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Anesthesia

A Comprehensive Review

FIFTH E DITION

Brian A. Hall, MD
Assistant Professor of Anesth esiology, College of Med icine, May o Clinic,
Roch ester, Minnesota

Robert C. Chantigian, MD
Associate Professor of Anesth esiology, College of Med icine, May o Clinic,
Roch ester, Minnesota
Table of Contents

Cove r ima ge

Title pa ge

Copyright

Pre fa ce

Contributors

Cre dits

Bibliogra phy

Acknowle dgme nts


Part 1. Basic Sciences

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


Anesthesia Equipment and Physics
Cha pte r 2. Re spira tory Physiology a nd Critica l Ca re Me dicine
Respiratory Physiology and Critical Care Medicine

Cha pte r 3. Pha rma cology a nd Pha rma cokine tics of Intra ve nous
Drugs
Pharmacology and Pharmacokinetics of Intravenous Drugs

Cha pte r 4. Pha rma cology a nd Pha rma cokine tics of Vola tile
Ane sthe tics
Pharmacology and Pharmacokinetics of Volatile Anesthetics

Part 2. Clinical Sciences

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


Blood Products, Transfusion, and Fluid Therapy

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


General Anesthesia

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


Pediatric Physiology and Anesthesia

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


Obstetric Physiology and Anesthesia

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


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

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


Cardiovascular Physiology and Anesthesia

Inde x
Copyright

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ANESTHESIA: A COMPREHENSIVE REVIEW, FIFTH

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


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Notices
Knowle dge a nd be st pra ctice in this fie ld a re consta ntly
cha nging. As ne w re se a rch a nd e xpe rie nce broa de n our
unde rsta nding, cha nge s in re se a rch me thods, profe ssiona l
pra ctice s, or me dica l tre a tme nt ma y be come ne ce ssa ry.

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


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

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


re a de rs a re a dvise d to che ck the most curre nt informa tion
provide d (i) on proce dure s fe a ture d or (ii) by the ma nufa cture r
of e a ch product to be a dministe re d, to ve rify the re comme nde d
dose or formula , the me thod a nd dura tion of a dministra tion,
a nd contra indica tions. It is the re sponsibility of pra ctitione rs,
re lying on the ir own e xpe rie nce a nd knowle dge of the ir
pa tie nts, to ma ke dia gnose s, to de te rmine dosa ge s a nd the be st
tre a tme nt for e a ch individua l pa tie nt, a nd to ta ke a ll
a ppropria te sa fe ty pre ca utions.

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


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injury a nd/or da ma ge to pe rsons or prope rty a s a ma tte r of
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conta ine d in the ma te ria l he re in.

Library of Congress Cataloging-in-Publication Data


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

Ex ecutive Content Strategist: W illia m Schmitt


Content Developm ent Manager: Ka tie De Fra nce sco
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Printe d in the Unite d Sta te s of Ame rica

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

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


Colle ge of Me dicine , Ma yo Clinic, Roche ste r, Minne sota

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


Ane sthe siology, Unive rsity of Ala ba ma School of Me dicine ,
Birmingha m, Ala ba ma

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


Colle ge of Me dicine , Ma yo Clinic, Roche ste r, Minne sota

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


Colle ge of Me dicine , Ma yo Clinic, Roche ste r, Minne sota

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


De pa rtme nt of Ane sthe siology a nd Critica l Ca re Me dicine , Colle ge
of Me dicine , Ma yo Clinic, Roche ste r, Minne sota
Credits
Figure 1-1, page 4
From va n Ge nde ringe n HR e t a l: Compute r-a ssiste d ca pnogra m
a na lysis, J Clin Monit 3:194-200, 1987, with kind pe rmission of
Kluwe r Aca de mic Publishe rs.
Figure 1-2, page 8
From Ma rk JB: Atlas of Card iovascular Monitoring, Ne w York,
Churchill Livingstone , 1998, Figure 9-4.
Figure 1-3, page 9
Modifie d from W illis BA, Pe nde r JW, Ma ple son W W : Re bre a thing
in a T-pie ce : volunte e r a nd the ore tica l studie s of Ja ckson-Re e s
modifica tion of Ayre ’s T-pie ce during sponta ne ous re spira tion, Br J
Anaesth 47:1239–1246, 1975. © The Boa rd of Ma na ge me nt a nd
Truste e s of the British Journa l of Ana e sthe sia . Re produce d by
pe rmission of Oxford Unive rsity Pre ss/British Journa l of
Ana e sthe sia .
Figure 1-5, page 11
Re printe d with pe rmission from Andre ws JJ: Unde rsta nding
a ne sthe sia ma chine s. In: 1988 Review Course Lectures, Cle ve la nd,
Inte rna tiona l Ane sthe sia Re se a rch Socie ty, 1988, p 78.
Figure 1-6, page 13
Modifie d from Ame rica n Socie ty of Ane sthe siologists (ASA): Ch eck-
out: A Guid e for Preoperative Inspection of an Anesth esia Mach ine, Pa rk
Ridge , IL, ASA, 1987. A copy of the full te xt ca n be obta ine d from the
ASA a t 520 N. Northwe st Highwa y, Pa rk Ridge , IL, 60068-2573.
Figure 1-7, page 16
From Andre ws JJ: Unde rsta nding your a ne sthe sia ma chine a nd
ve ntila tor. In: 1989 Review Course Lectures, Cle ve la nd, Inte rna tiona l
Ane sthe sia Re se a rch Socie ty, 1989, p 59.
Figure 1-9, page 21
Courte sy Dra e ge r Me dica l, Inc., Te lford, Pe nnsylva nia .
Figure 1-10, page 22
From Aza r I, Eise nkra ft JB: Wa ste a ne sthe tic ga s spilla ge a nd
sca ve nging syste ms. In Ehre nwe rth J, Eise nkra ft JB, e ditors:
Anesth esia Eq uipm ent: Principles and Applications, St Louis, Mosby,
1993, p 128.
Table 1-1, page 12
From Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2011, p 201, Ta ble 15-2.
Table 1-6, page 27
Da ta from Ehre nwe rth J, Eise nkra ft JB, Be rry JM: Anesth esia
Eq uipm ent: Principles and Applications, e d 2, Phila de lphia , Sa unde rs,
2013.
Figure 2-1, page 30
From Mille r RD: Miller’s Anesth esia, e d 7, Phila de lphia , Sa unde rs,
2011, Figure 15-4. Courte sy the e ditor of the BMJ se rie s: Re spira tory
Me a sure me nt.
Figure 2-12, page 38
From Stoe lting RK: Ph arm acology and Ph y siology in Anesth etic
Practice, e d 3, Phila de lphia , Lippincott W illia ms & W ilkins, 1999.
Figure 2-15, page 41
From Stoe lting RK, Die rdorf SF: Anesth esia and Co-Ex isting Disease,
e d 4, Ne w York, Churchill Livingstone , 2002.
Figure 3-1, page 71
From Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2011, Figure 10-3.
Table 3-1, page 62
From Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2011, p 151, Ta ble 12-6.
Table 3-2, page 64
From Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2011, p 76, Ta ble 7-3.
Table 3-3, page 65
From Stoe lting RK: Ph arm acology and Ph y siology in Anesth etic
Practice, e d 4, Phila de lphia , Lippincott W illia ms & W ilkins, 2006, p
293.
Table 3-4, page 67
From Mille r RD: Miller’s Anesth esia, e d 7, Phila de lphia , Sa unde rs,
2011, p 882, Ta ble 29-11.
Table 3-5, page 73
From Stoe lting RK: Ph arm acology and Ph y siology in Anesth etic
Practice, e d 4, Phila de lphia , Lippincott W illia ms & W ilkins, p 462.
Table 3-6, page 77
From Stoe lting RK, Mille r RD: Basics of Anesth esia, e d 5,
Phila de lphia , Churchill Livingstone , 2006, p 1794.
Table 3-7, page 84
From Hine s RL: Stoelting’s Anesth esia and Co-Ex isting Disease, e d 5,
Phila de lphia , Sa unde rs, 2008, p 371.
Figure 4-2, page 93
Modifie d from She ffe r L, Ste ffe nson JL, Birch AA: Nitrous oxide -
induce d diffusion hypoxia in pa tie nts bre a thing sponta ne ously,
Anesth esiology 37:436-439, 1972.
Figure 4-3, page 98
From Mille r RD: Miller’s Anesth esia, e d 6, Phila de lphia , Sa unde rs,
2005, Figure 5-2. Da ta from Ya suda N e t a l: Kine tics of de sflura ne ,
isoflura ne , a nd ha lotha ne in huma ns, Anesth esiology 74:489-498,
1991; a nd Ya suda N e t a l: Compa rison of kine tics of se voflura ne
a nd isoflura ne in huma ns, Anesth Analg 73:316–324, 1991.
Figure 4-4, page 101
Modifie d from Ege r EI II, Ba hlma n SH, Munson ES: Effe ct of a ge on
the ra te of incre a se of a lve ola r a ne sthe tic conce ntra tion,
Anesth esiology 35:365–372, 1971.
Figure 4-5, page 106
From Ca ha la n MK: Hem od y nam ic Effects of Inh aled Anesth etics.
Review Courses, Cle ve la nd, Inte rna tiona l Ane sthe sia Re se a rch
Socie ty, 1996, pp 14-18.
Table 4-4, page 103
From Stoe lting RK, Mille r RD: Basics of Anesth esia, e d 4, Ne w York,
Churchill Livingstone , 2000, p 26.
Table 5-2, page 116
From Mille r RD: Miller’s Anesth esia, e d 7, Phila de lphia , Sa unde rs,
2011, Ta ble 55-6.
Figure 6-1, page 150
Courte sy Philippe R. Housma ns, MD, PhD, Ma yo Clinic.
Table 6-2, page 142
Da ta from Ka ttwinke l J e t a l: Ne ona ta l re suscita tion: 2010
Ame rica n He a rt Associa tion Guide line s for Ca rdiopulmona ry
Re suscita tion a nd Eme rge ncy Ca rdiova scula r Ca re , Ped iatrics
126:e 1400–e 1413, 2010.
Figure 7-1, page 155
Modifie d from Gross RE: Th e Surgery of Infancy and Ch ild h ood ,
Phila de lphia , Sa unde rs, 1953.
Figure 7-4, page 168
From Da vis PJ: Sm ith ’s Anesth esia for Infants and Ch ild ren, e d 8,
Phila de lphia , Sa unde rs, 2011, Figure 16-3.
Figure 7-5, page 175
From Cote CI, Le rma n J, Todre s ID: A Practice of Anesth esia for
Infants and Ch ild ren, e d 4, Phila de lphia , Sa unde rs, 2008.
Table 7-1, page 165
Da ta from Mille r RD: Basics of Anesth esia, e d 6, Phila de lphia ,
Sa unde rs, 2011, pp 548–550.
Table 7-3, page 177
From Da vis PJ e t a l: Sm ith ’s Anesth esia for Infants and Ch ild ren, e d
8, Phila de lphia , Sa unde rs, 2011, pp 288-289.
Figure 8-1, page 196
From Be ne de tti TJ: Obste tric he morrha ge . In Ga bbe SG, Nie byl
JR, Simpson JL, e ditors: Obstetrics: Norm al and Problem Pregnancies,
e d 3, Ne w York, Churchill Livingstone , 1996, p 511.
Table 8-3, page 203
From Che stnut DH e t a l: Ch estnut’s Obstetric Anesth esia: Principles
and Practice, e d 4, Phila de lphia , Mosby, 2009, pp 161–162.
Figure 9-1, page 210
From Mille r RD: Anesth esia, e d 3, Ne w York, Churchill
Livingstone , 1990, p 1745.
Figure 9-2, page 217
From Mille r RD: Miller’s Anesth esia, e d 7, Phila de lphia , Sa unde rs,
2011, p 2014, Figure 63-11.
Figure 10-1, page 236
Modifie d from He bl J: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, Ne w York, Oxford Unive rsity
Pre ss, 2010, Figure 12A.
Figure 10-2, page 242
By pe rmission of Ma yo Founda tion for Me dica l Educa tion a nd
Re se a rch.
Figure 10-3, page 243
From Ra j PP: Practical Managem ent of Pain, e d 2, St Louis, Mosby,
1992, p 785.
Figure 10-4, page 250
From Cousins MJ, Bride nba ugh PO: Neural Blockad e in Clinical
Anesth esia and Managem ent of Pain, e d 2, Phila de lphia , JB Lippincott,
1988, pp 255–263.
Figure 10-5, page 256
Modifie d from He bl J: May o Clinic Atlas of Regional Anesth esia and
Ultrasound -Guid ed Nerve Blockad e, Ne w York, Oxford Unive rsity
Pre ss, 2010, Figure 12B.
Figure 11-2, page 259
From Ma rk JB: Atlas of Card iovascular Monitoring, Ne w York,
Churchill Livingstone , 1998.
Figure 11-3, page 259
From Ja ckson JM, Thoma s SJ, Lowe nste in E: Ane sthe tic
ma na ge me nt of pa tie nts with va lvula r he a rt dise a se , Sem in Anesth
1:244, 1982.
Figure 11-7, page 263
From Morga n GE, Mikha il MS: Clinical Anesth esiology, Ea st
Norwa lk, NJ, Apple ton & La nge , 1992, p 301.
Figure 11-8, page 263
From Spie ss BD, Iva nkovich AD: Thromboe la stogra phy:
ca rdiopulmona ry bypa ss. In: Effective Hem ostasis in Card iac Surgery,
Phila de lphia , Sa unde rs, 1988, p 165.
Figure 11-10, page 267
From Mille r RD: Miller’s Anesth esia, e d 6, Phila de lphia , Sa unde rs,
Figure 78-12.
Figure 11-12, page 279
From Stoe lting RK, Die rdorf SF: Anesth esia and Co-Ex isting Disease,
e d 4, Ne w York, Churchill Livingstone , 2002.
Bibliography
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: executive summary: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg. 2008;106:685–712.
American College of Obstetricians and Gynecologists. Task force on hypertension of
pregnancy. November 2013 Available at. http://www.acog.org/Resources-And-
Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-
Pregnancy Accessed August 18, 2014.
American Heart Association. American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Science. Circulation. 2010;122:S639–S946.
American Heart Association and American Academy of Pediatrics: Textbook of Neonatal
Resuscitation. Elk Grove Village, IL: American Academy of Pediatrics; 2011.
American Society of Regional Anesthesia and Pain Medicine. Checklist for treatment of
local anesthetic systemic toxicity Available at. http://www.asra.com/checklist-for-
local-anesthetic-toxicity-treatment-1-18-12.pdf Accessed August 18, 2014.
Barash P.G, Cullen B.F, Stoelting R.K. Clinical Anesthesia. ed 7. Philadelphia: Lippincott
Williams & Wilkins; 2013.
Baum V.C, O’Flaherty J.E. Anesthesia for Genetic, Metabolic, and Dysmorphic Syndromes of
Childhood. ed 2. Philadelphia: Lippincott Williams & Wilkins; 2007.
Brown D.L. Atlas of Regional Anesthesia. ed 3. Philadelphia: Lippincott Williams &
Wilkins; 2008.
Brunner J.M.R, Leonard P.F. Electricity, Safety, and the Patient. Chicago: Year Book Medical
Publishers; 1989.
Brunton L, Chabner B, Knollman B. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. ed 12. New York: McGraw-Hill; 2011.
Butterworth J.F, Mackey D.C, Wasnick J.D. Morgan & Mikhail’s Clinical Anesthesiology. ed
5. New York: Lange Medical Books/McGraw-Hill; 2013.
Chestnut D.H, et al. Chestnut’s Obstetric Anesthesia: Principles and Practice. ed
5. Philadelphia: Mosby; 2014.
Clemente C.D. Anatomy: A Regional Atlas of the Human Body. ed 3. Baltimore: Urban and
Schwarzenberg; 1987.
Coté C.J, et al. A Practice of Anesthesia for Infants and Children. ed
3. Philadelphia: Saunders; 2001.
Cottrell J.E, Smith D.S. Anesthesia and Neurosurgery. ed 4. St Louis: Mosby; 2001.
Cousins M.J, Bridenbaugh P.O. Neural Blockade in Clinical Anesthesia and Management of
Pain. ed 3. Philadelphia: Lippincott-Raven; 1998.
Cunningham F.G, et al. Williams Obstetrics. ed 22. New York: McGraw-Hill; 2005.
Davis P.J, Cladis F.P, Motoyama E.K. Smith’s Anesthesia for Infants and Children. ed
8. Philadelphia: Mosby; 2011.
Eger E.I II: Anesthetic Uptake and Action. Baltimore: Lippincott Williams & Wilkins; 1974.
Ehrenwerth J, Eisenkraft J.B. Anesthesia Equipment: Principles and Applications. St
Louis: Mosby; 1993.
Eisenkraft J.B. Potential for barotrauma or hypoventilation with the Drager AV-E
ventilator. J Clin Anesth. 1989;1:452–456.
Evers A.S, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical
Practice. Philadelphia: Churchill Livingstone; 2004.
Faust R.J, Cucchiara R.F, Rose S.H. Anesthesiology Review. ed 3. New York: Churchill
Livingstone; 2001.
Fleisher L.A. Anesthesia and Uncommon Diseases. ed 5. Philadelphia: Saunders; 2006.
Fleisher L.A. Anesthesia and Uncommon Diseases. ed 6. Philadelphia: Saunders; 2012.
Flick R.P, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary
referral center. A study of 92,881 patients. Anesthesiology. 2007;106:226–237.
Flick R.P, et al. Risk factors for laryngospasm in children during general anesthesia. Paediatr
Anaesth. 2008;18:289–296.
Gabbe S.G, Niebyl J.R, Simpson J.L. Obstetrics: Normal and Problem Pregnancies. ed 4. New
York: Churchill Livingstone; 2001.
Grines C.L, et al. Prevention of premature discontinuation of dual antiplatelet therapy in
patients with coronary artery stents: a science advisory from the American Heart
Association, American College of Cardiology, Society for Cardiovascular Angiography
and Interventions, American College of Surgeons, and American Dental Association,
with representation from the American College of Physicians. J Am Coll
Cardiol. 2007;49:734–739.
Groudine S.B, et al. New York state guidelines on the topical use of phenylephrine in the
operating room. Anesthesiology. 2000;92:859–864.
Hardman J.G, Limbird L.E, Gimman A.G. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. ed 10. New York: McGraw-Hill; 2001.
Harmening D.M. Modern Blood Banking and Transfusion Practices. ed 5. Philadelphia: FA
Davis; 2005.
Hebl J.R. The importance and implications of aseptic techniques during regional
anesthesia. Reg Anesth Pain Med. 2006;31:311–323.
Hebl J.R. Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-Guided Nerve Blockade. New
York: Oxford University Press; 2010.
Hebl J.R, Neal J.M. Infections complications: a new practice advisory. Reg Anesth Pain
Med. 2006;31:289–290.
Hemmings HC. J.r, Egan T.D. Pharmacology and Physiology for Anesthesia: Foundations and
Clinical Application. Philadelphia: Saunders; 2013.
Hensley FA. J.r, Martin D.E, Gravlee G.P. A Practical Approach to Cardiac Anesthesia. ed
4. Philadelphia: Lippincott Williams & Wilkins; 2007.
Hines R.L, Marschall K.E. Stoelting’s Anesthesia and Co-Existing Disease. ed
6. Philadelphia: Churchill Livingstone; 2012.
Horlocker T.T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic
therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-
Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64–101.
Johnston R.R, Eger EI. I.I, Wilson C. A comparative interaction of epinephrine with
enflurane, isoflurane and halothane in man. Anesth Analg. 1976;55:709–712.
Kahn R.A, et al. Intraoperative echocardiography. In: Kaplan J.A, ed. Essentials of Cardiac
Anesthesia. Philadelphia: Saunders; 2008.
Kaplan J.A. Kaplan’s Cardiac Anesthesia. ed 4. Philadelphia: Saunders; 1999.
Kaplan J.A, Reich D.L, Savino J.S. Kaplan’s Cardiac Anesthesia. ed
6. Philadelphia: Saunders; 2011.
Kasper D.L, et al. Harrison’s Principles of Internal Medicine. ed 16. New York: McGraw-
Hill; 2005.
Kattwinkel J, et al. Textbook of Neonatal Resuscitation. ed 5. Elk Grove Village, IL: American
Academy of Pediatrics and American Heart Association; 2006.
Lobato E.B, Gravenstein N, Kirby R.R. Complications in
Anesthesiology. Philadelphia: Lippincott Williams & Wilkins; 2008.
Loeser J.D. Bonica’s Management of Pain. ed 3. Philadelphia: Lippincott Williams &
Wilkins; 2001.
Longnecker D.E, Tinker J.H, Morgan GEJ.r. Principles and Practice of Anesthesiology. ed 2. St
Louis: Mosby; 1998.
Miller R.D. Basics of Anesthesia. ed 6. Philadelphia: Saunders; 2011.
Miller R.D, et al. Miller’s Anesthesia. ed 6. Philadelphia: Churchill Livingstone; 2005.
Miller R.D, et al. Miller’s Anesthesia. ed 7. Philadelphia: Churchill Livingstone; 2010.
Navarro R, et al. Humans anesthetized with sevoflurane or isoflurane have similar
arrhythmic response to epinephrine. Anesthesiology. 1994;80:545–549.
Neal J.M, et al. Upper extremity regional anesthesia: essentials of our current
understanding, 2008. Reg Anesth Pain Med. 2009;34:134–170.
Netter F.H. Atlas of Human Anatomy. Summit, NJ: Ciba-Geigy; 1989.
O’Grady N.P, et al. Guidelines for the prevention of intravascular catheter-related
infections. Centers for Disease Control and Prevention. MMWR Recomm
Rep. 2002;51(RR-10):1–29.
Orient J.M. Sapira’s Art and Science of Bedside Diagnosis. ed 4. Philadelphia: Lippincott
Williams & Wilkins; 2010.
Perlman J.M, et al. Part 11: neonatal resuscitation: 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation. 2010;122:S516–S538.
Physicians’ Desk Reference 2014. ed 68. Montvale, NJ: PDR Network; 2014.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce
the risk of pulmonary aspiration: application to healthy patients undergoing elective
procedures: a report by the American Society of Anesthesiologists Task Force on
Preoperative Fasting. Anesthesiology. 1999;90:896–905.
Raj P.P. Practical Management of Pain. ed 3. St Louis: Mosby; 2000.
Shott S.R. Down syndrome: analysis of airway size and a guide for appropriate
intubation. Laryngoscope. 2000;110:585–592.
Southorn P, et al. Reducing the potential morbidity of an unintentional spinal anaesthetic
by aspirating cerebrospinal fluid. Br J Anaesth. 1996;76:467–469.
Stoelting R.K, Dierdorf S.F. Anesthesia and Co-Existing Disease. ed 4. New York: Churchill
Livingstone; 2002.
Stoelting R.K, Hillier S.C. Pharmacology and Physiology in Anesthetic Practice. ed
4. Philadelphia: Lippincott Williams & Wilkins; 2006.
Suresh M.S, et al. Shnider and Levinson’s Anesthesia for Obstetrics. ed
5. Philadelphia: Lippincott Williams & Wilkins; 2013.
Thomas S.J, Kramer J.L. Manual of Cardiac Anesthesia. ed 2. Philadelphia: Churchill
Livingstone; 1993.
U.S. Food and Drug Administration. Fatalities reported to FDA following blood collection
and transfusion: annual summary for fiscal year. 2012 Available
at. http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/Tran
August 18, 2014.
Wedel D.J. Orthopedic Anesthesia. New York: Churchill Livingstone; 1993.
West J.B. Respiratory Physiology. ed 6. Philadelphia: Lippincott Williams & Wilkins; 1999.
Wilson W, et al. Prevention of infective endocarditis: guidelines from the American Heart
Association: a guideline from the American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease
in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular
Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group. Circulation. 2007;115:1736–1754.
Acknowledgments
The va rie ty a nd qua ntity of ma te ria l in the fifth e dition of Anesth esia:
A Com preh ensive Review a re va st. Effort ha s be e n ta ke n to e nsure
re le va nce a nd a ccura cy of e a ch ste m. The que stions ha ve be e n
re fe re nce d to the most re ce nt e ditions of a ne sthe sia te xtbooks or
journa l publica tions. Se ve ra l individua ls contribute d by sugge sting
ide a s for que stions or by ve tting one or more ite ms. The a uthors
wish to e xpre ss the ir gra titude to Drs. Ma rtin Abe l, J.P. Abe nste in,
Dorothe e Bre me rich, Da vid Da nie lson, Niki Die tz, Ja son Eldridge ,
Tra cy Ha rrison, W illia m La nie r, Ja me s Lynch, W illia m Ma ue rma nn,
Bria n McGlinch, Jura j Sprung, De nise We de l, a nd Roge r W hite , a s
we ll a s Robin Ha rdt, CRNA, a nd Ta ra Ha ll, RRT.
Se ve ra l Ma yo Clinic a ne sthe sia re side nts contribute d to this work
by che cking te xtbook re fe re nce s a nd cita tions a nd by proofre a ding
the cha pte rs be fore production. The a uthors wish to tha nk Drs.
Arnole y (Arne y) Abce jo, Je nnife r Ba rtlotti Te le sz, Se ri Ca rne y, Rya n
Hofe r, Erin Holl, Ke lly La rson, La ure n Lica tino, Emily Sha rpe ,
Thoma s Ste wa rt, Lore n Thompson, Cha nning Twyne r, Luke Va n
Alstine , Pa ul Wa rne r, a nd C.M. Armste a d-W illia ms. Additiona l he lp
with gra mma r a nd synta x, a s we ll a s typing a nd e diting, wa s
provide d by Ka re n Da nie lson, Ha rve y Johnson, a nd Lia na Johnson.
The de sign, pre pa ra tion, a nd production of the fina l ma nuscript
could not ha ve be e n a ccomplishe d without the he lp of ma ny skillful
pe ople a t Else vie r. Spe cia l tha nks to W illia m R. Schmitt, Exe cutive
Conte nt Stra te gist, a s we ll a s Ka thryn De Fra nce sco, Conte nt
De ve lopme nt Ma na ge r, a nd Kristine Fe e he rty, Se nior Proje ct
Ma na ge r.
Brian A. Hall, MD
Robert C. Chantigian, MD
PA R T 1

Basic Sciences
OUTLI NE

Chapter 1. Anesthesia Equipment and Physics


Chapter 2. Respiratory Physiology and Critical Care Medicine
Chapter 3. Pharmacology and Pharmacokinetics of Intravenous
Drugs
Chapter 4. Pharmacology and Pharmacokinetics of Volatile
Anesthetics
C H AP T E R 1
Anesthesia Equipment and Physics

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


incomple te sta te me nt in this se ction is followe d by a nswe rs
or by comple tions of the sta te me nt, re spe ctive ly. Se le ct the
ONE BEST a nswe r or comple tion for e a ch ite m.

