Hints For The ABA Anesthesiology Boards 4th Ed

Helpful Hints for
Mastering the ABA

Anesthesiology
Boards
4th Edition
D. John Doyle
Hints for the ABA Anesthesiology Boards, 4th Ed
Introduction
These informal notes are directed at

individuals preparing for the oral
examination of the American Board of
Anesthesiologists and other oral
examinations in anesthesiology. The notes
are the fourth edition of an earlier effort that
was first self-published as a free download
in 2006.
The current edition has been extensively

updated to reflect advances in anesthesia
practice and changes in the American Board
of Anesthesiologists examination process.
This is not an anesthesia textbook, but more

of a wide-ranging, self-paced collection of
hints, suggestions, stories, scenarios, and
anecdotes to help candidates prepare for
what is likely the most important
examination of their career.
Hints for the ABA Anesthesiology Boards Fourth Edition 2022 Rev 037 5point5 by 8point5 Format
1
The book begins with three little essays and

then moves on to offer a series of helpful
suggestions and a number of cases for
consideration. The hints offered herein are
broad and eclectic in nature, and some
important themes are repeated throughout
the book to serve as reinforcement.
In addition to discussion within the main

text of the book, a section towards the end of
the book provides numerous cases for
consideration. In most cases a scenario is
presented without providing a specific
blueprint for action, just a reminder to the
reader of the many excellent resources
available to develop a plan for each
encountered scenario.
Corrections, suggested case scenarios, ideas

for improvement and similar suggestions are
readily accepted, and may be directed to me
at [email protected].
Free PDF copies of the book are also

available at by writing me at the above email
address; these copies are formatted for easy
display on tablet devices. Also, please feel
free to redistribute these PDF copies to your
colleagues.
2
Finally, I would like to offer a special thanks

to three now-retired anesthesiologists who
kindly provided excellent material for some
of the material herein: John E. Tetzlaff, MD,
Walter Mauer, MD and Mary Ellen Cook,
MD, FRCPC.
D. John Doyle MD PhD DPhil
Cleveland Clinic and
Case Western Reserve University
January 2022
3
Vitae
Dr D. John Doyle is an anesthesiologist at

Cleveland Clinic, in Cleveland, Ohio, where
he holds the rank of Professor. He also spent
time working at Cleveland Clinic Abu
Dhabi, where he served as the Chief of the
Department of General Anesthesia.
Dr. Doyle received the MD, PhD and

FRCPC qualifications at the University of
Toronto in Toronto, Canada in 1982, 1986
and 1986 respectively. He then worked at
Toronto General Hospital, followed by
accepting a position at Cleveland Clinic in
2002.
Although he has numerous scholarly

publications in the fields of medicine and
anesthesiology, particularly in relation to
patient monitoring technology and difficult
airway management, in recent years he has
developed his long-standing interest in
philosophy by branching into occasional
research and academic writing in the fields
of ethics and bioethics. For this work he was
awarded the DPhil degree in 2017.
4
Dedication
This book is dedicated to my wife of four

decades, Jo-Anne Williams, and our son
Jonathan. I remain eternally grateful for
their support of my never-ending academic
pursuits.
I would also like to dedicate this work to the

numerous anesthesia residents I have had the
joy to work with over many years.
5
Organization of This Book
This book is organized into the following

four sections, as detailed in the following
pages.
Part I: Commentaries
Part II: Random Helpful Hints
Part III: Scenarios to Know
Part IV: Cases for Discussion
6
This part of the book contains three

thoughtful short essays to get you started
• How to Prepare for the Boards
• Organizing and Managing an

Anesthetic Case
• What to Do When You Don't

Know What to Do
7
Part II: Random Helpful Hints
This part of the book, the largest part,

contains numerous helpful hints for you
to consider. These hints are arranged in
no particular order, although that begin
by introducing the reader to the ABA
examination process.
8
This part of the book contains numerous

clinical scenarios for you to prepare for.
• Twelve obstetrical scenarios
• Twelve pediatric scenarios
• Twelve cardiac scenarios
• Twelve pulmonary / thoracic scenarios
• Twelve airway scenarios
• Twelve neurological scenarios
9
This part of the book contains numerous

clinical cases for you to consider.
• Eleven Short Cases for Discussion
• Short Discussion Questions
• Sample Full Case
• Seven Old ABA Examinations
10
11
Commentary One
How to Prepare for the Boards
… in order of priority A.B.C.
Courtesy of Mary Ellen Cooke, MD, FRCPC
A
1. Spend as much time in the O.R. as
possible in the 6-12 months prior to the
exam.
2. Read about your cases, think about cases,

plan them, discuss them with staff and
colleagues, prepare for them, think of
alternative plans of action.
3. Ask to be left to work independently i.e.,

not just in the middle of the case but at
induction and emergence. Afterwards think
about what you would have done differently
and what you learned. Follow up your cases
(ICU, PACU, ward). Be keen to do consults.
Keep an eye on the emergency board for
interesting cases and look in on or help with
traumas, obstetric emergencies etc. even if
you are not on call.
Attend and actively participate in case
discussions.
12
1. Review and organize in simple point

form:
• Your knowledge base

(surgical and medical diseases).
• Your management of routine cases.
• Recognition and management of

emergencies.
• Anesthesia equipment and

techniques.
2. Devise your own personal format or

framework for approaching a consult or a
case from pre-operative assessment, to
premed, to setting up the room induction,
maintenance, emergence, post-operative
care and long term follow up i.e.
conceptualize and formalize and hone the
approach you use in #1.
13
1. Participate in practice oral examinations
2. Group orals allows exposure to many

different examiners, examining styles and
lots of different questions as well as to other
candidates and their knowledge, judgment
and style of answering.
Candidates can learn from examiners and

other examinees. It can be positively
reinforcing or negatively reinforcing (but
hopefully in a constructive and stimulating
way) to see how you performed are assessed
vis a vis other candidates. Go to all of them.
3. One on one orals give you stamina

training i.e. more questions, no rest periods,
and practice in the necessary ability to go on
to a new question when the previous
questions may have been answered.
14
Commentary Two
Organizing and Managing an Anesthetic

Case
1. PREOPERATIVE ASSESSMENT
- History (including anesthetic history,

previous airway problems)
- Physical (esp. cardiopulmonary)
- Lab (esp. hemoglobin, EKG)
- Consent (problems: underage,

unconscious, Jehovah’s Witness child)
- Consultations (e.g., cardiology consult in

patient with recent myocardial infarct)
- Blood bank (e.g., crossmatch)
- Fasting status (how many hours for

liquids? for solids? special rules for kids)
Old anesthetic charts can be especially

helpful
15
2. PATIENT PREPARATION
Optimization (e.g., fluids or blood with

hypovolemia, preoperative bronchodilators,
antihypertensive treatment)
Drugs
- preoperative sedation
- usual medications
- antacids or H2 blockers
(e.g., patient with full stomach)
- drying agents (glycopyrrolate)
- prophylactic drugs
(e.g., bronchodilators)
- drugs to discontinue
(e.g., MAOIs, ARBs)
16
3. OR PREPARATION
“MSMAID” is a good mnemonic:
Machine check
Suction
Monitoring equipment
Airway supplies
IV lines
Drugs
17
4. INDUCTION CONCERNS
Drugs to be drawn up for emergencies

... may include atropine, nitroglycerine,
ephedrine, phenylephrine, esmolol etc.
Venous access needs (bloody cases)

... cardiac redo cases, liver transplant cases,
coagulopathy (hemophilia, von Willebrands,
extreme liver disease etc.)
Special monitoring needs

(CVP line, PA line, Evoked Potentials,
EEG)
Hypovolemic patient
... how to decide if replacement is OK
Hypertensive patient
... how to decide when an arterial line is
needed
Increased ICP
... lidocaine vs esmolol ?dose ?timing
Difficult Airway
… awake vs. asleep intubation; special
equipment
Full Stomach
… regional vs. RSI vs. awake intubation
Unstable Cervical Spine

… awake vs. asleep; special equipment
18
5. MAINTENANCE CONCERNS
Adequate depth of anesthesia
Maintaining fluid balance
What to do about decreased urine

output
Deciding when and what to transfuse
What degree of muscle relaxation?
6. EMERGENCE CONCERNS
Extubate wide awake (e.g., full

stomach)
Delayed extubation (e.g., ICU

transfer)
Avoid coughing (e.g., ENT cases,

increased ICP)
7. POSTOPERATIVE CONCERNS
Orders
Analgesia (epidural vs. IV vs. PCA)
Postoperative monitoring
Possible need for ICU bed
19
Commentary Three
What to do When You Don't

Know What to do
Know the "clinical crisis protocol":

“Look, Listen, Feel, Get”
Use it to enrich your answers.
The "crisis protocol" is an approach to managing

the patient whose life is in danger (e.g., from
stridor) and when there is limited time to act.
More examples are given in the table below.
Because response time is so limited, diagnosis of
the problem must be accompanied by empirical
treatment, i.e., diagnosis and treatment must be
carried out concurrently, even when it may be far
from clear what is going on. For example, severe
bradycardia (heart rate < 40) may or may not be
associated with symptoms such as syncope and
can be due to many different causes (e.g., third
degree heart block, beta blocker overdose, use of
an anticholinesterase without sufficient
anticholinergic (e.g., neostigmine without
glycopyrrolate or atropine), increased intracranial
pressure, etc.).
The book Crisis Management in Anesthesiology

by Gaba, Fish, Howard, and Burden (2014)
(ISBN-13: 978-0443065378; ISBN-10:
9780443065378) presents a basic protocol for the
management of serious problems.
21
While empirical treatment is essential while

diagnostic measures are in progress (for example,
giving intravenous atropine (0.6- 1 mg) in the
case of symptomatic severe bradycardia), there
are several other equally important aspects of
successful crisis management. These include (1)
mobilizing and allocating all available resources
(e.g., personnel, supplies and equipment,
cognitive aids such as checklists, and external
resources such as lab services and consultants),
(2) proper allocation of attention during this
period of high demands, (3) planning ahead and
anticipating (i.e. "staying ahead of the game"),
(4) efficient distribution of the workload amongst
all available personnel, and (5) frequent
reevaluation the situation to avoid fixation errors.
Note that, the initiation of immediate life-support

measures applies to virtually all crises. These
measures include (1) discontinuing anesthetics
(intraoperative crises), (2) increasing the oxygen
concentration to 100%, (3) maintaining
oxygenation at all costs (if in doubt about a
ventilation system or oxygen supply, use a
backup system or alternate oxygen source, and
(4) ensuring that the patient has a pulse and that
blood pressure is acceptable (if not, commence
ACLS protocol).
22
Examples of Urgent Clinical Problems

Requiring Immediate Intervention
• Intraoperative ventricular tachycardia,

cardiac arrest
• Cyanosis in recovery room
• Grand-mal seizures
• Severe bradycardia
• Severe tachycardia
• Stridor
• Syncopal attack
23
Some Forms of Initial Empirical

Treatment
• Dx: Symptomatic bradycardia
Rx: IV atropine 0.6 - 1 mg
(or IV glycopyrrolate 0.2-0.4 mg)
• Dx: Postintubation sinus tachycardia in

patient with coronary artery disease
Rx: IV esmolol 10-40 mg
• Dx: Sustained apnea

Rx: Positive pressure ventilation
• Dx: Pulseless ventricular tachycardia

Rx: Treat as ventricular fibrillation with
defibrillation and ACLS protocol
• Dx: Severe hypoxemia

Rx: 100% oxygen +/- endotracheal
intubation
• Dx: Ventricular fibrillation

Rx: Defibrillation; ACLS Protocol
24
Approach to the Patient in Crisis:
"Look, Listen, Feel, Get"
Look
• Color - cyanosis (hypoxia) - pallor –
patient’s ethnicity (e.g., sickle cell
disease in Blacks)
• Restlessness / discomfort
• Diaphoresis
• Wound Sites / Drains
• Neck - Jugular venous pulsations -
Trachea - Hematomas
(e.g. post carotid surgery)
• Respiration - rate - depth - pattern
• Full body exposure/ secondary survey
Listen
• Listen to the patient's complaints and
observations of bystanders
• Stridor and other breathing noises
• Heart sounds (muffled? murmur?
gallop?)
• Air entry - equal bilaterally? -
wheezes? - crackles?
25
Feel
• Pulse
o rate
o intensity
o pattern
• Forehead - diaphoresis? - fever?
• Grip strength
• Subcutaneous emphysema
Get
• Help
• Crash cart and other
equipment/resources, as needed
• Vital signs
• Old chart
• Laboratory tests e.g. arterial blood
gases, chest x-ray, electrolytes, etc.
26
Part II: Hints
27
Hint Number 1
Be familiar with the various ABA certifications.
Note that while most readers of this book will be

preparing for ABA certification in anesthesiology,
the ABA offers many other related certifications,
as listed below in Table 1-1:
• Anesthesiology
• Critical Care Medicine
• Hospice and Palliative Medicine
• Pain Medicine
• Pediatric Anesthesiology
• Sleep Medicine
• Neurocritical Care
Table 1-1: Certifications currently available

from the ABA. An adult cardiac anesthesiology
certification examination is also in the works.
https://theaba.org/subspecialty%20certification%
20exams.html
28
Hint Number 2
Be familiar with the various examinations
leading to ABA certification in anesthesiology.
[1] Basic Examination
Typically taken at the end of the CA-1 year, this

200 question, 4-hour, single-best-answer MCQ
examination deals with basic science matters
pertaining to clinical anesthesia delivery with
questions pertaining to anatomy, pharmacology,
physiology, physics, mathematics and chemistry,
as well as matters pertaining to patient
monitoring, anesthesia equipment and ethical
matters.
For a “blueprint” for the examination, visit

https://theaba.org/pdfs/BASIC_Blueprint.pdf.
For a sampling of questions, go to

https://theaba.org/pdfs/BASIC_Questions.pdf
29
[2] Advanced Examination
Taken following the completion of anesthesia

residency, this clinically focused 200 question, 4-
hour, single-best-answer MCQ examination is
designed to evaluate the ability of a board
candidate to navigate complex clinical situations
that demand a consultant-level understanding of
pathophysiology and other knowledge domains.
It is a computer-based examination administered
twice annually at Pearson VUE centers
nationwide.
For a “blueprint” for the examination, visit

https://theaba.org/pdfs/ADVANCED_Blueprint.p
df.
For a sampling of questions, go to

https://theaba.org/pdfs/ADVANCED_Questions.
pdf
30
[3] Standardized Oral Examination (SOE)
This is the BIG examination that requires

special preparation. It is the examination
everyone worries about. The SOE is an
sometimes messy interactive oral examination
that places special value on well-organized
answers that appropriately prioritize the issues
identified in the stem question and answers that
focus on obtaining a safe clinical outcome.
Sample SOE questions are available at

https://theaba.org/pdfs/SOE_Questions.pdf as
well as at the Appendix at the end of the book
31
[4] Objective Structured Clinical Exam

(OSCE)
This examination is usually performed on the

same day as the SOE, but the focus here is more
on communication and professionalism skills
although it may also include some purely clinical
matters.
As an example, you might be required to discuss

with a patient a medication error you made
during their anesthetic or discuss with a surgeon
why the elective case she wishes to undertake
should be postponed so that the patient’s
condition can be optimized. Other possibilities
include interpreting an electrocardiogram or an
echocardiogram or generating an ultrasound
image on a simulated patient that would be
suitable for carrying out a nerve block or for
establishing vascular access.
Sample OSCE scenarios are available at

https://theaba.org/pdfs/OSCE_Scenarios_2021.pdf
In addition to these examinations, residents

typically take an In-Training Examination (ITE)
every February (Figure 2-1).
32
Figure 2-1. ABA examination timeline, modified

from https://theaba.org/pdfs/Staged_Timeline.pdf
33
Hint Number 3
Visit the ABA web site early on
Be sure to get your American Board of

Anesthesiologists (ABA) paperwork in EARLY.
It would be a shame if you had to delay taking
the examination because of a paperwork
technicality.
Deadlines and other important information are

available at the ABA website (Figure 3-1):
http://www.theaba.org/
Here is a description of the examination from the

old ABA website:
“The Part 2 Examination is

designed to assess a candidate’s
ability to demonstrate the
attributes of an ABA diplomate
when managing patients presented
in clinical scenarios. The
attributes are sound judgment in
decision making and management of
surgical and anesthetic
34
complications, appropriate
application of scientific
principles to clinical problems,
adaptability to unexpected
changes in the clinical
situations, and logical
organization and effective
presentation of information.”
“The exam is based on a guided

question which includes a brief
clinical history of a patient and
emphasizes the scientific
rationale underlying clinical
management decisions. Candidates
are expected to select and defend
their plans of management. They
must convince the examiners, ABA
Directors and other diplomates,
that their knowledge and judgment
are sufficient to earn the
confidence and respect of
colleagues and patients.”
35
Figure 3-1. Early on, you should visit the ABA

Web site at http://www.theaba.org exam (old
ABA website shown in this figure).
36
Hint Number 4
Valuable introductory videos from the ABA
Review the ABA introductory videos describing

the ABA oral and OSCE examinations. These are
available at
https://theaba.org/video%20gallery.html
The best videos to start with are:
• Mastering Part 2: Successful Candidate

Behavior (8 minutes, 37 seconds)
• Mastering Part 2: Improper Candidate

Behavior (7 minutes, 55 seconds)
• OSCE Overview (11 minutes, 55

seconds)
37
Additionally, here are some YouTube videos that

will be very helpful:
• Outline the Stems for Anesthesia Oral

Boards
https://www.youtube.com/watch?v=oHPc
uuKW984
• 5 Style Tips for Anesthesia Oral Boards

Success
https://www.youtube.com/watch?v=zTMp
9UUFBVk
• Preparing for the OSCE Portion of the

Anesthesia Boards
https://www.youtube.com/watch?v=et7T
OUu6S-k
38
Hint Number 5
More on Exam Objectives – Emphasis on
Pathophysiology
Always bear in mind a central emphasis in the

ABA oral examination is that underlying
pathophysiological principles are correctly
applied to the presented clinical scenarios. This
means that you are not only expected to know
WHAT to do in a variety of situations, but also
WHY.
Example: It is not enough to know that

succinylcholine can produce a deadly
hyperkalemic response in patients with spinal
cord injuries, in patients with severe burns, etc.
(Figure 5-1.). You should also be able to discuss
what happens at the acetylcholine receptor level
in these patients.
39
In case you forgot:
Acetylcholine receptor upregulation and receptor

morphology changes may occur following severe
burns, upper or lower motor neuron denervation
(e.g., stroke or spinal cord injury, respectively),
severe muscle trauma, prolonged intrabdominal
sepsis, and prolonged immobilization or ICU
care (bed rest, steroids, prolonged neuromuscular
blockade)1. Here, changes in the acetylcholine
receptor subunit type and/or an increase in
receptor density occur (as “immature”
acetylcholine receptors spread over the muscle
surface outside the motor endplate area).
HOWEVER, note that hyperkalemic cardiac
arrest following succinylcholine can also to be
caused by acute rhabdomyolysis2.
1
For details read Martyn JA, Richtsfeld M. Succinylcholine-induced
hyperkalemia in acquired pathologic states: etiologic factors and
molecular mechanisms. Anesthesiology. 2006 Jan;104(1):158-69. Review.
PubMed PMID: 16394702. Available online at https://emcrit.org/wp-
content/uploads/2012/05/Succinylcholine_induced_Hyperkalemia_in_Acq
uired.22.pdf
2
See Gronert GA. Cardiac arrest after succinylcholine: Mortality greater
with rhabdomyolysis than receptor upregulation. Anesthesiology 2001
94:523-529. Available online at
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1945111
40
Figure 5-1. A cognitive aid regarding

succinylcholine use obtained from an Emergency
Medicine website. It is helpful to divide
contraindications to succinylcholine into two
categories: diseases or conditions that cause
hyperkalemia and diseases or conditions that that
may cause an atypical or exaggerated response to
succinylcholine, such as absent or atypical
plasma cholinesterase (not shown in the chart!).
Source: Modified from

https://i1.wp.com/emcrit.org/wp-
content/uploads/2012/05/Sux-Slide1.png
41
Hint Number 6
Understand the Candidate Evaluation Process
When you prepare for the ABA examination,

bear in mind some of the questions that the
examiners ask themselves about the candidates
being examined:
• Does the candidate have a solid foundation of clinical

and basic-science knowledge that makes him or her a
real consultant in anesthesiology?
• Can the candidate apply that knowledge to real-world

clinical situations?
• How does the candidate approach a clinical problem?

Does he/she appropriately and systematically organize
and prioritize the clinical considerations? Is the
approach logical and well thought out?
• Have alternative options (like canceling the case) been

carefully explored and understood?
• Above all, does the candidate appear to be clinically

safe?
42
Hint Number 7
Books to Read or Consult While on Call

There are some great anesthesia books out there
that are worth keeping with you for ready
reference or formal study while on call.
[1] Rapid Review Anesthesiology Oral Boards.

