cy is a ffe cte d by cha nge s in te mpe ra ture a nd
a tmosphe ric pre ssure
D. The rota me te rs for N2O a nd CO2 a re inte rcha nge a ble
41. W hich of the following combina tions would re sult in de live ry of
a lowe r-tha n-e xpe cte d conce ntra tion of vola tile a ne sthe tic to the
pa tie nt?
A. Se voflura ne va porize r fille d with de sflura ne
B. Isoflura ne va porize r fille d with se voflura ne
C. Se voflura ne va porize r fille d with isoflura ne
D. All of the a bove would re sult in le ss tha n the dia le d
conce ntra tion
42. At high a ltitude s, the flow of a ga s through a rota me te r will be
A. Gre a te r tha n e xpe cte d
B. Le ss tha n e xpe cte d
C. Le ss tha n e xpe cte d a t high flows but gre a te r tha n e xpe cte d a t
low flows
D. Gre a te r tha n e xpe cte d a t high flows but a ccura te a t low flows
43. A pa tie nt pre se nts for kne e a rthroscopy a nd te lls his
a ne sthe siologist tha t he ha s a VDD pa ce ma ke r. Se le ct the true
sta te me nt re ga rding this pa ce ma ke r.
A. It se nse s a nd pa ce s only the ve ntricle
B. It pa ce s only the ve ntricle
C. Its re sponse to a se nse d e ve nt is a lwa ys inhibition
D. It is not use ful in a pa tie nt with a triove ntricula r (AV) noda l
block
44. All of the following would re sult in le ss tra ce ga s pollution of
the OR a tmosphe re EXCEPT
A. Use of a high ga s flow in a circula r syste m
B. Tight ma sk se a l during ma sk induction
C. Use of a sca ve nging syste m
D. Allow pa tie nt to bre a the 100% O2 a s long a s possible be fore
e xtuba tion
45. The gre a te st source for conta mina tion of the OR a tmosphe re is
le a ka ge of vola tile a ne sthe tics
A. Around the a ne sthe sia ma sk
B. At the va porize r
C. At the CO2 a bsorbe r
D. At the e ndotra che a l tube
46. Upta ke of se voflura ne from the lungs during the first minute of
ge ne ra l a ne sthe sia is 50 mL. How much se voflura ne would be
ta ke n up from the lungs be twe e n the 16th a nd 36th minute s?
A. 25 mL
B. 50 mL
C. 100 mL
D. 500 mL
47. W hich of the drugs be low would ha ve the LEAST impa ct on
soma tose nsory e voke d pote ntia ls (SSEPs) monitoring in a 15-ye a r-
old pa tie nt unde rgoing scoliosis surge ry?
A. Mida zola m
B. Propofol
C. Isoflura ne
D. Ve curonium
48. W hich of the following is NOT found in the low-pre ssure circuit
on a n a ne sthe sia ma chine ?
A. Oxyge n supply fa ilure a la rm
B. Flowme te rs
C. Va porize rs
D. Va porize r che ck va lve
49. Frost de ve lops on the outside of a n N2O compre sse d-ga s
cylinde r during ge ne ra l a ne sthe sia . This phe nome non indica te s
tha t
A. The sa tura te d va por pre ssure of N2O within the cylinde r is
ra pidly incre a sing
B. The cylinde r is a lmost e mpty
C. The re is a ra pid tra nsfe r of he a t to the cylinde r
D. The flow of N2O from the cylinde r into the a ne sthe sia
ma chine is ra pid
50. The LEAST re lia ble site for ce ntra l te mpe ra ture monitoring is
the
A. Pulmona ry a rte ry
B. Skin on the fore he a d
C. Dista l third of the e sopha gus
D. Na sopha rynx
51. Of the following me dica l la se rs, which la se r light pe ne tra te s
tissue s the most?
A. Argon la se r
B. He lium–ne on la se r (He –Ne )
C. Nd:YAG (ne odymium:yttrium-a luminum-ga rne t) la se r
D. CO2 la se r
52. The re a son He liox (70% he lium a nd 30% oxyge n) is more
de sira ble tha n a mixture of 70% nitroge n a nd 30% oxyge n for a
sponta ne ously bre a thing pa tie nt with tra che a l ste nosis is tha t
A. He lium ha s a lowe r de nsity tha n nitroge n
B. He lium is a sma lle r mole cule tha n O2
C. Absorption a te le cta sis is de cre a se d
D. He lium ha s a lowe r critica l ve locity for turbule nt flow tha n
doe s O2
53. The ma ximum FIO2 tha t ca n be de live re d by a na sa l ca nnula is
A. 0.30
B. 0.35
C. 0.40
D. 0.45
54. Ge ne ra l a ne sthe sia is a dministe re d to a n othe rwise he a lthy 38-
ye a r-old pa tie nt unde rgoing re pa ir of a right inguina l he rnia . During
me cha nica l ve ntila tion, the a ne sthe siologist notice s tha t the
sca ve nging syste m re se rvoir ba g is diste nde d during inspira tion.
The most like ly ca use of this is
A. An incompe te nt pre ssure -re lie f va lve in the me cha nica l
ve ntila tor
B. An incompe te nt pre ssure -re lie f va lve in the pa tie nt’s bre a thing
circuit
C. An incompe te nt inspira tory unidire ctiona l va lve in the pa tie nt’s
bre a thing circuit
D. An incompe te nt e xpira tory unidire ctiona l va lve in the pa tie nt’s
bre a thing circuit
55. W hich color of na il polish would ha ve the gre a te st e ffe ct on the
a ccura cy of dua l-wa ve le ngth pulse oxime te rs?
A. Re d
B. Ye llow
C. Blue
D. Gre e n
56. The minimum ma croshock curre nt re quire d to e licit ve ntricula r
fibrilla tion is
A. 1 mA
B. 10 mA
C. 100 mA
D. 500 mA
57. The line isola tion monitor
A. Pre ve nts microshock
B. Pre ve nts ma croshock
C. Provide s e le ctric isola tion in the OR
D. Sounds a n a la rm whe n grounding occurs in the OR
58. Kinking or occlusion of the tra nsfe r tubing from the pa tie nt’s
bre a thing circuit to the close d sca ve nging syste m inte rfa ce ca n
re sult in
A. Ba rotra uma
C. Hypoxia
D. Hype rve ntila tion
59. The re a son a pa tie nt is not burne d by the re turn of e ne rgy from
the pa tie nt to the ESU (e le ctrosurgica l unit, Bovie ) is tha t
A. The coa gula tion side of this circuit is positive re la tive to the
ground side
B. Re sista nce in the pa tie nt’s body a tte nua te s the e ne rgy
C. The e xit curre nt de nsity is much le ss
D. The ove ra ll e ne rgy de live re d is too sma ll to ca use burns
60. Se le ct the FALSE sta te me nt re ga rding noninva sive a rte ria l BP
monitoring de vice s.
A. If the width of the BP cuff is too na rrow, the me a sure d BP will
be fa lse ly lowe re d
B. The width of the BP cuff should be 40% of the circumfe re nce of
the pa tie nt’s a rm
C. If the BP cuff is wra ppe d a round the a rm too loose ly, the
me a sure d BP will be fa lse ly e le va te d
D. Fre que nt cycling of a utoma te d BP monitoring de vice s ca n
re sult in e de ma dista l to the cuff
61. W he n e le ctroca rdiogra m (EKG) e le ctrode s a re pla ce d for a
pa tie nt unde rgoing a ma gne tic re sona nce ima ging (MRI) sca n,
which of the following is true ?
A. Ele ctrode s should be a s close a s possible a nd in the pe riphe ry
of the ma gne tic fie ld
B. Ele ctrode s should be a s close a s possible a nd in the ce nte r of
the ma gne tic fie ld
C. Pla ce me nt of e le ctrode s re la tive to fie ld is not importa nt a s
long a s the y a re fa r a pa rt
D. EKG ca nnot be monitore d during a n MRI sca n
62. The pre ssure ga uge of a size “E” compre sse d-ga s cylinde r
conta ining a ir shows a pre ssure of 1000 psi. Approxima te ly how
long could a ir be de live re d from this cylinde r a t the ra te of
10 L/min?
A. 10 minute s
B. 20 minute s
C. 30 minute s
D. 40 minute s
63. The most fre que nt ca use of me cha nica l fa ilure of the
a ne sthe sia de live ry syste m to de live r a de qua te O2 to the pa tie nt is
A. Atta chme nt of the wrong compre sse d-ga s cylinde r to the O2
yoke
B. Imprope rly a sse mble d O2 rota me te r
C. Fre sh-ga s line disconne ction from the a ne sthe sia ma chine to
the in-line hosing
D. Disconne ction of the O2 supply syste m from the pa tie nt
64. The e sopha ge a l de te ctor de vice
A. Use s a ne ga tive -pre ssure bulb
B. Is e spe cia lly use ful in childre n younge r tha n 1 ye a r of a ge
C. Re quire s a ca rdia c output to function a ppropria te ly
D. Is re lia ble in morbidly obe se pa tie nts a nd pa rturie nts
65. The re a son CO2 me a sure d by ca pnome te r is le ss tha n the
a rte ria l Pa CO2 va lue me a sure d simulta ne ously is
A. Use of ion-spe cific e le ctrode for blood ga s de te rmina tion
B. Alve ola r ca pilla ry gra die nt
C. One -wa y va lue s
D. Alve ola r de a d spa ce
66. W hich of the following a rra nge me nts of rota me te rs on the
a ne sthe sia ma chine ma nifold is sa fe st with le ft-to-right ga s flow?
A. O2, CO2, N2O, a ir
B. CO2, O2, N2O, a ir
C. Air, CO2, O2, N2O
D. Air, CO2, N2O, O2
67. A Da te x-Ohme da Te c 4 va porize r is tippe d ove r while be ing
a tta che d to the a ne sthe sia ma chine but is pla ce d upright a nd
insta lle d. The soone st it ca n be sa fe ly use d is
A. Afte r 30 minute s of flushing with dia l se t to “off”
B. Afte r 6 hours of flushing with dia l se t to “off”
C. Afte r 30 minute s with dia l turne d on
D. Imme dia te ly
68. In the e ve nt of misfilling, wha t pe rce nt se voflura ne would be
de live re d from a n isoflura ne va porize r se t a t 1%?
A. 0.6%
B. 0.8%
C. 1.0%
D. 1.2%
69. How long would a va porize r (fille d with 150 mL vola tile ) de live r
2% isoflura ne if tota l flow is se t a t 4.0 L/min?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
70. Ra ising the fre que ncy of a n ultra sound tra nsduce r use d for line
pla ce me nt or re giona l a ne sthe sia (e .g., from 3 MHz to 10 MHz) will
re sult in
A. Highe r pe ne tra tion of tissue with lowe r re solution
B. Highe r pe ne tra tion of tissue with highe r re solution
C. Lowe r pe ne tra tion of tissue with highe r re solution
D. Highe r re solution with no cha nge in tissue pe ne tra tion
71. The funda me nta l diffe re nce be twe e n microshock a nd
ma croshock is re la te d to
A. Loca tion of shock
B. Dura tion
C. Volta ge
D. Le tha lity
72. Intra ope ra tive a wa re ne ss unde r ge ne ra l a ne sthe sia ca n be
e limina te d by close ly monitoring
A. Ele ctroe nce pha logra m
B. BP/he a rt ra te
C. Bispe ctra l inde x (BIS)
73. A me cha nica lly ve ntila te d pa tie nt is tra nsporte d from the OR to
the ICU using a porta ble ve ntila tor tha t consume s 2 L/min of oxyge n
to run the me cha nica lly controlle d va lve s a nd drive the ve ntila tor.
The tra nsport ca rt is e quippe d with a n “E” cylinde r with a ga uge
pre ssure of 2000 psi. The pa tie nt re ce ive s a VT of 500 mL a t a ra te
of 10 bre a ths/min. If the ve ntila tor re quire s 200 psi to ope ra te , how
long could the pa tie nt be me cha nica lly ve ntila te d?
A. 20 minute s
B. 40 minute s
C. 60 minute s
D. 80 minute s
74. A 135-kg ma n is ve ntila te d a t a ra te of 14 bre a ths/min with a VT
of 600 mL a nd positive e nd-e xpira tory pre ssure (PEEP) of 5 cm H2O
during a la pa roscopic ba nding proce dure . Pe a k a irwa y pre ssure is
50 cm H2O, a nd the pa tie nt is fully re la xe d with a nonde pola rizing
ne uromuscula r blocking a ge nt. How ca n pe a k a irwa y pre ssure be
re duce d without a loss of a lve ola r ve ntila tion?
A. Incre a se the inspira tory flow ra te
B. Ta ke off PEEP
C. Re duce the I:E ra tio (e .g., cha nge from 1:3 to 1:2)
D. De cre a se VT to 300 a nd incre a se ra te to 28
75. The pre ssure a nd volume pe r minute de live re d from the ce ntra l
hospita l oxyge n supply a re
A. 2100 psi a nd 650 L/min
B. 1600 psi a nd 100 L/min
C. 75 psi a nd 100 L/min
D. 50 psi a nd 50 L/min
76. During norma l la mina r a irflow, re sista nce is de pe nde nt on
which cha ra cte ristic of oxyge n?
A. De nsity
B. Viscosity
C. Mole cula r we ight
D. Te mpe ra ture
77. If the oxyge n cylinde r we re be ing use d a s the source of oxyge n
a t a re mote a ne sthe tizing loca tion a nd the oxyge n flush va lve on a n
a ne sthe sia ma chine we re pre sse d a nd he ld down, a s during a n
e me rge ncy situa tion, e a ch of the ite ms be low would be bypa sse d
during 100% oxyge n de live ry EXCEPT
A. O2 flowme te r
B. First-sta ge re gula tor
C. Va porize r che ck va lve
D. Va porize rs
78. Afte r induction a nd intuba tion with confirma tion of tra che a l
pla ce me nt, the O2 sa tura tion be gins to fa ll. The O2 a na lyze r shows
4% inspire d oxyge n. The oxyge n line pre ssure is 65 psi. The O2 ta nk
on the ba ck of the a ne sthe sia ma chine ha s a pre ssure of 2100 psi
a nd is turne d on. The oxyge n sa tura tion continue s to fa ll. The ne xt
ste p should be to
A. Excha nge the ta nk
B. Re pla ce pulse oxime te r probe
C. Disconne ct O2 line from hospita l source
D. Extuba te a nd sta rt ma sk ve ntila tion
79. The corre ct loca tion for pla ce me nt of the V5 le a d is
A. Midcla vicula r line , third inte rcosta l spa ce
B. Ante rior a xilla ry line , fourth inte rcosta l spa ce
C. Midcla vicula r line , fifth inte rcosta l spa ce
D. Ante rior a xilla ry line , fifth inte rcosta l spa ce
80. The dia me te r inde x sa fe ty syste m re fe rs to the inte rfa ce
be twe e n
A. Pipe line source a nd a ne sthe sia ma chine
B. Ga s cylinde rs a nd a ne sthe sia ma chine
C. Va porize rs a nd re filling conne ctors a tta che d to bottle s of
vola tile a ne sthe tics
D. Both pipe line a nd ga s cylinde rs inte rfa ce with a ne sthe sia
ma chine
81. Ea ch of the following is cite d a s a n a dva nta ge of ca lcium
hydroxide lime (Amsorb Plus, Drä ge rsorb) ove r soda lime EXCEPT
A. Compound A is not forme d
B. CO is not forme d
C. More a bsorptive ca pa city pe r 100 g of gra nule s
D. It doe s not conta in Na OH or KOH
82.
The a rrows in the figure a bove indica te

A. Re spira tory va ria tion
B. An unde rda mpe d signa l
C. An ove rda mpe d signa l
D. Atria l fibrilla tion
83. During a la pa roscopic chole cyste ctomy, e xha le d CO2 is 6%, but
inha le d CO2 is 1%. W hich e xpla na tion could NOT a ccount for
re bre a thing CO2?
A. Cha nne ling through soda lime
B. Fa ulty e xpira tory va lve
C. Exha uste d soda lime
D. Absorption of CO2 through pe ritone um
DIRECT IONS (Que stions 84 through 86): Ple a se ma tch the color
of the compre sse d-ga s cylinde r with the a ppropria te ga s.
84. He lium
85. Nitroge n
86. CO2
A. Bla ck
B. Brown
C. Blue
D. Gra y
DIRECT IONS (Que stions 87 through 90): Ma tch the figure s

be low with the corre ct numbe re d sta te me nt. Ea ch le tte re d
figure ma y be se le cte d once , more tha n once , or not a t a ll.
87. Be st for sponta ne ous ve ntila tion

88. Be st for controlle d ve ntila tion
89. Ba in syste m is modifica tion of
90. Ja ckson-Re e s syste m
Corre ct Answ e rs, Ex pl a na ti ons, a nd
Re fe re nce s
1. (A) The control me cha nism of sta nda rd a ne sthe sia ve ntila tors,
such a s the Ohme da 7000, use s compre sse d oxyge n (100%) to
compre ss the ve ntila tor be llows a nd e le ctric powe r for the timing
circuits. Some ve ntila tors (e .g., North Ame rica n Drä ge r AV-E a nd AV-
2+) use a Ve nturi de vice , which mixe s oxyge n a nd a ir. Still othe r
ve ntila tors use sophistica te d digita l controls tha t a llow a dva nce d
ve ntila tion mode s. The se ve ntila tors use a n e le ctric ste ppe r motor
a tta che d to a piston (Miller: Miller’s Anesth esia, ed 8, p 757;
Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
160–161; Miller: Basics of Anesth esia, ed 6, pp 208–209).
2. (C) Continuous wave Doppler—Continuous wa ve Dopple r use s
two de dica te d ultra sound crysta ls, one for continuous tra nsmission
a nd a se cond for continuous re ce ption of ultra sound signa ls. This
pe rmits me a sure me nt of ve ry high fre que ncy Dopple r shifts or
ve locitie s. The “cost” is tha t this te chnique re ce ive s a continuous
signa l a long the e ntire le ngth of the ultra sound be a m. It is use d for
me a suring ve ry high ve locitie s (e .g., a s se e n in a ortic ste nosis).
Also, continuous wa ve Dopple r ca nnot spa tia lly loca te the source
of high ve locity (e .g., diffe re ntia te a mitra l re gurgita tion ve locity
from a ortic ste nosis; both a re systolic ve locitie s).
Pulsed Doppler—In contra st to continuous wa ve Dopple r, which
re cords the signa l a long the e ntire le ngth of the ultra sound be a m,
pulse d wa ve Dopple r pe rmits sa mpling of blood flow ve locitie s
from a spe cific re gion. This moda lity is pa rticula rly use ful for
a sse ssing the re la tive ly low ve locity flows a ssocia te d with
tra nsmitra l or tra nstricuspid blood flow, pulmona ry ve nous flow,
a nd le ft a tria l a ppe nda ge flow or for confirming the loca tion of
e cce ntric je ts of a ortic insufficie ncy or mitra l re gurgita tion. To
pe rmit this, a pulse of ultra sound is tra nsmitte d, a nd the n the
re ce ive r “liste ns” during a subse que nt inte rva l de fine d by the
dista nce from the tra nsmitte r a nd the sa mple site . This
tra nsduce r mode of tra nsmit-wa it-re ce ive is re pe a te d a t a n
inte rva l te rme d the pulse -re pe tition fre que ncy (PRF). The PRF is
the re fore de pth de pe nde nt, be ing gre a te r for ne a r re gions a nd
lowe r for dista nt or de e pe r re gions. The dista nce from the
tra nsmitte r to the re gion of inte re st is ca lle d the sa mple volume ,
a nd the width a nd le ngth of the sa mple volume a re va rie d by
a djusting the le ngth of the tra nsduce r “re ce ive ” inte rva l. In
contra st to continuous wa ve Dopple r, which is some time s
pe rforme d without two-dime nsiona l guida nce , pulse d Dopple r is
a lwa ys pe rforme d with two-dime nsiona l guida nce to de te rmine
the sa mple volume position.
Be ca use pulse d wa ve Dopple r e cho re pe a te dly sa mple s the
re turning signa l, the re is a ma ximum limit to the fre que ncy shift
or ve locity tha t ca n be me a sure d una mbiguously. Corre ct
ide ntifica tion of the fre que ncy of a n ultra sound wa ve form
re quire s sa mpling a t le a st twice pe r wa ve le ngth. Thus, the
ma ximum de te cta ble fre que ncy shift, or Nyquist limit, is one ha lf
the PRF. If the ve locity of inte re st e xce e ds the Nyquist limit,
“wra pa round” of the signa l occurs, first into the re ve rse cha nne l
a nd the n ba ck to the forwa rd cha nne l; this is known a s a lia sing
(Miller: Basics of Anesth esia, ed 6, pp 325–327).
3. (B) The pre ssure ga uge on a size “E” compre sse d-ga s cylinde r
conta ining liquid N2O shows 750 psi whe n it is full a nd will
continue to re giste r 750 psi until a pproxima te ly thre e fourths of the
N2O ha s le ft the cylinde r (i.e ., liquid N2O ha s a ll be e n va porize d). A
full cylinde r of N2O conta ins 1590 L. The re fore , whe n 400 L of ga s
re ma in in the cylinde r, the pre ssure within the cylinde r will be gin
to fa ll (Miller: Basics of Anesth esia, ed 6, p 201; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 12–13).
4. (D) De sflura ne is unique a mong the curre nt commonly use d
vola tile a ne sthe tics be ca use of its high va por pre ssure of 664 mm
Hg. Be ca use of the high va por pre ssure , the va porize r is
pre ssurize d to 1500 mm Hg a nd e le ctrica lly he a te d to 23° C to give
more pre dica ble conce ntra tions: 664/1500 = a bout 44%. If de sflura ne
we re use d a t 1 a tmosphe re , the conce ntra tion would be a bout 88%
(Barash : Clinical Anesth esia, ed 7, pp 666–668; Miller: Basics of
Anesth esia, ed 6, pp 202–203; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 60–64).
5. (D) Fa ctors tha t influe nce the ra te of la mina r flow of a substa nce
through a tube a re de scribe d by the Ha ge n-Poise uille la w of
friction. The ma the ma tic e xpre ssion of the Ha ge n-Poise uille la w of
friction is a s follows:
whe re is the flow of the substa nce , r is the ra dius of the tube ,
ΔP is the pre ssure gra die nt down the tube , L is the le ngth of the
tube , a nd µ is the viscosity of the substa nce . Note tha t the ra te of
la mina r flow is proportiona l to the ra dius of the tube to the fourth
powe r. If the dia me te r of a n intra ve nous ca the te r is double d,
flow would incre a se by a fa ctor of two ra ise d to the fourth powe r
(i.e ., a fa ctor of 16) (Eh renwerth : Anesth esia Eq uipm ent: Principles
and Applications, ed 2, pp 377–378).
6. (C) The World He a lth Orga niza tion re quire s tha t compre sse d-ga s
cylinde rs conta ining N2O for me dica l use be pa inte d blue . Size “E”
compre sse d-ga s cylinde rs comple te ly fille d with liquid N2O conta in
a pproxima te ly 1590 L of ga s. Se e ta ble from Expla na tion 10 (Miller:
Basics of Anesth esia, ed 6, p 201; Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, p 12).
7. (D) Ane sthe sia ma chine s should be che cke d e a ch da y be fore
the ir use . For most ma chine s, thre e pa rts a re che cke d be fore use :
ca libra tion for the oxyge n a na lyze r, the low-pre ssure circuit le a k
te st, a nd the circle syste m. Ma ny conside r the low-pre ssure circuit
the a re a most vulne ra ble for proble ms be ca use it is more subje ct
to le a ks. Le a ks in this pa rt of the ma chine ha ve be e n a ssocia te d
with intra ope ra tive a wa re ne ss (e .g., loose va porize r filling ca ps)
a nd hypoxia . To te st the low-pre ssure pa rt of the ma chine , se ve ra l
te sts ha ve be e n use d. For the positive -pre ssure te st, positive
pre ssure is a pplie d to the circuit by de pre ssing the oxyge n flush
button a nd occluding the Y-pie ce of the circle syste m (which is
conne cte d to the e ndotra che a l tube or the a ne sthe sia ma sk during
a ne sthe tic a dministra tion) a nd looking for positive pre ssure
de te cte d by the a irwa y pre ssure ga uge . A le a k in the low-pre ssure
pa rt of the ma chine or the circle syste m will be de monstra te d by a
de cre a se in a irwa y pre ssure . W ith ma ny ne we r ma chine s, a che ck
va lve is positione d downstre a m from the flowme te rs (rota me te rs)
a nd va porize rs but upstre a m from the oxyge n flush va lve , which
would not pe rmit the positive pre ssure from the circle syste m to
flow ba ck to the low-pre ssure circuit. In the se ma chine s with the
che ck va lve , the positive -pre ssure re a ding will fa ll only with a le a k
in the circle pa rt, but a le a k in the low-pre ssure circuit of the
a ne sthe sia ma chine will not be de te cte d. In 1993, use of the U.S.
Food a nd Drug Administra tion unive rsa l ne ga tive -pre ssure le a k te st
wa s e ncoura ge d, whe re by the ma chine ma ste r switch a nd the flow
va lve s a re turne d off, a nd a suction bulb is colla pse d a nd a tta che d
to the common or fre sh ga s outle t of the ma chine . If the bulb sta ys
fully colla pse d for a t le a st 10 se conds, a le a k did not e xist (this
ne e ds to be re pe a te d for e a ch va porize r, e a ch one ope ne d a t a
time ). Of course , whe n the te st is comple te d, the fre sh ga s hose is
re conne cte d to the circle syste m. Be ca use ma chine s continue to be
de ve lope d a nd to diffe r from one a nothe r, you should be fa milia r
with e a ch ma nufa cture r ’s ma chine pre ope ra tive che cklist. For
e xa mple , the ne ga tive -pre ssure le a k te st is re comme nde d for
Ohme da Unitrol, Ohme da 30/70, Ohme da Modulus I, Ohme da
Modulus II a nd II plus, Ohme da Exce l se rie s, Ohme da CD, a nd
Da te x-Ohme da Ae stiva . The Drä ge r Na rkome d 2A, 2B, 2C, 3, 4, a nd
GS re quire a positive -pre ssure le a k te st. The Fa bius GS, Na rkome d
6000, a nd Da te x-Ohme da S5/ADU ha ve se lf-te sts (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 83–85; Miller:
Miller’s Anesth esia, ed 8, pp 752–755).
8. (B) Che ck va lve s pe rmit only unidire ctiona l flow of ga se s. The se

va lve s pre ve nt re trogra de flow of ga se s from the a ne sthe sia
ma chine or the tra nsfe r of ga s from a compre sse d-ga s cylinde r a t
high pre ssure into a conta ine r a t a lowe r pre ssure . Thus, the se
unidire ctiona l va lve s will a llow a n e mpty compre sse d-ga s cylinde r
to be e xcha nge d for a full one during ope ra tion of the a ne sthe sia
ma chine with minima l loss of ga s. The a djusta ble pre ssure -limiting
va lve is a synonym for a pop-off va lve . A fa il-sa fe va lve is a
synonym for a pre ssure -se nsor shutoff va lve . The purpose of a fa il-
sa fe va lve is to discontinue the flow of N2O (or proportiona lly
re duce it) if the O2 pre ssure within the a ne sthe sia ma chine fa lls
be low 30 psi (Miller: Miller’s Anesth esia, ed 8, p 756).
9. (C) Boyle ’s la w sta te s tha t for a fixe d ma ss of ga s a t a consta nt
te mpe ra ture , the product of pre ssure a nd volume is consta nt. This
conce pt ca n be use d to e stima te the volume of ga s re ma ining in a
compre sse d-ga s cylinde r by me a suring the pre ssure within the
cylinde r (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, p 4).
10. (C) U.S. ma nufa cture rs re quire tha t a ll compre sse d-ga s cylinde rs
conta ining O2 for me dica l use be pa inte d gre e n. A compre sse d-ga s
cylinde r comple te ly fille d with O2 ha s a pre ssure of a pproxima te ly
2000 psi a nd conta ins a pproxima te ly 625 L of ga s. According to
Boyle ’s la w, the volume of ga s re ma ining in a close d conta ine r ca n
be e stima te d by me a suring the pre ssure within the conta ine r.
The re fore , whe n the pre ssure ga uge on a compre sse d-ga s cylinde r
conta ining O2 shows a pre ssure of 1600 psi, the cylinde r conta ins
500 L of O2. At a ga s flow of 2 L/min, O2 could be de live re d from the
cylinde r for a pproxima te ly 250 minute s (Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, p 4; Butterworth : Morgan &
CHARACTERISTICS OF COMPRESSED GASES STORED IN “E”
SIZE CYLINDERS THAT MAY BE ATTACHED TO THE ANESTHESIA
MACHINE
∗ The World Health Organization specifies that cylinders containing oxygen for medical use be
painted white, but manufacturers in the United States use green. Likewise, the international color
for air is white and black, whereas cylinders in the United States are color-coded yellow.
From Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, p 201, Table 15-2.
11. (B) Give n the de scription of the proble m, no flow of O2 through
the O2 rota me te r is the corre ct choice . In a norma lly functioning
rota me te r, ga s flows be twe e n the rim of the bobbin a nd the wa ll of
the Thorpe tube , ca using the bobbin to rota te . If the bobbin is
rota ting, you ca n be ce rta in tha t ga s is flowing through the
rota me te r a nd tha t the bobbin is not stuck (Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, pp 43–45).
12. (B) Fa il-sa fe va lve is a synonym for pre ssure -se nsor shutoff
va lve . The purpose of the fa il-sa fe va lve is to pre ve nt the de live ry
of hypoxic ga s mixture s from the a ne sthe sia ma chine to the pa tie nt
re sulting from fa ilure of the O2 supply. Most mode rn a ne sthe sia
ma chine s, howe ve r, would not a llow a hypoxic mixture , be ca use
the knob controlling the N2O is linke d to the O2 knob. W he n the O2
pre ssure within the a ne sthe sia ma chine de cre a se s be low 30 psi,
this va lve discontinue s the flow of N2O or proportiona lly de cre a se s
the flow of a ll ga se s. It is importa nt to re a lize tha t this va lve will not
pre ve nt the de live ry of hypoxic ga s mixture s or pure N2O whe n the
O2 rota me te r is off, be ca use the O2 pre ssure within the circuits of
the a ne sthe sia ma chine is ma inta ine d by a n ope n O2 compre sse d-
ga s cylinde r or a ce ntra l supply source . Unde r the se circumsta nce s,
a n O2 a na lyze r will be ne e de d to de te ct the de live ry of a hypoxic
ga s mixture (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 37–40; Miller: Basics of Anesth esia, ed 6, pp 199–
200).
13. (C) It is importa nt to ze ro the e le ctrome cha nica l tra nsduce r
syste m with the re fe re nce point a t the a pproxima te le ve l of the
he a rt. This will e limina te the e ffe ct of the fluid column of the
tra nsduce r syste m on the a rte ria l BP re a ding of the syste m. In this
que stion, the syste m wa s ze roe d a t the stopcock, which wa s
loca te d a t the pa tie nt’s wrist (a pproxima te le ve l of the ve ntricle ).
The BP e xpre sse d by the a rte ria l line will the re fore be a ccura te ,
provide d the stopcock re ma ins a t the wrist a nd the tra nsduce r is
not move d once ze roe d. Ra ising the a rm (e .g., 15 cm) de cre a se s the
BP a t the wrist but incre a se s the pre ssure on the tra nsduce r by the
sa me a mount (i.e ., the ve rtica l tubing le ngth is now 15 cm H2O
highe r tha n be fore ) (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 276–278; Miller: Miller’s Anesth esia, ed 8, pp 1354–
1355).
14. (C) O2 a nd N2O e nte r the a ne sthe sia ma chine from a ce ntra l
supply source or compre sse d-ga s cylinde rs a t pre ssure s a s high a s
2200 psi (O2) a nd 750 psi (N2O). First-sta ge pre ssure re gula tors
re duce the se pre ssure s to a pproxima te ly 45 psi. Be fore e nte ring the
rota me te rs, se cond-sta ge O2 pre ssure re gula tors furthe r re duce the
pre ssure to a pproxima te ly 14 to 16 psi (Miller: Miller’s Anesth esia, ed
8, p 761).
15. (C) NIOSH se ts guide line s a nd issue s re comme nda tions
conce rning the control of wa ste a ne sthe tic ga se s. NIOSH ma nda te s
tha t the highe st tra ce conce ntra tion of N2O conta mina tion of the OR
a tmosphe re should be le ss tha n 25 ppm. In de nta l fa cilitie s whe re
N2O is use d without vola tile a ne sthe tics, NIOSH pe rmits up to
50 ppm (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p
81).
16. (C) Age nt-spe cific va porize rs, such a s the Se vote c (se voflura ne )
va porize r, a re de signe d for e a ch vola tile a ne sthe tic. Howe ve r,
vola tile a ne sthe tics with ide ntica l sa tura te d va por pre ssure s ca n be
use d inte rcha nge a bly, with a ccura te de live ry of the vola tile
a ne sthe tic. Although ha lotha ne is no longe r use d in the Unite d
Sta te s, tha t va porize r, for e xa mple , ma y still be use d in de ve loping
countrie s for a dministra tion of isoflura ne (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 61–63; Eh renwerth : Anesth esia
VAPOR PRESSURES
Agent Vapor Pressure mm Hg at 20° C

Halothane 243
Sevoflurane 160
Isoflurane 240
Desflurane 669
17. (B) Turbule nt flow occurs whe n ga s flows through a re gion of

se ve re constriction such a s tha t de scribe d in this que stion. La mina r
flow occurs whe n ga s flows down pa ra lle l-side d tube s a t a ra te
le ss tha n critica l ve locity. W he n the ga s flow e xce e ds the critica l
ve locity, it be come s turbule nt (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 488–489).
18. (C) During turbule nt flow, the re sista nce to ga s flow is dire ctly
proportiona l to the de nsity of the ga s mixture . Substituting he lium
for oxyge n will de cre a se the de nsity of the ga s mixture , the re by
de cre a sing the re sista nce to ga s flow (a s much a s thre e fold)
through the re gion of constriction (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 498–499, 1286–1287; Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 230–234).
19. (C) Mode rn e le ctronic BP monitors a re de signe d to inte rfa ce
with e le ctrome cha nica l tra nsduce r syste ms. The se syste ms do not
re quire e xte nsive te chnica l skill on the pa rt of the a ne sthe sia
provide r for a ccura te use . A sta tic ze roing of the syste m is built into
most mode rn e le ctronic monitors. Thus, a fte r the ze roing proce dure
is a ccomplishe d, the syste m is re a dy for ope ra tion. The syste m
should be ze roe d with the re fe re nce point of the tra nsduce r a t the
a pproxima te le ve l of the a ortic root, e limina ting the e ffe ct of the
fluid column of the syste m on a rte ria l BP re a dings (Eh renwerth :
20. (B) Wa ste ga s disposa l syste ms, a lso ca lle d sca ve nging syste ms,
a re de signe d to de cre a se pollution in the OR by a ne sthe tic ga se s.
The se sca ve nging syste ms ca n be pa ssive (wa ste ga se s flow from
the a ne sthe sia ma chine to a ve ntila tion syste m on the ir own) or
a ctive (a ne sthe sia ma chine is conne cte d to a va cuum syste m, the n
to the ve ntila tion syste m). Positive -pre ssure re lie f va lve s ope n if
the re is a n obstruction be twe e n the a ne sthe sia ma chine a nd the
disposa l syste m, which would the n le a k the ga s into the OR. A le a k
in the soda lime ca niste rs would a lso ve nt to the OR. Give n tha t
most ve ntila tor be llows a re powe re d by oxyge n, a le a k in the
be llows will not a dd a ir to the e va cua tion syste m. The ne ga tive -
pre ssure re lie f va lve is use d in a ctive syste ms a nd will e ntra p room
a ir if the pre ssure in the syste m is le ss tha n −0.5 cm H2O (Miller:
Miller’s Anesth esia, ed 8, p 802; Miller: Basics of Anesth esia, ed 6, pp 212;
Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
101–103).
21. (D) The re la tionship be twe e n intra -a lve ola r pre ssure , surfa ce
te nsion, a nd the ra dius of a lve oli is de scribe d by La pla ce ’s la w for
a sphe re , which sta te s tha t the surfa ce te nsion of the sphe re is
dire ctly proportiona l to the ra dius of the sphe re a nd pre ssure
within the sphe re . W ith re ga rd to pulmona ry a lve oli, the
ma the ma tic e xpre ssion of La pla ce ’s la w is a s follows:
whe re T is the surfa ce te nsion, P is the intra -a lve ola r pre ssure ,
a nd R is the ra dius of the a lve olus. In pulmona ry a lve oli, surfa ce
te nsion is produce d by a liquid film lining the a lve oli. This occurs
be ca use the a ttra ctive force s be twe e n the mole cule s of the liquid
film a re much gre a te r tha n the a ttra ctive force s be twe e n the
liquid film a nd ga s. Thus, the surfa ce a re a of the liquid te nds to
be come a s sma ll a s possible , which could colla pse the a lve oli
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
493–494; Miller: Miller’s Anesth esia, ed 8, p 475).
22. (C) Be ca use vola tile a ne sthe tics ha ve diffe re nt va por pre ssure s,
the va porize rs a re a ge nt spe cific. Va porize rs a re de scribe d a s
ha ving va ria ble bypa ss, which me a ns tha t some of the tota l fre sh
ga s flow (usua lly le ss tha n 20%) is dive rte d into the va porizing
cha mbe r, a nd the re st bypa sse s the va porize r. Tipping the
va porize rs (which should not occur) ma y ca use some of the liquid
to e nte r the bypa ss circuit, le a ding to a high conce ntra tion of
a ne sthe tic be ing de live re d to the pa tie nt. The ga s tha t e nte rs the
va porize r flows ove r (doe s not bubble through) the vola tile
a ne sthe tic. The olde r (now obsole te ) Coppe r Ke ttle a nd Ve rn-Trol
va porize rs we re not a ge nt spe cific, a nd oxyge n (with a se pa ra te
flowme te r) wa s bubble d through the vola tile a ne sthe tic; the n, the
combina tion of oxyge n with vola tile ga s wa s dilute d with the fre sh
ga s flow (oxyge n, a ir, N2O) a nd a dministe re d to the pa tie nt.
Be ca use va poriza tion cha nge s with te mpe ra ture , mode rn
va porize rs a re de signe d to ma inta in a consta nt conce ntra tion ove r
clinica lly use d te mpe ra ture s (20° C-35° C) (Barash : Clinical Anesth esia,
ed 7, pp 661–672; Miller: Basics of Anesth esia, ed 6, pp 202–203;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 60–64).
23. (A) Va porize rs ca n be ca te gorize d into va ria ble -bypa ss a nd
me a sure d-flow va porize rs. Me a sure d-flow va porize rs
(nonconce ntra tion ca libra te d va porize rs) include the obsole te
Coppe r Ke ttle a nd Ve rnitrol va porize rs. W ith me a sure d-flow
va porize rs, the flow of oxyge n is se le cte d on a se pa ra te flowme te r
to pa ss into the va porizing cha mbe r, from which the a ne sthe tic
va por e me rge s a t its sa tura te d va por pre ssure . By contra st, in
va ria ble -bypa ss va porize rs, the tota l ga s flow is split be twe e n a
va ria ble bypa ss a nd the va porize r cha mbe r conta ining the
a ne sthe tic a ge nt. The ra tio of the se two flows is ca lle d the splitting
ra tio. The splitting ra tio de pe nds on the a ne sthe tic a ge nt, the
te mpe ra ture , the chose n va por conce ntra tion se t to be de live re d to
the pa tie nt, a nd the sa tura te d va por pre ssure of the a ne sthe tic
(Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
68–71).
24. (C) The contribution of the fre sh ga s flow from the a ne sthe sia
ma chine to the pa tie nt’s VT should be conside re d whe n se tting the
VT of a me cha nica l ve ntila tor. Be ca use the ve ntila tor pre ssure -re lie f
va lve is close d during inspira tion, both the ga s from the ve ntila tor
be llows a nd the fre sh ga s flow will be de live re d to the pa tie nt’s
bre a thing circuit. In this que stion, the fre sh ga s flow is 6 L/min, or
100 mL/se c (6000 mL/60 se c). Ea ch bre a th la sts 6 se conds
(60 se c/10 bre a ths), with inspira tion la sting 2 se conds (I:E
ra tio = 1:2). Unde r the se conditions, the 500 VT de live re d to the
pa tie nt by the me cha nica l ve ntila tor will be a ugme nte d by
a pproxima te ly 200 mL. In some ve ntila tors, such a s the Ohme da
7900, VT is controlle d for the fre sh ga s flow ra te in such a ma nne r
tha t the de live re d VT is a lwa ys the sa me a s the dia l se tting
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 79–
81).
25. (C) The ve ntila tor ra te is de cre a se d from 10 to 6 bre a ths/min.
Thus, e a ch bre a th will la st 10 se conds (60 se c/6 bre a ths), with
inspira tion la sting a pproxima te ly 3.3 se conds (I:E ra tio = 1:2) (i.e .,
3.3 se conds × 100 mL/se c). Unde r the se conditions, the a ctua l VT
de live re d to the pa tie nt by the me cha nica l ve ntila tor will be 830 mL
(500 mL + 330 mL) (Butterworth : Morgan & Mikh ail’s Clinical
26 (B) Endotra che a l tube s fre que ntly be come pa rtia lly or comple te ly
occlude d with se cre tions. Pe riodic suctioning of the e ndotra che a l
tube in the ICU a ssure s pa te ncy of the a rtificia l a irwa y. The re a re
ha za rds, howe ve r, of e ndotra che a l tube suctioning. The y include
mucosa l tra uma , ca rdia c dysrhythmia s, hypoxia , incre a se d
intra cra nia l pre ssure , coloniza tion of the dista l a irwa y, a nd
psychologic tra uma to the pa tie nt.
To re duce the possibility of coloniza tion of the dista l a irwa y it is
prude nt to ke e p the suction ca the te r within the e ndotra che a l
tube during suctioning. Pushing the suctioning ca the te r be yond
the dista l limits of the e ndotra che a l tube a lso ma y produce
suctioning tra uma to the tra che a l tissue (Tobin: Principles and
Practices of Mech anical Ventilation, ed 3, p 1223).
27. (D) CO ca n be ge ne ra te d whe n vola tile a ne sthe tics a re e xpose d
to CO2 a bsorbe rs tha t conta in Na OH or KOH (e .g., soda lime ) a nd
ha ve some time s produce d ca rboxyhe moglobin le ve ls of 35%.
Fa ctors tha t a re involve d in the production of CO a nd forma tion of
ca rboxyhe moglobin include (1) the spe cific vola tile a ne sthe tic use d
(de sflura ne ≥ e nflura ne > isoflura ne ≫ se voflura ne = ha lotha ne ), (2)
high conce ntra tions of vola tile a ne sthe tic (more CO is ge ne ra te d a t
highe r vola tile conce ntra tions), (3) high te mpe ra ture s (more CO is
ge ne ra te d a t highe r te mpe ra ture s), (4) low fre sh ga s flows, a nd
e spe cia lly (5) dry soda lime (dry gra nule s produce more CO tha n do
hydra te d gra nule s). Soda lime conta ins 15% wa te r by we ight, a nd
only whe n it ge ts de hydra te d to be low 1.4% will a ppre cia ble
a mounts of CO be forme d. Ma ny of the re porte d ca se s of pa tie nts
e xpe rie ncing e le va te d ca rboxyhe moglobin le ve ls occurre d on
Monda y mornings, whe n the fre sh ga s flow on the a ne sthe sia
circuit wa s not turne d off a nd high a ne sthe tic fre sh ga s flows
(>5 L/min) for prolonge d pe riods of time (e .g., >48 hours) occurre d.
Be ca use of some re sista nce of the inspira tory va lve , re trogra de
flow through the CO2 a bsorbe r (which ha ste ns the drying of the
soda lime ) will de ve lop, e spe cia lly if the bre a thing ba g is a bse nt,
the Y-pie ce of the circuit is occlude d, a nd the a djusta ble pre ssure -
limiting va lve is ope n. W he ne ve r you a re unce rta in a s to the
dryne ss of the CO2 a bsorbe r, e spe cia lly whe n the fre sh ga s flow
wa s not turne d off the a ne sthe sia ma chine for a n e xte nde d or
inde te rmina te pe riod of time , the CO2 a bsorbe r should be cha nge d.
This CO production occurs with soda lime a nd occurre d more so
with Ba ra lyme (which is no longe r a va ila ble ), but it doe s not occur
with Amsorb Plus or Drä ge rSorb Fre e (which conta ins ca lcium
chloride a nd ca lcium hydroxide a nd no Na OH or KOH) (Barash :
Clinical Anesth esia, ed 7, p 676; Miller: Basics of Anesth esia, ed 6, pp 212–
215; Miller: Miller’s Anesth esia, ed 8, pp 789–792).
28. (A) NIOSH ma nda te s tha t the highe st tra ce conce ntra tion of
vola tile a ne sthe tic conta mina tion of the OR a tmosphe re whe n
a dministe re d in conjunction with N2O is 0.5 ppm (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 81).
29. (B) The O2 a na lyze r is the la st line of de fe nse a ga inst the
ina dve rte nt de live ry of hypoxic ga s mixture s. It should be loca te d in
the inspira tory (not e xpira tory) limb of the pa tie nt’s bre a thing circuit
to provide ma ximum sa fe ty. Be ca use the O2 conce ntra tion in the
fre sh-ga s supply line ma y be diffe re nt from tha t of the pa tie nt’s
bre a thing circuit, the O2 a na lyze r should not be loca te d in the fre sh-
ga s supply line (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 209–210).
30. (A) The ve ntila tor pre ssure -re lie f va lve (a lso ca lle d the spill
va lve ) is pre ssure controlle d via pilot tubing tha t communica te s
with the ve ntila tor be llows cha mbe r. As pre ssure within the
be llows cha mbe r incre a se s during the inspira tory pha se of the
ve ntila tor cycle , the pre ssure is tra nsmitte d via the pilot tubing to
close the pre ssure -re lie f va lve , thus ma king the pa tie nt’s bre a thing
circuit “ga s tight.” This va lve should ope n during the e xpira tory
pha se of the ve ntila tor cycle to a llow the re le a se of e xce ss ga s
from the pa tie nt’s bre a thing circuit into the wa ste -ga s sca ve nging
circuit a fte r the be llows ha s fully e xpa nde d. If the ve ntila tor
pre ssure -re lie f va lve we re to stick in the close d position, the re
would be a ra pid buildup of pre ssure within the circle syste m tha t
would be re a dily tra nsmitte d to the pa tie nt. Ba rotra uma to the
pa tie nt’s lungs would re sult if this situa tion we re to continue
unre cognize d (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology,
ed 5, pp 34, 79–80).
31. (D) Va porize r output ca n be a ffe cte d by the composition of the

ca rrie r ga s use d to va porize the vola tile a ge nt in the va porizing
cha mbe r, e spe cia lly whe n N2O is e ithe r initia te d or discontinue d.
This obse rva tion ca n be e xpla ine d by the solubility of N2O in the
vola tile a ge nt. W he n N2O a nd oxyge n e nte r the va porizing cha mbe r,
a portion of the N2O dissolve s in the liquid a ge nt. Thus, the
va porize r output tra nsie ntly de cre a se s. Conve rse ly, whe n N2O is
withdra wn a s pa rt of the ca rrie r ga s, the N2O dissolve d in the
vola tile a ge nt come s out of solution, the re by tra nsie ntly incre a sing
the va porize r output (Miller: Miller’s Anesth esia, ed 8, pp 769–771).
32. (D) The ca pnogra m ca n provide a va rie ty of informa tion, such a s
ve rifica tion of e xha le d CO2 a fte r tra che a l intuba tion, e stima tion of
the diffe re nce s in Pa CO2 a nd P ETCO2, a bnorma litie s of ve ntila tion,
a nd hype rca pnia or hypoca pnia . The four pha se s of the ca pnogra m
a re inspira tory ba se line , e xpira tory upstroke , e xpira tory pla te a u,
a nd inspira tory downstroke . The sha pe of the ca pnogra m ca n be
use d to re cognize a nd dia gnose a va rie ty of pote ntia lly a dve rse
circumsta nce s. Unde r norma l conditions, the inspira tory ba se line
should be 0, indica ting tha t the re is no re bre a thing of CO2 with a
norma l functioning circle bre a thing syste m. If the inspira tory
ba se line is e le va te d a bove 0, the re is re bre a thing of CO2.
If this occurs, the diffe re ntia l dia gnosis should include a n
incompe te nt e xpira tory va lve , e xha uste d CO2 a bsorbe nt, or ga s
cha nne ling through the CO2 a bsorbe nt. Howe ve r, the inspira tory
ba se line ma y be e le va te d whe n the inspira tory va lve is
incompe te nt (e .g., the re ma y be a sla nte d inspira tory
downstroke ). The e xpira tory upstroke occurs whe n the fre sh ga s
from the a na tomic de a d spa ce is quickly re pla ce d by CO2-rich
a lve ola r ga s. Unde r norma l conditions, the upstroke should be
ste e p; howe ve r, it ma y be come sla nte d during pa rtia l a irwa y
obstruction, if a side stre a m a na lyze r is sa mpling ga s too slowly,
or if the re sponse time of the ca pnogra ph is too slow for the
pa tie nt’s re spira tory ra te . Pa rtia l obstruction ma y be the re sult of
a n obstruction in the bre a thing syste m (e .g., by a kinke d
e ndotra che a l tube ) or in the pa tie nt’s a irwa y (e .g., chronic
obstructive pulmona ry dise a se or a cute bronchospa sm). The
e xpira tory pla te a u is norma lly cha ra cte rize d by a slow but
sha llow progre ssive incre a se in CO2 conce ntra tion. This occurs
be ca use of impe rfe ct ma tching of ve ntila tion a nd pe rfusion in a ll
lung units. Pa rtia l obstruction of ga s flow e ithe r in the bre a thing
syste m or in the pa tie nt’s a irwa ys ma y ca use a prolonge d
incre a se in the slope of the e xpira tory pla te a u, which ma y
continue rising until the ne xt inspira tory downstroke be gins. The
inspira tory downstroke is ca use d by the ra pid influx of fre sh ga s,
which wa she s the CO2 a wa y from the CO2 se nsing or sa mpling
site . Unde r norma l conditions, the inspira tory downstroke is ve ry
ste e p. The ca use s of a sla nte d or blunte d inspira tory downstroke
include a n incompe te nt inspira tory va lve , slow me cha nica l
inspira tion, slow ga s sa mpling, a nd pa rtia l CO2 re bre a thing
(Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2,
p 248).
33. (B) The complica tions of tra che a l intuba tion ca n be divide d into
those a ssocia te d with dire ct la ryngoscopy a nd intuba tion of the
tra che a , tra che a l tube pla ce me nt, a nd e xtuba tion of the tra che a .
The most fre que nt complica tion a ssocia te d with dire ct
la ryngoscopy a nd tra che a l intuba tion is de nta l tra uma . If a tooth is
dislodge d a nd not found, ra diogra phs of the che st a nd a bdome n
should be ta ke n to de te rmine whe the r the tooth ha s pa sse d
through the glottic ope ning into the lungs. Should de nta l tra uma
occur, imme dia te consulta tion with a de ntist is indica te d. Othe r
complica tions of dire ct la ryngoscopy a nd tra che a l intuba tion
include hype rte nsion, ta chyca rdia , ca rdia c dysrhythmia s, a nd
a spira tion of ga stric conte nts. The most common complica tion tha t
occurs while the e ndotra che a l tube is in pla ce is ina dve rte nt
e ndobronchia l intuba tion. Fle xion, not e xte nsion, of the ne ck or a
cha nge from the supine position to the he a d-down position ca n
shift the ca rina upwa rd, which ma y conve rt a midtra che a l tube
pla ce me nt into a bronchia l intuba tion. Exte nsion of the ne ck ca n
ca use ce pha la d displa ce me nt of the tube into the pha rynx. La te ra l
rota tion of the he a d ca n displa ce the dista l e nd of the e ndotra che a l
tube a pproxima te ly 0.7 cm a wa y from the ca rina . The
complica tions a ssocia te d with e xtuba tion of the tra che a ca n be
imme dia te or de la ye d; of the imme dia te complica tions a ssocia te d
with e xtuba tion of the tra che a , the two most se rious a re
la ryngospa sm a nd a spira tion of ga stric conte nts. La ryngospa sm is
most like ly to occur in pa tie nts who a re lightly a ne sthe tize d a t the
time of e xtuba tion. If la ryngospa sm occurs, positive -pre ssure ba g
a nd ma sk ve ntila tion with 100% O2 a nd forwa rd displa ce me nt of
the ma ndible ma y be sufficie nt tre a tme nt. Howe ve r, if
la ryngospa sm pe rsists, succinylcholine should be a dministe re d
intra ve nously or intra muscula rly. Pha ryngitis is a nothe r fre que nt
complica tion a fte r e xtuba tion of the tra che a . It occurs most
commonly in fe ma le individua ls, pre suma bly be ca use of the
thinne r mucosa l cove ring ove r the poste rior voca l cords in
compa rision with ma le individua ls. This complica tion usua lly doe s
not re quire tre a tme nt a nd sponta ne ously re solve s in 48 to 72 hours.
De la ye d complica tions a ssocia te d with e xtuba tion of the tra che a
include la rynge a l ulce ra tions, tra che itis, tra che a l ste nosis, voca l
cord pa ra lysis, a nd a ryte noid ca rtila ge disloca tion (Miller: Miller’s
Anesth esia, ed 8, p 1655).
34. (B) Ga s le a ving a compre sse d-ga s cylinde r is dire cte d through a
pre ssure -re ducing va lve , which lowe rs the pre ssure within the
me ta l tubing of the a ne sthe sia ma chine to 45 to 55 psi (Eh renwerth :
35. (C) CO2 la se rs ca n ca use se rious corne a l injury, whe re a s a rgon,
Nd:YAG, ruby, or pota ssium tita nyl phospha te la se rs ca n burn the
re tina . Use of the incorre ct filte r provide s no prote ction! Cle a r gla ss
or pla stic le nse s a re opa que for CO2 la se r light a nd a re a de qua te
prote ction for this be a m (conta ct le nse s a re not a de qua te
prote ction). For a rgon or krypton la se r light, a mbe r-ora nge filte rs
a re use d. For Nd:YAG la se r light, spe cia l gre e n-tinte d filte rs a re
use d. For pota ssium tita nyl phospha te :Nd:YAG la se r light, re d
filte rs a re use d (Miller: Miller’s Anesth esia, ed 8, pp 2328–2331).
36. (B) The dia me te r inde x sa fe ty syste m pre ve nts incorre ct
conne ctions of me dica l ga s line s. This syste m consists of two
conce ntric a nd spe cific bore s in the body of one conne ction, which
corre spond to two conce ntric a nd spe cific shoulde rs on the nipple
of the othe r conne ction (Eh renwerth : Anesth esia Eq uipm ent: Principles
and Applications, ed 2, pp 20, 27–28).
37. (C) The modifie d Be rnoulli e qua tion de fine s the pre ssure drop
(or gra die nt) a cross a n obstruction, na rrowing, or ste nosis a s
follows:
W he re ΔP is the pre ssure gra die nt; V is the me a sure d ve locity

a cross the ste nosis using Dopple r e choca rdiogra phy.
In this e xa mple , ΔP = 4 × 42 = 64.
The pe a k pre ssure in the le ft ve ntricle is 130 + 64 = 194 mm Hg
(Kaplan: Kaplan’s Card iac Anesth esia: Th e Ech o Era, ed 6, pp 315–382).
38. (A) The output of the va porize r will be lowe r a t flow ra te s le ss
tha n 250 mL/min be ca use the re is insufficie nt pre ssure to a dva nce
the mole cule s of the vola tile a ge nt upwa rd. At e xtre me ly high
ca rrie r ga s flow ra te s (>15 L/min), the re is insufficie nt mixing in the
va porizing cha mbe r (Miller: Miller’s Anesth esia, ed 8, pp 777–778).
39. (C) Pulse oxime te rs e stima te a rte ria l he moglobin sa tura tion
(Sa O2) by me a suring the a mount of light tra nsmitte d through a
pulsa tile va scula r tissue be d. Pulse oxime te rs me a sure the
a lte rna ting curre nt compone nt of light a bsorba nce a t e a ch of two
wa ve le ngths (660 a nd 940 nm) a nd the n divide this me a sure me nt by
the corre sponding dire ct curre nt compone nt. The n the ra tio (R) of
the two a bsorba nce me a sure me nts is de te rmine d by the following
e qua tion:
Using a n e mpiric ca libra tion curve tha t re la te s a rte ria l

he moglobin sa tura tion to R, the a ctua l a rte ria l he moglobin
sa tura tion is ca lcula te d. Ba se d on the physica l principle s outline d
a bove , the source s of e rror in SpO2 re a dings ca n be e a sily
pre dicte d. Pulse oxime te rs ca n function a ccura te ly whe n only
two he moglobin spe cie s, oxyhe moglobin a nd re duce d
he moglobin, a re pre se nt. If a ny light-a bsorbing spe cie s othe r tha n
oxyhe moglobin a nd re duce d he moglobin a re pre se nt, the pulse
oxime te r me a sure me nts will be ina ccura te . Fe ta l he moglobin
ha s a minima l e ffe ct on the a ccura cy of pulse oxime try be ca use
the e xtinction coe fficie nts for fe ta l he moglobin a t the two
wa ve le ngths use d by pulse oxime try a re ve ry simila r to the
corre sponding va lue s for a dult he moglobin. In a ddition to
a bnorma l he moglobins, a ny substa nce pre se nt in the blood tha t
a bsorbs light a t e ithe r 660 or 940 nm, such a s intra ve nous dye s
use d for dia gnostic purpose s, will a ffe ct the va lue of R, ma king
a ccura te me a sure me nts of the pulse oxime te r impossible . The se
dye s include me thyle ne blue a nd indigo ca rmine . Me thyle ne blue
ha s the gre a te st e ffe ct on Sa O2 me a sure me nts be ca use the
e xtinction coe fficie nt is so simila r to tha t of oxyhe moglobin
pp 261–262).
40. (D) Rota me te rs consist of a ve rtica lly positione d ta pe re d tube
tha t is sma lle st in dia me te r a t the bottom (Thorpe tube ). Ga s e nte rs
a t the bottom of the Thorpe tube a nd e le va te s a bobbin or floa t,
which come s to re st whe n gra vity on the floa t is ba la nce d by the
fa ll in pre ssure a cross the floa t. The ra te of ga s flow through the
tube de pe nds on the pre ssure drop a long the le ngth of the tube , the
re sista nce to ga s flow through the tube , a nd the physica l prope rtie s
(de nsity a nd viscosity) of the ga s. Be ca use fe w ga se s ha ve the sa me
de nsity a nd viscosity, rota me te rs ca nnot be use d inte rcha nge a bly
(Barash : Clinical Anesth esia, ed 7, pp 655–657; Eh renwerth : Anesth esia
41. (B) Sa tura te d va por pre ssure s de pe nd on the physica l prope rtie s
of the liquid a nd the te mpe ra ture . Va por pre ssure s a re
inde pe nde nt of ba rome tric pre ssure . At 20° C the va por pre ssure s
of ha lotha ne (243 mm Hg) a nd isoflura ne (240 mm Hg) a re simila r,
a nd a t 1 a tmosphe re the conce ntra tion in the va porize r for the se
drugs is 240/760, or a bout 32%. Simila rly, the va por pre ssure for
se voflura ne (160 mm Hg) a nd e nflura ne (172 mm Hg) a re simila r,
a nd a t 1 a tmosphe re the conce ntra tion in the va porize r for the se
drugs is 160/760, or a bout 21%. If de sflura ne (va por pre ssure of
669 mm Hg) is pla ce d in a 1-a tmosphe re pre ssure va porize r, the
conce ntra tion would be 669/760 = 88%. Be ca use the bypa ss flow is
a djuste d for e a ch va porize r, putting a vola tile a ne sthe tic with a
highe r sa tura te d va por pre ssure would le a d to a highe r-tha n-
e xpe cte d conce ntra tion of a ne sthe tic de live re d from the va porize r,
whe re a s putting a drug with a lowe r sa tura te d va por pre ssure
would le a d to a lowe r-tha n-e xpe cte d conce ntra tion of drug
de live re d from the va porize r (Barash : Clinical Anesth esia, ed 7, pp 661–
672).
VAPOR PRESSURE AND MINIMUM ALVEOLAR CONCENTRATION
MAC, minimum alveolar concentration.
42. (D) Ga s de nsity de cre a se s with incre a sing a ltitude (i.e ., the
de nsity of a ga s is dire ctly proportiona l to a tmosphe ric pre ssure ).
Atmosphe ric pre ssure will influe nce the function of rota me te rs
be ca use the a ccura te function of rota me te rs is influe nce d by the
physica l prope rtie s of the ga s, such a s de nsity a nd viscosity. The
ma gnitude of this influe nce , howe ve r, de pe nds on the ra te of ga s
flow. At low ga s flows, the pa tte rn of ga s flow is la mina r.
Atmosphe ric pre ssure will ha ve little e ffe ct on the a ccura te function
of rota me te rs a t low ga s flows be ca use la mina r ga s flow is
influe nce d by ga s viscosity (which is minima lly a ffe cte d by
a tmosphe ric pre ssure ), not by ga s de nsity. Howe ve r, a t high ga s
flows, the ga s flow pa tte rn is turbule nt a nd is influe nce d by ga s
de nsity. At high a ltitude s (i.e ., low a tmosphe ric pre ssure ), the ga s
flow through the rota me te r will be gre a te r tha n e xpe cte d a t high
flows but a ccura te a t low flows (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 43–45, 230–231).
43. (B) Pa ce ma ke rs ha ve a thre e - to five -le tte r code tha t de scribe s
the pa ce ma ke r type a nd function. Give n tha t the purpose of the
pa ce ma ke r is to se nd e le ctric curre nt to the he a rt, the first le tte r
ide ntifie s the cha mbe r(s) pa ce d: A for a tria l, V for ve ntricle , a nd D
for dua l cha mbe r (A + V). The se cond le tte r ide ntifie s the cha mbe r
whe re e ndoge nous curre nt is se nse d: A,V, D, a nd O for none
se nse d. The third le tte r de scribe s the re sponse to se nsing: O for
none , I for inhibite d, T for trigge re d, a nd D for dua l (I + T). The
fourth le tte r de scribe s progra mma bility or ra te modula tion: O for
none a nd R for ra te modula tion (i.e ., fa ste r he a rt ra te with
e xe rcise ). The fifth le tte r de scribe s multisite pa cing (more
importa nt in dila te d he a rt cha mbe rs): A, V or D (A + V), or O. A
VDD pa ce ma ke r is use d for pa tie nts with AV node dysfunction but
inta ct sinus node a ctivity (Miller: Miller’s Anesth esia, ed 8, pp 1467–
1468).
44. (A) Although controve rsia l, it is thought tha t chronic e xposure to
low conce ntra tions of vola tile a ne sthe tics ma y constitute a he a lth
ha za rd to OR pe rsonne l. The re fore , re mova l of tra ce
conce ntra tions of vola tile a ne sthe tic ga se s from the OR a tmosphe re
with a sca ve nging syste m a nd ste ps to re duce a nd control ga s
le a ka ge into the e nvironme nt a re re quire d. High-pre ssure syste m
le a ka ge of vola tile a ne sthe tic ga se s into the OR a tmosphe re occurs
whe n ga s e sca pe s from compre sse d-ga s cylinde rs a tta che d to the
a ne sthe tic ma chine (e .g., fa ulty yoke s) or from tubing de live ring
the se ga se s to the a ne sthe sia ma chine from a ce ntra l supply
source . The most common ca use of low-pre ssure le a ka ge of
a ne sthe tic ga se s into the OR a tmosphe re is the e sca pe of ga se s
from site s loca te d be twe e n the flowme te rs of the a ne sthe sia
ma chine a nd the pa tie nt, such a s a poor ma sk se a l. The use of
high ga s flows in a circle syste m will not re duce tra ce ga s
conta mina tion of the OR a tmosphe re . In fa ct, this could contribute
to the conta mina tion if the re is a le a k in the circle syste m (Miller:
45. (A) Although the re is insufficie nt e vide nce tha t chronic e xposure
to low conce ntra tions of inha le d a ne sthe tics ma y pose a he a lth
ha za rd to those in the OR, pre ca utions a re ma de to de cre a se the
pollution of inha la tion a ne sthe tics the re . This include s ve ntila ting
the room a de qua te ly (a ir in the OR should be e xcha nge d a t le a st 15
time s a n hour), ma inte na nce of a ne sthe tic syste m sca ve nging
syste ms to re move a ne sthe tic va pors, a nd a tight a ne sthe tic se a l
with no le a ka ge of ga s into the OR a tmosphe re . Although pe riodic
e quipme nt ma inte na nce should be pe rforme d to ma ke sure the
a ne sthe tic e quipme nt is ope ra ting prope rly, le a ka ge a round a n
imprope rly se a le d fa ce ma sk a s we ll a s the fa ce ma sk not a pplie d
to the fa ce during a irwa y ma nipula tions (pla ce me nt of a n a irwa y)
pose s the gre a te st risk of OR conta mina tion from inha le d
a ne sthe tics (Barash : Clinical Anesth esia, ed 7, pp 62–64; Miller: Basics of
Anesth esia, ed 6, pp 211–212; Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 130–145; Miller: Miller’s Anesth esia,
ed 8, pp 3232–3234).
46. (C) The a mount of vola tile a ne sthe tic ta ke n up by the pa tie nt in
the first minute is e qua l to the a mount ta ke n up be twe e n the
squa re s of a ny two conse cutive minute s (squa re root of time
e qua tion). Thus, if 50 mL is ta ke n up in the first minute , 50 mL will
be ta ke n up be twe e n the first (1 squa re d) a nd fourth (2 squa re d)
minute s. Simila rly, be twe e n the fourth a nd ninth minute s (2 squa re d
a nd 3 squa re d), a nothe r 50 mL will be a bsorbe d. In this e xa mple ,
we a re looking for the upta ke be twe e n the 16th (4 squa re d) a nd
36th (6 squa re d) minute s, which would be 2 conse cutive minute s
squa re d, or 2 × 50 mL = 100 mL (Miller: Miller’s Anesth esia, ed 8, pp
650–651).
47. (D) In e va lua ting SSEPs, one looks a t both the a mplitude or
volta ge of the re corde d re sponse wa ve a nd the la te ncy (time
me a sure d from the stimulus to the onse t or pe a k of the re sponse
wa ve ). A de cre a se in a mplitude (>50%) a nd/or a n incre a se in
la te ncy (>10%) is usua lly clinica lly significa nt. The se cha nge s ma y
re fle ct hypope rfusion, ne ura l ische mia , te mpe ra ture cha nge s, or
drug e ffe cts. All of the vola tile a ne sthe tics a nd the ba rbitura te s
ca use a de cre a se in a mplitude a s we ll a s a n incre a se in latency .
Propofol a ffe cts both la te ncy a nd a mplitude a nd, like othe r
intra ve nous a ge nts, ha s a significa ntly le ss e ffe ct tha n “e quipote nt”
dose s of vola tile a ne sthe tics. Etomida te ca use s a n incre a se in
la te ncy a nd a n incre a se in a mplitude . Mida zola m de cre a se s the
a mplitude but ha s little e ffe ct on la te ncy. Opioids ca use sma ll a nd
not clinica lly significa nt incre a se s in la te ncy a nd a de cre a se in
a mplitude of the SSEPs. Muscle re la xa nts ha ve no e ffe ct on SSEPs
(Miller: Miller’s Anesth esia, ed 8, pp 1514–1517; Miller: Basics of
Anesth esia, ed 6, pp 505–506).
48. (A) The a ne sthe sia ma chine , now more prope rly ca lle d the
a ne sthe sia worksta tion, ha s two ma in pre ssure circuits. The
highe r-pre ssure circuits consist of the ga s supply from the pipe line s
a nd ta nks, a ll piping, pre ssure ga uge s, pre ssure re duction
re gula tors, che ck va lve s (which pre ve nt ba ckwa rd ga s flow), the
oxyge n pre ssure -se nsor shutoff va lve (a lso ca lle d the oxyge n fa ilure
cutoff or fa il-sa fe va lve ), the oxyge n supply fa ilure a la rm, a nd the
oxyge n flush va lve —or, simplistica lly, e ve rything up to the ga s flow
control va lve s a nd the ma chine common ga s outle t. The low-
pre ssure circuit sta rts with a nd include s the ga s flow control
va lve s, flowme te rs, va porize rs, a nd va porize r che ck va lve a nd goe s
to the ma chine common ga s outle t. Se e a lso figure for e xpla na tion
to Que stion 12 (Barash : Clinical Anesth esia, ed 7, pp 641–650; Miller:
Basics of Anesth esia, ed 6, pp 198–204).
49. (D) Va poriza tion of a liquid re quire s the tra nsfe r of he a t from the
obje cts in conta ct with the liquid (e .g., the me ta l cylinde r a nd
surrounding a tmosphe re ). For this re a son, a t high ga s flows,
a tmosphe ric wa te r will conde nse a s frost on the outside of
compre sse d-ga s cylinde rs (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 12–13; Miller: Basics of Anesth esia, ed 6, p 201).
50. (B) Te mpe ra ture me a sure me nts of the pulmona ry a rte ry,
e sopha gus, a xilla , na sopha rynx, a nd tympa nic me mbra ne corre la te
with ce ntra l te mpe ra ture in pa tie nts unde rgoing nonca rdia c surge ry.
Skin te mpe ra ture doe s not re fle ct ce ntra l te mpe ra ture a nd doe s not
wa rn a de qua te ly of ma ligna nt hype rthe rmia or e xce ssive
hypothe rmia (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology,
ed 5, p 137; Miller: Miller’s Anesth esia, ed 8, pp 1643–1644).
51. (C) La se r re fe rs to Light Amplifica tion by the Stimula te d
Emission of Ra dia tion. La se r light diffe rs from ordina ry light in
thre e ma in wa ys. First, la se r light is monochromic (posse sse s one
wa ve le ngth or color). Se cond, la se r light is cohe re nt (the photons
oscilla te in the sa me pha se ). Third, la se r light is collima te d (e xists
in a na rrow pa ra lle l be a m). Visible light ha s a wide spe ctrum of
wa ve le ngths in the 385- to 760-nm ra nge . Argon la se r light, which
ca n pe ne tra te tissue s to a de pth of 0.05 to 2.0 mm, is e ithe r blue
(wa ve le ngth 488 nm) or gre e n (wa ve le ngth 514 nm) a nd is ofte n
use d for va scula r pigme nte d le sions be ca use it is inte nsive ly
a bsorbe d by he moglobin. He lium–ne on la se r light is re d, ha s a
fre que ncy of 632 nm, a nd is ofte n use d a s a n a iming be a m be ca use
it ha s ve ry low powe r a nd pre se nts no significa nt da nge r to OR
pe rsonne l. Nd:YAG la se r light is the most powe rful me dica l la se r
a nd ca n pe ne tra te tissue s from 2 to 6 mm. Nd:YAG la se r light is in
the ne a r infra re d ra nge , with a wa ve le ngth of 1064 nm, ha s ge ne ra l
use s (e .g., prosta te surge ry, la rynge a l pa pilloma tosis, coa gula tion),
a nd ca n be use d with fibe roptics. CO2 la se r light is in the fa r
infra re d ra nge , with a long wa ve le ngth of 10,600 nm. Be ca use CO2
la se r light pe ne tra te s tissue s poorly, it ca n va porize supe rficia l
tissue s with little da ma ge to unde rlying ce lls (Barash : Clinical
Anesth esiology, ed 5, pp 776–777; Miller: Miller’s Anesth esia, ed 8, pp
2598–2601).
52. (A) Norma l ga s flow is la mina r within the tra che a , but with
tra che a l ste nosis, a irflow is more turbule nt. Re sista nce during
turbule nt flow de pe nds on ga s de nsity, a nd he lium ha s a lowe r ga s
de nsity tha n nitroge n. Thus, the re is le ss work of bre a thing whe n
he lium is substitute d for nitroge n. Re me mbe r, though: the highe r
the conce ntra tion of he lium, the lowe r the conce ntra tion of oxyge n
(Miller: Miller’s Anesth esia, ed 8, p 2545).
53. (D) The F I o 2 de live re d to pa tie nts from low-flow syste ms (e .g.,
na sa l prongs) is de te rmine d by the size of the O2 re se rvoir, the O2
flow, a nd the pa tie nt’s bre a thing pa tte rn. As a rule of thumb,
a ssuming a norma l bre a thing pa tte rn, the F I o 2 de live re d by na sa l
prongs incre a se s by a pproxima te ly 0.04 for e a ch L/min incre a se in
O2 flow up to a ma xima l F I o 2 of a pproxima te ly 0.45 (a t a n O2 flow of
6 L/min). In ge ne ra l, the la rge r the pa tie nt’s VT or the fa ste r the
re spira tory ra te , the lowe r the F I o 2 for a give n O2 flow (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 1282–1283).
54. (A)
In a close d sca ve nging syste m inte rfa ce , the re se rvoir ba g should
e xpa nd during e xpira tion a nd contra ct during inspira tion. During
the inspira tory pha se of me cha nica l ve ntila tion, the ve ntila tor
pre ssure -re lie f va lve close s, the re by dire cting the ga s inside the
ve ntila tor be llows into the pa tie nt’s bre a thing circuit. If the
ve ntila tor pre ssure -re lie f va lve is incompe te nt, the re will be a
dire ct communica tion be twe e n the pa tie nt’s bre a thing circuit a nd
the sca ve nging circuit. This will re sult in de live ry of pa rt of the
me cha nica l ve ntila tor VT dire ctly to the sca ve nging circuit,
ca using the re se rvoir ba g to infla te during the inspira tory pha se
of the ve ntila tor cycle (Eh renwerth : Anesth esia Eq uipm ent: Principles
and Applications, ed 2, pp 130–132).
55. (C) The a ccura te function of dua l-wa ve le ngth pulse oxime te rs is
a lte re d by na il polish. Be ca use blue na il polish ha s a pe a k
a bsorba nce simila r to tha t of a dult de oxyge na te d he moglobin (ne a r
660 nm), it ha s the gre a te st e ffe ct on the SpO2 re a ding. Na il polish
ca use s a n a rtifa ctua l a nd fixe d de cre a se in the SpO2 re a ding a s
shown by the se de vice s. Turning the finge r probe 90 de gre e s a nd
ha ving the light shining side wise through the finge r is use ful whe n
the re is na il polish on the pa tie nt’s finge rna ils (Miller: Miller’s
Anesth esia ed 8, p 1547).
56. (C) Le a ka ge e le ctric curre nts le ss tha n 1 mA a re impe rce ptible
to touch. The minima l ve ntricula r fibrilla tion thre shold of curre nt
a pplie d to the skin is a bout 100 mA. If the curre nt bypa sse s the high
re sista nce of the skin a nd is a pplie d dire ctly to the he a rt via
pa ce ma ke r, ce ntra l line , e tc. (microshock), curre nts a s low a s
100 µA (0.1 mA) ma y be fa ta l. Be ca use of this, the Ame rica n
Na tiona l Sta nda rds Institute ha s se t the ma ximum le a ka ge of
e le ctric curre nt a llowe d through e le ctrode s or ca the te rs in conta ct
with the he a rt a t 10 µA (Barash : Clinical Anesth esia, ed 7, p 192;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 17;
Miller: Miller’s Anesth esia, ed 8, p 3226).
57. (D) The line isola tion monitor give s a n a la rm whe n grounding
occurs in the OR or whe n the ma ximum curre nt tha t a short circuit
could ca use e xce e ds 2 to 5 mA. The line isola tion monitor is pure ly
a monitor a nd doe s not inte rrupt e le ctric curre nt. The re fore , the
line isola tion monitor will not pre ve nt microshock or ma croshock
(Brunner: Electricity, Safety, and th e Patient, ed 1, p 304; Miller: Miller’s
58. (A)
A sca ve nging syste m with a close d inte rfa ce is one in which
the re is communica tion with the a tmosphe re through positive -
pre ssure a nd ne ga tive -pre ssure re lie f va lve s. The positive -
pre ssure re lie f va lve will pre ve nt tra nsmission of e xce ssive
pre ssure buildup to the pa tie nt’s bre a thing circuit, e ve n if the re is
a n obstruction dista l to the inte rfa ce or if the syste m is not
conne cte d to wa ll suction. Howe ve r, obstruction of the tra nsfe r
tubing from the pa tie nt’s bre a thing circuit to the sca ve nging circuit
is proxima l to the inte rfa ce . This will isola te the pa tie nt’s
bre a thing circuit from the positive -pre ssure re lie f va lve of the
sca ve nging syste m inte rfa ce . Should this occur, ba rotra uma to the
pa tie nt’s lungs ca n re sult (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 130–137).
59. (C) Ele ctroca ute ry units, or e le ctrosurgica l units (ESUs), we re
inve nte d by Profe ssor W. T. Bovie a nd we re first use d in 1926. The y
ope ra te by ge ne ra ting ultra -high fre que ncy (0.1-3 MHz) a lte rna ting
e le ctric curre nts a nd a re commonly use d toda y for cutting a nd
coa gula ting tissue . W he ne ve r a curre nt pa sse s through a re sista nce
such a s tissue , he a t is ge ne ra te d a nd is inve rse ly proportiona l to
the surfa ce a re a through which the curre nt pa sse s. At the point of
e ntry to the body from the sma ll a ctive e le ctrode or ca ute ry tip, a
fa ir a mount of he a t is ge ne ra te d. For the curre nt to comple te its
circuit, the re turn e le ctrode pla te or dispe rsive pa d (incorre ctly but
commonly ca lle d the ground pa d) ha s a la rge surfa ce a re a , whe re
ve ry little he a t de ve lops. The dispe rsive pa d should be a s close a s
is re a sona ble to the site of surge ry. If the curre nt from the ESU
pa sse s through a n a rtificia l ca rdia c pa ce ma ke r, the pa ce ma ke r
ma y misinte rpre t the curre nt a s ca rdia c a ctivity a nd ma y not pa ce ,
which is why a ma gne t pla ce d ove r the pa ce ma ke r will turn off the
pa ce ma ke r se nsor, putting the pa ce ma ke r in the a synchronous
mode , a nd should be a va ila ble (if the pa ce ma ke r ’s se nsory mode
is not turne d off pre ope ra tive ly). In a ddition, a utoma tic impla nta ble
ca rdiove rte r-de fibrilla tors (AICDs) ma y misinte rpre t the e le ctric
a ctivity a s ve ntricula r fibrilla tion a nd de fibrilla te the pa tie nt. AICDs
should be turne d off be fore use of a n ESU (Barash : Clinical
Anesth esia ed 7, pp 204–206; Butterworth : Morgan & Mikh ail’s Clinical
60. (A) Automa te d noninva sive BP (ANIBP) de vice s provide
consiste nt a nd re lia ble a rte ria l BP me a sure me nts. Va ria tions in the
cuff pre ssure re sulting from a rte ria l pulsa tions during cuff de fla tion
a re se nse d by the de vice a nd a re use d to ca lcula te me a n a rte ria l
pre ssure . The n, va lue s for systolic a nd dia stolic pre ssure s a re
de rive d from formula s tha t use the ra te of cha nge of the a rte ria l
pre ssure pulsa tions a nd the me a n a rte ria l pre ssure (oscillome tric
principle ). This me thod provide s a ccura te me a sure me nts of a rte ria l
BP in ne ona te s, infa nts, childre n, a nd a dults. The ma in a dva nta ge
of ANIBP de vice s is tha t the y fre e the a ne sthe sia provide r to
pe rform othe r dutie s re quire d for optima l a ne sthe sia ca re .
Additiona lly, the se de vice s provide a la rm syste ms to dra w a tte ntion
to e xtre me BP va lue s, a nd the y ha ve the ca pa city to tra nsfe r da ta to
a utoma te d tre nding de vice s or re corde rs. Imprope r use of the se
de vice s ca n le a d to e rrone ous me a sure me nts a nd complica tions.
The width of the BP cuff should be a pproxima te ly 40% of the
circumfe re nce of the pa tie nt’s a rm. If the BP cuff is too na rrow or if
the BP cuff is wra ppe d too loose ly a round the a rm, the BP
me a sure me nt by the de vice will be fa lse ly e le va te d. Fre que nt BP
me a sure me nts ca n re sult in e de ma of the e xtre mity dista l to the
cuff. For this re a son, cycling of the se de vice s should not be more
fre que nt tha n e ve ry 1 to 3 minute s. Othe r complica tions a ssocia te d
with imprope r use of ANIBP de vice s include ulna r ne rve
pa re sthe sia , supe rficia l thrombophle bitis, a nd compa rtme nt
syndrome . Fortuna te ly, the se complica tions a re ra re (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 88–91; Miller: Basics
of Anesth esia, ed 6, pp 321–322; Miller: Miller’s Anesth esia, ed 8, pp 1347–
1348).
61. (B) EKG monitoring is ofte n not use d during MRI sca ns be ca use
a rtifa cts a re ve ry common (a bnorma litie s in T wa ve s a nd ST
wa ve s), a nd he a ting of the wire s during the sca n would pote ntia lly
burn the pa tie nt. Howe ve r, EKG ca n be use d if the e le ctrode s a re
pla ce d close toge the r a nd towa rd the ce nte r of the ma gne tic fie ld
a nd the wire s a re insula te d from the pa tie nt’s skin a nd stra ight. In
a ddition, the wire s should not be wound toge the r in loops (be ca use
this ca n induce he a ting of the wire s), a nd worn or fra ye d wire s
should not be use d (Barash : Clinical Anesth esia, ed 7, p 884; Miller:
Miller’s Anesth esia, ed 8, p 2655).
62. (C) A size “E” compre sse d-ga s cylinde r comple te ly fille d with a ir
conta ins 625 L a nd will show a pre ssure ga uge re a ding of 2000 psi.
The re fore , a cylinde r with a pre ssure ga uge re a ding of 1000 psi is
ha lf-full, conta ining a pproxima te ly 325 L of a ir. A ha lf-full size “E”
compre sse d-ga s cylinde r conta ining a ir ca n be use d for
a pproxima te ly 30 minute s a t a flow ra te of 10 L/min (se e de finition
of Boyle ’s la w, Que stion 9) (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 10–12; Miller: Basics of Anesth esia, ed 6, pp 199–
201).
63. (D) Fa ilure to oxyge na te pa tie nts a de qua te ly is a n importa nt
ca use of a ne sthe sia -re la te d morbidity a nd morta lity. All of the
choice s liste d in this que stion a re pote ntia l ca use s of ina de qua te
de live ry of O2 to the pa tie nt; howe ve r, the most fre que nt ca use is
ina dve rte nt disconne ction of the O2 supply syste m from the pa tie nt
(e .g., disconne ction of the pa tie nt’s bre a thing circuit from the
e ndotra che a l tube ) (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, p 121; Butterworth : Morgan & Mikh ail’s Clinical
64. (A) The e sopha ge a l de te ctor de vice (EDD) is e sse ntia lly a bulb
tha t is first compre sse d a nd the n a tta che d to the e ndotra che a l tube
a fte r the tube is inse rte d into the pa tie nt. The pre ssure ge ne ra te d
is a bout –40 cm of wa te r. If the e ndotra che a l tube is pla ce d in the
e sopha gus, the n the ne ga tive pre ssure will colla pse the e sopha gus,
a nd the bulb will not infla te . If the e ndotra che a l tube is in the
tra che a , the n the a ir from the lung will e na ble the bulb to infla te
(usua lly in a fe w se conds, but some time s more tha n 30 se conds). A
syringe tha t ha s a ne ga tive pre ssure a pplie d to it ha s a lso be e n
use d. Although initia l studie s we re ve ry positive a bout the use of
the EDD, more re ce nt studie s show tha t up to 30% of corre ctly
pla ce d e ndotra che a l tube s in a dults ma y be re move d be ca use the
EDD ha s sugge ste d e sopha ge a l pla ce me nt. Misle a ding re sults ha ve
be e n note d in pa tie nts with morbid obe sity, la te pre gna ncy, sta tus
a sthma ticus, a nd copious e ndotra che a l se cre tion, whe re in the
tra che a te nds to colla pse . Its use in childre n younge r tha n 1 ye a r of
a ge ha s shown poor se nsitivity a nd poor spe cificity. Although a
ca rdia c output is ne e de d to ge t CO2 to the lungs for a CO2 ga s
a na lyze r to function, a ca rdia c output is not ne e de d for a n EDD
65. (D) The ca pnome te r me a sure s the CO2 conce ntra tion of
re spira tory ga se s. Toda y this is most commonly pe rforme d by
infra re d a bsorption using a side stre a m ga s sa mple . The sa mpling
tube should be conne cte d a s close a s possible to the pa tie nt’s
a irwa y. The diffe re nce be twe e n the e nd-tida l CO2 (ETCO2) a nd the
a rte ria l CO2 (Pa CO2) is typica lly 5 to 10 mm Hg a nd is due to
a lve ola r de a d spa ce ve ntila tion. Be ca use nonpe rfuse d a lve oli do
not contribute to ga s e xcha nge , a ny condition tha t incre a se s
a lve ola r de a d spa ce ve ntila tion (i.e ., re duce s pulmona ry blood
flow, a s by pulmona ry e mbolism or ca rdia c a rre st) will incre a se
de a d spa ce ve ntila tion a nd the ETCO2-to-Pa CO2 diffe re nce .
Conditions tha t incre a se pulmona ry shunt re sult in minima l
cha nge s in the Pa CO2–ETCO2 gra die nt. CO2 diffuse s ra pidly a cross
the ca pilla ry-a lve ola r me mbra ne (Barash : Clinical Anesth esia, ed 7, pp
704–706; Miller: Miller’s Anesth esia, ed 8, pp 1551–1553).
66. (D) The la st ga s a dde d to a ga s mixture should a lwa ys be O2.
This a rra nge me nt is the sa fe st be ca use it e nsure s tha t le a ks
proxima l to the O2 inflow ca nnot re sult in the de live ry of a hypoxic
ga s mixture to the pa tie nt. W ith this a rra nge me nt (O2 a dde d la st),
le a ks dista l to the O2 inflow will re sult in a de cre a se d volume of
ga s, but the F I o 2 of a ne sthe sia will not be re duce d (Miller: Basics of
Anesth esia, ed 6, pp 201–202; Eh renwerth : Anesth esia Eq uipm ent:
67. (C) Most mode rn Da te x-Ohme da Te c or North Ame rica n Drä ge r
Va por va porize rs (e xce pt de sflura ne ) a re va ria ble -bypa ss, flow-ove r
va porize rs. This me a ns tha t the ga s tha t flows through the
va porize rs is split into two pa rts, de pe nding on the conce ntra tion
se le cte d. The ga s goe s through e ithe r the bypa ss cha mbe r on the
top of the va porize r or the va porizing cha mbe r on the bottom of the
va porize r. If the va porize r is tippe d, which might ha ppe n whe n a
fille d va porize r is switche d out or move d from one ma chine to
a nothe r ma chine , pa rt of the a ne sthe tic liquid in the va porizing
cha mbe r ma y ge t into the bypa ss cha mbe r. This could re sult in a
much highe r conce ntra tion of ga s tha n tha t dia le d. W ith the Da te x-
Ohme da Te c 4 or the North Ame rica n Drä ge r Va por 19.1 se rie s, it is
re comme nde d to flush the va porize r a t high flows with the
va porize r se t a t a low conce ntra tion until the output shows no
e xce ssive a ge nt (this usua lly ta ke s 20-30 minute s). The Drä ge r
Va por 2000 se rie s ha s a tra nsport (T) dia l se tting. This se tting
isola te s the bypa ss from the va porize r cha mbe r. The Ala din
ca sse tte va porize r doe s not ha ve a bypa ss flow cha mbe r a nd ha s
no tipping ha za rd (Miller: Miller’s Anesth esia, ed 8, p 771).
68. (A) Accura te de live ry of vola tile a ne sthe tic conce ntra tion is
de pe nde nt on filling the a ge nt-spe cific va porize r with the
a ppropria te (vola tile ) a ge nt. Diffe re nce s in a ne sthe tic pote ncie s
furthe r ne ce ssita te this re quire me nt. Ea ch a ge nt-spe cific va porize r
use s a splitting ra tio tha t de te rmine s the portion of the fre sh ga s
tha t is dire cte d through the va porizing cha mbe r ve rsus tha t which
tra ve ls through the bypa ss cha mbe r.
VAPOR PRESSURE, ANESTHETIC VAPOR PRESSURE, AND
SPLITTING RATIO
BP, blood pressure; VP, vapor pressure.
The ta ble shows the ca lcula tion (fra ction) tha t whe n multiplie d
by the qua ntity of fre sh ga s tra ve rsing the va porizing cha mbe r
(a fflue nt fre sh ga s in mL/min) will yie ld the output (mL/min) of
a ne sthe tic va por in the e fflue nt ga s. W he n this fra ction is
multiplie d by 100, it e qua ls the splitting ra tio for 1% for the give n
vola tile a ge nt. For e xa mple , whe n the isoflura ne va porize r is se t
to de live r 1% isoflura ne , one pa rt of fre sh ga s is pa sse d through
the va porizing cha mbe r while 47 pa rts tra ve l through the bypa ss
cha mbe r. One ca n de te rmine on inspe ction tha t whe n a le ss
soluble vola tile a ge nt like se voflura ne (or the obsole te vola tile
a ge nt e nflura ne , for the sa ke of e xa mple ) is pla ce d into a n
isoflura ne (or ha lotha ne ) va porize r, the output in volume pe rce nt
will be le ss tha n e xpe cte d; how much le ss ca n be de te rmine d by
simply compa ring the ir splitting ra tios 27/47 or 0.6. Ha lotha ne a nd
e nflura ne a re no longe r use d in the Unite d Sta te s, but old
ha lotha ne a nd e nflura ne va porize rs ca n be (a nd a re ) use d
e lse whe re in the world to a ccura te ly de live r isoflura ne a nd
se voflura ne , re spe ctive ly (Eh renwerth : Anesth esia Eq uipm ent:
69. (C) Two pe rce nt of 4 L/min will be 80 mL of isoflura ne pe r
minute .
VAPOR PRESSURE PER MILLILITER OF LIQUID
Give n tha t 1 mL of isoflura ne liquid yie lds 195 mL of a ne sthe tic

va por a nd by a pplying the ca lcula tion (195 mL va por/1 mL liquid
isoflura ne ) × (150 mL isoflura ne liquid) = 29,250 mL isoflura ne
va por, it follows tha t (29,250 mL ÷ 80 mL/min = 365 minute s). Thre e
hundre d sixty-five minute s is a round 6 hours (Eh renwerth :
70. (C) The huma n e a r ca n pe rce ive sound in the ra nge of 20 Hz to
20 kHz. Fre que ncie s a bove 20 kHz, ina udible to huma ns, a re
ultra sonic fre que ncie s (ultra = La tin for “be yond” or “on the fa r side
of”). In re giona l a ne sthe sia , ultra sound is use d for ima ging in the
fre que ncy ra nge of 2.5 to 10 MHz. Wa ve le ngth is inve rse ly
proportiona l to fre que ncy (i.e ., λ = C/f [λ = wa ve le ngth, C = ve locity
of sound through tissue or 1540 m/se c, f = fre que ncy]). Wa ve le ngth
in millime te rs ca n be ca lcula te d by dividing 1.54 by the Dopple r
fre que ncy in me ga he rtz. Pe ne tra tion into tissue is 200 to 400 time s
wa ve le ngth, a nd re solution is twice the wa ve le ngth. The re fore , a
fre que ncy of 3 MHz (wa ve le ngth 0.51 mm) would ha ve a re solution
of 1 mm a nd a pe ne tra tion of up to 100 to 200 mm (10-20 cm),
whe re a s 10 MHz (wa ve le ngth 0.15 mm) corre sponds to a re solution
of 0.3 mm but a pe ne tra tion de pth of no more tha n 60 to 120 mm (6-
12 cm) (Miller: Miller’s Anesth esia, ed 8, pp 1398–1405; Butterworth :
71. (A) Microsh ock re fe rs to e le ctric shock loca te d in or ne a r the
he a rt. A curre nt a s low a s 100 µA pa ssing through the he a rt ca n
produce ve ntricula r fibrilla tion. Pa ce ma ke r e le ctrode s, ce ntra l
ve nous ca the te rs, pulmona ry a rte ry ca the te rs, a nd othe r de vice s in
the he a rt a re ne ce ssa ry pre re quisite s for microshock. Be ca use the
line isola tion monitor ha s a thre shold of 2 mA (2000 µA) for
a la rming, it will not prote ct a ga inst microshock (Miller: Miller’s
72. (D) Intra ope ra tive a wa re ne ss or re ca ll during ge ne ra l
a ne sthe sia is ra re (ove ra ll incide nce is 0.2%, for obste trics 0.4%, for
ca rdia c 1%-1.5%) e xce pt for ma jor tra uma , which ha s a re porte d
incide nce a s high a s 43%. W ith the e le ctroe nce pha logra m, tre nds
ca n be ide ntifie d with cha nge s in the de pth of a ne sthe sia ; howe ve r,
the se nsitivity a nd spe cificity of the a va ila ble tre nds a re such tha t
none se rve a s a sole indica tor of a ne sthe sia de pth. Although using
the bispe ctra l inde x monitor ma y re duce the risk of re ca ll, it, like
the othe r liste d signs a s we ll a s pa tie nt move me nt, doe s not tota lly
e limina te re ca ll (Miller: Miller’s Anesth esia, ed 8, pp 1527–1528).
73. (D) The minute ve ntila tion is 5 L (0.5 L pe r bre a th a t
10 bre a ths/min) a nd 2 L/min to drive the ve ntila tor for a tota l O2
consumption of 7 L/min. A full oxyge n “E” cylinde r conta ins 625 L.
Nine ty pe rce nt of the volume of the cylinde r (≈560 L) ca n be
de live re d be fore the ve ntila tor ca n no longe r be drive n. At a ra te of
7 L/min, this supply would la st a bout 80 minute s (Miller: Basics of
Anesth esia, ed 6, pp 201, 209; Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 29–33, 37; Butterworth : Morgan &
74. (C) Afte r e limina ting re ve rsible ca use s of high pe a k a irwa y
pre ssure s (e .g., occlusion of the e ndotra che a l tube , ma inste m
intuba tion, or bronchospa sm), a djusting the ve ntila tor ca n re duce
the pe a k a irwa y pre ssure . Incre a sing the inspira tory flow ra te
would ca use the a irwa y pre ssure s to go up fa ste r a nd would
produce highe r pe a k a irwa y pre ssure s. Re moving PEEP would
lowe r pe a k pre ssure a t the e xpe nse of a lve ola r ve ntila tion.
Cha nging the I:E ra tio from 1:3 to 1:2 will pe rmit 8% (25% inspira tory
time to 33% inspira tory time ) more time for the VT to be
a dministe re d a nd will re sult in lowe r a irwa y pre ssure s.
De cre a sing the VT to 300 a nd incre a sing the ra te to 28 would give
the sa me minute ve ntila tion but not the sa me a lve ola r ve ntila tion.
Re ca ll tha t a lve ola r ve ntila tion e qua ls (fre que ncy) time s (VT minus
de a d spa ce ), a nd be ca use de a d spa ce is the sa me (a bout 2 mL/kg
ide a l we ight), a lve ola r ve ntila tion would be re duce d, in this ca se to
a da nge rously low le ve l. Anothe r option is to cha nge from volume -
cycle d to pre ssure -cycle d ve ntila tion, which produce s a more
consta nt pre ssure ove r time inste a d of the pe a ke d pre ssure s se e n
with fixe d VT ve ntila tion (Barash : Clinical Anesth esia, ed 7, pp 1593–
75. (D) The ce ntra l hospita l oxyge n supply to the ORs is de signe d to
give e nough pre ssure a nd oxyge n flow to run the thre e oxyge n
compone nts of the a ne sthe sia ma chine (pa tie nt fre sh ga s flow,
a ne sthe sia ve ntila tor, a nd oxyge n flush va lve ). The oxyge n
flowme te r on the a ne sthe sia ma chine is de signe d to run a t a n
oxyge n pre ssure of 50 psi, a nd for e me rge ncy purpose s the oxyge n
flush va lve de live rs oxyge n a t 35 to 75 L/min (Miller: Basics of
76. (B) W ithin the re spira tory syste m, both la mina r a nd turbule nt
flows e xist. At low flow ra te s, the re spira tory flow te nds to be
la mina r, like a se rie s of conce ntric tube s tha t slide ove r one
a nothe r with the ce nte r tube s flowing fa ste r tha n the more
pe riphe ra l tube s. La mina r flow is usua lly ina udible a nd is
de pe nde nt on ga s viscosity. Turbule nt flow te nds to be fa ste r, is
a udible , a nd is de pe nde nt on ga s de nsity. Ga s de nsity ca n be
de cre a se d by using a mixture of he lium with oxyge n (Butterworth :
77. (B) Ane sthe sia worksta tions ha ve high-pre ssure , inte rme dia te -
pre ssure , a nd low-pre ssure circuits (se e figure in the e xpla na tion
for Que stion 12). The high-pre ssure circuit is from the oxyge n
cylinde r to the oxyge n pre ssure re gula tor (first-sta ge re gula tor),
which ta ke s the oxyge n pre ssure from a high of 2200 psi to 45 psi.
The inte rme dia te -pre ssure circuit consists of the pipe line pre ssure
of a bout 50 to 55 psi a nd goe s to the se cond-sta ge re gula tor, which
the n lowe rs the pre ssure to 14 to 26 psi (de pe nding on the
ma chine ). The low-pre ssure circuit the n consists of the flow tube s,
va porize r ma nifold, va porize rs, a nd va porize r che ck va lve to the
common ga s outle t. The oxyge n flush va lve is in the inte rme dia te -
pre ssure circuit a nd bypa sse s the low-pre ssure circuit (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 34–36;
Miller: Basics of Anesth esia, ed 6, p 200).
78. (C) Two ma jor proble ms should be note d in this ca se . The first
obvious proble m is the inspire d oxyge n conce ntra tion of 4%, a
conce ntra tion tha t is not possible if the ga se s going to the ma chine
a re a ppropria te unle ss the oxyge n a na lyze r is fa ulty. Give n the dire
conse que nce s of a hypoxic ga s mixture , one must a ssume the
oxyge n a na lyze r is corre ct a nd work on the pre mise tha t the O2
pipe line is supplying a ga s othe r tha n oxyge n. Se cond, the oxyge n
line pre ssure is 65 psi. The pipe line pre ssure s a re norma lly a round
50 to 55 psi, whe re a s the pre ssure from the oxyge n cylinde r, if the
cylinde r is turne d on, is re duce d to 45 psi. For the oxyge n ta nk to
de live r oxyge n to the pa tie nt, the pipe line pre ssure ne e ds to be
le ss tha n 45 psi, which in this ca se will occur only whe n the
pipe line is disconne cte d. Although we ra re ly think of proble ms
with hospita l ga s line s, a surve y of more tha n 200 hospita ls showe d
a bout 33% ha d proble ms with the pipe line s. The most common
pipe line proble ms we re low pre ssure , followe d by high pre ssure
a nd, ve ry ra re ly, crosse d ga s line s (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, p 34; Miller: Miller’s Anesth esia, ed 8, p
756).
79. (D) The re a re ma ny wa ys to monitor the e le ctric a ctivity of the
he a rt. The five -e le ctrode syste m using one le a d for e a ch limb a nd
the fifth le a d for the pre cordium is commonly use d in the OR. The
pre cordia l le a d pla ce d in the V5 position (a nte rior a xilla ry line in
the fifth inte rcosta l spa ce ) give s the V5 tra cing, which, combine d
with the sta nda rd le a d II, a re the most common tra cings use d to
look for myoca rdia l ische mia (Miller: Miller’s Anesth esia, ed 8, pp
1429–1434).
80. (A) Se e a lso Que stion 36. The dia me te r inde x sa fe ty syste m
provide s thre a de d, noninte rcha nge a ble conne ctions for me dica l
ga s pipe line s through the hospita l a s we ll a s to the a ne sthe sia
ma chine . The pin inde x sa fe ty syste m ha s two me ta l pins in
diffe re nt a rra nge me nts a round the yoke on the ba ck of a ne sthe sia
ma chine s, with e a ch a rra nge me nt for a spe cific ga s cylinde r.
Va porize rs ofte n ha ve ke ye d fille rs tha t a tta ch to the bottle of
a ne sthe tic a nd the va porize r. Va porize rs not e quippe d with ke ye d
fille rs occa siona lly ha ve be e n misfille d with the wrong a ne sthe tic
liquid (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
49–50).
81. (C) Ca lcium hydroxide lime doe s not conta in the monova le nt
hydroxide ba se s tha t a re pre se nt in soda lime (na me ly, Na OH a nd
KOH). Se voflura ne in the pre se nce of Na OH or KOH is de gra de d to
tra ce a mounts of compound A, which is ne phrotoxic to ra ts a t high
conce ntra tions. Soda lime norma lly conta ins a bout 13% to 15%
wa te r, but if the soda lime is de sicca te d (wa te r conte nt <5%—which
ha s occurre d if the ma chine is not use d for a while a nd the fre sh
ga s flow is le ft on) a nd is e xpose d to curre nt vola tile a ne sthe tics
(isoflura ne , se voflura ne , a nd e spe cia lly de sflura ne ), CO ca n be
produce d. Ne ithe r compound A nor CO is forme d whe n ca lcium
hydroxide lime is use d. W ith soda lime a nd ca lcium hydroxide
lime , the indica tor dye cha nge s from white to purple a s the
gra nule s be come e xha uste d. The two ma jor disa dva nta ge s of
ca lcium hydroxide lime a re the e xpe nse a nd the fa ct tha t its
a bsorptive ca pa city is a bout ha lf tha t of soda lime (10.2 L of
CO2/100 g of ca lcium hydroxide lime ve rsus 26 L of CO2/100 g of
soda lime ) (Miller: Miller’s Anesth esia, ed 8, pp 787–789; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 36–38; Miller: Basics
of Anesth esia, ed 6, pp 212–214).
82. (B) The a im of dire ct inva sive monitoring is to give continuous
a rte ria l BPs tha t a re simila r to the inte rmitte nt noninva sive a rte ria l
BPs from a cuff, a s we ll a s to give a port for a rte ria l blood sa mple s.
The displa ye d signa l re fle cts the a ctua l pre ssure a nd the
distortions from the me a suring syste m (i.e ., the ca the te r, tubing,
stopcocks, a nd a mplifie r). Although the signa l is usua lly a ccura te ,
a t time s we se e a n unde rda mpe d or a n ove rda mpe d signa l. In a n
unde rda mpe d signa l, a s in this ca se , e xa gge ra te d re a dings a re
note d (wide ne d pulse pre ssure ). In a n ove rda mpe d signa l, re a dings
a re diminishe d (na rrowe d pulse pre ssure ). Howe ve r, the me a n BP
te nds to be a ccura te in both unde rda mpe d a nd ove rda mpe d signa ls
(Miller: Miller’s Anesth esia, ed 8, pp 1347–1359).
83. (D) Re bre a thing of e xpire d ga se s (e .g., stuck ope n e xpira tory or
inspira tory va lve s), fa ulty re mova l of CO2 from the CO2 a bsorbe r
(e .g., e xha uste d CO2 a bsorbe r, cha nne ling through a CO2 a bsorbe r,
or ha ving the CO2 a bsorbe r bypa sse d—a n option in some olde r
a ne sthe tic ma chine s), or a ddition of CO2 from a ga s supply (ra re ly
done with curre nt a ne sthe tic ma chine s) ca n a ll incre a se inspire d
CO2. The a bsorption of CO2 during la pa roscopic surge ry whe n CO2
is use d a s the a bdomina l diste nding ga s will incre a se a bsorption of
CO2 but will not ca use a n incre a se in inspire d CO2 (Miller: Miller’s
Anesth esiology, ed 5, p 42).
84. (B)
85. (A)
86. (D)
Me dica l ga s cylinde rs a re color code d, but the colors ma y diffe r
from one country to a nothe r. In the Unite d Sta te s, if the re is a
combina tion of two ga se s, the ta nk would ha ve both
corre sponding colors; for e xa mple , a ta nk conta ining oxyge n a nd
he lium would be gre e n a nd brown. The only e xce ption to the
mixe d ga s color sche me is O2 a nd N2 in the proportion of 19.5% to
23.5% O2 mixe d with N2, which is solid ye llow (a ir) (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, p 7).
GAS COLOR CODES
Gas United States International

Air Yellow White and black
CO2 Gray Gray
Helium Brown Brown
Nitrogen Black Black
N 2O Blue Blue
Oxygen Green White
Data from Ehrenwerth J, Eisenkraft JB, Berry JM: Anesthesia Equipment: Principles and
Applications, ed 2, Philadelphia, Saunders, 2013.
87. (A)
88. (D)
89. (D)
90. (F)
The re a re six diffe re nt type s of Ma ple son bre a thing circuits
(de signa te d A through F). The se circuits va ry in a rra nge me nt of
the fre sh-ga s-flow inle t, tubing, ma sk, re se rvoir ba g, a nd
unidire ctiona l e xpira tory va lve . The se syste ms a re lightwe ight,
porta ble , a nd e a sy to cle a n; the y offe r low re sista nce to
bre a thing, a nd, be ca use of high fre sh ga s inflows, the y pre ve nt
re bre a thing of e xha le d ga se s. In a ddition, with the se bre a thing
circuits, the conce ntra tion of vola tile a ne sthe tic ga se s a nd O2
de live re d to the pa tie nt ca n be a ccura te ly e stima te d. The
re se rvoir ba g e na ble s the a ne sthe sia provide r to provide a ssiste d
or controlle d ve ntila tion of the lungs. The unidire ctiona l
e xpira tory va lve functions to dire ct fre sh ga s into the pa tie nt a nd
e xha le d ga se s out of the circuit. In the Ma ple son A bre a thing
circuit, the unidire ctiona l e xpira tory va lve is ne a r the pa tie nt, a nd
the fre sh-ga s-flow inle t is proxima l to the re se rvoir ba g. This
a rra nge me nt is the most e fficie nt for e limina tion of CO2 during
sponta ne ous bre a thing. Howe ve r, be ca use the unidire ctiona l
e xpira tory va lve must be tighte ne d to pe rmit production of
positive a irwa y pre ssure whe n the ga s re se rvoir ba g is ma nua lly
compre sse d, this bre a thing circuit is le ss e fficie nt in pre ve nting
re bre a thing of CO2 during a ssiste d or controlle d ve ntila tion of the
lungs. The structure of the Ma ple son D bre a thing circuit is simila r
to tha t of the Ma ple son A bre a thing circuit e xce pt tha t the
positions of the fre sh-ga s-flow inle t a nd the unidire ctiona l
e xpira tory va lve a re re ve rse d. The pla ce me nt of the fre sh-ga s-
flow inle t ne a r the pa tie nt produce s e fficie nt e limina tion of CO2,
re ga rdle ss of whe the r the pa tie nt is bre a thing sponta ne ously or
with controlle d ve ntila tion. The Ba in a ne sthe sia bre a thing circuit
is a coa xia l ve rsion of the Ma ple son D bre a thing circuit e xce pt
tha t the fre sh ga s e nte rs through a na rrow tube within the
corruga te d e xpira tory limb of the circuit. The Ja ckson-Re e s
bre a thing circuit is a modifica tion of the Ma ple son E bre a thing
circuit a nd is ca lle d a Ma ple son F bre a thing circuit. In the
Ja ckson-Re e s bre a thing circuit, the a djusta ble unidire ctiona l
e xpira tory va lve is incorpora te d into the re se rvoir ba g, a nd the
fre sh-ga s-flow inle t is close to the pa tie nt. This a rra nge me nt
offe rs the a dva nta ge of e a se of instituting a ssiste d or controlle d
ve ntila tion of the lungs, a s we ll a s monitoring ve ntila tion by
move me nt of the re se rvoir ba g during sponta ne ous bre a thing
pp 109–117; Miller: Miller’s Anesth esia, ed 8, pp 780–781).
C H AP T E R 2
Respiratory Physiology and Critical
Care Medicine
DIRECT IONS (Que stions 91 through 168): Ea ch of the que stions

or incomple te sta te me nts in this se ction is followe d by
a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
Se le ct the ONE BEST a nswe r or comple tion for e a ch ite m.
91. A 29-ye a r-old ma n is a dmitte d to the inte nsive ca re unit (ICU)

a fte r a drug ove rdose . The pa tie nt is pla ce d on a ve ntila tor with a
se t tida l volume (VT) of 750 mL a t a ra te of 10 bre a ths/min. The
pa tie nt is ma king no inspira tory e ffort. The me a sure d minute
ve ntila tion is 6 L a nd the pe a k a irwa y pre ssure is 30 cm H2O. W ha t
is the compre ssion fa ctor for this ve ntila tor de live ry circuit?
A. 2 mL/(cm H2O)
B. 3 mL/(cm H2O)
C. 4 mL/(cm H2O)
D. 5 mL/(cm H2O)
92. A 62-ye a r-old ma n is brought to the ICU a fte r e le ctive re pa ir of
a n a bdomina l a ortic a ne urysm. His vita l signs a re sta ble , but he
re quire s a sodium nitroprusside infusion a t a ra te of 10 µg/kg/min to
ke e p the systolic blood pre ssure be low 110 mm Hg. The Sa O2 is
98% with controlle d ve ntila tion a t 12 bre a ths/min a nd a n F IO2 of
0.60. Afte r 3 da ys, his Sa O2 de cre a se s to 85% on the pulse oxime te r.
Che st x-ra y film a nd re sults of physica l e xa mina tion a re uncha nge d.
W hich of the following would most like ly a ccount for this
de sa tura tion?
A. Cya nide toxicity
B. Thiocya na te toxicity
C. Me the moglobine mia
D. Thiosulfa te toxicity
93. Ma ximizing which of the following lung pa ra me te rs is the most
importa nt fa ctor in pre ve ntion of postope ra tive pulmona ry
complica tions?
A. Tida l volume (VT)
B. Inspira tory re se rve volume
C. Vita l ca pa city
D. Functiona l re sidua l ca pa city (FRC)
94. An 83-ye a r-old woma n is a dmitte d to the ICU a fte r corona ry
a rte ry surge ry. A pulmona ry a rte ry ca the te r is in pla ce a nd yie lds
the following da ta : ce ntra l ve nous pre ssure (CVP) 5 mm Hg, ca rdia c
output (CO) 4.0 L/min, me a n a rte ria l pre ssure (MAP) 90 mm Hg,
me a n pulmona ry a rte ry pre ssure (PAP) 20 mm Hg, pulmona ry
a rte ry occlusion pre ssure (PAOP) 12 mm Hg, a nd he a rt ra te 90.
Ca lcula te this pa tie nt’s pulmona ry va scula r re sista nce (PVR).
A. 40 dyne -se c/cm5
B. 80 dyne -se c/cm5
C. 160 dyne -se c/cm5
D. 200 dyne -se c/cm5
95. A 72-ye a r-old ma n with a history of myoca rdia l infa rction
12 months e a rlie r is sche dule d to unde rgo e le ctive re pa ir of a 6-cm
a bdomina l a ortic a ne urysm unde r ge ne ra l a ne sthe sia . W he n
would this pa tie nt be a t highe st risk for a nothe r myoca rdia l
infa rction?
A. During pla ce me nt of the a ortic cross-cla mp
B. Upon re le a se of the a ortic cross-cla mp
C. 24 hours postope ra tive ly
D. On the third postope ra tive da y
96. Ca lcula te the body ma ss inde x (BMI) of a ma n 200 cm (6 fe e t
6 inche s) ta ll who we ighs 100 kg (220 lb).
A. 20
B. 25
C. 30
D. 35
97. The norma l FEV1/FVC ra tio is
A. 0.95
B. 0.80
C. 0.60
D. 0.50
98. Dire ct curre nt (DC) ca rdiove rsion is not use ful a nd, the re fore ,
NOT indica te d in a n unsta ble pa tie nt with which of the following?
A. Supra ve ntricula r ta chyca rdia in a pa tie nt with Wolff-Pa rkinson-
W hite syndrome
B. Atria l flutte r
C. Multifoca l a tria l ta chyca rdia (MAT)
D. Ne w-onse t a tria l fibrilla tion
99. During the first minute of a pne a , the Pa CO2 will rise
A. 2 mm Hg/min
B. 4 mm Hg/min
C. 6 mm Hg/min
D. 8 mm Hg/min
100. Pote ntia l complica tions a ssocia te d with tota l pa re nte ra l
nutrition (TPN) include a ll of the following EXCEPT
A. Ke toa cidosis
B. Hype rglyce mia
C. Hypoglyce mia
D. Hypophospha te mia
101. O2 re quire me nt for a 70-kg a dult is
A. 150 mL/min
B. 250 mL/min
C. 350 mL/min
D. 450 mL/min
102. The FRC is compose d of the
A. Expira tory re se rve volume a nd re sidua l volume
B. Inspira tory re se rve volume a nd re sidua l volume
C. Inspira tory ca pa city a nd vita l ca pa city
D. Expira tory ca pa city a nd VT
103. W hich of the following sta te me nts corre ctly de fine s the
re la tionship be twe e n minute ve ntila tion ( ), de a d spa ce
ve ntila tion ( ), a nd Pa CO2?
A. If is consta nt a nd incre a se s, the n Pa CO2 will incre a se
B. If is consta nt a nd incre a se s, the n Pa CO2 will de cre a se
C. If is consta nt a nd incre a se s, the n Pa CO2 will incre a se
D. If is consta nt a nd de cre a se s, the n Pa CO2 will de cre a se
104. A 22-ye a r-old pa tie nt who susta ine d a close d he a d injury is
brought to the ope ra ting room (OR) from the ICU for pla ce me nt of a
dura l bolt. He moglobin ha s be e n sta ble a t 15 g/dL. Blood ga s
a na lysis imme dia te ly be fore induction re ve a ls a Pa O2 of 120 mm Hg
a nd a n a rte ria l sa tura tion of 100%. Afte r induction, the Pa O2 rise s to
150 mm Hg a nd the sa tura tion re ma ins the sa me . How ha s the
oxyge n conte nt of this pa tie nt’s blood cha nge d?
A. It ha s incre a se d by 10%
B. It ha s incre a se d by 5%
C. It ha s incre a se d by le ss tha n 1%
D. Ca nnot be de te rmine d without Pa CO2
105. Inha la tion of CO2 incre a se s by
A. 0.5 to 1 L/min/mm Hg incre a se in Pa CO2
B. 2 to 3 L/min/mm Hg incre a se in Pa CO2
C. 3 to 5 L/min/mm Hg incre a se in Pa CO2
D. 5 to 10 L/min/mm Hg incre a se in Pa CO2
106. W ha t is the O2 conte nt of whole blood if the he moglobin
conce ntra tion is 10 g/dL, the Pa O2 is 60 mm Hg, a nd the Sa O2 is 90%?
A. 10 mL/dL
B. 12.5 mL/dL
C. 15 mL/dL
D. 17.5 mL/dL
107. Ea ch of the following will ca use e rrone ous re a dings by dua l-
wa ve le ngth pulse oxime te rs EXCEPT
A. Ca rboxyhe moglobin
B. Me thyle ne blue
C. Fe ta l he moglobin
D. Me the moglobin
108.
In the dia gra m a bove , curve “D” re pre se nts
A. Emphyse ma
B. Chronic bronchitis
C. Norma l lungs
D. Fibrotic lungs
109. The P 50 for norma l a dult he moglobin is a pproxima te ly
A. 15 mm Hg
B. 25 mm Hg
C. 35 mm Hg
D. 45 mm Hg
110. During a norma l VT (500-mL) bre a th, the tra nspulmona ry
pre ssure incre a se s from 0 to 5 cm H2O. The product of
tra nspulmona ry pre ssure a nd VT is 2500 cm H2O-mL. This
e xpre ssion of the pre ssure -volume re la tionship during bre a thing
de te rmine s wha t pa ra me te r of re spira tory me cha nics?
A. Lung complia nce
B. Airwa y re sista nce
C. Pulmona ry e la sta nce
D. Work of bre a thing
111. An oxime tric pulmona ry a rte ry ca the te r is pla ce d in a 69-ye a r-
old ma n who is unde rgoing surgica l re pa ir of a n a bdomina l a ortic
a ne urysm unde r ge ne ra l a ne sthe sia . Be fore the a ortic cross-cla mp
is pla ce d, the mixe d ve nous O2 sa tura tion de cre a se s from 75% to
60%. Ea ch of the following could a ccount for the de cre a se in mixe d
ve nous O2 sa tura tion EXCEPT
A. Hypovole mia
B. Ble e ding
C. Conge stive he a rt fa ilure
D. Se psis
112. The norma l vita l ca pa city for a 70-kg ma n is
A. 1 L
B. 2 L
C. 5 L
D. 7 L
113. A 32-ye a r-old ma n is found unconscious by the fire de pa rtme nt
in a room whe re he ha s inha le d 0.1% ca rbon monoxide for a
prolonge d pe riod. His re spira tory ra te is 42 bre a ths/min, but he is
not cya notic. Ca rbon monoxide ha s incre a se d this pa tie nt’s minute
ve ntila tion by which of the following me cha nisms?
A. Shifting the O2 he moglobin dissocia tion curve to the le ft
B. Incre a sing CO2 production
C. Ca using la ctic a cidosis
D. De cre a sing Pa O2
114. An a cute incre a se in Pa CO2 of 10 mm Hg will re sult in a
de cre a se in pH of
A. 0.01 pH unit
B. 0.02 pH unit
C. 0.04 pH unit
D. 0.08 pH unit
115. You a re ta king ca re of a pa tie nt in shock in the ICU, a nd, a fte r
a de qua te fluid re suscita tion, you de cide to a dd a va soa ctive
me dica tion. Ea ch of the following initia l infusion ra te s is corre ct
EXCEPT
A. Dopa mine 2 to 10 µg/kg/min
B. Nore pine phrine 0.1 to 0.5 µg/kg/min
C. Va sopre ssin 0.01 to 0.04 units/kg/min
D. None of the a bove ; the y a ll a re re a sona ble sta rting dose s
116. A 44-ye a r-old pa tie nt is hype rve ntila te d to a Pa CO2 of 24 mm Hg
for 48 hours. W ha t [HCO3−] would you e xpe ct (norma l [HCO3−] is
24 mEq/L)?
A. 10 mEq/L
B. 12 mEq/L
C. 14 mEq/L
D. 16 mEq/L
117. The dia gra m be low de picts which mode of ve ntila tion?
A. Sponta ne ous ve ntila tion

B. Controlle d ve ntila tion
C. Assiste d ve ntila tion
D. Assiste d/controlle d ve ntila tion
118. A 35-ye a r-old morbidly obe se pa tie nt is discha rge d a fte r ga stric
bypa ss surge ry. She is re a dmitte d 4 da ys la te r a fte r she fa lls a nd
twists he r a nkle . She is note d in the e me rge ncy room (ER) to be in
a tria l fibrilla tion a nd is hypote nsive but only compla ins of le g pa in.
She is a dmitte d to the hospita l, a nd te mpe ra ture on a dmission is
38.6° C a nd he a rt ra te is 105 be a ts/min. The ne xt ste p in
ma na ge me nt of he r dysrhythmia should be
A. Ibutilide
B. Proca ina mide
C. Echoca rdiogra phic study
D. DC ca rdiove rsion
119. The P 50 of sickle ce ll he moglobin is
A. 19 mm Hg
B. 26 mm Hg
C. 31 mm Hg
D. 35 mm Hg
120. Da ta from the ARDS ne twork tria l (ARDSNe t) showe d
incre a se d morta lity from
A. Ate le ctra uma
B. Volutra uma
C. Ba rotra uma
D. Inha le d nitric oxide
121. W hich of the following is the corre ct ma the ma tica l e xpre ssion
of Fick’s la w of diffusion of a ga s through a lipid me mbra ne ( =
ra te of diffusion, D = diffusion coe fficie nt of the ga s, A = a re a of the
me mbra ne , P1 − P2 = tra nsme mbra ne pa rtia l pre ssure gra die nt of
the ga s, T = thickne ss of the me mbra ne )?
A.
B.
C.
D.
122. Ea ch of the following is de cre a se d in e lde rly pa tie nts
compa re d with the ir younge r counte rpa rts EXCEPT
A. Closing volume
B. FEV1
C. Ve ntila tory re sponse to hype rca rbia
D. Vita l ca pa city
123. Ca lcula te the VD/VT ra tio (physiologic de a d spa ce ve ntila tion)
ba se d on the following da ta : Pa CO2 45 mm Hg, mixe d e xpire d CO2
te nsion (P ECO2) 30 mm Hg.
A. 0.1
B. 0.2
C. 0.3
D. 0.4
124. W hich of the following sta te me nts conce rning the distribution
of O2 a nd CO2 in the upright lungs is T RUE?
A. Pa O2 is gre a te r a t the a pe x tha n a t the ba se
B. Pa CO2 is gre a te r a t the a pe x tha n a t the ba se
C. Both Pa O2 a nd Pa CO2 a re gre a te r a t the a pe x tha n a t the ba se
D. Both Pa O2 a nd Pa CO2 a re gre a te r a t the ba se tha n a t the a pe x
125. W hich of the following a cid-ba se disturba nce s is the le a st
we ll-compe nsa te d?
A. Me ta bolic a lka losis
B. Re spira tory a lka losis
C. Incre a se d a nion ga p me ta bolic a cidosis
D. Norma l a nion ga p me ta bolic a cidosis
126. W ha t is the (ca lcula te d) P AO2 of a pa tie nt on room a ir in
De nve r, Colora do? (Assume a ba rome tric pre ssure of 630 mm Hg,
re spira tory quotie nt of 0.8, a nd Pa CO2 of 34 mm Hg.)
A. 80 mm Hg
B. 90 mm Hg
C. 100 mm Hg
D. 110 mm Hg
127. A ve nous blood sa mple from which of the following site s
would corre la te most re lia bly with Pa O2 a nd Pa CO2?
A. Jugula r ve in
B. Subcla via n ve in
C. Ante cubita l ve in
D. Ve in on poste rior surfa ce of a wa rme d ha nd
128. W hich of the following pulmona ry function te sts is LEAST
de pe nde nt on pa tie nt e ffort?
A. Force d e xpira tory volume in 1 se cond (FEV1)
B. Force d vita l ca pa city (FVC)
C. FEF 800 to 1200
D. FEF 25% to 75%
129. A 33-ye a r-old woma n with 20% ca rboxyhe moglobin is brought
to the ER for tre a tme nt of smoke inha la tion. W hich of the following
is LEAST consiste nt with a dia gnosis of ca rbon monoxide
poisoning?
A. Cya nosis
B. Pa O2 105 mm Hg, oxyge n sa tura tion 80% on initia l room a ir
a rte ria l blood ga se s (ABGs)
C. 98% oxyge n sa tura tion on dua l-wa ve le ngth pulse oxime te r
D. Oxyhe moglobin dissocia tion curve shifte d fa r to the le ft
130. The P AO2 − Pa O2 of a pa tie nt bre a thing 100% O2 is 240 mm Hg.
The e stima te d fra ction of the ca rdia c output shunte d pa st the lungs
without e xposure to ve ntila te d a lve oli (i.e ., tra nspulmona ry shunt)
is
A. 5%
B. 12%
C. 17%
D. 20%
131. Ea ch of the following will a lte r the position or slope of the CO2-
ve ntila tory re sponse curve EXCEPT
A. Hypoxe mia
B. Fe nta nyl
C. N2O
D. Ke ta mine
132. W hich of the following sta te me nts conce rning the distribution
of a lve ola r ve ntila tion ( ) in the upright lungs is T RUE?
A. The distribution of is not a ffe cte d by body posture
B. Alve oli a t the a pe x of the lungs (nonde pe nde nt a lve oli) a re
be tte r ve ntila te d tha n those a t the ba se
C. All a re a s of the lungs a re ve ntila te d e qua lly
D. Alve oli a t the ba se of the lungs (de pe nde nt a lve oli) a re be tte r
ve ntila te d tha n those a t the a pe x
133. In the re sting a dult, wha t pe rce nta ge of tota l body O2
consumption is due to the work of bre a thing?
A. 2%
B. 5%
C. 10%
D. 20%
134. The a na tomic de a d spa ce in a 70-kg ma n is
A. 50 mL
B. 150 mL
C. 250 mL
D. 500 mL
135. The most importa nt buffe ring syste m in the body is
A. He moglobin
B. Pla sma prote ins
C. Phospha te
D. [HCO3−]
136. A de cre a se in pH of 0.1 unit will re sult in
A. A de cre a se in se rum pota ssium conce ntra tion [K+] of 0.6 mEq/L
B. A de cre a se in [K+] of 1.2 mEq/L
C. An incre a se in [K+] of 0.6 mEq/L
D. An incre a se in [K+] of 1.2 mEq/L
137. An incre a se in [HCO3−] of 10 mEq/L will re sult in a n incre a se in
pH of
A. 0.10 pH unit
B. 0.15 pH unit
C. 0.20 pH unit
D. 0.25 pH unit
138. A 28-ye a r-old, 70-kg woma n with ulce ra tive colitis is re ce iving a
ge ne ra l a ne sthe tic for a colon re se ction a nd ile ostomy. The
pa tie nt’s lungs a re me cha nica lly ve ntila te d with the following
pa ra me te rs: 5000 mL a nd re spira tory ra te 10 bre a ths/min.
Assuming no cha nge in , how would cha nge if the
re spira tory ra te we re incre a se d from 10 to 20 bre a ths/min?
A. Incre a se by 500 mL
B. Incre a se by 1000 mL
C. De cre a se by 750 mL
D. De cre a se by 1500 mL
139. Ea ch of the following will shift the oxyhe moglobin dissocia tion
curve to the right EXCEPT
A. Vola tile a ne sthe tics
B. De cre a se d Pa O2
C. De cre a se d pH
D. Incre a se d te mpe ra ture
140. The ha lf-life of ca rboxyhe moglobin in a pa tie nt bre a thing 100%
O2 is
A. 5 minute s
B. 1 hour
C. 2 hours
D. 4 hours
141. A disa dva nta ge of using propofol for prolonge d se da tion (da ys)
of intuba te d pa tie nts in the ICU is pote ntia l
A. Acidosis
B. Ta chyphyla xis
C. Hype rglyce mia
D. Bra dyca rdia
142. A 17-ye a r-old type 1 dia be tic with history of re na l fa ilure is in
the pre ope ra tive holding a re a a wa iting a n ope ra tion for a cute
a ppe ndicitis. Arte ria l blood ga se s a re obta ine d with the following
re sults: Pa O2 88 mm Hg, Pa CO2 32 mm Hg, pH 7.2, [HCO3−] 12, [Cl−]
115 mEq/L, [Na +] 138 mEq/L, a nd glucose 251 mg/dL. The most like ly
ca use of this pa tie nt’s a cidosis is
A. Re na l tubula r a cidosis
B. La ctic a cidosis
C. Dia be tic ke toa cidosis
D. Aspirin ove rdose
143. Me thods to de cre a se the incide nce of ce ntra l ve nous ca the te r
infe ctions include a ll of the following EXCEPT
A. Cha nging the ce ntra l ca the te r e ve ry 3 to 4 da ys ove r a
guide wire
B. Using minocycline /rifa mpin impre gna te d ca the te rs ove r
chlorhe xidine /silve r sulfa dia zine impre gna te d ca the te rs for
suspe cte d long-te rm use
C. Using the subcla via n ove r the inte rna l jugula r route for a cce ss
D. Using a single lume n ove r a multilume n ca the te r
144. Signs of Sa rin ne rve ga s poisoning include a ll of the following
EXCEPT
A. Dia rrhe a
B. Urina tion
C. Mydria sis
D. La crima tion
145. W hich of the following conditions would be a ssocia te d with
the LEAST risk of ve nous a ir e mbolism during re mova l of a ce ntra l
line ?
A. Sponta ne ous bre a thing, he a d up
B. Sponta ne ous bre a thing, fla t
C. Sponta ne ous bre a thing, Tre nde le nburg
D. Me cha nica l ve ntila tion, Tre nde le nburg
146. W hich of the following a dve rse e ffe cts is NOT a ttributa ble to
re spira tory or me ta bolic a cidosis?
A. Incre a se d intra cra nia l pre ssure
B. Va soconstriction
C. Incre a se d pulmona ry va scula r re sista nce
D. Incre a se d se rum pota ssium conce ntra tion
147. W hich of the following ma ne uve rs is LEAST like ly to ra ise
a rte ria l sa tura tion in a pa tie nt in whom the e ndotra che a l tube
(ETT) is se a te d in the right ma inste m bronchus? The pa tie nt ha s
norma l lung function.
A. Infla ting the pulmona ry a rte ry ca the te r ba lloon (in the le ft
pulmona ry a rte ry)
B. Ra ising he moglobin from 8 to 12 mg/dL
C. Ra ising F IO2 from 0.8 to 1.0
D. Incre a sing ca rdia c output from 2 to 5 L/min
148. A 100-kg ma n is 24 hours sta tus post four-ve sse l corona ry a rte ry
bypa ss gra ft. W hich of the following pulmona ry pa ra me te rs would
be compa tible with succe ssful e xtuba tion in this pa tie nt?
A. Vita l ca pa city 2.5 L
B. Pa CO2 44 mm Hg
C. Ma ximum inspira tory pre ssure –38 cm H2O
D. All of the a bove
149. W hich of the following ca n ca use a rightwa rd shift of the
oxyhe moglobin dissocia tion curve ?
A. Me the moglobine mia
B. Ca rboxyhe moglobine mia
C. Hypothe rmia
D. Pre gna ncy
150. A 24-ye a r-old ma n is brought to the ope ra ting room 1 hour a fte r
a motor ve hicle a ccide nt. He ha s C7 spina l cord tra nse ction a nd
rupture d sple e n. Re ga rding his ne urologic injury, a ne sthe tic
conce rns include
A. Risk of hype rka le mia with succinylcholine a dministra tion
B. Risk of a utonomic hype r-re fle xia with urina ry ca the te r
inse rtion
C. Incre a se d risk of hypothe rmia
151. Afte r susta ining tra uma tic bra in injury, a 37-ye a r-old pa tie nt in
the ICU de ve lops polyuria a nd a pla sma sodium conce ntra tion of
159 mEq/L. W ha t pa thologic condition is a ssocia te d with the se
clinica l findings?
A. Syndrome of ina ppropria te a ntidiure tic hormone (SIADH)
B. Dia be te s me llitus
C. Dia be te s insipidus
D. Ce re bra l sa lt wa sting syndrome
152. W hich of the following drugs is the be st choice for tre a ting
hypote nsion in the se tting of se ve re a cide mia ?
A. Nore pine phrine
B. Epine phrine
C. Phe nyle phrine
D. Va sopre ssin
153. The e nd-tida l CO2 me a sure d by a n infra re d spe ctrome te r is
35 mm Hg. An a rte ria l blood ga s sa mple dra wn a t e xa ctly the sa me
mome nt is 45 mm Hg. W hich of the following is the LEAST
pla usible e xpla na tion for this?
A. Morbid obe sity
B. Pulmona ry e mbolism
C. Intra pulmona ry shunt
D. Chronic obstructive pulmona ry dise a se (COPD)
154. A tra nsfusion-re la te d a cute lung injury (TRALI) re a ction is
suspe cte d in a 48-ye a r-old ma n in the ICU a fte r a 10-hour ope ra tion
for scoliosis during which multiple units of blood a nd fa ctors we re
a dministe re d. W hich of the following ite ms is inconsiste nt with the
dia gnosis of a TRALI re a ction?
A. Fe ve r
B. Alve ola r-to-a rte ria l (A–a ) oxyge n gra die nt of 25 mm Hg
C. Acute rise in ne utrophil count a fte r onse t of symptoms
D. Bila te ra l pulmona ry infiltra te s
155. If a ce ntra l line loca te d in the supe rior ve na ca va (SVC) is
withdra wn such tha t the tip of the ca the te r is just proxima l to the
SVC, it would be loca te d in which ve sse l?
A. Subcla via n ve in
B. Bra chioce pha lic ve in
C. Ce pha lic ve in
D. Inte rna l jugula r ve in
156. The time course of a nticoa gula tion the ra py is va ria ble a fte r
diffe re nt pe rcuta ne ous corona ry inte rve ntions (PCIs). Arra nge the
inte rve ntions in orde r sta rting with the one re quiring the shorte st
course of a spirin a nd clopidogre l (Pla vix) the ra py to the one
re quiring the longe st course .
A. Ba re -me ta l ste nt, pe rcuta ne ous tra nslumina l corona ry
a ngiopla sty (PTCA), drug-e luting ste nt
B. Drug-e luting ste nt, ba re -me ta l ste nt, PTCA
C. PTCA, drug-e luting ste nt, ba re -me ta l ste nt
D. PTCA, ba re -me ta l ste nt, drug-e luting ste nt
157. Ba sic Life Support Working Group’s single re scue r ca rdia c
compre ssion-ve ntila tion ra tio for infa nt, child, a nd a dult victims
(e xcluding ne wborns) is
A. 10:1
B. 15:2
C. 30:2
D. 60:2
158. W hich of the fe a ture s be low is sugge stive of we a ponize d
a nthra x e xposure a s oppose d to a common flu-like vira l illne ss?
A. W ide ne d me dia stinum
B. Fe ve r, chills, mya lgia
C. Se ve re cough
D. Pha ryngitis
159. W hich of the following fa ctors could not e xpla in a Pa O2 of
48 mm Hg in a pa tie nt bre a thing a mixture of nitrous oxide a nd
oxyge n?
A. Hypoxic ga s mixture
B. Eise nme nge r syndrome
C. Profound a ne mia
D. Hype rca rbia
160. During a le ft he pa te ctomy unde r ge ne ra l isoflura ne a ne sthe sia ,
a rte ria l blood ga se s a re : O2 138, CO2 39, pH 7.38, sa tura tion 99%. At
the sa me time , CO2 on infra re d spe ctrome te r is 26 mm Hg. The
most pla usible e xpla na tion for the diffe re nce be twe e n CO2
me a sure d with infra re d spe ctrome te r ve rsus a rte ria l blood ga s
gra die nt is
A. Ma inste m intuba tion
B. Ate le cta sis
C. Shunting through the be sia n ve ins
D. Hypovole mia
161. Unde r which se t of circumsta nce s would e ne rgy e xpe nditure
pe r da y be the gre a te st?
A. Se psis with fe ve r
B. 60% burn
C. Multiple fra cture s
D. 1 hour sta tus post live r tra nspla nta tion
162. Se le ct the FALSE sta te me nt re ga rding a mioda rone (Corda rone ).
A. It is shown to de cre a se morta lity a fte r myoca rdia l infa rction
B. It is indica te d for ve ntricula r ta chyca rdia a nd fibrilla tion
re fra ctory to e le ctrica l de fibrilla tion
C. Adve rse e ffe cts include pulmona ry fibrosis a nd thyroid
dysfunction
D. It is use ful in tre a tme nt of torsa de s de pointe s
163. A 58-ye a r-old woma n is a wa iting orthotopic live r
tra nspla nta tion for prima ry bilia ry cirrhosis in the ICU. An oxime tric
pulmona ry a rte ry ca the te r is pla ce d a nd a n SVO2 of 90% is
me a sure d. W hich of the following blood pre ssure inte rve ntions is
the LEAST a ppropria te for tre a tme nt of hypote nsion in this pa tie nt?
A. Milrinone
B. Nore pine phrine
C. Va sopre ssin
D. Phe nyle phrine
164. Ea ch of the following me a sure s is pa rt of the Surgica l Ca re
Improve me nt Proje ct (SCIP) with the goa l of pre ve nting
pe riope ra tive infe ction EXCEPT
A. Normothe rmia
B. Oxyge n sa tura tion a bove 95% in the OR
C. Appropria te ha ir re mova l pre ope ra tive ly
D. Re mova l of urina ry ca the te r by postope ra tive da y 2
165. A 55-ye a r-old ma n with polycystic live r dise a se unde rgoe s a n 8-
hour right he pa te ctomy. The pa tie nt re ce ive s 5 units of pa cke d re d
ce lls, 1000 mL a lbumin, a nd 6 L norma l sa line . The pa tie nt is
e xtuba te d a nd ta ke n to a posta ne sthe sia ca re unit (PACU) whe re
ABGs a re : Pa O2 135, Pa CO2 44, pH 7.17, ba se de ficit −11, [HCO3−], 12,
97% sa tura tion, [Cl−] 119, [Na +] 145, a nd [K+] 5.6. The most like ly
ca use for this a cidosis is
A. La ctic a cid
B. Use of norma l sa line
C. Dia be tic ke toa cidosis
D. Polye thyle ne glycol from bowe l pre p
166. W hich of the following is the LEAST a ppropria te use of
noninva sive positive -pre ssure ve ntila tion (NIPPV)?
A. Acute re spira tory distre ss syndrome (ARDS)
B. COPD e xa ce rba tion
C. Obstructive sle e p a pne a
D. Multiple scle rosis e xa ce rba tion
167. A 68-ye a r-old a sthma tic drunk drive r come s into the ER a fte r
be ing in a motor ve hicle a ccide nt. Afte r a difficult intuba tion, you
fa il to obse rve e nd-tida l CO2 on the monitor. Re a sons for this
include a ll of the following EXCEPT
A. You intuba te d the e sopha gus by mista ke
B. You forgot to ve ntila te the pa tie nt
C. The conne ction be twe e n the circuit a nd monitor ha s be come
disconne cte d
D. The pa tie nt a lso ha s a pne umothora x, a nd high a irwa y
pre ssure s a re ne e de d to a de qua te ly ve ntila te the pa tie nt
168. A 30-ye a r-old woma n ha s unde rgone a 2-hour a bdomina l
surgica l proce dure a nd is se nt to the ICU intuba te d for
postope ra tive monitoring due to suspe cte d se psis. Thre e hours
la te r, the ve ntila tor ma lfunctions a nd the re side nt disconne cts the
pa tie nt from the ve ntila tor a nd ha nd ve ntila te s the pa tie nt with
100% oxyge n. The pa tie nt ha s good bila te ra l bre a th sounds, the
che st rise s nice ly, a nd moisture is se e n in the ETT. Shortly
the re a fte r, the pa tie nt’s he a rt ra te slows to 30 be a ts/min a nd the
blood pre ssure is 50 mm Hg systolic. The ne xt inte rve ntion tha t
should be done , in a ddition to che st compre ssions, is
A. Administe r a tropine
B. Sta rt e pine phrine
C. Confirm ETT position
D. Apply e xte rna l pa ce ma ke r
Respiratory Physiology and Critical Care
Medicine
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
91. (D) A volume -cycle d ve ntila tor se t to de live r a volume of 750 mL
a t a ra te of 10/min would de live r a minute ve ntila tion of 7.5 L. The
me a sure d minute ve ntila tion, howe ve r, is only 6 L; the re fore , 1.5 L
must be a bsorbe d by the bre a thing circuit. This volume is known
a s the compre ssion volume . If one divide s the volume by 10
(numbe r of bre a ths/min), the n one de te rmine s the compre ssion
volume /bre a th. This numbe r (mL) ca n be furthe r divide d by the
pe a k infla tion pre ssure (cm H2O) to de te rmine the a ctua l
compre ssion fa ctor, which in this ca se is 5 mL/(cm H2O) (Miller:
Basics of Anesth esia, ed 6, p 208; Eh renwerth : Anesth esia Eq uipm ent
Principles and Applications, p 364).
92. (C) The me ta bolism of nitroprusside in the body re quire s the

conve rsion of oxyhe moglobin (Fe ++) to me the moglobin (Fe +++). The
pre se nce of sufficie nt qua ntitie s of me the moglobin in the blood will
ca use the pulse oxime te r to re a d 85% sa tura tion re ga rdle ss of the
true a rte ria l sa tura tion. Cya nide toxicity is a lso a possibility in a ny
pa tie nt who is re ce iving nitroprusside . Cya nide toxicity should be
suspe cte d whe n the pa tie nt de ve lops me ta bolic a cidosis or
be come s re sista nt to the hypote nsive e ffe cts of this drug de spite a
sufficie nt infusion ra te . This ca n be confirme d by me a suring the
mixe d ve nous Pa O2, which would be e le va te d in the pre se nce of
cya nide toxicity. Thiocya na te toxicity is a lso a pote ntia l ha za rd of
nitroprusside a dministra tion in pa tie nts with re na l fa ilure . Pa tie nts
suffe ring from thiocya na te toxicity displa y na use a , me nta l
confusion, a nd ske le ta l-muscle we a kne ss (Miller: Miller’s Anesth esia,
ed 8, pp 1545, 2228; Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 782–783).
93. (D) (Ple a se se e dia gra m a nd ta ble for e xpla na tion with
Que stion 102.) FRC is compose d of e xpira tory re se rve volume plus
re sidua l volume . It is e sse ntia l to ma ximize FRC in the
postope ra tive pe riod to e nsure tha t it will be gre a te r tha n closing
volume . Closing volume is tha t lung volume a t which sma ll-a irwa y
closure be gins to occur. Ma ximizing FRC, the re fore , re duce s
a te le cta sis a nd le sse ns the incide nce of a rte ria l hypoxe mia a nd
pne umonia . Ma ne uve rs a ime d a t incre a sing FRC include e a rly
a mbula tion, ince ntive spirome try, de e p bre a thing, a nd inte rmitte nt
positive -pre ssure bre a thing (Barash : Clinical Anesth esia, ed 7, p 279).
94. (C)
whe re PVR is the pulmona ry va scula r re sista nce , PAP mean is the
me a n pulmona ry a rte ry pre ssure , PAOP is the me a n pulmona ry
ca pilla ry occlusion pre ssure , a nd CO is the ca rdia c output.
The norma l ra nge for PVR is 50 to 150 dyne -se c/cm5 (Miller: Miller’s
95. (D) For re a sons tha t a re not fully unde rstood, pa tie nts who ha ve
susta ine d a myoca rdia l infa rction a nd subse que ntly unde rgo
surge ry a re most like ly to ha ve a nothe r infa rction on the third
postope ra tive da y (Miller: Basics of Anesth esia, ed 6, p 385).
96. (B) Ca lcula tion of BMI for a dults (>20 ye a rs of a ge ) ca n he lp
ide ntify pa tie nts who a re unde rwe ight (BMI <18.5), norma l we ight
(BMI 18.5-24.9), ove rwe ight (BMI 25-29.9), cla ss 1 obe sity (BMI 30-
34.9), cla ss 2 obe sity (BMI 35-39.9), cla ss 3 obe sity (BMI 40-49.9), a nd
the supe robe se (BMI >50).
All ma jor orga n syste ms a re a ffe cte d a s a conse que nce of obe sity.
The gre a te st conce rns for the a ne sthe siologist a re , howe ve r,
re la te d to the he a rt a nd lungs. Ca rdia c output must incre a se
a bout 0.1 L/min for e a ch e xtra kilogra m of a dipose tissue . As a
conse que nce , obe se pa tie nts fre que ntly a re hype rte nsive , a nd
ma ny ultima te ly de ve lop ca rdiome ga ly a nd le ft-side d he a rt
fa ilure . FRC is re duce d in obe se pa tie nts, a nd ma na ge me nt of
the a irwa y ofte n ca n be difficult (Miller: Miller’s Anesth esia, ed 8, pp
2200–2201).
97. (B) The force d e xpira tory volume in 1 se cond (FEV1) is the tota l
volume of a ir tha t ca n be e xha le d in the first se cond. Norma l
he a lthy a dults ca n e xha le a pproxima te ly 75% to 85% of the ir force d
vita l ca pa city (FVC) in the first se cond, 94% in 2 se conds, a nd 97% in
3 se conds. The re fore , the norma l FEV1/FVC ra tio is 0.75 or highe r.
In the pre se nce of obstructive a irwa y dise a se , the FEV1/FVC ra tio
le ss tha n 70% re fle cts mild obstruction, le ss tha n 60% mode ra te
obstruction, a nd le ss tha n 50% se ve re obstruction. This ra tio ca n be
use d to de te rmine the se ve rity of obstructive a irwa y dise a se a nd to
monitor the e ffica cy of bronchodila tor the ra py (Barash : Clinical
98. (C) MAT is a non-re e ntra nt, e ctopic a tria l rhythm ofte n se e n in
pa tie nts with chronic obstructive pulmona ry dise a se (COPD). It is
fre que ntly confuse d with a tria l fibrilla tion but, in contra st to a tria l
fibrilla tion, a tria l flutte r, a nd pa roxysma l supra ve ntricula r
ta chyca rdia , DC ca rdiove rsion is ine ffe ctive in conve rting it to
norma l sinus rhythm. Ectopic a tria l ta chydysrhythmia s a re not
a me na ble to ca rdiove rsion be ca use the y la ck the re -e ntra nt
me cha nism, which is ne ce ssa ry for succe ssful te rmina tion with
e le ctrica l counte r shock (Miller: Miller’s Anesth esia, ed 8, pp 3191–
3193).
99. (C) During a pne a , the Pa CO2 will incre a se a pproxima te ly
6 mm Hg during the first minute a nd the n 3 to 4 mm Hg e a ch minute
the re a fte r (Miller: Basics of Anesth esia, ed 6, p 61).
100. (A) TPN the ra py is a ssocia te d with nume rous pote ntia l
complica tions. Blood suga rs ne e d to be ca re fully monitore d
be ca use hype rglyce mia ma y de ve lop due to the high glucose loa d
a nd re quire tre a tme nt with insulin, a nd hypoglyce mia ma y de ve lop
if TPN is a bruptly stoppe d (i.e ., infusion turne d off or me cha nica l
obstruction in the IV tubing). Othe r complica tions include
e le ctrolyte disturba nce s (e .g., hypoka le mia , hypophospha te mia ,
hypoma gne se mia , hypoca lce mia ), volume ove rloa d, ca the te r-
re la te d se psis, re na l a nd he pa tic dysfunction, thrombosis of the
ce ntra l ve ins, a nd nonke totic hype rosmola r coma . Incre a se d work
of bre a thing is re la te d to incre a se d production of CO2 most
fre que ntly due to ove rfe e ding. Acidosis in the se pa tie nts is
hype rchlore mic me ta bolic a cidosis re sulting from forma tion of HCl
during me ta bolism of a mino a cids. Ke toa cidosis is not a ssocia te d
with TPN the ra py (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 331).
101. (B) The O2 re quire me nt for a n a dult is 3 to 4 mL/kg/min. The O2
re quire me nt for a ne wborn is 7 to 9 mL/kg/min. Alve ola r ve ntila tion
(VA) in ne ona te s is double tha t of a dults to he lp me e t the ir
incre a se d O2 re quire me nts. This incre a se in VA is a chie ve d
prima rily by a n incre a se in re spira tory ra te a s VT is simila r to tha t
of a dults (i.e ., 7 mL/kg). Although CO2 production a lso is incre a se d
in ne ona te s, the e le va te d VA ma inta ins the Pa CO2 ne a r 38 to
40 mm Hg (Barash : Clinical Anesth esia, ed 7, pp 1181–1182).
102. (A) A compre he nsive unde rsta nding of re spira tory physiology is
importa nt for unde rsta nding the e ffe cts of both re giona l a nd ge ne ra l
a ne sthe sia on re spira tory me cha nics a nd pulmona ry ga s e xcha nge .
The volume of ga s re ma ining in the lungs a fte r a norma l e xpira tion
is ca lle d the functiona l re sidua l ca pa city. The volume of ga s
re ma ining in the lungs a fte r a ma xima l e xpira tion is ca lle d the
re sidua l volume . The diffe re nce be twe e n the se two volume s is
ca lle d the e xpira tory re se rve volume . The re fore , the FRC is
compose d of the e xpira tory re se rve volume a nd re sidua l volume
(Barash : Clinical Anesth esia, ed 7, pp 278–279; Stoelting: Ph arm acology
and Ph y siology in Anesth etic Practice, ed 4, pp 776–777).
LUNG VOLUMES AND CAPACITIES
Measurement Abbreviation Normal Adult Value

Tidal volume VT 500 mL (6-8 mL/kg)
Inspiratory reserve volume IRV 3000 mL
Expiratory reserve volume ERV 1200 mL
Residual volume RV 1200 mL
Inspiratory capacity IC 3500 mL
Functional residual capacity FRC 2400 mL
Vital capacity VC 4500 mL (60-70 mL/kg)
Forced exhaled volume in 1 sec FEV1 80%
Total lung capacity TLC 5900 mL
103. (A) The volume of ga s in the conducting a irwa ys of the lungs

(a nd not a va ila ble for ga s e xcha nge ) is ca lle d the a na tomic de a d
spa ce . The volume of ga s in ve ntila te d a lve oli tha t a re unpe rfuse d
(a nd not a va ila ble for ga s e xcha nge ) is ca lle d the functiona l de a d
spa ce . The a na tomic de a d spa ce toge the r with the functiona l de a d
spa ce is ca lle d the physiologic de a d spa ce . Physiologic de a d spa ce
ve ntila tion (VD) ca n be ca lcula te d by the Bohr de a d spa ce e qua tion,
which is ma the ma tica lly e xpre sse d a s follows:
whe re VD/VT is the ra tio of VD to VT, a nd a a nd E re pre se nt a rte ria l

a nd mixe d e xpire d, re spe ctive ly. Of the choice s give n, only the
first is corre ct. A la rge incre a se in VD will re sult in a n incre a se in
Pa CO2 (Barash : Clinical Anesth esia, ed 7, pp 275–277; West:
Respiratory Ph y siology, ed 9, pp 19–21; Miller: Miller’s Anesth esia, ed
8, pp 446–447).
104. (C) The oxyge n conte nt of blood ca n be ca lcula te d with the
following formula :
The diffe re nce in the oxyge n conte nt is 0.09 mL/dL. This re pre se nts
a cha nge of 0.42% (Miller: Basics of Anesth esia, ed 6, p 57).
105. (B) The de gre e of ve ntila tory de pre ssion ca use d by vola tile
a ne sthe tics ca n be a sse sse d by me a suring re sting Pa CO2, the
ve ntila tory re sponse to hype rca rbia , a nd the ve ntila tory re sponse to
hypoxe mia . Of the se te chnique s, the re sting Pa CO2 is the most
fre que ntly use d inde x. Howe ve r, me a suring the e ffe cts of incre a se d
Pa CO2 on ve ntila tion is the most se nsitive me thod of qua ntifying the
e ffe cts of drugs on ve ntila tion. In a wa ke una ne sthe tize d huma ns,
inha la tion of CO2 incre a se s minute ve ntila tion ( ) by
a pproxima te ly 2 to 3 L/min/mm Hg incre a se in Pa CO2. Using this
te chnique , ha lotha ne , isoflura ne , de sflura ne -O2, de sflura ne -N2O,
a nd N2O ca use a dose -de pe nde nt de pre ssion of the ve ntila tion
106. (B) (Se e a lso e xpla na tion to Que stion 104.) The a mount of O2 in
blood (O2 conte nt) is the sum of the a mount of O2 dissolve d in
pla sma a nd the a mount of O2 combine d with he moglobin. The
a mount of O2 dissolve d in pla sma is dire ctly proportiona l to the
product of the blood/ga s solubility coe fficie nt of O2 (0.003) a nd Pa O2.
The a mount of O2 bound to he moglobin is dire ctly re la te d to the
fra ction of he moglobin tha t is sa tura te d. One gra m of he moglobin
ca n bind 1.39 mL of O2. The ma the ma tica l e xpre ssion of O2 conte nt
is a s follows:
whe re [Hgb] is the he moglobin conce ntra tion (g/dL), Sa o 2 is the

fra ction of he moglobin sa tura te d with O2, a nd (0.003 × Pa o 2) is the
a mount of O2 dissolve d in pla sma . In this ca se
(1.39 × 10 × 0.9) + (0.003 × 60) = 12.51 + 0.18 = 12.69 or a pproxima te ly
13 mL/dL (Miller: Basics of Anesth esia, ed 6, p 57).
107. (C) The pre se nce of he moglobin spe cie s othe r tha n
oxyhe moglobin ca n ca use e rrone ous re a dings by dua l-wa ve le ngth
pulse oxime te rs. He moglobin spe cie s such a s ca rboxyhe moglobin
a nd me the moglobin, dye s such a s me thyle ne blue a nd indocya nine
gre e n, a nd some colors of na il polish will ca use e rrone ous
re a dings. Be ca use the a bsorption spe ctrum of fe ta l he moglobin is
simila r to tha t of a dult oxyhe moglobin, fe ta l he moglobin doe s not
significa ntly a ffe ct the a ccura cy of the se type s of pulse oxime te rs.
High le ve ls of bilirubin ha ve no significa nt e ffe ct on the a ccura cy of
dua l-wa ve le ngth pulse oxime te rs but ma y ca use fa lse ly low
re a dings by nonpulsa tile oxime te rs (Miller: Miller’s Anesth esia, ed 8,
pp 1545–1547).
108. (D) This gra ph de picts lung volume s a s a function of pre ssure
or complia nce ; one kPa is roughly e qua l to 10 cm H2O. Curve A
shows a n e normous volume with a sma ll pre ssure (i.e .,
e mphyse ma ). Curve B de picts chronic bronchitis or a sthma . The
complia nce curve is roughly the sa me a s the norma l lung, curve C,
but volume s ha ve incre a se d. Curve D de picts stiff noncomplia nt
lungs a s se e n with fibrosis or ARDS (Miller: Miller’s Anesth esia, ed 8,
pp 447–448).
109. (B) P 50 is the Pa O2 re quire d to produce 50% sa tura tion of
he moglobin. The P 50 for a dult he moglobin a t a pH of 7.4 a nd body
te mpe ra ture of 37° C is 26 mm Hg (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 788–789; Miller: Basics of
110. (D) The work of bre a thing is de fine d a s the product of
tra nspulmona ry pre ssure a nd VT. The work of bre a thing is re la te d
to two fa ctors: the work re quire d to ove rcome the e la stic force s of
the lungs, a nd the work re quire d to ove rcome a irflow or frictiona l
re sista nce s of the a irwa ys (Barash : Clinical Anesth esia, ed 7, pp 266–
268; Miller: Miller’s Anesth esia, ed 8, p 1563).
111. (D) The norma l mixe d ve nous O2 sa tura tion is 75%. Physiologic
fa ctors tha t a ffe ct mixe d ve nous O2 sa tura tion include he moglobin
conce ntra tion, a rte ria l Pa O2, ca rdia c output, a nd O2 consumption.
Ane mia , hypoxia , de cre a se d ca rdia c output, a nd incre a se d O2
consumption de cre a se mixe d ve nous O2 sa tura tion. During se psis
with a de qua te volume re suscita tion, the ca rdia c output is
incre a se d a nd ma ldistribution of pe rfusion (distributive shock)
re sults in a n e le va te d mixe d-ve nous O2 sa tura tion. Mixe d ve nous
O2 sa tura tion ( ) is re la te d to a numbe r of fa ctors, a s shown in
this e qua tion:
whe re Hgb is he moglobin conce ntra tion, 13.9 is a consta nt (O2

combining powe r of Hgb [mL/10 g]), is ca rdia c output, a nd
is the oxyge n consumption (Miller: Miller’s Anesth esia, ed 8, pp
1386–1387).
112. (C) The volume of ga s e xha le d during a ma ximum e xpira tion is
the vita l ca pa city. In a norma l he a lthy a dult, the vita l ca pa city is 60
to 70 mL/kg. In a 70-kg pa tie nt, the vita l ca pa city is a pproxima te ly
5 L (Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4,
p 776; Barash : Clinical Anesth esia, ed 7, p 278).
113. (C) Ca rbon monoxide inha la tion is the most common
imme dia te ca use of de a th from fire . Ca rbon monoxide binds to
he moglobin with a n a ffinity 200 time s gre a te r tha n tha t of oxyge n.
For this re a son, ve ry sma ll conce ntra tions of ca rbon monoxide ca n
gre a tly re duce the oxyge n-ca rrying ca pa city of blood. In spite of this,
the a rte ria l Pa O2 ofte n is norma l. Be ca use the ca rotid bodie s
re spond to a rte ria l Pa O2, the re would not be a n incre a se in minute
ve ntila tion until tissue hypoxia wa s sufficie nt to produce la ctic
a cidosis (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
554–555; Miller: Miller’s Anesth esia, ed 8, pp 2679–2680; West:
Respiratory Ph y siology, ed 9, pp 80–82).
114. (D) Re spira tory a cidosis is pre se nt whe n the Pa CO2 e xce e ds
44 mm Hg. Re spira tory a cidosis is ca use d by de cre a se d e limina tion
of CO2 by the lungs (i.e ., hypove ntila tion) or incre a se d me ta bolic
production of CO2. An a cute incre a se in Pa CO2 of 10 mm Hg will
re sult in a de cre a se in pH of a pproxima te ly 0.08 pH unit. The
a cidosis of a rte ria l blood will stimula te ve ntila tion via the ca rotid
bodie s, a nd the a cidosis of ce re brospina l fluid will stimula te
ve ntila tion via the me dulla ry che more ce ptors loca te d in the fourth
ce re bra l ve ntricle . Vola tile a ne sthe tics gre a tly a tte nua te the ca rotid
body–me dia te d a nd a ortic body–me dia te d ve ntila tory re sponse s to
a rte ria l a cidosis, but the y ha ve little e ffe ct on the me dulla ry
che more ce ptor–me dia te d ve ntila tory re sponse to ce re brospina l
fluid a cidosis (Miller: Basics of Anesth esia, ed 6, pp 339–340, 343).
115. (C) Dopa mine ca n be infuse d a t low dose s (2-5 µg/kg/min),
mode ra te dose s (5-10 µg/kg/min), or high dose s (10-20 µg/kg/min).
Ma ny fe e l tha t if dopa mine is ne e de d a t ra te s gre a te r tha n
10 µg/kg/min, one should use e pine phrine or nore pine phrine
infusions inste a d. Epine phrine a nd nore pine phrine infusion ra te s
a re commonly sta rte d a t 0.1 to 0.5 µg/kg/min. Although ma ny
ca rdiova scula r drugs a re ba se d on a µg/kg/min dose , va sopre ssin is
not. The sta rting va sopre ssin dose is 0.01 to 0.04 unit/min (Am erican
Heart Association: 2010 Am erican Heart Association Guid elines for
Card iopulm onary Resuscitation and Em ergency Card iovascular Care
Science, pp S774–S775; Kaplan: Card iac Anesth esia, ed 6, pp 1000, 1034–
1035; Miller: Basics of Anesth esia, ed 6, pp 675–676).
116. (D) Re spira tory a lka losis is pre se nt whe n the Pa CO2 is le ss
tha n 36 mm Hg. The re a re thre e compe nsa tory me cha nisms
re sponsible for a tte nua ting the incre a se in pH tha t a ccompa nie s
re spira tory a lka losis. First, the re is a n imme dia te shift in the
e quilibrium of the [HCO3−] buffe r syste m, which re sults in the
production of CO2. Se cond, a lka losis stimula te s the a ctivity of
phosphofructokina se , which incre a se s glycolysis a nd the
production of pyruva te a nd la ctic a cid. Third, the re is a de cre a se in
re a bsorption of [HCO3−] by the proxima l a nd dista l re na l tubule s.
The se thre e compe nsa tory me cha nisms re sult in a ma ximum
de cre a se in [HCO3−] of a pproxima te ly 5 mEq/L for e ve ry 10 mm Hg
de cre a se in Pa CO2 le ss tha n 40 mm Hg (Miller: Basics of Anesth esia,
ed 6, p 340; Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5,
pp 1154–1155).
117. (D) Me cha nica l ve ntila tion of the lungs ca n be a ccomplishe d by
va rious mode s. The se mode s a re ca te gorize d a s controlle d,
a ssiste d, a ssiste d/controlle d, controlle d with positive e nd-
e xpira tory pre ssure (PEEP), a nd a ssiste d/controlle d using
inte rmitte nt ma nda tory ve ntila tion (IMV). Assiste d/controlle d mode s
of me cha nica l ve ntila tion a re use d in pa tie nts whe n the muscle s of
re spira tion re quire re st be ca use minima l bre a thing e fforts a re
re quire d. W ith the a ssiste d/controlle d mode of ve ntila tion, positive -
pre ssure ve ntila tion is trigge re d by sma ll bre a thing e fforts produce d
by the pa tie nt. The a irwa y pre ssure tra cing shown is typica l of tha t
of a pa tie nt re quiring a ssiste d/controlle d ve ntila tion (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 207–208).
118. (C) The first ste p in e va lua ting a ny pa tie nt with a ta chyca rdia is
to de te rmine if the pa tie nt is he modyna mica lly sta ble or unsta ble
(se rious signs or symptoms a re che st pa in or conge stive he a rt
fa ilure due to the ta chyca rdia ). In the unsta ble pa tie nt, DC
ca rdiove rsion should be pe rforme d for ra pid he a rt ra te control
re ga rdle ss of the dura tion of a tria l fibrilla tion. In this ca se , whe re
the pa tie nt is re a sona bly sta ble , the thre e ma jor goa ls in the
ma na ge me nt of a tria l fibrilla tion should be conside re d. The se
goa ls a re control of ve ntricula r ra te , a sse ssme nt of a nticoa gula tion
ne e ds, a nd conve rsion to sinus rhythm. In a ddition, the unde rlying
ca use of a tria l fibrilla tion should be sought a nd tre a te d. Be ca use
this pa tie nt is fe brile a nd ma y be de hydra te d, a n intra ve nous (IV)
line for fluid re suscita tion should be initia te d. Be ca use we do not
know whe n a tria l fibrilla tion de ve lope d (a fte r 48 hours, e mbolic
e ve nts ma y occur with conve rsion to sinus rhythm), it would be
be st not to conve rt the a tria l fibrilla tion to sinus rhythm using e ithe r
ibutilide or proca ina mide until the pa tie nt is a de qua te ly
a nticoa gula te d. Ade qua te a nticoa gula tion should usua lly be
the ra pe utic for a t le a st 3 we e ks. In ma rgina l ca se s whe re the
dura tion of a tria l fibrilla tion is unce rta in, ca rdia c consulta tion a nd
tra nse sopha ge a l e choca rdiogra phy to e xclude a tria l thrombus
should be pe rforme d be fore ca rdiove rsion. This pa tie nt should
unde rgo ca rdia c e choca rdiogra phic study to look for intra -a tria l
thrombus a nd to de te rmine the e je ction fra ction (EF) of the
ve ntricle . Afte r a de qua te hydra tion, ra te control could be improve d
with ca lcium cha nne l blocke rs or β-blocke rs in pa tie nts with
pre se rve d le ft ve ntricula r function (EF > 40%) or with digoxin,
diltia ze m, or a mioda rone if EF is le ss tha n 40% (2010 AHA Guid elines
for CPR and Em ergency Card iovascular Care: Circulation 122 (Suppl 3)
S750–S756).
119. (C) A P 50 le ss tha n 26 mm Hg de fine s a le ftwa rd shift of the
oxyhe moglobin dissocia tion curve . This me a ns tha t a t a ny give n
Pa O2, he moglobin ha s a highe r a ffinity for O2. A P 50 gre a te r tha n
26 mm Hg de scribe s a rightwa rd shift of the oxyhe moglobin
dissocia tion curve . This me a ns tha t a t a ny give n Pa O2, he moglobin
ha s a lowe r a ffinity for O2. Conditions tha t ca use a rightwa rd shift
of the oxyhe moglobin dissocia tion curve a re me ta bolic a nd include
re spira tory a cidosis, hype rthe rmia , incre a se d e rythrocyte 2,3-
diphosphoglyce ra te (2,3-DPG) conte nt, pre gna ncy, a nd a bnorma l
he moglobins, such a s sickle ce ll he moglobin or tha la sse mia .
Alka losis, hypothe rmia , fe ta l he moglobin, a bnorma l he moglobin
spe cie s, such a s ca rboxyhe moglobin, me the moglobin, a nd
sulfhe moglobin, a nd de cre a se d e rythrocyte 2,3-DPG conte nt will
ca use a le ftwa rd shift of the oxyhe moglobin dissocia tion curve .
Also se e e xpla na tion to Que stion 109 (Miller: Miller’s Anesth esia, ed 8,
p 1843; West: Respiratory Ph y siology, ed 9, pp 79–82).
120. (B) Adult re spira tory distre ss disorde r (ARDS) wa s first re porte d
in a dults in 1967 a nd is a ssocia te d with de cre a se d lung complia nce .
Initia l the ra pie s for ARDS include d me cha nica l ve ntila tion with
tida l volume s of 10 to 15 mL/kg with ra te s to a chie ve a norma l pH
a nd Pa CO2. In 2000, the Na tiona l Institute s of He a lth (NIH) ARDS
Ne twork (ARDSNe t) tria l note d a re duction in morta lity for pa tie nts
with ARDS who we re ve ntila te d with low tida l volume s (6 mL/kg
pre dicte d body we ight [PBW ]—morta lity ra te of 31%) compa re d to
tra ditiona l tida l volume s (12 mL/kg PBW —morta lity ra te of 40%). It
wa s fe lt tha t the la rge r tida l volume s ca use d ove rdiste ntion of the
a lve oli (i.e ., produce d volume tra uma or volutra uma ). This
incre a se d a lve ola r volume re sulte d in me cha nica l injury a nd a
syste mic infla mma tory re sponse . It wa s fe lt tha t the stre tch a nd not
the pre ssure (ba rotra uma ) ca use d the re le a se of the infla mma tory
cytokinins into the circula tion. Be ca use the lowe r tida l volume s
use d we re a ssocia te d with a n e le va tion of a rte ria l CO2 a nd lowe r
a rte ria l oxyge n le ve ls, the te rm “pe rmissive hype rca pnia a nd
hypoxe mia ” wa s use d. Pa tie nts with ARDS a lso de ve lop
a te le cta sis. Re cruitme nt ma ne uve rs (susta ine d bre a ths of
incre a se d a irwa y pre ssure s) we re use d to re -e xpa nd a te le cta tic
a lve oli to a void a te le ctra uma . Howe ve r, re sults with the
re cruitme nt bre a ths showe d only a tra nsie nt incre a se in
oxyge na tion a nd no cha nge in morta lity. Anothe r re spira tory
te chnique propose d include d the use of inha le d nitrous oxide (iNO)
tha t ca n improve ve ntila tion-pe rfusion misma tch a nd improve
oxyge na tion. Ra ndomize d controlle d studie s ha ve shown only
limite d e ffe ctive ne ss with no ove ra ll improve me nt in morta lity or
dura tion of ve ntila tion. Furthe r studie s a re looking a t iNO for
spe cific conditions (e .g., se ve re pulmona ry hype rte nsion, right
ve ntricula r fa ilure re fra ctory hypoxe mia ) (Miller: Basics of Anesth esia,
ed 6, p 669; Miller: Miller’s Anesth esia, ed 8, pp 3040–3044, 3078–3079).
121. (C) The ra te a t which a ga s diffuse s through a lipid me mbra ne
is dire ctly proportiona l to the a re a of the me mbra ne , the
tra nsme mbra ne pa rtia l pre ssure gra die nt of the ga s, a nd the
diffusion coe fficie nt of the ga s, a nd it is inve rse ly proportiona l to
the thickne ss of the me mbra ne . The diffusion coe fficie nt of the ga s
is dire ctly proportiona l to the squa re root of ga s solubility a nd is
inve rse ly proportiona l to the squa re root of the mole cula r we ight of
the ga s. This is known a s Fick’s la w of diffusion (Barash : Clinical
122. (A) Aging is a ssocia te d with re duce d ve ntila tory volume s a nd
ca pa citie s, a nd de cre a se d e fficie ncy of pulmona ry ga s e xcha nge .
The se cha nge s a re ca use d by progre ssive stiffe ning of ca rtila ge a nd
re pla ce me nt of e la stic tissue in the inte rcosta l a nd inte rve rte bra l
a re a s, which de cre a se s complia nce of the thora cic ca ge . In
a ddition, progre ssive kyphosis or scoliosis produce s upwa rd a nd
a nte rior rota tion of the ribs a nd ste rnum, which furthe r re stricts
che st wa ll e xpa nsion during inspira tion. W ith a ging, the FRC,
re sidua l volume , a nd closing volume a re incre a se d, whe re a s the
vita l ca pa city, tota l lung ca pa city, ma ximum bre a thing ca pa city, FEV1,
a nd ve ntila tory re sponse to hype rca rbia a nd hypoxe mia a re
re duce d. In a ddition, a ge -re la te d cha nge s in lung pa re nchyma ,
a lve ola r surfa ce a re a , a nd diminishe d pulmona ry ca pilla ry be d
de nsity ca use ve ntila tion/pe rfusion misma tch, which de cre a se s
re sting Pa O2 (Miller: Basics of Anesth esia, ed 6, pp 571–572; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 644).
123. (C) Physiologic de a d spa ce ve ntila tion ca n be e stima te d using
the Bohr e qua tion (de scribe d in the e xpla na tion to Que stion 103):
(Barash : Clinical Anesth esia, ed 7, pp 276–277; West: Respiratory