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

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


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

The a rrows in the figure a bove indica te


A. Re spira tory va ria tion
B. An unde rda mpe d signa l
C. An ove rda mpe d signa l
D. Atria l fibrilla tion
83. During a la pa roscopic chole cyste ctomy, e xha le d CO2 is 6%, but
inha le d CO2 is 1%. W hich e xpla na tion could NOT a ccount for
re bre a thing CO2?
A. Cha nne ling through soda lime
B. Fa ulty e xpira tory va lve
C. Exha uste d soda lime
D. Absorption of CO2 through pe ritone um

DIRECT IONS (Que stions 84 through 86): Ple a se ma tch the color
of the compre sse d-ga s cylinde r with the a ppropria te ga s.

84. He lium
85. Nitroge n
86. CO2
A. Bla ck
B. Brown
C. Blue
D. Gra y

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


be low with the corre ct numbe re d sta te me nt. Ea ch le tte re d
figure ma y be se le cte d once , more tha n once , or not a t a ll.

87. Be st for sponta ne ous ve ntila tion


88. Be st for controlle d ve ntila tion
89. Ba in syste m is modifica tion of
90. Ja ckson-Re e s syste m
Anesthesia Equipment and Physics
Corre ct Answ e rs, Ex pl a na ti ons, a nd
Re fe re nce s
1. (A) The control me cha nism of sta nda rd a ne sthe sia ve ntila tors,
such a s the Ohme da 7000, use s compre sse d oxyge n (100%) to
compre ss the ve ntila tor be llows a nd e le ctric powe r for the timing
circuits. Some ve ntila tors (e .g., North Ame rica n Drä ge r AV-E a nd AV-
2+) use a Ve nturi de vice , which mixe s oxyge n a nd a ir. Still othe r
ve ntila tors use sophistica te d digita l controls tha t a llow a dva nce d
ve ntila tion mode s. The se ve ntila tors use a n e le ctric ste ppe r motor
a tta che d to a piston (Miller: Miller’s Anesth esia, ed 8, p 757;
Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
160–161; Miller: Basics of Anesth esia, ed 6, pp 208–209).
2. (C) Continuous wave Doppler—Continuous wa ve Dopple r use s
two de dica te d ultra sound crysta ls, one for continuous tra nsmission
a nd a se cond for continuous re ce ption of ultra sound signa ls. This
pe rmits me a sure me nt of ve ry high fre que ncy Dopple r shifts or
ve locitie s. The “cost” is tha t this te chnique re ce ive s a continuous
signa l a long the e ntire le ngth of the ultra sound be a m. It is use d for
me a suring ve ry high ve locitie s (e .g., a s se e n in a ortic ste nosis).
Also, continuous wa ve Dopple r ca nnot spa tia lly loca te the source
of high ve locity (e .g., diffe re ntia te a mitra l re gurgita tion ve locity
from a ortic ste nosis; both a re systolic ve locitie s).
Pulsed Doppler—In contra st to continuous wa ve Dopple r, which
re cords the signa l a long the e ntire le ngth of the ultra sound be a m,
pulse d wa ve Dopple r pe rmits sa mpling of blood flow ve locitie s
from a spe cific re gion. This moda lity is pa rticula rly use ful for
a sse ssing the re la tive ly low ve locity flows a ssocia te d with
tra nsmitra l or tra nstricuspid blood flow, pulmona ry ve nous flow,
a nd le ft a tria l a ppe nda ge flow or for confirming the loca tion of
e cce ntric je ts of a ortic insufficie ncy or mitra l re gurgita tion. To
pe rmit this, a pulse of ultra sound is tra nsmitte d, a nd the n the
re ce ive r “liste ns” during a subse que nt inte rva l de fine d by the
dista nce from the tra nsmitte r a nd the sa mple site . This
tra nsduce r mode of tra nsmit-wa it-re ce ive is re pe a te d a t a n
inte rva l te rme d the pulse -re pe tition fre que ncy (PRF). The PRF is
the re fore de pth de pe nde nt, be ing gre a te r for ne a r re gions a nd
lowe r for dista nt or de e pe r re gions. The dista nce from the
tra nsmitte r to the re gion of inte re st is ca lle d the sa mple volume ,
a nd the width a nd le ngth of the sa mple volume a re va rie d by
a djusting the le ngth of the tra nsduce r “re ce ive ” inte rva l. In
contra st to continuous wa ve Dopple r, which is some time s
pe rforme d without two-dime nsiona l guida nce , pulse d Dopple r is
a lwa ys pe rforme d with two-dime nsiona l guida nce to de te rmine
the sa mple volume position.
Be ca use pulse d wa ve Dopple r e cho re pe a te dly sa mple s the
re turning signa l, the re is a ma ximum limit to the fre que ncy shift
or ve locity tha t ca n be me a sure d una mbiguously. Corre ct
ide ntifica tion of the fre que ncy of a n ultra sound wa ve form
re quire s sa mpling a t le a st twice pe r wa ve le ngth. Thus, the
ma ximum de te cta ble fre que ncy shift, or Nyquist limit, is one ha lf
the PRF. If the ve locity of inte re st e xce e ds the Nyquist limit,
“wra pa round” of the signa l occurs, first into the re ve rse cha nne l
a nd the n ba ck to the forwa rd cha nne l; this is known a s a lia sing
(Miller: Basics of Anesth esia, ed 6, pp 325–327).
3. (B) The pre ssure ga uge on a size “E” compre sse d-ga s cylinde r
conta ining liquid N2O shows 750 psi whe n it is full a nd will
continue to re giste r 750 psi until a pproxima te ly thre e fourths of the
N2O ha s le ft the cylinde r (i.e ., liquid N2O ha s a ll be e n va porize d). A
full cylinde r of N2O conta ins 1590 L. The re fore , whe n 400 L of ga s
re ma in in the cylinde r, the pre ssure within the cylinde r will be gin
to fa ll (Miller: Basics of Anesth esia, ed 6, p 201; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 12–13).
4. (D) De sflura ne is unique a mong the curre nt commonly use d
vola tile a ne sthe tics be ca use of its high va por pre ssure of 664 mm
Hg. Be ca use of the high va por pre ssure , the va porize r is
pre ssurize d to 1500 mm Hg a nd e le ctrica lly he a te d to 23° C to give
more pre dica ble conce ntra tions: 664/1500 = a bout 44%. If de sflura ne
we re use d a t 1 a tmosphe re , the conce ntra tion would be a bout 88%
(Barash : Clinical Anesth esia, ed 7, pp 666–668; Miller: Basics of
Anesth esia, ed 6, pp 202–203; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 60–64).
5. (D) Fa ctors tha t influe nce the ra te of la mina r flow of a substa nce
through a tube a re de scribe d by the Ha ge n-Poise uille la w of
friction. The ma the ma tic e xpre ssion of the Ha ge n-Poise uille la w of
friction is a s follows:

whe re is the flow of the substa nce , r is the ra dius of the tube ,
ΔP is the pre ssure gra die nt down the tube , L is the le ngth of the
tube , a nd µ is the viscosity of the substa nce . Note tha t the ra te of
la mina r flow is proportiona l to the ra dius of the tube to the fourth
powe r. If the dia me te r of a n intra ve nous ca the te r is double d,
flow would incre a se by a fa ctor of two ra ise d to the fourth powe r
(i.e ., a fa ctor of 16) (Eh renwerth : Anesth esia Eq uipm ent: Principles
and Applications, ed 2, pp 377–378).
6. (C) The World He a lth Orga niza tion re quire s tha t compre sse d-ga s
cylinde rs conta ining N2O for me dica l use be pa inte d blue . Size “E”
compre sse d-ga s cylinde rs comple te ly fille d with liquid N2O conta in
a pproxima te ly 1590 L of ga s. Se e ta ble from Expla na tion 10 (Miller:
Basics of Anesth esia, ed 6, p 201; Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, p 12).
7. (D) Ane sthe sia ma chine s should be che cke d e a ch da y be fore
the ir use . For most ma chine s, thre e pa rts a re che cke d be fore use :
ca libra tion for the oxyge n a na lyze r, the low-pre ssure circuit le a k
te st, a nd the circle syste m. Ma ny conside r the low-pre ssure circuit
the a re a most vulne ra ble for proble ms be ca use it is more subje ct
to le a ks. Le a ks in this pa rt of the ma chine ha ve be e n a ssocia te d
with intra ope ra tive a wa re ne ss (e .g., loose va porize r filling ca ps)
a nd hypoxia . To te st the low-pre ssure pa rt of the ma chine , se ve ra l
te sts ha ve be e n use d. For the positive -pre ssure te st, positive
pre ssure is a pplie d to the circuit by de pre ssing the oxyge n flush
button a nd occluding the Y-pie ce of the circle syste m (which is
conne cte d to the e ndotra che a l tube or the a ne sthe sia ma sk during
a ne sthe tic a dministra tion) a nd looking for positive pre ssure
de te cte d by the a irwa y pre ssure ga uge . A le a k in the low-pre ssure
pa rt of the ma chine or the circle syste m will be de monstra te d by a
de cre a se in a irwa y pre ssure . W ith ma ny ne we r ma chine s, a che ck
va lve is positione d downstre a m from the flowme te rs (rota me te rs)
a nd va porize rs but upstre a m from the oxyge n flush va lve , which
would not pe rmit the positive pre ssure from the circle syste m to
flow ba ck to the low-pre ssure circuit. In the se ma chine s with the
che ck va lve , the positive -pre ssure re a ding will fa ll only with a le a k
in the circle pa rt, but a le a k in the low-pre ssure circuit of the
a ne sthe sia ma chine will not be de te cte d. In 1993, use of the U.S.
Food a nd Drug Administra tion unive rsa l ne ga tive -pre ssure le a k te st
wa s e ncoura ge d, whe re by the ma chine ma ste r switch a nd the flow
va lve s a re turne d off, a nd a suction bulb is colla pse d a nd a tta che d
to the common or fre sh ga s outle t of the ma chine . If the bulb sta ys
fully colla pse d for a t le a st 10 se conds, a le a k did not e xist (this
ne e ds to be re pe a te d for e a ch va porize r, e a ch one ope ne d a t a
time ). Of course , whe n the te st is comple te d, the fre sh ga s hose is
re conne cte d to the circle syste m. Be ca use ma chine s continue to be
de ve lope d a nd to diffe r from one a nothe r, you should be fa milia r
with e a ch ma nufa cture r ’s ma chine pre ope ra tive che cklist. For
e xa mple , the ne ga tive -pre ssure le a k te st is re comme nde d for
Ohme da Unitrol, Ohme da 30/70, Ohme da Modulus I, Ohme da
Modulus II a nd II plus, Ohme da Exce l se rie s, Ohme da CD, a nd
Da te x-Ohme da Ae stiva . The Drä ge r Na rkome d 2A, 2B, 2C, 3, 4, a nd
GS re quire a positive -pre ssure le a k te st. The Fa bius GS, Na rkome d
6000, a nd Da te x-Ohme da S5/ADU ha ve se lf-te sts (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 83–85; Miller:
Miller’s Anesth esia, ed 8, pp 752–755).

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


va lve s pre ve nt re trogra de flow of ga se s from the a ne sthe sia
ma chine or the tra nsfe r of ga s from a compre sse d-ga s cylinde r a t
high pre ssure into a conta ine r a t a lowe r pre ssure . Thus, the se
unidire ctiona l va lve s will a llow a n e mpty compre sse d-ga s cylinde r
to be e xcha nge d for a full one during ope ra tion of the a ne sthe sia
ma chine with minima l loss of ga s. The a djusta ble pre ssure -limiting
va lve is a synonym for a pop-off va lve . A fa il-sa fe va lve is a
synonym for a pre ssure -se nsor shutoff va lve . The purpose of a fa il-
sa fe va lve is to discontinue the flow of N2O (or proportiona lly
re duce it) if the O2 pre ssure within the a ne sthe sia ma chine fa lls
be low 30 psi (Miller: Miller’s Anesth esia, ed 8, p 756).
9. (C) Boyle ’s la w sta te s tha t for a fixe d ma ss of ga s a t a consta nt
te mpe ra ture , the product of pre ssure a nd volume is consta nt. This
conce pt ca n be use d to e stima te the volume of ga s re ma ining in a
compre sse d-ga s cylinde r by me a suring the pre ssure within the
cylinde r (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, p 4).
10. (C) U.S. ma nufa cture rs re quire tha t a ll compre sse d-ga s cylinde rs
conta ining O2 for me dica l use be pa inte d gre e n. A compre sse d-ga s
cylinde r comple te ly fille d with O2 ha s a pre ssure of a pproxima te ly
2000 psi a nd conta ins a pproxima te ly 625 L of ga s. According to
Boyle ’s la w, the volume of ga s re ma ining in a close d conta ine r ca n
be e stima te d by me a suring the pre ssure within the conta ine r.
The re fore , whe n the pre ssure ga uge on a compre sse d-ga s cylinde r
conta ining O2 shows a pre ssure of 1600 psi, the cylinde r conta ins
500 L of O2. At a ga s flow of 2 L/min, O2 could be de live re d from the
cylinde r for a pproxima te ly 250 minute s (Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, p 4; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 10–12).
CHARACTERISTICS OF COMPRESSED GASES STORED IN “E”
SIZE CYLINDERS THAT MAY BE ATTACHED TO THE ANESTHESIA
MACHINE

∗ The World Health Organization specifies that cylinders containing oxygen for medical use be
painted white, but manufacturers in the United States use green. Likewise, the international color
for air is white and black, whereas cylinders in the United States are color-coded yellow.
From Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, p 201, Table 15-2.
11. (B) Give n the de scription of the proble m, no flow of O2 through
the O2 rota me te r is the corre ct choice . In a norma lly functioning
rota me te r, ga s flows be twe e n the rim of the bobbin a nd the wa ll of
the Thorpe tube , ca using the bobbin to rota te . If the bobbin is
rota ting, you ca n be ce rta in tha t ga s is flowing through the
rota me te r a nd tha t the bobbin is not stuck (Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, pp 43–45).

12. (B) Fa il-sa fe va lve is a synonym for pre ssure -se nsor shutoff
va lve . The purpose of the fa il-sa fe va lve is to pre ve nt the de live ry
of hypoxic ga s mixture s from the a ne sthe sia ma chine to the pa tie nt
re sulting from fa ilure of the O2 supply. Most mode rn a ne sthe sia
ma chine s, howe ve r, would not a llow a hypoxic mixture , be ca use
the knob controlling the N2O is linke d to the O2 knob. W he n the O2
pre ssure within the a ne sthe sia ma chine de cre a se s be low 30 psi,
this va lve discontinue s the flow of N2O or proportiona lly de cre a se s
the flow of a ll ga se s. It is importa nt to re a lize tha t this va lve will not
pre ve nt the de live ry of hypoxic ga s mixture s or pure N2O whe n the
O2 rota me te r is off, be ca use the O2 pre ssure within the circuits of
the a ne sthe sia ma chine is ma inta ine d by a n ope n O2 compre sse d-
ga s cylinde r or a ce ntra l supply source . Unde r the se circumsta nce s,
a n O2 a na lyze r will be ne e de d to de te ct the de live ry of a hypoxic
ga s mixture (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 37–40; Miller: Basics of Anesth esia, ed 6, pp 199–
200).
13. (C) It is importa nt to ze ro the e le ctrome cha nica l tra nsduce r
syste m with the re fe re nce point a t the a pproxima te le ve l of the
he a rt. This will e limina te the e ffe ct of the fluid column of the
tra nsduce r syste m on the a rte ria l BP re a ding of the syste m. In this
que stion, the syste m wa s ze roe d a t the stopcock, which wa s
loca te d a t the pa tie nt’s wrist (a pproxima te le ve l of the ve ntricle ).
The BP e xpre sse d by the a rte ria l line will the re fore be a ccura te ,
provide d the stopcock re ma ins a t the wrist a nd the tra nsduce r is
not move d once ze roe d. Ra ising the a rm (e .g., 15 cm) de cre a se s the
BP a t the wrist but incre a se s the pre ssure on the tra nsduce r by the
sa me a mount (i.e ., the ve rtica l tubing le ngth is now 15 cm H2O
highe r tha n be fore ) (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 276–278; Miller: Miller’s Anesth esia, ed 8, pp 1354–
1355).
14. (C) O2 a nd N2O e nte r the a ne sthe sia ma chine from a ce ntra l
supply source or compre sse d-ga s cylinde rs a t pre ssure s a s high a s
2200 psi (O2) a nd 750 psi (N2O). First-sta ge pre ssure re gula tors
re duce the se pre ssure s to a pproxima te ly 45 psi. Be fore e nte ring the
rota me te rs, se cond-sta ge O2 pre ssure re gula tors furthe r re duce the
pre ssure to a pproxima te ly 14 to 16 psi (Miller: Miller’s Anesth esia, ed
8, p 761).
15. (C) NIOSH se ts guide line s a nd issue s re comme nda tions
conce rning the control of wa ste a ne sthe tic ga se s. NIOSH ma nda te s
tha t the highe st tra ce conce ntra tion of N2O conta mina tion of the OR
a tmosphe re should be le ss tha n 25 ppm. In de nta l fa cilitie s whe re
N2O is use d without vola tile a ne sthe tics, NIOSH pe rmits up to
50 ppm (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p
81).
16. (C) Age nt-spe cific va porize rs, such a s the Se vote c (se voflura ne )
va porize r, a re de signe d for e a ch vola tile a ne sthe tic. Howe ve r,
vola tile a ne sthe tics with ide ntica l sa tura te d va por pre ssure s ca n be
use d inte rcha nge a bly, with a ccura te de live ry of the vola tile
a ne sthe tic. Although ha lotha ne is no longe r use d in the Unite d
Sta te s, tha t va porize r, for e xa mple , ma y still be use d in de ve loping
countrie s for a dministra tion of isoflura ne (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 61–63; Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, pp 72–73).
VAPOR PRESSURES

