MCQ FOR BARASH - Connelly PDF

Table of Contents
Front ................................................................................................................................................................................................................ 1
Cover ....................................................................................................................................................................................................... 1
Copyright ................................................................................................................................................................................................ 2
Editors ...................................................................................................................................................................................................... 4
Dedication .............................................................................................................................................................................................. 6
Preface .................................................................................................................................................................................................... 7
Acknowledgments .............................................................................................................................................................................. 8
Contents .................................................................................................................................................................................................. 9
I. Introduction to Anesthesiology .......................................................................................................................................... 12
1. History of Anesthesia ................................................................................................................................................................ 12
2. Scope of Practice ....................................................................................................................................................................... 23
3. Occupational Health .................................................................................................................................................................. 29
4. Anesthetic Risk, Quality Improvement & Liability ........................................................................................................ 34
II. Scientific Foundations of Anesthesia .......................................................................................................................... 40
5. Mechanisms of Anesthesia & Consciousness ................................................................................................................ 40
6. Genomic Basis of Perioperative Medicine ...................................................................................................................... 43
7. Pharmacologic Principles ....................................................................................................................................................... 47
8. Electrical & Fire Safety ............................................................................................................................................................ 55
9. Experimental Design & Statistics ........................................................................................................................................ 59
III. Anatomy & Physiology ........................................................................................................................................................... 67
10. Cardiovascular Anatomy & Physiology .......................................................................................................................... 67
11. Respiratory Function ............................................................................................................................................................... 75
12. Immune Function & Allergic Response .......................................................................................................................... 85
13. Inflammation, Wound Healing & Infection .................................................................................................................... 90
14. Fluids, Electrolytes & Acid Base Physiology ................................................................................................................ 97
15. Autonomic Nervous System ............................................................................................................................................. 110
16. Hemostasis & Transfusion Medicine ............................................................................................................................ 123
IV. Anesthetic Agents, Adjuvants & Drug Interaction ......................................................................................... 134
17. Inhaled Anesthetics .............................................................................................................................................................. 134
18. Intravenous Anesthetics ..................................................................................................................................................... 140
19. Opioids ...................................................................................................................................................................................... 151
20. Neuromuscular Blocking Agents .................................................................................................................................... 160
21. Local Anesthetics .................................................................................................................................................................. 168
22. Drug Interactions ................................................................................................................................................................... 177
V. Preanesthetic Evaluation & Preparation ............................................................................................................... 183
23. Preoperative Patient Assessment & Management ................................................................................................. 183
24. Malignant Hyperthermia & Other Inherited Disorders ........................................................................................... 188
25. Rare & Co-existing Diseases ........................................................................................................................................... 192
26. The Anesthesia Workstation & Delivery Systems .................................................................................................. 201
VI. Anesthetic Management ................................................................................................................................................... 213
27. Standard Monitoring Techniques .................................................................................................................................... 213
28. Echocardiography ................................................................................................................................................................. 224
29. Airway Management ............................................................................................................................................................ 236
30. Patient Positioning & Related Injuries ......................................................................................................................... 247
31. Monitored Anesthesia Care .............................................................................................................................................. 253
32. Ambulatory Anesthesia ....................................................................................................................................................... 262
33. Office Based Anesthesia ................................................................................................................................................... 267
34. Anesthesia Provided at Alternate Sites ....................................................................................................................... 270
35. Anesthesia for the Older Patient .................................................................................................................................... 274
36. Anesthesia for Trauma & Burn Patients ...................................................................................................................... 279
37. Epidural & Spinal Anesthesia .......................................................................................................................................... 291
38. Peripheral Nerve Blockade .............................................................................................................................................. 304
VII. Anesthesia for Surgical Subspecialties .............................................................................................................. 312
39. Anesthesia for Neurosurgery ........................................................................................................................................... 312
40. Anesthesia for Thoracic Surgery .................................................................................................................................... 321
41. Anesthesia for Cardiac Surgery ...................................................................................................................................... 337
42. Anesthesia for Vascular Surgery .................................................................................................................................... 350
43. Obstetrical Anesthesia ........................................................................................................................................................ 357
44. Neonatal Anesthesia ............................................................................................................................................................ 366
45. Pediatric Anesthesia ............................................................................................................................................................ 374
46. Gastrointestinal Disorders ................................................................................................................................................. 384
47. Anesthesia & Obesity .......................................................................................................................................................... 388
48. Hepatic Anatomy, Function & Physiology .................................................................................................................. 394
49. Endocrine Function .............................................................................................................................................................. 402
50. Anesthesia for Otolaryngologic Surgery ..................................................................................................................... 415
51. Anesthesia for Ophthalmologic Surgery ..................................................................................................................... 422
52. The Renal System & Anesthesia for Urologic Surgery ......................................................................................... 429
53. Anesthesia for Orthopedic Surgery ............................................................................................................................... 434
54. Transplant Anesthesia ......................................................................................................................................................... 442
VIII. Perioperative & Consultative Services .............................................................................................................. 450
55. Post Anesthesia Recovery ................................................................................................................................................ 450
56. Critical Care Medicine ........................................................................................................................................................ 461
57. Acute Pain Management ................................................................................................................................................... 470
58. Chronic Pain Management ............................................................................................................................................... 478
59. Cardiopulmonary Resuscitation ..................................................................................................................................... 483
60. Disaster Preparedness ....................................................................................................................................................... 490
Review of Clinical Anesthesia, 5e [Vishal] Cover
1 / 494
Review of Clinical Anesthesia, 5e [Vishal] Copyright
2009
Lippincott Williams & Wilkins
Philadelphia
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Library of Congress Cataloging-in-Publication Data
Review of clinical anesthesia / edited by Neil Roy Connelly, David G. Silverman. – 5th ed.
p. ; cm.
ISBN-13: 978-0-7817-8951-6
ISBN-10: 0-7817-8951-6
1. Anesthesiology–Examinations, questions, etc. 2. Anesthesia–Examinations, questions, etc.
I. Connelly, Neil Roy. II. Silverman, David G.
[DNLM: 1. Anesthesia–Examination Questions. 2. Anesthesiology–Examination Questions.
WO 218.2 R454 2009]
RD82.3.R48 2009
617.9′6076–dc22
2008056103
Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible
for errors or omissions or for any consequences from application of the information in this book
2 / 494
Review of Clinical Anesthesia, 5e [Vishal] Copyright
and make no warranty, expressed or implied, with respect to the currency, completeness, or
accuracy of the contents of the publication. Application of the information in a particular
situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with current recommendations and practice at the
time of publication. However, in view of ongoing research, changes in government regulations,
and the constant flow of information relating to drug therapy and drug reactions, the reader is
urged to check the package insert for each drug for any change in indications and dosage and
for added warnings and precautions. This is particularly important when the recommended
agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
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responsibility of the health care provider to ascertain the FDA status of each drug or device
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3 / 494
Review of Clinical Anesthesia, 5e [Vishal] Editors
Edited By
Neil Roy Connelly MD
Professor of Anesthesiology
Tufts University School of Medicine; Director of Anesthesia Research, Department of
Anesthesiology, Baystate Medical Center, Springfield, Massachusetts
David G. Silverman MD
Professor and Director of Clinical Research
Department of Anesthesiology, Yale University School of Medicine; Medical Director of Pre-
Admission Testing, Yale–New Haven Hospital, New Haven, Connecticut
Contributing Authors
Contributors
Tim Abbott DO
Resident in Anesthesiology
Department of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts

Director of Anesthesiology Research
Baystate Medical Center, Springfield, Massachusetts; Professor of Anesthesiology, Tufts
University School of Medicine
Katharine O'Donnell Freeman MD

Assistant Section Chief, Pediatric Anesthesia
Baystate Medical Center, Springfield, Massachusetts; Assistant Professor, Tufts University
School of Medicine
Kamel H. Ghandour MD
Anesthesiologist
The Stamford Hospital, Stamford, Connecticut
David Han MD
Anesthesiology Resident
University of California, Los Angeles, Medical Center, Los Angeles, California
Wandana Joshi DO
Medical Director, Anesthesiology
Holyoke Medical Center, Holyoke, Massachusetts
Matthew R. Keller DO
Anesthesiology Resident
Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
Brian Kiessling MD
4 / 494
Review of Clinical Anesthesia, 5e [Vishal] Editors
Chief of Anesthesia
Northwest Michigan Surgery Center, Traverse City, Michigan
Albert Lim DO
Tanya Lucas MD
Section Chief, Obstetrical Anesthesia
Baystate Medical Center, Springfield, Massachusetts, Assistant Professor of Anesthesiology,
Tufts University School of Medicine
Karthik Raghunathan MD, MPH

Department of Anesthesiology and Critical Care, Baystate Medical Center, Springfield,
Massachusetts; Assistant Professor of Anesthesiology, Tufts University School of Medicine
Armin Rahimi DO
Pain Management Services, South County Anesthesia, St. Anthony's Medical Center, St.
Louis, Missouri
Stelian Serban MD
Assistant Professor of Anesthesiology and Pain Medicine; Director of Acute and Chronic
Inpatient Pain Service
Mount Sinai Medical Center, New York, New York
Lakshmi Priya Yalavarthy MD

5 / 494
Review of Clinical Anesthesia, 5e [Vishal] Dedication
Dedication
THIS BOOK IS DEDICATED TO OUR WIVES, ANN GIANCASPRO CONNELLY AND SALLY
KNIFFIN, TO OUR CHILDREN, KEVIN MATTHEW AND ELLEN ALEKSANDRA CONNELLY
AND TYLER AND CHARLOTTE SILVERMAN, TO MARY M. CONNELLY AND HENRIETTA
SILVERMAN, AND TO THE LATE ARTHUR SILVERMAN AND BROTHER ROY MOONEY,
F. M. S.
6 / 494
Review of Clinical Anesthesia, 5e [Vishal] Preface
Preface
One of the best ways to judge a book is by the company it keeps. Thus, even before it hits the
bookstore shelves, Review of Clinical Anesthesia is a “winner.” This totally revised work,
which parallels the new (sixth) edition of Clinical Anesthesia, enjoys a distinguished position on
a CDROM along with Clinical Anesthesia and other significant texts in the field of
anesthesiology.
As stated in the introductions to the previous editions of this review book, the amount of
information related to our specialty appears to be growing exponentially; even a carefully honed
text such as Clinical Anesthesia can seem quite imposing. At times, the reader would like to
pause and see what he or she has learned or should learn. These factors were the impetus
behind the development of Review of Clinical Anesthesia. In its simplest form, the multiple-
choice questions in this text can be used as a means of self-assessment before taking a written
examination. However, we feel that this book may be of even greater benefit if it is incorporated
throughout one's studies; a pretest will help the novice as well as the expert focus his or her
reading; a posttest will allow one to assess self-mastery of most relevant material.
The fifth edition of this text has benefited from the extensive updating of the parent text,
Clinical Anesthesia. This has led to our revision of the material in virtually every chapter, as
well as to the addition of several new chapters. As was the case in recent editions, each
answer includes a heading and a page number that refer the reader to a section in Clinical
Anesthesia. This information can be used to direct the reader to a more extensive discussion of
the subject matter addressed in the question.
David G. Silverman MD
7 / 494
Review of Clinical Anesthesia, 5e [Vishal] Acknowledgments
Acknowledgments
The generation of the questions in this text could not have been accomplished without the
dedicated efforts the secretarial staffs of our respective institutions. We appreciate the efforts of
the members of the staff at Lippincott Williams & Wilkins who were vital to the organization and
completion of this text. We would like to acknowledge the swift and excellent assistance of
Nicole Dernoski. We also wish to thank the editors (Drs. Paul Barash, Bruce Cullen, Robert
Stoelting, Michael Cahalan, and Christine Stock) and authors of Clinical Anesthesia for, once
again, providing us with such a fine source of material. Their careful attention to detail and
relevance have facilitated our efforts. We also would like to express our appreciation to our
coauthors, whose assiduous efforts have enabled us to assemble a detailed yet cohesive
series of questions and answers. Mostly, we would like to thank our families, who waited
patiently as we waded through pages of text in search of the questions.
8 / 494
Review of Clinical Anesthesia, 5e [Vishal] Contents
FRONT OF BOOK ↑
[+] Editors
[+] Contributing Authors
- Dedication
- Preface
- Acknowledgments
TABLE OF CONTENTS ↑
[-] Section I - Introduction to Anesthesiology
- Chapter 1 - History of Anesthesia
- Chapter 2 - Scope of Practice
- Chapter 3 - Occupational Health
- Chapter 4 - Anesthetic Risk, Quality Improvement and Liability
[-] Section II - Scientific Foundations of Anesthesia

- Chapter 5 - Mechanisms of Anesthesia and Consciousness
- Chapter 6 - Genomic Basis of Perioperative Medicine
- Chapter 7 - Pharmacologic Principles
- Chapter 8 - Electrical and Fire Safety
- Chapter 9 - Experimental Design and Statistics
[-] Section III - Anatomy and Physiology

- Chapter 10 - Cardiovascular Anatomy and Physiology
- Chapter 11 - Respiratory Function
- Chapter 12 - Immune Function and Allergic Response
- Chapter 13 - Inflammation, Wound Healing and Infection
- Chapter 14 - Fluids, Electrolytes, and Acid Base Physiology
- Chapter 15 - Autonomic Nervous System
- Chapter 16 - Hemostasis and Transfusion Medicine
[-] Section IV - Anesthetic Agents, Adjuvants, and Drug Interaction

- Chapter 17 - Inhaled Anesthetics
- Chapter 18 - Intravenous Anesthetics
- Chapter 19 - Opioids
- Chapter 20 - Neuromuscular Blocking Agents
- Chapter 21 - Local Anesthetics
- Chapter 22 - Drug Interactions
[-] Section V - PreAnesthetic Evaluation and Preparation
9 / 494
- Chapter 23 - Preoperative Patient Assessment and Management
- Chapter 24 - Malignant Hyperthermia and Other Inherited Disorders
- Chapter 25 - Rare and Co-existing Diseases
- Chapter 26 - The Anesthesia Workstation and Delivery Systems
[-] Section VI - Anesthetic Management

- Chapter 27 - Standard Monitoring Techniques
- Chapter 28 - Echocardiography
- Chapter 29 - Airway Management
- Chapter 30 - Patient Positioning and Related Injuries
- Chapter 31 - Monitored Anesthesia Care
- Chapter 32 - Ambulatory Anesthesia
- Chapter 33 - Office Based Anesthesia
- Chapter 34 - Anesthesia Provided at Alternate Sites
- Chapter 35 - Anesthesia for the Older Patient
- Chapter 36 - Anesthesia for Trauma and Burn Patients
- Chapter 37 - Epidural and Spinal Anesthesia
- Chapter 38 - Peripheral Nerve Blockade
[-] Section VII - Anesthesia for Surgical Subspecialties

- Chapter 39 - Anesthesia for Neurosurgery
- Chapter 40 - Anesthesia for Thoracic Surgery
- Chapter 41 - Anesthesia for Cardiac Surgery
- Chapter 42 - Anesthesia for Vascular Surgery
- Chapter 43 - Obstetrical Anesthesia
- Chapter 44 - Neonatal Anesthesia
- Chapter 45 - Pediatric Anesthesia
- Chapter 46 - Gastrointestinal Disorders
- Chapter 47 - Anesthesia and Obesity
- Chapter 48 - Hepatic Anatomy, Function and Physiology
- Chapter 49 - Endocrine Function
- Chapter 50 - Anesthesia for Otolaryngologic Surgery
- Chapter 51 - Anesthesia for Ophthalmologic Surgery
- Chapter 52 - The Renal System and Anesthesia for Urologic Surgery
- Chapter 53 - Anesthesia for Orthopedic Surgery
- Chapter 54 - Transplant Anesthesia
10 / 494
[-] Section VIII - Perioperative and Consultative Services
- Chapter 55 - Post Anesthesia Recovery
- Chapter 56 - Critical Care Medicine
- Chapter 57 - Acute Pain Management
- Chapter 58 - Chronic Pain Management
- Chapter 59 - Cardiopulmonary Resuscitation
- Chapter 60 - Disaster Preparedness
11 / 494
Review of Clinical Anesthesia, 5e [Vishal] 1. History of Anesthesia
Chapter 1
History of Anesthesia
1. Ancient Egyptian pictographs display nerve compression to possibly produce

regional anesthesia during upper extremity surgery.
A. True
B. False
1. A. True. Ancient Egyptian pictographs from approximately 3,000 BC display images of nerve
compression during upper extremity surgery. One pictograph shows a brachial plexus being
compressed, and another shows antecubital fossa nerve compression; both surgeries were
presumably done on alert patients and done on the hand. (See page 4: Physical and
Psychological Anesthesia.)
2. In the 17th century, Marco Aurelio Severino described using snow to create
anesthesia at a surgical site.
A. True
B. False
2. A. True. People have long recognized that cold temperatures produce insensibility to pain.
Remarkably, in the Middle Ages, people attempted to apply the property of cold to perform
surgery as an early form of cryo-anesthesia. (See page 4: Physical and Psychological
Anesthesia.)
3. During the 9th century, a soporphic sponge was used to provide pain relief during
surgery. What ingredient(s) were boiled together and cooked into this sponge&quest;
A. Mandrake leaves
B. Black nightshade
C. Poppies
D. All of the above
3. D. In the 1st century, mandragora was recognized to produce analgesia. Historically, a
soporific sponge was used to produce an acceptable level of surgical analgesia. This sponge
had various recipe forms depending on the producer; however, all of them included mandrake
leaves, black nightshade, and poppies boiled together to form a sponge that was administered
to a patient after reconstitution in hot water. (See page 4: Early Analgesics and Soporifics.)
4. Nitrous oxide has the ability to produce lightheadness. Some thrill seekers
intentionally expose themselves to nitrous oxide as a diversion. Who is credited with
first preparing nitrous oxide by heating ammonium nitrate with iron filings&quest;
A. Dr. Thomas Beddoes
B. Mr. Joseph Priestley
C. Dr. Humphry Davy
D. Dr. Horace Wells
12 / 494
E. Dr. Valerius Cordus
4. B. Nitrous oxide was first prepared in 1773 by the British clergyman and scientist Joseph
Priestley. Priestley prepared several other gases during his investigations, the most notable
being isolated oxygen. Davy and Wells performed later observations and experiments with
nitrous oxide, and Valerius Cordus is credited with having distilled diethyl ether (sweet oil of
vitriol) in the 16th century. (See page 4: Inhaled Anesthetics.)
5. Who is credited with the earliest documented use of diethyl ether for painless
surgery&quest;
A. Dr. Crawford W. Long
B. Dr. Henry Hill Hickman
C. Dr. William T.G. Morton
D. Dr. Horace Wells
E. Dr. Charles T. Jackson
5. A. Although Dr. William Morton has been credited with introducing diethyl ether as a
successful anesthetic in the public arena on October 16, 1846, Dr. Crawford W. Long of Athens,
Georgia, has the distinction of the first documented successful use of ether in the surgical
setting. Dr. Long first administered ether preoperatively on March 30, 1842, but he neglected to
make his findings known until 1849, well after Dr. Morton's demonstration. (See page 5: Public
Demonstration of Ether Anesthesia.)
6. In 1845, an anesthetist gave a public demonstration of nitrous oxide at the

Massachusetts General Hospital. Even though the patient was unaware, he still cried
out during the surgery. This anesthetist thus became the first in modern anesthesia to
hear a surgeon say, “Give him more gas&excl;” Who was this man&quest;
D. Dr. Horace Wells
6. D. Dr. Horace Wells has the distinction of being the first person in the history of modern
anesthesia to have a patient cry out and move during his public demonstration of nitrous oxide.
Although the patient did not recall the surgery, Dr. Wells undoubtedly had to listen to the
surgeon complain about the patient not holding still during the surgery. Modern anesthetists in
the 21st century no longer have this problem, of course. (See page 5: Almost Discovery.)
7. On October 16, 1846, there was a public demonstration of ether at the Massachusetts
General Hospital. The man who demonstrated this not only established ether as an
effective anesthetic he also managed to firmly establish in surgeons' minds that “the
anesthetist is always late&excl;” Who was the anesthetist&quest;
13 / 494
D. Dr. Horace Wells

7. C. On “ether day,” October 16, 1846, Dr. William Morton gave a public display of ether for
surgical anesthesia to Edward Abbott. The surgeon was Dr. John Warren. Dr. Warren will
always be remembered as the first modern surgeon to complain in public that the anesthetist
was late. (See page 5: Public Demonstration of Ether Anesthesia.)
8. Who published the use of chloroform for anesthesia during labor and childbirth in
the Lancet in 1847&quest;
A. Dr. James Young Simpson
B. Dr. Virginia Apgar
C. Dr. William Morton
D. Dr. Joseph Clover
E. Queen Victoria
8. A. Although Dr. Simpson, an accomplished obstetrician in Edinburgh, Scotland, had been a
champion of the use of ether and chloroform anesthesia for labor and childbirth, the relief of
obstetric pain had long been discouraged on prevailing religious grounds. It was not until Dr.
John Snow, an English contemporary of Dr. Simpson, administered chloroform to a laboring
Queen Victoria that widespread acceptance of obstetric anesthesia came into being. As head of
the Church of England, the queen's endorsement of the practice ended the debate as to the
appropriateness of such anesthetics. (See page 6: Chloroform and Obstetrics.)
9. Which notable advancement in the field of anesthesiology can be credited primarily

to work done by American surgeon Dr. Joseph O'Dwyer in the mid-1880s&quest;
A. Tracheal intubation
B. Central venous cannulation
C. Direct laryngoscopy
D. Brachial plexus conduction block
E. Anesthetic record
9. A. Although elective oral tracheal intubation was first performed by Scottish surgeon William
Macewen in 1878, it was the work of American surgeon Dr. Joseph O'Dwyer that popularized
the technique. In 1885, Dr. O'Dwyer developed a set of metal laryngeal tubes, which he
inserted blindly between the vocal cords of children with diphtheritic crises as an alternative to
hasty tracheotomies. Three years later, he developed a rigid endotracheal tube with a conical
tip, which allowed positive-pressure endotracheal ventilation to be used during thoracic
procedures. (See page 7: Tracheal Intubation.)
P.3
10. Which pioneer in the field of anesthesiology can be credited with the development
of the cuffed endotracheal tube&quest;
A. Dr. Ralph Waters
B. Dr. Joseph O'Dwyer
14 / 494
C. Dr. Arthur Guedel
D. Dr. Elmer McKesson
E. Ivan Magill
10. C. In 1926, Dr. Arthur Guedel began a series of experiments that led to the introduction of
the cuffed endotracheal tube. His goal was to combine tracheal anesthesia with the closed-
circuit technique recently refined by Waters. To showcase the utility of these new tubes, Dr.
Guedel performed a series of demonstrations with his own dog, “Airway,” who he anesthetized
and submerged underwater while using the cuffed endotracheal tube. (See page 7: Tracheal
Intubation.)
11. When Dr. Ralph Waters intentionally ventilated only one lung, what airway
instrument did Dr. Arthur Guedel propose&quest;
A. The fiberoptic bronchoscope
B. The elastic intubating stylet
C. Nasal endobronchial tubes
D. Double-cuffed single-lumen tubes
E. Double-lumen endobronchial tubes
11. D. Dr. Ralph Waters described a bronchial intubation and hypothesized that intentional
endobronchial intubation could facilitate surgery on the opposite lung. He related this to Dr.
Arthur Guedel, leading to the design of the single-lumen, double-cuff modification of the
emerging cuffed airway tube. Later, Dr. Frank Robertshaw popularized the double-lumen
endobronchial tube. Since then, there have been several modifications and new techniques
described for lung isolation; however, the basic reasoning remains the same. (See page 7:
Tracheal Intubation.)
12. Dr. Roger Bullard became frustrated by failed attempts to visualize the larynx of a
patient with Pierre-Robin syndrome. He then developed a laryngoscope called the:
A. Wu-scope
B. Bullard scope
C. Combi-Laryngoscope
D. LMA camerascope
E. Anesthesia kaleidoscope
12. B. Dr. Roger Bullard developed the Bullard laryngoscope in response to frustration with the
acute angle observed in a patient with Pierre-Robin syndrome. This laryngoscope incorporated
fiberoptic bundles that lie beside a curved blade and allowed the user to observe the larynx
lying at 90 degrees from the mouth. (See page 8: Advanced Airway Devices.)
13. With his radical thinking, Dr. Archie Brain made what contribution to airway
management&quest;
A. Patil face mask
B. Laryngeal mask airway
C. Wu-scope
15 / 494
D. Flexible fiberoptic bronchoscope

E. Bullard laryngoscope
13. B. Dr. Archie Brain produced and made popular the laryngeal mask airway after he realized
that it was an effective means of ventilating and delivering anesthetics to a patient. Shigeto
Ikeda developed the first flexible fiberoptic bronchoscope. Dr. Roger Bullard developed the
Bullard laryngoscope to “see around the corner” of the airway. The Wu-scope was later
developed to improve on the idea of the Bullard laryngoscope. The Patil Face Mask, developed
by Dr. Vijay Patil, was developed to oxygenate the anesthetized patient while a flexible
fiberoptic bronchoscope is used to intubate the airway. All of these innovations were prompted
by the need to manage patients with challenging, difficult airways. (See page 8: Advanced
Airway Devices.)
14. Dr. Elmer McKesson is credited with the innovation of which of the following
features of modern-day anesthesia machines&quest;
A. Oxygen fail-safe valve
B. Flow-ratio system
C. Oxygen flush valve
D. Variable bypass vaporizers
E. Partial rebreathing circuits
14. C. Dr. Elmer McKesson, one of the first specialists in anesthesiology in the United States,
developed a series of gas machines. Because of concerns over inflammable anesthetics, Dr.
McKesson popularized anesthetic inductions with 100% nitrous oxide, with titration of small
volumes of oxygen as the anesthetic progressed. Dr. McKesson developed the oxygen flush
valve to add oxygen quickly to the system in the event that the resultant cyanosis became too
profound. (See page 9: Early Anesthesia Delivery Systems.)
15. In 1907, the Draeger “Pulmotor” was introduced as the first intermittent positive-
pressure ventilator.
A. True
B. False
15. A. True. Mine rescue workers and firefighters were provided with early forms of positive-
pressure mechanical ventilators to help resuscitating injured patients. The first marketed
device, the “Pulmotor,” was produced by Draeger in 1907. Afterward, the European polio
epidemic inspired further refinements in mechanical ventilation. (See page 10: Ventilators.)
16. During World War II, British aviation researchers began research on devices to
improve the supply of oxygen that was provided to pilots flying at high altitude in
unpressurized aircraft. This research led to perhaps the most important technological
advance ever made in monitoring the well-being and safety of patients during
anesthesia. What is this monitoring system&quest;
A. Continuous capnography
B. Electrocardiography
C. Mass spectrometry
16 / 494
D. Oxygen sensors
E. Pulse oximetry
16. E. Pulse oximetry, described by Dr. Severinghaus as “the most important technologic
monitoring advance in the history of anesthesia,” was developed by Takuo Aoyagi, a Japanese
engineer. His work was a refinement of earlier investigations performed by Glen Millikan, an
American physiologist, that pertained to oximetric sensors for fighter pilots during World War II.
(See page 12: Electrocardiography, Pulse Oximetry, and Capnography.)
17. Trichloroethylene, a nonexplosive volatile anesthetic, releases what compound

when it is warmed in the presence of soda lime&quest;
A. Compound X
B. Compound A
C. Factor X
D. Phosgene
E. Ethyl chloride
17. D. Trichloroethylene was a widely used nonexplosive volatile anesthetic. However, it was
found to be toxic to multiple organ systems when administered for prolonged periods or at high
concentrations. When the gas is heated in the presence of soda lime, it produces phosgene as
a byproduct. When phosgene is inhaled, it reacts with water in the lungs to form hydrochloric
acid and carbon monoxide, with resultant pulmonary edema. Phosgene was used extensively
during World War I as a choking agent. Among the chemicals used in the war, phosgene was
responsible for the majority of deaths. (See page 13: Inhaled Anesthetics.)
18. What anesthetic, although popular in the mid-20th century, was abandoned after it
was learned that dose-related nephrotoxicity was associated with its prolonged
use&quest;
A. Chloroform
B. Methoxyflurane
C. Ether
D. Enflurane
E. Halothane
18. B. Over a protracted period, methoxyflurane use leads to increased serum fluoride
concentrations and nephrotoxicity. Before this was discovered, methoxyflurane was a very
popular volatile anesthetic in the 1960s. (See page 13: Inhaled Anesthetics.)
19. The cardiovascular effects of which drug became widely appreciated only after a
series of fatalities among military casualties during World War II&quest;
A. Curare
B. Thiopental
C. Fentanyl
D. Halothane
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E. Cyclopropane
19. B. Thiopental was synthesized in 1932 by Tabern and Volwiler of the Abbott Company and
was first administered to a patient at the University of Wisconsin in March 1934. The
cardiovascular depressive effects of thiopental were widely appreciated only after its use led to
fatalities among civilians and soldiers during World War II. After these experiences, fluid
replacement therapy was used more aggressively, and thiopental was administered with greater
caution. (See page 14: Intravenous Anesthetics.)
20. What medication introduced in the late 20th century suppressed pharyngeal
reflexes, produced anesthesia rapidly, had antiemetic properties, allowed patients to
wake promptly, and popularized total intravenous anesthetic techniques&quest;
A. Ketamine
B. Propofol
C. Meperidine
D. Chlorpromazine
E. Droperidol
20. B. Propofol combined with variable-duration paralytics and faster-acting narcotics made
total intravenous anesthesia techniques more accessible. Propofol's antiemetic property, along
with a ceiling context-sensitive half-life, makes it a popular anesthetic agent. (See page 14:
Intravenous Anesthetics.)
21. Oncologists identified the antiemetic properties of what medication when dealing
with intracranial edema from tumors&quest;
A. Antihistamines
B. Propofol
C. Droperidol
D. Corticosteroids
E. Promethazine
21. D. Corticosteroids decrease intracranial edema in patients with mass lesions and tumors.
They also reduce nausea. This antiemetic effect was quickly recognized by anesthesiologists.
(See page 18: Antiemetics.)
22. Dr. Leonard Corning is remembered for coining the term “spinal anesthesia” and
for performing a neuraxial block on a man “addicted to masturbation.”
A. True
B. False
22. A. Dr. Corning assessed the effects of cocaine injected into the lumbar neuraxial space. He
attempted to perform a therapeutic neuraxial block on a man “addicted to masturbation,” and
because Dr. Corning did not describe an escape of fluid, we assume that an epidural injection
of cocaine was performed. We do not know if the patient was “cured” of his addiction. (See
page 19: Regional Anesthesia.)
P.4
18 / 494
23. Drs. Bier and Hildebrandt performed a successful spinal anesthetic when Dr.
Hildebrandt did not feel pain after his legs were hit with a hammer and his testicles
were pulled. How did these physicians celebrate their success&quest;
A. Wine and cigars
B. Going out to the opera and then a “cabaret”
C. By visiting an opium den in Kiel, Germany
D. With more hammers
23. A. The first clearly defined spinal anesthetic involved the release of a large volume of
cerebrospinal fluid (CSF) through large-bore needles. The observation of CSF as an end point
is still used. This led to the first described postdural puncture headache. Drs. Bier and
Hildebrandt erroneously attributed the violent headaches to their celebratory wine and cigars.
(See page 19: Regional Anesthesia.)
24. Who described a continuous spinal anesthetic technique in or around 1940&quest;

A. Dr. Heinrich Quincke
B. Dr. August Bier
C. Dr. Theodor Tuffier
D. Dr. William Lemmon
E. Dr. Richard Hall
24. D. Dr. William Lemmon described the use of a malleable silver needle to puncture the dura.
Local anesthetic was introduced as needed through a hole in the operating table mattress.
Later, the same technique was described by Dr. Waldo Edwards and Dr. Robert Hingson for
continuous caudal anesthesia in obstetric patients. (See page 19: Regional Anesthesia.)
25. Dr. Achille Dogliott described what anesthetic technique in 1931&quest;

A. Intravenous regional anesthesia of the arm
B. Loss of resistance to identify the epidural space
C. Blind nasotracheal intubation
D. Cervical spinal anesthesia
E. Regional block of the ankle
25. B. Dr. Achille Dogliotti of Turin, Italy, wrote a classic study that made the epidural technique
well known. Dr. Dogliotti identified it by the loss-of-resistance technique. (See page 19:
Regional Anesthesia.)
26. Who first described the technique of intravenous regional anesthesia in

1908&quest;
A. Dr. Harvey Cushing
B. Dr. August Bier
C. Dr. Carl Koller
D. Dr. Leonard Corning
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E. Dr. Heinrich Braun
26. B. Intravenous regional anesthesia was first reported in 1908 by Dr. August Bier, who used
a technique in which procaine was injected into a vein of the upper limb between two
tourniquets. The technique was not widely used in the clinical setting until 1963, when Dr.
Mackinnon Holmes modified the block by exsanguination before applying a single proximal cuff.
27. Who created the first clinic for the treatment of chronic pain in the United
States&quest;
A. Dr. Emery Rovenstine
B. Dr. Frederick Cotton
C. Dr. John Snow
D. Dr. John Booka
E. Dr. Ambrose Bierce
27. A. Dr. Emery Rovenstine continued the work of Dr. Gaton Labat and his colleagues. At the
Bellevue Hospital in New York City, he used invasive techniques to lyse sensory nerves and to
inject local anesthetics in an attempt to treat chronic pain. This association of physicians
focused on pain management was the first of its kind in North America. (See page 19: Regional
Anesthesia.)
28. Dr. Jean Baptiste Denis first attempted blood transfusion in 1667. His patient
received blood from:
A. A slave
B. A cow
C. A lamb
D. Dr. Denis himself
E. A horse
28. C. Amazingly, Dr. Jean Denis, the court physician to Louis XIV, first transfused blood from a
lamb into a patient, who benefited from the transfusion. It is reported that the following attempts
at interspecies were not successful, and the transfusion of blood in humans was banned for
religious reasons for more than 100 years in Western Europe. (See page 22: Transfusion
Medicine.)
29. This person is credited with advancing American anesthesiology professional

societies in the early 20th century. He edited the precursor journal to Anesthesia and
Analgesia, acted as an ambassador to Europe for American anesthesiology, and
founded the International Anesthesia Research Society (IARS). Who was this
person&quest;
A. Dr. Harvey Cushing
B. Dr. Benjamin Franklin
C. Dr. Francis McMechan
D. Dr. Karl Landsteiner
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E. Dr. Carl Gauss
29. C. Dr. Francis McMechan retired from active anesthesia practice in Cincinnati in 1915
because of severe rheumatoid arthritis. Afterward, he dedicated himself to editing the precursor
to the anesthesiology journal Anesthesia and Analgesia (at the time, it was called Current
Researches in Anesthesia and Analgesia). In addition, he helped establish an international
society for anesthesia research (the IARS) while acting as an ambassador in Europe for
American anesthesiology. One byproduct of his efforts was the establishment of the
International College of Anesthetists, which certified early anesthesiologists and helped raise
the standards of anesthesiology quality in the early 20th century. (See page 23: Organized
Anesthesiology.)
30. Dr. Ralph Waters became frustrated by the low-quality training of anesthesia
providers, established the first postanesthetic recovery rooms, and became the first
American professor of anesthesiology. Where was he a professor&quest;
A. University of Michigan
B. St. Louis University
C. University of Tamaulipas
D. University of Wisconsin
E. Tufts University
30. D. Dr. Ralph Waters became the first American academic professor of anesthesiology at the
University of Wisconsin's medical school in 1927, where he established an anesthesiology
residency-training program. Dr. Waters attracted motivated and talented people to the
department, and he fostered many of the qualities that are common in modern academic
anesthesiology departments. International experts at the time visited this department and were
influenced by it. (See page 23: Organized Anesthesiology.)
For questions 31 and 32, choose A if 1, 2, and 3 are correct; B if 1 and 3 are correct; C if 2
and 4 are correct; D if 4 is correct; or E if all are correct.
31. In the late 19th and early 20th centuries, which of the following explosive volatile
anesthetics were in use&quest;
1. Chloroform
2. Ether
3. Cyclopropane
4. Nitrous oxide
31. A. Both ether and chloroform were known to be flammable gases and to be explosion
hazards. Cyclopropane (also called trimethylene) is an explosive, colorless gas first used in
1934 as a volatile general anesthetic. Both induction and emergence from cyclopropane
anesthesia were reported to be usually rapid and smooth, but because it is flammable and
could be a source of explosion in the operating area, it was replaced by nonflammable gases.
Nitrous oxide can support combustion, but it is not explosive. (See page 13: Inhaled
Anesthetics.)
32. Which of the following statements regarding the history of cocaine as an anesthetic
is/are TRUE&quest;
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1. Cocaine was the first effective local anesthetic.

2. Its utility as a local anesthetic was first introduced to the medical community by Dr.
Carl Koller in 1884.
3. Cocaine was the agent used in the first successful spinal anesthetic.
4. Although its local anesthetic actions were well recognized, cocaine was not used in
surgical procedures until 1911.
32. A. The anesthetic properties of cocaine, an extract of the coca leaf, had been known for
centuries before its formal introduction in 1884 by Dr. Carl Koller. Soon thereafter, cocaine
gained widespread acceptance as an anesthetic agent for surgical procedures involving the
mucous membranes, such as the eyes, mouth, nose, larynx, trachea, and rectum. Cocaine was
also used by Dr. Leonard Corning for the first successful spinal anesthetic in 1885. (See page
19: Regional Anesthesia.)
22 / 494
Review of Clinical Anesthesia, 5e [Vishal] 2. Scope of Practice
Chapter 2
Scope of Practice
1. Accreditation from The Joint Commission lasts for how many years&quest;
A. 1
B. 2
C. 3
D. 4
E. 5
1. C. Full accreditation from The Joint Commission lasts for 3 years. (See page 31: Establishing
Standards of Practice and Understanding the Standard of Care.)
2. The main goal of a managed care organization (MCO) is to attempt to manage what
aspects of the health care system&quest;
A. Number of facilities in a geographic area
B. Utilization of services within a patient population
C. Outline of the best management for each particular condition
D. Ensuring that physicians are managed to improve physician income
E. Being a division of the National Institutes of Health whose goal is the development of
universal coverage
2. B. MCOs are companies that provide health care for large populations. Their main goal is to
attempt to control costs through providing appropriate care, negotiating for the lowest prices on
services, and restricting access to more expensive services such as operative procedures. (See
page 45: New Practice Arrangements.)
3. All of the following factors are the benefits of an anesthesia preoperative clinic
EXCEPT:
A. Increase in the efficiency of operating rooms
B. Financial savings for the institution
C. Centralization of pertinent information, including consults, financial data, and
diagnostic and laboratory information
D. Patient and family education on the process, surgery, and postsurgical considerations
E. Ability to schedule presurgical evaluation at the last minute because of the
streamlined process of the clinic
3. E. The anesthesia preoperative clinic allows the running of a more efficient operating room
schedule. It reduces last-minute cancellations, shotgun ordering of laboratory work, and
unnecessary preoperative specialty consultation. Early identification of certain problems
requiring special care on the day of surgery (e.g., blocks, pulmonary artery catheters) leads to
fewer unanticipated delays. All relevant patient information can be centralized to one location.
However, all of these benefits are optimized when the patient is seen relatively early in relation
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to the day of surgery. Early recognition of patients requiring further workup allows time for
another patient to fill the vacant block in the schedule. (See page 52: Preoperative Clinic.)
4. All of the following facts are true EXCEPT:

A. Standard of care is the conduct and skill of a prudent practitioner that can be
expected by a reasonable patient.
B. Courts have traditionally relied on medical experts knowledgeable about the point in
question to give opinions as to what the standard of care is.
C. A less objective way of determining the standard of care is to review the published
standards of care, guidelines, practice parameters, and protocols established by the
American Society of Anesthesiology.
D. The standard of care is what a jury says it is.
E. Expert witnesses can establish the standard of care.
4. C. The standard of care is the conduct and skill of a prudent practitioner that can be
expected by a reasonable patient. Expert witnesses can define it. This was traditionally the
method of establishing the standard of care. The problem with this method was that both
parties could have expert witnesses, which can support the two opposing sides, thereby making
the process subjective. The more objective way of determining the standard of care is
reviewing the published standards of care, guidelines, practice parameters, and protocols
established by a national organization such as the American Society of Anesthesiologists. The
above two methods are the two main sources for information that a jury has available to them to
establish the standard of care. (See page 31: Establishing Standards of Practice and
Understanding the Standard of Care.)
For questions 5 to 12, choose A if 1, 2, and 3 are correct; B if 1 and 3 are correct; C if 2 and
4 are correct; D if 4 is correct; or E if all are correct.
5. Which of the following statements regarding “claims-made” insurance is/are
TRUE&quest;
1. Policies cover all malpractice claims made while the insurance is being paid.
2. Policies are very expensive during the first year of practice.
3. Tail coverage is a hidden expense with claims-made policies.
4. Claims-made policies are more expensive for insurance companies because they have
a longer period in which they are exposed to possible claims.
5. B. The two primary types of malpractice insurance are occurrence and claims-made
insurance. An “occurrence” insurance policy means that if the policy was in force at the time of
the occurrence of an incident resulting in a claim, whenever that claim might be filed, the
practitioner would be covered. “Claims-made” insurance only covers claims that are filed while
the insurance is in force. This kind of insurance is relatively inexpensive during the first year
because claims typically take some time to be filed. However, if the physician simply
discontinues a claims-made policy (e.g., by changing insurers or leaving a given practice) and a
claim is filed the next year, there will be no insurance coverage. Therefore, the physician
leaving a claims-made policy must secure “tail coverage” for claims filed after the physician is
no longer primarily covered by that insurance policy. (See page 36: Malpractice Insurance.)
24 / 494
6. Establishing standards of care, practice parameters, and guidelines in anesthesia
practice affords individuals with which of the following benefits&quest;
1. Improvement in quality of care
2. Providing the basis for legal defense in malpractice cases
3. Guiding thought processes through difficult clinical scenarios
4. Fulfilling legal mandates
6. A. Standards of care, practice guidelines, and parameters have been increasingly used over
the past few decades. The impetus for their increased use centers primarily on the
improvement of quality of care for patients. American Society of Anesthesiologists (ASA)
Monitoring Standards of Care is an excellent example of standard of care guidelines, and the
ASA Difficult Airway Algorithm is an outstanding example of practice guidelines. These
guidelines, if followed, typically improve patient outcomes and cost effectiveness by reducing
unnecessary tests and ineffective treatments. Because experts in the field usually develop
these standards, they constitute a powerful legal defense in light of a malpractice suit.
Practicing outside the standards of the specialty requires one to justify one's actions and
decisions. Standards of care, practice parameters, and practice guidelines are not legally
mandated. (See page 31: Establishing Standards of Practice and Understanding the Standard
of Care.)
7. After a critical adverse event occurs, which of the following should be

implemented&quest;
1. Immediately obtain appropriate help.
2. Involve the risk management department in the hospital only if a suit is filed.
3. Record any additions or alterations of the facts in the chart as amendments.
P.9
4. Chart the event, including the facts of the events and speculations regarding the
cause of the incident.
7. B. After the identification of a critical event, help should be called to minimize the sequelae of
the event. If permanent injury occurs, early involvement of the anesthesia department, hospital
administration, risk management department, and insurance company is essential. Charting of
the event is critical. Only facts should be included in the chart. No speculation regarding the
cause or who is to blame should be recorded. Any change to the chart's original documentation
should be recorded as an amendment and labeled as such, with an indication regarding why
such an amendment was necessary. (See page 36: Malpractice Insurance.)
8. Computer scheduling of cases has advantages over handwritten systems in which

of the following ways&quest;
1. Historical precedents of time for procedures can prevent overbooking.
2. It can result in a decrease of staff overtime costs.
3. It can easily generate reports and statistics for future use.
4. It can reduce personal bias in scheduling cases.
8. E. Computer scheduling programs are powerful tools in operating room management. When
historical times for procedures are input into the system, the program can prevent optimistic
25 / 494
bookings by surgeons and can prevent operating room time from running long and thus
requiring payment of overtime. Inputting this type of data can allow the program to generate
reports and statistics that will aid in future planning. The program can examine the schedule
and determine whether any staff or equipment double booking has occurred, which may not be
obvious on a standard ledger schedule. Computer programs require a large commitment to
training and data entry. Computerization can also eliminate personal bias in the scheduling of
case time. (See page 52: Computerization.)
9. Which of the following regarding the Health Insurance Portability and Accountability
Act (HIPAA) of 1996 is/are TRUE&quest;
1. Attention is focused on protected health information.
2. A “privacy officer” must be appointed for each practice group.
3. Patient charts must be locked away overnight.
4. A fax containing patient information does not need any special handling.
9. A. HIPAA requires that attention be focused on protected health information. Each practice
group must designate and appoint a “privacy officer.” HIPAA provisions require that patient
charts must be locked away overnight. Telephone calls and faxes must be handled specially if
they contain identifiable patient information. (See page 47: HIPAA.)
10. Which of the following regarding antitrust considerations is/are TRUE&quest;

1. Antitrust laws involve the rights of individuals to engage in business.
2. The Sherman Antitrust Act is approximately 50 years old.
3. The per se rule is the most frequently applied rule when judging violations.
4. Antitrust laws are concerned with the preservation of competition in a defined
marketplace.
10. D. The Sherman Antitrust Act is more than 100 years old. Antitrust laws do not involve the
right of individuals to engage in business but rather are solely concerned with the preservation
of competition within a defined marketplace. The per se rule, which is rarely applied, makes
conduct that obviously limits competition illegal. (See page 43: Antitrust Considerations.)
11. Which of the following is/are TRUE regarding operating room management&quest;
1. Anesthesiologists should develop a leading role among other operating room
personnel.
2. Block scheduling appears to be the most efficient manner for scheduling surgical
cases and should be used exclusively in the creation of the operating room schedule.
3. Prudent drug selection combined with appropriate anesthesia technique may result in
dollars savings.
4. Sharing the responsibility of “running the floor” among all the anesthesiologists is an
efficient way to manage the operating room schedule because all anesthesiologists will
come to appreciate the nuances of the day-to-day schedule.
11. B. The role of anesthesiologists in operating room management has changed dramatically
in the past few years. The current emphasis on cost containment and efficiency necessitates
anesthesiologists' involvement in operating room management. Anesthesiologists are in the best
26 / 494
position to see the “big picture,” both overall and on any given day. They are best qualified to
provide leadership in the operating room because they spend a large portion of their time in the
operating room. Surgeons, on the other hand, have commitments to their offices and sometimes
to multiple facilities.
Block scheduling may work in some facilities that have a large number of surgeons who book
far in advance and have very specific office and operating room schedules. However, some
degree of open scheduling is necessary, depending on the number of add-on emergencies at a
particular facility. Most large institutions use a combination of block scheduling and open
scheduling.
Prudent drug selection combined with appropriate technique may produce substantial savings.
Reducing fresh gas flow from 5 L/min to 2 L/min can save approximately &dollar;10 million per
year in the United States.
Delineating the responsibility of “running the floor” to a select few members of the department
provides more consistency in decision making and application of the operating room policies. It
helps individuals become very familiar with the nuances of managing the operating room
schedule in real time. An individual's personality affects his or her ability in managing difficult
surgeons in a consistent and fair manner. (See page 48: Operating Room Management.)
12. In dealing with an adverse event, one must consider which of the following&quest;
1. Establish an “adverse event protocol” in the department in the policies and
procedures manual.
2. Establish an “incident supervisor” whose responsibility is to help prevent continuation
or reoccurrence of incidents, investigating incidents, and ensuring documentation while
the original anesthesiologists focuses on caring for the patient.
3. The chief of anesthesiology, facility administrator, risk manager, and anesthesiologist's
insurance company should be notified in a timely manner.
4. Full disclosure of the events as they are best known is currently believed to be the
best presentation.
12. E. It is important to establish an adverse event protocol in the department's policies and
procedures manual. When a critical incident occurs, call for help. Establish an “incident
supervisor” whose responsibility is to help prevent continuation or reoccurrence of the incident,
investigate the incident, and ensure documentation while the original and helping
anesthesiologists focus on caring for the patient. Consultants may be helpful and should be
called without hesitation. The chief of anesthesiology, facility administrator, risk manager, and
anesthesiologist's insurance company should be notified in a timely manner. If the surgeon is
involved, he or she should notify the family first, but the anesthesiologist and others (risk
managers, legal counsel, or insurance loss control officer) might appropriately be included. Full
disclosure of the events as they are best known is currently believed to be the best
presentation. Any attempt to conceal or shade the truth will only confound an already difficult
situation.
There is a new movement in medical risk management advocating immediate full disclosure to
the victim, including “confessions” of medical judgment and performance errors with attendant
apologies. All discussions with the patient and family should be carefully documented in the
medical record. Judgments about causes or responsibilities should not be made. One should
never change an existing entry in the medical record. Only the facts, as they are known, should
27 / 494
be stated. (See page 37: Response to an Adverse Event.)
28 / 494
Review of Clinical Anesthesia, 5e [Vishal] 3. Occupational Health
Chapter 3
Occupational Health
1. Which of the following substances found in latex gloves is responsible for the
majority of generalized allergic reactions&quest;
A. Preservatives
B. Polyisoprenes
C. Protein content
D. Accelerators
E. Powder
1. C. Latex is a complex substance that contains polyisoprenes, lipids, phospholipids, and
proteins. Numerous additional substances, including preservatives, accelerators, antioxidants,
vulcanizing compounds, and lubricating agents, are added to latex gloves. The protein content
is responsible for causing the majority of allergic reactions. These reactions are exacerbated by
the presence of powder that enhances the potential of latex particles to aerosolize and spread
to the respiratory system of personnel and to environmental surfaces during donning and
removing gloves. (See page 62: Physical Hazards: Latex.)
2. Which of the following statements concerning tuberculosis (TB) is FALSE&quest;

A. It is transmitted by bacilli carried on airborne particles.
B. Using any face mask will prevent infection.
C. Patients with HIV are at increased risk for infection.
D. If surgery is required, bacterial filters (high-efficiency particulate filters) should be
used on the anesthetic breathing circuit for patients with TB.
E. Elective surgery should be postponed for infected patients.
2. B. Use of a special mask that is fitted to the person wearing it and that is capable of filtering
particles 1 to 5 mm in diameter is required to protect health care workers from patients with
active TB. (See page 65: Infection Hazards.)
3. Airborne precautions are an effective preventive measure against which of the

following infectious agents&quest;
A. Cytomegalovirus (CMV)
B. Tuberculosis (TB)
C. Herpes simplex
D. Herpetic whitlow
E. All of the above
3. B. Preventive measures for the listed infectious agents are as follows: CMV, standard
precautions; TB, airborne precautions and isoniazid or ethambutol for purified protein derivative
conversion; herpes simplex, standard precautions and contact precautions if disseminated
disease is present; influenza, vaccine, prophylactic antiretrovirals, and droplet precautions.
29 / 494
(See page 67: Table 3-3, Prevention of Occupationally Acquired Infections.)
4. Signs of substance abuse inside the hospital include:

A. Signing out large quantities of narcotics
B. Refusing breaks
C. Volunteering to relieve others and taking extra calls
D. Disappearing between cases
E. All of the above
4. E. Signing out large quantities of narcotics, refusing breaks, volunteering to relieve others,
disappearing between cases, weight loss, pale skin, pinpoint pupils, and taking extra calls are
all signs of substance abuse. Addicts also have unusual changes in behavior, have sloppy
charts, and want to work alone to divert narcotics for personal use. They are difficult to find
between cases. Their patients often complain of pain in the recovery room. (See page 76:
Table 3-5, Signs of Substance Abuse and Dependence.)
5. All of the following statements about radiation exposure are true EXCEPT:
A. The risk of exposure is not influenced by age or gender.
B. Because radiation exposure is inversely proportional to the square of the distance
from the source, increasing this distance is more universally protective.
C. The magnitude of radiation absorbed by the individual is a function of total radiation
intensity and time.
D. The lead aprons and thyroid collars commonly worn leave many sites exposed to
radiation.
5. A. The magnitude of radiation absorbed by individuals is a function of three variables: (1)
total radiation exposure, intensity, and time; (2) distance from the source of radiation; and (3)
the use of radiation shielding. Unfortunately, the lead aprons and thyroid collars commonly worn
leave exposed many vulnerable sites, such as the long bones of the extremities, the cranium,
the skin of the face, and the eyes. Because radiation exposure is inversely proportional to the
square of the distance from the source, increasing this distance is more universally protective.
The risks associated with radiation vary considerably depending on age, gender, and specific
organ site exposure. (See page 62: Radiation.)
6. Which of the following statements is/are TRUE regarding studies of anesthetic
trends in the operating room and effects on fertility and childbearing&quest;
1. Scavenging anesthetic lowers levels in operating rooms.
2. It is difficult to quantify the levels of anesthetic in an operating room.
3. There is a slight increase in the relative risk of congenital anomalies in the children of
female physicians who work in operating rooms.
4. Levels of anesthetic exposure are correlated with reproductive outcome.
6. B. The use of scavenging techniques lowers the environmental anesthetic levels in operating
30 / 494
rooms. Review of existing epidemiologic studies suggests a slight increase in the relative risk of
spontaneous abortion and congenital anomalies in the children of female physicians working in
operating rooms. Although it is easy to quantify the levels of anesthetic in an operating room, it
is harder to assess the effects of other factors such as stress, fatigue, and alterations in work
schedule. Levels of anesthetic exposure have not correlated with reproductive outcome. (See
page 58: Physical Hazards.)
7. Which of the following statements about methylmethacrylate is/are TRUE&quest;

1. Reported risks from repeated occupational exposure to methyl methacrylate include
skin irritation, allergic reactions, and asthma.
2. The Occupational Safety and Health Administration (OSHA) has established an 8-
hour, time-weighted allowable exposure of 100 ppm of methylmethacrylate.
3. Airborne concentrations greater than 170 ppm have been associated with chronic
lung, liver, and kidney damage.
4. When used properly, scavenging devices for venting methylmethacrylate vapor
decrease the peak
P.13
environmental concentration of vapor by 75%.
7. E. When methyl methacrylate is prepared in the operating room to cement prostheses to
bone, concentrations of up to 280 ppm have been measured. Scavenging devices for venting
the vapor can decrease peak concentrations by 75%. OSHA has established an 8-hour, time-
weighted average allowable exposure of 100 ppm. Airborne concentrations greater than 170
ppm have been associated with chronic lung, liver, and kidney damage. Reported risks from
occupational exposure include allergic reactions and asthma, dermatitis, eye irritation,
headache, and neurologic signs, which may occur at levels below the OSHA cutoffs. (See page
61: Physical Hazards: Methyl Methacrylate.)
8. Which of the following statements regarding latex allergy is/are TRUE&quest;

1. The prevalence in anesthesia personnel is about 15%.
2. Sensitivity to latex can be reversed by avoiding latex-containing compounds.
3. Type I immediate hypersensitivity reactions may manifest by a localized contact
urticaria.
4. Type IV reaction (T-cell mediated) is the more severe allergic reaction seen with latex
allergy.
8. B. Irritant or contact dermatitis accounts for the majority of reactions resulting from wearing
latex-containing gloves. The prevalence of latex sensitivity among anesthesiologists is 15%.
Type I immediate hypersensitivity reactions may manifest by a localized contact dermatitis or a
generalized systemic response. True allergic reactions present as type IV (T-cell–mediated
contact dermatitis) and the more severe type I (immunoglobulin E–mediated anaphylactic)
reactions. Sensitivity cannot be reversed. (See page 62: Physical Hazards: Latex.)
9. Which of the following statements concerning influenza viruses is/are TRUE&quest;

1. They are spread by coughing, sneezing, or talking via small particle aerosols.
2. Vaccination with inactivated virus confers immunity for life.
31 / 494
3. General anesthesia results in no increase of respiratory morbidity in asymptomatic
patients infected with influenza virus.
4. Influenza virus vaccine contains two viral strains, type A and type B.
9. B. Influenza viruses are easily transmitted by small particle aerosols (sneezing, coughing, or
talking). General anesthesia results in no increase in respiratory morbidity in asymptomatic
patients infected with influenza virus. Antigenic variation of influenza viruses occurs over time,
so new viral strains (usually two type A and one type B) are selected for inclusion in each year's
vaccine. Because the virus has antigenic variation from year to year, immunity is not for life.
(See page 65: Infection Hazards.)
10. Which of the following forms of hepatitis primarily is/are transmitted by

blood&quest;
1. B
2. D
3. C
4. E
10. A. Hepatitis A is primarily transmitted by the fecal–oral route. Hepatitis B, C, and D are
transmitted by blood. Hepatitis E is enterically transmitted. (See page 65: Infection Hazards.)
11. Which of the following form(s) of hepatitis can lead to a chronic carrier state&quest;
1. C
2. D
3. B
4. A
11. A. Hepatitis B, C, and D can progress to chronic hepatitis and a chronic carrier state. (See
page 65: Infection Hazards.)
12. Which of the following statements is/are TRUE&quest;

1. Respiratory syncytial virus (RSV) can be recovered for up to 6 hours on contaminated
environmental surfaces.
2. Severe acute respiratory syndrome (SARS) is spread by close person-to-person
contact.
3. Transmission of cytomegalovirus (CMV) occurs through person-to-person contact and
contact with contaminated urine or blood.
4. Rubella infection can be associated with congenital malformations and fetal death if it
is contracted during the first trimester of pregnancy.
12. E. RSV can be recovered for up to 6 hours on contaminated environmental surfaces. SARS
is spread by close person-to-person contact, large respiratory droplets, and possibly airborne
transmission. Transmission of CMV occurs through person-to-person contact and contact with
contaminated urine or blood. Rubella infection may be associated with congenital malformations
and fetal death if it is contracted during the first trimester of pregnancy. (See page 65: Infection
Hazards.)
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13. Which of the following statements concerning hepatitis B is/are TRUE&quest;

1. Contaminated dry blood on an environmental surface may be infectious for more than
1 week.
2. Routine vaccination has reduced the risk of occupationally acquired hepatitis B virus
(HBV) infection.
3. The presence of hepatitis B surface antigen (HbSa) in serum indicates active viral
replication in hepatocytes.
4. The rate of transmission is significantly lower after mucosal contact with infected oral
secretions than after percutaneous blood exposure.
13. E. HBV may be infectious for at least 1 week in dried blood on environmental surfaces. The
rate of transmission is lower after mucosal contact with infected oral secretions than after
percutaneous blood exposure. Routine vaccinations, use of safety devices, and postexposure
prophylaxis have significantly reduced the risk of occupationally acquired HBV infection. The
presence of HbSa in serum indicates active viral replication in hepatocytes and increases the
risk of transmission. (See page 65: Infection Hazards.)
14. Which of the following has been documented as a means for transmission of the
human immunodeficiency virus (HIV)&quest;
1. Sexual contact
2. Blood
3. Perinatal transmission
4. Saliva and tears
14. A. HIV may be transmitted by sexual contact, exposure to contaminated blood, and
perinatally. It can be found in saliva, tears, and urine, but these body fluids have not been
implicated in viral transmission. (See page 65: Infection Hazards.)

1. The magnitude of radiation absorbed is a function of total exposure intensity, distance
from the source of radiation, and the use of radiation shielding.
2. Radiation exposure is proportional to the square of the distance from the source.
3. Radiation exposure becomes minimal at a distance greater than 36 inches from the
source.
4. Wearing a thyroid collar in addition to a lead apron protects virtually all vulnerable
sites.
15. B. Radiation exposure is inversely proportional to the square of the distance from the
source. Lead aprons and thyroid collars leave many vulnerable sites exposed, such as the long
bones of the extremities, the cranium, the skin on the face, and the eyes. The magnitude of
radiation absorbed by operating room personnel is a function of total exposure intensity,
distance from the source of radiation, and the use of radiation shielding. Radiation exposure
becomes minimal at a distance of greater than 36 inches from the source. (See page 62:
Physical Hazards: Radiation.)
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Review of Clinical Anesthesia, 5e [Vishal] 4. Anesthetic Risk, Quality Improvement & Liability
Chapter 4
Anesthetic Risk, Quality Improvement and Liability
1. All the following statements are true EXCEPT:

A. The duty that the anesthesiologist owes the patient is to be a prudent and reasonable
physician.
B. Obtaining informed consent is a responsibility that all physicians have to their
patients.
C. Punitive damages are intended to punish the physician for negligence.
D. Causation refers to the fact that a reasonably close causal relation exists between the
anesthesiologist's acts and the resultant injury.
E. General damages are actual damages that are a consequence of the injury, such as
medical expenses.
1. E. In the most general terms, the duty that the anesthesiologist owes to the patient is to
adhere to the “standard of care” for the patient's treatment. Because it is virtually impossible to
delineate specific standards for all aspects of medical practice, the courts have created the
concept of the “reasonable and prudent physician.” One of the general duties of the physician
is obtaining informed consent for procedures. The requirement that the consent be “informed” is
somewhat more opaque. The definition of causation is that a reasonably close causal relation
exists between the anesthesiologist's acts and the resultant injury. Breach of duty is the failure
of an anesthesiologist to fulfill his or her duty. The court will try to find that the anesthesiologist
either did something that should not have been done or failed to do something that should have
been done by a prudent and reasonable physician. General damages are those such as pain
and suffering that directly result from the injury. Special damages are actual damages that are a
consequence of the injury, such as medical expenses, loss of income, and funeral expenses.
Punitive damages are intended to punish the physician for negligence that was reckless,
wanton, fraudulent or willful. (See page 88: Professional Liability.)
2. The court establishes “standard of care” through all of these EXCEPT:

A. factual witness
B. expert witness
C. published societal guidelines
D. textbooks
E. written hospital policies
2. A. In the most general terms, the duty that the anesthesiologist owes to the patient is to
adhere to the “standard of care” for the treatment of the patient. Because medical practice
usually includes issues beyond the comprehension of lay jurors and judges, the court
establishes a standard of care for a particular case by the testimony of “expert witnesses.”
These witnesses differ from factual witnesses mainly in that they are allowed to give opinions.
When a physician is called to court as the defendant in a malpractice suit, he or she becomes a
factual witness. The standard of care may also be determined from published societal
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guidelines, written policies of a hospital or department, and textbooks and monographs. (See
page 89: Standard of Care.)
3. Which of the following statements concerning risk management and quality

improvement is TRUE&quest;
A. Quality improvement is broadly oriented toward reducing the liability exposure of the
organization.
B. Quality improvement is concerned with patient safety, but risk management is not.
C. Risk management's exclusive goal is the reduction of institutional liability by
maintenance and improvement of patient care.
D. Risk management involves professional liability, contracts, employee safety, and
public safety.
E. Quality improvement is concerned primarily with liability exposure of the institution.
3. D. Risk management and quality improvement programs work hand in hand to minimize
liability and maximize quality of patient care. The two programs overlap their focus on patient
safety. A hospital risk management program is broadly oriented toward reducing the liability
exposure of the organization. This includes not only professional liability and therefore patient
safety but also contracts, employee safety, public safety, and any other liability exposure of the
institution. The main goals of quality improvement programs are the maintenance and
improvement of the quality of patient care. (See page 84: Risk Management.)
4. All of the following statements concerning record keeping are true EXCEPT:
A. Good records can form a strong defense in the face of malpractice litigation.
B. Change of anesthetic personnel should be documented.
C. The anesthesiologist's report of a catastrophic event need not be consistent with
concurrent records because inconsistencies are easy to defend.
D. A record-keeping error should be crossed out yet remain legible.
E. Catastrophic events should be documented in narrative form in the patient's progress
notes.
4. C. Good records can form a strong defense if they are adequate, and inadequate records
can be disastrous. The anesthetic record itself should be accurate, complete, and as neat as
possible. In addition to the patient's vital signs recorded every 5 minutes, special attention
should be paid to ensure that the American Society of Anesthesiologists classification, monitors
used, fluids administered, and doses and times of drugs given are accurately charted. All
respiratory variables that are monitored should be documented. It is important to note when a
change of anesthesia personnel occurs during the conduct of a case. If a critical incident
occurs during the conduct of an anesthetic regimen, the anesthesiologist should document in
narrative form in the patient's progress notes what happened, which drugs were used, what the
time sequence was, and who was present. A catastrophic intra-anesthetic event cannot be
summarized adequately in a small amount of space on the usual anesthetic record. The report
should be as consistent as possible with concurrent records such as those pertaining to the
anesthetic, the operating room, the recovery room, and cardiac arrest. (See page 84: Risk
Management in Anesthesia.)
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5. The National Practitioner Data Bank (NPDB) requires input from all of the following
EXCEPT:
A. medical malpractice payment
B. licensing actions by medical boards
C. patient safety foundations
D. clinical privilege actions by hospitals
E. actions taken by the Drug Enforcement Agency (DEA)
5. C. The NPDB is a nationwide information system that theoretically allows licensing boards
and hospitals a means of detecting adverse information about physicians. The NPDB requires
input from five sources: medical malpractice payments, licensing actions by medical boards,
clinical privilege actions by hospitals and professional societies, actions by the DEA, and
Medicare and Medicaid exclusions. (See page 86: National Practitioner Data Bank.)
6. Which statement about continuous quality improvement (CQI) is FALSE&quest;

A. The focus of CQI is not on blame but rather on identification of the causes of
undesirable outcomes.
B. CQI continually tries to identify random errors and prevent them from recurring.
C. CQI assumes that the operator is just one part of a complex system.
D. After areas in need of improvement are identified by CQI programs, outcomes are
measured and documented.
E. CQI is instituted from the bottom up, not from the administrators down.
6. B. CQI takes a systems approach to identifying and improving quality. A CQI program may
focus on undesirable outcomes as a way to identify opportunities for improvement in the
structure and process of care. The focus is not on blame but rather on identification of the
causes of undesirable outcomes. CQI assumes that the operator is just one part of a complex
system. Random errors are inherently difficult to prevent, and programs focused in this direction
are misguided. System errors, however, should be controllable, and strategies to minimize them
should be within reach. After areas for improvement have been identified, their current status is
measured and documented. If a change is identified that should lead to improvement, it is
implemented. It is a process that is instituted from the bottom up by those who are actually
involved in the process to be improved rather than from the top down by administrators. (See
page 86: Quality Improvement and Patient Safety in Anesthesia.)
P.17
7. Pay for performance:
A. is a program that pays physicians for the hours they work rather than for services
B. is a program that provides money to hospitals that service Medicare and Medicaid
patients
C. is a program that provides monetary incentives for implementation of safe practices
D. has been a part of quality improvement since its inception
E. is a program that ranks doctors' abilities and pays them according to their rankings
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7. C. A relatively recent development related to quality improvement is P4P, or “pay for
performance.” P4P programs provide monetary incentives for implementation of safe practices,
measuring performance, and achieving performance goals. This is a recent and evolving trend.
(See page 88: Pay for Performance.)
8. For a malpractice suit against a physician to succeed, the patient/plaintiff must
prove:
1. breach of duty
2. damages
3. causation
4. duty
8. E. “Malpractice” is a lay term that refers to professional negligence pursued in the legal
system of civil laws. A successful malpractice suit must prove four things: (1) duty: that the
anesthesiologist owed the patient a duty; (2) breach of duty: that the anesthesiologist failed to
fulfill his or her duty; (3) causation: that a reasonably close causal relationship exists between
the anesthesiologist's acts and the resultant injury; and (4) damages: that actual damage
resulted because of a breach in the standard of care. (See page 88: The Tort System.)
9. Considering the cause of lawsuits against anesthesiologists, which of the following

statements is/are TRUE&quest;
1. The leading causes of death and brain damage injury are airway management
problems.
2. Ulnar nerve injury often occurs despite apparently adequate positioning.
3. Anesthesia is a high-risk endeavor because of the use of complex equipment and
potent drugs.
4. The leading injury for suits against anesthesiologists is brain damage.
9. A. The leading causes of lawsuits against anesthesiologists are death (22%), nerve damage
(21%), and brain damage (10%). The causes of death and brain damage are predominantly
problems with airway management. In the past, ulnar nerve injury was the most common cause
of nerve damage claims, and it often occurs despite apparently adequate positioning. In the
1990s, spinal cord injury led the list. Anesthesia is a high-risk endeavor for many reasons. The
anesthesiologist is likely to be the target of a lawsuit if an untoward outcome occurs because
the physician–patient relationship is usually tenuous at best. (See page 90: Causes of
Anesthesia-Related Lawsuits.)
10. When a plaintiff's attorney files a complaint, the anesthesiologist should take
certain actions, including which of the following&quest;
1. Review the records but do not alter them.
2. Cooperate fully with the attorney provided by the insurer.
3. Make a detailed account of all events.
4. Discuss the case with all involved operating room personnel.
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10. A. A lawsuit begins when the patient/plaintiff's attorney files a complaint. The
anesthesiologist needs assistance in answering the complaint. Specific actions that should be
taken at this point include the following: (1) do not discuss the case with anyone, including
colleagues who may have been involved, operating personnel, or friends; (2) never alter any
records; (3) gather all pertinent records, including copies of the anesthetic record, billing
statements, and any correspondence concerning the case; (4) make notes recording all events
recalled about the case; and (5) cooperate fully with the attorneys provided by the insurer. (See
page 90: What to Do When Sued.)
11. If a physician is deposed by a plaintiff's attorney, the physician should do which of

the following&quest;
1. Never attempt to change his or her image by dressing conservatively.
2. Volunteer all information he or she has about the case.
3. Not spend too much time preparing so the responses do not seem to be rehearsed.
4. Rely on his or her attorney for assistance when preparing.
11. D. After a complaint has been filed, the malpractice suit moves on to the discovery phase. A
deposition is the second mechanism of discovery. The plaintiff's attorney deposes the
anesthesiologist, and the anesthesiologist must be constantly aware that what is said during the
deposition carries as much weight as what is said in court. It is important to be factually
prepared for the deposition. Review of notes, anesthetic records, and medical records is
necessary. The physician should dress conservatively and professionally. Information should
never be volunteered. The physician should rely on his or her attorney for assistance when
preparing for a deposition. (See page 90: What to Do When Sued.)
12. Concerning Jehovah's Witnesses and blood transfusions, which of the following
1. Physicians are obligated to treat all patients who apply for treatment, even if they
refuse to have a blood transfusion.
2. Parents of a minor child may not legally prevent that child from receiving blood.
3. If a Jehovah's Witness consents to a blood transfusion, the physician needs to obtain
a court order before giving the transfusion.
4. Some Jehovah's Witnesses will not accept an autotransfusion even if their blood
remains in constant contact with their body via tubing.
12. C. The religious beliefs of Jehovah's Witnesses preclude them from receiving blood or
blood products. Physicians are not obligated to treat all patients who apply for treatment. A
physician has the right to refuse to care for a patient in an elective situation if the patient
unacceptably limits the physician's ability to provide optimal care. Together, the physician and
patient may decide to limit the physician's obligation to adhere to the patient's religious beliefs.
Any agreement should be documented clearly in the medical record. It is true that some patients
will not allow any blood that has left the body to be infused, but others will accept transfusion if
the blood remains in constant contact with the body via tubing. Parents of a minor child may not
legally prevent that child from receiving blood. (See page 85: Special Circumstances: “Do Not
Attempt Resuscitation” and Jehovah's Witnesses.)
13. When considering the NPDB, which of the following statements is/are TRUE&quest;
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1. After a report is submitted to the NPDB, the physician may dispute the input.
2. Creation of the NPDB has allowed physicians to settle nuisance suits because their
names are not added to the database.
3. A practitioner may query the NPDB about his or her file at any time.
4. The NPDB is a statewide information system.
13. B. The NPDB is a nationwide information system that theoretically allows licensing boards
and hospitals a means of detecting adverse information about physicians. A practitioner may
query the NPDB any time about his or her file. After a report has been submitted, the physician
is notified and may dispute the input. The existence of the NPDB reporting requirements has
made physicians reluctant to allow settlement of nuisance suits because doing so would cause
their names to be added to the data bank. (See page 86: National Practitioner Data Bank.)
14. Considering quality improvement programs, which of the following statements

is/are TRUE&quest;
1. “Pay for performance” falls outside the domain of quality improvement.
2. Quality improvement outcome studies are easily applied to the field of anesthesia
because it has a high rate of catastrophic outcomes.
3. Sentinel events are events with poor outcomes that are directly related to operator
actions.
4. Critical incidents are events that cause or have the potential to cause patient injury if
they are not noticed and corrected in a timely manner.
14. D. It is generally accepted that attention to quality will improve patient safety and
satisfaction. Quality improvement programs are generally guided by requirements of The Joint
Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations
[JCAHO]). However, adverse outcomes are relatively rare in anesthesia practices, making
measurement of improvement difficult. To complement outcome measurements, anesthesia
quality improvement programs may focus on critical incidents and sentinel events. Critical
incidents are events that cause or have the potential to cause patient injury if they are not
noticed and corrected in a timely manner. Sentinel events are single, isolated events that may
indicate a systematic problem. “Pay for performance” is an evolving trend in quality
improvement programs. (See page 86: Quality Improvement and Patient Safety in Anesthesia.)
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Review of Clinical Anesthesia, 5e [Vishal] 5. Mechanisms of Anesthesia & Consciousness
Chapter 5
Mechanisms of Anesthesia and Consciousness
1. For volatile anesthetics, potency is proportional to:

A. Lipid solubility
B. Vapor pressure
C. Critical temperature
D. Minimum alveolar concentration (MAC)
E. None of the above
1. A. Anesthetic potency is proportional to lipid solubility. (See page 105: What Is the Chemical
Nature of Anesthetic Target Sites&quest;)
2. The Meyer-Overton rule:

A. Correlates the potency of anesthetic gases with their solubility in oil
B. Suggests the anesthetic target site to be hydrophilic in nature
C. Is contradicted by the unitary theory of anesthesia
D. Applies only to liquids
E. Applies only to gases that never exist in the liquid state
2. A. The Meyer-Overton rule states that the potency of anesthetic gases is proportional to their
lipid solubility. Because many different structurally unrelated anesthetics obey this rule, it has
been speculated that all anesthetics act at the same molecular site. This concept is known as
the unitary theory of anesthesia. The Meyer-Overton rule applies only to gases and volatile
liquids because an oil/gas partition coefficient cannot be determined for anesthetics in the liquid
state. (See page 105: What Is the Chemical Nature of Anesthetic Target Sites&quest; The
Meyer-Overton Rule.)
3. In humans, the definition of minimum alveolar concentration (MAC) is:

A. The alveolar partial pressure of a gas at which 50% of humans will not mount a
sympathetic response
B. The alveolar partial pressure of a gas at which 50% of humans will not respond to a
surgical incision
C. The alveolar partial pressure of a gas at which 30% of humans will not respond to a
surgical incision
D. The alveolar partial pressure of a gas at which 50% of subjects remain unresponsive
to verbal stimuli
E. The alveolar partial pressure of a gas at which 50% of subjects will follow a simple
command
3. B. MAC is the alveolar partial pressure of a gas at which 50% of subjects will respond to a
surgical incision. The use of end-tidal gas concentration provides an index of the “free”
concentration of anesthetic gas required to produce anesthesia. (See page 97: How Is
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Anesthesia Measured&quest;)
For questions 4 to 7, choose A if 1, 2, and 3 are correct; B if 1 and 3 are correct; C if 2 and 4
are correct; D if 4 is correct; or E if all are correct.
4. General anesthesia results from interruption of nervous system activity at which of
the following levels&quest;
1. Cerebral cortex
2. Spinal cord
3. Brainstem
4. Peripheral sensory receptors
4. A. Anesthetics are able to produce effects on a variety of anatomic structures in the central
nervous system, including the cerebral cortex, brainstem, and spinal cord. Anesthetics clearly
alter cortical electrical activity, as evidenced by the consistent changes (increased latency,
decreased amplitude) in surface electroencephalographic patterns recorded during anesthesia.
A role for the brainstem in anesthetic action is supported by studies examining somatosensory
evoked potentials. The actions of volatile anesthetics in the spinal cord are mediated, at least in
part, by direct effects on the excitability of spinal motor neurons. This is supported by several
electrophysiologic studies showing inhibition of excitatory synaptic transmission in the spinal
cord. Animal studies have shown that volatile anesthetics have no significant effects on
peripheral sensory receptors. (See page 99: Where in the Central Nervous System Do
Anesthetics Work&quest; Synaptic Function.)

1. γ -Aminobutyric acid (GABA) is an excitatory neurotransmitter.
2. Volatile anesthetics modulate GABA receptor function.
3. Benzodiazepines have no effect on GABA receptors.
4. Barbiturates and etomidate act at GABA receptors.
5. C. GABA receptors mediate the postsynaptic response to synaptically released GABA, an
important inhibitory neurotransmitter. Barbiturates, benzodiazepines, propofol, etomidate, and
volatile anesthetics all have been shown to modulate GABA receptor function. (See page 102:
Anesthetic Effects on Ligand-Gated Ion Channels: GABA-Activated Ion Channels.)
6. General anesthetics have been shown to inhibit excitatory synaptic transmission in

the:
1. Sympathetic ganglia
2. Olfactory cortex
3. Hippocampus
4. Spinal cord
6. E. General anesthetics have been shown to inhibit excitatory synaptic transmission in the
sympathetic ganglia, olfactory cortex, hippocampus, and spinal cord. (See page 99: How Do
Anesthetics Interfere with the Electrophysiologic Function of the Nervous System&quest;
Synaptic Function.)
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7. Important features of minimum alveolar concentration (MAC) include:
1. MAC represents the average response of a whole population of subjects rather than
the response of a single subject.
2. MAC can only be directly applied to anesthetic gases.
3. MAC does not reflect the end-tidal concentration at which there is loss of response to
verbal stimuli.
4. The MAC endpoint in a MAC determination is relative rather than quantal.
7. A. The MAC concept has several important limitations, particularly when trying to relate MAC
values to anesthetic potency observed in vitro. First, the endpoint in a MAC determination is
quantal: A subject is either anesthetized or unanesthetized; he or she cannot be partially
anesthetized. Furthermore, MAC represents the average response of a whole population of
subjects rather than the response of a single subject. Another limitation of MAC measurements
is that they can only be directly applied to anesthetic gases. Parenteral anesthetics
(barbiturates, neurosteroids, propofol) cannot be assigned a MAC value, making it difficult to
compare the potency of parenteral and volatile anesthetics. A further limitation of MAC is that it
is highly dependent on the anesthetic endpoint used to define it. For example, if loss of
response to verbal commands is used as an anesthetic endpoint, the MAC values obtained
(MACawake) will be much lower than classic MAC values based on response to a noxious
stimulus. (See page 97: How Is Anesthesia Measured&quest;)
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Review of Clinical Anesthesia, 5e [Vishal] 6. Genomic Basis of Perioperative Medicine
Chapter 6
Genomic Basis of Perioperative Medicine
Match the following genetic terms with the appropriate definitions:

1. Mutation
A. DNA sequence alternatives
B. Insertion or deletion of one or more nucleotides
C. Nucleotide polymorphisms inherited in blocks
D. Rare genetic variants
E. Widespread DNA sequence variations
1. D.
2. Polymorphism
2. E.
3. Indels
3. B.
4. Haplotypes
4. C.
5. Allele
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5. A. Perioperative genomics applies functional genomics into clinical practice. Physicians need
to understand the patterns of human genome variation and its methods of study. Mutations are
rare genetic variations that have been identified with more than 1500 disorders. Polymorphism
refers to widespread population-based DNA variations. Indels are insertions and deletions of
nucleotides. Single nucleotide polymorphisms inherited in blocks are referred to as haplotypes.
Alleles are DNA sequence alternatives that contribute to either mutant variants or
polymorphism within a population. (See page 116: Overview of Human Genetic Variation.)
6. The term used to refer to nearby single nucleotide polymorphisms on a

chromosome that are inherited in blocks is:
A. alleles
B. haplotypes
C. polymorphic mutations
D. indels
E. phenotype
6. B. Haplotypes are inherited in blocks, and an analysis of these can be useful in discovering
diseased genes. An indel is an insertion or deletion of one or more nucleotides. (See page 116:
Overview of Human Genetic Variation.)
7. One of the most common inherited prothrombotic risk factors is a point mutation in
which factor&quest;
A. Factor II
B. Factor V
C. Factor VII
D. Factor XI
E. Factor XII
7. B. A point mutation in coagulation factor V results in resistance to activated protein C and is
commonly known as factor V Leiden. This factor has been associated with thromboses in the
postoperative setting. (See page 123: Coagulation Variability and Perioperative Myocardial
Outcomes.)
8. After cardiac surgery, what is the incidence of significant neurologic morbidity

(ranging from focal stroke to coma)&quest;
A. 0.1%–0.2%
B. 1%–3%
C. 10%–15%
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D. 20%–30%
E. >40%
8. B. The incidence of coma and focal stroke after cardiac surgery is approximately 1% to 3%.
More subtle deficits occur in up to 69% of patients. This variability in neurologic deficit is poorly
explained by risk factors related to the procedure. The role of apolipoprotein E genotypes in
relation to modulating the inflammatory response, extent of aortic atheroma, and cerebral blood
flow and autoregulation may explain the observed associations with poor neurologic outcomes.
(See page 124: Genetic Susceptibility to Adverse Perioperative Neurologic Outcomes.)
9. Malignant hyperthermia follows what pattern of inheritance&quest;

A. Autosomal dominant
B. Autosomal recessive
C. X-linked dominant
D. X-linked recessive
E. It is not an inherited disease.
9. A. Malignant hyperthermia is a rare autosomal dominant genetic disease of skeletal muscle
calcium metabolism. Susceptibility to malignant hyperthermia has been linked to the ryanodine
receptor gene locus on chromosome 19. (See page 127: Genetics of Malignant Hyperthermia.)
10. In classical genetics, what is meant by “wild-type” individual&quest;

A. An individual with individual gene mutations
B. An individual with traits controlled by multiple genes
C. An individual with genes acutely affected by the environment
D. An individual with nonmutant individual genes
E. Your uncontrollable 3-year-old nephew
10. D. In classical genetics, single gene traits were identified and studied. Phenotypic
differences attributed to individual genes were observed, and the genes were isolated. The
nonmutant or original phenotype expressed by a single gene was termed “wild type” and was
compared with the new phenotypes or “mutants.” (See page 127: Genetic Variability and
Response to Anesthetic Agents.)
11. What is a “knockout” animal&quest;

A. An animal that misexpresses an additional gene
B. An animal that overexpresses an additional gene
C. A kangaroo with boxing gloves
D. An animal with a nonfunctional gene
E. An animal with a gene predisposing to sleep
11. D. “Knockout” animals are created by inserting a vector with a disrupted gene into an
animal. Typically, a mouse is used. The goal is to achieve two nonfunctioning alleles so that a
gene is not expressed. This is done to study specific functions of specific genes. Animals that
misexpress or overexpress a gene are termed “transgenic.” (See page 127: Genetic Variability
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and Response to Anesthetic Agents.)
12. Our understanding of pain has been increased by mice with knockout genes for:
A. Substance P
B. Opioid transmitters
C. Nerve growth factors
D. All of the above
12. D. Multiple genes appear to mediate sensitivity to noxious stimuli and chronically painful
exposure. Various knockout mice missing functional genes for neurotrophins, nerve growth
factors, substance P, opioid transmitters, and nonopioid transmitters and their receptors have
significantly contributed to our knowledge of pain processing. (See page 127: Genetic
Variability and Response to Anesthetic Agents.)
13. Numerous clinical trials attempting to block single inflammatory mediators in

patients with sepsis have been largely unsuccessful. Which of the following best
explains the lack of success&quest;
P.24
A. Large tertiary care centers have a low incidence of septic shock.
B. There is a lack of clinical investigators with an interest in septic shock.
C. Septic shock is unimportant as a disease syndrome.
D. Cascades of biologic pathways that interact in complex and redundant ways are
triggered by stressful stimuli.
E. Sepsis has a negligible worldwide economic impact and thus receives a small
percentage of funds for investigation.
13. D. At the cell level, various cascades and pathways are triggered when an organism is
stressed. These pathways are often interrelated and work to both increase and suppress gene
expression. Because negative and positive feedback occur in a complex manner, attempts to
study the expression of a single gene (products such as tumor necrosis factor-α) have been
difficult. (See page 130: Functional Genomics of Injury.)
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Review of Clinical Anesthesia, 5e [Vishal] 7. Pharmacologic Principles
Chapter 7
Pharmacologic Principles
1. Which of the following statements concerning passage of drugs across membranes

is FALSE&quest;
A. Small lipophilic drugs can passively diffuse across cell membranes.
B. The walls of most capillaries do not allow passage of water-soluble drugs.
C. Active transport is able to shuttle proteins against their concentration gradient.
D. Thiopental easily crosses cell membranes.
E. The capillaries of the central nervous system (CNS) do not allow passive transport of
water-soluble drugs.
1. B. The large spaces between capillaries allow for passage of water-soluble drugs, except in
the brain, where there are tight interendothelial cell junctions (the so-called blood–brain barrier).
Transcellular penetration is much easier for small, lipid-soluble drugs, which can more readily
cross lipid membranes. This accounts for the greater CNS penetrability of thiopental.
Distribution of highly polar drugs, such as neuromuscular blockers, is essentially limited to the
extracellular fluid. (See page 138: Pharmacokinetic Principles Absorption and Routes of
Administration.)
2. Which of the following statements about drug distribution to the central nervous
system (CNS) is FALSE&quest;
A. Equilibration in the brain and muscle does not occur simultaneously.
B. Diffusion of water-soluble drugs into the brain is severely restricted.
C. For more polar compounds, the rate of entry into the brain is proportional to their lipid
solubility.
D. Distribution of highly lipid-soluble drugs into the CNS is directly proportional to
cerebral blood flow.
E. Recovery from a single dose of thiopental depends primarily on hepatic elimination.
2. E. Recovery from thiopental largely depends on redistribution from the brain to other tissues
(e.g., muscle); the effects of elimination are not noted until later in the course of recovery and
are relatively minor unless large doses are used. The distribution of lipid-soluble drugs into the
CNS is very rapid and thus is directly proportional to cerebral blood flow (i.e., to the amount of
drug that is delivered to the brain). Polar compounds do not pass into the brain readily because
brain capillaries do not have the large aqueous channels typical of capillaries in other tissues.
For more polar compounds, the rate of entry into the brain is proportional to the lipid solubility of
the nonionized drug. (See page 139: Drug Distribution.)
3. How many minutes after an intravenous injection does the brain concentration of
propofol peak&quest;
A. 1
B. 4
47 / 494
C. 6
D. 8
E. 11
3. A. The brain concentration of propofol peaks within 1 minute because of high blood flow to
the brain and the high lipid solubility of propofol. Propofol quickly diffuses back into the blood,
where it is redistributed to other tissues that are still taking up drug. Its duration of action is thus
very short unless high doses are used and termination of drug action becomes dependent on
drug elimination. (See page 140: Drug Distribution: Redistribution.)
4. Elimination half-life
A. is not influenced by drug distribution
B. is not influenced by drug elimination
C. is the time it takes the amount of drug in the vessel-rich group to decrease by 50%
D. is not influenced by age
E. is the time it takes the amount of drug in the body to decrease by 50%
4. E. The elimination half-life of a drug is the time it takes the amount of drug in the body to
decrease by 50%. It is influenced by the volume of distribution for the drug and the rate of
elimination of the drug. The rate of elimination is dependent on the age of the patient taking the
drug. (See page 146: Elimination Half-Life.)
5. Which statement about drug elimination is FALSE&quest;

A. Elimination can occur by excretion of unchanged drug.
B. Metabolism is a step in some drug elimination.
C. The liver and kidney are the most important organs in drug elimination.
D. The liver eliminates drugs primarily by excretion.
E. The kidney primarily excretes water-soluble, polar compounds.
5. D. Elimination is an inclusive term that refers to all the processes that remove drugs from the
body. Elimination occurs either by excretion of unchanged drug or by metabolism
(biotransformation) and subsequent excretion of metabolites. The liver and kidneys are the
most important organs for drug elimination. The liver eliminates drugs primarily by metabolism to
less active compounds and, to a lesser extent, by hepatobiliary excretion of drugs or their
metabolites. The primary role of the kidneys is the excretion of water-soluble, polar compounds.
(See page 140: Drug Elimination.)
6. Which of the following indicates the units for elimination clearance (drug
clearance)&quest;
A. mL/min
B. mL/kg/min
C. %/kg
D. mL/kg
E. kg/%
48 / 494
6. A. Elimination clearance has units of flow (e.g., mL/ min). It is the portion of the volume of
distribution (the theoretical volume of a drug) from which the drug is completely removed in a
given time interval. (See page 140: Drug Elimination.)
7. Which of the following statements concerning the volume of drug distribution and
clearance is TRUE&quest;
A. The smaller the volume of distribution, the longer the half-time of elimination.
B. The calculated volume of steady-state distribution can exceed the actual volume of
the body.
C. The volume of distribution is equal to the total amount of drug present divided by
plasma volume and vessel-rich group volume.
D. The volume of distribution provides information regarding the tissues into which the
drug distributes and the concentration in those tissues.
E. The volume of distribution cannot be as small as the plasma volume.
7. B. Extensive tissue uptake of a drug is reflected by a large volume of the peripheral
compartment. If there is binding to the tissues, then the calculated volume of distribution may
exceed the actual volume of the body. It may be as small as the plasma volume. The volume of
distribution is equal to the total amount of drug divided by the concentration. The volume of
distribution does not provide any information regarding the tissues into which the drug
distributes or the concentrations in those tissues. (See page 145: Volume of Distribution.)
P.26
8. If 10 mg of drug is present and the plasma concentration is 2 mg/L, then the volume
of distribution (Vd) is ___________ L.
A. 5
B. 50
C. 500
D. 20
E. 0.2
8. A. The Vd is 5 L. Vd = Total amount of drug/ Concentration. (See page 146: Volume of
Distribution: One-Compartment Model.)
9. Which statement regarding renal function is FALSE&quest;

A. Drug doses must be altered in patients with decreased renal function.
B. Low cardiac output states decrease renal function.
C. Acute renal failure requires a change in drug doses.
D. Patients compensate for chronic renal failure, so drug doses should not be changed
in these patients.
E. Age decreases renal function.
9. D. Renal drug clearance, even for drugs eliminated primarily by tubular secretion, is
dependent on renal function. Therefore, in patients with acute and chronic causes of decreased
49 / 494
renal function, including age, low cardiac output states, and hepatorenal syndrome, drug dosing
must be altered to avoid accumulation of parent compounds and potentially toxic metabolites.
(See page 142: Renal Drug Clearance.)
10. Which form of biotransformation is particularly prominent when intracellular

oxygen tension is very low&quest;
A. Reduction
B. Oxidation
C. Hydrolysis
D. Hydroxylation
E. Dealkylation
10. A. Reductive biotransformation (i.e., transfer of electrons to the drug molecule) is inhibited
by oxygen. Thus, it is facilitated when intracellular oxygen tension is low. (See page 140: Phase
I Reactions.)
11. Which of the following statements concerning hepatic clearance is FALSE&quest;

A. If the extraction ratio (and intrinsic clearance) is very high, then total hepatic
clearance will be proportional to hepatic blood flow.
B. Clearance of drugs with low extraction ratios occurs relatively independently of the
amount of hepatic blood flow.
C. Intrinsic clearance is the amount of blood that bypasses the liver, not allowing for drug
clearance.
D. The hepatic extraction ratio is the fraction of the drug removed from the blood passing
through the liver.
E. Clearance of lidocaine is reduced in patients with congestive cardiac failure in
proportion to the decrease in hepatic blood flow.
11. C. Hepatic extraction ratio is the fraction of the drug removed from the blood passing
through the liver. Intrinsic clearance is the intrinsic ability of the liver to metabolize the drug.
When the intrinsic clearance is low, clearance occurs essentially independently of hepatic blood
flow. A very high liver extraction ratio indicates that the liver is removing most of the drug that is
passing through it. Until the liver's capacity is exceeded, drug removal increases as the blood
flow increases. A decrease in liver perfusion, as may occur with congestive heart failure,
decreases the clearance of drugs that are highly extracted (e.g., lidocaine). (See page 142:
Hepatic Drug Clearance.)
12. Each of the following has a high hepatic extraction ratio EXCEPT:
A. Rocuronium
B. Lidocaine
C. Metoprolol
D. Propofol
E. Meperidine
12. A. The extraction ratios for lidocaine, meperidine, propofol, and metoprolol are very high;
50 / 494
the extraction ratio for rocuronium is much lower. (See page 144: Table 7-3: Classification of
Drugs Encountered in Anesthesiology According to Hepatic Extraction Ratios.)
13. Which of the following statements concerning renal clearance is FALSE&quest;

A. Normally, only unbound drugs can pass through the glomerular membrane into the
renal tubule.
B. Active transport makes renal elimination more efficient.
C. Highly lipophilic drugs, such as thiopental, undergo virtually no renal clearance of the
parent molecule.
D. Changes in renal drug clearance are proportional to changes in creatinine clearance.
E. Passive elimination of drugs by glomerular filtration is very efficient.
13. E. All unbound drug is filtered by the glomerulus, with a glomerular filtration rate that is 20%
of renal plasma flow. Passive elimination of drugs by glomerular filtration is inefficient. Active
transport makes renal elimination more efficient. Lipid-soluble drugs undergo reuptake in the
renal tubule and have virtually no renal clearance. Renal clearance is directly proportional to
renal blood flow and hence creatinine clearance. (See page 142: Renal Drug Clearance.)
14. Which of the following statements about pharmacokinetics is FALSE&quest;

A. In first-order kinetics, when the concentration is high, it will decrease faster than when
it is low.
B. The brain, heart, lungs, and muscle make up the vessel-rich group.
C. A first-order kinetic process is one in which a constant fraction of the drug is removed
during a finite period of time.
D. Awakening after a single dose of thiopental is primarily the result of redistribution.
E. The disadvantage of perfusion-based pharmacokinetic models is their complexity.
14. B. The term pharmacokinetics refers to the quantitative analysis of the relationship
between the dose of a drug and the ensuing changes in drug concentration in the blood and
other tissues. Physiologic pharmacokinetic models provide much insight into factors that affect
drug action. In these models, body tissues are classified according to similarities in perfusion
and affinity for drugs. Highly perfused tissues, including the brain, heart, lungs, liver, and
kidneys, make up the vessel-rich group. Muscle and skin comprise the lean tissue group, and
fat is considered a separate group. These models have established that awakening after a
single dose of thiopental is primarily the result of redistribution from the brain to the muscles
and skin. The disadvantage of perfusion-based models is their complexity. The disposition of
most drugs follows first-order kinetics. A first-order kinetic process is one in which a constant
fraction of the drug is removed during a finite period of time. Because a constant fraction is
removed per unit of time in first-order kinetics, the absolute amount of drug removed is
proportional to the concentration of the drug. When the concentration is high, it decreases
faster than when it is low. (See page 144: Pharmacokinetic Models.)
15. What is the half-time of elimination for a drug that undergoes first-order elimination
with a rate constant of 0.1 minute&quest;
A. 10 minutes
51 / 494
B. 100 minutes
C. 0.1 minutes
D. 6.93 minutes
E. 693 minutes
15. D. Half-life (minutes) = Natural log of 2 ÷ Given drug's rate constant of elimination = 0.693 ÷
0.1 minute = 6.93 minutes. Thus, it would take 6.93 minutes for the concentration to change by
a factor of 2 for a drug with a rate constant of 0.1 minute. (See page 144: Rate Constants and
Half-Lives.)
16. How many minutes are required for approximately 97% elimination of a drug
undergoing first-order elimination with a half-time of 10 minutes&quest;
A. 10
B. 30
C. 50
D. 70
E. 100
16. C. When a drug is eliminated by first-order elimination, its concentration is generally
reduced by 97% after five half-times of elimination. Conversely, if a drug is infused at a
constant rate, the concentration approaches a steady state after approximately five half-lives.
(See page 144: Rate Constants and Half-Lives.)
17. What is mean residence time (MRT)&quest;

A. The time it takes a drug to reach its steady state after starting an infusion
B. The time a drug molecule spends in the vessel-rich group of tissues
C. The average time a drug molecule spends in the body before being eliminated
D. The average time a drug molecule spends in the renal cells before being excreted
E. The average time it takes a drug to reach its volume of distribution
17. C. MRT is the average time a drug molecule spends in the body before being eliminated. It
is the main unique parameter of noncompartmental analysis, which attempts to avoid the
experimental requirements of a physiologic model when describing pharmacokinetics. (See
page 149: Noncompartmental [Stochastic] Pharmacokinetic Models.)
18. Which statement regarding target-controlled infusions (TCI) is TRUE&quest;

A. They have been commercially available for more than 30 years.
B. They require the physician to calculate the volume of distribution for each drug and
patient.
P.27
P.28
P.29
C. All studies have shown that TCI improves times to emergence.
D. TCI is important intraoperatively but can not be used for postoperative pain
52 / 494
management.
E. The physician must program a target plasma concentration of the drug into the pump.
18. E. TCI is a method of drug delivery that links a computer with the appropriate
pharmacokinetic model to an infusion pump. It allows physicians to enter the desired target
plasma concentration of a drug, and the computer instantaneously calculates the appropriate
infusion scheme to achieve this target. TCI was first described in the early 1980s and became
commercially available in the late 1990s. Although the pharmacologic principle of relating a
concentration rather than a dose is scientifically sound, few studies have actually attempted to
determine whether TCI improves clinical performance or outcome. Only a few limited studies
have actually compared manual infusion control with TCI. Some have shown better control and
a more predictable emergence with TCI, but others have simply shown no advantage. TCI has
been used to provide postoperative analgesia with alfentanil. (See page 157: Target-Controlled
Infusions.)
19. Individual variation in drug metabolism can be caused by:
1. Genetic differences of metabolic enzymes
2. Age
3. Exposure to other drugs
4. Gender
19. A. Rates of drug metabolism vary between individuals based on age, differences in
metabolic enzymes, and exposure to xenobiotics. Gender does not seem to play a role in the
rate of drug metabolism. (See page 140: Drug Elimination.)
20. Which of the following have significant renal excretion&quest;

1. Pancuronium
2. Rocuronium
3. Nor-meperidine
4. Thiopental
20. A. Many drugs, including pancuronium and rocuronium, are excreted by the kidneys. Others
have pharmacologically active metabolites that are renally excreted, including meperidine's
metabolite nor-meperidine. (See page 142: Table 7-2: Drugs with Significant Renal Excretion.)
21. TRUE statements about agonists and antagonists include:

1. Competitive antagonists bind irreversibly to receptors.
2. Competitive antagonists do not change the maximum possible effect that can be
elicited by an agonist.
3. Noncompetitive antagonists bind reversibly to receptors.
4. Noncompetitive antagonists change the maximum effect elicited by an agonist.
21. D. Competitive antagonists bind reversibly to receptors, and their blocking effect can be
overcome by high concentrations of an agonist. Therefore, competitive antagonists produce a
53 / 494
parallel shift in the dose–response curve, but the maximum effect is not altered. Noncompetitive
antagonists bind irreversibly to receptors. This has the same effect as reducing the number of
receptors and shifts the dose–response curve downward and to the right, decreasing both the
slope and the maximum effect. (See page 150: Drug-Receptor Interactions: Agonists, Partial
Agonists, and Antagonists.)
22. TRUE statements regarding drug infusions of propofol include:

1. A multicompartment model must be used to predict propofol concentration during an
infusion.
2. The concentration of infused propofol reaches 90% of the steady state in 3.3 half-
lives.
3. Propofol's elimination half-life is 6 hours.
4. It takes 6 hours from the start of a propofol infusion to reach 50% of its steady-state
concentration.
22. B. In a one-compartment model, the rise of drug concentration during a constant infusion is
the mirror image of its elimination profile. Using a single-compartment model, drug infusions
reach 90% of their steady state in 3.3 half-lives. Propofol, however, partitions extensively to
pharmacologically inert body tissues, so a multicompartment model must be used to predict its
concentrations during infusions. The half-life of propofol is 6 hours, yet the multicompartment
model of drug concentration predicts that it will reach 50% of steady state in less than 30
minutes from starting a constant infusion. (See page 153: Rise to Steady-State Concentration.)
54 / 494
Review of Clinical Anesthesia, 5e [Vishal] 8. Electrical & Fire Safety
Chapter 8
Electrical and Fire Safety
1. Electrical contact may produce which of the following types of injuries&quest;
1. Disruption of normal electrical function of the cells
2. Respiratory paralysis
3. Muscle contraction
4. Cardiac arrhythmias
1. E. Electrical contact may result in flow of current through an individual. First, the electrical
current may disrupt the normal electrical function of cells. Depending on the magnitude, it can
cause muscle contraction, changes in brain function, respiratory paralysis, and disruption of
normal heart function leading to ventricular fibrillation. Depending on the path taken, the flow of
current through tissue will produce heat if the resistance to flow is high. (See page 167: Source
of Shocks.)
2. Injury from macroshock is affected by which of the following&quest;

1. Skin resistance
2. Duration of contact with the electrical source
3. Current density
4. Capacitance
2. A. Injury from electricity is influenced by skin resistance, duration of contact with the electrical
source, and current density. High skin resistance decreases the transfer of electricity and thus
is protective. Contact time results in more current flow and thus more energy transferred, which
produces more tissue damage in high-resistance tissues. Furthermore, prolonging the exposure
to current flow increases the risk of inducing ventricular fibrillation during a vulnerable period of
the cardiac cycle. Current density describes the surface area onto which the current is
transferred. The quantity of injury is inversely related to the surface area and is directly related
to the quantity of current transferred through that surface area. This is the reason that small
voltages applied to a small surface area of a vulnerable tissue result in injury (e.g., ventricular
fibrillation with current down a pacing wire). Capacitance refers to the storage of current in two
conductive materials separated by an insulatory layer. It does not play a role in the magnitude
of injury, although capacitance can store current, which can result in injury even when an item
is unplugged. (See page 166: Capacitance and page 167: Source of Shocks.)
3. Which of the following statements regarding grounded electrical systems is/are

TRUE&quest;
1. The hot wire (black) carries a voltage of 120 V above ground.
2. A ground wire (green or bare) is necessary to complete a circuit.
3. The white wire is neutral.
55 / 494
4. The circuit breaker prevents macroshock by preventing current flow.
3. B. In a normal grounded circuit, the power company delivers a hot wire with a voltage above
ground. Within a house, it is carried by a black wire. The power company also supplies a
neutral wire for the current to return to the earth. This is usually a white wire. These two wires
are all that are needed to produce the path for the current to flow through a resistance and
perform work. A circuit breaker between the hot supply and the receptacle prevents current flow
in excess of the wire's capabilities. Exceeding the wire's capabilities results in heat production
and a possible fire hazard. Circuit breakers do not prevent macroshock. The ground wire, which
is bare or green, acts as a safety feature to prevent shock in the event that the object
containing the electricity comes in contact with the hot wire. In these malfunctioning devices, the
casing of the object becomes hot and carries the same potential as the hot wire. If someone
comes into contact with the case (and if he or she is grounded), he or she will provide a path for
current to flow and will be electrocuted. The ground wire acts as a low-resistance pathway for
electrical potentials within the case and thus reduces the flow in the individual. A ground wire is
a safety feature but is not necessary to complete a circuit. (See page 169: Electrical Power:
Grounded.)
4. An ungrounded electrical system has which of the following properties&quest;

1. It makes the use of a ground wire obsolete.
2. The 120-V potential exists only between the two wires in the system.
3. It eliminates the potential for microshock.
4. It requires the presence of an isolation transformer.
4. C. An ungrounded power supply uses an isolation transformer to separate itself from the
power company. The isolation transformer creates a power gradient of 120 V between the two
wires within the system but no gradient between any of the two wires and the ground. Thus,
individuals can contact either wire of an ungrounded system and not complete a circuit. An
individual who contacts both wires within the isolated system will complete a circuit and be
electrocuted. Isolation transformer systems thus significantly reduce the risk of macroshock in
the operating room environment but do not reduce the risk of microshock. The use of a ground
wire is still used within an isolation transformer system because it constitutes an additional,
alternative safety system. The ground wire is attached to the device's case to provide a low-
resistance pathway if the case of the device becomes electrically hot. (See page 173: Electrical
Power: Ungrounded.)
5. Which of the following statements regarding the line isolation monitor (LIM) is/are
TRUE&quest;
1. The LIM measures the impedance of current flow to ground that exists in the system.
2. The LIM is set to alarm at 2 to 5 mA.
3. The LIM is necessary to identify faulty equipment, which, despite a contact to ground,
will function normally in an ungrounded system.
4. The value on the LIM display indicates that current is actively flowing to ground.
5. A. The LIM is a device that monitors the integrity of the isolation of the ungrounded electrical
system. Such monitoring is essential in that a first fault to the ground in an isolated system will
result in normal function of an electrical device (but will alert that the isolation of the power has
56 / 494
been breached). The typical cause of loss of isolation is that the case and the ground wire
have become connected. Because the ground is not in the path of the isolated power, no short
circuit exists, and the equipment is safe to use and will continue to function. However, if an
individual comes into contact with the other limb of the isolated circuit, he or she would then be
in contact with both sides of the isolated power (through the ground and the ground wire) and
will thus receive a shock. The LIM monitors the impedance to ground of each side of the
isolated power. The value measured on the LIM does not mean that current is actually flowing;
rather, it indicates how much current would flow in the event of a fault. Normally, the LIM is set
to alarm at 2 to 5 mA. In a perfect system, the impedance to ground is infinite, but because
alternating current creates capacitance (and this can leak to the ground even with perfect
isolation), a buffer of acceptable leak is permitted to prevent alarming secondary to capacitance
leakage. (See page 175: The Line Isolation Monitor.)
6. Which of the following statements regarding fires in the operating room is/are
TRUE&quest;
1. Fires in the operating room present much less danger compared with 100 years ago,
when patients were anesthetized with flammable anesthetic agents.
2. A combination of 50% oxygen and 50% nitrous oxide would support combustion as
well as 100% oxygen.
3. An ignition source and an oxidizer are enough to start a fire.
4. Paper drapes are much easier to ignite and can burn with greater intensity than cloth
drapes.
6. C. Fires in the operating room are just as much a danger today as they were 100 years ago,
when patients were anesthetized with flammable anesthetic agents. Today, the risk of an
operating room fire is probably as great as or greater than in the days when ether and
cyclopropane were used. This is because of the routine use of potential sources of ignition in
an environment rich in flammable materials. For a fire to start, three elements are necessary: a
heat or ignition source, fuel, and an oxidizer. The main oxidizers in the operating room are air,
oxygen, and nitrous oxide. Oxygen and nitrous oxide function equally well as oxidizers, so a
combination of 50% oxygen and 50% nitrous oxide would support combustion as well as 100%
oxygen. Fuel for a fire can be found everywhere in the operating room. Paper drapes have
largely replaced cloth drapes, and these are much easier to ignite and can burn with greater
intensity. Other sources of fuel include gauze dressings, endotracheal tubes, gel mattress pads,
and even facial or body hair. (See page 185: Fire Safety.)
7. Regarding fires in the operating room, which of the following is/are TRUE&quest;
1. Major ignition sources for operating room fires are the electrosurgical unit and the
laser.
2. The ends of some fiberoptic light cords can become hot enough to start a fire.
3. Fires on a patient occur most often during surgery in and around the head and neck,
where the patient is receiving monitored anesthesia care.
4. Fires in or on the patient represent an unlikely but possible type of operating room fire.
7. A. Major ignition sources for operating room fires are electrosurgical units and lasers.
However, the ends of some fiberoptic light cords can also become hot enough to start a fire if
57 / 494
they are placed on paper drapes. Operating room fires can be divided into two different types.
The more common type of fire occurs in or on the patient. These include endotracheal tube
fires; fires during laparoscopy or bronchoscopy; or a fire in the oropharynx, which may occur
during a tonsillectomy. The other type of operating room fire is one that is remote from the
patient, including an electrical fire in a piece of equipment. Fires on the patient seem to have
become the most frequent type of operating room fire. These cases most often occur during
surgery in and around the head and neck, where the patient is receiving monitored anesthesia
care and supplemental oxygen is being administered by either a face mask or a nasal cannula.
(See page 185: Fire Safety.)
8. Regarding the response to an operating room fire, which is/are TRUE&quest;

1. The operating room sprinkler systems effectively respond to the majority of fires.
2. If an endotracheal tube is on fire, it should be removed immediately and then
extinguished.
3. If the paper drapes are burning, water or saline will likely douse the fire effectively.
4. Common acronyms for responding to a fire include “RACE” and “PASS.”
8. D. If a fire does occur, it is important to extinguish it as soon as possible. This is best
accomplished by removing the oxidizer from the fire. Therefore, if an endotracheal tube is on
fire, disconnecting the anesthetic circuit from the tube or disconnecting the inspiratory limb of
the circuit will usually put out the fire immediately. It is not recommended to remove a burning
endotracheal tube because this may cause even greater harm to the patient. After the fire has
been extinguished, the endotracheal tube can be safely removed, the airway inspected via
bronchoscopy, and the patient's trachea reintubated. If the drapes are burning, particularly if
they are paper drapes, they must be removed and placed on the floor. Paper drapes are
impervious to water, so throwing water or saline on them will do little to extinguish the fire. After
the burning drapes have been removed from the patient, the fire can then be extinguished with
a fire extinguisher. In most operating room fires, the sprinkler system is not activated. This is
because sprinklers are usually not located directly over the operating room table, and operating
room fires are seldom hot enough to activate the sprinklers. To use a fire extinguisher
effectively, the acronym “PASS” can be helpful. This stands for pull the pin to activate the fire
extinguisher, aim at the base of the fire, squeeze the trigger, and sweep the extinguisher back
and forth across the base of the fire. When responding to a fire, the acronym RACE is useful.
This stands for rescue, alarm, confine, and extinguish. (See page 185: Fire Safety.)
58 / 494
Review of Clinical Anesthesia, 5e [Vishal] 9. Experimental Design & Statistics
Chapter 9
Experimental Design and Statistics
1. If a target population contains several strata of importance, the best method of

obtaining a representative population sample is:
A. Limit sampling
B. Convenience sampling
C. Crossover sampling
D. Random sampling
E. Double-blind sampling
1. D. A sample is a subset of the target population. The best hope for a representative sample
of the population would be realized if every subject in the population had the same chance of
being in the experiment; this is called random sampling. If there are several strata of
importance, random sampling from each stratum is appropriate. Convenience sampling is
subject to the nuances of the surgical schedule, the goodwill of the referring physician and
attending surgeon, and the willingness of the patient to cooperate. At best, a convenience
sample is representative of patients at the institution, with no assurance that these patients are
similar to those elsewhere. Convenience sampling is also the rule in studying new anesthetic
drugs in volunteers; such studies typically are performed on “healthy, young students.” (See
page 193: Sampling.)
2. An example of a contemporaneous-parallel control would be:

A. Each patient could receive the standard drug under identical experimental
circumstances at another time.
B. A group of patients could have been studied previously with the standard drug under
similar circumstances.
C. Another group of patients receiving the standard drug could be studied
simultaneously.
D. Literature reports show the effects of the drug under related but not necessarily
identical circumstances.
E. Each patient could receive the standard drug under nonexperimental conditions
simultaneously with the test group.
2. C. A researcher can obtain comparative data in several ways: (1) each patient could receive
the standard drug under identical experimental circumstances at another time; (2) another
group of patients receiving the standard drug could be studied simultaneously; (3) a group of
patients could have been studied previously with the standard drug under similar
circumstances; or (4) literature reports of the effects of the drug under related (but not
necessarily identical) circumstances could be used. Under the first two possibilities, the control
group is contemporaneous, either self-control (crossover) or a parallel control group. The
second two possibilities are examples of the use of historical controls. (See page 193: Control
Groups.)
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3. The risks of constructing a rigidly standardized study include all of the following
EXCEPT:
A. A fixed dose may produce excessive numbers of side effects in some patients.
B. A standardized treatment may be so artificial that it has no broad clinical relevance.
C. A fixed dose may be therapeutically insufficient in some patients.
D. A fixed dose makes the research work more difficult.
E. A fixed dose may not allow an effect or desired endpoint to be achieved.
3. D. The risks of constructing a rigidly standardized study do not include the likelihood that a
fixed dose will make the research work more difficult. In contrast, standardizing the treatment
groups by fixed doses simplifies the research work. There are risks to this standardization,
however: (1) a fixed dose may produce excessive numbers of side effects in some patients, (2)
a fixed dose may be therapeutically insufficient in others, and (3) a treatment standardized for
an experimental protocol may be so artificial that it has no broad clinical relevance even if it is
demonstrated to be superior. The researcher should carefully choose and report the adjustment
or individualization of experimental treatments. (See page 193: Experimental Constraints.)
4. The best method for random allocation of treatment groups is:

A. based on the day of the week
B. based on assignment of a previous patient
C. using hospital chart numbers
D. patient preference
E. computer-generated random numbering
4. E. The experimental groups should be as similar to each other as possible in reflecting the
target population; if the groups are different, this introduces a bias into the experiment. Although
randomly allocating subjects of a sample to one or another of the experimental groups requires
additional work, this principle prevents selection bias by the researcher, minimizes (but cannot
always prevent) the possibility that important differences exist among the experimental groups,
and disarms critics' complaints about research methods. Random allocation is most commonly
accomplished by computer-generated random numbers. (See page 193: Random Allocation of
Treatment Groups.)
5. Which statement about blinding is TRUE&quest;

A. It can bias a researcher's ability to administer the research protocol.
B. It causes the researchers to not trust themselves to record the data impartially and
dispassionately.
C. It can be used in case reports.
D. It masks from the patient and experimenters the experimental group to which the
patient is assigned.
E. It has the names single blind and double blind, which are often applied consistently
but uncommonly in research reports
5. D. Blinding refers to the masking from the view of patient and experimenters the experimental
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group to which the subject has been or will be assigned. In clinical trials, the necessity for
blinding starts even before a patient is enrolled in the research study; this is called the
concealment of random allocation. There is good evidence that if the process of random
allocation is accessible to view, the referring physicians, the research team members, or both
are tempted to manipulate the entrance of specific patients into the study to influence their
assignment to a specific treatment group; they do so having formed a personal opinion about
the relative merits of the treatment groups and desiring to get the “best” for someone they favor.
This creates bias in the experimental groups. A researcher's knowledge of the treatment
assignment can bias his or her ability to administer the research protocol and to observe and
record data faithfully; this is true for clinical, animal, and in vitro research. If the treatment group
is known, those who observe data cannot trust themselves to record the data impartially and
dispassionately. (See page 194: Blinding.)
6. The most potent scientific tool for evaluating medical treatment is:
A. A longitudinal prospective study of deliberate intervention with historical controls
B. A longitudinal prospective study of deliberate intervention with concurrent controls
C. A longitudinal retrospective study with concurrent case controls
D. A longitudinal retrospective study with historical controls
E. A cross-sectional prospective study without controls
6. B. The randomized, controlled clinical trial is the most potent scientific tool for evaluating
medical treatment. Randomization into treatment groups is relied on to equally weight the
subjects' baseline attributes that could predispose or protect the subjects from the outcome of
interest. (See page 194: Types of Research Design.)
7. The error of failing to reject a false null hypothesis is called a:

A. False-positive
B. Type II error
C. α error
D. Zero-order error
E. Parameter
7. B. Because statistics deal with probabilities rather than certainties, there is a chance that the
decision concerning the null hypothesis is erroneous. The error of wrongly rejecting the null
hypothesis (false-positive result) is called the type I or α error. The error of failing to reject a
false null hypothesis (false-negative result) is called a type II or β error. A parameter is a number
describing a variable of a population. (See page 197: Logic of Proof.)
P.34
8. The number of degrees of freedom and the value for each degree of freedom does
NOT depend on:
A. The type of statistical test
B. The number of subjects
C. Dividing the standard deviation by the square root of the sample size
D. The specifics of the statistical hypothesis
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E. The number of experimental groups

8. C. The number of degrees of freedom and the value for each degree of freedom depends on
the number of subjects, the number of experimental groups, the specifics of the statistical
hypothesis, and the type of statistical test. (See page 198: Inferential Statistics.)
9. Variance is the:
A. Statistical average
B. Average deviation
C. Average squared deviation
D. Square root of the average deviation
E. Square of the standard error
9. C. The concept of describing the spread of a set of numbers by calculating the average
distance from each number to the center of the numbers applies to both samples and
populations; this average squared distance is called the variance. (See page 196: Spread or
Variability.)
10. The mean ± 3 standard deviation encompasses what percentage of the sample
population&quest;
A. 50
B. 68
C. 75
D. 95
E. 99
10. E. Most biological observations appear to come from populations with normal or Gaussian
distributions. By accepting this assumption of a normal distribution, further meaning can be
given to the sample summary statistics that have been calculated. This involves the use of the
expression &OV0335; ± κ × s, where k = 1, 2, 3, and so on. If the population from which the
sample is taken is unimodal and roughly symmetric, then the bounds for 1, 2, and 3
encompasses roughly 68%, 95%, and 99% of the sample and population members. (See page
196: Spread or Variability.)
11. A study is performed looking at the difference in postoperative nausea in males and
females undergoing laparoscopic cholecystectomy. The category “male or female” is
an example of what kind of data&quest;
A. Ordinal
B. Dichotomous
C. Nominal
D. Discrete interval
E. Continuous interval
11. B. Dichotomous data allow only two possible variables. Ordinal data have three or more
categories that can be logically ranked or ordered. Whereas discrete interval data can have
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only integer values (e.g., age in years), continuous interval data can be decimal fractions (e.g.,
temperature of 37.1°C). A nominal variable can be placed into a category that has no logical
ordering (e.g., eye color). (See page 195: Data Structure and page 195: Table 9-2: Data
Types.)
12. All of the following are aspects of enumeration data EXCEPT:

A. They provide counts of subject responses.
B. They provide a measure of central location of a binary data.
C. They are also called categorical binary data.
D. They provide a measure of central location for continuous data.
E. They can be used to obtain a ratio of responders to the number of subjects.
12. D. Categorical binary data, also called enumeration data, provide counts of subject
responses. Given a sample of subjects of whom some have a certain characteristic (e.g., death,
female gender), a ratio of responders to the number of subjects can be easily calculated as P =
x/n; this ratio or rate can be expressed as a decimal fraction or as a percentage. It should be
clear that this is a measure of central location of binary data in the same way that μ is a
measure of central location for continuous data. (See page 199: Confidence Intervals on
Proportions.)
13. The most versatile approach for handling comparisons of means between more
than two groups or between several measurements in the same group is called a/an:
A. Paired t -test
B. Chi-square test
C. Interval data testing
D. Analysis of variance (ANOVA)
E. Unpaired t-test
13. D. The most versatile approach for handling comparisons of means between more than two
groups or between several measurements in the same group is called ANOVA. The currently
available nonparametric tests, such as the paired and unpaired t-tests, are not used more
commonly because they do not adapt well to complex statistical models and they are less able
than parametric tests to distinguish between the null and alternative hypotheses if the data are
normally distributed. (See page 200: Analysis of Variance.)
14. Identify the slope and y-intercept for the following linear regression equation: y=a +
bx
A. a,b
B. y,a
C. y,b
D. b,a
E. x,y
14. D. In the simplest type of experiment, a straight line (linear relationship) is assumed
between two variables; one (y), the response or dependent variable, is considered a function of
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the other (x), the explanatory or independent variable. This is expressed as the linear
regression equation y = a + bx ; the parameters of the regression equation are a and b. The
parameter b is the slope of the straight line relating x and y; for each 1-unit change in x, there
is a b unit change in y. The parameter a is the intercept (value of y when x equals 0). (See
page 201: Linear Regression.)
15. Systematic differences between the patients receiving each intervention are
called:
A. Selection bias
B. Performance bias
C. Attrition bias
D. Detection bias
E. Experimenter bias
15. A. Selection bias is systematic differences between the patients receiving each intervention.
Performance bias is systematic differences in care being given to study patients other than the
preplanned interventions being evaluated. Attrition bias is systematic differences in the
withdrawal of patients from each of the two intervention groups. Detection bias is systematic
differences in the ascertainment and recording of outcomes. Experimenter bias occurs when
the outcome of the experiment tends to be biased toward a result expected by the human
experimenter. (See page 201: Systematic Reviews and Meta-Analyses.)
16. In dichotomous data testing:
1. The results are often presented as rate ratios
2. The chi-square test can analyze contingency tables with more than two rows and two
columns
3. The Fishers exact test and the chi-square test allow comparison of the success rates
between two sampled populations of a procedure
4. The chi-square test is computationally more complex than Fishers exact test
16. A. A variety of statistical techniques allow a comparison of success rate. These include
Fishers exact test and (Pearson's) chi-square test. The chi-square test offers the advantage of
being computationally simpler, and it can also analyze contingency tables with more than two
rows and two columns. However, certain assumptions of sample size and response rate are not
achieved by this test. (See page 199: Dichotomous Data Testing.)
17. The probability of a type II error increases with which of the following&quest;
1. Small α value
2. Larger variability in populations being compared
3. Small difference between experimental conditions
4. Large sample size
17. A. The error of failing to reject a false null hypothesis (false-negative) is called a type II or β
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error. The power of a test is 1 - β. The probability of a type II error depends on four factors.
Unfortunately, the smaller the α, the greater the chance of a false-negative conclusion; this fact
keeps the experimenter from automatically choosing a very small α. Second, the more variability
there is in the populations being compared, the greater the chance of a type II error. This is
analogous to listening to a noisy radio broadcast: The more static there is, the harder it will be
to discriminate between words. Third, increasing the number of subjects lowers the probability
of a type II error. The fourth and most important factor is the magnitude of the difference
between the two experimental conditions. The probability of a type II error goes from very high,
when only a small difference exists, to extremely low, when the two conditions produce large
differences in population parameters. (See page 197: Logic of Proof.)
18. Which of the following are summary statistics&quest;

1. Mean
2. F ratio
3. Mode
4. P value
18. B. Although the results of a particular experiment may be presented by repeatedly showing
the entire set of numbers, there are concise ways of summarizing the information content of the
set into a few numbers. These numbers are called sample or summary statistics. The three
most common summary statistics are the mean, median, and mode. (See page 196: Central
Location.)
19. Nonparametric statistics:

1. Are used whenever there are serious concerns about the shape of the data
2. Do not require any assumptions about probability distributions of the populations
3. Are less able than parametric tests to distinguish between the null and alternative
hypotheses if the data are normally distributed
4. Are also called “order statistics”
19. E. Statistical tests that do not require any assumptions about probability distributions of the
populations are known as nonparametric tests; they can be used whenever there is very
serious concern about the shape of the data. Nonparametric statistics are also the tests of
choice for ordinal data. The basic concept behind nonparametric statistics is the ability to rank
or order the observations; nonparametric tests are also called order statistics . The currently
available nonparametric tests are not used more commonly because they do not adapt well to
complex statistical models, and they are less able than parametric tests to distinguish between
the null and alternative hypotheses if the data are normally distributed. (See page 201:
Robustness and Nonparametric Tests.)

1. A confidence interval describes how likely it is that the population parameter is
estimated by any particular sample statistic such as the mean.
2. The standard error (SE) is used to describe the dispersion of the sample.
3. Sample size planning is important because it is the main mechanism for increasing
statistical power.
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4. Studies using historical controls obtain the same results as studies with concurrent
controls if appropriate strata are selected.
20. B. The four options for decreasing type II error (increasing statistical power) are to increase
the α, reduce the population variability, make the sample bigger, and make the difference
between the conditions greater. Under most circumstances, only the sample size can be varied;
thus, sample size planning has become an important part of research design for controlled
clinical trials. When describing the spread, scatter, or dispersion of the sample, the standard
deviation should be used; when describing the precision with which the population center is
known, the SE should be used. A confidence interval describes how likely it is that the
population parameter is estimated by any particular sample statistic such as the mean.
Historical controls indicate a favorable outcome for a new therapy more often than concurrent
controls (i.e., parallel control group or self-control). If the outcome with an old treatment is not
studied simultaneously with the outcome of a new treatment, one cannot know whether any
differences in results are a consequence of the two treatments, of unsuspected and
unknowable differences between the patients, or of other changes over time in the general
medical environment. (See page 198: Sample Size Calculations and page 198: Confidence
Intervals.)
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Review of Clinical Anesthesia, 5e [Vishal] 10. Cardiovascular Anatomy & Physiology
Chapter 10
Cardiovascular Anatomy and Physiology
1. Regarding the cardiac cycle, which of the following is FALSE&quest;

A. Left ventricle (LV) systole has three phases.
B. Isovolumic contraction occurs after mitral valve closure.
C. The decrease in ejection fraction (EF) is proportional to the decrease in LV function.
D. Isovolumic contraction occurs in both the LV and right ventricle (RV).
E. Diastasis allows free blood flow through the left atrium (LA).
1. D. LV systole is commonly divided into three parts: isovolumic contraction, rapid ejection, and
slower ejection. Closure of both the tricuspid and mitral valves occurs when RV and LV
pressures exceed the corresponding atrial pressure and causes the source of the first heart
sound. Isovolumic contraction is the interval between closure of the mitral valve and the
opening of the aortic valve. True isovolumic contraction does not occur in the RV because of
the sequential nature of inflow followed by outflow during RV contraction. The normal LV end-
diastolic volume is about 120 mL. The average ejected stroke volume is 80 mL, and the normal
EF is approximately 67%. A decrease in EF below 40% is typically observed when the
myocardium is affected by ischemia, infarction, or cardiomyopathic disease processes (e.g.,
myocarditis, amyloid infiltration). After left atrial and LV pressures have equalized, the mitral
valve remains open, and pulmonary venous return continues to flow through the LA into the LV.
This phase of diastole is known as diastasis, during which the LA functions as a conduit.
Tachycardia progressively shortens and may completely eliminate this phase of diastole.
Diastasis accounts for no more than 5% of total LV end-diastolic volume under normal
circumstances. (See page 211: The Cardiac Cycle.)
2. Which statement regarding coronary circulation is FALSE&quest;

A. The left coronary artery gives rise to the left anterior descending artery and the
circumflex artery.
B. Occlusive disease to the left anterior descending artery causes ischemic
electrocardiographic (ECG) changes in leads V3, V4, and V5.
C. The majority of blood supply to the atrioventricular (AV) node and common bundle of
His is by the septal perforating branches of the left anterior descending artery.
D. Occlusive disease to the right coronary artery results in ischemic ECG changes in
leads II, III, and aVF.
E. The sinus node is supplied by the right coronary artery.
2. C. In most patients, the right coronary artery supplies the sinus node, AV node, and common
bundle of His. The left anterior descending artery supplies the AV node and common bundle of
His in approximately 10% of hearts. The left anterior descending artery supplies the anterior left
ventricle (LV), which is reflected in ECG leads V3 to V5. The circumflex artery supplies the
posterior LV, which is reflected in ECG leads I and aVL. The right coronary artery supplies the
inferior and diaphragmatic portions of the heart, as reflected in ECG leads II, III, and aVF. (See
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page 222: Coronary Circulation.)
3. Each of the following is a characteristic of cardiac and skeletal muscle fibers

EXCEPT:
A. Both sarcolemmas contain Na+ channels.

B. Impulses reach the myocytes through “T transverse tubules.”
C. Mitochondria are highly abundant in both types of fibers.
D. Actin and myosin are the contractile proteins.
E. They use transporter enzymes to regulate intracellular ion concentrations.
3. C. The sarcolemma is the external membrane of the cardiac muscle cell. The sarcolemma
contains ion channels (e.g., Na+, K+, Ca2+), ion pumps and exchangers (e.g., Na+-K+
ATPase, Ca2+-ATPase, Na+-Ca2+ or -H+ exchangers), G-protein–coupled and other receptors
(e.g., β 1-adrenergic, adenosine, opioid), and transporter enzymes. These regulate intracellular
ion concentrations, facilitate signal transduction, and provide metabolic substrates required for
energy production. Actin and myosin are the contractile proteins. Deep invaginations of the
sarcolemma, known as transverse (“T”) tubules, penetrate the internal structure of the myocyte
at regular intervals, ensuring rapid, uniform transmission of the depolarizing impulses that
initiate contraction to be simultaneously distributed throughout the cell. Unlike the skeletal
muscle cell, the cardiac myocyte is densely packed with mitochondria, which are responsible for
generation of the large quantities of high-energy phosphates (e.g., adenosine triphosphate)
required for the heart's phasic cycle of contraction and relaxation. The fundamental contractile
unit of cardiac muscle is the sarcomere. (See page 213: Ultrastructure of the Cardiac Myocyte.)
4. Each of the following events results in hypotension EXCEPT:

A. Urinary bladder retention
B. Ocular globe pressure
C. Valsalva maneuver
D. Immersion of a hand in ice water
E. Exposure to inhaled anesthetics
4. D. The arterial baroreceptor reflex appears to be especially important in short-term regulation
of arterial pressure. Its effects (e.g., regulation of heart rate) are inhibited by volatile and many
intravenous anesthetics. This inhibition of high-pressure baroreceptor reflexes by anesthetics
involves several discrete sites, including sympathetic ganglionic transmission, end-organ
responses, and central nervous system (CNS) pathways. The cold pressor reflex, which is
activated by complete immersion of one hand in ice water, increases heart rate and mean
arterial pressure (MAP). The cold environment causes local vasoconstriction to prevent heat
loss and stimulates reflex CNS thermoregulatory receptors in the hypothalamic preoptic region
to generate more widespread sympathetically mediated vasoconstriction. Somatic pain (as may
be induced by the ice water) increases heart rate and MAP by activation of sympathetic efferent
nerves. In contrast, visceral pain or distention of a hollow viscus (e.g., small intestine, bladder)
may produce reflex vagal bradycardia and hypotension. The oculocardiac reflex is activated by
pressure on the ocular globe and causes pronounced bradycardia and hypotension by
activation of vagal nerve fibers innervating the sinoatrial node. The Valsalva maneuver consists
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of forced expiration against a closed glottis. This maneuver reduces venous return to the right
heart, decreases cardiac output and MAP, and increases heart rate. The reflex tachycardia
occurs because of reduced activity of arterial baroreceptors and left ventricular
mechanoreceptors. (See page 221: Other Cardiovascular Reflexes.)
5. The x descent:
A. Is produced by atrial systole, coinciding with the P wave on the electrocardiogram
(ECG)
B. Results from the increasing intra-atrial pressure during atrial diastole
C. Results from isovolumetric ventricular contraction, the period between closure of the
atrioventricular (AV) valves and opening of the aortic and pulmonary valves
D. Results from the opening of the AV valves, along with ventricular relaxation
E. Results from forward blood flow and decreasing atrial pressure at the initiation of
ventricular ejection
5. E. The a wave is produced by atrial systole, coinciding with the P wave on ECG. The v wave
results from the increasing intra-atrial pressure during atrial diastole. The c wave results from
isovolumetric ventricular contraction, the period between closure of the AV valves and opening
of the aortic and pulmonary valves. The y descent results from the opening of the AV valves,
along with ventricular relaxation. The x descent results from forward blood flow and decreasing
atrial pressure at the initiation of ventricular ejection. (See page 211: The Cardiac Cycle.)
6. As a precipitant factor for myocardial infarction, which one is the MOST

important&quest;
A. Platelets
B. Fibrin
C. Calcium
D. Cholesterol
E. Mast cells
6. D. An atherosclerotic plaque is the most frequent cause of obstructed blood flow in large
epicardial coronary artery vessels. The most common site for development of an atherosclerotic
plaque is the first several centimeters of the major and coronary arteries and their primary
branches. The position of atherosclerotic plaques facilitates their palliation by coronary artery
bypass graft surgery. Atherosclerotic plaques typically develop very slowly, eventually
protruding into the vessel and partially or completely blocking flow. The atherosclerotic plaque
may also precipitate thrombus formation, which more rapidly occludes the coronary artery. A
thrombus usually develops when the plaque has broken through the vascular intima, thereby
exposing vascular smooth muscle or adventitia clotting factors and platelets contained in blood.
When fibrin and platelets begin to be deposited, blood cells become entrapped and form a
thrombus that grows rapidly until it produces a critical stenosis or complete occlusion of the
coronary artery. The thrombus may also embolize by detaching from its original site of formation
and flow to a more peripheral branch of the coronary arterial bed. Atherosclerotic plaques are
composed of cholesterol and other lipids that become deposited beneath the intima and fibrous
tissue, which also frequently becomes calcified. These calcium deposits are located
predominantly at the junction of the intimal and medial layers of the blood vessel. (See page
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225: Myocardial Ischemia and Infarction.)
7. Cardiac output is the product of heart rate and stroke volume. Several factors that
affect cardiac output are
P.40
preload, afterload, heart rate, contractility, and ventricular compliance. All of the
following statements are true EXCEPT:
A. Cardiac index (cardiac output divided by body surface area) is normally 2.5 to 3.5
L/m2/min.
B. Preload is determined by blood volume, venous tone, ventricular compliance,
ventricular afterload, and myocardial contractility.
C. Left ventricular afterload depends on left ventricular geometry (shape, size, radius),
aortic impedance, aortic wall stiffness, aortic blood mass, and blood viscosity.
D. Cardiac output is increased at heart rates of greater than 160 bpm by increasing the
extent and velocity of shortening of myocardial fibers and increased dP/dT.
E. Increased contractility increases the ejection fraction (EF) if end-systolic volume
(ESV) decreases while end-diastolic volume (EDV) remains the same.
7. D. Although cardiac output increases with increased heart rate, this increase becomes limited
at heart rates of above 160 bpm. The rapid filling phase of diastole occurs in the first half-
second of diastole. If diastole is shortened by increased heart rate, then ventricular filling is
reduced, ultimately decreasing cardiac output. EF is determined by the equation EF = EDV -
ESV/EDV. With increased contractility, ESV decreases. If EDV is unchanged, EF increases.
(See page 212: Determinants of Cardiac Output.)
8. Regarding pulmonary physiology, which of the following is FALSE&quest;

A. Muscarinic receptors mediate bronchoconstriction.
B. Pulmonary sympathetic effects originate in the thoracic spinal cord.
C. Zone I represents dead space ventilation.
D. Hypoxic pulmonary vasoconstriction is controlled by a well-defined receptor.
E. Zone III represents a physiologic shunt.
8. D. The lung is richly innervated by the parasympathetic and sympathetic nervous systems.
Vagal innervation of muscarinic receptors in airway smooth muscle produces
bronchoconstriction and is an important contributing factor to bronchospasm in atopic
pulmonary disease, pneumonia, and inhalation of noxious substances. The sympathetic
innervation of the lung is derived from upper thoracic sympathetic fibers that innervate both
airway and pulmonary vascular smooth muscle. Sympathetic stimulation of airway smooth
muscle produces bronchodilation by activation of β 2-adrenoceptors. The V/Q distribution within
the lung in an upright position varies because of the effect of gravity. In the upper lung (zone 1),
the V/Q ratio is greater than 1.0, indicating that alveolar ventilation occurs in excess of
pulmonary blood flow. Because part of this zone is ventilated but not perfused, zone 1
contributes to dead space ventilation. In the middle region of the lung (zone 2), the V/Q ratio is
close to 1.0, indicating a balance between ventilation and perfusion. In the lower regions of the
lung (zone 3), the V/Q ratio is substantially lower than 1.0. Under these conditions, ventilation
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inadequately matches perfusion, and intrapulmonary shunt occurs. Pulmonary arteriolar
vasoconstriction triggered by hypoxia shunts blood flow away from poorly to well ventilated
regions of the lung, improving arterial O2 saturation. The mechanism by which hypoxia
increases pulmonary vascular resistance appears to be mediated by an O2 sensor that is yet to
be identified. (See page 227: Pulmonary Circulation.)
9. Which of the following occurs during cerebral autoregulation&quest;

A. The brain has relatively low blood flow.
B. Cerebral oxygen consumption accounts for less than 1/8th of total body consumption.
C. Autoregulation is preserved in subjects with poorly controlled hypertension.
D. CO2 is a major regulator of cerebral blood flow.
E. Therapeutic epinephrine produces significant decreases in blood flow.
9. D. The brain is approximately 2% of total body weight, yet it receives approximately 15% of
cardiac output. This remarkably large cerebral blood flow (45–55 mL/100 g/min) reflects the
brain's high metabolic rate. Cerebral oxygen consumption averages 3.5 mL/100 g/min and
accounts for 20% of total body oxygen consumption at rest. Cerebral blood flow remains
relatively constant when mean arterial pressure (MAP) varies between 50 and 150 mm Hg in
healthy subjects. This autoregulation of cerebral blood flow shifted to the right in patients with
chronic, poorly controlled essential hypertension. For example, the autoregulation curve may
range between 80 and 200 mm Hg in a patient with hypertension, and reducing the MAP below
80 mm Hg may precipitate cerebral ischemia. Arterial CO2 tension is a major regulator of
cerebral blood flow within the physiologic range of arterial CO2 tensions. Cerebral blood flow
linearly increases 1 to 2 mL/100 g/min for each 1–mm Hg increase in PaCO2. Below an arterial
CO2 tension of 25 mm Hg, the cerebral blood flow response to PaCO 2 is attenuated.
Administration of exogenous vasodilators (e.g., sodium nitroprusside, adenosine, Ca2+ channel
blockers, volatile anesthetics) increases cerebral blood flow. In contrast, catecholamines such
as epinephrine do not substantially affect cerebral blood flow when these drugs are used to
alter a systemic hemodynamics unless cerebral perfusion pressure is affected at the extremes
of the autoregulation curve. (See page 228: Anatomy and Cerebral Autoregulation.)
10. Which of the following is/are TRUE&quest;
1. The P wave delineates atrial depolarization.
2. The QRS is larger than P wave because of the ventricular mass.
3. A PR delay occurs with atrioventricular blockade.
4. The ST segment is depressed during inadequate repolarization.
10. E. The first deflection of the electrocardiogram (ECG) is the P wave. (Einthoven began his
depiction of the ECG in the middle of the alphabet.) The P wave is a positive deflection that
occurs as a consequence of atrial depolarization. The initial electrical event is depolarization of
the sinoatrial (SA) node pacemaker cells and is followed almost immediately by progressive
depolarization of both atria. The PR interval is the duration between the onset of the P wave
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and the beginning of ventricular depolarization, which is signified by the onset of the QRS
complex. Prolongation of the PR interval usually indicates a delay between atrial and ventricular
conduction. The QRS complex records potentials at the body surface when the wave of
depolarization is distributed throughout ventricular myocardium. The QRS complex is much
larger in magnitude than the P wave because the ventricular mass is greater than the atrial
mass. The ST segment is the interval between the end of the QRS complex and the T wave.
The ST segment is normally isoelectric because all of the ventricular myocardium is
depolarized. The ST segment also reflects the long plateau phase of the cardiac action
potential. The injury current of an elevated or depressed ST segment observed during
myocardial ischemia or infarction may occur as a result of an abbreviated action potential within
the ischemic region or because depolarizing currents propagate more slowly through the
ischemic zone. (See page 217: The Clinical Electrocardiogram.)
11. The Bezold-Jarisch reflex:

1. Is transmitted via nonmyelinated C fibers resulting from stimulation of left ventricular
mechanoreceptors
2. May be seen in response to reperfusion of previous ischemic myocardium
3. Is in response to noxious stimuli to the ventricular wall
4. Results in decreased parasympathetic tone, leading to tachycardia, hypertension, and
coronary artery vasoconstriction
11. A. The Bezold-Jarisch reflex is initiated by left ventricular mechanoreceptors secondary to
noxious ventricular stimuli. It results in increased parasympathetic activity, causing bradycardia,
hypotension, and coronary artery vasodilation. Examples of stimuli include ischemia and
reperfusion after ischemia (i.e., nitrate or heparin therapy, thrombolytic therapy, or coronary
artery bypass graft). (See page 220: Baroreflex Regulation of Blood Pressure.)