Ph y siology, ed 9, pp 19–21; Miller: Miller’s Anesth esia, ed 8, pp 446–
447).
124. (A) The ve ntila tion/pe rfusion ra tio is gre a te r a t the a pe x of the
lungs tha n a t the ba se of the lungs. Thus, de pe nde nt re gions of the
lungs a re hypoxic a nd hype rca rbic compa re d to the nonde pe nde nt
re gions. Also se e e xpla na tion to Que stion 132 (Miller: Miller’s
Anesth esia, ed 8, pp 451–454; West: Respiratory Ph y siology, ed 9, pp 21–
22, 44–46).
125. (A) The de gre e to which a pe rson ca n hypove ntila te to
compe nsa te for me ta bolic a lka losis is limite d; he nce , this is the
le a st we ll-compe nsa te d a cid-ba se disturba nce . Re spira tory
compe nsa tion for me ta bolic a lka losis is ra re ly more tha n 75%
comple te . Hypove ntila tion to a Pa CO2 gre a te r tha n 55 mm Hg is the
ma ximum re spira tory compe nsa tion for me ta bolic a lka losis. A
Pa CO2 gre a te r tha n 55 mm Hg most like ly re fle cts concomita nt
re spira tory a cidosis (Miller: Basics of Anesth esia, ed 6, p 342).
126. (A) P AO2 ca n be e stima te d using the a lve ola r ga s e qua tion,
which is give n a s follows:
whe re P B is the ba rome tric pre ssure (mm Hg), F IO2 is the fra ction of
inspire d O2, Pa CO2 is the a rte ria l CO2 te nsion (mm Hg), a nd R is
the re spira tory quotie nt (Barash : Clinical Anesth esia, ed 7, p 277;
West: Respiratory Ph y siology, ed 9, p 59).
127. (D) W he n a rte ria l sa mpling is not possible , “a rte ria lize d”
ve nous blood ca n be use d to e stima te ABG te nsions. Be ca use
blood in the ve ins on the ba ck of the ha nds ha s ve ry little O2
e xtra cte d, the O2 conte nt in this blood be st a pproxima te s the O2
conte nt in a sa mple of blood obta ine d from a n a rte ry (Stoelting:
Basics of Anesth esia, ed 5, p 324).
128. (D) Pulmona ry function te sts ca n be divide d into those tha t
a sse ss ve ntila tory ca pa city a nd those tha t a sse ss pulmona ry ga s
e xcha nge . The simple st te st to a sse ss ve ntila tory ca pa city is the
FEV1/FVC ra tio. Othe r te sts to a sse ss ve ntila tory ca pa city include
the ma ximum mide xpira tory flow (FEF 25%-75%), MVV, a nd flow-
volume curve s. The most significa nt disa dva nta ge of the se te sts is
tha t the y a re de pe nde nt on pa tie nt e ffort. Howe ve r, be ca use the
FEF 25% to 75% is obta ine d from the mide xpira tory portion of the
flow-volume loop, it is le a st de pe nde nt on pa tie nt e ffort. Also se e
e xpla na tion to Que stion 97 (Barash : Clinical Anesth esia, ed 7, p 279).
129. (A) Ca rbon monoxide binds to he moglobin with a n a ffinity
gre a te r tha n 200 time s tha t of oxyge n. This sta bilize s the oxyge n–
he moglobin comple x a nd hinde rs re le a se of oxyge n to the tissue s,
le a ding to a le ftwa rd shift of the oxyhe moglobin dissocia tion curve .
The dia gnosis is sugge ste d whe n the re is a low oxyge n he moglobin
sa tura tion in the fa ce of a norma l Pa O2. The two-wa ve pulse
oxime te r ca nnot distinguish oxyhe moglobin from
ca rboxyhe moglobin so tha t a norma l oxyhe moglobin sa tura tion
would be obse rve d in the pre se nce of high conce ntra tions of
ca rboxyhe moglobin. Ca rbon monoxide poisoning is not a ssocia te d
with cya nosis. Se e a lso e xpla na tions for Que stions 113 a nd 140
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 554–555;
Miller: Miller’s Anesth esia, ed 8, pp 2679–2680).
130. (B) The fra ction of tota l ca rdia c output tha t tra ve rse s the
pulmona ry circula tion without pa rticipa ting in ga s e xcha nge is
ca lle d the tra nspulmona ry shunt. It ca n be ca lcula te d e xa ctly by the
e qua tion:
whe re Cc′, Ca , a nd sta nd for the conte nt of oxyge n in the

a lve ola r ca pilla ry, a rte ry, a nd mixe d ve nous sa mple s, re spe ctive ly.
This informa tion is not provide d in the que stion; howe ve r, the
a lve ola r-to-a rte ria l pa rtia l pre ssure of oxyge n diffe re nce is using
high inspire d oxyge n conce ntra tions. The a lve ola r to a rte ria l
oxyge n diffe re nce ca n be use d to e stima te ve nous a dmixture ,
most commonly tra nspulmona ry shunt. For e ve ry incre a se in
a lve ola r-a rte ria l O2 of 20 mm Hg, the re is a n incre a se in shunt
fra ction of 1% of the ca rdia c output. In the e xa mple , 240/20 = 12
a nd the tra nspulmona ry shunt ca n be e stima te d a t 12% (Miller:
131. (D) Me a suring the ve ntila tory re sponse to incre a se d Pa CO2 is a
se nsitive me thod for qua ntifying the e ffe cts of drugs on ve ntila tion.
In ge ne ra l, a ll vola tile a ne sthe tics (including N2O), na rcotics,
be nzodia ze pine s, a nd ba rbitura te s de pre ss the ve ntila tory re sponse
to incre a se d Pa CO2 in a dose -de pe nde nt ma nne r. The ma gnitude of
ve ntila tory de pre ssion by vola tile a ne sthe tics is gre a te r in pa tie nts
with COPD tha n in he a lthy pa tie nts. Arte ria l blood ga se s (ABGs)
ma y ne e d to be monitore d during re cove ry from ge ne ra l a ne sthe sia
in pa tie nts with COPD. Ke ta mine ca use s minima l re spira tory
de pre ssion. Typica lly, re spira tory ra te is de cre a se d only 2 to
3 bre a ths/min a nd the ve ntila tory re sponse to cha nge s in Pa CO2 is
ma inta ine d during ke ta mine a ne sthe sia . Also se e e xpla na tion to
Que stion 105 (Miller: Basics of Anesth esia, ed 6, pp 63–64, 93–94, 110;
132. (D) (Se e a lso e xpla nta tion to Que stion 124.) The orie nta tion of
the lungs re la tive to gra vity ha s a profound e ffe ct on e fficie ncy of
pulmona ry ga s e xcha nge . Be ca use a lve oli in de pe nde nt re gions of
the lungs e xpa nd more pe r unit cha nge in tra nspulmona ry pre ssure
(i.e ., a re more complia nt) tha n a lve oli in nonde pe nde nt re gions of
the lungs, incre a se s from the top to the bottom of the lungs.
Be ca use pulmona ry blood flow incre a se s more from the top to the
bottom of the lungs tha n doe s , the ve ntila tion/pe rfusion ra tio is
high in nonde pe nde nt re gions of the lungs a nd is low in de pe nde nt
re gions of the lungs. The re fore , in the upright lungs, the Pa O2 a nd
pH a re gre a te r a t the a pe x, whe re a s the Pa CO2 is gre a te r a t the
ba se (Miller: Miller’s Anesth esia, ed 8, pp 451–454; West: Respiratory
Ph y siology, ed 9, pp 21–22, 44–46).
133. (A) The work re quire d to ove rcome the e la stic re coil of the
lungs a nd thora x, a long with a irflow or frictiona l re sista nce s of the
a irwa ys, contribute s to the work of bre a thing. W he n the re spira tory
ra te or a irwa y re sista nce is high or pulmona ry or che st wa ll
complia nce is re duce d, a la rge a mount of e ne rgy is spe nt
ove rcoming the work of bre a thing. In the he a lthy re sting a dult, only
1% to 3% of tota l O2 consumption is use d for the work of bre a thing
a t re st, but up to 50% ma y be ne e de d in pa tie nts with pulmona ry
dise a se . Also se e e xpla na tion to que stion 110 (Miller: Miller’s
134. (B) The conducting a irwa ys (tra che a , right a nd le ft ma inste m
bronchi, a nd loba r a nd se gme nta l bronchi) do not conta in a lve oli
a nd, the re fore , do not ta ke pa rt in pulmona ry ga s e xcha nge . The se
structure s constitute the a na tomic de a d spa ce . In the a dult, the
a na tomic de a d spa ce is a pproxima te ly 2 mL/kg. The a na tomic de a d
spa ce incre a se s during inspira tion be ca use of the tra ction e xe rte d
on the conducting a irwa ys by the surrounding lung pa re nchyma . In
a ddition, the a na tomic de a d spa ce de pe nds on the size a nd posture
of the subje ct. Also se e e xpla na tion to Que stion 103 (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 778; Barash :
Clinical Anesth esia, ed 7, p 276).
135. (D) The re a re thre e ma in me cha nisms tha t the body ha s to
pre ve nt cha nge s in pH. The buffe r syste ms (imme dia te ), the
ve ntila tory re sponse (ta ke s minute s), a nd the re na l re sponse (ta ke s
hours to da ys). The buffe r syste ms re pre se nt the first line of
de fe nse a ga inst a dve rse cha nge s in pH. The [HCO3−] buffe r syste m
is the most importa nt syste m a nd re pre se nts gre a te r tha n 50% of
the tota l buffe ring ca pa city of the body. Othe r importa nt buffe r
syste ms include he moglobin, which is re sponsible for
a pproxima te ly 35% of the buffe ring ca pa city of blood, phospha te s,
pla sma prote ins, a nd bone (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 794–799; Miller: Basics of Anesth esia, ed 6. pp
335–336).
136. (C) Ca rdia c dysrhythmia s a re a common complica tion
a ssocia te d with a cid-ba se a bnorma litie s. The e tiology of the se
dysrhythmia s is re la te d pa rtly to the e ffe cts of pH on myoca rdia l
pota ssium home osta sis. As a ge ne ra l rule , pla sma K+ incre a se s
a pproxima te ly 0.6 for e a ch 0.1 de cre a se in pH (Butterworth : Morgan
& Mikh ail’s Clinical Anesth esia, ed 5, p 1149).
137. (B) Se ve ra l guide line s ca n be use d in the initia l inte rpre ta tion
of ABGs tha t will pe rmit ra pid re cognition of the type of a cid-ba se
disturba nce . The se guide line s a re a s follows: (1) a 1 mm Hg cha nge
in Pa CO2 a bove or be low 40 mm Hg re sults in a 0.008 unit cha nge in
the pH in the opposite dire ction; (2) the Pa CO2 will de cre a se by
a bout 1 mm Hg for e ve ry 1 mEq/L re duction in [HCO3−] be low
24 mEq/L; (3) a cha nge in [HCO3−] of 10 mEq/L from 24 mEq/L will
re sult in a cha nge in pH of a pproxima te ly 0.15 pH unit in the sa me
dire ction (Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, pp
1146, 1156–1157; Miller: Basics of Anesth esia, ed 6, pp 342–343).
138. (D) A pa tie nt with a VD of 150 mL a nd a VA of 350 mL (a ssuming
a norma l VT of 500 mL) will ha ve a VD minute ve ntila tion ( ) of
1500 mL a nd a VA minute ve ntila tion ( ) of 3500 mL ( of
5000 mL) a t a re spira tory ra te of 10 bre a ths/min. If the re spira tory
ra te is double d but re ma ins uncha nge d, the n the would
double to 3000 mL a nd the re would be a n incre a se in of
1500 mL a nd a de cre a se in of 1500 mL. Also se e e xpla na tion to
Que stions 103 a nd 134 (Barash : Clinical Anesth esia, ed 7, pp 275–277;
West: Respiratory Ph y siology, ed 9, pp 16–17; Miller: Miller’s Anesth esia,
ed 8, pp 446–447).
139. (B) In a ddition to the ite ms liste d in this que stion, othe r fa ctors
tha t shift the oxyhe moglobin dissocia tion curve to the right include
pre gna ncy a nd a ll a bnorma l he moglobins such a s he moglobin S
(sickle ce ll he moglobin). For re a sons unknown, vola tile a ne sthe tics
incre a se the P 50 of a dult he moglobin by 2 to 3.5 mm Hg. A rightwa rd
shift of the oxyhe moglobin dissocia tion curve will de cre a se the
tra nsfe r of O2 from a lve oli to he moglobin a nd improve re le a se of
O2 from he moglobin to pe riphe ra l tissue s. Also se e e xpla na tion to
Que stion 109 (Miller: Basics of Anesth esia, ed 6, p 56; West: Respiratory
Ph y siology, ed 9, pp 79–82).
140. (B) The most fre que nt imme dia te ca use of de a th from fire s is
ca rbon monoxide toxicity. Ca rbon monoxide is a colorle ss, odorle ss
ga s tha t e xe rts its a dve rse e ffe cts by de cre a sing O2 de live ry to
pe riphe ra l tissue s. This is a ccomplishe d by two me cha nisms. First,
be ca use the a ffinity of ca rbon monoxide for the O2 binding site s on
he moglobin is more tha n 200 time s tha t of O2, O2 is re a dily
displa ce d from he moglobin. Thus, O2 conte nt is re duce d. Se cond,
ca rbon monoxide ca use s a le ftwa rd shift of the oxyhe moglobin
dissocia tion curve , which incre a se s the a ffinity of he moglobin for
O2 a t pe riphe ra l tissue s. Tre a tme nt of ca rbon monoxide toxicity is
a dministra tion of 100% O2. Supple me nta l oxyge n de cre a se s the ha lf-
time of ca rboxyhe moglobin from 4 to 6 hours with room a ir to a bout
1 hour with 100% oxyge n. Bre a thing 100% oxyge n a t 3 a tm in a
hype rba ric cha mbe r re duce s the ha lf-time e ve n more to 15 to 30
minute s. Se e a lso e xpla na tions for Que stions 113 a nd 129 (Barash :
Clinical Anesth esia, ed 7, pp 1515–1516; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 554–555; Miller: Miller’s Anesth esia, ed 8, pp
2679–2680).
141. (A) Propofol infusion syndrome is a ra re condition a ssocia te d
with prolonge d (gre a te r tha n 48 hour) a dministra tion of propofol a t
a dose of 5 mg/kg/hr (83 µg/kg/min) or highe r. This syndrome wa s
first de scribe d in childre n but la te r obse rve d in critica lly ill a dults
a s we ll. It is ma nife ste d by ca rdiomyopa thy with a cute ca rdia c
fa ilure , me ta bolic a cidosis, ske le ta l muscle myopa thy,
he pa tome ga ly, hype rka le mia , a nd lipide mia . It is thought to be
re la te d to a fa ilure of fre e fa tty a cid tra nsport into the mitochondria
a nd fa ilure of the mitochondria l re spira tory cha in. Bra dyca rdia ca n
be a la te sign with this syndrome a nd he ra lds a poor prognosis
142. (A) Ca lcula ting the a nion ga p (i.e ., the unme a sure d a nions in
the pla sma ) is he lpful in de te rmining the ca use of a me ta bolic
a cidosis. Anion ga p = [Na +] − ([Cl−] + [HCO3−]) a nd is norma lly 10 to
12 nmol/L. In this ca se the a nion ga p = 138 − (115 + 12) = 11, a norma l
a nion ga p. Ca use s of a high a nion ga p me ta bolic a cidosis include
la ctic a cidosis, ke toa cidosis, a cute a nd chronic re na l fa ilure , a nd
toxins (e .g., sa licyla te s, e thyle ne glycol, me tha nol). Nona nion ga p
me ta bolic a cidosis include re na l tubula r a cidosis, e xpa nsion
a cidosis (e .g., ra pid sa line infusion), ga strointe stina l (GI)
bica rbona te loss (e .g., dia rrhe a , sma ll bowe l dra ina ge ), drug-
induce d hype rka le mia , a nd a cid loa ds (e .g., a mmonium chloride ,
hype ra lime nta tion). Vomiting a nd na soga stric dra ina ge a re some of
the ma ny ca use s of me ta bolic a lka losis (Longo: Harrison’s Principles
of Internal Med icine, ed 18, pp 365–369; Miller: Basics of Anesth esia, ed 6,
pp 340–342).
143. (A) Bloodstre a m infe ctious complica tions with ce ntra l ve nous
ca the te rs a re the most common la te complica tion se e n with ce ntra l
ca the te rs (>5%). Curre nt Ce nte rs for Dise a se Control a nd
Pre ve ntion (CDC) guide line s do not re comme nd re pla cing ce ntra l
ve nous ca the te rs. All the othe r sta te me nts a re true . In a ddition,
e vide nce is sugge sting tha t the use of ultra sound ma y de cre a se the
time ne e de d to pla ce ca the te rs a nd the numbe r of skin puncture s
ne e de d for ce ntra l ve in a cce ss a nd ma y a lso de cre a se infe ctions
(Miller: Miller’s Anesth esia, ed 8, p 1367; O’Grad y et al: Guid elines for
th e prevention of intravascular cath eter-related infections. Clin Infect Dis
52(9): e164–e166, 2011).
144. (C) Sa rin (a lso ca lle d GB), like GA (Ta bun), GD (Soma n), GF,
VR, a nd VX, is a cle a r liquid orga nophospha te tha t va porize s a t
room te mpe ra ture s. The se che mica l ne rve ga se s ma inly bind with
a ce tylcholine ste ra se a nd produce clinica l signs of e xce ssive
pa ra sympa the tic a ctivity. The te rm DUMBELS—Dia rrhe a , Urina tion,
Miosis, Bronchorrhe a a nd bronchoconstriction, Eme sis,
La crima tion, a nd Sa liva tion—ca n he lp you re me mbe r se ve ra l of the
signs. Note the e ye signs a re pupilla ry constriction (miosis) a nd not
pupilla ry dila tion (mydria sis). Othe r signs re la te to the
ca rdiova scula r syste m a nd include bra dyca rdia , prolonge d QT
inte rva l, a nd ve ntricula r dysrhythmia s. The se che mica ls a lso a ffe ct
the GABA a nd NMDA re ce ptors a nd ma y a lso ca use ce ntra l ne rvous
syste m (CNS) e xcita tion (i.e ., convulsions) (Barash : Clinical
Anesth esia, ed 7, pp 1540–1541; Miller: Miller’s Anesth esia, ed 8, p 2496).
145. (D) Ve nous a ir e mbolism occurs whe n a ir e nte rs the ve nous
syste m through a n incise d or ca nnula te d ve in. W he n ca nnula ting or
de ca nnula ting ce ntra l ve ins, it is importa nt to ke e p a positive
ve nous-to-a tmosphe ric pre ssure gra die nt. This is usua lly
a ccomplishe d by pla cing the site be low the le ve l of the he a rt (i.e .,
Tre nde le nburg position). In a ddition, unde r me cha nica l ve ntila tion
or whe n the sponta ne ously bre a thing pa tie nt e xha le s or pe rforms a
Va lsa lva ma ne uve r, the ve nous-to-a tmosphe ric pre ssure is gre a te r
tha n if a sponta ne ously bre a thing pa tie nt inha le s, a time whe n the
ve nous pre ssure ma y be le ss tha n a tmosphe ric pre ssure (Lobato:
Com plications in Anesth esiology, pp 198–200; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esia, ed 5, p 101; Marino’s Th e ICU Book, ed 4,
pp 32–33).
146. (B) Adve rse physiologic e ffe cts of re spira tory or me ta bolic
a cidosis include CNS de pre ssion a nd incre a se d intra cra nia l
pre ssure (ICP), ca rdiova scula r syste m de pre ssion (pa rtia lly offse t
by incre a se d se cre tion of ca te chola mine s a nd e le va te d [Ca ++]),
ca rdia c dysrhythmia s, va sodila tion, hypovole mia (which is a re sult
of de cre a se d pre ca pilla ry a nd incre a se d postca pilla ry sphincte r
tone ), pulmona ry hype rte nsion, a nd hype rka le mia (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esia, ed 5, pp 1148–1149; Miller:
147. (C) W ithdra wing the tube into the tra che a obviously would
improve a rte ria l sa tura tion a nd is the tre a tme nt of choice for
ina dve rte nt ma inste m intuba tion. Short of pulling the ETT ba ck, a ll
othe r succe ssful options a ddre ss wa ys of improving a rte ria l
oxyge na tion during one -lung ve ntila tion. In e sse nce , a ny ma ne uve r
tha t improve s the sa tura tion of the ve nous blood will a lso improve
the sa tura tion of a rte ria l blood (in this que stion). Norma l
pulmona ry circula tion is in se rie s with the syste mic circula tion.
Blood e xiting the lungs is ne a rly 100% oxyge na te d re ga rdle ss of the
sa tura tion of the ve nous blood whe n it e xits the right ve ntricle a nd
e nte rs the lungs via the pulmona ry a rte ry. In one -lung ve ntila tion,
de libe ra te or a ccide nta l, blood e xiting the ve ntila te d side of the
lungs (the right side in this que stion) is a lso e sse ntia lly fully
sa tura te d, but it mixe s with nonoxyge na te d blood. The
nonoxyge na te d blood ha s e ffe ctive ly bypa sse d the lungs by pa ssing
through a n a re a tha t is pe rfuse d but not ve ntila te d, tha t is, a shunt.
W he n the blood from the ve ntila te d lung (ne a rly 100% oxyge na te d)
mixe s with the shunte d blood, a mixture will be forme d tha t ha s
sa tura tion le ss tha n 100%, but highe r tha n the mixe d ve nous O2
sa tura tion.
whe re SvO2 = mixe d ve nous he moglobin sa tura tion a nd
Sa O2 = a rte ria l oxyge n sa tura tion
The e xa ct sa tura tion of the a rte ria l blood in this que stion de pe nds
on the ra tio of blood e xiting the right lung ve rsus tha t e xiting the
le ft lung. Fortuna te ly, during one -lung ve ntila tion, the
nonve ntila te d lung colla pse s a nd in so doing ra ise s its re sista nce
to blood flow. This re sults in pre fe re ntia lly dire cting blood to the
right ve ntila te d lung. A se cond fa ctor to conside r is how we ll-
sa tura te d the shunte d blood is. “Re d” blood from the right lung
mixe s with “blue ” blood from the le ft lung to give a mixture of
pa rtia lly sa tura te d blood. The sa tura tion of the shunte d “blue ”
blood de pe nds on the he moglobin conce ntra tion a nd ca rdia c
output. From the first e qua tion a bove you ca n se e tha t ra ising
e ithe r of the se would improve the mixe d ve nous oxyge n
sa tura tion a nd ultima te ly the a rte ria l sa tura tion during one -lung
ve ntila tion. Infla ting the pulmona ry a rte ry ca the te r ba lloon
loca te d in the nonve ntila te d (le ft) lung would a lso improve
a rte ria l sa tura tion by limiting blood flow to the le ft lung. Ra ising
the FIO2 from 80% to 100% will do little if a nything to improve
a rte ria l sa tura tion be ca use the blood e xiting the “working” lung
is a lre a dy fully sa tura te d. The sma ll rise in Pa O2 tha t would
re sult from a n incre a se in F IO2, once multiplie d by 0.003 (se e the
se cond e qua tion a bove ), would be a ve ry sma ll a nd insignifica nt
numbe r. In othe r words, ra ising F IO2 doe s not improve a rte ria l
sa tura tion in the pre se nce of a shunt (Miller: Miller’s Anesth esia, ed
8, p 1386; Miller: Basics of Anesth esia, ed 6, pp 444–445, 636).
148. (D) The de cision to stop me cha nica l support of the lungs is
ba se d on a va rie ty of fa ctors tha t ca n be me a sure d. Guide line s
sugge sting tha t ce ssa tion of me cha nica l infla tion of the lungs is
like ly to be succe ssful include a vita l ca pa city gre a te r tha n
15 mL/kg, a rte ria l Pa O2 gre a te r tha n 60 mm Hg (F IO2 < 0.5), a lve ola r-
a rte ria l (A–a ) gra die nt le ss tha n 350 mm Hg (F IO2 = 1.0), a rte ria l pH
gre a te r tha n 7.3, Pa CO2 le ss tha n 50 mm Hg, de a d spa ce /tida l
volume ra tio le ss tha n 0.6, a nd ma ximum inspira tory pre ssure of a t
le a st −20 cm H2O. In a ddition to the se guide line s, the pa tie nt should
be he modyna mica lly sta ble , conscious, orie nte d, a nd in good
nutritiona l sta tus (Butterworth : Morgan & Mikh ail’s Clinical Anesth esia,
ed 5, pp 1288, 1297; Miller: Basics of Anesth esia, ed 6, p 667).
149. (D) A shift to the le ft in the oxyhe moglobin dissocia tion curve
occurs with fe ta l he moglobin, a lka losis, hypothe rmia ,
ca rboxyhe moglobin, me the moglobin, a nd de cre a se d le ve ls of 2,3-
DPG. Stora ge of blood lowe rs 2,3-DPG le ve ls in a cid-citra te -
de xtrose store d blood, but minima l cha nge s a re se e n in 2,3-DPG
with citra te -de xtrose -store d blood. A shift to the right occurs with
a cidosis, hype rthe rmia , incre a se d le ve ls of 2,3-DPG, inha le d
a ne sthe tics, a nd pre gna ncy (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esia, ed 5, pp 516–517; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, p 415).
150. (C) W ith a cute spina l cord injurie s the ma jor a ne sthe tic
conce rns a re a irwa y ma na ge me nt a nd ma na ge me nt of
he modyna mic pe rturba tions a ssocia te d with inte rruption of the
sympa the tic ne rvous syste m be low the le ve l of the tra nse ction.
Hype rka le mia in re sponse to succinylcholine doe s not occur until
a t le a st 24 hours a fte r the injury. Autonomic hype r-re fle xia is not a
conce rn in the a cute ma na ge me nt of pa tie nts with spina l cord
injurie s. The re is no e vide nce tha t a wa ke intuba tion (fibe roptic) is
supe rior to dire ct la ryngoscopy a s long a s in-line tra ction is he ld in
both ca se s. The se pa tie nts a re more susce ptible to hypothe rmia
compa re d with pa tie nts without spina l cord injurie s be ca use the y
la ck the rmore gula tion be low the le ve l of the cord injury (Hines:
151. (C) Polyuria of ne uroge nic (ra the r tha n ne phroge nic) dia be te s
insipidus is ca use d by diminishe d or a bse nt a ntidiure tic hormone
(ADH) synthe sis or re le a se following injury to the hypotha la mus,
pituita ry sta lk, or poste rior pituita ry gla nd. He moconce ntra tion
re sulting in hype rna tre mia ofte n re sults. In contra st, SIADH is
a ssocia te d with e xce ssive a mounts of ADH, which in turn ca use s
hypona tre mia . Ce re bra l sa lt wa sting syndrome re sults from re le a se
of bra in na triure tic pe ptide in suba ra chnoid he morrha ge pa tie nts.
The re sulting na triure sis-me dia te d e le ctrolyte pe rturba tion is
hypona tre mia . Dia be te s me llitus a nd spina l shock do not ca use
hype rna tre mia (Longo: Harrison’s Principles of Internal Med icine, ed 18,
pp 349–351; Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p
1115).
152. (D) Va sopre ssin, a lso known a s a ntidiure tic hormone , is a
na tura lly occurring pe ptide synthe size d in the hypotha la mus a nd
store d in the poste rior pituita ry. It is use d clinica lly to tre a t dia be te s
insipidus, a nd in the ICU it is use d to tre a t hypote nsion. Pa tie nts
with se ve re se psis a nd se ptic shock ha ve a re la tive de ficie ncy of
va sopre ssin, a nd the se pa tie nts ma y be se nsitive to va sopre ssin.
Va sopre ssin inte ra cts with a diffe re nt re ce ptor a nd, unlike the
ca te chola mine s, it is e ffe ctive e ve n in the pre se nce of a cide mia
(Miller: Basics of Anesth esia, ed 6, p 676).
153. (C) Confusion ma y e xist be twe e n the conce pts of shunt ve rsus
de a d spa ce . Both of the se a re forms of misma tch. W ith
shunts, the re is a gra die nt be twe e n the a lve ola r a nd the a rte ria l
oxyge n pa rtia l pre ssure s. Alve ola r pa rtia l pre ssure (PA) is
ca lcula te d from the a lve ola r ga s e qua tion. The Pa CO2 with shunt is
compe nsa te d a nd is usua lly norma l e ve n in the pre se nce of a
significa nt misma tch. De a d spa ce re fe rs to the portion of a
bre a th tha t doe s not re a ch pe rfuse d a lve oli. In pa thologic
conditions, such a s COPD, morbid obe sity, a nd pulmona ry
e mbolism, de a d spa ce is incre a se d be ca use a ir pa sse s into a lve oli
tha t a re ve ntila te d but not pe rfuse d. This a ir doe s not pa rticipa te in
ga s e xcha nge a nd simply e xits the se unpe rfuse d a lve oli a nd
“dilute s” the ca rbon dioxide e xiting the lungs from the pe rfuse d
a lve oli. Unde r the se circumsta nce s the mixe d e xpire d CO2
me a sure d with ca pnome try will be le ss tha n the a ctua l a rte ria l CO2
(Miller: Miller’s Anesth esia, ed 8, pp 444–445; Miller: Basics of Anesth esia,
ed 6, pp 58–61).
154. (C) TRALI re a ctions a re a se rious complica tion of tra nsfusing
a ny product conta ining pla sma , tha t is, fre sh froze n pla sma , whole
blood, pa cke d re d blood ce lls, pla te le ts, or fa ctor concre te s de rive d
from huma n blood. The clinica l dia gnosis is ma de 1 to 2 hours a fte r
tra nsfusion (but ma y occur up to 6 hours la te r in the ICU). The ke y
fe a ture s include wide A–a gra die nt, nonca rdioge nic pulmona ry
e de ma , a nd le ukope nia (not le ukocytosis) se conda ry to
se que stra tion in the lungs. TRALI re a ctions a re one of the le a ding
ca use s of tra nsfusion-re la te d morta lity (Miller: Basics of Anesth esia, ed
6, p 637).
155. (B) The right inte rna l jugula r ve in a nd the right subcla via n ve in
form the right bra chioce pha lic ve in; simila rly, the le ft inte rna l
jugula r ve in a nd the le ft subcla via n ve in form the le ft
bra chioce pha lic ve in. The se two bra chioce pha lic ve ins form the
SVC (Netter: Atlas of Hum an Anatom y, ed 5, plates 70, 192, 200, 205).
156. (D) Pa tie nts who ha ve unde rgone a PCI a re pla ce d on a course
of a thie nopyridine (ticlopidine or clopidogre l) a nd a spirin. The
thie nopyridine is use d for a t le a st 2 we e ks a fte r PTCA, 1 month
a fte r a ba re -me ta l ste nt is pla ce d, a nd 1 ye a r a fte r a drug-e luting
ste nt is pla ce d. Aspirin is continue d for a longe r pe riod of time .
This is to de cre a se the cha nce of thrombosis of the tre a te d
corona ry a rte ry (ACC/AHA 2007 Guid elines on Perioperative
Card iovascular Evaluation and Care for Noncard iac Surgery : Ex ecutive
Sum m ary. Anesth Analg 106:698–701, 2008).
157. (C) The unive rsa l compre ssion-ve ntila tion ra tio for infa nt, child,
a nd a dult victims (e xcluding ne wborns) is 30 che st compre ssions to
two bre a th cycle s (5 cycle s in 2 minute s). Once a n a dva nce d a irwa y
is in pla ce , two re scue rs no longe r de live r “cycle s,” but ra the r
compre ssions a t a ra te of 100/min a nd ve ntila tion is 8 to 10/min. For
ne wborns the ra tio is 3:1 (90 compre ssions a nd 30 bre a ths/min)
(2010 AHA Guid elines for CPR and Em ergency Card iovascular Care:
Circulation 122 (Suppl 3) S688, S692–S693, S913).
158. (A) Afte r a n incuba tion pe riod (commonly within 2 we e ks),
inha la tiona l a nthra x symptoms initia lly look like vira l flu (fe ve r,
chills, mya lgia , a nd a nonproductive cough). Although le ukocytosis
is common with a nthra x a nd ra re with vira l flu, white blood ce ll
(W BC) counts initia lly ma y be norma l a t the time the pa tie nt
pre se nts. Afte r a short while , the pa tie nt sudde nly a ppe a rs
critica lly ill, a nd without tre a tme nt, de a th ca n occur within a fe w
da ys. Subste rna l che st pa in, hypoxe mia , cya nosis, dyspne a ,
a bdomina l pa in, a nd se psis syndrome a re common with inha le d
a nthra x but ra re with vira l flu. Afte r the a nthra x spore s a re inha le d,
ma cropha ge s pha gocytize the spore s a nd tra nsport the m to
me dia stina l lymph node s whe re the spore s ge rmina te , producing
e nla rge d node s a nd a wide ne d me dia stinum on the che st x-ra y
film. A wide ne d me dia stinum is not se e n with vira l flu. Pha ryngitis
is common with vira l flu a nd occa siona lly is se e n with a nthra x
(Miller: Basics of Anesth esia, ed 6, pp 691–693; Longo: Harrison’s
Principles of Internal Med icine, ed 18, pp 1769–1771).
159. (C) To a nswe r this que stion it is he lpful to re vie w the a lve ola r
ga s e qua tion:
P AO2 = pa rtia l pre ssure of oxyge n in the a lve ola r ga s; F IO2 = fra ction
of inha le d oxyge n; P b = ba rome tric pre ssure ; P H 2O = va por
pre ssure a t 100% sa tura tion (47 mm Hg a t 37° C); Pa CO2 = pa rtia l
pre ssure of CO2 in the a lve ola r ga s; R = re spira tory quotie nt.
Any fa ctor tha t lowe rs P AO2 (be low 100 mm Hg or so) will a lso
lowe r Pa O2. Hypoxic ga s mixture lowe rs F IO2, he nce Pa O2.
Hype rca rbia ma ke s the te rm Pa CO2/R la rge r a nd, the re fore ,
re duce s Pa O2. Eise nme nge r syndrome re sults in a la rge r shunt
fra ction a nd lowe r Pa O2 on tha t ba sis (se e e xpla na tion to
Que stion 147). In norma lly functioning lungs, a ne mia ha s a
minima l impa ct on Pa O2 be ca use physiologic shunt is norma lly
only 2% to 5% of ca rdia c output (Barash : Clinical Anesth esia, ed 6, pp
277–278).
160. (D) The diffe re nce be twe e n the Pa CO2 a nd the CO2 va lue
me a sure d by the infra re d spe ctrome te r is a function of the pa tie nt’s
physiologic de a d spa ce . Physiologic de a d spa ce is e qua l to
a na tomic de a d spa ce plus a lve ola r de a d spa ce . Ana tomic de a d
spa ce is roughly 1 mL/lb of body we ight. Be ca use a na tomic de a d
spa ce is re la tive ly “fixe d,” cha nge s in physiologic de a d spa ce a re
ma inly a ttributa ble to cha nge s in a lve ola r de a d spa ce . Alve oli tha t
a re ve ntila te d, but not pe rfuse d, a dd to a lve ola r de a d spa ce . In
e sse nce , a ir goe s into the se a lve oli but doe s not pa rticipa te in ga s
e xcha nge s a nd me re ly e xits the a lve oli upon e xha la tion. Ve ntila tion
of de a d spa ce se rve s no use ful purpose but doe s re sult in
“dilution” of the e xha le d CO2, thus e xpla ining why the CO2 se e n on
the infra re d spe ctrome te r ca n be substa ntia lly lowe r tha n tha t
obta ine d from a rte ria l blood ga s a na lysis. Se ve ra l fa ctors incre a se
de a d spa ce , including lung dise a se s such a s COPD, cystic fibrosis,
a nd pulmona ry e mboli. In a ddition, de cre a se d a lve ola r pe rfusion
from low ca rdia c output or hypovole mia ma y a lso contribute to
incre a se d de a d spa ce . Ma inste m intuba tion, a te le cta sis, shunting
through the be sia n ve ins, a nd a bla tion of hypoxic pulmona ry
va soconstriction by isoflura ne a re va rious ca use s of shunting.
Shunting is a lso a misma tch be twe e n ve ntila tion a nd pe rfusion, but,
in contra st to misma tch from de a d spa ce ve ntila tion,
shunting re sults in a norma l or ne a rly norma l Pa CO2 but a la rge r-
tha n-e xpe cte d A–a O2 gra die nt. The only choice in this que stion
tha t would e xpla in a n incre a se in de a d spa ce ve ntila tion is
hypovole mia (Barash : Clinical Anesth esia, ed 7, pp 276–277; Miller:
161. (B) The norma l huma n’s re sting e ne rgy e xpe nditure a s we ll a s
the postope ra tive sta te is a bout 1800 kca l/24 hr. W ith sta rva tion
(20 da ys), e ne rgy e xpe nditure de cre a se s to a bout 1080 kca l/da y (60%
of norma l). Pa tie nts who ha ve susta ine d multiple fra cture s
(2160 kca l/da y or 120% of norma l), ma jor se psis (2520 kca l/da y or
140% of norma l), a nd burns ha ve incre a se d e ne rgy e xpe nditure s.
The e ne rgy e xpe nditure in a pa tie nt with a ma jor burn a lso
de pe nds on the te mpe ra ture of the room. The highe st e ne rgy
e xpe nditure is a t a room te mpe ra ture of 25° C (3819 kca l/da y or
212% of norma l) a nd is lowe r a t 33° C (3342 kca l/da y or 185% of
norma l) a nd a t 21° C (3600 kca l/da y or 200% of norma l) (Miller:
162. (D) Amioda rone is use ful in the tre a tme nt of a va rie ty of
supra ve ntricula r a nd ve ntricula r ca rdia c a rrhythmia s. For the
tre a tme nt of ve ntricula r ta chyca rdia or fibrilla tion tha t is re fra ctory
to e le ctrica l de fibrilla tion, the re comme nde d dose is 300 mg IV.
Simila r to β-blocke rs, a mioda rone de cre a se s morta lity a fte r
myoca rdia l infa rctions. About 5% to 15% of tre a te d pa tie nts de ve lop
pulmona ry toxicity (e spe cia lly whe n dose s a re >400 mg/da y, or
unde rlying lung dise a se is pre se nt) a nd 2% to 4% de ve lop thyroid
dysfunction (a mioda rone is a structura l a na log of thyroid hormone ).
It ha s a prolonge d e limina tion ha lf-time of 29 hours a nd a la rge
volume of distribution. Be ca use it prolongs the QTc inte rva l, it ma y
le a d to the production of ve ntricula r ta chydysrhythmia s a nd thus is
not use ful in tre a ting torsa de s de pointe s (Brunton: Good m an &
Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 834, 837).
163. (A) Pa tie nts with cirrhosis ha ve hype rdyna mic circula tions a s
note d he re with the e le va te d SvO2 of 90%. The ca rdia c output is
usua lly incre a se d, pe riphe ra l va scula r re sista nce is low,
intra va scula r volume is incre a se d, a nd a rte riove nous shunts a re
pre se nt. Hypote nsion is common. Milrinone is a positive inotrope
with va sodila ting prope rtie s, some thing this pa tie nt doe s not ne e d.
If a tre a tme nt for hypote nsion is ne e de d, drugs with α-a gonist
prope rtie s ma y be he lpful. In a ddition, va sopre ssin is a lso a good
choice be ca use it incre a se s syste mic va scula r re sista nce (SVR) but
doe s not incre a se the a lre a dy high ca rdia c output (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p 714; Miller: Basics of
164. (B) For ma ny ye a rs ha nd hygie ne , we a ring surgica l ma sks, a nd
ste rile te chnique s ha ve be e n use d to de cre a se surgica l site
infe ctions (SSIs). The CDC ha s a lso re comme nde d tha t pa tie nts
unde rgo pre ope ra tive showe ring using a ntise ptic skin wa sh
products to re duce skin ba cte ria de spite no cle a r studie s showing a
dire ct inde pe nde nt re la tionship de cre a sing SSIs. In 2004, the
Na tiona l Surgica l Infe ction Pre ve ntion Proje ct ga ve guide line s for
a ntibiotic prophyla xis, whe ne ve r the re is more tha n minima l risk of
infe ction. Prophyla ctic a ntibiotics should be a dministe re d within 1
hour be fore surgica l incision in a ppropria te ly se le cte d pa tie nts a nd
discontinue d within 24 hours a fte r the surgica l e nd time or 48 hours
for ca rdia c pa tie nts. More re ce ntly, using e vide nce -ba se d re se a rch,
the SCIP ha s sugge ste d se ve ra l a dditiona l me a sure s to de cre a se
the incide nce of surgica l site infe ctions, including a ppropria te ha ir
re mova l a t the surgica l site (e .g., using de pila tory cre a m or ha ir
clippe rs ra the r tha n ra zors), glyce mic control in ca rdia c surgica l
pa tie nts (e .g., se rum glucose <200 mg/dL the morning a fte r surge ry),
re mova l of urina ry ca the te rs (e .g., re mova l on postope ra tive da y 1
or 2 a nd re a sse ssme nt of the ne e d e ve ry da y the re a fte r), a nd
ma inte na nce of pe riope ra tive normothe rmia (e .g., core
te mpe ra ture should be 36° C on a rriva l in the PACU). Inte re stingly,
surgica l time wa s not me ntione d (Barash : Clinical Anesth esia, ed 7, pp
304–314; Miller: Basics of Anesth esia, ed 6, pp 746–752; Miller: Miller’s
Anesth esia, ed 8, pp 100–101, 1104).
165. (B) This pa tie nt ha s a me ta bolic a cidosis. Re ca ll tha t a nion
ga p = [Na +] − ([Cl−] + [HCO3−]) a nd is norma lly 10 to 12 nmol/L. In this
ca se the a nion ga p = 145 − (119 + 12) = 14, which is slightly a bove the
norma l a nion ga p ra nge . In looking a t this ca se , the a cidosis is
quite profound a nd would most like ly be re la te d to the ra pid
infusion of norma l sa line . La ctic a cid, ke toa cidosis, a nd e thyle ne
glycol produce a high a nion ga p me ta bolic a cidosis. Na rcotics ma y
produce re spira tory but not me ta bolic a cidosis. Se e a lso Que stion
142 (Longo: Harrison’s Principles of Internal Med icine, ed 18, pp 365–369;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p 1165).
166. (A) Noninva sive positive -pre ssure ve ntila tion (NIPPV) re fe rs to
de live ring positive -pre ssure ve ntila tion to pa tie nts by wa y of a
na sa l ma sk, or full fa ce ma sk, without the pla ce me nt of a n
e ndotra che a l or tra che ostomy tube . This mode of the ra py re quire s
conscious a nd coope ra tive pa tie nts a nd doe s not prote ct the
a irwa y. NIPPV ha s be e n ve ry use ful in COPD pa tie nts a nd in
immunosuppre sse d pa tie nts in a cute re spira tory fa ilure . It most
like ly will fa il (i.e ., intuba tion would be ne e de d) in pa tie nts with
pne umonia a nd ARDS (Miller: Miller’s Anesth esia, ed 8, p 3068).
167. (D) Ca pnogra phy ha s be e n a va lua ble monitor for the ca rdia c
a nd pulmona ry syste ms a s we ll a s che cking the a ne sthe tic
e quipme nt. Forge tting to ve ntila te the pa tie nt, intuba ting the
e sopha gus, a nd ha ving the se nsing tube be come disconne cte d from
the monitor quickly will show no CO2 de te cte d. Any significa nt
re duction in lung pe rfusion (i.e ., a ir e mbolism, de cre a se d ca rdia c
output, or de cre a se d blood pre ssure ) incre a se s a lve ola r de a d
spa ce a nd le a ds to a lowe ring of the de te cte d CO2. A ca rdia c a rre st
whe re the re is no blood flow to the lungs a nd he nce no ca rbon
dioxide going to the lungs would a lso re sult in no de te cta ble CO2.
As CPR is sta rte d, de te cta ble CO2 would be a sign of lung pe rfusion
a nd ve ntila tion. A pa tie nt with a pne umothora x a nd high a irwa y
pre ssure s would still give you CO2 re a dings (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esia, ed 5, pp 125–127).
168. (C) Alwa ys confirm a n a de qua te Airwa y a nd Bre a thing be fore
tre a ting a Ca rdia c rhythm (A, B be fore C). Ha ving the ETT in prope r
position for se ve ra l hours doe s not e nsure tha t it re ma ins in prope r
position. In this ca se , the ETT slippe d out of the tra che a a nd we nt
into the e sopha gus. The only wa y you know the ETT is in the
tra che a is to se e the tube pa ssing be twe e n the voca l cords dire ctly
with a conve ntiona l la ryngoscope or by putting a fibe roptic
bronchoscope through the tube a nd se e ing ca rina . Othe r forms of
confirma tion such a s bila te ra l bre a th sounds, a de qua te che st rise ,
a nd moisture in the tube a re he lpful but could a lso be se e n with a n
e sopha ge a l intuba tion. Ge tting a consiste nt a nd a de qua te e nd tida l
CO2 on a monitor confirms some ga s e xcha nge , but in ca se s whe re
blood doe s not ge t to the lungs, a s in a ca rdia c a rre st, CO2 ca nnot
be re move d from the lungs. The first pa rt in the tre a tme nt of
bra dyca rdia is a de qua te ve ntila tion with oxyge n. Afte r tha t the
othe r choice s ma y be indica te d (Miller: Miller’s Anesth esia, ed 8, p
1654).
C H AP T E R 3
Pharmacology and
Pharmacokinetics of Intravenous
Drugs
169. W hich of the following muscle re la xa nts is e limina te d the most

by re na l e xcre tion?
A. Pa ncuronium
B. Ve curonium
C. Atra curium
D. Rocuronium
170. All of the following conditions ma y de ve lop whe n using
propofol for prolonge d se da tion in the inte nsive ca re unit (ICU)
EXCEPT
A. Pa ncre a titis
B. Hype rlipide mia
C. Me ta bolic a cidosis
D. Adre na l suppre ssion
171. W hich of the following β-a dre ne rgic a nta gonists is a
nonse le ctive β1 a nd β2 blocke r?
A. Ate nolol
B. Na dolol
C. Esmolol
D. Me toprolol
172. A 78-ye a r-old pa tie nt with Pa rkinson dise a se unde rgoe s a
ca ta ra ct ope ra tion unde r ge ne ra l a ne sthe sia . In the re cove ry room,
the pa tie nt ha s two e pisode s of e me sis a nd compla ins of se ve re
na use a . W hich of the following a ntie me tics would be the be st
choice for tre a tme nt of na use a in this pa tie nt?
A. Drope ridol
B. Prome tha zine
C. Onda nse tron
D. Me toclopra mide
173. W hich of the following dise a se s is a ssocia te d with incre a se d
re sista nce to ne uromuscula r blocka de with succinylcholine ?
A. Mya sthe nia gra vis
B. Mya sthe nic syndrome
C. Huntington chore a
D. Polymyositis
174. Se da tion with which of the following drugs is most like ly to
re se mble norma l sle e p?
A. Propofol
B. Mida zola m
C. De xme de tomidine
D. Ke ta mine
175. W hich of the following intra ve nous a ne sthe tics is conve rte d
from a wa te r-soluble to a lipid-soluble drug a fte r e xposure to the
bloodstre a m?
A. Propofol
B. Mida zola m
C. Ke ta mine
176. A 33-ye a r-old, 70-kg pa tie nt is brought to the ope ra ting room for
re se ction of a n a nte rior pituita ry prola ctin-se cre ting tumor.
Ane sthe sia is induce d with se voflura ne , nitrous oxide , a nd oxyge n.
The pa tie nt is intuba te d a nd nitrous oxide is discontinue d.
Ane sthe sia is ma inta ine d with 1.2 minimum a lve ola r conce ntra tion
(MAC) se voflura ne in oxyge n. The surge on pla ns to inje ct
e pine phrine into the na sa l mucosa to minimize ble e ding. W ha t is
the ma ximum volume of a 1:100,000 e pine phrine solution tha t ca n
be a dministe re d sa fe ly to this pa tie nt without producing ve ntricula r
a rrhythmia s?
A. 55 mL
B. 45 mL
C. 35 mL
D. 25 mL
177. Pa tie nts re ce iving a ntihype rte nsive the ra py with propra nolol
a re a t incre a se d risk for e a ch of the following EXCEPT
A. Blunte d re sponse to hypoglyce mia
B. Bronchoconstriction
C. Re bound ta chyca rdia a fte r discontinua tion
D. Orthosta tic hypote nsion
178. Atropine ca use s e a ch of the following EXCEPT
A. De cre a se d ga stric a cid se cre tion
B. Inhibition of sa liva ry se cre tion
C. Incre a se d lowe r e sopha ge a l sphincte r tone
D. Mydria sis
179. W hich of the following drugs is ca pa ble of crossing the blood-
bra in ba rrie r?
A. Ne ostigmine
B. Pyridostigmine
C. Edrophonium
D. Physostigmine
180. W hich drug e xe rts its ma in ce ntra l ne rvous syste m (CNS) a ction
by inhibiting the N-me thyl-D-a spa rta te (NMDA) re ce ptors?
A. Propofol
B. Mida zola m
C. Etomida te
D. Ke ta mine
181. W hich of the following opioid-re ce ptor a gonists ha s
a nticholine rgic prope rtie s?
A. Morphine
B. Hydromorphone
C. Sufe nta nil
D. Me pe ridine
182. W hich of the following sta te me nts a bout ke ta mine is FALSE?
A. In the Unite d Sta te s, it is a ra ce mic mixture of two isome rs
B. It is a pote nt ce re bra l va sodila tor a nd ca n incre a se intra cra nia l
pre ssure (ICP)
C. Re spira tory de pre ssion ra re ly occurs with induction dose s
D. Its me ta bolite norke ta mine is more pote nt tha n the pa re nt
compound
183. W hich of the following va sopre ssor a ge nts incre a se s syste mic
blood pre ssure (BP) indire ctly by stimula ting the re le a se of
nore pine phrine from sympa the tic ne rve fibe rs a nd dire ctly by
binding to a dre ne rgic re ce ptors?
A. Va sopre ssin
B. Ephe drine
C. Epine phrine
D. Phe nyle phrine
184. Me tha done -induce d constipa tion could be re ve rse d without
loss of a na lge sic e ffe ct with which of the following opioid
a nta gonists?
A. Na loxone
B. Na lme fe ne
C. Na ltre xone
D. Me thylna ltre xone
185. The tre a tme nt of pa tie nts with huma n immunode ficie ncy virus
(HIV) ma y include indina vir, ne lfina vir, or ritona vir. W ha t a ne sthe tic
conside ra tion is significa nt with the se drugs?
A. De cre a se d pla te le t function
B. Incre a se d se nsitivity to mida zola m
C. Hypoglyce mia
D. Hype rka le mia
186. Ne urokinin-1 (NK1) a nta gonists such a s a pre pita nt ha ve a ll the
following prope rtie s EXCEPT
A. Anxiolytic
B. Antide pre ssa nt
C. Ana lge sic
D. Antie me tic
187. W hich of the following drugs should be a dministe re d with
ca ution to pa tie nts re ce iving e chothiopha te for the tre a tme nt of
gla ucoma ?
A. Atropine
B. Succinylcholine
C. Ke ta mine
D. Re mife nta nil
188. W he n one of four thumb twitche s in the tra in-of-four (TOF)
stimula tion of the ulna r ne rve ca n be e licite d, how much
suppre ssion would the re be if you we re me a suring a single twitch?
A. 20 to 25
B. 45 to 55
C. 75 to 80
D. 90 to 95
189. W hich of the following muscle re la xa nts ca use s slight
hista mine re le a se a t two to thre e time s the ED95 (e ffe ctive dose in
95% of subje cts) dose ?
A. Rocuronium
B. Pa ncuronium
C. Atra curium
D. Cisa tra curium
190. Te rmina tion of a ction of the ne urotra nsmitte r nore pine phrine
is a chie ve d pre domina te ly by which me cha nism?
A. Re upta ke into postga nglionic sympa the tic ne rve e ndings
(upta ke 1)
B. Dilution by diffusion a wa y from re ce ptors
C. Me ta bolism by ca te chol-O-me thyltra nsfe ra se (COMT)
D. Me ta bolism by monoa mine oxida se (MAO)
191. The incide nce of unple a sa nt dre a ms a ssocia te d with
e me rge nce from ke ta mine a ne sthe sia ca n be re duce d by the
a dministra tion of
A. Ca ffe ine
B. Drope ridol
C. Physostigmine
D. Mida zola m
192. W hich of the following pre me dica tions is a ssocia te d with
e xtra pyra mida l side e ffe cts?
A. Me toclopra mide
B. Dia ze pa m
C. Scopola mine
D. Glycopyrrola te
193. Succinylcholine , whe n a dministe re d to pa tie nts with re na l
fa ilure , will incre a se se rum [K+] by a pproxima te ly
A. No incre a se in [K+]
B. 0.5 mEq/L
C. 1.5 mEq/L
D. 2.5 mEq/L
194. Ea ch of the following drugs ca n e nha nce the ne uromuscula r
blocka de produce d by nonde pola rizing muscle re la xa nts EXCEPT
A. Ca lcium
B. Aminoglycoside a ntibiotics
C. Ma gne sium
D. Intra ve nous lidoca ine
195. Discontinua tion of which of the following me dica tions is
strongly re comme nde d be fore e le ctive surge ry?
A. Clonidine
B. Me toprolol
C. Monoa mine oxida se inhibitors (MAOIs)
196. Circula ting BNP (B-type na triure tic pe ptide ) is a powe rful
bioma rke r pre dicting outcome s of which of the following?
A. He a rt
B. CNS
C. Kidne ys
D. Orga n re je ction
197. Hype rka le mia is NOT a risk for pa tie nts re ce iving
succinylcholine with which of the following?
A. Multiple scle rosis
B. Mya sthe nia gra vis
C. Guilla in-Ba rré syndrome
D. Be cke r muscula r dystrophy
198. W hich of the a ntibiotics be low doe s NOT a ugme nt
ne uromuscula r blocka de ?
A. Clinda mycin
B. Ne omycin
C. Stre ptomycin
D. Erythromycin
199. A 43-ye a r-old woma n with a scite s, he pa topulmona ry
syndrome , a nd ble e ding e sopha ge a l va rice s is a dmitte d to the ICU.
W hich of the the ra pie s be low is LEAST like ly to improve
symptoms a ssocia te d with he pa tic e nce pha lopa thy (HE)?
A. Amino a cid–rich tota l pa re nte ra l nutrition (TPN)
B. Ne omycin
C. La ctulose
D. Fluma ze nil
200. 100 mg succinylcholine is a dministe re d to a 70-kg a ne sthe tize d

ma n be fore intuba tion. The pa tie nt re ma ins pa ra lyze d for 20
minute s. W hich of the pa ra me te rs be low is NOT consiste nt with
this finding?
A. Dibuca ine numbe r 70
B. He te rozygous for a typica l choline ste ra se
C. Incide nce of 1/480
D. Pre se nce of fa scicula tions with this dose
201. In which of the following situa tions is succinylcholine most
like ly to ca use se ve re hype rka le mia ?
A. 24 hours a fte r a right he misphe re stroke
B. 14 da ys a fte r a se ve re burn injury
C. 24 hours a fte r a midthora cic spina l cord tra nse ction
D. 2 da ys with a se ve re a bdomina l infe ction
202. The most common minor side e ffe ct re porte d a fte r fluma ze nil
a dministra tion in a ne sthe sia is
A. Na use a a nd/or vomiting
B. Dizzine ss
C. Tre mors
D. Hype rte nsion
203. Ke torola c
A. Is a se le ctive cyclooxyge na se -2 (COX-2) inhibitor
B. Doe s not inhibit thromboxa ne A2 (TXA2)
C. Doe s not inhibit prosta gla ndin I2
D. Exhibits a dose ce iling e ffe ct with re ga rd to a na lge sia
204. A 37-ye a r-old pa tie nt with a history of a cute inte rmitte nt
porphyria is sche dule d for kne e a rthroscopy unde r ge ne ra l
a ne sthe sia . W hich of the following drugs is contra indica te d in this
pa tie nt?
A. Fe nta nyl
B. Isoflura ne
C. Propofol
D. Etomida te
205. A 57-ye a r-old ma le is discha rge d a fte r tooth e xtra ction of two
mola rs. His only me dica tion is pa roxe tine (Pa xil), which he ta ke s
for de pre ssion. Code ine is a poor a na lge sic choice for this pa tie nt
be ca use
A. It is like ly to be ine ffe ctive
B. It is like ly to ca use e xtre me se da tion
C. He is a t incre a se d risk for na use a
D. He is a t incre a se d risk for se rotonin syndrome
206. If e tomida te we re a ccide nta lly inje cte d into a le ft-side d ra dia l
a rte ria l line , the most a ppropria te ste p to ta ke would be
A. Le ft ste lla te ga nglion block
B. Administe r intra -a rte ria l clonidine
C. Slowly inje ct dilute (0.1 mEq/L) [HCO3–]

D. Obse rve
207. The most importa nt re a son for the more ra pid onse t a nd
shorte r dura tion of a ction of fe nta nyl with single dose compa re d
with morphine is the diffe re nce in
A. Volume of distribution
B. He pa tic cle a ra nce
C. Prote in binding
D. Lipid solubility
208. A na rcotic infusion is initia te d in a pa tie nt without a bolus
(loa ding dose ). Of the following drugs, which would re a ch ste a dy
sta te a fte r 2 hours or le ss of continuous infusion (fe nta nyl,
re mife nta nil, a lfe nta nil, a nd morphine )?
A. All of the se
B. Re mife nta nil a nd a lfe nta nil
C. Alfe nta nil only
D. Re mife nta nil only
209. The pe riod of vulne ra bility a fte r thre e course s of ble omycin for
te sticula r ca nce r is
A. 1 month
B. 1 ye a r
C. Life long
D. No vulne ra bility with just thre e course s
210. The unique a dva nta ge of rocuronium ove r othe r muscle
re la xa nts is its
A. Short dura tion of a ction
B. Me ta bolism by pse udocholine ste ra se
C. Onse t of a ction
D. La ck of ne e d for re ve rsa l
211. W hich of the following sta te me nts re ga rding the e ffica cy of
ne uromuscula r blocka de in the se tting of a cute hypoka le mia is
corre ct?
A. The re is no e ffe ct with de pola rizing or nonde pola rizing muscle
re la xa nts
B. The re is re sista nce to e ffe cts of both de pola rizing a nd
nonde pola rizing muscle re la xa nts
C. The re is incre a se d se nsitivity to e ffe cts of both de pola rizing
a nd nonde pola rizing muscle re la xa nts
D. The re is re sista nce to de pola rizing muscle re la xa nts a nd
incre a se d se nsitivity to nonde pola rizing muscle re la xa nts
212. A pa tie nt unde rgoing which of the following ope ra tions would
be a t highe st risk for ope ra tive re ca ll?
A. La pa roscopic chole cyste ctomy with tota l intra ve nous
a ne sthe sia (no vola tile )
B. Ce rvica l spine fusion with MEP (motor e voke d pote ntia ls)
monitoring
C. Pne umone ctomy with one -lung ve ntila tion
D. Eme rge ncy sple ne ctomy a fte r fa lling from a la dde r
213. A 58-ye a r-old pa tie nt is brought to the e me rge ncy room with the
following symptoms: miosis, a bdomina l cra mping, sa liva tion, loss
of bowe l a nd bla dde r control, bra dyca rdia , a ta xia , a nd ske le ta l
muscle we a kne ss. The most like ly dia gnosis is
A. Ce ntra l a nticholine rgic syndrome
B. Ma ligna nt ne urole ptic syndrome
C. Anticholine ste ra se poisoning
D. Se rotonin syndrome
214. Fluma ze nil
A. Is contra indica te d in na rcotic a ddicts
B. Ca n be give n ora lly a s we ll a s intra ve nously
C. Ca n produce se izure s in chronic be nzodia ze pine use rs
D. Ha s a longe r e limina tion ha lf-life compa re d to mida zola m
215. W ha t pe rce nta ge of ne uromuscula r re ce ptors could be blocke d
a nd still a llow pa tie nts to ca rry out a 5-se cond he a d lift?
A. 5%
B. 15%
C. 25%
D. 50%
216. A 25-ye a r-old woma n unde rgoe s thyroide ctomy unde r ge ne ra l
a ne sthe sia . Onda nse tron 4 mg IV is a dministe re d a s na use a

prophyla xis. She compla ins of na use a in the re cove ry room. W hich
of the follow a ge nts is LEAST like ly to be of be ne fit to he r for
tre a tme nt (re scue ) of postope ra tive na use a a nd vomiting (PONV)?
A. Apre pita nt
B. Gra nise tron
C. Prome tha zine
D. Drope ridol
217. W hich of the following drugs ca n pre ve nt ta chya rrhythmia s in
pa tie nts with Wolff-Pa rkinson-W hite (W PW ) syndrome ?
A. Drope ridol
B. Pa ncuronium
C. Ke ta mine
D. Ve ra pa mil
218. The ha lf-life of pse udocholine ste ra se is
A. 1 hour
B. 12 hours
C. 1 we e k
D. 2 we e ks
219. Some COX-2 inhibitors (e .g., rofe coxib [Vioxx]) ha ve be e n
withdra wn from the U.S. pha rma ce utica l ma rke t be ca use of
se rious complica tions involving
A. Pla te le t inhibition a nd ga strointe stina l (GI) he morrha ge
B. Re na l fa ilure
C. Hype rte nsion
D. Promotion of thrombotic sta te
220. W hich of the following e qua ls the a nti-infla mma tory a ctivity of
50 mg of pre dnisone (De lta sone )?
A. 100 mg cortisol (Solu-Corte f)
B. 80 mg me thylpre dnisolone (Solu-Me drol)
C. 7.5 mg de xa me tha sone (De ca dron)
D. 4 mg be ta me tha sone (Ce le stone )

221. The re cove ry inde x (RI) of which of the following
nonde pola rizing muscle re la xa nts is NOT a lte re d by a ging?
A. Atra curium
B. Ve curonium
C. Rocuronium
D. Pa ncuronium
222. Side e ffe cts a ssocia te d with cyclosporine the ra py include e a ch
of the following EXCEPT
A. Ne phrotoxicity
B. Pulmona ry toxicity
C. Se izure s
D. Limb pa re sthe sia s
223. W ha t is the pre domina nt me cha nism for succinylcholine -
induce d ta chyca rdia in a dults?
A. Dire ct sympa thomime tic e ffe ct a t postjunctiona l musca rinic
re ce ptors
B. Stimula tion of nicotinic re ce ptors a t a utonomic ga nglia
C. Blocka de of nicotinic re ce ptors a t a utonomic ga nglia
D. Dire ct va golytic e ffe ct a t postjunctiona l musca rinic re ce ptors
224. Bra dyca rdia obse rve d a fte r a dministra tion of succinylcholine to
childre n is a ttributa ble to which me cha nism?
A. Nicotinic stimula tion a t the a utonomic ga nglia
B. Stimula tion of the va gus ne rve ce ntra lly
C. Musca rinic stimula tion a t the sinus node
D. Musca rinic blocka de a t the sinus node
225. W hich of commonly use d drugs be low is NOT me ta bolize d by
nonspe cific e ste ra se s?
A. Propofol
B. Esmolol
C. Atra curium
D. Re mife nta nil
226. Succinylcholine is contra indica te d for routine tra che a l
intuba tion in childre n be ca use of a n incre a se d incide nce of which
of the following side e ffe cts?
A. Hype rka le mia
B. Ma ligna nt hype rthe rmia
C. Ma sse te r spa sm
D. Sinus bra dyca rdia
227. From MOST to LEAST ra pid, se le ct the corre ct te mpora l
se que nce of ne uromuscula r blocka de in the a dductor of the thumb,
the orbicula ris oculi, a nd the dia phra gm a fte r a dministra tion of a n
intuba ting dose of ve curonium to a n othe rwise he a lthy pa tie nt.
A. Dia phra gm, orbicula ris oculi, thumb
B. Orbicula ris oculi, dia phra gm, thumb
C. Orbicula ris oculi, thumb, dia phra gm
D. Orbicula ris oculi sa me a s dia phra gm, thumb
228. Se le ct the T RUE sta te me nt re ga rding inte ra ction of
nonde pola rizing ne uromuscula r blocking drugs whe n dura tions of
a ction a re dissimila r.
A. If a long-a cting drug is a dministe re d a fte r a n inte rme dia te -
a cting drug, the dura tion of the long-a cting drug will be longe r
tha n norma l
B. If a long-a cting drug is a dministe re d a fte r a n inte rme dia te -
a cting drug, the dura tion of the long-a cting drug will be a bout
the sa me a s e xpe cte d
C. If a n inte rme dia te -a cting drug is a dministe re d a fte r a long-
a cting drug, the dura tion of the inte rme dia te -a cting drug will be
a bout the sa me a s e xpe cte d
D. If a n inte rme dia te -a cting drug is a dministe re d a fte r a long-
a cting drug, the dura tion of a ction of the inte rme dia te -a cting
drug will be longe r tha n e xpe cte d
229. Se le ct the corre ct sta te me nt re ga rding the e ffe cts of vola tile
a ne sthe tics on nonde pola rizing ne uromuscula r blocking drugs a nd
the re ve rsa l a ge nts.
A. Vola tile a ne sthe tics pote ntia te ne uromuscula r blocka de but
re ta rd re ve rsa l a ge nts
B. Vola tile a ne sthe tics pote ntia te both ne uromuscula r blocking
drugs a nd re ve rsa l a ge nts
C. Vola tile a ne sthe tics re ta rd both ne uromuscula r blocking drugs
a nd re ve rsa l a ge nts
D. Vola tile a ne sthe tics re ta rd ne uromuscula r blocking drugs but
pote ntia te re ve rsa l a ge nts
230. Me pe ridine is contra indica te d in pa tie nts ta king which of the
following drugs for Pa rkinson dise a se ?
A. Bromocriptine
B. Trihe xyphe nidyl (Arta ne )
C. Se le giline (Elde pryl)
D. Ama nta dine (Symme tre l)
231. Eme rge nce de lirium occurs most ofte n with
A. Se voflura ne
B. De sflura ne
C. Ke ta mine
D. Propofol
232. The most common re a son for pa tie nts to ra te a ne sthe sia with
e tomida te a s unsa tisfa ctory is
A. PONV
B. Pa in on inje ction
C. Re ca ll of intuba tion
D. Postope ra tive hiccups
233. W hich of the following muscle re la xa nts inhibits the re upta ke
of nore pine phrine by the a dre ne rgic ne rve s?
A. Pa ncuronium
B. Ve curonium
C. Rocuronium
D. Atra curium
234. The most common side e ffe ct of ora l da ntrole ne use d to
pre ve nt ma ligna nt hype rthe rmia is
A. Na use a a nd vomiting
B. Muscle we a kne ss
C. Blurre d vision
D. Ta chyca rdia
235. A 65-ye a r-old pa tie nt is a dmitte d for right uppe r qua dra nt pa in.
Acute chole cystitis is dia gnose d a nd la pa roscopic chole cyste ctomy
pla nne d. The pa tie nt ha s no ma jor me dica l proble ms othe r tha n
type 2 dia be te s, for which she ta ke s me tformin, a nd de pre ssion, for
which she ta ke s pa roxe tine (SSRI inhibitor). W hich of the following
be st de scribe s the ra tiona le for discontinua tion of me tformin 48
hours be fore surge ry?
A. Risk of me ta bolic a cidosis
B. Risk of hypoglyce mia
C. Risk of se rotonin syndrome
236. A 37-ye a r-old ma n is brought to the ope ra ting room for re pa ir of
a broke n ma ndible susta ine d in a motor ve hicle a ccide nt. No othe r
injurie s a re significa nt. The pa tie nt ha s be e n in tre a tme nt for
a lcohol a buse a nd ta ke s disulfira m a nd na ltre xone . W hich of the
following would be the be st te chnique for ma na ge me nt of this
pa tie nt’s postope ra tive pa in?
A. Continue na ltre xone with round-the -clock low-dose
me tha done
B. Continue na ltre xone with sma ll dose s of morphine e ve ry 4
hours a s ne e de d
C. Continue na ltre xone with sma ll dose s of na lbuphine e ve ry 4
hours a s ne e de d
D. Discontinue na ltre xone a nd tre a t pa in with morphine a s
ne e de d
237. W hich of the following muscle re la xa nts is most suita ble for
ra pid intuba tion in a pa tie nt in whom succinylcholine is
contra indica te d?
A. Atra curium
B. Rocuronium
C. Ve curonium
D. Cisa tra curium
238. The ne uromuscula r e ffe cts of a n intuba tion dose of
ve curonium a re te rmina te d by
A. Diffusion from the ne uromuscula r junction ba ck into the
pla sma
B. Nonspe cific pla sma choline ste ra se s
C. The kidne ys
D. The live r
239. Re spira tory de pre ssion produce d by which of the following
a na lge sics is not re a dily re ve rse d by a dministra tion of na loxone ?
A. Me pe ridine
B. Me tha done
C. Hydromorphone
D. Bupre norphine
240. W hich of the following intra ve nous a ne sthe tic a ge nts is
a ssocia te d with the highe st incide nce of na use a a nd vomiting?
A. Mida zola m
B. Etomida te
C. Ke ta mine
D. Propofol
241. If na loxone we re a dministe re d to a pa tie nt who is re ce iving
ke torola c for postope ra tive pa in, the most like ly re sult would be
A. Bra dyca rdia
B. Hypote nsion
C. Pa in
242. W hich drug produce s strong pulmona ry a rte ria l dila tion with
the le a st a mount of syste mic a rte ry dila tion?
A. Nitroprusside
B. Prosta gla ndin E1
C. Phe ntola mine
D. Nitric oxide
243. The a ction of succinylcholine a t the ne uromuscula r junction is
te rmina te d by which me cha nism?
A. Hydrolysis by pse udocholine ste ra se
B. Diffusion into e xtra ce llula r fluid
C. Re upta ke into ne rve tissue
D. Re upta ke into muscle tissue
244. The LEAST like ly side e ffe ct of de xme de tomidine in a he a lthy
pa tie nt is
A. Re spira tory a rre st
B. Bra dyca rdia
C. Sinus a rre st
D. Hypote nsion
245. The a dva nta ge of fospropofol (Luse dra ) ove r propofol is the
a bse nce of
A. Pa in on inje ction
B. Risk of hype rtriglyce ride mia
C. Risk of infe ction, se psis, or both
246. W hich of the following fe a ture s of chronic morphine the ra py is
NOT subje ct to tole ra nce ?
A. Ana lge sia
B. Re spira tory de pre ssion
C. Constipa tion
D. All a re subje ct to tole ra nce
247. A 78-ye a r-old woma n with a history of re a ctive a irwa ys dise a se
ta ke s cime tidine (Ta ga me t) 400 mg a t night. An a dditiona l dose is

give n IV 30 minute s be fore induction of a ne sthe sia for a n
e xplora tory la pa rotomy. Possible side e ffe cts a ssocia te d with this
drug include a ll of the following EXCEPT
A. Bra dyca rdia
B. De la ye d a wa ke ning
C. Confusion
D. Incre a se d me ta bolism of dia ze pa m
248. Intra ope ra tive a lle rgic re a ctions a re LEAST common a fte r
pa tie nt e xposure to
A. Ke ta mine
B. La te x
C. Muscle re la xa nts
D. Hydroxye thyl sta rch
249. W hich of the following me dica tions would be use ful in the
de finitive tre a tme nt of sa rin ne rve ga s poisoning?
A. Sodium nitroprusside
B. Me thyle ne blue
C. Atropine
D. All the a bove a re use ful
250. Alfe nta nil
A. Ha s a more ra pid onse t of a ction compa re d to fe nta nyl
B. Ha s a longe r dura tion of a ction compa re d with fe nta nyl
C. Is 250 time s more pote nt tha n fe nta nyl
D. Is e xcre te d uncha nge d in the urine
251. W hich of the following me dica tions is NOT use ful in the
imme dia te ma na ge me nt of sta tus a sthma ticus?
A. Te rbuta line
B. Subcuta ne ous (SQ) e pine phrine
C. Ma gne sium sulfa te
D. Cromolyn
252. Clonidine
A. Is a n α2 blocke r
B. Incre a se s CNS sympa the tic re sponse to pa inful stimuli
C. Ca n be give n ora lly a s we ll a s intra ve nously, but not e pidura lly
or intra the ca lly
D. De cre a se s posta ne sthe tic shive ring
253. The pla sma ha lf-time of which of the following drugs is
prolonge d in pa tie nts with e nd-sta ge cirrhotic live r dise a se ?
A. Dia ze pa m
B. Pa ncuronium
C. Alfe nta nil
D. All a re prolonge d
254. A 24-ye a r-old, 100-kg pa tie nt is brought to the e me rge ncy room
by the fire de pa rtme nt a fte r suffe ring smoke inha la tion a nd third-
de gre e burns on the a bdome n, che st, a nd thighs 30 minute s e a rlie r.
The be st muscle re la xa nt choice for the most ra pid intuba tion
would be
A. 2 mg ve curonium followe d by succinylcholine
B. 1 mg of ve curonium, the n 2 to 4 minute s la te r, 9 mg

ve curonium
C. Rocuronium
D. Succinylcholine
255. Clonidine is use ful in e a ch of the following a pplica tions
EXCEPT
A. Re ducing BP with phe ochromocytoma
B. Tre a tme nt of postope ra tive shive ring
C. Prote ction a ga inst pe riope ra tive myoca rdia l ische mia
D. As a n a ge nt for prolonging a bupiva ca ine spina l
256. A 79-ye a r-old ma n is brought to the ope ra ting room for e le ctive
re pa ir of bila te ra l inguina l he rnia s. The pa tie nt ha s a history of
a wa re ne ss during ge ne ra l a ne sthe sia a nd re fuse s re giona l
a ne sthe sia . The pa tie nt is pre oxyge na te d be fore induction of
ge ne ra l a ne sthe sia ; 5 mg of mida zola m a nd 250 mg of fe nta nyl a re

a dministe re d. One minute la te r the pa tie nt lose s consciousne ss
a nd che st wa ll stiffne ss de ve lops to the e xte nt tha t positive -
pre ssure ve ntila tion is ve ry difficult. The most a ppropria te the ra py
for re ve rsa l of che st wa ll stiffne ss a t this point could include
A. Fluma ze nil
B. Na loxone
C. Succinylcholine
D. Albute rol
257. Re spira tory de pre ssion is LEAST a fte r the induction dose of
which of the following drugs?
A. Etomida te
B. Ke ta mine
C. Fe nta nyl
D. Propofol
258. A 64-ye a r-old ma n with colon ca nce r is a ne sthe tize d for he pa tic
re se ction of live r me ta sta se s. Me dica l history is significa nt for ile a l
conduit surge ry for bla dde r ca nce r, dia be te s tre a te d with glyburide ,
50 pa cks pe r ye a r smoking history, a nd fa mily history of ma ligna nt
hype rthe rmia . Ane sthe sia is provide d with morphine , mida zola m,
oxyge n, a nd a propofol infusion. Afte r a 3-unit pa cke d re d blood
ce ll (RBC) tra nsfusion a nd 8 hours of surge ry, the following blood
ga s va lue s a re re corde d: pH 7.2, CO2 34, [HCO3–] 14, ba se de ficit
−13, [Na +] 135, [K+] 5, [Cl–] 95, glucose 240 mg/dL. The most like ly
ca use of this pa tie nt’s a cidosis is
A. Exce ssive infusion of norma l sa line
B. Re na l tubula r a cidosis
C. Propofol infusion syndrome
D. Dia be tic ke toa cidosis
259. Tre a tme nt of ne urole ptic ma ligna nt syndrome ma y be ca rrie d
out with a dministra tion of the following drugs EXCEPT
A. Ama nta dine
B. Da ntrole ne
C. Bromocriptine
D. Physostigmine
260. A pa tie nt with a norma l qua ntity of pse udocholine ste ra se
(pla sma choline ste ra se ) ha s a dibuca ine numbe r of 57. A 1 mg/kg

dose of intra ve nous succinylcholine would like ly re sult in
A. Hype rka le mic ca rdia c a rre st
B. Pa ra lysis la sting 5 to 10 minute s
C. Pa ra lysis la sting 20 to 30 minute s
D. Pa ra lysis la sting more tha n 1 to 3 hours
261. Cya nide toxicity ma y be tre a te d with a ll of the following drugs
EXCEPT
A. Sodium nitrite
B. Hydroxocoba la min
C. Sodium thiosulfa te
D. Me thyle ne blue
262. A prolonge d ne uromuscula r block with succinylcholine ca n be
se e n in a ll of the following pa tie nts EXCEPT those
A. Chronica lly e xpose d to ma la thion
B. Tre a te d with e chothiopha te for gla ucoma
C. Tre a te d with cyclophospha mide for me ta sta tic ca nce r
D. Ha ving a C5 isoe nzyme va ria nt
263. W hich of the following sta te me nts conce rning mida zola m is
FALSE?
A. Mida zola m ha s gre a te r a mne stic tha n se da tive prope rtie s
B. Its bre a kdown is inhibite d by cime tidine
C. It produce s re trogra de a mne sia
D. It fa cilita te s the a ctions of the inhibitory ne urotra nsmitte r γ-
a minobutyric a cid (GABA) in the CNS
264. Afte r a 2-hour ve rtica l ga stric ba nding proce dure unde r
de sflura ne , oxyge n, a nd re mife nta nil a ne sthe sia , the troca r is
re move d a nd the wound is close d. Upon e me rge nce , the most
like ly sce na rio is
A. Ade qua te a na lge sia for 2 hours
B. De la ye d e me rge nce from na rcotic
C. Pa in
D. Re spira tory de pre ssion in posta ne sthe sia ca re unit (PACU)
265. An ora l surge on is a bout to pe rform a full mouth e xtra ction on
a 70-kg, 63-ye a r-old ma n unde r conscious se da tion. W ha t is the
ma ximum dose of lidoca ine with e pine phrine tha t he ca n sa fe ly
infiltra te ?
A. 200 mg
B. 300 mg
C. 400 mg
D. 500 mg
266. Posta ne sthe tic shive ring ca n be tre a te d with a ll of the
following EXCEPT
A. Na loxone
B. Physostigmine
C. Ma gne sium sulfa te
D. De xme de tomidine
267. The ma in disa dva nta ge of Suga mma de x (ORG 25969) compa re d
with ne ostigmine is
A. Re cura riza tion
B. Contra indica te d with re na l fa ilure
C. Not e ffe ctive with be nzylisoquinolinium re la xa nts
D. High incide nce of a lle rgic re a ctions
268. W hich of the biologic substa nce s liste d be low is by itse lf the
gre a te st de te rmina nt of se rum osmola lity?
A. AVP (a rginine va sopre ssin)
B. Angiote nsin I
C. Aldoste rone
D. Re na l prosta gla ndins (PGE2)
269. Above which infusion ra te doe s cya nide toxicity be come a
conce rn in a he a lthy a dult re ce iving sodium nitroprusside ?
A. 0.5 µg/kg/min
B. 2 µg/kg/min
C. 10 µg/kg/min
D. 20 µg/kg/min
270. Importa nt inte ra ctions involving chlorproma zine include a ll of
the following EXCEPT
A. Pote ntia tion of the de pre ssa nt e ffe cts of na rcotics
B. Lowe ring of the se izure thre shold
C. Prolonga tion of the QT inte rva l
D. Pote ntia tion of ne uromuscula r blocka de
271. Amrinone
A. Is a positive inotropic drug
B. Is a nta gonize d by e smolol
C. Is a va soconstrictor
D. All the a bove
272. W hich sta te me nt conce rning tricyclic a ntide pre ssa nts in
pa tie nts re ce iving ge ne ra l a ne sthe sia is T RUE?
A. The y should be discontinue d 2 we e ks be fore e le ctive
ope ra tions
B. The y ma y de cre a se the re quire me nt for vola tile a ne sthe tics
(de cre a se MAC)
C. Me pe ridine ma y produce hype rpyre xia in pa tie nts ta king
tricyclic a ntide pre ssa nts
D. The y ma y e xa gge ra te the re sponse to e phe drine
273. W hich of the following type s of insulin pre pa ra tions ha s the
fa ste st onse t of a ction if a dministe re d subcuta ne ously?
A. Gla rgine (La ntus)
B. Lispro (Huma log)
C. Re gula r (Humulin-R)
D. NPH (Humulin-N)
274. W hich of the following me cha nisms be st e xpla ins the
a nticoa gula tive prope rtie s of tirofiba n?
A. Cyclooxyge na se (COX) inhibition
B. Inte ra ction with von W ille bra nd fa ctor (vW F)
C. Inte ra ction with a ntithrombin III
D. Enha nce d a nti-Xa a ctivity
275. The dura tion of a ction of re mife nta nil is a ttributa ble to which
mode of me ta bolism?
A. Sponta ne ous de gra da tion in blood (Hofma nn e limina tion)
B. Hydrolysis by nonspe cific pla sma e ste ra se s
C. Hydrolysis by pse udocholine ste ra se
D. Ra pid me ta bolism in the la rge inte stine
276. Pa in a t the intra ve nous site is LEAST with which IV drug?
A. Dia ze pa m
B. Etomida te
C. Ke ta mine
D. Propofol
277. A 35-ye a r-old pa tie nt with a history of gra nd ma l se izure s is
a ne sthe tize d for thyroid biopsy unde r ge ne ra l a ne sthe sia consisting
of 4 mg mida zola m with infusion of propofol (150 µg/kg/min) a nd
re mife nta nil (1 µg/kg/min). The pa tie nt ta ke s phe nytoin for control
of se izure s. Afte r 30 minute s, the infusion is stoppe d a nd the

pa tie nt is tra nsporte d intuba te d to the re cove ry room whe re he is
a rousa ble , but not bre a thing. The most re a sona ble course of a ction
would be
A. Administe r na loxone
B. Administe r fluma ze nil
C. Administe r na loxone a nd fluma ze nil
D. Ve ntila te by ha nd
278. W hich of the following α-a nta gonists produce s a n irre ve rsible
blocka de ?
A. Phe ntola mine
B. Pra zosin
C. Phe noxybe nza mine
D. La be ta lol
279. Me toprolol is re la tive ly contra indica te d for tre a tme nt of
ta chyca rdia in the se tting of
A. Hype rtrophic obstructive ca rdiomyopa thy (HOCM)
B. W PW syndrome (with na rrow QRS)
C. Prolonge d QT syndrome
D. Ca rdia c ta mpona de
280. A dose of 150 mg of IV da ntrole ne is a dministe re d to a 24-ye a r-

old, 75-kg ma n in whom incipie nt ma ligna nt hype rthe rmia is
suspe cte d. An e xpe cte d conse que nce of this the ra py would be
A. Muscle spa sticity in the postope ra tive pe riod
B. Hypothe rmia
C. Ca rdia c dysrhythmia s
D. Diure sis
281. Atra curium diffe rs from cisa tra curium in which wa y?
B. Forma tion of la uda nosine
C. Hista mine re le a se
D. No re na l me ta bolism
282. Signs a nd symptoms of opioid withdra wa l include a ll of the
following EXCEPT
A. Incre a se d BP a nd he a rt ra te
B. Se izure s
C. Abdomina l cra mps
D. Je rking of the le gs
DIRECT IONS (Que stions 283 through 320): Ea ch group of

que stions consists of se ve ra l numbe re d sta te me nts followe d
by le tte re d he a dings. For e a ch numbe re d sta te me nt, se le ct
the ONE le tte re d he a ding tha t is most close ly a ssocia te d with
it. Ea ch le tte re d he a ding ma y be se le cte d once , more tha n
once , or not a t a ll.
Group 283-287
283. Adre na l suppre ssion
284. Thrombosis, phle bitis, spe cific a nta gonist a va ila ble
285. Pa in on inje ction, se ve re hypote nsion in e lde rly
286. Incre a se s ICP
287. La ctic a cidosis ma y de ve lop with prolonge d use
A. Ke ta mine
B. Dia ze pa m
C. Etomida te
D. Propofol
Group 288-292
288. Re duce s MAC
289. Blocka de of a ngiote nsin re ce ptor
290. W ith high dose s ma y ca use a syste mic lupus e rythe ma tosus–
like syndrome
291. Produce s α-a dre ne rgic re ce ptor a nd β-a dre ne rgic re ce ptor
blocka de
292. Ma y re sult in se ve re re bound hype rte nsion whe n a bruptly
discontinue d
A. Clonidine
B. Hydra la zine
C. Losa rta n
D. La be ta lol
Group 293-297
293. Alte rna tive to he pa rin for ca rdiopulmona ry bypa ss
294. Glycoprote in (GP)IIb/IIIa inhibition
295. Dire ct thrombin inhibition
296. Use d a fte r a ngiopla sty ofte n for a ye a r or more to pre ve nt
re ste nosis
297. Anti-Xa a ctivity me cha nism of a ction
A. Arga troba n
B. Clopidogre l
C. Abcixima b
D. Fonda pa rinux
Group 298-301
298. Of the list, most like ly to be a ssocia te d with opioid induce d
hype ra lge sia
299. De monstra te s ce iling e ffe ct with re ga rd to re spira tory
de pre ssion
300. Anta gonism of NMDA re ce ptors
301. Nore pine phrine re upta ke inhibitor (NRI)
A. Me tha done
B. Re mife nta nil
C. Ta pe nta dol (Nucynta )
D. Butorpha nol
Group 302-305
302. Block is a nta gonize d with a nticholine ste ra se drugs
303. Block is e nha nce d with a nticholine ste ra se drugs
304. Post-te ta nic fa cilita tion occurs
305. Susta ine d re sponse to te ta nic stimulus is se e n
A. True of nonde pola rizing blocka de only
B. True of pha se I de pola rizing blocka de only
C. True of pha se II de pola rizing blocka de only
D. True of nonde pola rizing a nd pha se II de pola rizing blocka de
Group 306-315
306. Amphe ta mine s
307. α2 Agonists (clonidine , de xme de tomidine )
308. Hype rthyroidism
309. Acute e tha nol inge stion
310. Lidoca ine
311. Lithium
312. Opioids
313. Dura tion of a ne sthe sia
314. Pre gna ncy
315. Pa O2 35 mm Hg
A. No cha nge in MAC
B. Incre a se s MAC
C. De cre a se s MAC
D. Acute a dministra tion incre a se s MAC; chronic a dministra tion
de cre a se s MAC
Group 316-320
316. Le a st e ffe ctive a ntisia la gogue
317. Produce s be st se da tion
318. Ca use s gre a te st incre a se in he a rt ra te
319. Doe s not produce ce ntra l a nticholine rgic syndrome
320. Ma y produce mydria sis a nd cyclople gia whe n pla ce d topica lly
in the e ye
A. Atropine
B. Glycopyrrola te
C. Scopola mine
D. Atropine a nd scopola mine
Pharmacology and Pharmacokinetics of
Intravenous Drugs
169. (A) The dura tion of a ction of ne uromuscula r blocking drugs is
re la te d to the dose a dministe re d, a s we ll a s how the drug is
me ta bolize d or ha ndle d in the body. Succinylcholine norma lly is
ra pidly me ta bolize d by pla sma choline ste ra se a nd ha s a n
ultra short dura tion of a ction. The inte rme dia te -dura tion
ne uromuscula r blocke rs a tra curium a nd cisa tra curium unde rgo
che mica l bre a kdown in the pla sma (Hofma nn e limina tion), a s we ll
a s e ste r hydrolysis. Ve curonium a nd rocuronium a lso ha ve
inte rme dia te dura tion of a ctions a nd unde rgo prima rily he pa tic
me ta bolism a nd bilia ry e xcre tion with limite d re na l e xcre tion
(10%-25%). Only the long-dura tion ne uromuscula r blocke r
pa ncuronium is prima rily e xcre te d in the urine (80%). In pa tie nts
with re na l fa ilure , the dura tion of a ction of ne uromuscula r blocke rs
is not prolonge d with a tra curium or cisa tra curium; is slightly
prolonge d with ve curonium a nd rocuronium; a nd is ma rke dly
prolonge d with D-tubocura rine , pa ncuronium, doxa curium, a nd
pipe curonium. Of the long-dura tion drugs, 80% of pa ncuronium, 70%
of doxa curium, a nd 70% of pipe curonium a re re na lly e xcre te d
uncha nge d in the urine . D-tubocura rine ha s a little more live r
e xcre tion a nd a little le ss re na l e limina tion compa re d with
pa ncuronium (Miller: Miller’s Anesth esia, ed 8, pp 975–977).
COMPARATIVE PHARMACOLOGY OF NONDEPOLARIZING
NEUROMUSCULAR BLOCKING DRUGS
NA, not applicable; NS, not significant.
∗ Control twitch height (minutes).
170. (D) Pa ncre a titis ha s be e n re porte d in pa tie nts on long-te rm

propofol infusions. Be ca use of the high fa t conte nt of propofol
solutions (propofol is insoluble in a que ous solutions a nd is
ma rke te d a s a n e mulsion conta ining 10% soybe a n oil, 2.25%
glyce rol, a nd 1.2% purifie d e gg phospha tide ), pa tie nts on long-te rm
infusion should be che cke d for hype rlipide mia a nd pa tie nts
re ce iving TPN should ha ve the Intra lipid portion of the TPN
re duce d. Propofol infusion syndrome is commonly de fine d a s a n
a cute onse t of me ta bolic a cidosis a ssocia te d with ca rdia c
dysfunction (e .g., bra dyca rdia or right bundle bra nch block), a nd
one of the following: rha bdomyolysis, hype rtriglyce ride mia ,
e nla rge d live r, or re na l fa ilure . Propofol de cre a se s myoca rdia l
contra ctility a nd re duce s syste mic va scula r re sista nce but doe s not
ca use a dre na l suppre ssion. The la tte r is a fe a ture of e tomida te
a dministra tion (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 536–537; Miller: Basics of Anesth esia, ed
6, p 671).
171. (B) β-Adre ne rgic re ce ptor a nta gonists a re of thre e ge ne ra tions.
First-ge ne ra tion a nta gonists a re nonse le ctive β1 a nd β2 re ce ptor
blocke rs a nd include na dolol (Corga rd), propra nolol (Inde ra l),
sota lol (Be ta pa ce ), a nd timolol (Bloca dre n, Timoptic). Se cond-
ge ne ra tion a nta gonists a re ca rdiose le ctive β1 re ce ptor blocke rs a nd
include a ce butolol (Se ctra l), a te nolol (Te normin), bisoprolol
(Ze be ta ), e smolol (Bre vibloc), a nd me toprolol (Lopre ssor). Third-
ge ne ra tion β-a dre ne rgic a nta gonists (mixe d a nta gonists) ha ve
nonse le ctive β1 a nd β2 re ce ptor blocking a ctions a nd ha ve
a dditiona l ca rdiova scula r e ffe cts (α1-a dre ne rgic a nta gonist) a nd
include la be ta lol (Normodyne , Tra nda te ) a nd ca rve dilol (Core g).
Ca rve dilol a lso ha s some a ntioxida nt a nd a nti-infla mma tory e ffe cts
a s we ll. Ma ny of the se drugs ha ve a dditiona l tra de na me s (Brunton:
Good m an & Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12,
pp 320–330; Hem m ings; Ph arm acology and Ph y siology for Anesth esia, pp
172. (C) Pa rkinson dise a se (pa ra lysis a gita ns or sha king pa lsy) is a
de ge ne ra tive CNS dise a se . It is ca use d by gre a te r tha n 80%
de struction of dopa mine rgic ne urons in the substa ntia nigra of the
ba sa l ga nglia . Dopa mine a cts a s a ne urotra nsmitte r to inhibit the
ra te of firing of ne urons tha t control the e xtra pyra mida l motor
syste m. The imba la nce of ne urotra nsmitte rs tha t re sults le a ds to
the e xtra pyra mida l symptoms of this dise a se . Symptoms include
bra dykine sia (slowne ss of move me nt), muscula r rigidity, re sting
tre mor (tha t le sse ns with volunta ry move me nt), a nd impa ire d
ba la nce . Drugs tha t ca n produce e xtra pyra mida l e ffe cts, such a s
the dopa mine a nta gonists drope ridol, prome tha zine , a nd
thie thylpe ra zine , a s we ll a s the dopa mine a nd se rotonin a nta gonist
me toclopra mide , a re contra indica te d. Onda nse tron, a 5-
hydroxytrypta mine type 3 (5-HT 3) re ce ptor a nta gonist, is the
pre fe rre d drug to tre a t na use a a nd vomiting for this pa tie nt (Barash :
Clinical Anesth esia, ed 7 , p 621; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 646–647).
173. (A) In orde r for de pola rizing muscle re la xa nts such a s
succinylcholine to work, the drug must inte ra ct with the re ce ptor a t
the myone ura l junction. Pa tie nts with mya sthe nia gra vis ha ve
fe we r a ce tylcholine re ce ptors on the muscle a nd a re more
re sista nt to succinylcholine but a re much more se nsitive to
nonde pola rizing muscle re la xa nts. Pa tie nts with mya sthe nic
syndrome (Ea ton-La mbe rt syndrome ) ha ve a de cre a se d re le a se of
a ce tylcholine a t the myone ura l junction; howe ve r, the numbe r of
re ce ptors is norma l. Pa tie nts with mya sthe nic syndrome a re more
se nsitive to both de pola rizing a nd nonde pola rizing muscle
re la xa nts. Huntington chore a is a de ge ne ra tive CNS dise a se tha t is
a ssocia te d with de cre a se d pla sma choline ste ra se a ctivity, a nd
prolonge d re sponse s to succinylcholine use ha ve be e n se e n. The
re sponse to de pola rizing a nd nonde pola rizing muscle re la xa nts
a ppe a rs to be uncha nge d in pa tie nts with polymyositis.
Succinylcholine is contra indica te d in pa tie nts with Duche nne
muscula r dystrophy be ca use of the risks of rha bdomyolysis,
hype rka le mia , a nd ca rdia c a rre st. Nonde pola rizing muscle
re la xa nts ha ve a norma l re sponse in pa tie nts with Duche nne
muscula r dystrophy, a lthough some pa tie nts ha ve promine nt
coe xisting ske le ta l muscle we a kne ss (Fleish er: Anesth esia and
Uncom m on Diseases, ed 6, pp 264–265, 313–316, 574; Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 247, 444, 448–452).
174. (C) Se da tion is commonly use d in the ICU to pre ve nt pa tie nt
injury, de cre a se a nxie ty, re duce pa in, re duce sympa the tic
stimula tion, a nd he lp with ve ntila tor dyssynchrony. Ma ny diffe re nt
drugs ha ve be e n use d, including ba rbitura te s, na rcotics (e .g.,
fe nta nyl, morphine ), be nzodia ze pine s (e .g., mida zola m, lora ze pa m),
e tomida te , ke ta mine , a ntipsychotics (e .g., ha lope ridol), propofol,
a nd α2-a dre ne rgic a gonists (e .g., de xme de tomidine ). Although de e p
se da tion wa s commonly use d, more re ce nt e vide nce ha s sugge ste d
tha t pa tie nts te nd to ha ve fe we r complica tions with light se da tion
a nd da ily a wa ke ning (e .g., shorte r dura tion of me cha nica l
ve ntila tion, le ss ca rdiova scula r de pre ssion, a nd shorte r ICU sta ys).
The choice of drugs de pe nds on the pa rticula r indica tions.
De xme de tomidine ha s se ve ra l de sira ble e ffe cts, e spe cia lly in the
ne urosurgica l ICU, including se da tion, a na lge sia , a nd little e ffe ct on
re spira tory drive . Its se da tive prope rtie s re se mble norma l sle e p in
tha t the se da te d pa tie nt ca n be e a sily a rouse d with stimula tion a nd
the n ra pidly fa ll ba ck to sle e p a fte r stimula tion e nds.
De xme de tomidine doe s ha ve some disa dva nta ge s, such a s cost
a nd U.S. Food a nd Drug Administra tion (FDA)-a pprove d use for
only 24 hours (Barash : Clinical Anesth esia, ed 7, pp 1584, 1599–1600;
175. (B) Dia ze pa m (Va lium) a nd lora ze pa m a re wa te r-insoluble
be nzodia ze pine s a nd a re usua lly mixe d with propyle ne glycol to
be come soluble solutions. The se propyle ne glycol solutions a re
pa inful whe n inje cte d. Mida zola m ha s a n imida zole ring tha t a llows
the drug to be wa te r soluble in a n a cid pH (pH 3.5). W he n inje cte d
into the bloodstre a m, mida zola m is e xpose d to the highe r
physiologic pH a nd the ring cha nge s sha pe a nd the drug be come s
lipid soluble . The lipid-soluble form re a dily crosse s the blood-bra in
ba rrie r to e xe rt its pha rma cologic e ffe cts. None of the othe r drugs
cha nge form with diffe re nt pH (Hem m ings: Ph arm acology and
Ph y siology for Anesth esia, pp 144–145).
176. (C) The a mount of submucosa lly inje cte d e pine phrine re quire d
to produce ve ntricula r ca rdia c dysrhythmia s (i.e ., thre e or more
pre ma ture ve ntricula r contra ctions during or a fte r inje ction) va rie s
with the vola tile a ne sthe tic a dministe re d. Pa tie nts unde r ha lotha ne
a ne sthe sia a re pa rticula rly se nsitive to ve ntricula r a rrhythmia s,
whe re a s pa tie nts with isoflura ne , de sflura ne , a nd se voflura ne a re
le ss se nsitive to e pine phrine . Fifty pe rce nt of pa tie nts ha ve
ve ntricula r a rrhythmia s whe n a dose of 2.1 µg/kg of e pine phrine is

a dministe re d submucosa lly into pa tie nts unde r ha lotha ne
a ne sthe sia . Ve ntricula r a rrhythmia s do not se e m to occur whe n a
dose of up to 5 µg/kg of e pine phrine is inje cte d submucosa lly into

pa tie nts unde r 1.2 MAC of se voflura ne or isoflura ne in oxyge n
a ne sthe sia . Howe ve r, whe n the dose of e pine phrine is incre a se d
to be twe e n 5 a nd 15 µg/kg, the n a bout one third of pa tie nts will

e xhibit ve ntricula r e ctopy unde r se voflura ne or isoflura ne
a ne sthe sia . Thus, using the 5 µg/kg ma ximum dose , a 70-kg pa tie nt
could re ce ive up to 350 µg of e pine phrine (70 kg × 5 µg/kg) or
35 mL of this 1:100,000 solution (10 µg/mL) without ve ntricula r

a rrhythmia s (Joh nston: A com parative interaction of epineph rine with
enflurane, isoflurane and h aloth ane in m an. Anesth Analg 55:709–712,
1976; Navarro: Hum ans anesth etized with sevoflurane or isoflurane h ave
sim ilar arrh y th m ic response to epineph rine. Anesth esiology 80:545–549,
1994; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed
4, pp 54–56; Miller: Miller’s Anesth esia, ed 8, p 713).
177. (D) β-Adre ne rgic re ce ptor a nta gonists a re e ffe ctive in the
tre a tme nt of e sse ntia l hype rte nsion a nd a ngina pe ctoris. The y ca n
be use d to de cre a se morta lity in pa tie nts suffe ring myoca rdia l
infa rctions; to tre a t hype rthyroidism or hype rtrophic obstructive
ca rdiomyopa thy; a nd to pre ve nt migra ine he a da che s. Although the y
a re use ful drugs, the ir use is limite d by ma ny side e ffe cts, which
include bronchoconstriction, suppre ssion of insulin se cre tion,
blunting of the ca te chola mine re sponse to hypoglyce mia , e xce ssive
myoca rdia l de pre ssion, a triove ntricula r he a rt block, a cce ntua te d
incre a se s in pla sma conce ntra tions of pota ssium with intra ve nous
infusion of pota ssium chloride , fa tigue , a nd re bound ta chyca rdia
a ssocia te d with a brupt drug discontinua tion. An importa nt
a dva nta ge of β-a dre ne rgic re ce ptor a nta gonists use d in tre a ting
hype rte nsion is the la ck of orthosta tic hypote nsion (Brunton:
Good m an & Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12,
pp 320–324; Miller: Basics of Anesth esia, ed 6, pp 745–775; Miller: Miller’s
178. (C) Anticholine rgics a re ra re ly give n with pre me dica tion toda y
unle ss a spe cific e ffe ct is ne e de d (e .g., drying of the mouth be fore
fibe roptic intuba tion, pre ve ntion of bra dyca rdia , a nd, ra re ly, a s a
mild se da tive ). Side e ffe cts a re ma ny a nd include re la xa tion or a
de cre a se of the lowe r e sopha ge a l sphincte r tone tha t ma y ma ke
pa tie nts more like ly to re gurgita te ga stric conte nts. Although the se
drugs ca n de cre a se ga stric a cid se cre tion a nd incre a se ga stric pH,
the pH e ffe cts a re sma ll a nd the dose ne e de d to a ccomplish this is
much highe r tha n clinica lly use d. The following ta ble compa re s the
e ffe cts of va rious a nticholine rgics (Hem m ings, Ph arm acology and
Ph y siology for Anesth esia, pp 229–232; Miller: Basics of Anesth esia, ed 6,
pp 75–76; Miller: Miller’s Anesth esia, ed 8, pp 377-378).
COMPARATIVE EFFECTS OF ANTICHOLINERGICS ADMINISTERED
INTRAMUSCULARLY AS PHARMACOLOGIC PREMEDICATION
179. (D) Ne ostigmine , pyridostigmine , e drophonium, a nd

physostigmine a re a nticholine ste ra se drugs. Ne ostigmine ,
pyridostigmine , a nd e drophonium a re qua te rna ry a mmonium
compounds a nd do not pa ss the blood-bra in ba rrie r. Howe ve r,
physostigmine is a te rtia ry a mine a nd doe s cross the blood-bra in
ba rrie r. This prope rty ma ke s physostigmine use ful in the tre a tme nt
for ce ntra l a nticholine rgic syndrome (a lso ca lle d postope ra tive
de lirium or a tropine toxicity) (Barash : Clinical Anesth esia, ed 7, pp 382–
383).
180. (D) W he re a s propofol, ba rbitura te s, e tomida te , a nd
be nzodia ze pine s e xe rt much, if not a ll, of the ir pha rma cologic
e ffe cts via the GABA re ce ptors, ke ta mine ha s only we a k a ctivity on
the GABA re ce ptors. Ke ta mine ’s me cha nism of a ction is comple x,
with most of the e ffe cts due to inte ra ction with NMDA re ce ptors.
Ke ta mine a lso inte ra cts with monoa mine rgic, musca rinic, a nd
opioid re ce ptors, a s we ll a s volta ge -se nsitive ca lcium ion cha nne ls
181. (D) All of the drugs liste d a re opioids. Me pe ridine is
structura lly simila r to a tropine a nd posse sse s mild a nticholine rgic
prope rtie s. In contra st to othe r opioid-re ce ptor a gonists,
me pe ridine ra re ly ca use s bra dyca rdia but ca n incre a se he a rt ra te .
Norme pe ridine , a me ta bolite of me pe ridine with some CNS-
stimula ting prope rtie s, ma y ca use de lirium a nd se izure s if the le ve l
is high e nough. This is more like ly in pa tie nts who ha ve re na l
impa irme nt a nd a re re ce iving me pe ridine ove r se ve ra l da ys
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
102–104).
182. (D) In the Unite d Sta te s, ke ta mine is pre pa re d a s a mixture of
the two isome rs S(+) a nd R(−). In some countrie s, the S(+) isome r,
which is more pote nt a nd ha s fe we r side e ffe cts, is a va ila ble . All of
the sta te me nts a re true e xce pt for a nswe r D. Norke ta mine
(ke ta mine ’s prima ry a ctive me ta bolite ) is one fifth to one third a s
pote nt a s ke ta mine a nd ca n contribute to prolonge d e ffe cts (Barash :
Clinical Anesth esia, ed 7, pp 743–747; Miller: Basics of Anesth esia, ed 6,
pp 109–111).
183. (B) Dire ct-a cting sympa thomime tic drugs work dire ctly on the
re ce ptors. Indire ct-a cting sympa thomime tic drugs ha ve the ir e ffe cts
prima rily by e nte ring the ne urons a nd the n displa cing
nore pine phrine a nd ca using the re le a se of nore pine phrine from the
postga nglionic sympa the tic ne rve fibe rs. Ephe drine ,
me phe nte rmine , a nd me ta ra minol a re prima rily indire ct-a cting
sympa thomime tic a ge nts tha t a lso ma y ha ve some dire ct-a cting
prope rtie s. The following ta ble summa rize s the sympa thomime tic
a ge nts a nd the ir e ffe cts on the a dre ne rgic re ce ptors (Miller: Basics of
CLASSIFICATION AND COMPARATIVE PHARMACOLOGY OF
SYMPATHOMIMETICS
From Stoelting RK: Pharmacology and Physiology in Anesthetic Practice, ed 4, Philadelphia,
Lippincott Williams & Wilkins, 2006, p 293.
184. (D) Na loxone , na ltre xone , a nd na lme fe ne a re opioid re ce ptor

a nta gonists tha t ca n re ve rse the ce ntra l a nd pe riphe ra l e ffe cts of
opioids (e .g., me tha done ). Me thylna ltre xone is a qua te rna ry
a mmonium opioid re ce ptor a nta gonist tha t doe s not pe ne tra te the
CNS (i.e ., doe s not re ve rse a na lge sia ) but doe s a nta gonize
pe riphe ra l opioid re ce ptors (i.e ., blocks the GI tra ct’s opioid
re ce ptors a nd ca n tre a t opioid-induce d constipa tion). Be ca use of its
structure it is not a bsorbe d a fte r ora l a dministra tion, so it is
a dministe re d by inje ction (Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, pp 265–267; Miller: Miller’s Anesth esia, ed 8, pp 904–906).
185. (B) Pa tie nts with HIV ta ke a t le a st thre e drugs simulta ne ously
during the ir tre a tme nt. A va rie ty of a ntire trovira l drugs such a s
nucle oside re ve rse tra nscripta se inhibitors (NRTIs), non-nucle oside
re ve rse tra nscripta se inhibitors (NNRTIs), e ntry inhibitors,
inte gra se inhibitors, a nd/or prote a se inhibitors a re use d. Indina vir,
ne lfina vir, a nd ritona vir a re thre e of ma ny prote a se inhibitors
curre ntly a va ila ble . All prote a se e nzyme inhibitors ha ve me ta bolic
drug inte ra ctions. Most (e spe cia lly ritona vir in clinica l dose s)
irre ve rsibly inhibits CYP3A4 a nd this inhibition could la st for 2 to 3
da ys a fte r the drug is stoppe d.
CYP3A4 is involve d in the me ta bolism of be nzodia ze pine s (e .g.,
mida zola m) a nd ma ny opioids (e .g., fe nta nyl), a nd the se drugs
will ha ve highe r conce ntra tions a nd prolonge d e limina tion time s
whe n prote a se inhibitors a re use d. Prote a se inhibitors ca n a lso
induce the production of the CYP e nzyme s a llowing some drugs
(e .g., e stroge ns) to be me ta bolize d more quickly. In a ddition,
prote a se inhibitors ma y ca use glucose intole ra nce , disorde rs in
lipid me ta bolism, pre ma ture a the roscle rosis, a nd dia stolic
dysfunction le a ding to he a rt fa ilure , a s we ll a s a cute tubula r
ne crosis a nd ne phrolithia sis (Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, pp 1623–1660; Hines:
186. (C) Apre pita nt is a n NK1 a nta gonist (substa nce P a nta gonist)
with a long ha lf-life of 9 to 13 hours. It is ora lly a dministe re d for the
pre ve ntion a nd tre a tme nt of PONV, a lthough it se e ms be tte r in
pre ve nting vomiting. NK1 a nta gonists ma y a ct syne rgistica lly with 5-
HT 3 a nta gonists a nd/or de xa me tha sone . Apre pita nt is not
a ssocia te d with QTc prolonga tion. Although ma rke te d for its
a ntie me tic e ffe cts, it ha s some a nxiolytic a nd mild a ntide pre ssa nt
e ffe cts a s we ll (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, p 512; Miller: Miller’s Anesth esia, ed 8, pp 2637, 2967–2968).
187. (B) Echothiopha te is a n orga nophospha te tha t inhibits
a ce tylcholine ste ra se a s we ll a s pse udocholine ste ra se , which is
re sponsible for the me ta bolism of succinylcholine a nd e ste r-type
loca l a ne sthe tics. It doe s this by forming a phosphoryla te d comple x
with a ce tylcholine ste ra se . The topica l solution is instille d in the
e ye for tre a tme nt of re fra ctory ope n-a ngle gla ucoma . The a mount
of drug a bsorbe d ma y be sufficie nt to inhibit a ce tylcholine ste ra se
a nd ca use prolonga tion in the dura tion of a ction of succinylcholine
or miva curium. Be ca use of this, it is “re comme nde d” to wa it a t
le a st 3 we e ks a fte r the stoppa ge of e chothiopha te be fore the
a dministra tion of the se two muscle re la xa nts. One must wonde r
a bout the se “re comme nda tions” be ca use clinica l ca se s ha ve
shown tha t whe n choline ste ra se a ctivity is de cre a se d (from
e chothiopha te ) to no a ctivity, the incre a se in dura tion of
ne uromuscula r block from succinylcholine wa s le ss tha n 25
minute s (Miller: Miller’s Anesth esia, ed 8, p 379).
188. (D) Monitoring ne uromuscula r blocka de for nonde pola rizing
muscle re la xa nts ca n be done in a va rie ty of wa ys. The simple st
wa y is to me a sure the re duction or suppre ssion of a single twitch
he ight. This is commonly pe rforme d by obse rving the twitch
re sponse of the thumb’s a dductor pollicis muscle , a fte r ulna r ne rve
stimula tion. At 90% to 95% re duction of twitch he ight (i.e ., ED90 to
ED95) the re is good muscle re la xa tion for intuba tion a nd intra -
a bdomina l surge ry. Howe ve r, me a suring the re duction of twitch
he ight is not pra ctica l. Be ca use the re is good corre la tion be twe e n
re duction of twitch he ight a nd the numbe r of thumb twitche s tha t
ca n be e licite d by TOF stimula tion, TOF stimula tion is more
commonly use d whe re four twitche s a re a dministe re d ove r 2
se conds. If only one twitch of a TOF is de monstra te d, single twitch
he ight is de pre sse d a t le a st 85%; with two to four thumb twitche s,
70% to 85% de pre ssion is se e n. Note tha t the pre se nce of four
twitche s doe s not me a n tha t ne uromuscula r function ha s
comple te ly re cove re d; in fa ct, a significa nt numbe r of re ce ptors
ma y still be occupie d by the muscle re la xa nt (Barash : Clinical
189. (C) The re a re two ma jor che mica l cla sse s of nonde pola rizing
muscle re la xa nts: the a minoste roids (-onium drugs) a nd the
be nzylisoquinolinium (-urium) drugs. In ge ne ra l, the a minoste roids
ca use no significa nt hista mine re le a se (a t the clinica l dose s of 2 to
3 × ED95), whe re a s some of the be nzylisoquinolinium drugs ca n.
The hista mine re le a se prima rily occurs with ra pid a dministra tion
of a tra curium but doe s not occur with cisa tra curium or doxa curium.
The a mount of hista mine re le a se d is ra re ly of clinica l significa nce .
The ca rdiova scula r e ffe cts of ne uromuscula r blocking drugs occur
by thre e ma in me cha nisms: (1) drug-induce d hista mine re le a se ; (2)
e ffe cts a t ca rdia c musca rinic re ce ptors; or (3) e ffe cts on nicotinic
re ce ptors a t a utonomic ga nglia . The following ta ble summa rize s
the me cha nisms for the ca rdiova scula r e ffe cts of muscle re la xa nts
CLINICAL AUTONOMIC EFFECTS OF NEUROMUSCULAR
BLOCKING DRUGS
From Miller RD: Miller’s Anesthesia, ed 7, Philadelphia, Saunders, 2011, p 882, Table 29-11.
190. (A) Postga nglionic sympa the tic ne rve fibe rs re le a se

nore pine phrine from the syna ptic ve sicle s in the ne rve te rmina ls.
Eighty pe rce nt of the re le a se d nore pine phrine ra pidly unde rgoe s
re upta ke into the sympa the tic ne rve te rmina ls (upta ke 1) a nd
re e nte rs stora ge ve sicle s for future re le a se . Only a sma ll a mount of
the nore pine phrine tha t is re a bsorbe d is me ta bolize d in the
cytopla sm by MAO. Twe nty pe rce nt of the nore pine phrine is dilute d
by diffusion a wa y from the re ce ptors a nd ca n ga in a cce ss to the
circula tion. COMT, which is loca te d prima rily in the live r,
me ta bolize s this nore pine phrine (Miller: Miller’s Anesth esia, ed 8, pp
357–358; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, pp 700–701).
191. (D) Administra tion of ke ta mine ma y be a ssocia te d with visua l,
a uditory, a nd proprioce ptive ha llucina tions. The se unple a sa nt side
e ffe cts of ke ta mine occur on e me rge nce a nd ma y progre ss to
de lirium. The incide nce of e me rge nce de lirium from ke ta mine is
dose de pe nde nt a nd occurs in a pproxima te ly 5% to 30% of pa tie nts.
Eme rge nce de lirium is le ss fre que nt a fte r re pe a te d a dministra tions
of ke ta mine . The most e ffe ctive pre ve ntion for e me rge nce de lirium
is a dministra tion of a be nzodia ze pine (mida zola m be ing more
e ffe ctive tha n dia ze pa m) a bout 5 minute s be fore induction of
a ne sthe sia with ke ta mine . Atropine a nd drope ridol give n
pe riope ra tive ly ma y incre a se the incide nce of e me rge nce de lirium
(Miller: Basics of Anesth esia, ed 6, pp 110–111; Miller: Miller’s Anesth esia,
ed 8, pp 827–828).
192. (A) Extra pyra mida l side e ffe cts a re se e n most ofte n with
a ntipsychotic drugs (e .g., phe nothia zine s, thioxa nthe ne s, a nd
butyrophe none s), but the y a lso ca n be se e n with a dministra tion of
me toclopra mide . Me toclopra mide , a dopa mine a nta gonist,
incre a se s lowe r e sopha ge a l sphincte r tone a nd stimula te s ga stric
a nd uppe r inte stina l tra ct motility. Side e ffe cts a ssocia te d with
me toclopra mide use include mild se da tion, dysphoria , a gita tion,
dry mouth, a nd, in ra re insta nce s, dystonic e xtra pyra mida l
re a ctions (oculogyric crise s, trismus, torticollis). Aka thisia , or the
fe e ling of une a se a nd motor re stle ssne ss, ha s occurre d following
IV me toclopra mide , which ma y re sult in ca nce lla tion of e le ctive
surge ry (Miller: Miller’s Anesth esia, ed 8, p 2963; Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp 499–502).
193. (B) Succinylcholine is a de pola rizing muscle re la xa nt tha t
che mica lly re se mble s a ce tylcholine a nd a tta che s to the
postjunctiona l me mbra ne ion cha nne l re ce ptors. Susta ine d ope ning
of ion cha nne ls produce d by succinylcholine (a s oppose d to a
tra nsie nt ope ning with a ce tylcholine ) is a ssocia te d with le a ka ge of
pota ssium from the inte rior of ce lls sufficie nt to incre a se pla sma
conce ntra tions of pota ssium by a bout 0.5 mEq/L in norma l pa tie nts.
This slight incre a se of pota ssium le ve ls in pa tie nts with re na l
fa ilure is simila r to pa tie nts with norma l re na l function (Miller:
Miller’s Anesth esia, ed 8, p 963; Miller: Basics of Anesth esia, ed 6, p 148;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
220).
194. (A) Ma ny drugs ca n e nha nce the ne uromuscula r block
produce d by nonde pola rizing muscle re la xa nts. The se include
vola tile a ne sthe tics, a minoglycoside a ntibiotics, ma gne sium,
intra ve nous loca l a ne sthe tics, furose mide , da ntrole ne , ca lcium
cha nne l blocke rs, a nd lithium. Ca lcium doe s not e nha nce
ne uromuscula r blocka de a nd, in fa ct, a ctua lly a nta gonize s the
e ffe cts of ma gne sium. In pa tie nts with hype rpa ra thyroidism a nd
hype rca lce mia the re is a de cre a se d se nsitivity to nonde pola rizing
muscle re la xa nts a nd shorte r dura tions of a ction (Miller: Miller’s
195. (D) None of the se drugs should be a bruptly stoppe d. Clonidine
is a ce ntra lly a ctive α-a dre ne rgic a gonist tha t is use d in the
tre a tme nt of hype rte nsion. Se ve re re bound hype rte nsion ca n be
se e n be twe e n 8 a nd 36 hours a fte r the la st dose , e spe cia lly in
pa tie nts re ce iving more tha n 1.2 mg/da y. Re bound hype rte nsion, a s
we ll a s ca rdia c ische mia , ca n be se e n a fte r discontinua tion of β-
blocke r the ra py (e .g., a te nolol or me toprolol). In the pa st, it wa s
re comme nde d to stop MAOIs 2 to 3 we e ks be fore e le ctive surge ry
be ca use of the possibility of de ve loping hype rte nsive crisis during
surge ry. More re ce ntly, it ha s be come a cce pta ble to use the se drugs
up to the time of surge ry, be ca use the ir discontinua nce could pla ce
the pa tie nt a t risk for suicide . Ce rta in drug inte ra ctions ma y occur
with MAOI use , including ske le ta l muscle rigidity or hype rpyre xia
with me pe ridine , a s we ll a s a n e xa gge ra te d hype rte nsive re sponse
with the indire ct-a cting va sopre ssor e phe drine . Abrupt withdra wa l
of chronic high-dose tricyclic a ntide pre ssa nt the ra py ca n be
a ssocia te d with withdra wa l symptoms (i.e ., ma la ise , chills, coryza ,
ske le ta l muscle a ching) a nd is not re comme nde d (Miller: Basics of
Anesth esia, ed 6, pp 179–182; Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 401–407).
196. (A) About 40 ye a rs a go it wa s note d tha t kidne y re sponse
va rie s with the type of shock. In ca nine s, hypovole mic shock
re duce d re na l blood flow to 10% of controls, whe re a s ca rdioge nic
shock re duce d re na l blood flow to only 75% of controls. The ma in
diffe re nce se e me d to be re la te d to the a tria l pre ssure s (de cre a se d
in hypovole mic shock but incre a se d in ca rdioge nic shock). About 10
ye a rs la te r, a pe ptide wa s isola te d from the a trium of ra ts na me d
a tria l or A-type na triure tic pe ptide (ANP). La te r a na triure tic
pe ptide wa s isola te d from porcine bra ins a nd wa s na me d bra in or
B-type na triure tic pe ptide (BNP). In huma ns, BNP is ma inly
produce d in the ca rdia c ve ntricle s. Na triure tic pe ptide s a re
prima rily re le a se d from the a tria (ANP) a nd ve ntricle s (BNP) whe n
the cha mbe rs a re ove rdiste nde d. Thus, in the fa iling he a rt, BNP is
re le a se d. Na triure tic pe ptide s ha ve a ma in e ffe ct on the kidne ys to
e xcre te sodium a nd wa te r. The y ha ve va sodila ting prope rtie s a nd
inhibit the re le a se of re nin. Blood le ve ls of BNP a re use d a s a
ma rke r for the se ve rity of ca rdiova scula r dise a se a nd ma y ha ve a
role in pre ope ra tive ca rdia c risk a sse ssme nt. Ne siritide is a
re combina nt BNP a nd is be ing studie d for the tre a tme nt of a cute
he a rt fa ilure (Barash : Clinical Anesth esia, ed 7, p 141; Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 123–125, 131; Miller:
197. (B) Multiple scle rosis (MS) is a n a cquire d infla mma tory
a utoimmune dise a se in which the re is de mye lina tion of ne rve
fibe rs within the CNS. In pa tie nts with MS a nd profound ne urologic
de ficits, succinylcholine ma y ca use hype rka le mia a nd should be
a voide d, a nd nonde pola rizing muscle re la xa nts a ppe a r sa fe .
Guilla in-Ba rré syndrome is a n infla mma tory polyne uritis a ffe cting
the pe riphe ra l ne rvous syste m a nd a ssocia te d with muscle
we a kne ss. In pa tie nts with Guilla in-Ba rré , succinylcholine ma y
ca use hype rka le mia a nd should be a voide d, whe re a s
nonde pola rizing muscle re la xa nts a re not contra indica te d but a re
a voide d be ca use of incre a se d se nsitivity a nd possible prolonge d
muscle we a kne ss in the postope ra tive pe riod.
Duche nne muscula r dystrophy a nd the le ss common Be cke r
muscula r dystrophy a re both X-linke d re ce ssive dise a se s. The y
a re cha ra cte rize d by progre ssive muscle we a kne ss. In 1992 the
U.S. Food a nd Drug Administra tion issue d a wa rning with re ga rd
to the use of succinylcholine in childre n a nd a dole sce nts be ca use
succinylcholine ha s be e n a ssocia te d with se ve ra l de a ths whe n
a dministe re d to pa tie nts with unsuspe cte d muscula r dystrophy
(ma ny de ve lope d hype rka le mia a nd we re la te r dia gnose d a s
ha ving muscula r dystrophy). Nonde pola rizing muscle re la xa nts
a ppe a r sa fe , but a slowe r onse t ma y e xist.
Mya sthe nia gra vis pa tie nts ha ve fe we r postsyna ptic re ce ptors a t
the myone ura l junction, a nd, if succinylcholine is a dministe re d,
the y a ppe a r to be re sista nt. La rge r dose s a ppe a r ne e de d (1.5-
2 mg/kg) for intuba tion, a nd the re is no a ssocia te d hype rka le mic

re sponse . The dura tion of a ction of succinylcholine , on the othe r
ha nd, will be prolonge d be ca use the se pa tie nts re ce ive
a nticholine ste ra se the ra py (pyridostigmine ). The y a re , howe ve r,
ve ry se nsitive to nonde pola rizing muscle re la xa nts, a nd a gre a tly
re duce d dose of a nonde pola rize r should be a dministe re d, if a t
a ll (Fleish er: Anesth esia and Uncom m on Diseases, ed 6, pp 267–273,
297-302, 314–315; Miller: Miller’s Anesth esia, ed 8, pp 1266–1284).
198. (D) Se ve ra l a ntibiotics pote ntia te ne uromuscula r blocka de . The
a minoglycoside s (ne omycin, stre ptomycin, ge nta micin, a nd
tobra mycin) a nd the lincosa mide s (clinda mycin a nd lincomycin) ca n
a ugme nt ne uromuscula r blocka de . The only drug in que stion tha t
doe s not a ffe ct ne uromuscula r blocka de is e rythromycin (of the
ma crolide a ntibiotic group). In a ddition, te tra cycline s, pe nicillins,
a nd ce pha losporins do not a ffe ct ne uromuscula r blocka de (Barash :
Clinical Anesth esia, ed 7, p 541; Miller: Miller’s Anesth esia, ed 8, pp 981–
982).
199. (A) W ith live r fa ilure , the live r ca nnot a de qua te ly de toxify
noxious che mica ls. Among pa tie nts with e nd-sta ge live r dise a se ,
50% to 70% de ve lop he pa tic HE. Symptoms va ry from mild
confusion, drowsine ss, a nd stupor to coma . The e tiology of HE is
comple x. Be ca use a n e le va tion in blood a mmonia le ve ls (e a sily
me a sure d) is strongly a ssocia te d with HE, tre a tme nt is a ime d a t
lowe ring the a mmonia le ve l. Othe r toxins a lso contribute to HE. To
lowe r the a mmonia le ve l, la ctulose (which de cre a se s the
a bsorption of a mmonia ) a nd ne omycin (which re duce s the
production of a mmonia by re ducing the a mmonia -producing
inte stina l flora ) a re commonly a dministe re d. Prote in re striction is
commonly done to de cre a se a mmonia production, so a mino a cid–
rich TPN is not he lpful. Fluma ze nil (a GABA re ce ptor a nta gonist)
ha s be e n shown to produce short-dura tion re ve rsa l of the
symptoms of HE in some pa tie nts a nd thus sugge sts tha t GABA
re ce ptors a re some how a ctiva te d during HE. GABA re ce ptors a re
re sponsible for inhibitory ne urotra nsmission in the CNS (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 280; Miller: Basics
of Anesth esia, ed 6, p 457; Miller: Miller’s Anesth esia, ed 8, p 541).
200. (A) In most pa tie nts, a n intra ve nous intuba ting dose of
succinylcholine (1 mg/kg = 2 × the ED95) will show ne uromuscula r

blocka de tha t la sts 5 to 10 minute s. The re a son for the short
dura tion of a ction re la te s to succinylcholine ’s ve ry ra pid
me ta bolism by typica l pla sma choline ste ra se (a lso ca lle d
pse udocholine ste ra se or butyrylcholine ste ra se ). Some pa tie nts,
howe ve r, ha ve a prolonge d e ffe ct, which could be due to e ithe r a
de cre a se in the qua ntity or a ge ne tic qua lita tive cha nge in the
e nzyme . Qua ntita tive de cre a se s ca n be se e n in pa tie nts with
ma lnutrition, live r dise a se , pre gna ncy, burns, or a dva nce d a ge .
Choline ste ra se a ctivity ca n a lso be de cre a se d by the
coa dministra tion of va rious me dica tions including
a nticholine ste ra se drugs (e .g., ne ostigmine ), me toclopra mide , a nd
e smolol. A ma rke d qua ntita tive re duction (e .g., se ve re live r
dise a se ) ca n prolong succinylcholine a ctivity a bout thre e time s the
norma l dura tion of block. A ma rke d prolonga tion of e ffe ct is due to
the ge ne tic production of a typica l pse udocholine ste ra se (a n
ina ctive form). To inve stiga te the ge ne tic or qua lita tive cha nge , a
dibuca ine inhibition te st is done . The loca l a ne sthe tic dibuca ine
ca n inhibit a norma l e nzyme more so tha n a n a bnorma l e nzyme .
Pe ople with a norma l dibuca ine numbe r of 70 to 80 a re
homozygous for the norma l typica l pla sma choline ste ra se a nd ha ve
the norma l 5- to 10-minute ne uromuscula r blocka de . Pe ople who
a re he te rozygous (incide nce of 1/480) for the a typica l pla sma
choline ste ra se ha ve a dibuca ine numbe r of 50 to 60 a nd a block
dura tion of 20 minute s. Pa tie nts who a re homozygous for the
a typica l pla sma choline ste ra se (incide nce 1/3200) ha ve a dibuca ine
numbe r of 20 to 30 a nd a block dura tion from 1 to 3 hours. This
ge ne tic va ria tion of pla sma choline ste ra se is the most common
a bnorma lity; howe ve r, the re a re a lso othe r, le ss fre que nt ge ne tic
cha nge s in the pla sma choline ste ra se . Se e a lso Que stion 260
(Miller: Basics of Anesth esia, ed 6, pp 148–149. Miller: Miller’s Anesth esia,
ed 8, pp 960–962, 1135–1136).
201. (B) In norma l pa tie nts, pota ssium le ve ls incre a se a bout
0.5 mEq/L a fte r the a dministra tion of succinylcholine . Howe ve r, in

some a cquire d conditions the pota ssium le ve l ma y incre a se 5 to
7 mEq/L a bove the ba se line pota ssium le ve l a fte r a dministra tion of

succinylcholine . This ma rke d e le va tion of pota ssium ma y le a d to
ca rdia c a rre st. The se a cquire d conditions include the following: (1)
de ne rva tion injury a s ca use d by spina l cord injury le a ding to
ske le ta l muscle a trophy; (2) ske le ta l muscle injury re sulting from
third-de gre e burns (until sca rring occurs); (3) a cute uppe r motor
ne uron injury such a s stroke ; (4) se ve re ske le ta l muscle tra uma ;
a nd (5) se ve re a bdomina l infe ctions. In the se a cquire d conditions
the pote ntia l to incre a se pota ssium le ve ls a fte r succinylcholine
usua lly ta ke s a fe w da ys to de ve lop, pe a ks 10 to 50 da ys a fte r the
initia l injury, a nd ma y pe rsist for 6 months or more . All fa ctors
conside re d, it might be prude nt to a void a dministra tion of
succinylcholine to a ny pa tie nt more tha n 24 hours a fte r the
conditions liste d he re . This vulne ra bility to hype rka le mia ma y
re fle ct a prolife ra tion of e xtra junctiona l choline rgic re ce ptors,
which provide more site s for pota ssium to le a k outwa rd a cross the
ce ll me mbra ne during de pola riza tion. Some ha ve sugge ste d tha t the
numbe r of re ce ptors is uncha nge d but tha t the re ce ptors
the mse lve s ha ve a lte re d a ffinity to a ce tylcholine or drugs. Simila r
ma rke d e le va tions of pota ssium ma y de ve lop in ca se s of
undia gnose d myopa thy (Miller: Basics of Anesth esia, ed 6, p 149–150).
202. (A) Although fluma ze nil (a spe cific be nzodia ze pine a nta gonist)
inhibits the a ctivity a t the GABA re ce ptor, it works only a t the
be nzodia ze pine re cognition site a nd ha s no e ffe ct in re ve rsing othe r
drugs tha t work on the GABA site (e .g., ba rbitura te s, e tomida te ,
propofol). It ha s a fa st onse t (within minute s), with pe a k bra in
le ve ls occurring within 6 to 10 minute s, a nd a re la tive ly short
dura tion of a ction. Fluma ze nil ca n re ve rse a ll be nzodia ze pine CNS
e ffe cts, including se da tive , a mne stic, muscle re la xa nt, a nd
a nticonvulsa nt e ffe cts. Side e ffe cts a re ra re , the most common
be ing na use a , vomiting, or both (a bout 10%). Na use a occurs more
commonly whe n fluma ze nil is give n to pa tie nts a fte r ge ne ra l
a ne sthe sia tha n a fte r conscious se da tion. Due to its short clinica l
dura tion of a ction, pa tie nts re ce iving fluma ze nil should be
monitore d for possible re se da tion a nd re spira tory de pre ssion
(Miller: Miller’s Anesth esia, ed 8, pp 843–844; Ph y sicians Desk Reference,
ed 63, 2009, pp 2646–2649; Butterworth : Morgan & Mikh ail’s Clinical
203. (D) Nonste roida l a nti-infla mma tory drugs (NSAIDs) (e .g.,
a spirin, a ce ta minophe n, indome tha cin, ibuprofe n, diclofe na c, a nd
ke torola c) inhibit COX e nzyme s tha t a re involve d in the conve rsion
of a ra chidonic a cid to prosta gla ndin, thromboxa ne , a nd
prosta cyclin. COX-1 is involve d with pla te le t a ggre ga tion a nd ga stric
mucosa l prote ction; COX-2 is involve d with pa in, infla mma tion, a nd
fe ve r. TXA2 ha s prothrombotic a nd va soconstricting prope rtie s.
Prosta cyclin I2 ha s a ntithrombotic a nd va sodila ting prope rtie s.
Ke torola c is a nonse le ctive inhibitor of both COX-1 a nd COX-2
e nzyme s. Se le ctive COX-2 drugs (e .g., only ce le coxib, curre ntly
a va ila ble in the Unite d Sta te s) ca n be use d, but in ge ne ra l the se
ha ve be e n shown to ca use a sma ll incre a se in thrombotic issue s
(but fe we r e ffe cts on ga stric mucosa a nd pla te le t a ctivity). Be ca use
of a ce iling e ffe ct with re ga rd to a na lge sia , ke torola c ha s only mild-
to-mode ra te a na lge sic e ffe cts (Hem m ings: Ph arm acology and
Ph y siology for Anesth esia, pp 272–278; Miller: Basics of Anesth esia, ed 6,
pp 703–704; Miller: Miller’s Anesth esia, ed 8, pp 2978–2982).
204. (D) Acute inte rmitte nt porphyria is the most se rious form of
porphyria . This dise a se a ffe cts both the ce ntra l a nd pe riphe ra l
ne rvous syste ms. An a cute inte rmitte nt porphyria a tta ck ca n be
trigge re d by a va rie ty of conditions, including sta rva tion,
de hydra tion, stre ss, se psis, a nd some drugs, such a s e tomida te a nd
ba rbitura te s. Drugs tha t a re sa fe or probably safe include loca l
a ne sthe tics, inha le d a ne sthe tics, ne uromuscula r blocking drugs,
some intra ve nous a ne sthe tics (propofol a nd ke ta mine ), some
a na lge sics (a ce ta minophe n, a spirin, morphine , fe nta nyl,
sufe nta nil), a ntie me tics (drope ridol, H2 blocke rs, me toclopra mide ,
onda nse tron), a nd ne ostigmine a nd na loxone . Drugs tha t a re
contra indica te d include some intra ve nous a ne sthe tics
(ba rbitura te s), some a na lge sics (ke torola c, pe nta zocine ), a nd
hyda ntoin a nticonvulsa nts (Barash : Clinical Anesth esia, ed 7, pp 624–
625; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 308).
205. (A) Cytochrome P450 (CYP) e nzyme s a re involve d in the
me ta bolism of ma ny me dica tions. The re a re ma ny such isoforms
a nd the se a re furthe r cha ra cte rize d into fa milie s with a n Ara bic
numbe r a nd furthe r cha ra cte rize d into subfa milie s (ca pita l le tte r).
The clinica l a ctivity of the se e nzyme s ca n be incre a se d (induce d) or
de cre a se d (inhibite d) by a ge , ge ne tics, me dica tions, a nd some
foods. CYP2D6 is ne e de d to conve rt the ina ctive code ine to the
a ctive morphine . Simila rly, CYP2D6 a lso me ta bolize s oxycodone
into a ctive oxymorphone , a nd ina ctive hydrocodone into a ctive
hydromorphone . CYP2D6 is inhibite d by selective serotonin reuptake
inh ibitors (SSRIs) a s we ll a s with quinidine . SSRIs include fluoxe tine
(Proza c), se rtra line (Zoloft), pa roxe tine (Pa xil), fluvoxa mine (Luvox),
cita lopra m (Ce le xa ), a nd e scita lopra m (Le xa pro). Thus, pa tie nts
ta king SSRIs or quinidine will ge t a poor a na lge sic e ffe ct with
code ine , oxycodone , a nd hydrocodone (Hem m ings; Ph arm acology
and Ph y siology for Anesth esia, pp 64–65, 183–186; Miller: Basics of
206. (D) Although e tomida te ca use s pa in on intra ve nous inje ction in
up to 80% of pa tie nts, the uninte ntiona l a dministra tion of e tomida te
into a n a rte ry doe s not re sult in de trime nta l e ffe cts to the a rte ry
207. (D) Fe nta nyl is more lipid soluble tha n morphine , so it pa sse s
through the blood-bra in ba rrie r more e a sily a nd ha s a fa ste r onse t
of a ction. Fe nta nyl a lso ha s a la rge r volume of distribution, slowe r
pla sma cle a ra nce , a nd longe r e limina tion ha lf-life tha n morphine .
Howe ve r, the dura tion of a ction of fe nta nyl (whe n give n in sma ll
dose s) is much shorte r tha n tha t of morphine be ca use fe nta nyl is
ra pidly re distribute d from the bra in to ina ctive tissue site s (e .g.,
lipid site s). In la rge r dose s, the se tissue site s ca n be come
sa tura te d, a nd the pha rma cologic a ction of fe nta nyl be come s
conside ra bly prolonge d (Miller: Basics of Anesth esia, ed 7, p 115–119;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
104–105).
208. (D) This que stion illustra te s the conce pt of infusion front-e nd
kine tics. This conce pt is use ful for compa ring the kine tics of
va rious intra ve nous a ge nts use d in a ne sthe sia . Re mife nta nil
re a che s the ste a dy sta te in le ss tha n 1 hour of continuous infusion.
Approxima te ly 8 hours a re re quire d to re a ch the ste a dy sta te with
a lfe nta nil a nd sufe nta nil, whe re a s fe nta nyl a nd morphine ha ve not
a chie ve d the ste a dy sta te conce ntra tion e ve n a fte r 10 hours of
continuous infusion.
Anothe r importa nt conce pt is the time a fte r bolus to re a ch pe a k
e ffe ct: bolus front-e nd kine tics. This conce pt is more intuitive to
most a ne sthe sia provide rs. Compa ring the sa me na rcotics use d
in this que stion, a lfe nta nil a nd re mife nta nil re a ch pe a k
conce ntra tion a t ne a rly the sa me time a nd fe nta nyl only slightly
la te r (Miller: Basics of Anesth esia, ed 6, p 119).
209. (C) Ble omycin is use d prima rily in the tre a tme nt of Hodgkin
lymphoma a nd te sticula r tumors. Ble omycin ca use s oxida tive
da ma ge to nucle otide s, which le a ds to bre a ks in DNA. Although
the more common side e ffe cts of ble omycin use a re
mucocuta ne ous, dose -re la te d pulmona ry toxicity is the most
se rious side e ffe ct. Ea rly signs a nd symptoms of pulmona ry toxicity
include dry cough, fine ra le s, a nd diffuse infiltra te s on x-ra y.
Approxima te ly 5% to 10% of pa tie nts will de ve lop pulmona ry
toxicity, a nd a bout 1% will die from this complica tion. Most be lie ve
tha t the risk of pulmona ry toxicity incre a se s with dose (e spe cia lly
tota l dose >250 mg), in pa tie nts olde r tha n 40 ye a rs of a ge , in
pa tie nts with a cre a tinine cle a ra nce (CrCl) of le ss tha n 80 mL/min,
a nd in pa tie nts with prior che st ra dia tion or pre e xisting pulmona ry
dise a se . Although a re la tionship a ppe a rs to e xist be twe e n the use
of ble omycin a nd the use of high conce ntra tions of oxyge n, the
de ta ils a re uncle a r. Curre ntly, it ha s be e n sugge ste d to use the
lowe st conce ntra tion of oxyge n consiste nt with pa tie nt sa fe ty with a
ca re ful e va lua tion of oxyge n sa tura tion with pulse oxime try in a ny
pa tie nt who ha s re ce ive d ble omycin (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1716–1718; Miller:
Miller’s Anesth esia, ed 8, p 1951; Stoelting: Ph arm acology and Ph y siology
in Anesth etic Practice, ed 4, pp 555–565).
210. (C) The first two le tte rs of the word “rocuronium” sta nd for
“ra pid onse t.” Of the nonde pola rizing muscle re la xa nts curre ntly
a va ila ble , rocuronium ha s the most ra pid onse t of a ction a t
clinica lly use ful dosa ge s. Rocuronium is a nonde pola rizing
ne uromuscula r re la xa nt with a n inte rme dia te dura tion of a ction
simila r to ve curonium, a tra curium, a nd cisa tra curium. At a n ED95
dose (0.3 mg/kg), the onse t time is 1.5 to 3 minute s, whe re a s with
the othe r inte rme dia te nonde pola rizing muscle re la xa nts, the onse t
time is 3 to 7 minute s. At la rge r dose s (i.e ., 2 × ED95 or 0.6 mg/kg),

onse t time ca n be re duce d to 1 to 1.5 minute s (Barash : Clinical
211. (D) An a cute de cre a se in se rum pota ssium ca use s
hype rpola riza tion of ce ll me mbra ne s. This ca use s re sista nce to
de pola rizing ne uromuscula r blocke rs a nd a n incre a se d se nsitivity
to nonde pola rizing ne uromuscula r blocke rs (Stoelting: Ph arm acology
212. (D) Awa re ne ss during ge ne ra l a ne sthe sia is the postope ra tive
re ca ll of e ve nts tha t ha ppe ne d during the a ne sthe tic. Ove ra ll
incide nce ha s de cre a se d from a bout 1% 50 ye a rs a go to a bout 0.1%
toda y (with some va ria tions from study to study). Pa tie nts a t
incre a se d risk include pa tie nts unde rgoing ca rdia c surge ry,
e ndoscopic a irwa y surge ry, ce sa re a n se ctions, a nd tra uma surge ry
213. (C) The symptoms de scribe d in this pa tie nt a re consiste nt with
choline rgic stimula tion or incre a se d le ve ls of a ce tylcholine tha t
occur with a nticholine ste ra se poisoning. Stimula tion of the
pa ra sympa the tic ne rvous syste m produce s miosis, a bdomina l
cra mping, e xce ss sa liva tion, loss of bowe l a nd bla dde r control,
bra dyca rdia , a nd bronchoconstriction. The se symptoms a re tre a te d
with a tropine . The a ce tylcholine ste ra se re a ctiva tor pra lidoxime
some time s is a dde d to tre a t the nicotinic e ffe cts of e le va tion of
a ce tylcholine a t the ne uromuscula r junction of ske le ta l muscle (i.e .,
ske le ta l muscle we a kne ss, a pne a ). CNS e ffe cts of e le va te d
a ce tylcholine le ve ls ca n include confusion, a ta xia , a nd coma . In
a ddition, supportive the ra py (the ABCs of re suscita tion [Airwa y,
Bre a thing, Circula tion, e tc.]) is provide d a s ne e de d (Miller: Miller’s
214. (C) Fluma ze nil is a be nzodia ze pine a nta gonist use d to
a nta gonize the be nzodia ze pine e ffe cts on the CNS. It doe s not
re ve rse the e ffe cts of ba rbitura te s, opia te s, or a lcohol. Se izure s ca n
be pre cipita te d in pa tie nts who ha ve be e n on be nzodia ze pine s for
long-te rm se da tion or pa tie nts showing signs of se rious cyclic
a ntide pre ssa nt ove rdosa ge (e .g., twitching, rigidity, wide ne d QRS
comple x, hypote nsion). Fluma ze nil ha s a shorte r e limina tion ha lf-
life (0.7-1.3 hours) compa re d with mida zola m (2-2.5 hours).
Fluma ze nil is poorly a bsorbe d ora lly (Miller: Miller’s Anesth esia, 8, p
843; Ph y sicians’ Desk Reference, ed 63, 2009, pp 2646–2649).
215. (D) Ade qua te re cove ry from ne uromuscula r blocka de is
be lie ve d to occur whe n 50% or le ss of re ce ptors a re occupie d with
muscle re la xa nts. This ca n be me a sure d with susta ine d te ta nus a t
100 Hz, but this te st is ve ry pa inful. Anothe r me thod re quire s

pa tie nt coope ra tion a nd consists of a susta ine d he a d lift for 5
se conds in the supine position. The “he a d lift” te st is the sta nda rd
te st to de te rmine a de qua te muscula r function (Miller: Basics of
216. (B) PONV is the se cond-most common compla int re porte d in
the pe riope ra tive pe riod (pa in is the numbe r one compla int). Ma ny
drugs ha ve be e n use d to both pre ve nt (prophyla xis) a nd to tre a t
(re scue ) PONV. Antie me tics we re ofte n a dministe re d a lone , but
now combina tion the ra py of two or more drugs such a s dopa mine
a nta gonists (e .g., drope ridol, me toclopra mide ), hista mine
a nta gonists (e .g., diphe nhydra mine , proma zine ), a nticholine rgics
(e .g., scopola mine ), ste roids (e .g., de xa me tha sone ), ne urokinin
a nta gonists (e .g., a pre pita nt), a nd se rotonin a nta gonist (e .g.,
onda nse tron, dola se tron, gra nise tron, a nd pa lonose tron) a re
commonly use d. Once a se rotonin a nta gonist is give n for
prophyla xis, a dding more of a se rotonin a nta gonist in the PACU
doe s not se e m to he lp. It is be tte r to use a n a ntie me tic from
a nothe r cla ss of drugs (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 503–551; Miller: Miller’s Anesth esia, ed 8, pp 2947, 2969–
2970).
217. (A) Pa tie nts with W PW syndrome a re pre dispose d to de ve lop
supra ve ntricula r a rrhythmia s. Sympa the tic stimula tion (e .g., a nxie ty,
hypovole mia ), a s we ll a s ma ny drugs (e .g., pa ncuronium,
me pe ridine , ke ta mine , e phe drine , digoxin, ve ra pa mil), ca n induce
ta chya rrhythmia s, ofte n by e nha ncing conduction through a cce ssory
a tria l pa thwa ys. Although ve ra pa mil is use d to tre a t
supra ve ntricula r ta chya rrhythmia s be ca use of its de pre ssa nt e ffe cts
on a lve ola r noda l conduction, it a ctua lly ma y incre a se the he a rt
ra te in pa tie nts with W PW syndrome be ca use it ca n incre a se
conduction of the a cce ssory pa thwa ys. Drope ridol, in a ddition to its
a ntidopa mine rgic prope rtie s, ha s a ntidysrhythmic prope rtie s tha t
prote ct a ga inst e pine phrine -induce d dysrhythmia s. Propose d
me cha nisms include α-a dre ne rgic re ce ptor blocka de a nd mild loca l
a ne sthe tic e ffe cts. La rge dose s of drope ridol (0.2-0.6 mg/kg) ca n
re duce impulse tra nsmission via the a cce ssory pa thwa ys
re sponsible for the ta chya rrhythmia s tha t occur in pa tie nts with
W PW syndrome (Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 413–415, 766).
218. (B) Pse udocholine ste ra se (a lso ca lle d pla sma choline ste ra se )
is a n e nzyme found in pla sma a nd most othe r tissue s (e xce pt
e rythrocyte s). Pse udocholine ste ra se me ta bolize s the a ce tylcholine
re le a se d a t the ne uromuscula r junction, a s we ll a s ce rta in drugs
such a s succinylcholine , miva curium, a nd e ste r-type loca l
a ne sthe tics. It is produce d in the live r a nd ha s a ha lf-life of
a pproxima te ly 8 to 16 hours. Pse udocholine ste ra se le ve ls ma y be
re duce d in pa tie nts with a dva nce d live r dise a se . The de cre a se
must be gre a te r tha n 75% be fore significa nt prolonga tion of
ne uromuscula r blocka de occurs with succinylcholine (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 218).
219. (D) COX inhibitors a re use ful a na lge sics for mild-to-mode ra te
pa in. The re a re thre e type s of COX inhibitors: cyclooxyge na se -1
(COX-1), cyclooxyge na se -2 (COX-2), a nd cyclooxyge na se -3 (COX-3).
COX-3 is a va ria nt of COX-1, a nd the re is some controve rsy a s to its
e xiste nce in huma ns. COX inhibitors block prosta gla ndin synthe sis
in the pe riphe ry a nd in the CNS. COX-1 ha s GI mucosa l prote cting
prope rtie s a nd stimula te s pla te le t a ggre ga tion. Drugs with COX-1
inhibiting prope rtie s ca n ca use ga stric a nd duode na l ulce rs a nd ca n
inte rfe re with pla te le t a ggre ga tion. COX-2 is involve d in
infla mma tion. NSAIDs a re nonspe cific COX-1 a nd COX-2 inhibitors.
Se le ctive COX-2 inhibitors such a s ce le coxib, va lde coxib, a nd
rofe coxib a re e ffe ctive a na lge sics with a nti-infla mma tory e ffe cts.
The y ha ve a lowe r risk of GI complica tions a nd a ntipla te le t
prope rtie s tha n the nonspe cific COX-1 a nd COX-2 inhibitors.
Be ca use of a n incre a se in se rious thromboe mbolic e ve nts (i.e .,
stroke s a nd myoca rdia l infa rctions), both va lde coxib a nd rofe coxib
ha ve be e n withdra wn from the ma rke t. Curre ntly, ce le coxib is the
only se le ctive COX-2 inhibitor a va ila ble in the Unite d Sta te s. In
a ddition, both the NSAIDs a nd se le ctive COX-2 inhibitors ca n
tra nsie ntly de cre a se re na l function, e spe cia lly in pa tie nts with
pre e xisting re na l dise a se a nd in pa tie nts who a re hypovole mic.
The se re na l e ffe cts ca n le a d to hype rte nsion, e de ma , a nd a cute
re na l fa ilure (Hem m ings: Ph arm acology and Ph y siology for Anesth esia,
pp 272–277; Miller: Basics of Anesth esia, ed 6, pp 703–704; Barash :
220. (C) The a dre na l corte x se cre te s two cla sse s of ste roids, the
corticoste roids (glucocorticoids a nd mine ra locorticoids) a nd the
a ndroge ns. The ma in glucocorticoid is hydrocortisone , a lso ca lle d
cortisol. The glucocorticoids a re use d prima rily for the ir a nti-
infla mma tory a nd immunosuppre ssive e ffe cts, but the y a lso ha ve
mine ra locorticoid a ctivity (i.e ., sodium-re ta ining e ffe cts). The se
drugs diffe r in pote ncy, a mount of mine ra locorticoid e ffe ct, a nd
dura tion of a ction. The norma l a mount of cortisol produce d da ily is
a bout 10 mg, but unde r stre ss, the le ve l ca n incre a se te nfold. The
ma in mine ra locorticoid is a ldoste rone . The norma l a mount of
a ldoste rone produce d da ily is a bout 0.125 mg. Be ca use

fludrocortisone ha s such significa nt mine ra locorticoid a ctivity, it is
use d only for this. The following ta ble compa re s se ve ra l
corticoste roids. In this ca se , 50 mg of pre dnisone is e quiva le nt in
glucocorticoid a ctivity to 7.5 mg of de xa me tha sone a nd 200 mg of

hydrocortisone (Hard m an: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 10, pp 1655–1666; Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 461–464).
COMPARATIVE PHARMACOLOGY OF CORTICOSTEROIDS
NA, not applicable.
From Stoelting RK: Pharmacology and Physiology in Anesthetic Practice, ed 4, Philadelphia,
Lippincott Williams & Wilkins, 2006, p 462.
221. (A) The RI of ne uromuscula r blocking drugs is the time ne e de d

for sponta ne ous re cove ry of a twitch he ight from 25% to 75% of the
ba se line he ight. The e lde rly, who te nd to ha ve re duce d re na l a nd
he pa tic function, ha ve a prolonge d RI for nonde pola rizing muscle
re la xa nts tha t a re de pe nde nt upon re na l or he pa tic e limina tion
(e .g., ve curonium, D-tubocura rine , pa ncuronium, rocuronium). The
RI for a tra curium a nd cisa tra curium, which a re broke n down in the
pla sma , a re not prolonge d in the e lde rly (Miller: Miller’s Anesth esia,
ed 8, pp 975–976).
222. (B) Cyclosporine is a drug tha t se le ctive ly inhibits he lpe r T-
lymphocyte -me dia te d but not B-lymphocyte –me dia te d immune
re sponse s. It is ma inly use d a lone or in combina tion with
corticoste roids to pre ve nt or tre a t orga n re je ction. Othe r use s
include the tre a tme nt of Crohn dise a se , uve itis, psoria sis, a nd
rhe uma toid a rthritis. Side e ffe cts tha t ma y a ccompa ny the
a dministra tion of cyclosporine include ne phrotoxicity (25%-38%),
hype rte nsion, limb pa re sthe sia s (50%), he a da che s, confusion,
somnole nce , se izure s, e le va tion of live r e nzyme s, a lle rgic
re a ctions, gum hype rpla sia , hirsutism, a nd hype rglyce mia . The re
a ppe a rs to be no pulmona ry toxicity a ssocia te d with cyclosporine
the ra py (Miller: Miller’s Anesth esia, ed 8, p 580).
223. (B) Succinylcholine is ba sica lly two a ce tylcholine mole cule s
hooke d toge the r. Succinylcholine ma y e xe rt ca rdiova scula r e ffe cts
by: (1) inducing hista mine re le a se from ma st ce lls; (2) stimula ting
a utonomic ga nglia , which incre a se s ne urotra nsmission a t both the
sympa the tic a nd pa ra sympa the tic ne rvous syste ms; a nd (3) dire ctly
stimula ting postjunctiona l ca rdia c musca rinic re ce ptors. The e ffe ct
of succinylcholine on he a rt ra te is va ria ble , with both bra dyca rdia
a nd ta chyca rdia possible . The fina l he a rt ra te de pe nds upon ma ny
fa ctors, including the a mount of nicotinic stimula tion of the
sympa the tic a nd pa ra sympa the tic ga nglia , which is gre a te r for the
nondomina nt a utonomic ne rvous syste m. For e xa mple , whe n
sympa the tic ne rvous syste m tone is high (a s in childre n),
bra dyca rdia is more like ly to de ve lop whe n succinylcholine is
a dministe re d. W he n pa ra sympa the tic ne rvous syste m tone is high
(a s in ma ny a dults), ta chyca rdia , a lthough not common, is more
like ly to occur whe n succinylcholine is a dministe re d. Bra dyca rdia
is more like ly to occur whe n a se cond intra ve nous dose of
succinylcholine is a dministe re d 4 to 5 minute s a fte r the first dose ,
e spe cia lly whe n difficult la ryngoscopy (e .g., inte nse va ga l
stimula tion) is be ing pe rforme d (Miller: Basics of Anesth esia, ed 6, p
150).
224. (C) Che mica lly, succinylcholine is two a ce tylcholine mole cule s
hooke d toge the r a nd ha s ma ny e ffe cts simila r to a ce tylcholine . In
a ddition to ca using ne uromuscula r blocka de , succinylcholine
stimula te s a ll choline rgic a utonomic re ce ptors, including the
nicotinic re ce ptors of the sympa the tic a nd pa ra sympa the tic ga nglia ,
a s we ll a s the musca rinic re ce ptors in the sinus node of the he a rt.
It is this musca rinic e ffe ct tha t ca use s the bra dyca rdia tha t ca n be
se e n a fte r the a dministra tion of succinylcholine in childre n. Also
se e e xpla na tion to Que stion 223 (Miller: Miller’s Anesth esia, ed 8, p
962).
225. (A) Propofol’s che mica l structure is 2,6-diisopropylphe nol (i.e .,
is not a n e ste r) a nd thus is not me ta bolize d by e ste ra se s. Propofol
is ra pidly me ta bolize d by the live r to more wa te r-soluble
compounds tha t a re the n re na lly e xcre te d. Esmolol is a n e ste r
compound a nd is ra pidly me ta bolize d by RBC e ste ra se s (short ha lf-
life of 9-10 minute s). Atra curium a nd cisa tra curium prima rily
unde rgo Hofma nn e limina tion, which is a che mica l re a ction.
Atra curium ha s a se cond me ta bolic route : me ta bolism by
nonspe cific pla sma e ste ra se s. Inte re stingly, cisa tra curium, which is
a n isola te d form of a tra curium (1 of the 10 ste re oisome rs), doe s not
unde rgo me ta bolism by nonspe cific pla sma e ste ra se s.
The short dura tion of a ction of re mife nta nil is due to its e ste r
structure , which is me ta bolize d by blood a nd tissue nonspe cific
e ste ra se s. Be ca use of the nonspe cific me ta bolism, its dura tion of
a ction is not prolonge d in pa tie nts with pse udocholine ste ra se
de ficie ncy (Miller: Basics of Anesth esia, ed 6, pp 75, 100–101, 125, 154;
Miller: Miller’s Anesth esia. ed 8, pp 371, 824, 888–889, 977).
226. (A) Hype rka le mia , ma ligna nt hype rthe rmia , ma sse te r spa sm,
sinus bra dyca rdia , noda l rhythms, a nd mya lgia s a re side e ffe cts
tha t ca n be se e n a fte r the a dministra tion of succinylcholine . In
re ce nt ye a rs, the re ha ve be e n se ve ra l ca se re ports of intra cta ble
ca rdia c a rre st in a ppa re ntly he a lthy childre n a fte r the
a dministra tion of succinylcholine . In the se ca se s, hype rka le mia ,
rha bdomyolysis, a nd a cidosis we re docume nte d. La te r, muscle
biopsy sa mple s de monstra te d tha t ma ny of the se ca se s we re
subclinica l ca se s of Duche nne muscula r dystrophy. For this re a son
of occa siona l se ve re hype rka le mia , succinylcholine is
contra indica te d for routine tra che a l intuba tion in childre n (Barash :
Clinical Anesth esia, ed 7, p 1227; Miller: Miller’s Anesth esia, ed 8, p 983).
227. (D) To ma ke intuba tion e a sie r, it is importa nt to know whe n
the muscle s of the a irwa y a re ma xima lly re la xe d a fte r
a dministra tion of a ne uromuscula r re la xa nt. This ofte n is done with
ne uromuscula r monitoring. Howe ve r, which muscle s one monitors
is importa nt be ca use ne uromuscula r blocka de de ve lops fa ste r,
la sts a shorte r time , a nd re cove rs more quickly in the ce ntra l
muscle s of the a irwa y (i.e ., the la rynx, ja w, a nd dia phra gm) tha n in
the more pe riphe ra l a bductor muscle s of the thumb (e .g., ulna r
ne rve monitoring). Also importa nt is the obse rva tion tha t the
pa tte rn of blocka de in the orbicula ris oculi (e .g., fa cia l ne rve
monitoring) is simila r to tha t of the la rynge a l muscle s a nd the
dia phra gm. The re fore , whe n the orbicula r oculi muscle s a re
ma xima lly re la xe d, intuba tion would be optima l. W he n a dductor
function of the thumb re turns to norma l, the dia phra gm a nd
la rynge a l muscle s will ha ve re cove re d (Barash : Clinical Anesth esia,
ed 7, p 545).
228. (D) Ra re ly, it is ne ce ssa ry to cha nge from one nonde pola rizing
drug to a nothe r. A ge ne ra l rule to de te rmine the dura tion of a ction
of a drug give n a fte r a nothe r drug of diffe re nt dura tion is a ma tte r of
simple kine tics. Thre e ha lf-live s will be re quire d for a clinica l
cha nge ove r so tha t 95% of the first drug will ha ve cle a re d for the
block dura tion to be gin to ta ke on the cha ra cte ristics of the se cond
drug. For e xa mple , if a n inte rme dia te -a cting muscle re la xa nt such
a s ve curonium is give n a fte r a long-a cting a ge nt such a s
pa ncuronium, the dura tion of a ction of ve curonium is prolonge d
a fte r the first two ma inte na nce dose s of ve curonium. Afte r the third
ma inte na nce dose the dura tion of ve curonium is not prolonge d
229. (A) Vola tile a ne sthe tics e nha nce ne uromuscula r blocka de in a
dose -de pe nde nt fa shion. Re ce nt studie s ha ve sugge ste d tha t
a nta gonism of ne uromuscula r block is slowe d by vola tile
a ne sthe tics; thus, vola tile a ne sthe tic va por conce ntra tions should
be re duce d a s much a s possible a t the e nd of the ca se to he lp
e nsure tha t re ve rsa l will ta ke pla ce a s promptly a s possible (Miller:
230. (C) Se le giline is a n MAOI tha t is some time s use d in the
tre a tme nt of Pa rkinson dise a se . Me pe ridine is the origina l
phe nylpipe ridine from which a numbe r of othe r conge ne rs a re
de rive d (e .g., fe nta nyl, sufe nta nil, a lfe nta nil, re mife nta nil).
Me pe ridine is ra re ly use d a s a n a na lge sic but ra the r a s a n a nti-
shive ring drug. Me pe ridine (a s we ll a s me tha done a nd tra ma dol) is
contra indica te d in pa tie nts ta king MAOIs be ca use of the possibility
of se rotonin syndrome (e .g., a gita tion, ske le ta l muscle rigidity,
hype rpyre xia ) or de pre ssion (e .g., hypote nsion, de pre sse d
ve ntila tion, coma ) tha t ma y re sult (Miller: Miller’s Anesth esia, ed 8, pp
894–896, 909–910).
231. (A) Some childre n a wa ke n from ge ne ra l a ne sthe sia a nd
a ppe a r re stle ss a nd inconsola ble during the e a rly re cove ry pe riod
from ge ne ra l a ne sthe sia . This is ca lle d e me rge nce “e xcite me nt”
de lirium (ED), a nd more inte nsive nursing will be ne e de d to
pre ve nt such childre n from hurting the mse lve s a s we ll a s pre ve nt
the m from pulling out intra ve nous line s or surgica l dra ins. This
usua lly re solve s quickly whe n the child a wa ke ns more fully.
Although untre a te d pa in is ofte n conside re d a n instiga ting fa ctor,
ma ny childre n ca n be pa in fre e a nd still de ve lop ED. Risk fa ctors
include a ge younge r tha n 5 ye a rs (pe a k incide nce , 2-4 ye a rs of a ge ),
the use of vola tile a ne sthe tics (se voflura ne ha s the highe st
fre que ncy of ED), otola ryngologic a nd ophtha lmologic surge rie s,
a nd a nxious pa re nts. Prophyla ctic tre a tme nt with a single IV dose
of fe nta nyl (2.5 µg/kg), clonidine (2 µg/kg), ke ta mine (0.25 mg/kg),
na lbuphine (0.1 mg/kg), or de xme de tomidine (0.15 µg/kg) ca n
de cre a se the incide nce . Some ha ve use d IV propofol (1 mg/kg)

a fte r turning off se voflura ne a t the conclusion of surge ry to
de cre a se the incide nce of ED. Intra na sa l fe nta nyl (1 µg/kg) ma y be

use ful whe n the IV route is una va ila ble (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, p 391; Miller: Basics of Anesth esia, ed 6, p
232. (A) Etomida te , a n imida zole de riva tive , is use d most ofte n for
induction of ge ne ra l a ne sthe sia , but it a lso ca n be use d for
ma inte na nce of ge ne ra l a ne sthe sia . Etomida te ha s a re la tive ly
short dura tion of a ction a nd provide s ve ry sta ble he modyna mics,
e ve n in pa tie nts with limite d ca rdiova scula r re se rve . Howe ve r, it is
a ssocia te d with se ve ra l a dve rse e ffe cts. The se a dve rse e ffe cts
include a high incide nce of na use a a nd vomiting (gre a te r tha n a fte r
thiope nta l), pa in on inje ction, thrombophle bitis, myoclonic
move me nts, a nd, some time s, hiccups. Na use a a nd vomiting
constitute the most common re a son pa tie nts ra te a ne sthe sia with
e tomida te a s unsa tisfa ctory. The a ddition of fe nta nyl to e tomida te
to de cre a se the pa in of inje ction a lso incre a se s the incide nce of
na use a a nd vomiting (Miller: Miller’s Anesth esia, ed 8, p 852).
233. (A) Pa ncuronium te nds to incre a se the he a rt ra te , me a n
a rte ria l BP, a nd ca rdia c output. This ma y be re la te d to se ve ra l
me cha nisms, including a mode ra te va golytic e ffe ct, nore pine phrine
re le a se , a nd de cre a se d re upta ke of nore pine phrine by a dre ne rgic
ne rve s. The othe r liste d drugs ra re ly ca use dire ct a dre ne rgic
stimula tion a nd do not inhibit the upta ke of nore pine phrine by
a dre ne rgic ne rve s (Miller: Miller’s Anesth esia, ed 8, p 978).
234. (B) Da ntrole ne is a muscle re la xa nt use d ora lly to he lp control
ske le ta l muscle spa sticity in pa tie nts with uppe r motor ne uron
le sions, a nd it ca n be use d a cute ly in the pre ve ntion of ma ligna nt
hype rthe rmia in pa tie nts unde rgoing a ne sthe sia . It is give n
intra ve nously in the tre a tme nt of ma ligna nt hype rthe rmia .
Da ntrole ne ha s little or no e ffe ct on smooth or ca rdia c muscle a t
clinica l dose s. Da ntrole ne works dire ctly on ske le ta l muscle by
de cre a sing the a mount of ca lcium re le a se d from the sa rcopla smic
re ticulum. This de cre a se s the e xcita tion–contra ction coupling
ne e de d for the muscle to contra ct. The most common side e ffe ct of
da ntrole ne a dministra tion is ske le ta l muscle we a kne ss. Othe r
a cute side e ffe cts include na use a , dia rrhe a , a nd blurre d vision.
W he n the drug is give n intra ve nously, a brisk diure sis occurs a nd is
re la te d to the ma nnitol a dde d to ma ke the intra ve nous solution
isotonic. W ith chronic ora l use , pa tie nts ma y ra re ly de ve lop
he pa titis a nd ple ura l e ffusions (Stoelting: Ph arm acology and
235. (D) (Ple a se a lso se e e xpla na tion to Que stion 435.) Dia be te s
me llitus is a dise a se cha ra cte rize d by a lte re d me ta bolism of
ca rbohydra te s (usua lly ma nife ste d by hype rglyce mia ), lipids, a nd
prote ins. Nine ty pe rce nt of dia be tic pa tie nts in the Unite d Sta te s
ha ve non–insulin-de pe nde nt dia be te s me llitus (NIDDM) or type 2
dia be te s a nd a re la tive de ficie ncy in circula ting insulin. Dia be tic
pa tie nts a lso ca n ha ve a de cre a se d tissue re sponse to circula ting
insulin (insulin re sista nce ). Ora l hypoglyce mic a ge nts, most
commonly of the sulfonylure a che mica l cla ss, ca n be use d in
pa tie nts with NIDDM. The se sulfonylure a drugs ha ve ma ny
me ta bolic e ffe cts, including the initia l stimula tion of the pa ncre a s to
re le a se insulin (chronica lly, insulin se cre tion is not incre a se d but
the hypoglyce mic e ffe cts a re ma inta ine d). Tolbuta mide (Orina se )
a nd chlorpropa mide (Dia bine se ) a re first-ge ne ra tion a na logs.
The bigua nide s me tformin (Glucopha ge ) a nd phe nformin work
by incre a sing the a ction of circula ting insulin on pe riphe ra l
tissue s a nd a re ca lle d a ntihype rglyce mic, not hypoglyce mic,
a ge nts. The re is no risk of hypoglyce mia with me tformin e ve n
with ove rnight fa sting.
Phe nformin wa s withdra wn from the ma rke t be ca use of a n
a ssocia tion with la ctic a cidosis. Me tformin, long thought to ca use
me ta bolic a cidosis, is now unde rstood to do so only in pa tie nts
who ha ve a bnorma l kidne y or live r function.
SSRIs a re drugs commonly use d for de pre ssion. SSRIs ha ve
se rious side e ffe cts, including hype rpyre xia . The re ha ve be e n
re ports of se rotonin syndrome with SSRI a nd me thyle ne blue , but
not with me tformin (Miller: Miller’s Anesth esia, ed 8, pp 1219–1220;
Miller: Basics of Anesth esia, ed 6, pp 182–183).
236. (D) Disulfira m a nd na ltre xone occa siona lly a re a dministe re d
ora lly in a lcoholic re ha bilita tion progra ms. Disulfira m a lte rs the
me ta bolism of a lcohol by irre ve rsibly ina ctiva ting the e nzyme
a lde hyde de hydroge na se . If the pa tie nt drinks a lcohol, the re is a
buildup of a ce ta lde hyde in the blood. This produce s the unple a sa nt
e ffe cts of flushing, he a da che , na use a , vomiting, che st pa in,
ta chyca rdia , hypote nsion, a nd confusion. The a lcohol se nsitivity
with disulfira m use ma y la st up to 2 we e ks a fte r the drug is
stoppe d. Na ltre xone is use d with disulfira m in the tre a tme nt of
a lcohol a ddiction. It a ppe a rs to block some of the re inforcing
prope rtie s of a lcohol. Pa tie nts ta king na ltre xone with disulfira m
ha ve a lowe r ra te of re la pse for a lcohol. Na ltre xone is a pure
opioid a nta gonist. Pa tie nts ta king na ltre xone a t the time of surge ry
will ha ve ma rke dly e le va te d opioid re quire me nts if opioids a re
chose n for pa in re lie f. The dura tion of a ction of na ltre xone is 24
hours, a nd the drug should be stoppe d during the hospita liza tion to
a llow be tte r pa in control with na rcotics, a s would be de sira ble in
this ma jor surgica l proce dure (Hard m an: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 10, pp 602–604; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 5, p 542; Miller:
237. (B) Ra pid-se que nce inductions a re pe rforme d in ca se s whe re
ra pid control of the a irwa y is ne e de d. Usua lly this is pe rforme d to
se cure the a irwa y in a pa tie nt who should be e a sily intuba te d a nd
ha s a “full stoma ch.” In the se ca se s, a fte r a de qua te pre oxyge na tion
a nd suctioning of the a irwa y ca n be re a dily pe rforme d, a n
intra ve nous induction of ge ne ra l a ne sthe sia is pe rforme d with
cricoid pre ssure , a nd a muscle re la xa nt with a short-onse t time is
a dministe re d. Succinylcholine ha s the fa ste st onse t time of a ll
ne uromuscula r re la xa nts a nd is the drug of choice . Howe ve r, in
some ca se s, succinylcholine is contra indica te d a nd a nothe r
ne uromuscula r blocke r is chose n. Of the drugs liste d, rocuronium
is the be st choice be ca use of its ra pid onse t. Although the onse t
time of othe r nonde pola rizing ne uromuscula r re la xa nts ca n be spe d
up with priming (a te chnique in which 10% of the intuba ting dose is
followe d 2 to 4 minute s la te r with a n intra ve nous induction of
ge ne ra l a ne sthe sia a nd the re ma ining 90% of the re la xa nt),
rocuronium is fa st e nough without priming a nd much simple r to
use . In pa tie nts who ma y be difficult to intuba te , e ve n with
a de qua te muscle re la xa tion, a n a wa ke intuba tion should be
strongly conside re d. D-Tubocura re should ne ve r ha ve a n intuba ting
dose boluse d be ca use it ca use s significa nt hista mine re le a se , a nd
it should be give n incre me nta lly ove r se ve ra l minute s if use d to
intuba te (Miller: Miller’s Anesth esia, ed 8, p 875).
238. (A) The e ffe cts of nonde pola rizing ne uromuscula r drugs a re
ba se d on the drug be ing a t the re ce ptor. Afte r intra ve nous inje ction
of a muscle re la xa nt, pla sma drug conce ntra tion imme dia te ly sta rts
to de cre a se . To produce pa ra lysis, the drug must diffuse from the
pla sma to the ne uromuscula r junction a fte r inje ction a nd bind to
the re ce ptors. The drug e ffe ct is la te r te rmina te d by diffusion of
drug ba ck into the pla sma . Re cove ry of ne uromuscula r function
occurs whe n the muscle re la xa nt diffuse s from the ne uromuscula r
junction ba ck into the pla sma to be me ta bolize d a nd/or e limina te d
from the body (Miller: Miller’s Anesth esia, ed 8, p 871).
239. (D) Bupre norphine (Bupre ne x) is a mixe d a gonist-a nta gonist
opioid with a ve ry strong a ffinity for µ re ce ptors. Be ca use of its
strong a ffinity (33 time s gre a te r tha n morphine ) a nd slow
dissocia tion from the re ce ptors, it ha s a prolonge d dura tion of
e ffe ct (>8 hours) a nd shows re sista nce to re ve rsa l from na loxone . In
ra re ca se s of re spira tory de pre ssion, re ve rsa l ma y not be a chie ve d
with high dose s of na loxone (Miller: Miller’s Anesth esia, ed 8, p 904;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
119).
240. (B) Na use a a nd vomiting ma y be a ssocia te d with a ny of the
drugs liste d. Propofol, a nd pe rha ps mida zola m, ma y a ctua lly be
prote ctive in some pa tie nts. Of the liste d drugs in this que stion,
e tomida te ha s the highe st incide nce of na use a a nd vomiting with
some re porting a n incide nce a s high a s 40% (Barash : Clinical
Anesth esia, ed 7, p 489; Miller: Basics of Anesth esia, ed 6, pp 108–112).
241. (D) Na loxone is a pure opioid a nta gonist (a ffinity but no
intrinsic a ctivity) a t a ll opioid re ce ptors. It ma inly is use d to re ve rse
na rcotic-induce d toxicity. In la rge dose s, na loxone ma y re ve rse the
e ffe cts of e ndoge nous opioids tha t a re e le va te d in conditions of
stre ss (e .g., shock or stroke ). Na loxone ha s no e ffe ct on NSAIDs
(e .g., ke torola c) (Miller: Miller’s Anesth esia ed 8, pp 905–906).
242. (D) Nitric oxide , nitroglyce rin, nitroprusside , phe ntola mine ,
a mrinone , milrinone , a nd prosta gla ndin E a ll ha ve a va sodila tory
e ffe ct on the pulmona ry a rte ria l tre e . Howe ve r, only nitric oxide
ha s ba sica lly no e ffe ct on the syste mic circula tion. The following
ta ble compa re s the re la tive e ffica cy of va rious intra ve nous
va sodila tors (Miller: Miller’s Anesth esia, ed 8, pp 3084–3088).
RELATIVE EFFICACY OF INTRAVENOUS VASODILATORS ON
HEMODYNAMIC VARIABLES
0, none; ±, small and variable; +, mild; +++, strongest effect of that particular drug; D, decrease;
I, increase.
∗ Effect on cardiac output depends on net balance of effects on preload, afterload, and myocardial
oxygenation.
† Amrinone and milrinone are inodilators (they have inotropic plus vasodilating effects).
‡ Prostaglandin E almost always requires left atrial infusion of norepinephrine to sustain
1
adequate systemic blood pressure.
From Stoelting RK, Miller RD: Basics of Anesthesia, ed 5, Philadelphia, Churchill Livingstone,
2006, p 1794.
243. (B) Succinylcholine is ra pidly me ta bolize d in the blood by

pse udocholine ste ra se (pla sma choline ste ra se ). This a ccounts for
the la rge dose re quire d to fa cilita te intuba tion. Be ca use
pse udocholine ste ra se is not pre se nt a t the ne uromuscula r junction,
succinylcholine ’s a ction is te rmina te d a fte r it diffuse s into the
e xtra ce llula r fluid (Miller: Miller’s Anesth esia, ed 8, p 961).
244. (A) De xme de tomidine is a highly se le ctive α2-a dre ne rgic
a gonist tha t is ma inly use d for se da tion. It ha s a ra pid onse t of
a ction (<5 minute s) a nd a pe a k e ffe ct in a bout 15 minute s. In
normovole mic he a lthy pa tie nts, the ca rdiova scula r e ffe cts include a
de cre a se in he a rt ra te a nd ca rdia c output. The he a rt-ra te cha nge s
ca n be profound, a nd occa siona lly sinus a rre st ma y de ve lop. Afte r
a n IV inje ction, the BP initia lly incre a se s (due to pe riphe ra l α
stimula tion), the n within 15 minute s re turns to norma l a nd is
followe d by a n a pproxima te ly 15% de cre a se in BP within a n hour.
This is re la te d to its CNS α-a dre ne rgic stimula tion ove rriding the
pe riphe ra l e ffe cts. Re spira tory cha nge s a re minima l, provide d tha t
e xce ssive se da tion doe s not produce obstructive a pne a . At clinica l
dose s of 1 to 2 µg/kg/min only a mild de cre a se in tida l volume (VT)

is se e n, with no cha nge in re spira tory ra te . W ith high dose s, the
Pa CO2 ma y incre a se a bout 20% due to a de cre a se in VT a s the
re spira tory ra te incre a se s (Miller: Miller’s Anesth esia, ed 8, pp 834–
838).
245. (D) Fospropofol (Luse dra ), a pprove d in De ce mbe r 2008 for
monitore d a ne sthe sia ca re , is a prodrug of propofol tha t, a fte r IV
infusion, is ra pidly conve rte d into propofol. Be ca use it is wa te r
soluble , the proble ms a ssocia te d with a lipid ve hicle (pa in on
inje ction, risk of hype rtriglyce ride mia , risk of pulmona ry e mbolism,
risk of se psis) a re a bse nt (Eisai Corporation prod uct inform ation;
246. (C) In a ddition to a na lge sia , re spira tory de pre ssion, na use a ,
a nd e uphoria , tole ra nce to se da tion with chronic a na lge sic the ra py
with morphine will de ve lop a fte r 2 to 3 we e ks of tre a tme nt. Miosis
a nd constipa tion occur with na rcotic a dministra tion re ga rdle ss of
le ngth of the ra py. The conce pt of tole ra nce is not a pplica ble to
the se two side e ffe cts (Butterworth : Morgan & Mikh ail’s Clinical
247. (D) H2-re ce ptor a nta gonists (e .g., cime tidine , ra nitidine ,
fa motidine , niza tidine ) ca n be use d pre ope ra tive ly to incre a se
ga stric fluid pH be fore induction of a ne sthe sia . Ele va tion of ga stric
fluid pH (a bove 2.5) is de sira ble to de cre a se the incide nce a nd
se ve rity of lung da ma ge if a spira tion of ga stric conte nts occurs. H2-
re ce ptor a nta gonists a re not uncommonly use d a s a pre me dica tion
for pa rturie nts, pa tie nts with symptoma tic ga stroe sopha ge a l re flux,
a nd obe se pa tie nts (who te nd to ha ve ve ry a cidic ga stric fluid
compa re d to nonobe se pa tie nts). H2-re ce ptor a nta gonists, in
contra st to me toclopra mide , ha ve no e ffe ct on lowe r e sopha ge a l
sphincte r tone , inte stina l motility, or ga stric e mptying. Although the
incide nce of side e ffe cts is low, side e ffe cts occa siona lly ma y
de ve lop in pa tie nts, e spe cia lly whe n the drug is a dministe re d
intra ve nously a nd whe n the drugs a re a dministe re d to the e lde rly
or to pa tie nts with he pa tic or re na l dysfunction. Bra dyca rdia ma y
de ve lop a nd ma y be re la te d to the e ffe cts on ca rdia c H2 re ce ptors.
Re ve rsible e le va tion of pla sma a minotra nsa mina se e nzyme s ma y
occur. H2-re ce ptor a nta gonists cross the blood-bra in ba rrie r a nd
ma y le a d to me nta l confusion or de la ye d a wa ke ning. Cime tidine
impa irs the me ta bolism of drugs such a s lidoca ine , propra nolol,
a nd dia ze pa m. This impa irme nt ma y be re la te d to the binding of
cime tidine to the cytochrome P-450 e nzyme s (Barash : Clinical
248. (A) Drug se nsitivity ha s be e n re porte d in a bout 3% to 4% of
a ne sthe tic-re la te d de a ths. Alle rgic drug re a ctions ha ve be e n
re porte d to occur with most drugs a dministe re d during a ne sthe sia ,
with the e xce ption of ke ta mine a nd the be nzodia ze pine s. Although
most drug-induce d a lle rgic re a ctions occur within 5 to 10 minute s of
e xposure , re a ctions to la te x products ma y ta ke longe r tha n 30
minute s to de ve lop (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 525–529).
249. (C) Atropine is a dministe re d in dose s of 2 to 6 mg a nd is

re pe a te d e ve ry 5 to 10 minute s until se cre tions be gin to de cre a se .
In most ca se s, 2 mg e ve ry 8 hours is ne e de d. Howe ve r, dose s of 15
to 20 mg a re not uncommon a nd occa siona lly dose s ove r 1000 mg
ha ve be e n ne e de d. Pra lidoxime 600 mg re move s the

orga nophospha te compounds from a ce tylcholine ste ra se a nd is
ofte n use d in conjunction with a tropine . Be nzodia ze pine s a re ofte n
a dministe re d to counte r the e ffe cts of the ne rve ga se s on the GABA
syste m (Barash : Clinical Anesth esiology, ed 7, p 1541).
250. (A) Alfe nta nil (a fe nta nyl a na log) is le ss pote nt (1/5 to 1/10), ha s
a more ra pid onse t (within 1.5 minute s), a nd ha s a shorte r dura tion
of a ction tha n fe nta nyl. The brie f dura tion of a ction of a lfe nta nil is a
re sult of re distribution to ina ctive tissue site s a nd its ra pid he pa tic
me ta bolism (96% cle a re d within 1 hour). Re na l fa ilure doe s not
a lte r the cle a ra nce of a lfe nta nil (Miller: Basics of Anesth esia, ed 6, p
119, Figure 10-3; Miller: Miller’s Anesth esia, ed 8, p 887; Butterworth :
251. (D) Asthma is a n infla mma tory illne ss a ssocia te d with
bronchia l hype r-re a ctivity a nd bronchospa sm. Me dica tions e ffe ctive
in the ma na ge me nt of a cute e xa ce rba tions of bronchia l a sthma
include the ra pid-onse t inha le d β2-a dre ne rgic re ce ptor a gonists
(e .g., a lbute rol, pirbute rol, te rbuta line ), a nticholine rgic drugs (e .g.,
inha le d ipra tropium), a nd IV corticoste roids. In a n a cute a tta ck,
ipra tropium (slowe r in onse t tha n β2-a dre ne rgic re ce ptor a gonists)
ca n be e ffe ctive whe n use d in combina tion with the ra pid-onse t β2
a gonists. W he n unre solving bronchospa sm occurs a nd is
conside re d life thre a te ning, the dia gnosis of sta tus a sthma ticus is
ma de . Although tre a tme nt ofte n sta rts with β2 a gonists (two to four
puffs e ve ry 15-20 minute s), whe n a lve ola r ve ntila tion is re duce d,
inha le d a ge nts ma y not be succe ssful. In this ca se , SQ e pine phrine
(a dult dose of 0.2 to 1 mg or 0.2 to 1 mL of 1:1000 solution) ca n be

give n. Corticoste roids e nha nce a nd prolong the re sponse to β2
a gonists, a nd, in sta tus a sthma ticus, IV corticoste roids such a s
cortisol (Solu-Corte f) 2 mg/kg IV bolus followe d by 0.5 mg/kg/hr, or
me thylpre dnisolone (Solu-Me drol) 60 to 125 mg e ve ry 6 hours, a re

a dministe re d e a rly in the tre a tme nt (but ma y ta ke se ve ra l hours to
work). Supple me nta l oxyge n is give n to ke e p the oxyge n sa tura tion
gre a te r tha n 90%. Be ca use He liox (70% he lium a nd 30% oxyge n) is
one third the de nsity of oxyge n, it ca n be trie d. IV te rbuta line
sta rting a t a ra te of 0.1 µg/kg/min a nd incre a se d until improve me nt

is se e n or significa nt ta chyca rdia de ve lops ma y be use ful.
Ma gne sium sulfa te a t a dose of 25 to 40 mg/kg (ma ximum of 2 g)

a dministe re d ove r 20 minute s ha s be e n use d. Broa d-spe ctrum
a ntibiotics a re a lso sta rte d. In se ve re ca se s whe re fa tigue se ts in
a nd the Pa CO2 is rising (e .g., >70-80 mm Hg), ge ne ra l a ne sthe sia

with me cha nica l ve ntila tion ma y be ne e de d. The vola tile
a ne sthe tics such a s isoflura ne , ha lotha ne , or se voflura ne ca n be
use d not only to se da te but a lso to re la x the smooth muscle in the
constricte d a irwa ys. Cromolyn, howe ve r, doe s not re lie ve
bronchospa sm. Cromolyn is use d prophyla ctica lly be ca use it
inhibits a ntige n-induce d re le a se of hista mine a nd othe r a uta coids,
such a s le ukotrie ne s, from ma st ce lls. Aminophylline once wa s
wide ly use d to tre a t a cute a sthma but is ra re ly use d toda y be ca use
it a dds little to β2-a gonist a ctivity a nd ha s significa nt side e ffe cts
(Hard m an: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 10, pp 733–749; Hines: Stoelting’s Anesth esia and Co-
252. (D) Clonidine is a n α2-a dre ne rgic a gonist. Unlike ma ny
pe riphe ra lly a cting a ntihype rte nsive drugs (e .g., gua ne thidine ,
propra nolol, ca ptopril), clonidine prima rily stimula te s ce ntra l
a dre ne rgic re ce ptors a nd de cre a se s the sympa the tic re sponse . As
with othe r drugs tha t a ffe ct the ce ntra l re le a se of ca te chola mine s,
clonidine not only re duce s a ne sthe tic re quire me nts (a s re pre se nte d
by a de cre a se in MAC) but a lso de cre a se s e xtre me s in a rte ria l BP
during a ne sthe sia . Clonidine ha s a na lge sic prope rtie s a nd re duce s
the re quire me nts for opioids. Clonidine ha s be e n give n ora lly,
intra ve nously, e pidura lly, intra the ca lly, a nd in pe riphe ra l ne rve
blocks a nd pote ntia te s the a na lge sic e ffe ct of loca l a ne sthe tics. α2-
Adre ne rgic a gonists ca n re duce the muscle rigidity se e n with the
a dministra tion of na rcotics a nd ca n be use d to de cre a se
posta ne sthe tic shive ring. Pa tie nts chronica lly ta king clonidine
should not ha ve it discontinue d be fore surge ry a nd should ke e p
ta king clonidine to pre ve nt clonidine withdra wa l a nd hype rte nsive
crisis (Miller: Miller’s Anesth esia, ed 8, pp 368, 1218, 1632).
253. (D) Chronic live r dise a se ma y inte rfe re with the me ta bolism of
drugs be ca use of the de cre a se d numbe r of e nzyme -conta ining
he pa tocyte s, de cre a se d he pa tic blood flow, or both. Prolonge d
e limina tion ha lf-time s for morphine , a lfe nta nil, dia ze pa m,
lidoca ine , pa ncuronium, a nd, to a le sse r e xte nt, ve curonium ha ve
be e n de monstra te d in pa tie nts with cirrhosis of the live r. In
a ddition, se ve re live r dise a se ma y de cre a se the production of
choline ste ra se (pse udocholine ste ra se ) e nzyme , which is ne ce ssa ry
for the hydrolysis of e ste r linka ge s in drugs such a s succinylcholine ,
a nd the e ste r loca l a ne sthe tics such a s proca ine (Miller: Basics of
254. (D) Succinylcholine is the drug of choice (unle ss
contra indica te d) whe n ra pid-se que nce tra che a l intuba tion is
ne e de d. Although hype rka le mic ca rdia c a rre st is a complica tion of
succinylcholine a dministra tions to pa tie nts who ha ve susta ine d
burns (a s we ll a s crush injurie s, spina l cord tra uma , or othe r
de ne rva tion injurie s, chronic illne ss polyne uropa thy, a nd chronic
illne ss myopa thy), the susce ptibility for hype rka le mia a fte r a burn
injury pe a ks a t 7 to 10 da ys but ma y be gin a s e a rly a s 2 da ys a fte r
susta ining a the rma l injury. The first 24 hours a fte r the injury a re
conside re d sa fe . Adding a de fa scicula ting dose of a
nonde pola rizing ne uromuscula r blocking drug be fore
succinylcholine use to the re gime n would slow down a chie ve me nt
of pa ra lysis. Although the “priming” te chnique of giving 10% of the
intuba ting dose followe d 2 to 4 minute s la te r by the re st of the
intuba ting dose ha s be e n use d to spe e d conditions for intuba tion, it
is still slowe r tha n succinylcholine , a nd this te chnique is ra re ly
use d be ca use rocuronium (which provide s the most ra pid
intuba ting conditions a mong the nonde pola rizing ne uromuscula r
blocking drugs a nd is a close se cond be hind succinylcholine ) is
a va ila ble . An intuba ting dose of D-tubocura rine should ne ve r be
give n a s a bolus be ca use of its mode ra te hista mine re le a se (Miller:
255. (A) Clonidine , a ce ntra lly a cting α-a gonist, de cre a se s
sympa the tic ne rvous syste m outflow a nd de cre a se s pla sma
ca te chola mine conce ntra tions in norma l pa tie nts, but it ha s no
e ffe ct in pa tie nts with phe ochromocytoma s. It is use d a s a n
a ntihype rte nsive a ge nt for tre a ting e sse ntia l hype rte nsion, a n
a na lge sic whe n inje cte d e pidura lly or into the suba ra chnoid spa ce
a lone , a drug tha t prolongs the e ffe ct of re giona l loca l a ne sthe tics,
a drug tha t ca n be use d to stop shive ring (75 µg IV), a drug tha t ca n
he lp prote ct a ga inst pe riope ra tive myoca rdia l ische mia (whe n
give n pre ope ra tive ly a nd typica lly for 4 da ys a fte r surge ry), a nd a
drug tha t ca n he lp de cre a se the symptoms of na rcotic a nd a lcohol
withdra wa l (Barash : Clinical Anesth esia, ed 7, p 392; Miller: Miller’s
Anesth esia, ed 8, p 473; Hines: Stoelting’s Anesth esia and Co-Ex isting
256. (C) Ske le ta l muscle spa sm, pa rticula rly of the
thora coa bdomina l muscle s (“stiff che st” syndrome ), ma y occur
whe n la rge dose s of opioids a re give n ra pidly. This ma y be
significa nt e nough to pre ve nt a de qua te ve ntila tion. Although the
a dministra tion of a muscle re la xa nt or a n opioid a nta gonist such a s
na loxone will te rmina te the ske le ta l muscle rigidity, re ve rsing the
na rcotic e ffe ct ma y not be de sira ble if surge ry is ne e de d (Miller:
257. (B) One of the a dva nta ge s of ke ta mine is the minima l e ffe ct on
re spira tions. Afte r the intra ve nous induction dose of 2 mg/kg,

ge ne ra l a ne sthe sia is induce d within 30 to 60 se conds with, a t
most, a tra nsie nt de cre a se in re spira tions (Pa CO2 ra re ly incre a se s
more tha n 3 mm Hg). W ith unusua lly high dose s, or if opioids a re

a lso a dministe re d, a pne a ca n occur (Miller: Basics of Anesth esia, ed 6,
p 108).
258. (C) This pa tie nt ha s a pa rtia lly compe nsa te d me ta bolic
a cidosis. Me ta bolic a cidosis is commonly divide d into those with a
norma l ion ga p, a lso ca lle d hype rchlore mic me ta bolic a cidosis
(bica rbona te loss is counte rba la nce d by a n incre a se in chloride
le ve ls), a nd those with a high a nion ga p. The a nion ga p ca n be
ca lcula te d by de te rmining the diffe re nce be twe e n the sodium
conce ntra tion a nd the sum of the chloride a nd bica rbona te
conce ntra tions (i.e ., [Na +] − [Cl–] + [HCO3–]) a nd is norma lly 8 to
14 mEq/L. In this ca se , the a nion ga p is 135 − [95 + 14] = 26. This

pa tie nt, the re fore , ha s a high a nion ga p a cidosis. This que stion ha s
two forms of a cidosis tha t ha ve a high a nion ga p: dia be tic
ke toa cidosis (DKA) a nd propofol infusion syndrome , which ca use s
a la ctic a cidosis. Be ca use this pa tie nt is a type 2 (non–insulin-
de pe nde nt) dia be tic, DKA doe s not occur a nd the ca use must be
propofol infusion syndrome (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 372–373; Miller: Miller’s Anesth esia, ed 8, p
832).
259. (D) Ne urole ptic ma ligna nt syndrome (NMS) ca n be se e n in up
to 1% of pa tie nts tre a te d with a ntipsychotic drugs. The syndrome
ha s ma ny fe a ture s tha t re se mble the condition ma ligna nt
hype rthe rmia , including incre a se d me ta bolism, ta chyca rdia , muscle
rigidity, rha bdomyolysis, fe ve r, a nd a cidosis. The morta lity ra te ma y
be 20% to 30%. The re a re ma ny diffe re nce s be twe e n NMS a nd
ma ligna nt hype rthe rmia . NMS is not inhe rite d a nd usua lly ta ke s 24
to 72 hours to de ve lop a fte r the use of ne urole ptic drugs (e .g.,
phe nothia zine s, ha lope ridol), whe re a s ma ligna nt hype rthe rmia
pre se nts more a cute ly. Stopping the a ntipsychotic me dica tion is
obviously ne ce ssa ry. Be ca use dopa mine de ple tion a ppe a rs to pla y
a role in ca using NMS, the dopa mine a gonists bromocriptine a nd
a ma nta dine a ppe a r use ful in the tre a tme nt. Abrupt withdra wa l of
le vodopa ma y a lso ca use this syndrome . Succinylcholine a nd
vola tile a ne sthe tics, which a re known trigge rs for ma ligna nt
hype rthe rmia , a re not trigge rs for NMS. Da ntrole ne ha s be e n use d
to tre a t this condition (Stoelting: Ph arm acology and Ph y siology in
260. (C) Norma l pse udocholine ste ra se is inhibite d 80% by dibuca ine
(dibuca ine numbe r of 80), whe re a s pa tie nts with a typica l
choline ste ra se show only 20% inhibition (dibuca ine numbe r of 20).
Pa tie nts who a re he te rozygous for a typica l pse udocholine ste ra se
(a s in this ca se ) ha ve inte rme dia te dibuca ine numbe rs ra nging from
50% to 60%. Succinylcholine pa ra lysis a fte r a n intuba ting dose of
1 mg/kg la sts up to 10 minute s with norma l pse udocholine ste ra se ,

up to 30 minute s in pa tie nts with the a typica l he te rozygous
pse udocholine ste ra se , a nd ma y pe rsist for 3 hours or longe r in
pa tie nts who ha ve a typica l choline ste ra se pa ra lysis. Se e a lso
Que stion 200 (Miller: Basics of Anesth esia, ed 6, pp 148–149).
261. (D) Cya nide (hydrocya nic a cid [HCN], prussic a cid) is a ra pidly
a cting poison. Cya nide is comme rcia lly use d a s a pe sticide , but it
ca n be re le a se d a s a ga s from burning nitroge n-conta ining pla stics.
Sodium nitroprusside (SNP) is me ta bolize d to cya nide a nd nitric
oxide . The cya nide produce d from SNP usua lly is ra pidly
me ta bolize d to re la tive ly nontoxic thiocya na te (SCN−), which is
e xcre te d into the urine . Although ra re , cya nide a nd/or thiocya na te
toxicity ca n de ve lop in pa tie nts re ce iving prolonge d high-dose
infusions of nitroprusside . Cya nide binds to iron in the fe rric sta te
a nd inhibits ce llula r re spira tion. This produce s se ve re la ctic
a cidosis a nd cytotoxic hypoxia . Be ca use oxyge n is not use d we ll,
the ve nous blood is we ll oxyge na te d (e le va te d ce ntra l ve nous
oxyge n le ve ls a nd pa tie nts a re not cya notic). Tre a tme nt (a dult
dose s in pa re nthe sis) ca n include sodium nitrite (Na NO2—300 mg

IV ove r 10 minute s), a myl nitrite (inha la tion), sodium thiosulfa te
(12.5 g IV ove r 10 minute s), a nd hydroxocoba la min (5-10 g IV ove r

20 minute s). Nitrite conve rts he moglobin to me the moglobin, which
compe te s with cytochrome oxida se for the cya nide ion forming
cya nme the moglobin. Nitrite ca n be a dministe re d IV a s sodium
nitrite or by inha la tion with a myl nitrite . Sodium thiosulfa te
(Na 2S2O3), the pre fe rre d drug, is a sulfur donor tha t conve rts
cya nide to thiocya na te .
Hydroxocoba la min combine s with cya nide to form

cya nocoba la min or vita min B12. Me thyle ne blue is not a n a ntidote
for cya nide toxicity a nd ca n complica te the ra py by conve rting
me the moglobin ba ck to he moglobin a nd re le a sing fre e cya nide .
Although oxyge n a lone (e ve n unde r hype rba ric conditions) ha s
little be ne fit, it should be use d be ca use it dra ma tica lly
pote ntia te s the a ctivity of thiosulfa te a nd nitrite s (Barash : Clinical
Anesth esia, ed 7, pp 403–404; Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, pp 782–783, 793–796;
262. (D) The dura tion of ne uromuscula r block by succinylcholine
ca n be ma rke dly prolonge d whe n the tota l a mount of pla sma
choline ste ra se is ve ry low, the a mount is norma l but of a n
a bnorma l type (i.e ., a typica l pla sma choline ste ra se ), or a n
a nticholine ste ra se drug (e .g., ne ostigmine , e chothiopha te , or the
orga nophospha te inse cticide ma la thion) is a dministe re d. To
e va lua te a prolonge d re sponse to succinylcholine , one ne e ds to
e va lua te both the tota l a mount of choline ste ra se (i.e ., qua ntita tive
te st) a nd the type of choline ste ra se (i.e ., qua lita tive te st). Atypica l
pla sma choline ste ra se is a n inhe rite d disorde r tha t occurs in
a pproxima te ly 1 of e ve ry 480 pa tie nts with he te rozygous ge nome
a nd in a pproxima te ly 1 of 3200 pa tie nts with homozygous ge nome .
The loca l a ne sthe tic dibuca ine ca n inhibit norma l pla sma
choline ste ra se e nzyme be tte r tha n a n a bnorma l e nzyme . In pa tie nts
with norma l pla sma choline ste ra se , the dibuca ine inhibition te st
re ports a numbe r a round 80 or produce s 80% inhibition.
He te rozygote s ha ve a dibuca ine numbe r of a round 50, a nd pa tie nts
who a re homozygous for the a typica l pla sma choline ste ra se ha ve a
numbe r a round 20. Tota l pla sma choline ste ra se le ve ls ca n be
re duce d with de cre a se d production, a s occurs with se ve re chronic
live r dise a se or with the use of some che mothe ra pe utic drugs (e .g.,
cyclophospha mide ). The dibuca ine numbe r is norma l whe n the
tota l pla sma choline ste ra se le ve ls a re re duce d, a s we ll a s a fte r the
use of a nticholine ste ra se drugs. Pa tie nts with a C5 isoe nzyme
va ria nt ha ve incre a se d pla sma choline ste ra se a ctivity, a more ra pid
bre a kdown of succinylcholine , a nd a shorte r dura tion of a ction
(Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, p 243; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 205–207; Miller: Basics of Anesth esia, ed 6, pp 76,
ed 4, pp 216–220).
263. (C) Be nzodia ze pine s a re drugs tha t ha ve the che mica l structure
of a be nze ne ring a tta che d to a se ve n-me mbe r dia ze pine ring.
Mida zola m, lora ze pa m, oxa ze pa m, a nd dia ze pa m a re
be nzodia ze pine a gonists a nd fluma ze nil is a n a nta gonist.
Be nzodia ze pine a gonists a re a ll se da tive s a nd posse ss a numbe r of
fa vora ble pha rma cologic cha ra cte ristics, including production of
se da tion, a nxiolysis, a nte rogra de a mne sia (a cquisition of ne w
informa tion), a nd a nticonvulsa nt a ctivity. The a mne stic prope rtie s
a re gre a te r tha n the se da tive prope rtie s, which is why pa tie nts
some time s forge t wha t you te ll the m a fte r the be nzodia ze pine is
give n, de spite the ir ha ving wha t a ppe a rs to be a lucid discussion
with you. The y do not produce re trogra de a mne sia (store d
informa tion). The y ra re ly ca use significa nt re spira tory or
ca rdiova scula r de pre ssion a nd ra re ly a re a ssocia te d with the
de ve lopme nt of significa nt tole ra nce or physica l de pe nde nce . The
a gonist a ctions of be nzodia ze pine s most like ly re fle ct the a bility of
the se drugs to fa cilita te the inhibitory ne urotra nsmitte r GABA
a ctions in the CNS. Mida zola m a nd dia ze pa m unde rgo oxida tive
me ta bolism, a nd the ir me ta bolite s a re conjuga te d with glucuronide
be fore re na l e xcre tion. Cime tidine inhibits oxida tive me ta bolism
a nd ma y prolong the dura tion of the se drugs. Lora ze pa m a nd
oxa ze pa m prima rily unde rgo conjuga tion with glucuronic a cid,
which is not influe nce d by cime tidine usa ge or a lte ra tions in
he pa tic function (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 458–467; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 179–181; Miller: Basics of
Anesth esia, ed 6, pp 106–109; Stoelting: Ph arm acology and Ph y siology in
264. (C) Re mife nta nil is a n ultra short-a cting opioid most commonly
a dministe re d by a n IV infusion. Its short dura tion of a ction is due to
its e ste r linka ge , which a llows for ra pid bre a kdown by nonspe cific
pla sma a nd tissue e ste ra se s (prima rily within e rythrocyte s). Its
me ta bolism is not significa ntly influe nce d by re na l fa ilure , he pa tic
fa ilure , or pse udocholine ste ra se le ve ls (be ca use it is not
me ta bolize d to a ny significa nt e xte nt by pla sma
pse udocholine ste ra se ). The clinica l e limina tion ha lf-time is le ss
tha n 6 minute s. For monitore d a ne sthe sia ca re se da tion a fte r 2 mg
of mida zola m, a n infusion ra te of 0.05 to 0.1 µg/kg/min is use d in

he a lthy a dults. For a na lge sia during ge ne ra l a ne sthe sia with
controlle d re spira tions, a ra te of 0.1 to 1.0 µg/kg/min is commonly
use d. A loa ding dose of 1 µg/kg of re mife nta nil (or 0.5 µg/kg, if a
be nzodia ze pine wa s a lso give n) ca n be give n IV ove r 60 to 90
se conds be fore sta rting the infusion. Although it e ffe ctive ly
suppre sse s a utonomic a nd he modyna mic re sponse s to pa inful
stimuli a nd de cre a se s re spira tions a s we ll, its ra pid dissipa tion of
opioid e ffe ct produce s ra pid onse t of postope ra tive pa in (in pa inful
surgica l ope ra tions), unle ss othe r a na lge sics a re a dministe re d for
postope ra tive pa in be fore stopping the infusion (Barash : Clinical
Anesth esia, ed 7, pp 514–515, 832–834; Miller: Miller’s Anesth esia, ed 8,
pp 888–897).
265. (D) The ma ximum re comme nde d single dose of lidoca ine give n
by infiltra tion is 300 mg of lidoca ine without e pine phrine a nd
500 mg of lidoca ine with e pine phrine . Ca re ful inje ction in the
mouth is re comme nde d due to the va scula r na ture of tha t a re a
(Barash : Clinical Anesth esia, ed 7, p 572; Miller: Miller’s Anesth esia, ed 8,
p 1041).
266. (A) Postope ra tive shive ring ca n be ca use d by ma ny fa ctors,
including hypothe rmia , tra nsfusion re a ctions, a nd pa in, a s we ll a s
a ne sthe tics. It is uncomforta ble for pa tie nts a nd ca n ma ke
monitoring more difficult, but it a lso ca n le a d to significa nt
incre a se s in oxyge n consumption (up to 200%). The e xa ct e tiology in
ma ny ca se s is uncle a r, but, a fte r routine skin surfa ce wa rming,
pha rma cologic tre a tme nt ma y be ne e de d. Clonidine ,
de xme de tomidine , propofol, ke ta nse rin, tra ma dol, physostigmine ,
ma gne sium sulfa te , a nd na rcotics (e spe cia lly me pe ridine ) ha ve
be e n use d. Na loxone use ma y incre a se pa in a nd doe s not he lp
de cre a se shive ring (Barash : Clinical Anesth esia, ed 7, p 1574; Miller:
267. (C) Suga mma de x is a cyclode xtrin (cyclic oligosa ccha ride )
compound tha t e nca psula te s nonde pola rizing ste roida l muscle
re la xa nts (rocuronium > ve curonium >> pa ncuronium) a nd

produce s ra pid re ve rsa l of profound block (e .g., re ve rsa l of
0.6 mg/kg rocuronium in 3 minute s). Be ca use it ha s no e ffe ct on

a ce tylcholine ste ra se , the re is no ne e d to combine it with the
a nticholine rgics a tropine or glycopyrrola te . It works only with
ste roida l muscle re la xa nts a nd ha s no e ffe ct on re ve rsing the
be nzylisoquinolinium re la xa nts (e .g., a tra curium, cisa tra curium,
doxa curium, D-tubocura rine ). The re a ppe a r to be no ca rdiova scula r
e ffe cts with suga mma de x. It is a va ila ble only outside the Unite d
Sta te s a t pre se nt (Miller: Basics of Anesth esia, ed 6, p 159; Miller:
268. (A) Arginine va sopre ssin (AVP), a lso ca lle d a ntidiure tic
hormone (ADH), ha s ma ny a ctions, but its prima ry role involve s
controlling se rum osmola lity by re gula ting diure sis. AVP is re le a se d
by the hypotha la mus a nd dire ctly ca use s the colle cting tubule s in
the kidne y to incre a se wa te r pe rme a bility a nd re a bsorption. This
incre a se s blood volume a nd lowe rs se rum osmola lity. Be low a
se rum osmola lity of 280 mOsm/kg, AVP is ba re ly de te cta ble ;
howe ve r, whe n the osmola lity is gre a te r tha n 290 mOsm/kg, AVP is
ma xima lly se cre te d. AVP is a lso se cre te d whe n the intra va scula r
volume is de te cte d to be low (e .g., he morrha ge , he a rt fa ilure ,
he pa tic cirrhosis, a nd a dre na l insufficie ncy). Angiote nsin I is
conve rte d to a ngiote nsin II, which is a pote nt va soconstrictor a nd
incre a se s a ldoste rone se cre tion from the a dre na l corte x.
Aldoste rone is a mine ra locorticoid a nd is involve d in sodium
re a bsorption a nd pota ssium e xcre tion in the re na l tubule s.
Aldoste rone se cre tion is stimula te d by hypovole mic sta te s. Re na l
prosta gla ndins a re re le a se d from the kidne y by sympa the tic
stimula tion or by a ngiote nsin II a nd he lp modula te the e ffe cts of
AVP (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p
738; Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, pp 671–704, 721–730; Miller: Basics of Anesth esia, ed
6, pp 449–450).
269. (B) Sodium nitroprusside (SNP) is a ra pid-a cting, dire ct-a cting
pe riphe ra l va sodila tor tha t is compose d of five cya nide moie tie s for
e ve ry NO (nitric oxide ) moie ty. Sodium nitroprusside unde rgoe s
ra pid me ta bolism to re le a se NO a s the a ctive ingre die nt. He a lthy
a dults ca n e a sily e limina te the cya nide produce d during SNP ra te s
of le ss tha n 2 µg/kg/min. Above 2 µg/kg/min a nd e spe cia lly if the
infusion ra te is gre a te r tha n 10 µg/kg/min for 10 minute s, one

should be conce rne d a bout cya nide toxicity. An e a rly sign of
cya nide toxicity is re sista nce to the hypote nsive e ffe cts of SNP
infusion, e spe cia lly whe n the ra te is le ss tha n 2 µg/kg/min. Othe r
signs include me ta bolic a cidosis a nd a n e le va tion of mixe d ve nous
P O2 va lue s (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, p 258).
270. (D) Phe nothia zine s, such a s chlorproma zine (Thora zine ), a re
e ffe ctive a ntipsychotic (ne urole ptic) drugs tha t block D2
dopa mine rgic re ce ptors in the bra in. Extra pyra mida l e ffe cts a re not
uncommon with the se drugs. The y a lso posse ss a ntie me tic e ffe cts.
Phe nothia zine s with low pote ncy, such a s chlorproma zine , ha ve
promine nt se da tive e ffe cts, which gra dua lly de cre a se with
tre a tme nt. The e ffe cts of CNS de pre ssa nts (e .g., na rcotics a nd
ba rbitura te s) a re e nha nce d by concomita nt a dministra tion of
phe nothia zine s. Lowe ring the se izure thre shold is more common
with a lipha tic phe nothia zine s with low pote ncy (e .g.,
chlorproma zine ) compa re d with pipe ra zine phe nothia zine s. The se
drugs a re a ssocia te d with chole sta tic ja undice , impote nce ,
dystonia , a nd photose nsitivity. Ele ctroca rdiogra phic a bnorma litie s,
such a s prolonga tion of the QT or PR inte rva ls, blunting of T
wa ve s, de pre ssion of the ST se gme nt, a nd, on ra re occa sions,
pre ma ture ve ntricula r contra ctions a nd torsa de s de pointe s, a re
se e n. The a ntihype rte nsive e ffe cts of gua ne thidine a nd gua na dre l
a re blocke d by phe nothia zine s. The se drugs ha ve no e ffe ct on
ne uromuscula r blocka de (Miller: Miller’s Anesth esia, ed 8, p 1219;
Hem m ings: Ph arm acology and Ph y siology for Anesth esia, pp 189–192).
271. (A) Amrinone is a nonca te chola mine , nonglycoside ca rdia c
inotropic drug tha t works a s a se le ctive phosphodie ste ra se III (PDE
III) inhibitor. Amrinone incre a se s cyclic a de nosine monophospha te
(cAMP) le ve ls by de cre a sing cAMP bre a kdown in the myoca rdium
a nd va scula r smooth muscle . Be ca use the a ctions of PDE III
inhibitors work by a diffe re nt me cha nism tha n ca te chola mine s
(cAMP le ve ls a re incre a se d by β-a dre ne rgic re ce ptor stimula tion),
a mrinone ca n work in the pre se nce of β-blocka de a nd in ca se s
whe re pa tie nts be come re fra ctory to ca te chola mine use . The
ca te chola mine a ctions ca n be e nha nce d with PDE III inhibitors.
Amrinone produce s both positive inotropic a nd va sodila tory e ffe cts
but ha s no a ntidysrhythmic e ffe cts (Hensley : A Practical Approach to
Card iac Anesth esia, ed 5, p 277).
272. (D) Tricyclic a ntide pre ssa nts ofte n a re a dministe re d a s the
initia l tre a tme nt of me nta l de pre ssion; howe ve r, the more re ce ntly
de ve lope d SSRIs a re more fre que ntly use d be ca use of fe we r side
e ffe cts. Tricyclic a ntide pre ssa nts work by inhibiting the re upta ke of
re le a se d nore pine phrine (a nd se rotonin) into the ne rve e ndings.
Although a t one time it wa s re comme nde d to stop tricyclic
a ntide pre ssa nts be fore e le ctive surge ry, this ha s not be e n shown to
be ne ce ssa ry. Howe ve r, a lte ra tions in pa tie nt re sponse s to some
drugs should be a nticipa te d. The incre a se d a va ila bility of
ne urotra nsmitte rs in the CNS ca n re sult in incre a se d a ne sthe tic
re quire me nts (i.e ., incre a se d MAC). In a ddition, the incre a se d
a va ila bility of nore pine phrine a t postsyna ptic re ce ptors in the
pe riphe ra l sympa the tic ne rvous syste m ca n be re sponsible for a n
e xa gge ra te d BP re sponse a fte r a dministra tion of a n indire ct-a cting
va sopre ssor such a s e phe drine . If a va sopre ssor is re quire d, a
dire ct-a cting drug such a s phe nyle phrine ma y be pre fe rre d. If
hype rte nsion occurs a nd re quire s tre a tme nt, de e pe ning the
a ne sthe tic or a dding a pe riphe ra l va sodila tor such a s nitroprusside
ma y be ne e de d. The pote ntia l for a n e xa gge ra te d BP re sponse (i.e .,
hype rte nsive crisis) is gre a te st during the a cute tre a tme nt pha se
(the first 14-21 da ys). Chronic tre a tme nt is a ssocia te d with down-
re gula tion re ce ptors a nd a de cre a se d like lihood of a n e xa gge ra te d
BP re sponse a fte r a dministra tion of a sympa thomime tic. Tricyclics
ha ve significa nt a nticholine rgic side e ffe cts (e .g., dry mouth, blurre d
vision, incre a se d he a rt ra te , urina ry re te ntion) a nd ca ution is
e spe cia lly importa nt in e lde rly pa tie nts who ma y de ve lop
a nticholine rgic de lirium de spite the the ra pe utic dose s
a dministe re d. Ca ution is a dvise d with the use of me pe ridine in
pa tie nts ta king MAOIs (not tricyclic a ntide pre ssa nts) be ca use of the
possibility of inducing se izure , hype rpyre xia , or coma (Hines:
273. (B) In norma l nondia be tic pa tie nts, a bout 40 units of insulin a re
se cre te d e ve ry da y. The re a re ma ny SQ insulin pre pa ra tions
a va ila ble . Afte r SQ a dministra tion the onse t of a ction is ve ry ra pid
with Lispro a nd Aspa rt (15 minute s); ra pid with Re gula r (30
minute s); inte rme dia te with NPH or Le nte (1-2 hours); a nd slow
with Gla rgine (1.5 hours) a nd Ultra le nte (4-6 hours) (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 380–381).
INSULIN PREPARATIONS
From Hines RL: Stoelting’s Anesthesia and Co-Existing Disease, ed 5, Philadelphia, Saunders,
2008, p 371.
274. (B) The GPIIb/IIIa re ce ptor is spe cific for pla te le ts. Pla te le t
a ctiva tion cha nge s the sha pe of the re ce ptor a nd incre a se s its
a ffinity for fibrinoge n a nd vW F. GPIIb/IIIa re ce ptor a nta gonists (e .g.,
tirofiba n, a bcixima b, a nd e ptifiba tide ) re ve rsibly bind to the pla te le t
GPIIb/IIIa re ce ptor a nd block the binding of fibrinoge n to pla te le ts.
The y do not prolong the prothrombin time or the a ctiva te d pa rtia l
thrombopla stin time . The se drugs a re a dministe re d intra ve nously
a s a bolus a nd the n a s a continuous infusion. The pla sma ha lf-life
a fte r a bolus intra ve nous inje ction is 2 hours for tirofiba n, 2.5 hours
for e ptifiba tide , a nd only 30 minute s for a bcixima b. The biologic
ha lf-life of the se drugs is 4 to 8 hours for tirofiba n, 4 to 6 hours for
e ptifiba tide , a nd 12 to 24 hours for a bcixima b. The longe r dura tion
of a ction for a bcixima b is prima rily due to cle a ra nce by the
re ticuloe ndothe lia l syste m (tirofiba n a nd e ptifiba tide a re cle a re d by
the kidne y) a nd its stronge r a ffinity to the re ce ptor (Hem m ings:
Ph arm acology and Ph y siology for Anesth esia, pp 662–664; Miller: Basics
275. (B) Re mife nta nil is ra pidly hydrolyze d by nonspe cific pla sma
a nd tissue e ste ra se s, ma king it ide a l for a n infusion whe re pre cise
control is sought. The onse t a nd offse t of re mife nta nil is ra pid
(clinica l ha lf-time of <6 minute s). Be ca use the a ctivity of the se
nonspe cific e ste ra se s is not usua lly a ffe cte d by live r a nd re na l
fa ilure , re mife nta nil is we ll suite d for such pa tie nts (Miller: Basics of
276. (C) Pa in with the intra ve nous inje ction is common with
dia ze pa m, e tomida te , me thohe xita l, a nd propofol. It is ve ry ra re
a fte r thiope nta l a nd ke ta mine (Miller: Basics of Anesth esia, ed 6, pp
102,109,112).
277. (D) Pa tie nts a ne sthe tize d with tota l intra ve nous a ne sthe sia
(TIVA), in this ca se consisting of mida zola m, re mife nta nil, a nd
propofol, some time s re quire a fe w minute s to re sume bre a thing
a fte r the infusions a re stoppe d. Although it ma y se e m a ppropria te
to re ve rse this pa tie nt a nd a void the ne e d for ha nd ve ntila tion,
re ve rsing be nzodia ze pine s (mida zola m) with fluma ze nil ma y
pre cipita te se izure s in e pile ptic pa tie nts, a nd, be ca use re mife nta nil
ha s such a short e limina tion ha lf-life (<6 minute s), re ve rsa l with
na loxone is not ne ce ssa ry. The pa tie nt ne e ds a brie f pe riod to
a llow the propofol to we a r off, during which ha nd or me cha nica l
ve ntila tion will be ne ce ssa ry (until the pa tie nt bre a the s
sponta ne ously). Also, muscle we a kne ss must be rule d out if a
muscle re la xa nt ha s be e n use d, a nd normoca pnia should be
a ssure d give n tha t hype rve ntila tion ma y re duce the a rte ria l CO2
be low the a pne ic thre shold (Miller: Miller’s Anesth esia, ed 8, p 897).
278. (C) Phe ntola mine , pra zosin, yohimbine , tola zoline , a nd
te ra zosin a re compe titive a nd re ve rsible α-a dre ne rgic a nta gonists.
Phe noxybe nza mine produce s a n irre ve rsible α-a dre ne rgic
blocka de . Once phe noxybe nza mine ’s α-blocka de de ve lops, e ve n
ma ssive dose s of sympa thomime tics a re ine ffe ctive until
phe noxybe nza mine ’s a ction is te rmina te d by me ta bolism.
Phe ntola mine a nd phe noxybe nza mine a re nonse le ctive α1 a nd α2
a nta gonists, pra zosin is a se le ctive α1 a nta gonist, a nd yohimbine is
a se le ctive α2 a nta gonist (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 227–229).
279. (C) Symptoma tic bra dyca rdia a s a re sult of e xce ssive β-
a dre ne rgic re ce ptor blocka de ca n be tre a te d with a va rie ty of
drugs, a s we ll a s with a pa ce ma ke r. Tre a tme nt de pe nds upon
se ve rity of symptoms. Atropine ca n block a ny pa ra sympa the tic
ne rvous syste m contribution to the bra dyca rdia . If a tropine is not
e ffe ctive , the n a pure β-a dre ne rgic re ce ptor a gonist ca n be trie d.
For e xce ssive ca rdiose le ctive β1 blocka de , dobuta mine ca n be
use d; for a nonca rdia c se le ctive β1 a nd β2 blocka de , isoprote re nol
ca n be chose n. Dopa mine is not re comme nde d be ca use the high
dose s ne e de d to ove rcome β-a dre ne rgic re ce ptor blocka de will
ca use significa nt α-a dre ne rgic re ce ptor–induce d va soconstriction.
Gluca gon a t a n initia l dose of 1 to 10 mg intra ve nously followe d by
a n infusion of 5 mg/hr ofte n is be lie ve d to be the drug of choice for