This book uses an engaging question-and-answer
format to allow for quick items to review.
ISBN-13: 978-1107653665
ISBN-10: 1107653665
[2] Faust’s Anesthesiology Review. Provides 1

to 3-page chapters on topics that allow you to do
some quick reading as well as the foundation for
some self-study cards.
ISBN-10: 0323567029
ISBN-13: 978-0323567022
[3] Anesthesiologist’s Manual of Surgical

Procedures, 6th Ed. Lists surgical and
anesthetic considerations in considerable depth.
ISBN-10: 1496371259
ISBN-13: 978-1496371256
43
44
45
46
Hint Number 8
Courtesy of John E. Tetzlaff, M.D.
Travel and Hotels
Getting to the site of the ABA oral exam is part of

taking the exam. Depending on the exam site and
where the candidate lives, this can involve
anything from a brief car trip to a transcontinental
flight. It is essential that the candidate arrive at the
site at a reasonable hour on the day BEFORE the
scheduled exam date. There are little literally
thousands of things that could delay last minute
arrival. At worst, the exam becomes a failure
because of a traffic jam or flight delay. Even
arriving on time after a delay could increase an
already elevated stress level to unacceptable levels.
There are mixed opinions about staying in the

exam hotel. On the plus side, this allows the
opportunity to locate the report room in the
evening on the day before decreasing the stress
immediately before the test. On the downside, the
visual and auditory contact with other candidates
47
can cause the loss of confidence (over hearing last

minute studying or the stress of the “recently
examined”). A good compromise is to choose the
exam hotel but avoid common facilities like the
restaurant and bar, where the encounter of other
candidates is likely. Room service or a walk or
cab ride to a restaurant may be a good strategic
choice.
48
Hint Number 9
The Last 24 Hours
Proper preparation for the orals is a sustained

process involving study and practice oral exams
that extends over the entire residency. Last minute
preparation should be unnecessary and could be
counterproductive. When a good candidate
approaches the oral exam, the study process
reaches capacity and last-minute preparation can
have the effect of undermining confidence without
increasing readiness. Undermining confidence
works against preparation. In the last few days,
the intensity of study should taper, and at some
point, practice exams should cease. Filling your
luggage with books for the trip to the orals will
accomplish nothing but lumbar strain. Pack a
good novel or your favorite magazine for the brief
trip and RELAX.
The final day before your oral exam is a test of

self-control. The level of nervous energy you will
experience will match or exceed any that you have
experienced in your professional career. To
49
optimize your performance during the two hour

interval that really matters, you need to control
this nervous energy, channeling it in a positive
direction. Sleep during the night before the exam
is critical. Intoxication and over-caffeination are
enemies. The evening before your oral exam is a
time to do something relaxing – read a novel,
watch a movie, reality TV….. (whatever is
relaxing for you). Beta blockers and sleep aides
have been advocated by some, but the number of
adverse-outcome anecdotes argues strongly
against self-medication. The practice of
anesthesiology involves an early day routine, and
the morning of your oral exam should follow your
routine. If you eat breakfast before work, you
should eat breakfast. If not, don’t. Keep your
caffeine level where it normally is. Dress well but
conservatively – avoid fashion statements and
items of clothing that call attention to themselves.
Avoid being very early or getting down to the last
minute before departing from your room. Ladies
should plan to avoid using a purse, if possible, as
this is one more item to worry about. Having a
garment with a pocket for your hotel key and
writing implements avoids the panic of the
missing purse panic, since you must be physically
separated from the purse during the exam.
50
One final suggestion – there’s only 24

hours left. Stop studying.
The evening before your oral exam is a time to

do something relaxing, like listening to soothing
music. Image credit: Thinkstock
51
Hint Number 10
Be familiar with various ASA standards,

advisories, and practice guidelines.
[1] Basic Standards for Preanesthesia Care
[2] Standards for Basic Anesthetic Monitoring
[3] Practice Guidelines for Acute Pain

Management in the Perioperative Setting
[4] Practice Guidelines for Perioperative Blood

Management
[5] Practice Guidelines for Central Venous

Access
[6] Practice Guidelines for Management of the

Difficult Airway
[7] Practice Guidelines for Obstetric Anesthesia
[8] Practice Guidelines for the Perioperative

Management of Patients with Obstructive Sleep
Apnea
52
[9] Practice Guidelines for Moderate Procedural

Sedation and Analgesia
[10] Practice Guidelines for Postanesthetic Care
[11] Practice Guidelines for Preoperative Fasting

and the Use of Pharmacologic Agents to Reduce
the Risk of Pulmonary Aspiration
[12] Practice Advisory for Preanesthesia

Evaluation
[13] Practice Advisory for Intraoperative

Awareness and Brain Function Monitoring
The above exemplifies some of many ASA

standards, advisories, and practice guidelines you
should be familiar with.
A comprehensive list is available at

https://www.asahq.org/standards-and-guidelines
53
Hint Number 11
Free Board Prep Resources
[1] Content Outline for Initial Certification in

Anesthesiology
Released in 2019, this 43-page PDF document is

a valuable resource for all the ABA’s
examinations, including their In-Training
examinations taken every February. This
document lists the material for which board-
certified anesthesiologists are expected to have a
thorough knowledge.
https://theaba.org/pdfs/Initial_C
ertification_Content_Outline.pdf
54
[2] Sample Questions from the M5 Board

Review.
The M5 Board Review is a question bank of

over 1000 multiple choice questions (MCQs)
with detailed answers and explanations.
While the full service is not free, they do offer a

free sampling of 25 MCQs with detailed answers
that are worth going through.
https://m5boardreview.com/sample-
questions/
55
Hint Number 12
Prep Resources that Mostly Cost Money
[1] Released in 2019, AudioDigest's

Anesthesiology Board Review provides a
comprehensive audio preparation platform for the
anesthesiology boards. Besides covering all the
expected clinical topics in some 50 hours / 64
lectures of material, this comprehensive review
course also offers helpful strategies for study and
test taking.
https://www.audio-
digest.org/Products/Board-
Review/Anesthesiology
[2] The M5 Board Review is a question bank of

over 1000 MCQs with detailed answers and
explanations.
https://m5boardreview.com/
56
[3] Released in 2020, this offering from Oakstone

CME is entitled Comprehensive Review of
Anesthesiology. It is an online course that
includes case-based lectures covering a broad
range of clinical topics likely to be helpful in
board preparation.
https://oakstone.com/comprehensive-
review-of-anesthesiology/
[4] The Ultimate Board Prep (UBP) team offers

a variety of board examination preparation plans,
including online video programs, as well as
materials for the SOE and OSCE examinations.
Private online examinations are also offered. Of
note, several free trial products are also offered
(registration required). A sampling of eight
UBP clinical scenario questions with wonderfully
detailed answers is available at
https://www.frca.co.uk/SectionContents.
aspx?sectionid=164
The UBP home web site can be accessed at
https://www.ultimateboardprep.com
57
[5] The TRUELEARN folks offer MCQ practice

questions pertaining to the ABA’s Basic and
Advanced examinations. Check them out at
https://truelearn.com/anesthesiology/
They also offer helpful guidance documents

pertaining to the ABA ITE, the ABA Basic
examination, and other matters. Start with
https://truelearn.com/resource-
library/aba-ite-everything-you-need-to-
know/
and
https://truelearn.com/resource-
library/everything-you-need-to-know-
studying-for-the-aba-basic-exam/
58
Hint Number 13
Know what to do when things go bad …
SOME EXAMPLES …
[1] Cords are not visible following direct laryngoscopy.

ANSWERS might include use of external laryngeal
manipulation to improve view; switch to video
laryngoscopy; switch to asleep fiberoptic intubation; use an
airway introducer; use an SGA either alone or as a conduit
to intubation; wake up patient and either intubate awake,
employ regional anesthesia or cancel case.
[2] At laryngoscopy it is obvious that the patient has

aspirated. DISCUSS Mendelson’s syndrome, pH and
volume of aspirated gastric contents usually required for
aspiration pneumonitis to develop, timing of the
pneumonitis, typical CXR findings, ARDS development
and management. Discuss the use of steroids and
antibiotics.
[3] Tooth got knocked out when teaching intubation to a

medical student. DISCUSS retrieving broken piece,
bleeding and infection concerns, legal liability.
Make a list of scenarios like these and

document key concerns and issues on a series
of file cards (real or virtual).
59
Hint Number 14
Be Sure to First Outline your Main Concerns

in your Answer
When answering, first summarize the case to

ensure that you got it right and to demonstrate
situational awareness. Here is an example: “This
is a head trauma case in an elderly gentleman
known to be diabetic and hypertensive and
presumed to have a full stomach. Based on his
Glasgow Coma Scale (GCS) he needs urgent
intubation. The main concerns here relate to his
co-morbidities, his full stomach, his neurological
status and his advanced age.”
Besides summarizing your case be sure to

emphasize your primary concern in the case
summary. Example: “This is a pediatric case, so
all the pediatric considerations apply here.
However, in this case I would be especially
concerned about the child’s airway, and I would
be sure to call for skilled assistance and special
airway equipment.”
60
Hint Number 15
Reasons for Failure
When you prepare for the ABA oral examination,

bear in mind some of the reasons that candidates
fail the examination:
• Lack of clinical and basic science knowledge
• Inability to apply knowledge and/or basic

science to clinical situations
• Language problems – the examiners want

thorough, articulate answers
• Arguing with the examiners
• Inability to organize their answers and express

their thoughts clearly
• Inability to prioritize concurrent or conflicting

clinical considerations
• Unsound judgment in clinical decision making

and in clinical problem solving
61
Above all, the examiners are looking for safe

clinicians!
In many cases, the problems identified above can

be eliminated by getting feedback through
practice oral examinations. With preparation and
practice you should have a fluid, pre-compiled
monologue ready for any condition the examiners
present to you. But this smoothness can only be
achieved by repeated practice.
Practice, Practice, Practice!
62
Hint Number 16
Reading the Question
There are two types of questions for the two

sessions that will make up your oral exam,
arbitrarily named “A” type and “B” type. The “A”
question (Figure 16-1) provides comprehensive
preoperative information and surgical plans. The
exam starts with Intraoperative issues for 10
minutes, and the candidate is expected to answer
on the basis of no unresolved preoperative issues.
The middle 15 minutes are Postoperative issues
and the last 10 minutes are Additional Topics. The
candidate is provided the question for the “A”
session during the briefing session and 20-20
minutes are allowed to read and prepare. The “B”
type question is used in the 2nd round of each
session. It provides an outline of the surgical
pathology, the procedure and a list of co-
morbidities, medications and vital signs. Ten
minutes (exactly) are allowed between exams and
this is the only preparation interval. The exam
starts with 10 minutes of questions about
63
Preoperative Preparation followed by 15 minutes

of Intraoperative Management and Additional
Topics. Both questions are printed on a page. It
should be read carefully (at least twice) and
written on. The 2nd reading should focus on
identifying some of the issues that are likely to be
key issues during the exam. It is also critical to
explicitly plan an anesthetic, including
premedication, monitors, agents and emergence.
It is a waste of valuable time and thought to have
preoperative questions before the “A” exam,
because the examiners will begin at Intraoperative
Management and not be willing to go backward.
It is critical to exert complete self-control between
“A” and “B” round. It is human nature to sit and
obsess about performance during the first exam,
except that every second of doing so is one less
second of preparing for round two – there is plenty
of time to ruminate at the airport and on the plane.
64
Figure 16-1: Outline of a typical oral

examination question series (type A).
Source:
https://www.sciencedirect.com/scienc
e/article/abs/pii/S0952818099000859
65
Hint Number 17
Strategic Answers
This suggestion comes from the legal education

arena. When learning the process of cross-
examination during trial law classes, law students
are taught to not ask a question unless they already
know the answer. For the ABA oral examination,
this concept applies in reverse.
When answering a question, if the candidate’s

fund of knowledge is deep, the answer can include
a brief justification. Good depth of knowledge
will be evident, and the examiner will sense the
substantial knowledge of the candidate.
Conversely, if the depth of knowledge for a given

question is limited, the answer should be brief.
This may prompt the examiner to issue a follow
up question. This may come in a format that the
candidate can answer. If not, a good answer is “I
do not know”, and more importantly, this avoids
the temptation to guess and focus the examiner on
an area where repeated gaps in knowledge can be
demonstrated.
66
Hint Number 18
Answering the Impossible Question
It is traditional on every oral examination that the

candidate get hit with a question for which there
is no good answer. A typical example concerns
the parturient with a known difficult airway that
now has extreme fetal bradycardia or a prolapsed
umbilical cord and needs a stat C-section. In such
a case, no matter what answer you give, the
examiner can give you good reasons why that
option won't work.
Here are some examples:
• If you put the patient to sleep, you won't

be able to intubate.
• If you try awake fiberoptic intubation, the

examiner will emphasize the fact that the
baby is dying, and a speedier choice is
necessary.
67
• If you mention doing a spinal, the

examiner will say that the patient is in the
Trendelenburg position with the
obstetrical resident's hand trying to push
the prolapsed cord back into the uterus.
• If you mention local anesthesia, the

examiner will state that the obstetrician
has never done anything like this and if
not about to start now.
However, the examiners know full well that there

is no good answer to the question. They are
interested that your answer is reasonable and
thoughtful and that who are aware of the various
options, as bad as they may all be. A bad answer
would be to say "This is an impossible situation. I
would let the baby die because I'm not about to
take any risks with the mother."
Sometimes the impossible question has ethical

dimensions, such as a prisoner who has been
stabbed in a drug deal gone bad but makes it
clear that he does not want any surgery, even
though the clinical need for surgical intervention
is obvious.
68
Another example is the adult Jehovah's Witness

patient who is in hypovolemic shock and
unconscious following a car accident. You may
be placed in a setting where the patient will die if
not given blood, but where you would be in
violation of the patient's clearly expressed wishes
if blood is given. Then they might make the
whole mess even more complicated by making
the patient a minor.
The idea in giving you these scenarios is to see

how well you handle stress, identify the various
options, and how you justify your decision even
though it is necessarily imperfect. That’s a tall
order, but the exam is looking for consultants, not
technicians.
69
Hint Number 19
Have pre-compiled plans for the following

complex scenarios
[1] Parturient for emergency Cesarian Section

with a known difficult airway (previously
intubated awake).
[2] Epiglottitis in an unvaccinated child; father

has a family history of malignant hyperthermia.
[3] Patient refuses clinically necessary awake

intubation.
[4] Parents refuse clinically necessary blood

transfusion in their child.
[5] Surgeon collapses on the floor in the middle

of an on-call surgical case.
[6] Hospital is being evacuated (bomb scare) but

surgery is well underway.
70
[7] You are the only anesthesiologist in house

during an on-call case when you are asked to run
down to the ER to assist with an intubation in a
coding patient. There is no ER doc present yet –
they take call from home in this small hospital.
[8] You are the only anesthesiologist in house

during an on-call case when you are asked to run
down to the ER to resuscitate a flat baby from a
precipitous delivery. There is no ER doc present
yet – they take call from home in this small
hospital.
Discussion: Some cases really have no “good”

answer. Here is a sampling of “impossible
“cases. Don’t get frazzled and be prepared to
explain the advantages and drawbacks for
various options, as well as to identify your
preferred approach.
71
Hint Number 20
Oral Exam Danger Signs
One of the most common ways to get in trouble

during an oral exam is the failure to listen carefully.
The candidate is very focused on what is being said,
has been and is about to be. With all this noise, it is
not hard to understand how a key word in a sentence
could be missed, and the answer delivered could be
correct in theory but wrong because it isn’t the
answer to the question that was asked. In some
instances, the examiner may sense this possibility
and repose the question, perhaps reformatted. The
candidate should recognize this as a warning sign.
The candidate should quickly identify the context
and think carefully to make sure that something vital
has been neglected such as resuscitation or ABC
issues.
Remember, setting the context is better done with a

parenthetical statement (“I assume that the blood
pressure has not changed”) versus asking a question
(“What is the blood pressure?”). The question will
likely prompt a “Why is that important?” question,
where the parenthetical statement will prompt the
examiner to re-set the context.
72
Hint Number 21
Professional Answers
In the energy of the oral exam, the candidate will

want to do well. One of the temptations will be to
make every answer impressive. Certainly, this is
good, if impressive is a clear, concise answer that
suggests depth of knowledge. One counter-
productive strategy is the plan to fill each answer
with expansive explanations. When asked a
question, your college English professor would fill
the answer with as much prose as he/she could
create. Using this approach in the ABA oral exam
will frustrate the examiners and not add to the
performance of the candidate.
The other temptation which can also be counter-

productive is to answer simple clinical questions
with information derived from the most current
literature. Often, the standard answer to the
question may be intentionally challenged in this
report. Ultimately the scientific validity of the
article will be supported or refuted by other
evidence, and published in major textbooks.
Before this time, it puts the candidate in the
73
position of arguing the literature, which is

dangerous and worse, the examiner may not have
read this reference, and may believe the
contradictory side. Arguing science with an
examiner, particularly a senior examiner, is not
wise. Venturing incomplete versions of
subspecialty science is also dangerous. The
candidate may accidentally enter an argument
with an expert, since board examiners are selected
from academic practices, where research
originates from. There are numerous anecdotes of
candidates trying to sneak a scientific bluff past an
examiner, who turns out to be an expert in the
science. The exchange that follows demonstrates
significant gaps in the candidate’s depth of
knowledge and/or judgment and in the “urban
legend” of these stories, flips a solid pass to a fail.
74
Figure. Bluffing is an accepted (but obviously

risky) strategy in playing poker, but it is
particularly dangerous to try to sneak a scientific
bluff past an examiner, who may be an expert in
the field. Chances are good that the examiner you
are trying to bluff will want to see if you really
know what you are talking about and expose your
ignorance with follow-up questions.
75
Hint Number 22
What is a “Gradable” Answer?
The goal of the candidate should be to provide the

maximum number of answers that can favorably
influence the outcome. One of the strategies to
maximize this element of performance on the oral
exam is to minimize the number of upgradeable
answers. Use of ASA standard monitors is
assumed and answering a question with
“application of ASA standard monitors”
accomplishes nothing. Sweeping general
statements like “I would completely review the
medical record” or “I would perform a complete
physical exam” gain nothing for the candidate but
a follow up question. A more appropriate
response identifies which elements of the history
or physical exam are relevant and why. Yes and
no answers about selection of a specific technique
are incomplete and not gradable without a reason.
A good tactic is to provide the reason with the
answer. The reason should be based on anatomy,
physiology or pharmacology, which are gradable,
76
versus personal preference, which is not. If two

options are physiologically equal, it is acceptable
and gradable. Medicolegal risk must be presented
in context of correct physiology or identified in a
defensible context. Ethics and professionalism
can be gradable answers under specific
circumstances.
77
Hint Number 23
“I Don’t Know”
“I don’t know” is not a statement that any

candidate wants to use frequently during either the
oral exam sessions. However, knowing when and
how to say “I don’t know” can save a pass or
prevent a fail. The use of “I don’t know” is an
excellent alternative to a guess. A tentative guess
will sound like a bluff and prompt the examiner to
explore an area with gaps.
If the candidate selects “I don’t know”, this will

likely prompt the examiner to create a follow-up
question. There may be enough new information
in the follow-up question to allow a successful
response by the candidate. Since the oral exam is
not an absolute knowledge examination, when an
“I don’t know” is encountered, the examiners are
expected to ask the candidate to apply knowledge.
Often, this will present a question that will give
the candidate enough of a clue to allow a
successful answer.
78
Hint Number 24
Review old ABA examinations
Provided below is an old (retired) oral

examination question from the ABA (link
unknown).
You can tell that the question is dated because of

the reference to thiopental as an induction agent,
but the management questions raised are just as
relevant today as they were when the question
was first written. Use these as the basis for
ongoing study.
Here is a great source for a sample ABA oral

examination experience:
https://theaba.org/pdfs/SOE_Questions.pdf
In addition to this sample examination, a number

of collections of old ABA examination questions
have been circulating cyberspace; a well-
constructed Google search request should allow
one to find them.
79
Figure 24-1. Sample oral examination scenario;

Figure 24-2 provides additional examination
details.
Full PDF available at

https://theaba.org/pdfs/SOE_Questions.pdf
80
81
Figure 24-2. More details concerning the sample

oral examination scenario. The reference to
thiopental dates this as an old, retired ABA
question.
82
Hint Number 25
Visit the Anesthesia Hub Website
This wonderful resource is available at

https://www.anesthesiahub.com and
is rich in anesthesia resources, such as tools (e.g.,
clinical calculators and algorithms), book
suggestions and guidelines (see figures).
Especially helpful to readers will be the section

on the ABA oral examination, located at
https://www.anesthesiahub.com/app
lied (see figure on next page).
83
Figure 25-1. A section of the “tools” portion of

the Anesthesia Hub website offering information
on various clinical calculators and algorithms.
84
Figure 25-2. The portion of the Anesthesia Hub

website offering information on the ABA oral
examination (now formally known as the ABA
Applied Exam).
85
Hint Number 26
Make Some Study Cards (Examples provided)
Early in you study program, make up a series of