1. Parasympathetic stimulation to the heart decreases heart rate via muscarinic
receptors, decreasing adrenergic receptor activation through G-protein–mediated
pathways.
2. Sympathetic stimulation occurs via α 1-, β 1-, and β 2-receptors through G-protein
–mediated pathways.
3. The chronotropic and inotropic effects of β 1 activation result from increased numbers
of calcium channels available for activation.
4. Sympathetic stimulation to the heart is via the stellate ganglia.
12. E. Parasympathetic stimulation to the heart decreases the heart rate via muscarinic
receptors, thus decreasing adrenergic receptor activation through G-protein–mediated
pathways. Sympathetic stimulation occurs via α 1-, β 1-, and β 2-receptors through G-protein
–mediated pathways. The chronotropic and inotropic effects of β 1-activation result from
increased numbers of calcium channels available for activation. Sympathetic stimulation to the
heart is via the stellate ganglia, which produces positive chronotropic, dromotropic, inotropic,
and lusitropic effects. (See page 220: Baroreflex Regulation of Blood Pressure.)
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1. Coronary arterial blood flow is determined by the duration of diastole, as well as the
difference between aortic diastolic pressure and left ventricular (LV) end-diastolic
pressure.
2. Right coronary artery flow occurs only during diastole.
3. Coronary blood flow is reduced in aortic insufficiency.
4. During periods of high oxygen demand, the myocardium can increase oxygen
extraction by 20% to 25%.
13. B. Coronary flow occurs during diastole for the LV and during both diastole and systole in
the right ventricle. The major determinants of coronary flow are aortic diastolic pressure and LV
end-diastolic pressure. During systole, the LV subendocardium is exposed to a higher pressure
than the subepicardial layer. Indeed, the systolic intraventricular pressure may be higher than
the peak LV systolic pressure. Because of these differences in tissue pressure, the
subendocardial layer is more susceptible to ischemia in the presence of coronary artery
disease, pressure-overload hypertrophy, or pronounced tachycardia concomitant with
compromised regional myocardial perfusion, a greater intraventricular–aortic pressure gradient,
or reduced total diastolic flow, respectively. Coronary blood flow is also compromised when
aortic diastolic pressure is reduced (e.g., severe aortic insufficiency). Elevated LV end-diastolic
pressure, as observed during acute heart failure, also reduces coronary blood flow because of
decreases in coronary perfusion pressure. (See page 223: Mechanics of Coronary Blood Flow.)
14. Concerning coronary autoregulation, which of the following statements is/are

correct&quest;
1. Myocardial oxygen tension, acting through mediators such as adenosine, is a primary
determinant of autoregulation.
2. Autoregulation varies between different myocardial layers.
3. Metabolic factors are major determinants of coronary blood flow.
4. “Coronary steal” occurs when pharmacologic vasodilation causes increased flow in
normal arteries and away from stenotic arteries.
14. E. Myocardial oxygen tension, acting through mediators such as adenosine, is a primary
determinant of autoregulation. Autoregulation varies among the different myocardial layers.
Arteriolar vasodilation, which occurs to maintain coronary flow in stenotic vessels, is exhausted
when the stenosis is above 90%. “Coronary steal” occurs when pharmacologic vasodilation
causes increased flow in normal arteries and away from stenotic arteries. Sympathetic nervous
system innervation modulates the contractile state of coronary vascular smooth muscle. In
addition, smooth muscle tone is affected by stretch of the muscle (termed the “myogenic
factor”). However, metabolic factors are the major physiologic determinants of coronary
vascular tone and hence myocardial perfusion. The epicardial to endocardial blood flow ratio
remains at near 1.0 throughout the cardiac cycle despite systolic compressive forces exerted on
the subendocardium. The more pronounced resistance to flow in the subendocardium is offset
by β -adrenoceptor–mediated vasodilation and by local metabolic autocrine factors (e.g.,
adenosine) produced by the myocardium itself. (See page 225: Regulation of Coronary Blood
Flow.)
15. Which of the following statements regarding specific peripheral circulations is/are
TRUE&quest;
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1. Renal blood flow is autoregulated to maintain glomerular filtration.

2. Hypoxic pulmonary vasoconstriction is decreased by respiratory alkalosis.
3. The major site of resistance to portal flow is postsinusoidal.
4. Normal compensatory increases in venous tone resulting from decreased blood
volume, posture change, or positive airway pressure are intact during anesthesia.
15. A. Renal blood flow is high to meet the metabolic demands of sodium reabsorption by the
kidney and is autoregulated. Hypoxic pulmonary vasoconstriction is enhanced by metabolic
acidosis, with no change resulting from respiratory acidosis. Both metabolic alkalosis and
respiratory alkalosis decrease hypoxic pulmonary vasoconstriction. The major site of resistance
to portal flow is postsinusoidal. Normal compensatory venous responses are abolished with
autonomic neuropathy or during anesthesia. Thus, alterations to venous return caused by
positive-pressure ventilation, change in posture, or decreased blood volume go
uncompensated. (See page 227: Pulmonary Circulation and page 230: Splanchnic and Hepatic
Circulation.)
P.41
P.42
P.43
P.44
16. When comparing myocardial supply with its demand, the following statement(s)
is/are CORRECT:
1. The oxygen supply is dependent upon the diameter of the coronary arteries, left
ventricular enddiastolic pressure, aortic diastolic pressure, and arterial oxygen content.
2. Coronary blood flow is influenced by intramyocardial pressure, heart rate, and blood
viscosity.
3. The coronary perfusion pressure is the difference between the aortic diastolic
pressure and left ventricular end-diastolic pressure.
4. Acidosis, hyperthermia, and increased 2,3-diphosphoglycerate (2,3-DPG) affect the
myocardial oxygen supply.
16. E. A balance must always exist between oxygen consumption (demand) and myocardial
oxygen supply if ischemia is to be avoided. Myocardial oxygen supply is dependent upon the
diameter of the coronary arteries, left ventricular end-diastolic pressure, aortic diastolic
pressure, and arterial oxygen content. In the normal heart, the coronary perfusion pressure is
the difference between the aortic diastolic pressure and the left ventricular end-diastolic
pressure. Myocardial blood flow is determined by the blood pressure at the coronary ostia,
arteriolar tone, intramyocardial pressure or extravascular resistance, coronary occlusive
disease, heart rate, coronary collateral development, and blood viscosity. Myocardial oxygen
supply is also affected by the level of arterial oxygenation. Oxygen content resulting from
changes in PaO2, hemoglobin, DPG, pH, PCO2, or temperature can affect the oxyhemoglobin
dissociation curve and can be important in patients with obstructive lung disease or severe
anemia. (See page 225: Oxygen Delivery and Demand.)
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Review of Clinical Anesthesia, 5e [Vishal] 11. Respiratory Function
Chapter 11
Respiratory Function
1. Which of the following statements regarding lung compliance is FALSE&quest;

A. Diseases that decrease lung compliance typically result in increased respiratory rates.
B. Spontaneous respiratory rate is a poor indicator of lung compliance.
C. Continuous positive airway pressure (CPAP) improves lung compliance and therefore
lowers the work of breathing in patients with reduced compliance.
D. Diseases that increase lung compliance typically result in increased functional
residual capacity (FRC).
E. Significant increases in lung compliance may require the use of the ventilatory
muscles to exhale actively.
1. B. When lung compliance is small, larger changes in intrapleural pressure are needed to
create the same tidal volume (Vt) (i.e., one has to inhale harder to force the same volume of gas
into the lungs). Thus, patients with low lung compliance typically breathe with a smaller Vt at
more rapid rates. Spontaneous ventilatory rate is one of the most sensitive indices of lung
compliance. CPAP shifts the vertical line to the right, allowing the patient to breathe on a
steeper and more favorable portion of the volume–pressure curve. This results in a slower
ventilatory rate with a larger Vt. Patients with diseases that increase lung compliance have
larger than normal FRCs (gas trapping) and pressure–volume curves that are shifted to the left
and steeper. These patients expend less elastic work to inspire, but elastic recoil is reduced
significantly. COPD and acute asthma are the most common examples of diseases with high
lung compliance. If lung compliance and FRC are sufficiently high (elastic recoil is minimal), the
patient must use the ventilatory muscles to expire actively. (See page 236: Elastic Work.)
2. Which of the following statements regarding ventilation–perfusion (V/Q) matching is

TRUE&quest;
A. West zone 1 can be best characterized as physiologic shunt.
B. West zone 1 can be increased by increasing pulmonary artery pressure (PPA).
C. West zone 3 occurs above the level of the third rib in the sitting position.
D. West zone 3 has PPA > Pulmonary venous pressure (PPV)> Alveolar pressure (PA)
and therefore has perfusion in excess of ventilation.
E. In west zone 1, pulmonary capillary wedge pressure (PCWP) is transmitted to the
alveoli promoting alveolar collapse, resulting in no ventilation of this area.
2. D. Zone 1 receives ventilation in the absence of perfusion and creates alveolar dead space
ventilation. Normally, zone 1 areas exist only to a limited extent. However, in conditions of
decreased PPA, such as hypovolemic shock, zone 1 enlarges. Because PA is approximately
equal to atmospheric pressure, PPA in zone 1 is subatmospheric but necessarily greater than
PPV (PA > PPA > PPV). PA that is transmitted to the pulmonary capillaries promotes their
collapse, with a consequent theoretical blood flow of zero to this lung region. Thus, zone 1
receives ventilation in the absence of perfusion and creates alveolar dead space ventilation.
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Zone 3 occurs in the most gravity-dependent areas of the lung, where PPA > PPV > PA and
blood flow is primarily governed by the PPA to PPV difference. Because gravity also increases
PPV, the pulmonary capillaries become distended. Thus, perfusion in zone 3 is lush, resulting in
capillary perfusion in excess of ventilation, or physiologic shunt. The pressure difference
between PPA and PA determines blood flow in zone 2. PPV has little influence. Well-matched
ventilation and perfusion occur in zone 2, which contains the majority of alveoli. (See page 243:
Distribution of Blood Flow.)
3. Functional residual capacity (FRC):

A. Is the maximal volume that can be exhaled in a single breath
B. Is increased by mechanical factors such as obesity and pregnancy
C. Can be used to quantify the degree of pulmonary restriction
D. Is significantly increased in the supine position
E. Is markedly reduced in patients with chronic obstructive pulmonary disease (COPD)
3. C. FRC is the volume of gas remaining in the lungs at passive end expiration. Residual
volume is the gas remaining within the lungs at the end of forced maximal expiration. The FRC
may also be used to quantify the degree of pulmonary restriction. Disease processes that
reduce FRC and lung compliance include acute lung injury, pulmonary edema, pulmonary
fibrotic processes, and atelectasis. Mechanical factors also reduce FRC (e.g., pregnancy,
obesity, and pleural effusion). The FRC decreases 10% when a healthy subject lies down.
Ventilatory muscle weakness and paralysis also decrease FRC. In contrast, patients with COPD
have excessively compliant lungs that recoil less forcibly. Their lungs retain an abnormally large
volume at the end of passive expiration, a phenomenon called gas trapping. (See page 247:
Lung Volumes and Capacities.)
4. Which of the following tests is most useful and cost effective in screening overall
pulmonary function&quest;
A. The flow–volume loop
B. The CO2 diffusing capacity of the lungs (DLCO)
C. The maximum voluntary ventilation
D. Spirometry measurements
E. Blood gas analysis
4. D. Although we have a host of pulmonary function tests from which to choose, spirometry is
the most useful, cost-effective, and most commonly used test. (See page 249: Pulmonary
Function Tests Summary.)
5. Which of the following statements regarding postoperative pulmonary function is

TRUE&quest;
A. The changes in postoperative pulmonary function are primarily obstructive.
B. Postoperative spontaneous ventilation is characterized by the absence of sighs.
C. Thoracic operations have a more severe impact on functional residual capacity (FRC)
than nonlaparoscopic upper abdominal operations.
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D. The normal postoperative respiratory rate is 12 to 13 breaths/min.
E. Intracranial procedures typically decrease FRC by 40% to 50%.
5. B. The changes in pulmonary function that occur postoperatively are primarily restrictive, with
proportional decreases in all lung volumes and no change in airway resistance. This defect is
generated by abdominal contents that impinge on and prevent normal movement of the
diaphragm and an abnormal respiratory pattern that is shallow, rapid, and devoid of sighs.
Whereas the normal resting respiratory rate for adults is 12 breaths/min, postoperative patients
usually breathe approximately 20 breaths/min. The operative site is one of the single most
important determinants of the degree of pulmonary restriction and the risk of postoperative
pulmonary complications. Nonlaparoscopic upper abdominal operations cause the most
profound restrictive defect, precipitating a 40% to 50% decrease in FRC compared with
preoperative levels when conventional postoperative analgesia is used. Lower abdominal and
thoracic operations cause the next most severe change in pulmonary function, with decreases
in FRC to 30% of preoperative levels. Most other operative sites, including intracranial, have
approximately the same effect on FRC, with reductions to 15% to 20% of preoperative levels.
(See page 253: Postoperative Pulmonary Function.)
6. The maximum benefit from preoperative smoking cessation occurs at

approximately:
A. 24 hours
B. 2 days
C. 2 weeks
D. 4 weeks
E. 8 weeks
6. E. Patients who smoke should be advised to stop smoking 2 months before elective
operations to maximize the effect of smoking cessation or for at least 4 weeks to gain some
benefit from improved mucociliary function. Normalization of mucociliary function requires 2 to 3
weeks of abstinence from smoking, during which time sputum increases. Several months of
smoking abstinence are required to return sputum clearance to normal. If patients cannot stop
smoking for these periods of time, they probably should be advised to stop smoking for at least
24 hours before the operation so that carboxyhemoglobin levels will approach normal. Smokers
who decrease but do not stop cigarette consumption without the aid of nicotine replacement
therapy continue to acquire equal amounts of nicotine from fewer cigarettes by changing their
technique of smoking to maximize nicotine intake. (See page 252: Effects of Cigarette Smoking
on Pulmonary Function.)
7. Which of the following statements regarding cigarette smoking and lung disease is
FALSE&quest;
P.46
A. Smoke increases mucus production and decreases ciliary motility.
B. Smoking leads to a decrease in proteolytic enzymes in the lung that directly cause
damage to lung parenchyma.
C. Patients with chronic obstructive pulmonary disease (COPD) who smoke have up to a
sixfold greater risk of developing postoperative pneumonia than nonsmokers.
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D. Normalization of mucociliary activity requires at least 2 to 3 weeks of abstinence from
smoking.
E. Smokers' relative risk of postoperative pulmonary complications is doubled even in the
absence of clinical pulmonary disease and abnormal pulmonary function test results.
7. B. Smoking affects pulmonary function in many ways. The irritant smoke decreases ciliary
motility and increases sputum production. Thus, these patients have a high volume of sputum
and decreased ability to clear it effectively. As smoking habits persist, airway reactivity and the
development of obstructive disease become problematic. Studies of the pathogenesis of COPD
suggest that smoking results in an excess of pulmonary proteolytic enzymes that directly cause
damage to the lung parenchyma. Exposure to smoke increases synthesis and release of
elastolytic enzymes from the alveolar macrophages, cells instrumental in the genesis of COPD
resulting from smoking.
Smoking is one of the main and most prevalent risk factors associated with postoperative
morbidity. Patients with COPD who smoke have a two- to a sixfold risk of developing
postoperative pneumonia compared with nonsmokers. Furthermore, smokers' relative risk of
postoperative pulmonary complications is doubled, even if they do not have evidence of clinical
pulmonary disease or abnormal pulmonary function. Normalization of mucociliary function
requires 2 to 3 weeks of abstinence from smoking, during which time sputum increases. (See
page 252: Effects of Cigarette Smoking on Pulmonary Function.)
8. All of the following strategies reduce the risk of postoperative pulmonary

complications EXCEPT:
A. Anesthetic technique
B. Postoperative pain management
C. Incentive spirometry
D. Stir-up regimens
E. Intermittent continuous positive airway pressure (CPAP) by mask
8. A. There are several strategies by which it is possible to reduce the risk of postoperative
pulmonary complications, including use of lung-expanding therapies after surgery, choice of
analgesia, and cessation of smoking. After upper abdominal operations, which are associated
with the highest incidence of postoperative pulmonary complications, functional residual
capacity (FRC) recovers over 3 to 7 days. With the use of intermittent CPAP by mask, FRC
recovers within 72 hours. Patients use incentive spirometers correctly only 10% of the time
unless therapy is supervised. Stir-up regimens are as effective as incentive spirometry at
preventing postoperative pulmonary complications and are less expensive than supervised
incentive spirometry, so they are preferred over incentive spirometry therapy. The choice of
anesthetic technique for intraoperative anesthesia does not change the risk of postoperative
pulmonary complications, but the choice of postoperative analgesia strongly influences the risk
of these complications. The advent of postoperative epidural analgesia, particularly for
abdominal and thoracic operations, has markedly decreased the risk of postoperative
pulmonary complications and appears to contribute to decreased length of stay in the hospital
postoperatively. (See page 253: Postoperative Pulmonary Complications.)
9. When diaphragm function is impaired in patients with cervical spinal cord

transection, which of the following act as primary inspiratory muscles&quest;
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A. Intercostal muscles
B. Cervical strap muscles
C. Abdominal muscles
D. Intervertebral muscles of the shoulder girdle
E. Sternocleidomastoid muscles
9. B. The ventilatory muscles include the diaphragm, intercostal muscles, abdominal muscles,
cervical strap muscles, sternocleidomastoid muscles, and large back and intervertebral muscles
of the shoulder girdle. During breathing, the diaphragm performs most of the muscle work.
Work contribution from the intercostal muscles is minor. With an increase in work, the cervical
strap muscles help elevate the sternum and upper portions of the chest. The cervical strap
muscles, active even during breathing at rest, are the most important inspiratory accessory
muscles. When diaphragm function is impaired, as in patients with cervical spinal cord
transaction, they can become the primary inspiratory muscles. During periods of maximal work,
the large back and paravertebral muscles of the shoulder girdle contribute to ventilatory effort.
The abdominal wall muscles are the most powerful muscles of expiration. (See page 234:
Functional Anatomy of the Lungs.)
10. Which is the last airway component that is incapable of gas exchange&quest;
A. Respiratory bronchiole
B. Terminal bronchiole
C. Alveolar ducts
D. Mainstem bronchi
E. Alveolar sacs
10. B. The airway generation next to trachea is composed of the right and left mainstem
bronchi. The next generation consists of bronchioles, of which the final generation is terminal
bronchiole; this is the last airway component incapable of gas exchange. The respiratory
bronchiole, which follows the terminal bronchiole, is the first site in the tracheobronchial tree
where gas exchange occurs. In adults, two or three generations of respiratory bronchioles lead
to alveolar ducts, of which there are four to five generations, each with multiple openings into
alveolar sacs. (See page 234: Lung Structures.)
11. Which of the following statements regarding type 1 cells is FALSE&quest;

A. They contain extremely thin cytoplasmic extensions that provide surface for gas
exchange.
B. They are highly differentiated.
C. They cover 80% of the alveolar surface.
D. They are very resistant to injury.
E. They are metabolically limited.
11. D. Type 1 alveolar cells cover approximately 80% of the alveolar surface. Type 1 cells
contain flattened nuclei and extremely thin cytoplasmic extensions that provide the surface for
gas exchange. They are highly differentiated and metabolically limited, which makes them
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highly susceptible to injury. (See page 234: Lung Structures.)
12. Which of the following primarily limits the depth of inspiration&quest;

A. Pneumotaxic center
B. Apneustic center
C. Ventral respiratory group
D. Dorsal respiratory group
E. Reticular activating system
12. A. The primary function of the pneumotaxic center is to limit the depth of inspiration. When
maximally activated, the pneumotaxic center secondarily increases ventilatory frequency.
However, it performs no pacemaking function and has no intrinsic rhythmicity. The dorsal
respiratory group is the source of elementary ventilatory rhythmicity and serves as the
pacemaker for the respiratory system. The ventral respiratory group serves as the expiratory
coordinating center. With activation, the apneustic center sends impulses to inspiratory dorsal
respiratory group neurons and is designed to sustain inspiration. (See page 239: Generation of
Ventilatory Pattern.)
13. Which of the following does not cause absolute or true shunt&quest;
A. Acute lobar atelectasis
B. Extensive acute lung injury
C. Advanced pulmonary edema
D. Pulmonary embolus
E. Consolidated pneumonia
13. D. Physiologic shunt occurs in a lung that is perfused but poorly ventilated. Physiologic
shunt is the portion of the total cardiac output that returns to the left heart and systemic
circulation without receiving oxygen in the lung. Diseases that cause absolute or true shunt
include acute lobar atelectasis, extensive acute lung injury, advanced pulmonary edema, and
consolidated pneumonia. Physiologic dead space ventilation applies to areas of the lung that
are ventilated but poorly perfused as in pulmonary embolus. (See page 246: Physiologic
Shunt.)
14. Which of the following statements is FALSE about the CO2 diffusing capacity of the
lungs (DLCO)&quest;
A. Decreased hemoglobin concentration decreases the DLCO.
B. DLCO values increase two to three times normal during exercise.
C. DLCO is decreased in obstructive disease states.
D. Decreased alveolar PCO2 increases DLCO.
E. Low DLCO is related to loss of lung volume or capillary bed perfusion.
14. D. DLCO collectively measures all of the factors that affect the diffusion of gas across the
alveolar capillary membrane. DLCO values may increase to two or three times normal during
exercise. Decreased hemoglobin concentration decreases DLCO. An increased PACO2
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increases DLCO. Low DLCO is more closely related to loss of lung volume or capillary bed
perfusion. DLCO is decreased in all obstructive disease states. (See page 249: Carbon
Monoxide Diffusing Capacity.)
15. Which of the following components comprise the alveolar wall&quest;
1. Thin capillary epithelial cell
2. Basement membrane
3. Pulmonary capillary endothelial cell
4. Surfactant lining layer
15. E. The alveolar–capillary interface is well designed to facilitate gas exchange. The alveolar
wall consists of a thin capillary epithelial cell, basement membrane, pulmonary capillary
endothelial cell, and surfactant lining layer. (See page 234: Lung Structures.)
16. Which of the following conditions changes laminar flow to turbulent flow&quest;
1. High gas flows
2. Sharp angles within the tube
3. Branching in the tube
4. Decrease in the tube's diameter
16. E. Four conditions that change laminar flow to turbulent flow are high gas flows, sharp
angles within the tube, branching in the tube, and a decrease in the tube's diameter. During
laminar flow, resistance is inversely proportional to the gas flow rate. During turbulent flow,
resistance increases significantly in proportion to the flow rate. (See page 237: Turbulent Flow.)
17. Which of the following statements regarding the trachea is/are TRUE&quest;
1. In the supine position, the most likely place for aspirated material to fall is the right
upper lobe.
2. It is totally intrathoracic, with 50% in the superior mediastinum and 50% in the inferior
mediastinum.
3. The tracheal bifurcation is usually at the level of T4.
4. The trachea's fixed position in the inferior mediastinum serves as an important
reference point.
17. B. The diameter of the right bronchus is generally greater than that of the left. In adults,
whereas the right bronchus leaves the trachea at approximately 25 degrees from the tracheal
axis, the angle of the left bronchus is approximately 45 degrees. Thus, inadvertent
endobronchial intubation or aspiration of foreign material is more likely to occur in the right lung
than in the left. Furthermore, the right upper lobe bronchus dives almost directly posterior at
approximately 90 degrees from the right main bronchus. Foreign bodies and fluid aspirated by a
supine subject usually fall into the right upper lobe. In adults, the trachea is a fibromuscular tube
approximately 10 to 12 cm long with an outside diameter of approximately 20 mm. The trachea
enters the superior mediastinum and bifurcates at the sternal angle (the lower border of the
fourth thoracic vertebral body). Normally, half of the trachea is intrathoracic, and the other half
81 / 494
is extrathoracic. Both ends of the trachea are attached to mobile structures. Thus, the carina
can move superiorly as much as 5 cm from its normal resting position. (See page 235:
Conductive Airways.)
18. Which of the following statements regarding bronchioles is/are TRUE&quest;

1. They are approximately 1 mm in diameter.
2. They are the last segment of the conducting airways to contain cartilage.
3. They have the highest proportion of smooth muscle in their walls.
4. The terminal bronchioles may be involved in terminal gas exchange if they are
recruited.
18. B. The bronchioles typically have diameters of 1 mm. They are devoid of cartilaginous
support and have the highest proportion of smooth muscle in the wall. There are approximately
three to four bronchiolar generations. The final bronchiolar generation is the terminal
bronchiole, which is the last airway component that is not directly involved in gas exchange.
(See page 235: Conductive Airways.)
P.47
P.48
P.49
P.50
19. Which of the following characteristics regarding gas flow is/are TRUE&quest;
1. With laminar gas flow, significant alveolar ventilation can occur, even when tidal
volume (Vt) is less than dead space.
2. Density is the only physical gas property that is relevant under laminar gas flow
conditions.
3. Helium does not improve gas flow under laminar conditions.
4. During turbulent flow, resistance decreases in proportion to flow rate.
19. B. A clinical implication of laminar flow in the airways is that significant alveolar ventilation
can occur even when the Vt is less than anatomic dead space. This phenomenon is important
in high-frequency ventilation. Viscosity is the only physical gas property that is relevant under
conditions of laminar flow. Helium has a low density, but its viscosity is close to that of air.
Therefore, helium will not improve gas flow that is laminar. Flow is usually turbulent when there
is critical airway narrowing or abnormally high airway resistance, thus making low-density
helium therapy useful. Resistance during laminar flow is inversely proportional to gas flow rate.
Conversely, during turbulent flow, resistance increases in proportion to the flow rate. (See page
237: Resistance to Gas Flow.)
20. The Hering-Breuer reflex:

1. Is blocked by bilateral vagotomy
2. Produces apnea in humans when continuous positive airway pressure (CPAP)
exceeds 40 cm H2O
3. Is a pulmonary stretch reflex that is primarily generated from the intercostal muscles
but not the diaphragm
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4. Is prominent in humans but not lower-order mammals
20. B. The Golgi tendon organs (tendon spindles), which occur in series arrangements within
ventilatory muscles, facilitate proprioception. Whereas the intercostal muscles are rich in tendon
spindles, the diaphragm has a limited number. Thus, the pulmonary stretch reflex primarily
involves the intercostal muscles but not the diaphragm. When the lungs are full and the chest
wall is stretched, these receptors send signals to the brainstem, further inhibiting inspiration. In
1868, Hering and Breuer reported that lightly anesthetized, spontaneously breathing animals
cease or decrease ventilatory effort during sustained lung distention. This response was
blocked by bilateral vagotomy. The Hering-Breuer reflex is prominent in lower-order mammals,
such as rabbits, but is only weakly present in humans. This reflex is sufficiently active in lower
mammals, such that 5 cm H2O CPAP induces apnea. In humans, however, the reflex is only
weakly present, as evidenced by the fact that humans continue to breathe spontaneously with
CPAP in excess of 40 cm H2O. This inflation reflex is associated with inspiratory muscle
inhibition, as documented by marked reductions in the electrical activity of both the phrenic
nerve and the diaphragmatic muscle itself. The second component of the Hering-Breuer reflex,
the deflation reflex, produces increased ventilatory muscle activity after sustained lung
deflation. (See page 240: Reflex Control of Ventilation.)
21. Which of the following result(s) in an enhanced CO2 response (shift of CO2
response curve upward and to the left)&quest;
1. Anxiety
2. Metabolic acidosis
3. Arterial hypoxemia
4. Opioid antagonists in the absence of opioids
21. A. Three clinical states result in a left shift or a steepened slope of the CO2 response
curve. These same three situations are the only causes of true hyperventilation (i.e., an
increase in minute ventilation such that the decreased PaCO2 creates respiratory alkalemia).
The three causes of hyperventilation (enhanced CO2 response) are arterial hypoxemia,
metabolic acidemia, and central etiologic factors. Examples of central etiologic factors that
cause hyperventilation include drug administration, intracranial hypertension, hepatic cirrhosis,
and nonspecific arousal states such as anxiety and fear. Aminophylline, salicylates, and
norepinephrine stimulate ventilation independent of peripheral chemoreceptors. Opioid
antagonists, given in the absence of opioids, do not stimulate ventilation. However, when they
are given after opiate administration, they do reverse the effects of opioids on the CO2
response curve. (See page 242: Quantitative Aspects of Chemical Control of Breathing.)
22. Inspiratory capacity:

1. Is defined as the greatest volume that can be inhaled from the resting expiratory level
2. Is commonly measured as part of routine pulmonary function testing
3. Can be a sensitive indicator of extrathoracic airway obstruction
4. Is less sensitive than expiratory measurements to extrathoracic obstruction
22. B. The inspiratory capacity is the largest volume of gas that can be inspired from the resting
expiratory level and is frequently decreased in the presence of significant extrathoracic airway
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obstruction. This measurement is one of the few simple tests that can detect extrathoracic
airway obstruction. Most routine pulmonary function tests measure only exhaled flows and
volumes, which are relatively unaffected by extrathoracic obstruction unless it is severe.
Changes in the absolute volume of inspiratory capacity usually parallel changes in vital
capacity. Expiratory reserve volume is not of great diagnostic value. (See page 247: Lung
Volumes and Capacities.)

1. The direct effect of CO2 on central chemoreceptors is responsible for more than 80%
of the resultant increase in ventilatory response.
2. A sudden decrease in the pressure of end-tidal CO 2 (PETCO2) in a mechanically
ventilated patient is most often caused by pulmonary air embolism.
3. Preoperative pulmonary function testing is important in predicting the likelihood of
postoperative pulmonary complications.
4. Patients having intrathoracic operations are at a slightly lower risk of experiencing
postoperative pulmonary complications than patients having abdominal operations.
23. D. Although the central response is the major factor in the regulation of breathing by CO 2,
CO2 has little direct stimulating effect on these chemosensitive areas. These receptors are
primarily sensitive to changes in H+ concentration. CO2 has a potent but indirect effect by
reacting with water to form carbonic acid, which dissociates into H+ and bicarbonate ions. The
PETCO2 in ventilated patients varies linearly with the dead space (Vd) to tidal volume (Vt) ratio
(Vd/Vt) and correlates poorly with PaCO2. Monitoring PETCO2 gives far more information
about ventilatory efficiency or Vd than it does about the absolute value of PaCO2.
Anesthesiologists commonly measure PETCO2 to detect venous air embolism during
anesthesia. A lowered cardiac output alone, in the absence of venous air embolism, may
sufficiently decrease pulmonary perfusion so that Vd increases and PETCO2 decreases. Thus,
a depressed PETCO2 is a sensitive but nonspecific monitor.
The goals one hopes to achieve through preoperative pulmonary function testing are to predict
the likelihood of pulmonary complications, obtain quantitative baseline information concerning
pulmonary function, and identify patients who may benefit from therapy to improve pulmonary
function preoperatively. For patients who will have lung resection, pulmonary function testing
provides some predictive benefit. However, for other patients, the overwhelming evidence
suggests that preoperative pulmonary function testing does not predict or assign risk for
postoperative pulmonary complications. The operative site is the single most important
determinant of both the degree of pulmonary restriction and postoperative pulmonary
complications. Nonlaparoscopic upper abdominal operations increase the risk of postoperative
pulmonary complications by at least twofold. Lower abdominal and intrathoracic operations are
associated with slightly lower risk but still higher risk than extremity, intracranial, and head and
neck operations. (See page 241: Central Chemoreceptors: Assessment of Physiologic Dead
Space; page 253: Postoperative Pulmonary Complications; and page 250: Preoperative
Pulmonary Assessment.)
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Review of Clinical Anesthesia, 5e [Vishal] 12. Immune Function & Allergic Response
Chapter 12
Immune Function and Allergic Response
1. The humoral defense system includes all the following EXCEPT:

A. Antibodies
B. Cytokines
C. Complement
D. Lymphocytes
E. Circulating proteins
1. D. The host defense systems can be divided into cellular and humoral elements. The
humoral system includes complement, cytokines, antibodies, and other circulating proteins. The
cellular system defense is mediated by specific lymphocytes of the T-cell series. (See page
257: Basic Immunologic Principles.)
2. Which type of T cell does not require specific antigen stimulation to initiate its
function&quest;
A. Cytotoxic
B. Lymphotrophic
C. Suppressor
D. Helper
E. Killer
2. E. The thymus of the fetus differentiates immature lymphocytes into thymus-derived cells (T
cells). The two types of regulator T cells are helper cells and suppressor cells. Helper cells are
important for effective cell responses. Suppressor cells inhibit immune function. Killer cells do
not require specific antigen stimulation to initiate their function. Cytotoxic T cells destroy
mycobacteria, fungi, and viruses. (See page 257: Basic Immunologic Principles: Thymus-
Derived Lymphocytes [T-Cell] and Bursa-Derived Lymphocytes [B-Cell].)
3. Which of the following statements regarding antibodies is TRUE&quest;

A. Each antibody has two heavy chains and one light chain.
B. The Fab segment binds the antigen.
C. The light chain is responsible for the unique biologic properties of the different
classes of immunoglobulins.
D. There are six major classes of antibodies in humans.
E. The light chain determines the structure and function of each molecule.
3. B. Each antibody has two heavy chains and two light chains that are bound together by
disulfide bonds. Whereas the Fab fragment has the ability to bind antigen, the Fc (crystallizable)
is responsible for the unique biologic properties of the different classes of immunoglobulins.
The five major classes of antibodies in humans are IgG, IgA, IgM, IgD, and IgE. The heavy
chain determines the structure and function of each molecule. (See page 257: Basic
85 / 494
Immunologic Principles: Antibodies.)
4. The attachment of an antibody or complement fragment to the surface of foreign

cells is called:
A. Immunogenicity
B. Hepatogenicity
C. Opsonization
D. Lymphotropism
E. Lymphokinesis
4. C. The attachment of an antibody or complement fragment on the surface of foreign cells is
called opsonization, a process that facilitates effector cell killing of foreign cells. Haptens are
small molecules that form bonds with either host proteins or cell membranes to form a complete
antigen. The ability to act as an antigen is referred to as immunogenicity. (See page 257: Basic
Immunologic Principles: Effector Cells and Proteins of the Immune Response Cells.)
5. Which kind of cells regulate immune responses by presenting antigens to result in

microbicidal function&quest;
A. Eosinophils
B. Basophils
C. Neutrophils
D. Mast cells
E. Macrophages
5. E. Neutrophils are the first cells to appear in an acute inflammatory reaction. Eosinophils
accumulate at sites of parasitic infection, tumor, and allergic reactions. Mast cells are tissue
fixed and located in the perivascular spaces of the skin and intestine; when they are activated,
they release a broad spectrum of physiologically active mediators. Basophils possess IgE
receptors on their surfaces and function similarly to mast cells. Macrophages regulate immune
responses by presenting antigens to result in microbicidal function. (See page 257: Basic
Immunologic Principles: Effector Cells and Proteins of the Immune Response Cells.)
6. Complement can be activated by all of the following EXCEPT:

A. Immunoglobulin G (IgG)
B. Plasmin
C. Killer T cells
D. Endotoxin
E. The alternate pathway
6. C. The primary humoral response to antigen and antibody binding is the activation of the
complement system. Complement activation can be initiated by IgG or IgM, by plasmin through
the classic pathway, by endotoxin, or by drugs through the alternate (properdin) pathway. The
major function of the complement system is to recognize bacteria, both directly and indirectly by
the attraction of phagocytes, as well as the increased adhesion of phagocytes to antigens and
cell lysis through activation of the complement system. T cells are a component of the cellular
86 / 494
immune response system. (See page 257: Basic Immunologic Principles: Effector Cells and
Proteins of the Immune Response Cells [Complement].)
7. True statements concerning the secondary treatment of anaphylaxis include all of

the following EXCEPT:
A. Bicarbonate should be given to treat severe acidemia.
B. Corticosteroids require 12 to 24 hours to work.
C. Corticosteroids are recommended for IgE-mediated reactions.
D. Antihistamines inhibit histamine release.
E. Catecholamines, such as epinephrine, can be used if bronchospasm is present.
7. D. Administration of a histamine (H 1) antagonist may be useful in treating acute anaphylaxis;
it does not inhibit H1 release but competes with H1 at the receptor sites. Steroids should be
considered a secondary treatment in the management of patients with anaphylactic
bronchospasm. Steroids require 12 to 24 hours to exert their peak clinical effect. Although the
exact corticosteroid dose and preparation are unclear, investigators have recommended 0.25 to
1 g intravenously of hydrocortisone for IgE-mediated reactions. Acidosis frequently
accompanies persistent hypotension. Acidemia decreases the effectiveness of administered
epinephrine on the myocardium. Therefore, with refractory hypotension and acidemia, sodium
bicarbonate should be given as indicated by arterial blood gas evaluation. Catecholamines,
such as epinephrine, can be used in patients with persistent hypotension or bronchospasm
after initial resuscitation. (See page 260: Anaphylactic reactions: Non–IgE-Mediated Reactions
[Nonimmunologic Release of Histamine, Treatment Plan, and Secondary Treatment].)
8. The purpose of _________________ is to determine basophil activation.

A. skin testing
B. the leukocyte histamine release test
C. enzyme-linked immunosorbent assay (ELISA)
D. the radioallergosorbent test
E. the protamine test
8. B. The leukocyte histamine release test is performed by incubating the patient's leukocytes
with the offending drug and measuring the histamine release as a marker for basophil
activation. The radioallergosorbent test allows in vitro detection of specific IgE directed toward
particular antigens by linking them to insoluble material to make them immunoabsorbent. ELISA
measures antigen-specific antibodies. (See page 266: Perioperative Management of the Patient
with Allergies: Evaluation of Patients with Allergic Reactions [Testing for Allergy].)
9. Type II reactions include all of the following EXCEPT:
1. ABO incompatibility reactions
2. Heparin-induced thrombocytopenia
3. Drug-induced immune hemolytic anemia
87 / 494
4. Classic serum sickness
9. D. Type II reactions are also known as antibody-dependent cell-mediated cytotoxic
hypersensitivity reactions. These reactions are mediated by IgG or IgM antibodies directed
against antigens on the surface of foreign cells. Examples of type II reactions in humans are
ABO-incompatible transfusion reactions, drug-induced immune hemolytic anemia, and heparin-
induced thrombocytopenia. Classic serum sickness is an example of a type III reaction. (See
page 259: Hypersensitivity Responses: Type II Reactions.)
P.52
P.53
10. Which of the following statements regarding intraoperative allergic reactions is/are
TRUE&quest;
1. They occur once every 5000 to 25,000 anesthetics.
2. The mortality is approximately 3.4%.
3. In anesthetized patients, the most common life-threatening manifestation of an allergic
reaction is circulatory collapse.
4. Most reactions occur more than 10 minutes after an intravenous drug injection.
10. A. Intraoperative allergic reactions occur once every 5000 to 25,000 anesthetics, with a
reported mortality of 3.4%. More than 90% of the allergic reactions evoked by intravenous
drugs occur within 5 minutes of their administration. In anesthetized patients, the most common
life-threatening manifestation of an allergic reaction is circulatory collapse. (See page 259:
Hypersensitivity Responses: Intraoperative Allergic Reactions.)
11. Which of the following statements regarding chemical mediators of inflammation

is/are TRUE&quest;
1. Leukotrienes are derived from arachidonic acid metabolism of phospholipid
membranes.
2. Prostaglandins are potent mast cell mediators.
3. Prostaglandin D2 produces bronchospasm.
4. Kinins are synthesized in mast cells.
11. E. Various leukotrienes are synthesized after mast cell activation from arachidonic acid
metabolism of phospholipid cell membranes via the lipoxygenase pathway. Prostaglandins are
potent mast cell mediators that produce vasodilation, bronchospasm, pulmonary hypertension,
and increased capillary permeability. Prostaglandin D2, the major metabolite of mast cells,
produces bronchospasm and vasodilation. Kinins are synthesized in mast cells and basophils
and produce vasodilation, increased capillary permeability, and bronchoconstriction. (See page
260: Anaphylactic Reactions.)
12. Which of the following statements regarding anaphylactic reactions is/are

TRUE&quest;
1. There is a more than 40% loss of intracellular fluid during anaphylactic reactions.
2. Inhalation anesthetics are the bronchodilators of choice after anaphylaxis.
3. Corticosteroids are important in attenuating the late-phase reactions that occur 1 to 2
88 / 494
hours after anaphylaxis.
4. Epinephrine is the drug of choice for resuscitation during anaphylactic shock.
12. D. Epinephrine, in conjunction with volume expansion, is the drug of choice during
anaphylactic shock because it reverses hypotension (α -adrenergic effects) and causes
bronchodilation (β- 2 receptor). Inhalation anesthetics are not the bronchodilators of choice for
treating bronchospasm after anaphylaxis because they interfere with the body's compensatory
response to the cardiovascular collapse associated with anaphylaxis. Up to a 40% loss of
intravascular fluid into the interstitial space during reactions has been reported. Corticosteroids
may be important in attenuating the late-phase reactions reported to occur 12 to 24 hours after
anaphylaxis. (See page 260: Anaphylactic Reactions: Treatment Plan [Initial Therapy].)
13. Which of the following statements regarding perioperative immunologic responses

is/are TRUE&quest;
1. Most anesthetic drugs and agents have been reported to produce anaphylactic
reactions.
2. Muscle relaxants are the most common agents responsible for intraoperative allergic
reactions.
3. Although life-threatening allergic reactions are more likely to occur in individuals with a
history of allergy, atopy, or asthma, this history is not a reliable predictor whether an
allergic reaction will occur.
4. There is no cross-sensitivity between succinylcholine and the nondepolarizing muscle
relaxants.
13. A. Most anesthetic agents administered perioperatively have been reported to produce
anaphylactic reactions. Muscle relaxants are the most common agents used that are
responsible for evoking intraoperative allergic reactions. There is a cross-sensitivity between
succinylcholine and the nondepolarizing muscle relaxants. Life-threatening allergic reactions
are more likely to occur in individuals with a history of allergy, atopy, or asthma but do not
necessarily predict whether an allergic reaction will occur. (See page 266: Perioperative
Management of the Patient with Allergies: Immunologic Mechanisms of Drug Allergy.)
14. Which of the following statements regarding latex reactions is/are TRUE&quest;
1. There is a 24% incidence of contact dermatitis among anesthesiologists.
2. Patients with an allergy to bananas have antibodies that may cross-react to latex.
3. A history of atopy is a risk factor for latex sensitization.
4. Pretreatment always prevents anaphylaxis.
14. A. There is a 24% incidence of contact dermatitis among anesthesiologists. Patients with an
allergy to bananas have antibodies that can cross-react to latex. A history of atopy is a risk
factor for latex sensitization. Pretreatment can help to prevent anaphylaxis. (See page 266:
Perioperative Management of the Patient with Allergies: Agents Implicated in Allergic Reactions
[Latex Allergy].)
89 / 494
Review of Clinical Anesthesia, 5e [Vishal] 13. Inflammation, Wound Healing & Infection
Chapter 13
Inflammation, Wound Healing and Infection
1. Which of the following is effective at removing spores&quest;

A. Alcohol-based rinses and gels
B. Plain soap and water
C. Iodine and iodophors
D. Chlorhexidine
1. B. The most crucial component of infection prevention is frequent and effective hand
hygiene. Plain (not antiseptic) soap and water are generally the least effective method of
reducing hand contamination but are very effective at removing spores and therefore should be
used when contamination with either Clostridium difficile or Bacillus anthracis is a concern.
Alcohol-based rinses and gels denature proteins, which confers their antimicrobial activity.
Alcohol-based rinses and gels are effective against bacteria and lipophilic viruses but not
against spores. Iodine and iodophors penetrate the cell wall and impair protein synthesis and
cell membrane function; they are effective against spore-forming bacteria but are inactive
against spores. Chlorhexidine disrupts cytoplasmic membranes and is effective against gram-
positive bacteria and lipophilic viruses but not against gram-negative bacteria or spore-forming
organisms. (See page 272: Hand Hygiene.)
2. The majority of postoperative surgical infections are caused by flora that are:
A. endogenous to the patient
B. environmental contaminants
C. airborne organisms
D. spore-forming organisms
2. A. Most postoperative surgical infections are caused by flora that are endogenous to the
patient. Environmental and airborne contaminants may also play a causative role to a lesser
extent. As the number of people in the operating suite increases, the patient exposure to
airborne organisms increases. Spore-forming organisms rarely contribute to postoperative
surgical infections. (See page 275: Antisepsis.)
3. Which of the following statements is FALSE regarding preoperative antibiotic

prophylaxis&quest;
A. Administration of antibiotics should be done within 1 hour of incision.
B. Drugs that require infusion over an hour should be completed before incision.
C. When a tourniquet is used, infusion must be completed before tourniquet inflation.
D. Depending on half-life, antibiotics should be repeated during long operations.
3. B. Antibiotic prophylaxis has now become standard for surgeries in which there is more than
a minimum risk of infection. Ideally, prophylaxis administration should be within 1 hour of
incision. For drugs such as vancomycin that require infusion over an hour, it is considered
acceptable if the infusion is started before incision. When a tourniquet is used, the infusion
90 / 494
must be complete before inflation of the tourniquet. Depending on the drug's half-life, antibiotics
should be repeated during long operations or operations with large blood loss. (See page 276:
Antibiotic Prophylaxis.)
4. Which of the following is not an independent risk factor for methicillin-resistant

Staphylococcus aureus (MRSA) infection&quest;
A. Use of drains for more than 24 hours
B. Increasing number of procedures performed on the patient
C. Long hospital stay
D. Use of prophylactic antibiotics for more than 48 hours
4. C. Unfortunately, MRSA is becoming a more common pathogen. Independent risk factors
identified for MRSA infection include prolonged use of prophylactic antibiotics, use of drains for
more than 24 hours, and increasing number of procedures performed on the patient. Long
hospital stay is not an independent risk factor for MRSA infection. Hand hygiene is among the
most effective means of preventing development of MRSA because when they are used
properly, alcohol-based gel kills more than 99.9% of all transient pathogens, including MRSA.
(See page 276: Antibiotic Prophylaxis.)
5. Which of the following is the most critical element for effective wound repair&quest;
A. Medical comorbidities
B. Nutrition
C. Oxygen supply to the wound
D. Sympathetic nervous system activation
5. C. Many factors may impair wound healing. Systemic factors such as medical comorbidities,
nutrition, sympathetic nervous system activation, and age have substantial effects on the repair
process. Although all of these factors are important, perhaps the most critical element is oxygen
supply to the wound. Wound hypoxia impairs all of the components of healing. (See page 277:
Mechanisms of Wound Repair.)
6. Which of the following phases of wound healing is characterized by erythema and

edema of the wound edges&quest;
A. Proliferation
B. Remodeling
C. Inflammation
D. Hemostasis
6. C. Wound healing has been described in four separate phases: hemostasis, inflammation,
proliferation, and remodeling. The initial response to injury is the hemostasis phase, which
prevents exsanguination but also widens the area that is no longer perfused. The inflammatory
phase is characterized by erythema and edema of the wound edges. The proliferative phase
consists of granulation tissue formation and epithelization. The final stage of wound repair is
the maturation (and remodeling) phase. (See page 277: The Initial Response to Injury.)
7. When the wound environment becomes hypoxic and acidotic with high lactate
91 / 494
levels, all of the following are present EXCEPT:
A. decreased oxygen supply
B. decreased respiratory burst activity
C. increased metabolic demand
D. aerobic glycolysis by inflammatory cells
7. B. In wounds, the local blood supply is compromised at the same time that metabolic demand
is increased. As a result, the wound environment becomes hypoxic and acidotic with high
lactate levels. This represents the sum of three effects: (1) decreased oxygen supply caused by
vascular damage and coagulation, (2) increased metabolic demand caused by the heightened
cellular response (anaerobic glycolysis), and (3) aerobic glycolysis by inflammatory cells. In
activated neutrophils, the respiratory burst, in which oxygen and glucose are converted to
superoxide, hydrogen ion, and lactate, accounts for up to 98% of oxygen consumption; in the
setting of injury, this activity increases by up to 50-fold over baseline. (See page 277: The Initial
Response to Injury.)
8. The proliferative phase of wound healing consists of all of the following EXCEPT:
A. neovascularization
B. synthesis of collagen
C. maturation
D. epithelization
8. C. The proliferative phase normally begins approximately 4 days after injury, concurrent with
a waning of the inflammatory phase. It consists of granulation tissue formation and
epithelization. Granulation involves neovascularization as well as synthesis of collagen and
connective tissue proteins. Maturation is the final stage of wound healing. (See page 277:
9. Which of the following statements is FALSE regarding wound healing&quest;

A. The proliferative phase normally begins 4 days after injury.
B. Helical configuration of collagen is primarily responsible for tissue strength.
C. Local hypoxia is a normal and inevitable result of tissue injury.
D. Neutrophil function does not depend on a high partial pressure of oxygen.
9. D. The proliferative phase normally begins approximately 4 days after injury. Collagen can
only be exported from the cell when it is in a triple helical structure. The helical configuration is
primarily responsible for tissue strength. Local hypoxia is a normal and inevitable result of
tissue injury. Hypoxia acts as a stimulus to repair but also leads to poor healing and increased
susceptibility to infection. The neutrophil is the primary cell responsible for nonspecific
immunity, and its function depends on a high partial pressure of oxygen. (See page 277:
P.55
10. Which of the following statements is FALSE about subcutaneous tissue&quest;
A. It is a reservoir used to maintain central volume.
92 / 494
B. It is the major site of thermoregulation.
C. The rate of wound infection is directly proportional to postoperative subcutaneous
wound tissue oxygen tension.
D. Peripheral vasoconstriction from subcutaneous vascular tone is an impediment to
wound healing.
10. C. The normal subcutaneous partial pressure of oxygen, measured in test wounds in
uninjured, euthermic, euvolemic volunteers breathing room, air is 65 ± 7 mm Hg. Thus, any
reduction in wound partial pressure of oxygen may impair immunity and repair. In surgical
patients, the rate of wound infections is inversely proportional, and collagen deposition is
directly proportional to postoperative subcutaneous wound tissue oxygen tension. High oxygen
tensions (>100 mm Hg) can be reached in wounds but only if perfusion is rapid and arterial
PO2 is high. This is because subcutaneous tissue serves a reservoir function, so there is
normal flow in excess of nutritional needs. Wound cells consume relatively little oxygen at a
normal perfusion rate. Peripheral vasoconstriction is probably the most frequent and clinically
the most important impediment to wound oxygenation. Subcutaneous tissue is both a reservoir
to maintain central volume and a major site of thermoregulation. (See page 282: Wound
Perfusion and Oxygenation.)
11. For an indwelling venous catheter placement, which agent is the BEST
antiseptic&quest;
A. Soap
B. Alcohol gels
C. Iodine
D. Chlorhexidine
E. Ethanol
11. D. A large number of products are available for hand hygiene. The ideal agent kills a broad
spectrum of bacteria and has antimicrobial activity that lasts for more than 6 hours after
application. Soap and water are generally the least effective at reducing hand contamination
with bacteria and are associated with an increased risk of skin irritation and drying. Alcohol-
based gels denature proteins and are germicidal against bacteria and lipophilic viruses such as
herpes, HIV, influenza, and hepatitis. Chlorhexidine is an antiseptic that disrupts cytoplasmic
membranes and ultimately leads to precipitation of cellular components; it has substantial skin
persistence, so the Centers for Disease Control and Prevention has identified it as the topical
agent of choice for central venous catheter placement. It may cause corneal damage if it
accidentally comes into contact with the eye, ototoxicity if it comes into contact with middle ear,
and potential neurotoxicity if it comes into contact with the brain or meninges. (See page 272:
Infection Control: Hand Hygiene.)
12. Which of the following statements involving antisepsis is FALSE&quest;

A. Wearing masks reduces surgical site infections.
B. An increased number of operating room personnel is related to an increased
incidence of infection.
C. Putting on a gown and gloves before central venous cannulation is vital to infection
control.
93 / 494
D. Masks and gowns significantly reduce the incidence of epidural abscesses.

E. The use of epidural catheters is contraindicated in patients with bacteremia.
12. D. Masks are almost universally used in operating rooms; their role has long been
established in protecting both patients and health care providers, especially when combined
with eye protection. A recent study shows a trend toward increased postoperative infectious
complications after orthopedic procedures that are associated with an increased number of
personnel in the operating room; current recommended practices are that traffic patterns should
limit the flow of people through operating rooms. Gowning and gloving should be routine when
central venous catheterization is being used. Epidural catheter placement requires a careful
aseptic technique such as hand washing, skin preparation, and draping. However, gowning and
wearing masks are unlikely to reduce the risk of infection. Epidural placement should be
avoided in patients suspected to have bacteremia because of an increased risk of seeding the
epidural space. (See page 275: Antisepsis.)
13. Which of the following factors is/are important for wound healing&quest;
1. Aseptic technique
2. Prophylactic antibiotics
3. Perfusion of wound
4. Oxygenation of wound
13. E. Effective hand hygiene and careful surgical technique are fundamental to optimal wound
healing. Antibiotic prophylaxis has become the standard for surgeries in which there is more
than a minimum risk of infection. Prophylactic antibiotics are given pre- or intraoperatively. At
the same time, maintaining oxygenation and perfusion of the wound is important for wound
healing. (See page 272: Hand Hygiene, Antisepsis, and Antibiotic Prophylaxis.)
14. Prolonging the course of prophylactic antibiotics for more than 24 hours increases
the risk of which of the following&quest;
1. Antibiotic resistance
2. Clostridium difficile infection
3. Sensitization
4. Effectiveness against infection
14. A. Prophylactic antibiotics are given pre- or intraoperatively. They should be discontinued
by 24 hours after surgery. Prolonging the course of prophylactic antibiotics does not reduce the
risk of infection but does increase the risk of adverse consequences of antibiotic administration,
including resistance, Clostridium difficile infection, and sensitization. (See page 276: Antibiotic
Prophylaxis.)
15. Oxygen plays an important role in which of the following physiologic

processes&quest;
1. Wound healing
94 / 494
2. Aerobic respiration
3. Oxidative phosphorylation
4. Leukocyte mediated bacterial killing and collagen formation
15. E. Oxygen plays a key role in aerobic respiration and energy production via oxidative
phosphorylation. In wound healing, oxygen is required as a cofactor for enzymatic processes
and for cell-signaling mechanisms. Oxygen is a rate-limiting component in leukocyte-mediated
bacterial killing and collagen formation because specific enzymes require oxygen at a partial
pressure of at least 40 mm Hg. (See page 277: Mechanisms of Wound Repair.)
16. Which of the following factors have shown to decrease wound infections in patients
undergoing major abdominal surgery&quest;
1. Prevention or correction of hypothermia
2. Providing supplemental oxygen postoperatively
3. Prevention or correction of blood volume deficit
4. Use of high inspired oxygen intraoperatively
16. E. Prevention and correction of hypothermia and blood volume deficits have been shown to
decrease wound infections and increase collagen deposition in patients undergoing major
abdominal surgery. Preoperative systemic or local warming has also been shown to decrease
wound infections, even in clean, low-risk surgeries. The preponderance of evidence indicates
that use of high inspired oxygen intraoperatively and providing supplemental oxygen
postoperatively in well-perfused patients undergoing major abdominal surgery will reduce the
risk of wound infection. (See page 282: Wound Perfusion and Oxygenation.)
17. Wound oxygen delivery depends on which of the following factors&quest;

1. Vascular anatomy
2. Degree of vasoconstriction
3. Arterial PO2
4. Hemoglobin-bound oxygen
17. A. Normally, wounds on the extremities and trunk heal more slowly than those on the face.
The major difference in these wounds is the degree of tissue perfusion and thus the wound
tissue oxygen tension. Wound oxygen delivery depends on the vascular anatomy, the degree of
vasoconstriction, and arterial PO2. The standard teaching that oxygen delivery depends more
on hemoglobin-bound oxygen than on arterial PO2 may be true of working muscle but is not
true for wound healing. In muscle, intercapillary distances are small, and oxygen consumption is
high. In contrast, intercapillary distances are large, and oxygen consumption is relatively low in
subcutaneous tissue. In wounds, where the microvasculature is damaged, diffusion distances
are substantially increased. Peripheral vasoconstriction further increases diffusion distance.
The driving force of diffusion is partial pressure. Resistance to infection is critically impaired by
wound hypoxia and becomes more efficient as partial pressure of oxygen increases to very high
levels. This is one mechanism for the proposed benefit of hyperbaric oxygen therapy as an
adjunctive treatment for necrotizing infections and chronic refractory osteomyelitis. (See page
282: Wound Perfusion and Oxygenation.)
95 / 494
96 / 494
Review of Clinical Anesthesia, 5e [Vishal] 14. Fluids, Electrolytes & Acid Base Physiology
Chapter 14
Fluids, Electrolytes, and Acid Base Physiology
1. A previously healthy patient acutely develops metabolic alkalosis resulting from

intravenous diuretic administration. The measured HCO3 is 36 mEq/L. The arterial
blood gas analysis shows:
A. pH, 7.51; PaCO2, 47; PO2, 90
B. pH, 7.42; PaCO2, 52; PO2, 90
C. pH, 7.51; PaCO2, 47; PO2, 110
D. pH, 7.61; PaCO2, 52; PO2, 90
E. pH, 7.51; PaCO2, 40; PO2, 100
1. A. This represents metabolic alkalosis with partial respiratory compensation. The rules of
thumb for calculating the expected response to metabolic alkalosis are as follows: (1) PaCO2
increases approximately 0.5 to 0.6 mm Hg for each 1.0-mEq/L increase in HCO3 and (2) the
last two digits of the pH should equal the HCO3 + 15. Hypercarbia is accompanied by a
reduced PaO2 as given by the alveolar gas equation. (See page 291: Metabolic Alkalosis and
page 292: Table 14-3.)
2. Metabolic acidosis with a normal anion gap may be caused by:

A. Aspirin toxicity
B. Diabetic ketoacidosis
C. Chronic diarrhea
D. Uremia
E. Lactic acidosis
2. C. Metabolic acidosis may be characterized by a high anion gap or a normal anion gap.
Metabolic acidosis with a high anion gap results from excess anions such as lactate,
ketoacetate, sulfate, salicylate, and other toxic compounds. Metabolic acidosis with a normal
anion gap is caused by loss of HCO3 resulting from diarrhea, biliary drainage, or renal tubular
acidosis. (See page 292: Metabolic Acidosis and page 292: Table 14-4.)
3. What is the best interpretation of an arterial blood gas analysis of pH, 7.35; PaCO 2,
60; PO2, 80; and HCO3, 32&quest;
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with metabolic compensation
C. Chronic respiratory acidosis without metabolic compensation
D. Chronic metabolic alkalosis with respiratory compensation
E. Acute metabolic alkalosis
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3. B. The pH below 7.40 suggests acidosis as the primary event, and the PaCO2 of 60 shows
that this patient has respiratory acidosis. The appropriate chronic metabolic compensation is
that HCO3 increases 4 mEq/L for each 10-mm Hg increase in PaCO2, thus bringing the HCO3
to 32 mEq/L. The pH will return toward normal. (See page 294: Practical Approach to Acid-Base
Interpretation.)
60; PO2, 80; and HCO3, 26&quest;
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with appropriate metabolic compensation
C. Chronic respiratory acidosis with inappropriate metabolic compensation
E. Acute metabolic alkalosis
4. A. The pH 7.24 suggests acidosis as the primary event, and the PaCO2 of 60 shows that this
patient has respiratory acidosis. (See page 294: Practical Approach to Acid-Base
Interpretation.)
30; PO2, 110; and HCO3, 22&quest;
A. Acute respiratory alkalosis
B. Chronic respiratory alkalosis with metabolic compensation
C. Acute metabolic acidosis with respiratory compensation
E. Chronic metabolic acidosis
5. A. The pH of 7.50 suggests alkalosis as the primary event, and the PaCO2 of 30 shows that
this patient has respiratory alkalosis. (See page 294: Practical Approach to Acid-Base
Interpretation.)
6. Total body water is approximately _________ % of total body weight.

A. 10
B. 20
C. 40
D. 60
E. 80
6. D. Total body water (in liters) is equal to approximately 60% of total body weight (in
kilograms). The intracellular volume constitutes 40% of total body weight, and the extracellular
volume constitutes 20% of body weight. (See page 296: Body Fluid Compartments.)
7. Intracellular volume (ICV) is _________ % of total body weight.

A. 10
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B. 20
C. 40
D. 60
E. 80
7. C. Total body water consists of ICV, which constitutes 40% of total body weight (28 L in a 70-
kg person), and extracellular volume, which constitutes 20% of body weight (14 L). (See page
296: Body Fluid Compartments.)
8. Plasma volume is approximately _________ % of the extracellular volume (ECV).

A. 10
B. 20
C. 30
D. 40
E. 50
8. B. Plasma volume, approximately 3 L, equals about one fifth (20%) of the ECV. The
remainder of the ECV is interstitial fluid. Red blood cell (RBC) volume, approximately 2 L, is part
of the intracellular volume. Total blood volume is approximately 5 L (3 L of plasma + 2 L of RBC
mass). (See page 296: Body Fluid Compartments.)
P.59
9. The extracellular concentrations of sodium (Na) is approximately _________ mEq/L.
A. 150
B. 130
C. 140
D. 120
E. 110
9. C. The extracellular fluid contains most of the Na in the body, with equal Na concentrations
(∼140 mEq/L) in the plasma and interstitium. (See page 296: Body Fluid Compartments.)
10. The intracellular concentration of potassium (K) is approximately _________ mEq/L.

A. 110
B. 130
C. 150
D. 4
E. 10
10. C. The predominant intracellular cation is K+, with an intracellular concentration of

approximately 150 mEq/L. (See page 296: Body Fluid Compartments.)
11. An acute blood loss of 2000 mL represents _________ % of the predicted blood
volume in a previously healthy 70-kg man.
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A. 10
B. 20
C. 30
D. 40
E. 50
11. D. A 2000-mL blood loss represents approximately 40% of the predicted 5-L blood volume in
a previously healthy 70-kg patient. The normal blood volume is approximately 70 mL/kg; the
normal plasma volume is three fifths of this value, or approximately 3 L. (See page 296: Body
Fluid Compartments.)
12. To achieve a more than transient 2000-mL restoration of plasma volume (PV) would
require infusion of _________ mL of D5W solution.
A. 2000
B. 4500
C. 7000
D. 14,000
E. 28,000
12. E. The volume that is to be infused to achieve a 2-L increase in PV is equal to Expected PV
increment × Distribution volume of infusate/Normal PV. The normal PV is 3 L; the distribution
volume for D5W is the total body water, which is 42 L (60% of 70 kg). Hence, the equation
becomes: 2 L × 42 L/3 L = 28 L. To achieve a 2-L increase in overall intravascular volume, 28 L
of D5W would theoretically be required. (See page 296: Body Fluid Compartments.)
13. To achieve a more than transient 2-L restoration of plasma volume using lactated
Ringer's solution would require infusion of approximately _________ L.
A. 10
B. 15
C. 30
D. 45
E. 50
13. A. The distribution volume for lactated Ringer's solution is the extracellular fluid, which is 14
L (20% of 70 kg). Hence, the equation for plasma expansion becomes 2 L × 14 L/3 L = 9.3 L.
(See page 296: Distribution of Infused Fluids.)
14. To achieve a more than transient 2-L restoration of plasma volume using 5%
albumin would require infusion of _________ L.
A. 1
B. 2
C. 5
D. 7
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E. 10
14. B. The distribution volume of 5% albumin is approximately equal to that of the plasma.
Hence, the replacement volume would be equal to the volume lost. (See page 296: Distribution
of Infused Fluids.)
15. To achieve a more than transient 2-L restoration of plasma volume using 6%
hetastarch would require infusion of _________ L.
A. 1
B. 2
C. 5
D. 7
E. 10
15. B. The distribution volume of 6% hetastarch is approximately equal to that of the plasma.
Hence, the replacement volume would be equal to the volume lost. (See page 296: Distribution
of Infused Fluids.)
16. Chronic gastric losses tend to cause:

A. hypochloremic alkalosis
B. hyperchloremic alkalosis
C. hypochloremic acidosis
D. hyperchloremic acidosis
E. alkalosis with a normal chloride value
16. A. Chronic gastric losses tend to produce hypochloremic metabolic alkalosis; potassium
may also be lost. (See page 299: Surgical Fluid Requirements.)
17. Chronic diarrhea tends to produce:

A. hypochloremic acidosis
B. hyperchloremic alkalosis
C. hyperchloremic acidosis
D. hyperchloremic alkalosis
E. alkalosis with a normal chloride value
17. C. Chronic diarrhea may produce hyperchloremic metabolic acidosis. (See page 299:
Surgical Fluid Requirements.)
18. What is the osmolality (mOsm/kg) of plasma that contains 140 mEq/L of Na, 90
mg/dL of glucose, and a blood urea nitrogen (BUN) of 11.5 mg/dL&quest;
A. 280
B. 290
C. 300
D. 310
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E. 320
18. B. The osmotic activity of body fluids represents the number of osmotically active particles
per kilogram of solvent. It is conventionally reported as osmolality (mmol/kg) and can be
estimated as follows: Osmolality = Na+ × 2 + (Glucose/18) + (BUN/2.3), where Na+ is
expressed in mEq/L and serum glucose and BUN is expressed in mg/dL. Hence, plasma, which
contains 140 mEq/L of Na+, 90 mg/dL of glucose, and a BUN of 11.5 mg/L, has 280 + 5 + 5 for
a total of 290 mmol/kg. The Na+ is doubled to account for “matching” anions (e.g., Cl). (See
page 301: Colloids, Crystalloids, and Hypertonic Solutions.)
19. Which of the following formulas accurately expresses Starling law of capillary
filtration&quest;
A. Q = kA[(Pc - Pi) + k(πi - πc)]
B. Q = kA[(Pc - Pi) - k(πi - πc)]
C. Q = kA[(Pc - Pi) - σ (πi - πc)]
D. Q = kA[(Pc - Pi) + σ (πi - πc)]
E. Q = kA[(Pc - Pi) + (πi - πc)]
19. D. The filtration rate of fluid from the capillaries into the interstitial space is the net result of
a combination of forces, including the gradient between intravascular and interstitial hydrostatic
pressures and the gradient between interstitial and intravascular colloid oncotic pressures. The
net filtration from capillary to interstitium may be expressed by the following equation: Q = kA
[(Pc - Pi)+ σ (πi - πc)], where Q is fluid filtration, k is the capillary filtration coefficient
(conductivity of water), A is the area of the capillary membrane, Pc - Pi is the difference
between capillary and interstitial hydrostatic pressures, and πi - πc is the difference between
interstitial and capillary oncotic pressures. The reflection coefficient (σ) describes the
permeability of capillary membranes to individual solutes. (See page 301: Colloids, Crystalloids,
and Hypertonic Solutions.)
20. Which of the following is NOT a typical finding during hypovolemia&quest;

A. Blood urea nitgrogen (BUN) >20 mg/dL
B. BUN/serum creatinine >20 mg/dL
C. Urinary Na <20 mEq/L
D. Urinary osmolality >400 mOsm/kg
E. Serum/urine creatinine ratio >1:40
20. E. If the ratio of BUN to serum creatinine exceeds the normal range (10–20 mg/dL), one
should suspect dehydration or one of the individual factors that alters the serum concentration
of the two metabolites. In prerenal oliguria, enhanced Na reabsorption should reduce urinary
Na to below 20 mEq/L, and enhanced water reabsorption should increase urinary concentration
(i.e., urinary osmolality >400 mOsm/kg; urine/plasma creatinine ratio >40:1). (See page 303:
Assessment of Hypovolemia and Tissue Hypoperfusion.)
21. What is the typical daily fluid requirement for a 30-kg child&quest;
A. 300 mL
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B. 3000 mL
C. 1100 mL
D. 1400 mL
E. 1700 mL
21. E. Typical maintenance requirements may be calculated according to formulas for hourly or
daily administration. For the first 10 kg of weight, 4 mL/kg/hr or 100 mL/kg/day should be
administered. For the eleventh to twentieth kg, 2 mL/kg/hr or 50 mL/kg/day should be given. For
each additional kilogram, 1 mL/kg/hr or 20 mL/kg per day should be administered. Thus, a 30-
kg child should receive 1000 mL + 500 mL + 200 mL = 1700 mL. (See page 299: Fluid
Replacement Therapy and page 299: Table 14-10.)
22. Which of the following statements concerning Na regulation is FALSE&quest;

A. Aldosterone promotes reabsorption of Na in the kidney.
B. Aldosterone promotes exchange of Na for potassium and hydrogen.
C. Stretching of the atria promotes release of atrial natriuretic peptide.
D. Antidiuretic hormone (ADH) affects serum Na concentration.
E. Excess ADH results in increased free water excretion.
22. E. Increased secretion of ADH results in reabsorption of water by the kidneys and
subsequent dilution of the plasma Na+; inadequate ADH secretion results in renal free water
excretion that, in the absence of adequate water intake, results in hypernatremia. Total body Na
is also regulated by aldosterone, which is responsible for renal Na reabsorption in exchange for
potassium and hydrogen. Alternatively, stretching of the cardiac atria causes secretion of atrial
natriuretic peptide, which increases renal Na excretion. (See page 304: Sodium.)
P.60
23. Physiologic consequences of metabolic alkalosis include:
1. rightward shift of the oxyhemoglobin dissociation curve
2. hyperkalemia
3. hypercalcemia
4. hypercarbia
23. D. Metabolic alkalosis is associated with decreased serum potassium and ionized calcium.
There is a compensatory respiratory acidosis, leading to hypercarbia. The oxyhemoglobin curve
is shifted to the left, impairing oxygen delivery to tissues. Bronchial tone is increased and may
lead to atelectasis. (See page 291: Metabolic Alkalosis.)
24. TRUE statements concerning the treatment of metabolic acidosis with HCO3
include:
1. It improves cardiovascular response to catecholamines.
2. It is clearly effective in improving outcome.
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3. The appropriate dose is 0.7 × (Body weight in kg) (24 - HCO3).

4. It reduces plasma ionized calcium.
24. D. Although many clinicians administer NaHCO3 to patients with persistent lactic acidosis,
there is little evidence that it is efficacious or improves outcome. NaHCO3 does not improve
cardiovascular response to catecholamines and reduces plasma ionized calcium. The initial
dose of HCO3 may be calculated as:
where 0.3 is the assumed distribution space of the HCO3. (See page 291: Metabolic Acidosis.)
25. Respiratory alkalosis and metabolic alkalosis both:

1. produce hypokalemia
2. decrease cerebral blood flow
3. potentiate digoxin toxicity
4. may be appropriately treated with HCl
25. B. Regardless of its origin, alkalosis may produce hypokalemia, hypocalcemia, cardiac
dysrhythmias, bronchoconstriction, and hypotension and may potentiate the toxicity of digoxin.
Cerebral blood flow is reduced by acute hypocapnia; metabolic alkalosis may be compensated
by hypercapnia, causing increased cerebral blood flow. Only metabolic alkalosis may be
appropriately treated with an acid. (See page 293: Respiratory Alkalosis.)
26. Renal adaptation to hypovolemia and decreased cardiac output includes:

1. decreased renal vascular resistance
2. redistribution of blood flow from outer cortical to inner cortical nephrons
3. increased reabsorption of water and Na resulting from increased atrial natriuretic
hormone
4. increased reabsorption of water from the medullary collecting ducts
26. C. The renal response to hypovolemia and decreased cardiac output is to increase renal
vascular resistance and decrease the loss of Na and water. Blood is redistributed to the inner
cortical nephrons, which have longer loops of Henle that penetrate more deeply into the
hypertonic renal medulla. Increased antidiuretic hormone (ADH) release promotes water
reabsorption through medullary collecting ducts and cortical collecting tubules. Aldosterone
promotes Na reabsorption, primarily in the distal tubules. The response to hypovolemia also
includes suppression of the release of atrial natriuretic hormone. The increased release of
renin promotes conversion of angiotensinogen to angiotensin I. (See page 297: Regulation of
Extracellular Fluid Volume.)
27. TRUE statements concerning fluid resuscitation and the brain include:
1. The cerebral capillary membrane is highly impermeable to protein.
2. Hyperglycemia may aggravate ischemic brain injuries.
3. Normal saline is superior to lactated Ringer's solution in the context of brain injury.
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4. Cerebral edema is an early sign of reduced plasma protein.
27. A. The osmolality of replacement fluid is very important in the presence of brain injury.
Lactated Ringer's solution is slightly hypo-osmotic relative to serum and thus may be associated
with increased cortical water content. Hypertonic solutions may exert favorable effects on
cerebral hemodynamics. The benefit usually is transient, and hypertonic therapy may be
associated with complications, including subdural hematoma. The cerebral capillary membrane
(the blood–brain barrier) is highly impermeable to protein, and oncotic pressure exerts little, if
any, effect on brain water accumulation. Hyperglycemia may aggravate ischemic brain injury.
(See page 302: Implications of Crystalloid and Colloid Infusions on Intracranial Pressure.)
28. Which of the following statements concerning abnormal Na+ concentrations is/are
TRUE&quest;
1. A decrease in plasma Na + leads to a decrease in intracellular brain water.

2. Hyponatremia may result from inappropriate antidiuretic hormone (ADH) secretion.
3. Mannitol may result in hypernatremia in the presence of a high serum osmolality.
4. Absorption of irrigant solution during transurethral resection of the prostate may result
in hyponatremia in the presence of a high serum osmolality.
28. C. Although the blood–brain barrier is poorly permeable to Na, water equilibrates rapidly.
Thus, acute hyponatremia causes a prompt increase in intracellular brain water. An acute
lowering of serum Na+ concentration may be induced by mannitol, sorbitol, and other non-Na
solutes, which do not diffuse freely across cell membranes and may cause an increase in
extracellular volume. Hyponatremia likewise may result from high levels of ADH. (See page 304:
Sodium.)
29. TRUE statements concerning hypermagnesemia include:

1. The therapeutic range for treatment of pre-eclampsia is between 15 and 18 mg/dL.
2. Heart block commonly is noted at 18 mg/dL.
3. Hypotension is not noted until concentrations are 13 mg/dL.
4. Areflexia often is noted by 12 mg/dL.
29. C. Normal serum Mg2+ ranges between 1.8 and 2.4 mg/dL (0.8–1.2 mmol/L; 1.6–2.4
mEq/L). The therapeutic range for treatment of pre-eclampsia is between 5 and 8 mg/dL.
Symptoms that develop above 3 mg/dL: hypotension (>3 mg/dL), hyporeflexia (>5 mg/dL),
somnolence (>8.5 mg/dL), areflexia and respiratory insufficiency (>12 mg/dL), heart block and
respiratory paralysis (>18 mg/dL), and cardiac arrest (>24 mg/dL). (See page 320: Magnesium
and page 321: Table 14-23.)
30. Which of the following statements concerning diabetes insipidus is/are

TRUE&quest;
1. It is more common after pituitary surgery.
2. Central diabetes insipidus is exacerbated by desmopressin.
3. In nephrogenic diabetes insipidus, the collecting ducts are resistant to antidiuretic
hormone (ADH).
105 / 494
4. It often results in hyponatremia.
30. B. Diabetes insipidus is associated with a loss of free water. It may be central in origin, with
decreased ADH secretion; this has an increased incidence after pituitary surgery. It may also be
peripheral in origin (nephrogenic), with the collecting ducts being resistant to ADH. Both the
central and peripheral forms lead to hypernatremia. Treatments include water replacement,
desmopressin (DDAVP), vasopressin, and drugs that stimulate ADH release (chlorpropamide,
clofibrate, thiazide diuretics). (See page 304: Sodium.)
31. Which of the following statements concerning regulation of serum potassium

levels is/are TRUE&quest;
1. Aldosterone increases potassium excretion.
2. Potassium excretion is increased in the presence of nonreabsorbable anions in the
renal luminal fluid.
3. Insulin causes an intracellular shift of potassium.
4. Epinephrine and exogenous β 2-agonists cause an extracellular shift of potassium.
31. A. Aldosterone increases renal reabsorption of Na + and excretion of K+. Renal excretion of
K+ is also increased by high urinary flow rates and the presence in the renal tubular fluid of
nonreabsorbable anions such as carbenicillin and phosphates. An intracellular shift of K+ is
caused by insulin, alkalosis, and β 2-agonists. (See page 311: Potassium.)
32. Which of the following statements concerning hypokalemia is/are TRUE&quest;

1. The ratio of intracellular to extracellular potassium remains relatively stable with
chronic potassium loss.
2. As a general rule, a decrease of 1.0 mEq/L represents a total body deficit of 200 to
300 mEq.
3. Both metabolic and respiratory alkalosis lead to decreases in plasma potassium
concentration.
4. Hypothermia may cause acute hypokalemia.
32. E. Chronic potassium loss that causes a 1.0-mEq/L decrease of plasma K + is typically
associated with a total body deficit of 200 to 300 mEq. However, in contrast to the
hyperpolarization that accompanies an acute loss, the ratio of intracellular to extracellular K+
remains relatively stable during a chronic loss. An intracellular shift of K+ (and hypokalemia)
may accompany respiratory and metabolic alkalosis and severe hypothermia; the changes
resolve upon correction of alkalosis and rewarming. (See page 311: Potassium.)
33. Changes associated with hypokalemia include:

1. hyperpolarization of cardiac cells
2. ST segment depression
3. re-entrant arrhythmias
4. exacerbation of digitalis toxicity
33. E. Acute hypokalemia causes hyperpolarization of the cardiac cell, which may lead to
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ventricular escape activity, re-entrant arrhythmias, and delayed conduction, with potentiation of
digitalis-induced effects. Common signs include first-degree atrioventricular block and ST
segment depression. (See page 311: Potassium.)
34. Which of the following statements concerning hyperkalemia is/are TRUE&quest;

1. It may be treated with triamterene.
2. It may result from mineralocorticoid deficiency.
3. It may be treated with angiotensin-converting enzyme (ACE) inhibitors.
4. Furosemide promotes kaliuresis.
34. C. A mineralocorticoid deficiency may lead to hyperkalemia. Likewise, administration of a
drug (e.g., ACE inhibitor) that reduces the release of aldosterone or opposes the effects of
aldosterone (e.g., triamterene or spironolactone) causes an increase in K+ levels. These
effects may be offset by a drug that promotes kaliuresis (e.g., furosemide). They may also be
treated with mineralocorticoid supplementation. (See page 311: Potassium.)
P.61
35. Effects of hyperkalemia include:
1. tall, peaked T waves
2. shortened P-R interval
3. widened QRS complex
4. peaked P waves
35. B. With progressive hyperkalemia, the electrocardiogram shows tall, peaked T waves
followed by a prolonged P-R interval and then a decrease in P-wave height. These changes
may progress to widening of the QRS complex and asystole. The effects are exacerbated by
hyponatremia, hypocalcemia, acidosis, and digitalis toxicity. (See page 311: Potassium.)
36. Symptomatic hyperkalemia may be treated with:

1. calcium chloride
2. NaHCO3
3. regular insulin
4. β 2-agonists
36. E. Serum K+ concentrations may be acutely lowered by administration of NaHCO3 (50–100

mEq), 5 to 10 U of regular insulin administered intravenously with 50 mL of 50% glucose, β 2-
adrenergic agonists, or furosemide (or related diuretics). Acute therapy may also include
calcium chloride, which depresses the membrane threshold potential. More delayed forms of
therapy include Na polystyrene sulfonate resin (Kayexalate) exchanges. (See page 311:
Potassium.)
37. TRUE statements about ionized calcium include:

1. The ionized calcium concentration in the extracellular fluid (ECF) is approximately 1.0
mM.
107 / 494
2. Its concentration is increased by increased parathyroid hormone activity.
3. Its concentration may be decreased by hyperphosphatemia.
4. Its concentration is decreased by acidemia.
37. A. The concentration of free calcium in the ECF is normally 1 to 1.25 mM. Because calcium
is divalent, this corresponds to 2.0 to 2.5 mEq/L. The remaining 50% of extracellular calcium is
protein bound (40%) or chelated (10%). Parathyroid hormone helps regulate the concentration
of the physiologically active (ionized) form and increases plasma calcium levels. Calcium may
be lowered by increased phosphate. Hyperphosphatemic hypocalcemia results from calcium
precipitation and suppression of calcitriol synthesis. Whereas acute acidemia decreases
protein-bound calcium (i.e., increases ionized calcium), acute alkalemia increases protein-
bound calcium (i.e., decreases ionized calcium). (See page 314: Calcium.)
38. TRUE statements concerning hypocalcemia include:

1. It may cause increased sensitivity to digitalis.
2. It does not necessarily occur after transfusion, even if 5 U of blood is infused within 1
hour.
3. It may cause Q-T shortening.
4. It may cause laryngeal spasm.
38. C. Hypocalcemia causes increased neuronal membrane irritability and tetany, as
demonstrated by eliciting the Chvostek or Trousseau sign. It causes Q-T and ST prolongation,
T-wave inversion, and insensitivity to digitalis. Hypocalcemia may cause laryngeal spasm after
parathyroid removal. In massive transfusion, citrate may produce hypocalcemia by chelating
calcium. However, a healthy, normothermic adult with intact hepatic and renal function can
adequately metabolize the citrate provided (without becoming hypocalcemic) when 5 U of blood
is infused in 1 hour. When citrate clearance is decreased or when blood transfusion rates are
rapid (e.g., 0.5–2 mL/kg/min), severe hypocalcemia can occur. (See page 314: Calcium.)
39. TRUE statements about hypercalcemia include:

1. Severe symptoms are generally noted when the total serum calcium concentration is
above 13 mg/dL.
2. Symptoms include lethargy, anorexia, nausea, and polyuria.
3. Cardiovascular effects include hypertension, heart block, and cardiac arrest.
4. A patient with hypercalcemia typically is helped by infusion of NaCl.
39. E. Patients with moderate hypercalcemia (total serum calcium, 11.5–13 mg/dL) may show
symptoms of lethargy, anorexia, nausea, and polyuria. Severe hypercalcemia (total serum
calcium >13 mg/dL) is associated with severe neuromyopathic symptoms (including muscle
weakness, depression, impaired memory, emotional lability, lethargy, stupor, and coma), renal
calcium salt precipitation (nephrocalcinosis), and cardiovascular changes (hypertension,
arrhythmias, heart block, cardiac arrest, and digitalis sensitivity). General supportive treatment
includes hydration, correction of associated electrolyte abnormalities, removal of offending
drugs, and dietary calcium restriction. Infusion of 0.9% saline will dilute serum calcium, reverse
Na and water depletion, and promote renal excretion. Other treatments include calcitonin,
mithramycin, and etidronate disodium (a diphosphonate). (See page 314: Calcium.)
108 / 494
40. TRUE statements about altered phosphate concentrations include:
1. High concentrations promote deposition of calcium in the bone, soft tissues, and
kidneys.
2. Hypophosphatemia leads to muscle weakness, which may lead to decreased
ventilatory strength.
3. The serum concentration of phosphate decreases in response to acute alkalemia.
4. Rapid administration of phosphate to a patient with hypocalcemia may precipitate
more severe hypocalcemia.
40. E. The clinical features of hyperphosphatemia relate primarily to the development of
hypocalcemia and ectopic calcification. Hyperphosphatemia can promote calcification in vital
organs such as the kidneys and myocardium. Neurologic manifestations of hypophosphatemia
include paresthesias, encephalopathy, delirium, seizures, and coma. Hematologic abnormalities
include dysfunction of erythrocytes, platelets, and leukocytes. Muscle changes include
myopathies, with respiratory muscle failure and myocardial dysfunction. Phosphate should be
administered cautiously to hypocalcemic patients because of the risk of precipitating more
severe hypocalcemia. (See page 319: Phosphate.)
41. TRUE statements concerning hypomagnesemia include:
1. Symptoms generally develop when the serum magnesium (Mg2+) concentration is

below 1.0 mg/dL.
2. It predisposes to digitalis toxicity.
3. Rapid correction of hypermagnesemia may cause symptoms consistent with
hypocalcemia.
4. It predisposes to coronary artery spasm.
41. E. Normal Mg2+ levels in the plasma are approximately 1.7 mg/dL. Symptoms of
hypomagnesemia occur at levels below 1.0 mg/dL. The clinical features of hypomagnesemia,
similar to those of hypocalcemia, are characterized by increased neuronal irritability, tetany,
weakness, lethargy, muscle spasms, paresthesias, and depression. Severe hypomagnesemia
may induce cardiovascular abnormalities, including coronary artery spasm, cardiac failure,
dysrhythmias, hypotension, and increased myocardial sensitivity to digitalis. Rapid correction of
hypomagnesemia may cause symptoms consistent with hypocalcemia. (See page 320:
Magnesium.)
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Review of Clinical Anesthesia, 5e [Vishal] 15. Autonomic Nervous System
Chapter 15
Autonomic Nervous System
1. Which of the following statements concerning the sympathetic nervous system

(SNS) is TRUE&quest;
A. The preganglionic fibers originate in the gray column of the two lower cervical, 12
thoracic, and first lumbar segments of the spinal cord.
B. There are 22 paired sympathetic ganglia.
C. Preganglionic fibers only synapse with postganglionic fibers in ganglia at the level of
exit.
D. Preganglionic fibers may also synapse in a ganglion that can then traverse to the
adrenal gland.
E. All preganglionic fibers are unmyelinated fibers.
1. B. The preganglionic fibers originate from T1–T12 and L1–L3 in the gray intermediolateral
column. These fibers are myelinated nerve axons that leave the spinal cord with the motor
fibers to form the white communicating rami. These fibers enter the 22 paired sympathetic
ganglia. After entering these ganglia, the fibers may take three possible courses: they may
synapse with postganglionic fibers in the ganglion, they may move up and down the SNS to
another ganglion, or they may track through the sympathetic chain and exit without synapsing to
SNS collateral ganglia. The exception to this rule is the group of myelinated fibers that
terminate in the adrenal medulla without first synapsing in a ganglion. Many of the
postganglionic fibers pass from the lateral SNS chain back into the spinal nerves to form the
gray (unmyelinated) communicating rami at all levels of the spinal cord. They are distributed
distally to the sweat glands, pilomotor muscle, and blood vessels of the skin and muscle. (See
page 329: Sympathetic Nervous System or Thoracolumbar Division.)
2. Which of the following statements concerning postganglionic fibers of the

sympathetic nervous system (SNS) is TRUE&quest;
A. The postganglionic nerve cell bodies are located only in the paired lateral ganglia.
B. The celiac and inferior mesenteric ganglia are located along the spinal cord and are
considered part of a sympathetic paired ganglion.
C. All ganglia of the sympathetic chain are located closer to the spinal cord than the
organs they innervate.
D. Postganglionic myelinated fibers proceed from paired ganglia to the respective
organs.
E. Approximately 25% of the fibers in the average somatic nerve are sympathetic.
2. C. Postganglionic neuronal cell bodies of the SNS are located in the paired lateral ganglia or
unpaired collateral ganglia. The celiac and inferior mesenteric ganglia are considered to be
collateral ganglia. SNS ganglia are located primarily near the spinal cord rather than near the
organs they innervate. The postganglionic fibers are unmyelinated. The average somatic nerve
has approximately 8% sympathetic fibers. (See page 329: Sympathetic Nervous System or
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Thoracolumbar Division.)
3. Which of the following statements concerning the sympathetic nervous system

(SNS) is TRUE&quest;
A. The first four to five thoracic spinal segments generate fibers that converge to form
three special paired ganglia.
B. The middle cervical ganglion also is known as the stellate ganglion.
C. The stellate ganglion provides sympathetic innervation only to the head and neck.
D. The response of the SNS is very discrete.
E. One preganglionic fiber influences one postganglionic neuron.
3. A. The first four to five thoracic segments' preganglionic fibers form three specialized paired
ganglia: the superior cervical, middle cervical, and cervicothoracic ganglia. The latter is known
as the stellate ganglion. It is a fusion of the inferior cervical and first thoracic SNS ganglia. This
provides sympathetic innervation to the head, neck, upper extremities, heart, and lungs. The
response from sympathetic system activation is diffuse. The preganglionic neurons are fewer
than the postganglionic neurons. Hence, preganglionic fibers influence a number of
postganglionic neurons. (See page 329: Sympathetic Nervous System or Thoracolumbar
Division.)
4. Which of the following statements regarding the parasympathetic nervous system

(PNS) is TRUE&quest;
A. The sacral fibers originate from the white matter of the second, third, and fourth sacral
nerves.
B. Preganglionic fibers are myelinated fibers analogous to those in the sympathetic
nervous system (SNS) and terminate in ganglia next to the spinal cord.
C. The ratio of preganglionic to postganglionic fibers in the PNS is the same as in the
SNS.
D. Postganglionic neurons are located in or near the organ to be innervated.
E. Cranial nerve X has the least innervation of all PNS nerves.
4. D. The PNS consists of preganglionic and postganglionic neurons. The preganglionic nerve
fibers originate in cranial nerves III (oculomotor), VII (facial), IX (glossopharyngeal), and X
(vagus) nerves. In addition, fibers originate from the intermediolateral horn of the second, third,
and fourth sacral nerves. Preganglionic nerve fibers pass directly to the organ that is
innervated. Postganglionic neurons are located in or near the organ to be innervated.
Therefore, postganglionic innervation is limited, and responses are discrete. Cranial nerve X
(vagus) accounts for 75% of the PNS activity. The ratio of postganglionic to preganglionic fibers
in many organs appears to be 1:1 to 3:1 compared with the 20:1 found in the SNS system. (See
page 330: Parasympathetic Nervous System or Craniosacral Division.)
5. All of the following are functions of the autonomic innervation of the heart EXCEPT:
A. The autonomic nervous system (ANS) changes the heart rate (chronotropism).
B. The ANS changes the strength of contraction (inotropism).
C. The ANS modulates coronary blood flow.
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D. There is parasympathetic innervation of the ventricles of the heart.
E. The vagus affects the sinoatrial (SA) and atrioventricular (AV) nodes.
5. D. The heart is well supplied by both the SNS and parasympathetic nervous system (PNS).
These fibers are responsible for changing the rate of the heart (chronotropism), changing the
strength of contraction (inotropism), and modulating coronary blood flow. PNS innervation is to
the SA and AV nodes. There is no PNS supply to the ventricles. (See page 330: Autonomic
Innervation: Heart.)
6. Which of the following statements regarding the autonomic nervous system (ANS)
and peripheral circulation is TRUE&quest;
A. The sympathetic nervous system (SNS) and parasympathetic nervous system (PNS)
are equally distributed in the peripheral circulation.
B. Distribution is equal among all tissues.
C. SNS stimulation of the coronary arteries may produce vasoconstriction or
vasodilation, depending on the predominant receptor activity.
D. Vascular tone is predominantly controlled by PNS activity.
E. Local autoregulatory factors do not influence coronary vascular tone.
6. C. The SNS is the predominant regulator of the peripheral circulation; PNS innervation is
minimal. The SNS may cause vasodilation or vasoconstriction, depending on receptor activity.
Distribution of the SNS is not equal among all organs. The skin, kidneys, spleen, and
mesentery have extensive SNS distribution; the heart, brain, and muscles have less. Vascular
tone is highly influenced by local factors such as metabolites and hormones. Blood vessels
have differing sensitivities to local or neurogenic tone. Local autoregulation is predominantly at
the precapillary and postcapillary sphincters. (See page 331: Peripheral Circulation.)
P.66
7. All of the following statements about neurotransmission in the autonomic nervous
system (ANS) are true EXCEPT:
A. The sympathetic nervous system (SNS) and parasympathetic nervous system (PNS)
are commonly designated as adrenergic and cholinergic, respectively.
B. In the PNS, the postganglionic receptors secrete acetylcholine (Ach).
C. Norepinephrine is the only neurotransmitter of the SNS at the postganglionic site.
D. The preganglionic neurotransmitter is Ach in both the PNS and the SNS.
E. Terminations of postganglionic fibers are anatomically and physiologically similar in
both the SNS and PNS.
7. C. The SNS and PNS are designated as adrenergic and cholinergic, respectively. In the
PNS, Ach is secreted at the postganglionic receptor site. In the SNS, norepinephrine is the main
neurotransmitter at postganglionic sites, with the exception of sweat glands. The preganglionic
neurotransmitter for both the PNS and SNS is Ach. The postganglionic fibers of the SNS and
PNS are anatomically and physiologically similar. The terminals branch out into terminal effector
plexuses. One terminal branches to thousands of effector cells. The terminal ending is called a
varicosity. Each varicosity contains vesicles within which the neurotransmitter is stored. (See
page 331: Autonomic Nervous System: Neurotransmission; page 332: Parasympathetic
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Nervous System Neurotransmission; and page 332: Sympathetic Nervous System
Neurotransmission.)
8. Which of the following statements regarding the parasympathetic nervous system

(PNS) is TRUE&quest;
A. In addition to acetylcholinesterase, pseudocholinesterase also plays a significant role
in the termination of acetylcholine (Ach).
B. Acetylcholine is stored in presynaptic vesicles and is released in small amounts called
quanta.
C. After it is released, Ach is taken up by the presynaptic membrane for release again.
D. Drugs that alter calcium release do not affect the release of Ach because its release is
calcium independent.
E. Ach is formed by acetylation of choline by the enzyme acetylcholinesterase.
8. B. Ach was once thought to be the only neurotransmitter; however, it is now believed that
vasoactive intestinal peptide may play a role as a secondary neurotransmitter. Ach is formed
within the presynaptic membrane by acetylation of choline with acetylcoenzyme. This process is
catalyzed by choline acetyltransferase. The active product of this reaction, Ach, is stored in
presynaptic vesicles. The depolarization of the end plate results in mass quantum release of
Ach into the synaptic cleft. This release is dependent on calcium influx. Drugs that alter calcium
influx may decrease the release of Ach. Ach is removed by rapid hydrolysis by the enzyme
acetylcholinesterase. This enzyme is found in neurons, at the neuromuscular junction, and in
various other tissues of the body. A similar enzyme, pseudocholinesterase or plasma
cholinesterase, is also found throughout the body but only to a limited extent in nervous tissue.
It does not appear to be physiologically important in the termination of the action of Ach. Both
acetylcholinesterase and pseudocholinesterase hydrolyze Ach as well as other esters (e.g., the
ester-type local anesthetics), but they may be distinguished by specific biochemical tests. (See
page 332: Parasympathetic Nervous System Neurotransmission and page 332: Metabolism.)
9. All of the following statements regarding the sympathetic nervous system (SNS) are
true EXCEPT:
A. Epinephrine and norepinephrine are mediators of the peripheral SNS.
B. In the adrenal medulla, the preganglionic neurotransmitter is acetylcholine (Ach).
C. Chromaffin cells in the adrenal medulla are responsible for release of epinephrine and
norepinephrine.
D. The massive release of norepinephrine and epinephrine is the “fight or flight”
response and lasts approximately 10 times as long as local direct stimulation.
E. Equal amounts of epinephrine and norepinephrine are released during stimulation of
the adrenal medulla.
9. E. Epinephrine and norepinephrine are mediators of SNS peripheral activity. Adenosine
triphosphate may be an additional neurotransmitter. In the adrenal medulla, Ach is the primary
neurotransmitter at the preganglionic site. It causes release of norepinephrine and epinephrine
from the chromaffin cells. These cells are considered the postganglionic neurons. Stimulation of
the adrenal medulla results in massive release of epinephrine and norepinephrine, which lasts
10 times as long as local direct stimulation. Epinephrine release is greater in proportion to
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norepinephrine release. (See page 332: Sympathetic Nervous System Neurotransmission.)
10. Which of the following statements about catecholamines is TRUE&quest;

A. Circulating catecholamines are responsible for stimulating receptors in the central
nervous system during the “fight or flight” response.
B. The only brain catecholamine is dopamine.
C. Endogenous catecholamines are dopamine, epinephrine, and norepinephrine.
D. Catecholamines have only a direct effect on adrenergic receptors.
E. Intermediate precursors of catecholamine synthesis have no effect on adrenergic
receptors.
10. C. A catecholamine is a compound consisting of a catechol nucleus and amine site chain.
Endogenous catecholamines are dopamine, norepinephrine, and epinephrine. Epinephrine is
the precursor of norepinephrine synthesis and has an effect on adrenergic receptor sites.
Dopamine is the primary neurotransmitter of the brain. Catecholamines may have a direct or
indirect effect on receptors. The indirect effect is mediated through the release of stored
neurotransmitter. Direct effects are independent of norepinephrine release. Some drugs may
have a mixed mode of action. The brain contains both noradrenergic and dopaminergic
receptors, but circulating catecholamines do not cross the blood–brain barrier. The
catecholamines present in the brain are synthesized there. (See page 333: Catecholamines:
The First Messenger.)
11. All of the following statements regarding the autonomic receptors are true EXCEPT:
A. Acetylcholine (Ach) is the neurotransmitter in the parasympathetic nervous system
(PNS), at preganglionic receptors of the sympathetic nervous system (SNS), and at the
neuromuscular junction.
B. Muscarinic receptors in the myocardium are stimulated by Ach and inhibit the release
of norepinephrine.
C. The two subdivisions of cholinergic receptors are muscarinic and nicotinic.
D. Muscarinic stimulation causes tachycardia, inotropism, bronchodilation, and miosis.
E. Nicotinic receptors are located in the SNS.
11. D. Cholinergic receptors are subdivided into muscarinic and nicotinic receptors. The
nicotinic receptors are located at the preganglionic receptors of the SNS and PNS and at the
neuromuscular junction of striated muscle. Muscarinic receptors are primarily associated with
the postganglionic junctions of the PNS. PNS muscarinic stimulation causes bradycardia,
decreased inotropism, bronchoconstriction, miosis, salivation, gastrointestinal hypermotility, and
increased gastric acid secretion. Muscarinic receptors are also found on the presynaptic
membrane of sympathetic nerve terminals in the myocardium, coronary vessels, and peripheral
vasculature. These are referred to as adrenergic muscarinic receptors because of their
location; however, they are stimulated by Ach. Stimulation of these receptors inhibits release of
norepinephrine in a manner similar to α 2 receptor stimulation. (See page 334: Receptors.)
12. Which of the following statements regarding the α receptors is TRUE&quest;

A. The α 1 receptors result in no positive inotropic effect on the myocardium.
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B. Whereas the α 1 receptors appear to be confined to the postsynaptic membrane, the
α 2 receptors are located on presynaptic and postsynaptic membranes.
C. The presynaptic α 2 receptors do not play a significant role in reducing sympathetic
outflow.
D. The α 1 agonists, such as phenylephrine, have an effect on coronary resistance by
creating vasoconstriction and hence consistently contribute to coronary ischemia.
E. Epinephrine is a more potent venoconstrictor than norepinephrine.
12. B. The α 1 receptors are believed to have a positive inotropic effect on cardiac tissues in
most mammals. Enhanced α 1 activity may play a role in malignant arrhythmias. Drugs such as
prazosin may have antiarrhythmic properties. The α 2 receptors are located at both the
presynaptic and postsynaptic membranes. The α 1 receptors are located postsynaptically. The
ratio of postsynaptic α 1 to α 2 receptors is approximately 1:1. The α 2 presynaptic receptors
play a significant role in reducing sympathetic outflow. This results in decreases in systemic
vascular resistance, cardiac output, and heart rate. In the CNS, these receptors may contribute
to analgesia and sedation. The α 1 receptors in the epicardial vessels only contribute 5% of the
total resistance in the normal coronary circulation. Therefore, phenylephrine probably has
minimal effect on coronary resistance. Norepinephrine is the most potent venoconstrictor. (See
page 335: α -Adrenergic Receptors.)
13. All of the following statements regarding β -adrenergic receptors are true EXCEPT:
A. The β receptors are found in both presynaptic and postsynaptic membranes.
B. Activation of the presynaptic β 2 receptor has the same physiologic response as
antagonism of the presynaptic α 2 receptor.
C. The postsynaptic β 2 receptors are noninnervated and respond to circulating
catecholamines.
D. The β 2 receptors are primarily located postsynaptically in the myocardium, sinoatrial
node, and ventricular conduction system.
E. The β 1 receptors are innervated receptors responding to neuronally released
norepinephrine.
13. D. β 1 and β 2 are the two subtypes of β -adrenergic receptors. The β 1 receptors are
located in the myocardium, sinoatrial node, and ventricular conduction system. They are
innervated and respond to neuronally released norepinephrine. The β 1 receptors are located
only postsynaptically. The β 2 receptors have the same distribution but are presynaptic. The
effects of activation of presynaptic β 2 receptors are diametrically opposed to α 2 presynaptic
receptors. The β 2 presynaptic receptors accelerate endogenous norepinephrine release.
Antagonism of these receptors results in a physiologic response that is similar to activation of
presynaptic α 2 receptors. (See page 339: β -Adrenergic Receptors.)
14. Which of the following statements regarding the β receptors in the heart and
peripheral vessels is FALSE&quest;
A. Both the β 1 and β 2 receptors are coupled to adenylate cyclase.
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P.67
B. Increased catecholamine levels in heart failure leads to a larger downregulation of β 2
receptors compared with β 1 receptors.
C. Whereas the inotropic effect of epinephrine is mediated via β 1 and β 2 receptors, the
inotropic effect of norepinephrine is mediated entirely through β 1 receptors.
D. The postsynaptic β 1 receptors are predominantly found in the myocardium, sinoatrial
node, and ventricular conduction system. The β 2 receptors have the same distribution
but are presynaptic.
E. The β 2 receptors approximate 20% to 30% of β receptors in the myocardium.
14. B. Both the β 1 and β 2 receptors are functionally coupled to adenylate cyclase, suggesting
a similar involvement in the regulation of inotropism and chronotropism. The postsynaptic β 1
receptors are distributed predominantly to the myocardium, the sinoatrial node, and the
ventricular conduction system. The β 2 receptors have the same distribution but are
presynaptic. Activation of the presynaptic β 2 receptor accelerates the release of
norepinephrine into the synaptic cleft. The β 2 receptor approximates 20% to 30% of the β
receptors in the ventricular myocardium and up to 40% of the β receptors in the atrium.
Whereas the effect of norepinephrine on inotropism in the normal heart is mediated entirely
through the postsynaptic β 1 receptor, the inotropic effects of ephedrine are mediated through
both the β 1 and β 2 myocardial receptors. (See page 339: β Receptors in the Cardiovascular
System.)
15. Which of the following statements regarding dopamine receptors is TRUE&quest;

A. The dopamine-1 receptors are located postsynaptically.
B. The dopamine-2 receptors are located only presynaptically.
C. The dopamine receptors have been located in the myocardium and are responsible
for increased inotropism.
D. The dopamine receptors inhibit the release of prolactin in the hypothalamus.
E. The dopamine receptors located on vascular smooth muscle of the kidneys and
mesentery produce regional vasoconstriction.
15. A. The dopamine receptors are of two types, dopamine-1 and dopamine-2. Whereas the
type 1 receptors are located postsynaptically, the type 2 receptors are located both
presynaptically and postsynaptically. Dopamine receptors have not been located in the
myocardium. They are located in the hypothalamus, where they enhance the release of
prolactin. They also are located in the basal ganglia, where they coordinate motor function.
Dopamine receptors in the smooth muscle of the kidneys and mesentery produce vasodilation,
resulting in increased blood flow to these organs. (See page 340: Dopaminergic Receptors.)
16. Which of the following statements regarding the baroreceptors is TRUE&quest;

A. Impulses from the carotid sinus and aortic arch reach the vasomotor center through
the hypoglossal and the vagal nerve, respectively.
B. Increased sensory input from the baroreceptors caused by decreased blood pressure
116 / 494
inhibits sympathetic nervous system (SNS) effector traffic.
C. The Valsalva maneuver can be used to identify patients at risk for autonomic nervous
system (ANS) instability.
D. Dysfunction in the SNS is suspected if prolonged hypertension develops during the
forced expiration phase of the Valsalva maneuver.
E. The presence of “overshoot” in blood pressure at the end of the Valsalva maneuver
indicates dysfunction of the sympathetic nervous system (SNS).
16. C. Impulses from the carotid sinus and aortic arch reach the medullary vasomotor center by
the glossopharyngeal and vagus nerves, respectively. Increased sensory traffic from the
baroreceptors, caused by increased blood pressure, inhibits SNS effector traffic. The relative
increase in vagal tone produces vasodilation, slowing of the heart rate, and a lowering of the
blood pressure. Real increases in vagal tone occur when the blood pressure exceeds normal
limits. The arterial baroreceptor reflex can best be demonstrated by the Valsalva maneuver. The
arterial blood pressure increases momentarily as the intrathoracic blood is forced into the heart
(preload). Sustained intrathoracic pressure diminishes venous return, reduces the cardiac
output, and decreases the blood pressure. Reflex vasoconstriction and tachycardia ensue. The
blood pressure returns to normal with release of the forced expiration but then briefly
“overshoots” because of the vasoconstriction and increased venous return. A slowing of the
heart rate accompanies the overshoot in pressure. The Valsalva maneuver has been used to
identify patients at risk for ANS instability. Dysfunction of the SNS is implicated if exaggerated
and prolonged hypotension develops during the forced expiration phase. In addition, the
overshoot at the end of the Valsalva maneuver is absent. (See page 341: Baroreceptors.)
17. Which of the following is the principal site of autonomic nervous system (ANS)
organization and long-term blood pressure control&quest;
A. Cerebral cortex
B. Hypothalamus
C. Medulla
D. Pons
E. Cerebellum
17. B. The cerebral cortex is the highest level of ANS integration. Fainting at the sight of blood
is an example of this higher level of somatic and ANS integration. The principal site of ANS
organization is the hypothalamus. Long-term blood pressure control, reactions to physical and
emotional stress, sleep, and sexual reflexes are regulated through the hypothalamus. The
medulla oblongata and pons are the vital centers of acute ANS organization. Together, they
integrate momentary hemodynamic adjustments and maintain the sequence and automaticity of
ventilation. (See page 327: Autonomic Nervous System.)
18. In which of the following organs do the preganglionic fibers pass directly without
synapsing in a ganglion&quest;
A. Sweat glands
B. Adrenal gland
C. Spleen
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D. Liver
E. Pancreas
18. B. The efferent sympathetic nervous system (SNS) is referred to as the thoracolumbar
nervous system. The preganglionic fibers of the SNS (thoracolumbar division) originate in the
intermediolateral gray column of the 12 thoracic (T1-T12) and the first three lumbar segments
(L1-L3) of the spinal cord. The myelinated axons of these nerve cells leave the spinal cord with
the motor fibers to form the white (myelinated) communicating rami. The rami enter one of the
paired 22 sympathetic ganglia at their respective segmental levels. Upon entering the
paravertebral ganglia of the lateral sympathetic chain, the preganglionic fiber may follow one of
three courses: synapse with postganglionic fibers in ganglia at the level of exit; course upward
or downward in the trunk of the SNS chain to synapse in ganglia at other levels; or track for
variable distances through the sympathetic chain and exit without synapsing to terminate in an
outlying, unpaired SNS collateral ganglion. The adrenal gland is an exception to the rule. The
preganglionic fibers pass directly into the adrenal medulla without synapsing in a ganglion. (See
page 329: Sympathetic Nervous System.)
19. Which of the following statements about dobutamine (DBT) is FALSE&quest;

A. Dobutamine does not cause norepinephrine release or stimulate dopamine receptors.
B. Dobutamine is a synthetic catecholamine modified from the classic inodilator
isoproterenol.
C. Dobutamine increases the heart rate more than epinephrine for a given increase in
cardiac output.
D. Dobutamine is a coronary artery constrictor.
E. Dobutamine is highly controllable, with a half-life of 2 minutes.
19. D. Dobutamine is a synthetic catecholamine modified from the classic inodilator
isoproterenol. It does not cause norepinephrine release or stimulate dopamine receptors.
Dobutamine possesses weak α 1 agonism, which can be unmasked by β blockade as a prompt
and dramatic increase in blood pressure. Dobutamine increases the heart rate more than
epinephrine for a given increase in cardiac output. Dobutamine is a coronary vasodilator.
Dobutamine is highly controllable, with a half-life of 2 minutes. (See page 352: Dobutamine.)
20. Which of the following statements is FALSE regarding fenoldopam&quest;

A. Fenoldopam is a selective dopamine-1 agonist with no α or β receptor activity.
B. Fenoldopam has direct natriuretic and diuretic properties.
C. Concomitant use with beta-blockers increases the effective dose of fenoldopam.
D. Fenoldopam has an elimination half-life of 5 minutes.
E. Fenoldopam reduces mortality in patients with acute kidney injury.
20. C. Fenoldopam, a benzazepine derivative, is a selective dopamine-1 agonist with no α or β
receptor activity. Intravenous fenoldopam has direct natriuretic and diuretic properties and
promotes an increase in creatinine clearance. Fenoldopam has an elimination half-life of 5
minutes. In a recent and complete meta-analysis, Landoni et al suggest that fenoldopam
reduces the risk of acute tubular necrosis, the need for renal replacement therapy, and overall
mortality in patients with acute kidney injury. Concomitant use with beta-blockers reduces the
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effective dose of fenoldopam. (See page 354: Fenoldopam.)
21. Which of the following symptoms is not included under clonidine withdrawal
syndrome&quest;
A. Hypertension
B. Headache
C. Tachycardia
D. Somnolence
E. Sweating
21. D. One of the more worrisome complications of chronic clonidine use is a withdrawal
syndrome upon acute discontinuation of the drug. This usually occurs about 18 hours after
discontinuation. The signs and symptoms are hypertension, tachycardia, insomnia, flushing,
headache, apprehension, sweating, and tremulousness. It lasts for 24 to 72 hours and is most
likely to occur in patients taking more than 1.2 mg/day of clonidine. The withdrawal syndrome
has been noted postoperatively in patients withdrawn from clonidine before surgery. The
withdrawal syndrome can be confused with anesthesia emergence symptoms, particularly in
patients with uncontrolled hypertension. Absent the availability of the oral route in the surgical
patient, withdrawal can be treated with transdermal clonidine or more rapidly with rectal
clonidine. (See page 354: Clonidine.)
22. Which of the following is/are the side effects of α- blockers&quest;
1. Hypotension
2. Orthostatic hypotension
3. Nasal stuffiness
4. Mydriasis
22. A. Drugs that bind selectively to α -adrenergic receptors block the action of endogenous
catecholamines or moderate the effects of exogenous adrenergics. The resultant effects may
be ascribed to either the blockade effect to α -adrenergic agonists or to unopposed β -
adrenergic receptor activity. The effect is smooth muscle relaxation. The prominent clinical
effects of α -blockers include hypotension, orthostatic hypotension, tachycardia, miosis, nasal
stuffiness, diarrhea, and inhibition of ejaculation. (See page 358: α- Antagonists.)
23. Which of the following is/are cardioselective beta-blockers&quest;

1. Atenolol
2. Esmolol
3. Metoprolol
4. Nadolol
23. A. Nonselective β -antagonists are referred to as first-generation β -blockers. These drugs
include propranolol, nadolol, sotalol, and timolol. Second-generation drugs are those
considered selective for β 1-adrenergic blockade and include atenolol, esmolol, and metoprolol.
119 / 494
(See page 359: β- Antagonists.)
P.68
24. Which of the following is/are interactions of the autonomic nervous system (ANS)
with endocrine regulatory systems&quest;
1. Release of antidiuretic hormone secondary to changes in plasma osmolality
2. α - or β -Receptor stimulation in the pancreas
3. Release of renin from the juxtaglomerular apparatus
4. Adrenal cortical function
24. E. The ANS is related to several endocrine systems that control blood pressure and
homeostasis. Antidiuretic hormone (ADH) is secreted by the hypothalamus in response to
changes in plasma osmolality. However, many factors, such as stress, pain, hypoxia,
anesthesia, and surgery, may stimulate release of ADH. Whereas β stimulation of the pancreas
increases insulin release, α stimulation decreases it. The complex rennin–angiotensin system
modulates blood pressure and water and electrolyte homeostasis. Renin release from the
juxtaglomerular complex acts on plasma angiotensinogen II, a potent vasoconstrictor. The ANS
is also closely linked to adrenocortical function; glucocorticoids modulate epinephrine synthesis.
(See page 342: Interaction with Other Regulatory Systems.)
25. Which of the following is/are mechanisms by which drugs may act on prejunctional
membranes&quest;
1. Interference with transmitter synthesis
2. Interference with transmitter storage
3. Interference with transmitter release
4. Interference with the shape or composition of the receptor
25. A. Drugs interact at the prejunctional membrane by a number of different mechanisms,
including interfering with transmitter synthesis, storage, release, or reuptake or modifying
neurotransmitter metabolism. Drugs acting at postjunctional sites may directly stimulate
postjunctional receptors and interfere with the transmitter agonist at postjunctional receptors.
(See page 343: Mode of Action.)
26. Features of ganglionic drugs include:

1. nonselective drugs that affect both the sympathetic nervous system (SNS) and
parasympathetic nervous system (PNS)
2. unpredictable side effects that limit their usefulness
3. nicotine as the prototypical agonist
4. histamine release at low doses
26. A. Autonomic ganglia are similar in that acetylcholine is the primary neurotransmitter in both
the PNS and the SNS. Most ganglionic drugs are nonselective. This property makes them
undesirable and unpredictable and thus limits their clinical usefulness. Nicotine is the
prototypical agonist. It stimulates autonomic ganglia and the neuromuscular junction at low
concentrations. In high doses, it creates blockade. (See page 343: Ganglionic Drugs.)
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27. Which of the following is/are properties of trimethaphan&quest;
1. It is a drug equivalent to nitroprusside.
2. It has a short duration of action because of hydrolysis by pseudocholinesterase.
3. It causes pupillary constriction.
4. It affects the ability of acetylcholine (Ach) to bind to receptor sites.
27. C. Trimethaphan is the only ganglionic blocker currently available in the United States. It
affects the ability of Ach to bind to receptor sites. Its side effects and short duration of action
limit its usefulness, and tachyphylaxis develops quickly. Pupillary dilation limits its use in
neurosurgical patients. It is not equivalent to nitroprusside. (See page 344: Antagonists.)
28. Which of the following statements regarding cholinomimetic drugs is/are

TRUE&quest;
1. There are three groups of these agents: esters, alkaloids, and anticholinesterases.
2. The choline esters (acetylcholine [Ach], methacholine, carbamylcholine, bethanechol)
make up the group of indirect agents.
3. Ach has no therapeutic application because of its diffuse action and rapid hydrolysis.
4. Choline esters other than Ach are metabolized at a faster rate.
28. B. Cholinomimetic drugs act where acetylcholine (Ach) is a neurotransmitter. There are
three groups of cholinergic drugs. The first two groups, which are direct muscarinic agents, are
the choline esters (Ach, methacholine, carbamylcholine, bethanechol) and the alkaloids
(pilocarpine, muscarine, arecoline). The third group consists of the indirect-acting agents: the
anticholinesterases (physostigmine, neostigmine, pyridostigmine, edrophonium, echothiophate).
Ach has a diffuse action and is rapidly hydrolyzed, so it has no therapeutic applications. Other
choline esters are more resistant to inactivation and therefore are more clinically useful. (See
page 344: Muscarinic Agonists.)
29. Which of the following statements regarding anticholinesterases is/are

TRUE&quest;
1. All anticholinesterases are tertiary amines and therefore readily cross the blood–brain
barrier.
2. The two types of anticholinesterase drugs are reversible and nonreversible.
3. Physostigmine is a quaternary ammonium compound that has no central muscarinic
stimulation.
4. The two types of anticholinesterase agents are categorized by their site of
cholinesterase inhibition.
29. C. Anticholinesterase drugs are classified as reversible and nonreversible. They are divided
into two different types based on the site of inhibition on the cholinesterase enzyme. Agents that
inhibit at the esteratic site are called acid-transferring inhibitors . These drugs are long acting
(physostigmine, neostigmine, pyridostigmine). Drugs acting at the anionic site are called
prosthetic, competitive inhibitors. These drugs tend to be short acting (e.g., edrophonium).
Physostigmine is a tertiary amine and therefore crosses the blood–brain barrier. It is useful for
reversing atropine poisoning but is not useful for reversing neuromuscular blockade. (See page
345: Indirect Cholinomimetics.)
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30. Which of the following statements regarding anticholinesterase is/are true&quest;

1. Most of the indirect-acting drugs inhibit both cholinesterase and
pseudocholinesterase.
2. Muscarinic activity is evoked at higher concentrations than are necessary to produce
the desired nicotinic effect.
3. Excess accumulation of acetylcholine (Ach) at the motor end plate produces a
depolarizing block similar to succinylcholine or high doses of nicotine.
4. Edrophonium is an esteratic drug (works on the esteratic site of cholinesterase).
30. B. The indirect-acting cholinomimetic drugs are of greater importance to anesthesiologists
than are the direct-acting cholinergic drugs. These drugs produce cholinomimetic effects
indirectly as a result of inhibition or inactivation of the enzyme acetylcholinesterase, which
normally destroys Ach by hydrolysis. They are referred to as cholinesterase inhibitors or
anticholinesterases. Most of these drugs inhibit both acetylcholinesterase and
pseudocholinesterase. The most prominent pharmacologic side effects of the
anticholinesterase drugs are muscarinic. Their most useful actions are their nicotinic effects.
Muscarinic activity is evoked by lower concentrations of Ach than are necessary to produce the
desired nicotinic effect. For example, the anticholinesterase neostigmine reverses
neuromuscular blockade by increasing Ach concentration at the muscle end plate, a nicotinic
receptor. However, reversal of neuromuscular blockade can usually be produced safely only
when the patient has been protected by atropine or another muscarinic antagonist. This
prevents the untoward muscarinic effects of bradycardia, hypotension, bronchospasm, and
intestinal spasm. Conversely, neuromuscular paralysis may be produced or increased if
excessive anticholinesterase is used. Excess accumulation of Ach at the motor end plates
produces a depolarizing block similar to that produced by succinylcholine or nicotine. The
differences in duration of various anticholinesterases apparently depend on whether they inhibit
the anionic or esteratic site of acetylcholinesterase. Therefore, the anticholinesterase drugs
have also been pharmacologically subdivided. Drugs that inhibit the anionic site are called
competitive inhibitors. Their action is the result of competition between the anticholinesterase
and Ach for the anionic site. These drugs tend to be short acting. Edrophonium is an example of
this type. (See page 345: Indirect Cholinomimetics.)
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Review of Clinical Anesthesia, 5e [Vishal] 16. Hemostasis & Transfusion Medicine
Chapter 16
Hemostasis and Transfusion Medicine
1. Which has the highest risk of ischemia under the conditions of isovolemic
hemodilution&quest;
A. Bowel
B. Heart
C. Lung
D. Liver
E. Kidney
1. B. With isovolemic hemodilution, blood flow to the tissues increases, but this increased blood
flow is not distributed equally to all tissue beds. Organs with higher extraction ratios (brain and
heart) receive disproportionately more of the increase in blood flow than organs with low
extraction ratios (muscle, skin, viscera). The redistribution of blood flow to the coronary
circulation is the principal means by which the healthy heart compensates for anemia. Under
basal conditions, the heart already has a high extraction ratio (50%–70% vs 30% in most
tissues) and the primary compensation for anemia involves cardiac work (increasing cardiac
output), so the heart must rely on redistributing blood flow to increase oxygen supply. These
factors make the heart the organ at greatest risk under conditions of isovolemic hemodilution.
When the heart can no longer increase either cardiac output or coronary blood flow, the limits of
isovolemic hemodilution are reached. Further decreases in oxygen delivery will result in
myocardial injury. (See page 379: Compensatory Mechanisms During Anemia.)
2. Which of the following is the most common infection associated with red blood cell
(RBC) transfusion&quest;
A. Hepatitis A
B. Human T-cell lymphotropic virus (HTLV-1 and HTLV-2)
C. Hepatitis C
D. Human immunodeficiency virus (HIV)
E. Hepatitis B
2. E. The rate of viral infectivity has decreased dramatically in the past 2 decades. In particular,
the advent of universal (in the United States) nucleic acid testing (NAT) for HIV and the
hepatitis C virus (HCV) has reduced the frequency of transmission of those agents to very low
levels (one in 2 million). Hepatitis B remains the greatest risk (currently about one in 350,000
donor exposures). Transmission of hepatitis A virus (HAV) by transfusion has been very rare.
Blood banks screen for HAV by history only, and there is no carrier state for this virus. HTLV-1
and HTLV-2 belong to the same retrovirus family as HIV. The incidence of clinical disease
resulting from transmitted virus appears to be very low, and the transmission rate is very low,
around one in 2.9 million. (See page 370: Infectious Risks Associated with Blood Product
Administration.)
3. Noninfectious risks associated with transfusion include all EXCEPT:

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A. hypothermia
B. dilutional coagulopathy
C. increase in 2,3 diphosphoglycerate
D. hyperkalemia
E. microaggregate delivery
3. C. Noninfectious risks associated with transfusion include hypothermia, dilutional
coagulopathy, hyperkalemia, and microaggregate delivery. A meta-analysis concluded that even
mild hypothermia increases blood loss. Hypothermia, after attempting to correct for covariates,
is an independent predictor of mortality in trauma patients. Hypothermia has been associated
with increased postoperative morbidity and mortality, including increased rates of postoperative
infection. Administration of large volumes of fluid deficient in platelets and clotting factors
results in coagulopathy as a consequence of dilution. Hazard exists if large volumes of stored
blood are administered rapidly. Although there is only 20 to 60 mL of plasma in a unit of packed
red blood cells, contemporary infusion devices allow blood to be transfused at rates of 500 to
1000 mL/ min. At these infusion rates, critical hyperkalemia can occur, and intraoperative
arrests have been documented. Microaggregates have been suspected in the pathogenesis of
pulmonary insufficiency after large volume transfusion. (See page 376: Other Noninfectious
Risks Associated with Transfusions.)
4. Which of the following is true regarding coagulation&quest;

A. Most clotting factors circulate in an active form.
B. Most clotting factors are synthesized extrahepatically.
C. von Willebrand factor and coagulation factor VIII combine to form factor IX.
D. Factors V and VIII have short storage half-lives.
E. Seven clotting factors are vitamin K dependent.
4. D. Most of the clotting factors circulate as inactive proenzymes. Most clotting factors are
synthesized by the liver. Factor VIII is actually a large two-molecule complex consisting of von
Willebrand factor and coagulant factor VIII. Four clotting factors (II, VII, IX, X) are vitamin K
dependent. Factors V and VIII have short storage half-lives. Factors V and VIII are also referred
to as the “labile factors” because their coagulant activity is not durable in stored blood.
Although packed red blood cells contain residual plasma with clotting factors, massive
transfusion with stored blood nonetheless lead to a dilutional coagulopathy because of
diminished activity of factors V and VII. (See page 386: The Coagulation Mechanism.)
5. Which of the following is not contained in cryoprecipitate&quest;

A. Factor VIII
B. Factor X
C. von Willebrand factor (vWF)
D. Fibrinogen
E. Fibronectin
5. B. Factor X is not contained in cryoprecipitate. Cryoprecipitate contains factor VIII, vWF,
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fibrinogen, fibronectin, and factor XIII. (See page 378: Blood Products and Transfusion
Thresholds: Cryoprecipitate.)
6. Which of the following is not a vitamin K–dependent factor&quest;

A. II
B. V
C. VII
D. IX
E. X
6. B. Most of the coagulation proteins are synthesized by the liver. Four of the clotting factors
(II, VII, IX, and X) require vitamin K for proper synthesis. (See page 386: The Coagulation
Mechanism.)
7. Which of the following is not a common cause of platelet dysfunction&quest;

A. Dialysis
B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Chronic liver disease
D. Disseminated intravascular coagulopathy (DIC)
E. Cardiopulmonary bypass (CPB)
7. A. The causes of thrombocytopenia may be categorized as follows: (1) inadequate
production by the bone marrow, (2) increased peripheral consumption or destruction (non
–immune mediated), (3) increased peripheral destruction (immune mediated), (4) dilution of
circulating platelets, and (5) sequestration. Bone marrow production of platelets may be
impaired in many ways. Chronic disease states such as uremia and liver disease may cause
bone marrow suppression. The many conditions that cause DIC also cause platelets to be
consumed or destroyed faster than they can be produced. Numerous medications are
administered expressly for the purpose of platelet inhibition to reduce the risk of myocardial
infarction, stroke, and other thromboembolic complications. These medications induce platelet
dysfunction by several mechanisms, including inhibition of cyclo-oxygenase, inhibition of
phosphodiesterase, adenosine diphosphate receptor antagonism, and blockade of the
glycoprotein IIb/IIIa receptor. Indomethacin, phenylbutazone, and all the NSAIDs similarly inhibit
cyclo-oxygenase. Platelets are subject to contact activation by the CPB circuit, thus causing
their numbers to decline. Platelet dysfunction is common in patients with uremia. The
accumulation of guanidinosuccinic acid and hydroxyphenolic acid is thought to contribute to this
dysfunction through interference with the platelet's ability to expose the PF3 phospholipid
surface. These compounds are dialyzable, so dialysis frequently improves the hemostatic
defect associated with uremia. (See page 398: Thrombocytopenia.)
8. Regarding autologous blood conservation strategies, which of the following
statements is FALSE&quest;
1. Regarding preoperative autologous donation, 4 U is typically the maximum possible
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donation.
2. Erythropoietin is often accepted by Jehovah's Witnesses.
3. Body weight of less than 100 lb is a relative contraindication to preoperative
autologous donation.
4. Acute normovolemic hemodilution may reduce the amount transfused by 3 to 4 U per
patient.
8. D. A recent meta-analysis reported that acute normovolemic hemodilution does not achieve
complete avoidance of allogeneic blood but that when transfusion is necessary, the amount
transfused is reduced by 1 to 2 U per patient. Erythropoietin, a recombinant product, is often
accepted by Jehovah's Witnesses, and its efficacy in that population has been demonstrated.
Severe aortic stenosis, significant coronary disease or myocardial dysfunction, and low initial
hematocrit and blood volume (body weight <110 lb) are relative contraindications to
preoperative autologous donation. If the patient's hemoglobin level, cardiac status, and general
condition permit, up to 4 U of blood can be donated at weekly intervals before surgery. (See
page 381: Blood Conservation Strategies: Autologous Donations.)
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9. Which of the following conditions may decrease the tolerance for anemia and
influence the red blood cell (RBC) transfusion threshold&quest;
1. Hyperthermia
2. Hypothermia
3. Myocardial dysfunction
4. High altitude
9. E. Ultimately, the decision to transfuse RBCs should be made based on the clinical judgment
that the oxygen-carrying capacity of the blood must be increased to prevent oxygen
consumption from outstripping oxygen delivery. Conditions that may decrease the tolerance for
anemia and influence the RBC transfusion threshold include factors that increase oxygen
demand, limit the ability to increase cardiac output, cause a left shift of the oxyhemoglobin
dissociation curve, and impair oxygenation. These factors include a wide range of states,
including hyperthermia, coronary artery disease and myocardial dysfunction, hypothermia, and
high altitude. (See page 383: Red Blood Cells and page 378: Table 16-7: Conditions That May
Decrease Tolerance for Anemia and Influence the Red Blood Cell Transfusion Threshold.)
10. Which of the following is/are TRUE concerning contemporary “cell saver”
devices&quest;
1. The salvaged blood is anticoagulated.
2. It returns blood with a hematocrit of 70% to 80%.
3. The red blood cells (RBCs) are separated by centrifugation.
4. It is a type of allogeneic transfusion.
10. B. Contemporary “intraoperative blood salvage” devices return blood with a hematocrit of
45% to 65%. These devices anticoagulate the salvaged blood as it leaves the surgical field,
separate the RBCs from other liquid and cellular elements by centrifugation, and then wash the
salvaged RBCs extensively with saline. The RBCs are typically returned to the patient
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suspended in saline in aliquots of 125 or 225 mL. (See page 381: Blood Conservation
Strategies: Perioperative Blood Salvage.)
11. Which of the following is/are important factors in a patient's ability to compensate
for the anemia associated with isovolemic hemodilution&quest;
1. Leftward shift in the oxyhemoglobin dissociation curve
2. Decrease in systemic vascular resistance (SVR)
3. Decrease in oxygen extraction ratio
4. Increase in cardiac stroke volume
11. C. When anemia develops but blood volume is maintained (isovolemic hemodilution), four
compensatory mechanisms serve to maintain oxygen delivery: an increase in cardiac output, a
redistribution of blood flow to organs with greater oxygen requirements, increases in the
extraction ratios of some vascular beds, and alteration of oxygen-hemoglobin binding to allow
the hemoglobin to deliver oxygen at lower oxygen tensions. With isovolemic hemodilution,
cardiac output increases primarily because of an increase in stroke volume brought about by
reductions in SVR. Organs with higher extraction ratios (brain and heart) receive
disproportionately more of the increase in blood flow than organs with low extraction ratios
(muscle, skin, viscera). Increasing oxygen extraction ratio is thought to play an important
adaptive role when the normovolemic hematocrit decreases below 25%. The oxyhemoglobin
dissociation curve can be shifted to the left or right. When the curve is shifted to the left, the
hemoglobin molecule is more “stingy” and requires lower oxygen partial pressures to release
oxygen to the tissues. By contrast, right shifting of the oxyhemoglobin dissociation curve
decreases hemoglobin affinity for the oxygen molecule and release of oxygen to tissues at
higher partial pressures of oxygen. (See page 379: Compensatory Mechanisms During
Anemia.)
12. The principal factor(s) affecting hemoglobin's P50 is/are:

1. pH
2. temperature
3. 2,3-diphosphoglycerate (2,3-DPG) levels
4. oxygen extraction ratio
12. A. The partial pressure of oxygen at which the hemoglobin molecule is 50% saturated is
termed the P50. Changes in pH, temperature, and 2,3-DPG levels can shift the oxyhemoglobin
dissociation curve and can thus raise or lower the P50 value. Changes in P50 determine how
tightly oxygen and hemoglobin bind and ultimately affect oxygen extraction ratios. (See page
379: Compensatory Mechanisms During Anemia.)
13. Regarding the collection and preparation of blood products for transfusion, which
of the statements below are true&quest;
1. By Food and Drug Administration (FDA) mandate, platelet storage is limited to 5 days.
2. A disadvantage of the solvent detergent technique to inactivate viruses in fresh-frozen
plasma (FFP) is that it is a process that pools large numbers of single FFP units (>1000).
3. Cryoprecipitate contains FVIII, FXIII, von Willebrand factor (vWF), and fibrinogen.
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4. Antithrombin III concentrates can be used in the treatment of fulminant hepatic failure.
13. E. Although platelets are potentially viable for as long as 10 days (the normal in vivo
lifespan), storage is limited 5 five days by FDA mandate because of the time-related risk of
bacterial growth. One of the principal hazards of FFP administration has been virus
transmission. Three procedures—pasteurization, photochemical treatment, and solvent
detergent treatment—have been used to inactivate viruses. The solvent detergent technique is
highly effective in inactivating all of the lipid-encapsulated viruses (i.e., human
immunodeficiency virus, hepatitis C virus, hepatitis B virus, human T-cell lymphotropic virus).
The disadvantage of the solvent detergent technique is that the process involves pooling of
large numbers of single FFP units (>1000) and is not effective against nonlipid enveloped
viruses (hepatitis A virus, parvovirus) or the agent of Creutzfeldt-Jakob disease. Cryoprecipitate
remains when FFP is thawed slowly at 4°C. It is a concentrated source of FVIII, FXIII, vWF, and
fibrinogen. (See page 379: Platelets.)
14. Which of the following statements regarding compatibility testing is/are

TRUE&quest;
1. Patients with Rh-negative blood have anti-D antibodies in serum.
2. Antibody screening is a check for anti-A and anti-B antibodies in donor serum.
3. Rh-negative patients given Rh-positive blood always have hemolytic reactions.
4. Cross-matching of blood involves simulation of actual anticipated transfusion by
mixing of recipient and donor blood.
14. D. Unlike the ABO system, patients who have Rh-negative blood will not necessarily have
Rh antibodies or D antibodies in their serum. Therefore, patients who have Rh-negative blood
may initially receive Rh-positive blood without risk of hemolysis. Antibody screening checks for
unexpected antibodies in the serum (excluding the ABO and Rh systems). The final phase of
compatibility testing is called cross-matching and actually does simulate anticipated transfusion
by mixing donor red blood cells with recipient serum. (See page 383: Compatibility Testing.)
15. Which of the following statements regarding citrate intoxication is/are TRUE&quest;
1. It occurs with multiple transfusions of packed red blood cells (RBCs) over long periods
of time.
2. It may result in electrocardiographic (ECG) changes.
3. It may result in hypertension secondary to increased systemic vascular resistance.
4. The citrate causes a temporary reduction of ionized calcium levels.
15. C. Commonly used additive solutions contain citrate, which anticoagulates by chelation of
ionized calcium. When large volumes of stored blood (>1 blood volume) are administered
rapidly, the citrate may cause a temporary reduction in ionized calcium levels. Decreased
ionized calcium levels should not occur unless the rate of transfusion exceeds 1 mL/kg/min or
about 1 U of blood per 5 minutes in an average-sized adult. Signs of citrate intoxication
(hypocalcemia) include hypotension, narrow pulse pressure, and elevated intraventricular end-
diastolic pressure and central venous pressure, prolonged Q-T interval, widened QRS
complexes, and flattened T waves. (See page 377: Citrate Intoxication.)
16. Immediate-type hemolytic transfusion reactions:
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1. may result from incompatibility in the Kell, Kidd, Lewis, or Duffy systems
2. may be treated with sodium bicarbonate and mannitol
3. are immune mediated and occur more commonly with antibodies that fix complement
4. can be confirmed and characterized by haptoglobin, plasma and urine hemoglobin,
and bilirubin assays
16. A. Immediate hemolytic transfusion reactions are the result of incompatibility in antibodies
that fix complement and commonly produce immediate intravascular hemolysis. These include
anti-A, anti-B, anti-Kell, anti-Kidd, anti-Lewis, and anti-Duffy antibodies. Although serum
haptoglobin, plasma and urine hemoglobin, and bilirubin tests give evidence of hemolysis, they
are not specific for an immune reaction. The confirmatory test for an immune reaction is a direct
antiglobulin or direct Coombs' test. Clinical management of patients centers on three main
goals: maintenance of systemic blood pressure, preservation of renal function, and prevention
of disseminated intravascular coagulopathy. Urine output should be promoted by administration
of fluids and the use of diuretics (mannitol, furosemide, or both). Sodium bicarbonate can be
administered to alkalinize the urine. (See page 373: Reactions to Red Blood Cell Antigens.)
17. Delayed hemolytic transfusion reactions:

1. usually occur after an apparently compatible transfusion
2. can be confirmed by an indirect Coombs' test
3. require previous exposure
4. generally result in hemolysis and have the same symptoms as immediate hemolytic
transfusion reactions
17. B. Delayed hemolytic transfusion reactions occur when the donor red blood cells possess
an antigen that the recipient at some time has been exposed to (either by previous transfusion
or pregnancy) and thus has been immunized. Over time, the recipient antibodies decrease to
levels too low to be detected by subsequent compatibility testing. Thus, these reactions appear
in patients who have an apparently compatible transfusion. Because the recipient experiences
an anamnestic response, it requires time for reaction to develop. These reactions occur outside
of the vascular tree, resulting in a less severe and less likely fatal reaction. Confirmatory
evidence is based on direct antiglobulin or direct Coombs' testing. (See page 373: Delayed
Hemolytic Transfusion Reactions.)
18. Transfusion reactions resulting from white blood cell antigens:

1. are immediate and life threatening
2. result from antibodies to human leukocyte antigens (HLAs) on transfused leukocytes
3. may produce transfusion-related acute lung injury as a consequence of cardiogenic
pulmonary edema
4. often result in fever
18. C. Patients who receive multiple transfusions of red blood cells (RBCs) or platelets often
develop antibodies to the HLA antigens on the passenger leukocytes in these products. During
subsequent RBC transfusions, febrile reactions may occur as a result of antibody attack on
donor leukocytes. Patients may experience only fever, but they may also develop chills,
respiratory distress, anxiety, headache, myalgias, nausea, and a nonproductive cough.
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Transfusion-related acute lung injury is a noncardiogenic form of pulmonary edema associated
with blood product administration. It occurs when agents present in the plasma phase of donor
blood activate leukocytes in the host. (See page 374: White Blood Cell–Related Transfusion
Reactions.)
19. Which of the following statements regarding platelet transfusion is/are

TRUE&quest;
1. One apheresis unit is obtained from a single donor.
2. One platelet concentrate unit will increase the platelet count by 5,000 to 10,000/uL
3. The transfusion threshold should be based on the possibility of additional causes.
4. A common practice is to administer 1 U of platelet concentrate to an adult per 10 kg of
body weight.
19. E. A platelet concentrate derived from a single unit of donor blood increases the platelet
count of a 70-kg recipient by 5,000 to 10,000/uL. However, the majority of platelets (>70%) are
now obtained by apheresis. One apheresis unit increases the platelet count by 30,000 to
60,000/uL. A common practice is to administer either 1 U of apheresis platelets to an adult or 1
U of platelet concentrate per 10 kg of body weight. The increase in platelets must be verified by
platelet count, especially in patients who may have been alloimmunized by frequent platelet
administration. A single apheresis unit (referred to as “apheresis platelets”) is obtained from a
single donor at a single session. (See page 378: Blood Products and Transfusion Thresholds:
Platelets.)
20. Which of the following statements regarding antithrombin III (ATIII) is/are
TRUE&quest;
1. It is inactivated by heparin.
2. It is a naturally occurring anticoagulant.
3. It is nonfunctional without the heparin cofactor.
4. In the presence of heparin, it can bind activated factors IX, X, and XII to accelerate
anticoagulation.
20. C. ATIII is a circulating serine protease inhibitor that binds to thrombin and thereby
inactivates it. It can bind and inactivate each of the activated clotting factors of the classical
“intrinsic” coagulation cascade—factors XIIa, XIa, IXa, and Xa. In the absence of heparin, ATIII
has a relatively low affinity for thrombin. However, when heparin is bound to ATIII, the efficiency
of binding of ATIII to thrombin and the other factors increases dramatically. (See page 391:
Thrombin and Antithrombin III.)
P.75
21. Which of the following statements regarding fibrinolysis is/are TRUE&quest;
1. Tissue plasminogen activator (t-PA) is produced by vascular endothelial cells.
2. The primary fibrinolytic enzyme is t-PA.
3. t-PA differs from streptokinase in that its action is more localized.
4. Fibrin degradation products are produced by the action of t-PA on plasminogen.
21. B. The process of fibrinolysis leads to dissolution of fibrin clots. Fibrinolysis serves to
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remodel fibrin clots and “recanalize” vessels that have been occluded by thrombosis. The
primary fibrinolytic enzyme is plasmin, which is derived by the conversion of plasminogen to
plasmin in the presence of t-PA and fibrin. Fibrin split products or fibrin degradation products
are produced by the action of plasmin on fibrin clots. The therapeutic fibrinolytic agents
streptokinase and urokinase differ from t-PA in that they activate circulating plasminogen,
leading to more widespread fibrinolysis. (See page 389: Fibrinolysis.)
22. Which of the following statements regarding the laboratory evaluation of

coagulation is/are TRUE&quest;
1. The prothrombin time (PT) tests the extrinsic pathway of coagulation by adding tissue
factors to whole blood.
2. The thrombin time is prolonged by low amounts of any of the factors that prolong the
PT.
3. The international normalized ratio (INR) standardizes the PT results obtained from
varying thromboplastin reagents.
4. The reptilase test uses snake venoms to confirm abnormal INR numbers.
22. B. The PT is measured by adding tissue thromboplastin or tissue factor to the blood and
measuring the time until clot formation occurs. PT is prolonged if deficiencies; abnormalities; or
inhibitors of factors I, II, V, VII, or X exist. This tests the classical extrinsic pathway. Because
different thromboplastin reagents produce values with different normal ranges, comparison of
PT results among laboratories is difficult. The INR value takes into account the different
sensitivities of varying reagents and allows INR results to be directly compared from one
laboratory to another. The thrombin time measures the ability of thrombin to convert fibrinogen
to fibrin. This test bypasses all other preceding reactions and is not necessarily prolonged by
abnormalities of many of the factors of the extrinsic pathway. Reptilase, a snake venom,
converts fibrinogen to fibrin; this is unaffected by the presence of heparin. The reptilase test is
used to differentiate a prolonged thrombin time as a result of heparin versus fibrin degradation
products. (See page 392: Laboratory Evaluation of Coagulation.)
23. Which of the following statements regarding von Willebrand disease is/are
TRUE&quest;
1. It is a rare hereditary bleeding disorder.
2. The activated partial thromboplastin time (aPTT) is commonly prolonged because of
the diminished half-life of factor VIII in von Willebrand disease.
3. Desmopressin (DDAVP) helps patients with all types of von Willebrand disease to
some extent.
4. Patients have a prolonged bleeding time (BT) and normal platelet count.
23. D. von Willebrand disease is the most common hereditary bleeding disorder in humans.
When von Willebrand factor is deficient, platelet function is impaired, leading to an abnormal BT
in the presence of normal platelet count. The aPTT and PT may be normal in patients with von
Willebrand disease. Although the half-life of factor VIII:C is diminished in people with von
Willebrand disease, they usually have sufficient VIII:C to yield a normal aPTT in basal
conditions. DDAVP is effective first-line therapy for most (∼80%) patients with von Willebrand
disease, including those with types 1 and 2A disease. However, the recognition of subtype 2B
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is important because DDAVP causes thrombocytopenia in these patients. (See page 396: von
Willebrand Disease.)
24. Which of the following statements regarding hemophilia is/are TRUE&quest;

1. Hemophilia A is caused by a deficiency of factor VIII activity.
2. Hemophilia B is an autosomal recessive disorder that occurs almost exclusively in
Ashkenazi Jews.
3. Hemophilia A may be treated with desmopressin (DDAVP).
4. Patients with hemophilia A usually have an abnormal prothrombin time (PT) and
bleeding time (BT).
24. B. Whereas hemophilia A is caused by a deficiency of factor VIII activity, hemophilia B
(Christmas disease) is caused by a deficiency of factor IX. Both hemophilia A and B are sex-
linked recessive disorders, which therefore occur almost exclusively in boys and men.
Hemophilia C is an autosomal recessive disorder that occurs almost exclusively in Ashkenazi
Jews. Patients with hemophilia A are generally treated with factor VIII concentrates. However,
DDAVP is helpful in increasing plasma factor VIII and von Willebrand factor concentrations; it is
most effective in patients with factor VIII:C levels above 5%. Laboratory diagnosis of hemophilia
A is based on the finding of a prolonged aPTT and a specific factor assay demonstrating
deficiency of factor VIII. The patient will have a normal PT and a normal BT. (See page 397:
The Hemophilias.)
25. Which of the following statements regarding disseminated intravascular

coagulation (DIC) is/are TRUE&quest;
1. It is triggered by the appearance of excessive procoagulant material (tissue factor or
equivalent) in the circulation.
2. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may remain
normal.
3. Activated protein C should be considered in any sustained episode of DIC.
4. Heparin has been advocated in situations in which thrombosis is clinically problematic.
25. E. DIC is triggered by the appearance of procoagulant material (tissue factor or equivalent)
in the circulation in amounts sufficient to overwhelm the mechanisms that normally restrain and
localize clot formation. PT and aPTT may remain normal despite decreasing factor levels
because of the presence of high levels of activated factors, including thrombin and Xa. Use of
heparin has been advocated, but the contemporary practice is to restrict its use to only
situations in which thrombosis is clinically problematic. An insufficiency in the protein C
endogenous coagulation inhibition system is thought to contribute to the prothrombotic state in
individuals with DIC. Activated protein C has been shown to decrease mortality and organ
failure in patients with sepsis, and this improvement is also evident among patients with sepsis
with overt DIC. The use of this agent should be considered in all sustained episodes of DIC.
(See page 402: Disseminated Intravascular Coagulation.)
26. Which of the following statements regarding low-molecular-weight heparins