β-a dre ne rgic blocka de ove rdosa ge . Gluca gon incre a se s myoca rdia l
contra ctility a nd he a rt ra te , prima rily by incre a sing cAMP forma tion
(not via β-a dre ne rgic re ce ptor stimula tion) a nd, to a le sse r e xte nt,
by stimula ting the re le a se of ca te chola mine s. Othe r drugs tha t ha ve
be e n use d include a minophylline a nd ca lcium chloride .
Aminophylline inhibits phosphodie ste ra se , re sulting in a n incre a se
in cAMP. Thus, like gluca gon, a minophylline incre a se s ca rdia c
output a nd he a rt ra te via a non–β-a dre ne rgic re ce ptor–me dia te d
me cha nism. Ca lcium chloride ma y prove use ful to counte ra ct a ny
de cre a se in myoca rdia l contra ctility induce d by the β-blocka de ;
howe ve r, this e ffe ct ma y be tra nsie nt (Stoelting: Ph arm acology and
280. (D) Da ntrole ne is a ske le ta l muscle re la xa nt tha t is e ffe ctive in
the tre a tme nt of ma ligna nt hype rthe rmia . Da ntrole ne is formula te d
with ma nnitol (300 mg ma nnitol/20 mg da ntrole ne ) so tha t diure sis
is promote d during da ntrole ne the ra py. Myoglobinuria from
ma ligna nt hype rthe rmia –a ssocia te d muscle bre a kdown
a ccumula te s in the re na l tubule s a nd ca n ca use kidne y fa ilure if
urine output is not ma inta ine d. Da ntrole ne works within the
muscle ce ll to re duce intra ce llula r le ve ls of ca lcium. In the usua l
clinica l dose s, da ntrole ne ha s little e ffe ct on ca rdia c muscle
contra ctility. In fulmina nt ma ligna nt hype rthe rmia , ca rdia c
dysrhythmia s ma y occur, but this is re la te d to pe rturba tions in pH
a nd e le ctrolyte s. (Ve ra pa mil should not be use d, be ca use it
inte ra cts with da ntrole ne a nd ma y produce hype rka le mia a nd
myoca rdia l de pre ssion. Lidoca ine a ppe a rs sa fe .) Some side e ffe cts
of short-te rm a dministra tion include muscle we a kne ss (which ma y
pe rsist for 24 hours a fte r da ntrole ne the ra py is discontinue d),
na use a a nd vomiting, dia rrhe a , blurre d vision, a nd phle bitis.
Hypothe rmia ma y a lso occur with ma ligna nt hype rthe rmia
tre a tme nt but is re la te d to ice pa cking, not to da ntrole ne
a dministra tion pe r se . W he n de cre a sing the fe ve r, cooling should
be stoppe d whe n core te mpe ra ture re a che s 38° C to a void
hypothe rmia . He pa totoxicity ha s be e n de monstra te d only with long-
te rm use of ora l da ntrole ne (Hines: Stoelting’s Anesth esia and Co-
281. (C) Cisa tra curium is a ste re oisome r of a tra curium a nd a s such
ha s the sa me mole cula r we ight. Both drugs unde rgo Hofma nn
e limina tion a nd form la uda nosine . Atra curium is a lso e stima te d to
unde rgo two thirds of its me ta bolism via e ste r hydrolysis ca ta lyze d
by nonspe cific pla sma e ste ra se s (not pse udocholine ste ra se ).
Ne ithe r drug re quire s re na l or he pa tic input for its de gra da tion;
he nce , both ca n be use d with re na l or he pa tic fa ilure . Atra curium
ca use s hista mine re le a se , whe re a s cisa tra curium doe s not (Miller:
282. (B) W ithdra wa l from opioids is ra re ly life -thre a te ning but ma y
complica te postope ra tive ca re . Opioid withdra wa l ma y
sponta ne ously sta rt within 6 to 12 hours a fte r the la st dose of a
short-a cting opioid a nd a s long a s 72 to 84 hours a fte r a long-a cting
opioid in a ddicte d pa tie nts. The dura tion of withdra wa l symptoms
a lso de pe nds on the opioid; for he roin, withdra wa l symptoms la st 5
to 10 da ys, a nd for me tha done , e ve n longe r. Opioid withdra wa l ca n
be pre cipita te d within se conds if na loxone is a dministe re d
intra ve nously to a n a ddict. (Na loxone is contra indica te d in opioid
a ddicts for this re a son.) Signs a nd symptoms of withdra wa l include
cra ving for opioids, re stle ssne ss, a nxie ty, irrita bility, na use a ,
vomiting, a bdomina l cra mps, muscle a che s, insomnia , sympa the tic
stimula tion (incre a se d he a rt ra te , incre a se d BP, mydria sis,
dia phore sis) a s we ll a s tre mors, je rking of the le gs (origin of the
te rm “kicking the ha bit”), a nd hype rthe rmia . Se izure s, howe ve r, a re
ve ry ra re a nd if se izure s occur, one should conside r tha t
withdra wa l from othe r drugs ma y a lso be occurring (e .g., from
ba rbitura te s) or tha t a n unde rlying se izure disorde r ma y a lso e xist
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 546).
For Questions 283-287: Sid e effects of each of th e intravenous ind uction
agents (th iopental, d iazepam , etom id ate, propofol, and ketam ine) occur.
Som e are uniq ue for each d rug.
283. (C) Etomida te is unique a mong the intra ve nous induction
a ge nts be ca use it ca n ca use a dre nocortica l suppre ssion by
inhibiting the conve rsion of chole ste rol to cortisol. This ca n occur
a fte r a single induction dose a nd ma y pe rsist for 4 to 8 hours. The
clinica l significa nce of this te mpora ry a dre nocortica l suppre ssion is
uncle a r. Howe ve r, in the ICU with prolonge d se da tion, clinica l
a dre na l insufficie ncy ma y de ve lop (i.e ., hypote nsion, hypona tre mia ,
a nd hype rka le mia ). He re corticoste roids should be a dministe re d in
stre ss dose s (e .g., cortisol 100 mg/da y) (Miller: Basics of Anesth esia,
ed 6, pp 111–112).
284. (B) Dia ze pa m is a be nzodia ze pine drug a nd wa s wide ly use d
intra ve nously for a ne sthe sia until mida zola m wa s de ve lope d.
Although it is a n e ffe ctive se da tive a nd a mne stic drug, dia ze pa m
ca use s significa nt pa in on inje ction a nd a t time s ve nous irrita tion
a nd thrombophle bitis. This doe s not se e m to occur with
mida zola m. Be nzodia ze pine s do not suppre ss the a dre na l gla nd.
The most significa nt proble m with be nzodia ze pine s is re spira tory
de pre ssion. Be nzodia ze pine s a re unique a mong the intra ve nous
se da tive s be ca use a spe cific be nzodia ze pine re ce ptor a nta gonist is
a va ila ble (fluma ze nil). One proble m with fluma ze nil is its re la tive ly
short dura tion of a ction (ha lf-life a bout 1 hour), which is shorte r
tha n tha t of dia ze pa m (21-37 hours) a nd mida zola m (1-4 hours)
285. (D) Pa in on inje ction is common with dia ze pa m, e tomida te ,
a nd propofol but ra re with thiope nta l a nd ke ta mine . Howe ve r,
he modyna mic sta bility is common with e tomida te a nd dia ze pa m,
whe re a s hypote nsion is common a fte r propofol a nd thiope nta l,
e spe cia lly in pa tie nts who a re volume -de ple te d or e lde rly.
Hype rte nsion ma y de ve lop with ke ta mine use due to its
sympa the tic ne rvous syste m stimula tion (Miller: Basics of Anesth esia,
ed 6, pp 99–102).
286. (A) ICP te nds to fa ll a fte r the a dministra tion of thiope nta l,
e tomida te , a nd propofol a nd ca n e ithe r fa ll or re ma in uncha nge d
with be nzodia ze pine s. Ke ta mine , howe ve r, ca n incre a se ICP a nd
should be a voide d in pa tie nts with intra cra nia l ma ss le sions a nd
e le va te d ICP be ca use it ca n furthe r incre a se the ICP (Miller: Basics
287. (D) Propofol infusion syndrome (la ctic a cidosis) ma y de ve lop
whe n high-dose infusions (i.e ., >75 µg/kg/min) a re infuse d for

longe r tha n 24 hours. Ea rly signs include ta chyca rdia ; la te r on,
se ve re me ta bolic a cidosis, bra dya rrhythmia s, a nd myoca rdia l
fa ilure ma y de ve lop. The ca use a ppe a rs to be re la te d to impa ire d
fa tty a cid oxida tion in the mitochondria (Miller: Basics of Anesth esia,
ed 6, pp 99–102).
For Questions 288-292: Antih y pertensive agents are used prim arily in th e
treatm ent of essential h y pertension to red uce BP toward norm al. Th ese
agents includ e d irect-acting sm ooth m uscle relax ants or vasod ilators (e.g.,
h y d ralazine), centrally acting α 2-sy m path etic receptor agonists (e.g.,
clonid ine), periph eral ad renergic receptor antagonists (e.g., labetalol),
calcium ch annel blockers, d iuretics, angiotensin-converting enzy m e (ACE)
inh ibitors (e.g., captopril, lisinopril), and angiotensin receptor blockers
(ARBs) (Barash : Clinical Anesth esiology, ed 7, pp 392, 399, 403–404).
288. (A) Ce ntra l-a cting sympa thomime tic a ge nts such a s clonidine
produce some se da tive e ffe cts a nd ca n re duce the a ne sthe tic
re quire me nt or MAC.
289. (C) Losa rta n (Coza a r) blocks the hormone a ngiote nsin a t the
re ce ptor. It is pha rma cologica lly simila r to ACE inhibitors, but with
fe we r side e ffe cts. It is use ful for tre a tme nt of dia be tic pa tie nts a nd
those with ca rdiova scula r dise a se . Hype rka le mia is a pote ntia l
side e ffe ct of the ra py with this drug.
290. (B) Approxima te ly 10% to 20% of pa tie nts who a re chronica lly
ta king hydra la zine (i.e ., >6 months) de ve lop a syste mic lupus
e rythe ma tosus–like syndrome , e spe cia lly if the da ily dose is high
(e .g., >200 mg). The syste mic lupus e rythe ma tosus–like syndrome
will re solve once hydra la zine the ra py is discontinue d.
291. (D) La be ta lol is a n α1-a dre ne rgic re ce ptor a nd nonse le ctive β-
a dre ne rgic re ce ptor a nta gonist.
292. (A) Abrupt discontinua tion of chronica lly a dministe re d
clonidine (e spe cia lly if the dose is >1.2 mg/da y) ma y re sult in

se ve re re bound hype rte nsion within 8 to 36 hours a fte r the la st
dose .
For Question 293: Som e d rugs inh ibit coagulation and d o so th rough a
m y riad of d ifferent path way s. An und erstand ing of th ese d rugs and
th eir m ech anism s is h elpful to th e anesth esia provid er.
293. (A) Pa tie nts susce ptible to HIT-2 (he pa rin-induce d
thrombocytope nia ) should wa it 3 months for a clinica lly significa nt
de cre a se in the a ntibody tite r be fore re ce iving he pa rin. If wa iting is
not possible a nd surge ry involving ca rdiopulmona ry bypa ss ca nnot
be de la ye d, dire ct thrombin inhibitors like hirudin, biva lirudin, or
a rga troba n ca n be use d a s a nticoa gula nts for bypa ss surge ry
294. (C) Abcixima b (Re oPro, pla sma ha lf-life 30 minute s), tirofiba n
(Aggra sta t, pla sma ha lf-life 2 hours), a nd e ptifiba tide (Inte grilin,
pla sma ha lf-life 2.5 hours) a re pote nt inhibitors of pla te le t a ctivity.
The y block the binding of vW F a nd fibrinoge n to the GPIIb/IIIa
re ce ptors on pla te le ts. The se drugs a re use d in the tre a tme nt of
a cute corona ry syndrome . If surge ry is re quire d, the ra py with
e ptifiba tide a nd tirofiba n should be stoppe d for 24 hours.
Abcixima b should be stoppe d for 72 hours be fore a n ope ra tion. All
thre e of the se drugs produce thrombocytope nia a nd a re
me ta bolize d by the kidne y, but dia lysis a s re ve rsa l is only e ffe ctive
with tirofiba n (Barash : Clinical Anesth esia, ed 7, pp 437–438, Miller:
Miller’s Anesth esia, ed 8, p 1873; Miller: Basics of Anesth esia, ed 6, pp
357–359).
295. (A) Arga troba n is a dire ct thrombin inhibitor. Ple a se se e
e xpla na tion a nd re fe re nce for Que stion 293.
296. (B) The thie nopyridine compounds, ticlopidine a nd clopidogre l,
a re P2Y12 a de nosine diphospha te (ADP) re ce ptor a nta gonists.
Binding to this ADP re ce ptor suppre sse s e xpre ssion of GPIIb/IIIa
a nd pre ve nts fibrinoge n from binding to pla te le ts. Although pla te le t
function studie s, pe r se , a re not a re lia ble wa y to te st the e ffe cts of
clopidogre l, the re is a te st to me a sure the inhibition of the
GPIIb/IIIa re ce ptor. Clopidogre l is a n ina ctive prodrug tha t must be
me ta bolize d into the a ctive form by live r oxida se s. A ge ne tic
polymorphism e xists whe re by pa tie nts a re una ble to oxidize
clopidogre l into the a ctive compound, thus ma king it the ra pe utica lly
ine ffe ctive (Barash : Clinical Anesth esia, ed 7, p 437; Miller: Basics of
297. (D) Fonda pa rinux is a n a nta gonist of fa ctor Xa . It a lso binds
with a ntithrombin III. Its principa l use is de e p ve in thrombosis
prophyla xis, a nd the re is no a ntidote for it othe r tha n stopping
the ra py a nd le tting it we a r off. Be ca use it is re na lly e limina te d,
dose must be re duce d in pa tie nts with re na l fa ilure . It is not
a pprove d for pa tie nts with history of he pa rin-induce d
thrombocytope nia (Barash : Clinical Anesth esia, ed 7, p 439).
298. (B) Both a cute tole ra nce to opioids a nd opioid-induce d
hype ra lge sia (OIH) re quire more a na lge sics to tre a t pa in. W ith
tole ra nce the pha rma cologic re sponse is le ss ove r time ; thus, more
opioids a re ne e de d to re lie ve the sa me a mount of pa in (e .g.,
chronic ba ck pa in). W ith OIH the re is a n e xa gge ra te d re sponse to
pa inful stimuli. This ca n occur unde r ce rta in situa tions such a s a n
e xa gge ra te d re sponse to pa in whe n a re mife nta nil infusion is
stoppe d (ra pid offse t of a na lge sia ). To pre ve nt this whe n using
re mife nta nil-ba se d a ne sthe sia , it is wise to a dd a longe r dura tion
opioid (e .g., morphine ) a nd/or to a dd nonopioid a na lge sics be fore
stopping a re mife nta nil infusion (if pa in is e xpe cte d in the
postope ra tive pe riod). Although the e tiology of OIH is unknown, it
ma y involve both ce ntra l a nd pe riphe ra l ne rvous syste m
a da pta tions involving the NMDA re ce ptor (Barash : Clinical
Anesth esia, ed 7, p 506; Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 267–268).
299. (D) Mixe d a gonist-a nta gonist drugs, such a s butorpha nol,
na lbuphine , a nd pe nta zocine , a re pa rtia l a gonists a t the κ re ce ptor
a nd comple te compe titive a nta gonists a t the µ re ce ptor. Both the
a na lge sia a nd re spira tory de pre ssa nt e ffe cts of the se drugs
a pproa ch a ce iling e ffe ct. The y a re use d a s a na lge sics for mild-to-
mode ra te pa in. The y a re a lso use d to re ve rse e xce ssive opioid-
induce d re spira tory de pre ssion due to the ir µ a nta gonism, while
ma inta ining some a na lge sia a t the κ re ce ptor (Miller: Miller’s
Anesth esia, ed 8, pp 903–904; Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, pp 265–266).
300. (A) Although opioids a re ma inly thought to work on opioid
re ce ptors, me tha done is a lso a most pote nt NMDA re ce ptor
a nta gonist (6-18 time s tha t of morphine ). This prope rty a ppe a rs to
be use ful in re ducing the e ffe cts of opioid tole ra nce a nd
withdra wa l syndrome (Barash : Clinical Anesth esia, ed 7, p 505;
Hem m ings: Ph arm acology and Ph y siology for Anesth esia, p 264).
301. (C) Ta pe nta dol (Nucynta ) is a ne w opioid ma rke te d for fe we r
GI a nd CNS side e ffe cts. It ha s a dua l me cha nism of a ction: a s a n
a gonist for the µ re ce ptor site a nd a s a nore pine phrine re upta ke
inhibitor (NRI). It should not be use d in pa tie nts ta king MAOIs,
be ca use a n a dre ne rgic crisis ma y de ve lop. It is a lso
contra indica te d with SSRIs, be ca use it ma y le a d to se rotonin
syndrome . It is only a va ila ble ora lly (Barash : Clinical Anesth esia, ed 7,
p 505; Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, p 508).
For Questions 302-305: Depolarizing neurom uscular blockad e usually is
d escribed as h aving two ph ases. Ph ase I blockad e occurs with
d epolarization of th e postjunctional m em brane. Ph ase II blockad e occurs
wh en th e postjunctional m em brane h as becom e repolarized but d oes not
respond norm ally to acety lch oline (i.e., often term ed d esensitized , but
oth er factors are involved ). Th is can occur wh en th e d ose of
succiny lch oline is greater th an 2 to 4 m g/kg. Th e response of a m uscle to

electrical nerve stim ulation for a ph ase II block is sim ilar to th at for a
nond epolarizing block. Nond epolarizing neurom uscular blockad e is only
of one ty pe (Miller: Basics of Anesth esia, ed 6, pp 148–149).
302. (D) Although the me cha nisms of a nonde pola rizing a nd a pha se
II de pola rizing block like ly a re diffe re nt, the y both ca n be
a nta gonize d with a nticholine ste ra se drugs.
303. (B) Only a pha se I de pola rizing block is e nha nce d with the use
of a nticholine ste ra se drugs.
304. (D) Post-te ta nic fa cilita tion occurs whe n a single twitch tha t is
induce d a short pe riod of time a fte r te ta nic stimula tion is la rge r
tha n the a mplitude of the te ta nus. This occurs with a pha se II
de pola rizing blocka de a s we ll a s with a nonde pola rizing blocka de .
305. (B) The a mplitude of the muscle re sponse to susta ine d te ta nic
stimula tion re ma ins the sa me with pha se I de pola rizing blocka de ,
but it shows a ma rke d fa de with a pha se II de pola rizing blocka de
or a nonde pola rizing blocka de .
SUMMARY OF MUSCULAR RESPONSES TO NERVE STIMULATION
WITH DIFFERENT TYPES OF BLOCKADE
For Questions 306-315: A sim ple way to m easure th e potency of inh aled
d rugs is to m easure th eir MAC values. MAC is th e m inim um alveolar
concentration of an inh aled d rug at 1 atm osph ere (atm ) (1 atm =
760 m m Hg) wh ere 50% of patients d o not m ove in response to a

painful stim ulus. It is com m only m easured as th e end -ex pired d rug
concentration. Various ph y siologic or ph arm acologic factors can increase
or d ecrease MAC. In general, factors th at increase m etabolic function of
th e brain (e.g., h y perth erm ia) or elevate brain catech olam ines (e.g.,
MAOIs, tricy clic antid epressants, cocaine, acute am ph etam ine use)
increase MAC, and factors th at d epress function (e.g., intravenous
anesth etics, acute eth anol use, narcotics, h y poth erm ia) d ecrease MAC.
Recently, it h as been suggested th at th ere m igh t be a genetic com ponent
to MAC, because red h ead ed fem ales h ave about a 20% increase in MAC
com pared with d ark-h aired fem ales (Barash : Clinical Anesth esia, ed 7,
pp 458–459).
306. (D) Acute a mphe ta mine use incre a se s MAC, whe re a s chronic
a mphe ta mine use de cre a se s MAC.
307. (C) α2 Agonists de cre a se MAC.
308. (A) Cha nge s in thyroid function (e .g., hype rthyroidism,
hypothyroidism) do not se e m to a ffe ct MAC. Howe ve r, the
ca rdiova scula r re sponse to vola tile drugs is a lte re d with thyroid
function.
309. (C) W ith a cute a dministra tion, e tha nol is a CNS de pre ssa nt a nd
de cre a se s MAC. Chronic e tha nol a dministra tion incre a se s MAC.
310. (C) Lidoca ine use de cre a se s MAC.
311. (C) Pa tie nts on lithium the ra py ha ve lowe r MAC va lue s. This
ma y be re la te d to the lowe r ca te chola mine le ve ls in the bra in.
312. (C) Opioids produce a dose -de pe nde nt de cre a se in MAC (up to
a bout 50%).
313. (A) The dura tion of a ne sthe sia , a s we ll a s the ge nde r of the
pa tie nt, doe s not a ffe ct MAC.
314. (C) Pre gna ncy lowe rs MAC. This ma y be re la te d to the
se da tive e ffe cts of proge ste rone . Pre gna nt pa tie nts a lso a re ve ry
se nsitive to loca l a ne sthe tics.
315. (C) Se ve re hypoxia (Pa O2 of 38 mm Hg), a s we ll a s se ve re
a ne mia (<4.3 mL/oxyge n/dL of blood), de cre a se s MAC.

For Questions 316-320: Th e goals of ph arm acologic prem ed ication m ust be
ind ivid ualized to m eet each patient’s req uirem ents. Som e of th ese goals
includ e am nesia, relief of anx iety, sed ation, analgesia, red uction of
gastric fluid volum e, elevation of gastric fluid pH, proph y lax is against
allergic reactions, and red uction of oral and respiratory secretions. Th e
d rugs m ost com m only used to ach ieve th ese goals includ e
benzod iazepines, barbiturates, opioid s, H2-receptor antagonists,
nonparticulate antacid s, antih istam ines, and antich olinergic agents. Th e
antich olinergics atropine, scopolam ine, and gly copy rrolate are rarely
given with prem ed ication tod ay unless a specific effect is need ed (e.g.,
d ry ing of th e m outh before fiberoptic intubation, prevention of
brad y card ia, and , rarely, as a m ild sed ative). Atropine and scopolam ine
are tertiary com pound s th at can read ily cross lipid m em branes such as
th e blood -brain barrier. Th ese tertiary am ines can prod uce sed ation,
am nesia, CNS tox icity (central antich olinergic sy nd rom e m anifested as
d elirium or prolonged som nolence after anesth esia), m y d riasis, and
cy cloplegia (wh ereas gly copy rrolate, a q uaternary com pound , d oes not
cross lipid m em branes well). All th ree antich olinergics can cause d ry ing
of airway secretions by inh ibiting salivation, can cause tach y card ia
(alth ough brad y card ia can be seen in som e patients), can d ecrease th e
lower esoph ageal sph incter tone, and can increase bod y tem perature by
inh ibiting sweating. Th e m ain d ifferences are listed in th e table following
th e ex planation to Question 178 (Miller: Basics of Anesth esia, ed 6, p
76).
316. (A) All thre e a nticholine rgics ca n ca use drying of a irwa y
se cre tions by inhibiting sa liva tion, but a tropine is the le a st e ffe ctive
of the se drugs.
317. (C) To produce se da tion, the drug must pa ss the blood-bra in
ba rrie r. This is much more promine nt with scopola mine a nd much
le ss so with a tropine . Glycopyrrola te doe s not ca use a ny se da tion.
318. (A) Atropine ha s the be st blocking e ffe ct on musca rinic
re ce ptors of the he a rt.
319. (B) The toxic sta te known a s ce ntra l a nticholine rgic syndrome
re quire s pa ssa ge of the drug a cross the blood-bra in ba rrie r a nd,
the re fore , pre clude s glycopyrrola te from ca usa tion.
320. (D) Both a tropine a nd scopola mine ca n ca use ocula r e ffe cts
(scopola mine more so tha n a tropine ), including mydria sis a nd
cyclople gia whe n a pplie d topica lly to the e ye . Ca ution is sugge ste d
whe n scopola mine is give n intra muscula rly to pa tie nts with
gla ucoma . IV a dministra tion of a tropine to pre ve nt or tre a t
bra dyca rdia a ppe a rs to ha ve little e ffe ct on the e ye . If a
scopola mine pa tch is pla ce d to he lp pre ve nt PONV, one ne e ds to
ca re fully wa sh one ’s ha nds a fte r a pplica tion, be ca use rubbing a n
e ye with a ny scopola mine on the finge rs ma y le a d to unila te ra l
mydria sis.
C H AP T E R 4
Pharmacology and
Pharmacokinetics of Volatile
Anesthetics

321. The minimum a lve ola r conce ntra tion (MAC) is highe st in
ne ona te s (0-30 da ys old) ve rsus othe r a ge groups with which of the
following?
A. Isoflura ne
B. Se voflura ne
C. De sflura ne
D. N2O
322. The ra te of incre a se in the a lve ola r conce ntra tion of a vola tile
a ne sthe tic re la tive to the inspire d conce ntra tion (F A/F I ) plotte d
a ga inst time is ste e p during the first mome nts of inha la tion with a ll
vola tile a ne sthe tics. The re a son for this obse rva tion is tha t
A. Vola tile a ne sthe tics re duce a lve ola r ve ntila tion (VA)
B. The re is minima l a ne sthe tic upta ke from the a lve oli into
pulmona ry ve nous blood
C. Vola tile a ne sthe tics incre a se ca rdia c output initia lly
D. The volume of the a ne sthe tic bre a thing circuit is sma ll
323. During sponta ne ous bre a thing, vola tile a ne sthe tics
A. Incre a se tida l volume (VT) a nd de cre a se re spira tory ra te
B. Incre a se VT a nd incre a se re spira tory ra te
C. De cre a se VT a nd de cre a se re spira tory ra te
D. De cre a se VT a nd incre a se re spira tory ra te
324. W hich of the following ca n NOT be conside re d a n a dva nta ge
of low-flow a ne sthe sia ?
A. Conse rva tion of fossil fue l
B. Le ss ozone de ple tion
C. Re duce d room pollution
D. Conse rva tion of a bsorbe nt
325. The ma in re a son de sflura ne is not use d for inha la tion
induction in clinica l pra ctice is be ca use of
A. Its low blood/ga s pa rtition coe fficie nt
B. Its prope nsity to produce hype rte nsion in high conce ntra tions
C. Its prope nsity to produce a irwa y irrita bility
D. Its prope nsity to produce ta chya rrhythmia s
326. A me dica l group pla nning a trip to South Ame rica ha s a la rge
supply of old e nflura ne va porize rs (va por pre ssure = 170 mm Hg).
W hich vola tile a ge nt could be de live re d through a n e nflura ne
va porize r in such a ma nne r tha t the dia le d se tting e qua ls the
va porize r ’s output?
A. De sflura ne
B. Se voflura ne
C. Isoflura ne
D. None ; a ll othe r vola tile a ge nts will be a t le a st 30% off
327. Se le ct the T RUE sta te me nt re ga rding blood pre ssure whe n 1.5
MAC N2O-isoflura ne is substitute d for 1.5 MAC isoflura ne -oxyge n.
A. Blood pre ssure is le ss tha n a wa ke va lue but gre a te r tha n tha t
se e n with isoflura ne -O2
B. Blood pre ssure is e qua l to a wa ke va lue
C. Blood pre ssure is gre a te r tha n a wa ke va lue
D. Blood pre ssure is le ss tha n isoflura ne -O2 pre ssure
328. W hich of the following vola tile a ne sthe tics de cre a se s syste mic
va scula r re sista nce ?
A. Se voflura ne
B. Isoflura ne
C. De sflura ne
329. W ith which of the following inha la tiona l a ge nts is ca rdia c
output mode ra te ly incre a se d?
A. N2O
B. Se voflura ne
C. De sflura ne
D. Isoflura ne
330. Se le ct the FALSE sta te me nt a bout isoflura ne (≤1 MAC).
A. Ma y a tte nua te bronchospa sm
B. Incre a se s right a tria l pre ssure
C. De cre a se s me a n a rte ria l pre ssure
D. De cre a se s ca rdia c output
331. Abrupt a nd la rge incre a se s in the de live re d conce ntra tion of
which of the following inha la tiona l a ne sthe tics ma y produce
tra nsie nt incre a se s in syste mic blood pre ssure a nd he a rt ra te ?
A. De sflura ne
B. Isoflura ne
C. Se voflura ne
D. N2O
332. Discontinua tion of 1 MAC of which vola tile a ne sthe tic followe d
by imme dia te introduction of 1 MAC of which se cond vola tile
a ne sthe tic would te mpora rily re sult in the gre a te st combine d
a ne sthe tic pote ncy?
A. Isoflura ne followe d by de sflura ne
B. Se voflura ne followe d by de sflura ne
C. De sflura ne followe d by isoflura ne
D. De sflura ne followe d by se voflura ne
333. Ca rdioge nic shock ha s the gre a te st impa ct on the ra te of
incre a se in F A/F I for which of the following vola tile a ne sthe tics?
A. Isoflura ne
B. De sflura ne
C. Se voflura ne
D. N2O
334. The ve sse l-rich group re ce ive s wha t pe rce nt of the ca rdia c
output?
A. 45%
B. 60%
C. 75%
D. 90%
335. W ha t pe rce nt de sflura ne is pre se nt in the vaporizing ch am ber of
a de sflura ne va porize r (pre ssurize d to 1500 mm Hg a nd he a te d to
23° C)?
A. Ne a rly 100%
B. 85%
C. 65%
D. 45%
336. A 25-ye a r-old ma n is unde rgoing lymph node disse ction for
te sticula r ca nce r unde r ge ne ra l a ne sthe sia . He ha s re ce ive d four
course s of ble omycin. The se voflura ne va porize r is se t a t 1.8%, the
oxyge n a t 100 mL/min, a nd a ir a t 900/mL/min. The F IO2 of the fre sh
ga s flow is
A. 26%
B. 29%
C. 34%
D. 41%
337. How would a right ma inste m intuba tion a ffe ct the ra te of
incre a se in a rte ria l pa rtia l pre ssure of vola tile a ne sthe tics?
A. It would be re duce d to the sa me de gre e for a ll vola tile
a ne sthe tics
B. It would be a cce le ra te d to the sa me de gre e for a ll vola tile
a ne sthe tics
C. It would be re duce d the most for highly soluble a ge nts
D. It would be re duce d the most for poorly soluble a ge nts
338. During a bre a st biopsy with the pa tie nt unde r ge ne ra l
a ne sthe sia , the e nd-tida l ca rbon dioxide (CO2) is 25 mm Hg on
infra re d spe ctrome te r. W hich of the following could NOT a ccount
for the se findings?
B. Enormous de a d spa ce
C. Incipie nt ca rdia c a rre st
D. Ove rve ntila tion
339. Isoflura ne , whe n a dministe re d to he a lthy pa tie nts in
conce ntra tions le ss tha n 1.0 MAC, will de cre a se a ll of the following
EXCEPT
A. Ca rdia c output
B. Myoca rdia l contra ctility
C. Stroke volume
D. Syste mic va scula r re sista nce
340. Incre a se d VA will a cce le ra te the ra te of rise of the F A/F I ra tio
the MOST for
A. De sflura ne
B. Se voflura ne
C. Isoflura ne
D. N2O
341. Se le ct the corre ct orde r from gre a te st to le a st for a ne sthe tic
re quire me nt.
A. Adults > infa nts > ne ona te s
B. Adults > ne ona te s > infa nts
C. Infa nts > ne ona te s > a dults
D. Ne ona te s > a dults > infa nts
342. W hich of the following MOST close ly de te rmine s a ne sthe tic
e ffe ct?
A. Volume pe rce nt a dministe re d to pa tie nt
B. Pa rtia l pre ssure a t the le ve l of the ce ntra l ne rvous syste m
(CNS)
C. Solubility in blood
D. End-tida l conce ntra tion
343. A 31-ye a r-old mode ra te ly obe se woma n is re ce iving a ge ne ra l
a ne sthe tic for ce rvica l spina l fusion. Afte r induction a nd intuba tion,
the pa tie nt is me cha nica lly ve ntila te d with isoflura ne a t a va porize r
se tting of 2.4%. The N2O flow is se t a t 500 mL/min, a nd the oxyge n
flowme te r is se t a t 250 mL/min. The infra re d spe ctrome te r displa ys
a n inspire d isoflura ne conce ntra tion of 1.7% a nd a n e xpire d
isoflura ne conce ntra tion of 0.6%. Approxima te ly how ma ny MAC of
a ne sthe sia would be re pre se nte d by the a lve ola r conce ntra tion of
a ne sthe tic ga se s?
A. 0.85 MAC
B. 1.1 MAC
C. 1.8 MAC
D. 2.1 MAC
344. The gra ph in the figure de picts
A. The se cond ga s e ffe ct
B. The conce ntra tion e ffe ct
C. The conce ntra ting e ffe ct
D. The e ffe ct of solubility on the ra te of rise of F A/F I
345. The ra te of induction of a ne sthe sia with isoflura ne would be
slowe r tha n e xpe cte d in pa tie nts
A. W ith a ne mia
B. W ith chronic re na l fa ilure
C. In shock
D. W ith a right-to-le ft intra ca rdia c shunt
346. A right-to-le ft intra ca rdia c shunt would ha ve the GREAT EST
impa ct on the ra te of inha la tion induction with which of the
following inha la tion a ne sthe tics?
A. De sflura ne
B. Isoflura ne
C. It would spe e d up induction for a ll a ge nts e qua lly
D. It would slow down induction for a ll a ge nts e qua lly
347. A le ft-to-right tissue shunt, such a s a rte riove nous fistula ,
physiologica lly most re se mble s which of the following?
A. A le ft-to-right intra ca rdia c shunt
B. A right-to-le ft intra ca rdia c shunt
C. Ve ntila tion of unpe rfuse d a lve oli
D. A pulmona ry e mbolism
348. A fre sh ga s flow ra te of 2 L/min or gre a te r is re comme nde d for
a dministra tion of se voflura ne be ca use
A. The va porize r ca nnot a ccura te ly de live r the vola tile a t le sse r
flow ra te s
B. It pre ve nts the forma tion of fluoride ions
C. It pre ve nts the forma tion of compound A
D. It diminishe s re bre a thing
349. A le ft-to-right shunt in a ne ona te with a pa te nt ductus
a rte riosus (PDA) ha s wha t e ffe ct on inha la tion induction?
A. Spe e ds it up
B. Slows down with insoluble vola tile a ge nts
C. Slows with soluble vola tile a ge nts
D. No e ffe ct with a ny vola tile a ge nt
350. Smoke rs a re MOST like ly to show a mild but tra nsie nt
incre a se in a irwa y re sista nce a fte r intuba tion a nd ge ne ra l
a ne sthe sia with which of the following?
A. Isoflura ne
B. Se voflura ne
C. Ha lotha ne
D. De sflura ne
351. If a pa tie nt is a ne sthe tize d with 6% de sflura ne in a hype rba ric
cha mbe r a t 1 a tm a nd the pre ssure is incre a se d to 2 a tm, the
de sflura ne dia l should be se t to which se tting if the a ne sthe sia
provide r wishe s to ma inta in the a ne sthe tic a t the sa me le ve l?
A. 3%
B. 6%
C. 12%
D. Ca nnot be de te rmine d without knowle dge of F IO2
352.
The gra ph a bove de picts which of the following?
A. Diffusion hypoxia
B. Se cond ga s e ffe ct
C. Conte xt se nsitive ha lf-time of de sflura ne
D. Conce ntra tion e ffe ct
353. W hich of the following orga ns is NOT conside re d a me mbe r of
the ve sse l-rich group?
A. Lungs
B. Bra in
C. He a rt
D. Kidne y
354. In isovolumic norma l huma n subje cts, 1 MAC of isoflura ne
a ne sthe sia de pre sse s me a n a rte ria l pre ssure by a pproxima te ly
25%. The single BEST e xpla na tion for this is
A. Re duction in he a rt ra te
B. Ve nous pooling
C. Myoca rdia l de pre ssion
D. De cre a se d syste mic va scula r re sista nce
355. If ca rdia c output a nd VA a re double d, the e ffe ct on the ra te of
rise of F A/F I for isoflura ne compa re d with tha t which e xiste d
imme dia te ly be fore the se inte rve ntions will be
A. Double d
B. Some wha t incre a se d
C. Uncha nge d
D. Some wha t de cre a se d
356. W hich of the following cha ra cte ristics of inha le d a ne sthe tics
most close ly corre la te s with re cove ry from inha le d a ne sthe sia ?
A. Blood/ga s pa rtition coe fficie nt
B. Bra in/blood pa rtition coe fficie nt
C. Fa t/blood pa rtition coe fficie nt
D. MAC
357. Afte r a 12-hour 60% N2O-de sflura ne a ne sthe tic, e vide nce of
N2O ca n be be st de te cte d by histologic e xa mina tion of
A. Bone ma rrow
B. Re na l tubule s
C. He pa tocyte s
358. An unconscious, sponta ne ously bre a thing pa tie nt is brought to
the ope ra ting room (OR) from the inte nsive ca re unit for wound
dé bride me nt. W hich of the following ma ne uve rs would se rve to
slow induction of inha la tiona l a ne sthe sia through the
tra che ostomy?
A. Using isoflura ne inste a d of se voflura ne (using MAC-e quiva le nt
inspire d conce ntra tions)
B. Incre a sing fre sh ga s flow from 2 to 6 L/min
C. Esmolol 30 mg intra ve nously
359. W hich of the se ttings be low would give the highe st a rte ria l
oxyge n conce ntra tion during inha la tion induction of ge ne ra l
a ne sthe sia with se voflura ne ?
360. If a pa tie nt we re a ne sthe tize d 90 minute s with 1.25 MAC

isoflura ne followe d by 30 minute s of 1.25 MAC se voflura ne
a ne sthe sia , wa ke -up would be
A. The sa me a s 2 hours of isoflura ne a ne sthe sia
B. The sa me a s 2 hours of se voflura ne a ne sthe sia
C. Le ss tha n 2 hours of isoflura ne a ne sthe sia , but gre a te r tha n
2 hours of se voflura ne
D. Gre a te r tha n 2 hours of isoflura ne a ne sthe sia
361. An a ne sthe sia circuit is prime d in pre pa ra tion for a n inha la tion
induction (with ope n a djusta ble pre ssure -limiting va lve ). The
a ne sthe sia hose is occlude d with a flow of 6 L/min. The a ne sthe sia
circuit (ca niste rs, hose s, ma sk, a ne sthe sia ba g) conta ins 6 L. A
ma chine ma lfunction a llows a dministra tion of 100% N2O.
Approxima te ly how much N2O would the re be in the circuit whe n
the ma lfunction is discove re d a t the 1-minute ma rk?
A. 32%
B. 48%
C. 63%
D. 86%
362. W hich of the following fa ctors lowe rs MAC for vola tile
a ne sthe tics?
A. Se rum sodium 151 mEq/L
B. Re d ha ir
C. Body te mpe ra ture 38° C
D. Acute e tha nol inge stion
363. Ea ch of the following fa ctors ca n influe nce the pa rtia l pre ssure
gra die nt ne ce ssa ry for the a chie ve me nt of a ne sthe sia EXCEPT
A. Inspire d a ne sthe tic conce ntra tion
B. Ca rdia c output
C. VA
D. Ve ntila tion of nonpe rfuse d a lve oli (de a d spa ce )
364. W hich of the following vola tile a ne sthe tics is unique in
conta ining pre se rva tive ?
A. Se voflura ne
B. De sflura ne
C. Isoflura ne
365. If the a lve ola r-to-ve nous pa rtia l pre ssure diffe re nce of a
vola tile a ne sthe tic (P A − P V) is positive (i.e ., P A > P V) a nd the
a rte ria l-to-ve nous pa rtia l pre ssure diffe re nce (Pa − P V) is ne ga tive
(i.e ., P V > Pa ), which of the following sce na rios is MOST like ly to
be true ?
A. The va porize r ha s be e n shut off a t the e nd of the ca se
B. Induction ha s just sta rte d
C. Ste a dy sta te ha s be e n a chie ve d
D. The va porize r wa s shut off during e me rge nce , the n turne d
ba ck on
366. Ane sthe tic loss to the pla stic a nd rubbe r compone nts of the
a ne sthe tic circuit, hinde ring a chie ve me nt of a n a de qua te inspire d
conce ntra tion, is a fa ctor with which of the following a ne sthe tics?
A. De sflura ne
B. Isoflura ne
C. Se voflura ne
D. N2O
367. Fa ctors pre disposing to forma tion a nd/or re bre a thing of
compound A include e a ch of the following EXCEPT
A. Low fre sh ga s flow
B. Use of ca lcium hydroxide lime ra the r tha n soda lime
C. High a bsorbe nt te mpe ra ture s
D. Fre sh a bsorbe nt
368. The e ffe cts of a le ft-to-right shunt such a s a n a rte riove nous
fistula on inha la tion induction of a ne sthe sia is to
A. Spe e d up induction
B. Slow down induction
C. Slow down inha la tion induction only if a n intra ca rdia c (right-to-
le ft) shunt a lso e xists
D. Spe e d up inha la tion induction only if a n intra ca rdia c (right-to-
le ft) shunt a lso e xists
369. The following vola tile a ge nts a re corre ctly ma tche d with the ir
de gre e of me ta bolism (de te rmine d by me ta bolite re cove ry):
A. Se voflura ne 2%
B. Isoflura ne 0.2%
C. De sflura ne 0.02%
D. All a re corre ctly ma tche d
370. W hich of the compone nts be low is NOT conside re d in the
proce ss of “wa shin” of the a ne sthe sia circuit a t the onse t of
a dministra tion?
A. Infra re d spe ctrome te r tubing a nd re se rvoir
B. Expira tory limb
C. Ane sthe sia ba g
D. CO2 a bsorbe r
371. W hich of the following ma ne uve rs would NOT incre a se the
ra te of a n inha la tion induction?
A. Giving the pa tie nt a n inotropic infusion
B. Substituting se voflura ne for isoflura ne
C. Ove rpre ssurizing
D. Ca rrying out the induction in Sa n Die go inste a d of De nve r
372. W hich of the following a ne sthe tics would unde rgo 90%
e limina tion the most ra pidly a fte r a 6-hour W hipple proce dure
unde r 1 MAC for the dura tion of the ope ra tion?
A. Isoflura ne
B. Se voflura ne
C. De sflura ne
D. Se voflura ne a nd de sflura ne a re tie d
373. Afte r induction a nd intuba tion of a he a lthy pa tie nt a nd
institution of a ve ntila tor, the se voflura ne va porize r is se t a t 2%, a nd
fre sh ga s flow is 1 L/min (50% N2O a nd 50% O2). The inspire d
conce ntra tion on the infra re d spe ctrome te r 1 minute la te r is 1.4%.
The MAIN re a son for the diffe re nce be twe e n the dia l se tting a nd
the conce ntra tion shown on the infra re d spe ctrome te r is
A. Ra pid upta ke of se voflura ne
B. Insufficie nt fre sh ga s flow for corre ct va porize r function
C. Se cond ga s e ffe ct
D. Dilution
374. Afte r ce ssa tion of ge ne ra l a ne sthe sia tha t consiste d of a ir,
oxyge n, a nd a vola tile a ge nt only, the pa tie nt is give n 100% oxyge n.
Ea ch of the following se rve s a s a re se rvoir for vola tile a ne sthe sia
a nd ma y de la y e me rge nce EXCEPT
A. Re bre a the d e xha le d ga se s
B. The a bsorbe nt
C. The pa tie nt
D. Ga se s e me rging from the common ga s outle t
375. W hich of the following cha ra cte ristics of vola tile a ne sthe tics is
ne ce ssa ry for ca lcula tion of the time consta nt?
B. Bra in/blood pa rtition coe fficie nt
C. Oil/ga s pa rtition coe fficie nt
376. The conce pt of “conte xt se nsitive ha lf-time ” e mpha size s the
importa nce of the re la tionship be twe e n ha lf time a nd
A. VA
B. Blood solubility
C. Conce ntra tion
D. Dura tion
377. Se le ct the FALSE sta te me nt re ga rding pha rma cokine tics for
vola tile a ne sthe tics. Afte r thre e time consta nts
A. 6 to 12 minute s ha ve e la pse d for “mode rn a ne sthe tics”
B. The a rte ria l-to-ve nous pa rtia l pre ssure diffe re nce (for the
vola tile ) for the bra in is ve ry sma ll
C. The e xpire d vola tile conce ntra tion will rise much le ss slowly
tha n in the pre ce ding 12 minute s
D. The ve nous blood will conta in 95% of vola tile conte nt of
a rte ria l blood
DIRECT IONS (Que stions 378 through 381): Ma tch the

inha la tiona l a ge nts with the cha ra cte ristics to which the y
most close ly corre spond. Ea ch le tte re d he a ding (A through D)
ma y be se le cte d once , more tha n once , or not a t a ll.
378. Ha lotha ne (1 MAC)

379. Isoflura ne (1 MAC)
380. De sflura ne (1 MAC)
381. Se voflura ne (1 MAC)
Pharmacology and Pharmacokinetics of
Volatile Anesthetics
321. (B) The MAC for inha la tion a ge nts va rie s with a ge . For most
vola tile a ne sthe tics, the highe st MAC va lue s a re for infa nts 1 to
6 months old. In infa nts younge r tha n 1 month or olde r tha n
6 months, the MAC is lowe r for isoflura ne , ha lotha ne , a nd
de sflura ne . Se voflura ne is diffe re nt. For se voflura ne , the MAC for
ne ona te s 0 to 30 da ys old is 3.3%, for infa nts 1 to 6 months old it is
3.2%, a nd for infa nts 6 to 12 months old it is 2.5% (Miller: Miller’s
322. (B) The a lve ola r pa rtia l pre ssure of a vola tile a ne sthe tic, which
ultima te ly de te rmine s the de pth of ge ne ra l a ne sthe sia , is
de te rmine d by the re la tive ra te s of input to re mova l of the
a ne sthe tic ga se s to a nd from the a lve oli. Re mova l of a ne sthe tic
ga se s from the a lve oli is a ccomplishe d by upta ke into the
pulmona ry ve nous blood, which is most de pe nde nt on a n a lve ola r
pa rtia l pre ssure diffe re nce . During the initia l mome nts of inha la tion
of a n a ne sthe tic ga s, the re is no vola tile a ne sthe tic in the a lve oli to
cre a te this pa rtia l pre ssure gra die nt. The re fore , the upta ke for a ll
vola tile a ne sthe tic ga se s will be minima l until the re sulta nt ra pid
incre a se in a lve ola r pa rtia l pre ssure e sta blishe s a sufficie nt
a lve ola r-to-ve nous pa rtia l pre ssure gra die nt to promote upta ke of
the a ne sthe tic ga s into the pulmona ry ve nous blood. This will occur
in spite of othe r fa ctors, which a re discusse d in the e xpla na tion to
Que stion 333 (Miller: Miller’s Anesth esia, ed 8, pp 648–649).
323. (D) At conce ntra tions of 1 MAC or le ss, vola tile a ne sthe tics, a s
we ll a s the inha le d a ne sthe tic N2O, will produce dose -de pe nde nt
incre a se s in the re spira tory ra te in sponta ne ously bre a thing
pa tie nts. This tre nd continue s a t conce ntra tions gre a te r tha n 1 MAC
for a ll of the inha le d a ne sthe tics e xce pt isoflura ne . W ith the
e xce ption of N2O, the e vide nce sugge sts tha t this e ffe ct is ca use d by
dire ct a ctiva tion of the re spira tory ce nte r in the CNS ra the r tha n by
stimula tion of pulmona ry stre tch re ce ptors. Additiona lly, vola tile
a ne sthe tics de cre a se VT a nd significa ntly a lte r the bre a thing
pa tte rn from the norma l a wa ke pa tte rn of inte rmitte nt de e p bre a ths
se pa ra te d by va rying time inte rva ls to one of ra pid, sha llow,
re gula r, a nd rhythmic bre a thing (Miller: Miller’s Anesth esia, ed 8, pp
691–692).
324. (D) Ba rium-conta ining a bsorbe nts tha t inte ra ct with vola tile
a ne sthe tics a nd produce ca rbon monoxide a nd compound A a re no
longe r use d in clinica l pra ctice . The y ha ve be e n re pla ce d with
ca lcium-conta ining products such a s Amsorb Plus. Conse que ntly,
a bsorbe nt gra nule s a re “consume d” by CO2 produce d by the
pa tie nt, not by the tota l flow of a ne sthe tic ga se s. On the contra ry,
with low flow te chnique s, re circula tion (re bre a thing) of e xpire d
ga se s re sults in more ra pid de ple tion of the CO2 a bsorbe nt.
Vola tile a ne sthe tics a re orga nic compounds, spe cifica lly a lka ne s
(ha lotha ne ) a nd substitute d me thyl-e thyl e the rs (de sflura ne ,
isoflura ne ) or substitute d isopropyl me thyl e the r (se voflura ne ).
The y a re ultima te ly de rive d from pe trole um source s a nd a re the n
ha loge na te d to be come substitute d orga nic compounds. The y
join a myria d of othe r orga nic ha lide s such a s ha irspra y,
prope lla nts, re frige ra nts, a nd solve nts tha t colle ctive ly contribute
to the de ple tion of the ozone la ye r in the e a rth’s a tmosphe re .
The ma in gre e nhouse ga se s a re CO2, me tha ne , a nd N2O. N2O
constitute s roughly 5% of the gre e nhouse ga se s. Anothe r
ra tiona le for the use of low-flow a ne sthe sia is the introduction of
le ss wa ste into the OR.
The disa dva nta ge of low-flow a ne sthe sia is tha t the F IO2 will
continua lly drop during the a dministra tion of a ne sthe sia (unle ss
100% oxyge n is a dministe re d), a nd vigila nce is re quire d be ca use
this drop ma y a pproa ch or e ve n re a ch the le ve l of a hypoxic
mixture (Miller: Miller’s Anesth esia, ed 8, pp 664–665).
325. (C) Although de sflura ne ha s a low blood/ga s pa rtition
coe fficie nt (0.42) a nd should produce ra pid induction of a ne sthe sia ,
its ma rke d punge ncy a nd a irwa y irrita tion ma ke inha la tion
inductions ve ry difficult. Not only do pa tie nts dislike the sce nt, but
the a irwa y irrita tion ofte n le a ds to coughing, incre a se d sa liva tion,
bre a th holding, a nd some time s la ryngospa sm (e spe cia lly if the
conce ntra tion is ra pidly incre a se d). In a ddition, with a brupt
incre a se s in conce ntra tion, pa tie nts ofte n e xpe rie nce ta chyca rdia
a nd hype rte nsion, thought to be due to incre a se d sympa the tic
discha rge (Miller: Basics of Anesth esia, ed 6, p 95).
326. (B) A va porize r ’s spe cificity is ba se d on the va por pre ssure of
the a ne sthe tic a ge nt for which it is ma de . Filling a va porize r with
a n a ge nt whose va por pre ssure is highe r re sults in a highe r
conce ntra tion in the va porize r ’s output. Simila rly, a vola tile a ge nt
with a lowe r va por pre ssure produce s a n output with a lowe r
conce ntra tion tha n tha t se e n on the dia l. The va por pre ssure of
e nflura ne , 172 mm Hg (20° C), most close ly a pproxima te s the va por
pre ssure of se voflura ne , which is 160 mm Hg (Miller: Basics of
327. (A) W he n N2O is substitute d for a n e qua l MAC va lue of
isoflura ne , the re sulting blood pre ssure is gre a te r tha n tha t se e n
with the sa me MAC va lue a chie ve d with isoflura ne a s the sole
a ne sthe tic a ge nt. W he n a dministe re d a lone , N2O doe s not a lte r
a rte ria l blood pre ssure , stroke volume , syste mic va scula r
re sista nce , or ba rore ce ptor re fle xe s. The a dministra tion of N2O
incre a se s he a rt ra te slightly, which ma y re sult in a mild incre a se in
ca rdia c output. In vitro, N2O ha s a dose -de pe nde nt dire ct
de pre ssa nt e ffe ct on myoca rdia l contra ctility, which is proba bly
ove rcome in vivo by sympa the tic a ctiva tion (Miller: Basics of
328. (D) All of the pre se nt-da y vola tile a ne sthe tics re duce blood
pre ssure in a dose -de pe nde nt fa shion. De sflura ne , se voflura ne ,
a nd isoflura ne ca use this prima rily through re ductions in syste mic
va scula r re sista nce . The obsole te a ge nts, ha lotha ne a nd e nflura ne ,
produce hypote nsion via dire ct myoca rdia l de pre ssion (Miller: Basics
329. (A) The olde r a ge nt ha lotha ne te nde d to de cre a se the ca rdia c
output, whe re a s se voflura ne , de sflura ne , a nd isoflura ne te nd to
ma inta in ca rdia c output. N2O te nds to incre a se ca rdia c output
prima rily be ca use of the mild incre a se in sympa the tic tone
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
53).
330. (D) At conce ntra tions of 1 MAC, isoflura ne ma y a tte nua te
a ntige n-induce d bronchospa sm, pre suma bly by de cre a sing va ga l
tone . At simila r conce ntra tions, isoflura ne will not re duce ca rdia c
output in pa tie nts with norma l le ft ve ntricula r function. Additiona lly,
isoflura ne will de cre a se stroke volume , me a n a rte ria l pre ssure ,
a nd syste mic va scula r re sista nce in a dose -de pe nde nt ma nne r.
Ca rdia c output re ma ins uncha nge d be ca use de cre a se s in syste mic
va scula r re sista nce re sult in a re fle x incre a se in he a rt ra te tha t is
sufficie nt to offse t the de cre a se in stroke volume . Howe ve r, dose -
de pe nde nt de cre a se s in both stroke volume a nd ca rdia c inde x ca n
be se e n whe n isoflura ne is a dministe re d in conce ntra tions gre a te r
tha n 1 MAC (Miller: Basics of Anesth esia, ed 6, pp 90–95).
331. (A) De sflura ne ca n (but doe s not a lwa ys) produce incre a se d
blood pre ssure a nd he a rt ra te whe n the conce ntra tions a re ra pidly
incre a se d. This ma y be re la te d to a irwa y irrita tion a nd a
sympa the tic re sponse . This ha s a lso occurre d with isoflura ne , but
to a much le ss fre que nt a nd usua lly lowe r e xte nt. The othe r a ge nts
liste d do not ca use this sympa the tic re sponse with a ra pid incre a se
in conce ntra tion. If de sflura ne is incre a se d slowly or a prior dose
of na rcotic is give n, this incre a se in blood pre ssure a nd he a rt ra te
ma y not occur (Miller: Basics of Anesth esia, ed 6, pp 90–92).
332. (A) Of a ll the options liste d, de sflura ne ha s the lowe st
solubility consta nt, which re sults in a ve ry ra pid rise in F A/F I . The
ra te of rise is ve ry simila r to tha t se e n with N2O a nd re sults in the
most ra pid a tta inme nt of 1 MAC conce ntra tion once the ne w
vola tile a ne sthe tic ha s be e n initia te d. Isoflura ne ha s the highe st
blood/ga s solubility coe fficie nt of a ll the options, re fle cting the
la rge st qua ntity of ga s store d in the blood. This re se rvoir will re sult
in the slowe st de cline in the a lve ola r conce ntra tion of this vola tile
a ge nt upon discontinua tion. The combina tion of the se diffe re nt
solubilitie s will ultima te ly re sult in the highe st combine d MAC
whe n 1 MAC of isoflura ne is discontinue d a nd 1 MAC of de sflura ne
is introduce d (Miller: Basics of Anesth esia, ed 6, p 88; Morgan &
Mikh ail: Clinical Anesth esiology, ed 4, pp 156–157, 159).
333. (A) The a lve ola r pa rtia l pre ssure of a n a ne sthe tic is
de te rmine d by the ra te of input re la tive to re mova l of the a ne sthe tic
from the a lve oli, a s e xpla ine d in Que stion 322. During induction,
the a ne sthe tic ga s is re move d from the a lve oli by upta ke into the
pulmona ry ve nous blood. The ra te of upta ke is influe nce d by
ca rdia c output, the blood/ga s solubility coe fficie nt, a nd the a lve ola r-
to-ve nous pa rtia l pre ssure diffe re nce of the a ne sthe tic. At a lowe r
ca rdia c output, a slowe r ra te of upta ke of vola tile a ne sthe tic from
the a lve oli into the pulmona ry ve nous blood re sults in a fa ste r ra te
of incre a se in the a lve ola r conce ntra tion. This will re sult in a n
incre a se d F A/F I . Upta ke of poorly soluble a ne sthe tic ga se s from the
a lve oli is minima l, a nd the ra te of rise of F A/F I is ra pid a nd virtua lly
inde pe nde nt of ca rdia c output. Upta ke of the more soluble
a ne sthe tics, such a s isoflura ne , from the a lve oli into the pulmona ry
ve nous blood ca n be conside ra ble a nd will be re fle cte d by a
slowe r ra te of rise of the F A/F I ra tio. Ca rdioge nic shock will ha ve
the sma lle st impa ct on the most insoluble a ge nts, such a s
de sflura ne , se voflura ne , a nd N2O, whe re a s the impa ct on the ra te
of rise of F A/F I of the re la tive ly soluble a ne sthe tic ga se s, such a s
isoflura ne , will be more profound (Miller: Miller’s Anesth esia, ed 8, pp
645–646).
334. (C) The ve sse l-rich group tha t re ce ive s a pproxima te ly 75% of
the ca rdia c output is compose d of the bra in, he a rt, sple e n, live r,
sple nic be d, kidne ys, a nd e ndocrine gla nds. This group, howe ve r,
constitute s only 10% of the tota l body we ight. Be ca use of this la rge
blood flow re la tive to tissue ma ss, the se orga ns ta ke up a la rge
volume of vola tile a ne sthe tic a nd e quilibra te with the pa rtia l
pre ssure of the vola tile a ne sthe tic in the blood a nd a lve oli during
the e a rlie st mome nts of induction (Miller: Basics of Anesth esia, ed 6, p
335. (D) De sflura ne is unique a mong the curre nt commonly use d
vola tile a ne sthe tics be ca use of its high va por pre ssure of
664 mm Hg. Be ca use of this, the va porize r is pre ssurize d to
1500 mm Hg a nd is e le ctrica lly he a te d to 23° C to give more
pre dica ble conce ntra tions: 664/1500 = a bout 44%. If the de sflura ne is
use d a t 1 a tm the conce ntra tion will be a bout 88% (Barash : Clinical
Anesth esia, ed 7, pp 666–668; Miller: Basics of Anesth esia, ed 6, pp 202–
203; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
60–64).
336. (B) Fre sh ga s flow = 1 L pe r minute (1000 mL/min).
F IO2 = [(100 mL/min) + (900 ×
0.21 mL/min)]/1000 mL/min = (100 + 180)/1000 = 289/1000 = 29%
Ane sthe tic flow me te rs a re de signe d to de live r ga se s ve ry
a ccura te ly (Miller: Miller’s Anesth esia, ed 8, pp 760–761).
337. (D) The situa tion de scribe d he re is a tra nspulmona ry shunt. In
pa tie nts with tra nspulmona ry shunting, blood e me rging from
unve ntila te d a lve oli conta ins no a ne sthe tic ga s. This a ne sthe tic-
de ficie nt blood mixe s with blood from a de qua te ly ve ntila te d,
a ne sthe tic-conta ining a lve oli, producing a n a rte ria l a ne sthe tic
pa rtia l pre ssure conside ra bly le ss tha n e xpe cte d. Be ca use upta ke
of a ne sthe tic ga s from the a lve oli into pulmona ry ve nous blood will
be le ss tha n norma l, tra nspulmona ry shunting a cce le ra te s the ra te
of rise in the F A/F I ra tio but re duce s the ra te of incre a se in the
a rte ria l pa rtia l pre ssure of a ll vola tile a ne sthe tics. The de gre e to
which the se cha nge s occur de pe nds on the solubility of the give n
vola tile a ne sthe tic. For poorly soluble a ne sthe tics, such a s N2O,
tra nspulmona ry shunting only slightly a cce le ra te s the ra te of rise in
the F A/F I ra tio, but it significa ntly re duce s the ra te of incre a se in
a rte ria l a ne sthe tic pa rtia l pre ssure . The opposite occurs with
highly soluble vola tile a ne sthe tics, such a s ha lotha ne a nd
isoflura ne (Miller: Miller’s Anesth esia, ed 8, pp 646–647).
338. (A) CO2 is a ve ry soluble ga s. ma king the e nd-tida l CO2 (ETCO2)
a t the le ve l of the a lve oli virtua lly ide ntica l to a rte ria l CO2 (Pa CO2).
Be ca use we me a sure ETCO2 on the tota l e xha le d ga s, the a lve ola r
CO2 is dilute d with the ga s in the de a d spa ce (e .g., a lve oli a re
ve ntila te d but a re not pe rfuse d a s we ll a s the re spira tory
pa ssa ge wa ys). A gra die nt of 2 to 5 mm Hg be twe e n Pa CO2 a nd
ETCO2 is se e n in norma l he a lthy pa tie nts. Any condition tha t
incre a se s de a d spa ce or re duce s lung pe rfusion (i.e ., incre a se s
V/Q) such a s pulmona ry e mbolism, se ve re hypote nsion, low
ca rdia c output, a nd ca rdia c a rre st will de cre a se ETCO2. ETCO2 ca n
a lso de cre a se with a n incre a se in minute ve ntila tion (incre a se d
re mova l of CO2) a nd ca n de cre a se with hypothe rmia (de cre a se d
production of CO2). Of course , ETCO2 ca n ra pidly de cre a se to ze ro
with a ny fa ilure to ve ntila te (e .g., e sopha ge a l intuba tion, circuit
disconne ction, fa ilure to turn the ve ntila tor on a fte r ma nua l
ve ntila tion is stoppe d) a s we ll a s with disruption of the sa mpling
line s. Be ca use CO2 ra pidly e quilibra te s be twe e n the bloodstre a m
a nd the a lve ola r ga s, a n e ndotra che a l tube tha t slips into a
ma inste m give s the sa me minute ve ntila tion a s a n e ndotra che a l
tube in the tra che a (a irwa y pre ssure , howe ve r, would incre a se ).
Incre a se d ETCO2 ca n ha ve ma ny ca use s, including hypove ntila tion,
re bre a thing of e xha le d ga s, incre a se d a bsorption of CO2 from the
a bdome n diste nde d with CO2 during la pa roscopy, ma ligna nt
hype rthe rmia , se psis, a nd a dministra tion of bica rbona te use d to
tre a t me ta bolic a cidosis (Barash : Clinical Anesth esia, ed 7, pp 704–705;
Miller: Basics of Anesth esia, ed 6, pp 328–329; Butterworth : Morgan and
339. (A) Isoflura ne is unique a mong the vola tile a ge nts in tha t it
doe s not re duce ca rdia c output (ca rdia c inde x) a t conce ntra tions of
1 MAC or le ss in he a lthy volunte e rs (Miller: Basics of Anesth esia, ed 6,
pp 90–92).
340. (C) The ra te of input of vola tile a ne sthe tics from the a ne sthe sia
ma chine to the a lve oli is influe nce d by thre e fa ctors: VA, the
inspire d a ne sthe tic pa rtia l pre ssure , a nd the cha ra cte ristics of the
a ne sthe tic bre a thing syste m. Incre a se d VA will a cce le ra te the ra te
of incre a se in F A/F I for a ll vola tile a ne sthe tics. Howe ve r, the
ma gnitude of this e ffe ct is de pe nde nt on the solubility of the
inha le d a ne sthe tic. The ra te of incre a se in F A/F I de pe nds ve ry little
on VA for poorly soluble a ne sthe tics be ca use the upta ke of the se is
minima l. In contra st, the ra te of incre a se in F A/F I for highly soluble
a ne sthe tics de pe nds significa ntly on VA. Isoflura ne is the most
soluble inha le d a ne sthe tic liste d in this que stion (blood/ga s
solubility coe fficie nt 1.46). The re fore , a n incre a se in VA will
a cce le ra te the ra te of incre a se in F A/F I the most for isoflura ne .
Blood/ga s solubility coe fficie nts for the othe r vola tile a ne sthe tics
a re a s follows: ha lotha ne 2.54, e nflura ne 1.90, se voflura ne 0.69,
de sflura ne 0.42, a nd N2O 0.46 (Miller: Miller’s Anesth esia, ed 8, pp 647–
650).
341. (C) Ane sthe tic re quire me nt incre a se s from birth until
a pproxima te ly a ge 3 to 6 months. The n, with the e xce ption of a
slight incre a se a t pube rty, a ne sthe tic re quire me nt progre ssive ly
de cline s with a ging. For e xa mple , the MAC for ha lotha ne in
ne ona te s is a pproxima te ly 0.87%, in infa nts it is a pproxima te ly 1.2%,
a nd in young a dults it is a pproxima te ly 0.75%. A nota ble e xce ption
to this pa tte rn is se e n with se voflura ne , for which MAC is the
highe st with ne ona te s. If the que stion pe rta ine d only to
se voflura ne , the corre ct re sponse would ha ve be e n C. Ple a se
re vie w the a nswe r to Que stion 321 (Miller: Miller’s Anesth esia, ed 8, p
2764).
342. (B) The e xa ct me cha nism in which vola tile a ne sthe tics e xe rt
the ir e ffe cts is not fully unde rstood a nd re ma ins a topic of
conside ra ble re se a rch. The most obvious e ffe ct of ge ne ra l
a ne sthe sia , unconsciousne ss (hypnosis), is produce d a t the le ve l of
the bra in. The e nd-tida l conce ntra tion of the vola tile in que stion
re fle cts the le ve l of a ne sthe sia “se e n” by the bra in, but only once
e quilibrium ha s be e n re a che d. At e quilibrium, P alveolar = P arterial =
P CNS. Afte r thre e (95% e quilibrium) to four (99% e quilibrium) time
consta nts, the e nd-tida l conce ntra tion a nd the pa rtia l pre ssure of
the a ne sthe tic a t the bra in (a nd blood for tha t ma tte r) would be the
sa me , provide d de live ry ha s re ma ine d consta nt. A time consta nt is
de fine d a s ca pa city (of the bra in) divide d by flow (of a ne sthe tic-
la de n blood) a nd is e xpre sse d by the following e qua tion:
τ = Vλ ÷ Q
The time consta nt, τ, is a bout 3 to 4 minute s for mode rn vola tile
a ne sthe tics. Accordingly, 10 to 15 minute s must e la pse be fore
a ssuming tha t the pa rtia l pre ssure of the a ne sthe tic ha s re a che d
e quilibrium in the bra in. For this re a son, choice D is a n incorre ct
re sponse for this que stion, be ca use no me ntion is ma de of time
(Barash : Clinical Anesth esia, ed 7, pp 447–454; Miller: Basics of
Anesth esia, ed 6, p 86; Hem m ings: Ph arm acology and Ph y siology for
343. (B) Two principle s of MAC must be conside re d in this situa tion.
First, MAC is a dditive , so the fra ction of MAC of e a ch individua l ga s
must be a dde d to a rrive a t tota l MAC. The se cond is tha t a lve ola r
conce ntra tions of soluble a ge nts a re re fle cte d more a ccura te ly by
e nd-e xpira tory conce ntra tions ra the r tha n by e ithe r inspira tory
conce ntra tions or gra die nts be twe e n inspira tory a nd e xpira tory
conce ntra tions. Be ca use N2O is ve ry insoluble , it is re a sona ble to
a ssume tha t e quilibrium will be e sta blishe d e a rly. The inspira tory
conce ntra tion of N2O, a pproxima te ly 0.6 MAC, should a pproxima te
the a lve ola r conce ntra tion. Howe ve r, the e xpira tory conce ntra tions
of the more soluble vola tile a ne sthe tics should be use d to e stima te
the a lve ola r conce ntra tion. The e nd-e xpira tory isoflura ne
conce ntra tion of 0.6 re fle cts a pproxima te ly 0.5 MAC, which in
a ddition to the 0.6 MAC of N2O would be close st to a nswe r C: 1.1
MAC (Miller: Basics of Anesth esia, ed 6, pp 83–84).
344. (B) The figure shown in this que stion de picts the conce ntra tion
e ffe ct. Note tha t the inspire d a ne sthe tic conce ntra tion influe nce s
not only the ma ximum a tta ina ble a lve ola r conce ntra tion but a lso
the ra te a t which the ma ximum a lve ola r conce ntra tion ca n be
a tta ine d. The gre a te r the inha le d a ne sthe tic conce ntra tion, the
fa ste r the incre a se in F A/F I (Miller: Basics of Anesth esia, ed 6, pp 84–
85).
345. (D) The de pth of ge ne ra l a ne sthe sia is dire ctly proportiona l to
the a lve ola r a ne sthe tic pa rtia l pre ssure . The fa ste r the ra te of
incre a se in F A/F I , the fa ste r the induction of a ne sthe sia . W ith the
e xce ption of a right-to-le ft intra ca rdia c shunt (se e e xpla na tion to
Que stion 337 on e ffe ct of shunt on the ra te of incre a se in F A/F I a nd
e xpla na tion to Que stion 346 on the e ffe ct of shunt on a rte ria l
a ne sthe tic pa rtia l pre ssure a nd ra te of induction of a ne sthe sia ), a ll
of the conditions liste d in this que stion will a cce le ra te the ra te of
incre a se in F A/F I a nd thus the ra te of induction of a ne sthe sia
30).
346. (A) In ge ne ra l, a right-to-le ft intra ca rdia c shunt or
tra nspulmona ry shunt will slow the ra te of induction of a ne sthe sia .
This occurs be ca use of a dilutiona l e ffe ct of shunte d blood, which
conta ins no vola tile a ne sthe tic, on the a rte ria l a ne sthe tic pa rtia l
pre ssure coming from ve ntila te d a lve oli. The impa ct of a right-to-
le ft shunt on the ra te of incre a se in pulmona ry a rte ria l a ne sthe tic
pa rtia l pre ssure , a nd ultima te ly the ra te of induction of a ne sthe sia ,
is gre a te st for poorly soluble vola tile a ne sthe tics. This occurs
be ca use the upta ke of poorly soluble vola tile a ne sthe tics into
pulmona ry ve nous blood is minima l; thus, the dilutiona l e ffe ct of
the shunt on pulmona ry ve nous a ne sthe tic pa rtia l pre ssure is
e sse ntia lly unoppose d. In contra st, the upta ke of highly soluble
vola tile a ne sthe tics is sufficie nt to pa rtia lly offse t the dilutiona l
e ffe ct. Of the a ne sthe tics liste d in the que stion, de sflura ne is the
le a st soluble (Miller: Miller’s Anesth esia, ed 8, p 645).
347. (A) Both a le ft-to-right intra ca rdia c shunt a nd a le ft-to-right
tissue shunt, such a s a n a rte riove nous fistula , will re sult in a highe r
pa rtia l pre ssure of a ne sthe tic ga s in the blood re turning to the
lungs, ultima te ly re sulting in a more ra pid rise in F A/F I . Howe ve r,
this e ffe ct is minima l a nd in most ca se s is clinica lly insignifica nt
30).
348. (D) Se voflura ne is a highly insoluble vola tile a ne sthe tic tha t
combine s with CO2 a bsorbe nts to form a vinyl e the r known a s
compound A. The blood/ga s pa rtition coe fficie nt for se voflura ne is
0.69. The va porize r ma nufa cture d by Ohme da is ca pa ble of
de live ring conce ntra tions ra nging from 0.2% to 8% a t fre sh-ga s flow
ra te s of 0.2 to 15 L/min. Its va por pre ssure is 160 mm Hg a t 20° C,
which is simila r to the va por pre ssure for the othe r vola tile
a ne sthe tics e xce pt de sflura ne (664 mm Hg a t 20° C). Ga s flows
gre a te r tha n 2 L/min pre ve nt the re bre a thing of compound A (not
the forma tion of it), thus re ducing the possibility of re na l toxicity
a ssocia te d with it (Miller: Miller’s Anesth esia, ed 8, p 662).
349. (D) Le ft-to-right shunts (e .g., PDA, a tria l se pta l de fe ct,
ve ntricula r se pta l de fe ct) a re a ssocia te d with a n incre a se in blood
flow through the lungs. W ith inha la tion induction the re is no re a l
e ffe ct on induction ra te . Re me mbe r a lso tha t a de cre a se in
syste mic va scula r re sista nce se e n with inha la tion a ge nts (e .g.,
se voflura ne ) a nd positive -pre ssure ve ntila tion te nd to de cre a se the
ma gnitude of the le ft-to-right shunt. Howe ve r, with right-to-le ft
shunts (e .g., te tra logy of Fa llot) the re is de cre a se d blood flow
through the lungs a nd a slowe r inha la tion induction. W ith a right-to-
le ft shunt, the de cre a se in syste mic va scula r re sista nce ca n
incre a se the shunt a nd le a d to a de cre a se in oxyge na tion.
Intra ve nous drugs work more ra pidly in right-to-le ft shunts.
Ha lotha ne ma y be pre fe rre d (to se voflura ne ) in right-to-le ft shunts
be ca use ha lotha ne de cre a se s contra ctility a nd be tte r ma inta ins
syste mic va scula r re sista nce (Miller: Basics of Anesth esia, ed 6, p 551).
350. (D) Vola tile a ne sthe tics produce minima l bronchodila tion
unle ss a irwa y re sista nce is incre a se d (bronchospa sm). This is
e xpla ine d by the fa ct tha t a irwa y smooth muscle tone is ordina rily
low, a nd a dditiona l bronchodila tion is difficult to de monstra te . The
irrita ting e ffe cts of de sflura ne ca n be re duce d by prior
a dministra tion of fe nta nyl or morphine (Miller: Basics of Anesth esia,
ed 6, p 95).
351. (A) Ple a se se e a lso Que stion 342 a nd its a nswe r. The
de te rmina nt of a ne sthe tic e ffe ct is pa rtia l pre ssure , ultima te ly a t
the CNS. If a pa tie nt is in a hype rba ric cha mbe r unde r 2 a tm
(1520 torr), the e ffe ctive pa rtia l pre ssure from a de sflura ne
va porize r would be double d for a ny give n dia l se tting in
compa rison with se a le ve l. A 6% se tting a t se a le ve l would be
760 × 0.06, or 45.6 mm Hg de sflura ne . The de sflura ne va porize r is
unique in tha t it is more a kin to a dua l ga s ble nde r. To a chie ve a
pa rtia l pre ssure of 45.6 mm Hg (a t 2 a tm), the dia l should be se t a t
3% (Miller: Miller’s Anesth esia, ed 8, pp 771–772).
352. (A) This cla ssic gra ph de picts the e ffe ct of switching from 21%
oxyge n a nd 79% N2O to 21% oxyge n a nd 79% nitroge n—tha t is, a ir.
W he n this occurs, la rge volume s of N2O a re re le a se d into the lungs
a nd dilute a ll ga se s, including oxyge n a nd CO2. The re duction in O2
re sults in hypoxia , a nd the re sulting fa ll in CO2 re duce s the drive to
bre a the . This combina tion occurs a t a time whe n most pa tie nts
ha ve na rcotics a nd othe r re spira tory de pre ssa nts in the body. For
this re a son, it is wise to a dministe r 100% oxyge n to pa tie nts for
se ve ra l minute s a fte r the y e me rge from ge ne ra l a ne sthe sia (Miller:
353. (A) The ve sse l-rich group re ce ive s 75% of the ca rdia c output
a nd re pre se nts 10% of the we ight of a le a n a dult. In a se nse , the
lungs re ce ive virtua lly 100% of the ca rdia c output, but this is the
right-side d CO (the supply side for oxyge n) a nd the re fore doe s not
“count” in the cla ssic de finition. Lung pa re nchyma , ironica lly, use s
a ve ry sma ll qua ntity of oxyge n compa re d with the bra in, live r,
kidne y, a nd myoca rdium (Miller: Miller’s Anesth esia, ed 8, p 648).
354. (D) At 1 MAC conce ntra tions, isoflura ne de pre sse s me a n
a rte ria l pre ssure s prima rily by de cre a sing syste mic va scula r
re sista nce . The de cre a se in me a n a rte ria l pre ssure ma y be gre a te r
tha n tha t se e n with the a dministra tion of ha lotha ne . Howe ve r,
he a rt ra te will be incre a se d, a nd stroke volume will de cre a se to a
le sse r e xte nt tha n is se e n with the a dministra tion of 1 MAC
ha lotha ne (Miller: Miller’s Anesth esia, ed 8, p 713).
355. (B) Cha nge s in both ca rdia c output a nd VA will a ffe ct the ra te s
of rise of F A/F I, but in opposite dire ctions. An incre a se in ca rdia c
output will de cre a se the ra te of F A/F I, whe re a s a n incre a se in VA
will incre a se the ra te of F A/F I . Howe ve r, the se two opposing
options do not comple te ly offse t e a ch othe r be ca use the incre a se d
ca rdia c output a lso a cce le ra te s the e quilibrium of the a ne sthe tic
be twe e n the blood a nd the tissue s. This e quilibrium re sults in a
na rrowing of the a lve ola r-to-ve nous pa rtia l pre ssure diffe re nce a nd
a tte nua te s the impa ct of the incre a se d ca rdia c output on upta ke .
The ne t re sult will be a slight incre a se in the ra te of rise of F A/F I
356. (A) Blood/ga s pa rtition coe fficie nt is the option liste d tha t most
close ly corre la te s with re cove ry from inha le d a ne sthe sia . A highe r
blood/ga s pa rtition coe fficie nt re fle cts a la rge r qua ntity of ga s
dissolve d in the blood for a give n a lve ola r conce ntra tion. Othe r
fa ctors tha t a ffe ct e me rge nce from a ne sthe sia include VA, ca rdia c
output, tissue conce ntra tions, a nd me ta bolism (Miller: Miller’s
357. (A) N2O inte rfe re s with the e nzyme me thionine synthe ta se ,
which ca ta lyze s the conve rsion of homocyste ine to me thionine .
Chronic e xposure to N2O le a ds to a dise a se sta te simila r to vita min
B12 de ficie ncy, but with one importa nt diffe re nce : it is not a lle via te d
with vita min B12 supple me nta tion.
In he a lthy pa tie nts, me ga lobla stic cha nge s ca n be se e n in the
bone ma rrow a fte r just 12 hours of e xposure to 50% N2O (or
highe r). In pa tie nts who a re se riously ill, the se cha nge s ca n be
se e n e ve n e a rlie r. The othe r dise a se ca use d by vita min B12
de ficie ncy, suba cute combine d de ge ne ra tion of the spina l cord,
a ppe a rs only a fte r months of e xposure , a s is se e n in long-te rm
N2O a buse rs (Miller: Miller’s Anesth esia, ed 8, p 664).
358. (A) Four ma in fa ctors a ffe ct the tota l or ra te of rise of the
a lve ola r conce ntra tion of a ne sthe tic (F A) a nd he nce the inha la tion
induction of a ne sthe tics. The se fa ctors a re the inspire d
conce ntra tion of a ne sthe tic (F I ), the solubility of the a ne sthe tic, the
VA, a nd the ca rdia c output. The ra te of rise in F A/F I is fa ste r with
the le ss soluble a ne sthe tics, a s note d by the blood/ga s pa rtition
coe fficie nts. The blood/ga s pa rtition coe fficie nt me a sure d a t 37° C
is the le a st with de sflura ne (0.45), followe d close ly by N2O (0.47),
the n se voflura ne (0.65), isoflura ne (1.4), e nflura ne (1.8), a nd
ha lotha ne (2.5); it is the highe st with e the r (12). Thus, re pla cing
se voflura ne with isoflura ne would slow down induction. Incre a sing
the minute ve ntila tion a s we ll a s incre a sing the fre sh ga s flow ra te
a llows more of the a ne sthe tic to ge t into the lungs a nd offse t the
upta ke of a ne sthe tic by the blood, thus spe e ding the induction of
inha la tiona l a ne sthe sia . De cre a sing the ca rdia c output a lso
a cce le ra te s the rise of F A/F I, re sulting in fa ste r inha la tion induction
(de cre a se s the a mount of blood e xpose d to the lung a nd de cre a se s
the upta ke of a ne sthe sia ) (Miller: Miller’s Anesth esia, ed 8, pp 647–650;
359. (B) The ta ble be low conta ins a fifth column, F IO2. Choice s B
a nd D a ppe a r to be tie d a t 50%. The que stion a sks for a rte ria l
oxyge n conce ntra tion (not F IO2). During induction of ge ne ra l
a ne sthe sia , N2O is ra pidly ta ke n up into the blood, re sulting in the
so-ca lle d se cond ga s e ffe ct a nd a conce ntra ting e ffe ct.
Conce ntra tion of oxyge n in this ma nne r is te rme d “a lve ola r
hype roxyge na tion” a nd re sults in a tra nsie nt incre a se in Pa O2 of
a pproxima te ly 10% (Miller: Basics of Anesth esia, ed 6, p 85).
360. (A) The insoluble vola tile a ge nt de sflura ne ha s the a dva nta ge
of ra pid wa shout a nd the re fore ra pid re cove ry. The downside is the
highe r cost of de sflura ne compa re d with isoflura ne . A study wa s
de vise d to te st wa ke -up a fte r volunte e rs we re a ne sthe tize d with
isoflura ne for the first 75% of the a ne sthe tic a nd switche d to
se voflura ne for the la st 25%. The re sults showe d tha t the “hybrid”
la ste d a s long a s a n a ne sthe tic tha t consiste d of isoflura ne a lone
a nd prove d the futility of this stra te gy (Miller: Miller’s Anesth esia, ed 8,
pp 656–657).
361. (C) Ca lcula tion of the wa shin of N2O re quire s use of the
conce pt of time consta nt. Give n a volume of 6 L for the circle
syste m, the time consta nt is 6 L/(6 L/min) or 1 minute . The numbe rs
to re me mbe r for time consta nts a re 63%, 84%, a nd 95% for 1, 2 a nd 3
time consta nts, re spe ctive ly. A prope rly functioning a ne sthe sia
ma chine would ne ve r a llow the a dministra tion of 100% N2O, but
this nightma re sce na rio is give n pure ly for illustra tive purpose s
(Barash : Clinical Anesth esia, ed 7, p 451).
362. (D) Acute e tha nol inge stion is the only fa ctor liste d tha t will
re duce MAC. Acute a mphe ta mine inge stion ra ise s MAC, a s do
hype rna tre mia , hype rthe rmia , a nd na tura lly occurring re d ha ir.
Ge nde r, thyroid function, a nd Pa CO2 be twe e n 15 a nd 95 mm Hg a nd
Pa O2 gre a te r tha n 38 mm Hg ha ve no e ffe ct on MAC (Miller: Basics of
363. (D) This ta ble summa rize s the fa ctors tha t influe nce the pa rtia l
pre ssure gra die nts. A right-to-le ft intra pulmona ry shunt a ffe cts the
de live ry of inha le d a ne sthe tics, but lung de a d spa ce doe s not,
be ca use the la tte r doe s not produce a dilutiona l e ffe ct on the
a rte ria l pa rtia l pre ssure of the a ne sthe tic in que stion (Miller: Basics
FACTORS DETERMINING PARTIAL PRESSURE GRADIENTS
NECESSARY FOR ESTABLISHMENT OF ANESTHESIA
Input from Anesthesia Uptake from Alveoli to Uptake from Arterial Blood
Machine to Alveoli Pulmonary Blood to Brain
Inspired anesthetic Blood gas partition Brain/blood partition
concentration coefficient coefficient
Alveolar ventilation Cardiac output Cerebral blood flow
Characteristics of the Alveolar-to-venous partial Arterial-to-venous partial
anesthesia breathing system pressure difference pressure difference
From Stoelting RK, Miller RD: Basics of Anesthesia, ed 4, New York, Churchill Livingstone,
2000, p 26.
364. (D) Ha lotha ne wa s the only “mode rn” vola tile a ne sthe tic
(me thoxyflura ne a lso conta ine d a pre se rva tive ) tha t conta ins a
pre se rva tive , thymol. Be ca use ha lotha ne wa s a t risk for
de gra da tion into chloride , hydrochloric a cid, bromide , hydrobromic
a cid, a nd phosge ne , it wa s store d in a mbe r-colore d bottle s, a nd
thymol wa s a dde d to pre ve nt sponta ne ous oxida tion. None of the
curre ntly use d vola tile a ge nts conta ins a pre se rva tive (Stoelting:
365. (D) The de live ry of a ne sthe tic ga se s to a pa tie nt is a comple x
se rie s of e ve nts tha t sta rts with the a ne sthe sia ma chine a nd
culmina te s with a chie ve me nt of a n a ne sthe tic pa rtia l pre ssure in
the bra in (PBr). The pa rtia l pre ssure me a sure d in the blood for a ny
vola tile a ge nt is e ithe r rising (a t first ra pidly, the n more slowly) or
fa lling (ra pidly a t first, the n more slowly). The ve sse l-rich group
re a che s ste a dy sta te in a bout 12 minute s (for a ny dia le d le ve l of
vola tile a ge nt). The re st of the body, howe ve r, a pproa che s, but
virtua lly ne ve r re a che s, e quilibrium (e .g., the e quilibrium ha lf-time
for the fa t group is 30 hours for se voflura ne ). He nce , a true ze ro
gra die nt is ne ve r a chie ve d in the ste a dy sta te . W he n the a ne sthe tic
is discontinue d or re duce d, the re is a fa ll in the a rte ria l pa rtia l
pre ssure such tha t it is le ss tha n the ve nous pa rtia l pre ssure . In
fa ct, whe n the ve nous pa rtia l pre ssure e xce e ds the a rte ria l pa rtia l
pre ssure , it me a ns tha t the vola tile a ge nt ha s be e n re duce d (or shut
off) be ca use the lungs a re “cle a nsing” the blood a s the vola tile -
fille d blood pa sse s through the m. The ne wly “cle a nse d” blood the n
finds its wa y to the le ft ve ntricle with a ve ry low P A for the vola tile
a ge nt in que stion (Barash : Anesth esiology, ed 7, pp 450–453).
366. (B) Ane sthe tic a ge nts a re soluble in the rubbe r a nd pla stic
compone nts found in the a ne sthe sia ma chine . This fa ct ca n impe de
the de ve lopme nt of a ne sthe tic conce ntra tions of the se drugs. The
worst offe nde r is the obsole te vola tile a ge nt me thoxyflura ne .
Howe ve r, both isoflura ne a nd ha lotha ne a re soluble in rubbe r a nd
pla stic, but to a le sse r de gre e . Se voflura ne , de sflura ne , a nd N2O
ha ve little or no solubility in rubbe r or pla stic. A diffe re nt but
importa nt issue should be borne in mind re ga rding the loss of
se voflura ne . This a ge nt ca n be de stroye d in a ppre cia ble qua ntitie s
by Ba ra lyme (no longe r a va ila ble ) a nd soda lime , but not ca lcium
hydroxide lime (Amsorb) (Miller: Miller’s Anesth esia, ed 8, pp 660–661).
367. (B) Compound A is a n e the r tha t forms whe n se voflura ne
inte ra cts with a bsorbe nt gra nule s. In ra ts, compound A is a
ne phrotoxin tha t ca use s da ma ge to the proxima l re na l tubule . It is
be lie ve d tha t compound A is not ne phrotoxic in huma ns, a t le a st
not a t the conce ntra tions tha t a re a chie ve d clinica lly (e ve n with
fre sh ga s flows a s low a s 1 L/min). The fa ctors tha t le a d to
incre a se d conce ntra tions of compound A a re use of fre sh
a bsorbe nt, use of Ba ra lyme inste a d of soda lime , high a bsorbe nt
te mpe ra ture s, highe r conce ntra tions of se voflura ne in the
a ne sthe sia syste m, a nd close d-circuit or low-flow a ne sthe sia .
Ca lcium hydroxide lime (Amsorb) doe s not conta in KOH or Na OH
a nd doe s not inte ra ct with se voflura ne to produce compound A or
othe r vola tile a ge nts to produce ca rbon monoxide (Miller: Miller’s
368. (D) A le ft-to-right pe riphe ra l shunt such a s a n a rte riove nous
fistula de live rs vola tile -conta ining ve nous blood to the lungs. This
a ction offse ts the dilutiona l e ffe ct of a right-to-le ft intra ca rdia c or
pulmona ry shunt a nd spe e ds up induction. The incre a se in the
a ne sthe tic pa rtia l pre ssure from a n a rte riove nous fistula is
de te cta ble only in the se tting of a concomita nt right-to-le ft shunt
369. (D) Ea ch of the vola tile a ge nts is corre ctly pa ire d with its
pe rce nta ge of re cove re d me ta bolite s. Se voflura ne is me ta bolize d
2% to 5% through oxida tive pa thwa ys using the cytochrome P-450
e nzyme pa thwa y. Like wise , the othe r vola tile a ge nts a re a ll
oxida tive ly me ta bolize d in va rying de gre e s. The obsole te a ne sthe tic
me thoxyflura ne unde rwe nt 50% me ta bolism, re sulting in high
conce ntra tions of fluoride ions a nd re sulta nt re na l fa ilure in some
pa tie nts. Ha lotha ne is unique a mong the vola tile a ge nts in tha t it
ca n unde rgo re ductive me ta bolism in the fa ce of low oxyge n
a va ila bility in the live r (Stoelting: Ph arm acology and Ph y siology in
370. (A) By de finition, the wa shin of the a ne sthe sia circuit re fe rs to
the filling of the compone nts of the circuit with a ne sthe tic ga se s.
The tota l wa shin volume s a re a round 7 L a nd bre a k down a s
follows: a ne sthe sia ba g 3 L, a ne sthe sia hose s 2 L, a nd a ne sthe sia
a bsorbe nt compa rtme nt 2 L. All of the compone nts liste d a re pa rt of
the a ne sthe sia circuit e xce pt the infra re d spe ctrome te r tubing. The
infra re d spe ctrome te r a nd ma ss spe ctrome te r ta ke a wa y (sa mple )
from incoming ga se s through a spira tion but do not dilute the m
371. (A) Incre a sing minute ve ntila tion is one of two me thods for
ma nipula ting ve ntila tion to incre a se the ra te of e sta blishing
a ne sthe sia . Anothe r me thod is incre a sing inspire d conce ntra tion,
which ca n be a chie ve d by turning up the dia l a bove the de sire d
ste a dy sta te conce ntra tion (ove rpre ssurizing) to re a ch ste a dy sta te
more quickly, or incre a sing fre sh ga s flow to re duce or e limina te
re bre a thing (dilution). Substituting a le ss soluble a ne sthe tic, such a s
se voflura ne for isoflura ne , a lso e sta blishe s a ne sthe sia more
ra pidly. Ca rrying out the induction in Sa n Die go inste a d of De nve r
constitute s a dministe ring the a ne sthe tic a t highe r a tmosphe ric
(ba rome tric) pre ssure , which de cre a se s the upta ke a nd he nce
incre a se s the ra te of rise of F A/F I —tha t is, a cce le ra te s the
e sta blishme nt of a ne sthe sia . The a dministra tion of a n inotropic
a ge nt incre a se s ca rdia c output, which a lso incre a se s upta ke a nd
slows the ra te of induction (Barash : Clinical Anesth esia, ed 7, pp 451–
454; Miller: Basics of Anesth esia, ed 6, pp 84–88).
372. (C) In a compa rison of the pha rma cokine tics of e limina tion for
vola tile a ne sthe tics, de sflura ne is the fa ste st. The time for a 50%
re duction (de cre me nt) in the a lve ola r pa rtia l pre ssure of the
“mode rn” a ne sthe tics is roughly the sa me : a bout 5 minute s,
re ga rdle ss of a ne sthe tic dura tion. For longe r a ne sthe tics, howe ve r,
the 80% a nd 90% de cre me nt time s be come ma rke dly diffe re nt. In
the pre se nt e xa mple , the 90% de cre me nt time for de sflura ne a fte r a
6-hour a ne sthe tic is 14 minute s. This is in sta rk contra st to
se voflura ne (65 minute s) a nd isoflura ne (86 minute s). Ple a se se e
Que stion 376 a nd its e xpla na tion (Miller: Basics of Anesth esia, ed 6, pp
373. (D) A prope rly functioning va porize r will produce the
conce ntra tion se t on the dia l (plus or minus a sma ll tole ra nce )
provide d the fre sh ga s flow ra te is gre a te r tha n 250 mL/min a nd
le ss tha n 15 L/min. The 1 L/min ra te in this que stion is we ll within
the limits of the va porize r. The fa ct tha t re bre a thing occurs with a
circula r a ne sthe sia syste m ca use s a significa nt dilutiona l e ffe ct. It is
true tha t upta ke would e nha nce dilution, but it (upta ke ), pe r se , is
not the ma in re a son for this discre pa ncy. Upta ke is conside re d in
the discussion of the F A/F I ra tio. This que stion a ddre sse s the
cha ra cte ristics of the a ne sthe sia ma chine a nd the re la tionship
be twe e n dia l se tting a nd de live re d conce ntra tion. To a chie ve a
de sire d conce ntra tion (e .g., 2%), you must e ithe r ra ise the fre sh ga s
flow to conve rt the syste m to a nonre bre a thing syste m or se t the
va porize r to a highe r le ve l tha n is a ctua lly de sire d: the conce pt of
ove rpre ssuriza tion. In this e ra of cost conta inme nt, the la tte r is
more e conomica l (Miller: Basics of Anesth esia, ed 6, p 207).
374. (D) The a ne sthe sia circuit ca n de la y e me rge nce significa ntly if
the pa tie nt is not disconne cte d (functiona lly) from it. Ane sthe tic
ga se s be come dissolve d in the rubbe r a nd pla stic compone nts of
the bre a thing circuit. Like wise , the soda lime ca n se rve a s a
de pository for a ne sthe tics a s we ll a s the pa tie nt’s own e xha le d
ga se s. To re duce the se e ffe cts to ne a rly ze ro, the fre sh ga s flow
should be ra ise d to a t le a st 5 L/min. Fre sh ga se s e me rge via the
common ga s outle t a nd do not conta in vola tile a ge nts or N2O
be ca use the y (vola tile a ge nts a nd N2O) a re shut off during
e me rge nce (Miller: Miller’s Anesth esia, ed 8, pp 660–661).
375. (B) The time consta nt is de fine d a s ca pa city divide d by flow.
The time consta nt for a vola tile a ne sthe tic is de te rmine d by the
ca pa city of a tissue to hold the a ne sthe tic re la tive to the tissue
blood flow. The ca pa city of a tissue to hold a vola tile a ne sthe tic
de pe nds both on the size of the tissue a nd on the a ffinity of the
tissue for the a ne sthe tic. The bra in time consta nt of a vola tile
a ne sthe tic ca n be e stima te d by doubling the bra in/blood pa rtition
coe fficie nt for the vola tile a ne sthe tic. For e xa mple , the time
consta nt of ha lotha ne (bra in/blood pa rtition coe fficie nt of 2.6) for
the bra in (ma ss of a pproxima te ly 1500 g, blood flow of 750 mL/min)
is a pproxima te ly 5.2 minute s (Eger: Anesth etic Uptake and Action, ed 1,
pp 85–87; Miller: Basics of Anesth esia, ed 6, p 86).
376. (D) This conce pt highlights the fa ct tha t the diffe re nce in ha lf-
time va lue s a mong the vola tile a ne sthe tics is simila r for a ll
vola tile s if the a ne sthe tic dura tion is ve ry brie f. W ith the
a dministra tion of vola tile a ne sthe tics for longe r time s, the
diffe re nce s in re cove ry time be come more profound. For e xa mple ,
a fte r a 1-hour a ne sthe tic with de sflura ne (blood/ga s tissue
coe fficie nt 0.45), a 95% re duction in the a lve ola r conce ntra tion ca n
be re a che d in 5 minute s. W ith a n hour-long se voflura ne a ne sthe tic
(blood/ga s tissue coe fficie nt 0.65), a 95% re duction re quire s
18 minute s, a nd a n hour-long isoflura ne a ne sthe tic (blood/ga s
tissue coe fficie nt 1.4) re quire s more tha n 30 minute s to re a ch a 95%
re duction in the a lve ola r conce ntra tion (Miller: Basics of Anesth esia,
ed 6, pp 89–90; Miller: Miller’s Anesth esia, ed 8, pp 654–655).
377. (D) Afte r a pe riod of time e qua l to thre e time consta nts, the
ve nous blood e xiting the ve sse l-rich group will be a t the 95% le ve l,
but the blood a s a whole will ha ve a le ve l of le ss tha n 95%. The
ve nous blood conta ins a mixture of blood from the ve sse l-rich
group, the muscle group, the fa t group, a nd the ve sse l-poor group,
a nd a t the thre e time consta nt ma rk will be le ss tha n 95% (Miller:
378. (A)
379. (C)
380. (D)
381. (B) The informa tion for the se que stions is summa rize d in the
gra phs be low. Ha lotha ne is unique a mong the vola tile a ge nts liste d
in tha t it doe s not a ffe ct the he a rt ra te or syste mic va scula r
re sista nce in the MAC ra nge s studie d. Se voflura ne re duce s he a rt
ra te until a bout 1 MAC, a t which time it produce s a dose -de pe nde nt
incre a se in he a rt ra te (Miller: Basics of Anesth esia, ed 6, pp 90–92).
PA R T 2
Clinical Sciences
OUTLI NE
Chapter 5. Blood Products, Transfusion, and Fluid Therapy

Chapter 6. General Anesthesia
Chapter 7. Pediatric Physiology and Anesthesia
Chapter 8. Obstetric Physiology and Anesthesia
Chapter 9. Neurologic Physiology and Anesthesia
Chapter 10. Anatomy, Regional Anesthesia, and Pain
Management
Chapter 11. Cardiovascular Physiology and Anesthesia
C H AP T E R 5
Blood Products, Transfusion, and
Fluid Therapy

382. Ea ch of the following tre a tme nts might be use ful in re storing a
prolonge d prothrombin time (PT) to the norma l ra nge EXCEPT
A. Re combina nt fa ctor VIII
B. Vita min K
C. Fre sh froze n pla sma (FFP)
D. Cryopre cipita te
383. Prope r proce ssing of pla te le t conce ntra te s (to a void future
he molytic tra nsfusion re a ctions) be fore a dministra tion involve s
A. Type a nd crossma tching
B. ABO a nd Rh ma tching
C. Rh ma tching only
D. ABO ma tching only
384. The most common inhe rite d coa gulopa thy is
A. He mophilia A
B. He mophilia B
C. von W ille bra nd dise a se (vW D)
D. Fa ctor V de ficie ncy
385. In a 70-kg pa tie nt, 1 unit of pla te le t conce ntra te should incre a se
the pla te le t count by
A. 2000 to 5000/mm3
B. 5000 to 10,000/mm3
C. 15,000 to 20,000/mm3
D. 20,000 to 25,000/mm3
386. A 68-ye a r-old pa tie nt re ce ive s a 1-unit tra nsfusion of pa cke d
re d blood ce lls (RBCs) in the re cove ry room a fte r a la pa roscopic
prosta te ctomy. As the blood is slowly dripping into his pe riphe ra l
intra ve nous line , the pa tie nt compla ins of itching on his che st a nd
a rms, but his vita l signs re ma in sta ble . The a ntibody most like ly
re sponsible for this is dire cte d a ga inst
A. Rh
B. ABO
C. MN, P, a nd Le wis
387. The like lihood of a clinica lly significa nt he molytic tra nsfusion
re a ction re sulting from a dministra tion of type -spe cific blood is le ss
tha n
A. 1 in 250
B. 1 in 500
C. 1 in 1000
D. 1 in 10,000
388. Froze n e rythrocyte s ca n be store d for
A. 1 ye a r
B. 3 ye a rs
C. 5 ye a rs
D. 10 ye a rs
389. W hich of the following clotting fa ctors ha s the shorte st ha lf-
life ?
A. Fa ctor II
B. Fa ctor V
C. Fa ctor VII
D. Fa ctor IX
390. W hich of the me a sure s be low doe s NOT re duce the incide nce
of tra nsfusion-re la te d a cute lung injury (TRALI)?
A. Exclusion of fe ma le donors
B. Use of a utologous blood
C. Le ukocyte re duction
D. Use of blood le ss tha n 14 da ys old
391. A 42-ye a r-old woma n is a ne sthe tize d for re se ction of a la rge
(22-kg), highly va scula r sa rcoma in the a bdome n. During the
re se ction, 20 units of RBCs, 6 units of pla te le ts, 10 units of
cryopre cipita te , 5 units of FFP, a nd 1 L of a lbumin a re a dministe re d.
At the conclusion of the ope ra tion, the pa tie nt’s vita l signs a re
sta ble , a nd she is tra nsporte d to the inte nsive ca re unit. Thre e a nd
a ha lf hours la te r, a dia gnosis of se psis is ma de , a nd a ntibiotic
the ra py is sta rte d. W hich of the ite ms be low would be the most
like ly ca use of se psis in this pa tie nt?
A. Pa cke d RBCs
B. Cryopre cipita te
C. Pla te le ts
D. FFP
392. Blood is routine ly scre e ne d (se rologica lly) for
A. He pa titis A
B. Se ve re a cute re spira tory syndrome (SARS)
C. We st Nile virus
D. Bovine spongiform e nce pha litis (BSE, or ma d cow dise a se )
393. The blood volume of a 10-kg, 1-ye a r-old infa nt is
A. 600 mL
B. 800 mL
C. 1000 mL
D. 1300 mL
394. W hich of the infe ctions be low is the most common tra nsfusion-
re la te d infe ction?
A. Huma n T-ce ll lymphotropic virus (HTLV)-II
B. He pa titis B
C. He pa titis C
D. Huma n immunode ficie ncy virus (HIV)
395. A 40-ye a r-old, 78-kg pa tie nt with he mophilia A is sche dule d for
a right tota l kne e a rthropla sty. His la bora tory te st re sults show a
he ma tocrit of 40, a fa ctor VIII le ve l of 0%, a nd no inhibitors to fa ctor
VIII. How much fa ctor VIII conce ntra te do you ne e d to give him to
bring his fa ctor VIII le ve l to 100%?
A. 3000 units
B. 2500 units
C. 2000 units
D. 1500 units
396. A 38-ye a r-old ma n is unde rgoing a tota l cole ctomy unde r
ge ne ra l a ne sthe sia . Urine output ha s be e n 20 mL/hr for the la st
2 hours. Volume re pla ce me nt ha s be e n a de qua te . The ra tiona le for
a dministe ring 5 to 10 mg of furose mide to this pa tie nt is to
A. Offse t the e ffe cts of incre a se d a ntidiure tic hormone (ADH)
B. Improve re na l blood flow
C. Conve rt oliguric re na l fa ilure to nonoliguric re na l fa ilure
D. Offse t the e ffe cts of incre a se d re nin
397. A 65-ye a r-old ma n involve d in a motor ve hicle a ccide nt (MVA) is
brought to the e me rge ncy room with a blood pre ssure of 60 mm Hg
systolic. He is tra nsfuse d with 4 units of type O, Rh-ne ga tive whole
blood a nd 4 L of norma l sa line solution. Afte r the pa tie nt is brought
to the ope ra ting room, his blood type is de te rmine d to be A
positive . W hich of the following is the most a ppropria te blood type
for furthe r intra ope ra tive tra nsfusions?
A. Type A, Rh-positive whole blood
B. Type O, Rh-ne ga tive RBCs
C. Type A, Rh-positive RBCs
D. Type O, Rh-ne ga tive whole blood
398. The crite rion use d to de te rmine how long blood ca n be store d
be fore tra nsfusion is
A. 90% of tra nsfuse d e rythrocyte s must re ma in in circula tion for
24 hours
B. 70% of tra nsfuse d e rythrocyte s must re ma in in circula tion for
24 hours
C. 70% of tra nsfuse d e rythrocyte s must re ma in in circula tion for
72 hours
D. 75% of tra nsfuse d e rythrocyte s must re ma in in circula tion for
7 da ys
399. The ra tiona le for stora ge of pla te le ts a t room te mpe ra ture
(22° C) is
A. The re is le ss sple nic se que stra tion
B. It optimize s pla te le t function
C. It re duce s the cha nce for infe ction
D. It de cre a se s the incide nce of a lle rgic re a ctions
400. An 18-ye a r-old woma n involve d in a n MVA is brought to the
e me rge ncy room in shock. She is tra nsfuse d with 10 units of type O,
Rh-ne ga tive whole blood ove r 30 minute s. Afte r infusion of the first
5 units, ble e ding is controlle d, a nd he r blood pre ssure rise s to
85/51 mm Hg. During the ne xt 15 minute s, a s the re ma ining 5 units
a re infuse d, he r blood pre ssure slowly fa lls to 60 mm Hg systolic.
The pa tie nt re ma ins in sinus ta chyca rdia a t 120 be a ts/min, but the
QT inte rva l is note d to incre a se from 310 to 470 mse c, a nd the
ce ntra l ve nous pre ssure incre a se s from 9 to 20 mm Hg. He r
bre a thing is ra pid a nd sha llow. The most like ly ca use of this
sce na rio is
A. Citra te toxicity
B. Hype rka le mia
C. He molytic tra nsfusion re a ction
D. Te nsion pne umothora x
401. A 20-kg, 5-ye a r-old child with a he ma tocrit of 40% could lose
how much blood a nd still ma inta in a he ma tocrit of 30%?
A. 140 mL
B. 250 mL
C. 350 mL
D. 450 mL
402. A 100-kg ma le pa tie nt ha s a me a sure d se rum sodium
conce ntra tion of 105 mEq/L. How much sodium would be ne e de d to
bring the se rum sodium to 120 mEq/L?
A. 600 mEq
B. 900 mEq
C. 1200 mEq
D. 1500 mEq
403. Pa ra me dics re spond to a n MVA site a nd imme dia te ly sta bilize
the ne ck, se cure the a irwa y, a nd pla ce a n intra ve nous line into a
19-ye a r-old 70-kg ma n lying in a pool of blood. Be fore the infusion is
sta rte d, 3 millilite rs of blood a re withdra wn for he moglobin a nd
drug scre e ning. The first re sponde rs e stima te tha t the pa tie nt ha s
lost one ha lf of his e ntire blood volume . Give n a sta rting va lue of
18 g/dL, the ne w va lue would like ly be
A. 9 g/dL
B. 11 g/dL
C. 14 g/dL
D. 17 g/dL
404. A 23-ye a r-old woma n who ha s be e n re ce iving tota l pa re nte ra l
nutrition (TPN) (15% de xtrose , 5% a mino a cids, a nd intra lipids) for
3 we e ks is sche dule d for surge ry for se ve re Crohn dise a se .
Induction of a ne sthe sia a nd tra che a l intuba tion a re une ve ntful.
Afte r pe riphe ra l intra ve nous a cce ss is e sta blishe d, the old ce ntra l
line is re move d a nd a ne w ce ntra l line is pla ce d a t a diffe re nt site .
At the e nd of the ope ra tion, a la rge volume of fluid is discove re d in
the che st ca vity on che st x-ra y film. Arte ria l blood pre ssure is
105/70 mm Hg, he a rt ra te is 150 be a ts/min, a nd Sa O2 is 96% (pulse
oxime te r). The most a ppropria te initia l ste p is to
A. Pla ce a che st tube
B. Cha nge the single -lume n to a double -lume n e ndotra che a l tube
C. Sta rt a dopa mine infusion
D. Che ck the blood glucose le ve l
405. In a n e me rge ncy whe n the re is a limite d supply of type O-
ne ga tive RBCs, type O-positive RBCs a re re a sona ble for tra nsfusion
for e a ch of the following pa tie nts EXCEPT
A. A 60-ye a r-old woma n with dia be te s who wa s involve d in a n
MVA
B. A 23-ye a r-old ma n who susta ine d a gunshot wound to the
uppe r a bdome n
C. An 84-ye a r-old ma n with a rupture d a bdomina l a ortic
a ne urysm
D. A 21-ye a r-old, gra vida 2, pa ra 1 woma n with pla ce nta pre via
who is ble e ding profuse ly
406. He ta sta rch e xe rts a n a nticoa gula tive e ffe ct through
inte rfe re nce with the function of
A. Antithrombin III
B. Fa ctor VIII
C. Fibrinoge n
D. Prosta cyclin
407. All of the following cha ra cte rize pa cke d RBCs tha t ha ve be e n
store d for 35 da ys a t 4° C in citra te phospha te de xtrose a de nine -1
(CPDA-1) a nticoa gula nt pre se rva tive EXCEPT
A. Se rum pota ssium gre a te r tha n 70 mEq/L
B. pH le ss tha n 7.0
C. Blood glucose le ss tha n 100 mg/dL
D. P 50 of 28
408. W ha t is the stora ge life of whole blood store d with citra te
phospha te de xtrose (CPD)?
A. 14 da ys
B. 21 da ys
C. 35 da ys
D. 42 da ys
409. In the a dult, the live r is the prima ry orga n for
A. He moglobin synthe sis
B. He moglobin de gra da tion
C. Fa ctor VIII synthe sis
D. Antithrombin III synthe sis
410. Anticoa gula tion with low-mole cula r-we ight he pa rin (LMW H)
ca n be be st monitore d through which of the following la bora tory
te sts?
A. Activa te d pa rtia l thrombopla stin time (a PTT)
B. Anti-Xa a ssa y
C. Thrombin time
D. Re ptila se te st
411. He pa rin re sista nce is like ly in pa tie nts with which of the
following he rita ble conditions?
A. Fa ctor V Le ide n muta tion
B. Prothrombin G20210A ge ne muta tion
C. Prote in S de ficie ncy
D. Antithrombin or a ntithrombin III (AT3) de ficie ncy
412. Von W ille bra nd dise a se (vW D) could be tre a te d by a ny of the
following EXCEPT
A. Cryopre cipita te
B. De smopre ssin (DDAVP)
C. FFP
D. Re combina nt fa ctor VIII
413. The significa nce of immunoglobulin A (IgA) a ntibodie s in
tra nsfusion me dicine is re la te d to
A. Alle rgic re a ction
B. Fe brile re a ction
C. De la ye d he molytic re a ction (immune e xtra va scula r re a ction)
D. Dia gnosis of TRALI re a ction
414. The most common ca use of morta lity a ssocia te d with
a dministra tion of blood is
A. TRALI
B. Non-ABO he molytic tra nsfusion re a ction
C. Microbia l infe ction
D. Ana phyla ctic re a ction
415. Fluid re suscita tion during ma jor a bdomina l surge ry with which
of the following a ge nts is a ssocia te d with the BEST surviva l da ta ?
A. 5% Albumin
B. 6% Hydroxye thyl sta rch
C. De xtra n 70
DIRECT IONS (Que stions 416 a nd 417): Choose the corre ct

re sponse be low for the following que stions:
416. W hich of the following proce sse s re duce s the possibility of

tra nsmission of cytome ga lovirus (CMV) to a susce ptible re cipie nt
via tra nsfusion of RBCs?
417. W ha t is the proce ss a ime d a t re ducing gra ft-ve rsus-host
dise a se (GVHD) in tra nsfusion re cipie nts?
A. Wa shing e rythrocyte s
B. Re duction of le ukocyte s
C. Irra dia tion
D. Stora ge in Adsol
Blood Products, Transfusion, and Fluid
Therapy
382. (A) PT a nd a PTT a re common te sts use d to e va lua te
coa gula tion fa ctors. The PT prima rily te sts for fa ctor VII in the
e xtrinsic pa thwa y, a s we ll a s fa ctors I, II, V, a nd X of the common
pa thwa y. The a PTT prima rily te sts for fa ctors VIII a nd IX of the
intrinsic pa thwa y, a s we ll a s fa ctors I, II, V, a nd X of the common
pa thwa y. Although the PT is prolonge d with de ficie nt function of
fa ctors I, II, V, VII, or X, it is more se nsitive to de ficie ncie s of fa ctor
VII a nd le ss so with de ficie ncie s of fa ctor I or II. In fa ct, the PT is
not prolonge d until the le ve l of fibrinoge n (fa ctor I) is le ss tha n
100 mg/dL a nd ma y be prolonge d for only 2 se conds whe n the le ve l
of fa ctor II (prothrombin) is 10% of norma l. Fa ctors II, VII, IX, a nd X
a re vita min K–de pe nde nt fa ctors, a nd the ir forma tion is blocke d
with Couma din the ra py. Administe ring fa ctor VIII will not he lp a
prolonge d PT (Miller: Miller’s Anesth esia, ed 8, pp 1872–1874; Barash :
Clinical Anesth esia, ed 7, pp 415–416).
383. (C) Pla te le t conce ntra te s conta in a fa ir a mount of pla sma a nd
white blood ce lls (W BCs) but re la tive ly fe w re d blood ce lls (RBCs).
Although ABO-compa tible pla te le t tra nsfusions a re pre fe rre d
(pla te le ts survive be tte r, a nd crossma tching for subse que nt RBCs is
e a sie r), in e me rge ncie s it ha s be e n note d tha t pla te le ts ofte n give
a de qua te he mosta sis without re ga rd to ABO compa tibility. Eve n
though the re a re only sma ll qua ntitie s of RBCs in pla te le ts, the
RBCs pre se nt ca n ca use Rh immuniza tion if Rh-positive pla te le t
conce ntra te s a re inje cte d into Rh-ne ga tive pa tie nts. Thus, until
childbirth is no longe r possible , Rh-ne ga tive wome n should re ce ive
only Rh-ne ga tive pla te le ts (Miller: Miller’s Anesth esia, ed 8, p 1860;
Hoffm an: Hem atology, ed 6, p 1655).
384. (C) Coa gulopa thie s ca n be inhe rite d or a cquire d. Of the
inhe rite d coa gulopa thie s, vW D is the most common, a ffe cting 1 in
100 to 500 pe ople . Both he mophilia A (fa ctor VIII) de ficie ncy a nd
he mophilia B (fa ctor IX or Christma s dise a se ) a re X-linke d
re ce ssive disorde rs. He mophilia A occurs in 1 to 2 pe r 10,000 ma le
individua ls, a nd he mophilia B occurs in 1 pe r 100,000 ma le
individua ls. Fa ctor V, fa ctor VII, fa ctor X, a nd prothrombin (fa ctor II)
de ficie ncie s a re e xce e dingly ra re a utosoma l re ce ssive disorde rs
(Miller: Miller’s Anesth esia, ed 8, p 1872; Barash : Clinical Anesth esia, ed
7, p 432).
385. (B) Pla te le t count is incre a se d a bout 5000 to 10,000/mm3 pe r
unit of pla te le t conce ntra te in the typica l 70-kg pa tie nt. Ea ch unit
conta ins gre a te r tha n 5.5 × 1010 pla te le ts (Miller: Miller’s Anesth esia,
ed 8, pp 1840, 1860; Barash : Clinical Anesth esia, ed 7, p 421).
386. (D) This is a n e xa mple of a typica l a lle rgic re a ction. All of the
othe r choice s in this que stion ma y be involve d in he molytic
re a ctions. Alle rgic re a ctions a re a form of nonhe molytic tra nsfusion
re a ctions, which a re thought to be ca use d by fore ign prote ins in the
tra nsfuse d blood. The re a ctions occur in a bout 3% of a ll
tra nsfusions, a nd the y pre se nt with urtica ria , e rythe ma , pruritus,
fe ve r, a nd some time s re spira tory symptoms. W he n such a re a ction
occurs, the tra nsfusion is stoppe d a nd supportive the ra py, including
a ntihista mine s, is a dministe re d. If the symptoms re solve a nd the re
a re no signs of a he molytic re a ction (no fre e he moglobin in the
pla sma or urine ) or a se ve re a na phyla ctic re a ction, the tra nsfusion
ca n be re sume d (Miller: Miller’s Anesth esia, ed 8, p 1853; Barash :
387. (C) He molytic tra nsfusion re a ctions a re ofte n the re sult of
cle rica l e rror. Thre e ma in blood compa tibility te sts ca n be
pe rforme d to re duce the cha nce of a he molytic re a ction: ABO Rh
typing, a ntibody scre e ning, a nd crossma tching. W ith corre ct ABO
a nd Rh typing, the possibility of a n incompa tible tra nsfusion is le ss
tha n 1 pe r 1000. If you a dd a type a nd scre e n, the possibility of a n
incompa tible tra nsfusion is le ss tha n 1 pe r 10,000. Optima l sa fe ty
occurs whe n crossma tching is pe rforme d (Miller: Miller’s Anesth esia,
ed 8, p 1840).
388. (D) Blood is most ofte n store d a s a liquid a t a bout 4° C but ca n
a lso be froze n for prolonge d stora ge . Be ca use of the a dde d
e xpe nse of froze n blood, it is use d prima rily for ra re blood type s
a nd for a utologous use . Blood tha t ha s a lre a dy be e n colle cte d ha s
a cryoprote ctive a ge nt (e .g., glyce rol) a dde d a nd is the n froze n a nd
store d a t a te mpe ra ture of −65° C (whe n 40% glyce rol is use d) or
−120° C (whe n 20% glyce rol is use d). Curre ntly, the U.S. Food a nd
Drug Administra tion (FDA) a llows froze n blood to be use d up to
10 ye a rs from the time of colle ction (Barash : Clinical Anesth esia, ed 7,
p 416).
389. (C) Fa ctor VII is one of the four vita min K–de pe nde nt clotting
fa ctors (fa ctors II, VII, IX, a nd X). It a lso ha s the shorte st ha lf-life of
a ll the clotting fa ctors (4-6 hours) a nd is the first fa ctor to be come
de ficie nt in pa tie nts with se ve re he pa tic fa ilure , wa rfa rin
(Couma din) a nticoa gula tion the ra py, a nd vita min K de ficie ncy. The
PT is most se nsitive to de cre a se s in fa ctor VII (Barash : Clinical
390. (C) TRALI occurs within 6 hours of blood compone nt
a dministra tion. Pa tie nts e xpe rie nce nonca rdioge nic pulmona ry
e de ma with a cute bila te ra l pulmona ry infiltra te s a nd hypoxe mia
(Pa O2/F I O2 ≤300 mm Hg or oxyge n sa tura tion ≤90% on room a ir with
no e vide nce of le ft a tria l hype rte nsion). The pa thologic cha nge s
a ssocia te d with TRALI a re comple x a nd ma y involve low-pre ssure
pulmona ry e de ma se conda ry to ne utrophil a ctiva tion a nd
se que stra tion in the lungs. Olde r tra nsfusion products (>14 da ys),
fe ma le donors (e spe cia lly multipa rous pa tie nts), a nd poole d
pla te le ts compa re d with a phe re sis pla te le ts a re a ssocia te d with a
highe r fre que ncy of this condition. Inte re stingly, a lthough le ukocyte s
ma y be pa rt of the a ctiva tion proce ss, le ukocyte re duction doe s not
se e m to significa ntly de cre a se the incide nce of TRALI but doe s
de cre a se the incide nce of fe brile re a ctions a nd the risk of CMV,
a nd it ma y de cre a se le ukocyte -induce d immunomodula tion.
Tre a tme nt for TRALI re a ctions is supportive (Barash : Clinical
Anesth esia, ed 7, pp 417–428; Miller: Basics of Anesth esia, ed 6, p 376;
391. (C) Of the five blood products liste d in this que stion, pla te le ts
a re the most like ly to ca use ba cte ria l se psis. Pla te le t-re la te d se psis
is e stima te d to occur in 1 ca se pe r 12,000. The source of ba cte ria
ca n be donor blood or conta mina tion during the colle ction,
proce ssing, a nd stora ge of the blood. If pla te le ts a re coole d, the n
re wa rme d, the pla te le ts te nd not to function ve ry e ffe ctive ly.
Be ca use pla te le ts a re store d a t room te mpe ra ture of 20 to 24° C,
ba cte ria te nd to survive a nd multiply. All othe r liste d blood products
a re coole d. W hole blood a nd pa cke d RBCs a re coole d to 4° C
(unle ss the y a re froze n, which would be colde r). FFP a nd
cryopre cipita te a re froze n to be low −70° C. Albumin is he a t
ste rilize d, ma king it a ste rile pre pa ra tion tha t the n ca n be sa fe ly
store d a t room te mpe ra ture s (Miller: Miller’s Anesth esia, ed 8, pp
1859–1860; Barash : Clinical Anesth esia, ed 7, pp 423–425).
392. (C) He pa titis A tra nsmission is ve ry ra re a nd is scre e ne d for by
history a lone (not se rologica lly) be ca use the re is no ca rrie r sta te for
the virus a nd the dise a se is re la tive ly mild. A de cre a se in the
tra nsmission for va rious othe r infe ctious a ge nts ha s be e n a ttribute d
to the re ce nt a ddition of nucle ic a cid te sting (se e ta ble ). At pre se nt,
the re a re no scre e ning te sts a va ila ble for ma la ria , Cha ga s, SARS,
va ria nt Cre utzfe ldt-Ja kob dise a se , or BSE (Miller: Miller’s Anesth esia,
ed 8, pp 1856–1858; Barash : Clinical Anesth esia, ed 7, pp 415–416).
TESTS USED FOR DETECTING INFECTIOUS AGENTS IN ALL UNITS
OF BLOOD, 2008
Virus RNA Minipool Antibody To

Human immunodeficiency virus (HIV) Nucleic acid technology HIV-1, HIV-2
Hepatitis C virus (HCV) Nucleic acid technology HCV
Hepatitis B virus (HBV) HBV
Human T-cell lymphotropic virus (HTLV) HTLV-1, HTLV-2
West Nile virus Nucleic acid technology
393. (B) Blood volume de cre a se s with a ge . A pre te rm ne wborn ha s

a blood volume of 100 to 120 mL/kg, a te rm ne wborn ha s a blood
volume of a bout 90 mL/kg, a n infa nt (3-12 months) ha s a blood
volume of 80 mL/kg, a child olde r tha n 1 ye a r ha s a blood volume of
70 mL/kg, a nd a n a dult ha s a blood volume of 65 mL/kg. This 10-kg,
1-ye a r-old infa nt would ha ve a n e stima te d blood volume (EBV) of
800 mL (Barash : Clinical Anesth esia, ed 7, p 1246).
394. (B) The risk of tra nsfusion-tra nsmitte d infe ction with a unit of
scre e ne d blood in the Unite d Sta te s va rie s from study to study, but it
is ve ry infre que nt with CMV be ca use of le ukocyte -re duce d blood: 1
in 205,000 for he pa titis B, 1 in 1,935,000 for he pa titis C, 1 in 2,135,000
for HIV, 1 in 2,993,000 for HTLV-II, a nd 1 in more tha n 1,100,000 for
We st Nile virus. Thus, the most common tra nsfusiona ssocia te d
infe ction in the Unite d Sta te s is now he pa titis B. The infe ctive a ge nt
for syphilis doe s not survive a t 4° C, ma king tra nsmission unlike ly
for whole blood, pa cke d RBCs, FFP, or cryopre cipita te . It is
possible for pla te le ts (store d a t room te mpe ra ture ) to tra nsmit
syphilis (Miller: Miller’s Anesth esia, ed 8, pp 1856–1858).
395. (A) The most common type of he mophilia is he mophilia A, a n
X-linke d re ce ssive dise a se ca using a re duction in fa ctor VIII a ctivity.
The dise a se occurs with a fre que ncy of 1 in 5000 ma le individua ls.
This dise a se ca n be se ve re (<1% fa ctor VIII), mode ra te (1%-4%
fa ctor VIII), or mild (5%-30% fa ctor VIII). Pa tie nts with mild
he mophilia ra re ly ha ve sponta ne ous ble e ding. La bora tory studie s
show a norma l pla te le t count a nd norma l PT but a prolonge d
a PTT. The prima ry goa l of pre ope ra tive pre pa ra tion of pa tie nts
with he mophilia A is to incre a se pla sma fa ctor VIII a ctivity to a
le ve l tha t will e nsure a de qua te he mosta sis (i.e ., 50%-100%), the n
ma inta in a le ve l (>40% fa ctor VIII le ve ls) for 7 to 10 da ys. One unit of
fa ctor VIII is e qua l to 1 mL of 100% a ctivity of norma l pla sma . Thus,
to ca lcula te the initia l dose , first ca lcula te the pa tie nt’s blood a nd
the n the pla sma volume . The n ca lcula te the a mount of a ctivity
ne e de d to incre a se the fa ctor VIII le ve l. In this ca se , the blood
volume is 78 kg × 65 mL/kg, or a bout 5000 mL. Knowing tha t the RBC
volume is 40% (i.e ., he ma tocrit is 40) ma ke s the pla sma volume
60%. Thus, the pla sma volume is 5000 mL × 0.6, or a bout 3000 mL.
Be ca use the pa tie nt is sta rting a t 0% a ctivity a nd you wish to ra ise it
to 100% a ctivity, you will ne e d 3000 units. (If you wish to ra ise the
a ctivity by 40%, the n 3000 mL of pla sma × 0.4 for 40% a ctivity = 1200
units.) In a ddition, be ca use the ha lf-life of fa ctor VIII is a bout
12 hours, a bout 1500 units will re ma in a fte r 12 hours. An infusion of
1500 units in 12 hours, or 125 units pe r hour, will be a good sta rting
ma inte na nce infusion ra te . Fa ctor VIII ca n be a dministe re d a s
fa ctor VIII conce ntra te or cryopre cipita te (a bout 10 units/mL).
Pa tie nts with fa ctor VIII inhibitors (10%-20% of pa tie nts with
he mophilia ) re quire more fa ctor VIII. He ma tology consulta tion
should be conside re d for a ll pa tie nts with he mophilia , a nd routine
che cking of fa ctor VIII le ve ls should be pe rforme d (Marx : Rosen’s
Em ergency Med icine, ed 8, p 1614).
396. (A) Se rum ADH le ve ls incre a se during pa inful stimula tion
a ssocia te d with surge ry, a s we ll a s during positive -pre ssure
me cha nica l ve ntila tion. Sma ll dose s of furose mide (i.e ., 0.1 mg/kg)
will counte ra ct this e ffe ct during surge ry (Miller: Miller’s Anesth esia,
ed 8, p 1773; Barash : Clinical Anesth esia, ed 7, pp 344–345).
397. (B) Type O, Rh-ne ga tive blood is a lso ca lle d unive rsa l donor
blood be ca use the tra nsfuse d RBCs la ck the a ntige ns ne e de d to be
he molyze d. Be ca use the pla sma of O-ne ga tive blood conta ins a nti-A
a nd a nti-B a ntibodie s, it is pre fe ra ble to a dministe r pa cke d RBCs
(with little pla sma ) ove r whole blood (lots of pla sma ) in a n
e me rge ncy. Howe ve r, if two or more units of type O-ne ga tive ,
uncrossma tche d whole blood a re a dministe re d to a pa tie nt a nd
subse que nt blood typing re ve a ls the pa tie nt’s blood type to be A, B,
or AB, the n switching ba ck to the pa tie nt’s own blood type could
le a d to ma jor intra va scula r he molysis of the tra nsfuse d RBCs a nd,
the re fore , is not a dvise d. The use of type O-ne ga tive unive rsa l
donor whole blood, or pre fe ra bly RBCs, is re comme nde d. In the
ma le pa tie nt or the olde r fe ma le pa tie nt who will not ha ve more
childre n, type O-positive whole blood ca n be a dministe re d if fe w
type O, Rh-ne ga tive units a re a va ila ble a nd ma ssive tra nsfusion is
a nticipa te d. Only a fte r it is de te rmine d tha t the pa tie nt ha s low
e nough le ve ls of tra nsfuse d a nti-A a nd a nti-B a ntibodie s should the
corre ct type of blood be a dministe re d (Miller: Miller’s Anesth esia, ed
8, p 1840).
398. (B) The re quire me nt for blood stora ge sta te s tha t a t le a st 70%
of the e rythrocyte s must re ma in in circula tion for 24 hours a fte r a
tra nsfusion for the tra nsfusion to be succe ssful. Erythrocyte s tha t
survive longe r tha n 24 hours a fte r tra nsfusion a ppe a r to ha ve a
norma l life spa n (Miller: Miller’s Anesth esia, ed 8, p 1841).
399. (B) At a pH be low 6.0 or in cold te mpe ra ture s such a s 4° C (the
te mpe ra ture use d for blood stora ge ), pla te le ts unde rgo irre ve rsible
sha pe cha nge s. The optima l te mpe ra ture for pla te le t stora ge is 22°
C ± 2° C, or room te mpe ra ture . The re a re two ma jor proble ms with
pla te le t stora ge a t this re comme nde d te mpe ra ture . First, the pH
fa lls be ca use of pla te le t me ta bolism. Se cond, ba cte ria l growth is
possible , which could pote ntia lly le a d to se psis a nd de a th. To
minimize the se proble ms, pla te le t stora ge is limite d to 5 da ys a t 22°
C (Miller: Miller’s Anesth esia, ed 8, pp 1859–1861; Barash : Clinical
400. (A) W hole blood is ra re ly use d toda y e xce pt in e me rge ncy
ca se s whe n the ra pid infusion of blood a nd volume is ne e de d.
Store d blood conta ins citra te , a n a nticoa gula nt tha t binds ionize d
ca lcium. W he n whole blood is ra pidly tra nsfuse d (i.e .,
>50 mL/70 kg/min) the citra te binds with ca lcium, producing
tra nsie nt de cre a se s in ionize d ca lcium. The a brupt de cre a se in
ionize d ca lcium ca n le a d to prolonge d QT inte rva ls, a n incre a se in
le ft ve ntricula r e nd-dia stolic pre ssure , a nd a rte ria l hypote nsion.
W ithin 5 minute s of stopping the tra nsfusion, ionize d ca lcium le ve ls
re turn to norma l. The volume of a n a ve ra ge unit of whole blood is
500 mL. This pa tie nt re ce ive d 10 units of whole blood, or 5000 mL,
ove r 30 minute s, the n a nothe r 5 units in 15 minute s. This a ve ra ge s
to a ra te gre a te r tha n 160 mL/min (Miller: Miller’s Anesth esia, ed 8, pp
1840–1841).
401. (C) A 20-kg, 5-ye a r-old child ha s a n EBV of 70 mL/kg = 1400 mL.
The a cce pta ble blood loss ca n be de te rmine d by use of the
following formula : ma ximum a llowa ble blood loss (in
mL) = EBV × (Hcts − Hct1)/Hcts whe re EBV is the e stima te d blood
volume (in mL), Hcts is the sta rting he ma tocrit, a nd Hct1 is the
lowe st a cce pta ble he ma tocrit. For this pa tie nt, the ma xima l
a llowa ble blood loss = 1400 × (40 − 30/40) = 1400 × (10/40) = 350 mL.
This a ssume s tha t the pa tie nt is ge tting volume e xpa nsion with
crysta lloid (3 mL pe r mL of blood loss). Also se e e xpla na tion to
Que stion 393 (Barash : Clinical Anesth esia, ed 7, p 1246).
402. (B) The norma l se rum sodium conce ntra tion is 135 to
145 mEq/L. Hypona tre mia occurs whe n the se rum le ve l is le ss tha n
135 mEq/L. Clinica l symptoms corre spond not only to the le ve l of
hypona tre mia but a lso to how ra pidly sodium le ve ls a re fa lling.
Hypona tre mia is most commonly not a de ficie ncy in tota l body
sodium but ra the r is a n e xce ss of tota l body wa te r (e .g., a bsorption
of irriga ting fluids a s se e n in tra nsure thra l re se ction of the prosta te
syndrome , a nd syndrome of ina ppropria te a ntidiure tic hormone
se cre tion). It ca n a lso be ca use d by a n e xce ssive loss of sodium, a s
is se e n in se ve re swe a ting, vomiting, dia rrhe a , burns, a nd the use
of diure tics. W ith a cute fa lls in se rum sodium, ne urologic
symptoms (confusion, re stle ssne ss, drowsine ss, se izure s, coma )
re sulting from ce re bra l e de ma ca n be se e n a t se rum le ve ls be low
120 mEq/L. Ca rdia c symptoms (ve ntricula r ta chyca rdia , ve ntricula r
fibrilla tion) ca n be se e n a t le ve ls be low 100 mEq/L. The ra py for
se ve re hypona tre mia include s wa te r re striction, loop diure tics, a nd
a t time s the a dministra tion of hype rtonic sa line (3% Na Cl). The
dose of sodium ne e de d for corre ction ca n be ca lcula te d by
multiplying the tota l body wa te r (TBW = body we ight × 0.6) time s
the incre a se in sodium de sire d; tha t is,
In this pa tie nt, the ca lcula te d dose of sodium would be 100

(we ight in kg) × 0.6 × (120 mEq/L-105 mEq/L) = 900 mEq. Thre e
pe rce nt Na Cl is infuse d no fa ste r tha n 100 mL/hr. Too ra pid a
corre ction ma y le a d to ce ntra l pontine mye linolysis. Once the
le ve l re a che s 120 mEq/L, furthe r tre a tme nt usua lly consists of
wa te r re striction a nd diure tics (Miller: Miller’s Anesth esia, ed 8, p
1773).
403. (D) The intra va scula r ha lf-life of crysta lloid solution is 20 to
30 minute s, whe re a s the intra va scula r ha lf-life of colloid is 3 to
6 hours. To re store intra va scula r volume , for e a ch mL of blood lost,
3 to 4 mL of crysta lloid or 1 mL of colloid is a dministe re d. In this
ca se , though, the blood sa mple is dra wn be fore the infusion is
sta rte d, so the he moglobin dra wn should be simila r to his
he moglobin conce ntra tion imme dia te ly be fore the MVA (Butterworth :
404. (D) Abrupt discontinua tion of TPN tha t conta ins 10% to 20%
de xtrose ma y re sult in profound re bound hypoglyce mia .
Ta chyca rdia in this pa tie nt ma y signify hypoglyce mia . Prompt
dia gnosis a nd tre a tme nt of se ve re hypoglyce mia a re e sse ntia l if
ne urologic da ma ge is to be a voide d. W he ne ve r a ce ntra l line is
pla ce d for TPN, it should be prope rly che cke d be fore the
hype rtonic infusion is sta rte d (Miller: Miller’s Anesth esia, ed 8, p 1782).
405. (D) In a n e me rge ncy whe n ma ssive a mounts of blood a re
imme dia te ly re quire d a nd the supply of O-ne ga tive RBCs in the
blood ba nk is low, it is a cce pta ble to tra nsfuse O-positive RBCs into
ma le pa tie nts or into fe ma le pa tie nts pa st the a ge of childbirth
be fore the pa tie nt’s blood type is known. This is be ca use de la ying
blood tra nsfusion for blood typing ma y be more ha za rdous to the
pa tie nt tha n the risk of a significa nt tra nsfusion re a ction ba se d on
Rh type for the se pa tie nts. Howe ve r, for the fe ma le pa tie nt who
ha s the pote ntia l for pre gna ncy, a dministra tion of Rh-positive RBCs
is not re comme nde d (unle ss no Rh-ne ga tive RBCs a re a va ila ble ).
This is be ca use a n Rh-ne ga tive pa tie nt who re ce ive s Rh-positive
RBCs would e xpe rie nce isoimmuniza tion. For the se wome n, future
pre gna ncie s with Rh-positive fe tuse s could be a ssocia te d with
e rythrobla stosis fe ta lis. Note : RBCs a re pre fe rre d ove r whole blood
be ca use Rh-ne ga tive whole blood conta ins a la rge qua ntity of a nti-
A a nd a nti-B a ntibodie s in the pla sma (Turgeon: Clinical Hem atology,
ed 1, pp 50–51).
406. (B) He ta sta rch (hydroxye thyl sta rch) a nd de xtra n 70 (glucose
polyme rs with me a n mole cula r we ights of 70,000) a re colloid
solutions tha t a re use d for intra va scula r fluid volume e xpa nsion.
Both he ta sta rch a nd de xtra n ha ve be e n a ssocia te d with a lle rgic
re a ctions, ca n inte rfe re with coa gula tion, a nd ca n ca use
hype rvole mia . He ta sta rch, unlike de xtra n, doe s not inte rfe re with
crossma tching of blood a t the re comme nde d ma xima l da ily dose of
20 mL/kg. Ne ithe r compound ne e ds to be a dministe re d through a
filte r.
He ta sta rch a lso re duce s le ve ls of vW F significa ntly a s we ll a s
a va ila bility of glycoprote in IIb/IIIa , a nd it ca n be come dire ctly
incorpora te d into the fibrin clot (Miller: Miller’s Anesth esia, ed 8, p
1783).
407. (D) RBCs a re coole d to a bout 4° C to de cre a se ce llula r
me ta bolism. CPDA-1 is a pre se rva tive a nticoa gula nt solution ofte n
a dde d to blood. It conta ins citra te , phospha te , de xtrose , a nd
a de nine . The citra te is use d to bind ca lcium a nd a cts a s a n
a nticoa gula nt. Phospha te a cts a s a buffe r. De xtrose is a dde d a s a n
e ne rgy source for ce llula r me ta bolism on the da y of dona tion to
ra ise the blood suga r to gre a te r tha n 400 mg/dL. At 35 da ys, the
glucose le ve l drops be low 100 mg/dL. Ade nine is a dde d a s a
substra te source so tha t the ce lls ca n produce a de nosine
triphospha te . Othe r bioche mica l cha nge s include a fa ll in pH to
a bout 6.7 a nd a rise in pla sma pota ssium from a round 4 mEq/L on
the da y of dona tion to 76 mEq/L a t 35 da ys. Conce ntra tions of 2,3-
diphosphoglyce ra te fa ll be low 1 µM/mL, which ca use s a le ftwa rd
shift in the oxyhe moglobin dissocia tion curve tha t a llows for a n
incre a se d oxyge n a ffinity for the he moglobin. This le ftwa rd shift
produce s a P 50 va lue le ss (not gre a te r) tha n the norma l 26 mm Hg
408. (B) Ma ny pre se rva tion solutions a re use d for whole blood a nd
RBCs. Acid citra te de xtrose , CPD, a nd citra te phospha te double
de xtrose (CP2D) e a ch a llows blood to ha ve a she lf life of 21 da ys.
In 1978, the FDA a pprove d the a dditive a de nine to CPD. This
e xte nde d the she lf life of blood by 2 we e ks. CPDA-1 ha s a she lf life
of 35 da ys. The se solutions we re use d ma inly for whole blood.
Howe ve r, whe n compone nt the ra py be ca me more wide spre a d, it
wa s note d tha t pa cking the RBCs by re moving the pla sma a lso
re move d a significa nt a mount of a de nine a nd glucose . By use of a n
a dditive solution (which conta ins prima rily a de nine , glucose , a nd
sa line ) to the CPD or CP2D whole blood tha t ha s the pla sma
re move d, the pa cke d RBCs ca n now be store d for 42 da ys. The
thre e diffe re nt a dditive solutions curre ntly use d in the Unite d Sta te s
a re Adsol (AS-1), Nutrice l (AS-3), a nd Optisol (AS-5) (Miller: Miller’s
409. (D) The live r produce s most of the coa gula tion fa ctors e xce pt
for fa ctor III (tissue thrombopla stin), fa ctor IV (ca lcium), a nd fa ctor
VIII (von W ille bra nd fa ctor). The live r a lso produce s the
coa gula tion re gula tory prote in C, prote in S, a nd a ntithrombin III.
Fe ta l RBCs a re produce d e xclusive ly by the live r; in the a dult, 80%
of RBCs a re produce d by the bone ma rrow a nd only 20% a re
produce d in the live r. The de gra da tion of blood is prima rily by the
re ticuloe ndothe lia l syste m (Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, ed 1, p 477; Miller: Basics of Anesth esia, ed 6, p 456).
410. (B) LMW H is produce d by the fra ctiona tion or cle a ving of
“unfra ctiona te d he pa rin (UFH)” into shorte r fra gme nts. The
a nticoa gula nt prope rtie s of UFH a nd LMW H a re comple x a nd
some wha t diffe re nt. UFH binds to a nd a ctiva te s a ntithrombin (more
e ffe ctive ly tha n LMW H) a nd ca n be monitore d e a sily with the
a PTT. At the usua l clinica l dose s of LMW H, a PTT is not prolonge d.
LMW H, on the othe r ha nd, is more e ffe ctive in ina ctiva ting fa ctor
Xa a nd ca n be monitore d by a nti-Xa le ve ls (a lthough commonly this
is not pe rforme d be ca use of the more pre dicta ble a ction of
prophyla ctic dosing of LMW H). At high dose s of LMW H, a ntifa ctor
Xa va lue s a re more commonly me a sure d. Thrombin time is a
me a sure of the a bility of thrombin to conve rt fibrinoge n to fibrin. It
is prolonge d with low a mounts of fibrinoge n, he pa rin, a nd fibrin
de gra da tion products (FDPs). A re ptila se te st is done by a dding
re ptila se to pla sma a nd wa iting for a clot to form a nd is prolonge d
in the pre se nce of lupus a nticoa gula nt, FDPs, fibrinoge n de ficie ncy,
or a bnorma l fibrinoge n. It is not prolonge d in the pre se nce of
he pa rin (Miller: Miller’s Anesth esia, ed 8, pp 1872–1874; Barash : Clinical
411. (D) The four se le ctions to this que stion a re four of the five
ma jor he re dita ry conditions a ssocia te d with hype rcoa gula tion.
The y ca use a n incre a se d like lihood of clot forma tion by e ithe r
incre a sing prothrombotic prote ins (e .g., fa ctor V Le ide n muta tion,
prothrombin G20210A ge ne muta tion) or de cre a sing e ndoge nous
a ntithrombotic prote ins (e .g., a ntithrombin de ficie ncy, prote in C
de ficie ncy, prote in S de ficie ncy). Clot ma y a lso de ve lop if he pa rin
re sista nce occurs (usua l dose s produce le ss tha n the e xpe cte d
prolonga tion of the pa rtia l thrombopla stin time or the a ctiva te d
clotting time ) a nd is not re cognize d, a s during ca rdiopulmona ry
bypa ss. It ma y occur a s a re sult of e xce ssive binding of he pa rin to
pla sma prote ins or a n insufficie nt a mount of a ntithrombin. Be ca use
he pa rin binds to a nd pote ntia te s a ntithrombin’s a ctivity, conditions
with low a mounts of a ntithrombin show re sista nce . Tre a tme nt of
AT3 de ficie ncy is re pla ce me nt of AT3 with e ithe r spe cific AT III
conce ntra te (Thromba te III) or FFP. Re pla ce me nt of a ntithrombin to
100% a ctivity is re comme nde d be fore ca rdia c surge ry in pa tie nts
with conge nita l AT3 de ficie ncy (Miller: Miller’s Anesth esia ed 8, pp
1871–1872, 1876–1877; Young: Clinical Hem atology, ed 1, pp 1116–1118).
412. (D) vW D is the most common inhe rite d a bnorma lity a ffe cting
pla te le t function a nd is ca use d by a qua ntita tive or qua lita tive
de ficie ncy of a prote in ca lle d von W ille bra nd fa ctor (vW F). vW F is
produce d by e ndothe lia l ce lls a nd pla te le ts a nd a ppe a rs to ha ve
two ma in functions: it a cts a s a n a dhe sion prote in tha t dive rts
pla te le ts to site s of va scula r injury, a nd it he lps prote ct fa ctor VIII
from ina ctiva tion a nd cle a ra nce . Pa tie nts with vW D ha ve
prolonge d ble e ding time s a nd a re duce d a mount of fa ctor VIII.
Pa tie nts with he mophilia A a lso ha ve a de cre a se in fa ctor VIII but
norma l ble e ding time s. Type 1 vW D is the most common type
(60%-80%) a nd is a ssocia te d with a qua ntita tive de cre a se in
circula ting pla sma vW F ca use d by a de cre a se in re le a se of
a va ila ble vW F. Type 2 vW D (20%-30%) ha s se ve ra l subtype s a nd is
a ssocia te d with qua lita tive de ficie ncy of vW F. Type 3 vW D is the
le a st fre que nt (1%-5%) a nd the most se ve re form, whe re in the re is
a lmost no vW F a nd ve ry low fa ctor VIII le ve ls (3%-10% of norma l).
Tre a tme nt of vW D include s DDAVP, which incre a se s the re le a se of
a va ila ble vW F, or blood products tha t conta in vW F a nd fa ctor III
(e .g., cryopre cipita te , FFP, or fa ctor III conce ntra te s). Re combina nt
fa ctor VIII is not use d be ca use it doe s not conta in vW F (Miller:
Miller’s Anesth esia, ed 8, pp 1123, 1872; Barash : Clinical Anesth esia, ed 7,
p 433).
413. (A) Although a lle rgic re a ctions a fte r blood tra nsfusions a re
common (up to 3%), true nonhe molytic a na phyla ctic re a ctions a re
ra re . W he n a na phyla ctic re a ctions de ve lop (ofte n with only a fe w
millilite rs of blood or pla sma tra nsfuse d), the signs a nd symptoms
ma y include dyspne a , bronchospa sm, la rynge a l e de ma , che st pa in,
hypote nsion, a nd shock. The se re a ctions a re ca use d by the
tra nsfusion of “fore ign” IgA prote in to pa tie nts who ha ve he re dita ry
IgA de ficie ncy a nd ha ve forme d a nti-IgA a s a re sult of pre vious
tra nsfusions or from e a rlie r pre gna ncie s. Tre a tme nt include s
stopping the tra nsfusion a nd a dministe ring e pine phrine a nd
ste roids. If furthe r tra nsfusion is ne e de d, wa she d RBCs or RBCs
from IgA-de ficie nt donors should be use d (Miller: Miller’s Anesth esia,
ed 8, p 1853; Barash : Clinical Anesth esia, ed 7, p 426).
414. (A) For the ye a rs 2005 to 2006, 125 confirme d tra nsfusion-re la te d
fa ta litie s we re liste d by the FDA in the Unite d Sta te s. The most
common ca use wa s TRALI (51%), followe d by non-ABO he molytic
tra nsfusion re a ction (20%), microbia l infe ction (12%), ABO he molytic
tra nsfusion re a ction (7%), de a th from tra nsfusion-a ssocia te d
circula tory ove rloa d (TACO) (7%), a nd othe r (2%). Since Ma rch 2004,
whe n volunta ry ba cte ria l de te ction te sting wa s imple me nte d for
pla te le t tra nsfusions, the re ha s be e n a de cre a se in fa ta litie s
a ssocia te d with tra nsfusion of ba cte ria lly conta mina te d a phe re sis
pla te le ts. Conside ring a bout 29 million compone nts a re tra nsfuse d
e a ch ye a r (2004 ca le nda r ye a r) in the Unite d Sta te s, the re porte d
incide nce of de a th is quite sma ll
(www.fd a.gov/cber/blood /fatal/0506.h tm ; Miller: Miller’s Anesth esia, ed 8,
pp 1855–1860; Barash : Clinical Anesth esia, ed 7, pp 425–427).
TRANSFUSION-RELATED FATALITIES IN THE UNITED STATES, 2004
TO 2006
Cause of Fatality 2004-2006 Average per Year
TRALI 86 29
Other reactions (non-ABO hemolytic therapy; anaphylaxis) 67 22
Bacterial contamination 20 7
ABO hemolytic transfusion therapy 15 5
Transfusion not ruled out 31 10
TRALI, transfusion-related acute lung injury.
From Miller RD: Miller’s Anesthesia, ed 7, Philadelphia, Saunders, 2011, Table 55-6.
415. (D) The re is controve rsy not only a s to which intra ve nous fluid
is the be st but a lso how much to give . Most would sugge st tha t
isotonic crysta lloids should be the initia l re suscita tive fluids to a ny
tra uma pa tie nts, a nd the y a re ce rta inly le ss e xpe nsive tha n 5%
a lbumin, 6% hydroxye thyl sta rch, a nd de xtra n 70. Cle a r a dva nta ge s
of one fluid ove r a nothe r a re ha rd to find (Miller: Miller’s Anesth esia,
ed 8, p 1800; Barash : Clinical Anesth esia, ed 7, pp 338–339).
416. (B) Tra nsmission of CMV to pa tie nts who ha ve norma l immune
me cha nisms is be nign a nd se lf-limiting, but in pa tie nts who a re
immunocompromise d (e .g., pre ma ture ne wborns, solid orga n a nd
bone ma rrow tra nspla nt pa tie nts, a cquire d immunode ficie ncy
syndrome pa tie nts), CMV infe ction ca n be se rious a nd life
thre a te ning. Le ukocyte re duction ca n re duce CMV tra nsmission,
but re striction of blood products from se rone ga tive donors is
pre fe rre d (Miller: Miller’s Anesth esia, ed 8, pp 1857–1858; Barash :
417. (C) GVHD is a n ofte n fa ta l condition tha t occurs in pa tie nts
who a re immunocompromise d. It occurs whe n donor lymphocyte s
(gra ft) e sta blish a n immune re sponse a ga inst the re cipie nt (host).
Blood products tha t ha ve a significa nt a mount of lymphocyte s
include RBCs a nd pla te le ts. FFP a nd cryopre cipita te a ppe a r to be
sa fe . Although dire cte d donor units from first-de gre e re la tive s a nd
le ukore duction ma y re duce the incide nce of GVHD, only irra dia te d
products (which ina ctiva te s donor lymphocyte s) ca n pre ve nt GVHD
(Miller: Miller’s Anesth esia, ed 8, p 1858; Barash : Clinical Anesth esia, ed
7, p 428).
C H AP T E R 6
General Anesthesia
418. A 78-ye a r-old pa tie nt with a history of hype rte nsion a nd a dult-
onse t dia be te s for which she ta ke s chlorpropa mide (Dia bine se ) is
a dmitte d for e le ctive chole cyste ctomy. On the da y of a dmission,
blood glucose is note d to be 270 mg/dL, a nd the pa tie nt is tre a te d
with 15 units of re gula r insulin subcuta ne ously (SQ) in a ddition to
he r re gula r dose of chlorpropa mide . Twe nty-four hours la te r a fte r
ove rnight fa sting, the pa tie nt is brought to the ope ra ting room (OR)
without he r da ily dose of chlorpropa mide a nd is a ne sthe tize d. A
se rum glucose is me a sure d a nd found to be 35 mg/dL. The MOST
like ly e xpla na tion for this is
A. Insulin
B. Chlorpropa mide
C. Hypovole mia
D. Effe ct of ge ne ra l a ne sthe sia
419. Se le ct the T RUE sta te me nt.
A. Dibuca ine is a n e ste r-type loca l a ne sthe tic
B. A dibuca ine numbe r of 20 is norma l
C. The dibuca ine numbe r re pre se nts the qua ntity of norma l
pse udocholine ste ra se
420. A 56-ye a r-old pa tie nt with a history of live r dise a se a nd
oste omye litis is a ne sthe tize d for tibia l dé bride me nt. Afte r induction
a nd intuba tion, the wound is inspe cte d a nd dé bride d with a tota l
blood loss of 300 mL. The pa tie nt is tra nsporte d intuba te d to the
re cove ry room, a t which time the systolic blood pre ssure fa lls to
50 mm Hg. He a rt ra te is 120 be a ts/min, a rte ria l blood ga se s (ABGs)
a re Pa O2 103, Pa CO2 45, pH 7.3, with 97% O2 sa tura tion with 100%
F IO2. Mixe d ve nous blood ga se s a re PvO2 60 mm Hg, PvCO2 50, a nd
pH 7.25. W hich of the following dia gnose s is MOST consiste nt with
this clinica l picture ?
A. Hypovole mia
B. Conge stive he a rt fa ilure (CHF)
C. Ca rdia c ta mpona de
D. Se psis with a cute re spira tory distre ss syndrome
421. Norma l tra che a l ca pilla ry pre ssure is
A. 10 to 15 mm Hg
B. 15 to 20 mm Hg
C. 25 to 30 mm Hg
D. 35 to 40 mm Hg
422. How ma ny hours should e la pse be fore pe rforming a single -
shot spina l a ne sthe tic in a pa tie nt who is re ce iving 1 mg/kg
e noxa pa rin (Love nox) twice a da y for the tre a tme nt of a de e p ve in
thrombosis?
A. 6 hours
B. 12 hours
C. 24 hours
D. 48 hours
423. W hich of the following pe riphe ra l ne rve s is MOST like ly to
be come injure d in pa tie nts who a re unde r ge ne ra l a ne sthe sia ?
A. Ulna r ne rve
B. Me dia n ne rve
C. Ra dia l ne rve
D. Common pe rone a l ne rve
424. W hich of the following is the most pla usible e xpla na tion for
the la ck of a na lge sia with code ine a dministra tion?
A. La ck of CYP2D6 e nzyme
B. VKORC1 polymorphism
C. CYP3A4 polymorphism
D. La ck of µ re ce ptors
425. A 62-ye a r-old pa tie nt with a ba re -me ta l ste nt in the mid portion
of the le ft a nte rior de sce nding a rte ry is sche dule d for rota tor cuff
re pa ir unde r ge ne ra l a ne sthe sia . The ste nt wa s pla ce d 6 we e ks
be fore surge ry a nd the pa tie nt is on dua l the ra py (a spirin a nd
clopidogre l). W hich of the pa ra digms be low would be be st for
ma na ging his a nticoa gula tion be fore surge ry?
A. Continue both up to the da y of surge ry
B. Stop both 7 to 10 da ys be fore surge ry
C. Stop a spirin a nd continue clopidogre l
D. Stop clopidogre l a nd continue a spirin
426. A pa tie nt with which of the following e ye dise a se s would be a t
gre a te st risk for re tina l da ma ge from hypote nsion during surge ry?
A. Stra bismus
B. Ope n e ye injury
C. Gla ucoma
D. Se ve re myopia
427. Na ltre xone is
A. A na rcotic with loca l a ne sthe tic prope rtie s
B. An opioid a gonist-a nta gonist simila r to na lbuphine
C. A pure opioid a nta gonist with a shorte r dura tion of a ction tha n
na loxone
D. An opioid a nta gonist use d for tre a tme nt of pre viously
de toxifie d he roin a ddicts
428. W hich of the following me cha nisms is most fre que ntly
re sponsible for hypoxia in the re cove ry room?
A. Ve ntila tion/pe rfusion misma tch
C. Hypoxic ga s mixture
D. Intra ca rdia c shunt
429. Hypopa ra thyroidism se conda ry to the ina dve rte nt surgica l
re se ction of the pa ra thyroid gla nds during tota l thyroide ctomy
typica lly re sults in symptoms of hypoca lce mia how ma ny hours
postope ra tive ly?
A. 1 to 2 hours
B. 3 to 12 hours
C. 12 to 24 hours
D. 24 to 72 hours
430. Da ma ge to which ne rve ma y le a d to wrist drop?
A. Ra dia l
B. Axilla ry
C. Me dia n
D. Ulna r
431. The most common ca use of bronchie cta sis is
A. Ciga re tte smoking
B. Air pollution
C. α1-Antitrypsin de ficie ncy
D. Re curre nt bronchia l infe ctions
432. A 6-ye a r-old child is tra nsporte d to the re cove ry room a fte r a
tonsille ctomy. The pa tie nt wa s a ne sthe tize d with isoflura ne ,
fe nta nyl, a nd N2O. Twe nty minute s be fore e me rge nce a nd tra che a l
e xtuba tion, drope ridol wa s a dministe re d. The a ne sthe siologist is
ca lle d to the re cove ry room be ca use the pa tie nt is “ma king stra nge
e ye move me nts.” The pa tie nt’s e ye s a re rolle d ba ck into his he a d,
a nd his ne ck is twiste d a nd rigid. The most a ppropria te drug for
tre a tme nt of the se symptoms is
A. Da ntrole ne
B. Dia ze pa m
C. Glycopyrrola te
D. Diphe nhydra mine
433. A 32-ye a r-old a rmy office r is una ble to oppose the le ft thumb
a nd le ft little finge r a fte r a n 8-hour e xplora tory la pa rotomy unde r
ge ne ra l a ne sthe sia . He ha d a n IV induction through a pe riphe ra l IV
a nd ha d a se cond IV pla ce d in the a nte cubita l fossa a fte r he wa s
a sle e p. Da ma ge to which of the following ne rve s would MOST
like ly a ccount for this de ficit?
A. Ra dia l
B. Ulna r
C. Me dia n
D. Musculocuta ne ous
434. Phe ochromocytoma would be MOST like ly to coe xist with
which of the following?
A. Insulinoma
B. Pituita ry a de noma
C. Prima ry hype ra ldoste ronism (Conn syndrome )
D. Me dulla ry ca rcinoma of the thyroid
435. W hich of the following ora l a ntidia be tic drugs is unique in tha t
it doe s NOT produce hypoglyce mia whe n a dministe re d to a fa sting
pa tie nt?
A. Glyburide (Microna se )
B. Glipizide (Glucotrol)
C. Tolbuta mide (Orina se )
D. Me tformin (Glucopha ge )
436. The onse t of de lirium tre me ns (DTs) a fte r a bstine nce from
a lcohol usua lly occurs in
A. 8 to 24 hours
B. 24 to 48 hours
C. 2 to 4 da ys
D. 4 to 7 da ys
437. A 78-ye a r-old re tire d coa l mine r with a n intra lumina l tra che a l
tumor is sche dule d for tra che a l re se ction. W hich of the following is
a re la tive contra indica tion for tra che a l re se ction?
A. Ne e d for postope ra tive me cha nica l ve ntila tion for unde rlying
lung dise a se
B. Tumor loca te d a t the ca rina
C. Docume nte d live r me ta sta se s
D. Ische mic he a rt dise a se with a history of CHF
438. A 78-ye a r-old pa tie nt with multiple mye loma is a dmitte d to the
inte nsive ca re unit (ICU) for tre a tme nt of hype rca lce mia . The
prima ry risk a ssocia te d with a ne sthe tizing pa tie nts with
hype rca lce mia (le ve ls of 14-16 mg/dL) is
A. Coa gulopa thy
B. Ca rdia c dysrhythmia s
C. Hypote nsion
D. La ryngospa sm
439. Just be fore induction of ge ne ra l a ne sthe sia for a n 85-ye a r-old
de me nte d ma n with a n ische mic bowe l, he me ntions to you tha t he
forgot to ta ke his gre e n-ca ppe d e ye drops. He sta te s tha t not ta king
it da ily will re sult in blindne ss. The gre e n-ca ppe d e ye drops a re
A. Na Cl drops use d to pre ve nt his e ye from drying out
B. Antibiotic drops
C. Ste roids
D. Use d to produce miosis
440. A norma l, he a lthy 3-ye a r-old child wa s involve d in a motor
ve hicle a ccide nt. He is coming e me rge ntly to the OR. Drug dose s
ne e d to be ca lcula te d, but his we ight is not known. W ha t va lue
should be use d to e stima te the 3-ye a r-old child’s we ight?
A. 8 kg
B. 10 kg
C. 12 kg
D. 14 kg
441. A 62-ye a r-old ma n unde rgoe s a n e me rge ncy cra niotomy for
subdura l he ma toma . Two ye a rs e a rlie r, a VVI pa ce ma ke r wa s
pla ce d for third-de gre e he a rt block. The pa tie nt re ce ive d
va ncomycin 1 g IV be fore a rriving in the OR. Ge ne ra l a ne sthe sia is
induce d with propofol 160 mg IV a nd the lungs a re hype rve ntila te d
to a Pa CO2 of 25 mm Hg by ma sk. Just be fore tra che a l intuba tion,
the pa tie nt’s he a rt ra te de cre a se s from 70 to 40 be a ts/min a nd the
pa ce ma ke r spike s tha t we re pre viously pre se nt in le a d II of the
e le ctroca rdiogra m disa ppe a r. The MOST like ly ca use of
bra dyca rdia in this pa tie nt is
A. Hypoca rbia
B. Va ncomycin a lle rgy
C. A side e ffe ct of propofol
D. Pa ce ma ke r ba tte ry fa ilure
442. A 28-ye a r-old obe se pa tie nt ha s diminishe d bre a th sounds
bila te ra lly a t the lung ba se s 18 hours a fte r a n e me rge ncy
a ppe nde ctomy unde r ge ne ra l a ne sthe sia . W hich of the following
ma ne uve rs would be LEAST e ffe ctive in pre ve nting postope ra tive
pulmona ry complica tions in this pa tie nt?
A. Coughing
B. Volunta ry de e p bre a thing
C. Pe rforming a force d vita l ca pa city (FVC)
D. Use of ince ntive spirome try
443. Be low wha t va lue of ce re bra l blood flow (CBF) will signs of
ce re bra l ische mia first be gin to a ppe a r on the
e le ctroe nce pha logra m (EEG)?
A. 6 mL/100 g/min
B. 15 mL/100 g/min
C. 22 mL/100 g/min
D. 31 mL/100 g/min
444. A 67-ye a r-old pa tie nt is me cha nica lly ve ntila te d in the ICU
2 da ys a fte r re pa ir of a rupture d a bdomina l a ortic a ne urysm. To
ma inta in Pa O2 in the 60 to 65 ra nge , 10 cm H2O positive e nd-
e xpira tory pre ssure (PEEP) is a dde d to the ve ntila tor cycle . The
pa tie nt’s blood pre ssure ha s a ve ra ge d 110/65 be fore a ddition of
PEEP. Afte r a ddition of PEEP, the blood pre ssure is note d to slowly
fa ll to a n a ve ra ge of a pproxima te ly 95/50. The be st e xpla na tion for
this de cre a se in blood pre ssure is
A. Te nsion pne umothora x
B. De cre a se d ve nous re turn to the he a rt
C. Incre a se d a fte rloa d on the right side of the he a rt
D. Incre a se d a fte rloa d on the le ft side of the he a rt
445. The me cha nism of a ction of clopidogre l is
A. Ade nosine diphospha te (ADP) re ce ptor blocka de (P2Y 12)
B. Pla te le t glycoprote in IIB/IIIa a nta gonism
C. Cyclooxyge na se COX-1 a nd COX-2 inhibition
D. Dire ct thrombin inhibition
446. W hich of the following is most close ly a ssocia te d with
minimum a lve ola r conce ntra tion (MAC)?
B. Oil/ga s pa rtition coe fficie nt
C. Va por pre ssure
D. Bra in/blood pa rtition coe fficie nt
447. A 15-ye a r-old, 65-kg pa tie nt with Cushing dise a se is to unde rgo
a tra nssphe noida l hypophyse ctomy to re move a pituita ry a de noma .
Ge ne ra l a ne sthe sia is induce d with propofol IV, a nd tra che a l
intuba tion is fa cilita te d with ve curonium 0.20 mg/kg IV. Ane sthe sia
is ma inta ine d with isoflura ne , N2O, a nd O2. Ma nnitol 1 g/kg is
a dministe re d IV to re duce intra cra nia l pre ssure . At the e nd of the
ope ra tion, the pa tie nt is e xtuba te d a nd ta ke n to the ICU. Ove r the
ne xt 6 hours the pa tie nt ha s a tota l urine output of 8.3 L. Se rum
sodium conce ntra tion is 154 mEq/L, se rum pota ssium conce ntra tion
is 4.8 mEq/L, a nd se rum glucose conce ntra tion is 160 mg/dL. Urine
spe cific gra vity is 1.002 a nd urine osmola lity is 125 mOsm/L. The
most like ly ca use of the la rge urine output is
A. Osmotic diure sis from ma nnitol
B. Exce ss mine ra locorticoid a ctivity
C. Hype rglyce mia
D. Ce ntra l dia be te s insipidus
448. Scopola mine should not be give n a s a pre me dica tion in
pa tie nts with which of the following ne urologic dise a se s?
A. Pa rkinson dise a se
B. Alzhe ime r dise a se
C. Multiple scle rosis
D. Na rcole psy
449. A 63-ye a r-old ma n is sche dule d to unde rgo a right
he micole ctomy unde r ge ne ra l a ne sthe sia . Ane sthe sia is induce d
with propofol 2 mg/kg IV a nd fe nta nyl 100 µg IV. Succinylcholine
1.5 mg/kg IV is a dministe re d to fa cilita te tra che a l intuba tion.
Ane sthe sia is ma inta ine d with isoflura ne a nd N2O. Afte r a ll four
twitche s of the tra in-of-four stimulus re turn to ba se line va lue s,
ve curonium 10 mg IV is a dministe re d. Ge nta micin 80 mg a nd
ce fa zolin 1 g a re a dministe re d IV a s a prophyla ctic tre a tme nt. At the
e nd of surge ry, two of four thumb twitche s ca n be e licite d to tra in-
of-four stimula tion of the ulna r ne rve , a nd ne uromuscula r blocka de
is a nta gonize d with ne ostigmine 0.05 mg/kg IV a nd a tropine
0.015 mg/kg IV. The pa tie nt, howe ve r, be gins to move be fore the
incision is comple te ly close d, a nd succinylcholine 40 mg IV is give n.
Fifte e n minute s la te r, a ll a ne sthe tics a re discontinue d a nd the
pa tie nt is ve ntila te d with 100% O2, but the pa tie nt re ma ins a pne ic.
The most like ly ca use of a pne a is
A. Fe nta nyl
B. Re cura riza tion
C. Succinylcholine
D. Ge nta micin
450. A 53-ye a r-old woma n with e ndome tria l ca nce r is unde rgoing a n
a bdomina l hyste re ctomy unde r ge ne ra l a ne sthe sia with de sflura ne .
During the first hour of a ne sthe sia , urine output is 100 mL. Blood
loss is minima l. W he n the pa tie nt is pla ce d in the Tre nde le nburg
position, the urine output de cline s to virtua lly ze ro. The most like ly
e xpla na tion for this sudde n de cre a se in urine output in this pa tie nt
is
A. Pooling of urine in the dome of the bla dde r
B. Incre a se d ce ntra l ve nous pre ssure
C. Incre a se d a ntidiure tic hormone (ADH) production from
surgica l stimula tion
D. Hypovole mia
451. W hich of the following dise a se s is NOT a ssocia te d with a
de cre a se in DLCO?
A. Emphyse ma
B. Obe sity
C. Pulmona ry e mboli
D. Ane mia
452. Ea ch of the following postope ra tive complica tions of thyroid
surge ry ca n re sult in uppe r a irwa y obstruction EXCEPT
A. Ce rvica l he ma toma
B. Te ta ny
C. Bila te ra l supe rior la rynge a l ne rve injury
D. Bila te ra l re curre nt la rynge a l ne rve injury
453. The MOST se nsitive e a rly sign of ma ligna nt hype rthe rmia
(MH) during ge ne ra l a ne sthe sia is
A. Ta chyca rdia
B. Hype rte nsion
C. Fe ve r
D. Incre a se d e nd-e xpira tory CO2 te nsion (P ECO2)
454. A 78-ye a r-old woma n is a ne sthe tize d for a right he micole ctomy
for 3 hours. At the e nd of the ope ra tion the pa tie nt’s blood pre ssure
is 130/85 mm Hg, he a rt ra te is 84 be a ts/min, core body te mpe ra ture
is 35.4° C, a nd P ECO2 on infra re d spe ctrome te r is 38 mm Hg. W hich
of the following would be the LEAST pla usible re a son for
prolonge d a pne a in this pa tie nt?
A. Re sidua l ne uromuscula r blocka de
B. Na rcotic ove rdose
C. Unre cognize d obstructive pulmona ry dise a se a nd high
ba se line Pa CO2
D. Pe rsiste nt intra ope ra tive hype rve ntila tion
455. A 68-ye a r-old woma n with se ve re rhe uma toid a rthritis
unde rgoe s pulmona ry function e va lua tion be fore a n e le ctive
a bdomina l surge ry. Force d e xpira tory volume in 1 se cond (FEV1)
a nd FVC a re within norma l limits; howe ve r, the ma ximum
volunta ry ve ntila tion (MVV) is only 40% of pre dicte d. The ne xt ste p
in the pulmona ry function e va lua tion of this pa tie nt should be to
A. Obta in ABGs on room a ir
B. Obta in a flow-volume loop
C. Obta in a me a sure me nt of pe a k flow
D. Obta in a ve ntila tion/pe rfusion sca n
456. W hich of the following is NOT a compone nt of the
posta ne sthe tic discha rge scoring syste m (PADSS) use d to e va lua te
the suita bility of a pa tie nt to be discha rge d from a n a mbula tory
surgica l fa cility?
A. Drinking
B. Ambula tion
C. Abse nce of na use a a nd vomiting
D. Pa in control
457. During e me rge ncy re pa ir of a ma ndibula r ja w fra cture in a n
othe rwise he a lthy 19-ye a r-old ma n, the pa tie nt’s te mpe ra ture is
note d to rise from 37° C on induction to 38° C a fte r 2 hours of
surge ry. W hich of the following informa tiona l ite ms would be
LEAST use ful in ruling out MH in this pa tie nt?
A. Norma l he a rt ra te a nd blood pre ssure
B. History of ne ga tive ca ffe ine -ha lotha ne contra cture te st ca rrie d
out 6 months e a rlie r
C. History of a n uncomplica te d ge ne ra l a ne sthe tic a t a ge 16 ye a rs
with ha lotha ne a nd succinylcholine
D. Norma l ABGs dra wn whe n the pa tie nt’s te mpe ra ture re a che d
38° C
458. W hich of the following drugs is use ful in the tre a tme nt of
a sthma by spe cifica lly inte rfe ring with the le ukotrie ne pa thwa y?
A. Flutica sone (Flove nt)
B. Ipra tropium bromide (Atrove nt)
C. Tria mcinolone (Azma cort)
D. Monte luka st (Singula ir)
459. A 68-ye a r-old, 100-kg pa tie nt is unde rgoing a tra nsure thra l
re se ction of the prosta te gla nd unde r ge ne ra l a ne sthe sia . Upon
a rriva l in the re cove ry room, the pa tie nt a ppe a rs re stle ss a nd
confuse d. Se rum sodium is che cke d a nd found to be 110 mEq/L.
How ma ny mEq of sodium a re ne e de d to ra ise the se rum [Na +] to
120 mEq/L?
A. 300 mEq
B. 400 mEq
C. 500 mEq
D. 600 mEq
460. Trismus a fte r a dministra tion of succinylcholine IV signa ls the
onse t of MH in wha t pe rce nta ge of pa tie nts?
A. Le ss tha n 50%
B. 50%
C. 75%
D. 85%
461. A 45-ye a r-old ma n is brought to the OR e me rge ntly for re pa ir of
a rupture d a bdomina l a ortic a ne urysm. Ane sthe sia is induce d with
ke ta mine 2 mg/kg IV, a nd tra che a l intuba tion is fa cilita te d with
succinylcholine 1.5 mg/kg IV. Imme dia te ly a fte r tra che a l intuba tion,
the pa tie nt’s blood pre ssure fa lls from 110/80 to 50/20 mm Hg. W ha t
is the MOST like ly ca use of the sudde n se ve re hypote nsion in this
pa tie nt?
A. Hypovole mia
B. Dire ct myoca rdia l de pre ssion from ke ta mine
C. Va sova ga l re sponse to dire ct la ryngoscopy
D. Arte riola r va sodila tion from succinylcholine -me dia te d
hista mine re le a se
462. MH is be lie ve d to involve a ge ne ra lize d disorde r of me mbra ne
pe rme a bility to
A. Sodium
B. Pota ssium
C. Ca lcium
D. Ma gne sium
463. A 25-ye a r-old ma n with a history of te sticula r ca nce r is
sche dule d to unde rgo a n e xplora tory la pa rotomy unde r ge ne ra l
a ne sthe sia . He ha s re ce ive d ble omycin for me ta sta tic dise a se .
W hich of the following is a n importa nt conside ra tion conce rning
the pulmona ry toxicity of ble omycin?
A. N2O should not be use d
B. Pre ope ra tive pulmona ry function te sts should be obta ine d
C. The pa tie nt should be ve ntila te d a t a slow ra te a nd
inspira tory-to-e xpira tory (I:E) ra tio of 1:3
D. F IO2 should be le ss tha n 0.3
464. A 39-ye a r-old obe se woma n unde rgoe s a n a bdomina l
hyste re ctomy unde r ge ne ra l a ne sthe sia . Induction of a ne sthe sia is
une ve ntful. Sa O2 is 98% during the first 15 minute s of the ope ra tion
with 50% oxyge n a nd 50% N2O. The n, a t the re que st of the surge on,
N2O is discontinue d (now 50% oxyge n, 50% N2), the he a d is fle xe d,
a nd the pa tie nt is pla ce d in the Tre nde le nburg position to improve
surgica l e xposure , a nd Sa O2 fa lls to 90%. The MOST like ly
e xpla na tion for this de sa tura tion is
A. Diffusion hypoxia
B. De cre a se d functiona l re sidua l ca pa city (FRC)
C. Ma inste m intuba tion
D. De cre a se d ca rdia c output
465. How long a fte r intra vitre a l inje ction of sulfur he xa fluoride a nd
a ir ca n N2O be use d without risk of incre a sing intra ocula r
pre ssure ?
A. 1 hour
B. 24 hours
C. 10 da ys
D. 1 month
466. A 54-ye a r-old woma n is unde rgoing a tota l thyroide ctomy unde r
ge ne ra l a ne sthe sia . The pa tie nt is a wa ke ne d in the OR, the mouth
a nd pha rynx a re suctione d, a nd a fte r inta ct la rynge a l re fle xe s a re
de monstra te d, the e ndotra che a l tube is re move d. Two da ys la te r,
the a ne sthe siologist is consulte d be ca use the pa tie nt ha s se ve re
stridor a nd uppe r a irwa y obstruction. The most like ly ca use of
a irwa y obstruction in this pa tie nt is
A. Da ma ge to the re curre nt la rynge a l ne rve
B. He ma toma
C. Tra che oma la cia
D. Hypoca lce mia
467. A 27-ye a r-old obe se woma n is sche dule d to unde rgo foot
surge ry unde r ge ne ra l a ne sthe sia . She unde rwe nt a subtota l
thyroide ctomy 3 ye a rs a go a nd ta ke s le vothyroxine (Synthroid).
W hich of the following la bora tory te sts would be the MOST use ful
in e va lua ting whe the r this pa tie nt is e uthyroid?
A. Tota l pla sma thyroxine (T 4)
B. Tota l pla sma triiodothyronine (T 3)
C. Thyroid-stimula ting hormone (TSH)
D. Re sin triiodothyronine upta ke
468. An 85-ye a r-old ma n with no pre vious me dica l history e xce pt for
ca ta ra cts is unde rgoing a tra nsure thra l re se ction of the prosta te
gla nd unde r spina l a ne sthe sia . Twe nty minute s into the proce dure
the pa tie nt be come s re stle ss. Ove r the ne xt 20 minute s, his blood
pre ssure incre a se s from 110/70 to 140/90 mm Hg a nd his he a rt ra te
slows from 90 to 50 be a ts/min. The pa tie nt is note d to ha ve some
difficulty bre a thing. The most like ly ca use of the se symptoms in this
pa tie nt is
A. Volume ove rloa d
B. Hypona tre mia
C. High spina l
D. Bla dde r pe rfora tion
469. A 17-ye a r-old pa tie nt with third-de gre e burns ove r 30% of his
body is sche dule d for dé bride me nt a nd skin gra fting 12 da ys a fte r
susta ining a the rma l injury. Se le ct the T RUE sta te me nt re ga rding
the use of de pola rizing a nd nonde pola rizing muscle re la xa nts in
this pa tie nt, compa re d with norma l pa tie nts.
A. Se nsitivity to both de pola rizing a nd nonde pola rizing muscle
re la xa nts is incre a se d
B. Se nsitivity to both de pola rizing a nd nonde pola rizing muscle
re la xa nts is de cre a se d
C. Se nsitivity to de pola rizing muscle re la xa nts is incre a se d while
se nsitivity to nonde pola rizing muscle re la xa nts is de cre a se d
D. Se nsitivity to de pola rizing muscle re la xa nts is de cre a se d while
se nsitivity to nonde pola rizing muscle re la xa nts is incre a se d
470. A pa tie nt unde rgoe s pa rotid gla nd re mova l unde r ge ne ra l
a ne sthe sia . Ea ch of the following a sse sse s fa cia l ne rve function
EXCEPT
A. Cle nching te e th
B. Closing e ye s
C. Pursing lips
D. Eye brow lift
471. A 65-ye a r-old pa tie nt with a history of chronic obstructive
pulmona ry dise a se a nd corona ry a rte ry dise a se (CAD) unde rgoe s a
la pa roscopic ne phre ctomy une ve ntfully unde r ge ne ra l de sflura ne
a ne sthe sia . In the re cove ry room, ABGs a re a s follows: Pa O2
60 mm Hg, Pa CO2 50 mm Hg, pH 7.35, a nd he moglobin 8.1 g/dL.
W hich of the following ste ps would produce the gre a te st incre a se
in O2 de live ry to the myoca rdium?
A. Administra tion of 100% O2 with a close -fitting ma sk
B. Administra tion of 35% O2 with a Ve nturi ma sk
C. Administe r 1 a mpule of HCO3
D. Tra nsfuse with 2 units of pa cke d re d blood ce lls (RBCs)
472. Alle rgic re a ctions occurring during the imme dia te pe riope ra tive
pe riod a re MOST commonly a ttributa ble to a dministra tion of
A. Muscle re la xa nts
B. Loca l a ne sthe tics
C. Antibiotics
D. Opioids
473. Ca ution is a dvise d whe n using succinylcholine in pa tie nts with
Huntington chore a be ca use
A. The y a re a t incre a se d risk for MH
B. Pota ssium re le a se ma y be e xce ssive
C. The y ma y ha ve a de cre a se d conce ntra tion of
pse udocholine ste ra se
D. The re ma y be a dve rse inte ra ctions be twe e n succinylcholine
a nd phe nothia zine
474. W hich of the following would NOT re sult in a n incre a se in
intra ocula r pre ssure ?
A. Incre a se in Pa CO2 from 35 to 40 mm Hg
B. 100 mg IM succinylcholine
C. Acute rise in ve nous pre ssure from coughing
D. 100 mg IV succinylcholine in a pa tie nt in whom e ye muscle s
ha ve be e n de ta che d from the globe
475. An a pne a -hypopne a inde x of 30 me a ns
A. Episode s of hypopne a a re 30 time s more common tha n a pne a
B. Apne a /hypopne a e pisode s occur a t a ra te of 30 pe r sle e p cycle
C. Episode s of a pne a a nd hypopne a occur a t a ra te of 30 pe r hour
D. Apne a /hypopne a e pisode s la st 30 se conds
476. W hich of the following pre ope ra tive pulmona ry function te sts
is NOT a ssocia te d with a n incre a se d ope ra tive risk for
pne umone ctomy?
A. FEV1 le ss tha n 50% of the FVC
B. FEV1 le ss tha n 2 L
C. Ma ximum bre a thing ca pa city le ss tha n 50% of pre dicte d
D. Re sidua l volume /tota l lung ca pa city (TLC) le ss tha n 50%
477. A 26-ye a r-old ma n is unde rgoing a n e me rge ncy e xplora tory
la pa rotomy unde r ge ne ra l a ne sthe sia with isoflura ne . Sa O2 is 89%
on the pulse oxime te r. Pa O2 on ABGs is 77 mm Hg. The pa tie nt’s
core body te mpe ra ture is 35° C. W ha t is the corre cte d Pa O2?
A. 68 mm Hg
B. 72 mm Hg
C. 77 mm Hg
D. 86 mm Hg
478. A 27-ye a r-old pa tie nt with a 10-ye a r history of Crohn dise a se is
sche dule d to unde rgo dra ina ge of a re cta l a bsce ss unde r ge ne ra l
a ne sthe sia . His pre ope ra tive me dica tions include pre dnisone ,
sulfa sa la zine , a nd cya nocoba la min. He ha s no known a lle rgie s a nd
is othe rwise he a lthy. Be fore induction of a ne sthe sia , the pa tie nt is
note d to ha ve ce ntra l cya nosis a nd the pulse oxime te r shows a n
Sa O2 of 89%, which doe s not incre a se a fte r the a dministra tion of
100% O2 for 2 minute s. ABGs a re a s follows: Pa O2 490 mm Hg,
Pa CO2 32 mm Hg, pH 7.43, Sa O2 89%. The MOST like ly ca use of
the se findings is
A. Pre se nce of sulfhe moglobin
B. Pre se nce of me the moglobin
C. Pre se nce of cya nhe moglobin
D. Pre se nce of ca rboxyhe moglobin
479. Low-mole cula r-we ight he pa rin (LMW H)
A. Is a s like ly to ca use he pa rin-induce d thrombocytope nia (HIT)
a s unfra ctiona te d he pa rin
B. Should be monitore d with pa rtia l thrombopla stin time (PTT)
for clinica l e ffe ct
C. Ca n be fully re ve rse d with prota mine
D. LMW H ha s a longe r pla sma ha lf-life tha n unfra ctiona te d
he pa rin
480. In a give n pa tie nt, if a cre a tinine of 1.0 corre sponds to a
glome rula r filtra tion ra te (GFR) of 120 mL/min, a cre a tinine of 4.0
would corre spond to
A. 20 mL/min
B. 30 mL/min
C. 40 mL/min
D. 50 mL/min
481. The incide nce of e a ch of the following is incre a se d in pa tie nts
with Down syndrome (trisomy 21) EXCEPT
A. Ma ligna nt hype rthe rmia
B. Conge nita l he a rt dise a se
C. Sma lle r tra che a
D. Occipito-a tla ntoa xia l insta bility
482. A 55-ye a r-old ma n is to unde rgo a la pa roscopic
chole cyste ctomy unde r ge ne ra l a ne sthe sia . The pa tie nt ha s a 40-
pa ck-pe r-ye a r smoking history a nd a history of CHF. The pa tie nt
re ce ive s me toclopra mide a nd scopola mine pre ope ra tive ly. Ge ne ra l
a ne sthe sia is induce d with ke ta mine , a nd the pa tie nt unde rgoe s
the proce dure une ve ntfully. Howe ve r, in the re cove ry room the
pa tie nt compla ins of not be ing a ble to se e obje cts “up close .”
W hich of the following would be the MOST like ly ca use of this
compla int?
A. Eme rge nce de lirium from ke ta mine a ne sthe sia
B. Effe ct of scopola mine
C. Effe ct of Tre nde le nburg position
D. Corne a l a bra sion
483. MH a nd ne urole ptic ma ligna nt syndrome sha re e a ch of the
following cha ra cte ristics EXCEPT
A. Ge ne ra lize d muscula r rigidity
B. Hype rthe rmia
C. Effe ctive ly tre a te d with da ntrole ne
D. Fla ccid pa ra lysis a fte r a dministra tion of ve curonium
484. A 23-ye a r-old ma n involve d in a motor ve hicle a ccide nt is
brought to the OR for ope n re duction a nd inte rna l fixa tion of
bila te ra l le g fra cture s unde r ge ne ra l a ne sthe sia . During the surge ry
the pa tie nt is tra nsfuse d with 7 units of type AB, Rh-ne ga tive
pa cke d RBCs a nd 3 units of pla te le ts. At the e nd of the proce dure ,
the e ndotra che a l tube is re move d a nd the pa tie nt is ta ke n to the
ICU. Postope ra tive ly, the pa tie nt compla ins of shortne ss of bre a th
a nd a rte ria l hypoxe mia is note d. His te mpe ra ture is 38° C, he a rt
ra te is 146 be a ts/min, blood pre ssure is 105/69 mm Hg, a nd
re spira tory ra te is 36 bre a ths/min. In a ddition, the pa tie nt is note d
to ha ve a fine pe te chia l ra sh on his ne ck, che st, a nd shoulde rs.
W hich of the following is the MOST like ly ca use of the se signs a nd
symptoms?
A. Pulmona ry e mbolism
B. Tra nsfusion re a ction to pa cke d RBCs
C. Tra nsfusion-re la te d a cute lung injury (TRALI re a ction)
D. Fa t e mbolism
485. Re mife nta nil is me ta bolize d prima rily by
A. Kidne ys
B. Live r
C. Nonspe cific e ste ra se s
D. Pse udocholine ste ra se
486. A te rm infa nt with good muscle tone a nd strong cry ha s a n 83%
sa tura tion on room a ir 5 minute s a fte r de live ry. The MOST
a ppropria te a ction a t this point would be
A. Ba g a nd ma sk ve ntila tion with 100% oxyge n
B. Intuba te a nd ve ntila te with 100% oxyge n
C. Sponta ne ous bre a thing with 100% oxyge n
D. Obse rve
487. Pa tie nts who unde rgo e xtra corpore a l shock wa ve lithotripsy
a re a t incre a se d risk for
A. Ve nous a ir e mbolism
B. Pne umothora x
C. Hypote nsion with re giona l a ne sthe sia a t the e nd of the
proce dure
D. Postdura l puncture he a da che with spina l a ne sthe sia
488. The most common re a son for a dmitting outpa tie nts to the
hospita l following ge ne ra l a ne sthe sia is
B. Ina bility to void
C. Ina bility to a mbula te
D. Surgica l pa in
489. A 37-ye a r-old ma n with mya sthe nia gra vis a rrive s in the
e me rge ncy room confuse d a nd a gita te d a fte r a 2-da y history of
we a kne ss a nd incre a se d difficulty bre a thing. ABGs on room a ir a re
Pa O2 60 mm Hg, Pa CO2 51 mm Hg, HCO3– 25 mEq/L, pH 7.3, Sa O2 of
90%. His re spira tory ra te is 30 bre a ths/min a nd tida l volume (VT) is
4 mL/kg. Afte r a dministra tion of e drophonium 2 mg IV, his VT
de cline s to 2 mL/kg. W ha t should be the most a ppropria te ste p in
the ma na ge me nt of this pa tie nt a t this time ?
A. Tra che a l intuba tion a nd me cha nica l ve ntila tion
B. Re pe a t the te st dose of e drophonium
C. Administe r ne ostigmine
D. Administe r a tropine for choline rgic crisis
490. Se le ct the FALSE sta te me nt re ga rding tra ma dol (Ultra m).
A. Onda nse tron ma y inte rfe re with pa rt of tra ma dol’s a na lge sia
B. Tra ma dol is a ssocia te d with se izure s in pa tie nts ta king
se le ctive se rotonin re upta ke inhibitors (SSRIs)
C. It is re la tive ly sa fe in pa tie nts whose pa in ma ke s the m
suicida l
D. Its a na lge sic e ffe cts a re pa rtia lly a nta gonize d by na loxone
491. In sta tistica l hypothe sis te sting, if the P va lue is le ss tha n the
pre de te rmine d α va lue , which of the following is most like ly?
A. The obse rve d re sult is unlike ly unde r the null hypothe sis
B. The obse rve d re sult is unlike ly unde r a n a lte rna tive
hypothe sis
C. The sa mple size is too sma ll
D. The pre de te rmine d powe r is too low
492. A 72-ye a r-old ma n unde rgoe s e me rge ncy re pa ir of a n
a bdomina l a ortic a ne urysm. In the first hour a fte r re le a se of the
supra re na l cross-cla mp, urine output is only 10 mL. Afte r
a dministra tion of furose mide 20 mg IV, urine output incre a se s to
100 mL/hr. Urine [Na +] is 43 mEq/L, a nd urine osmola lity is
210 mOsm/L. The MOST like ly ca use of the initia l oliguria is
A. Incre a se d ADH
B. Re na l hypope rfusion
C. Acute tubula r ne crosis
D. Impossible to diffe re ntia te
493. A he a lthy 25-ye a r-old ma n is a ne sthe tize d for a sa gitta l split
oste otomy. Ane sthe sia is induce d with propofol, hydromorphone ,
a nd ve curonium a nd ma inta ine d with 2.1% se voflura ne a nd 50%
N2O. Afte r induction, the nose is pre ppe d with 4% lidoca ine a nd 1%
phe nyle phrine , a nd the pa tie nt is intuba te d through the right na ris.
Be fore e me rge nce , the surge on pe rforms a bila te ra l infe rior
a lve ola r ne rve block. The pa tie nt is re ve rse d with ne ostigmine a nd
glycopyrrola te . W he n the pa tie nt a wa ke ns, he is note d to ha ve a n
8-mm pupil on the right a nd a 3-mm pupil on the le ft. Re sults of
physica l e xa mina tion a re othe rwise unre ma rka ble . The most like ly
e xpla na tion for the dila te d pupil is
A. Right ste lla te ga nglion block
B. Accide nta l introduction of lidoca ine into right e ye
C. Accide nta l introduction of phe nyle phrine into right e ye
D. Glycopyrrola te
494. A 40-ye a r-old ma n is unde rgoing a le ft inguina l he rnia re pa ir
unde r ge ne ra l a ne sthe sia in Sa n Die go, Ca lifornia . N2O is
a dministe re d a t 3 L/min, O2 a t 1 L/min, a nd isoflura ne a t 0.85%.
W ha t MAC is this pa tie nt re ce iving?
A. 0.8
B. 1.25
C. 1.50
D. 1.75
495. An othe rwise he a lthy 140-kg, 24-ye a r-old ma n is sche dule d for
voca l cord surge ry unde r ge ne ra l a ne sthe sia . W hich of the
following sta te me nts conce rning his ca rdia c output a t 140 kg
compa re d with his ca rdia c output a t his ide a l body we ight (70 kg) is
CORRECT ?
A. Ca rdia c output is the sa me
B. Ca rdia c output is incre a se d by 10%
C. Ca rdia c output is incre a se d by 50%
D. Ca rdia c output is double d
496. Fe noldopa m ma y be use d a s a n a lte rna tive to which of the
following?
A. Epine phrine
B. Phe nyle phrine
C. Sodium nitroprusside
D. Dopa mine
497. A 58-ye a r-old he mophilia c is sche dule d for tota l kne e
a rthropla sty. His fa ctor VIII le ve ls a re 35% of norma l. W hich of the
following would be the most a ppropria te the ra py be fore surge ry?
A. Administe r sufficie nt cryopre cipita te to ra ise fa ctor VIII le ve ls
to 50% norma l
B. Administe r fa ctor VIII conce ntra te s to a chie ve le ve ls of 100%
norma l
C. Tra nsfuse fre sh froze n pla sma until fa ctor VIII le ve ls a re 100%
norma l
498. A 16-ye a r-old boy whose ma te rna l uncle ha s he mophilia A is
sche dule d for wisdom tooth e xtra ction. W hich te st be low would be
the be st scre e ning te st for he mophilia A?
A. PTT
B. Prothrombin time (PT)
C. Thrombin time
D. Ble e ding time
499. The re a son four twitche s a re use d in the tra in-of-four to
de te rmine de gre e of ne uromuscula r blocka de ve rsus five (or more )
is
A. Compa rison of gre a te r tha n four twitche s is too difficult
B. Four twitche s inform the use r of the de gre e of blocka de in the
use ful clinica l ra nge (i.e ., 75%-100% blocka de )
C. Post-te ta nic fa cilita tion will be gin to a ppe a r a fte r four twitche s
D. The re would be no a dditiona l de cre me nt in twitch he ight a fte r
four twitche s
500. A 57-ye a r-old ma n is unde rgoing a right e ye e nucle a tion unde r
ge ne ra l a ne sthe sia . The pa tie nt ha s no history of ca rdia c dise a se .
During the ope ra tion, 5-mm ST-se gme nt e le va tion is note d on le a d
II a nd the pa tie nt de ve lops comple te he a rt block. The corona ry
a rte ry most like ly a ffe cte d is
A. Circumfle x corona ry a rte ry
B. Right corona ry a rte ry
C. Le ft ma in corona ry a rte ry
D. Le ft a nte rior de sce nding corona ry a rte ry
501. Ea ch of the following ma y incre a se MAC for vola tile
a ne sthe tics EXCEPT
A. Coca ine
B. Hype rthyroidism
C. Hype rna tre mia
D. Tricyclic a ntide pre ssa nts
502. A 37-ye a r-old pa tie nt with a history of ma nic-de pre ssive illne ss
is sche dule d to unde rgo surge ry for re mova l of a n intra me dulla ry
rod in the le ft tibia . W hich of the following sta te me nts re ga rding
pote ntia l untowa rd e ffe cts of lithium the ra py is NOT true ?
A. Long-te rm a dministra tion ma y be a ssocia te d with ne phroge nic
dia be te s insipidus
B. Administra tion of succinylcholine to pa tie nts tre a te d with
lithium ma y re sult in hype rka le mia
C. Long-te rm the ra py ma y be a ssocia te d with hypothyroidism
D. Dura tion of a ction of ve curonium ma y be prolonge d
503. Tre a tme nt of hypote nsion in a pa tie nt a ne sthe tize d for
re se ction of me ta sta tic ca rcinoid would be be st a ccomplishe d with
A. Epine phrine
B. Ephe drine
C. Va sopre ssin (DDAVP)
D. Octre otide
504. A 75-ye a r-old ma n is sche dule d to unde rgo e le ctive
orchie ctomy for prosta te ca nce r. The pa tie nt ha s se le cte d spina l
a ne sthe sia . W ha t is the minimum de rma toma l le ve l tha t must be
a chie ve d to ca rry out this ope ra tion?
A. T4
B. T10
C. L3
D. S1
505. A 31-ye a r-old pa tie nt ha s be e n in the ICU on a ve ntila tor for
24 hours a fte r a motor ve hicle a ccide nt. The pa tie nt doe s not ope n
his e ye s to a ny stimulus a nd ha s no ve rba l or motor re sponse . The
Gla sgow Coma Sca le corre sponding to this pa tie nt would be
A. 0
B. 1
C. 2
D. 3
506. Hypoglyce mia is more like ly to occur in the dia be tic surgica l
pa tie nt with which of the following dise a se s?
A. Re na l dise a se
B. Rhe uma toid a rthritis re quiring high-dosa ge pre dnisone
C. Chronic obstructive lung dise a se tre a te d with a te rbuta line
inha le r a nd a minophylline
D. Ma nic-de pre ssive disorde r tre a te d with lithium
507. W hich of the following is most like ly to be a ssocia te d with a
fa lse ly e le va te d Sa O2 a s me a sure d by pulse oxime try (dua l wa ve )?
A. He moglobin F
B. Ca rboxyhe moglobin
C. Me thyle ne blue dye
D. Fluore sce in dye
508. Se le ct the FALSE sta te me nt re ga rding clinica l pe rforma nce a nd
sle e p de priva tion
A. A pe riod of vulne ra bility ha s be e n ide ntifie d be twe e n 2 AM a nd
7 AM
B. The re is a n incre a se d incide nce of motor ve hicle a ccide nts in
post-ca ll house sta ff
C. W he n pa tie nt simula tion wa s use d to study sle e p de priva tion
in a ne sthe sia re side nts, no re duction in clinica l pe rforma nce
wa s de monstra ble
D. Afte r ince ption of re striction of re side nt work hours in July
2003, a re duction in pa tie nt de a th ra te s wa s shown to be le ss
in hospita ls with la rge numbe rs of re side nt physicia ns ve rsus
those with fe we r
509. Ga ba pe ntin (Ne urontin) a s use d in the tre a tme nt of chronic
pa in be longs to the sa me broa d cla ss of drugs a s
A. Ca rba ma ze pine
B. Imipra mine
C. Clonidine
D. Fluoxe tine (Proza c)
510. A 72-ye a r-old ma n with a history of smoking, hype rte nsion, a nd
CHF unde rgoe s a colonoscopy unde r se da tion. The night be fore the
proce dure , he took his bowe l pre p but omitte d his me toprolol a nd
lisinopril. At the e nd of the proce dure , his oxyge n sa tura tion is 83%
a nd blood pre ssure is 175/85 mm Hg, a nd the ECG shows sinus
rhythm with a he a rt ra te of 120. Ra le s a re e a sily he a rd in both lung
fie lds. The pa tie nt is intuba te d. Echoca rdiogra m shows 80%
e je ction fra ction (EF). W hich of the ite ms be low would be LEAST
he lpful in ma na ge me nt?
A. PEEP
B. Furose mide
C. Incre a se F IO2
D. Esmolol
511. A 47-ye a r-old morbidly obe se pa tie nt de ve lops bila te ra l
blindne ss (only a ble to pe rce ive light) a fte r a 6-hour, thre e -se gme nt
la mine ctomy a nd fusion. The pa tie nt re ce ive d 6 units of blood a nd
5 L of la cta te d Ringe r solution. A me a n a rte ria l blood pre ssure wa s
ma inta ine d a t 50 to 60 mm Hg. The MOST like ly structure involve d
in this visua l loss is
A. Ce ntra l re tina l a rte ry
B. Optic ne rve
C. Re tina
D. Ce re bra l corte x
512. Ea ch of the following sta te me nts re ga rding postope ra tive
shive ring is true EXCEPT
A. It ma y incre a se me ta bolism a nd oxyge n consumption
significa ntly
B. It ma y be tre a te d with me pe ridine
C. It ma y be tre a te d with drope ridol
D. It doe s not occur in the a bse nce of hypothe rmia
513. Ele ctroca rdiogra phic (ECG) cha nge s a ssocia te d with
hype rka le mia include
A. Incre a se d P wa ve a mplitude
B. Shorte ne d PR inte rva l
C. Na rrowe d a nd pe a ke d T wa ve s
D. Incre a se in U-wa ve a mplitude
514. A 24-ye a r-old is unde rgoing ope n re duction of a n a nkle fra cture
unde r ge ne ra l a ne sthe sia with se voflura ne , N2O, a nd O2 through a
la rynge a l ma sk a irwa y (LMA). Just a fte r the va porize r dia l is turne d
up to 2%, the pa tie nt be gins sponta ne ously bre a thing, but the
inspira tory va lve is not fully closing. The like ly re sult of this
(ma lfunctioning va lve ) is a n incre a se in the inspire d conce ntra tion
of
A. N2O
B. CO2
C. O2
515. Ea ch of the following is a ssocia te d with a crome ga lic pa tie nts
unde rgoing tra nssphe noida l hypophyse ctomy EXCEPT
A. Enla rge me nt of the tongue a nd e piglottis
B. Na rrowing of the glottic ope ning
C. Na sa l turbina te e nla rge me nt
D. Continuous positive a irwa y pre ssure (CPAP) should be use d
postope ra tive ly be ca use obstructive sle e p a pne a (OSA) is
common
516. Evide nce of a n a na phyla ctic re a ction to a tra curium 1 to 2 hours
a fte r the e pisode could be be st e sta blishe d by me a suring blood
le ve ls of
A. Trypta se
B. La uda nosine
C. Hista mine
D. Bra dykinin
517. W hich of the following findings is NOT consiste nt with a
dia gnosis of ma ligna nt hype rthe rmia ?
A. Pa CO2 150 mm Hg
B. MVO2 50 mm Hg
C. pH 6.9
D. Onse t of symptoms a n hour a fte r e nd of ope ra tion
518. A 52-ye a r-old busine ss e xe cutive unde rgoe s a ra dica l
re tropubic prosta te ctomy une ve ntfully unde r ge ne ra l isoflura ne
a ne sthe sia . He ta ke s fluoxe tine (Proza c) for de pre ssion. Upon
discha rge , which of the following a na lge sics would be the be st
choice for postope ra tive pa in ma na ge me nt in this pa tie nt?
A. Oxycodone plus a spirin (Pe rcoda n)
B. Hydrocodone with a ce ta minophe n (Vicodin)
C. Code ine with a ce ta minophe n (Tyle nol No. 3)
D. Hydromorphone (Dila udid)
519. Ane sthe sia is induce d in a 50-ye a r-old, 125-kg ma n for a nte rior
ce rvica l fusion. The pa tie nt is pla ce d on a ve ntila tor. Pe a k a irwa y
pre ssure is note d to be 20 cm H2O with O2 sa tura tion 99% on pulse
oxime te r. An hour la te r, the pe a k a irwa y pre ssure rise s to 40 cm
H2O a nd Pa CO2 is 38 mm Hg on infra re d spe ctrome te r a nd on O2
sa tura tion fa lls to 88%. Blood pre ssure a nd he a rt ra te a re
uncha nge d. The MOST like ly ca use of the se findings is
B. Thrombotic pulmona ry e mbolism
C. Te nsion pne umothora x
D. Ve nous a ir e mbolism
520. The pha se of live r tra nspla nta tion whe re the gre a te st de gre e
of he modyna mic insta bility is e xpe cte d is
A. Induction
B. Disse ction pha se
C. Anhe pa tic pha se
D. Re pe rfusion pha se
521. W hich of the following drugs is (a re ) like ly to prolong
nonde pola rizing ne uromuscula r blocka de ?
A. Pre dnisone
B. Diltia ze m
C. Clinda mycin
522. W hich of the fa ctors in a dults liste d be low is the stronge st
inde pe nde nt pre dictor of postope ra tive na use a a nd vomiting
(PONV) in most studie s?
A. Fe ma le ge nde r
B. History of PONV
C. History of migra ine s
D. History of ciga re tte smoking
523. Ne a r the e nd of a 3-hour cole ctomy, the surge on compla ins tha t
the pa tie nt is not re la xe d. Two twitch monitors pla ce d a t diffe re nt
loca tions show only one twitch of a tra in-of-four. Blood ga se s a re
re porte d to be pH 6.9, CO2 82, K 4.6. The most a ppropria te a ction
would be
A. Administe r more ve curonium
B. Administe r bica rbona te
C. Incre a se minute ve ntila tion
D. Administe r da ntrole ne
524. A 22-ye a r-old pa rturie nt is a ne sthe tize d for a n e me rge ncy
la pa roscopic chole cyste ctomy. She is in the twe nty-fourth we e k of
ge sta tion a nd re ce ive s ge ne ra l se voflura ne a ne sthe sia a nd ha s
re ce ive d rocuronium for muscle re la xa tion. Just be fore e me rge nce ,
muscle re la xa tion is re ve rse d with glycopyrrola te a nd ne ostigmine .
Thre e minute s la te r, the fe ta l he a rt ra te fa lls to 88 be a ts/min. The
most like ly ca use of this is
A. Fe ta l he a d compre ssion
B. Ute ropla ce nta l insufficie ncy
C. Fe ta l hypoxia
D. Re ve rsa l a ge nts
525. A 43-ye a r-old woma n with e nd-sta ge live r dise a se is a dmitte d
to the ICU. W hich the ra py is LEAST like ly to improve symptoms
a ssocia te d with he pa tic e nce pha lopa thy (HE)?
A. Amino a cid–rich tota l pa re nte ra l nutrition (TPN)
B. Ne omycin
C. La ctulose
D. Fluma ze nil
526. Ke torola c is contra indica te d in pa tie nts unde rgoing scoliosis
surge ry be ca use of
A. Re na l e ffe cts
B. Risk of postope ra tive he morrha ge
C. Effe cts on bone he a ling
D. Effe cts on pulmona ry function
527. Ca use s of sickling in pa tie nts with sickle ce ll a ne mia include
a ll of the following EXCEPT
A. Inha le d nitric oxide
B. De hydra tion
D. Hypothe rmia
528. W hich of the following fa ctors is the gre a te st pre dictor of sle e p
a pne a s in a n a dult?
A. Ne ck circumfe re nce
B. Microgna thia
C. We ight
D. Body ma ss inde x (BMI)
529. The gre a te st numbe r of ma lpra ctice cla ims ma de a ga inst
a ne sthe siologists (a ccording to the Ame rica n Socie ty of
Ane sthe siologists [ASA] close d cla ims ta sk force ) is a ssocia te d with
which a dve rse outcome ?
A. Eye injury
B. Bra in da ma ge
C. Ne rve da ma ge
D. De a th
530. Re synchroniza tion the ra py
A. Is indica te d for short QRS comple xe s
B. Is contra indica te d in pa tie nts with corona ry a rte ry dise a se
C. Re quire s pa ce ma ke r impla nta tion
D. Is usua lly a ccomplishe d with bipha sic de fibrilla tor
531. The unde rlying fe a ture in pa tie nts with syndrome X is
A. Hype rte nsion
B. Morbid obe sity
C. Hypoglyce mia
D. Insulin re sista nce
532. A 65-ye a r-old hospita lize d pa tie nt is be ing tre a te d for pa in from
pa ncre a tic ca nce r a nd is we ll controlle d on 30 mg IV morphine pe r
da y. W ha t is the e quiva le nt tota l ora l da ily dosa ge of morphine in
this pa tie nt for discha rge pla nning?
A. 10 mg
B. 30 mg
C. 90 mg
D. 120 mg
533. A 64-ye a r-old pa tie nt is brought to the posta ne sthe sia ca re unit
a fte r a 7-hour cosme tic surge ry ope ra tion unde r 1.7% se voflura ne
a ne sthe sia for the e ntire ca se . W hich of the following de scribe s the
se voflura ne conce ntra tion in the ve sse l-rich group (VRG), the
muscle group (MG), a nd the fa t or ve sse l-poor group (VPG)
imme dia te ly a fte r the va porize r is turne d off?
A. VRG: fa lling, MG: fa lling, VPG: rising
B. VRG: fa lling, MG: rising, VPG: rising
C. VRG: rising, MG: fa lling, VPG: fa lling
D. All thre e compa rtme nts (VRG, MG, a nd VPG) fa lling
534. Ha za rds of O2 a dministra tion include
A. Re tinopa thy of pre ma turity
B. Bronchopulmona ry dyspla sia
C. Adsorption a te le cta sis
535. W hich of the following ne rve s is NOT de rive d from a cra nia l
ne rve ?
A. Gre a t a uricula r
B. Infra orbita l
C. Supra trochle a r
D. Supra orbita l
536. A 45-ye a r-old woma n is e xpe rie ncing progre ssive me nta l
de te riora tion ove r a 6-hour pe riod, 5 da ys a fte r e me rge ncy
e va cua tion of a la rge suba ra chnoid he morrha ge a nd clipping of a
middle ce re bra l a rte ry a ne urysm. The MOST like ly ca use for
de te riora tion is
A. Ce re bra l e de ma
B. Imprope r pla ce me nt of the a ne urysm clip
C. Re curre nt ce re bra l he morrha ge
D. Va sospa sm
537. The pe riod of vulne ra bility a fte r thre e course s of ble omycin for
te sticula r ca nce r is
A. 1 month
B. 1 ye a r
C. Life long
D. No vulne ra bility with just thre e course s
538. The most common a dve rse ca rdia c e ve nt in the pe dia tric
popula tion is
A. Hypote nsion
B. Bra dyca rdia
C. Ta chyca rdia
D. Bige miny
539. Ea ch of the following is a pre dictor of difficulty with ma sk
ve ntila tion EXCEPT
A. Pre se nce of be a rd
B. BMI gre a te r tha n 26
C. Pre se nce of te e th
D. Age gre a te r tha n 55
540. In a pa tie nt with compa rtme nt syndrome , which of the
following signs would be the la st to a ppe a r?
A. Pulse le ssne ss
B. Pa in
C. Pa re sthe sia
D. Pa ra lysis
541. Se le ct the T RUE sta te me nt re ga rding the dose pe r kilogra m of
body we ight a nd dura tion, re spe ctive ly, of loca l a ne sthe tics for
spina ls in infa nts compa re d with a dults.
A. Gre a te r dose a nd longe r dura tion
B. Gre a te r dose a nd shorte r dura tion
C. Gre a te r dose a nd dura tion is the sa me
D. Sma lle r dose a nd longe r dura tion
542. A numbe r 6 e ndotra che a l tube indica te s which size ?
A. 6-mm inte rna l dia me te r (ID)
B. 6-mm e xte rna l dia me te r
C. 6-mm e xte rna l circumfe re nce
D. 6-mm inte rna l circumfe re nce
543. If a pa tie nt we re to be come tra ppe d in the ma gne tic re sona nce
ima ging (MRI) sca nne r by a me ta l obje ct a nd the e ngine e rs de cide d
to que nch the ma gne t, the gre a te st ha za rd to the pa tie nt would be
A. He a t
B. Cold
C. Fire
D. Noise
544. A 25-ye a r-old bla ck ma n is brought to the e me rge ncy room
unconscious. Supple me nta l oxyge n is a dministe re d, a nd a pulse
oxime te r is pla ce d on his finge r a nd a re a ding of 98% is re corde d.
Arte ria l ga s sa mpling a t the sa me time shows Pa O2 of 190 mm Hg,
pH 7.2, a nd O2 sa tura tion of 90%. Pre se nce of which of the
following could e xpla in the discre pa ncie s be twe e n the se two
re a dings?
A. Me the moglobin (Hb Me t)
B. Sickle ce ll he moglobin
C. Ca rboxyhe moglobin (HbCO)
D. He moglobin shifte d to right
545. During surge ry for corre ction of scoliosis, soma tose nsory
e voke d pote ntia l (SSEP) monitoring is e mploye d. An incre a se in
SSEP la te ncy a nd a de cre a se in a mplitude could be e xpla ine d by
e a ch of the following EXCEPT
A. Ante rior spina l a rte ry syndrome
B. Propofol infusion (200 µg/kg/min)
C. Hypote nsion
D. 2 MAC isoflura ne a ne sthe sia
546. In which of the following conditions would the re sponse to
a tropine be MOST pronounce d?
A. Dia be tic a utonomic ne uropa thy
B. Bra in de a th
C. Sta tus post he a rt tra nspla nt
D. High (C8) spina l a ne sthe sia