“study cards” using small index cards. You will
want to have a series of cards for each of the
following:
• Drug synopses (e.g., information on

succinylcholine)
• Procedure synopses (e.g., how to do

a Bier block)
• Differential diagnosis in anesthesia

(e.g., intraoperative oliguria)
• Approach to interoperative
problems (e.g., elevated airway
pressure)
• Anesthetic considerations (e.g.,

diabetic patients)
• Airway issues and problems (e.g.,

can’t intubate)
86
• Important anatomical information

(e.g., brachial plexus layout)
• Algorithms (e.g., preoperative

evaluation of the cardiac patient)
• Consensus statements (e.g.,

neuraxial blockade and
anticoagulants)
• Landmark studies
• Safety features of the anesthesia

machine
Keep some of these cards with you at all times,

so that you can MEMORIZE them whenever
time becomes available. Study them in airport
lounges, while waiting for late surgeons to show
up, while in the cafeteria line, or at any other
opportunity. Of course, the cards need not be in
paper format - you might want to put them in a
format suitable for display on your smart phone
(especially in a format for easy editing and
updating.) Here is a relevant YouTube video:
https://www.youtube.com/watch?v=pMQkoWLn
_oM
87
Figure 26-1. A sample study card dealing with the ASA Physical
Status Classification.
Source:
https://twitter.com/Med432/status/720319633253732357/photo/1.
Hint: For more information on the ASA Physical Status

Classification visit https://www.ncbi.nlm.nih.gov/books/
NBK441940/.
Hint: Want to learn more about study card ideas? Then pay a visit
to https://www.pinterest.com/pin/272678952418599677/.
88
CONTRAINDICATIONS TO
SUCCINYLCHOLINE
• Lack of Airway Management Skills

• Susceptibility to Malignant Hyperthermia
• Incomplete Airway Obstruction such that
positive pressure ventilation would not likely
be successful (as in epiglottitis) [Goal: keep
patient breathing spontaneously as long as possible]
• Extensive Burns
• Extensive Muscle Trauma
• Disuse Atrophy or Prolonged Immobilization
• Prolonged Intraabdominal Sepsis
• Preexisting Hyperkalemia
1. Denervation Syndromes such as:
Spinal Cord injury
Stroke
Guillain-Barre Syndrome
Botulism
• Myopathies such as:
Duchenne Muscular Dystrophy
Becker Muscular Dystrophy
• Pseudohypertrophic Muscular Dystrophy
Non-specific Myopathies
89
Figure 26-2. A sample study card on

contraindications to succinylcholine. In addition
to these contraindications to succinylcholine,
clinicians should avoid its use in patients with
atypical or absent plasma cholinesterase.
Adapted from
http://www.theairwaysite.com/feat
ured_airway_article.html
90
91
Figure 26-3. A sample study card relating METS

to physical activity. From Wikipedia:
The metabolic equivalent of task (MET) is the
objective measure of the ratio of the rate at which
a person expends energy, relative to the mass of
that person, while performing some specific
physical activity compared to a reference, set by
convention at 3.5 mL of oxygen per kilogram per
minute, which is roughly equivalent to the energy
expended when sitting quietly.
Image Credit:
https://blog.dacadoo.com/wp-
content/uploads/2013/03/Physical-
activity-MET.png
92
ANESTHETIC CONSIDERATIONS IN THE
ALCOHOLIC PATIENT
Respiratory System
1. Most alcoholics are heavy smokers with some

degree of bronchitis and chronic obstructive lung
disease (COPD).
2. If ascites is present, the patient may have

reduced lung volume. A reduced functional
residual capacity (FRC) leads to early
desaturation when apnea is present. The ascites
also appears as a restrictive lung defect on
pulmonary function testing.
3. Alcoholic patients are potentially aspiration

prone if they are drunk to the extent that
pharyngeal reflexes are blunted.
4. Rib fractures may be present (from falls)
5. Pleural effusions may be present.

THE ALCOHOLIC PATIENT
Cardiovascular System
1. May have a high-shunt state with reduced

systemic vascular resistance (SVR) and increased
cardiac output (CO).
2. An alcoholic cardiomyopathy may be present.
Gastrointestinal System
1. Portal hypertension and esophageal varices

may be present. May require portosystemic
shunts or sclerotherapy respectively.
2. Ascites may be present.
3. Hepatic insufficiency may lead to:
(i) low protein levels (esp. albumin)
(ii) low clotting factors (all factors

except VIII are made in the liver;
factors II, VII, IX and X need
vitamin K for their synthesis)
(iii) hepatic encephalopathy
(iv) predisposition to hypoglycemia
94
Endocrine System
1. Alcoholic patients are prone to hypoglycemia
2. Hypogonadism may be present.
Hematologic System
1. Malnutrition may lead to megaloblastic anemia

(Folate / B12 deficiency)
2. Iron deficiency anemia may be present from

bleeding esophageal varices
3. Chronic thrombocytopenia from

hypersplenism (platelet sequestration in the
spleen).
4. Acute thrombocytopenia may occur with

severe alcohol intoxication
Central Nervous System
1. Central, peripheral and autonomic lesions.
(i) Central
(a) cortical atrophy
(b) agitation, delirium tremens

(DTs) and seizures with alcohol
withdrawal
(c) Wernicke-Korsakoff syndrome

with memory loss and
confabulation
(d) Hepatic encephalopathy

/hepatic coma
(ii) Peripheral
peripheral neuropathy, often in

glove and stocking distribution
(iii) Autonomic lesions: possible

orthostatic hypotension
2. Alcoholic patients are more likely to develop

epidural/subdural hematomas from falling in a
drunken stupor.
96
Drug-Related Issues
1. Decreased albumin means less protein binding

sites and higher drug levels in protein-bound
drugs (e.g. thiopental)
2. Decreased metabolism of hepatically

metabolized drugs.
3. Increased volume of distribution for many

drugs; means that a larger loading dose and
smaller maintenance dose is appropriate.
4. MAC is decreased in the acutely intoxicated

alcoholic but may be elevated with chronic
intoxication.
Miscellaneous Issues
1. Malnutrition +/- vitamin deficiency (e.g.

thiamine)
2. Poor dental hygiene (teeth may be easily

knocked out with intubation).
97
Remember
Elective surgery should only be undertaken

with extreme caution (or not at all) in patients
with acute hepatitis or cirrhosis, since the
operative mortality rate is quite high in these
patients.
Figure 26-4. A comprehensive (6 page) study

card concerning the alcoholic patient.
98
Hint Number 27
Visit Open Anesthesia
Open Anesthesia maintains an online presence at

http://www.openanesthesia.org/. While the site
offers many useful resources for residents, I
particularly like their keyword section at
https://selfstudyplus.openanesthesia.org/kw.
They also offer a series of educational podcasts at
https://vimeo.com/openanesthesia. The keywords
provided by the website can be easily made into
study cards, as illustrated below.
Figure: Sample screen captures from the

keyword section of Open Anesthesia.
99
Hint Number 28
Buy Some Study Cards
While making your own study cards is a great

way to prepare for the boards, some individuals
may prefer to use a commercial product. One
such product is Anesthesiology Oral Board Flash
Cards, 2nd Edition, by Jeff Gadsden and Dean
Jones (ISBN-13: 978-0071819466; ISBN-10:
0071819460). It is available from Amazon at
https://www.amazon.com/Anesthesiology-Oral-
Board-Flash-Cards/dp/0071819460
Here is the description from Amazon:
100
Anesthesiology Oral Board Flash Cards,

Second Edition are the perfect way for
residents to prepare for any random
question that an examiner may ask on the
anesthesia oral boards. The cards are
designed to impart best patient care for a
specific disease/condition or surgical
procedure. Great for studying alone or with
a partner, these cards teach residents how
to think through an unexpected operating
scenario. The set includes approximately
180 color-coded cards (30 more than the
previous edition) plus an instruction booklet
that includes tips on how to excel on the
oral boards. The flip side of each card has
been enhanced to include full-color figures,
suggested readings, typical oral board
questions, and tips.
Another source of anesthesia flash cards is at
https://quizlet.com/58550596/anes
thesiology-aba-oral-boards-flash-
cards/
There are 71 flash cards in this set, but you must

sign up to access more than a minimal sample.
101
Hint Number 29
Buy A Board Review Book
102
This is not a stand-alone board prep book but,

just like the present volume, is an adjunct to
standard texts like Miller and Barash. It is an
easy-to-read volume, 220 pages in length,
intended for residents early in their training. It is
available from Amazon at
https://www.amazon.com/Anesthesio
logy-Boards-Made-step-
step/dp/0989840158
ISBN-10: 0989840158
ISBN-13: 978-0989840156
For a full description go to

https://www.anesthesiamadeeasy.co
m/abme
103
Hint Number 30
Read About Your Patients’ Comorbidities the

Night Before
When reviewing your cases on the night before

the surgery be sure to take notes on any
disease processes or anesthesia techniques that
are unfamiliar to you. This is a good opportunity
to make note cards or flash cards for later review.
Here are two resources that can be especially
helpful in this respect.
104
[1] Uptodate.com
This medical reference website is rigorously

edited and updated almost daily. It is my “go to”
resource when I need quick, reliable clinical
information and includes a rich variety of clinical
calculators (e.g., BMI) as well as useful
information on drug interactions. After residency,
you will want to additionally use this site as a
source of the Type 1 CME needed for licensure.
105
[2] Stoelting’s Anesthesia and Co-Existing

Disease, 8e
This classic text is now in its 8th edition and is

available from Amazon in paper and electronic
formats. The print version is now rather bulky at
over 750 pages so consider getting the electronic
version if you want to easily access this resource
on your iPad or iPhone.
106
Hint Number 31
When answering questions … Avoid unneeded
verbosity … Speak confidently
NOT
• Gee... there are so many ways you could

do this case. I'm not sure how I'd go
about it. I suppose...
• Oh my … what a tough question. I’ve

never really had a case like that one. I
suppose I could ...
107
BUT
• Although there are several management

options here, I would prefer a continuous
lumbar epidural technique for several
reasons, the most important being...
• I would employ a Bier block using

preservative-free 0.5 % lidocaine without
epinephrine, in a dose not exceeding 5
mg/kg.
AVOID
• "might"
• "probably"
• “perhaps”
108
Hint Number 32
Identify Key Considerations
Be sure to identify the key considerations of

the case early in your answer. Use a
hierarchical approach where possible.
EXAMPLE: This 38-week gestation pregnant

patient can be thought of as consisting of two
patients (parturient and fetus). In addition, as a
parturient, she has a “full stomach”, has a
potentially difficult airway, has the potential for
developing preeclampsia, etc.
109
EXAMPLE: This 3-year-old boy, like all young

pediatric patients, has altered pharmacokinetics
and pharmacodynamics, has increased oxygen
consumption per kg, has airway differences as
compared to an adult, etc.
EXAMPLE: This otherwise healthy but mildly

obese 42-year-old nonsmoking ASA 2 patient is
scheduled for a bowel resection. He has primary
hypertension well managed by atenolol but
requires further laboratory investigations because
…
110
Hint Number 33
Know some standard phrases and

use them fluently.
EXAMPLES:
STARTING A CASE
After having assessed the patient, checked my

machine and equipment, drawn up all my
drugs, applied standard monitors and started
an IV, I would...
111
EMERGENCIES
This is a serious emergency which requires

immediate action. After calling for help I
would ...
AIRWAY ASSESSMENT IN AN
EMERGENCY
I would first determine that the patient's

airway was not obstructed ...
or
I would first determine that the patient was
breathing in an obstructed manner ...
112
INDICATING KNOWLEDEGE OF TOXIC

DOSES
I would carry out a Bier block3 using plain

lidocaine using a dose not exceeding 5 mg/kg...
DISCUSSING KEY CONSIDERATIONS
Assuming that there are no other problems

than the ones identified so far, I would ….
EMPHASIZING SPECIAL CONCERNS
In addition to my usual preoperative

assessment, I would pay attention to ….
3
A Bier block involves injecting local anesthetic into the venous system
of an upper (or, on occasion, lower) extremity that has been exsanguinated
by compression or gravity and that has been isolated from the central
circulation by means of a double tourniquet system.
For details visit https://www.nysora.com/techniques/intravenous-regional-

anesthesia/intravenous-regional-block-upper-lower-extremity-surgery/.
Excellent YouTube videos are available at

https://www.youtube.com/watch?v=yntMJydewJk and
https://www.youtube.com/watch?v=S_9dTd2FoA0
113
Hint Number 34
Know when to stop resuscitating

and when to start operating.
EXAMPLE Continuing prolonged nonsurgical
resuscitation in spite of being unable to keep up
with the blood loss is a common mistake, both in
the oral exam and in real life. Sometimes the
correct answer is to proceed with surgery despite
incomplete resuscitation.
Figure: This is a common sight in massive

transfusion situations.
Image source: https://blog.aabb.org/wp-
content/uploads/beans/images/massivetransfusion
2-8b38574.jpg
114
Hint Number 35
Know when to launch the Massive

Transfusion Protocol
It is not uncommon to present examination
candidates with a trauma case or a liver
transplantation cases involving massive bleeding.
Massive transfusion protocols (MTPs) are
frequently invoked to guide blood replacement in
such settings.
One definition4 of a massive transfusion is when

either
[1] The patient’s total blood volume is replaced

within 24 hours, or
[2] 50% of the patient’s total blood volume is

replaced within 3 hours, or
[3] Rapid bleeding rate is occurring, as defined

by more than 4 units of red blood cells (RBCs)
transfused within 4 hours with active major
bleeding or more than 150 mL/minute of blood
loss.
4
From https://www.dovepress.com/massive-transfusion-
protocols-current-best-practice-peer-reviewed-fulltext-
article-IJCTM
115
Here is what happens in one hospital when a

Massive Transfusion Protocol is launched5:
The blood bank responds to the call for

protocol activation by immediately
placing 6 units of group O or type-
specific RBCs and 6 units of group AB
fresh frozen plasma (FFP) in a cooler
as the “initiation package.” For this
purpose, the blood bank maintains an
adequate inventory of thawed plasma
products for immediate distribution.
The blood bank then continues to
prepare predesignated packages of
components to be picked up every 30
minutes with a goal ratio of
RBC:FFP:platelets of 1:1:1. The blood
bank continues to issue group O RBCs,
but, owing to limited group AB plasma
inventory, will issue ABO type
compatible FFP once the patient’s blood
5
Ball CG, Dente CJ, Shaz B, Wyrzykowski AD, Nicholas
JM, Kirkpatrick AW, Feliciano DV. The impact of a
massive transfusion protocol (1:1:1) on major hepatic
injuries: does it increase abdominal wall closure rates? Can
J Surg. 2013 Oct;56(5):E128-34. doi: 10.1503/cjs.020412.
PMID: 24067528; PMCID: PMC3788022. Available at
https://www.ncbi.nlm.nih. gov/ pmc/articles/PMC3788022/
116
type is known. If requested, the blood

bank is able to double up the protocol
to allow for 12 units of RBCs and 12
units of FFP to be delivered every 30
minutes. In addition, if bleeding is
uncontrolled, the clinical service can
request a 3.6 mg dose of rFVIIa after
package 2 (18 units of RBCs), with an
identical second dose, if needed,
distributed 30 minutes later.
The charge nurse in the area of

resuscitation is responsible for
designating a “runner,” who picks up a
cooler every 30 minutes from the blood
bank, returns used coolers and delivers
product to the patient area. In
addition to hemorrhage control, the
attending physician is responsible for
starting and stopping the protocol and
for activating rFVIIa use.
117
Hint Number 36
Know when to stop investigating

and give anesthesia.
EXAMPLE If you insist on a cardiac

catheterization study prior to arthroscopy in an
asymptomatic patient with good exercise
tolerance who had an uncomplicated myocardial
infarct 3 years ago, the examiners will not be
impressed by your cautious nature.
The American Society of Anesthesiologists Task

Force on Preanesthesia Evaluation has provided
useful guidelines to assist clinicians in patient
assessment before surgery6. You should be
familiar with their recommendations.
6
Committee on Standards and Practice Parameters, Apfelbaum
JL, Connis RT, Nickinovich DG; American Society of
Anesthesiologists Task Force on Preanesthesia
Evaluation, Pasternak LR, Arens JF, Caplan RA, Connis RT,
Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich
DG, Rice LJ, Roizen MF, Twersky RS. Practice
advisory for preanesthesia evaluation: an updated report by the
American Society of Anesthesiologists Task Force on
Preanesthesia Evaluation. Anesthesiology. 2012
Mar;116(3):522-38. doi: 10.1097/ALN.0b013e31823c1067.
PubMed PMID: 22273990.
(https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2443
414)
118
Hint Number 37
Managing Very Complex Cases
In answering a very complex case management

question, always remember that the examiner
may not necessarily expect you to do the case all
by yourself. In many cases it is entirely
appropriate to say things like:
“I’d really like to have a second pair of hands

available for a case like this. In our hospital the
anesthesia coordinator frequently helps out to
make complicated cases run smoothly. I’d be
sure to consult with him and get his help before
proceeding.”
or
“I’d make sure that an ENT surgeon was in the

room before proceeding. This is the kind of case
where airway problems can develop quickly, and
if an ENT surgeon experienced in the area of a
rigid bronchoscope (or whatever) is in the room
with his equipment already I think the situation
would be much safer.”
119
or
“This is starting to look like a case of DIC. I’d

be sure to call the hematologist on call for some
advice, as well as to help smooth out any possible
issues with the blood bank”
or
“This case looks like the patient may be an

emancipated minor7, so there are potential
consent issues that vary with each state. I’d be
sure to call the administrator on call for some
advice before proceeding”
7
Emancipation of minors is a legal mechanism by which a
child before attaining the age of majority (usually 18) is
freed from control by their parents or guardians, and the
parents or guardians are freed from any and all
responsibility toward the child. In various US states
marriage, incarceration, living apart, pregnancy and
parenthood may automatically confer some of the rights of
emancipation, particularly in matters of health consent and
privacy (Wikipedia).
120
Hint Number 38
Avoid Common Oral Board Traps
Know and avoid the many traps awaiting you in

the oral examination. Here is a partial list:
1. Poor organization of your answer.
2. Excessive verbosity. Lack of fluency and

clarity in your delivery.
3. Not distinguishing between standard and

controversial clinical practices (e.g.,
technique variations in rapid sequence
intubations).
4. Not admitting ignorance. Bluffing.
5. Mentioning things with which you are

unfamiliar. For instance, don't mention
systolic time intervals or the
sympathogalvanic reflex unless you are
prepared to discuss them with the
examiner.
121
6. Not canceling an elective case when

appropriate.
7. Not proceeding appropriately to do a

necessary case.
8. Forgetting to mention the obvious (e.g.,

giving oxygen).
9. Not knowing the differential diagnosis

"down cold" (e.g., increased airway
pressure, hypotension, bradycardia, etc.).
10. Getting shaken up by "no-win" situations.
11. Not emphasizing the emergency nature of

the situation.
12. Not calling for help when it is clearly the

right thing to do.
122
Figure: Everyone needs help from time to time.
Image Credit: https://kittentoob.com/wp-

content/uploads/2015/10/cat-in-a-box-Copy-
640x480.jpeg
123
Hint Number 39
Local Anesthetics
Whenever discussing a case involving the use of

local anesthetics, let the examiner know that you
know the maximum dose without having him or
her having to specifically ask you.
• EXAMPLE 1: I would do a Bier block

using 0.5% plain lidocaine. The maximum
dose of lidocaine without epinephrine is
5mg/kg or 400mg in this 80kg patient.
Using 0.5% plain lidocaine, that works out
to a maximum of 80ml. I would use only 40
to 50ml to provide a nice safety margin.
• EXAMPLE 2: I would use 0.25%

bupivacaine with epinephrine 1 in 200,000,
in a dose not exceeding 3mg/kg.
• EXAMPLE 3: Because a motor block is

important in this case, I would use 0.5%
ropivacaine in a dose not exceeding
3mg/kg. In addition, ropivacaine has less
toxicity than bupivacaine.
124
Hint Number 40
Choice of Local Anesthetic
One question on the oral boards that sometimes

arises concerns the choice of local anesthetic for
a particular procedure. The table below nicely
summarizes what you should know.
Table 40-1: Suggested dosing recommendations

for commonly used local anesthetic agents
Source: https://www.dovepress.com/local-
anesthetic-systemic-toxicity-current-
perspectives-peer-reviewed-fulltext-article-LRA
125
Hint Number 41
Management of Local Anesthetic