(LMWHs) is/are TRUE&quest;
1. They are associated with a lesser incidence of heparin-induced thrombocytopenia.
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2. Protamine successfully neutralizes LMWH.
3. Their half-life is longer than that of standard heparin.
4. They cause more platelet inhibition than standard heparin.
26. B. Protamine neutralization of LMWH is reported to be incomplete. The half-life is longer
than that of standard heparin, allowing for once-per-day dosing. It appears to cause less
platelet inhibition and is associated with a lower incidence of heparin-induced
thrombocytopenia than standard heparin. (See page 399: Acquired Disorders of Clotting
Factors.)
27. Which of the following statements regarding thromboelastography is/are

FALSE&quest;
1. It measures platelet aggregation, coagulation, and fibrinolysis.
2. The maximum amplitude (MA) is a measure of the strength of the fully formed clot.
3. A (MA + 60)/MA ratio of less than 0.85 is evidence of abnormal fibrinolysis.
4. The teardrop configuration usually prompts the administration of red blood cells.
27. D. Thromboelastography provides a measure of the mechanical properties of evolving clot
as a function of time. A principal advantage is that the processes it measures require the
integrated action of all the elements of the hemostatic process: platelet aggregation,
coagulation, and fibrinolysis. The (MA + 60)/MA ratio has been used most widely. A ratio of less
than 0.85 is evidence of abnormal fibrinolysis. In clinical practice, particularly in liver
transplantation, a nonquantitative appreciation of the typical teardrop shape is used more often
to support a diagnosis of increased fibrinolysis than are specific numerical values. (See page
394: The Thromboelastogram.)
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Review of Clinical Anesthesia, 5e [Vishal] 17. Inhaled Anesthetics
Chapter 17
Inhaled Anesthetics
1. Which of the following statements regarding minimum alveolar concentration (MAC)

is FALSE&quest;
A. Pregnancy decreases MAC.
B. The MAC of inhaled drugs is additive.
C. MAC is lowered in preterm neonates compared with term neonates.
D. Acute ethanol administration increases MAC.
E. MAC in an 80-year-old patient is only three fourths that of a young adult.
1. D. MAC is influenced by age; in humans, MAC is lower in preterm neonates than term
neonates. It is higher in term infants than at any other age. Anesthetic requirements decrease
with age: An 80-year-old patient requires only three fourths the alveolar concentration of
anesthetic that is required for a young adult. Pregnancy decreases MAC in sheep. Acute
ethanol administration decreases MAC. (See page 424: Minimum Alveolar Concentration [MAC];
page 424: Table 17-4; and page 425: Table 17-5.)
2. Which of the following statements about minimum alveolar concentration (MAC) is

FALSE&quest;
A. MAC-awake is the alveolar concentration at which 50% of patients respond to the
command “open your eyes.”
B. Standard MAC values are roughly additive.
C. MAC-block adrenergic response (BAR) is the alveolar concentration that blocks the
adrenergic response to noxious stimuli in 50% of patients.
D. MAC-awake for halothane is approximately equivalent to standard MAC.
E. MAC-BAR is 1.5 times the standard MAC value.
2. D. MAC-awake is the dose at which 50% of patients respond to the command “open your
eyes.” The alveolar concentration at this point is approximately 50% of the standard MAC value
for halothane. MAC-BAR is the alveolar concentration required to block the adrenergic
response to noxious stimuli in 50% of patients; this value is approximately 1.5 times the
standard MAC value. MAC values are roughly additive. (See page 424: Minimum Alveolar
Concentration [MAC].)
3. Which of the following best relates the relative degree to which inhalational
anesthetics decrease cerebral metabolic rate&quest;
A. Sevoflurane = Halothane < Isoflurane
B. Isoflurane < Halothane < Sevoflurane
C. Sevoflurane < Isoflurane < Halothane
D. Isoflurane = Sevoflurane > Halothane
E. Halothane < Isoflurane = Sevoflurane
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3. D. Each of the potent inhaled anesthetics decreases cerebral metabolic oxygen consumption
(CMRO2), with the order of effect from greatest to least being Isoflurane = Sevoflurane =
Desflurane > Halothane. (See page 425: Cerebral Metabolic Rate and Electroencephalogram.)
4. Which of the following statements regarding the central nervous system (CNS)
effects of inhalational agents is FALSE&quest;
A. All potent inhalational agents depress the cerebral metabolic rate (CMR).
B. Desflurane and sevoflurane cause a similar decrease in CMR.
C. After an isoelectric electroencephalogram (EEG) is achieved, a further increase in
isoflurane concentration will further decrease the cerebral metabolic oxygen consumption
(CMRO2).
D. Isoflurane abolishes EEG activity at clinically used doses that are usually
hemodynamically tolerable.
E. Desflurane's effects on the CNS system are similar to isoflurane's.
4. C. It has been shown that after an isoelectric EEG is achieved with isoflurane, further
increases in isoflurane's concentration do not lead to further decreases in CMR. Isoflurane
abolishes EEG activity at clinically used doses that are usually hemodynamically tolerated.
Desflurane and sevoflurane cause similar decreases in CMR. Desflurane's effects are similar to
those of isoflurane. (See page 425: Cerebral Metabolic Rate and Electroencephalogram.)
5. True statements regarding inhalational agents include all of the following EXCEPT:
A. A second gas effect exists for nearly every combination of inhaled drugs.
B. The two major components of the second gas effect are the concentration effect and
decreased solubility.
C. For the more soluble anesthetics, augmentation of anesthetic delivery by increasing
minute ventilation also increases the rate of increase in the ratio of the alveolar
anesthetic concentration (FA) to the inspired anesthetic concentration (FI) over time
(FA/FI).
D. During emergence, washout of high concentrations of nitrous oxide can lower alveolar
concentrations of O2 and CO2.
E. The rate of alveolar concentration approaching the inspired concentration is inversely
related to the blood solubility of the agent.
5. B. The rate at which the alveolar concentration approaches the inspired concentration is
inversely related to the blood solubility of the anesthetic. Administration of high concentrations
of one gas (e.g., nitrous oxide) facilitates the increase in alveolar concentration of another gas
(e.g., halothane); this phenomenon is called the second gas effect . The two components of the
second gas effect (increased ventilation [increased tracheal inflow] and the concentrating
effect) are operative at the alveolar level. Although a second gas effect exists for nearly all
combinations of inhaled drugs given simultaneously, it is most pronounced when nitrous oxide
is used with a more soluble drug, such as halothane (the second gas). For more soluble
anesthetics, increasing the minute ventilation increases rate of increase in FA/FI. Emergence
from anesthesia is more rapid with low blood or tissue anesthetic solubility, increased
ventilation, and replacement of nitrous oxide with nitrogen. During washout of high
135 / 494
concentrations of nitrous oxide, alveolar concentrations of O2 and CO2 can be lowered. This
phenomenon is called diffusion hypoxia. (See page 419: Second Gas Effect and page 421:
Exhalation and Recovery.)
6. True statements regarding the effects of anesthetics on the chemical control of

breathing include all of the following EXCEPT:
A. Subanesthetic concentrations of potent inhalational agents depress the hypoxic
response in humans.
B. The ventilatory response to CO2 is depressed by all inhalational agents.
C. With a 2 minimum alveolar concentration (MAC) inhalational agent in a spontaneously
breathing
P.82
patient, the apneic threshold is generally 5 mm Hg below the resting PaCO2.
D. Residual effects of inhalation agents may impair the ventilatory drive of patients in the
recovery room.
E. Nitrous oxide decreases PaCO2 during spontaneous breathing.
6. E. The ventilatory response to CO2 is depressed more or less proportionately by all
anesthetic agents. Apnea results if the anesthetic dose is high enough. If apnea occurs, the
apneic threshold is approximately 4 to 5 mm Hg below the PaCO2 maintained during
spontaneous breathing, regardless of the type of anesthesia. It should be anticipated that the
PaCO2 will be 50 to 55 mm Hg at surgical planes of anesthesia when potent inhaled
anesthetics are used. Surgical stimuli decrease this level by 4 to 5 mm Hg at an equivalent level
of anesthesia. Nitrous oxide maintains (or may slightly increase) the PaCO2 during
spontaneous breathing. Subanesthetic concentrations of halothane, enflurane, and isoflurane
depress the hypoxic response in humans. Residual effects of inhalational agents may impair the
ventilatory drive of patients in the recovery room. (See page 433: Response to Carbon Dioxide
and Hypoxemia.)
7. True statements concerning the hemodynamic effects of inhalational agents include

all of the following EXCEPT:
A. All potent inhaled agents decrease arterial pressure.
B. Heart rate changes least with halothane and sevoflurane.
C. Volatile anesthetics cause dose-dependent myocardial depression.
D. Isoflurane causes greater slowing in the His-Purkinje system than does halothane.
E. All inhalational agents attenuate baroreflex control of heart rate.
7. D. Volatile anesthetics cause dose-dependent myocardial depression. All the potent inhaled
agents decrease arterial pressure in a dose-related manner. The mechanism of the decrease in
blood pressure includes vasodilation, decreased cardiac output resulting from myocardial
depression, and decreased sympathetic nervous system tone. The heart rate changes least
with halothane and increases most with desflurane. Halothane causes a greater slowing of the
His-Purkinje system than does isoflurane. (See page 427: The Circulatory System and page
428: Fig. 17-14.)
136 / 494
8. Which of the following statements regarding metabolism of inhaled agents is
FALSE&quest;
A. The production of compound A is enhanced during low-flow anesthesia.
B. Baralyme produces more compound A than soda lime.
C. Compound A production is decreased by warm or very dry CO 2 absorbents.
D. The potential effect of compound A is renal toxicity.
E. CO2 absorbents degrade all modern-day potent inhalational anesthetics.
8. C. Sevoflurane is degraded by CO2 absorbents to produce compound A. Baralyme produces
more compound A than does soda lime, which can be attributed to slightly higher absorbent
temperatures during CO2 extraction. The risk from compound A is renal tubular necrosis.
Sevoflurane metabolism to compound A is enhanced in low-flow or closed-circuit breathing
systems and by warm or very dry CO2 absorbents. All the potent inhaled agents (halothane,
sevoflurane, enflurane, desflurane, and isoflurane) are degraded by CO2 absorbents. (See
page 437: Anesthetic Degradation by Carbon Dioxide Absorbers.)
9. Which statement is FALSE regarding fluoride-induced nephrotoxicity&quest;

A. The treatment of choice is vasopressin.
B. Sevoflurane transiently increases serum fluoride concentration.
C. Fluoride-induced nephrotoxicity presents as high-output renal insufficiency.
D. Obesity causes increased defluorination of isoflurane.
E. Faster washout may contribute to the improved safety of sevoflurane regarding
fluoride concentrations compared with enflurane.
9. A. Fluoride-induced nephrotoxicity, which is caused by inorganic fluoride, presents as high-
output renal insufficiency that is unresponsive to vasopressin and is characterized by dilute
polyuria, dehydration, serum hypernatremia, and hyperosmolality with elevated levels of blood
urea nitrogen and creatinine. Sevoflurane undergoes 5% metabolism that transiently increases
serum fluoride concentrations. The safety of sevoflurane regarding fluoride concentrations may
be caused by a rapid decline in plasma fluoride concentrations because of less availability of
the anesthetic for metabolism from a faster washout compared with enflurane. Factors such as
total dose of anesthetic, liver enzyme induction, and obesity have been proven to enhance
biotransformation (defluorination). (See page 438: Fluoride-Induced Nephrotoxicity.)
10. True statements regarding inhalational agents include all of the following EXCEPT:
A. Inhalational agents have muscle relaxant properties of their own.
B. Situations that decrease hepatic blood flow make patients vulnerable to the effects of
inhalational anesthetics on hepatic blood flow.
C. Of the volatile anesthetics, halothane is the most potent trigger of caffeine-induced
contractions.
D. Volatile anesthetics cause a dose-dependent decrease in uterine smooth muscle
contractility.
E. No inhalational anesthetic has been shown to be teratogenic in animals.
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10. E. The potent inhaled anesthetic agents not only potentiate the action of neuromuscular
blocking drugs but also have muscle relaxant properties of their own. Situations that decrease
hepatic blood flow or increase hepatic oxygen consumption make patients more vulnerable to
the unwanted effects of volatile anesthetics on hepatic blood flow. Volatile anesthetic agents
have been shown to be teratogenic in animal studies, but none has been shown to be
teratogenic in humans. Halothane causes a stronger contraction to the caffeine-induced
contracture test than isoflurane or enflurane. Volatile anesthetics produce a dose-dependent
decrease in uterine smooth muscle contractility. (See page 435: Hepatic Effects.)
11. The FALSE statement concerning the effect of inhalational agents on cerebrospinal
fluid (CSF) and cerebral blood flow (CBF) is:
A. Sevoflurane at 1 minimum alveolar concentration (MAC) decreases CSF production.
B. Desflurane at 1 MAC leaves CSF production unchanged or slightly increased.
C. Isoflurane, sevoflurane, and desflurane cause far less cerebral vasodilation per MAC-
multiple than halothane.
D. Isoflurane significantly increases CSF production and decreases resistance to
reabsorption.
E. At high anesthetic doses, CBF is essentially pressure passive.
11. D. Isoflurane does not appear to alter CSF production but may increase, decrease, or leave
unchanged the resistance to reabsorption, depending on the dose. Sevoflurane at 1 MAC
depresses CSF production up to 40%. At 1 MAC, desflurane leaves CSF production unchanged
or increased. All the potent agents increase CBF in a dose-dependent manner. Isoflurane,
sevoflurane, and desflurane cause far less cerebral vasodilation per MAC-multiple than
halothane. Because the volatile anesthetics are direct vasodilators, all of them are considered
to diminish autoregulation in a dose-dependent fashion such that at high anesthetic doses, CBF
is essentially pressure passive. In general, anesthetic effects on intracranial pressure via
changes in CSF dynamics are clinically far less important than their effects on CBF. (See page
427: Cerebrospinal Fluid Production and Reabsorption and page 426: Cerebral Blood Flow,
Flow-Metabolism Coupling, and Autoregulation.)
12. TRUE statements regarding the effects of inhaled anesthetics on circulation
include:
1. Spontaneous ventilation decreases systemic vascular resistance.
2. Sevoflurane provides a stable heart rate.
3. Desflurane slows sinoatrial (SA) node discharge.
4. Isoflurane is associated with an increase in heart rate.
12. E. Spontaneous ventilation is associated with higher PaCO2, causing a decrease in
cerebral and systemic vascular resistance. Sevoflurane provides a stable heart rate.
Desflurane, sevoflurane, and isoflurane are known to maintain cardiac output. Enflurane and
isoflurane are associated with an increase in heart rate of 10% to 20% at 1 MAC. The SA node
discharge rate is slowed by the volatile anesthetics. (See page 427: The Circulatory System.)
138 / 494
13. TRUE statements regarding inhaled anesthetics include:
1. The partial pressure is the pressure a gas exerts proportional to its fractional mass.
2. A low-solubility agent results in a fast increase in the ratio of the alveolar anesthetic
concentration (FA) to the inspired anesthetic concentration (FI) over time (FA/FI).
3. The depth of anesthesia can be adjusted quickly.
4. Fat has a slow time for equilibration with blood.
13. E. The partial pressure is the pressure a gas exerts proportional to its fractional mass. The
inhaled anesthetics with the lowest solubilities in the blood show the fastest increase in FA/FI.
Fat has a slow time for equilibration with blood. (See page 414: Pharmacokinetic Principles.)
139 / 494
Review of Clinical Anesthesia, 5e [Vishal] 18. Intravenous Anesthetics
Chapter 18
Intravenous Anesthetics
1. The rapid onset of the central nervous system (CNS) effects of most intravenous (IV)
anesthetics is best explained by their:
A. low hepatic extraction ratio
B. small volume of distribution
C. high lipid solubility
D. large ratio of ionized to unionized drug
E. slow elimination half-life
1. C. The rapid onset of IV anesthetics is primarily attributable to their high lipid solubility and
the relatively high proportion of cardiac output that perfuses the brain. Only the unionized
fraction of a drug can cross the blood–brain barrier, so onset is also affected by the pKa of the
drug relative to the pH of body fluids; onset is also more rapid when the ratio of unionized to
ionized drug is high. Although the volume of distribution, elimination half-life, and hepatic
extraction ratio contribute to drug pharmacokinetics, these factors are not primarily responsible
for the rapid onset of anesthetic effects. (See page 445: General Pharmacology of Intravenous
Hypnotics.)
2. Ketamine interacts with all of the following receptors EXCEPT:

A. N-methyl-D-aspartate (NMDA)
B. opioid receptors
C. γ -Aminobutyric acid (GABA)
D. muscarinic receptors
E. monoaminergic receptors
2. C. Ketamine interacts with NMDA and opioid, muscarinic, and monoaminergic receptors, but
it does not interact with GABA receptors. This is in contrast to most intravenous anesthetics,
which exert their primary effect through GABA receptors. (See page 455: Ketamine.)
3. Which of the following intravenous anesthetic agents has the highest degree of
plasma protein binding&quest;
A. Thiopental
B. Propofol
C. Ketamine
D. Methohexital
E. Etomidate
3. B. Whereas about 98% of propofol is protein bound, about 85% of the barbiturates
methohexital and thiopental bind to protein, and 75% of etomidate is protein bound. In contrast,
only about 12% of ketamine is protein bound. (See page 447: Pharmacokinetics and
Metabolism.)
140 / 494
4. Which of the following has the lowest hepatic extraction ratio&quest;

A. Ketamine
B. Propofol
C. Thiopental
D. Midazolam
E. Etomidate
4. C. The hepatic extraction ratio is a measure of the rate at which anesthetics are cleared from
the systemic circulation by the liver. The hepatic clearance of intravenous anesthetics may be
categorized into three groups: high, intermediate, and low. Thiopental, diazepam, and
lorazepam have low hepatic extraction ratios, and propofol, etomidate, and ketamine have high
hepatic extraction ratios. Methohexital and midazolam have hepatic extraction ratios that are
intermediate between these two groups. (See page 447: Pharmacokinetics and Metabolism.)
5. Recovery of cognitive function after general anesthesia is slowest when which of

the following agents is used for induction&quest;
A. Thiopental
B. Propofol
C. Midazolam
D. Etomidate
E. Ketamine
5. C. In general, benzodiazepines such as midazolam are associated with a relatively prolonged
time to recovery of cognitive function compared with other intravenous anesthetics. In contrast,
recovery from propofol is usually quite rapid, making it an ideal induction agent for outpatient
procedures. Recovery from ketamine, etomidate, and thiopental is intermediate between the
benzodiazepines and propofol. (See page 457: Use of Intravenous Anesthetics as Induction
Agents.)
6. Concerning the antiemetic effect of propofol, all of the following hypotheses have
been postulated EXCEPT:
A. It has antidopaminergic activity.
B. It has a depressant effect on the chemoreceptor trigger zone.
C. It increases the release of glutamate and aspartate in the olfactory cortex.
D. It decreases the concentration of serotonin in the area postrema.
E. It has a depressant effect on the vagal nucleus.
6. C. Propofol has antidopaminergic activity and depresses the chemoreceptor trigger zone and
vagal nucleus. It also decreases the release of glutamate and aspartate in the olfactory cortex
and reduces serotonin levels in the area postrema. All of these mechanisms are believed to
contribute to propofol's antiemetic properties. (See page 451: Propofol.)
7. Context-sensitive half-time describes:

A. the rate of fall of drug concentration at the effect site after discontinuation of
141 / 494
continuous infusion
B. the rate of decrease in drug concentration in the bloodstream after discontinuation of
continuous infusion
C. the rate of decrease of drug concentration in the body after discontinuation of
continuous infusion
D. the rate of decrease of drug concentration in its volume of distribution after
discontinuation of continuous infusion
E. the rate of decrease of drug concentration in the liver after discontinuation of
continuous infusion
7. A. Context-sensitive half-time is defined as the time necessary for the effect-compartment
concentration of drug to decrease by 50% after discontinuation of continuous infusion. (See
page 447: Pharmacokinetics and Metabolism.)
8. The involuntary myoclonus seen during induction with etomidate is:

A. not associated with cortical seizure activity
B. unaffected by prior administration of opioid analgesics
C. unaffected by prior administration of benzodiazepines
D. extremely uncommon
E. best treated with intravenous phenytoin
8. A. A common reaction to induction with etomidate is involuntary myoclonic movements, which
occur as a result of subcortical disinhibition. This response is not associated with cortical
seizure activity and may be attenuated by prior administration of opioid analgesics or
benzodiazepines. The use of antiseizure drugs such as phenytoin is not indicated. (See page
454: Etomidate.)
9. Rank the following induction agents in order of their degree of cardiovascular

depression.
P.86
A. Propofol > Etomidate > Thiopental
B. Thiopental > Propofol > Etomidate
C. Propofol > Thiopental > Etomidate
D. Etomidate > Thiopental > Propofol
E. Thiopental > Etomidate > Propofol
9. C. The cardiovascular effects of propofol are more profound than those of thiopental or
etomidate. Etomidate is the induction agent considered to have the least impact on the
cardiovascular system. (See page 450: Comparative Physiochemical and Clinical
Pharmacologic Properties.)
10. Which of the following statements concerning the mechanisms of action of

intravenous induction agents is NOT true&quest;
A. Barbiturates appear to increase the duration of γ -aminobutyric acid (GABA)-activated
opening of chloride ion channels.
142 / 494
B. Benzodiazepines appear to increase the efficiency of coupling between GABA

receptors and chloride ion channels.
C. Ketamine produces dissociative amnesia through interaction with N-methyl-D-aspartic
acid (NMDA) receptors.
D. Thiopental appears to act as a competitive inhibitor at central nicotinic acetylcholine
(Ach) receptors.
E. Propofol appears to have a mechanism of action similar to that of the
benzodiazepines.
10. E. Propofol appears to increase the duration of GABA-mediating chloride channel opening.
Therefore, its mechanism of action is most similar to that of the barbiturates, not the
benzodiazepines. However, benzodiazepines also act via the GABA receptor, increasing the
efficiency of coupling between the GABA receptor and chloride ion channels. Whereas
thiopental is believed to exert its effect via competitive inhibition of nicotinic Ach receptors in the
central nervous system, ketamine acts via NMDA receptors. (See page 445: General
Pharmacology of Intravenous Hypnotics.)
11. Which of the following is NOT a typical induction regimen for a healthy adult
patient&quest;
A. Etomidate, 0.3 to 0.6 mg/kg
B. Ketamine, 0.5 to 1.0 mg/kg
C. Methohexital, 3 to 5 mg/kg
D. Midazolam, 0.1 to 0.2 mg/kg
E. Propofol, 1.5 to 2.5 mg/kg
11. C. The typical induction dose of methohexital is 1.0 to 1.5 mg/kg intravenously. All of the
other choices represent typical induction drug dosages. (See page 450: Comparative
Physiochemical and Clinical Pharmacologic Properties.)
12. Ketamine is associated with all of the following physiologic effects EXCEPT:
A. bronchodilation
B. elevation of intracranial pressure
C. decreased oral secretions
D. sympathetic stimulation
E. increased pulmonary artery pressure
12. C. Ketamine is a sympathetic stimulant that increases peripheral arteriolar resistance,
arterial blood pressure, heart rate, and pulmonary artery pressure. It also possesses
bronchodilatory activity. In contrast to the other commonly used intravenous induction agents,
ketamine increases cerebral blood flow, cerebral metabolic oxygen demand, and intracranial
and intraocular pressures. Ketamine also increases oral secretions. Therefore, pretreatment
with an antisialogogue is sometimes useful. (See page 455: Ketamine.)
13. Which of the following induction agents may facilitate the interpretation of
somatosensory evoked potentials (SSEPs)&quest;
143 / 494
A. Ketamine
B. Propofol
C. Methohexital
D. Midazolam
E. Etomidate
13. E. Etomidate increases the amplitude of SSEPs and can be useful in the interpretation of
SSEPs when signal quality is poor. (See page 454: Etomidate.)
14. For which of the following patients would ketamine be LEAST appropriate as an
induction agent&quest;
A. A 39-year-old woman with acute asthma exacerbation who is undergoing emergency
appendectomy
B. A 70-year-old woman with cardiac tamponade who is undergoing emergency
thoracotomy
C. A 50-year-old woman with glaucoma who is scheduled for elective cataract resection
D. A 55-year-old man with mild renal insufficiency who is undergoing sigmoid resection
for diverticulitis
E. A 7-year-old child without intravenous access who is scheduled for elective
tonsillectomy
14. C. Ketamine increases intraocular pressure and is therefore not an appropriate induction
agent in patients with glaucoma. Ketamine is a sympathetic stimulant that has bronchodilatory
effects. These properties make it a useful agent in a carefully defined subset of patients, such
as those with acute bronchospasm, hypovolemic shock, right-to-left intracardiac shunts, and
cardiac tamponade. However, its sympathomimetic effects may be ineffective in the context of
maximal sympathetic output. Ketamine may be delivered intramuscularly in patients without
intravenous access. (See page 455: Ketamine.)
15. Which of the following intravenous (IV) induction agents produces dissociative
anesthesia&quest;
A. Propofol
B. Etomidate
C. Thiopental
D. Ketamine
E. Midazolam
15. D. Ketamine produces dose-dependent central nervous system depression leading to a so-
called dissociative anesthetic state characterized by profound analgesia and amnesia, even
though patients may be conscious and maintain protective reflexes. The proposed mechanism
for this cataleptic state includes electrophysiologic inhibition of thalamocortical pathways and
stimulation of the limbic system. None of the other IV anesthetic agents produce a dissociative
anesthetic state. (See page 455: Ketamine.)
16. Which of the following intravenous induction agents has metabolites that are
144 / 494
pharmacologically inactive&quest;
A. Diazepam
B. Ketamine
C. Propofol
D. Thiopental
E. Midazolam
16. C. Propofol is rapidly and extensively metabolized to inactive, water-soluble sulphate and
glucuronic acid metabolites, which are eliminated by the kidneys. Midazolam undergoes
extensive oxidation by hepatic enzymes to form water-soluble hydroxylated metabolites, which
are excreted in the urine. However, the primary metabolite, 1-hydroxymethylmidazolam, has mild
central nervous system (CNS) depressant activity. Diazepam is metabolized to active
metabolites (desmethyldiazepam, 3-hydroxydiazepam), which can prolong diazepam's residual
sedative effects because of their long t½β values. Thiopental is metabolized in the liver to
hydroxythiopental and the carboxylic acid derivative, which are more water soluble and have
little CNS activity. When high doses of thiopental are administered, a desulfuration reaction may
occur with the production of pentobarbital, which has long-lasting CNS depressant activity.
Ketamine is metabolized into norketamine, which is also pharmacologically active. (See page
448: Pharmacodynamic Effects.)
17. Flumazenil is an antagonist of which of the following intravenous (IV) induction

agents&quest;
A. Ketamine
B. Propofol
C. Midazolam
D. Methohexital
E. Etomidate
17. C. In contrast to all other sedative–hypnotic drugs, there is a specific antagonist for
benzodiazepines. Flumazenil, a 1,4-imidazobenzodiazepine derivative, has a high affinity for the
benzodiazepine receptor but minimal intrinsic activity. Flumazenil acts as a competitive
antagonist in the presence of benzodiazepine agonist compounds. Flumazenil is short acting,
with an elimination half-life of approximately 1 hour. Recurrence of the central effects of
benzodiazepines (resedation) may occur after a single dose of flumazenil because of the more
slowly eliminated agonist drug. If sustained antagonism is desired, it may be necessary to
administer flumazenil as repeated doses or by a continuous infusion. In general, 45 to 90
minutes of antagonism can be expected after 1 to 3 mg of flumazenil IV. However, the
respiratory depression produced by benzodiazepines is not completely reversed by flumazenil.
Reversal of benzodiazepine sedation with flumazenil is not associated with adverse
cardiovascular effects or evidence of an acute stress response. (See page 453:
Benzodiazepines.)
18. Which of the following intravenous (IV) induction agents is associated with least
respiratory depression&quest;
A. Ketamine
145 / 494
B. Propofol
C. Thiopental
D. Etomidate
E. Lorazepam
18. A. With the exception of ketamine (and to a lesser extent, etomidate), IV anesthetics
produce dose-dependent respiratory depression, which is enhanced in patients with chronic
obstructive pulmonary disease. Ketamine causes minimal respiratory depression in clinically
relevant doses and can facilitate the transition from mechanical to spontaneous ventilation after
anesthesia. In contrast to the other IV anesthetics, protective airway reflexes are more likely to
be preserved with ketamine. The respiratory depression is characterized by a decrease in tidal
volume and minute ventilation, as well as a transient rightward shift in the CO2 response curve.
After the rapid injection of a large bolus dose of an IV anesthetic, transient apnea lasting 30 to
90 seconds is usually produced. (See page 455: Ketamine.)
19. Which of the following intravenous (IV) anesthetics is considered to be the most
immunologically “safe&quest;”
A. Ketamine
B. Etomidate
C. Propofol
D. Midazolam
E. Methohexital
19. B. Severe anaphylactic reactions to IV anesthetics are extremely uncommon; however,
profound hypotension attributed to nonimmunologically mediated histamine release has been
reported with thiopental use. Although anaphylactic reactions to etomidate have been reported,
it does not appear to release histamine and is considered to be the most “immunologically safe”
IV anesthetic. Although propofol does not normally trigger histamine release, life-threatening
anaphylactoid reactions have been reported in patients with a previous history of multiple drug
allergies. With the exception of etomidate, all IV induction agents have been alleged to cause
some histamine release. (See page 450: Hypersensitivity Reactions.)
20. Which of the following intravenous (IV) induction agents is contraindicated in

patients who are predisposed to acute intermittent porphyria&quest;
A. Lorazepam
B. Ketamine
C. Etomidate
D. Thiopental
E. Propofol
20. D. Barbiturates can precipitate episodes of acute intermittent porphyria, so their use is
contraindicated in patients who are predisposed to acute intermittent porphyria. Although the
benzodiazepines, ketamine, and etomidate are reported to be safe in humans, these drugs have
been shown to be porphyrogenic in animal models. Propofol is not contraindicated in patients
who are predisposed to acute intermittent porphyria. (See page 448: Pharmacodynamic
146 / 494
Effects.)
21. Which of the following intravenous (IV) induction agents may produce adverse
effects when administered in the presence of tricyclic antidepressants (TCAs)&quest;
P.87
A. Etomidate
B. Midazolam
C. Thiopental
D. Ketamine
E. Lorazepam
21. D. Ketamine can produce adverse effects when administered in the presence of TCAs
because both drugs inhibit norepinephrine reuptake and may produce severe hypotension,
heart failure, or myocardial ischemia. None of the other IV induction agents produces these
effects when given in the presence of TCAs. (See page 455: Ketamine.)
22. Which of the following factor(s) contribute(s) to the hemodynamic changes
associated with intravenous (IV) induction of anesthesia&quest;
1. Pre-existing cardiovascular and fluid status
2. Resting sympathetic nervous system tone
3. Preanesthetic medication
4. Speed of drug injection
22. E. Many different factors contribute to the hemodynamic changes associated with IV
induction of anesthesia, including the patient's pre-existing cardiovascular and fluid status, the
resting sympathetic nervous system tone, chronic cardiovascular drug use, use of
preanesthetic medications, the speed of drug injection, and the onset of unconsciousness. In
addition, cardiovascular changes can be attributed to the direct pharmacologic actions of
anesthetic and analgesic drugs on the heart and peripheral vasculature. IV anesthetics can
depress the central nervous system and peripheral nervous system responses, blunt the
compensatory baroreceptor reflex mechanisms, produce direct myocardial depression, and
lower peripheral vascular resistance (or dilate venous capacitance vessels), thereby decreasing
venous return. Profound hemodynamic effects occur at induction of anesthesia in the presence
of hypovolemia because a higher than expected drug concentration is achieved in the central
compartment. Not surprisingly, the acute cardiocirculatory depressant effects of all IV
anesthetics are accentuated in elderly individuals and in the presence of pre-existing
cardiovascular disease (e.g., coronary artery disease, hypertension). (See page 448:
Pharmacodynamic Effects.)
23. TRUE statements about the use of propofol for sedation include:
1. It produces more reliable amnesia than midazolam.
2. It has little effect on hypoxic ventilatory response.
3. It is the drug of choice for patients with hemodynamic instability.
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4. It allows for relatively rapid transitions from deeper to lighter levels of anesthesia.
23. D. Propofol is associated with relatively rapid recovery, facilitating transitions from deeper to
lighter levels of anesthesia. In the intensive care unit setting, when compared with midazolam,
propofol sedation has been associated with more rapid weaning from artificial ventilation.
However, propofol produces less reliable amnesia and more pain on injection than midazolam.
In addition, even at low concentrations, propofol depresses the normal hypoxic ventilatory
response, so supplemental oxygen should always be used in conjunction with propofol
sedation. (See page 451: Propofol.)
24. Which of the following statements concerning the pharmacology of intravenous

(IV) induction agents is/are TRUE&quest;
1. At typical clinical concentrations, the rate of drug elimination is described by zero-
order kinetics.
2. Termination of initial central nervous system effects is primarily the result of drug
redistribution.
3. At high steady-state plasma concentrations, the rate of drug elimination decreases as
the exponential function of the drug's plasma concentration.
4. They typically undergo hepatic metabolism followed by renal excretion.
24. C. Termination of the central effects of intravenous anesthetics is primarily related to
redistribution from the brain rather than elimination from the body. Most IV agents undergo
hepatic metabolism into water-soluble compounds that are then excreted by the kidneys. At
typical clinical concentrations, the rate of drug elimination decreases as the exponential
function of the drug's plasma concentration—so-called first-order kinetics. However, at high
steady-state concentrations, the rate of drug elimination becomes independent of drug
concentration resulting from saturation of enzymes responsible for their metabolism (zero-order
kinetics). (See page 447: Pharmacokinetics and Metabolism.)
25. Which of the following statements concerning intravenous (IV) anesthetic agents in
elderly patients compared with younger adults is/are TRUE&quest;
1. Redistribution from vessel-rich tissue compartments is slower.
2. The steady-state volume of distribution is reduced.
3. The rate of hepatic clearance is reduced.
4. There is a decreased volume of the central compartment.
25. E. Elderly patients have increased steady-state volume of distribution for most IV
anesthetics and decreased hepatic clearance, leading to prolongation of their β half-life values.
They also have decreased volume of the central compartment and slower redistribution from
vessel-rich tissue to intermediate compartments. As a result, the dose of anesthetic required to
elicit effect is lower and the time to recovery is longer in elderly patients than in younger
patients. (See page 447: Pharmacokinetics and Metabolism.)
26. Which of the following statements concerning methohexital is/are TRUE&quest;

1. It is an oxybarbiturate.
2. It is associated with a more profound degree of hypotension compared with thiopental.
148 / 494
3. It can be used to evoke epileptic activity in patients with temporal lobe epilepsy.
4. It is approximately one third as potent as thiopental.
26. B. Methohexital is an oxybarbiturate that is two to three times more potent than thiopental.
Compared with thiopental, it produces a relatively more robust tachycardic response, leading to
a lesser degree of hypotension. Methohexital can produce epileptiform electroencephalographic
(EEG) activity and is used to activate cortical EEG seizure discharges in patients with temporal
lobe epilepsy. (See page 450: Barbiturates.)
27. Accidental intra-arterial injection of barbiturates is commonly treated with:

1. intra-arterial administration of papaverine
2. intra-arterial administration of lidocaine
3. heparinization
4. tourniquet application to the affected limb
27. A. Treatments for accidental intra-arterial injection of thiobarbiturates include intra-arterial
administration of papaverine and/or lidocaine, heparinization, and/or regional anesthesia
–induced sympathectomy. Isolation of regional blood flow via tourniquet application is not
appropriate. (See page 450: Barbiturates.)
28. Concerning propofol, which of the following statements is/are TRUE&quest;

1. It is a reasonable induction agent for patients susceptible to malignant hyperthermia.
2. It can be used safely in patients with a history of acute intermittent porphyria.
3. It can be used to decrease pruritus associated with administration of intrathecal
opioids.
4. Its effects are usually prolonged in patients with pre-existing hepatic disease.
28. A. Propofol is a reasonable induction agent in patients who are susceptible to malignant
hyperthermia, and it can be used safely in patients with acute intermittent porphyria. Propofol
also decreases pruritus associated with intrathecal opioid use and cholestatic liver disease.
Even though propofol is metabolized by the liver, its effects are generally not prolonged in
patients with pre-existing hepatic disease. (See page 451: Propofol.)
29. Which of the following statements concerning etomidate is/are TRUE&quest;

1. It does not stimulate histamine release.
2. It induces involuntary myoclonic movements, which can be attenuated by prior
administration of opioid analgesics.
3. It is associated with a high incidence of postoperative nausea and vomiting.
4. A single induction dose does not cause any measurable adrenal suppression.
29. A. Etomidate sometimes induces nonepileptogenic involuntary myoclonus during induction
that can be attenuated by the preinduction use of an opioid analgesic. In addition, it is
associated with a high incidence of postoperative nausea and vomiting and has been shown to
depress adrenocortical function for several hours after a single induction dose. Etomidate does
not induce histamine release and can be safely used in patients with reactive airway disease.
(See page 454: Etomidate.)
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30. Which of the following statements concerning the cardiovascular effects of
propofol is/are TRUE&quest;
1. It causes arterial dilation.
2. It increases peripheral venous pooling.
3. It impairs the baroreceptor reflex response.
4. It is not a direct myocardial depressant.
30. A. Propofol causes arterial and venous dilatation as well as impairment of the baroreceptor
reflex, all of which contribute to a decrease in systemic arterial pressure. In addition, propofol
has myocardial depressant effects. All of these factors contribute to the decrease in systemic
arterial pressure commonly observed after propofol induction. These cardiovascular effects are
more profound than those associated with thiopental or etomidate. (See page 451: Propofol.)
31. Which of the following statements regarding the structure and metabolism of
intravenous induction agents is/are correct&quest;
1. Pentobarbital is a potential metabolite of thiopental that can cause long-lasting central
nervous system (CNS) depressant activity.
2. Thiopental solution (2.5%) is highly acidic.
3. The hydroxyl derivative of methohexital is inactive.
4. The analgesic and anesthetic potency of the S(+) isomer of ketamine is less than that
of the racemic mixture.
31. B. Thiopental is metabolized in the liver to hydroxythiopental and a carboxylic acid
derivative. However, at high doses, thiopental undergoes a desulfuration reaction that leads to
the production of pentobarbital, a compound associated with long-lasting CNS depression.
Methohexital is metabolized in the liver to inactive hydroxyderivates. Thiopental is available in a
2.5% solution that is highly alkalotic (pH >9), and as such, inadvertent extravenous injection
causes tissue irritation. The anesthetic and analgesic potency of the S(+) isomer of ketamine is
greater than that of the racemic mixture. (See page 450: Comparative Physiochemical and
Clinical Pharmacologic Properties.)
32. Which of the following intravenous agents has intrinsic analgesic

properties&quest;
1. Ketamine
2. Dexmedetomidine
3. Clonidine
4. Thiopental
32. A. Ketamine, dexmedetomidine, and the α 2 agonist clonidine appear to possess analgesic
properties. In contrast, thiopental appears to have a mild antianalgesic effect. (See page 448:
Pharmacodynamic Effects.)
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Review of Clinical Anesthesia, 5e [Vishal] 19. Opioids
Chapter 19
Opioids
1. All of the following statements regarding opioid–receptor interactions are true

EXCEPT:
A. The analgesic effects of opioids are thought to result primarily from the activation of μ
receptors in the brain and spinal cord.
B. Opioid–receptor activation in peripheral tissues may play a role in the modulation of
painful stimuli.
C. Naloxone is highly specific for the μ subtype of opioid receptors.
D. Most opioids clinically used are highly selective for the μ subtype opioid receptor.
E. Opioid receptors are coupled to G proteins that regulate the activity of adenylate
cyclase.
1. C. Most observed opioid effects involve interactions with receptor systems at spinal and
supraspinal sites, although clinical studies suggest that morphine can produce analgesia by
peripheral mechanisms, especially when inflammation is present. Whereas the intrinsic activity,
or efficacy, of an opioid is described by the dose–response curve resulting from drug–receptor
interaction, affinity describes the ability of a drug to bind a receptor to produce a stable
complex. Most opioids used in current clinical practice are highly selective for μ receptors, but
naloxone, the most commonly used opioid antagonist, is not selective for opioid receptor type.
For this reason, identification of an opioid receptor–mediated drug effect requires
demonstration of naloxone reversibility. (See page 466: Endogenous Opioids and Opioid
Receptors.)
2. The ability of an opioid to cross the blood–brain barrier depends on all of the
following properties EXCEPT:
A. lipid solubility
B. ionization
C. protein binding
D. μ activity
E. molecular size
2. D. Physicochemical properties of the opioids influence both pharmacokinetics and
pharmacodynamics. To reach its effector sites in the central nervous system (CNS), an opioid
must cross biologic membranes from the blood to receptors on neuronal cell membranes. The
ability of opioids to cross this blood–brain barrier depends on such properties as molecular size,
ionization, lipid solubility, and protein binding (see Table 19-2). Of these characteristics, lipid
solubility and ionization assume major importance in determining the rate of penetration to the
CNS. (See page 468: Pharmacokinetics and Pharmacodynamics.)
3. Which of the following statements regarding opioid-induced muscle rigidity is/are

TRUE&quest;
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A. Muscle rigidity does not occur with morphine doses below 0.2 mg/kg.
B. The phenomenon is seen only on induction of anesthesia without the use of
neuromuscular blocking agents.
C. Muscle rigidity is reduced by the addition of nitrous oxide.
D. The effects are eliminated by naloxone.
E. Opioid-induced muscle rigidity is mediated by σ receptors.
3. D. Large doses of opioids may produce profound muscle rigidity, an effect that appears to be
mediated by μ receptors at supraspinal sites, most notably the nucleus raphe pontis and sites
lateral to it in the hindbrain. Such muscle rigidity is most often witnessed on induction with large
doses of opioids, although postoperative occurrences have been observed, as have feelings of
muscle tension after small doses (10–15 mg) of morphine. Opioid-induced muscle rigidity is
drastically increased by the addition of 70% nitrous oxide, but it is reduced or eliminated by
naloxone, drugs that facilitate γ -aminobutyric acid agonist activity, and muscle relaxants. (See
page 469: Morphine: Muscle Rigidity.)
4. Which of the following routes of opioid administration reliably reduces the incidence
of opioid-induced nausea&quest;
A. Intramuscular
B. Intrathecal
C. Subcutaneous
D. Transdermal
4. E. Opioid-induced nausea is thought to be a result of input to the vomiting center from
stimulation of the chemotactic trigger zone in the area postrema of the medulla, which is rich in
opioid receptors. Not only does the incidence of opioid-induced nausea appear to be
irrespective of the route of administration, but clinical studies also reveal no differences among
opioid species, including morphine, meperidine, fentanyl, sufentanil, and alfentanil. (See page
469: Morphine: Nausea and Vomiting.)
5. A 46-year-old man with a history of multiple uneventful general anesthetics is

undergoing a spinal fusion procedure during which 1 mg/kg of morphine is
administered over 15 minutes. Shortly thereafter, the patient exhibits modest
hypotension with a concomitant decrease in systemic vascular resistance, as well as
an increase in pulmonary vascular resistance as measured by a pulmonary artery
catheter. These findings are unaffected by the administration of 0.2 mg of naloxone.
The most likely cause of this clinical constellation is:
A. morphine-induced histamine release
B. a previously undiagnosed anaphylaxis
C. an opioid-mediated increase in vascular permeability
D. the central vagotonic effects of morphine
E. direct myocardial depression by morphine
5. A. Opioids stimulate the release of histamine from mast cells and basophils in a dose-
152 / 494
dependent manner, an effect seen commonly after high doses of morphine. Decreases in
peripheral vascular resistance and corresponding increases in pulmonary vascular resistance
after morphine administration have been shown to correlate well with elevated plasma
histamine concentrations. Opioid-induced histamine release is not prevented by pretreatment
with naloxone, a finding suggesting a mechanism independent of opioid receptor activation. In
clinically relevant doses, morphine does not depress myocardial contractibility. It does, however,
produce dose-dependent bradycardia, probably by both sympatholytic and
parasympathomimetic mechanisms. (See page 469: Morphine: Histamine Release.)
6. The occurrence of myoclonic activity and seizures observed after repeated or

prolonged administration of meperidine is most likely the result of:
A. direct central nervous system (CNS) effects resulting from the inherent local
anesthetic actions of meperidine
B. direct CNS excitation by meperidine
C. neurotoxic effects of normeperidine, an active metabolite of meperidine
D. insidious hypoxemia as a consequence of the prolonged clinical half-life of meperidine
E. selective activation of spinal κ receptors with increasing serum levels of meperidine
6. C. Meperidine is metabolized primarily in the liver by N-methylation to form normeperidine, an
active metabolite, and to a lesser extent by hydrolysis to form meperidinic acid. In humans, CNS
effects such as restlessness, agitation, tremors, myoclonus, and seizures have been associated
with increased serum levels of normeperidine. Normeperidine, which has a considerably longer
elimination half-life than its parent compound, is more apt to accumulate with repeated or
prolonged administration of meperidine or in patients with renal dysfunction. (See page 473:
Meperidine: Active Metabolites.)
7. Which physical characteristic of fentanyl best accounts for its rapid onset of clinical
effect as well as its brief duration of action&quest;
A. High lipid solubility
B. High degree of ionization
C. Relatively small molecular weight
D. Negligible protein binding
E. Low hepatic clearance
7. A. Fentanyl's high degree of lipid solubility enables it to cross biologic membranes very
rapidly and to permeate highly perfused tissue groups, such as the brain, heart, and lung. This
same characteristic accounts for the relatively brief clinical duration of effect seen with fentanyl
because redistribution of the drug to other tissues, including muscle and fat, also results from
high lipid solubility. Similarly, accumulation of fentanyl in such tissue compartments can be
extensive with prolonged administration, thus creating “reservoirs” of drug. (See page 476:
Fentanyl: Disposition Kinetics.)
P.92
8. Regarding methadone, which of the statements below is FALSE&quest;
A. Methadone is primarily a μ agonist.
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B. After parenteral administration, the onset of analgesia is within 20 minutes.
C. Methadone is not well absorbed orally, with only 10% bioavailability.
D. Methadone reaches peak plasma concentration four hours after oral administration.
E. Methadone is nearly 90% protein bound.
8. C. Methadone, a synthetic opioid introduced in the 1940s, is primarily a μ agonist with
pharmacologic properties that are similar to morphine. Although its chemical structure is very
different from that of morphine, steric factors force the molecule to simulate the
pseudopiperidine ring conformation that appears to be required for opioid activity. Methadone is
well absorbed after an oral dose, with bioavailability approximately 90%, and reaches peak
plasma concentration at 4 hours after oral administration. Because of its long elimination half-
life, methadone is most often used for long-term pain management and for treatment of opioid
abstinence syndromes. After parenteral administration, the onset of analgesia is within 10 to 20
minutes. After a single dose up to 10 mg, the duration of analgesia is similar to morphine, but
with large or repeated parenteral doses, prolonged analgesia can be obtained. It is nearly 90%
bound to plasma proteins. (See page 475: Methadone.)
9. All of the following statements regarding clinical characteristics of alfentanil are true
EXCEPT:
A. On a milligram basis, the clinical potency of alfentanil is roughly 10 times that of
morphine and one tenth that of fentanyl.
B. Alfentanil displays a significantly faster onset of action than fentanyl and sufentanil.
C. Alfentanil has a longer terminal half-life than fentanyl and sufentanil.
D. The incidence of nausea and vomiting associated with alfentanil is no higher than that
with either fentanyl or sufentanil.
E. Similar to fentanyl and sufentanil, alfentanil may produce profound muscle rigidity
when it is given in high doses.
9. C. Alfentanil is a synthetic tetrazole derivative of fentanyl with a clinical potency nearly 10
times that of morphine and one fourth to one tenth that of fentanyl. Alfentanil is a weaker base
than other opioids, with a pKa of 6.8. As such, nearly 90% of unbound plasma alfentanil is
nonionized at physiologic pH. This property, in addition to its moderately high lipid solubility,
allows alfentanil to cross the blood–brain barrier rapidly and accounts for its rapid onset of
action. Alfentanil has a terminal elimination half-life of 84 to 90 minutes, considerably shorter
than that of fentanyl or sufentanil, mainly because of its relatively small volume of distribution.
The incidences of clinical side effects with alfentanil have been shown to be similar to those
with fentanyl and sufentanil when compared at equianalgesic doses. Early reports of a higher
incidence of nausea and vomiting with alfentanil have not been substantiated. (See page 482:
Alfentanil.)
10. Remifentanil exhibits a markedly shorter clinical duration of action compared with
other commonly used opioids because of:
A. rapid redistribution resulting from high lipid solubility
B. a lesser degree of opioid receptor affinity
C. a high protein-bound (α 1-acid glycoprotein) fraction
154 / 494
D. a relatively high volume of distribution
E. metabolism of an ester side chain by blood and tissue esterases
10. E. Remifentanil is a recently synthesized 4-anili-dopiperidine opioid with a methyl ester side
chain that is susceptible to metabolism by blood and tissue esterases. A unique property of
remifentanil compared with other clinically useful opioids is its lack of accumulation with
repeated dosing or prolonged infusion. This is because its ultrashort duration of action is the
result of metabolism to a substantially less active compound, rather than simply redistribution of
an unchanged opioid. (See page 484: Remifentanil.)
11. Which of the following statements regarding sufentanil is TRUE&quest;

A. It has a clinical potency 100 to 200 times that of morphine.
B. Bradycardia is usually not seen when pancuronium is used during anesthesia with
sufentanil.
C. Sufentanil has a higher volume of distribution than fentanyl because of its decreased
plasma protein binding.
D. Approximately 60% of an intravenous (IV) bolus dose of sufentanil is cleared from the
plasma in 90 minutes.
E. Sufentanil is extremely hydrophilic.
11. B. Sufentanil has a clinical potency ratio 2000 to 4000 times that of morphine. It is extremely
lipophilic. Combining vecuronium and sufentanil may cause a decrease in mean arterial
pressure during induction, and significant bradycardia and sinus arrest have been reported.
Bradycardia is not seen when pancuronium is used during anesthesia with sufentanil. Because
of a smaller degree of ionization at physiologic pH and higher degree of plasma protein binding,
its volume of distribution is somewhat smaller and its elimination half-life is shorter than those of
fentanyl. Plasma sufentanil concentration decreases very rapidly after an IV bolus dose, and
98% of the drug is cleared from plasma within 30 minutes. (See page 478: Cardiovascular and
Endocrine Effects.)
12. Which of the following characteristics of remifentanil is FALSE&quest;

A. Remifentanil is about 40 times more potent than alfentanil.
B. Remifentanil is devoid of muscle rigidity side effects because of its rapid metabolism.
C. Remifentanil has less depressant effect on motor evoked potentials than other
opioids.
D. Remifentanil is associated with poor postoperative pain control if it is used
intraoperatively because of its rapid metabolism.
E. Shivering is more common with remifentanil than with alfentanil.
12. C. Nalbuphine is a partial opioid agonist at both κ and μ receptors. Administered alone,
partial agonists exhibit a more shallow dose–response curve and lower maximal effects than full
agonists. The respiratory depression produced by nalbuphine has a ceiling effect equivalent to
that produced by 30 mg/70 kg of morphine. Because of this, nalbuphine has been used to
antagonize the adverse effects of other opioids while still providing analgesic effects. Indeed,
nalbuphine has been shown to be as effective as full μ agonists in providing postoperative
analgesia in some instances. However, there is still the potential for respiratory depression. As
155 / 494
an opioid agonist–antagonist, nalbuphine may precipitate withdrawal symptoms in patients who
are dependent on opioids. (See page 488: Partial Agonist and Mixed Agonist–Antagonists:
Nalbuphine.)
13. All of the following statements regarding nalbuphine are true EXCEPT:
A. The analgesic properties of nalbuphine exhibit a ceiling effect.
B. In some instances, nalbuphine can be as effective as full μ agonists in providing
postoperative analgesia.
C. Significant respiratory depression is not seen with nalbuphine.
D. Nalbuphine may be used to antagonize the respiratory depressant effects of another
opioid while still providing analgesia.
E. Nalbuphine may precipitate withdrawal symptoms in patients who are physically
dependent on opioids.
13. B. Remifentanil is about 40 times as potent as alfentanil. A high incidence of muscle rigidity
and purposeless movement has been seen with remifentanil. Although all opioids and propofol
depress motor evoked potentials in a dose-dependent fashion, remifentanil exerts less
suppression than other opioids and propofol. One drawback of remifentanil use for general
anesthesia is that patients require analgesics soon after an infusion is stopped. Shivering is
less common with alfentanil than with remifentanil. (See page 484: Remifentanil.)
14. Which of the following statements regarding opioid-induced nausea and vomiting is
TRUE&quest;
A. Equipotent doses of opioids cause an equal incidence of nausea and vomiting.
B. Morphine has no direct effect on the chemoreceptor trigger zone.
C. Subcutaneous administration of opioids is associated with a lower incidence of
nausea and vomiting compared with intravenous (IV) administration.
D. Vestibular stimulation such as ambulation attenuates the nausea caused by morphine.
E. All of the above
14. A. The incidence of opioid-induced nausea appears to be similar irrespective of the route of
administration (including oral, IV, intramuscular, subcutaneous, transmucosal, transdermal,
intrathecal, and epidural). Laboratory and clinical studies comparing the incidence and severity
of nausea and vomiting have found no differences among opioids (including morphine,
hydromorphone, meperidine, fentanyl, sufentanil, alfentanil, and remifentanil) in equianalgesic
doses. (See page 469: Morphine: Nausea and Vomiting.)
15. Which of the following statements regarding morphine-induced pupillary
constriction (miosis) in humans is/are TRUE&quest;
1. The presence of miosis correlates with opioid-induced respiratory depression.
2. The effect is thought to be mediated via the nucleus tractus solitarius of the
oculomotor nerve.
3. A near-maximal degree of miosis is seen with as little as 0.5 mg/kg of morphine.
156 / 494
4. The absence of miosis virtually eliminates opioids as a cause of respiratory

depression.
15. B. Morphine produces dose-dependent miosis in humans, an effect that is believed to be
mediated by the Edinger-Westphal nucleus of the third cranial nerve. Although significant
differences exist between opioid species and their effects on pupillary size, morphine produces
a near-maximal degree of constriction with 0.5 mg/kg. In the absence of other drugs, the
resultant miosis appears to correlate with opioid-induced respiratory depression, although
severe hypoxemia may result in pupillary dilation. (See page 469: Morphine: Other Central
Nervous System Effects.)
P.93
16. The chemoreceptor trigger zone (CTZ) in the area posterior of the medulla is rich in
which receptors&quest;
1. Opioid
2. Dopamine
3. Histamine
4. Serotonin
16. E. The CTZ is rich in opioid, dopamine, serotonin, histamine, and (muscarinic) acetylcholine
receptors and receives input from the vestibular portion of the eighth cranial nerve. Morphine
and related opioids induce nausea by direct stimulation of the CTZ and can also produce
increased vestibular sensitivity. (See page 471: Nausea and Vomiting.)
17. The clinical effects of meperidine that differ from those observed with other
commonly used opioids include:
1. absence of histamine release from tissue mast cells
2. decrease in cardiac contractility after high doses
3. less nausea and vomiting at equianalgesic doses
4. direct local anesthetic effects
17. C. Meperidine is a synthetic opioid with an analgesic potency about one tenth that of
morphine. Although the analgesic effects are primarily mediated via μ receptor activation,
meperidine has demonstrated local anesthetic properties, which has led to its increasing
popularity for epidural and subarachnoid administration. This local anesthetic effect is thought
to be responsible for decreases in cardiac contractility observed with high plasma
concentrations of meperidine, a finding not consistent with other clinically used opioids.
Meperidine administration does result in histamine release, an effect that may contribute to the
hemodynamic instability often encountered when high doses are used in the clinical setting. At
equianalgesic doses, the respiratory depression caused by meperidine is no different from that
induced by morphine, hydromorphone, meperidine, fentanyl, sufentanil, alfentanil, or
remifentanil. (See page 473: Meperidine: Side Effects.)
18. Common potential disadvantages of a high-dose opioid anesthetic technique using

fentanyl as the sole agent for anesthesia include:
1. hemodynamic instability and cardiac depression
157 / 494
2. impaired ventilation resulting from intense chest wall muscle rigidity
3. prolonged anterograde amnesia
4. the need for protracted postoperative ventilatory support
18. C. High-dose opioid-based anesthetic techniques, particularly those using synthetic opioids
(e.g., fentanyl), initially gained popularity because of the reliable hemodynamic stability that is
achieved with minimal cardiovascular depression. In addition, hormonal responses to surgical
stimuli are significantly blunted with such a regimen. Notable disadvantages include prolonged
respiratory depression, a high incidence of clinically significant muscle rigidity on induction, and
frequent reports of intraoperative awareness and recall when opioids are used as the sole
anesthetic agent. (See page 476: Fentanyl: Use in Anesthesia.)
19. Characteristics of buprenorphine include:

1. it does not appear to have agonist activity at the κ -opioid receptor
2. at small to moderate doses, it is 25 to 50 times more potent than morphine
3. at very high doses, it produces progressively less analgesia
4. the maximum naloxone antagonist effect may not occur until 3 hours after naloxone
administration because of buprenorphine's slow dissociation from μ receptors
19. E. Buprenorphine is a highly lipophilic thebaine derivative and is a partial μ -opioid agonist.
At small to moderate doses, it is 25 to 50 times more potent than morphine. Unlike nalbuphine
and butorphanol, buprenorphine does not appear to have agonist activity at the κ -opioid
receptor. Another unique characteristic of buprenorphine is its slow dissociation from μ
receptors, which may lead to prolonged effects not easily antagonized by naloxone.
Buprenorphine also appears to have an unusual bell-shaped dose–response curve such that at
very high doses, it produces progressively less analgesia. (See page 490: Buprenorphine.)
20. Potential disadvantages to use remifentanil as a component to a balanced

anesthetic technique include:
1. prolonged respiratory depression with infusion techniques resulting from accumulation
of active metabolites
2. ultrashort duration of analgesic effect
3. a single dose of 20 μg/kg reliably produces unconsciousness when used for induction
4. intraoperative muscle rigidity
20. C. Remifentanil is rapidly metabolized by blood and tissue esterases to a substantially less
active compound. The duration of the respiratory depression seen with remifentanil has been
shown to parallel the duration of its analgesic effects. The side effects of remifentanil, including
a high incidence of muscle rigidity with high doses, are similar to those of other commonly used
opioids at equianalgesic doses. Although an ultrashort duration of action makes remifentanil an
appealing agent for opioid infusion techniques and ease of titration, this characteristic poses a
potential disadvantage because patients may require additional analgesics very soon after
remifentanil is discontinued. Loss of consciousness is not reliably achieved with remifentanil
alone. (See page 484: Remifentanil.)
21. Potential hazards in the use of naloxone to reverse opioid-induced respiratory

depression include:
158 / 494
1. sudden, severe pain in postoperative patients

2. precipitation of withdrawal syndromes in patients who are physically dependent on
opioids
3. late respiratory depression
4. acute pulmonary edema
21. E. Naloxone is a pure opioid antagonist at μ, κ, and δ opioid receptors that is used most
often in clinical practice to antagonize opioid-induced respiratory depression and sedation.
Because naloxone antagonizes all opioid–receptor interactions, it interrupts μ - and κ -receptor
–mediated analgesia and may lead to severe pain. In some instances, acute, and sometimes
fatal, pulmonary edema may ensue, an effect that is believed to result from a centrally mediated
catecholamine release causing acute pulmonary hypertension. Because the duration of clinical
effect seen with naloxone ranges from 1 to 4 hours, it is possible for renarcotization to occur
when pre-existing opioids reactivate receptors after the effects of naloxone have subsided.
(See page 490: Opioid Antagonists [Naloxone and Naltrexone].)
159 / 494
Review of Clinical Anesthesia, 5e [Vishal] 20. Neuromuscular Blocking Agents
Chapter 20
Neuromuscular Blocking Agents
1. All of the following statements regarding a peripheral nerve are true EXCEPT:
A. It is made up of a large number of axons of different threshold potentials.
B. Each axon responds in an all-or-none fashion to a given stimulus.
C. When a stimulating current reaches a high enough level, all axons are activated, and
the amplitude of the action potential reaches a maximum level.
D. There is a linear relationship between the amplitude of the muscle contraction and the
current applied.
E. Sodium channels in the nerve axon are activated in response to electrical stimulation.
1. D. A peripheral nerve is made up of a large number of axons of different thresholds and
sizes. Each axon responds in an all-or-none fashion, but not all axons may respond to a given
stimulus. The relationship between the amplitude of the muscle contraction and the current
applied is sigmoid, not linear. At low currents, an insufficient number of axons is depolarized. As
the current increases, increasingly more axons are depolarized to threshold, and the strength of
the muscle contraction increases up to a maximum level. The mechanism of action of nerve cell
activation is via the opening of sodium channels. (See page 501: Physiology and
Pharmacology: Structure.)
2. The duration of the current delivered by a nerve stimulator should be

approximately:
A. 0.2 sec
B. 0.02 sec
C. 0.2 ms
D. 0.02 ms
E. 2.0 ms
2. C. The duration of the current delivered by a nerve stimulator should be 0.1 to 0.2 ms. (See
page 501: Physiology and Pharmacology: Nerve Stimulation.)
3. Which of the following statements regarding acetylcholine (Ach) is FALSE&quest;

A. The amount of Ach released with repetitive stimulation decreases.
B. Calcium is required for vesicle binding to docking proteins and subsequent release of
Ach.
C. The action of magnesium augments the release of Ach from vesicle stores.
D. Ach is released in quanta, each of which contains 5000 to 10,000 molecules.
E. In the absence of stimulation, a small amount of Ach is released at random.
3. C. Ach is packaged into 45-nm vesicles, each of which contains 5000 to 10,000 molecules of
Ach. A few vesicles are available for immediate release, but a much larger pool can be recruited
with time. With repetitive stimulation, the amount of Ach released decreases rapidly because of
160 / 494
the limited availability of immediately releasable Ach. Even in the absence of nerve stimulation,
Ach is released in small quantities called quanta, producing so-called miniature end plate
potentials. When an action potential reaches the nerve terminal, about 200 to 400 quanta are
released simultaneously, causing a rapid increase in the concentration of Ach at the motor end
plate. Calcium enters the nerve terminals through channels that open in response to
depolarization and is responsible for release of Ach from vesicles. Magnesium antagonizes the
action of calcium and causes inhibition of Ach release. (See page 501: Physiology and
Pharmacology: Release of Acetylcholine.)
4. Which of the following statements regarding neuromuscular blocking drugs (NMBs)

is FALSE&quest;
A. The ED50 is the median dose corresponding to a 50% depression in twitch.
B. The ED95 corresponds to the dose required to achieve neuromuscular blockade in
95% of patients.
C. The ED95 of vecuronium is approximately 0.05 mg/kg.
D. The time to maximal neuromuscular blockade can be shortened if the dose of NMB is
increased.
E. The duration of action of NMBs increases with increasing dose.
4. B. The ED50 and ED95 are two measures of NMB potency. The ED50 is the median dose
corresponding to a 50% depression in twitch. The ED95, a more clinically relevant measure of
potency, is defined as the amount of drug necessary to produce a 95% block in twitch response
in half of patients. For example, the ED95 of vecuronium is approximately 0.05 mg/kg. The time
needed to reach maximal neuromuscular blockade and duration of block are both affected by
amount of drug given. The response time can be shortened and the duration increased when
an increased amount of drug is administered. (See page 503: Neuromuscular Blocking Agents:
Pharmacologic Characteristics of Neuromuscular Blocking Agents.)
5. Which of the following statements regarding the depolarizing blockade produced by

succinylcholine (Sch) is FALSE&quest;
A. During phase I block, fade in response to train-of-four (TOF) stimulus is not observed.
B. Phase II block is not antagonized by cholinesterase inhibitors.
C. After administration of a 7 to 10 mg/kg dose of Sch, TOF and tetanic fade typically
become apparent.
D. The prevalence of fasciculations after injection of Sch is greater than 50%.
E. Sinus bradycardia in response to Sch is more common in children than in adults.
5. B. Administration of a usual intubating dose of Sch produces a phase I block marked by a
decrease in single-twitch height, but sustained response to high-frequency stimulation and
minimal, if any, TOF or tetanic fade. Phase I blockade is potentiated by inhibitors of
acetylcholinesterase. After administration of larger doses of Sch (7–10 mg/kg) or within 30 to 60
minutes after initiating infusion, TOF and tetanic fade typically become apparent. This is
referred to as phase II blockade. In contrast to phase I block, phase II block can be antagonized
by acetylcholinesterase inhibitors. Sch produces a number of characteristic side effects.
Fasciculations in response to Sch injection occur in 60% to 90% of patients and can often be
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reduced with the prior administration of a small dose of a nondepolarizing neuromuscular

blocking drug such as rocuronium. Sinus bradycardia with nodal or ventricular escape beats is
a relatively common cardiovascular side effect, more so in children than adults. (See page 504:
Depolarizing Drugs: Characteristics of Depolarizing Blockade.)
6. Regarding the clinical use of succinylcholine (Sch), all of the following statements
are true EXCEPT:
A. Infants and children are relatively resistant to Sch compared with adults.
B. The duration of neuromuscular blockade produced by Sch is significantly increased in
patients homozygous for an atypical form of plasma cholinesterase.
C. Increases in serum potassium levels after Sch injection can be mitigated by
precurarization.
D. Precurarization may be effective at blocking the increase in intragastric pressure
observed after Sch administration.
E. At a dose of 1 mg/kg, the duration of action of Sch is approximately 5 to 6 minutes.
6. C. Sch is the only depolarizing neuromuscular blocking drug (NMDB) regularly used in
clinical practice. It has an onset of action of approximately 30 to 60 seconds and a duration of
action of 5 to 6 minutes, making it a useful agent for rapid sequence intubations and for patients
in whom prolonged muscle relaxation is not desired. Side effects commonly observed after
administration of a neuromuscular blocking drug include muscle fasciculations and an elevation
of intragastric and intraocular pressures. Both of these reactions can be blocked (but not with
100% consistency) by the prior administration of a small dose of nondepolarizing NMB
(precurarization). Sch also increases serum potassium levels by approximately 0.5 to 1.0
mEq/L. This effect is not prevented by precurarization. Therefore, Sch should be used with
caution in patients at risk of developing clinically significant hyperkalemia. Sch is metabolized
by plasma cholinesterase. Patients with atypical versions of this enzyme experience
prolongation of neuromuscular blockade caused by succinylcholine. However, this prolongation
is only significant in patients who are homozygous for atypical cholinesterase. (See page 504:
Depolarizing Drugs: Succinylcholine.)
P.98
7. All of the following statements regarding the pharmacokinetics of nondepolarizing
neuromuscular blocking drugs (NMBs) are true EXCEPT:
A. Termination of the clinical effects of vecuronium depends primarily on redistribution
rather than elimination.
B. Termination of the clinical effects of cisatracurium depends primarily on elimination.
C. The volume of distribution of most nondepolarizing NMBs is approximately equal to
extracellular fluid (ECF) volume.
D. More potent drugs have a faster onset of action than less potent agents.
E. The onset and duration of action are determined by the concentration of drug at its
site of action.
7. D. The duration of action of NMBs is a function of either their elimination from the body or
redistribution away from the site of effect. Cisatracurium is an intermediate-duration drug whose
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effects are terminated as a result of elimination. By contrast, vecuronium has a long elimination
half-life but an intermediate effect duration as a result of redistribution away from the motor end
plate. The volume of distribution of nondepolarizing NMBs is about equal to the volume of the
ECF compartment. The onset and duration of action of most NMBs are determined by the time
required for drug concentrations to reach a critical level at their site of action. Drug
concentration at the effect site approximately parallels plasma concentration, but drug onset
lags slightly behind peak plasma concentration. More potent drugs actually have slower onsets
of action than less potent ones because there are fewer molecules of the more potent agent
than of an equivalent dose of a less potent agent. (See page 507: Nondepolarizing Drugs:
Pharmacokinetics and page 507: Onset and Duration of Action.)
8. Which of the following muscle groups demonstrates the earliest recovery from
neuromuscular blockade after administration of an anticholinesterase agent&quest;
A. Adductor pollicis
B. Diaphragm
C. Geniohyoid
D. Pharyngeal
E. Flexor hallucis
8. B. The diaphragm exhibits the most rapid recovery from neuromuscular blockade. Recovery
of upper airway and pharyngeal muscles (e.g., geniohyoid) and the flexor hallucis muscle
generally parallels that of the adductor pollicis. (See page 517: Monitoring Neuromuscular
Blockade: Choice of Muscle.)
9. Which of the following is an acetylcholinesterase inhibitor with an onset of action

most similar to atropine&quest;
A. Glycopyrrolate
B. Edrophonium
C. Neostigmine
D. Pyridostigmine
E. Physostigmine
9. B. Anticholinergic agents such as atropine and glycopyrrolate are frequently administered
with neuromuscular reversal agents to blunt the cardiovascular effects of vagal stimulation
produced by reversal agents. To achieve the best effect, agents with similar pharmacokinetics
should be paired. The onset of action of atropine is rapid (∼1 min) and closely parallels that of
edrophonium. The onset of action of neostigmine is about 7 to 11 minutes, and pyridostigmine's
onset of action is 15 to 20 minutes. Physostigmine has an onset of about 5 minutes. It is not
used as a neuromuscular reversal agent because of its central side effects. The
pharmacokinetic profile of glycopyrrolate (onset, 2–3 minutes) is most similar to that of
neostigmine. (See page 522: Antagonism of Neuromuscular Block: Reversal Agents.)
10. All of the following are side effects associated with anticholinesterase drugs
EXCEPT:
A. increased salivation
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B. increased peristalsis
C. bradycardia
D. bronchodilation
E. increased bladder motility
10. D. Anticholinesterase agents produce vagal stimulation, leading to bradycardia and
bradyarrhythmias. Other cholinergic effects observed with anticholinesterase drugs include
increased salivation and increased bladder and bowel motility. Anticholinesterases may also be
associated with bronchoconstriction, not bronchodilation. (See page 522: Antagonism of
Neuromuscular Block: Anticholinesterases: Other Effects.)
11. All of the following statements about Sugammadex are true EXCEPT:
A. Sugammadex has no affect on succinylcholine.
B. Sugammadex has a higher affinity for rocuronium than for vecuronium and
pancuronium.
C. Sugammadex acts on neuromuscular blocking agents that do not contain a steroid
nucleus.
D. In larger doses, Sugammadex is an effective agent when neuromuscular blockade is
deep.
E. Sugammadex has no known major cardiovascular side effects.
11. C. Sugammadex (previously referred to as ORG 25969) reverses neuromuscular blockade
by binding to neuromuscular blocking agents in the plasma, which decreases the free or
unbound drug in the plasma. This creates a concentration gradient between the neuromuscular
junction and plasma, leading to the movement of the respective agents from the neuromuscular
junction to the plasma and thus a decrease in neuromuscular block. Sugammadex selectively
binds neuromuscular blocking agents that contain a steroid nucleus (rocuronium, vecuronium,
and pancuronium), with a noted higher affinity toward rocuronium compared with vecuronium
and pancuronium. There are no known major cardiovascular side effects because it does not
bind to any known receptors. In larger doses, Sugammadex can be effective when blockade is
deep. (See page 522: Antagonism of Neuromuscular Block: Sugammadex.)
For questions 12 through 18, answer A if 1, 2, and 3 are correct; B if 1 and 3 are correct; C if
2 and 4 are correct; D if 4 is correct; or E if all are correct.
12. Which of the following statements about the nondepolarizing neuromuscular
blocking drugs (NMDBs) is/are TRUE&quest;
1. Laudanosine is a metabolite of cisatracurium.
2. Pancuronium is associated with histamine release.
3. Mivacurium is metabolized by plasma cholinesterase.
4. Hypotension after administration of d-tubocurarine is mainly the result of autonomic
ganglionic blockade.
12. B. Laudanosine is a compound produced by the ester hydrolysis of atracurium and
cisatracurium. Similar to succinylcholine, mivacurium is metabolized by plasma cholinesterase.
Several of the nondepolarizing NMBs are associated with histamine release, which may cause
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transient hypotension after administration. This is the primary reason for the hypotension
observed after administration of d-tubocurarine; it also causes ganglionic block. Pancuronium
does not release histamine but does appear to cause a transient increase in catecholamine
release, leading to a temporary increase in heart rate, blood pressure, and cardiac output. (See
page 507: Nondepolarizing Drugs: Individual Nondepolarizing Agents.)
13. Which of the following agents augment(s) neuromuscular blockade&quest;

1. Isoflurane
2. Erythromycin
3. Lidocaine
4. Metronidazole
13. B. Several agents potentiate the effect of the neuromuscular blocking drugs. These include
the halogenated inhalational agents such as isoflurane and local anesthetics such as lidocaine.
Aminoglycosides such as neomycin and streptomycin also potentiate neuromuscular blockade.
Erythromycin, penicillins, and metronidazole, however, do not produce this effect. (See page
514: Drug Interactions.)
14. Which of the following statements regarding patients with myasthenia gravis is/are
TRUE&quest;
1. They often demonstrate resistance to depolarizing neuromuscular blocking drugs
(NMDBs).
2. They often demonstrate resistance to nondepolarizing NMBDs.
3. The number of acetylcholine quanta at the neuromuscular junction is generally normal
or increased.
4. They demonstrate a voltage increment in response to repeated stimulation at 2 to 5
Hz.
14. B. Myasthenia gravis is an autoimmune disorder characterized by the production of
antibodies to postsynaptic acetylcholine receptors. The number of acetylcholine (Ach) quanta at
the neuromuscular junction is normal or increased. However, muscle contraction in response to
acetylcholine is blunted by a functional decline in acetylcholine receptors. The characteristic
electromyographic finding in patients with myasthenia gravis is a voltage decrement in response
to repeated stimulation at the 2- to 5-Hz level. Patients with myasthenia gravis have
unpredictable responses to NMBs. They are often resistant to succinylcholine, partly because
of the presence of higher concentrations of Ach at the motor end plate. In contrast, sensitivity
and prolonged duration of action are usually observed in response to nondepolarizing NMBs,
as a result of the decreased number of functional Ach receptors present on postsynaptic
membranes. (See page 515: Altered Responses to Neuromuscular Blocking Agents:
Myasthenia Gravis.)
15. In which of the following patients is a greater than average increase in serum
potassium in response to succinylcholine (Sch) administration found compared with
the general population&quest;
1. A 57-year-old woman who sustained extensive burns 1 week ago
2. A 19-year-old patient with T12 paralysis after a motor vehicle collision 1 month ago
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3. A 69-year-old man after a major stroke
4. A 40-year-old woman diagnosed with myasthenia gravis 1 month ago
15. A. An exaggerated increase in serum potassium concentration after Sch administration is
relatively more common in children with muscular dystrophies (e.g., Duchenne). It is also
observed as early as 24 to 48 hours after extensive burn injuries; this response usually lessens
with healing. In addition, patients with upper motor neuron lesions are more susceptible to
hyperkalemia induced by Sch. This response is most prominent when the drug is given 1 week
to 6 months after injury, although it may occur at any time. Hyperkalemia after Sch
administration is not frequently associated with myasthenia gravis. (See page 504: Depolarizing
Drugs: Side Effects.)
16. Which of the following statements regarding train-of-four (TOF) response

monitoring of the degree of nondepolarizing neuromuscular blockade is/are
TRUE&quest;
1. The second twitch reappears when approximately 80% to 90% of receptors remained
blocked.
2. The third twitch reappears when approximately 70% to 80% of receptors remained
blocked.
3. All four twitches are visible when 65% to 75% of receptors are blocked.
4. The single-twitch height has recovered to about 100% when the TOF ratio is
approximately 70%.
16. E. TOF response monitoring to nondepolarizing neuromuscular blockade involves the
application of four stimuli at 0.5-second intervals (2 Hz). Recovery from neuromuscular block is
measured by the return of response to these stimuli. In general, the first twitch reappears if less
than 90% to 92% of receptors are blocked (8% to 10% are unblocked). The second twitch
appears when 80% to 90% of receptors remain blocked, and the third appears when 75% to
80% are blocked. All four responses are usually visible when there is less than 65% to 75%
receptor blockade. At this time, single-twitch height has recovered to approximately 100% of
pre-relaxant height, and the height of T4 increases to approximately 70% of the height of T1.
(See page 517: Monitoring Neuromuscular Block: Monitoring Modalities.)
P.99
17. Regarding the differential impact of neuromuscular blocking drugs (NMDBs) on
specific muscle groups, which of the following statements is/are TRUE&quest;
1. The adductor pollicis is relatively resistant to nondepolarizing NMBs compared with
the diaphragm.
2. Facial nerve stimulation with monitoring of response in the eyebrow is reliably
predictive of intubating conditions.
3. Time to maximal response occurs more quickly in the adductor pollicis than in the
diaphragm.
4. The diaphragm and laryngeal muscles are relatively resistant to nondepolarizing
agents.
17. C. Muscle groups demonstrate a differential response to NMBs. The adductor pollicis is
relatively sensitive to nondepolarizing NMBs, but the diaphragm and laryngeal muscles are
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relatively resistant. The time to maximal blockade occurs somewhat later in the adductor pollicis
compared with the more centrally located airway muscles. Facial nerve stimulation with
response monitored in the eyebrow is thought to be indicative of the action of the corrugator
supercilii muscle. The impact of nondepolarizing NMBs on this muscle approximates that of the
laryngeal adductors, so response monitoring to eyebrow movement may be a reliable predictor
of adequate intubating conditions. However, monitoring in the supraorbital region may pose
some technical difficulties. (See page 517: Monitoring Neuromuscular Block: Choice of Muscle.)
18. Which of the following acetylcholinesterase inhibitors can cross the blood–brain
barrier&quest;
1. Edrophonium
2. Pyridostigmine
3. Neostigmine
4. Physostigmine
18. D. Neostigmine, edrophonium, and pyridostigmine are all charged quaternary ammonium
compounds that do not cross the blood–brain barrier. Physostigmine is an uncharged molecule
that can cross the blood–brain barrier. (See page 522: Antagonism of Neuromuscular Block:
Reversal Agents.)
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Review of Clinical Anesthesia, 5e [Vishal] 21. Local Anesthetics
Chapter 21
Local Anesthetics
1. Which statement regarding myelinated nerves is FALSE&quest;

A. They have a diameter of more than 1 μm.
B. They are surrounded by Schwann cells, which account for more than half of the
nerve's thickness.
C. They conduct impulses more slowly than similar-sized unmyelinated nerves.
D. They have both afferent and efferent functions.
E. The nodes of Ranvier are covered by negatively charged glycoproteins.
1. C. Myelinated nerves generally conduct impulses faster than unmyelinated nerves. The
presence of myelin accelerates conduction velocity by increased electrical isolation of nerve
fibers and by saltatory conduction. Increased nerve diameter accelerates conduction velocity
both by increased myelination and by improved electrical cable conduction properties of the
nerve. Myelinated and unmyelinated nerves carry both afferent and efferent functions. All
nerves with a diameter larger than 1 μm are myelinated. Myelinated nerve fibers in the
peripheral nervous system are segmentally enclosed by Schwann cells forming a bilipid
membrane that is wrapped several hundred times around each axon. Myelinated nerve fibers in
the central nervous system are segmentally enclosed by oligodendrocytes. Thus, myelin
accounts for more than half the thickness of large nerve fibers. The nodes of Ranvier are
separated by the myelinated regions. The nodes are covered by interdigitations from
nonmyelinated Schwann cells and by negatively charged glycoproteins. (See page 531:
Anatomy of Nerves.)
2. Which statement regarding neuronal conduction is FALSE&quest;

A. The resting membrane potential is predominantly maintained by a potassium gradient
with a 10 times greater concentration of potassium within the cell.
B. Generation of action potentials is primarily the result of activation of voltage-gated
sodium channels.
C. Impulse generation is an all-or-nothing phenomenon.
D. A three-state kinetic scheme conceptualizes the change in sodium channel
conformation and accounts for changes in sodium conductance during depolarization
and repolarization.
E. The resting membrane potential of neural membranes averages -30 to -40 mV.
2. E. The resting potential of neural membranes averages –60 to –70 mV, with the interior being
negative compared with the exterior. This resting potential is predominately maintained by a
potassium gradient with a 10 times greater concentration of potassium within the cell. An active
protein pump transports potassium into the cell and sodium out of the cell through voltage-
gated potassium channels. Generation of an action potential is primarily the result of voltage-
gated sodium channels. After activation (opening) of the sodium channel, it spontaneously
closes into an inactive state and then reverts to a resting confirmation. Thus, a three-state
168 / 494
kinetic scheme conceptualizes the changes in the sodium channel confirmation that account for
shifts in sodium conductance during depolarization and repolarization. An action potential is
generated when the depolarization threshold of an axon is reached. This threshold is not an
absolute voltage but depends on the dynamics of the sodium and potassium channels. After an
action potential is generated, propagation of the potential along nerve fibers is required for
information to be transmitted. Both impulse generation and propagation are “all-or-nothing”
phenomena. Nonmyelinated fibers require achievement of threshold potential at the
immediately adjacent membrane, but myelinated fibers require generation of threshold potential
at a subsequent node of Ranvier. (See page 532: Electrophysiology of Neural Conduction and
Voltage-Gated Sodium Channels.)
3. The rate of absorption from injection of local anesthetic to various sites generally
increases in the following order:
A. intercostal, caudal, epidural, brachial plexus, sciatic/femoral
B. caudal, intercostal, epidural, brachial plexus, sciatic/femoral
C. intercostal, epidural, caudal, brachial plexus, sciatic/femoral
D. sciatic/femoral, brachial plexus, epidural, caudal, intercostal
E. intercostal, brachial plexus, epidural, caudal, sciatic/femoral
3. D. In general, local anesthetics with decreased systemic absorption have a greater margin of
safety in clinical use. The rate and extent of absorption depend on numerous factors; the most
important factors are the site of injection, the dose of local anesthetic, the physicochemical
properties of the local anesthetic, and the addition of epinephrine. The relative amount of fat
and vasculature surrounding the site of injection interact with the physicochemical properties of
the local anesthetic and affect the rate of systemic uptake. In general, areas with greater
vascularity have more rapid and complete uptake than those with more fat, regardless of the
type of local anesthetic. Hence, multiple injections near intercostal vascular bundles have a
faster uptake than injections in the buttocks and groin. The greater the total dose of local
anesthetic injected, the greater the systemic absorption and peak blood levels. (See page 536:
Chemical Properties and Relationship to Activity and Potency.)
4. Which of the following descriptions of local anesthetics is FALSE&quest;

A. They are weak bases.
B. The charged form of local anesthetics is lipid soluble.
C. They have substituted benzene rings.
D. They contain either an ester or amide linkage.
E. They exert their effects on the intracellular side of the sodium channel.
4. B. The clinically used local anesthetics consist of a lipid-soluble substituted benzene ring
linked to an amine group (tertiary or quaternary, depending on the pKa and pH) via an alkyl
chain containing either an amide or ester linkage. The type of linkage separates the local
anesthetics into either amino amides, which are metabolized in the liver, or aminoesters, which
are metabolized by plasma cholinesterases. Several chemical properties of local anesthetics
affect their efficacy and potency. All clinically used local anesthetics are weak bases that can
exist as either the lipid-soluble (neutral) form or as the hydrophilic (charged) form. The primary
site of action of local anesthetics appears to exist on the intracellular side of the sodium
169 / 494
channel, and the charged form appears to be the predominately active form. Penetration of the
lipid-soluble (neutral) form through the lipid neural membrane appears to be the primary form of
access of local anesthetic molecules. Increased lipid solubility usually hastens the rate of onset
of action, increases the duration of action, and increases potency. The degree of protein
binding also affects activity of local anesthetics because only the unbound form is free for
pharmacologic activity. In general, increased protein binding is associated with an increased
duration of action. (See page 536: Chemical Properties and Relationship to Activity and
Potency.)
5. Which statement concerning pKa is FALSE&quest;

A. The pKa is the dissociation constant.
B. When the pH equals the pKa of a compound, 50% of it is neutral and 50% of it is
charged.
C. Increasing the pKa of a local anesthetic increases the lipid-soluble form.
D. Onset of action is slowed by increasing the pKa.
E. Knowing the pKa of a local anesthetic allows one to predict the relative speed of its
onset of action.
5. C. The combination of pH of the environment and pKa, or dissociation constant, of a local
anesthetic determines how much of the compound exists in each form. Decreasing the pKa for
a given environmental pH increases the percentage of the lipid-soluble form and hastens
penetration of neural membranes and hence the onset of action. (See page 536: Chemical
Properties and Relationship to Activity and Potency.)
6. Which statement regarding the cardiovascular toxicity of bupivacaine is

FALSE&quest;
A. Vasodilation is a prominent feature.
B. Bupivacaine quickly dissociates from cardiac sodium channels during cardiac
diastole.
C. Cardiac myocyte release and utilization of calcium are inhibited.
D. Mitochondrial energy metabolism is reduced.
E. The cardiotoxicity of bupivacaine may be mediated centrally and peripherally.
6. B. It has been demonstrated that the central and peripheral nervous systems are involved
with the cardiotoxic effects of bupivacaine, which may be exacerbated by its potent direct
vasodilating properties. Bupivacaine exhibits a much stronger binding affinity to resting and
inactivated sodium channels than lidocaine. It dissociates from sodium channels during cardiac
diastole much more slowly than lidocaine, so slowly that complete sodium channel recovery is
not achieved and a bupivacaine conduction block accumulates. Bupivacaine also inhibits
myocyte release and utilization of calcium and reduces mitochondrial energy metabolism,
especially during hypoxia. (See page 542: Toxicity of Local Anesthetics.)
7. Which statement concerning clearance and elimination of local anesthetics is

FALSE&quest;
A. Ester local anesthetics are primarily cleared by plasma cholinesterases.
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B. Local anesthetics with higher rates of clearance have greater margins of safety.
C. Renal disease is important in altering the pharmacokinetic parameters of local
anesthetics.
D. Protein binding of amino amide local anesthetics is important in determining the rate
of clearance.
E. Correlation of resultant systemic blood levels between the dose of local anesthetic
and the patient's weight is often inconsistent.
7. C. Whereas clearance of ester local anesthetics is primarily dependent on plasma clearance
by cholinesterase, amide local anesthetic clearance is dependent on hepatic metabolism. Thus,
hepatic extraction, hepatic perfusion, hepatic metabolism, and protein binding primarily
determine the rate of clearance of amide local anesthetics. In general, local anesthetics with
higher rates of clearance have greater margins of safety. Renal disease has little effect on the
pharmacokinetic parameters of local anesthetics. Correlation of the resulting systemic blood
levels between the dose of local anesthetic and the patient's weight often is inconsistent. (See
page 538: Pharmacokinetics of Local Anesthetics.)
P.103
8. Which statement concerning treatment of systemic toxicity from local anesthetics is
FALSE&quest;
A. Signs of central nervous system (CNS) toxicity typically occur before cardiovascular
events.
B. Propofol can terminate seizures from systemic local anesthetic toxicity.
C. Succinylcholine (Sch) may terminate seizure activity.
D. Ventricular dysrhythmias may be difficult to treat.
E. Amiodarone is indicated in the treatment of bupivacaine toxicity.
8. C. Treatment of patients with systemic toxicity is primarily supportive. Injection of the local
anesthetic should be stopped. Oxygenation and ventilation should be maintained because
systemic toxicity of local anesthetics is enhanced by hypoxemia, hypercarbia, and acidosis. If
needed, the patient's trachea should be intubated and positive-pressure ventilation instituted.
Signs of CNS toxicity occur before cardiovascular events. Seizures may increase body
metabolism and cause hypoxemia, hypercarbia, and acidosis (three well-known factors that
further enhance the systemic toxicity of local anesthetics). Intravenous administration of
thiopental, midazolam, and propofol may terminate seizures from systemic local anesthetic
toxicity. Sch may terminate muscular activity from seizures and facilitate ventilation and
oxygenation; however, Sch does not terminate seizure activity in the CNS, and increased
cerebral metabolic demands continue unabated. Potent local anesthetics (e.g., bupivacaine)
may produce profound cardiovascular depression and malignant dysrhythmias that should be
treated promptly. Oxygenation and ventilation must be immediately instituted, with
cardiopulmonary resuscitation used if needed. Ventricular dysrhythmias may be difficult to treat
and may need repeated electrical cardioversion and large doses of epinephrine, vasopressin,
and amiodarone. (See page 544: Treatment of Systemic Toxicity from Local Anesthetics.)
9. Which statement concerning transient neurologic symptoms (TNS) after spinal

anesthesia is FALSE&quest;
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A. An increased risk of TNS is associated with lidocaine.
B. The baricity of the local anesthetic is an important factor in the development of TNS.
C. The dose of local anesthetic is not an important factor in the development of TNS.
D. TNS may be a manifestation of subclinical neurotoxicity.
E. The incidence of TNS varies with patient position.
9. B. There is a 4% to 40% incidence of TNS after lidocaine spinal anesthesia. All local
anesthetics have the potential to be neurotoxic, particularly in higher concentrations, and
symptoms have been reported with multiple agents. The incidence of TNS varies with the type
of surgical procedure and positioning (particularly the lithotomy position). Apparently, the
incidence is unaffected by the baricity or dose. Reports of cauda equina syndrome after spinal
anesthesia have led several authors to label TNS as a manifestation of subclinical neural
toxicity. Other potential causes of TNS include patient positioning, early mobilization, needle
trauma, neural ischemia, pooling of local anesthetics, and the addition of glucose. Clearly, the
cause of TNS remains undetermined, and further studies are needed to elucidate the
underlying mechanism. (See page 545: Transient Neurologic Symptoms After Spinal
Anesthesia.)
10. Which of the following statements is FALSE&quest;

A. Bupivacaine 0.75% is not an acceptable concentration for obstetric use.
B. Central nervous system (CNS) toxicity is more common with epidural local anesthetic
injection than with peripheral nerve blocks.
C. Levobupivacaine is approximately equipotent to racemic bupivacaine.
D. Both ropivacaine and levobupivacaine appear to have approximately 30% to 40% less
systemic toxicity than bupivacaine on a milligram-to-milligram basis.
E. Levobupivacaine is an isomer of bupivacaine.
10. B. Enhanced awareness of potential cardiovascular toxicity with long-acting local
anesthetics led to withdrawal of Food and Drug Administration approval for high concentrations
of bupivacaine (0.75%) for obstetric use in the United States. The incidence of CNS toxicity
with epidural injection is approximately one in 10,000; with peripheral nerve blocks, it is seven
in 10,000. Levobupivacaine, an isomer of bupivacaine, appears to be approximately equally
potent to racemic bupivacaine for epidural anesthesia. Both ropivacaine and levobupivacaine
appear to have approximately 30% to 40% less toxicity than bupivacaine on a milligram-to-
milligram basis in both animal and human volunteer studies. This is likely the result of reduced
affinity in brain and myocardial tissue. (See page 542: Systemic Toxicity of Local Anesthetics:
Central Nervous System Toxicity.)
11. All of the following local anesthetics are racemic mixtures EXCEPT:
A. lidocaine
B. bupivacaine
C. mepivacaine
D. tetracaine
E. chloroprocaine
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11. A. All currently available local anesthetics, with the exception of lidocaine (achiral),
ropivacaine, and levo-bupivacaine, are racemic mixtures. Stereoisomers of local anesthetics
appear to have potentially different effects on anesthetic potency, pharmacokinetics, and
systemic toxicity. For example, R isomers appear to have greater in vitro potency for block of
both neural and cardiac sodium channels and may thus have greater therapeutic efficacy and
potential systemic toxicity. (See page 536: Pharmacology and Pharmacodynamics.)
12. Which of the following statements concerning spinal administration of opioids are
TRUE&quest;
1. It is not dependent on supraspinal mechanisms.
2. Combining a local anesthetic with opioids results in synergistic analgesia.
3. 2-Chloroprocaine appears to decrease the effectiveness of epidural opioids.
4. Spinal administration of opioids provides analgesia primarily by attenuating the α δ
fiber nociception.
12. A. Opioids have multiple central neuraxial mechanisms of analgesic action. Supraspinal
administration of opioids results in analgesia via opiate receptors in multiple sites, including
activation of descending spinal pathways. Spinal administration of opioids provides analgesia
primarily by attenuating C-fiber nociception and is independent of supraspinal mechanisms.
Coadministration of opioids with most local anesthetics results in synergistic analgesia. An
exception to this analgesic synergy is 2-chloroprocaine, which appears to decrease the
effectiveness of epidural opioids when used for epidural anesthesia. The mechanism for this
action is unclear but does not appear to involve direct anatomization of opioid receptors. (See
page 538: Opioids.)
13. Which of the following statements concerning peripheral opioid receptors are
TRUE&quest;
1. Peripheral opioid receptors are found primarily at the end terminals of efferent fibers.
2. Intra-articular and peri-incisional opioids have not been found to provide postoperative
analgesia.
3. Local tissue inflammation does not influence the analgesic effectiveness of peripheral
opioid agonists.
4. Combining local anesthetics with opioids for peripheral nerve blocks appears to be
ineffective.
13. C. The recent discovery of peripheral opioid receptors offers yet another circumstance in
which the coadministration of local anesthetics and opioids may be useful. Cumulative evidence
now suggests that neither intra-articular administration of local anesthetic and opioid for
postoperative analgesia nor combining local anesthetics and opioids for nerve blocks increases
efficacy. There are several reasons for a predicted lack of effective coadministration of local
anesthetics and opioids for peripheral nerve blocks. (See page 538: Opioids.)
14. Which of the following statements concerning local anesthetics are TRUE&quest;
1. pKa determines the onset of action.
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2. Lipophilicity influences potency.
3. Protein binding influences the duration of action.
4. Clinically used local anesthetics cannot be alkalinized beyond a pH of 9 before
precipitation occurs.
14. E. The physicochemical properties of local anesthetics affect systemic absorption. In
general, use of the more potent agents with greater lipid solubility and protein binding results in
lower systemic absorption and lower peak blood levels. Sequestration into lipid-rich
compartments and locally induced vasoconstriction are two mechanisms that affect systemic
absorption. The pH of commercial preparations of local anesthetics ranges from 3.9 to 6.47 and
is especially acidic if they are prepackaged with epinephrine. Because the pKa of commonly
used local anesthetics ranges from 7.6 to 8.9, less than 3% of the commercially prepared local
anesthetic exists as the lipid-soluble neutral form. However, clinically used local anesthetics
cannot be alkalinized beyond a pH of 6.05 to 8 before precipitation occurs, and such a pH will
increase the neutral form only to about 10%. (See page 538: Pharmacokinetics of Local
Anesthetics and page 537: Alkalinization of Local Anesthetic Solution.)
15. Systemic absorption and peak blood levels of local anesthetics are:
1. linearly related to the total dose of local anesthetic injected
2. reduced with the addition of epinephrine, especially for the less lipid-soluble, less
potent, shorter-acting agents
3. diminished with the more potent agents with greater lipid solubility and protein binding
4. independent of anesthetic concentration
15. E. Epinephrine may counteract the inherent vasodilating characteristics of most local
anesthetics. The reduction in blood concentration with epinephrine is most effective for the less
lipid-soluble, less potent, shorter-acting agents. The greater the total dose of local anesthetic
injected, the greater the systemic absorption and peak blood levels will be. This relationship is
nearly linear and is relatively unaffected by the anesthetic concentration and speed of injection.
(See page 537: Systemic Absorption and Additives to Increase Local Anesthetic Activity:
Epinephrine.)
16. Which of the following statements concerning the central nervous system (CNS)
toxicity of local anesthetics are FALSE&quest;
1. CNS depression is a sign of high-dose local anesthetic toxicity.
2. CNS excitation is a sign of low-dose local anesthetic toxicity.
3. In general, decreased local anesthetic protein binding decreases potential CNS
toxicity.
4. The seizure threshold is increased by the administration of benzodiazepines.
16. A. Decreases in local anesthetic protein binding and clearance increase potential CNS
toxicity. Local anesthetics readily cross the blood–brain barrier, and generalized CNS toxicity
may occur from systemic absorption or direct vascular injection. Signs of generalized CNS
toxicity from local anesthetics are dose dependent. Low doses produce CNS depression, and
higher doses result in CNS excitation and seizures. The rate of intravenous administration of
local anesthetic affects signs of CNS toxicity because higher rates of infusion lessen the
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appearance of CNS depression while leaving excitation intact. This dichotomous reaction to
local anesthetics may be caused by a greater sensitivity of cortical inhibitory neurons to the
impulse-blocking effects of local anesthetics. External factors, such as acidosis and increased
PCO2, may increase CNS toxicity, perhaps by increasing cerebral perfusion and decreasing
protein binding of the local anesthetic. Seizure thresholds in response to local anesthetics are
increased by administration of barbiturates and benzodiazepines. (See page 542: Toxicity of
Local Anesthetics: Central Nervous System Toxicity.)
17. Which of the following statements regarding the cardiovascular toxicity of local
anesthetics are TRUE&quest;
1. In general, much greater doses of local anesthetics are required to produce
cardiovascular toxicity than neurotoxicity.
P.104
2. Bupivacaine cardiovascular toxicity is resistant to resuscitation.
3. The central and peripheral nervous systems may be involved in the increased
cardiotoxicity seen with bupivacaine.
4. Generally, the more potent, more water-soluble agents have increased cardiotoxicity.
17. A. In general, much greater doses of local anesthetics are required to produce
cardiovascular toxicity than central nervous system toxicity. Similar to CNS toxicity, the potency
for cardiovascular toxicity reflects the anesthetic potency of the agent. Recent attention has
focused on the apparently exceptional cardiotoxicity of the more potent, more lipid-soluble
agents (bupivacaine, etidocaine). These agents appear to have a different sequence of
cardiovascular toxicity than the less potent agents. For example, whereas increasing doses of
lidocaine lead to hypotension, bradycardia, and hypoxia, bupivacaine often results in sudden
cardiovascular collapse from ventricular dysrhythmias that are resistant to resuscitation. (See
page 542: Toxicity of Local Anesthetics: Cardiovascular Toxicity of Local Anesthetics.)
18. Which of the following statements concerning allergic reactions to local anesthetics
are TRUE&quest;
1. True allergic reactions to local anesthetics are rare.
2. Allergic reactions to local anesthetics usually involve a type I reaction.
3. The allergenic potential from esters may result from hydrolytic metabolism to para-
aminobenzoic acid.
4. Reactions are more common with amide than with ester anesthetics.
18. A. True allergic reactions to local anesthetics are rare and usually involve type I
(immunoglobulin E) or type IV (cellular immunity) reactions. Type I reactions are worrisome
because anaphylaxis may occur. They are more common with ester than with amide local
anesthetics. True allergy to amide agents is extremely rare. Increased allergenic potential with
esters may result from hydrolytic metabolism to para-aminobenzoic acid (a documented
allergen). Added preservatives, such as methylparaben and metabisulfite, may also provoke an
allergic response. (See page 546: Allergic Reactions to Local Anesthetics.)
19. Intravenous (IV) lidocaine has been associated with which of the following during
airway instrumentation&quest;
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1. Decreased intraocular pressure
2. Increased intracranial pressure
3. Decreased intraabdominal pressure
4. Fully intact airway reflexes
19. C. IV lidocaine may be effective for decreasing airway sensitivity to instrumentation by
depressing airway reflexes and decreasing calcium flux in airway smooth muscle. It is also
effective for attenuating increase in intraocular pressure, intracranial pressure, and intra-
abdominal pressure during airway instrumentation. IV lidocaine also has well-recognized
antidysrhythmic effects and is an effective analgesic used to treat patients with postoperative
and chronic neuropathic pain. (See page 540: Clinical Use of Local Anesthetics.)
176 / 494
Review of Clinical Anesthesia, 5e [Vishal] 22. Drug Interactions
Chapter 22
Drug Interactions
1. Pronounced drug interactions are not commonly seen by anesthesiologists because

of all of the following EXCEPT:
A. Interactions may occur, but they usually do not present a problem.
B. Variability in response to anesthetic drugs is commonly seen.
C. The qualitative nature of most anesthetic interactions is predictable even though the
magnitude of the responses may not be known with certainty.
D. Many intravenous anesthetic drugs have small safety margins, particularly when
respiration is supported.
E. It is likely that many instances of anesthetic drug interactions go unrecognized.
1. D. Drug interactions are not commonly seen in operating rooms even though patients
routinely take antihypertensives, antidepressants, or gastrointestinal drugs in the preoperative
period, and most of them receive five to 10 drugs during general anesthesia. One does not
normally hear about significant complications attributable to drug interaction, and numerous
explanations for this are possible. First, interactions may occur, but they usually do not present
a problem. Anesthesia practitioners are always prepared to titrate drugs and deal with the
possibility of significant respiratory, central nervous system, and cardiovascular depression.
Toxicity from a drug interaction is likely to become a source of morbidity primarily when it occurs
in a setting where it is not rapidly recognized and treated. An example of this occurred when
opioid–midazolam combination agents were first used by non-anesthesia personnel for
endoscopic and radiologic procedures. The unexpectedly large sedative and ventilatory effects
led to numerous deaths. A second explanation is variability in response to anesthetic drugs. As
a rule, different patients may have a three- to fivefold difference in the therapeutic and toxic
effects of a given dose even when a drug is given alone. Third, the qualitative nature of most
anesthetic interactions is predictable, although the magnitude of the response may not be
known with certainty. For example, two cardiovascular depressants will almost always produce
more hypotension. Similarly, combinations of central nervous system depressants produce
more (not less) depression. Drug interactions that produce a totally unexpected or dangerous
effect stand out because of their rarity. Fourth, many intravenous anesthetic drugs have large
safety margins, particularly when respiration is supported, so small changes in drug
concentration are not extremely important. The mere fact that a measurable interaction exists
does not mean that it will cause a difference in outcome or the need for intervention. It is
noteworthy that clinically meaningful interactions most often involve drugs such as warfarin,
digoxin, and theophylline (drugs with only small differences between therapeutic and toxic
concentrations). Finally, it is likely that many instances of anesthetic drug interactions go
unrecognized (the clinician must consider the possibility to make the diagnosis). Excessive drug
effects are often attributed to some ill-defined “patient sensitivity.” When a drug fails to produce
an effect, it is because a patient is “tolerant” or “resistant.” It is almost never considered a drug
reaction or interaction. (See page 550: Problems Created by Drug–Drug Interaction.)
2. Pharmacokinetic interaction is defined as one drug altering what property of another

drug&quest;
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A. Absorption
B. Distribution
C. Metabolism
D. Elimination
E. All of the above
2. E. A pharmacokinetic interaction occurs when one drug alters the absorption, distribution,
metabolism, or elimination of another. A pharmacodynamic interaction occurs when one drug
alters the sensitivity of a target receptor to the effects of a second drug. This means that the
dose–response or concentration–response curve is shifted by another medication. An example
of a drug-delayed absorption by a change in the physiologic environment is morphine's
decreasing gastrointestinal motility so that absorption of orally administered acetaminophen is
slowed. Another example of a drug's influencing the absorption of another is the common
addition of epinephrine to a local anesthetic solution to retard uptake of the local anesthetic
from the site of action. This effect also influences the distribution of the local anesthetic.
Distribution of a drug may also be influenced by coadministering a second drug that changes
the pH of the environment. Also, administering two drugs that compete for protein-binding sites
results in an increase of the free (active) fraction of each drug. Metabolism of one drug can be
either increased or decreased by the presence of another; an example is neostigmine's
inhibiting both motor end plate acetylcholinesterase and plasma pseudocholinesterase, which
may prolong the effect of succinylcholine (and potentially ester-type local anesthetics in the
bloodstream). (See page 551: Pharmacokinetic Interactions and Pharmacodynamic
Interactions.)
3. Monoamine oxidase (MAO) inhibitors:

A. may increase the effect of indirect-acting sympathomimetics
B. may interact with morphine to increase the brain concentration of serotonin
C. may interfere with beta-blockers
D. may be safely given with meperidine
E. should be discontinued for 24 hours before elective surgery to return enzyme levels to
baseline levels
3. A. MAO is found in tissues throughout the body, but the largest amounts are found in the
liver, kidney, and brain. MAO acts to regulate the presynaptic pool of norepinephrine,
dopamine, epinephrine, and serotonin available for synaptic transmission. MAO exists in two
isoforms: MAO-A preferentially metabolizes serotonin, dopamine, and norepinephrine, and
MAO-B preferentially metabolizes phenylethylamine and tyramine. MAO inhibitors are used
mainly for the treatment of patients with refractory depression and certain other mood disorders.
Interaction with indirect-acting sympathomimetic drugs (ephedrine, amphetamine, metaraminol)
occurs because MAO inhibitor treatment increases the amount of presynaptic transmitters that
can be released by these drugs. Normal doses of ephedrine may produce exaggerated
sympathetic responses, including a severe hypertensive crisis. Deaths have been attributed to
severe hyperpyrexia and cerebral hemorrhage. The “wine and cheese reaction” is essentially
the same interaction. Many foods, such as aged cheese, contain tyramine, a phenylethyl-amine
that has ephedrine-like actions at sympathetic nerve endings. Normal exogenous tyramine is
178 / 494
degraded by MAO in the gut wall and liver, but patients taking MAO inhibitors may achieve high
systemic concentrations and consequently have a hypertensive crisis. Because MAO plays little
role in the metabolism of compounds in the synaptic cleft, the response to sympathomimetics,
which act directly on postsynaptic receptor sites (phenylephrine, norepinephrine, epinephrine),
should be less affected by such interactions. Beta-blockers can be safely used in these
patients. Unquestionably, the most important interaction of MAO inhibitors is with meperidine.
When meperidine is given to a patient who is taking an MAO inhibitor, a life-threatening reaction
may occur accompanied by excitation, hyperpyrexia, hypertension, profuse sweating, and
rigidity. This may progress to seizures, coma, and death. This reaction does not occur in every
instance. The mechanism of the interaction between meperidine and MAO inhibitors is
unknown, but animal modes suggest that it involves elevation in the brain concentration of
serotonin. Current clinical opinion probably favors continuing MAO inhibitor therapy up to the
time of therapy. Most patients are receiving these drugs for moderate to severe psychiatric
disorders that have not responded to other treatments. It is unpleasant and possibly risky for a
patient with refractory depression to endure 2 to 3 weeks without effective therapy. But if a
general anesthetic is planned, it seems prudent to use as few drugs as possible. Avoiding drugs
with substantial sympathetic effects probably makes sense. Because opioids, such as fentanyl,
appear safe and there are no major interactions with local anesthetics or nonsteroidal anti-
inflammatory analgesics, providing anesthesia without meperidine should not be a hardship.
(See page 553: Monoamine Oxidase Interactions.)
4. Which statement concerning hepatic biotransformation is FALSE&quest;

A. Drugs undergo oxidative metabolism by cytochrome P450.
B. Cytochrome P450 has low substrate specificity.
C. Removal of drug from blood by hepatic clearance is a function of hepatic blood flow
and intrinsic clearance.
D. With drugs that have low extraction ratios, hepatic blood flow is the major rate-limiting
factor in overall hepatic clearance.
E. With drugs that have low extraction ratios, hepatic enzyme activity is a rate-limiting
factor.
4. D. Many anesthetic drugs undergo oxidative metabolism by one of the isoforms of the
cytochrome P450 found in liver microsomes. The P450 isoforms have low substrate specificity,
meaning that drugs of diverse structures can be biotransformed by a single group of enzymes.
The removal of drug from the blood by hepatic biotransformation (hepatic clearance) is a
function of two independent variables, the hepatic blood flow and the intrinsic clearance (the
maximal ability of the liver to metabolize that drug). The intrinsic clearance is often expressed
as the extraction ratio, which is defined as the fraction of drug that can be metabolized in a
single pass through the liver. Drugs may be classed broadly as high extraction or low extraction,
a distinction with important implications for drug interactions. For drugs with high extraction
ratios (e.g., lidocaine, propranolol), hepatic blood flow is a rate-limiting factor in overall hepatic
clearance (i.e., the delivery of drug to the liver determines the amount cleared). Clearance is
decreased by drugs or maneuvers that lower hepatic blood flow. Clearance of these rapidly
metabolized drugs is much less sensitive to changes in enzyme activity. Plasma-protein binding
does not have a large effect, either. Low-extraction drugs (e.g., diazepam, mepivacaine) behave
quite differently because hepatic enzyme activity is rate limiting (hepatic clearance is limited by
intrinsic clearance). Stimulation or inhibition of enzyme activity can have a large effect on
179 / 494
intrinsic clearance). Stimulation or inhibition of enzyme activity can have a large effect on
overall pharmacokinetics. Protein binding is also more likely to affect clearance because the
bound forms of these drugs are protected from hepatic metabolism. (See page 554: Hepatic
Biotransformation.)
5. Which statement about drug interactions is FALSE&quest;

A. A pharmacodynamic interaction occurs when one drug alters the sensitivity of a target
receptor or tissue to the effects of a second drug.
B. Additive interactions are most likely to occur when drugs with identical mechanisms
are combined.
C. There is usually an additive effect between succinylcholine and the nondepolarizing
relaxants.
D. Synergistic interactions are characterized by small doses of two or more drugs that
produce very large effects.
E. Isobolographic analysis is used for quantitatively assessing the effects of drug
combinations to see whether synergism occurs.
5. C. A pharmacodynamic interaction occurs when one drug alters the sensitivity of a target
receptor or tissue to the effects of a second drug. This means that the dose–response or
concentration–response curve for one drug is shifted by another. Additive interactions are most
likely to occur when drugs with identical mechanisms are combined. There is an antagonistic
interaction between succinylcholine and the nondepolarizing relaxants. Antagonistic drug
interactions involve deliberate reversal with drugs that compete at the same receptor site.
Synergistic drug interactions, in which small doses of two or more drugs can produce very large
effects, are most likely to occur when drugs of different classes, or even those with slightly
different mechanisms, are used to produce the same effects. Two of the most common
techniques used by experimental pharmacologists to study the effects of drug combinations are
algebraic (fractional) analysis and isobolographic analysis. (See page 556: Pharmacodynamic
Interactions.)
For questions 6 to 8, choose A if 1, 2, and 3 are correct, B if 1 and 3 are correct; C if 2 and 4
6. Which of the following statements are examples of a pharmaceutical
reaction&quest;
1. Bicarbonate added to bupivacaine causes a precipitation reaction.
2. Halogenated anesthetics have been shown to interact with dry soda lyme or baralyme
to produce carbon monoxide.
3. Nitric oxide reacts with oxygen to form nitrogen dioxide.
4. Orally administered tetracycline can be inactivated by chelation when it is given with
antacids containing magnesium, calcium, or aluminum.
6. A. A pharmaceutical interaction is a chemical or physical interaction that occurs before a drug
is administered or absorbed systemically. The most obvious pharmaceutical drug interactions
are the incompatibilities that may occur between intravenous drugs and solution (e.g.,
precipitation of barbiturate when thiopental is injected together with succinylcholine into an
intravenous line). In addition, two drugs may interact chemically to form a toxic compound (e.g.,
180 / 494
when halogenated anesthetics produce carbon monoxide when interacting with dry soda lyme
or nitric oxide forming nitrogen dioxide when it contacts oxygen). Tetracycline inactivation by
antacids is an example of a pharmacokinetic reaction. (See page 551: Pharmacokinetic
Interactions.)
P.109
7. Distribution changes resulting from drug–drug interactions may occur secondary to:
1. alterations in hemodynamics
2. changes in drug ionization
3. changes in binding to plasma and tissue proteins
4. changes in drug metabolism
7. A. Many drug–drug interactions occur when one drug alters the distribution of a second drug.
This may result from alterations in hemodynamics, drug ionization, or binding to plasma or
tissue proteins. Drug-induced hemodynamic compromise may affect pharmacokinetics. Drugs
such as beta-blockers, calcium channel blockers, and vasodilators may decrease cardiac
output by a variety of mechanisms and may produce significant changes in drug distribution.
For a given rate of drug administration, a decrease of cardiac output will increase the arterial
drug concentration to highly perfused tissues such as the brain and myocardium. Drug-induced
changes in pH in a particular body region or fluid compartment may alter the distribution of
other drugs by so-called “ion trapping.” A drug that is protein bound will not be filtered by a
normal glomerulus and (for some drugs) will not be acted upon by drug-metabolizing enzymes.
A drug that is highly bound to plasma protein effectively exists as a depot, similar to a deep
intramuscular injection. The potential therefore exists that one drug can alter the disposition,
clearance, or biologic effect of another by altering its binding. An example of this is illustrated by
a highly bound potentially toxic drug such as warfarin, which is more than 98% bound to
albumin. When another drug is given (e.g., phenylbutazone) that competes for the same binding
sites, it displaces warfarin and increases the free fraction, increasing the anticoagulant effect.
(See page 551: Pharmacokinetic Interactions.)
8. Which of the following are TRUE&quest;

1. Enzyme induction is an explanation for increased intrinsic clearance.
2. A single inducer can affect the products of several gene families.
3. Phenobarbital may increase the amount of P450 enzyme and may therefore increase
the clearance of many drugs.
4. Cimetidine forms an inactive complex with cytochrome P450 and therefore inhibits the
metabolism of many drugs, including warfarin and diazepam.
8. E. The most common reason for increased intrinsic clearance is enzyme induction. Many
drugs of importance in anesthesiology are metabolized by the cytochrome P450 enzymes.
Hundreds of drugs and environmental toxins can stimulate (or induce) microsomal enzymes.
Typically, a single inducer can affect the products of several gene families. Phenobarbital
increases the amount of many P450 enzymes. The increase in the quantity of enzyme protein
can therefore simultaneously increase the clearance of many drugs. Cimetidine has an
imidazole group that binds to the heme iron of cytochrome P450 and forms an inactive complex.
Cimetidine inhibits the metabolism of many drugs, including warfarin, diazepam, phenytoin, and
181 / 494
morphine. (See page 554: Hepatic Biotransformation.)
182 / 494
Review of Clinical Anesthesia, 5e [Vishal] 23. Preoperative Patient Assessment & Management
Chapter 23
Preoperative Patient Assessment and Management
1. All of the following are important predictors of cardiac postoperative complications

EXCEPT:
A. preoperative serum creatinine of 1.0 mg/dL
B. history of cerebrovascular accident
C. preoperative treatment with insulin
D. history of congestive heart failure
E. major vascular surgery
1. A. The Revised Cardiac Risk Index identified six independent predictors of complications:
high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure,
history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum
creatinine above 2.0 mg/dL. (See page 572: Cardiovascular Disease.)
2. After an episode of asthma, airway hyperreactivity may persist up to:

A. 24 hours
B. 48 hours
C. 72 hours
D. 4 days
E. several weeks
2. E. After an episode of asthma, airway hyperreactivity may persist for several weeks. (See
page 579: Asthma.)
3. The current recommendation of the National Blood Resource Education Committee

is that a hemoglobin of ________________ g/dL is acceptable in patients without
systemic disease.
A. 9
B. 6
C. 7
D. 10
E. 8
3. C. The current recommendation of the National Blood Resource Education Committee is that
a hemoglobin of 7 g/dL is acceptable in patients without systemic disease. (See page 584:
Complete Blood Count and Hemoglobin Concentration.)
4. Which of the following tests, if done preoperatively in a patient without risk factors,
can lead to more harm than benefit&quest;
A. Electrocardiography (ECG)
183 / 494
B. Blood urea nitrogen (BUN)/creatinine
C. Chest radiography (CXR)
D. Urinalysis (U/A)
4. C. A preoperative CXR can identify abnormalities that may lead to either a delay or a
cancellation of the planned surgical procedure or modification of perioperative care. However,
routine testing in the population without risk factors can lead to more harm than benefit. The
American College of Physicians suggests that a CXR is indicated in the presence of active
chest disease and before intrathoracic procedures but not solely on the basis of advanced age.
(See page 585: Chest Radiography.)
5. Postoperatively, functional residual capacity may take up to ________________ to

return to baseline.
A. 24 hours
B. 48 hours
C. 3 days
D. 7 days
E. 14 days
5. E. Functional residual capacity may take up to 2 weeks to return to baseline. (See page 578:
Pulmonary Disease.)
6. As a general rule, oral medications should be given to the patient ________________

before arrival in the operating room.
A. 60 to 90 minutes
B. 30 to 60 minutes
C. 20 minutes
D. 10 minutes
E. 5 minutes
6. A. As a general rule, oral medications should be given to the patient 60 to 90 minutes before
arrival in the operating room. It is acceptable to administer oral drugs with up to 150 mL of
water. Intravenous agents produce effects after a few circulation times, but for full effect,
intramuscular medications should be given at least 20 minutes and preferably 30 to 60 minutes
before the patient's arrival in the operating room. (See page 586: Pharmacologic Preparation.)
7. All of the following are true regarding patients with obstructive sleep apnea (OSA)
EXCEPT:
A. Chronic pulmonary hypertension and right heart failure may be present.
B. Increased neck circumference is a risk factor.
C. Patients with OSA are more susceptible to the respiratory depressant effects of
narcotics.
D. Initiation of continuous positive airway pressure (CPAP) preoperatively does not
184 / 494
reduce the perioperative risk.
E. Patients with OSA are considered to have difficult airways.
7. D. Patients with OSA have chronic sleep deprivation, with daytime hypersomnolence and
even behavioral changes in children. Depending on the frequency and severity of events, OSA
may lead to changes such as chronic pulmonary hypertension and right heart failure. Increased
neck circumference, body mass index above 35 kg/m2, severe tonsillar hypertrophy, and
anatomic abnormalities of the upper airway are factors commonly associated with OSA. These
patients are especially susceptible to the respiratory depressant and airway effects of
sedatives, narcotics, and inhaled anesthetics. Preoperative initiation of CPAP reduces the
perioperative risk, and the difficult airway algorithm should be followed, with emergency airway
equipment readily available. (See page 579: Obstructive Sleep Apnea.)
8. Which of the following place(s) a patient at risk for increased perioperative
cardiovascular morbidity and should be considered in a preoperative
evaluation&quest;
1. Peripheral arterial disease
2. Diabetes mellitus
P.114
3. Hypertension with left ventricular hypertrophy (LVH)
4. Diminished exercise tolerance
8. E. Peripheral arterial disease has been shown to be associated with coronary artery disease
in multiple studies; at least 60% of the patients scheduled for major vascular surgery exhibit at
least one coronary vessel with critical stenosis. Although a critical coronary stenosis delineates
an area of risk for developing myocardial ischemia, this area may or may not be the underlying
cause for a perioperative myocardial infarction that occurs. In the ambulatory population, many
infarctions are the result of acute thrombosis of a noncritical stenosis. Diabetes mellitus is
common in elderly individuals, represents a disease that affects multiple organ systems, is
associated with coronary artery disease, and increases the chance of silent myocardial
ischemia and infarction. Hypertension can also be associated with an increased risk of silent
myocardial ischemia and infarction, especially if the hypertension is associated with LVH with a
strain pattern on electrocardiography. A strain pattern usually suggests a chronic ischemic
state. An excellent exercise tolerance suggests that the myocardium can be stressed without
failing. If patients experience dyspnea associated with chest pain during minimal exertion, the
probability of extensive coronary artery disease is high; this has been associated with greater
perioperative risk. (See page 572: Cardiovascular Disease.)
9. The hallmark features of Cushing syndrome include:

1. easy bruisability
2. truncal “thinning”
3. moon facies
4. hypotension
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9. B. The prolonged use of glucocorticoids may lead to Cushing syndrome. Truncal obesity,
moon facies, skin striations, easy bruisability, and hypertension are hallmark signs of Cushing
syndrome. Preoperative preparations include correction of fluid and electrolyte abnormalities
(e.g., hypokalemia, hyperglycemia). In patients with long-term corticosteroid use, perioperative
steroid supplementation is indicated to cover the stress of anesthesia and surgery. (See page
580: Endocrine Disease.)
10. Which of the following should be included in the preoperative history to rule out a
bleeding abnormality&quest;
1. Easy bruising
2. Unusual bleeding after a tooth extraction
3. Liver disease
4. Use of chemotherapeutic agents
10. E. Coagulation disorders can have significant impact on the surgical procedure and
perioperative management. Abnormal laboratory study results require preoperative evaluation
of the patient; however, in the absence of a clinical bleeding diathesis, complications are
extremely rare. Analyses of prothrombin time and partial thromboplastin time are indicated in the
presence of previous bleeding disorders (e.g., after injuries, tooth extraction, or surgical
procedures) and in patients with known or suspected liver disease, malabsorption or
malnutrition, or taking certain medications (e.g., chemotherapeutic agents). (See page 584:
Coagulation Studies.)
11. A preoperative electrocardiogram (ECG) should be ordered and evaluated in which

of the following patient populations&quest;
1. Patients with a prior myocardial infarction
2. Patients with a history of hypertension, diabetes mellitus, or peripheral vascular
disease
3. Patients without cardiac risk factors who are about to undergo vascular surgery
4. Women older than age 70 years
11. E. The preoperative 12-lead ECG can provide important information on the status of the
patient's myocardium and coronary circulation. Abnormal Q waves in high-risk patients are
highly suggestive of a past myocardial infarction. Patients with Q-wave infarctions are known to
be at increased risk of perioperative cardiac events and have worse long-term prognoses.
Patients who exhibit left ventricular hypertrophy or ST segment changes on a preoperative
ECG are also at an increased risk of perioperative cardiac events. Reasonable
recommendations for a preoperative ECG include patients with systemic cardiovascular
disease, diabetes mellitus, men older than age 60 years, women older than age 70 years, and
patients with no clinical risk factors about to undergo vascular surgical procedures. (See page
576: Cardiovascular Tests and page 574: Table 23-4.)
12. TRUE statements about cessation of smoking include:

1. Stopping for 48 hours reduces the amount of carboxyhemoglobin.
2. Cessation between 48 hours and 6 weeks is associated with increased mucociliary
clearance.
186 / 494
3. Cessation for 48 hours abolishes the effects of nicotine.
4. Stopping for 1 week is sufficient to eliminate the increased incidence of postoperative
pulmonary complications.
12. B. Cessation of smoking for 2 days may decrease carboxyhemoglobin levels, abolish the
effects of nicotine, and improve mucous clearance. Between 2 days and 6 weeks, there is no
real improvement because mucociliary clearance does not improve during this time. A
prospective study showed that smoking cessation for at least 8 weeks was necessary to reduce
the rate of postoperative pulmonary complications. (See page 579: Tobacco.)
13. A resting echocardiogram provides information about:

1. ventricular function
2. regional wall motion
3. ventricular wall thickness
4. valvular function
13. E. A resting echocardiogram can determine the presence of ventricular dysfunction, regional
wall abnormalities, ventricular wall thickness, and valvular function. Pulsed-wave Doppler can
be used to obtain the velocity–time integral. Ejection fraction then can be calculated by
determining the cross-sectional area of the ventricle. (See page 576: Assessment of Ventricular
and Valvular Function.)
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Review of Clinical Anesthesia, 5e [Vishal] 24. Malignant Hyperthermia & Other Inherited Disorders
Chapter 24
Malignant Hyperthermia and Other Inherited Disorders
1. What is the earliest sign of malignant hyperthermia (MH) in an intubated, paralyzed

patient&quest;
A. Ventricular arrhythmia
B. Tachycardia
C. Tachypnea
D. Fever
E. Increased end-tidal CO2
1. E. Elevation of end-tidal CO2 is one of the earliest signs of MH. Tachypnea does not occur
in intubated, paralyzed patients. Tachycardia and hypertension result from sympathetic nervous
system stimulation secondary to underlying hypermetabolism and hypercarbia. Ventricular
dysrhythmias may occur and are induced by sympathetic nervous system stimulation,
hypercarbia, hyperkalemia, or catecholamine release. (See page 599: Classic Malignant
Hyperthermia.)
2. Which statement regarding masseter muscle rigidity (MMR) is TRUE&quest;

A. It is not associated with malignant hyperthermia (MH).
B. MMR is only seen in children.
C. MMR most commonly occurs after administration of succinylcholine (Sch) after
administration of an intravenous (IV) induction agent.
D. It is predictive of MH susceptibility in up to 25% of cases.
E. Repeat doses of a depolarizing muscle relaxant relieve MMR.
2. D. Although MMR probably occurs in patients of all ages, it is more common in children and
young adults. In most cases of MMR, anesthesia was induced by inhalation of halothane or
sevoflurane after which Sch was administered. Although less common, MMR may occur after
Sch administration after IV induction. MMR may even occur after induction with any IV or
inhalation anesthetic agent. Repeat doses of Sch do not relieve MMR, and nondepolarizing
relaxants do not reliably relieve MMR. (See page 600: Masseter Muscle Rigidity.)
3. Which of the following are signs and symptoms of neuroleptic malignant
syndrome&quest;
1. Bradycardia
2. Hypertension
3. Flaccid paralysis
4. Acidosis
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3. C. The symptoms and signs of neuroleptic malignant syndrome include fever,
rhabdomyolysis, tachycardia, hypertension, agitation, muscle rigidity, and acidosis. The
mortality rate is unknown but may be significant. Dantrolene is an effective therapeutic modality
in many cases of neuroleptic malignant syndrome. (See page 602: Neuroleptic Malignant
Syndrome and Other Drug-Induced Hyperthermia Reactions.)
4. Which of the following may occur during an episode of malignant hyperthermia

(MH)&quest;
1. Hyperkalemia
2. Myoglobinuria
3. Lactic acidosis
4. Hypocalcemia
4. A. Hyperkalemia, hypercalcemia, lactic acidosis, and myoglobinuria are characteristic of MH
episodes. A mixed venous sample will show even more dramatic evidence of increased CO2
production and metabolic acidosis. (See page 599: Classic Malignant Hyperthermia.)
5. Which of the following statements regarding masseter muscle rigidity (MMR) are
TRUE&quest;
1. It is most commonly seen in children.
2. Peripheral nerve stimulation typically does not reveal muscle relaxation.
3. Tachycardia is frequent.
4. Repeat doses of succinylcholine (Sch) cause relaxation.
5. B. Although MMR probably occurs in patients of all ages, it is distinctly most common in
children and young adults. Several studies have shown a peak incidence at age 8 to 12 years.
A peripheral nerve stimulator on the arm usually reveals flaccid paralysis. However, increased
tone of other muscles may also be noted. Repeat doses of Sch do not relieve the problem.
Tachycardia and dysrhythmias are frequent. (See page 600: Masseter Muscle Rigidity.)
6. Which of the following should be considered as a possibility in the differential

diagnosis of masseter muscle rigidity (MMR)&quest;
1. Myotonic syndrome
2. Low dose of succinylcholine (Sch)
3. Insufficient time to intubation after Sch administration
4. Temporomandibular joint (TMJ) syndrome
6. E. The differential diagnosis of MMR includes myotonic syndrome, TMJ dysfunction,
underdosing with Sch, or not allowing sufficient time for Sch to act before intubation. (See page
600: Masseter Muscle Rigidity.)
7. Which of the following statements regarding neuroleptic malignant syndrome are

TRUE&quest;
1. Symptoms usually occur after an acute exposure to a triggering agent.
2. Haloperidol is a cause.
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3. Bromocriptine administration often precipitates this disorder.
4. Sudden withdrawal of levodopa may cause onset of symptoms.
7. C. Although the resemblance of neuroleptic malignant syndrome to malignant hyperthermia
(MH) is striking, there are significant differences between the two disorders. MH is acute, but
neuroleptic malignant syndrome often occurs after long-term drug exposure. Phenothiazines
and haloperidol or other antipsychotic agents are the usual triggering agents for neuroleptic
malignant syndrome. Sudden withdrawal of drugs used to treat Parkinson's disease may also
trigger neuroleptic malignant syndrome. Electroconvulsive therapy with succinylcholine does
not appear to trigger the syndrome. A variety of drugs have been found useful in the treatment
of neuroleptic malignant syndrome, including benzodiazepines, bromocriptine, and dantrolene.
(See page 602: Neuroleptic Malignant Syndrome and Other Drug-Induced Hyperthermia
Reactions.)
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8. Which of the following can trigger malignant hyperthermia (MH)&quest;
1. Ether
2. Succinylcholine (Sch)
3. Methoxyflurane
4. Decamethonium
8. E. It is clearly established that potent inhalational agents, including sevoflurane, desflurane,
isoflurane, halothane, methoxyflurane, cyclopropane, and ether, may trigger MH. Sch and
decamethonium (depolarizing muscle relaxants) also are triggers. (See page 602: Drugs That
Trigger Malignant Hyperthermia.)
9. Which of the following statements regarding treatment of malignant hyperthermia

(MH) are TRUE&quest;
1. A reasonable initial dose of dantrolene is 2.0 to 2.5 mg/kg.
2. Calcium channel blockers are useful in acute phase treatment.
3. Lidocaine is effective in managing dysrhythmias.
4. The recommended maximum dose of dantrolene is 7.5 mg/kg.
9. B. Initial intravenous therapy should be started with a minimum dose of 2.5 mg/kg, with
repeat doses as needed. Although it has been recommended that the maximum dose of
dantrolene is 10 mg/kg, more should be given as dictated by clinical circumstances.
Dysrhythmia control usually occurs after hyperventilation, dantrolene therapy, and correction of
acidosis. Lidocaine can be safely used during MH crises. Calcium channel blockers should not
be used in the acute treatment of MH. Several studies have shown that verapamil may interact
with dantrolene to produce hyperkalemia and myocardial depression. (See page 606: The
Treatment of Malignant Hyperthermia.)
10. Which of the following statements regarding dantrolene are TRUE&quest;

1. It acts intracellularly.
2. It inhibits excitation contraction coupling.
3. In usual clinical doses, it has little effect on myocardial contractility.
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4. It increases the reuptake of intracellular calcium.

10. A. Dantrolene acts within the muscle cell itself by reducing intracellular levels of calcium.
This most likely results from a reduction of calcium release by the sarcoplasmic reticulum. In
usual clinical doses, dantrolene has little effect on myocardial contractility. (See page 607:
Dantrolene.)
11. Which of the following may result in legal judgment in favor of the plaintiff if an
episode of malignant hyperthermia (MH) occurs&quest;
1. Failure to obtain a complete history
2. Not having a temperature monitor
3. Having an inadequate supply of dantrolene
4. Not investigating unexplained fever
11. E. Most of the common themes underlying the basis of litigation in MH cases include failure
to obtain a thorough personal history, failure to continuously monitor temperature, failure to
have an adequate supply of dantrolene, and failure to investigate an unexplained increase in
body temperature. (See page 608: Medicolegal Aspects.)
12. Which of the following statements regarding porphyria are TRUE&quest;

1. It is a defect in heme synthesis.
2. Inducible porphyria may cause a neurologic syndrome.
3. Conjugation of succinyl coenzyme A is the limiting step.
4. All barbiturates are contraindicated in patients with porphyria.
12. E. All the porphyrias result from a defect in heme synthesis. The very limiting step in heme
synthesis is the conjugation of succinyl coenzyme A with glycine to form D-aminolevulinic acid.
The inducible porphyrias are those in which the acute symptoms are precipitated during drug
exposure. These porphyrias may cause an acute neurologic syndrome. Barbiturates are
contraindicated in patients with porphyria. (See page 615: The Porphyrias.)
13. Which of the following may be characteristic of glucose-6-phosphate

deficiency&quest;
1. Hyperglycemia
2. Poor tolerance to fasting
3. Alkalosis
4. Prolonged bleeding time
13. C. Glucose-6-phosphate deficiency is an autosomal recessive disorder. The prognosis is
moderately good, with many patients surviving into adulthood. These patients tolerate fasting
very poorly. Hypoglycemia, acidosis, and convulsions may be problems. Prolonged bleeding
time has been described. (See page 617: Defects in Glucose Metabolism.)
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Review of Clinical Anesthesia, 5e [Vishal] 25. Rare & Co-existing Diseases
Chapter 25
Rare and Co-existing Diseases
1. Which of the following statements about Duchenne muscular dystrophy is

TRUE&quest;
A. The underlying defect is the lack of the muscle protein dystrophin, a major component
of the muscle membrane.
B. Cardiac muscle is spared from the disease process.
C. Painful degeneration and atrophy of skeletal muscle is a hallmark of the disease.
D. It is a genetic dominant trait.
E. Death rarely occurs.
1. A. Duchenne muscular dystrophy is a sex-linked recessive disorder that is evident in boys
and young men. In Duchenne muscular dystrophy, the underlying defect is a lack of the muscle
protein dystrophin. Progressive painless muscle degeneration with atrophy of skeletal muscle
occurs. Cardiac muscle and smooth muscle are not spared. Pneumonia and congestive heart
failure are common causes of death, which may occur between the ages of 15 and 25 years.
(See page 622: Duchenne Muscular Dystrophy.)
2. Anesthetic management of patients with muscular dystrophy involves attention to

all of the following EXCEPT:
A. myocardial depressant sensitivity to inhalational agents
B. avoidance of succinylcholine (Sch) secondary to massive release of potassium
C. malignant hyperthermia precautions
D. use of high doses of nondepolarizing muscle relaxants (NDMRs) because of
resistance to these drugs
E. use of drugs for aspiration precautions
2. D. Patients with muscular dystrophy have increased susceptibility to the myocardial
depressant effects of inhalation anesthetics. Use of NDMRs should be modified because of
increased sensitivity to these drugs from pre-existing muscle weakness. Use of Sch may result
in increased potassium secondary to membrane instability. Some patients with muscular
dystrophy may be susceptible to malignant hyperthermia, but this is unpredictable. Smooth
muscle involvement causes intestinal hypomobility, delayed gastric emptying, and
gastroparesis. (See page 622: Muscular Dystrophy: Management of Anesthesia.)
3. All of the following statements about myotonia are true EXCEPT:

A. Myotonia results in delayed skeletal muscle relaxation.
B. Myotonia diseases are similar to muscular dystrophy in that the underlying defect is a
membrane-stabilizing protein.
C. Reversal with neostigmine may provoke a myotonic contracture.
D. Pulmonary function studies demonstrate a restrictive type of lung disease pattern.
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E. There are two types of myotonic dystrophy that are caused by abnormalities in two
distinct gene loci.
3. B. The myotonias are a group of illnesses characterized by delayed relaxation of skeletal
muscle. There are two types of myotonic dystrophies that are caused by abnormalities in two
different gene loci. Myotonic dystrophy is the most common form. The underlying defect is
secondary to defects in sodium channels that alter ion channel function. Reversal with
neostigmine may provoke a myotonic contracture. Pulmonary function studies demonstrate a
restrictive type of lung disease pattern, mild arterial hypoxia, and diminished ventilatory
response to hypoxia and hypercapnia. (See page 624: Myotonias.)
4. What is an important consideration in the anesthetic management of patients with

familial periodic paralysis&quest;
A. Maintenance of hypokalemia in all forms of myotonia
B. Use of succinylcholine (Sch) is acceptable in the presence of normokalemia
C. Maintaining mild hypothermia
D. No change in dosing of nondepolarizing muscle relaxants (NDMRs)
E. Avoidance of large carbohydrate loads
4. E. Familial periodic paralysis includes a subgroup of skeletal muscle channelopathies. This
group includes hyperkalemic, hypokalemic, paramyotonic congenital, normokalemic periodic
paralysis, and potassium-aggravated myotonia. All have persistent sodium inward current
depolarization causing membrane inexcitability and subsequent muscle weakness. Anesthetic
management consists of maintenance of a normal potassium level and avoiding precipitating
weakness. During episodes of weakness, patients are more sensitive to NDMRs. Sch should
be avoided to prevent changes in serum potassium levels. Serial potassium measurements
during the perioperative period are recommended. Avoidance of hypothermia and of large
carbohydrate loads is also recommended. (See page 625: Familial Periodic Paralysis.)
5. All of the following statements about myasthenia gravis are true EXCEPT:
A. It is a disease of the neuromuscular junction involving the muscarinic acetylcholine
(Ach) receptors.
B. It is an autoimmune disorder with the production of antibodies against Ach receptors.
C. The mainstay of medical therapy involves the cholinesterase inhibitor pyridostigmine,
corticosteroids, immunosuppressive agents, and intravenous immunoglobulin.
D. The hallmark of myasthenia gravis is skeletal muscle weakness.
E. The process most likely originates in the thymus gland.
5. A. Myasthenia gravis is a disease of the neuromuscular junction in which antibodies are
formed against the nicotinic Ach receptors; T-helper cells assist in this antibody production. The
hallmark of myasthenia gravis is skeletal muscle weakness. The disease probably originates in
the thymus gland; 90% of patients have histiologic abnormalities such as thymoma, thymic
hyperplasia, or thymic atrophy. Thymectomy may help in controlling the symptoms. The
mainstay therapy is medical treatment with the cholinesterase inhibitor pyridostigmine. Other
treatment modalities may include corticosteroids, immunosuppressants, plasmapheresis, and
thymectomy. (See page 626: Myasthenia Gravis.)
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6. Intraoperative management of myasthenia gravis may include all of the following
EXCEPT:
A. consideration of increased sensitivity to nondepolarizing muscle relaxants (NDMRs)
B. use of a defasciculating dose of NDMR to facilitate intubation
C. use of a short-acting NDMR with neuromuscular monitoring
P.120
D. consideration of resistance to succinylcholine (Sch)
E. use of an anesthetic technique that avoids the use of muscle relaxants
6. B. Patients with myasthenia gravis are exquisitely sensitive to NDMRs, so a defasciculating
dose of an NDMR may result in excessive muscle relaxation. Use of a short-acting NDMR is
recommended to avoid prolonged postoperative paralysis. Response to Sch includes greater
resistance and prolonged duration of action (which may partially be attributable to use of
pyridostigmine in the treatment of the disease). Use of regional anesthesia may avoid
respiratory depression associated with opioids. Use of an anesthetic technique that avoids use
of muscle relaxants may be useful. (See page 626: Myasthenia Gravis: Management of
Anesthesia.)
7. All of the following statements about Lambert-Eaton syndrome are true EXCEPT:
A. It is a disorder of neuromuscular transmission associated with carcinomas.
B. Antibodies against the acetylcholine (Ach) receptor are produced.
C. Treatment involves treating the underlying malignancy.
D. 3,4-Diaminopyridine may be used in the treatment to increase release of Ach.
E. A typical patient is a man older than age 40 years with proximal extremity weakness.
7. B. Lambert-Eaton syndrome is a disorder of neuromuscular transmission associated with
carcinomas, especially small cell carcinoma of the lung. A typical patient is a man older than
age 40 years with proximal extremity weakness. The onset may precede detection of carcinoma
by years. Immunoglobulin G antibodies are produced against presynaptic calcium channels; this
inhibits the proper release of Ach. Autonomic dysfunction may also occur. Patients are sensitive
to both depolarizing muscle relaxants and nondepolarizing muscle relaxants. In addition to
treating the underlying malignancy, the most effective symptomatic therapy includes 3,4-
diaminopyridine, which improves synaptic transmission by opening voltage-gated potassium
channels and increasing release of Ach. Pyridostigmine may also be used to treat symptoms of
weakness. Treatment may also include immunoglobulin and plasmapheresis. (See page 627:
Myasthenic Syndrome [Lambert-Eaton Syndrome].)
8. Which of the following statements about Guillain-Barré syndrome

(polyradiculoneuritis) is TRUE&quest;
A. It is an autoimmune disorder triggered by a bacterial or viral infection.
B. The autoimmune response is against myocytes of skeletal muscle.
C. Ventilatory support is rarely needed.
D. Eighty-five percent of patients do not recover.
E. Administration of succinylcholine (Sch) is not associated with hyperkalemia.
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8. A. Guillain-Barré syndrome is an autoimmune disorder triggered by bacterial or viral

infections. Antibodies are produced against myelin, which results in demyelination of nerve
tissue. Symptoms include subacute or acute skeletal muscle weakness, which may result in
respiratory compromise. Prognosis is good, with 85% of patients achieving full recovery.
Treatment consists of plasmapheresis or high-dose immunoglobulin. Patients are exquisitely
sensitive to Sch, so this drug should be avoided. This response may persist after symptoms
have resolved. (See page 628: Guillain-Barré Syndrome.)
9. Multiple sclerosis may have all of the following anesthetic considerations EXCEPT:
A. Patients with multiple sclerosis should be advised that an exacerbation of their
neurologic symptoms may occur during the perioperative period.
B. It is speculated that demyelinated areas of the spinal cord are more sensitive to the
neurotoxicity of local anesthetics.
C. A thorough neurologic examination before surgery or anesthesia is helpful.
D. Autonomic dysfunction is not a concern in patients with multiple sclerosis.
E. Multiple sites of demyelination of the brain and spinal cord are the hallmarks of the
disease.
9. D. Multiple sclerosis is an acquired disease of the central nervous system (CNS) that results
in demyelination of the brain and spinal cord. The cause is multifactorial, and the disease
occurs in genetically susceptible individuals. A viral cause has been suspected but not proven.
Symptoms of multiple sclerosis are related to the site of demyelination. It is speculated that
demyelinated areas of the spinal cord are sensitive to the neurotoxicity of local anesthetics.
The course of the disease process is characterized by waxing and waning of symptoms.
Therapy for patients with multiple sclerosis is directed at modulating the immunologic and
inflammatory responses that damage the CNS. Corticosteroids are used to control acute
exacerbations of symptoms but have no influence on long-term outcome. Corticosteroids have
diverse effects that suppress cellular immune responses and inflammatory edema. Other
treatments include interferon, glatiramer, mitoxantrone, and symptomatic treatment with
baclofen and carbamazepine. Interferon alters the inflammatory response, augments natural
disease suppression, and has been shown to reduce the relapse rate. Mitoxantrone, which may
be cardiotoxic, can be used to treat patients with aggressive multiple sclerosis. Patient
response to immunosuppressants has been variable. Patients with multiple sclerosis should be
advised that an exacerbation of their neurologic symptoms may occur during the perioperative
period. A thorough neurologic examination before surgery or anesthesia is helpful.
Hyperthermia and metabolic and hormonal changes induced by surgery or anesthesia may
exacerbate symptoms. Autonomic dysfunction caused by multiple sclerosis may exaggerate the
hypotensive effects of volatile anesthetics. (See page 628: Multiple Sclerosis.)
10. All of the following statements concerning epilepsy are true EXCEPT:
A. Many different types of central nervous system (CNS) disorders may cause excessive
discharge of neurons to synchronously depolarize and thereby generate seizures.
B. Grand mal seizures are characterized by tonic-clonic motor activity with respiratory
arrest and hypoxemia.
C. In status epilepticus, skeletal muscle activity diminishes over time, and seizure activity
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can only be detected on electroencephalography (EEG).
D. Use of ketamine for induction is a reasonable choice.
E. Maintenance of chronic antiseizure medication is critical throughout the perioperative
period.
10. D. Seizures may be the manifestation of many disorders of the CNS. Seizures result from
excessive discharge of neurons that synchronously depolarize. Symptoms are related to the
area of neuronal activity. There are more than 40 different types of epilepsy based on the
clinical features. Grand mal seizures are characterized by tonic-clonic motor activity that results
in respiratory arrest and arterial hypoxemia. Patients with status epilepticus have recurrent
grand mal seizures with loss of consciousness lasting more than 30 minutes; mortality is high
unless the condition is treated effectively. In status epilepticus, skeletal muscle activity
diminishes over time, and seizure activity can only be seen on EEG. Lack of muscular activity
may confuse and prevent proper diagnosis as a seizure progresses. During the perioperative
period, antiseizure medication should be continued. In the event of seizure activity,
benzodiazepines are the drug of choice for treatment. Use of muscle relaxants abolishes
muscular activity; however, CNS neuronal activity continues. Ketamine and methohexital may
produce seizures in patients with known seizure disorders. (See page 629: Epilepsy.)
11. Anesthetic management of patients with a medically treated seizure disorder
involves which of the following considerations&quest;
1. Sevoflurane may be epileptogenic, but the significance of this is not certain.
2. Patients receiving phenytoin or carbamazepine exhibit resistance to nondepolarizing
muscle relaxants.
3. Potent opioids may produce myoclonic activity or chest wall rigidity, which can be
confused with seizure activity.
4. Use of ketamine for induction is indicated.
11. A. Most inhaled anesthetics, including nitrous oxide, have been reported to produce seizure
activity, but it is rare with isoflurane and desflurane. Sevoflurane may be epileptogenic, but the
clinical significance is uncertain. There is a potential for significant drug interaction for the same
reason. Potent opioids may produce myoclonic activity or chest wall rigidity, which may be
confused with seizure activity. Use of ketamine may produce seizure-like activity, so this drug is
relatively contraindicated in these patients because better alternative medicines exist. Patients
receiving phenytoin or carbamazepine exhibit resistance to nondepolarizing muscle relaxants.
(See page 629: Epilepsy: Management of Anesthesia.)
12. Which of the following statements regarding Parkinson's disease are TRUE&quest;
1. It is a disease of the central nervous system characterized by destruction of
dopamine-containing nerve cells in the substantia nigra of the basal ganglion.
2. Parkinson's disease is commonly caused by a virus.
3. γ -Aminobutyric acid (GABA) levels increase with resultant suppression of cortical
motor function.
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4. Decreasing dopamine levels in the brainstem result in resolution of symptoms.
12. B. Parkinson's disease is a disabling neurologic disease that primarily affects adults older
than 65 years of age. It is characterized by the destruction of dopamine-containing nerve cells
in the substantia nigra of the basal ganglia of the brain. Deficiency of dopamine results in
increases in activity of GABA. This acid results in inhibition of brainstem nuclei, which suppress
cortical motor function. This causes the characteristic features of the disease, such as resting
tremor, akinesia, and postural abnormalities. Treatment of the disease is directed at increasing
dopamine levels in the brain with minimal peripheral side effects. The etiology of Parkinson's
disease is multifactorial, with genetic and environmental factors. It may also develop after
encephalitis. There is little evidence for a viral cause. (See page 630: Parkinson's Disease.)
13. Management of anesthesia in patients with Parkinson's disease includes which of

1. Use of phenothiazines and butyrophenones is contraindicated.
2. Gastrointestinal dysfunction is manifested by salivation, dysphagia, and esophageal
dysfunction.
3. Autonomic dysfunction is a common manifestation.
4. Drug therapy should be discontinued before induction of anesthesia.
13. A. In Parkinson's disease, use of butyrophenones (droperidol) and phenothiazines is
contraindicated because of their effects on dopamine levels in the central nervous system.
Autonomic dysfunction is common; symptoms include orthostatic hypotension, gastrointestinal
dysfunction, and an exaggerated response to inhalational agents. Drug therapy should not be
discontinued because muscular rigidity may interfere with the ability to extubate a patient.
Gastrointestinal manifestations include dysphagia, esophageal dysfunction, and salivation.
Patients with Parkinson's disease should be considered at risk of aspiration pneumonitis. (See
page 630: Parkinson's Disease.)
14. Which of the following statements regarding Huntington's chorea are TRUE&quest;
1. Disordered movement and dementia are clinical hallmarks of the disease.
2. Mental depression and suicide are common.
3. Specific therapy is directed at control of the movement disorder.
4. Duration of disease averages 17 years from the time of diagnosis to death.
14. E. Huntington's disease is a neurodegenerative disease of the corpus striatum and cerebral
cortex. It is an inherited disorder that is autosomal dominant. Clinical symptoms include
disordered movement, dementia, clinical depression, athetosis, and dystonia. Mental
depression and suicide are common. The duration of the disease averages approximately 17
years from diagnosis to death. There is no specific therapy; treatment is directed at both
depression and control of movement disorders. (See page 631: Huntington's Disease.)
P.121
15. Amyotrophic lateral sclerosis is manifested by which of the following&quest;
1. It is a degenerative disease involving motor cells of the central nervous system (CNS).
2. Although the cause is unknown, glutamate excitotoxicity and oxidant stress secondary
to exposure to metal toxicity or environmental toxins are hypothesized factors.
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3. There is an increased sensitivity to nondepolarizing muscle relaxants (NDMRs).