Questions 547-554:
547. Skin le sions a ll a ppe a r a t the sa me sta ge a nd a t the sa me time
548. Ciprofloxa cin for 60 da ys is prophyla xis for e xpose d pa tie nts
549. Not conta gious
550. Tre a tme nt ma y include stre ptomycin, ge nta micin, or
te tra cycline
551. Tre a tme nt include s triva le nt e quine a ntitoxin
552. Thre e prima ry type s: cuta ne ous, ga strointe stina l, a nd
inha la tion
553. Va ccine ma y pre ve nt or gre a tly a tte nua te symptoms if give n
within 4 da ys of e xposure
554. He morrha gic fe ve r
A. Sma llpox
B. Anthra x
C. Pla gue
D. Botulism
E. Ebola virus
Questions 555-560:
555. De cre a se d FEV1/FVC ra tio
556. De cre a se d tota l pulmona ry complia nce
557. Incre a se d TLC
558. De cre a se d FRC
559. De cre a se d FEV1, norma l FEV1/FVC ra tio
560. Incre a se d lung complia nce due to loss of e la stic re coil of the
lung
A. Pulmona ry e mphyse ma
B. Chronic bronchitis
C. Re strictive pulmona ry dise a se
D. Pulmona ry e mphyse ma a nd chronic bronchitis
E. Pulmona ry e mphyse ma a nd re strictive pulmona ry dise a se
Questions 561-566:
561. We a kne ss of a ll muscle s be low the kne e
562. Footdrop; loss of dorsa l e xte nsion of the toe s
563. We a kne ss of the muscle s tha t e xte nd the kne e
564. Ina bility to a dduct the le g; diminishe d se nsa tion ove r the
me dia l side of the thigh
565. Most commonly ca use d by pla ce me nt of pa tie nt into the
lithotomy position
566. Numbne ss ove r the la te ra l a spe ct of the thigh
A. Scia tic ne rve injury
B. Common pe rone a l ne rve injury
C. Fe mora l ne rve injury
D. Obtura tor ne rve injury
E. La te ra l fe mora l cuta ne ous ne rve injury
General Anesthesia
418. (B) Pa tie nts with insulin-de pe nde nt dia be te s a nd non–insulin-
de pe nde nt dia be te s re quire spe cia l conside ra tion whe n pre se nting
for surge ry. Ge ria tric a ge pa tie nts come to the OR in the fa sting
sta te a nd without ha ving ta ke n the ir morning dose of the ir ora l
dia be tic a ge nt. Chlorpropa mide is the longe st-a cting sulfonylure a
a nd ha s a dura tion of a ction up to 72 hours. Accordingly, it is
prude nt to me a sure se rum glucose be fore inducing a ne sthe sia a nd
pe riodica lly during the course of the a ne sthe tic a nd surge ry.
Re gula r insulin ha s a pe a k e ffe ct 2 to 3 hours a fte r SQ
a dministra tion a nd a dura tion of a ction a pproxima te ly 6 to 8 hours
a nd would the re fore not ca use a se rum glucose of 35 mg/dL
24 hours a fte r it wa s a dministe re d (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 479, 483–484).
419. (D) Dibuca ine is a n a mide -type loca l a ne sthe tic tha t inhibits
norma l pse udocholine ste ra se by a pproxima te ly 80%. In pa tie nts
who a re he te rozygous for a typica l pse udocholine ste ra se , e nzyme
a ctivity is inhibite d by 40% to 60%. In pa tie nts who a re homozygous
for a typica l pse udocholine ste ra se , e nzyme a ctivity is inhibite d by
only 20%. The dibuca ine numbe r is a qua lita tive a sse ssme nt of
pse udocholine ste ra se . Qua ntita tive a s we ll a s qua lita tive
de te rmina tion of e nzyme a ctivity should be ca rrie d out in a ny
pa tie nt who is suspe cte d of ha ving a pse udocholine ste ra se
a bnorma lity (Miller: Basics of Anesth esia, ed 6, p 149).
420. (D) All hypote nsion ca n be broa dly broke n down into two ma in
ca te gorie s: de cre a se d ca rdia c output a nd de cre a se d syste mic
va scula r re sista nce . Flow or ca rdia c output ca n be furthe r
subdivide d into proble ms re la te d to de cre a se d he a rt ra te (i.e .,
bra dyca rdia ve rsus proble ms re la te d to de cre a se s in stroke
volume ). Norma l P O2 in mixe d ve nous blood is 40 mm Hg.
Incre a se d mixe d ve nous a rte ria l oxyge n le ve ls ca n be due to ma ny
conditions including high ca rdia c output, se psis, le ft-to-right ca rdia c
shunts, impa ire d pe riphe ra l upta ke (e .g., cya nide ), a nd de cre a se d
oxyge n consumption (e .g., hypothe rmia ), a s we ll a s sa mpling e rror.
The othe r choice s in this que stion a ll re pre se nt conditions whe re by
ca rdia c output is diminishe d a nd conse que ntly would not be
consiste nt with the da ta give n in the que stion (Butterworth : Morgan &
421. (C) Tra che a l ca pilla ry a rte riola r pre ssure (25-35 mm Hg) is
importa nt to ke e p in mind in pa tie nts who a re intuba te d with
cuffe d e ndotra che a l tube s. If the e ndotra che a l tube cuff e xe rts a
pre ssure gre a te r tha n ca pilla ry a rte riola r pre ssure , tissue ische mia
ma y re sult. Pe rsiste nt ische mia ma y le a d to de struction of tra che a l
rings a nd tra che oma la cia . Endotra che a l tube s with low-pre ssure
cuffs a re re comme nde d in pa tie nts who a re to be intuba te d for
pe riods longe r tha n 48 hours be ca use this will minimize the
cha nce s for de ve lopme nt of tissue ische mia (Miller: Miller’s
422. (C) Enoxa pa rin, da lte pa rin, a nd a rde pa rin a re low-mole cula r-
we ight he pa rins (LMW Hs). Be ca use of the possibility of spina l a nd
e pidura l he ma toma in the a nticoa gula te d pa tie nt with ne ura xia l
blocka de , ca ution is a dvise d. The pla sma ha lf-life of LMW H is two
to four time s longe r tha n sta nda rd he pa rin. The se drugs a re
commonly use d for prophyla xis for de e p ve in thrombosis. The se
drugs a re a lso use d a t high dose s for tre a tme nt of de e p ve in
thrombosis a nd (off la be l) a s “bridge the ra py” for pa tie nts
chronica lly a nticoa gula te d with wa rfa rin (Couma din). In the se
pa tie nts who a re be ing pre pa re d for surge ry, Couma din is
discontinue d a nd LMW H sta rte d. W ith high-dose e noxa pa rin
a dministra tion (1 mg/kg twice da ily), it is re comme nde d to wa it a t
le a st 24 hours be fore a dministra tion of a single -shot spina l
a ne sthe tic (Miller: Miller’s Anesth esia, ed 8, p 1691; Barash : Clinical
Anesth esia, ed 7, p 929; Th ird Consensus Conference on Neurax ial
Anesth esia and Anticoagulation, Jan-Feb 2010;
h ttp://www.asra.com /publications-anticoagulation-3rd -ed ition-2010.ph p).
423. (A) The principa l me cha nism of pe riphe ra l ne rve injury is
ische mia ca use d by stre tching or compre ssion of the ne rve s.
Ane sthe tize d pa tie nts a re a t incre a se d risk for pe riphe ra l ne rve
injurie s be ca use the y a re unconscious a nd una ble to compla in
a bout uncomforta ble positions tha t a n a wa ke pa tie nt would not
tole ra te a nd be ca use of re duce d muscle tone tha t fa cilita te s
pla ce me nt of pa tie nts into a wkwa rd positions. The ulna r ne rve in
pa rticula r is vulne ra ble be ca use it pa sse s a round the poste rior
a spe ct of the me dia l e picondyle of the hume rus. The ulna r ne rve
ma y be come compre sse d be twe e n the me dia l e picondyle a nd the
sha rp e dge of the ope ra ting ta ble , le a ding to ische mia a nd possible
ne rve injury, which ma y be tra nsie nt or pe rma ne nt (Miller: Basics of
424. (A) The ora lly a dministe re d prodrug code ine (me thylmorphine )
must be me ta bolize d to morphine in orde r to work. About 7% to
10% of white pa tie nts ha ve a n ina ctive va ria nt of the e nzyme
CYP2D6, which is the e nzyme ne e de d to me ta bolize code ine . In
the se pa tie nts, a s we ll a s in pa tie nts who ha ve the norma l e nzyme
but the e nzyme is inhibite d (e .g., coa dministra tion of quinidine ),
code ine doe s not produce a na lge sia but morphine will produce the
e xpe cte d a na lge sia . The CYP2D6 e nzyme is a lso ne e de d to
me ta bolize oxycodone into oxymorphone a nd hydrocodone into
hydromorphone . In a ddition, some pa tie nts ha ve a polymorphism
form of CYP2D6 tha t re sults in ve ry ra pid me ta bolism of code ine
a nd ca n re sult in morphine toxicity (Miller: Miller’s Anesth esia, ed 8,
pp 574–575).
425. (D) Pa tie nts who ha ve unde rgone pe rcuta ne ous corona ry
inte rve ntion (PCI) with a nd without ste nts re quire dua l a ntipla te le t
the ra py (usua lly a spirin a nd clopidogre l) to pre ve nt re ste nosis or
a cute thrombosis a t the site of the ste nt, ofte n for the pa tie nt’s
life time . Ce ssa tion of the se drugs should be re vie we d with the
pa tie nt’s ca rdiologist. In ge ne ra l, if the e le ctive surgica l proce dure
ma y involve ble e ding, the e le ctive proce dure is de la ye d for a t le a st
2 we e ks a fte r ba lloon a ngiopla sty without a ste nt, 6 we e ks a fte r a
ba re -me ta l ste nt, a nd 12 months a fte r a drug-e luting ste nt ha s be e n
pla ce d. The n the clopidogre l is stoppe d a nd re sta rte d a s soon a s
possible a fte r the surge ry (a spirin is usua lly continue d). In a n
e me rge ncy situa tion a nd whe n the pa tie nt is ta king clopidogre l,
pla te le t tra nsfusion ma y be ne e de d (e ffe ctive ne ss of pla te le ts
de pe nds on the la st dose of clopidogre l—pla te le ts a re e ffe ctive
a fte r 4 hours but much be tte r 24 hours a fte r the la st dose of
clopidogre l) (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 13-–14; Miller: Basics of Anesth esia, ed 6, pp 168–170).
426. (C) Blood flow to the re tina ca n be de cre a se d by e ithe r a
de cre a se in me a n a rte ria l pre ssure or a n incre a se in intra ocula r
pre ssure . De cre a se d blood flow a nd sta sis a re more like ly in
pa tie nts with gla ucoma be ca use of the ir e le va te d intra ocula r
pre ssure . During pe riods of prolonge d hypote nsion, the incide nce
of re tina l a rte ry thrombosis incre a se s in the se pa tie nts (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 253-–254; Miller:
427. (D) Na loxone (Na rca n) is a compe titive inhibitor a t a ll opioid
re ce ptors but ha s the gre a te st a ffinity for µ re ce ptors. Its dura tion of
a ction is re la tive ly short (e limina tion ha lf-life of a bout 1 hour). For
this re a son, one must be vigila nt for the possibility of
re na rcotiza tion whe n re ve rsing long-a cting na rcotics. Na ltre xone
(Re Via ) is the N-cyclopropylme thyl de riva tive of oxymorphone with
a long e limina tion ha lf-life of 8 to 12 hours. It is curre ntly a va ila ble
only a s a n ora l pre pa ra tion a nd is use d to block the e uphoric
e ffe cts of inje cte d he roin in a ddicts who ha ve be e n pre viously
de toxifie d. Na lme fe ne (Re ve x) is a nothe r opioid a nta gonist tha t ca n
be a dministe re d ora lly or pa re nte ra lly a nd ha s a n e xtre me ly long
dura tion of a ction (e limina tion te rmina l ha lf-life of 8.5 hours) (Miller:
Miller’s Anesth esia, ed 8, pp 906–907; Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, p 290).
428. (A) In the re cove ry room, the most common ca use of
postope ra tive hypoxe mia is a n une ve n ve ntila tion/pe rfusion
distribution ca use d by loss of lung volume re sulting from sma ll
a irwa y colla pse a nd a te le cta sis. Risk fa ctors for
ve ntila tion/pe rfusion misma tch in the postope ra tive pe riod include
old a ge , obstructive lung dise a se , obe sity, incre a se d intra -
a bdomina l pre ssure , a nd immobility. Supple me nta l oxyge n should
be a dministe re d to ke e p the Pa O2 in the 80 to 100 mm Hg ra nge ,
which is a ssocia te d with a 95% sa tura tion of he moglobin. Othe r
me a sure s ca n be ta ke n to re store lung volume , which include
re cove ring obe se pa tie nts in the sitting position, coughing, a nd
de e p bre a thing (Barash : Clinical Anesth esia, ed 7, pp 1566–1567).
429. (D) Airwa y obstruction a fte r tota l thyroide ctomy ma y be ca use d
by a postope ra tive he ma toma , compre ssion of the tra che a ,
tra che oma la cia , bila te ra l re curre nt la rynge a l ne rve da ma ge , or
hypoca lce mia re sulting from ina dve rte nt re mova l of the pa ra thyroid
gla nds. Although the a irwa y symptoms of hypoca lce mia ca n
de ve lop a s e a rly a s 1 to 3 hours a fte r surge ry, the y typica lly do not
de ve lop until 24 to 72 hours postope ra tive ly. Be ca use the la rynge a l
muscle s a re pa rticula rly se nsitive to hypoca lce mia , e a rly symptoms
ma y include inspira tory stridor, la bore d bre a thing, a nd e ve ntua l
la ryngospa sm. The ra py consists of IV a dministra tion of ca lcium
glucona te or ca lcium chloride (Miller: Basics of Anesth esia, ed 6, p 634;
Barash : Clinical Anesth esiology, ed 7, p 1330).
430. (A) Da ma ge to the ra dia l ne rve is ma nife ste d by we a kne ss in
a bduction of the thumb, ina bility to e xte nd the
me ta ca rpopha la nge a l joints, wrist drop, a nd numbne ss in the
we bbe d spa ce be twe e n the thumb a nd inde x finge rs. The ra dia l
ne rve pa sse s a round the hume rus be twe e n the middle a nd lowe r
portions in the spira l groove poste riorly. As it wra ps a round the
bone , the ra dia l ne rve ca n be come compre sse d be twe e n it a nd the
OR ta ble , re sulting in ne rve injury (Barash : Clinical Anesth esia, ed 7,
pp 808, 949).
431. (D) Bronchie cta sis is one of se ve ra l obstructive lung dise a se s
cha ra cte rize d by a diminishe d FEV1 whe n pulmona ry function is
e va lua te d. It is cha ra cte rize d by pe rma ne ntly dila te d bronchi tha t
fre que ntly conta in purule nt se cre tions. The a ffe cte d bronchi a re
ofte n highly va scula rize d, giving rise to the possibility of
he moptysis. Colla te ra l circula tion through the inte rcosta l a nd
bronchia l a rte rie s is a lso possible in the se pa tie nts. If the se ve sse ls
conne ct with the pulmona ry circula tion, pulmona ry hype rte nsion
a nd e ve ntua l cor pulmona le a re possible se que la e . Any pa tie nt
with chronic bronchia l infe ctions ma y de ve lop bronchie cta sis
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 195–196).
432. (D) Drugs tha t block dopa mine re ce ptors ma y ca use a cute
dystonic re a ctions in some pa tie nts. The incide nce with drope ridol
is a bout 1%. Tre a tme nt is the a dministra tion of a drug tha t crosse s
the blood-bra in ba rrie r with a nticholine rgic prope rtie s such a s
diphe nhydra mine or be nza tropine . Although glycopyrrola te is a n
a nticholine rgic drug, it would not be use ful in this se tting be ca use it
doe s not cross the blood-bra in ba rrie r (Miller: Miller’s Anesth esia, ed
8, p 2963; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, p 414).
433. (C) The me dia n ne rve is most fre que ntly injure d a t the
a nte cubita l fossa by e xtra va sa tion of IV drugs tha t a re toxic to
ne ura l tissue , or by dire ct injury ca use d by the ne e dle during
a tte mpts to ca nnula te the me dia l cubita l or ba silic ve ins. The
me dia n ne rve provide s se nsory inne rva tion to the pa lma r surfa ce
of the la te ra l thre e a nd one -ha lf finge rs a nd a dja ce nt pa lm, a nd
motor function to the a bductor pollicis bre vis, fle xor pollicis bre vis,
a nd oppone ns pollicis muscle s (Miller: Basics of Anesth esia, ed 6, p
313).
434. (D) Phe ochromocytoma is a n e ndocrine tumor (with re le a se of
ca te chola mine s) in which 90% of pa tie nts a re hype rte nsive , 90% of
the tumors origina te in one a dre na l me dulla , a nd 90% of a ll
phe ochromocytoma s a re be nign. This dise a se is ra re (<0.1% of
hype rte nsion in a dults), but whe n it occurs, it is ofte n se e n with a
tria d of dia phore sis, ta chyca rdia , a nd he a da che in pa tie nts with
hype rte nsion. Othe r symptoms include pa lpita tions, tre mulousne ss,
we ight loss, hype rglyce mia , hypovole mia , a nd in some ca se s
dila te d ca rdiomyopa thy a nd CHF. De a th a s a re sult of
phe ochromocytoma is due to ca rdia c conditions (e .g., myoca rdia l
infa rction, CHF) or a n intra cra nia l ble e d. In a bout 5% of ca se s,
phe ochromocytoma s show a n a utosoma l domina nt pa tte rn a nd
ma y coe xist with othe r e ndocrine dise a se s such a s me dulla ry
ca rcinoma of the thyroid a nd hype rpa ra thyroidism. This
combina tion is ca lle d multiple e ndocrine ne opla sia (MEN) type II or
IIA (Sipple syndrome ). MEN type IIB consists of phe ochromocytoma ,
me dulla ry ca rcinoma of the thyroid, a nd ne uroma s of the ora l
mucosa . The von Hippe l-Linda u dise a se consists of he ma ngioma s
of the ne rvous syste m (i.e ., re tina or ce re be llum), a nd 10% to 25% of
the se pa tie nts a lso ha ve a phe ochromocytoma . The a ve ra ge -size d
phe ochromocytoma conta ins 100 to 800 mg of nore pine phrine
(Barash : Clinical Anesth esia, ed 7, pp 1339–1340; Hines: Stoelting’s
435. (D) Ora l a ge nts tha t a re use d to he lp control hype rglyce mia in
type 2 dia be tic pa tie nts (re la tive β-ce ll insufficie ncy a nd insulin
re sista nce ) include four ma jor drug cla sse s:
1. Drugs tha t stimula te insulin se cre tion (hypoglyce mia is a risk)
a . sulfonylure a s
i. first-ge ne ra tion (chlorpropa mide , tola za mide , tolbuta mide )
ii. se cond-ge ne ra tion (glime piride , glipizide , glyburide )
b. me glitinide s (re pa glinide , na te glinide )
2. Drugs tha t de cre a se he pa tic glucone oge ne sis (hypoglyce mia not
a risk)
a . bigua nide s (me tformin)
3. Drugs tha t improve insulin se nsitivity (hypoglyce mia not a risk)
a . thia zolidine dione s (rosiglita zone , pioglita zone )
b. glita zone s
4. Drugs tha t de la y ca rbohydra te a bsorption (hypoglyce mia not a
risk)
a . α-glucosida se inhibitors (a ca rbose , miglitol)
Only drugs tha t stimula te insulin se cre tion a re a risk for producing
hypoglyce mia .
Initia l the ra py is usua lly with se cond-ge ne ra tion sulfonylure a s
(more pote nt a nd fe we r side e ffe cts tha n first-ge ne ra tion
sulfonylure a s) or with a bigua nide (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1255–1270; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 376–380;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
481–485).
436. (C) Although e a rly mild symptoms of a lcohol withdra wa l ca n
be se e n within 6 to 8 hours a fte r a substa ntia l drop in the se rum
a lcohol le ve ls, DTs, which is se e n in a bout 5% of pa tie nts, is a life -
thre a te ning me dica l e me rge ncy tha t de ve lops 2 to 4 da ys a fte r the
ce ssa tion of a lcohol in a lcoholics. Symptoms of DTs include
ha llucina tions, comba tive ne ss, hype rthe rmia , ta chyca rdia ,
hype rte nsion or hypote nsion, a nd gra nd ma l se izure s. Tre a tme nt of
se ve re a lcohol withdra wa l consists of fluid re pla ce me nt,
e le ctrolyte re pla ce me nt, a nd IV vita min a dministra tion with
pa rticula r a tte ntion pa id to thia mine . Aggre ssive a dministra tion of
be nzodia ze pine s is indica te d to pre ve nt se izure s (5-10 mg of
dia ze pa m e ve ry 5 minute s until the pa tie nt be come s se da te d but
not unconscious). β-Blocke rs a re use d to suppre ss ove ra ctivity of
the sympa the tic ne rvous syste m, a nd lidoca ine ma y be e ffe ctive in
the tre a tme nt of ca rdia c dysrhythmia s (Hines: Stoelting’s Anesth esia
and Co-Ex isting Disease, ed 6, p 544).
437. (A) Ope ra tions on the tra che a ma y be indica te d in pa tie nts
who ha ve tra che a l tumors or pa tie nts who ha d a pre vious tra uma
to the tra che a re sulting in tra che a l ste nosis or tra che oma la cia .
Eighty pe rce nt of the ope ra tions on the tra che a involve se gme nta l
re se ction with prima ry a na stomosis, 10% involve re se ction with
prosthe tic re construction, a nd a nothe r 10% involve inse rtion of a T-
tube ste nt. The se ope ra tions fre que ntly a re ve ry complica te d a nd
re quire consta nt communica tion be twe e n the surge on a nd the
a ne sthe siologist. Pre ope ra tive pulmona ry function te sts a re
indica te d in a ll pa tie nts who a re to unde rgo e le ctive tra che a l
re se ction. Se ve re lung dise a se ne ce ssita ting postope ra tive
me cha nica l ve ntila tion is a re la tive contra indica tion for tra che a l
re se ction be ca use positive a irwa y pre ssure ma y ca use wound
de hisce nce (Miller: Miller’s Anesth esia, ed 8, pp 1987–1988).
438. (B) Hype rca lce mia is a ssocia te d with a numbe r of signs a nd
symptoms, including hype rte nsion, dysrhythmia s, shorte ning of QT
inte rva l, kidne y stone s, se izure , na use a a nd vomiting, we a kne ss,
de pre ssion, pe rsona lity cha nge s, psychosis, a nd e ve n coma .
Ge ne ra lly, pa tie nts with tota l se rum ca lcium le ve ls of 12 mg/dL or
le ss do not re quire a ny inte rve ntion, with the possible e xce ption of
re hydra tion with sa line . Highe r ca lcium le ve ls ma y be a ssocia te d
with clinica l symptoms a nd should be tre a te d be fore a ne sthe tizing
the pa tie nt. Ca ution should be ta ke n with digita lis a dministra tion to
a ny pa tie nt who is hype rca lce mic be ca use some pa tie nts ma y
e xhibit e xtre me digita lis se nsitivity (Miller: Miller’s Anesth esia, ed 8, p
1794; Barash : Clinical Anesth esia, ed 7, pp 354–355).
NORMAL CALCIUM LEVELS
Serum Calcium Serum Ionized Calcium

Conventional units (mEq/L) 4.5-5.5 mEq/L 2.1-2.6 mEq/L
Conventional units (mg/dL) 9.0-11.0 mg/dL 4.25-5.25 mg/dL
SI units (mmol/L) 2.25-2.75 mmol/L 1.05-1.30 mmol/L
439. (D) Re d-top e ye drops ca use mydria sis a nd should be use d

with ca ution in pa tie nts with close d-a ngle gla ucoma . Gre e n-top e ye
drops ca use miosis, a nd the pupilla ry constriction he lps ke e p the
dra ina ge route ope n in pa tie nts with gla ucoma a nd he lps pre ve nt
a n a cute a tta ck of gla ucoma . Cle a r or white -top e ye drops do not
cha nge pupilla ry size .
440. (D) W he n re vie wing growth curve s, the norma l 40-we e k te rm
ne wborn we ighs a bout 3.5 kg. Infa nts the n double the ir birth we ight
by 5 months a nd triple the ir we ight by 1 ye a r. The re fore , the
a ve ra ge 1-ye a r-old we ighs 10 kg (22 lb). From the a ge of 1 to
6 ye a rs, childre n ga in a bout 2 kg pe r ye a r. Thus, a n a ve ra ge 2-ye a r-
old we ighs 12 kg, 3-ye a r-old we ighs 14 kg, 4-ye a r-old we ighs 16 kg,
5-ye a r-old we ighs 18 kg, a nd 6-ye a r-old we ighs 20 kg. From a ge 6 to
10 ye a rs, childre n ga in a bout 3 kg pe r ye a r (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, pp A6-A13).
441. (A) Ca use s for a cute pa ce ma ke r ma lfunction in the OR a re
nume rous a nd include thre shold cha nge s, inhibition, ge ne ra tor
fa ilure , a nd le a d or e le ctrode dislodge me nt or bre a ka ge . A VVI
pa ce ma ke r ma y be inhibite d by myopote ntia ls. In this re ga rd,
a dministra tion of succinylcholine could a ctua lly inhibit a VVI
pa ce ma ke r. Simila rly, e le ctroca ute ry ca n inhibit a VVI pa ce ma ke r
through e le ctroma gne tic inte rfe re nce . Should this occur (in most
ca se s, de pe nding on ma nufa cture r), a ma gne t should be pla ce d
ove r the pa ce ma ke r to conve rt it into a VOO pa ce ma ke r,
e limina ting the possibility of furthe r inhibition. Pa ce ma ke rs should
be e va lua te d pre ope ra tive ly to e limina te the possibility of
ge ne ra tor fa ilure . Le a d bre a ka ge or dislodge me nt is a n unlike ly
ca use of pa ce ma ke r fa ilure unle ss the surge on is working in the
vicinity of the e le ctrode s. Acute thre shold cha nge s a re a lmost
a lwa ys a ssocia te d with cha nge s in the se rum pota ssium
conce ntra tion. In this pa rticula r pa tie nt, hype rve ntila tion ca use s a
re spira tory a lka losis tha t re sults in the intra ce llula r shifting of
se rum pota ssium. The ne t re sult is tha t the e le ctrica l thre shold for
the pa ce ma ke r is ra ise d, pre ve nting ve ntricula r ca pture (Miller:
Miller’s Anesth esia, ed 8, p 1476; Th om as: Manual of Card iac Anesth esia,
ed 2, pp 382–383).
442. (C) The ra pie s a ime d a t incre a sing functiona l re sidua l ca pa city
(FRC) of the lungs a re use ful in re ducing the incide nce of
postope ra tive pulmona ry complica tions. Force d e xpira tory
ma ne uve rs ma y le a d to a irwa y closure , which would be of no
be ne fit for this pa tie nt (Miller: Miller’s Anesth esia, ed 8, pp 447, 2932–
2934).
443. (C) The huma n bra in is a ble to ma inta in ne urona l function in
the fa ce of de cre a sing CBF be low the norma l le ve l of
50 mL/100 g/min. Be ca use O2 de live ry is dire ctly re la te d to CBF, EEG
e vide nce of ce re bra l ische mia will a ppe a r if CBF is diminishe d
sufficie ntly. The CBF re se rve , howe ve r, is substa ntia l, a nd the first
signs of ce re bra l ische mia do not a ppe a r on EEG until CBF ha s
fa lle n to a pproxima te ly 22 mL/100 g/min. W he n CBF ha s fa lle n to 15
mL/100 g/min, the EEG be come s isoe le ctric. Irre ve rsible me mbra ne
da ma ge a nd ce llula r de a th do not occur, howe ve r, until CBF fa lls to
6 mL/100 g/min. Are a s of the bra in in which CBF fa lls in the 6 to
15 mL/100 g/min ra nge a re re fe rre d to a s zone s of ische mic
pe numbra . Se ve ra l hours ma y e la pse in the se a re a s of the bra in
be fore irre ve rsible me mbra ne da ma ge occurs (Miller: Miller’s
444. (B) Positive e nd-e xpira tory pre ssure (PEEP) is the ma inte na nce
of positive a irwa y pre ssure during the e ntire ve ntila tor cycle . The
a ddition of PEEP to the ve ntila tor cycle is ofte n re comme nde d
whe n Pa O2 is not ma inta ine d a bove 60 mm Hg, whe n bre a thing a n
F IO2 of 0.50 or gre a te r. Although not comple te ly unde rstood, PEEP is
thought to incre a se a rte ria l oxyge na tion, pulmona ry complia nce ,
a nd FRC by e xpa nding pre viously colla pse d but pe rfuse d a lve oli,
the re by de cre a sing shunt a nd improving ve ntila tion/pe rfusion
ma tching. An importa nt a dve rse e ffe ct of PEEP is a de cre a se in
a rte ria l blood pre ssure ca use d by a de cre a se in ve nous re turn, le ft
ve ntricula r filling a nd stroke volume , a nd ca rdia c output. The se
e ffe cts a re e xa gge ra te d in pa tie nts with de cre a se d intra va scula r
fluid volume . Othe r pote ntia l a dve rse e ffe cts of PEEP include
pne umothora x, pne umome dia stinum, a nd subcuta ne ous
e mphyse ma (Miller: Miller’s Anesth esia, ed 8, pp 3077–3078; Miller:
445. (A) Pla te le ts conta in two purine rgic re ce ptors (P2Y 1 a nd P2Y 12).
Clopidogre l (Pla vix) is a prodrug a nd a n irre ve rsible inhibitor of
pla te le t P2Y 12 re ce ptors, which blocks the ADP re ce ptors a nd
inhibits pla te le t a ctiva tion, a ggre ga tion, a nd de gra nula tion. The re is
wide inte rindividua l va ria bility for clopidogre l to inhibit ADP-
induce d pla te le t a ggre ga tion, a nd some pa tie nts a re re sista nt to its
e ffe cts. Glycoprote in IIb/IIIa inhibitors block fibrinoge n binding to
pla te le t glycoprote in IIb/IIIa re ce ptors, which is the fina l common
pa thwa y of pla te le t a ggre ga tion a nd include s the intra ve nous drugs
a bcixima b (Re oPro), e ptifiba tide (Inte grilin), a nd tirofiba n
(Aggra sta t). Aspirin, na proxe n, a nd ibuprofe n inhibit pla te le t COX-1
a nd inhibit the re le a se of ADP by pla te le ts a nd pla te le t
a ggre ga tion. Se le ctive COX-2 inhibitors such a s ce le coxib,
pa re coxib, a nd va lde coxib ha ve no e ffe ct on pla te le t function
be ca use only COX-1 inhibitors a ffe ct pla te le t function. Dire ct
thrombin inhibitors suppre ss pla te le t function a nd include the
pa re nte ra l drugs hirudin, a rga troba n, le pirudin (Re fluda n),
de sirudin (Ipriva sk), biva lirudin (Angioma x), a nd drotre cogin α
(Xigris), a s we ll a s the ora l drug da biga tra n (Pra da xa , Pra da x) a nd
xime la ga tra n (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 859-871; Miller: Basics of Anesth esia, ed 6,
pp 358-359; Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 277–281, 516–518).
446. (B) As a rough a pproxima tion, if one divide s 150 by the MAC for
a ny give n vola tile a ne sthe tic, the quotie nt will be a pproxima te ly
e qua l to the oil/ga s pa rtition coe fficie nt. For e xa mple , if one we re
to divide the MAC of ha lotha ne (0.75) into 150, the quotie nt would
be 200, which is ve ry close to the a ctua l oil/ga s pa rtition coe fficie nt
for ha lotha ne (224). Simila rly, if one we re to divide the MAC of
e nflura ne (1.68) into 150, the quotie nt would be 89, which is ve ry
simila r to the oil/ga s pa rtition coe fficie nt for e nflura ne (98). The fa ct
tha t a ne sthe tics with a high oil/ga s pa rtition coe fficie nt (i.e ., lipid-
soluble a ge nts) ha ve lowe r MACs supports the Me ye r-Ove rton
the ory (critica l volume hypothe sis) (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, p 29).
447. (D) Dia be te s insipidus is cha ra cte rize d by hype rna tre mia ,
se rum hype rosmola lity, polyuria , a nd urine hypo-osmola lity.
Dia be te s insipidus ma y occur a fte r a ny intra cra nia l proce dure , but
it is pa rticula rly common in surge ry involving the pituita ry gla nd. It
ma y de ve lop intra ope ra tive ly, but it commonly de ve lops 4 to
12 hours postope ra tive ly. Intra ve nous ha lf-norma l sa line a nd
de xtrose 5% in wa te r a re sta rte d a s re pla ce me nt fluids. The
pha rma cologic tre a tme nt for dia be te s insipidus is de smopre ssin
a ce ta te (synthe tic 1-de sa mino-8-D-a rginine va sopre ssin [DDAVP])
commonly sta rte d whe n the urine output is gre a te r tha n 350 to
400 mL/hr. In a conscious pa tie nt, it is not e sse ntia l to a dministe r
DDAVP be ca use the pa tie nt ma y incre a se his ora l inta ke to
compe nsa te for polyuria . In the unconscious pa tie nt, howe ve r,
a dministra tion of DDAVP is ne ce ssa ry. De smopre ssin (DDAVP) ma y
be a dministe re d SQ, IV, or intra na sa lly. Fortuna te ly, dia be te s
insipidus re la te d to surge ry a nd he a d tra uma usua lly is tra nsie nt
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 404–405;
Barash : Clinical Anesth esia, ed 7, p 1013).
448. (B) The principa l fe a ture of Alzhe ime r dise a se is progre ssive
de me ntia . The onse t typica lly occurs a fte r a ge 60 ye a rs a nd ma y
a ffe ct a s ma ny a s 20% of pa tie nts olde r tha n a ge 80 ye a rs. In
a ddition to a ge , othe r risk fa ctors include history of se rious he a d
tra uma (e .g., boxing), Down syndrome , a nd pre se nce of the dise a se
in a pa re nt or sibling. One bioche mica l fe a ture of this dise a se is a
de cre a se in the e nzyme choline a ce tyltra nsfe ra se in the bra in.
The re is a strong corre la tion be twe e n re duce d e nzyme a ctivity a nd
de cre a se d cognitive function. Inte re stingly, a dministra tion of the
a nticholine rgic drugs scopola mine or a tropine (but not
glycopyrrola te , which doe s not cross the blood-bra in ba rrie r)
ca use s confusion simila r to tha t se e n in the e a rly sta ge s of
Alzhe ime r dise a se . Conve rse ly, a dministra tion of a nticholine ste ra se
drugs ca pa ble of pe ne tra ting the blood-bra in ba rrie r, such a s
done pe zil (Arice pt), ga la nta mine , riva stigmine (Exe lon), a nd ta crine
a re use d to tre a t pa tie nts with Alzhe ime r dise a se . Physostigmine
ma y ha ve be ne ficia l e ffe cts in some pa tie nts a s we ll. Scopola mine
is the re fore a poor choice for pre me dica tion in pa tie nts with
Alzhe ime r dise a se (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 245; Butterworth : Morgan & Mikh ail’s Clinical
449. (C) At the e nd of a ny ge ne ra l a ne sthe tic, sponta ne ous
ve ntila tion must be re store d be fore the pa tie nt ca n be e xtuba te d.
The diffe re ntia l dia gnosis for pe rsiste nt a pne a include s muscle
re la xa nts (ina de qua te re ve rsa l or pse udocholine ste ra se
de ficie ncy), vola tile a ne sthe tics, na rcotics, hypoca rbia , da ma ge to
the phre nic ne rve s bila te ra lly, a nd the possibility of a ce ntra l
ne rvous syste m (CNS) e ve nt. Succinylcholine is hydrolyze d by
pse udocholine ste ra se to succinylmonocholine a nd choline . This is
furthe r hydrolyze d by pla sma choline ste ra se to succinic a cid a nd
choline . All of the a nticholine ste ra se a ge nts use d to re ve rse
nonde pola rizing ne uromuscula r blocka de a lso inhibit
pse udocholine ste ra se . Administra tion of succinylcholine to a ny
pa tie nt who ha s a lre a dy re ce ive d a n a nticholine ste ra se will re sult
in a prolonge d block from the succinylcholine be ca use it ca n no
longe r be e a sily hydrolyze d. In this pa tie nt, the re fore ,
succinylcholine would be by fa r the most like ly ca use of a pne a a t
the e nd of the ope ra tion (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, p 218).
450. (A) Comple te or a lmost comple te ce ssa tion of urine flow
sugge sts a postre na l obstruction. Howe ve r, a t time s pooling of the
urine in the dome of the bla dde r should be conside re d a s a
possible ca use of oliguria in this pa tie nt in the a bse nce of
significa nt ble e ding (Miller: Miller’s Anesth esia, ed 8, pp 556–557).
451. (B) DL is de fine d a s the diffusing ca pa city of the lung. W he n a
nontoxic, low conce ntra tion of ca rbon monoxide is use d for the
me a sure me nt, it is ca lle d DLCO. The norma l va lue of DLCO is 20 to
30 mL/min/mm Hg a nd is influe nce d by the volume of blood
(he moglobin) within the pulmona ry circula tion. Thus, dise a se s
a ssocia te d with a de cre a se in pulmona ry blood volume (i.e .,
a ne mia , e mphyse ma , hypovole mia , pulmona ry hype rte nsion) will
be re fle cte d by a de cre a se in the DLCO. DLCO is a lso de cre a se d
with oxyge n toxicity a s we ll a s pulmona ry e de ma . Conditions
a ssocia te d with a n incre a se d DLCO include the supine position,
e xe rcise , obe sity, a nd le ft-to-right ca rdia c shunts (Barash : Clinical
Anesth esia, ed 7, pp 369–370, 373–374; Miller: Miller’s Anesth esia, ed 8, p
365).
452. (C) Pa tie nts unde rgoing thyroid surge ry a re a t risk for a irwa y
obstruction from a numbe r of ca use s. Postope ra tive he morrha ge
sufficie nt to ca use a la rge he ma toma could compre ss the tra che a
a nd ca use a irwa y obstruction be ca use of the close proximity of the
thyroid gla nd to the tra che a . Pe rma ne nt hypopa ra thyroidism is a
ra re complica tion tha t ma y ca use hypoca lce mia le a ding to
progre ssive stridor followe d by la ryngospa sm. The most common
ne rve injury a fte r thyroid surge ry is da ma ge to the a bductor fibe rs
of the re curre nt la rynge a l ne rve . Unila te ra lly, this is ma nife ste d a s
hoa rse ne ss. Bila te ra l re curre nt la rynge a l ne rve da ma ge , howe ve r,
ma y le a d to a irwa y obstruction during inspira tion. Se le ctive injury
of the a dductor fibe rs of the re curre nt la rynge a l ne rve is a possible
complica tion of thyroid surge ry. This injury would le a ve the voca l
cords ope n be ca use the a bductor fibe rs would be unoppose d,
pla cing the pa tie nt a t gre a t risk for a spira tion. The supe rior
la rynge a l ne rve ha s a n e xtrinsic bra nch tha t inne rva te s the
cricothyroid muscle (which te nse s the voca l cords) a nd a n inte rna l
bra nch tha t provide s se nsory inne rva tion to the pha rynx a bove the
voca l cords. Bila te ra l da ma ge to this ne rve would re sult in
hoa rse ne ss a nd would pre dispose the pa tie nt to a spira tion but
would not le a d to a irwa y obstruction pe r se (Miller: Basics of
453. (D) MH is a clinica l syndrome tha t ma y de ve lop ra pidly or ta ke
hours to ma nife st, some time s not occurring until the pa tie nt is in
the re cove ry room. Clinica l signs include hype rte nsion, ta chyca rdia ,
re spira tory a cidosis, me ta bolic a cidosis, muscle rigidity,
myoglobinuria , a nd fe ve r. The dia gnosis of MH is unlike ly, howe ve r,
if only one of the se signs is ma nife ste d. Be ca use MH is a me ta bolic
disorde r, one of the first se nsitive signs is a n incre a se in the
production of CO2 a nd concomita nt re spira tory a cidosis. This is the
most re lia ble e a rly sign of the syndrome (Barash : Clinical Anesth esia,
ed 7, pp 612, 622–624).
454. (D) Hype rve ntila tion to Pa CO2 of 20 mm Hg or highe r for more
tha n 2 hours will re sult in a ctive tra nsport of HCO3– out of the CNS.
This re sults in sponta ne ous bre a thing a t a lowe r (not highe r)
Pa CO2. The othe r choice s should be include d in the diffe re ntia l
dia gnosis of a pne a (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 5, pp 359–361; Miller: Basics of Anesth esia, ed 6, pp 62–64,
340; Barash : Clinical Anesth esia, ed 7, pp 271–273).
455. (B) Ma ximum volunta ry ve ntila tion (MVV) is a nonspe cific
pulmona ry function te st tha t me a sure s the e ndura nce of the
ve ntila tory muscle s a nd indire ctly re fle cts the complia nce of the
lung a nd thora x a s we ll a s a irwa y re sista nce . A de cre a se d MVV
ma y be ca use d by impa irme nt to inspira tion or e xpira tion. In this
pa tie nt, FEV1 is norma l, which strongly sugge sts tha t the ve ntila tory
impa irme nt is during inspira tion. A flow-volume loop would be a
ve ry use ful confirma tory te st (Barash : Clinical Anesth esia, ed 7, pp
1033–1034).
456. (A) Guide line s for sa fe discha rge of pa tie nts from a mbula tory
surgica l ce nte rs include sta ble vita l signs, a bility to wa lk without
dizzine ss, controlle d pa in, a bse nce of na use a a nd vomiting, a nd
minima l surgica l ble e ding. The PADSS is a tool for obje ctive ly
a sse ssing a pa tie nt’s re a dine ss for discha rge from the surgica l
ce nte r a nd include s the se five crite ria . Re quire me nts to drink fluids
a nd to void be fore home discha rge a re controve rsia l a nd a re not
pa ra me te rs include d in the PADSS (Barash : Clinical Anesth esia, ed 7,
pp 1560–1561).
457. (C) Ma ligna nt hype rthe rmia (MH) is a difficult dia gnosis to
ma ke on clinica l grounds a lone . Signs of MH ma y be fulmina nt or
ve ry subtle . The y ma y occur imme dia te ly a fte r induction or ma y not
be ma nife ste d until the pa tie nt ha s re a che d the re cove ry room or
e ve n la te r. MH is a disorde r of me ta bolism a nd is a ssocia te d with
hype rte nsion, ta chyca rdia , dysrhythmia s, re spira tory a cidosis,
me ta bolic a cidosis, muscula r rigidity, rha bdomyolysis, a nd fe ve r.
Contra ry to wha t one might be lie ve ba se d on the na me of this
dise a se , fe ve r is typica lly a la te finding. Othe r dise a se s tha t ma y
mimic MH include a lcohol withdra wa l, a cute coca ine toxicity,
ba cte re mia , phe ochromocytoma , hype rthyroidism, a nd ne urole ptic
ma ligna nt syndrome . An e le va tion in te mpe ra ture a lone with
norma l blood ga se s, he a rt ra te , a nd blood pre ssure , a nd no
e vide nce of muscle bre a kdown would ve ry like ly not be due to
MH. If a pa tie nt ha d be e n pre viously subje cte d to muscle biopsy
a nd ca ffe ine -ha lotha ne contra cture te sting with ne ga tive re sults,
MH would be e xce e dingly ra re , a lthough a fa lse -ne ga tive re sult is
possible . A history of a pre vious a ne sthe tic without MH trigge ring
would be of little re a ssura nce in a pa tie nt in whom a n MH e pisode
is suspe cte d. It is not uncommon for MH-susce ptible individua ls to
not trigge r whe n a trigge ring a ne sthe tic is a dministe re d initia lly but
de ve lop fulmina nt MH with a subse que nt a ne sthe tic (Barash :
458. (D) Asthma is a n infla mma tory illne ss tha t ha s bronchia l
hype rre a ctivity a nd bronchospa sm a s a re sult. Tre a tme nt is first
dire cte d a t the infla mma tory compone nt a s the unde rlying proble m,
re se rving bronchodila tors for symptoma tic use . Be ca use
le ukotrie ne s ma y function a s infla mma tory me dia tors, the
le ukotrie ne pa thwa y inhibitors such a s zile uton a nd the le ukotrie ne
re ce ptor a nta gonist monte luka st (Singula ir) a re be ing use d for
tre a tme nt of a sthma . Zile uton a nd monte luka st a re a va ila ble only
a s ora l pre pa ra tions, whe re a s the othe r drugs liste d a re give n by
inha la tion. Flutica sone a nd tria mcinolone a re a nti-infla mma tory
corticoste roids. Ipra tropium is a qua te rna ry a mmonium compound
forme d by the introduction of a n isopropyl group to the N a tom of
a tropine a nd produce s e ffe cts simila r to those of a tropine . One
une xpe cte d finding is a re la tive la ck of e ffe ct on mucocilia ry
cle a ra nce , which ma ke s it use ful in pa tie nts with a irwa y dise a se ,
e spe cia lly if pa ra sympa the tic tone of the a irwa ys is incre a se d.
Sa lme te rol is a β2-se le ctive a dre ne rgic drug (Hard m an: Good m an &
Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 11, pp 721–725,
ed 4, pp 271, 427).
459. (D) Acute de cre a se s in se rum sodium, due to a bsorption of
bla dde r irriga ting fluids, ra re ly ca use symptoms unle ss the sodium
le ve l drops be low 120 mEq/L. At this le ve l, tissue e de ma ma y
de ve lop a nd clinica l ne urologic signs (e .g., re stle ssne ss, na use a ,
confusion, se izure s, a nd coma ) or ECG cha nge s (e .g., wide ning of
the QRS comple x, e le va tion of the ST se gme nt, ve ntricula r
ta chyca rdia , or ve ntricula r fibrilla tion) ma y be ma nife ste d.
Tre a tme nt of mild de cre a se s in se rum sodium (i.e ., 120-135 mEq/L
with no ne urologic or ECG cha nge s) is by fluid re striction a nd/or
a dministra tion of a diure tic such a s furose mide . W he n the sodium
le ve l drops be low 120 mEq/L a nd ne urologic symptoms or cha nge s
in the ECG de ve lop, sodium chloride a dministra tion is ne e de d. To
ca lcula te the a mount ne e de d, one multiplie s the pa tie nt’s tota l
body wa te r (i.e ., 0.6 × body we ight = TBW ) by the cha nge in sodium
de sire d. In this ca se , the TBW is 60 L (0.6 × 100 kg) a nd the cha nge
of sodium is 10 mEq (120 mEq/L − 110 mEq/L), thus
60 L × 10 mEq/L = 600 mEq. Ca ution is a dvise d in a dministe ring
sodium be ca use too ra pid a dministra tion ma y le a d to
de mye lina ting CNS le sions. The re comme nde d ra te of 3% sodium
chloride (513 mEq/L) is 1 to 2 mL/kg/hr. Se rum sodium le ve ls should
be che cke d a t le a st e ve ry hour until the sodium le ve l incre a se s
a bove 120 mEq/L (Barash : Clinical Anesth esia, ed 7, pp 341–344).
460. (A) Trismus (ma sse te r spa sm) is cha ra cte rize d by rigidity of the
ja w muscle s while the limb muscle s re ma in fla ccid a fte r
a dministra tion of succinylcholine . Trismus ma y he ra ld the onse t of
MH in some pa tie nts but ma y be due to a numbe r of othe r ca use s
a nd ma y occur in norma l pa tie nts. It pre viously ha d be e n be lie ve d
tha t 50% of pa tie nts who e xpe rie nce trismus a fte r a dministra tion of
succinylcholine would go on to de ve lop MH. Re ce nt e vide nce
sugge sts, howe ve r, tha t the incide nce is le ss. If ma sse te r spa sm
occurs in a pa tie nt a fte r a dministra tion of succinylcholine , the most
conse rva tive course would be to ca nce l the ope ra tion. If
ca nce lla tion of the ope ra tion is not fe a sible , the n a nontrigge ring
a ne sthe tic should be use d, a nd the a ne sthe siologist should pa y
close a tte ntion for a ny signs of MH (Miller: Miller’s Anesth esia, ed 8, p
1296).
461. (B) Ke ta mine is unique a mong the IV induction a ge nts in tha t it
usua lly produce s ca rdia c stimula tion ma nife ste d by incre a se d he a rt
ra te , me a n a rte ria l pre ssure , a nd ca rdia c output. Ke ta mine is
be lie ve d to ha ve a ce ntra lly me dia te d sympa the tic ne rvous syste m
stimula ting e ffe ct. This e ffe ct is, howe ve r, not re la te d to dose . In
isola te d ra bbit a nd ca nine he a rts a nd in inta ct dogs, ke ta mine ha s
be e n de monstra te d to produce myoca rdia l de pre ssion. Clinica lly,
howe ve r, the myoca rdia l de pre ssa nt prope rtie s of ke ta mine a re
ove rridde n by its sympa the tic ne rvous syste m stimula ting
prope rtie s. W he n syste mic ca te chola mine s ha ve be e n de ple te d or
whe n the pa tie nt is unde r de e p a ne sthe sia , the myoca rdia l
de pre ssa nt prope rtie s of ke ta mine ma y pre domina te (Stoelting:
462. (C) In the norma l muscle ce ll, de pola riza tion re sults in re le a se
of ca lcium from the sa rcopla smic re ticulum. The incre a se d
intra ce llula r ca lcium conce ntra tion re sults in muscle contra ction.
The ca lcium the n is ra pidly ta ke n up via ca lcium pumps ba ck into
the sa rcopla smic re ticulum, re sulting in re la xa tion. Both the re le a se
a nd re upta ke of ca lcium a re e ne rgy-re quiring proce sse s (i.e ., re sult
in the hydrolysis of a de nosine triphospha te [ATP]). Da ntrole ne , the
pha rma cologic tre a tme nt for MH, blocks re le a se of ca lcium from
the sa rcopla smic re ticulum without a ffe cting the re upta ke proce ss.
The de fe ct in MH is thought to be de cre a se d control of intra ce llula r
ca lcium store s pre ve nting muscle re la xa tion (Barash : Clinical
463. (D) Approxima te ly 4% of pa tie nts tre a te d with ble omycin
de ve lop pulmona ry toxicity, which ma nife sts a s se ve re pulmona ry
fibrosis a nd hypoxe mia . De a th from se ve re pulmona ry toxicity
occurs in a pproxima te ly 1% to 2% of pa tie nts tre a te d with
ble omycin. Pa tie nts who a re a t gre a te r risk for ble omycin-induce d
pulmona ry toxicity include e lde rly pa tie nts, those re ce iving more
tha n 200 to 400 mg, those with coe xisting lung dise a se , a nd those
re ce ntly e xpose d to ble omycin. In a ddition, the re is e vide nce tha t
prior ra diothe ra py a nd possibly re ce ipt of e nriche d conce ntra tions
of O2 (i.e ., inspire d oxyge n >30%) during surge ry incre a se risk of
pulmona ry toxicity. Clinica lly, pa tie nts gra dua lly de ve lop dyspne a , a
nonproductive cough, a nd hypoxe mia , a nd pulmona ry function te sts
typica lly de monstra te cha nge s in ga s flow a nd lung volume s
consiste nt with re strictive pulmona ry dise a se . If ra diogra phic
e vide nce such a s bila te ra l diffuse inte rstitia l infiltra te s a ppe a rs,
pulmona ry fibrosis usua lly is irre ve rsible (Stoelting: Ph arm acology
464. (C) He a d fle xion ca n a dva nce the tube up to 1.9 cm towa rd the
ca rina a nd in some ca se s conve rt a n e ndotra che a l intuba tion into
a n e ndobronchia l intuba tion. Exte nsion of the he a d ha s the
opposite e ffe ct a nd ca n withdra w the tube up to 1.9 cm, re sulting in
e xtuba tion of some pa tie nts. Turning the he a d la te ra lly ca n move
the dista l tip of the e ndotra che a l tube a bout 0.7 cm a wa y from the
ca rina . The Tre nde le nburg position ca use s a ce pha la d shift of the
me dia stinum a nd ca n ca use the e ndotra che a l tube to migra te
dista lly a s we ll (Miller: Basics of Anesth esia, ed 6, p 242).
465. (C) Sulfur he xa fluoride is some time s inje cte d in the vitre ous in
pa tie nts with a de ta che d re tina to me cha nica lly fa cilita te
re a tta chme nt. To pre ve nt cha nge s in the size of the ga s bubble , the
pa tie nts should be give n 100% O2 15 minute s be fore inje ction of
sulfur he xa fluoride . If the se pa tie nts a re a ne sthe tize d with ge ne ra l
a ne sthe sia within 10 da ys, N2O should not be give n be ca use N2O
ca n diffuse into the ga s bubble , incre a sing intra ocula r pre ssure ,
a nd ma y re sult in blindne ss (Barash : Clinical Anesth esia, ed 7, pp
1391–1392).
466. (D) The symptoms of hypoca lce mia , which ma nife st a s
la ryngospa sm or la rynge a l stridor, usua lly de ve lop within the first
24 to 96 hours a fte r tota l thyroide ctomy. Afte r the a irwa y is
e sta blishe d a nd se cure d, the pa tie nt should be tre a te d with IV
ca lcium in the form of e ithe r ca lcium glucona te or ca lcium chloride
(Barash : Clinical Anesth esia, ed 7, pp 352–353, 1330).
467. (C) Be ca use the circula ting le ve ls of T 3 a nd T 4 re gula te TSH
re le a se from the a nte rior pituita ry gla nd by a ne ga tive fe e dba ck
me cha nism, a norma l pla sma conce ntra tion of TSH confirms a
e uthyroid sta te . The pha rma cologic tre a tme nt of choice for pa tie nts
with hypothyroidism is sodium le vothyroxine (T 4). Sodium
le vothyronine (triiodothyronine , T 3) a nd de sicca te d thyroid a re
a lte rna te the ra pe utic a ge nts (Barash : Clinical Anesth esia, ed 7, p 1328;
Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 389–390).
468. (A) La rge qua ntitie s of irriga ting fluid ca n be a bsorbe d during
tra nsure thra l re se ction of the prosta te gla nd be ca use the ope n
ve nous sinuse s in the prosta te a llow the irriga tion fluid to be
a bsorbe d. On a ve ra ge , from 10 to 30 mL of fluid pe r minute a re
a bsorbe d, a nd during long ca se s this ca n a mount to se ve ra l lite rs,
ca using hype rte nsion, re fle x bra dyca rdia , a nd pulmona ry
conge stion. Tre a tme nt consists of fluid re striction a nd a loop
diure tic (e .g., furose mide ) whe n the [Na +] le ve l is gre a te r tha n
120 mEq/L. Ra re ly doe s the a mount of fluid a bsorbe d ca use
significa nt hypona tre mia ([Na +] <120 mEq/L). In the se ca se s of
significa nt hypona tre mia , 3% sodium chloride ma y be infuse d
slowly intra ve nously (in a ddition to the loop diure tic a nd fluid
re striction) until the sodium le ve l re a che s 120 mEq/L (Barash :
469. (C) Pa tie nts who ha ve susta ine d the rma l injurie s a re a t risk for
ma ssive pota ssium re le a se a nd pote ntia l ca rdia c a rre st if
succinylcholine is a dministe re d 24 hours or more a fte r the y susta in
the burn, a nd the y re ma in a t risk until the burn ha s he a le d. This
incre a se d se nsitivity to succinylcholine is thought to be re la te d to
prolife ra tion of e xtra junctiona l re ce ptors. The se sa me re ce ptors
a re thought to be re la te d to the incre a se d re quire me nt for
nonde pola rizing ne uromuscula r blocking a ge nts in the se pa tie nts
(Barash : Clinical Anesth esia, ed 7, p 1523).
470. (A) The fa cia l ne rve (se ve nth cra nia l ne rve ) runs within the
substa nce of the pa rotid gla nd a nd might be come da ma ge d during
pa rotid surge ry. The fa cia l ne rve inne rva te s the la crima l,
subma ndibula r, a nd sublingua l gla nds, is se nsory to the a nte rior
two thirds of the tongue , a nd inne rva te s a ll of the muscle of fa cia l
e xpre ssion (including the orbicula ris oculi—close the e ye lids;
orbicula ris oris—purse the lips; fronta lis—ra ise the e ye brows).
The trige mina l ne rve (fifth cra nia l ne rve ) inne rva te s the muscle s of
ma stica tion (ma sse te r, te mpora lis, me dia l, a nd la te ra l
pte rygoids), which a re use d to cle nch the te e th (Miller: Basics of
Anesth esia, ed 6, p 497; Orient: Sapira’s Art and Science of Bed sid e
Diagnosis ed 4, pp 533–537).
471. (D) One gra m of he moglobin ca n combine with 1.34 mL of O2.
None of the othe r choice s in this que stion will do a s much to
incre a se the O2-ca rrying ca pa city of this pa tie nt’s blood a s a
tra nsfusion (Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 787, 849).
472. (A) Ma ny of the drugs commonly a dministe re d during surge ry
a nd a ne sthe sia ha ve the pote ntia l to e voke a lle rgic re a ctions (e .g.,
morphine , propofol, loca l a ne sthe tics, a ntibiotics, a nd prota mine ,
a s we ll a s othe r ma te ria ls use d during surge ry, such a s va scula r
gra ft ma te ria l, chymopa pa in, a nd la te x). Virtua lly a ll drugs
a dministe re d IV ha ve be e n re porte d to ca use a lle rgic re a ctions.
Possible e xce ptions include be nzodia ze pine s a nd ke ta mine . An
a lle rgic re a ction should be conside re d whe n the re is a n a brupt fa ll
in blood pre ssure a ccompa nie d by incre a se s in he a rt ra te tha t
e xce e d 30% of the control va lue s. Gre a te r tha n 60% of a ll drug-
induce d a lle rgic re a ctions obse rve d during the pe riope ra tive pe riod
a re a ttributa ble to muscle re la xa nts. La te x a lle rgy is thought to be
re sponsible for 15% of a lle rgic re a ctions unde r a ne sthe sia ,
some time s including re a ctions origina lly a ttribute d to othe r
substa nce s. Pa tie nts a t risk for la te x a lle rgy include he a lth ca re
worke rs a nd pa tie nts with spina bifida . Although most drug-
induce d a lle rgic re a ctions de ve lop within 5 to 10 minute s of
e xposure , la te x signs typica lly ta ke more tha n 30 minute s to
de ve lop (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
525–529).
473. (C) De cre a se d le ve ls of pse udocholine ste ra se ha ve be e n
re porte d in pa tie nts with Huntington chore a . For this re a son, the
e ffe cts of succinylcholine ma y be prolonge d in some of the se
pa tie nts. It ha s be e n sugge ste d tha t the se nsitivity to
nonde pola rizing muscle re la xa nts is a lso incre a se d (Hines:
474. (A) Norma l intra ocula r pre ssure is 10 to 22 mm Hg. In ge ne ra l,
IV a ne sthe tics, with the possible e xce ption of ke ta mine , de cre a se
intra ocula r pre ssure . In a ddition, nonde pola rizing ne uromuscula r
blocke rs, inha le d a ne sthe tics, na rcotics, ca rbonic a nhydra se
inhibitors, osmotic diure tics, a nd hypothe rmia de cre a se intra ocula r
pre ssure . Howe ve r, e le va tion of Pa CO2 out of the physiologic ra nge ,
a s se e n with hypove ntila tion a s we ll a s a rte ria l hypoxe mia , will
incre a se intra ocula r pre ssure . De pola rizing ne uromuscula r
blocke rs, such a s succinylcholine , a lso incre a se intra ocula r
pre ssure . This incre a se in intra ocula r pre ssure occurs whe n
succinylcholine is a dministe re d IM or IV. Pre tre a tme nt with a
nonde pola rizing muscle re la xa nt be fore a dministe ring
succinylcholine ma y a tte nua te the rise in intra ocula r pre ssure . The
me cha nism for the incre a se in intra ocula r pre ssure a fte r
succinylcholine use is re la te d to drug-induce d cyclople gia ra the r
tha n contra ction of e xtra ocula r muscle s, a s this incre a se in
intra ocula r pre ssure will occur e ve n if the intra ocula r muscle s a re
cut. The gre a te st incre a se in intra ocula r pre ssure occurs with
coughing or vomiting, whe re the intra ocula r pre ssure ma y incre a se
a s much a s 35 to 50 mm Hg. The propose d me cha nism for the a cute
incre a se in intra ocula r pre ssure is a n incre a se in ve nous pre ssure .
The re doe s not a ppe a r to be a cha nge in intra ocula r pre ssure with
cha nge s within norma l physiologic ra nge s in a rte ria l blood
pre ssure or Pa CO2 (Barash : Clinical Anesth esia, ed 7, pp 1375–1376;
475. (C) The a pne a -hypopne a inde x (AHI) is use d to qua ntify the
numbe r of a pne a or hypopne a e pisode s tha t occur pe r hour. Apne a
is de fine d a s no ve ntila tion for pe riods of 10 se conds or more .
Hypopne a is de fine d a s a 50% de cre a se in a irflow or a de cre a se
sufficie nt to ca use a de cre a se in oxyge n sa tura tion of 4%. An AHI of
gre a te r tha n 30 signifie s se ve re OSA (Miller: Miller’s Anesth esia, ed 8,
p 2203; Lobato: Com plications in Anesth esiology, p 625).
476. (D) Any pa tie nt who is sche dule d for a pne umone ctomy should
unde rgo a se rie s of pre ope ra tive pulmona ry function te sts. The se
te sts a re ge ne ra lly conducte d in thre e pha se s. The te sts liste d in
this que stion pe rta in to the first ba tte ry of pulmona ry function te sts,
which a re whole -lung te sts. Re sidua l volume to TLC gre a te r tha n
50% (not <50%) is a ssocia te d with a n incre a se d ope ra tive risk. If the
re sults of a ny of the initia l whole -lung te sts a re be low the
a cce pta ble limits, a se cond pha se of te sting should be ca rrie d out
in which the function of e a ch lung is e va lua te d se pa ra te ly. The
pre dicte d postope ra tive FEV1 a fte r the se cond pha se of pulmona ry
function te sting is ca rrie d out should be gre a te r tha n 0.85 L. If the
crite ria for the se cond le ve l of pulmona ry function te sting ca nnot be
me t a nd pne umone ctomy is still de sire d, the n a third le ve l of
te sting should be ca rrie d out. During the third pha se of te sting,
postope ra tive conditions mimicking pne umone ctomy a re produce d
by occluding the pulmona ry a rte ry with a ba lloon on the side tha t is
to be re se cte d. Re sults of this te st tha t a re consiste nt with poor
outcome a fte r pne umone ctomy include me a n pulmona ry a rte ry
pre ssure gre a te r tha n 40 mm Hg, Pa CO2 gre a te r tha n 60 mm Hg, or
Pa O2 le ss tha n 45 mm Hg (Miller: Miller’s Anesth esia, ed 8, pp 1943–
1945, 1981–1982).
477. (A) Me a sure d Pa O2 should be de cre a se d a bout 6% for e a ch
de gre e Ce lsius coole r the pa tie nt’s te mpe ra ture is tha n the
e le ctrode (37° C). Be ca use the pa tie nt is 2° C coole r tha n the
e le ctrode , a 12% de cre a se (9 mm Hg) would be e xpe cte d in this
pa tie nt (77 mm Hg − 9 mm Hg = 68 mm Hg) (Miller: Basics of
Anesth esia, ed 6, p. 338).
478. (A) The two ma in ca use s of ce ntra l cya nosis a re de cre a se d
a rte ria l oxyge n sa tura tion a nd he moglobin a bnorma litie s (e .g.,
me the moglobine mia a nd sulfhe moglobine mia ). Sulfa sa la zine
(Azulfidine ) ca n ca use the forma tion of sulfhe moglobin.
Sulfhe moglobin, like me the moglobin, ma y ca use low O2 sa tura tion
in the fa ce of high Pa O2. The re is no tre a tme nt for
sulfhe moglobine mia e xce pt to wa it for the de struction of the
e rythrocyte s (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 296, 415).
479. (D) Unfra ctiona te d he pa rin is a mixture of highly sulfa te d
glycosa minoglyca ns with mole cula r we ights of 5000 to
30,000 da ltons. The onse t of a ction of unfra ctiona te d he pa rin is
imme dia te , the pla sma ha lf-life is ½ hour to 2 hours, a nd it ca n be
comple te ly re ve rse d with prota mine . Clinica lly, monitoring of
a nticoa gula tion is usua lly pe rforme d with the a PTT te st with a
ta rge t prolonga tion of 1.5 to 2 time s control. W he n unfra ctiona te d
he pa rin is use d for ca rdiopulmona ry bypa ss, the dose s a re much
highe r a nd it is monitore d with the a ctiva te d clotting time or ACT
te st (>400 se conds is usua lly conside re d sa fe for ca rdiopulmona ry
bypa ss). LMW Hs a re 4000 to 5000 da ltons in size , the onse t of a ction
is 20 to 60 minute s, the pla sma ha lf-life is 4.5 hours, a nd it ca n only
be pa rtia lly re ve rse d (65%) with prota mine . Monitoring the LMW H’s
e ffe cts is not pe rforme d, be ca use the PT a nd the a PTT te sts a re
most ofte n una ffe cte d. LMW Hs ha ve a much lowe r risk for HIT
compa re d to the unfra ctiona te d he pa rin (Miller: Basics of Anesth esia,
ed 6, pp 357–358; Miller: Miller’s Anesth esia, ed 8, pp 1872–1873).
480. (B) Se rum cre a tinine is inve rse ly proportiona l to the GFR. W ith
the incre a se in cre a tinine by a fa ctor of 4, the GFR is divide d by
four; tha t is, 120/4 = 30 mL/min (Lobato: Com plications in
Anesth esiology, p 433; Miller: Miller’s Anesth esia, ed 8, pp 558–559).
481. (A) Trisomy 21 or Down syndrome is the most common huma n
chromosoma l syndrome se e n. An incre a se d incide nce of conge nita l
hypothyroidism occurs. About one fourth of childre n with Down
syndrome a nd ma ny a dults ha ve sma lle r tra che a s tha n pre dicte d
a nd re quire a n e ndotra che a l tube tha t is one or two size s sma lle r.
One should a void unne ce ssa ry fle xion or e xte nsion of the ne ck
during intuba tion be ca use occipito-a tla ntoa xia l insta bility occurs in
a bout 15% to 20% of pa tie nts. Be ca use subluxa tion is re la tive ly
uncommon, routine ne ck ra diogra phs for a ll Down syndrome
pa tie nts a re e xce ssive . More tha n 40% of Down syndrome childre n
ha ve conge nita l he a rt dise a se (e .g., e ndoca rdia l cushion de fe cts,
ve ntricula r se pta l de fe cts, te tra logy of Fa llot, pa te nt ductus
a rte riosus). Although some childre n ha ve hypotonia , a n incre a se d
incide nce of MH ha s not be e n re porte d in the se pa tie nts (Baum :
Anesth esia for Genetic, Metabolic, and Dy sm orph ic Sy nd rom es of
Ch ild h ood , ed 2, pp 105–107; Hines: Stoelting’s Anesth esia and Co-
482. (B) Scopola mine is a n a nticholine rgic tha t ma y produce
mydria sis a nd cyclople gia . This ca n re sult in the ina bility of a
pa tie nt’s e ye s to a ccommoda te (Stoelting: Basics of Anesth esia, ed 6, p
76).
483. (D) Ne urole ptic ma ligna nt syndrome is a pote ntia lly fa ta l
dise a se tha t a ffe cts 0.5% to 1% of a ll pa tie nts be ing tre a te d with
ne urole ptic (a ntipsychotic) drugs. The syndrome de ve lops gra dua lly
ove r 1 to 3 da ys in young ma le s a nd is cha ra cte rize d by the
following: (1) hype rthe rmia , (2) ske le ta l muscle rigidity, (3)
a utonomic insta bility ma nife ste d by cha nge s in blood pre ssure a nd
he a rt ra te , a nd (4) fluctua ting le ve ls of consciousne ss. The morta lity
from ne urole ptic ma ligna nt syndrome is 20% to 30%. Live r
tra nsa mina se s a nd cre a tine phosphokina se le ve ls a re ofte n
e le va te d in the se pa tie nts. Tre a tme nt include s supportive ca re a nd
a dministra tion of da ntrole ne . This dise a se ma y mimic MH be ca use
of its ma ny simila ritie s. One diffe re nce be twe e n ne urole ptic
ma ligna nt syndrome a nd MH is the fa ct tha t nonde pola rizing
muscle re la xa nts such a s ve curonium or cisa tra curium will ca use
fla ccid pa ra lysis in pa tie nts with ne urole ptic ma ligna nt syndrome
but not in pa tie nts with MH (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 540, 635–640).
484. (D) The cla ssic signs of fa t e mbolism include ta chyca rdia ,
dyspne a , me nta l confusion, a nd fe ve r, a nd fre que ntly the re ma y be
a pe te chia l ra sh on the uppe r pa rt of the body. Fa t e mbolism is
more common a fte r long bone fra cture s (e .g., fe mur a nd tibia ) a nd
usua lly occurs be twe e n 12 a nd 72 hours a fte r long bone fra cture s
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 213–214).
485. (C) Re mife nta nil is a n ultra short-a cting na rcotic. Che mica lly it
is a de riva tive of pipe ridine (like fe nta nyl), but re mife nta nil ha s a n
e ste r linka ge a nd is ra pidly broke n down by nonspe cific pla sma a s
we ll a s tissue e ste ra se s. The e limina tion ha lf-life is le ss tha n
20 minute s a nd is be st a dministe re d by a continuous infusion.
Pse udocholine ste ra se de ficie ncy or re na l or he pa tic fa ilure doe s
not a ffe ct re mife nta nil’s ra pid me ta bolism (Barash : Clinical
Anesth esia, ed 7, p 509; Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, p 114).
486. (D) A te rm infa nt with a strong cry a nd good muscle tone doe s
not re quire oxyge n the ra py ba se d on a 5-minute sa tura tion a lone .
The fe ta l lungs ma ke a ra pid tra nsition from a fluid-fille d orga n to
a n a ir-fille d orga n. As the zone s of a te le cta sis ope n, the sa tura tion
rise s. The ta ble be low shows a cce pta ble pre ducta l oxyge n
sa tura tion a s a function of time .
Minutes Preductal Oxygen Saturation

1 60%-65%
2 65%-70%
3 70%-75%
4 75%-80%
5 80%-85%
10 85%-95%
Data from Kattwinkel J et al: Neonatal resuscitation: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Pediatrics 126:e1400–
e1413, 2010.
487. (C) Ane sthe sia for e xtra corpore a l shock wa ve lithotripsy ma y
be a ccomplishe d with e ithe r ge ne ra l a ne sthe sia or e pidura l
a ne sthe sia . W he n a pa tie nt is subme rge d in the sta inle ss ste e l tub,
the pe riphe ra l va scula ture be come s compre sse d by the hydrosta tic
pre ssure , re sulting in a n incre a se in pre loa d. Re moving the pa tie nt
from the ta nk ha s the opposite e ffe ct. In pa tie nts who ha ve
re ce ive d e pidura l a ne sthe sia , the re is a n incre a se d incide nce of
hypote nsion ca use d by e pidura l-induce d sympa the ctomy a fte r the y
e me rge from the ba th (Miller: Basics of Anesth esia, ed 6, p 627).
488. (A) The most common re a son for une xpe cte d hospita l
a dmission a fte r outpa tie nt ge ne ra l a ne sthe sia , a s we ll a s a
prolonge d re cove ry-room sta y (for both a dults a nd childre n), is
na use a a nd vomiting. Two othe r re a sons for a prolonge d re cove ry-
room sta y a re pa in a nd drowsine ss (Barash : Clinical Anesth esia, ed 7,
pp 854, 856).
489. (A) Choline rgic crisis ca n be diffe re ntia te d from mya sthe nic
crisis by a dministe ring sma ll IV dose s of a nticholine ste ra se s. W ith
a choline rgic crisis, the re a re significa nt musca rinic e ffe cts (e .g.,
sa liva tion, bra dyca rdia , miosis) a nd a n a cce ntua te d muscle
we a kne ss. Be ca use this pa tie nt’s VT de cre a se d with the
a dministra tion of e drophonium, the dia gnosis of choline rgic crisis is
ma de . Although a tropine ma y be ne e de d to tre a t the choline rgic
symptoms, muscle we a kne ss will be worse a nd the se pa tie nts
ne e d to be intuba te d until the muscle stre ngth re turns (Hines:
490. (C) Tra ma dol, a synthe tic code ine a na log, is a ce ntra lly a cting
a na lge sic. It ca n be use d for mild to mode ra te pa in but is not a s
e ffe ctive a s morphine or me pe ridine for se ve re or chronic pa in.
One dra wba ck for tra ma dol’s pe riope ra tive use is its high
incide nce of na use a a nd vomiting. Its me cha nism of a ction for
a na lge sia is comple x. It is a we a k µ-re ce ptor a gonist, it inhibits
se rotonin a nd nore pine phrine re upta ke , a nd it e nha nce s se rotonin
re le a se . Tra ma dol-induce d a na lge sia is not e ntire ly re ve rse d with
na loxone ; howe ve r, the re spira tory de pre ssion a nd se da tion ca n be
re ve rse d. Onda nse tron, a se rotonin a nta gonist, ma y inte rfe re with
pa rt of tra ma dol’s a na lge sic a ction. Be ca use of its low µ-re ce ptor
a gonist a ctivity, it ma y be le ss like ly to produce physica l
de pe nde nce tha n othe r stronge r na rcotics. Se izure s ha ve be e n
re porte d in pa tie nts re ce iving tra ma dol a lone . The drug should be
use d with ca ution in pa tie nts ta king drugs tha t lowe r the se izure
thre shold, such a s tricyclic a ntide pre ssa nts a nd SSRIs. It ha s some
monoa mine oxida se (MAO) inhibiting a ctivity a nd should not be
use d in pa tie nts ta king MAO inhibitors. Anothe r wa rning is its use
in pa tie nts who a re de pre sse d or suicida l. Tra ma dol is not
re comme nde d in de pre sse d or suicida l pa tie nts be ca use e xce ssive
dose s, e ithe r a lone or with othe r CNS de pre ssa nts including
a lcohol, a re a ma jor ca use of drug-re la te d de a ths with fa ta litie s
re porte d within the first hour of ove rdosa ge . Pa tie nts who a re
de pre sse d or suicida l a re be tte r ma na ge d with non-na rcotic
a na lge sics (Hard m an: Good m an & Gilm an’s Th e Ph arm acological Basis
of Th erapeutics, ed 10, p 590; Ph y sicians’ Desk Reference 2009, ed 63, pp
2428–2431; Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, p 117).
491. (A) The null hypothe sis sta te s tha t the re is no diffe re nce
be twe e n two groups of da ta , while the a lte rna tive hypothe sis
sta te s the opposite or tha t the re is a diffe re nce be twe e n the
groups. The P va lue is de rive d from a te st sta tistic a nd is the
proba bility tha t we could ha ve obse rve d a diffe re nce if in re a lity
the null hypothe sis wa s true a nd the re wa s not a diffe re nce . If the
P va lue is le ss tha n a pre de te rmine d le ve l of significa nce (the α
va lue , ofte n se t a t = 0.05) the n the null hypothe sis (no diffe re nce ) is
re je cte d a nd the diffe re nce s obse rve d a re sta te d to be sta tistica lly
significa nt (P < 0.05). It ca n the n be sta te d tha t it is unlike ly
(ca lcula te d to be le ss tha n a 1 in 20 proba bility) tha t the diffe re nce s
de te cte d in the two groups occurre d by ra ndom cha nce or tha t the
null hypothe sis wa s true . W he n the P va lue is le ss tha n α but the re
a ctua lly is not a diffe re nce be twe e n the groups, it is ca lle d a type 1
e rror.
On the othe r ha nd, if no sta tistica lly significa nt diffe re nce s a re
de te cte d (P va lue > α), we a cce pt tha t the null hypothe sis (no
diffe re nce e xists) is true . If we a cce pt the null hypothe sis whe n
the a lte rna tive hypothe sis (the re is a diffe re nce ) is in fa ct true , a
type 2 e rror ha s occurre d. Type 2 e rrors a re re la te d to the powe r
of the study. Powe r is the proba bility of re je cting the null
hypothe sis (no diffe re nce ) whe n a spe cific a lte rna tive hypothe sis
(diffe re nce ) is corre ct. Powe r is re la te d to the ma gnitude of the
diffe re nce to de te ct, the va ria bility of the da ta , the α le ve l, a nd
the sa mple size . Ofte n a powe r of 0.8 is se le cte d, me a ning tha t
we a cce pt a n 80% proba bility tha t the null hypothe sis (no
diffe re nce ) is true or tha t the re is a lso a 20% cha nce tha t a
diffe re nce doe s e xist but wa s not obse rve d. La rge r sa mple size s
ma ke it e a sie r to obse rve tha t a diffe re nce e xists a nd incre a se
the powe r of a n a na lysis (Miller: Miller’s Anesth esia, ed 8, pp 3250–
3251).
492. (D) In the a bse nce of diure tics, oliguria a ssocia te d with urine
sodium conce ntra tion gre a te r tha n 40 mEq/L a nd urine osmola lity
le ss tha n 400 mOsm/L is strongly sugge stive of intrinsic re na l
dise a se (e .g., a cute tubule ne crosis), whe re a s pre re na l ca use s
ha ve urine sodium conce ntra tion le ss tha n 20 mEq/L a nd urine
osmola lity gre a te r tha n 400 mOsm/L. Furose mide , ma nnitol, a nd
dopa mine , howe ve r, obscure the a ccura te dia gnosis (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 335–338; Miller:
493. (C) In a n unconscious pa tie nt, a unila te ra l dila te d pupil would
be a ma tte r of gra ve conce rn. In a n a wa ke pa tie nt with a norma l
ne urologic e xa mina tion, howe ve r, it is le ss worrisome . An infe rior
a lve ola r ne rve block involve s inje ction of a bout 2 mL of 2%
lidoca ine a round the infe rior a lve ola r ne rve just be hind the mola rs
in the lowe r ja w. Eve n a grossly misdire cte d ne e dle proba bly could
not re a ch the ste lla te ga nglion, but we re it possible , the re sult
would be a Horne r syndrome (miosis, not mydria sis, ptosis,
a nhidrosis, a nd va sodila tion ove r the fa ce ). Blocka de of the cilia ry
ga nglion could ca use mydria sis on the ipsila te ra l side , but re a ching
the cilia ry ga nglion, loca te d be twe e n the optic ne rve a nd la te ra l
re ctus muscle a bout 1 cm from the poste rior limit of the orbit,
would be a lmost impossible with a ne e dle dire cte d towa rd the
ma ndible . Glycopyrrola te a dministe re d syste mica lly doe s not ca use
mydria sis, a s it is not ca pa ble of crossing the blood-bra in ba rrie r.
Lidoca ine instille d dire ctly into the e ye doe s not produce mydria sis,
but phe nyle phrine doe s. Ca re must be ta ke n not to spra y loca l
a ne sthe tic (with or without va soconstrictor) into the e ye s while
a pplying topica l a ne sthe sia to the na re s (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, p 304).
494. (C) MAC is the minimum a lve ola r conce ntra tion of a ne sthe tic
tha t will pre ve nt move me nt of 50% of pa tie nts whe n a skin incision
is ma de a t se a le ve l (e .g., Sa n Die go). MAC × 1.3 will pre ve nt
move me nt in 95% of pa tie nts. In this que stion, tota l ga s flow is
4 L/min (1 L/min + 3 L/min). Roughly 75% of the tota l ga s is N2O. The
MAC of N2O is 104%. The pa tie nt is re ce iving a bout 0.75 MAC N2O.
The MAC for isoflura ne is 1.15. A conce ntra tion of 0.85% would
re pre se nt 0.75 MAC. Be ca use MACs a re a dditive , the tota l MAC
would be 1.5 (Barash : Clinical Anesth esia, ed 7, pp 458–459; Miller:
495. (D) Ca rdia c output incre a se s by a bout 100 mL/min for e a ch
kilogra m of we ight ga ine d. It is e stima te d tha t e ve ry kilogra m of
a dipose tissue conta ins ne a rly 3000 m of a dditiona l blood ve sse ls.
The a dditiona l ca rdia c output is due to ve ntricula r dila tion a nd
incre a se d stroke volume , a s re sting he a rt ra te s a re not incre a se d
in obe se pa tie nts (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, p 318; Miller: Basics of Anesth esia, ed 6, pp 83–84).
496. (C) Fe noldopa m (Corlopa m) is a se le ctive dopa mine -1 re ce ptor
a gonist with significa nt va sodila ting prope rtie s. It ha s mode ra te
a ffinity for α2 re ce ptors but ha s no a ffinity for dopa mine -2, α1, β, 5-
hydroxytrypta mine type 1 (5-HT 1), or 5-HT 2 re ce ptors. It is use d for
tre a tme nt of pa tie nts with se ve re hype rte nsion (e spe cia lly with
re duce d re na l function) a nd is a dministe re d a s a n IV infusion. It
ca n be use d a s a n a lte rna tive to sodium nitroprusside a nd ha s the
a dva nta ge of no thiocya na te toxicity, re bound e ffe ct, or “corona ry
ste a l” e ffe ct, but it doe s conta in sodium bisulfite a nd is
contra indica te d in pa tie nts with a known sulfite se nsitivity.
Dope xa mine (Dopa ca rd) is a synthe tic a na log re la te d to dopa mine
with intrinsic a ctivity a t dopa mine a s we ll a s β2 re ce ptors a nd is
use d a s a n inotropic a ge nt (Miller: Miller’s Anesth esia, ed 8, pp 367–
368).
497. (B) Ide a lly, fa ctor VIII le ve ls should be ra ise d to 100% pre dicte d
be fore e le ctive surge ry to e nsure tha t the le ve ls will not fa ll be low
30% intra ope ra tive ly. Thirty pe rce nt of the norma l fa ctor VIII
conce ntra tion or gre a te r is thought to be ne ce ssa ry for a pa tie nt
who is to unde rgo ma jor surge ry. Elimina tion ha lf-time of fa ctor VIII
is 12 hours. This ma y be a ccomplishe d with fa ctor VIII conce ntra te
or cryopre cipita te . Fre sh froze n pla sma is no longe r conside re d
the ra py for he mophilia (Hines: Stoelting’s Anesth esia and Co-Ex isting
498. (A) He mophilia A is a ssocia te d with de cre a se d le ve ls of fa ctor
VIII. PTT te sts the intrinsic coa gula tion ca sca de a nd would be
a bnorma lly e le va te d in a ll but the most mild dise a se . A norma l
PTT is 25 to 35 se conds. Pla te le t count, PT, a nd ble e ding time s a re
norma l (se e a lso e xpla na tion to Que stion 395) (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, p 421; Barash : Clinical
499. (D) Conve ntiona l pe riphe ra l ne rve stimula tors de live r four
twitche s a t 2 Hz spa ce d 0.5 se cond a pa rt. The se de vice s we re
de signe d with the knowle dge tha t succe ssive twitche s de ple te
a ce tylcholine store s. Afte r the fourth twitch, the re is no a dditiona l
de cre me nt in twitch he ight (Miller: Basics of Anesth esia, ed 6, p 156).
500. (B) Infe rior ische mia is a ssocia te d with blocka ge or spa sm of
the right corona ry a rte ry. The right corona ry a rte ry supplie s blood to
the a triove ntricula r node in 90% of pa tie nts. Comple te he a rt block
the re fore is not une xpe cte d in pa tie nts with se ve re CAD involving
the right corona ry a rte ry (Hines: Stoelting’s Anesth esia and Co-Ex isting
501. (B) MAC is influe nce d by a va rie ty of dise a se sta te s, conditions,
drugs, a nd othe r fa ctors. Drugs tha t incre a se CNS ca te chola mine s,
such a s MAO inhibitors, tricyclic a ntide pre ssa nts, a cute
a mphe ta mine inge stion, a nd coca ine , incre a se MAC. Othe r fa ctors
tha t incre a se MAC include hype rthe rmia , hype rna tre mia , pa tie nts
with na tura l re d ha ir, a nd infa ncy. It is inte re sting tha t MAC va lue s
a re highe r for infa nts tha n for ne ona te s or olde r childre n a nd
a dults. Thyroid gla nd dysfunction including hype rthyroidism doe s
not a ffe ct the MAC. Fa ctors tha t lowe r MAC include na rcotics, IV
a ne sthe tics, loca l a ne sthe tics (e xce pt coca ine ) a nd othe r se da tive s,
a ge (6% pe r de ca de ), hypothe rmia , hypoxia , a nd se ve re a ne mia
(e .g., Hgb < 5). The following ta ble modifie d from the re fe re nce s in
this que stion summa rize s the impa ct of va rious fa ctors on MAC
(Barash : Clinical Anesth esia, ed 7, pp 458-459; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, p 164; Miller: Basics of
IMPACT OF PHYSIOLOGIC AND PHARMACOLOGIC FACTORS ON
MINIMUM ALVEOLAR CONCENTRATION (MAC)
No Change in Increase in MAC Decrease in MAC

MAC
Duration of Drugs that increase CNS catecholamines CNS depressants
anesthesia (MAO inhibitors, tricyclic antidepressants, (narcotics, IV
Type of surgery acute amphetamine use, cocaine, anesthetics, chronic
Hyperthyroidism ephedrine) amphetamine use)
Hypothyroidism Chronic ethanol abuse Acute ethanol use
Gender Hyperthermia Hypernatremia
Hyperkalemia Hypothermia Hyponatremia
Infants Increasing age
Patients with natural red hair Pregnancy
Hypoxia
CNS, central nervous system; MAO, monoamine oxidase.
502. (B) Long-te rm lithium the ra py in pa tie nts with ma nic-de pre ssive
illne ss ma y be a ssocia te d with ne phroge nic dia be te s insipidus.
Hypothyroidism ma y de ve lop in a bout 5% of pa tie nts be ca use
lithium ca n inhibit the re le a se of thyroid hormone s. Lithium is
a lmost 100% re na lly e xcre te d. Re a bsorption occurs a t the proxima l
convolute d tubule a nd is inve rse ly re la te d to the conce ntra tion of
sodium in the glome rula r filtra te . Conse que ntly, a dministra tion of
diure tics (ma inly thia zide , but to a le sse r e xte nt loop diure tics) ma y
le a d to the de ve lopme nt of toxic lithium le ve ls. Lithium ha s
se da tive prope rtie s a nd ma y re duce the ne e d for IV a nd
inha la tiona l a ne sthe tic a ge nts. It ma y prolong the dura tion of a ction
of both pa ncuronium a nd succinylcholine , but it is not a ssocia te d
with a n e xa gge ra te d re le a se of pota ssium whe n succinylcholine is
a dministe re d (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 448–449; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, p 539).
503. (D) Ca rcinoid tumors ca n a rise whe re ve r e nte rochroma ffin
ce lls a re pre se nt. Most (>70%) origina te in the inte stine , a nd a bout
20% origina te in the lung. Of those tha t origina te in the
ga strointe stina l tra ct, 50% occur in the a ppe ndix, 25% in the ile um,
a nd 20% in the re ctum. The se inte re sting tumors we re ca lle d
ca rcinoid be ca use the y we re origina lly be lie ve d not to me ta sta size .
We now know this is not true . The hormone s re le a se d by the
nonme ta sta tic tumors re a ch the live r by the porta l ve in a nd a re
ra pidly ina ctiva te d. Howe ve r, once me ta sta se s re a ch the live r, the
re le a se d hormone s re a ch the syste mic circula tion a nd produce
signs a nd symptoms of the “ca rcinoid syndrome .” Symptoms
include cuta ne ous flushing, a bdomina l pa in, vomiting, dia rrhe a ,
hypote nsion or hype rte nsion, bronchospa sm, a nd hype rglyce mia .
The na tura l hormone soma tosta tin suppre sse s the re le a se of
se rotonin a nd othe r va soa ctive substa nce s from the tumor. Be ca use
the ha lf-life is a bout 3 minute s, soma tosta tin is give n by infusion.
Octre otide is a synthe tic soma tosta tin a na log with a ha lf-life of
2.5 hours a nd is give n SQ or IV for the pre ve ntion a nd tre a tme nt of
ca rcinoid symptoms (e .g., hypote nsion, hype rte nsion,
bronchospa sm). Howe ve r, the tre a tme nt of hypote nsion in pa tie nts
with ca rcinoid dise a se is diffe re nt be ca use e phe drine ,
e pine phrine , a nd nore pine phrine ca n re le a se va soa ctive hormone s
from the tumor a nd ma ke the hypote nsion worse . Hypote nsion is
be st tre a te d with fluids a nd IV octre otide or soma tosta tin.
Hype rte nsion is tre a te d with de e pe ning the a ne sthe tic a nd
a dministe ring octre otide , soma tosta tin, or la be ta lol. Bronchospa sm
is tre a te d with IV octre otide , soma tosta tin, or ne bulize d
ipra tropium. W he n giving a ne sthe sia to the se pa tie nts it is proba bly
wise to a void drugs tha t re le a se hista mine a nd othe r va soa ctive
hormone s tha t ma y pre cipita te symptoms. Propofol or e tomida te
a re good induction a ge nts, followe d by ma inte na nce a ne sthe sia
with a vola tile a ne sthe tic (e .g., isoflura ne , se voflura ne , or
de sflura ne ) a nd/or nitrous oxide with oxyge n. Ve curonium,
cisa tra curium, a nd rocuronium a ppe a r to be sa fe muscle re la xa nts.
Fe nta nyl, sufe nta nil, a lfe nta nil, re mife nta nil, a nd be nzodia ze pine s
a re a lso sa fe to use . The se rotonin a nta gonist onda nse tron is a
use ful a ntie me tic (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, pp 297–298).
504. (B) Te sticula r inne rva tion ca n be tra ce d up to the T10
de rma toma l le ve l. For this re a son, a ny ope ra tion tha t involve s
ma nipula tion or tra ction on the te sticle s must ha ve a de qua te
a ne sthe sia to pre ve nt pa in. This ca n be a chie ve d with spina l or
e pidura l a ne sthe sia , which is a ssocia te d with a T10 le ve l of
blocka de (Barash : Clinical Anesth esia, ed 7, p 916).
505. (D) The Gla sgow Coma Sca le ha s thre e ca te gorie s: e ye
ope ning, for which a ma ximum of 4 points ca n be re ce ive d; be st
ve rba l re sponse , for a ma ximum of 5 points; a nd be st motor
re sponse , for a ma ximum of 6 points. The highe r the score , the
be tte r the re sponse ; the minima l score for e a ch ca te gory is 1. Mild
he a d injury score s a re 13 to 15, mode ra te a re 9 to 12, a nd se ve re
a re 3 to 8. This se ve re he a d-injure d pa tie nt is tota lly unre sponsive
a nd would re ce ive a score of 3 (Barash : Clinical Anesth esia, ed 7, p
1018).
506. (A) Insulin me ta bolism involve s both the live r a nd kidne ys.
Re na l dysfunction, howe ve r, ha s a gre a te r impa ct on insulin
me ta bolism tha n doe s he pa tic dysfunction. In fa ct, une xpe cte d
prolonge d e ffe cts of insulin some time s a re se e n in pa tie nts with
re na l dise a se (Stoelting: Ph arm acology and Ph y siology in Anesth etic
507. (B) Most pulse oxime te rs illumina te tissue with two
wa ve le ngths of light: 660-nm re d light a nd 940-nm infra re d light.
Be ca use ca rboxyhe moglobin ha s a n a bsorba nce a t 660 nm, ve ry
simila r to O2 he moglobin, it produce s a fa lse ly e le va te d Sa O2 whe n
pre se nt in the blood. He moglobin F, bilirubin, a nd fluore sce in dye
ha ve no e ffe ct on pulse oxime try. Me thyle ne blue , a s we ll a s indigo
ca rmine a nd indocya nine gre e n, lowe rs the Sa O2 a s me a sure d by
pulse oxime try. Me the moglobin a bsorbs re d a nd infra re d light
e qua lly we ll a nd give s sa tura tion re a dings of 85% (Barash : Clinical
Anesth esia, ed 7, pp 702–703; Miller: Basics of Anesth esia, ed 6, p 327).
508. (D) On Ma rch 4, 1984, Libby Zion, a n 18-ye a r-old colle ge
fre shma n, wa s a dmitte d with a high fe ve r, de hydra tion, a nd chills
to a Ne w York Hospita l a nd die d within a da y. The ca use of he r
de a th wa s wide ly be lie ve d to be due to a drug inte ra ction be twe e n
phe ne lzine , which she ha d ta ke n for de pre ssion, a nd me pe ridine ,
which wa s use d to ca lm he r down. This le d to a se rotonin
syndrome a nd more a gita tion. During the night he r te mpe ra ture
rose to 107° F (42° C) a nd she suffe re d a ca rdia c a rre st a nd could
not be re suscita te d. Coca ine ha d be e n de te cte d in he r body a nd
ma y ha ve contribute d to he r de a th a s we ll. This ca se wa s use d to
e xe mplify the fa ct tha t the inte rn a nd re side nts ta king ca re of he r
we re ove rworke d, a nd this e ve ntua lly le d to Ne w York Sta te
De pa rtme nt of He a lth Code , Se ction 405, known a s the Libby Zion
La w, which limits the a mount of work for re side nts to 80 hours pe r
we e k. In 2003, the Accre dita tion Council for Gra dua te Me dica l
Educa tion (ACGME) a dopte d re gula tions for me dica l tra ining in the
Unite d Sta te s. Since the n, studie s ha ve looke d a t fa tigue a nd
clinica l pe rforma nce . A ma jor pe a k in vulne ra bility occurs be twe e n
2 AM a nd 7 AM , with a sma lle r pe a k in the mida fte rnoon. Single -
occupa nt motor ve hicle a ccide nts occur more fre que ntly in the
morning. Although pa tie nt simula tion of the e ffe cts of sle e p
de priva tion ha ve be e n studie d, psychomotor pe rforma nce a nd
mood ha ve be e n a ffe cte d, but clinica l pe rforma nce wa s not
a ffe cte d. No diffe re nce in morta lity ra te s we re se e n in the 2 ye a rs
be fore compa re d to the 2 ye a rs a fte r the 2003 guide line s we re put
into e ffe ct, a nd no diffe re nce in morta lity wa s note d whe n la rge
te a ching progra ms (thought to be the most a ffe cte d) we re compa re d
to sma lle r progra ms (Lerner: A Life-Ch anging Case for Doctors in
Training, New York Tim es, August 14, 2011; Miller: Miller’s Anesth esia, ed
8, p 3239; New York State Departm ent of Health Cod e, Section 405, known
as th e Libby Zion Law).
509. (A) Ga ba pe ntin, a n a nticonvulsa nt, wa s de ve lope d to be a
ce ntra lly a ctive γ-a minobutyric a cid (GABA) a gonist but doe s not
a ppe a r to inte ra ct with GABA re ce ptors. Its me cha nism for
producing a na lge sia is uncle a r, but it ma y involve inhibition of
volta ge -a ctiva te d ca lcium cha nne ls a s we ll a s pote ntia ting GABA
re le a se . Ca rba ma ze pine slows the re cove ry ra te of volta ge -ga te d
sodium cha nne ls, but it a lso is a n a nticonvulsa nt. Ca rba ma ze pine
is indica te d in the tre a tme nt of trige mina l ne ura lgia (Benzon:
Essentials of Pain Med icine, ed 3, pp 123–129).
510. (B) In e va lua ting this pa tie nt in he a rt fa ilure (e .g., ra le s), one
obse rve s tha t the EF is high (e .g., 80%), a fte rloa d is high (e .g.,
e le va te d systolic blood pre ssure ), a nd the he a rt ra te is high (e .g.,
120 be a ts/min). Although he ha s diffuse ra le s (ofte n a sign of high
pre loa d a nd fluid ove rloa d), this pa tie nt is a ctua lly de hydra te d from
his bowe l pre p, a nd his le ft ve ntricle doe s not fill prope rly. To
compe nsa te for the low filling volume , the he a rt ra te incre a se s.
Pa tie nts with he a rt fa ilure a nd a norma l e je ction fra ction (HFNEF),
pre viously ca lle d dia stolic he a rt fa ilure , ha ve signs of le ft-side d
he a rt fa ilure . To be tte r unde rsta nd this, think of the he a rt a s a
hydra ulic pump tha t you ne e d to not only e mpty e ffe ctive ly (during
systole ) but a lso ne e d to fill e ffe ctive ly (during dia stole ). So in this
ca se , your ma in goa ls a re to slow the he a rt ra te to a llow the le ft
ve ntricle a de qua te time to fill (e .g., with a β-blocke r such a s
e smolol) a nd to be tte r oxyge na te him (e .g., incre a se the F IO2 a nd
a dd PEEP). The diure tic furose mide would e xa ce rba te the
situa tion. Othe r conditions in which the le ft ve ntricle doe s not fill
e ffe ctive ly include le ss complia nt ve ntricula r wa lls (e .g., thick from
long-sta nding hype rte nsion or a ortic va lve ste nosis, fibrotic wa lls),
le ss room to fill (e .g., ca rdia c ta mpona de ), loss of the a tria l kick
(e .g., a tria l fibrilla tion), a nd va lvula r ste nosis (e .g., mitra l ste nosis)
(Miller: Basics of Anesth esia, ed 6, p 172; Butterworth : Morgan &
511. (B) Pe riope ra tive visua l loss a ssocia te d with nonocula r surge ry
is ra re a nd ma y re sult from corne a l tra uma , re tina l a rte ry
occlusion, re tina l ve in occlusion, optic ne rve ische mia , or cortica l
dise a se . Although ove ra ll it is a ra re proble m, it ma y de ve lop in up
to 1% of prone spina l surgica l ca se s a nd is most commonly due to
ische mic optic ne uropa thy. The ca use is unknown a nd
multifa ctoria l. Associa te d fa ctors include prolonge d intra ope ra tive
hypote nsion, a ne mia (Hgb <8), la rge intra ope ra tive blood loss,
prolonge d surge ry, a nd fa cia l e de ma . It is more common in ma le s
a nd in pa tie nts with pe riphe ra l va scula r dise a se , dia be te s me llitus,
a nd in toba cco use rs (Miller: Miller’s Anesth esia, ed 8, pp 3011–3012).
512. (D) Postope ra tive shive ring or posta ne sthe tic tre mor ca n occur
during re cove ry from a ll type s of ge ne ra l a ne sthe sia . If profound,
shive ring ca n incre a se me ta bolic ra te a nd O2 consumption (100% to
200%) with a n a ssocia te d incre a se in ca rdia c output a nd minute
ve ntila tion. Although shive ring usua lly occurs in pa tie nts with
de cre a se d body te mpe ra ture , it a lso ma y occur in pa tie nts with
norma l body te mpe ra ture a fte r a ne sthe sia . Posta ne sthe sia
shive ring is be st tre a te d by a combina tion of supple me nta l oxyge n,
re wa rming the pa tie nt, a nd/or a dministe ring IV me pe ridine . Othe r
le ss fre que ntly use d pha rma cologic tre a tme nts include clonidine ,
ma gne sium sulfa te , ca lcium chloride , chlorproma zine , drope ridol,
a nd othe r opioids (e .g., butorpha nol). Applica tion of ra dia nt he a t to
the fa ce , he a d, ne ck, che st, a nd a bdome n ha s be e n shown to
e limina te shive ring within minute s in postope ra tive pa tie nts,
de spite low core body te mpe ra ture s (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 1185, 1264; Miller: Basics of
513. (C) The ECG signs of hype rka le mia include na rrowe d a nd
pe a ke d T wa ve s (e a rlie st ma nife sta tion of hype rka le mia ),
de cre a se in P-wa ve a mplitude , prolonge d PR inte rva l, a nd a
wide ne d QRS inte rva l. In e xtre me ca se s, the ECG ca n a ppe a r a s a
sine wa ve a s we ll a s ca rdia c a rrhythmia s (e .g., sinus a rre st,
supra ve ntricula r ta chyca rdia , a tria l fibrilla tion, pre ma ture
ve ntricula r contra ctions, ve ntricula r ta chyca rdia , a nd ve ntricula r
fibrilla tion). The se cha nge s a re pote ntia te d by hypoca lce mia , a nd
intra ve nous ca lcium ca n ra pidly corre ct some of the se ECG
cha nge s. An incre a se in U-wa ve a mplitude sugge sts hypoka le mia ,
not hype rka le mia (Miller: Miller’s Anesth esia, ed 8, pp 1205–1206).
514. (B) If the inspira tory va lve be come s stuck in the ope n position,
it will “ma lfunction” only during e xha la tion be ca use , during
inha la tion, it is suppose d to be ope n. During the e xha la tion pha se
of bre a thing, e xha le d ga se s will e xit through the e xpira tory va lve
into the e xpira tory limb of the circuit a nd be yond (prope r pa th), a s
we ll a s through the inspira tory va lve into the inspira tory limb of the
circuit (e rra nt pa th). Ga se s tra ve ling into the inspira tory limb (old
ga s) will be re turne d to the pa tie nt with ne xt bre a th. The volume of
re ce ntly e xha le d ga s is now dra wn ba ck into the pa tie nt’s lungs
a long with the “ne w” ga s tha t would be inspire d in a fully
functiona l bre a thing circuit. The ne t e ffe ct is tha t oxyge n,
se voflura ne , a nd N2O will a ll be dilute d, but the pa tie nt re bre a the s
CO2; thus, it will be the only ga s with a n incre a se d inspire d
conce ntra tion (norma l inspire d CO2 is ze ro) a s a re sult of the stuck
inspira tory va lve (Miller: Basics of Anesth esia, ed 6, p 208).
515. (D) Enla rge me nt of the tongue a nd e piglottis pre dispose s the
pa tie nt to uppe r a irwa y obstruction a nd ma ke s visua liza tion of the
voca l cords more difficult. The voca l cords a re e nla rge d, ma king
the glottic ope ning na rrowe r. In a ddition, subglottic na rrowing ma y
be pre se nt a s we ll a s tra che a l compre ssion from a n e nla rge d
thyroid (se e n in a bout 25% of a crome ga lic pa tie nts). This ofte n
ne ce ssita te s the use of a na rrowe r e ndotra che a l tube tha n one
might choose ba se d on the fa cia l e nla rge me nt. The pla ce me nt of
na sa l a irwa ys ma y be more difficult due to the e nla rge d na sa l
turbina te s. The use of CPAP is contra indica te d a fte r
tra nssphe noida l hypophyse ctomy (Barash : Clinical Anesth esia, ed 7, p
1351; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 404).
516. (A) The re a re four type s of immune -me dia te d a lle rgic
re a ctions. Ana phyla xis is a type I IgE-me dia te d re a ction tha t
involve s ma st ce lls a nd ba sophils. Ana phyla ctoid re a ctions a ppe a r
like a na phyla xis but a re not immune me dia te d. Trypta se is a
ne utra l prote a se norma lly store d in ma st ce lls but is re le a se d into
syste mic circula tion during a na phyla ctic but not a na phyla ctoid
re a ctions. Trypta se le ve ls would ne e d to be me a sure d within 1 to
2 hours of the suspe cte d a lle rgic re a ction. Pla sma hista mine le ve ls
re turn to ba se line within 30 to 60 minute s of a n a na phyla ctic
re a ction. La uda nosine is a norma l me ta bolic product of a tra curium
me ta bolism (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 523–524; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, pp 1217–1221).
517. (B) Signs of MH re fle ct the hype rme ta bolic sta te (up to 10 time s
norma l) tha t de ve lops. Clinica l signs include ta chyca rdia ,
ta chypne a , a rte ria l hypoxe mia , hype rca rbia (e .g., Pa CO2 100-
200 mm Hg), me ta bolic, a nd re spira tory a cidosis (e .g., pH 6.80-7.15),
hype rka le mia , hypote nsion, muscle rigidity, trismus a fte r
succinylcholine a dministra tion, a nd incre a se d body te mpe ra ture .
Mixe d ve nous oxyge n te nsion would be ve ry low. The clinica l
pre se nta tions a re quite va ria ble , a nd some re a ctions ma y not
de ve lop until the postope ra tive pe riod (Hines: Stoelting’s Anesth esia
and Co-Ex isting Disease, ed 6, pp 635–640).
518. (D) The SSRI fluoxe tine is one of the most pote nt inhibitors of
the cytochrome P-450 e nzyme s CYP3A4 a nd CYP2D6. CYP2D6
fa cilita te s the conve rsion of code ine to morphine , me a ning the
re sponse from a “norma l” dose would be le ss tha n e xpe cte d
be ca use of de cre a se d conve rsion. Oxycodone a nd hydrocodone
a re me ta bolize d by CYP2D6 to the ir a ctive form a s we ll, a nd a
“norma l” dose of the se would give le ss re sponse tha n e xpe cte d.
Thus, code ine , oxycodone , a nd hydrocodone would be poor
a na lge sic choice s for pa tie nts ta king SSRIs. CYP3A4 is re sponsible
for the me ta bolism of fe nta nyl, sufe nta nil, a nd a lfe nta nil.
Re mife nta nil is me ta bolize d by nonspe cific pla sma e ste ra se s
519. (A) Symptoms of a ma inste m or bronchia l intuba tion include
a symme tric che st e xpa nsion, unila te ra l bre a th sounds, e le va tion of
pe a k a irwa y pre ssure s, a nd ABG a bnorma litie s (e .g., hypoxe mia ).
Fre que ntly, bronchia l intuba tion is inte ntiona l (e .g., thora cic surge ry
with double -lume n e ndotra che a l tube s), but, if unde te cte d with a
single -lume n tube , a te le cta sis, hypoxia , a nd pulmona ry e de ma ma y
re sult in time . Pe a k a irwa y pre ssure s ca n a lso incre a se with ma ny
conditions such a s a irwa y obstruction (e .g., kinke d e ndotra che a l
tube , se cre tions, ove rinfla te d cuffs), bronchospa sm, incre a sing VT,
incre a se in che st wa ll muscle tone (rigid che st with na rcotics,
coughing), a nd te nsion pne umothora x. If a te nsion pne umothora x
de ve lops, a ssocia te d hypote nsion usua lly is pre se nt. Pulmona ry
e mbolism would not ca use the pe a k a irwa y pre ssure to rise a s in
this ca se (Lobato: Com plications in Anesth esiology, pp 101–102).
520. (D) Although he modyna mic insta bility ca n occur a t a ny time
during live r tra nspla nta tion, it is during the initia l pa rt of the
re pe rfusion pha se , whe n the va scula r cla mps a re re move d from
the live r gra ft, whe n ca rdiova scula r insta bility is most ma rke d. At
this time the re ca n be profound hypote nsion, re duce d ca rdia c
contra ctility, ca rdia c a rrhythmia s, a nd hype rka le mic ca rdia c a rre st.
Epine phrine , a tropine , ca lcium, a nd sodium bica rbona te should be
a va ila ble , a s we ll a s blood products, during this critica l pa rt of the
surge ry (Miller: Miller’s Anesth esia, ed 8, pp 2281–2282; Miller: Basics of
521. (D) Me ta bolic a nd physiologic conditions a s we ll a s ce rta in
me dica tions ca n contribute to a prolonge d dura tion of a ction of
nonde pola rizing ne uromuscula r blocka de . Me ta bolic a nd
physiologic conditions include re spira tory a cidosis, mya sthe nia
syndrome s, he pa tic/re na l fa ilure , hypoca lce mia , hypothe rmia , a nd
hype rma gne se mia . Both inha le d a nd loca l a ne sthe tics a s we ll a s
corticoste roids, ma ny a ntibiotics (e .g., polymyxins,
a minoglycoside s, lincosa mine s [e .g., clinda mycin], me tronida zole
[Fla gyl]), ca lcium cha nne l blocke rs, da ntrole ne , a nd furose mide
ca n prolong nonde pola rizing ne uromuscula r blocka de (Miller: Basics
522. (A) PONV is the se cond most common compla int from pa tie nts
a fte r surge ry (postope ra tive pa in is the numbe r one compla int). Of
the ma ny inde pe nde nt pre dictors of PONV in a dult prospe ctive
studie s, fe ma le ge nde r is the stronge st pre dictor for PONV a nd the
ne e d for postope ra tive a ntie me tic re scue tre a tme nts. It is
inte re sting to note tha t a lthough pa tie nts ofte n e xpe rie nce na use a
whe n smoking the ir first ciga re tte s, smoke rs ha ve a lowe r
incide nce of PONV compa re d to nonsmoke rs. Othe r pre dictors of
PONV include nonsmoke rs, pre vious history of PONV, history of
migra ine he a da che s, use of postope ra tive na rcotics, le ngthy
surgica l proce dure s, use of nitrous oxide , a nd the use of vola tile
a ne sthe tics (Miller: Miller’s Anesth esia, ed 8, pp 2947–2954).
523. (D) Ra re muscle dise a se s ca n ha ve dra ma tic a ne sthe tic
implica tions. MH is a mong the most importa nt ma nife sta tions of a
muscula r disorde r. MH is thought to be ca use d by a lte ra tions in
ca lcium control in muscle sa rcopla smic re ticulum in re sponse to
succinylcholine or pote nt vola tile a ne sthe tics (most like ly me dia te d
by muta tions of the rya nodine re ce ptor). Be ca use MH is a disorde r
in muscle me ta bolism, rigidity during a dministra tion of a vola tile
a ne sthe tic or a fte r succinylcholine use ma y be the pre se nting sign.
Additiona lly, a dministra tion of a ny muscle re la xa nt would not
provide muscle re la xa tion, a nd succinylcholine would be
contra indica te d. The pa tie nt doe s ha ve a re spira tory a nd me ta bolic
a cidosis a nd significa ntly incre a sing minute ve ntila tion with 100%
oxyge n, a nd the use of sodium bica rbona te would be ne e de d;
howe ve r, stopping the trigge ring a ge nt a nd a dministra tion of
da ntrole ne is most importa nt (Hines: Stoelting’s Anesth esia and Co-
524. (D) Atropine a nd scopola mine cross the pla ce nta e a sily,
whe re a s glycopyrrola te is poorly tra nsfe rre d a cross the pla ce nta .
Although ne ostigmine crosse s the pla ce nta poorly, e nough doe s
cross the pla ce nta a nd ca n ca use fe ta l bra dyca rdia in ute ro. Tha t is
why it is be tte r to re ve rse muscle re la xa nts in pre gna nt pa tie nts for
nonde live ry surge ry with ne ostigmine a nd a tropine (Butterworth :
525. (A) W ith live r fa ilure , the live r ca nnot a de qua te ly de toxify
noxious che mica ls. Fifty to se ve nty pe rce nt of pa tie nts with e nd-
sta ge live r dise a se de ve lop HE. Symptoms va ry from mild
confusion, drowsine ss, a nd stupor to coma . The e tiology of HE is
comple x. Be ca use a n e le va tion in blood a mmonia le ve ls (e a sily
me a sure d) is strongly a ssocia te d with HE, tre a tme nt is a ime d a t
lowe ring the a mmonia le ve l. Othe r toxins a lso contribute to HE. To
lowe r the a mmonia le ve l, la ctulose (which de cre a se s the
a bsorption of a mmonia ) a nd ne omycin (which re duce s the
production of a mmonia by re ducing the a mmonia -producing
inte stina l flora ) a re commonly a dministe re d. Prote in re striction is
commonly done to de cre a se a mmonia production, so a mino a cid–
rich TPN is not he lpful. Fluma ze nil (a GABA re ce ptor a nta gonist)
ha s be e n shown to produce short-dura tion re ve rsa l of the
symptoms of HE in some pa tie nts a nd thus sugge sts tha t GABA
re ce ptors a re some how a ctiva te d during HE. GABA re ce ptors a re
re sponsible for inhibitory ne urotra nsmission in the CNS (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 280; Miller: Basics
526. (C) Ke torola c is one of the fe w nonste roida l a nti-infla mma tory
drugs (NSAIDs) a pprove d for pa re nte ra l use . Although NSAIDs ha ve
a na lge sic a nd a nti-infla mma tory e ffe cts without ve ntila tory
de pre ssion, the y a lso inhibit pla te le t a ggre ga tion, ca n produce
ga stric ulce ra tion, a re a ssocia te d with re na l dysfunction, a nd ma y
impa ir bone he a ling. NSAIDs a re contra indica te d in pa tie nts
unde rgoing spina l fusion, whe re bone he a ling is e sse ntia l to a
succe ssful surgica l proce dure (Miller: Miller’s Anesth esia, ed 8, p
2982).
527. (A) Sickle ce ll a ne mia is a n inhe rite d dise a se tha t a ffe cts
a pproxima te ly 0.3% to 1% of the bla ck popula tion in the Unite d
Sta te s. Affe cte d pa tie nts a re homozygous for he moglobin S such tha t
70% to 98% of the he moglobin found in the ir RBCs is of the unsta ble
S type , re sulting in se ve re he molytic a ne mia . Fa ctors tha t fa vor the
forma tion of sickle ce lls include a rte ria l hypoxe mia , a cidosis,
de hydra tion, a nd re ductions in body te mpe ra ture . Inha le d nitric
oxide a nd othe r ne w inve stiga tiona l drugs ma y he lp re duce the
sickling proce ss a nd ma y e ve n unsickle ce lls (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 1177–1180; Hines: Stoeling’s
528. (A) Although ma ny books sugge st tha t obe sity is the most
common ca use of OSA, more re ce nt da ta sugge st tha t a la rge ne ck
circumfe re nce (>44 cm) re fle cts pha rynge a l fa t de position a nd is
more strongly corre la te d with OSA tha n obe sity (BMI >30). Othe r risk
fa ctors include ma le ge nde r, middle a ge , e ve ning a lcohol
consumption, or sle e p-inducing me dica tions (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, p 320; Miller: Miller’s
Anesth esia, ed 8, pp 2203–2204; Miller: Basics of Anesth esia, ed 6, pp 435–
436).
529. (D) The ASA close d cla ims ta sk force lists the le a ding ca use s of
ma lpra ctice cla ims a ga inst a ne sthe siologists in the 1990s to be
de a th (22%), followe d by ne rve da ma ge (21%) a nd bra in da ma ge
(10%) (Barash : Clinical Anesth esia, ed 7, pp 100–101).
530. (C) Ca rdia c re synchroniza tion the ra py (CRT) is use d in pa tie nts
with he a rt fa ilure (EF <35%) a nd ve ntricula r conductive de la y
(prolonge d QRS comple x usua lly is 120 to 150 mse c). The
conduction de la y cre a te s a me cha nica l dyssynchrony a nd worse ns
the he a rt fa ilure . CRT re quire s bive ntricula r pa cing with one le a d
in the corona ry sinus to a ctiva te the le ft ve ntricle . CRT ha s nothing
to do with bre a thing. Although CRT ha s nothing to do with a n
impla nta ble ca rdiove rte r-de fibrilla tor (ICD), ma ny pa tie nts ma y
re quire both be ca use typica lly a pa tie nt with poor le ft ve ntricle
function is a lso a t risk for sudde n de a th. Most of the se pa tie nts a lso
ha ve unde rlying CAD (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 129; Miller: Miller’s Anesth esia, ed 8, pp 2078–2079).
531. (D) Pa tie nts with syndrome X (a lso ca lle d me ta bolic syndrome
X) ha ve insulin re sista nce tha t le a ds to e le va te d le ve ls of insulin
a nd the me ta bolic cha nge s tha t occur with e le va te d insulin le ve ls,
e xce pt tha t hypoglyce mia doe s not de ve lop. Associa te d with it a re
low le ve ls of high-de nsity lipoprote ins, hype rte nsion, a nd incre a se d
pla sminoge n a ctiva tor inhibitor-1 le ve ls, which a re a ssocia te d with
CAD. Ma ny of the se pa tie nts a re obe se (Miller: Miller’s Anesth esia, ed
8, pp 2201–2203).
532. (C) The pa re nte ra l-to-ora l conve rsion for morphine sulfa te is
1:3; thus, 30 mg morphine pa re nte ra lly would be simila r to 30
mg × 3 = 90 mg of morphine ora lly. The pa re nte ra l-to-ora l
conve rsion for me tha done is 1:2 (Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, p 498).
533. (A) The VRG comprise s only 10% of the body but re ce ive s 75%
of the ca rdia c output. Equilibrium with a lve ola r pa rtia l pre ssure is
ra pid (8 to 10 minute s [4 time consta nts]). Afte r tha t point, upta ke is
a ccounte d for by the MG a nd this e quilibrium would be
a pproa che d in a time fra me on the orde r of 2 to 4 hours. The la st
compa rtme nt to re a ch e quilibrium is the VPG, which include s fa t.
This e quilibrium re quire s ma ny hours, e ve n da ys, to be a chie ve d.
W he n the va porize r is turne d off, the a lve ola r (a rte ria l) pa rtia l
pre ssure fa lls ra pidly. The pa rtia l pre ssure in the VRG would
a lso fa ll, a s would the MG. The fa t continue s to ta ke up vola tile
a ne sthe tic for hours a nd a ctua lly contribute s to re cove ry. The
pa rtia l pre ssure of ga s in the VPG a t the time the va porize r is
turne d off would be lowe r tha n the pa rtia l pre ssure in the VRG
a nd MG a nd thus would initia lly ta ke up some a ne sthe tic from
the highe r pre ssure VRG a nd MG (Miller: Miller’s Anesth esia, ed 8,
pp 639, 654–655).
534. (D) Re tinopa thy of pre ma turity (re trole nta l fibropla sia ) is a
ha za rd a ssocia te d with O2 a dministra tion to ne ona te s up to
44 we e ks (ge sta tiona l a ge + life a ge ). It is e spe cia lly a ha za rd in the
e xtre me ly pre ma ture (birth we ight <1000 g a nd ge sta tiona l a ge
<28 we e ks). Bronchopulmona ry dyspla sia is a chronic lung disorde r
tha t a fflicts infa nts who re quire d me cha nica l ve ntila tion a t birth to
tre a t re spira tory distre ss syndrome . CO2 re te ntion is a ha za rd in
pa tie nts with chronic obstructive lung dise a se . Adsorption
a te le cta sis is a pote ntia l ha za rd of oxyge n a dministra tion in a ny
pa tie nt re ce iving oxyge n conce ntra tions gre a te r tha n 50%. It re sults
from ra pid upta ke of oxyge n into the circula tion gre a te r tha n the
de live ry of oxyge n by ve ntila tion. Norma lly, the pre se nce of nitroge n
se rve s a s a n inte rna l splint, prote cting the a lve oli from colla pse .
Prolonge d high conce ntra tion of oxyge n ca n da ma ge “norma l
lungs” if give n for prolonge d pe riods of time a nd ma y le a d from
mild irrita tion to tra che obronchitis to pulmona ry inte rstitia l e de ma
to pulmona ry fibrosis (Miller: Miller’s Anesth esia, ed 8, pp 457–460,
1287–1288).
535. (A) All of the ne rve s liste d in this que stion a re de rive d from the
fifth cra nia l ne rve (trige mina l ne rve ) e xce pt the gre a t a uricula r
ne rve . The ophtha lmic ne rve (V1 bra nch of trige mina l ne rve ) give s
rise to the supra trochle a r, infra trochle a r, a nd supra orbita l ne rve s.
The infra orbita l ne rve is a bra nch of V2 (ma xilla ry bra nch of the
trige mina l ne rve ). The me nta l ne rve is a bra nch of V3 (ma ndibula r
ne rve ). The gre a t a uricula r ne rve a rise s from bra nche s of C2 a nd
C3 spina l ne rve s a nd inne rva te s the skin of the oute r e a r, the
ma stoid proce ss, a nd the pa rotid gla nd (Miller: Miller’s Anesth esia, ed
8, pp 1722–1724).
536. (D) Ce re bra l va sospa sm is ofte n a ssocia te d in pa tie nts who
ha ve suffe re d a suba ra chnoid ble e d. Angiogra phic e vide nce of
va sospa sm ca n be note d in up to 70% of pa tie nts; howe ve r, clinica l
va sospa sm with de te cta ble ische mia (e .g., me nta l confusion,
le tha rgy, foca l motor, a nd spe e ch impa irme nts) is de te cte d in a bout
30% of pa tie nts. W he n clinica l va sospa sm de ve lops, it usua lly
occurs be twe e n 4 a nd 12 da ys a fte r the ble e d. Although it ma y
re solve sponta ne ously, it ma y a lso progre ss to coma a nd de a th
within a fe w hours or da ys. Re ble e ding te nds to occur e a rlie r (i.e .,
within 24 hours) (Barash : Clinical Anesth esia, ed 6, pp 1585–1586).
537. (C) Ble omycin is use d prima rily in the tre a tme nt of Hodgkin
lymphoma a nd te sticula r tumors. Ble omycin ca use s oxida tive
da ma ge to nucle otide s, which le a ds to bre a ks in DNA. Although
the more common side e ffe cts of ble omycin use a re
mucocuta ne ous, it is the dose -re la te d pulmona ry toxicity tha t is the
most se rious side e ffe ct. Ea rly signs a nd symptoms of pulmona ry
toxicity include dry cough, fine ra le s, a nd diffuse infiltra te s on
ra diogra ph. Approxima te ly 5% to 10% of pa tie nts will de ve lop
pulmona ry toxicity, a nd a bout 1% will die from this complica tion.
Most be lie ve tha t the risk of pulmona ry toxicity incre a se s with dose
(e spe cia lly tota l dose >250 mg), pa tie nts olde r tha n 40 ye a rs of a ge ,
pa tie nts with a cre a tinine cle a ra nce (CrCl) of <80 mL/min, a nd in
pa tie nts with prior che st ra dia tion or pre e xisting pulmona ry
dise a se . Although a re la tionship a ppe a rs to e xist be twe e n the use
of ble omycin a nd the use of high conce ntra tions of oxyge n, the
de ta ils a re uncle a r. Curre ntly, it ha s be e n sugge ste d to use the
lowe st conce ntra tion of oxyge n consiste nt with pa tie nt sa fe ty, with
a ca re ful e va lua tion of oxyge n sa tura tion with pulse oxime try in a ny
pa tie nt who ha s re ce ive d ble omycin (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1716–1718; Miller:
Miller’s Anesth esia, ed 8, p 1943; Stoelting: Ph arm acology and Ph y siology
in Anesth etic Practice, ed 4, pp 555–565).
538. (B) The most common a dve rse ca rdia c e ve nt in the pe dia tric
popula tion is bra dyca rdia . An outcome study from the Me dica l
Colle ge of Virginia e xa mine d the incide nce of bra dyca rdia in ne a rly
8000 childre n younge r tha n 4 ye a rs old. The most common ca use s
of bra dyca rdia we re ca rdia c dise a se or surge ry a nd inha la tion
a ne sthe sia , followe d by hypoxe mia . Of those childre n who ha d
bra dyca rdia , hypote nsion occurre d in 30%, a systole or ve ntricula r
fibrilla tion in 10%, a nd de a th in 8%. Ta chyca rdia , which is common,
is not a n a dve rse e ve nt (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 1232–1236; Barash : Clinical Anesth esia, ed 7, p 1245;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 879).
539. (C) Ma sk ve ntila tion, one of the most ba sic a ne sthe sia
te chnique s, ca n be cha lle nging in some pa tie nts. Use of ma sk
ve ntila tion in pa tie nts who a re prone to a irwa y obstruction ca n be
more difficult be ca use of e xtra a irwa y tissue (i.e ., obe se pa tie nts
with a BMI >26), pa tie nts without te e th (i.e ., tongue is close r to the
roof of the mouth, a nd fa ce conformity ma y not fit the ma sk we ll),
a nd pa tie nts who snore (i.e ., a lre a dy ha ve re a son for a irwa y
obstruction). Ma sk ve ntila tion ca n a lso be more difficult in pa tie nts
who ha ve a be a rd (i.e ., ha rde r to ge t a good ma sk se a l), pa tie nts
whose a ge is olde r tha n 55 ye a rs, pa tie nts with fa cia l tumors, a nd
pa tie nts with fa cia l tra uma . Use of a n ora l a irwa y ma y be ne e de d
in ma ny of the se pa tie nts (Miller: Basics of Anesth esia, ed 6, p 227;
540. (A) W he ne ve r pe rfusion to a n e xtre mity is ina de qua te (e .g.,
tra uma or poor pe rfusion), hypoxic e de ma de ve lops, producing
swe lling. W he n this occurs in a compa rtme nt, tissue pre ssure s
rise , de cre a sing ca pilla ry pe rfusion. Symptoms of compa rtme nt
syndrome include e xtre me pa in unre lie ve d by a na lge sics,
pa re sthe sia s, pa ra lysis, a nd pa llor. Exte nsive rha bdomyolysis ma y
de ve lop a s we ll a s pe rma ne nt ne rve a nd muscle injury in the
compa rtme nt. Be ca use the proble m is a t the tissue le ve l, pulse s
a nd ca pilla ry re fill ma y still be pre se nt. Tre a tme nt include s
fa sciotomy to re lie ve the e le va te d pre ssure (Barash : Clinical
Anesth esia, ed 7, p 1514; Miller: Miller’s Anesth esia, ed 8, p 2450).
541. (B) The a mount a nd distribution of ce re brospina l fluid (CSF) is
diffe re nt in ne ona te s compa re d with a dults. The ne ona te ha s a bout
4 mL/kg of CSF compa re d to the a dult’s 2 mL/kg. In a ddition, a lmost
ha lf of the ne ona te ’s CSF is in the spina l suba ra chnoid spa ce ,
compa re d with a bout a qua rte r of the a dult’s CSF in the spina l
suba ra chnoid spa ce . The se fa ctors he lp e xpla in why the dose is
gre a te r in ne ona te s a nd infa nts a nd of shorte r dura tion compa re d
to a dults (Miller: Miller’s Anesth esia, ed 8, pp 2727–2728).
542. (A) Endotra che a l tube size s a re me a sure d a ccording to the ID.
The y a re a va ila ble in 0.5-mm ID incre me nts (Miller: Basics of
543. (B) MRI sca nne rs ha ve supe rconducting e le ctrica l curre nts tha t
produce la rge ma gne tic fie lds (up to 6 m) a nd a re a lwa ys “on”. The
pre se nce of a ny fe rroma gne tic obje cts in the room ma y ca use a
missile -type injury whe n the obje cts a re strongly a ttra cte d to the
sca nne r. If a pa tie nt is pinne d into the sca nne r by a ma gne tic obje ct
tha t fle w into the sca nne r, the MRI te chnicia ns ma y ha ve to turn off
the supe rconducting ma gne t. During ma gne tic shutdown (que nch)
the sca nne r will be come e xtre me ly cold (Miller: Basics of Anesth esia,
ed 6, p 621).
544. (C) Ca rbon monoxide is a colorle ss, odorle ss ga s tha t binds to
he moglobin with a n a ffinity more tha n 200 time s stronge r tha n
oxyge n. Inha la tion of CO is a ma jor ca use of morbidity a nd
morta lity in the Unite d Sta te s. A dua l-wa ve (660 nm a nd 940 nm)
pulse oxime te r is inca pa ble of distinguishing CO he moglobin from
oxyhe moglobin, but the distinction is e a sily ma de in the clinica l
la bora tory with a co-oxime te r. Significa nt qua ntitie s of
me the moglobin would re sult in a sa tura tion of 85% of the pulse
oxime te r. The slight right shift from a mild a cide mia would be
insufficie nt to a ccount for 90% sa tura tion in the fa ce of a Pa O2 of
190. Furthe rmore , the pulse oxime te r re a ding would be ne a rly the
sa me a s the co-oxime te r va lue (Miller: Miller’s Anesth esia, ed 8, pp
2679–2680; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
554–555).
545. (A) The pa thwa y for SSEP monitoring of the lowe r e xtre mity
sta rts with a stimulus of the poste rior tibia l ne rve , which ge ne ra te s
a n impulse tha t pa sse s through the dorsa l root ga nglion into the
dorsa l (poste rior) columns a nd the n to the dorsa l column nucle i.
Se cond-orde r ne rve s ca rry the impulse a cross the midline to the
tha la mus, a nd the impulse tra ve ls ove r third-orde r ne rve s to the
se nsory corte x of the bra in. Ele ctrode s in the sca lp re cord the
e le ctrica l a ctivity in the bra in. Se ve re hypote nsion or ische mia in
a ny portion of the pa thwa y a long which the induce d signa l is
conducte d ca n re sult in a re duce d e voke d pote ntia l a mplitude or
incre a se d la te ncy. Vola tile a ne sthe tic a dministra tion in MAC va lue s
gre a te r tha n 0.5 to 0.75 ca n produce a simila r e ffe ct. Ba rbitura te s,
be nzodia ze pine s, propofol, a nd othe r se da tive drugs ca n like wise
inte rfe re with SSEP monitoring. Ante rior spina l a rte ry syndrome
a ffe cts the a nte rior (motor) portion of the spina l cord a nd doe s not
inte rfe re with SSEP monitoring (Miller: Basics of Anesth esia, ed 6, pp
327–328).
546. (D) Dia be tic a utonomic ne uropa thy ca n a ffe ct the a utonomic
ne rvous syste m to such a n e xte nt tha t a tropine a nd propra nolol
would ha ve little e ffe ct (be ca use the re would be nothing to block).
Afte r he a rt tra nspla nta tion, the ne w he a rt (donor he a rt) is
de ne rva te d a nd will not re spond to a utonomic ne rvous syste m
blocking drugs. Bra in de a th by de finition is a ssocia te d with
a bse nce of a utonomic function. A high spina l would be a ssocia te d
with tota l sympa the ctomy, a nd propra nolol would ha ve no e ffe ct on
he a rt ra te , but the va gus ne rve would be una ffe cte d. Atropine
would ha ve no e ffe ct on a pa tie nt with a tria l fibrilla tion a nd
comple te he a rt block (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 26–28, 383; Miller: Basics of Anesth esia, ed 6, pp 281,
585–586).
547. (A)
548. (B)
549. (D)
550. (C)
551. (D)
552. (B)
553. (A)
554. (E)
The re a re thre e ca te gorie s of biologica l we a pons: A, B, a nd C. All
of the dise a se s in this que stion a re in the highly conta gious
Ca te gory A a ge nts.
Sma llpox is ca use d by a virus (Variola m ajor) a nd in 1980 wa s
de cla re d e xtinct by the World He a lth Orga niza tion. The
incuba tion pe riod wa s 7 to 14 da ys, a nd pa tie nts with the dise a se
pre se nte d with ma la ise , he a da che , a nd fe ve r. Two to 4 da ys la te r
a cha ra cte ristic ra sh de ve lops whe re a ll le sions a re a t the sa me
sta ge (pa pule s, ve sicle s, pustule s, a nd sca bs). Expose d pa tie nts
a nd he a lth ca re worke rs who re ce ive d a va ccina tion within
4 da ys of e xposure ha d gre a tly a tte nua te d symptoms.
Unva ccina te d pa tie nts who we re untre a te d ha d a morta lity ra te
of gre a te r tha n 30%. Pa tie nts who pre viously ha d be e n
va ccina te d ha d a lowe r morta lity ra te . Tre a tme nt include s the
drug cidofovir.
Anthra x is ca use d by a n a e robic gra m-positive spore -forming
ba cillus (Bacillus anth racis) a nd ha s thre e prima ry forms:
cuta ne ous, ga strointe stina l, a nd inha la tiona l. We a ponize d
a nthra x is ma inly a n inha la tiona l dise a se . Inha la tiona l a nthra x
symptoms occur within 1 to 7 da ys of e xposure a nd initia lly look
like vira l flu (fe ve r, chills, mya lgia , a nd a nonproductive cough).
La te r on, the pa tie nt’s me dia stina l lymph node s, whe re the
spore s ge rmina te , e nla rge , producing a wide ne d me dia stinum
tha t ca n be se e n on a che st x-ra y film. Tre a tme nt is prima rily
with ciprofloxa cin; prophyla xis to e xpose d pe rsonne l include s
60 da ys of ciprofloxa cin. Morta lity ra te for inha le d a nthra x is
gre a te r tha n 80%.
Pla gue is ca use d by a gra m-ne ga tive coccoba cillus (Yersinia pestis)
a nd ha s two forms: bubonic a nd pne umonic. W ith the more
common bubonic pla gue , the re is pa inful swe lling of the lymph
node s (buboe s), which ca n grow to 5 to 10 cm in dia me te r. The
pa tie nts de ve lop cya nosis, shock, a nd ga ngre ne in pe riphe ra l
tissue s (bla ck de a th). If the lungs be come infe cte d the n
pne umonic pla gue de ve lops, which, if untre a te d, ha s 100%
morta lity. Tre a tme nt is prima rily with stre ptomycin, a lthough
ge nta micin, te tra cycline , a nd chlora mphe nicol ha ve be e n use d.
Botulism is ca use d by the toxin from Clostrid ium botulinum . Be ca use
this dise a se is due to a ne urotoxin, it is not conta gious. The
ne urotoxin a ffe cts choline rgic ne urons a nd pre ve nts the re le a se
of a ce tylcholine . Symptoms typica lly de ve lop within 12 to 36 hours
of e xposure a nd include a cute fla ccid pa ra lysis, de cre a se d
sa liva tion, ile us, a nd urina ry re te ntion. The re a re no se nsory
de ficits. W ith a ppropria te supportive ca re a nd triva le nt e quine
a ntitoxin, the morta lity ra te is le ss tha n 5%. W ithout the use of
a ntitoxin, pa tie nts ma y ta ke 2 to 8 we e ks to re cove r. Morta lity
ra te is 5% to 10%.
The re a re more tha n 18 he morrha gic fe ve r viruse s, including Ebola
virus. The incuba tion pe riod is 2 to 21 da ys, a nd pa tie nts pre se nt
with fe ve r, mya lgia s, he a da che s, thrombocytope nia , a nd
he morrha gic complica tions (pe te chia e , e cchymosis). Untre a te d,
the morta lity ra te for Ebola virus is 90%. Tre a tme nt include s the
drug riba virin (Barash : Clinical Anesth esia, ed 7, pp 1543–1545; Miller:
Miller’s Anesth esia, ed 8, pp 2501–2502; Miller: Basics of Anesth esia, ed
6, pp 691–695).
555. (D)
556. (C)
557. (D)
558. (C)
559. (C)
560. (A)
Pulmona ry function te sts ca n be use d to cla ssify pa tie nts with
chronic pulmona ry dise a se into those with obstructive a irwa y
dise a se s (e .g., a sthma , pulmona ry e mphyse ma , a nd chronic
bronchitis) a nd those with re strictive pulmona ry dise a se s (e .g.,
pulmona ry fibrosis, scoliosis). The force d e xpira tory volume in
1 se cond or FEV1 is the a mount of a ir e xpire d in 1 se cond a nd
commonly is e xpre sse d a s a pe rce nta ge of the force d vita l
ca pa city, or FEV1/FVC. The norma l FEV1/FVC is 75% to 80%. In the
pre se nce of obstructive a irwa y dise a se , FEV1 of le ss tha n 70%
ha s mild obstruction, le ss tha n 60% ha s mode ra te obstruction,
a nd le ss tha n 50% ha s se ve re obstruction. Pa tie nts with
obstructive lung dise a se a lso ha ve a norma l (a sthma ) or incre a se
in (bronchitis, e mphyse ma ) TLC a nd FRC. In the pre se nce of
re strictive pulmona ry dise a se , FEV1 is re duce d, but be ca use FVC
is a lso re duce d, the FEV1/FVC is norma l. Pa tie nts with re strictive
dise a se ha ve a TLC, FRC, a nd tota l pulmona ry complia nce tha t
a re re duce d. In pa tie nts with pulmona ry e mphyse ma , lung
complia nce is incre a se d be ca use the e la stic re coil of the lungs is
de cre a se d (Miller: Miller’s Anesth esia, ed 8, p 1149; Miller: Basics of
Anesth esia, ed 6, pp 431-–434).
561. (A)
562. (B)
563. (C)
564. (D)
565. (B)
566. (E)
In ma ny ca se s of pe riphe ra l ne rve injurie s, the me cha nism of injury
is la rge ly unknown; howe ve r, stre tching or compre ssion of the
ne rve s ca n le a d to ne rve ische mia a nd da ma ge . In the lithotomy
position, hype rfle xion of the hips a nd/or e xte nsion of the kne e s
ca n a ggra va te stre tch of the scia tic ne rve . Also in the lithotomy
position, compre ssion of the common pe rone a l ne rve be twe e n
the he a d of the fibula a nd the me ta l supporting fra me ca n occur.
The common pe rone a l ne rve is the most common ne rve injure d
in the lithotomy position. Prope r pa dding be twe e n the me ta l le g
bra ce s a nd positioning of the le gs will limit the occurre nce of
the se injurie s. The scia tic ne rve provide s motor function for a ll
the ske le ta l muscle s be low the kne e s a nd se nsory inne rva tion
for the la te ra l ha lf of the le g a nd most of the foot. Injury to the
common pe rone a l ne rve , a bra nch of the scia tic ne rve , ca use s a
footdrop from the impa ire d a nkle dorsifle xion a nd the loss of foot
e ve rsion a nd toe e xte nsion. Injury to the fe mora l or obtura tor
ne rve s ca n occur with e xce ssive re tra ction during lowe r
a bdomina l surge ry. The obtura tor ne rve ca n a lso be injure d
during a difficult force ps va gina l de live ry or by e xce ssive fle xion
of the thigh to the groin. Injury to the fe mora l ne rve will ma nife st
a s de cre a se d e xte nsion of the kne e (pa re sis of the qua drice ps
fe moris muscle ) a nd numbne ss ove r the a nte rior a spe ct of the
thigh a nd me dia l/a nte rome dia l side of the le g. The ina bility to
a dduct the le g a nd thigh a s we ll a s numbne ss ove r the me dia l
side of the thigh a re clinica l ma nife sta tions consiste nt with
da ma ge to the obtura tor ne rve . Exce ssive fle xion of the hip on the
a bdome n ca n ca use a ne uropa thy of the la te ra l fe mora l
cuta ne ous ne rve (se nsory only) re sulting in numbne ss of the
la te ra l a spe ct of the thigh (Miller: Miller’s Anesth esia, ed 8, pp 1256–
1258; Miller: Basics of Anesth esia, ed 6, pp 304, 305, 313, 314).
C H AP T E R 7
Pediatric Physiology and
Anesthesia
567. A pre viously he a lthy 1-month-old infa nt with a strong fa mily