Agent Vapor Pressure mm Hg at 20° C


Halothane 243
Sevoflurane 160
Isoflurane 240
Desflurane 669

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


se ve re constriction such a s tha t de scribe d in this que stion. La mina r
flow occurs whe n ga s flows down pa ra lle l-side d tube s a t a ra te
le ss tha n critica l ve locity. W he n the ga s flow e xce e ds the critica l
ve locity, it be come s turbule nt (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 488–489).
18. (C) During turbule nt flow, the re sista nce to ga s flow is dire ctly
proportiona l to the de nsity of the ga s mixture . Substituting he lium
for oxyge n will de cre a se the de nsity of the ga s mixture , the re by
de cre a sing the re sista nce to ga s flow (a s much a s thre e fold)
through the re gion of constriction (Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, pp 498–499, 1286–1287; Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 230–234).
19. (C) Mode rn e le ctronic BP monitors a re de signe d to inte rfa ce
with e le ctrome cha nica l tra nsduce r syste ms. The se syste ms do not
re quire e xte nsive te chnica l skill on the pa rt of the a ne sthe sia
provide r for a ccura te use . A sta tic ze roing of the syste m is built into
most mode rn e le ctronic monitors. Thus, a fte r the ze roing proce dure
is a ccomplishe d, the syste m is re a dy for ope ra tion. The syste m
should be ze roe d with the re fe re nce point of the tra nsduce r a t the
a pproxima te le ve l of the a ortic root, e limina ting the e ffe ct of the
fluid column of the syste m on a rte ria l BP re a dings (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 276–278).
20. (B) Wa ste ga s disposa l syste ms, a lso ca lle d sca ve nging syste ms,
a re de signe d to de cre a se pollution in the OR by a ne sthe tic ga se s.
The se sca ve nging syste ms ca n be pa ssive (wa ste ga se s flow from
the a ne sthe sia ma chine to a ve ntila tion syste m on the ir own) or
a ctive (a ne sthe sia ma chine is conne cte d to a va cuum syste m, the n
to the ve ntila tion syste m). Positive -pre ssure re lie f va lve s ope n if
the re is a n obstruction be twe e n the a ne sthe sia ma chine a nd the
disposa l syste m, which would the n le a k the ga s into the OR. A le a k
in the soda lime ca niste rs would a lso ve nt to the OR. Give n tha t
most ve ntila tor be llows a re powe re d by oxyge n, a le a k in the
be llows will not a dd a ir to the e va cua tion syste m. The ne ga tive -
pre ssure re lie f va lve is use d in a ctive syste ms a nd will e ntra p room
a ir if the pre ssure in the syste m is le ss tha n −0.5 cm H2O (Miller:
Miller’s Anesth esia, ed 8, p 802; Miller: Basics of Anesth esia, ed 6, pp 212;
Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
101–103).
21. (D) The re la tionship be twe e n intra -a lve ola r pre ssure , surfa ce
te nsion, a nd the ra dius of a lve oli is de scribe d by La pla ce ’s la w for
a sphe re , which sta te s tha t the surfa ce te nsion of the sphe re is
dire ctly proportiona l to the ra dius of the sphe re a nd pre ssure
within the sphe re . W ith re ga rd to pulmona ry a lve oli, the
ma the ma tic e xpre ssion of La pla ce ’s la w is a s follows:
whe re T is the surfa ce te nsion, P is the intra -a lve ola r pre ssure ,
a nd R is the ra dius of the a lve olus. In pulmona ry a lve oli, surfa ce
te nsion is produce d by a liquid film lining the a lve oli. This occurs
be ca use the a ttra ctive force s be twe e n the mole cule s of the liquid
film a re much gre a te r tha n the a ttra ctive force s be twe e n the
liquid film a nd ga s. Thus, the surfa ce a re a of the liquid te nds to
be come a s sma ll a s possible , which could colla pse the a lve oli
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
493–494; Miller: Miller’s Anesth esia, ed 8, p 475).
22. (C) Be ca use vola tile a ne sthe tics ha ve diffe re nt va por pre ssure s,
the va porize rs a re a ge nt spe cific. Va porize rs a re de scribe d a s
ha ving va ria ble bypa ss, which me a ns tha t some of the tota l fre sh
ga s flow (usua lly le ss tha n 20%) is dive rte d into the va porizing
cha mbe r, a nd the re st bypa sse s the va porize r. Tipping the
va porize rs (which should not occur) ma y ca use some of the liquid
to e nte r the bypa ss circuit, le a ding to a high conce ntra tion of
a ne sthe tic be ing de live re d to the pa tie nt. The ga s tha t e nte rs the
va porize r flows ove r (doe s not bubble through) the vola tile
a ne sthe tic. The olde r (now obsole te ) Coppe r Ke ttle a nd Ve rn-Trol
va porize rs we re not a ge nt spe cific, a nd oxyge n (with a se pa ra te
flowme te r) wa s bubble d through the vola tile a ne sthe tic; the n, the
combina tion of oxyge n with vola tile ga s wa s dilute d with the fre sh
ga s flow (oxyge n, a ir, N2O) a nd a dministe re d to the pa tie nt.
Be ca use va poriza tion cha nge s with te mpe ra ture , mode rn
va porize rs a re de signe d to ma inta in a consta nt conce ntra tion ove r
clinica lly use d te mpe ra ture s (20° C-35° C) (Barash : Clinical Anesth esia,
ed 7, pp 661–672; Miller: Basics of Anesth esia, ed 6, pp 202–203;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 60–64).
23. (A) Va porize rs ca n be ca te gorize d into va ria ble -bypa ss a nd
me a sure d-flow va porize rs. Me a sure d-flow va porize rs
(nonconce ntra tion ca libra te d va porize rs) include the obsole te
Coppe r Ke ttle a nd Ve rnitrol va porize rs. W ith me a sure d-flow
va porize rs, the flow of oxyge n is se le cte d on a se pa ra te flowme te r
to pa ss into the va porizing cha mbe r, from which the a ne sthe tic
va por e me rge s a t its sa tura te d va por pre ssure . By contra st, in
va ria ble -bypa ss va porize rs, the tota l ga s flow is split be twe e n a
va ria ble bypa ss a nd the va porize r cha mbe r conta ining the
a ne sthe tic a ge nt. The ra tio of the se two flows is ca lle d the splitting
ra tio. The splitting ra tio de pe nds on the a ne sthe tic a ge nt, the
te mpe ra ture , the chose n va por conce ntra tion se t to be de live re d to
the pa tie nt, a nd the sa tura te d va por pre ssure of the a ne sthe tic
(Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp
68–71).
24. (C) The contribution of the fre sh ga s flow from the a ne sthe sia
ma chine to the pa tie nt’s VT should be conside re d whe n se tting the
VT of a me cha nica l ve ntila tor. Be ca use the ve ntila tor pre ssure -re lie f
va lve is close d during inspira tion, both the ga s from the ve ntila tor
be llows a nd the fre sh ga s flow will be de live re d to the pa tie nt’s
bre a thing circuit. In this que stion, the fre sh ga s flow is 6 L/min, or
100 mL/se c (6000 mL/60 se c). Ea ch bre a th la sts 6 se conds
(60 se c/10 bre a ths), with inspira tion la sting 2 se conds (I:E
ra tio = 1:2). Unde r the se conditions, the 500 VT de live re d to the
pa tie nt by the me cha nica l ve ntila tor will be a ugme nte d by
a pproxima te ly 200 mL. In some ve ntila tors, such a s the Ohme da
7900, VT is controlle d for the fre sh ga s flow ra te in such a ma nne r
tha t the de live re d VT is a lwa ys the sa me a s the dia l se tting
(Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 79–
81).
25. (C) The ve ntila tor ra te is de cre a se d from 10 to 6 bre a ths/min.
Thus, e a ch bre a th will la st 10 se conds (60 se c/6 bre a ths), with
inspira tion la sting a pproxima te ly 3.3 se conds (I:E ra tio = 1:2) (i.e .,
3.3 se conds × 100 mL/se c). Unde r the se conditions, the a ctua l VT
de live re d to the pa tie nt by the me cha nica l ve ntila tor will be 830 mL
(500 mL + 330 mL) (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 79–81).
26 (B) Endotra che a l tube s fre que ntly be come pa rtia lly or comple te ly
occlude d with se cre tions. Pe riodic suctioning of the e ndotra che a l
tube in the ICU a ssure s pa te ncy of the a rtificia l a irwa y. The re a re
ha za rds, howe ve r, of e ndotra che a l tube suctioning. The y include
mucosa l tra uma , ca rdia c dysrhythmia s, hypoxia , incre a se d
intra cra nia l pre ssure , coloniza tion of the dista l a irwa y, a nd
psychologic tra uma to the pa tie nt.
To re duce the possibility of coloniza tion of the dista l a irwa y it is
prude nt to ke e p the suction ca the te r within the e ndotra che a l
tube during suctioning. Pushing the suctioning ca the te r be yond
the dista l limits of the e ndotra che a l tube a lso ma y produce
suctioning tra uma to the tra che a l tissue (Tobin: Principles and
Practices of Mech anical Ventilation, ed 3, p 1223).
27. (D) CO ca n be ge ne ra te d whe n vola tile a ne sthe tics a re e xpose d
to CO2 a bsorbe rs tha t conta in Na OH or KOH (e .g., soda lime ) a nd
ha ve some time s produce d ca rboxyhe moglobin le ve ls of 35%.
Fa ctors tha t a re involve d in the production of CO a nd forma tion of
ca rboxyhe moglobin include (1) the spe cific vola tile a ne sthe tic use d
(de sflura ne ≥ e nflura ne > isoflura ne ≫ se voflura ne = ha lotha ne ), (2)
high conce ntra tions of vola tile a ne sthe tic (more CO is ge ne ra te d a t
highe r vola tile conce ntra tions), (3) high te mpe ra ture s (more CO is
ge ne ra te d a t highe r te mpe ra ture s), (4) low fre sh ga s flows, a nd
e spe cia lly (5) dry soda lime (dry gra nule s produce more CO tha n do
hydra te d gra nule s). Soda lime conta ins 15% wa te r by we ight, a nd
only whe n it ge ts de hydra te d to be low 1.4% will a ppre cia ble
a mounts of CO be forme d. Ma ny of the re porte d ca se s of pa tie nts
e xpe rie ncing e le va te d ca rboxyhe moglobin le ve ls occurre d on
Monda y mornings, whe n the fre sh ga s flow on the a ne sthe sia
circuit wa s not turne d off a nd high a ne sthe tic fre sh ga s flows
(>5 L/min) for prolonge d pe riods of time (e .g., >48 hours) occurre d.
Be ca use of some re sista nce of the inspira tory va lve , re trogra de
flow through the CO2 a bsorbe r (which ha ste ns the drying of the
soda lime ) will de ve lop, e spe cia lly if the bre a thing ba g is a bse nt,
the Y-pie ce of the circuit is occlude d, a nd the a djusta ble pre ssure -
limiting va lve is ope n. W he ne ve r you a re unce rta in a s to the
dryne ss of the CO2 a bsorbe r, e spe cia lly whe n the fre sh ga s flow
wa s not turne d off the a ne sthe sia ma chine for a n e xte nde d or
inde te rmina te pe riod of time , the CO2 a bsorbe r should be cha nge d.
This CO production occurs with soda lime a nd occurre d more so
with Ba ra lyme (which is no longe r a va ila ble ), but it doe s not occur
with Amsorb Plus or Drä ge rSorb Fre e (which conta ins ca lcium
chloride a nd ca lcium hydroxide a nd no Na OH or KOH) (Barash :
Clinical Anesth esia, ed 7, p 676; Miller: Basics of Anesth esia, ed 6, pp 212–
215; Miller: Miller’s Anesth esia, ed 8, pp 789–792).
28. (A) NIOSH ma nda te s tha t the highe st tra ce conce ntra tion of
vola tile a ne sthe tic conta mina tion of the OR a tmosphe re whe n
a dministe re d in conjunction with N2O is 0.5 ppm (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 81).
29. (B) The O2 a na lyze r is the la st line of de fe nse a ga inst the
ina dve rte nt de live ry of hypoxic ga s mixture s. It should be loca te d in
the inspira tory (not e xpira tory) limb of the pa tie nt’s bre a thing circuit
to provide ma ximum sa fe ty. Be ca use the O2 conce ntra tion in the
fre sh-ga s supply line ma y be diffe re nt from tha t of the pa tie nt’s
bre a thing circuit, the O2 a na lyze r should not be loca te d in the fre sh-
ga s supply line (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, pp 209–210).
30. (A) The ve ntila tor pre ssure -re lie f va lve (a lso ca lle d the spill
va lve ) is pre ssure controlle d via pilot tubing tha t communica te s
with the ve ntila tor be llows cha mbe r. As pre ssure within the
be llows cha mbe r incre a se s during the inspira tory pha se of the
ve ntila tor cycle , the pre ssure is tra nsmitte d via the pilot tubing to
close the pre ssure -re lie f va lve , thus ma king the pa tie nt’s bre a thing
circuit “ga s tight.” This va lve should ope n during the e xpira tory
pha se of the ve ntila tor cycle to a llow the re le a se of e xce ss ga s
from the pa tie nt’s bre a thing circuit into the wa ste -ga s sca ve nging
circuit a fte r the be llows ha s fully e xpa nde d. If the ve ntila tor
pre ssure -re lie f va lve we re to stick in the close d position, the re
would be a ra pid buildup of pre ssure within the circle syste m tha t
would be re a dily tra nsmitte d to the pa tie nt. Ba rotra uma to the
pa tie nt’s lungs would re sult if this situa tion we re to continue
unre cognize d (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology,
ed 5, pp 34, 79–80).

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


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

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


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

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


he moglobin sa tura tion to R, the a ctua l a rte ria l he moglobin
sa tura tion is ca lcula te d. Ba se d on the physica l principle s outline d
a bove , the source s of e rror in SpO2 re a dings ca n be e a sily
pre dicte d. Pulse oxime te rs ca n function a ccura te ly whe n only
two he moglobin spe cie s, oxyhe moglobin a nd re duce d
he moglobin, a re pre se nt. If a ny light-a bsorbing spe cie s othe r tha n
oxyhe moglobin a nd re duce d he moglobin a re pre se nt, the pulse
oxime te r me a sure me nts will be ina ccura te . Fe ta l he moglobin
ha s a minima l e ffe ct on the a ccura cy of pulse oxime try be ca use
the e xtinction coe fficie nts for fe ta l he moglobin a t the two
wa ve le ngths use d by pulse oxime try a re ve ry simila r to the
corre sponding va lue s for a dult he moglobin. In a ddition to
a bnorma l he moglobins, a ny substa nce pre se nt in the blood tha t
a bsorbs light a t e ithe r 660 or 940 nm, such a s intra ve nous dye s
use d for dia gnostic purpose s, will a ffe ct the va lue of R, ma king
a ccura te me a sure me nts of the pulse oxime te r impossible . The se
dye s include me thyle ne blue a nd indigo ca rmine . Me thyle ne blue
ha s the gre a te st e ffe ct on Sa O2 me a sure me nts be ca use the
e xtinction coe fficie nt is so simila r to tha t of oxyhe moglobin
(Eh renwerth : Anesth esia Eq uipm ent: Principles and Applications, ed 2,
pp 261–262).
40. (D) Rota me te rs consist of a ve rtica lly positione d ta pe re d tube
tha t is sma lle st in dia me te r a t the bottom (Thorpe tube ). Ga s e nte rs
a t the bottom of the Thorpe tube a nd e le va te s a bobbin or floa t,
which come s to re st whe n gra vity on the floa t is ba la nce d by the
fa ll in pre ssure a cross the floa t. The ra te of ga s flow through the
tube de pe nds on the pre ssure drop a long the le ngth of the tube , the
re sista nce to ga s flow through the tube , a nd the physica l prope rtie s
(de nsity a nd viscosity) of the ga s. Be ca use fe w ga se s ha ve the sa me
de nsity a nd viscosity, rota me te rs ca nnot be use d inte rcha nge a bly
(Barash : Clinical Anesth esia, ed 7, pp 655–657; Eh renwerth : Anesth esia
Eq uipm ent: Principles and Applications, ed 2, pp 43–45).
41. (B) Sa tura te d va por pre ssure s de pe nd on the physica l prope rtie s
of the liquid a nd the te mpe ra ture . Va por pre ssure s a re
inde pe nde nt of ba rome tric pre ssure . At 20° C the va por pre ssure s
of ha lotha ne (243 mm Hg) a nd isoflura ne (240 mm Hg) a re simila r,
a nd a t 1 a tmosphe re the conce ntra tion in the va porize r for the se
drugs is 240/760, or a bout 32%. Simila rly, the va por pre ssure for
se voflura ne (160 mm Hg) a nd e nflura ne (172 mm Hg) a re simila r,
a nd a t 1 a tmosphe re the conce ntra tion in the va porize r for the se
drugs is 160/760, or a bout 21%. If de sflura ne (va por pre ssure of
669 mm Hg) is pla ce d in a 1-a tmosphe re pre ssure va porize r, the
conce ntra tion would be 669/760 = 88%. Be ca use the bypa ss flow is
a djuste d for e a ch va porize r, putting a vola tile a ne sthe tic with a
highe r sa tura te d va por pre ssure would le a d to a highe r-tha n-
e xpe cte d conce ntra tion of a ne sthe tic de live re d from the va porize r,
whe re a s putting a drug with a lowe r sa tura te d va por pre ssure
would le a d to a lowe r-tha n-e xpe cte d conce ntra tion of drug
de live re d from the va porize r (Barash : Clinical Anesth esia, ed 7, pp 661–
672).
VAPOR PRESSURE AND MINIMUM ALVEOLAR CONCENTRATION

MAC, minimum alveolar concentration.