4. There is sparing of pulmonary function.
15. A. Amyotrophic lateral sclerosis is a degenerative disease of the anterior horn cell (motor
cells) throughout the CNS. It is believed to be viral in origin and bears similarity to poliomyelitis.
Glutamate excitotoxicity and oxidant stress secondary to exposure to toxic metals or other
environmental toxins have been implicated. It is a rapidly progressive disorder in which death
results within 3 to 5 years of diagnosis. Pulmonary function is severely affected, with all patients
eventually requiring mechanical ventilation. Neuromuscular transmission is altered, and patients
have increased sensitivity to NDMRs. These patients may also exhibit a hyperkalemic response
to succinylcholine because of the emergence of extrajunctional acetylcholine receptors. (See
page 632: Amyotrophic Lateral Sclerosis.)
16. Which of the following facts should be considered when anesthetizing a patient
with anemia&quest;
1. Healthy individuals do not develop symptoms until hemoglobin (Hgb) levels decrease
to below 7 g/dL.
2. Physiologic compensation includes increased plasma volume, increased cardiac
output, and increased 2,3-diphosphoglycerate (2,3-DPG) levels.
3. Symptoms are highly variable and depend on concurrent disease processes and the
speed of developing anemia.
4. There is no accepted Hgb level at which transfusion should be administered.
16. E. There are numerous causes of anemia. Compensations include an increase in plasma
volume, cardiac output, and 2,3-DPG levels as well as decreased viscosity. Symptoms depend
on concurrent disease processes, and most healthy individuals can tolerate an Hgb level of 7
g/dL without significant symptoms. No specific Hgb level exists below which a transfusion
should be administered. Concurrent disease and the need for increased oxygen-carrying
capacity influence the need for transfusion. (See page 632: Anemias.)
17. Which of the following facts are TRUE regarding nutritional deficiency
anemias&quest;
1. All deficiency anemias result in microcytic hypochromic red blood cells (RBCs).
2. Deficiency anemias can be categorized into three subtypes based on the cause: iron
deficiency, vitamin B12, and folic acid.
3. The use of nitrous oxide (N2O) is contraindicated in patients with iron deficiency
anemia.
4. Causes of folic acid deficiency include alcoholism, pregnancy, and malabsorption
syndromes.
17. C. Nutritional deficiency anemias are categorized into three subtypes: iron, vitamin B12, and
folic acid deficiency. Only iron deficiency anemia produces RBCs that are microcytic and
hypochromic. This anemia may be from poor iron intake or from rapid turnover of RBCs.
Hemoglobin and ferritin levels are good clinical tests for iron deficiency. In vitamin B12 and
folate deficiency, the RBCs are enlarged. Causes of folic acid deficiency include alcoholism,
pregnancy, and malabsorption syndromes. N2O is not contraindicated in iron deficiency
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anemia. The clinical significance of an N2O effect on vitamin B12 metabolism is controversial.
(See page 632: Nutritional Deficiency Anemia.)
18. Which of the following statements regarding hemolytic anemias are TRUE&quest;
1. Spherocytosis is a disorder of the hemoglobin-carrying capacity of the red blood cell
(RBC).
2. Glucose-6-phosphate dehydrogenase (G6PD) deficiency results in an inability to
reduce methemoglobin; therefore, sodium nitroprusside is contraindicated.
3. The life span of an RBC in a patient with hereditary spherocytosis is 120 days.
4. Splenectomy may be indicated in patients with hereditary spherocytosis.
18. C. Hereditary spherocytosis is a disorder of the proteins that comprise the skeleton of the
RBC membrane and renders the membrane unstable; this predisposes the patient to chronic
hemolysis. G6PD deficiency is a hemolytic disorder in which nicotinamide adenine dinucleotide
phosphate (NADPH) is not produced. This results in an increased sensitivity to oxidation. G6PD
deficiency also results in a reduced level of glutathione. The cells become rigid, which
accelerates clearance by the spleen. Numerous drugs induce hemolysis. Patients with G6PD
deficiency are unable to reduce methemoglobin, so nitroprusside and prilocaine should not be
administered. Treatment of patients with hereditary spherocytosis consists of a splenectomy;
however, splenectomy is rarely indicated before age 6 years because of the high incidence of
pneumococcal infection. The life span of a normal RBC is 120 days. Because the RBC
membrane in hereditary spherocytosis is altered, the life span of the RBC is shortened. (See
page 633: Hemolytic Anemias.)
19. Anesthetic management of a patient with sickle cell disease (SCD) involves which
of the following&quest;
1. Adequate systemic oxygenation and hydration
2. Maintenance of the hematocrit between 40% and 42% is optimal
3. Maintenance of normothermia for all types of surgery
4. Always avoiding tourniquets
19. B. SCD is a hereditary disorder associated with the formation of abnormal hemoglobin
(Hgb). This Hgb has the tendency to sickle under specific environmental conditions (e.g.,
hypoxia, hypothermia, and acidosis). Individuals who are homozygous have a greater tendency
to develop sickling because of the greater proportion of abnormal Hgb. Arterial tourniquets have
been used safely in patients with SCD; however, these devices should be used only when they
are critical to the surgical procedure because of the possibility of local hypoxia and acidosis.
Most commonly used anesthetic medications do not have an effect on the sickling process.
Maintenance of a hematocrit between 30% and 35% is desired. (See page 634: Sickle Cell
Disease.)
20. Which of the following statements concerning rheumatoid arthritis are

TRUE&quest;
1. It is characterized by chronic inflammation of multiple organ systems.
2. Polyarthropathy is the hallmark of the disease.
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3. Rheumatoid arthritis is a multisystem disease that causes subclinical cardiac and
pulmonary dysfunction.
4. Rheumatoid arthritis may affect the joints of the larynx with generalized edema and
limitation of vocal cord movement.
20. E. Rheumatoid arthritis is a chronic inflammatory disease with symmetric polyarthropathy
and involvement of other systemic organs. It often causes subclinical cardiac and pulmonary
dysfunction. Polyarthropathy initially occurs in the hands and wrists but may involve the joints of
the lower extremities, atlantoaxial joints, temporomandibular joint, cervical spine, and joints of
the larynx. Involvement of the larynx may result in generalized edema and limitation of vocal
cord movement. Other potential systemic manifestations include pericarditis, aortitis, pulmonary
nodules, interstitial lung disease, renal failure, and anemia. Felty syndrome is the clinical triad
of rheumatoid arthritis, leukopenia, and hepatosplenomegaly. (See page 636: Rheumatoid
Arthritis.)
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Review of Clinical Anesthesia, 5e [Vishal] 26. The Anesthesia Workstation & Delivery Systems
Chapter 26
The Anesthesia Workstation and Delivery Systems
1. The anesthesia machine has been redefined by the American Society for Testing
and Materials (ASTM). What is the new term&quest;
A. Anesthesia pump system
B. Anesthesia supply station
C. Anesthesia workstation
D. Anesthesia sleep station
E. Magic sleeping machine
1. C. Modern anesthesia systems administer anesthetics by a gas supply system and ventilator.
There are also built-in monitors and protection devices. This integration of technologies is now
termed the “anesthesia workstation” by the ASTM. Although the unit is a variation of a pump
and it does supply anesthetics, these two labels are incomplete. Our surgical colleagues
sometimes refer to the unit as a “magic sleeping machine,” but this is also inaccurate. (See
page 645: Anesthesia Workstation Standards and Pre-Use Procedures.)
2. To comply with the 2005 American Society for Testing Materials (ASTM) standards,
newly manufactured anesthesia work stations must have all of the following EXCEPT:
A. exhaled tidal volume monitors
B. anesthetic vapor concentration monitors
C. a prioritized alarm system
D. a way to measure supplied O2 pressure
E. a low-pressure circuit leak alarm
2. E. To comply with the 2005 ASTM standards, newly manufactured workstations must have
monitors that measure the following parameters: continuous breathing system pressure,
exhaled tidal volume, ventilatory CO2 concentration, anesthetic vapor concentration, inspired
O2 concentration, O2 supply pressure, arterial hemoglobin oxygen saturation, arterial blood
pressure, and continuous electrocardiogram. The anesthesia workstation must have a
prioritized alarm system that groups alarms into three categories: high, medium, and low priority.
(See page 646: Standards for Anesthesia Machines and Workstations.)
3. Considering the O2 cylinder supply source, which of the following statements is

TRUE&quest;
A. Anesthesia machines hold reserve D cylinders.
B. The hanger yoke assemblies that attach the cylinders to the anesthesia machine are
equipped with a pin index safety system to eliminate cylinder interchange.
C. The cylinder supply source is the primary gas source for the anesthesia machine.
D. A cylinder exchange cannot take place while gas is flowing from another cylinder into
the machine.
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E. The cylinder should be left open when the machine is in use in case of a pipeline
failure.
3. B. The anesthesia machines hold reserve E cylinders if a pipeline supply source is not
available or if the pipeline fails. Each hanger yoke is equipped with the pin index safety system,
which is a safeguard that eliminates cylinder interchanging and the possibility of accidentally
placing the incorrect gas on a yoke designed to accommodate another gas. A check valve is
located downstream from each cylinder. It minimizes gas transfer from a cylinder at high
pressure to one with low pressure. It also allows an empty cylinder to be exchanged for a full
one while gas continues to flow from another cylinder. The cylinder should be turned off except
during the preoperative machine checking period or when a pipeline source is unavailable. (See
page 654: Cylinder Supply Source.)
4. Piston-type anesthesia ventilators use less oxygen per minute than conventional
gas-driven ventilators: True or false&quest;
4. True. Pneumatic gas-driven ventilators consume more oxygen from pipeline sources or
cylinder sources than piston-type ventilators or ventilating by hand. (See page 654: Cylinder
Supply Source.)
5. If there is a suspected pipeline crossover malfunction (non-oxygen gas is

substituted into the oxygen designated pipeline), what action should the anesthesia
provider take&quest;
A. Nothing. The oxygen E-cylinder is already on, and it will automatically provide an
oxygen source to the patient.
B. Simply switch on the backup E-cylinder oxygen source.
C. Switch on the backup E-cylinder source and disconnect the pipeline gas sources until
the gases being piped in are identified.
D. None of the above.
5. C. This situation is a good example of why understanding the underlying details of
anesthesia equipment design and function is essential in caring for anesthetized patients.
Intuitively, the correct action is to have the backup E cylinder in the “on” position at all times to
provide an automatic source of 100% oxygen; however, this would lead to an undetected
exhausted oxygen backup supply. The second intuitive answer is to switch on the backup
supply when a gas pipeline crossover event is suspected; however, this would ignore that the
pressure difference between pipeline and E cylinder regulators ensures a preferential supply
from the compromised pipeline. (See page 653: Pipeline Supply Source.)
6. The flow meter assembly includes all of the following EXCEPT:

A. a physically distinguishable O2 flow control knob
B. a high-flow alarm to prevent turbulent flow
C. a series arrangement when two flow tubes are present for a single gas
D. float stops at the top and bottom of the flow tubes
E. flow meter scales individually hand calibrated using a specific float
6. B. Contemporary flow control valve assemblies have numerous safety features. The O2 flow
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control knob is physically distinguishable from other gas knobs. It is distinctively fluted, projects
beyond the control knobs of the other gases, and is larger in diameter than all the other flow
control knobs. If a single gas has two flow tubes, the tubes are arranged in series and are
controlled by a single control valve. Flow tubes are equipped with float stops at the top and
bottom of the tube. The upper stop prevents the float from ascending to the top of the tube and
plugging the outlet. It also ensures that the float will be visible at maximum flows (instead of
being hidden in the manifold). The bottom float provides a central foundation for the indicator
when the flow control valve is turned off. Flow meter scales are individually hand calibrated
using a specific float. There is no high-flow alarm to prevent turbulent flow. (See page 656:
Components of Flow Meter Assembly.)
7. Considering the flush valve, which of the following statements is TRUE&quest;

A. Using it intraoperatively may lead to patient awareness.
B. Using it intraoperatively may cause barotrauma, especially if it is used during the
expiratory phase of positive-pressure ventilation.
C. It is never suitable as a high-pressure O2 source for jet ventilation.
D. Flow from the flush valve enters the low-pressure circuit upstream from the vaporizer.
E. Using it never leads to retrograde flow.
7. A. The O2 flush valve is associated with several hazards. Improper use of a normally
functional O2 valve may also result in problems. Overzealous intraoperative O2 flushing may
dilute inhaled anesthetics and lead to patient awareness. O2 flushing during the inspiratory
phase of positive-pressure ventilation may cause barotrauma. Flow from the O2 flush valve
enters the low-pressure circuit downstream from the vaporizers and downstream from the
Ohmeda machine check valve. Inappropriate preoperative use of the O2 flush valve to evaluate
the low-pressure circuit for leaks may be misleading, particularly on the Ohmeda machine,
which has the check valve at the common outlet. Back pressure from the breathing circuit
closes the check valve airtight, and large low-pressure circuit leaks may go undetected. Some
machines, including the Ohmeda Modulus 2+, do not have check valves; thus, O2 may flow in
retrograde fashion through an internal relief valve located upstream from the O2 flush valve.
The O2 flush valve may provide a high-pressure O2 source suitable for jet ventilation. (See
page 660: Oxygen Flush Valve.)
P.126
8. Most modern vaporizers are classified as all of the following EXCEPT:
A. out-of-circuit
B. temperature compensated
C. flow-over
D. pressure compensated
E. variable bypass
8. D. Most modern vaporizers, including the Ohmeda Tec 4, Tec 5, and Tec 7 along with the
North American Drager Vapor 19.n and 20.n, are classified as variable bypass, flow-over,
temperature-compensated, agent-specific, out-of-circuit vaporizers. Variable bypass refers to
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the method of regulating output concentration. As gas enters the vaporizer's inlet, the setting of
the concentration control valve determines the ratio of flow that goes through the bypass
chamber and through the vaporizing chamber. The gas channel to the vaporizing chamber flows
over the liquid anesthetic and becomes saturated with vapor. Thus, flow-over refers to the
method of vaporization. These vaporizers are temperature compensated because they are
equipped with an automatic temperature-compensating device that maintains a constant vapor
output over a wide range of temperatures. These vaporizers are also agent specific and out-of-
circuit because they are designed to accommodate a single agent and to be located outside the
breathing circuit. Most modern vaporizers are not pressure compensated. However, vaporizers
for desflurane do need to be pressure compensated because desflurane has a vapor pressure
that is three to four times that of other contemporary inhaled anesthetics. (See page 662:
Variable Bypass Vaporizers.)
9. When considering flow rate and vaporizer output, which of the following statements
is TRUE&quest;
A. The vaporizer output is most consistent at extremes of flow rates.
B. The output of variable bypass vaporizers is less than the dial setting at high flow
rates.
C. At high flow rates, the vaporizer output can be higher than the dial setting secondary
to increased resistance to bypass flow.
D. Incomplete mixing leads to the output being higher than the dial setting at extremely
high flow rates.
E. The low level of turbulence at low flow rates affects the number of molecules
vaporized.
9. E. With a fixed dial setting, vaporizer output varies with the rate of gas flowing through the
vaporizer. This variation is particularly notable at extremes of flow rates. The output of all
variable bypass vaporizers is less than the dial setting at low flow rates (<250 mL/min). This
results from a relatively high density of volatile inhaled anesthetics. At low flows, insufficient
turbulence is generated in the vaporizing chamber to upwardly advance the vapor molecules. At
extremely high flow rates, such as 15 L/min, the output of most variable bypass vaporizers is
less than the dial setting. This discrepancy is attributed to incomplete mixing and saturation in
the vaporizing chamber. The resistant characteristics of the bypass chamber and the vaporizing
chamber may vary as flow increases. These changes may result in decreased output
concentration. (See page 662: Variable Bypass Vaporizers, Flow Rate.)
10. Considering desflurane and the Datex-Ohmeda Tec 6 vaporizer for desflurane,
which of the following statements is FALSE&quest;
A. The vapor pressure of desflurane is six to seven times that of contemporary inhaled
anesthetics.
B. Desflurane has a low blood gas coefficient, making recovery from anesthesia more
rapid.
C. Desflurane can boil at room temperature.
D. The Tec 6 is electrically heated and pressurized.
E. The Tec 6 output is affected by carrier gas composition.
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10. A. Desflurane has unique physical properties compared with other inhalation anesthetics. It
has a minimal alveolar concentration value of 6% to 7%. Desflurane is valuable because it has
a low blood gas solubility coefficient of 0.45° at 37°C and thus promotes rapid recovery from
anesthesia. The vapor pressure of desflurane is three to four times that of contemporary
inhaled anesthetics. It boils at 22.8°C, which is near room temperature. To achieve controlled
vaporization of desflurane, Ohmeda has introduced the Tec 6 vaporizer, which is electrically
heated and pressurized. The vaporizer output approximates the dial setting when O2 is the
carrier gas because the Tec 6 vaporizer is calibrated using 100% O2. At low flow rates when a
carrier gas other than 100% O2 is used, however, a clear trend toward reduction in vaporizer
output emerges. This reduction parallels the proportional decrease in viscosity of the carrier
gas. (See page 665: Datex Ohmeda Tec 6 Vaporizer for Desflurane.)
11. The Datex-Ohmeda Aladin (S3) cassette vaporizer unit uses safety features to
permit one vaporizer to deliver five different inhaled anesthetics. Which of the
following is NOT a safety feature&quest;
A. Each different inhaled anesthetic cassette is color coded.
B. Each inhaled anesthetic cassette identifies itself to the vaporizer using a magnetic
code.
C. Inhaled anesthetic agents are filled into an agent-specific cassette using an agent-
specific filler.
D. All of the above are true.
11. D. All of the listed features allow the Datex-Ohmeda Aladin (S3) vaporizer to identify and
deliver one of five inhaled anesthetic agents safely. The vaporizer's internal control unit
identifies the color-coded, magnetically labeled, agent-specific cassette, and each cassette is
filled using an agent-specific filler. (See page 668: The Datex-Ohmeda Aladin Cassette
Vaporizer.)
12. Considering the Mapleson circuits and their relative efficiency with respect to
prevention of rebreathing CO2, which of the following statements regarding
spontaneous ventilation is TRUE&quest;
A. A > DFE > BC
B. DFE > A > BC
C. BC > DFE > A
D. DFE > BC > A
E. A > BC > DFE
12. A. Comparing the different Mapelson systems to prevent rebreathing, A > DFE > BC during
spontaneous ventilation, and DFE > BC >A during controlled ventilation. (See page 671:
Mapleson Systems.)
13. Regarding the circle system, which statement is FALSE&quest;

A. Circle systems prevent rebreathing of CO2.
B. Circle systems prevent rebreathing of all exhaled gases.
C. A circle system can be semi-open.
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D. Numerous variations of the circle arrangement are possible.

E. The semi-closed system is the most commonly used application of the circle system.
13. B. The circle system prevents rebreathing of CO2 by use of CO2 absorbents but allows
partial rebreathing of other gases. A circle system may be semi-open, semi-closed, or closed,
depending on the amount of fresh gas inflow. A semi-closed system is associated with some
rebreathing of exhaled gases and is the most commonly used application in the United States.
Numerous variations of the circle arrangement are possible, depending on the relative positions
of the components. (See page 672: Circle Breathing Systems.)
14. All of the following factors can lead to increased production of compound A from
the interaction of sevoflurane and CO2 absorbent EXCEPT:
A. low fresh gas flow
B. high absorbent temperature
C. barium hydroxide lime (Baralyme) versus soda lime
D. dehydration of the Baralyme absorbent
E. old absorbent
14. E. Sevoflurane has been shown to produce degradation products upon interaction with CO2
absorbents. The major degradation product produced is fluoromethyl-2, 2-difluoro-
1(trifluoromethyl) vinyl ether, or compound A. During sevoflurane anesthesia, factors that
apparently lead to an increase in the concentration of compound A include low-flow or closed-
circuit anesthetic techniques, use of Baralyme rather than soda lime, higher concentrations of
sevoflurane in the anesthetic circuit, higher absorbent temperatures, and fresh absorbent.
Baralyme dehydration increases the concentration of compound A, and soda lime dehydration
decreases the concentration of compound A. (See page 674: Interactions of Inhaled Anesthetics
with Absorbents.)
15. When considering breathing circuits, which of the following statements is

TRUE&quest;
A. Absorbent canister leaks are the leading cause of critical incidents in anesthesia.
B. The most common site of disconnection is the inspiratory limb.
C. Leaks in the disposable anesthesia circuit can be detected through the high-pressure
system leak test.
D. The effectiveness of electronic pressure monitors in diagnosing a disconnection is
independent of the threshold pressure alarm limit.
E. Pressure monitors are probably the best device for revealing patient disconnection.
15. C. Breathing circuit disconnections are the leading cause of critical incidents in anesthesia.
The most common disconnection site is the Y-piece. Disconnections may be complete or partial.
The disposable anesthesia circuit must be fully expanded before the circuit is checked for
leaks. This is done to detect leaks in the high-pressure system, not the low-pressure system.
Pneumatic and electronic pressure monitors are helpful in diagnosing disconnections. Factors
that influence monitor effectiveness include the disconnection site, pressure sensor location,
threshold pressure alarm limit, inspiratory flow rate, and resistance of the disconnected
206 / 494
breathing circuit. When an adjustable-threshold pressure alarm limit is available, the operator
should set the alarm limit to within 5 cm H2O of the peak inspiratory pressure. CO2 monitors
are probably the best devices for revealing patient disconnections. (See page 677: Traditional
Circle System Problems.)
16. Considering the scavenging interfaces:

A. Positive-pressure and negative-pressure reliefs are mandatory if an active system is
used.
B. Neither positive-pressure nor negative-pressure relief is necessary when using an
active system.
C. Negative-pressure but not positive-pressure relief is necessary when using an active
system.
D. Positive-pressure but not negative-pressure relief is necessary when using an active
system.
E. Positive-pressure and negative-pressure relief are mandatory for a passive system.
16. A. Positive-pressure relief is mandatory in both active and passive systems to vent excess
gas in case of occlusion downstream from the scavenging interface. If the system is active,
negative-pressure relief is also necessary. It protects the breathing circuit or ventilator from
excessive subatmospheric pressure. Passive systems need only a single positive-pressure
relief valve. In this system, transfer of the waste gas from the interface to the basal system
relies on pressure of the waste gas itself because the vacuum is not used positively. The
positive-pressure relief valve opens at a preset value, such as 5 cm H2O, if an obstruction
between the interface and disposal system occurs. (See page 683: Scavenging Interface.)
17. Considering the O2 and nitrous oxide (N2O) pipeline supply source, which of the
following statements are TRUE&quest;
1. The O2 cylinder supply source should not be regulated from the cylinder pressure
upon entering the machine.
2. The hospital piping system supplies gases to the anesthesia machine at 50 lb per
square inch gauge (psig).
P.127
3. The fail-safe valve links the O2 and N2O flow control valves.
4. The second-stage O2 regulator in the Ohmeda machine supplies a constant pressure
to the O2 flow control valve regardless of the fluctuating pipeline pressure.
17. C. The hospital piping system provides gases to the machine at approximately 50 psig,
which is the normal working pressure of most machines. The cylinder supplies are the source
of backup if the pipeline fails. The O2 cylinder source is regulated from 2200 to approximately
45 psig, and the N2O cylinder source is regulated from 745 to approximately 45 psig. Most
Ohmeda machines have a second-stage O2 regulator located downstream from the O2 supply
source. This regulator supplies a constant pressure to the O2 flow control valve regardless of
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fluctuating O2 pipeline pressures. A safety device, traditionally referred to as the fail-safe valve,
is located downstream from the N2O supply source. It serves as an interface between the O2
and N2O supply source. This valve shuts off, or proportionally decreases, the supply of N2O
and other gases if the O2 supply pressure decreases. A proportioning system is a safety
feature that links O2 and N2O flow control valves, either mechanically or pneumatically, so the
minimum O2 concentration at the common outlet is 25%. (See page 653: Anesthesia
Workstation Pneumatics.)
18. Considering flow meter assembly, which of the following statements are
TRUE&quest;
1. The space between the float and the wall of the flow tube varies with different flow
rates.
2. The flow meters are referred to as constant pressure because the pressure across the
float does not change with changing flow rates.
3. They are made up of tapered tubes and a mobile indicator float.
4. Flow through the annular space can only be laminar.
18. A. The flow meter assembly precisely controls measured gas flow to the common gas
outlet. The flow control valve regulates the amount of gas that enters the tapered transparent
tube known as the flow tube. A mobile indicator located inside the flow tube indicates the
amount of gas passing through the flow control valve. The flow meters are commonly referred
to as constant-pressure flow meters because the pressure decrease across the float remains
constant for all positions in the tube. The term variable orifice designates the type of unit
because the annular space between the float and the flow tube varies with the position of the
float. Flow through the constriction created by the float may be laminar or turbulent, depending
on the flow rate. (See page 655: Flow Meter Assembly and page 656: Operating Principles of
the Flow Meters.)
19. Which of the following are the safest configuration(s) for the flow meter
sequence&quest;
1. N2O → Air → O2 → Outlet
2. O2 → N2O→ Air → Outlet
3. Air → N2O→O2 → Outlet
4. O2 → Air → N2O→ Outlet
19. B. It has been demonstrated that in the presence of a flow meter leak, a hypoxic mixture is
less likely to occur if the O2 flow meter is located downstream from all other flow meters. A
potentially dangerous arrangement has the nitrous oxide (N2O) flow meter located in the
downstream position. A hypoxic mixture may result because a substantial portion of O2 flow
passes through the leak, and all the N2O is directed to the common outlet. A safer configuration
has the O2 flow meter located in the downstream position. A portion of the N 2O flow escapes
through the leak, and the remainder goes toward the common outlet. A hypoxic mixture is less
likely because all of the O2 flow is advanced by the N2O. A leak in the O 2 flow tube may
produce a hypoxic mixture even when O2 is located in the downstream position. (See page 657:
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Problems with Flow Meters.)
20. A hypoxic mixture can be delivered even with a proportioning system if:
1. the wrong gas is in the O2 pipeline
2. there is a leak downstream from the flow valves
3. there are defective pneumatics or mechanics in the system
4. an inert gas (helium, CO2) is being delivered in addition to or instead of nitrous oxide
(N2O)
20. E. All of these conditions may lead to hypoxic mixture delivery, even with a proportioning
system. The proportioning system will be fooled if a gas other than O2 is present in the O2
pipeline. Normal operation of the proportioning system is contingent upon the pneumatic and
mechanical integrity. A leak downstream from these devices, such as a broken O2 flow tube,
may cause delivery of a hypoxic mixture. In this case, the O2 analyzer is the only machine
safety device that may detect the problem. Also, administration of a third inert gas, such as
helium, nitrogen, or CO2, may cause a hypoxic mixture because contemporary proportioning
systems link only N2O and O2. (See page 658: Proportioning Systems.)
21. Saturated vapor pressure:

1. is independent of temperature
2. is dependent on atmospheric pressure
3. is the same for all inhalation agents
4. is equal to atmospheric pressure at the boiling point of a liquid
21. D. Saturated vapor pressure is the pressure created by the molecules in the vapor phase of
a volatile liquid. As more molecules enter the vapor phase from the volatile liquid, the vapor
pressure increases. Vapor pressure is dependent on the temperature and physical
characteristics of the liquid; it is independent of the atmospheric pressure. The boiling point of
a liquid is the temperature at which the vapor pressure equals atmospheric pressure. All
inhalation agents have a unique saturated vapor pressure. (See page 661: Physics: Vapor
Pressure.)
22. The pumping effect is increased with which of the following&quest;

1. Low flow rates
2. Rapid respiratory rates
3. Low levels of liquid anesthetic in the vapor chamber
4. High peak inspiratory pressure
22. E. Intermittent back-pressure associated with positive-pressure ventilation or O2 flushing
may cause higher vaporizer output concentration than the dial setting. This phenomenon,
known as the pumping effect, is more pronounced at low flow rates, low dial settings, and low
levels of liquid anesthetics in the vaporizing chamber. Additionally, the pumping effect is
increased by rapid respiratory rates, high peak inspired pressures, and rapid decreases in
pressure during expiration. (See page 663: Factors That Influence Vaporizer Output.)
209 / 494
23. Which of the following vaporizer hazards are correctly matched with their safety
features&quest;
1. Misfiling—Keyed filling devices
2. Tipping—Interlock system
3. Overfilling—Filler port location
4. Simultaneous inhaled anesthetic administration—Fail-safe system
23. B. Agent-specific, key-filling devices help prevent filling a vaporizer with the wrong agent.
Overfilling of these vaporizers is minimized because the filler port is located at the maximum
safe liquid level. Today's vaporizers are firmly secured to the vaporizer manifold, and there is
little need to move them. Thus, problems associated with tipping are minimized. Some
vaporizers are equipped with extensive baffles to make them even more immune to the
problems associated with tipping. Administration of more than one inhaled anesthetic at a time
is prevented by an interlock system that does not allow more than one vaporizer at a time to be
operational. (See page 664: Vaporizer Safety Feature.)
24. Considering the Bain circuit, which of the following statements are TRUE&quest;
1. The fresh gas inflow rate necessary to prevent rebreathing is 2.5 times the minute
ventilation.
2. It is a modification of the Mapleson D circuit.
3. The major hazard of the Bain circuit is kinking or disconnection of the inner fresh gas
hose.
4. Fresh gas enters the circuit near the reservoir bag.
24. A. The Bain circuit is a modification of the Mapleson D circuit. It is a coaxial circuit in which
the fresh gas flows through a narrow tube within the outer corrugated tubing. The central tube
originates near the reservoir bag, but the fresh gas actually enters the circuit at the patient end.
Exhaled gases enter the corrugated tubing and are vented through the respiratory valve near
the reservoir bag. The Bain circuit may be used for both spontaneous and controlled ventilation.
The fresh gas inflow rate necessary to prevent rebreathing of CO2 is 2.5 times the minute
ventilation. The main hazard of the Bain circuit is unrecognized disconnection or kinking of the
inner fresh gas hose. (See page 671: Bain Circuit.)
25. When considering CO2 absorption, which of the following statements are
TRUE&quest;
1. The absorption of CO2 by soda lime is a chemical process, not a physical one.
2. The maximum amount of CO2 that can be absorbed is 26 L of CO 2/100 g of
absorbent.
3. The size of the absorptive granules is very important and takes both resistance to
airflow and absorptive efficiency into consideration.
4. It is not necessary for all closed and semi-closed circle systems.
25. A. The closed and semi-closed circle systems both require that the CO2 is absorbed from
exhaled gases. Two formulations of CO2 absorbents (soda lime and Baralyme) are commonly
used. The size of the absorptive granules has been determined by trial and error, which
210 / 494
represents a compromise between resistance to airflow and absorptive efficiency. The
absorption of CO2 by soda lime is a chemical process, not a physical process. The maximum
amount of CO2 that may be absorbed is 26 L of CO 2/100 g of absorbent. However, channeling
of gas through the granules may substantially decrease efficiency and allow only 10 to 20 L of
CO2 to actually be absorbed. (See page 673: Carbon Dioxide Absorbents.)
26. Problems associated with the bellows assembly include which of the
following&quest;
1. A bellows leak may lead to a change in the delivered FiO 2.
2. Hypoventilation may occur if the ventilator relief valve is incompetent.
3. A bellows leak may cause barotrauma if ventilators use a high-pressure driving gas.
4. Hypoventilation may occur if the ventilator relief valve is stuck in the closed position.
26. A. Many problems may occur with the bellows assembly. Leaks may occur from improper
seating of the plastic bellows resulting in inadequate ventilation because a portion of the driving
gas is vented to the atmosphere. A hole in the bellows may lead to alveolar hyperventilation and
possibly barotrauma when high-pressure driving gas is used. The value of delivered O2 may
increase when the driving gas is 100% O2, but it may also decrease if the driving gas is
composed of an air–O2 mixture. The ventilator relief valve may cause problems as well.
Hypoventilation occurs if the valve is incompetent because the anesthetic gas is delivered to
the scavenging system during the inspiratory phase instead of to the patient. If the ventilator
relief valve is stuck in the closed position, it may produce barotrauma. (See page 678: Bellows
Assembly Problems.)
27. Which of the following anesthetic techniques are associated with increased
operating room contamination&quest;
1. Failure to turn off gas flow at the end of an anesthetic
2. Filling of vaporizers
3. Use of uncuffed endotracheal tubes
4. Jackson-Reese circuits
27. E. The two major causes of waste gas contamination in the operating room are the
anesthetic technique used and the equipment used. Regarding the anesthetic technique, the
following factors cause operating room contamination: failure to turn off gas flow control valves
at the end of an anesthetic, poorly fitting mask, flushing of the circuit, filling anesthetic
vaporizers, use of uncuffed endotracheal tubes, and use of breathing circuits such as the
Jackson-Reese circuit, which is difficult to scavenge. (See page 681: Scavenging Systems.)
28. The low-pressure circuit test:

1. can detect loose filler caps
2. evaluates the portion of the machine that is downstream from all safety devices,
except the O2 analyzer
3. evaluates the integrity of the machine from the flow control valves to the common gas
outlet
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4. evaluates the portion of the machine with least possibility of leaks
28. A. The low-pressure leak test checks the integrity of the machine from the flow control
valves to the common outlet. It evaluates the portion of the machine that is downstream from all
safety devices except for the O2 analyzer. The components located in this area are precisely
the ones that may be subject to breakage and leaks. Leaks in the low-pressure system may
cause hypoxia and patient awareness. The North American Drager uses a positive-pressure
leak test, and the Ohmeda uses a negative-pressure leak test on the low-pressure circuit. (See
page 650: Low-Pressure Circuit Leak Test.)
29. Considering the new breathing system technology of fresh gas decoupling, which
of the following statements is TRUE&quest;
1. N2O and O2 are decoupled at the fresh gas inflow site.
P.128
2. The expiratory and inspiratory limbs of the breathing circuit are no longer connected at
the Y-piece.
3. The O2 flush valve is eliminated.
4. The fresh gas flow is no longer added to the volume of gas delivered to the patient
during inspiration.
29. D. The technology of fresh gas decoupling refers to a new breathing system that does not
allow the volume of gas that enters the circuit via the fresh gas inlet to be part of the volume of
gas delivered to the patient during inspiration. (See page 660: Oxygen Flush Valve.)
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Review of Clinical Anesthesia, 5e [Vishal] 27. Standard Monitoring Techniques
Chapter 27
Standard Monitoring Techniques
1. The O2 sensor location is on which part of the anesthesia circuit&quest;
A. Expiratory limb
B. Inspiratory limb
C. Fail-safe valve
D. Second-stage O2 pressure regulator
E. O2 pipeline supply
1. B. The O2 monitor is located on the inspiratory limb of the anesthesia circuit. Beyond this
point, the only alteration to the delivered anesthetic mixture would be the entrainment of room
air, which would not produce a hypoxic mixture. The expiratory limb is downstream to the
patient, providing no protection regarding what is delivered to the patient. The other possible
answers are all upstream sites in the anesthesia circuit, and although they would ensure that
the mixture was not hypoxic at that site, they could not ensure that downstream contamination
will not occur. (See page 698: Inspiratory and Expired Gas Monitoring: Oxygen.)
2. In the above capnograph, dead space ventilation occurs during which

interval&quest;
A. A–B
B. B–C
C. C–D
D. D–E
E. C–E
2. A. During the initial phase of ventilation, the gases being expired are from the conducting
airways, trachea, and anesthesia circuit. These areas are not involved in gas exchange, so
their composition reflects the inspired mixture. Unless the inspired mixture contains CO2, the
initial phase of expiration will be a horizontal line at 0 mm Hg of CO2. With further exhalation,
alveolar gas reaches the sampling site, and an increase in the capnograph occurs. (See page
699: Fig. 27-1.)
3. In the above capnograph, the point defined as end-tidal CO2 (ETCO2) occurs at:
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A. A
B. B
C. C
D. D
E. E
3. D. The end-tidal CO2 value is recorded at the end of expiration, which on the capnograph
occurs just before the steep decline back to baseline. (See page 699: Fig. 27-1.)
4. O2 saturation determination by a pulse oximeter is based on what physical

law&quest;
A. Charles' law
B. Bohr law
C. Beer-Lambert law
D. Boyle law
E. Bernoulli principle
4. C. O2 saturation detection via a pulse oximeter uses the physical principle described by the
Beer-Lambert law. The Beer law states that a parallel beam of light transmitted through a clear
solution with a solute dissolved within it will fall exponentially as the solute level increases. The
Lambert law states that a parallel beam of light will have its intensity fall exponentially as the
distance through which it must shine increases. (See page 700: Pulse Oximetry.)
5. The correct formula for determination of mean arterial pressure (MAP) based on
systolic pressure (SP) and diastolic pressure (DP) is:
A. DP + 1/3(SP – DP)
B. SP – 1/3(SP – DP)
C. DP – 1/2(SP – DP)
D. (SP – DP) × 3
E. (SP + DP)/3
5. A. The formula for MAP is DP plus one third the difference between the DP and SP. (See
page 702: Indirect Measurement of Arterial Blood Pressure.)
6. Patients with which condition are at increased risk of developing complete heart
block during insertion of a pulmonary artery catheter (PAC)&quest;
A. Right bundle branch block
B. Left bundle branch block
C. Atrial fibrillation
D. Anterior fascicular block
E. Posterior fascicular block
6. B. Individuals who have a left bundle branch block rely on their right bundle branch to
transmit the impulses from their atrioventricular node to the ventricular mass. In individuals with
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a left bundle branch block, passing a PAC through the right side of the heart could injure the
right bundle and produce complete heart block. (See page 707: Complications of Pulmonary
Catheter Monitoring.)
7. Which of the following monitors is the most accurate indicator of ventricular

preload&quest;
A. Central venous pressure (CVP) trends
B. Pulmonary capillary wedge pressure (PCWP)
C. Transesophageal echocardiography (TEE)
D. Mixed venous saturation
E. Urine output
7. C. The most accurate preload indicator for the left ventricle is the TEE probe because it can
assess actual intracardiac chamber size and thus preload. Urine output is also a very accurate
method of detecting adequacy of left ventricular (LV) preload; however, in healthy people with
inadequate LV preload, urine output may be maintained. Conversely, in numerous conditions,
urine output is inadequate despite adequate LV preload. CVP trends can be altered by
abnormalities within the right ventricle, pulmonary circulation, and left side of the heart. PCWP
is accurate only if there are no complicating matters within the lungs (e.g., excessive positive
end-expiratory pressure), left atrial abnormalities (e.g., mitral stenosis), or LV abnormalities
(e.g., ischemia). Mixed venous O2 saturation is an accurate indicator of total body O2 balance
but does not directly measure LV preload; it may be normal despite inadequate LV preload if the
heart rate is increased to maintain cardiac output. (See page 705: Monitoring Applications.)
P.134
8. Which of the following is the most sensitive indicator of myocardial
ischemia&quest;
A. Central venous pressure (CVP)
B. Pulmonary artery catheter (PAC)
D. ST analysis of the electrocardiographic (ECG) tracing in leads II and V5
E. Cardiac output
8. C. Of all the answers, TEE and ST analysis of the ECG are the most accurate of the
monitors for detecting myocardial ischemia. The most sensitive and specific of the two is TEE.
The regional wall motion abnormalities that occur during ischemia are readily detected by TEE.
Abnormal wall thickening and inward motion of the ischemic segment occur within seconds of
the segment's becoming ischemic. However, not all wall motion abnormalities are caused by
ischemia. Comparing TEE with ECG ST analysis, TEE picks up more ischemic episodes; ST
analysis is very sensitive for ischemia. Increasing its sensitivity and specificity can be
accomplished by placing the leads in the areas most likely to become ischemic. CVP, PAC
readings, and cardiac output become abnormal with ischemia; however, they become abnormal
late and are not very specific for ischemia. (See page 705: Monitoring Applications.)
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9. True statements about the use of monitoring devices include:

1. Invasive monitoring may place patients at risk for complications related to the devices'
application and use.
2. Monitoring devices are not subject to fatigue or distraction.
3. Monitoring devices may make measurements at higher frequencies than is humanly
possible.
4. Monitoring devices always enhance patient safety.
9. A. Because monitors are mechanical devices, they do not become distracted. They can also
make repetitive measurements more often than humans because they do not experience
fatigue. Monitoring the patient's vital sign allows one to detect derangements in the patient's
early stages and make interventions to prevent irreversible injury. Monitors enhance patient
safety only if an appropriate intervention is undertaken to correct the perturbation in the
patient's physiology. Invasive monitoring may place patients at risk for complications related to
the devices' application and use. (See page 698: Introduction.)
10. Methods of analyzing O2 concentration include:

1. paramagnetic
2. galvanic cell
3. polarographic
4. photovoltaic
10. A. The first three options are all methods used clinically to detect O2 levels in the anesthetic
mixture. Photovoltaics involve the generation of electrical current when certain metals are
exposed to light. Examples of their use include the system that prevents elevator doors from
closing on people within the threshold of the elevator. (See page 698: Paramagnetic Oxygen
Analysis; page 698: Galvanic Cell Analyzers; and page 698: Polarographic Oxygen Analyzers.)
11. End-tidal CO2 (ETCO2) values can be altered because of changes in which of the
following&quest;
1. Ventilation
2. Pulmonary blood flow
3. Metabolic activity
4. Cardiac output
11. E. The production of end-tidal CO2 is dependent on its generation (i.e., metabolic rate),
transportation from the cells to the lungs (i.e., cardiac output and pulmonary blood flow), and
excretion from the lung (resulting from ventilation). (See page 698: Monitoring of Expired
Gases.)
12. The assumption that end-tidal CO2 (ETCO2) reflects PaCO2 is dependent on which
of the following statements being TRUE&quest;
1. Ventilation and perfusion are appropriately matched.
2. No diffusion gradient exists for CO2.
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3. No sampling errors occur during measurement.

4. All alveoli empty at the same time.
12. A. Ventilation–perfusion (V/Q) mismatch results in an increase in dead space ventilation,
which produces a situation in which alveolar gas is diluted by dead space gas (whose PaCO2
value is 0). This increases the PaCO2–ETCO2 gradient. Diffusion abnormalities, such as acute
respiratory distress syndrome, restrict the diffusion of CO2 from the blood into the alveoli and
thus widen the PaCO2–ETCO2 gradient. Sampling errors, such as excessive sampling rate in
which fresh gas is entrained, or leaks in the system dilute the expired CO2, resulting in a
widened gradient. The alveolar emptying rate does not affect the gradient between PaCO2 and
ETCO2, but it does produce the gentle upward trend of the plateau phase of the capnograph.
(See page 698: Monitoring of Expired Gas: Carbon Dioxide.)
13. Increasing dead space ventilation results in which change to end-tidal CO2
(ETCO2)&quest;
1. It reduces the ETCO2 value measured.
2. It increases the baseline ETCO2 value.
3. It widens the PaCO2–ETCO2 gradient.
4. It causes downsloping of the plateau phase of the capnogram.
13. B. Increasing dead space ventilation results in a larger reservoir or tidal volume, which is
not involved in respiration. During exhalation, this reservoir of nonrespiratory gas mixes with
alveolar gas and dilutes its concentration of CO2, resulting in a widening of the
PaCO2–ETCO2 gradient. This has no effect on the baseline value seen during inspiration.
Downsloping of the capnograph plateau phase can be seen when the sampling rate exceeds
the exhaled volume. (See page 698: Monitoring of Expired Gas: Carbon Dioxide.)
14. The presence of a stable (three breaths) CO2 waveform via capnography may
indicate which of the following&quest;
1. An endotracheal tube (ETT) in the trachea
2. An ETT in the pharynx
3. An ETT in the right mainstream bronchus
4. An ETT in the esophagus
14. A. Three stable CO2 waveforms on a capnograph indicate that the ETT is in such a
position as to be exposed to expired pulmonary gas. Thus, the ETT could be anywhere from
the nose to the alveoli. Sampling gases from an ETT within the stomach may result in detection
of CO2; however, the quantity measured will decrease rapidly with subsequent breaths. (See
page 698: Monitoring of Expired Gas: Carbon Dioxide.)
15. Possible causes for a sudden loss of end-tidal CO2 (ETCO2) include:
1. extubation
2. massive pulmonary embolism
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3. disrupted sample line
4. hyperventilation
15. A. For ETCO2 to be detected, there must be adequate pulmonary blood flow to deliver the
CO2 to the lungs for excretion, ventilation of the lungs, and an intact sampling system. The
presence of a massive pulmonary embolism will cease pulmonary blood flow. Extubation in a
mechanically ventilated patient would result in cessation of ventilation. A disrupted sampling line
in a sidestream sampling system would result in a sudden loss of CO2 waveform.
Hyperventilation would result in a gradual lowering of ETCO2, not a sudden decrease. (See
page 698: Monitoring of Expired Gas: Carbon Dioxide.)
16. Common clinical causes for a widened PaCO2–end-tidal CO2 (ETCO2) gradient
include:
1. pulmonary embolism
2. hypoperfusion
3. chronic obstructive pulmonary disease
4. pulmonary shunt
16. A. The common clinical causes associated with a widened PaCO2–ETCO2 gradient include
embolic phenomena (thrombus, fat, air, amniotic fluid), hypoperfusion states with reduced
pulmonary blood flow, and chronic obstructive pulmonary disease. In contrast, conditions that
increase pulmonary shunt (perfusion in the absence of ventilation) result in minimal changes in
the PaCO2–ETCO2 gradient. (See page 698: Monitoring of Expired Gas: Carbon Dioxide.)
17. The cause(s) of a sudden rise in nitrogen level in exhaled gases during O2/N2O
anesthesia include(s):
1. failure of O2 fail-safe alarm
2. leak in anesthesia circuit
3. failed inspiratory one-way valve
4. venous air embolism
17. C. During O2/N2O anesthesia, no nitrogen should be detected in the system. Any nitrogen
in the circuit must be coming from the air surrounding the patient or the anesthesia circuit.
Thus, the possible causes include venous air embolism and leaks in the anesthesia or sampling
circuit. Failure of the O2 fail-safe alarm will prevent one from detecting a loss in sufficient
pipeline O2 pressure. A failure in the inspiratory one-way valve will result in the patient's
rebreathing expired gases that, if the system is closed, will not contain nitrogen. (See page 698:
Monitoring of Expired Gases.)
18. During a laparoscopic cholecystectomy, an arterial blood gas sample is drawn

because of difficulty maintaining O2 saturation. When reviewed, the practitioner notes
a large discrepancy between PaCO2 and end-tidal CO2 (ETCO2). Possible causes for
this include which of the following&quest;
1. Air embolism
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2. Hypoxic mixture
3. Baseline obstructive airway disease
4. Pre-existing restrictive airway disease
18. B. The gradient between PaCO2 and ETCO2 is dependent on the degree of dead space
ventilation. The common clinical causes associated with a widened PaCO2–ETCO2 gradient
include embolic phenomena (thrombus, fat, air, amniotic fluid), hypoperfusion states with
reduced pulmonary blood flow, and chronic obstructive pulmonary disease. Hypoxic mixture and
restrictive pulmonary disease do not affect the ETCO2–PaCO2 gradient. (See page 698:
Monitoring of Expired Gases: Carbon Dioxide.)
19. Which of the following statements regarding arterial pulse contour analysis are
TRUE&quest;
1. It gives a beat-to-beat estimation of left ventricular output.
2. It is not accurate in patients with septic shock.
3. It requires calibration to a reference cardiac output determined by thermodilution or
lithium dilution.
4. It is more accurate than cardiac outputs determined by thermodilution.
19. B. Pulse contour analysis of the arterial waveform allows one to estimate left ventricular
output. It requires calibration using thermodilution or lithium dilution cardiac output
determinations as a reference. Numerous clinical studies have demonstrated that the precision
and accuracy of arterial pulse contour analysis are acceptable when compared with
thermodilution cardiac output measurements obtained by pulmonary artery catheters. (See
page 710: Noninvasive Techniques for Cardiac Output: Arterial Pulse Contour Analysis.)
20. Falsely high estimations of blood pressure determined by a noninvasive cuff occur
in which of the following conditions&quest;
1. Use of a cuff that is too small
2. Use of a loosely applied cuff
3. The extremity being below the level of the heart
4. Use of excessively quick deflation of the cuff
20. A. For a noninvasive blood pressure cuff to give accurate blood pressure readings, the cuff
must be appropriately sized, with the width of the cuff bladder being 40% of the arm's
circumference. The bladder length should be sufficient to encircle at least 80% of the extremity.
Use of excessively large or small cuffs results in falsely low and falsely high pressures,
respectively. The cuff must be applied appropriately tight because use of a loose cuff results in
an artificially high reading. Deflation of the cuff must be slow enough to detect the Korotkoff
sounds and the resultant changes with deflation. Use of excessively quick deflation results in
falsely low blood pressure readings. (See page 702: Indirect Measurement of Arterial Blood
Pressure.)
P.135
21. The fidelity of fluid transducing systems (i.e., arterial lines) is constrained by which
of the following properties&quest;
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1. Damping
2. Piezoelectric impedance
3. Natural frequency
4. Laminar flow
21. B. Natural frequency and damping are the two primary conditions that influence
reproduction of the arterial wave measured by a fluid-filled transducer system. The natural
frequency of the monitoring systems must be higher than the frequency within the arterial
waveform. If the frequency within the arterial pulse wave approaches the natural frequency of
the fluid-filled transducer, resonance will occur. This will be seen as overshoot or ringing. This
produces amplification of the original signal by the monitoring device. Systolic pressure will be
overestimated in such situations. Damping within the system impedes the transducer from
detecting the changes of the pressure within the arterial waveform. This impedance results in a
loss of the fine details contained within the arterial waveform. An overdampened arterial
waveform results in blunting of the pulse pressure, little change in mean arterial pressure, and
loss of the dicrotic notch. Underdampened systems produce an overshoot of the systolic
pressure and the development of artifacts produced not by the waveform but rather secondary
to the monitoring system. (See page 704: Fig. 27-4).
22. Which of the following may complicate placement of a radial arterial line&quest;
1. Median nerve injury
2. Thrombosis of the artery
3. Hematoma formation
4. Ulnar nerve injury
22. A. The radial artery may be damaged during catheter placement. Hematoma formation and
thrombosis of the artery may occur during placement, while in situ, or during removal. The
median nerve lies approximately 1 cm medially from the radial artery but is sufficiently close as
to risk possible injury. The ulnar nerve lies on the opposite side of the wrist along with the ulnar
artery. (See page 703: Complications of Invasive Arterial Monitoring.)
23. Compared with the right internal jugular (IJ) vein, the left IJ vein is used less often
for central venous access because of which of the following&quest;
1. Potential for damage to the thoracic duct
2. Closer proximity to the carotid artery
3. Difficulty passing through the jugular–subclavian junction
4. Increased risk of injury to the phrenic nerve
23. B. The right IJ vein is the jugular vein of choice for a number of reasons. It tends to be
larger than the left IJ vein, and it travels in a more direct line path into the superior vena cava.
The left IJ vein's more tortuous route and the presence of the thoracic duct at the left IJ vein
–subclavian junction (which may lead to thoracic duct injury) make it a less desirable site. Both
the right and left IJ veins are in similarly close approximation with the ipsilateral carotid artery
and the phrenic nerve. (See page 705: Central Venous and Pulmonary Artery Monitoring.)
24. Determination of mixed venous O2 saturation (SvO2) allows one to assess which of
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1. Adequacy of O 2 delivery
2. Adequacy of cerebral perfusion
3. Determination of intracardiac and pulmonary shunts
4. Quantity of dead space within the lungs
24. B. SvO2 allows for assessment of the total body O2 balance. SvO2 is dependent on
cardiac output, O2 saturation, and hemoglobin concentration. A patient can have a normal
SvO2 despite inadequate blood flow to an area of the body because a small regional area of
hypoperfusion does not significantly alter SvO2. Intracardiac or intrapulmonary shunts produce
elevations of SvO2 beyond normal (70%). The point at which the increase in the SvO2 occurs
may determine the anatomic site of the shunt. Cellular poisons and sepsis are other examples
of situations in which an elevation in SvO2 beyond normal may occur. (See page 705:
Pulmonary Artery Monitoring.)
25. Which of the following conditions may alter the relationship between pulmonary
capillary occlusion pressure (PCOP) and pulmonary diastolic pressure (PDP)&quest;
1. Pulmonary embolism
2. Alveolar hypoxia
3. Acidosis
4. Chronic pulmonary disease
25. E. In most cases, pulmonary capillary occlusion pressure (PCOP) and pulmonary diastolic
pressure (PDP) are very similar, with PCOP being just slightly higher. This similarity allows one
to estimate PCOP, which reflects left ventricular end-diastolic pressure (LVEDP) from the value
of the PDP on a beat-to-beat basis and without the inherent risk that balloon inflation entails.
There are several conditions in which the relationship between PDP and pulmonary capillary
wedge pressure is altered, and using PDP in these cases results in an underloaded ventricle
because the pressure will be overestimated. Most of these cases involve conditions of
increased pulmonary pressures resulting from increased pulmonary resistance. This is seen in
patients with chronic pulmonary disease, such as chronic obstructive pulmonary disease and
idiopathic pulmonary hypertension, and in acute situations, such as pulmonary embolism,
hypoxia, and acidosis. When treating patients with these conditions, PCOP should be sought to
ensure accurate estimations of LVEDP. (See page 707: Pulmonary Vascular Resistance.)
26. Which of the following statements describes conditions in which a pulmonary

artery catheter (PAC) is located in west zone 3&quest;
1. Pulmonary capillary occlusion pressure (PCOP) > Pulmonary diastolic pressure (PDP)
2. Ability to aspirate blood from the distal port when the PAC is wedged
3. Nonphasic PCOP tracing
4. Chest radiograph showing the catheter tip below the level of the left atrium
26. C. To use a PAC to estimate left ventricular end-diastolic pressure (LVEDP) through the
measurement of PCOP, the PAC must be positioned in the lungs at a site where a continuous
column of blood will be present from the tip of the catheter to the left atrium when the balloon is
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inflated. This condition occurs in west zone 3. A PAC positioned in west zone 2 will measure
airway pressure during the respiratory cycle because the alveolar pressure exceeds the
capillary pressure at peak inspiration. Conditions that increase west zones 2 and 1 (e.g.,
hypovolemia, positive end-expiratory pressure) may convert a properly placed PAC into an
improperly placed one, rendering the PAC useless for pulmonary capillary wedge pressure
monitoring. A PAC in west zone 4 will be compressed by interstitial pressure, which is greater
than left atrial pressure and thus gives falsely elevated PCOP values. The following
characteristics suggest that a PAC is not in west zone 3: PCOP > PDP (if no pulmonary
hypertension is present), nonphasic PCOP tracing, and an inability to withdraw blood when
wedged. The location of a PAC may be confirmed by lateral chest radiography to ascertain that
the catheter tip is below the level of the left atrium. (See page 707: Alveolar–Pulmonary Artery
Pressure Relationships.)
27. Pulmonary capillary occlusion pressure (PCOP) is not a valid reflection of left
ventricular end-diastolic pressure (LVEDP) in which of the following conditions&quest;
1. Ischemic left ventricle
2. Aortic regurgitation
3. Mitral valve stenosis
4. Prolonged Q-T interval
27. A. PCOP as an accurate estimation of LVEDP is predicated on normal LV compliance, the
absence of aortic or mitral valve disease (aortic regurgitation, mitral stenosis, or mitral
regurgitation), normal pulmonary airway pressures, normal size of pulmonary vascular bed, and
normal pulmonary vascular resistance. Altering these assumptions results in the inability to
predict LV loading conditions with PCOP values. (See page 707: Intracardiac Factors.)
28. Factors that increase the risk of mortality after a pulmonary artery catheter (PAC)
–induced pulmonary artery rupture include:
1. coagulopathy
2. pulmonary hypertension
3. heparinization
4. hypotension
28. A. Pulmonary artery rupture is a rare but serious and possibly fatal complication of a PAC.
The risk of rupture is increased in patients with pulmonary hypertension. Mortality after the
rupture is aggravated further in patients who are heparinized or coagulopathic. (See page 707:
Complications of Pulmonary Artery Catheter Monitoring.)
29. Which of the following statements are TRUE&quest;

1. Convection is heat loss resulting from contact with surfaces.
2. Radiation is heat loss resulting from infrared irradiation.
3. Conduction is heat loss resulting from movement of air.
4. Evaporation is heat loss resulting from energy required for vaporization of water.
29. C. Convection is the change in heat content resulting from the movement of air over the
surface of the object. Conduction is the change in heat content resulting from the object's
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contact with another surface. Radiation is the change in heat content resulting from absorption
or emission of photons. Evaporation is heat loss resulting from the vaporization of water. (See
page 711: Temperature Monitoring.)
30. Which of the following statement(s) about pulse oximetry are true&quest;
1. Pulse oximetry combines the technology of plethysmography and spectrophotometry.
2. Ambient light, nail polish, and motion may compromise the accuracy of pulse oximetry.
3. Electrocautery can interfere with pulse oximetry.
4. Pulse oximetry measures the fractional oxygen saturation.
30. A. Pulse oximetry combines the technology of plethysmography and spectrophotometry.
Ambient light, nail polish, and motion may compromise the accuracy of pulse oximetry.
Electrocautery may interfere with pulse oximetry. Whereas pulse oximetry measures the
functional oxygen saturation, co-oximetry measures the fractional oxygen saturation. (See page
700: Pulse Oximetry.)
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Review of Clinical Anesthesia, 5e [Vishal] 28. Echocardiography
Chapter 28
Echocardiography
1. Understanding the principles of ultrasound and echocardiographic instrumentation is

essential to optimizing image quality. Which of the following statements regarding
image resolution is TRUE&quest;
A. Image resolution increases with long wavelength sound waves.
B. The greatest axial resolution is offered by long pulses of high-frequency ultrasound.
C. Broadening beam size improves the lateral and elevational resolution.
D. High frame rates and high pulse repetition frequencies (PRF) enhance resolution.
1. D. The PRF is the rate at which sound pulses are triggered. The greater the PRF, the greater
the number of scan lines that are emitted in a given period. This enhances the motion display.
Short pulses of high-frequency ultrasound offer the greatest axial resolution but have a
decreased tissue penetration. Because resolution is highest along the axial plane,
echocardiographic measurements are most precise when taken parallel to the beam's axis. The
frame rate is the frequency at which the sector is rescanned. A high frame rate improves the
capture of movement. Increases in sector size and depth come at the cost of a decreased frame
rate and decreased PRF, respectively, producing poor motion imaging. High-frequency, short-
wavelength ultrasound is more easily focused and directed to a specific target location. Image
resolution increases with short-wavelength sound waves, so ultrasonic frequencies of 2 to 10
MHz are preferred in clinical echocardiography. The shorter the length of the sound pulses, the
better the axial resolution of the system. The beam size determines the lateral and elevational
resolution. Whereas broad beams produce a “smeared” image of two nearby objects, narrow
beams can identify each object individually. (See page 716: Properties of Sound Transmission
in Tissue.)
2. Which of the following is an important factor in determining the potential for tissue
damage with ultrasonography&quest;
A. Frequency
B. Wavelength
C. Propagation velocity
D. Amplitude
2. D. The amplitude of a sound wave represents its peak pressure and is appreciated as
loudness. The level of sound energy in an area of tissue is referred to as intensity. The
intensity of the sound signal is proportional to the square of the amplitude and is an important
factor regarding the potential for tissue damage with ultrasound. The Food and Drug
Administration limits the intensity output of cardiac ultrasonography systems to be less than 720
W/cm2 because of concerns of potential tissue injury. Sound waves are also characterized by
their frequency (f), or pitch, expressed in cycles per second or Hertz (Hz), and by their
wavelength (λ). These attributes significantly impact the depth of penetration of a sound wave
in tissue and the image resolution of the ultrasound system. The propagation velocity of sound
(v) is determined solely by the medium through which it passes. In soft tissue, the speed of
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sound is approximately 1540 m/s. (See page 716: Physics of Sound.)
3. The figure below shows an M-mode image across the aortic valve. Which of the
following statements regarding M-mode (motion-mode) imaging is FALSE&quest;
A. M-mode imaging displays a series of sequentially collected brightness-mode (B-

mode) images.
B. M-mode imaging remains the best technique for examining the timing of cardiac
events.
C. M-mode imaging provides a one-dimensional, single-beam view through the heart.
D. M-mode imaging can display shape and lateral motion information about cardiac
anatomy.
3. D. Ultrasonic imaging is based on the amplitude and time delay of the reflected signals. By
timing the interval between transmission and return of the reflections, the echocardiography
system can precisely calculate the distance of a structure from the transducer. Current imaging
is based on B-mode technology. With B-mode imaging, the amplitude of the returning echoes
from a single pulse determines the display brightness of the representative pixels. M-mode
imaging adds temporal information to B-mode imaging by displaying a series of sequentially
collected B-mode images. M-mode echocardiography provides a one-dimensional, single-beam
view through the heart but updates the B-mode images at a very high rate, providing dynamic
real-time imaging. M-mode imaging remains the best technique for examining the timing of
cardiac events. Two-dimensional (2-D) echocardiography is a modification of B-mode
echocardiography and is the mainstay of the echocardiographic examination. Instead of
repeatedly firing ultrasound pulses in a single direction, the transducer in 2-D echocardiography
sequentially directs the ultrasound pulses across a sector of the cardiac anatomy. In this way,
2-D imaging displays a tomographic section of the cardiac anatomy, and unlike M-mode,
reveals shape and lateral motion. (See page 716: Instrumentation.)
4. Transesophageal echocardiography (TEE) is the favored approach to intraoperative

echocardiography because:
A. Compared with transthoracic echocardiography (TTE), TEE offers additional
“windows” to view the heart.
B. TEE examination is not limited by obesity, emphysema, surgical dressings, or
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prosthetic valves.
C. The TEE probe can be left in situ, providing continuous, real-time hemodynamic
information.
D. All of the above.
4. D. TEE is the favored approach to intraoperative echocardiography. Compared with TTE,
TEE offers additional “windows” to view the heart, often with improved image quality because
of the anatomic proximity of the esophagus and heart. In the operating room, TEE is useful
because the probe does not interfere with the operative field and can be left in situ, providing
continuous, real-time hemodynamic information used to diagnose and manage critical cardiac
events. TEE is also useful in situations in which the transthoracic examination is limited by
various factors (obesity, emphysema, surgical dressings, prosthetic valves) and for examining
cardiac structures that are not well visualized with TTE (e.g., the left atrial appendage). (See
page 718: Two-Dimensional and Three-Dimensional Transesophageal Echocardiography
Examination.)
5. Which of the following preclude the placement of a transesophageal

echocardiography (TEE) probe&quest;
A. Esophageal stricture, rings, or webs
B. Recent bleeding of esophageal varices
C. Zenker's diverticulum
D. Recent gastric bypass surgery
5. E. To maintain the safety profile of TEE, each patient should be evaluated before the
procedure for signs, symptoms, and history of esophageal pathology. The most feared
complication of TEE is esophageal or gastric perforation. For skilled practitioners, this
complication is extremely rare. Patients with extensive esophageal and gastric disease are at
highest risk of perforation. Contraindications to TEE probe placement include esophageal
stricture, rings, or webs; esophageal masses (especially malignant tumors); recent bleeding of
esophageal varices; Zenker's diverticulum; recent radiation to the neck; and recent gastric
bypass surgery. In the rare case in which TEE is essential and is the only alternative,
placement of the TEE probe can be performed under direct visualization with a combined
gastroscopic and echocardiographic examination. (See page 719: Transesophageal
Echocardiography Safety.)
6. The midesophageal ascending aorta short-axis (ME AA SAX) view shown on the next
page is useful for evaluating:
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A. the ascending aorta for dimensions and the presence of dissection flaps
B. the pulmonary artery (PA) or the position of a PA catheter or to rule out thrombus
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C. blood flow in the main PA
D. all of the above
6. D. The ME AA SAX view is obtained by advancing the probe slightly from the upper
esophagus until the ascending aorta (AA) is seen and then rotating the multiplane angle from 0
to 45 degrees to obtain a true short axis. This “great vessel view” images the AA in short axis
and the main PA with its bifurcation and right pulmonary artery in long axis. The main uses of
the ME AA SAX view are to evaluate the AA for dimensions and presence of dissection flaps,
evaluate the PA (position of catheter or rule out thrombus), and assess PA blood flow (by
aligning the Doppler beam parallel to the blood flow in the main PA). (See page 720: Goals of
the Two-Dimensional Examination.)
7. Which of the following monitors is the most accurate indicator of ventricular

preload&quest;
B. Pulmonary capillary wedge pressure (PCWP)
D. Mixed venous saturation
E. Urine output
7. C. The most accurate preload indicator for the left ventricle is the TEE probe because it can
assess actual intracardiac chamber size and thus preload. Urine output is another very
accurate method of detecting adequacy of left ventricular (LV) preload; however, in healthy
people with inadequate LV preload, urine output may be maintained. Conversely, in numerous
conditions, urine output is inadequate despite adequate LV preload. CVP trends can be altered
by abnormalities within the right ventricle, pulmonary circulation, and left side of the heart.
PCWP is accurate only if there are no complicating matters within the lungs (excessive positive
end-expiratory pressure), left atrial abnormalities (mitral stenosis), and LV abnormalities
(ischemia). Mixed venous O2 saturation is an accurate indicator of the total body O2 supply
–demand balance but does not directly measure LV preload; it may be normal despite
inadequate LV preload if the heart rate is increased to maintain cardiac output. (See page 719:
Monitoring Applications.)
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8. Which of the following is the most sensitive indicator of myocardial

ischemia&quest;
B. Pulmonary artery catheter (PAC)
D. ST analysis of the electrocardiographic (ECG) tracing in leads II and V5
E. Cardiac output
8. C. Of all the answers, TEE and ST analysis of the ECG are the most accurate of the
monitors for detecting myocardial ischemia. The most sensitive and specific of the two is TEE.
The regional wall motion abnormalities that occur during ischemia are readily detected by TEE.
Abnormal wall thickening and inward motion of the ischemic segment occur within seconds of
the segment's becoming ischemic. However, not all wall motion abnormalities are caused by
ischemia. When comparing TEE with ECG ST segment analysis, TEE picks up more ischemic
episodes. ST analysis is very sensitive for ischemia. Increasing its sensitivity and specificity can
be accomplished by placing the leads in the areas most likely to become ischemic. CVP, PAC
readings, and cardiac output become abnormal with ischemia; however, they become abnormal
late and are not very specific for ischemia. (See page 726: Monitoring Applications.)
9. All of the following statements regarding the transgastric midpapillary short-axis (TG
mid-SAX) view shown here are true EXCEPT:
A. It allows the immediate diagnosis of a hypovolemic state or pump failure.

B. The left ventricle (LV) is visualized as doughnut shaped in cross-section, and both
papillary muscles should be seen.
C. It visualizes all the LV walls perfused by each of the three major coronary arteries.
D. Doppler assessment of blood flow velocities is most accurate in this view.
9. D. The TG mid-SAX view is obtained by advancing the TEE probe from the midesophageal
position into the stomach and anteflexing and then withdrawing it until contact is made with the
gastric wall. The LV is visualized as a doughnut shape in cross-section, and both papillary
muscles should be seen. Advancement of the probe allows visualization of the LV apex in cross-
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section. The TG mid-SAX view is unique in that it visualizes all the LV walls perfused by each of
the three major coronary arteries. The view is considered to be the most useful one in
situations of intraoperative hemodynamic instability because it allows immediate diagnosis of
hypovolemic state, pump failure, and coronary ischemia. The primary uses of the TG mid-SAX
include assessment of the LV size (enlargement, hypertrophy) and cavity volume and global
ventricular systolic function and regional wall motion. Two-dimensional echocardiography
captures high-fidelity motion images of cardiac structures but not blood flow. Blood flow indices
such as blood velocities, stroke volume, and pressure gradients are the domain of Doppler
echocardiography. (See page 720: Goals of Two-Dimensional Examination.)
10. Doppler assessments are an essential element of the echocardiographic

examination. Which of the following statements regarding Doppler measurements is
FALSE&quest;
A. By monitoring the frequency pattern of reflections from red blood cells (RBCs),
Doppler echocardiography can determine the speed, direction, and timing of blood flow.
B. The requirement of near parallel orientation to blood flow for Doppler examinations
contrasts with the near-perpendicular orientation to cardiac structures preferred for two-
dimensional (2-D) imaging.
C. When the beam angle divergence is greater than 30 degrees, the Doppler system will
markedly overestimate blood velocity.
D. Two Doppler techniques, pulsed-wave Doppler (PWD) and continuous-wave Doppler
(CWD), are commonly used to evaluate blood flow.
10. C. Unlike 2-D imaging, which relies on the time delay and amplitude of reflected ultrasound,
Doppler technologies are based on the change in frequency that occurs when ultrasound
interacts with moving objects. Reflections from RBCs are used to determine the blood flow
velocity and calculate the hemodynamic parameters. The requirement of near-parallel
orientation to blood flow for Doppler examinations contrasts with the near-perpendicular
orientation to cardiac structures preferred for 2-D imaging. The Doppler equation Δ f = v ×
cos&thetas; × 2f t/c describes the relationship between the alteration in ultrasound frequency
and blood flow velocity. Conceptually, the equation is simplified by observing that the change in
ultrasound frequency is related to just two variables: blood flow velocity and cos &thetas;.
When the beam angle divergence is greater than 30 degrees, the value of cos &thetas;
decreases rapidly, and the Doppler system markedly underestimates blood velocity. PWD and
CWD are commonly used to evaluate blood flow. (See page 728: Doppler Techniques.)
11. Which of the following statements regarding pulsed-wave Doppler (PWD) is

FALSE&quest;
A. By time gating, PWD offers the ability to sample only signals associated with a
specific location, referred to as the sample volume.
B. Because PWD data are collected intermittently, the maximal frequency and blood flow
velocity that can be accurately measured are limited.
C. Aliasing appears on the spectral display as a signal on the other side of the baseline.
D. With continuous reception of the PWD signal, the Nyquist limit is not applicable.
11. D. PWD offers the echocardiographer the ability to sample blood flow from a particular
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location. The PWD system transmits a short burst of ultrasound toward the target and then
switches to receive mode to interpret the returning echoes. Because the speed of sound (c) in
tissue is constant, the time delay for a signal to reach its target and return to the transducer
depends solely on the distance (d) to the target. By time gating, the electronic circuitry of the
PW transducer interprets returning echoes only after a predetermined time delay after the
transmission of an ultrasound pulse. In this way, only signals associated with a location,
referred to as the sample volume, are selected for evaluation. Doppler data are frequently
presented as a velocity–time plot known as the spectral display. Because the PWD data are
collected intermittently, the maximal frequency and blood flow velocity that can be accurately
measured by PWD are limited. The maximal frequency, which equals 50% of the pulse
repetition frequency, is known as the Nyquist limit. At blood velocities above the Nyquist limit,
analysis of the returning signal becomes ambiguous, with the velocities appearing to be in the
opposite direction. The ambiguous signal from frequencies above the Nyquist limit, known as
aliasing, appears on the spectral display as a signal on the other side of the baseline, hence
the term wraparound. (See page 728: Doppler Techniques.)
12. Given the following data, which of these hemodynamic calculations is

CORRECT&quest; The left ventricular outflow tract (LVOT) time velocity integral (VTI)
is 7, the LVOT diameter is 2 cm, the aortic valve (AoV) VTI is 22, and the heart rate is
100 bpm.
A. The cardiac output is above 3 L/min.
B. The aortic valve area is 1 cm2.
C. The LVOT area is about 4 cm2.

D. The stroke volume (SV) is about 40 cc.
12. B. Volumetric parameters are calculated using the principle that volumetric flow (Q) equals
the blood flow velocity (v) times the cross-sectional area (CSA) of the conduit, that is, Q = v ×
CSA. In effect, the VTI (in centimeters, traced from the spectral Doppler display) represents the
distance blood traveled during systole (i.e., stroke distance). By multiplying the VTI by the CSA
(cm2) of the conduit through which the blood traveled, the SV (in cm3) is obtained: SV = VTI ×
CSA. The principle of conservation of mass is the basis of the continuity equation, which is
commonly used to measure the AoV area. The continuity equation simply states that the volume
of blood passing through one site in the heart (e.g., the LVOT) is equal to the mass or volume
of blood passing through another site (e.g., the AoV).
Volumetric flow1 = Volumetric flow2
Therefore, CSA1 × VTI1 = CSA2 × VTI2 and CSA1 = CSA2 × VTI2/VTI1
Based on the given data, because the LVOT diameter is 2 cm, the radius is 1 cm. The LVOT
cross-sectional area or LVOT CSA is Π × (Radius)2 or approximately 3.14 × 1 cm2. The SV is
LVOT VTI × LVOT CSA. This equals 22 cc for the given data. Cardiac output is SV × Heart rate.
This equals 2200 cc/min or 2.2 Lpm for the given data. Aortic valve area = LVOT CSA × LVOT
VTI/AV VTI. Based on the given data, this works out to exactly 1 cm2. (See page 730:
Hemodynamic Assessments.)
13. Given the following data, calculate the estimated pulmonary artery (PA) systolic
pressure. The central venous pressure (CVP) is 4 mm Hg. The maximum velocity of
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the regurgitant tricuspid jet (TR jet) is 3 cm/sec. There is no evidence of a stenotic
pulmonary valve.
A. 40 mm Hg
B. 36 mm Hg
C. 32 mm Hg
D. More data are needed.
13. A. Pressure gradients (PGs) are used to estimate intracavitary pressures and to assess
conditions such as valvular disease (e.g., aortic stenosis), septal defects, outflow tract
obstruction, and major vessel pathology (e.g., coarctation). As blood flows across a narrowed or
stenotic orifice, the blood flow velocity increases. The increase in velocities relates to the
degree of narrowing. In the clinical situation, the simplified Bernoulli equation describes the
relation between the increases in blood flow velocity and the pressure gradient across the
narrowed orifice ΔP = 4V2 where ΔP in mm Hg is the pressure gradient across the narrowed
orifice and V in meters per second is the maximum velocity across that orifice measured by
Doppler. Based on the given data, the pressure gradient across the tricuspid valve should equal
4 × 32 = 36 mm Hg. Because the CVP (approximating the right atrial pressure) is 4 mm Hg, the
right ventricular systolic pressure should equal 40 mm Hg (36 + 4). Given no stenosis across
the pulmonic orifice, a reasonable estimate of the PA systolic pressure is 40 mm Hg. (See page
732: Intracardiac Pressure Assessment: The Bernoulli Equation.)
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14. Which of the following statements regarding echocardiographic evaluation of left
ventricular (LV) systolic function is FALSE&quest;
A. Global LV systolic function is influenced by load and contractility alterations.
B. Wall motion is the most reliable marker of regional systolic function.
C. The most frequently used technique to evaluate global LV function is visual estimation
of the fractional area change (FAC).
D. Ejection fraction (EF) and stroke volume are not always indicators of intrinsic systolic
function.
14. B. Abnormal myocardial wall thickening is a sensitive marker of myocardial ischemia that
appears earlier than electrocardiographic and hemodynamic changes. The evaluation of
segmental wall motion to detect ischemia is not error free. In addition to being a subjective
assessment, wall motion may be affected by tethering, regional loading conditions, and
stunning. Epicardial pacing of the free wall of the right ventricle (as in postbypass period)
produces a left bundle block and induces septal wall motion abnormalities. Interobserver
reproducibility is better for normally contracting segments than for dysfunctional segments.
Because of these issues, wall thickening is a more reliable marker of regional function. EF is
the most frequently used estimate of LV systolic function. The evaluation of EF provides
prognostic information about mortality and morbidity. EF and stroke volume are affected by
factors such as preload, afterload, and heart rate and thus are not always indicators of intrinsic
systolic function. Typical clinical scenarios in which EF does not represent LV systolic function
include the hypercontractile LV in mitral regurgitation (in which more than half of ED volume
may regurgitate inside the left atrium) or the hypocontractile LV in aortic stenosis (in which LV
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systolic performance is poor despite preserved contractility). The most frequently used
technique to evaluate global LV function as well as preload is visual estimation of fractional
area change (FAC), often referred to as “eyeball” EF. Although highly subjective, it is practiced
widely and is accurate when determined by experienced echocardiographers, especially in
patients with normally contracting ventricles. (See page 732: Echocardiographic Evaluation of
Systolic Function.)
15. Which of the following statements regarding color-flow Doppler (CFD) shown in the
image below are TRUE&quest;
1. CFD provides a display of both blood flow and cardiac anatomy by combining two-
dimensional (2-D) echocardiography and pulsed-wave Doppler (PWD) methods.
2. CFD performs multiple sample volume recordings along each scan line as the beam is
swept through the sector.
3. In the most widely accepted color code, red hues indicate flow toward the transducer,
and blue hues indicate flow away from the transducer.
4. Aliasing in the color-flow map can be useful to calculate blood flow in mitral valve
disease using the proximal isovelocity surface area (PISA) method.
15. E. CFD provides a dramatic display of both blood flow and cardiac anatomy by combining
2-D echocardiography and PWD methods. The PWD used for CFD performs multiple sample
volume recordings along each scan line as the beam is swept through the sector. This
approach provides flow data at each location in the sector, which can be overlaid on the
structural data obtained by 2-D imaging. The Doppler velocity data from each sample volume
are color coded and superimposed on top of the grayscale 2-D image. In the most widely
accepted color code, red hues indicate flow toward the transducer, and blue hues indicate flow
away from the transducer. An important caveat to CFD use in the clinical setting is that CFD is
susceptible to alias artifacts. Aliasing in the color-flow map can be useful in calculating blood
flow in mitral valve disease using the PISA method. (See page 730: Color-Flow Doppler.)
16. A 67-year-old man is scheduled to have an infra-abdominal aortic aneurysm

repaired. The surgeon desires a pulmonary artery catheter (PAC) to be placed in the
patient, but the anesthesiologist wants to place a transesophageal echocardiography
(TEE) probe. Which of the following statements regarding TEE are TRUE&quest;
1. TEE gives a more accurate estimation of left ventricular (LV) preload than a PAC.
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2. Left arterial filling pressures can be calculated by measuring blood flow rates from the
pulmonary veins into the left atrium.
3. TEE can accurately identify myocardial ischemia.
4. TEE is free from major complications.
16. A. TEE gives the most accurate estimation of LV preload. It gives a very early indication of
myocardial ischemia by its ability to detect wall motion abnormalities. By determining flows
across the mitral valve or from the pulmonary veins, LV and left arterial filling pressures can be
calculated. TEE is not without its complications. Damage to the esophagus, hemodynamic
instability, and dysrhythmias have been reported. (See page 718: Transesophageal
Echocardiography: Monitoring Applications.)
17. Which of the following statements regarding the evaluation of left ventricular (LV)
diastolic function are TRUE&quest;
1. Diastolic dysfunction is defined as the inability of the LV to fill at normal left atrial (LA)
pressures.
2. The transmitral flow curve of an individual with impaired relaxation is represented by a
high E wave, low A wave, and shortened deceleration time (DT).
3. Tissue Doppler imaging, which directly measures myocardial velocities, provides a
more load-independent methodology of diastolic function assessment.
4. During the “pseudonormal” stage, there is a higher systolic/diastolic (S/D) ratio on the
pulmonary vein flow curves.
17. B. Diastolic dysfunction is defined as the inability of the LV to fill at normal LA pressures and
is characterized by a decrease in relaxation, LV compliance, or both. The early manifestation of
diastolic dysfunction is characterized by impaired relaxation, implying that the rate and duration
of decrease in LV pressure after systolic contraction are prolonged, resulting in an inability of
the LV to fill adequately during the rapid filling phase. A compensatory increase in filling occurs
with atrial contraction. This stage of disease is known as grade I diastolic dysfunction. In more
advanced stages of disease (grades II and III of diastolic dysfunction), a decrease in LV
compliance ensues. The transmitral flow Doppler (TMF) curve of an individual with abnormal
relaxation is represented by a low E, high A, and prolonged DT. Progression of diastolic
disease is marked by decreases in LV compliance. LA pressure increases as a compensatory
mechanism to normalize the pressure gradient across the MV. In this scenario, the TMF
velocities resemble the normal curve; thus, this stage is known as “pseudonormal.” Because of
the high LA pressure, there is less flow from the pulmonary veins during ventricular systole; this
generates a lower S wave on the pulmonary vein flow (PVF) curves and thus a lower S/D ratio.
One of the important caveats to assessing diastolic function using pulsed-wave Doppler is that
the flow patterns depend on pressure gradients and therefore are affected by both preload and
afterload. In settings in which the load conditions vary at a fast pace, such as the operating
room, changes in TMF or PVF velocities may be difficult to interpret. Tissue Doppler imaging,
which directly measures myocardial velocities, provides a more load-independent methodology
of diastolic function assessment. (See page 736: Evaluation of Left Ventricular Diastolic
Function.)
18. Which of the following statements regarding the echocardiographic evaluation of

aortic regurgitation (or incompetence) is FALSE&quest;
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1. Associated findings may include dilated aortic root, endocarditis lesions, dilated
ascending aorta, calcified aortic valve, or aortic dissection.
2. Vena contracta, the narrowest “neck” of the aortic insufficiency (AI) jet as it traverses
the atrioventricular (AV) plane, is usually best appreciated in the midesophagus long-axis
(ME AV LAX) view.
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3. Retrograde diastolic flow in the descending and abdominal aorta is sensitive and
specific for severe AI.
4. A prolonged pressure half time (PHT) (≥220 ms) is related to severe AI.
18. D. Findings associated with aortic incompetence include a dilated aortic root (Marfan's
syndrome), endocarditis lesions, dilated ascending aorta, calcified aortic valve, aortic dissection
(may be associated with acute AI), fluttering of the anterior mitral leaflet and restricted diastolic
opening of the MV from the AI jet, or a dilated LV in chronic AI. In either of the ME or the
transgastric views of AV, a color-flow Doppler (CFD) sector over the AV and the left ventricular
outflow tract (LVOT) demonstrate the presence or absence of the AI regurgitant jet. Vena
contracta, the narrowest “neck” of the AI jet as it traverses the AV plane, is usually best
appreciated in the ME AV LAX view. The largest diameter of the vena contracta in diastole is
selected. The size of the vena contracta is relatively load independent and provides a reliable
way to quantitate AI intraoperatively in the presence of fluctuating hemodynamics. The pressure
half time (PHT) of the AI jet is recorded in the TG LAX or deep TG LAX views. PHT expresses
the pressure equilibration of the diastolic blood pressure (“driving” pressure) and the diastolic
left ventricular pressure (“resistance” pressure). A short PHT (<200 ms) is associated with
severe AI. Retrograde diastolic flow in the descending and abdominal aorta is sensitive and
specific for severe AI. This is imaged with pulsed-wave Doppler in the ME LAX view of the distal
descending aorta. (See page 739: Evaluation of Valvular Heart Disease.)
19. In addition to its role in diagnostics, echocardiography is also used to assist in

placement of:
1. central venous catheters
2. intra-aortic balloon pumps (IABPs)
3. coronary sinus cannula
4. guidewires for other venous or arterial cannulas
19. E. In addition to its role in diagnostics, echocardiography is also used to assist various
procedures such as placement of central venous catheter, IABPs, coronary sinus cannula, and
guidewires for other venous or arterial cannulas. For patient safety reasons, the National
Institute for Clinical Excellence has recommended that central lines be placed under guidance
of two-dimensional ultrasound imaging. A linear array handheld transducer with high
frequencies (7.5–12 MHz) is preferred for ultrasound-guided central line placement. The
technique relies on placing the transducer over the traditional anatomic landmarks and
identifying the internal jugular vein (IJ) and carotid artery (CA) in the short-axis view and their
anatomical relationship. Use of transesophageal echocardiography (TEE) during IABP
placement allows positioning of the catheter to the preferred location, which is distal to the left
subclavian artery. TEE is helpful in guiding placement of the cannula and in checking for proper
position. Improper insertion of a coronary sinus cannula may result in injury to the interatrial
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septum or to the crux of the heart, the fragile area joining the atria and ventricles. View of the
CS is obtained from the midesophagus four-chamber view by retroflexing the probe. TEE is
useful in verifying the position of various other cannulas. For example, when femoral artery
–femoral vein bypass is instituted, the venous cannula can be visualized as it advances in the
inferior vena cava up to the level of the right atrium. Proper positioning of the guidewires used
for aortic cannulation can be confirmed with TEE. (See page 746: Echocardiography-Assisted
Procedures.)
20. Which of the following statements regarding epicardial and epiaortic

echocardiography are TRUE&quest;
1. Epiaortic scanning for atheroma is performed using a small-footprint, linear array
transducer.
2. The epicardial probe uses high-frequency transducers that may require a standoff
device or saline in the mediastinum for best imaging.
3. Epicardial echocardiography is particularly valuable in those cases in which the
transesophageal echocardiography (TEE) probe cannot be placed or is contraindicated.
4. The epicardial views are similar to the ones obtained via transthoracic
echocardiography (TTE).
20. E. During surgeries performed via sternotomy or thoracotomy, epicardial echocardiography
can be performed and is particularly valuable in cases in which the TEE probe cannot be
placed or is contraindicated. The epicardial views are similar to the ones obtained via TTE. In
collaboration with the Society of Cardiovascular Anesthesiologists, the America Society of
Echocardiography has recently issued guidelines for the performance of epicardial
echocardiography. The epicardial probe uses high-frequency transducers (5–12 MHz) that may
require a standoff device or saline in the mediastinum for best imaging. Epicardial imaging
offers superior image quality as well as a better window to the anterior cardiac structures
(aorta, aortic valve, pulmonary artery, and pulmonary vein). Because of interposition of the left
bronchus, the distal ascending aorta and proximal aortic arch cannot be visualized with TEE.
The ascending aorta and proximal aortic arch are of particular interest during cardiac surgeries
because they represent sites for aortic cannulation. Epiaortic scanning for atheroma is
performed using a small-footprint, linear array transducer. Guidelines for intraoperative epiaortic
examination have been published. (See page 748: Epicardial and Epiaortic Echocardiography.)
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Review of Clinical Anesthesia, 5e [Vishal] 29. Airway Management
Chapter 29
Airway Management
1. Which of the following drugs is NOT being used appropriately for pharmacologic
preparation during awake intubation&quest;
A. 0.2 to 0.4 mg of glycopyrrolate intramuscularly (IM) or intravenously (IV)
B. 400 to 800 mg of lidocaine administered by nebulizer
C. 1 μg/kg of IV dexmedetomidine over 10 minutes and then a maintenance infusion at
0.5 μg/kg/hr
D. 2 to 24 drops of oxymetazoline instilled in each nostril
1. B. Local anesthetics are the cornerstone of awake airway control techniques. Because much
of the agent used will be within the tracheal–bronchial tree and can travel to the alveoli, there is
a potential for significant intravascular absorption with some techniques. In a recent study using
400 mg or 800 mg of lidocaine administered by nebulizer, serum levels of 2.8 μg/mL and 6.5
μg/mL were measured within 10 minutes of dose completion, respectively. The toxic level of
lidocaine is considered to be 4.0 μg/mL. Administration of antisialagogues is important to the
success of awake intubation techniques; the commonly used drugs are atropine (0.5–1 mg IM
or IV) and glycopyrrolate (0.2–0.4 mg IM or IV). Dexmedetomidine, a highly selective centrally
acting α 2-adrenergic agonist, has been used for sedation and analgesia without respiratory
depression in patients undergoing awake fiberoptic intubation. Combined with topical
anesthesia, dexmedetomidine sedation provides for a smooth intubation. A loading dose of
dexmedetomidine is 1 μg/kg IV over 10 minutes, and the maintenance infusion dose is 0.2 to 0.7
μg/kg/hr. Vasoconstriction of the nasal passages is required if there is to be instrumentation of
this part of the airway. Oxymetazoline is a potent and long-lasting vasoconstrictor that is
available over the counter. (See page 773: Awake Airway Management.)
2. Awake airway management may NOT be appropriate in which of the following

circumstances&quest;
A. Patients with unstable cervical spine pathology
B. Patients with an acute myocardial infarction
C. Intoxicated adults
D. Patients with sleep-disordered breathing (obstructive sleep apnea)
2. C. Patients at risk for neurologic sequelae (e.g., those with unstable cervical spine
pathology) may undergo active sensory–motor testing immediately after tracheal intubation
during awake airway management. In an emergent situation, there may be cautions (e.g.,
cardiovascular stimulation in the presence of cardiac ischemia or ischemic risk, bronchospasm,
increased intraocular pressure, increased intracranial pressure) but no absolute
contraindications to awake intubation. Contraindications to elective awake intubation include
patient refusal or inability to cooperate (e.g., children or patients with profound mental
retardation, dementia, or intoxication) or allergy to local anesthetics. Awake intubation provides
many advantages over the anesthetized state, including maintenance of spontaneous
ventilation in the event that the airway cannot be secured rapidly, increased size and patency of
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the pharynx, relative forward placement of the base of the tongue, posterior placement of the
larynx, and patency of the retropalatal space. (See page 773: Awake Airway Management.)
3. Which of the following statements regarding the laryngeal mask airway (LMA) as a
supraglottic airway tool is TRUE&quest;
A. In patients with asthma, the peri-induction period represents the highest risk period for
wheezing.
B. The LMA cannot be used together with an endotracheal tube (ETT).
C. The incidence of sore throat is higher than with an endotracheal tube.
D. It should always be removed either when the patient is deeply anesthetized or after
the protective airway reflexes have returned.
E. The LMA should always be deflated before removal.
3. D. Timing of the removal of the LMA at the end of surgery is critical. The LMA should be
removed either when the patient is deeply anesthetized or after the protective reflexes have
returned and the patient is able to open the mouth on command. Removal during excitation
stages of emergence can be accompanied by coughing, laryngospasm, or both. Because the
halogenated inhaled anesthetics are potent bronchodilators, it is at the time of emergence,
when the anesthetic is discontinued, that patients at risk for bronchospasm are most likely to
wheeze. In patients managed with LMAs, there is no foreign body in the sensitive
bronchorespiratory tree, and the patient can be fully emerged before removal of the device.
Many clinicians remove the LMA fully inflated, so it acts as a “scoop” for secretions above the
mask, bringing them out of the airway. The incidence of sore throat is approximately 10%
compared with 30% with tracheal intubation, but it has been reported with a range of 0% to
70%. When tracheal intubation is mandatory (for the surgical procedure) yet concerns
regarding bronchospasm exist, the Bailey maneuver should be used. In this maneuver, the
deflated LMA is placed behind the in situ ETT. The ETT is removed, and the LMA is inflated.
The patient is then emerged on the LMA. (See page 758: The Laryngeal Mask Airway Classic.)
4. Which of the following statements regarding face mask ventilation is TRUE&quest;

A. The sniffing position causes the tongue to be more anterior.
B. It is made more difficult when prosthetics (dentures) are left in place.
C. It should not be used for the duration of the anesthetic.
D. In the presence of normal lung compliance and an open airway, face mask ventilation
should require as much as 40 cm H2O positive pressure.
E. The sniffing position causes the esophagus to be more posterior.
4. A. In preparation for using a face mask for positive-pressure ventilation (after apnea is
induced), appropriate positioning of the patient is paramount. With the patient in the supine
position, the head and neck are placed in the sniffing position. This position improves mask
ventilation by anteriorizing the base of the tongue and the epiglottis, as has been demonstrated
on endoscopic studies in anesthetized patients. When a patient has presented with removable
dentures, leaving the prosthetics in place can aid face mask ventilation; however, the risk of
displacement should be considered. Patients with normal lung compliance should require no
more than 20 to 25 cm H2O pressure to inflate the lungs. If more pressure than this is required,
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the clinician should re-evaluate the adequacy of the airway, adjust the fit of the mask, seek the
aid of a second operator to perform two- or three-handed mask holds, or consider other devices
that aid in the creation of an open passage for air flow through the upper airway. If there are no
contraindications (e.g., a “full stomach” or other aspiration risk), mask ventilation can be used
for the duration of anesthesia maintenance. (See page 756: The Anesthesia Face Mask.)
5. Which of the following statements regarding airway anatomy is FALSE&quest;

A. The right principal bronchus is larger in diameter than the left.
B. Cartilaginous rings support only the first two generations of the bronchi.
C. The larynx is innervated bilaterally by two branches of each vagus nerve.
D. The laryngeal “skeleton” consists of nine cartilages.
E. The trachea measures approximately 15 cm in adults.
5. B. The laryngeal skeleton consists of nine cartilages (three paired and three unpaired) that
together house the vocal folds, which extend in an anterior–posterior plane from the thyroid
cartilage to the arytenoid cartilages. The larynx is innervated bilaterally by two branches of
each vagus nerve: the superior laryngeal nerve and the recurrent laryngeal nerve. The trachea
measures approximately 15 cm in adults and is circumferentially supported by 17 to 18 C-
shaped cartilages, with a posterior membranous aspect overlying the esophagus. The right
principal bronchus is larger in diameter than the left and is deviated from the plane of the
trachea at a less acute angle. Cartilaginous rings support the first seven generations of the
bronchi. (See page 752: Review of Airway Anatomy.)
6. With regard to preoxygenation, all of the following are true EXCEPT:

A. Preoxygenation with a fraction of inspired oxygen (FiO2) of 1.0 may increase the
apneic oxygenation reserve fivefold compared with room air.
B. In emergencies, preoxygenation may be performed with eight vital capacity breaths
over 60 seconds.
C. In obese patients, preoxygenation is improved by bilevel positive airway pressure
(BiPAP).
D. The mask does not need to be tight fitting to ensure optimal preoxygenation.
E. Without preoxygenation, nitrogen may occupy more than 60% of the functional
residual capacity (FRC).
6. D. Preoxygenation (also commonly termed denitrogenation) should be practiced in all cases
when time permits. This procedure entails the replacement of the nitrogen volume of the lung
(>69% of the FRC) with oxygen to provide a reservoir for diffusion into the alveolar capillary
blood after the onset of apnea. Even under ideal conditions, patients breathing room air (FIO2 =
0.21) will experience oxyhemoglobin desaturation to a level of less than 90% after
approximately 2 minutes of apnea. Preoxygenation with 100% O2 via a tight-fitting face mask
for 5 minutes in spontaneously breathing patients can furnish up to 10 minutes of oxygen
reserve after apnea (in patients without significant cardiopulmonary disease and normal oxygen
consumption). A modified vital capacity technique, in which the patient is asked to take eight
deep breaths in a 60-second period, shows promise in terms of prolonging the time to
desaturation. In obese patients, BiPAP and the head-up position (∼25 degrees) have been
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advocated to both reach maximal preinduction arterial oxygenation and to delay oxyhemoglobin
desaturation. The most common reason for not achieving a maximum alveolar oxygen store
during preoxygenation is use of a loose-fitting mask, which allows the entrainment of room air.
Leaks as small as 4 mm (cross-section) may cause significant reductions in the inspired oxygen
content. (See page 754: Preoxygenation.)
7. The maximum recommended intracuff pressure for a &num;4 laryngeal mask airway
(LMA) is:
A. 20 cm H2O
B. 40 cm H2O
C. 60 cm H2O
P.148
D. 80 cm H2O
E. none; a volume of air (30 mL) is inserted regardless of pressure
7. C. Before attachment of the anesthesia circuit, the LMA is inflated with the minimum amount
of gas to form an effective seal. Although it is difficult to suggest a particular volume of gas to
be used, the operator should be accustomed to the feel of the pilot bulb when it is inflated to 60
cm H2O pressure, the maximum suggested seal pressure. (See page 757: Supraglottic
Airways.)
8. All of the following statements regarding endotracheal intubation in children are true
EXCEPT:
A. Elevation of the head on a pillow is not usually necessary.
B. Cricoid pressure may be needed to displace an anterior-appearing larynx into view.
C. A Macintosh blade is generally more useful because of a larger tongue-to-mouth ratio
in children.
D. The cricoid cartilage is the narrowest part of the child's airway.
E. Hyperextension at the atlanto-occipital joint may cause airway obstruction.
8. C. Because of the relatively larger size of the occiput in children, which produces an
“anatomic sniffing position,” elevation of the head (as done in adults) is not needed. On
occasion, the thorax may need to be elevated instead. The relatively short neck in children
gives the impression of an anterior position of the larynx. Posterior cricoid pressure is often
helpful to place the laryngeal inlet into view. A straight blade is more helpful than a curved blade
in displacing the stiff, omega-shaped, high epiglottis. Because the cricoid cartilage is the
narrowest aspect of the airway until children are 6 to 8 years of age, one must be sensitive to
resistance to advancement of the endotracheal tube that has easily passed the vocal folds.
Hyperextension at the atlanto-occipital joint, as done in adults, may cause airway obstruction in
children because of the relative pliability of the trachea. (See page 762: Tracheal Intubation:
Use of the Direct Laryngoscope Blade.)
9. Which of the following statements regarding innervation of the airway is

TRUE&quest;
A. The oropharynx is innervated by branches of the facial, glossopharyngeal, and vagus
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nerves.
B. The oropharynx is innervated by branches of the vagus, glossopharyngeal, and
hypoglossal nerves.
C. The hypoglossal nerve provides for sensation over the posterior third of the tongue,
vallecula, and epiglottis.
D. The internal branch of the superior laryngeal nerve provides all sensory innervation
below the vocal cords.
E. The external branch of the superior laryngeal nerve provides all sensory innervation
above the vocal cords.
9. A. The oropharynx is innervated by branches of the vagus, facial, and glossopharyngeal
nerves. The glossopharyngeal nerve travels anteriorly along the lateral surface of the pharynx.
Its three branches supply sensory innervation to the posterior third of the tongue, the vallecula,
the anterior surface of the epiglottis (lingual branch), the walls of the pharynx (pharyngeal
branch), and the tonsils (tonsillar branch). The internal branch of the superior laryngeal nerve,
which is a branch of the vagus nerve, provides sensory innervation to the base of the tongue,
epiglottis, aryepiglottic folds, and arytenoids. The remaining portion of the superior laryngeal
nerve, the external branch, supplies motor innervation to the cricothyroid muscle. The
hypoglossal nerve provides purely motor innervation to the tongue. (See page 773: Awake
Airway Management.)
10. Laryngospasm is commonly caused by:
1. saliva
2. hypercapnia
3. light anesthesia
4. hypoxemia
10. B. Obstruction to mask ventilation may be caused by laryngospasm, which is a reflex
closure of the vocal folds. Laryngospasm may occur as a result of foreign body (oral or nasal
airway), saliva, blood, or vomitus touching the glottis, or it may occur during a light plane of
anesthesia. (See page 756: The Anesthesia Face Mask.)
11. Which of the following statements regarding use of a laryngeal mask airway (LMA)
and gastroesophageal reflux is/are TRUE&quest;
1. The LMA fits in the esophageal inlet but does not reliably seal it.
2. There is a high incidence of aspiration when an LMA is used in the presence of a “full
stomach.”
3. Aspiration is more common when a bag-valve mask device is used for
cardiopulmonary resuscitation than when an LMA is used.
4. If regurgitation is noted when an LMA is in place, it should be removed immediately.
11. B. Although the distal tip of the LMA's mask sits in the esophageal inlet, it does not reliably
seal it. A predominant clinical perception is that the LMA does not protect the trachea from
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regurgitated gastric contents. During cardiopulmonary resuscitation, the incidence of
gastroesophageal regurgitation is four times greater with a bag-valve mask than with an LMA. If
regurgitated gastric contents are noted in the LMA, maneuvers similar to those applied when
using an endotracheal tube should be instituted (i.e., the Trendelenburg position, 100% oxygen,
and leaving the LMA in place and using a flexible suction device down the barrel). When
populations of patients considered to have a “full stomach” are studied (in controlled trials,
prospective series, or case reports), there is a very low incidence of aspiration noted with
elective or emergency LMA use. (See page 758: The Laryngeal Mask Airway Classic.)
12. Which of the following statements regarding the laryngeal mask airway (LMA) is/are
TRUE&quest;
1. Positive-pressure ventilation is generally not useful.
2. Gastric inflation is much more likely when positive-pressure ventilation with a pressure
of 10 cm H2O is used with an LMA than with an endotracheal tube (ETT).
3. An LMA cannot be used in the lateral position.
4. Tidal volumes of up to 8 mL/kg and airway pressure below 20 cm H 2O can be used in
positive-pressure ventilation with an LMA.
12. D. Although first introduced for use with spontaneous ventilation, the LMA has shown to be
useful when positive-pressure ventilation is either desired or preferred. There is no difference
found in gastric inflation with positive pressures below 17 cm H2O when comparing LMA with
the ETT. When using the LMA, tidal volumes should be limited to 8 mL/kg and airway pressure
to 20 cm H2O because this is the sealing pressure of the device under normal circumstances.
Patients' airways have been managed with the LMA in the supine, prone, lateral, oblique,
Trendelenburg, and lithotomy positions. (See page 758: The Laryngeal Mask Airway Classic.)
13. Which of the following statements regarding the Sellick maneuver is/are
TRUE&quest;
1. It can obliterate the esophageal lumen while maintaining the tracheal opening.
2. It is contraindicated when there is active vomiting.
3. It can be used in conjunction with gentle positive-pressure ventilation.
4. It should be used for rapid sequence induction in patients with laryngeal fractures who
have full stomachs.
13. A. Cricoid pressure entails the downward displacement of the cricoid cartilage against the
cervical vertebral bodies. In this manner, the lumen of the esophagus is ablated while the
completely circular nature of the cricoid cartilage maintains the tracheal lumen. Early cadaveric
studies showed that correctly applied cricoid pressure is effective in preventing gastric fluids
(<100 cm H2O pressure) from leaking into the pharynx. Cricoid pressure is contraindicated in
patients with active vomiting (risk of esophageal rupture), cervical spine fracture, and laryngeal
fracture. If there are difficulties in securing the airway during rapid sequence induction, gentle
positive-pressure ventilation may be used while cricoid pressure is maintained. (See page 767:
NPO Status and the Rapid Sequence Induction.)
14. Which of the following statements regarding laryngospasm is/are TRUE&quest;

1. It may be triggered by abdominal visceral stimulation.
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2. It accounts for approximately 75% of all critical postoperative respiratory events in

adults.
3. It is a possible cause of pulmonary edema.
4. It should always be treated with muscle relaxants.
14. B. As a cause of ventilatory compromise, laryngospasm deserves special attention because
of its prevalence in children and because it accounts for 23% of all critical postoperative
respiratory events in adults. Laryngospasm may be triggered by respiratory secretions, vomitus,
or blood in the airway; pain in any part of the body; and pelvic or abdominal visceral stimulation.
The cause of airway obstruction during laryngospasm is contraction of the lateral
cricoarytenoids, the thyroarytenoid, and the cricothyroid muscles. Management of patients with
laryngospasm consists of immediate removal of the offending stimulus (if identifiable);
administration of oxygen with continuous positive airway pressure; and if other maneuvers are
unsuccessful, use of a small dose of short-acting muscle relaxant. Negative-pressure
pulmonary edema may result from any airway obstruction in a patient who continues to have a
voluntary respiratory effort. Negative intrathoracic pressure is transmitted to the alveoli, which
are unable to expand as a result of the more proximal obstruction. (See page 769: Difficult
Extubation.)
15. Which of the following statements regarding the local anesthetic cocaine is/are
TRUE&quest;
1. It may be especially useful in blunting the exaggerated blood pressure response to
intubation often seen in hypertensive patients.
2. It is an excellent topical anesthetic as well as a potent vasodilator.
3. It is poorly absorbed from the tracheal mucosa and must be given in larger doses to be
effective (10% solution).
4. It is metabolized by pseudocholinesterase and should not be given to patients with this
enzyme deficiency.
15. D. Among otolaryngologists, cocaine is a popular topical agent. Not only is it a highly
effective local anesthetic, it is the only local anesthetic that is a potent vasoconstrictor. It is
commonly available in a 4% solution. The total dose applied to the mucosa should not exceed
200 mg in adults. Cocaine should not be used in patients with known cocaine hypersensitivity,
hypertension, ischemic heart disease, or pre-eclampsia or in those taking monoamine oxidase
inhibitors. Because cocaine is metabolized by pseudocholinesterase, it is contraindicated in
patients deficient in this enzyme. (See page 773: Awake Airway Management.)
16. Which technique(s) is/are almost always useful for endotracheal intubation in a
patient with gross blood in the airway&quest;
1. Retrograde wire intubation
2. Intubating laryngeal mask airway (LMA)
3. Esophageal–tracheal Combitube
4. Fiberoptic bronchoscopy
16. A. Retrograde wire intubation has been described in a number of clinical situations as a
primary intubation technique (elective or urgent) and after failed attempts at direct
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laryngoscopy, fiberoptic-aided intubation, and LMA-guided intubation. The most common
indications are an inability to visualize the vocal folds because of blood, secretions, or anatomic
variations; an unstable cervical spine; an upper airway malignancy; and mandibular fracture.
Contraindications to fiberoptic bronchoscope–aided intubation are relative and revolve around
the limitations of the device. Because the optical elements are small, minute amounts of airway
secretions, blood, or traumatic debris can hinder visualization. Advantages to the esophageal
–tracheal Combitube include rapid airway control, airway protection from regurgitation, ease of
use for inexperienced operators, lack of requirement to visualize the larynx, and ability to
maintain the patient's neck in a neutral position. This device has been shown to be useful in
patients with massive upper gastrointestinal bleeding or vomiting. The LMA-Fastrach is
indicated for routine elective intubation and for anticipated and unanticipated difficult intubation.
Because it was designed to facilitate blind tracheal intubation, the presence of airway
secretions, blood, or edema does not interfere with its use. (See page 782: Use of Retrograde
Wire Intubation in Airway Management; page 785: Use of the Esophageal Tracheal Combitube;
page 767: The Intubating Laryngeal Mask Airway; and page 779: Use of the Fiberoptic
Bronchoscope in Airway Management.)
17. Which of the following statements regarding airway management is/are

TRUE&quest;
1. The backward-upward-rightward pressure (BURP) maneuver helps to expel air
entrained in the stomach after bag mask ventilation.
P.149
2. In general, the Miller blade provides a better laryngeal view in patients with a smaller
mandibular space.
3. The best treatment for laryngospasm is the Sellick maneuver.
4. Cricoid pressure (the Sellick maneuver) can be effectively used with a laryngeal mask
airway (LMA) in place.
17. C. Treatment of laryngospasm includes removal of an offending stimulus (if it can be
identified), continuous positive airway pressure, deepening of the anesthetic state, and use of a
rapidly acting muscle relaxant. If a satisfactory laryngeal view is not achieved during
laryngoscopy, the BURP maneuver may aid in improving the view. In this maneuver, a second
operator displaces the larynx backward (B) against the cervical vertebrae, as superiorly (U) as
possible and slightly lateral to the right (R), using external pressure (P) over the cricoid
cartilage. As a generalization, the Macintosh blade is regarded as a better option wherever
there is little room to pass an ETT (e.g., small mouth), but the Miller blade is regarded better in
patients who have a small mandibular space, large incisor teeth, or a large epiglottis. The major
disadvantage of the LMA in resuscitation is suboptimal mechanical protection from regurgitation
and aspiration. Lower rates of regurgitation during cardiopulmonary resuscitation (3.5%) than
with bag-valve mask ventilation (12.4%) have been shown. Even in the presence of
regurgitation, pulmonary aspiration is a rare event with the LMA. Unfortunately, use of the
Sellick maneuver may prevent proper seating of the LMA in a minority of instances. This may
require brief removal of cricoid pressure until the LMA has been properly seated. Cricoid
pressure is effective with an LMA in place. (See page 762: Direct Laryngoscopy; page 756: The
Anesthesia Face Mask; page 765: Use of the Laryngoscope Blade; and page 762: Preparing
for Laryngoscopy and the “Best Attempt.”)
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18. Which of the following statements regarding the cricothyroid area is/are
TRUE&quest;
1. The cricothyroid membrane is often crossed horizontally in its upper third by vascular
structures.
2. The cricoid cartilage is the only circumferential cartilage in the laryngeal skeleton.
3. Cricothyroid punctures should be made in the inferior third of the membrane and
should be directed posteriorly.
4. The cricotracheal ligament suspends the trachea superiorly from the cricoid cartilage.
18. E. The cricothyroid membrane provides coverage to the cricothyroid space. It is located in
the anterior neck between the thyroid cartilage superiorly and the cricoid cartilage inferiorly. It
can be identified 1 to 1.5 fingerbreadths below the laryngeal prominence (thyroid notch) and is
composed of a yellow elastic tissue that lies directly beneath the skin and a thin facial layer. It is
often crossed horizontally in its upper third by the anastomosis of the left and right superior
cricothyroid arteries. The membrane has a central portion known as the conus elasticus and
two lateral, thinner portions. Directly beneath the membrane is the laryngeal mucosa. Because
of anatomic variability in the course of veins and arteries and the membrane's proximity to the
vocal folds (which may be 0.9 cm above the ligament's upper border), it is suggested that any
incisions or needle punctures to the cricothyroid membrane be made in its inferior third and be
directed posteriorly (posterior probing needles will strike the back side of the ring-shaped
cricoid cartilage). At the base of the larynx, the signet ring–shaped cricoid cartilage is
suspended by the underside of the cricothyroid membrane. The trachea is suspended from the
cricoid cartilage by the cricotracheal ligament. (See page 752: Review of Airway Anatomy.)
19. When attempting to predict a difficult airway, it is important to acknowledge that:

1. A small thyromental distance correlates with poor descent of the larynx.
2. Multivariate composite indices currently have the best predictive ability for difficult
laryngoscopy.
3. A small as well as a large thyromental distance (TMD) can both predict difficult
laryngoscopy.
4. The Mallampati classification alone provides adequate information for the prediction of
difficult laryngoscopy.
19. A. Poor descent of the larynx results in a TMD and may indicate a difficult direct
laryngoscopy. Despite the disappointing usefulness of individual indexes for anticipating difficult
direct laryngoscopy, some authors have recognized that combinations of tests may provide
improved predictability. El-Ganzouri et al designed a statistical model for stratifying risk of
difficult direct laryngoscopy in a large population. This multivariate index assigned relative
weights to each physical examination or historical finding based on the odds of a high-grade
laryngeal view being achieved on direct laryngoscopy with an increasing examination score.
Compared with the Mallampati classification alone, the multivariate composite index had
improved positive predictive and specificity values at equal sensitivity. A long descent of the
larynx results in a large part of the tongue being in the hypopharynx. Chou et al also noted that
the long mandibulohyoid distance can be partly caused by a shortened mandibular ramus. A
short ramus results in the floor of the mouth being more rostrad and less compliant, so
displacement of the tongue is more difficult. (See page 762: Routine Laryngoscopy.)
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20. When positioning a patient for direct laryngoscopy, it is important to remember

that:
1. Maximal mouth opening is greater with atlanto-occipital extension compared with the
neutral head position.
2. Atlanto-occipital extension anteriorly displaces the tongue.
3. Obese patients may need the head and neck raised above the thorax with a wedge-
shaped lift beginning under the scapula.
4. Claims for laryngeal injury during direct laryngoscopy usually arise during
laryngoscopies that were anticipated to be difficult.
20. A. The extension of the atlanto-occipital joint provides wider mouth opening. Calder et al
have shown that the maximal mouth opening is 26% greater in full atlanto-occipital extension
than in the neutral head position. Although atlanto-occipital extension cannot by itself allow
direct laryngeal vision, it does provide anterior displacement of the mass of the tongue and
brings the upper alveolar ridge into improved position relative to the tongue and larynx. Obese
patients may need further positioning to move the mass of the chest away from the plane
across which the laryngoscope handle will sweep as it is manipulated in the mouth. This may
require placing a wedge-shaped lift under the scapula, shoulders, and nape of neck; raising the
head and neck above the thorax; and providing a grade to allow gravity to take the pandicular
mass away from the airway. Domino et al's analysis of the American Society of
Anesthesiologists' Closed Claims Database reveals that claims for laryngeal injury during direct
laryngoscopy arise more often in “easy” as opposed to difficult laryngoscopies. (See page 762:
Direct Laryngoscopy.)
21. Generally, when approaching a patient at risk for postextubation stridor, one must
consider:
1. An endotracheal cuff leak test to rule in or rule out stridor
2. The use of multiple-dose dexamethasone to reduce the risk of laryngeal edema
3. Preparation of standby reintubation equipment, including routine establishment of a
route for reintubation and oxygenation
4. A single dose of dexamethasone given 1 hour before extubation to reduce the
likelihood of reintubation
21. A. A popular test used to predict airway patency after extubation is the detection of a leak
on deflation of the endotracheal cuff. Patients with a reduced cuff leak volume are at risk for
postextubation stridor, although the absence of an airway leak on cuff deflation is not predictive
of subsequent ventilatory failure after extubation. A randomized control trial study in 2007
revealed that multiple-dose dexamethasone effectively reduced the incidence of postextubation
stridor in adult patients at high risk for postextubation laryngeal edema, but single-dose injection
of dexamethasone given 1 hour before extubation did not reduce the number of patients
requiring reintubation. When there is a suspicion that a patient may have difficulty with
oxygenation or ventilation after tracheal extubation, the clinician may choose from a number of
management strategies ranging from the preparation of standby reintubation equipment to the
active establishment of a route or guide for reintubation or oxygenation. (See page 769: Difficult
Extubation.)
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Review of Clinical Anesthesia, 5e [Vishal] 30. Patient Positioning & Related Injuries
Chapter 30
Patient Positioning and Related Injuries
1. A 67-year-old woman is scheduled for exploratory laparotomy because of a large

pelvic mass. Before induction, she suddenly develops hypotension and tachycardia.
What is the most appropriate next step&quest;
A. Increase the FIO2 to 100%.
B. Put the patient in the Trendelenburg position.
C. Rapidly infuse 1000 mL of intravenous saline.
D. Place a wedge underneath the patient's right hip.
E. Administer 100 μg of phenylephrine.
1. D. With the patient in the supine position, a mobile abdominal mass, such as a very large
tumor or a pregnant uterus, may rest on the great vessels of the abdomen and compromise
circulation. This is known as the aortocaval syndrome or supine hypotensive syndrome. A
significant degree of perfusion may be restored if the compressive mass is rolled toward the left
hemiabdomen by a mechanical device that produces leftward displacement (e.g., a wedge
under the right hip). (See page 794: Variations of the Dorsal Decubitus Positions.)
2. All of the following statements concerning the exaggerated lithotomy position are
true EXCEPT:
A. It provides easy access to the perineum.
B. The patient's pelvis is flexed ventrally on the spine.
C. It is more easily tolerated by awake patients.
D. This position has been associated with a high frequency of lower extremity
compartment syndrome.
E. Bulky thighs may cause abdominal compression and restrict ventilation.
2. C. The exaggerated lithotomy position is rarely tolerated by awake patients. In this position,
the pelvis is flexed ventrally on the spine, the thighs are flexed on the trunk, and the legs are
aimed skyward. Maintenance of perfusion pressure is important because the position has been
associated with a high frequency of lower extremity compartment syndrome. Controlled
ventilation is usually necessary because abdominal compression by the thighs may restrict
ventilation. (See page 795: Lithotomy.)
3. All of the following statements concerning upper extremity injuries are true EXCEPT:
A. The long thoracic nerve arises from nerve roots C5 to C7.
B. Winging of the scapula is commonly associated with injury of the long thoracic nerve.
C. The long thoracic nerve is routinely involved in stretch injuries of the brachial plexus.
D. Hyperabduction of the arm may push the humerus into the axillary neurovascular
bundle.
E. A dampened pulse oximetry tracing may be a sign of neurovascular compression.
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3. C. The long thoracic nerve arises from nerve roots C5 to C7 and innervates the serratus
anterior muscle. Dysfunction of this nerve causes winging of the scapula. The effect of patient
position is speculative because the nerve is not routinely involved in a stretch injury of the
brachial plexus and because the plexus is not routinely involved when long thoracic nerve
dysfunction occurs. Hyperabduction of an arm may force the head of the humerus into the
axillary neurovascular bundle and may be associated with dampening of the distal pulse and
the ipsilateral pulse oximeter waveform. (See page 798: Brachial Plexus and Upper Extremity
Injuries.)
4. All of the following statements concerning radial nerve injury are true EXCEPT:
A. Compression at the mid-humerus level by sheets used to tuck the arm may cause
damage to the nerve.
B. Radial nerve injury results in wrist drop and weakness of thumb abduction.
C. The most common site of injury is the olecranon groove.
D. A patient with a radial nerve injury cannot extend the distal phalanx of the thumb.
E. A patient with a radial nerve injury has decreased sensation in the web space
between the thumb and index finger.
4. C. The radial nerve may be injured by compression against the underlying bone as it wraps
around the humerus approximately 3 cm above the lateral epicondyle. Excessive cycling of an
automatic blood pressure cuff has been implicated in causing damage to the radial nerve.
Compression at the mid-humerus level by sheets or towels used to tuck the arm may also result
in injury. Radial nerve injury results in wrist drop, weakness of thumb abduction, inability to
extend the metacarpophalangeal joints, and loss of sensation in the web space between the
thumb and the index finger. (See page 798: Brachial Plexus and Upper Extremity Injuries.)
5. Which of the following statements concerning ulnar nerve injury is TRUE&quest;

A. The nerve is most susceptible to injury when the arm is on an arm board with the
hand supinated.
B. Elbow flexion may cause ulnar nerve damage by compression by the aponeurosis of
the flexor carpi ulnaris muscle.
C. The nerve is susceptible to injury as it passes in the ulnar groove of the lateral
epicondyle.
D. Injury causes loss of sensation in the thumb.
E. Men have less statistical chance of postoperative ulnar neuropathy than women.
5. B. The ulnar nerve passes though the groove between the medial epicondyle and the
olecranon process of the humerus. The nerve may be compressed as the arm lies abducted on
a normal arm board with the hand pronated. Injury should be suspected if a pinprick of the fifth
finger is not felt. Elbow flexion may cause ulnar nerve damage by several mechanisms,
including compression by aponeurosis of flexor carpi ulnaris muscle and cubital tunnel
retinaculum or anterior subluxation of the ulnar nerve over the medial epicondyle of the
humerus. Men are statistically more likely to have postoperative ulnar neuropathy than women.
(See page 798: Brachial Plexus and Upper Extremity Injuries.)
6. To have the pelvis retained in place on a fracture table, a vertical pole at the
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perineum should be placed:
A. between the genitalia and the uninjured limb
B. between the genitalia and the injured limb
C. between the limbs at the midthigh level
D. against the surface of the sacral prominence
E. none of the above
6. A. The vertical pole on a fracture table should be well padded and placed against the pelvis
between the genitalia and the uninjured limb. Damage to the genitalia and pudendal nerve and
complete loss of penile sensation have been reported after improper use of the fracture table.
(See page 801: Perineal Crush Injury.)
P.155
7. All of the following may cause a compartment syndrome EXCEPT:
A. systemic hypotension with loss of perfusion pressure
B. vascular obstruction by pelvic retractors
C. external compression of leg wrappings that are too tight
D. compression stockings
E. prolonged lithotomy position
7. D. Causes of compartment syndrome that are associated with positioning include systemic
hypotension with loss of perfusion pressure, vascular obstruction by intrapelvic retractors,
external compression by straps, and wrappings that are too tight. Compression stockings and
devices used to prevent deep venous thrombosis are not associated with compartment
syndrome. (See page 801: Compartment Syndrome.)
8. Signs and symptoms of a compartment syndrome include all of the following

EXCEPT:
A. rhabdomyolysis
B. hypoxic edema
C. renal failure
D. pain
E. deep venous thrombosis (DVT)
8. E. Signs and symptoms of a compartment syndrome include ischemia, hypoxic edema,
elevated tissue perfusion pressure within fascial compartments of the extremity,
rhabdomyolysis, pain, and renal failure. A sequential compression device is used to prevent
development of DVT in prolonged procedures; this is not associated with compartment
syndrome. (See page 801: Compartment Syndrome.)
9. All of the following accurately describe problems resulting from the lateral decubitus
position EXCEPT:
A. Improper neck positioning may intensify pain from protrusion of a cervical disc.
B. There is the potential for excessive ventilation of the upside lung.
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C. Respiratory compromise may be lessened if the point of flexion is at the iliac crest as
opposed to the costal margin or flank.
D. There is the potential for winging of the scapula.
E. The saphenous nerve of the downside leg is likely to be compressed.
9. E. The lateral decubitus position may compromise ventilation and lead to injuries of the
shoulder, scapula, and extremities. Damage of the peroneal nerve of the downside leg is
common as it courses laterally around the neck of the fibula. The saphenous nerve courses
medially and is less likely to be compressed. (See page 804: Complications of the Lateral
Decubitus Positions.)
10. Which of the following statements regarding postoperative complications of
positioning are TRUE&quest;
1. Severe postoperative macroglossia may be caused by prolonged marked neck flexion.
2. Neuropathies that result in motor function loss are generally associated with more
prolonged or permanent nerve dysfunction than those with isolated sensory loss.
3. The loss of functional residual capacity is less in the prone position than in either the
supine or lateral position.
4. No studies have proven that the use of gel pads is beneficial in the reduction of
peripheral neuropathies.
10. E. Postoperative macroglossia may result from marked neck flexion. The prone position
results in less of a loss of functional residual capacity than does either the supine or the lateral
position. Motor neuropathies are generally more prolonged than are sensory neuropathies. No
studies have proven that the use of gel pads is beneficial in the reduction of peripheral
neuropathies, although it seems like a reasonable idea. (See page 793: Keypoints; page 810:
Complications of the Head Elevated Positions; and page 804: Ventral Decubitus Positions.)
11. Which of the following statements concerning pulmonary perfusion zones are
TRUE&quest;
1. West zone 2 is the ideal portion to match perfusion with ventilation.
2. West zone 1 may be produced by excessive positive-end expiratory pressure and
pulmonary hypotension.
3. When the patient is tilted head down, zone 3 is in the dorsal portion of the lung.
4. In the supine position, dorsal portions of the lung will have increased compliance and
less ventilation–perfusion mismatch.
11. A. In west zone 1, alveolar pressure exceeds both arterial and venous pressure and
prevents perfusion of the lung unit. West zone 1 may be produced by pulmonary hypotension,
excessive positive end-expiratory pressure, or overdistention of alveolar units from large tidal
volumes. In west zone 2, arterial pressure exceeds alveolar pressure, and alveolar pressure
remains higher than venous pressure. Perfusion is the result of fluctuation between arterial and
alveolar pressure. In supine positions (especially when the head is down), gravity-induced
vascular congestion forces the dorsal portions of the lung to function as a zone 3.
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Consequently, the compliance of the area is reduced, and passive ventilation tends to distribute
gas preferentially to more easily dispensable substernal areas. (See page 794: Circulatory and
Respiratory Physiology of the Dorsal Decubitus Positions.)
12. Which of the following may result from the prone position&quest;
1. Conjunctival edema
2. Breast injuries, especially if the breast is displaced laterally
3. Distention of paravertebral vessels
4. Increased pulmonary compliance
12. A. Compression of the abdominal viscera and restricted chest expansion in the prone
position decrease pulmonary compliance. Conjunctival edema is common in prone patients
whose heads are at or below the level of the heart. It is usually transient, but permanent loss of
vision may occur. When intra-abdominal pressure approaches or exceeds venous pressure,
return of blood from the pelvis and lower extremities is reduced or obstructed, and there is
distention of paravertebral vessels. Finally, medial and cephalad displacement of the breasts is
better tolerated than forced lateral displacement. (See page 806: Complications of the Ventral
Decubitus Positions.)
13. Which complication(s) is/are associated with the sitting position&quest;

1. Paradoxical air embolus
2. Tension pneumocephalus
3. Peripheral nerve injury
4. Postural hypotension
13. E. Postural hypotension may occur in the sitting position because the normal protective
reflexes are inhibited by drugs used during anesthesia. The sitting position predisposes
patients to air embolization when venous pressure becomes subatmospheric. Pneumocephalus
occurs if air from the dural incision site spreads over the surface of the brain. There is risk of
peripheral nerve injury, especially of the sciatic nerve, as a result of marked hip flexion. If the
neck is excessively extended, diminished cervical spinal cord perfusion pressure may cause
quadriplegia. (See page 810: Complications of the Head-Elevated Positions.)
14. Practice advisory guidelines for the prevention of postoperative visual loss (POVL)
include the following:
1. There is no specific minimum mean blood pressure identified that reliably prevents
blindness.
2. For adolescent girls, a hematocrit of 24% appears to be the appropriate transfusion
threshold for prevention of POVL.
3. Anesthesiologists should consider informing high-risk patients about the small and
unpredictable risk of POVL.
4. Colloids are superior to crystalloids for maintenance of intravascular volume and
prevention of POVL.
14. B. A subset of patients who undergo spinal fusion in the prone position are at increased risk
for POVL. These factors include anticipated prolonged procedures involving substantial blood
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loss. No threshold for the lowest allowable blood pressure or hematocrit has been identified.
Anesthesiologists should consider informing high-risk patients that there is a small,
unpredictable risk of POVL loss. (See page 807: Table 30-1: Summary of Practice Advisory for
Perioperative Visual Loss Associated with Spine Surgery.)
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Review of Clinical Anesthesia, 5e [Vishal] 31. Monitored Anesthesia Care
Chapter 31
Monitored Anesthesia Care
1. Sedation/analgesia:
A. has been replaced by the term conscious sedation in the American Society of
Anesthesiologists (ASA) practice guidelines
B. describes a state in which a patient's only response is reflex withdrawal from a painful
stimulus
C. describes a state that allows the patient to respond purposefully to a verbal command
or tactile stimulation
D. is a deeper level of sedation than that provided by monitored anesthesia care (MAC)
E. was a term first introduced by the American Dental Association
1. C. Sedation/analgesia is the term currently used by the ASA in its practice guidelines for
sedation and analgesia by non-anesthesiologists. The current ASA definition of
sedation/analgesia is “a state that allows patients to tolerate unpleasant procedures while
maintaining adequate cardiorespiratory functions and the ability to respond purposefully to
verbal command or tactile stimulation.” Thus, sedation/analgesia is intended to be a lighter level
of sedation than may be encountered during MAC. The term sedation/analgesia is used most
frequently in the context of care provided by non-anesthesiologists and implies a level of
vigilance that is less than that required for general anesthesia. The ASA specifically states that
patients whose only response is reflex withdrawal from a painful stimulus are sedated to a
greater degree than encompassed by the term sedation/analgesia. (See page 815:
Terminology.)
2. The condition in which a patient has no movement in response to a painful stimulus

describes:
A. conscious sedation
B. intravenous sedation
C. monitored anesthesia care (MAC)
D. sedation/analgesia
E. general anesthesia
2. E. In general anesthesia, the patient is medicated to the extent that he or she has no
movement in response to a painful stimulus. (See page 815: Terminology.)
3. All of the following statements regarding monitored anesthesia care (MAC) are true
EXCEPT:
A. The patient remains able to protect the airway for most of the procedure.
B. It always involves the administration of sedative drugs.
C. It requires performance of a preanesthesia examination and evaluation.
D. It is reimbursed at the same level as general or regional anesthesia.
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E. It may include the administration of bronchodilators.
3. B. MAC refers to clinical situations in which the patient remains able to protect the airway
during most of the procedure. Because MAC is a physician service provided to an individual
patient and is based on medical necessity, it should be subject to the same level of
reimbursement as general or regional anesthesia. The American Society of Anesthesiologists
(ASA) states that MAC must include performance of a preanesthetic examination and
evaluation. Also, the ASA states that all institutional regulations pertaining to anesthesia
services shall be observed and all the usual services performed by an anesthesiologist should
be provided, including administration of sedatives, tranquilizers, antiemetics, narcotics, other
analgesics, beta-blockers, vasopressors, bronchodilators, antihypertensives, or other
pharmacologic therapy as may be required in the judgment of the anesthesiologist. (See page
815: Terminology.)
4. The context-sensitive half-time:

A. is directly related to the elimination half-time
B. is independent of the duration of infusion
C. is the half-time of equilibration between drug concentration in the blood and its effect
D. depends on both metabolism and distribution phenomena
E. is generally measured by serum assay of drug concentrations
4. D. The context-sensitive half-time is the time required for the plasma drug concentration to
decline by 50% after terminating an infusion of a particular duration. The context-sensitive half-
time takes into account both metabolism and distribution effects. It is highly dependent on the
duration of infusion, particularly for drugs such as thiopental and fentanyl. It bears no constant
relationship to the elimination half-times. Generally, it is calculated by computer simulation of
multicompartmental pharmacokinetic models. (See page 818: Context-Sensitive Half-Time.)
5. Which statement about drug interactions is TRUE&quest;

A. Coexisting respiratory disease is not related to the frequency of respiratory
depression in patients receiving opioid–benzodiazepine combinations.
B. There is no difference in the incidence of adverse respiratory effects when midazolam
is used alone or in combination with fentanyl.
C. Most of the fatalities reported after the use of midazolam and opioids were related to
adverse cardiac events.
D. Opioids and benzodiazepines are synergistic in producing hypnosis.
E. When an opioid is used in the analgesic dose range, there is little risk of adverse
cardiorespiratory interaction.
5. D. During MAC, the maximum benefit of opioid supplementation in terms of potentiation of
other administered sedatives will accrue when the opioid is used in the analgesic dose range.
Within this dose range, there is great potential for an adverse cardiorespiratory interaction.
Opioid–benzodiazepine combinations are frequently used to achieve the components of
hypnosis, amnesia, and analgesia. The opioid–benzodiazepine combination displays marked
synergism in producing hypnosis. Several fatalities have been reported after the use of
midazolam, most of them related to adverse respiratory events. In many of these cases,
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midazolam was used in combination with an opioid. Studies have shown that midazolam usually
does not produce significant respiratory effects when used alone; however, the combination of
midazolam and fentanyl has a higher incidence of hypoxemia in study subjects. The respiratory
depressive effects of this drug combination are likely to be even more significant in patients with
coexisting respiratory or central nervous system disease or at the extremes of age. (See page
819: Drug Interactions in Monitored Anesthesia Care.)
6. When used for monitored anesthesia care (MAC), propofol:

A. causes greater respiratory depression than midazolam when combined with an opioid
B. reliably causes amnesia
C. possesses antiemetic effects
D. has excellent analgesic properties
E. has a context-sensitive half-time that depends markedly on the duration of the infusion
6. C. Propofol has many ideal properties for use during MAC. The context-sensitive half-time
remains short regardless of the length of infusion, and its rapid onset allows for easier titration.
Propofol appears to have antiemetic properties but no analgesic or amnestic effects. When
combined with opioids, propofol appears to result in minimal respiratory depression. This is in
contrast to benzodiazepine–opioid combinations, which may cause severe respiratory
depression. (See page 820: Specific Drugs Used for Monitored Anesthesia Care.)
7. Advantages of midazolam over diazepam include all of the following EXCEPT:

A. It has a lower incidence of resedation.
B. Clearance is unaffected by cimetidine.
C. Thrombophlebitis is rare.
D. It is usually painless on injection.
E. Active metabolites work synergistically with the parent drug.
7. E. The major advantages of midazolam over diazepam include the following: midazolam is
water soluble, it is usually painless upon injection, thrombophlebitis is rare, it has a short
elimination half-life of 1 to 4 hours, its clearance is unaffected by histamine (H2)-antagonists, it
has inactive metabolites, and resedation is unlikely. (See page 820: Specific Drugs Used for
Monitored Anesthesia Care.)
P.159
8. Which statement regarding remifentanil is TRUE&quest;
A. Compared with other opioids, a bolus of remifentanil is associated with an increased
incidence of respiratory depression.
B. It is predominately metabolized by the P450 hepatic enzyme system.
C. When used with midazolam, remifentanil causes less respiratory depression than
other opioids.
D. The initial infusion rate should be 1 μg/kg/min.
E. It is supplied in a multidose vial that should be refrigerated.
8. A. Unlike previously available opioids, remifentanil is predominately metabolized by
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nonspecific esterases generating an extremely rapid clearance and offset of effect. Published
data suggest that bolus administration of remifentanil is associated with an increased incidence
of respiratory depression and chest wall rigidity. Because these side effects are likely to be
related to high peak concentration of drug, it is recommended that remifentanil boluses be
administered slowly or by using a pure infusion technique. The most logical method for the
administration of remifentanil during monitored anesthesia care is by an adjustable infusion.
Most investigators have used infusion rates that start at 0.1 μg/kg/min approximately 5 minutes
before the first painful stimulus. This initial loading infusion is then weaned to approximately
0.05 μg/kg/min to maintain patient comfort. Remifentanil is supplied as a powder that must be
reconstituted before use. (See page 820: Specific Drugs Used for Monitored Anesthesia Care.)
9. Choose the correct order of symptoms observed with worsening local anesthetic
toxicity.
A. Muscle twitching, metallic taste, vertigo
B. Tinnitus, numbness of the tongue, seizure
C. Slurred speech, muscle twitching, restlessness
D. Sedation, tinnitus, seizure
E. Blurred vision, circumoral numbness, vertigo
9. D. The clinically recognizable effects of local anesthetic toxicity on the central nervous
system are concentration dependent. Initial symptoms are sedation, numbness of the tongue
and circumoral tissues, and a metallic taste. As concentrations increase, restlessness, vertigo,
tinnitus, and difficulty focusing may occur. Higher concentrations result in slurred speech and
skeletal muscle twitching, which often herald the onset of tonic-clonic seizures. (See page 828:
Preparedness to Recognize and Treat Local Anesthetic Toxicity.)
10. Dexmedetomidine:
A. has the same half-life as clonidine
B. decreases cardiac vagal activity
C. is not associated with hypotension
D. is a selective α 2-receptor antagonist
E. is administered as an initial bolus of 0.5 to 1.0 μg/kg
10. E. Similar to clonidine, dexmedetomidine is a selective α 2-receptor agonist. Stimulation of α
2-receptors produces sedation and analgesia, a reduction of sympathetic outflow, and an
increase in cardiac vagal activity. The use of clonidine in the perioperative period is limited by
its long half-life of 6 to 10 hours. However, dexmedetomidine has a much shorter half-life and
greater α 2-receptor selectivity. Despite its α 2-selectivity, dexmedetomidine may still cause
significant bradycardia and hypotension. Initial bolus doses range from 0.5 to 1.0 μg/kg over 10
to 20 minutes followed by a continuous infusion of 0.2 to 0.7 μg/kg/hr. (See page 820: Specific
Drugs Used for Monitored Anesthesia Care.)
11. Which statement regarding ketamine is TRUE&quest;

A. It has been shown to preserve airway reflexes when used in large doses.
B. It is a good choice for open globe injuries.
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C. It produces a dissociative state.