Toxicity
One question on the oral boards that sometimes

arises is how to manage patients who are
experiencing LAST (local anesthetic systemic
toxicity). LAST is a life-threatening complication
with the potential for central nervous system and
cardiac manifestations. CNS symptoms may
include perioral numbness, dizziness, tinnitus,
impaired vision, restlessness, tongue paresthesia,
and even full-blown seizures. Cardiovascular
findings many include hypertension and
tachycardia early on, sometimes followed by
hypotension, ventricular arrhythmias and cardiac
arrest.
While basic airway principles and other

resuscitation measures apply in these cases
(including the need to call for assistance), early
intravenous lipid emulsion therapy is central to
management. An initial bolus of 100 mL 20%
intravenous lipid emulsion should be
administered over 2 to 3 minutes (1.5 mL/kg if
the lean body weight is under 70 kg), followed
126
by an infusion of 200–250 mL over 15–20

minutes (0.25 mL/kg/min if the lean body
weight is under 70 kg)8.
If circulatory stability is not attained, re-bolusing

up to two further times or increasing the infusion
to 0.5 mL/kg/min is suggested. The maximum
recommended dose of 20% lipid emulsion is 12
mL/kg.
Need for information? Go to

lipidrescue.org. Screenshot below:
8
Taken from https://www.dovepress.com/local-anesthetic-
systemic-toxicity-current-perspectives-peer-reviewed-
fulltext-article-LRA
127
Hint Number 42
Sedation Scales
One board question that sometimes arises

concerns the level of sedation obtained with
sedative agents. The information below nicely
summarizes the Ramsay Sedation Scale and the
Richmond Agitation Sedation Scales – two
popular scales used to succinctly describe a
patient’s level of sedation for use with MAC
cases and for use in the ICU.
128
Ramsay Sedation Scale
129
Hint Number 43
Hemorrhage
If you get a trauma question, there is a good
chance you will get some bleeding.
Be sure to be familiar with the American College

of Surgeons' classes of acute hemorrhage, nicely
summarized on the next page. (Source: Miller,
6th Edition, Table 47-1)
130
American College of Surgeons' Classes of Acute

Hemorrhage
Factors Class I Class II Class III Class IV

Blood loss (mL) 750 750–1500 1500–2000 2000 or more
Blood loss (% blood 15 15–30 30–40 40 or more

volume)
Pulse (beats/min) 100 100 120 140 or higher
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Normal or Decreased Decreased Decreased

Hg) increased
Capillary refill test Normal Positive Positive Positive
Respirations per 14–20 20–30 30–40 35

minute
Urine output (mL/hr) 30 20–30 5–10 Negligible
Central nervous Slightly Mildly anxious Anxious, Confused,

system: mental status anxious confused lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + Crystalloid +

(3-1 rule) blood blood
131
Hint Number 44
www.capnography.com
This Web site is an unparalleled educational

resource on the topic of capnography. It is vast
and comprehensive, covering every aspect of the
topic. The site is authored by Bhavani Shankar
Kodali, MD. The author dedicates the site "to
enhancing the safety of patient care, inside as
well as outside of the operating rooms" and
emphasizes that "capnography is much more than
simply checking the position of endotracheal
tube." As such, it is his goal that this effort "not
only addresses the basic principles but also be a
forum for active discussion on issues related to
capnography in all medical fields."
132
What makes this site particularly special is the

use of animated graphical techniques to assist in
the understanding of capnographic concepts.
These animations show capnographic tracings
moving across the computer screen as they do in
real life, with special areas of interest highlighted
and labeled for easy comprehension. This makes
this Web resource far more valuable than an
ordinary textbook.
The site includes many sections. The section

"ASA Guidelines" discusses clinical standards
pertaining to capnographic monitoring. Another
section "Why Capnography?" discusses
terminology, definitions, physics, physiology,
and clinical matters. An atlas of capnograms is
also provided, as well as a quiz section for
personal knowledge testing. Other sections
include: clinical tips, frequently asked questions,
and discussions on capnography concerning
pediatrics, laparoscopic surgery, thoracic surgery,
and intensive care medicine.
133
Hint Number 45
Attributes of a Good Consultant

Anesthesiologist
• A good candidate should be able to convince

the examiners that they have worked
independently and are eager to and capable of
doing so.
• They should be able to make decisions.
• They should have their own opinions and be

able to defend these opinions.
• They should be able to express a personal

preference for managing general or specific
scenarios.
• They should not be afraid to express where

and when they feel competent and can act
assertively, and where and when they need
help and advice and want to be conservative.
134
• They should be knowledgeable of current

standards, aware of current controversies and
know where they stand on issues.
• They should be able to distill the essence of a

clinical problem and see the major issues and
conflicts.
• They should express willingness to

communicate, consult, and compromise when
necessary and a willingness to stand their
ground when necessary.
• In routine as well as complicated, difficult or

controversial cases they should recognize the
issues, hazards and the choices and be able to
bite the bullet and make a clean cut well,
reasoned, personal choice to cancel, delay, to
get help or to go ahead with the approach
they feel is safest and most appropriate in
their hands at this point in their career.
135
Hint Number 46
Good Clinical Judgment
A candidate with good clinical judgment

should be able to:
• differentiate between elective, semi-

urgent, truly urgent cases
• delineate the considerations or
problems in a clinical scenario
• prioritize the considerations
• recognize competing or conflicting
considerations
• know when he/she can go ahead with
a case
• know when he/she must go ahead
with a case
136
• know when to delay and what to do in

the interim
(i.e. investigate, optimize, consult)
• know when to cancel a case
• recognize and delineate options (i.e.
regarding monitors or anesthetic
technique)
• choose the best option, or a good
option, or the option that is best in
their hands
• know the pros and the cons of an
option and be able to defend it
• deal with the potential problems of a
given plan or action
• know when to truncate or abort or
revise a plan of action for a case
• know when to consult other services
• know when to call for help and who to
call
• recognize an emergency situation
137
• be able to deal with unexpected

emergencies
• recognize classical catastrophes or
obvious diagnoses and be able to
deal with them
• be able to manage a catastrophe
even when diagnosis is unclear
• be able to compromise when
necessary
• be able to be unwavering when
necessary
• be decisive when appropriate
• be conservative when appropriate
• be able to outline indications,
contraindications, advantageous and
disadvantages of a piece of
equipment, a technique or a plan of
action
138
Hint Number 47
Practice oral exams
These are intended to give you practice, so you are

less stressed and more confident going into the
orals. Once you feel confident and/or when you
feel they are no longer helping you improve
communications skills and build confidence stop
them. That is, do not overdo it.
You will get lots of free advice and some very

adamant advice. Say thank you but be selective.
These are not supposed to ingrain you with one
perfect method of organization and the perfect
answer to each scenario. They are supposed to
help you develop a personalized organizational
method that facilitates you in expressing your
knowledge base, experience and judgment and to
facilitate you in doing it in the very short and
artificial time frame of an oral exam.
139
There is not one way to organize that you must

follow and your organization does not need to be
perfect. Likewise there is rarely one perfect
correct answer to a clinical scenario. Even an
emergency air way may have several possibilities.
You are not supposed to be learning “the right
answers” in the practice orals. You are supposed
to be learning to express how you would do a case
based on your training, skills and current level of
experience and comfort.
In the end it will hopefully not teach you just

gamesmanship or exam technique but will spur
you onto to review your clinical knowledge base,
think of options, decide how you like to do things
and why, and help you explain to patients, families,
surgeons, colleagues and your future students as
well as the examiners why you chose the
approaches you do, why you hold the opinions you
do and what your concerns are in given cases.
140
Hint Number 48
How to Perform at Exam Time
1. Have faith in yourself – you are well-

trained, experienced and competent.
2. Have faith in your examiners – they are

not out to get you. There are no dirty
tricks and they will draw a clear scenario
for you to deal with. They will be
surprisingly pleasant.
3. Be honest.
4. Be practical and realistic.
5. Say what you could do at this point in

your career with your current knowledge
and experience not what you think the
examiners want to hear. Speak from your
own experience about your own
capabilities and opinions.
141
6. Imagine yourself in your own O.R. in

your own hospital with the resources and
equipment and equipment and help you
are used to.
7. Listen to the question carefully before

answering. Write it down if you wish.
Stop to write or marshal your thoughts at
any time. Ask for clarification of the
scenario at any time. Ask specifically
what the examiner wants addressed if it is
not clear.
8. If you wish to change your mind or your

course of action at any time do so.
9. If you need time to reconsider your

approach take the time.
10. If you don’t know or don’t have an

opinion say so – let them go on to
something else where you might shine.
142
11. If it is a very controversial or difficult

situation with no clear-cut answer or no
one best answer you can certainly point
this out. However, you should also have
an opinion as to what is the best option
and/or the least of all possible evils.
12. If you want to explain your approach,

decision or opinion, do so.
13. If questioned regarding an approach,

decision or opinion it may only be
because they just wish to hear your
rationale or because they just want to
know if you know the cost/benefit ratio or
if you are aware of and can deal with
potential problems in a given approach.
If your choice is rational and defendable
and a good choice in your hands,
rationalize it, defend it and explain why
you feel comfortable with it.
143
14. Assume full responsibility and

management of a case.
15. Continue on with management unless

interrupted, redirected or given new
information which changes your plans.
16. Be proactive, anticipate and deal with

common problems, treat emergencies
aggressively.
17. But paint the best scenario possible for

yourself unless they tell you otherwise i.e.
“Assuming this trauma patient is stable
enough to go to C.T. I would…..”.
“Assuming the C spine is clear and the
airway looks easy, I would….”. “Most
thyroid goiters or fractured mandibles do
not cause major airway problems and
assuming this was the case here I
would….”
144
18. If the situation is very complicated

or is deteriorating:
a) Call for help, but specify who or

what kind of expert help
b) Delegate general or specific duties

– e.g., the second anesthesiologist can
look after the baby, I’ll look after
mom. The surgical resident can put in
the CVP while I do the arterial line.
c) Don’t “hope” the art line will go in

or that there is a bed in ICU – say the
arterial line goes in and take the
patient to ICU.
145
19. Be prepared to do the vast majority of

the talking. Don’t ask specific questions or
ask for specific values one at a time. State
all the things you want to know in the
history, physical and lab and then expect
feedback.
20. You can control the speed of the exam.

As long as you state that you do recognize
an emergency, may need to intervene
immediately, that you recognize the
patient is deteriorating etc. You can then
always stop to think, marshal your thoughts
and calm down and consider options. That
is as long as you let them know you do
recognize an emergency and can act and will
make a decision you may then take time to
think and you may even tell the examiners
that you are doing just that.
146
Hint Number 49
Planning on using an epidural for

your case? Heed this advice from
Miller (6th Edition)
“The benefits of postoperative epidural analgesia

are optimized when the epidural catheter is
inserted in a location corresponding to the
dermatomes covered by the surgical incision (i.e.,
catheter-incision congruent analgesia), resulting
in a lower dose of drug administered and
decreased incidence of drug-induced side effects,
such as pruritus, nausea, vomiting, urinary
retention, motor block, and hypotension.”
“Maximal attenuation of perioperative

pathophysiology occurs with use of a local
anesthetic-based epidural analgesic solution. The
use of a local anesthetic-based (versus opioid-
based) analgesic solution is associated with an
earlier recovery of gastrointestinal motility after
abdominal surgery and less frequent occurrence
of pulmonary complications.”
“Epidural analgesia is not a generic entity

because different catheter locations and analgesic
regimens may differentially affect perioperative
morbidity.”
147
Hint Number 50
Regional Anesthesia in a Patient with a

Known Difficult Airway
One common question on the oral boards
concerns the debate about when it is appropriate
to proceed with regional anesthesia (RA) in a
patient with a known difficult airway (as opposed
to, say, performing an awake intubation and
proceeding with general anesthesia). The
information below nicely summarizes the
discussion.
148
SOURCE: Barash, 4th Edition. Table 23-12.
149
Hint Number 51
Laboratory Testing and Subspecialty

Consultation
Common questions on the oral boards concern
preoperative laboratory testing and the need for
subspecialty consultation. This chart from the
ASA nicely summarizes one approach to the
former matter [1]. Additionally, you will be
expected to know when it is appropriate to refer
patients who may need subspecialty consultation,
such as poorly controlled diabetics [2]. Reference
[3] provides a helpful Open Access review.
References:
[1] American Society of Anesthesiologists Task Force on

Preanesthesia Evaluation. Practice advisory for preanesthesia
evaluation: a report by the American Society of Anesthesiologists
Task Force on Preanesthesia Evaluation. Anesthesiology. 2002
Feb;96(2):485-96.. PubMed PMID: 11818784.
[2] Sreedharan R, Abdelmalak B. Diabetes Mellitus: Preoperative

Concerns and Evaluation. Anesthesiol Clin. 2018 Dec;36(4):581-
597. doi: 10.1016/j.anclin.2018.07.007. Review. PubMed PMID:
30390780.
[3] Zambouri A. Preoperative evaluation and preparation for

anesthesia and surgery. Hippokratia. 2007 Jan;11(1):13-21.
PubMed PMID: 19582171; PubMed Central PMCID:
PMC2464262.
150
Another very useful resource is the Choosing

Wisely website, located at
https://www.choosingwisely.org/pa
tient-resources/lab-tests-before-
surgery.
151
Choosing Wisely
This site collates recommendations across a

number of clinical specialty societies. Listed
below are some of its recommendations
152
Hint Number 52
Contributed by Dr. Walter Mauer
You should be familiar with the following

guidelines and the definitions used
concerning sedation and analgesia by non-
anesthesiologists
Source: American Society of Anesthesiologists

Task Force on Sedation and Analgesia by Non-
Anesthesiologists. Practice guidelines for
sedation and analgesia by non-anesthesiologists.
Anesthesiology. 2002 Apr;96(4):1004-17.
153
154
Minimal Sedation (Anxiolysis) = a drug-induced

state during which patients respond normally to
verbal commands. Although cognitive function
and coordination may be impaired, ventilatory
and cardiovascular functions are unaffected.
Moderate Sedation/Analgesia (Conscious

Sedation) = a drug-induced depression of
consciousness during which patients respond
purposefully to verbal commands, either alone or
accompanied by light tactile stimulation. No
interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained.
155
Deep Sedation/Analgesia = a drug-induced

depression of consciousness during which
patients cannot be easily aroused but respond
purposefully following repeated or painful
stimulation. The ability to independently
maintain ventilatory function may be impaired.
Patients may require assistance in maintaining a
patent airway, and spontaneous ventilation may
be inadequate. Cardiovascular function is usually
maintained.
General Anesthesia = a drug-induced loss of

consciousness during which patients are not
arousable, even by painful stimulation. The
ability to independently maintain ventilatory
function is often impaired. Patients often require
assistance in maintaining a patent airway, and
positive pressure ventilation may be required
because of depressed spontaneous ventilation or
drug-induced depression of neuromuscular
function. Cardiovascular function may be
impaired.
156
Because sedation is a continuum, it is not always

possible to predict how an individual patient will
respond. Hence, practitioners intending to
produce a given level of sedation should be able
to rescue patients whose level of sedation
becomes deeper than initially intended.
Individuals administering Moderate
Sedation/Analgesia (Conscious Sedation) should
be able to rescue patients who enter a state of
Deep Sedation/Analgesia, while those
administering Deep Sedation/Analgesia should
be able to rescue patients who enter a state of
general anesthesia.
* Reflex withdrawal from a painful stimulus is not

considered a purposeful response.
157
Hint Number 53
Be familiar with various

controversial issues
EXAMPLE 1
Epidural or spinal anesthesia in patients with

a known difficult airway. If things go badly
wrong and the patient needs to be intubated,
what will you do then?
Suggested Reading:
Saxena N. Airway management plan in
patients with difficult airways having
regional anesthesia. J Anaesthesiol Clin
Pharmacol. 2013 Oct;29(4):558 -60. doi:
10.4103/0970-9185.119106. PubMed
PMID: 24250001; PubMed Central
PMCID: PMC3819858.
158
EXAMPLE 2
Use of the LMA ProSeal and positive pressure

ventilation for abdominal surgical procedures.
Suggested Reading:
Anand LK, Goel N, Singh M, Kapoor D.
Comparison of the Supreme and the
ProSeal laryngeal mask airway in
patients undergoing laparoscopic
cholecystectomy: A randomized
controlled trial. Acta Anaesthesiol
Taiwan. 2016 Jun;54(2):44 -50. doi:
10.1016/j.aat.2016.03.001. Epub 2016
Apr 19. PubMed PMID: 27106162.
159
EXAMPLE 3
Hyperventilation in the head-injured patient.
Suggested Reading:
Stocchetti N, Maas AI, Chieregato A, van
der Plas AA. Hyperventilation in head
injury: a review. Chest. 2005
May;127(5):1812-27. Review. PubMed
PMID: 15888864.
160
EXAMPLE 4
Perioperative blood transfusion trigger levels.
Suggested Reading:
Bolliger D, Fassl J. Less Transfusion,
Less Infections-Controversies in Patient
Blood Management. J Cardiothorac Vasc
Anesth. 2020 Feb 28. pii: S1053-
0770(20)30195-6. doi:
10.1053/j.jvca.2020.02.037. [Epub ahead
of print] PubMed PMID: 32241679.
161
Hint Number 54
You may be asked the question “Would

this case be safer to carry out using
regional anesthesia?” You should say
something like this …
The risks of life-threatening events are

substantially increased after major surgery, but
there is debate about whether the type of
anesthesia plays a big role. Neuraxial blockade
has several physiological effects that provide a
rationale for expecting to improve outcome with
this technique. There effects are … (YOU
SHOULD HAVE THIS LIST ON A REVIEW
CARD, READY TO BE MEMORIZED).
Unfortunately, the few clinical trials of epidural

or spinal anesthesia that have focused specifically
on fatal or life-threatening events have been
underpowered. A meta-analysis published in
BMJ has provided encouraging information
(Rodgers et al. Reduction of postoperative
mortality and morbidity with epidural or spinal
anaesthesia: results from overview of randomised
trials. BMJ. 2000 16; 321(7275): 1493.) Here is
what they say:
162
What is already known on this topic
• Neuraxial blockade with epidural or

spinal anesthesia reduces the incidence of
deep vein thrombosis and one-month
mortality in hip fracture patients
• Insufficient evidence exists for other

postoperative outcomes in this surgical
group
What this study adds
• Mortality was reduced by one third in

patients allocated neuraxial blockade
• Reductions in mortality did not differ by

surgical group, type of blockade, or in
trials in which neuraxial blockade was
combined with general anesthesia
• Neuraxial blockade also reduced the risk

of deep vein thrombosis, pulmonary
embolism, transfusion requirements,
pneumonia, respiratory depression,
myocardial infarction, and renal failure
163
Hint Number 55
More Exam Performance Hints
• Dress conservatively for the

examination. Very conservatively. That
means no nose rings.
• Never show cockiness or excessive

confidence. This is simply an invitation
to get asked a very difficult question to
put you back in your place.
• Try to maintain a stance of graceful

confidence. Bluffing on an examination
can be very dangerous. Even deadly. Do
not get caught on a bluff that causes your
examiners to lose confidence in you.
•Get a good night’s sleep the night

before.
• And no alcohol the eve ning before

either.
• Arrange for a wakeup call the night

before.
164
Hint Number 56
Generic Drug Names
Always use generic drug names.
• Use midazolam - not Versed
• Use propofol – not Diprivan
• Use fentanyl – not Sublimaze
• Use dexmedetomidine – not Precedex
• Use furosemide – not Lasix
165
Hint Number 57
Know these regional blocks
1. Interscalene
2. Supraclavicular
3. Transversus abdominis plane (TAP)
4. Femoral
5. Adductor canal (saphenous)
6. Popliteal
Table 57-1. Blocks you should know. NYSORA

(New York School of Regional Anesthesia)
offers excellent didactic videos on each of these
blocks.
Visit https://www.nysora.com/ and

https://www.youtube.com/c/nysoravideo for
educational videos and other didactic materials.
166
167
Obstetrical Scenarios
1] Failed spinal or epidural for C/S.
Also high spinals.
[2] Placenta previa
[3] Placenta accreta
[4] Retained placenta
[5] Twins
[6] Molar pregnancies
[7] Use of tocolytics
[8] Use of nitroglycerine
[9] Postpartum hemorrhage
[10] Neonatal resuscitation
[11] VBAC
[12] Preeclampsia / eclampsia
Twelve obstetrical scenarios to be familiar with.