42. (D) Ga s de nsity de cre a se s with incre a sing a ltitude (i.e ., the
de nsity of a ga s is dire ctly proportiona l to a tmosphe ric pre ssure ).
Atmosphe ric pre ssure will influe nce the function of rota me te rs
be ca use the a ccura te function of rota me te rs is influe nce d by the
physica l prope rtie s of the ga s, such a s de nsity a nd viscosity. The
ma gnitude of this influe nce , howe ve r, de pe nds on the ra te of ga s
flow. At low ga s flows, the pa tte rn of ga s flow is la mina r.
Atmosphe ric pre ssure will ha ve little e ffe ct on the a ccura te function
of rota me te rs a t low ga s flows be ca use la mina r ga s flow is
influe nce d by ga s viscosity (which is minima lly a ffe cte d by
a tmosphe ric pre ssure ), not by ga s de nsity. Howe ve r, a t high ga s
flows, the ga s flow pa tte rn is turbule nt a nd is influe nce d by ga s
de nsity. At high a ltitude s (i.e ., low a tmosphe ric pre ssure ), the ga s
flow through the rota me te r will be gre a te r tha n e xpe cte d a t high
flows but a ccura te a t low flows (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 43–45, 230–231).
43. (B) Pa ce ma ke rs ha ve a thre e - to five -le tte r code tha t de scribe s
the pa ce ma ke r type a nd function. Give n tha t the purpose of the
pa ce ma ke r is to se nd e le ctric curre nt to the he a rt, the first le tte r
ide ntifie s the cha mbe r(s) pa ce d: A for a tria l, V for ve ntricle , a nd D
for dua l cha mbe r (A + V). The se cond le tte r ide ntifie s the cha mbe r
whe re e ndoge nous curre nt is se nse d: A,V, D, a nd O for none
se nse d. The third le tte r de scribe s the re sponse to se nsing: O for
none , I for inhibite d, T for trigge re d, a nd D for dua l (I + T). The
fourth le tte r de scribe s progra mma bility or ra te modula tion: O for
none a nd R for ra te modula tion (i.e ., fa ste r he a rt ra te with
e xe rcise ). The fifth le tte r de scribe s multisite pa cing (more
importa nt in dila te d he a rt cha mbe rs): A, V or D (A + V), or O. A
VDD pa ce ma ke r is use d for pa tie nts with AV node dysfunction but
inta ct sinus node a ctivity (Miller: Miller’s Anesth esia, ed 8, pp 1467–
1468).
44. (A) Although controve rsia l, it is thought tha t chronic e xposure to
low conce ntra tions of vola tile a ne sthe tics ma y constitute a he a lth
ha za rd to OR pe rsonne l. The re fore , re mova l of tra ce
conce ntra tions of vola tile a ne sthe tic ga se s from the OR a tmosphe re
with a sca ve nging syste m a nd ste ps to re duce a nd control ga s
le a ka ge into the e nvironme nt a re re quire d. High-pre ssure syste m
le a ka ge of vola tile a ne sthe tic ga se s into the OR a tmosphe re occurs
whe n ga s e sca pe s from compre sse d-ga s cylinde rs a tta che d to the
a ne sthe tic ma chine (e .g., fa ulty yoke s) or from tubing de live ring
the se ga se s to the a ne sthe sia ma chine from a ce ntra l supply
source . The most common ca use of low-pre ssure le a ka ge of
a ne sthe tic ga se s into the OR a tmosphe re is the e sca pe of ga se s
from site s loca te d be twe e n the flowme te rs of the a ne sthe sia
ma chine a nd the pa tie nt, such a s a poor ma sk se a l. The use of
high ga s flows in a circle syste m will not re duce tra ce ga s
conta mina tion of the OR a tmosphe re . In fa ct, this could contribute
to the conta mina tion if the re is a le a k in the circle syste m (Miller:
Miller’s Anesth esia, ed 8, pp 3232–3234).
45. (A) Although the re is insufficie nt e vide nce tha t chronic e xposure
to low conce ntra tions of inha le d a ne sthe tics ma y pose a he a lth
ha za rd to those in the OR, pre ca utions a re ma de to de cre a se the
pollution of inha la tion a ne sthe tics the re . This include s ve ntila ting
the room a de qua te ly (a ir in the OR should be e xcha nge d a t le a st 15
time s a n hour), ma inte na nce of a ne sthe tic syste m sca ve nging
syste ms to re move a ne sthe tic va pors, a nd a tight a ne sthe tic se a l
with no le a ka ge of ga s into the OR a tmosphe re . Although pe riodic
e quipme nt ma inte na nce should be pe rforme d to ma ke sure the
a ne sthe tic e quipme nt is ope ra ting prope rly, le a ka ge a round a n
imprope rly se a le d fa ce ma sk a s we ll a s the fa ce ma sk not a pplie d
to the fa ce during a irwa y ma nipula tions (pla ce me nt of a n a irwa y)
pose s the gre a te st risk of OR conta mina tion from inha le d
a ne sthe tics (Barash : Clinical Anesth esia, ed 7, pp 62–64; Miller: Basics of
Anesth esia, ed 6, pp 211–212; Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 130–145; Miller: Miller’s Anesth esia,
ed 8, pp 3232–3234).
46. (C) The a mount of vola tile a ne sthe tic ta ke n up by the pa tie nt in
the first minute is e qua l to the a mount ta ke n up be twe e n the
squa re s of a ny two conse cutive minute s (squa re root of time
e qua tion). Thus, if 50 mL is ta ke n up in the first minute , 50 mL will
be ta ke n up be twe e n the first (1 squa re d) a nd fourth (2 squa re d)
minute s. Simila rly, be twe e n the fourth a nd ninth minute s (2 squa re d
a nd 3 squa re d), a nothe r 50 mL will be a bsorbe d. In this e xa mple ,
we a re looking for the upta ke be twe e n the 16th (4 squa re d) a nd
36th (6 squa re d) minute s, which would be 2 conse cutive minute s
squa re d, or 2 × 50 mL = 100 mL (Miller: Miller’s Anesth esia, ed 8, pp
650–651).
47. (D) In e va lua ting SSEPs, one looks a t both the a mplitude or
volta ge of the re corde d re sponse wa ve a nd the la te ncy (time
me a sure d from the stimulus to the onse t or pe a k of the re sponse
wa ve ). A de cre a se in a mplitude (>50%) a nd/or a n incre a se in
la te ncy (>10%) is usua lly clinica lly significa nt. The se cha nge s ma y
re fle ct hypope rfusion, ne ura l ische mia , te mpe ra ture cha nge s, or
drug e ffe cts. All of the vola tile a ne sthe tics a nd the ba rbitura te s
ca use a de cre a se in a mplitude a s we ll a s a n incre a se in latency .
Propofol a ffe cts both la te ncy a nd a mplitude a nd, like othe r
intra ve nous a ge nts, ha s a significa ntly le ss e ffe ct tha n “e quipote nt”
dose s of vola tile a ne sthe tics. Etomida te ca use s a n incre a se in
la te ncy a nd a n incre a se in a mplitude . Mida zola m de cre a se s the
a mplitude but ha s little e ffe ct on la te ncy. Opioids ca use sma ll a nd
not clinica lly significa nt incre a se s in la te ncy a nd a de cre a se in
a mplitude of the SSEPs. Muscle re la xa nts ha ve no e ffe ct on SSEPs
(Miller: Miller’s Anesth esia, ed 8, pp 1514–1517; Miller: Basics of
Anesth esia, ed 6, pp 505–506).
48. (A) The a ne sthe sia ma chine , now more prope rly ca lle d the
a ne sthe sia worksta tion, ha s two ma in pre ssure circuits. The
highe r-pre ssure circuits consist of the ga s supply from the pipe line s
a nd ta nks, a ll piping, pre ssure ga uge s, pre ssure re duction
re gula tors, che ck va lve s (which pre ve nt ba ckwa rd ga s flow), the
oxyge n pre ssure -se nsor shutoff va lve (a lso ca lle d the oxyge n fa ilure
cutoff or fa il-sa fe va lve ), the oxyge n supply fa ilure a la rm, a nd the
oxyge n flush va lve —or, simplistica lly, e ve rything up to the ga s flow
control va lve s a nd the ma chine common ga s outle t. The low-
pre ssure circuit sta rts with a nd include s the ga s flow control
va lve s, flowme te rs, va porize rs, a nd va porize r che ck va lve a nd goe s
to the ma chine common ga s outle t. Se e a lso figure for e xpla na tion
to Que stion 12 (Barash : Clinical Anesth esia, ed 7, pp 641–650; Miller:
Basics of Anesth esia, ed 6, pp 198–204).
49. (D) Va poriza tion of a liquid re quire s the tra nsfe r of he a t from the
obje cts in conta ct with the liquid (e .g., the me ta l cylinde r a nd
surrounding a tmosphe re ). For this re a son, a t high ga s flows,
a tmosphe ric wa te r will conde nse a s frost on the outside of
compre sse d-ga s cylinde rs (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 12–13; Miller: Basics of Anesth esia, ed 6, p 201).
50. (B) Te mpe ra ture me a sure me nts of the pulmona ry a rte ry,
e sopha gus, a xilla , na sopha rynx, a nd tympa nic me mbra ne corre la te
with ce ntra l te mpe ra ture in pa tie nts unde rgoing nonca rdia c surge ry.
Skin te mpe ra ture doe s not re fle ct ce ntra l te mpe ra ture a nd doe s not
wa rn a de qua te ly of ma ligna nt hype rthe rmia or e xce ssive
hypothe rmia (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology,
ed 5, p 137; Miller: Miller’s Anesth esia, ed 8, pp 1643–1644).
51. (C) La se r re fe rs to Light Amplifica tion by the Stimula te d
Emission of Ra dia tion. La se r light diffe rs from ordina ry light in
thre e ma in wa ys. First, la se r light is monochromic (posse sse s one
wa ve le ngth or color). Se cond, la se r light is cohe re nt (the photons
oscilla te in the sa me pha se ). Third, la se r light is collima te d (e xists
in a na rrow pa ra lle l be a m). Visible light ha s a wide spe ctrum of
wa ve le ngths in the 385- to 760-nm ra nge . Argon la se r light, which
ca n pe ne tra te tissue s to a de pth of 0.05 to 2.0 mm, is e ithe r blue
(wa ve le ngth 488 nm) or gre e n (wa ve le ngth 514 nm) a nd is ofte n
use d for va scula r pigme nte d le sions be ca use it is inte nsive ly
a bsorbe d by he moglobin. He lium–ne on la se r light is re d, ha s a
fre que ncy of 632 nm, a nd is ofte n use d a s a n a iming be a m be ca use
it ha s ve ry low powe r a nd pre se nts no significa nt da nge r to OR
pe rsonne l. Nd:YAG la se r light is the most powe rful me dica l la se r
a nd ca n pe ne tra te tissue s from 2 to 6 mm. Nd:YAG la se r light is in
the ne a r infra re d ra nge , with a wa ve le ngth of 1064 nm, ha s ge ne ra l
use s (e .g., prosta te surge ry, la rynge a l pa pilloma tosis, coa gula tion),
a nd ca n be use d with fibe roptics. CO2 la se r light is in the fa r
infra re d ra nge , with a long wa ve le ngth of 10,600 nm. Be ca use CO2
la se r light pe ne tra te s tissue s poorly, it ca n va porize supe rficia l
tissue s with little da ma ge to unde rlying ce lls (Barash : Clinical
Anesth esia, ed 7, pp 212–214; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 776–777; Miller: Miller’s Anesth esia, ed 8, pp
2598–2601).
52. (A) Norma l ga s flow is la mina r within the tra che a , but with
tra che a l ste nosis, a irflow is more turbule nt. Re sista nce during
turbule nt flow de pe nds on ga s de nsity, a nd he lium ha s a lowe r ga s
de nsity tha n nitroge n. Thus, the re is le ss work of bre a thing whe n
he lium is substitute d for nitroge n. Re me mbe r, though: the highe r
the conce ntra tion of he lium, the lowe r the conce ntra tion of oxyge n
(Miller: Miller’s Anesth esia, ed 8, p 2545).
53. (D) The F I o 2 de live re d to pa tie nts from low-flow syste ms (e .g.,
na sa l prongs) is de te rmine d by the size of the O2 re se rvoir, the O2
flow, a nd the pa tie nt’s bre a thing pa tte rn. As a rule of thumb,
a ssuming a norma l bre a thing pa tte rn, the F I o 2 de live re d by na sa l
prongs incre a se s by a pproxima te ly 0.04 for e a ch L/min incre a se in
O2 flow up to a ma xima l F I o 2 of a pproxima te ly 0.45 (a t a n O2 flow of
6 L/min). In ge ne ra l, the la rge r the pa tie nt’s VT or the fa ste r the
re spira tory ra te , the lowe r the F I o 2 for a give n O2 flow (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 1282–1283).
54. (A)
In a close d sca ve nging syste m inte rfa ce , the re se rvoir ba g should
e xpa nd during e xpira tion a nd contra ct during inspira tion. During
the inspira tory pha se of me cha nica l ve ntila tion, the ve ntila tor
pre ssure -re lie f va lve close s, the re by dire cting the ga s inside the
ve ntila tor be llows into the pa tie nt’s bre a thing circuit. If the
ve ntila tor pre ssure -re lie f va lve is incompe te nt, the re will be a
dire ct communica tion be twe e n the pa tie nt’s bre a thing circuit a nd
the sca ve nging circuit. This will re sult in de live ry of pa rt of the
me cha nica l ve ntila tor VT dire ctly to the sca ve nging circuit,
ca using the re se rvoir ba g to infla te during the inspira tory pha se
of the ve ntila tor cycle (Eh renwerth : Anesth esia Eq uipm ent: Principles
and Applications, ed 2, pp 130–132).
55. (C) The a ccura te function of dua l-wa ve le ngth pulse oxime te rs is
a lte re d by na il polish. Be ca use blue na il polish ha s a pe a k
a bsorba nce simila r to tha t of a dult de oxyge na te d he moglobin (ne a r
660 nm), it ha s the gre a te st e ffe ct on the SpO2 re a ding. Na il polish
ca use s a n a rtifa ctua l a nd fixe d de cre a se in the SpO2 re a ding a s
shown by the se de vice s. Turning the finge r probe 90 de gre e s a nd
ha ving the light shining side wise through the finge r is use ful whe n
the re is na il polish on the pa tie nt’s finge rna ils (Miller: Miller’s
Anesth esia ed 8, p 1547).
56. (C) Le a ka ge e le ctric curre nts le ss tha n 1 mA a re impe rce ptible
to touch. The minima l ve ntricula r fibrilla tion thre shold of curre nt
a pplie d to the skin is a bout 100 mA. If the curre nt bypa sse s the high
re sista nce of the skin a nd is a pplie d dire ctly to the he a rt via
pa ce ma ke r, ce ntra l line , e tc. (microshock), curre nts a s low a s
100 µA (0.1 mA) ma y be fa ta l. Be ca use of this, the Ame rica n
Na tiona l Sta nda rds Institute ha s se t the ma ximum le a ka ge of
e le ctric curre nt a llowe d through e le ctrode s or ca the te rs in conta ct
with the he a rt a t 10 µA (Barash : Clinical Anesth esia, ed 7, p 192;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 17;
Miller: Miller’s Anesth esia, ed 8, p 3226).
57. (D) The line isola tion monitor give s a n a la rm whe n grounding
occurs in the OR or whe n the ma ximum curre nt tha t a short circuit
could ca use e xce e ds 2 to 5 mA. The line isola tion monitor is pure ly
a monitor a nd doe s not inte rrupt e le ctric curre nt. The re fore , the
line isola tion monitor will not pre ve nt microshock or ma croshock
(Brunner: Electricity, Safety, and th e Patient, ed 1, p 304; Miller: Miller’s
Anesth esia, ed 8, pp 3221–3223).
58. (A)
A sca ve nging syste m with a close d inte rfa ce is one in which
the re is communica tion with the a tmosphe re through positive -
pre ssure a nd ne ga tive -pre ssure re lie f va lve s. The positive -
pre ssure re lie f va lve will pre ve nt tra nsmission of e xce ssive
pre ssure buildup to the pa tie nt’s bre a thing circuit, e ve n if the re is
a n obstruction dista l to the inte rfa ce or if the syste m is not
conne cte d to wa ll suction. Howe ve r, obstruction of the tra nsfe r
tubing from the pa tie nt’s bre a thing circuit to the sca ve nging circuit
is proxima l to the inte rfa ce . This will isola te the pa tie nt’s
bre a thing circuit from the positive -pre ssure re lie f va lve of the
sca ve nging syste m inte rfa ce . Should this occur, ba rotra uma to the
pa tie nt’s lungs ca n re sult (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 130–137).
59. (C) Ele ctroca ute ry units, or e le ctrosurgica l units (ESUs), we re
inve nte d by Profe ssor W. T. Bovie a nd we re first use d in 1926. The y
ope ra te by ge ne ra ting ultra -high fre que ncy (0.1-3 MHz) a lte rna ting
e le ctric curre nts a nd a re commonly use d toda y for cutting a nd
coa gula ting tissue . W he ne ve r a curre nt pa sse s through a re sista nce
such a s tissue , he a t is ge ne ra te d a nd is inve rse ly proportiona l to
the surfa ce a re a through which the curre nt pa sse s. At the point of
e ntry to the body from the sma ll a ctive e le ctrode or ca ute ry tip, a
fa ir a mount of he a t is ge ne ra te d. For the curre nt to comple te its
circuit, the re turn e le ctrode pla te or dispe rsive pa d (incorre ctly but
commonly ca lle d the ground pa d) ha s a la rge surfa ce a re a , whe re
ve ry little he a t de ve lops. The dispe rsive pa d should be a s close a s
is re a sona ble to the site of surge ry. If the curre nt from the ESU
pa sse s through a n a rtificia l ca rdia c pa ce ma ke r, the pa ce ma ke r
ma y misinte rpre t the curre nt a s ca rdia c a ctivity a nd ma y not pa ce ,
which is why a ma gne t pla ce d ove r the pa ce ma ke r will turn off the
pa ce ma ke r se nsor, putting the pa ce ma ke r in the a synchronous
mode , a nd should be a va ila ble (if the pa ce ma ke r ’s se nsory mode
is not turne d off pre ope ra tive ly). In a ddition, a utoma tic impla nta ble
ca rdiove rte r-de fibrilla tors (AICDs) ma y misinte rpre t the e le ctric
a ctivity a s ve ntricula r fibrilla tion a nd de fibrilla te the pa tie nt. AICDs
should be turne d off be fore use of a n ESU (Barash : Clinical
Anesth esia ed 7, pp 204–206; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 19–22).
60. (A) Automa te d noninva sive BP (ANIBP) de vice s provide
consiste nt a nd re lia ble a rte ria l BP me a sure me nts. Va ria tions in the
cuff pre ssure re sulting from a rte ria l pulsa tions during cuff de fla tion
a re se nse d by the de vice a nd a re use d to ca lcula te me a n a rte ria l
pre ssure . The n, va lue s for systolic a nd dia stolic pre ssure s a re
de rive d from formula s tha t use the ra te of cha nge of the a rte ria l
pre ssure pulsa tions a nd the me a n a rte ria l pre ssure (oscillome tric
principle ). This me thod provide s a ccura te me a sure me nts of a rte ria l
BP in ne ona te s, infa nts, childre n, a nd a dults. The ma in a dva nta ge
of ANIBP de vice s is tha t the y fre e the a ne sthe sia provide r to
pe rform othe r dutie s re quire d for optima l a ne sthe sia ca re .
Additiona lly, the se de vice s provide a la rm syste ms to dra w a tte ntion
to e xtre me BP va lue s, a nd the y ha ve the ca pa city to tra nsfe r da ta to
a utoma te d tre nding de vice s or re corde rs. Imprope r use of the se
de vice s ca n le a d to e rrone ous me a sure me nts a nd complica tions.
The width of the BP cuff should be a pproxima te ly 40% of the
circumfe re nce of the pa tie nt’s a rm. If the BP cuff is too na rrow or if
the BP cuff is wra ppe d too loose ly a round the a rm, the BP
me a sure me nt by the de vice will be fa lse ly e le va te d. Fre que nt BP
me a sure me nts ca n re sult in e de ma of the e xtre mity dista l to the
cuff. For this re a son, cycling of the se de vice s should not be more
fre que nt tha n e ve ry 1 to 3 minute s. Othe r complica tions a ssocia te d
with imprope r use of ANIBP de vice s include ulna r ne rve
pa re sthe sia , supe rficia l thrombophle bitis, a nd compa rtme nt
syndrome . Fortuna te ly, the se complica tions a re ra re (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 88–91; Miller: Basics
of Anesth esia, ed 6, pp 321–322; Miller: Miller’s Anesth esia, ed 8, pp 1347–
1348).
61. (B) EKG monitoring is ofte n not use d during MRI sca ns be ca use
a rtifa cts a re ve ry common (a bnorma litie s in T wa ve s a nd ST
wa ve s), a nd he a ting of the wire s during the sca n would pote ntia lly
burn the pa tie nt. Howe ve r, EKG ca n be use d if the e le ctrode s a re
pla ce d close toge the r a nd towa rd the ce nte r of the ma gne tic fie ld
a nd the wire s a re insula te d from the pa tie nt’s skin a nd stra ight. In
a ddition, the wire s should not be wound toge the r in loops (be ca use
this ca n induce he a ting of the wire s), a nd worn or fra ye d wire s
should not be use d (Barash : Clinical Anesth esia, ed 7, p 884; Miller:
Miller’s Anesth esia, ed 8, p 2655).
62. (C) A size “E” compre sse d-ga s cylinde r comple te ly fille d with a ir
conta ins 625 L a nd will show a pre ssure ga uge re a ding of 2000 psi.
The re fore , a cylinde r with a pre ssure ga uge re a ding of 1000 psi is
ha lf-full, conta ining a pproxima te ly 325 L of a ir. A ha lf-full size “E”
compre sse d-ga s cylinde r conta ining a ir ca n be use d for
a pproxima te ly 30 minute s a t a flow ra te of 10 L/min (se e de finition
of Boyle ’s la w, Que stion 9) (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 10–12; Miller: Basics of Anesth esia, ed 6, pp 199–
201).
63. (D) Fa ilure to oxyge na te pa tie nts a de qua te ly is a n importa nt
ca use of a ne sthe sia -re la te d morbidity a nd morta lity. All of the
choice s liste d in this que stion a re pote ntia l ca use s of ina de qua te
de live ry of O2 to the pa tie nt; howe ve r, the most fre que nt ca use is
ina dve rte nt disconne ction of the O2 supply syste m from the pa tie nt
(e .g., disconne ction of the pa tie nt’s bre a thing circuit from the
e ndotra che a l tube ) (Eh renwerth : Anesth esia Eq uipm ent: Principles and
Applications, ed 2, p 121; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 43–47).
64. (A) The e sopha ge a l de te ctor de vice (EDD) is e sse ntia lly a bulb
tha t is first compre sse d a nd the n a tta che d to the e ndotra che a l tube
a fte r the tube is inse rte d into the pa tie nt. The pre ssure ge ne ra te d
is a bout –40 cm of wa te r. If the e ndotra che a l tube is pla ce d in the
e sopha gus, the n the ne ga tive pre ssure will colla pse the e sopha gus,
a nd the bulb will not infla te . If the e ndotra che a l tube is in the
tra che a , the n the a ir from the lung will e na ble the bulb to infla te
(usua lly in a fe w se conds, but some time s more tha n 30 se conds). A
syringe tha t ha s a ne ga tive pre ssure a pplie d to it ha s a lso be e n
use d. Although initia l studie s we re ve ry positive a bout the use of
the EDD, more re ce nt studie s show tha t up to 30% of corre ctly
pla ce d e ndotra che a l tube s in a dults ma y be re move d be ca use the
EDD ha s sugge ste d e sopha ge a l pla ce me nt. Misle a ding re sults ha ve
be e n note d in pa tie nts with morbid obe sity, la te pre gna ncy, sta tus
a sthma ticus, a nd copious e ndotra che a l se cre tion, whe re in the
tra che a te nds to colla pse . Its use in childre n younge r tha n 1 ye a r of
a ge ha s shown poor se nsitivity a nd poor spe cificity. Although a
ca rdia c output is ne e de d to ge t CO2 to the lungs for a CO2 ga s
a na lyze r to function, a ca rdia c output is not ne e de d for a n EDD
(Miller: Miller’s Anesth esia, ed 8, p 1654).
65. (D) The ca pnome te r me a sure s the CO2 conce ntra tion of
re spira tory ga se s. Toda y this is most commonly pe rforme d by
infra re d a bsorption using a side stre a m ga s sa mple . The sa mpling
tube should be conne cte d a s close a s possible to the pa tie nt’s
a irwa y. The diffe re nce be twe e n the e nd-tida l CO2 (ETCO2) a nd the
a rte ria l CO2 (Pa CO2) is typica lly 5 to 10 mm Hg a nd is due to
a lve ola r de a d spa ce ve ntila tion. Be ca use nonpe rfuse d a lve oli do
not contribute to ga s e xcha nge , a ny condition tha t incre a se s
a lve ola r de a d spa ce ve ntila tion (i.e ., re duce s pulmona ry blood
flow, a s by pulmona ry e mbolism or ca rdia c a rre st) will incre a se
de a d spa ce ve ntila tion a nd the ETCO2-to-Pa CO2 diffe re nce .
Conditions tha t incre a se pulmona ry shunt re sult in minima l
cha nge s in the Pa CO2–ETCO2 gra die nt. CO2 diffuse s ra pidly a cross
the ca pilla ry-a lve ola r me mbra ne (Barash : Clinical Anesth esia, ed 7, pp
704–706; Miller: Miller’s Anesth esia, ed 8, pp 1551–1553).
66. (D) The la st ga s a dde d to a ga s mixture should a lwa ys be O2.
This a rra nge me nt is the sa fe st be ca use it e nsure s tha t le a ks
proxima l to the O2 inflow ca nnot re sult in the de live ry of a hypoxic
ga s mixture to the pa tie nt. W ith this a rra nge me nt (O2 a dde d la st),
le a ks dista l to the O2 inflow will re sult in a de cre a se d volume of
ga s, but the F I o 2 of a ne sthe sia will not be re duce d (Miller: Basics of
Anesth esia, ed 6, pp 201–202; Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 43–45).
67. (C) Most mode rn Da te x-Ohme da Te c or North Ame rica n Drä ge r
Va por va porize rs (e xce pt de sflura ne ) a re va ria ble -bypa ss, flow-ove r
va porize rs. This me a ns tha t the ga s tha t flows through the
va porize rs is split into two pa rts, de pe nding on the conce ntra tion
se le cte d. The ga s goe s through e ithe r the bypa ss cha mbe r on the
top of the va porize r or the va porizing cha mbe r on the bottom of the
va porize r. If the va porize r is tippe d, which might ha ppe n whe n a
fille d va porize r is switche d out or move d from one ma chine to
a nothe r ma chine , pa rt of the a ne sthe tic liquid in the va porizing
cha mbe r ma y ge t into the bypa ss cha mbe r. This could re sult in a
much highe r conce ntra tion of ga s tha n tha t dia le d. W ith the Da te x-
Ohme da Te c 4 or the North Ame rica n Drä ge r Va por 19.1 se rie s, it is
re comme nde d to flush the va porize r a t high flows with the
va porize r se t a t a low conce ntra tion until the output shows no
e xce ssive a ge nt (this usua lly ta ke s 20-30 minute s). The Drä ge r
Va por 2000 se rie s ha s a tra nsport (T) dia l se tting. This se tting
isola te s the bypa ss from the va porize r cha mbe r. The Ala din
ca sse tte va porize r doe s not ha ve a bypa ss flow cha mbe r a nd ha s
no tipping ha za rd (Miller: Miller’s Anesth esia, ed 8, p 771).
68. (A) Accura te de live ry of vola tile a ne sthe tic conce ntra tion is
de pe nde nt on filling the a ge nt-spe cific va porize r with the
a ppropria te (vola tile ) a ge nt. Diffe re nce s in a ne sthe tic pote ncie s
furthe r ne ce ssita te this re quire me nt. Ea ch a ge nt-spe cific va porize r
use s a splitting ra tio tha t de te rmine s the portion of the fre sh ga s
tha t is dire cte d through the va porizing cha mbe r ve rsus tha t which
tra ve ls through the bypa ss cha mbe r.
VAPOR PRESSURE, ANESTHETIC VAPOR PRESSURE, AND
SPLITTING RATIO

BP, blood pressure; VP, vapor pressure.

The ta ble shows the ca lcula tion (fra ction) tha t whe n multiplie d
by the qua ntity of fre sh ga s tra ve rsing the va porizing cha mbe r
(a fflue nt fre sh ga s in mL/min) will yie ld the output (mL/min) of
a ne sthe tic va por in the e fflue nt ga s. W he n this fra ction is
multiplie d by 100, it e qua ls the splitting ra tio for 1% for the give n
vola tile a ge nt. For e xa mple , whe n the isoflura ne va porize r is se t
to de live r 1% isoflura ne , one pa rt of fre sh ga s is pa sse d through
the va porizing cha mbe r while 47 pa rts tra ve l through the bypa ss
cha mbe r. One ca n de te rmine on inspe ction tha t whe n a le ss
soluble vola tile a ge nt like se voflura ne (or the obsole te vola tile
a ge nt e nflura ne , for the sa ke of e xa mple ) is pla ce d into a n
isoflura ne (or ha lotha ne ) va porize r, the output in volume pe rce nt
will be le ss tha n e xpe cte d; how much le ss ca n be de te rmine d by
simply compa ring the ir splitting ra tios 27/47 or 0.6. Ha lotha ne a nd
e nflura ne a re no longe r use d in the Unite d Sta te s, but old
ha lotha ne a nd e nflura ne va porize rs ca n be (a nd a re ) use d
e lse whe re in the world to a ccura te ly de live r isoflura ne a nd
se voflura ne , re spe ctive ly (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 72–73).
69. (C) Two pe rce nt of 4 L/min will be 80 mL of isoflura ne pe r
minute .
VAPOR PRESSURE PER MILLILITER OF LIQUID