D. Doses of 0.3 mg/kg are frequently associated with significant cardiorespiratory
depression.
E. It is a di-isophenol derivative.
11. C. Ketamine is a phencyclidine derivative. When used in small doses (0.25–0.5 mg/kg), its
use is associated with minimal respiratory and cardiovascular depression. Ketamine produces a
dissociative state in which the eyes remain open with a nystagmic gaze. Ketamine can elevate
intraocular pressure and is thus relatively contraindicated in patients with open globe injuries.
Increased oral secretions make laryngospasm more likely. Although it has been suggested that
airway reflexes are relatively preserved with ketamine, no convincing evidence supports this
notion. (See page 820: Specific Drugs Used for Monitored Anesthesia Care.)
12. Monitored anesthesia care (MAC):
1. includes diagnosis and treatment of clinical problems that occur during a procedure
2. may be provided by intensive care unit nurses
3. conceptually should allow for a more rapid recovery than general anesthesia
4. does not include postprocedure anesthesia management
12. B. MAC includes all aspects of anesthesia care, including the preoperative visit,
intraoperative care, and postprocedure anesthesia management. During MAC, the
anesthesiologist or a member of the anesthesia care team provides a number of specific
services, including (but not limited to) monitoring of vital signs, maintenance of the patient's
airway, continual evaluation of vital functions, and diagnosis and treatment of clinical problems
that occur during the procedure. (See page 815: Terminology.)
13. Monitored anesthesia care (MAC) resembles general anesthesia in that both:
1. include preoperative assessment
2. require continual physical presence of the anesthesiologist or nurse anesthetist
3. include intraoperative monitoring
4. always involve the administration of sedative drugs
13. A. MAC usually is provided to conscious patients undergoing therapeutic or diagnostic
procedures that would otherwise be unacceptably uncomfortable or unsafe without the attention
of an anesthesiologist. As with general anesthesia, there must be a preanesthetic examination
and evaluation, a prescription of anesthesia care, personal participation in or medical direction
of the entire plan of care, and continuous physical presence of the anesthesia care provider.
MAC always involves monitoring of a patient but does not necessarily require the administration
of sedative drugs. (See page 816: Preoperative Assessment.)
14. The ideal sedation technique for monitored anesthesia care (MAC):
1. should provide rapid and complete recovery at the end of the procedure
2. should have a low incidence of side effects
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3. may provide deeper sedation than that provided during sedation/analgesia
4. allows the patient to be able to communicate during the procedure
14. E. The ideal sedation technique involves the administration of either individual or
combinations of analgesic, amnestic, and hypnotic drugs. There should be a minimal incidence
of side effects such as cardiorespiratory depression, nausea and vomiting, delayed emergence,
and dysphoria. Patients should be able to communicate when indicated. Recovery after the
completion of the procedure should be rapid and complete. (See page 816: Techniques of
Monitored Anesthesia Care.)
15. Sedation may depress:

1. protective laryngeal and pharyngeal reflexes
2. the ventilatory response to hypoxia and hypercapnia
3. the swallowing reflex
4. the resting arterial partial pressure of oxygen
15. E. Protective laryngeal and pharyngeal reflexes are depressed by sedation and may render
the patient vulnerable to aspiration. The swallowing reflex may be depressed for a long time
after the return of consciousness. Opioids depress the normal ventilatory response to hypoxia
and hypercapnia. Benzodiazepines appear to have a variable effect on ventilatory response,
although they clearly potentiate the respiratory depression of opioids. Hypoventilation leads to
reduced oxygen saturation in the absence of supplemental inspired oxygen. (See page 826:
Sedation and Protective Airway Reflexes.)
16. Agitation during monitored anesthesia care (MAC) may be caused by:
1. hypoxia
2. local anesthetic toxicity
3. distended bladder
4. cerebral hypoperfusion
16. E. Agitation during MAC may be a result of pain or anxiety, but it is of paramount importance
that hypoxia and cerebral hypoperfusion be excluded as causes. Other possible causes of
agitation include local anesthetic toxicity, hypothermia, a distended bladder, nausea, an
uncomfortable position or equipment, and prolonged tourniquet inflation. (See page 816:
Techniques of Monitored Anesthesia Care.)
17. Advantages of administration of drugs by continuous infusion rather than by

intermittent dosing during monitored anesthesia care (MAC) include:
1. reduced total amount of drug administered
2. facilitation of a more rapid recovery
3. fewer episodes of excessive sedation
4. fewer episodes of inadequate sedation
17. E. Continuous infusions of sedative drugs are superior to intermittent bolus dosing because
they produce less fluctuation in drug concentration, thus reducing the number of episodes of
inadequate or excessive sedation. Also, the total amount of drug may be lower, facilitating a
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more prompt recovery. (See page 817: Pharmacologic Basis of Conscious Sedation
Techniques: Optimizing Drug Administration.)
18. Which statement(s) regarding the advantages of propofol over benzodiazepines for
conscious sedation is/are TRUE&quest;
1. Immediate recovery is faster.
2. Psychomotor function returns to baseline earlier.
3. There is less postoperative clumsiness.
4. The postanesthesia care unit stay is consistently markedly shorter.
18. A. A study by Mackenzie showed that a group of patients receiving propofol had faster
immediate recovery than did the group of patients that received midazolam. Furthermore,
psychomotor function was comparable to baseline values immediately after propofol sedation
but did not return to baseline until 2 hours after midazolam administration. Another study by
White et al showed that propofol produced less postoperative sedation, drowsiness, confusion,
and clumsiness than midazolam; however, both drugs had similar discharge times. (See page
820: Specific Drugs Used for Monitored Anesthesia Care: Propofol.)
19. Flumazenil reversal of benzodiazepine-induced sedation:

1. is inexpensive and should be routine
2. is associated with undesirable hemodynamic effects
3. does not reverse the amnestic effect
4. may be associated with resedation because of its short elimination half-life
19. D. Flumazenil is a specific benzodiazepine antagonist that reverses the sedative and
anesthetic effects without adverse side effects. It has a short elimination half-time, so there is a
potential for resedation after the flumazenil has been cleared. The routine use of flumazenil
represents a significant cost disadvantage compared with propofol sedation. (See page 820:
Benzodiazepines.)
20. Which of the following statements about the use of opioids during monitored
anesthesia care (MAC) is/are TRUE&quest;
1. They are a good choice for sedation during a working spinal anesthetic.
2. Alfentanil is a good choice for brief, intense analgesia.
P.160
3. They are associated with reliable amnesia.
4. They are associated with a significant risk of nausea.
20. C. Opioids are best used to provide the analgesic component during MAC. They are not
appropriate for a sedative or anesthetic component because they cannot reliably produce
sedation without significant respiratory depression, and they lack significant amnestic
properties. Propofol and midazolam produce more specific sedative effects. Opioids are
associated with a significant risk of nausea and vomiting in ambulatory patients. Alfentanil's
pharmacokinetic profile makes it well suited for treatment of brief painful periods such as
placement of a retrobulbar block. (See page 822: Opioids.)
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21. Oxygen administration during monitored anesthesia care (MAC):
1. can “mask” significant alveolar hypoventilation
2. must be administered in high concentrations to be effective
3. may be required in the postoperative period
4. is required by the American Society of Anesthesiologists (ASA) standards for basic
monitoring
21. B. Even in moderate concentrations, oxygen administration is very effective for increasing a
low oxygen saturation resulting from hypoventilation. However, when the patient is receiving
oxygen, significant hypoventilation and hypercarbia may be present even though the oxygen
saturation is normal. Oxygen administration is not required by ASA standards but should be
highly considered whenever sedatives or respiratory depressants are used. Respiratory
depression may persist into the recovery period; measurement of oxygen saturation on room air
may be useful before discharging a patient from the postanesthesia care unit without
supplemental oxygen. (See page 826: Supplemental Oxygen Administration.)
22. Bispectral index (BIS) monitoring:

1. may help avoid complications of overdosing medications
2. is a processed electroencephalogram parameter
3. ideally should be used as an adjunct to clinical evaluation
4. increases upon deepening of sedation
22. A. The BIS is a processed electroencephalogram parameter. Sedation monitoring is
attractive because of the potential to titrate drugs more accurately and thus avoid the adverse
effects of both overdosing and underdosing. An increased depth of sedation is associated with
a predictable decrease in the BIS. Although the use of the BIS to monitor sedation is appealing,
conventional assessment of sedation is an important mechanism whereby continuous patient
contact is maintained. Ideally, BIS monitoring will be used in the future as an adjunct to clinical
evaluation rather than as the primary monitor of consciousness. (See page 828: Bispectral
Index Monitoring During Monitored Anesthesia Care.)
23. The American Society of Anesthesiologists (ASA) practice guidelines for sedation
and analgesia by non-anesthesiologists:
1. suggest that the individual performing the procedure should also monitor the patient's
vital signs
2. suggest the routine administration of supplemental oxygen
3. emphasize the importance of preprocedure patient evaluations but not fasting
4. suggest that an individual with advanced life support skills be present during the
procedure
23. C. The ASA practice guidelines for sedation and analgesia by non-anesthesiologists
emphasize the importance of preprocedure patient evaluation, patient preparation, and
appropriate fasting periods. These guidelines also suggest that an individual other than the
person performing the procedure be available to monitor the patient's comfort and physiologic
status. The routine administration of supplemental oxygen is recommended. At least one person
with advanced life support skills should be present during the procedure. (See page 829:
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Sedation and Analgesia by Non-anesthesiologists.)
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Review of Clinical Anesthesia, 5e [Vishal] 32. Ambulatory Anesthesia
Chapter 32
Ambulatory Anesthesia
1. Which of the following is not a candidate for outpatient surgery requiring general
anesthesia&quest;
A. A patient with a body mass index of 35 and obstructive sleep apnea (OSA) who is
having laparoscopic surgery of the upper abdomen
B. An asymptomatic ex-premature child who is 62 weeks' postconceptional age
C. A patient in whom a blood transfusion is anticipated
D. Any patient in American Society of Anesthesiologists (ASA) class IV
E. Any patient older than 80 years of age
1. A. In a review of 258 morbidly obese patients who underwent outpatient surgery, they did not
have a greater incidence of unplanned admissions, minor complications, or unplanned contact
with health care professionals. However, morbidly obese patients have a higher incidence of
OSA. The ASA has published practice guidelines for the perioperative management of patients
with OSA. In the guidelines, the authors state that for patients with OSA, if local or regional
anesthesia is used, the procedure can also be performed as an ambulatory procedure. Certain
infants should be monitored for 12 hours after procedures because they are at risk of
developing apnea. These include infants who are younger than 46 weeks postconceptual age,
infants who are younger than 60 weeks of age who also have a history of chronic lung or
neurologic disease, and infants with anemia (hemoglobin <6 mmol/L). Infants without disease
who are 46 to 60 weeks of age should be monitored for 6 hours after procedures. At the other
extreme of life, advanced age alone is not a reason to disallow surgery in an ambulatory
setting. Patients classified as ASA class III and IV should be considered for outpatient
procedures provided their systemic diseases are medically controlled. The need for transfusion
is also not a contraindication for ambulatory procedures. (See page 833: Places, Procedures,
and Patient Selection.)
2. Which of the following statements concerning epidural and caudal anesthesia is

TRUE&quest;
A. Recovery from spinal anesthesia is always faster than recovery from epidural
anesthesia.
B. Bicarbonate can be added to solutions to increase the potency of epidural
anesthesia.
C. Additives for increasing duration of blockade include opioids, ketamine, clonidine, and
neostigmine.
D. Although caudal blocks result in better pain control, they do not affect discharge times.
E. Caudal anesthesia is commonly performed on children for upper abdominal surgery.
2. C. Epidural anesthesia takes longer to perform than spinal anesthesia. Onset with spinal
anesthesia is more rapid, although recovery may be the same with either technique. In one
study of patients undergoing knee arthroscopy, spinal anesthesia with small-dose lidocaine and
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fentanyl was compared with 3% 2-chloroprocaine administered in the epidural space.
Intraoperative conditions, discharge characteristics and times, and recovery profiles were
similar. Some studies suggest that bicarbonate can be added to solutions for faster onset of
epidural anesthesia. Other useful (albeit controversial) additives for increasing duration of
blockade include opioids, ketamine, clonidine, and neostigmine. Caudal anesthesia is a form of
epidural anesthesia commonly used in children undergoing surgery below the umbilicus and to
control postoperative pain. Because of better pain control after a caudal block, children can
usually ambulate earlier and be discharged sooner than when a caudal block is not performed.
Pain control and discharge times are no different whether the caudal block is placed before
surgery or after it is completed. (See page 839: Epidural and Caudal Anesthesia.)
3. Which of the following statements regarding induction with propofol is

FALSE&quest;
A. 0.2 mg/kg of intravenous (IV) lidocaine may be used to decrease the incidence and
severity of pain.
B. Thrombophlebitis is a common problem after IV administration of this agent.
C. 20 mL of propofol mixed with more than 20 mg of lidocaine should be avoided
because it may lead to instability of the mixture.
D. The elimination half-life of propofol is 1 to 3 hours.
E. After induction doses of propofol, psychomotor impairment may last for up to 1 hour.
3. B. The popularity of propofol as an induction agent for outpatient surgery in part relates to its
half-life: The elimination half-life of propofol is 1 to 3 hours, which is shorter than the half-lives
of methohexital (6 to 8 hours) and thiopental (10 to 12 hours). Although the effect of drugs given
for induction seems to be transient, they can depress psychomotor performance for several
hours. Impairment after thiopental administration may be apparent for up to 5 hours; impairment
after propofol administration only lasts for 1 hour. Thrombophlebitis does not appear to be a
problem after IV administration of propofol, but it can be evident after thiopental administration.
0.2 mg/kg of IV lidocaine may be used to decrease the incidence and severity of pain upon
propofol injection; other techniques have been tried, including 0.1 mg/kg of ketamine
immediately before propofol injection or 20 mg of lidocaine plus 10 mg of metoclopramide. 20
mL of propofol mixed with more than 20 mg of lidocaine, though, should be avoided because it
may lead to instability of the mixture. (See page 840: Induction.)
4. Which of the following statements regarding children with current or recent upper
respiratory tract infections (URIs) is TRUE&quest;
A. The incidence of laryngospasm and bronchospasm is no different in children with a
current URI than in children who had a URI within the past 4 weeks.
B. Children with recent URIs are more likely to have incidences of desaturation (<90%)
than children with current URIs.
C. The risk of adverse respiratory events is the same whether an endotracheal tube
(ETT) or a laryngeal mask airway (LMA) is used.
D. Children of parents who smoke have the same risk of adverse airway reactions as
children of nonsmoking parents.
E. Nonproductive cough carries the same risk of adverse airway reactions as does
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cough accompanied by copious secretions.
4. A. One study of 1078 children 1 month to 18 years old could find no difference in
laryngospasm or bronchospasm when the children had active URIs, a URI within 4 weeks, or no
symptoms. However, children with active or recent URIs had more episodes of breathholding,
more incidences of desaturation below 90%, and more respiratory events than children without
symptoms. Independent risk factors for adverse respiratory events in children with URIs include
use of an ETT (versus use of a LMA), a history of prematurity, a history of reactive airway
disease, a history of parental smoking, surgery involving the airway, presence of copious
secretions, and nasal congestion. Generally, if a patient with a URI has a normal appetite, does
not have a fever or an elevated respiratory rate, and does not appear acutely ill, it is probably
safe to proceed with the planned procedure. (See page 835: Upper Respiratory Tract Infection.)
5. Which of the following statements reflect(s) the current thinking on preoperative
fasting and the risk of pulmonary aspiration of gastric contents in ambulatory adult
patients&quest;
1. The longer the withholding of liquids, the safer the gastric environment will be.
2. In outpatients, 50 mL of clear fluid given 2 hours preoperatively increases gastric
volume.
3. It is acceptable to allow a patient to have a small solid meal the morning of surgery.
4. Coffee drinkers should be encouraged to drink black coffee the morning of surgery to
avoid the risk of withdrawal.
5. D. For patients who are not at an increased risk for aspiration, prolonged fasting does not
improve the gastric environment compared with patients who receive clear liquids 2 hours
preoperatively. The clear liquids promote emptying and probably dilute the endogenous gastric
secretions to some extent. Coffee is free of particulate matter and is accepted as a clear liquid.
Coffee drinkers should be encouraged to drink coffee before their procedures because physical
signs of withdrawal (e.g., headache) may easily occur. (See page 835: Restriction of Food and
Liquids Before Ambulatory Surgery.)
P.164
6. Which of the following statements regarding perioperative opioids and nonsteroidal
anti-inflammatory drugs is/are TRUE&quest;
1. Preoperative opioids help control hypertension during tracheal intubation and provide
for pre-emptive analgesia.
2. Meperidine is helpful in controlling shivering.
3. Preoperative celecoxib is accompanied by a reduced need for supplemental analgesia
in the postanesthesia care unit.
4. Opioids are particularly effective agents in relieving anxiety in adults in the
preoperative period.
6. A. Preoperative opioids can be used to sedate patients, control hypertension with tracheal
intubation, and decrease pain before surgery. However, the effectiveness of these agents in
relieving anxiety is controversial, particularly in adults. Meperidine is known to help control
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postoperative shivering. Preoperative administration of nonsteroidal anti-inflammatory drugs is
also useful in the early postoperative period. Celecoxib has been shown to reduce
postoperative pain. (See page 837: Opioids and Nonsteroidal Analgesics.)
7. Which of the following statements regarding postoperative nausea and vomiting

(PONV) with ambulatory surgery is/are TRUE&quest;
1. 40 μg/kg of granisetron (a serotonin [5-HT 3] antagonist) is a superior antiemetic
compared with 0.25 mg/kg of metoclopramide.
2. Midazolam may possess some antiemetic properties.
3. The ReliefBand acustimulation device is as effective as ondansetron in treating PONV
in patients who are still nauseous after receiving metoclopramide and droperidol.
4. If a dose of ondansetron is given in the operating room and the patient complains of
nausea in the postanesthesia care unit (PACU), a repeat dose is often effective.
7. A. The 5-HT3 antagonists seem particularly effective for PONV. For example, in one study of
children who underwent strabismus surgery and were then nauseated during the first 3 hours
after recovery from anesthesia, emesis-free episodes were greater after 40 μg/kg of granisetron
was administered (88%) compared with 40 μg/kg of droperidol (63%) or 0.25 mg/kg of
metoclopramide (58%). Midazolam and propofol, although more commonly used for sedation,
have antiemetic effects that are longer in duration than their effects on sedation. When the use
of a ReliefBand acustimulation device was compared with ondansetron for patients who were
nauseated in the PACU after receiving metoclopramide or droperidol and who were undergoing
laparoscopic surgery, nausea was most effectively treated with both the ReliefBand and
ondansetron, although both therapies were equally effective individually in treating PONV. If a
patient has already received ondansetron prophylaxis in the operating room and is nauseous in
the PACU, another repeat dose is not particularly effective. (See page 843: Nausea and
Vomiting.)
8. Which of the following statements regarding spinal anesthesia is/are TRUE&quest;

1. Chloroprocaine carries the same risk of transient neurologic symptoms (TNS) as does
lidocaine.
2. Adding fentanyl to the local anesthetic in the spinal technique improves the tolerance
for tourniquet pain.
3. Nausea after spinal or epidural anesthesia is the same as after general anesthesia.
4. Early ambulation after spinal anesthesia may decrease the incidence of postdural
puncture headache.
8. C. Nausea is much less frequent after epidural or spinal anesthesia than after general
anesthesia. Lidocaine and mepivacaine are ideal for ambulatory surgery because of their short
durations of action, although lidocaine use has been problematic because of TNS. Although
transient neurologic symptoms may be seen after other local anesthetics, the risk is seven times
more after intrathecal lidocaine than after bupivacaine, prilocaine, or procaine administration.
Likewise, lidocaine is associated with a higher rate of TNS than chloroprocaine. When fentanyl
is added to spinal local anesthetic, tourniquet tolerance is improved. Bed rest does not reduce
the frequency of headache. Indeed, early ambulation may decrease the incidence. (See page
839: Spinal Anesthesia.)
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9. Which of the following statements regarding depth of anesthesia is/are

TRUE&quest;
1. The use of bispectral index (BIS) monitoring has been shown to reduce the use of
intraoperative anesthetics by up to 20%.
2. The use of sympatholytics to treat hemodynamics is associated with faster recovery
and fewer side effects than treating the hemodynamics with inhalational agents.
3. The use of BIS monitoring may result in quicker awakening from general anesthetics.
4. The use of BIS monitoring has significantly reduced the length of stay in the hospital
and has significantly decreased the incidence of postoperative nausea and vomiting
(PONV).
9. A. BIS monitors are thought to decrease anesthesia used during general anesthesia.
Because less anesthesia is used, titration of anesthesia with these monitors results in earlier
emergence from anesthesia. In a meta-analysis of BIS monitoring for ambulatory anesthesia,
BIS monitoring was shown to reduce anesthetic use by 19%, with more modest decreases in
postanesthesia care unit duration (4 minutes) and PONV (6%). [Editors' note: A more recent
study (after the parent text went to press) did not report a benefit of BIS.] Sympatholytic drugs,
instead of anesthesia, can be used to control autonomic responses to anesthesia. In fact,
recovery is faster, and side effects are fewer in ambulatory patients whose blood pressure is
controlled by sympatholytics instead of inhalation agents. (See page 842: Depth of Anesthesia.)
10. Which of the following statements regarding intraoperative management of

postoperative nausea (PONV) and vomiting is/are TRUE&quest;
1. Risk factors include a previous history of motion sickness.
2. Acupuncture has not been shown to be effective in reducing the incidence of PONV.
3. Serotonin antagonists are particularly effective in preventing PONV.
4. Propofol increases the incidence of PONV.
10. B. Women, especially those who are pregnant, have a higher incidence of PONV. Other risk
factors include a history of motion sickness or postanesthetic emesis; surgery within 1 to 7 days
of the menstrual cycle; not smoking; and procedures such as laparoscopy, lithotripsy, major
breast surgery, and ear, nose, or throat surgery. The greater the number of risk factors, the
greater risk for PONV. Therapies useful in controlling PONV include acupuncture, supplemental
fluid therapy, clonidine (perhaps partly because it decreases anesthesia requirements), and
dexamethasone. In one study, acupuncture therapy was effective in controlling both PONV and
postoperative pain. Receptor antagonists, specifically selective serotonin antagonists
(ondansetron, dolasetron, and granisetron), have been shown to have similar efficacy in helping
to alleviate PONV. Dopamine antagonists, antihistamines, and anticholinergic drugs are useful
and are generally less expensive, but they are associated with a higher incidence of side
effects. Because of its ability to decrease PONV, propofol is an excellent general anesthetic for
ambulatory anesthesia. (See page 841: Intraoperative Management of Postoperative Nausea
and Vomiting.)
266 / 494
Review of Clinical Anesthesia, 5e [Vishal] 33. Office Based Anesthesia
Chapter 33
Office Based Anesthesia
1. Which of the following statements regarding injuries during office-based anesthesia
is/are TRUE&quest;
1. Most of them occur intraoperatively.
2. The second most common incidence is in the recovery room.
3. Fifty percent of injuries have a respiratory cause.
4. Injuries after discharge account for less than 10% of the injuries.
1. B. Injuries during office-based procedures occur throughout the perioperative period and are
multifactorial in origin. Most of them occur intraoperatively. 14% occur in the postanesthesia
care unit, and 21% occur after discharge. Fifty percent of injuries are respiratory and included
airway obstruction, bronchospasm, inadequate oxygenation and ventilation, and unrecognized
esophageal intubation. The second most common events are drug related. (See page 848:
Office Safety.)
2. Which of the following statements regarding patient selection for office-based

anesthesia is/are TRUE&quest;
1. The surgeon's office staff can arrange the surgery for patients with American Society
of Anesthesiologists (ASA) status I and II.
2. Close monitoring of oxygen saturation in an observational unit or intensive care unit
(ICU) setting may be required postoperatively for patients with obstructive sleep apnea
(OSA).
3. Preoperative anesthesia consultation should be obtained for patients with comorbid
conditions.
4. A preoperative history and physical examination should be obtained within 6 months of
the date of surgery.
2. A. Guidelines change. As of this writing, the patient should have a preoperative history and
physical examination recorded within 30 days of the procedure, including all pertinent
laboratory tests and any medically indicated specialist consultations. If the patient has an ASA
status I or II, the surgeon's office can arrange the surgery as per office protocol. However, if a
patient has a significant comorbid condition, a preoperative anesthesiology consultation should
be obtained before scheduling the patient for office-based surgery. Morbidly obese patients and
patients with OSA present unique challenges. It has been recommended that an observational
unit with close monitoring of oxygen saturation or an ICU setting be used for postoperative
monitoring of patients with OSA. (See page 850: Patient Selection.)
3. Which of the following statements regarding office-based anesthesia is/are

TRUE&quest;
1. Continuous heart rate monitoring is required.
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2. The ability for continuous electrocardiographic (ECG) monitoring is needed.

3. Monitoring of oxygen saturation is required.
4. At least 12 bottles of dantrolene should be available.
3. E. Perioperative monitoring should adhere to the standards for basic anesthetic monitoring.
These standards include continuous monitoring of heart rate and oxygen saturation, intermittent
noninvasive blood pressure monitoring, and the capacity for both temperature and continuous
ECG monitoring. Office-based anesthesiologists should be prepared to begin the initial
treatment of malignant hyperthermia, which requires having at least 12 bottles of dantrolene
available. (See page 851: Office Selection.)
4. Which of the following contribute(s) to the mortality rate in liposuction

procedures&quest;
1. Pulmonary embolism
2. Abdominal perforation
3. Fat embolism
4. Anesthetic “causes”
4. E. Mortality related to liposuction may be secondary to pulmonary embolism, abdominal
viscous perforation, anesthesia-related “causes,” fat embolism, infection, or hemorrhage. (See
page 854: Specific Procedures: Liposuction.)
5. Epidural and spinal anesthesia for liposuction is discouraged in office-based

anesthesia because of possible:
1. vasodilatation
2. fluid overload
3. hypotension
4. paralysis
5. A. Epidural and spinal anesthesia in an office-based setting is discouraged because of the
possibility of vasodilatation, hypotension, and fluid overload. (See page 854: Specific
Procedures: Liposuction.)
6. Which of the following statements regarding office-based gastrointestinal (GI)

endoscopy is/are TRUE&quest;
1. Endotracheal intubation is often required.
2. General anesthesia is usually required.
3. Colonoscopy does not cause cardiac dysrhythmia.
4. Hypotension may be caused by colonoscopy.
6. D. Upper GI procedures rarely require endotracheal intubation because the stomach is
emptied under direct visualization. The procedure may be accomplished with sedation using
midazolam and small doses of propofol. Colonoscopy is painful secondary to insertion and
manipulation of the endoscope and may be associated with cardiovascular effects, including
dysrhythmia, bradycardia, hypotension, hypertension, myocardial infarction, and death. (See
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page 855: Gastrointestinal Endoscopy.)
7. Which of the following ophthalmic and otorhinolaryngologic procedures is/are

suitable for office-based anesthesia&quest;
1. Cataract extraction
2. Ocular plastic
3. Lacrimal duct probing
4. Endoscopic sinus surgery
7. E. Ophthalmologic procedures suitable for the office include cataract extraction, lacrimal duct
probing, and ocular plastics. Topical anesthesia or periorbital and retrobulbar blocks are
frequently used to provide analgesia. Otolaryngology procedures acceptable for an office
setting include endoscopic sinus surgery, septoplasty, and myringotomy. (See page 855:
Ophthalmology/ Otolaryngology.)
8. Which of the following statements regarding the use of ketamine for office-based
analgesia is/are TRUE&quest;
1. It functions as an analgesic.
2. It is associated with nausea and vomiting.
3. It can be used as an induction agent.
4. It may increase the risk of aspiration.
8. B. Ketamine, a phencyclidine derivative, functions as both an anesthetic and an analgesic. It
does not depress respiration and increases laryngeal reflexes, thus decreasing the risk of
aspiration. It is not associated with nausea and vomiting; however, ketamine may increase
secretions and may cause hallucinations. (See page 857: Anesthetic Agents.)
P.168
9. Which of the following statements regarding postoperative nausea and vomiting
(PONV) in office-based anesthesia is/are FALSE:
1. Ketorolac does not decrease the incidence of PONV.
2. Dexamethasone potentiates the effects of antiemetics.
3. Routine prophylaxis using dexamethasone is advantageous.
4. Adequate hydration may decrease PONV.
9. C. Ketorolac decreases the incidence of PONV, and patients tolerate oral fluid and meet
discharge criteria earlier than those receiving opioids. Dexamethasone has been shown to
improve the efficacy of both serotonin (5-HT3) antagonists and dopamine antagonists. Routine
prophylaxis use of this medication, however, has not shown any advantage over symptomatic
treatment. Ensuring adequate hydration is an intervention that may be useful in the prevention
of PONV. (See page 857: Postanesthesia Care Unit.)
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Review of Clinical Anesthesia, 5e [Vishal] 34. Anesthesia Provided at Alternate Sites
Chapter 34
Anesthesia Provided at Alternate Sites
1. Anesthesia equipment required in alternate sites includes which of the
following&quest;
1. Central oxygen supply
2. Wall suction
3. Spare oxygen cylinder
4. Gas scavenger system
1. E. The American Society of Anesthesiologists has developed a standard to apply to
anesthesia remote locations. Before commencing an anesthetic, it is vital to confirm the
presence and proper functioning of all equipment an anesthesiologist would expect in the
operating room. This includes a central oxygen supply, spare oxygen cylinders, wall suction,
overhead lighting, gas scavenging systems, and electrical outlets. (See page 861: General
Principles.)
2. Which of the following statements regarding conscious sedation is/are TRUE&quest;

1. The patient is relaxed.
2. The patient should be able to respond to verbal stimulation.
3. The patient should be able to respond to physical stimulation.
4. The use of an oral airway is routine for maintaining respiration.
2. A. Conscious sedation is a state in which the patient is calm and relaxed yet able to respond
to verbal or physical stimulation. The patient is able to maintain both a patent airway and
protective airway reflexes during this minimally depressed level of consciousness. (See page
861: General Principles.)
3. The American Society of Anesthesiologists (ASA) standard II for continual

monitoring includes which of the following&quest;
1. Temperature
2. Oxygenation
3. Circulation
4. Ventilation
3. E. The ASA basic standards of monitoring should be adhered to in any location where
anesthesia or sedation is being performed. Standard I requires a qualified anesthesia provider
to be present in the room throughout the conduct of anesthesia. Standard II calls for continual
evaluation of the patient's oxygenation, ventilation, circulation, and temperature. The degree of
invasive monitoring that should be used depends on the patient's status and the procedure
being undertaken. (See page 861: General Principles.)
270 / 494
4. The physiologic response to electroconvulsive therapy (ECT) may include which of
1. Tachycardia
2. Bradycardia
3. Hypertension
4. Increase in cerebral blood flow
4. E. A minimum seizure duration of 25 seconds is recommended to ensure adequate
antidepressant efficacy. The cardiovascular response includes increased cerebral blood flow
and intracranial pressure. Generalized autonomic nervous system stimulation results in an initial
10 to 15 seconds of bradycardia and occasional asystole followed by a more prominent
sympathetic response of hypertension and tachycardia. Occasional cardiac dysrhythmias,
myocardial ischemia, infarction, or a neurologic vascular event may be precipitated. (See page
871: Electroconvulsive Therapy.)
5. Which of the following statements regarding dental surgery is/are TRUE&quest;

1. Ketamine and midazolam may be given intravenously, intramuscularly, or orally.
2. There is not an increased likelihood of postoperative laryngospasm.
3. Tracheal intubation may be required.
4. Ketamine always abolishes upper airway reflexes.
5. B. Ketamine is a useful induction agent. It may be used alone or in combination with atropine
and midazolam by an intravenous, oral, intramuscular, rectal, or intranasal route. Ketamine is
also advantageous in that, in standard doses, it does not abolish upper airway reflexes.
Tracheal intubation, often via the nasal route, is required to protect the airway, although the
laryngeal mask airway has recently been used successfully in adults and children undergoing
dental surgery. The immediate postoperative complications include bleeding, airway
obstruction, and laryngospasm. (See page 872: Dental Surgery.)
6. Anesthetic considerations for electroconvulsive therapy (ECT) include which of the

following&quest;
1. Etomidate is associated with a longer duration of seizures.
2. The anesthetic agent need not provide amnesia.
3. Succinylcholine (Sch) is most commonly used as a muscle relaxant.
4. Propofol commonly results in longer duration of seizures than barbiturates.
6. B. The anesthetic goals for a patient undergoing ECT include amnesia, airway management,
prevention of bodily injury from seizures, control of hemodynamic changes, and a smooth and
rapid emergence. Etomidate is associated with seizures of longer duration. Propofol is effective
for ECT, and its effect on outcome is similar to that of barbiturates. Several investigators have
found that propofol tends to result in seizures of shorter duration. Muscle relaxants are needed
to prevent injury to the patient during grand mal seizures. Sch is most commonly used because
of its rapid onset and short duration. (See page 871: Electroconvulsive Therapy.)
7. Which of the following statements regarding external-beam radiation treatment

is/are TRUE&quest;
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1. The patient needs to be immobile.

2. Sedation is preferred to general anesthesia in children.
3. The anesthesiologist should leave the treatment room.
4. Patients require a deep level of anesthesia because of the pain associated with this
procedure.
7. B. Because the radiation dose is so high, all medical personnel must leave the room during
the actual treatment. Direct observation of the patient is not possible. Closed-circuit television
and microphones are used. The need for patient immobility is a primary reason anesthesia is
required for these procedures; it is difficult for children to keep completely still when only
sedation is administered. If sedation is attempted, airway management problems increase, and
the recovery period is greatly prolonged. General anesthesia offers several advantages over
conscious sedation. Because there is no surgical stimulation, patients can be maintained at
light levels of anesthesia; emergence and recovery can then be rapid. (See page 864:
Radiology and Radiation Therapy.)
8. Which of the following statements concerning magnetic resonance imaging (MRI)

is/are TRUE&quest;
1. The pulse oximeter may cause tissue burn.
2. The anesthesia equipment can be made of aluminum or nonmagnetic steel.
3. The technique is contraindicated in the presence of a pacemaker, an intracranial
aneurysm clip, or an intravascular wire.
4. There is no dangerous ionizing radiation.
8. E. MRI is noninvasive and produces no ionizing radiation. There are no reports of harm from
tissue contact with the magnetic field itself. Several types of physiologic monitors, oxygen-
powered ventilators, laryngoscopic equipment, and anesthesia machines can be used within
the MRI suite. Most of the equipment differs in that it is made of aluminum or nonferromagnetic
material. Absolute and relative contraindications for MRI scanning include patients with cardiac
pacemakers near the site of scanning, intracranial aneurysm clip, or intravascular wires. (See
page 868: Magnetic Resonance Imaging.)
P.170
9. Which of the following statements regarding radiologic contrast material is/are
TRUE&quest;
1. The use of newer low-osmolarity nonionic agents has been associated with an
increased incidence of anaphylactic reactions.
2. Patients should be fluid restricted because of the large volume load presented by the
contrast agent.
3. Prophylaxis with diphenhydramine or methylprednisolone should be administered in all
patients.
4. The incidence of severe reaction to contrast media is 0.04%.
9. D. Contrast media are eliminated via the kidneys, so contrast-induced nephropathy is a
concern. Adequate hydration, careful monitoring of urine output, and the use of low-osmolarity
contrast media help reduce the risk of contrast-induced nephropathy. The overall incidence of
272 / 494
adverse drug reactions with nonionic contrast media is reported to be 3.13%, and the incidence
of severe reactions is 0.04%. Patients receiving contrast agents usually diurese large volumes
of urine because of the osmotic load of the dye. Adequate hydration of these patients should be
ensured to prevent worsening of pre-existing hypovolemia or azotemia. For patients with a
history of reactions to dyes and for patients for whom a dye reaction is anticipated, it is
beneficial to treat prophylactically with diphenhydramine, steroids, or both. (See page 864:
Radiology and Radiation Therapy.)
10. Which of the following statements regarding cardioversion is/are TRUE&quest;

1. Invasive monitoring is rarely required.
2. Etomidate provides a more stable electrocardiogram tracing than thiopental.
3. In general, patients do not require intubation.
4. Propofol produces less hypotension than etomidate.
10. B. Cardioversion is a brief but distressing procedure that is usually performed after a small
bolus of intravenous induction agent. Invasive monitoring is rarely required. Propofol produces
more hypotension than etomidate. Etomidate causes a high incidence of myoclonus that can
render interpretation of the electrocardiogram difficult. In general, patients do not require
intubation for cardioversion unless there is a risk of aspiration. (See page 870: Cardioversion.)
273 / 494
Review of Clinical Anesthesia, 5e [Vishal] 35. Anesthesia for the Older Patient
Chapter 35
Anesthesia for the Older Patient
1. All of the following are associated with aging EXCEPT:

A. Free radicals and non-enzymatic glycosylation of sugars and amines are responsible
for many age-related tissue changes.
B. The cardiovascular system and lung parenchyma become stiffer with age.
C. Mitochondrial DNA experiences more damage than nuclear DNA with aging.
D. After elastin is damaged and removed, it is usually replaced by collagen.
E. Many of the changes associated with aging are the result of damage to protein.
1. B. A variety of deleterious processes continually attack DNA, proteins, and lipids. The
primary culprits are free radicals and non-enzymatic glycosylation of sugars and amines.
Whereas free radicals are a byproduct of oxidative metabolism, glycosylation is enhanced by
elevated glucose levels. Many of the changes associated with aging are the result of damage
to protein. Collagen becomes stiffer from aromatic ring cleavage and by cross-linking to other
collagen molecules. After elastin is damaged and removed, it is usually replaced by the stiffer
collagen. In the cardiovascular system, arteries, veins, and the myocardium all stiffen with age.
In contrast, lung parenchyma becomes less stiff because of loss of elastin without collagen
substitution. DNA damage occurs as well, and curiously, mitochondrial DNA experiences more
damage than nuclear DNA. (See page 877: The Process of Aging.)
2. All of the following are associated with age-related changes in the kidney EXCEPT:
A. decreased ability to maintain sodium homeostasis
B. loss of up to 20% of glomeruli by age 80 years
C. decreased renal cortical mass
D. reduced renal excretion of drugs
E. decreased glomerular filtration rate (GFR)
2. B. Renal cortical mass decreases by 20% to 25% with age, but the most prominent effect of
aging is the loss of up to 50% of the glomeruli by age 80 years. The decrease in the GFR of
approximately 1 mL/min/yr after age 40 years typically reduces renal excretion of drugs to a
level at which drug dosage adjustment becomes a progressively important consideration
beginning at approximately age 60 years. Nevertheless, the degree of decline in GFR is highly
variable and is likely to be much less than predicted in many individuals, especially those who
avoid excessive dietary protein. Aged kidneys do not eliminate excess sodium or retain sodium
when necessary as effectively as kidneys of young adults. (See page 878: Changes in Body
Composition and Liver and Kidney Aging.)
3. Which statement regarding drug pharmacology and aging is CORRECT&quest;

A. Elderly patients typically manifest a decrease in volume of distribution at steady state.
B. Typically, the initial blood concentration of bolus drugs is lower in older patients.
C. The most prominent pharmacokinetic effect of aging is a decrease in drug
274 / 494
metabolism.
D. Medications dependent on hepatic metabolism undergo increased clearance.
E. Pharmacokinetics are affected by a decrease in body fat associated with aging.
3. C. The most prominent pharmacokinetic effect of aging is a decrease in drug metabolism
caused both by a decrease in clearance and an increase in the volume of distribution at steady-
state (Vdss). The increase in Vdss with age is likely attributable to the increase in body fat.
When drug metabolism is via the liver, decreased liver mass and blood flow decrease
clearance. (See page 879: Drug Pharmacology and Aging.)
4. Which of the following statements regarding aging and the cardiovascular system is
FALSE&quest;
A. Maintenance of an adequate central blood volume becomes more critical to
myocardial performance with age.
B. There is a downregulation of β -receptors on the heart.
C. The prevalence of atrial fibrillation increases with age.
D. Aging diminishes or eliminates any protective effect of ischemic preconditioning.
E. Most cases of congestive heart failure in very old individuals are attributable to
diastolic dysfunction.
4. B. Most cases of congestive heart failure in very old individuals are attributable to diastolic
dysfunction; this occurs in the absence of clinically significant systolic dysfunction. Ventricular
filling becomes more critical with age. The decreased response to β -receptor stimulation
requires the ventricles to depend more on adequate end-diastolic volume to generate enough
contractile strength via the length–tension (Frank-Starling) relationship. There does not appear
to be a downregulation of β -receptors on the heart but rather a defect in the intracellular
coupling. The diastolic dysfunction requires an increase in central blood volume and atrial
pressure to maintain that end-diastolic volume. Therefore, maintenance of an adequate central
blood volume becomes more critical to myocardial performance with age. (See page 882:
Cardiovascular Aging.)
5. Which statement regarding postoperative mental status changes in elderly patients

is FALSE&quest;
A. Postoperative delirium and postoperative cognitive decline are distinct clinical entities.
B. Emergence delirium does not qualify as postoperative delirium.
C. Low cognitive function, dementia, depression, and dehydration are risk factors for
postoperative delirium.
D. Regional anesthesia significantly reduces the incidence of postoperative delirium.
E. Hip surgery carries a relatively high risk of postoperative delirium.
5. D. Postoperative cognitive decline and postoperative delirium are receiving increased
attention as significant sources of debilitating morbidity. Although these two entities may yet
prove to be related to each other, at present they appear to be distinct clinical syndromes.
Postoperative delirium is an acute confusional state manifested by an acute onset (hours to
days) and vacillating levels of attention and cognitive skill. Disorientation, perceptual
275 / 494
disturbances (from misinterpretation of the situation to hallucinations), disorganized thinking,
and problems with memory may be manifested. Emergence delirium does not qualify as
postoperative delirium. The risk of postoperative delirium after major surgery in older patients is
approximately 10%; however, the risk varies with the surgical procedure. The highest risk is
associated hip surgery, with an approximate incidence of 35%. The cause of delirium is
multifactorial. Patient risk factors include age, baseline low cognitive function or dementia,
depression, and possibly general debility (including dehydration or visual or auditory
impairment). The choice of regional versus general anesthesia does not appear to be a factor
in postoperative delirium, especially if sedation is used in conjunction with the regional
technique. (See page 886: Perioperative Complications.)
6. Which of the following statements regarding age-related changes in body
composition is/are TRUE&quest;
1. The increase in body fat associated with aging is greater in women.
2. Aging is characterized by a gradual loss of skeletal muscle.
3. There is a reduction in total body water.
4. Aging causes a significant decrease in plasma albumin levels.
6. A. Changes in body composition are primarily characterized by a gradual loss of skeletal
muscle and an increase in body fat, although the latter is more prominent in women. Basal
metabolism declines with age, with most of the decline accounted for by the change in body
composition. A reduction in total body water reflects the reduction in cellular water that is
associated with a loss of muscle and an increase in adipose tissue. Aging causes a small
decrease in plasma albumin levels. (See page 878: Changes in Body Composition and Liver
and Kidney Aging.)
P.173
7. Which of the following statements regarding the hepatic system and aging is/are
FALSE&quest;
1. Liver mass decreases with age.
2. There is a minimal reduction in phase I drug metabolism.
3. Liver blood flow decreases with age.
4. Healthy elderly patients experience reduced liver reserve and markedly prolonged
drug metabolism.
7. C. Liver mass decreases with age and accounts for most, but not all, of the 20% to 40%
decrease in liver blood flow. There is also a modest reduction in phase I drug metabolism and
bile secretion with age. Even in very old individuals, liver reserve should be more than
adequate in the absence of disease other than for the effect of aging on drug metabolism. (See
page 878: Changes in Body Composition and Liver and Kidney Aging.)
8. Which of the following statements regarding central nervous system changes in

elderly patients is/are TRUE&quest;
1. Nearly 50% of patients older than age 85 years have significant cognitive impairment.
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2. Changes in the function of the neurotransmitter acetylcholine (Ach) is connected to
Alzheimer's disease.
3. An 80-year-old brain has typically lost 10% of its weight.
4. The aged brain is incapable of forming new dendritic connections.
8. A. Brain mass begins to decrease slowly beginning at approximately age 50 years and
declines more rapidly later such that an 80-year-old brain has typically lost 10% of its weight.
Neurotransmitter functions suffer more significantly, including levels of dopamine, serotonin, γ -
aminobutyric acid, and especially the Ach system. The latter is especially important because of
its connection to Alzheimer's disease. Response times increase, and learning is more difficult,
but vocabulary, “wisdom,” and past knowledge are better preserved. Nevertheless, of people
age 85 years and older, nearly half have significant cognitive impairment. In addition, some
degree of atherosclerosis appears to be inevitable. Fortunately, and contrary to prior belief, the
aged brain does make new neurons and is capable of forming new dendritic connections. (See
page 879: Central Nervous System Aging.)
9. Which of the following statements regarding the cardiovascular system and aging
is/are TRUE&quest;
1. There is decreased parasympathetic activity.
2. There is decreased response to β -receptor stimulation.
3. Stiffening of the veins occurs.
4. Sympathetic nervous system activity increases with age.
9. E. Nearly all components of the cardiovascular system are affected by the aging process.
The major changes include decreased response to β -receptor stimulation; stiffening of the
myocardium, arteries, and veins; changes in the autonomic nervous system with increased
sympathetic activity and decreased parasympathetic activity; conduction system changes; and
defective ischemic preconditioning. (See page 882: Cardiovascular Aging.)
10. Which of the following statements regarding the pulmonary system in geriatric
patients is/are TRUE&quest;
1. The chest wall becomes more compliant.
2. Closing capacity typically exceeds tidal volume by age 60 years.
3. The diaphragm becomes more dome shaped.
4. Lung elasticity decreases.
10. D. The most prominent effects of aging on the pulmonary system are stiffening of the chest
wall and a decrease in elasticity of the lung parenchyma. Chest wall stiffening increases the
work of breathing and produces a more barrel-shaped thorax that leads to flattening of the
diaphragm. Closing capacity typically exceeds functional residual capacity in the mid 60s and
eventually exceeds the tidal volume at some later age. (See page 883: Pulmonary Aging.)
11. Which of the following changes in the respiratory system is/are associated with
aging&quest;
1. Aging results in less effective coughing and impaired swallowing.
2. The majority of people older than age 65 years have sleep-disordered breathing.
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3. There is a decreased ventilatory response to hypercapnia.

4. Loss of muscle tone predisposes elderly individuals to upper airway obstruction.
11. E. Aging leads to an approximate 50% decrease in the ventilatory response to hypercapnia
and an even greater decrease in the response to hypoxia, especially at night. Generalized loss
of muscle tone with age applies to the hypopharyngeal and genioglossal muscles and
predisposes elderly individuals to upper airway obstruction. A high percentage of people older
than age 65 years have sleep-disordered breathing. Aging also results in less effective
coughing and impaired swallowing. (See page 883: Pulmonary Aging.)
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Review of Clinical Anesthesia, 5e [Vishal] 36. Anesthesia for Trauma & Burn Patients
Chapter 36
Anesthesia for Trauma and Burn Patients
1. Which of the following statements regarding airway management in trauma patients

is FALSE&quest;
A. Blind passage of a nasopharyngeal airway should be avoided if a basilar skull
fracture is suspected.
B. A cuffed supraglottic airway provides protection against pulmonary aspiration of
gastric contents.
C. Cricothyrotomy is contraindicated in patients younger than 12 years of age and in
patients suspected of having laryngeal trauma.
D. The esophageal–tracheal Combitube has been associated with esophageal
lacerations.
1. B. The cuffed oropharyngeal airways and laryngeal mask airway provide for an adequate
airway but do not protect against gastric aspiration. Blind passage of a nasopharyngeal airway
in a patient with a basilar skull fracture may result in entry into the anterior cranial fossa and is
therefore contraindicated with this injury. Cricothyrotomy is contraindicated in patients younger
than 12 years old and in patients suspected of having laryngeal trauma. Permanent laryngeal
damage may occur in young patients, and uncorrectable airway obstruction may occur in
patients with laryngeal trauma. The esophageal–tracheal Combitube is an acceptable airway
alternative. It is not, however, without complications, such as esophageal laceration and its
sequelae, including pneumothorax, pneumomediastinum, and subcutaneous emphysema. A
cuffed supraglottic airway does not consistently provide protection against the pulmonary
aspiration of gastric contents in trauma patients. (See page 890: Airway Evaluation and
Intervention.)
2. For trauma patients with head or neck injuries, which of the following statements is
FALSE&quest;
A. The intubating laryngeal mask airway (iLMA) is safe and appropriate for use in
patients with unstable cervical spine injuries.
B. An LMA may protect against aspiration in patients with maxillofacial injuries.
C. Cricoid pressure with rapid sequence induction reduces the likelihood of pulmonary
aspiration of gastric contents.
D. Serious airway compromise may develop within a few hours in up to 50% of patients
with major penetrating facial injuries.
E. The presence of cartilaginous fractures or mucosal abnormalities of the airway
necessitates performing an awake intubation.
2. A. An important disadvantage of the iLMA is that its metal part may exert considerable
pressure against the cervical vertebrae, potentially exacerbating an unstable injury in this
region. The intubating laryngeal mask was developed specifically for blind intubation and can
accommodate an 8-mm tube rather than the 6-mm tube via conventional LMAs. In patients with
maxillofacial injuries, aspiration of pharyngeal blood or secretions is more likely than aspiration
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of gastric contents. If it can be inserted in these circumstances, an LMA may protect the lungs.
A full stomach is a background condition in acute trauma; the urgency of securing the airway
often does not permit adequate time for pharmacologic measures to reduce gastric volume and
acidity. Thus, rather than relying on these agents, emphasis should be placed on selection of a
safe technique for securing the airway when necessary, including rapid sequence induction with
cricoid pressure for patients without serious airway problems and awake intubation with
sedation and topical anesthesia, if possible, for patients with anticipated serious airway
difficulties. Serious airway compromise may develop within a few hours in up to 50% of patients
with major penetrating facial injuries or multiple trauma as a result of progressive inflammation
or edema resulting from liberal administration of fluids. The presence of cartilaginous fractures
or mucosal abnormalities necessitates awake intubation with a fiberoptic bronchoscope or
awake tracheostomy. (See page 891: Full Stomach; and Head, Open Eye, and Contained Major
Vessel Injuries; page 892: Cervical Spine Injury; and page 893: Cervical Airway Injuries.)
3. Considerations in the management of patients with tension pneumothorax or flail

chest injury should include all of the following EXCEPT:
A. Immediate treatment for tension pneumothorax should be done with the insertion of a
14-gauge angiocatheter via the second intercostal space on the midclavicular line.
B. A flail chest injury results in impaired respiratory mechanics, so intubation and
mechanical ventilation are the primary treatments of choice.
C. Classic symptoms of tension pneumothorax include cyanosis, tachypnea,
hypotension, and neck vein distention.
D. Contusion of the underlying lung with increased elastic recoil and work of breathing is
the main cause of respiratory insufficiency in flail chest.
3. B. Evidence suggests that liberal use of mechanical ventilation in the presence of a flail
chest or pulmonary contusion increases the rate of pulmonary complications and mortality and
prolongs the hospital stay. A flail chest results from comminuted fractures of at least three
adjacent ribs or rib fractures with associated costochondral separation or sternal fracture.
Without significant gas exchange abnormalities, chest wall instability alone is not an indication
for ventilatory support. Effective pain relief by itself can improve respiratory function and often
avoids the need for mechanical ventilation. Tension pneumothorax can be manifested by
cyanosis, tachypnea, hypoxia, and neck vein distention. The definitive treatment is chest tube
placement with suction (tube thoracostomy). The emergency treatment of tension
pneumothorax, however, may require insertion of a 14-gauge angiocatheter (needle
thoracostomy) via the second intercostal space at the midclavicular line on the affected side.
(See page 894: Management of Breathing Abnormalities and page 894: Thoracic Airway
injuries.)
4. Which of the following statements regarding manual in-line immobilization (MILI) of

the cervical spine is FALSE&quest;
A. Two operators in addition to the laryngoscopist are needed.
B. Cephalad traction should be used because it aligns the head in a neutral position.
C. MILI produces a higher incidence of inadequate visualization during direct
laryngoscopy.
D. Part of the cervical hard collar may be removed after MILI.
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4. B. Stabilization of the head, neck, and torso in the neutral position for airway management in
patients whose cervical spines are yet to be cleared is best accomplished by MILI. This is best
accomplished by having two operators in addition to the physician who is managing the airway.
The first operator stabilizes and aligns the head in the neutral position without applying
cephalad traction, and the second operator stabilizes both shoulders by holding them against
the table or stretcher. The anterior portion of the hard collar, which limits mouth opening, may
be removed after immobilization. In-line stabilization, however, decreases the visibility of the
larynx in a significant proportion of patients. The incidence of inadequate exposure of the larynx
increases from less than 3% in the general population to approximately 10% with immobilization
of the neck. Almost all airway maneuvers, including jaw thrust, chin lift, head tilt, and oral airway
placement, result in some degree of cervical spine movement. (See page 892: Initial Evaluation:
Airway Management.)
5. Which of the following statements regarding resuscitation in trauma is TRUE&quest;

A. Tamponade is the most common cause of shock in patients with chest trauma.
B. Resuscitation with 2000 mL of isotonic fluids administered over 15 minutes should
normalize vital signs in patients with 20% to 40% loss of blood volume.
C. The base deficit, blood lactate level, and probably sublingual PCO2 (SLPCO2) are
the most useful and practical markers of organ perfusion that can be used to set the
goals of resuscitation in trauma patients.
P.176
D. Intraosseous cannulation has many severe side effects and should not be used in
children younger than 5 years old.
5. C. Hemorrhage is the most common cause of traumatic hypotension and shock. Other
sources include abnormal pump function, pericardial tamponade, pre-existing cardiac disease,
pneumothorax or hemothorax, and spinal cord injury. Response to fluids aids in the assessment
of hypovolemia. Administration of 2 L of lactated Ringer's solution over 15 minutes in adults
should normalize the vital signs if hemorrhage is mild (10% to 20% blood volume), transiently
improve moderate hemorrhage (20% to 40% blood volume), and have no response in patients
with severe hemorrhage (>40% blood volume). Some of the proven markers of organ perfusion
can be used during early management to set the goals of resuscitation. Of these, the base
deficit, blood lactate level, and probably SLPCO2 are the most useful and practical tools during
all phases of shock. Intraosseous cannulation is an acceptable form of vascular access in
children younger than 5 years and has a low incidence of complications. (See page 895:
Management of Shock.)
6. Which one of the following statements regarding the management of patients with
head injuries is FALSE&quest;
A. After the initial traumatic event, a leading cause of morbidity is the progression of
secondary injury resulting from tissue hypoxia.
B. A maximally dilated and unresponsive pupil suggests uncal herniation under the falx
cerebri.
C. The most important therapeutic maneuvers are aimed at maintaining cerebral
perfusion pressure and O2 delivery.
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D. A reduction in intracranial pressure with pentobarbital is an effective means of
cerebral protection and should be instituted in all instances of head injury.
E. The Glasgow Coma Scale (GCS) is a valuable tool in the evaluation of head-injured
patients.
6. D. Of all the possible secondary insults to the injured brain, decreased oxygen delivery as a
result of hypotension and hypoxia has the greatest detrimental impact. Therefore, rapid
diagnosis and treatment of head injury are paramount. Every effort should be made to support
the blood pressure with fluids and vasopressors (preferably phenylephrine, which does not
constrict the cerebral vessels) and ensure adequate oxygenation before the unconscious
patient is evaluated. The GCS is a valuable tool in the evaluation of head-injured patients and
provides a standard means of evaluating the patient's neurologic status. Physical signs of brain
injury include motor dysfunction, which, in turn, includes ocular motor abnormalities such as
unresponsive pupils. Management of head-injured patients should be aimed at maintaining
cerebral perfusion and O2 delivery. Decreasing intracranial pressure is a major step in this
process. High-dose barbiturates (e.g., pentobarbital), however, are of no routine value and are
used only for refractory intracranial pressure elevation. A maximally dilated and unresponsive
pupil suggests uncal herniation under the falx cerebri and compression of the oculomotor nerve
by the medial portion of the temporal lobe (uncus). (See page 898: Early Management of
Specific Injuries: Head Injury.)
7. Which of the following statements regarding abdominal injuries is FALSE&quest;

A. Traumatic herniation after diaphragmatic injury is more common on the left side than
on the right side.
B. A focused assessment with sonography for trauma (FAST) scan requires one third of
the time the conventional approach requires.
C. Laparoscopy is an excellent screening tool in patients with abdominal trauma.
D. Significant intra-abdominal bleeding is typically accompanied by considerable
changes in abdominal girth.
7. D. Laparoscopy is an excellent screening tool in abdominal trauma patients. An analysis
showed that it avoided laparotomy in 63% of patients and missed only 1% of injuries. It is also
possible to repair diaphragmatic, bladder, and solid organ injuries with this technique. FAST
requires one third of the time as the conventional approach. FAST is operator dependent, has
good specificity but moderate sensitivity, can diagnose injuries associated with intraperitoneal
fluid but not those without it, and cannot determine the severity of organ injury. The liver
protects the right side of the diaphragm, so traumatic herniation is more common on the left
side. Absence of abdominal distention does not rule out intra-abdominal bleeding; at least L of
blood can accumulate before the smallest change in girth is apparent, and the diaphragm can
also move cephalad, allowing further significant blood loss without any change in abdominal
circumference. (See page 907: Diaphragmatic Injury and Abdominal and Pelvic Injuries.)
8. Of the following methods of intraoperative monitoring for trauma patients, which

single monitor is the most necessary before surgery&quest;
A. Right radial intra-arterial catheter (A-line)
B. Esophageal temperature monitoring
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C. Central venous pressure (CVP) monitoring
D. Transesophageal echocardiography (TEE)
8. A. Intra-arterial blood pressure monitoring allows beat-to-beat data acquisition and sampling
for blood gases. A relatively stable patient may rapidly decompensate when the abdomen or
chest is open. Thus, arterial blood pressure monitoring is valuable for therapeutic decisions.
The radial artery is the vessel of choice in abdominal and chest trauma in which the aorta may
be cross-clamped, making a femoral or dorsalis pedis cannula nonfunctional. The right radial
artery is preferred in cases of chest trauma in which cross-clamping of the descending aorta
may result in occlusion of the left subclavian artery. CVP monitoring is often unnecessary in
young, healthy patients, but this approach can guide fluid replacement in elderly patients and
when myocardial damage is likely. Delaying emergent surgery to place a central venous line is
rarely indicated unless a large-bore catheter is needed for volume resuscitation. CVP
measurements are subject to error in the presence of decreased ventricular compliance or
pulmonary contusion, and systolic pressure variation and stroke volume estimates based on the
arterial pressure tracing appear to correlate best with intravascular volume status.
Normothermia is critical in trauma patients, but devices for temperature monitoring should not
delay the start of surgery. TEE provides valuable diagnostic information, including right and left
ventricular volumes, ejection fraction, and the presence of tamponade and wall motion
abnormalities. Visualization of fat and air entry into the right side of the heart and monitoring
ventricular volume are added benefits. Despite this, TEE probe insertion before surgery is
typically not critical. (See page 911: Monitoring.)
9. Which statement regarding resuscitation during trauma is FALSE&quest;

A. Patients with burns of greater than 30% of the total body surface area develop
resistance to most nondepolarizing muscle relaxants.
B. The current recommendation for administration of hydroxyethyl starch (“hespan”)
should not exceed 20 mL/kg over 24 hours.
C. Patients with hemorrhagic shock often exhibit bradycardia and respond readily to
catecholamine infusions.
D. Hypothermia leads to impaired O2 release from red blood cells because of a leftward
shift of the O2 dissociation curve.
E. Hypothermia, acidosis, and coagulopathy can form a “lethal triad” in patients with
hemorrhagic shock.
9. C. Confusion may arise concerning whether a patient is experiencing hemorrhagic shock or
neurogenic shock. Indeed, a trauma patient may experience both types of shock
simultaneously. However, the hallmark of neurogenic shock is that patients exhibit bradycardia
and readily respond to fluids and catecholamine infusions. Flaccid areflexia, loss of rectal
sphincter tone, paradoxical respiration, and bradycardia in a hypovolemic patient suggest the
diagnosis. Hemorrhagic shock usually manifests with tachycardia and hypotension. Burns of
greater than 30% of the total body surface area lead to resistance to all nondepolarizing muscle
relaxants, with the possible exception of mivacurium, beginning at 1 week and peaking around
5 to 6 weeks after injury. Current dosing recommendations for hydroxyethyl starch are to give
no more than 20 mL/kg over 24 hours. This is because of potential coagulation abnormalities
resulting from reduced platelet function, reduced fibrinogen levels, reduced factor VIII, and
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reduced von Willebrand factor. Patients with hypothermia have a left shift of the O2 dissociation
curve, which impairs tissue oxygenation. One of the principal goals during early management of
hemorrhaging trauma victims is to avoid the development of the so-called “vicious cycle” or
“lethal triad,” of acidosis, hypothermia, and coagulopathy. Both acidosis and hypothermia are
major factors in the induction of coagulopathy. (See page 915: Anesthetic and Adjunct Drugs:
Burns and page 918: Management of Intraoperative Complications: Persistent Hypotension,
Hypothermia, and Coagulation Abnormalities.)
10. The Brain Trauma Foundation and the American Association of Neurological
Surgeons recommend the maintenance of all of the following therapeutic interventions
EXCEPT:
A. PaO2 greater than 95 mm Hg.
B. Mean arterial pressure (MAP) greater than 80 mm Hg.
C. Cerebral perfusion pressure (CPP) between 50 and 70 mm Hg.
D. Head-of-bed elevation greater than 30 degrees.
E. PaCO2 between 25 and 30 mm Hg.
10. E. The Brain Trauma Foundation and the American Association of Neurological Surgeons
have published evidence-based guidelines for the treatment of head-injured patients. The most
important therapeutic maneuvers in these patients are aimed at normalizing intracranial
pressure (ICP), CPP, and oxygen delivery. Primary therapy includes normalization of the
systemic blood pressure (mean blood pressure >80 mm Hg) and maintaining the PaO2 above
95, the ICP below 20 to 25 mm Hg, and the CPP at 50 to 70 mm Hg. Maintaining the CPP
above 70 mm Hg (the former standard) is no longer advised because it may be associated with
an increased incidence of adult respiratory distress syndrome. The patient is kept at 30
degrees of head elevation, sedation and paralysis are given as necessary, and cerebrospinal
fluid is drained through a ventriculostomy catheter, if available. Until about 1995,
hyperventilation to a PaCO2 of 25 to 30 mm Hg was a mainstay of therapy of patients with
head injury. However, brain ischemia, which is probably the most threatening consequence of
head injury, is likely to occur during the first 6 hours after trauma even when the CPP is
maintained above the generally recommended 50 to 70 mm Hg. This hypoperfusion seems to
be caused largely by increased cerebral vascular resistance, which may be enhanced by
hyperventilation. However, some degree of hyperventilation may be necessary for short periods
in patients who have severe injuries and elevated ICP that does not respond to normal
ventilation and diuretics, although this should not be used during the first 24 hours after injury.
(See page 898: Head Injury.)
11. Which statement(s) regarding neck and chest injuries is/are TRUE&quest;
1. Signs of airway injury include respiratory distress, subcutaneous crepitus, and
laryngeal tenderness.
2. First rib fractures are an indication of severe underlying trauma.
3. The most definitive test for pneumothorax in supine patients is computed tomography
(CT).
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4. After placement of a thoracostomy tube, drainage of 1000 mL of blood and collection

of more than 200 mL/hr are indications for thoracotomy.
11. E. Respiratory distress, cyanosis, and stridor are obvious signs of airway injury. Other signs
that strongly suggest airway injury are dysphonia, hoarseness, cough, hemoptysis, air bubbling
from the wound, subcutaneous crepitus, laryngeal tenderness, pneumothorax, and hemothorax.
First rib fractures, because of the high amount of injury required for fracture, indicate severe
underlying trauma, particularly to the aorta, subclavian vessels, heart, brain, or spinal cord.
Likewise, scapula fractures suggest severe thoracic injury, particularly cardiac and lung injuries.
Paradoxically, sternal fractures are usually not associated with serious trauma to the thoracic or
abdominal viscera. Upright plain radiographs provide the best opportunity for detection of
pleural air. This position, however, may be impossible or contraindicated in some trauma
patients. Although chest radiography and an ultrasonography may complement each other, CT
is the most definitive radiologic test for detecting pneumothorax. Initial drainage of 1000 mL of
blood, or collection of above 200 mL/hr for several hours after thoracostomy, is an indication for
thoracotomy. Additional indications are a “white lung” appearance on the anteroposterior chest
radiograph, a continuous major air leak from the chest tube, and evidence of pericardial
tamponade. (See page 903: Neck Injury, Chest Wall Injury, and Pleural Injury.)
12. Which of the following statements regarding pelvic and extremity injuries is/are
TRUE&quest;
1. After pelvic fracture, retroperitoneal hematomas may lead to respiratory difficulty
because of pressure on the diaphragm.
2. Angiographic embolization is indicated to treat arterial bleeding after pelvic fracture.
3. Open fractures of the extremities should be repaired within 6 hours to reduce the
likelihood of sepsis.
4. Immediate surgery is indicated for extremity compartment syndrome when
intracompartmental pressure exceeds 15 cm H2O.
12. A. Pelvic fractures may often result in significant bleeding, but the bleeding tends to be
venous in nature and often tamponades itself. Arterial bleeding, in turn, may lead to large
retroperitoneal hematomas and thus respiratory difficulty. Thus, angiography and embolization
are indicated for treatment of arterial bleeding. Delayed fracture repair is associated with an
increased risk of sepsis, pneumonia, deep venous thrombosis, and cerebral complications of fat
embolism. Therefore, fixation should occur as soon as possible. In particular, open fractures
should be repaired within 6 hours to reduce the risk of sepsis. Compartment syndrome, which is
characterized by severe pain in the affected extremity, should be recognized early so
emergency fasciotomy can be effective in preventing irreversible muscle and nerve damage.
The definitive diagnosis is made by measuring compartment pressures. Pressures exceeding
40 cm H2O are an indication for immediate surgery. (See page 908: Fractures of the Pelvis and
Extremity Injuries.)
13. Which statement(s) regarding burns is/are TRUE&quest;

1. Fourth-degree burns involve muscle, fascia, and bone and thus necessitate complete
excision, leaving the patient with limited function.
2. Full-thickness burns involving more than 10% of the total body surface area are
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considered major burns.
P.177
3. Sources of airway compromise after burns include upper airway edema from fluid
resuscitation and copious, thick secretions.
4. Because swelling of the airway after thermal injury is only minimal in children,
intubation is often not necessary in pediatric patients.
13. A. The pediatric airway can be greatly compromised by even minimal amounts of swelling
because of its small diameter. Prophylactic intubation may often be required in children who are
suspected of having an inhalational injury even though they are not yet in respiratory distress.
Burns are classified as first, second, third, and fourth degree. First- and second-degree burns
are partial thickness, and third- and fourth-degree burns are full thickness. Fourth-degree burns
are the most severe and leave the patient with the highest likelihood of decreased function.
Major burns include the following: (1) full-thickness burns of more than 10% of the total body
surface area; (2) partial-thickness burns of more than 25% of the total body surface area in
adults and more than 20% of the total body surface area at extremes of age; (3) burns involving
the face, hands, feet, or perineum; (4) inhalational, chemical, or electrical burns; and (5) burns
in patients with severe pre-existing medical conditions. In the upper airway, glottic and
periglottic edema as well as copious, thick secretions may produce respiratory obstruction; this
may be aggravated by fluid resuscitation even in the absence of significant inhalation injury.
(See page 908: Burns and Airway Complications.)
14. Which statement(s) regarding carbon monoxide and cyanide poisoning is/are
TRUE&quest;
1. Methylene blue is the main treatment for cyanide toxicity.
2. The classic cherry red color of the blood occurs only at carboxyhemoglobin (HbCO)
concentrations above 40%.
3. Patients with an HbCO level of above 10% at admission are recommended for
hyperbaric O2 therapy.
4. Immediate O2 administration and removal from the toxic environment often obviate the
need for specific treatment of cyanide toxicity resulting from smoke inhalation.
14. C. Carbon monoxide interferes with mitochondrial function and produces tissue hypoxia by
shifting the hemoglobin dissociation curve to the left. The ultimate effect is impaired release of
O2 to tissues. This effect can be offset by high concentrations of inspired O2. The classic
cherry red color of blood occurs at an HbCO concentration of above 40%, but this may be
obscured by coexistent hypoxia and cyanosis. Therefore, HbCO concentration by co-oximetry is
the most sensitive indicator of carbon monoxide toxicity. The most effective treatment to date for
carbon monoxide toxicity is hyperbaric O2 therapy. An HbCO level of 30% or more is an
indication for this therapy. Cyanide toxicity may also accompany smoke inhalation in victims of
fires within a closed space. Specific treatments for cyanide toxicity include amyl nitrate, sodium
nitrite, and thiosulfate. The half-life of cyanide, however, is short (∼1 hour), so removal from the
toxic environment and treatment with O2 are often all that are necessary to reduce cyanide
levels. (See page 909: Carbon Monoxide Toxicity and Cyanide Toxicity.)
15. Which statement(s) regarding the management of burn injuries is/are TRUE&quest;
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1. Fluid flux in burn patients is enhanced by increased intravascular hydrostatic and
interstitial osmotic pressures and decreased interstitial hydrostatic pressure.
2. Colloid solutions are preferred for resuscitation during the first day after a burn injury.
3. Fluid resuscitation is essential in the early care of burned patients with injuries of
more than 15% of the total body surface area; smaller burns can be managed with
replacement at 150% of the calculated maintenance rate.
4. The hematocrit in burn patients should be kept above 30%.
15. B. Fluid flux in burn patients is enhanced by increased intravascular hydrostatic and
interstitial osmotic pressures and decreased interstitial hydrostatic pressure. Intravascular
volume may be restored with either crystalloid or colloid solutions. Crystalloid solutions are
preferred for resuscitation during the first day after a burn injury; leakage of colloids during this
phase may increase edema. Fluid resuscitation is essential in the early care of burned patients
with injuries of more than 15% of the total body surface area; smaller burns can be managed
with replacement at 150% of the calculated maintenance rate and careful monitoring of fluid
status. Patients often tolerate a decreased hematocrit after a burn injury. Transfusion is usually
not initiated until the hematocrit is below 15% to 20% in healthy patients, approximately 25% in
healthy patients who need extensive procedures, and 30% or more in patients with a history of
pre-existing cardiac disease. (See page 910: Fluid Replacement.)
16. Which statement(s) regarding markers for adequate resuscitation is/are

TRUE&quest;
1. Sublingual PCO2 is an acceptable marker of organ perfusion.
2. An O2 delivery index of 500 mL/m2/min is an acceptable goal for optimal shock

resuscitation.
3. An arterial–end-tidal–arterial CO2 difference above 10 mm Hg predicts mortality after
resuscitation in trauma patients.
4. Unrecognized hypoperfusion may allow the passage of luminal micro-organisms
across the intestinal wall and may lead to sepsis and multiple organ failure.
16. E. O2 transport variables, base deficit, blood lactate levels, gastric intramucosal pH, and
sublingual PCO2 are considered acceptable markers of organ hypoperfusion in apparently
resuscitated patients and may be used to set the optimal endpoints of resuscitation. An O2
delivery index of 500 mL/m2/min has been shown to be an acceptable goal for optimal shock
resuscitation. A parameter that has been recently used intraoperatively as a guide to
resuscitation during emergency surgery for trauma patients is the end-tidal–arterial CO2
difference (Pa-ET)CO2. Values above 10 mm Hg after resuscitation predict mortality. It may also
be useful in the decision about when to perform damage control surgery and intraoperatively in
guiding resuscitation with fluids, inotropes, and vasopressors. Unrecognized hypoperfusion may
lead to splanchnic ischemia with resulting acidosis in the intestinal wall, permitting the passage
of luminal micro-organisms into the circulation and release of inflammatory mediators and
causing sepsis and multiple organ failure. (See page 914: Organ Perfusion and Oxygen
Utilization.)
17. Which statement(s) regarding early postoperative complications in trauma patients
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is/are FALSE&quest;
1. The wake-up time after a midazolam infusion for postoperative sedation can be up to
six times longer than the wake-up time after a propofol infusion.
2. A urine output below 0.5 mL/kg is the most sensitive indicator of acute renal failure.
3. Intra-abdominal pressures above 20 to 25 mm Hg indicate the need for immediate
abdominal decompression.
4. In trauma patients, deep venous thrombosis (DVT) usually occurs more than 1 week
after the injury.
17. C. Postoperative sedation with midazolam for mechanically ventilated patients can result in
mean wake-up times of 660 ± 440 minutes; the wake-up time for a similar group of patients
sedated with propofol was 110 ± 50 minutes. Although both drugs are safe and effective,
propofol clearly results in a faster wake-up time and earlier ability to extensively examine a
patient's neurologic status. Urine output is a relatively insensitive test for diagnosing acute renal
failure. More objective data are obtained by calculating free-water clearance or creatinine
clearance. A creatinine clearance below 25 mL/min or free-water clearance above 15 mL/hr
suggests the likelihood of acute renal failure. Abdominal compartment syndrome results from
increased intra-abdominal pressure and associated decreased organ perfusion pressure,
leading to multiple organ failure and death. A normal intra-abdominal pressure is 3 to 10 mm Hg;
values above 20 to 25 mm Hg indicate the need for immediate decompression. Clinically, a
tense, distended abdomen should direct the clinician to measure the intravesical pressure via a
Foley catheter, which reflects the intra-abdominal pressure. Trauma patients are at extreme risk
for DVT. The overall incidence of DVT is approximately 18% in trauma patients. Almost 50% of
all cases of pulmonary embolus occur within the first week, suggesting that DVT develops
shortly after trauma. (See page 922: Early Postoperative Considerations: Sedation and
Analgesia, Acute Renal Failure, Abdominal Compartment Syndrome, and Thromboembolism.)
18. Airway management in the presence of potential cervical spine injury should
include which of the following consideration(s)&quest;
1. Associated head injury
2. Manual in-line stabilization of the neck
3. “Clearance” of the cervical spine at the earliest possible time
4. Radiographic studies in comatose patients
18. E. Approximately 2% to 10% of head trauma victims have cervical spine injuries, and 25% to
50% of patients with cervical spine injuries have an associated head injury. In conscious
patients, neck pain, tenderness, and extremity paresthesias are strong indicators of spine
injury. It is a priori necessary to protect the neck during airway maneuvers in any patient with a
possibly unstable cervical spine. Clearance of the neck should be performed at the earliest
possible time, not necessarily to facilitate airway management but to minimize the risk of
pressure ulceration by the collar. In awake patients with suggestive findings by the NEXUS or
Canadian criteria and those who are in a coma or obtunded, the diagnosis of cervical spine
injury necessitates the use of radiographic studies in addition to the clinical examination.
Stabilization of the head, neck, and torso in neutral position for airway management in patients
whose cervical spines are yet to be cleared is best accomplished by manual in-line
immobilization. (See page 892: Cervical Spine Injury.)
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19. In patients with pulmonary contusions, which of the following statement(s) is/are
TRUE&quest;
1. Low tidal volumes, positive end-expiratory pressure (PEEP), and low plateau
pressures decrease the likelihood of acute respiratory distress syndrome (ARDS)
–related lung injury.
2. Airway pressure release ventilation (APRV) may provide improved V/Q matching.
3. Double-lumen tubes may be used to provide differential lung ventilation.
4. High-frequency jet ventilation (HFJV) may enhance oxygenation in life-threatening
hypoxemia.
19. E. In patients with pulmonary contusion, respiratory insufficiency or failure despite adequate
analgesia, clinical evidence of severe shock, associated severe head injury or injury requiring
surgery, airway obstruction, and significant pre-existing chronic pulmonary disease are
indications for tracheal intubation and mechanical ventilation. PEEP with low tidal volumes (6–8
mL/kg) and low inspiratory alveolar or plateau pressures should be used to decrease the
likelihood of ARDS if ventilation is controlled. In intubated, spontaneously breathing patients,
airway pressure release ventilation, in which spontaneous breathing is superimposed on
mechanical ventilation by intermittent sudden, brief decrease of continuous positive airway
pressure, provides improved V/Q matching and systemic blood pressure, lower sedation
requirements, greater O2 delivery, and shorter periods of intubation. Patients with severe,
unilateral pulmonary contusion unresponsive to these measures may be treated by differential
lung ventilation via a double-lumen endobronchial tube. In bilateral severe contusions with life-
threatening hypoxemia, HFJV may enhance oxygenation and cardiac function, which may be
compromised by concomitant myocardial contusion or ischemia. (See page 894: Thoracic
Airway Injuries: Management of Breathing Abnormalities.)
20. During the initial management of shock in trauma patients:

1. normal heart rate and blood pressure indicate adequate tissue perfusion
2. an elevated base deficit may reflect oxygen debt
3. blood lactate levels decline promptly with adequate resuscitation
4. maximal fluid therapy may be delayed until surgical control of bleeding
20. C. Some of the proven markers of organ perfusion may be used during the early
management of patients with shock to set the goals of resuscitation. Of these, the base deficit
and blood lactate level are the most useful and practical tools during all phases of shock,
including the earliest. The base deficit reflects the severity of shock, the oxygen debt, changes
in O2 delivery, the adequacy of fluid resuscitation, and the likelihood of multiple organ failure
and survival with reasonable accuracy in previously healthy adult and pediatric trauma patients.
The normal plasma lactate concentration is 0.5 to 1.5 mmol/L; levels above 5 mmol/L indicate
significant lactic acidosis. The half-life of lactate is approximately 3 hours, so the level
decreases rather gradually after correction of the cause. Equating a normal heart rate and
systemic blood pressure with normovolemia during initial resuscitation may lead to loss of
valuable time for treating underlying occult hypovolemia or hypoperfusion. Bickell et al showed
that delaying fluid resuscitation until surgical control of bleeding in victims of penetrating trauma
improved survival to hospital discharge and decreased the length of hospital stay. Vigorous fluid
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therapy increases arterial and venous pressures, dilutes clotting factors and platelets, and
decreases blood viscosity, so it may reinitiate bleeding already stopped by a soft thrombus. In
contrast, slow infusion of isotonic or hypertonic crystalloids, preferably of packed red blood
cells, titrated to lower than normal systemic pressure had beneficial effects on animal survival
without tissue injury or organ failure. (See page 895: Management of Shock.)
21. Secondary brain injury (after initial traumatic brain injury) may occur as a result of:
1. hypotension
2. hypoxemia
3. anemia
4. hyperglycemia
21. E. Approximately 40% of deaths from trauma are caused by head injury, and even a
moderate brain injury may increase the mortality rate of patients with other injuries. In
nonsurvivors, progression of the damaged area beyond the directly injured region (i.e.,
secondary brain injury) can be demonstrated at autopsy. The primary objective of the early
management of patients with brain trauma is to prevent or alleviate the secondary injury
process that may follow any complication that decreases the oxygen supply to the brain,
including systemic hypotension, hypoxemia, anemia, increased intracranial pressure, acidosis,
and possibly hyperglycemia (serum glucose >200 mg dL-1). (See page 898: Management of
Injuries: Head Injury.)
22. Which statement(s) regarding hypothermia is/are TRUE&quest;

1. Hypothermia is an independent predictor of mortality after trauma.
2. The risk for hypothermia is higher during trauma surgery than for elective surgery.
3. Rapid rewarming may cause hypotension.
4. Convective surface warming effectively treats serious hypothermia.
22. A. Admission hypothermia, which is present in approximately 50% of trauma patients, is an
independent risk factor after major trauma, and the mortality rate increases with decreasing
temperature. The intraoperative risk of hypothermia is also higher for trauma victims than for
patients undergoing elective surgery. Heat loss increases, especially in patients with spinal
cord, extensive soft tissue, and burn injuries and in patients who consumed ethanol before
surgery or are undergoing body cavity surgery. Rewarming after hypothermia, especially at a
rapid rate, may release accumulated metabolic products into the central circulation, causing
further myocardial depression, hypotension, and increased acidosis. Convective warming with
forced dry air at 43°C may prevent a temperature decrease in most trauma victims but cannot
effectively treat severe hypothermia. Because the low specific heat of air has little heat content
to give to the cold trauma patient and often because of the nature of the surgical procedure,
only a limited body surface area is exposed to warming. (See page 918: Hypothermia.)
290 / 494
Review of Clinical Anesthesia, 5e [Vishal] 37. Epidural & Spinal Anesthesia
Chapter 37
Epidural and Spinal Anesthesia
1. All of the following statements regarding epidural anesthesia are true EXCEPT:
A. It can be used to provide postoperative analgesia.
B. It has been shown to decrease some postoperative complications.
C. It may improve surgical outcome.
D. It has become absolutely indicated as the standard of care for certain procedures.
E. It has been shown to reduce intraoperative blood loss.
1. D. There are no absolute indications for spinal or epidural anesthesia. Spinal and epidural
anesthesia have been shown to blunt the stress response to surgery, decrease intraoperative
blood loss, lower the incidence of postoperative thromboembolic events, and decrease
morbidity and mortality in high-risk surgical patients. Also, both spinal and epidural techniques
may be used to extend analgesia into the postoperative period and to provide analgesia to
nonsurgical patients. (See page 927: Introduction.)
2. All of the following statements are true EXCEPT:

A. The epidural space is bounded inferiorly by the intervertebral ligament.
B. The interspinous ligament attaches to the ligamentum flavum anteriorly.
C. The ligamentum nuchae continues inferiorly as the supraspinous ligament.
D. Elastin is the primary component of the ligamentum flavum.
E. The ligamentum flavum is thickest in the midline.
2. A. The epidural space is bounded inferiorly by the sacrococcygeal ligament covering the
sacral hiatus. The interspinous ligament attaches between the spinous processes and blends
anteriorly with the ligamentum flavum. Above T7, the supraspinous ligament continues as the
ligamentum nuchae. The ligamentum flavum is a tough, wedge-shaped ligament composed of
elastin. The ligamentum flavum is thickest in the midline, measuring 3 to 5 mm at the L2–L3
interspace in adults. (See page 929: Ligaments.)
3. The epidural space:

A. terminates cranially at C1
B. communicates with the intervertebral space by way of the paravertebral foramina
C. surrounds the vertebral canal
D. contains a rich network of veins posteriorly
E. becomes discontinuous upon injection of liquid
3. C. The epidural space is the space that lies between the spinal meninges and the sides of
the vertebral canal. It is bounded cranially by the foramina magnum. The epidural space is not a
closed space but communicates with the paravertebral space by way of the intervertebral
foramina. The epidural space is composed of a series of discontinuous compartments that
become continuous when the potential space separating the compartments is opened by
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injection of air or liquid. A rich network of valveless veins courses through the anterior and
lateral portions of the epidural space, with few, if any, veins present in the posterior epidural
space. (See page 929: Epidural Space.)
4. Which of the following statements regarding spinal needle insertion is TRUE&quest;

A. The first significant resistance encountered when advancing a needle using the
paramedian approach is the interspinous ligament.
B. If bone is repeatedly encountered at the same depth when the needle is advanced,
the needle is likely walking down the inferior spinous process.
C. The midline approach is preferred in patients with heavily calcified interspinous
ligaments.
D. Free flow of cerebrospinal fluid (CSF) after resolution of a paresthesia usually
indicates that the needle is in a good position.
E. Penetration of the dura mater is more easily detected with a beveled needle.
4. D. If a paresthesia occurs upon insertion of a spinal needle, the practitioner should
immediately stop advancing the needle, remove the stylet, and look for CSF at the needle hub.
Obtaining CSF after resolution of a paresthesia indicates that the needle encountered a cauda
equina nerve root in the subarachnoid space and the needle tip is in a good position. Of
course, one should not inject local anesthetic in the presence of a persistent paresthesia. The
first significant resistance encountered using the paramedian approach should be the
ligamentum flavum because the interspinous ligament is bypassed. If bone is repeatedly
encountered at the same depth when the needle is advanced, the needle is likely off the midline
and walking along the vertebral lamina. The paramedian approach to the epidural and
subarachnoid space is useful in situations in which the patient's anatomy does not favor the
midline approach (e.g., the inability to flex the spine or heavily calcified intraspinous ligaments).
Penetration of the dura mater produces a subtle “pop” that is most easily detected with pencil-
point needles. (See page 933: Midline Approach.)
5. The epidural test dose:

A. if negative, confirms that the catheter is in the epidural space
B. must be administered before giving a therapeutic dose
C. may be omitted if aspiration of the catheter is negative for blood or cerebrospinal fluid
(CSF)
D. should have an increased concentration of epinephrine if the patient is taking β -
adrenergic blockers
E. contains epinephrine, which, if given intravenously, typically produces an immediate
increase in heart rate within 10 seconds
5. B. Because of the risk of undetected intravenous or subarachnoid migration of the catheter,
additional test doses must be administered before a therapeutic dose is given through the
catheter. Aspiration of the catheter or needle to check for blood or CSF is helpful if positive, but
the incidence of false-negative aspirations is too high to rely on this technique alone. The most
common test dose is 3 mL of local anesthetic containing 5 μg/mL of epinephrine. Intravascular
injection of this dose of epinephrine typically produces an average heart rate increase of 30
292 / 494
bpm between 20 and 40 seconds after the injection. Heart rate increases may not be as evident
in some patients taking β -adrenergic blockers. In β -blocked patients, systolic blood pressure
increases of 20 mm Hg or more may be a more reliable indicator of intravascular injection. (See
page 936: Epidural Test Dose.)
6. Rank the following local anesthetics in order of increasing duration for spinal
anesthesia.
A. Procaine, mepivacaine, tetracaine
B. Lidocaine, mepivacaine, procaine
C. Lidocaine, procaine, mepivacaine
D. Procaine, bupivacaine, mepivacaine
E. Tetracaine, procaine, bupivacaine
6. A. The principal determinant of spinal block duration is the local anesthetic drug used.
Procaine is the shortest-acting local anesthetic for subarachnoid use. Lidocaine and
mepivacaine are agents of intermediate duration, and bupivacaine and tetracaine are the
longest-acting drugs currently available in the United States. (See page 940: Local Anesthetic.)
7. The duration of spinal anesthesia is most prolonged when 100 μg of clonidine is

added to which of the following local anesthetics&quest;
A. Mepivacaine
B. Lidocaine
C. Tetracaine
D. Procaine
E. Bupivacaine
7. C. Tetracaine is the local anesthetic that is most dramatically prolonged by addition of
adrenergic agonists. Clonidine prolongs tetracaine spinal block by 50% to 70%, with a larger
effect occurring at lumbar dermatomes. (See page 940: Adrenergic Agonists.)
P.184
8. Rank the following local anesthetics in order of increasing duration for epidural
anesthesia.
A. Ropivacaine, bupivacaine, mepivacaine
B. Etidocaine, mepivacaine, ropivacaine
C. Chloroprocaine, etidocaine, mepivacaine
D. Ropivacaine, chloroprocaine, mepivacaine
E. Chloroprocaine, mepivacaine, etidocaine
8. E. Chloroprocaine is the shortest-duration local anesthetic used for epidural anesthesia.
Lidocaine and mepivacaine provide blocks of intermediate duration, and bupivacaine,
ropivacaine, and etidocaine produce the longest-duration epidural blocks. (See page 940:
Duration.)
9. All of the following statements regarding complications associated with epidural and
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spinal anesthesia are true EXCEPT:
A. Use of fluid instead of air for loss of resistance during epidural anesthesia reduces
the risk of headache upon accidental meningeal puncture.
B. An epidural blood patch immediately relieves postdural puncture headache (PDPH)
symptoms in approximately 99% of patients.
C. Transient reduction in hearing acuity after spinal anesthesia is more common in
female than in male patients.
D. Back pain is more common after epidural anesthesia than after spinal anesthesia.
E. Neurologic injury occurs in about 0.03% to 0.1% of all central neuraxial blocks.
9. B. An epidural blood patch is effective in relieving symptoms within 1 to 24 hours in 85% to
95% of patients; approximately 90% of patients in whom an initial blood patch has failed do
respond to a second blood patch. The use of fluid instead of air for loss of resistance during
attempted epidural anesthesia does not alter the risk of accidental meningeal puncture, but it
does markedly decrease the risk that the patient will subsequently develop PDPH. Compared
with spinal anesthesia, back pain after epidural anesthesia is more common and lasts longer. It
has been demonstrated that a 1- to 3-day transient, mild decrease in hearing acuity is common
after spinal anesthesia, with an incidence of roughly 40% and a 3:1 female-to-male
predominance. Multiple large studies of spinal and epidural anesthesia report that neurologic
injury occurs in approximately 0.03% to 0.1% of all central neuraxial blocks, although the block
was not clearly proven to be causative in most of these series. (See page 947: Complications.)
10. All of the following statements regarding spinal or epidural anesthesia and spinal
hematoma are true EXCEPT:
A. Patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) and receiving mini-
dose heparin are not at increased risk.
B. Patients treated with enoxaparin are at increased risk.
C. Patients most commonly present with numbness or lower extremity weakness.
D. Spinal hematoma occurs at an estimated incidence of less than one in 150,000.
E. The removal of an epidural or an intrathecal catheter presents nearly as great a risk
for spinal hematoma as its insertion.
10. A. Drugs not considered putting patients at increased risk of neuraxial bleeding and spinal
hematoma formation when used alone may actually increase the risk when they are combined.
This may be the case when mini-dose unfractionated heparin and NSAIDs are used
concurrently. Patients receiving fractionated low-molecular-weight heparin (e.g., enoxaparin)
are considered to be at increased risk for spinal hematoma. Patients with spinal hematoma
most commonly present with numbness or lower extremity weakness. Spinal hematoma is a rare
but potentially devastating complication of spinal and epidural anesthesia, with an incidence
estimated to be less than one in 150,000. The removal of an epidural or intrathecal catheter
places the patient at nearly as great a risk of hematoma as catheter insertion. The timing of
removal and anticoagulation should be coordinated. (See page 950: Complications: Spinal
Hematoma.)
11. Structures traversed by a properly placed needle in the subarachnoid space via the
midline approach include all the following EXCEPT:
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A. interspinous ligament
B. dura mater
C. posterior longitudinal ligament
D. supraspinous ligament
E. ligamentum flavum
11. C. In the midline, the needle penetrates the skin, subcutaneous tissue, supraspinous
ligament (superficial to the spinous processes), interspinous ligament (between the spinous
processes), ligamentum flavum, epidural space, dura mater, and arachnoid membrane. The
anterior and posterior longitudinal ligaments are anterior to the subarachnoid space, attaching
to the anterior and posterior surfaces of the vertebral bodies. (See page 928: Anatomy:
Ligaments.)
12. A patient receives a spinal anesthetic with a sensory level of T5. Which of the
following is likely to occur&quest;
A. The small bowel will be dilated and relaxed.
B. Glomerular filtration will be decreased by one third.
C. Tidal volume will be reduced by one third.
D. The cardioaccelerator nerves will be unaffected.
E. Blood pressure will lower predominantly by decreasing venous return.
12. E. Spinal anesthesia to a level that affects the sympathetic nervous system (which
originates from the intermediolateral cell column between T1 and L2) causes peripheral
vasodilation (venodilation and arterial dilation). Blood pressure decreases as a result of
decreased venous return. The cardioaccelerator nerves arise from the T1–T4 dermatomes;
they are affected by spinal anesthesia to T5 because the level of sympathetic blockade can be
two to six dermatomal levels higher than the sensory block. Renal blood flow and glomerular
filtration rate tend to be maintained during spinal anesthesia unless the mean blood pressure
decreases markedly. Spinal anesthesia causes contraction of the intestines and increased
peristalsis because of unopposed vagal activity. High thoracic levels of spinal anesthesia have
virtually no effect on resting ventilatory mechanics, but they compromise active exhalation.
Intercostal paralysis interferes with the patient's ability to cough and clear secretions. (See page
945: Cardiovascular Physiology: Spinal Anesthesia.)
13. Which of the following has the lowest baricity&quest;

A. Lidocaine 5% in dextrose 7.5%
B. A mixture obtained by mixing equal volumes of tetracaine 1% and water
C. Bupivacaine 0.75% in dextrose 8.25%
D. A mixture obtained by mixing equal volumes of tetracaine 1% and dextrose 10%
E. Procaine 10%
13. B. Solutions of local anesthetic that have dextrose are hyperbaric. When an additive such
as dextrose is not added, then density, and hence baricity, depend on the concentration (g%) of
local anesthetic. Hence, 0.5% tetracaine has a lower baricity than 10% procaine. (See page
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936: Block Height.)
14. At 37°C, the average density of cerebrospinal fluid (CSF) is ________________ g/mL.
A. 1.3
B. 1.03
C. 1.003
D. 1.0003
E. 0.03
14. D. The average density of CSF is 1.0003 g/mL at 37°C. (See page 936: Block Height.)
15. Intravenous (IV) injection of a typical epidural test dose of an epinephrine-

containing solution causes an average increase in heart rate of ________________
bpm.
A. 0
B. 2
C. 6
D. 30
E. 60
15. D. The most common test dose is 3 mL of local anesthetic containing 5 μg/mL of
epinephrine (1:200,000). IV injection of this dose of epinephrine typically produces an average
heart rate increase of 30 bpm between 20 and 40 seconds after injection. Heart rate increases
may not be as evident in some patients taking beta-blockers; systolic blood pressure increases
of more than 20 mm Hg may be a more reliable indicator of intravascular injection in these
patients. (See page 936: Epidural Test Dose.)
16. Which of the following statements concerning the addition of epinephrine to a local
anesthetic solution during spinal anesthesia is TRUE&quest;
A. It is more effective at increasing the duration of lidocaine than tetracaine.
B. It is important for modulating the systemic blood level of local anesthetic.
C. It may inhibit antinociceptive afferents in the spinal cord.
D. It is typically administered in a concentration of 10 g/mL.
E. It is typically administered in a concentration of 1:200,000.
16. C. Epinephrine is frequently added to local anesthetic solutions to increase the duration of
spinal anesthesia. This effect is believed to result, at least in part, from vasoconstriction of
spinal cord and dural vessels. This leads to decreased vascular uptake of the local anesthetic.
The fact that it is more effective for tetracaine than for lidocaine or bupivacaine may be
attributed to the finding that of the three drugs, tetracaine causes the greatest (and bupivacaine
the least) vasoconstriction in spinal cord blood flow. Blood concentrations of local anesthetic
during spinal anesthesia are not clinically significant; hence, epinephrine is not important for
modulating the systemic levels of local anesthetic. Epinephrine and related agents may cause
inhibition of antinociceptive afferents, an effect that is mediated by stimulation of α 2 receptors
in the spinal cord. The dose of epinephrine during spinal anesthesia usually is 0.2 to 0.3 mg
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(0.2–0.3 mL of 1:1000 solution). Lesser concentrations are used during epidural anesthesia,
typically 1:200,000 (1 g/200,000 mL or 5 μg/mL). (See page 940: Adrenergic Agonists.)
17. Which of the following statements concerning the choice of local anesthetic
solution for epidural use is TRUE&quest;
A. Agents of high anesthetic potency and duration of action necessarily have slow
onsets.
B. Etidocaine is an excellent choice for obstetric use because of wide sensory/motor
discrimination.
C. Ropivacaine has a time course similar to that of lidocaine.
D. Prilocaine has less cardiovascular toxicity than bupivacaine and etidocaine.
E. The onset and duration of epidural anesthesia are most closely related to the volume
of local anesthetic used.
17. D. Bupivacaine and etidocaine are highly potent, long-duration local anesthetics. The onset
of bupivacaine epidural anesthesia is relatively slow (15–20 minutes); the onset of etidocaine is
more rapid. Bupivacaine has excellent sensory/motor discrimination; when used in obstetrics as
a 0.125% solution, it may provide good sensory analgesia with minimal motor block. Etidocaine
has relatively little sensory/motor discrimination and generally induces profound motor block.
Prilocaine has less cardiovascular and central nervous system toxicities than lidocaine or
bupivacaine, but it may cause methemoglobinemia when given in doses above 600 mg.
Ropivacaine has a time course similar to that of bupivacaine. Within limits, the onset and
duration of epidural blockade are more closely related to the mass of drug rather than to
variations in volume or concentration. (See page 940: Duration.)
P.185
18. The first function to be lost during the onset of spinal anesthesia is:
A. touch
B. motor power
C. temperature sensation
D. vibration
E. autonomic activity
18. E. The onset of block is fastest at sympathetic fibers. The level of sympathetic block may
extend two to six dermatomes higher than loss of pinprick sensation and four to eight
dermatomes higher than motor blockade. (See page 944: Differential Nerve Block.)
19. Which of the following statements concerning a decrease in blood pressure of 30%
during spinal anesthesia is TRUE&quest;
A. It is primarily the result of arteriolar dilation.
B. It should be treated with a modest head-up position to prevent further cephalad
spread of the local anesthetic.
C. It must be treated aggressively in all patients.
D. It may be treated effectively with a venoselective constrictor.
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E. It indicates that the patient was hypovolemic before induction of spinal anesthesia.
19. D. Hypotension during spinal anesthesia that is below that which blocks cardioaccelerator
fibers is primarily caused by venodilation leading to venous pooling and decreased cardiac
output as well as decreased systemic vascular resistance resulting from arterial dilation. The
amount of hypotension is related to the level of the sympathectomy. Although the cephalad
spread of a hyperbaric solution may be limited by placing the patient in a head-up position, this
should not be done to treat patients with existing hypotension because it will further decrease
venous return. A decrease in blood pressure of 20% to 30% is usually well tolerated, but
selected patients with cardiac, renal, or cerebrovascular disease may require treatment.
Potential treatments may include modest head-down position, vasoconstrictors, and fluid
administration. (See page 947: Complications of Spinal and Epidural Anesthesia.)
20. All of the following statements about postdural puncture headaches (PDPHs) are
true EXCEPT:
A. They are frequently unilateral.
B. They are improved by recumbency.
C. They are usually frontal or occipital.
D. They may be accompanied by tinnitus and photophobia.
E. They are usually self-limiting.
20. A. PDPHs are classically described as bilateral, in the occipital or frontal regions. They are
worsened by the upright position, improved in the supine position, and may be accompanied by
tinnitus or photophobia. Nearly all PDPHs resolve over time without invasive therapy; however,
an epidural blood patch may be indicated when the symptoms are severe. (See page 947:
Postdural Puncture Headache.)
21. Measures to decrease the incidence of postdural puncture headache (PDPH)

include all of the following EXCEPT:
A. use of a paramedian approach
B. use of small-gauge spinal needles
C. lowering the glucose concentration of the local anesthetic solution
D. maintaining the patient in the supine position for at least 12 hours after surgery
E. inserting the spinal needle bevel parallel to the dural fibers
21. D. The incidence of PDPH is increased in young patients, women, and pregnant patients.
The paramedian approach results in less CSF leakage and thus decreases the chance for
development of PDPH. Small-gauge and closed-tip needles are associated with a lower
incidence of PDPH. Interestingly, there appears to be a direct relationship between the glucose
concentration in the local anesthetic and the incidence of PDPH. Although bed rest is indicated
in the treatment of patients with PDPH, it does not decrease the likelihood of developing PDPH.
(See page 947: Postdural Puncture Headache.)
22. Which of the following statements concerning high spinal anesthesia is

TRUE&quest;
A. It is less common in parturients.
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B. It carries a high mortality rate.
C. If it occurs, phrenic nerve paralysis is relatively short-lived.
D. It is most likely to occur 30 minutes after the induction of spinal anesthesia.
E. Apnea is virtually always a consequence of either ventilatory muscle paralysis or
sedative medications.
22. C. Excessive spread of spinal anesthesia may occur in any patient, but parturients are most
susceptible. It is most likely to occur shortly after induction of spinal anesthesia, but block
height may be influenced for as long as 60 minutes after injection. When recognized early and
treated with pressor support and ventilation, high spinal anesthesia should be merely an
inconvenience, with no mortality. If phrenic nerve paralysis occurs, it usually is short-lived.
Respiratory arrest may occur as a result of respiratory muscle paralysis or dysfunction of
brainstem respiratory control centers. (See page 948: Total Spinal Anesthesia.)
23. Which of the following vertebrae has the most prominent spinous process&quest;
A. C5
B. C2
C. T1
D. T12
E. L5
23. C. The most prominent spinous process is T1. (See page 928: Anatomy: Vertebrae.)
1. The vertebral canal is formed by two laminae anteriorly.
2. The spinous process for C1 serves as a site for muscle and ligament attachments.
3. Six sacral vertebrae are fused together to form the sacrum.
4. The first cervical vertebra does not have a vertebral body.
24. D. With the exception of C1, the cervical, thoracic, and lumbar vertebrae consist of a body
anteriorly, two pedicles that project posteriorly from the body, and two laminae that connect the
pedicles. The first cervical vertebra differs from this typical structure in that it does not have a
body or a spinous process. The five sacral vertebrae are fused together to form the wedge-
shaped sacrum. (See page 928: Vertebrae.)
25. Which of the following statements regarding vertebral anatomy is/are TRUE&quest;
1. The sacral cornu are located on either side of the sacral hiatus.
2. The twelfth thoracic rib can be helpful in identifying the twelfth thoracic vertebrae.
3. A horizontal line at the level of the iliac crests corresponds to the L4–L5 interspace.
4. C5 is the most prominent spinous process encountered upon palpation of the
posterior neck.
25. A. The sacral cornu are bony prominences on either side of the sacral hiatus and aid in
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identifying it. The spine of C7 is the first prominent spinous process encountered while running
the hand down the back of the neck. The twelfth thoracic vertebrae can be identified by
palpating the twelfth rib and tracing it back to its attachment to T12. A line drawn between the
iliac crests crosses the body of L5 or the L4–L5 interspace. (See page 928: Vertebrae.)
26. Which of the following statements is/are FALSE&quest;

1. The subdural space lies between the arachnoid mater and the pia mater.
2. The dura mater fuses with the filum terminale at the level of the second sacral
vertebrae.
3. The plica medianis dorsalis is usually the structure responsible for inadequate spread
of epidural anesthesia.
4. At birth, the spinal cord ends at about the level of the third lumbar vertebra.
26. B. Distally, the dura mater ends at approximately S2, where it fuses with the filum terminale.
At birth, the spinal cord ends at about the level of the third lumbar vertebrae. In adults, the
caudal tip of the spinal cord typically lies at the level of the first lumbar vertebrae. The inner
surface of the dura mater abuts the arachnoid mater. There is a potential space between these
two membranes called the subdural space. The plica medianis dorsalis is thought to be a
connective tissue band running from the dura mater to the ligamentum flavum. The plica
medianis dorsalis does not appear to be clinically relevant with respect to clinical epidural
anesthesia. (See page 929: Dura Mater.)
27. Which of the following statements regarding spinal needles is/are TRUE&quest;
1. The Quinke needle has a cutting edge.
2. The Sprotte needle requires more insertion force than the Greene needle.
3. Use of a stylet in a spinal needle may prevent formation of dermoid tumors in the
subarachnoid space.
4. The Whitacre needle has a “pencil-point” tip.
27. E. The Whitacre and Sprotte needles each have a pencil-point tip with a needle hole on the
side of the shaft. The Greene and Quinke needles have beveled tips with cutting edges. Pencil-
point needles require more force to insert than beveled-tip needles, but they provide a better
tactile feel of the various tissues encountered as the needle is inserted. All spinal and epidural
needles come with a tight-fitting stylet. The stylet prevents the needle from being plugged with
skin or fat and dragging the skin into the epidural or subarachnoid spaces, where the skin may
grow and form dermoid tumors. (See page 932: Needles.)
28. Combined spinal–epidural anesthesia (CSEA):

1. has proven to be a technique without risk or limitation
2. requires an epidural needle with a second lumen for the spinal needle
P.186
3. has recently fallen out of favor as a viable anesthetic option
4. may result in high subarachnoid concentrations of medication administered via the
epidural catheter
28. D. CSEA is growing in popularity because it combines the rapid-onset, dense block of
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spinal anesthesia with the flexibility afforded by an epidural catheter. Special epidural needles
with a separate lumen to accommodate a spinal needle are available for CSEA. However, the
technique is easily performed by first placing a standard epidural needle in the epidural space
and then inserting an appropriately sized spinal needle through the shaft of the epidural needle
into the subarachnoid space. A potential risk of CSEA is that the meningeal hole made by the
spinal needle may allow dangerously high concentrations of subsequently administered
epidural drugs to reach the subarachnoid space. (See page 936: Combined Spinal–Epidural
Anesthesia.)
29. Transient radicular irritation (TRI):

1. is defined as pain or dysesthesia in the legs or buttocks after spinal anesthesia
2. occurs more frequently in obese patients
3. usually resolves within 72 hours
4. occurs most frequently when bupivacaine is used
29. A. TRI is defined as pain or dysesthesia in the legs or buttocks after spinal anesthesia. All
local anesthetics have been shown to cause TRI, although the risk appears to be greater with
lidocaine than with other local anesthetics. Additional risk factors for TRI include surgery in the
lithotomy position, outpatient status, and obesity. The pain usually resolves spontaneously
within 72 hours. (See page 949: Transient Neurologic Symptoms.)
30. Anatomic features pertinent to the performance of neuraxial blockade include:

1. In adults, the spinal cord ends at L1–L2.
2. The angulation of the spinous processes of the thoracic vertebrae makes a
paramedian approach preferable.
3. In adults, the dural sac ends at S2.
4. The largest interspace in the vertebral column is L2–L3.
30. A. The largest interspace in the vertebral column is L5–S1, the site of the Taylor
paramedian approach. In adults, the spinal cord ends at L1–L2, and the dural sac ends at S2. A
line connecting the iliac crests most likely crosses L4 or the L4–L5 interspace. The angulation
of the spinous processes of the thoracic vertebrae complicates a midline approach, making the
paramedian approach preferable in this region. (See page 928: Anatomy.)
31. The epidural space contains:

1. cerebrospinal fluid (CSF)
2. blood vessels
3. unsheathed spinal roots
4. adipose tissue
31. C. The epidural space is a potential space that normally is filled with loose connective
tissue, fatty tissue, and blood vessels. CSF is in the subarachnoid space. The spinal roots
appear to traverse the epidural space, but they maintain a thin sleeve of dura around them.
(See page 929: Epidural Space.)
32. Factors that may worsen hypotension during epidural anesthesia include:
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1. epinephrine in the local anesthetic solution
2. absorption of local anesthetic from the epidural space
3. hypovolemia
4. use of chloroprocaine
32. E. As with spinal anesthesia, epidural anesthesia has hemodynamic effects secondary to
interruption of preganglionic sympathetic vasoconstrictor fibers. In addition, the relatively large
doses of local anesthetic used are absorbed rapidly and may cause hypotension because of
their negative inotropic and peripheral vasodilating effects. Epinephrine absorbed from the
epidural space stimulates β 2-receptors and leads to additional vasodilation and reduced
diastolic blood pressure. The agents with more rapid onset, chloroprocaine and etidocaine,
tend to produce greater hypotension because of rapid blockade of sympathetic fibers.
Alternatively, high plasma concentrations of bupivacaine are more likely to cause myocardial
depression. The hypotensive effects of epidural anesthesia are exaggerated in hypovolemic
patients. (See page 945: Cardiovascular Physiology.)
33. Important factors that influence the distribution of local anesthetics in the
subarachnoid space include the:
1. density of the local anesthetic solution
2. shape of the spinal canal
3. position of the patient
4. site of injection
33. E. Many factors are considered to influence the spread of local anesthetic in cerebrospinal
fluid. The most important factors are the density of the local anesthetic solution, site of
injection, shape of the spinal canal, and position of the patient (for hyperbaric and hypobaric
solutions). (See page 936: Block Height.)
34. Isobaric solutions injected at the L1 level are appropriate for spinal anesthesia for:
1. cesarean section
2. femoropopliteal bypass
3. appendectomy
4. repair of hip fracture
34. C. An isobaric solution tends to remain near the site of injection regardless of patient
position (unless the solution is not truly isobaric). An isobaric injection in the lumbar region is
appropriate for surgical procedures below the L1 dermatome (e.g., femoropopliteal bypass,
repair of hip fracture). However, it is not appropriate for surgery at sites innervated by higher
dermatomes. (See page 936: Block Height.)
35. TRUE statement(s) about anatomy include:

1. The ligamentum flavum is thickest in the midline, measuring 3 to 5 mm at the L2–L3
interspace in adults.
2. Midline insertion of an epidural needle is least likely to result in unintended meningeal
puncture.
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3. In adults, the caudad tip of the spinal cord typically lies at the level of the first lumbar
vertebrae.
4. At birth, the spinal cord ends at about the level of the fifth lumber vertebra.
35. A. The ligamentum flavum is thickest in the midline, measuring 3 to 5 mm at the L2–L3
interspace in adults. Midline insertion of an epidural needle is least likely to result in unintended
meningeal puncture. In adults, the caudad tip of the spinal cord typically lies at the level of the
first lumbar vertebrae. However, in 10% of individuals, the spinal cord may extend to L3. At
birth, the spinal cord ends at about the level of the third lumber vertebra. (See page 928:
Anatomy.)
36. Spinal cord segments that contain the cell bodies of preganglionic sympathetic
neurons include:
1. T4
2. C6
3. T10
4. S1
36. B. The intermediolateral gray matter of the T1–L2 spinal cord segments contains the cell
bodies of the preganglionic sympathetic neurons. (See page 931: Spinal Cord.)
303 / 494
Review of Clinical Anesthesia, 5e [Vishal] 38. Peripheral Nerve Blockade
Chapter 38
Peripheral Nerve Blockade
1. In comparing ultrasound imaging with neurostimulation, all of the following

statements are true EXCEPT:
A. It has an improved block success.
B. It has a reduced time to onset of blockade.
C. It is associated with fewer complications.
D. Lower frequencies offer the best spatial resolution at superficial locations.
E. Whereas high-impedance structures appear hyperechoic, low-impedance structures
appear hypoechoic.
1. D. Compared with neurostimulation, ultrasound guidance for blocks results in improved block
success and completeness, prolonged duration of blocks, and reduction in complications.
Whereas higher frequencies offer the best spatial resolution at superficial locations, lower
frequencies offer better resolution for deeper locations. High-impedance structures result in a
bright (hyperechoic) image, and low-impedance structures appear grey (hypoechoic). (See
page 957: Common Techniques: Ultrasound Imaging: Basics of Technique and Equipment.)
2. The highest systemic blood concentration of local anesthesia occurs after which of
A. Epidural anesthesia with pinprick level at T6
B. Spinal anesthesia with pinprick level at T4
C. Bier block anesthesia to left upper extremity
D. Bilateral intercostal blocks at T6–T12
E. Interscalene block to the right shoulder
2. D. The highest blood level of local anesthetic occurs after multiple intercostal nerve blocks.
(See page 960: Avoiding Complications: Local Anesthetic Drug Selection and Doses.)
3. The absorption of local anesthetic drug and duration of anesthesia are related to all
of the following EXCEPT:
A. total dose of local anesthetic used
B. use of epinephrine
C. location of injection
D. ester versus amide local anesthetic
E. physical properties of the local anesthetic
3. D. The higher the dose of local anesthetic, the greater the amount of drug that is available
for local effect. Epinephrine causes local vasoconstriction and therefore decreases the uptake
of local anesthetic into the bloodstream. The relative absorption of local anesthetic is greatest
after an intercostal nerve block. The physical properties of the local anesthetic influence the
absorption of the drug and the body's ability to break down the drug and excrete it. However,
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there is no difference in the absorption of the drug based on the classification of the local
anesthetic as an amide or ester. (See page 961: Local Anesthetic Drug Selection and Doses.)
4. Select the correct order of anesthetic techniques with respect to systemic blood
concentration from highest to lowest.
A. Spinal anesthesia, caudal block, brachial plexus block, intercostal block
B. Intercostal block, spinal anesthesia, brachial plexus block, caudal block
C. Intercostal block, caudal block, epidural block, brachial plexus block
D. Epidural block, intercostal block, caudal block, spinal block
E. Caudal block, intercostal block, brachial plexus block, spinal block
4. C. The highest blood concentration occurs after an intercostal blockade, followed by caudal
blockade, epidural blockade, and brachial plexus blockade. The lowest blood concentration
occurs after a spinal blockade. (See page 961: Local Anesthetic Drug Selection and Doses.)
5. All of the following concerning peripheral nerve blockade are true EXCEPT:
A. Complaints of a “cramping” or “aching” sensation during injection may indicate
intraneural injection.
B. Use of a nerve stimulator with a variable amperage output and an insulated needle
requires familiarity with anatomy.
C. Obtaining a sensory paresthesia is an acceptable technique.
D. Aspiration of blood or proximity of nerves to bones may make localization simpler.
E. Ultrasound guidance to localize nerves is a simple technique to master.
5. E. The traditional sign of successful localization of a nerve is eliciting a paresthesia. The
patient will complain of an “electrical shock”–like sensation in the involved area. Complaints of
“cramping” or “aching” sensation during injection is a sign of possible intraneural injection. A
greater incidence of residual neuropathy is associated with this technique compared with other
techniques. Use of a nerve stimulator for localization of the nerve is an alternative technique. A
nerve stimulator with variable amperage allows localization of the nerve without contacting it
and may reduce the chance of nerve injury. When a low current is applied to a peripheral
nerve, it will produce stimulation of the motor fibers. The closer it is in proximity to the nerve, the
less amperage required to elicit the motor response. Familiarity with anatomy and technique is
necessary to bring the needle in close proximity to the nerve. Transarterial localization of the
brachial plexus is a technique for performing an axillary block. The axillary artery is transfixed,
and the needle is passed through the artery. Local anesthetic is deposited on this side of the
artery, and the needle is withdrawn until it is brought back through the proximal wall. Additional
local anesthetic is deposited there as well. Ultrasound guidance to localize nerves shows
promise but requires complex equipment and experience. (See page 957: Common Techniques:
Nerve Stimulation and Ultrasound Imaging.)
6. Which of the following statements concerning the trigeminal nerve is FALSE&quest;

A. It is a sensory and motor nerve innervating the face.
B. Four major branches of the trigeminal nerve exit from the skull.
C. The mandibular nerve is the largest branch and is the only one to receive motor
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fibers.
D. Most applications of trigeminal nerve block may be performed by injection of the
terminal branches of the nerve.
E. The frontal branch bifurcates into the supratrochlear and supraorbital nerves.
6. B. The trigeminal nerve (fifth cranial nerve) is a sensory and motor nerve to the face. Its roots
arise from the base of the pons, and it sends sensory branches to the large gasserian ganglion.
The three major branches of this nerve are the ophthalmic, maxillary, and mandibular branches.
The ophthalmic branch bifurcates to form the supratrochlear and supraorbital nerves. The
maxillary branch is the middle branch and is a sensory nerve. The mandibular branch is the
third and largest branch and is the only one with motor fibers. Blockade of the gasserian
ganglion is used for treatment of disabling trigeminal neuralgia; however, it is very difficult to
perform. Blockade of the three terminal branches is relatively simple. (See page 962: Specific
Techniques: Head and Neck [Trigeminal Nerve Blocks].)
7. All of the following statements concerning cervical plexus blockade are true
EXCEPT:
A. The cervical plexus consists solely of nerve fibers from C1 and C2.
B. Blockade of the cervical plexus may involve only sensory nerves because of the
separation of motor and sensory fibers early in their course.
C. Carotid endarterectomy may be performed under cervical plexus blockade.
P.192
D. Blockade of this plexus may provide adequate anesthesia for thyroid surgery.
E. Paresthesias are usually not necessary to perform adequate blockade of the cervical
plexus.
7. A. The sensory fibers of the neck and posterior neck arise from nerve roots of the C2, C3,
and C4 nerves. The sensory fibers separate from the motor fibers early, so isolated sensory
blockade is possible. Cervical plexus blockade can be used for surgery on the neck, such as
thyroidectomy and carotid endarterectomy. Occasionally, the thyroid gland may need
supplemental local anesthesia, and the carotid bifurcation will need infiltration to block reflex
hemodynamic changes. Paresthesias are not required to perform this procedure. (See page
962: Specific Techniques: Head and Neck [Cervical Plexus Blocks].)
8. Even when properly performed, cervical plexus blockade may result in all of the
following EXCEPT:
A. intravascular injection of local anesthetic with rapid onset of seizures
B. phrenic nerve paralysis
C. recurrent laryngeal nerve blockade
D. epidural or subarachnoid anesthesia
E. ipsilateral pneumothorax
8. E. Complications from cervical plexus blockade may include intravascular injection into the
vertebral artery, epidural or spinal anesthesia if the needle is advanced too far medially, phrenic
nerve blockade, recurrent laryngeal nerve blockade, and vagal blockade. Ipsilateral
pneumothorax should not occur. (See page 962: Specific Techniques: Head and Neck [Cervical
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Plexus Blocks].)
9. Interscalene blockade is typically associated with all of the following EXCEPT:

A. anesthesia to the shoulder and upper arm
B. anesthesia of the ulnar border of the forearm
C. anesthesia of the musculocutaneous nerve
D. anesthesia to the radial and median nerves of the upper arm
E. possible Horner syndrome by spread to the sympathetic chain
9. B. The interscalene approach to the brachial plexus at the level of C6 provides blockade for
operations on the shoulder and upper arm procedures. It frequently spares C8 and T1 fibers
and therefore does not provide adequate blockade to the ulnar border of the forearm. Nerve
roots for the musculocutaneous, radial, and median nerves are adequately anesthetized.
However, if a tourniquet is being used, a subcutaneous ring of anesthetic is required to block
the superficial intercostobrachial fibers in the axilla. Horner syndrome may occur by spread of
local anesthesia to the sympathetic chain. (See page 968: Upper Extremity: Brachial Plexus
Blockade: Interscalene Block.)
10. The interscalene approach to the brachial plexus involves all of the following
EXCEPT:
A. head positioning so that it is turned to the opposite side
B. palpation of the groove between the anterior and middle scalene muscle, which is
located by having the patient tense the scalene muscles by raising the head slightly in
the sniffing position
C. injection of 25 to 30 mL of local anesthetic when using a nerve stimulation technique
D. introduction of the needle perpendicular to the skin in all planes so that it is directed
medially, cephalad, and slightly anteriorly
E. locating the cricoid cartilage
10. D. The patient is placed in the supine position with the head turned to the side opposite that
to be blocked. The lateral border of the sternocleidomastoid muscle is identified. By tensing the
scalene muscles, the groove between the anterior and middle scalene muscles may be
palpated. The level of the cricoid cartilage is marked. A 22-gauge, 2.5-cm or less (≤5 cm for
ultrasound guidance) needle is introduced through the skin perpendicular to all planes at the
level of the cricoid cartilage so that it is directed medially, caudad, and slightly posterior.
Approximately 25 to 30 mL of local anesthetic is required for adequate blockade when a nerve
stimulation technique is used. (See page 962: Specific Techniques: Upper Extremity: Brachial
Plexus Blockade: Interscalene Block.)
11. Complications of the interscalene approach to the brachial plexus may include:
1. puncture of the lung viscera and a pneumothorax
2. injection of local anesthesia into the epidural or subarachnoid space
307 / 494
3. intravascular injection of local anesthesia via the vertebral artery
4. ipsilateral Horner syndrome
11. E. Complications from the interscalene approach to the brachial plexus are pneumothorax (if
the needle is directed too inferiorly), spinal or epidural anesthesia (if the needle passes
medially and enters the intervertebral foramina), intravascular injection into the vertebral artery
(if the needle is too posterior because the artery passes posteriorly at the level of the sixth
vertebra to lie in its canal in the transverse process), and ipsilateral Horner syndrome (because
of blockade of the sympathetic chain on the anterior vertebral body). Phrenic nerve blockade
may occur as well. (See page 962: Specific Techniques: Upper Extremity: Brachial Plexus
Blockade: Interscalene Block.)
12. Which of the following statements regarding the axillary approach to the brachial
plexus is/are TRUE&quest;
1. It carries the least chance of pneumothorax.
2. The musculocutaneous nerve is easily anesthetized.
3. Septa within the sheath may limit the spread of local anesthetic.
4. Injection at multiple sites in the axilla is not recommended because the axillary artery
may be punctured.
12. B. The axillary approach to the brachial plexus carries the least chance of pneumothorax.
Fascial septa within the sheath may limit the spread of local anesthetic; therefore, injection of
local anesthetic at multiple sites in the axilla is recommended. The musculocutaneous nerve
departs from the sheath high in the axilla and may be spared with this technique. (See page
962: Specific Techniques: Brachial Plexus: Axillary Block.)
13. Which of the following statements regarding intravenous regional anesthesia is/are
TRUE&quest;
1. The tourniquet should be inflated to 300 mm Hg or 2.5 times the patient's systolic
blood pressure.
2. Lidocaine with epinephrine is the most commonly used anesthetic for this procedure.
3. If surgery is completed in 15 minutes, the tourniquet should be deflated and then
reinflated to delay the sudden reabsorption of anesthetic.
4. Bupivacaine is the local anesthetic of choice in patients with lidocaine allergy.
13. B. Intravenous regional anesthesia (Bier block) is a form of regional anesthesia in which
local anesthetic is injected into the upper extremity distal to an occluding tourniquet. The arm is
elevated and exsanguinated by an elastic bandage. The tourniquet is inflated to 300 mm Hg or
2.5 times the patient's blood pressure. The radial pulse must be tested for occlusion. This may
be done by palpation or by placement of the pulse oximeter on the extremity. Lidocaine 0.5% is
the local anesthetic of choice, but it should not be used with epinephrine. Bupivacaine is not
used because of its toxicity. Ideally, surgery lasting up to 1 hour may be performed by this
procedure. However, the cannula may be left in place, and medication may be reinjected after
90 minutes. For surgical procedures between 20 and 40 minutes long, the tourniquet should be
deflated, reinflated, and then subsequently deflated in an attempt to minimize sudden
reabsorption of local anesthetic. (See page 962: Specific Techniques: Upper Extremity:
Intravenous Regional Anesthesia.)
308 / 494
14. Intercostal blockade of T6–T12 results in which of the following&quest;

1. It provides analgesia and motor relaxation for upper abdominal procedures.
2. It is useful in reducing pain associated with chest tube insertion and percutaneous
biliary drainage procedures.
3. It has the potential for local anesthesia toxicity, especially if performed bilaterally.
4. There is a high incidence of pneumothorax even when the anesthetic is performed by
an experienced individual.
14. A. Intercostal blockade may provide both motor and sensory anesthesia of the abdomen
and chest. This technique is also useful for reducing pain from chest tube insertion and
percutaneous biliary drainage. It is advantageous over spinal or epidural blockade because
there is no accompanying sympathetic blockade. Intercostal blockade results in the highest
blood concentration of local anesthetic and therefore has the greatest likelihood of toxicity from
local anesthetic. The incidence of pneumothorax is rare in experienced hands. (See page 962:
Specific Technique: Trunk: Intercostal Nerve Blockade.)
15. Which of the following statements regarding ilioinguinal/iliohypogastric nerve block

is/are TRUE&quest;
1. Anesthesia of the iliohypogastric nerve and ilioinguinal nerve is adequate for hernia
repair.
2. The nerve roots from T12, L1, and L2 provide fibers to these two nerves.
3. The anteroinferior iliac spine provides the landmark for location of these two nerves.
4. Hematoma formation is a rare complication of this nerve block.
15. D. Ilioinguinal/iliohypogastric nerve blockade provides sensory anesthesia to the lower
portion of the abdomen and groin. It is used for anesthesia for hernia repair, but blockade of
these two nerves alone is inadequate for hernia repair. Subcutaneous infiltration is needed as
well. These two nerves are easily located because of their anatomic relationship to the
anterosuperior iliac spine. Nerve roots from L1 and sometimes T12 provide fibers to these two
nerves. Hematoma formation is a rare complication of this block. (See page 962: Specific
Techniques: Trunk: Inguinal Nerve Block.)
16. Which of the following statements regarding penile nerve block is/are TRUE&quest;
1. Penile blockade is used for surgical procedures of the glans and shaft of the penis.
2. The penile branches of the pudendal nerve are targeted.
3. A ring block is typically performed.
4. Lidocaine with epinephrine is typically used.
16. A. Penile block is used in surgical procedures involving the glans and the shaft of the penis.
The penile branches of the pudendal nerve (S2–S4) are blocked by a circumferential infiltration
of the root of the penis (ring block). To avoid compromising penile circulation, epinephrine-
containing solutions should not be used. (See page 962: Specific Techniques: Penile Block.)
17. Which of the following statements regarding blocks of the terminal nerves of the
lumbar plexus is/are TRUE&quest;
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1. When using a nerve stimulation technique for the lateral femoral cutaneous nerve
block, the primary endpoint is paresthesia over the lateral leg thigh with a current of 0.5
to 0.6 mA.
2. An obturator nerve block may be used to prevent obturator reflex during transurethral
bladder tumor resections.
P.193
3. A lateral femoral cutaneous nerve block may be used to prevent adductor spasm in
patients with multiple sclerosis.
4. A lateral femoral cutaneous nerve block may be used as a diagnostic tool to identify
cases of meralgia paresthetica.
17. E. Blockade of the lateral femoral cutaneous nerve may be used as a diagnostic tool to
identify cases of meralgia paresthetica. An obturator nerve block aids in preventing the
obturator reflex during transurethral bladder tumor resections and for adductor spasms (seen in
patients with multiple sclerosis). When using nerve stimulation technique for blockade of the
lateral femoral cutaneous nerve, the primary endpoint is paresthesia of the lateral thigh with a
current of approximately 0.5 to 0.6 mA. (See page 962: Specific Techniques: Lower Extremity:
Separate Blocks of the Terminal Nerves of the Lumbar Plexus.)
18. Which of the following statements regarding sciatic nerve block is/are
TRUE&quest;
1. When used with a saphenous nerve block, a sciatic nerve block may produce
adequate anesthesia to the sole of the foot and the lower leg.
2. The sciatic nerve is located deep within the gluteal region, making it difficult to locate.
3. The anterior sciatic nerve block is ideal for patients who cannot be positioned laterally.
4. In the gluteal region, the sciatic nerve is located lateral to the ischial spine and
superficial to the ischial bone.
18. E. When used with a saphenous nerve block, a sciatic nerve block may produce adequate
anesthesia to the sole of the foot and the lower leg. The sciatic nerve is difficult to locate
because of its deep location. With the aid of ultrasound-guided blockade, the identification of
various anatomic landmarks may help identify its location. In the gluteal region, the sciatic nerve
is seen on ultrasonography lateral to the ischial spine and superficial the ischial bone. For the
anterior sciatic nerve block, the patient is positioned supine with the selected leg to be blocked
externally rotated, making this block ideal for patients who cannot be positioned laterally. (See
page 962: Specific Techniques: Lower Extremity: Sciatic Nerve Blockade using Posterior,
Anterior, and Posterior Popliteal Approaches.)
19. Which of the following statements regarding an ankle block is/are TRUE&quest;
1. The three main peripheral nerves need to be blocked.
2. The deep peroneal nerve is located in the deep plane of the anterior tibial artery.
3. The sural nerve is the major sensory nerve to the sole of the foot.
4. The deep peroneal nerve may be located by palpating the tendon of the extensor
hallucis longus.
19. C. Five peripheral nerves are anesthetized for an ankle block: the posterior tibial, sural,
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saphenous, deep peroneal, and superficial peroneal nerves. The posterior tibial nerve is the
major nerve to the sole of the foot and is located just posterior to the posterior tibial artery. The
sural nerve also innervates the sole of the foot. The saphenous nerve, which is located
medially, innervates the anterior surface of the foot. The deep peroneal nerve is located in the
deep plane of the anterior tibial artery and may be located by identifying the anterior tibial artery
or the tendon of the extensor hallucis longus. The superficial peroneal nerve is located along
the skin crease between the anterior tibial artery and the lateral malleolus. (See page 962:
Specific Techniques: Lower Extremity: Ankle Blockade.)
311 / 494
Review of Clinical Anesthesia, 5e [Vishal] 39. Anesthesia for Neurosurgery
Chapter 39
Anesthesia for Neurosurgery
1. Considering cerebrospinal fluid (CSF), which statement is TRUE&quest;

A. Normal volume is 250 mL, but four times this amount is produced each day.
B. Normal volume is 150 mL, but three times this amount is produced each day.
C. Normal volume is 100 mL, but four times this amount is produced each day.
D. Normal volume is 50 mL, but three times this amount is produced each day.
E. Normal volume is 250 mL, but two times this amount is produced each day.
1. B. Although CSF volume is approximately 150 mL, more than three times this amount is
produced in a 24-hour period. (See page 1006: Neurophysiology.)
2. Which of the following statements regarding intracranial pressure (ICP) is

TRUE&quest;
A. ICP fluctuates significantly in normal states.
B. ICP is not changed with changes in cerebrospinal fluid (CSF) volume.
C. ICP never changes quickly, always gradually reaching new states of equilibrium.
D. ICP is dependent on the volume of intracranial blood, brain tissue, and CSF.
E. ICP is increased with any small increase in intracranial volume.
2. D. Intracranial pressure (ICP) is low except in pathologic states. The Monroe-Kellie doctrine
states that in the setting of a nondistensible cranial vault, the volume of blood, CSF, and brain
tissue must be in equilibrium. An increase in one of these three elements or the addition of a
space-occupying lesion can be accommodated initially through displacement of CSF into the
thecal sac, but only to a small extent. A further increase, as with significant cerebral edema or
accumulation of an extradural hematoma, quickly leads to a marked increase in ICP because of
the low intracranial compliance. (See page 1006: Neurophysiology.)
3. Which of the following statements regarding autoregulation of cerebral blood flow

(CBF) is FALSE&quest;
A. Autoregulation leads to constant CBF over a range of mean arterial pressures
(MAPs).
B. Autoregulation maintains constant CBF between MAPs of approximately 60 to 150 mm
Hg.
C. At the low end of the autoregulation plateau, the cerebrovascular resistance (CVR) is
at a maximum.
D. Cerebral perfusion pressure (CPP) is dependent on MAP and intracranial pressure
(ICP).
E. CBF is maintained by adjusting CVR in response to changes in CPP.
3. C. CBF remains approximately constant despite modest swings in arterial blood pressure.
The mechanism by which CBF is maintained, originally described by Lassen, is called
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autoregulation of CBF. As CPP, defined as the difference of MAP and ICP, changes, CVR
adjusts to maintain stable flow. Although this range is frequently quoted as a mean arterial
pressure range of 60 to 150 mm Hg, there is significant variability between individuals, and
these numbers are only approximate. At the low end of the plateau, CVR is at a minimum, and
any further decrease in CPP compromise CBF. At the high end of the plateau, CVR is at a
maximum, and any further increase in CPP result in hyperemia. (See page 1006:
Neurophysiology.)
4. Which of the following statements regarding the effects of anesthetics on cerebral

blood flow is TRUE&quest;
A. Inhalation anesthetics cause cerebral vasodilatation in a dose-dependent manner.
B. Inhalation anesthetics have no effect on cerebral metabolic rate (CMR).
C. Thiopental causes increased cerebral blood flow (CBF) and decreased CMR.
D. Propofol causes vasoconstriction and increased CMR.
E. Ketamine decreases CBF and decreases CMR.
4. A. Inhalation anesthetics tend to cause vasodilation in a dose-related manner. Higher doses
result in dominance of the vasodilatory effect and an increase in CBF. They also decrease
cerebral metabolism. Intravenous agents, including thiopental and propofol, cause
vasoconstriction coupled with a reduction in metabolism. Ketamine, on the other hand,
increases flow and metabolism. (See page 1008: Anesthetic Influences.)
5. Which of the following statements regarding the use of hyperventilation to provide

brain relaxation is TRUE&quest;
A. Hyperventilation is recommended in all patients with traumatic brain injury (TBI).
B. Hyperventilation should be continued for 48 hours.
C. Hyperventilation is helpful for ischemia because it decreases cerebral blood flow
(CBF).
D. Hyperventilation is always contraindicated in patients with TBI.
E. Hyperventilation should be used for brief periods to manage acute increases in
intracranial pressure (ICP).
5. E. Hypocapnic cerebral vasoconstriction provides anesthesiologists with a powerful tool for
manipulating CBF. Hyperventilation is routinely used to provide brain relaxation and optimize
surgical conditions. But because hyperventilation decreases CBF, it has the theoretical potential
for causing or exacerbating cerebral ischemia. Clinically, it has been associated with harm only
in the early period of TBI, but it is still recommended to be avoided in all patients with TBI
except when necessary for a brief period to manage acute increases in ICP. (See page 1017:
Ventilation Management.)
6. Which of the following statements regarding venous air embolism (VAE) is

TRUE&quest;
A. The sitting position carries little risk of VAE.
B. A multi-orifice catheter placed in the superior vena cava is optimal.
C. The presence of a patent foramen ovale (PFO) increases the risk of paradoxical
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emboli.
D. Precordial Doppler has not been shown to help detect VAE.
E. Patient position should not be changed when treating a VAE.
6. C. For neurosurgery, the sitting position confers the greatest risk for VAE. A Doppler device
should be placed on the chest, end-tidal CO2 should be monitored, and plans should be made
for treating a VAE if it occurs. A multi-orifice catheter can be placed in the right atrium to
evacuate air. Its location can be confirmed either electrocardiographically or with
echocardiography. The presence of a PFO increases the risk of paradoxical embolism. (See
page 1019: Surgery for Intracranial Tumors.)
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7. All of the following complications may occur in patients with aneurysmal
subarachnoid hemorrhage EXCEPT:
A. Cardiac dysfunction
B. Neurogenic pulmonary edema
C. Cardiogenic pulmonary edema
D. Hydrocephalus
E. Secondary hyperthyroidism
7. E. Patients with aneurysmal subarachnoid hemorrhage are at risk for numerous
complications that may affect the anesthetic plan. These include cardiac dysfunction,
neurogenic or cardiogenic pulmonary edema, hydrocephalus, and further hemorrhage from the
aneurysm. (See page 1020: Cerebral Aneurysm Surgery and Endovascular Treatment.)
8. Which of the following statements regarding blood pressure during carotid surgery
is true&quest;
A. It should be maintained 20% below baseline throughout surgery.
B. It should be maintained as close to baseline as possible throughout surgery.
C. It should be maintained as close to baseline as possible except during carotid cross-
clamping, when it should be increased 20%.
D. It should be maintained 20% below baseline except during carotid cross-clamping,
when it should be increased to 20% above baseline.
E. It should be maintained 20% above baseline throughout surgery.
8. B. Blood pressure should be maintained as close to baseline as possible throughout carotid
surgery. Without evidence to support it, some advocate increasing the blood pressure during
carotid cross-clamping to improve flow through collateral vessels. This practice presupposes
that collateralization is marginal and will be helped by the elevation in pressure. Although
collateral flow may be marginal, it may also be absent or entirely adequate. In the latter two
situations, elevation in blood pressure, through the use of phenylephrine, will only increase
myocardial oxygen demand. (See page 1021: Carotid Surgery.)
9. Which of the following is NOT an indication for endotracheal intubation in a patient

with traumatic brain injury (TBI)&quest;
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A. Decreased level of consciousness
B. Hypertension
C. Increased risk of aspiration
D. Hypoxemia
E. Need for sedation during diagnostic studies
9. B. If the patient's trachea is not intubated, immediate attention should focus on assessing the
airway and making preparations for intubation. Patients with TBI usually have several
indications for intubation, including a decreased level of consciousness, increased risk of
aspiration, and concern for hypoxemia and hypercarbia. Sometimes these patients must be
tracheally intubated and sedated simply to allow further diagnostic studies. (See page 1022:
Overview of Traumatic Brain Injury.)
10. The Cushing's response to elevated intracranial pressure (ICP) includes:

A. hypertension and bradycardia
B. hypotension and tachycardia
C. hypertension and tachycardia
D. hypotension and bradycardia
E. vasodilation and prolonged QRS
10. A. Patients may demonstrate the Cushing's response of hypertension and bradycardia,
which signifies brainstem compression from increased ICP. (See page 1025: Emergent Surgery:
Neurosurgical.)
11. Cauda equina syndrome is defined by which symptoms&quest;

A. Back pain extending to the lower extremities
B. Loss of pain and temperature sensation with sparing of proprioception in the lower
extremities
C. Loss of motor and touch sensation ipsilateral to the lesion and urinary retention
D. Perineal anesthesia, urinary retention, and lower extremity weakness
E. Loss of motor sensation in the lower extremities with no sensory deficit
11. D. Cauda equina syndrome is the result of injury below the level of the conus, or caudal
end of the spinal cord, typically below L2. Compression of the cauda equina results in perineal
anesthesia, urinary retention, fecal incontinence, and lower extremity weakness. (See page
1026: Spinal Cord Injury.)
12. Which of the following statements regarding electroencephalography (EEG) is/are
TRUE&quest;
1. Brain ischemia disrupts the EEG but not in a predictable pattern.
2. Brain ischemia may lead to EEG silence.
3. It is easy to differentiate ischemia from anesthetic effects on EEG.
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4. EEG asymmetry between the right and left sides of the brain is a useful tool.
12. C. A progressive reduction in cerebral blood flow produces a reliable pattern change in
EEG, and the eventual progression to EEG silence. The monitor is therefore useful when
surgical procedures jeopardize the perfusion of the brain, such as during cross-clamping of the
carotid artery during carotid endarte-rectomy. EEG is particularly useful in this setting because
the spectral analysis on the at-risk side can be compared in real time with the unaffected side,
facilitating detection of ischemia by the resultant asymmetry of EEG. The changes in the EEG
spectrum seen with ischemia may occur as a result of other influences, however. Intravenous
anesthetic agents such as propofol and thiopental, as well as inhaled agents such as
isoflurane, cause a similar change in a dose-related manner, with eventual progression to a
drug-induced isoelectric EEG. (See page 1009: Electrocardiography.)
13. Which of the following statements regarding evoked potentials is/are TRUE&quest;
1. Inhalation agents disrupt evoked potentials more than intravenous (IV) anesthetics.
2. Brainstem auditory evoked potentials (BAEPs) can be recorded under any anesthetic.
3. No muscular relaxation can be used when monitoring motor evoked potentials (MEPs).
4. Total IV anesthesia is not recommended when monitoring MEPs.
13. A. Inhalation agents, including nitrous oxide, generally have more depressant effects on
evoked potential monitoring than IV agents. Whereas cortical evoked potentials with long
latency involving multiple synapses are exquisitely sensitive to the influence of anesthetic,
short-latency brainstem and spinal components are resistant to anesthetic influence. Thus,
BAEPs can be recorded under any anesthetic technique. Monitoring of MEPs in general
precludes the use of muscle relaxant, although use of a short-acting neuromuscular blocking
agent for the purpose of tracheal intubation is not contraindicated if its effect wears off before
monitoring and surgery begins. MEP is exquisitely sensitive to the depressant effects of
inhalation anesthetics, including nitrous oxide. Although it can be recorded with low-dose
agents, the signals are so severely attenuated that this practice is generally not advisable. Total
IV anesthesia without nitrous oxide is the ideal anesthetic technique for MEP monitoring. (See
page 1011: Influence of Anesthetic Technique.)
14. Which of the following statements concerning intracranial pressure (ICP)

monitoring is/are TRUE&quest;
1. ICP provides a measurement of cerebral blood flow (CBF).
2. Ideally, ICP is kept below 30 mm Hg.
3. Patient position has no effect on ICP.
4. It is possible to drain cerebrospinal fluid (CSF) to lower ICP.
14. D. Although monitoring ICP does not provide direct information about CBF, it allows one to
calculate CPP, which must be in an appropriate range for CBF to be adequate. When ICP is
high and CPP is low, interventions can target either ICP or mean arterial pressure to restore a
favorable balance of the two. Ideally, ICP should be maintained below 20 mm Hg. Interventions
to lower ICP include suppression of cerebral metabolic activity, positional changes to decrease
cerebral venous blood volume, drainage of CSF, removal of brain water with osmotic agents
such as mannitol, and if absolutely essential, mild to moderate hyperventilation to further
decrease cerebral blood volume. (See page 1012: Intracranial Pressure Monitoring.)
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15. Which of the following statements regarding profound hypothermia is/are

TRUE&quest;
1. Profound hypothermia has well-known cerebroprotective effects.
2. Cardiopulmonary bypass is necessary when using profound hypothermia.
3. Hypothermia-induced coagulopathy is a concern when using profound hypothermia.
4. When core temperature is below 25°C, circulatory arrest is tolerated for 30 minutes.
15. A. Profound hypothermia is well known for its neuroprotective effects. When core body
temperature is below 20°C, circulatory arrest of less than 30 minutes appears to be well
tolerated. The practical constraints against using deep hypothermia in settings in which
cerebral ischemia is anticipated are numerous. Foremost is the need for cardiopulmonary
bypass during the cooling and warming portion of the procedure. Hypothermia-induced
coagulopathy is another concern during surgical procedures in cold patients. (See page 1015:
Hypothermia.)
16. Which of the following statements regarding hypertension accompanying high

intracranial pressure (ICP) are TRUE&quest;
1. Hypertension is a desirable finding because it shows that the patient has an intact
stress response.
2. Hypertension may lead to brainstem herniation.
3. Hypertension has been shown to have no effect on the bleeding from a cerebral
aneurysm.
4. Hypertension may lead to worsening ICP.
16. C. Hypertension is poorly tolerated by patients after aneurysmal subarachnoid hemorrhage
because systolic hypertension is thought to be a cause of recurrent hemorrhage from the
aneurysm. Additionally, hypertension may worsen elevated ICP and possibly lead to herniation
of cranial contents into the foramen magnum. (See page 1017: Induction and Airway
Management.)
17. Succinylcholine (Sch) is contraindicated in all of the following situations EXCEPT:

1. a patient with myelopathy
2. a patient with L4–L5 cord transaction 5 years previously
3. a patient with a stroke 72 hours ago
4. a patient with a stroke 24 hours ago
17. A. Many neurosurgical and spine surgery patients have conditions in which Sch is
contraindicated. Muscle denervation from stroke, myelopathy, and spinal cord injury result in
upregulation of acetylcholine receptor isoforms across the muscle belly. This upregulation leads
to massive release of potassium with use of Sch. It takes 48 hours for this upregulation to
occur, so Sch may be used in the first 2 days after the denervation. (See page 1017: Induction
and Airway Management.)
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18. Which of the following is/are contraindications for extubation in a neurosurgical
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patient&quest;
1. Prolonged prone surgery
2. Facial edema and no cuff leak
3. Rales and low oxygen saturation
4. Massive transfusion and no cuff leak
18. E. For extensive spine surgeries in the prone position, significant dependent edema
frequently occurs. Although the predictive value of an air leak from around the endotracheal
tube cuff is poor in general, the combination of pronounced facial edema and an absent cuff
leak after prone surgery should make one suspicious for upper airway edema. Delaying
extubation of the trachea under these circumstances is appropriate. Other factors that may
delay extubation in these patients include the development of pulmonary edema and hypoxemia
from fluid administration, as well as persistent hemodynamic instability. (See page 1018:
Emergence.)
19. Which of the following statements regarding endovascular treatment of cerebral

aneurysms is/are TRUE&quest;
1. It is a minimally invasive surgery.
2. It typically requires general anesthesia.
3. It may cause severe complications.
4. It is often performed in the cardiac surgery room in case cardiopulmonary bypass is
necessary.
19. A. In contrast to aneurysm surgery, endovascular treatment of aneurysms is a minimally
invasive procedure performed in the interventional radiology suite. Despite the less invasive
nature of this procedure, it can have equally severe complications as surgery, including further
hemorrhage, stroke, and vessel dissection. Although the procedure is not particularly
stimulating, the general anesthetic needs to be performed with great care. (See page 1009:
Electroence-phalography.)
20. Which of the following is/are relative contraindications to an “awake”

craniotomy&quest;
1. Tumor resection surgery
2. Severe anemia
3. Multiple opioid allergies
4. Difficult airway
20. D. Frequently, the decision to perform a procedure “awake” has been made by the
neurosurgeon before the patient meets the anesthesiologist. Typically, these surgeries are for
tumors adjacent to the eloquent cortex or for resection of an epileptic focus. It is the role of the
anesthesiologist to determine whether the patient is an appropriate candidate for an “awake”
procedure. Although patients with difficult airways, obstructive sleep apnea, or orthopnea may
present relative contraindications to an “awake” craniotomy, patients with severe anxiety,
claustrophobia, or other psychiatric disorders may be particularly inappropriate for this type of
procedure. (See page 1021: Epilepsy Surgery and the “Awake” Craniotomy.)
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21. Which of the following statements regarding hypertonic saline to manage elevated
intracranial pressure (ICP) is/are TRUE&quest;
1. It must be used before attempting ICP control with mannitol.
2. It has never been compared with mannitol for efficacy in controlling ICP.
3. It may cause significant electrolyte disturbances.
4. Unlike mannitol, it does not cause a brisk diuresis.
21. D. Both hypertonic saline (HS) and HS-Dextran have been used to manage patients with
elevated ICP, primarily in the setting of intracranial hypertension refractory to mannitol therapy.
Because the blood–brain barrier reflection coefficient to sodium ions is approximately 1, HS
establishes a gradient that facilitates the movement of water from the brain into the
intravascular space. A 2005 study indicated that HS may be more effective in controlling ICP
than mannitol. In addition to efficacy, the proposed benefit of HS is lack of severe electrolyte
disturbance, which is common with mannitol. The brisk diuresis seen with mannitol is absent
from HS therapy. (See page 1022: Overview of Traumatic Brain Injury.)
22. Risk factors for postdecompressive hypotension include all the following EXCEPT:
1. low Glasgow Coma Scale (GCS) score
2. midline shift of the brain on computed tomography (CT)
3. bilateral dilated pupils
4. use of inhalation anesthetics
22. B. Profound hypotension may occur after anesthesia induction, or more likely, after
craniectomy when the intrinsic stimulus for blood pressure elevation diminishes. Risk factors for
postdecompressive hypotension include low GCS score, absence of basal cisterns on CT, and
bilateral dilated pupils. (See page 1025: Emergent Surgery: Neurosurgical.)
23. Spinal column damage may cause spinal cord ischemia through which of the
following mechanisms&quest;
1. Hemorrhage
2. Compression
3. Vasospasm
4. Emboli
23. A. Damage to the spinal column may occur without injury to the spinal cord or may cause
spinal cord injury through various insults, including compression, hemorrhage, and vasospasm,
all of which result in spinal cord ischemia and infarction. (See page 1026: Spinal Cord Injury.)
24. Which of the following statements regarding urgent intubation of a patient with a
spinal cord injury is/are TRUE&quest;
1. Never assume that a patient has a cervical spine injury until there is radiologic
evidence.
2. Rapid sequence induction is only rarely indicated.
3. Assessment of neck mobility is important before induction.
4. Manual in-line stabilization is appropriate.
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4. Manual in-line stabilization is appropriate.
24. D. Cervical spine injury should be presumed in any trauma patient requiring intubation
before complete physical and radiographic evaluation. Intubation should proceed with little
movement of the cervical spine. A rapid sequence induction with cricoid pressure and manual
in-line stabilization is appropriate unless a difficult airway is anticipated. (See page 1027:
Urgent Airway Management.)
25. Autonomic hyperreflexia is characterized by:

1. tachycardia
2. its occurrence in patients with spinal cord lesions above T7
3. intense vasoconstriction above the level of the lesion
4. intense vasoconstriction below the level of the lesion
25. C. Patients with chronic spinal cord lesion above T7 may develop autonomic reflexia when
stimulated below the site of the lesion. This is a condition characterized by intense
vasoconstriction below the site of the lesion accompanied by cutaneous vasodilation above,
hypertension, and bradycardia. This is the result of reflex sympathetic stimulation below the
lesion unmodulated by supraspinal influence from above. (See page 1028: Autonomic
Hyperreflexia.)
26. Which of the following statements regarding postoperative visual loss is/are
TRUE&quest;
1. It occurs in surgeries with long durations.
2. It is commonly bilateral.
3. It is caused by ischemic optic neuropathy.
4. It is always associated with pressure on the eyes from positioning errors.
26. A. The complication of postoperative visual loss is of particular concern in prone spine
surgery, although it can occur in other settings. The visual loss is commonly bilateral and is
caused by ischemic optic neuropathy, although retinal artery occlusion and cortical blindness
may also occur. These incidents of visual loss occur despite the absence of pressure on the
eyes from positioning errors, which would result in central retinal artery thrombosis rather than
anterior or posterior ischemic optic neuropathy. Ischemic optic neuropathy is associated with
blood loss, hypotension, and surgery of long duration in the prone position. It most certainly has
a multifactorial cause, including anatomic variation in the vasculature of individual patients.
(See page 1028: Postoperative Visual Loss.)
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Review of Clinical Anesthesia, 5e [Vishal] 40. Anesthesia for Thoracic Surgery
Chapter 40
Anesthesia for Thoracic Surgery
1. The leading cause of cancer mortality in the United States is:

A. lung cancer
B. colorectal cancer
C. breast cancer
D. prostate cancer
1. A. Lung cancer has long been the most common cause of cancer mortality in the United
States. In 2004, which was the most recent year in which statistics are available from the
Centers for Disease Control and Prevention, 108,355 men and 87,897 women were diagnosed
with lung cancer. In that year, lung cancer caused more deaths than breast, prostate, and colon
cancer combined. (See page 1032: Key Points.)
2. The leading cause of cancer death in women in the United States is:
A. lung cancer
B. colorectal cancer
C. breast cancer
D. ovarian cancer
2. A. In 1987, lung cancer surpassed breast cancer as the leading cause of cancer death in
women in the United States. (See page 1032: Key Points.)
3. During a preanesthetic interview, you elicit the history of severe exertional dyspnea
from an elderly man who smokes cigarettes. This implies:
A. He is at increased risk of high peak airway pressures on mechanical ventilation.
B. Wet crackles will be heard at his lung bases on auscultation.
C. Preoperative flow volume loops will demonstrate a restrictive pattern.
D. He has a severely diminished respiratory reserve and is at high risk of postoperative
ventilatory support.
E. He will require mechanical ventilatory tidal volumes of 15 to 20 mL/kg.
3. D. During all preanesthetic assessments, it is important to ask about dyspnea. Dyspnea is a
sensation of shortness of breath that occurs when a patient's requirement for ventilation is
greater than his or her ability to respond to that demand. When the anesthesiologist quantitates
the degree of physical activity required to produce the sensation of dyspnea, certain
postoperative predictions can be made. After a patient complains of dyspnea produced by
minimal exertion, the ventilatory reserve is implicitly significantly diminished, and the forced
expiratory volume in one second (FEV1) is predicted to be less than 1500 mL. It is not unusual
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for these patients to need postoperative ventilatory support. (See page 1033: Preoperative
Evaluation.)
4. Acute lung injury, an early form of acute respiratory distress syndrome, is

sometimes seen after thoracic surgery. Risk factors for acute lung injury after chest
surgery include:
A. alcohol abuse
B. planned pneumonectomy
C. high intraoperative ventilatory pressures
D. excessive amounts of fluid administration
E. all of the above
4. E. Patients with a preoperative history of alcohol abuse have been identified as being at
increased risk for acute lung injury after thoracic surgery. Patients who undergo
pneumonectomy, who are exposed to high airway pressures on mechanical ventilation, or who
receive an excessive amount of fluid relative to their needs have also been identified as being
at increased risk for acute lung injury. (See page 1033: History.)
5. Which statement regarding the physical examination of a patient undergoing

thoracic surgery is FALSE&quest;
A. Deviation of the trachea indicates potentially difficult intubation.
B. Clubbing is often seen in patients with a left-to-right shunt.
C. If cyanosis is present, the patient's PaO2 level is typically below 55 mm Hg.
D. The compliance of the pulmonary circulation is reduced in patients with chronic
obstructive pulmonary disease (COPD).
E. A narrowly split second heart sound is a sign of pulmonary hypertension.
5. B. Clubbing is seen frequently in patients with congenital heart disease associated with a
right-to-left shunt, in patients with chronic lung disease, and in patients with malignancies. If
cyanosis is present, the arterial saturation is 80% or less, which correlates with a PaO2 level of
50 to 52 mm Hg. Displacement of the trachea should alert the anesthesiologist to the potential
for difficult intubation. Patients with COPD have reduced compliance of the pulmonary capillary
bed. A narrowly split second heart sound is a sign of pulmonary hypertension. (See page 1033:
Respiratory Pattern: Evaluation of the Cardiovascular System.)
6. Which of the following can increase pulmonary vascular resistance&quest;

A. Systemic acidemia
B. Septicemia
C. Systemic hypoxia
D. Positive end-expiratory pressure (PEEP)
E. All of the above
6. E. Systemic acidosis, sepsis, hypoxemia, and PEEP may increase pulmonary vascular
resistance, which may place the patient at risk of right ventricular failure. This risk of right
ventricular failure is further increased if the patient had chronic obstructive pulmonary disease
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characterized by distention of the pulmonary capillary bed with decreased compliance in

response to increased pulmonary blood flow. (See page 1034: Evaluation of the Cardiovascular
System.)
7. Which statement regarding flow–volume loops is FALSE&quest;

A. Small airway resistance is best displayed at expiration between 25% and 75% of vital
capacity.
B. Lung volume is displayed on the horizontal axis.
C. Patients with restrictive lung disease have a decreased maximum midexpiratory flow
rate.
D. The flow–volume loop displays essentially the same information as the spirometer.
E. Effort-dependent areas of the loop determine large airway patency.
7. C. In patients with restrictive lung disease, the maximum midexpiratory flow rate is usually
normal, but total lung capacity is reduced. Lung volume is displayed on the horizontal axis of a
flow–volume curve, and flow is displayed on the vertical axis. The shape and peak of flow rates
during expiration at high volumes are effort dependent and indicate the patency of the larger
airways. Effort-independent expiration occurs at low lung volumes and usually reflects smaller
airway resistance. The best measurement for small airway disease is a maximum midexpiratory
flow rate of 25% to 75% of vital capacity. The flow–volume loop essentially displays the same
information as the spirometer but is more convenient for measurement of specific flow rates.
(See page 1035: Flow–Volume Loops.)
8. All of the following statements regarding the treatment of wheezing are true
EXCEPT:
A. Ipratropium bromide causes bronchodilation by increasing 3′5′-cyclic guanosine
monophosphate levels.
P.204
B. Aminophylline should be used cautiously in patients with myocardial ischemia.
C. Cromolyn sodium is of little value in the treatment of acute wheezing episodes.
D. Steroids decrease mucosal edema and prevent the release of bronchoconstricting
substances.
E. β-Agonist aerosols cause bronchodilation by increasing 3′5′-cyclic adenosine
monophosphate levels.
8. A. Ipratropium bromide blocks the formation of 3′5′-cyclic guanosine monophosphate and
therefore has a bronchodilatory effect. The balance between 3′5′-cyclic adenosine
monophosphate (which produces bronchodilation) and 3′5′-cyclic guanosine monophosphate
(which produces bronchoconstriction) determines the state of contraction of the bronchial
smooth muscle. Aminophylline may cause ventricular dysrhythmias, so it should be used
cautiously when treating patients with cardiac disease. Steroids decrease mucosal edema and
prevent the release of bronchoconstricting substances. Cromolyn sodium stabilizes the mast
cells and inhibits degranulation and histamine release. It is useful in the prevention of
bronchospastic attacks but is of little value in the treatment of acute exacerbations. (See page
1037: Wheezing and Bronchodilation.)
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9. The following are true regarding intraoperative monitoring during thoracic surgery
EXCEPT:
A. Pulmonary artery (PA) catheters often cannot be relied on to accurately assess left
ventricular end-diastolic volume (LVEDV).
B. The central venous pressure (CVP) is helpful in determining right ventricular
performance.
C. A central line placed in the external jugular vein often kinks after patient positioning.
D. The CVP has been shown to have a poor correlation with left atrial pressure in
patients with pulmonary disease.
E. Patients with chronic obstructive pulmonary disease (COPD) presenting for lung
resection usually have a left-sided heart strain pattern on the electrocardiogram (ECG).
9. E. Patients presenting for lung surgery often have COPD owing to cigarette smoking and
right-sided heart strain evident on the ECG. A CVP catheter reflects blood volume, right
ventricular performance, and venous tone. The major disadvantage of using the external jugular
vein for placement of a CVP is that the catheter may kink when the patient is turned laterally.
The CVP has been shown to have poor correlation with the left atrial pressure in patients with
pulmonary disease. A major limitation of the PA catheter is the assumption that the pulmonary
capillary wedge pressure provides a good approximation of LVEDV. (See page 1038:
Intraoperative Monitoring.)
10. Pulmonary artery (PA) catheters:

A. are most often directed to the left upper lobe
B. should lie in the nondependent lung when one-lung ventilation is used
C. are most reliably inserted through the right internal jugular vein
D. yield inaccurate data when placed in the dependent lung
E. provide a good approximation of left ventricular end-diastolic volume (LVEDV)
10. C. The tip of a flow-directed PA catheter usually ends up in the right lower lobe because
this is the area of highest pulmonary blood flow. The PA catheter is most reliably inserted
through the right internal jugular vein using a modified Seldinger technique. During thoracotomy
with one-lung ventilation, a catheter in the dependent lung should produce accurate
hemodynamic measurements. A major limitation of PA catheters is the assumption that the
pulmonary capillary wedge pressure (PCWP) provides a good approximation of LVEDV. The
use of PCWP directly to assess preload assumes a linear relationship between ventricular end-
diastolic volume and ventricular end-diastolic pressure. However, alterations in ventricular
compliance affect this pressure–volume relationship during surgery. Decreases in ventricular
compliance may occur with myocardial ischemia, shock, right ventricular overload, or pericardial
effusion. (See page 1039: Pulmonary Artery Catheterization.)
11. Which of the following is TRUE regarding the diffusing capacity for carbon
monoxide (DLCO)&quest;
A. A preoperative DLCO less than 60% of predicted indicates high risk of mortality after
lung resection.
B. DLCO testing is of little clinical use.
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C. DLCO correlates well with forced expiratory volume in 1 second (FEV1).