Remember to call for assistance earlier rather
than later when trouble is encountered.
168
Pediatric Scenarios
[1] Neonatal emergencies
[2] Tonsillar rebleed
[3] Gastroschisis
[4] Pyloric stenosis
[5] Hypospadias
[6] Child with muscular dystrophy
[7] Child with inhaled foreign body
[8] Child for eye surgery (squint / strabismus)
[9] Child with T-E fistula
[10] Pediatric preoperative sedation
[11] Child with Down syndrome (Trisomy 21)
[12] Child with congenital anomalies
Twelve pediatric scenarios to be familiar with.
169
Cardiac Scenarios
[1] Aortic stenosis
[2] Mitral stenosis
[3] Aortic insufficiency
[4] Mitral insufficiency
[5] IHSS
[6] ACS / unstable angina
[7] Recent myocardial infarction
[8] Recent coronary stent placement
[9] Atrial fibrillation with RVR
[10] Patient with pacemaker
[11] Patient with AICD
[12] ACLS protocol
Twelve cardiac scenarios to be familiar with.
170
Pulmonary / Thoracic Scenarios

[1] Pulmonary hypertension
[2] Anterior mediastinal mass
[3] Tracheal stenosis
[4] Post lung-transplant patient for bronchoscopy
[5] Asthmatic patient unresponsive to initial

therapy
[6] Bronchoscopic foreign body removal
[7] Bronchoscopic stent placement
[8] Near-drowning victim
[9] Patient presenting with massive hemoptysis
[10] Patient presenting with stridor
[11] Patient with extreme COPD awaiting lung

transplantation
[12] Chest tube insertion for pneumothorax
Twelve pulmonary / thoracic scenarios to be

familiar with.
171
Airway Scenarios
[1] Loose tooth
[2] Trismus
[3] Full stomach
[4] Radiated head and neck (for cancer treatment)
[5] Awake intubation in cooperative patient
[6] Awake intubation in uncooperative patient
[7] Can’t intubate; but can ventilate by face mask
[8] Can’t intubate; but can ventilate by SGA
[9] Can’t intubate; can’t ventilate
[10] Can’t ventilate; can’t oxygenate
[11] Massive thyroid goiter
[12] Orogastric material seen at laryngoscopy -

aspiration suspected
Twelve airway scenarios to be familiar with.
172
Neurological Scenarios
[1] Patient with an uncleared cervical spine
[2] Patient with a low Glasgow coma scale
[3] Paraplegic patient
[4] Myasthenia Gravis
[5] Eaton-Lambert Syndrome
[6] Parkinson’s disease
[7] Epidural hematoma following epidural

placement
[8] Guillain Barre syndrome
[9] Brain dead patient
[10] Increased ICP – Brain bleed
[11] Increased ICP – Brain tumor
[12] Neurological injury following cardiac arrest
Twelve neurological scenarios to be familiar

with.
173
174
Eleven Short Cases for Discussion
Listed below are some question

snippets that are similar to
typical ABA oral board scenarios.
A rich collection of similar
cases is available at
https://www.frca.co.uk/
[1] A 77-year-old man weighing 114 kg, 177

cm in height, is scheduled for an elective
repair of a 10 cm suprarenal abdominal
aortic aneurysm. He had an uncomplicated
myocardial infarction 8 months previously
and has been a non-insulin dependent
diabetic for over 20 years. Discuss your
anesthetic management of this case. What
are your main concerns? What would you do
differently if this were a leaking aneurysm?
175
[2] A 25-year-old man develops masseter

muscle spasm after receiving fentanyl 50
mcg, propofol 200 mg and succinylcholine
140 mg during a rapid sequence induction
for a suspected hot appendix. To your
horror, you find that you are unable to open
the patient’s mouth.
1. What do you do about this? Should you

cancel the case? Should you administer
dantrolene?
2. When you finally are able to open up the

mouth to insert your laryngoscope, you see
copious gastric contents pooled in the
oropharynx. What do you do now?
Resource: Saddler JM. Jaw stiffness - an ill

understood condition. Br J Anaesth
1991; 67: 515-16
176
[3] During a one-hour appendectomy in a

75 kg, 30 year old otherwise healthy
female, succinylcholine 100 mg was given
for intubation, and rocuronium 30 mg was
given for muscle relaxation. Postoperatively
the patient remained unexpectedly apneic,
despite having received only 100 mcg of
fentanyl. What do you think might be going
on? How will you sort out this matter? Can
you provide a differential diagnosis? Are
there any blood tests that might be helpful
in this setting?
177
[4] Repair of a diaphragmatic hernia.

What signs and symptoms will you expect to
find during your preoperative evaluation?
What are the anesthetic concerns for this
patient? Are there initial therapeutic
maneuvers necessary prior to the
procedure? Discuss. Should N20 be avoided?
Should 100% oxygen be administered?
Why/why not? Outline/defend your
anesthetic choice.
From
http://www.wethington.net/boardreview/oral/neu
ro/cervical_epidural_mass.htm
178
[5] Regional anesthesia: A 23-year-old

male is scheduled for shoulder arthroplasty.
He is terrified of general anesthesia and
desires to remain awake. You respond.
What alternatives are available for
anesthesia? What would you choose? Why?
Compare an interscalene vs. supraclavicular
block. Advantages/disadvantages. Could
this procedure be done with an interscalene
block alone? Why/why not?
From
179
[6] Emergency surgery in a cocaine

addict: What potential problems in
anesthetic management might occur in a
cocaine addict who requires emergency
surgery for repair of a trimalleolar fracture
of the ankle? Would a general or regional
anesthetic be preferable? Why? Would acute
intoxication vs. chronic use of cocaine alter
choice? Why/Why not?
From
180
[7] A 69-year old, 92 kg man with benign

prostatic hypertrophy with occasional
urinary retention. He is scheduled for a
trans-urethral resection of the prostate
(TURP). He has hypertension, for which he
takes metoprolol when he remembers.
Blood pressure is 200/110 mmHg, and pulse
is 75 bpm. Creatinine is 2.1 mg/dl.
Is he adequately beta blocked? Is his blood

pressure adequately treated? Should you
cancel the case? How might you reduce the
blood pressure preoperatively? Why is the
creatinine elevated? Are there any
advantages of regional anesthesia for this
operation? If a spinal is done, what level of
block is required? Almost an hour into the
case (under spinal anesthesia), the patient
becomes agitated and confused. What is
likely going on? What are you going to do
about it?
181
[8] A 29-year old, 82 kg man is a T5

paraplegic scheduled for a cystoscopy.
Given that he has no sensation below the
waist, is anesthesia necessary for the
procedure? What is autonomic
hyperreflexia, and what level of spinal cord
lesion is it associated with? If the patient is
to be intubated, are there any special
concerns about administering
succinylcholine?
182
[9] A 3-year-old boy is scheduled for

bilateral myringotomy and tubes. The case
was previously cancelled because of a
fever. Now he has rhinorrhea and a
temperature of 38.6 Celsius by oral
thermometer. No cough is present, and the
chest is clear.
Should you cancel the case once again? If

you proceed, should the child be intubated?
What about management of the case when
there is a cough productive of sputum?
183
[10] A 38-year-old, 50 Kg woman is

scheduled for excision of an occipital glioma
while in the sitting position. You are first to
note a late systolic murmur, loudest at left
sternal border. She has mild controlled
hypertension. Medications include
hydrochlorothiazide for 5 years and
dexamethasone for 5 days. P 74, BP 135/80,
R 16, Temp 37°C, Hgb 13 gm/dl, Na 140
mEq/l, K+ 2.9 mEq/l.
Source:
http://my.anconsultants.com/hubfs/eB
ooks/Oral_Exam_Format_Ebook.pdf
184
[11] A 26-year-old 82 kg ASA-1 man is

scheduled for a posterior fossa
craniotomy for resection of a mass
lesion. He had been perfectly healthy
until 48 hours ago, when his wife noted
him to be lethargic and took him to the
ER. What anesthetic technique and
monitors would you favor? During the
case the surgeon encounters bleeding
and requests an immediate reduction in
blood pressure. What is your response?
How will you decide what the lowest
permissible blood pressure should be?
During the resection, the arterial blood
pressure suddenly drops to 50/10 mm
Hg, and his oxygen saturation decreases
to 80%. What might be the cause? What
to tell the surgeon? You suspect this is
an air embolism - what additional
information might be helpful? (Drop in
ETCO2). Discuss management. Discuss
the challenges of providing anesthesia to
patients in the “sitting” position.
185
Short Discussion Questions

• List some things that indicate that your
patient is hypovolemic.
• List some contraindications to

succinylcholine
• How does one treat a beta-blocker

overdose?
• List methods to ensure that the ETT is

[A] not in the esophagus and [B] not
endobronchial
• What are the kinds of shock? What are

the stages of hypovolemic shock? What is
the usual hemodynamic response to
hypovolemia?
• What herbal drugs will make

intraoperative bleeding more likely to
be a problem?
• What is the lowest Hb you will accept in

an otherwise healthy patient? What do
the ASA guidelines suggest?
186
Discussion Questions
• What does blood cross matching involve?

What is the role of
[A] O-neg uncrossmatched blood?
[B] O-pos uncrossmatched blood?
[C] type=specific uncrossmatched blood?
• What are the anesthetic considerations

in a patient with a fresh cardiac stent?
What is the difference between a Bare
Metal Stent (BMS) and a Drug Eluting
Stent (DES)? What medications would
such a patient typically be taking? When
can they stop these medications?

in a patient with tracheal stenosis? What
are some causes of tracheal stenosis?
ANSWER: idiopathic / GERD-related?;
previous prolonged intubation; tumor
(intrinsic vs extrinsic compression);
What is the role of balloon dilation?
What is the role of tracheal resection?
Why is it so important to monitor ETT
cuff pressures?
187

in a patient on dialysis because of renal
failure? What is the difference between
hemodialysis and peritoneal dialysis?
How would you define renal
insufficiency? How would you define
renal failure? When is a central line
needed for renal transplantation? What
about an arterial line? What are the
considerations in a patient with an AV
fistula? What is a Quinton catheter?
• Patient with a small bowel obstruction

presents for emergency laparotomy
without a NG tube. What to do? What if
the patient refuses awake NGT
placement?
• Patient with a hot appendix presents for

emergency appendectomy. When he is
hooped up to the ECG monitor you
notice that the patient is in atrial
fibrillation with a ventricular rate of
140. What to do?
188
• That are the anesthetic considerations

for the alcoholic patient with a GI
bleed?
• Should full-blown anaphylaxis develop

following the induction of anesthesia,
what is the likely clinical presentation?
Clinical management? Likely molecular
culprit? How could the fact that the
patient is on beta-blocker therapy
influence management?
• List some causes of refractory

hypotension with the induction of
anesthesia. (Discuss ACE inhibitors,
ARBs, analyphaxis, vasoplegia causes,
causes of myocardial depression; use of
hydroxocobalamin, or vitamin B12; use
of vasopressin; use of methylene blue)
189
Sample Full Case
A 60-year-old 80 kg woman presents with

the sudden onset of upper and lower
extremity weakness and tingling. MRI scan
reveals a cervical epidural mass. An
emergent laminectomy in the prone
position is planned. Patient has a 100 pack
year smoking history, chronic cough and
shortness of breath on walking two blocks.
BP 150/90; HR 96; R 28; T 37.5 deg. C; Hgb
17.
190
A. Preoperative Evaluation
• Evaluation of head and neck position

and neurologic status: Is it important to
evaluate the effect of the patient's head
and neck position on her neurologic
system? Why/why not? Can you do this
safely? Suppose she is symptom-free only
when in the right lateral decubitus
position. How will you position patient
for anesthetic induction?
• Evaluation of pulmonary function: How

would you assess patient's pulmonary
function preoperatively? Would you
require PFT's? Why/why not? Which ones
with reasons? How will results affect
your anesthetic management? Might
patient's neurologic problem affect the
results of PFT's? Why/why not? Would
ABG's be of value? What would you be
looking for?
191
B. Intraoperative Course
• Monitors: Is an arterial catheter

indicated? Why/why not? Does the
presence of an arterial catheter make a
pulse oximeter unnecessary? Why/why
not? Would you insert a central venous
catheter? Is the measurement of central
venous pressure accurate in a patient in
the prone position? Is PAOP
measurement accurate? Explain.
• Anesthetic induction and maintenance:

A colleague suggests that you intubate
patient awake and allow her to turn
herself into the prone position.
Agree/disagree? Rationale for answer.
How would you manage airway and
protect neurologic function during
induction and endotracheal intubation?
What agent(s) would you choose for
induction? Reasons for choice(s). Would
you administer a muscle relaxant?
Why/why not? Which one? What are your
primary considerations in choosing an
agent for anesthetic maintenance? Your
choice and rationale.
192
• Wheezing and hypoxemia: Immediately

after patient is turned into the prone
position, Sp02 falls from 98% to 94%.
Causes? Mgmt? You listen to the chest
and hear bilateral expiratory wheezes.
Mgmt? Sa02 falls to 91%. DDx? Rx? Would
you allow case to proceed?
• Air embolus: During resection of mass,

extensive bleeding develops. Surgeon
requests reverse Trendelenburg position
to control bleeding. You respond? After
position change and bleeding diminishes
you note the PetCO2 has decreased from
32 to 21 mmHg. What might be the
etiology? How would you proceed?
193
C. Postoperative Care
• Postoperative airway management: The

surgeon requests early extubation in
order to do a neurologic evaluation in
the operating room. Agree/disagree?
Following extubation patient exhibits air
hunger. Breath sounds are inaudible
bilaterally. Mgmt? What do you think is
the cause of her respiratory
insufficiency?
• Burn: Patient is noted to have silver

dollar sized burn over right iliac crest.
What might be the cause? How does this
happen? Management? Explanation to
patient.
From
194
Seven Old ABA Examinations
DOWNLOADED FROM
http://www.physiciantravels.com/wp-
content/uploads/2017/03/Mock_Oral_Ex
ams_II.pdf
195
ABA ORAL EXAMINATION

QUESTION – SAMPLE 1
SESSION 1 – 35 Minutes (total time)
A 55-year-old 80 kg woman is brought to the

operating room for an anterior communicating
artery aneurysm clipping.
HPI: Severe headache and lapse of

consciousness occurred 2 days ago. No apparent
neurological deficit at present time. Cerebral
angiogram yesterday did not show cerebral
vasospasm.
MEDS: Nimodipine, enalapril and furosemide.
PMH: 20-year history of hypertension. Patient

told of difficulty with tracheal intubation for
laparoscopic procedure 5 years ago. No known
allergies.
196
PHYS EXAM: P 92, BP 150/90 mmHg, R 16, T

37.2 Celsius. Awake and oriented, very
apprehensive. Micrognathic, full dentition and
mildly limited TMJ mobility, cervical spine
normal. Neurologic exam normal. No peripheral
edema.
CXR: LV concentric hypertrophy.
ECG: LVH with nonspecific ST-T wave

changes.
LABS Hgb 12.2 gm/dL, Na 145 mEq/L, K 3.2

mEq/L, creatinine 0.9mg/dL, BUN 17 mg/dL.
197
A. INTRA-OPERATIVE MANAGEMENT
– 10 Minutes
1. Monitoring: Would you choose a CVP or

PA catheter in this patient? Explain your
choice. Will you insert preop? Why/why
not? Assume subclavian approach.
Subclavian artery is cannulated. What will
you do? Assume subclavian vein cannulated.
Is EEG monitoring of value in this patient?
SSEPs? Why/why not? How will you use
information from these monitors?
2. Airway mgmt and induction: Do you require

further airway evaluation? If so, how will it
alter your mgmt? Is IV induction followed
by fiberoptic intubation acceptable?
Why/why not? If awake intubation chosen,
how will you minimize hemodynamic
effects?
3. Anesthetic maintenance: Is propofol, N2O,
vecuronium an acceptable maintenance
technique? Why/why not? Surgeon
requests deliberate hypotension. Do you
agree? Why/why not? How low will you
bring the BP? Explain. Is isoflurane or
sodium nitroprusside preferred for this?
Explain your choice. Surgeon requests
lumbar subarachnoid drain. Why?
Risk/benefit?
198
4. Brain protection: Surgeon does not request

deliberate hypotension but instead plans to
temporarily clip the anterior cerebral artery.
How does this change your mgmt? Can
you provide brain protection with
intravenous barbiturates? Explain. How do
you determine appropriate dose? What
does burst suppression mean? Is
hypothermia of value? Why/why not?
5. Aneurysm rupture: During dissection,

aneurysm suddenly ruptures. What will you
do? Will you raise or lower BP? Why?
Surgeon places clip and posterior tibial to
vertex SSEPs disappear. What will you do?
Why?
199
B. POST-OPERATIVE CARE
– 15 Minutes
1. Hypothermia: At conclusion of surgery,

patient's temperature is 34.5oC. Is this a
problem? Why/why not? Will you warm
the patient? Why? How? Effect of
hypothermia on muscle relaxant reversal?
2. Decision to extubate vs. ventilate: Are

criteria for extubation different than for
healthy patient after appendectomy? What
are important differences? What are your
criteria for extubation for this patient?
Explain.
3. Persistent somnolence: On POD #2 patient

is responsive only to painful stimuli. A few
hours ago she was arousable to her name
being called. Your concerns? How can
cause be evaluated? Is transcranial doppler
indicated? Angiography? Why for each?
4. Cerebral vasospasm: Cerebral angiogram

reveals diffuse vasospasm. How will you
treat? Barbiturate coma? Hypervolemia?
Deliberate hypertension? How will you
judge effectiveness of therapy? Patient
develops progressive hypoxemia during
hypervolemic therapy. How will you
200
determine cause? Rx if pulmonary edema?

Pneumonia?
5. SIADH: On POD #3, serum sodium is 125
mEq/dL. DDX? What is mechanism of
SIADH in this patient? How will you
confirm Dx? Rx? Why?
6. Severe hoarseness post-extubation: On day

5, patient’s neurologic and physiologic
status near normal. On extubation patient
has severe hoarseness progressing to stridor.
Your plan? Patient cyanotic. Your plan?
Racemic epinephrine vs. steroids vs.
cricothyroidotomy vs. re-intubation?
201
C ADDITIONAL TOPICS
– 10 Minutes
1. Cesarean delivery in a patient with asthma:

A 38-year-old, 55 kg parturient with a
history of asthma presents for urgent C-
delivery due to cephalopelvic disproportion.
What are effects of pregnancy on her
pulmonary status? What of labor? How do
these affect your choice of anesthetic
technique? Suppose epidural. Following
local anesthetic administration the level rises
to C8 and she complains of difficulty
breathing. How would you treat? Explain.
202
2. Complication of retrobulbar block: You are

called STAT to the ophthalmology suite by
the surgeon who has just performed a
retrobulbar block on an 82-year-old woman
for cataract extraction. The pt is
unconscious and apneic. Cause?
Evaluation? How proceed? Mgmt?
3. Liver disease: A 48-year-old man with

cirrhosis and ascites is to undergo a right
hemicolectomy for carcinoma. What tests
would you require preop? Why? How
induce anesthesia? Why? Choice of
muscle relaxant? Why? Dose? Would
normal saline be an appropriate fluid for the
maintenance intravenous infusion?
Why/why not? At what rate would you
infuse fluids? Why? Patient becomes
hypotensive coincident with peritoneal
incision and loss of ascetic fluid. DDX?
Rx?
203
A 60-year-old 120 kg man scheduled for an

exploratory laparotomy for a suspected ruptured
diverticulum. 8-year history of chronic renal
failure and is hemodialyzed 3 times a week.
Meds include clonidine and metoprolol for
hypertension and epoetin for anemia. BP
165/110 mmHg, P 90, R 24, T 38o C, Hgb 10.5
gm/dL, K 5.2 Meq/L.
204
A. PRE-OPERATIVE EVALUATION
- 10 Minutes
1. Cardiovascular status: Is preop cardiac

stress test indicated? Why/why not? What
information do you require? Why? How
does data alter your mgmt? Continue
cardiac drugs? How? Why? How
determine volume status? Why important?
Assume EF of 55%.
2. Metabolic assessment: Concerned about his

creatinine level? Why/why not? K+? If it
were 6.0 mEq/L, your plan? Why? What
would you expect patient's arterial pHa,
PaCO2, HCO3- to be and why?
205
3. Obesity / anesthetic implications: Effect of

obesity on pulmonary function? How
evaluate pulmonary function in this patient?
How will data help your mgmt? What will
you tell patient about the risks of anesthesia?
4. Anemia: Why is patient receiving epoetin?