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


va por a nd by a pplying the ca lcula tion (195 mL va por/1 mL liquid
isoflura ne ) × (150 mL isoflura ne liquid) = 29,250 mL isoflura ne
va por, it follows tha t (29,250 mL ÷ 80 mL/min = 365 minute s). Thre e
hundre d sixty-five minute s is a round 6 hours (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 65–70).
70. (C) The huma n e a r ca n pe rce ive sound in the ra nge of 20 Hz to
20 kHz. Fre que ncie s a bove 20 kHz, ina udible to huma ns, a re
ultra sonic fre que ncie s (ultra = La tin for “be yond” or “on the fa r side
of”). In re giona l a ne sthe sia , ultra sound is use d for ima ging in the
fre que ncy ra nge of 2.5 to 10 MHz. Wa ve le ngth is inve rse ly
proportiona l to fre que ncy (i.e ., λ = C/f [λ = wa ve le ngth, C = ve locity
of sound through tissue or 1540 m/se c, f = fre que ncy]). Wa ve le ngth
in millime te rs ca n be ca lcula te d by dividing 1.54 by the Dopple r
fre que ncy in me ga he rtz. Pe ne tra tion into tissue is 200 to 400 time s
wa ve le ngth, a nd re solution is twice the wa ve le ngth. The re fore , a
fre que ncy of 3 MHz (wa ve le ngth 0.51 mm) would ha ve a re solution
of 1 mm a nd a pe ne tra tion of up to 100 to 200 mm (10-20 cm),
whe re a s 10 MHz (wa ve le ngth 0.15 mm) corre sponds to a re solution
of 0.3 mm but a pe ne tra tion de pth of no more tha n 60 to 120 mm (6-
12 cm) (Miller: Miller’s Anesth esia, ed 8, pp 1398–1405; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 979).
71. (A) Microsh ock re fe rs to e le ctric shock loca te d in or ne a r the
he a rt. A curre nt a s low a s 100 µA pa ssing through the he a rt ca n
produce ve ntricula r fibrilla tion. Pa ce ma ke r e le ctrode s, ce ntra l
ve nous ca the te rs, pulmona ry a rte ry ca the te rs, a nd othe r de vice s in
the he a rt a re ne ce ssa ry pre re quisite s for microshock. Be ca use the
line isola tion monitor ha s a thre shold of 2 mA (2000 µA) for
a la rming, it will not prote ct a ga inst microshock (Miller: Miller’s
Anesth esia, ed 8, p 3226).
72. (D) Intra ope ra tive a wa re ne ss or re ca ll during ge ne ra l
a ne sthe sia is ra re (ove ra ll incide nce is 0.2%, for obste trics 0.4%, for
ca rdia c 1%-1.5%) e xce pt for ma jor tra uma , which ha s a re porte d
incide nce a s high a s 43%. W ith the e le ctroe nce pha logra m, tre nds
ca n be ide ntifie d with cha nge s in the de pth of a ne sthe sia ; howe ve r,
the se nsitivity a nd spe cificity of the a va ila ble tre nds a re such tha t
none se rve a s a sole indica tor of a ne sthe sia de pth. Although using
the bispe ctra l inde x monitor ma y re duce the risk of re ca ll, it, like
the othe r liste d signs a s we ll a s pa tie nt move me nt, doe s not tota lly
e limina te re ca ll (Miller: Miller’s Anesth esia, ed 8, pp 1527–1528).
73. (D) The minute ve ntila tion is 5 L (0.5 L pe r bre a th a t
10 bre a ths/min) a nd 2 L/min to drive the ve ntila tor for a tota l O2
consumption of 7 L/min. A full oxyge n “E” cylinde r conta ins 625 L.
Nine ty pe rce nt of the volume of the cylinde r (≈560 L) ca n be
de live re d be fore the ve ntila tor ca n no longe r be drive n. At a ra te of
7 L/min, this supply would la st a bout 80 minute s (Miller: Basics of
Anesth esia, ed 6, pp 201, 209; Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, pp 29–33, 37; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 10–11).
74. (C) Afte r e limina ting re ve rsible ca use s of high pe a k a irwa y
pre ssure s (e .g., occlusion of the e ndotra che a l tube , ma inste m
intuba tion, or bronchospa sm), a djusting the ve ntila tor ca n re duce
the pe a k a irwa y pre ssure . Incre a sing the inspira tory flow ra te
would ca use the a irwa y pre ssure s to go up fa ste r a nd would
produce highe r pe a k a irwa y pre ssure s. Re moving PEEP would
lowe r pe a k pre ssure a t the e xpe nse of a lve ola r ve ntila tion.
Cha nging the I:E ra tio from 1:3 to 1:2 will pe rmit 8% (25% inspira tory
time to 33% inspira tory time ) more time for the VT to be
a dministe re d a nd will re sult in lowe r a irwa y pre ssure s.
De cre a sing the VT to 300 a nd incre a sing the ra te to 28 would give
the sa me minute ve ntila tion but not the sa me a lve ola r ve ntila tion.
Re ca ll tha t a lve ola r ve ntila tion e qua ls (fre que ncy) time s (VT minus
de a d spa ce ), a nd be ca use de a d spa ce is the sa me (a bout 2 mL/kg
ide a l we ight), a lve ola r ve ntila tion would be re duce d, in this ca se to
a da nge rously low le ve l. Anothe r option is to cha nge from volume -
cycle d to pre ssure -cycle d ve ntila tion, which produce s a more
consta nt pre ssure ove r time inste a d of the pe a ke d pre ssure s se e n
with fixe d VT ve ntila tion (Barash : Clinical Anesth esia, ed 7, pp 1593–
1596; Miller: Miller’s Anesth esia, ed 8, pp 3064–3074).
75. (D) The ce ntra l hospita l oxyge n supply to the ORs is de signe d to
give e nough pre ssure a nd oxyge n flow to run the thre e oxyge n
compone nts of the a ne sthe sia ma chine (pa tie nt fre sh ga s flow,
a ne sthe sia ve ntila tor, a nd oxyge n flush va lve ). The oxyge n
flowme te r on the a ne sthe sia ma chine is de signe d to run a t a n
oxyge n pre ssure of 50 psi, a nd for e me rge ncy purpose s the oxyge n
flush va lve de live rs oxyge n a t 35 to 75 L/min (Miller: Basics of
Anesth esia, ed 6, pp 199–201).
76. (B) W ithin the re spira tory syste m, both la mina r a nd turbule nt
flows e xist. At low flow ra te s, the re spira tory flow te nds to be
la mina r, like a se rie s of conce ntric tube s tha t slide ove r one
a nothe r with the ce nte r tube s flowing fa ste r tha n the more
pe riphe ra l tube s. La mina r flow is usua lly ina udible a nd is
de pe nde nt on ga s viscosity. Turbule nt flow te nds to be fa ste r, is
a udible , a nd is de pe nde nt on ga s de nsity. Ga s de nsity ca n be
de cre a se d by using a mixture of he lium with oxyge n (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 54–56).
77. (B) Ane sthe sia worksta tions ha ve high-pre ssure , inte rme dia te -
pre ssure , a nd low-pre ssure circuits (se e figure in the e xpla na tion
for Que stion 12). The high-pre ssure circuit is from the oxyge n
cylinde r to the oxyge n pre ssure re gula tor (first-sta ge re gula tor),
which ta ke s the oxyge n pre ssure from a high of 2200 psi to 45 psi.
The inte rme dia te -pre ssure circuit consists of the pipe line pre ssure
of a bout 50 to 55 psi a nd goe s to the se cond-sta ge re gula tor, which
the n lowe rs the pre ssure to 14 to 26 psi (de pe nding on the
ma chine ). The low-pre ssure circuit the n consists of the flow tube s,
va porize r ma nifold, va porize rs, a nd va porize r che ck va lve to the
common ga s outle t. The oxyge n flush va lve is in the inte rme dia te -
pre ssure circuit a nd bypa sse s the low-pre ssure circuit (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, pp 34–36;
Miller: Basics of Anesth esia, ed 6, p 200).
78. (C) Two ma jor proble ms should be note d in this ca se . The first
obvious proble m is the inspire d oxyge n conce ntra tion of 4%, a
conce ntra tion tha t is not possible if the ga se s going to the ma chine
a re a ppropria te unle ss the oxyge n a na lyze r is fa ulty. Give n the dire
conse que nce s of a hypoxic ga s mixture , one must a ssume the
oxyge n a na lyze r is corre ct a nd work on the pre mise tha t the O2
pipe line is supplying a ga s othe r tha n oxyge n. Se cond, the oxyge n
line pre ssure is 65 psi. The pipe line pre ssure s a re norma lly a round
50 to 55 psi, whe re a s the pre ssure from the oxyge n cylinde r, if the
cylinde r is turne d on, is re duce d to 45 psi. For the oxyge n ta nk to
de live r oxyge n to the pa tie nt, the pipe line pre ssure ne e ds to be
le ss tha n 45 psi, which in this ca se will occur only whe n the
pipe line is disconne cte d. Although we ra re ly think of proble ms
with hospita l ga s line s, a surve y of more tha n 200 hospita ls showe d
a bout 33% ha d proble ms with the pipe line s. The most common
pipe line proble ms we re low pre ssure , followe d by high pre ssure
a nd, ve ry ra re ly, crosse d ga s line s (Eh renwerth : Anesth esia Eq uipm ent:
Principles and Applications, ed 2, p 34; Miller: Miller’s Anesth esia, ed 8, p
756).
79. (D) The re a re ma ny wa ys to monitor the e le ctric a ctivity of the
he a rt. The five -e le ctrode syste m using one le a d for e a ch limb a nd
the fifth le a d for the pre cordium is commonly use d in the OR. The
pre cordia l le a d pla ce d in the V5 position (a nte rior a xilla ry line in
the fifth inte rcosta l spa ce ) give s the V5 tra cing, which, combine d
with the sta nda rd le a d II, a re the most common tra cings use d to
look for myoca rdia l ische mia (Miller: Miller’s Anesth esia, ed 8, pp
1429–1434).
80. (A) Se e a lso Que stion 36. The dia me te r inde x sa fe ty syste m
provide s thre a de d, noninte rcha nge a ble conne ctions for me dica l
ga s pipe line s through the hospita l a s we ll a s to the a ne sthe sia
ma chine . The pin inde x sa fe ty syste m ha s two me ta l pins in
diffe re nt a rra nge me nts a round the yoke on the ba ck of a ne sthe sia
ma chine s, with e a ch a rra nge me nt for a spe cific ga s cylinde r.
Va porize rs ofte n ha ve ke ye d fille rs tha t a tta ch to the bottle of
a ne sthe tic a nd the va porize r. Va porize rs not e quippe d with ke ye d
fille rs occa siona lly ha ve be e n misfille d with the wrong a ne sthe tic
liquid (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
49–50).
81. (C) Ca lcium hydroxide lime doe s not conta in the monova le nt
hydroxide ba se s tha t a re pre se nt in soda lime (na me ly, Na OH a nd
KOH). Se voflura ne in the pre se nce of Na OH or KOH is de gra de d to
tra ce a mounts of compound A, which is ne phrotoxic to ra ts a t high
conce ntra tions. Soda lime norma lly conta ins a bout 13% to 15%
wa te r, but if the soda lime is de sicca te d (wa te r conte nt <5%—which
ha s occurre d if the ma chine is not use d for a while a nd the fre sh
ga s flow is le ft on) a nd is e xpose d to curre nt vola tile a ne sthe tics
(isoflura ne , se voflura ne , a nd e spe cia lly de sflura ne ), CO ca n be
produce d. Ne ithe r compound A nor CO is forme d whe n ca lcium
hydroxide lime is use d. W ith soda lime a nd ca lcium hydroxide
lime , the indica tor dye cha nge s from white to purple a s the
gra nule s be come e xha uste d. The two ma jor disa dva nta ge s of
ca lcium hydroxide lime a re the e xpe nse a nd the fa ct tha t its
a bsorptive ca pa city is a bout ha lf tha t of soda lime (10.2 L of
CO2/100 g of ca lcium hydroxide lime ve rsus 26 L of CO2/100 g of
soda lime ) (Miller: Miller’s Anesth esia, ed 8, pp 787–789; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 36–38; Miller: Basics
of Anesth esia, ed 6, pp 212–214).
82. (B) The a im of dire ct inva sive monitoring is to give continuous
a rte ria l BPs tha t a re simila r to the inte rmitte nt noninva sive a rte ria l
BPs from a cuff, a s we ll a s to give a port for a rte ria l blood sa mple s.
The displa ye d signa l re fle cts the a ctua l pre ssure a nd the
distortions from the me a suring syste m (i.e ., the ca the te r, tubing,
stopcocks, a nd a mplifie r). Although the signa l is usua lly a ccura te ,
a t time s we se e a n unde rda mpe d or a n ove rda mpe d signa l. In a n
unde rda mpe d signa l, a s in this ca se , e xa gge ra te d re a dings a re
note d (wide ne d pulse pre ssure ). In a n ove rda mpe d signa l, re a dings
a re diminishe d (na rrowe d pulse pre ssure ). Howe ve r, the me a n BP
te nds to be a ccura te in both unde rda mpe d a nd ove rda mpe d signa ls
(Miller: Miller’s Anesth esia, ed 8, pp 1347–1359).
83. (D) Re bre a thing of e xpire d ga se s (e .g., stuck ope n e xpira tory or
inspira tory va lve s), fa ulty re mova l of CO2 from the CO2 a bsorbe r
(e .g., e xha uste d CO2 a bsorbe r, cha nne ling through a CO2 a bsorbe r,
or ha ving the CO2 a bsorbe r bypa sse d—a n option in some olde r
a ne sthe tic ma chine s), or a ddition of CO2 from a ga s supply (ra re ly
done with curre nt a ne sthe tic ma chine s) ca n a ll incre a se inspire d
CO2. The a bsorption of CO2 during la pa roscopic surge ry whe n CO2
is use d a s the a bdomina l diste nding ga s will incre a se a bsorption of
CO2 but will not ca use a n incre a se in inspire d CO2 (Miller: Miller’s
Anesth esia, ed 8, pp 1551–1559; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, p 42).
84. (B)
85. (A)
86. (D)
Me dica l ga s cylinde rs a re color code d, but the colors ma y diffe r
from one country to a nothe r. In the Unite d Sta te s, if the re is a
combina tion of two ga se s, the ta nk would ha ve both
corre sponding colors; for e xa mple , a ta nk conta ining oxyge n a nd
he lium would be gre e n a nd brown. The only e xce ption to the
mixe d ga s color sche me is O2 a nd N2 in the proportion of 19.5% to
23.5% O2 mixe d with N2, which is solid ye llow (a ir) (Eh renwerth :
Anesth esia Eq uipm ent: Principles and Applications, ed 2, p 7).
GAS COLOR CODES

Gas United States International


Air Yellow White and black
CO2 Gray Gray
Helium Brown Brown
Nitrogen Black Black
N 2O Blue Blue
Oxygen Green White
Data from Ehrenwerth J, Eisenkraft JB, Berry JM: Anesthesia Equipment: Principles and
Applications, ed 2, Philadelphia, Saunders, 2013.

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

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


or incomple te sta te me nts in this se ction is followe d by
a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
Se le ct the ONE BEST a nswe r or comple tion for e a ch ite m.

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


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

A. Sponta ne ous ve ntila tion


B. Controlle d ve ntila tion
C. Assiste d ve ntila tion
D. Assiste d/controlle d ve ntila tion
118. A 35-ye a r-old morbidly obe se pa tie nt is discha rge d a fte r ga stric
bypa ss surge ry. She is re a dmitte d 4 da ys la te r a fte r she fa lls a nd
twists he r a nkle . She is note d in the e me rge ncy room (ER) to be in
a tria l fibrilla tion a nd is hypote nsive but only compla ins of le g pa in.
She is a dmitte d to the hospita l, a nd te mpe ra ture on a dmission is
38.6° C a nd he a rt ra te is 105 be a ts/min. The ne xt ste p in
ma na ge me nt of he r dysrhythmia should be
A. Ibutilide
B. Proca ina mide
C. Echoca rdiogra phic study
D. DC ca rdiove rsion
119. The P 50 of sickle ce ll he moglobin is
A. 19 mm Hg
B. 26 mm Hg
C. 31 mm Hg
D. 35 mm Hg
120. Da ta from the ARDS ne twork tria l (ARDSNe t) showe d
incre a se d morta lity from
A. Ate le ctra uma
B. Volutra uma
C. Ba rotra uma
D. Inha le d nitric oxide
121. W hich of the following is the corre ct ma the ma tica l e xpre ssion
of Fick’s la w of diffusion of a ga s through a lipid me mbra ne ( =
ra te of diffusion, D = diffusion coe fficie nt of the ga s, A = a re a of the
me mbra ne , P1 − P2 = tra nsme mbra ne pa rtia l pre ssure gra die nt of
the ga s, T = thickne ss of the me mbra ne )?
A.
B.

C.

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

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


conve rsion of oxyhe moglobin (Fe ++) to me the moglobin (Fe +++). The
pre se nce of sufficie nt qua ntitie s of me the moglobin in the blood will
ca use the pulse oxime te r to re a d 85% sa tura tion re ga rdle ss of the
true a rte ria l sa tura tion. Cya nide toxicity is a lso a possibility in a ny
pa tie nt who is re ce iving nitroprusside . Cya nide toxicity should be
suspe cte d whe n the pa tie nt de ve lops me ta bolic a cidosis or
be come s re sista nt to the hypote nsive e ffe cts of this drug de spite a
sufficie nt infusion ra te . This ca n be confirme d by me a suring the
mixe d ve nous Pa O2, which would be e le va te d in the pre se nce of
cya nide toxicity. Thiocya na te toxicity is a lso a pote ntia l ha za rd of
nitroprusside a dministra tion in pa tie nts with re na l fa ilure . Pa tie nts
suffe ring from thiocya na te toxicity displa y na use a , me nta l
confusion, a nd ske le ta l-muscle we a kne ss (Miller: Miller’s Anesth esia,
ed 8, pp 1545, 2228; Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 782–783).
93. (D) (Ple a se se e dia gra m a nd ta ble for e xpla na tion with
Que stion 102.) FRC is compose d of e xpira tory re se rve volume plus
re sidua l volume . It is e sse ntia l to ma ximize FRC in the
postope ra tive pe riod to e nsure tha t it will be gre a te r tha n closing
volume . Closing volume is tha t lung volume a t which sma ll-a irwa y
closure be gins to occur. Ma ximizing FRC, the re fore , re duce s
a te le cta sis a nd le sse ns the incide nce of a rte ria l hypoxe mia a nd
pne umonia . Ma ne uve rs a ime d a t incre a sing FRC include e a rly
a mbula tion, ince ntive spirome try, de e p bre a thing, a nd inte rmitte nt
positive -pre ssure bre a thing (Barash : Clinical Anesth esia, ed 7, p 279).
94. (C)

whe re PVR is the pulmona ry va scula r re sista nce , PAP mean is the
me a n pulmona ry a rte ry pre ssure , PAOP is the me a n pulmona ry
ca pilla ry occlusion pre ssure , a nd CO is the ca rdia c output.
The norma l ra nge for PVR is 50 to 150 dyne -se c/cm5 (Miller: Miller’s
Anesth esia, ed 8, pp 1460–1461).
95. (D) For re a sons tha t a re not fully unde rstood, pa tie nts who ha ve
susta ine d a myoca rdia l infa rction a nd subse que ntly unde rgo
surge ry a re most like ly to ha ve a nothe r infa rction on the third
postope ra tive da y (Miller: Basics of Anesth esia, ed 6, p 385).
96. (B) Ca lcula tion of BMI for a dults (>20 ye a rs of a ge ) ca n he lp
ide ntify pa tie nts who a re unde rwe ight (BMI <18.5), norma l we ight
(BMI 18.5-24.9), ove rwe ight (BMI 25-29.9), cla ss 1 obe sity (BMI 30-
34.9), cla ss 2 obe sity (BMI 35-39.9), cla ss 3 obe sity (BMI 40-49.9), a nd
the supe robe se (BMI >50).

All ma jor orga n syste ms a re a ffe cte d a s a conse que nce of obe sity.
The gre a te st conce rns for the a ne sthe siologist a re , howe ve r,
re la te d to the he a rt a nd lungs. Ca rdia c output must incre a se
a bout 0.1 L/min for e a ch e xtra kilogra m of a dipose tissue . As a
conse que nce , obe se pa tie nts fre que ntly a re hype rte nsive , a nd
ma ny ultima te ly de ve lop ca rdiome ga ly a nd le ft-side d he a rt
fa ilure . FRC is re duce d in obe se pa tie nts, a nd ma na ge me nt of
the a irwa y ofte n ca n be difficult (Miller: Miller’s Anesth esia, ed 8, pp
2200–2201).
97. (B) The force d e xpira tory volume in 1 se cond (FEV1) is the tota l
volume of a ir tha t ca n be e xha le d in the first se cond. Norma l
he a lthy a dults ca n e xha le a pproxima te ly 75% to 85% of the ir force d
vita l ca pa city (FVC) in the first se cond, 94% in 2 se conds, a nd 97% in
3 se conds. The re fore , the norma l FEV1/FVC ra tio is 0.75 or highe r.
In the pre se nce of obstructive a irwa y dise a se , the FEV1/FVC ra tio
le ss tha n 70% re fle cts mild obstruction, le ss tha n 60% mode ra te
obstruction, a nd le ss tha n 50% se ve re obstruction. This ra tio ca n be
use d to de te rmine the se ve rity of obstructive a irwa y dise a se a nd to
monitor the e ffica cy of bronchodila tor the ra py (Barash : Clinical
Anesth esia, ed 7, p 279).
98. (C) MAT is a non-re e ntra nt, e ctopic a tria l rhythm ofte n se e n in
pa tie nts with chronic obstructive pulmona ry dise a se (COPD). It is
fre que ntly confuse d with a tria l fibrilla tion but, in contra st to a tria l
fibrilla tion, a tria l flutte r, a nd pa roxysma l supra ve ntricula r
ta chyca rdia , DC ca rdiove rsion is ine ffe ctive in conve rting it to
norma l sinus rhythm. Ectopic a tria l ta chydysrhythmia s a re not
a me na ble to ca rdiove rsion be ca use the y la ck the re -e ntra nt
me cha nism, which is ne ce ssa ry for succe ssful te rmina tion with
e le ctrica l counte r shock (Miller: Miller’s Anesth esia, ed 8, pp 3191–
3193).
99. (C) During a pne a , the Pa CO2 will incre a se a pproxima te ly
6 mm Hg during the first minute a nd the n 3 to 4 mm Hg e a ch minute
the re a fte r (Miller: Basics of Anesth esia, ed 6, p 61).
100. (A) TPN the ra py is a ssocia te d with nume rous pote ntia l
complica tions. Blood suga rs ne e d to be ca re fully monitore d
be ca use hype rglyce mia ma y de ve lop due to the high glucose loa d
a nd re quire tre a tme nt with insulin, a nd hypoglyce mia ma y de ve lop
if TPN is a bruptly stoppe d (i.e ., infusion turne d off or me cha nica l
obstruction in the IV tubing). Othe r complica tions include
e le ctrolyte disturba nce s (e .g., hypoka le mia , hypophospha te mia ,
hypoma gne se mia , hypoca lce mia ), volume ove rloa d, ca the te r-
re la te d se psis, re na l a nd he pa tic dysfunction, thrombosis of the
ce ntra l ve ins, a nd nonke totic hype rosmola r coma . Incre a se d work
of bre a thing is re la te d to incre a se d production of CO2 most
fre que ntly due to ove rfe e ding. Acidosis in the se pa tie nts is
hype rchlore mic me ta bolic a cidosis re sulting from forma tion of HCl
during me ta bolism of a mino a cids. Ke toa cidosis is not a ssocia te d
with TPN the ra py (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 331).
101. (B) The O2 re quire me nt for a n a dult is 3 to 4 mL/kg/min. The O2
re quire me nt for a ne wborn is 7 to 9 mL/kg/min. Alve ola r ve ntila tion
(VA) in ne ona te s is double tha t of a dults to he lp me e t the ir
incre a se d O2 re quire me nts. This incre a se in VA is a chie ve d
prima rily by a n incre a se in re spira tory ra te a s VT is simila r to tha t
of a dults (i.e ., 7 mL/kg). Although CO2 production a lso is incre a se d
in ne ona te s, the e le va te d VA ma inta ins the Pa CO2 ne a r 38 to
40 mm Hg (Barash : Clinical Anesth esia, ed 7, pp 1181–1182).
102. (A) A compre he nsive unde rsta nding of re spira tory physiology is
importa nt for unde rsta nding the e ffe cts of both re giona l a nd ge ne ra l
a ne sthe sia on re spira tory me cha nics a nd pulmona ry ga s e xcha nge .
The volume of ga s re ma ining in the lungs a fte r a norma l e xpira tion
is ca lle d the functiona l re sidua l ca pa city. The volume of ga s
re ma ining in the lungs a fte r a ma xima l e xpira tion is ca lle d the
re sidua l volume . The diffe re nce be twe e n the se two volume s is
ca lle d the e xpira tory re se rve volume . The re fore , the FRC is
compose d of the e xpira tory re se rve volume a nd re sidua l volume
(Barash : Clinical Anesth esia, ed 7, pp 278–279; Stoelting: Ph arm acology
and Ph y siology in Anesth etic Practice, ed 4, pp 776–777).
LUNG VOLUMES AND CAPACITIES

Measurement Abbreviation Normal Adult Value


Tidal volume VT 500 mL (6-8 mL/kg)
Inspiratory reserve volume IRV 3000 mL
Expiratory reserve volume ERV 1200 mL
Residual volume RV 1200 mL
Inspiratory capacity IC 3500 mL
Functional residual capacity FRC 2400 mL
Vital capacity VC 4500 mL (60-70 mL/kg)
Forced exhaled volume in 1 sec FEV1 80%
Total lung capacity TLC 5900 mL