D. It is impaired by interstitial lung disease.
E. Predicted postoperative diffusing capacity percent is a poor predictor of mortality after
lung resection.
11. D. Gas exchange ability by the lungs can be evaluated by testing the DLCO. This parameter
is impaired in disorders such as interstitial lung disease. If the tested DLCO is less than 40%,
there is an increased risk of postoperative respiratory complications and mortality after lung
resection surgery. Little relationship exists between predicted postoperative DLCO and
predicted postoperative FEV1. Predicted postoperative diffusing capacity percent is the
strongest single predictor of risk of complications and mortality after lung resection. (See page
1036: Diffusing Capacity for Carbon Monoxide.)
12. With respect to the intraoperative use of transesophageal echocardiography (TEE),

which of the following statements is FALSE&quest;
A. TEE is useful for detecting ventricular dysfunction.
B. Peripheral and central lung tumors are equally easy to locate with TEE.
C. TEE may be used to detect pulmonary artery compression by a mediastinal tumor.
D. TEE can help determine whether cardiopulmonary bypass is necessary for tumor
resection.
E. Aortic dissection may be diagnosed with TEE.
12. B. TEE can consistently locate central lung tumors, but peripheral lung tumors are located
only 30% of the time. TEE is a useful intraoperative monitor for ventricular function, valvular
function, and wall motion abnormalities. TEE may help determine when cardiopulmonary
bypass is necessary for mediastinal tumor resection. TEE may also show mediastinal tumors
compressing the pulmonary artery. In an exploratory thoracotomy for hemothorax, intraoperative
TEE revealed the presence of a subacute aortic dissection, which was believed to be the cause
of the hemothorax. (See page 1039: Transesophageal Echocardiography.)
13. Which of the following statements is TRUE regarding changes seen when a patient
is positioned in the lateral decubitus position&quest;
A. Blood flow to the nondependent lung is significantly greater than it is to the dependent
lung.
B. The distribution of blood flow is turned by 180 degrees compared with the supine
position.
C. An awake, spontaneously breathing patient will demonstrate poor ventilation
–perfusion matching in the dependent lung.
D. Ventilation in the dependent lung is greater than in the nondependent lung.
E. The nondependent hemidiaphragm is displaced higher into the chest.
13. D. In the lateral decubitus position, blood flow and ventilation to the dependent lung are
significantly greater than to the nondependent lung. In the lateral decubitus position, the
distribution of blood flow and ventilation is similar to that in the upright position but turned by 90
degrees. Good ventilation–perfusion matching at the level of the dependent lung results in
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adequate oxygenation in the awake, spontaneously breathing patient. The dependent
hemidiaphragm is pushed higher into the chest by the abdominal contents than is the
nondependent diaphragm. (See page 1040: Physiology of One-Lung Ventilation, Lateral
Position, Awake, Breathing Spontaneous, Chest Closed.)
14. A patient undergoing a right thoracotomy with one-lung ventilation is given

vecuronium bromide and is placed in the left lateral decubitus position. The following
statements are true EXCEPT:
A. Thirty-five percent of the cardiac output participates in gas exchange in the left lung.
B. Hypoxic pulmonary vasoconstriction reduces blood flow to the nondependent hypoxic
lung by 50%.
C. The patient's functional residual capacity (FRC) is reduced by receiving vecuronium
bromide.
D. One-lung ventilation causes a right-to-left shunt in the nonventilated lung.
E. Atelectasis may inhibit optimal ventilation to the dependent lung.
14. A. Before the initiation of one-lung anesthesia, the average percentage of cardiac output
participating in gas exchange is 35% in the nondependent lung and 60% in the dependent lung.
After the initiation of one-lung anesthesia, hypoxic pulmonary vasoconstriction reduces the
blood flow to the nondependent lung by 50%. The FRC and the total lung volume decrease
during one-lung ventilation. There are several reasons for this, including general anesthesia,
paralysis, pressure from the abdominal contents, compression by the weight of mediastinal
structures, and suboptimal positioning on the operating table. Atelectasis is one cause of
suboptimal ventilation to the dependent lung. (See page 1040: Physiology of One-Lung
Ventilation, One-Lung Ventilation, Anesthetized, Paralyzed, Chest Open.)
15. When positioning a double-lumen tube:

A. insertion through the vocal cords is performed with the distal curvature facing laterally
B. the tube should be advanced until moderate resistance is encountered
C. the Miller laryngoscope blade yields a much easier tube insertion than does a
Macintosh laryngoscope blade
D. the stylet should be removed after the tube is rotated 90 degrees
E. a left-sided tube should be rotated 90 degrees to the right after the tip passes through
the vocal cords
15. B. Advancement of a double-lumen tube should be stopped when moderate resistance to
further passage is encountered, which indicates that the tube tip has been seated in the stem
bronchus. A Macintosh laryngoscope blade is preferred for intubation with a double-lumen tube
because it provides the largest area through which to pass the tube. The insertion of the tube
between the vocal cords is performed with the distal concave curvature facing anteriorly. It is
important to remove the stylet before rotating or advancing the tube farther to avoid tracheal or
bronchial lacerations. After the tip of the tube passes the vocal cords, the stylet is removed. A
right-sided tube then is rotated 90 degrees to the right; a left-sided tube is rotated 90 degrees to
the left. (See page 1044: Placement of Double-Lumen Tubes.)
16. All the following are absolute indications for one-lung ventilation EXCEPT:
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A. pneumonectomy
B. massive hemorrhage
C. bronchopleural fistula
D. unilateral abscess
E. bronchopulmonary lavage
16. A. In clinical practice, a double-lumen tube is commonly used for lobectomy or
pneumonectomy; however, these are relative indications for lung separation. Separation of the
lungs to prevent spillage of pus or blood from an infected or bleeding source is an absolute
indication for one-lung ventilation. Bronchopleural or bronchocutaneous fistulae represent low-
resistance escape pathways for the tidal volume delivered by positive-pressure ventilation.
These are both absolute indications for one-lung ventilation. During bronchopulmonary lavage,
an effective separation of the lungs is mandatory to avoid accidental spillage of fluid from the
lavaged lung to the nondependent ventilated lung. (See page 1042: Absolute Indications for
One-Lung Ventilation and page 1043: Relative Indications for One-Lung Ventilation.)
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17. When checking the position of the double-lumen tube, all of the following are true
EXCEPT:
A. Use of an underwater seal is a good method to verify separation before
bronchopulmonary lavage.
B. Inflation of the bronchial cuff rarely requires more than 2 mL of air.
C. Selective capnography can be used to ensure correct placement.
D. A pediatric bronchoscope should be passed through the tracheal lumen first.
E. If breath sounds are not equal after the tracheal cuff is inflated, the tube should be
advanced 2 to 3 cm.
17. E. If breath sounds are not equal after the tracheal cuff is inflated, the double-lumen tube is
likely too far down. Withdrawing the tube by 2 or 3 cm usually restores equal breath sounds.
Inflation of the bronchial cuff rarely requires more than 2 mL of air. The bronchoscope usually is
introduced first through the tracheal lumen. The carina is visualized, and bronchial cuff
herniation should not be seen. Common methods of ensuring the correct placement of a
double-lumen tube include fluoroscopy, chest radiography, selective capnography, and the use
of an underwater seal. If the bronchial cuff is not inflated and positive-pressure ventilation is
applied to the bronchial lumen of the double-lumen tube, gas will leak past the bronchial cuff
and will return to the tracheal lumen. If the tracheal lumen is connected to an underwater seal
system, gas will be seen bubbling up through the water. The bronchial cuff can then be
gradually inflated until no gas bubbles are seen. (See page 1044: Placement of Double-Lumen
Tubes.)
18. All of the following inhibit hypoxic pulmonary vasoconstriction EXCEPT:

A. propofol
B. pulmonary embolism
C. epinephrine
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D. mitral stenosis
E. infection
18. A. It is generally believed that inhaled agents inhibit human papillomavirus (HPV), but
intravenous drugs do not have this effect. Factors associated with an increase in pulmonary
artery pressure antagonize the effects of increased resistance caused by hypoxic pulmonary
vasoconstriction and result in increased flow to the hypoxic region. Indirect inhibitors of hypoxic
pulmonary vasoconstriction include mitral stenosis, thromboembolism, and vasopressors such
as epinephrine. Direct inhibitors of hypoxic pulmonary vasoconstriction include infection and
vasodilator drugs. (See page 1054: Effects of Anesthetics and Hypoxic Pulmonary
Vasoconstriction.)
19. All of the following are true regarding patients with mediastinal masses EXCEPT:
A. Local anesthesia is an anesthetic option for biopsy.
B. Airway obstruction on induction of anesthesia may be relieved with neuromuscular
blocking agents.
C. Hypotension on induction of anesthesia may be secondary to cardiac compression.
D. Mediastinal masses may coexist with superior vena cava syndrome.
E. Passage of a rigid bronchoscope beyond the obstruction may be lifesaving.
19. B. When a patient has a mediastinal mass and there is concern that airway obstruction may
occur during anesthetic induction, an awake fiberoptic intubation is the technique of choice.
Spontaneous respiration should be maintained because muscle paralysis may result in airway
compression and may worsen the obstruction. Ventilatory difficulties may be relieved by passing
the rigid bronchoscope beyond the obstruction under direct laryngoscopy or by changing the
patient's position. Mediastinal masses may cause superior vena cava syndrome. Cardiac
compression may become apparent after the induction of anesthesia. (See page 1058:
Diagnostic Procedures for Mediastinal Masses.)
20. Mediastinoscopy:
A. commonly occludes the left radial pulse
B. may be associated with right hemiparesis
C. may cause injury to the superior laryngeal nerve
D. is a procedure with potential for life-threatening hemorrhage
E. must be performed with the patient under general anesthesia
20. D. Mediastinoscopy is a means of assessing the spread of lung carcinoma. Hemorrhage is
a real risk and may be life threatening, so blood must be available. Pressure on the innominate
artery by the mediastinoscope has been thought to cause transient left hemiparesis; therefore,
it is recommended that blood pressure be monitored in the left arm and that the right radial
pulse be monitored continuously. Recurrent laryngeal nerve injury may occur either secondary
to damage by the mediastinoscope or by tumor involvement. If both recurrent laryngeal nerves
are damaged, upper airway obstruction may result. Most surgeons and anesthesiologists prefer
general anesthesia using an endotracheal tube and continuous ventilation because this offers a
more controlled situation and greater flexibility in terms of surgical manipulation. (See page
1059: Mediastinoscopy.)
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21. Regarding lung volume reduction surgery, all of the following are true EXCEPT:
A. This procedure is necessary in patients with end-stage emphysema.
B. Ventilation can usually be decreased after the chest is open.
C. Nitrous oxide should be avoided.
D. Pneumothorax may be difficult to diagnose.
E. Patients have a greater amount of functional lung tissue after surgery.
21. B. Extensive bullae represent end-stage emphysematous destruction of the lung. After the
chest is open during lung volume reduction surgery, more of the tidal volume may enter the
compliant bullae, which are no longer limited by chest wall integrity, and an increase in
ventilation is needed until the bullae are resected. Nitrous oxide should be avoided because it
may cause expansion of the bullae. The diagnosis of pneumothorax may be made by a
unilateral decrease in breath sounds (which may be difficult to distinguish in a patient with
bullous disease). Unlike most cases of pulmonary resection, after bullectomy, patients are left
with a greater amount of functional lung tissue than was previously available to them, and the
mechanics of respiration are improved. (See page 1062: Lung Cysts and Bullae.)
22. Which of the following statements regarding bronchopulmonary lavage is

TRUE&quest;
A. The cuff seal of an endobronchial tube should be adjusted so that no leak is present
at 50 cm H2O.
B. Most patients require 3 days of mechanical ventilation after lavage.
C. The patient is turned so the lavage side is uppermost.
D. After lung separation is achieved while the patient is under general anesthesia, the
patient is allowed to regain consciousness for the procedure.
E. The onset of rales in the ventilated lung indicates heart failure.
22. A. During bronchopulmonary lavage, the cuff seal should be checked to maintain perfect
separation of lungs at a pressure of 50 cm H2O to prevent leakage of lavage fluid. A
stethoscope should be placed over the ventilated lung to check for rales that may indicate
leakage of lavage fluid into this lung. After the trachea is intubated, the patient is turned so the
side to be treated is lowermost, and the double-lumen tube position and seal are checked
again. After another period of ventilation, most patients can be extubated in the operating room.
(See page 1063: Bronchopulmonary Lavage.)
23. Which of the following statements regarding fiberoptic bronchoscopy is

FALSE&quest;
A. Suction through the bronchoscope leads to a decreased PaO2.
B. Airway obstruction after fiberoptic bronchoscopy is a rare complication.
C. Positive end-expiratory pressure (PEEP) should be discontinued before passage of
the fiberscope.
D. The adult fiberscope can pass through a 7.5-mm endotracheal tube.
E. Jet ventilation may be achieved by attachment to the suction channel.
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23. B. During and after fiberoptic bronchoscopy, patients experience increased airway
obstruction. These changes are believed to be secondary to direct mechanical activation of
irritative reflexes in the airway and possibly to mucosal edema. The standard adult fiberoptic
bronchoscope has an external diameter of 5.7 mm and a 2-mm diameter suction channel. If
suction at 1 atm is applied to the fiberscope, air is removed at a rate of 14 L/min. If the
fiberscope is in the airway, this causes decreases in the fraction of inspired oxygen (FIO2),
PAO2, and functional residual capacity, leading to decreased PaO2. Therefore, suctioning
should be kept brief. The adult fiberscope can be passed through endotracheal tubes of 7 mm
or greater internal diameter. Clearly, passage through an endotracheal tube decreases the
cross-sectional area available for ventilating the patient, so if fiberoscopy is planned, an
endotracheal tube of the largest possible diameter should be used. Insertion of the
bronchoscope also causes a significant PEEP effect that may result in barotrauma in ventilated
patients. If PEEP is already being used, it should be discontinued before passage of the
fiberscope. Post-endoscopy chest radiography is advisable to exclude the presence of
mediastinal emphysema or pneumothorax. The suction channel of the adult fiberoptic
bronchoscope has been used to oxygenate and ventilate the lungs of patients. (See page 1056:
Anesthesia for Diagnostic Procedures and page 1057: Fiberoptic Bronchoscopy.)
24. Which of the following statements regarding choice of anesthesia for thoracic
surgery is FALSE&quest;
A. Ketamine produces bronchodilation.
B. Remifentanil in combination with propofol significantly blunts hypoxic pulmonary
vasoconstriction.
C. Rocuronium is a preferred neuromuscular blocking agent.
D. Isoflurane may be beneficial because it increases the cardiac arrhythmia threshold.
E. Morphine may cause bronchoconstriction.
24. B. The potent inhaled anesthetic agents have all been shown to decrease airway reactivity
and bronchoconstriction provoked by hypocapnia or inhaled or irritant aerosols. Their
mechanism of action is probably a direct one on the airway musculature itself, and potent
inhaled anesthetic agents are therefore the drugs of choice in patients with reactive airways.
For an inhalation induction, halothane or sevoflurane may be preferable because they are the
least pungent of the three drugs, although after the patient is asleep, isoflurane may be the
preferred drug because it increases the cardiac arrhythmia threshold and provides greater
cardiovascular stability than halothane. Fentanyl does not appear to influence bronchomotor
tone, but morphine may increase tone by a central vagotonic effect and by releasing histamine.
In patients with reactive airways, ketamine may be the drug of choice for induction because it
has a bronchodilator effect and has been successfully used in the treatment of patients with
asthma. Propofol infused in doses of 6 to 12 mg/kg/hr does not abolish HPV during one-lung
ventilation in humans. Propofol infusion in combination with remifentanil is probably the
technique of choice for producing a stable OLV with no effect on HPV. (See page 1053: Choice
of Anesthesia for Thoracic Surgery.)
25. The goals of performing pulmonary function tests (PFTs) in patients scheduled for
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lung resection for treatment of a malignancy are to:
1. establish the maximum amount of resectable lung tissue
2. identify patients needing postoperative ventilatory support
3. evaluate the benefits of bronchodilators in reversing existing airway obstruction
4. evaluate whether increased inspired O2 concentration increases ventilation and
therefore the work of breathing
25. A. Preoperative PFTs allow the surgeon and anesthesiologist to determine the maximum
amount of resectable lung before the patient would become a pulmonary cripple. If the amount
of planned resection would cause significant morbidity, then reconsideration of the surgical plan
may be in order. PFTs also allow one to plan for postoperative ventilatory support after lung
resection. Preoperative PFTs also evaluate whether the patient exhibits airway obstruction and
whether that obstruction reverses completely or partly after bronchodilator therapy. (See page
1034: Pulmonary Function Testing and Evaluation for Lung Resectability.)
26. Which of the following sympathomimetic drugs are β 2-selective and produce
minimal cardiac effect from β 1-stimulation&quest;
1. Albuterol
2. Terbutaline
P.206
3. Metaproterenol
4. Epinephrine
26. A. Albuterol, terbutaline, and metaproterenol are β 2-selective sympathomimetic drugs that
have little effect on β 1-receptors (cardiac receptors). They are used to increase intracellular
cyclic adenosine monophosphate concentrations in bronchial smooth muscle and thereby
produce bronchodilation. Epinephrine stimulates both β 1- and β 2-receptors. (See page 1037:
Wheezing and Bronchodilation.)
27. Respiratory changes that occur after lower abdominal surgery include:
1. Total lung capacity decreases to the same extent after abdominal surgery as after
extremity surgery.
2. Tidal volume is decreased for approximately 2 weeks.
3. Pulmonary compliance increases.
4. Vital capacity decreases by 25%.
27. C. Tidal volume decreases by 20% within 24 hours after surgery and gradually returns to
normal after 2 weeks. Vital capacity is decreased by 25% to 50% within 1 to 2 days after
surgery and generally returns to normal after 1 to 2 weeks. Pulmonary compliance decreases
by 33% with similar reductions in functional residual capacity. Total lung capacity decreases
after abdominal surgery but not after extremity surgery. (See page 1034: Effects of Anesthesia
and Surgery on Lung Volume.)
28. Which of the following statements regarding pulmonary evaluation for lung
resectability is/are TRUE&quest;
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1. It is more useful to use the percent of predicted forced expiratory volume in 1 second
(FEV1) rather than the absolute value.
2. A patient with an abnormal vital capacity has a 33% likelihood of complications.
3. An FEV1 of less than 800 mL in a 70-kg patient is an absolute contraindication to lung
resection.
4. A ratio of residual volume to total lung capacity of 10% is consistent with a high risk for
pulmonary resection.
28. A. A patient with an abnormal vital capacity has a 33% likelihood of complications and a
10% risk of postoperative mortality. An FEV1 of less than 800 mL in a 70-kg patient is probably
incompatible with life and is an absolute contraindication to lung resection. It is preferable to
indicate the percentage of predicted rather than just using the absolute value. The percentage
of predicted takes into account the age and size of the patient, and the same number may have
a different implication in another patient. A ratio of residual volume to total lung capacity of more
than 50% indicates a patient who is at high risk for pulmonary resection. (See page 1035:
Spirometry.)
29. Which of the following statements concerning smoking is/are TRUE&quest;

1. Smoking decreases forced vital capacity and maximum midexpiratory flow rate.
2. Cessation of smoking for 48 hours before surgery shifts the oxyhemoglobin curve to
the left.
3. Most of the beneficial effects of smoking cessation do not occur before 2 to 3 months.
4. Smoking increases mucociliary transport.
29. B. Most of the beneficial effects of smoking cessation, such as improvement in ciliary
function, improvement in closing volume, increased maximum midexpiratory flow rate, and
reduction in sputum, usually occur 2 to 3 months after smoking cessation. Smoking increases
airway irritability, decreases mucociliary transport, and increases secretions. Smoking also
decreases forced vital capacity. Smoking cessation 48 hours before surgery has been shown to
decrease the level of carboxyhemoglobin and to shift the oxyhemoglobin dissociation curve to
the right, thus increasing O2 availability. (See page 1036: Smoking.)
30. Which of the following statements concerning oxygenation and ventilation is/are
TRUE&quest;
1. Arterial blood gases are unnecessary as long as end-tidal CO2 is monitored.
2. The alveolar dead space affects the arterial–alveolar CO2 gradient.
3. Hypercarbia is usually a greater problem than systemic hypoxia during one-lung
ventilation.
4. CO2 readings may help indicate correct double-lumen tube placement.
30. C. Normally, a small arterial–alveolar CO2 gradient of approximately 4 to 6 mm Hg is
dependent on the alveolar dead space. The capnogram waveform is helpful in diagnosing
airway obstruction, incomplete relaxation, and incorrect positioning of the double-lumen tube.
Adequacy of ventilation should be confirmed by monitoring arterial blood gases and PaCO2, in
particular. This may be estimated continuously and noninvasively by using capnography. During
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one-lung ventilation, systemic hypoxia is usually a greater problem than hypercarbia, making it
necessary to monitor arterial oxygenation. This is because CO2 is 20 times more diffusible than
O2; arterial CO2 concentration is more dependent on ventilation, but arterial O2 concentration
is more dependent on perfusion. (See page 1039: Monitoring of Oxygenation and Ventilation.)
31. Which of the following statements regarding bronchial blockers is/are TRUE&quest;
1. They are effective in maintaining lung isolation despite surgical manipulation.
2. An advantage is that they are useful in patients with difficult airways.
3. Placement of an endobronchial catheter into the bronchus should be performed
blindly.
4. A bronchial blocker may be used in a 12-year-old child.
31. C. The Univent tube may be helpful for cases in which changing the double-lumen tube to a
single-lumen tube may be difficult (e.g., after bilateral lung transplantation). The Univent tube is
a single-lumen endotracheal tube with a movable endobronchial blocker. An independently
passed bronchial blocker may be used with a single-lumen tube to obtain lung isolation, thereby
avoiding the use of a double-lumen tube in a patient with a difficult airway. The bronchial
blocker technique may be useful in achieving selective ventilation in adults and may be used in
children younger than 12 years old. It should be placed via bronchoscopic guidance. These
tubes are not used very commonly because they are easily displaced. Displacement of the
bronchial blocker necessitates a pause in surgery while it is replaced under bronchoscopic
guidance. (See page 1043: Methods of Lung Separation.)
32. During one-lung ventilation:

1. tidal volumes should be adjusted to 10 to 12 mL/kg
2. continuous positive airway pressure (CPAP) to the nondependent lung increases
arterial O2 concentration
3. hyperventilation can lead to a decreased PaO2 level
4. a fraction of inspired oxygen (FIO2) of 1.0 is frequently used
32. E. During one-lung ventilation, the dependent lung should be ventilated with a tidal volume
of 10 to 12 mL/ kg. The single most effective maneuver to increase arterial O2 concentration
during one-lung ventilation is the application of CPAP to the nondependent lung. It is important
not to hyperventilate the patient's lungs because hypocapnia will increase vascular resistance
in the dependent lung, inhibit nondependent lung hypoxic pulmonary vasoconstriction, increase
the shunt, and therefore decrease the PaO2 concentration. An FIO2 of 1.0 is usually used
during one-lung ventilation. This high oxygen concentration serves to protect against
hypoxemia during the procedure. (See page 1051: Tidal Volume and Respiratory Rate and
page 1052: Continuous Positive Airway Pressure to the Nondependent Lung.)
33. Hypoxic pulmonary vasoconstriction:

1. is increased in the presence of potent inhaled anesthetics
2. is indirectly inhibited by hypothermia
3. is inhibited by volume overload
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4. is activated by collapse of the nondependent lung
33. C. Normally, collapse of the nonventilated, nondependent lung results in the activation of
reflex hypoxic pulmonary vasoconstriction. Some indirect inhibitors of hypoxic pulmonary
vasoconstriction include volume overload, thromboembolism, and hypothermia. (See page
1054: Hypoxic Pulmonary Vasoconstriction.)
34. Rigid bronchoscopy is the procedure of choice for:

1. assessing vascular tumors of the lower airway
2. securing an airway in a difficult intubation
3. bronchoscopy in small children
4. evaluation of upper lobe lesions
34. B. The rigid bronchoscope is the instrument of choice for removal of foreign bodies, control
of massive hemoptysis, assessment of vascular tumors, bronchoscopy in small children, and
resection of endobronchial lesions. Flexible bronchoscopy is useful in evaluating upper lobe
lesions and in securing an airway in difficult intubations. (See page 1056: Table 40-4:
Anesthesia for Diagnostic Procedures.)
35. Which of the following statements regarding myasthenia gravis is/are TRUE&quest;
1. Examination of pupillary size may differentiate between myasthenic and cholinergic
crisis.
2. These patients are very sensitive to depolarizing muscle relaxants and are resistant to
nondepolarizing muscle relaxants.
3. Thymectomy is considered to be the treatment of choice in many patients with
generalized myasthenia gravis.
4. This condition is associated with a markedly decreased release of acetylcholine from
nerve terminals.
35. B. The distinction between a myasthenic crisis and a cholinergic crisis may be made using
a Tensilon test or by examining pupillary size (which is large during a myasthenic crisis but
small during a cholinergic crisis). Thymectomy is now considered the treatment of choice in
many patients with myasthenia gravis. Patients with myasthenia gravis are sensitive to the
nondepolarizing relaxants and are resistant to succinylcholine. The basic abnormality in
myasthenia gravis is a decrease in the number of postsynaptic acetylcholine receptors at the
end plates of the affected muscles. Myasthenia gravis is an autoimmune disorder, and most
affected patients have circulating antibodies to the acetylcholine receptors. (See page 1064:
Myasthenia Gravis.)
36. Which of the following statements regarding video-assisted thoracoscopic surgery

(VATS) is/are TRUE&quest;
1. CO2 may be insufflated into the pleural cavity.
2. Continuous positive airway pressure (CPAP) may interfere with the surgical
procedure.
3. The need for one-lung ventilation is greater for VATS than for open thoracotomy.
4. It may take 30 minutes for complete lung collapse.
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36. E. During VATS, CO2 may be insufflated into the pleural cavity to help visualization by the
surgeon. CPAP may interfere with the surgical procedure and should be used only as a last
resort in VATS. The need for one-lung ventilation is greater with VATS than with open
thoracotomy because it is not possible to retract the lung during VATS, although it is possible
during open thoracotomy. It may take 30 minutes for complete lung collapse; thus, the operated
lung should be deflated as soon as possible after tracheal intubation and positioning of the
double-lumen tube. (See page 1060: Video-Assisted Thoracoscopic Surgery.)
37. Which of the following statements about central venous pressure (CVP) monitoring
is/are TRUE&quest;
1. It reflects right-sided heart function.
2. One common use is for the infusion of vasoactive drugs.
3. A CVP catheter can be place from either the internal or external jugular vein.
4. It reliably reflects intravascular status.
37. A. The CVP reflects right-sided heart function, not left ventricular performance. Uses of
CVP catheters or large-bore introducers include insertion of a transvenous pacemaker, infusion
of vasoactive drugs, and insertion of a pulmonary artery (PA) catheter, which may subsequently
be required during surgery or in the postoperative period. A recent study in healthy subjects
indicated that contrary to common belief, the CVP did not reflect intravascular volume status.
The CVP catheter may be placed centrally from the external or the internal jugular vein, from
the subclavian veins, or from one of the arm veins. The success rate is highest using the right
internal jugular vein, and a pacemaker or PA catheter may be inserted most easily from this
vein. The major disadvantage of using the external jugular vein during thoracotomy is that the
catheter often kinks when the patient is turned to the lateral decubitus position. (See page
1038: Central Venous Pressure Monitoring.)
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38. Which of the following statements about double-lumen endobronchial tubes (DLT)
is/are TRUE&quest;
1. The depth required for insertion of the tube correlates with the patient's height.
2. A left-sided tube is preferred for both right- and left-sided procedures.
3. The width of the left bronchus is directly proportional to the width of the trachea.
4. A 37-Fr double-lumen tube is the correct size for most women.
38. E. Because the left main bronchus is considerably longer than the right bronchus, there is a
narrower margin of safety on the right main bronchus with potentially a greater risk of upper
lobe obstruction whenever a right-sided DLT is used. Hence, a left-sided DLT is preferred for
both right- and left-sided procedures. In patients in whom the left main bronchus cannot be
directly measured, the left bronchial diameter can be accurately estimated by measuring
tracheal width. The width of the left bronchus is directly proportional to the width of the trachea.
The left bronchial width is estimated by multiplying the tracheal width by 0.68. Typically, most
women need a 37-Fr DLT, and most men can be adequately managed with a 39-Fr DLT. The
depth required for insertion of the DLT correlates with the height of the patient. For any adult
who is 170 to 180 cm tall, the average depth for a left DLT is 29 cm. For every 10-cm increase
or decrease in height, the DLT is advanced or withdrawn approximately 1.0 cm. (See page X:
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Methods of Lung Separation and page 1043: Double-Lumen Endobronchial Tubes.)
39. Which of the following statements concerning malposition of a double-lumen tube

(DLT) is/are TRUE&quest;
1. If the DLT is not inserted far enough, breath sounds are not audible over the
contralateral side.
2. The mean distance from the carina to the right upper lobe orifice is 2 to 3 cm.
3. If the DLT is inserted too far down either bronchus, breath sounds will be heard
bilaterally when ventilating through the bronchial lumen.
4. Tracheal rupture is a rare complication.
39. C. Upon insertion, the DLT may be passed too far down into either the right or the left
mainstem bronchus. In this case, breath sounds are very diminished or are not audible over the
contralateral side. This situation is corrected when the tube is withdrawn and until the opening
of the tracheal lumen is above the carina. A right-sided DLT may occlude the right upper lobe
orifice. The mean distance from the carina to the right upper lobe orifice is 2.3 ± 0.7 cm in men
and 2.1 ± 0.7 cm in women. Upon insertion, the DLT may not be inserted far enough, leaving
the bronchial lumen opening above the carina. In this position, good breath sounds are heard
bilaterally when ventilating through the bronchial lumen even after its cuff is inflated, but no
breath sounds are audible when ventilating through the tracheal lumen because the inflated
bronchial cuff obstructs gas flow arising from the tracheal lumen. The cuff should be deflated
and the DLT rotated and advanced into the desired mainstem bronchus. A rare complication
with DLTs is tracheal rupture. Overinflation of the bronchial cuff, inappropriate positioning, and
trauma owing to intraoperative dislocation that resulted in bronchial rupture have been
described in association with the Robertshaw tube and the disposable DLT. (See page 1043:
Methods of Lung Separation and page 1043: Double-Lumen Endobronchial Tubes.)
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Review of Clinical Anesthesia, 5e [Vishal] 41. Anesthesia for Cardiac Surgery
Chapter 41
Anesthesia for Cardiac Surgery
1. The area of the myocardium most at risk for ischemia is the:

A. right ventricle
B. apex of the left ventricle
C. interventricular septum
D. portion of the right atrium containing the sinoatrial node
E. subendocardial region of the left ventricle
1. E. Although zones of ischemic myocardium may result from inadequate coronary blood flow
through the vessels supplying each region, the area of myocardium most vulnerable to ischemia
is the subendocardial region of the left ventricle. This is not only because of a greater metabolic
requirement in the presence of greater systolic shortening but also because subendocardial
blood flow is restricted during systole. (See page 1074: Coronary Blood Flow.)
2. The principal determinants of myocardial oxygen demand are:

A. wall tension and contractility
B. systemic vascular resistance and heart rate
C. mean arterial blood pressure and heart rate
D. preload and afterload
E. mean arterial blood pressure and systemic vascular resistance
2. A. Wall tension and contractility are the principal determinants of myocardial oxygen demand.
Wall tension, in turn, is directly proportional to intracavitary pressure and ventricular radius and
is inversely proportional to the thickness of the ventricular wall. Therefore, myocardial oxygen
demand may be reduced by interventions that prevent or treat ventricular distention and reduce
contractility. (See page 1074: Coronary Artery Disease: Myocardial Oxygen Demand.)
3. Under normal conditions, approximately what is the oxygen saturation of blood

entering the coronary sinus&quest;
A. 10%
B. 25%
C. 50%
D. 75%
E. 90%
3. C. Oxygen extraction in the coronary circulation is extremely efficient; blood entering the
coronary sinus is typically about 50% saturated. Although extraction may be increased
somewhat in response to stress, the principal mechanism by which oxygen supply is increased
in response to increased oxygen demand is through an increase in coronary blood flow. (See
page 1074: Coronary Artery Disease: Myocardial Oxygen Supply.)
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4. Regarding perfusion of the left ventricular subendocardium, which one of the
following statements is most accurate&quest;
A. It occurs mostly during systole.
B. It occurs mostly during diastole.
C. It increases with an increase in left ventricular end-diastolic pressure.
D. It is unaffected by heart rate.
E. It decreases with an increase in aortic diastolic pressure.
4. B. The left ventricular subendocardium is one of the areas of the heart that is most
vulnerable to ischemia because of its high metabolic requirements. Perfusion of the
subendocardial tissue of the left ventricle takes place mostly during diastole; this is in contrast
to perfusion of the right ventricle, which occurs principally during systole. Perfusion pressure is
defined as the difference between aortic diastolic pressure and left ventricular end-diastolic
pressure. Whereas an increase in aortic diastolic pressure increases perfusion, an increase in
left ventricular end-diastolic pressure decreases perfusion. Insofar as changes in heart rate
affect diastolic time, changes in heart rate do cause changes in perfusion. (See page 1074:
Coronary Artery Disease: Coronary Blood Flow.)
5. The normal area of the aortic valve is:
A. 0.2 to 0.4 mm2
B. 2 to 4 mm2
C. 0.2 to 0.4 cm2

D. 4 to 8 cm
E. 2 to 4 cm2
5. E. The normal aortic valve diameter is 1.9 to 2.3 cm, and the normal aortic valve area is 2 to
4 cm2. Aortic stenosis is classified based on the degree of narrowing of the aortic valve area.
Aortic stenosis is considered critical when the area of the aortic valve is below 0.8 cm2.
Patients with this degree of aortic stenosis are almost always symptomatic, and surgical
correction is indicated. (See page 1078: Valvular Heart Disease: Aortic Stenosis.)
6. Which of the following conditions best describes a physiologic change associated

with mitral stenosis&quest;
A. Left ventricular outflow obstruction
B. Left ventricular dysfunction resulting from chronic pressure overload
C. Left ventricular dysfunction resulting from chronic volume overload
D. Decreased right ventricular pressure
E. Increased left atrial pressure and concomitant right ventricular hypertrophy
6. E. In mitral stenosis, left atrial pressure elevation is a consequence of a narrowed mitral
orifice. This increased pressure is transmitted back through the pulmonary circulation, leading
to right ventricular hypertrophy. Conversely, the left ventricle is not subject to pressure or
volume overload, and normal function is generally preserved. (See page 1082: Mitral Stenosis.)
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7. An advantage of membrane over bubble oxygenators in cardiopulmonary bypass

circuits is:
A. The uptake of inhaled anesthetics is more predictable with membrane oxygenators.
B. There is less trauma to blood constituents.
C. Pulsatile flow is possible with the use of a membrane oxygenator.
D. Membrane oxygenators offer a cost advantage over bubble oxygenators.
E. Carbon dioxide exchange is significantly more effective.
7. B. Studies comparing the two types of oxygenators reveal less trauma to blood constituents
with membrane oxygenators. Hemolysis and the resultant release of red blood cell debris are
potential problems associated with bubble oxygenators. Likewise, a decrease in platelet activity
resulting from platelet destruction, increased aggregation, and adherence to the oxygenator
may lead to impairment of postoperative hemostasis. (See page 1087: Oxygenators.)
8. The most commonly used test to evaluate the adequacy of anticoagulation for
cardiopulmonary bypass is:
A. heparin concentration assay
B. antithrombin III index
C. activated partial thromboplastin time (APTT)
D. activated clotting time (ACT)
E. prothrombin time (PT)
8. D. The ACT indicates the time required for thrombus formation after a sample of whole blood
is mixed with a clotting accelerator. A value of more than 400 seconds is generally believed to
reflect a degree of anticoagulation that is adequate for cardiopulmonary bypass. (See page
1088: Anticoagulation.)
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9. Advantages of centrifugal versus roller pumps cardiopulmonary bypass (CPB)
machines include all of the following EXCEPT:
A. less blood trauma
B. less risk of air emboli
C. elimination of tubing wear and the risk of plastic microemboli
D. ability to deliver pulsatile blood flow
E. reduction in line pressures
9. D. Centrifugal CPB machines operate by a magnetically controlled impeller and an electric
motor and are rapidly replacing the older roller pump systems. Advantages of the centrifugal
system include less trauma to blood entering the system, lower line pressures, reduced risk of
air emboli, and elimination of tubing wear and plastic emboli resulting from tubing compression
(spallation). Neither roller pumps nor centrifugal pumps may deliver physiologically significant
pulsatile blood flow. (See page 1095: Cardiopulmonary Bypass: Pumps.)
10. For each degree of Celsius decrease in body temperature, metabolic rate is
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decreased by approximately:
A. 1%
B. 2%
C. 4%
D. 8%
E. 10%
10. D. For each degree of Celsius decrease in body temperature, there is a reduction of 8% in
the metabolic rate. (See page 1095: Cardiopulmonary Bypass: Heat Exchanger.)
11. Nitric oxide dilates pulmonary vascular beds via:

A. production of cyclic adenosine monophosphate (cAMP)
B. inhibition of cAMP
C. production of cyclic guanosine monophosphate (cGMP)
D. inhibition of cGMP
11. C. Nitric oxide exerts most of its effects by stimulating the guanylyl cyclase enzyme, leading
to increased production of cGMP. In turn, cGMP stimulates phosphodiesterases, which relax
vascular smooth muscle, promoting vasodilation. (See page 1095: Cardiopulmonary Bypass.)
12. A patient with previously normal left ventricular function is undergoing elective
coronary artery bypass grafting. Immediately after separation from cardiopulmonary
bypass (CPB), the following measurements are noted: a blood pressure via radial intra-
arterial catheter of 78/52 mm Hg, a heart rate of 94 bpm, a pulmonary artery pressure
of 28/18 mm Hg, and a cardiac index of 2.7. The most prudent initial intervention would
be:
A. direct measurement of intra-aortic pressures to verify radial artery correlation
B. the addition of a phenylephrine infusion to provide α -receptor–mediated
vasoconstriction
C. the addition of an epinephrine infusion to provide both inotropic support and α -
receptor–mediated vasoconstriction
D. an intra-aortic volume infusion using pulmonary capillary wedge pressures as a guide
to the adequacy of left ventricular filling
E. a trial of atrial pacing after placement of epicardial leads
12. A. Although frequently accurate, radial artery pressure may be as much as 30 mm Hg lower
than central aortic pressure after CPB. Peripheral vasodilation during rewarming is thought to
be the cause of the discrepancy, which may be readily detected by direct transduction of intra-
aortic pressure via the operative field. This aortic–radial pressure gradient usually dissipates
within 45 minutes of separation from bypass. (See page 1091: Arterial Blood Pressure.)
13. The most frequent cause of perioperative neurologic complications after coronary
artery bypass grafting is:
A. changes in carotid artery flow dynamics during aortic cross-clamping
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A. changes in carotid artery flow dynamics during aortic cross-clamping
B. low-flow states in patients with pre-existing cerebrovascular disease
C. emboli
D. intraoperative hemodilution
E. ischemia to watershed regions of the brain during the rewarming phase of
cardiopulmonary bypass
13. C. Although the incidence of stroke after coronary artery bypass grafting is approximately
3%, the incidence of subtle cognitive deficits elicited by postoperative neuropsychiatric testing
is much higher (60%–70%). The origin of perioperative neurologic insults is believed to be
primarily embolic. Macroemboli, such as atheroma and particulate matter, account for most
overt perioperative strokes. Microemboli (air, platelet aggregates) are likely responsible for the
subtle cognitive changes seen after coronary artery bypass grafting. Most neuropsychiatric
deficits improve over the initial 2 to 6 months after cardiac surgery, although significant numbers
of patients (13%–39%) exhibit residual impairment. (See page 1092: Central Nervous System
Function and Complications.)
14. Of the following anesthetic techniques for cardiac surgery, the one associated with
the best outcome in terms of perioperative morbidity is:
A. a predominantly opioid-based anesthetic in conjunction with benzodiazepines
B. a “balanced” anesthetic technique using opioid analgesics combined with potent
inhalation agents titrated for varying degrees of stimulation
C. continuous high-dose sufentanil infusion
D. a predominantly potent inhalation agent–based technique with epidural catheter
placement for postoperative analgesia
14. E. Two large outcome studies by Tuman et al. and Slogoff and Keats reinforced the premise
that the choice of anesthetic per se has no effect on outcome in patients undergoing cardiac
surgery. More important is the ability of the anesthesiologist to preserve compensatory
cardiovascular mechanisms while preventing perioperative episodes of myocardial ischemia.
Because no data exist to document the superiority of any one anesthetic technique for cardiac
surgery, it becomes apparent that the proper management of the anesthetic is more important
than the technique used. (See page 1093: Selection of Anesthetic Drugs.)
15. In the immediate postcardiopulmonary bypass period, milrinone may be

particularly useful in the treatment of right ventricular failure secondary to high
pulmonary vascular resistance because:
A. the positive chronotropic effect of milrinone results in improved cardiac output from
the noncompliant right ventricle
B. milrinone improves right ventricular contractility while decreasing pulmonary vascular
resistance
C. milrinone decreases preload to the right ventricle by decreasing resistance in venous
capacitance vessels
D. the improvement in left ventricular performance afforded by milrinone in turn
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decreases right ventricular afterload
E. all of the above
15. B. A phosphodiesterase III inhibitor, milrinone, acts via a non–β -receptor pathway to effect a
decrease in pulmonary vascular resistance while improving left and right heart contractility.
Such interventions are the treatments of choice in conditions of right ventricular failure
secondary to high pulmonary vascular resistance; overdistention of the ventricle is carefully
avoided. (See page 1096: Discontinuation of Cardiopulmonary Bypass.)
16. The most common cause of persistent bleeding after heparin reversal in cardiac
surgical patients is:
A. heparin rebound
B. hypothermia
C. reduced platelet count or function
D. diminished capillary integrity
E. inactivation of antithrombin III
16. C. The usual causes of persistent oozing after heparin neutralization include inadequate
surgical hemostasis and reduced platelet count or function, although insufficient doses of
protamine, dilution of clotting factors, and (rarely) “heparin rebound” may be contributing
factors. Thrombocytopenia and diminished platelet function are frequent consequences of
extracorporeal circulation, resulting from platelet activation and destruction when in contact with
the bypass circuit. (See page 1100: Postbypass Bleeding.)
17. Compared with volatile anesthetics, which of the following statements about
propofol is FALSE&quest;
A. Propofol is associated with more favorable cardiac function.
B. Propofol is associated with higher need for inotropic support.
C. Propofol is associated with elevated plasma troponins after cardiac surgery in elderly
patients.
D. Propofol is associated with a predictable and fairly rapid awakening after
discontinuation.
E. Propofol may be continued postoperatively in the intensive care unit (ICU).
17. A. Compared with volatile anesthetics, propofol is associated with less favorable cardiac
function, a higher need for inotropic support, and elevated plasma troponins after cardiac
surgery in elderly patients. It may be continued postoperatively in the ICU, and it affords a
predictable and fairly rapid awakening after discontinuation. (See page 1077: Intravenous
Sedatives and Hypnotics.)
18. Which of the following statements regarding magnesium is FALSE&quest;

A. It has coronary vasodilating properties.
B. It reduces the size of myocardial infarction in the setting of acute ischemia.
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C. It acts as an antiarrhythmic agent.
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D. It decreases mortality associated with infarction.
E. It increases myocardial reperfusion injury.
18. E. Magnesium has use in the treatment of myocardial ischemia. It has coronary artery
vasodilating properties, reduces the size of myocardial infarction in the setting of acute
ischemia, and decreases mortality associated with infarction. In addition, it is an antiarrhythmic
agent, and it minimizes myocardial reperfusion injury. (See page 1077: Treatment of Ischemia.)
19. Which of the following statements regarding hypertrophic cardiomyopathy (HOCM)

is FALSE&quest;
A. HOCM is a dynamic obstruction.
B. The obstruction is attenuated by any intervention that reduces ventricular size.
C. HOCM is a genetically determined disease.
D. Angina during exercise occurs even in the absence of epicardial coronary artery
disease.
E. Hypotension is managed with volume replacement and vasoconstrictors.
19. B. Hypertrophic cardiomyopathy is a genetically determined disease. In patients with
HOCM, systolic septal bulging into the left ventricular outflow tract (LVOT), malposition of the
anterior papillary muscle, drag forces, and a hyperdynamic ventricular contraction may
contribute to creation of a LVOT gradient. This type of obstruction is dynamic and is
accentuated by any intervention that reduces ventricular size. Therefore, increases in
contractility and heart rate or decreases in either preload or afterload are harmful because they
facilitate septal–leaflet contact. In patients with HOCM, myocardial oxygen balance is tenuous,
and angina during exercise occurs even in the absence of epicardial coronary artery disease
when the coronary microcirculation is unable to supply the hypertrophied myocardium. In
patients with HOCM, angina results from the elevated left ventricular systolic pressure.
Pharmacologic management of hypotension in patients with HOCM should be done with volume
replacement and vasoconstrictors rather than inotropes and vasodilators. (See page 1080:
Hypertrophic Cardiomyopathy.)
20. What is the average prime volume for a cardiopulmonary bypass machine for
adults&quest;
A. 500–1000 cc
B. 1500–2500 cc
C. 3000–4000 cc
D. 4000–4500 cc
E. 5500–6500 cc
20. B. Many institutions use a standard volume prime for all adult patients, and others use a
minimum volume based on body weight or body surface area. The average prime volume is
1500 to 2500 cc. (See page 1088: Prime.)
21. Which of the following statements regarding heparin is FALSE&quest;

A. Intravenous heparin's peak onset of action is less than 5 minutes.
B. Heparin is a polyionic mucopolysaccharide.
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C. Heparin's half-life is approximately 90 minutes after intravenous (IV) injection.

D. Hypothermia decreases the half-life of heparin.
E. Heparin's anticoagulant effect is because of its ability to potentiate the antithrombin III
activity.
21. D. Heparin is a polyionic mucopolysaccharide extracted from either bovine lung or porcine
intestinal mucosa. After IV injection, the peak onset of heparin is less than 5 minutes with a half-
life of approximately 90 minutes in normothermic patients. In hypothermic patients, there is a
progressive increase in the half-life proportional to the degree of hypothermia. The
anticoagulant effect of heparin is derived from its ability to potentiate the activity of antithrombin
III. (See page 1088: Anticoagulation.)
22. Which of the following volatile anesthetic(s) has/have the fastest recovery&quest;
1. Desflurane
2. Isoflurane
3. Sevoflurane
4. Halothane
22. B. Desflurane and sevoflurane have the fastest recovery of all the volatile anesthetics. (See
page 1076: Inhalation Anesthetics.)
23. Which of the following are adverse effects of sodium nitroprusside (SNP)&quest;
1. Cyanide and thiocyanate toxicity
2. Rebound hypertension
3. Blood coagulation abnormalities
4. Hypothyroidism
23. E. SNP improves ventricular compliance in the ischemic myocardium. The recommended
dose of SNP is 0.5 to 3 μg/kg/min and is reduced in the presence of hepatic or renal disease.
Adverse effects include cyanide and thiocyanate toxicity, rebound hypertension, intracranial
hypertension, blood coagulation abnormalities, increased pulmonary shunting, and
hypothyroidism. (See page 1077: Sodium Nitroprusside.)
24. Which of the following are treatment options for cyanide toxicity&quest;
1. Discontinuation of sodium nitroprusside (SNP) infusion
2. Administration of 100% oxygen
3. Administration of amyl nitrate (inhaler)
4. Administration of intravenous sodium nitrite
24. E. Cyanide is produced when SNP is metabolized. The presenting signs of cyanide toxicity
include the triad of elevated mixed venous oxygen, requirements for increasing SNP dose, and
metabolic acidosis. Treatment should consists of discontinuing the infusion, administering 100%
oxygen, administering amyl nitrate (inhaler) or intravenous sodium nitrite and intravenous
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thiosulfate, except in patients with abnormal renal function, for whom hydroxocobalamin is
recommended. (See page 1077: Sodium Nitroprusside.)
25. Nitroglycerin is a useful agent in the treatment of myocardial ischemia because it:
1. is a coronary arterial vasodilator
2. reduces venous return
3. may reverse acute coronary vasospasm
4. reduces heart rate via baroreceptor mechanisms
25. A. Nitroglycerin is a modest coronary arterial dilator and as such is the drug of choice for
the acute treatment of coronary artery vasospasm. The reduction in venous return afforded by
the venodilatory effect of nitroglycerin leads to a lessening in myocardial wall tension and thus
to a reduction in myocardial oxygen demand. The use of nitroglycerin may result in reflex
tachycardia caused by a sudden decrease in venous return. (See page 1077: Nitrates.)
26. A 48-year-old man with a history of severe hypertrophic cardiomyopathy (HCOM) is

undergoing general anesthesia for elective total knee arthroplasty. A precipitous
decrease in cardiac output is noted just before the skin incision. His vital signs include
a blood pressure of 172/88 mm Hg and a heart rate of 104 bpm. Which of the following
intervention(s) is/are most likely to improve cardiac output&quest;
1. Administration of an inotropic agent
2. Administration of a volatile anesthetic agent
3. Titration of a vasodilator to decrease afterload
4. Administration of esmolol to decrease heart rate
26. C. The anesthetic management of patients with HCOM is directed at maintaining ventricular
filling and minimizing the factors predisposing to variable outflow obstruction. In this case, the
myocardial depression afforded by a volatile agent may be desirable, as would be a decrease in
heart rate. Similarly, inotropic agents may compound the problem. Vasodilators do not improve
the outflow obstruction and may result in precipitous decreases in systemic arterial pressures.
(See page 1080: Hypertrophic Cardiomyopathy.)
27. Which of the following conditions may be associated with segmental wall motion
abnormalities on transesophageal echocardiography&quest;
1. Myocardial ischemia
2. Hypovolemia
3. Myocardial infarction
4. Left bundle branch block
27. E. Segmental wall motion abnormalities are most commonly associated with myocardial
ischemia or infarction. However, other conditions may also cause segmental wall motion
abnormalities. Among these conditions are pacing, bundle branch blocks, myocarditis,
tachycardia, and hypovolemia. In addition, nonischemic myocardium in proximity to ischemic or
infarcted tissue may appear to have abnormal wall motion (“tethering phenomenon”). (See page
1075: Ischemia.)
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28. Which of the following statements regarding stroke after coronary artery bypass
graft surgery with is/are TRUE&quest;
1. Stroke occurs in approximately 2% to 5% of patients.
2. Diabetes is an independent risk factor.
3. Excessive warming during and after cardiopulmonary bypass may increase the
likelihood of its occurrence.
4. Stroke is most commonly the result of perioperative hypoperfusion injury.
28. A. The incidence of stroke after coronary artery bypass graft surgery is approximately 3%.
They most commonly result from macroemboli. Patients of advanced age (>70 years) and those
with diabetes, peripheral vascular disease, pre-existing cerebrovascular disease, history of
stroke, or atheromatous plaque in the ascending aorta are at increased risk for postoperative
stroke. In addition, operative factors such as prolonged duration of bypass and excessive
rewarming during and after bypass increase the risk of neurologic complications. (See page
1102: Preoperative Evaluation: Central Nervous System Function and Complications.)
29. Physiologic effects of nitroglycerin include:

1. systemic venodilation
2. decreased afterload
3. coronary artery dilation
4. cyanide production
29. A. Nitroglycerin is a systemic venodilator. In addition, at higher doses, nitroglycerin dilates
systemic arterial beds. Therefore, it both reduces preload (by decreasing venous return) and
reduces afterload (by decreasing systemic arterial pressure). Nitroglycerin is the drug of choice
in the treatment of patients with coronary vasospasm because it is also an effective dilator of
the coronary arterial bed, including stenosed arteries and collateral beds. However,
nitroglycerin may also cause methemoglobinemia, especially in patients with deficiencies of
methemoglobin reductase. Sodium nitroprusside, not nitroglycerin, may produce cyanide and
thiocyanate upon metabolism, posing the risk of toxicity during prolonged infusions or after
administration of relatively large quantities over short time periods. (See page 1074: Coronary
Artery Disease: Treatment of Ischemia.)
30. Pharmacologic agents with coronary artery dilator properties include:

1. nifedipine
2. nitroglycerin
3. diltiazem
4. magnesium
30. E. Nifedipine and diltiazem are calcium channel blockers that dilate coronary arteries and
are used as antianginal agents in the prevention of coronary vasospasm. Nitroglycerin also has
coronary artery dilating properties associated with the production of nitric oxide. Magnesium is
another coronary artery vasodilator that has been used to reduce infarct size and minimize
reperfusion injury in the setting of acute ischemia. (See page 1074: Coronary Artery Disease:
Treatment of Ischemia.)
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P.216
31. Which of the following statements regarding cardiac valvular structure and
pathology is/are TRUE&quest;
1. The normal aortic valve is composed of three leaflets.
2. The normal mitral value consists of three leaflets.
3. Mitral valve stenosis is most commonly of rheumatic origin.
4. Chordae tendineae connected to the papillary muscles help prevent prolapse of the
aortic valve leaflets into the left ventricle during systole.
31. B. The normal aortic valve consists of three leaflets, and the normal mitral valve is
composed of two leaflets. Rheumatic fever is by far the most common cause of mitral stenosis.
Chordae tendineae connected to the papillary muscles help prevent prolapse of the mitral valve
leaflets. (See page 1078: Valvular Heart Disease.)
32. Mechanisms by which heparin exerts its anticoagulant effect include:

1. activation of factor XIIa
2. direct inhibition of factor II
3. inhibition of kallikrein
4. potentiation of antithrombin III
32. C. Heparin is a polyionic mucopolysaccharide extracted from bovine lung or porcine
intestinal mucosa. Binding of heparin to antithrombin III greatly increases its intrinsic thrombin
inhibitory properties, thereby preventing the formation of fibrinous clots. In addition, heparin
binds directly to factor II (thrombin), thus inhibiting its action. Aprotinin is an antifibrinolytic agent
and protease inhibitor that delays activation of the intrinsic coagulation cascade via inhibition of
factor XIIa. In addition, it inhibits kallikrein and other serine proteases such as plasmin. It is used
during cardiopulmonary bypass (CPB) to reduce blood loss, improve platelet function, and
reduce the systemic inflammatory response to CPB. (See page 1086: Cardiopulmonary Bypass:
Anticoagulation.)
33. Which of the following statements about cardiac tamponade is/are TRUE&quest;
1. Clinical signs and symptoms include paradoxical pulse, tachycardia, and hypotension.
2. Stroke volume increases.
3. Cardiac output becomes rate dependent.
4. Compression of the left ventricle is usually most severe.
33. B. Cardiac tamponade involves an elevation in intrapericardial pressure, which impairs
venous return and may cause cardiac chamber collapse. Under this circumstance, the
chambers with the lowest intracardiac pressures (atria and right ventricle during diastole) are
most at risk of collapse. Stroke volume in cardiac tamponade is relatively fixed, so cardiac
output becomes dependent on heart rate. (See page 1102: Postoperative Considerations.)
34. Which of the following statements regarding the normal function of an intra-aortic
balloon pump (IABP) is/are TRUE&quest;
1. It is designed to reduce afterload.
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2. It is designed to increase diastolic blood pressure.
3. A properly inserted IABP should have its distal tip just below the subclavian artery.
4. The balloon is designed to deflate during diastole.
34. A. The IABP uses a synchronized counterpulsation method to improve myocardial function
by decreasing myocardial oxygen demand and increasing myocardial oxygen supply. The
device is most commonly inserted into the femoral artery and advanced so the distal tip lies just
below the subclavian artery and the proximal end is above the renal arteries. The balloon
inflates during diastole, increasing aortic diastolic pressure and improving coronary perfusion as
well as facilitating forward flow. During the subsequent systole, the balloon deflates, reducing
systemic afterload and facilitating left ventricular ejection. (See page 1102: Preoperative
Evaluation: Intra-aortic Balloon Pump.)
35. Techniques commonly used for perioperative blood conservation during cardiac
surgery include:
1. red blood cell scavenging
2. perioperative administration of antifibrinolytic agents
3. intraoperative autologous hemodilution
4. nonpulsatile flow during cardiopulmonary bypass
35. A. Antifibrinolytic agents such as tranexamic acid, epsilon-aminocaproic acid, and aprotinin
have been shown to decrease blood loss in high-risk patients undergoing cardiac surgery. Such
agents act to inhibit the fibrinolytic cascade triggered by the effects of extracorporeal
circulation. Intraoperative hemodilution achieved by the removal of autologous blood provides a
safe source of whole blood for reinfusion while being spared the damaging effects of the
bypass circuit. (See page 1089: Blood Conservation in Cardiac Surgery.)
36. TRUE statements regarding intraoperative electrocardiographic monitoring include:

1. Lead II may be monitored to detect ischemia in the inferior wall of the left ventricle, as
well as to assist in the detection of cardiac arrhythmias.
2. Lead V5 aids in the detection of ischemia to the anterior wall of the left ventricle.
3. Lead V5 is monitored to detect ischemia in regions of the myocardium supplied by the
left anterior descending coronary artery.
4. Ischemia of the lateral wall of the left ventricle is detected by monitoring leads I and
aVL.
36. E. Simultaneous monitoring of multiple electrocardiographic leads improves the sensitivity
of ischemia detection while aiding in its localization. Leads II, III, and aVF are the most sensitive
to ischemic changes in the inferior ventricular wall, typically supplied by the right coronary
artery. Lead V5 is commonly used to monitor the anterior wall of the left ventricle (left anterior
descending artery), and leads I and aVL provide the greatest information concerning the lateral
left ventricular wall (left circumflex artery). (See page 1091: Monitoring.)
37. Relatively strong indications for the perioperative placement of a pulmonary artery
catheter in a patient undergoing cardiac surgery include:
1. procedures in which continuous retrograde cardioplegia is to be used during
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cardiopulmonary bypass
2. a patient with moderate to severe pulmonary hypertension
3. access to central circulation for the infusion of vasoactive drugs
4. assistance in the management of a patient with impaired left ventricular function
37. C. Although indications for the placement of a pulmonary catheter vary among institutions,
conditions in which left ventricular filling pressures cannot be reliably predicted by transduced
right atrial pressures generally predicate pulmonary artery catheter placement. These
conditions include pulmonary hypertension, left ventricular dysfunction or decreased
compliance, and valvular dysfunction. Other indications include operations requiring prolonged
operative time or combined procedures (valve replacement plus coronary grafting). (See page
1091: Monitoring.)
38. Examples of congenital cardiac lesions in which cyanosis develops as a result of

obstruction to pulmonary flow include:
1. patent ductus arteriosus
2. ventricular septal defect
3. coarctation of the aorta
4. tetralogy of Fallot
38. D. In patients with tetralogy of Fallot, the right ventricular outflow obstruction may lead to
cyanosis as a result of decreased pulmonary flow. The presence of a ventricular septal defect
complicates the problem by providing a path of preferential flow in the setting of decreased
systemic vascular resistance. Whereas ventricular septal defects and patent ductus arteriosus
result in increased pulmonary blood flow from volume overload, coarctation of the aorta results
in left ventricular pressure overload. (See page 1103: Table 41-21.)
39. Which of the following statements regarding amrinone and milrinone is/are
TRUE&quest;
1. They are phosphodiesterase inhibitors.
2. They increase myocardial contractility.
3. They decrease pulmonary vascular resistance.
4. They increase systemic vascular resistance.
39. A. Amrinone and milrinone are two drugs in a class of phosphodiesterase III inhibitors.
These agents are very effective at decreasing pulmonary vascular resistance and increasing
myocardial contractility. They are also systematic arterial vasodilators and therefore reduce left
ventricular afterload, reducing myocardial work. (See page 1102: Preoperative Evaluation:
Discontinuation of Cardiopulmonary Bypass.)
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Review of Clinical Anesthesia, 5e [Vishal] 42. Anesthesia for Vascular Surgery
Chapter 42
Anesthesia for Vascular Surgery
1. The most effective medical therapy for atherosclerotic peripheral vascular disease
is:
A. dipyridamole
B. urokinase
C. warfarin (Coumadin)
D. aspirin
E. smoking cessation
1. E. Although antiplatelet medications such as aspirin may slow the progression of
atherosclerosis and may be associated with cardiovascular events, cessation of smoking is by
far the most effective form of medical therapy. This emphasizes the dramatic impact of tobacco
abuse on the progression of atherosclerotic disease. Smoking cessation rates are
approximately 25% after major surgery. Despite the low success rates, the benefits of smoking
cessation are so great that such programs may be cost effective. Systemic anticoagulation and
thrombolytic agents are generally reserved for cases of acute ischemia. (See page 1110:
Medical Therapy for Atherosclerosis.)
2. In patients presenting for vascular surgery, the incidence of significant coronary

artery disease (stenosis >70%) detected by angiography in patients without any
clinical symptoms of coronary stenosis is approximately:
A. <1%
B. 11%
C. 37%
D. 78%
E. >90%
2. C. Hertzer et al performed coronary angiography in 1000 consecutive patients slated to
undergo vascular surgery and identified significant coronary artery stenosis (>70% occlusion) in
37% of patients who had no symptoms of coronary disease. These data indicate a high index
of suspicion for coronary artery stenosis in patients presenting for vascular surgery even in the
absence of a prior history of cardiac disease. (See page 1110: Coronary Artery Disease in
Patients with Peripheral Vascular Disease.)
3. Most neurologic deficits after carotid endarterectomy are thought to result from:
A. concomitant contralateral carotid stenosis
B. prolonged carotid artery cross-clamp in the absence of shunt use
C. thromboembolism
D. perioperative vasospasm
E. inadequate intraoperative carotid artery perfusion pressure
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3. C. Although maintenance of adequate carotid artery perfusion pressure is an anesthetic goal

during carotid endarterectomy, most studies indicate that as many as 65% to 95% of all
neurologic deficits after carotid endartectomy may result from thromboembolic events. These
may occur during surgical manipulation of the diseased vessel or in association with shunt
placement. An embolism-related stroke rate of at least 0.7% has been reported in association
with shunt placement, although no convincing data exist to indicate that routine shunt insertion
reduces the incidence of postoperative neurologic deficits. (See page 1118: Monitoring and
Preserving Neurologic Integrity.)
4. Each of the following are potential postoperative complications specific to carotid

endarterectomy EXCEPT:
A. hypertension
B. bradycardia
C. neurologic deficits
D. respiratory insufficiency
E. renal insufficiency
4. E. Common problems arising after carotid endarterectomy include the onset of new
neurologic dysfunction, hemodynamic instability during emergence from general anesthesia,
and respiratory insufficiency. Blood pressure abnormalities are common after carotid
endarterectomy; hypertension is more common than hypotension. Severe hypertension seems
to occur more often in patients with poorly controlled preoperative hypertension. (See page
1117: Carotid Endarterectomy Postoperative Management.)
5. Distal ischemia as a consequence of aortic surgery generally results from:

A. prolonged aortic occlusion
B. inadequate distal runoff
C. thrombosis resulting from inadequate anticoagulation
D. postperfusion vasospasm
E. atheroemboli
5. E. Although heparin is routinely administered before aortic occlusion to reduce the risk of
thrombus formation, it is recognized that distal ischemic events after aortic surgery are generally
the result of dislodgment of atheroemboli from the diseased aorta. It is believed by some that in
the absence of major distal occlusive disease, systemic heparinization may be unnecessary
when repairing abdominal aortic aneurysms. (See page 1127: Surgical Procedures for Aortic
Reconstruction.)
6. The most important factor shown to be of clinical importance in preserving renal

function during aortic cross-clamping is:
A. lisinopril
B. fenoldopam
C. dopamine
D. intravascular volume status
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E. mannitol
6. D. Renal protection is still a controversial topic, with no therapies proven to yield superior
outcome. Many different methods of renal protection have been advocated, most of them
centering on improving renal blood flow or glomerular flow. These include dopamine,
fenoldopam, angiotensin-converting enzyme inhibitors, prostaglandins, vasodilators, isovolemic
hemodilution, furosemide, and mannitol. Outcomes have not been shown to improve with any of
these techniques. One of the most important factors for preventing postoperative renal failure
remains good hydration (as the most important factor for maintaining renal blood flow) during
clamping and post-clamp release. (See page 1125: Protecting the Spinal Cord and Visceral
Organs.)
7. Strategies that have been shown to reduce the incidence of myocardial ischemia in
patients undergoing vascular surgery include:
1. treatment of tachycardia with β -adrenergic blocking agents
2. prevention of hypothermia
3. correction of anemia (hematocrit of <28)
4. prophylactic infusions of nitroglycerin
7. A. In high-risk patients undergoing noncardiac surgery, there is an increased incidence of
myocardial ischemia associated with anemia (hematocrit level of <28) and hypothermia
(presumably resulting from increased oxygen consumption accompanying postoperative
shivering). Although the perioperative treatment of tachycardia with β -adrenergic blocking
agents has proven efficacious in the prevention of myocardial ischemia, the use of prophylactic
infusions of intravenous nitroglycerin has not been shown to reduce the incidence of ischemic
episodes in patients with known or suspected coronary artery disease who are undergoing
noncardiac surgery. (See page 1113: Management of Perioperative Myocardial Ischemia and
Infarction in Vascular Patients.)
8. Which of the following statements regarding carotid artery occlusive disease is/are
TRUE&quest;
1. It is rarely bilateral.
2. Plaques most often develop at the lateral aspect of the carotid bifurcation.
3. Patients who present with transient ischemic attacks have a 40% risk of stroke during
the subsequent year.
4. The most common cause is atherosclerosis.
8. C. The most common cause of carotid occlusive disease is atherosclerotic plaque, which
usually develops at the lateral aspect of the carotid bifurcation. It is bilateral in approximately
50% of cases. The natural history of patients who present with transient ischemic attacks
resulting from carotid occlusive disease is an approximate 10% risk of stroke during the ensuing
year. (See page 1117: Carotid Endarterectomy.)
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9. Methods that have been used to determine the need for shunt placement during
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carotid endarterectomy include:
1. intraoperative electroencephalography evaluation
2. xenon-gated measurements of cerebral blood flow
3. transcranial Doppler techniques
4. somatosensory evoked potential (SSEP) monitoring
9. E. Surgeons who perform shunt procedures selectively use a monitor of cerebral perfusion to
identify appropriate subjects for shunt insertion. Methods used include carotid SSEP
monitoring, intraoperative electroencephalography, and direct monitoring of cerebral blood flow
(e.g., xenon-gated flow measurements). However, none of these techniques has been shown to
significantly improve neurologic outcomes in patients undergoing carotid vascular surgery. (See
page 1118: Monitoring and Preserving Neurologic Integrity.)
10. Factors that may contribute to systemic hypotension or organ dysfunction after
aortic occlusion and subsequent reperfusion include:
1. metabolic acidosis
2. activated complement
3. oxygen-derived free radicals
4. endotoxemia
10. E. Hypoxia to tissues distal to aortic occlusion leads to anaerobic metabolism and resultant
acidosis. In addition, oxygen-derived free radicals, prostaglandins, cytokines, and other
vasoactive mediators are produced, and this may result in hypotension and organ dysfunction
when reperfusion occurs. Among the many factors described are renin, angiotensin,
epinephrine, norepinephrine, prostacyclin, endothelin, prostaglandin F1, thromboxane A2 and
B2, lactate, potassium, oxygen-derived free radicals, platelet activators, cytokines, and
activated complement (C3 and C4). Reactive hyperemia after reperfusion of ischemic vascular
beds contributes to systemic hypotension resulting from a redistribution of blood flow. Hypoxic
insult to the intestines during aortic occlusion and the associated increase in gut permeability
may produce endotoxemia. (See page 1125: Humoral and Coagulation Profiles.)
11. Which of the following statements regarding the artery of Adamkiewicz is/are
FALSE&quest;
1. It is responsible for more than 85% of the spinal cord blood supply.
2. It originates between L1 and L2 in 10% of patients.
3. It is the sole source of arterial flow to the posterior portions of the spinal cord.
4. It originates between T8 and T12 in 75% of patients.
11. C. The blood supply to the thoracolumbar spinal cord (from T8 to the conus terminalis) is
derived in large part by the major radicular artery known as the artery of Adamkiewicz. It arises
from the left side in 60% of cases. In 75% of patients, it joins the anterior spinal artery between
T8 and T12; it arises between L1 and L2 in 10% of patients. Although much of the blood flow in
the anterior spinal artery is dependent on the artery of Adamkiewicz, the posterior portions of
the spinal cord are supplied by the paired posterior spinal arteries, derived in part from the
vertebral system. These arteries account for approximately 25% of spinal cord blood flow. (See
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page 1126: Central Nervous System and Spinal Cord Ischemia Protection.)
12. Which of the following measures have demonstrated definitive utility in the
prevention of spinal cord ischemia associated with aortic occlusion during vascular
procedures&quest;
1. Early use of sodium bicarbonate
2. Maintenance of normal cardiac function
3. Cerebrospinal fluid (CSF) drainage
4. Brief aortic cross-clamp times
12. C. Spinal cord ischemia with resultant paraplegia is a devastating complication of aortic
occlusion and occurs in 1% to 11% of procedures involving the distal descending thoracic
aorta. Although attempts to improve spinal cord perfusion pressure through CSF drainage and
hyperventilation have been undertaken, the only definitive methods in the prevention of spinal
cord ischemia are rapid surgery and the maintenance of normal cardiac function. (See page
1123: Pathophysiology of Aortic Occlusion and Reperfusion.)
13. In comparing surgical approaches for either occlusive or aneurysmal abdominal

aortic disease, advantages of a retroperitoneal over a traditional transabdominal
approach include:
1. lower incidence of ileus and small bowel obstruction
2. fewer postoperative pulmonary complications
3. shorter intensive care unit (ICU) and overall hospital stays
4. decreased long-term incisional pain
13. B. In a randomized, prospective trial comparing the traditional transabdominal approach with
the retroperitoneal approach for elective infrarenal aortic reconstruction, the retroperitoneal
approach was associated with a lower incidence of ileus and small bowel obstruction, shorter
stays in the hospital and ICU, and lower hospital costs. There was no difference in
postoperative pulmonary complications, however, and the retroperitoneal approach was
accompanied by an increase in long-term incisional pain. (See page 1127: Traditional “Open”
Surgical Procedures for Aortic Reconstruction.)
14. Surgical techniques used during occlusion of the thoracic aorta to decompress the
heart and allow some degree of distal perfusion include:
1. placement of an aortic shunt
2. normovolemic hemodilution
3. placement of an ex vivo axillofemoral bypass graft
4. segmental surgical repair
14. B. The placement of aortic (Gott) shunts, the use of temporary ex vivo axillofemoral bypass
grafts, and partial bypass techniques have been used as a means to decompress the heart and
provide distal perfusion in the face of thoracic aortic occlusion. These techniques attenuate the
hemodynamic response to aortic unclamping, reduce reperfusion acidosis, and possibly
ameliorate the hormonal and metabolic aberrations associated with aortic occlusion. Although
segmental, sequential surgical repair may minimize the duration of ischemia to any given
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vascular bed, and it does not allow for decompression or distal perfusion during periods of
occlusion. (See page 1126: CNS and Spinal Cord Ischemia and Protection.)
15. Which of the following statements regarding renal function after aortic
reconstruction procedures is/are TRUE&quest;
1. Procedures involving infrarenal aortic occlusion do not adversely affect renal function.
2. Dopamine has been shown to be highly effective in preventing renal failure.
3. Intraoperative urine output is a reasonable predictor of postoperative renal function.
4. The best measures to prevent perioperative renal compromise are maintenance of
adequate intravascular volume and of myocardial function.
15. D. The development of acute renal failure after aortic reconstruction is associated with a
mortality rate of more than 30%. Although it is more common in patients requiring supraceliac
aortic occlusion, infrarenal occlusion is not without risk, as evidenced by data indicating that
infrarenal aortic cross-clamping decreased renal blood flow by 38%, increased renal vascular
resistance by 75%, and redistributed blood flow from the renal cortex. Indeed, infrarenal aortic
reconstruction may be associated with a 3% incidence of renal failure. Previous data have
shown that intraoperative urine output is a poor indicator of postoperative renal function. The
best predictor of postoperative renal failure is preoperative renal function. Although various
strategies, including administration of mannitol, furosemide, and low-dose dopamine, have been
used to increase renal blood flow and promote diuresis, none has been shown conclusively to
prevent renal failure. Maintenance of adequate intravascular volume and maintenance of
myocardial function are the most successful preventative measures. (See page 1125: Renal
Hemodynamics and Renal Protection.)
16. Potential advantage(s) of regional anesthetic techniques over general anesthesia

for lower extremity vascular bypass procedures include(s):
1. avoidance of hyperdynamic responses to tracheal intubation and extubation
2. reduced postoperative hypercoagulability and graft thrombosis
3. reduced incidence of postoperative respiratory complications
4. a reduction in perioperative cardiac complications
16. A. It is a widely held belief that regional anesthetic techniques are associated with fewer
postoperative respiratory complications than are general anesthetic techniques. Data indicate
that regional techniques may reduce postoperative hypercoagulability and graft thrombosis in
patients undergoing lower extremity vascular bypass procedures. A reduction in cardiac
complications is often cited as a reason for avoiding general anesthesia. Although some studies
have suggested a possible reduction of cardiac complications, this remains unsubstantiated.
(See page 1133: Anesthetic Management of Elective Lower Extremity Revascularization.)
17. During an endovascular repair of an aortic aneurysm, the following potential

incident(s) or complication(s) may occur:
1. potential renal impairment secondary to intravenous dye
2. aneurysm rupture
3. graft migration
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4. electrolyte abnormalities
17. E. The technique for implantation of endovascular aortic grafts generally requires bilateral
common femoral artery or iliac artery cutdown in the supine position. Preimplantation
angiography is required to identify the vasculature. Dye loads may be considerable (100–250
mL). Major complications in endovascular stent grafting have included aneurysm rupture during
the time of graft implantation, renal insufficiency secondary to contrast use, and late
complications such as graft migration with late aneurysmal rupture. (See page 1128: Abdominal
Aortic Repair.)
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Review of Clinical Anesthesia, 5e [Vishal] 43. Obstetrical Anesthesia
Chapter 43
Obstetrical Anesthesia
1. Plasma volume and red blood cell (RBC) volume increase by which of the following
percentages in pregnancy&quest;
A. Plasma volume, 70%; RBC volume, 50%
B. Plasma volume, 40%; RBC volume, 40%
C. Plasma volume, 40%; RBC volume, 20%
D. Plasma volume, 60%; RBC volume, 20%
E. Plasma volume, 60%; RBC volume, 60%
1. C. Increased mineralocorticoid activity during pregnancy produces sodium retention and
increased body water content. Thus, plasma volume and total blood volume begin to increase
in early gestation, resulting in a final increase of 40% to 50% and 25% to 40%, respectively, at
term. The relatively smaller increase in RBC blood volume (20%) accounts for the reduction in
hematocrit during pregnancy. (See page 1138: Hematologic Alterations.)
2. Which of the following factors does not influence the placental transfer of
drugs&quest;
A. Fetal osmolality
B. The placental area
C. Ionization of the drug
D. Molecular weight
E. Concentration in fetal blood
2. A. Drugs cross biological membranes by simple diffusion, the rate of which is determined by
the Fick principle. The Fick equation is dependent on the diffusion constant of the drug, which
depends on molecular size, lipid solubility, and degree of ionization. Other factors important in
the Fick equation include surface area available for exchange or placental area, concentration
of free drug in maternal blood, concentration of free drug in fetal blood, and thickness of the
diffusion barrier. Most drugs commonly used by anesthesiologists have molecular weights
below 500 and are easily transferred through the placenta. (See page 1140: Placental Transfer
and Fetal Exposure to Anesthetic Drugs.)
3. Which dermatomes are affected in the first stage of labor&quest;

A. T5–T10
B. S2–S4
C. T10–L1
D. T12–L2
E. T6–L2
3. C. In early labor, only the lower thoracic dermatomes T11 and T12 are affected, but with
progressing cervical dilation and the transitional phase, adjacent dermatomes may be involved,
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and pain is referred from T10–L1. In the second stage of labor, additional pain impulses
resulting from distention of the vaginal vault and perineum are carried by the pudendal nerve,
which is composed of lower sacral fibers S2–S4. (See page 1142: Anesthesia for Labor and
Vaginal Delivery.)
4. The most common side effect of neuraxial anesthesia for obstetrics is:
A. meningitis
B. decreased variability of fetal heart rate
C. nausea and vomiting
D. hypotension
E. nerve group damage
4. D. Hypotension resulting from sympathectomy is the most frequent complication that occurs
with central neuraxial blockade. Therefore, maternal blood pressure must be monitored at
regular intervals, typically 2 to 5 minutes for the first 20 minutes after initiating the block.
Meningitis is a rare complication of neuraxial anesthesia, as is nerve group damage. Nausea
and vomiting may result from hypotension. Fetal heart rate variability is much less affected by
neuraxial anesthesia than by intravenous anesthetics. (See page 1144: Regional Anesthesia.)
5. Considering regional anesthesia for cesarean section, which of the following is

TRUE&quest;
A. Epidural anesthesia is by far the most common regional technique.
B. Prehydration is not necessary when using epidurals.
C. Epidural anesthesia consistently eliminates visceral discomfort during exteriorization
of the uterus.
D. Spinal narcotics are contraindicated in parturients.
E. Epidural anesthesia has the advantage of slower onset and controllability.
5. E. Subarachnoid or spinal block is the most commonly administered regional anesthetic
technique for cesarean delivery because of its speed and reliability. Despite an adequate
dermatomal level with either spinal or epidural anesthesia, women may experience varying
degrees of visceral discomfort, particularly during exteriorization of the uterus and traction on
abdominal viscera. Improved perioperative anesthesia and analgesia may be provided with the
addition of narcotics to the neuraxial local anesthetic solution. In contrast to spinal anesthesia,
epidural anesthesia is associated with a slower onset of action and more controllability.
Prehydration is necessary when either spinal or epidural anesthetics are used because
sympathetic tone is decreased and hypotension is a common side effect of neuraxial
anesthesia. (See page 1145: Anesthesia for Cesarean Delivery.)
6. When considering anesthetic complications relating to cesarean section, which of

the following is TRUE&quest;
A. Fatality with general anesthesia is equal to that with regional anesthesia.
B. Paresthesia and pain with spinal needle placement are common, and the procedure
should proceed despite these complaints.
C. Phenylephrine should not be used to treat hypotension in pregnant patients.
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D. Colloid is superior to crystalloid prehydration in preventing hypotension associated

with neuraxial anesthesia.
E. The risk of hypotension with regional anesthesia is increased in women in labor
compared with nonlaboring women.
6. D. A recent study of anesthesia-related death in the United States (between 1979 and 1990)
revealed that the case fatality rate for general anesthesia was 16.7 times greater than that for
regional anesthesia. Hypotension is a common complication of neuraxial anesthesia for
cesarean section, and colloid prehydration has been shown to be superior to crystalloid solution
in preventing this hypotension. The risk of hypotension after regional anesthesia is lower in
women who are in labor compared with nonlaboring women. In the presence of maternal
tachycardia, 25 to 50 μg of phenylephrine may be substituted for ephedrine. Pressure or trauma
exerted by a needle on spinal nerve roots or the spinal cord produces immediate pain. Needle
advancement should stop immediately upon patient complaint of paresthesia or pain, and if the
pain does not resolve within seconds, the needle or catheter should be withdrawn and
repositioned. (See page 1147: Anesthetic Complications.)
7. The incidence of postdural puncture headache after dural puncture with a 25- or 26-
gauge spinal needle in pregnant women is:
A. 0%
B. 1%
C. 3%
D. 5%
E. 10%
7. B. The frequency of postdural puncture headache development is related to the diameter of
the puncture needle, ranging from more than 70% after the use of a 16-gauge needle to
approximately 1% with a smaller 25- or 26-gauge spinal needle. The incidence of the headache
is reduced with the use of atraumatic pencil-point needles (e.g., Whitaker or Sprotte needles).
(See page 1149: Postdural Puncture Headache.)
8. Many of the symptoms associated with pre-eclampsia may result from an imbalance
between the placental production of:
A. renin and angiotensin
B. endothelin and nitric oxide
C. prostacyclin and thromboxane
D. platelets and antithrombin III
E. progesterone and estrogen
8. C. Many of the symptoms associated with pre-eclampsia, including placental ischemia,
systemic vasoconstriction, and increased platelet aggregation, may result from an imbalance
between the placental production of prostacyclin and thromboxane. During normal pregnancy,
the placenta produces equivalent quantities of these prostaglandins. During pre-eclamptic
pregnancy, seven times more thromboxane than prostacyclin is present. (See page 1149: Pre-
eclampsia and Eclampsia.)
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9. The greatest change in cardiac output in pregnant patients occurs:
A. during the second trimester
B. after the delivery of the placenta
P.226
C. during the third trimester
D. during the first stage of labor
E. during the second stage of labor
9. B. During labor, cardiac output increases above antepartum levels. Between contractions,
the cardiac output increases approximately 30% during the first stage and 45% during the
second stage. The greatest change occurs immediately after delivery of the placenta, when
cardiac output increases to an average of 80% above prepartum values. In some cases, it may
increase by as much as 150%. (See page 1155: Heart Disease.)
10. When considering fetal heart rate, which of the following is TRUE&quest;
A. The normal fetal heart rate is 80 to 120 bpm.
B. Acceleration of fetal heart rate in response to fetal stimulation is ominous.
C. A fetal heart rate of more than 170 bpm may be caused by intravenous narcotics.
D. Baseline variability of fetal heart rate may be affected by ephedrine.
E. Baseline variability of fetal heart rate is a reflection of the integrity of the sympathetic
nervous system but is not affected by the parasympathetic nervous system.
10. D. The baseline fetal heart rate is measured between contractions and ranges from 120 to
160 bpm. An acceleration of fetal heart rate in response to fetal stimulation (e.g., during vaginal
examination or fetal capillary blood sampling) is a reassuring sign that the fetus is not acidotic.
Persistently elevated fetal heart rates may be associated with chronic fetal distress, maternal
fever, or administration of drugs such as ephedrine or atropine. Fetal hypoxia and acidosis
often lead to low fetal heart rates. The baseline fetal heart rate variability, which is normally
present, reflects the beat-to-beat adjustments of parasympathetic and sympathetic nervous
symptoms to various internal and external stimuli. Fetal central nervous system depression by
asphyxia may decrease baseline variability. Therefore, a smooth fetal heart rate may be an
ominous finding. Ephedrine may increase heart rate variability. Intravenous opioids can cause a
decrease in fetal heart rate variability. (See page 1160: Biophysical Monitoring.)
11. Normal fetal oxygen saturation is:

A. 90% to 100%
B. 50% to 100%
C. 50% to 80%
D. 30% to 70%
E. 10% to 50%
11. D. Fetal oxygen saturation between 30% and 70% is considered normal. Saturation
readings consistently below 30% for a prolonged period of time (i.e., 10–15 minutes) are
suggestive of acidemia. Fetal blood scalp sampling or prompt obstetric intervention may be
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indicated. (See page 1161: Fetal Pulse Oximetry.)
12. The average arterial blood pH of healthy, vigorous infants is:

A. 7.04
B. 7.14
C. 7.24
D. 7.34
E. 7.44
12. C. Uterine contractions decrease or even eliminate the blood flow through the intervillous
space of the placenta. On the fetal side, cord compression occurs during the final stages of
approximately one third of vaginal deliveries. Thus, mild degrees of hypoxia and acidosis occur
even during normal labor and delivery and play an important role in initiation of ventilation. On
average, healthy, vigorous infants have an oxygen saturation of 21%, a pH of 7.24, and a
PCO2 of 56 mm Hg at birth. (See page 1162: Fetal Asphyxia.)
13. The initial breath during neonatal resuscitation may entail a peak pressure up to
____________ cm H2O.
A. 10 to 15
B. 15 to 20
C. 20 to 30
D. 30 to 40
E. 40 to 50
13. D. Initial resuscitative methods include rubbing the back and slapping the neonate's feet. If
these maneuvers produce no response and the baby remains apneic, ventilation should be
instituted at a rate of 40 breaths/min. The initial breath may require pressures of 30 to 40 cm
H2O. Subsequently, inflation pressure should be reduced to 15 to 20 cm H2O in infants with
normal lungs. (See page 1164: Treatment of Moderately Depressed Infants.)
14. The studies that relate surgery and anesthesia during pregnancy to fetal outcomes
have found that:
A. only gynecologic surgery in the third trimester is correlated with increased fetal death
B. neither surgery nor anesthesia can be correlated with an increase in congenital
disorders
C. maternal condition at the time of surgery has no affect on fetal outcomes
D. operative exposure to nitrous oxide dramatically increases the chance of congenital
disorders in humans
E. general anesthesia is associated with a significant increase in the incidence of
congenital disorders
14. B. Although many commonly used anesthetics are teratogenic at high doses in animals, few,
if any studies support teratogenic effects of anesthetic or sedative medications in the doses
used for human anesthesia care. There was an increased risk of spontaneous abortion in
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women who had received general anesthesia during the first or second trimesters, which was
most evident after gynecologic operations. No particular anesthetic agent or technique has
been implicated, and it seems that the factors that necessitated surgery, including the severity
of the maternal condition, were relevant. (See page 1166: Anesthesia for Non-obstetric Surgery
in Pregnant Women.)
15. Which of the following statements concerning lung volume changes during
pregnancy is/are TRUE&quest;
1. Functional residual capacity (FRC) decreases by 40%.
2. Inspiratory reserve volume decreases.
3. Tidal volume is unchanged.
4. Minute ventilation increases 50%.
15. D. From the fifth month, the expiratory reserve volume, residual volume, and FRC decrease.
The latter decreases by 20% compared with the nonpregnant state. Concomitantly, there is an
increase in inspiratory reserve volume, so total lung capacity remains unchanged. Minute
ventilation increases from the beginning of pregnancy to a maximum of 50% above normal at
term. This is accomplished by a 40% increase in tidal volume and a 15% increase in respiratory
rate. (See page 1138: Ventilatory Changes.)
16. Considering a pregnant patient's response to anesthetic, which of the following

is/are TRUE&quest;
1. Progesterone levels have no effect on minimum alveolar concentration (MAC).
2. Lower doses of local anesthetics are needed per dermatomal segment for an epidural
or spinal block.
3. A decrease in MAC is not seen until after 20 weeks gestation.
4. Pregnancy leads to increased neurosensitivity to local anesthetics.
16. C. The MAC for inhaled agents is decreased by 8 to 12 weeks of gestation and may be
related to an increase in the progesterone levels. Lower doses of local anesthetics are needed
per dermatomal segment for epidural or spinal block; this has been attributed to an increased
spread of local anesthetic within the epidural and subarachnoid spaces, which occurs as a
result of epidural venous engorgement. In addition, an increased neurosensitivity to local
anesthetics has been suggested (which may be mediated by progesterone). (See page 1139:
Altered Drug Responses.)
17. Which of the following is/are side effects of systemic meperidine analgesia for
labor&quest;
1. Decreased variability of the fetal heart rate
2. Fetal bradycardia
3. Neonatal depression
4. Prolongation of the first stage of labor
17. B. Meperidine is the most commonly used systemic opioid during the first stage of labor.
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The major side effects are nausea and vomiting, dose-related depression of ventilation,
orthostatic hypotension, and potential for neonatal depression. Meperidine may cause transient
alterations of fetal heart rate, such as decreased beat-to-beat variability and tachycardia. No
studies have shown that systemic opioids prolong the first stage of labor. (See page 1143:
Opioids.)
18. Considering paracervical block, which of the following statements is/are

TRUE&quest;
1. Paracervical block effectively relieves pain during the first stage of labor.
2. Bupivacaine is the local anesthetic agent of choice.
3. Paracervical block may cause uterine artery constriction.
4. Paracervical block is safe for the fetus.
18. B. Although the paracervical block effectively relieves pain during the first stage of labor, the
technique has fallen out of favor because it was associated with a high incidence of fetal
asphyxia and poor neonatal outcome (particularly with the use of bupivacaine). This may be
related to uterine artery constriction or increased uterine tone. The technique is basically simple
and involves submucosal injection of local anesthesia at the vaginal fornix. (See page 1145:
Paracervical Block.)
19. Which of the following would cause pre-eclampsia to be classified as

severe&quest;
1. Intrauterine growth retardation
2. Systolic blood pressure of 170 mm Hg
3. Oliguria (400 mL/24 hr)
4. Epigastric pain
19. E. Pre-eclampsia is classified as severe if it is associated with any of the following: systolic
blood pressure above 160 mm Hg, diastolic blood pressure of 110 mm Hg, proteinuria of 5 g/24
hr, oliguria (400 mL/24 hr), cerebral or visual disturbances, pulmonary edema, epigastric pain,
and intrauterine growth retardation. (See page 1149: Pre-eclampsia and Eclampsia.)

1. Magnesium increases the duration of action of depolarizing muscle relaxants.
2. Magnesium does not affect the duration of action of nondepolarizing muscle relaxants.
3. Magnesium decreases the amount of the acetylcholine liberated from motor nerve
endings.
4. Magnesium makes the end plate more sensitive to acetylcholine.
20. B. Magnesium potentiates the duration and intensity of action of depolarizing and
nondepolarizing muscle relaxants. It seems to do this by decreasing the amount of acetylcholine
liberated from the motor nerve terminals and diminishing the sensitivity of the end plate to
acetylcholine. It has also been found to depress the excitability of the skeletal muscle. (See
page 1152: General Management.)
21. Which of the following statements concerning pregnancy and human
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immunodeficiency virus (HIV) is/are TRUE&quest;
1. Pregnancy accelerates the progression of HIV.
P.227
2. There is no risk of vertical transmission through breastfeeding.
3. There is no risk of fetal intrauterine transmission before labor and delivery.
4. Zidovudine prophylaxis decreases vertical transmission to less than 2%.
21. D. Women now represent nearly half of the people worldwide living with HIV. There is no
evidence that pregnancy accelerates the progression of the disease. However, there is
compelling interest to prevent vertical transmission of HIV from mother to fetus. The risk of
intrauterine infection is 4.4%. Intrapartum transmission accounts for 60% of the risk of
peripartum transmission; the remainder is through breastfeeding. However, when zidovudine
prophylaxis is given to women with HIV perinatally and to the newborn in the first weeks of life,
vertical transmission is reduced to less than 2%. (See page 1158: HIV and AIDS.)
22. When considering neonatal adaptations at birth, which of the following statements
is/are TRUE&quest;
1. There is a dramatic decrease in pulmonary vascular resistance with increasing
pulmonary arterial oxygen tension.
2. Functional closure of the ductus arteriosus occurs within hours to days.
3. Prompt expansion of the lungs is of primary importance.
4. The foramen ovale functionally closes almost immediately.
22. E. Many morphologic and functional changes occur in neonates. The onset of ventilation
and expansion of the lungs opens the pulmonary vasculature, resulting in decreased resistance
and a significant increase in pulmonary blood flow. Pulmonary vascular resistance decreases
as oxygen tension increases and the carbon dioxide level decreases. As soon as the pulmonary
perfusion increases, the foramen ovale (which constitutes a communication between the inferior
vena cava and the left atrium) undergoes functional closure. Cessation of the umbilical
circulation reduces pressure in the inferior vena cava and right atrium. The increase in
pulmonary blood flow increases the pressure in the left atrium. The smooth muscle of the
ductus arteriosus constricts in response to increased oxygen tension. Catecholamines also help
to constrict the ductus arteriosus. However, the ductus does not constrict abruptly or completely
after birth; in fact, functional closure may take hours or even days. (See page 1162: Neonatal
Adaptations at Birth.)
23. Considering non-obstetric surgery in pregnant women, which statement(s) is/are

TRUE&quest;
1. Hyperventilation is necessary for fetal well-being.
2. Left uterine displacement is not necessary until the start of the second trimester.
3. It is not necessary to monitor for uterine contractions after surgery in patients in their
third trimester.
4. Nonparticulate antacid should be given to all pregnant patients before induction of
anesthesia.
23. C. It is generally agreed that only surgical procedures that cannot be delayed for months,
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including emergency surgery, should be performed during pregnancy. Beginning in the second
trimester, uterine displacement must be maintained at all times during surgery. 15 to 30 mL of a
nonparticulate antacid should be administered within one half hour before induction of
anesthesia. Maternal hyperventilation should be avoided, and end-expiratory PaCO2 or arterial
blood gases should be monitored. Hyperventilation may decrease uterine blood flow and
change fetal pH. Monitoring uterine activity should be continued after the operation to detect
preterm labor. (See page 1166: Anesthesia for Non-obstetrical Surgery in Pregnant Women.)
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Review of Clinical Anesthesia, 5e [Vishal] 44. Neonatal Anesthesia
Chapter 44
Neonatal Anesthesia
1. The neonatal period is defined as the period that begins with the birth and ends at:
A. 24 hours
B. 14 days
C. 30 days
D. 6 months
E. 1 year
1. C. The neonatal period is defined as the first 30 days of extrauterine life and includes the
newborn period. The newborn period is the first 24 hours of life. (See page 1171: Physiology of
the Infant and the Transition Period.)
2. Which of the following statements regarding the fetal circulation is FALSE&quest;

A. Fetal pulmonary vascular resistance is relatively high compared with the systemic
vascular resistance.
B. The ductus arteriosus allows 90% of the blood leaving the right ventricle to bypass
the lungs and flow through the ascending aorta.
C. Persistent probe patency of the foramen ovale is seen in 10% to 20% of adult
patients.
D. Pulmonary vascular resistance decreases acutely at the time of birth and reaches
neonatal levels within 1 hour.
E. The ductus arteriosus is dilated secondary to a low PaO2 level.
2. D. The pulmonary vascular bed has a high vascular resistance because the alveoli are
relatively closed and filled with fluid, and the blood vessels are compressed. However, the
ductus arteriosus represents a low-resistance system, which is dilated secondary to low PaO2.
Therefore, the blood that leaves the right ventricle by the pulmonary artery is shunted
preferentially (90%) through the ductus arteriosus to the aorta; only 10% of the cardiac output
of the right ventricle flows through the pulmonary artery into the pulmonary vascular bed. The
transition of alveoli from a fluid-filled to an air-filled state results in a reduced compression of
the pulmonary alveolar capillaries and thus a reduction in pulmonary vascular resistance. It
takes 3 to 4 days for the pulmonary vascular resistance to decrease to the eventual level that it
will achieve during the neonatal period. Anatomic closure of the foramen ovale usually occurs in
the first year of life but may remain probe patent into adulthood in 10% to 20% of patients. (See
page 1172: Fetal Circulation.)
3. True statements regarding the transition of the cardiopulmonary system and

persistent pulmonary hypertension (PPH) include all of the following EXCEPT:
A. The goal of therapy is to keep PaO2 between 80 and 90 mm Hg.
B. Pulmonary circulation is sensitive to O2, pH, and nitric oxide.
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C. Hypoxia and acidosis are pivotal etiologic factors in PPH.
D. Because of the elevated pulmonary vascular resistance, a right-to-left shunt develops.
E. Patency of the ductus arteriosus beyond 4 days of age is abnormal regardless of the
infant's gestational age.
3. A. Patency of the ductus arteriosus beyond the fourth day of life is abnormal regardless of
the infant's gestational age. The major transition of circulatory system occurs over the first 24
hours of life. The pulmonary circulation is extremely sensitive to O2, pH, and nitric oxide.
Hypoxia and acidosis, along with inflammatory mediators, may cause the pulmonary artery
pressure to either persist at a high level or to increase to pathologic levels; the result is PPH.
The goals of therapy are to achieve a PaO2 of between 50 and 70 mm Hg with a PaCO2 of
between 50 and 55 mm Hg. The elevated pulmonary vascular resistance causes both the
ductus arteriosus and foramen ovale to remain open, with subsequent right-to-left (bypassing
the pulmonary circulation) shunting. (See page 1175: Persistent Pulmonary Hypertension of the
Newborn.)
4. Which of the following corresponds with the location of glottis in full-term

neonates&quest;
A. C2
B. C3
C. C4
D. C5
E. C6
4. C. In healthy adults, the glottis is at the level of C5–C6. In full-term infants, the glottis is at the
level of C4. In premature infants, it is at a level of C3. (See page 1177: Anatomy of the Neonatal
Airway.)
5. Which of the following statements regarding O2 consumption in adults versus

neonates is correct&quest;
A. 7 cc/kg/min in adults; 3 cc/kg/min in neonates
B. 6 cc/kg/min in adults; 5 cc/kg/min in neonates
C. 10 cc/kg/min in adults; 4 cc/kg/min in neonates
D. 3 cc/kg/min in adults; 7 cc/kg/min in neonates
E. 5 cc/kg/min in adults; 5 cc/kg/min in neonates
5. D. The O2 consumption of infants is 7 to 9 cc/kg/min; it is 3 cc/kg/min in adults. Therefore,
varying degrees of early obstruction have more impact on O2 delivery and reserve in neonates,
infants, and children than in adults. (See page 1174: The Pulmonary System.)
6. The ratio of minute ventilation to functional residual capacity is approximately 1.5:1

in adults and approximately __________:1 in neonates.
A. 0.5
B. 1
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C. 1.5
D. 2
E. 5
6. E. Tidal ventilation for adults is the same, in cubic centimeters per kilogram, as for neonates,
but O2 consumption is three times greater; thus, the respiratory rate must be three times
greater (which results in an alveolar ventilation that is three times greater). Consequently,
whereas the ratio of minute ventilation to functional residual capacity is approximately 5:1 in
neonates, it is 1.5:1 in adults. (See page 1174: The Pulmonary System.)
7. Fetal circulation contains which of the following shunts&quest;
1. Placenta
2. Foramen ovale
3. Ductus arteriosus
4. Foramen secundum
7. A. Fetal circulation is characterized by presence of three main shunts: the placenta, foramen
ovale, and ductus arteriosus. The relatively low pressure in the left atrium and the high
pressure in the right atrium cause the foramen ovale to be open. (See page 1172: Fetal
Circulation.)
8. Persistent pulmonary hypertension (PPH) may be caused by which of the

following&quest;
1. Sepsis
2. Respiratory distress
3. Meconium aspiration
4. No specific cause
8. E. PPH is a syndrome that may be primary, with no recognized origin, or it may be secondary
to meconium aspiration, sepsis, pneumonia, respiratory distress, or congenital diaphragmatic
hernia. (See page 1175: Persistent Pulmonary Hypertension of the Newborn.)
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9. Which of the following statements regarding the neonatal kidney is/are TRUE&quest;
1. The neonatal kidney is more than 90% mature by 1 week of age.
2. Fluids should be restricted intraoperatively.
3. The half-life of renally excreted drugs is decreased.
4. Urine output in neonates is 1 to 2 mL/kg/hr.
9. D. By the time the healthy full-term infant is 1 month of age, the kidneys are approximately
60% mature. Urine output is low in the first 24 hours, but it then increases to an expected level
of at least 1 to 2 mL/kg/hr. After the first day of life, a urine output of less than 1 mL/kg/hr should
be considered indicative of either hypovolemia or decreased renal function. From an anesthetic
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standpoint, the half-life of medications excreted by means of glomerular filtration will be
prolonged. The relative inability to conserve water means that neonates, especially in the first
week of life, poorly tolerate fluid restriction. (See page 1176: The Renal System.)
10. Which of the following statements regarding neonatal airway is/are TRUE&quest;
1. The head is flexed forward when the patient is in the supine position.
2. Neonates are obligate nose breathers.
3. They have a relatively large tongue.
4. The vocal cords are the narrowest portion.
10. A. Neonates are obligate nose breathers; therefore, anything that obstructs the nares will
compromise a neonate's ability to breathe. The large tongue occupies relatively more space in
the infant's airway and makes it difficult to laryngoscope and intubate an infant's trachea. The
narrowest portion of a neonate's airway is not the vocal cords but the cricoid ring. Neonates
have large occiputs, so their heads flex forward onto the chest when they are lying supine and
the head is in midline. (See page 1177: Anatomy of the Neonatal Airway.)
11. Which of the following statements regarding the neonatal pulmonary system is/are
TRUE&quest;
1. Neonates have a high closing volume.
2. Neonates have rigid ribs.
3. Neonates have high O2 consumption.
4. Neonates have a low ratio of minute ventilation to functional residual capacity (FRC).
11. B. Anatomically and physiologically, the neonatal pulmonary system differs in at least four
respects from that of adults: high O2 consumption, high closing volumes, high ratio of minute
ventilation to FRC, and pliable ribs. (See page 1174: The Pulmonary System.)
12. Which of the following statements regarding the neonatal cardiovascular system
is/are TRUE&quest;
1. Increases in cardiac output are primarily achieved through the increase in heart rate.
2. The parasympathetic system dominates over the sympathetic system in the
myocardium.
3. Cardiac output may typically be increased by no more than 40% in neonates.
4. Neonates have immature baroreceptors.
12. E. Any increase in cardiac output must be accomplished by an increase in the heart rate.
For this reason, infants are said to be rate dependent for their cardiac output. Especially in the
first 3 months of life, the parasympathetic nervous system's influence on the heart is more
mature than the sympathetic system, and the myocardium does not respond to inotropic support
as well as in older children and adults. The neonatal heart can increase cardiac output by 30%
to 40%. Neonates have immature baroreceptors; the baroreceptors are responsible for the
reflex tachycardia that occurs in response to hypotension. (See page 1172: The Cardiovascular
System.)
13. Which of the following statements about muscle relaxants in pediatrics is/are
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TRUE&quest;
1. The duration of action of vecuronium is twice as long in children younger than 1 year
of age than it is in older children.
2. Rocuronium is considered the drug of choice for intermediate action.
3. Epinephrine may be indicated after succinylcholine-induced hyperkalemia.
4. Succinylcholine (Sch) should be used in boys younger than 8 years of age only for
rapid sequence induction, difficult airway, and other emergencies.
13. E. Rocuronium is the drug of choice among the intermediate-acting nondepolarizing muscle
relaxants for neonates. In infants younger than 1 year of age, the duration of action of
vecuronium is approximately twice that observed in older children (because of their immature
livers). The reports of hyperkalemia with cardiac arrest in boys younger than age 8 years
(because of unrecognized muscular dystrophy) have caused some clinicians to recommend that
Sch should not be used routinely in this age group. However, Sch is still recommended in rapid
sequence situations, in patients with potential difficult airways, and if airway emergencies
develop with desaturation. If the circulation is unstable with severe bradycardia, hypotension, or
cardiac arrest, the first drug of choice is epinephrine. (See page 1179: Neuromuscular Blocking
Agents.)
14. Which of the following statements regarding neonatal anesthetic requirement is/are
TRUE&quest;
1. Neonates require as much anesthetic as older infants.
2. In premature infants, the minimum alveolar concentration (MAC) is decreased by 30%.
3. Premature infants have decreased endorphins.
4. Immature infants have immature blood–brain barriers.
14. C. Neonates and premature infants have lower anesthetic requirements than older infants
and children. In premature infants, the MAC value will decrease by 20% to 30%. The reason for
the lower MAC requirements is thought to be multifactorial: an immature nervous system,
progesterone from the mother, elevated levels of endorphins, and an immature blood–brain
barrier. (See page 1188: Anesthetic Dose Requirements of Neonates.)
15. Which of the following statements regarding regional anesthesia in neonates is/are
TRUE&quest;
1. The requirement for intraoperative opioids may be eliminated.
2. The dose of muscle relaxants needs to be increased.
3. The most common response to a high spinal anesthesia is respiratory insufficiency.
4. The requirement for inhalation anesthetics is unchanged.
15. B. Regional anesthetic techniques allow for early extubation in neonates because they may
eliminate the need for intraoperative narcotics, reduce the need for muscle relaxants, and
reduce the concentration of volatile agents needed. High spinal anesthesia presents as
respiratory insufficiency rather than hypotension; the reason for this is the lack of sympathetic
tone. (See page 1188: Regional Anesthesia.)
16. Which of the following statements regarding anesthetic uptake in infants versus
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adults is/are TRUE&quest;
1. The ratio of alveolar ventilation to functional residual capacity is 1.5:1.
2. Neonates have a greater cardiac index.
3. Infants have higher blood gas partition coefficient.
4. In neonates, the brain and heart receive relatively more of cardiac output.
16. C. Various reasons for the faster uptake of anesthetic in infants have been proposed,
including the ratio of alveolar ventilation to functional residual capacity is 5:1 in infants and
1.5:1 in adults; in neonates, more of the cardiac output goes to the vessel-rich group of organs,
which include the heart and the brain; neonates have a greater cardiac output per kilogram of
body mass; and infants have lower blood gas partition coefficients for volatile anesthetics. (See
page 1187: Uptake and Distribution of Anesthetics in Neonates.)
17. Which of the following statements regarding congenital diaphragmatic hernia is/are
TRUE&quest;
1. The occurrence of symptoms partly depends on the effect on the pulmonary
circulation.
2. Most congenital diaphragmatic hernias are left sided.
3. After diagnosis, the patient requires immediate intubation.
4. High-frequency ventilation has not been shown to be beneficial.
17. A. The left side of the diaphragm closes later than the right side, resulting in a higher
incidence (90%) of left-sided congenital diaphragmatic hernias (foramen of Bochdalek). The
occurrence of symptoms depends on the degree of herniation and interference with pulmonary
function. At times, the degree of interference is so great that the neonate's clinical condition
begins to deteriorate immediately. In other situations, it may be several hours before the infant's
condition is fully appreciated. Immediate supportive care includes tracheal intubation and
control of the airway, along with decompression of the stomach. High-frequency ventilation has
been used in place of conventional ventilation in an attempt to reduce barotrauma and has
been demonstrated to be beneficial. (See page 1193: Congenital Diaphragmatic Hernia.)
18. Omphalocele is associated with:

1. a 20% incidence of congenital heart disease
2. a sac (amnion) that increases the extra-abdominal contents
3. Beckwith-Wiedemann syndrome
4. more fluid loss preoperatively than is associated with gastroschisis
18. A. Failure of part or all of the intestinal content to return to the abdominal cavity results in
omphalocele that is covered with a membrane called an amnion. The amnion protects the
abdominal contents from infection and loss of extracellular fluid (ECF). In gastroschisis, the
intestines and viscera are not covered by any membrane and are susceptible to infection and
loss of ECF. There is a high instance of associated congenital anomalies with omphalocele but
none with gastroschisis. The Beckwith-Wiedemann syndrome consists of mental retardation,
hypoglycemia, congenital heart disease, an enlarged tongue, and omphalocele. Congenital
heart defects are found in approximately 20% of infants with omphalocele. (See page 1195:
Omphalocele and Gastroschisis.)
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19. Which of the following statements regarding tracheoesophageal fistula is/are

TRUE&quest;
1. Eighty-five percent of these connections consist of a fistula between the distal trachea
and the esophagus, with a blind proximal esophageal pouch.
2. Fifty percent of these patients have associated congenital anomalies.
3. Primary repair can be done 24 to 48 hours after diagnosis.
4. A major complication is dehydration.
19. E. Approximately 85% of tracheoesophageal fistulae consist of a fistula from the distal
trachea to the esophagus and a blind proximal esophageal pouch. Fifty percent of affected
infants have associated congenital anomalies, of which approximately 15% to 20% involve the
cardiovascular system. The two major complications of esophageal atresia with a distal tracheal
fistula are aspiration pneumonia and dehydration. If the infant is in good condition, primary
repair can be performed 24 to 48 hours after diagnosis. (See page 1196: Tracheoesophageal
Fistula.)
20. Which of the following statements regarding meningomyelocele is/are

TRUE&quest;
1. Fifty percent to 90% of meningomyeloceles are detected by serum alpha-fetoprotein.
2. Amniotic fluid alpha-fetoprotein is more reliable than serum alpha-fetoprotein.
3. Meningocele does not contain the neural elements.
P.232
4. Regional anesthesia is absolutely contraindicated in these patients.
20. A. Elevation of maternal serum alpha-fetoprotein will detect 50% to 90% of open neural
tube defects, but this test has a false-positive rate of 5%. Amniotic fluid alpha-fetoprotein is
more reliable. By definition, the lesion involves both meninges and neural components
compared with meningocele, which does not contain neural elements. Regional anesthesia has
been reported as a safe alternative to general anesthesia in neonates with meningomyelocele.
(See page 1198: Meningomyelocele.)
21. Which of the following statements regarding postoperative apnea is/are

TRUE&quest;
1. Premature infants with congenital anomalies are at highest risk.
2. Spinal anesthesia may decrease the incidence of postoperative apnea.
3. The cause is multifactorial.
4. A 44-week postconceptional infant undergoing a spinal anesthetic does not require
prolonged postoperative monitoring.
21. A. The infants at highest risk for postoperative apnea are those born prematurely, those
with multiple congenital anomalies, those with a history of apnea and bradycardia, and those
with chronic lung disease. The cause of apnea is multifactorial. Spinal anesthesia without
supplemental sedation decreases the incidence of postoperative apnea and bradycardia in
high-risk infants. The most conservative approach is to monitor all infants younger than 60
weeks postconceptual age overnight after surgery. (See page 1191: Postoperative Apnea.)
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22. Which of the following metabolic abnormalities is/are classically described in a

patient with pyloric stenosis&quest;
1. Hyponatremia
2. Metabolic acidosis
3. Hypochloremia
4. Hyperkalemia
22. B. The classic electrolyte pattern in infants with severe vomiting consists of hyponatremia,
hypokalemia, hypochloremia, and metabolic alkalosis with compensatory respiratory acidosis.
(See page 1201: Pyloric Stenosis.)
23. Which of the following statements regarding pyloric stenosis is/are TRUE&quest;
1. It is a surgical emergency.
2. Dextrose 5% in water should be used for fluid replacement.
3. It is usually evident in the first week of life.
4. Postoperative apnea is a concern in these patients.
23. D. Pyloric stenosis is a medical emergency, not a surgical one. These patients need fluid
resuscitation (full-strength, balanced salt solution), and after the infant begins to urinate,
potassium chloride should be added. Pyloric stenosis may appear as early as the second week
of life. The risk of postoperative apnea in these patients is a concern. (See page 1201: Pyloric
Stenosis.)
24. Which of the following statements regarding retinopathy of prematurity (ROP)

is/are TRUE&quest;
1. The exact cause is unknown.
2. Hypoxia may be a cause.
3. Prolonged bright-light exposure does not contribute to the cause.
4. In a premature infant, a pulse oximetry reading of 96% is appropriate.
24. E. Although the exact cause of ROP is unknown, variations in arterial oxygenation (hypoxia
or hyperoxia) are believed to play significant roles. At one time, there was concern that
exposure to bright ambient light could cause ROP, but this has been disproven. The risks of the
development of ROP from hyperoxia have been of concern to anesthesiologists who
anesthetize preterm neonates for any type of surgery. It is not known whether supplemental
oxygen may start the development of ROP in preterm patients. A study demonstrated that the
use of supplemental oxygen for a prolonged period of time, not just for the short duration of a
general anesthetic, was not deleterious as long as the pulse oximetry readings were kept in the
96% to 99% range. (See page 1191: Retinopathy of Prematurity.)
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Review of Clinical Anesthesia, 5e [Vishal] 45. Pediatric Anesthesia
Chapter 45
Pediatric Anesthesia
1. Fear and anxiety experienced by a child may persist for several weeks after routine
outpatient surgery.
A. True
B. False
1. A. Children, as well as adults, manifest anxiety in different ways. They also feel increasingly
anxious when their parents are anxious. The separation anxiety and other behavioral
disturbances manifested by about 50% of all children who had routine ambulatory surgery
persists for 3 to 4 weeks; these behavioral changes disappear and are self-limited. (See page
1207: The Preoperative Evaluation.)
2. Which of the following statements regarding pediatric patients with upper

respiratory infections (URIs) is FALSE&quest;
A. They are at a higher risk if they live in a household with parents who smoke.
B. Bronchial hyperreactivity consistently resolves within 4 weeks after a URI.
C. They have fewer perioperative complications if a mask anesthetic is used rather than
an endotracheal tube.
D. Children younger than 1 year of age with a URI are at a greater risk than are older
children undergoing anesthesia.
E. Children with sickle cell disease are at a greater risk.
2. B. Children with asthma, infants and young children with bronchopulmonary dysplasia,
children younger than 1 year of age, children with sickle cell disease, children who live in
households that include parents who smoke, and children who are to undergo bronchoscopy
are at a higher risk to develop perioperative morbidity if they have a URI. It is unclear how long
surgery should be delayed after a URI because bronchial hyperreactivity may exist for up to 7
weeks. (See page 1208: Coexisting Health Conditions.)
3. Obese children should be evaluated for sleep apnea symptoms preoperatively

because they have an increased rate of difficult airway, airway obstruction in the
recovery phase, extended recovery, and postoperative nausea.
A. True
B. False
3. A. All pediatric patients with markedly elevated body mass index should be evaluated for
sleep apnea symptoms. These children have an increased incidence of difficult airway, upper
airway obstruction, extended recovery times, and postoperative nausea and vomiting.
Discussion with the surgeon regarding possible overnight monitoring should occur before the
procedure. (See page 1208: Coexisting Health Conditions.)
4. An infant younger than 50 weeks postconceptual age undergoing general anesthesia

with a previous history of bronchopulmonary dysplasia may be discharged after an
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uneventful 2-hour recovery.
A. True
B. False
4. B. Regardless of postconceptual age, any infant considered to be at significant risk for
severe respiratory illness should have arrangements for overnight hospital monitoring after
general anesthesia. (See page 1208: Coexisting Health Conditions.)
5. Healthy children undergoing elective minor surgery require the following

preoperative tests:
A. coagulation screening (bleeding time)
B. hematocrit
C. chest radiography
D. urinalysis
5. E. It is currently the standard of care that healthy children undergoing elective minor surgery
require no laboratory evaluation. Routine chest radiography and urinary analysis are also
unnecessary. Commonly used coagulation screening tests, such as bleeding time and
prothrombin time, do not reliably predict abnormal perioperative bleeding. (See page 1208:
Laboratory Evaluation.)
6. In younger infants who still feed frequently, formula should be given up to

____________ hours preoperatively.
A. 2
B. 4
C. 6
D. 8
E. 10
6. C. Solids are prohibited within 6 to 8 hours, formula within 6 hours, breast milk within 4 hours,
and clear liquids within 2 hours of surgery. Regardless of the length of fasting, a defined
population of children is at an increased risk for aspiration of stomach contents: those with
delayed gastric emptying times and abdominal pathology. (See page 1209: Preoperative
Fasting Period.)
7. Which statement regarding the American Society of Anesthesiologists (ASA)'s

practice guidelines for preoperative fasting is TRUE&quest;
A. Solids are always prohibited after midnight.
B. Formula is not allowed within 8 hours of surgery.
C. Breast milk is allowed until 4 hours of surgery.
D. Flat cola is not allowed within 6 hours of surgery.
E. Apple juice is not allowed within 4 hours of surgery.
7. C. According to the ASA's practice guidelines for preoperative fasting, solids are prohibited
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within 6 to 8 hours of surgery, formula within 6 hours, breast milk within 4 hours of surgery, and
clear liquids within 2 hours of surgery. Indeed, liquids such as apple or grape juice, flat cola,
and sugar water may be encouraged up to 2 hours before the induction of anesthesia because
their consumption has been shown to decrease the gastric residual volume. (See page 1209:
Preoperative Fasting Period.)
8. Which statement regarding oral premedications is TRUE&quest;

A. The effect of oral midazolam lasts about 2 hours.
B. The onset of peak effect is faster for ketamine than for midazolam.
C. Patients receiving midazolam have more oral secretions than those receiving
ketamine.
D. The recommended dose of oral ketamine is 1 mg/kg.
E. The appropriate dose of midazolam is 0.1 mg/kg.
8. B. The most common oral sedative premedication in the United States is midazolam. In a
dose of 0.5 to 0.75 mg/kg, the effect peaks in about 30 minutes after administration and lasts
about 60 minutes. Maximal sedation occurs within 20 minutes after oral ketamine administration;
nystagmus occurs in 60% of patients, and increased oral secretions occur in 33% of patients.
Oral ketamine has been used as a sedative at a dose of 5 to 6 mg/kg. (See page 1209:
Preoperative Sedatives.)
9. Oral clonidine at a dose of 4 μg/kg reliably causes sedation and decreases

anesthetic and analgesic requirements.
A. True
B. False
9. A. Orally administered clonidine (an α 2 agonist) causes sedation within 45 minutes after a
dose of 4 μg/kg. The requirements for anesthetics and analgesics are lower, and the response
to tracheal stimulation is attenuated. Compared with midazolam, the onset of action is slower.
(See page 1209: Preoperative Sedatives.)
10. Dexmedetomidine is not effective for preoperative sedation in children.

A. True
B. False
10. B. Dexmedetomidine is an α 2 agonist (as is clonidine) that has been used as on oral
sedative for pediatrics. It has been effective in doses of 1 μg/kg transmucosally and 3 to 4 μg/kg
orally. (See page 1209: Preoperative Sedatives.)
P.236
11. Which dose range for intramuscular ketamine reliably provides for a quiet,
breathing, and minimally responsive pediatric patient in approximately 5 minutes.
A. 0.1–0.2 mg/kg
B. 0.5–1.0 mg/kg
C. 1–2 mg/kg
D. 3–4 mg/kg
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E. 8–9 mg/kg
11. D. A dose of 3 to 4 mg/kg of ketamine intramuscular yields a minimally responsive
spontaneously breathing child in approximately 5 minutes. Planning for the management of
oversedation, respiratory depression and increased secretions are important before
administration of ketamine. (See page 1209: Preoperative Sedatives.)
12. Emergence delirium is a phenomenon of recovery from inhaled anesthetic use in

children. For this reason, intravenous anesthetic induction is recommended for most
pediatric patients.
A. True
B. False
12. B. Use of mask-inhaled anesthesia induction has several advantages over intravenous
induction in children, particularly with potent, less soluble, and nonpungent agents such as
sevoflurane. The agitation behaviors observed after rapid emergence from inhaled anesthetics
(sevoflurane and desflurane) may be decreased using intravenous medications, including
midazolam, ketorolac, fentanyl, propofol, and dexmedetomidine. The exact reason for this
disturbance is not clear. (See page 1211: Anesthetic Agents.)
13. Intravenous anesthetics that act on the N-methyl-D-aspartic acid receptor or the γ -
aminobutyric acid receptor have been associated with neurodegeneration in animal
studies. For this reason, they should be considered relatively contraindicated in
pediatric patients.
A. True
B. False
13. B. The U.S. Food and Drug Administration reviewed information addressing observed
possible cognition and neurodegentation risks from both inhalation and intravenous anesthesia.
The conclusion at this time is that there is not enough information available to suggest that
operative anesthesia is harmful in humans, and there is also not enough evidence to suggest
that one type of anesthetic agent is safer than another. (See page 1211: Anesthetic Agents.)
14. Which of the following statements regarding the use of succinylcholine (Sch) in
pediatric patients is TRUE&quest;
A. Patients with muscular dystrophy can safely receive Sch without a concern for
hyperkalemia.
B. Sch is indicated for rapid airway control in cases of laryngospasm.
C. The use of Sch in all children is absolutely contraindicated.
D. Sch is not contraindicated after a recent burn injury.
E. Sch is not contraindicated in a patient with a family history of malignant hyperthermia.
14. B. Succinylcholine can be recommended only when ultrarapid onset and short duration of
action are of paramount importance such as is laryngospasm. Its use is absolutely
contraindicated in patients with muscular dystrophy, recent burn injury, spinal cord transaction
or immobilization, as well as in a family history of malignant hyperthermia. The need for
succinylcholine has been decreased by the availability of fast-acting nondepolarizing agents
377 / 494
such as rocuronium. (See page 1213: Muscle Relaxants.)
15. Which statement regarding postoperative nausea and vomiting (PONV) in pediatric
patients is TRUE&quest;
A. The effectiveness of ondansetron as the best rescue medication has been proven.
B. Droperidol should be avoided because of prolongation of the P-R interval.
C. Postoperative nausea and vomiting (PONV) is common after orchiopexy, strabismus
surgery, and tonsillectomy.
D. The type of anesthetic technique has no effect on PONV.
E. Patients should eat or drink before discharge so as to avoid PONV.
15. C. PONV is particularly prominent after certain surgical procedures such as orchiopexy,
strabismus surgery, and tonsillectomy. The type of anesthetic used for a particular surgical
procedure also influences the incidence of PONV. For instance, when propofol is used in place
of inhaled agents as the primary anesthetic for high-risk procedures, there is evidence that
PONV is decreased. The Food and Drug Administration issued a report warning of prolonged
QT syndrome and possible torsades de pointes with droperidol use. The practice of requiring
patients to eat or drink before discharge does not appear to improve outcomes. (See page
1214: Antiemetics.)
16. An otherwise healthy 10-kg, 2-year-old girl presents for 2-hour eye muscle surgery.
She has been fasting since 10 PM and enters the operating room at 8 AM.
Approximately how much intravenous fluid should she receive during the first hour of
anesthesia&quest;
A. 50 mL
B. 100 mL
C. 150 mL
D. 250 mL
E. 350 mL
16. D. The hourly maintenance fluid requirement for a child who weighs less than 10 kg is 4
mL/kg. This child would have an hourly requirement of 40 mL (10 kg × 4 mL/kg). The fluid
deficit is then calculated by multiplying the hourly fluid requirement by the time since the last
oral fluid intake (40 mL × 10 hours = 400 mL). Generally, half of the total deficit (200 mL) is
replaced in the first hour of the anesthetic in addition to the scheduled fluid maintenance under
anesthesia. Because the third-space and evaporative losses are minimal during eye surgery,
the hourly intraoperative maintenance is approximately 4 mL/kg. Hence, approximately 240 mL
should be given in the first hour. (See page 1214: Fluid and Blood Product Management.)
17. The average hourly maintenance fluid requirement for a 22-kg child is
approximately how many milliliters&quest;
A. 42
B. 52
C. 54
D. 62
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E. 84
17. D. For the “first” 10 kg, the hourly fluid requirement is 4 mL/kg/hr. For the “next” 10 kg, it is 2
mL/kg/hr. For the “remaining” kg, it is 1 mL/kg/hr. Hence, the average hourly maintenance fluid
requirement is 62 mL (40 + 20 + 2). (See page 1214: Fluid and Blood Product Management.)
18. The hourly maintenance fluid requirement for a pediatric patient weighing 16 kg is:
A. 36 mL/hr
B. 42 mL/hr
C. 46 mL/hr
D. 52 mL/hr
E. 56 mL/hr
18. D. The hourly maintenance fluid requirement for pediatric patients is 4 mL/kg for the first 10
kg plus 2 mL/kg for each kilogram between 11 and 20 kg and 1 mL/kg for each kilogram over 20
kg. For the foregoing example with a 16-kg patient, this would be 40 mL/hr (first 10 kg) + 2
mL/hr × 6 kg = 52 mL/ hr. (See page 1214: Fluid and Blood Product Management.)
19. What is the maximum allowable blood loss (MABL) for a 4-kg term infant with a
starting hematocrit of 32% and a target hematocrit of 24%&quest;
A. 70 mL
B. 80 mL
C. 90 mL
D. 100 mL
E. 110 mL
19. C. MABL is estimated as follows:
In general, estimated blood volume (EBV) is 90 mL/kg for term infants, so the EBV = 4 kg × 90
mL/kg = 360 cc. Therefore:
(See page 1214: Fluid and Blood Product Management.)
20. Infants have high stores of calcium; therefore, administration of citrated blood
products will not result in hypocalcemia because body calcium is mobilized.
A. True
B. False
20. B. In general, infants have smaller stores of calcium. The rapid administration to
physiologically immature patients with a low body store of calcium will result in some degree of
hypocalcemia. The citrate is metabolized by the liver to some degree; however, evaluation of
ionized calcium and its replacement may be necessary. Another consideration of rapidly
administering a blood product is hypothermia. (See page 1214: Fluid and Blood Product
379 / 494
Management.)
21. In pediatric patients, the endpoint(s) of fluid and blood therapy is/are:
A. adequate blood pressure
B. adequate tissue perfusion
C. adequate urine output
D. correction of identifiable deficiencies in hemostasis
E. all of the above
21. E. All of the options are true regarding goal-directed fluid and blood component therapy for
pediatric (and adult) patients. (See page 1214: Fluid and Blood Product Management.)
22. The design of multiple pediatric nonrebreathing anesthesia circuits was because
of:
A. the observation that neonates and infants would exhibit increased work during
spontaneous breathing because older ventilators had high-resistance valves to be
opened by the child's respiratory effort
B. the concept that a smaller volume inside the pediatric circuit would allow the partial
pressure
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of the inhaled anesthetic to increase faster at the alveoli of the child
C. the volume of compression inside the pediatric breathing circuit that allowed a greater
fraction of ventilator or hand delivered gas volume to reach the child
D. anesthesiologists spending free time in their home workshops innovating
E. all of the above
22. E. All of the options are true. Understanding the physiology and mechanics of breathing
circuits is much more important than memorizing the labeling and what happens with
spontaneous versus mechanical ventilation. By understanding the rationale and modifications
that were made by innovators, we can apply them to both pediatric and adult patients.
Neonates and infants exhibit increased work during spontaneous breathing because older
ventilators have high-resistance valves to be opened by the child's respiratory effort. The
concept of a smaller volume inside the pediatric circuit allows the partial pressure of inhaled
anesthetic to increase faster at the alveoli of the child. The volume of compression inside the
pediatric breathing circuit allows more fraction of ventilator or hand-delivered gas volume to
reach the child. (See page 1216: Pediatric Breathing Circuits.)
23. Ketorolac is not effective or safe in managing pediatric pain.