Transfuse pre-op? Why/why not? How
does Hgb level assist with decision? Cross
match difficult. Proceed with anesthesia?
Why/why not? How does anemia affect
pulse oximetry? SVO2?
5. Febrile state: Is 38oC temperature of

concern? Why/why not? Your plan? Most
effective method to decrease temp in this
patient? Why?
206
B. INTRA-OPERATIVE MANAGEMENT
– 15 Minutes
1. Monitors: Arterial catheter attempted in arm

without shunt without success. Your plan?
What are advantages of mass spectrometry
over capnography in this patient? Any
patient? Pulse oximeter reading not
obtainable in any extremity or ear. Your
plan?
2. Selection and mgmt of anesthesia: Is a

lumbar epidural indicated? Why/why not?
You get a wet tap. What next? Assume
epidural placed. Will you administer
fentanyl or bupivacaine? Why/why not?
Does ropivacaine offer any advantage?
3. Mgmt of intraop hypoxemia: Ten minutes

after intubation, SpO2 decreases to 94%.
Possible causes? Your plan? Does
capnograph help in DDX? How? Cannot
pass suction catheter down tube. Your plan?
Assume suction catheter passes. Breath
sounds diminished on right. Your plan?
207
4. Fluid mgmt during colon resection: Assume

minimal blood loss. How much fluid will
you administer? Why? What are 3rd space
losses? Why do they occur? What are
consequences of 3rd space fluid in this
patient?
5. Mgmt of intraop hypotension: BP

continues to be in 80-90 mmHg systolic
range despite fluid replacement. Why
could this happen? How will you
determine the Dx? Differentiate blood loss
vs. cardiac cause vs. sepsis? Rx of each?
6. Electrosurgical Unit: Surgeon requests

ESU power to be increased. Does this
concern you? What will you do? Patient
has a burn under dispersive pad at end of
case. Could this happen without any
intraop signs? How?
208
C. ADDITIONAL TOPICS
– 10 Minutes
1. Carotid surgery: You are asked to evaluate a 60-

year-old man scheduled for a right carotid
thromboendarterectomy for TIA's. In the PACU
following a left carotid TEA 2 weeks ago, he had
an episode of ST segment depression in leads V4-
6 that resolved with intravenous propranolol and
nitroglycerin ointment. Do you desire further
information? Be specific. Why? Will you insist
on any further evaluation prior to surgery?
Explain.
2. Pediatrics-pyloric stenosis: A 3-month-old infant

has been vomiting for four days and is scheduled
for a pyloromyotomy. How will you assess
volume status? Endpoint of fluid therapy? Is
awake intubation preferable? Why/why not?
What technique would you select for induction
and intubation? Why? What anesthetic circuit?
Why?
209
3. Pain control: A 45-year-old man has low back

pain with pain radiating down his left leg into his
big toe of 4 weeks duration. How assess?
Therapeutic options? Compare
advantages/disadvantages of each. Suppose select
epidural steroids. Choice of drug? Why? How to
administer? Co-administer with local anesthetic?
You do that and shortly thereafter patient
complains of tingling upper extremities and
difficulty breathing. What might have occurred?
What will you do?
210


operating room for nephrectomy and
transplantation of a cadaveric kidney harvested
16 hours ago.
HPI: Chronic renal failure secondary to

hypertension. Hemodialysis for 8 years; last
dialysis 36 hours ago. Hypertension for 24 years
with an episode of acute pulmonary edema one
year ago.
MEDS: Nifedipine, lisinopril (ACE inhibitor),

ranitidine and antacids.
PMH: Symptomatic hiatal hernia for 4 years.

Allergy to PCN (hives). Nonsmoker.
211
PHYS EXAM: P 95, BP 175/110 mmHg, R 20,

T 37C Airway appears adequate. Lungs clear to
auscultation. AV fistula for dialysis in left
forearm.
CXR: Left ventricular concentric hypertrophy.

Prominent vascular markings.
ECG: LVH with nonspecific ST-T wave

changes.
LABS: Hgb 8.0 gm/dL; Na 135 mEq/L; K 5.6

mEq/L; BUN 49 mg/dL, creatinine 5.0 mg/dL.
On arrival to the operating room a 20 gauge IV

catheter is present in the right dorsal hand. The
patient is extremely anxious.
212
– 10 Minutes
1. Monitoring: Does history suggest using

other than the standard 3 lead ECG? Explain.
Modification to the 3 lead ECG? Why?
How use an ECG monitor that measured ST
segment changes in mgmt? Surgeon asks to
avoid radial artery catheterization.
Reasonable request? Will an automated BP
cuff be adequate?
2. Choice of anesthesia: regional vs. general:

Any unique benefits to regional anesthesia in
this patient for this operation? Spinal
anesthetic? Why/why not? Any advantages
over a continuous epidural? Does it matter
which local anesthetics selected in the
presence of renal failure? Patient requests
general anesthesia. Your priorities in
planning induction? How will you quickly
secure the airway? Is patient at risk for
aspiration? What will you do? How to
control hypertension during RSI? If a RSI,
what muscle relaxant? Explain choice.
213
3. Anesthetic maintenance: Would a total

intravenous anesthetic technique with
remifentanil be appropriate? Why/why not?
Your choice of inhalation agent for
anesthesia matter? Avoid nitrous oxide?
Why/why not?
4. Severe hypertension: Coincident with the

surgical incision, the BP increases to
240/140 mmHg. Why important to treat
hypertension of this degree? If ST segments
have changed, reasonable to deepen the
inhalation anesthetic? What drugs to control
the hypertension? Explain your choice.
5. Extubation: Special concerns for extubation

result from renal failure? Muscle relaxants
more likely to result in a prolonged block?
Will a train of four give reliable results in a
patient with renal failure? Concerns of a
hiatal hernia present at this time?
214
– 15 Minutes
1. Dyspnea and rales (CHF): After extubation

in OR patient develops rapid and labored
respirations and auscultation reveals diffuse
rales (CHF). Reintubate? Why/why not?
How would mechanical ventilation improve
her problem? Would CPAP without
intubation be as helpful? What drugs other
than diuretics would be helpful? How so? If
used CVP monitoring during operation,
what would cause you to replace it with a
pulmonary artery catheter? Explain.
2. Ventricular ectopy, tachycardia: Several

hours after resolution of the respiratory
problem, onset of frequent, multifocal PVCs.
Metabolic problems in this setting contribute
to the occurrence of PVCs? How could
hypertension cause PVCs? Hypoxia? What
indications to treat? What if the dysrhythmia
is SVT? First drug choice? Explain. How to
decide to use electrical cardioversion?
215
3. Oliguria (transplant): In the first few hours

after transplantation, urine output is only 10
cc/hr. Would urine lab studies help with a
Dx? Surgeon suggests increasing CO.
Reasonable? Your approach in light of her
heart disease? How to decide if filling
pressures are adequate?
4. Postop analgesia: Does regional postop

analgesia offer special advantages? Special
concerns? Explain. Would a thoracic
epidural offer any advantages over a lumbar
epidural? The patient is agreeable but wants
to be asleep for catheter placement. Your
response? Infuse local anesthetic, opioids or
both? How decide?
5. Nerve injury: 2 days later patient complains

of numbness and tingling in the right 4th and
5th fingers. What motor deficits to look for?
Diagnostic studies indicated? What is likely
injury? What is likely mechanism?
Recommended Rx? What to tell patient
about the injury?
216
– 10 Minutes
1. Increased intracranial pressure: A 48-year-

old man with a head CT suggestive of
increased ICP is to undergo resection of a
brain tumor. BP increases from 130/90 to
160/110 during induction of anesthesia.
Lower BP? Why? How? Would an
inhalation agent be appropriate? Which?
Why? Implications of increased ICP for
anesthetic mgmt? Management of increased
ICP intraop? Monitor ICP postop? Why?
How?
2. Chronic pain: A 62-year-old man has severe

abdominal pain produced by pancreatic
carcinoma. You are asked to evaluate for
long-term analgesia. Alternatives for
predicted 6-12 month longevity?
Recommendation? Why? Colleague
suggests neurolytic celiac plexus block.
Agree? Why/why not? What agent? Why?
What to tell patient regarding
complications? Is an implantable morphine
pump indicated?
217
3. Regional anesthesia: A 37-year-old T5

paraplegic patient scheduled for cystoscopy
and crushing of bladder stones. Is spinal
anesthesia contraindicated? Why/why not?
Takes warfarin daily because of a prior
mitral valve replacement. Does this change
plan? What complication(s) concerned
about? Criteria to use to decide to use
spinal/epidural anesthesia in a patient with
possible abnormal coagulation? Explain.
218
A 58-year-old 55 kg woman is scheduled for

exploratory laparotomy for ovarian cancer. She
smoked 2-2.5 ppd until 2 years ago. Stopped
because of increasing dyspnea and exercise
intolerance. Uses nasal oxygen for night sleeping
and cannot walk more than 30 steps without
severe shortness of breath. Meds include
albuterol and ipratroprium inhalers. She has
moderate ascites. BP 130/85 mmHg, P 104, R
18, T 37.4oC, Hgb 14.8 gm/dL. ABG (room air)
- pHa 7.36, PaO2 54 mmHg, PaCO2 46 mmHg.
219
- 10 Minutes
1. Analysis of ABGs: How to interpret her

ABGs? What is the significance of
hypercarbia to anesthetic mgmt? Why is she
not acidemic? Receive nasal O2
continuously rather than just for night
sleeping? Why/why not?
2. Pulmonary evaluation: Presume last PFTs

were done six months ago. Should new
PFTs be ordered? Why/why not? What
specific information do you seek that is not
evident from the hx and ABGs? Can you
rule out pulmonary infection without sputum
culture? How? Why is this an important
consideration preop?
3. Ascites - anesthetic implications: Why does

the patient have ascites? Does ascites alter
your plan for mgmt? How? Why? Should
ascites be drained preop? Why/why not?
4. Preoperative medications: What

medications would you continue/
discontinue preop? Why for each? If
extremely anxious, would you provide
sedation? Why/why not?
220
– 15 Minutes
1. Monitoring: Is a central venous catheter

necessary? Why/why not? Insert an arterial
catheter? Why/why not? Is the information
from oximetry and end tidal CO2 monitoring
adequate? Why/why not?
2. Induction: Colleague recommends RSI due

to ascites. Agree? Why/why not? For
induction, ketamine preferable to
thiopental? Propofol? Explain. How to
attenuate the tracheobronchial response to
intubation in this patient? Important to do
so? Why?
3. Severe bronchospasm, hypoxemia with

intubation: Immediately after induction and
tracheal intubation, PIP increases to 50
cmH20. How to distinguish bronchospasm
from endobronchial intubation? From tube
obstruction? From pneumothorax? Bilateral
wheezing present. How to manage?
Compare deep anesthesia vs. albuterol rx.
What if BP, and PetCO2? Rx?
221
4. Anesthetic selection: Is N2O-narcotic good

choice? Why/why not? Is insoluble
inhaled anesthetic preferable to a
moderately soluble anesthetic? Compare
desflurane vs. sevoflurane vs. isoflurane.
Your choice? Why? Would you prefer
pancuronium, vecuronium or rocuronium
for relaxation? Defend choice.
5. Management of intraop ventilation, ABGs:

Would ventilation settings of VT = 550 ml,
RR = 16, I:E ratio = 1:1 be appropriate for
this case? Why/why not? Your preferred
settings? Why? 45 min into case ABGs are
PaO2 202 mmHg, (FiO2 1.0), PaCO2 52
mmHg, pHa 7.41. Appropriate? Would you
alter ventilation? How? Why? What if
PaCO2 65 mmHg and bilateral wheezing is
prominent?
6. Extubate or ventilate at surgical end: Does

early extubation minimize the risk of
recurrent bronchospasm? Explain.
Recommend overnight postop ventilation
for this patient? Why/why not? If ventilated,
use IMV or controlled ventilation? Why?
At extubation, pulmonologist recommends
no supplemental O2 to avoid depression of
respiratory drive. Agree? How would you
manage?
222
– 10 Minutes
1. Carotid surgery: You evaluate a 60-year-old

man scheduled for right carotid
thromboendarterectomy for TIA's. In PACU
following a left carotid TEA 2 wks ago, he
had an episode of ST segment depression in
leads V4-6 that resolved with intravenous
propranolol and nitroglycerin ointment.
Further information? Be specific. Why?
Any further evaluation prior to surgery?
Explain.
2. Pediatrics-pyloric stenosis: A 3-month-old

infant has been vomiting for four days and is
scheduled for a pyloromyotomy. How to
assess volume status? Endpoint of fluid
therapy? Is awake intubation preferable?
Why/why not? What technique selected for
induction and intubation? Why? What
anesthetic circuit? Why?
223
3. Regional anesthesia: A 23-year-old male

is scheduled for shoulder arthroplasty. He is
terrified of general anesthesia and desires to
remain awake. You respond. What options
are available for anesthesia? Which would
you choose? Why? Compare an
interscalene vs. supraclavicular block.
Advantages/disadvantages. Could this
procedure be done with an interscalene
block alone? Why/why not?
224

A 54-year-old 100 kg, 5'9" man is brought to the

operating room for CABG.
HPI: The patient was asymptomatic until 4 days ago when

he developed severe chest pain with exertion that
responded to NTG and metoprolol. ECG demonstrates
anterolateral ST segment depression. CK MB enzymes
were elevated and cardiac catheterization revealed 90% left
main coronary artery stenosis. EF is 45% and LVEDP rose
from 18 mmHg to 28 mmHg during ventriculography. He
has had hypertension for 15 years
MEDS: Nitroglycerin and heparin infusions, metoprolol,

diltiazem, NPH insulin q AM and PM
PMH: Poorly controlled type 2 diabetes for 6 years.

Smoker 1 ppd for 30 years until 4 years ago.
PHYS P 60, BP 130/82 mmHg, R 18, T 37.2 Celsius
EXAM: Airway appears adequate, teeth intact. Moderately

obese. Asymptomatic (R) carotid bruit. Lungs clear. No
peripheral edema.
CXR: Left ventricular prominence, poor inspiratory effort.
ECG: V3-V6 ST segment depression, no Q waves.
LABS: Hgb 14 gm/dL, serum glucose 197 mg/dL, Na 140

mEq/L, K 4.2 mEq/L
225
– 10 Minutes
1. Monitoring: Will you select a CVP or PA

catheter? Why? Place before or after
induction? Why? Would use of TEE
obviate the need for a PA catheter?
Why/why not? Does the heparin infusion
need to be discontinued before insertion of
a central catheter? Why/why not? Possible
adverse consequences of discontinuing
heparin? Does right carotid bruit lead you
to avoid the right internal jugular vein?
Why/why not?
2. Anesthetic induction: Assume all monitors

in place. Is induction of anesthesia with
thiopental acceptable? Why/why not? Your
choice? Hemodynamic effects expected?
How do you prevent response to
laryngoscopy and intubation?
226
3. Post-induction bradycardia and

hypotension: Prior to chest incision BP
80/50 mmHg, P 50. Etiology? Assume
nodal rhythm. Do you need to treat?
Why/why not? If sinus bradycardia, how
treat? How do you rule out ischemia as a
cause?
4. ST-segment alteration: During aortic root

dissection, ST segments become depressed
in II, aVF. How treat? Difference if P 60 vs.
90, BP normal vs. elevated?
5. CPB mgmt and weaning: Glucose is 300

mg/dL during CPB. Treat? Why/why not?
How will you treat? Potential
complications of hyperglycemia?
Difficulty inflating/deflating lungs just
prior to separation from CPB. How will
you proceed? How do you determine need
for inotropic support prior to separation?
Explain.
227
– 15 Minutes
1. Heart block after chest closure: Patient

becomes hypotensive on arrival in ICU. BP
90/65 mmHg. DDx? ECG shows HR 40
with PVCs. Rx? Pacemaker wires in place.
How to set? If not operating, what will you
do?
2. Chest tube bleeding - surgical vs.

coagulopathic: Chest tube drainage is 200
ml/hr for 2 hours. Does patient need more
protamine? Platelets? How decide? Does
patient need to go back to O.R. for surgical
exploration? Difference if patient is
hypotensive, normotensive, hypertensive?
Explain.
3. Oliguria: Urine output 25 cc/hr x 2 hours.

Why is patient oliguric? How will you treat?
End point? Rationale?
4. Failure to awaken at 10 hours postop: 6

hours after arrival in ICU, patient has not yet
shown any signs of awakening. Concerned?
Possible causes? How will you investigate
delayed emergence?
228
5. Ventilatory weaning and extubation: On

POD #1 patient awakens. SVO2 is 60%,
SpO2 98% with FIO2 = 0.4. Reasonable to
start weaning? Why/why not? Next steps?
6. Intraop awareness: Despite slow awakening,

patient complains on POD #2 that he was
awake during surgery. Reasons? Why did
awareness possibly occur in this patient?
What will you tell patient?
7. Ulnar nerve injury: Patient also complains

of numbness over right ulnar nerve
distribution. Etiology? Natural course?
How treat?
– 10 Minutes
1. Pediatrics: A 3 kg infant requires

laparotomy for bowel obstruction. Specific
problems related to this complication? How
do you plan to deal with fluid status? Preop?
Intraop? What anesthetic circuit will you
choose? Why? What anesthetic agents will
you choose? Why? Extubate or ventilate
after surgery? How will you decide? Pain
control?
229
2. Peritonsilar abscess: A 50-year-old man

presents for urgent drainage of a
peritonsilar abscess. Severe pain and
anxiety make local anesthesia unrealistic.
How would you assess patient preop? Able
to open mouth 2 cm. How would you
induce anesthesia and secure airway?
Rationale.
3. Eye surgery: A 88-year-old man is to have

a cataract extraction. He is anxious and he
has chronic bronchitis. How would you
make the decision whether to use regional or
general anesthesia? Assume regional.
Administer IV sedation while surgeon places
block? Why/why not? Immediately
following placement of block the patient
becomes unconscious and apneic. DDx?
Rx? Continue with case? Why/why not?
230
A 20-year-old 60 kg, 5'4" tall primigravida is

scheduled for urgent Cesarean delivery at 37
weeks gestation. She presented one hour ago in
labor and is pre-eclamptic. She has received one
dose of hydralazine and magnesium sulfate. She
admits to frequent heroin use. The obstetrician
has just notified you that late decelerations of
FHR are occurring. P 110, BP 170/110 mmHg, R
22, T 37.5o C, Hgb 9.8 gm/dL.
231
- 10 Minutes
1. Pre-eclampsia: What are the anesthetic

implications of pre-eclampsia? Why is the
fetus at increased risk when pre-eclampsia
occurs? Volume status of preeclamptic
patient? Is this patient adequately treated?
Additional therapy? Endpoint to Rx of BP?
2. FHR - late decelerations: Significance of

late decelerations? Other diagnostic tests of
fetal distress? Is the next 30 minutes better
spent medically treating mother or
delivering baby? Why?
232
3. Heroin use: Last heroin use was 24 hours

ago. How will this affect anesthetic
management? How will this affect fetus?
Affect neonate?
4. Preanesthetic management: No blood typed

and crossed. Would you delay procedure
until blood is available? What if antibodies
are complicating cross-match? Additional
lab tests required? Which? Why? Preop
medications? Explain.
233
– 15 Minutes
1. Monitoring: Do you need a CVP catheter

for procedure? Why/why not? Possible
complications that are more likely to occur
associated with CVP placement because of
her medical history?
2. Anesthesia choice - regional vs. general: Is

spinal anesthesia an appropriate choice?
Why/why not? Epidural better? Benefits
vs. risk of general anesthesia in this patient?
Explain.
3. Induction of general anesthesia: Patient

insists on general anesthesia. Assume
normal airway. Problems anticipated
during induction? How will you
treat/avoid? Likelihood of intra-op
awareness? Can you avoid? How?
234
4. Severe post-induction hypertension:

Following intubation, BP 240/140 mmHg.
Possible adverse consequences to mother,
fetus? How treat?
5. Neonatal resuscitation: BP controlled,

mother stable. Colleague relieves you to
care for neonate. Apgar 2 with thick
meconium. How will you proceed? Will
you give naloxone? Why/why not?
6. Severe hemorrhage: Neonatologist arrives

to care for neonate. During extraction of
placenta, severe hemorrhage occurs. How
proceed? Transfuse? Reason(s). What if
cross-match not complete?
235
– 10 Minutes
1. Posterior fossa craniotomy: A 58-yr-old

man is to undergo craniotomy while in the
sitting position for a posterior fossa tumor.
Is isoflurane the preferred anesthetic for
this procedure? Why/why not? Is N2O
useful in this procedure?
Advantages/disadvantages? Is CVP
essential? Why/why not? How verify
correct placement? Can increase in ICP be
prevented? How? Is mannitol more
effective than furosemide to reduce ICP?
Why/why not? Is there a limit to how low
PaCO2 should be taken? Explain. How
will you differentiate brain stem ischemia
from venous air embolism? Are there
similarities? Explain.
236
2. Pain management: A 68-year-old woman is

referred to you with acute herpes zoster and
pain involving the T6 – T7 dermatomes on
the right. She has COPD requiring nasal
oxygen. How does her COPD affect your
therapeutic options? Explain. What therapy
would you offer her? Role of antiviral
medications? Does your Rx plan differ if the
herpes zoster is chronic vs. acute? Explain.
3. AICD: A 60-year-old patient with an AICD

(automatic implantable cardiac defibrillator)
in place presents for exploratory laparotomy
for suspected acute appendicitis. Anesthetic
implications? Should the device be
disarmed? Why/why not? Should
succinylcholine be avoided? If so, why?
How will you proceed? Rationale.
237


operating room for urgent left carotid
endarterectomy.
HPI: The patient has experienced

recurrent unilateral transient ischemic
attacks over the past week. Carotid
angiogram demonstrated 90% stenosis with
an ulcerated plaque.
MEDS: Digoxin, furosemide, nifedipine, aspirin

and NTG prn.
PMH: Hypertension for 20 years. Anterior wall

MI one year ago with mild CHF following
infarct. Cardiac catheterization 8 months ago
demonstrated EF of 30%. Occasional exertional
angina and 2 pillow orthopnea. No known
allergies.
238
PHYS EXAM: P 68, BP 170/105 mmHg, R 20,