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


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

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


a nd mixe d e xpire d, re spe ctive ly. Of the choice s give n, only the
first is corre ct. A la rge incre a se in VD will re sult in a n incre a se in
Pa CO2 (Barash : Clinical Anesth esia, ed 7, pp 275–277; West:
Respiratory Ph y siology, ed 9, pp 19–21; Miller: Miller’s Anesth esia, ed
8, pp 446–447).
104. (C) The oxyge n conte nt of blood ca n be ca lcula te d with the
following formula :
The diffe re nce in the oxyge n conte nt is 0.09 mL/dL. This re pre se nts
a cha nge of 0.42% (Miller: Basics of Anesth esia, ed 6, p 57).
105. (B) The de gre e of ve ntila tory de pre ssion ca use d by vola tile
a ne sthe tics ca n be a sse sse d by me a suring re sting Pa CO2, the
ve ntila tory re sponse to hype rca rbia , a nd the ve ntila tory re sponse to
hypoxe mia . Of the se te chnique s, the re sting Pa CO2 is the most
fre que ntly use d inde x. Howe ve r, me a suring the e ffe cts of incre a se d
Pa CO2 on ve ntila tion is the most se nsitive me thod of qua ntifying the
e ffe cts of drugs on ve ntila tion. In a wa ke una ne sthe tize d huma ns,
inha la tion of CO2 incre a se s minute ve ntila tion ( ) by
a pproxima te ly 2 to 3 L/min/mm Hg incre a se in Pa CO2. Using this
te chnique , ha lotha ne , isoflura ne , de sflura ne -O2, de sflura ne -N2O,
a nd N2O ca use a dose -de pe nde nt de pre ssion of the ve ntila tion
(Miller: Basics of Anesth esia, ed 6, pp 93–94).
106. (B) (Se e a lso e xpla na tion to Que stion 104.) The a mount of O2 in
blood (O2 conte nt) is the sum of the a mount of O2 dissolve d in
pla sma a nd the a mount of O2 combine d with he moglobin. The
a mount of O2 dissolve d in pla sma is dire ctly proportiona l to the
product of the blood/ga s solubility coe fficie nt of O2 (0.003) a nd Pa O2.
The a mount of O2 bound to he moglobin is dire ctly re la te d to the
fra ction of he moglobin tha t is sa tura te d. One gra m of he moglobin
ca n bind 1.39 mL of O2. The ma the ma tica l e xpre ssion of O2 conte nt
is a s follows:

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


fra ction of he moglobin sa tura te d with O2, a nd (0.003 × Pa o 2) is the
a mount of O2 dissolve d in pla sma . In this ca se
(1.39 × 10 × 0.9) + (0.003 × 60) = 12.51 + 0.18 = 12.69 or a pproxima te ly
13 mL/dL (Miller: Basics of Anesth esia, ed 6, p 57).
107. (C) The pre se nce of he moglobin spe cie s othe r tha n
oxyhe moglobin ca n ca use e rrone ous re a dings by dua l-wa ve le ngth
pulse oxime te rs. He moglobin spe cie s such a s ca rboxyhe moglobin
a nd me the moglobin, dye s such a s me thyle ne blue a nd indocya nine
gre e n, a nd some colors of na il polish will ca use e rrone ous
re a dings. Be ca use the a bsorption spe ctrum of fe ta l he moglobin is
simila r to tha t of a dult oxyhe moglobin, fe ta l he moglobin doe s not
significa ntly a ffe ct the a ccura cy of the se type s of pulse oxime te rs.
High le ve ls of bilirubin ha ve no significa nt e ffe ct on the a ccura cy of
dua l-wa ve le ngth pulse oxime te rs but ma y ca use fa lse ly low
re a dings by nonpulsa tile oxime te rs (Miller: Miller’s Anesth esia, ed 8,
pp 1545–1547).
108. (D) This gra ph de picts lung volume s a s a function of pre ssure
or complia nce ; one kPa is roughly e qua l to 10 cm H2O. Curve A
shows a n e normous volume with a sma ll pre ssure (i.e .,
e mphyse ma ). Curve B de picts chronic bronchitis or a sthma . The
complia nce curve is roughly the sa me a s the norma l lung, curve C,
but volume s ha ve incre a se d. Curve D de picts stiff noncomplia nt
lungs a s se e n with fibrosis or ARDS (Miller: Miller’s Anesth esia, ed 8,
pp 447–448).
109. (B) P 50 is the Pa O2 re quire d to produce 50% sa tura tion of
he moglobin. The P 50 for a dult he moglobin a t a pH of 7.4 a nd body
te mpe ra ture of 37° C is 26 mm Hg (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 788–789; Miller: Basics of
Anesth esia, ed 6, p 56).
110. (D) The work of bre a thing is de fine d a s the product of
tra nspulmona ry pre ssure a nd VT. The work of bre a thing is re la te d
to two fa ctors: the work re quire d to ove rcome the e la stic force s of
the lungs, a nd the work re quire d to ove rcome a irflow or frictiona l
re sista nce s of the a irwa ys (Barash : Clinical Anesth esia, ed 7, pp 266–
268; Miller: Miller’s Anesth esia, ed 8, p 1563).
111. (D) The norma l mixe d ve nous O2 sa tura tion is 75%. Physiologic
fa ctors tha t a ffe ct mixe d ve nous O2 sa tura tion include he moglobin
conce ntra tion, a rte ria l Pa O2, ca rdia c output, a nd O2 consumption.
Ane mia , hypoxia , de cre a se d ca rdia c output, a nd incre a se d O2
consumption de cre a se mixe d ve nous O2 sa tura tion. During se psis
with a de qua te volume re suscita tion, the ca rdia c output is
incre a se d a nd ma ldistribution of pe rfusion (distributive shock)
re sults in a n e le va te d mixe d-ve nous O2 sa tura tion. Mixe d ve nous
O2 sa tura tion ( ) is re la te d to a numbe r of fa ctors, a s shown in
this e qua tion:

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


combining powe r of Hgb [mL/10 g]), is ca rdia c output, a nd
is the oxyge n consumption (Miller: Miller’s Anesth esia, ed 8, pp
1386–1387).
112. (C) The volume of ga s e xha le d during a ma ximum e xpira tion is
the vita l ca pa city. In a norma l he a lthy a dult, the vita l ca pa city is 60
to 70 mL/kg. In a 70-kg pa tie nt, the vita l ca pa city is a pproxima te ly
5 L (Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4,
p 776; Barash : Clinical Anesth esia, ed 7, p 278).
113. (C) Ca rbon monoxide inha la tion is the most common
imme dia te ca use of de a th from fire . Ca rbon monoxide binds to
he moglobin with a n a ffinity 200 time s gre a te r tha n tha t of oxyge n.
For this re a son, ve ry sma ll conce ntra tions of ca rbon monoxide ca n
gre a tly re duce the oxyge n-ca rrying ca pa city of blood. In spite of this,
the a rte ria l Pa O2 ofte n is norma l. Be ca use the ca rotid bodie s
re spond to a rte ria l Pa O2, the re would not be a n incre a se in minute
ve ntila tion until tissue hypoxia wa s sufficie nt to produce la ctic
a cidosis (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
554–555; Miller: Miller’s Anesth esia, ed 8, pp 2679–2680; West:
Respiratory Ph y siology, ed 9, pp 80–82).
114. (D) Re spira tory a cidosis is pre se nt whe n the Pa CO2 e xce e ds
44 mm Hg. Re spira tory a cidosis is ca use d by de cre a se d e limina tion
of CO2 by the lungs (i.e ., hypove ntila tion) or incre a se d me ta bolic
production of CO2. An a cute incre a se in Pa CO2 of 10 mm Hg will
re sult in a de cre a se in pH of a pproxima te ly 0.08 pH unit. The
a cidosis of a rte ria l blood will stimula te ve ntila tion via the ca rotid
bodie s, a nd the a cidosis of ce re brospina l fluid will stimula te
ve ntila tion via the me dulla ry che more ce ptors loca te d in the fourth
ce re bra l ve ntricle . Vola tile a ne sthe tics gre a tly a tte nua te the ca rotid
body–me dia te d a nd a ortic body–me dia te d ve ntila tory re sponse s to
a rte ria l a cidosis, but the y ha ve little e ffe ct on the me dulla ry
che more ce ptor–me dia te d ve ntila tory re sponse to ce re brospina l
fluid a cidosis (Miller: Basics of Anesth esia, ed 6, pp 339–340, 343).
115. (C) Dopa mine ca n be infuse d a t low dose s (2-5 µg/kg/min),
mode ra te dose s (5-10 µg/kg/min), or high dose s (10-20 µg/kg/min).
Ma ny fe e l tha t if dopa mine is ne e de d a t ra te s gre a te r tha n
10 µg/kg/min, one should use e pine phrine or nore pine phrine
infusions inste a d. Epine phrine a nd nore pine phrine infusion ra te s
a re commonly sta rte d a t 0.1 to 0.5 µg/kg/min. Although ma ny
ca rdiova scula r drugs a re ba se d on a µg/kg/min dose , va sopre ssin is
not. The sta rting va sopre ssin dose is 0.01 to 0.04 unit/min (Am erican
Heart Association: 2010 Am erican Heart Association Guid elines for
Card iopulm onary Resuscitation and Em ergency Card iovascular Care
Science, pp S774–S775; Kaplan: Card iac Anesth esia, ed 6, pp 1000, 1034–
1035; Miller: Basics of Anesth esia, ed 6, pp 675–676).
116. (D) Re spira tory a lka losis is pre se nt whe n the Pa CO2 is le ss
tha n 36 mm Hg. The re a re thre e compe nsa tory me cha nisms
re sponsible for a tte nua ting the incre a se in pH tha t a ccompa nie s
re spira tory a lka losis. First, the re is a n imme dia te shift in the
e quilibrium of the [HCO3−] buffe r syste m, which re sults in the
production of CO2. Se cond, a lka losis stimula te s the a ctivity of
phosphofructokina se , which incre a se s glycolysis a nd the
production of pyruva te a nd la ctic a cid. Third, the re is a de cre a se in
re a bsorption of [HCO3−] by the proxima l a nd dista l re na l tubule s.
The se thre e compe nsa tory me cha nisms re sult in a ma ximum
de cre a se in [HCO3−] of a pproxima te ly 5 mEq/L for e ve ry 10 mm Hg
de cre a se in Pa CO2 le ss tha n 40 mm Hg (Miller: Basics of Anesth esia,
ed 6, p 340; Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5,
pp 1154–1155).
117. (D) Me cha nica l ve ntila tion of the lungs ca n be a ccomplishe d by
va rious mode s. The se mode s a re ca te gorize d a s controlle d,
a ssiste d, a ssiste d/controlle d, controlle d with positive e nd-
e xpira tory pre ssure (PEEP), a nd a ssiste d/controlle d using
inte rmitte nt ma nda tory ve ntila tion (IMV). Assiste d/controlle d mode s
of me cha nica l ve ntila tion a re use d in pa tie nts whe n the muscle s of
re spira tion re quire re st be ca use minima l bre a thing e fforts a re
re quire d. W ith the a ssiste d/controlle d mode of ve ntila tion, positive -
pre ssure ve ntila tion is trigge re d by sma ll bre a thing e fforts produce d
by the pa tie nt. The a irwa y pre ssure tra cing shown is typica l of tha t
of a pa tie nt re quiring a ssiste d/controlle d ve ntila tion (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 207–208).
118. (C) The first ste p in e va lua ting a ny pa tie nt with a ta chyca rdia is
to de te rmine if the pa tie nt is he modyna mica lly sta ble or unsta ble
(se rious signs or symptoms a re che st pa in or conge stive he a rt
fa ilure due to the ta chyca rdia ). In the unsta ble pa tie nt, DC
ca rdiove rsion should be pe rforme d for ra pid he a rt ra te control
re ga rdle ss of the dura tion of a tria l fibrilla tion. In this ca se , whe re
the pa tie nt is re a sona bly sta ble , the thre e ma jor goa ls in the
ma na ge me nt of a tria l fibrilla tion should be conside re d. The se
goa ls a re control of ve ntricula r ra te , a sse ssme nt of a nticoa gula tion
ne e ds, a nd conve rsion to sinus rhythm. In a ddition, the unde rlying
ca use of a tria l fibrilla tion should be sought a nd tre a te d. Be ca use
this pa tie nt is fe brile a nd ma y be de hydra te d, a n intra ve nous (IV)
line for fluid re suscita tion should be initia te d. Be ca use we do not
know whe n a tria l fibrilla tion de ve lope d (a fte r 48 hours, e mbolic
e ve nts ma y occur with conve rsion to sinus rhythm), it would be
be st not to conve rt the a tria l fibrilla tion to sinus rhythm using e ithe r
ibutilide or proca ina mide until the pa tie nt is a de qua te ly
a nticoa gula te d. Ade qua te a nticoa gula tion should usua lly be
the ra pe utic for a t le a st 3 we e ks. In ma rgina l ca se s whe re the
dura tion of a tria l fibrilla tion is unce rta in, ca rdia c consulta tion a nd
tra nse sopha ge a l e choca rdiogra phy to e xclude a tria l thrombus
should be pe rforme d be fore ca rdiove rsion. This pa tie nt should
unde rgo ca rdia c e choca rdiogra phic study to look for intra -a tria l
thrombus a nd to de te rmine the e je ction fra ction (EF) of the
ve ntricle . Afte r a de qua te hydra tion, ra te control could be improve d
with ca lcium cha nne l blocke rs or β-blocke rs in pa tie nts with
pre se rve d le ft ve ntricula r function (EF > 40%) or with digoxin,
diltia ze m, or a mioda rone if EF is le ss tha n 40% (2010 AHA Guid elines
for CPR and Em ergency Card iovascular Care: Circulation 122 (Suppl 3)
S750–S756).
119. (C) A P 50 le ss tha n 26 mm Hg de fine s a le ftwa rd shift of the
oxyhe moglobin dissocia tion curve . This me a ns tha t a t a ny give n
Pa O2, he moglobin ha s a highe r a ffinity for O2. A P 50 gre a te r tha n
26 mm Hg de scribe s a rightwa rd shift of the oxyhe moglobin
dissocia tion curve . This me a ns tha t a t a ny give n Pa O2, he moglobin
ha s a lowe r a ffinity for O2. Conditions tha t ca use a rightwa rd shift
of the oxyhe moglobin dissocia tion curve a re me ta bolic a nd include
re spira tory a cidosis, hype rthe rmia , incre a se d e rythrocyte 2,3-
diphosphoglyce ra te (2,3-DPG) conte nt, pre gna ncy, a nd a bnorma l
he moglobins, such a s sickle ce ll he moglobin or tha la sse mia .
Alka losis, hypothe rmia , fe ta l he moglobin, a bnorma l he moglobin
spe cie s, such a s ca rboxyhe moglobin, me the moglobin, a nd
sulfhe moglobin, a nd de cre a se d e rythrocyte 2,3-DPG conte nt will
ca use a le ftwa rd shift of the oxyhe moglobin dissocia tion curve .
Also se e e xpla na tion to Que stion 109 (Miller: Miller’s Anesth esia, ed 8,
p 1843; West: Respiratory Ph y siology, ed 9, pp 79–82).
120. (B) Adult re spira tory distre ss disorde r (ARDS) wa s first re porte d
in a dults in 1967 a nd is a ssocia te d with de cre a se d lung complia nce .
Initia l the ra pie s for ARDS include d me cha nica l ve ntila tion with
tida l volume s of 10 to 15 mL/kg with ra te s to a chie ve a norma l pH
a nd Pa CO2. In 2000, the Na tiona l Institute s of He a lth (NIH) ARDS
Ne twork (ARDSNe t) tria l note d a re duction in morta lity for pa tie nts
with ARDS who we re ve ntila te d with low tida l volume s (6 mL/kg
pre dicte d body we ight [PBW ]—morta lity ra te of 31%) compa re d to
tra ditiona l tida l volume s (12 mL/kg PBW —morta lity ra te of 40%). It
wa s fe lt tha t the la rge r tida l volume s ca use d ove rdiste ntion of the
a lve oli (i.e ., produce d volume tra uma or volutra uma ). This
incre a se d a lve ola r volume re sulte d in me cha nica l injury a nd a
syste mic infla mma tory re sponse . It wa s fe lt tha t the stre tch a nd not
the pre ssure (ba rotra uma ) ca use d the re le a se of the infla mma tory
cytokinins into the circula tion. Be ca use the lowe r tida l volume s
use d we re a ssocia te d with a n e le va tion of a rte ria l CO2 a nd lowe r
a rte ria l oxyge n le ve ls, the te rm “pe rmissive hype rca pnia a nd
hypoxe mia ” wa s use d. Pa tie nts with ARDS a lso de ve lop
a te le cta sis. Re cruitme nt ma ne uve rs (susta ine d bre a ths of
incre a se d a irwa y pre ssure s) we re use d to re -e xpa nd a te le cta tic
a lve oli to a void a te le ctra uma . Howe ve r, re sults with the
re cruitme nt bre a ths showe d only a tra nsie nt incre a se in
oxyge na tion a nd no cha nge in morta lity. Anothe r re spira tory
te chnique propose d include d the use of inha le d nitrous oxide (iNO)
tha t ca n improve ve ntila tion-pe rfusion misma tch a nd improve
oxyge na tion. Ra ndomize d controlle d studie s ha ve shown only
limite d e ffe ctive ne ss with no ove ra ll improve me nt in morta lity or
dura tion of ve ntila tion. Furthe r studie s a re looking a t iNO for
spe cific conditions (e .g., se ve re pulmona ry hype rte nsion, right
ve ntricula r fa ilure re fra ctory hypoxe mia ) (Miller: Basics of Anesth esia,
ed 6, p 669; Miller: Miller’s Anesth esia, ed 8, pp 3040–3044, 3078–3079).
121. (C) The ra te a t which a ga s diffuse s through a lipid me mbra ne
is dire ctly proportiona l to the a re a of the me mbra ne , the
tra nsme mbra ne pa rtia l pre ssure gra die nt of the ga s, a nd the
diffusion coe fficie nt of the ga s, a nd it is inve rse ly proportiona l to
the thickne ss of the me mbra ne . The diffusion coe fficie nt of the ga s
is dire ctly proportiona l to the squa re root of ga s solubility a nd is
inve rse ly proportiona l to the squa re root of the mole cula r we ight of
the ga s. This is known a s Fick’s la w of diffusion (Barash : Clinical
Anesth esia, ed 7, p 1147).
122. (A) Aging is a ssocia te d with re duce d ve ntila tory volume s a nd
ca pa citie s, a nd de cre a se d e fficie ncy of pulmona ry ga s e xcha nge .
The se cha nge s a re ca use d by progre ssive stiffe ning of ca rtila ge a nd
re pla ce me nt of e la stic tissue in the inte rcosta l a nd inte rve rte bra l
a re a s, which de cre a se s complia nce of the thora cic ca ge . In
a ddition, progre ssive kyphosis or scoliosis produce s upwa rd a nd
a nte rior rota tion of the ribs a nd ste rnum, which furthe r re stricts
che st wa ll e xpa nsion during inspira tion. W ith a ging, the FRC,
re sidua l volume , a nd closing volume a re incre a se d, whe re a s the
vita l ca pa city, tota l lung ca pa city, ma ximum bre a thing ca pa city, FEV1,
a nd ve ntila tory re sponse to hype rca rbia a nd hypoxe mia a re
re duce d. In a ddition, a ge -re la te d cha nge s in lung pa re nchyma ,
a lve ola r surfa ce a re a , a nd diminishe d pulmona ry ca pilla ry be d
de nsity ca use ve ntila tion/pe rfusion misma tch, which de cre a se s
re sting Pa O2 (Miller: Basics of Anesth esia, ed 6, pp 571–572; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 644).
123. (C) Physiologic de a d spa ce ve ntila tion ca n be e stima te d using
the Bohr e qua tion (de scribe d in the e xpla na tion to Que stion 103):