A. True
B. False
23. B. Ketorolac is effective in the management of pediatric pain. It may be administered
intravenously, intramuscularly, or orally. Avoiding ketorolac in cases of underlying hemostasis
disorders and nephropathies should not preclude its appropriate use in other aspects of
pediatric pain management. (See page 1217: Pharmacologic Treatment of Pain.)
380 / 494
24. Which of the followed should be addressed when planning for recovery after a
pediatric anesthetic&quest;
1. Appropriately calming the frightened child as he or she becomes more oriented and
planning for cases of emergence agitation
2. Ensuring the child recovers from mild hypothermia
3. Planning to manage nausea and vomiting
4. Analgesia in the recovery phase
24. E. The preparation for anesthesia recovery should be made before the procedure is begun.
Children in the recovery phase may exhibit emergence agitation after a general anesthetic
(more common after certain procedures such as strabismus surgery and a sevoflurane-based
anesthetic). Pediatric patients also exhibit a natural disorientation as they recover, so having a
plan to soothe the child by having a parent available or adjuvant pharmacology is helpful.
Nausea and vomiting should be expected after procedures associated with a higher nausea
risk, and the adjustment of anesthetic techniques used may decrease the risk. Analgesia
preparations are also done by administering a customized anesthetic technique and having the
recovery team that is familiar with managing pediatric patients as they recover from procedures
and anesthetics. (See page 1218: Postanesthesia Care).
25. A child with a URI or who is recovering from a URI is at increased risk of
developing:
1. laryngospasm
2. bronchospasm
3. postoperative atelectasis
4. croup
25. E. Multiple investigations have found that children with URIs and those who are recovering
from URIs are at increased risk for developing laryngospasm, bronchospasm, oxygen
desaturation, postoperative atelectasis, and croup. Although these complications usually do not
cause significant morbidity in otherwise healthy children, they may be very significant in children
with underlying conditions. (See page 1208: Coexisting Health Conditions.)
26. Which of the following patient(s) may be at increased risk for developing
postoperative apnea after general anesthesia&quest;
1. A 2-year-old child undergoing strabismus surgery
2. A 4-month-old infant who was delivered at 35 weeks
3. A 1-year-old child undergoing inguinal hernia surgery
4. A 3-month-old infant with a history of apnea and bradycardia
26. C. Research indicates that former preterm infants are more likely to develop postoperative
apnea after general anesthesia. These reports indicate that the risk of postoperative apnea is
inversely related to postconceptional age, and infants with a history of apnea and bradycardia,
respiratory distress, and mechanical ventilation may be at increased risk. Infants who are 52 to
381 / 494
60 weeks postconceptional age should generally be admitted to the hospital and monitored
after anesthesia. (See page 1208: Coexisting Health Conditions.)
27. Which of the following are appropriate drug and dose amounts for oral preoperative
sedation&quest;
1. Midazolam 0.5 to 0.75 mg/kg
2. Ketamine 2 mg/kg
3. Clonidine 4 μg/kg
4. Methohexital 25 mg/kg
27. B. Midazolam is the most commonly used sedative premedication in the United States. It
has rapid onset and predictable effect without causing significant cardiorespiratory depression.
In an oral dose of 0.5 to 0.75 mg/kg, midazolam peaks approximately 30 minutes after
administration, and its effect lasts approximately 30 minutes. Oral ketamine has been used as a
sedative medication in doses of 5 to 6 mg/kg for children 1 to 6 years of age. Orally
administered clonidine in a dose of 4 μg/kg has been demonstrated to cause sedation,
decrease anesthetic requirements, and decrease the requirement for postoperative analgesics.
(See page 1209: Preoperative Sedatives.)
28. Which statement(s) regarding mask induction of general anesthesia in pediatric

1. A right-to left intracardiac shunt slows the rate of mask induction.
2. Desflurane has an unacceptable incidence of laryngospasm when used for mask
induction.
3. The incidence of bradycardia, hypotension, and cardiac arrest is highest in patients
younger than 1 year of age.
4. The minimum alveolar concentration (MAC) of sevoflurane is approximately 2.5% for
young infants compared with 2% for adolescents and adults.
28. E. Mask induction of general anesthesia remains the most common induction technique for
pediatric anesthesia in the United States. The incidence of bradycardia, hypotension, and
cardiac arrest during mask induction is higher in infants younger than 1 year of age than in
older children and adults. There is actually a small increase in MAC between birth and 2 to 3
months of age that represents the age of highest MAC requirement. For sevoflurane, the
change in MAC is marked, with a value of approximately 2.5% for young infants compared with
2% for adolescents and adults. A right-to-left shunt slows the inhaled induction of anesthesia
because the anesthetic concentration in the arterial blood increases more slowly. Desflurane
has an unacceptable incidence of laryngospasm when used for inhalational induction. (See
page 1211: Anesthetic Agents.)
29. Which statement(s) regarding airway management in pediatric patients is/are

TRUE&quest;
1. After the endotracheal tube is placed, air should leak out at 20 to 25 cm H2O.
2. The narrowest portion of the pediatric airway is at the level of the cricoid cartilage.
3. The appropriately sized endotracheal tube may be determined by comparison with the
fifth digit.
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4. If a cuffed tube is used, the cuff pressure should not exceed 20 cm H 2O.
29. E. Because the narrowest portion of the pediatric airway is at the level of the cricoid
cartilage, uncuffed tubes can be used and create a functional seal when appropriately sized.
Several formulas have been used for tube selection in children older than 1 year of age, the
most common being (16 + age)/4. The size may also be estimated by comparing the size of the
fifth digit or of a nostril. After the tube is in place, it should be checked to determine at what
pressure air can escape around the tube. Air should leak out at no higher than 20 to 25 cm H2O
to minimize the risk of postextubation croup. Cuffed tubes may also be safely used in children
by selecting a tube 0.5 mm smaller in internal diameter than the uncuffed choice. Care should
be taken to check the pressure in the cuff to ensure that it does not exceed 20 cm H2O. (See
page 1215: Airway Management.)
30. Which of the following statement(s) regarding regional anesthesia in pediatric

patients is/are FALSE&quest;
1. The dural sac is at the S1 level at 1 year of age.
2. The recommended dose of bupivacaine for a caudal anesthetic is 1.5 mL/kg of 0.25%
solution.
3. The sitting position facilitates free flow of cerebrospinal fluid (CSF) when placing a
spinal block in neonates.
4. A spinal anesthetic is contraindicated in preterm infants.
30. C. When using bupivacaine for a caudal block, a 0.175% solution in a dose of 1 mL/kg is
used, and if larger volumes are needed, 0.125% solution is recommended. When considering
spinal anesthesia, it is important to note that the dural sac migrates cephalad during the first
year of life, and in neonates, it is at S3; after age 1 year, it is at the S1 level. The sitting position
may be especially helpful in neonates to maintain midline needle position and free flow of CSF.
383 / 494
Review of Clinical Anesthesia, 5e [Vishal] 46. Gastrointestinal Disorders
Chapter 46
Gastrointestinal Disorders
1. Which statement best describes the anesthetic considerations for abdominal

surgery&quest;
A. Nitrous oxide (N2O) diffuses into gas-containing body cavities from the bloodstream
faster than nitrogen in those cavities can diffuse out into the circulation.
B. N2O is 10 times more soluble than nitrogen.
C. The extent of distention from N2O depends only on the amount of gas in the bowel.
D. Intestinal wall distention occurs with administration of N2O; however, it never results
in bowel ischemia.
E. N2O should be avoided in all abdominal surgery.
1. A. N2O diffuses into gas-containing body cavities from the bloodstream faster than nitrogen
can diffuse out into the circulation. Use of a 50:50 mixture of N2O results in a twofold increase
in bowel gas. N2O is 30 times more soluble than nitrogen. In a severely compromised patient,
abdominal distention may be so severe as to cause bowel ischemia. N2O can be used for
abdominal surgery, provided no signs of severe distention are present. It is reasonable to use
low concentrations of N2O in short elective operations in which no significant amount of gas is
present in the bowel. The extent of abdominal distention depends on the amount of gas present
in the bowel, the concentration of N2O, and the duration of N2O administration. Neostigmine
increases bowel peristalsis. This effect may be ameliorated by the concurrent administration of
glycopyrrolate. (See page 1226: Nitrous Oxide and the Bowel and page 1225: Splanchnic
Blood Flow.)
2. Which of the following statements concerning the gastrointestinal tract is/are
TRUE&quest;
1. Barrier pressure is the difference between the lower esophageal pressure (LES) and
the gastric pressure.
2. Dopamine and glucagon increase LES tone.
3. In an anesthetized patient, gastroesophageal reflux is more dependent on barrier
pressure than on LES tone.
4. LES tone is not affected by thiopental or propofol.
2. B. The esophagus is innervated by both intrinsic and extrinsic nerve supply. The intrinsic
nerve supply includes the myenteric plexus of Auerbach and submucosal plexus of Meissner.
The extrinsic nerve supply is derived from parasympathetic fibers from the vagus with
sympathetic fibers from the superior and inferior cervical fourth and fifth sympathetic ganglia.
Dopamine, secretin, glucagon, β -adrenergic agents, thiopental, propofol, opioids, and
anticholinergics all reduce LES pressure. In a patient undergoing general anesthesia, the
384 / 494
occurrence of reflux depends on barrier pressure, which is the difference between LES
pressure and gastric pressure. Barrier pressure is more important than LES tone in the
production of gastroesophageal reflux. (See page 1221: Esophagus.)
3. Which of the following statements regarding gastric aspiration is/are TRUE&quest;

1. The patient is most susceptible to aspiration during induction of general anesthesia.
2. Breast milk is cleared more rapidly than other milk products; however, it predisposes
to an increased severity of aspiration pneumonitis.
3. There is a dose–response relationship in the severity of aspiration pneumonitis for
both gastric volume and acidity that reaches the lung.
4. Bedridden states, pregnancy, and trauma are associated with high gastric volume.
3. E. Reducing the perioperative aspiration risk involves the control of gastric contents (volume
and acidity) and prevention of pulmonary aspiration (cricoid pressure and a cuffed endotracheal
tube). The incidence of regurgitation of gastric contents is low. Aspiration is most likely to occur
during induction of anesthesia. Breast milk predisposes to an increased severity of aspiration
pneumonitis compared with other milk products. Soy-based formulas cause a less severe form
of acute lung injury. Breast milk is cleared more rapidly than other milk products, and milk
products are cleared more slowly than clear liquids. Pregnancy, trauma, shock, and pain are
examples of physiologic states associated with high gastric volumes. There is a dose–response
relationship in the severity of aspiration pneumonitis for both gastric volume and acidity that
reaches the lung. (See page 1223: Reducing Perioperative Aspiration Risk: Control of Gastric
Contents.)
4. The risk of regurgitation and pulmonary aspiration may be reduced by:

1. use of histamine (H2)-receptor antagonists and proton pump inhibitors (PPIs)
2. application of the Sellick maneuver (cricoid pressure), which occludes the upper end
of the esophagus to prevent passive regurgitation of gastric contents
3. use of bimanual cricoid pressure, which provides similar laryngoscopic views as does
the single-handed technique
4. application of a 1-Newton force to the cricoid cartilage
4. A. Anesthesia risk of regurgitation and aspiration may be reduced by use of H 2 receptor
antagonists and PPIs, minimizing intake, increasing gastric emptying and reducing gastric
volume. Cricoid pressure may be used to decrease risk of pulmonary aspiration if properly
performed. It occludes the upper esophagus and prevents passive regurgitation of gastric
contents. Application of a 10-Newton force to the cricoid cartilage is suggested while the patient
is awake. This prevents pain, coughing, and retching. After the patient is anesthetized, a 20-
Newton force is required to prevent aspiration. Bimanual cricoid pressure is counter pressure
with a hand beneath the cervical vertebrae to support the neck, which minimizes the distortion
of the position of the head and alignment of the trachea that may occur with one-handed cricoid
pressure. No difference in laryngoscopic view was noted when comparing single with bimanual
cricoid pressure. (See page 1223: Control of Gastric Contents.)
5. Which of the following statements is/are TRUE regarding perioperative risk of

aspiration&quest;
385 / 494
1. American Society of Anesthesiologists (ASA) guidelines suggest clear liquids may be
consumed 2 hours before surgery.
2. Famotidine effectively reduces gastric volume and acidity if given the night before
surgery.
3. A nasogastric tube provides a direct connection to the outside for passive drainage of
gastric contents and should remain in place during induction.
4. A nasogastric tube diminishes the effectiveness of cricoid pressure.
5. B. ASA guidelines recommend a fasting period of 4 hours for breast milk, 6 hours for both
nonhuman milk and infant formula, and 6 hours for a light solid meal. Famotidine effectively
reduces gastric volume and acidity better than ranitidine if given a few hours before surgery.
Proton pump inhibitors (rebeprazole, lansoprazole, and omeprazole) are more effective when
given the night before surgery and on the morning of surgery. A nasogastric tube may be used
to decrease gastric volume before induction. It does not guarantee an “empty stomach.” It
provides a direct connection to outside for passive drainage of abdominal contents and is best
left in place during induction. It does not diminish the effectiveness of cricoid pressure. (See
page 1223: Prevention of Pulmonary Aspiration: Control of Gastric Contents.)
6. Which of the following statements concerning the intestine is/are TRUE&quest;

1. Bowel denervation results in a marked decrease in intestinal activity.
2. Risk factors for anastomotic leak include smoking, excessive alcohol consumption,
and preoperative chemotherapy.
3. There is no reason to avoid prokinetic medications (e.g., metoclopramide) during the
early postoperative period after colon surgery.
4. Epidural analgesia with local anesthetic decreases the duration of postoperative ileus.
6. C. Parasympathetic stimulation increases the activity of the small intestines. However, bowel
denervation results in minimal change in intestinal activity, lending credence to the possibility
that humoral secretions play a major role in intestinal activity. Risk factors for anastomotic leaks
include male gender, low anastomosis, smoking, excessive alcohol consumption, and
preoperative chemotherapy or radiotherapy. Hypocapnia significantly reduces splanchnic blood
flow; hypercapnia does the opposite. Therefore, hyperventilation is best avoided after colon
resection to maintain adequate blood flow. Use of prokinetics such as metoclopramide has
been associated with colonic anastomotic dehiscence in the early perioperative period.
Mesenteric traction syndrome consists of sudden tachycardia, hypotension, and cutaneous
hyperemia during mesenteric traction. Epidural analgesia with local anesthetic decreases the
duration of postoperative ileus by blocking sympathetic outflow and increasing relative
gastrointestinal parasympathetic activity. Other beneficial adjuncts include minimally invasive
surgery, early ambulation, and early enteral nutrition. (See page 1224: Intestines: Postoperative
Anastomotic Leakage/Postoperative Ileus.)
P.242
7. Which of the following statements regarding carcinoid tumors is/are TRUE&quest;
1. The gastrointestinal tract is the most common site of origin for carcinoid tumors.
2. The hormones secreted by nonmetastatic carcinoid tumors are usually deactivated by
the liver.
386 / 494
3. Typical symptoms manifested by metastatic carcinoid include cutaneous flushing,
brochoconstriction, hypotension, and diarrhea.
4. Carcinoid crisis may be precipitated by stress, tumor necrosis, and succinylcholine-
induced fasciculations.
7. E. The gastrointestinal tract is the most common site for carcinoid tumors. Most of these
tumors are small and occur at multiple sites. Twenty percent of carcinoid tumors may be located
in the lung. The portal circulation may be a site of inactivation of the hormones secreted by
these tumors. Nonmetastatic carcinoid tumors secrete hormones that are usually transported to
the liver through the portal vein, where they are subsequently deactivated. The presentation
and manifestation of metastatic carcinoid disease are variable. Most symptoms are a result of
hormones and substances secreted in the gastrointestinal tract into the systemic circulation.
Cutaneous flushing, abdominal pain, vomiting, diarrhea, bronchospasm, hypotension,
hypertension, and hyperglycemia are all symptoms of a carcinoid tumor, which are related to
secretion of bradykinin and serotonin. Whereas bradykinin produces cutaneous flushing,
bronchospasm, and hypotension, serotonin causes hypertension or hypotension. Other
substances secreted include histamine, substance P, bradykinin, tachykinin, motilin,
corticotrophin, prostaglandins, kallikrein, and neurotensin. Carcinoid crisis may be precipitated
by physical or chemical factors that trigger mediator release. These include stress, tumor
necrosis from hepatic artery ligation or embolization, chemotherapy, and succinylcholine-
induced fasciculations. (See page 1227: Carcinoid Tumors.)
8. Which of the following statements regarding carcinoid tumors is/are TRUE&quest;

1. Complete surgical excision is the most effective treatment for carcinoid tumor.
2. Octreotide is a synthetic somatostatin analog with a half-life similar to that of
somatostatin.
3. Carcinoid heart disease predominantly affects the right side of the heart.
4. Histamine-releasing drugs are not contraindicated in patients with carcinoid tumors.
8. B. Complete surgical excision is the most effective treatment for carcinoid tumor. Medical
treatment consists of administration of octreotide. Octreotide is a somatostatin analog with
approximately 50 times the half-life of somatostatin. It has a half-life of approximately 2.5 hours.
It may be administered either subcutaneously or intravenously. Therapy may be given
prophylactically as well as intraoperatively to control symptoms. However, octreotide should not
be abruptly discontinued in the postoperative period; it should be continued at least 24 hours
after surgery. Metastatic carcinoid-secreting tumors affect the heart and result in lesions on the
valves of the right side of the heart (tricuspid and pulmonic valves). Histamine-releasing drugs
are contraindicated because they may evoke a carcinoid episode. Other factors that may cause
a carcinoid episode include perioperative anxiety, hypothermia, hypercapnia, hypotension, and
hypertension. (See page 1227: Carcinoid Tumors.)
387 / 494
Review of Clinical Anesthesia, 5e [Vishal] 47. Anesthesia & Obesity
Chapter 47
Anesthesia and Obesity
1. Body mass index (BMI) is defined by which of the following&quest;

A. Weight in pounds divided by height in inches
B. Weight in kilograms divided by height in squared centimeters
C. Weight in pounds divided by height in square inches
D. Weight in kilograms divided by height in squared meters
E. Weight in pounds divided by height in squared centimeters
1. D. BMI is defined by weight in kilograms divided by height in squared meters. This is called
the BMI. (See page 1230: Obesity.)
2. Which of the following statements regarding obesity is FALSE&quest;

A. Visceral fat is particularly associated with cardiovascular disease and left ventricular
dysfunction.
B. Morbid obesity is defined by a body mass index (BMI) above 40 kg/m2.

C. Risks associated with obesity are related to the distribution of fat.
D. The effects of obesity are almost exclusively related to the cardiovascular system.
E. An android distribution is associated with increased oxygen consumption and
increased incidence of cardiovascular disease.
2. D. Even modest obesity is associated with an increased risk of premature death or
complications during the perioperative period. Visceral fat is particularly associated with
cardiovascular disease and left ventricular dysfunction. Obesity and morbid obesity are
associated with a BMI of 30 or above and 40 kg/m2 or above, respectively. Truncal distribution
of fat, also called android distribution, is associated with increased oxygen consumption and an
increased incidence of cardiovascular disease. Multiple physiologic systems are affected by
obesity, such as the respiratory, cardiovascular, endocrine and metabolic, and gastrointestinal
systems. (See page 1230: Obesity.)
3. Which of the following does not occur in obese patients&quest;

A. Normal basal metabolic rate in relationship to body surface area
B. Decreased expiratory reserve volume and functional residual capacity (FRC) in the
upright position
C. Normal closing capacity in the upright position but abnormal in the supine position
D. Reduced chest wall and lung compliance
E. Normal lung compliance
3. C. In obesity, oxygen consumption and carbon dioxide production are increased, but the
basal metabolic rate is normal because it is related to body surface area. A decreased
expiratory reserve volume and a decrease in FRC occur in the upright position such that tidal
388 / 494
volume may encroach upon the range of the closing capacity. This effect is exaggerated in the
supine position. The results of this are ventilation–perfusion abnormalities, left-to-right shunting,
and hypoxemia. Chest wall compliance is reduced in obesity, although lung compliance is
unchanged. Respiratory functions, such as forced vital capacity, forced expiratory volume, and
peak expiratory flows, are unchanged in obesity. As obesity increases, hypoventilation
syndrome may occur. This is characterized by loss of hypercapnic drive, sleep apnea,
hypersomnolence, and airway difficulties. This may progress to Pickwickian syndrome
(hypercarbia, hypoxia, polycythemia, hypersomnolence, pulmonary hypertension, and
biventricular failure). (See page 1231: Respiratory System.)
4. Cardiovascular system changes that may occur with obesity include all of the
following EXCEPT:
A. mild to moderate hypertension
B. accelerated increase in cardiac output in response to exercise or stress
C. cardiomegaly with an elevated circulating blood volume
D. impairment of diastolic function with elevated left ventricular end-diastolic pressure
E. absence of accelerated atherosclerosis
4. E. Arterial hypertension is associated with obesity. Mild to moderate hypertension with a 3- to
4-mm Hg increase in systolic and a 2-mm Hg increase in diastolic pressure occurs for every 10-
kg weight gain. Cardiac output increases with exercise and stress. Cardiomegaly may occur,
associated with an elevated circulating blood volume and cardiac output and hypertension. An
accelerated increase in cardiac output occurs in response to exercise and stress in obese
patients. Left ventricular wall stress leads to hypertrophy, reduced compliance, and impaired left
ventricular filling (diastolic dysfunction) with elevated left ventricular end-diastolic pressure and
pulmonary edema. Obesity accelerates atherosclerosis. (See page 1233: Cardiovascular
System.)
5. Which of the following is FALSE&quest;

A. Up to 50% of obese patients have clinically significant obstructive sleep apnea (OSA).
B. The apnea–hypopnea index qualifies the severity of OSA.
C. An apnea–hypopnea index of 10 signifies severe OSA.
D. Physiologic abnormalities from OSA include hypercapnia and pulmonary
vasoconstriction.
E. Obesity hypoventilation (Pickwickian) syndrome occurs in up to 10% of morbidly
obese patients.
5. C. Obese patients with upper airway obstructive syndrome can be classified into three
categories: those with OSA, obstructive hypopnea syndrome, and upper airway resistance. Up
to 50% of obese patients have significant OSA. OSA is defined as 10 seconds or more of total
cessation of airflow five or more times per hour of sleep despite continuous respiratory effort
against a closed glottis in combination with a decrease in arterial oxygenation greater than 4%.
The apnea–hypopnea index quantifies the severity of OSA. An index of above 30 signifies OSA,
and an index of 5 to 15 signifies mild OSA, and an index of 16 to 30 signifies moderate OSA.
Physiologic abnormalities resulting from OSA include hypoxemia, hypercapnia, pulmonary and
systemic vasoconstriction, and secondary polycythemia. These result in an increased risk of
389 / 494
ischemic heart disease and cerebral vascular disease. Obesity hypoventilation (Pickwickian)
syndrome results from long-term syndrome and is seen in 5% to 10% of morbidly obese
patients. It is a combination of obesity and chronic hypoventilation resulting in pulmonary
hypertension and cor pulmonale. (See page 1232: Obstructive Sleep Apnea and page 1232:
Obesity Hypoventilation Syndrome.)
6. Which of the following with respect to obesity and the gastrointestinal system and
liver is FALSE&quest;
A. There is delayed gastric emptying.
B. A positive correlation exists between obesity and esophageal erosions.
C. Weight loss does not significantly improve gastroesophageal reflux symptoms.
D. Fatty liver infiltrates of the liver are unlikely to result in significantly diminished
capacity to metabolize drugs.
E. There is increased gastric acidity.
6. C. Gastric volume and acidity are increased, hepatic function is altered, and drug metabolism
is adversely affected by obesity. Delayed gastric emptying occurs because of increased
abdominal mass that causes antral distention, gastrin release, and a decrease in pH with
parietal cell secretion. Weight loss significantly decreases gastroesophageal reflux symptoms. A
positive correlation exists between obesity and frequent gastroesophageal reflux symptoms and
erosions. Fatty infiltration of the liver reflects duration rather than the degree of obesity.
Histologic and liver function abnormalities are seen in up to one third of obese patients who
have no evidence of concomitant liver disease, of which an increase in alanine
aminotransferase is most frequently seen. No clear correlation exists between routine liver
function tests and the capacity of the liver to metabolize drugs. (See page 1234:
Gastrointestinal System.)
P.245
7. Which of the following statements regarding preoperative assessment of obese
1. Thorough evaluation of airway with consideration for fiberoptic intubation is indicated.
2. Serum evaluation of liver function studies for evidence of fatty liver infiltration is
recommended.
3. Aspiration prophylaxis and antibiotic prophylaxis are indicated.
4. Body mass index (BMI) correlates with the degree of difficulty of intubation.
7. B. Evaluation of the airway is critical because of the numerous anatomic changes that could
potentially result in difficulty intubating the obese patient. For example, flexion of the neck could
result in difficulty because of excessive soft tissue. Submental fat may limit mouth opening. A
large tongue, fleshy cheeks, redundant palate, and pharyngeal tissue may narrow the airway.
However, BMI does not seem to have much influence on the difficulty of laryngoscopy. Neck
circumference has been identified as the single best predictor of problematic intubation in
morbidly obese patients. Liver function studies are not necessary because they may not
necessarily be indicative of fatty infiltration of the liver. Fatty infiltration of the liver reflects the
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duration rather than the degree of obesity. Despite histologic and enzymatic changes, no clear
correlation exists between routine liver function tests and the capacity of the liver to metabolize
drugs. All obese patients should receive aspiration prophylaxis and antibiotic prophylaxis. The
incidence of wound infection is increased in obese patients. (See page 1240: Preoperative
Evaluation; page 1241: Concurrent, Preoperative, and Prophylactic Medications; and page
1241: Airway.)
8. Which statement(s) best describe(s) anesthetic considerations for abdominal

surgery in morbidly obese patients&quest;
1. Carpal tunnel syndrome is the most common mononeuropathy after bariatric surgery.
2. Supine positioning may cause ventilatory impairment and compression of the inferior
vena cava and aorta.
3. Prone positioning, if necessary, should be used to allow freedom of abdominal
movement.
4. Adequate preoxygenation is vital to preventing hypoxemia after loss of consciousness
resulting from increased oxygen consumption.
8. E. Carpal tunnel syndrome is the most common mononeuropathy after bariatric surgery.
Supine positioning causes ventilatory impairment and occlusion of the inferior vena cava and
aorta. This may compromise venous return to the heart, with resultant hypotension. Prone
positioning decreases functional residual capacity. In obese patients, care should be exercised
to maintain freedom of abdominal movement and thus prevent added detrimental effects on
lung compliance, ventilation, and arterial oxygenation. Lateral decubitus positioning is favored
over prone positioning whenever possible. Adequate preoxygenation is vital to prevent
hypoxemia after loss of consciousness resulting from increased oxygen consumption. (See
page 1241: Positioning and page 1242: Induction, Intubation, and Maintenance.)
9. Which of the following may apply to the intraoperative anesthetic management of

obese patients&quest;
1. Consideration of an awake fiberoptic intubation should be given in all patients who
meet the criteria for potential difficult intubation.
2. Stacking is a useful positioning maneuver used to facilitate intubation.
3. Myalgias are not frequently seen after administration of succinylcholine in morbidly
obese patients.
4. Larger induction doses of medications are not necessary in morbidly obese patients.
9. A. An awake fiberoptic intubation should be considered in all patients who are 75% over ideal
body weight because of the greater incidence of difficulty with intubation. Neck circumference is
the greatest predictor of problematic intubation. Myalgias are not frequently seen after
succinylcholine administration in morbidly obese patients, so succinylcoline is acceptable to use
for tracheal intubation. Stacking is a useful maneuver used to facilitate intubation so that the
chin is at a higher level than the chest. The head-elevated laryngoscopy position (HELP) is a
step beyond “stacking.” The HELP position elevates the obese patient's head, upper body, and
shoulders above the chest to the extent that an imaginary horizontal line connects the sternal
notch to the external auditory meatus; this improves the laryngoscopy view. Larger induction
doses may be required because obese patients have larger blood volumes, muscle mass, and
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cardiac output. Intra-arterial blood pressure monitoring may be necessary if proper fit of the
blood pressure cuff is not possible. (See page 1242: Induction, Intubation, and Maintenance.)
10. Which of the following statements regarding pharmacology in obese patients is/are
TRUE&quest;
1. A drug that is mainly distributed to lean tissue should have the loading dose calculated
on lean body weight.
2. Hyperlipidemia and an increase in concentration of α 1-acid glycoprotein may affect
protein binding leading to a reduction of free drug concentration.
3. Prolonged somnolence with thiopental is expected because of its highly lipophilic
nature and large volume of distribution in obese patients.
4. Prolonged somnolence with propofol is expected because of its highly lipophilic nature
and large volume of distribution in obese patients.
10. A. General pharmacokinetic principles dictate that drug dosing should take into account the
volume of distribution for administration of the loading dose and on clearance for the
maintenance dose. A drug mainly distributed to lean tissues should have loading dose
calculated on lean body weight. If a drug is equally distributed between adipose and lean
tissue, dosing should be calculated based on total body weight. Hyperlipidemia and an increase
concentration of α 1-acid glycoprotein may affect protein binding, leading to a decreased
concentration of free drug. Prolonged somnolence may be expected with thiopental because it
is highly lipophilic and has a large volume of distribution in obese patients. Conversely, propofol
is dosed as it is in non-obese patients; there is no difference in propofol's volume of distribution
between obese and non-obese patients. (See page 1236: Pharmacology.)
11. Which of the following statements regarding the treatment of obesity is/are
TRUE&quest;
1. The combination of phentermine and fenfluramine is a safe medical treatment for
patients with a body mass index (BMI) above 30.
2. Sibutramine inhibits the reuptake of norepinephrine to increase satiety rather than
decrease appetite.
3. Rhabdomyolosis occurs more commonly in morbidly obese patients undergoing open
gastric bypass procedures compared with laparoscopic procedures.
4. Bariatric surgery is the most effective treatment for morbid obesity.
11. C. Medications used to treat obesity are formulated to decrease energy uptake, increase
energy utilization, and decrease absorption of nutrients. The combination of phentermine and
fenfluramine was popular until it became evident that it was associated with valvular heart
disease and pulmonary hypertension. Sibutramine, a newer antiobesity drug, inhibits reuptake
of norepinephrine and increases satiety rather than decreasing appetite. It has no effect on
release of serotonin, so it has not been associated with valvular heart disease. Bariatric surgery
is the most effective treatment for morbid obesity. Procedures are classified as malabsorption,
restrictive, or both. Malabsorption procedures (jejuno–ileo bypass and bilo–pancreatic
diversion) are rarely used today. Restrictive procedures include vertical banded gastroplasty,
adjustable gastric banding, and Roux-en-Y. Rhabdomyolosis is more common after
laparoscopic procedures compared with open procedures. Long duration of surgery is a risk
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factor. Increase serum creatinine and creatinine phosphokinase or symptoms of buttocks,
shoulder, or hip pain may be suggestive of rhabdomyolosis. (See page 1238: Medical
Treatment for Obesity.)
12. Which of the following must be considered during intraoperative management of

obese and morbidly obese patients&quest;
1. Most operating room tables have a maximum weight capacity of 200 kg.
2. Supine positioning causes ventilatory impairment and inferior vena cava and aortic
compression.
3. The head-up position provides the longest safe apnea period.
4. Forearm measurements of blood pressure overestimate both systolic and diastolic
blood pressure.
12. E. Obesity may pose several challenges. Specially designed tables or two regular operating
room tables may be required for the management of morbidly obese patients; regular operating
room tables usually have a maximum weight limit of 200 kg. Obesity may cause a significant
increase in oxygen consumption and cardiac output. The supine position causes ventilatory
impairment and inferior vena cava and aortic compression in obese patients. Functional
residual capacity (FRC) and oxygenation are further decreased with the supine position. Head-
down positioning during laparoscopic procedures worsens FRC and should be avoided. The
head-up position provides the longest safe apnea period during induction. Blood pressure
measurements can be falsely elevated if the blood pressure cuff is too small. Cuffs with
bladders, which encircle 75% of the entire upper arm, are preferable. Forearm measurements
with a standard cuff overestimate both systolic and diastolic blood pressure. (See page 1241:
Positioning and page 1242: Monitoring.)
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Review of Clinical Anesthesia, 5e [Vishal] 48. Hepatic Anatomy, Function & Physiology
Chapter 48
Hepatic Anatomy, Function and Physiology
1. All of the following statements regarding liver physiology are true EXCEPT:
A. Hepatic blood flow equals approximately 100 mL/100 g/min.
B. Twenty-five percent of total hepatic flow is supplied by the hepatic artery and nearly
50% of hepatic oxygen delivery.
C. The portal vein has partially deoxygenated blood and is enriched with nutrients
absorbed from the gastrointestinal tract.
D. The liver receives 40% of the cardiac output.
E. The portal vein provides 75% of total hepatic blood flow and 50% of its oxygen
delivery.
1. D. The liver is supplied by two large vessels, the hepatic artery and the portal vein. The liver
receives approximately 25% of the cardiac output. Hepatic blood flow equals about 100 mL/100
g/min. The hepatic artery supplies 25% of total hepatic blood flow but 50% of oxygen supply.
The portal vein supplies 50% of the oxygen supply and 75% of total hepatic blood flow. The
liver weighs approximately 1.4 to 1.8 kg, representing about 2% of the total body weight in
adults. Because portal venous blood has already perfused the preportal organs, it is partially
deoxygenated and is enriched with nutrients from the gastrointestinal tract. (See page 1248:
Hepatic Homeostasis and page 1248: Vascular Supply.)
2. All of the following are functions of the liver EXCEPT:

A. excretion of glycogen after excess carbohydrate ingestion
B. erythrocyte breakdown and bilirubin excretion
C. several endocrine functions, which include synthesis of insulin-like growth factor,
angiotensinogen, and thrombopoietin
D. hormone biotransformation and catabolism
E. a critical role in glucose buffering and maintenance of euglycemia
2. A. The liver has many physiologic functions, including regulation of blood coagulation,
synthesis of hormones, erythrocyte breakdown, carbohydrate metabolism, lipid metabolism,
amino acid metabolism, synthesis of proteins, and immunologic function. The liver stores
glycogen after hyperglycemia after a carbohydrate meal. Endocrine function includes synthesis
of insulin-like growth factor, angiotensinogen, and thrombopoietin. The liver is the primary site
of thyroxine conversion to triiodothyronine. It also synthesizes thyroid-binding globulin.
Corticosteroids, aldosterone, estrogen, androgens, insulin, and antidiuretic hormone are
inactivated by the liver. (See page 1248: Table 48-1: Major Physiologic Functions of the Liver.)
3. Which statement regarding pharmacokinetics and liver function is FALSE&quest;

A. The liver influences the plasma concentration and availability of most orally and
parenterally administered drugs.
B. Plasma proteins such as albumin and α 1-acid glycoprotein increase free drug
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concentrations.
C. Hepatic clearance is the process by which the liver biotransforms drugs and changes
them to inactive water-soluble substances that can be excreted into bile or urine.
D. Phase 1 and phase 2 reactions are a series of biotransformations.
E. Phase 1 reactions are much more susceptible to inhibition by advanced age or
hepatic disease than phase 2 reactions.
3. B. Drug metabolism is a primary hepatic event. The liver influences plasma concentrations
and the systemic availability of most orally and parenterally administered drugs. Synthesis of
drug-binding proteins such as albumin and α 1-acid glycoprotein partitions drugs into various
compartments of the body (volume of distribution). These proteins decrease free drug
concentration. Hepatic clearance is the sum of all processes by which the liver eliminates drugs
from the body. Biotransformation is the metabolism of drugs by the hepatocytes to water-soluble
inactive substances that are excreted into the bile or urine. Phase 1 and phase 2 comprise a
series of reactions in this biotransformation process. Phase 1 reactions (oxidation, reduction, N-
dealkylation) are more susceptible to inhibition by advanced age or hepatic disease than phase
2 reactions. (See page 1248: Hepatic Hemostasis and page 1250: Pharmacokinetics.)
4. All of the following are true regarding laboratory evaluation of liver function EXCEPT:
A. Aspartate aminotransferase (AST) is detected in increased levels when there is
hepatocellular injury and necrosis.
B. Mild elevations in alanine aminotransferase (ALT) and AST may be seen with fatty
liver infiltration, nonalcoholic steatohepatitis, drug toxicity, and chronic viral hepatitis.
C. Lactate dehydrogenase (LDH) has poor diagnostic specificity for liver disease and
limited clinical usefulness.
D. Elevation of alkaline phosphatase disproportionate to ALT and AST is indicative of
intrahepatic or extrahepatic obstruction.
E. Prothrombin time (PT) and international normalized ratio (INR) are insensitive
indicators of hepatic dysfunction.
4. E. Laboratory evaluation of liver function involves measurement of indices of hepatocellular
damage and hepatic synthetic function. AST (formally called serum glutamic oxaloacetic
transaminase) and ALT (formally called serum glutamic pyruvic transaminase) are detected in
increased levels when hepatocellular injury and necrosis are present. Mild elevations in AST
and ALT may be seen with fatty infiltration of the liver, nonalcoholic steatohepatitis, and drug
toxicity. LDH has poor diagnostic specificity for liver disease and limited clinical usefulness.
Elevation of alkaline phosphatase disproportionate to AST and ALT is indicative of intrahepatic
or extrahepatic bile obstruction. PT and INR are sensitive indicators of hepatic dysfunction
because of the short half-life of factor VII. Mild to moderate hepatic disease may not be
detected by PT and INR because coagulation factors are present in quantities that far exceed
requirements for normal coagulation. (See page 1252: Assessment of Hepatic Function.)
5. All of the following are true regarding hepatobiliary imaging EXCEPT:

A. Plain radiography has a limited role in evaluation of hepatobiliary disease.
B. Ultrasonography is the primary screening tool for hepatic disease because it can
penetrate air, allowing visualization of abdominal organs.
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C. Radioisotope scanning of the biliary tract remains an important tool in patients with
suspected acute cholecystitis.
D. Liver biopsy plays a key role in evaluation of otherwise unexplained abnormality of
the liver enzymes in patients with or without hepatomegaly.
P.249
E. Endoscopic retrograde cholangiopancreatography (ERCP) uses endoscopy to
visualize the ampulla of Vater. It is the imaging technique of choice in patients with
choledocholithiasis.
5. B. Plain radiography has a limited role in the evaluation of hepatobiliary disease. It is only
useful for calcified or gas-containing lesions. Ultrasonography is the primary screening tool for
hepatic disease, gallstones, and biliary tract disease. It is the best method for detecting
gallstones and confirming extrahepatic obstruction. Its major limitations are its dependence on
the operator's skill and its inability to penetrate bone and air, which may prevent complete
examination of the abdominal organs. Radioisotope scanning of the biliary tract remains an
important tool in patients with suspected acute cholecystitis. Radioisotopes that are cleared
rapidly by hepatocytes and excreted into the bile permit rapid visualization of the biliary tract.
This is helpful in diagnosing obstruction of the cystic duct. ERCP is the imaging choice in
patients with choledocholithiasis. It uses endoscopy to visualize the ampulla of Vater and guide
the insertion of a guidewire through the ampulla, permitting injection of contrast material into the
pancreatic and common bile ducts. ERCP permits biopsy, brushing, balloon dilation, and stent
insertion to relieve obstruction caused by tumors. Liver biopsy provides the only means of
determining the precise nature of hepatic damage (necrosis, inflammation, steatosis, or
fibrosis). It plays a key role in the evaluation of otherwise unexplained abnormalities of liver
enzymes in patients with or without hepatomegaly. (See page 1254: Miscellaneous Tests.)
6. All of the following are true regarding viral hepatitis EXCEPT:

A. Chronic hepatitis may occur after infection with hepatitis B, hepatitis C, and hepatitis
D.
B. Hepatitis A is a highly contagious disease primarily transmitted by blood products.
C. Hepatitis A superinfection in patients with chronic hepatitis C progresses to fulminant
hepatitis with a 35% fatality rate.
D. Development of serum antibodies to HbsAg confirms immunity to hepatitis B virus
(HBV).
E. Hepatitis C virus (HCV) is the most common bloodborne infection in the United States.
6. B. HAV is a highly contagious enterovirus transmitted by intake of fecally contaminated food.
Virus is shed 14 to 21 days before jaundice occurs. It is not associated with a chronic carrier
state or chronic liver disease. 41% of patients with chronic hepatitis C who acquire HAV
superinfection progress to fulminant hepatitis with a 35% mortality rate. Chronic hepatitis may
occur after infection with hepatitis B, C, and D. HBV infection is transmitted through
percutaneous inoculation of infected serum or blood products. Development of antibodies to
HbsAg confirms immunity. HbsAg is the major antigen on the surface coat of the virus. HCV
(non-A, non-B) is the most common bloodborne infection in the United States. It is also
transmitted by serum or blood product and intravenous drug abuse. It accounts for 40% of
chronic liver disease. (See page 1255: Viral Hepatitis.)
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7. All of the following statements regarding massive hepatic necrosis after halothane
exposure are true EXCEPT:
A. The incidence of hepatic necrosis and death is one in 35,000 anesthetics.
B. Classic symptoms include fever, anorexia, nausea, chills, myalgias, rash, and
subsequent jaundice.
C. Predictors of poor prognosis include short latency of symptoms from exposure,
obesity, age older than 40 years, and severe hepatic dysfunction.
D. Prior exposure to halothane has no significance on the development of halothane
hepatitis.
E. Children are resistant to the development of halothane hepatitis.
7. D. The incidence of fulminant hepatic necrosis and death associated with halothane is one in
35,000 anesthetics. The incidence of nonfatal hepatitis may be as high as one in 3000
anesthetics. As a result of the National Halothane Study, the use of halothane dramatically
decreased. Classic symptoms of volatile anesthetic-associated hepatitis include fever, anorexia,
nausea, chills, myalgias, and rash. Jaundice appears 3 to 6 days later. The syndrome may
occur after an uneventful anesthetic of short duration. Overt jaundice indicates severe disease
and has a high mortality. Other predictors of a poor prognosis are short latency between
anesthetic exposure and symptoms, age older than 40 years, obesity, and severe hepatic
dysfunction. The single most important risk factor is prior exposure. Children are highly resistant
to developing halothane hepatitis. (See page 1256: Toxic Acute Hepatitis and Volatile
Anesthetics.)
8. All of the following statements regarding cirrhosis are true EXCEPT:

A. The most common causes of hepatic cirrhosis are chronic hepatitic C infection and
alcoholism.
B. Clinical signs are hepatosplenomegaly, ascites, jaundice, spider nevi, and metabolic
encephalopathy.
C. Hyperdynamic circulation exists with high cardiac output, low peripheral vascular
resistance, and low to normal blood pressure.
D. Gastroesophageal varices are the most dreadful complication of portal hypertension.
E. Portal hypertension is the hallmark of all chronic liver diseases.
8. E. Cirrhosis affects more than 3 million persons in the United States. The most common
causes of hepatic cirrhosis are chronic hepatitis and alcoholism. The most common clinical
symptoms are anorexia, weakness, nausea, vomiting, and abdominal pain. Clinical signs
include hepatosplenomegaly, ascites, jaundice, spider nevi, and metabolic encephalopathy.
Patients with cirrhosis and portal hypertension have a hyperdynamic circulation with high
cardiac output, low peripheral vascular resistance, low to normal arterial blood pressure, normal
to increased stroke volume, normal filling pressures, and mildly elevated heart rate. Portal
hypertension may complicate the course of chronic liver disease but is the hallmark of end-
stage cirrhosis. Gastroesophageal varices are the most dreadful complication of portal
hypertension. They are present in 40% to 60% of patients with cirrhosis. (See page 1261:
Cirrhosis: A Paradigm for End-Stage Parenchymal Liver Disease.)
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9. Which of the following statements regarding hepatorenal syndrome (HRS) is
TRUE&quest;
A. Fifty percent of patients with advanced cirrhosis and ascites develop HRS.
B. HRS is characterized by intense vasoconstriction of renal circulation, low glomerular
filtration, preserved renal tubular function, and normal renal histology.
C. Patients showing improvement in renal function after vasoconstrictor therapy for HRS
do not survive any longer than patients who do not respond to therapy.
D. Perioperative renal failure does not change the outcome of liver transplantation.
E. HRS is typed into two categories based on histologic findings.
9. B. HRS is functional prerenal failure that occurs only in approximately 10% of patients with
advanced cirrhosis and ascites. It is characterized by intense vasoconstriction of renal
circulation, low glomerular filtration, preserved renal tubular function, and normal renal
histology. HRS is diagnosed after all other causes of renal failure are excluded. There are two
major types of HRS based on intensity and presentation. Intense renal vasoconstriction results
from extreme vasodilation of splanchnic arterial circulation. The resultant abnormal distribution
of arterial volume is associated with reduced blood flow to extrasplanchnic areas, including the
kidneys. Because HRS develops as a result of splanchnic vasodilation, drugs that reduce
vasodilation have been used to treat HRS. Patients responding to vasoconstriction therapy
survive longer than nonresponders. Transplant survival is reduced in cirrhotic patients with
preoperative renal failure. (See page 1261: A Paradigm for End-Stage Parenchymal Liver
Disease and page 1264: Hepatorenal Syndrome.)
10. All of the following are true regarding hepatic encephalopathy (HE) EXCEPT:
A. HE is a complex, irreversible metabolic encephalopathy presenting with a wide variety
of neuropsychiatric abnormalities.
B. Clinical manifestations are highly variable and range from minimal changes in
personality or altered sleep pattern to confusion, lethargy, and coma.
C. Large dietary protein load, gastrointestinal bleeding, constipation, hypokalemia,
diuretics, and azotemia may precipitate HE.
D. It is believed that HE is caused by substances that are efficiently metabolized by the
liver under normal circumstances.
E. Clinical and neurophysiologic manifestations of HE seem to reflect a global
depression of central nervous system function caused by an increase in inhibitory
neurotransmitters.
10. A. HE is a complex, reversible metabolic encephalopathy presenting as a wide spectrum of
neuropsychiatric abnormalities. Clinical manifestations are highly variable and range from
minimal changes in personality or altered sleep pattern to confusion, lethargy, and coma.
Several well-recognized factors, such as large protein load, gastrointestinal hemorrhage,
constipation, hypokalemia, diuretics, and azotemia, may precipitate HE. It is believed that HE is
caused by substances that under normal circumstances are efficiently metabolized by the liver
rather than by insufficient synthesis of substances essential for normal neurologic function.
Clinical and neurologic manifestations of HE seem to reflect a global depression of central
nervous system function caused by an increase in inhibitory neurotransmitters. Treatment with
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flumazenil has been effective in some patients. (See page 1266: Hepatic Encephalopathy.)
11. Which of the following is FALSE regarding liver disease in pregnancy&quest;

A. Parturients are unusually susceptible to morbidity and mortality from hepatitis E
infection.
B. Acute fatty infiltration of the liver occurs early in pregnancy.
C. There is an association between inherited defects in β oxidation of fatty acids and
acute fatty liver of pregnancy (AFLP).
D. Hyperbilirubinemia occurs in approximately 40% of cases of HELLP (hemolytic
anemia, elevated liver enzymes, and low platelet count) syndrome and is caused by
hemolysis and liver dysfunction.
E. Patients are unusually susceptible to morbidity for herpes simplex hepatitis.
11. B. AFLP and HELLP syndrome are two pregnancy-related disorders that may cause hepatic
failure during the third trimester of pregnancy or immediate postpartum period. Parturients may
be unusually susceptible to morbidity and mortality from hepatitis E infection or herpes simplex
hepatitis. AFLP occurs late in pregnancy. It exists in a broad spectrum ranging from mild to
severe hepatic disease. Its pathogenesis is unclear. However, there is an association between
inherited defects in β oxidation of fatty acids and AFLP. Symptoms related to hepatic failure
develop. Prolonged prothrombin time and disseminated intravascular coagulation occur in
AFLP, which is the distinguishing feature from HELLP syndrome. AFLP improves in response to
delivery of the fetus. HELLP syndrome is an ominous potential complication of pre-eclampsia.
Diagnosis is made by the presence of signs of pre-eclampsia and laboratory evidence of
hemolysis (elevated lactate dehydrogenase, schistocytes and burr cells on peripheral smear,
elevated transaminases because of necrosis of the liver). Hyperbilirubinemia occurs in 40% of
patients and is caused by hemolysis and liver dysfunction. HELLP syndrome is most often
misdiagnosed as viral hepatitis, although a decreased platelet count is uncommon in patients
with viral hepatitis. (See page 1268: Preeclampsia and HELLP Syndrome.)
12. Which of the following statements regarding the anesthetic management of

patients with advanced liver disease is TRUE&quest;
A. Physical examination of patients with chronic liver disease is not valuable because
patients do not appear ill before laboratory evidence of hepatic dysfunction.
B. An increased magnitude of liver dysfunction does not correlate with higher morbidity
and mortality.
C. Plasma concentrations of vasodilatory substances are increased in patients with
cirrhosis.
D. Plasma clearance of fentanyl is not significantly altered.
P.250
E. Decreased doses of vasoconstrictors are needed in these patients.
12. C. Physical examination of the patient is particularly valuable because patients may appear
ill before there is laboratory evidence of hepatic dysfunction. If no suspicion of liver dysfunction
arises, then routine laboratory testing for liver function is not necessary. Regardless of the
cause, an increased magnitude of liver dysfunction correlates with a higher morbidity and
mortality. Drugs administered to patients with advanced liver disease require careful titration.
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Encephalopathic changes are associated with clinically important alterations in
pharmacodynamics and pharmacokinetics of various medications. Plasma clearance of fentanyl
is significantly lower in cirrhotic patients. An increase in plasma concentrations of vasodilatory
substances in cirrhotic patients results in reduced responses to catecholamines and other
vasoconstrictors. (See page 1273: Induction of General Anesthesia and Maintenance of
Anesthesia.)
13. Which of the following statements regarding maintenance of anesthesia in patients
with liver disease is/are TRUE&quest;
1. The initial dose requirement to achieve relaxation with a nondepolarizing muscle
relaxant may be higher.
2. It is prudent to avoid halothane and enflurane in patients with liver disease.
3. Dose requirements for a variety of medications may be unpredictable, so titration to
effect is important.
4. Patients with liver disease have a reduced sensitivity to vasopressor drugs.
13. E. Dose requirements for a variety of medications may be unpredictable because of
substantial alterations in pharmacokinetics. The volume of distribution of most nondepolarizing
muscle relaxants is increased. Subsequent doses should be decreased owing to decreases in
hepatic blood flow, hepatic clearance, and possible concurrent renal disease. It is prudent to
avoid halothane and enflurane because they cause the most prominent decreases in hepatic
blood and oxygen supply and are associated with the highest incidences of postoperative
hepatic dysfunction. Patients with liver disease have a reduced sensitivity to vasopressor
drugs. (See page 1273: Maintenance of Anesthesia.)
14. Which of the following statements regarding postoperative liver disease is/are
TRUE&quest;
1. Postoperative liver dysfunction is common but rarely severe.
2. It is usually symptomatic and may progress to overt liver failure on rare occasions.
3. Subclinical hepatocellular injury may occur in 20% of patients who have received
enflurane anesthesia.
4. Jaundice is a late sign of serious hepatic or hepatobiliary dysfunction.
14. B. Postoperative liver dysfunction is common but rarely severe. Although it is usually
asymptomatic, it may progress to overt liver failure on rare occasions. Mild transient increases
in hepatic enzymes may be detected after surgery but rarely persist after 2 days. Subclinical
hepatocellular injury may occur in 20% of patients after enflurane anesthesia and in up to 50%
of those receiving halothane. Jaundice rarely occurs in healthy patients after minor procedures,
but it may occur in 20% of patients after major surgical procedures. Jaundice is typically the
earliest sign of serious hepatic or hepatobiliary dysfunction. (See page 1275: Conclusion:
Prevention and Treatment of Postoperative Liver Dysfunction.)
15. Which of the following statements regarding prevention of postoperative liver

dysfunction is/are TRUE&quest;
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1. Identification of patients at high risk of developing liver dysfunction or exacerbation of
pre-existing liver disease should influence the anesthetic plan.
2. One should consider postponing elective surgery when pre-existing liver abnormalities
are recognized.
3. Preservation of cardiac output and adequate splanchnic, hepatic, and renal perfusion
are critically important in patients with liver dysfunction who are undergoing major
surgical procedures.
4. Epidural analgesia is contraindicated in patients with severe liver dysfunction.
15. A. Identifying patients at high risk of developing liver dysfunction or of having an
exacerbation of liver disease is important for minimizing the morbidity and mortality of patients
with liver disease. Patient outcome is optimized by understanding the interactions of liver
disease, surgical procedure, physiologic stress, and anesthetic intervention. This is particularly
important in patients undergoing major surgical procedures. Any liver abnormalities detected
preoperatively should be evaluated and may necessitate delaying an elective surgical
procedure. The addition of epidural analgesia to general anesthesia may decrease circulating
catecholamine levels and mitigate the surgical stress response. The general anesthetic plan
should include agents that preserve cardiac output and do not affect the oxygen supply
–demand relationship of the liver. Splanchnic, hepatic, and renal perfusion should be
preserved. (See page 1275: Conclusion: Prevention and Treatment of Postoperative Liver
Dysfunction.)
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Review of Clinical Anesthesia, 5e [Vishal] 49. Endocrine Function
Chapter 49
Endocrine Function
1. Which of the following patients would not be hyperthyroid&quest;

A. A patient with elevated thyroxine (T 4) and elevated T4-binding globulin levels
B. A patient with elevated T 4 and elevated triiodothyronine (T3)
C. A patient with elevated T 4 and normal T3
D. A patient with elevated T 4 and low T 4-binding globulin
E. A patient with normal T 4-binding globulin and elevated T3
1. A. Elevations in T4-binding globulin concentration are the most common cause of
hyperthyroxinemia in euthyroid patients. Elevations of T4, T3, or both in the presence of an
elevated thyroid hormone binding rate all indicate hyperthyroidism. (See page 1280: Tests of
Thyroid Function.)
2. Which of the following statements regarding the uptake of radioactive iodine by the
thyroid gland is FALSE&quest;
A. Radioactive iodine uptake (RAIU) is elevated in patients with hyperthyroidism.
B. RAIU is decreased in cases of hyperthyroidism caused by thyroiditis.
C. RAIU is increased by dietary deficiency of iodine.
D. RAIU increases with corticosteroid use.
E. No uptake of radioactive iodine may indicate thyroid malignancy.
2. D. Radioactive iodine is generally taken up by normally functioning thyroid tissue. Uptake is
under the control of thyroid-stimulating hormone (TSH), and factors that decrease TSH, such
as corticosteroid use, decrease RAIU. Hyperfunctioning thyroid tissue increases RAIU activity,
but malignant or nonfunctioning tissue decreases RAIU. (See page 1281: Radioactive Iodine
Uptake.)
3. Patients with mild to moderate hypothyroidism:

A. are at significant risk of perioperative congestive heart failure
B. can be anesthetized safely without preoperative thyroid supplementation
C. should have urgent thyroid replacement before surgery if they have a history of
coronary artery disease
D. are very sensitive to the effects of anesthetic drugs
E. are at significant risk of postoperative ventilatory failure
3. B. Several studies have shown that patients with mild to moderate hypothyroidism may be
anesthetized safely without preoperative supplementation and are not at an increased risk for
perioperative complications. Patients with a history of coronary artery disease or unstable
angina may have symptoms precipitated by supplementation with thyroxine, and they should
have replacement delayed until the postoperative period. (See page 1282: Treatment and
402 / 494
have replacement delayed until the postoperative period. (See page 1282: Treatment and
Anesthetic Considerations.)
4. Which of the following increases ionized serum calcium&quest;

A. Elevated serum albumin
B. Alkalosis
C. Acute hypomagnesemia
D. Hypoparathyroidism
E. Acute hyperphosphatemia
4. C. Acute hypomagnesemia causes increases in parathyroid hormone release and serum
ionized calcium. An increase in serum albumin levels increases the total serum calcium, as well
as calcium binding, and subsequently results in a lowered free or ionized calcium level. Acute
hyperphosphatemia and alkalosis lower ionized calcium. (See page 1284: Calcium Physiology.)
5. Regarding glucocorticoid physiology, which of the following statements is

FALSE&quest;
A. Cortisol is the most potent endogenous glucocorticoid.
B. Cortisol is the most potent regulator of adrenocorticotropic hormone (ACTH).
C. The anti-inflammatory actions of cortisol relate to its effect in stabilizing lysosomes
and promoting capillary integrity.
D. Glucocorticoids facilitate free water clearance and stimulate hematopoiesis.
E. Cortisol increases the killing potential of macrophages and monocytes.
5. E. Actually, cortisol antagonizes leukocyte migration inhibition factor, thus reducing white cell
adherence to vascular endothelium and diminishing leukocyte response to local inflammation.
Phagocytic activity does not decrease, although the killing potential of macrophages and
monocytes is diminished, not increased. Other diverse actions include the facilitation of free
water clearance, maintenance of blood pressure, a weak mineralocorticoid effect, promotion of
appetite, stimulation of hematopoiesis, and induction of liver enzymes. The anti-inflammatory
actions of cortisol relate to its effect in stabilizing lysosomes and promoting capillary integrity.
(See page 1287: Glucocorticoid Physiology.)
6. Which statement about perioperative steroid replacement in patients who have

received steroids is TRUE&quest;
A. Steroid replacement is not necessary with subarachnoid block or deep general
anesthesia.
B. Steroid replacement should always be given in supraphysiologic doses.
C. Steroid replacement is not necessary if the patient is already steroid dependent.
D. Steroid replacement in a low-dose regimen has been shown to be ineffective for most
patients.
E. There is no proven optimal regimen for steroid replacement in the perioperative
period.
6. E. Because acute adrenal crisis is life threatening and there is relatively little risk in providing
steroid coverage for isolated periods of stress, most clinicians empirically administer
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supplemental steroids to all patients who have received steroid replacement for 1 to 2 weeks
during the previous 6 to 12 months. There is no proven optimal regimen for perioperative
steroid replacement. A low-dose regimen (125 mg of hydrocortisone in 24 hours) has been
shown to be equally effective compared with the more traditional use of supraphysiologic
doses. (See page 1290: Steroid Replacement During the Perioperative Period.)
7. Which of the following statements regarding Conn's syndrome (primary

hyperaldosteronism) is TRUE&quest;
A. It causes fatigue, hypertension, and hyperkalemia.
B. Patients with Conn's syndrome have a high incidence of diastolic hypertension.
C. Measuring plasma renin levels is not helpful in distinguishing primary from secondary
hyperaldosteronism.
P.254
D. Hyperaldosteronism should be considered in edematous hypertensive patients with
persistent hypokalemia.
E. There is a decrease in renal sodium reabsorption.
7. B. Possibly as many as 1% of unselected hypertensive patients have primary
hyperaldosteronism (Conn's syndrome). The increase in renal sodium reabsorption and
extracellular volume expansion is partly responsible for the high incidence of diastolic
hypertension in these patients. Hypersecretion of the major adrenal mineralocorticoid
aldosterone increases the renal tubular exchange of sodium for potassium and hydrogen ions.
This leads to hypertension, hypokalemic alkalosis, skeletal muscle weakness, and fatigue. The
diagnosis of primary or secondary hyperaldosteronism should be entertained in non-edematous
hypertensive patients with persistent hypokalemia who are not receiving potassium-wasting
diuretics. There is an increase in renal sodium reabsorption in these patients. The
measurement of plasma renin levels is useful in distinguishing primary from secondary
hyperaldosteronism. (See page 1288: Mineralocorticoid Excess.)
8. Which of the following statements regarding pheochromocytoma is TRUE&quest;

A. Pheochromocytoma is a common adrenal cortical malignancy.
B. Pheochromocytoma is a common cause of primary hypertension.
C. Cardiovascular effects from pheochromocytoma are treated easily with deep
anesthesia.
D. Pheochromocytomas are not directly innervated, and catecholamine release is
random.
E. Pheochromocytoma is diagnosed easily and reliably by measurement of free
catecholamines in the urine.
8. D. Pheochromocytoma is the only important disease process associated with the adrenal
medulla. These tumors, which are not innervated directly, produce, store, and secrete
catecholamines. Although pheochromocytomas occur in fewer than 1% of hypertensive
patients, it is important to aggressively evaluate patients with clinically suspected symptoms
because surgical excision is curative in more than 90% of patients. Most deaths in patients with
pheochromocytoma are from cardiovascular causes. Malignant spread occurs in approximately
404 / 494
10% of cases. The most common screening tests are measurements of catecholamine
metabolites, vanillylmandelic acid, and unconjugated norepinephrine in the urine. However,
urinary levels are not always elevated to a significant degree. (See page 1292:
Pheochromocytoma.)
9. Which of the following statements regarding the perioperative anesthetic

management of the patient with pheochromocytoma is TRUE&quest;
A. Patients who present with normotension do not require preoperative α -adrenergic
blocking agents.
B. Patients who present with normotension may be easily managed on an outpatient
basis until the time of surgery.
C. If α -adrenergic blocking agents have not been instituted before surgery, no special
anesthetic induction technique is necessary.
D. Although there is no clear advantage to one anesthetic technique over another,
halothane should be avoided.
E. Invasive monitoring is not required for patients whose blood pressure has been well
controlled preoperatively.
9. D. Occasionally, a patient with pheochromocytoma may present without hypertension. These
patients are noted to be difficult to manage on an outpatient basis because of the fear of
clinically significant orthostatic hypotension with α -blockade therapy. Because of the
unpredictable and potentially lethal nature of the patient's response to the stress of anesthesia
and surgery, all patients presenting for pheochromocytoma surgery should receive preoperative
α -blocking therapy. When this is not possible, sodium nitroprusside infusions are often initiated
in anticipation of the marked blood pressure elevations that may occur with laryngoscopy and
surgical stimulation. Although there is no clear advantage of any one anesthetic technique,
drugs that are known to liberate histamine should be avoided. Halothane should also be
avoided because it sensitizes the myocardium to catecholamines and predisposes to ventricular
irritability. Invasive monitors are used in most adult patients. (See page 1295: Perioperative
Anesthetic Management.)
10. Which of the following statements regarding type 1 diabetes mellitus is

TRUE&quest;
A. Patients usually have normal insulin levels and significant insulin resistance in
peripheral tissues.
B. Patients are often treated with diet alone.
C. Patients are frequently obese.
D. Patients are prone to ketoacidosis.
E. End-organ damage is rare.
10. D. Diabetes often is divided into two broad types: type 1, or insulin-dependent diabetes
mellitus, and type 2, or non–insulin-dependent diabetes mellitus. Patients with type 1 diabetes
typically experience the onset of disease in early life. Consequently, this form also is referred to
as juvenile-onset diabetes. Generally, patients with type 1 diabetes are not obese, have an
abrupt onset of the disease, and have very low levels of circulating insulin. Treatment of these
patients requires insulin. Patients with type 1 disease are prone to becoming ketotic and are
405 / 494
likely to develop end-organ complications of diabetes. (See page 1295: Diabetes Mellitus.)
11. Which of the following statements regarding insulin is TRUE&quest;

A. The normal adult pancreas produces 200 to 300 U/day of insulin.
B. The half-life of human insulin is 90 minutes.
C. Hepatic dysfunction increases circulating insulin levels.
D. Vagal stimulation decreases circulating insulin levels.
E. α -Adrenergic stimulation increases circulating insulin levels.
11. C. Insulin is metabolized in the liver and kidneys. In patients with hepatic dysfunction, the
loss of gluconeogenesis and the prolongation of insulin effect increase the risk of
hypoglycemia. Normal production of insulin in adults is equivalent to 40 to 50 U/day. The half-
life of insulin in the circulation is only a few minutes. Insulin release is related to a number of
events. First, and most important, is the direct effect of glucose to stimulate insulin release. The
mechanism involves interaction with hormones from the gastrointestinal tract released during
enteral feeding. An increase in insulin release results from vagal stimulation. Insulin release is
also caused by β -adrenergic stimulation blockade. (See page 1296: Physiology.)
12. Regarding thyroid metabolism and function, which of the statements below is/are
FALSE&quest;
1. Triiodothyronine (T3) and thyroxine (T4) are attached to the thyroglobulin protein and
stored as colloid.
2. Approximately 80% of T 3 is produced by the extrathyroidal deiodination of T 4.
3. Most of the effects of thyroid hormones are mediated by the more potent and less
protein-bound T3.
4. The half-life of T 3 is approximately 14 days.
12. D. The half-life of T 3 is 24 to 30 hours. The half-life of T 4 in the circulation is 6 to 7 days.
After organification, monoiodotyrosine or diiodotyrosine is coupled enzymatically by thyroid
peroxidase to form either T3 or T4. These hormones are attached to the thyroglobulin protein
and stored as colloid in the gland. The release of T3 and T4 from the gland is accomplished
through proteolysis from the thyroglobulin and diffusion into the circulation. Approximately 80%
of T3 is produced by the extrathyroidal deiodination of T 4, and 20% is produced by direct
thyroid secretion. Most of the effects of thyroid hormones are mediated by the more potent and
less protein-bound T3. The degree to which these hormones are protein bound in the
circulation is the major factor influencing their activity and degradation. (See page 1279:
Thyroid Metabolism and Function.)
13. Which of the following would be appropriate in the preoperative preparation of a

patient with Graves disease&quest;
1. Administration of potassium iodide for 7 to 14 days preoperatively
2. A short-term course of thyroxine (T 4) supplementation
406 / 494
3. Administration of propranolol for 1 week preoperatively

4. Administration of propylthiouracil for 3 days preoperatively
13. B. The combination of propranolol and potassium iodide every 8 hours for 7 to 14 days may
be used to ameliorate cardiovascular symptoms and to reduce the circulating concentration of
T4 and triiodothyronine (T3). Although propylthiouracil is also an effective treatment, it would
require 6 to 8 weeks to render the patient euthyroid. Patients with Graves disease already have
elevated levels of T4 and should not be given T4 supplements. (See page 1282: Treatment and
Anesthetic Considerations.)
14. Which of the following statements regarding hyperparathyroidism is/are

TRUE&quest;
1. Pregnant women with primary hyperparathyroidism should generally be treated with
surgery.
2. Treatment of hypercalcemia includes intravenous administration of normal saline and
furosemide.
3. Hypophosphatemia increases gastrointestinal absorption of Ca2+, stimulates

breakdown of bone, and impairs the uptake of Ca2+ by bone.
4. The definitive diagnosis of primary hyperparathyroidism is made by RIA demonstration
of an elevation in parathyroid hormone levels in the presence of hypercalcemia.
14. E. Primary hyperparathyroidism is most commonly caused by a benign parathyroid
adenoma (90% of cases) or hyperplasia (9%) and very rarely by a parathyroid carcinoma.
Primary hyperparathyroidism may also exist as part of a multiple endocrine neoplastic (MEN)
syndrome. Hyperplasia usually involves all four glands. Although most patients with primary
hyperparathyroidism have hypercalcemia, most are asymptomatic at the time of diagnosis.
When symptoms occur, they usually result from the hypercalcemia that accompanies the
disease. Primary hyperparathyroidism occurring during pregnancy is associated with a high
maternal and fetal morbidity rate (50%). The placenta allows the fetus to concentrate calcium,
promoting fetal hypercalcemia and leading to hypoparathyroidism in the newborn. Pregnant
women with primary hyperparathyroidism should generally be treated with surgery. Emergency
treatment of hypercalcemia is undertaken before surgery when the serum Ca2 + concentration
exceeds 15 mg/dL (7.5 mEq/L). Lowering the serum Ca2 + concentration is initially
accomplished by expanding the intravascular volume and establishing a sodium diuresis. This
is achieved with the intravenous administration of normal saline and furosemide. (See page
1284: Hyperparathyroidism.)
15. Which of the following statements regarding hypoparathyroidism is/are

TRUE&quest;
1. The cardiovascular manifestations are shortened QT interval and pericardial effusion.
2. Neuronal irritability may cause seizures and muscle tetany.
3. The Trousseau sign usually is positive, and the Chvostek sign usually is negative.
4. Acute hypoparathyroidism may manifest as stridor or apnea.
15. C. The clinical features of hypoparathyroidism result from hypocalcemia. Neuronal irritability
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and skeletal muscle spasms, tetany, or seizures reflect a reduced threshold of excitation. The
Chvostek sign is a contracture of the facial muscles produced by tapping the facial nerve. The
Trousseau sign is contraction of the fingers and wrist after application of a blood pressure cuff
inflated above the systolic pressure for approximately 3 minutes. Both the Chvostek sign and
Trousseau signs indicate hypocalcemia. The acute onset of hypocalcemia after thyroid or
parathyroid surgery may manifest itself as stridor and apnea. (See page 1286: Clinical Features
and Treatment.)
16. Which of the following statements regarding mineralocorticoid physiology is/are

TRUE&quest;
1. Angiotensin I is the most potent vasoconstrictor produced in the body.
P.255
2. The renin–angiotensin system is the body's most important protector of volume status.
3. Angiotensin I is altered enzymatically by converting enzyme primarily in the liver.
4. Aldosterone is the most potent mineralocorticoid produced by the adrenal gland.
16. C. Angiotensin II, not angiotensin I, is the most potent vasopressor produced in the body. It
directly stimulates the adrenal cortex to produce aldosterone. The renin–angiotensin system is
the body's most important protector of volume status. The major regulators of aldosterone
release are the renin–angiotensin system and serum potassium. The juxtaglomerular apparatus
that surrounds the renal afferent arterioles produces renin in response to decreased perfusion
pressures and sympathetic stimulation. Renin splits the hepatic precursor angiotensinogen to
form the decapeptide angiotensin I, which is then altered enzymatically by converting enzyme
(primarily in the lung, not the liver) to form the octapeptide angiotensin II. Aldosterone is the
most potent mineralocorticoid produced by the adrenal gland. Aldosterone binds to receptors in
sweat glands, the alimentary tract, and the distal convoluted tubule of the kidney. (See page
1287: Mineralocorticoid Physiology.)
17. Which of the following statements regarding Cushing syndrome is/are

TRUE&quest;
1. Most cases occur secondary to bilateral adrenal hyperplasia.
2. Cushing syndrome usually represents adrenal adenocarcinoma when it occurs in older
patients.
3. Twenty-five percent of cases are caused by adrenal neoplasm.
4. Cushing syndrome may occur iatrogenically from steroid treatment of chronic illness.
17. E. Cushing syndrome may be caused either by overproduction of cortisol by the adrenal
cortex or by exogenous glucocorticoid therapy. Most cases of Cushing syndrome that occur
spontaneously result from bilateral adrenal hyperplasia secondary to adrenocorticotropic
hormone (ACTH) production by an anterior pituitary microadenoma. The primary overproduction
of cortisol is caused by an adrenal neoplasm in 20% to 25% of patients. When Cushing
syndrome occurs in patients older than 60 years, the most likely causes are adrenal
adenocarcinoma or ectopic ACTH produced from a nonendocrine tumor. An increasingly
common cause of Cushing syndrome is the prolonged administration of exogenous
glucocorticoids used to treat various illnesses. (See page 1287: Glucocorticoid Excess
[Cushing Syndrome].)
408 / 494
18. Which of the following statements with respect to patients with Addison disease
is/are TRUE&quest;
1. The predominant cause of Addison disease is autoimmune destruction of the adrenal
gland.
2. Patients with secondary forms of Addison disease always have hyperpigmentation.
3. Treatment includes replacement of mineralocorticoids.
4. Diagnosis is confirmed by an increased adrenal response to adrenocorticotropic
hormone (ACTH).
18. B. Addison disease results from a lowered secretion of adrenal cortical hormones. At
present, the most frequent cause of Addison disease is autoimmune destruction of the adrenal
gland. Primary Addison disease causes hyperpigmentation as ACTH levels increase in
response to low cortisol levels. Secondary forms of the disease result from low levels of ACTH,
and these patients never have hyperpigmentation. The diagnosis of primary adrenal
insufficiency is unequivocally confirmed by the failure of the adrenal gland to respond to
exogenously administered ACTH. Treatment of the disease involves glucocorticoid (e.g.,
prednisone or hydrocortisone) and mineralocorticoid (e.g., fludrocortisone) replacement. (See
page 1289: Adrenal Insufficiency.)
19. Which of the following statements regarding acute adrenal insufficiency is/are
TRUE&quest;
1. It rarely, if ever, occurs in the perioperative period.
2. Treatment consists of fluid and electrolyte resuscitation, as well as steroid
replacement.
3. It usually requires continued steroid therapy for 4 to 6 weeks after the acute event.
4. It may require the use of inotropes and invasive monitoring despite aggressive steroid
treatment.
19. C. Acute adrenal insufficiency is usually precipitated by sepsis, trauma, or surgical stress.
Immediate therapy is mandatory regardless of the cause and consists of fluid and electrolyte
resuscitation and steroid replacement. Steroid replacement is continued during the first 24
hours, and if the patient is stable, the steroid dose reduction begins on the second day. If the
patient continues to be hemodynamically unstable after adequate fluid resuscitation, inotropic
support and invasive monitoring may be necessary. (See page 1289: Treatment and Anesthetic
Considerations.)
20. Hypoaldosteronism:
1. may be defined as failure to increase aldosterone production in response to
adrenocorticotropic hormone (ACTH)
2. commonly occurs in patients with mild renal failure and long-standing diabetes mellitus
3. commonly presents with life-threatening hypokalemia and hypotension
4. may be treated adequately with furosemide alone in patients with congestive heart
failure
20. C. Mineralocorticoid insufficiency may occur for various reasons and is commonly seen in
patients with mild renal failure and long-standing diabetes. It results from a failure to increase
409 / 494
aldosterone production in response to salt restriction or volume contraction. Most patients
present with hypotension, hyperkalemia that may be life threatening, and metabolic acidosis (as
a result of impaired sodium and potassium exchange). Patients may be treated with
mineralocorticoid replacement. An alternative approach in patients with pre-existing
hypertension or congestive heart failure involves administering furosemide alone or in
combination with mineralocorticoid. (See page 1291: Mineralocorticoid Insufficiency.)
21. Which of the following statements regarding the preoperative preparation of the
patient with pheochromocytoma is/are TRUE&quest;
1. Preoperative preparation is usually unnecessary if deep opioid anesthesia is planned.
2. Preoperative treatment for 10 to 14 days with phenoxybenzamine is advocated by
most clinicians.
3. Preoperative treatment usually is started with β -adrenergic blocking drugs to avoid
reflex tachycardia when α -blocking drugs are added.
4. Prazosin is a shorter acting α -blocking agent that may be used in place of
phenoxybenzamine.
21. C. A dramatic reduction in perioperative mortality in patients undergoing surgery for
pheochromocytoma has been achieved with the introduction of α -antagonists preoperatively. β
-adrenergic blockade is often added after α -blockade has been established. Beta-blockers
should not be given until adequate α -blockade is achieved to avoid the possibility of
unopposed α -mediated vasoconstriction. Phenoxybenzamine is a long-acting, noncompetitive,
presynaptic α 2- and postsynaptic α 1-blocker. Prazosin is a postsynaptic α 1-blocking agent
with a shorter half-life than phenoxybenzamine. Both drugs have been used successfully in the
preoperative preparation of patients with pheochromocytoma. (See page 1293: Anesthetic
Considerations.)
22. Which of the following statements regarding the pharmacologic therapy for
pheochromocytoma is/are TRUE&quest;
1. Acute hypertensive crises are best treated with short-acting drugs, such as sodium
nitroprusside, esmolol, and phentolamine.
2. Labetalol, a combination α - and β -adrenergic antagonist, is an excellent second-line
therapy.
3. α -Methyltyrosine is an agent used for reduction of catecholamine biosynthesis in
situations in which surgery is contraindicated.
4. Adrenergic blocking agents should not be given to pregnant patients.
22. A. Acute hypertensive crises are best treated with intravenous infusions of short-acting
drugs. These include phentolamine, nitroprusside, and esmolol. Labetalol is a β -antagonist
with α -blocking activity that is an effective second-line medication. α -Methyltyrosine inhibits the
enzyme tyrosine hydroxylase, which is the rate-limiting step in catecholamine biosynthesis. This
medication is currently reserved for patients with metastatic disease and those in whom surgery
is contraindicated. Unrecognized pheochromocytoma during pregnancy may be life threatening
to the mother and the fetus. Although the safety of adrenergic blocking agents during
pregnancy has not been established, these agents probably improve fetal survival. (See page
1293: Anesthetic Considerations.)
410 / 494
23. Which of the following are potential causes of diabetes mellitus&quest;

1. Cystic fibrosis
2. Pancreatic surgery
3. Pheochromocytoma
4. Cushing disease
23. E. Diabetes can be a secondary result of a disease that damages the pancreas. Examples
include pancreatic surgery, chronic pancreatitis, cystic fibrosis, and hemochromatosis. Diabetes
may also result from one of the endocrine diseases that produce a hormone that opposes the
action of insulin. Examples include glucagonoma, pheochromocytoma, and acromegaly. An
increased effect of glucocorticoids from Cushing disease or from steroid therapy may also
oppose the effect of insulin and may thereby elicit clinical diabetes. (See page 1295:
Classification.)
24. Regarding treatment for diabetes, which statement(s) is/are TRUE&quest;

1. Thiazolidinediones increase insulin secretion from the pancreas.
2. Sulfonylureas inhibit β -cell insulin secretion.
3. Biguanides decrease postprandial glucose absorption.
4. Amylin analogs suppress glucagon secretion and slow gastric emptying.
24. D. Whereas amylin analogs (pramlintide [Symlin]) suppress glucagon secretion and slow
gastric emptying, incretin mimetics (exenatide [Byetta]), as the name implies, emulate natural
incretin hormones (glucagon-like peptide 1, glucose-dependent insulinotropic polypeptide),
increase insulin production, inhibit glucagon secretion, and decrease glucose absorption.
Rosiglitazone (Avandia) and pioglitazone (Actos) are thiazolidinediones that increase insulin
sensitivity. α -Glucosidase inhibitors (acarbose, miglitol) decrease postprandial glucose
absorption. Metformin is a biguanide that decreases hepatic glucose output and enhances the
sensitivity of both hepatic and peripheral tissues to insulin. Sulfonylureas (glyburide, glipizide,
glimepiride) and glinides (repaglinide, nateglinide) enhance β -cell insulin secretion. (See page
1296: Treatment.)
25. Which of the following options may be acceptable in the perioperative

management of patients with diabetes mellitus&quest;
1. Maintain a continuous intravenous infusion of insulin.
2. Give half the usual insulin dose preoperatively.
3. Give insulin intraoperatively based on the level of measured glucose level.
4. Do not give insulin.
25. E. There is no consensus about the optimal way to manage perioperative metabolic
changes in diabetic patients. For some diabetic patients, the best method of management is to
not give insulin. For short procedures in nonstressed patients, particularly if they are not
receiving insulin on a long-term basis, they may have enough endogenous insulin production to
maintain a reasonable glucose balance in the unfed state. (See page 1298: Management
Regimens.)
26. Regarding anesthetic management of diabetes, which statement(s) is/are

411 / 494
TRUE&quest;
1. The “prayer sign” is associated with stiff joint syndrome and may predict different
laryngoscopy.
2. The standard glucose dosage for an adult patient is 5 to 10 g/hr (100 to 200 mL of 5%
dextrose solution hourly).
3. It is desirable to discontinue metformin preoperatively because it has been associated
with severe lactic acidosis.
P.256
4. Peripheral nerves are more vulnerable to pressure or stretch injuries.
26. E. Laryngoscopy may be difficult in up to 40% of juvenile patients with diabetes mellitus
presenting for renal transplantation. This may be because of diabetic stiff joint syndrome, a
frequent complication of type I diabetes, leading to decreased mobility of the atlanto-occipital
joint. The “prayer sign,” which is an inability to approximate the palmar surfaces of the
interphalangeal joints, is associated with stiff joint syndrome and may predict difficult
laryngoscopy. The standard glucose dosage for an adult patient is 5 to 10 g/hr (100 to 200 mL
of 5% dextrose solution hourly). Fasting patients will not have postprandial hyperglycemia.
Sulfonylureas should be held while the patient is NPO (nothing per mouth) to decrease the risk
of hypoglycemia and because they interfere with the cardioprotective effect of ischemic
preconditioning. Metformin should probably also be held, especially if there is a risk of
decreased renal function because of a risk of lactic acidosis. Another area of patient monitoring
that is extremely important in diabetic patients is positioning on the operating table. Injuries to
the limbs or nerves are more likely in patients who arrive in the operating room already
compromised by diabetic peripheral vascular disease or neuropathy. The peripheral nerves may
already be partially ischemic and therefore more vulnerable to pressure or stretch injuries. (See
page 1288: Anesthetic Management.)
27. Which of the following statements regarding nonketotic hyperosmolar coma is/are
TRUE&quest;
1. Patients often present with extremely high blood sugar concentrations.
2. It usually occurs in “brittle” diabetics.
3. Cerebral edema may result in delayed recovery of mental status.
4. The mainstay of treatment is high-dose intravenous insulin by continuous infusion.
27. B. An occasional elderly patient with minimal or mild diabetes may present with remarkably
high blood glucose levels and profound dehydration. Such patients usually have enough
endogenous insulin activity to prevent ketosis. Marked hyperosmolarity may lead to coma and
seizures with increased plasma viscosity, producing a tendency to intravascular thrombosis. It is
characteristic of this syndrome that the metabolic disturbance responds quickly to rehydration
and small doses of insulin. With rapid correction of hyperosmolarity, cerebral edema is a risk,
and recovery of mental acuity may be delayed after the blood glucose level and circulating
volume have been normalized. (See page 1299: Hyperosmolar Nonketotic Coma.)
28. Which of the following statements regarding patients with diabetic ketoacidosis
is/are TRUE&quest;
1. The serum potassium level will always be low.
412 / 494
2. The total body potassium level will always be low.
3. With appropriate treatment, the serum potassium level will tend to increase toward the
normal range.
4. All patients with ketoacidosis, except those with acute renal failure, should be given
intravenous potassium supplementation.
28. C. Potassium replacement is a key concern in patients with diabetic ketoacidosis. Because
of the hyperglycemia-induced osmotic diuresis, the total body's potassium stores are reduced.
However, acidosis by itself causes a shift of potassium ions out of the cell. Thus, the serum
potassium concentration may be normal or even slightly elevated while the patient remains
acidotic. As soon as the metabolic acidosis is corrected, the potassium ions shift back into cells.
Consequently, the serum potassium concentration may decline acutely. Therefore, early and
vigorous potassium replacement is required in these patients. (Patients with renal failure are the
exception.) (See page 1300: Diabetic Ketoacidosis.)
29. Concerning the anterior pituitary, which of the following is/are TRUE&quest;
1. About 20% to 30% of acromegalic patients are difficult to intubate.
2. Impotence in men and secondary amenorrhea in women are early manifestations of
panhypopituitarism.
3. Sheehan's syndrome occurs after postpartum hemorrhagic shock.
4. Vasopressin is secreted by the posterior pituitary.
29. E. Acromegaly in adult patients may pose several problems for anesthesiologists.
Hypertrophy occurs in skeletal, connective, and soft tissues. The tongue and epiglottis are
enlarged, making the patient susceptible to upper airway obstruction. The incidence of difficult
intubation is 20% to 30%, and it may be clinically unpredictable. Impotence in men and
secondary amenorrhea in women are early manifestations of panhypopituitarism.
Panhypopituitarism after postpartum hemorrhagic shock (Sheehan's syndrome) is caused by
necrosis of the anterior pituitary gland. Vasopressin (antidiuretic hormone) and oxytocin are the
two principal hormones secreted by the posterior pituitary. (See page 1301: Anterior Pituitary.)
30. Hypoglycemia in patients undergoing general anesthesia:

1. is diagnosed easily by recognition of the usual signs and symptoms
2. causes effects that are misinterpreted as light anesthesia
3. rarely occurs in diabetic patients who receive insulin perioperatively
4. occurs more commonly in diabetic patients with renal insufficiency
30. C. Hypoglycemia is the most feared clinical occurrence when dealing with diabetic patients
and is almost impossible to diagnose in unconscious patients. With hypoglycemia, a reflex
catecholamine release produces overt sympathetic hyperactivity, causing tachycardia,
diaphoresis, and hypertension. In anesthetized patients, the signs of sympathetic hyperactivity
can be misinterpreted as inadequate or light anesthesia. Hypoglycemia is more likely to occur in
diabetic surgical patients with renal insufficiency in whom the action of insulin and oral
hypoglycemic agents may be prolonged. An avoidable cause of inadvertent hypoglycemia is the
administration of insulin to a patient who is not receiving sufficient caloric input. (See page
1300: Hypoglycemia.)
413 / 494
31. Which of the following statements regarding the posterior pituitary is/are
TRUE&quest;
1. It is composed of terminal nerve endings that extend from the ventral hypothalamus.
2. It secretes vasopressin.
3. It secretes antidiuretic hormone (ADH).
4. It secretes oxytocin.
31. E. The posterior pituitary, or neurohypophysis, is composed of terminal nerve endings that
extend from the ventral hypothalamus. The two hormones it secretes are vasopressin (also
called ADH) and oxytocin. (See page 1301: Posterior Pituitary.)
32. Which of the following statements regarding vasopressin is/are TRUE&quest;

1. It promotes the reabsorption of sodium from the thick ascending limb of the loop of
Henle.
2. Serum levels decrease with increasing osmolality.
3. It functions to relax vascular smooth muscle.
4. It may be used in the treatment of patients with von Willebrand disease.
32. D. Antidiuretic hormone (ADH; also called vasopressin because it constricts vascular
smooth muscle) promotes reabsorption of free water by increasing the cell membrane's
permeability to water. The target sites for ADH are the collecting tubules of the kidneys. The
primary stimulus for ADH release is an increase in serum osmolality. ADH may also promote
hemostasis through an increase in the level of circulating von Willebrand factor. (See page
1301: Vasopressin.)
33. Which of the following statements regarding diabetes insipidus is/are TRUE&quest;
1. It may occur after intracranial trauma.
2. Urine output is highly concentrated.
3. Symptoms include polydipsia.
4. There is an excessive secretion of antidiuretic hormone (ADH).
33. B. Diabetes insipidus results from inadequate secretion of ADH. Failure to secrete an
adequate amount of ADH results in polydipsia, hypernatremia, and a high output of poorly
concentrated urine. This disorder usually occurs after destruction of the pituitary gland by
intracranial trauma, infiltrating lesions, or surgery. (See page 1301: Diabetes Insipidus.)
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Review of Clinical Anesthesia, 5e [Vishal] 50. Anesthesia for Otolaryngologic Surgery
Chapter 50
Anesthesia for Otolaryngologic Surgery
1. The most serious complication of tonsillectomy is postoperative hemorrhage.

Approximately 75% of postoperative tonsillar hemorrhages occur within how many
hours of surgery&quest;
A. 1
B. 6
C. 12
D. 24
E. 48
1. B. Approximately 75% of postoperative tonsillar hemorrhages occur within 6 hours of surgery.
Most of the remaining 25% occur within the first 24 hours of surgery, although bleeding may not
be noted until the sixth postoperative day. About two thirds of postoperative bleeding originates
from the tonsillar fossa, 27% occurs in the nasopharynx, and 7% involves both regions. (See
page 1307: Complications.)
2. All of the following statements regarding emesis after tonsillectomy are true
EXCEPT:
A. It occurs in about 30% to 65% of patients.
B. It may result from central stimulation of the chemoreceptor trigger zone.
C. It is sometimes responsive to meperidine.
D. It may be avoided by decompressing the stomach before extubation.
E. It may be treated with 0.10 to 0.15 mg/kg of intravenous ondansetron.
2. C. The incidence of postoperative emesis after tonsillectomy is approximately 30% to 65%.
The exact cause is unclear but is probably multifactorial. Potential causative factors include
irritant blood in the stomach, impaired gag reflex resulting from inflammation and edema, and
central nervous stimulation of the chemoreceptor trigger zone as a result of gastric distention.
Management of postoperative nausea and vomiting commonly includes administration of
ondansetron, dexamethasone, or both. The use of meperidine for postoperative pain control
has been shown to exacerbate symptoms, especially in children. (See page 1307:
Complications.)
3. All of the following statements regarding negative pressure pulmonary edema are
true EXCEPT:
A. It is associated with a decrease in pulmonary hydrostatic pressure.
B. It is caused by the sudden relief of a previously obstructed airway.
C. Intrapleural pressure in an obstructed airway may reach –30 cm H2O.
D. It may be prevented by the application of continuous positive airway pressure.
E. It is associated with diffuse bilateral infiltrates on chest radiographs.
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3. A. Negative-pressure pulmonary edema is a rare but serious condition caused by the sudden
relief of a previously obstructed airway. Under normal circumstances, intrapleural pressures
range from –2.5 to –10.0 cm H2O during inspiration. In the presence of airway obstruction, the
intrapleural pressure may reach –30.0 cm H2O. Rapid relief of airway obstruction results in a
decrease in airway pressure, an increase in venous return, and an increase in pulmonary
hydrostatic pressure. The net result is the development of pulmonary edema. Mild cases may
be asymptomatic. However, in serious cases, the condition is marked by the appearance of
frothy pink fluid in the endotracheal tube, decreased O2 saturation, wheezing, dyspnea, and
tachypnea. A chest radiograph illustrating diffuse, usually bilateral, interstitial pulmonary
infiltrates, combined with an appropriate clinical history, supports the diagnosis. (See page
1307: Complications.)
4. The most common cause of stridor in infants is:

A. peritonsillar abscess
B. foreign body obstruction
C. laryngomalacia
D. croup
E. epiglottitis
4. C. Laryngomalacia is the most common cause of stridor in infants. Laryngomalacia is most
often secondary to a long epiglottis that prolapses posteriorly as well as prominent arytenoid
cartilages with redundant aryepiglottic folds that obstruct the glottic opening during inspiration.
Symptoms usually present shortly after birth. Peritonsillar abscess, foreign body obstruction,
croup, and epiglottitis are also potential but less common causes of stridor in this age group.
(See page 1311: Stridor.)
5. Regarding the pain associated with tonsillectomy, which of the following statements
is TRUE&quest;
A. It is usually less severe when intraoperative hemostasis is achieved with laser and
electrocautery rather than with sharp surgical dissection and ligation of blood vessels.
B. It is usually less severe than after adenoidectomy.
C. Its severity is often reduced when the peritonsillar space is infiltrated with local
anesthetic.
D. Its occurrence may be reduced with the intraoperative use of corticosteroids.
E. It is usually related to underlying infection.
5. D. Pain after tonsillectomy is often severe in contrast to the minimal discomfort usually
associated with adenoidectomy. An increase in pain medication requirements has been noted in
patients in whom intraoperative hemostasis is achieved using laser or electrocautery as
opposed to sharp surgical dissection and ligation of blood vessels. Intraoperative administration
of corticosteroids appears to be somewhat effective at reducing postoperative pain by
decreasing edema formation. In contrast, injection of local anesthetic into the peritonsillar space
has not been associated with a decrease in postoperative pain. (See page 1307:
Complications.)
416 / 494
6. A Le Fort III fracture:
A. passes above the floor of the nose but involves the lower third of the nasal septum
B. crosses the medial wall of the orbit, including the lacrimal bone
C. passes through the base of the nose and the orbital plates
D. is a horizontal fracture of the maxilla
E. always involves a fracture of the cribiform plate of the ethmoid bone
6. C. In the course of his studies, Le Fort determined the common lines of fracture of the
midface. The Le Fort I fracture is a horizontal fracture of the maxilla, passing above the floor of
the nose but involving the lower third of the septum and mobilizing the palate, maxillary alveolar
process, lower third of the pterygoid plates, and parts of the palatine bones. The Le Fort II
fracture crosses the medial wall of the orbit, involving the lacrimal bone, passes beneath the
zygomaticomaxillary suture, crosses the lateral wall of the antrum, and passes through the
pterygoid plates. The Le Fort III fracture parallels the base of the skull, passing through the
base of the nose and ethmoid as well as the orbital plates. The Le Fort III fracture may, but
does not always, involve fracture of the cribiform plate. (See page 1316: Le Fort Classification
of Fractures.)
7. A rigid bronchoscope with an internal diameter of 3.0 mm would have an external

diameter of approximately:
A. 3.5 mm
B. 4.0 mm
C. 5.0 mm
D. 6.0 mm
E. 7.0 mm
7. C. Bronchoscopes are sized based on their internal diameter. Their external diameters are
significantly greater than those of endotracheal tubes of similar size. Whereas the external
diameter of a rigid bronchoscope with an internal diameter of 3.0 mm is 5.0 mm, the external
diameter of a comparably sized endotracheal tube is 4.3 mm. (See page 1311: Bronchoscopy
and page 1311: Table 50-2: Causes of Stridor.)
P.262
8. The most common site of cervical spine injury in patients presenting with facial
fractures sustained in high-velocity trauma is:
A. C1–C2
B. C2–C3
C. C3–C4
D. C4–C5
E. C6–C7
8. E. The most common site of cervical spine injury in patients presenting with facial fractures
after high-velocity injuries is at the level of C6–C7, accounting for approximately 50% of cases.
The C2 level is the second most common site of fracture (31% of cases). (See page 1317:
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Patient Evaluation.)
9. Relative contraindications to a superior laryngeal nerve block include:
1. tumor at the site of the block
2. pregnancy
3. infection at the site of the block
4. partially obtunded patient
9. E. A full stomach, pregnancy, and partially obtunded mental status are relative
contraindications to superior laryngeal nerve block because of the possibility of vomiting and
aspiration after the protective airway reflexes have been blunted. Tumor and infection are
considered relative contraindications because of the possibility of dissemination secondary to
the manipulation associated with the block. (See page 1318: Awake Intubation.)
10. Which statement(s) about airway anatomy is/are TRUE&quest;

1. The cricothyroid muscle is innervated by the external branch of the superior laryngeal
nerve.
2. The mandible is capable of both translational and rotational motion.
3. The internal branch of the superior laryngeal nerve provides sensory innervation to
the vocal cords.
4. Trismus involves spasm of the masseter muscles.
10. E. Knowledge of airway anatomy is essential to practicing anesthesiologists, particularly
when preparing for an awake intubation. The superior laryngeal nerve has an external and
internal branch. The external branch innervates the cricothyroid muscle, a tensor of the vocal
cords, and the internal branch provides sensory innervation to the vocal cords. The normal
mandible has a biphasic motion, anterior–posterior translational movement, and rotation about
an axis passing through the condyles. Several conditions cause mechanical dysfunction of the
jaw that may complicate tracheal intubation. Trismus, spasm of the masseter muscles that
impairs jaw relaxation, may occur secondary to infection and trauma. The muscles usually relax
in response to anesthetics and muscle relaxants; however, if the jaw has been closed for more
than 2 weeks, masseter fibrosis limits jaw opening and is unresponsive to general anesthesia
and muscle relaxants. A jaw closed for 2 weeks for any reason merits awake tracheal
intubation. (See page 1317: Intubating the Trachea.)
11. Which statement(s) about peritonsillar abscesses is/are TRUE&quest;

1. They are located below the laryngeal inlet.
2. They usually interfere with ventilation by mask.
3. They usually impair vocal cord visualization.
4. They often require surgical intervention.
11. D. Peritonsillar abscess, previously known as quinsy tonsil, is a serious consequence of
tonsillar infection that frequently requires surgical drainage. The abscess is usually located in
the lateral pharynx above the glottis and laryngeal inlet. It does not typically interfere with mask
418 / 494
ventilation or vocal cord visualization. (See page 1307: Complications.)
12. According to most guidelines, which of the following patients undergoing

adenotonsillectomy should be admitted for inpatient management&quest;
1. A 10-year-old child with Down syndrome
2. A healthy 1-year-old child
3. A 7-year-old child with a peritonsillar abscess
4. A 15-year-old patient with a mild upper respiratory infection
12. A. According to most guidelines, patients who should be admitted to the hospital after
adenotonsillectomy include children age 3 years and younger and patients with anatomic and
medical conditions that may lead to increased risk of bleeding (e.g., abnormal coagulation
profile, bleeding diathesis) or airway obstruction (e.g., craniofacial abnormality, achondroplasia,
or Treacher Collins, Crouzon, Goldenhar, or Down syndrome). A patient for whom surgery is
being performed because of the presence of an acute peritonsillar abscess would also warrant
postoperative inpatient monitoring. However, an otherwise healthy child older than age 3 years
with a mild upper respiratory infection need not routinely be admitted unless the patient did not
meet discharge criteria in the recovery room. (See page 1307: Complications and page 1310:
Table 50-1: Goals of Anesthesia for Tonsillectomy and Adenoidectomy.)
13. Which of the following statements about middle ear surgery is/are TRUE&quest;
1. Patient positioning carries the risk of C1–C2 subluxation in the pediatric population as
a result of laxity of the cervical spine ligaments.
2. Maintenance of relative hypotension may be requested to reduce intraoperative
bleeding.
3. Nitrous oxide should be avoided during procedures involving tympanic grafts.
4. Dissection carries the potential for injury to the third cranial nerve.
13. A. Tympanoplasty and mastoidectomy are two of the most common procedures performed
on the middle ear and accessory structures, particularly in the pediatric age group. To gain
access to the surgical site, the surgeon positions the head on a head rest, which may be lower
than the operative table. Extreme degrees of lateral rotation may be requested to facilitate
surgical exposure. Extreme tension on the heads of the sternocleidomastoid muscles must be
avoided. The laxity of the ligaments of the cervical spine, as well as immaturity of the odontoid
process in children, make children especially prone to C1–C2 subluxation. Ear surgery often
involves surgical dissection near the facial nerve (cranial nerve VII), thus placing it at risk of
being injured if not properly identified and protected. Cranial nerve III, the oculomotor nerve,
innervates the extrinsic muscles of the eye and is not encountered during typical dissections for
middle ear surgery. Bleeding must be kept to a minimum during surgery of the small structures
of the middle ear, and maintenance of relative hypotension is often effective at minimizing
bleeding. In addition, injection of concentrated epinephrine solution is performed in the area of
the tympanic vessels to produce vasoconstriction. The middle ear and sinuses are air-filled,
nondistensible cavities. An increase in the volume of gas contained within these structures
results in an increase in pressure. Nitrous oxide diffuses along a concentration gradient into the
air-filled middle ear spaces more rapidly than nitrogen moves out. During procedures in which
the eardrum is replaced or a perforation is patched, nitrous oxide should be discontinued before
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the application of the tympanic membrane graft to avoid pressure-related displacement. (See
page 1310: Middle Ear and Mastoid.)
14. Which statement(s) about epiglottitis is/are TRUE&quest;

1. Symptoms include sudden onset of fever, dysphagia, and a muffled voice.
2. It is associated with a characteristic “steeple sign” appearance on radiologic
examination.
3. It is caused by Haemophilus influenzae type B.
4. It often responds to nebulized racemic epinephrine.
14. B. Acute epiglottitis is most commonly caused by H. influenzae infection. Characteristic
signs and symptoms of acute epiglottitis include sudden onset of fever, dysphagia, drooling, a
thick muffled voice, and preference for the sitting position with the head extended and leaning
forward. Retractions, labored breathing, and cyanosis may be observed when obstruction is
present. If the clinical situation allows, oxygen should be administered by mask, and lateral
radiographs of the soft tissues in the neck may be obtained. Thickening of the aryepiglottic
folds as well as swelling of the epiglottis may be noted, producing a classic “thumb sign.” In
contrast, narrowing of the airway column produces the “steeple sign” on radiographic
examination of patients with larygnotracheobronchitis (croup). Treatment of epiglottitis involves
establishing an artificial airway. In anticipation of local swelling, the endotracheal tube chosen
should be at least one size (0.5 mm) smaller than would normally be chosen. Racemic
epinephrine is not part of the standard management of patients with epiglottitis. (See page
1312: Epiglottitis.)
15. Which statement(s) about laryngotracheobronchitis is/are TRUE&quest;

1. Symptoms include sudden onset of fever, dysphagia, and a muffled voice.
2. It is associated with a characteristic “steeple sign” appearance on radiologic
examination.
3. It is caused by Haemophilus influenzae type B.
4. It often responds to nebulized racemic epinephrine.
15. C. Laryngotracheobronchitis, or croup, occurs in children 6 months to 6 years of age but is
primarily seen in children younger than 3 years of age. It is usually viral in origin, and its onset
is more insidious than that of epiglottitis. The child presents with low-grade fever, inspiratory
stridor, and a “barking” cough. Radiologic examination confirms the diagnosis; subglottic
narrowing of the airway column secondary to circumferential soft tissue edema produces a
characteristic “steeple sign.” Treatment includes cool, humidified mist and oxygen therapy
usually administered in a tent for mild to moderate cases. More severe cases are accompanied
by tachypnea, tachycardia, and cyanosis; in these cases, racemic epinephrine administered by
nebulizer is often beneficial. The use of steroids is controversial, but a short course may be
helpful. (See page 1313: Laryngotracheobronchitis.)
16. Which statement(s) about laser surgery of the airway is/are TRUE&quest;
1. The energy emitted by the CO2 laser is absorbed by water in tissue and blood.
2. The neodymium:ytrrium-aluminum-garnet (Nd:YAG) laser has more limited penetrance
than the CO2 laser.
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3. Stand polyvinyl chloride (PVC) endotracheal tubes are flammable.

4. The CO2 laser may cause retinal injury.
16. B. The CO2 laser is the most widely used in medical practice, having particular application
in the treatment of laryngeal or vocal cord papillomas, laryngeal webs, resection of redundant
subglottic tissue, and coagulation of hemangiomas. The energy emitted by a CO2 laser is
absorbed by water contained in blood and tissues. Human tissue is approximately 80% water,
and laser energy absorbed by tissue water rapidly increases the temperature, thus denaturing
protein and causing vaporization of the target tissue. The CO2 laser does not penetrate deeply
(0.01 mm); it may cause injury to the cornea, but its energy does not reach the retina. This is in
contrast to the Nd:YAG laser, which has a deeper penetration and may therefore cause retinal
injury. All standard PVC endotracheal tubes are flammable and may ignite and vaporize when in
contact with the laser beam. Endotracheal tubes have been specifically designed for use during
laser surgery. Another option is the use of a red rubber tube wrapped with reflective metallic
tape. However, the cuff of this tube remains unwrapped and therefore does not completely
exclude the potential for laser damage. (See page 1314: Laser Surgery of the Airway.)
17. Findings in a patient with foreign body aspiration may include:

1. refractory wheezing
2. stridor
3. tachypnea
4. fever
17. E. Patients with foreign body aspiration may have coughing, choking, refractory wheezing,
stridor, tachypnea, and fever. (See page 1313: Foreign Body Aspiration.)
18. Patients with obstructive sleep apnea (OSA) syndrome may have:
1. increased incidence of systemic and pulmonary hypertension
2. centrally mediated elevations in PCO2
3. cardiac enlargement
4. decreased myocardial sensitivity to hypoxia
18. A. Patients with OSA experience upper airway obstruction while awake and apnea during
sleep. The two most frequent levels of obstruction are at the soft palate and the base of the
tongue. Patients may have electrocardiographic evidence of right ventricular hypertrophy, and
one third of patients have chest radiographs consistent with cardiomegaly. This is frequently
reversible with digitalization and surgical removal of the tonsils and adenoids. Each apneic
episode causes progressively increasing pulmonary artery pressure and systemic hypertension.
These patients often have dysfunction in the medulla or hypothalamic areas of the central
nervous system, causing persistently elevated CO2. They also have increased pulmonary
vascular resistance and myocardial depression in response to hypoxia, hypercarbia, and
acidosis. (See page 1306: Tonsillectomy and Adenoidectomy.)
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Review of Clinical Anesthesia, 5e [Vishal] 51. Anesthesia for Ophthalmologic Surgery
Chapter 51
Anesthesia for Ophthalmologic Surgery
1. When considering the anatomy of the eye, all of the following statements are correct
EXCEPT:
A. The sphenoid and zygomatic bones are integral parts of the orbit.
B. Blood supply to the eye is achieved by means of both internal and external carotid
arteries.
C. The eye is composed of three layers: the sclera, uveal tract, and retina.
D. The trochlear nerve supplies the lateral rectus muscle.
E. The motor innervation of the eye and its adnexa are supplied by the oculomotor,
trochlear, abducens, and facial nerves.
1. D. The walls of the orbit are composed of the frontal, zygomatic, greater wing of the
sphenoid, maxilla, palatine, lacrimal, and ethmoid bones. Blood supply to the eye and orbit is by
means of branches of both the internal and external carotid arteries. Venous drainage of the
orbit is accomplished through the multiple anastomoses of the superior and inferior ophthalmic
veins. Venous drainage of the eye is achieved mainly through the central retinal vein. All of
these veins empty directly into the cavernous sinus. The covering of the eye is composed of
three layers: the sclera, uveal tract, and retina. The sensory and motor innervations of the eye
and its adnexa are as follows: a branch of the oculomotor nerve supplies a motor root to the
ciliary ganglion, which in turn supplies the sphincter of the pupil and the ciliary muscle; the
trochlear nerve supplies the superior oblique muscle; the abducens nerve supplies the lateral
rectus muscle; and the facial nerve supplies the frontalis and the upper eyelid orbicularis, and
the lower branch supplies the orbicularis of the lower eyelid. (See page 1322: Ocular Anatomy.)
2. Which of the following statements about aqueous humor is TRUE&quest;

A. It is entirely formed in the posterior chamber.
B. The formation process entails active transport of sodium.
C. Aqueous humor is iso-osmolar to plasma.
D. Carbonic anhydrase has an active role in the active secretion in the posterior
chamber.
E. Obstruction of venous return to the right side of the heart does not affect intraocular
pressure (IOP).
2. B. Two thirds of the aqueous humor is formed in the posterior chamber by the ciliary body in
an active secretory process involving both the carbonic anhydrase and the cytochrome oxidase
systems. The remaining third is formed by passive filtration of aqueous humor from the vessels
on the anterior surface of the iris. At the ciliary epithelium, sodium is actively transported into
the aqueous humor in the posterior chamber. Bicarbonate and chloride ions passively follow the
sodium ions. This active mechanism causes the osmotic pressure of the aqueous to be many
times greater than that of plasma. Aqueous humor flows from the posterior chamber through the
pupillary aperture into the anterior chamber, and then the aqueous flows into the peripheral
422 / 494
segment of the anterior chamber and exits the eye through the trabecular network, the
Schlemm canal, and the episcleral venous system. A network of connecting venous channels
eventually leads to the superior vena cava and right atrium. Thus, obstruction of venous return
at any point from the eye to the right side of the heart impedes aqueous drainage, elevating IOP
accordingly. (See page 1323: Ocular Physiology.)
3. Which of the following statements with respect to intraocular pressure (IOP) is

FALSE&quest;
A. IOP normally varies between 10 and 22 mm Hg.
B. IOP is equal to intracranial pressure.
C. IOP becomes atmospheric if the eye cavity has been entered.
D. The major control of IOP is exerted by the fluid content.
E. Coughing may increase IOP by as much as 40 mm Hg.
3. B. IOP exceeds not only tissue pressure by 2 to 3 mm Hg but also intracranial pressure by as
much as 7 to 8 mm Hg. IOP normally varies between 10 and 22 mm Hg. If the eye cavity has
been entered, IOP becomes atmospheric. A major control of IOP is exerted by the fluid content,
particularly the aqueous humor. Straining, vomiting, or coughing may increase IOP by as much
as 40 mm Hg. (See page 1324: Maintenance of Intraocular Pressure.)
4. Which statement regarding the relationship between intraocular pressure (IOP) and
glaucoma is FALSE&quest;
A. IOP above 22 mm Hg is considered abnormal.
B. IOP is influenced by both external pressure on the eye and obstruction of venous
return.
C. Open-angle glaucoma results from sclerosis in the trabecular system and responds to
epinephrine and selective beta-blockers.
D. Closed-angle glaucoma is an acute process that responds well to atropine.
E. Laryngoscopy and tracheal intubation may elevate IOP.
4. D. IOP normally varies between 10 and 22 mm Hg and is considered abnormal above 22 mm
Hg. Three main factors influence IOP: external pressure on the eye by the contraction of the
orbicularis oculi muscle and the tone of the extraocular muscles, venous congestion of orbital
veins (as may occur with vomiting and coughing), and changes in intraocular contents (lens,
vitreous, intraocular tumor, blood, or aqueous humor). Laryngoscopy and tracheal intubation
may also elevate IOP, even without any visible reaction to intubation, although the effect is
exaggerated when the patient coughs. Topical anesthetization of the larynx may attenuate the
hypertensive response to laryngoscopy, but it does not reliably prevent associated increases in
IOP. With open-angle glaucoma, the elevated IOP exists with an anatomically open anterior
chamber angle; it is thought that sclerosis of trabecular tissue results in impaired aqueous
filtration and drainage. Treatment consists of medication to produce miosis and trabecular
stretching. Closed-angle glaucoma is characterized by movement of the peripheral iris into
direct contact with the posterior corneal surface, mechanically obstructing aqueous outflow.
Atropine premedication in the dose range used clinically has no effect on IOP in either open- or
closed-angle glaucoma. (See page 1324: Maintenance of Intraocular Pressure.)
423 / 494
5. Which of the following statements regarding neuromuscular blocking drugs is
FALSE&quest;
P.267
A. In contrast to depolarizing drugs, nondepolarizing neuromuscular blocking drugs lower
intraocular pressure (IOP).
B. Succinylcholine (Sch) causes an average increase in IOP of approximately 8 mm Hg.
C. No technique consistently and completely blocks the ocular hypertensive response to
Sch administration.
D. Sch should be used only with extreme reluctance in ocular surgery because of the
high probability of causing eye injury.
E. Sch causes an increase in IOP that dissipates within minutes.
5. D. Neuromuscular blocking drugs have both direct and indirect actions on IOP. If paralysis of
the respiratory muscles is accompanied by alveolar hypoventilation, the latter secondary effect
may supervene to increase IOP. In contrast to nondepolarizing drugs, the depolarizing drug Sch
elevates IOP by an average of 8 mm Hg. Changes in extraocular muscle tone do not contribute
significantly to the increase in IOP observed after Sch administration. Various methods have
been advocated to prevent Sch-induced elevations in IOP. Although some attenuation of the
increase results, no technique consistently and completely blocks the ocular hypertensive
response. The efficacy of pretreatment with nondepolarizing drugs is controversial. Sch, if
unaccompanied by pretreatment with a nondepolarizing neuromuscular blocking drug, is
relatively contraindicated in patients with penetrating ocular wounds and should not be given for
the first time after the eye has been opened. Nonetheless, it no longer is valid to recommend
that Sch be used only with extreme reluctance in ocular surgery. Clearly, any Sch-induced
increment in IOP is usually dissipated before surgery is started. (See page 1326:
Neuromuscular Blocking Drugs.)
6. Decreased intraocular pressure (IOP) is associated with all of the following EXCEPT:
A. sevoflurane
B. elevated body temperature
C. trimethaphan
D. sorbitol
E. glycerin
6. B. Hypoventilation, as well as administration of carbon dioxide, elevates IOP. Virtually all
central nervous system depressants, including neuroleptics, opioids, and induction agents (e.g.,
barbiturates, etomidate, and propofol), lower IOP. Inhalation anesthetics purportedly cause
dose-related decreases in IOP. Hypothermia lowers IOP. On initial consideration, hypothermia
may be expected to increase IOP because of the associated increase in viscosity of aqueous
humor. However, hypothermia is linked with decreased formation of aqueous humor and with
vasoconstriction; the net result is a reduction in IOP. Ganglionic blockers such as trimethaphan
significantly lower IOP in normal subjects despite mydriasis. Intravenous administration of
hypertonic solutions such as dextran, urea, mannitol, and sorbitol elevate plasma osmotic
pressure, decreasing aqueous humor formation and reducing IOP. Glycerin decreases IOP,
although it is less predictable than mannitol. (See page 1325: Effects of Anesthesia and
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Adjuvant Drugs on Intraocular Pressure.)
7. Which of the following statements regarding the oculocardiac reflex is

FALSE&quest;
A. It may be triggered by pressure on the globe or a retrobulbar block.
B. If the oculocardiac reflex occurs, the procedure may continue without pausing if the
patient has been premedicated with an anticholinergic agent.
C. This reflex may result in serious cardiac complications, including cardiac arrest.
D. Atropine premedication may have an abortive action on this effect.
E. The oculocardiac reflex dissipates within seconds after cessation of eye manipulation.
7. B. The oculocardiac reflex is triggered by pressure on the globe and traction on the
extraocular muscles, the conjunctiva, or the orbital structures. The reflex may also be elicited by
performance of a retrobulbar block. Although the most common manifestation of the
oculocardiac reflex is sinus bradycardia, a wide spectrum of cardiac dysrhythmias may occur,
including junctional rhythm, ectopic atrial rhythm, atrioventricular blockade, ventricular bigeminy,
multifocal premature ventricular contractions, wandering pacemaker, idioventricular rhythm,
asystole, and ventricular tachycardia. Hypercarbia and hypoxemia are thought to augment the
incidence and the severity of the oculocardiac reflex. The most common manifestation of this
reflex is bradycardia. The afferent limb is trigeminal, and the efferent limb is the vagus. This
reflex has a higher incidence in children. Various maneuvers to abolish or obtund the
oculocardiac reflex have been promulgated. None of these have been consistently effective,
safe, and reliable. Complete vagolytic blockade in adults mandates 2 to 3 mg (0.03–0.05 mg/kg)
of atropine. Because the peak effect of intramuscular atropine occurs approximately 30 minutes
after administration, it is not surprising that studies with the usual routine dose have shown
inconsistent protection against the oculocardiac reflex. If a cardiac dysrhythmia appears, the
surgeon should be asked to cease operative manipulation. Next, the patient's anesthetic depth
and ventilatory status should be evaluated. Commonly, the heart rate and rhythm return to
baseline within 20 seconds after institution of these measures. (See page 1327: Oculocardiac
Reflex.)
8. Which of the following statements is TRUE&quest;

A. Treatment of patients with glaucoma with echothiophate poses minimal implications
for general anesthesia.
B. Intraocular acetylcholine administration may be associated with bronchospasm.
C. Cocaine used alone for topical anesthesia in ocular surgery sensitizes the heart to
endogenous catecholamines.
D. Cyclopentolate administration is associated with miosis.
E. Intraocular sulfur hexafluoride administration requires minimal changes in the general
anesthetic technique.
8. B. Acetylcholine is commonly used intraocularly after lens extraction to produce miosis. The
local use of this drug may occasionally result in systemic effects such as bradycardia,
increased salivation, bronchial secretions, and bronchospasm. Echothiophate is a long-acting
anticholinesterase miotic that lowers IOP and may prolong the action of succinylcholine. In
addition, a delay in metabolism of ester local anesthetics should be expected. It has been
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shown that cocaine used alone, without topical epinephrine, to shrink the nasal mucosa in
conjunction with halothane or enflurane does not sensitize the heart to endogenous epinephrine
during halothane or enflurane anesthesia. Cyclopentolate is a mydriatic with side effects that
include central nervous system toxicity that is manifested by dysarthria, disorientation, and frank
psychotic reactions. Intraocular sulfur hexafluoride has been used for retinal detachment
surgery to facilitate reattachment mechanically. Nitrous oxide should be terminated 15 minutes
before gas injection to prevent expansion of intravitreous gas bubble. If the patient requires
general anesthesia after this procedure, nitrous oxide should be avoided for 10 days. (See
page 1327: Anesthetic Ramifications of Ophthalmic Drugs.)
9. True statements regarding ocular injuries during general anesthesia include all of
the following EXCEPT:
A. Clear goggles should be worn to protect the eyes from injury from argon laser.
B. Use of Hibiclens solution may result in corneal damage.
C. Corneal abrasion is the most common ocular complication of general anesthesia.
D. Venous retinal hemorrhages are usually selflimiting and resolve completely within a
few months.
E. Retinal infarction may result from pressure exerted by an anesthetic face mask.
9. A. When working with argon laser, orange-tinted goggles should be used. Hibiclens, a 4%
chlorhexidine gluconate solution, has been reported to result in serious corneal damage from
eye contact. The most common ocular complication of general anesthesia is corneal abrasion;
these lesions usually heal in 24 hours. Retinal ischemia or infarction may result from direct
ocular pressure; this is particularly true in a hypotensive setting. (See page 1340: Postoperative
Ocular Complications.)
10. Related concerns regarding sympathomimetics and beta-blockers used for

intraocular surgery include all of the following EXCEPT:
A. Adrenergic agents are associated with mydriasis.
B. Epinephrine administered in the anterior chamber causes systemic effects (e.g.,
tachycardia) in more than 20% of patients.
C. Phenylephrine in a concentration of 10% administered locally has been associated
with cardiac dysrhythmias and ischemia.
D. Timolol may cause bronchospasm.
E. Topical beta-blockers should be used with caution in patients with congestive heart
failure.
10. B. Although topical epinephrine has been associated with systemic effects, Smith et al
reported that administration of epinephrine in doses up to 68 μg/kg into the anterior chamber of
patients undergoing cataract surgery does not lead to much systemic absorption; the iris, with
its rich network of adrenergic receptors, is able to capture most of the agent. Pupillary dilation
and capillary decongestion are reliably produced by topical phenylephrine. In patients with
coronary artery disease, severe myocardial ischemia, cardiac dysrhythmias, and even
myocardial infarction may develop after administration of topical 10% eye drops. Timolol, a
nonselective β -adrenergic agent, should be administered with caution to patients with known
obstructive airway disease, congestive heart failure, or greater than first-degree heart block.
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Life-threatening asthmatic crises have been reported after the administration of timolol drops to
some patients with chronic, stable asthma. A newer antiglaucoma drug, betaxolol, a beta1-
blocker, is said to be more oculospecific and to have minimal systemic effects. However,
patients receiving an oral beta-blocker and betaxolol should be observed for potential additive
side effects. (See page 1327: Anesthetic Ramifications of Ophthalmic Drugs.)
11. Differences between a retrobulbar and peribulbar block include all of the following
EXCEPT:
A. The oculocardiac reflex occurs with both the retrobulbar block and the peribulbar
block.
B. The peribulbar block requires larger doses of local anesthetic.
C. The onset of action for peribulbar block is quicker.
D. There have been no reported cases of brainstem anesthesia with peribulbar block.
E. The approach for peribulbar block includes two sites: inferotemporal and superonasal.
11. C. Since the late 1980s, peribulbar block has become increasingly popular. The advantages
of this technique include its safety and the fact that an eyelid block is usually superfluous
because the relatively large volume of injected local anesthetic usually diffuses into the eyelids.
Two injections are required, one placed inferotemporally and one between the supraorbital
notch and trochlea. The onset is usually slower than with retrobulbar blockade and may be
delayed for as long as 15 to 20 minutes. Another disadvantage of peribulbar blockade is that
pressure on the globe is required to distribute the local anesthetic. However, no cases of either
retrobulbar hemorrhage or brainstem anesthesia have been documented associated with
peribulbar block. Both retrobulbar and peribulbar blocks are associated with the oculocardiac
reflex. (See page 1329: Preoperative Evaluation and page 1331: Retrobulbar and Peribulbar
Blocks.)
12. A 27-year-old man is brought to the emergency room after sustaining a motor
vehicle accident. Massive bleeding and visible damage to the right orbit are noticed
during assessment. Surgical intervention is mandatory. Which of the following
1. Succinylcholine (Sch) may be safely used to secure the airway.
2. Awake intubation is an acceptable alternative for securing the airway.
3. Additional injuries (e.g., cranial fractures, airway injury) must be included in the
anesthesia assessment.
4. Retrobulbar block offers the advantage of local anesthesia without the need of airway
manipulation, which could trigger increases in the intraocular pressure (IOP).
12. A. The anesthesiologist involved in caring for a patient with a penetrating eye injury and a
full stomach confronts special challenges. The anesthesiologist must weigh the risk of
aspiration against the risk of blindness in the injured eye that could result from elevated IOP
and extrusion of ocular contents. As in all cases of trauma, attention should be given to the
exclusion of other injuries, such as skull and orbital fractures, intracranial trauma associated
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with subdural hematoma formation, and the possibility of thoracic or abdominal bleeding.
Although regional anesthesia is an often valuable alternative for the management of trauma
patients who have recently eaten, such an option is not available for patients with penetrating
eye injuries. Retrobulbar blockade is ill advised because extrusion of intraocular contents may
ensue. Even though it is conceivable that a well-conducted, extremely smooth awake intubation
after topical anesthesia may not increase IOP, it seems much more probable that the coughing
and straining that will occur will result in increased IOP. Sch offers the distinct advantages of
swift onset, superb intubating conditions, and a brief duration of action. If administered after
careful pretreatment with a nondepolarizing drug and an induction agent, Sch typically produces
only a modest increase in IOP. (See page 1336: Anesthetic Management of Specific Situations:
Open-Eye, Full Stomach.)
13. A 4-month-old boy is scheduled for elective strabismus corrective surgery. Which
of the following is/are of concern for the anesthesiologist&quest;
1. Strabismus may be acquired secondary to cataracts.
2. The risk of nausea and vomiting may be attenuated with a combination of serotonin
(5-HT) inhibitors, dopamine inhibitors, and corticosteroids.
3. A laryngeal mask airway (LMA) may be safely used if there are no risk factors for
aspiration.
4. Pretreatment with atropine is contraindicated.
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13. A. Infantile strabismus occurs within the first 6 months of life and is often observed in the
neonatal period. Although most patients with strabismus are healthy, the incidence of
strabismus is increased in those with central nervous system dysfunction. The use of atropine
affords some protection against elicitation of the oculocardiac reflex. For this reason, many
anesthesiologists routinely administer intravenous atropine to children scheduled for strabismus
surgery. The LMA is gaining popularity for strabismus surgery. To decrease the risk of vomiting,
combination therapy with a 5-HT antagonist, metoclopramide, and a glucocorticoid is gaining
popularity. Strabismus may be acquired secondary to oculomotor nerve trauma or to sensory
abnormalities such as cataracts or refractive aberrations. (See page 1337: Strabismus
Surgery.)
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Review of Clinical Anesthesia, 5e [Vishal] 52. The Renal System & Anesthesia for Urologic Surgery
Chapter 52
The Renal System and Anesthesia for Urologic Surgery
1. Which of the following is believed responsible for blindness after transurethral

resection of the prostate (TURP)&quest;
A. Sorbitol
B. Glycine
C. Mannitol
D. Urea
E. Glycogen
1. B. All of these substances (except for glycogen) are used as osmotic agents in TURP
procedures. Glycine is the only agent that directly produces transient blindness. It is believed
that blindness is a result of glycine action as an inhibitory neurotransmitter. (See page 1365:
Irrigating Solutions for Transurethral Resection of the Prostate.)
2. Which of the following blood tests best predicts the development of acute renal
failure (ARF) in critically ill patients&quest;
A. Creatinine clearance (CrCl)
B. Urine sodium concentration (UNa)
C. Serum creatinine (Cr)
D. Fractional excretion of sodium (FENa)
E. Oliguria
2. C. Serum creatinine is the most effective blood test for reflecting change in renal filtration and
predicting renal outcome, even during the perioperative period. Although poor urine output
(<400 mL urine/24 hr) may reflect hypovolemia or impending “prerenal” failure, the majority of
perioperative renal failure episodes develop in the absence of oliguria. CrCl is a predictor of
imminent renal failure but requires a multi-hour urine sample. Estimates of glomerular filtration
rate can be made by determining CrCl from urine and blood creatinine tests. UNa+ reflects
resuscitative fluids being used. FENa does not serve as an early indicator of ARF. It can
differentiate prerenal from renal causes of ARF after the condition is established. (See page
1350: Clinical Assessment of the Kidney.)
3. Which of the following medications have altered pharmacodynamics significant
enough to warrant alterations in dosing in patients with end-stage renal disease
(ESRD)&quest;
1. Thiopental
2. Dexmedetomidine
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3. Midazolam
4. Isoflurane
3. A. Thiopental, midazolam, and dexmedetomidine all undergo significant protein binding. This
binding is reduced in ESRD, resulting in a larger free fraction of the drug. This requires an
altered dosing scheme for these medications. Isoflurane pharmacodynamics are not affected by
renal failure. (See page 1357: Induction Agents and Sedatives.)
4. Causes for increased release of antidiuretic hormone (ADH) include which of the
following&quest;
1. Increased extracellular sodium
2. Increased extracellular osmolality
3. Reduced atrial filling pressures
4. Arterial baroreceptor stimulation by hypertension
4. A. ADH is released by the posterior pituitary gland in response to increased extracellular
sodium or increased osmolality. It is also released during times of hypotension through
receptors in the atria and the arterial tree. ADH release results in increased free water
absorption at the distal and the collecting tubules. By increasing the quantity of free water
absorbed, the elevated sodium and osmolality levels are diluted, and hypovolemia is abated.
(See page 1349: Tubular Resorption of Sodium and Water.)
5. Which of the following statements regarding anesthesia and renal function is/are
TRUE&quest;
1. Methoxyflurane is consistently the only agent that produces clinically relevant renal
damage.
2. Anesthesia does not directly affect renal hormonal control.
3. Most renal injuries during anesthesia are caused by physiologic perturbations.
4. Spinal anesthesia is the safest anesthetic for the kidney.
5. A. In general, an anesthetic is not injurious to the renal system; an exception is
methoxyflurane. During the metabolism of this drug, free fluoride is released, which causes
renal injury. Enflurane and sevoflurane also generate free fluoride; however, the quantity
released is substantially less than with methoxyflurane, and enflurane and sevoflurane have not
consistently caused clinically relevant renal injury. No comparative studies have demonstrated
superior renal protection or improved renal outcome with general versus regional anesthesia.
Most renal injury occurs secondary to physiologic perturbations as a result of surgery, as well
as complications such as hypoxia, hypovolemia, and hypotension. Anesthetics do not directly
alter renal hormonal regulation. (See page 1356: Anesthetic Agents in Renal Failure.)
6. Alterations in drug administration in patients with chronic renal failure are required
because of which of the following alterations in homeostasis&quest;
1. Alterations in volume of distribution
2. Alterations in protein binding
3. Alterations in elimination half-life for various compounds
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4. Alteration in the increase of F A/FI for inhaled agents
6. A. The pharmacokinetics of most enteral and parenteral medications are altered in patients
with chronic renal failure (with the exclusion of inhaled anesthetic agents). There is an increase
in the volume of distribution for water-soluble drugs, resulting in lower concentration of a drug
given as a single bolus. Reduced excretion of the parent drug and any of its active metabolites
results in prolonged duration of action for a number of agents. Protein binding is typically
reduced in chronic renal failure, resulting in a larger free fraction (which produces the effects).
There is no alteration in alveolar uptake in patients with chronic renal failure (as long as they
are not in congestive heart failure). (See page 1356: Drug Prescribing in Renal Failure.)
7. Electrocardiographic (ECG) changes are associated with which of the

following&quest;
1. Hypocalcemia
2. Hypercalcemia
3. Hypokalemia
4. Hypermagnesemia
7. E. Clinical manifestations of hypokalemia include ECG changes (flattened T waves, U
waves, prodysrhythmic state) and skeletal muscle weakness. QT interval shortening and
dysrhythmias are associated with both hypercalcemia and hypocalcemia. In more extreme
cases of hypermagnesemia flaccid skeletal muscle paralysis, hyporeflexia, bradydysrhythmias,
and cardiac arrest may occur. (See page 1351: Electrolyte Disorders.)
8. Preoperative factors associated with an increased risk of postoperative renal

dysfunction include which of the following&quest;
1. Pre-existing renal disease
2. Preoperative hypovolemia
3. Congestive heart failure
4. Cirrhosis
8. E. The single most reliable predictor of postoperative renal dysfunction is preoperative renal
dysfunction. Other risk factors include cardiac dysfunction, sepsis, volume depletion, and
hepatic failure. By itself, advanced age is not predictive of postoperative renal dysfunction.
(See page 1354: Prerenal Azotemia and page 1353: Acute Kidney Injury.)
9. During cardiac surgery, proven techniques to prevent renal injury include which of
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1. Dopamine
2. Mannitol
3. Furosemide
4. Avoidance of hypovolemia and hypotension
9. D. Numerous agents (including dopamine, mannitol, or furosemide) have been used
intraoperatively without success in attempts to protect the kidney during cardiac surgery. In
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general, maintenance of adequate intravascular volume and blood pressure are the only proven
preventive measures that can be taken to preserve renal function. (See page 1360: High-Risk
Surgical Procedures.)
10. Qualities of the ideal irrigation solution for transurethral resection of the prostate
(TURP) include which of the following&quest;
1. Isotonic
2. Transparent
3. Nonhemolytic
4. Nonelectrolytic
10. E. TURP involves the use of a fiberoptic scope and an electrocautery loop to resect the
prostate from inside the lumen of the urethra. To clear the resected material and blood, an
irrigating solution is infused. This irrigating solution must be optically clear and nonconductive
toward electricity (because the cautery unit will be in direct contact with fluid). During resection,
the fluid used during irrigation is absorbed by the open veins within the prostate, so the fluid
must be isotonic and nonhemolytic. (See page 1365: Irrigating Solution for Transurethral
Resection of the Prostate.)
11. Which of the following statements regarding regional anesthesia and transurethral
resection of the prostate (TURP) is/are TRUE&quest;
1. A T10 sensory level is required to prevent sensation of bladder distention.
2. Epidural anesthesia is the regional technique of choice for TURP.
3. Regional anesthesia may improve detection of TURP syndrome symptoms.
4. Regional anesthetics have been shown to reduce mortality compared with general
anesthesia.
11. B. Regional anesthesia is used extensively for TURP procedures. There is no difference in
mortality between patients receiving general anesthesia and those receiving regional
anesthetics. Spinal anesthesia is the technique of choice if a regional technique is selected
because spinal anethesisa provides a more reliable block than epidural anethesia. If a patient
selects a regional block for TURP, the anesthesiologist must anesthetize to the T10 level to
block sensation from an overdistended bladder. Because patients are awake during regional
anesthesia, there is an increased likelihood that the TURP syndrome symptoms will be
detected earlier. (See page 1367: Anesthetic Technique for Transurethral Resection of the
Prostate and page 1362: Transurethral Resection of Bladder Tumors.)
12. Which of the following statements regarding lithotripsy is/are TRUE&quest;

1. Minimal immersion techniques are devoid of cardiovascular and pulmonary side
effects.
2. Pregnancy is a contraindication.
3. Small patients are at risk of pulmonary contusion from the shock wave.
4. Pacemakers are a contraindication to lithotripsy.
12. A. Lithotripsy involves crushing renal calculi with an externally generated shock wave. Early
lithotripsy machines transferred the shock wave to the patient by immersing the patient in a
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water bath. The water transferred the shock wave effectively because tissue and water have
similar acoustic properties. Immersion in the water bath may lead to significant physiologic
changes, including increased central venous pressure, vasodilation, decreased vital capacity,
and decreased functional residual capacity. The new minimal immersion techniques are devoid
of physiologic derangements. Small patients are at risk of pulmonary contusions because their
lungs lie within the path of the shock wave. Pacemakers were once believed to be a
contraindication for lithotripsy, but a review of shock wave lithotripsy treatments in pacemaker-
dependent patients found a low (<1%) incidence of major pacemaker complications. Pregnancy
is a contraindication to lithotripsy. (See page 1363: Extracorporeal Shock Wave Lithotripsy and
page 1364: Complications of Shock Wave Lithotripsy.)
13. Which of the following is/are TRUE regarding patients with renal cell
carcinoma&quest;
1. Surgery is the treatment of choice.
2. Postoperative pain is significant after open radical nephrectomy, often requiring
multimodal therapy.
3. There is a decreased incidence of deep venous thrombosis (DVT) compared with
other cancer patients.
4. Patients undergoing open radical nephrectomy are prone to hemodynamic instability.
13. E. Renal cell carcinoma is the most common malignancy of the kidney. Surgical excision is
the mainstay of treatment because it is refractory to nonsurgical therapies (chemotherapy and
radiation). Patients undergoing open radical nephrectomy are prone to hemodynamic instability
not only from blood loss but also because of compression of the inferior vena cava secondary
to positioning or surgical compression. Patients having open resections often experience
significant postoperative pain, and the use of multimodal therapies, including epidural
analgesia, may be helpful. DVT rates for patients with renal cell carcinoma resection are lower
than those seen for cancer patients overall (1.5% vs 10–20%). (See page 1369: Radical
Nephrectomy.)
14. Endovascular repair of an abdominal aortic aneurysm is gaining in popularity

compared with the open approach. Which of the following statements regarding the
endovascular approach is/are TRUE&quest;
1. Typically, hemodynamic alterations are reduced.
2. Long-term incidences of renal failure or insufficiency are similar.
3. Patients typically experience less postoperative pain.
4. It cannot be performed in patients with severe chronic obstructive pulmonary disease
(COPD).
14. A. Endovascular procedures to repair abdominal aortic aneurysms typically produce fewer
hemodynamic alterations and because of the smaller incisions, produce less postoperative
pain. Endovascular procedures do not have a lower incidence of long-term renal complications.
This is probably because of the similar risk of atheroembolism and because of the significant
quantity of radiographic contrast dye used during the procedure. Severe COPD is not a
contraindication. (See page 1360: High-Risk Surgical Procedures.)
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Review of Clinical Anesthesia, 5e [Vishal] 53. Anesthesia for Orthopedic Surgery
Chapter 53
Anesthesia for Orthopedic Surgery
1. Which of the following statements regarding peripheral nerve block for the foot is
TRUE&quest;
A. The saphenous, sural, and peroneal nerves are branches of the femoral nerve, which
may be blocked at the knee level.
B. If anesthesia is provided by an ankle block, surgery using a midleg or thigh tourniquet
must be limited to 90 minutes.
C. Induction or “setup” time is consistently reduced compared with an intrathecal
injection.
D. Clonidine may be used to prolong surgical anesthesia.
E. Prolonged block delays postanesthesia care unit and hospital discharge times.
1. D. Innervation of the foot is provided by the femoral nerve (via the saphenous nerve) and by
the sciatic nerve (via the posterior tibial, sural, deep, and superficial peroneal nerves).
Therefore, central neuraxial blockade and peripheral nerve blocks at the upper leg, knee, or
ankle are appropriate regional anesthetic techniques for foot surgery. The selection of the
regional technique is based on the surgical site, the use of a calf or thigh tourniquet, the degree
of weight bearing or ambulation, and the need for postoperative analgesia. For example,
inflation of a thigh tourniquet for more than 15 to 20 minutes necessitates a general or neuraxial
anesthetic, regardless of the surgical site. Often patients undergoing lower extremity peripheral
techniques may be discharged directly from the operating room to the outpatient nursing
station, reducing recovery time and charges. The use of long-acting local anesthetics and the
addition of epinephrine or clonidine allow prolongation of postoperative analgesia. However,
additional onset time is required with bupivacaine and ropivacaine; this may translate into a
longer “induction time.” (See page 1385: Surgery to the Ankle and Foot.)
2. All of the following apply to microvascular surgery EXCEPT:

A. To avoid compromising blood flow to a replanted limb, phenylephrine should not be
used to maintain systemic blood pressure.
B. Maintenance of blood flow through anastomoses may be achieved with vasodilators
and an increase in the perfusion pressure.
C. Dextran and papaverine may be used to preserve blood flow.
D. An epidural catheter placement may improve the perfusion.
E. Hypothermia may have a deleterious effect.
2. A. Microvascular surgery includes both replantation, the reattachment of a completely
severed body part, and revascularization, the re-establishment of blood flow through a severed
body part. Most replantation surgery involves the upper extremity. Blood flow may be improved
by increasing the perfusion pressure, preventing hypothermia, and using vasodilators and
sympathetic blockade. Microvascular perfusion pressure depends on both adequate
intravascular volume and oncotic pressure. Evidence suggests that the use of phenylephrine to
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support blood pressure does not jeopardize blood flow to the tissue being replanted. Body
temperature is also a determinant of blood flow. Hypothermia not only results in peripheral
vasoconstriction but also causes sympathetic activation, shivering, increased oxygen demand,
a leftward shift of the oxygen–hemoglobin dissociation curve, and altered coagulation.
Therefore, hypothermia must be prevented in patients undergoing microvascular surgery.
Regional anesthetic techniques provide sympathectomy and vasodilation to the proximal
(innervated) segment of an extremity but have no effect on vasospasm in the replanted
(denervated) tissue. Antithrombotics (heparin), fibrinolytics (streptokinase, urokinase, low-
molecular-weight dextran), and smooth muscle relaxants (papaverine, local anesthetics) are
also used to preserve blood flow in microvascular anastomoses. A combination of general and
continuous regional anesthesia allows prolonged intraoperative anesthesia and postoperative
analgesia, reduces the amount of inhalational agent, and increases the patient's acceptance of
lengthy surgical procedures. However, regardless of anesthetic technique, conditions that
stimulate vasospasm or vasoconstriction, such as pain, hypotension, and hypovolemia, should
be avoided. (See page 1386: Microvascular Surgery.)
3. Which of the following statements regarding patients with scoliosis is TRUE&quest;

A. Scoliosis that requires surgery is usually the result of a neuromuscular disorder.
B. Resting hypercapnia is the best indicator of the need for postoperative ventilatory
support.
C. They may have associated cyanotic heart disease.
D. They should be managed with hemodilution or controlled hypotension but never both.
E. Moderate, controlled hypotension is complicated by thrombosis and therefore is not
usually beneficial.
3. C. Idiopathic scoliosis represents 75% to 90% of scoliosis cases. The remaining 10% to 25%
of cases are associated with neuromuscular diseases and congenital abnormalities, including
congenital heart disease, trauma, and mesenchymal disorders. Vital capacity appears to be a
reliable prognostic indicator of perioperative respiratory reserve. Postoperative ventilation is
most likely required for patients with a vital capacity of less than 40% of predicted vital capacity.
Scoliosis is also associated with congenital heart conditions, including mitral valve prolapse,
coarctation, and cyanotic heart disease, suggesting a common embryonic insult or collagen
defect. Normovolemic hemodilution combined with induced hypotension and autotransfusion
may decrease or eliminate the need for homologous transfusion. Moderate induced
hypotension (reduction of systolic pressure 20 mm Hg from baseline or lowering mean arterial
pressure to 65 mm Hg in normotensive patients) has been shown to decrease blood loss,
reduce transfusion requirements by 50%, and shorten operating times. (See page 1377:
Scoliosis.)
4. Which of the following statements regarding neurophysiologic monitoring is

TRUE&quest;
A. Motor-evoked potentials (MEPs) are commonly monitored during spine surgery.
B. The anesthetic technique of choice when MEPs are being monitored is a nitrous
–narcotic–relaxant technique.
C. Somatosensory-evoked potentials (SSEPs) monitor motor function only in areas of
the spinal cord supplied by the anterior spinal artery.
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D. SSEP waveforms may be altered by acute nerve injury, hypercarbia, hypoxia, or

hypotension.
E. Volatile anesthetics commonly produce a dose-related increase in SSEP amplitude.
4. D. Although the use of MEPs remains limited, SSEP monitoring is widely accepted. However,
somatosensory stimulation follows the dorsal column pathways of proprioception and vibration,
pathways supplied by the posterior spinal artery. Conversely, MEPs monitor motor pathways
that are supplied by the anterior spinal artery. MEPs are not routinely monitored because they
are technically more difficult to use. Muscle relaxants cannot be used in patients having
maximum expiratory pressure monitoring. It is critical to note that postoperative paraplegia has
occurred in at least one patient with preserved SSEP monitoring intraoperatively. Numerous
variables are known to alter SSEP waveforms. In addition to neural injury, SSEPs are altered by
hypercarbia, hypoxia, hypotension, and hypothermia. All of the volatile anesthetics produce a
dose-related decrease in the amplitude and an increase in the latency of SSEPs. (See page
1379: Spinal Cord Monitoring.)
5. Risk factors for fat embolism syndrome include all of the following EXCEPT:
A. generally 20 to 40 years of age
B. male gender
C. disorders of lipid metabolism
D. rheumatoid arthritis
E. intramedullary instrumentation
5. C. Fat embolism syndrome is associated with multiple traumatic injuries and surgery involving
long bone fractures. Risk factors include all genders between 20 and 30 years of age,
hypovolemic shock, intramedullary instrumentation, rheumatoid arthritis, cemented total hip
arthroplasty, and bilateral total knee surgery. The incidence of fat embolism syndrome in
isolated long bone fractures is 3% to 4%, and mortality associated with this condition is
significant (10% to 20%). (See page 1388: Fat Embolus Syndrome.)
6. In conducting an anesthesia technique for orthopaedic hip surgery, the following
should be taken into consideration:
1. The fracture table offers the advantages of easy maintenance of traction and
radiographic images.
P.276
2. An isobaric intrathecal technique can be used.
3. Using a regional technique can decrease the blood loss during surgery.
4. Calcium channel blockers as well as beta-blockers can be used for deliberate
hypotension.
6. E. Whereas the lateral decubitus position is frequently used to facilitate surgical exposure for
total hip replacement, a fracture table is often used for repair of femur fractures. In transferring
the patient from the supine to lateral decubitus position, care must be taken to maintain the
patient's head and shoulders in a neutral position. The fracture table affords two advantages:
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maintenance of traction on the fractured extremity, allowing manipulation for closed reduction
and fixation, and access to the fracture site for radiography in several planes. The patient must
be carefully monitored for hemodynamic changes during positioning, whether he or she is under
regional or general anesthesia. Regional anesthetic techniques are well suited to procedures
involving the hip. Central neuraxial blockade, including spinal and epidural blockade, is
commonly used. Both hypobaric and isobaric spinal anesthetic solutions are effective. Epidural
blockade also provides excellent surgical anesthesia, allowing for prolonged anesthesia as well
as postoperative analgesia. Regional anesthetic techniques reduce blood loss in patients
undergoing hip surgery. Deliberate hypotension may also be used with general anesthesia as a
means of reducing surgical blood loss. Diltiazem, nitroprusside with and without captopril, beta-
blockers, and nitroglycerin have also been used to induce hypotension. (See page 1383:
Surgery to the Hip.)
7. Which of the following statements regarding procedures for the upper extremity
is/are TRUE&quest;
1. Regional anesthesia may reduce blood loss as well as lower the incidence of
thromboembolism.
2. Prolonged regional block often delays hospital discharge.
3. Venous air embolism is uncommon.
4. Neurpraxia is rare and occurs most commonly after axillary block.
7. B. Regional anesthetics offer several advantages over general anesthetics in patients
undergoing orthopaedic procedures, including improved postoperative analgesia, decreased
incidence of nausea and vomiting, less respiratory and cardiac depression, improved perfusion
via sympathetic block, reduced blood loss, and decreased risk of thromboembolism. Although
prolonged blockade of the lower extremities interferes with ambulation and therefore delays
outpatient discharge, persistent upper extremity block is not a contraindication to hospital
discharge. Theoretically, venous air embolism may occur during surgical procedures to the
shoulder because the operative site is higher than the heart; however, this complication has not
been reported in the literature. Four percent of patients undergoing total shoulder arthroplasty
have a documented postoperative neurologic deficit, including 3% of patients with injury to the
brachial plexus. The level of injury is at the level of the nerve trunks, which is the level at which
an interscalene block is performed, making it impossible to determine the origin of the nerve
injury (surgical vs anesthetic). Most of these nerve injuries represent a neuropraxia; 90% of
them resolve in 3 to 4 months. (See page 1381: Surgery to the Upper Extremities.)
8. Which of the following statements regarding infraclavicular block for surgery at the
elbow is/are TRUE&quest;
1. It should be avoided in outpatients because of the risk of pneumothorax.
2. Patients must have postoperative chest radiography to identify pneumothorax.
3. It is most reliable for surgery below the proximal humerus.
4. A pneumothorax of 10% should be treated with a chest tube.
8. B. Surgical procedures to the distal humerus, elbow, and forearm are commonly performed
using regional anesthetic techniques. Infraclavicular and supraclavicular approaches to the
brachial plexus are the most reliable and provide consistent anesthesia to the four major nerves
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of the brachial plexus: median, ulnar, radial, and musculocutaneous. It does not include the
intercotobrachial nerve, which needs to blocked for procedures at or above the elbow.
However, the small but definite risk of pneumothorax associated with supraclavicular and
infraclavicular blocks makes this approach unsuitable for outpatient procedures. Typically, the
pneumothorax becomes evident 6 to 12 hours after hospital discharge. Therefore,
postoperative chest radiography is not helpful. Although chest tube placement is advised for
pneumothorax greater than 20% of lung volume, the lung may also be re-expanded with a small
Teflon catheter under fluoroscopic guidance, eliminating the need for hospital admission. The
axillary approach to the brachial plexus eliminates the risk of pneumothorax and reliably
provides adequate anesthesia for surgery near the elbow. (See page 1382: Surgery to the
Elbow.)
9. Which of the following statements regarding continuous brachial plexus anesthesia

using an indwelling catheter is/are TRUE&quest;
1. It may reduce postoperative vasospasm after limb replantation.
2. It may be performed using interscalene, infraclavicular, or axillary techniques.
3. It usually produces profound analgesia in the major nerve distributions.
4. There are no long-term benefits with a single injection regional anesthetic technique
compared with a general anesthetic.
9. A. A continuous infusion of local anesthetic solution, such as bupivacaine 0.125%, prevents
vasospasm and increases circulation after limb replantation or vascular repair. More
concentrated solutions of bupivacaine result in complete sensory block and allow early joint
mobilization after painful surgical procedures to the elbow. Brachial plexus catheters may be
inserted using interscalene, infraclavicular, and axillary approaches. However, the axillary
approach is the most common. Overall, there are early but no long-term benefits with the use of
a single injection regional anesthetic technique compared with a general anesthetic. However,
placement of an indwelling perineural catheter results in more substantial and lasting benefits,
including avoidance of hospital admission and readmission, decreased opioid-related side
effects and sleep disturbance, and improved rehabilitation. (See page 1383: Continuous
Brachial Plexus Anesthesia.)
10. Peripheral nerve blocks for surgery on the knee in which a tourniquet will be used
must include which nerve(s)&quest;
1. femoral nerve
2. lateral femoral cutaneous nerve
3. sciatic nerve
4. obturator nerve
10. E. Surgical anesthesia for operative procedures on the knee in which a tourniquet will be
used requires blockade of all four nerves (femoral, lateral femoral cutaneous, obturator, and
sciatic) that innervate the leg. (See page 1384: Total Knee Arthroplasty.)
11. Which of the following statements regarding the use of regional anesthesia for
orthopaedic surgery in children is/are TRUE&quest;
1. It carries the same advantages for adults such as decreased nausea and vomiting and
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decreased time to discharge.
2. Regional techniques are readily adaptable and often underused.
3. Brachial plexus block may be facilitated with a nerve stimulator.
4. Regional techniques are often technically difficult to perform in the pediatric
population.
11. A. Pediatric patients present with a variety of orthopaedic conditions, including congenital
deformities, traumatic injuries, infections, and malignancies. Anesthetic management of
pediatric orthopaedic patients involves not only the usual pediatric patient considerations, such
as airway management, fluid replacement, and maintenance of body temperature, but also the
unique concerns associated with orthopaedic surgery. Often regional anesthetic procedures are
technically easier to perform on children because their relative lack of subcutaneous tissue
facilitates both identification of bony and vascular landmarks and spread of local anesthetic.
The advantages of regional anesthesia in children are similar to those in adults and include
earlier ambulation and hospital discharge, decreased incidence of nausea and vomiting, and
prolonged postoperative analgesia. However, pediatric patients are often not considered
candidates for regional techniques. Neural blockade may be initiated after induction of general
anesthesia and before surgical incision, to provide possible pre-emptive analgesia, or on
completion of the surgical procedure, to extend the duration of postoperative analgesia.
Blockade of the brachial plexus is usually accomplished with perivascular, sheath, or nerve
stimulator techniques in children younger than 7 years of age because elicitation of
paresthesias is regarded as uncomfortable (and therefore unacceptable) by younger pediatric
patients. (See page 1387: Pediatric Orthopaedic Surgery.)
12. Which of the following statements regarding patients with spinal shock is/are
TRUE&quest;
1. They should never receive succinylcholine (Sch) because of the potential for
hyperkalemia.
2. Hyperventilation and resultant hypocarbia can improve blood flow and “protect” an
ischemic spinal cord tissue.
3. Spinal shock is short lived and usually improves within 24 to 48 hours.
4. Spinal shock may mask ongoing hypovolemic shock.
12. D. In spinal shock, hyperventilation should be avoided because hypocarbia decreases
spinal cord blood flow. Spinal shock may persist from a few days to 3 months. It is usually safe
to administer Sch for the first 48 hours. Spinal shock may mask underlying hypovolemic shock.
(See page 1376: Surgery to the Spine.)
13. Which of the following statements regarding a “wake-up test” is/are TRUE&quest;
1. Up to 20% of patients will have recall of the test.
2. Patients who do experience recall frequently describe it as intensely painful.
3. It is an accurate test with very few false-negative results.
4. It can be safely and easily performed.
13. B. If there is satisfactory movement of the hands, but not the feet, during a wakeup test, the
distraction on the rod is released one notch, and the test is repeated. Increasing the blood
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pressure and blood volume may be attempted to increase spinal cord perfusion. Recall of the
event occurs in up to 20% of patients and is rarely viewed as unpleasant. It is important to
describe what will transpire to the patient before surgery so anxiety will be minimized if the
patient is fully awake. The “wake-up test” is associated with few false-negative results; that is,
it is extremely rare for a patient who was neurologically intact when awakened intraoperatively
to have a neurologic deficit upon completion of the procedure. However, certain hazards of the
“wake-up test” do exist and include recall, pain, air embolism, dislocation of spinal
instrumentation, and accidental tracheal extubation or removal of intravenous and arterial lines.
Because the “wake-up test” requires patient cooperation, it may be difficult to perform on young
children and mentally deficient patients. (See page 1379: Spinal Cord Monitoring.)
14. Which of the following statements regarding the use of limb tourniquets is/are
TRUE&quest;
1. The tourniquet overlap should always be placed directly over the neurovascular
bundle to reduce the likelihood of nerve injury.
2. When selecting a tourniquet, the width of an inflated cuff should be greater than 50%
of the limb diameter.
3. Cuff pressure must be maintained at no less than 200 mm Hg more than the patient's
systolic blood pressure.
4. The presence of a tumor is a relative contraindication to the use of a limb tourniquet.
14. C. The cuff should be large enough to circle the limb comfortably to ensure uniform
pressure. The point of overlap should be placed 180 degrees from the neurovascular bundle
because there is some area of decreased compression at the overlap point. The width of the
inflated cuff should be greater than 50% of the limb diameter. Pressure is usually maintained by
compressed gas (air or oxygen) and must be monitored continually while the tourniquet is in
use. Before tourniquet inflation, the limb should be elevated for about 1 minute and tightly
wrapped with an elastic bandage distally to proximally to ensure exsanguination. Limb
tourniquets are relatively contraindicated when infection or a tumor is present. Opinions differ
as to the pressure required in tourniquets to prevent bleeding. Leg tourniquets are often
pressurized more than arm tourniquets on the theory that larger limbs require more pressure
than smaller limbs. In general, a cuff pressure of 100 mm Hg above a patient's measured
systolic pressure is adequate for the thigh, and 50 mm Hg above systolic pressure is adequate
for the arm, with the understanding that if hypertensive episodes occur, the cuff pressure
should be increased. (See page 1387: Tourniquets.)