history of sickle ce ll a ne mia is brought to the e me rge ncy room with
a n inca rce ra te d inguina l he rnia . W hich of the following should be
ca rrie d out be fore surge ry?
A. He moglobin e le ctrophore sis
B. Pe riphe ra l sme a r
C. He ma tology consulta tion
568. In the pre ma ture ne wborn, the glottis is a t which le ve l re la tive
to the ce rvica l spine ?
A. C3
B. C4
C. C5
D. C6
569. A 5-month-old infa nt is sche dule d for a n e le ctive ope ra tive
re duction of a right inguina l he rnia . Spina l a ne sthe sia is pe rforme d.
The first sign of a high spina l block in this pa tie nt would be
A. Hypote nsion
B. Ta chyca rdia
C. Hypoxia
D. Asystole
570. W ha t pe rce nta ge of a te rm ne wborn’s tota l body we ight
consists of wa te r?
A. 45%
B. 60%
C. 75%
D. 90%
571. W ha t is the ma ximum F IO2 tha t ca n be a dministe re d to the
mothe r without incre a sing the risk of re tinopa thy of pre ma turity
(ROP) in the fe tus in ute ro?
A. 0.35
B. 0.50
C. 0.75
D. 1.0
572. W hich of the following pa tie nts is LEAST like ly to de ve lop
ROP?
A. A te rm infa nt, 46 we e ks’ postconce ptua l a ge (PCA), e xpose d to
100% oxyge n for 6 hours
B. A pre ma ture infa nt, 29 we e ks’ PCA, e xpose d to a Pa O2 of
150 mm Hg for 1 hour
C. A pre ma ture infa nt, 28 we e ks’ PCA, ne ve r e xpose d to
supple me nta l oxyge n
D. A cya notic infa nt with te tra logy of Fa llot, 34 we e ks’ PCA,
re ce iving supple me nta l oxyge n
573. A 5-we e k-old ma le infa nt is brought to the e me rge ncy room
with proje ctile vomiting. At the time of a dmission the pa tie nt is
le tha rgic with a re spira tory ra te of 16 bre a ths/min a nd ha s ha d no
urine output in the pre ce ding 3 hours. A dia gnosis of pyloric
ste nosis is ma de , a nd the infa nt is brought e me rge ntly to the
ope ra ting room (OR) for pyloromyotomy. The MOST a ppropria te
a ne sthe tic ma na ge me nt would be
A. Awa ke intuba tion a fte r pla cing a n ora l ga stric tube
B. Inha la tion induction with se voflura ne with cricoid pre ssure
C. Awa ke sa phe nous IV ca the te r or a n intra osse ous ne e dle
pla ce me nt followe d by a ra pid-se que nce induction with
ke ta mine , a tropine , a nd rocuronium
D. Postpone surge ry
574. W hich figure of e sopha ge a l a tre sia (EA) or tra che oe sopha ge a l
fistula (TEF) is the MOST common?
575. W ha t is the ma ximum a llowa ble blood loss (MABL) for a 10-kg,
11-month-old infa nt whose sta rting he ma tocrit (Hct) is 36 a nd the
minima l a cce pta ble Hct is 25?
A. 110 mL
B. 245 mL
C. 350 mL
D. Ca nnot be ca lcula te d without a dditiona l informa tion
576. W ha t volume of pa cke d re d blood ce lls (PRBCs) with a n Hct of
60 is ne e de d to ra ise the Hct from 20 to 28 in a 10-kg, 11-month-old?
A. 55 mL
B. 105 mL
C. 155 mL
D. Ca nnot be ca lcula te d without a dditiona l informa tion
577. Re a sons for se le cting a cuffe d e ndotra che a l tube ove r a n
uncuffe d e ndotra che a l tube include a ll of the following EXCEPT
A. Fe we r intuba tions a nd e ndotra che a l tube s a re ne e de d
B. Le ss cha nce for a irwa y fire s
C. Sponta ne ous bre a thing is e a sie r
D. Aspira tion of ga stric conte nts is le ss like ly
578. An othe rwise he a lthy 4-ye a r-old ma le pa tie nt is unde rgoing
e le ctive tonsille ctomy. Be fore induction of ge ne ra l a ne sthe sia , the
pa tie nt is bre a thing a t a ra te of 20 bre a ths/min. An inha la tion
induction is be gun with se voflura ne , nitrous oxide , a nd oxyge n.
Nine ty se conds la te r, the pa tie nt is note d to bre a the a t a ra te of
40 bre a ths/min. This ra pid re spira tory ra te most like ly re pre se nts
A. Hypoxia
B. Hype rca rbia a nd e a rly de ve lopme nt of ma ligna nt hype rthe rmia
(MH)
C. The e xcite me nt sta ge of a ne sthe sia
D. Aspira tion of ga stric conte nts
579. A he a lthy 3-kg, 1-month-old ne ona te is a ne sthe tize d for a n
inguina l he rnia re pa ir. An inha la tion induction with se voflura ne is
ca rrie d out a nd the pa tie nt is intuba te d. Be fore the surgica l
incision, the systolic blood pre ssure is note d to be 65 mm Hg a nd
the he a rt ra te is 130 be a ts/min. The most a ppropria te inte rve ntion
for this pa tie nt’s blood pre ssure would be
A. Administra tion of e phe drine
B. Administra tion of phe nyle phrine
C. 50-mL fluid bolus
580. A 5-ye a r-old boy is a ne sthe tize d for e le ctive re pa ir of a n
umbilica l he rnia . Ge ne ra l a ne sthe sia is induce d a nd ma inta ine d
with se voflura ne , nitrous oxide , a nd oxyge n via a n a ne sthe sia
ma sk. At the conclusion of the ope ra tion, the pa tie nt is ta ke n to the
re cove ry room a nd subse que ntly discha rge d to the outpa tie nt wa rd.
Be fore discha rge , the pa tie nt’s mothe r note s tha t the urine a ppe a rs
da rk brown (cola -colore d). The most a ppropria te a ction a t this time
would be
A. Discha rge the pa tie nt with instructions to re turn if urine color
doe s not norma lize
B. Discha rge the pa tie nt in 3 hours if no othe r signs or symptoms
a re ma nife ste d
C. Obta in se rum cre a tinine a nd blood ure a nitroge n (BUN) le ve ls
a nd discha rge the pa tie nt if the y a re norma l
D. Eva lua te the pa tie nt for MH
581. At wha t ma ximum inspira tory pre ssure should a n e ndotra che a l
tube le a k in a child?
A. 5 to 15 cm H2O
B. 15 to 25 cm H2O
C. 25 to 35 cm H2O
582. A pre ma ture ne wborn de live re d a t 32 we e ks of ge sta tion is
brought to the OR for re pa ir of a le ft-side d conge nita l dia phra gma tic
he rnia (CDH). Afte r a n a wa ke tra che a l intuba tion, ge ne ra l
a ne sthe sia is ma inta ine d with se voflura ne , O2, a nd fe nta nyl.
Shortly the re a fte r, the a ne sthe siologist note s significa nt difficulty
with a de qua te ve ntila tion. The Sa O2 subse que ntly fa lls to 65%, a nd
the he a rt ra te de cre a se s to 50 be a ts/min. W ha t would be the most
a ppropria te ste p to ta ke a t this time ?
A. Pull the e ndotra che a l tube from the right ma inste m bronchus
B. Ve ntila te with positive e nd-e xpira tory pre ssure (PEEP) a nd
a dministe r furose mide
C. Pla ce a che st tube on the right side a fte r confirming a te nsion
pne umothora x
D. Pull out the e ndotra che a l tube , ma sk ve ntila te , a nd re -
intuba te the pa tie nt
583. An 8-ye a r-old boy found a t the site of a motor ve hicle a ccide nt
(MVA) ha s a rrive d in the OR for e xplora tory la pa rotomy. He ha s not
re ce ive d a ny se da tion or pa in me dica tion be ca use he a ppe a re d
“confuse d a nd did not se e m bothe re d.” He is ta chyca rdic, with
thre a dy dista l pulse s a nd cold e xtre mitie s. In spite of a 500-mL fluid
bolus, the pa tie nt ha s produce d minima l urine . W ha t is the
a pproxima te pe rce nta ge of blood volume loss in this pa tie nt?
A. <20%
B. 25%
C. 40%
D. Ca nnot de te rmine
584. In a 6-ye a r-old child, the le ngth of a n ora l e ndotra che a l tube
(from the a lve ola r ridge to the midtra che a ) most ofte n is
A. 10 cm
B. 13 cm
C. 15 cm
D. 18 cm
585. W hich of the following is the most suita ble re pla ce me nt fluid
for a 3-ye a r-old, 14-kg child unde rgoing re pa ir of clubfe e t?
A. D5W
B. D5 ½NS
C. Norma l sa line
D. La cta te d Ringe r solution
586. An othe rwise he a lthy 14-da y-old ne ona te is tra nsporte d to the
OR we ll-hydra te d for surge ry for a bowe l obstruction. A ra pid-
se que nce induction is pla nne d. Compa re d with the a dult dose , the
dose of succinylcholine a dministe re d to this pa tie nt should be
A. Diminishe d be ca use of the imma ture ne rvous syste m
B. The sa me a s the a dult dose
C. De cre a se d be ca use of de cre a se d a ce tylcholine re ce ptors
D. Incre a se d be ca use of a gre a te r volume of distribution
587. The most common ca use of ne ona ta l bra dyca rdia (he a rt ra te
<100 be a ts/min) in the de live ry room is
A. Conge nita l he a rt dise a se
B. Ma te rna l drug intoxica tion (na rcotics, a lcohol, ma gne sium,
ba rbitura te s, digitoxin)
C. Postpa rtum cold stre ss
D. Hypoxe mia
588. A 10-we e k-old infa nt born a t 31 we e ks’ ge sta tion is
a ne sthe tize d for re pa ir of a n inguina l he rnia . Ge ne ra l a ne sthe sia is
induce d by ma sk with se voflura ne , a n e ndotra che a l tube is pla ce d,
a nd a ne sthe sia is ma inta ine d with se voflura ne a nd oxyge n. W ha t
is the be st postope ra tive pa in ma na ge me nt for this pa tie nt?
A. Ca uda l block with 0.25% bupiva ca ine , 1 mL/kg, a nd a dmitte d
to a pe dia tric wa rd for ove rnight obse rva tion
B. Ca uda l block with 0.25% bupiva ca ine , 2 mL/kg, a nd a dmitte d to
a pe dia tric wa rd for ove rnight obse rva tion
C. Ora l pa in me dica tion (a ce ta minophe n) a nd discha rge d home
D. Fe nta nyl, 1 mL IV, a nd a dmitte d to a pe dia tric wa rd for
ove rnight obse rva tion
589. A 6-ye a r-old, 20-kg girl de ve lops pulse le ss ve ntricula r
ta chyca rdia a fte r induction of ge ne ra l a ne sthe sia for a
tonsille ctomy. The a ne sthe siologist intuba te s the child, a dministe rs
100% oxyge n, a nd sta rts che st compre ssions. W he n the bipha sic
de fibrilla tor quickly a rrive s in the OR a nd is a tta che d to the child,
the de fibrilla tor should be cha rge d to wha t e ne rgy le ve l for the
initia l shock?
A. 20 joule s (J)
B. 40 joule s (J)
C. 60 joule s (J)
D. 80 joule s (J)
590. The spina l cord of ne wborns e xte nds to the
A. L1 ve rte bra
B. L2-L3 ve rte bra e
C. L4-L5 ve rte bra e
D. S1 ve rte bra
591. The most common initia l symptom of EA a nd TEF is
A. Re spira tory distre ss a t de live ry (e .g., re tra ctions, ta chypne a )
B. Proje ctile vomiting
C. Hypoxia
D. Re gurgita tion during fe e ding
592. A 4-kg, 3-hour-old ne wborn with ma crosomia a nd la rge
fonta ne lle s is sche dule d for surgica l re pa ir of a n ompha loce le .
Physica l e xa mina tion re ve a ls ma croglossia but no othe r a noma lie s.
W hich of the following is like ly to occur in this pa tie nt?
A. Hype rka le mia
B. Me ta bolic a cidosis
C. Hypoxe mia
D. Hypoglyce mia
593. W hich of the following is the LEAST a ppropria te te chnique for
induction of ge ne ra l a ne sthe sia in a ne wborn for surgica l re pa ir of
TEF?
A. Awa ke tra che a l intuba tion
B. Inha la tion induction with sponta ne ous ve ntila tion a nd tra che a l
intuba tion
C. Inha la tion induction using positive -pre ssure ba g a nd ma sk
ve ntila tion a nd tra che a l intuba tion
D. Ra pid-se que nce IV induction a nd tra che a l intuba tion
594. A 3-ye a r-old with cough a nd sore throa t, but no fe ve r, is
sche dule d for tonsille ctomy. Physica l e xa mina tion re ve a ls minima l
inspira tory whe e zing. Che st x-ra y re ve a ls sma ll le ft lowe r lobe
(LLL) infiltra te . The be st course of a ction would be
A. Administe r IV ste roids a nd proce e d
B. De la y for 10 to 14 da ys a nd tre a t with ora l a ntibiotics
C. Postpone surge ry for a t le a st 1 month
D. Proce e d
595. The pre dicte d blood volume in a 4-kg ne ona te is
A. 240 mL
B. 280 mL
C. 340 mL
D. 400 mL
596. The pulmona ry va scula r re sista nce in ne wborns de cre a se s to
tha t of a dults by a ge
A. 1 to 2 da ys
B. 1 to 2 we e ks
C. 1 to 2 months
D. 1 ye a r
597. A 10-month-old infa nt is unde rgoing e le ctive re pa ir of a le ft
te sticula r hydroce le unde r ge ne ra l a ne sthe sia with isoflura ne ,
nitrous oxide , oxyge n, a nd fe nta nyl. All of the following a re
e ffe ctive a nd re a sona ble me a ns of pre ve nting hypothe rmia in this
pa tie nt EXCEPT
A. Pla ce me nt of a n infra re d he a te r ove r the ope ra ting ta ble a nd
pre wa rming the OR
B. Cove ring the OR ta ble with a he a ting bla nke t
C. Wra pping the e xtre mitie s with she e t wa dding a nd cove ring the
he a d with a cloth ca p
D. Ve ntila ting the pa tie nt with a Ma ple son D circuit a t low ga s
flows (e .g., 50 mL/kg/min)
598. Ce ntra l postope ra tive de pre ssion of ve ntila tion in a full-te rm
ne ona te is MOST like ly to occur a fte r surge ry for which of the
following?
A. Ga stroschisis
B. Ompha loce le
C. Tra che oe sopha ge a l fistula
D. Pyloric ste nosis
599. A pre ma ture ma le ne ona te born a t 34 we e ks of ge sta tion is
sche dule d to unde rgo e me rge ncy re pa ir of a le ft-side d
dia phra gma tic he rnia . W hich of the following ve sse ls could be
ca nnula te d for pre ducta l a rte ria l blood sa mpling?
A. Fe mora l a rte ry
B. Umbilica l a rte ry
C. Right ra dia l a rte ry
D. Le ft ra dia l a rte ry
600. In which of the following pa tie nts would the minimum a lve ola r
conce ntra tion (MAC) for isoflura ne be the gre a te st?
A. A pre ma ture infa nt 30 we e ks’ PCA
B. Full-te rm ne ona te
C. 3-month-old infa nt
D. 19-ye a r-old ma n with hype rthyroidism
601. A 40-kg, 10-ye a r-old child susta ins a the rma l injury to his le gs,
buttocks, a nd ba ck. The e stima te d a re a involve d is 50%. Using only
crysta lloid fluids, how much fluid should be a dministe re d during
the first 24 hours a fte r the burn?
A. 2.5 L
B. 5.5 L
C. 8.0 L
D. 10.0 L
602. An othe rwise he a lthy 3-month-old bla ck fe ma le infa nt with a
he moglobin of 19 mg/dL a t birth pre se nts for e le ctive re pa ir of a n
inguina l he rnia . He r pre ope ra tive he moglobin is 10 mg/dL. He r
fa the r ha s a history of polycystic kidne y dise a se . The most like ly
e xpla na tion for this pa tie nt’s a ne mia is
A. Sickle ce ll a ne mia
B. Iron de ficie ncy
C. Undia gnose d polycystic kidne y dise a se
D. It is a norma l finding
603. The a ne sthe siologist is ca lle d to the e me rge ncy room by the
pe dia tricia n to he lp ma na ge a 3-ye a r-old boy with a high fe ve r a nd
uppe r a irwa y obstruction. His mothe r sta te d tha t e a rlie r tha t
a fte rnoon, he compla ine d of a sore throa t a nd hoa rse ne ss. The
pa tie nt is sitting e re ct a nd le a ning forwa rd; ha s inspira tory stridor,
ta chypne a , a nd ste rna l re tra ctions; a nd is drooling. W hich of the
following is the MOST a ppropria te ma na ge me nt of a irwa y
obstruction in this pa tie nt?
A. Ae rosolize d ra ce mic e pine phrine
B. Awa ke tra che a l intuba tion in the e me rge ncy room or the OR if
time pe rmits
C. Tra nsfe r to the OR, inha la tion induction, a nd tra che a l
intuba tion
D. Tra nsfe r to the OR, IV induction, pa ra lysis with
succinylcholine , a nd tra che a l intuba tion
604. A 2-ye a r-old child with ce re bra l pa lsy a nd known se ve re
ga stroe sopha ge a l re flux (with fre que nt nightly a spira tion) a nd a
se izure disorde r is sche dule d to unde rgo iliopsoa s re le a se unde r
ge ne ra l a ne sthe sia . W hich of the following would be the pre fe rre d
te chnique for inducing ge ne ra l a ne sthe sia in this pa tie nt?
A. Inha la tion induction with se voflura ne followe d by tra che a l
intuba tion
B. IV induction with propofol followe d by la rynge a l ma sk a irwa y
C. IV induction with e tomida te a nd ve curonium followe d by
tra che a l intuba tion
D. Ra pid-se que nce induction with propofol a nd succinylcholine
followe d by tra che a l intuba tion
605. A 7-we e k-old ma le infa nt is a dmitte d to the pe dia tric inte nsive
ca re unit (ICU) with a bowe l obstruction. His la bora tory va lue s a re
sodium 120 mEq/L, chloride 85 mEq/L, glucose 85 mg/dL, a nd
pota ssium 2.0 mEq/L. Re spira tory ra te is 20 bre a ths/min, a nd
a ccording to the pa tie nt’s mothe r, urine output ha s be e n 0 for the
la st 4 hours. The most a ppropria te fluid for re suscita tion of this
pa tie nt would be
A. D2.5W with 0.45 sodium chloride a nd 20 mEq/L pota ssium
chloride
B. 0.45% sodium chloride
C. 0.9% sodium chloride with 30 mEq/L pota ssium chloride
D. 0.9% sodium chloride
606. A 12-hour-old, 1800-g ne ona te , 30 we e ks’ postge sta tiona l a ge , is
note d in the ICU to be gin ma king twitching move me nts. Blood
pre ssure is 45 mm Hg systolic, blood glucose is 50 mg/dL, a nd urine
output is 5 mL/hr. The O2 sa tura tion on pulse oxime te r is 88%. The
MOST a ppropria te course of a ction to ta ke a t this point would be
A. Administe r ca lcium glucona te (2 mL of 10% solution)
B. Glucose 10 mg IV ove r 5 minute s (2 mL of D5W )
C. Hype rve ntila te with 100% O2
D. Administe r a 20-mL bolus of 5% a lbumin
607. A Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m is a
mixture of which loca l a ne sthe tics?
A. Lidoca ine 2.5% a nd priloca ine 2.5%
B. Lidoca ine 2.5% a nd be nzoca ine 2.5%
C. Priloca ine 2% a nd be nzoca ine 2%
D. Lidoca ine 4%
608. Adva nta ge s of ca the te riza tion of the umbilica l a rte ry ve rsus the
umbilica l ve in in a ne wborn include a ll of the following EXCEPT
A. It a llows a sse ssme nt of oxyge na tion
B. He pa tic da ma ge from hype rtonic infusion is a voide d
C. It pe rmits a sse ssme nt of syste mic blood pre ssure
D. It is e a sie r to ca nnula te
609. The T RUE sta te me nt conce rning the rmore gula tion in ne ona te s
is which of the following?
A. A significa nt proportion of the ir he a t loss ca n be a ccounte d for
by the ir sma ll surfa ce a re a –to-we ight ra tio
B. The y compe nsa te for hypothe rmia by shive ring
C. The principa l me thod of he a t production is me ta bolism of
brown fa t
D. He a t loss through conduction ca n be re duce d by
humidifica tion of inspire d ga se s
610. Norma l va lue s for a he a lthy 6-month-old, 7-kg infa nt include
A. He moglobin 17 g/dL
B. He a rt ra te 90 be a ts/min
C. Re spira tory ra te 30 bre a ths/min
D. Systolic blood pre ssure of 60
611. A 5-ye a r-old child unde rgoing stra bismus surge ry unde r ge ne ra l
a ne sthe sia sudde nly de ve lops sinus bra dyca rdia a nd inte rmitte nt
ve ntricula r e sca pe be a ts but is he modyna mica lly sta ble . W hich
the ra py is a ppropria te for tre a ting this a rrhythmia ?
A. Te ll the surge on to stop pulling on the e ye muscle
B. Te ll the surge on to do a re trobulba r block
C. De cre a se the de pth of the vola tile a ne sthe tic
D. Administe r a tropine
612. W hich of the following re spira tory indice s is incre a se d in
ne ona te s compa re d with a dults?
A. Tida l volume (VT) (mL/kg)
B. Alve ola r ve ntila tion (mL/kg/min)
C. Functiona l re sidua l ca pa city (mL/kg)
D. Pa CO2
613. A 14-ye a r-old girl with ne urofibroma tosis is a ne sthe tize d for
re se ction of a n a coustic ne uroma . Ea ch of the following ma y
pote ntia lly complica te the a ne sthe tic ma na ge me nt of this pa tie nt
EXCEPT
A. Pre se nce of a phe ochromocytoma
B. Uppe r a irwa y obstruction from a la rynge a l ne urofibroma
C. Intra cra nia l hype rte nsion
D. Incre a se d risk for MH
614. W ith which of the following conge nita l a noma lie s is pe rsiste nt
right-to-le ft intra ca rdia c shunting of blood MOST like ly?
A. TEF
B. Ga stroschisis
C. Ompha loce le
D. CDH
615. The most re lia ble me thod of de te rmining mild de hydra tion in a
child is by the obse rva tion of
A. Dryne ss of mucous me mbra ne
B. Skin turgor a nd fonta ne lle s
C. Urine output
D. Blood pre ssure
616. Postope ra tive ble e ding following tonsille ctomy occurs most
commonly
A. By the first 6 hours
B. 6 to 24 hours a fte r surge ry
C. On the third postope ra tive da y
D. On the se ve nth postope ra tive da y
617. A 9-ye a r-old unde rgoing sinus surge ry is tre a te d with a n
unme a sure d a mount of 0.5% phe nyle phrine by the surge on, a nd the
pa tie nt de ve lops a blood pre ssure of 250/150. The most a ppropria te
tre a tme nt for this would be
A. Administe r ve ra pa mil
B. Administe r e smolol
C. Administe r la be ta lol
D. Administe r phe ntola mine
618. A 6-kg, 3-month-old ma le infa nt unde rgoe s a le ft inguina l
he rniorrha phy with a spina l a ne sthe tic. Typica lly, how long would
0.5 mL of a 0.5% bupiva ca ine solution la st?
A. Le ss tha n 30 minute s
B. 30 to 60 minute s
C. 60 to 90 minute s
D. 90 minute s to 2 hours
619. In a ddition to inspira tory stridor, which sign or symptom is
consiste nt with e piglottitis?
A. Ra pid onse t in le ss tha n 24 hours
B. Mild te mpe ra ture e le va tion (<39° C)
C. Age younge r tha n 2 ye a rs
D. Rhinorrhe a
620. W hich of the following sta te me nts re ga rding re suscita tion of
the infa nt by he a lth ca re provide rs is NOT corre ct?
A. Mouth-to-mouth or mouth-to nose ve ntila tion a t a ra te of 12 to
20 bre a ths/min is pe rforme d whe n bre a thing is ina de qua te but
a n a de qua te pulse is pre se nt
B. Sta rt che st compre ssions whe n the pulse is le ss tha n 60
be a ts/min a nd the re a re signs of poor tissue pe rfusion
C. Che st compre ssion de pth is 1/5 the a nte roposte rior dia me te r
of the che st (a bout 1 cm)
D. Compre ssion-to-ve ntila tion ra tio is 30:2 for one -pe rson a nd
15:2 for two-pe rson ca rdiopulmona ry re suscita tion (CPR)
621. All of the following a re true sta te me nts conce rning physiology
of ne wborns compa re d with tha t of a dults EXCEPT
A. Ne wborns ha ve a gre a te r pe rce nta ge of tota l body wa te r
compa re d with a dults
B. Ne wborns ha ve a highe r glome rula r filtra tion ra te (GFR) tha n
a dults
C. Ne wborns’ he a rts a re re la tive ly noncomplia nt compa re d with
a dults
D. Ne wborns’ dia phra gms ha ve a lowe r proportion of type I
muscle fibe rs (i.e ., fa tigue re sista nt, highly oxida tive fibe rs)
622. W hich of the following sta te me nts conce rning the a na tomy of
the infa nt a nd the a dult a irwa y is NOT true ?
A. An infa nt’s tongue is re la tive ly la rge in re la tion to the
oropha rynx compa re d with a n a dult’s
B. The la rynx is in a more ce pha lic position in infa nts tha n in
a dults
C. The voca l cords a re in a more horizonta l position within the
la rynx in infa nts tha n in a dults
D. The na rrowe st pa rt of the infa nt a nd a dult la rynx is a t the
le ve l of the cricoid ca rtila ge
623. W hich of the following ope ra tions would be a ssocia te d with
the LEAST incide nce of postope ra tive na use a a nd vomiting (PONV)
in a 5-ye a r-old boy?
A. Tonsille ctomy
B. Stra bismus surge ry
C. Myringotomy tube pla ce me nt
D. Orchiope xy
624. Anoma lie s a nd fe a ture s a ssocia te d with Down syndrome
include
A. Sma lle r tra che a s
B. Atla nto-occipita l insta bility
C. Thyroid hypofunction
625. Conge nita l syndrome s fre que ntly a ssocia te d with ca rdia c
a bnorma litie s include a ll of the following EXCEPT
A. TEF
B. Me ningomye loce le
C. Ompha loce le
D. Ga stroschisis
626. Appropria te ma na ge me nt of a ne ona te born with CDH should
include
A. Inse rtion of a n oroga stric tube
B. Expa nsion of the hypopla stic lung with positive -pre ssure
ve ntila tion
C. Hype rve ntila tion to ke e p the Pa CO2 be low 40 a nd pH gre a te r
tha n 7.40
D. Ra pid tra nsport to the OR for surgica l corre ction
627. Fa ctors a ssocia te d with a n incre a se d incide nce of
la ryngospa sm include a ll of the following EXCEPT
A. Age olde r tha n 5 ye a rs
B. Pre se nce of a n a irwa y a noma ly
C. Pre se nce of a n a ctive uppe r re spira tory infe ction (URI)
D. Use of a la rynge a l ma sk a irwa y
628. W hich of the following sta te me nts re ga rding pe riope ra tive
ca rdia c a rre st in childre n is NOT corre ct?
A. Ca rdia c a rre st is more common in ne ona te s tha n infa nts or
olde r childre n
B. “Equipme nt re la te d” ca use s occur in more tha n 25% of ca rdia c
a rre sts
C. Re suscita tion is more ofte n succe ssful if the ca use is
a ne sthe sia -re la te d ra the r tha n nona ne sthe sia re la te d
D. Eme rge ncy surge ry is a ssocia te d with gre a te r tha n five time s
the cha nce of a ca rdia c a rre st
629. W hich of the following re pre se nts the gre a te st risk for
postope ra tive a pne a in a n infa nt?
A. PCA of 60 we e ks
B. He moglobin 10 g/dL
C. Re cove ry in the posta ne sthe sia ca re unit (PACU) a fte r pyloric
ste nosis re pa ir
D. 20th we ight pe rce ntile on growth cha rt
630. W hich of the following sta te me nts re ga rding the Ma ple son D
bre a thing circuit is FALSE?
A. It ha s a proxima l fre sh ga s inflow a nd a dista l ove rflow va lve
B. W ith a n inspira tory-to-e xpira tory (I:E) bre a thing ra tio of 1:2,
re bre a thing is e limina te d with sponta ne ous ve ntila tion whe n
the fre sh ga s flow is thre e time s the minute ve ntila tion
C. To e limina te re bre a thing, highe r fre sh ga s flows a re ne e de d
with controlle d ve ntila tion tha n with sponta ne ous ve ntila tion
D. The Ma ple son D circuit is the most wide ly use d of the
Ma ple son circuits for pe dia tric a ne sthe sia
631. W hich of the following is LEAST like ly to re duce the incide nce
of postope ra tive a pne a in pre te rm infa nts unde rgoing surge ry for
inguina l he rnia re pa ir?
A. De la ying ope ra tion until 60 we e ks’ postconce ptua l a ge
B. Pre ope ra tive corre ction of a ne mia
C. Ca ffe ine a dministra tion
D. Spina l a ne sthe tic with ke ta mine se da tion
632. Air should not be use d to ide ntify the e pidura l spa ce in
childre n be ca use of the risk of
A. Ve nous a ir e mbolism
B. Infe ction
C. Subcuta ne ous e mphyse ma
D. Epidura l he ma toma
633. Induction of ge ne ra l a ne sthe sia for a n e le ctive ope ra tion
should be de la ye d how ma ny hours a fte r bre a stfe e ding?
A. 2 hours
B. 4 hours
C. 6 hours
D. No fa sting ne e de d be ca use bre a st milk is OK
634. In the infa nt, hypothe rmia would LEAST like ly ma nife st a s
A. Me ta bolic a cidosis
B. Prolonge d dura tion of a ction of nonde pola rizing muscle
re la xa nts
C. Hype rglyce mia
D. Bra dyca rdia
635. Ne crotizing e nte rocolitis (NEC) ha s a ll of the following
cha ra cte ristics EXCEPT
A. Most ha ve thrombocytope nia (<70,000/mm3) a nd a prolonge d
prothrombin time (PT) a nd a ctiva te d pa rtia l thrombopla stin
time (a PTT)
B. Commonly a ssocia te d with de cre a se d ca rdia c output in the
pre se nce of fe ta l a sphyxia or postna ta l re spira tory
complica tions
C. Umbilica l a rte ry ca the te rs a re use ful to a sse ss a cid-ba se
sta tus
D. Occurs in 10% to 20% of ne wborns we ighing le ss tha n 1500 g
636. W hich of the following na rcotics ha s a shorte r ha lf-life in the
ne wborn compa re d with olde r childre n?
A. Alfe nta nil
B. Fe nta nyl
C. Re mife nta nil
D. Sufe nta nil
637. In a ne wborn, a cce ss to the ve na ca va ca n be ga ine d by
pa ssa ge of a ca the te r through the
A. Ductus a rte riosus
B. Ductus ve nosus
C. Umbilica l a rte rie s
D. Fora me n ova le
638. A 5-ye a r-old girl with he molytic-ure mic syndrome (HUS) is
brought to the OR for pla ce me nt of a dia lysis ca the te r. Me dica l
issue s typica l for this dise a se include
A. Thrombocytope nia
B. Incre a se d intra cra nia l pre ssure
C. Pa ncre a titis
639. A 3-ye a r-old child sta tus post re se ction of W ilms tumor a t a ge
2 ye a rs is re ce iving doxorubicin (Adria mycin) a nd
cyclophospha mide for me ta sta tic dise a se . The pa tie nt is sche dule d
for pla ce me nt of a Hickma n ca the te r for continue d che mothe ra py.
Ane sthe tic conce rns re la te d to this pa tie nt’s che mothe ra pe utic
tre a tme nt include e a ch of the following EXCEPT
A. Thrombocytope nia
B. Inhibition of pla sma choline ste ra se
C. Ca rdia c de pre ssion
D. Pulmona ry fibrosis
640. Pre ope ra tive ly, hypote nsion (i.e ., de compe nsa te d shock) is
cha ra cte rize d by a systolic blood pre ssure
A. Le ss tha n 60 mm Hg for the te rm ne ona te (0-28 da ys old)
B. Le ss tha n 70 mm Hg for infa nts 1 to 12 months old
C. Le ss tha n 70 mm Hg + (2 × a ge in ye a rs) for childre n 1 to
10 ye a rs old
641. W ha t pe rce nt of the a dult’s GFR (inde xe d to body surfa ce a re a )
doe s a 2-ye a r-old posse ss?
A. 30%
B. 50%
C. 75%
D. 100%
642. Ea ch of the following re sults in a re duction of the incide nce of
postope ra tive vomiting (POV) in childre n unde rgoing stra bismus
surge ry EXCEPT
A. IV hydra tion of 30 mL/kg/hr
B. De xa me tha sone 0.15 to 1 mg/kg IV
C. Onda nse tron 50 to 200 µg/kg IV
D. Anticholine rgics (a tropine 10-20 µg/kg or glycopyrrola te
10 µg/kg)
Pediatric Physiology and Anesthesia
567. (D) At birth, the conce ntra tion of he moglobin F (fe ta l
he moglobin) is a bout 80% a nd re a che s its lowe st le ve l by 2 to
4 months of a ge . Sickle ce ll a ne mia (he moglobin SS) is a n inhe rite d
disorde r of the β-cha in of the a dult he moglobin mole cule ca use d by
a single a mino a cid substitution. It ha s a n incide nce of a bout 0.2%
in the Africa n-Ame rica n popula tion, in contra st to the re la tive ly
be nign he te rozygous condition, sickle ce ll tra it (he moglobin AS),
which a ffe cts 8% to 10% of the sa me group. Sickling ca n occur in
homozygous pa tie nts who be come hypoxic, a cidotic, hypothe rmic,
or de hydra te d. The pre domina nt he moglobin in this 1-month-old
infa nt is he moglobin F, which would te mpora rily prote ct the infa nt
from the ma nife sta tions of sickle ce ll a ne mia we re he or she
homozygous for he moglobin S. The pa tie nt should, howe ve r, be
worke d up for sickle ce ll a ne mia a t some point in e a rly life (if
he moglobin e le ctrophore sis wa s not done a s pa rt of routine
ne wborn scre e ning in a t-risk popula tions), but such a workup is not
a pre re quisite for surge ry a t 1 month of a ge (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 284, 1062, 1130; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 411–412; Miller:
568. (A) The glottis of a pre ma ture ne wborn is a t the le ve l of C3, for
the te rm ne wborn the le ve l is C4, a nd in the a dult the glottis is a t
the C5 le ve l. The re la tive ly high glottis ma ke s intuba tion more
difficult in the pre ma ture ne wborn (i.e ., more tissue a nd le ss
dista nce ) (Barash : Clinical Anesth esia, ed 7, p 1185; Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 351; Miller: Miller’s
569. (C) Spina l a ne sthe sia ca n be a dministe re d sa fe ly to childre n of
a ll a ge s. Hypote nsion se conda ry to a loss of sympa the tic tone ,
common in the a dult, is ra re in the child younge r tha n 5 ye a rs of
a ge e ve n with le ve ls a s high a s T3. Be ca use of this he modyna mic
sta bility, some pe dia tric a ne sthe siologists sta rt a n IV line in the le g
a fte r the spina l a ne sthe tic is a dministe re d to the infa nt. Re spira tory
de pre ssion including a pne a a nd hypoxia with a ssocia te d
bra dyca rdia will like ly be initia l signs a ssocia te d with a tota l spina l
block in the infa nt (Barash : Clinical Anesth esia, ed 7, pp 1196–1197;
Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 463–465).
570. (C) The body compa rtme nt volume s cha nge with a ge . Muscle
conta ins a bout 75% wa te r, whe re a s a dipose tissue conta ins only
10% wa te r. Ove ra ll, tota l body wa te r de cre a se s with a ge ma inly
due to a de cre a se in e xtra ce llula r fluid, whe re a s the muscle a nd
fa t conte nt incre a se s. The fra ction of tota l body we ight tha t consists
of wa te r is 80% in pre ma ture ne wborns, 75% in te rm ne wborns,
a nd 60% in 6-month-old infa nts a nd in a dults. The se a lte ra tions in
body composition ha ve implica tions for the volume of distribution
a nd re distribution of drugs (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, p 123; Miller: Miller’s Anesth esia, ed 8, pp 2763–2764).
571. (D) The fe ta l Pa O2 doe s not incre a se a bove 60 mm Hg whe n
100% O2 is a dministe re d to the mothe r be ca use of the high O2
consumption of the pla ce nta a nd une ve n distribution of the
ma te rna l a nd fe ta l blood flow in the pla ce nta . For the se re a sons,
the F IO2 a dministe re d to the mothe r is not a fa ctor in the e tiology of
ROP in ute ro (Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics,
ed 5, p 811).
572. (A) Re tinopa thy of pre ma turity (ROP), forma lly ca lle d
re trole nta l fibropla sia , typica lly occurs in ne wborns who a re born
a t le ss tha n 35 we e ks’ ge sta tiona l a ge . It is the se cond le a ding
ca use of childhood blindne ss in the Unite d Sta te s. The risk of ROP
is inve rse ly re la te d to a ge a nd birth we ight, with a significa nt risk
occurring in infa nts we ighing le ss tha n 1500 g. ROP occurs in a bout
70% of infa nts who we igh le ss tha n 1000 g a t birth; fortuna te ly, 80%
to 90% of the se ha ve sponta ne ous re gre ssion of the re tina l cha nge s.
The risk is ne gligible a fte r 44 we e ks’ postconce ptua l a ge . The
me cha nism for ROP is comple x a nd is re la te d to the complica te d
proce ss of re tina l de ve lopme nt a nd ma tura tion. Unde r norma l
circumsta nce s, re tina l va scula ture de ve lops from the optic disk
towa rd the pe riphe ry of the re tina . This proce ss typica lly is
comple te d by 40 to 44 we e ks of ge sta tion. Hype roxia ca use s
constriction of the re tina l a rte riole s, re sulting in swe lling a nd
de ge ne ra tion of the e ndothe lium tha t disrupts norma l re tina l
de ve lopme nt. Va scula riza tion of the re tina re sume s in a n a bnorma l
fa shion whe n normoxic conditions re turn, re sulting in
ne ova scula riza tion a nd sca rring of the re tina . In the worst-ca se
sce na rio, this proce ss ca n le a d to re tina l de ta chme nt a nd
blindne ss. Conse que ntly, hype roxia should be a voide d whe n
a ne sthe tizing pre te rm infa nts. Exposure of pre te rm infa nts to Pa O2
gre a te r tha n 80 mm Hg for prolonge d pe riods of time ma y be
a ssocia te d with incre a se d incide nce a nd se ve rity of re tinopa thy of
pre ma turity. To re duce this risk, it is re comme nde d tha t the oxyge n
sa tura tion be ma inta ine d be twe e n 88% a nd 93% (a bout Pa O2 of 50-
70 mm Hg) during a ne sthe sia . On the othe r ha nd, one must ne ve r
compromise oxyge n de live ry to a ne ona te ’s bra in to prote ct the
e ye s. Although oxyge n toxicity ha s be e n strongly a ssocia te d with
ROP, othe r fa ctors a re a lso importa nt, such a s re spira tory distre ss
syndrome , me cha nica l ve ntila tion, hypoxia , hypoca rbia ,
hype rca rbia , blood tra nsfusions, se psis, conge nita l infe ctions, a nd
vita min E de ficie ncy. In fa ct, ne wborns with cya notic conge nita l
he a rt dise a se who ha ve ne ve r be e n e xpose d to supple me nta l
oxyge n the ra py ha ve a lso de ve lope d ROP (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, p 883; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 591–592; Miller: Basics of Anesth esia, ed 6, p
564).
573. (D) This pa tie nt ha s signs consiste nt with se ve re de hydra tion
a nd ne e ds re suscita tion with fluid a nd e le ctrolyte s be fore surge ry.
Surge ry should be de la ye d until the re is thorough e va lua tion a nd
tre a tme nt of the fluid a nd e le ctrolyte imba la nce s. Pyloric ste nosis
occurs in a pproxima te ly 1 in e ve ry 300 live births, ma king it one of
the most common ga strointe stina l a bnorma litie s se e n in the first
6 months of life . Pyloric ste nosis occurs a s fre que ntly in pre te rm a s
in te rm ne ona te s, a nd the re is a pre dile ction for ma le infa nts.
Pe rsiste nt vomiting usua lly ma nife sts itse lf be twe e n the se cond
a nd sixth we e ks of a ge a nd ca n re sult in de hydra tion,
hypoka le mia , hypochlore mia , a nd me ta bolic a lka losis. Fluid
re suscita tion should be initia te d with isotonic sa line . If a n IV line
ca the te r ca nnot be e sta blishe d, a n intra osse ous ne e dle should be
pla ce d. Afte r the pa tie nt voids, pota ssium the n ca n be sa fe ly a dde d
to the IV fluids. Once the re ha s be e n a de qua te hydra tion a nd
corre ction of the e le ctrolyte a nd a cid-ba se a bnorma litie s, the
pa tie nt ca n more sa fe ly unde rgo a ne sthe sia a nd surge ry. Although
se ve ra l da ys ma y be re quire d to re store norma l fluid a nd
e le ctrolyte ba la nce in some childre n, most re spond within 12 to
48 hours (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
750–751; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
600–601).
574. (A) EA a nd TEFs re sult from fa ilure of the e sopha gus a nd the
tra che a to comple te ly se pa ra te during de ve lopme nt. Incide nce is
a pproxima te ly 1 in 4000 live births. Although e a ch of the liste d
a nswe rs is possible , Figure A re pre se nts the most common type
(86% of ca se s) ca lle d a Ty pe C TEF (EA with a dista l TEF). In the
de live ry room, one is una ble to pa ss a suction ca the te r into the
stoma ch a nd, if a n x-ra y is ta ke n, the pre se nce of a ir in the
stoma ch sugge sts a fistula be twe e n the tra che a a nd the stoma ch. If
it is not de te cte d in the de live ry room, the ne wborn te nds to ha ve
e xce ssive ora l se cre tions a nd is una ble to fe e d. In a ddition,
be ca use the fe tuse s ca nnot swa llow, the re is a highe r incide nce of
ma te rna l polyhydra mnios a nd pre ma ture de live rie s. Note : About
20% of pa tie nts with EA or TEF ha ve ma jor ca rdiova scula r
a noma lie s (e .g., a tria l se pta l de fe ct [ASD], ve ntricula r se pta l de fe ct
[VSD], te tra logy of Fa llot, a triove ntricula r [AV] ca na l, coa rcta tion of
the a orta ). Figure B (8% of ca se s) is a Ty pe A TEF (EA without a TEF).
Figure C (4% of ca se s) is a Ty pe E TEF (TEF without a n EA), a nd is
a lso ca lle d a n H-type TEF. Figure D (1% of ca se s) is a Ty pe D TEF
(EA with a proxima l a nd a dista l TEF). Type B (1% of ca se s; not
shown) is a Ty pe B TEF (EA with a proxima l TEF). Se e a lso Que stion
591 (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 574–
579; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 581–
582, 596–598; Miller: Basics of Anesth esia, ed 6, pp 561–562).
575. (B) To ca lcula te the MABL, the following formula is commonly
use d:
The e stima te d blood volume (EBV) in mL/kg for a pre ma ture infa nt
is 90 to 100 mL/kg, te rm ne wborns is 80 to 90 mL/kg, 3-month-olds
to 1-ye a r-olds is 75 to 80 mL/kg, 3-ye a r-olds to 6-ye a r-olds is 70 to
75 mL/kg, a nd olde r tha n 6 ye a rs of a ge is 65 to 70 mL/kg.
In this ca se , using 80 mL/kg, the EBV for the 10-kg 11-month-old, we
ha ve a n EBV of 800 mL.
Be fore infusing blood, the circula ting blood volume is usua lly
e xpa nde d with crysta lloids in a ra tio of 3 mL of crysta lloid for
e a ch mL of blood lost (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 384–385, 409; Miller: Miller’s Anesth esia, ed 8, pp
2784–2785).
576. (B) If blood loss e xce e ds the MABL re pla ce me nt, PRBCs a re
usua lly ne e de d. The norma l Hct of PRBCs is 60% to 80%. To
ca lcula te the volume of PRBCs to be tra nsfuse d, the following
formula is use d:
In this ca se , volume to be infuse d = 800 × (28 − 20)/60 = 106 mL
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 384–385;
577. (C) Give n tha t cuffe d e ndotra che a l tube s a re ofte n chose n to be
a size sma lle r (i.e ., 0.5 mm) tha n uncuffe d e ndotra che a l tube s, the
lume n is na rrowe r a nd, the re fore , sponta ne ous bre a thing is more
difficult. Be ca use a sma lle r e ndotra che a l tube ca n be use d with a
cuff, fe we r intuba tions a re ne e de d to se le ct the corre ct tube size .
Also be ca use of the cuff, le ss ga s le a ks from the tra che a into the
pha rynx, a llowing a dministra tion of lowe r ga s flows with pote ntia l
cost sa vings a s we ll a s le ss e nvironme nta l pollution. The ga se s a re
le ss like ly to le a k into the pha rynx, a nd this should de cre a se the
cha nce of a n a irwa y fire whe n high oxyge n or nitrous oxide
conce ntra tions a re use d with ca ute ry in the ora l ca vity. To furthe r
de cre a se the cha nce of a n a irwa y fire , most a ne sthe siologists
would a void the use of nitrous oxide a nd would de cre a se the F IO2
to a round 0.30 if oxyge n sa tura tions a re a cce pta ble . The cha nce of
a spira tion of ga stric conte nts should a lso be le ss like ly (Davis:
Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 356–357; Miller:
578. (C) Inha la tion a ge nts a re re spira tory de pre ssa nts. In ge ne ra l,
the y incre a se the re spira tory ra te a nd de cre a se the tida l volume
(VT) of re spira tions a nd a re a ssocia te d with a n incre a se in Pa CO2.
W he n inducing a child with a n inha la tion a ge nt, e spe cia lly be low
the minimum a lve ola r conce ntra tion (MAC) le ve l, the re spira tory
pa tte rn ca n va ry a nd include bre a th holding, e xce ssive
hype rve ntila tion, a nd la ryngospa sm. Although the sta ge s of
inha la tion a ne sthe sia we re cla ssica lly de scribe d with e the r, simila r
sta ge s a re se e n with the ne we r inha la tion a ge nts, but be ca use the
signs a re le ss pronounce d the y a re ra re ly de scribe d a nymore . The
cla ssic sta ge s of de pth of e the r a ne sthe sia include the first sta ge of
a ne sthe sia (a na lge sia ). Pa tie nts in the first sta ge ca n re spond to
ve rba l stimula tion, ha ve a n inta ct lid re fle x, ha ve norma l
re spira tory pa tte rns a nd inta ct a irwa y re fle xe s, a nd ha ve some
a na lge sia . The se cond sta ge of a ne sthe sia (de lirium or e xcite me nt
sta ge ) is a ssocia te d with unconsciousne ss, irre gula r a nd
unpre dicta ble re spira tory pa tte rns (including hype rve ntila tion),
nonpurpose ful muscle move me nts, a nd the risk of clinica lly
importa nt re fle x a ctivity (e .g., la ryngospa sm, vomiting, ca rdia c
a rrhythmia s). The third sta ge of a ne sthe sia (surgica l a ne sthe sia ) is
a ssocia te d with a re turn to more re gula r pe riodic re spira tions a nd
is the le ve l a ssocia te d with the a chie ve me nt of MAC. MAC is note d
by the a bse nce of move me nt (in 50% of pa tie nts) in re sponse to a
surgica l incision. As a ne sthe sia is de e pe ne d, sta ge 4 (re spira tory
pa ra lysis) is a ssocia te d with re spira tory a nd ca rdiova scula r a rre st.
In the ca se cite d in this que stion, the se cond sta ge of a ne sthe sia is
de monstra te d. Note : MH trigge re d by the sole use of vola tile
a ne sthe tics produce s a n e le va tion of ca rbon dioxide le ve ls with
ta chypne a a nd ta chyca rdia , but this is ra re during the first
20 minute s of a n a ne sthe tic. Se voflura ne a nd de sflura ne se e m to be
le ss of a trigge r tha n ha lotha ne . Mild hypothe rmia , propofol,
nonde pola rizing ne uromuscula r blocke rs, a nd tra nquilize rs ma y
de la y or pre ve nt MH from de ve loping. Succinylcholine (the only
de pola rizing ne uromuscula r blocke r in use toda y) ofte n ha ste ns the
de ve lopme nt of MH in susce ptible pa tie nts. Aspira tion of ga stric
conte nts would more like ly le a d to la ryngospa sms, whe e zing, a nd
hypoxia (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
230–231; Miller: Miller’s Anesth esia, ed 8, pp 691–692, 1294–1295;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 890–
891).
579. (D) The he modyna mic indice s de scribe d in this que stion a re
norma l for he a lthy 1-month-old ne ona te s (Miller: Basics of Anesth esia,
ed 6, pp 548–550).
COMPARISON OF CARDIOVASCULAR VARIABLES
Data from Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, pp 548–550.
580. (D) Da rk brown or cola -colore d urine (i.e ., myoglobine mia )

ma y be ca use d by rha bdomyolysis, a possible sign of MH, a nd this
pa tie nt should be e va lua te d. More typica l signs a nd symptoms of
MH include ta chyca rdia , ta chypne a , hype rca rbia , hype rka le mia
with pe a ke d T wa ve s, a cidosis, incre a se d sympa the tic a ctivity,
irre gula r he a rtbe a t, mottle d cya notic skin, profuse swe a ting, a nd a
la te sign of incre a se d te mpe ra ture (> 1.5° C ove r 5 minute s or
te mpe ra ture >38.8° C). Supportive la bora tory te sts for MH include
e le va te d se rum cre a tine phosphokina se (CPK); myoglobin in the
se rum a nd urine ; incre a se d se rum pota ssium, ca lcium, a nd la cta te
le ve ls; a nd a me ta bolic/re spira tory a cidosis on a n a rte ria l blood
ga s. If the pre sume d dia gnosis is MH, the ra py should be initia te d
581. (B) In infa nts a nd young childre n, the re should be a sma ll a ir
le a k a round the e ndotra che a l tube a t pe a k infla tion pre ssure s of
a pproxima te ly 15 to 25 cm H2O. The le a k te st ca n be pe rforme d by
slowly incre a sing the a irwa y pre ssure a nd liste ning with a
ste thoscope ove r the la rynx to he a r whe n a le a k de ve lops. An a ir
le a k within this pre ssure ra nge a llows for a de qua te ve ntila tion a nd
re duce s the incide nce of postintuba tion croup. The most common
ca use of postintuba tion croup is a tight-fitting e ndotra che a l tube
without a le a k a t 30 to 40 cm H2O (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 356–357, 389–390).
582. (C) A conge nita l dia phra gma tic he rnia (CDH) is the he rnia tion
of a bdomina l visce ra into the che st ca vity through a de fe ct in the
dia phra gm a nd occurs in a pproxima te ly 1 in e ve ry 3000 live births.
Most CDHs occur through a de fe ct in the le ft side of the dia phra gm
a nd produce the cla ssic tria d of dyspne a , cya nosis, a nd a ppa re nt
de xtroca rdia . Symptoms de pe nd upon the de gre e of he rnia tion a nd
the a mount of re spira tory compromise . Some ne wborns show
significa nt re spira tory compromise in the de live ry room, whe re a s
othe rs de te riora te hours la te r. If ve ntila tion is ne e de d, intuba tion is
pre fe rre d ove r ma sk ve ntila tion (ma sk ve ntila tion ma y push some
ga s into the stoma ch, incre a sing re spira tory compromise ). Usua lly,
imme dia te intuba tion of the tra che a with ge ntle re spira tory support
is ne e de d, but occa siona lly intuba tion is pe rforme d la te r in the OR.
Ora l or na soga stric tube s a re pla ce d e a rly to pre ve nt ga stric
diste ntion a nd worse ning re spira tory compromise . Be ca use CDH is
a ssocia te d with hypopla stic lungs, curre nt ve ntila tory support a ims
a t ma inta ining a pre ducta l oxyge n sa tura tion of 90% to 95%, using
low a irwa y pre ssure s a nd a llowing for mode ra te pe rmissive
hype rca rbia (Pa CO2 of 60-65 mm Hg). If the pa tie nt e xpe rie nce s
sudde n oxyge n de sa tura tion during positive -pre ssure ve ntila tion, a
te nsion pne umothora x should be suspe cte d (usua lly on the
contra la te ra l side to the CDH) a nd if confirme d, a che st tube should
be pla ce d. De spite inte nsive tre a tme nts, a bout 40% to 50% of the se
ne wborns will die in the ne wborn pe riod. At one time , the se
pa tie nts we re rushe d to the OR; now the y a re usua lly sta bilize d
(some time s for 5-15 da ys) a nd more e le ctive ly ta ke n to the OR. Also
se e e xpla na tion for Que stion 626 (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 567–574; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 594–596; Miller: Miller’s Anesth esia, ed 8, pp
2792–2793).
583. (B) Unlike a dults, childre n ma inta in sta ble he modyna mics until
re a ching a 25% to 35% loss of the ir circula ting blood volume . This is
thought to be re la te d to the ir high sympa the tic tone tha t produce s
profound pe riphe ra l va soconstriction in a n e ffort to ma inta in blood
pre ssure . The re a re , howe ve r, clinica l signs tha t he ra ld incipie nt
shock be fore blood pre ssure cha nge s. He is most like ly
a pproxima te ly 25% de ple te d a nd not in the le ss tha n 20% ra nge ,
be ca use he is confuse d a nd le tha rgic a nd not just a nxious with
norma l me nta tion (<20%). His re na l sta tus is oliguric (25% loss)
inste a d of a nuric, which would corre spond to 40% blood volume
de ple tion (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
980–981).
584. (C) The de pth of inse rtion of a n ora l e ndotra che a l tube from
the a lve ola r ridge to the midtra che a l le ve l is a pproxima te ly 7 cm for
a 1-kg ne wborn, 8 cm for a 2-kg ne wborn, 9 cm for a 3-kg ne wborn,
a nd 10 cm for a typica l 3.5-kg te rm ne wborn. The re a re ma ny wa ys
to e stima te the a ppropria te de pth of inse rtion of a n ora l
e ndotra che a l tube (in ce ntime te rs) for infa nts a nd childre n.
One me thod is using a ge (e .g., >3 ye a rs): (Age in ye a rs)/2 + 12 = tube
le ngth inse rte d
In this 6-ye a r-old child: 6/2 + 12 = 15 cm
Anothe r wa y is to multiply the inte rna l dia me te r (ID) size of the
e ndotra che a l tube by 3. For e xa mple , whe n you use a 5.0 ID size
e ndotra che a l tube , inse rt the tube a bout 15 cm. W he n using a
cuffe d e ndotra che a l tube , the cuff should be visua lize d a s just
pa ssing the voca l cords. If a n uncuffe d e ndotra che a l tube is use d,
the tube is inse rte d to the first or se cond line on the tube a t the
le ve l of the voca l cords (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, p 356).
585. (D) In e le ctive ca se s, intra ve nous fluids a re a dministe re d to
re pla ce fluid de ficits from pre ope ra tive fa sting, to ma inta in
ma inte na nce fluid re quire me nts, a nd to re pla ce ongoing fluid
losse s from the surgica l proce dure . In e me rge ncy ca se s, fluid ma y
a lso be ne e de d to re store intra va scula r volume , if hypovole mia
occurs from the e me rge ncy condition.
Ma inte na nce fluid re quire me nts follow the 4:2:1 rule , whe re
4 mL/kg is a dministe re d for the first 10 kg of we ight, 2 mL/kg for
the ne xt 10 kg of we ight, a nd 1 mL/kg for a ny we ight ove r 20 kg.
Thus, for this 14-kg child, the de ficit is ca lcula te d to be
[(4 mL × 10 kg) + (2 mL × 4 kg)] pe r hour × 10 hours = 480 mL. This
is proba bly a slight ove re stima te give n tha t the fa sting pa tie nt
conse rve s fluid. In ge ne ra l, ha lf of the fluid de ficit + the hourly
ma inte na nce fluid is a dministe re d in the first hour of a ne sthe sia ,
one fourth of the de ficit + ma inte na nce fluids for the se cond a nd
third hours, the n ma inte na nce fluids the re a fte r + re pla ce me nt
fluids for ongoing losse s.
Glucose solutions a re commonly a dministe re d to pe dia tric pa tie nts
whe n the de ve lopme nt of hypoglyce mia is gre a te st, na me ly
ne ona te s a nd a ny pa tie nt who is critica lly ill or ha s he pa tic
dysfunction. Typica lly, he a lthy childre n olde r tha n 1 ye a r of a ge
(or >10-kg we ight) do not re quire supple me nta l glucose during
surge ry, be ca use the ir glycoge n store s a re a de qua te for the stre ss
of surge ry.
The two most common isotonic solutions use d a re la cta te d Ringe r
solution a nd Pla sma Lyte A solution. Most would a void the use of
norma l sa line be ca use the re is a risk of de ve loping
hype rchlore mic me ta bolic a cidosis. Norma l sa line conta ins
154 mEq/L of Na +, which ca use s the kidne y to e xcre te
bica rbona te to pre se rve e le ctrica l ne utra lity (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 383; Miller: Basics of
Anesth esia, ed 6, pp 552–553; Miller: Miller’s Anesth esia, ed 8, pp 2783–
2784).
586. (D) Ne ona te s a nd infa nts (<2 ye a rs of a ge ) re quire more
succinylcholine pe r body we ight tha n do olde r childre n a nd a dults
to produce ne uromuscula r blocka de , be ca use the e xtra ce llula r
fluid volume is much gre a te r in ne ona te s a nd infa nts. Be ca use the
volume of distribution of succinylcholine is gre a te r, the
re comme nde d dose of succinylcholine in ne ona te s a nd infa nts to
provide optima l conditions for tra che a l intuba tion is 2 mg/kg
inste a d of the 1 mg/kg use d for a dults (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 247, 537; Miller: Miller’s Anesth esia, ed 8,
p 2771).
587. (D) He a rt ra te s le ss tha n 100 be a ts/min a re poorly tole ra te d in
the ne ona te be ca use of the re duce d ca rdia c output a nd poor tissue
pe rfusion tha t de ve lops. Conge nita l he a rt dise a se , such a s
conge nita l he a rt block or conge nita l he a rt fa ilure , is ra re a nd ca n
be dia gnose d by ne ona ta l e le ctroca rdiogra m a nd e choca rdiogra m.
Ma te rna l me dica tions during la bor a nd de live ry ra re ly ca use
bra dyca rdia ; howe ve r, fe ta l distre ss a s a re sult of hypoxia ma y
ca use it. Fe ve r a s we ll a s ma te rna l a dministra tion of β-mime tics
(e .g., te rbuta line , ritodrine ) te nd to ca use ta chyca rdia . Cold stre ss
of the ne ona te ma y le a d to hypoxe mia , which will promote
pe rsiste nce of the fe ta l circula tion, which is why a ne utra l the rma l
e nvironme nt to minimize he a t loss is importa nt. Howe ve r, the most
common ca use of ne ona ta l bra dyca rdia in the de live ry room is
re spira tory fa ilure re sulting in hypoxia a nd a cidosis. In the OR,
bra dyca rdia re sults from hypoxia , va ga l stimula tion, a nd the
de pre ssa nt e ffe cts of a ne sthe tic a ge nts (e .g., ha lotha ne ), which ca n
le a d to ca rdia c a rre st (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 513–514).
588. (A) Apne a spe lls a re de fine d a s ce ssa tion of bre a thing for a t
le a st 15 se conds a nd a re ofte n a ccompa nie d by bra dyca rdia a nd/or
cya nosis. Infa nts (e spe cia lly forme r pre ma ture ne wborns) younge r
tha n 60 we e ks’ PCA a re a t risk for a pne a a fte r ge ne ra l a ne sthe sia ,
a lthough most ca se s will occur in infa nts le ss tha n 45 we e ks’ PCA.
The se pa tie nts should be a dmitte d to the hospita l a nd ha ve a t le a st
12 a pne a -fre e hours of monitoring be fore discha rge . This child wa s
born a t 31 we e ks’ e stima te d ge sta tiona l a ge a nd is now 10 we e ks
old or is 41 we e ks’ PCA a nd ne e ds to be a dmitte d. Of the
postope ra tive a na lge sia pla ns liste d with ove rnight obse rva tion,
a nswe r A is the most a ppropria te . Answe rs B a nd D include
a na lge sic dose s tha t a re too high. Ane mia (Hct <30) a lso a ppe a rs to
incre a se the cha nce s for postope ra tive a pne ic spe lls (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 388; Miller: Miller’s
589. (B) The tre a tme nt for docume nte d ve ntricula r fibrilla tion or
pulse le ss ve ntricula r ta chyca rdia is e le ctrica l de fibrilla tion a s soon
a s possible . Ca rdiopulmona ry re suscita tion is pe rforme d until the
de fibrilla tor a rrive s a nd de fibrilla tion is a tte mpte d. W ith ma nua l
de fibrilla tors (monopha sic or bipha sic) the initia l dose should be
2 J/kg, incre a sing to 4 J/kg up to a ma ximum of 10 J/kg (or a dult
dose ). In this 20-kg child the initia l dose is 20 × 2 J/kg = 40 J.
Automa te d e xte rna l de fibrilla tors (AEDs) ca n be sa fe ly use d in
childre n 1 to 8 ye a rs of a ge . W he n using a n AED, it is be st to use
one with a pe dia tric a tte nua tor syste m, which de cre a se s the
de live re d e ne rgy to dose s a ppropria te for childre n (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 1229–1230; 2010 Am erican
Heart Association Guid elines for Card iopulm onary Resuscitation and
Em ergency Card iovascular Care, Circulation 122:S706–S719, 2010).
590. (B)
Common te a ching sta te s tha t the spina l cord of the ne wborn or

infa nt e nds a t L3 a nd the dura l sa c e nds a t S3, so lumba r
puncture should be pe rforme d in the se childre n no highe r tha n
the L4-L5 inte rspa ce . Re ce nt da ta using ultra sound sugge st tha t
the spina l cord of ne wborns e nds a t L2. For the a dult, the spina l
cord e nds a t L1 a nd the dura l sa c e nds a t S1 (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 463–464).
591. (D) EA a nd TEF ma y be suspe cte d pre na ta lly whe n the mothe r
ha s polyhydra mnios; othe rwise it is suspe cte d soon a fte r birth
whe n e xce ssive ora l se cre tions, drooling, or coughing a re note d
a nd a n ora l suction ca the te r ca nnot be pa sse d into the stoma ch.
Be ca use the pa ssa ge of a n ora l ga stric tube is not routine in ma ny
ce nte rs, the first ma nife sta tion of EA occurs whe n the ne wborn ha s
trouble bre a thing (e .g., coughing) a nd re gurgita te s with the first
fe e ding. Afte r the dia gnosis is ma de , the se pa tie nts should be
pla ce d in the he a d-up position a nd the blind uppe r pouch of the
e sopha gus should be de compre sse d with a suction tube
imme dia te ly to re duce pulmona ry a spira tion of se cre tions. Othe r
a bnorma litie s a ssocia te d with EA a nd TEF include VACTERL
(Ve rte bra l a bnorma litie s, impe rfora te Anus, Conge nita l he a rt
dise a se , Tra che oEsopha ge a l fistula , Re na l a bnorma litie s, Limb
a bnorma litie s). Se e a lso Que stion 574 (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 574–576; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 596–597; Miller: Miller’s Anesth esia, ed 8, p
2792).
592. (D) Ompha loce le is the e xte rna l he rnia tion of a bdomina l
visce ra through the ba se of the umbilica l cord. It occurs in a bout 1
of 5000 births. Thirty pe rce nt of the se ne wborns will die in the
ne ona ta l pe riod, prima rily from ca rdia c de fe cts or pre ma turity.
Some of the se ne wborns with ompha loce le ha ve a syndrome
ca lle d Be ckwith-W ie de ma nn syndrome . This syndrome is
cha ra cte rize d by ompha loce le , orga nome ga ly, ma crosomia , la rge
fonta ne lle s, ma croglossia , polycythe mia , a nd hypoglyce mia . The se
pa tie nts ma y be ve ry difficult to intuba te be ca use of the ir significa nt
ma croglossia (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed
6, p 598).
593. (C) Ane sthe sia for pa tie nts with EA a nd TEF ca n be sa fe ly
induce d with e ithe r a n intra ve nous or vola tile a ne sthe tic. Howe ve r,
positive -pre ssure ba g a nd ma sk ve ntila tion should be a voide d
be ca use it will force ga s into the stoma ch, pote ntia lly ma king
ve ntila tion of the lungs more difficult. A fre que ntly use d te chnique
to fa cilita te corre ct pla ce me nt of the e ndotra che a l tube is to
a dva nce the tube into a bronchus. W hile liste ning ove r the
stoma ch, slowly withdra w the tube until bre a th sounds a re he a rd
ove r the stoma ch. Adva nce the tube until the se sounds be come
diminishe d. Bronchoscopy is use d by some a ne sthe siologists to
ma ke sure only one fistula is pre se nt a nd to he lp position the
e ndotra che a l tube (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren,
ed 8, pp 576–577; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, pp 597–598).
594. (C) This child most like ly ha s a lowe r re spira tory infe ction. The
pla nne d proce dure should be de la ye d for a pe riod of 4 to 6 we e ks.
This child ma y ha ve e a rly ma nife sta tions of pne umonia with the
LLL infiltra te a nd should be e va lua te d by a pe dia tricia n. W ithout a
physica l a sse ssme nt, simply sta rting ora l a ntibiotic the ra py would
be ill a dvise d.
The spe cific time to re sche dule surge ry for childre n with uppe r
re spira tory infe ctions (URIs) is not a bsolute . Ge ne ra lly
a cce pta ble guide line s for postpone me nt of e le ctive surge rie s for
the se pa tie nts sugge st 1 to 2 we e ks a fte r re cove ry from the a cute
illne ss. Ma nife sta tion of URI include (1) mildly sore or scra tchy
throa t; (2) cha nge in fe e ding or le ve l of a ctivity; (3) cough or
sne e zing; (4) rhinorrhe a (ne w or cha nge in consiste ncy); (5) na sa l
conge stion; (6) fe ve r highe r tha n 101° F (38.8° C); a nd (7) infla me d
throa t or hoa rse voice .
The pre se nce of the se signs a nd symptoms incre a se s the
like lihood of postope ra tive a irwa y complica tions a nd ma y
ne ce ssita te a n ove rnight a dmission. Childre n with pre e xisting
re a ctive a irwa y dise a se , re ga rdle ss of e tiology, who de ve lop URI
a re a t highe r risk of postope ra tive complica tions, a nd the
thre shold for postponing surge ry should be e ve n lowe r tha n for
simila r pa tie nts without comorbiditie s (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, pp 1112–1114: Miller: Basics of
595. (C) The e stima te d blood volume (EBV) of he a lthy full-te rm
ne ona te s is a pproxima te ly 80 to 90 mL/kg. For this 4-kg ne ona te , the
volume is 320 to 360 mL. Pre ma ture ne wborns ha ve a n EBV of 90 to
100 mL/kg, whe re a s the 3- to 12-month-old infa nt ha s a n EBV of 75
to 80 mL/kg (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, p
409).
596. (C) In the fe tus, pulmona ry va scula r re sista nce is e xtre me ly
high. In ute ro, most of the right ve ntricula r output bypa sse s the
lungs a nd flows into the de sce nding a orta through the ductus
a rte riosus. W ith the onse t of ve ntila tion a t birth the pulmona ry
va scula r re sista nce sudde nly de cre a se s, e na bling blood to flow
more e a sily through the lungs. Pulmona ry va scula r re sista nce
continue s to de cre a se a fte r birth, re a ching a dult le ve ls by 1 to
2 months of life . This is whe n pulmona ry ove rcircula tion might
occur a nd re sult in pulmona ry e de ma a nd e ve ntua l fa ilure . The
incre a se in Pa O2 not only a cts a s a pulmona ry a rte ry va sodila tor
(a long with the lowe ring of the Pa CO2) but a lso a cts a s a
va soconstrictor to the ductus a rte riosus (thus furthe r a ssisting the
cha nge from the fe ta l to the a dult circula tion) (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 86–87, 519).
597. (D) A compre he nsive unde rsta nding of the rmore gula tion a nd a
me ticulous a tte ntion to de ta il during the a ne sthe tic ca re of infa nts
a re both ne ce ssa ry to minimize intra ope ra tive he a t loss. In
a ne sthe tize d infa nts, he a t loss occurs through the tra nsfe r of he a t
from the pa tie nt to the e nvironme nt in one of four wa ys: ra dia tion
(tra nsfe r be twe e n obje cts not in conta ct), conduction (tra nsfe r
be twe e n obje cts in conta ct), conve ction (tra nsfe r to moving
mole cule s such a s a ir a nd fluid), a nd e va pora tion. Of the se ,
ra dia tion a nd conve ction a ccount for a bout 75% of the infa nt’s he a t
loss. For this re a son, pla ce me nt of a n infra re d he a te r ove r the OR
ta ble a nd pre wa rming the OR a tmosphe re a re the most e ffe ctive
me a ns of pre ve nting hypothe rmia in the se pa tie nts. Cove ring the
OR ta ble with a he a ting bla nke t; ve ntila ting the pa tie nt with wa rm,
humidifie d a ne sthe tic ga se s; wra pping the e xtre mitie s of the
pa tie nt with she e t wa dding; a nd cove ring the pa tie nt’s he a d with a
cloth or pla stic ca p ca n a lso re duce he a t loss a nd pre ve nt
hypothe rmia . Conve ctive force d-a ir wa rme rs ca n he lp pre ve nt a
de cre a se in body te mpe ra ture a nd a lso ha ve be e n e ffe ctive in
re wa rming hypothe rmic pa tie nts. A Ma ple son D bre a thing circuit is
not a circle syste m a nd doe s not pre se rve he a t or moisture . To
pre ve nt re bre a thing of e xpire d ga se s, sponta ne ous bre a thing flow
ra te s ne e d to be two to thre e time s the minute ve ntila tion, a nd for
controlle d ve ntila tion fre sh ga s flows ne e d to be gre a te r tha n
90 mL/kg/min. Low flows such a s 50 mL/kg/min with Ma ple son
circuits a re ina de qua te a nd will re sult in re spira tory a cidosis
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 162–165,
598. (D) Although a ll of the se conditions ca n produce ve ntila tory
de pre ssion in the postope ra tive pe riod, only pyloric ste nosis
produce s ce ntra l ne rvous syste m (CNS) de pre ssion of re spira tion.
Pa tie nts with pyloric ste nosis ha ve protra cte d vomiting tha t le a ds to
de hydra tion, hypoka le mia , hypona tre mia , hypochlore mia , a nd
me ta bolic a lka losis. Postope ra tive ve ntila tory de pre ssion
fre que ntly occurs in infa nts with pyloric ste nosis, thought to be
re la te d to ce re brospina l fluid (CSF) a lka losis tha t is worse ne d by
intra ope ra tive hype rve ntila tion of the lungs. Thus, the se pa tie nts
should be fully a wa ke with a norma l ra te a nd pa tte rn of re spira tion
be fore e xtuba tion is conside re d. This is one re a son infa nts with
pyloric ste nosis should be sta bilize d a nd hydra te d be fore coming to
the OR. The othe r conditions liste d ca n le a d to me cha nica l, not
ce ntra l, ca use s of re spira tory difficulty in the postope ra tive pe riod
599. (C) Ne wborns with dia phra gma tic he rnia ha ve significa nt
re spira tory difficulty. In a ddition to the ir hypopla stic lungs,
pe rsiste nt pulmona ry hype rte nsion is pre se nt, producing right-to-le ft
shunting through the pa te nt ductus a rte riosus. To more
a ppropria te ly a dministe r the a ne sthe tic, a pre ducta l (ductus
a rte riosus) a rte ry should be ca nnula te d to monitor a rte ria l blood
ga se s a nd blood pre ssure . The right ra dia l or te mpora l a rte rie s
a rise from ve sse ls tha t origina te from the a orta proxima l to the
ductus a rte riosus. The oxyge n sa tura tion monitors should be
pla ce d on the right a rm a s we ll (Hines: Stoelting’s Anesth esia and Co-
600. (C) The MAC for isoflura ne is gre a te st a t a ge 3 months. The
MAC is lowe r in pre te rm ne ona te s compa re d with te rm ne ona te s.
The low MAC in the ne wborns ma y be re la te d to the imma turity of
the CNS a nd/or re la te d to the e le va te d le ve ls of proge ste rone a nd
β-e ndorphins. The incre a se in MAC in the first fe w we e ks a fte r
birth se e ms to be re la te d to the fa lling proge ste rone le ve ls. Afte r
a ge 3 months, the MAC of the se vola tile a ne sthe tics ste a dily
de cline s with a ging e xce pt for a slight incre a se a t pube rty. For
re a sons tha t a re uncle a r, the MAC for se voflura ne is simila r in
ne ona te s a nd infa nts younge r tha n 1 ye a r (3.2%). The MAC of
se voflura ne the n de cre a se s with a ge (1 to 12 ye a rs, 2.5%; 40-ye a r-
old, 2%) (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
190, 556; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p
587).
601. (C) Se ve ra l formula s (none ide a l) ha ve be e n use d a s a guide
for initia l fluid re suscita tion in burn injurie s. Intra va scula r fluid-
volume de ficits in pa tie nts with burn injurie s a re roughly
proportiona l to the e xte nt a nd de pth of the burn. The Pa rkla nd
formula , more re ce ntly re na me d the Conse nsus formula , is
pe rha ps the most commonly use d formula . This formula e stima te s
fluid ne e ds to be 4 mL/kg of crysta lloid for e a ch pe rce nt of body
surfa ce a re a burne d. Thus, in this ca se : 4 × 40 (kg) × 50
(%) = 8000 mL. Approxima te ly two thirds of this fluid should be
re pla ce d with isotonic crysta lloid solutions during the first 8 hours
a fte r the injury, the re st ove r the ne xt 16 hours. This e stima te is
modifie d clinica lly by the pa tie nt’s clinica l re sponse a s note d by the
vita l signs a nd urine output (ta rge t urine output of 0.5 mL/kg/hr)
602. (D) The most like ly e xpla na tion for the “fa lling” he moglobin
le ve l in this pa tie nt is tha t this is a norma l physiologic finding. At
birth, a full-te rm infa nt ha s a he moglobin le ve l of a pproxima te ly 15
to 20 g/dL. A ph y siologic anem ia occurs by a ge 2 to 3 months,
re sulting in he moglobin conce ntra tions of a pproxima te ly 10 to
11 g/dL. Afte r 3 months, the re is a progre ssive incre a se in
he moglobin conce ntra tion, which re a che s le ve ls simila r to tha t of
a dults by a ge 6 to 9 months. For pre ma ture infa nts, the a ne mia is
more pronounce d (ofte n to a s low a s 8.0 g/dL), occurs e a rlie r, a nd
pe rsists longe r (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed
8, pp 398–399).
603. (C) This history is consiste nt with a n a cute life -thre a te ning
ca use of uppe r a irwa y obstruction ca lle d e piglottitis (or more
a ppropria te ly supra glottitis be ca use othe r supra glottic structure s
a re involve d a s we ll). In the pa st, more tha n 75% of ca se s we re
ca use d by Haem oph ilus influenza type b (Hib). W ith wide spre a d
immuniza tion a ga inst H. influenzae, this condition ha s be come much
le ss fre que nt a nd the ca use s now include Haem oph ilus
parainfluenzae, group A stre ptococci, pne umococci, a nd
sta phylococci. This condition is a me dica l e me rge ncy tha t usua lly
sta rts out a s a se ve re sore throa t a nd ra pidly progre sse s to the
“four Ds” (dyspha gia , dysphonia , dyspne a , a nd drooling). It ca n
progre ss ra pidly a nd ca use de a th within 6 to 12 hours a fte r the
onse t of symptoms. The child typica lly is se e n sitting up, a ppe a rs
dyspne ic with the mouth ope n, is drooling, a nd ha s a high fe ve r
a nd ta chyca rdia . Inspira tory stridor is a la te finding a nd sugge sts
impe nding comple te uppe r a irwa y obstruction. W he n suspe cte d,
the a ne sthe siologist a nd otola ryngologist should be notifie d a nd the
child imme dia te ly tra nsfe rre d to the OR (with the pa re nt if
a ppropria te ) be fore comple te uppe r a irwa y obstruction e nsue s. In
the OR, a ne sthe sia should be induce d with se voflura ne a nd oxyge n
with the child in a sitting position. Se voflura ne is le ss like ly to
induce la ryngospa sm tha n isoflura ne or de sflura ne . IV a cce ss
should be e sta blishe d a s soon a s the child is de e ply a ne sthe tize d.
Atropine (0.02 mg/kg) should be a dministe re d to block va ga lly
me dia te d bra dyca rdia induce d by dire ct la ryngoscopy. Muscle
re la xa nts a re contra indica te d be ca use the y ca n ca use comple te
obstruction of the uppe r a irwa y in the se pa tie nts. The tra che a
should be intuba te d unde r dire ct la ryngoscopy whe n the de pth of
a ne sthe sia is sufficie nt to blunt la rynge a l re fle xe s. Also se e
e xpla na tion for Que stion 619 (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 811–813; Hines: Stoelting’s Anesth esia and Co-
604. (D) Ce re bra l pa lsy is a CNS symptom comple x. The most
common clinica l ma nife sta tion is ske le ta l muscle spa sticity. It is
usua lly cla ssifie d a ccording to the e xtre mity a ffe cte d (e .g.,
monople gia , he miple gia , diple gia , or qua driple gia ) a nd the
cha ra cte ristics of the ne urologic dysfunction (spa stic, hypotonic,
dystonic, a the totic). Othe r ma nife sta tions include ce re be lla r a ta xia ,
se izure disorde rs, va rying de gre e s of me nta l re ta rda tion, a nd
spe e ch de ficits. Ga stroe sopha ge a l re flux is a lso common. For this
re a son, the pre fe rre d induction of ge ne ra l a ne sthe sia in the se
pa tie nts should include a ra pid-se que nce IV induction with
propofol followe d by imme dia te tra che a l intuba tion. Etomida te ,
ke ta mine , a nd me thohe xita l a re proconvulsa nts in pa tie nts with
unde rlying se izure disorde rs a nd should proba bly be a voide d. Eve n
though the se pa tie nts ha ve ske le ta l muscle spa sticity, the re ha ve
be e n no re ports of succinylcholine -induce d hype rka le mia . The
re sponse to nonde pola rizing muscle re la xa nts is norma l in most
re ports; howe ve r, some ha ve re porte d re sista nce to
nonde pola rizing muscle re la xa nts. For a ra pid-se que nce induction,
succinylcholine is fa ste r tha n ve curonium. Rocuronium could a lso
be use d due to its ra pid onse t (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 863–865; Hines: Stoelting’s Anesth esia and Co-
605. (D) The symptoms de scribe d in this pa tie nt a re consiste nt with
se ve re de hydra tion. Thus, the va scula r volume should be
e xpa nde d initia lly with a n isotonic sa line solution or a colloid
solution until the pa tie nt voids. W he n the urine output incre a se s,
pota ssium ca n be a dde d to the IV fluids. Although glucose
a dministra tion for long proce dure s ma y pre ve nt hypoglyce mia ,
D5W a lone or with a crysta lloid solution should not be use d to
re pla ce fluid de ficits (Davis: Sm ith ’s Anesth esia for Infants and
606. (A) Pre te rm infa nts ha ve ve ry limite d ca lcium re se rve s a nd a re
ve ry susce ptible to hypoca lce mia . Hypoca lce mia (se rum ionize d
ca lcium le ve l <1.5 mEq/L) ma nife sts itse lf in a numbe r of
nonspe cific wa ys, including irrita bility, twitching, hypote nsion, a nd
se izure . A dose of 10 to 20 mg/kg of e le me nta l ca lcium a dministe re d
ove r 5 to 10 minute s will be a n a ppropria te sta rting dose a nd ma y
ne e d to be re pe a te d e ve ry 6 to 8 hours until the ca lcium le ve ls
sta bilize . Bra dyca rdia a nd occa siona lly a systole ca n be se e n if it is
inje cte d too ra pidly. In this infa nt of 1800 g, the sta rting dose of
1.8 kg × 10 mg/kg = 18 mg of e le me nta l ca lcium ca n be use d.
Ca lcium glucona te 10% solution conta ins a bout 9 mg/mL of
e le me nta l ca lcium so the dose is 2 mL. Some of the signs of
hypoglyce mia a re simila r to those of hypoca lce mia a nd include
se izure , irrita bility, hypote nsion, a nd some time s bra dyca rdia a nd
a pne a . In the pa tie nt de scribe d in this que stion, the glucose ha s
a lre a dy be e n me a sure d a t 50 mg/dL, which is a cce pta ble for a
pre te rm infa nt. An O2 sa tura tion of 88% is a lso a cce pta ble be ca use
the pa tie nt is a t risk for ROP (i.e ., <44 we e ks’ PCA).
Hype rve ntila tion would ca use a lka losis, which would de cre a se the
unbound fra ction of ca lcium a nd ma ke the pa tie nt more susce ptible
to se izure s. Furthe rmore , ca lcium binds to a lbumin, which would
furthe r re duce the fre e ca lcium. Be ca use the urine output is more
tha n a de qua te , it is unlike ly tha t the pa tie nt ne e ds a fluid bolus to
corre ct hypote nsion (Hines: Stoelting’s Anesth esia and Co-Ex isting
607. (A) EMLA cre a m conta ins lidoca ine (2.5%) a nd priloca ine (2.5%).
W he n the 5% EMLA cre a m is a pplie d to dry inta ct skin a nd cove re d
with a n occlusive dre ssing for a t le a st 1 hour, topica l a ne sthe sia to
a de pth of 5 mm is obta ine d. Four pe rce nt lidoca ine (ELA-Ma x) ca n
a lso be use d a nd re quire s only 30 minute s to be come e ffe ctive
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, p 441).
608. (D) Although the umbilica l ve in is la rge r a nd e a sie r to
ca nnula te tha n the umbilica l a rte ry, the umbilica l ve in will not
a llow for a de qua te a sse ssme nt of a rte ria l blood ga se s or syste mic
blood pre ssure . Additiona lly, a dministra tion of drugs or hype rtonic
solutions into the umbilica l ve in ma y be ha za rdous, be ca use the
ca the te r ca n be come we dge d in a porta l ra dicle , possibly le a ding
to he pa tic ne crosis or porta l ve in thrombosis. To pre ve nt this, the
umbilica l ve in ca the te r tip is a dva nce d only 2 to 3 cm into the
umbilica l ve in (to a point whe re blood ca n first be a spira te d).
Ca re ful pla ce me nt of a n umbilica l a rte ry ca the te r is e qua lly
importa nt. The tip of the umbilica l a rte ry ca the te r should be pla ce d
just a bove the bifurca tion of the a orta a nd be low the le ve l of the
re na l a rte rie s (L2). All intra -a rte ria l ca the te rs a re a ssocia te d with
thrombosis or e mbolism in the se ve sse ls, but fortuna te ly, se rious
injurie s a re ra re . Be ca use the re a re two a rte rie s a nd only one ve in,
difficulty with one a rte ry none the le ss offe rs a nothe r a rte ry to use
609. (C) Be ca use of the la rge surfa ce a re a –to-we ight ra tio, the thin
la ye r of insula ting subcuta ne ous fa t, a nd the limite d a bility to
compe nsa te for cold stre ss, ne ona te s a nd infa nts a re a t gre a te r risk
for intra ope ra tive hypothe rmia tha n a dults. Infa nts younge r tha n
3 months do not produce he a t by shive ring; the ir principa l me thod
of the rmoge ne sis is me ta bolism of brown fa t. He a t loss ca n occur
by ra dia tion, conduction, conve ction, a nd e va pora tion. He a t loss
through e va pora tion (not conduction) ca n be re duce d by
humidifica tion of inspire d ga se s. He a t loss by conduction (not
conve ction) is re duce d with the use of a wa rming bla nke t (Miller:
610. (C) In a 6-month-old infa nt, a norma l he moglobin va lue is
a pproxima te ly 11 to 12 g/dL. The norma l he a rt ra te is a bout 100 to
140 be a ts/min, systolic blood pre ssure is 70 to 90, a nd the
re spira tory ra te is a bout 25 to 35 bre a ths/min (Miller: Basics of
611. (A) The oculoca rdia c re fle x (OCR) is commonly de fine d a s a
10% to 20% de cre a se in he a rt ra te tha t is susta ine d for more tha n
5 se conds. It ca n be induce d by tra ction on e xtra ocula r muscle s,
pre ssure on the e ye , orbita l he ma toma , ocula r tra uma , or e ye pa in.
It is commonly se e n with stra bismus ope ra tions a nd ma y produce a
wide va rie ty of ca rdia c a rrhythmia s, including sinus bra dyca rdia ,
noda l bra dyca rdia , e ctopic be a ts, ve ntricula r fibrilla tion, a nd,
ra re ly, a systole (1 in 2200 stra bismus ope ra tions). The initia l
tre a tme nt of this is to stop the stimulus (i.e ., te ll the surge on to stop
wha t he or she is doing). This re fle x quickly re sponds, a nd future
simila r stimula tion typica lly e licits le ss of a re sponse . In ma ny
ca se s no furthe r tre a tme nt is ne ce ssa ry. Incre a sing the de pth of
ge ne ra l a ne sthe sia ma y he lp to block the re fle x, a s ma y
re a sse ssing the a de qua cy of ve ntila tion (be ca use hype rca rbia a nd
hypoxe mia de cre a se the thre shold to e licit the OCR). A re trobulba r
block will pre ve nt the re fle x. Infiltra ting lidoca ine loca lly into the
re cti muscle s ma y be e ffe ctive in pre ve nting a nd tre a ting the OCR.
Atropine (0.01-0.02 mg/kg) or glycopyrrola te ca n be a dministe re d
intra ve nously if the a rrhythmia pe rsists. Some a dvoca te the
prophyla ctic use of a tropine or glycopyrrola te during stra bismus
surge ry, e spe cia lly in childre n (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 880–888; Miller: Basics of Anesth esia, ed 6, pp
487–488).
612. (B) The re is no diffe re nce in VT (mL/kg) be twe e n ne ona te s a nd
a dults. Ne ona te s ha ve a high O2 consumption (a bout twice tha t of
a dults). To compe nsa te for the incre a se d oxyge n de ma nd, a lve ola r
ve ntila tion is incre a se d (a lso a bout twice the a dult). The incre a se
in a lve ola r ve ntila tion e xpla ins the slightly lowe r Pa CO2. Of note ,
the pH a lso is slightly lowe r. The re duce d functiona l re sidua l
ca pa city with the incre a se d O2 consumption pla ce s the ne ona te a t
a n incre a se d risk for hypoxia during ge ne ra l a ne sthe sia if the re is
a ny difficulty with ve ntila tion (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 584–586; Miller: Basics of Anesth esia, ed 6, pp
547–548).
PHYSIOLOGIC VARIABLES
613. (D) Ne urofibroma tosis (von Re cklingha use n dise a se ) is a n
a utosoma l domina nt ge ne tic disorde r cha ra cte rize d by multiple
ne urofibroma s involving the skin, pe riphe ra l ne rvous syste m, a nd
ce ntra l ne rvous syste m. The clinica l fe a ture s of this dise a se a re
dive rse a nd a lwa ys progre ss with time . The a ne sthe tic
ma na ge me nt of pa tie nts with ne urofibroma tosis ca n be
complica te d by the a ssocia te d clinica l ma nife sta tions of this
dise a se . For e xa mple , a phe ochromocytoma ma y be pre se nt in
a pproxima te ly 1% of pa tie nts. If this goe s unre cognize d, se ve re
hype rte nsion ca n occur during a ne sthe sia . Intra cra nia l tumors
occur in 5% to 10% of pa tie nts, a nd signs a nd symptoms of
intra cra nia l hype rte nsion ma y de ve lop. If intra cra nia l pre ssure is
e le va te d, e fforts to re duce intra cra nia l pre ssure should be initia te d.
Fina lly, a irwa y pa te ncy ma y be come compromise d by a n e nla rging
la rynge a l ne urofibroma . Abnorma l re sponse s to both de pola rizing
ne uromuscula r blocking a ge nts (se nsitive or re sista nt) a nd
nonde pola rizing ne uromuscula r blocking a ge nts (se nsitive ) ha ve
be e n de scribe d. The re is no e vide nce tha t the se pa tie nts a re a t
incre a se d risk for MH (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, p 843; Hines: Stoelting’s: Anesth esia and Co-Ex isting
614. (D) The initia l de cline (from fe ta l le ve ls) in pulmona ry va scula r
re sista nce a nd rise in pulmona ry blood flow is de pe nde nt on
a de qua te function of the e ndothe lia l ce lls in the pulmona ry
va scula ture . W ith a CDH, this proce ss doe s not occur norma lly.
This is ca use d by pulmona ry hypopla sia a nd pulmona ry
hype rte nsion. Pa tie nts with e a ch of the othe r a noma lie s a lso a re a t
risk for right-to-le ft intra ca rdia c shunting, but e a ch one ca n be
re a dily tre a te d, thus a voiding significa nt shunting a nd concomita nt
hypoxe mia . In pa tie nts with CDH, shunting is e xce e dingly difficult
to ma na ge be ca use of pulmona ry hype rte nsion, pulmona ry
hypopla sia , a nd e ndothe lia l cha nge s (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 57 –58).
615. (C) The a mount of de hydra tion tha t childre n ha ve ca n be
a sse sse d by a va rie ty of obse rva tions. For mild de hydra tion (5%
we ight loss—fluid de ficit of 50 mL/kg) the only a bnorma l finding of
the liste d a nswe rs is a de cre a se in urine output le ss tha n
2 mL/kg/hr. W ith mode ra te de hydra tion (10% we ight loss—fluid
de ficit of 100 mL/kg) mucous me mbra ne s would be dry, skin turgor
would be de cre a se d, urine output would be le ss tha n 1 mL/kg/hr,
the a nte rior fonta ne lle would be de pre sse d, a nd blood pre ssure
would be norma l to low. W ith se ve re de hydra tion (15% we ight loss
—fluid de ficit of 150 mL/kg) mucous me mbra ne s would be ve ry dry,
skin turgor would be gre a tly de cre a se d, urine output would be le ss
tha n 0.5 mL/kg/hr, the a nte rior fonta ne lle would be ma rke dly
de pre sse d, a nd blood pre ssure would be re duce d a nd orthosta tic
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 126–127).
616. (A) Postope ra tive ble e ding a fte r a tonsille ctomy occurs in 0.1%
to 8% of ca se s. The ble e ding is de fine d a s prima ry if it occurs
within 24 hours a nd se conda ry if more tha n 24 hours a fte r surge ry.
Prima ry ble e ding te nds to be more profuse tha n se conda ry
ble e ding. Se conda ry ble e ding (1 to 10 da ys postope ra tive ly) occurs
whe n the e scha r cove ring of the tonsilla r be d sloughs. Be ca use
ble e ding most ofte n occurs within the first 6 hours a fte r the surge ry
(75% of ble e ding ca se s), most outpa tie nt units ke e p pa tie nts for a t
le a st 6 to 8 hours a fte r the surge ry is comple te d. The a mount of
ble e ding te nds to be unde re stima te d be ca use ofte n a la rge a mount
of blood is swa llowe d (Barash : Clinical Anesth esia, ed 7, pp 1357–1360;
Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 799–800).
617. (D) Ea r, nose , a nd throa t surge ons ofte n use va soconstrictors
(e .g., phe nyle phrine , coca ine , or oxyme ta zoline ) to control ble e ding
in pha rynge a l a nd na sa l surge ry. For a dults, the initia l dose of
phe nyle phrine is up to 0.5 mg (4 drops of a 0.25% solution). For
childre n le ss tha n 25 kg, the initia l dose is up to 20 µg/kg. W he n
e xce ssive dose s a re use d, se ve re hype rte nsion a nd ca rdiova scula r
de compe nsa tion ma y de ve lop due to the ma rke d incre a se in
pe riphe ra l va scula r re sista nce . This a lso shifts blood from the
pe riphe ra l site into the pulmona ry va scula ture (which is le ss
se nsitive to va soconstrictors) a nd incre a se s le ft ve ntricula r filling
pre ssure . In this ca se , the use of la be ta lol a nd de e pe ning the
a ne sthe sia ha s be e n a ssocia te d with se ve re pulmona ry e de ma ,
ca rdia c a rre st, a nd de a th. If la be ta lol or a β-blocke r (e .g., e smolol)
is use d a nd conge stive he a rt fa ilure de ve lops, conside r using high-
dose gluca gon (5-10 mg) to counte ra ct the loss of ca rdia c
contra ctility. This ma y a lso occur with the use of ca lcium cha nne l
blocke rs. Ba rore ce ptor-induce d bra dyca rdia ma y not occur in the
pe dia tric pa tie nt who ha s be e n pre tre a te d with a tropine or
glycopyrrola te during the a ne sthe tic. The hype rte nsion ma y be
short live d, a nd de e pe ning the inha la tion a ne sthe tic ma y he lp;
howe ve r, tre a tme nt of se ve re hype rte nsion is most e ffe ctive with
dire ct va sodila tors or α-a dre ne rgic re ce ptor a nta gonists (e .g.,
phe ntola mine ). The ma ximum re comme nde d dose for coca ine
(usua lly a 4% solution) is 1.5 to 3 mg/kg with a ma ximum dose of
200 mg (Groud ine et al: New York State Guid elines on th e Topical Use of
Ph eny leph rine in th e Operating Room , Anesth esiology 92:859–864, 2000;
618. (C) The tota l volume of CSF in the ne wborn is 4 mL/kg
compa re d with the a dult’s 2 mL/kg. Infa nts re quire highe r volume s
ba se d on we ight compa re d to a dults; the dura tion of block a ppe a rs
to be shorte r. Te tra ca ine a nd bupiva ca ine a re the most commonly
use d drugs for spina l a ne sthe sia in infa nts. For infa nts who we igh 5
to 15 kg, a dose of 0.4 mg/kg of 1% te tra ca ine will la st a bout
80 minute s; 0.4 mg/kg (or 0.08 mL/kg) of 0.5% bupiva ca ine would la st
a bout 70 to 80 minute s. This child we ighs 6 kg, so the dose would
be 2.4 mg or 0.48 mL (a bout 0.5 mL) of 0.5% bupiva ca ine . For infa nts
le ss tha n 5 kg, the dose is la rge r (i.e ., 0.5 mg/kg for te tra ca ine a nd
0.5 mg/kg for bupiva ca ine ), a nd the dura tion of the a ne sthe tic is
a bout 5 minute s shorte r. If e pine phrine is a dde d, the dura tion of a
te tra ca ine spina l a ne sthe tic is a bout 30% to 50% longe r. Epine phrine
a dde d to bupiva ca ine ha s little e ffe ct (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, p 464).
619. (A) About 80% of childre n with inspira tory stridor ha ve croup
(la ryngotra che obronchitis) a nd a bout 5% ha ve e piglottitis (a lso
ca lle d a cute supra glottitis). All of the a nswe rs liste d e xce pt A, a s
we ll a s a “ba rking cough,” re fe r to signs a nd symptoms of croup, a
vira l illne ss of the subglottic a re a tha t usua lly pre se nts in childre n
younge r tha n 2 ye a rs of a ge . Croup usua lly pre se nts with a
re la tive ly slow onse t (ove r 24-72 hours) a nd is a ssocia te d with a
mild fe ve r (ra re ly ove r 39° C) a nd lymphocytosis. Pa tie nts with
a cute e piglottitis a re usua lly olde r, tha t is, 2 to 6 ye a rs of a ge . The
onse t of signs a nd symptoms of a cute e piglottitis is typica lly ra pid,
tha t is, le ss tha n 24 hours. Pa tie nts pre se nt with difficulty
swa llowing, a high fe ve r (ofte n >39° C), a nd inspira tory stridor.
Othe r signs a nd symptoms include drooling, le tha rgy, cya nosis,
ta chypne a , ne utrophilia , a nd a prope nsity to sit up a nd le a n
forwa rd (in a n a tte mpt to ma inta in the ir a irwa y). Tota l uppe r
a irwa y obstruction ca n occur in the se childre n a t a ny time be ca use
of the ra pid progre ssion of the dise a se . For this re a son, a tte mpts to
visua lize the e piglottis should not be unde rta ke n until the pa tie nt is
in the OR a nd a ppropria te pre pa ra tions a re comple te d for dire ct
la ryngoscopy a nd tra che a l intuba tion, a nd possible e me rge ncy
tra che ostomy. The de finitive tre a tme nt of a cute e piglottitis include s
a ppropria te a ntibiotic the ra py a nd a se cure d a irwa y. Also se e
e xpla na tion to Que stion 603 (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 811–813; Hines: Stoelting’s Anesth esia and Co-Ex isting
620. (C) The te chnique for CPR of infa nts (<1 ye a r) a nd childre n
(a ge s 1 ye a r to pube rty) is diffe re nt from tha t of a dults. Pube rty is
de fine d he re a s bre a st de ve lopme nt in fe ma le s a nd a xilla ry ha ir in
ma le s. More e mpha sis ha s be e n pla ce d on “push ha rd a nd push
fa st,” give n tha t che st compre ssion de pth a nd spe e d a re ofte n
ina de qua te . If only ve ntila tion is ne e de d, the ra te for a dults is 10 to
12 bre a ths/min, whe re a s for childre n a nd infa nts, the ra te is 12 to
20 bre a ths/min. For a dults, ste rna l compre ssions should be
pe rforme d with the he e l of one ha nd pla ce d on top of the othe r
ha nd a nd compre ssing the lowe r ha lf of the ste rnum a t le a st 5 cm
(2 inche s). For childre n, ste rna l compre ssions should be pe rforme d
with the he e l of one or two ha nds compre ssing the lowe r ha lf of
the ste rnum a t le a st one third the de pth of the che st or a bout 5 cm
(2 inche s). For infa nts, lone re scue rs compre ss the ste rnum with
two finge rs pla ce d just be low the inte rma mma ry line . Ste rna l
compre ssions a re pe rforme d a t le a st one third the de pth of the
che st or a bout 4 cm (1.5 inche s). W he n two re scue rs a re pre se nt,
compre ssions a re pe rforme d by e ncircling the infa nt’s che st with
both ha nds a nd pla cing the thumbs toge the r ove r the lowe r third of
the ste rnum. The compre ssion ra te is the sa me for a dults, childre n,
a nd infa nts, tha t is, a pproxima te ly 100 compre ssions/min. La y
re scue rs should not che ck for pulse s in infa nts or childre n be ca use
the y ofte n fe e l a pulse tha t is not pre se nt. W he n he a lth ca re
provide rs pa lpa te for pulse s, the bra chia l a rte ry is pre fe rre d in the
infa nt a nd the ca rotid or fe mora l is pre fe rre d in the child. A
unive rsa l compre ssion-to-ve ntila tion ra tio of 30:2 is use d for infa nts,
childre n, a nd a dults by single re scue rs; a ra te of 15:2 is use d for
two-pe rson infa nt CPR. Ea rlie r spe cifica tions ca lle d for a 5:1 ra tio,
but more re ce nt e vide nce shows 30:2 to be more e ffe ctive . For
ne wborns, howe ve r, a ra tio of 3:1 (90 compre ssions a nd 30
ve ntila tions/min) is use d (2010 Am erican Heart Association Guid elines
for Card iopulm onary Resuscitation and Em ergency Card iovascular Care,
Circulation 122:S685–S705, S862–S875, 2010).
621. (B) Body composition cha nge s dra ma tica lly during the first ye a r
of life . Tota l body wa te r is a bout 80% for a te rm ne wborn compa re d
with 55% for a n a dult woma n a nd 60% for a n a dult ma n. Drugs tha t
a re wa te r soluble (such a s ma ny a ntibiotics) will ne e d to ha ve
highe r mg/kg dose to a chie ve the de sire d blood conce ntra tions.
W ith the corre sponding lowe r fa t conte nt of the pre te rm ne wborn
(<5%) a nd te rm ne wborn (10%) compa re d with the a dult (15+%), fa t-
soluble drugs tha t de pe nd on re distribution will ha ve a longe r
clinica l e ffe ct. The GFR of ne wborns is low a t birth a nd double s or
triple s ove r the first 3 months of life , with a slowe r rise until a dult
va lue s a re re a che d by 1 to 2 ye a rs of a ge . This de cre a se in re na l
function ca n de la y e xcre tion of drugs tha t a re de pe nde nt on re na l
cle a ra nce for e limina tion. The re la tive ly noncomplia nt he a rt of a
ne wborn give s it a limite d ca pa city to de a l with a volume loa d,
compa re d with the a dult. The pre te rm ne wborn ha s 10%, the te rm
ne wborn ha s 25%, a nd the a dult ha s 55% of type I muscle fibe rs
(i.e ., fa tigue re sista nt, highly oxida tive fibe rs). The lowe r proportion
of type I fibe rs pre dispose s the ne wborn’s prima ry re spira tory
muscle fibe rs to fa tigue (Miller: Miller’s Anesth esia, ed 8, pp 2763–2765;
622. (C)
The a na tomy of the infa nt’s a irwa y is diffe re nt in some re spe cts
from tha t of the a dult. The na rrowe st pa rt of the a dult la rynx a nd
the infa nt a irwa y ha s be e n re e va lua te d to be simila r (i.e ., the
na rrowe st pa rt is a t the le ve l of the cricoid ring). The infa nt he a d
a nd tongue a re re la tive ly la rge r tha n the a dult. The la rynx is
more ce pha lic in the infa nt tha n in the a dult (infa nt’s C3-C4,
a dult’s C4-C5) ma king stra ight bla de s more use ful tha n curve d
bla de s for la ryngoscopy in infa nts. The infa nt’s e piglottis is short,
stubby, a nd “ome ga ” sha pe d. The voca l cords in the infa nt a re in
a dia gona l (not horizonta l) position within the la rynx. The
dia gona l position ma ke s it more like ly to ha ve the e ndotra che a l
tube lodge in the a nte rior commissure ra the r tha n slide down the
tra che a (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, p
623. (C) Childre n a t the highe st risk for PONV include those whose
surge ry la sts more tha n 30 minute s, those olde r tha n 3 ye a rs of a ge ,
those with a fa mily or pa tie nt history of PONV, those unde rgoing
stra bismus surge ry, a nd, fina lly, ca se s whe re na rcotics a re routine ly
ne e de d, such a s tonsille ctomy, orchiope xy a nd he rniorrha phy. Brie f
proce dure s with minima l pa in such a s myringotomy tube
pla ce me nts ha ve a low incide nce of PONV. In ca se s whe re PONV
is like ly, prophyla xis is re comme nde d (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 1074–1075, 1285).
624. (D) Down syndrome (trisomy 21) occurs in 1 in 600 to 800 live
births. More tha n ha lf of trisomy conce ptions sponta ne ously a bort.
Although va ria ble de gre e s of me nta l re ta rda tion a re common,
ma ny othe r significa nt conditions a re pre se nt. Conge nita l ca rdia c
le sions a re se e n in a bout ha lf of the se pa tie nts (comple te AV ca na l,
VSDs, pa te nt ductus a rte riosus, ASDs, te tra logy of Fa llot) a nd
commonly ne ce ssita te prophyla ctic a ntibiotics. Othe r findings
include he a ring loss, short ne ck, sma ll mouth, na rrow
na sopha rynx, la rge tongue , thyroid hypofunction (50%), a tla nto-
occipita l insta bility (15%-20%, which is most ofte n a symptoma tic),
a nd sma lle r a irwa ys. De spite the se a bnorma litie s, tra che a l
intuba tion usua lly is not difficult in the ha nds of a n e xpe rie nce d
a ne sthe siologist. The size of the e ndotra che a l tube use d to cre a te
a n a ir “le a k” with incre a sing a irwa y pre ssure should be one to two
size s sma lle r be ca use of the sma lle r tra che a . For e xa mple , in
childre n a ge 18 months to 8 ye a rs the e ndotra che a l tube size is
1 mm sma lle r (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8,
pp 1172–1174; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 634–635; Miller: Miller’s Anesth esia, ed 8, p 1201; Sh ott: Down
sy nd rom e: analy sis of airway size and a guid e for appropriate intubation,
Lary ngoscope 110:585–592, 2000).
625. (D) Conge nita l ca rdia c a bnorma litie s fre que ntly occur in
a ssocia tion with CDHs, TEFs, me ningomye loce le s, a nd
ompha loce le s. Ga stroschisis is ra re ly a ssocia te d with othe r
conge nita l a noma lie s (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 594–599, 608–609).
626. (A) Ne wborns with CDH ofte n pre se nt with re spira tory distre ss
imme dia te ly a fte r birth. The y ofte n ha ve a fla t (sca phoid) a bdome n
be ca use some of the inte stine s he rnia te into the che st a nd a re ,
the re fore , not in the a bdome n. Imme dia te ca re include s
e ndotra che a l intuba tion for ve ntila tory support in infa nts with
re spira tory distre ss a nd the pla ce me nt of a n oroga stric or
na soga stric tube to e va cua te the stoma ch. Ve ntila tion of the lungs
with a ba g a nd ma sk ma y ca use more re spira tory compromise by
producing ga stric a nd inte stina l diste ntion a nd is re la tive ly
contra indica te d. W he n ve ntila ting the ne wborn with a n
e ndotra che a l tube , you must re me mbe r not to try to e xpa nd the
lungs to norma l size be ca use the lungs a re hypopla stic a nd prone
to rupturing a nd producing a pne umothora x. Although a t one time
hype rve ntila tion wa s re comme nde d, more re ce ntly be tte r
outcome s ha ve be e n found whe n mode ra te pe rmissive hype rca rbia
ha s be e n use d (Pa CO2 60-65 mm Hg ra nge ). Associa te d conge nita l
a noma lie s include CNS a noma lie s (e .g., spina bifida ,
hydroce pha lus, a ne nce pha ly), ca rdiova scula r (e .g., hypopla stic le ft
he a rt syndrome , ASDs a nd VSDs, coa rcta tion, te tra logy of Fa llot),
ga strointe stina l (e .g., ma lrota tion, a tre sia ), a nd ge nitourina ry (e .g.,
hypospa dia s). Rushing the child to the OR doe s not incre a se
surviva l. It a ppe a rs be tte r to sta bilize the child a nd look for
a ssocia te d conge nita l a noma lie s (se e n in up to 50% of the se
childre n) be fore proce e ding with surge ry. Se e e xpla na tion for
Que stion 582 (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8,
pp 567–574; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 594–596).
627. (A) Re spira tory a dve rse e ve nts a re common in childre n
unde rgoing nonca rdia c surge rie s. The y a re more ofte n a ssocia te d
with younge r childre n (<5 ye a rs of a ge compa re d with >5 ye a rs of
a ge ), in childre n with a re ce nt URI (a lthough a fe w studie s que stion
this), in childre n with a irwa y a noma lie s (e .g., cle ft pa la te , subglottic
ste nosis, Pie rre Robin syndrome ), a nd whe n a la rynge a l ma sk
a irwa y is use d, compa re d with the use of ma sk a ne sthe sia (Davis:
Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 7, pp 1161–1162; Flick
et al: Risk factors for lary ngospasm in ch ild ren d uring general anesth esia,
Ped iatric Anesth esia 18:289–296, 2008).
628. (B) Pe riope ra tive ca rdia c a rre st is ofte n de fine d a s the ne e d for
CPR during a ne sthe sia ca re (OR a nd PACU). It is more tha n four
time s more fre que nt in ne ona te s (0-30 da ys) tha n infa nts or
childre n. Ca use s of ca rdia c a rre st va ry from study to study a nd
ofte n a re me dica tion-re la te d (e .g., inha la tion or intra ve nous
ove rdosa ge , succinylcholine -induce d dysrhythmia , me dica tion
“swa ps,” high spina l a ne sthe sia , loca l a ne sthe tic toxicity, opioid-
induce d re spira tory de pre ssion, ina de qua te re ve rsa l of muscle
re la xa nts), ca rdiova scula r-re la te d (e .g., he morrha ge , hype rka le mia ,
va ga l re fle xe s, e mbolism, se psis), re spira tory-re la te d (e .g.,
ina de qua te ve ntila tion, loss of the a irwa y, a spira tion,
pne umothora x), a nd e quipme nt-re la te d (e .g., disconne cts, stuck
va lve s). Of the se , e quipme nt-re la te d ca use s a re re la tive ly ra re
(a bout 4% of ca se s). About 90% of ca rdia c a rre sts due to a ne sthe sia -
re la te d e pisode s a re re ve rse d (a de qua te na tive he a rtbe a t a nd
blood pre ssure for a t le a st 20 minute s a fte r the a rre st). If the
ca rdia c a rre st is not a ne sthe sia -re la te d, outcome is worse (of
the se , only a bout 50%-60% a re re ve rse d). Re ga rdle ss of surgica l
proce dure , childre n with conge nita l he a rt dise a se ha ve a gre a te r
cha nce of a ca rdia c a rre st. Eme rge ncy surge ry is a ssocia te d with a
six time s gre a te r incide nce of ca rdia c a rre st tha n e le ctive surge ry
Flick et al: Perioperative card iac arrests in ch ild ren between 1988 and 2005
at a tertiary referral center, Anesth esiology 106:226–237, 2007).
629. (C) Afte r surgica l re pa ir of pyloric ste nosis, prolonge d
e me rge nce from a ne sthe sia is not uncommon e ve n with minima l
na rcotic a dministra tion. It is thought tha t the se pa tie nts re quire ve ry
little opioid a na lge sia , be ca use of pe rturba tions in CSF pH, a
conse que nce of prolonge d a nd pe rsiste nt e me sis. Loss of
hydrochloric a cid from the stoma ch produce s a me ta bolic a lka losis
with concomita nt CSF a lka losis. Eve n a fte r corre ction of the se rum
a lka losis, the pH in the CSF could still be high be ca use
e quilibra tion with the blood ma y not ha ve be e n a chie ve d.
Te rm infa nts younge r tha n 44 we e ks a re high risk for postope ra tive
a pne a a nd, the re fore , ca nnot be a ne sthe tize d a s a n outpa tie nt.
By contra st, pre ma ture infa nts olde r tha n 60 we e ks a re a t a much
lowe r risk for postope ra tive a pne a a nd, the re fore , ca n be
a ne sthe tize d a s outpa tie nts if discha rge crite ria a re othe rwise
me t. At 8 to 12 we e ks of a ge , the he moglobin re a che s the
physiologic na dir of 10 to 11 g/dL. As the tra nsition from Hgb F to
Hgb A occurs, the infa nts e xpe rie nce the so-ca lle d physiologic
a ne mia of infa ncy. The re la tionship be twe e n he moglobin
conce ntra tion a nd a pne a of pre ma turity is controve rsia l. It is not
cle a r wha t he moglobin le ve l would pla ce a n othe rwise he a lthy
infa nt a t risk for a pne a (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 36, 398, 750–751).
630. (C) All of the sta te me nts a re corre ct e xce pt for C. The
Ma ple son D syste m is a se miope n a ne sthe tic syste m with a
proxima l fre sh ga s inflow a nd a dista l ove rflow va lve . To e limina te
re bre a thing, highe r fre sh ga s flows a re ne e de d with sponta ne ous
ve ntila tion tha n with controlle d ve ntila tion. Note the Ma ple son A
syste m is a se miope n a ne sthe tic syste m with a dista l fre sh ga s flow
a nd a proxima l ove rflow va lve (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 294–297).
631. (D) The re spira tory ce nte r of ne wborns is not fully de ve lope d
a t birth. Ne wborns not uncommonly show two type s of pa use s in
re spira tion. Pe riodic bre a thing e xists if the pa use s a re short (i.e ., 5-
10 se conds) a nd not a ssocia te d with a de cre a se in he a rt ra te or
oxyge n sa tura tion. Pe riodic bre a thing ca n be se e n in up to 78% of
full-te rm ne wborns a nd more commonly in pre ma ture ne wborns.
Episode s of ce ntra l a pne a of infa ncy, a lso ca lle d a pne a a nd
bra dyca rdia (A&B) spe lls, a re longe r, more significa nt, a nd le ss
common tha n pe riodic bre a thing. W ith A&B spe lls, the re spira tory
pa use s a re usua lly longe r tha n 15 to 20 se conds a nd a re a ssocia te d
with a de cre a se in he a rt ra te (<100), a de cre a se in oxyge n
sa tura tion, cya nosis, a nd/or pa llor. Tre a tme nt is usua lly ta ctile
stimula tion for A&B spe lls, whe re a s pe riodic bre a thing pa tte rns do
not ne e d tre a tme nt. Untre a te d A&B spe lls ca n be le tha l.
Postope ra tive a pne a is inve rse ly corre la te d with both ge sta tiona l
a ge a t birth (GA) a nd PCA (PCA = GA + chronologic a ge ) up to
60 we e ks’ PCA. Postope ra tive a pne a is highe st in the first 4 to
6 hours but ca n pre se nt up to 12 hours a fte r surge ry. Postope ra tive
a pne a is a lso a ssocia te d with infa nts who ha ve ha d a history of
A&B spe lls a s we ll a s a ne mia (Hct <30). Ca ffe ine ha s be e n use d a s
a re spira tory stimula nt to de cre a se the incide nce a nd se ve rity of
postope ra tive a pne a . Although spina l a ne sthe sia with no se da tion
ha s a lowe r incide nce of a pne a , compa re d with ge ne ra l
a ne sthe sia , the a ddition of a ny se da tion such a s ke ta mine
incre a se s the incide nce of a pne a more tha n tha t obse rve d with
ge ne ra l a ne sthe sia . Some controve rsy e xists a s to whe n young
infa nts ca n be tre a te d a s outpa tie nts due to this risk of
postope ra tive a pne a . In our pra ctice , he a lthy full-te rm infa nts
(>38 we e ks’ GA) who ha ve not re a che d 44 we e ks’ PCA a nd he a lthy
pre te rm infa nts (<38 we e ks’ GA) who ha ve not re a che d 50 we e ks
a re a dmitte d for ove rnight monitoring (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 35–36, 1283–1284).
632. (A) The loss-of-re sista nce te chnique use d whe n pla cing a n
e pidura l ne e dle into the e pidura l spa ce of a child should be done
with sa line ra the r tha n a ir to de cre a se the risk of a n a ir e mbolism.
Note : the loss of re sista nce is much more subtle in the child
compa re d with the a dult whe n the e pidura l spa ce is loca te d (Davis:
Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 474–475).
633. (B) The fa sting re comme nda tion to re duce the risk of
pulmona ry a spira tion of ga stric conte nts is commonly ca lle d “the 2-
4-6-8 rule .”
MINIMUM FASTING PERIODS
Ingested Material Minimum Fasting Period

Clear fluids (water, Jello, apple or grape juice) 2 hr
Breast milk 4 hr
Infant formula, nonhuman milk, orange juice 6 hr
Solid food (toast or cereal) or high-fat meals 8 hr
From Davis PJ et al: Smith’s Anesthesia for Infants and Children, ed 8, Philadelphia, Saunders,
2011, pp 288–289.
634. (C) In ne ona te s or infa nts, hypothe rmia ca n incre a se tota l body
oxyge n consumption, produce me ta bolic a cidosis a nd hypoglyce mia
(not hype rglyce mia ), de pre ss ve ntila tion, de cre a se me ta bolism of
drugs, prolong the dura tion of a ction of nonde pola rizing muscle
re la xa nts, produce coa gulopa thie s a nd pla te le t dysfunction, a nd
incre a se wound infe ctions. The re fore , monitoring the body
te mpe ra ture a nd ma ne uve rs to minimize or e limina te significa nt
loss of body he a t during a ne sthe sia for ne ona te s a nd sma ll infa nts
a re e sse ntia l during the pe riope ra tive pe riod (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 174–175; Miller: Miller’s
Anesth esia, ed 8, pp 1631–1632, 2763; Butterworth : Morgan & Mikh ail’s
635. (C) NEC follows inte stina l mucosa l injury from ische mia a nd
cla ssica lly occurs in pre ma ture infa nts a nd in infa nts with low birth
we ight (typica lly <2500 g). In ve ry-low-birth-we ight (VLBW )
ne wborns le ss tha n 1500 g, the incide nce of NEC is 10% to 20%. NEC
ca rrie s a high morta lity ra te (10%-30% if me dica lly tre a te d a nd a
highe r morta lity ra te if surge ry is ne e de d). The se childre n ma y be
a cidotic, hypoxic, a nd in shock. Most ha ve thrombocytope nia
(50,000-70,000/mm3), prolonge d PT, a nd prolonge d a PTT. NEC is
most commonly a ssocia te d with de cre a se d ca rdia c output in the
pre se nce of fe ta l a sphyxia or postna ta l re spira tory complica tions in
the e a rly postna ta l pe riod. Othe r fa ctors a ssocia te d with the
pa thoge ne sis of NEC include a history of umbilica l a rte ry
ca the te riza tion, e nte ra l fe e ding of sma ll pre te rm infa nts, ba cte ria l
infe ction, polycythe mia , a nd gra m-ne ga tive e ndotoxe mia . Although
umbilica l a rte ry ca the te rs a re ofte n use d in the ne wborn pe riod,
the se should be re move d if NEC de ve lops, be ca use the y ma y
compromise me se nte ric blood flow. Unle ss the re is e vide nce of
inte stina l ne crosis or pe rfora tion, nonope ra tive the ra py should be
institute d. This include s ce ssa tion of e nte ra l fe e ding,
de compre ssion of the stoma ch, a dministra tion of broa d-spe ctrum
a ntibiotics, fluid a nd e le ctrolyte the ra py, pa re nte ra l nutrition, a nd
corre ction of he ma tologic a bnorma litie s. Inotropic drugs ma y be
ne e de d in the pre se nce of shock. Postope ra tive ly the se infa nts
re quire ve ntila tor support, a nd inotrope s ofte n a re ne e de d for
ca rdiova scula r support (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 601–602; Davis: Sm ith ’s Anesth esia for Infants and
636. (C) Re mife nta nil is a unique opioid in ne wborns be ca use its
ha lf-life is shorte r in ne wborns tha n in olde r childre n. Re mife nta nil
is ra pidly me ta bolize d by nonspe cific pla sma a nd tissue
choline ste ra se s in the blood a nd ha s a highe r volume of
distribution in childre n younge r tha n 2 months of a ge compa re d
with childre n olde r tha n 2 months of a ge . Re mife nta nil doe s not
a ccumula te e ve n a t high dose s. The othe r na rcotics ha ve a
re la tive ly short ha lf-life due to re distribution whe n give n in low
dose s. Elimina tion is more importa nt for the othe r liste d na rcotics
a t high dose s (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 7,
pp 428; Miller: Miller’s Anesth esia, ed 8, pp 2757, 2769–2771).
637. (B) In the ne ona ta l pe riod, the ne wborn’s circula tion ca n be
a cce sse d via the umbilica l a rte ry or ve in. The umbilica l ve in is
la rge r a nd e a sie r to ca nnula te . A size 5 Fr. ca the te r (3.5 Fr. ca the te r
in pre ma ture ne wborns) is commonly use d. The umbilica l ve in
ca the te r ca n be inse rte d through the ductus ve nosus dire ctly into
the ve na ca va (a nd usua lly positione d just a bove the dia phra gm).
Ca nnula tion of the umbilica l a rte ry will le a d the ca the te r tip into
the a orta (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
559–560; Miller: Basics of Anesth esia, ed 6, p 549).
638. (D) HUS is one of the most common a cquire d ca use s of a cute
re na l fa ilure in childre n. Pa tie nts pre se nt with a bdomina l
cra mping, bloody dia rrhe a , a nd vomiting; it is ofte n ca use d by the
toxin from Esch erich ia coli O157. About 10% of childre n with bloody
dia rrhe a ca use d by E. coli O157 progre ss to HUS. HUS is
cha ra cte rize d by a tria d of microa ngiopa thic he molytic a ne mia (Hgb
le ve ls a round 4-5 g/dL), thrombocytope nia (pla te le t de struction a s
we ll a s se que stra tion of pla te le ts in the live r a nd sple e n), a nd
a cute ne phropa thy. Although the a ge of childre n most fre que ntly
a ffe cte d by this dise a se is be twe e n 6 months a nd 4 ye a rs, HUS ca n
occur from the ne ona ta l pe riod through a dulthood. Occa siona lly,
CNS a bnorma litie s de ve lop (e .g., de cre a se d le ve ls of
consciousne ss, se izure s, a nd a t time s ce re bra l e de ma a nd
incre a se d intra cra nia l pre ssure ). Pa ncre a titis is common a nd
conge stive he a rt fa ilure ma y de ve lop a s a re sult of fluid ove rloa d,
hype rte nsion, a nd myoca rdia l de pre ssion from the toxins.
Tre a tme nt is supportive a nd ma ny of the se childre n will re quire
te mpora ry pe ritone a l dia lysis. The morta lity ra te is le ss tha n 5%
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 425; Miller:
639. (D) W ilms tumor, a lso ca lle d ne phrobla stoma , is a common
a bdomina l ma ligna ncy of childre n. Childre n commonly pre se nt
with incre a sing a bdomina l girth a nd ha ve a pa lpa ble ma ss. Pe a k
a ge of dia gnosis is 1 to 3 ye a rs. Re na l function is usua lly pre se rve d
but hype rte nsion, ofte n mild, is common (60%). Fe ve r, he ma turia ,
a nd a ne mia a re ofte n pre se nt. Tre a tme nt consists of surge ry,
ra dia tion, a nd che mothe ra py. Che mothe ra pe utic drugs use d in this
tumor include da ctinomycin, doxorubicin (Adria mycin), vincristine ,
a nd cyclophospha mide (Cytoxa n). Bone ma rrow suppre ssion (e .g.,
a ne mia , thrombocytope nia ) ca n occur with a ll cytotoxic drugs.
Be ca use ca rdiomyopa thy ca n occur with cyclophospha mide
(>100 mg/m2) a nd with doxorubicin (>220 mg/m2), pre ope ra tive
e choca rdiogra phy should be conside re d e ve n in a symptoma tic
pa tie nts. La te ca rdia c dysfunction ma y de ve lop 7 to 14 ye a rs a fte r
tre a tme nt. Alkyla ting a ge nts, such a s cyclophospha mide , inhibit
pla sma choline ste ra se s, which ma y a ffe ct the me ta bolism of
succinylcholine . Pulmona ry fibrosis a nd/or pne umonitis ca n occur
in pa tie nts who ha ve re ce ive d ble omycin (the pa tie nt in this ca se
did not re ce ive ble omycin). This pulmona ry toxicity ma y be re la te d
to high-inspire d oxyge n conce ntra tions a nd e xce ssive fluid
a dministra tion. Vincristine ha s se ve ra l CNS side e ffe cts, including
pe riphe ra l ne uropa thy, impa ire d se nsorium, a nd e nce pha lopa thy
a nd re na l toxicity (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren,
ed 8, pp 751–754, 1138–1141; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 628–629; Miller: Miller’s Anesth esia, ed 8, pp
1216–1217).
640. (D) All of the a nswe rs a re corre ct. Shock occurs whe n
pe rfusion to vita l orga ns is ina de qua te to me e t the orga n’s
me ta bolic de ma nds. W he n shock is de ve loping, ca rdia c output is
initia lly we ll-ma inta ine d by incre a sing the he a rt ra te a nd
myoca rdia l contra ctility. W he n ca rdia c output fa lls, blood pre ssure
ca n only be ma inta ine d by a compe nsa tory va soconstriction. Shock
is cla ssifie d a s compe nsa te d shock (systolic blood pre ssure in the
norma l ra nge ) or de compe nsa te d shock (systolic blood pre ssure
le ss tha n the 5th pe rce ntile for a ge ). If hypote nsion is pre se nt, one
must be vigorous in tre a tme nt. Tre a tme nt is ofte n be gun with
volume e xpa nsion; howe ve r, othe r ca use s of hypote nsion must be
conside re d a nd tre a te d a s ne ce ssa ry (e .g., te nsion pne umothora x,
pe rica rdia l ta mpona de , ne urologic injury). Hypote nsion (i.e .,
de compe nsa te d shock) is ba se d on systolic blood pre ssure s a nd is
corre ctly de scribe d in e a ch of the choice s in the que stion. In
a ddition, for childre n 10 ye a rs of a ge or olde r, hypote nsion is a
systolic blood pre ssure le ss tha n 90 (2010 Am erican Heart Association
Guid elines for Card iopulm onary Resuscitation and Em ergency
Card iovascular Care, Circulation 122:S878, 2010).
641. (D) At birth, the GFR is 15% to 30% of a dult va lue s a nd
incre a se s to a bout 50% by 10 da ys of life a nd to 75% by 6 months.
Re na l function is comple te by 2 ye a rs of a ge (Miller: Basics of
642. (D) Prophyla xis for POV is re comme nde d for pa tie nts
unde rgoing stra bismus surge ry, be ca use untre a te d, the incide nce is
40% to 90% of pa tie nts. No be ne fit wa s de monstra te d with the use
of a nticholine rgic me dica tions or with ga stric conte nt e va cua tion
be fore e me rge nce from a ne sthe sia . IV hydra tion is ve ry importa nt.
Re ce nt studie s ha ve re comme nde d tha t “supe rhydra tion” with
30 mL/kg/hr of la cta te d Ringe r solution de cre a se s the PONV ra te by
a bout ha lf whe n compa re d to 10 mL/kg/hr fluid use . De cre a sing or
a voiding na rcotic a na lge sics ha s a lso be e n e ffe ctive . Avoiding the
ma inte na nce use of nitrous oxide re ma ins controve rsia l (Davis:
C H AP T E R 8
Obstetric Physiology and
Anesthesia
643. W hich of the following drugs doe s NOT pa ss the pla ce nta
e a sily?
A. Etomida te
B. Ephe drine
C. Atropine
D. Glycopyrrola te
644. A 38-ye a r-old obe se pa tie nt is re ce iving subcuta ne ous low-
mole cula r-we ight he pa rin (LMW H) for thromboprophyla xis. She
re ce ive d he r e pidura l 14 hours a fte r the he pa rin wa s stoppe d a nd
de ve lope d Horne r syndrome on the le ft side 30 minute s a fte r
pla ce me nt of a n e pidura l for a n e le ctive ce sa re a n se ction. On
physica l e xa mina tion, a T4 a ne sthe tic le ve l is note d, but a side from
the Horne r syndrome no othe r findings a re re ve a le d. The most
a ppropria te course of a ction a t this time would be to
A. Re move the e pidura l
B. Consult a ne urosurge on
C. Obta in a compute d tomogra phic sca n
645. W ha t pe rce nta ge of a ll pre gna ncie s in the Unite d Sta te s is
a ffe cte d by hype rte nsion?
A. 2%
B. 7%
C. 12%
D. 17%
646. A 16-ye a r-old, a nxious, pre e cla mptic pa tie nt in a ctive la bor
de ve lops ba ck pa in a fte r the pla ce me nt of a n e pidura l for la bor
a na lge sia . The pa in is se ve re , a nd the pa tie nt ha s more we a kne ss
of the le gs tha n e xpe cte d. The most a ppropria te course of a ction a t
this time would be to
A. Inje ct a highe r conce ntra tion of a loca l a ne sthe tic or a dd
intra ve nous (IV) na rcotics
B. Re pla ce the e pidura l a nd use e pidura l na rcotics to de cre a se
the motor we a kne ss
C. Re a ssure he r tha t she will ge t be tte r with de live ry
D. Consult a ne urosurge on
647. Ma gne sium sulfa te (MgSO4) is use d a s a n a nticonvulsa nt in
pa tie nts with pre e cla mpsia a s we ll a s a tocolytic to pre ve nt
pre te rm de live ry. MgSO4 ma y produce a ny of the following e ffe cts
EXCEPT
A. Se da tion
B. Re spira tory pa ra lysis
C. Inhibition of a ce tylcholine re le a se a t the myone ura l junction
D. Hype rte nsion whe n use d with nife dipine
648. Norma l fe ta l he a rt ra te (FHR) is
A. 60 to 100 be a ts/min
B. 90 to 130 be a ts/min
C. 110 to 160 be a ts/min
D. 150 to 200 be a ts/min
649. W hich of the following is the LEAST like ly ca use of pre gna ncy-
re la te d de a ths in the Unite d Sta te s (1998-2005)?
A. Ge ne ra l a ne sthe sia (fa ile d intuba tion or a spira tion)
B. He morrha ge
C. Thrombotic pulmona ry e mbolism
D. Hype rte nsive disorde rs of pre gna ncy
650. Drugs use ful in the tre a tme nt of ute rine a tony in a n a sthma tic
pa tie nt with se ve re pre e cla mpsia include
A. Oxytocin (Pitocin) only
B. Ergonovine (Ergotra te ) or me thyle rgonovine (Me the rgine ) only
C. 15-Me thyl prosta gla ndin F 2α (PGF 2α) (Ca rboprost, He ma ba te )
only
D. All of the a bove a re sa fe a nd ca n be use d a lone or in
combina tion with the othe rs
651. W ha t is the P 50 of fe ta l he moglobin a t te rm?
A. 12
B. 18
C. 24
D. 30
652. Side e ffe cts of te rbuta line include a ll of the following EXCEPT
A. Hype rte nsion
B. Hype rglyce mia
C. Pulmona ry e de ma
D. Hypoka le mia
653. Ca rdia c output incre a se s dra ma tica lly during pre gna ncy a nd
de live ry. The ca rdia c output re turns to nonpre gna nt va lue s by how
long postpa rtum?
A. 12 hours
B. 1 da y
C. 2 we e ks
D. 6 months
654. A 32-ye a r-old pa rturie nt with a history of spina l fusion, se ve re
a sthma , a nd hype rte nsion (blood pre ssure 180/110) is brought to the
ope ra ting room whe e zing. She ne e ds a n e me rge ncy ce sa re a n
se ction unde r ge ne ra l a ne sthe sia for a prola pse d umbilica l cord.
W hich of the following induction a ge nts would be MOST
a ppropria te for he r induction?
A. Se voflura ne
B. Mida zola m
C. Ke ta mine
D. Propofol
655. Ute rine blood flow a t te rm pre gna ncy typica lly incre a se s to
a bout
A. 100 mL/min
B. 250 mL/min
C. 500 mL/min
D. 750 mL/min
656. W hich one of the following sta te me nts is T RUE re ga rding
huma n immunode ficie ncy virus (HIV)infe cte d pa rturie nts?
A. Ce ntra l ne urologic blocka de a s we ll a s e pidura l blood pa tche s
incre a se the cha nce of ne urologic complica tions
B. Nine ty pe rce nt of ne wborns of untre a te d HIV-se ropositive
mothe rs be come infe cte d in ute ro, during va gina l de live ry, or
with bre a stfe e ding
C. The pha rma cologic e ffe cts of be nzodia ze pine s a nd na rcotics
a re prolonge d in pa tie nts ta king prote a se inhibitors
D. The risk of se roconve rsion a fte r pe rcuta ne ous e xposure to
HIV-infe cte d blood is a bout 5%
657. W hich of the following ca rdiova scula r pa ra me te rs is
de cre a se d a t te rm?
A. Ce ntra l ve nous pre ssure
B. Pulmona ry ca pilla ry we dge pre ssure
C. Syste mic va scula r re sista nce
D. Le ft ve ntricula r e nd-systolic volume
658. W hich of the following signs a nd symptoms is NOT a ssocia te d
with a mniotic fluid e mbolism?
A. Che st pa in
B. Ble e ding (disse mina te d intra va scula r coa gula tion [DIC])
C. Pulmona ry va sospa sm with se ve re pulmona ry hype rte nsion
a nd right he a rt fa ilure
D. Le ft ve ntricula r fa ilure a nd pulmona ry e de ma
659. W he n is the fe tus most susce ptible to the e ffe cts of te ra toge nic
a ge nts?
A. 1 to 2 we e ks of ge sta tion
B. 3 to 8 we e ks of ge sta tion
C. 9 to 14 we e ks of ge sta tion
D. 15 to 20 we e ks of ge sta tion
660. A 28-we e k e stima te d ge sta tiona l a ge (EGA), 1000-g ma le infa nt
is born to a 24-ye a r-old mothe r who is a ddicte d to he roin. The
mothe r a dmits ta king a n e xtra “hit” of he roin be fore coming to the
hospita l be ca use she wa s ne rvous. The infa nt’s re spira tory
de pre ssion would be be st ma na ge d by
A. 0.1 mg/kg na loxone intra muscula rly (IM) in the ne wborn’s thigh
muscle
B. 0.1 mg/kg na loxone down the e ndotra che a l tube
C. 0.4 mg na loxone IM to the mothe r during the se cond sta ge of
la bor
661. Ca rdia c output is GREAT EST
A. During the first trime ste r of pre gna ncy
B. During the third trime ste r of pre gna ncy
C. During la bor
D. Imme dia te ly a fte r de live ry of the ne wborn
662. A 1000-g, 27-we e k EGA boy is born with a he a rt ra te of 80
be a ts/min. He ha s slow irre gula r re spira tory e fforts, grima ce s
whe n a suction ca the te r is in inse rte d into the mouth a nd nose for
suctioning, a nd fle xe s his limbs some but is tota lly cya notic. The
umbilica l cord ha s only two ve sse ls. The 1-minute Apga r score
would be
A. 3
B. 4
C. 6
D. 7
663. W hich of the following re spira tory pa ra me te rs is NOT
incre a se d in the pa rturie nt?
A. Minute ve ntila tion
B. Tida l volume (VT)
C. Arte ria l Pa O2
D. Se rum bica rbona te
664. W hich of the following drugs should NOT be use d during
tra nsva gina l oocyte re trie va l (TVOR) for a ssiste d re productive
te chnology (ART)?
A. Propofol
B. Ke ta mine
C. Mida zola m
D. All a re sa fe a nd ca n be use d
665. W hich of the following conditions is a ssocia te d with incre a se d
ble e ding during pre gna ncy?
A. Lupus a nticoa gula nt
B. Fa ctor V Le ide n muta tion
C. Prote in C de ficie ncy
666. W ha t is the BEST wa y to pre ve nt a utonomic hype rre fle xia in a
qua driple gic woma n who is to unde rgo induction of la bor? The
comple te spina l cord le sion occurre d 2 ye a rs a go.
A. Only IV drugs should be use d; spina l a nd e pidura l a ne sthe sia
a re contra indica te d
B. Spina l or e pidura l lumba r loca l a ne sthe tics such a s
bupiva ca ine a lone a re e ffe ctive
C. Spina l or e pidura l na rcotics such a s fe nta nyl a lone a re
e ffe ctive
D. Autonomic hype rre fle xia a ppe a rs only whe n the comple te
spina l cord le sion is be low T6, so the re is no ne e d to worry
667. A 24-ye a r-old gra vida 2, pa ra 1 pa rturie nt is a ne sthe tize d for
e me rge ncy ce sa re a n se ction. On e me rge nce from ge ne ra l
a ne sthe sia , the e ndotra che a l tube is re move d a nd the pa tie nt
be come s cya notic. Oxyge n is a dministe re d by positive -pre ssure ba g
a nd ma sk ve ntila tion. High a irwa y pre ssure s a re ne ce ssa ry to
ve ntila te the pa tie nt, a nd whe e zing is note d ove r both lung fie lds.
The pa tie nt’s blood pre ssure fa lls from 120/80 to 60/30 mm Hg, a nd
he a rt ra te incre a se s from 105 to 180 be a ts/min. The MOST like ly
ca use of the se ma nife sta tions is
A. Amniotic fluid e mbolism
B. Mucous plug in tra che a
C. Pne umothora x
D. Aspira tion
668. A 29-ye a r-old gra vida 1, pa ra 0 pa rturie nt a t 8 we e ks of
ge sta tion is to unde rgo a n e me rge ncy a ppe nde ctomy unde r ge ne ra l
a ne sthe sia with isoflura ne , N2O, a nd oxyge n. W hich of the
following is a prove n untowa rd conse que nce of ge ne ra l a ne sthe sia
in the unborn fe tus?
A. Conge nita l he a rt dise a se
B. Cle ft pa la te
C. Be ha viora l de fe cts
669. A lumba r e pidura l is pla ce d in a 24-ye a r-old gra vida 1, pa ra 0
pa rturie nt with mya sthe nia gra vis (MG) for la bor. Se le ct the T RUE
sta te me nt re ga rding ne ona ta l MG.
A. The ne wborn is a lmost a lwa ys a ffe cte d with mya sthe nia
B. The ne wborn is a ffe cte d by ma te rna l immunoglobulin M (IgM)
a ntibodie s
C. The ne wborn ma y re quire a nticholine ste ra se the ra py for up to
4 we e ks
D. The ne wborn will ne e d life long tre a tme nt
670. A pa tie nt ha ving which of the following conditions is LEAST
like ly to de ve lop DIC?
A. Se ve re pre e cla mpsia
B. Pla ce nta a bruption
C. Pla ce nta pre via (ble e ding)
D. De a d fe tus syndrome
671. A 28-ye a r-old gra vida 1, pa ra 0 pa rturie nt with Eise nme nge r
syndrome (pulmona ry hype rte nsion with a n intra ca rdia c right-to-le ft
or bidire ctiona l shunt) is to unde rgo pla ce me nt of a lumba r
e pidura l for a na lge sia during la bor. It ma y be wise to a void a loca l
a ne sthe tic with e pine phrine in this pa tie nt be ca use it
A. Lowe rs pulmona ry va scula r re sista nce
B. Lowe rs syste mic va scula r re sista nce
C. Incre a se s he a rt ra te
D. Ca use s e xce ssive incre a se s in systolic blood pre ssure
672. W hich of the following pa tie nts is MOST like ly to ne e d a n
e me rge ncy hyste re ctomy for uncontrolle d ble e ding a t the time of
de live ry?
A. Pa tie nt unde rgoing ce sa re a n se ction a fte r a n unsucce ssful tria l
of la bor a fte r ce sa re a n (TOLAC)
B. Pa tie nt with qua druple ts
C. Pa tie nt with a pla ce nta pre via (not ble e ding) for a n e le ctive
re pe a t ce sa re a n se ction
D. Pa tie nt with a n a bdomina l pre gna ncy
673. The MOST common injury re corde d in the Ame rica n Socie ty of
Ane sthe siologists’ (ASA’s) Close d Cla im Proje ct re ga rding obste tric
a ne sthe tic cla ims is
A. Pa in during a ne sthe sia
B. Ma te rna l ne rve da ma ge
C. He a da che
D. Aspira tion pne umonitis
674. W hich of the following sta te me nts a bout chorioa mnionitis is
FALSE?
A. Chorioa mnionitis occurs in a bout 1% of a ll pre gna ncie s
B. Clinica l signs include te mpe ra ture highe r tha n 38° C, ma te rna l
a nd fe ta l ta chyca rdia , a nd ute rine te nde rne ss
C. Antibiotics a re a dministe re d only a fte r de live ry, be ca use
intra pa rtum a ntibiotics ma y “obscure the re sults of ne ona ta l
blood culture s”
D. Epidura l a ne sthe sia ca n be sa fe ly a dministe re d
675. W hich of the following sta te me nts re ga rding ne wborns with
thick me conium-sta ine d a mniotic fluid is T RUE?
A. Routine intra pa rtum oropha rynge a l a nd na sopha rynge a l
suction is not re comme nde d
B. Intuba tion is re quire d for a ll such ne wborns
C. Antibiotics a nd ste roids a re ofte n ne e de d to tre a t the infe ction
D. Re spira tory distre ss syndrome (RDS) is common
676. A 38-ye a r-old primipa rous pa tie nt with pla ce nta pre via a nd
a ctive va gina l ble e ding a rrive s in the ope ra ting room with a systolic
blood pre ssure of 85 mm Hg. A ce sa re a n se ction is pla nne d. The
pa tie nt is lighthe a de d a nd sca re d. W hich of the following
a ne sthe tic induction pla ns would be most a ppropria te for this
pa tie nt?
A. Spina l a ne sthe tic with 12 to 15 mg bupiva ca ine
B. Ge ne ra l a ne sthe tic induction with 2 to 2.8 mg/kg propofol a nd
pa ra lysis with 1 to 1.5 mg/kg succinylcholine
C. Ge ne ra l a ne sthe sia induction with 0.75 to 1 mg/kg ke ta mine
a nd pa ra lysis with 1 to 1.5 mg/kg succinylcholine
D. Re pla ce lost blood volume first, the n use a ny a ne sthe tic the
pa tie nt wishe s
677. W hich of the following lung volume s or ca pa citie s cha nge the
LEAST during pre gna ncy?
A. Tida l volume (VT)
B. Functiona l re sidua l ca pa city (FRC)
C. Expira tory re se rve volume (ERV)
D. Vita l ca pa city (VC)
678. Ge ne ra l a ne sthe sia is induce d in a 35-ye a r-old pa tie nt for
e le ctive ce sa re a n se ction. No pa rt of the glottic a ppa ra tus is visible
a fte r two unsucce ssful a tte mpts to intuba te , but ma sk ve ntila tion is
a de qua te . The most a ppropria te ste p a t this point would be to
A. Wa ke up the pa tie nt
B. Atte mpt a blind na sa l intuba tion
C. Continue ma sk ve ntila tion a nd cricoid pre ssure
D. Use a la rynge a l ma sk a irwa y
679. W hich pa tie nts de scribe the ir la bor pa in a s be ing the MOST
inte nse ?
A. Primipa ra pa tie nts a tte nding pre pa re d childbirth cla sse s
B. Primipa ra pa tie nts not a tte nding pre pa re d childbirth cla sse s
C. Multipa ra pa tie nts a tte nding pre pa re d childbirth cla sse s
D. Multipa ra pa tie nts not a tte nding pre pa re d childbirth cla sse s
680. W hich of the following prope rtie s of e pidura lly a dministe re d
loca l a ne sthe tics de te rmine s the e xte nt to which e pine phrine will
prolong the dura tion of blocka de ?
B. Lipid solubility
C. pKa
D. Conce ntra tion
681. W hich intra the ca l na rcotic ca n be use d a s a sole a ge nt for
ce sa re a n se ction (i.e ., without a n e ste r or a mide loca l a ne sthe tic)?
A. Morphine
B. Fe nta nyl
C. Me pe ridine
D. None of the a bove ; a loca l a ne sthe tic is ne e de d
682. A 23-ye a r-old pa rturie nt in the first trime ste r is brought to the
ope ra ting room for e me rge ncy a ppe nde ctomy. Ge ne ra l a ne sthe sia
is pla nne d. W hich drug ha s a U.S. Food a nd Drug Administra tion
(FDA) Use -In-Pre gna ncy ra ting of D (studie s in huma ns a nd in
inve stiga tiona l or postma rke ting da ta de monstra te fe ta l risk;
ne ve rthe le ss, pote ntia l be ne fits ma y outwe igh pote ntia l risk)?
A. Nitrous oxide
B. Isoflura ne
C. Mida zola m
683. True sta te me nts re ga rding inclusion of intra the ca l morphine ,
fe nta nyl, or sufe nta nil in obste tric a ne sthe sia pra ctice include e a ch
of the following EXCEPT
A. The chie f site of a ction is the substa ntia ge la tinosa of the
dorsa l horn of the spina l column
B. The re is no motor a nd no sympa the tic blocka de
C. Pa in re lie f is a de qua te for the se cond sta ge of la bor
D. Lipophilic na rcotics a re a ssocia te d with le ss re spira tory
de pre ssion tha n nonlipophilic na rcotics
684. The MOST common side e ffe ct of intra spina l na rcotics in the
obste tric popula tion is
A. Pruritus
B. Na use a a nd vomiting
C. Re spira tory de pre ssion
D. Urina ry re te ntion
685. A 110-kg (242-lb), gra vida 1, pa ra 0 woma n ha s a blood pre ssure
of 180/95 during a n office visit a t the 18th we e k of ge sta tion a nd
170/95 one we e k la te r. She ha s some a nkle but no fa cia l e de ma ,
a nd no prote in de te cte d in he r urine . The se findings would be
cla ssifie d a s
A. Ge sta tiona l hype rte nsion
B. Pre e cla mpsia
C. Chronic hype rte nsion
D. Chronic hype rte nsion with supe rimpose d pre e cla mpsia
686. An e pidura l is pla ce d into a 32-ye a r-old pa rturie nt in a ctive
la bor re ce iving ma gne sium the ra py for pre e cla mpsia . Five minute s
a fte r a dministra tion of the te st dose , the loa ding dose of
bupiva ca ine a nd fe nta nyl is a dministe re d. The pa tie nt be come s
pa nic-stricke n, wre stle s brie fly with the re a ssuring nurse s, ga sps
for a ir, se ize s, a nd de ve lops ca rdiova scula r colla pse . During
re suscita tion, blood is oozing from the IV site s a nd a pink froth is
note d in the e ndotra che a l tube . The MOST like ly dia gnosis is
A. Amniotic fluid e mbolism
B. High spina l
C. Intra va scula r bupiva ca ine inje ction
D. Ecla mpsia
687. W hich of the following na rcotics ha s the LONGEST dura tion of
a ction whe n a dde d during a ce sa re a n se ction unde r e pidura l
a ne sthe sia ?
A. 50 to 100 µg fe nta nyl
B. 10 to 20 µg sufe nta nil
C. 3 to 4 mg morphine
D. 50 to 75 mg me pe ridine
688. W hich of the following is NOT incre a se d during pre gna ncy?
A. Re na l pla sma flow
B. Cre a tinine cle a ra nce
C. Blood ure a nitroge n (BUN)
D. Glucose e xcre tion
689. W hich inha la tion a ne sthe tic doe s NOT produce ute rine
re la xa tion?
A. Isoflura ne
B. Se voflura ne
C. Nitrous oxide
D. All produce ute rine re la xa tion
690. Pa ssive diffusion of substa nce s a cross the pla ce nta is
e nha nce d by a ll of the following EXCEPT
A. Low mole cula r we ight of the substa nce
B. High wa te r solubility of the substa nce
C. Low de gre e of ioniza tion of the substa nce
D. La rge conce ntra tion gra die nt of the drug
691. Ce sa re a n de live ry is a ssocia te d with a blood loss of a bout
A. 250 mL
B. 500 mL
C. 750 mL
D. 1000 mL
692. W hich of the following sta te me nts is CORRECT in de scribing
diffe re nce s be twe e n fe ta l a nd ma te rna l blood during la bor?
A. Fe ta l blood ha s a lowe r he moglobin conce ntra tion tha n doe s
ma te rna l blood
B. Fe ta l pla ce nta l blood flow is twice ma te rna l pla ce nta l blood
flow
C. Fe ta l he moglobin ha s a gre a te r a ffinity for O2 tha n doe s
ma te rna l he moglobin
D. The fe ta l oxyhe moglobin dissocia tion curve is shifte d to the
right of the ma te rna l oxyhe moglobin dissocia tion curve
693. In ge ne ra l, morbidly obe se pa tie nts ha ve a highe r incide nce of
A. Ce sa re a n de live rie s
B. Postdura l puncture he a da che s (PDPHs)
C. Pre e cla mpsia
D. Thromboe mbolic dise a se s
694. A te rm infa nt with good muscle tone a nd a strong cry ha s a n
oxyge n sa tura tion of 83%, bre a thing room a ir 5 minute s a fte r
de live ry. The MOST a ppropria te a ction a t this point would be
A. Supple me nta l incre a se d oxyge n conce ntra tion with a ble nde r
up to 50% by a fa ce ma sk
B. Sponta ne ous bre a thing with 100% oxyge n by fa ce ma sk
C. Positive -pre ssure ve ntila tion with 100% oxyge n
D. Obse rva tion
695. W hich condition BEST de scribe s the third-trime ste r ma te rna l
condition with the following signs a nd symptoms: ne w-onse t
va gina l ble e ding tha t stops, no pa in, no fe ta l distre ss?
A. Pla ce nta a bruption
B. Pla ce nta pre via
C. Ute rine rupture
D. Va sa pre via
696. During the se cond sta ge of la bor, comple te pa in re lie f ca n be
obta ine d with
A. Pa ra ce rvica l block
B. Ne ura xia l block with fe nta nyl a nd morphine
C. Pude nda l ne rve block
D. Lumba r e pidura l block with bupiva ca ine a nd no na rcotic
697. Ane sthe tic conside ra tions for ope n fe ta l surge ry include a ll of
A. Ute rine re la xa tion is e sse ntia l
B. Ma te rna l hypote nsion (me a n blood pre ssure <65 mm Hg) ca n
be tre a te d with phe nyle phrine or e phe drine
C. Ve curonium a t the ED95 dose of 0.04 mg/kg should be
a dministe re d IM or IV by the obste tricia n or surge on if fe ta l
muscle re la xa tion is ne e de d
D. Norma l fe ta l oxyge n sa tura tion is 50% to 70%
698. 15-Me thyl PGF 2α is a dministe re d dire ctly into the myome trium
to tre a t ute rine a tony in a 28-ye a r-old mothe r. Possible e ffe cts from
tre a tme nt with this drug include
B. Bronchospa sm
C. Hypoxia
699. W hich of the following sta te me nts re ga rding MgSO4 the ra py for
pre e cla mpsia is T RUE?
A. The the ra pe utic ra nge for se rum ma gne sium is 10 to 15 mEq/L
B. High se rum ma gne sium le ve ls ca n be e stima te d by cha nge s in
de e p te ndon pa te lla r re fle xe s in a pa tie nt with a n e pidura l
a ne sthe tic loa de d for a ce sa re a n se ction
C. Exce ssive se rum ma gne sium le ve ls ca use wide ning of the QRS
comple x
D. As soon a s de live ry occurs, the cha nce for e cla mpsia no
longe r e xists a nd the ma gne sium should be re ve rse d so tha t
postpa rtum ble e ding is le ss like ly to occur
700. W hile moving a pa rturie nt from the birthing room to the
ope ra ting room for a n e me rge ncy ce sa re a n se ction for a prola pse d
umbilica l cord, the pa tie nt de ve lops cough, whe e zing, a nd stridor
a nd be come s cya notic. The tra che a is intuba te d, a nd food is note d
in the pha rynx. Appropria te tre a tme nt in this pa tie nt should consist
of
A. Intra ve nous lidoca ine to suppre ss the cough
B. Glucocorticoids
C. 100% oxyge n a nd positive e nd-e xpira tory pre ssure (PEEP)
D. Sa line la va ge
701. Aortoca va l compre ssion sta rts to be come significa nt in a
norma l pre gna ncy a t how ma ny we e ks EGA?
A. 10 we e ks
B. 15 we e ks
C. 20 we e ks
D. 25 we e ks
702. W hich a ge nt is the MOST use ful for ra ising the ga stric pH just
be fore induction of ge ne ra l a ne sthe sia for e me rge ncy ce sa re a n
se ction?
A. Ra nitidine
B. Sodium citra te
C. Me toclopra mide
D. Ma gne sium hydroxide a nd a luminum hydroxide
703. Ca use s of fe ta l bra dyca rdia include a ll of the following
EXCEPT
A. Ma te rna l smoking of ciga re tte s
B. Ne ostigmine a nd glycopyrrola te re ve rsa l of ne uromuscula r
blocke rs
C. Acidosis
D. Umbilica l cord compre ssion
704. Most ca se s of ce re bra l pa lsy (CP) a re due to conditions during
A. Ante pa rtum
B. La bor
C. De live ry
D. The first 30 da ys of life
705. All of the following sta te me nts re ga rding pre gna nt dia be tic
pa tie nts a re true EXCEPT
A. Ge sta tiona l dia be te s me llitus (DM) occurs in a bout 7% of a ll
pre gna ncie s in the Unite d Sta te s
B. Insulin re a dily crosse s the pla ce nta a nd ca use s la rge r ba bie s
C. Ce sa re a n se ction is more common in dia be tic pre gna ncie s
D. Dia be tic ke toa cidosis (DKA) occurs in 1% to 2% of type 1 DM
pre gna ncie s
706. In a ddition to the postura l compone nt of a postdura l puncture
he a da che (PDPH), signs a nd symptoms ma y include a ny of the
following EXCEPT
A. Double vision
B. He a ring cha nge s
C. Ne ck stiffne ss
D. Fe ve r
707. Ea rly de ce le ra tions ma y occur in re sponse to
A. Fe ta l he a d compre ssion
B. Ute ropla ce nta l insufficie ncy
C. Ma te rna l hypote nsion
D. Umbilica l cord compre ssion
708. Age nts tha t a re use ful for de cre a sing the incide nce of shive ring
during ce sa re a n se ction unde r re giona l a ne sthe sia or for tre a ting
shive ring include a ll of the following EXCEPT
A. Administra tion of intra the ca l loca l a ne sthe tic with fe nta nyl
a nd/or morphine
B. Intra ve nous ma gne sium sulfa te
C. Administra tion of e pidura l loca l a ne sthe tic solutions with
e pine phrine
D. Intra ve nous me pe ridine
709. An umbilica l a rte ria l blood ga s sa mple a t the time of a n
e me rge ncy ce sa re a n de live ry shows a P O2 of 20 mm Hg, a P CO2 of
50 mm Hg, a bica rbona te va lue of 22 mEq/L, a nd a pH of 7.25. This
shows
A. Se ve re hypoxe mia
B. Re spira tory a cidosis
D. Norma l va lue s
710. W hich condition MOST fre que ntly re quire s blood tra nsfusions
during or a fte r a ce sa re a n de live ry?
A. Multiple ge sta tions
B. Pla ce nta a bruption
C. Pla ce nta pre via
D. Postpa rtum he morrha ge
711. All of the following a re a ppropria te te chnique s or drug dose s
to be use d in re suscita ting a de pre sse d te rm ne wborn EXCEPT
A. Be gin ve ntila tion with a ir ra the r tha n 100% oxyge n
B. If the he a rt ra te is le ss tha n 60 be a ts/min, sta rt che st
compre ssions (ra tio of che st compre ssions to ve ntila tions is 3:1)
C. Afte r a de qua te ve ntila tion a nd che st compre ssions, a dministe r
0.1 mg/kg of e pine phrine IV
D. Afte r 10 minute s of no de te cta ble he a rt ra te , it ma y be
re a sona ble to discontinue re suscita tion e fforts
712. Afte r a va gina l de live ry unde r e pidura l a ne sthe sia , a he a lthy 8-
lb ba by is born. The 23-ye a r-old now gra vida 1, pa ra 1 woma n is
note d to ha ve a te mpe ra ture of 38.2° C. A le ukocyte count is
obta ine d a nd is 15,000/mm3. The most a ppropria te course of a ction
would be to
A. Ge t a blood culture
B. Sta rt a ntibiotics
C. Administe r a se da tive
D. Obse rve
713. Compa re d with a he a lthy 25-ye a r-old primigra vida , which of
the following conditions is NOT a ssocia te d with a significa ntly
highe r incide nce of hype rte nsive disorde rs of pre gna ncy?
A. Multiple ge sta tions
B. Ciga re tte smoking (>1 pa ck/da y)
C. Obe sity
D. Pla ce nta l a bruption
714. Adve rse e ffe cts (on the mothe r) a ssocia te d with a ortoca va l
compre ssion by the gra vid ute rus include
B. Cha nge s in ce re bra tion
C. Fe ta l distre ss
715. W hich of the following sta te me nts re ga rding a pre gna nt pa tie nt
a busing coca ine is FALSE?
A. Hype rte nsion, a rrhythmia s, myoca rdia l ische mia , a nd
ta chyca rdia ma y occur with the ra pid-se que nce induction of
ge ne ra l a ne sthe sia in the a cute ly intoxica te d pa tie nt
B. The MAC for ge ne ra l a ne sthe tics is incre a se d in chronic
coca ine a ddicts
C. Some sta te s conside r in ute ro drug e xposure to be a form of
child a buse a nd re quire physicia ns to re port the se pa tie nts
D. If a va sopre ssor is ne e de d to tre a t hypote nsion, phe nyle phrine
is pre fe rre d ove r e phe drine
716. Ea ch of the following is corre ct whe n a dvising the surge on to
pe rform infiltra tion a ne sthe sia for a n e me rge ncy ce sa re a n de live ry
whe n ge ne ra l a nd ne ura xia l a ne sthe sia is contra indica te d EXCEPT
A. A midline incision is most de sira ble
B. The re ctus muscle should be inje cte d to provide good skin
a na lge sia
C. Bupiva ca ine with bica rbona te is the loca l a ne sthe tic of choice
D. Mild se da tion with ke ta mine a nd mida zola m is pe rmissible
717. A 24-ye a r-old primipa rous woma n is unde rgoing a n e le ctive
ce sa re a n se ction (bre e ch position). Afte r pre hydra tion with 1500 mL
of sa line , a spina l a ne sthe tic is pe rforme d; 5 minute s la te r, the
blood pre ssure is note d to be 80/40 mm Hg a nd the he a rt ra te is
110 be a ts/min. The BEST tre a tme nt (be st fe ta l pH) a fte r e nsuring
tha t a de qua te le ft ute rine displa ce me nt is pe rforme d would be
A. Phe nyle phrine
B. Ephe drine
C. Epine phrine
D. 1000 mL 5% de xtrose in la cta te d Ringe r ’s solution
718. A woma n ha s be e n a dmitte d for a dila tion a nd e va cua tion
(D&E) a t 10 we e ks’ EGA. She ha s some pe rsiste nt ble e ding a nd
cra mping a fte r the e xpulsion of some tissue . He r obste tric condition
is ca lle d
A. A thre a te ne d a bortion
B. An ine vita ble a bortion
C. A comple te a bortion
D. An incomple te a bortion
719. The a ction of e pidura l na rcotics is a nta gonize d by the prior or
concomita nt a dministra tion of which of the following e pidura lly
a dministe re d loca l a ne sthe tics?
A. Lidoca ine
B. Bupiva ca ine
C. Ropiva ca ine
D. Chloroproca ine
720. Fa ctors a ssocia te d with a dva nce d mola r pre gna ncy (i.e ., >14- to
16-we e k size ute rus) include a ll of the following EXCEPT
A. Hype rte nsive disorde rs of pre gna ncy
B. Hypothyroidism
C. Acute ca rdiopulmona ry distre ss
D. Hype re me sis gra vida rum
721. Re fra ctory ca rdia c a rre st is MOST like ly a fte r the ra pid
uninte ntiona l IV inje ction of which of the following loca l
a ne sthe tics?
A. Lidoca ine
B. Bupiva ca ine
C. Ropiva ca ine
D. Chloroproca ine
722. Ame rica n Socie ty of Re giona l Ane sthe sia (ASRA) guide line s for
the tre a tme nt of loca l a ne sthe tic syste mic toxicity (LAST) for ca rdia c
a rrhythmia s include the use of Intra lipid a nd the AVOIDANCE of a ll
of the following drugs EXCEPT
A. Va sopre ssin
B. β-Blocke rs
C. Ca lcium cha nne l blocke rs
D. Low-dose e pine phrine (<1 µg/kg)
723. Tra nsie nt ne urologic syndrome (TNS) is MOST commonly se e n
a fte r the spina l a ne sthe tic inje ction of which loca l a ne sthe tic?
A. Lidoca ine
B. Bupiva ca ine
C. Priloca ine
D. Te tra ca ine
724. You ha ve a we ll-working T10 la bor e pidura l in a woma n with
a que stiona ble difficult a irwa y a nd ha ve just be e n informe d tha t a n
urge nt ce sa re a n se ction is ne e de d for a nonre a ssuring FHR tra cing.
W hich of the following loca l a ne sthe tics would give you the
SLOWEST onse t of surgica l a ne sthe sia ?
A. 3% chloroproca ine with fre shly a dde d e pine phrine (1:200,000)
B. 2% lidoca ine with fre shly a dde d e pine phrine (1:200,000)
C. 2% lidoca ine a nd e pine phrine with a dde d bica rbona te
D. 0.5% le vobupiva ca ine with fe nta nyl
725. W hich loca l a ne sthe tic ha s the MOST ra pid me ta bolism in
ma te rna l a nd fe ta l blood?
A. Lidoca ine
B. Bupiva ca ine
C. Ropiva ca ine
D. Chloroproca ine
Obstetric Physiology and Anesthesia
643. (D) The fe ta l/ma te rna l (F/M) drug ra tio is a wa y to
qua ntita tive ly de scribe drug tra nsfe r a cross the pla ce nta . Time is
a lso importa nt whe n conside ring how much drug crosse s into the
fe tus. Ma ny a ne sthe tic drugs cross the pla ce nta such a s loca l
a ne sthe tics, intra ve nous induction a ge nts (e .g., propofol [F/M ra tio
of 0.7-1.1], e tomida te [F/M ra tio of 0.5], ke ta mine [F/M ra tio of 0.5]),
inha la tion a ge nts (e .g., vola tile a ne sthe tics a nd nitrous oxide [F/M
ra tio of 0.7]), a nd na rcotics (e .g., fe nta nyl [F/M ra tio of 0.4],
re mife nta nil [F/M ra tio of 0.9], morphine [F/M ra tio of 0.6]) a nd with
time ma y a ffe ct the fe tus/ne wborn. For va sopre ssors, e phe drine
ha s a n F/M ra tio of 0.7, whe re a s phe nyle phrine ha s a n F/M ra tio of
0.2. The ionize d ne uromuscula r blocking a ge nts do not re a dily
cross the pla ce nta (F/M ra tios of nonde pola rizing drugs a re a round
0.1-0.2); succinylcholine , a de pola rizing muscle re la xa nt, crosse s
ve ry poorly a s we ll. The a nticholine rgic drugs a tropine a nd
scopola mine ha ve F/M drug ra tios of 1.0 a nd re a dily cross the
pla ce nta , whe re a s glycopyrrola te ha s a n F/M drug ra tio of 0.1 a nd
poorly crosse s the pla ce nta . Be ca use the a nticholine ste ra se a ge nts
(ne ostigmine , pyridostigmine , a nd e drophonium) cross the pla ce nta
to a limite d e xte nt but more so tha n glycopyrrola te , a pre gna nt
pa tie nt unde rgoing nonobste tric surge ry in which ne uromuscula r
blocking drugs a re be ing re ve rse d with a nticholine ste ra se a ge nts
should ha ve a tropine ra the r tha n glycopyrrola te use d with the
a nticholine ste ra se mixture to pre ve nt possible fe ta l bra dyca rdia
(Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 63–69; Suresh :
Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp 47–51).
644. (D) Afte r low-dose prophyla xis with low-mole cula r-we ight
he pa rin (LMW H) (e .g., e noxa pa rin 0.5 mg/kg da ily), a time of a t
le a st 10 to 12 hours should e la pse prior to pe rforming ne ura xia l
te chnique s to de cre a se the like lihood of a n e pidura l he ma toma
forming (a t le a st 24 hours a fte r high-dose LMW H [e .g., e noxa pa rin
1 mg/kg twice da ily or 1.5 mg/kg da ily] use d for the ra pe utic
a nticoa gula tion). If the pa tie nt ha s ba ck pa in a nd une xpe cte d
ne urologic pa ra lysis, a workup for a he ma toma should be
pe rforme d. This ca se de monstra te s a be nign condition in which the
sympa the tic ne rve supply to the e ye is blocke d (Horne r syndrome
[tria d of miosis, ptosis, a nd a nhidrosis]). This occa siona lly de ve lops
a fte r a lumba r e pidura l a ne sthe tic e ve n whe n the highe st
de rma tome le ve l blocke d is be low T5. It ma y be re la te d to the
supe rficia l a na tomic loca tion of the de sce nding spina l sympa the tic
fibe rs tha t lie just be low the spina l pia of the dorsola te ra l funiculus
(which is within diffusion ra nge of suba ne sthe tic conce ntra tions of
loca l a ne sthe tics in the ce re brospina l fluid) a s we ll a s incre a se d
se nsitivity of loca l a ne sthe tics during pre gna ncy (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 923–925, 1046–1048; Suresh :
Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp 133, 355–359;
ASRA Practice Ad visory : Regional Anesth esia in th e Patient Receiving
Antith rom botic or Th rom boly tic Th erapy —Th ird Consensus Conference
on Neurax ial Anesth esia and Anticoagulation, Jan-Feb
2010, www.asra.com /consensus-statem ents).
645. (B) In the Unite d Sta te s, hype rte nsion (susta ine d systolic blood
pre ssure [SBP] >140 mm Hg or a susta ine d dia stolic blood pre ssure
[DBP] >90 mm Hg) occurs with a n ove ra ll incide nce of
a pproxima te ly 5% to 10% of a ll pre gna ncie s. Hype rte nsion is a
le a ding ca use of ma te rna l de a th worldwide . Hype rte nsion during
pre gna ncy is divide d into four groups: pre e cla mpsia -e cla mpsia ,
chronic hype rte nsion (of a ny ca use ), chronic hype rte nsion with
supe rimpose d pre e cla mpsia , a nd ge sta tiona l hype rte nsion.
Pre e cla mpsia -e cla mpsia is a hype rte nsive disorde r of pre gna ncy
usua lly a ssocia te d with prote inuria (≥300 mg prote in pe r 24-hour
urine colle ction). Re ce ntly (Nove mbe r 2013), the pre se nce of
prote inuria is no longe r ne e de d for the de signa tion of
pre e cla mpsia -e cla mpsia . The re a son for the cha nge is tha t some
pa tie nts de ve lop prote inuria la te a nd ha ve the ir dia gnosis a nd
ne e de d tre a tme nt de la ye d. Curre nt de finition of pre e cla mpsia -
e cla mpsia is the ne w onse t of hype rte nsion a ssocia te d with
thrombocytope nia (pla te le t count <100,000/mL), impa ire d live r
function, re na l insufficie ncy (se rum cre a tinine >1.1 mg/dL or
doubling of se rum cre a tinine in the a bse nce of a ny othe r re na l
dise a se ), pulmona ry e de ma , or ne w-onse t ce re bra l or visua l
disturba nce s. Ge sta tiona l hype rte nsion is just ne w onse t of
hype rte nsion. W ith both pre e cla mpsia -e cla mpsia a nd ge sta tiona l
hype rte nsion, the hype rte nsion re solve s se ve ra l da ys a fte r de live ry.
Pre e cla mpsia -e cla mpsia ra re ly occurs be fore the 20th we e k of
ge sta tion (unle ss a hyda tidiform mole is pre se nt). The incide nce of
pre e cla mpsia is significa ntly highe r in pa rturie nts with a
hyda tidiform mole , multiple ge sta tions, obe sity, polyhydra mnios, or
dia be te s a nd occurs more commonly with the first pre gna ncy.
Mothe rs with pre e cla mpsia during the ir first pre gna ncy ha ve a 33%
cha nce of ha ving pre e cla mpsia in subse que nt pre gna ncie s.
Pre e cla mpsia ca n progre ss to e cla mpsia (pre e cla mpsia
a ccompa nie d by a se izure not re la te d to othe r conditions). Eighty
pe rce nt of the se izure s occur be fore or during de live ry; 85% of the
re ma ining 20% will ha ve the se izure within the first 24 hours a fte r
de live ry. Approxima te ly 5% of untre a te d pa rturie nts with
pre e cla mpsia will de ve lop e cla mpsia (Am erican College of
Obstetricians and Gy necologists Task Force on Hy pertension in Pregnancy,
Novem ber 2013 Website; Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 825–829; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed
5, pp 437–438).
646. (D) Epidura l he ma toma s a nd e pidura l a bsce sse s a re quite
ra re . Se ve re ba ck pa in a nd/or le g we a kne ss tha t is gre a te r tha n
e xpe cte d (or the re curre nce of we a kne ss a fte r pa rtia l re cove ry of a
ne ura xia l block) a re pre se nting symptoms of spina l cord
compre ssion. Epidura l he ma toma s ca n de ve lop within 12 hours of
a ne ura xia l proce dure , whe re a s e pidura l a bsce sse s usua lly ta ke
da ys to de ve lop a nd a lso pre se nt with fe ve r a nd le ukocytosis.
The se conditions ne e d ima ging (e .g., ma gne tic re sona nce ima ging
[MRI]) a nd ne urosurgica l consulta tion. Studie s ha ve shown tha t
whe n spina l cord de compre ssion occurs within 8 hours of the onse t
of pa ra lysis, ne urologic re cove ry is significa ntly be tte r tha n a fte r
8 hours. Although e pidura l he ma toma forma tion is ra re , clotting
disorde rs a nd pe rha ps ma rke d difficulty in pla cing a block could
le a d to e pidura l ble e ding a nd he ma toma forma tion. Be ca use the
pre e cla mptic pa tie nt ma y de ve lop a coa gulopa thy, one should
ca re fully e va lua te he r coa gula tion sta tus prior to initia ting a
re giona l block. Most a ne sthe siologists would e va lua te a pla te le t
count in the pre e cla mptic pa tie nt a nd look for a ny clinica l signs of
une xpla ine d ble e ding prior to initia ting a re giona l block. Be ca use
a n e pidura l blood pa tch ofte n is pe rforme d with 20 mL of blood, the
e pidura l he ma toma tha t ca use s spina l cord compre ssion must be
significa ntly gre a te r (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp
749–750; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5,
p 415).
647. (D) The norma l se rum ma gne sium le ve l is 1.5 to 2 mEq/L, with
a the ra pe utic ra nge of 4 to 8 mEq/L. Note : ma ny la bora torie s re port
va lue s in mg/dL (1 mEq/L = 1.2 mg/dL). As ma gne sium sulfa te is

a dministe re d IV, pa tie nts ofte n note a wa rm fe e ling in the ve in a s
we ll a s some se da tion. W ith incre a sing se rum le ve ls, loss of de e p
te ndon re fle xe s occurs a t 10 mEq/L (12 mg/dL), re spira tory pa ra lysis
occurs a t 15 mEq/L (18 mg/dL), a nd ca rdia c a rre st a t gre a te r tha n
25 mEq/L (>30 mg/dL) ca n occur. Ma gne sium de cre a se s the re le a se
of a ce tylcholine (ACh) a t the myone ura l junction a nd de cre a se s the
se nsitivity of the motor e ndpla te to ACh. This ca n produce ma rke d
pote ntia tion of nonde pola rizing muscle re la xa nts. The e ffe ct on
de pola rizing muscle re la xa nts is le ss cle a r, a nd most clinicia ns use
sta nda rd intuba ting dose s of succinylcholine (i.e ., 1 to 1.5 mg/kg)
followe d by a ma rke dly re duce d dose of a nonde pola rizing re la xa nt
if ne e de d. Be ca use ma gne sium a nta gonize s the e ffe cts of α-
a dre ne rgic a gonists, e phe drine is usua lly pre fe rre d ove r
phe nyle phrine if a va sopre ssor is ne e de d to re store blood
pre ssure , a long with fluids, a fte r a ne ura xia l blocka de . W he n a
ca lcium cha nne l blocke r, such a s nife dipine , is a dministe re d a long
with ma gne sium, gre a te r hypote nsion ha s re sulte d. The a ntidote
for ma gne sium toxicity is ca lcium (which, if ne e de d, should be
a dministe re d slowly) (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 803–804, 838–839, 848; Suresh : Sh nid er and Levinson’s Anesth esia for
Obstetrics, ed 5, pp 282, 448).
648. (C) Fe ta l monitors consist of a two-cha nne l re corde r for
simulta ne ous re cording of FHR a nd ute rine a ctivity. In looking a t the
FHR, one a sse sse s the ba se line ra te , the FHR va ria bility, a nd the
pe riodic cha nge s (a cce le ra tions or de ce le ra tions) tha t occur with
ute rine contra ctions. The norma l FHR va rie s be twe e n 110 a nd 160
be a ts/min. Se e a lso Answe r 703 (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, pp 150–151; Suresh : Anesth esia for Obstetrics, ed 5, pp
70–75).
649. (A) Worldwide , he morrha ge (H), infe ction (I), a nd hype rte nsive
disorde rs of pre gna ncy (pre e cla mpsia [P]), or HIP, a ccount for more
tha n ha lf of a ll ma te rna l de a ths. In the de ve lope d world,
hype rte nsive disorde rs, e mbolic disorde rs, a nd he morrha ge
a ccount for slightly le ss tha n ha lf of ma te rna l de a ths. In the Unite d
Sta te s be twe e n 1998 a nd 2005, se ve n conditions e a ch a ccount for
10% to 13% of a ll pre gna ncy-re la te d de a ths (he morrha ge ,
hype rte nsive disorde rs of pre gna ncy, se psis, thrombotic pulmona ry
e mbolism, ca rdiomyopa thy, othe r ca rdiova scula r disorde rs, a nd
nonca rdiova scula r disorde rs). Ane sthe tic complica tions a re a ra re
ca use of ma te rna l de a th (1%) (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, pp 932–941; Suresh : Sh nid er and Levinson’s Anesth esia
for Obstetrics, ed 5, p 740).
650. (A) Ute rine a tony is a common ca use of postpa rtum
he morrha ge (2%-5% of a ll va gina l de live rie s). Tre a tme nt consists of
ute rine ma ssa ge , drugs, a nd, in ra re ca se s, hyste re ctomy. Drugs
commonly use d include oxytocin, e rgot a lka loids (e rgonovine ,
me thyle rgonovine ), a nd prosta gla ndins (PGE2, PGF 2α, 15-me thyl
PGF 2α). Oxytocin is the first-line drug use d for the tre a tme nt of
ute rine a tony a nd ma y be use d in pa tie nts with a sthma or
hype rte nsive disorde rs of pre gna ncy. If oxytocin is give n a s a n IV
bolus, va sodila tion a nd hypote nsion ofte n re sult. The e rgot
a lka loids a re a ssocia te d with a high incide nce of na use a a nd
vomiting. The y not infre que ntly ca use va soconstriction, producing
e le va tions in blood pre ssure , a nd a re contra indica te d in pa tie nts
with hype rte nsion (a nd in this ca se pre e cla mpsia ). Ergot a lka loids
ha ve a lso be e n a ssocia te d with bronchospa sm (ra re ly) a nd ma y not
be a ppropria te in a sthma tic pa tie nts. Thus, the e rgot a lka loids a re
re la tive ly contra indica te d in pa tie nts with hype rte nsion (such a s
pre e cla mpsia ), corona ry a rte ry dise a se , a nd a sthma . The
prosta gla ndin 15-me thyl PGF 2α (Ca rboprost, He ma ba te ) is the only
prosta gla ndin curre ntly a pprove d for ute rine a tony in the Unite d
Sta te s a nd ma y ca use significa nt bronchospa sm in susce ptible
pa tie nts (a nd is contra indica te d in a sthma tic pa tie nts). Othe r
smooth muscle contra ction-a ssocia te d side e ffe cts of prosta gla ndin
15-me thyl PGF 2α include ve noconstriction a s we ll a s
ga strointe stina l muscle spa sm (na use a , vomiting, a nd dia rrhe a )
(Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 589–590, 888–891;
Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, p 321).
651. (B) Ne wborns ha ve high he moglobin le ve ls a round 15 to
20 g/100 mL. The te rm P 50 de note s the blood oxyge n te nsion (Pa O2)
tha t produce s 50% sa tura tion of e rythrocyte he moglobin. The P 50
va lue of fe ta l he moglobin is 18 mm Hg ve rsus the a dult va lue of
27 mm Hg. Thus, fe ta l he moglobin ha s a highe r a ffinity for oxyge n
tha n ma te rna l he moglobin (Ch estnut: Ch estnut’s Obstetric Anesth esia,
ed 5, pp 83–84; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics,
ed 5, pp 26–27).
652. (A) Te rbuta line is a β-a dre ne rgic a gonist with tocolytic
prope rtie s a nd ca n be a dministe re d intra ve nously a nd
subcuta ne ously a s we ll a s ora lly. Side e ffe cts a re simila r to those of
othe r β-a dre ne rgic drugs a nd include ta chyca rdia , hypote nsion,
myoca rdia l ische mia , pulmona ry e de ma (0.3% incide nce ),
hypoxe mia (inhibition of hypoxic pulmona ry va soconstriction),
hype rglyce mia (30% incide nce ), me ta bolic (la ctic) a cidosis,
hypoka le mia (39% incide nce a nd due to a shift of pota ssium from
e xtra ce llula r to intra ce llula r spa ce ), a nxie ty, a nd ne rvousne ss.
Ele ctroca rdiogra m (ECG) cha nge s in ST se gme nt de pre ssion a nd T
wa ve fla tte ning or inve rsion ma y occur a nd typica lly re solve a fte r
stopping the β-a dre ne rgic the ra py. W he the r the se ECG cha nge s
re fle ct myoca rdia l ische mia or hypoka le mia is uncle a r (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 802–803; Suresh : Sh nid er and
Levinson’s Anesth esia for Obstetrics, ed 5, pp 280–286).
653. (C) The nume rous cha nge s tha t ta ke pla ce in the
ca rdiova scula r syste m during pre gna ncy provide for the ne e ds of
the fe tus a nd pre pa re the mothe r for la bor a nd de live ry. During the
first trime ste r of pre gna ncy, ca rdia c output incre a se s by
a pproxima te ly 30% to 40%. At te rm, the ca rdia c output is incre a se d
50% ove r nonpre gna nt va lue s. This incre a se in ca rdia c output is
due to a n incre a se in stroke volume a nd a n incre a se in he a rt ra te .
During la bor, the ca rdia c output incre a se s a nothe r 10% to 15%
during the la te nt pha se , 25% to 30% during the a ctive pha se , a nd
40% to 45% during the e xpulsive sta ge . Ea ch ute rine contra ction
incre a se s the ca rdia c output by a bout 10% to 25%. The gre a te st
incre a se in ca rdia c output occurs imme dia te ly a fte r de live ry of the
ne wborn, whe n the ca rdia c output ca n incre a se to 75% a bove
pre la bor va lue s. This fina l incre a se in ca rdia c output is a ttribute d
prima rily to a utotra nsfusion a nd incre a se d ve nous re turn
a ssocia te d with ute rine involution. Ca rdia c output fa lls to pre la bor
va lue s within 2 da ys a fte r de live ry; howe ve r, it ta ke s a bout
2 we e ks for the ca rdia c output to de cre a se to nonpre gna nt va lue s
654. (D) Asthma occurs in a bout 4% to 8% of a ll pre gna ncie s.
Although se voflura ne is a good induction a ge nt for a sthma tic
pa tie nts, a ra pid-se que nce IV induction with e ndotra che a l
intuba tion to se cure the a irwa y is pre fe rre d. Be ca use mida zola m
ha s a slow onse t of a ction, it is not re comme nde d for a ra pid-
se que nce induction. W he n inducing ge ne ra l a ne sthe sia in a n
a sthma tic pa tie nt, it is impe ra tive to e sta blish a n a de qua te de pth of
a ne sthe sia be fore pla cing a n e ndotra che a l tube . If the pa tie nt is
“light,” the n se ve re bronchospa sm ma y occur. In pa tie nts with
a sthma , intra ve nous induction will work with ke ta mine or
propofol. Ke ta mine is conside re d by ma ny a s the induction a ge nt of
choice due to its mild bronchodila tor prope rtie s, but be ca use
propofol (a lso a good induction a ge nt in a sthma tic pa tie nts) doe s
not stimula te the ca rdiova scula r syste m a s ke ta mine doe s, in this
ca se propofol would be pre fe rre d in this pa tie nt with hype rte nsive
disorde rs of pre gna ncy. In pa tie nts with mild a sthma who do not
ne e d the a cce ssory muscle s of re spira tion re giona l a ne sthe sia
should be strongly conside re d if time pe rmits, be ca use it would
e limina te the ne e d for e ndotra che a l intuba tion. In a ddition, inha le d
β2-a dre ne rgic a gonist (e .g., a lbute rol) a nd intra ve nous ste roids ma y
be be ne ficia l a s we ll (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 1179–1186; Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp
524–535).
655. (D) Ute rine blood flow incre a se s dra ma tica lly from 50 to
100 mL/min be fore pre gna ncy to a bout 700 to 900 mL/min a t te rm
(i.e ., >1 unit of blood pe r minute ). From 70% to 90% of the ute rine
blood flow a t te rm goe s to the inte rvillous spa ce s. Ute rine blood
flow is re la te d to the pe rfusion pre ssure (ute rine a rte ria l pre ssure
minus ute rine ve nous pre ssure ) divide d by the ute rine va scula r
re sista nce . Thus, fa ctors tha t de cre a se ute rine blood flow include
syste mic hypote nsion, a ortoca va l compre ssion, ute rine contra ction,
a nd va soconstriction (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 40–42; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5,
pp 23–24).
656. (C) Ce ntra l ne urologic blocka de (i.e ., e pidura l, spina l, or
combine d spina l-e pidura l) a s we ll a s e pidura l blood pa tche s,
a ppe a r to be sa fe for HIV-infe cte d pa rturie nts. Ve rtica l tra nsmission
from the mothe r to the ne wborn ca n occur in 15% to 40% whe n the
mothe r is untre a te d. W ith a ntire trovira l the ra py a nd e le ctive
ce sa re a n de live ry, the ra te of tra nsmission is re duce d to a bout 1%
to 2%. The risk of de ve loping HIV a fte r a ne e dle stick injury with
HIV-infe cte d blood is 0.3%. (Risk of de ve loping he pa titis B from a
ne e dle stick injury with he pa titis B–infe cte d blood is 30% a nd
he pa titis C from a ne e dle stick injury with he pa titic C–infe cte d
blood is 2% to 4%.) Pa tie nts ta king prote a se inhibitors a s pa rt of
the ir drug the ra py ha ve inhibition of cytochrome P-450, a nd both
be nzodia ze pine s a s we ll a s na rcotics ha ve prolonge d e ffe cts
657. (C) The re is no cha nge in ce ntra l ve nous pre ssure , pulmona ry
ca pilla ry we dge pre ssure , pulmona ry a rte ry dia stolic pre ssure , or
le ft ve ntricula r e nd-systolic volume . Le ft ve ntricula r e nd-dia stolic
volume is incre a se d, a s is stroke volume , e je ction fra ction, he a rt
ra te , a nd ca rdia c output. Syste mic va scula r re sista nce is de cre a se d
a bout 20% (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 16–19;
Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp 1–3).
658. (A) Amniotic fluid e mbolism (AFE) is a ve ry ra re but se rious
complica tion of la bor a nd de live ry tha t re sults from the e ntra nce of
a mniotic fluid a nd constitue nts of a mniotic fluid into the ma te rna l
syste mic circula tion. About 10% of ma te rna l de a ths a re ca use d by
AFE, a nd two thirds of the se de a ths occur within 5 hours. Of those
pa tie nts who survive the AFE, a bout 50% ha ve significa nt ne urologic
dysfunction. For AFE to occur, the pla ce nta l me mbra ne s must be
rupture d, a nd a bnorma l ope n sinusoids a t the ute ropla ce nta l site
or la ce ra tions of e ndoce rvica l ve ins must e xist. The cla ssic tria d is
a cute hypoxe mia , he modyna mic colla pse (i.e ., se ve re hypote nsion),
a nd coa gulopa thy without a n obvious ca use . More tha n 80% of
the se wome n de ve lop ca rdiopulmona ry a rre st. He modyna mic
monitoring ofte n shows a bipha sic re sponse ; initia lly pulmona ry
va sospa sm with se ve re pulmona ry hype rte nsion a nd right he a rt
dysfunction is se e n, followe d by le ft ve ntricula r fa ilure a nd
pulmona ry e de ma . DIC occurs in a bout 66% of ca se s, a nd se izure s
occur a bout 50% of the time . Re ce ntly, AFE is be lie ve d to be a bit
diffe re nt from a pure e mbolic e ve nt, be ca use findings of
a na phyla xis a nd se ptic shock a lso a re involve d. Bronchospa sm,
howe ve r, is ra re (<15%) during a n AFE, a nd che st pa in is ve ry ra re
(2% of pa tie nts) (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 915–
572; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp
333–348).
659. (B) Orga noge ne sis ma inly occurs be twe e n the 15th a nd 56th
da ys (3-8 we e ks) of ge sta tion in huma ns a nd is the time during
which the fe tus is most susce ptible to te ra toge nic a ge nts. Although
a ll commonly use d a ne sthe tic drugs a re te ra toge nic in some a nima l
spe cie s, the re is no conclusive e vide nce to implica te a ny curre ntly
use d loca l a ne sthe tics, IV induction a ge nts, or vola tile a ne sthe tic
a ge nts in the ca usa tion of huma n conge nita l a noma lie s (Ch estnut:
660. (D) Opioid a buse during pre gna ncy is e stima te d to occur in
a bout 5% of pa tie nts in the Unite d Sta te s, most ofte n with the
nonpre scription use of pa in-re lie ving drugs such a s oxycodone .
Othe r opioids include morphine , he roin, me tha done , me pe ridine ,
a nd fe nta nyl. The proble ms a ssocia te d with a buse a re ma ny a nd
include the drug e ffe ct itse lf a nd substa nce s mixe d with the
na rcotics (e .g., ta lc, cornsta rch), a s we ll a s infe ction a nd
ma lnutrition. Ne wborn re spira tory de pre ssion a s ma nife ste d by a
low re spira tory ra te is tre a te d with controlle d ve ntila tion but not
with na loxone . Na loxone ca n pre cipita te a n a cute withdra wa l
re a ction a nd should not be a dministe re d to pa tie nts with chronic
na rcotic use (mothe r or ne wborn). The dose of na loxone to tre a t
na rcotic-induce d re spira tory de pre ssion in the nona ddicte d
ne wborn was 0.1 mg/kg, but more re ce nt da ta sugge st tha t it ma y
worse n the ne urologic da ma ge ca use d by a sphyxia . Curre nt
re comme nda tions a re to a ssist ve ntila tion until the na rcotic e ffe cts
we a r off a nd not to use na loxone (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, pp 177, 1209–1213; Suresh : Sh nid er and Levinson’s
Anesth esia for Obstetrics, ed 5, pp 253, 693–696).
661. (D) Imme dia te ly a fte r de live ry, the ca rdia c output ca n incre a se
75% a bove pre la bor va lue s. This is thought to re sult from
a utotra nsfusion a nd incre a se d ve nous re turn to the he a rt
a ssocia te d with involution of the ute rus, a s we ll a s incre a se d blood
re turn a s the re sult of the lithotomy position. Se e a lso Answe r 653
662. (B) The Apga r score is a subje ctive scoring syste m use d to
e va lua te the ne wborn a nd is commonly pe rforme d 1 minute a nd
5 minute s a fte r de live ry. If the score is le ss tha n 7, the scoring is
a lso pe rforme d a t 10, 15, a nd 20 minute s a fte r de live ry. A va lue of 0,
1, or 2 is give n to e a ch of five signs (he a rt ra te , re spira tory e ffort,
re fle x irrita bility, muscle tone , a nd color) a nd tota le d. In this ca se ,
the child ge ts 1 point for he a rt ra te , 1 point for re spira tory e ffort, 1
point for re fle x irrita bility, 1 point for muscle tone , a nd 0 points for
color.
THE APGAR SCORE
An Apga r score of 7 to 10 is norma l, 4 to 6 is mode ra te , a nd 0 to 3

indica te s se ve re de pre ssion. We ight, ge sta tiona l a ge , a nd se x a re
not fa ctors include d in the scoring syste m (Ch estnut: Ch estnut’s
Obstetric Anesth esia, ed 5, pp 168–170; Suresh : Sh nid er and Levinson’s
Anesth esia for Obstetrics, ed 5, 244–246).
663. (D) The re spira tory syste m unde rgoe s ma ny importa nt cha nge s
during pre gna ncy. Oxyge n consumption incre a se s a bout 20% to 60%.
To he lp supply the ne e de d oxyge n for the me ta bolica lly a ctive
mothe r a nd fe tus, minute ve ntila tion (MV) incre a se s a bout 45% to
50%. The incre a se in MV is prima rily due to a n incre a se in tida l
volume (VT) of 40% to 45%, with a slight incre a se in re spira tory ra te .
The incre a se in MV produce s a fa ll in the Pa CO2 to a pproxima te ly
30 to 32 mm Hg, a nd a re spira tory a lka losis de ve lops. To he lp ge t
the pH ba ck to norma l, the se rum bica rbona te le ve l fa lls a n
a ve ra ge of 4 mEq/L. The a rte ria l Pa O2 incre a se s slightly due to the
fa ll in Pa CO2 (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 19–22;
664. (D) In 2011, the re we re more tha n 163,000 ART cycle s in the
Unite d Sta te s, with live births occurring in a lmost 40% of the se
proce dure s. The oocyte s ca n be re trie ve d by la pa roscopy or, more
commonly now, tra nsva gina lly (tra nsva gina l oocyte re trie va l
[TVOR]). Most a ne sthe tic drugs ha ve be e n studie d a nd found not to
be a proble m, including propofol, mida zola m, ke ta mine , a lfe nta nil,
fe nta nyl, re mife nta nil, a nd me pe ridine . W he n ge ne ra l a ne sthe sia
wa s use d (la pa roscopic re trie va l), isoflura ne with a nd without
nitrous oxide wa s usua lly use d a nd a ppe a re d sa fe . Howe ve r, with
incre a se d time during ge ne ra l a ne sthe sia , the oocyte s re trie ve d
e a rlie r ha d be tte r fe rtiliza tion ra te s tha n the oocyte s obta ine d ne a r
the e nd of the la pa roscopy. It is uncle a r whe the r this wa s due to
our a ne sthe tics or to the lowe re d pH a s a re sult of the ca rbon
dioxide pne umope ritone um. Etomida te ha s not be e n wide ly use d,
a nd pa tie nt numbe rs a re too sma ll to re comme nd its use . W he n
morphine is use d in high dose s in a nima l studie s, chromosoma l
a bnorma litie s a re ve ry common (25%-33%), a nd morphine is not
re comme nde d for ART proce dure s. It is re comme nde d to a void
using the dopa mine a nta gonists (e .g., drope ridol a nd
me toclopra mide ) during ART cycle s be ca use the se drugs induce
hype rprola ctine mia , which impa irs ova ria n follicula r ma tura tion. A
single dose imme dia te ly prior to oocyte re trie va l proba bly is sa fe .
The 5-hydroxytrpta mine type 3 (5-HT 3) re ce ptor a nta gonists a re
commonly use d, but the re is insufficie nt e vide nce to re comme nd
the ir use . The phe nothia zine s a nd the a ntihista mine H1-re ce ptor
a nta gonists a re thought to be pre fe rre d be ca use the y ha ve be e n
studie d without a dve rse e ffe cts (Ch estnut: Ch estnut’s Obstetric
for Obstetrics, ed 5, pp 765–773).
665. (D) All of the conditions liste d in this que stion, a s we ll a s
de ficie ncie s of a ntithrombin III a nd prote in S (a cofa ctor for prote in
C), le a d to hype rcoa gula ble sta te s. Unle ss tre a te d with
a nticoa gula tion the ra py, the se conditions will ha ve a n incre a se d
fre que ncy of thrombosis. The se conditions ma y a lso ca use
pla ce nta l thrombosis a nd insufficie ncy, a nd ca n incre a se the
incide nce of obste tric conditions such a s intra ute rine growth
re striction, pre e cla mpsia , pla ce nta l a bruption, a nd intra ute rine
de a th. Lupus a nticoa gula nt, a lso ca lle d lupus a ntibody, is a
prothrombotic a ge nt. It ge ts its na me be ca use the pre se nce of the se
a ntibodie s ca use s a n incre a se in the a ctiva te d pa rtia l
thrombopla stin (a PTT) te st, a s the se a ntibodie s inte rfe re with
phospholipids use d to induce in vitro coa gula tion. Howe ve r, in vivo,
the se a ntibodie s inte ra ct with pla te le t me mbra ne phospholipids,
incre a sing a dhe sions a nd the a ggre ga tion of pla te le ts. Fa ctor V
Le ide n muta tion a llows fa ctor V to pe rsist longe r in the circula tion
(not me ta bolize d a s ra pidly by a ctiva te d prote in C), le a ding to a
hype rcoa gula ble sta te . Prote in C inhibits a ctiva te d clotting fa ctors V
a nd VIII; thus, during a de ficie ncy sta te , fa ctors V a nd VIII pe rsist
longe r in the circula tion, le a ding a ga in to a hype rcoa gula ble sta te .
During pre gna ncy, the incide nce of thrombosis with prote in C
de ficie ncy is a bout 25% unle ss a nticoa gula tion the ra py is
a dministe re d (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 951–
952, 1048–1049).
666. (B) Pa tie nts with comple te spina l cord le sions a bove T10 do
not ha ve pa in with la bor. Howe ve r, a bout 85% of wome n with
comple te spina l cord le sions a t the T6 a nd highe r le ve l will
de ve lop a utonomic hype rre fle xia (se ve re he a da che , hype rte nsion,
bra dyca rdia , swe a ting a bove the le sion, a nd fa cia l flushing) during
la bor a nd de live ry. Autonomic hype rre fle xia typica lly occurs with
the contra ctions a nd disa ppe a rs be twe e n contra ctions. An e pidura l
or a spina l with loca l a ne sthe tics works we ll to pre ve nt a nd/or
tre a t a utonomic hype rre fle xia . Epidura l na rcotics such a s fe nta nyl
a lone a re not e ffe ctive (unle ss the na rcotic is me pe ridine , which
ha s loca l a ne sthe tic prope rtie s in a ddition to na rcotic e ffe cts). To
che ck whe the r the e pidura l or spina l tha t is loa de d with a loca l
a ne sthe tic is working in a qua driple gic pa tie nt, che ck the re fle xe s
be low the e xpe cte d le ve l of a ne sthe sia (e .g., pa te lla r) be fore a nd
a fte r the block. The loca l a ne sthe tic conce ntra tion for la bor
e pidura ls (a lone without na rcotics) typica lly is 0.25% or highe r. If a
ce sa re a n se ction is ne e de d, 2% lidoca ine with e pine phrine
(1:200,000) ha s be e n re porte d to be sa fe . If a ce sa re a n se ction is
ne e de d with ge ne ra l a ne sthe sia , typica l IV a ne sthe tics a nd
inha la tion drugs a re use d e xce pt for muscle re la xa tion, whe re
succinylcholine is contra indica te d (hype rka le mic re sponse ) a nd a
nonde pola rizing muscle re la xa nt such a s rocuronium is pre fe rre d
Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, p 564).
667. (D) Ma ny of the signs a re consiste nt with the choice s de scribe d
in this que stion. From the te mpora l pe rspe ctive , ga stric a cid
a spira tion is the most like ly ca use , be ca use a spira tion ca n de ve lop
not only on induction but a lso on e xtuba tion, a s in this ca se . Tha t is
why it is so importa nt to a lwa ys e mpty the pa tie nt’s stoma ch with
a n oroga stric tube a fte r a n e ndotra che a l tube is pla ce d in a ny
pre gna nt pa tie nt ove r 20 we e ks’ unde rgoing ge ne ra l a ne sthe sia ,
a nd e xtuba te the pa tie nt whe n she is fully a wa ke a nd re sponsive .
Morbidity a nd morta lity occurring a fte r ga stric a cid a spira tion is
de te rmine d by both the a mount a nd the pH of the a spira te d
ma te ria l. Ba se d on a n a nima l study in which 0.4 mL/kg with a pH
le ss tha n 2.5 inje cte d into the right ma inste m of one rhe sus monke y
ca use d de a th, ma ny ha ve use d tha t de finition (0.4 mL/kg with a pH
<2.5) to ca te gorize pa tie nts who a re “a t risk” for significa nt
a spira tion morbidity a nd morta lity. Using the se va lue s, up to 70% of
wome n who fa ste d be fore e le ctive ce sa re a n se ction a re “a t risk for
a spira tion.” Re ce ntly, it ha s be e n note d tha t the volume ne e de d to
ca use a spira tion in prima te s should be gre a te r (e .g., 0.8 mL/kg) a nd
the pH le ss tha n 2.5. Re ga rdle ss of the de finition of the “pa tie nt a t
risk,” whe n a spira tion occurs it ca n be le tha l. Bronchospa sm (ofte n
a ssocia te d with highe r a irwa y pre ssure s) a nd whe e zing a re
sugge stive of ga stric a cid a spira tion a nd not a mniotic fluid
e mbolism. Othe r signs a nd symptoms of a spira tion include sudde n
coughing or la ryngospa sm, dyspne a , ta chypne a , the pre se nce of
fore ign ma te ria l in the mouth or poste rior pha rynx, che st wa ll
re tra ction, cya nosis not re lie ve d by oxyge n supple me nta tion,
ta chyca rdia , hypote nsion, a nd the de ve lopme nt of pinky frothy
e xuda te s. The onse t of the se signs a nd symptoms is usua lly ra pid.
Ea rly tre a tme nt consists of supple me nta l oxyge n with positive -
pre ssure ve ntila tion, PEEP, or continuous positive a irwa y pre ssure ,
a nd suctioning of the a irwa y ca n de cre a se the incide nce of
morta lity from a cid a spira tion. Morta lity se e ms to be re duce d whe n
prote ctive ve ntila tory stra te gie s a re use d (i.e ., tida l volume s of
6 mL/kg with pla te a u pre ssure s of <30 cm H2O a re be tte r tha n if
12 mL/kg a nd pla te a u pre ssure s of 50 cm H2O a re use d).
Conse rva tive a s compa re d to libe ra l fluid ma na ge me nt (guide d by
ce ntra l ve nous pre ssure s a nd/or pulmona ry a rte ry we dge
pre ssure s) a lso a ppe a rs to improve lung function. The use of
prophyla ctic a ntibiotics a nd/or ste roids ha s not be e n he lpful
668. (D) The prima ry obje ctive s in the a ne sthe tic ma na ge me nt of
pa rturie nts unde rgoing ge ne ra l a ne sthe sia for nonobste tric surge ry
a re a s follows: to (1) e nsure ma te rna l sa fe ty; (2) a void te ra toge nic
drugs; (3) a void intra ute rine fe ta l a sphyxia ; a nd (4) pre ve nt the
induction of pre te rm la bor. Pre ma ture onse t of la bor is the most
common complica tion a ssocia te d with surge ry during the se cond
trime ste r of pre gna ncy. Pe rforma nce of intra -a bdomina l proce dure s
in which the ute rus is ma nipula te d is the most significa nt fa ctor in
ca using pre ma ture la bor in the se pa tie nts. Ne urosurgica l,
orthope dic, thora cic, or othe r surgica l proce dure s tha t do not
involve ma nipula tion of the ute rus do not ca use pre te rm la bor. No
a ne sthe tic a ge nt or te chnique ha s be e n found to be significa ntly
a ssocia te d with a highe r or lowe r incide nce of pre te rm la bor.
Furthe rmore , the re is no e vide nce tha t the risk of de ve loping a ny of
the conditions liste d in this que stion is incre a se d for the offspring of
pa tie nts who re ce ive ge ne ra l a ne sthe sia during pre gna ncy (Suresh :
669. (C) Mya sthe nia gra vis (MG) is a n a utoimmune ne uromuscula r
dise a se in which immunoglobulin G (IgG) a ntibodie s a re dire cte d
a ga inst the ACh re ce ptors in ske le ta l muscle , ca using pa tie nts to
pre se nt with ge ne ra l muscle we a kne ss a nd e a sy fa tiga bility.
Smooth muscle a nd ca rdia c muscle a re not a ffe cte d. About 10% to
20% of ne wborns born to mothe rs with MG a re tra nsie ntly a ffe cte d
be ca use the IgG a ntibody is tra nsfe rre d through the pla ce nta .
Ne ona ta l MG is cha ra cte rize d by muscle we a kne ss (e .g.,
hypotonia , re spira tory difficulty) a nd ma y a ppe a r within the first
4 da ys of life (80% a ppe a r within the first 24 hours).
Anticholine ste ra se the ra py ma y be re quire d for se ve ra l we e ks until
the ma te rna l IgG a ntibodie s a re me ta bolize d (Ch estnut: Ch estnut’s
Anesth esia for Obstetrics, ed 5, pp 537–539).
670. (C) Disse mina te d intra va scula r coa gula tion (DIC) is a n
a cquire d coa gulopa thy cha ra cte rize d by e xce ssive fibrin de position,
de pre ssion of the norma l coa gula tion inhibition me cha nism, a nd
impa ire d fibrin de gra da tion. The forma tion of clots ca use s a
de ple tion of pla te le ts a nd fa ctors. La bora tory dia gnosis of DIC is
ba se d on the de monstra tion of a bnorma litie s in pla te le t count (i.e .,
<100,000/mm3), prolonge d prothrombin time (i.e ., >3 se conds a bove
norma l), pre se nce of fibrin de gra da tion products, a nd fibrinoge n
le ve l (i.e ., ≤1 g/L). DIC is a ssocia te d with the following obste tric
conditions: pla ce nta l a bruption, de a d fe tus syndrome , a mniotic
fluid e mbolism, gra m-ne ga tive se psis, a nd se ve re pre e cla mpsia .
Pla ce nta l a bruption is the most common ca use of DIC in pre gna nt
pa tie nts. If one looks a t se ve re pla ce nta a bruptions (in which the
a bruption is la rge e nough to ca use fe ta l de a th), a bout 30% of
pa tie nts will de ve lop DIC within 8 hours of the a bruption.
Nonobste tric ca use s of DIC include se psis a nd ma ligna ncy. Pa tie nts
with pla ce nta pre via who a re ble e ding do not de ve lop DIC be ca use
the blood loss doe s not induce a coa gulopa thy (Barash : Clinical
Anesth esia, ed 7, pp 435–437; Ch estnut: Ch estnut’s Obstetric Anesth esia,
ed 5, pp 1045–1046; Suresh : Sh nid er and Levinson’s Anesth esia for
Obstetrics, ed 5, pp 311–321, 444–445, 574–575).
671. (B) Eise nme nge r syndrome ma y de ve lop in pa tie nts with
uncorre cte d le ft-to-right intra ca rdia c shunting such a s for ve ntricula r
se pta l de fe ct, a tria l se pta l de fe ct, or pa te nt ductus a rte riosus. In
this syndrome , the pulmona ry a nd va scula r tone a nd right
ve ntricula r muscle unde rgo cha nge s in re sponse to the shunt,
producing pulmona ry hype rte nsion a nd a cha nge in the dire ction of
the shunt to a right-to-le ft or bidire ctiona l type with pe riphe ra l
cya nosis. The ma te rna l morta lity ra te is 30% to 50%. Approxima te ly
3% of a ll pa tie nts with conge nita l he a rt de fe cts will de ve lop this
condition ove r time . W he n the Eise nme nge r syndrome de ve lops,
the pulmona ry va scula r re sista nce be come s fixe d, ma king this
condition not a me na ble to surgica l corre ction. Surviva l be yond a ge
40 ye a rs is uncommon. Any e ve nt or drug tha t incre a se s pulmona ry
va scula r re sista nce (e .g., hype rca rbia , a cidosis, hypoxia ) or
de cre a se s syste mic va scula r re sista nce will worse n the right-to-le ft
shunt, will e xa ce rba te pe riphe ra l cya nosis, a nd ma y pre cipita te
right ve ntricula r he a rt fa ilure in the se pa tie nts. Controve rsy e xists
re ga rding pa in ma na ge me nt for the se pa tie nts be ca use pa in ca n
e le va te pulmona ry a rte ry pre ssure s a nd ca use more shunting.
Ma ny pra ctitione rs pre fe r a na rcotic-ba se d a na lge sic (spina l or
e pidura l). Be ca use the se pa tie nts a re ve ry de pe nde nt upon pre loa d
a nd a fte rloa d, pla cing inva sive monitors (ce ntra l ve nous pre ssure
a nd a rte ria l ca the te r), a nd using the pulse oxime te r to e va lua te the
a mount of shunting, a ggre ssive tre a tme nt of a ny fa ll in pre loa d or
pe riphe ra l va scula r re sista nce ca n be pe rforme d. It should be
re ca lle d tha t ce ntra lly a dministe re d loca l a ne sthe tics re duce
pre loa d a nd a fte rloa d. Low-dose e pine phrine , which ca n be use d
to de cre a se the a bsorption of loca l a ne sthe tics, should be use d
ca utiously, if a t a ll, be ca use a furthe r de cre a se in syste mic va scula r
re sista nce ma y re sult from the β e ffe ct of a bsorbe d e pine phrine ,
a nd intra va scula r inje ction ma y e le va te pulmona ry pre ssure s more ,
e xa ce rba ting the right-to-le ft shunt (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, p 975; Fleish er: Anesth esia and Uncom m on Diseases, ed
5, pp 118–119; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 59–60; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5,
pp 491–492).
672. (C) The ne e d for a hyste re ctomy for a pla nne d re pe a t ce sa re a n
de live ry is 0.3%, for a succe ssful va gina l birth a fte r ce sa re a n is
0.1%, a nd for a n unsucce ssful TOLAC is 0.5%. W ith multiple
ge sta tions, ute rine a tony is common, a nd the ne e d for a
hyste re ctomy is sixfold a norma l de live ry. Howe ve r, the pa tie nt with
pla ce nta pre via a nd a pre vious sca r in the ute rus ha s the highe st
cha nce of ne e ding a n e me rge ncy hyste re ctomy for uncontrolle d
ble e ding a t the time of de live ry be ca use of the a ssocia te d pla ce nta
a ccre ta (a bnorma lly a dhe re nt pla ce nta ). The incide nce of pla ce nta
a ccre ta in a pa tie nt with pla ce nta pre via a nd no pre vious ce sa re a n
se ction is 3% to 4%, with one pre vious ce sa re a n se ction is a bout
10% to 25%, a nd with two or more pre vious ce sa re a n se ctions is
40% to a lmost 70%. About two thirds of pa tie nts with pla ce nta
a ccre ta will re quire a ce sa re a n hyste re ctomy. The a ve ra ge blood
loss during a n e me rge ncy obste tric hyste re ctomy is 5 to 7 units of
blood (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 893–895;
Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, pp 147–
149, 274–275, 311–321).
673. (B) According to the ASA’s Close d Cla im Proje ct for Obste tric
Ane sthe sia Cla ims (640 cla ims a s of De ce mbe r 2010 re port),
ma te rna l ne rve da ma ge (19%), ne ona ta l bra in da ma ge (16%), a nd
ma te rna l de a th (15%) we re the thre e most fre que nt cla ims. Othe r
ca use s include he a da che (11%), ba ck pa in (10%), ne ona ta l de a th
(9%), e motiona l distre ss (8%), ma te rna l bra in da ma ge (7%), pa in
during a ne sthe sia (6%), a nd a spira tion pne umonitis (1%) (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 776–779).
674. (C) Chorioa mnionitis occurs in a bout 1% of a ll pre gna ncie s. It
include s the clinica l signs a nd symptoms of infe ction, te mpe ra ture
highe r tha n 38° C, ma te rna l a nd fe ta l ta chyca rdia , ute rine
te nde rne ss (a bout 10% of pa tie nts) a nd/or foul-sme lling a mniotic
fluid. Prompt de live ry is the corne rstone of the ra py. At one time it
wa s thought tha t a ntibiotics should be a dministe re d only a fte r
de live ry be ca use a nte pa rtum or intra pa rtum a ntibiotics ma y
“obscure the re sults of ne ona ta l blood culture s.” Howe ve r, e a rly
a nte pa rtum tre a tme nt with a ntibiotics le a ds to a de cre a se in
ma te rna l a nd ne ona ta l morbidity, compa re d to de la ying the
a ntibiotics until a fte r de live ry, a nd is curre ntly re comme nde d.
Epidura l a ne sthe sia ha s be e n shown to be commonly use d a nd
sa fe in the se pa tie nts, pre fe ra bly a fte r a ntibiotics ha ve be e n
sta rte d. It se e ms prude nt, howe ve r, to a lwa ys individua lize ca re
a nd to we igh the risks ve rsus the be ne fits of e pidura l a ne sthe sia in
a pa tie nt with suspe cte d ba cte re mia (Ch estnut: Ch estnut’s Obstetric
675. (A) Me conium-sta ine d a mniotic fluid occurs in a bout 5% to 15%
of a ll de live rie s. Although intra pa rtum oropha rynge a l a nd
na sopha rynge a l suction for a ll ne wborns born to mothe rs with
me conium sta ining ha s be e n routine ca re for ma ny ye a rs, curre nt
e vide nce shows no re a l be ne fit, a nd it is no longe r re comme nde d.
Intuba tion a nd tra che a l suction should be pe rforme d only in
ne wborns who a re not vigorous a nd doe s not de pe nd upon the
consiste ncy of the me conium-sta ine d fluid a s wa s once
re comme nde d. In ne wborns who a re vigorous (i.e ., strong
re spira tory e fforts, good muscle tone , a nd he a rt ra te
>100 be a ts/min), no furthe r tre a tme nt is ne e de d. Be ca use
me conium is ste rile , a ntibiotics a re not ne e de d. Ste roids ha ve not
be e n ne ce ssa ry in the tre a tme nt of me conium-sta ine d ne wborns.
RDS is a condition tha t occurs a s a re sult of low le ve ls of
pulmona ry surfa cta nt in the a lve oli. RDS occurs in pre ma ture
ne wborns, whe re a s me conium sta ining occurs typica lly in olde r,
ofte n post-te rm, ne wborns (Ch estnut: Ch estnut’s Obstetric Anesth esia,
ed 5, pp 156–157, 179–180; Suresh : Sh nid er and Levinson’s Anesth esia for
Obstetrics, ed 5, pp 251–252).
676. (C)
Pla ce nta pre via occurs whe n the pla ce nta impla nts on the lowe r
ute rine se gme nt so tha t a ll (tota l) or pa rt of the pla ce nta (pa rtia l)
cove rs the inte rna l ce rvica l os. A ma rgina l pla ce nta pre via occurs
whe n the pla ce nta lie s close to but doe s not cove r the inte rna l
ce rvica l os. Pla ce nta pre via occurs in a bout 0.5% of a ll
pre gna ncie s a nd ha s a ma te rna l morta lity of le ss tha n 1% but a
fe ta l morta lity a pproa ching 20% (prima rily be ca use of pre ma turity
a nd intra ute rine a sphyxia ). Pa tie nts typica lly pre se nt with
pa inle ss va gina l ble e ding tha t stops sponta ne ously (first ble e d).
De live ry is ce sa re a n a nd is ofte n ma de a fe w we e ks a fte r the
“first” ble e d, whe n the ba by’s lungs a re more ma ture (e .g., a fte r
37 we e ks EGA). A la te r ble e d ca n be uncontrolle d a nd ma y be
a ccompa nie d by significa nt hypovole mia a nd hypote nsion.
Re giona l a ne sthe sia is contra indica te d in se ve re ly hypovole mic
pa tie nts. Re pla cing blood loss ma y not be pra ctica l be ca use
ble e ding ma y be quicke r tha n re pla ce me nt is possible (i.e ., ma y
be >1 unit/min). A ra pid-se que nce ge ne ra l a ne sthe tic (a ssuming
a cce pta ble a irwa y) is pre fe rre d. Ke ta mine (0.75-1 mg/kg) a s we ll
a s e tomida te (0.3 mg/kg) supports the ca rdiova scula r syste m
be tte r tha n propofol. In ra re but se ve re ca se s of hypovole mic
shock, a ll IV a ne sthe tics ma y ca use the blood pre ssure to fa ll
furthe r, a nd succinylcholine a lone ma y be a ll tha t is re quire d. In
the se se ve re ca se s, ma te rna l re ca ll should be conside re d
se conda ry to ma te rna l sa fe ty. In ca se s in which a difficult
intuba tion is like ly a nd the pa tie nt is hypovole mic, a n infiltra tion
loca l a ne sthe tic ma y be be st (Ch estnut: Ch estnut’s Obstetric
677. (D) At te rm pre gna ncy, VT incre a se s a bout 40% to 45%, a nd the
inspira tory re se rve volume (IRV) incre a se s a bout 5%. A de cre a se
occurs in both the e xpira tory re se rve volume (ERV; 20%-25%) a nd
the re sidua l volume (RV; 15%-20%). A ca pa city is de fine d a s two or
more lung volume s. Functiona l re sidua l ca pa city
(FRC = ERV + RV) is de cre a se d a bout 15% to 20% a nd is pa rtly