T 37 C Airway appears adequate; edentulous.
Loud left carotid bruit. Minimal rales at both
bases. Questionable S3 gallop. 1+ peripheral
edema.
CXR: Prominent vascular markings,

cardiothoracic ratio 0.6.
ECG: NSR, LVH, Q waves V1-V4, nonspecific

ST-T wave changes.
LABS: Hgb 12.5 gm/dL; Na 134 mEq/L; K 3.1

mEq/L; digoxin level 2.2 ng/ml (normal 0.5
ng/ml - 2.0 ng/ml) v
239
– 10 Minutes
1. Anesthetic technique - regional vs. GA: Is

regional anesthesia your choice for this
patient? Why/why not? Major risks of
deep cervical block? How would you
detect problems? Rx of total spinal (BP
80/40 mmHg, P 40)?
2. Monitoring: Assume patient refuses

regional anesthesia. Will you monitor brain
function intraop? Why? How? Compare
EEG to SSEPs for ischemia detection. Will
PA catheter data change your management
in this patient? How? If unable to place
PA catch, will you proceed with case?
Why/why not?
240
3. Induction (assume GA): Is remifentanil

appropriate for this patient? Why/why not?
Your choice. Defend. Unable to mask
ventilate patient after etomidate. Your
plan? Oral airway placed, patient develops
stridor, will you give succinylcholine?
Why/why not? After intubation, you note
elevation in ETCO2 (53 mmHg). What will
you do? DDx? Assume resolution.
4. Management of BP during procedure:

During dissection pulse slows to 50. How
will you evaluate? Rx? Carotid cross
clamp is imminent. Is IV bolus of
thiopental indicated? Why/why not?
Should BP be increased or decreased during
cross clamp? Why? Clamp is on and EEG
slowing is noted bilaterally. Why? Rx?
5. ST segment depression in inferior leads:

As surgeon is closing wound, you notice ST
segment depression in inferior leads. What
will you do? Why?
241
– 15 Minutes
1. Severe hypertension with emergence: As

patient emerges, BP increases to 190/120
mmHg. Of concern? Why? Mechanism?
Rx? How will you determine whether
patient has had an MI? Compare CK
enzymes and ECG. Patient develops
frequent PVCs. Etiology? Rx?
Delayed awakening: Patient does not

follow commands at the end of anesthetic.
DDx? How will you R/O intracranial
problem? Patient received midazolam at
beginning of anesthetic. Will you
administer flumazenil? Why/why not?
2. Dyspnea and hypoxemia in PACU: Patient

has awakened more and complains of
shortness of breath. Respiratory rate
24/min. How will you evaluate? SpO2 is
92% on face mask. DDx? Rx?
242
3. Cervical hematoma 4 hours postop:

Assume patient has had an uneventful
recovery for 4 hours. She now complains
of pressure in her neck near incision. How
will you determine dx? As you are
examining her she complains of difficulty
breathing. What will you do? Why? Will
you open wound or reintubate? In PACU?
In OR? Explain choices.
4. Ischemic left hand (arterial catheter

location): Later in evening, nurse notifies
you that left hand is cold and pale. DDx?
Rx? Is local anesthetic infiltration at the
wrist indicated? Why/why not? Are warm
compresses advisable? What will you do?
Why? Stellate ganglion block not effective.
How will you determine if sympathectomy
occurred? Your plan?
243
– 10 Minutes
1. Obstetrics - placenta previa: A 25-year-old,

110 kg woman G-2, P-1, presents for
emergency Cesarean delivery due to
placenta previa with moderate bleeding.
Her first baby was delivered by cesarean
section. BP 100/80; P 110. What is the
significance of the previous cesarean
section? The patient had planned on an
epidural for her delivery. How will you
advise her regarding choice of anesthesia?
Why? How would you induce general
anesthesia if such is deemed best?
Rationale? How manage massive blood
loss? Cell-saver?
244
2. Pain management: An obese 23-year-old

woman complains of severe abdominal pain
and is nearly hysterical 5 hours after open
cholecystectomy under general anesthesia.
She has been addicted to meperidine and
was receiving methadone. What would you
recommend? Why? Would an epidural be
appropriate now? Why/why not? Where
place? Drugs? Why? Alternative
approaches to management? Could this be
due to pancreatitis? How Dx? Would you
proceed differently? Why/why not? If so,
how? Rationale.
3. Mask anesthesia: You are asked to serve as

an expert witness on a malpractice case. A
30-year-old woman with steroid-dependent
asthma underwent a vaginal hysterectomy.
She had a cup of black coffee 3 hrs
previously. The anesthesiologist elected
not to intubate the trachea and used a
laryngeal mask airway. The patient
aspirated during the procedure and
developed pneumonia. Was the
anesthesiologist negligent? Why/why not?
Describe appropriate fasting guidelines.
245
A 30-year-old 110 kg, 5'7" woman is scheduled

for a repeat C-section at term pregnancy. History
includes asymmetric septal hypertrophy (IHSS)
and mental depression. Medications include
propranolol and amitriptyline. CXR and ECG
demonstrate left ventricular hypertrophy. P 64,
BP 130/85 mmHg, R 18, T 37o C. Hgb 10.4
gm/dL.
246
- 10 Minutes
1. Pregnancy anesthesia implications: What

changes occur in cardiovascular physiology
secondary to pregnancy? What implications
do these changes have regarding IHSS?
How to interpret Hgb of 10.4 gm/dL?
Consistent with dilutional anemia of
pregnancy? Implications of anemia in this
patient? Transfuse preop? Why/why not?
2. Obesity airway assessment: Would you

expect endotracheal intubation to be
difficult? Why? Does obesity play a role
here? How?
247
3. Cardiac assessment/IHSS: What is IHSS?

Why important in this case? How to assess
the pt's cardiac functional status? Why on
propranolol?
4. Antidepressants anesthesia implications:

What anesthetic implications of
amitriptyline? Should this be discontinued
preop? Why/why not? What side effects
may occur in conjunction with
amitriptyline?
5. Preop medication: Pre-medicate this

patient? If so, why? What to use for pre-
medications? Would the premedication
have any effect on the fetus? Explain.
248
– 15 Minutes
1. Monitoring: Does this patient require any

special monitoring? A colleague suggests
that you place an arterial catheter and a PA
catheter. Do you agree? Why/why not?
2. Induction: How will you induce

anesthesia? Why did you select that
technique? How would your choice affect a
patient with IHSS?
3. Difficult intubation: You are unable to
visualize the larynx at the time of
laryngoscopy. What do you do? You are
having difficulty ventilating the patient and
the SpO2 has fallen to 80%. What do you
do? You can now ventilate the patient and
attempt a fiberoptic assisted intubation.
Will you select an oral or nasal approach?
Why? Suppose you choose the nasal route
and marked epistaxis occurs. What do you
do now?
249
4. Anesthetic maintenance - choices: What is

your choice for maintenance? Would N2O-
O2-opioid-muscle relaxant be a good
choice? Why/why not? If you select a
volatile agent would you prefer isoflurane,
desflurane or sevoflurane? Why?
5. Severe hypotension: Immediately after

delivery of the fetus the patient's heart rate
climbs to 140 bpm and the BP falls to 70/40
mmHg. DDx? How to differentiate? Rx?
250
6. Neonatal resuscitation: Neonate is limp and

cyanotic. Gasping intermittently, with heart
rate of 60 bpm and covered with thick
meconium. An associate is able to manage
the mother. How to resuscitate the baby?
Management of airway in relationship to
meconium? Effects of meconium
aspiration? When is cardiac massage
indicated? You ventilate after suctioning the
trachea and placing an endotracheal tube.
Heart rate remains at 60 bpm despite
ventilation and cardiac massage. Is drug
therapy indicated? If so, what and why?
251
C. ADDITIONAL TOPICS – 10 Minutes
1. ICU consult - pulmonary insufficiency: You

are consulted about a 72-year-old man being
resuscitated from septic shock secondary to
a urinary tract infection. Developed
respiratory distress with bilateral pulmonary
infiltrates and ABG shows PaO2 50mmHg,
PaCO2 33mmHg, pH 7.32 while breathing
100% oxygen by mask. DDx? Differentiate
cardiogenic edema from ARDS? Assume
ARDS, how manage? Intubate? Controlled
ventilation vs. IMV vs. pressure support?
What is "best PEEP"?
252
2. Regional anesthesia: A 24-year-old man

having hand surgery requests intravenous
regional block. Is premedication
necessary? Why/why not? What anesthetic
for a 60 minute procedure? Why? Add
epinephrine? Why/why not? 10 minutes
after injection of local anesthetic tourniquet
accidentally deflates. What now? Pt
begins having a grand mal seizure?
Response? Shortly after ECG shows
ventricular fibrillation. Immediate Rx?
How to set defibrillator? Is IV lidocaine
indicated? Why/why not? Alternative drug
therapy?
3. Sickle cell disease: A 10-year-old child

with sickle cell disease requires anesthesia
for repair of a tendon laceration in his
forearm. Discuss anesthetic implications of
sickle cell disease. How to anesthetize?
Defend choice. Surgeons wish to use
tourniquet. Agree? Would your concerns
be different if patient had sickle cell trait?
Why/why not?
253

A 68-year-old 110 kg man is brought to the

operating room for cervical laminectomy in the
prone position.
HPI: The patient has long-standing, severe

osteoarthritis and symptomatic cervical stenosis.
Bilateral upper extremity pain and paresthesias
have been present for 6 months. Mild cervical
extension increases symptoms.
MEDS: Diltiazem, furosemide and aspirin.
PMH: Hypertension since age 40. Inferior wall

MI 10 years ago without CHF or subsequent
symptoms. Type 2 diabetes for 3 years under
poor dietary control. Anesthetic record from
cholecystectomy 8 years ago unavailable. No
known allergies.
254
PHYS EXAM: P 80, BP 170/95 mmHg, R 18, T

37o C Anxious appearing obese man. TMJ
mobility mildly restricted, tongue large, full
dentition, base of uvula visualized. C-spine
extension minimal due to paresthesias. Chest
exam WNL. No peripheral edema.
CXR: LV concentric hypertrophy.
ECG: NSR, Q waves - lead II, III, AVF;

nonspecific ST-T wave changes.
LABS: Fasting a.m. blood sugar 210 mg/dL; Hgb

14.0 gm/dL; SpO2 (room air) 94%.
The patient has a 16-gauge peripheral IV

catheter.
255
– 10 Minutes
1. Monitoring: Assume pt in 10 degree head-

up position. Does patient require a CVP or
PA catheter? Why/why not? What
modalities are available for insuring the
integrity of the cervical cord during the
surgical procedure? What are SSEPs?
Reliable for monitoring spinal cord
function? Why/why not? Does anesthesia
affect interpretation of SSEPs? If so, how?
Explain.
2. Initiation of anesthetic: Securing airway -

is direct laryngoscopy contraindicated in
this patient? If so, why? What mechanism
for potential cord injury? Intubate? Does
his diabetes and/or heart disease influence
plan? If so, how? Can hemodynamic
response to awake intubation be lessened?
Explain. Induction - how to induce
anesthesia? Why? Evidence that thiopental
is hazardous in patients with this degree of
heart disease? Evidence that other
induction agents are safe? Explain.
Positioning of patient - special requirements
when positioning patient prone? Explain.
If ventilation being controlled, still
256
necessary for the abdomen to be “free”?

Why/why not? Is application of lubricant
to the eyes necessary? Why/why not?
3. Anesthetic choices for maintenance: Is

high-dose opioid technique most
appropriate for this patient? Why/why not?
Choice for maintenance? Why? Patient’s
minimum acceptable BP during procedure?
Why? Muscle relaxant necessary for
procedure? Why/why not?
4. Diabetic management: One hour after

induction blood glucose is 300 mg/dL.
Necessary to treat? If so, why/how? If
excess insulin inadvertently administered,
what would be manifestations of
hypoglycemia during anesthesia? How
treat?
257
– 15 Minutes
1. Criteria for extubation: Spinal cord was

traumatized during surgical procedure and
SSEPs were lost for 30 minutes. How to
decide whether or not to extubate patient at
end of procedure? If choose to wait until
patient is responsive, how prevent coughing
on tube, tachycardia and hypertension?
How does a NIF of -25 cm H2O compare to
that achievable by an awake healthy
person? Implications?
2. Pressure support in PACU prior to

extubation: Assume pt weak. Elect to keep
ET tube in place. What ventilator settings
would you order? Why? How do values
you choose for VT and ventilatory rate
differ from the pt’s awake values? If
different, why? Advantage to pressure
support, CPAP or PEEP? Why/why not?
Explain.
258
3. Severe hypertension: While endotracheal

tube in place and patient being ventilated,
BP rises abruptly to 250/110 mmHg and
HR is 120. DDx? Rx? Choice for therapy
be different if the HR = 75? If so,
how/why?
4. ST segment depression in anterior leads:

While nurse is obtaining medications to
treat elevated BP, ST segment depression in
anterior leads on ECG. Would this alter
your therapy? If so, how/why? Is PA
catheter indicated at this time? Why/why
not? Assume TEE available, what would
you look for? Draw blood for any lab
analyses at this time? If so, which/why?
5. Pain management: How to assess and

manage the pt’s pain while being
mechanically ventilated? Would protocol
change after the pt extubated? If so,
how/why? Does meperidine offer any
advantages or disadvantages in this patient?
Why/why not? Dilaudid (hydromorphone)?
6. Nausea and vomiting: 24 hrs postop the

patient has been extubated but he has
nausea and occasionally vomits. How
would you assess and treat this problem?
259
– 10 Minutes
1. Mitral stenosis: A 30-year-old woman to

undergo emergent laparotomy for a
perforated viscus. Pt has mitral stenosis,
orthopnea, and basilar rales. Meds include
digoxin and warfarin. BP 90/70; HR 100
(irregular); T 39°C. Surgeon asks OK to
proceed. Agree? Why/why not? Preop
evaluation and Rx(s)? Which? Why?
Reverse warfarin? Why/why not? How?
Insert PA catheter? Why/why not? Choice
of anesthesia? Why?
260
2. Pediatrics-pyloric stenosis: A 3-month-old

infant has been vomiting for 4 days and is
scheduled for a pyloromyotomy. How to
assess volume status? Endpoint of fluid
therapy? Awake intubation preferable?
Why/why not? Technique to select for
induction and intubation? Why? What
anesthetic circuit? Why?
3. Carotid surgery: You evaluate a 60-year-

old man scheduled for right carotid
thromboendarterectomy for TIA's. In
PACU following a left carotid TEA 2 wks
ago, he had an episode of ST segment
depression in leads V4-6 that resolved with
intravenous propranolol and nitroglycerin
ointment. Further information? Be
specific. Why? Any further evaluation
prior to surgery? Explain.
261
An 11-year-old 65 kg boy is scheduled for urgent

ORIF of an open fractured olecranon sustained in
motor vehicle accident 90 minutes ago. He has a
history of asthma treated with cromolyn sodium
and an albuterol inhaler. He required
hospitalization and prednisone for status
asthmaticus 6 weeks ago. He ate a full lunch
before the accident. Bilateral diffuse expiratory
wheezes are noted. BP 125/80 mmHg, P 104, R
22, T 36.8o C.
262
- 10 Minutes
1. Implications of obesity: Anesthetic

implications of obesity? Does obesity alter
the amount of anesthetic drugs required?
Explain. Does obesity increase incidence
of difficult intubation? Explain.
2. Pulmonary assessment: How will you

assess status of asthma? Does child require
ABGs before surgery? Why/why not?
Does presence of bilateral wheezing
contraindicate anticipated ORIF?
Why/why not? Assume neurovascular
compromise and surgery proceeding.
263
3. Assessment of associated trauma:

Additional assessment given recent MVA?
Which? If trauma limited to elbow fx, do
you need any lab studies? Explain.
4. Preop meds (steroid, bronchodilator,

gastrokinetic, etc.: Is steroid rx indicated?
Purpose(s)? Can you empty stomach
preop? Why/why not? Role of
metoclopramide? Child is in moderate
pain. Is it appropriate to give an
intravenous opioid? Why/why not?
264
– 15 Minutes
1. Regional vs. general anesthesia: If child

cooperative and calm, would you consider
upper extremity block?
Why/why not? If so, axillary vs.
interscalene? Explain. Presume parents
and patient request general anesthetic.
Your priorities for patient as you plan for
GA?
2. Assume general - induction, airway mgmt:

Colleague suggests inhalation induction
because of asthma. Agree?
Why/why not? Is thiopental a reasonable
choice for induction? Why/why not? If
not, your choice. Explain. Is
succinylcholine appropriate for paralysis?
Why/why not? Is use of laryngotracheal
lidocaine by an LTA kit contraindicated
given recent lunch? What benefit does it
offer? How does it prevent bronchospasm?
265
3. Severe bronchospasm after intubation:

Assume lidocaine via LTA kit not used.
Ventilation is very difficult following
intubation. Airway pressures are high.
What will you do? What drugs will you
give? Epinephrine? Why/why not? Does
pattern of ventilation during bronchospasm
make a difference? How?
4. Anesthetic maintenance - choices:

Bronchospasm improved. Is halothane
your choice for maintenance? Why/why
not? Colleague states halothane
contraindicated because of obesity.
Agree/disagree? Your choice and
reason(s). Does patient require muscle
relaxant during procedure? Why/why not?
266
5. Temperature elevation intraop - assessment:

Temperature during procedure increases to
38o C. What will you do? ABGs normal.
Further diagnostic tests? Change
anesthetic? Why/why not?
6. Vomiting at emergence, extubation - mgmt:

Patient opens eyes and vomits with ETT
still in place. What will you do? Is patient
at risk for aspiration? Why? How will you
prevent?
267
– 10 Minutes
1. Transplant anesthesia: A 55-year-old

woman requires anesthesia for a cadaveric
kidney transplant for chronic renal failure.
How to evaluate cardiac function,
coagulation? K+ is 5.6mEq/L. Treat?
Why/why not? Regional vs. general?
Why? Assume general. Choice of agents
for maintenance? Why? Choice of
relaxant(s)? Why?
268
2. Anaphylactic reaction: You are called

urgently to radiology where you find a 25-
year-old woman undergoing an arteriogram
for upper extremity ischemia. Hypotensive
with urticaria, stridor and sternal retraction.
What to do? Likely cause? Mechanism of
signs and symptoms? Rationale. How
proceed if cardiac arrest ensues?
3. Emergent burn management: A 71-year-

old male fell asleep while smoking in bed
brought to ER with third degree burns over
his face, neck and upper trunk. He is
obtunded, stridorous with face and neck
swelling. He has O2 saturation of 91%
while receiving 40% oxygen by mask, and
stable vital signs (BP 140/80, P 95). How
to assess airway? Why? Respiration?
How might a 30% carboxyhemoglobin
level be relevant? How could this be
consistent with the SpO2? Mgmt of his
airway?
269

A 58-year-old 90 kg, 5'4" woman is brought to

the operating room for resection of a 10 cm
infrarenal AAA.
HPI: The patient was admitted 2 hours ago

with severe back pain.
Vital signs have been stable but workup,
including aortogram, demonstrates a
10 cm infrarenal AAA.
MEDS: Metoprolol, Dyazide, diltiazem,

NPH insulin q a.m. and p.m., occasional NTG.
PMH: Hypertension and obesity for more than 20 years.

Occasional angina began 3 years ago.
Cardiac catheterization at that time revealed a
60% RCA stenosis and normal LV ejection fraction.
Type 2 diabetes mellitus for 7 years treated with
insulin; control is described by patient as erratic.
270
PHYS P 80, BP 160/95 mmHg, R 22, T 37.2o C.

EXAM: Obese, apprehensive woman with back pain.
Airway - full dentition, uvula visible to tip,
TMJ mobile, C-spine extension mildly limited.
Chest exam WNL. No peripheral edema
CXR: Prominent left ventricle,

poor inspiratory effort.
ECG: NSR, nonspecific ST-T wave abnormalities.
LABS: Hgb 12.8 gm/dL, creatinine 2.4 mg/dL,

BUN 32 mg/dL, Na 142 mEq/L,
K 3.8 mEq/L, blood sugar 215 mg/dL.
PT, PTT, platelet count WNL.
The patient has two 16 gauge peripheral IV

catheters in place. She ate lunch approximately 5
hours ago.
271
– 10 Minutes
1. Monitoring: Central vascular access

required? Why? CVP vs. PA catheter?
Reason(s) for choice. Right atrial pressure
an accurate measure of cardiac filling?
Why/why not? How to monitor diabetes
intraop? Blood glucose vs. pHa vs. urine
ketones? Which? Why?
2. Anesthetic selections: Induction and

airway mgmt-is RSI indicated? Why/why
not? Fiberoptic intubation through an LMA
appropriate? Why/why not? Propofol
appropriate for induction? Which/why?
Choice and reason(s). Anesthetic
maintenance-is a combined technique with
GA and continuous epidural appropriate?
Why/why not? Use a volatile GA for
maintenance? Why/why not? Isoflurane
vs. sevoflurane vs. desflurane? Reason.
Should nitrous oxide be avoided?
Why/why not?
272
3. Aortic cross clamp - implications:

Hypertension with aortic cross clamp
application. BP increases from 135/75 to
195/105 without arrhythmia or ST segment
changes when cross clamp applied. Does
this increase risk? How? Should it be
treated by increasing anesthetic depth?
Why/ why not? NTG vs. SNP? Your
choice/why?
Preparation for aortic cross clamp removal.