1. The optimal treatment of a patient with suspected fat embolism syndrome includes
stabilization of long bone fractures.
2. Autonomic hyperreflexia occurs in approximately 20% of patients after recovery from
spinal shock as a consequence of a high spinal cord injury.
3. Nitrous oxide should be discontinued before the use of methyl methacrylate.
4. Reduction of intraoperative blood pressure during total hip arthroplasty resulting from
central neuraxial blockade probably does not reduce blood loss during total hip
arthroplasty.
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15. B. Appropriate treatment of fat embolism syndrome requires early surgical stabilization of
fracture sites, aggressive respiratory support, and reversal of possible aggravating factors (e.g.,
hypovolemia). After recovery from spinal shock, 85% of patients exhibit autonomic hyperreflexia
when there has been complete cord transection above T5. The syndrome is characterized by
severe paroxysmal hypertension with bradycardia, arrhythmias, and cutaneous vasoconstriction
below and vasodilation above the level of the injury. Methyl methacrylate is often injected under
pressure, and it is theorized that air embolism may be one of the causes of hypotension that
may accompany injection of cement; thus, nitrous oxide should be discontinued several minutes
before this point. Multiple studies have demonstrated reduced intraoperative blood loss during
total hip arthroplasty completed under central neuraxial blockade compared with general
anesthesia. (See page 1383: Surgery to the Lower Extremities; page 1377: Autonomic
Hyperreflexia; page 1388: Fat Embolus Syndrome; and page 1389: Methyl Methacrylate.)
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Review of Clinical Anesthesia, 5e [Vishal] 54. Transplant Anesthesia
Chapter 54
Transplant Anesthesia
1. Which of the following statements concerning transplant immunology is

FALSE&quest;
A. Transplant recipients who are not seropositive for cytomegalovirus (CMV) should
receive CMV-negative blood.
B. Interleukin-2 (IL-2) is involved in T-cell activation.
C. Calcineurin enhances transcription of IL-2.
D. The major blood group antigens are not potent transplant antigens.
E. T lymphocytes play a major role in the immune response to a transplanted organ.
1. D. The antigens on the tissue's cell surface induce an immunologic reaction. T lymphocytes
play a primary role in the immune response and allograft destruction. The major blood group
antigens (ABO) are particularly potent transplant antigens. Calcineurin enhances transcription
of T-cell IL-2. “Humanized” antibodies are both directed against a portion of the IL-2 receptor
and work by blocking IL-2–mediated T-cell activation. Because recipients are
immunosuppressed, a diagnosis of occult infection (e.g., tuberculosis) should be excluded. For
the same reason, it is standard to order CMV-negative blood for transfusion for seronegative
recipients. (See page 1398: Immunosuppressive Drugs and page 1400: Renal Transplantation.)
2. Which of the following statements concerning renal transplantation is FALSE&quest;

A. Cadaveric grafts can be safely transplanted after 24 hours of cold ischemia time.
B. Intraoperative administration of insulin likely is effective in diabetic patients with
elevated glucose concentrations during transplantation.
C. Regional anesthesia for kidney transplantation is often contraindicated.
D. Inhaled anesthetic techniques are better at preserving (graft) renal flow than
intravenous techniques.
E. Patients undergoing cadaveric transplants are more prone to pulmonary edema.
2. D. Cadaveric grafts can be safely transplanted after 24 hours of cold ischemia time and up to
36 hours, allowing scheduling of preoperative dialysis. In general, concerns over uremic platelet
dysfunction and residual heparin from preoperative dialysis have limited the use of regional
anesthesia for kidney transplantation. The major anesthetic consideration is maintenance of
renal blood flow. No data are available to determine whether inhaled or intravenous techniques
are better at preserving (graft) renal flow. For patients with diabetes, intraoperative
administration of insulin to normalize blood glucose has not been formally studied for improving
outcome. However, recent studies in patients in intensive care units suggest that outcome is
significantly improved when glucose is tightly controlled. Therefore, optimal management of
glucose (80–110 mg/dL) seems a reasonable anesthetic goal during renal transplantation. (See
page 1400: Renal Transplantation.)
3. Which of the following is not a major anesthetic consideration during liver

transplantation&quest;
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A. Hypothermia
B. Hypovolemia
C. Hypocalcemia
D. Metabolic alkalosis
E. Reperfusion syndrome
3. D. Loss of ascitic fluid and persistent bleeding may lead to hypovolemia and associated
oliguria during liver transplantation. Metabolic acidosis may result from poor perfusion; it tends
to persist in the absence of hepatic metabolic function. Rapid blood replacement may cause
citrate-induced hypocalcemia. Preparation of fluid-warming units, gas circuit humidifiers,
warming blankets, and nonconductive wraps for the head and extremities is essential for
optimal preservation of normothermia. Sodium bicarbonate and calcium are given just before
unclamping to counteract the effects of potassium on the heart. The original descriptions of
reperfusion syndrome emphasized (often severe) hypotension and bradycardia with portal
reperfusion. (See page 1401: Liver Transplantation.)
4. Which of the following statements concerning organ transplantation in children is

FALSE&quest;
A. Children are susceptible to lymphoproliferative malignancy as a consequence of
immunosuppressive therapy.
B. Children have a lower rate of successful renal transplantation than adults.
C. Small children receiving large grafts may have respiratory compromise with abdominal
closure.
D. Hyperacute rejection does not occur because of the immaturity of the immune system
and the absence of antibodies to various antigens.
E. ABO-incompatible transplantation is contraindicated in the pediatric population.
4. E. Immunosuppressed children, as well as adults, are susceptible to lymphoproliferative
malignancies. Although ABO-incompatible transplantation is contraindicated in the adult
population, it is more successful in pediatric recipients. Hyperacute rejection does not occur
because of the immaturity of the immune system and the absence of antibodies to various
antigens, including blood group antigens. Pediatric renal transplantation is associated with
somewhat lower rates of success than adult transplantation, with vascular thromboses of the
grafts more common in young children. Small children receiving large grafts may have
respiratory compromise with abdominal closure. (See page 1398: Immunosuppressive Drugs
and page 1400: Renal Transplantation.)
5. The maximum tolerable cold ischemia time for a kidney that is being transported for
transplantation is ________ hour(s).
A. 1
B. 3
C. 12
D. 36
E. 60
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5. D. A cadaver allograft may be transplanted semielectively because the tolerable ischemic

time for kidneys is up to 36 hours. (See page 1400: Renal Transplantation: Preoperative
Considerations.)
6. Which of the following is not a contraindication for a heart transplant&quest;

A. Significant atherosclerosis
B. Intrinsic renal disease
C. Forced expiratory volume in 1 second (FEV1) below 50%
D. Severe, irreversible pulmonary hypertension
E. Ischemic cardiomyopathy
6. E. Pulmonary hypertension is associated with increased perioperative mortality, so severe,
irreversible pulmonary hypertension is a contraindication to cardiac transplantation. Other
contraindications to cardiac transplantation include significant noncardiac diseases. Because
immunosuppressive agents have renal and hepatic side effects, the presence of intrinsic renal
or hepatic disease increases the perioperative risk of organ dysfunction or failure. Patients with
FEV1 below 50% predicted despite optimal management of congestive heart failure are at
increased risk for ventilatory failure and respiratory infections after the transplant procedure.
The presence of significant atherosclerosis is a contraindication because of the increased
perioperative morbidity and mortality of atheroembolic phenomena. The most common
diagnoses leading to cardiac transplantation are ischemic and idiopathic dilated
cardiomyopathies. (See page 1409: Heart Transplantation.)
7. Which of the following statements concerning lung transplantation is TRUE&quest;

A. Diabetes and hypertension are contraindications to lung transplantation.
B. The age limit for single lung transplantation is 55 years.
C. Left-side endobronchial double-lumen tubes are typically preferred for right as well as
left transplants.
D. Patients are not screened for malignancy.
E. Hepatitis B and hepatitis C are not contraindications to lung transplantation.
7. C. Because the right upper lobe bronchial orifice is relatively close to the origin of the main
bronchus, left-sided endobronchial double-lumen tubes have been recommended for both right
and left single-lung transplants, as well as for the bilateral operation. As for other transplants,
patients are screened for malignancy (e.g., mammography, Pap test, colonoscopy). Systemic
disease processes such as diabetes and hypertension are not considered contraindications as
long as they are clinically stable and medically optimized. Absolute contraindications are
significant dysfunction of other organs, human immunodeficiency virus (HIV) infection, chronic
hepatitis B or C, and malignancy (other than basal cell or squamous cell skin carcinoma).
Recommended age limits are as follows: heart–lung transplant, 55 years; double-lung
transplant, 60 years; and single-lung transplant, 65 years. (See page 1406: Lung
Transplantation.)
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8. Which of the following statements concerning glucocorticoids is/are TRUE&quest;
1. They produce glucose intolerance.
2. They may cause hypertension.
3. They may cause weight gain.
4. They facilitate cytotoxic T-cell expression.
8. A. Corticosteroids disrupt the expression of many cytokines in T cells, antigen-presenting
cells, and macrophages. Well-known side effects are hypertension, diabetes, hyperlipidemia,
weight gain (including Cushingoid features), and gastrointestinal ulceration. (See page 1399:
Calcineurin Inhibitors.)
9. Which of the following statements concerning azathioprine is/are TRUE&quest;

1. Cardiac arrest and upper airway edema have been reported complications.
2. Pancytopenia is a side effect.
3. The S phase of the cell cycle is affected.
4. The M phase of the cell cycle is affected.
9. A. Azathioprine is hydrolyzed in blood to 6-mercap-topurine, a purine analog and metabolite
with the ability to incorporate into DNA during the S phase of the cell cycle. Because DNA
synthesis is a necessary prerequisite to mitosis, azathioprine exerts an antiproliferative effect.
Azathioprine's major side effect is repression of bone marrow cell cycling, which may cause
pancytopenia. Cardiac arrest and severe upper airway edema are rare complications. The
intravenous dose is about half the oral dose. (See page 1399: Azathioprine.)
10. Which of the following statements concerning cyclosporine is/are TRUE&quest;

1. It may exacerbate risk factors for coronary artery disease.
2. It is nephrotoxic.
3. It may cause hypertension.
4. It may induce ischemic vascular disease.
10. E. Complications of cyclosporine use include hypertension (often requiring therapy),
hyperlipidemia, ischemic vascular disease (including in heart recipients), diabetes, and
nephrotoxicity. Ischemic cardiac disease is the leading cause of death in kidney transplant
recipients, partly because of the underlying disease that preceded transplantation, but the use
of calcineurin inhibitors may exacerbate risk factors for coronary artery disease. (See page
1399: Calcineurin Inhibitors.)
11. Which of the following statements concerning monoclonal and polyclonal

antibodies is/are TRUE&quest;
1. OKT3 antibody does not affect T cells.
2. OKT3 may cause generalized weakness, fever, chills, and hypotension.
3. Antilymphocyte globulin administration is not specific for lymphocytes.
4. They contain human constant regions in the immunoglobulin.
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11. C. Antilymphocyte globulin is a polyclonal antibody that seems to diminish the availability of
activated T lymphocytes and T-cell proliferation. OKT3 antibody is directed against a
component of the T-cell receptor complex and affects immunosuppression by blocking T-cell
function. Acute administration of OKT3 in awake patients (especially in the first administration)
may result in generalized weakness, fever, chills, and some hypotension. More severe
hypotension, bronchospasm, and pulmonary edema have also been reported. (See page 1398:
Immunosuppressive Drugs.)
12. Which of the following statements concerning the recipient during renal
transplantation is/are TRUE&quest;
1. After the first anastomosis is started, diuresis is initiated with mannitol and furosemide.
2. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used in renal transplant
recipients.
3. Recipient iliac artery and vein are usually used for graft vascularization.
4. The donor should be kept relatively volume depleted to minimize the kidney's work of
filtration.
12. B. The recipient iliac artery and vein are used for renal graft vascularization. After the first
anastomosis is started, a diuresis is initiated (mannitol and furosemide are often both given).
The major anesthetic consideration is maintenance of renal blood flow. No data are available to
determine whether inhaled or intravenous techniques are better at preserving (graft) renal flow.
Therefore, typical hemodynamic goals during transplantation are systolic pressure above 90
mm Hg, mean systemic pressure above 60 mm Hg, and central venous pressure above 10 mm
Hg. These goals are usually achieved without use of vasopressors by using isotonic fluids and
adjusting anesthetic doses. The donor volume should be maintained. It is recommended that
NSAIDs be avoided in renal transplant recipients. (See page 1400: Renal Transplantation.)
13. Which of the following statements accurately describe the anhepatic stage of
orthotopic liver transplantation&quest;
1. Venovenous bypass from the portal and femoral veins to the axillary vein may be
instituted to minimize intra-abdominal venous congestion.
2. Most patients can be managed without venovenous bypass.
3. Venovenous bypass improves venous return.
4. Venous return decreases by 50% to 60% with complete caval clamping.
13. E. During the anhepatic stage, many centers use venovenous bypass from the portal and
femoral veins extracorporeally to the axillary vein. This helps to avoid drastic decreases in
venous return and relieves venous congestion in the lower body, bowel, and kidneys. With
complete vena cava cross-clamp, venous return decreases by 50% to 60%, often resulting in
hypotension. Most patients can be managed without venovenous bypass by using some volume
loading. (See page 1401: Liver Transplantation.)
14. Which of the following may be seen upon unclamping the new liver after vascular
anastomosis&quest;
1. Hypotension
2. Bradycardia
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3. T-wave elevation
4. Ventricular arrhythmias
14. E. The original descriptions of reperfusion syndrome emphasized (often severe)
hypotension and bradycardia with portal reperfusion. Now with flushing techniques that
precede reperfusion and changes in preservation solution, bradycardia is uncommon. Typically,
reperfusion is associated with hypotension (a further decrease of already low systemic vascular
resistance and increase in cardiac output), which may or may not require treatment. Portal
unclamping may result in an increase in serum potassium. T waves may become elevated after
unclamping. Ventricular arrhythmias, bradyarrhythmias, and severe hypotension may also
occur. (See page 1401: Liver Transplantation.)
15. Which of the following may be effective therapy for the patient with severe,
irreversible pulmonary hypertension&quest;
1. Heterotopic heart transplant
2. Orthotopic heart transplant
3. Heart–lung transplant
4. Left ventricular assist device (LVAD)
15. D. Pulmonary hypertension is associated with increased perioperative mortality. Although
reversible pulmonary hypertension may be an indication for transplantation, severe, irreversible
pulmonary hypertension is a contraindication to transplantation. Patients with irreversible
pulmonary hypertension may be candidates for LVAD insertion as definitive therapy or as a
bridge to transplantation. Totally implantable artificial hearts are not currently used because of
technical issues. Heterotopic heart transplantation has been virtually abandoned. Bilateral
sequential lung transplant has largely replaced heart–lung transplantation combined with
advances in the pharmacologic management of pulmonary hypertension and right ventricular
failure. (See page 1409: Heart Transplantation and page 1409: Heart–Lung Transplant.)
16. Which of the following statements concerning heart transplantation is/are

TRUE&quest;
1. The pulmonary artery catheter is withdrawn from the surgical field before caval
cannulation.
2. In the classic approach to transplantation, none of the native heart remains.
3. Isoproterenol is frequently used to increase graft heart rate.
4. Prostacyclin infusion is often indicated to selectively decrease systemic vascular
resistance.
16. B. During heart transplantation, a long, sterile sheath should cover the pulmonary artery
catheter so it may be pulled back before caval cannulation. The recipient heart is excised,
except for the left atrial tissue encompassing the pulmonary veins. In the classic approach, the
atria are transected at the grooves. Isoproterenol is used frequently to increase heart rate
because of its direct effects on cardiac β -receptors. Use of temporary epicardial pacing is
sometimes needed until isoproterenol has had adequate time to reach maximal effect. Therapy
for graft right-sided heart failure is similar to therapy for right-sided heart failure in other cardiac
cases. The goals are to improve contractility and decrease pulmonary vascular resistance. If
intravenous agents are not adequate to wean the patient from cardiopulmonary bypass, inhaled
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nitric oxide and inhaled prostacyclin (Iloprost) have been shown to be beneficial in this
population. (See page 1409: Heart Transplantation.)
17. Which of the following statements about patients after cardiac transplantation is/are
TRUE&quest;
1. The transplanted heart is able to compensate in a reflex manner for hemodynamic
changes induced by neuraxial anesthesia.
2. Isoproterenol is the mainstay of chronotropic therapy in these patients.
3. The α effects of epinephrine and norepinephrine are exaggerated in heart transplant
recipients.
4. The transplanted heart is relatively resistant to indirect-acting agents such as
ephedrine.
17. C. The transplanted heart cannot respond to indirect-acting agents, such as ephedrine, or
to peripheral interventions that induce hemodynamic changes, such as carotid massage, the
Valsalva maneuver, or laryngoscopy. β effects (not α effects) of epinephrine and norepinephrine
are exaggerated in heart transplant recipients. Isoproterenol is the mainstay of chronotropic
therapy in these patients. The denervated heart does not compensate in reflex fashion for
hemodynamic changes induced by regional anesthetics. (See page 1413: Management of
Transplant Patients for Nontransplant Surgery and page 1409: Heart Transplantation.)
18. Which of the following statements concerning electrical conduction and autonomic
sensitivity in the heart after transplantation is/are TRUE&quest;
1. The basal rate of the donor atria tends to be less than that of the native atria.
2. Digoxin does not increase the refractory period of the atrioventricular (AV) node.
3. Denervation results in significant slowing of resting ventricular conduction.
4. Atropine has minimal effect on heart rate.
18. C. The electrocardiogram of the heart after transplantation may contain both donor and
native P waves. Because the sinus node is normally under continual vagal influence, the rate of
the native atria tends to be less than that of the donor atria, especially with parasympathetic
activation (e.g., visceral traction). In contrast to effects on the sinuatrial node, denervation
generally does not alter the AV nodal conduction time or affect ventricular conduction. Drugs
that act indirectly on the heart fail to produce their typical effects after denervation. Atropine is
not vagolytic in the denervated heart. Digoxin still causes its direct inotropic effect but does not
increase the refractory period of the AV node because this effect of digoxin is mediated vagally.
(See page 1413: Management of Transplant Patients for Nontransplant Surgery.)
19. Which of the following statements about heart–lung and lung transplant is/are
TRUE&quest;
1. Hepatitis B and hepatitis C are absolute contraindications for lung transplantation.
P.282
2. Single-lung transplantations may be performed without cardiopulmonary bypass
(CPB).
3. During one-lung ventilation, clamping of the nondependent pulmonary artery may
improve oxygenation.
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4. Heart–lung transplantation is not effective for patients with Eisenmenger syndrome.

19. A. Primary pulmonary hypertension and pulmonary hypertension associated with
Eisenmenger syndrome are the most common indications for heart–lung transplant. (However,
severe, irreversible pulmonary hypertension is a contraindication to transplantation.) CPB is
indicated during lung transplantation if adequate oxygenation cannot be maintained despite
ventilatory and pharmacologic maneuvers or pulmonary artery clamping by the surgeon. The
inability to ventilate and the development of right ventricular dysfunction are also indications for
CPB. Absolute contraindications are significant dysfunction of other organs, HIV infection,
chronic hepatitis B or C, and malignancy (other than basal cell or squamous cell skin
carcinoma). (See page 1409: Heart–Lung Transplant [Adult and Pediatric] and page 1406: Lung
Transplantation.)
20. Which of the following is/are likely to be required during the anhepatic stage of
liver transplantation&quest;
1. Positive end-expiratory pressure (PEEP)
2. Insulin
3. Calcium
4. Potassium
20. A. During the anhepatic stage, the need for vigorous retraction under the diaphragm often
worsens hypoxemia; PEEP may be helpful. Citrate intoxication as a result of rapid infusion may
necessitate the need to administer calcium. Hyperkalemia may require treatment with insulin.
(See page 1401: Liver Transplantation.)
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Review of Clinical Anesthesia, 5e [Vishal] 55. Post Anesthesia Recovery
Chapter 55
Post Anesthesia Recovery
1. The greatest postanesthesia care unit (PACU) cost is for:

A. disposable items
B. antiemetics
C. routine diagnostic testing
D. staffing
E. respiratory therapy
1. D. The greatest PACU cost is for staffing. The mix of nursing staff (e.g., amount of training,
experience, salaries, and benefit levels), the number of patients per caregiver, and the duration
of PACU stay all determine an overall personnel cost per admission. Routine postoperative
diagnostic testing increases costs for securing and processing tests, as well as for professional
interpretation. Use of routine therapies such as oxygen, antiemetic therapy, and respiratory
therapy increases the expenditure per patient for drugs and disposable items and may add to
the staffing resources required per patient. (See page 1422: Value and Economics of the
Postanesthesia Care Unit.)
2. Postoperative patient triage decisions should be based on:

A. ambulatory versus inpatient status
B. potential for postoperative complications
C. age
D. American Society of Anesthesiologists (ASA) classification
E. insurance coverage
2. B. Patients must be carefully evaluated to determine which level of postoperative care is
most appropriate. Triage should be based on clinical condition and the potential for
complications that require intervention. Alternatives to postanesthesia care unit (PACU) care
must be used in a nondiscriminatory fashion. Triage should not be based on age, ASA
classification, ambulatory versus inpatient status, or type of insurance. A wide margin of safety
and applicable PACU standards should be preserved when appropriate. (See page 1422:
Postanesthesia Therapy.)
3. Disadvantages of intramuscular opioid administration (compared with intravenous

administration) include all of the following EXCEPT:
A. unpredictable uptake
B. larger dose requirements
C. shortened onset
D. pain on administration
E. risk of hematoma formation
3. C. Disadvantages of the intramuscular route include larger dose requirements, delayed
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onset, and unpredictable uptake in hypothermic patients. The risk of hematoma formation is
another consideration in anticoagulated patients. (See page 1424: Postoperative Pain
Management.)
4. Which of the following statements regarding epidural opioid analgesia is

FALSE&quest;
A. Serotonin antagonists may be used to treat side effects.
B. It may improve outcome after urologic procedures.
C. The addition of clonidine enhances analgesia.
D. It is a useful technique for controlling pain after gastroplasty surgery.
E. Delayed respiratory depression results from vascular uptake.
4. E. Epidural opioid analgesia is effective after thoracic and abdominal procedures. It helps to
wean patients with obesity or chronic obstructive pulmonary disease from mechanical
ventilation. Immediate and delayed ventilatory depression may occur related to vascular uptake
and cephalad spread in cerebrospinal fluid, respectively. Nausea and pruritus are troubling side
effects. Whereas nausea resolves with antiemetics, pruritus often responds to naloxone
infusion. Epidural analgesia may also improve surgical outcomes after orthopaedic and urologic
procedures. Addition of local anesthetic or clonidine enhances analgesia and decreases the
risk of side effects from epidural opioids. (See page 1424: Postoperative Pain Management.)
5. Which statement regarding hypoxemia in the postanesthesia care unit (PACU) is

TRUE&quest;
A. Hypoxemia rarely occurs after regional anesthesia.
B. Children with adenotonsillar hypotrophy are at risk for hypoxemia.
C. The incidence of hypoxemia in postoperative patients breathing room air in the PACU
is low.
D. The cost of providing supplemental oxygen is prohibitive.
E. The use of oxygen prevents hypoxemia.
5. B. The incidence of hypoxemia in postoperative patients is high. In one study of PACU
patients placed on room air, 30% of patients younger than 1 year old, 20% of those 1 to 3 years
old, 14% of those 3 to 14 years old, and 7.8% of adults had their hemoglobin saturations
decrease to below 90%. Perioperative hypoxemia occurs more frequently in children with
respiratory infections or chronic adenotonsillar hypertrophy. Hypoxemia occurs frequently after
regional anesthesia. Use of oxygen neither consistently prevents hypoxemia nor addresses
underlying causes. The cost of supplemental oxygen is minimal, the inconvenience to patients
is minor, and the overall risk is small. (See page 1433: Supplemental Oxygen.)
6. Which of the following is not a cause of hyponatremia&quest;

A. Intravenous administration of excess free water
B. Use of sodium-free irrigating solutions
C. Excess use of salt-wasting diuretics such as furosemide
D. Syndrome of inappropriate antidiuretic hormone secretion
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E. Prolonged attempts of induction of labor with oxytocin
6. C. Postoperative hyponatremia occurs when excess free water is infused during surgery or
sodium-free irrigating solution is absorbed by prostatic sinuses during transurethral prostate
resection. Free-water retention may also be caused by inappropriate antidiuretic hormone
secretion or prolonged induction of labor with oxytocin. Therapy for hyponatremia includes
administration of normal saline and intravenous furosemide to promote renal wasting of free
water in excess of sodium. (See page 1436: Hyponatremia.)
7. Which statement regarding adjuncts used for postoperative analgesia is

TRUE&quest;
A. Rofecoxib administration provides a secondary cardioprotective benefit.
B. Ketorolac administration may decrease cardiac ischemic events.
C. Ibuprofen and acetaminophen are ineffective when they are administered orally before
surgery.
D. Agonist–antagonist analgesics are the best adjuncts to supplement analgesia.
E. The use of clonidine is limited by bradycardia.
7. B. Perioperative oral or intravenous administration of cyclo-oxygenase-2 (COX-2) inhibitors
offers promising adjuvant therapy to augment postoperative analgesia. Unfortunately, recent
concerns about negative cardiac side effects of these agents led to the withdrawal of rofecoxib
and clouded the overall appropriateness of this approach. Ibuprofen and acetaminophen are
effective when administered orally before surgery. The antiplatelet properties of ketorolac may
decrease cardiac ischemic events in patients with coronary artery disease. Agonist–antagonist
analgesics offer little advantage. The use of clonidine to supplement analgesia is effective but
may be limited by hypotension. (See page 1423: Admission to the Postanesthesia Care Unit.)
8. Which of the following statements regarding postoperative pain control in the

postanesthesia care unit (PACU) is TRUE&quest;
A. Intravenous opioid loading is unnecessary before starting intravenous patient-
controlled analgesia (PCA).
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B. Addition of clonidine to epidural infusions reduces the side effects of epidural opioids.
C. Epidural analgesia always improves surgical outcomes.
D. The use of intrawound continuous-flow catheters increases the length of hospital
stay.
E. Alternative modalities such as hypnosis or transcutaneous nerve stimulation are very
effective in controlling surgical pain.
8. B. Intravenous opioid loading in the PACU is important for a smooth transition to intravenous
PCA. Addition of local anesthetic or clonidine enhances analgesia and decreases the risk of
side effects from epidural opioids, although local anesthetics add risk of hypotension or motor
blockage. Whether epidural analgesia improves surgical outcomes is debatable. Continuous-
flow catheters with pressure delivery systems of local anesthetics have been used intrawound
to reduce pain and opioid requirements, increase patient satisfaction, and reduce the length of
hospital stay. Modalities such as guided imagery, hypnosis, transcutaneous nerve stimulation,
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music, massage, and acupuncture have limited utility for controlling surgical pain. (See page
1424: Postoperative Pain Management.)
9. The most common sign of myocardial ischemia in the postanesthesia care unit
(PACU) is:
A. ST-T wave changes on the electrocardiogram (ECG) or monitor.
B. Diaphoresis
C. Angina
D. Dyspnea
E. Tachycardia
9. E. In the PACU, it is a rare event for a patient to complain de novo of chest pain. The most
common sign of myocardial ischemia is tachycardia. Tachycardia is often a reaction to, not
necessarily the cause of, myocardial ischemia. The ECG may show classic ST-T wave
elevation or depression depending on lead placement and the area of ischemia. But the lack of
ST-T wave elevation does not rule out coronary artery disease. (See page 1426:
Cardiovascular Complications.)
10. Patients with obstructive sleep apnea (OSA) should be monitored with pulse
oximetry until the oxygen saturation remains above ____________ on room air while
sleeping.
A. 85%
B. 90%
C. 92%
D. 95%
E. 99%
10. B. In May 2003, the American Society of Anesthesiologists (ASA) Task Force on
Perioperative Management of Patients with Obstructive Sleep Apnea issued guidelines based
on the ASA scoring system for OSA and classifying patients as having mild, moderate, or severe
OSA based on the apnea–hypopnea index. Patients who use continuous positive airway
pressure or noninvasive positive-pressure ventilation should continue to use these therapies.
Regarding monitoring, there is agreement among the Task Force consultants that pulse
oximetry should be used until the patient's oxygen saturation remains above 90% on room air
while sleeping. The use of telemetry for monitoring pulse oximetry, electrocardiography, or
ventilation may be beneficial in reducing adverse postoperative events and should be used on a
patient need basis. (See page 1432: Obstructive Sleep Apnea.)
11. According to the American Society of Anesthesiologists (ASA) and the Cardiac
Anesthesia/Surgery Societies, patients who are not bleeding, are stable, and are
euvolemic can tolerate a hemoglobin as low as:
A. 6.0 g/dL
B. 7.0 g/dL
C. 8.0 g/dL
D. 9.0 g/dL
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E. 10.0 g/dL
11. A. Recent works from the ASA and the cardiac anesthesia and surgery societies (Society of
Thoracic Surgeons and Society of Cardiovascular Anesthesiologists) have published guidelines
for transfusion and blood management. It is now well accepted that patients who are stable, not
bleeding, and euvolemic can tolerate a hemoglobin of 6.0 g/dL. (See page 1433: Anemia.)
12. Which of the following is/are not risk factor(s) for postoperative apnea in preterm
infants&quest;
1. Preoperative hematocrit
2. Type of anesthetic
3. Postconceptual age
4. Weight
12. D. The risk for apnea after anesthesia in preterm infants depends on the type of anesthetic,
postconceptual age, and preoperative hematocrit. (See page 1428: Inadequate Respiratory
Drive.)
13. Laryngospasm that occurs during emergence can be overcome by:

1. applying positive pressure by mask
2. deepening sedation with propofol
3. 0.1 mg/kg of intravenous succinylcholine
4. intramuscular ketamine
13. A. During emergence, stimulation of the pharynx or vocal cords by secretions, blood, foreign
matter, or extubation may precipitate laryngospasm. The laryngeal constrictor muscles occlude
the tracheal inlet and reduce gas flow. Patients are at higher risk if they smoke or are
chronically exposed to smoke have irritable airway conditions, have copious secretions, or have
undergone upper airway surgery. Laryngospasm can usually be overcome by providing gentle
positive pressure (10–20 mm Hg) in the oropharynx with 100% oxygen. Prolonged
laryngospasm is relieved with a small dose of succinylcholine (e.g., 0.1 mg/kg) or deepening
sedation with propofol. (See page 1428: Increased Airway Resistance.)
14. The level of postoperative care a patient requires is determined by:

1. underlying illness
2. duration and complexity of anesthesia and surgery
3. risk of postoperative complications
4. the inhalation anesthetic used
14. A. For both ambulatory and inpatient surgery, the level of postoperative care a patient
requires is determined by the degree of the underlying illness, the duration and complexity of
the anesthesia and surgery, and the risk of postoperative complications. Using a less intensive
postanesthesia setting for selected patients may reduce the cost of the surgical procedure and
may allow the facility to divert scarce postanesthesia care unit resources to patients with
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greater needs. (See page 1423: Levels of Postanesthetic Care.)
15. Upon arrival in the postanesthesia care unit (PACU), each patient assessment
should include:
1. heart rhythm
2. temperature
3. ventilatory rate
4. blood pressure
15. E. Every patient admitted to a PACU should have heart rate and rhythm, systemic blood
pressure, and ventilatory rate recorded. Assessment every 5 minutes for the first 15 minutes
and every 15 thereafter is a prudent minimum. Temperature should be documented at least on
admission and discharge, along with the level of consciousness, airway patency, and skin color.
(See page 1423: Admission to the Postanesthesia Care Unit.)
16. Which of the following statements concerning postoperative pain management

is/are TRUE&quest;
1. Appropriate postoperative pain management helps control hypertension and
tachycardia.
2. A tachycardic patient with low blood pressure should be treated aggressively with
opioids.
3. Sufficient analgesia is the desired endpoint, even if large doses of opioids are
necessary.
4. Agonist–antagonist analgesics are of significant value in treating patients with opioid
tolerance.
16. B. Relief of surgical pain with minimal side effects is a primary goal of PACU care.
Improving patient comfort and relief of pain reduces sympathetic nervous system response,
helping to control postoperative hypertension and tachycardia. Analgesics may precipitate
hypotension in hypovolemic patients who rely on sympathetic activity for cardiovascular
homeostasis such as tachycardic patients with normal or low blood pressure. Sufficient
analgesia is the desired clinical endpoint for all patients, even if large doses of opioids are
necessary. Agonist–antagonist analgesics are thought to offer little advantage over regular
opioids in those with opioid tolerance. (See page 1424: Postoperative Pain Management.)
17. Discharge criteria for the postanesthesia care unit (PACU) include:
1. observation for at least 60 minutes after the last intravenous opioid is administered
2. achieving of normal body temperature
3. monitoring of oxygen saturation for 45 minutes after discontinuation of supplemental
oxygen
4. the presence of airway reflexes to prevent aspiration
17. D. Before discharge from the PACU, each patient should be sufficiently oriented to assess
his or her physical condition and to summon assistance upon discharge. Airway reflexes and
motor function must be adequate to prevent aspiration. Blood pressure, heart rate, and indices
of peripheral perfusion should be relatively constant for at least 15 minutes. Achieving normal
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body temperature is not an absolute requirement. Patients should be observed for at least 15
minutes after the last intravenous opioid or sedative is administered. Oxygen saturation should
be monitored for 15 minutes after discontinuation of supplemental oxygen to detect hypoxemia.
(See page 1426: Discharge Criteria.)
18. Which of the following statements concerning upper airway edema is/are
TRUE&quest;
1. It often leads to complete obstruction of the airway.
2. It may necessitate emergency endotracheal intubation.
3. It should be treated with emergency jet ventilation as soon as possible.
4. It may be exacerbated by laryngoscopy.
18. C. Acute extrinsic upper airway compression must be relieved if possible. If the obstruction
is fixed, emergency tracheal intubation may become necessary. However, airway manipulation
is fraught with danger. Even minor trauma from intubation attempts may convert a partially
obstructed airway into a totally obstructed airway. Complete obstruction from airway edema is
rare. Edema is often resolved by nebulized racemic epinephrine. Small doses of corticosteroid
have also been effective. An acute airway emergency may be precipitated if tracheal intubation
or face mask ventilation cannot be accomplished. In these cases, cricothyroidotomy and
emergency jet ventilation are the treatments of choice. However, these should be attempted
after endotracheal intubation has failed. (See page 1428: Increased Airway Resistance.)
19. Which of the following can be used to treat postoperative wheezing&quest;

1. Aeresolized epinephrine
2. Intramuscular terbutaline
3. Ipratropium bromide
4. Intravenous epinephrine infusion
19. E. The treatment of small airway resistance is directed at the underlying cause. Patients
often respond well to their existing regimens of albuterol or other inhalers. Intramuscular or
sublingual terbutaline may be added. If ventilation is still compromised or is unduly labored, an
aminophylline loading dose and maintenance infusion may be administered. Bronchospasm
resistant to β -sympathomimetic medication may improve with an anticholinergic medication
such as atropine or ipratropium. If bronchospasm is life threatening, an intravenous epinephrine
infusion usually yields profound bronchodilation. (See page 1428: Increased Airway
Resistance.)
20. Which medications(s) is/are known to potentiate neuromuscular relaxation&quest;

1. Diltiazem (Cardizem)
2. Intravenous phenytoin (Dilantin)
3. Digoxin
4. Furosemide
20. C. Medications that potentiate neuromuscular relaxation include some antibiotics,
furosemide, propranolol, and acutely administered (intravenous) phenytoin. Conversely, long-
term phenytoin use increases the dose requirements for nondepolarizing neuromuscular
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blocking agents. (See page 1430: Neuromuscular and Skeletal Problems.)
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21. Which of the following tests reliably predict recovery of airway protective
reflexes&quest;
1. A negative inspiratory pressure of 25 cm H 2O or less
2. Sustained head lift for 10 seconds
3. Return of train-of-four (TOF) response to preoperative levels
4. None of the above
21. D. A forced vital capacity of 10 to 12 mL/kg and an inspiratory pressure of 25 cm H 2O or
less imply that the strength of ventilatory muscles is adequate to sustain ventilation. The ability
to sustain head elevation in a supine position is a rough index of muscular recovery. Tactile
TOF assessment accurately assesses the patient's ability to ventilate. However, none of these
clinical endpoints reliably predicts recovery of the airway protective reflexes. (See page 1430:
Neuromuscular and Skeletal Problems.)
22. Pulmonary dead space increases with:

1. pulmonary embolism
2. endotracheal intubation
3. pulmonary hypotension
4. pneumothorax
22. B. Any decrease in pulmonary blood flow, as would be caused by pulmonary embolism or
pulmonary hypotension, causes an increase in physiologic dead space. Upper airway dead
space (anatomic dead space) has been shown to be reduced by approximately 75% after
endotracheal intubation and almost eliminated by tracheostomy. Pneumothorax is a cause of
shunt and does not affect dead space. (See page 1430: Increased Dead Space).
23. Increased CO2 production in the postanesthesia care unit (PACU) may be caused
by:
1. shivering
2. infection
3. malignant hyperthermia
4. hyperalimentation
23. E. In the PACU, metabolic rate and CO2 production may increase by as much as 40%.
Shivering, high work of breathing, infection, sympathetic nervous system activity, and rapid
carbohydrate metabolism during intravenous hyperalimentation also accelerate CO2
production. Malignant hyperthermia generates CO2 production many times greater than normal.
(See page 1430: Increased Carbon Dioxide Production.)
24. Which of the following usually are effective treatments for postoperative
hypoxemia&quest;
1. Incentive spirometry
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2. Intermittent positive-pressure breathing techniques
3. Continuous positive airway pressure (CPAP) by mask
4. Endotracheal intubation without CPAP
24. B. In the PACU, conservative measures to improve lung volume often produce lasting
improvements in oxygenation. Incentive spirometry and mask CPAP both increase functional
residual capacity and improve ventilation–perfusion matching, resulting in improved
oxygenation. Intermittent positive-pressure breathing techniques are probably not effective.
Endotracheal intubation without CPAP results in a progressive reduction of functional residual
capacity and ventilation–perfusion mismatching that may actually worsen arterial hypoxemia.
(See page 1431: Distribution of Ventilation.)
25. Which of the following can worsen ventilation–perfusion matching&quest;

1. An increase in pulmonary artery pressure
2. A decrease in pulmonary artery pressure
3. Impaired hypoxic pulmonary vasoconstrictive reflex
4. An increase in the percentage of inspired oxygen
25. E. Increased pulmonary artery pressure may interfere with ventilation–perfusion matching
by increasing blood flow to less dependent (and less ventilated) portions of the lung as well as
by increasing flow through the bronchial circulation and pulmonary arterial venous
anastomoses. Reduction in pulmonary artery pressures may also change ventilation–perfusion
matching by compromising perfusion to the nondependent lung. Inhalation anesthetics,
nitroprusside, and other medications impair hypoxic pulmonary vasoconstriction; this partially
explains the increase in the alveolar–arterial oxygen gradient associated with general
anesthetics. The effects of anesthetics on hypoxic pulmonary vasoconstriction persist into the
recovery period. An increased inspired O2 fraction may interfere with ventilation–perfusion
matching in patients with acute lung disease, perhaps resulting from interference with hypoxic
pulmonary vasoconstriction or promotion of reabsorption atelectasis. (See page 1431:
Distribution of Perfusion.)
26. Aspiration of gastric contents:

1. typically results in bacterial tracheal bronchitis
2. may rapidly progress to acute respiratory distress syndrome (ARDS) and pulmonary
edema
3. is much more likely to occur in elderly patients, even if they have no coexisting
disease
4. often causes an increase in pulmonary dead space
26. C. Aspiration of gastric contents during vomiting or regurgitation causes chemical
pneumonitis that is characterized initially by diffuse bronchospasm, hypoxemia, and atelectasis.
This may rapidly progress to ARDS and pulmonary edema. Occlusion or destruction of the
pulmonary microvasculature is often evident, resulting in increased pulmonary vascular
resistance and increased dead space. Bacterial infection rarely results. Advancing age, in the
absence of coexisting disease, is not a risk factor for aspiration. (See page 1433: Perioperative
Aspiration.)
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27. Patients who aspirate a large amount of gastric contents:

1. should be intubated and undergo suctioning before the administration of positive-
pressure ventilation
2. should have tracheal pH ascertained and bicarbonate solutions instilled to increase
the pH in the trachea to above 7.4
3. should be observed for 24 to 48 hours with serial temperature, white blood cell count,
chest radiography, and arterial blood gas (ABG) measurements
4. should receive prophylactic antibiotics
27. B. Patients who aspirate a large amount of gastric contents should be observed for 24 to 48
hours for the development of aspiration pneumonitis. Observation includes serial temperature
checks, white blood cell counts with differential, chest radiography, and ABG determinations.
Fluffy infiltrates may appear on the chest radiograph within 24 hours of the event. If a large
aspiration has occurred, the trachea should be intubated, and suctioning should be performed
before institution of positive-pressure ventilation (to avoid widely disseminating any aspirated
material into the distal airways). Instillation of saline or alkalotic solutions is not recommended.
Bacterial infection does not necessarily occur after aspiration, and prophylactic antibiotics are
thus not recommended. In fact, they may promote colonization by resistant organisms. (See
page 1433: Perioperative Aspiration.)
28. Treatment of patients with significant aspiration and resultant hypoxemia includes:
1. administration of furosemide
2. administration of high-dose steroids
3. aggressive fluid restriction
4. positive end-expiratory pressure (PEEP) mechanical ventilation
28. D. If significant aspiration causes hypoxemia, increased airway resistance, consolidation, or
pulmonary edema, then institution of supplemental oxygen, continuous positive airway
pressure, or mechanical ventilation with PEEP may be necessary. Pulmonary edema is usually
secondary to increased capillary permeability and should not be treated with diuretics.
Hypovolemia from fluid losses into the lung may necessitate aggressive fluid infusion. High-
dose steroids yield little improvement of long-term outcome after aspiration. (See page 1433:
Perioperative Aspiration.)
29. Risk factors for corneal abrasion include:

1. pediatric patients
2. head or neck surgery
3. supine positioning
4. long surgical time
29. C. Corneal abrasions occur more frequently in elderly patients, after long procedures, with
lateral or prone positioning, and after head or neck surgery. (See page 1437: Ocular Injuries
and Visual Changes.)
30. Which of the following statements concerning hypothermia and shivering in the
postanesthesia care unit (PACU) is/are TRUE&quest;
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1. Severe shivering may increase CO2 production by more than 100%.

2. Myocardial ischemia and ventilatory failure may occur secondary to severe shivering.
3. Intensity of shivering may be accentuated by inhalation anesthetic–related tremor.
4. Meperidine is an effective treatment for postoperative shivering.
30. E. Postoperative shivering is uncomfortable and increases the risk of accidental trauma.
Moreover, severe shivering may increase oxygen consumption and CO2 production by 200%.
This increases cardiac output and minute ventilation; myocardial ischemia or ventilatory failure
may result. The intensity of postoperative shivering is sometimes accentuated by inhalation
anesthetic–related tremors. Meperidine is a particularly effective treatment for postoperative
shivering. (See page 1438: Hypothermia and Shivering.)
31. Potential causes for prolonged unresponsiveness after anesthesia include:

1. pseudocholinesterase deficiency
2. hypoglycemia
3. hypothermia
4. residual inhalation anesthetic
31. E. Residual sedation from inhalation anesthetics is a frequent cause of prolonged
unconsciousness, particularly after long procedures, in obese patients, and when high inspired
concentrations are continued through the end of surgery. Profound residual neuromuscular
paralysis may mimic unconsciousness by precluding any motor response to stimuli. This may
occur after gross overdose, if reversal agents are omitted in patients with unrecognized
neuromuscular disease, and in patients with phase II blockade (caused by either excessive
succinylcholine administration or pseudocholinesterase deficiency). Hypothermia (<33°C)
impairs consciousness and increases the depressant effect of medications. A serum glucose
level should be evaluated to rule out hypoglycemia. (See page 1439: Persistent Sedation.)
32. Hearing impairment after anesthesia and surgery:

1. is a rare event
2. occurs in 8% to 16% of patients after dural puncture for spinal anesthesia
3. is never bilateral
4. is often related to disruption of the round window or tympanic membrane rupture
32. C. Hearing impairment after anesthesia and surgery is relatively common. Although
impairment is often subclinical, patients sometimes experience decreased auditory acuity,
tinnitus, or roaring. The incidence of detectable hearing impairment is particularly high after
dural puncture for spinal anesthesia (8% to 16%), and it varies with the needle size, needle
type, and patient age. Impairment can be unilateral or bilateral and usually resolves
spontaneously. Hearing loss is often related to disruption of the round window or rupture of the
tympanic membrane. (See page 1437: Hearing Impairment.)
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Review of Clinical Anesthesia, 5e [Vishal] 56. Critical Care Medicine
Chapter 56
Critical Care Medicine
1. According to a recent study examining the red blood cell transfusion threshold in the
critically ill population, barring any extenuating circumstances (active bleeding, early
shock, active neurologic injury, or acute myocardial infarction), the transfusion
threshold should be which of the following values&quest;
A. 10 g/dL
B. 9 g/dL
C. 8 g/dL
D. 7 g/dL
E. 6 g/dL
1. D. A recent study examining critically ill patients found that patients transfused at a threshold
value of 7 g/dL (hemoglobin level) had no higher mortality than patients transfused at a
threshold of 10 g/dL. (See page 1461: Anemia and Transfusion Therapy in Critical Illness.)
2. Decreased brain tissue oxygen pressure (PbrO2) measurements may occur as a

result of all of the following EXCEPT:
A. an increase in intracranial pressure (ICP)
B. a decrease in cerebral perfusion pressure (CPP)
C. arterial oxygen desaturation
D. barbiturate coma
E. hyperventilation
2. D. PbrO2 measurements are performed by introducing a small, oxygen-sensitive catheter into
the brain tissue. The device monitors a very local area of the brain tissue, and this technique is
increasingly used for evaluation of cerebral oxygenation (normal PbrO2 values: 25–30 mm Hg).
Monitoring may be performed in relatively undamaged parts of the brain or, preferably, in the
penumbra region of an intracerebral lesion. Various studies have shown that an increase in ICP,
a decrease in CPP or arterial oxygenation, and hyperventilation may result in decreased PbrO2.
Studies have demonstrated improvement in PbrO2 after red blood cell transfusion, during
barbiturate coma, and after decompressive hemicraniectomy. (See page 1446: Brain Tissue
Oxygenation.)
3. Which of the following statements regarding therapies that lower intracranial

pressure (ICP) is FALSE&quest;
A. Despite the induction of systemic hypotension, propofol decreases cerebral
metabolism, resulting in a coupled decline in cerebral blood flow (CBF) with a
consequent decrease in ICP.
B. Although barbiturates are effective at reducing ICP, their routine use in patients with
traumatic brain injury (TBI) does not appear beneficial and may actually result in excess
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mortality in patients with diffuse brain injury.
C. Although neuromuscular blockade may result in a lowering of ICP, the routine
prolonged intensive care unit (ICU) use of neuromuscular blockade is discouraged.
D. Hyperventilation effectively reduces ICP by reducing CBF, and prophylactic
hyperventilation has proven to be beneficial in TBI.
3. D. Hyperventilation effectively reduces ICP by reducing CBF. However, the role that
hyperventilation should play in routine management of patients with TBI is not clear. Primarily,
this is related to concerns that hyperventilation may lead to critically low CBF, resulting in
worsening cerebral ischemia. In small, randomized trials, prophylactic hyperventilation has not
proven to be beneficial in TBI. In contrast, it has been proposed that “optimized
hyperventilation” in the presence of “luxury perfusion” (excess CBF) may increase global
cerebral oxygen metabolism and help normalize global cerebral glucose extraction. Based on
the available evidence, prolonged or prophylactic hyperventilation should be avoided after
severe TBI, especially in the first 24 hours after the injury. Propofol rapidly penetrates the
central nervous system and has rapid elimination kinetics. Despite the induction of systemic
hypotension, propofol decreases cerebral metabolism, resulting in a coupled decline in CBF,
with consequent decrease in ICP. The use of high-dose propofol to control refractory
intracranial hypertension is not recommended, and barbiturates should be considered if ICP is
not controlled by moderate doses of propofol. The mechanisms by which barbiturates exert
their cerebroprotective effect appear to be mediated by a reduction in ICP via alteration in
vascular tone, reduction of cerebral metabolic rate, and inhibition of free radical peroxidation.
Although barbiturates are effective at reducing ICP, their routine use in patients with TBI does
not appear beneficial and may actually result in excess mortality in patients with diffuse brain
injury. This effect may in part relate to the profound cardiovascular depressant effects of
barbiturates. Although neuromuscular blockade may result in a decrease in ICP, the routine use
of neuromuscular blockade is discouraged because its use has been associated with a longer
ICU course, a higher incidence of pneumonia, and a trend toward more frequent sepsis without
any improvement in outcome. (See page 1447: Traumatic Brain Injury.)
4. Which of the following statements is TRUE regarding cerebral vasospasm after

subarachnoid hemorrhage (SAH)&quest;
A. There is a good correlation between the transcranial Doppler (TCD) velocities and
angiographic findings, especially for the posterior circulation.
B. The calcium channel blocker nimodipine is effective primarily because it reduces the
frequency of angiographic vasospasm compared with a placebo-treated group.
C. Prophylactic “triple-H” therapy is one of the proven mainstays of management for
cerebral ischemia associated with SAH-induced vasospasm.
D. Patients treated within 6 to 12 hours after the development of ischemic symptoms with
the use of balloon angioplasty have better results than those receiving delayed
intervention.
4. D. Interventional neuroradiology with the use of balloon angioplasty may reverse or improve
vasospasm-induced neurologic deficits. Patients treated within 6 to 12 hours after the
development of ischemic symptoms have better results than those receiving delayed
intervention. The risks of angioplasty include intimal dissection, vessel rupture, ischemia, and
infarction. Hypervolemic or hypertensive and hemodilution (“triple-H”) therapy is one of the
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mainstays of treatment for cerebral ischemia associated with SAH-induced vasospasm despite
the lack of evidence for its effectiveness, especially for its prophylactic use. There is no
consensus with regard to the goals of therapy, and it is unclear which component of this
therapy is necessary or sufficient to treat vasospasm. The calcium channel blocker nimodipine
(60 mg orally q4h for 21 days) is recognized as effective prophylaxis for cerebral vasospasm
and improvement in neurologic outcome (reduction of cerebral infarction and poor outcome)
and mortality from cerebral vasospasm in patients with SAH (level I evidence). Although
angiographic studies do not demonstrate a difference in the frequency of vasospasm compared
with a placebo-treated group, the benefits of nimodipine have been attributed to a
cytoprotective effect related to the reduced availability of intracellular calcium and improved
microvascular collateral flow. Transcranial Doppler has been used to identify and quantify
cerebral vasospasm on the basis that velocity profiles increase as the diameter of the vessel
decreases. There is a poor correlation between the TCD velocities and angiographic findings,
especially for the posterior circulation. (See page 1449: Subarachnoid Hemorrhage.)
5. Which of the following statements about ventilator-induced lung injury (VILI) or

associated lung injury (VALI) is FALSE&quest;
A. Histologically, the features seen are diffuse alveolar damage and increased
microvascular permeability.
B. VILI is associated with the systemic release of inflammatory mediators.
C. Tidal volume selection based on actual body weight improves mortality.
D. Tidal volumes as low as 4 cc/kg may be appropriate to avoid VILI.
5. C. VILI or VALI refers to microscopic injury to the lung caused by overdistention and cyclic
reopening of alveoli. VALI has been well demonstrated in numerous experimental models and is
histologically similar to the features seen in acute lung injury (ALI) of other causes, with diffuse
alveolar damage and increased microvascular permeability. In addition, VALI is associated with
the systemic release of inflammatory mediators that may contribute to multiple organ failure.
Clinically, patients believed to be at risk for VALI are those with abnormally low recruitable lung
volumes, particularly those with ALI and acute respiratory distress syndrome (ARDS). Thus, a
“lung-protective” ventilatory strategy using low tidal volume ventilation has been proven to save
lives when applied to patients with ALI and ARDS. In summary, although tidal volumes of 10 to
12 mL/kg may still be indicated for some patients, in most cases, an initial tidal volume of 8
mL/kg is probably appropriate, and volumes as low as 4 mL/kg may be appropriate in some
cases. In addition, because lung volumes correlate with height rather than weight, tidal volume
selection should be based on predicted, or ideal, body weight rather than actual weight to avoid
lung overdistention. (See page 1456: Acute Respiratory Failure.)
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6. Which of the following statements regarding the acute respiratory distress
syndrome (ARDS) is/are TRUE&quest;
1. Pulmonary injury is not the only trigger for the syndrome.
2. The mortality rate is approximately 30% to 40%.
3. Positive end-expiratory pressure (PEEP) is a useful adjunct in maintaining
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oxygenation.
4. Late in the syndrome, increasing inspired O2 resolves the hypoxia more effectively
than PEEP.
6. A. ARDS arises from various underlying pathophysiologic perturbations, such as sepsis,
trauma, hypotension, pneumonia, aspiration, and amniotic fluid embolism. The syndrome arises
from a loss in alveolar capillary integrity, which results in the leakage of plasma and red blood
corpuscles into the alveoli. Leukoaggregation on the endothelial surface and proliferation of
type II pneumocytes also occur. Clinically, ARDS and acute lung injury (ALI) are characterized
by reduced static thoracic (lung and chest wall) compliance and severe impairment of gas
exchange, including high intrapulmonary shunt and dead space fraction. There is a large
increase in the arterial–alveolar (A–a) gradient for O2, and the patient complains of dyspnea
and is tachypneic with increased work of breathing. Initially, increased inspired O2 improves
oxygenation, but as the shunt fraction increases and the work of breathing overwhelms the
patient, positive-pressure ventilation will have to be instituted. PEEP is the mainstay of
treatment to improve oxygenation. Because the disease process is one of shunt, PEEP helps
recruit nonventilated alveoli and thereby reduces the A–a gradient. PEEP also reduces
pulmonary water and decreases the work of breathing. The treatment of ALI and ARDS is
largely supportive and includes aggressive treatment of inciting events, avoidance of
complications, and mechanical ventilation. Mortality associated with ARDS has decreased
substantially over the past 20 years and is currently in the 30% to 40% range overall. (See
page 1456: Acute Respiratory Failure and Clinical Manifestations.)
7. Which of the following statements is/are TRUE regarding tissue plasminogen

activator (TPA) administration in patients with an acute ischemic stroke&quest;
1. TPA is equally effective when administered any time within 12 hours of the onset of
symptoms.
2. It reduces mortality.
3. Direct intra-arterial administration is more effective than systemic administration.
4. Patients should not be treated with any other anticoagulants within 24 hours after
receiving TPA.
7. D. TPA must be administered within 3 hours of the onset of symptoms of cerebral occlusion
to be effective. Even within the 3-hour window, the benefits of TPA appear to be greater the
sooner the treatment is started. Administration does not reduce mortality, but it does improve
neurologic outcome. Regional or local intra-arterial administration of a thrombolytic agent within
6 hours of symptom onset demonstrate a high recanalization rate, but a potential limitation to
the use of intra-arterial treatment is the time required to mobilize a team to perform angiography
(level II evidence). However, direct arterial injection has yet to be proven more effective than
peripheral administration. After TPA has been administered, no other anticoagulants or
antiplatelet agents can be administered within 24 hours of treatment because doing so would
increase the risk of bleeding and increase mortality. (See page 1450: Acute Ischemic Stroke.)
8. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of
developing auto positive end-expiratory pressure (PEEP) while intubated. Which of the
following strategies help(s) prevent the development of auto PEEP&quest;
1. Reducing tidal volumes to 6 to 8 mL/kg
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2. Permissive hypercapnia and resultant respiratory acidosis

3. Prolonged expiratory phase of ventilation
4. Limiting inspired O2 concentration
8. A. In patients with obstructive lung disease (asthma and COPD), limitation of expiratory flow
leads to air trapping and the development of intrinsic PEEP, or auto PEEP. To reduce the
occurrence of auto PEEP, tidal volume should be limited to 6 to 8 mL/kg. The expiratory phase
of ventilation should be made as long as possible to facilitate alveolar emptying. Both of the
foregoing strategies may result in insufficient ventilation, and respiratory acidosis may occur.
This produces minimal physiologic effects and should be tolerated. O2 concentration in the
inspired mixture does not affect auto PEEP. (See page 1457: Principles of Mechanical
Ventilation.)
9. Which of the following statements regarding glucose management in critically ill

1. Hyperglycemia is associated with increased risk of postoperative infection (wound and
otherwise).
2. The blood glucose level is a risk factor for mortality in diabetic patients admitted with
acute myocardial infarction.
3. Patients in the intensive care unit (ICU) may have elevated blood glucose levels
because of total parenteral nutrition (TPN) or steroid administration.
4. Elevated blood glucose levels in patients with traumatic brain injury (TBI) are expected
and do not require intervention.
9. A. Increased blood glucose levels in critically ill patients result from diabetes, TPN, and
steroid administration as well as from stroke or trauma to the central nervous system.
Hyperglycemia results from increased glucose production and insulin resistance caused by
inflammatory and hormonal mediators that are released in response to injury. Hyperglycemia is
associated with increased risk of postoperative infection (wound and otherwise) and poor
outcome in patients with stroke or TBI. In addition, the blood glucose level is a risk factor for
mortality in diabetic patients admitted with acute myocardial infarction. An elevated glucose
level in patients with brain trauma is a harbinger of poor outcome and should be treated to
reduce mortality and morbidity. (See page 1460: Glucose Management in Critical Illness.)
10. Which of the following statements is/are TRUE regarding sedation with propofol for
patients with traumatic brain injury (TBI)&quest;
1. Propofol improves cerebral metabolic O2 balance better than benzodiazepines.
2. Prolonged administration of high-dose propofol may produce lactic acidosis and
death.
3. Propofol may decrease cerebral perfusion pressure (CPP) because of hemodynamic
instability.
4. Propofol improves mortality resulting from improved intracranial pressure (ICP)
regulation.
10. A. Sedation of neurologically impaired patients should typically be achieved with short-
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acting sedatives to allow for frequent assessment of neurologic status. Although no studies
have investigated the effect of sedation on outcome, a common practice is to provide sedation
with propofol or benzodiazepines in patients after TBI. Both agents have favorable effects on
cerebral oxygen balance, although propofol is more potent in this regard. Propofol produces
rapidly reversible sedation that reduces cerebral metabolic demand and coupled blood flow.
This, in turn, results in a reduction of ICP, which improves CPP. In inadequately resuscitated
individuals, propofol may produce hypotension, which would result in a worsening of CPP.
Prolonged high-dose administration of propofol (>80 μg/kg/min and >24 hours) may produce
lactic acidosis and death (propofol infusion syndrome). Sedation-mediated alterations in CPP
and reduced cerebral O2 requirements have not produced a reduction in mortality. (See page
1447: Traumatic Brain Injury.)
11. Which of the following statements is/are TRUE regarding septic shock&quest;
1. Intestinal villi, because of their countercurrent circulation, are very vulnerable to septic
shock–mediated alterations in perfusion.
2. Metabolic acidosis may occur even if there are sufficient levels of O 2 delivery.
3. Intramucosal pH and PCO2 may be used to assess the splanchnic metabolic rate.
4. Insufficient splenic circulation may result in thrombocytopenia.
11. A. Septic shock is a form of distributive shock associated with activation of the systemic
inflammatory response. The hemodynamic profile of septic shock is influenced by several
sepsis-induced physiologic changes, including hypovolemia and vasodilation, in addition to
cardiac depression. Microcirculation is altered, and metabolic needs are increased. The ability
of tissues to extract and use oxygen may be impaired. Thus, metabolic acidosis may be present
despite normal levels of oxygen transport. Intestinal villi have a countercurrent flow that makes
them susceptible to low flow states. These alterations result in insufficient blood flow to the
intestinal mucosa, which produces localized acidosis. This flow can be indirectly measured
(intramucosal pH and PCO2), and hemodynamic therapy may be altered to improve splanchnic
oxygenation. Decreased splanchnic circulation does not cause thrombocytopenia. (See page
1453: Septic Shock.)
12. Which of the following statements is/are TRUE regarding the use of norepinephrine
in shock&quest;
1. Its effects are mediated through α - and β -adrenoreceptors.
2. In volume-resuscitated hypotensive individuals, norepinephrine improves renal
perfusion.
3. Norepinephrine may produce a reduction in lactate levels by improving perfusion.
4. Norepinephrine should be administered at the first sign of sepsis because early
intervention may prevent progression to profound septic shock.
12. A. Norepinephrine's effects are mediated through α - and β -adrenoreceptors.
Norepinephrine produces an increase in systolic blood pressure with variable effects on cardiac
output and heart rate. In septic individuals, intravascular volume expansion is the first line of
therapy. If patients remain persistently hypotensive despite volume expansion and markers of
adequate preload, the use of vasopressors is indicated. Norepinephrine increases systemic
vascular resistance, which improves splanchnic blood flow and decreases lactate levels. In
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patients who are septic and euvolemic, norepinephrine increases renal blood flow. In all cases,
norepinephrine should not be administered to improve hemodynamics before fluid
administration has been attempted. (See page 1455: Management of Shock with Vasopressors
or Inotropes.)
13. Which of the following statements regarding vasopressin use in shock is/are
TRUE&quest;
1. It significantly increases systemic vascular resistance (SVR).
2. It significantly increases heart rate.
3. In patients with hepatorenal syndromes, vasopressin improves urinary output.
4. It produces a significant increase in pulmonary vascular resistance (PVR).
13. B. Vasopressin is a potent vasoconstrictor when administered in low doses to patients in
shock, particularly those with distributive shock caused by sepsis or hepatic failure and those
with circulatory failure after cardiopulmonary bypass. Vasopressin administration results in
significant increase in systemic blood pressure with little or no effect on cardiac output, heart
rate, or pulmonary vascular resistance. At low doses, it does not affect renal blood flow, and in
the hepatorenal syndrome, it increases urinary output. (See page 1455: Management of Shock
with Vasopressors or Inotropes.)
14. Ventilator-associated pneumonia (VAP) occurs in patients who are intubated and
mechanically ventilated in the intensive care unit. Which of the following statements
is/are TRUE regarding VAP&quest;
1. Early onset VAP is associated with organisms such as Haemophilus influenzae,
Streptococcus pneumoniae, and methicillin-sensitive Staphylococcus aureus.
2. Strict hand washing, oral care, and the head-up position reduce the incidence of VAP.
3. Late-onset VAP carries a higher risk of mortality than early-onset VAP.
4. Acid suppression therapy helps reduce the incidence of VAP.
14. A. VAP occurs typically in two forms: early, which is a low-mortality form, and late, a high-
mortality form. The early form of VAP is caused by H. influenzae, S. pneumoniae, and
methicillin-sensitive S. aureus. Late-onset VAP is associated with virulent organisms such as
methicillin-resistant S. aureus, Pseudomonas aeruginosa, and Acinetobacter spp. Whereas
late-onset VAP has a high mortality rate, early-onset VAP has almost no mortality rate.
Precautions, including thorough hand washing, oral care, and a head-up position, may reduce
its incidence. Acid suppression therapy increases the risk of VAP because of gastric bacterial
overgrowth. (See page 1464: Ventilator-Associated Pneumonia.)
15. Which of the following statements regarding dexmedetomidine is/are TRUE&quest;

1. It is an α 2-adrenergic receptor agonist.
2. It has some analgesic effects.
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3. It produces sedation without inducing unresponsiveness.
4. It is approved by the Food and Drug Administration (FDA) for routine intensive care
unit sedation during mechanical ventilation.
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15. A. Dexmedetomidine is an α 2-adrenergic receptor agonist like clonidine, which produces
sedation and mild analgesia. It does not produce respiratory depression. The sedation it
creates allows the patient to be responsive when stimulated. The drug is expensive and is
currently approved only for 24 hours of use. (See page 1462: Sedation of Critically Ill Patients.)
16. Which of the following statements regarding nutritional supplementation in the

intensive care unit (ICU) is/are TRUE&quest;
1. Gastric feeding should be started within 48 hours of ICU admission.
2. Postpyloric positioning of feeding tubes reduces the risk of pneumonia.
3. Enteral and parenteral feedings are both equally efficient.
4. Raising the head of the bed to 30 to 40 degrees helps reduce aspiration.
16. D. Enteral nutrition should be started as early as possible after admission to the ICU. Early
feeding (within 4 hours) resulted in less organ dysfunction than delayed (36 hours) initiation.
Parenteral nutrition is inferior to enteral nutrition. Patients who receive enteral nutrition have a
lower infection risk and reduced translocation and nitrogen imbalance compared with patients
receiving parenteral nutrition. The location of the feeding tube does not affect mortality, ICU
length of stay, or development of pneumonia. Elevating the head of the head of the bed may
reduce aspiration. (See page 1462: Nutrition in Critically Ill Patients.)
17. The Glasgow Coma Scale (GCS) is the most widely used clinical measure of injury
severity in patients with traumatic brain injury (TBI). The advantages of this scale are
that:
1. It provides an objective method of measuring the level of consciousness.
2. It has high intra- and interrater reliability across observers with a wide variety of
experience.
3. It is a powerful predictor of poor outcome from TBI.
4. It is accurate even when only the partial score is used, such as in patients with
endotracheal intubation whose verbal responses cannot be assessed.
17. A. The GCS is the most widely used clinical measure of injury severity in patients with TBI.
The advantages of this scale are that it provides an objective method of measuring
consciousness, it has high intra- and interrater reliability across observers with a wide variety of
experience, and it has an excellent correlation with outcome. However, the GCS score is
unmeasurable in up to 25% to 45% of patients at admission and is inaccurate when only the
partial score is used, such as in patients with endotracheal intubation whose verbal responses
cannot be assessed. TBI qualifies as severe when the GCS score is 8 or less after
cardiopulmonary resuscitation. The predictive value of the GCS score at admission is about
69% for good neurologic outcome and 76% for unfavorable outcome. After 7 days, these figures
approximate 80% for both favorable and unfavorable outcome. (See page 1447: Diagnosis and
Management of the Most Common Types of Neurologic Failure: Traumatic Brain Injury.)
18. Which of the following statements regarding the use of a pulmonary artery catheter
(PAC) is TRUE&quest;
1. In elderly, high-risk surgical patients, mortality is improved with use of a PAC.
2. In patients with acute respiratory distress syndrome (ARDS), there is no difference in
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survival with PAC- or central venous catheter–guided therapy.
3. Patients in septic shock benefit from supraphysiologic resuscitation guided by the
PAC.
4. Further research is necessary to establish the utility, if any, of PACs in critically ill
patients.
18. C. Despite the theoretical benefits of the PAC, few data support a positive effect on
mortality or other substantive outcome variables. There was no benefit to therapy directed by
PAC over standard therapy in elderly, high-risk surgical patients requiring intensive care. More
recently, the FACTT (Fluid and Catheter Treatment Trial) conducted in a large cohort of
approximately 1000 ARDS patients assigned to receive PAC- or central venous catheter–guided
therapy did not find any survival or organ function differences between the two groups but did
find twice as many catheter-related complications (mostly dysrhythmias) in PAC-monitored
patients. A large, randomized, prospective study of the therapeutic strategy known as
supraphysiologic resuscitation to defined endpoints (cardiac index >4.5 L/min, DO2> 600
mL/m2/min, and VO2 >170 mL/m2/min) in patients with septic and surgical- or trauma-related
shock found that this approach was associated with increased mortality in patients with septic
shock. (See page 1451: Functional Hemodynamic Monitoring.)
19. Which of the following statements regarding catheterrelated bloodstream

infections (CR BSI) is/are TRUE:
1. Skin cleansing with chlorhexidine is more effective than cleansing with other agents.
2. Catheters coated with either antiseptics or antibiotics have been consistently shown to
reduce bacteremia.
3. The subclavian vein should be used rather than the femoral vein.
4. Routine catheter replacement at 3 or 7 days results in a reduced incidence of
infection.
19. B. CR BSI is more likely when placement occurs under emergency conditions and is
reduced by the use of strict aseptic technique with full barrier precautions. This includes pre-
insertion hand washing, the use of a full gown and gloves, and the use of a large barrier drape.
In addition, skin cleansing with chlorhexidine is more effective than cleansing with other agents.
These simple interventions should be considered as standards of care and are recommended
by the Centers for Disease Control and Prevention. Catheter-related infection is insertion site
dependent, increasing in frequency from subclavian to internal jugular to femoral vein sites,
respectively. Catheter-related infection and bacteremia increase with the duration of
catheterization, particularly for durations of longer than 2 days. However, routine catheter
replacement at 3 or 7 days does not reduce the incidence of infection and results in increased
mechanical complications. Thus, routine guidewire exchange of catheters is not recommended.
Catheters coated with either antiseptics (chlorhexidine and silver sulfadiazine) or antibiotics
(rifampin and minocycline) reduce bacterial colonization of catheters but have not been
consistently shown to reduce bacteremia or other morbidities. (See page 1463: Complications
in the Intensive Care Unit: Detection, Prevention, and Therapy.)
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Review of Clinical Anesthesia, 5e [Vishal] 57. Acute Pain Management
Chapter 57
Acute Pain Management
1. Which of the following is NOT a characteristic of epidurally administered lipophilic

opioids&quest;
A. Primarily supraspinal mechanism of action
B. Quick onset
C. Short duration
D. Slow systemic uptake
1. D. In general, the epidural administration of hydrophilic opioids tends to have a slow onset, a
long duration, and a mechanism of action that is primarily spinal in nature. The epidural
administration of lipophilic opioids, on the other hand, has a quick onset, a short duration, and a
mechanism of action that is primarily supraspinal, secondary to rapid systemic uptake. (See
page 1488: Neuraxial Analgesia.)
2. End results of the surgical stress response include all of the following EXCEPT:
A. Hyperglycemia
B. Poor wound healing
C. Positive nitrogen balance
D. Impaired immunocompetency
2. C. Surgical stress causes release of cytokines and precipitates adverse neuroendocrine and
sympathoadrenal responses, resulting in detrimental physiologic responses, particularly in high-
risk patients. The increased secretion of the catabolic hormones cortisol, glucagon, growth
hormone, and catecholamines and the decreased secretion of the anabolic hormones insulin
and testosterone characterize the neuroendocrine response. The end result of this is
hyperglycemia and a negative nitrogen balance; the consequences include poor wound
healing, muscle wasting, fatigue, and impaired immunocompetency. (See page 1478: The
Surgical Stress Response.)
3. The safety of epidural administration of which of the following adjuvants

medications has not yet been determined and is therefore not recommended for
use&quest;
A. Clonidine
B. Ketamine
C. Alfentanil
D. Hydromorphone
3. B. The safety of epidurally administered ketamine has not been determined, so routine use
cannot be recommended at this time. (See page 1487: Methods of Anesthesia: Neuraxial
Analgesia.)
4. The circulating levels of which of the following hormones is not increased
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postoperatively&quest;
A. Insulin
B. Glucagon
C. Antidiuretic hormone
D. Growth hormone
E. Cortisol
4. A. The surgical stress response to pain includes an increase in the level of circulating
catecholamines, cortisol, angiotensin II, glucagon, growth hormone, and antidiuretic hormone,
as well as a decrease in the levels of anabolic hormones (testosterone and insulin). The overall
metabolic effects are gluconeogenesis, hyperglycemia, a negative nitrogen balance, and
sodium and water retention. The magnitude of the neuroendocrine and cytokine response to
surgery correlates with the degree of tissue injury and with overall outcome. (See page 1478:
Pathophysiology of Pain.)
5. Which of the following statements concerning the analgesia provided by intrathecal

clonidine is FALSE&quest;
A. It binds to pre- and postsynaptic receptors in the dorsal horn.
B. It may cause hypotension and bradycardia.
C. It interacts synergistically with opioids and local anesthetics.
D. It prolongs sensory and motor blockade.
E. It produces respiratory depression comparable to that produced by morphine.
5. E. α 2-Agonists (e.g., clonidine) produce analgesia when they bind to the α 2-presynaptic and
postsynaptic receptors in the dorsal horn of the spinal cord. They modulate pain sensation in a
manner similar to that of the opioids and act synergistically with opioids and local anesthetics to
produce analgesia. Hypotension and bradycardia may occur with epidurally administered
clonidine, probably as a result of inhibition of the preganglionic sympathetic fibers. They
prolong sensory and motor blockade and cause less urinary retention than morphine. The α 2-
agonists produce minimal respiratory depression compared with the opioids. (See page 1487:
Selection of Analgesics.)
6. Which of the following statements concerning non-opioid analgesics is

FALSE&quest;
A. Paracetamol has both analgesic and antipyretic properties but is devoid of anti-
inflammatory effects.
B. Acetaminophen is associated with impaired platelet function and gastrointestinal (GI)
ulceration.
C. Dexmedetomidine is a highly selective α 2-agonist that does not depress respiration.
D. Gabapentin is effective for neuropathic pain syndrome and postoperative pain.
6. B. Acetaminophen is not associated with the impaired platelet function and GI ulceration that
are seen with many nonsteroidal anti-inflammatory drugs. Paracetamol has both analgesic and
antipyretic properties but is devoid of anti-inflammatory effects. Dexmedetomidine is a highly
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selective α 2-agonist that does not depress respiration. Gabapentin is effective for neuropathic
pain syndrome and postoperative pain. (See page 1484: Non-opioid Analgesic Adjuncts.)
7. Which of the following statements is NOT associated with increased risk of

nephrotoxicity in the perioperative period&quest;
A. Hypovolemia
B. Congestive heart failure
C. Concomitant morphine use
D. Chronic renal insufficiency
7. C. The risk of nephrotoxicity is increased in patients with hypovolemia, congestive heart
failure, and chronic renal insufficiency. Morphine does not specifically increase the risk of
nonsteroidal anti-inflammatory drug (NSAID)–induced nephrotoxicity. NSAIDs have been proven
effective in the treatment of postoperative pain when used with opioids. In addition, they are
opioid sparing and may significantly decrease the incidence of opioid-related side effects such
as postoperative nausea and vomiting and sedation. (See page 1484: Non-opioid Analgesic
Adjuncts.)
8. Which of the following are opioid sparing and may be used in the perioperative
period to attenuate excessive sedation induced by opioids&quest;
1. acetaminophen
2. nonsteroidal anti-inflammatory drugs (NSAIDs)
3. N-methyl-D-aspartate (NMDA) receptor antagonists
4. Gabapentin
8. E. Excessive sedation may respond to a change in the opioid. Use of a multimodal analgesic
technique, which incorporates the use of a regional anesthetic (e.g., epidural or peripheral
nerve blockade), an NSAID, acetaminophen or other non-opioid analgesics such as an NMDA
receptor antagonist, or an α 2-δ subunit calcium channel ligand will have an opioid-sparing
effect, which should attenuate opioid induced sedation. Gabapentin and pregabalin are α 2-δ
subunit calcium channel ligands. (See page 1487: Patient-Controlled Analgesia.)
P.300
9. Which of the following practices maximizes the success of pre-emptive
analgesia&quest;
1. The chosen technique should include the entire surgical field.
2. The anesthetic depth should block all nociceptive input during surgery.
3. Analgesia should include the surgical and postsurgical time periods.
4. Patients with chronic pain should be selected preferentially.
9. A. Although the use of pre-emptive analgesia is certainly enticing, its clinical benefit in
humans has received mixed reviews. For pre-emptive analgesia to be successful, three critical
principles must be adhered to: the depth of analgesia must be adequate enough to block all
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nociceptive input during surgery, the analgesic technique must be extensive enough to include
the entire surgical field, and the duration of analgesia must include both the surgical and
postsurgical time periods. Patients with pre-existing chronic pain tend to respond poorly to pre-
emptive techniques because of pre-existing sensitization of the nervous system. (See page
1478: Pre-emptive Analgesia.)
10. Which of the following statements regarding strategies for acute pain management
is/are TRUE&quest;
1. The majority of postoperative pain is neuropathic in nature.
2. Neuropathic pain may be a result of accidental nerve injury secondary to cutting,
entrapment, or compression.
3. Neuropathic pain only follows a dermatomal distribution in the postoperative period.
4. Nociceptive pain typically responds best to N-methyl-D-aspartate (NMDA) agonists.
10. B. Although the majority of postoperative pain is nociceptive in character, a small
percentage of patients may experience neuropathic pain postoperatively. It is critical to
recognize this fact because patients with neuropathic pain are at increased risk of progressing
to a chronic pain state. Neuropathic pain may be the result of accidental nerve injury secondary
to cutting, traction compression, or entrapment. There may be a delay in the onset of the pain,
and it may follow a nondermatomal distribution. Nociceptive pain responds best to opioids,
nonsteroidal anti-inflammatory drugs, para-aminophenols, and regional anesthesia techniques.
Patients with neuropathic pain, on the other hand, may benefit from the addition of the non-
opioid analgesic adjuvants such as the NMDA receptor antagonists, α 2-agonists, and the α 2-δ
subunit calcium channel ligands. (See page 1479: Acute Pain Management.)
11. Which of the following statements regarding intramuscular administration of

analgesics is/are TRUE&quest;
1. The onset is more rapid than with oral administration.
2. Absorption depends on the potency of the agent.
3. There is potential for delayed respiratory depression.
4. It provides more effective analgesia than intravenous administration.
11. B. Intramuscular administration of analgesics results in a faster onset than oral
administration. The agent's potency is not related to its absorption. Plasma levels are less
consistently maintained. There is, however, the potential for delayed respiratory depression.
(See page 1487: Routes of Analgesic Delivery: Intramuscular.)
12. The benefits of continuous peripheral nerve block (CPNB) include:

1. prolonged postoperative analgesia
2. facilitated discharge from the hospital
3. fewer opioid-related side effects
4. greater patient satisfaction
12. E. The benefits of CPNB in the ambulatory setting include prolonged postoperative
analgesia, facilitated discharge from the hospital, fewer opioid-related side effects, and greater
patient satisfaction. (See page 1490: Peripheral Nerve Blockade.)
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13. Cyclo-oxygenase (COX) exists as two separate isomers, COX-1 and COX-2. Which
of the following statements regarding these isomers is/are TRUE&quest;
1. COX-2 is the inducible form.
2. COX-1 is the constitutive enzyme form.
3. COX-1 mediates hemostasis.
4. COX-2 mediates pain and fever.
13. A. The therapeutic benefit of nonsteroidal anti-inflammatory drugs is believed to be
mediated through the inhibition of COX enzymes, types I and II, which convert arachidonic acid
to prostaglandins. COX-1 is the constitutive enzyme that produces prostaglandins, which are
important for general “housekeeping” functions such as gastric protection and hemostasis.
COX-2, on the other hand, is the inducible form of the enzyme that produces prostaglandins
that mediate pain, inflammation, fever, and carcinogenesis. (See page 1484: Non-opioid
Analgesics.)
14. Which of the following statements regarding the administration of opioid analgesics
is/are TRUE&quest;
1. Opioid-induced hyperalgesia (OIH) is a rare phenomenon.
2. Patients with OIH become suddenly more sensitive to pain despite continued
treatment with opioids.
3. Tolerance rarely develops to the constipating effects of opioids.
4. N-methyl-D-aspartate (NMDA) receptor antagonists may abolish OIH.
14. E. OIH is a relatively rare phenomenon whereby patients who are receiving opioids
suddenly and paradoxically become more sensitive to pain despite continued treatment with
opioids. Evidence suggests that OIH is more likely to develop after administration of high doses
of phenanthrene opioids such as morphine. Changing the opioid to a phenyl piperidine
derivative such as fentanyl may thwart OIH. Evidence also suggests that coadministration of an
NMDA receptor antagonist may abolish opioid-induced tolerance (OIT) and OIH. OIT rarely
develops to the constipating effects of opioids. A peripherally acting μ -receptor antagonist that
has negligible systemic absorption, Alvimopan attenuates opioid-induced constipation and
shortens postoperative ileus and length of hospital stay. (See page 1480: Opioid Analgesics.)
15. Which of the following statements regarding methadone is/are TRUE&quest;

1. It is well absorbed from the gastrointestinal (GI) tract.
2. It is a relatively inexpensive synthetic opioid.
3. It inhibits monoamine transmitter uptake.
4. Its elimination is primarily renal.
15. A. Methadone is a relatively inexpensive synthetic opioid considered to be a “broad-
spectrum” opioid because it is a μ -receptor agonist, an N-methyl-D-aspartate antagonist, and
an inhibitor of monoamine transmitter reuptake, making it potentially useful for the treatment of
neuropathic pain. The drug is well absorbed from the GI tract, with a reported bioavailability of
approximately 80%. The drug is extensively metabolized in the liver by the cytochrome P450
(CYP450) system to inactive metabolites, which are cleared in the bile and urine, and unlike
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with morphine, it is generally not necessary to adjust the dosage of methadone in patients with
renal insufficiency. (See page 1480: Opioid Analgesics.)
16. Which statements regarding the performance of ultrasound-guided nerve blocks

is/are TRUE&quest;
1. Single injection peripheral nerve blocks have been shown to provide pain control that
is superior to pain control supplied by opioids.
2. Anticoagulation is not a concern in the placement of continuous peripheral nerve block
(CPNB) catheters, unlike with epidural placement.
3. With ultrasound guidance, the endpoint for injection has become real-time observation
of hydrodissection.
4. Perioperative nerve injury should be primarily attributed to intraneural injection or
“double-crush” injury.
16. B. Single-injection peripheral nerve blockade has been shown to provide pain control that is
superior to that of opioids with fewer side effects. Single-injection techniques are limited in
duration, but CPNB techniques may extend the benefits of peripheral nerve blockade well into
the postoperative period. CPNB has proven to be an effective technique for postoperative pain
management, which is superior to opioid analgesia with fewer opioid related side effects and
rare neurologic and infectious complications. Although bleeding complications may be
associated with the placement of CPNB catheters, the actual risks related to this technique are
not well defined. Hemorrhagic complications, rather than neurologic deficits, appear to be the
predominant risk associated with the performance of peripheral nerve blockade in
anticoagulated patients. If a perioperative nerve injury occurs, it is incumbent upon the
physician to determine which combination of anesthetic, surgical, and patient risk factors are
involved in any nerve injury and not assume a priori that the regional anesthetic is the culprit. A
recent study of interscalene block has confirmed that regardless of motor response, as long as
the needle tip is positioned between the two most lateral nerve structures, a successful
blockade of the plexus will be achieved. The endpoint for injection of local anesthetic has now
become real-time observation of hydrodissection rather than motor stimulation. (See page
1490: Peripheral Nerve Blockade.)
17. Which of the following statements regarding chronic pain is/are TRUE&quest;
1. It is defined as pain without apparent biologic value that has persisted beyond the
normal tissue healing time.
2. It is often associated with depression and anxiety.
3. Antiarrhythmics and anticonvulsants may be used for treatment.
4. Associated psychiatric diagnoses may include hypochondriasis.
17. E. Chronic pain is defined as “pain without apparent biological value that has persisted
beyond the normal tissue healing time usually taken to be three months” (International
Association for the Study of Pain) and “pain of a duration or intensity that adversely affects the
function or well-being of the patient” (American Society of Anesthesiologists). Chronic pain is
often associated with anxiety and depression, which may require treatment with various
anxiolytics, antidepressants, anticonvulsants, and antiarrhythmic and skeletal muscle relaxants
in addition to opioids. Symptoms unique to chronic pain include tight musculature, limited range
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of motion, lack of energy, sleep disturbance, irritability, and social withdrawal. Associated
psychiatric diagnoses include hypochondriasis and psychosis. (See page 1498: Opioid-
Dependent Patients.)
18. Which of the following statements concerning epidural anesthesia with opioids
is/are TRUE&quest;
1. Compared with fentanyl, morphine produces a more segmental block.
2. Hydrophilic opioids have a slower onset and longer duration.
3. Fentanyl may provide adequate analgesia after thoracotomy if it is infused at the L3
–L4 level.
4. Hydromorphone has a reduced incidence of pruritus compared with morphine.
18. D. Various opioids, including agonist–antagonist agents, may be used via the epidural route.
Lipophilic agents, such as fentanyl, tend to provide a greater segmental analgesic effect;
therefore, the epidural catheter should be sited in a position to cover the dermatomes included
in the surgical field. Morphine is more hydrophilic and thus can be infused at a lower lumbar
level and still provide analgesia for upper abdominal and thoracic procedures. Hydrophilic
opioids have a slower onset and longer duration of action. Hydromorphone is associated with
less incidence of pruritus and nausea than morphine. (See page 1488: Neuraxial Analgesia.)
19. Which of the following are accepted techniques to reduce anxiety in

children&quest;
1. Parental counseling
2. Distraction techniques
3. Game playing
4. Pharmacologic premedication
19. E. Good evidence suggests that the level of preoperative anxiety and stress adversely
impacts postoperative pain and recovery from surgery. A number of methods can be used to
reduce preoperative anxiety in children. They include preoperative parental education and
counseling about the operative experience; distraction techniques, including videos and music;
handheld video games; game playing with the support of the family or child life specialists; and
parental presence coupled with oral midazolam administration to ease the anxiety associated
with the transition to the induction of anesthesia. (See page 1501: Special Considerations in
the Perioperative Pain Management of Children.)
20. Which of the following statements regarding pediatric acute pain management
is/are TRUE&quest;
1. Evaluation of pain intensity is easier than in the adult population.
2. Parental behavior and attitudes may be major determinants of a child's behavior.
P.301
3. Patient-controlled analgesia (PCA) by proxy poses no risk to infants provided it is
parent controlled.
4. There is risk associated with epidural analgesia related to systemic toxicity.
20. C. Acute pain management in children undergoing surgery or invasive procedures offers
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several specific and unique challenges for anesthesiologists. Assessment of the degree of pain
is often more difficult in children because of their poor communication ability and their emotional
responses. Parental behavior and attitudes may be major determinants of a child's behavior
during the inhalational induction of anesthesia and the perioperative period. Despite a parent's
potential ability to help with assessment of pain, PCA by proxy is a safety risk because there is
no complete assurance that parents will be competent in assessing the intensity of their
children's pain or be able to regulate the bolus dosages to avoid opioid overdosage. Regarding
epidural anesthesia, serious risk is associated with epidural analgesia in children related to the
systemic toxicity of the local anesthetic and the need to place the epidural under general
anesthesia. (See page 1501: Special Considerations in Pediatric Acute Pain Management.)
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Review of Clinical Anesthesia, 5e [Vishal] 58. Chronic Pain Management
Chapter 58
Chronic Pain Management
1. Which nerve fibers mediate the “second,” or protopathic, pain response&quest;

A. Aα
B. Aβ
C. Aδ
D. C
1. D. Aδ and C fibers are nociceptors that both respond to painful stimuli but mediate different
aspects of pain sensation. Aδ fibers are fast-conducting fibers involved in the “first,” or epicritic,
pain response, which is localized and characterized as sharp or pricking. C fibers are slow-
conducting fibers that are involved in the “second,” or protopathic, pain response, which is
poorly localized and characterized as burning or dull. (See page 1506: Anatomy, Physiology,
and Neurochemistry of Somatosensory Pain Processing: Primary Afferents and Peripheral
Stimulation.)
2. The “windup” phenomenon involves which of the following nerve fibers&quest;

A. Aβ
B. B
C. Aδ
D. C
E. Aγ
2. D. The “windup” phenomenon involves C fibers. (See page 1506: Anatomy, Physiology, and
Neurochemistry of Somatosensory Pain Processing: Transition from Acute to Persistent
Nociception.)
3. Which of the following statements regarding the spinothalamic tract (STT) is/are
TRUE&quest;
1. STT neurons are the primary relay cells relaying nociceptive input from the spinal cord
to the supraspinal levels.
2. Axons of the STT ascend primarily in the contralateral and anterolateral tracts of the
spinal cord.
3. Axons of the STT terminate in the posterior complex of the thalamus.
4. STT neurons are primarily located in lamina VIII.
3. A. STT cells are the primary relay cells that provide nociceptive information from the spinal
cord to the supraspinal levels. The axons of the STT transcend up the spinal cord primarily in
the contralateral and anterolateral tracts, where they terminate in the posterior complex of the
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thalamus, including the ventral posterior lateral and ventral posterior medial nuclei. STT cells
that receive input are located in various laminae (I, IV, V, VII, and X). (See page 1506: Anatomy,
Physiology, and Neurochemistry of Somatosensory Pain Processing: Neurobiology of
Ascending Pathways.)
4. Which of the following is/are chemical mediators that are released after
injury&quest;
1. Substance P
2. Serotonin
3. Bradykinin
4. Histamine
4. E. Numerous chemical mediators are released after injury. These substances include
bradykinin, serotonin, prostaglandins, leukotrienes, histamine, and substance P. Bradykinin,
which is released locally after tissue injury, is capable of evoking pain on intradermal injection.
(See page 1506: Anatomy, Physiology, and Neurochemistry of Somatosensory Pain
Processing: Primary Afferents and Peripheral Stimulation.)
5. Which of the following is/are considered excitatory amino acids&quest;

1. Arginine
2. Aspartate
3. Valine
4. Glutamate
5. C. Considerable evidence suggests that excitatory amino acids such as glutamate and
aspartate are the principal neurotransmitters responsible for activation of dorsal horn neurons
after noxious stimulation. (See page 1506: Anatomy, Physiology, and Neurochemistry of
Somatosensory Pain Processing: Neurochemistry of Peripheral Nerve and the Dorsal Root
Ganglion.)
6. Which of the following statements regarding chronic regional pain syndrome (CRPS)
is/are TRUE&quest;
1. In CPRS II, a preceding nerve injury correlates with the associated pain symptoms.
2. Risk factors for the development of CRPS include prior trauma, prior surgery, work-
related injuries, and female gender.
3. A discrepancy exists between the severity of the symptoms and the severity of the
inciting injury.
4. Signs and symptoms include spontaneous pain, hyperalgesia, and allodynia as well as
trophic, sudomotor, and vasomotor abnormalities.
6. E. After trauma, surgery, and certain illness, a syndrome of pain, hyperalgesia, autonomic
dysfunction, and dystrophy, known as CRPS, may occur. The International Association for the
Study of Pain has further differentiated CPRS into two types: CRPS I and CRPS II
(“causalgia”). Unlike with CRPS I, in CRPS II, there is a known preceding nerve injury. (See
page 1516: Neuropathic Pain Syndromes: Complex Regional Pain Syndrome.)
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7. Which of the following statements regarding diabetic painful neuropathy (DPN) is/are
true&quest;
1. Symptoms include burning pain; deep, aching pain; electrical or stabbing sensations;
paresthesias; and hyperesthesia.
2. Management includes tight sugar control.
3. The incidence of diabetic neuropathy increases with the duration of diabetes, age,
and the degree of hyperglycemia.
4. Peripheral neuropathy is seen in 20% of patients with insulin-dependent diabetes.
7. A. Diabetic peripheral neuropathy is present in up to 65% of patients with insulin-dependent
diabetes. The incidence increases with the duration of diabetes, age, and the degree of
hyperglycemia. Symptoms include burning pain; deep, aching pain; electrical or stabbing
sensations; paresthesias; and hyperesthesia. Management includes tight glucose control and
pharmacologic agents such as anticonvulsants, tricyclic antidepressants, selective serotonin
reuptake inhibitors, and opioids. (See page 1516: Neuropathic Pain Syndromes: Diabetic
Painful Neuropathy.)
8. Which of the following statements regarding herpes zoster is/are TRUE&quest;

1. After resolution of an acute episode of herpes zoster, some patients develop a
persistent pain known as postherpetic neuralgia (PHN).
2. Steroids reduce incidence of PHN.
P.305
3. Antiviral agents such as acyclovir, famciclovir, and valacyclovir may hasten the healing
of the rash and reduce the duration of viral shedding.
4. A local anesthetic block is effective in long-term management of PHN.
8. B. Herpes zoster most commonly involves the thoracic and the trigeminal dermatomes, with
the ophthalmic division of the trigeminal nerve being the second most common. Persistent pain
after the resolution of the rash is known as PHN. Antiviral agents have been advocated for
management of acute stage of the disease and have been shown to hasten the healing of the
rash and reduce the duration of viral shedding. Corticosteroids have enjoyed some popularity
for the treatment of pain from acute herpes zoster; however, studies have failed to demonstrate
a reduction of incidence in PHN. Substantial evidence suggests that local anesthetic blocks are
ineffective in the management of PHN; at best, they provide very temporary relief. (See page
1516: Neuropathic Pain Syndromes: Herpes Zoster and Postherpetic Neuralgia.)
9. Which of the following statements regarding tricyclic antidepressants (TCAs) is/are

TRUE&quest;
1. Side effects include sedation, dry mouth, and urinary retention.
2. Sleep pattern improvement is usually prompt after initiation of these drugs.
3. The antidepressant effects are typically delayed.
4. They reduce the reuptake of norepinephrine.
9. E. The most popular explanation for the analgesic property of TCAs is a reuptake inhibition
of serotonin and norepinephrine, which increases the level of these neurotransmitters in the
brainstem and spinal cord. Although the antidepressant and pain-relieving effects are often
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delayed in onset, the improvement in sleep patterns provided by these drugs usually occurs
promptly, often with the initial dose. The common antimuscarinic side effects of the TCAs
include xerostomia, impaired visual accommodation, urinary retention, and constipation. (See
page 1520: Pharmacologic Management: Antidepressants.)
10. Which of the following statements regarding cancer pain is/are TRUE&quest;
1. Up to 25% of patients with cancer who are in active treatment and up to 90% of
patients with advanced cancer experience significant pain.
2. Opioids are the mainstay of treatment.
3. Neurolytic blocks and intrathecal opioids should be considered when pharmacologic
agents fail to effectively control pain.
4. Behavioral and psychological management are not meaningful components of cancer
pain control.
10. A. Up to 25% of patients with cancer who are in active treatment and up to 90% of patients
with advanced cancer experience significant pain. The management of cancer pain should be
multifaceted, including antineoplastic treatment, pharmacologic management, interventional
management, behavioral and psychological management and (if desired) hospice care. The
mainstay of treatment is opioids, and up to 70% to 95% of patients experience relief when
appropriate guidelines are followed. When failure of pharmacologic agents occurs, neurolytic
blocks and intrathecal opioids may be used. (See page 1518: Cancer Pain.)
11. Which of the following is/are TRUE about spinal cord stimulation (SCS)&quest;
1. It is based on the gate control theory.
2. Analgesia is brought about by alteration of the sympathetic tone.
3. After a trial period, a permanent stimulator is placed.
4. Complications include nerve and spinal cord injury, infection, hematoma, and lead
breakage or migration.
11. E. The effects of SCS are based on the gate control theory, in which increasing the input of
large nerve fibers would close the “gate” at the substantia gelatinosa of the dorsal horn of the
spinal horn from transmitting information of painful stimuli to the brain. Placement of a
permanent pacemaker is preceded by a trial period to confirm its efficacy. Complications of SCS
include nerve and spinal cord injury, infection, hematoma, and lead breakage or migration. (See
page 1523: Interventional Techniques: Spinal Cord Stimulation.)
12. Which of the following statements concerning celiac plexus block is/are
TRUE&quest;
1. Needles are placed just anterior to the body of L1.
2. Injections are performed with 5 mL of 50% alcohol.
3. Orthostatic hypotension is a potential side effect.
4. Approximately 50% of patients with upper abdominal cancer experience good to
excellent pain relief.
12. B. In a meta-analysis of 21 retrospective studies, it has been reported that 89% of 1145
patients who underwent celiac plexus block for pain of upper abdominal cancer had good to
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excellent pain relief in the first 2 weeks after the block; partial to complete pain relief continued
in 90% of the patients as of the 3-month interval. Complications from a celiac plexus block
include orthostatic hypotension, interscapular back pain, retroperitoneal hematoma, reactive
pleurisy, hiccups, hematuria, transient diarrhea, abdominal aortic dissection, transient motor
paralysis, and paraplegia. The classical technique for percutaneous injection of the celiac
plexus involves bilateral placement of the block needle just anterior to the body of L1 and
posterior to the aorta and diaphragmatic crura. 30 to 40 mL of the neurolytic agents (50%
alcohol or 6% to 10% phenol) are used for the retrocrural approach and anterocrural approach.
(See page 1518: Cancer Pain: Neurolytic Blocks for Visceral Pain from Cancer.)
13. Which of the following statements regarding intrathecal drug delivery systems
(IDDS) is/are TRUE&quest;
1. IDDS allows direct administration of drugs near the spinal cord receptors, bypassing
the blood–brain barrier.
2. High testosterone levels are seen with IDDS usage.
3. Complications include infection, bleeding, respiratory depression, pump malfunction
catheter failure, hormonal dysfunction, peripheral edema, and the formation of an
inflammatory mass.
4. Compared with spinal cord stimulation, a trial period is not needed for IDDS.
13. B. IDDS may be used in situations in which oral or transdermal opioids are ineffective at
reasonable doses or when they cause unacceptable side effects. IDDS allows direct infusion of
drugs near the spinal cord receptors, thus bypassing the blood–brain barrier and allowing a
decreased equianalgesic dose to be given with a decrease in side effects and adverse events.
A trial period is recommended before an intrathecal pump is permanently placed. Complications
of IDDS may include infection, bleeding, respiratory depression, pump malfunction, catheter
failure, hormonal dysfunction, peripheral edema, and the formation of an inflammatory mass.
IDDS is associated with decreased testosterone levels and small gonads, which may be treated
with hormonal replacement therapy. (See page 1526: Intrathecal Pumps.)
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Review of Clinical Anesthesia, 5e [Vishal] 59. Cardiopulmonary Resuscitation
Chapter 59
Cardiopulmonary Resuscitation
1. Which of the following statements is FALSE&quest;

A. Cardiovascular mortality in the United States is approximately 50%.
B. Optimum outcome from ventricular fibrillation is more likely to be obtained if ventilation
and chest compressions are initiated within 4 minutes.
C. In the operating room, cardiac arrest occurs approximately seven times for every
10,000 anesthetics.
D. The highest rate of survival after out-of-operating room cardiovascular arrest occurs
in patients cared for in the intensive care unit (ICU).
E. Optimum outcome from ventricular fibrillation is more likely to be obtained if
defibrillation is applied within 8 minutes.
1. D. Although cardiovascular mortality has declined since the mid-1960s, the leading cause of
death is still cardiovascular disease, at a rate of nearly 50%. Prompt chest compressions and
defibrillation (within 4 and 8 minutes, respectively) are the most important determinants of
optimum survival after ventricular fibrillation. Cardiac arrest in the operating room occurs at a
rate of seven of 10,000 anesthetics; 4.5 of 10,000 arrests are anesthesia related. Successful
resuscitation occurs in approximately 90% of anesthesia-related arrests, leading to a small (0.4
of 10,000) anesthetic mortality rate. Within the hospital, the operating room is the location
where cardiopulmonary resuscitation has the highest rate of success. Outside the operating
suite, the best initial resuscitation rates are found in the ICU; the best survival rates are for
patients who experience cardiac arrest in the emergency department. (See page 1533: Scope
of the Problem.)
2. All of the following statements are correct EXCEPT:

A. There are two levels of cardiopulmonary resuscitation (CPR) care, basic life support
(BLS) and advanced cardiac life support (ACLS).
B. The guidelines for CPR care in the United States are developed by the American
Heart Association's National Conference on CPR.
C. “Do not resuscitate” orders are automatically suspended when patients consent for
surgery.
D. Patients in cardiac arrest can receive all forms of therapy except those specifically
stated in their “do not resuscitate” orders.
E. Changes to CPR protocols are based on the most current scientific literature.
2. C. BLS and ACLS are the two forms of CPR. Guidelines are periodically updated for CPR by
the American Health Association's National Conference on CPR in accordance with the latest
scientific evidence in CPR therapy. Although they can be uncomfortable for anesthesia and
surgical caregivers, “do not resuscitate” orders can be maintained throughout surgery.
However, therapies that the patient wishes not to receive need to be clearly delineated in the
order, and appropriate personnel can render care excluding these specific items. (See page
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1546: Putting It All Together and page 1533: Ethical Issues.)
3. Considering basic life support, all the following statements are true EXCEPT:
A. Techniques for airway support should take precedence.
B. In case of choking, aggressive maneuvers are not indicated if the coughing
mechanism is intact.
C. Considering its low O2 concentration, performing mouth-to-mouth ventilation could
harm the patient.
D. Both the cardiac pump and thoracic pump mechanisms are responsible for blood flow
during cardiopulmonary resuscitation (CPR).
E. During CPR, the brain and the heart receive most of the blood flow.
3. C. Common practice is to approach a victim with the airway–breathing–circulation (ABC)
sequence, although the circulation–airway–breathing (CAB) sequence has been used in some
countries with comparable results. For CPR in the absence of airway obstruction, mouth-to-
mouth or mouth-to-nose ventilation is the most expeditious and effective method immediately
available. Although inspired gas with this method contains about 4% CO2 and only about 17%
O2 (composition of exhaled air), it is sufficient to maintain viability. During the compression
phase of CPR, all intrathoracic structures are compressed equally by the increase in
intrathoracic pressure caused by sternal depression, forcing blood out of the chest. Backward
flow through the venous system is prevented by valves in the subclavian and internal jugular
veins and by dynamic compression of the veins at the thoracic outlet by the increased
intrathoracic pressure. Thicker, less compressible vessel walls prevent collapse on the arterial
side, although arterial collapse will occur if intrathoracic pressure is significantly increased.
These are thought to be the mainstays of events that belong to both the cardiac and thoracic
pump mechanisms. Whereas myocardial perfusion is 20% to 50% of normal, cerebral perfusion
is maintained at 50% to 90% of normal. Abdominal visceral and lower extremity flow is reduced
to 5% of normal. The signs of total airway obstruction are the lack of air movement despite
respiratory efforts and the inability of the victim to speak or cough. Cyanosis, unconsciousness,
and cardiac arrest occur quickly. Partial airway obstruction results in a raspy vocalization or
wheezing accompanied by coughing. If the victim has good air movement and is able to cough
forcefully, no intervention is indicated. However, if the cough weakens or cyanosis develops,
the patient must be treated as if complete obstruction were present. (See page 1534: Airway
Management and page 1536: Circulation.)
4. Which of the following doses is not correct&quest;

A. Sodium bicarbonate: 1 mEq/kg with 0.5 mEq/kg every 10 minutes PRN
B. Atropine: 1 mg repeated every 3 to 5 minutes to a total of 0.04 mg/kg
C. Epinephrine: 1 mg repeated every 3 to 5 minutes
D. Amiodarone: 1000-mg IV bolus with 500 mg PRN to total daily dose of 4 g
E. Calcium chloride: 2–4 mg/kg
4. D. Correct doses include:
Sodium bicarbonate: 1 mEq/kg with 0.5 mEq/kg every 10 minutes PRN
Atropine: 1.0 mg repeated every 3 to 5 minutes to a total of 0.04 mg/kg
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Epinephrine: 1.0 mg repeated every 3 to 5 minutes

Amiodarone: 300-mg intravenous bolus with 150 mgPRN to total daily dose of 2 g
Calcium chloride: 2 to 4 mg/kg of the 10% solution
Lidocaine: 1.5 mEq/kg with 0.5 to 1.5 mg/kg every 5 to 10 minutes to a total of 3 mg/kg
Routine use of sodium bicarbonate is not helpful. However, in cardiac arrest resulting from
hyperkalemia, tricyclic antidepressant, or phenobarbital overdose or severe pre-existing
metabolic acidosis, sodium bicarbonate may be indicated.
Although evidence is weak for its efficacy, atropine is given for pulseless electrical activity and
asystole. Atropine has few adverse side effects and may be helpful when chest compressions,
oxygenation, and epinephrine have not resolved the situation.
Epinephrine remains the standard pharmacologic intervention for cardiac arrest. Studies
comparing high-dose (3–5 mg) epinephrine with a standard dose (1 mg) have failed to show
improved outcome with initial bolus dosing with high-dose epinephrine. However, it is beginning
to appear that if initial therapy with standard-dose (1 mg) epinephrine fails, a second higher
dose (3–8 mg) should be considered.
Calcium chloride is indicated during cardiac arrest resulting from hyperkalemia, for
hypocalcemia, and during calcium channel blocker toxicity. Calcium chloride is recommended
because it produces higher and more consistent ionized calcium levels than other salts.
Calcium gluconate contains one third as much molecular calcium and requires gluconate
metabolism in the liver.
Amiodarone is helpful at suppressing ectopic activity and aiding defibrillation when ventricular
fibrillation is refractory to electrical countershock therapy. (See page 1539: Pharmacologic
Therapy.)
5. All of the following statements regarding patient ventilation during cardiac arrest are
true EXCEPT:
A. Mouth-to-mouth ventilation is sufficient to maintain viability.
B. During rescue breathing without an endotracheal tube, volumes of 2 L should be
given quickly (i.e., <1 sec).
C. Studies have shown that cricoid pressure may prevent gastric insufflation and gastric
distention.
D. During rescue breathing with a single rescuer, current recommendations are two
breaths every 30 compressions.
E. During rescue breathing with an endotracheal tube, breaths should be given at a
steady, continuous rate without a pause in chest compressions.
5. B. Mouth-to-mouth ventilation is effective at maintaining viability in victims of cardiac arrest
despite a relatively low O2 content (∼17%). During rescue breathing without an endotracheal
tube, care must be made to avoid insufflating the stomach. Large breaths (0.5–0.6 L) given over
1 to 2 seconds during pauses in chest compressions are effective for delivering proper tidal
volumes without distending the stomach. The Sellick maneuver has also been shown to reduce
or eliminate gastric insufflation, although two rescuers are often needed to accomplish this
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correctly. During cardiopulmonary resuscitation (CPR) in adults and one-rescuer CPR in
children, a pause for two breaths should be made after each 30 chest compressions. When
there are two rescuers with a child victim, a pause for two breaths should be made after each
15 compressions. After definitive airway management is achieved with endotracheal intubation,
interrupting chest compressions for breaths is unnecessary. In fact, circulation and subsequent
oxygenation have been shown to improve with continuous chest compression. Pausing during
mouth-to-mouth ventilations, however, is still necessary to reduce airway resistance, improve
ventilation, and reduce gastric insufflation. (See page 1535: Ventilation; page 1536: Physiology
of Ventilation During Cardiopulmonary Resuscitation; and page 1536: Techniques of Rescue
Breathing.)
6. All the following statements regarding the adequacy of circulation are correct
EXCEPT:
A. Myocardial perfusion correlates with diastolic pressure, and the pulse pressure
correlates with systolic pressure.
B. A minimum blood flow of 15 mL/100 g/min of myocardium is necessary for successful
resuscitation.
P.308
C. The critical coronary perfusion pressure is associated with a diastolic pressure of 40
mm Hg or above.
D. The end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR) is
an accurate measure of tissue perfusion.
E. Ten to 15 minutes after administration of bicarbonate, ETCO2 will return to previous
baseline.
6. E. The adequacy of closed-chest compression is usually judged by palpation of a pulse in
the carotid or femoral vessels. The palpable pulse primarily reflects systolic pressure. Cardiac
output correlates well with mean pressure and coronary perfusion with diastolic pressure. In
experimental models, a minimum blood flow of 15 to 20 mL/100 g/min of myocardium has been
shown to be necessary for successful resuscitation. During standard CPR, critical myocardial
blood flow is associated with aortic diastolic pressure of 40 mm Hg or above. ETCO2 has also
been found to be an excellent noninvasive guide to the adequacy of closed-chest
compressions. CO2 excretion during CPR with an endotracheal tube in place is flow dependent
rather than ventilation dependent. Sodium bicarbonate administration liberates CO2 into the
blood and causes a temporary increase in ETCO2. The elevation returns to baseline within 3 to
5 minutes of drug administration, and ETCO2 monitoring can again be used for monitoring
effectiveness of closed-chest compressions. (See page 1536: Circulation: Assessing the
Adequacy of Circulation During Cardiopulmonary Resuscitation.)
7. Which of the following statements is TRUE&quest;

A. According to advanced cardiac life support protocol, medication administration is key
to survival in patients in cardiac arrest.
B. Epinephrine, lidocaine, atropine, and sodium bicarbonate can all be given through the
endotracheal tube.
C. The efficacy of epinephrine use for cardiac arrest results from its strong β -adrenergic
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stimulus.
D. Of all the medications currently used in advanced cardiac life support, only
epinephrine is acknowledged as being effective at regaining spontaneous cardiac
function.
E. A possible postresuscitation complication of epinephrine is hypotension.
7. D. Although adjunctive medications such as bretylium, lidocaine, and atropine have been
shown to be helpful to maintain rhythm after cardiac function returns, only epinephrine is
acknowledged as being effective in regaining spontaneous cardiac function after cardiac arrest.
Medication administration should be secondary to airway management, chest compressions, or
defibrillation. Withholding these interventions to gain intravenous access and give medications
is contraindicated. Although atropine, lidocaine, and epinephrine can be given via the
endotracheal tube, sodium bicarbonate should not be given by this route. Medications given via
the endotracheal tube should be in doses two to 2.5 times larger than intravenous doses and in
volumes of 5 to 10 mL to ensure proper drug delivery and systemic effect.
Epinephrine's efficacy during cardiac arrest is related to its strong α -adrenergic properties. The
α -adrenergic activity causes peripheral vasoconstriction, increased aortic diastolic pressure,
and improved myocardial blood flow. Possible postresuscitation complications of epinephrine
use are hypertension and tachyarrhythmias. Despite this, epinephrine is the vasopressor of
choice in cardiopulmonary resuscitation because of strong animal study evidence of its efficacy
and extensive clinical experience with its use in humans. (See page 1539: Pharmacologic
Therapy: Routes of Administration and page 1541: Catecholamines and Vasopressors.)
1. The recommended first step in airway management for cardiac arrest is the head-tilt
–chin-lift or jaw-thrust maneuver.
2. Endotracheal intubation is the most definitive airway control method and limits the risk
of aspiration.
3. A complication of abdominal thrust includes spleen or liver laceration.
4. Signs of total airway obstruction include a raspy voice or wheezing respirations.
8. A. The recommended first step in airway management of the unconscious victim is to perform
the head-lift–chin-lift maneuver. This allows the tongue to move anterior to the posterior
pharynx and creates a passage for airflow. The jaw-thrust maneuver (lifting the jaw forward with
anterior force on the angle of the mandible) is also effective. If cardiopulmonary resuscitation is
required for a longer time, the most definitive means of airway management is endotracheal
intubation. If airway obstruction results from a foreign body, signs of total airway occlusion
include lack of air movement despite respiratory efforts and an inability to speak or cough.
Abdominal thrusts are recommended to help dislodge the foreign body when total occlusion is
present. Injury may occur with abdominal thrust, including liver or spleen laceration, gastric
injury, or regurgitation. (See page 1534: Airway Management and Foreign Body Airway
Obstruction.)
9. Which of the following statements regarding the mechanism and physiology of
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cardiopulmonary resuscitation (CPR) is/are TRUE&quest;
1. The cardiac pump mechanism assumes that sternal compression increases
intraventricular pressure.
2. The thoracic pump mechanism assumes that sternal compression increases
intrathoracic pressures in all cardiac chambers equally.
3. Abdominal compression or ventilation with chest compression increases arterial
pressure.
4. Chest wall compliance influences the mechanism of blood flow during CPR.
9. E. Although various techniques have been investigated regarding circulation during CPR, no
theory or technique has shown improvements in survival over standard CPR. Thus, standard
ventilation with chest compressions is still recommended as the most efficacious means of
ventilatory support. Research continues regarding alternative means of circulation. The cardiac
pump mechanism assumes that sternal compression increases intraventricular pressure, thus
leading to mitral and tricuspid valve closure, causing forward blood flow as intrathoracic
pressure increases. The thoracic pump mechanism assumes that sternal compressions
increase intrathoracic pressures in all cardiac chambers equally, that the heart is merely a
passive conduit, and that forward flow during increased intrathoracic pressure is the result of
backflow prevention in the venous system by the valves in the subclavian and internal jugular
veins that favors flow into nondistensible arteries (i.e., aorta and carotids). Evidence supporting
the thoracic pump mechanism includes the observation that simultaneous abdominal
compression or ventilation with chest compression increases arterial pressure and carotid blood
flow compared with standard CPR. Factors that may influence the mechanism of blood flow
during CPR include chest wall compliance and configuration, heart size, sternal compression
force, and the duration of cardiac arrest. (See page 1536: Circulation; page 1536: Cardiac
Pump Mechanism; and page 1536: Thoracic Pump Mechanism.)
10. Which of the following statements concerning defibrillation is/are TRUE&quest;

1. The most important determinant of failure to resuscitate a patient with ventricular
fibrillation is the duration of ventricular fibrillation.
2. Defibrillation is significantly more successful if epinephrine is given immediately before
application of current.
3. Defibrillation occurs via current passing through a critical mass of myocardium,
causing simultaneous myofibril depolarization, with the primary determinant of energy
delivery being transthoracic impedance.
4. Because of large body size, adult patients in cardiac arrest respond better to initial
energy levels of 50 to 100 J.
10. B. Research continues to support the efficacy of immediate defibrillation. Decreasing time to
defibrillation strongly correlates with survival. Defibrillation within 1 minute of fibrillation obviates
the need for cardiopulmonary resuscitation. Although the amplitude of fibrillation waves
correlates with the success of defibrillation, and α -adrenergic agonists (e.g., epinephrine)
increase fibrillation amplitude, little evidence supports increased success of defibrillation after
epinephrine administration. On the contrary, defibrillation should not be delayed at all when
indicated.
Defibrillation is the simultaneous depolarization of fibrillating myofibrils, thus providing an
488 / 494
environment for more effective myocardial contraction and re-establishment of automatism. The
average transthoracic impedance in human defibrillation is 70 to 80 ohm. Resistance is
probably of little clinical significance when reasonably proper technique and high-energy (300
J) shocks are used. Although optimal energy level is not known, expert consensus is that the
2005 guidelines should change the algorithm for applying shocks with monophasic defibrillators
to a single shock of 360 J with immediate resumption of chest compressions.
Less myocardial damage, improved postdefibrillation rhythm, and improved ability to convert
have been demonstrated with lower energy levels with biphasic shocks with 150 J as the initial
value. (See page 1545: Electrical Pattern and Duration of Ventricular Fibrillation; page 1545:
Defibrillators: Energy, Current, and Voltage; and page 1546: Adverse Effects and Energy
Requirements.)

1. Children usually experience cardiac arrest primarily because of intrinsic cardiac
dysfunction.
2. When indicated, standard defibrillation energy levels in children are 2 J/kg, and these
are doubled if defibrillation fails.
3. To prevent postresuscitation cerebral hyperemic flow, mean blood pressure should be
maintained below 90 mm Hg.
4. A high correlation exists in postresuscitation patients between neurologic function and
mild hypothermia (32° to 34°C).
11. C. Cardiac arrest is less likely to be a sudden event and is more likely related to progressive
deterioration of respiratory and circulatory function in the pediatric age group. Airway and
ventilation problems lead to asystole and pulseless electrical activity as the most common
presenting rhythms. However, the consequences of myocardial and cerebral ischemia are the
same as for adults. Effective ventilation is especially critical because respiratory problems are
frequently the cause of arrest. Mouth-to-mouth or mouth-to-nose and -mouth (for infants)
ventilation can be used as well as bag-valve mask devices until intubation is possible. Although
defibrillation is less frequently necessary in children, the same principles apply as in adults.
However, the recommended starting energy is 2 J/kg, which is doubled if defibrillation is
unsuccessful. Considerations for drug administration are the same as for adults except that the
interosseous route in the anterior tibia provides an additional option in small children. The major
factors contributing to mortality after successful resuscitation are progression of the primary
disease and cerebral damage suffered as a result of the cardiac arrest. Because cerebral
autoregulation of blood flow is severely attenuated, both prolonged hypertension and
hypotension are associated with a worsened outcome. Therefore, mean arterial pressure
should be maintained at 90 to 110 mm Hg. For comatose survivors of cardiopulmonary
resuscitation, the question of ultimate prognosis is important. Most patients who completely
recover show rapid improvement within the first 48 hours. In contrast to pharmacologic therapy,
two more recent studies have demonstrated improved neurologic outcome when mild
therapeutic hypothermia (32° to 34°C) was induced for 12 to 24 hours in cardiac arrest
survivors who remained comatose after admission to the hospital. (See page 1549: Pediatric
Cardiopulmonary Resuscitation; page 1552: Postresuscitation Care; and page 1555:
Prognosis.)
489 / 494
Review of Clinical Anesthesia, 5e [Vishal] 60. Disaster Preparedness
Chapter 60
Disaster Preparedness
1. The US federal agency in charge of organizing emergency assistance to state and

local governments in the event of a disaster is:
A. Federal Emergency Management Agency (FEMA)
B. Food and Drug Administration (FDA)
C. National Guard
D. The Joint Commission
E. Centers for Disease Control and Prevention (CDC)
1. A. FEMA provides management assistance to state and local governments in response to
disaster. FEMA assists by distributing emergency relief to affected individuals and businesses,
decontaminating affected areas, and helping to ensure public health safety. The Joint
Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations
[JCAHO]) has made recommendations to help hospitals create emergency preparedness plans,
but it is not part of the direct response to disaster management. The National Guard may be
called on to assist in disaster management but is not a lead agency by definition. The CDC also
has a role in disaster planning and response, specifically with the dissemination of necessary
medical and surgical supplies to affected regions. However, the CDC does not take the lead in
providing support to local and state governments when disaster occurs. The FDA has no direct
role in emergency planning or response. (See page 1563: Disaster Preparedness: Role of
Government.)
2. The initial response to any disaster situation occurs at what level of

government&quest;
A. Local
B. State
C. Federal
D. Judicial
E. Executive
2. A. The initial response to any disaster occurs at the local level. If the situation calls for
resources beyond the capacity of local authorities, state emergency management resources
and the National Guard may be mobilized through the governor's office. Federal authorities may
also be called in if the situation warrants assistance beyond state control. (See page 1563:
Disaster Preparedness: Role of Government.)
3. Which of the following statements regarding the National Pharmaceutical Stockpile

is FALSE&quest;
A. It includes airway maintenance supplies.
B. It was established by the Centers for Disease Control and Prevention (CDC).
C. It is organized in two phases, the first phase involving distribution of prepackaged
490 / 494
“push packages” with critical medical supplies and a second phase in which additional
resources can be quickly mobilized if necessary.
D. It includes certain antibiotics and chemical antidotes.
E. It is controlled by the Federal Emergency Management Agency (FEMA).
3. E. The National Pharmaceutical Stockpile was established by the CDC to ensure the rapid
availability of medical supplies to facilitate emergency response in the event of a national
disaster. The stockpile contains specific antibiotics, chemical antidotes, life-support
medications, intravenous administration supplies, and airway maintenance supplies, as well as
other medical and surgical items. There are two phases to this program. The first is the
provision of eight separate yet identical prepackaged caches of medical materials called 12-
hour “push packages” that are deployed around the United States. The second involves
mobilizing specific additional supplies from vendor management inventories capable of arriving
within 24 to 36 hours of the initial request. FEMA does not have authority over the National
Pharmaceutical Stockpile. (See page 1563: Disaster Preparedness: Role of Government.)
4. The most common source of radiation injury comes from what type of
disaster&quest;
A. Detonation of a nuclear bomb
B. Terrorist attack
C. Nuclear power plant accident
D. Volcano eruption
E. Earthquake
4. C. The disaster most likely to cause radiation injuries is contamination from a nuclear power
plant or reactor. Although terrorist attacks and nuclear bomb detonations may also produce
radiation causing human injury, these events are far less common. Neither volcano eruptions
nor earthquakes typically involve radiation injury. (See page 1565: Radiation Injury.)
5. The American Academy of Pediatrics recommends that at least two tablets of

potassium iodide be available for emergency use among which of the following
populations&quest;
A. All children who live within 1 mile of nuclear power facilities
B. All inhabitants who live within 1 mile of nuclear power facilities
C. All children who live within 10 miles of nuclear power facilities
D. All inhabitants who live within 10 miles of nuclear power facilities
E. All individuals working in nuclear power facilities
5. D. Because of the risk of exposure to ionizing radiation, the American Academy of Pediatrics
recommends that at least two tablets of potassium iodide be readily available for all inhabitants
within a 10-mile radius of nuclear power facilities. If taken soon enough, potassium iodide
protects the thyroid from the deleterious effects of radioactive iodine that may be released from
an accident involving a nuclear power plant or nuclear reactor. (See page 1565: Radiation
Injury.)
6. Which of the following types of radiation exposure has the deepest

491 / 494
penetrance&quest;
A. α Particles
B. β Particles
C. δ Particles
D. γ Rays
E. σ rays
6. D. Of the choices listed, γ rays have the deepest penetrance. In a nuclear accident, several
types of radiation exposure may occur, including exposure to α and β particles, as well as γ rays
and x-rays. These exposures are of various strengths. Human tissue can block α particles. In
contrast, β particles may be stopped by an aluminum shield, and γ rays and x-rays are stopped
only by a lead shield. Neither δ particles nor σ rays are types of ionizing radiation. (See page
1565: Radiation Injury: Potential Sources of Ionizing Radiation Exposure and page 1566: Table
60-7: Types of Radiation.)
7. Which of the following tissues are most sensitive to the effects of ionizing
radiation&quest;
A. Lymphoid > Gastrointestinal > Reproductive > Dermal > Nervous system
B. Dermal > Gastrointestinal > Lymphoid > Reproductive > Nervous system
C. Lymphoid > Reproductive > Gastrointestinal > Nervous system > Dermal
D. Lymphoid > Dermal > Reproductive > Gastrointestinal > Nervous system
E. Nervous system > Reproductive > Lymphoid > Dermal > Gastrointestinal
7. A. Tissue sensitivity to the effects of ionizing radiation varies based on cellular turnover rate.
In general, tissue with the highest turnover rate is most affected by exposure to ionizing
radiation. From greatest to least, sensitivity of human tissue to ionizing radiation is as follows:
lymphoid > gastrointestinal > reproductive > dermal > nervous system. (See page 1565:
Radiation Injury: Potential Sources of Ionizing Radiation Exposure.)
P.313
8. The influenza virus typically associated with pandemics, including the Spanish flu of
1918, is of type:
A. A
B. B
C. C
D. D
E. E
8. A. There were three large influenza pandemics in the twentieth century: one in 1918 during
World War I, another in 1957 and 1958, and a third in 1968 and 1969. All of these pandemics
were caused by antigenic shifts in the influenza type A virus. Major pandemics occur when a
change in viral surface antigens occurs (antigenic shift) and naïve human hosts are exposed to
a virus for which their immune systems have not made protective antibodies. Every year,
influenza A vaccines are prepared in an attempt to predict the most likely combinations of viral
492 / 494
surface antigens. However, because the behavior of the virus can be unpredictable, these
vaccines are not 100% protective, and the risk of major outbreaks caused by unforeseen
antigenic combinations is a persistent threat. (See page 1567: Biological Disasters: Epidemic:
Influenza.)
9. Specific therapy for high-dose exposure to cyanide includes:

A. sodium thiosulfate
B. arsine
C. pralidoxime chloride
D. hyperbaric oxygen
E. pyridostigmine
9. A. Cyanide ions are normally metabolized by the rhodanese liver enzyme in a sulfur-requiring
step that leads to the formation of methemoglobin. In the setting of cyanide poisoning, sulfur
stores are depleted, leading to enzymatic dysfunction. Treatment of cyanide poisoning therefore
includes administration of sodium thiosulfate as a sulfur donor to regenerate enzymatic
metabolism of cyanide ions. In the meantime, the patient may require tracheal intubation and
mechanical ventilation, sodium bicarbonate to treat metabolic acidosis, and inotropes and
vasopressors for hemodynamic support. Arsine is one of the cyanogens that may cause
cyanide toxicity, along with hydrogen cyanide, hydrocyanic acid, and cyanogen chloride.
Hyperbaric oxygen may play a role in the management of carbon monoxide poisoning but is not
indicated for cyanide poisoning. Pralidoxime chloride reactivates acetylcholinesterase and is
used to counteract the muscarinic and nicotinic stimulant effects of nerve agents that inhibit
acetylcholinesterase. Pyridostigmine is sometimes administered prophylactically in situations in
which exposure to a nerve agent is anticipated because it binds to acetylcholinesterase and
thereby protects it and allows for spontaneous enzyme regeneration. (See page 1572:
Chemical: Blood Agents.)
10. Which of the following statements regarding potential biological agents of terrorism
is/are TRUE&quest;
1. Smallpox transmission occurs mostly through aerosolized droplets.
2. The antibiotic treatment of choice for plague caused by Yersinia pestis is
streptomycin.
3. Bacillus anthracis is a gram-positive, spore-forming bacillus.
4. Francisella tularensis infection may present as a skin ulceration.
10. E. Several types of biological agents carry the potential to be used as agents of terrorism.
Smallpox is a highly infective virus that is most commonly transmitted via aerosolized droplets.
Infection causes a prodrome of malaise, headache, and backache followed by the onset of high
fever. As the fever subsides, smallpox lesions of multiple stages appear and are often
particularly prominent on the face and distal extremities. Although it is infrequently fatal,
smallpox is considered a biological threat because of its high infectivity and ability to cause
significant and rapid morbidity. B. anthracis is a gram-positive spore-forming bacterium that
causes three main types of infection: cutaneous, inhalation, and gastrointestinal. Anthrax
493 / 494
spores are extremely resistant to destruction and may survive dormant in the soil for years.
Inhalational anthrax is the most lethal form of infection, although it is far less common than the
cutaneous form. In addition to supportive care, treatment should include ciprofloxacin or
doxycycline. Y. pestis is a gram-positive bacillus that causes plague. The treatment of choice is
streptomycin, but chloramphenicol and tetracycline may also be used. F. tularemia is a gram-
negative rod that may be contracted by humans via direct contact with an infected animal (most
common), ingestion of infected food, or inhalation of aerosolized bacteria. The bacteria invade
the body via hair follicles or microabrasions of the skin. At the site of entry, swelling becomes
visible, followed by the development of a necrotic ulcer with a black eschar. Alternatively,
inhalation of tularemia may lead to the development of pneumonia. As with anthrax and plague,
the treatment of tularemia includes streptomycin antibiotic therapy. (See page 1567: Biological
Disasters: Biological Terrorism.)
11. Which of the following is/are a unit used to measure radiation exposure&quest;
1. Roentgen-equivalent-man (rem)
2. Sievert (Sv)
3. Gray (Gy)
4. Radiation absorbed dose (rad)
11. E. All of the units listed are measures of radiation exposure. Gray is the International
System unit of measurement for the energy deposited by any type of radiation in joules per
kilogram. Radiation absorbed dose also refers to the amount of energy deposited by any type
of radiation to any tissue or other material, where 1 rad = 0.01 Gray. Roentgen-equivalent-man
and sievert are used to quantify human exposure to radiation. The sievert is part of the
International System of units and, like the gray, is measured in joules per kilogram. One sievert
(1 Sv) is equivalent to 100 rem. (See page 1565: Radiation Injury: Potential Sources of Ionizing
Radiation Exposure and page 1566: Table 60-7: Types of Radiation.)
12. Which of the following is/are a category A biological agent(s)&quest;

1. Variola major
2. Clostridium botulinum
3. Bacillus anthracis
4. Vibrio cholerae
12. A. Potential biological agents of warfare are classified into three categories based on
degree of threat to national security: categories A, B, and C. Category A agents have the
greatest potential to cause harm as a result of relative ease of transmission and high mortality.
Bacillus anthracis (anthrax), Variola major (smallpox), Yersinia pestis (plague), Clostridium
botulinum (botulism), Francisella tularensis (tularemia), and the viruses that cause
hemorrhagic fever (Ebola, Lassa, Marburg, Argentine) are the six agents currently listed in
category A. Vibrio cholerae (cholera) is a category B agent. (See page 1567: Biological
Disasters; and page 1569: Table 60-9: Biological Agents Used for Warfare.)
494 / 494

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What are the main types of biological agents that could potentially be used as weapons?

What are the main types of biological agents that could potentially be used as weapons?

What are the main characteristics of smallpox infection?

What are the main characteristics of smallpox infection?

Table of Contents

© 2009 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business

Neil Roy Connelly MD

Katharine O'Donnell Freeman MD

Karthik Raghunathan MD, MPH

Lakshmi Priya Yalavarthy MD

[-] Section II - Scientific Foundations of Anesthesia

[-] Section III - Anatomy and Physiology

[-] Section IV - Anesthetic Agents, Adjuvants, and Drug Interaction

[-] Section V - PreAnesthetic Evaluation and Preparation

[-] Section VI - Anesthetic Management

[-] Section VII - Anesthesia for Surgical Subspecialties

1. Ancient Egyptian pictographs display nerve compression to possibly produce

6. In 1845, an anesthetist gave a public demonstration of nitrous oxide at the

D. Dr. Horace Wells

9. Which notable advancement in the field of anesthesiology can be credited primarily

D. Flexible fiberoptic bronchoscope

17. Trichloroethylene, a nonexplosive volatile anesthetic, releases what compound

24. Who described a continuous spinal anesthetic technique in or around 1940&quest;

25. Dr. Achille Dogliott described what anesthetic technique in 1931&quest;

26. Who first described the technique of intravenous regional anesthesia in

29. This person is credited with advancing American anesthesiology professional

1. Cocaine was the first effective local anesthetic.

4. All of the following facts are true EXCEPT:

7. After a critical adverse event occurs, which of the following should be

8. Computer scheduling of cases has advantages over handwritten systems in which

10. Which of the following regarding antitrust considerations is/are TRUE&quest;

2. Which of the following statements concerning tuberculosis (TB) is FALSE&quest;

3. Airborne precautions are an effective preventive measure against which of the

(See page 67: Table 3-3, Prevention of Occupationally Acquired Infections.)

4. Signs of substance abuse inside the hospital include:

7. Which of the following statements about methylmethacrylate is/are TRUE&quest;

8. Which of the following statements regarding latex allergy is/are TRUE&quest;

9. Which of the following statements concerning influenza viruses is/are TRUE&quest;

10. Which of the following forms of hepatitis primarily is/are transmitted by

12. Which of the following statements is/are TRUE&quest;

13. Which of the following statements concerning hepatitis B is/are TRUE&quest;

15. Which of the following statements is/are TRUE&quest;

1. All the following statements are true EXCEPT:

2. The court establishes “standard of care” through all of these EXCEPT:

3. Which of the following statements concerning risk management and quality

6. Which statement about continuous quality improvement (CQI) is FALSE&quest;

9. Considering the cause of lawsuits against anesthesiologists, which of the following

11. If a physician is deposed by a plaintiff's attorney, the physician should do which of

14. Considering quality improvement programs, which of the following statements

1. For volatile anesthetics, potency is proportional to:

2. The Meyer-Overton rule:

3. In humans, the definition of minimum alveolar concentration (MAC) is:

5. Which of the following statements is/are TRUE&quest;

6. General anesthetics have been shown to inhibit excitatory synaptic transmission in

Match the following genetic terms with the appropriate definitions:

6. The term used to refer to nearby single nucleotide polymorphisms on a

8. After cardiac surgery, what is the incidence of significant neurologic morbidity

9. Malignant hyperthermia follows what pattern of inheritance&quest;

10. In classical genetics, what is meant by “wild-type” individual&quest;