re sponsible for the ra pid fa ll in ma te rna l oxyge na tion tha t occurs
with a pne a during the induction of ge ne ra l a ne sthe sia . Tota l lung
ca pa city (TLC = VT + IRV + ERV + RV) de cre a se s a bout 5%,
whe re a s vita l ca pa city (VC = VT + IRV + ERV) re ma ins

uncha nge d (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 19–21;
678. (A) Eva lua tion of the a irwa y should be pe rforme d be fore the
induction of a ny ge ne ra l a ne sthe tic. In ca se s in which a n
unre cognize d difficult a irwa y e xists (una ble to pe rform
e ndotra che a l intuba tion in a re a sona ble pe riod of time ), the pa tie nt
should be a wa ke ne d if the proce dure is pure ly e le ctive a nd if the
fe tus ha s minima l or no fe ta l distre ss (a s in this e le ctive ca se ). A
re giona l a ne sthe tic or a wa ke intuba tion the n ca n be sa fe ly
pe rforme d. In ca se s of fe ta l or ma te rna l distre ss, othe r options for
se curing the a irwa y ma y be ne ce ssa ry (Ch estnut: Ch estnut’s Obstetric
679. (B) La bor pa in is some of the most inte nse pa in tha t pe ople ca n
e xpe rie nce . In ge ne ra l, primpa rous pa tie nts ha ve more pa in tha n
multipa rous pa tie nts. Primpa rous wome n who ha ve a tte nde d
pre pa re d childbirth cla sse s ha ve some wha t le ss pa in tha n wome n
who ha ve not a tte nde d pre pa re d childbirth cla sse s. For wome n
who ha ve e xpe rie nce d la bor a nd de live ry, a tte nding pre pa re d
childbirth cla sse s doe s not se e m to a ffe ct the a mount of pa in tha t
the y e xpe rie nce . La bor pa in a ppe a rs to e xce e d chronic low ba ck
pa in, nonte rmina l ca nce r pa in, posthe rpe tic ne ura lgia , or the pa in
from a fra cture . Pa tie nts with ca usa lgia or pa tie nts e xpe rie ncing a n
a mputa tion of a digit ha ve more pa in tha n the pa rturie nt (Miller:
680. (B) Epine phrine is prima rily a dde d to loca l a ne sthe tics to che ck
for the IV pla ce me nt of a n e pidura l ca the te r, to de cre a se the
va scula r upta ke of loca l a ne sthe tics, or to incre a se the inte nsity
a nd dura tion of the block. By producing va soconstriction of the
e pidura l blood ve sse ls, va scula r upta ke of the loca l a ne sthe tic is
re duce d, a llowing more of the drug to e nte r the ne rvous tissue . The
more lipid soluble the loca l a ne sthe tic, the le ss e ffe ct e pine phrine
ha s (e .g., lidoca ine is prolonge d much more tha n bupiva ca ine
whe n e pine phrine is a dde d to the loca l a ne sthe tic) (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 288–289).
681. (C) Me pe ridine is unique a mong na rcotics in tha t it
de monstra te s loca l a ne sthe tic a ctions in a ddition to its na rcotic
e ffe cts a nd ca n be use d a lone for a ne sthe sia for ce sa re a n se ction.
The dose is a bout 1 mg/kg. W he n a dde d to a loca l a ne sthe tic for
postope ra tive a na lge sia , a 10-mg dose of me pe ridine ca n produce 4
to 6 hours of a na lge sia (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 472, 562).
682. (C) An incre a se d risk of conge nita l ma lforma tions ha s be e n
sugge ste d by se ve ra l olde r studie s with the use of minor
tra nquilize rs such a s dia ze pa m, me proba ma te , a nd
chlordia ze poxide during the first trime ste r of pre gna ncy. The ca use -
a nd-e ffe ct re la tionship ha s not be e n prove d; in fa ct, se ve ra l ne we r
studie s fa ile d to show a n a ssocia tion be twe e n minor tra nquilize rs
a nd conge nita l ma lforma tions. The FDA de ve lope d a ra ting
sche dule for me dica tion use in pre gna ncy (se e ta ble be low).
FDA USE-IN-PREGNANCY RATINGS
Schedule Interpretation
A Controlled studies show no risk
B No evidence of risk in humans
C Risk cannot be ruled out
D Positive evidence of risk
X Contraindicated in pregnancy
The FDA cla ssifica tion for dia ze pa m a nd mida zola m is D (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, p 364; Suresh : Sh nid er and
Levinson’s Anesth esia for Obstetrics, ed 5, pp 806–809; Ph y sicians’ Desk
Reference 2014, ed 68, p 211).
683. (C) Intra the ca l opia te s (e .g., morphine , fe nta nyl, sufe nta nil) a re
ve ry e ffe ctive in re lie ving the visce ra l pa in during the first sta ge of
la bor. Intra the ca l opia te s a dministe re d a lone (e xce pt for
me pe ridine , which ha s loca l a ne sthe tic prope rtie s) do not provide
a de qua te pa in re lie f for se cond-sta ge soma tic pa in (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 277–282, 465–468; Suresh :
684. (A) The most common side e ffe ct of intra spina l na rcotics is
pruritus. The ne xt most common side e ffe cts a re na use a a nd
vomiting, followe d by urina ry re te ntion a nd drowsine ss.
Re spira tory de pre ssion a nd he a da che ma y occur but a re re la tive ly
infre que nt (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 283–287;
186).
685. (C) Hype rte nsion (systolic blood pre ssure [SBP] >140 or a n
incre a se >30 mm Hg ove r ba se line ; dia stolic blood pre ssure [DBP]
>90 or a n incre a se of 15 mm Hg ove r ba se line ) occurs in a bout 7%
of a ll pre gna ncie s. It is cla ssifie d into four type s (pre e cla mpsia -
e cla mpsia , chronic hype rte nsion [of a ny ca use ], chronic
hype rte nsion with supe rimpose d pre e cla mpsia , a nd ge sta tiona l
hype rte nsion). Pre e cla mpsia -e cla mpsia is the ne w onse t of
hype rte nsion a ssocia te d with thrombocytope nia (pla te le t count
<100,000/mm3), impa ire d live r function, re na l insufficie ncy (se rum
cre a tinine >1.1 mg/dL, or doubling of se rum cre a tinine in the
a bse nce of a ny othe r re na l dise a se ), pulmona ry e de ma , or ne w-
onse t ce re bra l or visua l disturba nce s. Ge sta tiona l hype rte nsion,
which is isola te d ne w-onse t hype rte nsion (usua lly a fte r 37 we e ks)
tha t re solve s by 12 we e ks’ postpa rtum, is a re trospe ctive dia gnosis.
Pre e cla mpsia ra re ly occurs be fore 20 we e ks’ EGA e xce pt in
pa tie nts with ge sta tiona l trophobla stic ne opla sms (e .g., mola r
pre gna ncy); if se izure s occur in a pa tie nt with pre e cla mpsia , the
condition is ca lle d e cla mpsia . HELLP syndrome (He molysis,
Ele va te d Live r e nzyme s, a nd Low Pla te le t count) is a va ria nt of
pre e cla mpsia . Chronic hype rte nsion is pe rsiste nt hype rte nsion
be fore , during, a nd a fte r pre gna ncy (e .g., >6 we e ks’ postpa rtum).
Chronic hype rte nsion with supe rimpose d pre e cla mpsia occurs
whe n a pa tie nt with chronic hype rte nsion de ve lops pre e cla mpsia .
Se e a lso Que stion 645 (Am erican College of Obstetricians and
Gy necologists Task Force on Hy pertension in Pregnancy, Novem ber 2013
Website; Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 825–826;
438).
686. (A) Amniotic fluid e mbolism is a ra re condition (5 pe r 100,000
live births). It pre se nts in a va rie ty of wa ys but ofte n in a dra ma tic
wa y, with a cute hypoxe mia , ca rdiova scula r colla pse , DIC, a nd, in
a bout 50% of ca se s, a se izure . Pa tie nts with a high spina l or
e pidura l ma y compla in of dyspne a , but the y a lso ha ve ma rke d
we a kne ss a nd would ce rta inly not be a ble to wre stle or struggle
with the ir he a lth ca re provide rs. Pa tie nts e xpe rie ncing a n
intra va scula r inje ction of loca l a ne sthe tic pre se nt with ce ntra l
ne rvous syste m (CNS) signs of toxicity (light-he a de dne ss, visua l or
a uditory disturba nce s, muscula r twitching, convulsion, coma ) or, a t
highe r le ve ls, ca rdiova scula r colla pse . Ma gne sium ove rdosa ge is
a lso a ssocia te d with muscle we a kne ss. The typica l e cla mptic
se izure is tonic–clonic. Pa tie nts with e cla mpsia do not compla in of
dyspne a , a lthough a n a ssocia te d a spira tion ma y produce simila r
symptoms. Se e Que stion 658 (Ch estnut: Ch estnut’s Obstetric
687. (C) Epidura l fe nta nyl (50-100 µg) a nd e pidura l sufe nta nil (10-
20 µg) e a ch ha s a dura tion of a ction for a bout 2 to 4 hours. Epidura l
me pe ridine (50-75 mg) ha s a n inte rme dia te dura tion of a ction of 4 to
12 hours, whe re a s e pidura l morphine (3-4 mg) ha s the longe st
dura tion of a ction, of 12 to 24 hours (Ch estnut: Ch estnut’s Obstetric
688. (C) The re na l syste m unde rgoe s dra ma tic a na tomic (incre a se
in kidne y size a s we ll a s dila tion of the ure te rs) a nd functiona l
cha nge s in pre gna ncy. Re na l pla sma flow incre a se s a bout 75% to
85%, a nd glome rula r filtra tion ra te (GFR) incre a se s a bout 50% a nd
is re fle cte d by a n incre a se in cle a ra nce of ure a , cre a tinine , a nd
uric a cid. Be ca use of the incre a se d cle a ra nce , we se e a de cre a se
in BUN to 8 to 9 mg/dL, se rum cre a tinine to 0.5 to 0.6 mg/dL, a nd
se rum ura te to 2.0 to 3.0 mg/dL. Glucosuria is common a nd is
a ttribute d to both the incre a se in GFR a nd a re duce d re na l tubula r
re sorption of glucose (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, p
689. (C) All vola tile ha loge na te d a ne sthe tic a ge nts (e .g., ha lotha ne ,
e nflura ne , isoflura ne , de sflura ne , se voflura ne ) ca use a dose -
re la te d re la xa tion of ute rine smooth muscle . W ith a ne sthe tic
conce ntra tions of 0.2 MAC, the de cre a se in ute rine a ctivity is slight,
a nd the se a ge nts ha ve be e n use d for inha la tion a na lge sia during
la bor. At 0.5 MAC, ute rine re la xa tion is more significa nt, but the
ute rine re sponse to oxytocin re ma ins inta ct. Nitrous oxide doe s not
a ffe ct ute rine a ctivity (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 452–454; 575–576; Suresh : Sh nid er and Levinson’s Anesth esia for
Obstetrics, ed 5, pp 156–157, 176–177).
690. (B) Pa ssive diffusion is the prima ry me a ns for the pla ce nta l
tra nsfe r of drugs. Fa ctors tha t promote diffusion of drugs a cross
pla ce nta l me mbra ne s include de cre a se d ma te rna l prote in binding
(a lthough some be lie ve tha t this is not ve ry importa nt be ca use of
ra pid diffusion of drugs from prote in), low mole cula r we ight
(<500 Da ), high lipid solubility (low wa te r solubility), a low de gre e
of ioniza tion, a nd a la rge conce ntra tion gra die nt a cross the
me mbra ne s. Highly ionize d drugs, such a s ne uromuscula r drugs, do
not pa ss the pla ce nta in significa nt a mounts (Ch estnut: Ch estnut’s
691. (D) The a ve ra ge blood loss a ssocia te d with a va gina l de live ry
is a bout 600 mL a nd a fte r a ce sa re a n de live ry is a bout 1000 mL
(Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 24–25).
692. (C) The fe tus ha s se ve ra l compe nsa tory me cha nisms for
de a ling with low O2 pre ssure s (umbilica l ve in P O2 a pproxima te ly
e qua l to 30 mm Hg whe n the mothe r is bre a thing room a ir) to
which it is e xpose d. The se include a highe r he moglobin
conce ntra tion (15-20 g/dL) a nd the pre se nce of fe ta l he moglobin,
which ha s a gre a te r a ffinity for oxyge n (the fe ta l oxyhe moglobin
dissocia tion curve is shifte d to the le ft of the ma te rna l
oxyhe moglobin dissocia tion curve ). At te rm, ma te rna l blood flow
through the pla ce nta (700 mL/min) is a bout double the fe ta l blood
flow through the pla ce nta (300-360 mL/min). Fe ta l blood ha s a lowe r
pH tha n ma te rna l blood, which ma y be re la te d to the highe r Pa CO2
le ve ls se e n in fe ta l blood (Suresh : Sh nid er and Levinson’s Anesth esia
693. (B) An obe se pa tie nt ha s a body ma ss inde x (BMI) gre a te r tha n
or e qua l to 30 kg/m2, a nd a morbidly obe se pa tie nt ha s a BMI
gre a te r tha n or e qua l to 40 kg/m2. The obe se a nd morbidly obe se
pa tie nt (28.9% a nd 8%, re spe ctive ly, of nonpre gna nt wome n of
childbirth a ge in the Unite d Sta te s) is a t incre a se d risk for se ve ra l
comorbid dise a se s, including obstructive sle e p a pne a , dia be te s,
hype rte nsion, a nd ca rdiova scula r dise a se . Obste tric-re la te d
incre a se d incide nce s include ge sta tiona l dia be te s, pre e cla mpsia ,
thromboe mbolic dise a se s, wound infe ctions, postpa rtum
he morrha ge , a nd ce sa re a n de live rie s. The incre a se d incide nce of
ce sa re a n de live rie s ma y re la te to a n incre a se in a bnorma l
pre se nta tions, fe ta l ma crosomia , me conium sta ining, la te
de ce le ra tions in the FHR, a nd prolonge d la bor. Ane sthe tic
cha lle nge s include incre a se d risk of a spira tion, difficulty finding
a de qua te ve nous a cce ss, difficulty with ma sk ve ntila tion, difficulty
with e ndotra che a l intuba tion, difficulty in pe rforming re giona l
a ne sthe sia , ope ra tive positioning, a nd prolonge d surge ry.
Inte re stingly, obe se a nd morbidly obe se pa tie nts a ppe a r to ha ve a
lowe r incide nce of PDPHs. Etiology for the lowe r incide nce is
uncle a r (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 1141–1153;
Miller: Miller’s Anesth esia, ed 8, p 2349; Suresh : Sh nid er and Levinson’s
Anesth esia for Obstetrics, ed 5, pp 428, 580–592).
694. (D) Norma l he a lthy te rm ne wborns bre a thing room a ir ta ke a
while for the oxyge n sa tura tions to rise to norma l 90% to 95% le ve ls.
In ca ring for the ne wborn who is not bre a thing, ba g a nd ma sk
ve ntila tion with room a ir is now re comme nde d, with ta rge te d
pre ducta l oxyge n sa tura tions (right ha nd or wrist) incre a se s of
a bout 5% for e a ch minute of the first 5 minute s of life sta rting a t
1 minute oxyge n sa tura tion of 60% to 65% (a t 2 minute s 65%-70%, a t
3 minute s 70%-75%, a t 4 minute s 75%-80% a nd a t 5 minute s
80%-85%). Afte r 5 minute s, oxyge n sa tura tion more slowly incre a se s
to 85% to 95% by 10 minute s of life . If highe r conce ntra tions of
oxyge n a re ne e de d to re a ch the ta rge te d oxyge n sa tura tions
(e spe cia lly in pre te rm ne wborns <32 we e ks), a ble nde r for oxyge n
a nd a ir ca n be use d. For this ne wborn, a n oxyge n sa tura tion of 83%
a t 5 minute s is a ppropria te , a nd obse rva tion only is ne e de d
(Am erican Heart Association: Part 11 – Neonatal Resuscitation,
Circulation 122:S516–S521, 2010; Neonatal Resuscitation Tex tbook, ed 6,
Am erica Heart Association and th e Am erican Acad em y of Ped iatrics, pp
37–58).
695. (B) Se cond- a nd third-trime ste r obste tric he morrha ge is not
uncommon in obste trics. Pla ce nta pre via (whe re the pla ce nta is
ne a r the ma rgin or cove ring the ce rvica l os) is cla ssica lly de scribe d
a s pa inle ss va gina l ble e ding during the se cond or third trime ste r
tha t is not a ssocia te d with ma te rna l shock or fe ta l distre ss with the
first e pisode of ble e ding. Howe ve r, with a se cond or third e pisode ,
ble e ding ma y continue . Pla ce nta l a bruption (se pa ra tion of the
pla ce nta from the ute rine wa ll a fte r 20 we e ks’ EGA a nd prior to
de live ry) more typica lly is a ssocia te d with a bdomina l pa in a nd ca n
be a ssocia te d with fe ta l distre ss. Ble e ding for pla ce nta a bruption
ma y be re ve a le d or conce a le d be hind the pla ce nta . Ute rine rupture
usua lly pre se nts with se ve re a bdomina l pa in a nd fe ta l distre ss.
Va sa pre via re fe rs to the ve la me ntous inse rtion of the fe ta l ve sse ls
ove r the ce rvica l os, which me a ns tha t the fe ta l blood ve sse ls a re
not prote cte d by the pla ce nta or the umbilica l cord a nd a re a he a d
of the pre se nting pa rt of the fe tus. W he n the fe ta l me mbra ne s
rupture , a te a r in a fe ta l blood ve sse l ma y de ve lop, le a ding to fe ta l
e xsa nguina tion (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 882–
312–317).
696. (D) The first sta ge of la bor sta rts with the onse t of la bor a nd
e nds with comple te ce rvica l dila tion (10 cm). It is visce ra l pa in,
a ssocia te d with ute rine contra ctions a nd dila tion of the ce rvix, a nd
is tra nsmitte d via the a utonomic ne rvous syste m through the
sympa the tic fibe rs tha t pa ss through the pa ra ce rvica l re gion a nd
e nte r the CNS a t T10-L1 se gme nts. The se cond sta ge of la bor
include s the se pa thwa ys a nd a dds the soma tic fibe rs of the birth
ca na l tha t a re tra nsmitte d via the pude nda l ne rve e nte ring the CNS
a t S2-S4. Ne ura xia l block (spina l a nd/or e pidura l) with only
na rcotics ca n be use ful for first-sta ge pa in; howe ve r, the soma tic
pa in is not we ll tre a te d with na rcotics a lone . A loca l a ne sthe tic–
induce d lumba r e pidura l block with or without na rcotics ca n
produce comple te a ne sthe sia during both first a nd se cond sta ge of
la bor pa in. If a low spina l or sa ddle block is pe rforme d with loca l
a ne sthe tics (cove ring only sa cra l a re a s), the ute rine contra ction
pa in still will be fe lt. Pa ra ce rvica l blocks block only the first-sta ge
pa in. Pude nda l blocks block the soma tic compone nt during the
se cond sta ge but not the visce ra l pa in of ute rine contra ctions
(Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 412–415, 459–480,
pp 119–133).
697. (C) Ane sthe tic conside ra tions for ope n fe ta l surge ry include
a dministe ring a ne sthe sia for the mothe r a nd the child, giving
e xce lle nt ute rine re la xa tion, ma inta ining a n a de qua te ma te rna l
blood pre ssure , providing muscle re la xa tion to the fe tus if ne e de d,
a nd pre ve nting postope ra tive pre ma ture la bor. Ute rine re la xa tion is
ne e de d to pre ve nt ute rine contra ctions with possible se pa ra tion of
the pla ce nta from the ute rine wa ll. High-dose vola tile a ne sthe tics
(e .g., 2 or 3 MAC) ca n provide e xce lle nt ma te rna l a ne sthe sia a s
we ll a s ute rine re la xa tion a nd a ne sthe sia for the fe tus. If a dditiona l
a ne sthe sia is ne e de d, IV na rcotics ca n be use d (e .g., re mife nta nil
infusions a re ofte n use d). If one choose s to use a lowe r dose of
vola tile a ne sthe tics, nitroglyce rin infusion ca n be use d to ke e p the
ute rus from contra cting. Ma te rna l hypote nsion (me a n blood
pre ssure <65) is not uncommon a nd is tre a te d with more le ft
ute rine tilt, fluids, a nd, if ne e de d, phe nyle phrine or e phe drine .
Monitoring the fe ta l oxyge n sa tura tion re ve a ls norma l va lue s of 50%
to 70%; va lue s le ss tha n 50% signa l impa ire d pla ce nta l pe rfusion
(e .g., ma te rna l hypote nsion, cord compre ssion). If the obste tricia n
ne e ds the fe tus to be pa ra lyze d, the n a ne uromuscula r blocking
drug must be give n dire ctly into the fe tus be ca use pla ce nta l tra nsfe r
is poor. The dose , howe ve r, must be la rge r tha n if the fe tus we re
de live re d be ca use the blood volume of the fe tus include s the
pla ce nta l blood a s we ll a s the blood in the fe tus. Typica lly the dose
is a bout four time s the e ffe ctive dose in 95% of subje cts (ED95) or for
ve curonium is 0.2 mg/kg. Ma gne sium sulfa te should be sta rte d to
de cre a se the cha nce of pre ma ture la bor a t the e nd of the surge ry
a s the vola tile a ne sthe tic conce ntra tion is de cre a se d or the
nitroglyce rin infusion is discontinue d. One should re ca ll tha t the
ma gne sium sulfa te pote ntia te s ne uromuscula r blocking drugs
significa ntly (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 135–
792–799).
698. (D) 15-Me thyl PGF 2α (ca rboprost, He ma ba te ) is the pre fe rre d
prosta gla ndin for use in the tre a tme nt of re fra ctory ute rine a tony
(a fte r oxytocin). The dose is 0.25 mg inje cte d intra muscula rly or
dire ctly into the ute rine wa ll, re pe a te d a s ne e de d e ve ry 15 to
30 minute s with a ma ximum tota l dose of 2 mg. It ha s se ve ra l
importa nt side e ffe cts, such a s bronchospa sm, ve ntila tion-to-
pe rfusion misma tch with a n incre a se in intra pulmona ry shunting,
a nd hypoxe mia . Othe r side e ffe cts include ga strointe stina l spa sms
(e .g., na use a , vomiting, a nd dia rrhe a ) (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, p 891; Suresh : Sh nid er and Levinson’s Anesth esia for
Obstetrics, ed 5, p 321).
699. (C) Inte rna tiona l conse nsus sta te s tha t ma gne sium sulfa te
(MgSO4) is the a nticonvulsa nt of choice in the pre e cla mptic pa tie nt.
In a ddition to its a nticonvulsa nt e ffe ct, MgSO4 ha s ma ny othe r
a ctions on ske le ta l a nd ca rdia c muscle s. MgSO4 is usua lly sta rte d
a s a n intra ve nous bolus of 6 g ove r 20 minute s followe d by a n
infusion of 2 g/hr (provide d tha t kidne y function is norma l). Clinica l
monitoring for toxicity is pe rforme d looking a t de e p te ndon
re fle xe s, a nd blood le ve ls a re ofte n pe rforme d a nd re porte d in
e ithe r mEq/L or mg/dL (1 mEq/L = 1.22 mg/dL). The the ra pe utic

ra nge for se rum MgSO4 is 4 to 8 mEq/L (4.8-9.6 mg/dL). In a n
una ne sthe tize d pa tie nt, a loss of de e p te ndon re fle xe s occurs a t
10 mEq/L (12 mg/dL), re spira tory a rre st occurs a t 15 mEq/L
(18 mg/dL), a nd ca rdia c a rre st occurs a t 25 mEq/L (30 mg/dL). As
long a s de e p te ndon re fle xe s a re pre se nt, significa nt toxicity is
unlike ly. In a pa tie nt with a n e pidura l or spina l a ne sthe tic loa de d
for a ce sa re a n se ction, the pa te lla r re fle x is ofte n de pre sse d by the
loca l a ne sthe tic; e stima tion of de e p te ndon re fle xe s should be
done with the bice ps te ndon (unle ss a tota l spina l de ve lops).
Ele ctroca rdiogra phic (ECG) cha nge s, including PR inte rva l
prolonga tion a nd QRS comple x wide ning, occur a t se rum le ve ls of 5
to 10 mEq/L (6-12 mg/dL), sinoa tria l a nd a triove ntricula r block a t
15 mEq/L (18 mg/dL), a nd ca rdia c a rre st a t le ve ls gre a te r tha n
25 mEq/L (30 mg/dL). The tre a tme nt for ma gne sium toxicity is
ca lcium. The dose of 1 g of ca lcium glucona te (10 mL of a 10%
solution) ca n be a dministe re d slowly ove r a t le a st 2 minute s to
tre a t high ma gne sium le ve ls. Ra pid a dministra tion ma y ta ke a wa y
the a nticonvulsa nt e ffe cts, so ca re ful slow titra tion is
re comme nde d. About 60% of e cla mptic se izure s occur be fore
de live ry. Most postpa rtum se izure s de ve lop in the first 24 hours
a fte r de live ry, but e cla mptic se izure s ma y occur a s la te a s 22 da ys
a fte r de live ry (Miller: Miller’s Anesth esia, ed 8, p 2348; Suresh : Sh nid er
and Levinson’s Anesth esia for Obstetrics, ed 5, 448–449).
700. (C) Thre e diffe re nt a spira tion syndrome s ha ve be e n de scribe d
in the ge ne ra l popula tion: a spira tion of pa rticula te ma tte r ca using
a irwa y obstruction, a spira tion of a cid fluid ca using a spira tion
pne umonitis (Me nde lson syndrome ), a nd a spira tion of gra m-
positive , gra m-ne ga tive , a nd a na e robic ba cte ria ca using a spira tion
pne umonia . Aspira tion pne umonia ha s the highe st morta lity ra te
but fortuna te ly occurs only with a n a ssocia te d bowe l obstruction,
which is ra re ly a proble m in obste trics. Symptoms of a spira tion
pne umonitis include coughing, ta chypne a , ta chyca rdia ,
bronchospa sm, a nd hypoxe mia . Tre a tme nt is supportive a nd
include s the He imlich ma ne uve r if a la rge fore ign body is lodge d in
the tra che a (which is unlike ly in the fa sting la boring pa tie nt),
e ndotra che a l intuba tion, suctioning the a irwa y to re move
pa rticula te ma te ria l, a dministra tion of incre a se d conce ntra tions of
oxyge n, a nd a pplica tion of PEEP to a chie ve oxyge na tion goa ls a s
ne e de d (prophyla ctic PEEP doe s not provide a ny be ne fit). Coughing
is due to the a irwa y irrita tion a nd is most e ffe ctive ly de cre a se d
with muscle pa ra lysis. Intra ve nous lidoca ine would not be
e ffe ctive . Use of sa line or bica rbona te la va ge doe s not de cre a se
lung da ma ge a nd ca n worse n hypoxe mia . Glucocorticoids or othe r
a nti-infla mma tory drugs ha ve not be e n e ffe ctive in limiting the
infla mma tion a nd ma y incre a se the risk of se conda ry ba cte ria l
infe ction (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 671–675;
405).
701. (C) Aortoca va l compre ssion typica lly is not a proble m until
a bout 18 to 20 we e ks’ ge sta tion, whe n the ute rus is la rge e nough to
compre ss the a orta a nd ve na ca va whe n the pa tie nt a ssume s the
supine position. If the ute rus is la rge r tha n norma l (e .g., multiple
ge sta tions or polyhydra mnios), the n a ortoca va l compre ssion ma y
a ppe a r e a rlie r (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, p 340;
Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed 5, p 5).
702. (B) Cime tidine a nd ra nitidine a re H2-re ce ptor a nta gonists tha t
will incre a se ga stric pH but ta ke a t le a st 30 minute s to work.
Me toclopra mide is not a n a nta cid but ma y be use ful by incre a sing
the lowe r e sopha ge a l sphincte r tone . Only liquid a nta cids ra ise
ga stric pH quickly. Sodium citra te , a cle a r nonpa rticula te a nta cid
(0.3 M sodium citra te ) is pre fe rre d ove r pa rticula te a nta cids
(a luminum hydroxide , ma gne sium trisilica te , ma gne sium hydroxide )
be ca use cle a r nonpa rticula te a nta cids ca use le ss pulmona ry
da ma ge if a spira te d. Sodium citra te 30 mL ne utra lize s 255 mL of HCl
with a pH of 1.0. Ne utra liza tion of ga stric a cid occurs ra pidly (i.e .,
<5 minute s) a nd will la st up to a n hour (Ch estnut: Ch estnut’s Obstetric
703. (A) Ca use s of fe ta l bra dyca rdia (FHR <110 be a ts/min) include
hypote nsion, e xce ssive ute rine a ctivity, hypoxe mia , a cidosis,
comple te he a rt block, a nd some drugs. Atropine re a dily crosse s the
pla ce nta but a t low dose s doe s not se e m to ca use fe ta l
ta chyca rdia ; a t high dose s, it ma y produce ta chyca rdia . The
combina tion of ne ostigmine , which crosse s the pla ce nta slightly,
a nd glycopyrrola te , which doe s not cross the pla ce nta we ll, ha s
be e n a ssocia te d with fe ta l bra dyca rdia , which is why ne ostigmine
with a tropine is pre fe rre d whe n re ve rsing ne uromuscula r blocke rs
if a fe tus is pre se nt. Bra dyca rdia s a re a ssocia te d with e a rly
de ce le ra tions (he a d compre ssion with va ga l stimula tion), la te
de ce le ra tions (fe ta l hypoxe mia with va ga l stimula tion or
myoca rdia l fa ilure ), a nd va ria ble de ce le ra tions (umbilica l cord
compre ssions with va ga l stimula tion). Ca use s of fe ta l ta chyca rdia
(FHR >160 be a ts/min) include infe ction, fe ve r, ma te rna l ciga re tte
smoking, fe ta l pa roxysma l supra ve ntricula r ta chyca rdia , a nd some
drugs (ritodrine , te rbuta line , a tropine ) (Ch estnut: Ch estnut’s Obstetric
Anesth esia for Obstetrics, ed 5, pp 69–73, 843).
704. (A) CP is a nonprogre ssive disorde r of the CNS a rising from
le sions in the bra in tha t occurre d during de ve lopme nt (in ute ro 75%,
a t birth 10%, soon a fte r birth 15%). CP is a ssocia te d with
impa irme nt of motor function. Me nta l re ta rda tion ma y or ma y not
be pre se nt a nd is not a n e sse ntia l dia gnostic crite rion. The ca use is
unknown a nd most like ly multifa ctoria l. Associa te d conditions
include ma te rna l me nta l re ta rda tion (now ca lle d inte lle ctua l
disa bility), birth we ight of le ss tha n 2000 g a nd fe ta l ma lforma tions,
bre e ch pre se nta tion (but not bre e ch va gina l de live ry), se ve re
prote inuria during the se cond ha lf of pre gna ncy, third-trime ste r
ble e ding, a nd ge sta tiona l a ge le ss tha n 32 we e ks, but ma ny othe r
fa ctors ma y pla y a role . It occurs in a bout 2 pe r 1000 live births. At
one time , FHR monitoring wa s thought to be a ble to pre ve nt CP, but
this ha s not ha ppe ne d. In fa ct, a mong pa tie nts with ne w-onse t la te
de ce le ra tion pa tte rns, the fa lse -positive ra te is 99% if use d to
pre dict the de ve lopme nt of CP. This is not to sa y tha t intra pa rtum
a sphyxia l insults do not ca use da ma ge ; the y might, a nd the y
proba bly a ccount for some ca se s of CP. The re is a lso a ve ry we a k
a ssocia tion of low Apga r score s a nd CP; in fa ct, most childre n who
de ve lop CP ha d a 5-minute Apga r score tha t wa s norma l (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 193–197; Miller: Miller’s
705. (B) DM is the most common e ndocrine proble m a ssocia te d
with pre gna ncy. Type 1 DM (due to a de cre a se in insulin se cre tion)
occurs in 1 of e ve ry 700 to 1000 ge sta tions. Ge sta tiona l dia be te s,
which occurs only during pre gna ncy, is curre ntly se e n in a bout 7%
of a ll pre gna ncie s in the Unite d Sta te s. Although substa ntia l
a dva nce s in the obste tric a nd a ne sthe tic ma na ge me nt of dia be tic
pa rturie nts ha ve be e n ma de , ma te rna l a nd fe ta l morta lity a re still
highe r in the se pa tie nts tha n in pa rturie nts without dia be te s. DKA
ha s de cre a se d from 9% to curre ntly a round 1% to 2% of type 1 DM
pre gna ncie s. One importa nt goa l of insulin the ra py in the se
pa tie nts is to a void both hype rglyce mia a nd hypoglyce mia . In
ge ne ra l, insulin re quire me nts in type 1 dia be tic pa tie nts initia lly
de cre a se during e a rly pre gna ncy to the ir lowe st re quire me nt by
a round 16 to 18 we e ks (10%-20% re duction in dose ), the n incre a se
a bove pre pre gna nt va lue s a round 26 we e ks to re a ch va lue s tha t
a re highe st a t te rm (50% a bove pre pre gna nt dose ). The dose
re quire me nts the n ra pidly de cre a se a t the time of de live ry. Insulin
doe s not re a dily cross the pla ce nta a nd the re fore doe s not ha ve
a ny dire ct e ffe cts on glucose me ta bolism in the fe tus. Glucose ,
howe ve r, re a dily crosse s the pla ce nta . Pre e cla mpsia a nd la rge -for-
ge sta tiona l-a ge fe tuse s occur more fre que ntly in pa rturie nt wome n
with dia be te s. Be ca use of fe ta l ma crosomia , ce sa re a n se ction is
more common in dia be tic tha n nondia be tic pa tie nts (Ch estnut:
706. (D) PDPHs a re positiona l he a da che s (e xa ce rba te d by sitting or
sta nding a nd re lie ve d with re cumbe ncy) tha t usua lly pre se nt within
48 hours of a dura l puncture (but could ta ke up to a we e k to
pre se nt) a nd typica lly re solve in 2 to 14 da ys. The y a re bila te ra l a nd
typica lly loca te d in the fronta l or occipita l re gions. In one
prospe ctive se rie s of nonobste tric pa tie nts with PDPH, symptoms
include d na use a (60%), vomiting (24%), ne ck stiffne ss (43%), ocula r
cha nge s (photophobia , diplopia , difficulty in a ccommoda tion) (13%),
a nd a uditory cha nge s (he a ring loss, hype ra cusis, tinnitus) (12%).
Although postpa rtum se izure s ha ve be e n a ssocia te d with PDPH,
othe r e tiologie s a re more like ly. Se izure s, le tha rgy, fe ve r, nucha l
rigidity, foca l ne urologic de ficits (othe r tha n liste d a bove ), a nd a
unila te ra l loca tion sugge st othe r he a da che e tiologie s (Ch estnut:
707. (A) The re a re se ve ra l pe riodic FHR pa tte rns. Acce le ra tions in
FHR in re sponse to fe ta l move me nt signify fe ta l we ll-be ing.
De ce le ra tions a re a de cre a se in FHR of a t le a st 15 be a ts/min tha t
la st a t le a st 15 se conds. Early d ecelerations a re de cre a se s in FHR
tha t a re usua lly le ss tha n 20 be a ts/min a nd occur concomita ntly
with ute rine contra ctions. Typica lly the y a re smooth a nd a re mirror
ima ge s of the ute rine contra ctions. The y a re not a ssocia te d with
fe ta l compromise a nd a re ca use d by he a d compre ssion, which
produce s a va ga l slowing of the FHR. Late d ecelerations a re
de cre a se s in FHR tha t occur 10 to 30 se conds a fte r the onse t of a
contra ction a nd e nd 10 to 30 se conds a fte r the e nd of a contra ction.
The y a re due to ute ropla ce nta l insufficie ncy a nd ca n re sult
whe ne ve r ute rine blood flow de cre a se s. The de la ye d onse t is due
to the time re quire d to se nse a low oxyge n te nsion. The de cre a se
in FHR ma y be a va ga l re fle x (mild ca se s) or ma y be due to dire ct
myoca rdia l de pre ssion from hypoxia (se ve re ca se s). Typica lly, in
se ve re ca se s, be a t-to-be a t va ria bility is de cre a se d or a bse nt a s
we ll. Variable d ecelerations a re a brupt de cre a se s in FHR tha t va ry in
sha pe , de pth, a nd dura tion from contra ction to contra ction. The y
a re thought to be due to tra nsie nt umbilica l cord compre ssion. A
sinusoid al pattern is a re gula r smooth wa ve like pa tte rn with no
short-te rm va ria bility. It ma y be ca use d by se ve re fe ta l a ne mia or
ma y re sult from the ma te rna l a dministra tion of na rcotics (Ch estnut:
Levinson’s Anesth esia for Obstetrics, ed 5, pp 71–73, 245).
708. (C) Shive ring occurs in 15% to 20% of a ll norma l va gina l
de live rie s. The fre que ncy incre a se s from 20% to 85% of pa tie nts
re ce iving e pidura l or spina l a ne sthe sia for ce sa re a n de live rie s.
The postula te d re a son is tha t ne ura xia l a ne sthe sia impa irs
ce ntra lly me dia te d pe riphe ra l va soconstriction a nd shive ring
thre sholds a nd a llows gre a te r e nvironme nta l he a t loss (core to
pe riphe ra l he a t re distribution). Intra the ca l na rcotics (e .g.,
e spe cia lly fe nta nyl with morphine ) a nd e pidura l na rcotics (e .g.,
fe nta nyl, sufe nta nil, me pe ridine , butorpha nol), whe n a dde d to loca l
a ne sthe tics, de cre a se the incide nce of ma te rna l shive ring.
Intra ve nous me pe ridine (25 mg), clonidine (75 µg), ke ta nse rin
(10 mg), ma gne sium sulfa te (30 mg/kg), or de xme de tomidine
de cre a se the incide nce of shive ring. Wa rming the e pidura l
a ne sthe sia solution to body te mpe ra ture ha s no e ffe ct on the
incide nce of shive ring; howe ve r, a dding e pine phrine to the loca l
a ne sthe tic a ppe a rs to incre a se the fre que ncy of shive ring (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 483, 588–589, 646).
709. (D) The va lue s liste d in the que stion a re norma l umbilica l cord
va lue s. The cha rt is modifie d from va lue s liste d in the Che stnut a nd
Sure sh re fe re nce s (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp
p 246).
NORMAL VALUES FOR UMBILICAL CORD BLOOD
From Chestnut DH et al: Chestnut’s Obstetric Anesthesia: Principles and Practice, ed 4,

Philadelphia, Mosby, 2009, pp 161–162.
710. (D) For a ll obste tric-re la te d a dmissions, the incide nce of

tra nsfusion of blood is le ss tha n 1%. The most common re a son for
tra nsfusion wa s postpa rtum he morrha ge . Estima te s sugge st tha t
a bout one third of tra nsfusions we re not a ppropria te with curre nt
guide line s (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 888, 899–
902).
711. (C) Re suscita tion guide line s continue to e volve . The Ame rica n
He a rt Associa tion 2010 Conse nsus Guide line s for Ne ona ta l
Re suscita tion re comme nds be ginning re suscita tion of a ne wborn by
first ope ning the a irwa y, the n wa rming, drying, a nd stimula ting the
ne wborn for the first 30 se conds of life . If in 30 se conds the he a rt
ra te is le ss tha n 100 be a ts/min or the ne wborn is ga sping or a pne ic,
the n positive -pre ssure ve ntila tion is sta rte d a nd oxime try
monitoring is sugge ste d. In te rm ne wborns, re suscita tion is sta rte d
with a ir ra the r tha n with 100% oxyge n. Howe ve r, pre te rm ne wborns
(<32 we e ks’ ge sta tion) ma y ne e d a ir ble nde d with oxyge n to re a ch
a de qua te oxyge n sa tura tions. The oxime try probe should be pla ce d
pre ducta lly (i.e ., on the right wrist) to a sse ss oxyge na tion. If, a fte r
the first minute of life ,the he a rt ra te is le ss tha n 100 be a ts/min, one
should e nsure a de qua te positive -pre ssure ve ntila tion a nd conside r
e ndotra che a l intuba tion. If the he a rt ra te is now le ss tha n
60 be a ts/min, che st compre ssions should be gin, with a che st
compre ssion-to-ve ntila tion ra tio of 3:1. At this point the ne wborn
re ce ive s 30 bre a ths a nd 90 compre ssions/min (e .g., one a nd two
a nd thre e a nd bre a th). If the ne wborn is known to ha ve a ca rdia c
e tiology, the n a highe r compre ssion-to-ve ntila tion ra tio should be
conside re d (e .g., 15:2). If the he a rt ra te is le ss tha n 60 be a ts/min
a fte r che st compre ssions a nd positive -pre ssure ve ntila tion ha ve
be e n sta rte d for a t le a st 30 se conds, conside r a dministe ring
e pine phrine . The corre ct dose is 0.01 mg/kg IV. If the ne wborn is
intuba te d a nd IV a cce ss ha s not ye t be e n a chie ve d, conside r
a dministe ring a highe r dose of e pine phrine such a s 0.05 to
0.1 mg/kg down the e ndotra che a l tube (the highe r dose is use d
be ca use blood le ve ls a re unpre dicta ble a fte r e ndotra che a l
instilla tion). In a ne wborn with blood loss, volume e xpa nsion is
ne e de d a nd ca n be a chie ve d with norma l sa line , Ringe r ’s la cta te ,
or type O Rh-ne ga tive blood. The re is little e vide nce of a ny be ne fit
with volume e xpa nsion in the a bse nce of blood loss. Ra re ly will a
na rcotic a nta gonist (e .g., na loxone ), sodium bica rbona te , or a
va sopre ssor be ne e de d for re suscita tion. If a fte r 10 minute s the re is
no de te cta ble he a rt ra te , it ma y be a ppropria te to discontinue
re suscita tion (a lthough ma ny fa ctors ca n contribute to continue
re suscita tion be yond 10 minute s) (Am erican Heart Association; Part 11
– Neonatal Resuscitation, Circulation 122, pp S516–S523).
712. (D) Although e pidura l a ne sthe sia ofte n ca use s a fa ll in body
te mpe ra ture (due to the va sodila tion a nd re distribution of body
he a t a nd loss to the e nvironme nt), some wome n de ve lop a rise in
body te mpe ra ture e ve n though the re is no e vide nce of infe ction.
This rise in body te mpe ra ture of gre a te r tha n 38° C (100.4° F)
usua lly occurs only whe n the e pidura l wa s use d for a t le a st 4 to
5 hours (fre que ncy of 1%-36% of pa tie nts). The e tiology of this rise in
te mpe ra ture in some wome n is uncle a r but include s thre e ma in
fa ctors (the rmore gula tory, e ffe ct of syste mic opioids, a nd
infla mma tion). Epidura l a ne sthe sia ma y de cre a se swe a ting a nd the
hype rve ntila tion a ssocia te d with la bor, a s we ll a s shive ring, which
ma y incre a se body te mpe ra ture . The use of intra ve nous syste mic
opioids ma y de cre a se the incide nce of fe ve r. Infla mma tion ma y
pla y a n importa nt role be ca use ma te rna l te mpe ra ture s a re simila r
in wome n with or without e pidura l a ne sthe sia whe n histologic
e xa mina tion of the pla ce nta s re ve a ls the a bse nce of pla ce nta l
infla mma tion. It ma y be tha t the te mpe ra ture rise wa s me re ly a n
a ssocia tion with obste tric fa ctors such a s nullipa rity with prolonge d
la bor, more fre que nt ce rvica l e xa mina tions, prolonge d rupture of
me mbra ne s, or e a rly chorioa mnionitis. The pre pre gna nt blood
le ukocyte count of 6000/mm3 rise s during pre gna ncy to 9000 to
11,000/mm3. During la bor the le ukocyte count incre a se s to
13,000/mm3, a nd during the first postpa rtum da y is on a ve ra ge
15,000/mm3 (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 25, 867–
871).
713. (B) Although the ca use of hype rte nsive disorde rs of pre gna ncy
(HDP) is not known, ma ny fa ctors a re a ssocia te d with a highe r
fre que ncy of HDP. Fa ctors include nullipa rous woma n, a ge
(e spe cia lly <20 ye a rs a nd >40 ye a rs), fa mily history of HDP or a
pre vious history of HDP, some chronic me dica l conditions (e .g.,
hype rte nsion, dia be te s, obe sity, thrombotic va scula r dise a se ), some
obste tric conditions (e .g., pla ce nta l a bruption, intra ute rine growth
re striction, fe ta l de a th) a nd conditions in which the ute rus is ra pidly
e nla rging (e .g., multiple ge sta tions, polyhydra mnios, hyda tidiform
mole ). Although smoking is a ssocia te d with ma ny a dve rse
pre gna ncy outcome s, the re a ppe a rs to be a lowe r incide nce of
HDP in wome n who smoke (Ch estnut: Ch estnut’s Obstetric Anesth esia,
Obstetrics, ed 5, pp 683, 689).
714. (D) Aortoca va l compre ssion, a s its na me sugge sts, produce s
both compre ssion of the a orta (incre a se in a fte rloa d) a s we ll a s
compre ssion of the ve na ca va (de cre a se in ve nous re turn). The
pa tie nt’s re sponse is va ria ble . Although some wome n ha ve no
symptoms, up to 15% of pre gna nt pa tie nts a t te rm will, ove r se ve ra l
minute s in the supine position, de ve lop hypote nsion a nd
bra dyca rdia (a lso ca lle d the supine hypote nsion syndrome ). Some
wome n will a ctua lly show a n incre a se in bra chia l a rte ry blood
pre ssure due to the incre a se in a fte rloa d. The se wome n ma y ha ve
a condition re fe rre d to a s conce a le d hypote nsion (blood pre ssure
a bove the compre ssion tha t is a de qua te but blood pre ssure be low
the compre ssion tha t is re duce d). Be ca use the blood supply to the
ute rus is dista l to the a ortic compre ssion a nd ute rine blood flow is
de cre a se d, the fe tus ma y de ve lop fe ta l distre ss. Othe r signs a nd
symptoms of a ortoca va l compre ssion include na use a , vomiting,
pa llor, a nd cha nge s in ce re bra tion (Ch estnut: Ch estnut’s Obstetric
Obstetrics, ed 5, p 5).
715. (B) Coca ine ca n produce life -thre a te ning complica tions tha t a re
usua lly re la te d to the a ccumula tion of ca te chola mine s, a nd pa tie nts
ma y pre se nt with the cla ssic signs of toxe mia (i.e ., hype rte nsion
a nd prote inuria ) a s we ll a s che st pa in. The typica l ha lf-life of
coca ine is 30 to 90 minute s, but the a cute e ffe cts ca n la st a s long a s
6 hours. Be ca use some sta te s conside r in ute ro coca ine e xposure a
form of child a buse tha t re quire s physicia ns to re port positive drug
te sts in pre gna nt wome n, ma ny pa tie nts who use coca ine ha ve no
pre na ta l ca re . Urine te sts ma y be positive for 24 to 72 hours a fte r
coca ine use (de pe nding on the a mount use d). Life -thre a te ning
e ve nts a re more common with ge ne ra l tha n re giona l a ne sthe sia .
The most fre que nt proble m with induction of ge ne ra l a ne sthe sia is
se ve re hype rte nsion. Arrhythmia s, myoca rdia l ische mia , a nd
ta chyca rdia ma y a lso occur with the induction of ge ne ra l
a ne sthe sia . La be ta lol a nd nitroglyce rin ha ve be e n use d to tre a t
the se conditions. The MAC le ve l is incre a se d in pa tie nts who a re
a cute ly intoxica te d, whe re a s pa tie nts chronica lly a busing coca ine
ha ve a lowe r MAC (due to the de ple tion of ca te chola mine s). The se
pa tie nts a re a t risk for hypote nsion, which is commonly se e n a fte r
the induction of re giona l a ne sthe sia for ce sa re a n se ction.
Ephe drine ma y not be a n e ffe ctive va sopre ssor in the se
ca te chola mine -de ple te d pa tie nts. Phe nyle phrine , a dire ct-a cting
drug, is a be tte r va sopre ssor (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, pp 1204–1207; Suresh : Sh nid er and Levinson’s
716. (C) In ca se s of e me rge ncy ce sa re a n se ction whe n ge ne ra l
a ne sthe sia is contra indica te d (e .g., poor a irwa y whe n one
que stions one ’s a bility to intuba te a nd/or ve ntila te the pa tie nt), a nd
ne ura xia l a ne sthe sia is contra indica te d (e .g., se ve re hypovole mia
or coa gulopa thy), e me rge ncy infiltra tion a ne sthe sia is a cce pta ble .
All of the choice s a re corre ct e xce pt the choice of a loca l
a ne sthe tic. As the surge on will be inje cting a fa ir volume of loca l
a ne sthe tic (ofte n 100 mL), a nd a s bupiva ca ine ha s a slow onse t a nd
pote ntia lly da nge rous ca rdia c toxicity with la rge dose s, bupiva ca ine
is a poor choice . A dose of 0.5% lidoca ine (pla sma ha lf-life of
90 minute s) is ofte n use d be ca use it is re a dily a va ila ble a nd
re la tive ly sa fe . Chloroproca ine ma y be sa fe r be ca use it a lso ha s a
fa st onse t a nd its pla sma ha lf-life is e xtre me ly short (23 se conds).
Both mida zola m a nd ke ta mine ma y le a d to some a mne sia for the
pa tie nt, which ma y be a dva nta ge ous in this e me rge ncy situa tion;
howe ve r, too much of the IV drugs could obtund the pa tie nt a nd
ma y le a d to a spira tion of ga stric conte nts. A good coa ch a t the he a d
of the be d ma y be inva lua ble for re a ssuring the pa tie nt a s to the
ca re (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5, pp 577–578).
717. (A) The most common complica tion a fte r a spina l or e pidura l
a ne sthe tic is pla ce d is syste mic hypote nsion. Be ca use the ca rdia c
output is influe nce d by four ma in fa ctors (pre loa d, a fte rloa d,
contra ctility, a nd he a rt ra te a nd rhythm), tre a tme nt is dire cte d a t
the se fa ctors. First, conside ra tion of more le ft ute rine displa ce me nt
is ma de (which ca n incre a se pre loa d). Ne xt, a dministe ring more
intra ve nous fluids to incre a se pre loa d is done if the pre loa d of fluid
a dministra tion is ina de qua te . Intra ve nous fluids with de xtrose a re
use d only for ma inte na nce fluids a nd should not be use d to pre ve nt
or tre a t hypote nsion from re giona l a ne sthe sia be ca use the fluid
loa d ca use s significa nt ma te rna l a nd fe ta l hype rglyce mia a nd
hype rinsuline mia . Afte r de live ry, the suga r supply for the ne wborn
stops but the insulin re sponse continue s, ofte n ca using fe ta l
hypoglyce mia a fte r de live ry. It should be note d tha t 5% a lbumin
solutions a re e xpe nsive a nd a re not re comme nde d for routine use
to tre a t hypote nsion. Conside ra tion of the use of va sopre ssors
a nd/or drugs tha t incre a se contra ctility a re commonly ne e de d to
incre a se a fte rloa d a nd incre a se ca rdia c contra ctility. Initia l
la bora tory studie s with pre gna nt e we s sugge ste d tha t e phe drine
wa s a be tte r choice compa re d with phe nyle phrine a nd othe r α-
a dre ne rgic a gonists, whe n looking a t cha nge s in ute rine blood flow.
In the se initia l studie s the blood pre ssure wa s ra ise d from norma l
to highe r le ve ls, a nd e phe drine wa s the drug of choice be ca use
phe nyle phrine de cre a se d ute rine blood flow, whe re a s e phe drine
did not. Howe ve r, ra ising a norma l pre ssure to highe r le ve ls is not
the sa me thing a s ra ising a low blood pre ssure to norma l. In more
re ce nt huma n studie s looking a t e phe drine a nd phe nyle phrine use ,
studie s ha ve note d no diffe re nce in the prophyla ctic or tre a tme nt
use of the se drugs for ma te rna l hypote nsion. It wa s a lso note d tha t
ma te rna l bra dyca rdia wa s more common with ma te rna l
phe nyle phrine a dministra tion, whe re a s ma te rna l ta chyca rdia wa s
more common with ma te rna l e phe drine a dministra tion; a lso,
ne ona ta l a rte ria l pH wa s slightly highe r whe n phe nyle phrine wa s
use d a s compa re d with e phe drine . W hy this occurs is uncle a r but
ma y be re la te d to e phe drine ’s a bility to cross the pla ce nta ca using
β-a dre ne rgic stimula tion in the ne wborn (F/M blood ra tio is 0.7 for
e phe drine a nd 0.2 for phe nyle phrine ). In this pa tie nt who ha s le ft
ute rine displa ce me nt, a de qua te IV hydra tion, a nd a he a rt ra te of
110 be a ts/min, phe nyle phrine would be the pre fe rre d va sopre ssor.
If the mothe r ha s hypote nsion with bra dyca rdia , e phe drine might
be a be tte r choice . Epine phrine is ra re ly ne e de d but should be
a va ila ble a nd use d whe n the re is se ve re hypote nsion tha t is not
re sponsive to phe nyle phrine or e phe drine , e spe cia lly whe n the re
is a ssocia te d fe ta l bra dyca rdia (Ch estnut: Ch estnut’s Obstetric
Anesth esia, ed 5, pp 480–481, 580–583; Suresh : Sh nid er and Levinson’s
Anesth esia for Obstetrics, ed 5, pp 50, 135–136, 174).
718. (D) A th reatened abortion is de fine d a s ute rine ble e ding without
ce rvica l dila tion be fore 20 we e ks’ ge sta tion. Ble e ding ma y be
a ccompa nie d by ute rine cra mps or ba cka che . Ha lf of the se ca se s
will go on to sponta ne ously a bort. An inevitable abortion ha s ce rvica l
dila tion a nd/or rupture of me mbra ne s a nd will sponta ne ously
a bort. A com plete abortion occurs whe n the re is comple te e xpulsion
of the fe tus a nd the pla ce nta , a nd in the se ca se s the re is no ne e d
for a dila tion a nd cure tta ge (D&C). If the re is only pa rtia l e xpulsion
of tissue , a s in this ca se , a n incom plete abortion ha s occurre d, a nd
this re quire s a D&E to re move the re ma ining fe ta l or pla ce nta l
tissue . In the se ca se s the ce rvix ha s usua lly dila te d some a nd the
pa tie nt usua lly ca n be ma na ge d with some mild se da tion, be ca use
the most pa inful pa rt of a D&E is ce rvica l dila tion. A pa ra ce rvica l
block ca n be most use ful for pa in control during the proce dure if
the ce rvix ne e ds to be dila te d. A fe ta l de a th tha t is unre cognize d for
se ve ra l we e ks is ca lle d a m issed abortion, a nd if this occurs a t a n
a dva nce d ge sta tiona l a ge , DIC ma y re sult. A h abitual or recurrent
abortion re fe rs to the occurre nce of thre e or more conse cutive
sponta ne ous a bortions (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed 5,
pp 345–348).
719. (D) 2-Chloroproca ine a dministe re d e pidura lly a ppe a rs to
de cre a se the qua lity a nd dura tion of subse que ntly a dministe re d
fe nta nyl or morphine a nd a lso to re duce the e ffe ctive ne ss of
bupiva ca ine . The e xa ct me cha nism is uncle a r but doe s not se e m to
be re la te d to the a cid pH of chloroproca ine (be ca use ne utra liza tion
with bica rbona te ha s simila r a nta gonistic prope rtie s). Butorpha nol
(a κ-re ce ptor a gonist) doe s not a ppe a r to be a nta gonize d (Ch estnut:
Levinson’s Anesth esia for Obstetrics, ed 5, p 172).
720. (B) Ea rlie r dia gnosis of comple te mola r pre gna ncie s ha s
de cre a se d the incide nce of me dica l complica tions. Howe ve r,
e xce ssive ute rine size occurs in up to one ha lf of pa tie nts with a
comple te mola r pre gna ncy a nd is a ssocia te d with a high incide nce
of me dica l complica tions. Me dica l complica tions whe n the ute rine
size is gre a te r tha n 14 to 16 we e ks’ ge sta tiona l size include ova ria n
the ca -lute in cysts (4%-50%), hype re me sis gra vida rum (15%-30%),
hype rte nsive disorde rs of pre gna ncy (11%-27%), a ne mia
(he moglobin <10 g/dL) (10%-54%), a cute ca rdiopulmona ry distre ss
(6%-27%), ma ligna nt se que la e (me ta sta sis) (4%-36%), a nd
hype rthyroidism (1%-7%) (Ch estnut: Ch estnut’s Obstetric Anesth esia, ed
5, pp 351–354).
721. (B) Se ve ra l ca se s of ma te rna l ca rdia c a rre st ha ve occurre d in
pre gna nt wome n who we re a dministe re d bupiva ca ine (Ma rca ine ,
Se nsorca ine ). Typica lly, the pa tie nts re ce ive d a n uninte ntiona l IV
bolus of 0.75% bupiva ca ine inte nde d for the e pidura l spa ce . The y
ha d a brie f gra nd ma l se izure followe d by ca rdiova scula r colla pse .
Succe ssful tre a tme nt wa s ofte n prolonge d a nd involve d ba sic
re suscita tion (intuba tion, ve ntila tion with 100% oxyge n, ca rdia c
compre ssion with le ft ute rine tilt, de fibrilla tion, e pine phrine ,
va sopre ssin, a tropine ), a s we ll a s ra pid de live ry of the fe tus (if
possible within 4-5 minute s). De live ry of the fe tus ma ke s succe ssful
re suscita tion of the mothe r more like ly. Incre me nta l sma ll
inje ctions of loca l a ne sthe tic looking for toxicity should de cre a se
the cha nce for ca rdiova scula r colla pse . Bupiva ca ine 0.75% now is
conside re d contra indica te d for use in the e pidura l spa ce of
pa rturie nts. Re ce nt lite ra ture (since 2006) ha s shown tha t the IV
inje ction of 20% Intra lipid ma y be he lpful (se e Que stion 722). Both
le vobupiva ca ine (Chiroca ine ) a nd ropiva ca ine (Na ropin) we re
de ve lope d to ha ve a long dura tion of a ction, like bupiva ca ine but
with le ss ca rdia c toxicity. Although the se compounds ha ve le ss
ca rdia c toxicity tha n bupiva ca ine , the y a re more ca rdia c toxic tha n
lidoca ine (inte rme dia te dura tion of a ction) a nd chloroproca ine
(short dura tion of a ction) (ASRA.com – Download able ch ecklist for
Treatm ent of Local Anesth etic Sy stem ic Tox icity 9/19/11; Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, p 266; Miller: Miller’s Anesth esia,
722. (D) Curre nt (2012) ASRA guide line s for LAST for a 70-kg pa tie nt
with ca rdiova scula r colla pse include the following:
1. Ge t he lp
2. Initia l focus—a irwa y ma na ge me nt, se izure suppre ssion, a nd
conside ra tion for ca rdiopulmona ry bypa ss
3. Ma na ge me nt of ca rdia c a rrhythmia s—ba sic a nd a dva nce d
ca rdia c life support, the AVOIDANCE of va sopre ssin, ca lcium
cha nne l blocke rs, β-blocke r, or loca l a ne sthe tics. Epine phrine
dose s should be re duce d to <1 µg/kg.
4. Lipid e mulsion the ra py should be sta rte d. For a 70-kg pa tie nt,
the initia l bolus Intra lipid (20%) dose is 1.5 mL/kg (le a n body
ma ss) or a bout 100 mL ove r 1 minute , followe d by a continuous
infusion of 0.25 mL/kg/min (a bout 18 mL/min). Re pe a t the bolus
one or two time s for pe rsiste nt ca rdiova scula r colla pse a nd
double in continuous infusion ra te if the blood pre ssure
re ma ins low. Continue the infusion for a t le a st 10 minute s a fte r
ca rdiova scula r sta bility is a tta ine d. The uppe r limit of Intra lipid
(20%) is 10 mL/kg ove r 30 minute s.
5. Post LAST e ve nts a t www.lipidre scue .org a nd re port use of
lipid to www.lipidre gistry.org
(ASRA.com – Download able ch ecklist for Treatm ent of Local Anesth etic
Sy stem ic Tox icity 9/19/11).
723. (A) Tra nsie nt ne urologic syndrome (TNS), forme rly ca lle d
tra nsie nt ra dicula r irrita tion (TRI), occurs most commonly a fte r
spina l a ne sthe sia with lidoca ine (Xyloca ine ). Symptoms include
ba ck pa in tha t de ve lops a fte r the block re solve s a nd ra dia te s to the
buttocks a nd le gs. The pa in is not a ssocia te d with motor or se nsory
loss or e le ctromyogra phic cha nge s. It ca n be se ve re , re quiring
hospita l a dmission of outpa tie nts, a nd typica lly re solve s within 1 to
4 da ys. It a ppe a rs to occur more commonly whe n outpa tie nts a re
ope ra te d on in the lithotomy position a nd a ppe a rs to be le ss like ly
whe n pa tie nts a re pre gna nt (Ch estnut: Ch estnut’s Obstetric Anesth esia,
ed 5, p 756; Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics, ed
5, pp 112– 113).
724. (D) W he n de a ling with a n urge nt ce sa re a n se ction in a pa tie nt
with a we ll-functioning la bor e pidura l, ra ising the le ve l of
a ne sthe sia is ofte n chose n. Of the commonly use d loca l
a ne sthe tics, 2-chloroproca ine a nd lidoca ine ha ve much fa ste r
onse ts of a ction tha n bupiva ca ine or le vobupiva ca ine , which ha ve
re la tive ly slow onse ts of a ction. Alka liniza tion of the loca l
a ne sthe tic with bica rbona te shifts more of the loca l a ne sthe tic
mole cule s to the nonionize d a nd more lipid-soluble form for a
fa ste r onse t (a nd a more solid block); howe ve r, it doe s ta ke a little
time to mix the solution. Typica lly, 1 mL of 8.4% sodium bica rbona te
(1 mEq/mL) is a dde d to e a ch 10 mL of 2-chloroproca ine or lidoca ine .
If one a dds sodium bica rbona te to le vobupiva ca ine (or ropiva ca ine
or bupiva ca ine ), only 0.1 mL (0.1 mEq) is a dde d to e a ch 10 mL, or
e lse the bupiva ca ine will pre cipita te out. Fe nta nyl is ofte n a dde d to
the loca l a ne sthe tic solution for a more solid block a nd for some
postope ra tive a na lge sia . Onse t time s re porte d diffe r a mong
studie s, but the following time s a re re porte d: onse t for 3% 2-
chloroproca ine a s we ll a s 2% lidoca ine with fre shly a dde d
e pine phrine is 8 minute s, using the pre mixe d 2% lidoca ine with
e pine phrine a nd a dding bica rbona te will give a n onse t time of
5 minute s, 3% 2-chloroproca ine with bica rbona te ha s a n onse t of
3 minute s, a nd le vobupiva ca ine with fe nta nyl ha s a n onse t of 10 to
11 minute s. Anothe r option whe n de a ling with a pa tie nt with a
difficult a irwa y is to use a highe r conce ntra tion of loca l a ne sthe tic
from the be ginning of the la bor (e .g., 0.5% bupiva ca ine ) a nd a
highe r le ve l (to T6) so tha t if a n e me rge ncy ce sa re a n se ction is
ne e de d, the pa tie nt ha s a le ve l tha t is a lmost high e nough a nd
de nse e nough for the ope ra tion. If this is done , the obste tricia n,
nurse s, a nd pa tie nt ne e d to know tha t the block will be quite
de nse a nd a n ope ra tive force ps de live ry ma y be ne e de d (Ch estnut:
725. (D) Chloroproca ine (Ne sa ca ine ) is a n e ste r-type loca l
a ne sthe tic tha t is ra pidly me ta bolize d by pla sma
pse udocholine ste ra se . The in vitro ha lf-life is 11 to 21 se conds for
ma te rna l blood a nd 43 se conds for fe ta l blood. Afte r a n e pidura l
inje ction, the ma te rna l in vivo ha lf-life is le ss tha n 7 minute s; the
longe r dura tion in vivo is due to the continua l a bsorption of
chloroproca ine from the e pidura l spa ce . All the othe r loca l
a ne sthe tics a re a mide s a nd re quire live r me ta bolism (Ch estnut:
Ch estnut’s Obstetric Anesth esia, ed 5, pp 263-265; Suresh : Sh nid er and
C H AP T E R 9
Neurologic Physiology and
Anesthesia
DIRECT IONS (Que stions 726 through 787): Ea ch of the

que stions or incomple te sta te me nts in this se ction is followe d
by a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
726. Following clipping of a n a nte rior communica ting a rte ry

a ne urysm, a 59-ye a r-old ma n is a dmitte d to the inte nsive ca re unit
(ICU). Se rum sodium is 115 mEq/L, 24-hour urine sodium colle ction
is 350 mmol (norma l ra nge 40-117 mmol/24 hr), a nd ce ntra l ve nous
pre ssure (CVP) is 1 cm H2O. The MOST like ly ca use of the se
findings is
A. Tubula r ne crosis
B. Dia be te s insipidus
C. Ce re bra l sa lt-wa sting syndrome
D. Syndrome of ina ppropria te a ntidiure tic hormone (SIADH)
727. Intra cra nia l hype rte nsion is de fine d a s a susta ine d incre a se in
intra cra nia l pre ssure (ICP) a bove
A. 5 mm Hg
B. 15 mm Hg
C. 25 mm Hg
D. 40 mm Hg
728. Ca lcula te ce re bra l pe rfusion pre ssure from the following da ta :
blood pre ssure (BP) 100/70, he a rt ra te (HR) 65 be a ts/min, a nd ICP
15 mm Hg.
A. 60 mm Hg
B. 65 mm Hg
C. 70 mm Hg
D. 75 mm Hg
729. The a ffe re nt input for soma tose nsory e voke d pote ntia ls (SSEPs)
is ca rrie d through which spina l cord tra ct?
A. Spinoce re be lla r
B. Spinotha la mic
C. Dorsa l columns
D. Corticospina l
730. By wha t pe rce nta ge doe s ce re bra l blood flow (CBF) cha nge for
e a ch mm Hg incre a se in Pa CO2?
A. 1%
B. 2%
C. 7%
D. 10%
731. W hich of the following intra ve nous a ne sthe tics is
contra indica te d in pa tie nts with intra cra nia l hype rte nsion?
A. Propofol
B. Fe nta nyl
C. Ke ta mine
D. All a re a cce pta ble
732. The te rm lux ury perfusion re fe rs to a situa tion tha t occurs in the
bra in whe n
A. Blood flow ha s re sume d a fte r a pe riod of ische mia
B. Blood flow is dire cte d from a norma l re gion of the bra in to a n
ische mic re gion
C. Va sopa ra lysis e xists
D. The Robin Hood phe nome non e xists
733. A 62-ye a r-old pa tie nt is sche dule d to unde rgo re se ction of a
fronta l lobe intra cra nia l tumor unde r ge ne ra l a ne sthe sia .
Pre ope ra tive ly, the pa tie nt is a le rt a nd orie nte d, a nd ha s no foca l
ne urologic de ficits. W ithin wha t ra nge should Pa CO2 be ma inta ine d
during surge ry?
A. 15 a nd 20 mm Hg
B. 20 a nd 25 mm Hg
C. 25 a nd 30 mm Hg
D. 40 a nd 45 mm Hg
734. A 2-ye a r-old child is a ne sthe tize d for re se ction of a poste rior
fossa tumor. Pre ope ra tive ly, the pa tie nt is le tha rgic a nd disorie nte d.
W hich of the following is MOST like ly to a dve rse ly a lte r ICP?
A. 5% De xtrose in wa te r
B. Norma l sa line
C. La cta te d Ringe r solution
D. 5% Albumin
735. A 22-ye a r-old pa tie nt is a ne sthe tize d for re se ction of a te mpora l
lobe tumor. Pre ope ra tive ly, he is le tha rgic a nd confuse d. Afte r
induction of ge ne ra l a ne sthe sia , which of the following would be
the MOST a ppropria te drug to control syste mic a rte ria l blood
pre ssure during dire ct la ryngoscopy a nd tra che a l intuba tion?
A. Esmolol
B. Nitroprusside
C. Hydra la zine
D. Isoflura ne
736. Norma l globa l CBF is
A. 25 mL/100 g/min
B. 50 mL/100 g/min
C. 75 mL/100 g/min
D. 100 mL/100 g/min
737. The lowe r a nd uppe r me a n a rte ria l blood pre ssure limits of
CBF a utore gula tion a re , re spe ctive ly,
A. 25 a nd 125 mm Hg
B. 25 a nd 200 mm Hg
C. 40 a nd 250 mm Hg
D. 60 a nd 160 mm Hg
738. How much will CBF incre a se in a pa tie nt whose Pa CO2 is
incre a se d from 35 to 45 mm Hg?
A. The re is no re la tionship be twe e n Pa CO2 a nd CBF
B. 10 mL/100 g/min
C. 20 mL/100 g/min
D. 40 mL/100 g/min
739. Se le ct the FALSE sta te me nt conce rning a utonomic
hype rre fle xia .
A. Diste ntion of a hollow viscus be low the le ve l of the spina l
cord tra nse ction ca n e licit a utonomic hype rre fle xia
B. Up to 85% of pa tie nts with a spina l cord tra nse ction a bove the
T6 de rma tome will e xhibit a utonomic hype rre fle xia unde r
ge ne ra l a ne sthe sia
C. Propra nolol is e ffe ctive in tre a ting hype rte nsion a ssocia te d
with a utonomic hype rre fle xia
D. Spina l a ne sthe sia is e ffe ctive in pre ve nting a utonomic
hype rre fle xia
740. W ha t is the norma l ce re bra l me ta bolic ra te for oxyge n
(CMRO2) pe r minute ?
A. 0.5 mL/100 g bra in tissue
B. 2.0 mL/100 g bra in tissue
C. 3.5 mL/100 g bra in tissue
D. 7.5 mL/100 g bra in tissue
741. A 14-ye a r-old girl with se ve re scoliosis is to unde rgo spine
surge ry. Ane sthe sia is ma inta ine d with fe nta nyl, N2O 50% in O2,
ve curonium, a nd isoflura ne . Ne urologic function of the spina l cord
is monitore d by SSEPs. In re fe re nce to the SSEP wa ve form, spina l
cord ische mia would be ma nife ste d a s
A. Incre a se d a mplitude a nd incre a se d la te ncy
B. De cre a se d a mplitude a nd incre a se d la te ncy
C. De cre a se d a mplitude a nd de cre a se d la te ncy
D. Incre a se d a mplitude a nd de cre a se d la te ncy
742. For e a ch 1° C de cre a se in body te mpe ra ture , how much will
CMRO2 be diminishe d?
A. 3%
B. 5%
C. 6%
D. 10%
743. A 24-ye a r-old ca rpe nte r is tre a te d for a close d he a d injury
susta ine d 3 da ys e a rlie r a fte r fa lling from a roof. He ha s be e n
he modyna mica lly sta ble . De spite a ggre ssive e fforts to
pha rma cologica lly re duce ICP, he is now unconscious a nd
unre sponsive to pa inful stimuli. All of the following a re clinica l
crite ria consiste nt with a dia gnosis of bra in de a th in this pa tie nt
EXCEPT
A. Pe rsiste nt a pne a for 10 minute s
B. Abse nce of pupilla ry light re fle x
C. Pe rsiste nt spina l re fle xe s
D. De cortica te posturing
744. W hich of the following is the MOST se nsitive me a ns of
de te cting ve nous a ir e mbolism (VAE)?
A. Ele ctroe nce pha logra phy (EEG)
B. Pulmona ry a rte ry ca the te r
C. Tra nse sopha ge a l e choca rdiogra phy
D. Right a tria l ca the te riza tion
745. W he n intra cra nia l hype rte nsion e xists, the ma in compe nsa tory
me cha nism from the body is
A. Incre a se d a bsorption of ce re brospina l fluid (CSF) a t the
intra cra nia l a ra chnoid villi
B. Incre a se d a bsorption of CSF in the spina l a ra chnoid villi
C. Shifting of CSF from intra cra nia l to spina l suba ra chnoid spa ce
D. Re duction of ce re bra l blood volume due to compre ssion of
intra cra nia l a rte rie s
746. Administra tion of ve curonium during spina l surge ry ma y
inte rfe re with monitoring of
A. Dorsa l columns
B. Corticospina l tra ct
C. Ele ctrocorticogra phy
D. Bispe ctra l inde x
747. Pa tie nts ca n be sa fe ly ima ge d in the ma gne tic re sona nce
ima ging (MRI) sca nne r with conve ntiona l ve rsions of which of the
following monitors?
A. Pulmona ry a rte ry ca the te r with ca rdia c output probe
B. Fole y ca the te r with te mpe ra ture probe
C. Ele ctroca rdiogra phy (ECG) e le ctrode s
D. Arte ria l line
748. W ha t is the minimum qua ntity of intra ca rdia c a ir tha t ca n be
de te cte d by a pre cordia l Dopple r?
A. 0.25 mL
B. 5.0 mL
C. 10 mL
D. 25 mL
749. W ith re ga rd to re gula tion of blood flow, the corre ct orde r of
va scula r re sponsive ne ss to Pa CO2 from most to le a st se nsitive is
A. Ce re brum > spina l cord > ce re be llum
B. Ce re brum > ce re be llum > spina l cord
C. Ce re be llum > ce re brum > spina l cord
D. Ce re be llum > spina l cord > ce re brum
750. Se le ct the T RUE sta te me nt conce rning a dministra tion of
glucose -conta ining solutions to the pa tie nt with a close d he a d
injury ve rsus a pa tie nt with a spina l cord injury.
A. Glucose -conta ining solutions a re contra indica te d in both
pa tie nt groups
B. Glucose -conta ining solutions a re contra indica te d in pa tie nts
with close d he a d injury but a cce pta ble in pa tie nts with spina l
cord injurie s
C. Glucose -conta ining solutions a re a cce pta ble in pa tie nts with
close d he a d injurie s but contra indica te d in pa tie nts with spina l
cord injurie s
D. Glucose -conta ining solutions ma y be give n to e ithe r pa tie nt
group if blood glucose conce ntra tions do not e xce e d 200 mg/dL
751. A 67-ye a r-old pa tie nt is sche dule d to unde rgo poste rior ce rvica l
fusion in the sitting position unde r ge ne ra l a ne sthe sia . A ce ntra l
ve nous ca the te r is inse rte d from the right ba silic ve in a nd a dva nce d
towa rd the he a rt. Intra va scula r e le ctroca rdiogra phy (ECG; with the
e xploring e le ctrode a tta che d to the V le a d) is use d to a id in
pla ce me nt of the ca the te r. Afte r the ca the te r is a dva nce d 45 cm, the
tra cing shown in the figure is note d on the e le ctroca rdiogra m.
At this time the a ne sthe siologist should
A. Adva nce the ca the te r 5 cm
B. Adva nce the ca the te r slightly
C. Le a ve the ca the te r in the pre se nt position
D. W ithdra w the ca the te r 1 cm
752. Critica l CBF in pa tie nts a ne sthe tize d with isoflura ne is
A. 5 mL/100 g/min
B. 10 mL/100 g/min
C. 18 mL/100 g/min
D. 25 mL/100 g/min
753. W ha t e ffe ct doe s ce re bra l ische mia ha ve on CBF
a utore gula tion?
A. CBF a utore gula tion is a bla te d
B. CBF a utore gula tion is a bla te d a t low ce re bra l pe rfusion
pre ssure s but re ma ins inta ct a t high ce re bra l pe rfusion
pre ssure s
C. CBF a utore gula tion is a bla te d a t high ce re bra l pe rfusion
pre ssure s but re ma ins inta ct a t low ce re bra l pe rfusion
pre ssure s
D. The CBF a utore gula tory curve is shifte d to the right
754. The MOST ra pid ma ne uve r a va ila ble for lowe ring ICP in a
pa tie nt with a la rge intra cra nia l ma ss is
A. Ma nnitol, 1 g/kg IV
B. Me thylpre dnisolone , 30 mg/kg IV
C. Hype rve ntila tion to 25 mm Hg Pa CO2
D. Furose mide , 1 mg/kg IV
755. W ha t e ffe ct doe s propofol ha ve on the CO2 re sponsive ne ss of
the ce re bra l va scula ture ?
A. Propofol a tte nua te s the e ffe ct of hypoca rbia on CBF
B. Propofol a tte nua te s the e ffe ct of hype rca rbia on CBF
C. Propofol a ugme nts the e ffe ct of hypoca rbia on CBF
D. Propofol doe s not a ffe ct CO2 re a ctivity a t a dose use d
clinica lly
756. Ce re bra l a utore gula tion is MOST like ly to re ma in inta ct
A. Imme dia te ly a fte r ce re bra l a ne urysm rupture
B. In a pa tie nt with tra uma tic bra in injury a nd a Gla sgow coma
sca le of 3
C. W ith tota l intra ve nous a ne sthe sia (TIVA) a ne sthe tic using
propofol
D. W ith 2.5% e nd-tida l se voflura ne a ne sthe sia
757. A 72-ye a r-old pa tie nt unde rgoing re se ction of a n a strocytoma in
the sitting position sudde nly de ve lops hypote nsion. Air is he a rd on
the pre cordia l Dopple r ultra sound. Ea ch of the following
the ra pe utic ma ne uve rs to tre a t VAE is a ppropria te EXCEPT
A. Discontinue N2O
B. Apply jugula r ve nous pre ssure
C. Imple me nt positive e nd-e xpira tory pre ssure (PEEP)
D. Administe r e pine phrine to tre a t hypote nsion
758. W hich of the following is the LEAST like ly se que la of VAE
during poste rior fossa surge ry in the upright position?
A. Incre a se in pulmona ry de a d spa ce
B. Bronchoconstriction
C. Stroke
D. Pulmona ry a nd syste mic hype rte nsion
759. A 55-ye a r-old busine ss e xe cutive is sche dule d for colonoscopy
a nd polype ctomy unde r ge ne ra l a ne sthe sia . A bruit is a usculta te d
ove r the right ca rotid a rte ry on physica l e xa mina tion. The pa tie nt is
othe rwise he a lthy. W hich of the following would be the MOST
a ppropria te course of a ction?
A. Ca nce l surge ry a nd obta in corona ry a ngiogra m
B. Ca nce l surge ry a nd obta in Dopple r ultra sound ca rotid blood
flow studie s
C. Ca nce l surge ry a nd obta in dobuta mine stre ss e choca rdiogra m
D. Proce e d with surge ry
760. How long a fte r a stroke ca n a ne sthe sia for surge ry be ca rrie d
out with a bout the sa me risk of a pe riope ra tive occlusive va scula r
a ccide nt a s e xiste d imme dia te ly be fore the pre vious stroke ?
A. 1 we e k
B. 6 we e ks
C. 6 months
D. 1 ye a r
761. A 13-ye a r-old boy is a ne sthe tize d with 0.5% isoflura ne , 50%
N2O, a nd fe nta nyl for scoliosis re pa ir. Soma tose nsory e voke d
pote ntia ls (SSEP) monitoring is conducte d during the proce dure .
W hich of the following structure s is NOT involve d in conve ya nce of
the stimulus from the poste rior tibia l ne rve to the ce re bra l corte x?
A. Corticospina l tra ct
B. Me dia l le mniscus
C. Bra in ste m
D. Inte rna l ca psule
762. A 19-ye a r-old woma n is unde rgoing surge ry for a Ha rrington
rod pla ce me nt. Ge ne ra l a ne sthe sia is a dministe re d with
de sflura ne , nitrous oxide , a nd fe nta nyl. Afte r comple tion of spina l
instrume nta tion, a wa ke -up te st is unde rta ke n. Four thumb
twitche s a re pre se nt whe n the ne rve stimula tor a tta che d to the
ulna r ne rve is a ctiva te d. The vola tile a ne sthe tic a nd nitrous oxide
ha ve be e n discontinue d for 10 minute s whe n the pa tie nt is a ske d to
move he r ha nds a nd fe e t. Afte r re pe a te d comma nds, the pa tie nt
still doe s not move he r ha nds or fe e t. The most a ppropria te
inte rve ntion a t this time would be
A. 3 mg ne ostigmine plus 0.6 mg glycopyrrola te IV
B. 20 µg na loxone IV
C. 0.1 mg fluma ze nil IV
D. Re duce the distra ction on the rods
763. A 75-ye a r-old pa tie nt is unde rgoing cra niotomy for re se ction of
a la rge a strocytoma . During a dministra tion of isoflura ne
a ne sthe sia , a rte ria l blood ga s sa mpling re ve a ls a Pa CO2 of 30 mm
Hg. At this time , this pa tie nt’s globa l ce re bra l blood flow would be
a pproxima te ly
A. 20 mL × 100 g/bra in we ight/min
B. 30 mL × 100 g/bra in we ight/min
C. 40 mL × 100 g/bra in we ight/min
D. 50 mL × 100 g/bra in we ight/min
764. A 24-ye a r-old pa tie nt is brought to the inte nsive ca re unit a fte r
susta ining a close d he a d injury in a motor ve hicle a ccide nt. Ea ch of
the following would be use ful in ma na ging intra cra nia l
hype rte nsion in this pa tie nt EXCEPT
A. Corticoste roids
B. Propofol
C. Hype rve ntila tion to a Pa CO2 of 35 mm Hg
D. Osmotic diure tics
765. Pre ope ra tive tre a tme nt of suba ra chnoid he morrha ge (SAH)
pa tie nts, without concomita nt ce re bra l va sospa sm, might include
a ny of the following EXCEPT
A. Induce d hype rte nsion (to 20% a bove ba se line )
B. Administra tion of nimodipine
C. Se da tion
D. Administra tion of a ntie pile ptic drugs
766. W hich of the following pha rma cologic a ge nts would ha ve the
LEAST e ffe ct on soma tose nsory e voke d pote ntia ls?
A. Isoflura ne
B. Nitrous oxide
C. Ve curonium
D. Etomida te
767. A 75-ye a r-old pa tie nt with signs a nd symptoms of a le a king
ce re bra l a ne urysm is brought to the e me rge ncy room for
e va lua tion. T-wa ve inve rsion, a prolonga tion of the QT inte rva l,
a nd U wa ve s a re note d on the pre ope ra tive e le ctroca rdiogra m.
Appropria te a ction a t this point would be
A. Be gin infusion of nitroglyce rin
B. Che ck se rum ca lcium a nd pota ssium
C. Administe r e smolol
D. Pla ce a pulmona ry a rte ry ca the te r
768. W hich of the following pha rma cologic a ge nts would ha ve the
LEAST e ffe ct on tra nscra nia l motor e voke d pote ntia ls (MEPs)?
A. Isoflura ne
B. Nitrous oxide
C. Etomida te
D. Fe nta nyl
769. Ke ta mine
A. De cre a se s ce re bra l blood flow (CBF)
B. Augme nts the CO2 re sponsive ne ss of the ce re bra l va scula ture
C. Re duce s ce re bra l me ta bolic ra te (CMR)
D. Incre a se s ce re bra l blood volume (CBV)
770. CMR is de cre a se d by
A. Isoflura ne
B. Se izure
C. Hype rthe rmia
D. Ke ta mine
771. W hich of the following is LEAST like ly to impa ir CBF
a utore gula tion?
A. Se voflura ne 2 minimum a lve ola r conce ntra tion (MAC)
B. Intra cra nia l tumors
C. Nitrous oxide 50%
D. Ce re bra l ische mia
772. An 18-ye a r-old pa tie nt is brought to the inte nsive ca re unit a fte r
susta ining a ce rvica l spine injury a nd qua driple gia during a motor
ve hicle a ccide nt. In the first 24 hours a fte r the injury, the pa tie nt is
a t risk for
A. Hypothe rmia , hypote nsion, pulmona ry e de ma
B. Fe ve r, hype rte nsion
C. Fe ve r, hypote nsion, hypoglyce mia
D. Autonomic hype rre fle xia
773. Signs a nd symptoms of intra cra nia l hype rte nsion include
A. Pa pille de ma
B. He a da che
C. Na use a a nd vomiting
774. An 89-ye a r-old ma n with a history of tra nsie nt ische mic a tta cks
is sche dule d to unde rgo a ca rotid e nda rte re ctomy unde r ge ne ra l
a ne sthe sia . W hich of the following would be a ppropria te in the
a ne sthe tic ma na ge me nt of this pa tie nt?
A. Hype rve ntila tion of the lungs to a Pa CO2 of 30 mm Hg to re duce
ICP
B. Inje ction of loca l a ne sthe tic a round the ca rotid body to pre ve nt
bra dyca rdia
C. Initia tion of de libe ra te hypote nsion (a fte r induction of
a ne sthe sia ) to re duce ble e ding
D. Induction of a ne sthe sia with propofol
775. Ane sthe tics tha t de cre a se ICP include
A. Fe nta nyl
B. Nitrous oxide
C. Propofol
776. The ra py tha t is use ful in the tre a tme nt of ce re bra l va sospa sm
include s a ll of the following EXCEPT
A. Blood pre ssure e le va tion
B. He modilution
C. Diure tics
D. Ca lcium cha nne l blocke rs
777. All of the following a re a ssocia te d with a crome ga lic pa tie nts
unde rgoing tra nssphe noida l hypophyse ctomy EXCEPT
A. Enla rge me nt of the tongue a nd e piglottis
B. Na rrowing of the glottic ope ning
C. A 20% to 30% incide nce of difficult intuba tion
D. Incre a se d ne e d for postope ra tive continuous positive a irwa y
pre ssure (CPAP) be ca use obstructive sle e p a pne a (OSA) is
more common
778. The CBF a utore gula tory curve is shifte d to the right by
A. Hypoxia
B. Vola tile a ne sthe tics
C. Hype rca rbia
D. Chronic hype rte nsion
779. Autore gula tion is a bolishe d by
A. Hype rba ric oxyge n
B. Ca rdiopulmona ry bypa ss with a core te mpe ra ture of 27° C
C. Chronic hype rte nsion
D. 3% Isoflura ne
780. Etomida te doe s a ll of the following EXCEPT
A. Abolishe s CO2 re a ctivity
B. Re duce s CMRO2
C. Incre a se s both SSEP a mplitude a nd la te ncy
D. Re duce s CBF
781. Following a motor ve hicle a ccide nt, a 25-ye a r-old ma n is
brought to the ope ra ting room for re pa ir of fa cia l la ce ra tions a nd
fra cture s, a nd a bdomina l e xplora tion. The pa tie nt is e xtre me ly
microgna thic a nd we ighs 150 kg (330 lb). Acce pta ble te chnique s for
se curing the a irwa y include
A. La rynge a l ma sk a irwa y
B. Awa ke fibe roptic intuba tion
C. Dire ct la ryngoscopy a fte r ra pid-se que nce induction
D. Blind na sa l intuba tion
782. Afte r re se ction of a gra de II a strocytoma in a 60-ye a r-old
pa tie nt, the se rum sodium is 127 mEq/L. Urine sodium is 25 mEq/L.
The ra py could include which of the following?
A. Intra na sa l or IV va sopre ssin (DDAVP)
B. 500 mL 3% sa line ove r 30 minute s
C. Chlorpropa mide
D. De me clocycline
783. A 48-ye a r-old, 110-kg ma n with history of me ningioma is
sche dule d for cra niotomy for tumor de bulking. His wife sta te s he
ha s be e n somnole nt a nd confuse d. On e xa mina tion he is note d to
be hype rve ntila ting a nd sle e py, but a rousa ble a nd hype rte nsive .
Use ful me a sure s for his a ne sthe tic include
A. Ra pid-se que nce induction using succinylcholine
B. Hype rve ntila tion to 20 mm Hg
C. 10 cm H2O PEEP to re duce a te le cta sis
D. Esmolol to re duce re sponse to intuba tion
784. If, during a n MRI sca n, a pa tie nt we re to be come pinne d by a
la rge (50 kg) me ta llic obje ct, the a ppropria te course of a ction would
be to
A. Stop the sca n imme dia te ly to re le a se the ma gne t
B. Summon e nough pe ople to pull the obje ct a wa y
C. Inte rrupt e le ctrica l powe r for 60 se conds to re le a se the
ma gne tic force
785. A 45-ye a r-old ma n is unde rgoing a poste rior ce rvica l fusion in
the sitting position. Induction of a ne sthe sia a nd tra che a l intuba tion
a re une ve ntful. Ane sthe sia is ma inta ine d with N2O 50% in O2, a nd
se voflura ne . Sudde nly, a ir is he a rd on the pre cordia l Dopple r
ultra sound. Othe r obse rva tions consiste nt with VAE include
A. De cre a se d Pa CO2
B. De cre a se d ce ntra l ve nous pre ssure
C. De cre a se d pulmona ry a nd a rte ria l blood pre ssure
D. De cre a se d e nd-tida l CO2
786. In pa tie nts with incre a se d ICP, hype rve ntila tion is typica lly
limite d to a Pa CO2 of 25 to 30 mm Hg be ca use a dditiona l
hype rve ntila tion
A. Is virtua lly impossible
B. Ca use s bra in ische mia due to a rightwa rd shifting of the
oxyhe moglobin dissocia tion curve
C. Ma y be a ssocia te d with a worse ning of ne urologic outcome
D. Could re sult in pa ra doxica l ce re bra l va sodila tion
787. Of the me a sure s be low, which is the LEAST use ful in
re sponse to suspe cte d VAE during a ne urosurgica l proce dure in the
upright position?
A. Applica tion of 10 cm H2O PEEP
B. Discontinua tion of N2O
C. Pla ce me nt of wa x on cut bone e dge s
D. Tre nde le nburg position
Neurologic Physiology and Anesthesia
726. (C) The tria d a ssocia te d with ce re bra l sa lt-wa sting syndrome
consists of hypona tre mia , volume contra ction, a nd urine sodium
conce ntra tions ina ppropria te ly high for the give n le ve l of se rum
sodium. It is ma inly se e n in pa tie nts with suba ra chnoid
he morrha ge (SAH). A possible e tiology ma y be re le a se of bra in
na triure tic pe ptide , le a ding to e xce ss urina ry sodium e xcre tion. It is
tre a te d with volume re pla ce me nt, using norma l to hype rtonic
intra ve nous sodium chloride solution, but a voiding ove rly ra pid
se rum sodium corre ction, a s this ma y re sult in ce ntra l pontine
mye linolysis. Ce re bra l sa lt-wa sting syndrome (usua lly hypovole mic)
is difficult to diffe re ntia te from SIADH (usua lly normovole mic or
mildly hype rvole mic) be ca use pa tie nts with SAH ca n ha ve high
a ntidiure tic hormone (ADH) le ve ls se conda ry to tra uma , pa in, e tc. A
de finitive dia gnosis re quire s de monstra tion of a ne ga tive sodium
ba la nce ove r se ve ra l da ys in the se tting of ongoing hypovole mia or
obta ining a 24-hour urine sodium sa mple . Clinica lly, the forme r is
ofte n not fe a sible be ca use of compe ting inte re sts for prophyla xis or
tre a tme nt of ce re bra l va sospa sm with mode ra te hype rvole mia . In
the se tting of ce re bra l sa lt-wa sting syndrome , the 24-hour sodium
va lue is e le va te d. In contra st, hypona tre mia a ssocia te d with SIADH
is due to re na l re te ntion of fre e wa te r (ra the r tha n re na l loss of
sodium). Accordingly, the qua ntity of sodium colle cte d ove r the 24-
hour pe riod a nd CVP should be re la tive ly norma l in SIADH
pa tie nts. The pa tie nt pre se nte d in this que stion is hypona tre mic
a nd ha s a low CVP a nd a 24-hour urine sodium tha t is cle a rly
e le va te d. Colle ctive ly, this supports the dia gnosis of ce re bra l sa lt-
wa sting syndrome . Dia be te s insipidus a nd prima ry
hype ra ldoste ronism a re incorre ct re sponse s, a s both would be
a ssocia te d with incre a se d pla sma sodium conce ntra tions. Tubula r
ne crosis ha s nothing to do with this pa thophysiologic proce ss
727. (B) Ele va te d ICP fre que ntly is the fina l sta ge of a pa thologic
ce re bra l insult (e .g., he a d injury, intra cra nia l tumor, suba ra chnoid
he morrha ge , me ta bolic e nce pha lopa thy, or hydroce pha lus). The
intra cra nia l conte nts consist of thre e compa rtme nts: bra in
pa re nchyma (80%-85%), blood (5%-10%), a nd CSF (5%-10%). None of
the se compone nts is compre ssible ; a ccordingly, a n incre a se in the
volume of a ny of the se re quire s a compe nsa tory de cre a se in the
volume of one or both of the othe r compone nts to a void the
de ve lopme nt of intra cra nia l hype rte nsion. Norma l ICP is le ss tha n
15 mm Hg. As me a sure d in the supine position, intra cra nia l
hype rte nsion is de fine d a s a susta ine d incre a se in ICP a bove 15 to
20 mm Hg (Miller: Basics of Anesth esia, ed 6, p 478).
728. (B) Ce re bra l pe rfusion pre ssure is e qua l to me a n a rte ria l
pre ssure (MAP) minus ICP. In the pre se nt ca se , MAP e qua ls
80 mm Hg (dia stolic pre ssure , 70, plus one third the pulse pre ssure ,
10). Thus, 80 − 15 = 65 (Miller: Basics of Anesth esia, ed 6, p 478).
729. (C) Soma tose nsory e voke d pote ntia ls (SSEPs) a re volta ge
signa ls tha t a ppe a r in re sponse to e le ctrica l stimula tion of
pe riphe ra l ne rve s. The impulse e licite d by e le ctrica l stimula tion of
a pe riphe ra l ne rve a sce nds the ipsila te ra l dorsa l column of the
spina l cord, de cussa te s in the me dulla oblonga ta , a nd is ultima te ly
re corde d on the contra la te ra l soma tose nsory corte x of the bra in.
The signa ls a re compose d of ne ga tive a nd positive volta ge
de fle ctions with spe cific la te ncie s a nd a mplitude s. In ge ne ra l, the
e a rlie r de fle ctions re pre se nt impulse s a nd syna pse s within the
spina l cord or bra in ste m, whe re a s the la te r impulse s re pre se nt
tha la mic a nd/or cortica l syna pse s. Intra ope ra tive monitoring of
SSEPs provide s the a bility to a sse ss the inte grity of the se nsory
structure s a long this a sce nding ne ura l pa thwa y (e .g., a pe riphe ra l
ne rve such a s the poste rior tibia l ne rve , dorsa l columns, bra in
ste m, me dia l le mniscus, inte rna l ca psule , a nd soma tose nsory
corte x) (Miller: Basics of Anesth esia, ed 6, p 328; Miller: Miller’s
730. (B) Hype rve ntila tion of the lungs ca use s constriction of ce re bra l
blood ve sse ls, which re duce s globa l ce re bra l blood flow (CBF) a nd
ce re bra l blood volume (CBV). This e ffe ct is me dia te d by cha nge s in
the pH induce d in the e xtra ce llula r fluid. In contra st to
a utore gula tion, CO2 re a ctivity is pre se rve d in most pa tie nts with
se ve re bra in injury; thus, hype rve ntila tion ca n ra pidly lowe r ICP
through the re duction in CBV. Although the e ffe cts of
hype rve ntila tion on CBV a nd ICP a re a lmost imme dia te , the
dura tion of e ffe ct wa ne s a fte r 6 to 10 hours of hype rve ntila tion a nd
ma y la st up to 24 to 36 hours, be ca use the pH of the e xtra ce llula r
fluid e quilibra te s to the lowe r Pa CO2 le ve l. Ge ne ra lly spe a king,
CBF incre a se s (or de cre a se s) by a pproxima te ly 2% for e a ch mm Hg
incre a se (or de cre a se ) in Pa CO2. CBF incre a se s (or de cre a se s) 1
mL/100 g/min pe r 1 mm Hg incre a se (or de cre a se ) in Pa CO2.
Be ca use norma l globa l CBF is 50 mL/100 g/min, a 1-mL/100 g/min
a lte ra tion in CBF re pre se nts a 2% cha nge (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 5, p 200; Miller: Miller’s
Anesth esia, ed 8, pp 388–390, Box 17-1).
731. (C) Of the choice s liste d in this que stion, ke ta mine is the only
intra ve nous a ne sthe tic tha t is not re comme nde d for pa tie nts with
intra cra nia l hype rte nsion be ca use it incre a se s ce re bra l me ta bolic
ra te (CMR), CBF, CBV, a nd ICP. Ba rbitura te s, e tomida te , a nd
propofol de cre a se CMR, CBF, CBV, a nd ICP. All thre e of the se
a ge nts indire ctly de cre a se CBF by the ir inhibitory e ffe ct on CMR.
Howe ve r, unlike thiope nta l, e tomida te a lso ha s a dire ct
va soconstrictor e ffe ct on the ce re bra l va scula ture . One pote ntia l
a dva nta ge of e tomida te ove r thiope nta l is tha t it doe s not produce
significa nt ca rdiova scula r de pre ssion. Although not a s pronounce d
a s the ba rbitura te s, be nzodia ze pine s such a s mida zola m a lso
re duce CMR a nd CBF. Fluma ze nil, a be nzodia ze pine a nta gonist, ha s
be e n re porte d to re ve rse the e ffe ct of mida zola m on CMR, CBF,
CBV, a nd ICP. Conse que ntly, fluma ze nil should be a voide d in
mida zola m-a ne sthe tize d pa tie nts known to ha ve intra cra nia l
hype rte nsion. Ge ne ra lly spe a king, the opioid a ne sthe tics, such a s
morphine a nd fe nta nyl, ca use e ithe r a minor re duction or ha ve no
e ffe ct on CBF a nd CMR. Although ma ny of the se IV drugs re duce
ICP, none ha s be e n shown to provide ne uroprote ction to huma ns
with e ithe r foca l (like stroke ) or globa l (like ca rdia c a rre st)
ische mia (Miller: Basics of Anesth esia, ed 6, p 478).
732. (C) During a cute foca l ce re bra l ische mia , re giona l
va sopa ra lysis re sults in impa ire d coupling be twe e n CBF a nd CMR.
Conse que ntly, CBF e xce e ds CMR a nd is pa ssive ly a ssocia te d with
syste mic a rte ria l blood pre ssure . Unde r the se circumsta nce s,
a utore gula tion a nd the re a ctivity of the ce re brova scula ture to
ca rbon dioxide is a lso impa ire d. Thus, tight control of syste mic
a rte ria l blood pre ssure is importa nt in ma na ging pa tie nts with foca l
ische mia , be ca use ce re bra l pe rfusion is highly de pe nde nt on me a n
a rte ria l blood pre ssure . Blood flow dire cte d from a norma l re gion
of the bra in to a n ische mic re gion is known a s the “Robin Hood
phe nome non” (i.e ., robbing from the rich a nd giving to the poor).
Thus, choice s B a nd D a re synonymous incorre ct re sponse s (Miller:
733. (C) Ce re bra l ische mia ha s be e n re porte d in both huma ns a nd
la bora tory a nima ls whe n the Pa CO2 is re duce d be low 20 mm Hg. It
is like ly tha t ce re bra l ische mia is ca use d by a le ftwa rd shift of the
oxyhe moglobin dissocia tion curve (produce d by the se ve re
a lka losis) a nd possibly by inte nse ce re bra l va soconstriction. A
le ftwa rd shift of the oxyhe moglobin dissocia tion curve incre a se s
the a ffinity of he moglobin for O2, which re duce s off-loa ding of O2
from he moglobin a t the ca pilla ry be d. This e ffe ct combine d with
de cre a se d CBF ca n re sult in ce re bra l ische mia . Combine d with the
fa ct tha t the re is ve ry little a dditiona l be ne fit in te rms of re ducing
CBV a nd ICP, it is re comme nde d to limit a cute hype rve ntila tion of
the lungs to a Pa CO2 of 25 to 30 mm Hg. W ithin this ra nge , re duction
in ICP is ma xima l, a nd risk of ce re bra l ische mia is minima l. As a n
a side , hype rve ntila tion-induce d re spira tory a lka losis ca n
pre cipita te hypoka le mia . Spe cifica lly, se rum pota ssium de cre a se s
0.6 mEq/L for e a ch 0.1-unit incre a se in pH. Thus, ove rly a ggre ssive
hype rve ntila tion should be gua rde d a ga inst to a void possible
hypoka le mia -induce d ca rdia c a rrhythmia s (Miller: Miller’s
734. (A) Five pe rce nt de xtrose in wa te r (D5W ) is contra indica te d in
ne urosurgica l pa tie nts with intra cra nia l hype rte nsion for two
re a sons. First, D5W e a sily pa sse s through the blood-bra in ba rrie r.
Once in the bra in tissue , glucose is ra pidly me ta bolize d, le a ving
only fre e wa te r, which ca use s ce re bra l e de ma . Se cond,
hype rglyce mia is a ssocia te d with incre a se d se ve rity of ne urologic
da ma ge in pa tie nts with ce re bra l ische mia . The e tiology of
hype rglyce mia -induce d worse ning of ne urologic injury is a ssocia te d
with simple bioche mica l proce sse s.
Both la cta te a nd H+ a re ha rmful to compromise d ne urons a nd

glia . Furthe rmore , in the se tting of hype rglyce mia the a na e robic
re a ction is force d to the right, re sulting in a dditiona l
a ccumula tion of the se toxic me ta bolite s, the re by worse ning
ne urologic outcome (Miller: Miller’s Anesth esia, ed 8, pp 2172–2173).
735. (A) Exce pt e smolol, a ll of the drugs liste d a re pote nt ce re bra l
va sodila tors ca pa ble of furthe r incre a sing ICP, which would be
highly unde sira ble in this pa tie nt. By contra st, e smolol is a
ca rdiose le ctive β1-a dre ne rgic re ce ptor a nta gonist with ra pid onse t
a nd short dura tion of a ction due to hydrolysis by re d blood ce ll
e ste ra se s. Pla sma choline ste ra se s a nd re d ce ll me mbra ne
a ce tylcholine ste ra se do not pla y a role in its de gra da tion. Esmolol
e ffe ctive ly blunts the sympa the tic re sponse to dire ct la ryngoscopy
a nd tra che a l intuba tion, ye t is de void of de le te rious e ffe cts on CBV
or ICP (Miller: Miller’s Anesth esia, ed 8, pp 394-395; Cottrell: Cottrell and
Young’s Neuroanesth esia, ed 5, pp 82–83).
736. (B) Norma l globa l CBF is a pproxima te ly 45 to 55 mL/100 g/min.
Cortica l CBF (gra y ma tte r) is a pproxima te ly 75 to 80 mL/100 g/min,
a nd subcortica l CBF (mostly white ma tte r) is a pproxima te ly
20 mL/100 g/min. Fa ctors tha t re gula te CBF include Pa CO2, Pa O2,
CMR, ce re bra l pe rfusion pre ssure , a utore gula tion, a nd the
a utonomic ne rvous syste m (Miller: Miller’s Anesth esia, ed 8, p 388, Box
17-1).
737. (D) Ce re bra l blood flow (CBF) a utore gula tion is the intrinsic
ca pa bility of the ce re bra l va scula ture to a djust its re sista nce to
ma inta in CBF consta nt ove r a wide ra nge of me a n a rte ria l blood
pre ssure s. In normote nsive a dults, lowe r a nd uppe r limits of
a utore gula tion a re ce re bra l pe rfusion pre ssure s of 50 to 60 mm Hg
a nd 150 to 160 mm Hg, re spe ctive ly. Above or be low the limits of
CBF a utore gula tion, CBF is pre ssure de pe nde nt. Although the
pre cise me cha nism of CBF a utore gula tion is not known, it is
thought to re sult from a n intrinsic cha ra cte ristic of ce re bra l va scula r
smooth muscle tha t ha s not ye t be e n ide ntifie d (Morgan: Clinical
Anesth esiology, ed 4, p 616; Miller: Miller’s Anesth esia, ed 8, p 391).
738. (B) Ce re bra l blood flow (CBF) will incre a se by a pproxima te ly
1 mL/100 g/min for e ve ry 1-mm Hg incre a se in Pa CO2 (i.e .,
a pproxima te ly 2%). This e ffe ct is ca use d by a CO2-me dia te d
de cre a se in the pH of the e xtra ce llula r fluid surrounding the
ce re bra l ve sse ls, which ca use s ce re bra l va sodila ta tion. The pH
cha nge s ra pidly be ca use CO2 diffuse s fre e ly a cross the ce re bra l
va scula r e ndothe lium into the e xtra ce llula r fluid. Howe ve r, the
cha nge in pH wa ne s a fte r 6 to 10 hours be ca use e xtra ce llula r fluid
pH is gra dua lly norma lize d by re a bsorption of HCO3– a nd e xcre tion
of H by the kidne ys. An incre a se in Pa CO2 of 10 mm Hg (from 35 to
45 mm Hg) will re sult in a n incre a se in CBF of a pproxima te ly
10 mL/100 g/min (Miller: Miller’s Anesth esia, ed 8, p 390).
739. (C) Autonomic hype rre fle xia is a ne urologic disorde r tha t
occurs in a ssocia tion with re solution of spina l shock a nd a re turn
of spina l cord re fle xe s. Cuta ne ous or visce ra l stimula tion (such a s
diste ntion of the urina ry bla dde r or re ctum) be low the le ve l of the
spina l cord tra nse ction initia te s a ffe re nt impulse s tha t a re
tra nsmitte d to the spina l cord a t this le ve l, which subse que ntly
e licits re fle x sympa the tic a ctivity ove r the spla nchnic ne rve s.
Be ca use modula tion of this re fle x sympa the tic a ctivity from highe r
ce nte rs in the ce ntra l ne rvous syste m is lost (a s a re sult of the
spina l cord tra nse ction), the re fle x sympa the tic a ctivity be low the
le ve l of the injury re sults in inte nse ge ne ra lize d va soconstriction
a nd hype rte nsion. Bra dyca rdia occurs se conda ry to a ctiva tion of
ba rore ce ptor re fle xe s a rising from the ca rotid or a ortic sinus. The
incide nce of a utonomic hype rre fle xia during ge ne ra l a ne sthe sia
de pe nds on the le ve l of the spina l cord tra nse ction. Approxima te ly
85% of pa tie nts with a spina l cord tra nse ction a bove the T6
de rma tome will e xhibit this re fle x during ge ne ra l a ne sthe sia . In
contra st, it is difficult to e licit this re fle x in pa tie nts with a spina l
cord tra nse ction be low the T10 de rma tome . Tre a tme nt of
a utonomic hype rre fle xia is with α-a dre ne rgic re ce ptor a nta gonists
(e .g., phe ntola mine ), dire ct-a cting va sodila tors (e .g., nitroprusside ,
fe noldopa m, or nitroglyce rin), a nd de e p ge ne ra l or re giona l
a ne sthe sia . Pa tie nts with a utonomic hype rre fle xia should not be
tre a te d initia lly with propra nolol or othe r β-a dre ne rgic re ce ptor
a nta gonists for thre e re a sons. First, bra dyca rdia ca n be pote ntia te d
by β1-a dre ne rgic re ce ptor blocka de ; se cond, β2-a dre ne rgic re ce ptor
blocka de in ske le ta l muscle will le a ve the α-a dre ne rgic prope rtie s
of circula ting ca te chola mine s unoppose d, the re by ca using a
pa ra doxica l hype rte nsive re sponse ; a nd third, a combina tion of
unoppose d α-me dia te d va soconstriction couple d with β1-a dre ne rgic
ne ga tive inotropy could re sult in conge stive he a rt fa ilure (Miller:
740. (C) The bra in is a n obliga te a e robe , a s it ca nnot store oxyge n.
Unde r norma l circumsta nce s, the re is a substa ntia l sa fe ty ma rgin in
tha t the de live ry of oxyge n is conside ra bly gre a te r tha n de ma nd.
Oxyge n consumption is in the ra nge of 3 to 5 mL/100 g of bra in
tissue /min, whe re a s the de live ry of oxyge n is a pproxima te ly 50 mL
blood/100 g bra in tissue /min. W hole -bra in oxyge n consumption
re pre se nts a bout 20% of tota l-body oxyge n utiliza tion (Miller: Miller’s
741. (B) Soma tose nsory e voke d pote ntia ls (SSEPs) a re compose d of
ne ga tive a nd positive volta ge de fle ctions with spe cific la te ncie s a nd
a mplitude s. Ba se line va lue s for la te ncy a nd a mplitude must be
e sta blishe d for e a ch pa tie nt prior to surge ry be ca use the
cha ra cte ristics of SSEP wa ve forms cha nge with re cording
circumsta nce s (e .g., the la te ncy be come s gre a te r a nd the a mplitude
be come s sma lle r a s the dista nce be twe e n the ne ura l ge ne ra tor
a nd the re cording e le ctrode is incre a se d). Ische mia , ne urologic
injury, or tra nse ction of a ne ura l pa thwa y (i.e ., surgica l ca use s) will
re sult in a de cre a se in signa l a mplitude a nd/or incre a se in signa l
la te ncy. Alte rna tive ly, such cha nge s ma y re sult from me dica tions
a dministe re d by the a ne sthe sia ca re te a m (e .g., isoflura ne ,
se voflura ne , de sflura ne , propofol, ba rbitura te s, be nzodia ze pine s).
Ta ke n toge the r, should signa l de ca y occur during surge ry, it is
impe ra tive for the a ne sthe siologist to ha ve a ve ry syste ma tic
a pproa ch to e lucida te the e tiology of signa l cha nge . More
spe cifica lly, nonsurgica l ca use s should be promptly rule d out (e .g.,
wa s a me dica tion re ce ntly a dministe re d or dose cha nge d,
hypothe rmia , hypote nsion, a ne mia , hypoxe mia ). Also se e
e xpla na tion to Que stion 746 (Miller: Miller’s Anesth esia, ed 8, pp 1520–
1521).
742. (C) The ce re bra l me ta bolic ra te for oxyge n (CMRO2) de cre a se s
a pproxima te ly 6% pe r 1° C of te mpe ra ture re duction. Hypothe rmia
ha s be e n re porte d to improve ne urologic outcome a fte r foca l or
globa l bra in ische mia . Historica lly, the e xte nt of bra in prote ction
wa s thought to be proportiona l to the ma gnitude of hypothe rmia -
me dia te d re duction in CMRO2. Howe ve r, more re ce nt studie s ha ve
de monstra te d tha t te mpe ra ture re ductions of a me re 1° C to 2° C
significa ntly improve postische mic ne urologic outcome . Propose d
me cha nisms for te mpe ra ture modula tion of postische mic
ne urologic outcome include a lte ra tions in CMRO2, blood-bra in
ba rrie r sta bility, me mbra ne de pola riza tion, ion home osta sis (e .g.,
ca lcium fluxe s), ne urotra nsmitte r re le a se (e .g., gluta ma te or
a spa rta te ), e nzyme function (e .g., phospholipa se , xa nthine oxida se ,
or nitric oxide syntha se ), a nd fre e ra dica l production or sca ve nging
743. (D) Bra in de a th is de fine d a s irre ve rsible ce ssa tion of bra in
function. It is e xtre me ly importa nt to ide ntify a nd re ve rse a ny
fa ctors tha t ca n mimic the clinica l or la bora tory crite ria for bra in
de a th, such a s hypothe rmia , drug intoxica tion (hypnotic se da tive s
a nd ma jor tra nquilize rs), or me ta bolic e nce pha lopa thy. Clinica l
crite ria for bra in de a th ca n be divide d into those tha t a re re la te d to
cortica l function a nd those tha t a re re la te d to bra in ste m function.
Abse nce of cortica l function is ma nife ste d by la ck of sponta ne ous
motor a ctivity, consciousne ss, a nd purpose ful move me nt in
re sponse to pa inful stimuli. Abse nce of bra in ste m function is
ma nife ste d by the ina bility to e licit re fle xe s, such a s the pupilla ry
re sponse to light a nd the corne a l, oculoce pha lic, oculove stibula r,
oropha rynge a l, a nd re spira tory re fle xe s. For e xa mple , in pa tie nts
without bra in ste m function, the re is no incre a se in he a rt ra te
whe n a tropine is a dministe re d intra ve nously (due to a bse nce of
na tive va ga l tone from the bra in ste m), a nd the re is no re spira tory
e ffort during a pne a e ve n whe n the Pa CO2 is gre a te r tha n 60 mm Hg.
De ce re bra te a nd de cortica te posturing a re not consiste nt with the
dia gnosis of bra in de a th (Miller: Miller’s Anesth esia, ed 8, pp 2317–
2326).
744. (C) The most common complica tions a ssocia te d with the
surgica l sitting position include ve nous a ir e mbolism (VAE),
pa ra doxica l VAE, ca rdiova scula r insta bility, pne umoce pha lus,
subdura l he ma toma , pe riphe ra l ne uropa thy, a nd qua driple gia
(qua driple gia is possibly ca use d by compre ssion ische mia of the
ce rvica l spina l cord in pa tie nts with a be rra nt spina l cord blood
supply). VAE occurs whe n a ir is e ntra ine d into ope n ve ins in the
pre se nce of ne ga tive intra lumina l pre ssure s (i.e ., ne ga tive with
re spe ct to a tmosphe ric pre ssure ). Significa nt VAE ca n re sult in
re duce d ca rdia c output a nd profound hypoxia . Curre nt de vice s
use d to de te ct VAE include the tra nse sopha ge a l e choca rdiogra ph,
Dopple r ultra sound, pulmona ry a rte ry ca the te r, infra re d
spe ctrome te r (to monitor cha nge s in P ECO2 a nd P EN 2), right a tria l
ca the te r, a nd e sopha ge a l ste thoscope (to liste n for a “mill whe e l”
ca rdia c murmur). The most se nsitive me a ns of dia gnosing VAE
include tra nse sopha ge a l e choca rdiogra phy or pre cordia l Dopple r
monitoring (se e e xpla na tion to Que stion 748) (Miller: Miller’s
Anesth esia, ed 8, p 2170; Faust: Anesth esiology Review, ed 3, pp 389–391,
Figure 158-1).
745. (C) Intra cra nia l pre ssure is de te rmine d by the pre ssure
contribution of thre e volume compa rtme nts: bra in pa re nchyma 80%
to 90%, CSF 5% to 10%, a nd blood 5% to 10%. Unde r norma l
circumsta nce s, ICP is ma inta ine d within the norma l ra nge (i.e .,
≤15 mm Hg) ove r a wide ra nge of intra cra nia l volume s (ICVs) due to
the following thre e compe nsa tory me cha nisms: (1) tra nsloca tion of
CSF from the intra cra nia l to spina l suba ra chnoid spa ce ; (2)
tra nsloca tion of intra cra nia l blood (prima rily ve nous) to syste mic
circula tion; a nd (3) re a bsorption of CSF a cross a ra chnoid villi into
the dura l ve nous sinus a nd, ultima te ly, into syste mic circula tion.
Once the se compe nsa tory me cha nisms a re e xha uste d, sma ll
incre a se s in ICV re sult in la rge incre a se s in ICP (i.e ., a situa tion
of incre a se d intra cra nia l e la sta nce ), which le a ve s the bra in
vulne ra ble to ische mia a nd he rnia tion. CSF production is fa irly
consta nt (0.35 to 0.40 mL/min) re ga rdle ss of ICP (Miller: Miller’s
Anesth esia, ed 8, p 2159, Figure 63-3; Faust: Anesth esiology Review, ed
3, p 376).
746. (B) Postope ra tive ne urologic dysfunction is a ra re but se rious

complica tion of spina l re constructive surge ry. In ca se s whe re spina l
cord dysfunction is more like ly to occur (e .g., surgica l corre ction of
se ve re scoliosis), spina l cord monitoring is use d to ide ntify
ische mia a nd ide a lly to a llow the surge on time to modify the
proce dure to re ve rse a ny spina l cord dysfunction se e n during
ge ne ra l a ne sthe sia .
Soma tose nsory e voke d pote ntia ls (SSEPs) involve re pe titive
stimula tion of the e xtre mity a nd monitoring the signa ls a t the
le ve l of the sca lp. SSEPs a re use d to monitor the dorsa l columns
of the spina l cord. As this a re a is se nsory, ne uromuscula r
blocke rs such a s ve curonium do not a ffe ct SSEP monitoring.
Motor e voke d pote ntia ls (MEPs) monitoring is use d to monitor
corticospina l tra cts (motor pa thwa ys) tha t a re not a sse sse d with
SSEPs. Ne uromuscula r blocke rs inte rfe re with MEP monitoring
a nd should not be use d.
Ele ctrocorticogra phy (ECoG) monitoring is use d to ide ntify
e pile ptoge nic foci during se izure surge ry or to a sse ss ce re bra l
cortica l inte grity during ca rotid e nda rte re ctomy. The ECoG is
a lte re d by drugs tha t a ffe ct the se izure thre shold (e .g.,
be nzodia ze pine s a s we ll a s vola tile a ne sthe tics). The bispe ctra l
inde x monitor (BIS) use s proce sse d e le ctroe nce pha logra phic
(EEG) signa ls to me a sure le ve l of consciousne ss in a n a tte mpt to
de cre a se intra ope ra tive a wa re ne ss (Miller: Basics of Anesth esia, ed
6, p 480).
747. (D) The MRI sca nne r is pote ntia lly da nge rous for se ve ra l
re a sons. The most obvious is the risk of proje ctile s tra ve ling
towa rd the pa tie nt. Obje cts ma de of iron, nicke l, a nd coba lt a re
strongly pulle d by the consta nt ma gne tic force (up to 3 T). A more
insidious but e qua lly da nge rous ha za rd is re pre se nte d by
indwe lling de vice s, such a s pa ce ma ke rs, pumps, a ne urysm clips,
a nd orthope dic prosthe se s. The inte ra ctions be twe e n the se a nd
the ma gne tic fie ld ca n be ha rmful or e ve n le tha l for the pa tie nt
unde r some circumsta nce s. Fina lly, the a nte nna e ffe ct of the MRI
sca nne r ca n induce he a t in wire s tha t a re in close proximity to the
pa tie nt. For this re a son, pulmona ry a rte ry (PA) ca the te rs a nd
urina ry ca the te rs with te mpe ra ture wire s e mbe dde d in the m
ca nnot be use d in pa tie nts unde rgoing MRI sca nning. Sta nda rd
pulse oxime te rs a nd ECG wire s a re a lso una cce pta ble , but spe cia l
MRI-compa tible probe s with fibe roptic “ca ble s” ca n be sa fe ly use d
a s ca n “wire le ss” ECG pa tche s. Arte ria l line s do not pose a
proble m in the sca nne r be ca use no wire s come into conta ct with
the pa tie nt. The fluid-fille d tubing is not fe rroma gne tic a nd the
tra nsduce r is fixe d, a wa y from the pa tie nt (Faust: Anesth esiology
Review, ed 3, pp 533–534; Miller: Miller’s Anesth esia, ed 8, p 2660).
748. (A) Exce pt for the tra nse sopha ge a l e choca rdiogra ph (TEE), the
Dopple r ultra sound is the most se nsitive de vice for de te ction of
intra ca rdia c a ir. Unde r ide a l circumsta nce s, a s little a s 0.25 mL of
intra ca rdia c a ir ca n be de te cte d by this de vice . In contra st, TEE ca n
de te ct e ve n sma lle r volume s of intra ca rdia c a ir (Cottrell: Cottrell and
Young’s Neuroanesth esia, ed 5, p 210; Miller: Basics of Anesth esia, ed 6, p
482).
749. (B) Arte ria l ca rbon dioxide te nsion (Pa CO2) is one of the most
importa nt e xtra ce re bra l bioche mica l fa ctors re gula ting CBF. The
ce re bra l va scula ture is most se nsitive to cha nge s in Pa CO2 within
the physiologic ra nge (i.e ., a pproxima te ly 20-80 mm Hg). In ge ne ra l,
the re giona l se nsitivity of the ce re bra l va scula ture to cha nge s in
Pa CO2 (i.e ., CO2 re sponsive ne ss) is dire ctly proportiona l to the
re sting CMR for e a ch re gion of the bra in. Thus, re giona l CO2
re sponsive ne ss is gre a te st in the ce re brum, le ss in the ce re be llum,
a nd le a st in the spina l cord (Cottrell: Cottrell and Young’s
Neuroanesth esia, ed 5, pp 25–26).
750. (A) Both la bora tory a nd clinica l studie s ha ve re porte d tha t
hype rglyce mia a t the time of e ithe r foca l (e .g., stroke ) or globa l
(e .g., syste mic shock or ca rdia c a rre st) ische mia re sults in a
worse ning of ne urologic outcome (i.e ., both histologic a nd
functiona l). Unfortuna te ly, it is not wide ly a ppre cia te d tha t the
a dministra tion of glucose doe s not ne e d to produce high blood
glucose le ve ls to a ugme nt postische mic ce re bra l injury. Thus,
glucose -conta ining solutions should not be a dministe re d to pa tie nts
who a re a t risk for e ithe r ce re bra l or spina l cord injury (Gupta:
Essentials of Neuroanesth esia and Neurointensive Care, ed 1, pp 238-240;
Cottrell: Cottrell and Young’s Neuroanesth esia, ed 5, p 409).
751. (D) The tip of multiorifice d right a tria l ca the te rs must be
a ccura te ly pla ce d a t the junction of the supe rior ve na ca va a nd
right a trium, be ca use a ir ha s a te nde ncy to loca lize a t this junction.
Se ve ra l me thods ca n be use d to e nsure tha t the ca the te r tip is
a ccura te ly positione d a t this junction. For e xa mple , a che st x-ra y
film ca n be obta ine d. Howe ve r, the re ma y be difficulty in
inte rpre ting the position of the tip of the ca the te r, a nd the ca the te r
could migra te a fte r the x-ra y film is obta ine d. Ca rdiova scula r
pre ssure s could be monitore d, but this te chnique re quire s tha t the
tip of the ca the te r first be introduce d into the right ve ntricle a nd
the n pulle d ba ck into the right a trium. Introduction of the tip of the
ca the te r into the right ve ntricle could ca use dysrhythmia s, he a rt
block, or ble e ding, or rupture of ca rdia c structure s. A te chnique
fre que ntly use d to a ccura te ly pla ce multiorifice d ca the te rs a t the
junction of the supe rior ve na ca va a nd right a trium is intra va scula r
ECG. The a ppropria te position of the ca the te r is confirme d whe n a
la rge ne ga tive P comple x is obta ine d on the e le ctroca rdiogra m.
The P comple x shown in the figure of this que stion is bipha sic,
which indica te s tha t the tip of the ca the te r is in the mida tria l
position a nd should be withdra wn slightly until the re is a la rge
ne ga tive downwa rd configura tion of the P comple x. Fina lly,
tra nse sopha ge a l e choca rdiogra phy ca n be use d to confirm ca the te r
tip pla ce me nt (Atlee: Com plications in Anesth esia, ed 2, p 582, Table 144-
1).
752. (B) Critica l CBF is the CBF be low which EEG e vide nce of
ce re bra l ische mia be gins to a ppe a r. Critica l CBF in pa tie nts
a ne sthe tize d with isoflura ne , de sflura ne , or se voflura ne is
a pproxima te ly 10 mL/100 g/min. In contra st, critica l CBF in pa tie nts
a ne sthe tize d with ha lotha ne is 18 to 20 mL/100 g/min, a nd critica l
CBF in pa tie nts a ne sthe tize d with e nflura ne is a bout
15 mL/100 g/min. Ba se d on studie s tha t compa re d the re quire me nt
for shunt pla ce me nt a fte r ca rotid a rte ry cross-cla mping in pa tie nts
unde r isoflura ne , e nflura ne , a nd ha lotha ne a ne sthe sia , it a ppe a rs
tha t isoflura ne might provide some de gre e of ce re bra l prote ction
a ga inst incomple te re giona l ce re bra l ische mia in huma ns;
howe ve r, a ne sthe sia -modula te d bra in prote ction re ma ins
spe cula tive , a s outcome -ba se d e vide nce is la cking in huma ns
(Cottrell: Cottrell and Young’s Neuroanesth esia, ed 5, pp 30–31).
753. (A) It is importa nt to note tha t CBF a utore gula tion is e a sily
impa ire d a nd modifie d by nume rous fa ctors, such a s ce re bra l
va sodila tors (including vola tile a ne sthe tics), chronic hype rte nsion,
a nd ce re bra l ische mia . Ce re bra l ische mia a bolishe s CBF
a utore gula tion such tha t CBF be come s pa ssive ly de pe nde nt on the
ce re bra l pe rfusion pre ssure (Cottrell: Cottrell and Young’s
Neuroanesth esia, ed 5, pp. 30–31).
754. (C) Cha nge s in pla sma Pa CO2 will a ffe ct ce re bra l va scula r tone .
Hypoca rbia (a ssocia te d with hype rve ntila tion) will ra pidly ca use
va soconstriction, the re by re ducing CBF, CBV, a nd ICP. Thus,
hype rve ntila tion is the te chnique tha t will be most ra pidly a va ila ble
to de cre a se ICP in pa tie nts with a n intra cra nia l ma ss (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, pp 187–188).
755. (D) In ge ne ra l, the ce re brova scula r re sponse to cha nge s in
Pa CO2 is pre se rve d a fte r the a dministra tion of intra ve nous
a ne sthe tics. Spe cifica lly, in huma ns, CO2 re a ctivity is ma inta ine d
with propofol or ba rbitura te conce ntra tions sufficie nt to produce
burst suppre ssion on the EEG (Miller: Miller’s Anesth esia, ed 8, pp
396–397).
756. (C) Ce re bra l a utore gula tion ca n be impa ire d unde r ce rta in
conditions including bra in tumors, a rte riove nous ma lforma tions,
suba ra chnoid he morrha ge , intra cra nia l surge ry, a nd tra uma tic bra in
injury (TBI). Vola tile a ne sthe tics a bove 1 MAC impa ir ce re bra l
a utore gula tion; howe ve r, in low dose s (i.e ., be low 1 MAC),
a utore gula tion is ma inta ine d. Tota l intra ve nous a ne sthe sia (TIVA)
doe s not impa ir ce re bra l a utore gula tion (Miller: Basics of Anesth esia,
ed 6, p 478; Miller: Miller’s Anesth esia, ed 8, pp 2176–2187).
757. (C) The ge ne ra l a pproa ch to tre a ting pa tie nts following VAE is
to: (1) stop furthe r a ir e ntra inme nt; (2) a spira te e ntra ine d a ir; (3)
pre ve nt e xpa nsion of e xisting a ir; a nd (4) support ca rdiova scula r
function. Ce ssa tion of subse que nt a ir e ntra inme nt is a chie ve d by
flooding the surgica l fie ld with irriga tion fluid. Additiona lly,
noncolla psible ve ins ca n be se a le d using e le ctroca ute ry, ve sse l
liga tion, or bone wa x. Ne ck ve ins ca n be compre sse d a s a me a ns
of incre a sing jugula r ve nous pre ssure , which mitiga te s or pre ve nts
furthe r a ir e ntry a nd he lps loca lize the source of a ir. A multiorifice d
right a tria l ca the te r, pla ce d be fore the e ve nt, is the most e ffe ctive
me a ns of a spira ting VAE. To pre ve nt e xpa nsion of the VAE, nitrous
oxide is imme dia te ly discontinue d. Ca rdiova scula r function is
supporte d using inotrope s, va sopre ssors, a nd intra ve nous fluids a s
indica te d. Of the re sponse options provide d, PEEP is the le a st
corre ct a nswe r. Approxima te ly 20% to 30% of huma ns ha ve a probe
pa te nt fora me n ova le . Initia tion of PEEP ma y incre a se the risk of
pa ra doxica l e mbolism or de cre a se ve nous e fflue nt from the
ca lva rium, re sulting in incre a se d CBV a nd ICP (Barash : Clinical
758. (D) The risk of ve nous a ir e ntra inme nt e xists whe ne ve r the
ope ra tive fie ld is a bove the le ve l of the right a trium. Air e nte rs the
ve nous circula tion a nd tra ve ls to the right a trium, whe re it
continue s into the right ve ntricle a nd pa sse s into the lungs or
pa sse s right to le ft through a pa te nt fora me n ova le . Pa ssa ge
through the pa te nt fora me n ma y le a d to stroke or, if a ir finds its
wa y into corona ry a rte rie s, myoca rdia l infa rction a nd ca rdia c
a rre st. Air in the pulmona ry a rte ry ca n incre a se pulmona ry
va scula r re sista nce (PVR) a nd ca use right he a rt stra in a nd
dysrhythmia s. Re fle x bronchoconstriction ma y be ca use d by
microva scula r bubble s a nd by the re le a se of infla mma tory
me dia tors from e ndothe lia l ce lls re sulting in hypoxe mia . VAE
ca use s hypote nsion, not hype rte nsion, a nd de a th is usua lly from
ca rdiova scula r colla pse (Barash : Clinical Anesth esia, ed 7, p 1446;
Cottrell: Cottrell and Young’s Neuroanesth esia, ed 5, pp 207–208; Faust:
Anesth esiology Review, ed 3, pp 389–391, Figure 158-1).
759. (B) Surgica l tre a tme nt of ca rotid a rte ry ste nosis gre a tly
de cre a se s the risk of stroke , e spe cia lly in me n with a ste nosis
dia me te r gre a te r tha n 70%. Studie s show a high ra te of stroke in
pa tie nts with a symptoma tic ca rotid ste nosis gre a te r tha n 75%, a nd
80% of ca rotid a the rothrombotic stroke s occur without wa rning.
The Asymptoma tic Ca rotid Athe roscle rosis Study, the la rge st
comple te d clinica l tria l, de monstra te d tha t pa tie nts with
a symptoma tic ca rotid ste nosis (≥60%) who we re tre a te d with
ca rotid e nda rte re ctomy a nd a spirin ha ve a re duce d 5-ye a r risk of
ipsila te ra l stroke compa re d with pa tie nts tre a te d with a spirin
a lone (5.1% ve rsus 11.0%). Dopple r studie s a lso show tha t 70% to
75% ste nosis re pre se nts the point a t which a pre ssure drop a cross
the ste nosis is like ly to occur. Thus, if colla te ra l circula tion is not
a de qua te , low-flow tra nsie nt ische mic a tta cks a nd infa rcts occur. It
would be conside re d most a ppropria te to furthe r study the pa tie nt’s
ca rotid a rte ry dise a se be fore proce e ding with a n e le ctive ca se
(Cottrell: Cottrell and Young’s Neuroanesth esia, ed 5, pp 279–285; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 165–167.)
760. (B) In pa tie nts who ha ve ha d a ce re bra l va scula r a ccide nt a s a
re sult of occlusive va scula r dise a se , the re is a loss of norma l
va somotor re sponse s to cha nge s in Pa CO2 a nd a rte ria l blood
pre ssure in the a re a s of ische mia (i.e ., va somotor pa ra lysis), a s
we ll a s disruption of the blood-bra in ba rrie r. Approxima te ly 4 to
6 we e ks is re quire d for the se cha nge s to sta bilize . The re fore , it is
re comme nde d tha t a ne sthe sia for e le ctive non-ne urologic surgica l
proce dure s be postpone d for a t le a st 4 we e ks a nd pre fe ra bly
6 we e ks a fte r a n occlusive va scula r a ccide nt, to minimize the risk
of a subse que nt pe riope ra tive occlusive va scula r a ccide nt (Miller:
761. (A) Soma tose nsory e voke d pote ntia ls (SSEPs) re corde d on the
contra la te ra l ce re bra l corte x a re the physiologic re sponse of the
ne rvous syste m to pe riphe ra l ne rve stimula tion. Extra ction of SSEPs
from the ba ckground EEG is a ccomplishe d by compute rize d signa l
a ve ra ging for summa tion. SSEPs a sse ss the inte grity of the
pe riphe ra l ne rve (usua lly poste rior tibia l or me dia n), dorsa l
column, bra in ste m, me dia l le mniscus, inte rna l ca psule , a nd
contra la te ra l soma tose nsory corte x. Howe ve r, the y do not e va lua te
the inte grity of the ve ntra l or la te ra l spinotha la mic tra cts or the
corticospina l tra ct. The corticospina l tra ct is re a dily e limina te d
from the a nswe r se t be ca use it is a motor (ra the r tha n se nsory)
pa thwa y (Miller: Miller’s Anesth esia, ed 8, p 1497).
762. (B) The diffe re ntia l dia gnosis for a nonmoving pa tie nt during a
wa ke -up te st include s pre se nce of ne uromuscula r blocka de ,
ina de qua te vola tile or nitrous oxide wa shout, or pre se nce of
opia te s or se da tive hypnotic me dica tion. The re a re a lso a fe w
othe r e xtre me ly ra re ce ntra l ca use s, such a s stroke . Be ca use gross
ne uromuscula r blocka de ha s worn off in this pa tie nt a nd the
vola tile a ne sthe tic a nd nitrous oxide ha ve la rge ly be e n wa she d out,
a tria l of low-dose na loxone would not be unre a sona ble . An initia l
sma ll dose (e .g., 20 µg) ma y be a ll tha t is ne e de d to re ve rse the
e ffe cts of the morphine . If this dose is not e ffe ctive , it should be
re pe a te d. Re ducing distra ction on the Ha rrington rods would be
conside re d only if the pa tie nt sque e ze d he r ha nds, ye t fa ile d to
move he r fe e t (Yao: Yao and Artusio’s Anesth esiology, ed 7, pp 1261–
1262).
763. (C) Arte ria l CO2 te nsion (Pa CO2) is the single most pote nt
physiologic de te rmina nt of CBF a nd CBV. Be twe e n Pa CO2 va lue s of
20 a nd 80 mm Hg, CBF de cre a se s 1 to 1.5 mL × 100 g/bra in
we ight/min a nd CBV de cre a se s a pproxima te ly 0.05 mL × 100 g/bra in
we ight for e a ch 1 mm Hg de cre a se in Pa CO2. De cre a sing the Pa CO2
to 25 to 30 mm Hg should provide ne a r-ma xima l re ductions in CBF,
CBV, a nd ICP, la sting up to 24 hours, without a dve rse ly a ffe cting
a cid–ba se /e le ctrolyte (e .g., de cre a se s in pota ssium or ionize d
ca lcium) sta tus or de cre a sing ce re bra l oxyge n de live ry (i.e ., a s a
re sult of inte nse ce re bra l va soconstriction a nd a le ftwa rd shift of
the oxyhe moglobin dissocia tion curve ). Be ca use this pa tie nt’s Pa CO2
is 10 mm Hg be low norma l, CBF a lso would be re duce d to
a pproxima te ly 35 to 40 mL × 100 g/bra in we ight/min (Miller: Miller’s
Anesth esia, ed 8, p 391; Cottrell: Cottrell and Young’s Neuroanesth esia, ed
5, p 25).
764. (A) Intra cra nia l pre ssure (ICP) is de te rmine d by the
re la tionship be twe e n the intra cra nia l va ult (forme d by the skull),
volume of bra in pa re nchyma , volume of CSF, a nd CBV. Studie s
e va lua ting the e ffe ctive ne ss of corticoste roids in the se tting of he a d
injury, or globa l or foca l bra in ische mia , ha ve de monstra te d e ithe r
no improve me nt or a worse ning of ne urologic outcome . All
intra ve nous a ne sthe tics, e xce pt ke ta mine , ca use some de gre e of
re duction in CMR, CBF, CBV, a nd ICP (provide d ve ntila tion is not
de pre sse d). As a n a side , re ga rding intra ve nous a ne sthe tics,
ba rbitura te s a re thought to be the “gold sta nda rd” for a ne sthe tic-
me dia te d bra in prote ctive the ra py in a nima l mode ls of foca l or
incomple te globa l bra in ische mia . Howe ve r, this ha s ye t to be
prove d in huma ns. In the se tting of tra uma tic bra in injury,
hype rve ntila tion is a n a cce pta ble inte rve ntion. Howe ve r, the Bra in
Tra uma Founda tion a dvise s a ga inst a ggre ssive hype rve ntila tion,
be ca use the da ta sugge st worse ning of outcome s a ssocia te d with
Pa CO2 va lue s be low 25 to 30 mm Hg. Both osmotic a nd loop
diure tics a re e ffe ctive in re ducing ICP. Provide d the pa tie nt is
he modyna mica lly sta ble , e le va tion of the he a d a bove the le ve l of
the he a rt fa cilita te s e fflue nt of blood from the ca lva rium, which
re sults in de cre a se s in CBV a nd ICP (Cottrell: Cottrell and Young’s
Neuroanesth esia, ed 5, pp 320–322, Box 18-4; Barash : Clinical Anesth esia,
ed 7, pp 1504-1505; BTF Guid elines, J Neurotraum a 2007:S87–S90).
765. (A) Afte r SAH, pa tie nts ma y e xpe rie nce re ble e ding, ce re bra l
va sospa sm, intra cra nia l hype rte nsion, a nd se izure s. Provide d tha t
the pa tie nt is not e xpe rie ncing ce re bra l va sospa sm, hype rte nsion
should be a voide d in orde r to minimize a ne urysma l wa ll te nsion,
the re by mitiga ting the risk of re -rupture . In contra st, ha d this pa tie nt
be e n in va sospa sm, induce d hype rte nsion would ha ve be e n a n
a ppropria te the ra pe utic inte rve ntion (a lso se e e xpla na tion to
Que stion 776). Hype rte nsion is a voide d, in pa rt, by the
a dministra tion of se da tive a nd a na lge sic me dica tions. Antie pile ptic
drugs a nd ca lcium cha nne l blocke rs (e .g., nimodipine ) ofte n a re
a dministe re d in a n a tte mpt to pre ve nt or mitiga te se izure s a nd
a dve rse se que la e of ce re bra l va sospa sm, re spe ctive ly (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, pp 222–224; Hines: Stoelting’s
766. (C) Soma tose nsory e voke d pote ntia ls (SSEPs) a re use d to
monitor the inte grity of se nsory pa thwa ys in the ne rvous syste m
during ne urosurgica l or orthope dic surge ry (a lso se e e xpla na tion to
Que stion 761). Vola tile a ne sthe tics (e .g., isoflura ne ), ba rbitura te s
(e .g., sodium thiope nta l), a nd propofol de cre a se the a mplitude a nd
incre a se the la te ncy of SSEP wa ve forms. Nitrous oxide de cre a se s
the a mplitude but ha s no e ffe ct on la te ncy. Etomida te incre a se s
both the a mplitude a nd la te ncy. In contra st, nonde pola rizing muscle
re la xa nts (e .g., ve curonium) ha ve no e ffe ct on se nsory pa thwa ys of
the ne rvous syste m a nd thus ca n be use d during SSEP monitoring
767. (B) In a ddition to ECG cha nge s (e .g., T-wa ve inve rsion,
de pre ssion of the ST se gme nt, a ppe a ra nce of U wa ve s, prolonge d
QT inte rva l, a nd, ra re ly, Q wa ve s), a bnorma l tha llium scintigra phy,
re giona l wa ll-motion a bnorma litie s, a nd e le va te d cre a tine kina se –
MB isoe nzyme s ha ve be e n re porte d in pa tie nts with SAH. Although
the y ha ve historica lly be e n conside re d functiona lly insignifica nt
ne uroge nic phe nome na , the re is incre a sing e vide nce tha t the se
cha nge s ma y be a sign of unde rlying myoca rdia l ische mia .
Howe ve r, e ve n if myoca rdia l ische mia is pre se nt, it se e ms to ha ve
a minima l impa ct on pa tie nt outcome (i.e ., morbidity a nd morta lity).
Be ca use e le ctrolyte a bnorma litie s (e .g., hypoka le mia or
hypoca lce mia ) ma y contribute to the e tiology of the ECG cha nge s, it
would proba bly be most a ppropria te to qua ntify the se e le ctrolyte s
be fore initia ting othe r the ra pie s or ca nce ling e me rge ncy surge ry.
Nitroglyce rin is a pote nt ce re bra l va sodila tor tha t could ha ve a
de le te rious e ffe ct on ICP in pa tie nts with incre a se d intra cra nia l
e la sta nce (se e e xpla na tion to Que stion 745) (Cottrell: Cottrell and
Young’s Neuroanesth esia, ed 5, pp 220–221).
768. (D) The principa l ne uromonitoring moda litie s curre ntly use d to
a sse ss spina l cord inte grity a re : soma tose nsory e voke d pote ntia ls
(SSEPs), motor e voke d pote ntia ls (MEPs), a nd e le ctromyogra phy
(EMG). Ea ch of the se e va lua te a functiona lly se pa ra te a re a of the
ne rvous syste m. The ne uromonitoring te chnique (s) de pe nds on the
loca tion of the surge ry a nd the pa tie nt’s pre e xisting ne urologic
de ficits. MEPs a re use d to monitor the inte grity of motor pa thwa ys
in the ne rvous syste m during ne urosurgica l, orthope dic, or ma jor
va scula r (e .g., proce dure s tha t involve cross-cla mping of the
thora cic a orta ) surge ry. Ele ctrica l or ma gne tic stimula tion of the
motor corte x produce s a n e voke d pote ntia l tha t is propa ga te d via
de sce nding motor pa thwa ys a nd ca n be re corde d from the spina l
e pidura l spa ce , spina l cord, pe riphe ra l ne rve , or the muscle itse lf.
In ge ne ra l, inha la tiona l a nd intra ve nous a ne sthe tics de cre a se the
a mplitude a nd incre a se the la te ncy of the MEP re sponse . Opioids
(e .g., fe nta nyl, sufe nta nil) a re the e xce ption to this rule a nd ha ve
little , if a ny, e ffe ct on MEP monitoring. The corre ct orde r from
gre a te st to le a st for the se nsitivity of ne urophysiologic monitoring
te chnique s to vola tile a ne sthe tics is MEP > SSEP >>> EMG (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, pp 125–126; Deiner S:
High ligh ts of anesth etic consid erations for intraoperative neurom onitoring,
Sem in Card ioth orac Vasc Anesth 14:51–53, 2010).
769. (D) Ke ta mine is thought to incre a se CBF a nd, conse que ntly,
CBV a nd ICP, by two me cha nisms: (1) the re ma y be a dire ct e ffe ct
on ce re bra l va scula r smooth muscle to ca use va sodila tion, a nd (2)
the re ma y be a “couple d” e ffe ct ca use d by a n incre a se in CMR.
The re is some controve rsy re ga rding the e ffe ct of ke ta mine on
CBF/CMR coupling. Anima l studie s in vivo indica te tha t CMR a nd
CBF a re incre a se d proportiona lly in structure s of the limbic syste m.
In contra st, the re is e vide nce from one huma n study tha t a lthough
ke ta mine incre a se d CBF (up to 62%), CMR re ma ine d uncha nge d.
Ce re bra l CO2 re sponsive ne ss a nd a utore gula tion a re not a lte re d by
ke ta mine (Miller: Miller’s Anesth esia, ed 8, pp 833–834).
770. (A) In contra st to ke ta mine a nd incre a se d ne ura l a ctivity (e .g.,
se izure s or hype rthe rmia ), which incre a se CBF a nd CMR, vola tile
a ne sthe tics ca use a simulta ne ous, dose -de pe nde nt incre a se in CBF
a nd de cre a se in CMR (i.e ., vola tile a ne sthe tics “uncouple ” globa l
CBF a nd CMR) (Miller: Miller’s Anesth esia, ed 8, p 390).
771. (C) Ma inte na nce of a re la tive ly consta nt CBF de spite cha nge s
in syste mic me a n a rte ria l blood pre ssure is te rme d a utore gula tion.
The uppe r a nd lowe r limits of a utore gula tion, in normote nsive
a dult huma ns, a re ce re bra l pe rfusion pre ssure s of 150 to 160 a nd 50
to 60 mm Hg, re spe ctive ly. Autore gula tion a ppe a rs to be impa ire d
by intra cra nia l tumors, he a d tra uma , a nd vola tile a ne sthe tics. By
contra st, nitrous oxide , ba rbitura te s, a nd fe nta nyl do not a ppe a r to
disturb a utore gula tion (Faust: Anesth esiology Review, ed 3, pp 57–59;
772. (A) Acute spina l cord injury a bove T4 to T6 produce s a
sympa the ctomy be low the le ve l of injury, which de cre a se s syste mic
a rte riola r a nd ve nous va somotor tone , a nd a bolishe s va sopre ssor
re fle xe s (i.e ., spina l shock). This pa thophysiologic proce ss ma y
continue for up to 6 we e ks a fte r injury. As spina l shock re solve s,
pa tie nts with spina l cord injurie s ce pha la d to T4 to T6 ma y de ve lop
a utonomic hype rre fle xia (i.e ., a cute ge ne ra lize d sympa the tic
hype ra ctivity a s a re sult of stimula tion be low the le ve l of injury).
Ne uroge nic pulmona ry e de ma ma y de ve lop during e ithe r spina l
shock or a utonomic hype rre fle xia . The rmore gula tion is lost,
re sulting in poikilothe rmia , be ca use the hypotha la mic
the rmore gula tory ce nte r is una ble to communica te with the
pe riphe ra l sympa the tic pa thwa ys. In the cool e nvironme nt of the
inte nsive ca re unit, spina l cord injury pa tie nts a re una ble to
va soconstrict be low the le ve l of injury a nd thus ma y e xpe rie nce
hypothe rmia . Loss of sympa the tic-me dia te d va somotor tone a lso
re sults in hypote nsion (Hines: Stoelting’s Anesth esia and Co-Ex isting
773. (D) Signs a nd symptoms of intra cra nia l hype rte nsion include
na use a a nd vomiting, a lte re d le ve l of consciousne ss, pa pille de ma ,
se izure a ctivity, pe rsona lity cha nge s, a nd coma . Additiona lly,
pa tie nts ma y ma nife st a conste lla tion of clinica l signs re fe rre d to a s
Cushing tria d (i.e ., syste mic hype rte nsion, bra dyca rdia , a nd
irre gula r bre a thing pa tte rn) (Hines: Stoelting’s Anesth esia and Co-
774. (D) Ge ne ra l a ne sthe sia ca n be induce d sa fe ly in pa tie nts with
ca rotid a rte ry dise a se using intra ve nous a ne sthe tics, such a s
thiope nta l, mida zola m, propofol, or e tomida te . Isoflura ne , in
conjunction with N2O or opioids, is a good choice for ma inte na nce
of a ne sthe sia in the se pa tie nts, be ca use critica l CBF is re duce d
during isoflura ne , se voflura ne , or de sflura ne a ne sthe sia , which
ma y provide some ce re bra l prote ction (a lso se e e xpla na tion to
Que stion 752). Arte ria l blood pre ssure a nd Pa CO2 should be
ma inta ine d in the norma l ra nge s for e a ch pa tie nt be ca use the
va scula ture within ische mic re gions of the bra in ha ve lost the
a bility to a utore gula te CBF a nd re spond to cha nge s in Pa CO2.
Ma rke d re ductions in a rte ria l blood pre ssure ma y re duce CBF
(e spe cia lly via colla te ra l cha nne ls) to ische mic bra in tissue .
The ore tica lly, if Pa CO2 is incre a se d from norma l, ce re bra l blood
ve sse ls surrounding the re gion of ische mia tha t re ta in norma l CO2
re sponsive ne ss will dila te , dive rting re giona l ce re bra l blood flow
a wa y from the ische mic bra in tissue (i.e ., ste a l phe nome non).
Conve rse ly, if the Pa CO2 is re duce d from norma l, the ce re bra l blood
ve sse ls surrounding the ische mic bra in tissue will constrict,
dive rting re giona l CBF (rCBF) to ische mic a re a s of the bra in (inve rse
ste a l phe nome non or Robin Hood e ffe ct). Hype rve ntila ting the
lungs in a n a tte mpt to produce the inve rse ste a l phe nome non is not
re comme nde d be ca use the a ctua l e ffe ct ma y be unpre dicta ble a nd
supportive e vide nce in huma ns tha t this is be ne ficia l is la cking.
The ca rotid sinus (not ca rotid body) ba rore ce ptor re fle x ca n be
blunte d by intra ve nous inje ction of a tropine or by loca l infiltra tion
of the a re a of the ca rotid sinus with a loca l a ne sthe tic (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, pp 278–279, 285–288).
775. (C) In ge ne ra l, a ll vola tile a ne sthe tics (e .g., isoflura ne ,
se voflura ne , a nd de sflura ne ) a re pote nt dire ct ce re bra l va sodila tors
tha t produce dose -de pe nde nt incre a se s in CBF, CBV, a nd ultima te ly
ICP whe n conce ntra tions e xce e d 0.6 MAC. The orde r of va sodila tor
pote ncy is a pproxima te ly
ha lotha ne ≫ e nflura ne > isoflura ne = se voflura ne = de sflura ne . As
discusse d in the re sponse to Que stion 731, opioids ha ve little , if
a ny, e ffe ct on CMR, CBF, or ICP (provide d minute ve ntila tion is
ma inta ine d). The e ffe ct of N2O on CBF, CBV, a nd ICP is
controve rsia l. In a numbe r of a nima l a nd huma n studie s, N2O
incre a se d CBF by 35% to 103%. Conve rse ly, in othe r a nima l studie s,
N2O wa s consiste ntly found to ha ve only minima l e ffe cts on CBF.
Diffe re nce s be twe e n spe cie s ma y be one fa ctor contributing to
the se conflicting re sults. Be ca use N2O a ppe a rs to incre a se CBF a nd
CBV in huma ns, it se e ms prude nt to discontinue N2O in pa tie nts in
whom intra cra nia l hype rte nsion is not re sponsive to othe r
the ra pe utic ma ne uve rs. Propofol a nd ba rbitura te s a re pote nt
ce re bra l va soconstrictors a nd ca n de cre a se ICP (Hines: Stoelting’s
776. (C) Afte r SAH, the incide nce a nd se ve rity of ce re bra l
va sospa sm ha ve be e n re porte d to corre la te with the a mount a nd
loca tion of blood in the ca lva rium. Angiogra phic e vide nce of
va sospa sm ha s be e n note d in up to 70% of SAH pa tie nts. Howe ve r,
clinica lly significa nt va sospa sm occurs in only 20% to 30% of SAH
pa tie nts. The incide nce pe a ks a pproxima te ly 7 da ys a fte r SAH.
Ca lcium cha nne l blocke rs (e .g., nimodipine ) de cre a se the morbidity
a nd morta lity a ssocia te d with va sospa sm, but inve stiga tors ha ve
be e n una ble to de monstra te a ny significa nt cha nge in the incide nce
or se ve rity of va sospa sm. This sugge sts tha t the be ne ficia l e ffe cts of
nimodipine ma y be re la te d to inhibition of prima ry a nd se conda ry
ische mic ca sca de s, ra the r tha n dire ct ce re bra l va sodila tion.
Tre a tme nt of va sospa sm a lso include s “triple H the ra py”
(Hype rvole mia , induce d Hype rte nsion, a nd He modilution) a nd
ce re bra l a ngiopla sty. The ra tiona le for induce d hype rvole mia a nd
hype rte nsion is tha t ische mic re gions of bra in ha ve impa ire d
a utore gula tion, a nd thus CBF is pe rfusion pre ssure de pe nde nt.
He modilution is thought to incre a se blood flow through the
ce re bra l microcircula tion (be ca use of improve d rhe ology a nd
re a ctive hype re mia ). One a rgume nt a ga inst he modilution is tha t
incre a se s in CBF a re offse t by concomita nt de cre a se s in the
oxyge n-ca rrying ca pa city. Ta ke n toge the r, blood pre ssure re ductions
a nd diure tic use a re incorre ct re sponse s to this condition (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, pp 223–224).
777. (D) Enla rge me nt of the tongue a nd e piglottis pre dispose s the
pa tie nt to uppe r a irwa y obstruction a nd ma ke s visua liza tion of the
voca l cords more difficult. The voca l cords a re e nla rge d, ma king
the glottic ope ning na rrowe r. In a ddition, subglottic na rrowing ma y
be pre se nt a s we ll a s tra che a l compre ssion from a n e nla rge d
thyroid (se e n in a bout 25% of a crome ga lic pa tie nts). This ofte n
ne ce ssita te s the use of a na rrowe r e ndotra che a l tube tha n one
might choose ba se d on the fa cia l e nla rge me nt. The pla ce me nt of
na sa l a irwa ys ma y be more difficult due to the e nla rge d na sa l
turbina te s. The use of CPAP is contra indica te d a fte r
tra nssphe noida l hypophyse ctomy (Miller: Miller’s Anesth esia, ed 8, p
2188; Gupta: Essentials of Neuroanesth esia and Neurointensive Care, ed
1, pp 144–145; Fleish er: Anesth esia and Uncom m on Diseases, ed 6, pp
417).
778. (D) Chronic hype rte nsion shifts the CBF a utore gula tory curve to
the right. The clinica l significa nce of this obse rva tion is tha t CBF
could de cre a se a nd ce re bra l ische mia could occur a t a highe r
me a n syste mic a rte ria l blood pre ssure in pa tie nts with chronic
hype rte nsion compa re d with normote nsive pa tie nts. Chronic
a ntihype rte nsive the ra py to control syste mic blood pre ssure s within
the norma l ra nge ma y re store norma l CBF a utore gula tion (Cottrell:
Cottrell and Young’s Neuroanesth esia, ed 5, p 29).
779. (D) Ce re bra l a utore gula tion is disturbe d in a numbe r of
dise a se s (e .g., a cute ce re bra l ische mia , ma ss le sions, tra uma ,
infla mma tion, pre ma turity, ne ona ta l a sphyxia , a nd dia be te s
me llitus). The fina l common pa thwa y of dysfunction, in its most
e xtre me form, is te rme d “va somotor pa ra lysis.” Hype roxia ha s little
or no e ffe ct on a utore gula tion. During normothe rmic a nd mode ra te
hypothe rmic (i.e ., a pproxima te ly 27° C) ca rdiopulmona ry bypa ss,
a utore gula tion is we ll pre se rve d. Chronic hype rte nsion ca use s a
rightwa rd shift of the a utore gula tion curve towa rd highe r uppe r a nd
lowe r ce re bra l pe rfusion pre ssure limits (a lso se e e xpla na tion to
Que stion 778). Autore gula tion is impa ire d by vola tile a ne sthe tics
(e .g., isoflura ne ). At gre a te r tha n 2 MAC, a utore gula tion is
a bolishe d (Faust: Anesth esiology Review, ed 3, pp 58-59; Cottrell: Cottrell
and Young’s Neuroanesth esia, ed 5, p 88).
780. (A) The ce re bra l pha rma cologic profile of e tomida te is simila r
to tha t of thiope nta l a nd propofol in tha t it produce s a dose -re la te d
de cre a se in the CMR a nd CBF (via dire ct ce re bra l va soconstriction
a nd coupling to de cre a se d CMR). As note d, a fte r ba rbitura te
a dministra tion, intra ve nous e tomida te doe s not disturb ce re bra l
a utore gula tion or CO2 re a ctivity, a s discusse d in the e xpla na tion to
Que stion 755. Etomida te incre a se s both a mplitude a nd la te ncy
during SSEP monitoring (Cottrell: Cottrell and Young’s Neuroanesth esia,
ed 5, p 84).
781. (B) Na sa l intuba tion should be a voide d in pa tie nts with
suspe cte d a nte rior ba sa l skull fra cture s (e .g., disruption of the
cribriform pla te of the e thmoid bone ) or sinus injurie s. Be ca use
a pproxima te ly 10% of he a d injury pa tie nts ha ve a ssocia te d ce rvica l
spine injurie s, it is prude nt to a ssume tha t a ll he a d injury pa tie nts
ha ve coe xisting ce rvica l spine injury until prove d othe rwise .
Additiona lly, the pa tie nt de scribe d in this que stion ma y ha ve
a bnorma l a irwa y a na tomy be ca use of e xtre me microgna thia , fa cia l
injurie s, a nd obe sity. Ta ke n toge the r, dire ct la ryngoscopy with
ra pid-se que nce induction is proba bly not a n a cce pta ble te chnique
for se curing this pa tie nt’s a irwa y. In contra st, a wa ke intuba tion by
dire ct, vide o, or fibe roptic la ryngoscopy or pe rforma nce of
tra che ostomy a re conside re d a ppropria te te chnique s for tra che a l
intuba tion of this pa tie nt. Ma sk a nd la rynge a l ma sk a irwa y (LMA)
te chnique s ma y provide a pa te nt a irwa y but do not e nsure
prote ction of the a irwa y a ga inst a spira tion of ga stric conte nts
782. (D) This pa tie nt ha s mild hypona tre mia a nd is una ble to
e xcre te a dilute urine a s note d by the urine sodium gre a te r tha n 20
mEq/L. The se a re consiste nt with the syndrome of ina ppropria te
se cre tion of ADH (SIADH). Antidiure tic hormone (ADH) is a lso
known a s va sopre ssin. SIADH ma y re sult from a va rie ty of ca use s
including ce ntra l ne rvous syste m le sions, pulmona ry infe ctions,
hypothyroidism, a nd drugs (e .g., chlorpropa mide , na rcotics). Afte r
ide ntifying the ca use , tre a tme nt is sta rte d a nd usua lly consists
ma inly of wa te r re striction. W ith se ve re hypona tre mia (i.e ., Na le ss
tha n 120 mEq/L a nd signs of me nta l confusion), a ggre ssive
tre a tme nt with hype rtonic sodium chloride ma y be ne e de d;
howe ve r, too much a nd too ra pid infusion, a s in choice B, ma y
induce ce ntra l pontine mye linolysis a nd ma y ca use pe rma ne nt
bra in da ma ge . W ith se ve re hypona tre mia , the dose of 200 to 300 mL
of a 3% solution of sodium chloride is usua lly a dministe re d ove r
se ve ra l hours. The a ntibiotic de me clocycline inte rfe re s with ADH
a t the le ve l of the re na l tubule s to produce dilute urine a nd is
some time s use d for the tre a tme nt of SIADH. In the future , the
e xpe rime nta l drug tolva pta n (OPC-41061) ma y re pla ce
de me clocycline . Tolva pta n is a va sopre ssin a nta gonist.
De smopre ssin a ce ta te (DDAVP) is use d to tre a t pa tie nts with
comple te dia be te s insipidus (DI), whe re a s chlorpropa mide is use d
to tre a t incomple te DI. In contra st to SIADH, pa tie nts with DI ha ve a
la ck of ADH a nd ha ve high output of poorly conce ntra te d urine a nd
hype rna tre mia . Le a ving the pa tie nt intuba te d a nd hype rve ntila ting
him or he r will not he lp (Barash : Clinical Anesth esia, ed 7, p 1352;
783. (D) This pa tie nt ha s se ve ra l signs consiste nt with e le va te d
intra cra nia l pre ssure : hype rte nsion, hype rve ntila tion, a nd
somnole nce . Use of morphine pre me dica tion is ill-a dvise d be ca use
it would se da te him furthe r, blunt his hype rve ntila tion, a nd thus
ra ise ICP. Furthe rmore , na rcotics in this se tting ca n lowe r blood
pre ssure sufficie ntly to a lte r ce re bra l pe rfusion pre ssure . Use of
PEEP ca n promote impa irme nt of ve nous dra ina ge a s we ll a s ra ise
ICP in pa tie nts with intra cra nia l hype rte nsion. Hype rve ntila tion is
a n e ffe ctive ma ne uve r for lowe ring ICP in the short te rm. As
discusse d in the e xpla na tions to Que stions 733 a nd 764, Pa CO2
le ve ls in the ra nge of 25 to 30 mm Hg suffice for this, a nd the re is no
e vide nce tha t a dditiona l hype rve ntila tion ha s a ny a dde d
the ra pe utic be ne fit. Use of e smolol prior to intuba tion ma y blunt
the hype rdyna mic re sponse to la ryngoscopy a nd pre ve nt ICP
e le va tion (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
222–223, 226).
784. (D) MRI sca nne rs conta in powe rful ma gne ts tha t ra nge from 0.5
to 3 T (5000-30,000 G). By contra st, the Ea rth’s ma gne tic fie ld is 0.5 G.
Me ta l obje cts brought into the sca nne r room ca n be come
da nge rous proje ctile s tha t fly towa rd the middle of the ma gne t,
whe re the pa tie nt is loca te d. Sma ll ite ms ca n be pulle d a wa y, but
la rge r ite ms ma y not be re mova ble e ve n with a winch a nd thus
re quire a ma gne t shut-down, the proce ss known a s a que nch.
MRI ma gne ts a re a lwa ys on. Stopping the sca n or cutting the powe r
to ma gne t for 60 se conds doe s not re le a se the ma gne tic force .
Que nching is a n e xpe nsive proce ss tha t ca use s the cooling
me dium (liquid he lium) to boil off a nd ve nt to the outside . During
this proce ss, the coils be come re sistive a nd ce a se
supe rconducting, the re by diminishing ma gne tic fie ld stre ngth.
Atte mpting to pull the obje ct de scribe d in this que stion a wa y
from the ma gne t would be ne a rly impossible ; but, e ve n if it could
be succe ssfully ca rrie d out, the re would be gre a t risk. For
e xa mple , if the grip we re lost a nd the obje ct re le a se d, it could fly
towa rd the pa tie nt inside the sca nne r. Cutting up me ta llic obje cts
a tta che d to the sca nne r (if a nonfe rroma gne tic sa w could be
found) would be e qua lly if not more da nge rous tha n a tte mpting a
pull a wa y (Stoelting: Basics of Anesth esia, ed 6, pp 620–621).
785. (D) Progre ssive e ntra inme nt of a ir into the pulmona ry
microcircula tion re duce s lung pe rfusion a nd incre a se s pulmona ry
va scula r re sista nce a nd a lve ola r de a d-spa ce ve ntila tion. The
incre a se in pulmona ry va scula r re sista nce is re fle cte d by incre a se s
in pulmona ry a rte ria l a nd ce ntra l ve nous pre ssure s. A la rge a ir
e mbolus ca n re sult in right ve ntricula r outflow obstruction, which
will dra ma tica lly re duce ca rdia c output, re sulting in syste mic
hypote nsion. Incre a se d a lve ola r de a d spa ce re sults in a de cre a se
in e nd-tida l CO2. In se ve re VAE, CO2 ca nnot be e limina te d a nd
Pa CO2 incre a se s. End-tida l N2 incre a se s be ca use a ir diffuse s into
the pulmona ry a lve oli. The se nsitivity of continuous e nd-tida l CO2
monitoring is simila r to tha t for continuous e nd-tida l N2 monitoring
(a lso se e e xpla na tion to Que stion 744) (Faust: Anesth esiology Review,
ed 3, pp 389–391, Figure 158-1).
786. (C) The ce re brova scula r re sponse to hype rve ntila tion wa s
re vie we d in the e xpla na tions to Que stions 733, 763, 764, a nd 783.
Hype rve ntila tion, a nd the re sulting re spira tory a lka losis, ca use s a
le ftwa rd (not rightwa rd) shifting of the oxyhe moglobin dissocia tion
curve . In doing so, he moglobin unde rgoe s a conforma tion cha nge ,
ma king it more re lucta nt to re le a se oxyge n a t the tissue le ve l. As
discusse d in the e xpla na tion to Que stion 733, hype rve ntila tion-
induce d re spira tory a lka losis ca n pre cipita te hypoka le mia .
Spe cifica lly, se rum pota ssium de cre a se s 0.6 mEq/L for e a ch 0.1-unit
incre a se in pH. Thus, ove rly a ggre ssive hype rve ntila tion should be
gua rde d a ga inst to a void e le ctrolyte pe rturba tions tha t ma y re sult in
ca rdia c a rrhythmia s (Miller: Miller’s Anesth esia, ed 8, pp 2163–2164).
787. (A) VAE is a ha za rd of a ny ope ra tion in which the ope ra tive
fie ld is loca te d a bove the he a rt. As discusse d in the e xpla na tion for
Que stion 757, me a sure s to succe ssfully ma na ge VAE include
pre ve ntion of furthe r a ir e ntra inme nt (Tre nde le nburg position,
flooding surgica l fie ld with sa line , pla ce me nt of wa x on cut bone
e dge s), re mova l of a ir from the right a trium if a ca the te r is
indwe lling, supporting he modyna mics (e .g., with ca lcium,
va sopre ssors, a nd inotrope s), a nd discontinua tion of N2O to
pre ve nt bubble e xpa nsion. Some ne uroa ne sthe siologists a void use
of N2O in a ny insta nce whe re the re is a cha nce of VAE (Barash :
Clinical Anesth esia, ed 7, p 1446; Miller: Miller’s Anesth esia, ed 8, pp
2172–2173).
C H AP T E R 1 0
Anatomy, Regional Anesthesia, and
Pain Management
788. Ta chyphyla xis to loca l a ne sthe tics is MOST close ly re la te d to

which of the following?
A. Spe e d of inje ction
B. Dosing inte rva l
C. Volume of loca l a ne sthe tic
D. pH of solution
789. W hich of the following te chnique s is LEAST e ffe ctive in the
tre a tme nt of pruritus from a dministra tion of ne ura xia l opia te s?
A. Na lbuphine 5 mg IV
B. De xme de tomidine 30 µg IV
C. Diphe nhydra mine 50 mg IV
D. Propofol 10 mg IV
790. The MAXIMUM dose of lidoca ine conta ining 1:200,000
e pine phrine tha t ca n be a dministe re d to a 70-kg pa tie nt for most
ma jor re giona l a ne sthe tic te chnique s (a nd e xcluding spina l a nd IV
re giona l) is
A. 100 mg
B. 200 mg
C. 500 mg
D. 1000 mg
791. W hich of the following conce ntra tions of e pine phrine
corre sponds to a 1:200,000 mixture ?
A. 0.5 µg/mL
B. 5 µg/mL
C. 50 µg/mL
D. 0.5 mg/mL
792. An a ne sthe sia pa in se rvice consult is sought for a 78-ye a r-old
pa tie nt with a compla int of pa in in the distribution of the trige mina l
ne rve . The pa tie nt ha s no othe r me dica l proble ms e xce pt a history
of conge stive he a rt fa ilure , for which he ta ke s digoxin a nd thia zide .
In a ddition to his chie f compla int, the pa tie nt ove r the la st 72 hours
ha s compla ine d of dyse sthe sia in the fe e t, difficulty with vision, a nd
e me sis time s thre e . The MOST a ppropria te ste p a t this time would
be
A. Trige mina l ne rve block with bupiva ca ine
B. Ne urologic workup for multiple scle rosis
C. Administra tion of fe nta nyl a nd onda nse tron
D. Obta ining a digoxin le ve l
793. W hich of the following is the EARLIEST sign of lidoca ine
toxicity from a high blood le ve l?
A. Shive ring
B. Nysta gmus
C. Light-he a de dne ss a nd dizzine ss
D. Tonic-clonic se izure s
794. An a na lge sic e ffe ct simila r to the e pidura l a dministra tion of
5 mg of morphine could be a chie ve d by which dose of intra the ca l
morphine ?
A. 0.05 mg
B. 0.3 mg
C. 1 mg
D. Morphine should not be inje cte d into the intra the ca l spa ce
795. W hich loca l a ne sthe tic unde rgoe s the LEAST he pa tic
cle a ra nce ?
A. Chloroproca ine
B. Bupiva ca ine
C. Ropiva ca ine
D. Lidoca ine
796. W hich of the following is the MOST importa nt disa dva nta ge of
inte rsca le ne bra chia l ple xus block compa re d with othe r
a pproa che s?
A. La rge volume s of loca l a ne sthe tics re quire d
B. Fre que nt spa ring of the ulna r ne rve
C. Fre que nt spa ring of the musculocuta ne ous ne rve
D. High incide nce of pne umothora x
797. A 68-ye a r-old woma n is to unde rgo lowe r e xtre mity surge ry
unde r spina l a ne sthe sia . W hich of the following sta te me nts
conce rning the imme dia te physiologic re sponse to the surgica l
incision is T RUE?
A. The ca rdiova scula r (CV) re sponse to stre ss will be blocke d,
but the a dre ne rgic re sponse will not
B. The a dre ne rgic re sponse to stre ss will be blocke d, but the CV
re sponse will not
C. Both the a dre ne rgic a nd CV re sponse s will be blocke d
D. Ne ithe r the a dre ne rgic nor the CV re sponse will be blocke d
798. The “sna p” fe lt just be fore e nte ring the e pidura l spa ce
re pre se nts pa ssa ge through which liga me nt?
A. Poste rior longitudina l liga me nt
B. Liga me ntum fla vum
C. Supra spinous liga me nt
D. Inte rspinous liga me nt
799. The common e le me nt thought to be pre se nt in ca se s of ca uda
e quina syndrome a fte r continuous spina l a ne sthe sia is
A. Use of microca the te r
B. Ma ldistribution of loca l a ne sthe tic
C. Administra tion of lidoca ine
D. Addition of e pine phrine
800. W he n pe rforming a single -shot spina l a ne sthe tic, the le ve l of
block for motor, se nsory, a nd sympa the tic blocks diffe rs ofte n by a t
le a st two de rma tome s. W hich of the following se que nce s is corre ct
from the highe st to the lowe st le ve l of block?
A. Se nsory, sympa the tic, motor
B. Sympa the tic, se nsory, motor
C. Sympa the tic, motor, se nsory
D. Se nsory, motor, sympa the tic
801. A 95-ye a r-old woma n ha s pe rsiste nt a nd prolonge d thora cic
pa in a fte r a he rpe s zoste r infe ction. W hich of the tre a tme nts be low
would be the LEAST e ffica cious in the tre a tme nt of he r pa in?
A. Ora l a mitriptyline
B. Ora l clonidine
C. Topica l ca psa icin ointme nt
D. Topica l lidoca ine pa tch
802. The de e p pe rone a l ne rve inne rva te s the
A. La te ra l a spe ct of the dorsum of the foot
B. Entire dorsum of the foot
C. We b spa ce be twe e n the gre a t toe a nd the se cond toe
D. Me dia l a spe ct of the dorsum of the foot
803. The corre ct a rra nge me nt of loca l a ne sthe tics in orde r of the ir
a bility to produce ca rdiotoxicity from most to le a st is
A. Bupiva ca ine , lidoca ine , ropiva ca ine
B. Bupiva ca ine , ropiva ca ine , lidoca ine
C. Ropiva ca ine , bupiva ca ine , lidoca ine
D. Lidoca ine , ropiva ca ine , bupiva ca ine
804. Allodynia is de fine d a s
A. Sponta ne ous pa in in a n a re a or re gion tha t is a ne sthe tic
B. Pa in initia te d or ca use d by a prima ry le sion or dysfunction in
the ne rvous syste m
C. An incre a se d re sponse to a stimulus tha t is norma lly pa inful
D. Pa in ca use d by a stimulus tha t doe s not norma lly provoke
pa in
805. The prima ry me cha nism by which the a ction of te tra ca ine is
te rmina te d whe n use d for spina l a ne sthe sia is
A. Syste mic a bsorption
B. Upta ke into ne urons
C. Hydrolysis by pse udocholine ste ra se
D. Hydrolysis by nonspe cific e ste ra se s
806. Comple x re giona l pa in syndrome type I (re fle x sympa the tic
dystrophy [RSD]) is diffe re ntia te d from comple x re giona l pa in
syndrome type II (ca usa lgia ) by knowle dge of its
A. Etiology
B. Chronicity
C. Type of symptoms
D. Ra pidity of onse t
807. The prima ry de te rmina nt of loca l a ne sthe tic pote ncy is
A. pKa
B. Mole cula r we ight
C. Lipid solubility
D. Prote in binding
808. W hich of the following would ha ve the GREAT EST e ffe ct on
the le ve l of se nsory blocka de a fte r a suba ra chnoid inje ction of
hype rba ric 0.75% bupiva ca ine ?
A. Pa tie nt a ge
B. Addition of e pine phrine to the loca l a ne sthe tic solution
C. Pa tie nt we ight
D. Pa tie nt position
809. W hich of the following loca l a ne sthe tics would produce the
LOWEST conce ntra tion in the fe tus re la tive to the ma te rna l se rum
conce ntra tion during a continuous lumba r e pidura l?
A. Ropiva ca ine
B. Bupiva ca ine
C. Lidoca ine
D. Chloroproca ine
810. Se ve re hypote nsion a ssocia te d with high spina l a ne sthe sia is
ca use d prima rily by
A. De cre a se d ca rdia c output se conda ry to de cre a se d pre loa d
B. De cre a se d syste mic va scula r re sista nce
C. De cre a se d ca rdia c output se conda ry to bra dyca rdia
D. De cre a se d ca rdia c output se conda ry to de cre a se d myoca rdia l
contra ctility
811. Se le ct the one T RUE sta te me nt conce rning pha ntom limb pa in.
A. The incide nce of pha ntom limb pa in incre a se s with more
dista l a mputa tions
B. Most a mpute e s do not e xpe rie nce pha ntom limb pa in
C. Ne rve blocks ma y be use d to de cre a se the incide nce of
pha ntom limb pa in
D. Tra uma tic a mpute e s ha ve a much highe r incide nce of
pha ntom limb pa in tha n nontra uma tic a mpute e s
812. W hich of the following is T RUE re ga rding intra ve nous re giona l
a ne sthe sia (Bie r block)?
A. Use ful for postope ra tive pa in in e xtre mity surge ry
B. Ca n be use d for e xtre mity surge rie s la sting 2 to 3 hours
C. Bupiva ca ine is the drug of choice for prolonge d blocks
D. Lidoca ine is most commonly use d
813. Se le ct the FALSE sta te me nt re ga rding spina l a na tomy a nd
spina l a ne sthe sia .
A. The a ddition of phe nyle phrine to lidoca ine will prolong spina l
a ne sthe sia
B. A high thora cic se nsory block will re sult in tota l sympa the tic
blocka de
C. The la rge st ve rte bra l inte rspa ce is L5-S1
D. The dura l sa c e xte nds to the S4-S5 inte rspa ce
814. Four da ys a fte r a le ft tota l hip a rthropla sty, a n obe se 62-ye a r-
old woma n compla ins of se ve re ba ck pa in in the re gion whe re the
e pidura l wa s pla ce d. Ove r the e nsuing 72 hours, the ba ck pa in
gra dua lly worse ns a nd a se ve re a ching pa in tha t ra dia te s down the
le ft le g to the kne e de ve lops. The MOST like ly dia gnosis is
A. Epidura l a bsce ss
B. Epidura l he ma toma
C. Ante rior spina l a rte ry syndrome
D. Me ra lgia pa re sthe tica
815. W hich of the following choice s is NOT consiste nt with a limb
a ffe cte d by comple x re giona l pa in syndrome ?
A. Allodynia
B. De rma toma l distribution of pa in
C. Atrophy of the involve d e xtre mity
D. Hype re sthe sia
816. The MAIN a dva nta ge of ne urolytic ne rve blocka de with
phe nol ve rsus a lcohol is
A. De nse r blocka de
B. Blocka de is pe rma ne nt
C. The e ffe cts of the block ca n be e va lua te d imme dia te ly
D. The block is le ss pa inful
817. How much loca l a ne sthe tic should be a dministe re d pe r spina l
se gme nt to pa tie nts be twe e n 20 a nd 40 ye a rs of a ge re ce iving a
lumba r e pidura l a ne sthe tic?
A. 0.25 to 0.5 mL
B. 0.5 to 1.0 mL
C. 1 to 2 mL
D. 2 to 3 mL
818. The a rte ry of Ada mkie wicz MOST fre que ntly a rise s from the
a orta a t which spina l le ve l?
A. T1-T4
B. T5-T8
C. T9-T12
D. L1-L4
819. W hich loca l a ne sthe tic ha s the longe st e limina tion ha lf-time
(T ½)?
A. Bupiva ca ine
B. Lidoca ine
C. Me piva ca ine
D. Ropiva ca ine
820. Importa nt la ndma rks for pe rforming a scia tic ne rve block
(cla ssic a pproa ch of La ba t) include
A. Ilia c cre st, sa cra l hia tus, a nd gre a te r trocha nte r
B. Ilia c cre st, coccyx, a nd gre a te r trocha nte r
C. Poste rior supe rior ilia c spine , coccyx, a nd gre a te r trocha nte r
D. Poste rior supe rior ilia c spine , gre a te r trocha nte r, a nd sa cra l
hia tus
821. A 76-ye a r-old fe ma le pa tie nt is unde rgoing a ca rotid
e nda rte re ctomy unde r a de e p ce rvica l ple xus ne rve block. W hich
of the following complica tions would be LEAST like ly with this
unila te ra l block?
A. Unila te ra l phre nic ne rve pa ra lysis
B. Suba ra chnoid inje ction
C. Blocka de of the spina l a cce ssory ne rve
D. Ve rte bra l a rte ry inje ction
822. A re trobulba r block a ne sthe tize s e a ch of the following ne rve s
EXCEPT
A. Cilia ry ne rve s
B. Cra nia l ne rve III (oculomotor ne rve )
C. Cra nia l ne rve V (fa cia l ne rve )
D. Cra nia l ne rve VI (a bduce ns ne rve )
823. W hich of the following muscle s of the la rynx is inne rva te d by
the e xte rna l bra nch of the supe rior la rynge a l ne rve ?
A. Voca lis muscle
B. Thyroa ryte noid muscle s
C. Poste rior cricoa ryte noid muscle
D. Cricothyroid muscle
824. All the following a ge nts a re a cce pta ble for use in a Bie r block
EXCEPT
A. 0.5% Lidoca ine
B. 0.5% Me piva ca ine
C. 0.25% Bupiva ca ine
D. 0.5% Priloca ine
825. The ste lla te ga nglion lie s in close st proximity to which of the
following va scula r structure s?
A. Common ca rotid a rte ry
B. Inte rna l ca rotid a rte ry
C. Ve rte bra l a rte ry
D. Aorta
826. W hich of the following structure s in the a nte cubita l fossa is the
MOST me dia l?
A. Bra chia l a rte ry
B. Ra dia l ne rve
C. Te ndon of the bice ps
D. Me dia n ne rve
827. During pla ce me nt of a n e pidura l in a 78-ye a r-old pa tie nt
sche dule d for a tota l kne e a rthropla sty, the pa tie nt compla ins of a
sha rp susta ine d pa in ra dia ting down his le ft le g a s the ca the te r is
inse rte d to 2 cm. The MOST a ppropria te a ction a t this time would
be to
A. Le a ve the ca the te r a t 2 cm, a nd give a te st dose
B. Give a sma ll dose to re lie ve pa in, the n a dva nce 1 cm
C. W ithdra w the ca the te r 1 cm, the n give a te st dose
D. W ithdra w the ne e dle a nd ca the te r, the n re inse rt in a ne w
position
828. Cuta ne ous inne rva tion of the pla nta r surfa ce of the foot is
provide d by the
A. Sura l ne rve
B. Poste rior tibia l ne rve
C. Sa phe nous ne rve
D. De e p pe rone a l ne rve
829. W hich of the following loca l a ne sthe tics ha s the LOWEST ra tio
of dosa ge re quire d for ca rdiova scula r colla pse to dosa ge re quire d
for ce ntra l ne rvous syste m (CNS) toxicity?
A. Lidoca ine
B. Etidoca ine
C. Bupiva ca ine
D. Priloca ine
830. A 57-ye a r-old pa tie nt is sche dule d for he morrhoide ctomy. The
pa tie nt ha s a history of mild chronic obstructive pulmona ry dise a se ,
hype rte nsion, a nd tra uma tic foot a mputa tion from a tra ctor
a ccide nt. His only hospita liza tions we re for two suicide a tte mpts
re la te d to pha ntom limb se nsa tions 10 ye a rs a go. He ta ke s
phe ne lzine (Na rdil), thia zide , a nd pota ssium. W hich of the
following a ne sthe tic te chnique s would be MOST a ppropria te for
this pa tie nt?
A. Spina l a ne sthe tic with 0.5% hype rba ric bupiva ca ine
B. Epidura l a ne sthe tic with 0.5% bupiva ca ine
C. Loca l infiltra tion with lidoca ine a nd e pine phrine , se da tion
with propofol a nd me pe ridine
D. Ge ne ra l a ne sthe sia with propofol, succinylcholine , nitrous
oxide , a nd fe nta nyl
831. If the re curre nt la rynge a l ne rve we re tra nse cte d bila te ra lly, the
voca l cords would
A. Be in the ope n position
B. Be in the close d position
C. Be in the inte rme dia te position (i.e ., 2-3 mm a pa rt)
D. Not be a ffe cte d unle ss the supe rior la rynge a l ne rve we re a lso
injure d
832. A 63-ye a r-old woma n unde rgoe s tota l kne e a rthropla sty unde r
spina l a ne sthe sia . Two da ys la te r she compla ins of a se ve re
he a da che . Pa in inte nsity is not re la te d to posture . The LEAST
like ly ca use of this he a da che is
A. Ca ffe ine withdra wa l
B. Vira l illne ss
C. Migra ine
D. Postdura l puncture he a da che (PDPH)
833. W ha t is the CORRECT orde r of structure s (from ce pha la d to
ca uda d) in the inte rcosta l spa ce ?
A. Ne rve , a rte ry, ve in
B. Ve in, ne rve , a rte ry
C. Ve in, a rte ry, ne rve
D. Arte ry, ne rve , ve in
834. W hich of the following type s of re giona l a ne sthe sia is
a ssocia te d with the GREAT EST se rum conce ntra tion of lidoca ine ?
A. Inte rcosta l
B. Epidura l
C. Bra chia l ple xus
D. Fe mora l ne rve block
835. Diffe re nce s in which of the following loca l a ne sthe tic
prope rtie s a ccount for the fa ct tha t the onse t of a n e pidura l block
with 3% 2-chloroproca ine is more ra pid tha n 2% lidoca ine ?
A. Prote in binding
B. pKa
C. Lipid solubility
D. Conce ntra tion
836. A 69-ye a r-old ma n with a history of dia be te s me llitus a nd
chronic re na l fa ilure is to unde rgo pla ce me nt of a dia lysis fistula
unde r re giona l a ne sthe sia . During ne e dle ma nipula tion for a
supra cla vicula r bra chia l ple xus block, the pa tie nt be gins to cough
a nd compla in of che st pa in a nd shortne ss of bre a th. The MOST
like ly dia gnosis is
A. Angina
B. Pne umothora x
C. Phre nic ne rve irrita tion
D. Intra va scula r inje ction of loca l a ne sthe tic
837. Ea ch of the following sta te me nts is true conce rning a fe mora l
ne rve block EXCEPT
A. The fe mora l ne rve prima rily a rise s from the se cond to the
fourth lumba r ne rve roots
B. The fe mora l ne rve provide s se nsa tion to the a nte rior a nd
me dia l a spe ct of the thigh
C. The fe mora l ne rve lie s la te ra l to the fe mora l a rte ry a nd
fe mora l ve in
D. Prope r ne e dle pla ce me nt produce s sa rtorius muscle
contra ction without pa te lla r move me nt whe n e le ctrica lly
stimula te d
838. If a ne e dle is introduce d 1.5 cm infe rior a nd 1.5 cm la te ra l to
the pubic tube rcle , to which ne rve will it lie in close proximity?
A. Obtura tor ne rve
B. Fe mora l ne rve
C. La te ra l fe mora l cuta ne ous ne rve
D. Ilioinguina l ne rve
839. The MOST common complica tion a ssocia te d with a
supra cla vicula r bra chia l ple xus block is
A. Blocka de of the phre nic ne rve
B. Intra va scula r inje ction into the ve rte bra l a rte ry
C. Blocka de of the re curre nt la rynge a l ne rve
D. Pne umothora x
840. W hich portion of the uppe r e xtre mity is NOT inne rva te d by the
bra chia l ple xus?
A. Poste rior me dia l portion of the a rm
B. Elbow
C. La te ra l portion of the fore a rm
D. Me dia l portion of the fore a rm
841. W hich se ction of the bra chia l ple xus is blocke d with a
supra cla vicula r block?
A. Roots/trunks
B. Trunks/divisions
C. Cords
D. Bra nche s
842. A ce lia c ple xus block would NOT e ffe ctive ly tre a t pa in
re sulting from a ma ligna ncy involving which of the following
orga ns?
A. Ute rus
B. Stoma ch
C. Pa ncre a s
D. Ga llbla dde r
843. A he a lthy 27-ye a r-old woma n ste ppe d on a na il a nd is to
unde rgo dé bride me nt of a wound on he r right gre a t toe . She is
a nxious a bout ge ne ra l a ne sthe sia but a gre e s to a n a nkle block
with mild se da tion. W hich ne rve s must be a de qua te ly blocke d in
orde r to pe rform the surge ry?
A. De e p pe rone a l, poste rior tibia l, sa phe nous, sura l
B. De e p pe rone a l, sa phe nous, supe rficia l pe rone a l, sura l
C. De e p pe rone a l, poste rior tibia l, supe rficia l pe rone a l, sura l
D. De e p pe rone a l, supe rficia l pe rone a l, poste rior tibia l,
sa phe nous
844. A 54-ye a r-old ma n is a dministe re d morphine via pa tie nt-
controlle d a na lge sia (PCA) pump a fte r a le ft tota l hip a rthropla sty.
The pump is progra mme d to de live r a ma ximum dose of 2 mg e ve ry
15 minute s (lockout time ) a s ne e de d for pa tie nt comfort. The tota l
ma ximum dose tha t ca n be de live re d in 4 hours is 30 mg. On the
first da y the pa tie nt re ce ive s 15 dose s e ve ry 4 hours by pre ssing the
de live ry button e ve ry 15 to 18 minute s. How should his pa in control
be furthe r ma na ge d?
A. Discontinue the PCA pump a nd a dministe r intra muscula r
morphine
B. Incre a se the lockout time from 15 to 25 minute s
C. Cha nge the a na lge sic from morphine to me pe ridine
D. Incre a se the dose to 3 mg e ve ry 15 minute s a s ne e de d up to a
tota l ma ximum dose of 40 mg e ve ry 4 hours
845. The me cha nism of low-fre que ncy tra nscuta ne ous e le ctrica l
ne rve stimula tion (TENS) units in re lie ving pa in is
A. Dire ct e le ctrica l inhibition of type A-δ a nd C fibe rs
B. De ple tion of ne urotra nsmitte r in nocice ptors
C. Hype rpola riza tion of spinotha la mic tra ct ne urons
D. Activa tion of inhibitory ne urons
846. Epidura l use of which of the following opioids would re sult in
the GREAT EST incide nce of de la ye d re spira tory de pre ssion?
A. Sufe nta nil
B. Fe nta nyl
C. Morphine sulfa te
D. Hydromorphone
847. A 21-ye a r-old pa tie nt re ports tingling in he r thumb during he r
ce sa re a n se ction unde r e pidura l a ne sthe sia . To which de rma toma l
le ve l would this corre spond?
A. C5
B. C6
C. C7
D. C8
848. W hich of the following would ha ste n the onse t a nd incre a se
the clinica l dura tion of a ction of a loca l a ne sthe tic, a nd provide the
GREAT EST de pth of motor a nd se nsory blocka de whe n use d for
e pidura l a ne sthe sia ?
A. Incre a sing the volume of loca l a ne sthe tic
B. Incre a sing the conce ntra tion of loca l a ne sthe tic
C. Incre a sing the dose
D. Pla cing the pa tie nt in the he a d-down position
849. Se le ct the FALSE sta te me nt conce rning ne urolytic ne rve blocks.
A. De struction of pe riphe ra l ne rve s ca n be followe d by a
de ne rva tion hype rse nsitivity tha t is worse tha n the origina l
pa in
B. Ne urolytic blocks should be re se rve d for pa tie nts with short
life e xpe cta ncie s
C. Ne urolytic blocka de with phe nol is pe rma ne nt
D. Intra the ca l ne urolysis ma y be a n e ffe ctive ma na ge me nt for
ce rta in pa in conditions
850. Tra nsie nt ne urologic symptoms (TNS) a fte r spina l a ne sthe sia is
a ssocia te d with e a ch of the following EXCEPT
A. Lidoca ine
B. Lithotomy position
C. Ambula tory a ne sthe sia
D. Conce ntra tion of loca l a ne sthe tic inje cte d
851. Afte r you se le ct the a ppropria te ultra sound tra nsduce r, you ca n
a djust se ve ra l fa ctors to optimize the ima ge for re giona l a ne sthe sia .
W hich of the following de scriptions is FALSE?
A. Fre que ncy—highe r fre que ncy ultra sound use is be tte r for
vie wing de e p structure s
B. De pth—a djuste d to limit the ce ntime te rs of vie wing a re a on
the monitor
C. Ga in—incre a se d ga in produce s incre a se d brightne ss
D. Fre que ncy—highe r fre que ncy ultra sound use produce s be tte r
ima ge re solution
852. Ea ch of the following is a ssocia te d with a n incre a se d
incide nce of PDPHs EXCEPT
A. Younge r a dults
B. Ea rly a mbula tion
C. Pre gna ncy
D. La rge ne e dle size
853. Ea ch of the following ite ms de scribe s pa in in the a bdomina l
visce ra EXCEPT
A. Pa in is tra nsmitte d via the va gus ne rve
B. The ne rve fibe rs a re type C
C. Pa in is cha ra cte rize d by a dull a ching or burning se nsa tion
D. Diste ntion of the tra nsve rse colon ca use s more pa in tha n
surgica l tra nse ction
854. W hich of the following blocks ha s the LONGEST dura tion of
a ction whe n bupiva ca ine with e pine phrine is a dministe re d?
A. Axilla ry
B. Epidura l
C. Infiltra tion
D. Spina l
855. All of the following sta te me nts conce rning a psoa s
compa rtme nt block a re true EXCEPT
A. Compa rtme nta l block is use d to provide unila te ra l a ne sthe sia
to the proxima l a spe ct of the thigh a nd hip
B. Stimula tion of the qua drice ps muscle de monstra te s good
ne e dle pla ce me nt
C. Comple te le g a ne sthe sia ca n be obta ine d whe n combine d
with a scia tic ne rve block
D. Continuous ca the te rs a re not use d be ca use the a mount of
drug infuse d would le a d to toxicity
856. A 35-ye a r-old woma n re ce ive s a poplite a l block for a nkle a nd
foot surge ry. W hich othe r ne rve must be blocke d in orde r to ha ve
comple te a ne sthe sia of the foot?
A. Supe rficia l pe rone a l ne rve
B. Sura l ne rve
C. Sa phe nous ne rve
D. Poste rior tibia l ne rve
857. The most common complica tion of a ce lia c ple xus block is
A. Hypote nsion
B. Se izure
C. Re trope ritone a l he ma toma
D. Constipa tion
858. The occipita l portion of the skull re ce ive s se nsory inne rva tion
from
A. Spina l a cce ssory ne rve (ne rve XI)
B. Fa cia l ne rve (ne rve VII)
C. Ophtha lmic bra nch of trige mina l ne rve (ne rve V)
D. Ce rvica l ple xus
859. Ea ch of the following is a pote ntia l complica tion of thora cic
pa ra ve rte bra l blocks EXCEPT
A. Pne umothora x
B. Epidura l spre a d of loca l a ne sthe tic
C. Hype rte nsion
D. Tota l spina l
860. Afte r pla ce me nt of a n e pidura l ca the te r in a 55-ye a r-old pa tie nt
for tota l hip a rthropla sty, a n e ntire e pidura l dose is a dministe re d
into the suba ra chnoid spa ce . Physiologic e ffe cts consiste nt with
suba ra chnoid inje ction of la rge volume s of loca l a ne sthe tic include
A. Hypote nsion a nd bra dyca rdia
B. Re spira tory de pre ssion
C. Constricte d pupils
D. Possible ca uda e quina syndrome
861. A 49-ye a r-old type 1 dia be tic pa tie nt with a long history of
burning pa in in the right lowe r e xtre mity re ce ive s a spina l
a ne sthe tic with 100 mg of proca ine with 5% de xtrose . The pa tie nt
re ports no re lie f in symptoms but ha s comple te bila te ra l motor
blocka de . W ha t dia gnosis is consiste nt with this diffe re ntia l
blocka de e xa mina tion?
A. Dia be tic ne uropa thy
B. Ce ntra l pa in
C. Myofa scia l pa in
D. Comple x re giona l pa in syndrome I (RSD)
862. An 18-ye a r-old ma n ha s a se izure during pla ce me nt of a n
inte rsca le ne bra chia l ple xus block with 0.5% bupiva ca ine . The
a ne sthe siologist be gins to hype rve ntila te the pa tie nt’s lungs with
100% O2 using a n a ne sthe sia ba g a nd ma sk. The ra tiona le for this
the ra py include s a ll of the following EXCEPT
A. The the ra py he lps to pre ve nt a nd tre a t hypoxia
B. Hype rve ntila tion de cre a se s blood flow a nd de live ry of loca l
a ne sthe tic to the bra in
C. Hype rve ntila tion e le va te s the se izure thre shold
D. Hype rve ntila tion induce s a lka losis a nd conve rts loca l
a ne sthe tics to the protona te d (ionize d) form, which is le ss
like ly to cross the ce ll me mbra ne s
863. Pa ra -a minobe nzoic a cid is a me ta bolite of
A. Me piva ca ine
B. Ropiva ca ine
C. Bupiva ca ine
D. Proca ine
864. W hich sta te me nt conce rning pe riphe ra l ne rve structure a nd
function is FALSE?
A. Both nonmye lina te d a nd mye lina te d ne rve s a re surrounde d by
Schwa nn ce lls
B. The spe e d of propa ga tion of a n a ction pote ntia l a long a ne rve
a xon is gre a tly e nha nce d by mye lin
C. Ge ne ra tion of a n a ction pote ntia l is a n “a ll-or-nothing”
phe nome non
D. Mye lina tion re nde rs ne rve s le ss se nsitive to loca l a ne sthe tic
blocka de
865. A 42-ye a r-old woma n with a morbid fe a r of ge ne ra l a ne sthe sia
re ce ive s a n inte rsca le ne block for shoulde r a rthroscopy consisting
of 20 mL 0.5% ropiva ca ine . Much of he r a rm, shoulde r, a nd ha nd
a re numb, but the pa tie nt compla ins of pa in a s the incision is ma de
a t the uppe r portion of the shoulde r. The most a ppropria te ne xt
ste p is to
A. Re pe a t block
B. Pe rform inte rcostobra chia l block
C. Pe rform supe rficia l ce rvica l ple xus block
D. Pe rform a de e p ce rvica l ple xus block
866. According to the 2004 Ame rica n Socie ty of Re giona l Ane sthe sia
a nd Pa in Me dicine (ASRA) pra ctice a dvisory on infe ctious
complica tions of re giona l a ne sthe sia a nd pa in me dicine , the MOST
importa nt a ction to ma inta in a se ptic te chnique a nd pre ve nt cross-
conta mina tion during re giona l a ne sthe sia te chnique s is
A. We a ring a surgica l gown
B. Ha nd wa shing
C. Using soa p a nd wa te r inste a d of a lcohol-ba se d a ntise ptics
D. Using povidone -iodine (e .g., Be ta dine ) inste a d of a lcohol-
ba se d chlorhe xidine to scrub
867. A 75-ye a r-old woma n with a history of pulmona ry e mbolism is
sche dule d for a right lowe r lobe ctomy for lung ca nce r. She is
re ce iving da lte pa rin (Fra gmin) for de e p ve in thrombosis (DVT)
prophyla xis. How long a fte r he r la st dose should one wa it prior to
pla ce me nt of a thora cic e pidura l?
A. 12 hours
B. 24 hours
C. 72 hours
D. No wa iting is ne ce ssa ry since the dose for prophyla xis is low
868. How long should a pa tie nt be off clopidogre l (Pla vix) be fore a
ce ntra l ne ura xia l block is pe rforme d?
A. 24 hours
B. 7 da ys
C. 14 da ys
D. No wa iting ne ce ssa ry
869. Addition of bica rbona te to loca l a ne sthe tics re sults in
A. De la ye d onse t of a ction
B. Re duce d toxicity
C. Incre a se d dura tion of a ction
D. Re duce d pa in with skin infiltra tion
870. Through which of the following would a spina l ne e dle NOT
pa ss during a midline pla ce me nt of a suba ra chnoid block in the L3-
L4 lumba r spa ce ?
A. Supra spinous liga me nt
B. Inte rspinous liga me nt
C. Poste rior longitudina l liga me nt
D. Dura ma te r
871. W ha t e pidura l dose of bupiva ca ine will give se nsory a na lge sia
simila r to 10 mL of 2% lidoca ine ?
A. 5 mL of 0.25%
B. 10 mL of 0.25%
C. 5 mL of 0.5%
D. 10 mL of 0.5%
872. Ea ch of the following a dditive s to a spina l a ne sthe tic
posse sse s a na lge sic prope rtie s EXCEPT
A. Clonidine
B. Hydromorphone
C. Epine phrine
D. All of the a bove ha ve a na lge sic prope rtie s
873. W hich of the following loca l a ne sthe tics is ina ppropria te ly
pa ire d with a clinica l a pplica tion be ca use of its prope rtie s or
toxicity?
A. Te tra ca ine , topica l a ne sthe sia
B. Bupiva ca ine , intra ve nous a ne sthe sia
C. Priloca ine , infiltra tive a ne sthe sia
D. Chloroproca ine , e pidura l a ne sthe sia
874. Discha rge crite ria from the posta ne sthe sia ca re unit would be
re a che d FAST EST a fte r a 20- to 30-mL volume of which of the
following e pidura lly a dministe re d loca l a ne sthe tics?
A. 3% 2-Chloroproca ine
B. 2% Lidoca ine
C. 0.75% Ropiva ca ine
D. 0.5% Le vobupiva ca ine
875. A ca uda l block (pe rforme d unde r se voflura ne ge ne ra l
a ne sthe sia ) with 0.25% bupiva ca ine a nd 1:200,000 e pine phrine is
pla nne d for postope ra tive a na lge sia a fte r bila te ra l inguina l he rnia
re pa ir in a 5-month-old pa tie nt. Ea ch of the following would be
consiste nt with a n intra va scula r inje ction EXCEPT
A. Systolic blood pre ssure incre a se by gre a te r tha n 15 mm Hg
B. He a rt ra te de cre a se by gre a te r tha n 10 be a ts/min
C. Ve ntricula r e xtra systole s
D. Incre a se in T-wa ve a mplitude >25% ove r ba se line
876. W hich is NOT a pote ntia l complica tion of a ste lla te ga nglion
block?
A. Re curre nt la rynge a l ne rve pa ra lysis
B. Suba ra chnoid block
C. Bra chia l ple xus block
D. Incre a se d he a rt ra te
877. An a xilla ry block using the tra nsa rte ria l a pproa ch with 0.5%
bupiva ca ine a nd e pine phrine (1:200,000) is pe rforme d in a 70-kg
pa tie nt. A 30-mL qua ntity is inje cte d poste rior to the a xilla ry a rte ry
a nd 30 mL a nte rior to it. How ma ny milligra ms ha ve be e n inje cte d,
a nd wa s the ma ximum re comme nde d dose e xce e de d?
A. 150 mg bupiva ca ine , 150 µg e pine phrine did not e xce e d
ma ximum dose
B. 150 mg bupiva ca ine , 150 µg e pine phrine e xce e de d ma ximum
dose
C. 300 mg bupiva ca ine , 300 µg e pine phrine did not e xce e d
ma ximum dose
D. 300 mg bupiva ca ine , 300 µg e pine phrine e xce e de d ma ximum
dose
878. Thre e da ys a fte r kne e a rthroscopy unde r spina l a ne sthe sia , a
55-ye a r-old pa tie nt compla ins of double vision a nd difficulty
he a ring. The othe r like ly finding would be
A. He a da che
B. Fe ve r
C. We a kne ss in le gs
D. Me nta l sta tus cha nge s
879. W hich of the following sta te me nts is T RUE conce rning
tra nsve rsus a bdominis pla ne (TAP) block?
A. Ultra sound is use ful in finding the inte rcosta l ne rve s
B. The loca l a ne sthe tic is inje cte d dire ctly into the tra nsve rsus
a bdominis muscle
C. The subcosta l, ilioinguina l, a nd iliohypoga stric ne rve s a re
blocke d
D. 10 mL of loca l a ne sthe tic is a ll tha t is ne e de d for good spre a d
880. W hich of the following ne rve s ca n be e le ctrica lly stimula te d a t
the a nkle to produce fle xion of the toe s?
A. Poste rior tibia l ne rve
B. Sa phe nous ne rve
C. De e p pe rone a l ne rve
D. Supe rficia l pe rone a l ne rve
881. W hich motor re sponse from pe riphe ra l ne rve stimula tion is
INCORRECT LY pa ire d with the a ppropria te ne rve ?
A. Musculocuta ne ous ne rve —fle xion of the fore a rm a t the e lbow
B. Ra dia l ne rve —e xte nsion of a ll digits a s we ll a s the wrist a nd
fore a rm
C. Ulna r ne rve —a bduction of the thumb
D. Me dia n ne rve —fle xion of the wrist, prona tion of the fore a rm
882. During a n a irwa y e xa m, a 53-ye a r-old pa tie nt me ntions tha t his
right thumb tingle s a nd the n be come s numb if he e xte nds his he a d
for more tha n a fe w se conds. This symptom MOST like ly
re pre se nts a (n)
A. Unsta ble C-spine
B. Lhe rmitte ’s phe nome non
C. C6 ne rve root irrita tion
D. C8 ra diculopa thy
883. W he n pe rforming a n inte rsca le ne block with a pe riphe ra l
ne rve stimula tor, you note dia phra gma tic move me nt. You should
now
A. Inje ct the loca l a ne sthe tic, a s the ne e dle is in a n a ppropria te
loca tion
B. Re dire ct the ne e dle in a n a nte rior dire ction
C. Re dire ct the ne e dle in a poste rior dire ction
D. Adva nce the ne e dle a bout 0.5 cm more a nd inje ct
884. During pla ce me nt of a n inte rsca le ne block, the pa tie nt
be come s hypote nsive , bra dyca rdic, a pne ic, a nd cya notic. The
MOST like ly ca use is
A. Ve rte bra l a rte ry inje ction
B. Phre nic ne rve blocka de
C. Tota l spina l
D. Ste lla te ga nglion block
885. The re a son tha t ropiva ca ine is ma rke te d a s pure S
e na ntiome rs is be ca use the S form is a ssocia te d with
A. Incre a se d pote ncy
B. Longe r dura tion
C. Re duce d ca rdia c toxicity
D. Re duce d incide nce of a na phyla xis
886. Ne rve s tha t origina te from the sa cra l ple xus include e a ch of
A. Fe mora l ne rve
B. Tibia l ne rve
C. Scia tic ne rve
D. Common pe rone a l ne rve
887. The only te chnique shown to pre ve nt a ne sthe tic-re la te d ne rve
injury during pla ce me nt of pe riphe ra l ne rve blocks is
A. Ultra sound-guide d re giona l te chnique
B. Tra nsa rte ria l te chnique
C. Ne rve stimula tor
888. An a xilla ry block is pe rforme d on a he a lthy 19-ye a r-old a thle te .
A 30-mL qua ntity of 0.75% bupiva ca ine is inje cte d incre me nta lly. Five
minute s a fte r the bupiva ca ine inje ction, the pa tie nt ha s a se izure
a nd e xpe rie nce s ca rdiova scula r colla pse . W hich of the me a sure s
be low is NOT indica te d?
A. Be gin che st compre ssions a t 100 pe r minute
B. Ve ntila te with 100% oxyge n
C. Bolus propofol to bind loca l a ne sthe tic
D. Infuse 20% lipid e mulsion
889. The structure MOST like ly to be blocke d during pla ce me nt of
a n inte rsca le ne block in a ddition to the bra chia l ple xus is the
A. Phre nic ne rve
B. Ve rte bra l a rte ry
C. Re curre nt la rynge a l ne rve
D. Va gus ne rve
890. All of the following a re symptoms of a de ve loping e pidura l
he ma toma EXCEPT
A. Ra dicula r ba ck pa in
B. Bowe l a nd bla dde r dysfunction
C. Motor de ficits
D. Fe ve r
891. In a ddition to C ne rve fibe rs, which ne rve fibe rs ca rry pa in
impulse s?
A. A-a lpha (Aα)
B. A-be ta (Aβ)
C. A-de lta (Aδ)
D. B
892. An intra dura l ma ss le sion a t the tip of a drug infusion ca the te r
is LEAST like ly to pre se nt a s
A. Incre a sing pa in
B. De ve lopme nt of numbne ss in T8 de rma toma l pa tte rn
C. Hypopne a
D. Pe ria na l numbne ss
893. Be nzoca ine ha s a ll of the following prope rtie s EXCEPT
A. It is a we a k a lka li
B. It is use d only topica lly
C. It is me ta bolize d by a n e ste ra se in the blood
D. It ca n promote forma tion of me the moglobin
894. W hich sta te me nt conce rning loca l a ne sthe tics is CORRECT ?
A. The un-ionize d form of a loca l a ne sthe tic binds to the ne rve
me mbra ne to a ctua lly block conduction
B. If one node of Ra nvie r is blocke d, conduction will be re lia bly
inte rrupte d
C. The pre se nce of mye lin e nha nce s the a bility of a loca l
a ne sthe tic to block ne rve conduction
D. Loca l a ne sthe tics block tra nsmission by inhibiting the volta ge -
ga te d pota ssium ion cha nne ls
895. Postdura l puncture he a da che s
A. Usua lly occur imme dia te ly following dura l puncture
B. Are re lie ve d 8 to 12 hours a fte r a n e pidura l blood pa tch is
pe rforme d
C. Occur more fre que ntly in nonpre gna nt pa tie nts compa re d with
pre gna nt pa tie nts
D. Ca n be a ssocia te d with ne urologic de ficits
896. W hich of the following proce dure s for tre a tme nt of chronic
pa in re quire s loca liza tion of the e pidura l spa ce with a n e pidura l
ne e dle a s pa rt of te chnique ?
A. Intra disca l e le ctrothe rma l the ra py (IDET)
B. Spina l cord stimula tion
C. Pe rcuta ne ous disk de compre ssion
D. Ve rte bropla sty
897. Ea ch of the following drugs ha s be e n use d to tre a t ne uropa thic
pa in. Se le ctive inhibition of se rotonin a nd nore pine phrine re upta ke
is the me cha nism of which drug?
A. Duloxe tine
B. Me xile tine
C. Ga ba pe ntin
D. Ca rba ma ze pine
DIRECT IONS (Que stions 898 through 901): Ple a se ma tch the
structure be low with the le tte r tha t corre sponds to it in the
ultra sound ima ge .
898. Musculocuta ne ous ne rve