Why can there be hemodynamic instability
with aortic declamping? Colleague
suggests large fluid bolus before
declamping? Agree? Why/why not?
Should vasopressors be administered
immediately before declamping? Why/why
not? Bicarbonate? Why/why not?
4. Diabetic management intraop: Blood

glucose increases to 295mg/dL after start of
surgery. Colleague recommends glucose
not be regulated until emergence from
anesthesia in the recovery room.
Agree/disagree? Why? Should insulin be
administered? Explain. Does insulin
therapy mandate administration of
dextrose? Why/why not? Other concerns
for intraop insulin therapy?
273
– 15 Minutes
1. Extubation vs. ventilation: Should trachea

be extubated in the OR? Why/why not?
Does anesthetic technique influence this
decision? How? Is decision to extubate
altered by presence of continuous epidural
analgesia? How? Your criteria for
discontinuing mechanical ventilation and
extubating at this time? Explain.
2. Mechanical ventilation and weaning: You

elect continued mechanical ventilation in
the early postop period. Order IMV or
controlled ventilation? Which? Why?
What orders to write to minimize postop
atelectasis in this obese patient? Why?
Patient now awake, alert and thrashing
about. Extubate? What criteria do you
use? Are these criteria altered by patient’s
obesity? How?
3. Oliguria - dx and mgmt: During first 3

hours in recovery room, urine output is 40
ml. Adequate? Why/why not? Cause(s)?
How to investigate etiology? PAoP is 14
mmHg and CO is 4.0 L/min. Should fluids
be administered? Which? How much fluid
appropriate? Surgeon recommends
furosemide. Agree/disagree? Explain.
274
Therapy if oliguria continues?
4. ST segment changes and ventricular

tachycardia: 6 hours postop you are called
to ICU for new ST segment depression and
T-wave inversion in V4-5. Consistent with
RCA stenosis? Explain. Possible causes?
Is NTG indicated? Why/why not? While
examining pt, ventricular tachycardia with
moderate hypotension (BP 100/65) occurs.
Recovery room nurse suggests lidocaine.
Agree? Why/why not? Is cardioversion
indicated? Why/why not? Your
management? Why? Would management
be different if BP 70/40? How/why?
5. Pain management - thoracic epidural: 4

hours after extubation pt complains of
increasing abdominal pain despite T6
thoracic epidural with fentanyl and
bupivacaine infusion. Should opioid be
changed to morphine? Why/why not?
Should intravenous PCA be administered?
Why/why not? Management? If epidural
appears nonfunctional, should lumbar
epidural be attempted? How does this
change medication and infusion? Explain.
275
– 10 Minutes
1. Obstetrical anesthesia/amniotic fluid

embolism: A 28-year-old primigravida
parturient suddenly becomes hypotensive
and cyanotic following a severe
contraction. How to evaluate cause?
Manage? Rationale. Fetal distress is noted
and emergent C-section is required. How
to induce anesthesia? Explain.
2. Monitored anesthesia care: A 48-year-old

cachectic woman with metastatic breast
cancer to undergo a Hickman catheter
placement. You are asked to provide
monitored anesthesia care. BP 90/40, P 92.
Preferred drugs for sedation and analgesia?
Why? During procedure becomes anxious
and cannot lie still. What to do? Explain.
Administer IV sedation and surgery
continues. Pt no longer follows commands
and is apneic. Evaluation? Management?
Could this be a pneumothorax?
Hemothorax? How to tell? How would
this alter your management?
276
3. Laryngoscopy: A healthy 25-year-old

vocalist for laryngoscopy and removal of
recurrent vocal cord papillomas. Surgeon
requests no endotracheal tube. Agree?
How to anesthetize and ventilate the pt's
lungs? Succinylcholine infusion
acceptable? Why/why not? How to
determine dose? How manage if dual block
develops? Prefer alternate relaxant?
Why/why not? Which? Why? Would
your management of pt differ if surgeon
was to use laser? How? Why?
277
A 5-year-old boy is scheduled for bilateral

inguinal hernia repair. Mother states the child
was febrile a week ago and has had a "runny
nose". Several relatives are known to have
experienced fever during surgery and one cousin
died 15 years ago in an operating room. The
patient has not had a prior anesthetic. P 100, BP
95/60 mmHg, R 22, T 37.5o C. Hgb 14 gm/dL.
278
- 10 Minutes
1. Significance of recent fever: Should

procedure be postponed due to upper
respiratory infection? Why/why not? Does
a URI increase intraoperative risks?
Which? What are your criteria for
postponement on a case such as this? What
to tell family about the fever one week ago
and the rhinorrhea?
2. Family MH history: Should procedure be

postponed to explore family history?
Why/why not? What family info would be
helpful? Lab tests (CPK, muscle bx)
indicated? How is info used? Reliable? If
history of extended family unavailable, safe
to proceed? Why/why not? Can procedure
be done in the outpatient surgical unit?
Why/why not? Does duration of postop
observation change with presumptive
family history? Why/why not?
279
3. Additional preop assessment: CXR

indicated? Why/why not? Order a CBC to
check WBC count or diff? Why/why not?
How would the info change your anesthetic
plan? Explain.
4. Preop medication: Should dantrolene be

administered preop? Why/why not? Is it
effective prophylactically? Risks with preop
dantrolene? Will you administer preop
sedation? Why/why not? Should child
receive drying agent such as atropine or
glycopyrrolate preop? Why/why not?
280
– 15 Minutes
1. Choice of anesthetic techniques: Would you

recommend local field block for this patient?
Why/why not? Local anesthetics safe in this
patient? Explain. Concerns about providing
general anesthesia in this patient? Explain.
2. Assume general anesthesia - mgmt of

induction: Assume child is uncooperative
and requires general anesthesia. Is an
intravenous induction preferred to a volatile
anesthetic induction? Why/why not? Child
is extremely anxious, frightened and crying
without an IV. Is intramuscular ketamine
appropriate for induction? Why/why not?
Rectal methohexital? Assume pre-induction
IV in place. How to induce? Reason(s) for
your choice. Is tracheal intubation
indicated? Why/why not? Can LMA be
utilized without volatile anesthetic? Explain.
3. Anesthetic maintenance: Which anesthetic

to use for maintenance? Advantages/
disadvantages of your choice? Does
presence of a URI alter your choice? How?
Does concern for MH alter your choice?
How?
281
4. Hyperthermia 30 minutes after induction:

Rectal temperature increases to 38.9 C 30
min after induction. Could this be due to
viral upper respiratory infection? Could it be
MH? How will you decide? Lab tests
indicated? Which? Why? Is emperic Rx
indicated? Rectal acetaminophen vs.
intravenous dantrolene? How decide?
5. Severe bronchospasm and hypoxemia:

Fever adequately controlled, but child
develops severe coughing, wheezing and
SpO2 decreases to 88% on emergence.
Cause of airway reactivity? Management?
Is tracheal intubation indicated? Why/why
not? Subcutaneous epinephrine? Why/why
not? Nebulized racemic epinephrine?
Why/why not? Albuterol? Why/why not?
6. Postop pain relief: Is a caudal injection of

local anesthetic appropriate for postop
analgesia? Risks/benefits for child?
Surgeon asks if recent viral infection a
contraindication to caudal technique? Your
response? Possible to produce a
subarachnoid block when doing a caudal
technique? Explain. How would you know
that it occurred? What would you do?
282
C ADDITIONAL TOPICS
– 10 Minutes
1. Increased intracranial pressure: A 48-year-

old man with a head CT suggestive of
increased ICP is to undergo resection of a
brain tumor. BP increases from 130/90 to
160/110 during induction of anesthesia.
Lower BP? Why? How? Would an
inhalation agent be appropriate? Which?
Why? Implications of increased ICP for
anesthetic management? Management of
increased ICP intraop? Monitor ICP
postop? Why? How?
2. Chronic pain: A 45-year-old woman with

invasive cervical cancer is referred to you
because her pelvic pain is not controlled by
oral or parenteral opioids. Alternative
therapy? Factors influencing choice?
Explain. What minimum work-up would
be required before you begin therapy?
Explain.
283
3. Hypothyroidism: A 30-year-old woman

scheduled for emergency drainage of a
perirectal abscess while in the prone
position. Hypothyroidism was diagnosed
12 hours preop. Total T4 was less than 3
mcg/dL (normal value is 6.1-11.8 mcg/dL).
Anesthetic concerns? Anesthetic technique
you select? Why? Are there specific post-
op complications you would anticipate?
How to minimize the sequelae? Rationale.
284


operating room for an urgent exploratory
laparotomy for small bowel obstruction.
HPI: The patient presented 2 days ago with

vomiting and abdominal distention.
She underwent a hemicolectomy for colon
cancer 2 years ago and current workup has
demonstrated small bowel obstruction,
probably secondary to adhesions.
She is very uncomfortable and has
required intravenous hydration since admission.
MEDS: Digoxin, furosemide, KCl.
285
PMH: Long-standing mitral stenosis with limited

exercise tolerance. Episode of pulmonary edema
with new-onset Afib 8 months ago.
Tolerated general anesthetic for colectomy
2 years ago without difficulty.
No known allergies.
PHYS P 108 - irregular, BP 100/70 mmHg, R 30, T 38o C

EXAM: Patient appears cachectic, dyspneic with a grossly
distended abdomen.
Airway appears adequate for intubation.
Lungs - slight basilar rales bilaterally.
1+ pitting edema at distal lower extremities.
CXR: Right ventricular prominence, increased

pulmonary vascular markings.
ECG: Atrial fibrillation.
LABS: Hgb 10.5 gm/dL, Na 132 mEq/L, K 2.8 mEq/L.

ABG (room air): PaO2 50 mmHg,
PaCO2 28 mmHg, pHa 7.36.
On arrival to the operating room, the patient has

an 18-gauge peripheral IV catheter and a right
internal jugular vein double lumen CVP catheter
in place.
286
– 10 Minutes
1. Monitoring: Unable to establish left or

right radial arterial catheter. Is BP cuff
adequate? If not, what will you do? Change
CVP to PA catheter prior to induction of
anesthesia? Why/why not? Patient unable
to lie flat? Unclear from waveform that PA
catheter in wedged position. How to
determine? Blood gas from PA port useful?
How?
2. Immediate pre-induction management:

Thoracic epidural? Why/why not?
Possible problems associated with current
potassium level? What will you do?
3. Induction and airway management: Is

awake intubation appropriate? Why/why
not? Ketamine appropriate choice for
induction? Why/why not? How to induce
anesthesia? Explain choices of induction
agents. Succinylcholine an appropriate
relaxant for intubation? Why/why not? If
airway is difficult to secure, is LMA
acceptable? Why/why not?
287
4. Anesthetic choices: Assume

induction/intubation successful. Is
isoflurane suitable for maintenance?
Why/why not? Propofol infusion?
Why/why not? Your choices and reasons.
5. Pulmonary edema - management: During

procedure, Afib occurs with heart rate 150
bpm. Dangers? Rx? Despite FiO2 1.0,
SpO2 decreases 98% to 85% over 15
minutes. Etiology? How to treat? Assume
pulmonary edema. Rx? PEEP decreases
BP. Response? PETCO2 32 mmHg but
PaCO2 48 mmHg. Cause of increase
difference?
288
– 15 Minutes
1. Extubation vs. ventilation: Assume

hemodynamic stability with pulmonary
edema resolved. Do you plan to extubate at
end of surgery? Why/why not?
2. Ventilatory management for 24-48 hours:

Assume post-op ventilation. What kind of
ventilator? What mode of ventilation?
Explain choices. Role for pressure support
ventilation? Explain. Patient "bucking"
and fighting ventilator. Reason(s)? Will
you paralyze? Why/why not?
3. Pain management during controlled

ventilation: Patient awake and indicating
pain. Is IM morphine appropriate?
Why/why not? Your choice for analgesia?
Explain. Does presence of controlled
ventilation influence choice? Explain.
4. Extubation criteria: How will you wean

from ventilator? What if on PEEP?
Extubation criteria? With FIO2 0.4, PaO2
70 mmHg, PaCO2 45 mmHg, pHa 7.33
during spontaneous ventilation. Interpret.
Is this adequate? Why/why not?
289
5. Oliguria - dx and management: Urine

output 0.5 ml/kg/hr. Is this adequate? Why
not? How will you decide between fluid
and a diuretic? Is dopamine appropriate?
Why/why not?
6. Intraop awareness: On POD #3, patient is

extubated and states that she was awake
during the surgery. How is this possible?
What will you tell her?
7. Postop delirium: On POD #4 patient

becomes disoriented. Etiology? Rx?
290
– 10 Minutes
1. Pediatric anesthesia: A 3-year-old child is

scheduled for a laparotomy for possible
resection of a kidney tumor. What anesthetic
circuit to choose? Why? Use a closed
system? Why/why not? Disadvantages?
Parents and child prefer no needles while
awake. Agree? Would you do a mask
induction? Why/why not? If so, which
inhalation agent? Why? What fluids would
you give? Why? Consider transfusing patient
when blood loss exceeds 20% of blood
volume? Why/why not? If not, when? Why?
2. Cholecystectomy: A 40-year-old 100 kg

woman is scheduled for a laparoscopic
cholecystectomy. Any premeds indicated?
Which? Why? Use RSI? Why/why not?
Method for induction? Explain? How to
maintain anesthesia? Why? Use opioids?
Why/why not? During creation of
pneumoperitoneum pt's SpO2 falls to 80%.
DDx? Rx? Thirty minutes into procedure pt
begins to "override" ventilator. Your
response? Explain. Is patient at increased risk
for postop nausea? Why/why not? How
avoid? Use ondansetron? Why/why not?
291
3. Pediatrics - epiglottitis: You are called to the

ER for consultation for a 5-year-old girl with a
sore throat, high fever, sternal retraction and
stridor on inspiration. DDx? How to
determine Dx? Immediate management prior
to Dx? Rationale. Suppose Dx of epiglottitis
is made and stridor worsens with SpO2
intermittently as low as 91%. What to do
now? Why? Airway obstruction worsens.
How proceed? Explain.
292
A 23-year-old, 130 kg, 5’10” man was involved

in a motor vehicle accident 2 hours ago
sustaining a femoral fracture. He is scheduled for
insertion of an intramedullary rod. He complains
of pain in the posterior cervical area and is
slightly dyspneic. He has a history of
hypertension treated with captopril (ACE-
inhibitor) for 2 years. P 120, BP 90/60 mmHg, R
28, T 37°C. Hgb is 10.5 gm/dL.
293
- 10 Minutes
1. Hemodynamic assessment: What

impression do you have concerning the
patient’s hemodynamic state from the
above vital signs? Why? Do you need
more information to assess hemodynamic
status? If so, what? Why?
2. Dyspnea - assessment, implications: Why

is patient dyspneic? How will you evaluate
further? Is a pulmonary contusion likely?
How will you confirm or rule out? Why is
it important to diagnose if present? Is fat
embolic disease likely? What is it? How
do you diagnose? Treat? Explain.
3. Obesity, airway: What are the anesthetic

implications of patient’s weight? How will
you assess airway? Does assessment
minimize anesthetic risk? Explain.
4. Cervical pain - implications: The patient

has had no evaluation of neck pain. Is this
of concern? Why? What would you
consider to be minimally acceptable for
evaluation of C-spine? Explain.
294
– 15 Minutes
1. Monitoring: How will end-tidal CO2 assist

your anesthetic management? Does the
history of hypertension and/or the presence
of obesity impact your monitoring plans?
How? Explain?
2. General vs. regional anesthesia: Surgeon

inquires if regional anesthesia appropriate
for procedure. Your response? Explain.
Benefits vs. risks of general anesthesia?
Assume general anesthetic chosen.
3. Induction and airway management:

Assume you were able to visualize uvula
preop. Does this influence your approach
to general anesthesia? How? Explain.
Should patient be intubated awake?
Why/why not? Assume awake intubation
not indicated. Is ketamine indicated for
induction? Why/why not? Your choice of
induction agent(s) and reasons.
295
4. Anesthetic maintenance - choices: What

anesthetic agent(s) will you select for
maintenance? Why? Will you need a
muscle relaxant for the procedure?
Why/why not? Will you use N2O? Discuss
reasons for decision.
5. Difficult to ventilate - increased PIP: You

have successfully intubated patient but note
increased inspiratory pressure over next 15
minutes. Discuss your evaluation. Breath
sounds are decreased over left chest. What
is your Dx? How will you determine
cause? You aspirate blood from ET tube
and breath sounds improve. What will you
do now? Rationale.
6. Blood loss, transfusion: During rodding the

patient loses 1500 ml of blood. Will you
transfuse? Why/why not? If not, how do
you determine need for transfusion? Is cell
saver indicated? Why/why not?
7. Oliguria - causes, management: Towards

end of this 2-hour procedure you note only
60 ml of urine. Discuss your evaluation,
likely causes and management of patient’s
low urine output.
296
– 10 Minutes
1. Posterior fossa craniotomy: A 58-year-old

man to undergo craniotomy while in the
sitting position for a posterior fossa tumor.
Is isoflurane the preferred anesthetic for
this procedure? Why/why not? Is N2O
useful in this procedure?
Advantages/disadvantages? Is CVP
essential? Why/why not? How verify
correct placement? Can increase in ICP be
prevented? How? Is mannitol more
effective than furosemide to reduce ICP?
Why/why not? Is there a limit to how low
PaCO2 should be taken? Explain. How
will you differentiate brain stem ischemia
from venous air embolism? Are there
similarities? Explain.
297
2. Pediatrics - ventriculo-peritoneal shunt: A

10-month-old presents for emergency V-P
shunt. Anterior fontanelle is bulging, and
child is irritable. Pt drank milk 2 hours ago.
BP is 110/60, HR 80. Anesthetize using
inhalation technique? Why/why not?
Different if apple juice? Use a pediatric
circle system? Why/why not? If not, what
system? Explain. How to maintain
anesthesia? Why? Muscle relaxant? If so,
how monitor?
3. Myasthenia gravis: A 45-year-old woman

with well-controlled myasthenia gravis is
scheduled for cholecystectomy. Her only
medication is pyridostigmine 60mg q 6h.
How does Dx influence your anesthetic
management? If surgery scheduled for 11
am? Regional or general? Assume general.
Administer a muscle relaxant? Why/why
not? If so, which? Why? Assume
atracurium given but one hour later, after 5
mg neostigmine, train-of-four remains
absent. How proceed? How differentiate
myasthenic vs. cholinergic crisis?
298

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Helpful Hints for

Mastering the ABA

These informal notes are directed at

The current edition has been extensively

This is not an anesthesia textbook, but more

The book begins with three little essays and

In addition to discussion within the main

Corrections, suggested case scenarios, ideas

Free PDF copies of the book are also

Finally, I would like to offer a special thanks

D. John Doyle MD PhD DPhil

Cleveland Clinic and

Case Western Reserve University

Dr D. John Doyle is an anesthesiologist at

Dr. Doyle received the MD, PhD and

Although he has numerous scholarly

This book is dedicated to my wife of four

I would also like to dedicate this work to the

Organization of This Book

This book is organized into the following

Part II: Random Helpful Hints

Part III: Scenarios to Know

Part IV: Cases for Discussion

This part of the book contains three

• How to Prepare for the Boards

• Organizing and Managing an

• What to Do When You Don't

Part II: Random Helpful Hints

This part of the book, the largest part,

Part III: Scenarios to Know

This part of the book contains numerous

• Twelve obstetrical scenarios

• Twelve pediatric scenarios

• Twelve cardiac scenarios

• Twelve pulmonary / thoracic scenarios

• Twelve airway scenarios

• Twelve neurological scenarios

Part IV: Cases for Discussion

This part of the book contains numerous

• Eleven Short Cases for Discussion

• Short Discussion Questions

• Sample Full Case

• Seven Old ABA Examinations

How to Prepare for the Boards

… in order of priority A.B.C.

Courtesy of Mary Ellen Cooke, MD, FRCPC

2. Read about your cases, think about cases,

3. Ask to be left to work independently i.e.,

1. Review and organize in simple point

• Your knowledge base

• Your management of routine cases.

• Recognition and management of

• Anesthesia equipment and

2. Devise your own personal format or

1. Participate in practice oral examinations

2. Group orals allows exposure to many

Candidates can learn from examiners and

3. One on one orals give you stamina

Organizing and Managing an Anesthetic