899. Axilla ry a rte ry
900. Axilla ry ve in
901. Ulna r ne rve
902. Phre nic ne rve

903. Ca rdia c a cce le ra tor fibe rs
904. Pude nda l ne rve
905. Pa in fibe rs to the ute rus
906. Inhibitory pre syna ptic fibe rs to the ga strointe stina l tra ct
A. C3-C5
B. T1-T4
C. T5-T12
D. T10-L1
E. S2-S4
907. Se nsory inne rva tion of the mucous me mbra ne s of the nose
908. Ma in se nsory inne rva tion to supe rior a nd infe rior pa rts of the
ha rd a nd soft pa la te
909. Se nsory inne rva tion of the la rynx a bove the voca l cords
910. Se nsory inne rva tion be low the voca l cords to the ca rina
911. Se nsory inne rva tion to poste rior third of the tongue
912. Se nsory inne rva tion to the pha rynge a l wa lls a nd the tonsils
913. Motor inne rva tion to the intrinsic muscle s of the la rynx, e xce pt
cricothyroid muscle
914. Motor inne rva tion to the cricothyroid muscle
A. Trige mina l ne rve
B. Glossopha rynge a l ne rve
C. Inte rna l bra nch of the supe rior la rynge a l ne rve
D. Exte rna l bra nch of the supe rior la rynge a l ne rve
E. Re curre nt la rynge a l ne rve
Anatomy, Regional Anesthesia, and Pain
Management
788. (B) Ta chyphyla xis is a we ll-known phe nome non a ssocia te d
with re pe a te d inje ctions of loca l a ne sthe tics le a ding to de cre a se d
e ffe ctive ne ss. Inte re stingly, the dosing inte rva l se e ms most
importa nt in the de ve lopme nt of ta chyphyla xis. If the dosing inte rva l
is short (a nd the re is no pa in be twe e n inje ctions), ta chyphyla xis
doe s not de ve lop. Howe ve r, with longe r dosing inte rva ls (a nd pa in
be twe e n inje ctions), ta chyphyla xis de ve lops (Miller: Miller’s
789. (B) The tre a tme nt of pruritus, the most common side e ffe ct of
ne ura xia l opia te s, is prima rily with opioid a nta gonists, mixe d
opioid a gonist–a nta gonists, a nd a ntihista mine drugs (by the ir
se da ting e ffe cts). Na lbuphine is a mixe d opioid a gonist–a nta gonist;
diphe nhydra mine ha s a ntihista mine prope rtie s. Propofol a t ve ry
low dose s (e .g., 10 mg) ha s be e n use ful to tre a t pruritus not only
induce d by ne ura xia l opia te s but a lso the pruritus a ssocia te d with
chole sta tic live r dise a se . Propofol doe s not a ffe ct a na lge sia ,
whe re a s opioid a nta gonists a nd mixe d a gonist–a nta gonists ma y
re ve rse some or a ll of the a na lge sia , de pe nding upon dose .
De xme de tomidine is a highly se le ctive α2-re ce ptor a gonist tha t ha s
a fa ste r onse t a nd shorte r dura tion of a ction compa re d with
clonidine . De xme de tomidine ha s a na lge sic prope rtie s, ca n
pote ntia te ne ura xia l a na lge sia whe n inje cte d spina lly, a nd ca n
pe rha ps de cre a se the incide nce of pruritus by re ducing the a mount
of na rcotic dose use d. It doe s not tre a t pruritus (Barash : Clinical
Anesth esia, ed 7, p 519; Miller: Miller’s Anesth esia, ed 8, pp 2986–2987).
790. (C) The ma ximum dose of loca l a ne sthe tics conta ining 1:200,000
e pine phrine tha t ca n be use d for ma jor ne rve blocks in a he a lthy
70-kg a dult is lidoca ine , 500 mg; me piva ca ine , 500 mg; priloca ine ,
600 mg; bupiva ca ine , 225 mg; le vobupiva ca ine , 225 mg; ropiva ca ine
250 mg (Miller: Miller’s Anesth esia, ed 8, p 1043, Table 36-6).
791. (B) 1:200,000 me a ns
1 g/200,000 mL = 1000 mg/200,000 mL = 1 mg/200 mL
1 mg/200 mL = 1000 µg/200 mL = 10 µg/2 mL = 5 µg/mL
792. (D) The e a rly signs of digita lis toxicity include loss of a ppe tite
a nd na use a a nd vomiting. In some pa tie nts, the re ma y be pa in tha t
is simila r to trige mina l ne ura lgia . Pa in or discomfort in the fe e t a nd
pa in a nd discomfort in the e xtre mitie s ma y be a fe a ture of digita lis
toxicity. Tra nsie nt visua l disturba nce s (e .g., a mblyopia , scotoma ta )
ha ve be e n re porte d in pa tie nts with digita lis toxicity. In this pa tie nt,
it would be prude nt to obta in a digoxin le ve l a s a n e a rly pa rt of the
workup for the se compla ints. He ma y a lso ha ve true trige mina l
ne ura lgia , a nd workup for this condition ca n be unde rta ke n a fte r
digita lis toxicity ha s be e n rule d out (Stoelting: Ph arm acology and
793. (C) Toxic re a ctions to loca l a ne sthe tics a re usua lly due to
intra va scula r or intra the ca l inje ction or to a n e xce ssive dosa ge .
The initia l symptoms of loca l a ne sthe tic toxicity from high blood
le ve ls (ina dve rte nt IV inje ction or e xce ssive dosa ge s) a re light-
he a de dne ss a nd dizzine ss, a nd numbne ss of the tongue . Pa tie nts
a lso ma y note pe riora l numbne ss a nd tinnitus. Progre ssive CNS
e xcita tory e ffe cts include visua l disturba nce s (difficulty focusing),
a uditory disturba nce s (tinnitus), shive ring, muscula r twitching, a nd,
ultima te ly, ge ne ra lize d tonic-clonic se izure s. CNS de pre ssion ca n
e nsue , le a ding to re spira tory de pre ssion or a rre st. Highe r le ve ls
ca n le a d to ca rdiova scula r colla pse . To he lp pre ve nt e xce ssive ly
high le ve ls of loca l a ne sthe tic, common pra ctice is to a spira te for
blood a nd inje ct the loca l a ne sthe tic slowly a nd incre me nta lly,
looking for signs of toxicity (a nd, if a ppropria te , a dding e pine phrine
to use a s a n intra va scula r ma rke r a s note d by a n incre a se in he a rt
ra te a nd blood pre ssure ) (Barash : Clinical Anesth esia, ed 7, pp 572–
794. (B) The site of a ction of spina lly a dministe re d opia te s is the
substa ntia ge la tinosa of the spina l cord. Epidura l a dministra tion is
complica te d by fa ctors re la te d to dura l pe ne tra tion, a bsorption in
fa t, a nd syste mic upta ke ; the re fore , the qua ntity of intra the ca lly
a dministe re d opioid re quire d to a chie ve e ffe ctive a na lge sia is
typica lly much sma lle r. Lipid-soluble opioids (e .g., fe nta nyl) ha ve a
fa ste r onse t of a ction but a shorte r dura tion of a ction compa re d to
the more wa te r soluble opioids (e .g., morphine ). A dose of 1 to 5 mg
of e pidura l morphine is a pproxima te ly e qua l to a n intra the ca l dose
of 0.1 to 0.3 mg of morphine . Onse t time for e pidura l a dministra tion
is 30 to 60 minute s with a pe a k e ffe ct in 90 to 120 minute s. Onse t
time for intra the ca l a dministra tion is shorte r tha n for e pidura l
a dministra tion. Dura tion of 12 to 24 hours of a na lge sic e ffe ct ca n be
e xpe cte d by e ithe r route with morphine (Barash : Clinical Anesth esia,
ed 7, pp 1627–1630; Miller: Miller’s Anesth esia, ed 8, pp 2983–2984, Table
98-4).
795. (A) Commonly inje cte d loca l a ne sthe tics a re divide d che mica lly
into two groups: the a mino e ste rs (e ste rs) a nd the a mino a mide s
(a mide s). The e ste rs include proca ine , chloroproca ine , a nd
te tra ca ine (a ll ha ve one le tte r i in the na me ). The a mide s a re
lidoca ine , me piva ca ine , priloca ine , bupiva ca ine , le vobupiva ca ine ,
e tidoca ine , a nd ropiva ca ine (a ll ha ve two i’s in the na me ). The
e ste rs unde rgo pla sma cle a ra nce by choline ste ra se s a nd ha ve
re la tive ly short ha lf-live s, whe re a s the a mide s unde rgo he pa tic
cle a ra nce a nd ha ve longe r ha lf-live s (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 266–271; Miller: Miller’s
796. (B) The ma jor disa dva nta ge of the inte rsca le ne block for ha nd
a nd fore a rm surge ry is tha t blocka de of the infe rior trunk (C8-T1) is
ofte n incomple te . Supple me nta tion of the ulna r ne rve ofte n is
re quire d. The risk of pne umothora x is quite low, but blocka de of
the ipsila te ra l phre nic ne rve occurs in up to 100% of blocks. This
ca n ca use re spira tory compromise in pa tie nts with significa nt lung
dise a se . Horne r syndrome from blocka de of the ste lla te ga nglion
ca n occur in 70% to 90% of pa tie nts if la rge volume s of loca l
a ne sthe tic a re inje cte d (Hebl: May o Clinic Atlas of Regional Anesth esia
and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 191–205; Miller:
797. (C) Surgica l tra uma include s a wide va rie ty of physiologic
re sponse s. Ge ne ra l a ne sthe sia ha s no or only a slight inhibitory
e ffe ct on e ndocrine a nd me ta bolic re sponse s to surge ry. Re giona l
a ne sthe sia inhibits the nocice ptive signa l from re a ching the CNS
a nd, the re fore , ha s a significa nt inhibitory e ffe ct on the stre ss
re sponse , including a dre ne rgic, ca rdiova scula r, me ta bolic,
immunologic, a nd pituita ry. This e ffe ct is most pronounce d with
proce dure s on the lowe r pa rt of the body a nd le ss with ma jor
a bdomina l a nd thora cic proce dure s. The va ria ble e ffe ct is proba bly
due to unblocke d a ffe re nts (i.e ., va ga l, phre nic, or sympa the tic)
(Barash : Clinical Anesth esia, ed 7, p 1353; Miller: Miller’s Anesth esia ed
8, pp 3139–3141).
798. (B) The structure s tha t a re tra ve rse d by a ne e dle pla ce d in the
midline prior to the e pidura l spa ce a re a s follows: skin,
subcuta ne ous tissue , supra spinous liga me nt, inte rspinous liga me nt,
a nd liga me ntum fla vum. The liga me ntum fla vum is tough a nd
de nse , a nd a cha nge in the re sista nce to a dva ncing the ne e dle is
ofte n pe rce ive d a nd to ma ny fe e ls like a “sna p.” The a nte rior a nd
poste rior longitudina l liga me nts bind the ve rte bra l bodie s toge the r.
Se e a lso e xpla na tion a nd dia gra m in Que stion 870 (Barash : Clinical
1688).
799. (B) The symptoms of ca uda e quina syndrome include low ba ck
pa in, bila te ra l lowe r e xtre mity we a kne ss, sa ddle a ne sthe sia , a nd
loss of bowe l a nd bla dde r control. Pooling of loca l a ne sthe tics in
de pe nde nt a re a s of the spine within the suba ra chnoid spa ce ha s
be e n ide ntifie d a s the ca usa tive fa ctor in ca se s of ca uda e quina
syndrome . Microlume n ca the te rs (27-ga uge a nd sma lle r) ma y
e nha nce the nonuniform distribution of solutions within the
intra the ca l spa ce , but ca uda e quina syndrome ha s be e n a ssocia te d
with the use of la rge r ca the te rs, 5% lidoca ine with de xtrose , a nd 2%
lidoca ine , a s we ll a s 0.5% te tra ca ine (Barash : Clinical Anesth esia, ed
7, pp 576, 928; Miller: Basics of Anesth esia, ed 6, p 269).
800. (B) Diffe re ntia l ne rve blocka de is a comple x proce ss with both
pe riphe ra l ne rve blocks a nd ce ntra l ne rve blocks. W ith spina l
a ne sthe sia , the sympa the tic ne rve block ma y be a nywhe re
be twe e n two a nd six de rma tome s highe r tha n the se nsory block,
a s note d by pin prick. Se nsory block is two to thre e de rma tome s
highe r tha n the motor block. Howe ve r, with e pidura l a ne sthe sia ,
the sympa the tic a nd se nsory blocks te nd to be a t the sa me
de rma tome le ve l a nd a re highe r tha n the motor block (Barash :
801. (B) Acute he rpe s zoste r is due to the re a ctiva tion of the
va rice lla -zoste r virus. Acute tre a tme nt include s symptoma tic pa in
tre a tme nt a nd a ntivira l drugs (e .g., a cyclovir, fa mciclovir, or
va la cyclovir). It is typica lly a be nign a nd se lf-limiting dise a se in
pa tie nts younge r tha n 50 ye a rs of a ge . As one ge ts olde r, the
incide nce of posthe rpe tic ne ura lgia (PHN), de fine d a s pa in
pe rsisting for more tha n 3 months a fte r re solution of the ra sh,
incre a se s. The incide nce of PHN is a bout 30% to 50% in pa tie nts
olde r tha n 50 ye a rs. Tre a tme nt of e sta blishe d PHN ha s be e n
shown to be re sista nt to inte rve ntions a nd, thus, ca n be difficult.
Howe ve r, prove n the ra pie s include tricyclic a ntide pre ssa nts,
a nticonvulsa nts, opioids, topica l loca l a ne sthe tics (e .g., 5%
lidoca ine pa tch), topica l ca psa icin, a nd TENS. Sympa the tic blocks
ca n provide e xce lle nt a na lge sia but a re most use ful during the
more a cute sta ge s of the dise a se ra the r tha n during the la te chronic
sta ge s. Sympa the tic blocks in the a cute sta ge s ma y de cre a se the
incide nce of PHN. Ora l clonidine , which is use d to tre a t
hype rte nsion a nd opioid withdra wa l, ha s not be e n shown to be a n
e ffe ctive tre a tme nt for PHN (Barash : Clinical Anesth esia. ed 7, p 1657;
1050; Raj: Practical Managem ent of Pain, ed 3, pp 187–189).
802. (C) The de e p pe rone a l ne rve inne rva te s the short e xte nsors of
the toe s a nd the skin of the we b spa ce be twe e n the gre a t a nd
se cond toe . The de e p pe rone a l ne rve is blocke d a t the a nkle by
infiltra tion be twe e n the te ndons of the a nte rior tibia l a nd e xte nsor
ha llucis longus muscle s (Hebl: May o Clinic Atlas of Regional
Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 424–427,
446–450).
803. (B) CNS toxicity from loca l a ne sthe tics ge ne ra lly pa ra lle ls
a ne sthe tic pote ncy (e .g., bupiva ca ine is four time s a s pote nt a s
lidoca ine , a nd ropiva ca ine is thre e time s a s pote nt a s lidoca ine ).
Ca rdiova scula r (CV) toxicity occurs a t a highe r blood le ve l tha n CNS
toxicity. For bupiva ca ine a nd ropiva ca ine , CV toxicity occurs a t two
time s the CNS dose , whe re a s for lidoca ine the CV toxicity occurs a t
se ve n time s the CNS toxicity le ve ls, ma king lidoca ine the le a st
ca rdiotoxic a nd bupiva ca ine the most ca rdiotoxic of the liste d loca l
a ne sthe tics (Barash : Clinical Anesth esia, ed 7, pp 573–575; Miller:
804. (D) The Inte rna tiona l Associa tion for the Study of Pa in (IASP)
ha s de fine d se ve ra l pa in te rms. Ane sthe sia dolorosa re fe rs to
sponta ne ous pa in in a n a re a or re gion tha t is a ne sthe tic.
Ne uropa thic pa in is pa in initia te d or ca use d by a prima ry le sion or
dysfunction in the ne rvous syste m. Dyse sthe sia is a n unple a sa nt
a bnorma l se nsa tion, whe the r sponta ne ous or e voke d.
Hype ra lge sia is a n incre a se d re sponse to a stimulus tha t is
norma lly pa inful. Allodynia is pa in ca use d by a stimulus tha t doe s
not norma lly provoke pa in (Barash : Clinical Anesth esia, ed 7, pp 1649–
1025–1026).
805. (A) Este r loca l a ne sthe tics a re hydrolyze d by choline ste ra se
e nzyme s tha t a re pre se nt ma inly in pla sma a nd, in a sma lle r
a mount, in the live r. Be ca use the re a re no choline ste ra se e nzyme s
pre se nt in ce re brospina l fluid (CSF), the a ne sthe tic e ffe ct of
te tra ca ine will pe rsist until it is a bsorbe d into syste mic circula tion.
The ra te of hydrolysis va rie s, with chloroproca ine be ing fa ste st,
proca ine inte rme dia te , a nd te tra ca ine the slowe st. Toxicity is
inve rse ly re la te d to the ra te of hydrolysis; te tra ca ine is, the re fore ,
the most toxic of the thre e e ste rs liste d in this que stion (Butterworth :
806. (A) Comple x re giona l pa in syndrome type I (CRPS type I), a lso
ca lle d RSD, is a clinica l syndrome of continuous burning pa in,
usua lly occurring a fte r minor tra uma . Pa tie nts pre se nt with va rious
se nsory, motor, a utonomic, a nd trophic cha nge s. Comple x re giona l
pa in syndrome type II (CRPS type II; ca usa lgia ) e xhibits the sa me
fe a ture s of RSD, but the re is a pre ce ding ne rve injury (e .g., me dia n
ne rve of the uppe r e xtre mity or tibia l division of the scia tic ne rve in
the lowe r e xtre mity) (Barash : Clinical Anesth esia, ed 7, pp 1657–1658;
1049).
807. (C) The pote ncy of loca l a ne sthe tics is dire ctly re la te d to the ir
lipid solubility. In ge ne ra l, the spe e d or onse t of a ction of loca l
a ne sthe tics is re la te d to the pKa of the drug. Drugs with lowe r pKa
va lue s ha ve a highe r a mount of non-ionize d mole cule s a t
physiologic pH a nd pe ne tra te the lipid portion of ne rve s fa ste r (a n
e xce ption is chloroproca ine , which ha s a fa st onse t of a ction tha t
ma y be re la te d to the highe r conce ntra tion of drug use d) (Barash :
Clinical Anesth esia, ed 7, pp 566–567; Butterworth : Morgan & Mikh ail’s
808. (D) Ma ny fa ctors ha ve a n e ffe ct on the se nsory le ve l a fte r a
suba ra chnoid inje ction. The ba ricity of the solution a nd the pa tie nt
position (e .g., la te ra l, sitting, prone ) a re the most importa nt
de te rmina nts of se nsory le ve l. The othe r liste d options ha ve little to
no e ffe ct on se nsory le ve l. Pa tie nt he ight a lso ha s little e ffe ct on
se nsory le ve l (Barash : Clinical Anesth esia, ed 7, pp 916–919; Miller:
809. (D) Chloroproca ine is a n e ste r loca l a ne sthe tic tha t is ra pidly
me ta bolize d by pse udocholine ste ra se . W ith the e pidura l inje ction
of chloroproca ine , ve ry little drug is a va ila ble to cross the pla ce nta ,
be ca use the ha lf-life is a bout 45 se conds in the mothe r (a nd tha t
which crosse s is a lso ra pidly me ta bolize d, ma king fe ta l e ffe cts
e sse ntia lly nonsignifica nt). The a mide loca l a ne sthe tics (e .g.,
ropiva ca ine , bupiva ca ine , lidoca ine ) unde rgo live r me ta bolism a nd
ha ve re la tive ly long ha lf-live s, but with prolonge d e pidura l
a dministra tion ma y a ccumula te in the fe tus (Barash : Clinical
810. (A) Hypote nsion with a high spina l a ne sthe sia is re la te d to
sympa the tic blocka de , ve nodila tion (de cre a se s pre loa d), a rte ria l
dila tion (de cre a se s a fte rloa d), a nd a de cre a se in he a rt ra te
(ca rdioa cce le ra tor fibe rs T1-T4 blocka de a nd a fa ll in right a tria l
filling tha t a ffe cts the intrinsic chronotropic stre tch re ce ptors). W ith
a high spina l, the de cre a se in ve nous dila tion is the pre domina nt
ca use of hypote nsion (Barash : Clinical Anesth esia, ed 7, pp 923–925;
Miller: Miller’s Anesth esia, ed 8, pp 1688–1690; Miller: Basics of
811. (C) The incide nce of pha ntom limb pa in is e stima te d to be up
to 80% a fte r a n a mputa tion. This pa in ma y be imme dia te but, in
ma ny ca se s, will de ve lop within a fe w da ys of the a mputa tion. The
pa in a lso ma y not be pre se nt a ll the time but only a fe w da ys a
month. The incide nce of pha ntom limb pa in doe s not diffe r
be twe e n tra uma tic a nd nontra uma tic a mpute e s. The incide nce of
pha ntom pa in incre a se s with more proxima l a mputa tion. About
50% of pa tie nts will ha ve a de cre a se in pa in ove r time ; the re st
ha ve no cha nge or a n incre a se in pa in with time . Although ve ry
difficult to tre a t, ne rve blocks a re commonly use d in the
pe riope ra tive se tting to de cre a se the incide nce of pha ntom limb
pa in. Ora l a ge nts such a s opioids, a ntide pre ssa nts, a nd ga ba pe ntin
a re commonly use d a s we ll a s TENS units, spina l cord stimula tors,
a nd biofe e dba ck me thods (Barash : Clinical Anesth esia, ed 7, p 1658).
812. (D) Intra ve nous re giona l a ne sthe sia (IVRA, or Bie r blocks a fte r
August Bie r, who first de scribe d the te chnique ) is simple to pe rform
a nd is usua lly done only on a n uppe r e xtre mity. A sma ll 20- or 22-
ga uge IV ca the te r is pla ce d in the e xtre mity to be blocke d, the n the
limb is ra ise d a nd a n Esma rch ba nda ge is wra ppe d a round the
e xtre mity to re move a s much blood from the limb a s possible ,
followe d by the infla tion of a tournique t to 250 to 300 mm Hg, or 2.5
time s the pa tie nt’s systolic pre ssure , a nd inje ction of a loca l
a ne sthe tic into the limb. An intra ve nous line is a lwa ys pla ce d in
a nothe r site (not be low the tournique t) in ca se se da tion is ne e de d
for tournique t pa in or if loca l a ne sthe tic toxicity de ve lops whe n the
tournique t is e ve ntua lly re le a se d. Typica lly, a minimum of 40 to
45 minute s of tournique t time is ne e de d to ha ve e nough loca l
a ne sthe tic to diffuse into the tissue s to pre ve nt se rious syste mic
loca l a ne sthe tic toxicity from de ve loping whe n the tournique t is
de fla te d. For sa fe ty, the tournique t is de fla te d for a bout 5 se conds
a nd the n re infla te d for 45 se conds while one looks for signs of
toxicity. This should be re pe a te d four to five more time s.
Postope ra tive a na lge sia is lost once the tournique t is de fla te d a nd
the loca l a ne sthe tic diffuse s from the ne rve s. Tournique t time s le ss
tha n 60 to 90 minute s a re use d to pre ve nt pa in a nd ne rve da ma ge
from the tournique t. Lidoca ine 0.5% a t a dose of 1.5 to 3 mg/kg is
the most commonly a dministe re d loca l a ne sthe tic be ca use of its
re la tive sa fe ty a nd e ffe ctive ne ss. About a 10-minute pe riod is
ne e de d for surgica l a ne sthe sia to de ve lop. Bupiva ca ine is not
re comme nde d for Bie r blocks be ca use of re ports of ca rdiova scula r
toxicity a nd de a th tha t ha ve occurre d a fte r the tournique t wa s
re le a se d (Barash : Clinical Anesth esia, ed 7, p 970; Hebl: May o Clinic
Atlas of Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, pp
317–320; Miller: Basics of Anesth esia, ed 6, pp 194, 297).
813. (D) Both phe nyle phrine a nd e pine phrine will prolong a spina l
a ne sthe tic whe n a dministe ring lidoca ine . The Ta ylor a pproa ch for
spina l a ne sthe sia use s a pa ra me dia n a pproa ch to the L5-S1
inte rspa ce —the la rge st inte rspa ce of the ve rte bra l column. The
sympa the tic ne rvous syste m origina te s in the thora cic a nd lumba r
spina l cord T1-L3; the re fore , a high thora cic se nsory le ve l ca n
ca use a comple te sympa the tic block. The dura l sa c e xte nds to S2,
not S4-S5. The spina l cord e xte nds to L3 in the infa nt a nd L1-L2 in
a dults (Barash : Clinical Anesth esia, ed 7, pp 906–920; Miller: Miller’s
814. (A) De ve lopme nt of a n e pidura l a bsce ss is fortuna te ly a n
e xce e dingly ra re complica tion of spina l a nd e pidura l a ne sthe sia .
Most a ne sthe tic-re la te d e pidura l a bsce sse s a re a ssocia te d with
e pidura l ca the te rs. W he n a n e pidura l a bsce ss is de ve loping,
prompt re cognition a nd tre a tme nt a re e sse ntia l if pe rma ne nt
se que la e a re to be a voide d. Symptoms from a n e pidura l a bsce ss
ma y not be come a ppa re nt until se ve ra l da ys (me a n, 5 da ys) a fte r
pla ce me nt of the block. The re a re four clinica l sta ge s of e pidura l
a bsce ss symptom progre ssion. Initia lly, loca lize d ba ck pa in
de ve lops. The se cond sta ge include s ne rve root or ra dicula r pa in.
The third sta ge involve s motor a nd se nsory de ficits or sphincte r
dysfunction, followe d by the la st sta ge of pa ra ple gia . Unlike a n
e pidura l he ma toma , in which se ve re ba ck pa in is the ke y fe a ture ,
pa tie nts with e pidura l a bsce sse s will compla in of ra dicula r pa in
a pproxima te ly 3 da ys a fte r de ve lopme nt of the ba ck pa in. Fe ve r
ma y de ve lop with a n a bsce ss a nd is ra re with a he ma toma . A
ma gne tic re sona nce ima ging (MRI) sca n is he lpful in the dia gnosis.
Ante rior spina l a rte ry syndrome is cha ra cte rize d pre domina ntly by
motor we a kne ss or pa ra lysis of the lowe r e xtre mitie s. Me ra lgia
pa re sthe tica is re la te d to e ntra pme nt of the la te ra l fe mora l
cuta ne ous ne rve a s it course s be low the inguina l liga me nt a nd is
a ssocia te d with burning pa in ove r the la te ra l a spe ct of the thigh. It
is not a complica tion of e pidura l a ne sthe sia (Butterworth : Morgan &
815. (B) Comple x re giona l pa in syndrome s a re a ssocia te d with
tra uma . The ma in fe a ture is burning a nd continuous pa in tha t is
e xa ce rba te d by norma l move me nt, cuta ne ous stimula tion, or
stre ss, usua lly we e ks a fte r the injury. The pa in is not a na tomica lly
distribute d. Othe r a ssocia te d fe a ture s include cool, re d, cla mmy
skin a nd ha ir loss in the involve d e xtre mity. Chronic ca se s ma y be
a ssocia te d with a trophy a nd oste oporosis (Barash : Clinical
816. (D) Ne urolytic blocka de with phe nol (6%-10% in glyce rine ) is
pa inle ss be ca use phe nol ha s a dua l a ction a s both a loca l
a ne sthe tic a nd a ne urolytic a ge nt. The initia l block we a rs off ove r a
24-hour pe riod, during which time ne urolysis occurs. For this
re a son you must wa it a da y to de te rmine the e ffe ctive ne ss of the
ne urolytic block. Alcohol (50%-100% e tha nol) is pa inful on inje ction
a nd should be pre ce de d by loca l a ne sthe tic inje ction.
Unfortuna te ly, the re is no ne urolytic a ge nt tha t a ffe cts only
sympa the tic fibe rs (Barash : Clinical Anesth esia, ed 7, pp 1658–1659;
817. (C) In ge ne ra l, e a ch 1 to 2 mL of loca l a ne sthe tic will
a ne sthe tize a bout one spina l se gme nt in the 20- to 40-ye a r-old
pa tie nt. Be ca use of the ne ga tive intra thora cic pre ssure tra nsmitte d
to the e pidura l spa ce with bre a thing, a bout two thirds of the
se gme nts a re blocke d a bove the le ve l of the lumba r pla ce me nt a nd
one third of se gme nts a re blocke d be low the inje ction. For
e xa mple , to a chie ve a T4 block whe n a n e pidura l is pla ce d a t the
L2-L3 spa ce , a bout 10 se gme nts a bove a nd five se gme nts be low the
e pidura l would be ne e de d (15 se gme nts) or a bout 15 to 30 mL. As
one ge ts olde r, the dose of loca l a ne sthe tic mL/se gme nt de cre a se s
(e .g., a n 80-ye a r-old ma y ne e d 0.75-1.5 mL/se gme nt). Also, pre gna nt
pa tie nts a re more se nsitive to loca l a ne sthe tics, a nd re duce d dose s
a re ne e de d (Barash : Clinical Anesth esia, ed 7, pp 920–922; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 962; Miller: Basics of
818. (C) Blood supply to the spina l cord come s from se ve ra l
source s. The a nte rior spina l a rte ry is de rive d from the ve rte bra l
a rte rie s a nd runs the e ntire le ngth of the spina l cord a nd supplie s
the a nte rior two thirds of the cord. The re a re se gme nta l a rte rie s
from the a orta tha t join the a nte rior spina l a rte ry to he lp supply the
spina l cord. One of the la rge r a rte rie s is ca lle d the a rte ry of
Ada mkie wicz, which a rise s from the lowe r thora cic a re a (T9-T12).
Da ma ge to this a rte ry ca n le a d to ische mia for the lowe r two thirds
of the spina l cord a nd pa ra ple gia . The poste rior one third of the
cord is supplie d by two poste rior spina l a rte rie s tha t a lso a rise
from the ve rte bra l a rte rie s a nd re ce ive some blood supply from the
se gme nta l a rte rie s (Barash : Clinical Anesth esia, ed 7, pp 997–998;
819. (A) Amino e ste r loca l a ne sthe tics unde rgo hydrolysis in the
bloodstre a m a nd te nd to ha ve short e limina tion ha lf-time s. Amino
a mide s unde rgo biotra nsforma tion by the live r a nd ha ve longe r
e limina tion ha lf-time s. The e limina tion ha lf-time for bupiva ca ine is
3.5 hours, for le vobupiva ca ine is 3.5 hours, for lidoca ine is
1.6 hours, for me piva ca ine is 1.0 hour, for proca ine is 0.1 hour, a nd
for ropiva ca ine is 1.9 hours (Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, ed 1, p 298).
820. (D) To pe rform a scia tic ne rve block, first dra w a line from the
poste rior supe rior ilia c spine to the gre a te r trocha nte r of the fe mur,
the n dra w a 5-cm line pe rpe ndicula r from the midpoint of this line
ca uda lly a nd a se cond line from the sa cra l hia tus to the gre a te r
trocha nte r. The inte rse ction of the se cond line with the
pe rpe ndicula r line ma rks the point of e ntry (Hebl: May o Clinic Atlas
of Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp
821. (C) De e p ce rvica l ple xus blocks (C2, C3, a nd C4) ca n be use d
for unila te ra l ne ck a ne sthe sia for ca rotid e nda rte re ctomy a nd
ce rvica l node disse ctions. Complica tions of de e p ce rvica l ple xus
block include inje ction of the loca l a ne sthe tic into the ve rte bra l
a rte ry, suba ra chnoid spa ce , or e pidura l spa ce . Othe r ne rve s tha t
ma y be a ne sthe tize d include the phre nic ne rve (which is why
bila te ra l de e p ce rvica l ple xus blocks should be pe rforme d with
ca ution, if a t a ll), a nd the re curre nt la rynge a l ne rve . Some loca l
a ne sthe tic ma y spre a d outside the de e p ce rvica l fa scia a nd ma y
produce blocka de of the sympa the tic cha in, producing Horne r
syndrome . Ina dve rte nt blocka de of the re curre nt la rynge a l ne rve
ha s a lso be e n re porte d. The spina l a cce ssory ne rve is cra nia l
ne rve XI a nd inne rva te s the ste rnocle idoma stoid muscle a s we ll a s
the tra pe zius muscle . The a cce ssory ne rve come s out ce pha la d to
the inje ctions (Barash : Clinical Anesth esia, ed 7, pp 946–947; Hebl:
May o Clinic Atlas of Regional Anesth esia and Ultrasound -Guid ed Nerve
Blockad e, ed 1, pp 179–185).
822. (C) A re trobulba r block a ne sthe tize s the thre e cra nia l ne rve s
re sponsible for move me nt of the e ye (cra nia l ne rve III—oculomotor
ne rve , cra nia l ne rve IV—trochle a r ne rve , a nd cra nia l ne rve VI—
a bduce ns ne rve ). The cilia ry ga nglion (de e p within the orbit a nd
la te ra l to the optic ne rve ) a nd cilia ry ne rve s a re a lso blocke d,
providing a ne sthe sia to the conjunctiva , corne a , a nd uve a .
Bra nche s of the fa cia l ne rve (cra nia l ne rve V) a re not blocke d by
the re trobulba r block but a re ofte n se pa ra te ly blocke d to produce
a kine sia of the e ye lids (Barash : Clinical Anesth esia, ed 7, pp 1383–
1386; Brown: Atlas of Regional Anesth esia, ed 3, pp 185–188).
823. (D) The va gus ne rve inne rva te s the a irwa y by two bra nche s:
the supe rior la rynge a l ne rve s a nd the re curre nt la rynge a l ne rve s.
All of the muscle s of the la rynx a re inne rva te d by the re curre nt
la rynge a l ne rve e xce pt for the cricothyroid muscle . The supe rior
la rynge a l ne rve divide s into the inte rna l a nd e xte rna l la rynge a l
bra nche s. The e xte rna l la rynge a l bra nch inne rva te s the
cricothyroid muscle . The inte rna l la rynge a l bra nch provide s
se nsory fibe rs to the cords, e piglottis, a nd a ryte noids (Barash :
824. (C) Be ca use of the pote ntia l for ca rdiotoxicity a nd be ca use
bupiva ca ine ha s no a dva nta ge s ove r othe r loca l a ne sthe tics in this
se tting, it is contra indica te d for use in intra ve nous re giona l
a ne sthe sia (Miller: Miller’s Anesth esia, ed 8, p 1736).
825. (C)
The ste lla te ga nglion usua lly lie s in front of the ne ck of the first rib.
The ve rte bra l a rte ry lie s a nte rior to the ga nglion, a s it ha s just
origina te d from the subcla via n a rte ry. Afte r pa ssing ove r the
ga nglion, it e nte rs the ve rte bra l fora me n a nd lie s poste rior to the
a nte rior tube rcle of C6 (Brown: Atlas of Regional Anesth esia, ed 3, pp
199–203; Miller: Miller’s Anesth esia, ed 8, p 1732).
826. (D) The me dia n ne rve is the most me dia l structure in the
a nte cubita l fossa . To block this ne rve , first the bra chia l a rte ry is
pa lpa te d a t the le ve l of the inte rcondyla r line be twe e n the me dia l
a nd la te ra l e picondyle s, a nd the n a ne e dle is inse rte d just me dia l
to the a rte ry a nd dire cte d pe rpe ndicula rly to the skin (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 994–995; Hebl:
May o Clinic Atlas of Regional Anesth esia and Ultrasound -Guid ed Nerve
Blockad e, ed 1, pp 286–288).
827. (D) W he n a n e pidura l ca the te r is pla ce d without fluoroscopic
guida nce , the e xa ct loca tion of the ne e dle tip re la tive to the
a na tomic structure s of the ba ck ca n only be surmise d. If
ma lposition of e ithe r the ne e dle or the ca the te r is suspe cte d, it is
prude nt to withdra w the e ntire a ppa ra tus a nd re inse rt a se cond
time . In this ca se , it is possible tha t the ca the te r tip ha s found its
wa y into a ne rve root. Unde r the se circumsta nce s, inje ction of a
loca l a ne sthe tic or na rcotic could produce pre ssure tha t could
possibly le a d to ische mia a nd ne urologic da ma ge . During
pla ce me nt or inje ction of a ne e dle or e pidura l ca the te r, a
pa re sthe sia tha t is susta ine d is a lwa ys a wa rning sign tha t should
be he e de d (Barash : Clinical Anesth esia, ed 7, p 910; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 949; Raj: Practical
Managem ent of Pain, ed 3, p 650).
828. (B) The re a re five ne rve s tha t inne rva te the a nkle a nd foot: the
poste rior tibia l, sura l, supe rficia l pe rone a l, de e p pe rone a l, a nd
sa phe nous ne rve s. The se ne rve s a re supe rficia l a t the le ve l of the
a nkle a nd a re e a sy to block. The poste rior bra nch of the tibia l
ne rve give s rise to the me dia l a nd la te ra l pla nta r ne rve s, which
supply the pla nta r surfa ce of the foot (Barash : Clinical Anesth esia, ed
7, pp 990–991; Hebl: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 444–448).
829. (C) In ge ne ra l, in both in vivo a nd in vitro studie s the re is a n
ove ra ll dire ct corre la tion be twe e n a ne sthe tic’s pote ncy a nd its
dire ct de pre ssa nt e ffe ct on myoca rdia l contra ctility. The ra tio of
dosa ge re quire d for ca rdiova scula r syste m (CVS) toxicity in a nima l
mode ls compa re d with CNS toxicity is lowe st for bupiva ca ine ,
le vobupiva ca ine , a nd ropiva ca ine (2.0). Ra tios for othe r loca l
a ne sthe tics a re a s follows: priloca ine , 3.1; proca ine a nd
chloroproca ine , 3.7; e tidoca ine , 4.4; lidoca ine a nd me piva ca ine , 7.1.
Re me mbe r tha t this que stion re fe rs only to the ra tio of CVS to CNS
toxicity; it doe s not re fe r to which drug is more ca rdiotoxic (Barash :
830. (D) Re a ctiva tion of pha ntom limb se nsa tions ha s be e n re porte d
in pa tie nts who ha ve re ce ive d both spina l a nd e pidura l a ne sthe tics
(90% in some se rie s). In the ma jority of the se ca se s (80%), pha ntom
limb se nsa tion pe rsiste d until the block re ce de d. W ith a history of
pha ntom limb se nsa tions tha t drove this pa tie nt to a tte mpt suicide ,
it is proba bly wise to a void spina l a nd e pidura l a ne sthe tics.
Phe ne lzine (Na rdil) is a monoa mine oxida se (MAO) inhibitor tha t is
occa siona lly use d for the tre a tme nt of de pre ssion. Any a ne sthe tic
or combina tion of te chnique s tha t involve s me pe ridine is
contra indica te d in pa tie nts re ce iving MAO inhibitors. The
combina tion of me pe ridine a nd MAO inhibitors ha s be e n
a ssocia te d with hype rthe rmia , hypote nsion, hype rte nsion,
ve ntila tory de pre ssion, ske le ta l muscle rigidity, se izure s, a nd coma .
Be ca use of this unfa vora ble drug inte ra ction, me pe ridine should be
a voide d in pa tie nts re ce iving MAO inhibitors. Accordingly, the only
a cce pta ble choice in this que stion would be ge ne ra l a ne sthe sia
with propofol, succinylcholine , nitrous oxide , a nd fe nta nyl. As a n
inte re sting side point, the drug phe ne lzine prolongs the dura tion of
a ction of succinylcholine by de cre a sing pla sma choline ste ra se
a ctivity (Miller: Miller’s Anesth esia, ed 8, p 909; Raj: Practical
Managem ent of Pain, ed 3, p 212; Wald m an: Pain Managem ent, ed 2,
Ch apter 32).
831. (C) The re curre nt la rynge a l ne rve inne rva te s a ll the muscle s of
the la rynx (e .g., a bductors a nd a dductors) e xce pt the cricothyroid
muscle (which te nse s the voca l cords a nd is inne rva te d by the
e xte rna l bra nch of the supe rior la rynge a l ne rve ). W ith comple te
bila te ra l tra nse ctions of the re curre nt la rynge a l ne rve , both the
a bductor a nd a dductor muscle s a re a ffe cte d, a nd the voca l cords
will a dopt a n inte rme dia te position (i.e ., lie within 2-3 mm of the
midline ). Acute comple te injury to the re curre nt la rynge a l ne rve s
ca n re sult in stridor a nd re spira tory distre ss re quiring tre a tme nt
(e .g., intuba tion a nd possible tra che ostomy). If a pa tie nt susta ine d a
pa rtia l bila te ra l pa ra lysis of the re curre nt la rynge a l ne rve tha t
a ffe cte d only the a bductor muscle s, the n the unoppose d a dductor
muscle s would bring the cords toge the r (i.e ., close d) a nd comple te
a irwa y obstruction would e nsue (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 310–312; Miller: Miller’s Anesth esia, ed
8, p 2526).
832. (D) PDPH is due to a loss of CSF through a dura l puncture a nd
cha ra cte ristica lly ha s a postura l compone nt. W he n supine , the
he a da che is usua lly gone but ma y be mild in some ca se s. W he n
the he a d is e le va te d, the he a da che ma y be se ve re , is bila te ra l, a nd
ma y be a ssocia te d with diplopia , na use a , a nd vomiting. The
he a da che pa in is typica lly fronta l a nd/or occipita l in loca tion.
Typica lly the onse t of the he a da che is 12 to 24 hours a fte r a dura l
puncture a nd la sts se ve ra l da ys if untre a te d (ra re ly it ca n la st for
months). The othe r he a da che s liste d ra re ly ha ve a significa nt
postura l compone nt (Barash : Clinical Anesth esia, ed 7, pp 926–927;
833. (C) VAN (Ve in, Arte ry, Ne rve ) de scribe s the a na tomic
re la tionship of the inte rcosta l structure s de e p to the lowe r borde r
of the ribs from the ce pha la d to ca uda l dire ction. The block is
pe rforme d by wa lking off the infe rior e dge of the rib with the
ne e dle , typica lly a bout 5 to 7 cm from midline . The two principa l
risks a re pne umothora x a nd intra va scula r inje ction of loca l
a ne sthe tics. Be ca use of the close proximity of the ve in a nd a rte ry to
the ne rve , inte rcosta l blocks ha ve re la tive ly high blood le ve ls a s
compa re d to othe r blocks (e .g., e pidura l, bra chia l ple xus, bra chia l
ple xus block, infiltra tion), a nd ca ution with dose is ne e de d if ma ny
le ve ls a re blocke d (Butterworth : Morgan & Mikh ail’s Clinical
834. (A) The site of inje ction of the loca l a ne sthe tic is one of the
most importa nt fa ctors influe ncing syste mic loca l a ne sthe tic
a bsorption a nd toxicity. The de gre e of a bsorption from the site of
inje ction de pe nds on the blood supply to tha t site . Are a s tha t ha ve
the gre a te st blood supply ha ve the gre a te st syste mic a bsorption.
For this re a son, the gre a te st pla sma conce ntra tion of loca l
a ne sthe tic occurs a fte r a n inte rcosta l block, followe d by ca uda l
e pidura l, lumba r e pidura l, bra chia l ple xus, scia tic/fe mora l ne rve
block, a nd subcuta ne ous (Barash : Clinical Anesth esia, ed 7, pp 569–
835. (D) Loca l a ne sthe tics a re we a k ba se s. The ne utra l (non-
ionize d) form of the mole cule is a ble to pa ss through the lipid ne rve
ce ll me mbra ne , whe re a s the ionize d (protona te d) form a ctua lly
produce s a ne sthe sia . Chloroproca ine ha s the highe st pKa of loca l
a ne sthe tics, me a ning tha t a gre a te r pe rce nta ge of it will e xist in the
ionize d form a t a ny give n pH tha n a ny of the othe r loca l
a ne sthe tics. De spite this fa ct, 3% chloroproca ine ha s a more ra pid
onse t tha n 2% lidoca ine , pre suma bly be ca use of the gre a te r
numbe r of mole cule s (conce ntra tion). Howe ve r, if one compa re s
onse t time for 1.5% lidoca ine a ga inst 1.5% chloroproca ine , the
forme r will ha ve a more ra pid onse t (Miller: Miller’s Anesth esia, ed 8,
p 1039).
836. (B) The risk of pne umothora x is a significa nt limita tion for
supra cla vicula r bra chia l ple xus blocks (tra ditiona lly the incide nce
is 0.5% to 6% de pe nding upon e xpe rie nce ; with the ultra sound
te chnique , the incide nce ma y be lowe r). Furthe rmore , the
te chnique is difficult to te a ch a nd de scribe . For the se re a sons, this
block should not be pe rforme d in pa tie nts in whom a
pne umothora x or phre nic ne rve block (30%-60% of pa tie nts) would
re sult in significa nt dyspne a or re spira tory distre ss. A
pne umothora x should be conside re d if the pa tie nt be gins to
compla in of che st pa in or shortne ss of bre a th or be gins to cough
during pla ce me nt of supra cla vicula r bra chia l ple xus block. In some
ca se s, symptoms of a pne umothora x ma y be de la ye d up to 24 hours
(Barash : Clinical Anesth esia, ed 7, pp 961–962; Hebl: May o Clinic Atlas of
Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp
837. (D) The fe mora l ne rve is the la rge st bra nch of the lumba r
ple xus (it prima rily a rise s from the se cond to fourth lumba r ne rve
roots). The fe mora l ne rve divide s into a n a nte rior a nd a poste rior
division. The a nte rior division provide s motor inne rva tion to the
sa rtorius muscle a nd cuta ne ous se nsa tion to the a nte rior a nd
me dia l a spe cts of the thigh. The poste rior division inne rva te s the
qua drice ps muscle a nd cuta ne ous se nsa tion to the a nte rior,
me dia l, a nd la te ra l a spe cts of the kne e a s we ll a s the a rticula r
a spe cts of the kne e joint. The ne rve pa sse s unde r the inguina l
liga me nt a nd lie s just la te ra l to the fe mora l a rte ry a nd ve in. If the
stimula ting ne e dle produce s sa rtorius muscle contra ction without
pa te lla r move me nt, the n you a re too a nte rior for prope r fe mora l
ne rve blocka de , a nd the ne e dle ne e ds to be a dva nce d in a more
poste rior (i.e ., de e pe r) dire ction. Prope r ne e dle pla ce me nt will
e licit qua drice ps muscle contra ction with pa te lla r e le va tion tha t
disa ppe a rs with loca l a ne sthe tic inje ction (Hebl: May o Clinic Atlas of
347–362).
838. (A) The obtura tor ne rve provide s va ria ble cuta ne ous
inne rva tion of the thigh a nd ca n be use d to supple me nt fe mora l
a nd scia tic ne rve blocka de for pa tie nts ha ving lowe r e xtre mity
surge ry. An obtura tor ne rve block is a chie ve d by pla ce me nt of the
ne e dle 1 to 2 cm la te ra l to a nd 1 to 2 cm be low the pubic tube rcle .
Afte r conta ct with the pubic bone , the ne e dle is withdra wn a nd
wa lke d ce pha la d to ide ntify the obtura tor ca na l. Be twe e n 10 a nd
15 mL of loca l a ne sthe tic should be pla ce d in the ca na l. If a ne rve
stimula tor is use d, contra ction of the a dductor muscle s with ne rve
stimula tion indica te s proximity to the ne rve (Barash : Clinical
Anesth esia, ed 7, pp 982–983; Hebl: May o Clinic Atlas of Regional
Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 386–394;
839. (A) The most se rious complica tion a ssocia te d with a
supra cla vicula r bra chia l ple xus block is pne umothora x, which
fortuna te ly is ra re (0.5%-5%). The most common complica tion is a
phre nic ne rve block, which is usua lly mild a nd re la tive ly common
(30%-60% of blocks). Bila te ra l supra cla vicula r blocks, howe ve r, a re
not re comme nde d due to the possibility of bila te ra l phre nic ne rve
pa ra lysis or pne umothora ce s. Othe r pote ntia l complica tions
include Horne r syndrome (ipsila te ra l e ye ptosis, miosis, a nd
a nhidrosis), ne rve da ma ge or ne uritis, infe ction, or intra va scula r
inje ction (Barash : Clinical Anesth esia, ed 7, pp 962; Hebl: May o Clinic
Atlas of Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed
1, p 231; Miller: Miller’s Anesth esia, ed 8, pp 1727–1728).
840. (A) The a rm re ce ive s se nsory inne rva tion from the bra chia l
ple xus e xce pt for the shoulde r, which is inne rva te d by the
supra cla vicula r ne rve s from the ce rvica l ple xus, a nd the poste rior
me dia l a spe ct of the a rm, which is supplie d by the
inte rcostobra chia l ne rve (Hebl: May o Clinic Atlas of Regional
841. (B) The bra chia l ple xus sta rts out a t the root le ve l from the
ve ntra l ra mi of C5-T1 with a sma ll a mount from C4 a nd T2. The se
roots a t the le ve l of the sca le ne muscle be come the thre e trunks:
supe rior, middle , a nd infe rior. The trunks the n divide into the
dorsa l a nd ve ntra l divisions a t the la te ra l e dge of the first rib.
W he n the divisions e nte r the a xilla , the y be come the cords:
poste rior, la te ra l, a nd me dia l. At the la te ra l borde r of the pe ctora lis
muscle , the y be come the five pe riphe ra l ne rve s: ra dia l,
musculocuta ne ous, me dia n, ulna r, a nd a xilla ry. The inte rsca le ne
block is a t the le ve l of the roots/trunks (but spa re s the infe rior
trunk); the supra cla vicula r block is a t the le ve l of the
trunks/divisions; the infra cla vicula r block is a t the le ve l of the
cords; a nd the a xilla ry block is a t the le ve l of the bra nche s (Barash :
Clinical Anesth esia, ed 7, pp 959–966; Hebl: May o Clinic Atlas of Regional
842. (A) The ce lia c ple xus inne rva te s most of the a bdomina l
visce ra , including the lowe r e sopha gus, stoma ch, a ll of the sma ll
inte stine , a nd the la rge inte stine up to the sple nic fle xure a s we ll
a s the pa ncre a s, live r, bilia ry tra ct, sple e n, kidne ys, a dre na l gla nds,
a nd ome ntum. The pe lvic orga ns (e .g., ute rus, ova rie s, prosta te ,
dista l colon) a re supplie d by the hypoga stric ple xus (Barash : Clinical
843. (D) The gre a t toe is inne rva te d ma inly by the de e p pe rone a l,
poste rior tibia l, supe rficia l pe rone a l, a nd occa siona lly by the
sa phe nous ne rve . All four of the se ne rve s should be blocke d for
surge ry on the gre a t toe . The sura l ne rve is the fifth ne rve for a nkle
blocks but cove rs only the la te ra l side of the foot, a nd not the
me dia l side or gre a t toe a re a (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 1015–1017; Hebl: May o Clinic Atlas of
443–452).
844. (D) Fre que nt dosing by a pa tie nt re ce iving postope ra tive
a na lge sia through a PCA pump sugge sts the ne e d to incre a se the
ma gnitude of the dose . It is importa nt to ke e p in mind tha t a pa tie nt
should be give n a sufficie nt loa ding dose of na rcotic be fore
initia tive the ra py with a PCA pump. Othe rwise , the pa tie nt will be
pla ying the frustra ting ga me of “ca tch up.” The most commonly
use d na rcotics in the Unite d Sta te s for PCA pump use a re
morphine , fe nta nyl, a nd hydromorphone . Me pe ridine should not be
use d a s the na rcotic for PCA pumps, since the toxic me ta bolite
norme pe ridine ma y a ccumula te (Barash : Clinical Anesth esia, ed 7, pp
1626–1627).
845. (D) TENS produce s a tingling or vibra tory se nsa tion in the a re a
in which pa ds a re pla ce d. Although the e xa ct me cha nism is
uncle a r, it is thought tha t TENS units produce a na lge sia by
re le a sing e ndoge nous e ndorphins, since its e ffe cts a re pa rtia lly
blocke d by na loxone . The se e ndorphins ha ve a n inhibitory e ffe ct a t
the spina l cord le ve l a nd a ugme nt de sce nding inhibitory pa thwa ys
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 1081;
Miller: Miller’s Anesth esia, ed 8, pp 2339, 2991).
846. (C) Although the more hydrophilic drugs such a s morphine
ha ve a longe r dura tion of a ction of a na lge sia , the y a lso ha ve a
highe r pote ntia l for inducing de la ye d re spira tory de pre ssion
through ce pha la d migra tion in the CNS, a s compa re d with the more
lipid-soluble drugs liste d in this que stion (Barash : Clinical Anesth esia,
ed 7, pp 1627–1629; Miller: Miller’s Anesth esia, ed 8, p 2983).
847. (B) The thumb corre sponds to de rma tome C6, the se cond a nd
middle finge rs corre spond to de rma tome C7, a nd the fourth a nd
little finge rs corre spond to de rma tome C8 (Hebl: May o Clinic Atlas of
Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, p 86;
848. (C) Incre a sing the tota l dose (ma ss) of loca l a ne sthe tic is more
e ffica cious in ha ste ning the onse t a nd incre a sing the dura tion of a n
e pidura l a ne sthe tic tha n incre a sing the volume or incre a sing the
conce ntra tion (while holding the tota l dose consta nt) (Barash :
849. (C) Alcohol a nd phe nol a re simila r in the ir a bility to ca use
nonse le ctive da ma ge to ne ura l tissue s. Alcohol ca use s pa in whe n
inje cte d a nd some time s is mixe d with bupiva ca ine , whe re a s
phe nol is re la tive ly pa inle ss. Alcohol ha s a slightly longe r dura tion
of a na lge sia (3-6 months) compa re d to phe nol (2-3 months). Ne ura l
tissue will re ge ne ra te ; the re fore , ne urolytic blocks a re ne ve r
“pe rma ne nt,” a nd ne urolysis ca n le a d to de ne rva tion
hype rse nsitivity, which ca n be e xtre me ly pa inful (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 1079–1080; Miller:
850. (D) TNS, pre viously ca lle d tra nsie nt ra dicula r irrita tion (TRI),
ca n occur in 4% to 40% of pa tie nts a fte r spina l a ne sthe sia with
lidoca ine in a mbula tory pa tie nts unde rgoing surge ry in the
lithotomy position or kne e a rthroscopy. The ba ricity, conce ntra tion
inje cte d (lidoca ine 0.5%-5%), a ddition of e pine phrine , pre se nce of
de xtrose , or hypote nsion doe s not se e m to be re la te d to the
de ve lopme nt of TNS. The symptoms of TNS include pa in or se nsory
a bnorma litie s in the lowe r ba ck, buttocks, or lowe r e xtre mitie s.
Although TNS ha s be e n re porte d with a ll loca l a ne sthe tics, the
incide nce is significa ntly gre a te r with lidoca ine (Barash : Clinical
Anesth esia, ed 7, pp 576, 928; Miller: Miller’s Anesth esia, ed 8, p 1692).
851. (A) Afte r the prope r tra nsduce r is se le cte d, you ca n a djust the
fre que ncy, de pth, a nd ga in to optimize a n ima ge . In ge ne ra l, highe r-
fre que ncy ultra sound wa ve s provide be tte r ima ge qua lity (i.e .,
be tte r re solution) due to the highe r numbe r of cycle s pe r se cond of
tra nsmitte d a nd re fle cte d e ne rgy use d to produce the ima ge .
Howe ve r, highe r fre que ncy wa ve s ha ve more signa l a tte nua tion a t
incre a sing de pths a nd ca nnot pe ne tra te to de e pe r tissue le ve ls.
The re fore , highe r-fre que ncy ultra sound is typica lly use d for
sha llowe r structure s, a nd lowe r fre que ncie s a re use d for de e pe r
structure s. Usua lly the de pth is a djuste d so the structure in
que stion is in the ce nte r, top-to-bottom, of the ima ge . Incre a sing the
ga in incre a se s, or a mplifie s, the re fle cte d signa l e ne rgy a nd
incre a se s the brightne ss of the ima ge (Hebl: May o Clinic Atlas of
Regional Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 99–
112).
852. (B) Younge r a dults ha ve a highe r incide nce of PDPH tha n olde r
a dults or childre n. Wome n ha ve a slightly highe r incide nce tha n
me n. Pre gna nt wome n ha ve a highe r incide nce tha n nonpre gna nt
wome n. Since the incide nce a nd se ve rity of PDPH re la te s to the
a mount of CSF le a ka ge through the dura l hole , it ma ke s se nse tha t
the la rge r the ne e dle a nd the more hole s in the dura , the gre a te r
incide nce of PDPH. In a ddition, the sha pe of the tip of the ne e dle is
importa nt; a cutting ne e dle (e .g., Quincke ) ha s a gre a te r incide nce
of PDPH tha n noncutting ne e dle s (e .g., W hita cre , Sprotte ). The
incide nce of he a da che ha s be e n shown to be le ss whe n the dura l
fibe rs a re split longitudina lly ra the r tha n whe n the y a re cut while
the ne e dle is he ld in a tra nsve rse dire ction. The timing of
a mbula tion re la tive to dura l puncture ha s not be e n shown to a ffe ct
the incide nce of postspina l he a da che . The block should we a r off
be fore a mbula tion is a tte mpte d (Barash : Clinical Anesth esia, ed 7, pp
853. (A) Virtua lly a ll pa in a rising in the thora cic or a bdomina l
visce ra is tra nsmitte d via the sympa the tic ne rvous syste m in
unmye lina te d type C fibe rs. Visce ra l pa in is dull, a ching, burning,
a nd nonspe cific. Visce ra l pa in is ca use d by a ny stimulus tha t
e xcite s nocice ptive ne rve e ndings in diffuse a re a s. In this re ga rd,
diste ntion of a hollow viscus ca use s a gre a te r se nsa tion of pa in
tha n doe s the highly loca lize d da ma ge produce d by tra nse cting the
gut. Although the va gus ne rve ha s a la rge a mount of a ffe re nt fibe rs,
the y do not include pa in fibe rs (Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, pp 174–175, 567–570; Raj:
Practical Managem ent of Pain, ed 3, pp 223–225).
854. (A) The dura tion of re giona l blocks is diffe re nt be twe e n loca l
a ne sthe tics a s we ll a s with diffe re nt loca tion of blocks. W he n
bupiva ca ine with e pine phrine (1:200,000) is use d, e pidura l
a ne sthe sia ma y la st 180 to 350 minute s; infiltra tion a ne sthe sia ma y
la st 180 to 240 minute s; a nd ma jor ne rve blocks such a s a xilla ry
block ma y la st 360 to 720 minute s. Spina l bupiva ca ine without
e pine phrine ma y la st 90 to 200 minute s; if e pine phrine (0.2-0.3 mg)
is a dde d to the spina l block, it will la st a bout 50% longe r (Miller:
855. (D) Psoa s compa rtme nt block is a lso ca lle d the poste rior
lumba r ple xus block a nd ca n be use d for a ny proce dure in which a
lumba r ple xus block is re quire d, but most ofte n it is use d for
a na lge sia for the proxima l a spe ct of the thigh a nd hip. W he n
combine d with a scia tic block, comple te le g a ne sthe sia will re sult.
Re me mbe ring tha t the fe mora l ne rve (which inne rva te s the
qua drice ps muscle s) is a dista l bra nch he lps one to unde rsta nd
why qua drice ps muscle contra ction is use ful in loca ting the ple xus
with a stimula ting ne e dle (1-1.5 mA). If the ha mstring muscle s a re
stimula te d, the ne e dle is too ca uda lly loca te d, a nd the ne e dle
should be a ime d in a more ce pha la d dire ction. Continuous psoa s
ca the te rs a re commonly use d for postope ra tive a na lge sia (Barash :
Clinical Anesth esia, ed 7, pp 978–980; Hebl: May o Clinic Atlas of Regional
Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 333–345).
856. (C) All of the ne rve s of the foot (with the e xce ption of the
sa phe nous) a re de rive d from the scia tic ne rve . The scia tic ne rve
dista lly be come s the tibia l a nd pe rone a l ne rve s, which ca n be
blocke d a t the poplite a l fossa for surge ry be low the kne e . The
sa phe nous ne rve is a bra nch of the fe mora l ne rve a nd provide s
se nsory inne rva tion a long the me dia l a spe ct of the lowe r le g
be twe e n the kne e a nd the me dia l ma lle olus, a nd must a lso be
blocke d for surge ry be low the kne e (Hebl: May o Clinic Atlas of
423–426; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5,
pp 1013–1015).
857. (A) The sympa the ctomy produce d by a ce lia c ple xus block
ca use s hypote nsion by de cre a sing pre loa d to the he a rt. This
complica tion ca n be a voide d by volume loa ding the pa tie nt with
la cta te d Ringe r solution. By blocking the sympa the tic cha in,
unoppose d pa ra sympa the tic a ctivity ma y a lso re sult in incre a se d
ga strointe stina l a ctivity a nd tra nsie nt dia rrhe a . Ba ck pa in is a lso
common. Pa ra ple gia ma y re sult from spa sm of the lumba r
se gme nta l a rte rie s tha t pe rfuse the spina l cord, dire ct va scula r or
ne urologic injury, or re trogra de spre a d of drug to the ne rve roots
a nd spina l cord. Se izure is possible with a n intra va scula r inje ction.
Re trope ritone a l he ma toma is a lso possible , but ra re (Barash :
858. (D) The occiput re ce ive s se nsory inne rva tion from the gre a te r
a nd le sse r occipita l ne rve s (C2 a nd C3 spina l roots), which a re
te rmina l bra nche s of the ce rvica l ple xus. Blocka de of the se ne rve s
is usua lly ca rrie d out a s a dia gnostic ste p in the e va lua tion of he a d
a nd ne ck pa in (Barash : Clinical Anesth esia, ed 7, pp 946–947, 958–959;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 1065).
859. (C) Thora cic pa ra ve rte bra l blocks a re use d for surgica l
a ne sthe sia a nd postope ra tive a na lge sia for bre a st, a xilla ry, or che st
wa ll surge ry. The ma jor complica tion is a pne umothora x. Since the
pa ra ve rte bra l spa ce is continuous with the e pidura l spa ce me dia lly,
e pidura l spre a d ma y re sult if la rge volume s of loca l a ne sthe tic a re
inje cte d into the pa ra ve rte bra l. Typica lly 5 mL a re inje cte d a t e a ch
of thre e site s for unila te ra l pa ra ve rte bra l blocks, a nd 3 mL pe r e a ch
of six site s (thre e on e a ch side ) if bila te ra l pa ra ve rte bra l blocks a re
pe rforme d. If the ne e dle is dire cte d too me dia lly, the n the
intra the ca l spa ce ma y be e nte re d (dura l sle e ve s e xte nd to the le ve l
of the inte rve rte bra l fora mina ) with the possibility of a tota l spina l if
5 to 10 mL is inje cte d. The sympa the tic cha in is in the a nte rior pa rt
of the pa ra ve rte bra l spa ce , a nd sympa the tic blocka de ma y
de ve lop; howe ve r, hypote nsion would be more like ly tha n
hype rte nsion to de ve lop from blocking the sympa the tic cha in
(Barash : Clinical Anesth esia, ed 7, pp 972–975; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 1019, 1067–1068; Hebl: May o
Clinic Atlas of Regional Anesth esia and Ultrasound Guid ed Periph eral
Nerve Blockad e, ed 1, pp 323–329).
860. (C) W ith the uninte ntiona l inje ction of a n e pidura l dose of loca l
a ne sthe tic into the suba ra chnoid spa ce , spina l a ne sthe sia de ve lops
ra pidly. Blocka de of the sympa the tic fibe rs (T1-L2) produce s
hypote nsion, pa rticula rly if the pa tie nt is hypovole mic. Bra dyca rdia
is produce d by blocking the ca rdia c a cce le ra tor fibe rs (T1-T4).
Re spira tory a rre st is due to hypope rfusion of the re spira tory
ce nte rs a s we ll a s pa ra lysis of the phre nic ne rve (C3-C5). The
pupils be come dila te d (mydria sis) a fte r intra the ca l inje ction of la rge
qua ntitie s of loca l a ne sthe tics; the y will re turn to norma l size a fte r
the block re ce de s. Ca uda e quina syndrome ha s occa siona lly
de ve lope d whe n the e pidura l dose wa s uninte ntiona lly
a dministe re d into the suba ra chnoid spa ce (most commonly with
chloroproca ine ). If one suspe cts a n uninte ntiona l pla ce me nt of the
e pidura l dose suba ra chnoid, supportive me thods a re initia lly use d
(the ba sic ABC’s of re suscita tion). One ca n a lso a spira te CSF from
the e pidura l ca the te r (if it wa s inse rte d) to he lp re move some of the
drug a s we ll a s re ducing the pre ssure in the suba ra chnoid spa ce ,
which might he lp be tte r pe rfuse the spina l cord a nd de cre a se the
cha nce of ca uda e quina syndrome de ve loping (Barash : Clinical
Anesth esia, ed 7, pp 927–928; Miller: Miller’s Anesth esia, ed 8, pp 1690,
1702; South orn: Red ucing th e potential m orbid ity of an unintentional
spinal anaesth etic by aspirating cerebrospinal fluid , Br J Anaesth 76:467–
469, 1996).
861. (B) Soma tic pa in in the e xtre mitie s is re lie ve d with spina l
a ne sthe sia . If a pa tie nt fa ils to obta in pa in re lie f de spite comple te
sympa the tic, se nsory, a nd motor blocka de , a “ce ntra l” me cha nism
for the pa in is like ly or the le sion ca using the pa in is highe r in the
CNS tha n the le ve l of blocka de a chie ve d by the spina l. Ce ntra l pa in
sta te s ma y include e nce pha liza tion, psychoge nic pa in, or
ma linge ring. Pe rsiste nce of pa in in the lowe r e xtre mitie s a fte r
succe ssful spina l blocka de sugge sts a ce ntra l source or
psychologica l source of pa in (Miller: Miller’s Anesth esia, ed 8, pp 1898–
1910; McMah on: Wall and Melzack’s Tex tbook of Pain, ed 6, Ch apter 69).
862. (D) During a se izure , both a rte ria l hypoxe mia a nd a cidosis
(me ta bolic a nd re spira tory) de ve lop due to the incre a se d oxyge n
consumption from contra cting muscle s a nd hypove ntila tion tha t
occurs. Administra tion of 100% O2 he lps to pre ve nt a nd tre a t
hypoxe mia . Ele va te d CO2 not only e nha nce s ce re bra l blood flow
a nd de live ry of loca l a ne sthe tic to the bra in but a lso diffuse s into
ne ura l tissue , ca using intra ce llula r pH to fa ll. Be ca use loca l
a ne sthe tics a re e ithe r a mino e ste rs or a mino a mide s, lowe ring the
pH a llows more binding of hydroge n ions to the a mino group,
ma king it more ionic or protona te d, which tra ps the loca l
a ne sthe tic inside the ce lls. Hype rve ntila tion ca n re ve rse ma ny of
the cha nge s tha t occur with a cidosis (i.e ., ca use s ce re bra l
va soconstriction a nd ca n de cre a se de live ry of loca l a ne sthe tic to
the bra in). Hype rve ntila tion induce s hypoka le mia a nd re spira tory
a lka losis, both of which re sult in hype rpola riza tion of ne rve
me mbra ne s a nd e le va tion of the se izure thre shold.
Hype rve ntila tion a lso ra ise s the pa tie nt’s pH (re spira tory a lka losis)
a nd conve rts loca l a ne sthe tics into the non-ionize d (nonprotona te d)
form, which crosse s the me mbra ne more e a sily tha n the ionize d
form, which is de trime nta l. Be nzodia ze pine s a nd/or propofol a re
use d to suppre ss the se izure a ctivity (Barash : Clinical Anesth esia, ed
7, p 575; Miller: Miller’s Anesth esia, ed 8, pp 1048–1050).
863. (D) Pa ra -a minobe nzoic a cid is a me ta bolite of the e ste r-type
loca l a ne sthe tics. Loca l a ne sthe tics ma y be pla ce d into two distinct
ca te gorie s ba se d on the ir che mica l structure : a mino e ste rs or
a mino a mide s. The a mide s (two i’s in the na me ), which a re
ropiva ca ine , lidoca ine , e tidoca ine , priloca ine , me piva ca ine , a nd
bupiva ca ine , a re me ta bolize d in the live r. The e ste r loca l
a ne sthe tics (one i in the na me ) a re coca ine , proca ine ,
chloroproca ine , te tra ca ine , a nd be nzoca ine . The se drugs a re
me ta bolize d by the e nzyme pse udocholine ste ra se found in the
blood. Pa ra -a minobe nzoic a cid is a me ta bolic bre a kdown product
of e ste r a ne sthe tic a nd is re sponsible for a lle rgic re a ctions in some
individua ls (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, pp 270–271; Hem m ings: Ph arm acology and Ph y siology for Anesth esia,
ed 1, pp 298–303).
864. (D) Pe riphe ra l ne rve a xons a re a lwa ys e nve lope d by a
Schwa nn ce ll. The mye lina te d ne rve s ma y be e nve lope d ma ny
time s by the sa me Schwa nn ce ll. Tra nsmission of ne rve impulse s
(i.e ., a ction pote ntia ls) a long nonmye lina te d ne rve s occurs in a
continuous fa shion, whe re a s tra nsmission a long mye lina te d ne rve s
occurs by sa lta tory conduction from one node of Ra nvie r to the
ne xt. Mye lina tion spe e ds tra nsmission of ne urologic impulse s; it
a lso re nde rs ne rve s more susce ptible to loca l a ne sthe tic blocka de .
An a ction pote ntia l is a ssocia te d with a n inwa rd flux of sodium tha t
occurs a fte r a ce rta in me mbra ne thre shold ha s be e n e xce e de d
865. (C) The ne e dle inse rtion site for a n inte rsca le ne block is C6
(i.e ., la te ra l to the cricoid ca rtila ge ). Loca l a ne sthe tics usua lly
spre a d to C5, C6, a nd C7, which supply much, but not a ll, of the
cuta ne ous inne rva tion to the shoulde r. W ith low-to-mode ra te
volume blocks, the re will be spa ring of the C3-C4 ne rve roots,
which supply some of the inne rva tion to the a nte rior shoulde r. Of
note , C8 a nd T1 ma y a lso be spa re d, ofte n re sulting in the ne e d for
ulna r ne rve supple me nta tion if this block we re use d for a ha nd
ope ra tion. Comple te a ne sthe sia for shoulde r a rthroscopy ma y
re quire a supple me nta l supe rficia l ce rvica l ple xus with use of low-
to-mode ra te volume s of a loca l a ne sthe tic (Hebl: May o Clinic Atlas of
Regional Anesth esia and Ultrasound Guid ed Periph eral Nerve Blockad e,
ed 1, pp 185–193).
866. (B) Ha nd wa shing is one of the most importa nt te chnique s to
pre ve nt infe ctions, e spe cia lly whe n a lcohol-ba se d a ntise ptic
solutions a re use d with ste rile glove s. Although soa p a nd wa te r
re move ba cte ria , the y do not e ffe ctive ly kill orga nisms. Antise ptic
solutions with a lcohol a ppe a r to be be tte r tha n nona lcoholic
a ntise ptics (e .g., povidone -iodine ). Na il le ngth doe s not a ppe a r to
be a risk fa ctor for infe ctions, be ca use the ma jority of ba cte ria l
growth occurs a long the proxima l 1 mm of na il a dja ce nt to the
subungua l skin. Unive rsa l use of gowns a nd glove s doe s not
a ppe a r to be be tte r tha n glove s a lone in pre ve nting infe ctions in
inte nsive ca re units (ICUs) a nd pre suma bly is le ss importa nt tha n
a de qua te ha nd wa shing a nd use of ste rile glove s (Hebl: Infectious
com plications: a new practice ad visory, Reg Anesth Pain Med 31:289–290,
2006; Hebl: Th e im portance and im plications of aseptic tech niq ues d uring
regional anesth esia, Reg Anesth Pain Med 31:311–323, 2006).
867. (A) In pa tie nts ta king low-mole cula r-we ight he pa rin (LMW H)
(e .g., e noxa pa rin, da lte pa rin, tinza pa rin), ca ution should be
e xe rcise d be fore proce e ding with a n e pidura l or spina l a ne sthe tic
be ca use of the risk of producing a n e pidura l or spina l he ma toma .
The a mount of time be twe e n the la st dose of the LMW H a nd the
re la tive sa fe ty of sta rting a ce ntra l ne ura xia l block de pe nds on the
dose of the LMW H. At the lowe r dose s, use d for
thromboprophyla xis, the LMW H should be he ld a t le a st 10 to
12 hours prior to the block. At the highe r dose s, use d to tre a t a n
e sta blishe d DVT, one should wa it a t le a st 24 hours a fte r the la st
dose of LMW H prior to the block (Barash : Clinical Anesth esia, ed 7, p
929; Miller: Miller’s Anesth esia, ed 8, pp 1702, 2344–2345; Horlocker:
Regional anesth esia in th e patient receiving antith rom botic or th rom boly tic
th erapy : Am erican Society of Regional Anesth esia and Pain Med icine
Evid ence-Based Guid elines (Th ird Ed ition), Reg Anesth Pain Med 35:64–
101, 2010).
868. (B) Ta king nonste roida l a nti-infla mma tory drugs (NSAIDs),
ticlopidine , a nd clopidogre l e xe rt e ffe cts on pla te le t function.
NSAIDs a re not a proble m if give n a lone be fore e pidura l or spina l
a ne sthe sia ; howe ve r, pa tie nts ta king ticlopidine should wa it
14 da ys a nd pa tie nts ta king clopidogre l should wa it 7 da ys be fore
ha ving a ne ura xia l block pla ce d, be ca use of the incre a se d risk of
spina l he ma toma forma tion. Ke e p in mind tha t ca ution is a lwa ys
ne e de d a nd tha t the ASRA sta te me nt “Ca re ful pre ope ra tive
a sse ssme nt of the pa tie nt to ide ntify a lte ra tions of he a lth tha t might
contribute to ble e ding is crucia l” is importa nt (Barash : Clinical
Anesth esia, ed 7, p 929; Horlocker: Regional anesth esia in th e patient
receiving antith rom botic or th rom boly tic th erapy : Am erican Society of
Regional Anesth esia and Pain Med icine Evid ence-Based Guid elines (Th ird
Ed ition), Reg Anesth Pain Med 35:64–101, 2010).
869. (D) Adding sodium bica rbona te to loca l a ne sthe tic solutions
ha ste ns the onse t of a ction of the loca l a ne sthe tics, e spe cia lly
whe n the loca l a ne sthe tic solution conta ins e pine phrine (which is
produce d a t a lowe r pH). By ra ising the pH, more of the loca l
a ne sthe tic is in the non-ionize d, more lipid-soluble sta te . Ra ising
the pH too much (i.e ., >6.05-8) would ca use pre cipita tion of the loca l
a ne sthe tic. Some studie s ha ve shown tha t a lka liza tion of the loca l
a ne sthe tic ma y de cre a se the dura tion of a pe riphe ra l block,
e spe cia lly if e pine phrine wa s not a dde d. It a lso se e ms to de cre a se
pa in with skin infiltra tion. Pa in on inje ction ca n a lso be de cre a se d
by a slow inje ction of the loca l a ne sthe tic (Barash : Clinical
870. (C) This figure shows the a na tomic structure s tha t must be
tra ve rse d by the spina l ne e dle during the pe rforma nce of a
suba ra chnoid block. The structure s include the skin, subcuta ne ous
tissue , supra spinous liga me nt, inte rspinous liga me nt, liga me ntum
fla vum, the e pidura l spa ce , a nd fina lly the dura (poste riorly). If you
we re to continue to a dva nce the spina l ne e dle , you would
e ncounte r the dura (a nte riorly) while e xiting the suba ra chnoid
spa ce , the poste rior longitudina l liga me nt, the pe rioste um of the
ve rte bra l body, a nd fina lly bone (Cousins: Neural Blockad e in Clinical
Anesth esia and Managem ent of Pain, ed 3, p 205).
871. (D) In the e pidura l spa ce , bupiva ca ine (a s we ll a s
le vobupiva ca ine ) is four time s more pote nt tha n lidoca ine , so 0.5%
bupiva ca ine is simila r to 2% lidoca ine for a na lge sia . The dura tion
of the bupiva ca ine block will be longe r be ca use bupiva ca ine ha s a
long dura tion of a ction a nd lidoca ine ha s a n inte rme dia te dura tion
of a ction. In a ddition, motor block would be le ss for bupiva ca ine
compa re d with lidoca ine , since the re is more of a gre a te r
diffe re nce be twe e n se nsory a nd motor block for bupiva ca ine a s
compa re d with lidoca ine (Barash : Clinical Anesth esia, ed 7, pp 920–
922; Miller: Basics of Anesth esia, ed 6, pp 134, 277).
872. (D) Drugs with α-a dre ne rgic a gonist a ctivity (phe nyle phrine , 2-5
mg; e pine phrine , 0.2-0.5 mg; clonidine , 75-150 mg) posse ss some
a na lge sic a ctivity but le ss tha n na rcotics a nd loca l a ne sthe tics. In
a ddition, the se intra the ca l α-a dre ne rgic a gonists ma y re duce
syste mic/va scula r upta ke of loca l a ne sthe tics, the re by e nha ncing
the ir e ffe cts, including hypote nsion. Clonidine a lone , whe n
a dministe re d ne ura xia lly, is a n e ffe ctive a na lge sic. Ne ostigmine ha s
some mild a na lge sia prope rtie s, but e xpe rie nce is limite d. Opioids
(e .g., fe nta nyl, sufe nta nil, hydromorphone , a nd morphine ) a dde d to
the spina l solution e nha nce surgica l a ne sthe sia a nd provide
postope ra tive pa in re lie f. Fe nta nyl or sufe nta nil is commonly a dde d
for short surgica l proce dure s (outpa tie nt), whe re a s hydromorphone
or morphine ca n be use d whe n longe r postope ra tive a na lge sia is
de sire d for inpa tie nts (Barash : Clinical Anesth esia, ed 7, pp 919–920;
Miller: Miller’s Anesth esia, ed 8, pp 1693, 2983).
873. (B) For topica l a ne sthe sia , lidoca ine , te tra ca ine , coca ine ,
dibuca ine , a nd be nzoca ine a re e ffe ctive , a s we ll a s the
combina tion of lidoca ine a nd priloca ine , or EMLA cre a m. For
intra ve nous re giona l a ne sthe sia or Bie r blocks, ma ny drugs ha ve
be e n use d. Este r loca l a ne sthe tics a re not use d for IV re giona l
blocks be ca use the y ca n be broke n down in the bloodstre a m (by
pla sma e ste r hydrolysis), which ca n shorte n the drug’s dura tion of
a ction a nd ca n a lso ca use thrombophle bitis of the ve in (re porte d
with chloroproca ine ). Be ca use ca rdiova scula r colla pse ha s be e n
re porte d with bupiva ca ine , it should not be use d for intra ve nous
re giona l a ne sthe sia . Lidoca ine a nd priloca ine a re use d for Bie r
blocks be ca use of the ir re la tive sa fe ty. For infiltra tive a nd e pidura l
a ne sthe sia , a lmost a ll loca l a ne sthe tics ca n be use d (with the
e xce ption of coca ine a nd be nzoca ine , which a re use d only
topica lly) (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, p 272; Miller: Miller’s Anesth esia, ed 8, pp 1041–1044, 1736).
874. (A) Proca ine a nd 2-chloroproca ine ha ve a short dura tion of
a ction; lidoca ine , me piva ca ine , a nd priloca ine ha ve a n
inte rme dia te dura tion of a ction; a nd e tidoca ine , bupiva ca ine ,
le vobupiva ca ine , te tra ca ine , a nd ropiva ca ine ha ve a long dura tion
of a ction. For simila r se nsory a ne sthe sia , a highe r conce ntra tion of
loca l a ne sthe tic is ne e de d for the short dura tion of loca l
a ne sthe tics compa re d with both the inte rme dia te a nd long-dura tion
a ge nts, be ca use the y a re le ss pote nt (Barash : Clinical Anesth esia, ed
7, pp 920–922; Miller: Miller’s Anesth esia, ed 8, pp 1710–1711).
875. (B) Unde r se voflura ne ge ne ra l a ne sthe sia , a n incre a se in the T-
wa ve a mplitude of 25% (usua lly in le a d II), a n incre a se in he a rt ra te
of 10 be a ts/min, or a systolic blood pre ssure incre a se gre a te r tha n
15 mm Hg is conside re d a positive dose re sponse to a n
e pine phrine -conta ining loca l a ne sthe tic solution. Unde r tota l
intra ve nous a ne sthe sia , a n incre a se in blood pre ssure is more
se nsitive tha n a n incre a se in T-wa ve a mplitude or a n incre a se in
he a rt ra te . As a lwa ys, slow incre me nta l dosing is sa fe r tha n a la rge
bolus dose (Barash : Clinical Anesth esia, ed 7, pp 1247–1248; Davis:
876. (D) All of the choice s liste d a re pote ntia l complica tions of
ste lla te ga nglion blocka de e xce pt a n incre a se in he a rt ra te . The
ste lla te ga nglion supplie s sympa the tic fibe rs to the uppe r e xtre mity
a nd he a d a nd some to the he a rt. Loss of the ca rdia c a cce le ra tory
fibe rs ma y slow the he a rt ra te , not spe e d it up. Othe r pote ntia l
complica tions of ste lla te ga nglion blocka de include a ccide nta l
inje ction of the loca l a ne sthe tic into a ve rte bra l a rte ry, re sulting in
se izure , phre nic ne rve pa ra lysis, a nd ina dve rte nt ce rvica l e pidura l
(Miller: Basics of Anesth esia, ed 6, pp 707–710; Miller: Miller’s Anesth esia,
ed 8, p 1732).
877. (D) A tota l of 60 mL of 0.5% bupiva ca ine with e pine phrine
(1:200,000) wa s use d. A 0.5% solution = 0.5 g in 100 mL of
fluid = 500 mg/100 mL = 5 mg/mL. A 1:200,000 solution me a ns 1 g in
200,000 mL = 1000 mg/200,000 mL = 1 mg/200 mL = 1000 µg/200 mL = 5 µg
The re fore 60 mL of 0.5% bupiva ca ine conta ins
60 mL × 5 mg/mL = 300 mg bupiva ca ine a nd 1:200,000 e pine phrine
60 mL × 5 µg/mL = 300 µg of e pine phrine . For a ma jor ne rve block,
the ma ximum re comme nde d dose with e pine phrine (1:200,000) is
500 mg for lidoca ine a nd me piva ca ine , 600 mg with priloca ine , a nd
225 mg with bupiva ca ine . Epine phrine is use d in the loca l
a ne sthe tic to che ck for intra va scula r inje ction of the incre me nta l
dose s a nd is not contra indica te d but should be include d for this
block. Typica lly 40 to 45 mL is use d for the tra nsa rte ria l a pproa ch to
the a xilla ry block (Barash : Clinical Anesth esia, ed 7, p 572; Miller:
Miller’s Anesth esia, ed 8, pp 1043, 1728–1729).
878. (A) Postdura l puncture he a da che s (spina l he a da che s) usua lly
de ve lop within 12 to 72 hours a fte r a dura l puncture but ma y
de ve lop imme dia te ly or ta ke months to de ve lop. The most
cha ra cte ristic symptom is a postura l compone nt in which the
he a da che occurs in the upright position a nd is usua lly comple te ly
gone whe n the pa tie nt is in the supine position. The he a da che is
typica lly fronta l a nd/or occipita l in loca tion. Othe r symptoms
include na use a , vomiting, a nore xia , visua l disturba nce s (blurre d
vision, double vision, photophobia ), a nd occa siona lly he a ring loss
(routine ly found with a uditory te sting) (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 969–970; Miller: Basics of
879. (C) TAP block is use d to provide a bdomina l wa ll a na lge sia .
The subcosta l (T12), ilioinguina l (L1), a nd iliohypoga stric (L1) ne rve s
a re the ne rve s prima rily blocke d. Ultra sound is ofte n use d to loca te
the prope r pla ne whe re the loca l a ne sthe tic is inje cte d, since the
ne rve s a re too sma ll to visua lize . Afte r visua liza tion of the thre e
a bdomina l wa ll muscle s, the e xte rna l oblique , the inte rna l oblique ,
a nd the tra nsve rsus a bdominis muscle s, the ne e dle is inse rte d.
The loca l a ne sthe tic is inje cte d into the muscle pla ne be twe e n the
inte rna l oblique a nd the tra nsve rsus a bdominis muscle s (which is
whe re the se ne rve s tra ve l) a nd not the muscle for e ffe ctive
a na lge sia . Typica lly 20 to 30 mL of loca l a ne sthe tic (e .g., 2 mg/kg of
bupiva ca ine ) is ne e de d for a de qua te spre a d of loca l a ne sthe tic
880. (A) Five ne rve s a re blocke d whe n pe rforming a n a nkle block.
The sa phe nous, supe rficia l pe rone a l, a nd sura l ne rve s a re a ll
se nsory be low the a nkle , a nd e le ctrica l stimula tion would ha ve no
e ffe ct. Stimula tion of the poste rior tibia l ne rve ca use s fle xion of the
toe s by stimula ting the fle xor digitorum bre vis muscle s a nd
a bduction of the first toe by stimula ting the a bductor ha llucis
muscle s. The poste rior tibia l ne rve a lso is se nsory to most of the
pla nta r pa rt of the foot. Stimula tion of the de e p pe rone a l ne rve
ca use s e xte nsion of the toe s by stimula ting the e xte nsor digitorum
bre vis muscle s. The de e p pe rone a l ne rve ha s a sma ll se nsory
bra nch for the first inte rdigita l cle ft. From a pra ctica l sta ndpoint,
ma ny a ne sthe siologists pe rform a pure ly infiltra tion block of the se
ne rve s. If a ne rve stimula tor is use d, it is ma inly use d to find the
poste rior tibia l ne rve , which ca n be difficult to a ne sthe tize if sma ll
volume s of loca l a ne sthe tic a re a dministe re d. The poste rior tibia l
ne rve ca n be difficult to stimula te in dia be tic pa tie nts with dia be tic
ne uropa thy (Hebl: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, ed 1, pp 443–446; Barash : Clinical
881. (C) Pe riphe ra l ne rve stimula tion is a common te chnique whe n
pe rforming a xilla ry ne rve blocks. The de sire d motor re sponse from
the ne rve ca n be se e n with 0.5 mA or le ss. The musculocuta ne ous
ne rve e licits e lbow fle xion. The ra dia l ne rve e licits e xte nsion of a ll
the digits, the wrist, a nd the e lbow, a s we ll a s supina tion of the
fore a rm. The ulna r ne rve e licits fle xion a t the wrist, fourth a nd fifth
digits, a nd a dduction (not a bduction) of the thumb. The me dia n
ne rve e licits fle xion a t the wrist a nd se cond a nd third digits a s we ll
a s opposition of the thumb a nd prona tion of the fore a rm
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 992;
Hebl: May o Clinic Atlas of Regional Anesth esia and Ultrasound -Guid ed
Nerve Blockad e, ed 1, pp 256–260).
882. (C) Unila te ra l numbne ss or pa re sthe sia in the uppe r e xtre mity
during e xte nsion of the ne ck usua lly re pre se nts ne rve root
impinge me nt a t the ve rte bra l fora mina . C6 ne rve distribution is the
thumb. Spe cifica lly, unila te ra l de ge ne ra tive cha nge s re strict the
fora me n to such a de gre e tha t it compre sse s a nd irrita te s the ne rve
root tra ve rsing the ve rte bra l fora me n whe n the he a d is e xte nde d.
Tre a tme nt ra nge s from NSAIDs to ste roids a nd ma y re quire surgica l
inte rve ntion if the re is muscle we a kne ss. Lhe rmitte sign, na me d
a fte r Je a n Lhe rmitte , occurs whe n he a d fle xion ca use s shooting
se nsa tions down the ba ck a nd into the lowe r limbs. It is a sign of
poste rior column dise a se (Hebl: May o Clinic Atlas of Regional
Anesth esia and Ultrasound -Guid ed Nerve Blockad e, ed 1, p 86; Miller:
883. (C) Although a succe ssful inte rsca le ne block ca use s ipsila te ra l
phre nic ne rve pa ra lysis in a lmost 100% of pa tie nts, ide ntifying the
phre nic ne rve me a ns tha t you a re a nte rior to the bra chia l ple xus
a nd tha t you should re position your ne e dle . You should re dire ct the
ne e dle in a poste rior dire ction (Barash : Clinical Anesth esia, ed 7, pp
959–961; Hebl: May o Clinic Atlas of Regional Anesth esia and Ultrasound -
Guid ed Nerve Blockad e, ed 1, pp 195–199; Miller: Miller’s Anesth esia, ed
8, pp 1725–1727).
884. (C) W ith a n intra va scula r inje ction, the ma in symptoms would
most like ly be CNS toxicity (e .g., se izure s), a s blood flow is dire ctly
to the bra in. The Be zold-Ja risch re fle x (hypote nsion a nd
bra dyca rdia ) ha s be e n re porte d in a wa ke , sitting pa tie nts
unde rgoing shoulde r surge ry with a n inte rsca le ne block. This ma y
be re la te d to intra ca rdia c me cha nore ce ptors be ing stimula te d by
the de cre a se d ve nous re turn in the sitting position. This le a ds to
de cre a se d sympa the tic tone a nd incre a se d pa ra sympa the tic tone .
Bre a thing is still pre se nt with this re fle x. Block of the ste lla te
ga nglion would produce Horne r syndrome , which is not a ssocia te d
with bre a thing a bnorma litie s. Inje ction into the intra the ca l spa ce is
uncommon, but possible (e spe cia lly if the ne e dle is not pointe d in
the ca uda l dire ction), a nd would le a d to a tota l spina l block with
little loca l a ne sthe tic inje cte d (e .g., hypote nsion, bra dyca rdia
re spira tory pa ra lysis tha t would le a d to cya nosis) (Barash : Clinical
Anesth esia, ed 7, pp 959–961; Hebl: May o Clinic Atlas of Regional
885. (C) The pipe coloxylidide loca l a ne sthe tics (me piva ca ine ,
bupiva ca ine , ropiva ca ine , a nd le vobupiva ca ine ) a re chira l drugs,
which me a ns tha t the y ha ve a n a symme tric ca rbon a tom (i.e ., ha ve
a le ft or S a nd a right or R ha nd configura tion). Me piva ca ine a nd
bupiva ca ine a re produce d a s ra ce mic mixture s (50% S:50% R). The
pure S forms show re duce d ne urotoxicity a nd re duce d
ca rdiotoxicity (e .g., ropiva ca ine a nd le vobupiva ca ine ). Clinica l
studie s sugge st tha t the pure S forms ha ve a slight de cre a se in
pote ncy a nd a shorte r dura tion of a ction compa re d with ra ce mic
mixture s. Lidoca ine is a n a chira l compound (i.e ., ha s no chira l
ca rbon a tom) (Barash : Clinical Anesth esia, ed 7, pp 566–567; Brunton:
Good m an & Gilm an’s Th e Ph arm acological Basis of Th erapeutics ed 12,
pp 565–574).
886. (A) Ne rve s to the lowe r e xtre mity e me rge from the L1-S4 ne rve
roots. The uppe r roots (ma inly L1-L4) form the lumba r ple xus,
which give s rise to the ge nitofe mora l (L1-L2), la te ra l fe mora l
cuta ne ous (L2-L3), obtura tor (L2-L4), a nd the fe mora l (L2-L4) ne rve s.
A bra nch from the lumba r ple xus (L4) a long with the sa cra l ple xus
(L4-S3) give s rise to the scia tic ne rve . Bra nche s of the scia tic ne rve
include the common pe rone a l (bra nche s to ma ke the supe rficia l
a nd de e p) a nd the tibia l, a nd the sura l ne rve s (Barash : Clinical
887. (D) Ane sthe tic-re la te d ne rve injurie s to the bra chia l ple xus a re
ra re a nd poorly unde rstood. The only wa y to minimize ne rve injury
is to minimize tra uma to ne ura l fibe rs. Although ultra sound-guide d
te chnique is promising, curre ntly the re is no clinica l e vide nce for
this (Neal: Upper ex trem ity regional anesth esia: Essentials of our current
und erstand ing, 2008, Reg Anesth Pain Med 34:134–170, 2009).
888. (C) Loca l a ne sthe tic syste mic toxicity (LAST) is a multisyste m
phe nome non, but the most crucia l ma nife sta tion involve s the he a rt
(a triove ntricula r conduction block, a rrhythmia s, myoca rdia l
de pre ssion, a nd ca rdia c a rre st). In this ca se of ca rdiova scula r (CV)
colla pse , tre a tme nt consists of ge tting he lp with the initia l focus of
a irwa y ma na ge me nt a nd CV support (i.e ., ba sic a nd a dva nce d
ca rdia c life support). BUT AVOID the use of va sopre ssin, ca lcium
cha nne l blocke rs, β-blocke rs, or loca l a ne sthe tics. Epine phrine
dose s should be re duce d to le ss tha n 1 µg/kg. Lipid e mulsion
the ra py should be sta rte d; the initia l bolus of 20% Intra lipid is
1.5 mL/kg (le a n body ma ss) ove r 1 minute , followe d by a continuous
infusion of 0.25 mL/kg/min. Re pe a t the bolus one or two time s for
pe rsiste nt CV colla pse a nd double the continuous infusion ra te if
the blood pre ssure re ma ins low. Continue the infusion for a t le a st
10 minute s a fte r CV sta bility is a tta ine d. The uppe r limit of 20%
Intra lipid is 10 mL/kg ove r 30 minute s. Fa ilure to re spond with the
a bove tre a tme nt should prompt conside ra tion for ca rdiopulmona ry
bypa ss. Although propofol is formula te d a s a lipid e mulsion a nd a s
such would bind bupiva ca ine to some de gre e , the ca rdia c
de pre ssa nt e ffe cts of propofol would fa r ove rsha dow a ny
the ra pe utic be ne fit of binding bupiva ca ine . Also se e e xpla na tion for
Que stion 722 (ASRA.com : Download able Ch ecklist for Treatm ent of Local
Anesth etic Sy stem ic Tox icity 9/19/11; Barash : Clinical Anesth esia, ed 7, p
1155; Miller: Basics of Anesth esia, ed 6, p 138).
889. (A) W he n pe rforming a n inte rsca le ne block, the ne e dle is
usua lly inse rte d whe re the line e xte nding la te ra l to the cricoid
ca rtila ge (C6 le ve l) inte rse cts the inte rsca le ne groove . The ne e dle
is inse rte d pe rpe ndicula r to the skin a nd is slowly a dva nce d in a
me dia l, ca uda l, a nd slightly poste rior dire ction. The ca uda l
dire ction is use d to de cre a se the cha nce of inje cting the loca l
a ne sthe tic into the ve rte bra l a rte ry, or obta ining a spina l or e pidura l
block. Inje cting into the ve rte bra l a rte ry ma y le a d to a n imme dia te
convulsion since the loca l a ne sthe tic would go dire ctly to the bra in.
The phre nic ne rve is routine ly blocke d (100% of the time ) a nd, in
he a lthy pa tie nts, ra re ly le a ds to symptoms. Howe ve r, in pa tie nts
with borde rline re spira tory insufficie ncy, re spira tory compromise
ca n re sult. Occa siona lly the re curre nt la rynge a l ne rve is blocke d.
Unila te ra l pa ra lysis ra re ly is clinica lly significa nt, but if
contra la te ra l re curre nt pa ra lysis e xiste d pre ope ra tive ly the n
comple te a irwa y obstruction ma y de ve lop. The va gus ne rve ca n
a lso be blocke d but is ra re ly clinica lly significa nt (Miller: Basics of
1728).
890. (D) Epidura l he ma toma s a re ra re complica tions of spina l
a ne sthe sia (1:220,000) a nd e pidura l a ne sthe sia (1:150,000). Howe ve r,
in the pre se nce of LMW H, the incide nce is much highe r: 1:40,000
with spina l a ne sthe sia a nd 1:3000 with continuous e pidura l
ca the te r. Clinica l symptoms include ra dicula r ba ck pa in, bowe l a nd
bla dde r dysfunction, a nd se nsory or motor de ficits. An MRI is the
dia gnostic te st of choice , a nd prompt (<8 hours) de compre ssive
la mine ctomy is the tre a tme nt of choice . Epidura l a bsce sse s
typica lly progre ss slowly compa re d to e pidura l he ma toma s a nd a re
a lso a ssocia te d with fe ve r. Se e a lso e xpla na tion for Que stion 814.
(Barash : Clinical Anesth esia, ed 7, p 929; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 970–972; Fleish er: Anesth esia
and Uncom m on Diseases, ed 6, pp 562–563; Miller: Miller’s Anesth esia,
ed 8, pp 2344–2345).
891. (C) Pe riphe ra l ne rve s a re cla ssifie d a ccording to the fibe r size
a nd physiologic prope rtie s such a s the pre se nce or a bse nce of
mye lin, conduction ve locity, loca tion, a nd function. All type A fibe rs
a re mye lina te d. The se fibe rs a re subcla ssifie d into four groups
ba se d on the ir dia me te r, loca tion, a nd function. A-a lpha (Aα) a nd A-
be ta (Aβ) fibe rs a re 6 to 22 µm in dia me te r a nd ha ve conduction
ve locitie s of 30 to 120 m/se c. Aα fibe rs a re e ffe re nt to the ske le ta l
muscle s. Aβ fibe rs a re a ffe re nt from the skin a nd joints to provide
touch a nd proprioce ption se nsa tions. A-ga mma (Aγ) fibe rs a re 3 to
6 µm in dia me te r, ha ve conduction ve locitie s of 15 to 35 m/se c, a nd
a re e ffe re nt to the muscle spindle s to provide muscle tone . A-de lta
(Aδ) fibe rs a re 1 to 4 µm in dia me te r a nd ha ve conduction ve locitie s
of 5 to 25 m/se c a nd a re a ffe re nt fibe rs, which provide sha rp
loca lize d pa in a nd te mpe ra ture a nd touch se nsa tions. B fibe rs a re
mye lina te d, pre ga nglionic sympa the tic ne rve fibe rs tha t a re le ss
tha n 3 µm in dia me te r, ha ve me dium conduction ve locitie s 3 to
15 m/se c, a nd a re involve d with va rious a utonomic ne rvous syste m
control. C fibe rs a re nonmye lina te d, postga nglionic sympa the tic
ne rve s tha t a re 0.3 to 1.3 µm in dia me te r a nd ha ve slow conduction
ve locitie s of 0.1 to 2 m/se c. C fibe rs a re a ffe re nt se nsory ne rve s
involve d with nonloca lize d pa in, te mpe ra ture , a nd touch se nsa tions
(Barash : Clinical Anesth esia, ed 7, pp 1646–1648; Miller: Miller’s
892. (C) Ove rdose of intra the ca l opia te s would not be a sign of a n
intra dura l ma ss le sion. Gra nuloma s a t the tip of intra the ca l
ca the te rs use d with intra the ca l drug de live ry syste ms a re ga ining
incre a se d a tte ntion. Gra nuloma s a re more fre que ntly a ssocia te d
with high conce ntra tions a nd dose s of e ithe r morphine (>10 mg/da y)
or hydromorphone (>10 mg/da y). Most pa tie nts who will de ve lop
gra nuloma s re ce ive the intra the ca l me dica tions for more tha n
6 months. Pre se nting symptoms ma y include loss of drug e ffe ct,
ne w pa in or pa re sthe sia s, or ne urologic de ficits. Pa tie nts should be
routine ly scre e ne d for signs a nd symptoms of gra nuloma forma tion
a t sche dule d intra the ca l pump re fill a ppointme nts. In suspicious
ca se s, pa tie nts should unde rgo prompt dia gnostic ima ging a nd
conside ra tion of ne urosurgica l consulta tion (Barash : Clinical
Anesth esiology, ed 5, pp 1059–1060; Miller: Miller’s Anesth esia, ed 8, pp
1911–1912).
893. (A) In a ddition to be nzoca ine , te tra ca ine , coca ine , a nd
lidoca ine ca n a lso be use d a s topica l a ne sthe tics.
Pse udocholine ste ra se , the e nzyme re sponsible for the me ta bolism
of succinylcholine , me ta bolize s the e ste r loca l a ne sthe tics,
be nzoca ine , proca ine , chloroproca ine , a nd te tra ca ine . Be nzoca ine
doe s promote the forma tion of me the moglobin but is not a lone in
tha t re ga rd, a s priloca ine a lso ca use s forma tion of me the moglobin.
The pKa of be nzoca ine is 3.5, which qua lifie s it a s a we a k a cid a nd
a s such e xists in uncha rge d form a t physiologic pH. All othe r loca l
a ne sthe tic pKa ’s a re highe r tha n 7.4, me a ning tha t some fra ction of
the m e xists in the protona te d form (Barash : Clinical Anesth esia, ed 5,
p 572; Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, pp 566, 572; Butterworth : Morgan & Mikh ail’s
894. (C) The un-ionize d form of the loca l a ne sthe tic tra ve rse s the
ne rve me mbra ne , whe re a s the ionize d form a ctua lly blocks
conduction. About thre e node s of Ra nvie r must be blocke d to
a chie ve a ne sthe sia . The pre se nce of mye lin e nha nce s the a bility of
a loca l a ne sthe tic to block conduction, a s doe s ra pid firing. The
loca l a ne sthe tic blocks ne rve tra nsmission by inhibiting the volta ge -
ga te d sodium ion cha nne ls (Miller: Basics of Anesth esia, ed 6, pp 131–
135).
895. (D) PDPHs typica lly a ppe a r within 12 to 48 hours of a dura l
puncture but ma y be imme dia te a nd occa siona lly ha ve be come
de la ye d for se ve ra l da ys or months a fte r a dura l puncture . The
he a da che s a re cha ra cte rize d by dull or throbbing fronta l or
occipita l pa in, which worse ns with sitting a nd improve s with
re clining. Postspina l he a da che s ma y be a ssocia te d with ne urologic
symptoms such a s diplopia , tinnitus, a nd re duce d he a ring a cuity.
Ve ry ra re ly, a subdura l he ma toma will de ve lop. The e tiology of
postspina l he a da che s is be lie ve d to be due to a re duction in CSF
pre ssure a nd re sulting te nsion on me ninge a l ve sse ls a nd ne rve s
(which re sults from le a ka ge of CSF through the ne e dle hole in the
dura ma te r). Fa ctors a ssocia te d with a n incre a se d incide nce of
postspina l he a da che s include pre gna ncy, size (la rge r ne e dle s le a ve
bigge r hole s tha n sma lle r ne e dle s), type of ne e dle use d to pe rform
the block (cutting Quincke ne e dle s more commonly a ssocia te d with
PDPH tha n pe ncil-point W hita cre or bulle t-sha pe d Sprotte
ne e dle s), a nd the numbe r of dura l puncture s. The y occur more
fre que ntly in young a dults compa re d with childre n a nd e lde rly
pe rsons. Conse rva tive the ra py for a postspina l he a da che include s
be d re st, a na lge sics, a nd ora l a nd intra ve nous hydra tion. If
conse rva tive the ra py is not succe ssful a fte r 24 to 48 hours, a n
e pidura l “blood pa tch” with 10 to 20 mL of the pa tie nt’s blood ca n
be pe rforme d. An e pidura l blood pa tch usua lly provide s prompt
re lie f of the postspina l he a da che (Barash : Clinical Anesth esia, ed 7, pp
926–927; Miller: Basics of Anesth esia, ed 6, pp 271–272).
896. (B) IDET is a proce dure ra re ly use d for intra cta ble discoge nic
low ba ck pa in, in which a fle xible the rma l e le ctrode is a dva nce d
through a n introduce r pe rcuta ne ously into the poste rola te ra l
portion of a disk. The e le ctrode is gra dua lly he a te d to 90° C for
4 minute s (or 80-85° C for 5 minute s), which ca use s the colla ge n of
the a nnulus fibrosus of the disk to contra ct a nd de cre a se s
intra disca l pre ssure . W ith pe rcuta ne ous disk de compre ssion or
nucle opla sty, a n e le ctrode is pa sse d through a n introduce r into the
disk, the tissue is he a te d (40-70° C ra nge ), a nd a portion of the disk
is re move d. For spina l cord stimula tion the ra py, a tria l is first
pe rforme d, a nd, if it is succe ssful, the n pe rma ne nt impla nta tion is
pe rforme d. W he n inse rting a spina l cord stimula tor, a Touhy
e pidura l ne e dle is a dva nce d into the e pidura l spa ce . Afte r
confirma tion of prope r ne e dle pla ce me nt with a nte roposte rior a nd
la te ra l fluoroscopic vie ws, the stimula tion e le ctrode is pa sse d
through the ne e dle a nd thre a de d to the de sire d ve rte bra l le ve l. The
ne e dle is the n re move d a nd the le a ds a tta che d to the e xte rna l
progra mme r. Ve rte bropla sty involve s the inje ction of 2 to 6 mL of
ce me nt (polyme thylme tha cryla te ) into a ve rte bra l body to he lp tre a t
ve rte bra l compre ssion fra cture s (Barash : Clinical Anesth esia, ed 7, pp
1663–1665).
897. (A) Ma ny drugs ha ve be e n use d to tre a t ne uropa thic pa in,
including a na lge sics (NSAIDs a nd opioids), first-ge ne ra tion
a ntie pile ptic drugs (e .g., ca rba ma ze pine a nd phe nytoin), se cond-
ge ne ra tion a ntie pile ptic drugs (e .g., ga ba pe ntin, pre ga ba lin), topica l
a ge nts (e .g., lidoca ine , ca psa icin), a ntia rrhythmics (e .g., me xile tine ),
a nd tricyclic a ntide pre ssa nts (e .g., a mitriptyline , nortriptyline ,
de sipra mine ), a s we ll a s othe r a ntide pre ssa nts (e .g., duloxe tine ,
ve nla fa xine ). Duloxe tine (Cymba lta ) is a se le ctive se rotonin a nd
nore pine phrine re upta ke inhibitor (SNRI) tha t is use d for ma jor
de pre ssive disorde rs, ge ne ra lize d a nxie ty disorde rs, fibromya lgia ,
a nd ne uropa thic pa in. Me xile tine is a n ora lly e ffe ctive a mine
a na log of lidoca ine a nd ma y be e ffe ctive in de cre a sing ne uropa thic
pa in whe n othe r drugs ha ve fa ile d. Ga ba pe ntin, a structura l a na log
of γ-a minobutyric a cid (GABA), works by incre a sing the synthe sis of
the inhibitory ne urotra nsmitte r GABA. Ca rba ma ze pine (Te gre tol) is
a n a nticonvulsa nt with spe cific a na lge sic prope rtie s for trige mina l
ne ura lgia . Ca rba ma ze pine se e ms to re duce polysyna ptic re sponse s
by a n unknown me cha nism (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 1037–1055; Cousins: Neural Blockad e in Clinical
Anesth esia and Pain Med icine, ed 4, p 1065; Hem m ings: Ph arm acology
and Ph y siology for Anesth esia, ed 1, pp 280–281; Miller: Miller’s
898. (E)
899. (B)
900. (A)
901. (C)
(Hebl: May o Clinic Atlas of Regional Anesth esia and Ultrasound -Guid ed
Nerve Blockad e, ed 1, pp 260–269.)
902. (A)
903. (B)
904. (E)
905. (D)
906. (C)
In the norma l a dult, bre a thing a nd coughing ca n be done
e xclusive ly by the dia phra gm, which is inne rva te d by the phre nic
ne rve (C3-C5). The he a rt ra te is de pe nde nt upon intrinsic
pa ce ma ke r a ctivity of the sinoa tria l node , which ca n be a ffe cte d
by the a utonomic ne rvous syste m’s sympa the tic ne rvous syste m’s
ca rdia c a cce le ra tor fibe rs (T1-T4) a s we ll a s the pa ra sympa the tic
ne rvous syste m’s va gus ne rve (cra nia l ne rve X). The first sta ge of
la bor pa in is re la te d to ute rine contra ctions a nd dila tion of the
ce rvix (T10-L1). The se cond sta ge of la bor is re la te d to both
ute rine pa in (T10-L1) a nd birth ca na l pa in, which is conducte d by
the pude nda l ne rve (S2-S4). The gre a te r spla nchnic (T5-T9) a nd
the le sse r spla nchnic (T10-T12) ne rve s supply sympa the tic fibe rs
to the ce lia c ple xus, which inhibits much of the ga strointe stina l
tra ct (Barash : Clinical Anesth esia, ed 7, pp 364–367, 1149; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 492, 846, 1073;
Miller: Miller’s Anesth esia, ed 8, pp 347–349, 1688, 2339).
907. (A)
908. (A)
909. (C)
910. (E)
911. (B)
912. (B)
913. (E)
914. (D)
W he n a n a wa ke intuba tion is ne e de d, loca l a ne sthe tics ca n be
a pplie d topica lly or inje cte d to a ne sthe tize the a irwa y. The
se nsory ne rve supply to the uppe r a irwa y is pre domina ntly by
thre e cra nia l ne rve s: the trige mina l ne rve (cra nia l ne rve V), the
glossopha rynge a l ne rve (cra nia l ne rve IX), a nd the va gus ne rve
(cra nia l ne rve X). Bra nche s from the trige mina l ne rve provide
se nsory supply to the mucous me mbra ne s of the nose a s we ll a s
the supe rior a nd infe rior portions of the ha rd a nd soft pa la te . The
glossopha rynge a l ne rve provide s se nsory inne rva tion of the
poste rior third of the tongue , the va lle cula , a nd the a nte rior
surfa ce of the e piglottis (lingua l bra nch), the pha rynge a l wa lls
(pha rynge a l bra nch), a nd the tonsils (tonsilla r bra nch). The va gus
ne rve give s rise to the inte rna l a nd e xte rna l bra nche s of supe rior
la rynge a l ne rve a s we ll a s the re curre nt la rynge a l ne rve . The
se nsory inne rva tion of the mucosa of the la rynx a bove the voca l
cords come s from the inte rna l bra nch of the supe rior la rynge a l
ne rve , a nd the se nsory inne rva tion of the mucosa of the la rynx
be low the voca l cords come s from the re curre nt la rynge a l ne rve .
W ith the e xce ption of the cricothyroid muscle , the re curre nt
la rynge a l ne rve provide s motor inne rva tion of a ll the intrinsic
muscle s of the la rynx. The cricothyroid muscle is supplie d by the
e xte rna l bra nch of the supe rior la rynge a l ne rve . The muscle s of
the pha rynx a re supplie d through the pha rynge a l ple xus from
motor fibe rs from the spina l a cce ssory ne rve (cra nia l ne rve XI)
C H AP T E R 11
Cardiovascular Physiology and
Anesthesia
DIRECT IONS (Que stions 915 through 994): Ea ch of the

que stions or incomple te sta te me nts in this se ction is followe d
by a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
915. A 67-ye a r-old ma n is to unde rgo a ra dica l re tropubic

prosta te ctomy. He ha s a ortic ste nosis with a gra die nt of 37 mm Hg
a t re st. He ha s a n a lle rgy to pe nicillin. W hich of the following is the
be st re gime n for suba cute ba cte ria l e ndoca rditis prophyla xis in this
pa tie nt?
A. Ampicillin a nd ge nta micin
B. Va ncomycin a nd ge nta micin
C. Clinda mycin a nd ge nta micin
916. A 64-ye a r-old ma n de ve lops he pa rin-induce d thrombocytope nia
(HIT), type II (a ntibody prove n), a fte r a nticoa gula tion for a ortic va lve
re pla ce me nt with 25,000 units of he pa rin. The sa me pa tie nt
re quire s a n e le ctive tricuspid va lve re pla ce me nt soon the re a fte r
be ca use of tra uma from a tra nsve nous pa ce ma ke r. The be st option
for ca rdiopulmona ry bypa ss a nticoa gula tion for this pa tie nt with the
se cond ope ra tion would be
A. De fe r until disa ppe a ra nce of a ntibodie s; use he pa rin
B. Ca rdiopulmona ry bypa ss with le pirudin in pla ce of he pa rin
C. Ca rdiopulmona ry bypa ss with tirofiba n in pla ce of he pa rin
D. Anticoa gula tion with fonda pa rinux
917. W hich of the following is the MOST se nsitive indica tor of le ft
ve ntricula r myoca rdia l ische mia ?
A. Wa ll-motion a bnorma litie s on the e choca rdiogra m
B. ST se gme nt cha nge s in le a d V5 of the e le ctroca rdiogra m (ECG)
C. Appe a ra nce of V wa ve s on the pulmona ry ca pilla ry we dge
pre ssure tra cing
D. De cre a se in ca rdia c output a s me a sure d by the the rmodilution
te chnique
918. Oxyge n consumption (VO2) is me a sure d in a 70-kg subje ct on a
tre a dmill a t 2500 mL pe r minute . This corre sponds to:
A. 1 me ta bolic e quiva le nt (MET)
B. 5 METs
C. 10 METs
D. 15 METs
919. Accide nta l inje ction of a ir into a pe riphe ra l ve in would be
LEAST like ly to re sult in a rte ria l a ir e mbolism in a pa tie nt with
which of the following a na tomic ca rdia c de fe cts?
A. Pa te nt ductus a rte riosus
B. Eise nme nge r syndrome
C. Te tra logy of Fa llot
D. Tricuspid a tre sia
920. Ea ch of the following could be pla ce d on the x-a xis of the curve
shown in the figure EXCEPT
A. Stroke volume
B. Le ft ve ntricula r e nd-dia stolic pre ssure
C. Le ft ve ntricula r e nd-dia stolic volume
D. Le ft a tria l pre ssure
921. The ECG rhythm strip be low re pre se nts
A. Atria l flutte r
B. Third-de gre e he a rt block
C. Sinus ta chyca rdia se cond-de gre e he a rt block
D. Junctiona l rhythm
922. A 71-ye a r-old ma n is unde rgoing re va scula riza tion of thre e
corona ry ve sse ls on ca rdiopulmona ry bypa ss a t 28° C. Afte r the la st
gra ft is se wn into the a orta , the a rte ria l pre ssure me a sure d from a
le ft ra dia l a rte ry is 47 mm Hg a nd the pulmona ry a rte ry (PA)
pre ssure is 6 mm Hg. Thirty minute s la te r, the a rte ria l pre ssure is
52 mm Hg a nd PA pre ssure is 31 mm Hg. The MOST like ly
e xpla na tion for this is
A. Ma lposition of the a ortic ca nnula
B. Ma lposition of the ve nous ca nnula
C. Fa ulty ve ntricula r ve nting
D. PA ca the te r migra tion
923. A 78-ye a r-old pa tie nt is a ne sthe tize d for right he micole ctomy
with isoflura ne a nd nitrous oxide . Ve curonium is a dministe re d to
fa cilita te muscle re la xa tion. At the e nd of the ope ra tion, the
ne uromuscula r blocka de is re ve rse d with ne ostigmine 4 mg a nd
glycopyrrola te 0.8 mg. The rhythm be low is note d shortly a fte r
a dministra tion of the se drugs. The pa tie nt’s blood pre ssure is 90/60.
The MOST a ppropria te course of a ction a t this point is
A. DC ca rdiove rsion
B. Isoprote re nol drip
C. Atropine
D. Tra nscuta ne ous pa ce ma ke r
924. W hile on ca rdiopulmona ry bypa ss during e le ctive corona ry
a rte ry re va scula riza tion, the pa tie nt is note d to ha ve bulging
scle ra e . Me a n a rte ria l pre ssure is 50 mm Hg, te mpe ra ture is 28° C,
a nd the re is no ECG a ctivity. The MOST a ppropria te a ction to ta ke
a t this time is to
A. Administe r ma nnitol, 50 g IV
B. De cre a se the ca rdia c inde x
C. Che ck the position of the a ortic ca nnula
D. Che ck the position of the ve nous re turn ca nnula
925. W hich of the following corre ctly de scribe s the e ffe ct of
tra nsposition of the gre a t ve sse ls on the ra te of induction of
a ne sthe sia ?
A. Inha la tion induction is fa ste r tha n norma l; intra ve nous
induction is slowe r tha n norma l
B. Inha la tion induction is slowe r tha n norma l; intra ve nous
induction is fa ste r tha n norma l
C. Both inha la tion a nd intra ve nous induction a re fa ste r tha n
norma l
D. Both inha la tion a nd intra ve nous induction a re slowe r tha n
norma l
926. Ana stomosis of the right a trium to the PA (Fonta n proce dure ) is
a use ful surgica l tre a tme nt for e a ch of the following conge nita l
ca rdia c de fe cts EXCEPT
A. Tricuspid a tre sia
B. Hypopla stic le ft he a rt syndrome
C. Pulmona ry va lve ste nosis
D. Truncus a rte riosus
927. By wha t pe rce nta ge is tissue me ta bolic ra te re duce d during
ca rdiopulmona ry bypa ss a t 30° C?
A. 10%
B. 25%
C. 50%
D. 75%
928. Effe ctive infla tion of a n intra -a ortic ba lloon ca the te r should
occur a t which of the following time s?
A. Imme dia te ly a fte r P wa ve on ECG
B. Imme dia te ly a fte r closure of a ortic va lve
C. During ope ning of the a ortic va lve
D. During systolic upstroke on a rte ria l tra cing
929. Afte rloa d re duction is be ne ficia l during a ne sthe sia for
nonca rdia c surge ry in pa tie nts with e a ch of the following conditions
EXCEPT
A. Aortic insufficie ncy
B. Pa te nt ductus a rte riosus
C. Te tra logy of Fa llot
D. Conge stive he a rt fa ilure
930. Administra tion of prota mine to a pa tie nt who ha s not re ce ive d
he pa rin ca n re sult in
A. Anticoa gula tion
B. Hype rcoa gula tion
C. Profound bra dyca rdia
D. Hype rte nsion
931. The prima ry de te rmina nts of myoca rdia l O2 consumption, from
most to le a st importa nt, a re
A. Pre loa d > a fte rloa d > he a rt ra te
B. He a rt ra te > pre loa d > a fte rloa d
C. Afte rloa d > pre loa d > he a rt ra te
D. He a rt ra te > a fte rloa d > pre loa d
932. Ca rdia c ta mpona de is a ssocia te d with
A. Pulsus a lte rna ns
B. Pulsus ta rdus
C. Pulsus pa rvus
D. Pulsus pa ra doxus
933. W hich of the following drugs should NOT be a dministe re d via
a n e ndotra che a l tube ?
A. Lidoca ine
B. Na HCO3
C. Atropine
D. Na loxone
934. The me a n a rte ria l pre ssure in a pa tie nt with a blood pre ssure
of 180/60 mm Hg is
A. 90 mm Hg
B. 100 mm Hg
C. 110 mm Hg
D. 120 mm Hg
935. Hypothyroidism a nd hype rthyroidism could de ve lop in pa tie nts
re ce iving which of the following a ntidysrhythmic drugs?
A. Amioda rone
B. Ve ra pa mil
C. Proca ina mide
D. Lidoca ine
936. Ca lcula te the syste mic va scula r re sista nce (in dyne -se c/cm5)
from the following da ta : ca rdia c output 5.0 L/min, ce ntra l ve nous
pre ssure 8 mm Hg, me a n a rte ria l blood pre ssure 86 mm Hg, me a n
pulmona ry a rte ria l blood pre ssure 20 mm Hg, pulmona ry ca pilla ry
we dge pre ssure 9 mm Hg, he a rt ra te 85 be a ts/min, pa tie nt we ight
100 kg.
A. 750
B. 1000
C. 1250
D. 1500
937. W hich of the following is NOT include d in te tra logy of Fa llot?
A. Pa te nt ductus a rte riosus
B. Right ve ntricula r hype rtrophy
C. Ve ntricula r se pta l de fe ct
D. Ove rriding a orta
938. A 65-ye a r-old fe ma le pa tie nt with se psis is unde rgoing a n
e me rge ncy e xplora tory la pa rotomy. Afte r induction of a ne sthe sia
a nd tra che a l intuba tion, the pa tie nt’s blood pre ssure is note d to be
65 systolic with a he a rt ra te of 120 be a ts/min. Ca rdia c output
de te rmine d by a the rmodilution PA ca the te r is 13 L/min. Of the
following va sopre ssors the LEAST a ppropria te choice would be
A. Dobuta mine
B. Va sopre ssin
C. Nore pine phrine
D. Phe nyle phrine
939. A 61-ye a r-old ma n de ve lops this rhythm a fte r thora cotomy a nd
right uppe r lobe re se ction. Ca rdiove rsion is pla nne d, the ima ge
be low is ta ke n from the bipha sic de fibrilla tor, a nd the de vice is se t
to de live r 200 J.
The MOST a ppropria te ste p would be

A. Se le ct a diffe re nt le a d
B. De live r shock
C. Re duce e ne rgy a nd de live r shock
D. Se t to a synchronous mode a nd shock
940. The MOST importa nt pa thophysiologic diffe re nce be twe e n
pe rica rdia l e ffusion a nd ca rdia c ta mpona de is
A. Type of fluid (e .g., tra nsuda te , e xuda te , blood)
B. Qua ntity of fluid
C. Pre ssure
D. Infla mma tion
941. A he a lthy 59-ye a r-old, 60-kg woma n with a norma l pre ope ra tive
ECG de ve lops wide comple x ta chyca rdia unde r ge ne ra l a ne sthe sia
for bre a st biopsy. Blood pre ssure is 81/47 mm Hg, a nd he a rt ra te is
220 be a ts/min a nd re gula r. The MOST a ppropria te the ra py would
be
A. Ele ctrica l ca rdiove rsion
B. Administra tion of lidoca ine , 60 mg IV
C. Administra tion of proca ina mide , 20 mg/min IV
D. Administra tion of a mioda rone , 300 mg IV
942. Although β-a dre ne rgic re ce ptor blocka de is the be st tre a tme nt
for re e ntra nt ta chydysrhythmia a ssocia te d with Roma no-Wa rd
syndrome , the se dysrhythmia s ca n a lso be e ffe ctive ly tre a te d with
A. Lidoca ine
B. Proca ina mide
C. Le ft ste lla te ga nglion blocka de
D. Right ste lla te ga nglion blocka de
943. A 64-ye a r-old pa tie nt with a n a xia l flow le ft ve ntricula r a ssist
de vice (e .g., He a rtMa te II, Ja rvik 2000) is sche dule d for la pa roscopic
chole cyste ctomy unde r ge ne ra l a ne sthe sia . Monitoring which of the
following pa ra me te rs is like ly to be difficult in this pa tie nt?
A. Blood pre ssure with blood pre ssure cuff
B. Blood pre ssure with a rte ria l line
C. PA pre ssure with PA ca the te r
D. Te mpe ra ture with e sopha ge a l te mpe ra ture probe
944. In a norma l pe rson, wha t pe rce nta ge of the ca rdia c output is
de pe nde nt on the “a tria l kick”?
A. 25%
B. 35%
C. 45%
D. 55%
945. This a rte ria l wa ve form is consiste nt with
A. Aortic re gurgita tion

B. Aortic ste nosis
C. Ca rdia c ta mpona de
D. Hypovole mia
946. A 1-ye a r-old child with te tra logy of Fa llot is to unde rgo e le ctive
re pa ir of a le ft inguina l he rnia unde r ge ne ra l a ne sthe sia . W hich of
the following a ne sthe tics would provide the MOST sta ble
he modyna mics in this pa tie nt?
A. Se voflura ne a nd N2O
B. Fe nta nyl a nd N2O
C. De sflura ne a nd oxyge n
D. Ke ta mine
947. The le ft ve ntricula r pre ssure -volume loop shown in the figure
de picts
A. Mitra l ste nosis

B. Mitra l re gurgita tion
C. Aortic ste nosis
D. Acute a ortic insufficie ncy
948. A 54-ye a r-old pa tie nt is unde rgoing a thre e -ve sse l corona ry
a rte ry bypa ss gra ft unde r ge ne ra l a ne sthe sia . Afte r induction, the
pulmona ry ca pilla ry we dge pre ssure is 15 mm Hg a nd PA pre ssure s
a re 26/13 mm Hg. Sudde nly, ne w 30-mm Hg V wa ve s a ppe a r on the
monitor scre e n. Syste mic blood pre ssure is 120/70 mm Hg, he a rt
ra te is 75 be a ts/min, a nd PA pre ssure is 50/35 mm Hg. W hich of the
following drugs should be a dministe re d to the pa tie nt?
A. Nitroglyce rin
B. Nitroprusside
C. Esmolol
D. Dobuta mine
949. A 62-ye a r-old pa tie nt sche dule d for e le ctive re pa ir of a n
a bdomina l a ortic a ne urysm de ve lops a wide comple x re gula r
ta chyca rdia (he a rt ra te 150 be a ts/min) during induction of
a ne sthe sia . Blood pre ssure is 110/78 mm Hg. W hich of the following
drugs would be MOST use ful in the ma na ge me nt of this
dysrhythmia ?
A. Esmolol, 35 mg IV
B. Amioda rone , 150 mg IV ove r 10 minute s
C. Ade nosine , 6 mg ra pidly ove r 3 se conds
D. Ve ra pa mil, 5 to 10 mg IV
950. Unde r ma ximum stre ss, how much cortisol is produce d pe r
da y?
A. 50 mg
B. 150 mg
C. 250 mg
D. 350 mg
951. W ith pa ce ma ke rs, the conce pt of uppe r tra cking ra te (UTR) is
re le va nt with which type (s) of de vice ?
A. VDD
B. DDI
C. AAI
952. Ca lcula te the ca rdia c output from the following da ta : pa tie nt
we ight 70 kg, he moglobin conce ntra tion 10 mg/dL, a rte ria l blood
ga se s on 100% O2: Pa O2 450 mm Hg, Pa CO2 32 mm Hg, pH 7.46, Sa O2
99%. Mixe d ve nous blood ga se s a re : PvO2 30 mm Hg, Pa CO2
45 mm Hg, pH 7.32, SvO2 60%.
A. 1.5 L/min
B. 2.5 L/min
C. 3.5 L/min
D. 4.5 L/min
953. Norma l re sting myoca rdia l O2 consumption is
A. 2.0 mL/100 g/min
B. 3.5 mL/100 g/min
C. 8 mL/100 g/min
D. 15 mL/100 g/min
954. A 22-ye a r-old ma n with hype rtrophic ca rdiomyopa thy (HOCM)
is unde rgoing a n e le ctive chole cyste ctomy unde r ge ne ra l
a ne sthe sia . Imme dia te ly a fte r induction with propofol, 2.5 mg/kg IV,
the a rte ria l blood pre ssure de cre a se s from 140/82 to 70/40 mm Hg.
W ha t would be the most a ppropria te drug for tre a tme nt of
hypote nsion in this pa tie nt?
A. Ephe drine
B. Epine phrine
C. Isoprote re nol
D. Phe nyle phrine
955. A 65-ye a r-old pa tie nt with mode ra te a ortic ste nosis de ve lops a
sudde n incre a se in he a rt ra te during a n a ppe nde ctomy unde r
ge ne ra l a ne sthe sia . The ve ntricula r ra te is 190 be a ts/min a nd is
irre gula rly irre gula r, a rte ria l blood pre ssure is 70/45 mm Hg, a nd
the re is 2-mm ST se gme nt de pre ssion in le a d V5 of the ECG. W hich
of the following would be the MOST a ppropria te tre a tme nt for
myoca rdia l ische mia in this pa tie nt?
A. Ele ctrica l ca rdiove rsion
B. Esmolol
C. Phe nyle phrine
D. Ve ra pa mil
956. Afte r e me rge ncy re pa ir of a rupture d a bdomina l a ortic
a ne urysm, a 68-ye a r-old pa tie nt is me cha nica lly ve ntila te d in the
inte nsive ca re unit with 20 cm H2O of positive e nd-e xpira tory
pre ssure (PEEP) for 3 da ys. Sodium nitroprusside ha s be e n infuse d
a t a ra te of 1.5 µg/kg/min for 48 hours to control hype rte nsion.
Sudde nly, the syste mic blood pre ssure fa lls from 130/70 to 50 mm Hg
systolic a nd the Sa O2 drops to 75%. The MOST like ly ca use of this
sce na rio is
A. Cya nide toxicity
B. Acute myoca rdia l infa rction
C. Te nsion pne umothora x
D. Hype rve ntila tion
957. Norma l re sting corona ry a rte ry blood flow is
A. 10 mL/100 g/min
B. 40 mL/100 g/min
C. 75 mL/100 g/min
D. 120 mL/100 g/min
958. Ea ch of the following is a ssocia te d with a n incre a se d
incide nce of PA rupture in pa tie nts with PA ca the te rs EXCEPT
A. Hypothe rmia
B. Pre se nce of PA a the roma s
C. Old a ge
D. Anticoa gula tion
959. Alle rgic re a ctions to prota mine ca n occur with e a ch of the
following EXCEPT
A. Dia be te s tre a te d with NPH insulin
B. Dia be te s tre a te d with re gula r insulin
C. Dia be te s tre a te d with PZI insulin
D. Pre vious va se ctomy
960. A 66-ye a r-old pa tie nt is unde rgoing a thre e -ve sse l corona ry
a rte ry bypa ss ope ra tion. Anticoa gula tion is a chie ve d with 20,000
units of he pa rin. How much prota mine should be a dministe re d to
this pa tie nt to comple te ly re ve rse the he pa rin a fte r
ca rdiopulmona ry bypa ss?
A. 150 mg
B. 250 mg
C. 350 mg
D. 450 mg
961. The gra ph be low re pre se nts
A. Dia stolic time (a s pe rce nta ge of ca rdia c cycle ) a s a function of

he a rt ra te
B. Stroke volume a s a function of e nd-dia stolic pre ssure
C. Ca rdia c inde x a s a function of e nd-dia stolic pre ssure
D. Ca rdia c output a s a function of ve ntricula r e nd-dia stolic
volume
962. A 72-ye a r-old woma n is unde rgoing ca rdiopulmona ry bypa ss
for a ortic a nd mitra l va lve re pla ce me nt. The surge ry is une ve ntful;
howe ve r, in the inte nsive ca re unit, blood is note d to ooze from the
PA ca the te r a nd ve nous a cce ss site s. Me dia stina l che st tube output
is 500 mL/hr. A thromboe la stogra m is obta ine d a nd shown in the
figure . W ha t is the MOST like ly ca use of profuse ble e ding in this
pa tie nt?
A. Fibrinolysis
B. Exce ss he pa rin
C. Thrombocytope nia
D. Fa ctor VIII de ficie ncy
963. A 69-ye a r-old ma n with a n a xia l flow le ft ve ntricula r a ssist
de vice is a ne sthe tize d for kidne y stone re mova l from the le ft ure te r.
The pa tie nt is “dry” a nd blood pre ssure fa lls pre cipitously to a
me a n pre ssure of 51 mm Hg with no pulsa tility on the a rte ria l
tra cing. In a ddition to a fluid bolus, e a ch of the othe r inte rve ntions
would be use ful EXCEPT
A. Incre a se pump spe e d from 7800 to 8500 rpm
B. Ephe drine
C. Phe nyle phrine
D. Tre nde le nburg position
964. The dose of a de nosine ne ce ssa ry to conve rt pa roxysma l
supra ve ntricula r ta chyca rdia to norma l sinus rhythm should be
initia lly re duce d
A. In pa tie nts re ce iving the ophylline for chronic a sthma
B. In pa tie nts with a history of a rte ria l thrombotic dise a se ta king
dipyrida mole
C. In pa tie nts with a history of chronic re na l fa ilure
D. In chronic a lcoholics
965. A 56-ye a r-old ma le pa tie nt is a ne sthe tize d for e le ctive corona ry
re va scula riza tion. A urina ry ca the te r is pla ce d a fte r induction a nd
couple d to a te mpe ra ture tra nsduce r. A PA ca the te r is inse rte d, a nd
the te mpe ra ture probe on the dista l portion of the ca the te r is a lso
conne cte d to a tra nsduce r. The re a son for me a suring the
te mpe ra ture of both the bla dde r a nd the blood in the pulmona ry
va scula ture is
A. Both a re ne ce ssa ry for de te rmining ca rdia c output by the
the rmodilution te chnique
B. Bla dde r te mpe ra ture is more a ccura te pre bypa ss; PA ca the te r
te mpe ra ture is more a ccura te postbypa ss
C. PA ca the te r te mpe ra ture is more a ccura te pre bypa ss; bla dde r
te mpe ra ture is more a ccura te postbypa ss
D. It is he lpful in de te rmining the like lihood of re cooling a fte r
discontinua tion of ca rdiopulmona ry bypa ss
966. W hich of the following would be the be st intra ope ra tive
tra nse sopha ge a l e choca rdiogra ph (TEE) vie w to monitor for
myoca rdia l ische mia ?
A. Mid-e sopha ge a l four cha mbe r vie w
B. Tra nsga stric mid-pa pilla ry le ft ve ntricula r short a xis vie w
C. Mid-e sopha ge a l long a xis vie w
D. Mid-e sopha ge a l two cha mbe r vie w
967. Se le ct the T RUE sta te me nt re ga rding ca rdiopulmona ry
re suscita tion (CPR) a nd de fibrilla tion by a he a lth ca re provide r in
pa tie nts e xpe rie ncing sudde n ca rdia c a rre st.
A. De fibrilla tion time s one should a lwa ys pre ce de CPR
B. CPR should a lwa ys be ca rrie d out for 2 minute s prior to
de fibrilla tion
C. Two minute s of che st compre ssions a lone (no ve ntila tion)
should be ca rrie d out prior to first shock
D. If a rre st le ss tha n 1 minute (witne sse d), de live r one bipha sic
shock the n five cycle s of CPR
968. W hich of the following me dica tions blocks a ngiote nsin a t the
re ce ptor?
A. Losa rta n (Coza a r)
B. Te ra zosin (Hytrin)
C. Lisinopril (Prinivil, Ze stril)
D. Spironola ctone (Alda ctone )
969. Untowa rd e ffe cts a ssocia te d with a dministra tion of sodium
bica rbona te during ma ssive blood tra nsfusion include e a ch of the
following EXCEPT
A. Hype rka le mia
B. Pa ra doxica l ce re brospina l fluid a cidosis
C. Hype rca rbia
D. Hype rna tre mia
970. Use ful the ra py for hype rcya notic “te t spe lls” in pa tie nts with
te tra logy of Fa llot might include a ny of the following EXCEPT
A. Esmolol
B. Morphine
C. Phe nyle phrine
D. Isoprote re nol
971. Silde na fil (Via gra ) be longs to the sa me cla ss of drugs a s which
of the following?
A. Yohimbine
B. Hydra la zine
C. Ena la pril
D. Milrinone
972. W ha t is the minima l time a fte r a ngiopla sty a nd pla ce me nt of a
drug-e luting ste nt tha t dua l a ntipla te le t the ra py should be continue d
be fore conside ring stopping it for e le ctive surge ry?
A. 3 months
B. 6 months
C. 1 ye a r
D. 18 months
973. Biva lirudin is use d a s a n a nticoa gula nt for ca rdiopulmona ry
bypa ss prima rily in pa tie nts with
A. He pa rin re sista nce
B. Prota mine a lle rgy
C. HIT type I
D. HIT type II
974. W hich of the following a na tomic site s is a ssocia te d with the
LEAST incide nce of ce ntra l line infe ction?
A. Inte rna l jugula r ve in
B. Exte rna l jugula r ve in
C. Subcla via n ve in
D. Fe mora l ve in
975. The e ffe cts of clopidogre l (Pla vix) ca n be re ve rse d with
A. Fre sh froze n pla sma
B. Fa ctor VIII conce ntra te
C. Aprotinin
976. A disa dva nta ge of port a cce ss corona ry a rte ry bypa ss surge ry
utilizing the da Vinci robot ve rsus “sta nda rd” corona ry a rte ry
re va scula riza tion with ca rdiopulmona ry bypa ss is
A. Ne e d for hypothe rmic ca rdia c a rre st
B. Gre a te r incide nce of intra ope ra tive hypoxia
C. Gre a te r incide nce of tra uma to ste rnum
D. Incre a se d tra nsfusion re quire me nts
977. A right-side d double -lume n tube will be use d to se pa ra te
ve ntila tion of the right a nd le ft lungs for a le ft pne umone ctomy. The
pla n for pla ce me nt is to inse rt the dista l tube into the tra che a with
a la ryngoscope a nd the n to a dva nce the dista l tube into the right
ma inste m bronchus unde r bronchoscopic guida nce . Afte r inse rtion
of the tube with the la ryngoscope , CO2 is se e n on infra re d
spe ctrome te r a nd the scope is pa sse d through bronchia l port until it
e xits the tube inside the lume n of the pa tie nt’s a irwa y. A structure is
se e n tha t a ppe a rs to be the ca rina . The scope is the n pa sse d into
the right bra nch, a nd the structure in the picture be low is
visua lize d. The scope is loca te d in the
A. Right ma inste m bronchus
B. Le ft ma inste m bronchus
C. Lingula r se gme nt
D. Right uppe r lobe
978. W hich of the following ma ne uve rs (a fte r a ssuring prope r tube
pla ce me nt) is LEAST like ly to ra ise the Pa O2 during one -lung
ve ntila tion with a double -lume n e ndotra che a l tube ?
A. Continuous positive a irwa y pre ssure (CPAP) to the
nonde pe nde nt lung
B. PEEP to the de pe nde nt lung
C. Continuous infusion of e poproste nol (Flola n) via ce ntra l line
D. Ra ising me a n a rte ria l pre ssure from 60 to 85 mm Hg
979. W hich of the following drugs or inte rve ntions will ca use the
LEAST incre a se in he a rt ra te in the tra nspla nte d de ne rva te d he a rt?
A. Gluca gon
B. Atropine
C. Isoprote re nol
D. Nore pine phrine
980. A pa tie nt with known Wolff-Pa rkinson-W hite (W PW ) syndrome
de ve lops a wide comple x ta chyca rdia during a he rnia ope ra tion
unde r ge ne ra l a ne sthe sia . Vita l signs a re sta ble a nd pha rma cologic
tre a tme nt is de sire d. W hich of the following drugs is MOST like ly
to be succe ssful in controlling he a rt ra te in this pa tie nt?
A. Ve ra pa mil
B. Esmolol
C. Ade nosine
D. Proca ina mide
981. A 63-ye a r-old pa tie nt with a DDD-R pa ce ma ke r is sche dule d
for right he micole ctomy. The indica tion for pa ce ma ke r impla nta tion
wa s sick sinus syndrome , a nd the pa ce ma ke r ha s be e n
re progra mme d to the a synchronous (DOO) mode a t a ra te of 70 for
surge ry. Afte r induction, the pa tie nt’s na tive he a rt ra te rise s to
85 be a ts/min with blood pre ssure 130/90 mm Hg. W hich of the
following a ctions would be MOST a ppropria te ?
A. Turn off pa ce ma ke r for dura tion of ca se
B. Administe r lidoca ine
C. Administe r e smolol
D. Obse rve
982. The ma in a dva nta ge of milrinone is tha t it la cks which side
e ffe ct, compa re d with a mrinone , for long-te rm use ?
A. Ta chyca rdia
B. Hypothyroidism
C. Thrombocytope nia
D. Hype rglyce mia
983. Syste mic infla mma tory re sponse syndrome (SIRS) diffe rs from
se psis in tha t pa tie nts with SIRS ha ve
A. A norma l te mpe ra ture
B. A he a rt ra te le ss tha n 90 be a ts/min
C. A norma l white blood ce ll count
D. No docume nte d infe ction
984. Arra nge the pe rcuta ne ous inse rtion site s from ne a re st to
fa rthe st for pla ce me nt of a PA ca the te r.
A. Le ft inte rna l jugula r, right inte rna l jugula r, a nte cubita l, fe mora l
B. Right inte rna l jugula r, le ft inte rna l jugula r, a nte cubita l, fe mora l
C. Right inte rna l jugula r, le ft inte rna l jugula r, fe mora l, a nte cubita l
D. Le ft inte rna l jugula r, right inte rna l jugula r, fe mora l, a nte cubita l
985. A pulmona ry a rte ry ca the te r ca pa ble of continuously
monitoring is pla ce d in a pa tie nt for corona ry a rte ry bypa ss
surge ry. Just be fore instituting ca rdiopulmona ry bypa ss, the
fa lls from 85% to 71%. W hich of the following could a ccount for this
cha nge in ?
A. Cooling the pa tie nt to 27° C
B. Tra nsfusion of two units pa cke d re d blood ce lls
C. Epine phrine , 25 µg IV
D. Myoca rdia l ische mia
986. W hich of the following te rms re fe rs to myoca rdia l re la xa tion or
dia stole ?
A. Inotropy
B. Chronotropy
C. Dromotropy
D. Lusitropy
987. A 31-ye a r-old fe ma le with prima ry pulmona ry hype rte nsion is
sche dule d for a ma ste ctomy. Pha rma cologic a ge nts tha t might be
use ful in re ducing pulmona ry va scula r re sista nce include e a ch of
A. Prosta gla ndin I2 (e poproste nol)
B. Oxyge n
C. Nitrous oxide
D. Milrinone
988. Pulmona ry va scula r re sista nce a s a function of lung volume is
the LEAST a t which volume ?
A. Tota l lung volume
B. Re sidua l volume
C. Functiona l re sidua l ca pa city (FRC)
D. Expira tory re se rve volume
989. A 45-ye a r-old pa tie nt with hype rtrophic ca rdiomyopa thy is
a ne sthe tize d for skin gra fting a fte r suffe ring third-de gre e burns on
his le gs. As skin is ha rve ste d from his ba ck, his he a rt ra te rise s a nd
his systolic blood pre ssure fa lls to 85 mm Hg. W hich of the
following inte rve ntions is LEAST like ly to improve this pa tie nt’s
he modyna mics?
A. Administra tion of e smolol
B. Fluid bolus
C. Dobuta mine infusion
D. Administra tion of sufe nta nil
990. A 59-ye a r-old pa tie nt is sche dule d for right kne e re pla ce me nt.
The pa tie nt ha s a long history of conge stive he a rt fa ilure (CHF) with
87% oxyge n sa tura tion while bre a thing room a ir in the holding a re a .
Ra le s a re a udible throughout both lung fie lds with the pa tie nt
upright. The MOST a ppropria te pla n would be
A. Arte ria l line a nd spina l with isoba ric bupiva ca ine
B. Arte ria l line , e tomida te induction, se voflura ne , intra ope ra tive
TEE
C. Arte ria l line , ce ntra l ve nous pre ssure line (CVP), ke ta mine
induction, N2O na rcotic a ne sthe tic, furose mide , milrinone
D. Ca nce l the ca se
991. W hich of the following drugs is LEAST like ly to ca use
unfa vora ble he modyna mic cha nge s in pa tie nts with se ve re mitra l
ste nosis?
A. Ke ta mine
B. Re mife nta nil
C. Pa ncuronium
D. De sflura ne
992. You ma de a n infusion of dopa mine by mixing 200 mg of
dopa mine in 250 mL of sodium chloride (NS) or 5% de xtrose
inje ction (D5W ). W ha t is the infusion pump ra te whe n infusing
dopa mine a t a ra te of 5 µg/kg/min for this 70-kg pa tie nt?
A. 10 mL/hr
B. 16 mL/hr
C. 20 mL/hr
D. 26 mL/hr
993. A79-ye a r-old pa tie nt re turns to the ope ra ting room with ca rdia c
ta mpona de a fte r thre e -ve sse l corona ry a rte ry gra fting. In a ddition to
ge ntle positive -pre ssure ve ntila tion, which of the following
pe rmuta tion in he modyna mics would be MOST be ne ficia l in this
sce na rio?
A. Incre a se d pre loa d, slow he a rt ra te , incre a se d a fte rloa d
B. Norma l pre loa d, slow he a rt ra te , de cre a se d a fte rloa d
C. Norma l pre loa d, fa st he a rt ra te , de cre a se d a fte rloa d
D. Incre a se d pre loa d, fa st he a rt ra te , incre a se d a fte rloa d
994. W hich of the following tre a tme nts would be the LEAST use ful
in tre a tme nt of the rhythm shown be low?
A. Proca ina mide

B. Ma gne sium
C. Ove rdrive pa cing
D. Unsynchronize d ca rdiove rsion

by le tte re d he a dings. For e a ch numbe re d sta te me nt, se le ct the
ONE le tte re d he a ding tha t is most close ly a ssocia te d with it.
Ea ch le tte re d he a ding ma y be se le cte d once , more tha n once ,
or not a t a ll.
995. P wa ve fla tte ning, wide ning of the QRS comple x, pe a ke d T

wa ve
996. De pre sse d ST se gme nts, fla t T wa ve , U wa ve pre se nt
997. Norma l or incre a se d PR inte rva l, short QT inte rva l
A. Hypoka le mia
B. Hype rka le mia
C. Hypona tre mia
D. Hype rca lce mia

by le tte re d he a dings. For e a ch numbe re d sta te me nt, se le ct the
ONE le tte re d he a ding tha t is most close ly a ssocia te d with it.
Ea ch le tte re d he a ding ma y be se le cte d once , more tha n once ,
or not a t a ll.
How long doe s the a ntipla te le t e ffe ct of e a ch of the following

me dica tions la st?
998. Clopidogre l
999. Ticlopidine
1000. ASA
1001. Ibuprofe n
A. 3 da ys
B. 7 da ys
C. 21 da ys
D. Life of pla te le t
Cardiovascular Physiology and
Anesthesia
915. (D) In 2007, the Ame rica n He a rt Associa tion re vise d the
guide line s for pre ve ntion of infe ctive e ndoca rditis (IE). Pre se ntly,
only pa tie nts with unde rlying ca rdia c conditions with the highe st
risk for a n a dve rse outcome from IE should re ce ive a ntibiotic
prophyla xis for se le cte d de nta l proce dure s. Prophyla xis is not
re comme nde d for pa tie nts unde rgoing e le ctive ge nitourina ry (GU)
or ga strointe stina l (GI) proce dure s. The ca rdia c conditions with the
highe st risk include : prosthe tic ca rdia c va lve s, pre vious IE, se ve ra l
type s of conge nita l he a rt dise a se (CHD), a nd ca rdia c
tra nspla nta tion re cipie nts who de ve lop ca rdia c va lvulopa thy. Any of
the a ntibiotics liste d in the que stion, ce pha le xin 2 g ora lly (or othe r
first- or se cond-ge ne ra tion ora l ce pha losporin in e quiva le nt
dosa ge ), or clinda mycin 600 mg ora lly, IM, or IV should be
a dministe re d 30 to 60 minute s be fore the proce dure . This pa tie nt
ha s a ortic ste nosis a nd doe s not ne e d a ny prophyla xis (Wilson et al:
Prevention of infective end ocard itis—Guid elines from th e Am erican Heart
Association, Circulation 115:1736–1754, 2007. h ttp://circ.ah ajournals.org).
916. (A) Type II HIT is a se rious, life -thre a te ning condition. The
clinica l dia gnosis is ma de by de monstra ting a de cre a se in pla te le t
count to 100,000/mm3 or ha lf the pre ope ra tive va lue 5 to 10 da ys
a fte r a dministra tion of he pa rin. Pa tie nts with HIT a re prone to
pa ra doxica l thrombosis a nd must be close ly monitore d.
Se rologica lly, pa tie nts de monstra te a ntibodie s to the pla te le t fa ctor
4 (PF4)/he pa rin a ntige n.
If surge ry involving ca rdiopulmona ry bypa ss is conte mpla te d,
wa iting until a ntibody tite rs be come unde te cta ble is the be st
choice . For e me rge ncy ope ra tions, va rious stra te gie s for
a nticoa gula tion e xist tha t include dire ct thrombin inhibitors,
biva lirudin, a nd le pirudin. Othe r options a re use of da na pa roid
(fa ctor Xa inhibitor) or use of unfra ctiona te d he pa rin plus a drug
to pre ve nt thrombosis such a s tirofiba n (glycoprote in IIb/IIIa
inhibitor), or e poproste nol (prosta cyclin [PGI2]). Fonda pa rinux is
not use d for ca rdiopulmona ry bypa ss a nticoa gula tion. The re is
a lso the option of pe rforming pla sma phore sis to re move
a ntipla te le t a ntibodie s if time a llows (Miller: Miller’s Anesth esia, ed
8, pp 2017–2022; Miller: Basics of Anesth esia, ed 5, pp 358–359).
917. (A) All of the choice s liste d in this que stion occur during
myoca rdia l ische mia . Howe ve r, of the choice s liste d, pre se nce of
le ft ve ntricula r wa ll-motion a bnorma litie s is the most se nsitive
indica tor (Barash : Clinical Anesth esia, ed 7, p 744).
918. (C) One MET is e qua l to the a mount of e ne rgy e xpe nde d during
1 minute a t re st, which is roughly 3.5 mL of oxyge n pe r kilogra m of
body we ight pe r minute (3.5 mL/kg/min). For a 70-kg (150 lb) pe rson,
one MET would e qua l 250 mL O2 pe r minute . So 2500 mL would
corre spond to 10 METs (Barash : Clinical Anesth esia, ed 7, p 591).
919. (A) The a ne sthe tic ma na ge me nt of pa tie nts with CHD re quire s
thorough knowle dge of the pa thophysiology of the de fe ct. In
ge ne ra l, conge nita l he a rt de fe cts ca n be ca te gorize d into those tha t
re sult in le ft-to-right intra ca rdia c shunting a nd into those tha t re sult
in right-to-le ft shunting. The ma in fe a ture in conge nita l he a rt
de fe cts tha t re sult in right-to-le ft intra ca rdia c shunting is a re duction
in pulmona ry blood flow a nd a rte ria l hypoxe mia . The more
common conge nita l he a rt de fe cts tha t re sult in right-to-le ft
intra ca rdia c shunting include te tra logy of Fa llot, Eise nme nge r
syndrome , Ebste in ma lforma tion of the tricuspid va lve , pulmona ry
a tre sia with a ve ntricula r se pta l de fe ct, tricuspid a tre sia , a nd
pa te nt fora me n ova le . Me ticulous ca re must be ta ke n to a void
infusion of a ir via intra ve nous solutions, be ca use this ca n le a d to
a rte ria l a ir e mbolism. Pa tie nts with conge nita l ca rdia c de fe cts tha t
re sult in le ft-to-right intra ca rdia c shunting, such a s pa te nt ductus
a rte riosus, a re a t minima l risk for a rte ria l a ir e mbolism, be ca use
blood flow through the shunt is prima rily from the syste mic
va scula r syste m to the pulmona ry va scula r syste m (Barash : Clinical
920. (A) The Fra nk-Sta rling curve re la te s le ft ve ntricula r filling
pre ssure to le ft ve ntricula r work. Le ft ve ntricula r e nd-dia stolic
volume , le ft ve ntricula r e nd-dia stolic pre ssure , le ft a tria l pre ssure ,
PA occlusion pre ssure , a nd, in some insta nce s, ce ntra l ve nous
pre ssure ca n re fle ct le ft ve ntricula r filling pre ssure . Le ft ve ntricula r
work ca n be re pre se nte d on the y-a xis by le ft ve ntricula r stroke
work inde x, stroke volume , ca rdia c output, ca rdia c inde x, a nd
a rte ria l blood pre ssure (Miller: Miller’s Anesth esia, ed 8, pp 476–477).
921. (A) The rhythm strip in the que stion de picts a tria l flutte r. The
importa nce of e xa mining more tha n one le a d is e mpha size d in this
que stion. The lowe r tra cing looks like a junctiona l rhythm, but
upon e xa mina tion of the uppe r tra cing, discre te P wa ve s (a ctua lly F
wa ve s) corre sponding to a ra te of a bout 300/min a re e a sily
disce rne d. An a tria l ra te of 300 is common, ofte n with 2:1
conduction, yie lding a ve ntricula r ra te of 150/min. In the rhythm
pre se nte d he re , the ve ntricula r ra te is a round 75/min,
corre sponding to a 4:1 conduction (Miller: Miller’s Anesth esia, ed 8, p
1441).
922. (D) During ca rdiopulmona ry bypa ss, it is common for a PA
ca the te r to migra te dista lly 3 to 5 cm into the PA. In fa ct, PA ca the te r
migra tion during ca rdiopulmona ry bypa ss is so common tha t
withdra wing the ca the te r 3 to 5 cm be fore the initia tion of
ca rdiopulmona ry bypa ss ma y be routine ly indica te d. Dista l ca the te r
migra tion into a we dge position is ofte n de te cte d by noting a n
incre a se in the me a sure d PA pre ssure . PA ca the te r migra tion during
ca rdiopulmona ry bypa ss ha s be e n implica te d in ca se s of PA
rupture . Although ca the te r migra tion is the most like ly e xpla na tion
for a rise in PA pre ssure during ca rdiopulmona ry bypa ss, the
a ne sthe siologist must a lso conside r ina de qua te ve ntricula r ve nting
a s a pote ntia l ca use of incre a sing PA pre ssure s during
ca rdiopulmona ry bypa ss, pa rticula rly if the PA pre ssure doe s not
de cline a fte r withdra wa l of the PA ca the te r from a pre sume d
we dge position. Ve ntricula r diste ntion during ca rdiopulmona ry
bypa ss is de trime nta l be ca use it ca n incre a se myoca rdia l oxyge n
de ma nd a t a time whe n the re is no corona ry blood flow.
Ma lposition of the a ortic ca nnula ma y re sult in unila te ra l fa cia l
bla nching. Ma lposition of the ve nous ca nnula ma y re sult in fa cia l or
scle ra l e de ma or ma y ma nife st a s poor blood re turn to the
ca rdiopulmona ry bypa ss circuit (Barash : Clinical Anesth esia, ed 7, p
1095).
923. (C) Anticholine ste ra se drugs ma y ha ve significa nt choline rgic
side e ffe cts, including sinoa tria l a nd a triove ntricula r node slowing,
bronchoconstriction, a nd pe rista lsis. The re is a high incide nce of
tra nsie nt ca rdia c dysrhythmia s a fte r a dministra tion of the se drugs.
The ca rdia c e ffe cts va ry from clinica lly unimporta nt a tria l a nd
junctiona l bra dydysrhythmia s, e ctopic ve ntricula r foci, to clinica lly
importa nt dysrhythmia s such a s high-gra de he a rt block, including
comple te he a rt block a nd ca rdia c a rre st. The rhythm strip in this
que stion is tha t of a low-gra de he a rt block with a junctiona l
rhythm. The most a ppropria te tre a tme nt of this rhythm is
a dministra tion of a tropine (Butterworth : Morgan & Mikh ail’s Clinical
924. (D) Incorre ct positioning of the a ortic pe rfusion a nd ve nous
re turn ca nnula e a re possible complica tions a ssocia te d with
ca rdiopulmona ry bypa ss. Imprope r positioning of the a ortic ca nnula
would te nd to re sult in unila te ra l fa cia l bla nching, whe re a s fa cia l
e de ma (e .g., bulging scle ra e ) re fle cts ve nous conge stion a nd ma y
be ca use d by imprope r positioning of the ve nous re turn ca nnula .
Incorre ct positioning of the ve nous re turn ca nnula ca n occur whe n
the ca nnula is inse rte d too fa r into the supe rior ve na ca va , which
ca use s obstruction of the right innomina te ve in. If the ve nous
ca nnula is inse rte d too fa r into the infe rior ve na ca va , ve nous
re turn from the lowe r re gions of the body ca n be impa ire d a nd
a bdomina l diste ntion ca n occur. If this ha ppe ns, the ve na ca va l
ca nnula should be withdra wn to a more proxima l position, a nd the
a de qua cy of the ve nous re turn from the pa tie nt to the
ca rdiopulmona ry bypa ss ma chine should be confirme d. A prope rly
positione d ve nous re turn ca nnula will ble e d ba ck with nonpulsa tile
flow whe n the proxima l e nd is lowe re d be low the pa tie nt (Miller:
925. (B) Tra nsposition of the gre a t ve sse ls is a conge nita l ca rdia c
de fe ct tha t re sults from fa ilure of the truncus a rte riosus to rota te
during orga noge ne sis such tha t the a orta a rise s from the right
ve ntricle a nd the PA a rise s from the le ft ve ntricle . As a re sult, the
le ft a nd right ve ntricle s a re not conne cte d in se rie s a nd the
pulmona ry a nd syste mic circula tions function inde pe nde ntly. This
re sults in profound a rte ria l hypoxe mia ; surviva l is not possible
unle ss the re is a concomita nt de fe ct tha t a llows for inte rmixing of
blood be twe e n the two circula tions. Induction of a ne sthe sia with
vola tile a ne sthe tics will be de la ye d be ca use minima l portions of
inha le d drugs will re a ch the syste mic circula tion. In contra st,
a ne sthe tic drugs tha t a re a dministe re d intra ve nously will be
distribute d with minima l dilution to the bra in; the re fore , dose s a nd
ra te s of inje ction should be re duce d in the se pa tie nts (Butterworth :
926. (D) The Fonta n proce dure (usua lly modifie d Fonta n) is a n
a na stomosis of the right a tria l a ppe nda ge to the PA. This proce dure
is most fre que ntly pe rforme d to tre a t conge nita l ca rdia c de fe cts,
which de cre a se PA blood flow (e .g., pulmona ry a tre sia a nd
ste nosis, a nd tricuspid a tre sia ). The Fonta n proce dure is a lso use d
to incre a se pulmona ry blood flow whe n it is ne ce ssa ry to surgica lly
conve rt the right ve ntricle to a syste mic ve ntricle (e .g., hypopla stic
le ft he a rt syndrome ). Truncus a rte riosus occurs whe n a single
a rte ria l trunk, which ove rride s both ve ntricle s (which a re
conne cte d via a ve ntricula r se pta l de fe ct), give s rise to both the
a orta a nd PA. Surgica l tre a tme nt of this de fe ct include s ba nding of
the right a nd le ft pulmona ry a rte rie s a nd e nclosure of the
a ssocia te d ve ntricula r se pta l de fe ct (Miller: Miller’s Anesth esia, ed 8,
p 2809).
927. (C) For e a ch de gre e Ce lsius body te mpe ra ture is lowe re d,
tissue me ta bolic ra te de cline s a pproxima te ly 5% to 8%. A core
te mpe ra ture of 28° to 30° C would corre spond roughly to a 50%
re duction in me ta bolic ra te (Barash : Clinical Anesth esia, ed 7, pp 1092–
1093).
928. (B) By de fla ting just be fore ve ntricula r systole , a n intra -a ortic
ba lloon pump (IABP) is de signe d to re duce a ortic pre ssure a nd
a fte rloa d, the re by e nha ncing le ft ve ntricula r e je ction a nd re ducing
wa ll te nsion a nd oxyge n consumption. By infla ting in dia stole , just
a fte r closure of the a ortic va lve , dia stolic a ortic pre ssure a nd
corona ry blood flow a re incre a se d. Thus, prope r timing of infla tion
a nd de fla tion is crucia l to corre ct functioning of a n IABP. The P
wa ve on the ECG is a la te dia stolic e ve nt, a nd infla ting the IABP
just a fte r the P wa ve would minimize a ugme nta tion of dia stolic
corona ry blood flow. In a ddition, infla tion of the de vice tha t la te in
dia stole would risk ha ving the ba lloon infla te d during ve ntricula r
systole , which would dra ma tica lly incre a se ve ntricula r a fte rloa d
a nd worse n the myoca rdia l oxyge n supply a nd de ma nd ba la nce .
Simila rly, the midpoint of the QRS comple x re pre se nts the e le ctrica l
a ctiva tion of the ve ntricle s, which he ra lds the e nd of ve ntricula r
dia stole , a time whe n the ba lloon should be de fla ting be fore
ve ntricula r e je ction (Barash : Clinical Anesth esia, ed 7, pp 1102–1103).
929. (C) Afte rloa d re duction during a ne sthe sia is be ne ficia l in a ll of
the conditions liste d in this que stion e xce pt te tra logy of Fa llot. In
te tra logy of Fa llot, blood is shunte d through a ve ntricula r se pta l
de fe ct from the pulmona ry circula tion to the syste mic circula tion
be ca use of right ve ntricula r outflow obstruction. A de cre a se in
syste mic va scula r re sista nce would a ugme nt this right-to-le ft shunt
through the ve ntricula r se pta l de fe ct, which would re duce
pulmona ry va scula r blood flow a nd e xa ce rba te syste mic
hypoxe mia (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, pp 426–427).
930. (A) Prota mine is a ba sic compound isola te d from the spe rm of
ce rta in fish spe cie s a nd is a spe cific a nta gonist of he pa rin. The
dose of prota mine is 1.3 mg for e a ch 100 units of he pa rin. If
prota mine is a dministe re d to a pa tie nt who ha s not re ce ive d
he pa rin, it ca n bind to pla te le ts a nd soluble coa gula tion fa ctors,
producing a n a nticoa gula nt e ffe ct. The re is no e vide nce tha t
prota mine ha s ne ga tive inotropic or chronotropic prope rtie s. Some
pe rsons (e .g., dia be tics ta king NPH insulin) ma y be a lle rgic to
prota mine . Hypote nsion ma y occur whe n prota mine is
a dministe re d ra pidly be ca use it induce s hista mine re le a se from
ma st ce lls (Kaplan: Kaplan’s Card iac Anesth esia, ed 6, p 963).
931. (D) The prima ry goa l in the a ne sthe tic ma na ge me nt of pa tie nts
with corona ry a rte ry dise a se is to ma inta in the ba la nce be twe e n
myoca rdia l O2 supply a nd de ma nd. Myoca rdia l O2 consumption
(i.e ., myoca rdia l O2 de ma nd) is de te rmine d by thre e fa ctors:
myoca rdia l wa ll te nsion, he a rt ra te , a nd myoca rdia l contra ctile
sta te . Myoca rdia l wa ll te nsion is dire ctly re la te d to the e nd-
dia stolic ve ntricula r pre ssure or volume (pre loa d) a nd syste mic
va scula r re sista nce (a fte rloa d). In ge ne ra l, myoca rdia l work in the
form of incre a se d he a rt ra te re sults in the gre a te st incre a se in
myoca rdia l O2 consumption. Also, for a give n incre a se in
myoca rdia l work, the incre a se in myoca rdia l O2 consumption is
much le ss with volume work (pre loa d) tha n with pre ssure work
(a fte rloa d) (Stoelting: Ph arm acology and Ph y siology in Anesth etic
932. (D) Pulsus pa ra doxus de scribe s a n inspira tory fa ll in systolic
a rte ria l blood pre ssure of gre a te r tha n 10 mm Hg ofte n se e n in
ca rdia c ta mpona de . This inspira tory de cline in systolic blood
pre ssure re pre se nts a n e xa gge ra tion of the norma l sma ll drop in
blood pre ssure se e n with inspira tion in sponta ne ously bre a thing
pa tie nts. In ca rdia c ta mpona de , ve ntricula r filling is limite d by the
pre se nce of blood, thrombus, or othe r ma te ria l in the pe rica rdia l
spa ce . During inspira tion in the sponta ne ously bre a thing pa tie nt,
ne ga tive intra thora cic pre ssure e nha nce s filling of the right
ve ntricle . Be ca use tota l ca rdia c volume is limite d by the
pre ssurize d pe rica rdium in ta mpona de ca se s, a s the right ve ntricle
fills with inspira tion, le ft ve ntricula r pre loa d a nd blood pre ssure
de cline . Pulsus pa ra doxus is occa siona lly se e n in ca se s of se ve re
a irwa y obstruction a nd right ve ntricula r infa rction. Pulsus pa rvus
a nd pulsus ta rdus de scribe , re spe ctive ly, the diminishe d pulse
wa ve a nd de la ye d upstroke in pa tie nts with a ortic ste nosis. Pulsus
a lte rna ns de scribe s a lte rna ting sma lle r a nd la rge r pulse wa ve s, a
condition some time s se e n in pa tie nts with se ve re le ft ve ntricula r
dysfunction. A bisfe rie ns pulse is a pulse wa ve form with two
systolic pe a ks se e n in ca se s of significa nt a ortic va lvula r
re gurgita tion (Miller: Miller’s Anesth esia, ed 8, pp 2073–2074).
933. (B) The word ALONE is a n a cronym for five drugs tha t ca n be
a dministe re d down the e ndotra che a l tube : Atropine , Lidoca ine ,
Oxyge n, Na loxone , Epine phrine . In a ddition, va sopre ssin ma y be
a dministe re d down the e ndotra che a l tube . Although pre ope ra tive ly
cle a r a nta cids (e .g., Bicitra ) ha ve be e n a dministe re d ora lly to ra ise
ga stric pH in pa tie nts a t high risk for a spira tion with induction of
ge ne ra l a ne sthe sia to de cre a se the se ve rity of a cid a spira tion,
should a spira tion occur, bica rbona te should not be instille d down
the e ndotra che a l tube be ca use it would worse n the a spira tion a nd
might produce a n a lka line burn to the lung (Barash : Clinical
934. (B) Me a n a rte ria l pre ssure ca n be ca lcula te d using the
following formula :
W he re MAP (mm Hg) is the me a n a rte ria l pre ssure , BP D (mm Hg) is
the dia stolic blood pre ssure , a nd BP S (mm Hg) is the systolic
blood pre ssure (Barash : Clinical Anesth esia, ed 7, p 708).
935. (A) Amioda rone is a be nzofura ne de riva tive with a che mica l
structure simila r to tha t of thyroxine , which a ccounts for its a bility
to ca use e ithe r hypothyroidism or hype rthyroidism. Alte re d thyroid
function occurs in 2% to 4% of pa tie nts whe n a mioda rone is
a dministe re d ove r a long pe riod. Amioda rone prolongs the dura tion
of the a ction pote ntia l of both a tria l a nd ve ntricula r muscle without
a lte ring the re sting me mbra ne pote ntia l. This a ccounts for its a bility
to de pre ss sinoa tria l a nd a triove ntricula r node function. Thus,
a mioda rone is e ffe ctive pha rma cologic the ra py for both re curre nt
supra ve ntricula r a nd ve ntricula r ta chydysrhythmia s. In pa tie nts
with W PW syndrome , a mioda rone incre a se s the re fra ctory pe riod
of the a cce ssory pa thwa y. Atropine -re sista nt bra dyca rdia a nd
hypote nsion ma y occur during ge ne ra l a ne sthe sia be ca use of the
significa nt a ntia dre ne rgic e ffe ct of a mioda rone . Should this occur,
isoprote re nol should be a dministe re d or a te mpora ry a rtificia l
ca rdia c pa ce ma ke r should be inse rte d (Miller: Miller’s Anesth esia, ed
8, p 1175).
936. (C) Syste mic va scula r re sista nce ca n be ca lcula te d using the
following formula :
whe re SVR is the syste mic va scula r re sista nce , MAP (mm Hg) is the
me a n a rte ria l pre ssure , CVP (mm Hg) is the ce ntra l ve nous
pre ssure , CO (L/min) is the ca rdia c output, a nd 80 is a fa ctor to
conve rt Wood units to dyne -se c/cm5. Ca lcula tion of SVR from the
da ta in this que stion is a s follows:
(Miller: Miller’s Anesth esia, ed 8, p 1387)

937. (A) Te tra logy of Fa llot is the most common conge nita l he a rt
de fe ct a ssocia te d with a right-to-le ft intra ca rdia c shunt. This
conge nita l de fe ct is cha ra cte rize d by a te tra d of conge nita l ca rdia c
a noma lie s, including a ve ntricula r se pta l de fe ct, a n a orta tha t
ove rride s the ve ntricula r se pta l de fe ct, obstruction of the PA
outflow tra ct, a nd right ve ntricula r hype rtrophy. The ve ntricula r
se pta l de fe ct is typica lly la rge a nd single , a n infundibula r PA
ste nosis is usua lly promine nt, a nd the dista l PA ma y be hypopla stic
or e ve n a bse nt. Although ma ny pa tie nts with te tra logy of Fa llot
ha ve a pa te nt ductus a rte riosus, this is not include d in the
de finition (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
56–57).
938. (A) The e tiology of hypote nsion ca n be pla ce d into two broa d
ca te gorie s: de cre a se d ca rdia c output a nd de cre a se d syste mic
va scula r re sista nce , or both. In this ca se , ca rdia c output is gre a te r
tha n norma l, a s one ofte n se e s in e a rly se psis. Tre a tme nt of this
hypote nsion should be ca rrie d out with pha rma cologic a ge nts with
strong α-a gonist prope rtie s. Of the choice s in this que stion,
phe nyle phrine is the only drug tha t is a pure α-a gonist. Dopa mine
in high dose s ha s strong a ctivity but significa nt β1 a ctivity a nd some
β2 a ctivity a s we ll. Nore pine phrine like wise posse sse s strong α
a ctivity with some β1 a ctivity. Va sopre ssin is a pote nt
va soconstrictor use ful in the ma na ge me nt of se ptic shock. Any of
the a fore me ntione d pha rma cologic a ge nts could be use d to support
pre ssure in pa tie nts with se psis in conjunction with de finitive
tre a tme nt for the se ptic source . Be ca use dobuta mine is
pre domina ntly a β1 a gonist, it would be a n e xtre me ly poor choice
for a pa tie nt with a high ca rdia c output in the fa ce of a low
syste mic va scula r re sista nce (Barash : Clinical Anesth esia, ed 7, p
1592).
939. (A) The rhythm de picte d is a tria l flutte r with 4:1 he a rt block.
The a tria l flutte r wa ve s (F wa ve s) a re occurring a t a pproxima te ly
300 pe r minute a nd the ve ntricula r ra te is a pproxima te ly 75 pe r
minute . The scre e n shows a rrows indica ting whe n the
synchronous shock would be give n. Ide a lly, the shock should occur
during ve ntricula r contra ction (de pola riza tion), tha t is, with QRS
comple x. This will e ffe ctive ly “re se t” the he a rt a nd a llow the
norma l P wa ve to be ma nife ste d. The curre nt displa y shows the
shock synchronize d with the flutte r wa ve s. Shocking on a flutte r
wa ve tha t is not occurring during ve ntricula r re pola riza tion would
not be a proble m, but a shock during re pola riza tion would be
ta nta mount to a n R on T phe nome non a nd might induce ve ntricula r
ta chyca rdia or e ve n ve ntricula r fibrilla tion. It would be fa r
pre fe ra ble to cha nge to a diffe re nt le a d in which the R wa ve is
synchronize d with the QRS a nd the n a pply the shock.
Most a tria l flutte r ca n be te rmina te d with a se tting a s low a s 50 J.
De live ring 200 J with the first a tte mpt to conve rt to NSR is
unwa rra nte d in most ca se s. De live ring a n a synchronous shock is
ill a dvise d since it too could induce a n unsta ble rhythm through
the R on T me cha nism (Miller: Miller’s Anesth esia, ed 8, p 1441;
940. (C) Pa tie nts with pe rica rdia l dise a se ma y de ve lop a n incre a se
in the a mount of fluid (norma lly 15-30 mL) in the pe rica rdia l sa c.
Norma lly the pre ssure in the pe rica rdia l sa c is 5 mm Hg le ss tha n
the CVP a nd a pproxima te s ple ura l pre ssure . W he n the fluid
pre ssure be come s e le va te d a nd impa irs ca rdia c filling, ca rdia c
ta mpona de is sa id to de ve lop. If the a mount of fluid incre a se s
a cute ly, a s little a s 100 mL ma y ca use ta mpona de . If the incre a se in
fluid de ve lops slowly, a n incre a se in volume of 2 L ma y de ve lop
be fore ta mpona de is produce d. The type of fluid doe s not a ffe ct
pre ssure . Infla mma tion ma y ca use a n incre a se in fluid, but it is the
pre ssure tha t ca use s the ta mpona de (Hines: Stoelting’s Anesth esia
and Co-Ex isting Disease, ed 6, pp 145–146; Miller: Miller’s Anesth esia, ed
8, pp 2073–2074).
941. (A) An unsta ble pa tie nt with a wide comple x ta chyca rdia is
pre sume d to be ve ntricula r ta chyca rdia (VT), a nd this rhythm
re pre se nts a me dica l e me rge ncy tha t re quire s imme dia te
synchronize d ca rdiove rsion (ECC Com m ittee: 2005 Am erican Heart
Association Guid elines for Card iopulm onary Resuscitation and
Em ergency Card iovascular Care, Circulation 112:IV69–IV73, 2005; Miller:
942. (C) Roma no-Wa rd syndrome is a ra re conge nita l a bnorma lity
cha ra cte rize d by prolonge d QT inte rva ls on the ECG. Je rve ll-La nge -
Nie lse n syndrome is a conge nita l syndrome cha ra cte rize d by
prolonge d QT inte rva ls on the ECG in a ssocia tion with conge nita l
de a fne ss. An imba la nce be twe e n the right a nd le ft side s of the
sympa the tic ne rvous syste m ma y pla y a role in the e tiology of the se
syndrome s. This imba la nce ca n be te mpora rily a bolishe d with a
le ft ste lla te ga nglion block, which shorte ns the QT inte rva ls. If this
is succe ssful, surgica l ga nglione ctomy ma y be pe rforme d a s
pe rma ne nt tre a tme nt (Hines: Stoelting’s Anesth esia and Co-Ex isting
943. (A) The use of me cha nica l circula tory support is be coming
more fre que nt be ca use of a dva nce s in te chnology a nd a re la tive
sca rcity of orga ns a va ila ble for tra nspla nt. Me cha nica l circula tory
support ca n be use d a s bridge the ra py for pa tie nts a wa iting ca rdia c
tra nspla nta tion or a s a bridge to re cove ry from a vira l
ca rdiomyopa thy or from ca rdioge nic shock a fte r myoca rdia l
infa rction. In othe r pa tie nts, it ca n be de stina tion the ra py. Curre ntly,
the He a rtMa te VE (ve nte d e le ctrica l) is the only me cha nica l de vice
a pprove d for de stina tion the ra py in the Unite d Sta te s. Va rious
ve rsions of the se de vice s ca n be use d to support the right (not
a pprove d for de stina tion the ra py), the le ft, or both ve ntricle s. Axia l
(continuous) flow is nonpulsa tile a nd nonphysiologic. The se pumps
a re conne cte d in pa ra lle l to the he a rt. Spe cifica lly, on the le ft side ,
blood is ta ke n from the a pe x of the he a rt a nd re turne d to
circula tion via the a orta . In this configura tion, little or no blood e xits
the a ortic va lve during systole . Me a suring blood pre ssure with a
cuff is not a ccura te in most pa tie nts a nd ma y be impossible . Pulse
oxime te rs do work with some pa tie nts, but this, too, re quire s
pulsa tile flow. Me a sure me nt of blood pre ssure with a n a rte ria l line
is e a sily done , just a s it is in pa tie nts on ca rdiopulmona ry bypa ss
unde rgoing ope n-he a rt ope ra tions (Miller: Miller’s Anesth esia, ed 8, pp
2066–2067).
944. (A) In a norma l he a rt, a pproxima te ly 15% to 20% of the ca rdia c
output is produce d by a tria l systole “a tria l kick.” In pa thologic
conditions, such a s a ortic ste nosis, the “a tria l kick” ma y contribute
more substa ntia lly to ca rdia c output (Kaplan: Kaplan’s Card iac
945. (A) The figure in this ca se shows a bisfe rie ns pulse , re cognize d
by its two systolic pe a ks. A bisfe rie ns pulse ca n be se e n in pa tie nts
with significa nt a ortic re gurgita tion. In a ortic re gurgita tion, the le ft
ve ntricle e je cts a la rge volume of blood in systole with a ra pid
dia stolic runoff a s blood flows both to the pe riphe ry a nd ba ck into
the le ft ve ntricle . The first systolic pe a k of the bisfe rie ns pulse
re pre se nts the wa ve of blood e je cte d from the le ft ve ntricle . The
se cond systolic pe a k re pre se nts a re fle cte d pre ssure wa ve from
the pe riphe ry. In contra st, pa tie nts with a ortic ste nosis displa y a
de la ye d pulse wa ve with a diminishe d upstroke (pulsus ta rdus a nd
pulsus pa rvus), whe re a s pa tie nts with ca rdia c ta mpona de show a n
e xa gge ra te d inspira tory de cline in systolic blood pre ssure (pulsus
pa ra doxus). Pa tie nts with hypovole mia ma y de monstra te systolic
blood pre ssure va ria tion, pa rticula rly during me cha nica l ve ntila tion
946. (D) In pa tie nts with te tra logy of Fa llot, it is importa nt to
ma inta in syste mic va scula r re sista nce to re duce the ma gnitude of
the right-to-le ft intra ca rdia c shunt. The re fore , induction of
a ne sthe sia in the se pa tie nts is be st a ccomplishe d with ke ta mine 3
to 4 mg/kg IM or 1 to 2 mg/kg IV. Re me mbe r tha t with right-to-le ft
shunts, IV me dica tions work more ra pidly. Induction of a ne sthe sia
with a vola tile a ne sthe tic such a s se voflura ne ma y be use d, but
ca re ful monitoring of syste mic oxyge na tion is ne e de d be ca use a ny
de cre a se in syste mic blood pre ssure would incre a se the right-to-
le ft shunt (a nd would de cre a se the oxyge n sa tura tion). Ke ta mine
will usua lly improve a rte ria l oxyge na tion, which re fle cts incre a se d
pulmona ry blood flow due to ke ta mine -induce d incre a se s in
syste mic va scula r re sista nce (Butterworth : Morgan & Mikh ail’s
947. (A) Mitra l ste nosis in a dults occurs a lmost e xclusive ly in
individua ls who ha d rhe uma tic fe ve r during childhood. Mitra l
ste nosis ca use s pa thophysiologic cha nge s both proxima l a nd dista l
to the a bnorma l va lve . In ge ne ra l, the le ft ve ntricle is “prote cte d” or
unloa de d; tha t is, it is not e xpose d to e xce ssive volume or pre ssure
loa ds a nd the re fore is ra re ly a ssocia te d with a bnorma litie s in le ft-
side d myoca rdia l contra ctility. In contra st, proxima l to the va lve , a
dia stolic pre ssure gra die nt de ve lops be twe e n the le ft a trium a nd
le ft ve ntricle in orde r to force blood a cross the ste notic va lve
orifice , which re sults in e le va te d le ft a tria l pre ssure s a nd
de cre a se d le ft a tria l complia nce a nd function. The e le va te d le ft
a tria l pre ssure s a re re fle cte d ba ck into the pulmona ry va scula r
syste m, ca using a n incre a se in pulmona ry va scula r re sista nce a nd
e ve ntua lly poor right ve ntricula r function. The le ft ve ntricula r
pre ssure -volume loop in pa tie nts with mitra l ste nosis de monstra te s
low-to-norma l le ft ve ntricula r e nd-dia stolic volume s a nd pre ssure s
a nd a corre sponding re duction in stroke volume (Miller: Miller’s
948. (A) Ische mia of the poste rior wa ll of the le ft ve ntricle a nd
poste rior le a fle t of the mitra l va lve ca n ca use prola pse of the
poste rior le a fle t a nd re trogra de blood flow into the le ft a trium
during systole . This ca n be ma nife ste d a s V (ve ntricula r) wa ve s on
the pulmona ry ca pilla ry we dge pre ssure tra cing e ve n be fore ST
se gme nt de pre ssion ca n be se e n on the ECG (Miller: Miller’s
949. (B) The pa tie nt de scribe d in this que stion ha s a wide comple x
ta chyca rdia of unde te rmine d origin. As this pa tie nt a ppe a rs to be
he modyna mica lly sta ble a nd ha s a n unce rta in rhythm, a mioda rone
150 mg IV ove r 10 minute s, re pe a te d a s ne e de d to a ma ximum dose
of 2.2 g IV ove r 24 hours is re comme nde d (Miller: Miller’s Anesth esia,
ed 8, pp 1391–1393).
950. (B) The da ily production of cortisol unde r norma l
circumsta nce s is a pproxima te ly 15 to 20 mg. Unde r ma ximum
stre ss, da ily cortisol production ca n incre a se to 75 to 150 mg/da y
yie lding a pla sma cortisol le ve l of 30 to 50 µg/dL (Hem m ings:
Ph arm acology and Ph y siology for Anesth esia, ed 1, p 548; Hines:
951. (A) The ge ne ric pa ce ma ke r code NASPE/BPEG (North
Ame rica n Socie ty of Pa cing a nd Ele ctrophysiology/British Pa cing
a nd Ele ctrophysiology Group) ha s five positions for pa ce ma ke r
de signa tion: I = pa ce d cha mbe r(s), II = se nse d cha mbe r(s),
III = re sponse (s) to se nsing, IV = progra mma bility, V = multisite
pa cing.
UTR is a pplica ble only to de vice s progra mme d to pa ce the
ve ntricle ba se d on de pola riza tion (tra cking) of the a trium, i.e ., a
trigge ring function. The purpose of UTR is to pre ve nt a ra pid
(pa ce d) ve ntricula r ra te in re sponse to a ra pid a tria l ra te such a s
pa roxysma l supra ve ntricula r ta chyca rdia (PSVT), a tria l
fibrilla tion, or a tria l flutte r. W he n the se nse d a tria l de pola riza tion
e xce e ds the UTR, the pa ce ma ke r (de pe nding on mode l) will
switch to the DDI mode (a tria l ta chy re sponse ). This would
e ffe ctive ly stop the ra pid supra ve ntricula r impulse s from driving
the ve ntricle s unle ss the se impulse s could cross the na tive AV
node .
W ith othe r mode ls, e xce e ding the UTR will re sult in the
pa ce ma ke r cre a ting a type II he a rt block. This would modula te
the numbe r of a tria l contra ctions tha t ultima te ly drive the
ve ntricle .
UTR is a pplica ble only to DDD a nd VDD pa ce ma ke rs. AAI doe s
not re quire UTR be ca use it (1) doe s not pa ce the ve ntricle a nd (2)
re sponds only with inhibition, not trigge ring (Miller: Miller’s
952. (D) The Fick e qua tion ca n be use d to ca lcula te ca rdia c output (
) if the pa tie nt’s O2 consumption ( ), a rte ria l O2 conte nt (Ca O2),
a nd mixe d ve nous O2 conte nt a re de te rmine d. The
downfa lls of this type of me a sure me nt a re thre e fold: (1)
sa mpling a nd a na lysis e rrors in , (2) cha nge s in Q while
sa mple s a re be ing ta ke n, a nd (3) a ccura te de te rmina tion of
ma y be difficult be ca use of cumbe rsome e quipme nt. The Fick
e qua tion is a s follows:
∗The fa ctor 10 conve rts O2 conte nt to mL O2/L of blood (inste a d of
mL O2/dL of blood) (Miller: Miller’s Anesth esia, ed 8, pp 478–479).
953. (C) Myoca rdia l pre se rva tion is a chie ve d during
ca rdiopulmona ry bypa ss prima rily by infusing cold (4° C)
ca rdiople gia solutions conta ining pota ssium chloride 20 mEq/L.
This ra pidly produce s hypothe rmia of the ca rdia c muscle a nd a
fla ccid myoca rdium. In the norma l contra cting muscle a t 37° C,
myoca rdia l O2 consumption is a pproxima te ly 8 to 10 mL/100 g/min.
This is re duce d in the fibrilla ting he a rt a t 22° C to a pproxima te ly
2 mL/100 g/min. Myoca rdia l O2 consumption of the
e le ctrome cha nica lly quie sce nt he a rt a t 22° C is le ss tha n
0.3 mL/100 g/min (Hem m ings: Ph arm acology and Ph y siology for
954. (D) All of the drugs liste d in this que stion e xce pt phe nyle phrine
will incre a se the inotropic sta te of the myoca rdium, which ca n
incre a se le ft ve ntricula r outflow obstruction a nd de cre a se ca rdia c
output. Phe nyle phrine , be ca use it is a pure α-a dre ne rgic re ce ptor
a gonist, ha s minima l dire ct e ffe cts on myoca rdia l contra ctility
955. (A) The cla ssic signs a nd symptoms of critica l a ortic ste nosis
(a ngina , syncope , a nd conge stive he a rt fa ilure ) a re re la te d
prima rily to a n incre a se in le ft ve ntricula r systolic pre ssure , which
is ne ce ssa ry to ma inta in forwa rd stroke volume . The se e le va te d
pre ssure s ca use conce ntric le ft ve ntricula r hype rtrophy. W ith
se ve re dise a se , the le ft ve ntricula r cha mbe r be come s dila te d a nd
myoca rdia l contra ctility diminishe s. The prima ry goa ls in the
a ne sthe tic ma na ge me nt of such pa tie nts unde rgoing nonca rdia c
surge ry a re to ma inta in norma l sinus rhythm a nd a void prolonge d
a lte ra tions in he a rt ra te (e spe cia lly ta chyca rdia ), syste mic va scula r
re sista nce , a nd intra va scula r fluid volume . Supra ve ntricula r
ta chyca rdia (e spe cia lly ne w-onse t a tria l fibrilla tion) should be
te rmina te d promptly by e le ctrica l ca rdiove rsion in this pa tie nt
be ca use of concomita nt hypote nsion a nd myoca rdia l ische mia
956. (C) PEEP is produce d by the a pplica tion of positive pre ssure to
the e xha la tion va lve of the me cha nica l ve ntila tor a t the conclusion
of the e xpira tory pha se . It is ofte n use d to incre a se a rte ria l
oxyge na tion whe n F IO2 e xce e ds 0.50 to re duce the ha za rd of O2
toxicity. PEEP incre a se s lung complia nce a nd FRC by e xpa nding
pre viously colla pse d but pe rfuse d a lve oli, thus improving
ve ntila tion/pe rfusion ma tching a nd re ducing the ma gnitude of the
right-to-le ft tra nspulmona ry shunt. The re a re , howe ve r, a numbe r of
pote ntia l ha za rds a ssocia te d with the use of PEEP. The se include
de cre a se d ca rdia c output, pulmona ry ba rotra uma (i.e ., te nsion
pne umothora x), incre a se d e xtra va scula r lung wa te r, a nd
re distribution of pulmona ry blood flow. Ba rotra uma , such a s
pne umothora x, pne umome dia stinum, a nd subcuta ne ous
e mphyse ma , occurs a s a re sult of ove rdiste ntion of a lve oli by PEEP.
Pulmona ry ba rotra uma should be suspe cte d whe n the re is a brupt
de te riora tion of a rte ria l oxyge na tion a nd ca rdiova scula r function
during me cha nica l ve ntila tion with PEEP. If ba rotra uma is
suspe cte d a che st x-ra y film should be obta ine d, a nd if a te nsion
pne umothora x is pre se nt a che st tube should be pla ce d in the
involve d che st ca vity (Butterworth : Morgan & Mikh ail’s Clinical
957. (C) Re sting corona ry a rte ry blood flow is a pproxima te ly 225 to
250 mL/min or a bout 75 mL/100 g/min, or a pproxima te ly 4% to 5% of
the ca rdia c output. Re sting myoca rdia l O2 consumption is 8 to
10 mL/100 g/min, or a pproxima te ly 10% of the tota l body
consumption of O2 (Barash : Clinical Anesth esia, ed 7, p 244).
958. (B) PA rupture is a disa strous but fortuna te ly ra re complica tion
a ssocia te d with the use of PA ca the te rs. The ha llma rk of PA rupture
is he moptysis, which ma y be minima l or copious. Efforts should be
ma de to se pa ra te the lungs. This ca n be a chie ve d by
e ndobronchia l intuba tion with a double -lume n e ndotra che a l tube .
The pre se nce of a the roma s in the PA is not a ssocia te d with a n
incre a se d risk of PA rupture . Athe roma tous cha nge s a re usua lly
minima l or a bse nt in the middle a nd dista l portions of the PA (i.e .,
in the se gme nts whe re the tip of the PA ca the te r typica lly re side s)
959. (B) Ana phyla ctic a nd a na phyla ctoid re a ctions to prota mine
occur in le ss tha n 5% of a ll a lle rgic re a ctions during a ne sthe sia ,
a nd whe n the y occur, usua lly do so within 5 to 10 minute s of
e xposure . The se re a ctions ca n occur in pa tie nts who ha ve be e n
e xpose d to prota mine (e .g., dia be tics ta king NPH or PZI insulin,
both of which conta in prota mine a s a prote in modifie r; re gula r
insulin doe s not conta in prota mine ). Since prota mine is de rive d
from sa lmon spe rm, pa tie nts with se a food a lle rgie s a s we ll a s me n
who ha ve ha d a va se ctomy (who ma y de ve lop circula ting
a ntibodie s to spe rma tozoa ) ma y a lso de ve lop a re a ction. The
like lihood of re a ctions ma y be re duce d with prior a dministra tion of
H1 blocke rs, H2 blocke rs, a nd corticoste roids. Prota mine should be
a voide d in pa tie nts who ha ve a history of pre vious a na phyla ctic
re a ctions to prota mine (Hines: Stoelting’s Anesth esia and Co-Ex isting
960. (B) Twe nty thousa nd units of he pa rin a re e qua l to 200 mg.
He pa rin is commonly ne utra lize d by a dministra tion of 1.3 mg of
prota mine for e a ch milligra m of he pa rin. Prota mine is a ba sic
prote in tha t combine s to the a cidic he pa rin mole cule to produce a n
ina ctive comple x tha t ha s no a nticoa gula nt prope rtie s. The ha lf-life
of he pa rin is 1.5 hours a t 37° C. At 25° C, me ta bolism of he pa rin is
minima l (Miller: Miller’s Anesth esia, ed 8, p 2017).
961. (A) Unlike most orga ns of the body whe re pe rfusion is
continuous, corona ry pe rfusion is some wha t inte rmitte nt. It is
de te rmine d by the diffe re nce be twe e n a ortic dia stolic pre ssure a nd
le ft a nd right ve ntricula r e nd-dia stolic pre ssure s. During systole , le ft
ve ntricula r pre ssure incre a se s to or a bove syste mic a rte ria l
pre ssure , re sulting in a lmost comple te occlusion of the
intra myoca rdia l portions of the corona ry a rte rie s. Thus, pe rfusion
of the le ft ve ntricula r myoca rdium occurs a lmost e ntire ly during
dia stole , re sulting in a de cre a se in le ft ve ntricula r corona ry
pe rfusion a s he a rt ra te incre a se s. In contra st, the right ve ntricle is
pe rfuse d during both systole a nd dia stole , be ca use right ve ntricula r
pre ssure s re ma in le ss tha n tha t of the a orta . An incre a se in he a rt
ra te re sults in a re la tive ly shorte r dia stolic pe riod (Butterworth :
962. (A) The thromboe la stogra ph is a viscoe la stome te r tha t
me a sure s the viscoe la stic prope rtie s of blood during clot forma tion.
The coa gula tion va ria ble s me a sure d from a thromboe la stogra m
a re (1) the R va lue (re a ction time ; norma l va lue 7.5-15 minute s) a nd
K va lue (norma l 3-6 minute s), which re fle cts clot forma tion time ; (2)
MA (ma ximum a mplitude ; norma l va lue 50-60 mm), which
re pre se nts ma ximum clot stre ngth; a nd (3) A60 (a mplitude 60
minute s a fte r the MA; norma l va lue MA—5 mm), which re pre se nts
the ra te of clot de struction (i.e ., fibrinolysis). The MA is de te rmine d
by fibrinoge n conce ntra tion, pla te le t count, a nd pla te le t function.
The thromboe la stogra m de picte d in the figure of this que stion is
consiste nt with fibrinolysis (Miller: Miller’s Anesth esiology, ed 8, p
1878).
963. (A) Ve ntricula r a ssist de vice s (VADs) a re impla nte d in pa tie nts
with e nd-sta ge he a rt fa ilure in whom me dica l ma na ge me nt ha s
fa ile d or is be ginning to fa il. VADs ca n be le ft side d only (LVAD),
right side d only (RVAD), or bive ntricula r (BiVAD). VADs ma y be
impla nte d until the pa tie nt re cove rs (bridge to re cove ry), until the
pa tie nt ca n re ce ive a he a rt tra nspla nt (bridge to tra nspla nta tion), or
a s the fina l me thod of tre a ting he a rt fa ilure (de stina tion the ra py).
Pa tie nts ca n survive for long pe riods of time with LVAD the ra py; the
curre nt re cord is just ove r 5 ye a rs. “De stina tion LVADs” ha ve be e n
impla nte d in pa tie nts ine ligible for he a rt tra nspla nt, whose sta tus
improve d to the e xte nt the y we re subse que ntly re cla ssifie d a nd
re ce ive d he a rt tra nspla nta tion.
LVADs a re in re la tive ly wide spre a d use , a nd pa tie nts a re
pre se nting to the ope ra ting room for othe r nonca rdia c-re la te d
ope ra tions. Tre a tme nt of hypote nsion ma y be a proble m a fte r
induction of a ne sthe sia . LVADs re quire a de qua te pre loa d to
function prope rly. The de cre a se in SVR a s we ll a s ve nodila tion
a ssocia te d with induction a nd ma inte na nce of ge ne ra l
a ne sthe sia ca n be tre a te d in se ve ra l wa ys. Phe nyle phrine a nd
e phe drine a re α1 a gonists a nd incre a se SVR. Ephe drine ma y a lso
incre a se inotropy a nd be be ne ficia l on tha t ba sis in the fa ce of
right ve ntricula r dysfunction. Fluids a nd Tre nde le nburg position
a re a lso like ly to he lp ra ise the me a n a rte ria l pre ssure . An LVAD
with ina de qua te pre loa d will not pe rform be tte r by incre a sing the
rpm. Such a n incre a se could simply ma ke the de vice “suck
down” a nd ma y a ctua lly worse n pe rforma nce . The suck-down
e ffe ct re sults in a comple te ly e mpty le ft ve ntricle with
myoca rdium be ing dra wn ove r the inflow ca nnula . This gre a tly
impa irs pre loa d to the LVAD a nd ca n re sult in he modyna mic
colla pse (Miller: Miller’s Anesth esia, ed 8, p 2067; Kaplan: Kaplan’s
Card iac Anesth esia, ed 6, pp 818–827).
964. (B) Ade nosine in dose s of 6 mg IV (re pe a te d if ne e de d 1-2
minute s la te r with 12 mg) ca n be ve ry e ffe ctive in the tre a tme nt of
supra ve ntricula r ta chyca rdia s, including those a ssocia te d with
W PW syndrome (unle ss a tria l fibrilla tion [AF] with a wide comple x
W PW occurs, whe re a de nosine ma y incre a se the he a rt ra te [HR]).
The drug is ra pidly me ta bolize d such tha t it is not influe nce d by
live r or re na l dysfunction. Its e ffe cts, howe ve r, ca n be ma rke dly
e nha nce d by drugs tha t inte rfe re with nucle otide me ta bolism such
a s dipyrida mole . Administra tion of the usua l dose of a de nosine to
a pa tie nt re ce iving dipyrida mole ma y re sult in a systole . If
a de nosine is use d in pa tie nts re ce iving dipyrida mole , or the pa tie nt
ha s a ce ntra l line , the initia l dose is 3 mg. Me thylxa nthine s, such a s
ca ffe ine , the ophylline , a nd a mrinone , a re compe titive a nta gonists
of this drug, a nd dose s ma y ne e d to be a djuste d a ccordingly (Miller:
965. (D) Te mpe ra ture of the the rma l compa rtme nt ca n be me a sure d
a ccura te ly in the PA, dista l e sopha gus, tympa nic me mbra ne , or
na sopha rynx. The se te mpe ra ture monitoring site s a re re lia ble ,
e ve n during ra pid the rma l pe rturba tions such a s ca rdiopulmona ry
bypa ss. Othe r te mpe ra ture site s, such a s ora l, a xilla ry, re cta l, a nd
urina ry bla dde r, will e stima te core te mpe ra ture re a sona bly
a ccura te ly e xce pt during e xtre me the rma l pe rturba tions. During
ca rdia c surge ry, the te mpe ra ture of the urina ry bla dde r is usua lly
e qua l to the PA whe n urine flow is high. Howe ve r, it ma y be
difficult to inte rpre t urina ry bla dde r te mpe ra ture be ca use it is
strongly influe nce d by urine flow. The a de qua cy of re wa rming a fte r
corona ry a rte ry bypa ss is thus be st e va lua te d by conside ring both
the core a nd urina ry bla dde r te mpe ra ture s (Stoelting: Ph arm acology
and Ph y siology in Anesth etic Practice, ed 4, p 694).
966. (B) The tra nsga stric mid-pa pilla ry short a xis vie w ima ge s the
myoca rdium supplie d by a ll thre e ma jor corona ry a rte rie s: le ft
a nte rior de sce nding (LAD), le ft circumfle x (CX), a nd right corona ry
(RCA) a rte rie s. Thus, this vie w is pre fe rre d for the purpose of
ische mia monitoring. The mid-e sopha ge a l four cha mbe r vie w
displa ys the a nte rola te ra l (LAD or CX) a nd infe rose pta l (LAD or
RCA) wa lls only, while the long a xis vie w displa ys the a nte rior
se pta l (LAD) a nd infe rola te ra l (CX or RCA) wa lls. Two cha mbe r
vie ws displa y the a nte rior (LAD) a nd infe rior (RCA) wa lls (Kah n
et al: Intraoperative ech ocard iograph y. In Kaplan: Essentials of Card iac
967. (D) The most fre que nt initia l rhythm in a witne sse d sudde n
ca rdia c a rre st (SCA) is ve ntricula r fibrilla tion (VF). De la ys in e ithe r
sta rting CPR or de fibrilla tion re duce surviva l from SCA. Curre nt
re comme nda tions for he a lth ca re provide rs in a ny fa cility with a n
a utoma te d e xte rna l de fibrilla tor (AED) re a dily a va ila ble is AED use
within mome nts of the ca rdia c a rre st. If a n AED is not re a dily
a va ila ble , the n CPR is sta rte d until the AED a rrive s a t the sce ne .
Re ca ll one cycle of CPR is 30 compre ssions a nd two bre a ths. It is
no longe r re comme nde d to de live r a thre e -shock se que nce with
bipha sic de fibrilla tors, be ca use it is unlike ly for the se cond or third
shock to work a fte r a fa ile d first shock, a nd the se cond a nd third
shocks ma y be ha rmful. Afte r the shock, continue CPR for five
cycle s, the n che ck for a pulse . If VF pe rsists, re pe a t one shock a nd
a dd e pine phrine or va sopre ssin be fore or a fte r a shock whe n a n IV
or intra osse ous (IO) line is a va ila ble . W ith monopha sic
de fibrilla tors, it ma y be a cce pta ble to de live r thre e -shock
se que nce s, but a ll a dult shocks should be 360 J. W ith out-of-
hospita l unwitne sse d ca rdia c a rre st by e me rge ncy me dica l se rvice
(EMS) pe rsonne l, five cycle s of CPR (a bout 2 minute s) should be
pe rforme d be fore che cking the ECG a nd a tte mpting de fibrilla tion,
e spe cia lly whe n the re sponse inte rva l is gre a te r tha n 4 minute s
be ca use shock e ffe ctive ne ss a ppe a rs more succe ssful a fte r CPR
(Part 1: Ex ecutive Sum m ary : 2010 International Consensus on
Card iopulm onary Resuscitation and Em ergency Card iovascular Care
Science with Treatm ent Recom m end ations, Circulation 122:S250–S275,
2010).
968. (A) The re nin-a ngiote nsin-a ldoste rone syste m is importa nt in
controlling blood pre ssure a nd blood volume . Re nin he lps to
conve rt a ngiote nsinoge n to a ngiote nsin I. Angiote nsin-conve rting
e nzyme (ACE) he lps to conve rt a ngiote nsin I to a ngiote nsin II.
Angiote nsin II ha s ma ny pha rma cologic a ctions including pote nt
va soconstriction a ction a s we ll a s stimula ting a ldoste rone re le a se
from the a dre na l gla nd. Losa rta n is a n a ngiote nsin re ce ptor blocke r
(ARB) a nd is commonly use d to tre a t hype rte nsion. Pa tie nts ta king
ARBs, a s we ll a s pa tie nts who a re on ACE inhibitors, a re more
prone to de ve lop hypote nsion during a ne sthe sia . In a ddition, the
hypote nsion tha t de ve lops ma y be more difficult to tre a t. Tha t is
why ARBs a re commonly discontinue d the da y be fore surge ry.
Te ra zosin is a n α1 blocke r, lisinopril is a n ACE inhibitor,
spironola ctone is a compe titive a nta gonist to a ldoste rone , a nd
a mlodipine is a ca lcium cha nne l blocke r. Note : The e ndings of
ma ny ge ne ric drug na me s indica te the drug cla ss (e .g., ARBs e nd in
-sartan, α1 blocke rs e nd in -osin, ACE inhibitors e nd in -pril, a nd
ca lcium cha nne l blocke rs e nd in -d ipine) (Miller: Miller’s Anesth esia,
ed 8, p 377).
969. (A) He modyna mica lly unsta ble ca rdia c dysrhythmia s ca n re sult
in hypope rfusion a nd me ta bolic a cidosis. If se ve re me ta bolic
a cidosis is confirme d on a rte ria l blood ga se s, intra ve nous sodium
bica rbona te should be a dministe re d. Adve rse e ffe cts a ssocia te d
with a dministra tion of sodium bica rbona te a re we ll docume nte d
a nd include se ve re pla sma hype rosmola lity, pa ra doxic
ce re brospina l fluid a cidosis, hype rna tre mia , a nd hype rca rbia ,
pa rticula rly in pa tie nts who a re not a de qua te ly ve ntila te d.
Bica rbona te lowe rs pota ssium by lowe ring the e xtra ce llula r
hydroge n ion conce ntra tion, which re sults in lowe ring, not ra ising,
the pota ssium conce ntra tion (Barash : Clinical Anesth esia, ed 7, p
1685).
970. (D) Hype rcya notic a tta cks prima rily occur in infa nts 2 to
3 months of a ge a nd a re fre que ntly a bse nt a fte r 2 to 3 ye a rs of a ge .
The se a tta cks usua lly occur without provoca tion but ca n be
a ssocia te d with e pisode s of e xcite me nt, such a s crying or e xe rcise .
The me cha nism for the se a tta cks is not known. It is be lie ve d,
howe ve r, tha t hype rcya notic a tta cks occur a s a re sult of spa sm of
the infundibula r ca rdia c muscle or a de cre a se in syste mic va scula r
re sista nce ; both will e xa ce rba te the right-to-le ft intra ca rdia c shunt.
Phe nyle phrine , a n α-a dre ne rgic re ce ptor a gonist, is the drug of
choice for tre a tme nt of hype rcya notic a tta cks, be ca use pre suma bly
phe nyle phrine incre a se s syste mic va scula r re sista nce , which
re duce s the intra ca rdia c right-to-le ft shunt a nd improve s a rte ria l
oxyge na tion. Esmolol is a lso e ffe ctive , pre suma bly be ca use it
re duce s spa sm of the infundibula r ca rdia c muscle . Isoprote re nol
with its β-mime tic e ffe cts re duce s a fte rloa d a nd the re fore incre a se s
right-to-le ft shunting a nd ma y e xa ce rba te infundibula r spa sm.
Be ca use hypovole mia ma y incre a se sympa the tic stimula tion,
a de qua te hydra tion with IV fluids ma y be he lpful (Yao: Yao and
Artusio’s Anesth esiology, ed 7, pp 910–912).
971. (D) Silde na fil (Via gra ) is use d for e re ctile dysfunction. Ere ction
of the pe nis involve s the loca l re le a se of nitric oxide (NO), which
incre a se s cyclic gua nine monophospha te (cGMP) in the corpus
ca ve rnosum. Silde na fil ha s no dire ct e ffe cts but inhibits
phosphodie ste ra se type 5 (PDE5), which bre a ks down cGMP. The
ne t e ffe ct is incre a sing cGMP. Yohimbine is a n α-a dre ne rgic
blocke r. Nitroglyce rin a nd hydra la zine a re both dire ct-a cting smooth
muscle re la xa nts. Ena la pril is a n ACE inhibitor. Milrinone is a n
inhibitor of phosphodie ste ra se type 3 (PDE3) (Hem m ings:
Ph arm acology and Ph y siology for Anesth esia, ed 1, p 413).
972. (C) Afte r a drug-e luting ste nt (DES) is pla ce d, dua l a ntipla te le t
the ra py (ASA + clopidogre l) is sta rte d to de cre a se the cha nce of
ste nt thrombosis. Be ca use ste nt thrombosis ma y de ve lop months
a fte r a DES is pla ce d, a minimum of 1 ye a r of dua l a ntipla te le t
the ra py is re comme nde d be fore stopping the drugs prior to e le ctive
surge ry. W ith ne we r ge ne ra tion (drug-e luting) ste nts with be tte r
pha rma cologic pla tforms like e ve rolimus, the ACC/AHA guide line s
for DAPT (dua l a ntipla te le t the ra py) ma y be re vise d in the ne a r
future . If surge ry is pla nne d within 1 ye a r of a ngiopla sty a nd ste nt
pla ce me nt, conside ra tion for using a ba re -me ta l ste nt is
re comme nde d (whe re a minimum of 1 month of a ntipla te le t
the ra py is re comme nde d) (Miller: Miller’s Anesth esia, ed 8, p 1185).
973. (D) He pa rin-induce d thrombocytope nia (HIT) ca n be e ithe r
nonimmune (type I) or immune (type II). HIT type I is a tra nsie nt
a nd clinica lly insignifica nt condition in which he pa rin binds to
pla te le ts ca using a shorte ning of the pla te le t’s le ft spa n a nd a
mode st de cre a se in the pla te le t count. Howe ve r, HIT type II ca n be
a se rious condition in which a ntibodie s a re forme d (in 6%-15% of
pa tie nts who a re re ce iving unfra ctiona te d he pa rin for >5 da ys) to a
comple x of he pa rin a nd a pla te le t prote in fa ctor 4. This he pa rin-
pla te le t fa ctor 4 a ntibody comple x binds to e ndothe lia l ce lls, which
the n stimula te s thrombin production with a ne t re sult of both
thrombocytope nia (>50% re duction in the pla te le t count) a nd ve nous
a nd/or a rte ria l thrombosis (<10% of ca se s). In pa tie nts with HIT,
he pa rin should be a voide d. In the se tting of a thrombotic e ve nt or a
pa tie nt with HIT ne e ding a nticoa gula tion (e .g., corona ry a rte ry
bypa ss gra ft [CABG]) a dire ct thrombin inhibitor such a s hirudin,
le pirudin, biva lirudin, or a rga troba n should be use d.
Alle rgy to prota mine ca n a lso be a n indica tion for dire ct thrombin
inhibitors, but HIT type II is a stronge r re a son for using
biva lirudin (or othe r) tha n prota mine a lle rgy. Furthe rmore ,
he pa rina se , a n e nzyme de rive d from a gra m-ne ga tive ba cte rium
(Flavobacterium h eparinum ), ca n a lso be use d to ne utra lize the
e ffe cts of he pa rin. Se e a lso Answe r 411 (Barash : Clinical
Anesth esia, ed 7, p 416; Hines: Stoelting’s Anesth esia and Co-Ex isting
974. (C) De nsity of ba cte ria l skin conta mina tion a nd prope nsity to
de ve lop thrombosis in a ca nnula te d ve in a re risk fa ctors for the
de ve lopme nt of ca the te r-re la te d bloodstre a m infe ctions (CRBSIs).
The se risk fa ctors a re like ly highe st for fe mora l line s. In mostly
obse rva tiona l studie s, the risk of CRBSI wa s found to be lowe st for
subcla via n ce ntra l ve nous a cce ss. The Ce nte rs for Dise a se Control
a nd Pre ve ntion re comme nds use of subcla via n ce ntra l line s whe n
clinica lly possible (Miller: Miller’s Anesth esia, ed 8, p 1366).
975. (D) Clopidogre l e xe rts its a ntithrombotic a ction by
noncompe titive ly a nd irre ve rsibly inhibiting the spe cific pla te le t
a de nosine diphospha te (ADP) re ce ptor na me d P2Y12. Be ca use the
P2Y12 re ce ptor is pe rma ne ntly a ffe cte d, the dura tion of a ction of
clopidogre l is for the life of the pla te le ts. No drug re ve rse s the se
e ffe cts, a nd only pla te le t tra nsfusion ca n re ve rse the e ffe cts of
clopidogre l (Miller: Miller’s Anesth esia, ed 8, p 1873).
976. (B) Port a cce ss robotic surge ry is a le ss inva sive te chnique for
corona ry a rte ry re va scula riza tion in se le cte d pa tie nts. Acce ss is
ga ine d to the he a rt through a le ft-side d minithora cotomy. This
obvia te s the ne e d for a ste rnotomy but doe s re quire one -lung
ve ntila tion a nd ma y re sult in hypoxia prior to initia tion of
ca rdiopulmona ry bypa ss a nd a fte r ce ssa tion. Hypothe rmic ca rdia c
a rre st is not re quire d for robotic surge ry (Miller: Miller’s Anesth esia,
ed 8, pp 2586–2588).
977. (D) One te chnique for pla ce me nt of double -lume n tube s is to
simply a dva nce the tube such tha t the tip of the dista l lume n is just
a bove the ca rina , a nd the n to pla ce it e xa ctly (the dista l tube
including cuff) into the right ma inste m bronchus unde r dire ct vision
using the bronchoscope . If the tube is initia lly a dva nce d too fa r into
the right ma inste m bronchus (a s it wa s in this que stion) a structure
re se mbling the ca rina will be visua lize d. The “re a l” ca rina
se pa ra te s the le ft a nd right lungs, a nd if the bronchoscope is
pushe d into e ithe r the right or the le ft ma inste m bronchi, a
se conda ry “ca rina ” will be visua lize d. In both ca se s, the se conda ry
ca rina ha s only two bra nch points. On the le ft, the bra nche s le a d to
the le ft uppe r lobe a nd le ft lowe r lobe . On the right, the bra nche s
le a d to the right uppe r lobe a nd the right middle lobe . If the thre e
lume ns a re se e n a fte r bra nching right from the “ca rina ,” the
“ca rina ” in que stion is not the true ca rina but is, in fa ct, the
bra nching point for the right uppe r a nd right middle lobe s (se e
figure ) (Barash : Clinical Anesth esia, ed 7, pp 1044–1046).
978. (C) During one -lung ve ntila tion, a bnorma litie s incre a se .
Afte r a fe w minute s of one -lung ve ntila tion, hypoxic pulmona ry
va soconstriction (HPV) de ve lops, which he lps de cre a se blood flow
to the nonde pe nde nt lung. Most pa tie nts will ha ve a de qua te Pa O2
whe n the de pe nde nt lung is ve ntila te d with 100% oxyge n, using a
tida l volume (VT) of 8 to 10 mL/kg a nd a djusting the re spira tory ra te
to a chie ve a Pa CO2 of 40 mm Hg. In pa tie nts who de ve lop
hypoxe mia with the se se ttings, corre ction of poor he modyna mics
a s we ll a s che cking the position of the double -lume n tube is done
first, the n a dding CPAP to the nonde pe nde nt lung, a dding PEEP to
the de pe nde nt lung, or ha ving the surge on cla mp the PA to the lung
a bout to be re move d, will he lp de cre a se the misma tch.
Occa siona lly, inte rmitte nt infla tion of the nonde pe nde nt lung with
100% oxyge n will be ne e de d. Epoproste nol a nd nitric oxide (NO)
would inhibit HPV a nd might le a d to a n incre a se in shunt a nd a
de cre a se in Pa O2 (Miller: Miller’s Anesth esia, ed 8, pp 1969–1970).
979. (B) The tra nspla nte d he a rt is e sse ntia lly de ne rva te d a nd
initia lly ha s a n intrinsic ra te of a bout 110 be a ts/min. About 25% of
pa tie nts e ve ntua lly de ve lop a bra dyca rdia tha t will re quire
impla nta tion of a pe rma ne nt ca rdia c pa ce ma ke r. If bra dyca rdia
doe s de ve lop, drugs tha t e xe rt the ir e ffe ct by blocking the
pa ra sympa the tic bra nche s of the a utonomic ne rvous syste m (e .g.,
a tropine ) will ha ve no e ffe ct. Dire ct-a cting drugs such a s gluca gon,
isoprote re nol, e pine phrine , a nd nore pine phrine will still be
e ffe ctive . Isoprote re nol is commonly use d for incre a sing he a rt ra te
in ca rdia c tra nspla nt re cipie nts. Epine phrine a nd nore pine phrine
ma y ha ve e xa gge ra te d β-mime tic e ffe cts on the he a rt ra te be ca use
the incre a se in blood pre ssure will not le a d to a re fle x slowing of
the he a rt ra te via the ba rore ce ptor re fle xe s (i.e ., e ffe re nt va gus
ne rve ). Drugs with both dire ct a nd indire ct e ffe cts such a s
e phe drine e voke a le ss inte nse re sponse . Impla nte d me cha nica l
pa ce ma ke rs work norma lly in he a rt tra nspla nt re cipie nts since the
ca rdia c le a ds a re pla ce d dire ctly into the myoca rdium (Barash :
Clinical Anesth esia, ed 7, p 1848; Miller: Miller’s Anesth esia, ed 8, p
2066).
980. (D) Pa tie nts with W PW syndrome ha ve a n a cce ssory pa thwa y
known a s the bundle of Ke nt, which conne cts the a tria with
ve ntricle s without pa ssing through the a triove ntricula r (AV) node .
AV noda l re e ntra nt ta chyca rdia (AVNRT) is the most common
ta chydysrhythmia a ssocia te d with W PW syndrome a nd comprise s
95% of a rrhythmia s a ssocia te d with this syndrome . Gre a te r tha n
90% of the time , conduction is orthodromic; tha t is, conduction
pa sse s through the AV node a nd the His-Purkinje syste m. Such
conduction re sults in na rrow, comple x ta chyca rdia , a nd a ny of the
drugs me ntione d in this que stion could be use d to control ra te .
AVNRTs tha t tra ve l through the a cce ssory pa thwa y (<10% of
AVNRTs) a re ma nife ste d a s wide comple x ta chyca rdia s (a ntidromic
conduction) a nd a re not a me na ble to tre a tme nt with β-blocke rs,
ca lcium cha nne l blocke rs, a de nosine , or digoxin, a nd ca n, in fa ct,
be ma de worse with the se drugs. Intra ve nous proca ina mide , a
cla ss Ia a ntidysrhythmic a ge nt, is the only use ful pha rma cologic
a ge nt a mong the drugs liste d in the que stion. If pha rma cologic
the ra py fa ils, e le ctrica l ca rdiove rsion is indica te d to control ra te
(Fleish er: Anesth esia and Uncom m on Diseases, ed 6, p 33).
981. (C) The DOO se tting is the simple st dua l cha mbe r pa cing
mode . Be ca use of conce rns a bout e le ctroma gne tic inte rfe re nce
from a n e le ctrica l surgica l unit (ESU) (i.e ., the Bovie ), pa ce ma ke rs
ma y be te mpora rily progra mme d into the a synchronous mode for
surge ry a nd the n re progra mme d to the pre surgica l mode in the
re cove ry room. W ith the VOO or DOO mode s, the possibility of a n
R-on-T phe nome non e xists if the na tive he a rt ra te e xce e ds the
progra mme d ra te or whe n the re a re fre que nt pre ma ture ve ntricula r
contra ctions (PVCs) or pre ma ture a tria l contra ctions (PACs). In the
la tte r ca se , re pola riza tion (from a PAC or PVC) ma y occur a t the
pre cise mome nt tha t the pa ce ma ke r is discha rging (R wa ve ).
Turning off a n impla nte d pa ce ma ke r would be e xtre me ly difficult in
the middle of a n ope ra tion. Furthe rmore , a slow rhythm could
occur whe re in pa cing we re a ga in ne ce ssa ry. Intra ve nous lidoca ine
would be use le ss in this se tting, a s would switching the vola tile
a ge nt from isoflura ne to de sflura ne . At conce ntra tions gre a te r tha n
1 minimum a lve ola r conce ntra tion (MAC), de sflura ne ca n a ctua lly
incre a se he a rt ra te furthe r. Administra tion of e smolol would slow
the he a rt ra te down be low 70 so tha t the pa ce ma ke r could a ga in
“le a d” (Miller: Miller’s Anesth esia, ed 8, pp 1464–1467).
982. (C) Milrinone a nd a mrinone (ina mrinone ) a re
phosphodie ste ra se type 3 (PDE3) inhibitors tha t incre a se cyclic
a de nosine monophospha te (cAMP) le ve ls in ca rdia c a nd smooth
muscle ce lls. The y both produce positive inotropic e ffe cts a nd
va sodila tion (a rte ria l a nd ve nous). Unlike milrinone , a mrinone
ra pidly produce s clinica lly significa nt thrombocytope nia e spe cia lly
a fte r prolonge d use (Hem m ings: Ph arm acology and Ph y siology for
983. (D) SIRS ca n re sult from a va rie ty of se ve re clinica l insults,
including ca rdiopulmona ry bypa ss. The dia gnosis of SIRS re quire s
the pre se nce of two or more of the following four conditions:
te mpe ra ture gre a te r tha n 38° C or le ss tha n 36° C; he a rt ra te gre a te r
tha n 90 be a ts/min; re spira tory ra te more tha n 20 bre a ths/min or a
Pa CO2 of le ss tha n 32 mm Hg; a le ukocyte count gre a te r tha n 12,000
or le ss tha n 4000/mm3 or gre a te r tha n 10% imma ture (ba nd) forms.
Se psis is SIRS plus a docume nte d infe ction (Barash : Clinical
984. (C) W he n a PA ca the te r is pla ce d from the right inte rna l jugula r
ve in, the right a trium typica lly is re a che d a t 20 to 25 cm, the right
ve ntricle a t 30 to 35 cm, the PA a t a bout 40 to 45 cm, a nd the we dge
position a t 45 to 55 cm. Add a bout 5 to 10 cm from the le ft inte rna l
jugula r ve in a nd the le ft a nd right e xte rna l jugula r ve ins, 15 cm from
the fe mora l ve ins, a nd 30 to 35 cm from the a nte cubita l ve ins
985. (D) The re fle cts the ove ra ll a bility of ca rdia c output to
a de qua te ly me e t me ta bolic ne e ds a nd is thus a compre he nsive
me a sure of ca rdia c pe rforma nce . The re a re se ve ra l fa ctors tha t
ca n influe nce . The se fa ctors a re e a sily unde rstood by
re a rra nging the Fick e qua tion a s follows:
Se e e xpla na tion to Que stion 106 for comple te de finition of O2

conte nt. Thus, SO2 ca n be re duce d by a de cre a se in Sa O2, CO,
a nd he moglobin, a nd a n incre a se in O2. In the pre se nt ca se ,
la be ta lol re duce s ca rdia c output through its ne ga tive inotropic
e ffe ct. The se fa ctors must be a ccounte d for whe n inte rpre ting SO2
me a sure me nts (Miller: Miller’s Anesth esia, ed 8, p 1387).
986. (D) Inotropy re fe rs to the force a nd ve locity of ve ntricula r
contra ctions whe n pre loa d a nd a fte rloa d a re he ld consta nt.
Chronotropy re fe rs to the he a rt ra te . Dromotropy re fe rs to the
conduction of impulse s a long conductive tissue . Ba thmotropy re fe rs
to muscula r e xcita tion in re sponse to a stimulus. Lusitropy re fe rs to
myoca rdia l re la xa tion or dia stole . A de cre a se in lusitropy is se e n
with the a ging myoca rdium (Miller: Miller’s Anesth esia, ed 8, p 485).
987. (C) PA hype rte nsion is de fine d a s a me a n PA pre ssure of
gre a te r tha n 25 mm Hg a t re st or gre a te r tha n 30 mm Hg with
e xe rcise . Epoproste nol, a lso ca lle d prosta cyclin (PGI2), a nd Flola n,
a s we ll a s a lprosta dil (PGE1), a re usua lly a dministe re d by a
continuous IV infusion ce ntra lly, producing both pulmona ry a nd
syste mic va sodila tion, but be ca use syste mic hypote nsion is
common, the ir use is limite d. Re ce ntly, inha le d e poproste nol a nd
a lprosta dil ha ve be e n de scribe d to re duce the syste mic side
e ffe cts. Be ca use hypoxia produce s pulmona ry va soconstriction,
oxyge n the ra py is ofte n a dministe re d to re duce the ma gnitude of
pulmona ry va soconstriction tha t ma y de ve lop. Inha le d nitric oxide
(NO) in conce ntra tions from 1 to 80 ppm (typica lly 20-40 ppm)
produce s smooth muscle re la xa tion a nd re duce s PA pre ssure s.
Be ca use NO is so ra pidly me ta bolize d, it ha s minima l syste mic
e ffe cts. Milrinone is a phosphodie ste ra se inhibitor tha t re duce s
pulmona ry va scula r re sista nce while ha ving some inotropic e ffe cts.
(If right ve ntricle fa ilure is se ve re , nore pine phrine or e pine phrine
ma y be pre fe rre d a s a n inotrope e ve n though PA pre ssure s will
incre a se .) Milrinone is usua lly a dministe re d IV, but re ce ntly inha le d
milrinone ha s be e n de scribe d to re duce syste mic side e ffe cts.
Inha le d vola tile a ne sthe tics te nd to de cre a se PA re sista nce . On the
othe r ha nd, NO te nds to incre a se pulmona ry va scula r re sista nce
a nd is not re comme nde d to be use d in pa tie nts with pulmona ry
hype rte nsion (Miller: Basics of Anesth esia, ed 6, p 435; Hines: Stoelting’s
988. (C) Pulmona ry va scula r re sista nce (PVR) is the sum of the
re sista nce of sma ll a nd la rge blood ve sse ls a nd is le a st a t the FRC.
W he n the lung volume incre a se s a bove FRC, PVR incre a se s due to
a lve ola r compre ssion of the sma ll intra -a lve ola r blood ve sse ls.
W he n the lung volume de cre a se s be low FRC, PVR incre a se s due
to the me cha nica l tortuosity or kinking of the la rge e xtra -a lve ola r
blood ve sse ls. Pulmona ry va scula r re sista nce a lso incre a se s in
a re a s of a te le cta sis whe n hypoxia ca use s pulmona ry
va soconstriction (HPV) (Miller: Miller’s Anesth esia, ed 8, pp 681–687).
989. (C) Hype rtrophic ca rdiomyopa thy is cha ra cte rize d by le ft
ve ntricula r outflow tra ct (LVOT) obstruction a nd is ca use d by
a symme tric hype rtrophy of the intra ve ntricula r se pta l muscle . The
compe nsa tory me cha nism to ma inta in ca rdia c output is le ft
ve ntricula r hype rtrophy. Eve nts tha t incre a se outflow obstruction
include incre a se d myoca rdia l contra ctility (e .g., β stimula tion),
de cre a se d ve ntricula r pre loa d (e .g., hypovole mia , ve nodila tion,
ta chyca rdia with re duce d time to fill the ve ntricle , positive -pre ssure
ve ntila tion), a nd de cre a se d a fte rloa d (e .g., va sodila tion).
Pe riope ra tive ma na ge me nt is a ime d a t pre ve nting a n incre a se in
outflow obstruction. Hypote nsion ofte n re sponds by incre a sing
pre loa d (fluid a dministra tion) a nd/or incre a sing a fte rloa d (α-
a dre ne rgic stimula tion with phe nyle phrine ). β-Blocka de (e .g.,
e smolol) ca n he lp slow a fa st he a rt ra te a nd a llow more time for
ve ntricula r filling a s we ll a s de cre a sing contra ctility. If the pa tie nt
ha s a pa inful ca te chola mine re sponse to surge ry, na rcotics ma y be
he lpful. Drugs with β-a dre ne rgic a ctivity such a s e phe drine ,
dopa mine , a nd dobuta mine a re contra indica te d, be ca use the y
incre a se myoca rdia l contra ctility a nd he a rt ra te , which ca use s
more LVOT obstruction (Miller: Basics of Anesth esia, ed 6, p 403).
990. (D) CHF is one of the six ma jor risk fa ctors for pa tie nts
unde rgoing e le ctive ma jor nonca rdia c surge ry. The othe r ma jor risk
fa ctors a re high-risk surge ry, ische mic he a rt dise a se ,
ce re brova scula r dise a se , insulin-de pe nde nt dia be te s me llitus, a nd
pre ope ra tive se rum cre a tinine of gre a te r tha n 2 mg/dL. As this is a n
e le ctive ca se , pa tie nts with CHF ne e d to be optima lly ma na ge d
prior to surge ry. This pa tie nt doe s not a ppe a r to be optima lly
ma na ge d, a nd surge ry should be ca nce le d (Miller: Basics of
991. (B) Symptoms of mitra l ste nosis de ve lop whe n the mitra l va lve
orifice (norma lly 4-6 cm2) is re duce d 50% or more . Goa ls in
ma na ge me nt re volve a round four ma in a re a s: pre ve nting
ta chyca rdia (which de cre a se s the dia stolic time ne e de d for LV
filling); a voiding a ma rke d incre a se in ce ntra l blood volume (which
ma y ca use a tria l fibrilla tion or CHF); pre ve nting sudde n drug-
induce d de cre a se s in syste mic va scula r re sista nce (which ma y
ca use hypote nsion a nd re fle x ta chyca rdia ); a nd a voiding hypoxia
a nd hype rca rbia (which ma y e xa ce rba te pulmona ry hype rte nsion
a nd ca use right ve ntricula r fa ilure ). Ke ta mine , pa ncuronium, a nd a
ra pid incre a se in the conce ntra tion of de sflura ne ma y a ll ca use
ta chyca rdia , which re sults in a de cre a se in ca rdia c output. Nitrous
oxide ca n be use d in most ca se s; howe ve r, in se ve re ca se s whe re
the re is a n incre a se in PA pre ssure , a voiding nitrous oxide ma y be
be ne ficia l. Re mife nta nil a s we ll a s fe nta nyl a nd sufe nta nil give
good a na lge sia without incre a sing he a rt ra te (HR) (Miller: Basics of
992. (D) Dopa mine ca n be mixe d in e ithe r D5W or norma l sa line
(NS) solution. A mixture of 200 mg of dopa mine in 250 mL of D5W
would yie ld a conce ntra tion of 800 µg/mL
(200 mg/250 mL = 0.8 mg/mL = 800 µg/mL). At a n infusion ra te of
5 µg/70 kg/60 min, one would ne e d
5 µg × 70 kg × 60 min = 21,000 µg/hr. 21,000 µg/hr ÷
800 µg/mL = 26 mL/hr.
993. (D) Pa tie nts with ste notic he a rt va lve s (mitra l ste nosis [MS],
a ortic ste nosis [AS]) te nd to do be tte r with slow norma l he a rt ra te s
be ca use it ta ke s time for the he a rt cha mbe rs to fill during dia stole
(MS) or e mpty during systole (AS). Ta chyca rdia in pa tie nts with AS
ma y be e spe cia lly ha rmful, be ca use ta chyca rdia le a ds to
myoca rdia l ische mia a nd ve ntricula r dysfunction due to the thick
ve ntricula r wa lls. W ith ca rdia c va lve s tha t a re insufficie nt (e .g.,
a ortic insufficie ncy [AI]), fa ste r he a rt ra te s a re he lpful be ca use
re gurgita tion occurs during dia stole a nd fa ste r ra te s de cre a se
dia stolic time . Pa tie nts with AI a lso be ne fit from a lowe r syste mic
va scula r re sista nce (SVR), which promote s a be tte r ca rdia c output
(high SVR incre a se s the a mount of re gurgita tion during dia stole ).
Too low of a n SVR in the se pa tie nts ma y le a d to de cre a se d
corona ry a rte ry filling, be ca use filling occurs during dia stole . W ith
hype rtrophic ca rdiomyopa thy, a high SVR he lps to de cre a se the
outflow obstruction, but a fa st he a rt ra te incre a se s outflow
obstruction. Pa tie nts with ca rdia c ta mpona de ha ve a fixe d e je ction
fra ction tha t is ve ry de pe nde nt upon high filling pre ssure s, a nd the
ca rdia c output is ve ry much de pe nde nt upon the he a rt ra te . A high
SVR he lps to ma inta in blood pre ssure in the fa ce of the de cre a se d
ca rdia c output (Miller: Basics of Anesth esia, ed 6, pp 404–405).
994. (A) The figure shows torsa de s de pointe s (“twisting of the
points”) in a pa tie nt who ha d a QTc inte rva l of 450 mse c a nd wa s
ha ving a n a cute myoca rdia l infa rction (MI). This condition ca n be
induce d by drugs (e .g., quinidine , proca ina mide , a nd
phe nothia zine s such a s drope ridol), e le ctrolyte a bnorma litie s (e .g.,
hypoka le mia , hypoma gne se mia ), a nd a cute ca rdia c ische mia or
infa rction. If a prolonge d QT inte rva l is pre se nt, the shorte ning of
the QT inte rva l is pe rforme d a s time pe rmits (e .g., corre ction of
e le ctrolyte a bnorma litie s). In the pa st, isoprote re nol wa s use d
(shorte ns QT inte rva l) but ove rdrive a tria l or ve ntricula r pa cing is
the more de finitive tre a tme nt. Ma gne sium sulfa te ha s a lso be e n
use d a nd is re comme nde d by ma ny a s the first-line e me rge ncy
drug. If the pa tie nt doe s not ha ve a prolonge d QT inte rva l, sta nda rd
drugs use d for ve ntricula r ta chyca rdia ca n be use d. If the pa tie nt
be come s he modyna mica lly unsta ble , unsynchronize d shocks
(de fibrilla tion dose s) should be de live re d (Miller: Miller’s Anesth esia,
ed 8, pp 3197–3198).
995. (B)
996. (A)
997. (D)
The ECG re cording is a re fle ction of ca rdia c muscle e le ctrica l
a ctivity, a nd, a lthough it is prima rily use d to dia gnose a rrhythmia s
or ca rdia c ische mia , the cha nge s tha t occur ma y be re la te d to
e le ctrolyte disturba nce s. Both hype rka le mia a nd hypoka le mia
a re a ssocia te d with impa ire d myoca rdia l contra ctility, conduction
disturba nce s, a nd ca rdia c a rrhythmia s. W ith hype rka le mia , the
e a rlie st cha nge s a re na rrowing a nd pe a king of the T wa ve (7-
9 mEq/L). More se ve re de gre e s of hype rka le mia (>7 mEq/L)
produce wide ning of the QRS comple x tha t ca n me rge with the T
wa ve producing a sine wa ve pa tte rn, de cre a se in P-wa ve
a mplitude , a nd a n incre a se in the PR inte rva l. The te rmina l
e ve nt would be VF or a systole .
The e a rlie st cha nge s with hypoka le mia include T-wa ve fla tte ning
or inve rsion, a ppe a ra nce of U wa ve s, a nd ST se gme nt
de pre ssion. W ith se ve re hypoka le mia , the PR inte rva l ma y
be come prolonge d a nd the QRS comple x ma y wide n, the n
a rrhythmia s de ve lop.
Hypoca lce mia prolongs the QT inte rva l (ST portion), whe re a s
hype rca lce mia shorte ns the QT inte rva l. Hype rna tre mia a nd
hypona tre mia do not produce cha ra cte ristic cha nge s in the ECG
(Barash : Clinical Anesth esia, ed 7, pp 1701–1720).
998. (B)
999. (C)
1000. (D)
1001. (A)
Pa tie nts with ca rdiova scula r dise a se ofte n pre se nt for nonca rdia c
surge ry, both e le ctive a nd e me rge nt. Ma ny pa tie nts re ce ive
a ntipla te le t the ra py, a nd knowle dge of the dura tion of a ction is
importa nt. Nonste roida l a nti-infla mma tory drugs such a s
ibuprofe n re ve rsibly inhibit cyclooxyge na se a nd pre ve nt the
synthe sis of thromboxa ne A2, a s we ll a s PGI2, but the forme r
e ffe cts pre domina te clinica lly. Aspirin a ntipla te le t e ffe cts la st for
the life of the pla te le t (7-10 da ys).
Thie nopyridine de riva tive s, which include clopidogre l (Pla ve x) a nd
ticlopidine (Ticlid), inhibit pla te le t a ggre ga tion by inte rfe re nce
with fibrinoge n binding. The a ntipla te le t e ffe cts from Ticlopidine
the ra py la st 14 to 21 da ys, while clopidogre l’s dura tion of a ction is
shorte r (7 da ys) (Miller: Basics of Anesth esia, ed 6, pp 358–359).
Index
Pa ge numbe rs followe d by f indica te figure s; t, ta ble s; b, boxe s.
A
A-be ta (Aβ) fibe rs, a s pa in ca rrie rs, 235
Abcixima b, 60, 87
Abdomina l visce ra , pa in in, 232, 247
Abortion, incomple te , 186, 205
Acid-ba se a bnorma litie s, ca rdia c dysrhythmia s a nd, 44
Acidosis
a dve rse e ffe cts of, 33, 46
from prolonge d use of propofol, 33, 45
re spira tory, 31
Acrome ga lic pa tie nts
symptoms of, 212, 224
tra nssphe noida l hypophyse ctomy a nd, 127, 147
Activa te d pa rtia l thrombopla stin time (a PTT), 107, 111
Acute a mphe ta mine inge stion, MAC incre a se by, 102
Acute dystonic re a ctions, diphe nhydra mine for, 119, 133
Acute e tha nol inge stion, MAC re duction by, 93, 102
Acute he rpe s zoste r, 238–239
Acute myoca rdia l infa rction, proca ina mide for, 267, 267f, 282
Acute re spira tory distre ss syndrome (ARDS), 35, 49
Acute spina l cord injurie s
ma jor a ne sthe tic conce rns with, 34, 47
risks re la te d to, 223
Ade nosine , dipyrida mole with, 264, 276
β-Adre ne rgic a gonists, 181, 190
β-Adre ne rgic a nta gonists, na dolol a s nonse le ctive β1 a nd β2
blocke r, 51, 62–63
Adre ne rgic re ce ptor, β-a dre ne rgic a nta gonists, 51, 62–63
Adre ne rgic re sponse , blocking physiologic re sponse to surgica l
tra uma , 227, 238
Adsol, blood/RBC stora ge with, 115
Adsorption a te le cta sis, 150–151
Adult re spira tory distre ss disorde r, 31, 42
Adults
a ne sthe tic re quire me nt for, 91, 99
blood volume of, 112
body composition compa re d with ne wborn, 160, 174
ca rdiopulmona ry re suscita tion compa re d with childre n, 174
ca rdiova scula r va ria ble s, 165t
O2 re quire me nt, 30, 37
physiologic va ria ble s, 172t
pre dictors of OSA in, 128, 149
re spira tory indice s whe n compa re d with ne ona te s, 159
Afte rloa d re duction, during a ne sthe sia , 260, 270
Aging
e ffe cts on closing volume , 32, 42
impa ct on nonde pola rizing muscle re la xa nts, 55, 74
α2 Agonists, impa ct on MAC, 60, 89
Air, color indica tors for compre sse d ga se s in ga s cylinde r, 12t
Airwa y
compa ring physiology of ne wborns with a dults, 160, 175, 175f
e piglottitis ca using obstruction of, 158, 170
irrita bility from de sflura ne , 90, 96
ma na ging for a cute spina l cord injurie s, 34, 47
Alcohol, in ne urolytic blocka de , 229, 232, 241, 247
Alcohol withdra wa l, tre a tme nt of, 134
Alfe nta nil, compa re d with fe nta nyl, 57, 79
Alka losis
me ta bolic, 32, 43
re spira tory, 31, 40
Alle rgic (nonhe molytic) tra nsfusion re a ctions, 107, 111
Alle rgic re a ctions
drug-induce d, 57, 78
to muscle re la xa nts, 123, 140
Allodynia , 228, 239
Alve ola r ga s e qua tion, e stima te d P AO2 using, 32, 43, 43f
Alve ola r hype roxyge na tion, 93, 93t, 102, 102t
Alve ola r ve ntila tion (V‫ݵ‬A)
distribution of, 32, 44
e ffe ct of incre a se on F A/F I , 93, 101–102, 101f–102f
incre a sing the ra te of inha la tion induction, 94, 104
in ne ona te s, 37
re ducing pe a k a irwa y pre ssure without loss of, 7, 26
Alzhe ime r dise a se , 120, 136
Ambula tion, postdura l puncture he a da che a nd, 232, 247
Ame rica n Socie ty of Re giona l Ane sthe sia (ASRA), guide line s for
tre a tme nt of loca l a ne sthe tic syste mic toxicity (LAST), 187, 206
Amide -type loca l a ne sthe tic, dibuca ine a s, 131
Amino a cid-rich tota l pa re nte ra l nutrition, he pa tic e nce pha lopa thy
a nd, 53, 69
Amino a mide s, che mica l groups of loca l a ne sthe tics, 227, 238
Aminoste roids, a s muscle re la xa nt, 52, 66
Amioda rone , 35, 49
hypothyroidism/hype rthyroidism from, 260, 271
for ta chyca rdia , 262, 273
Amniotic fluid, me conium-sta ine d in ne wborns, 183, 195
Amniotic fluid e mbolism (AFE)
cha ra cte ristics of, 184, 198
signs a nd symptoms of, 181, 191
Amphe ta mine s, impa ct on MAC, 60, 89
Amrinone
a s positive inotropic drug, 59, 83
thrombocytope nia from, 265, 280
Ana lge sics, a s a dditive s to spina l a ne sthe tics, 234, 251
Ana phyla ctic re a ctions, 116
blood le ve ls of trypta se in, 127, 147–148
Ana tomic de a d spa ce , a ve ra ge size of, 33, 44
Ane mia , norma l physiologic a ne mia in infa nts, 158, 170
Ane sthe sia , pe dia tric physiology a nd, 155–179
Ane sthe sia e quipme nt, 1–28
Ane sthe sia ma chine , 1, 11, 11f–12f
compre sse d ga se s cha ra cte ristics, 12t
fa il-sa fe va lve on, 20
pre ssure circuits, 5, 20
pre ssure -se nsor shut-off va lve , 13
Ane sthe siologists, ma lpra ctice cla ims a ga inst, 128, 149
Ane sthe tic dura tion
ha lf-time a nd, 95, 105
not a ffe cting MAC, 60, 89
Ane sthe tic-re la te d ne rve injurie s, 235, 253
Ane sthe tic re quire me nt, orde r of, 91, 99
Ane sthe tic sta ge s, 156, 165
Ane sthe tic upta ke , into pulmona ry ve nous blood, 90, 96, 98f
Ane urysms, e va lua ting ce re bra l, 211, 222
Angina pe ctoris, tre a tme nt of, 51, 64
Angiote nsin, losa rta n blocking, 264, 277
Anion ga p, ca lcula ting, 33, 45
Ankle , chronic hype rte nsion indica te d by a nkle e de ma , 184, 197–198
Anta gonists
a nticholine ste ra se ha ving a nta gonist e ffe ct on nonde pola rizing
a nd de pola rizing muscle re la xa nts, 60, 88
chloroproca ine ha ving a nta gonistic e ffe ct on na rcotics, 186, 205
H2-re ce ptor, 57, 78
opioid, na ltre xone a s, 119, 132
Ante cubita l fossa
me dia n ne rve da ma ge a t, 133
structure s in, 230, 243
Anthra x, ciprofloxa cin for, 130, 153
Anti-infla mma tory drugs, de xa me tha sone (De ca dron), 55, 73
Anti-Xa a ssa y, for monitoring LMW H a nticoa gula tion the ra py, 110,
115
Antibiotics, impa ct on ne uromuscula r blocka de , 53, 69
Anticholine rgics
compa ra tive e ffe cts of, 64t
inhibition of sa liva tion, 61, 89
me pe ridine , 52, 65
Anticholine ste ra se drugs
for Alzhe ime r dise a se , 136
a nta gonist e ffe ct on nonde pola rizing a nd de pola rizing blocks, 60,
88
for mya sthe nia gra vis, 182, 194
type s of, 64–65
Anticholine ste ra se poisoning, symptoms of, 54, 72
Anticoa gula tion, from prota mine , 260, 270
Anticoa gula tion the ra py, with LMW H, 110, 115
Anticonvulsa nts, ma gne sium sulfa te a s, 180, 189
Antidiure tic hormone (ADH), 224–225
furose mide to offse t incre a se d, 108, 113
Antie me tics, for tre a tme nt of na use a in Pa rkinson dise a se , 51, 63
Antihype rte nsive the ra py
propra nolol for, 51, 64
to re store CBF a utore gula tion, 212, 224
Antipla te le t the ra py
a fte r pe rcuta ne ous corona ry inte rve ntion, 118, 132
a fte r pla ce me nt of drug-e luting ste nt, 264, 278
Antipsychotic drugs
e xtra pyra mida l side e ffe cts, 53, 67
phe nothia zine s a s, 59, 83
Aortic re gurgita tion, bisfe rie ns pulse in, 261, 261f, 273
Aortoca va l compre ssion
a dve rse e ffe cts on mothe r, 186, 204
significa nt in norma l pre gna ncy a t 20 we e ks, 185, 201
Apga r score , for e va lua tion of ne wborns, 181, 192, 192t
Apne a
infa nt risk for postope ra tive , 157, 161, 167, 176
Pa CO2 incre a se during, 30, 37
postope ra tive , in infa nts unde rgoing inguina l he rnia surge ry, 161,
177
succinylcholine ca using, 121, 136
Apne a a nd bra dyca rdia (A&B) spe lls, 177
Apne a -hypopne a inde x (AHI), de fine d, 123, 140
Apre pita nt, 52, 66
Arga troba n, 60, 87
Arginine va sopre ssin (AVP), a s de te rmina nt of se rum osmola lity, 58,
82–83
Arm, inne rva tion of, 231, 246
Arte ria l a ir e mbolism, pa te nt ductus a rte riosus a nd, 258, 268
Arte ria l a lve ola r pa rtia l pre ssure , of vola tile a ne sthe tics, 90–91, 96–
98, 98f
Arte ria l blood pre ssure , de cre a se due to PEEP, 120, 135
Arte ria l line pre ssure , 2, 13
Arte ria l oxyge n sa tura tion (Sa O2)
ce ntra l cya nosis due to, 141
pulse oxime try re a dings of, 126, 146
“Arte ria lize d” ve nous blood, from the ba ck of a ha nd, 32, 43
Arte riove nous fistula , incre a se d inha la tion induction of a ne sthe sia
with, 94, 103
Arte ry of Ada mkie wicz, 229, 241–242, 242f
ASA Close d Cla im Proje ct, 182, 195
Aspira tion
symptoms of ga stric a cid a spira tion, 182, 193–194
type s of a spira tion syndrome s, 200–201
Aspirin, le ngth of a ntipla te le t e ffe ct of, 267, 283
Assiste d/controlle d ve ntila tion, of lungs, 31, 40, 41f
Asthma
occurre nce during pre gna ncie s, 190–191
tre a tme nt of, 122, 138
Asymptoma tic Ca rotid Athe roscle rosis Study, 220
Athe roma s, pulmona ry a rte ry rupture a nd, 263, 275
Atmosphe re , ope ra ting room, re mova l of vola tile a ne sthe tic tra ce
conce ntra tion in, 5, 19–20
Atmosphe ric pre ssure , ga s flow a nd, 5, 19
Atra curium
a na phyla ctic re a ction to, 127, 147–148
compa ra tive pha rma cology of, 62t
compa re d with cis-a tra curium, 59, 85
hista mine re le a se a t e le va te d dose s, 52, 66
Atria l fibrilla tion, e choca rdiogra phic study, 31, 41
Atria l flutte r
in ECG rhythm strip, 259, 259f, 269
se le cting diffe re nt le a d in, 261, 261f, 272
“Atria l kick,” ca rdia c output a nd, 261, 273
Atropine , 61, 89
high (C8) spina l a ne sthe sia a nd, 130, 152
for low-gra de he a rt block, 259, 259f, 269
ocula r e ffe cts of, 61, 89
a s re ve rsa l a ge nt, 149
for sa rin ne rve ga s poisoning, 57, 78
side e ffe cts of, 52, 64, 64t
in tra nspla nte d de ne rva te d he a rt, 265, 279–280
Auricula r ne rve , 151
Automa te d e xte rna l de fibrilla tors (AEDs), 167–168
Automa te d noninva sive BP (ANIBP) de vice s, 6, 23
Autonomic hype rre fle xia , 209, 216
Autore gula tion, of CBF
a bolishing, 212, 224
ce re bra l ische mia impa cting, 210, 219
chronic hype rte nsion impa cting, 212, 224
impa irme nts to, 209, 212, 216, 222
Awa re ne ss, during ge ne ra l a ne sthe sia , postope ra tive re ca ll, 54, 72
Axilla ry a rte ry, ide ntifying on ultra sound, 236, 236b, 255, 256f
Axilla ry block
loca l a ne sthe tic syste mic toxicity a nd, 235, 253
using bupiva ca ine a nd e pine phrine , 232, 234, 247, 251–252
Axilla ry ve in, ide ntifying on ultra sound, 236, 236b, 255, 256f
B
Ba cte ria l se psis, pla te le t-re la te d, 108, 112
Ba in syste m, 9, 9f–10f, 28
Ba rbitura te s, impa ct on SSEPs, 222
Ba rotra uma , 3, 6, 16, 22
Be ckwith-W ie de ma nn syndrome , 168
Be nza tropine , for a cute dystonic re a ctions, 133
Be nzoca ine , prope rtie s of, 235, 254
Be nzodia ze pine s
dia ze pa m a s, 60, 86
drug se nsitivity a nd, 57, 78
Be rnoulli e qua tion, for me a suring pe a k pre ssure in le ft ve ntricle , 4,
18
Bica rbona te , a dding to loca l a ne sthe tics for pa in re duction, 233, 250
Bila te ra l motor blocka de , 233, 248–249
Bisfe rie ns pulse , in a ortic re gurgita tion, 261, 261f, 273
Biva lirudin, he pa rin-induce d thrombocytope nia type II a nd, 264, 278
Bla dde r te mpe ra ture , in re cooling a fte r ca rdiopulmona ry bypa ss,
264, 276
Ble omycin
pulmona ry toxicity of, 122, 139
for te sticula r ca nce r, 54, 71, 129, 151
Blood
ca lcula ting ma ximum a llowa ble blood loss, 109, 114, 156, 164
ca lcula ting oxyge n conte nt of, 30, 38
ce ntra l ve nous ca the te rs ca using infe ctions, 45
de te cting infe ctious a ge nts in, 112, 112t
incre a sing O2 de live ry with tra nsfusion of, 123, 140
pla ce nta pre via ca using ne e d for tra nsfusion during ce sa re a n
se ction, 186, 203
Blood-bra in ba rrie rs
drugs ca pa ble of crossing, 52, 64–65
se da tion a nd, 61, 89
Blood flow
ca rotid a rte ry blood flow studie s, 211, 220
va scula r re sponsive ne ss to Pa CO2, 210, 219
Blood/ga s pa rtition coe fficie nt, corre la tion to re cove ry from inha le d
a ne sthe sia , 93, 102
Blood oxyge n te nsion (Pa O2)
de cre a se d a ccording to pa tie nt’s te mpe ra ture , 123, 141
fe ta l, 155, 163, 190
va scula r re sponsive ne ss to, 210, 219
Blood pre ssure , See BP (blood pre ssure )
Blood/RBC stora ge , 107, 111
with Adsol, 115
CPDA-1, 109, 115
e rythrocyte s a nd, 107, 111
fa ctors involve d in, 111, 113
glyce rol in, 111
she lf life with va rious pre se rva tive solutions, 108, 115
Blood ure a nitroge n (BUN), 184, 198
Blood volume
of a dults, 112
a llowa ble blood loss a nd, 109, 114, 164
of childre n, 112
of infa nts, 108, 112
loss of, in childre n, 156, 166
of ne wborns, 112
BMI (body ma ss inde x)
ca lcula te , 29, 37, 37f
ma sk ve ntila tion difficultie s a nd, 151
Body compa rtme nt volume s, in infa nts, 155, 163
Body composition, compa ring physiology of ne wborn with a dults,
160, 174
Bohr e qua tion, 42, 42f
Botulism, tre a tme nt for, 130, 153
Boyle ’s la w, 1, 12
BP (blood pre ssure )
a rte ria l line pre ssure compa re d with, 2, 13
de cre a se in syste mic, 90, 97
dire ct inva sive monitoring, 8, 8f, 27
e smolol for controlling syste mic a rte ria l blood pre ssure , 208, 215–
216
incre a se by de sflura ne , 91, 97
inte rve ntion for, 35, 49
lowe r a nd uppe r me a n a rte ria l limits in CBF a utore gula tion, 209,
216
monitoring with ANIBP de vice , 6, 23
monitoring with mode rn e le ctronic monitor, 2, 14
Bra chia l ple xus
a ne sthe tic-re la te d ne rve injurie s a nd, 253
in a rm, 231, 246
blocking trunks of, 231, 246
Bra chioce pha lic ve in, 34, 48
Bra dyca rdia
a pne a a nd bra dyca rdia (A&B) spe lls, 177
in childre n, 129, 151
due to hypoca rbia , 120, 135
in fe tus, 185, 201
in ne ona te s, 157, 167
succinylcholine -induce d, 55, 74
Bra in/blood pa rtition coe fficie nt, for ca lcula ting time consta nt, 95,
104–105
Bra in de a th, crite ria /te sts for de te rmining, 209, 217
Bra in injury, tra uma tic, 34
Bre a stfe e ding, de la ying ge ne ra l a ne sthe sia following, 161, 177
Bre a thing, O2 consumption a nd, 33, 44
Bronchia l (ma inste m) intuba tion, 128, 148
Bronchie cta sis, re curre nt bronchia l infe ctions ca using, 119, 133
Bronchopulmona ry dyspla sia , 150–151
B-type na triure tic pe ptide , 53, 68
Buffe ring syste m, [HCO3- ] a s, 33, 44
BUN, See Blood ure a nitroge n (BUN)
Bupiva ca ine
for a xilla ry block, 232, 247
Bie r block a nd, 230, 243
ca rdia c a rre st in ma te rna l wome n a nd, 187, 206
ca rdiotoxicity a nd, 228, 239
dura tion of a ne sthe tic e ffe ct in infa nts, 160, 173–174
e limina tion ha lf-time for, 229, 242
e pidura l dose simila r to lidoca ine , 234, 251
in intra ve nous a ne sthe sia , 234, 251
lumba r e pidura l block for se cond sta ge of la bor pa in, 184, 199–200
ra tio of dosa ge re quire d for ca rdiova scula r colla pse , 230, 244
Bupre norphine , 56, 77
Butorpha nol, 60, 87
C
C ne rve fibe rs, a s pa in ca rrie rs, 235, 254
C3 le ve l, glottis of pre ma ture ne wborn a t, 155, 163
C5 isoe nzyme va ria nt, 58, 81
C6
de rma toma l le ve l, 232, 246
ne rve root irrita tion, 235, 252
C7, 246
C8, 246
Ca lcium, intra ce llula r store s of, 138–139
Ca lcium glucona te , a s tre a tme nt for hypoca lce mia , 159, 171
Ca lcium hydroxide lime (Amsorb Plus, Drä ge rsorb), a dva nta ge s, 8,
27
Ca nnula ting ce ntra l ve ins, ve nous a ir e mbolism, 46
Ca pnogra m, pha se s of, 4, 4f, 17
Ca pnogra phy, 35, 50
Ca pnome te r, for me a suring CO2 conce ntra tion of re spira tory ga se s,
6, 24
Ca rba ma ze pine , for chronic pa in, 127
Ca rbon dioxide (CO2)
CO2-ve ntila tory re sponse curve , 32, 44
color indica tors for compre sse d ga se s in ga s cylinde r, 12t
la se r, 4, 18
re bre a thing e xpire d ga se s, 8, 27
stuck inspira tory va lve re sulting in incre a se d conce ntra tion of,
127, 147
V‫ݵ‬E incre a se with inha la tion of, 30, 39
Ca rbon monoxide
ca using la ctic a cid, 31, 40
poisoning e ffe cts, 45
toxicity tre a tme nt with 100% O2, 45
Ca rboxyhe moglobin
distinguishing from oxyhe moglobin, 129, 152
fa lse ly e le va te d Sa O2 me a sure d by pulse oxime try a nd, 126, 146
ha lf-life re duction with O2, 33, 45
Ca rcinoid tumors, symptoms a nd tre a tme nt of, 145
Ca rcinoma , me dulla ry, of thyroid, 133
Ca rdia c a bnorma litie s, conge nita l, 160, 175
Ca rdia c a cce le ra tor fibe rs, 236, 256
Ca rdia c a rre st
bupiva ca ine a ssocia te d with, 187, 206
pe riope ra tive in childre n, 161, 176
Ca rdia c dysrhythmia s, 59, 85
a cid-ba se a bnorma litie s, 44
risk for a ne sthe tize d pa tie nts with hype rca lce mia , 119, 134, 134t
Ca rdia c output
75% to ve sse l-rich group, 91, 98
ca lcula tion of, 262, 274, 274f
e ffe ct on F A/F I ra tio, 93, 101–102, 101f–102f
gre a te st imme dia te ly a fte r de live ry, 181, 192
hypote nsion a nd, 131
incre a se d we ight a nd, 125, 144
lungs a nd, 93, 101
re duction by ha lotha ne , 90, 97
re turning to nonpre gna nt va lue s a fte r 2 we e ks postpa rtum, 181,
190
vola tile a ne sthe tics’ e ffe ct on, 90, 97
Ca rdia c re synchroniza tion the ra py (CRT), 128, 149–150
Ca rdia c ta mpona de
pe rmuta tion in he modyna mics in, 266, 282
pre ssure in, 261, 272
pulsus pa ra doxus a nd, 260, 270–271
Ca rdioge nic shock, impa ct on F A/F I ra te of incre a se , 91, 97–98
Ca rdiomyopa thy, 45
Ca rdiopulmona ry re suscita tion
of de pre sse d ne wborn, 186, 203
sudde n ca rdia c a rre st a nd, 264, 277
te chnique for infa nts a nd childre n versus a dults, 160, 174
using until de fibrilla tion e quipme nt a rrive s, 167–168
Ca rdiova scula r syste m
a ge compa risons from ne ona te through a dult, 165t
blocking physiologic re sponse to surgica l tra uma , 227, 238
pa ra me te rs tha t de cre a se a t te rm pre gna ncy, 181, 191
ra tio of dosa ge re quire d for ca rdiova scula r colla pse , 230, 244
re turning to nonpre gna nt va lue s a fte r 2 we e ks postpa rtum, 181,
190
Ca rina , 265, 265f, 279, 279f
Ca rotid a rte ry dise a se , tre a ting, 223
Ca rotid a rte ry ste nosis, incre a sing risk of stroke , 211, 220
Ca the te rs
e pidura l, pla ce me nt of, 230, 243
la mina r flow a nd, 10–11
psoa s compa rtme nt block a nd, 232, 247–248
Ca uda e quina syndrome , 228, 238
Ca uda l block, 234, 251
Ce lia c-ple xus block, 231, 246
complica tion of, 232, 248
Ce ntra l a nticholine rgic syndrome , 61, 89
Ce ntra l cya nosis, 124, 141
Ce ntra l line infe ction, on subcla via n ve in, 264, 278
Ce ntra l ne rvous syste m (CNS)
ce re bra l pa lsy symptom comple x, 158, 171
inhibition of N-me thyl-D-a spa rta te (NMDA) re ce ptors, 52, 65
pyloric ste nosis ca using re spira tory de pre ssion, 169
ra tio of dosa ge re quire d for toxicity in, 230, 244
Ce ntra l ne ura xia l block, clopidogre l a nd, 233, 250
Ce ntra l ve nous ca the te rs
corre ct pla ce me nt of, 210, 210f, 219
infe ction pre ve ntion for, 33, 45
Ce re bra l a ne urysm, e va lua ting, 211, 222
Ce re bra l a utore gula tion, 210, 220
Ce re bra l blood flow (CBF)
a rte ria l te nsion (Pa CO2) a s de te rmina nt of, 211, 221
a utore gula tion, 209–210, 216, 219
ce re bra l ische mia a nd, 120, 135, 210, 219
critica l le ve l of, 210, 219
hype rve ntila tion re ducing, 208, 214–215
ke ta mine impa ct on, 222
norma l globa l, 209, 216
re la tionship to Pa CO2, 209, 216
Ce re bra l blood volume (CBV), a rte ria l te nsion (Pa C02) a s
de te rmina nt of, 211, 221
Ce re bra l corte x, SSEPs monitoring, 211, 221
Ce re bra l ische mia
contra indica ting use of glucose , 219
critica l CBF a nd, 219
EEG e vide nce of, 120, 135
e ffe ct on CBF a utore gula tion, 210, 219
whe n Pa CO2 re duce d be low 20 mm Hg, 208, 215
Ce re bra l me ta bolic ra te (CMR)
de cre a sing, 212, 222
Ce re bra l me ta bolic ra te for oxyge n (CMRO2)
norma l ra nge , 209, 216
re la tionship to body te mpe ra ture , 209, 217
Ce re bra l pa lsy (CP), 185, 201–202
a s CNS symptom comple x, 158, 171
e tiology of, 185, 201–202
Ce re bra l pe rfusion
fa ctors in ca lcula tion of pre ssure , 208, 214
luxury pe rfusion, 208, 215
Ce re bra l sa lt-wa sting syndrome , 208, 214
Ce re bra l va scula ture , impa ct of propofol on CO2 re sponsive ne ss,
210, 220
Ce re bra l va sospa sm
suba ra chnoid ble e d a nd, 129, 151
tre a tme nt of, 212, 223–224
Ce re brospina l fluid (CSF), 209, 218, 218f
Ce rvica l ple xus, in occipita l portion of skull, 232, 248
Ce rvica l ple xus block, for shoulde r a rthroscopy, 233, 249
Ce sa re a n se ction
a ne sthe tic induction pla n for, 183, 196, 196f
blood loss a ssocia te d with, 184, 198
ge ne ra l a ne sthe sia for, 183, 196
infiltra tion a ne sthe sia for e me rge ncy de live ry, 186, 204
loca l a ne sthe tics for, 187, 206–207
pla ce nta pre via ca using ne e d for blood tra nsfusion during, 186,
203
ra ising ga stric pH prior to, 185, 201
re ducing incide nce of shive ring during, 185, 202–203
tre a ting complica tions of, 186, 205
Che ck va lve s, on compre sse d-ga s cylinde r, 1, 12
Che st wa ll stiffne ss, succinylcholine for tre a ting, 57, 80
Child a buse ,in ute ro drug e xposure a s, 186, 204
Childre n
bra dyca rdia in, 129, 151
ca rdiopulmona ry re suscita tion te chnique for, 160, 174
compe nsa ting for de ficits of intra va scula r fluids in, 158, 170
ide ntifying e pidura l spa ce of, 161, 177
Chloroproca ine
a nta gonistic to a ction of e pidura l na rcotics, 186, 205
discha rge from posta ne sthe sia ca re unit a nd, 234, 251
ha lf-life of, 187, 207
nonsignifica nt e ffe cts on fe tus, 228, 240
pla sma cle a ra nce a nd, 238
ra pidly me ta bolize d in fe ta l a nd ma te rna l blood, 187, 207
Chlorproma zine (Thora zine ), 59, 83
Chlorpropa mide (Dia bine se ), 118, 131
Choline rgic crisis, tra che a l intuba tion a nd me cha nica l ve ntila tion
for, 125, 142
Chorioa mnionitis, 183, 195
Chronic bronchitis
FEV1/FVC ra tio de cre a se d in, 130, 153
tota l lung ca pa city incre a se d with, 130, 153
Chronic hype rte nsion, impa cting CBF a utore gula tory curve , 212, 224
Chronic live r dise a se , proca ine for prolonge d tre a tme nt of, 57, 79
Chronic pa in, spina l cord stimula tion for tre a ting, 236, 255
Cime tidine (Ta ga me t), side e ffe cts of, 57, 78
Ciprofloxa cin, for a nthra x, 130, 152
Cisa tra curium, 62t
Citra te phospha te de xtrose a de nine -1 (CPDA-1), for blood stora ge ,
109, 115
Citra te phospha te de xtrose (CPD), 109, 115
Citra te toxicity, with whole blood tra nsfusions, 109, 113
Clonidine
de cre a sing posta ne sthe tic shive ring, 57, 79
discontinuing prior to e le ctive surge ry, 53, 68
impa ct on MAC, 60, 86
ora l, for a cute he rpe s zoste r, 228, 238–239
re sulting in se ve re re bound hype rte nsion, 60, 87
whe n to use , 57, 80
Clopidogre l
ce ntra l ne ura xia l block a nd, 233, 250
le ngth of a ntipla te le t e ffe ct of, 267, 283
me cha nism of a ction of, 120, 135
re ve rsing e ffe cts of, 264, 278
use d a fte r a ngiopla sty to pre ve nt re ste nosis, 60, 87
Closing volume , incre a se with a ge , 32, 42
Clotting fa ctors
fa ctor VII, 107, 112
fa ctor VIII, 112
Coa gula tion
he ta sta rch inte rfe re nce with, 109, 114
PT a nd a PTT to te st, 107
Coa gulopa thie s, inhe rite d, 107, 111
Coca ine a buse , during pre gna ncy, 186, 204
Code ine , 132
tooth e xtra ction a nd, 53, 70
Common pe rone a l ne rve injury
ca use d by lithotomy position, 130, 154
foot drop a nd dorsa l e xte nsion of toe s loss with, 130, 154
Compa rtme nt syndrome , 129, 151–152
Comple te he a rt block, 144
Comple x re giona l pa in syndrome (CRPS)
e tiology of type I (re fle x sympa the tic dystrophy), 228, 239
e tiology of type II (ca usa lgia ), 228, 239
fe a ture s of, 229, 241
Compound A, forma tion/re bre a thing of, 94, 103
Compre sse d-ga s cylinde r
che ck va lve s, 1, 12
conta ining N2O for me dica l use , 1, 11
conta ining O2 for me dica l use , 2, 12
pre ssure ga uge in, 1, 6, 10, 23
pre ssure -re ducing va lve , 4, 18
Compre ssion volume , in volume -cycle d ve ntila tor, 29, 36, 36f
Conce ntra tion e ffe ct, 92, 92f, 100
Conge nita l dia phra gma tic he rnia (CDH)
ma na ge me nt of, 160, 175–176
re pa iring in infa nt, 156, 166
risk for right-to-le ft intra ca rdia c shunting of blood, 159, 173
Conge nita l he a rt dise a se , 167
Conge nita l ma lforma tion, 197, 197t
Conge nita l syndrome s, ca rdia c a bnorma litie s, 160, 175
Conge stive he a rt fa ilure (CHF), a s risk fa ctor for nonca rdia c surge ry,
266, 281
Constipa tion, a nd morphine , 57, 78
Constricte d pupils, suba ra chnoid inje ction of loca l a ne sthe tics a nd,
233, 248
Conta mina tion, vola tile a ne sthe tic, 3, 16
Conte xt se nsitive ha lf-time , 95, 105
Controlle d ve ntila tion, 9, 9f–10f, 28, 40, 41f
Corlopa m (Fe noldopa m), 125, 144
Corona ry a rte ry blood flow, norma l re sting, 263, 275
Corona ry a rte ry dise a se (CAD), 144
Corticospina l tra ct, 209, 218
Corticoste roids
for ma na ging ICP, 211, 221
Cortisol, unde r ma ximum stre ss, 262, 273
Coughing/vomiting, rise in intra ocula r pre ssure with, 140
COX-2 inhibitors, complica tions involving, 55, 73
Cra nia l ne rve s, re trobulba r block a nd, 229, 242
Cre a tinine , inve rse ly proportiona l to GFR, 124, 141
Cricothyroid muscle
motor inne rva tion of, 236, 257
supe rior la rynge a l ne rve a nd, 229, 243
Critica l ca re me dicine , 29–50
Critica l CBF, ce re bra l ische mia a nd, 219
Croup
inspira tory stridor a nd, 174
postintuba tion, 166
Cuta ne ous a nthra x, 130, 153
Cuta ne ous ne rve injury, fe mora l, 130, 154
Cya nide toxicity, 36
sodium nitroprusside a nd, 58, 83
tre a tme nt of, 58, 81, 81f
Cya nosis, ca rbon monoxide poisoning versus, 32, 43
Cyclople gia , from scopola mine , 141
Cyclosporine the ra py, side e ffe cts of, 55, 74
CYP2D6 e nzyme , 118, 132
Cytome ga lovirus (CMV)
le ukocyte re duction to re duce tra nsmission of, 112, 112t
tra nsfusion-a ssocia te d, 110, 117
D
Da ntrole ne
blocking ca lcium re le a se , 138–139
for muscle re la xa tion, 128, 148–149
side e ffe cts of, 56, 76
for tre a ting ma ligna nt hype rthe rmia , 59, 85
Da te x-Ohme da Te c 4 va porize r, 7, 24
De ca dron (de xa me tha sone ), a s a nti-infla mma tory drugs, 55, 73
De ca nnula ting ce ntra l ve ins, ve nous a ir e mbolism, 46
De cre me nt time s, of vola tile a ne sthe tics, 94, 104
De e p ce rvica l ple xus block, complica tions of, 229, 242
De e p pe rone a l ne rve , inne rva tion of toe s by, 228, 231, 239, 246
De fibrilla tion, sudde n ca rdia c a rre st a nd, 264, 277
De fibrilla tor, cha rge le ve l for infa nts, 157, 167–168
De hydra tion
de te rmining by obse rving urine output, 159, 173
re suscita tion of infa nt fluid le ve ls, 159, 171
re suscita tion prior to surge ry, 155, 164
De lirium tre me ns (DTs), 119, 134
De me clocycline the ra py, for SIADH, 212, 224–225
De pe nde nt a lve oli, supe rior ve ntila tion of, 32, 44
De pola rizing muscle re la xa nts
for the rma l injurie s, 139
De pola rizing ne uromuscula r blocka de
a nticholine ste ra se drugs ha ving a nta gonist e ffe ct on, 60, 88
e nha ncing a nticholine ste ra se drugs, 88
muscula r re sponse to ne rve stimula tion, 88t
De pre ssion/suicida l te nde ncie s, tra ma dol contra indica te d for, 125,
143
De sflura ne , 1, 10
a irwa y irrita bility from, 90, 92, 96, 100
de gre e of me ta bolism of, 94, 104
following ha lotha ne for highe st pote ncy, 91, 97
he a rt ra te incre a se with, 91, 95, 95t, 97, 105, 106f
ra pid e limina tion of, 94, 104
va por pre ssure a nd conce ntra tion, 91, 98
wa shout, 93, 102
De smopre ssin (DDAVP)
for dia be te s insipidus, 224–225
for von W ille bra nd dise a se , 110, 116
De xa me tha sone (De ca dron), a s a nti-infla mma tory drug, 55, 73
De xme de tomidine , 51, 57, 63, 78, 227, 237
Dia be te s insipidus
following pituita ry gla nd surge ry, 120, 136
lithium the ra py for, 145
tra uma tic bra in injury, 34, 47
va sopre ssin, 47
Dia be te s me llitus (DM), 185, 202
se rum glucose me a sure me nt be fore a ne sthe sia a nd, 131
Dia me te r Inde x Sa fe ty Syste m (DISS)
pre ve nts incorre ct conne ctions of me dica l ga s line s, 4, 18
provide s thre a de d, noninte rcha nge a ble conne ctions for me dica l
ga s pipe line s, 8, 26–27
Dia phra gma tic he rnia , re spira tory difficultie s in infa nts due to, 158,
170
Dia stolic time , a s a function of he a rt ra te , 263, 263f, 275–276
Dia ze pa m, 60, 86
chronic live r dise a se a nd, 57, 79
conge nita l ma lforma tion a nd, 197
pa in a s side e ffe ct of inje cting, 60, 86
Dibuca ine , pse udocholine ste ra se inhibition by, 58, 81, 131
Diffusion hypoxia , nitrous oxide a nd, 93, 93f, 101
Digita lis, hype rca lce mia a nd, 134, 134t
Digita lis toxicity, signs of, 227, 237
Dila tion a nd e va cua tion (D&E), symptoms of incomple te a bortion,
186, 205
Dila udid (Hydromorphone ), 127, 148
Diphe nhydra mine , for a cute dystonic re a ctions, 119, 133
Dipyrida mole , a de nosine with, 264, 276
Dire ct curre nt (DC) ca rdiove rsion
for a tria l fibrilla tion in unsta ble pa tie nts, 41
ine ffe ctive ne ss for MAT, 30, 37
Disse mina te d intra va scula r coa gula tion (DIC)
a mniotic fluid e mbolism a nd, 191
pla ce nta pre via a nd, 182, 194
DLCO, 121, 136–137
Dobuta mine
hype rtrophic ca rdiomyopa thy a nd, 266, 281
for hypote nsion, 260, 271–272
Dopa mine
infusion ra te of, 266, 282
intra ve nous flow incre a sing re na l blood flow, 63
oliguria obscure d by, 143
Dopple r ultra sound
for ca rotid a rte ry blood flow studie s, 211, 220
continuous wa ve , 1, 10
de te cting intra ca rdia c a ir, 209, 219
de te rmining ve nous a ir e mbolism (VAE), 209, 217, 217f–218f
Dorsa l toe , common pe rone a l ne rve injury ca using loss of
e xte nsion, 130, 154
Double lume n tube , pla ce me nt of, 265, 265f, 279, 279f
Down syndrome
a noma lie s a nd fe a ture s of, 160, 175
hypothyroidism in, 124, 141
Drope ridol, 54, 72
Dua l-wa ve le ngth pulse oxime te rs
a ccura cy of, 6, 22
e rrone ous re a dings by, 30, 30f, 39
Duloxe tine (Cymba lta ), for ne uropa thic pa in, 236, 255
E
Ea r, nose , a nd throa t surge ons, 173
Ebola virus, 130, 152
Echoca rdiogra m, a sse ssing a bnorma litie s in ne ona te s, 167
Echoca rdiogra ph, of a tria l fibrilla tion, 31, 41
Echothiopha te , for tre a tme nt of gla ucoma , 52, 66
Ede ma
chronic hype rte nsion indica te d by a nkle e de ma , 184, 197–198
hypoxic, 151–152
pulmona ry, 47, 136–137, 212, 223
Edrophonium, for mya sthe nia gra vis, 142
Eise nme nge r syndrome , 182, 194–195
Ele ctrica l ca rdiove rsion
for myoca rdia l ische mia , 263, 275
for ta chyca rdia , 261, 272
Ele ctroca rdiogra ph (ECG)
e le ctrode s, in pa tie nt unde rgoing MRI sca n, 6, 23
intra va scula r monitoring of ca the te r pla ce me nt, 210, 219
not using ECG wire s with MRIs, 209, 218
signs of hype rka le mia , 127, 147
Ele ctroca ute ry units, See Ele ctrosurgica l units (ESUs)
Ele ctroe nce pha logra m (EEG), e vide nce of ce re bra l ische mia , 120,
135
Ele ctrome cha nica l tra nsduce r syste m, ze roing, 2, 13
Ele ctrosurgica l units (ESUs), 6, 22–23
Embolism
a mniotic fluid e mbolism (AFE), 181, 191
signs of fa t, 124, 142
thromboe mbolism, 189
End-e xpira tory CO2 te nsion, a s a n e a rly MH sign, 121, 137
End-tida l ca rbon dioxide (ETCO2), 91, 98–99
de cre a sing, ve nous a ir e mbolism a nd, 213, 225
Endotra che a l tube s, 35, 50
a ir le a ka ge a t pe a k pre ssure for infa nts, 156, 166
corre ct pla ce me nt of, 168
cuffe d versus uncuffe d, 156, 165
le ngth for 6-ye a r-old child, 157, 166
size of, 129, 152
suction ca the te r inse rte d in, 3, 15
tra che a l ca pilla ry a rte riola r pre ssure a nd, 118, 131
Ene rgy e xpe nditure pe r da y, 35, 49
Enflura ne
fluoride ion-induce d ne phrotoxicity from, 104
va por pre ssure , a ne sthe tic va por pre ssure , a nd splitting ra tio, 24t
va por pre ssure a nd minimum a lve ola r conce ntra tion, 19t
va por pre ssure compa ra ble to se voflura ne , 90, 97
va por pre ssure pe r millilite r of liquid, 25t
Enoxa pa rin (Love nox), 118, 131
Ephe drine , a s va sopre ssor a ge nts, 52, 65, 65t
Epidura l a bsce ss, ba ck pa in due to, 229, 241
Epidura l he ma toma , symptoms of, 235, 254
Epidura l spa ce , a ir not use d a s me a ns of ide ntifying in childre n,
161, 177
Epidura ls
chloroproca ine a nta gonistic to a ction of, 186, 205
for se cond sta ge of la bor pa in, 184, 199–200
sympa the ctomy a nd na sa l conge stion from blocka de due to, 181,
191
symptoms of e pidura l he ma toma , 180, 189
tre a ting shive ring due to, 185, 202–203
Epiglottitis
ca using a irwa y obstruction, 158, 170
Epine phrine
a voiding use in conjunction with Eise nme nge r syndrome , 182,
194–195
a xilla ry block with, 232, 247
conce ntra tions corre spond to a 1:200,000 mixture , 227, 237
ma ximum dose limit for, 51, 58, 64, 82
prolonging a ne sthe tic e ffe ct of lidoca ine , 229, 240
prolonging dura tion of blocka de , 183, 197
Epoproste nol, in Pa O2, 265, 279
Erythrobla stosis fe ta lis, 114
Erythrocyte 2,3-diphosphoglyce ra te (2,3-DPG), 42
Erythrocyte s
blood stora ge re quire me nts for, 108, 113
CPDA-1 for, 109, 115
he molytic tra nsfusion re a ctions to, 108, 112
stora ge time of froze n, 107
Esmolol
controlling syste mic a rte ria l blood pre ssure , 208, 215–216
pa ce ma ke r a nd, 265, 280
re ducing re sponse to intuba tion, 213, 225
Esopha ge a l a tre sia (EA)
a ne sthe sia for pa tie nts with, 157, 168
ca use s of, 155, 155f–156f, 164
initia l symptom of, 157, 168
Esopha ge a l de te ctor de vice (EDD), 6, 23–24
Este ra se s, nonspe cific
drugs me ta bolize d by, 55, 74
re mife nta nil me ta bolize d by, 124, 142
Estima te d blood volume (EBV), in ne ona te s, 158, 169
Estima te d ge sta tiona l a ge (EGA)
a ortoca va l compre ssion a t 20 we e ks, 185, 201
susce ptibility of fe tus to te ra toge nic a ge nts, 181, 191–192
Etha nol, impa ct on MAC, 60, 89
Etomida te
a dre na l suppre ssion with, 60, 86
ce re bra l pha rma cologic profile of, 224
a s contra indica tion for porphyria , 53, 70
impa ct on SSEPs, 222
inje ction of, 54, 70
na use a a nd vomiting, a s side e ffe ct of, 56, 75, 77
tre a ting ca rotid a rte ry dise a se , 223
Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m, 159, 171
Euthyroid, TSH confirma tion of, 122, 139
Evoke d pote ntia ls
bra in ste m a uditory, 211, 221
se nsitivity to vola tile a ne sthe tics, 211, 221
Expira tory pla te a u pha se , of ca pnogra m, 17
Expira tory re se rve volume (ERV)
cha nge s during pre gna ncy, 196
FRC a nd, 36
Expira tory upstroke pha se , of ca pnogra m, 17
F
F A/F I
ca rdia c output a nd V‫ݵ‬A e ffe cts on, 93, 101–102
ca rdioge nic shock impa cting, 91, 97–98
incre a sing proportiona l to de pth of ge ne ra l a ne sthe sia , 92, 100
tra nspulmona ry shunting a nd, 91, 98
Fa ce ma sk, le a ka ge a s he a lth ha za rd, 5, 20
Fa cia l ne rve , 123, 140
Fa ctor V Le ide n muta tion, 193
Fa ctor VII, ha lf-life , 107, 112
Fa ctor VIII
conce ntra te s for von W ille bra nd dise a se , 110, 116
he mophilia a nd, 108, 113, 125, 144
he ta sta rch a nd, 109, 114
synthe sizing, 115
Fa il-sa fe va lve , on a ne sthe sia ma chine , 12–13
Fa sting pe riods, pulmona ry a spira tion a nd, 177t
Fa t e mbolism, 124, 142
FEF 25% to 75% pulmona ry function te sts, 32, 43
Fe mora l ne rve block, 231, 245
Fe mora l ne rve injury, 130, 154
Fe nta nyl
a buse of, 182, 193
a s obste tric a ne sthe tic, 183, 197
onse t a nd dura tion compa re d with morphine , 54, 70–71
Fe ta l he a d compre ssion, 185, 202
Fe ta l he a rt ra te (FHR), 180, 189
Fe ta l he moglobin
dua l-wa ve le ngth pulse oxime te rs a nd, 30, 30f, 39
P 50 va lue , 180, 190
Fe tus
ca use s of bra dyca rdia , 185, 201
chloroproca ine me ta bolism in fe ta l blood, 186, 205
conse que nce of ge ne ra l a ne sthe sia in, 182, 194
fe ta l a nd ma te rna l blood during la bor, 184, 198–199
FHR pa tte rns a nd, 202
oxyge n consumption in te rm fe tus, 182, 193–194
Pa O2 (blood oxyge n te nsion), 155, 163
susce ptibility to te ra toge nic a ge nts, 181, 191
FEV1/FVC ra tio, 29, 37
de cre a se d with pulmona ry e mphyse ma a nd re strictive
pulmona ry dise a se , 130, 153
de cre a se d with re strictive pulmona ry dise a se , 130, 153
FEV (force d e xpira tory volume ), 37
norma l with re strictive pulmona ry dise a se , 130, 153
pulmona ry function te st to a sse ss ve ntila tory ca pa city, 32, 43
Fibe roptic intuba tion, for pa tie nts with ba sa l skull or sinus injurie s,
212, 224
Fibrilla tion, minimum ma croshock curre nt in ve ntricula r fibrilla tion,
6, 22
Fibrinolysis, on thromboe la stogra m, 263, 263f, 276
Fick e qua tion, 274, 274f
Fick’s la w of diffusion, 32, 42
Fifth cra nia l ne rve (trige mina l ne rve ), 129, 151
F IO2
na sa l ca nnula a nd, 5, 21
not a fa ctor in re tinopa thy of pre ma turity in ute ro, 155, 163
First sta ge re gula tor, oxyge n cylinde r, 7
Five -e le ctrode syste m, monitoring e le ctric a ctivity of he a rt, 8, 26
Five pe rce nt de xtrose in wa te r (D5W ), contra indica te d in
ne urosurgica l pa tie nts with ICP, 208, 215
Flow-volume loop, 137
Fluids
compe nsa ting for de ficits in childre n, 158, 170
re suscita tion a ge nts, 110, 116
tre a ting infa nt to re suscita te fluid le ve ls, 159, 171
Fluma ze nil
ca using se izure s in chronic be nzodia ze pine use rs, 54, 72
side e ffe cts of, 53, 70
Fluoride toxicity, nonoliguric re na l fa ilure a ssocia te d with, 136
Fluoxe tine (Proza c), 127, 148
Fonda pa rinux, 60, 87
Fonta n proce dure , 260, 270
Foot, cuta ne ous inne rva tion of pla nta r surfa ce of, 230, 244
Foot drop, pe rone a l ne rve injury ca using, 130, 154
Force d e xpira tory volume in 1 se cond (FEV1), 37
Fospropofol (Luse dra ), 57, 78
Fra nk-Sta rling curve , stroke volume a nd, 258, 258f, 268–269
Fre sh ga s flow, ca lcula tion of, 91, 98
Functiona l re sidua l ca pa city (FRC)
composition of, 37, 38f, 38t
de cre a se d in re strictive pulmona ry dise a se , 130, 153
in pre ve ntion of postope ra tive pulmona ry complica tions, 29, 36,
120, 135
pulmona ry va scula r re sista nce a nd, 266, 281
Furose mide
to offse t incre a se d ADH, 108, 113
oliguria obscure d by, 125, 143
G
Ga ba pe ntin (Ne urontin), 127, 146
Ga s cylinde r
See also Compre sse d-ga s cylinde r
blue color indica ting N2O, 8, 12t, 27
brown color indica ting he lium, 8, 27
che ck va lve s, 1
frost on, 5, 20
ga s colors in, 27t
gra y color indica ting CO2, 8, 27–28
gre e n color indica ting O2, 12t
Ga stric fluid
ra ising pH prior to ce sa re a n se ction, 185, 201
symptoms of ga stric a cid a spira tion, 182, 193–194
Ga strointe stina l a nthra x, 130, 153
Ge nde r of pa tie nts, not a ffe cting MAC, 89
Ge ne ra l a ne sthe sia , 118–154
na use a a nd vomiting following, 124, 142
Ge nta micin, for pla gue , 130, 152
Gla sgow Coma Sca le , 126, 146
Gla ucoma
e chothiopha te for tre a tme nt of, 52, 66
a s risk for re tina l da ma ge , 119, 132
Glome rula r filtra tion ra te (GFR), 141, 162, 179, 198
Glycopyrrola te , 61, 89, 180, 188
Gra ft-ve rsus-host dise a se (GVHD), 110, 117
Gra nd ma l se izure s, 59, 84
Gra nise tron, 54, 72
Gre a t a uricula r ne rve , 151
Gre e n-top e ye drops, 120, 134
Growth curve s, 134
H
H2-re ce ptor a nta gonist, 57, 78
Haem oph ilus influenzae, ca using e piglottitis, 170
Ha ge n-Poise uille la w of friction, 10–11, 10f–11f
Ha lf-time , a ne sthe tic dura tion a nd, 95, 105
Ha lotha ne
blood solubility coe fficie nt of, 99
e ffe cts of blood/ga s solubility in, 99–100
following with de sflura ne for highe st pote ncy, 91, 97
me ta bolism unde rgone by, 104
in ne ona te s, 91, 99
pre se rva tive thymol in, 94, 103
re ducing ca rdia c output, 90, 95, 95t, 97, 105
a nd right-to-le ft shunts, 92, 100
soluble in rubbe r/pla stic, 94, 103
va por pre ssure s, 14t
Ha nd wa shing, to pre ve nt infe ctions, 233, 249
Ha rd pa la te , se nsory inne rva tion of, 236, 257
HCO3- , 33, 44
a s buffe ring syste m, 33, 44
in re spira tory a lka losis, 40
He a d fle xion/e xte nsion, tube pla ce me nt a nd, 122, 139
“He a d lift” te st, 54, 72
He a da che , See Postdura l puncture he a da che
He a rt
monitoring e le ctric a ctivity of, 26
pe rce nta ge of ca rdia c output a nd, 91, 98
He a rt fa ilure , e va lua tion of, 127, 146–147
He a rt ra te
de sflura ne incre a sing, 91, 97
drugs incre a sing, in tra nspla nte d de ne rva te d he a rt, 265, 279–280
intra va scula r inje ction a nd, 234, 251
isoflura ne incre a sing, 91, 95, 95t, 97
ste lla te ga nglion block a nd, 234, 251
He lium
color indica tor for ga s in ga s cylinde r, 27t
substituting for nitroge n in bre a thing a ssista nce , 5, 21
He ma tocrit, in ma ximum a llowa ble blood loss ca lcula tion, 109, 114,
156
He modyna mic indice s, of ne ona te , 156, 165
He modyna mic insta bility, during live r tra nspla nta tion re pe rfusion,
128, 148
He modyna mic pe rturba tions, with a cute spina l cord injurie s, 47
He moglobin
a rte ria l he moglobin sa tura tion (Sa O2), 4, 18
a s buffe ring syste m, 44
fe ta l a nd ma te rna l blood during la bor, 184, 198–199
oxyge n conte nt, 30, 38
P 50 va lue for a dult, 30, 39
P 50 va lue for fe tus, 180, 190
pulse oxime te rs, 30, 39
He moglobin S, in sickle ce ll a ne mia , 128, 149
He molytic tra nsfusion re a ctions, 107, 111
He molytic-ure mic syndrome (HUS), 161, 178
He mophilia , 108, 113
fa ctor VIII conce ntra te for, 108, 113
ra ising fa ctor VIII le ve ls prior to surge ry, 144
He mophilia A, PTT scre e ning te st for, 126, 144
He morrha ge , ca use s of ma te rna l de a th, 189
He morrha gic fe ve r, with Ebola virus, 130, 153
He pa rin
he re dita ry conditions a ssocia te d with he pa rin re sista nce , 110, 115
LMW H, See Low-mole cula r-we ight he pa rin (LMW H)
a s prophyla xis for de e p ve in thrombosis, 131
prota mine in ne utra lizing, 263, 275
unfra ctiona te d he pa rin for a nticoa gula tion the ra py, 115
He pa rin-induce d thrombocytope nia (HIT), 258, 268
biva lirudin a nd, 264, 278
He pa tic e nce pha lopa thy, 53, 69
e nd-sta ge live r dise a se a nd, 128, 149
He pa titis A, 108, 112
He pa titis B, 112, 112t
He roin, a buse of, 181, 191–192
He rpe s zoste r, tre a tme nt for, 228, 238–239
He ta sta rch (hydroxye thyl sta rch), 109, 114
High a bsorbe nt te mpe ra ture s, a nd incre a se d conce ntra tions of
compound A, 94, 103
Hista mine s, e le va te d dose of a tra curium re le a sing, 52, 66
Huma n immunode ficie ncy virus (HIV), 181, 191
Huntington chore a , 123, 140
Hydra la zine , ca using lupus e rythe ma tosus-like syndrome , 60, 86
Hydrolysis, by nonspe cific pla sma e ste ra se s, 59, 84
Hydromorphone (Dila udid), 127, 148
Hydroxye thyl sta rch (He ta sta rch), 109, 114
Hype rca lce mia , 267, 282–283
ca rdia c dysrhythmia s risk with a ne sthe sia , 119, 134, 134t
Hype rchlore mic me ta bolic a cidosis, 37, 58, 80
Hype rcoa gula tion, he re dita ry conditions a ssocia te d with, 115
Hype rcya notic a tta cks, isoprote re nol a nd, 264, 277–278
Hype rglyce mia , 219
Hype rka le mia , 267, 282
ECG signs of, 127, 147
from sodium bica rbona te a dministra tion, 264, 277
succinylcholine ca using, 53, 68
tre a ting side e ffe cts of succinylcholine , 55, 74
Hype rna tre mia , 47
Hype rte nsion
ca use s of ma te rna l de a th, 189
chronic hype rte nsion impa cting CBF a utore gula tory curve , 212,
224
chronic hype rte nsion indica te d by a nkle e de ma , 184, 197–198
drug ca using, 60, 87
fe noldopa m for, 144
hype rte nsive the ra py for, 51, 64
intra cra nia l, 208, 214
signs consiste nt with e le va tion of ICP, 225
thora cic pa ra ve rte bra l blocks a nd, 232, 248
Hype rte nsive disorde rs of pre gna ncy, 180, 188–189
incide nce of, 186, 204
propofol for, 181, 190–191
Hype rthyroidism, impa ct on MAC, 60, 89
Hype rtrophic ca rdiomyopa thy, dobuta mine infusion a nd, 266, 281
Hype rve ntila tion, 121, 137
with oxyge n for se izure s, 233, 249
for pa tie nts with incre a se d ICP, 213, 225
re ducing ce re bra l blood flow (CBF), 208, 214–215
re ducing intra cra nia l pre ssure (ICP), 212, 223
signs consiste nt with e le va tion of ICP, 225
Hypoca lce mia
following re se ction of pa ra thyroid gla nds, 119, 132
following thyroide ctomy, 122, 139
twitching indica ting, 159, 171
Hypoca rbia , ca using bra dyca rdia , 120, 135
Hypoglyce mia , re bound, following TP, 109, 114
Hypoka le mia , 267, 282
Hypona tre mia , 224–225
se rum conce ntra tion de ficie ncy in, 114
volume ove rloa d ca using, 123, 139
Hypopa ra thyroidism, 119, 132
Hypopne a , intra dura l ma ss le sion a nd, 235, 254
Hypote nsion
a ssocia te d with high spina l a ne sthe sia , 228, 240
ca te gorie s of, 131
from ce lia c ple xus block, 232, 248
drugs ca using, 60, 86
from e xtra corpore a l shock wa ve lithotripsy, 124, 142
from ke ta mine , 122, 138
re tina l da ma ge from, 119, 132
risks re la te d to spina l cord injury, 212, 223
systolic blood pre ssure cha ra cte rizing, 162, 178–179
tre a tme nt of, in pa tie nts with ca rcinoid dise a se , 126, 145
va sopre ssin for, 34, 47
Hypothe rmia
a cute spina l cord injurie s a nd, 47
ma nife sta tion in infa nt, 161, 177
pre ve nting in infa nts unde r a ne sthe sia , 158, 169
Hypothe sis te sting, sta tistica l, 125, 143
Hypothyroidism, 187, 205–206
in Down syndrome pa tie nts, 124, 141
from long-te rm lithium the ra py, 145
sodium le vothyroxine for, 139
Hypove ntila tion, due to me ta bolic a lka losis, 43
Hypovole mia , 35, 48
Hypoxe mia , from ble omycin, 139
Hypoxia , 155, 163
due to ve ntila tion/pe rfusion misma tch, 119, 132
with low flow/close d circuit a ne sthe sia , 90, 96
port a cce ss robotic surge ry a nd, 265, 278–279
Hypoxic e de ma , compa rtme nt syndrome a nd, 151–152
Hypoxic ga s mixture s, de live ry, de te cting, 3, 13
Hyste re ctomy, for uncontrolle d ble e ding a t de live ry, 182, 195
I
Ibuprofe n, le ngth of a ntipla te le t e ffe ct of, 267, 283
IgA a ntibodie s, in tra nsfusion re a ctions, 110
Ina ppropria te se cre tion of ADH (SIADH), 224–225
Induction of a ne sthe sia
fa ctors a ffe cting ra te of, 92, 100
proportiona l to ra te of incre a se in F A/F I , 93, 102
with right-to-le ft intra ca rdia c shunts, 92, 100
tra nsposition of gre a t ve sse ls on, 260, 269
Infa nts
a ir le a ka ge a round e ndotra che a l tube s a t pe a k pre ssure , 156, 166
a ne sthe tic re quire me nt for, 99
a pne a risk following surge ry, 157, 167
blood volume of, 108, 112
body compa rtme nt volume s in, 155, 163
ca rdiopulmona ry re suscita tion te chnique s for, 160, 174
de fibrilla tor cha rge le ve l for, 157, 167–168
dura tion of a ne sthe tic e ffe ct of te tra ca ine in, 173–174
hypothe rmia in, 161, 177
MAC va lue for, 96
ma croglossia a bnorma lity in, 157, 168
norma l physiologic a ne mia in, 158, 170
postope ra tive a pne a in, 177
pre ducta l oxyge n sa tura tion for oxyge n the ra py in, 124, 142, 142t
re pa iring CDH (conge nita l dia phra gma tic he rnia ), 156, 166
re spira tory difficultie s due to dia phra gma tic he rnia , 158, 170
re suscita tion of fluid le ve ls in, 159, 171
succinylcholine dose , 157, 167
the rmore gula tion unde r a ne sthe sia , 169
Infe ctions, pre ca utions for use of ce ntra l ve nous ca the te rs, 219
Infe rior ische mia , right corona ry a rte ry blocka ge in, 126, 144
Infiltra tion a ne sthe tics, for e me rge ncy ce sa re a n de live ry, 186, 204
Infra re d spe ctrome te r
functioning of, 94, 104
wa ve form, 4, 4f, 17
Inguina l he rnia , 155, 163
postope ra tive a pne a in infa nts, 161, 177
Inha la tion a nthra x, 130, 153
Inha la tiona l a ne sthe tics, re cove ry from, corre la tion to blood/ga s
pa rtition coe fficie nt, 93, 102
Inhibitory pre syna ptic fibe rs, to ga strointe stina l tra ct, 236, 256
Inspira tory ba se line pha se , of ca pnogra m, 17
Inspira tory downstroke pha se , of ca pnogra m, 17
Inspira tory re se rve volume (IRV), 196
Inspira tory stridor, e piglottitis a nd la ryngotra che obronchitis a nd,
160, 174
Inspira tory va lve , e ffe ct of be ing stuck, 147
Insulin
a lle rgic re a ctions to prota mine a nd, 263, 275
pre pa ra tions, 84t
re na l dysfunction impa ct on me ta bolism of, 126, 146
re sista nce , in syndrome X, 128, 150
subcuta ne ous a dministra tion, 59, 84
Inte rcosta l spa ce
lidoca ine inje ctions a nd, 230, 245
orde r of structure s in, 230, 244
Inte rna tiona l Associa tion for the Study of Pa in (IASP), 239
Inte rsca le ne bra chia l ple xus block
dia phra gma tic move me nt indica ting ne e d to re dire ct ne e dle , 235,
252–253
disa dva nta ge s of, 227, 238
for shoulde r a rthroscopy, 233, 249
structure s e ncounte re d during pla ce me nt of, 235, 253–254
tota l spina l block from, 235, 253
Intra -a lve ola r pre ssure , in La pla ce ’s la w, 3, 14–15
Intra -a ortic ba lloon ca the te r, e ffe ctive infla tion of, 260, 270
Intra ca rdia c a ir, Dopple r de te ction of, 209, 219
Intra cra nia l hype rte nsion, 208, 214
a ne sthe tics re comme nde d for, 208, 215
ma in compe nsa tory me cha nism of body for, 209, 218, 218f
ma na ging, 211, 221
Intra cra nia l pre ssure (ICP)
a ne sthe tics tha t de cre a se , 212, 223
corticoste roids for ma na ging intra cra nia l hype rte nsion, 211, 221
drug e ffe cts on, 60, 86
five pe rce nt de xtrose in wa te r (D5W ) contra indica te d in
ne urosurgica l pa tie nts, 208, 215
hype rve ntila tion re ducing, 212, 223
intra cra nia l hype rte nsion, 208, 214
lowe ring of, 210, 219
signs consiste nt with e le va tion of, 225
Intra cra nia l volume s (ICVs), 218, 218f
Intra dura l ma ss le sion, 235, 254
Intra ocula r pre ssure
incre a se in, 123, 140
sulfur he xa fluoride a nd, 122, 139
Intra ope ra tive a wa re ne ss, unde r ge ne ra l a ne sthe sia , 7, 25
Intra pulmona ry shunts, 34, 47
Intra spina l na rcotics, pruritus a s side e ffe ct of, 183, 197
Intra the ca l opioids, mixing with loca l a ne sthe tics, 183, 197
Intra va scula r fluid-volume de ficits, in childre n, 170
Intra va scula r volume , re stora tion of, 109, 114
Intra ve nous drugs, pha rma cokine tics of, 51–89
Intra ve nous inje ction, pa in a t IV site , 59, 84
Intra ve nous re giona l a ne sthe sia (IVRA) (Bie r block)
a cce pta ble a ge nts for, 230, 243
loca l a ne sthe tics for, 229, 240
Intuba tion
a voiding na sa l intuba tion for pa tie nts with ba sa l skull or sinus
injurie s, 212, 224
che st tube for CDH tre a tme nt, 166
complica tions of tra che a l intuba tion, 4, 17
cuffe d versus uncuffe d e ndotra che a l tube s, 156, 165
e smolol re ducing re sponse to, 213, 225
muscle re la xa nts for, 56–57, 76–77, 79–80
ne uromuscula r blocka de impa cting muscle s of a irwa y, 55, 75
postintuba tion croup, 166
symptoms of ma inste m (bronchia l), 128, 148
tra che a l intuba tion for choline rgic crisis, 125, 142
tra che a l intuba tion for re ducing ute rine blood flow, 180, 189
Ipra tropium, for a irwa y dise a se pa tie nts, 138
Irra dia tion, for GVHD pre ve ntion, 110, 117
Ische mia
ce re bra l, See Ce re bra l ische mia
critica l CBF re la te d to, 219
right corona ry a rte ry blocka ge in infe rior, 126, 144
spina l cord ische mia , 209, 216–217
Ische mic optic ne uropa thy, 147
Ische mic pe numbra , 135
Isoflura ne
blood solubility coe fficie nt of, 91, 99
bronchospa sm a nd, 90, 97
ca rdioge nic shock impa ct on F A/F I ra te of incre a se of, 91, 97–98,
98f
cha ra cte ristics of, 105
e ffe cts of, 91, 99
e xpire d, 3, 17
he a rt ra te incre a se with, 91, 95, 95t, 97, 106f
impa ct on CBF a utore gula tion, 212, 224
MAC for, 4, 19, 19t, 158, 170
N2O a nd, 90, 97
soluble in rubbe r/pla stic, 94, 103
syste mic va scula r re sista nce re duce d by, 93, 101
va por pre ssure pe r millilite r of liquid, 25t
va porize r, 7, 24–25
wa shout of, 93, 102
Isoprote re nol, hype rcya notic a tta cks a nd, 264, 277–278
Isotonic crysta lloids, for fluid re suscita tion, 116
J
Ja ckson-Re e s bre a thing circuit, 9, 9f–10f, 28
K
Ke ta mine
drug se nsitivity a nd, 57, 78
impa cting CBF, 222
inhibition of N-me thyl-D-a spa rta te (NMDA) re ce ptors, 52, 65
minima l re spira tory de pre ssion, 44
myoca rdia l de pre ssa nt prope rtie s of, 122, 138
ove rvie w of, 52, 65
ra re ly ca using pa in a t IV site , 59, 84
re spira tory de pre ssion a nd, 58, 80
for te tra logy of Fa llot, 261, 273
unple a sa nt dre a ms a ssocia te d with, 52, 67
Ke toa cidosis, 30, 37
Ke torola c
contra indica te d for spina l fusion surge ry, 128, 149
e ffe cts on tra nsmission of pa inful stimuli, 53, 70
Kne e
fe mora l ne rve injury ca using muscle we a kne ss tha t e xte nd, 130,
154
scia tic ne rve injury ca using muscle we a kne ss be low, 130, 154
L
La ba t a pproa ch, scia tic ne rve block, 229, 242
La be ta lol, a s a dre ne rgic re ce ptor a nta gonist, 60, 86
La bor
See also Pre gna ncy
e pidura l for la bor pa in, 180, 189
e pidura l for se cond sta ge of la bor pa in, 184, 199–200
fe ta l a nd ma te rna l blood during, 184, 198–199
tocolytics for pre te rm, 180, 189
La cta te d Ringe r ’s solution, 157, 167
La mina r flow
fa ctors tha t influe nce the ra te of, 1, 10–11, 10f–11f
re spira tory syste m a nd, 7, 26
La pla ce ’s la w, for a sphe re , 3, 14–15
La rynge a l ma sk a irwa y (LMA), 224
La ryngospa sm, fa ctors ca using, 160, 176
La ryngotra che obronchitis (croup), inspira tory stridor a nd, 174
La rynx
a na tomy in infa nt a nd a dult, 175
motor inne rva tion of, 236, 257
se nsory inne rva tion a bove voca l cords, 236, 257
se nsory inne rva tion be low voca l cords, 236, 257
La se r, pe ne tra ting tissue s, 5, 20–21
La te ra l fe mora l cuta ne ous ne rve injury, 130, 154
Le ft-to-right intra ca rdia c shunt, 92, 100
a nd inha la tion induction of a ne sthe sia , 94, 103
Le ft-to-right shunt, a nd pa te nt ductus a rte riosus (PDA), 92, 100
Le ft-to-right tissue shunt, 92, 100
Le ft ute rine displa ce me nt (LUD), tre a ting complica tions of ce sa re a n
de live ry, 186, 205
Le ft ve ntricula r a ssist de vice
blood pre ssure monitoring a nd, 261, 272–273
inte rve ntions for, 263, 276
Le g, ina bility to a dduct due to obtura tor ne rve injury, 130, 154
Le ukocyte re duction, re ducing tra nsmission of cytome ga lovirus
(CMV), 112, 112t
Le ukope nia , with TRALI, 34, 47
Libby Zion La w, 146
Lidoca ine
in Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m, 159, 171
inte rcosta l inje ction for gre a te st se rum conce ntra tion of, 230, 245
in intra ve nous re giona l a ne sthe sia , 229, 240
ma ximum dose of, 58, 82, 227, 237
toxicity, signs of, 227, 237
tra nsie nt ne urologic syndrome (TNS) a nd, 187, 206
Liga me ntum fla vum, sign whe n e nte ring e pidura l spa ce , 228, 238
Line isola tion monitor, 6, 21
Lipid solubility
loca l a ne sthe tic pote ncy a nd, 228, 239
onse t/dura tion of a ction of fe nta nyl a nd morphine re la te d to, 54,
70–71
prolonging e pine phrine blocka de , 183, 197
Lispro (Huma log), 59, 84
Lithium
se da tive prope rtie s a nd e ffe cts of, 145
Lithotomy position, pe rone a l ne rve injury ca use d by, 130, 154
Live r
clotting fa ctor a nd, 110, 115
re pe rfusion pha se he modyna mic insta bility in tra nspla nta tion of,
128, 148
Loca l a ne sthe tics
a dding bica rbona te for pa in re duction, 233, 250
a mino e ste rs a nd a mino a mide s, 227, 238
a mount a dministe re d for lumba r e pidura l, 229, 241
conce ntra tion of, 230, 245
dose re quire d for ca rdiova scula r colla pse , 230, 244
Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m, 159, 171
incre a sing tota l dose to ha ste n/prolong e ffe ct, 232, 246
inje ction site in se rum conce ntra tion, 230, 245
intra the ca l na rcotic with, 183, 197
intra ve nous re giona l a ne sthe sia (Bie r block), 229, 240
with lowe st conce ntra tion in fe tus, 228, 240
ma ximum dose of e pine phrine in, 227, 237
pa iring of, 234, 251
prima ry de te rmina nt of pote ncy of, 228, 239
suba ra chnoid inje ction of, 233, 248
ta chyphyla xis to, 227, 237
toxicity, sign of, 227, 237
Losa rta n, blocking a ngiote nsin a t re ce ptor, 60, 86, 264, 277
Low-flow a ne sthe sia , a dva nta ge of, 90, 96
Low-mole cula r-we ight he pa rin (LMW H), 124, 141
a nticoa gula tion the ra py, monitore d with a nti-Xa a ssa y, 110, 115
ca utions be fore proce e ding with e pidura l for pa tie nts ta king, 233,
250
e noxa pa rin use with, 131
for thromboprophyla xis, 180, 188
Lowe r re spira tory infe ction, 157, 168
Lumba r blocks, for se cond sta ge of la bor pa in, 184, 199–200
Lung complia nce , pulmona ry e mphyse ma incre a sing, 130, 153
Lung volume /ca pa city, cha nge s during pre gna ncy, 183, 196
Lungs, ca rdia c output a nd, 93, 101
Lupus a nticoa gula nt, 193
Lusitropy, 266, 281
Luxury pe rfusion, 208, 215
M
Ma croglossia , a bnorma lity in infa nts, 157, 168
Ma croshock
microshock versus, 7, 25
minimum ma croshock curre nt ve ntricula r fibrilla tion, 6, 22
Ma gne sium sulfa te , a s a nticonvulsa nt for pa tie nts with
pre e cla mpsia , 180, 185, 189, 200
Ma gne tic re sona nce ima ging (MRI)
a ppropria te course of a ction if pa tie nt pinne d by la rge me ta llic
obje ct, 213, 225
pote ntia l da nge rs of, 129, 152, 209, 218
Ma inste m (bronchia l) intuba tion, symptoms of, 128, 148
Ma ligna nt hype rthe rmia (MH), 156, 166
clinica l signs of, 127, 148
da ntrole ne for tre a ting, 59, 85, 128, 148–149
a s disorde r of me mbra ne pe rme a bility to ca lcium, 122, 138–139
drug tre a tme nt for, 148–149
incre a se d e nd-e xpira tory CO2 te nsion indica ting, 121, 137
ne urole ptic ma ligna nt syndrome a nd, 124, 141–142
physiologic a nd pha rma cologic fa ctors impa cting, 126, 144, 145t
signs a nd mimicking dise a se s of, 121, 137–138
trismus signa ling onse t of, 122, 138
Ma lpra ctice cla ims, a ga inst a ne sthe siologists, 128, 149
Ma nic-de pre ssive illne ss, lithium the ra py for, 126, 145
Ma nnitol, oliguria obscure d by, 143
Ma ple son bre a thing circuit, cha ra cte ristics of D circuit, 161, 176
Ma ple son bre a thing circuits, type s of, 28
Ma sk ve ntila tion, pre dictors of difficulty with, 129, 151
Ma sse te r spa sm (trismus), a fte r succinylcholine a dministra tion, 122,
138
Ma te rna l de a th, le a ding ca use of, 180, 189
Ma ximum volunta ry ve ntila tion (MVV), 121, 137
Me a n a rte ria l pre ssure , ca lcula tion of, 260, 271
Me conium-sta ine d a mniotic fluid, in ne wborns, 183, 195
Me dia l thigh, obtura tor ne rve injury diminishing se nsa tion in, 130,
154
Me dia n ne rve
in a nte cubita l fossa , 230, 243
da ma ge to, 119, 133
Me dulla ry ca rcinoma , of thyroid, 133
Me nde lson syndrome , 200–201
Me pe ridine
a nticholine rgic prope rtie s of, 52, 65
contra indica te d in combina tion with se le giline (Elde pryl), 55, 75
loca l a ne sthe tic a nd na rcotic prope rtie s of, 198
proble ms a ssocia te d with a buse of, 183, 197
Me ta bolic a cidosis, 35, 49
a dve rse e ffe cts of, 33, 46
de ficit of HCO3- in, 49
hype rchlore mic, 37
prolonge d use of propofol ca using, 33
Me ta bolic a lka losis, 32, 43
Me ta bolic e quiva le nt (MET), 258, 268
Me ta bolism
e me rge nce from a ne sthe sia a nd, 93, 102
ha lotha ne a nd, 104
me ta bolic fa ctors producing nonde pola rizing ne uromuscula r
blocka de , 148
vola tile a ne sthe tics’ de gre e s of, 94, 104
Me tformin (Glucopha ge ), 119, 133
la ctic a cidosis a s side e ffe ct of, 56, 76
Me tha done
a buse of, 191–192
a s NMDA re ce ptor a nta gonist, 60, 88
pa re nte ra l-to-ora l conve rsion for, 150
Me the moglobine mia
ce ntra l cya nosis from, 141
re sulting in de sa tura tion, 29, 36
Me thionine synthe ta se , a nd N2O, 93, 102
Me thoxyflura ne , va por pre ssure a nd minimum a lve ola r
conce ntra tion, 19t
15-Me thyl PGF 2α, 185, 200
Me thyle ne blue , 58, 81
Me thylna ltre xone , 52, 555
Me toclopra mide , 53, 67
Me toprolol, discontinuing prior to e le ctive surge ry, 53, 68
Me ye r-Ove rton the ory, 136
Microshock, ma croshock versus, 7, 25
Mida zola m
a s be nzodia ze pine , 65–66
FDA Use -In-Pre gna ncy ra ting of D, 183, 197, 197t
re ducing unple a sa nt dre a ms a ssocia te d with ke ta mine , 52, 67
wa te r solubility of, 51, 63
Milrinone , 264, 278
compa re d to a mrinone , 265, 280
Minimum a lve ola r conce ntra tion (MAC)
a ssocia te d with oil/ga s pa rtition coe fficie nt, 120, 136
ca lcula ting, 92, 99–100, 125, 144
ha lotha ne /de sflura ne a nd, 91, 97
isoflura ne a nd, 4, 19
for ne ona te s, 90, 96
va por pre ssure a nd, 19t
Minute ve ntila tion (V‫ݵ‬E), 7, 25
CO2 inha la tion incre a sing, 30, 39
re la tionship to V‫ݵ‬D a nd Pa CO2, 30, 38, 38f
Miosis, e ye drops ca using, 120, 134
Mitra l ste nosis
in le ft ve ntricula r pre ssure -volume loop, 262, 262f, 273
re mife nta nil a nd, 266, 281–282
Miva curium, 62t
Mixe d ve nous he moglobin sa tura tion (S O2), ca lcula ting, 46
Mixe d ve nous O2 sa tura tion (S O2), 39f
myoca rdia l ische mia a nd, 266, 280–281, 280f–281f
Monoa mine oxida se inhibitor, discontinuing prior to e le ctive
surge ry, 53, 68
Monte luka st (Singula ir), 122, 138
Morphine
e pidura l versus intra the ca l dose s, 227, 237–238
onse t/dura tion compa re d with fe nta nyl, 54, 70–71
tre a ting postope ra tive pa in, 56, 76
Morphine sulfa te
de la ye d re spira tory de pre ssion a nd, 231, 246
pa re nte ra l-to-ora l conve rsion for, 129, 150
Motor e voke d pote ntia ls (MEPs), pha rma cologic a ge nts e ffe cting,
211, 222
Mucous me mbra ne s, of nose , se nsory inne rva tion of, 236, 256–257
Multifoca l a tria l ta chyca rdia (MAT), 30, 37
Multiple e ndocrine ne opla sia (MEN), 133
Muscle re la xa nts
a lle rgic re a ctions to, 123, 140
che mica l cla sse s of, 52, 66
da ntrole ne , 128, 148–149
for intuba tion, 56–57, 76–77, 79–80
se nsitivity to, 123, 139
Muscle tone , infa nt, 184, 199
Musculocuta ne ous ne rve , 236, 236b, 255, 256f
Mya sthe nia gra vis
a ssocia te d with incre a se d re sista nce to succinylcholine , 51, 63
e drophonium for, 142
Mydria sis
from phe nyle phrine , 125, 143–144
from scopola mine , 141
Myoca rdia l de pre ssion, from ke ta mine , 122, 138
Myoca rdia l infa rction, risks for, 29, 36
Myoca rdia l ische mia
e le ctrica l ca rdiove rsion for, 263, 275
indica tor of, 258, 268
S O2, 266, 280–281, 280f–281f
tra nse sopha ge a l e choca rdiogra ph (TEE) vie w for monitoring, 264,
277
Myoca rdia l O2 consumption
de te rmina nts of, 260, 270
norma l re sting, 262, 274
Myoca rdia l pota ssium home osta sis, ca rdia c dysrhythmia s, 44
Myoglobine mia , a s indica tor of rha bdomyolysis, 166
N
Na lme fe ne (Re ve x), 132
Na loxone , 132
re ve rse na rcotic-induce d toxicity, 56, 77
tre a ting nonmoving pa tie nt following wa ke -up te st, 211, 221
Na ltre xone (Re Via ), for tre a tme nt of he roin a ddicts, 119, 132
Na sa l ca nnula , ma ximum F IO2 de live ry, 5, 21
Na tiona l Institute for Occupa tiona l Sa fe ty a nd He a lth (NIOSH), 2, 14
Na use a
See also Postope ra tive na use a a nd vomiting (PONV)
a s side e ffe ct of fluma ze nil a dministra tion, 53, 70
tre a ting in Pa rkinson dise a se pa tie nt, 51, 63
Ne crotizing e nte rocolitis (NEC), 161, 177–178
Ne ona te s
a lve ola r ve ntila tion in, 37
a ne sthe tic re quire me nt for, 91, 99
bra dyca rdia in, 157, 167
ca rdiova scula r syste m of, 165t
e choca rdiogra m for a sse ssing a bnorma litie s, 167
e stima te d blood volume (EBV) in, 158, 169
he modyna mic indice s of, 156, 165
oxyge n consumption in, 159, 172
physiologic va ria ble s, 172t
postope ra tive ve ntila tory de pre ssion in, 158, 169
risk pe riod for re tinopa thy of pre ma turity (ROP), 155, 163–164
succinylcholine dose , 157, 167
the rmore gula tion in, 159, 171–172
Ne ostigmine
compa ring with Suga mma de x (ORG 25969), 58, 82
a s re ve rsa l a ge nt in surge ry with pre gna nt pa tie nts, 149
Ne rve disorde rs, a utonomic hype rre fle xia a s, 209, 216
Ne rve ga s poisoning
a tropine for tre a ting, 57, 78
signs of (DUMBELS), 33, 46
Ne urofibroma tosis (von Re cklingha use n dise a se ), 159, 172–173
Ne urole ptic ma ligna nt syndrome , cha ra cte ristics of, 141–142
Ne urologic injury, use of glucose -conta ining solutions a nd, 210, 219
Ne urolytic ne rve blocks, 232, 247
a lcohol versus phe nol, 229, 241
Ne uromuscula r blocka de
de gre e of, 126, 144
drugs use to prolong nonde pola rizing, 128, 148
impa cting muscle s of a irwa y, 55, 75
monitoring, 52, 66
re ve rsing with a nticholine ste ra se drugs, 136
Ne uromuscula r blocking drugs
ca rdiova scula r e ffe cts of, 66
clinica l a utonomic e ffe cts of, 67t
dura tion of a ction of, 62
nonde pola rizing, 55, 75
succinylcholine , 51, 63
Ne urontin (ga ba pe ntin), 127, 146
Ne uropa thic pa in, tre a tme nt of, 236, 255
Nitric oxide , 56, 77
Nitroglyce rin, for ische mia , 262, 273
Nitrous oxide (N2O)
ca lcula ting wa shin of, 93
ca rdia c output incre a se by, 90, 97
diffusion hypoxia a nd, 93, 93f, 101
histologic de te ction of, 93, 102
impa ct on SSEPs, 222
in pulmona ry va scula r re sista nce , 266, 281
substituting for a n e qua l MAC va lue of isoflura ne , 90, 97
sulfur he xa fluoride a nd, 139
tra nspulmona ry shunting a nd, 91, 98
N-me thyl-D-a spa rta te (NMDA) re ce ptors, ke ta mine inhibiting, 52, 65
Nonde pola rizing muscle re la xa nts
drugs e nha ncing ne uromuscula r blocka de , 53, 67–68
impa ct of a ging on, 55, 74
for the rma l injurie s, 123, 139
Nonde pola rizing ne uromuscula r blocka de
a nticholine ste ra se drugs ha ving a nta gonist e ffe ct on, 60, 88
me ta bolic a nd physiologic conditions contributing to, 148
Nonde pola rizing ne uromuscula r blocking drugs, compa ra tive
pha rma cology of, 62t
Noninva sive positive -pre ssure ve ntila tion (NIPPV), 49
Nonste roida l a nti-infla mma tory drugs (NSAIDs), contra indica tions
for, 149
Nore pine phrine , upta ke 1, 52, 67–73
Nutrice l, blood/RBC stora ge with, 109, 115
O
Obstructive sle e p a pne a , pre dictors in a dults, 128, 149
Obtura tor ne rve
injury to, 130, 154
inne rva tion of thigh, 231, 245
Octre otide , for ca rcinoid symptoms, 145
Oculoca rdia c re fle x (OCR), 159, 172
Oil/ga s pa rtition coe fficie nt, 120, 136
Oliguria
obscure d by furose mide , ma nnitol, a nd dopa mine , 125, 143
from pooling of urine in the dome of bla dde r, 121, 136
Ompha loce le , re pa iring in ne wborn, 157, 168
Onda nse tron
inte rfe re nce with, 143
for tre a tme nt of na use a in Pa rkinson dise a se pa tie nt, 51, 63
One -lung ve ntila tion, 34, 46
Ope n fe ta l surge ry, 185, 200
Opia te s, site of a ction for spina lly a dministe re d, 237–238
Opioids
e pidura l use of, 231, 246
me pe ridine a s opioid a gonist, 52, 65
na ltre xone a s opioid a nta gonist, 119, 132
withdra wa l, signs a nd symptoms of, 59, 85–86
O-positive RBCs, indica tions/contra indica tions for, 109, 114
Optisol, blood/RBC stora ge with, 109, 115
Ove rpre ssurizing
to a chie ve de sire d conce ntra tion, 94, 104
to incre a se the ra te of inha la tion induction, 94, 104
Oxyge n (O2)
a dministra tion of, ha za rds of, 129, 150–151
a dult re quire me nt for, 30
ca lcula ting conte nt of blood, 30, 38
ca use s of a ne sthe sia de live ry syste m fa ilure in de live ring
a de qua te , 6, 23
ce re bra l me ta bolic ra te for oxyge n (CMRO2), 209, 216
consumption in ne ona te s versus a dults, 159, 172
consumption in te rm fe tus, 182, 193–194
conte nt re la te d to he moglobin conce ntra tion, 30, 38
disconne ct line , 8, 26
flow through rota me te rs, 2, 12
during inha la tion induction, 93, 93t, 102, 102t
postope ra tive shive ring re la te d to, 82, 147
pre ssure -se nsor shut-off va lve , 2, 13
se cond-sta ge pre ssure re gula tor, 2, 13
supply to ope ra ting rooms, 7, 26
tra nsfusion to incre a se de live ry of, 123, 140
tre a ting ca rbon monoxide toxicity with, 45
Oxyhe moglobin dissocia tion curve , 33
a lte re d e rythrocyte 2,3-DPG me ta bolism ca using compe nsa tory
shift, 34, 47
ca rbon dioxide e ffe ct on, 45
le ftwa rd shift of, 42
P 50 le ve ls ca using shifts in, 42
rightwa rd shift of, 34, 47
Oxytocin (Pitocin), for tre a tme nt of ute rine a tony, 180, 189–190
P
P 50
for a dult he moglobin, 30, 39
shifting oxyhe moglobin dissocia tion curve a nd, 31, 42
vola tile a ne sthe tics incre a sing, 45
Pa ce ma ke rs
ca use s of ma lfunctioning of, 135
thre e - to five -le tte r code de scribing type a nd function, 19
uppe r tra cking ra te in, 262, 274
Pa cke d re d blood ce lls (PRBCs), 156, 165
Pa CO2
a pne a ca using incre a se in, 30, 37
a rte ria l te nsion a s de te rmina nt of CBF a nd CBV, 211, 221
for a sse ssing ve ntila tory de pre ssion, 39
CBF re la tionship to, 208, 214–215
ce re brova scula r re sponsive ne ss to, 220
hype rve ntila tion limits a nd, 213, 225
hype rve ntila tion re ducing intra cra nia l pre ssure (ICP), 212, 223
postope ra tive ma inte na nce ra nge , 208, 215
re spira tory a cidosis a nd, 31, 40
VAE ca using incre a se in, 213, 226
Pa in
in a bdomina l visce ra , 232, 247
a fte r re mife nta nil a dministra tion, 58, 82
bica rbona te a dde d to loca l a ne sthe tic for re ducing, 233, 250
ce ntra l, 233, 248–249
CRPS type I versus type II, 228, 239
de rma toma l distribution of, 229, 241
digita lis toxicity ca using, 237
drugs ca using pa in on inje ction, 86
a t intra ve nous site , 59, 84
la bor pa in, 256
ma na ging in infa nts following surge ry, 157
ne rve fibe rs a s pa in ca rrie rs, 254
ne uropa thic, tre a tme nt of, 236, 255
pha ntom limb, 229, 240
postope ra tive , ma na ge me nt of, 56, 76
spina l cord stimula tion for tre a ting chronic, 236, 255
thora cic, re la te d to a cute he rpe s zoste r, 238–239
tra nscuta ne ous e le ctrica l ne rve stimula tion (TENS) for re lie f of,
231, 246
Pa in fibe rs, to ute rus, 236, 256
Pa ncuronium
dura tion a nd me ta bolism of, 51, 62
inhibiting re upta ke of nore pine phrine , 56, 75–76
prolonge d e limina tion ha lf-time s for, in e nd-sta ge cirrhotic live r
dise a se , 57, 79
Pa ra -a minobe nzoic a cid, 233, 249
Pa ra thyroid gla nds, hypoca lce mia following re se ction of, 119, 132
Pa rkinson dise a se , 63
Pa rtia l pre ssure gra die nts
fa ctors de te rmining, 94, 103, 103t
with the vola tile sudde nly turne d off, the n on, 94, 103
Pa rtia l thrombopla stin time (PTT), 144
Pa ssive diffusion, of substa nce a cross pla ce nta , 184, 198
Pa te nt ductus a rte riosus
a rte ria l a ir e mbolism a nd, 258, 268
te tra logy of Fa llot a nd, 260, 271
Pa tie nt-controlle d a na lge sia (PCA) pump, 231, 246
Pe a k a irwa y pre ssure , 26
P ECO2, 217, 217f–218f
Pe dia tric physiology, a nd a ne sthe sia , 155–179
Pe n2, 217, 217f–218f
Pe rcuta ne ous corona ry inte rve ntions, 34, 48
Pe rica rdia l e ffusion, pre ssure in, 261, 272
Pe riope ra tive visua l loss, a ssocia te d with nonocula r surge ry, 127,
147
Pe riphe ra l ne rve s
four twitche s in ne rve stimula tors, 144
injury while unde r ge ne ra l a ne sthe sia , 118, 131
structure a nd function of, 233, 249
Pha ntom limb pa in
re a ctiva tion of pha ntom limb se nsa tions, 230, 244
Pha rma cology, 51–89
Pha rynge a l wa lls, se nsory inne rva tion to, 236, 257
Phe nol, ne urolytic blocka de with, 229, 232, 241, 247
Phe nothia zine s, a s a ntipsychotic drugs, 59, 83
Phe noxybe nza mine , ca using irre ve rsible blocka de , 59, 85
Phe nyle phrine
ca using mydria sis, 125, 143–144
dose for childre n a nd a dults, 160, 173
for hypote nsion, 262, 274
prolonging a ne sthe tic e ffe ct of lidoca ine , 229, 240
Phe ochromocytoma , me dulla ry ca rcinoma of the thyroid a nd, 119,
133
Phospha te , 109
Phre nic ne rve
C3-C5, 236, 256
inte rsca le ne block a nd, 235, 253–254
Physics, 1–28
Physiology
compa ring ne wborns with a dults, 160, 174
compa risons from ne ona te to a dult, 172t
physiologic fa ctors impa cting on MAC, 144, 145t
physiologic fa ctors producing nonde pola rizing ne uromuscula r
blocka de , 148
Physostigmine , 52, 58, 64–65, 80
Pin inde x sa fe ty syste m, 26–27
Pipe line proble ms, in oxyge n de live ry, 26
Pituita ry gla nd surge ry, dia be te s insipidus following, 120, 136
Pla ce nta pre via , 184, 199
Pla gue (Yersinia pestis), 153
Pla stic, a ne sthe tic loss to, 94, 103
Pla te le t conce ntra te (s)
incre a sing pla te le t count with, 107, 111
Rh ma tching in, 107, 111
Pla te le t(s)
ba cte ria l se psis re la te d to, 108, 112
incre a sing pla te le t count, 107, 111
stora ge re quire me nts of, 108, 113
te mpe ra ture s for, 108, 113
Pne umone ctomy, 123, 140–141
Pne umothora x
a s complica tion of supra cla vicula r bra chia l ple xus block, 245
Polyuria , from dia be te s insipidus, 120, 136
Poplite a l block, for a nkle a nd foot surge ry, 232, 248
Porphyria , 70
Port a cce ss robotic surge ry, disa dva nta ge of, 265, 278–279
Positive e nd-e xpira tory pre ssure (PEEP)
a dve rse e ffe ct of, 135
controlle d ve ntila tion with, 31, 40, 41f
te nsion pne umothora x a nd, 263, 275
tre a ting a spira tion syndrome s, 185, 200–201
Posta ne sthe tic discha rge scoring syste m (PADSS), 121, 137
Postdura l puncture he a da che (PDPH), 184, 199
a fte r spina l a ne sthe sia , 234, 252
ca use s of, 230, 244
Poste rior longitudina l liga me nt, in suba ra chnoid block pla ce me nt,
233, 250–251, 250f–251f
Poste rior tibia l ne rve
inne rva tion of gre a t toe by, 231, 246
inne rva tion of pla nta r surfa ce of foot, 230, 244
stimula ting to produce fle xion of toe s, 234, 252
Posthe rpe tic ne ura lgia , tre a tme nt of, 228, 238–239
Postintuba tion croup, 166
Postope ra tive na use a a nd vomiting (PONV), 128
pre dictors of, 148
prophyla xis for, 162, 179
a s side e ffe ct of e tomida te , 56, 75
type s of ope ra tions a nd, 160, 175
Postope ra tive pa in
ma na ge me nt of, 56, 76
ra pid dissipa tion of opioid e ffe ct a nd, 82
Post-te ta nic fa cilita tion, in nonde pola rizing a nd de pola rizing
blocka de , 60, 88
Pre ducta l a rte ria l blood sa mpling, 158
Pre e cla mpsia
hype rte nsion a ssocia te d with, 197–198
ma gne sium sulfa te for tre a tme nt of, 180, 185, 189, 200
Pre e cla mpsia -e cla mpsia , hype rte nsive disorde r of pre gna ncy, 188–
189
Pre gna ncy
See also La bor
a ortoca va l compre ssion significa nt in norma l pre gna ncy a t 20
we e ks, 185, 201
cha nge s during, 196
coca ine a buse during, 186, 204
hype rte nsive disorde rs of, 180, 188–189
lung volume /ca pa city cha nge s during, 183, 196
oxyhe moglobin dissocia tion curve rightwa rd shift from, 34, 47
propofol for hype rte nsive disorde rs of, 181, 190–191
Rh-positive RBC tra nsfusions a nd, 109, 114
Pre ope ra tive pulmona ry function te sts, for pne umone ctomy, 123,
140–141
Pre ssure -re lie f va lve s
incompe te nt, in me cha nica l ve ntila tor, 5, 21–22, 21f–22f
ve ntila tors, 3, 16, 16f–17f
Priloca ine , in Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m,
159, 171
Primipa ra s pa tie nts, 183, 196–197
Proca ina mide
“twisting of points” a nd, 267, 267f, 282
for W PW syndrome -a ssocia te d ta chyca rdia , 265, 280
Proca ine , pa ra -a minobe nzoic a cid a s me ta bolite of, 233, 249
Profound a ne mia , 35, 48
Prolonge d QT syndrome , 59, 85
Propofol
a fte r prolonge d se da tion of, 51, 540
bolus propofol to bind loca l a ne sthe tic, 235, 253
ca using pa in on inje ction, 60, 86
impa ct on CO2 re sponsive ne ss of ce re bra l va scula ture , 210, 220
intra ve nous a ne sthe tics for tre a ting ca rotid a rte ry dise a se , 223
prolonge d use , de ve lop la ctic a cidosis, 60, 86
Propofol infusion syndrome , 45, 540, 58, 80
from ca rbon monoxide inha la tion, 33, 45
Propra nolol, for a ntihype rte nsive the ra py, 51, 64
Prota mine
a nticoa gula tion from, 260, 270
in ne utra lizing he pa rin, 263, 275
Prote in C de ficie ncy, 193
Prothrombin time (PT), re storing to norma l ra nge , 107, 111
Proza c (fluoxe tine ), 127, 148
Pruritus, tre a tme nt of, 227, 237
Pse udocholine ste ra se
de cre a se d le ve ls of, in Huntington chore a , 123, 140
dibuca ine inhibiting, 118, 131
ha lf-life of, 54, 72
Psoa s compa rtme nt block, 232, 247–248
Pude nda l ne rve , 236, 256
Pulmona ry a rte ry ca the te r, 31, 39
migra tion, during ca rdiopulmona ry bypa ss, 259, 269
pla ce me nt, pe rcuta ne ous inse rtion site s for, 265, 280
Pulmona ry a rte ry (PA), not using PA ca the te rs with MRIs, 218
Pulmona ry a rte ry rupture , a the roma s a nd, 263, 275
Pulmona ry a spira tion, 2-4-6-8 rule , 177
Pulmona ry complica tions, ma ximizing FRC to pre ve nt, 29, 36, 120,
135
Pulmona ry e de ma
de cre a se d DLCO with, 136–137
with TRALI, 47
Pulmona ry e mphyse ma
FEV1/FVC ra tio de cre a se d with, 130, 153
incre a se d lung complia nce with, 130, 153
tota l lung ca pa city incre a se d with, 130, 153
Pulmona ry va scula r re sista nce (PVR)
a ir in pulmona ry a rte ry incre a sing, 211, 220
ca lcula ting, 29, 36, 36f
de cre a sing in ne wborns up to 2 months of a ge , 158, 169
functiona l re sidua l ca pa city a nd, 281
Pulmona ry ve nous blood, a ne sthe tic upta ke into, 90, 96, 98f
Pulse oxime te rs
a ccura cy of, 6, 22
distinguishing CO he moglobin from oxyhe moglobin, 129, 152
e rrone ous re a dings by, 30, 30f, 39
me a suring a rte ria l he moglobin sa tura tion (Sa O2), 4, 18, 18f
me a suring a rte ria l oxyge n sa tura tion, 126, 146
not using with MRIs, 218
Pulse -re pe tition fre que ncy (PRF), 10
Pulse d Dopple r ultra sound, 1, 10
Pulsus pa ra doxus, ca rdia c ta mpona de a nd, 260, 270–271
Pyloric ste nosis
ca using CNS de pre ssion of re spira tion, 158, 169
ca using ga strointe stina l obstruction in pe dia tric pa tie nts, 155, 164
Q
Que nching MRI, 225
R
Ra dia l ne rve , da ma ge ca using wrist drop, 119, 132–133
Ra pid-se que nce induction, for child with ce re bra l pa lsy, 158, 171
Re bre a thing, of e xpire d ga se s, 8, 27
Re cooling, a fte r ca rdiopulmona ry bypa ss, 264, 276
Re cove ry inde x, 55, 74
Re curre nt la rynge a l ne rve , voca l cords a nd, 230, 244
Re d-top e ye drops, ca using mydria sis, 134
Re fle x sympa the tic dystrophy, e tiology of, 228, 239
Re mife nta nil, 54, 60, 71, 71f, 87, 161, 178
dura tion of a ction of, 59, 84
me ta bolize d by e ste ra se s, 124, 142
mitra l ste nosis a nd, 266, 281–282
a s ultra short-a cting opioid, 82
Re na l dysfunction, impa ct on insulin me ta bolism, 126, 146
Re na l fa ilure
due to HUS, 178
fluoride toxicity a ssocia te d with, 136
Re sidua l volume (RV), FRC a nd, 30, 37, 38f, 38t
Re spira tion, difficultie s in infa nts with dia phra gma tic he rnia , 158,
170
Re spira tory a cidosis
a dve rse e ffe cts, 33, 46
Pa CO2 incre a se ca using, 31
Re spira tory a dve rse e ve nts, 176
Re spira tory a lka losis, 31, 40
Re spira tory de pre ssion
minima l re spira tory de pre ssion with ke ta mine , 44
pyloric ste nosis ca using, 169
Re spira tory indice s, ne ona te s versus a dults, 159
Re spira tory physiology, 29–50
Re spira tory ra te , 33, 45
incre a se by vola tile a ne sthe tics, 96
of infa nt, 159, 172
inha la tion a ge nts impa cting in child pa tie nt, 156, 165
Re strictive pulmona ry dise a se
de cre a se d FEV1 with, 130, 153
de cre a se d FRC in, 130, 153
norma l FEV1/FVC ra tio with, 130, 153
tota l pulmona ry complia nce de cre a se d in, 130, 153
Re tina l da ma ge , from hypote nsion, 119, 132
Re tinopa thy of pre ma turity (ROP)
fa ctors in, 163
O2 a dministra tion a nd, 150–151
risk pe riod in pre te rm ne ona te s, 155, 163–164
Re trobulba r block, 229, 242
Re trole nta l fibropla sia , See Re tinopa thy of pre ma turity (ROP)
Re ve rsa l a ge nts, for surge ry with pre gna nt pa tie nts, 128, 149
Rh ma tching, in proce ssing pla te le t conce ntra te s, 107, 111
Rha bdomyolysis, 166
Right-to-le ft intra ca rdia c shunt
de sflura ne a nd, 92, 100
slow ra te of induction of a ne sthe sia with, 92, 100
Rocuronium, 54, 56, 62t, 71, 76–77
Roma no-Wa rd syndrome , le ft ste lla te ga nglion blocka de for, 261,
272
Ropiva ca ine
ra tio of dosa ge re quire d for ca rdiova scula r colla pse , 244
re duce d ca rdia c toxicity with, 235, 253
Rota me te rs
a rra nge me nt of, 6, 24
oxyge n flow through, 2, 12
Thorpe tube in, 12
Rubbe r, a ne sthe tic loss to, 94, 103
S
Sa cra l ple xus, ne rve s origina ting from, 235, 253
Sa phe nous ne rve
inne rva tion of gre a t toe by, 231, 246
poplite a l block in, 232, 248
Sa rin ne rve ga s poisoning
a tropine for tre a ting, 57, 78
signs of (DUMBELS), 33, 46
Sca ve nging syste ms
kinking or occlusion of tra nsfe r tubing, 6, 22, 22f
in ope ra ting rooms, 3, 14
Scia tic ne rve
block, la ndma rks for, 229, 242
injury to, 130, 154
Scopola mine , 61, 89
contra indica te d for Alzhe ime r dise a se , 120, 136
cyclople gia from, 124, 141
mydria sis from, 141
ocula r e ffe cts of, 61, 89
a s re ve rsa l a ge nt, 149
Se da tion
blood-bra in ba rrie rs a nd, 61, 89
de xme de tomidine use d for, 78
Se izure s
a dministra tion of oxyge n for, 233, 249
fluma ze nil ca using, in chronic be nzodia ze pine use rs, 54, 72
Se le giline (Elde pryl), 55, 75
Se psis
with a cute re spira tory distre ss syndrome , 118, 131
pla te le t-re la te d, 108, 112
Se ptic shock, va sopre ssin de ficie ncy with, 47
Se rum bica rbona te , 181, 192
Se rum pota ssium conce ntra tion [K+]
pH le ve l, 33, 44
succinylcholine impa ct on, 53, 67
Se rum pota ssium le ve ls, 54, 71
Se rum sodium conce ntra tion
a cute de cre a se s in, tre a tme nt of, 122, 138
ca lcula ting dose ne e de d for corre ction of, 109, 114
Se voflura ne , 56, 75
compound A forma tion a nd, 94, 103
conce ntra tion in VRG, MG, VPG, 129, 150
de live re d through e nflura ne va porize r, 90, 97
de struction by ba ra lyme a nd soda lime , 94, 103
fre sh-ga s flow ra te of, 92, 100
inha la tion induction with, 156
loss of, 94, 103
with ne ona te s, 91, 99
syste mic va scula r re sista nce /he a rt ra te una ffe cte d by, 106, 95, 95t,
106f
upta ke of, 5, 20
va por pre ssure , 14t
va por pre ssure a nd minimum a lve ola r conce ntra tion, 19t
va porize r, 2, 14
Shive ring
clonidine for, 57, 79
tre a tme nt of postope ra tive , 58, 82, 127, 147
Shock, systolic blood pre ssure a nd, 162, 178–179
Shunt(s)
intra pulmona ry versus de a d spa ce , 34, 47
le ft-to-right intra ca rdia c, 92, 100
le ft-to-right tissue , 92, 100
right-to-le ft intra ca rdia c, 92, 100
tra nspulmona ry, a rte ria l pa rtia l pre ssure a nd, 91, 98
Sickle ce ll a ne mia , 149, 155, 163
Sickle ce ll he moglobin, 45
Silde na fil (Via gra ), 264, 278
Single -shot spina l a ne sthe tic, 131
Singula ir (Monte luka st), 122, 138
Sipple syndrome , 133
Sitting position, surgica l
common complica tions of, 217, 217f–218f
risk of VAE, 210, 220
Ske le ta l muscle spa sticity, indica ting ce re bra l pa lsy, 171
Sle e p de priva tion, clinica l pe rforma nce a nd, 126, 146
Sma llpox, 130, 153
e ffe ct of va ccine on, 130, 153
Sodium bica rbona te (Na HCO3)
e ffe cts of, during ma ssive blood tra nsfusion, 264, 277
in e ndotra che a l tube , 260, 271
Sodium chloride
for a cute de cre a se in se rum sodium, 138
tre a ting infa nt to re suscita te fluid le ve ls, 159, 171
Sodium le vothyroxine , for hypothyroidism, 139
Sodium nitroprusside (SNP)
cya nide toxicity a nd, 58, 83
fe noldopa m a s a lte rna tive to, 125, 144
Soft pa la te , se nsory inne rva tion of, 236, 256–257
Soma tose nsory e voke d pote ntia ls (SSEPs)
dorsa l columns of spina l tra ct a s ca rrie rs for, 208, 214
drug impa ct on, 5, 20
incre a se in la te ncy, 130, 152
monitoring ce re bra l corte x, 211, 221
pha rma cologic a ge nts e ffe cting, 211, 222
se nsitivity to vola tile a ne sthe tics, 211, 221
spina l cord ische mia ma nife sting via de cre a se d a mplitude a nd
incre a se d la te ncy, 209, 216–217
Somnole nce , signs consiste nt with e le va tion of ICP, 213, 225
Spill va lve , See Ve ntila tor pre ssure -re lie f va lve
Spina l a na tomy, 229, 240
Spina l a ne sthe sia , 229, 240
a dditive s posse ssing a na lge sic prope rtie s, 234, 251
de cre a se in he a rt ra te a nd, 240
de rma toma l le ve l for, 126, 145
dose /dura tion for a dult versus child, 129, 152
hypote nsion a ssocia te d with, 228, 240
ne rve blocka de in, 228, 238
re a ctiva tion of pha ntom limb se nsa tions, 230, 244
Spina l cord
ce re bra l a nd spina l cord injurie s contra indica ting use of glucose ,
210, 219
dorsa l columns a s ca rrie rs for SSEPs, 208, 214
of ne wborns e xte nding to L3 ve rte bra , 157, 168, 168f
Spina l cord ische mia , 209, 216–217
Spina l fusion, NSAIDs contra indica te d for, 149
Splitting ra tio
compa ring a ne sthe tic ga se s, 24t
in va ria ble -bypa ss va porize rs, 15
Sponta ne ous ve ntila tion, 9, 9f–10f, 28
Sta tus a sthma ticus, me dica tions for tre a ting, 57, 79
Ste lla te ga nglion
block, complica tion of, 234, 251
proximity to ve rte bra l a rte ry, 230, 243, 243f
Ste lla te ga nglion blocka de , for Roma no-Wa rd syndrome , 261, 272
Ste notic he a rt va lve s, pe rmuta tion in he modyna mics for, 266, 282
Stre ptomycin, for pla gue , 130, 152
Stroke
ca rotid a rte ry ste nosis incre a sing risk of, 211, 220
wa iting pe riod for ope ra tive proce dure s following occlusive
va scula r a ccide nt, 211, 220
Stroke volume , Fra nk-Sta rling curve a nd, 258, 258f, 268–269
Suba cute ba cte ria l e ndoca rditis prophyla xis, 258, 268
Suba ra chnoid ble e d, ce re bra l va sospa sm a nd, 129, 151
Suba ra chnoid block, a na tomic structure s tra ve rse d whe n
pe rforming, 233, 250–251, 250f–251f
Suba ra chnoid he morrha ge (SAH), 211, 221
Suba ra chnoid inje ction
fa ctors impa cting se nsory le ve l following, 228, 240
physiologic e ffe cts of inje cting la rge volume of loca l a ne sthe tics,
233, 248
Subcla via n ve in, ce ntra l line infe ction on, 264, 278
Succinylcholine , 57, 79–80
a ction of, 56, 78
bra dyca rdia due to a dministra tion of, 55, 74
ca re in combining with e chothiopha te for gla ucoma , 52, 66
ca using a pne a , 121, 136
dose for ne ona te s a nd infa nts, 157, 167
findings a fte r a dministra tion of, 53, 69
Huntington chore a a nd, 140
hype rka le mia a s side e ffe ct of, 53, 68
incre a se d se nsitivity with the rma l injurie s, 139
incre a sing se rum (K+), 67
re sista nce to ne uromuscula r blocka de with, 51, 63
ta chyca rdia induce d by, 55, 74
trismus following a dministra tion of, 122, 138
Suga mma de x (ORG 25969), disa dva nta ge of, 58, 82
Sulfhe moglobine mia , ce ntra l cya nosis from, 141
Sulfur he xa fluoride , 139
Supe rficia l pe rone a l ne rve , inne rva tion of gre a t toe by, 231, 246
Supe rior la rynge a l ne rve
bila te ra l da ma ge to, 137
cricothyroid muscle inne rva te d by, 229, 243
Supra cla vicula r bra chia l ple xus block
blocking trunks of bra chia l ple xus, 231, 246
common complica tion a ssocia te d with, 231, 245
pne umothora x a nd, 231, 245
Supra glottitis, ca using a irwa y obstruction, 170
Surgica l Ca re Improve me nt Proje ct (SCIP), 35, 49
Sympa the tic ne rve s
blocka de of, 228, 238
pa in in a bdomina l visce ra tra nsmitte d by, 232, 247
Sympa thomime tics, cla ssifica tion a nd compa ra tive pha rma cology
of, 65t
Syndrome X, insulin re sista nce in, 128, 150
Syste mic a bsorption, te rmina ting a ction of te tra ca ine , 228, 239
Syste mic infla mma tory re sponse syndrome (SIRS), 265, 280
Syste mic va scula r re sista nce
ca lcula tion of, 260, 271
re duction by isoflura ne , 93, 101
re duction by vola tile a ne sthe tics, 90, 97
Systolic blood pre ssure , 162
T
Ta chya rrhythmia s, pre ve nting in pa tie nts with Wolff-Pa rkinson-
W hite (W PW ) syndrome , 54, 72
Ta chyca rdia
de sflura ne ca using, 96
succinylcholine induce d, 55, 74
tre a ting with e le ctrica l de fibrilla tion, 167–168
Ta chyphyla xis, to loca l a ne sthe tics, 227, 237
Ta pe nta dol (Nucynta ), 60, 88
Te mpe ra ture monitoring, re lia ble site for ce ntra l, 5, 20
Te nsion pne umothora x, positive e nd-e xpira tory pre ssure a nd, 263,
275
Te rbuta line , 181, 190
Te sticula r inne rva tion, 145
Te ta nic stimulus, 60, 88
Te tra ca ine
dura tion of a ne sthe tic e ffe ct in infa nts, 173–174
te rmina ting a ction of, 228, 239
Te tra cycline , for pla gue , 130, 152
Te tra logy of Fa llot
a fte rloa d re duction a nd, 260, 270
ke ta mine for, 261, 273
pa te nt ductus a rte riosus a nd, 260, 271
The ra pe utic inde x, 91, 99
The rma l injurie s, ma ssive pota ssium re le a se with, 139
The rmore gula tion
for infa nts unde r a ne sthe sia , 169
in ne ona te s, 159, 171–172
Thie nopyridine , 48
Thigh, me dia l thigh se nsa tion diminishe d with obtura tor ne rve
injury, 130, 154
Thiocya na te toxicity, 36
Thiope nta l
ce re bra l pha rma cologic profile of, 224
tre a ting ca rotid a rte ry dise a se , 223
Thora cic pa ra ve rte bra l blocks, complica tion of, 232, 248
Thorpe tube , in rota me te rs, 4, 12, 13f, 19
Thrombin time , 115
Thrombocytope nia , from a mrinone , 265, 280
Thromboe la stogra m, fibrinolysis on, 263, 263f, 276
Thumb
a bduction of, 234, 252
corre sponding de rma tome of, 232, 246
numbne ss indica ting C6 ne rve root irrita tion, 235, 252
Thymol, in ha lotha ne , 94, 103
Thyroid, me dulla ry ca rcinoma of, 133
Thyroid stimula ting hormone (TSH), to confirm e uthyroid sta te , 122,
139
Thyroid surge ry, postope ra tive complica tions of, 121, 137
Thyroide ctomy
ca use of a irwa y obstruction following, 132
hypoca lce mia following, 122, 139
Ticlopidine , le ngth of a ntipla te le t e ffe ct of, 267, 283
Tida l volume (VT)
ca lcula ting ve ntila tor de live ry of, 3, 15
de cre a se by vola tile a ne sthe tics, 90, 96
ne ona te s versus a dults, 172
work of bre a thing a nd, 29, 31, 39
Time consta nts
ca lcula ting, 95, 104–105
in ca lcula tion of N2O wa shin, 93, 102
Tirofiba n, a nticoa gula tive prope rtie s of, 59, 84–89
Tissue me ta bolic ra te , during ca rdiopulmona ry bypa ss, 260, 270
Tongue , poste rior third of, se nsory inne rva tion to, 236, 256–257
Tonsille ctomy, postope ra tive ble e ding, 159, 173
Tonsils, se nsory inne rva tion to, 236, 256–257
Tota l body wa te r
compa ring physiology of ne wborns with a dults, 174
in infa nts, 163
Tota l lung ca pa city (TLC), incre a se d with pulmona ry e mphyse ma
a nd chronic bronchitis, 130, 153
Tota l pa re nte ra l nutrition (TPN), 30, 109, 114
Tota l pulmona ry complia nce , de cre a se d with re strictive pulmona ry
dise a se , 130, 153
Tra che a l ca pilla ry a rte riola r pre ssure , 118, 131
Tra che a l re se ction, contra indica tion for me cha nica l ve ntila tion, 134
Tra che oe sopha ge a l fistula (TEF)
a ne sthe sia for pa tie nts with, 157
ca use s of, 155, 155f–156f, 164
initia l symptom of, 157, 168
Tra in-of-four (TOF) stimula tion, monitoring ne uromuscula r
blocka de , 52, 66
Tra ma dol (Ultra m), 143
Tra nscuta ne ous e le ctrica l ne rve stimula tion (TENS), me cha nism of,
231, 246
Tra nse sopha ge a l e choca rdiogra ph (TEE), 209, 217, 217f–218f
for myoca rdia l ische mia monitoring, 264, 277
Tra nsfusion-re la te d a cute lung injury (TRALI), 108, 112
ke y fe a ture s of, 34, 47
prima ry ca use of tra nsfusion-re la te d fa ta litie s, 108, 112
Tra nsfusions
blood stora ge crite ria , 108, 115
citra te toxicity in, 109, 113
he molytic re a ctions to, 107, 111
infe ctions tra nsmitte d by, 108, 112, 112t
morta litie s a ssocia te d with, 110, 116, 116t
situa tions re quiring type O, Rh-ne ga tive blood, 108, 113
Tra nsie nt ne urologic symptoms, a fte r spina l a ne sthe sia , 232, 247
Tra nsie nt ne urologic syndrome (TNS), 187, 206
Tra nsposition of gre a t ve sse ls, a ne sthe sia induction a nd, 260, 269
Tra nspulmona ry pre ssure , work of bre a thing a nd, 31, 39
Tra nspulmona ry shunt
a rte ria l pa rtia l pre ssure a nd, 91, 98
ca lcula ting, 32, 43, 43f
Tra nssphe noida l hypophyse ctomy, 127, 147, 212, 224
Tra nsure thra l re se ction, of prosta te gla nd, 139
Tra nsva gina l oocyte re trie va l (TVOR), for a ssiste d re productive
te chnique , 182, 192–193
Tra nsve rsus a bdominis pla ne (TAP) block, 234, 252
Tra uma tic bra in injury, 34, 47
Tre nde le nburg position, 33, 46
e ndotra che a l tube migra tion from, 139
pooling of urine in the dome of bla dde r with, 121, 136
Tricyclic a ntide pre ssa nts, 59, 83–84
Trige mina l ne rve , 129, 151
Trismus (ma sse te r spa sm), a fte r succinylcholine a dministra tion,
122, 138
Trisomy 21, See Down syndrome
Truncus a rte riosus, a na stomosis for, 260, 270
Trypta se , me a suring in a na phyla ctic re a ctions, 147–148
D-Tubocura rine , ca using re le a se of hista mine s, 57, 79–80
Turbule nt flow, 2, 14
“Twisting of points,” proca ina mide a nd, 267, 267f, 282
Twitching, a s indica tor of hypoca lce mia , 159, 171
2-4-6-8 Rule , 177
Type O, Rh-ne ga tive blood (unive rsa l donor blood), 108, 113
Type -O positive RBCs, tra nsfusion of, 109, 114
U
Ulna r ne rve , 234, 252
ide ntifying on ultra sound, 236, 236b, 256, 256f
injury to, 118, 131
spa ring of, 227, 238
Ultra m (tra ma dol), 143
Ultra sound
use in re giona l a ne sthe sia , 7, 25, 232, 247
use with ce ntra l ve nous ca the te rs, 45
Umbilica l a rte ry
ne wborn’s circula tion, 161, 178
versus umbilica l ve in, ca the te riza tion, 159, 171
Umbilica l cord
compre ssion, 201–202
norma l va lue s, 186, 203, 203t
Unfra ctiona te d he pa rin (UFH), for a nticoa gula tion the ra py, 115
Unive rsa l compre ssion-ve ntila tion ra tio, 34, 48
Unive rsa l donor blood (type O, Rh-ne ga tive ), 108, 113
Uppe r tra cking ra te (UTR), in pa ce ma ke rs, 262, 274
Urina ry ca the te rs, not using with MRIs, 218
Urine output, de te rmining mild de hydra tion in child by obse rving,
159
Ute rine a tony
ca using postpa rtum he morrha ge , 189–190
tre a tme nt of, 180, 189–190
Ute rine blood flow, incre a se of, 181, 191
Ute rine re la xa tion, inha la tion a ne sthe tics producing, 184, 198
Ute rus
ce lia c ple xus block a nd, 231, 246
pa in fibe rs to, 236, 256
V
Va ccine , e ffe ct on sma llpox, 130, 153
Va por pre ssure
a ne sthe tic va por pre ssure , a nd splitting ra tio, 24t
cha ra cte ristics of vola tile a ne sthe tic, 3, 15
compa ring a ne sthe tic ga se s, 14t
compa ring e nflura ne to se voflura ne , 90, 97
a nd minimum a lve ola r conce ntra tion, 19t
pe r millilite r of liquid, 25t
Va porize rs
ca lcula ting output, 4, 18
composition of ca rrie r ga s a ffe cting output of, 17
va ria ble -bypa ss a nd me a sure d-flow, 15
for vola tile a ne sthe tics, 3, 15
Va scula r syste m
CBF re la tionship to Pa CO2, 210, 219
ce re bra l va scula r occlusion, 211, 220
Va soconstrictors, 173
Va sodila tors
intra ve nous, e ffica cy of, 77t
vola tile a ne sthe tics a s, 223
Va sopre ssin, 31, 40
a ntidiure tic hormone (ADH) a nd, 224–225
for dia be te s insipidus, 136
for hypote nsion, 34, 47
Va sopre ssor a ge nts, e phe drine a s, 52, 65, 65t
Va sospa sm, tre a ting ce re bra l va sospa sm following SAH, 212, 223–
224
V‫ݵ‬D/VT ra tio (physiologic de a d-spa ce ve ntila tion)
Bohr de a d-spa ce e qua tion, 38, 38f
ca lcula te , 32, 42, 42f
Ve curonium
ne uromuscula r e ffe cts of a n intuba tion dose of, 56, 77
Ve ins, ca nnula ting or de ca nnula ting ce ntra l ve ins, 46
Ve nous a ir e mbolism (VAE)
ca nnula ting or de ca nnula ting ce ntra l ve ins, 46
ne urosurge ry in upright position a nd, 213, 226
risk fa ctors in, 210, 220
tra nse sopha ge a l e choca rdiogra phy for de te rmining, 209, 217f–218f
tre a ting, 210, 220
Ve nous blood, 95, 105
Ve nous re turn ca nnula positioning, during ca rdiopulmona ry bypa ss,
259, 269
Ve ntila tion
a ssiste d/controlle d, 31, 40, 41f
controlle d with PEEP, 40, 41f
me cha nica l, 40, 41f
Ve ntila tion/pe rfusion misma tch, 119, 132
Ve ntila tion/pe rfusion ra tio, 32, 43
Ve ntila tor pre ssure -re lie f va lve , 16, 16f–17f
Ve ntila tor ra te , 3, 15
Ve ntila tors
compre ssion volume , in volume -cycle d ve ntila tor, 29, 36, 36f
driving force of, 1, 10
Ve ntila tory de pre ssion, 169
See also Re spira tory de pre ssion
Ve ntricula r a rrhythmia s, 51, 64
Ve ntricula r conductive de la y, 149–150
Ve ntricula r ta chyca rdia , e le ctrica l ca rdiove rsion for, 261, 272
Ve ra pa mil, combine d with da ntrole ne incre a sing risk of
hype rka le mia , 59, 85
Ve rnitrol, 91, 99
Ve rte bra l a rte ry, ste lla te ga nglion a nd, 230, 243, 243f
Ve sse l-rich group (VRG), 150, 150f
ca rdia c output to, 91, 98
orga ns include d in, 91, 98
Visua l loss, pe riope ra tive , 127, 147
Vita l ca pa city, of ma n, 31, 40
Voca l cords
inne rva tion to ca rina , 236, 257
re curre nt la rynge a l ne rve a nd, 230, 244
Vola tile a ne sthe tics, 55, 75, 90, 96
a lve ola r pa rtia l pre ssure of, 90–91, 96–98, 98f
bronchodila tion in, 92, 100
ca rdia c output incre a se by, 90, 97
fa ctors in lowe r MAC, 102
impa ct on SSEPs, 211, 221
MAC re duction by, 93
pha rma cokine tics of, 95, 105
ra te of input of, 91, 99
re cove ry from, 93, 102
re se rvoirs of, 94, 104
a nd slow induction, 93, 102
a s va sodila tors, 223
VT de cre a se a nd re spira tory ra te incre a se by, 90, 96
Volume -cycle d ve ntila tor, 29, 36
Volume ove rloa d, during tra nsure thra l re se ction of the prosta te
gla nd, 123, 139
von Hippe l-Linda u dise a se , 133
von Re cklingha use n dise a se , 159, 172–173
von W ille bra nd dise a se
most common inhe rite d coa gulopa thy, 107, 111
tre a tme nt of, 110, 116
W
Wa ke -up te sts, 211, 221
Wa ll-motion a bnorma litie s, in myoca rdia l ische mia , 258, 268
Wa shin
of the a ne sthe sia circuit, 94, 104
of nitrous oxide , 93, 102
We ight
ca lcula ting, 120, 134
ca rdia c output incre a se a ccording to, 125, 144
We st Nile virus, 112, 112t
W hole blood, 109, 113
CPDA, 109, 115
stora ge life of, 109, 115
W ide ne d me dia stinum, 34, 48
W ilms tumor (ne phrobla stoma ), 161, 178
Wolff-Pa rkinson-W hite (W PW ) syndrome , 54, 72
Work of bre a thing, 31, 39
Wrist drop, due to ra dia l ne rve da ma ge , 119, 132–133
Y
Yersinia pestis (pla gue ), 153
Z
Zile uton, for a sthma , 138

Hall

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Hall

Transféré par

Droits d'auteur :

Formats disponibles

Anesthesia

Acknowle dgme nts

Cha pte r 1. Ane sthe sia Equipme nt a nd Physics

Part 2. Clinical Sciences

Cha pte r 5. Blood Products, Tra nsfusion, a nd Fluid The ra py

Cha pte r 6. Ge ne ra l Ane sthe sia

Cha pte r 7. Pe dia tric Physiology a nd Ane sthe sia

Cha pte r 8. Obste tric Physiology a nd Ane sthe sia

Cha pte r 9. Ne urologic Physiology a nd Ane sthe sia

Cha pte r 11. Ca rdiova scula r Physiology a nd Ane sthe sia

1600 John F. Ke nne dy Blvd.

ANESTHESIA: A COMPREHENSIVE REVIEW, FIFTH

EDITION ISBN: 978-0-323-28662-6

No pa rt of this publica tion ma y be re produce d or tra nsmitte d in a ny

This book a nd the individua l contributions conta ine d in it a re

Pra ctitione rs a nd re se a rche rs must a lwa ys re ly on the ir own

W ith re spe ct to a ny drug or pha rma ce utica l products ide ntifie d,

To the fulle st e xte nt of the la w, ne ithe r the Publishe r nor the

Library of Congress Cataloging-in-Publication Data

Ex ecutive Content Strategist: W illia m Schmitt

Printe d in the Unite d Sta te s of Ame rica

La st digit is the print numbe r: 9 8 7 6 5 4 3 2 1

Dawit T. Haile, MD, Assista nt Profe ssor of Ane sthe siology,

Keith A. Jones, MD, Profe ssor a nd Cha irma n, De pa rtme nt of

Kent Rehfeldt, MD, Assista nt Profe ssor of Ane sthe siology,

C. T homas Wass, MD, Associa te Profe ssor of Ane sthe siology,

Francis X. Whalen, MD, Assista nt Profe ssor of Ane sthe siology,

Chapter 1. Anesthesia Equipment and Physics

DIRECT IONS (Que stions 1 through 90): Ea ch que stion or

The ca pnogra m wa ve form a bove re pre se nts which of the

The a rrows in the figure a bove indica te

DIRECT IONS (Que stions 87 through 90): Ma tch the figure s

87. Be st for sponta ne ous ve ntila tion

8. (B) Che ck va lve s pe rmit only unidire ctiona l flow of ga se s. The se

Agent Vapor Pressure mm Hg at 20° C

17. (B) Turbule nt flow occurs whe n ga s flows through a re gion of

31. (D) Va porize r output ca n be a ffe cte d by the composition of the

W he re ΔP is the pre ssure gra die nt; V is the me a sure d ve locity

Using a n e mpiric ca libra tion curve tha t re la te s a rte ria l

MAC, minimum alveolar concentration.

BP, blood pressure; VP, vapor pressure.

Give n tha t 1 mL of isoflura ne liquid yie lds 195 mL of a ne sthe tic

Gas United States International

DIRECT IONS (Que stions 91 through 168): Ea ch of the que stions

91. A 29-ye a r-old ma n is a dmitte d to the inte nsive ca re unit (ICU)

A. Sponta ne ous ve ntila tion

92. (C) The me ta bolism of nitroprusside in the body re quire s the

Measurement Abbreviation Normal Adult Value

103. (A) The volume of ga s in the conducting a irwa ys of the lungs

whe re VD/VT is the ra tio of VD to VT, a nd a a nd E re pre se nt a rte ria l

whe re [Hgb] is the he moglobin conce ntra tion (g/dL), Sa o 2 is the

whe re Hgb is he moglobin conce ntra tion, 13.9 is a consta nt (O2

(Barash : Clinical Anesth esia, ed 7, pp 276–277; West: Respiratory

whe re Cc′, Ca , a nd sta nd for the conte nt of oxyge n in the

169. W hich of the following muscle re la xa nts is e limina te d the most

200. 100 mg succinylcholine is a dministe re d to a 70-kg a ne sthe tize d

C. Slowly inje ct dilute (0.1 mEq/L) [HCO3–]

a ne sthe sia . Onda nse tron 4 mg IV is a dministe re d a s na use a

50 mg of pre dnisone (De lta sone )?

A. 100 mg cortisol (Solu-Corte f)

B. 80 mg me thylpre dnisolone (Solu-Me drol)

C. 7.5 mg de xa me tha sone (De ca dron)

D. 4 mg be ta me tha sone (Ce le stone )

ta ke s cime tidine (Ta ga me t) 400 mg a t night. An a dditiona l dose is