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


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

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


a lve ola r ca pilla ry, a rte ry, a nd mixe d ve nous sa mple s, re spe ctive ly.
This informa tion is not provide d in the que stion; howe ve r, the
a lve ola r-to-a rte ria l pa rtia l pre ssure of oxyge n diffe re nce is using
high inspire d oxyge n conce ntra tions. The a lve ola r to a rte ria l
oxyge n diffe re nce ca n be use d to e stima te ve nous a dmixture ,
most commonly tra nspulmona ry shunt. For e ve ry incre a se in
a lve ola r-a rte ria l O2 of 20 mm Hg, the re is a n incre a se in shunt
fra ction of 1% of the ca rdia c output. In the e xa mple , 240/20 = 12
a nd the tra nspulmona ry shunt ca n be e stima te d a t 12% (Miller:
Miller’s Anesth esia, ed 8, p 1557).
131. (D) Me a suring the ve ntila tory re sponse to incre a se d Pa CO2 is a
se nsitive me thod for qua ntifying the e ffe cts of drugs on ve ntila tion.
In ge ne ra l, a ll vola tile a ne sthe tics (including N2O), na rcotics,
be nzodia ze pine s, a nd ba rbitura te s de pre ss the ve ntila tory re sponse
to incre a se d Pa CO2 in a dose -de pe nde nt ma nne r. The ma gnitude of
ve ntila tory de pre ssion by vola tile a ne sthe tics is gre a te r in pa tie nts
with COPD tha n in he a lthy pa tie nts. Arte ria l blood ga se s (ABGs)
ma y ne e d to be monitore d during re cove ry from ge ne ra l a ne sthe sia
in pa tie nts with COPD. Ke ta mine ca use s minima l re spira tory
de pre ssion. Typica lly, re spira tory ra te is de cre a se d only 2 to
3 bre a ths/min a nd the ve ntila tory re sponse to cha nge s in Pa CO2 is
ma inta ine d during ke ta mine a ne sthe sia . Also se e e xpla na tion to
Que stion 105 (Miller: Basics of Anesth esia, ed 6, pp 63–64, 93–94, 110;
Miller: Miller’s Anesth esia, ed 8, pp 691–693).
132. (D) (Se e a lso e xpla nta tion to Que stion 124.) The orie nta tion of
the lungs re la tive to gra vity ha s a profound e ffe ct on e fficie ncy of
pulmona ry ga s e xcha nge . Be ca use a lve oli in de pe nde nt re gions of
the lungs e xpa nd more pe r unit cha nge in tra nspulmona ry pre ssure
(i.e ., a re more complia nt) tha n a lve oli in nonde pe nde nt re gions of
the lungs, incre a se s from the top to the bottom of the lungs.
Be ca use pulmona ry blood flow incre a se s more from the top to the
bottom of the lungs tha n doe s , the ve ntila tion/pe rfusion ra tio is
high in nonde pe nde nt re gions of the lungs a nd is low in de pe nde nt
re gions of the lungs. The re fore , in the upright lungs, the Pa O2 a nd
pH a re gre a te r a t the a pe x, whe re a s the Pa CO2 is gre a te r a t the
ba se (Miller: Miller’s Anesth esia, ed 8, pp 451–454; West: Respiratory
Ph y siology, ed 9, pp 21–22, 44–46).
133. (A) The work re quire d to ove rcome the e la stic re coil of the
lungs a nd thora x, a long with a irflow or frictiona l re sista nce s of the
a irwa ys, contribute s to the work of bre a thing. W he n the re spira tory
ra te or a irwa y re sista nce is high or pulmona ry or che st wa ll
complia nce is re duce d, a la rge a mount of e ne rgy is spe nt
ove rcoming the work of bre a thing. In the he a lthy re sting a dult, only
1% to 3% of tota l O2 consumption is use d for the work of bre a thing
a t re st, but up to 50% ma y be ne e de d in pa tie nts with pulmona ry
dise a se . Also se e e xpla na tion to que stion 110 (Miller: Miller’s
Anesth esia, ed 8, p 1563).
134. (B) The conducting a irwa ys (tra che a , right a nd le ft ma inste m
bronchi, a nd loba r a nd se gme nta l bronchi) do not conta in a lve oli
a nd, the re fore , do not ta ke pa rt in pulmona ry ga s e xcha nge . The se
structure s constitute the a na tomic de a d spa ce . In the a dult, the
a na tomic de a d spa ce is a pproxima te ly 2 mL/kg. The a na tomic de a d
spa ce incre a se s during inspira tion be ca use of the tra ction e xe rte d
on the conducting a irwa ys by the surrounding lung pa re nchyma . In
a ddition, the a na tomic de a d spa ce de pe nds on the size a nd posture
of the subje ct. Also se e e xpla na tion to Que stion 103 (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 778; Barash :
Clinical Anesth esia, ed 7, p 276).
135. (D) The re a re thre e ma in me cha nisms tha t the body ha s to
pre ve nt cha nge s in pH. The buffe r syste ms (imme dia te ), the
ve ntila tory re sponse (ta ke s minute s), a nd the re na l re sponse (ta ke s
hours to da ys). The buffe r syste ms re pre se nt the first line of
de fe nse a ga inst a dve rse cha nge s in pH. The [HCO3−] buffe r syste m
is the most importa nt syste m a nd re pre se nts gre a te r tha n 50% of
the tota l buffe ring ca pa city of the body. Othe r importa nt buffe r
syste ms include he moglobin, which is re sponsible for
a pproxima te ly 35% of the buffe ring ca pa city of blood, phospha te s,
pla sma prote ins, a nd bone (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 794–799; Miller: Basics of Anesth esia, ed 6. pp
335–336).
136. (C) Ca rdia c dysrhythmia s a re a common complica tion
a ssocia te d with a cid-ba se a bnorma litie s. The e tiology of the se
dysrhythmia s is re la te d pa rtly to the e ffe cts of pH on myoca rdia l
pota ssium home osta sis. As a ge ne ra l rule , pla sma K+ incre a se s
a pproxima te ly 0.6 for e a ch 0.1 de cre a se in pH (Butterworth : Morgan
& Mikh ail’s Clinical Anesth esia, ed 5, p 1149).
137. (B) Se ve ra l guide line s ca n be use d in the initia l inte rpre ta tion
of ABGs tha t will pe rmit ra pid re cognition of the type of a cid-ba se
disturba nce . The se guide line s a re a s follows: (1) a 1 mm Hg cha nge
in Pa CO2 a bove or be low 40 mm Hg re sults in a 0.008 unit cha nge in
the pH in the opposite dire ction; (2) the Pa CO2 will de cre a se by
a bout 1 mm Hg for e ve ry 1 mEq/L re duction in [HCO3−] be low
24 mEq/L; (3) a cha nge in [HCO3−] of 10 mEq/L from 24 mEq/L will
re sult in a cha nge in pH of a pproxima te ly 0.15 pH unit in the sa me
dire ction (Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, pp
1146, 1156–1157; Miller: Basics of Anesth esia, ed 6, pp 342–343).
138. (D) A pa tie nt with a VD of 150 mL a nd a VA of 350 mL (a ssuming
a norma l VT of 500 mL) will ha ve a VD minute ve ntila tion ( ) of
1500 mL a nd a VA minute ve ntila tion ( ) of 3500 mL ( of
5000 mL) a t a re spira tory ra te of 10 bre a ths/min. If the re spira tory
ra te is double d but re ma ins uncha nge d, the n the would
double to 3000 mL a nd the re would be a n incre a se in of
1500 mL a nd a de cre a se in of 1500 mL. Also se e e xpla na tion to
Que stions 103 a nd 134 (Barash : Clinical Anesth esia, ed 7, pp 275–277;
West: Respiratory Ph y siology, ed 9, pp 16–17; Miller: Miller’s Anesth esia,
ed 8, pp 446–447).
139. (B) In a ddition to the ite ms liste d in this que stion, othe r fa ctors
tha t shift the oxyhe moglobin dissocia tion curve to the right include
pre gna ncy a nd a ll a bnorma l he moglobins such a s he moglobin S
(sickle ce ll he moglobin). For re a sons unknown, vola tile a ne sthe tics
incre a se the P 50 of a dult he moglobin by 2 to 3.5 mm Hg. A rightwa rd
shift of the oxyhe moglobin dissocia tion curve will de cre a se the
tra nsfe r of O2 from a lve oli to he moglobin a nd improve re le a se of
O2 from he moglobin to pe riphe ra l tissue s. Also se e e xpla na tion to
Que stion 109 (Miller: Basics of Anesth esia, ed 6, p 56; West: Respiratory
Ph y siology, ed 9, pp 79–82).
140. (B) The most fre que nt imme dia te ca use of de a th from fire s is
ca rbon monoxide toxicity. Ca rbon monoxide is a colorle ss, odorle ss
ga s tha t e xe rts its a dve rse e ffe cts by de cre a sing O2 de live ry to
pe riphe ra l tissue s. This is a ccomplishe d by two me cha nisms. First,
be ca use the a ffinity of ca rbon monoxide for the O2 binding site s on
he moglobin is more tha n 200 time s tha t of O2, O2 is re a dily
displa ce d from he moglobin. Thus, O2 conte nt is re duce d. Se cond,
ca rbon monoxide ca use s a le ftwa rd shift of the oxyhe moglobin
dissocia tion curve , which incre a se s the a ffinity of he moglobin for
O2 a t pe riphe ra l tissue s. Tre a tme nt of ca rbon monoxide toxicity is
a dministra tion of 100% O2. Supple me nta l oxyge n de cre a se s the ha lf-
time of ca rboxyhe moglobin from 4 to 6 hours with room a ir to a bout
1 hour with 100% oxyge n. Bre a thing 100% oxyge n a t 3 a tm in a
hype rba ric cha mbe r re duce s the ha lf-time e ve n more to 15 to 30
minute s. Se e a lso e xpla na tions for Que stions 113 a nd 129 (Barash :
Clinical Anesth esia, ed 7, pp 1515–1516; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 554–555; Miller: Miller’s Anesth esia, ed 8, pp
2679–2680).
141. (A) Propofol infusion syndrome is a ra re condition a ssocia te d
with prolonge d (gre a te r tha n 48 hour) a dministra tion of propofol a t
a dose of 5 mg/kg/hr (83 µg/kg/min) or highe r. This syndrome wa s
first de scribe d in childre n but la te r obse rve d in critica lly ill a dults
a s we ll. It is ma nife ste d by ca rdiomyopa thy with a cute ca rdia c
fa ilure , me ta bolic a cidosis, ske le ta l muscle myopa thy,
he pa tome ga ly, hype rka le mia , a nd lipide mia . It is thought to be
re la te d to a fa ilure of fre e fa tty a cid tra nsport into the mitochondria
a nd fa ilure of the mitochondria l re spira tory cha in. Bra dyca rdia ca n
be a la te sign with this syndrome a nd he ra lds a poor prognosis
(Miller: Miller’s Anesth esia, ed 8, p 831).
142. (A) Ca lcula ting the a nion ga p (i.e ., the unme a sure d a nions in
the pla sma ) is he lpful in de te rmining the ca use of a me ta bolic
a cidosis. Anion ga p = [Na +] − ([Cl−] + [HCO3−]) a nd is norma lly 10 to
12 nmol/L. In this ca se the a nion ga p = 138 − (115 + 12) = 11, a norma l
a nion ga p. Ca use s of a high a nion ga p me ta bolic a cidosis include
la ctic a cidosis, ke toa cidosis, a cute a nd chronic re na l fa ilure , a nd
toxins (e .g., sa licyla te s, e thyle ne glycol, me tha nol). Nona nion ga p
me ta bolic a cidosis include re na l tubula r a cidosis, e xpa nsion
a cidosis (e .g., ra pid sa line infusion), ga strointe stina l (GI)
bica rbona te loss (e .g., dia rrhe a , sma ll bowe l dra ina ge ), drug-
induce d hype rka le mia , a nd a cid loa ds (e .g., a mmonium chloride ,
hype ra lime nta tion). Vomiting a nd na soga stric dra ina ge a re some of
the ma ny ca use s of me ta bolic a lka losis (Longo: Harrison’s Principles
of Internal Med icine, ed 18, pp 365–369; Miller: Basics of Anesth esia, ed 6,
pp 340–342).
143. (A) Bloodstre a m infe ctious complica tions with ce ntra l ve nous
ca the te rs a re the most common la te complica tion se e n with ce ntra l
ca the te rs (>5%). Curre nt Ce nte rs for Dise a se Control a nd
Pre ve ntion (CDC) guide line s do not re comme nd re pla cing ce ntra l
ve nous ca the te rs. All the othe r sta te me nts a re true . In a ddition,
e vide nce is sugge sting tha t the use of ultra sound ma y de cre a se the
time ne e de d to pla ce ca the te rs a nd the numbe r of skin puncture s
ne e de d for ce ntra l ve in a cce ss a nd ma y a lso de cre a se infe ctions
(Miller: Miller’s Anesth esia, ed 8, p 1367; O’Grad y et al: Guid elines for
th e prevention of intravascular cath eter-related infections. Clin Infect Dis
52(9): e164–e166, 2011).
144. (C) Sa rin (a lso ca lle d GB), like GA (Ta bun), GD (Soma n), GF,
VR, a nd VX, is a cle a r liquid orga nophospha te tha t va porize s a t
room te mpe ra ture s. The se che mica l ne rve ga se s ma inly bind with
a ce tylcholine ste ra se a nd produce clinica l signs of e xce ssive
pa ra sympa the tic a ctivity. The te rm DUMBELS—Dia rrhe a , Urina tion,
Miosis, Bronchorrhe a a nd bronchoconstriction, Eme sis,
La crima tion, a nd Sa liva tion—ca n he lp you re me mbe r se ve ra l of the
signs. Note the e ye signs a re pupilla ry constriction (miosis) a nd not
pupilla ry dila tion (mydria sis). Othe r signs re la te to the
ca rdiova scula r syste m a nd include bra dyca rdia , prolonge d QT
inte rva l, a nd ve ntricula r dysrhythmia s. The se che mica ls a lso a ffe ct
the GABA a nd NMDA re ce ptors a nd ma y a lso ca use ce ntra l ne rvous
syste m (CNS) e xcita tion (i.e ., convulsions) (Barash : Clinical
Anesth esia, ed 7, pp 1540–1541; Miller: Miller’s Anesth esia, ed 8, p 2496).
145. (D) Ve nous a ir e mbolism occurs whe n a ir e nte rs the ve nous
syste m through a n incise d or ca nnula te d ve in. W he n ca nnula ting or
de ca nnula ting ce ntra l ve ins, it is importa nt to ke e p a positive
ve nous-to-a tmosphe ric pre ssure gra die nt. This is usua lly
a ccomplishe d by pla cing the site be low the le ve l of the he a rt (i.e .,
Tre nde le nburg position). In a ddition, unde r me cha nica l ve ntila tion
or whe n the sponta ne ously bre a thing pa tie nt e xha le s or pe rforms a
Va lsa lva ma ne uve r, the ve nous-to-a tmosphe ric pre ssure is gre a te r
tha n if a sponta ne ously bre a thing pa tie nt inha le s, a time whe n the
ve nous pre ssure ma y be le ss tha n a tmosphe ric pre ssure (Lobato:
Com plications in Anesth esiology, pp 198–200; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esia, ed 5, p 101; Marino’s Th e ICU Book, ed 4,
pp 32–33).
146. (B) Adve rse physiologic e ffe cts of re spira tory or me ta bolic
a cidosis include CNS de pre ssion a nd incre a se d intra cra nia l
pre ssure (ICP), ca rdiova scula r syste m de pre ssion (pa rtia lly offse t
by incre a se d se cre tion of ca te chola mine s a nd e le va te d [Ca ++]),
ca rdia c dysrhythmia s, va sodila tion, hypovole mia (which is a re sult
of de cre a se d pre ca pilla ry a nd incre a se d postca pilla ry sphincte r
tone ), pulmona ry hype rte nsion, a nd hype rka le mia (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esia, ed 5, pp 1148–1149; Miller:
Basics of Anesth esia, ed 6, p 339).
147. (C) W ithdra wing the tube into the tra che a obviously would
improve a rte ria l sa tura tion a nd is the tre a tme nt of choice for
ina dve rte nt ma inste m intuba tion. Short of pulling the ETT ba ck, a ll
othe r succe ssful options a ddre ss wa ys of improving a rte ria l
oxyge na tion during one -lung ve ntila tion. In e sse nce , a ny ma ne uve r
tha t improve s the sa tura tion of the ve nous blood will a lso improve
the sa tura tion of a rte ria l blood (in this que stion). Norma l
pulmona ry circula tion is in se rie s with the syste mic circula tion.
Blood e xiting the lungs is ne a rly 100% oxyge na te d re ga rdle ss of the
sa tura tion of the ve nous blood whe n it e xits the right ve ntricle a nd
e nte rs the lungs via the pulmona ry a rte ry. In one -lung ve ntila tion,
de libe ra te or a ccide nta l, blood e xiting the ve ntila te d side of the
lungs (the right side in this que stion) is a lso e sse ntia lly fully
sa tura te d, but it mixe s with nonoxyge na te d blood. The
nonoxyge na te d blood ha s e ffe ctive ly bypa sse d the lungs by pa ssing
through a n a re a tha t is pe rfuse d but not ve ntila te d, tha t is, a shunt.
W he n the blood from the ve ntila te d lung (ne a rly 100% oxyge na te d)
mixe s with the shunte d blood, a mixture will be forme d tha t ha s
sa tura tion le ss tha n 100%, but highe r tha n the mixe d ve nous O2
sa tura tion.
whe re SvO2 = mixe d ve nous he moglobin sa tura tion a nd
Sa O2 = a rte ria l oxyge n sa tura tion

The e xa ct sa tura tion of the a rte ria l blood in this que stion de pe nds
on the ra tio of blood e xiting the right lung ve rsus tha t e xiting the
le ft lung. Fortuna te ly, during one -lung ve ntila tion, the
nonve ntila te d lung colla pse s a nd in so doing ra ise s its re sista nce
to blood flow. This re sults in pre fe re ntia lly dire cting blood to the
right ve ntila te d lung. A se cond fa ctor to conside r is how we ll-
sa tura te d the shunte d blood is. “Re d” blood from the right lung
mixe s with “blue ” blood from the le ft lung to give a mixture of
pa rtia lly sa tura te d blood. The sa tura tion of the shunte d “blue ”
blood de pe nds on the he moglobin conce ntra tion a nd ca rdia c
output. From the first e qua tion a bove you ca n se e tha t ra ising
e ithe r of the se would improve the mixe d ve nous oxyge n
sa tura tion a nd ultima te ly the a rte ria l sa tura tion during one -lung
ve ntila tion. Infla ting the pulmona ry a rte ry ca the te r ba lloon
loca te d in the nonve ntila te d (le ft) lung would a lso improve
a rte ria l sa tura tion by limiting blood flow to the le ft lung. Ra ising
the FIO2 from 80% to 100% will do little if a nything to improve
a rte ria l sa tura tion be ca use the blood e xiting the “working” lung
is a lre a dy fully sa tura te d. The sma ll rise in Pa O2 tha t would
re sult from a n incre a se in F IO2, once multiplie d by 0.003 (se e the
se cond e qua tion a bove ), would be a ve ry sma ll a nd insignifica nt
numbe r. In othe r words, ra ising F IO2 doe s not improve a rte ria l
sa tura tion in the pre se nce of a shunt (Miller: Miller’s Anesth esia, ed
8, p 1386; Miller: Basics of Anesth esia, ed 6, pp 444–445, 636).
148. (D) The de cision to stop me cha nica l support of the lungs is
ba se d on a va rie ty of fa ctors tha t ca n be me a sure d. Guide line s
sugge sting tha t ce ssa tion of me cha nica l infla tion of the lungs is
like ly to be succe ssful include a vita l ca pa city gre a te r tha n
15 mL/kg, a rte ria l Pa O2 gre a te r tha n 60 mm Hg (F IO2 < 0.5), a lve ola r-
a rte ria l (A–a ) gra die nt le ss tha n 350 mm Hg (F IO2 = 1.0), a rte ria l pH
gre a te r tha n 7.3, Pa CO2 le ss tha n 50 mm Hg, de a d spa ce /tida l
volume ra tio le ss tha n 0.6, a nd ma ximum inspira tory pre ssure of a t
le a st −20 cm H2O. In a ddition to the se guide line s, the pa tie nt should
be he modyna mica lly sta ble , conscious, orie nte d, a nd in good
nutritiona l sta tus (Butterworth : Morgan & Mikh ail’s Clinical Anesth esia,
ed 5, pp 1288, 1297; Miller: Basics of Anesth esia, ed 6, p 667).
149. (D) A shift to the le ft in the oxyhe moglobin dissocia tion curve
occurs with fe ta l he moglobin, a lka losis, hypothe rmia ,
ca rboxyhe moglobin, me the moglobin, a nd de cre a se d le ve ls of 2,3-
DPG. Stora ge of blood lowe rs 2,3-DPG le ve ls in a cid-citra te -
de xtrose store d blood, but minima l cha nge s a re se e n in 2,3-DPG
with citra te -de xtrose -store d blood. A shift to the right occurs with
a cidosis, hype rthe rmia , incre a se d le ve ls of 2,3-DPG, inha le d
a ne sthe tics, a nd pre gna ncy (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esia, ed 5, pp 516–517; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, p 415).
150. (C) W ith a cute spina l cord injurie s the ma jor a ne sthe tic
conce rns a re a irwa y ma na ge me nt a nd ma na ge me nt of
he modyna mic pe rturba tions a ssocia te d with inte rruption of the
sympa the tic ne rvous syste m be low the le ve l of the tra nse ction.
Hype rka le mia in re sponse to succinylcholine doe s not occur until
a t le a st 24 hours a fte r the injury. Autonomic hype r-re fle xia is not a
conce rn in the a cute ma na ge me nt of pa tie nts with spina l cord
injurie s. The re is no e vide nce tha t a wa ke intuba tion (fibe roptic) is
supe rior to dire ct la ryngoscopy a s long a s in-line tra ction is he ld in
both ca se s. The se pa tie nts a re more susce ptible to hypothe rmia
compa re d with pa tie nts without spina l cord injurie s be ca use the y
la ck the rmore gula tion be low the le ve l of the cord injury (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 255–258).
151. (C) Polyuria of ne uroge nic (ra the r tha n ne phroge nic) dia be te s
insipidus is ca use d by diminishe d or a bse nt a ntidiure tic hormone
(ADH) synthe sis or re le a se following injury to the hypotha la mus,
pituita ry sta lk, or poste rior pituita ry gla nd. He moconce ntra tion
re sulting in hype rna tre mia ofte n re sults. In contra st, SIADH is
a ssocia te d with e xce ssive a mounts of ADH, which in turn ca use s
hypona tre mia . Ce re bra l sa lt wa sting syndrome re sults from re le a se
of bra in na triure tic pe ptide in suba ra chnoid he morrha ge pa tie nts.
The re sulting na triure sis-me dia te d e le ctrolyte pe rturba tion is
hypona tre mia . Dia be te s me llitus a nd spina l shock do not ca use
hype rna tre mia (Longo: Harrison’s Principles of Internal Med icine, ed 18,
pp 349–351; Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p
1115).
152. (D) Va sopre ssin, a lso known a s a ntidiure tic hormone , is a
na tura lly occurring pe ptide synthe size d in the hypotha la mus a nd
store d in the poste rior pituita ry. It is use d clinica lly to tre a t dia be te s
insipidus, a nd in the ICU it is use d to tre a t hypote nsion. Pa tie nts
with se ve re se psis a nd se ptic shock ha ve a re la tive de ficie ncy of
va sopre ssin, a nd the se pa tie nts ma y be se nsitive to va sopre ssin.
Va sopre ssin inte ra cts with a diffe re nt re ce ptor a nd, unlike the
ca te chola mine s, it is e ffe ctive e ve n in the pre se nce of a cide mia
(Miller: Basics of Anesth esia, ed 6, p 676).
153. (C) Confusion ma y e xist be twe e n the conce pts of shunt ve rsus
de a d spa ce . Both of the se a re forms of misma tch. W ith
shunts, the re is a gra die nt be twe e n the a lve ola r a nd the a rte ria l
oxyge n pa rtia l pre ssure s. Alve ola r pa rtia l pre ssure (PA) is
ca lcula te d from the a lve ola r ga s e qua tion. The Pa CO2 with shunt is
compe nsa te d a nd is usua lly norma l e ve n in the pre se nce of a
significa nt misma tch. De a d spa ce re fe rs to the portion of a
bre a th tha t doe s not re a ch pe rfuse d a lve oli. In pa thologic
conditions, such a s COPD, morbid obe sity, a nd pulmona ry
e mbolism, de a d spa ce is incre a se d be ca use a ir pa sse s into a lve oli
tha t a re ve ntila te d but not pe rfuse d. This a ir doe s not pa rticipa te in
ga s e xcha nge a nd simply e xits the se unpe rfuse d a lve oli a nd
“dilute s” the ca rbon dioxide e xiting the lungs from the pe rfuse d
a lve oli. Unde r the se circumsta nce s the mixe d e xpire d CO2
me a sure d with ca pnome try will be le ss tha n the a ctua l a rte ria l CO2
(Miller: Miller’s Anesth esia, ed 8, pp 444–445; Miller: Basics of Anesth esia,
ed 6, pp 58–61).
154. (C) TRALI re a ctions a re a se rious complica tion of tra nsfusing
a ny product conta ining pla sma , tha t is, fre sh froze n pla sma , whole
blood, pa cke d re d blood ce lls, pla te le ts, or fa ctor concre te s de rive d
from huma n blood. The clinica l dia gnosis is ma de 1 to 2 hours a fte r
tra nsfusion (but ma y occur up to 6 hours la te r in the ICU). The ke y
fe a ture s include wide A–a gra die nt, nonca rdioge nic pulmona ry
e de ma , a nd le ukope nia (not le ukocytosis) se conda ry to
se que stra tion in the lungs. TRALI re a ctions a re one of the le a ding
ca use s of tra nsfusion-re la te d morta lity (Miller: Basics of Anesth esia, ed
6, p 637).
155. (B) The right inte rna l jugula r ve in a nd the right subcla via n ve in
form the right bra chioce pha lic ve in; simila rly, the le ft inte rna l
jugula r ve in a nd the le ft subcla via n ve in form the le ft
bra chioce pha lic ve in. The se two bra chioce pha lic ve ins form the
SVC (Netter: Atlas of Hum an Anatom y, ed 5, plates 70, 192, 200, 205).
156. (D) Pa tie nts who ha ve unde rgone a PCI a re pla ce d on a course
of a thie nopyridine (ticlopidine or clopidogre l) a nd a spirin. The
thie nopyridine is use d for a t le a st 2 we e ks a fte r PTCA, 1 month
a fte r a ba re -me ta l ste nt is pla ce d, a nd 1 ye a r a fte r a drug-e luting
ste nt is pla ce d. Aspirin is continue d for a longe r pe riod of time .
This is to de cre a se the cha nce of thrombosis of the tre a te d
corona ry a rte ry (ACC/AHA 2007 Guid elines on Perioperative
Card iovascular Evaluation and Care for Noncard iac Surgery : Ex ecutive
Sum m ary. Anesth Analg 106:698–701, 2008).
157. (C) The unive rsa l compre ssion-ve ntila tion ra tio for infa nt, child,
a nd a dult victims (e xcluding ne wborns) is 30 che st compre ssions to
two bre a th cycle s (5 cycle s in 2 minute s). Once a n a dva nce d a irwa y
is in pla ce , two re scue rs no longe r de live r “cycle s,” but ra the r
compre ssions a t a ra te of 100/min a nd ve ntila tion is 8 to 10/min. For
ne wborns the ra tio is 3:1 (90 compre ssions a nd 30 bre a ths/min)
(2010 AHA Guid elines for CPR and Em ergency Card iovascular Care:
Circulation 122 (Suppl 3) S688, S692–S693, S913).
158. (A) Afte r a n incuba tion pe riod (commonly within 2 we e ks),
inha la tiona l a nthra x symptoms initia lly look like vira l flu (fe ve r,
chills, mya lgia , a nd a nonproductive cough). Although le ukocytosis
is common with a nthra x a nd ra re with vira l flu, white blood ce ll
(W BC) counts initia lly ma y be norma l a t the time the pa tie nt
pre se nts. Afte r a short while , the pa tie nt sudde nly a ppe a rs
critica lly ill, a nd without tre a tme nt, de a th ca n occur within a fe w
da ys. Subste rna l che st pa in, hypoxe mia , cya nosis, dyspne a ,
a bdomina l pa in, a nd se psis syndrome a re common with inha le d
a nthra x but ra re with vira l flu. Afte r the a nthra x spore s a re inha le d,
ma cropha ge s pha gocytize the spore s a nd tra nsport the m to
me dia stina l lymph node s whe re the spore s ge rmina te , producing
e nla rge d node s a nd a wide ne d me dia stinum on the che st x-ra y
film. A wide ne d me dia stinum is not se e n with vira l flu. Pha ryngitis
is common with vira l flu a nd occa siona lly is se e n with a nthra x
(Miller: Basics of Anesth esia, ed 6, pp 691–693; Longo: Harrison’s
Principles of Internal Med icine, ed 18, pp 1769–1771).
159. (C) To a nswe r this que stion it is he lpful to re vie w the a lve ola r
ga s e qua tion:

P AO2 = pa rtia l pre ssure of oxyge n in the a lve ola r ga s; F IO2 = fra ction
of inha le d oxyge n; P b = ba rome tric pre ssure ; P H 2O = va por
pre ssure a t 100% sa tura tion (47 mm Hg a t 37° C); Pa CO2 = pa rtia l
pre ssure of CO2 in the a lve ola r ga s; R = re spira tory quotie nt.
Any fa ctor tha t lowe rs P AO2 (be low 100 mm Hg or so) will a lso
lowe r Pa O2. Hypoxic ga s mixture lowe rs F IO2, he nce Pa O2.
Hype rca rbia ma ke s the te rm Pa CO2/R la rge r a nd, the re fore ,
re duce s Pa O2. Eise nme nge r syndrome re sults in a la rge r shunt
fra ction a nd lowe r Pa O2 on tha t ba sis (se e e xpla na tion to
Que stion 147). In norma lly functioning lungs, a ne mia ha s a
minima l impa ct on Pa O2 be ca use physiologic shunt is norma lly
only 2% to 5% of ca rdia c output (Barash : Clinical Anesth esia, ed 6, pp
277–278).
160. (D) The diffe re nce be twe e n the Pa CO2 a nd the CO2 va lue
me a sure d by the infra re d spe ctrome te r is a function of the pa tie nt’s
physiologic de a d spa ce . Physiologic de a d spa ce is e qua l to
a na tomic de a d spa ce plus a lve ola r de a d spa ce . Ana tomic de a d
spa ce is roughly 1 mL/lb of body we ight. Be ca use a na tomic de a d
spa ce is re la tive ly “fixe d,” cha nge s in physiologic de a d spa ce a re
ma inly a ttributa ble to cha nge s in a lve ola r de a d spa ce . Alve oli tha t
a re ve ntila te d, but not pe rfuse d, a dd to a lve ola r de a d spa ce . In
e sse nce , a ir goe s into the se a lve oli but doe s not pa rticipa te in ga s
e xcha nge s a nd me re ly e xits the a lve oli upon e xha la tion. Ve ntila tion
of de a d spa ce se rve s no use ful purpose but doe s re sult in
“dilution” of the e xha le d CO2, thus e xpla ining why the CO2 se e n on
the infra re d spe ctrome te r ca n be substa ntia lly lowe r tha n tha t
obta ine d from a rte ria l blood ga s a na lysis. Se ve ra l fa ctors incre a se
de a d spa ce , including lung dise a se s such a s COPD, cystic fibrosis,
a nd pulmona ry e mboli. In a ddition, de cre a se d a lve ola r pe rfusion
from low ca rdia c output or hypovole mia ma y a lso contribute to
incre a se d de a d spa ce . Ma inste m intuba tion, a te le cta sis, shunting
through the be sia n ve ins, a nd a bla tion of hypoxic pulmona ry
va soconstriction by isoflura ne a re va rious ca use s of shunting.
Shunting is a lso a misma tch be twe e n ve ntila tion a nd pe rfusion, but,
in contra st to misma tch from de a d spa ce ve ntila tion,
shunting re sults in a norma l or ne a rly norma l Pa CO2 but a la rge r-
tha n-e xpe cte d A–a O2 gra die nt. The only choice in this que stion
tha t would e xpla in a n incre a se in de a d spa ce ve ntila tion is
hypovole mia (Barash : Clinical Anesth esia, ed 7, pp 276–277; Miller:
Basics of Anesth esia, ed 6, pp 328–329).
161. (B) The norma l huma n’s re sting e ne rgy e xpe nditure a s we ll a s
the postope ra tive sta te is a bout 1800 kca l/24 hr. W ith sta rva tion
(20 da ys), e ne rgy e xpe nditure de cre a se s to a bout 1080 kca l/da y (60%
of norma l). Pa tie nts who ha ve susta ine d multiple fra cture s
(2160 kca l/da y or 120% of norma l), ma jor se psis (2520 kca l/da y or
140% of norma l), a nd burns ha ve incre a se d e ne rgy e xpe nditure s.
The e ne rgy e xpe nditure in a pa tie nt with a ma jor burn a lso
de pe nds on the te mpe ra ture of the room. The highe st e ne rgy
e xpe nditure is a t a room te mpe ra ture of 25° C (3819 kca l/da y or
212% of norma l) a nd is lowe r a t 33° C (3342 kca l/da y or 185% of
norma l) a nd a t 21° C (3600 kca l/da y or 200% of norma l) (Miller:
Miller’s Anesth esia, ed 8, pp 3136–3138).
162. (D) Amioda rone is use ful in the tre a tme nt of a va rie ty of
supra ve ntricula r a nd ve ntricula r ca rdia c a rrhythmia s. For the
tre a tme nt of ve ntricula r ta chyca rdia or fibrilla tion tha t is re fra ctory
to e le ctrica l de fibrilla tion, the re comme nde d dose is 300 mg IV.
Simila r to β-blocke rs, a mioda rone de cre a se s morta lity a fte r
myoca rdia l infa rctions. About 5% to 15% of tre a te d pa tie nts de ve lop
pulmona ry toxicity (e spe cia lly whe n dose s a re >400 mg/da y, or
unde rlying lung dise a se is pre se nt) a nd 2% to 4% de ve lop thyroid
dysfunction (a mioda rone is a structura l a na log of thyroid hormone ).
It ha s a prolonge d e limina tion ha lf-time of 29 hours a nd a la rge
volume of distribution. Be ca use it prolongs the QTc inte rva l, it ma y
le a d to the production of ve ntricula r ta chydysrhythmia s a nd thus is
not use ful in tre a ting torsa de s de pointe s (Brunton: Good m an &
Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 834, 837).
163. (A) Pa tie nts with cirrhosis ha ve hype rdyna mic circula tions a s
note d he re with the e le va te d SvO2 of 90%. The ca rdia c output is
usua lly incre a se d, pe riphe ra l va scula r re sista nce is low,
intra va scula r volume is incre a se d, a nd a rte riove nous shunts a re
pre se nt. Hypote nsion is common. Milrinone is a positive inotrope
with va sodila ting prope rtie s, some thing this pa tie nt doe s not ne e d.
If a tre a tme nt for hypote nsion is ne e de d, drugs with α-a gonist
prope rtie s ma y be he lpful. In a ddition, va sopre ssin is a lso a good
choice be ca use it incre a se s syste mic va scula r re sista nce (SVR) but
doe s not incre a se the a lre a dy high ca rdia c output (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p 714; Miller: Basics of
Anesth esia, ed 6, p 457).
164. (B) For ma ny ye a rs ha nd hygie ne , we a ring surgica l ma sks, a nd
ste rile te chnique s ha ve be e n use d to de cre a se surgica l site
infe ctions (SSIs). The CDC ha s a lso re comme nde d tha t pa tie nts
unde rgo pre ope ra tive showe ring using a ntise ptic skin wa sh
products to re duce skin ba cte ria de spite no cle a r studie s showing a
dire ct inde pe nde nt re la tionship de cre a sing SSIs. In 2004, the
Na tiona l Surgica l Infe ction Pre ve ntion Proje ct ga ve guide line s for
a ntibiotic prophyla xis, whe ne ve r the re is more tha n minima l risk of
infe ction. Prophyla ctic a ntibiotics should be a dministe re d within 1
hour be fore surgica l incision in a ppropria te ly se le cte d pa tie nts a nd
discontinue d within 24 hours a fte r the surgica l e nd time or 48 hours
for ca rdia c pa tie nts. More re ce ntly, using e vide nce -ba se d re se a rch,
the SCIP ha s sugge ste d se ve ra l a dditiona l me a sure s to de cre a se
the incide nce of surgica l site infe ctions, including a ppropria te ha ir
re mova l a t the surgica l site (e .g., using de pila tory cre a m or ha ir
clippe rs ra the r tha n ra zors), glyce mic control in ca rdia c surgica l
pa tie nts (e .g., se rum glucose <200 mg/dL the morning a fte r surge ry),
re mova l of urina ry ca the te rs (e .g., re mova l on postope ra tive da y 1
or 2 a nd re a sse ssme nt of the ne e d e ve ry da y the re a fte r), a nd
ma inte na nce of pe riope ra tive normothe rmia (e .g., core
te mpe ra ture should be 36° C on a rriva l in the PACU). Inte re stingly,
surgica l time wa s not me ntione d (Barash : Clinical Anesth esia, ed 7, pp
304–314; Miller: Basics of Anesth esia, ed 6, pp 746–752; Miller: Miller’s
Anesth esia, ed 8, pp 100–101, 1104).
165. (B) This pa tie nt ha s a me ta bolic a cidosis. Re ca ll tha t a nion
ga p = [Na +] − ([Cl−] + [HCO3−]) a nd is norma lly 10 to 12 nmol/L. In this
ca se the a nion ga p = 145 − (119 + 12) = 14, which is slightly a bove the
norma l a nion ga p ra nge . In looking a t this ca se , the a cidosis is
quite profound a nd would most like ly be re la te d to the ra pid
infusion of norma l sa line . La ctic a cid, ke toa cidosis, a nd e thyle ne
glycol produce a high a nion ga p me ta bolic a cidosis. Na rcotics ma y
produce re spira tory but not me ta bolic a cidosis. Se e a lso Que stion
142 (Longo: Harrison’s Principles of Internal Med icine, ed 18, pp 365–369;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esia, ed 5, p 1165).
166. (A) Noninva sive positive -pre ssure ve ntila tion (NIPPV) re fe rs to
de live ring positive -pre ssure ve ntila tion to pa tie nts by wa y of a
na sa l ma sk, or full fa ce ma sk, without the pla ce me nt of a n
e ndotra che a l or tra che ostomy tube . This mode of the ra py re quire s
conscious a nd coope ra tive pa tie nts a nd doe s not prote ct the
a irwa y. NIPPV ha s be e n ve ry use ful in COPD pa tie nts a nd in
immunosuppre sse d pa tie nts in a cute re spira tory fa ilure . It most
like ly will fa il (i.e ., intuba tion would be ne e de d) in pa tie nts with
pne umonia a nd ARDS (Miller: Miller’s Anesth esia, ed 8, p 3068).
167. (D) Ca pnogra phy ha s be e n a va lua ble monitor for the ca rdia c
a nd pulmona ry syste ms a s we ll a s che cking the a ne sthe tic
e quipme nt. Forge tting to ve ntila te the pa tie nt, intuba ting the
e sopha gus, a nd ha ving the se nsing tube be come disconne cte d from
the monitor quickly will show no CO2 de te cte d. Any significa nt
re duction in lung pe rfusion (i.e ., a ir e mbolism, de cre a se d ca rdia c
output, or de cre a se d blood pre ssure ) incre a se s a lve ola r de a d
spa ce a nd le a ds to a lowe ring of the de te cte d CO2. A ca rdia c a rre st
whe re the re is no blood flow to the lungs a nd he nce no ca rbon
dioxide going to the lungs would a lso re sult in no de te cta ble CO2.
As CPR is sta rte d, de te cta ble CO2 would be a sign of lung pe rfusion
a nd ve ntila tion. A pa tie nt with a pne umothora x a nd high a irwa y
pre ssure s would still give you CO2 re a dings (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esia, ed 5, pp 125–127).
168. (C) Alwa ys confirm a n a de qua te Airwa y a nd Bre a thing be fore
tre a ting a Ca rdia c rhythm (A, B be fore C). Ha ving the ETT in prope r
position for se ve ra l hours doe s not e nsure tha t it re ma ins in prope r
position. In this ca se , the ETT slippe d out of the tra che a a nd we nt
into the e sopha gus. The only wa y you know the ETT is in the
tra che a is to se e the tube pa ssing be twe e n the voca l cords dire ctly
with a conve ntiona l la ryngoscope or by putting a fibe roptic
bronchoscope through the tube a nd se e ing ca rina . Othe r forms of
confirma tion such a s bila te ra l bre a th sounds, a de qua te che st rise ,
a nd moisture in the tube a re he lpful but could a lso be se e n with a n
e sopha ge a l intuba tion. Ge tting a consiste nt a nd a de qua te e nd tida l
CO2 on a monitor confirms some ga s e xcha nge , but in ca se s whe re
blood doe s not ge t to the lungs, a s in a ca rdia c a rre st, CO2 ca nnot
be re move d from the lungs. The first pa rt in the tre a tme nt of
bra dyca rdia is a de qua te ve ntila tion with oxyge n. Afte r tha t the
othe r choice s ma y be indica te d (Miller: Miller’s Anesth esia, ed 8, p
1654).
C H AP T E R 3
Pharmacology and
Pharmacokinetics of Intravenous
Drugs

DIRECT IONS (Que stions 169 through 282): Ea ch of the que stions
or incomple te sta te me nts in this se ction is followe d by
a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
Se le ct the ONE BEST a nswe r or comple tion for e a ch ite m.

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


by re na l e xcre tion?
A. Pa ncuronium
B. Ve curonium
C. Atra curium
D. Rocuronium
170. All of the following conditions ma y de ve lop whe n using
propofol for prolonge d se da tion in the inte nsive ca re unit (ICU)
EXCEPT
A. Pa ncre a titis
B. Hype rlipide mia
C. Me ta bolic a cidosis
D. Adre na l suppre ssion
171. W hich of the following β-a dre ne rgic a nta gonists is a
nonse le ctive β1 a nd β2 blocke r?
A. Ate nolol
B. Na dolol
C. Esmolol
D. Me toprolol
172. A 78-ye a r-old pa tie nt with Pa rkinson dise a se unde rgoe s a
ca ta ra ct ope ra tion unde r ge ne ra l a ne sthe sia . In the re cove ry room,
the pa tie nt ha s two e pisode s of e me sis a nd compla ins of se ve re
na use a . W hich of the following a ntie me tics would be the be st
choice for tre a tme nt of na use a in this pa tie nt?
A. Drope ridol
B. Prome tha zine
C. Onda nse tron
D. Me toclopra mide
173. W hich of the following dise a se s is a ssocia te d with incre a se d
re sista nce to ne uromuscula r blocka de with succinylcholine ?
A. Mya sthe nia gra vis
B. Mya sthe nic syndrome
C. Huntington chore a
D. Polymyositis
174. Se da tion with which of the following drugs is most like ly to
re se mble norma l sle e p?
A. Propofol
B. Mida zola m
C. De xme de tomidine
D. Ke ta mine
175. W hich of the following intra ve nous a ne sthe tics is conve rte d
from a wa te r-soluble to a lipid-soluble drug a fte r e xposure to the
bloodstre a m?
A. Propofol
B. Mida zola m
C. Ke ta mine
D. None of the a bove
176. A 33-ye a r-old, 70-kg pa tie nt is brought to the ope ra ting room for
re se ction of a n a nte rior pituita ry prola ctin-se cre ting tumor.
Ane sthe sia is induce d with se voflura ne , nitrous oxide , a nd oxyge n.
The pa tie nt is intuba te d a nd nitrous oxide is discontinue d.
Ane sthe sia is ma inta ine d with 1.2 minimum a lve ola r conce ntra tion
(MAC) se voflura ne in oxyge n. The surge on pla ns to inje ct
e pine phrine into the na sa l mucosa to minimize ble e ding. W ha t is
the ma ximum volume of a 1:100,000 e pine phrine solution tha t ca n
be a dministe re d sa fe ly to this pa tie nt without producing ve ntricula r
a rrhythmia s?

A. 55 mL

B. 45 mL

C. 35 mL

D. 25 mL
177. Pa tie nts re ce iving a ntihype rte nsive the ra py with propra nolol
a re a t incre a se d risk for e a ch of the following EXCEPT
A. Blunte d re sponse to hypoglyce mia
B. Bronchoconstriction
C. Re bound ta chyca rdia a fte r discontinua tion
D. Orthosta tic hypote nsion
178. Atropine ca use s e a ch of the following EXCEPT
A. De cre a se d ga stric a cid se cre tion
B. Inhibition of sa liva ry se cre tion
C. Incre a se d lowe r e sopha ge a l sphincte r tone
D. Mydria sis
179. W hich of the following drugs is ca pa ble of crossing the blood-
bra in ba rrie r?
A. Ne ostigmine
B. Pyridostigmine
C. Edrophonium
D. Physostigmine
180. W hich drug e xe rts its ma in ce ntra l ne rvous syste m (CNS) a ction
by inhibiting the N-me thyl-D-a spa rta te (NMDA) re ce ptors?
A. Propofol
B. Mida zola m
C. Etomida te
D. Ke ta mine
181. W hich of the following opioid-re ce ptor a gonists ha s
a nticholine rgic prope rtie s?
A. Morphine
B. Hydromorphone
C. Sufe nta nil
D. Me pe ridine
182. W hich of the following sta te me nts a bout ke ta mine is FALSE?
A. In the Unite d Sta te s, it is a ra ce mic mixture of two isome rs
B. It is a pote nt ce re bra l va sodila tor a nd ca n incre a se intra cra nia l
pre ssure (ICP)
C. Re spira tory de pre ssion ra re ly occurs with induction dose s
D. Its me ta bolite norke ta mine is more pote nt tha n the pa re nt
compound
183. W hich of the following va sopre ssor a ge nts incre a se s syste mic
blood pre ssure (BP) indire ctly by stimula ting the re le a se of
nore pine phrine from sympa the tic ne rve fibe rs a nd dire ctly by
binding to a dre ne rgic re ce ptors?
A. Va sopre ssin
B. Ephe drine
C. Epine phrine
D. Phe nyle phrine
184. Me tha done -induce d constipa tion could be re ve rse d without
loss of a na lge sic e ffe ct with which of the following opioid
a nta gonists?
A. Na loxone
B. Na lme fe ne
C. Na ltre xone
D. Me thylna ltre xone
185. The tre a tme nt of pa tie nts with huma n immunode ficie ncy virus
(HIV) ma y include indina vir, ne lfina vir, or ritona vir. W ha t a ne sthe tic
conside ra tion is significa nt with the se drugs?
A. De cre a se d pla te le t function
B. Incre a se d se nsitivity to mida zola m
C. Hypoglyce mia
D. Hype rka le mia
186. Ne urokinin-1 (NK1) a nta gonists such a s a pre pita nt ha ve a ll the
following prope rtie s EXCEPT
A. Anxiolytic
B. Antide pre ssa nt
C. Ana lge sic
D. Antie me tic
187. W hich of the following drugs should be a dministe re d with
ca ution to pa tie nts re ce iving e chothiopha te for the tre a tme nt of
gla ucoma ?
A. Atropine
B. Succinylcholine
C. Ke ta mine
D. Re mife nta nil
188. W he n one of four thumb twitche s in the tra in-of-four (TOF)
stimula tion of the ulna r ne rve ca n be e licite d, how much
suppre ssion would the re be if you we re me a suring a single twitch?
A. 20 to 25
B. 45 to 55
C. 75 to 80
D. 90 to 95
189. W hich of the following muscle re la xa nts ca use s slight
hista mine re le a se a t two to thre e time s the ED95 (e ffe ctive dose in
95% of subje cts) dose ?
A. Rocuronium
B. Pa ncuronium
C. Atra curium
D. Cisa tra curium
190. Te rmina tion of a ction of the ne urotra nsmitte r nore pine phrine
is a chie ve d pre domina te ly by which me cha nism?
A. Re upta ke into postga nglionic sympa the tic ne rve e ndings
(upta ke 1)
B. Dilution by diffusion a wa y from re ce ptors
C. Me ta bolism by ca te chol-O-me thyltra nsfe ra se (COMT)
D. Me ta bolism by monoa mine oxida se (MAO)
191. The incide nce of unple a sa nt dre a ms a ssocia te d with
e me rge nce from ke ta mine a ne sthe sia ca n be re duce d by the
a dministra tion of
A. Ca ffe ine
B. Drope ridol
C. Physostigmine
D. Mida zola m
192. W hich of the following pre me dica tions is a ssocia te d with
e xtra pyra mida l side e ffe cts?
A. Me toclopra mide
B. Dia ze pa m
C. Scopola mine
D. Glycopyrrola te
193. Succinylcholine , whe n a dministe re d to pa tie nts with re na l
fa ilure , will incre a se se rum [K+] by a pproxima te ly
A. No incre a se in [K+]

B. 0.5 mEq/L

C. 1.5 mEq/L

D. 2.5 mEq/L
194. Ea ch of the following drugs ca n e nha nce the ne uromuscula r
blocka de produce d by nonde pola rizing muscle re la xa nts EXCEPT
A. Ca lcium
B. Aminoglycoside a ntibiotics
C. Ma gne sium
D. Intra ve nous lidoca ine
195. Discontinua tion of which of the following me dica tions is
strongly re comme nde d be fore e le ctive surge ry?
A. Clonidine
B. Me toprolol
C. Monoa mine oxida se inhibitors (MAOIs)
D. None of the a bove
196. Circula ting BNP (B-type na triure tic pe ptide ) is a powe rful
bioma rke r pre dicting outcome s of which of the following?
A. He a rt
B. CNS
C. Kidne ys
D. Orga n re je ction
197. Hype rka le mia is NOT a risk for pa tie nts re ce iving
succinylcholine with which of the following?
A. Multiple scle rosis
B. Mya sthe nia gra vis
C. Guilla in-Ba rré syndrome
D. Be cke r muscula r dystrophy
198. W hich of the a ntibiotics be low doe s NOT a ugme nt
ne uromuscula r blocka de ?
A. Clinda mycin
B. Ne omycin
C. Stre ptomycin
D. Erythromycin
199. A 43-ye a r-old woma n with a scite s, he pa topulmona ry
syndrome , a nd ble e ding e sopha ge a l va rice s is a dmitte d to the ICU.
W hich of the the ra pie s be low is LEAST like ly to improve
symptoms a ssocia te d with he pa tic e nce pha lopa thy (HE)?
A. Amino a cid–rich tota l pa re nte ra l nutrition (TPN)
B. Ne omycin
C. La ctulose
D. Fluma ze nil

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


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

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


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

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


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

50 mg of pre dnisone (De lta sone )?

A. 100 mg cortisol (Solu-Corte f)

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

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

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


221. The re cove ry inde x (RI) of which of the following
nonde pola rizing muscle re la xa nts is NOT a lte re d by a ging?
A. Atra curium
B. Ve curonium
C. Rocuronium
D. Pa ncuronium
222. Side e ffe cts a ssocia te d with cyclosporine the ra py include e a ch
of the following EXCEPT
A. Ne phrotoxicity
B. Pulmona ry toxicity
C. Se izure s
D. Limb pa re sthe sia s
223. W ha t is the pre domina nt me cha nism for succinylcholine -
induce d ta chyca rdia in a dults?
A. Dire ct sympa thomime tic e ffe ct a t postjunctiona l musca rinic
re ce ptors
B. Stimula tion of nicotinic re ce ptors a t a utonomic ga nglia
C. Blocka de of nicotinic re ce ptors a t a utonomic ga nglia
D. Dire ct va golytic e ffe ct a t postjunctiona l musca rinic re ce ptors
224. Bra dyca rdia obse rve d a fte r a dministra tion of succinylcholine to
childre n is a ttributa ble to which me cha nism?
A. Nicotinic stimula tion a t the a utonomic ga nglia
B. Stimula tion of the va gus ne rve ce ntra lly
C. Musca rinic stimula tion a t the sinus node
D. Musca rinic blocka de a t the sinus node
225. W hich of commonly use d drugs be low is NOT me ta bolize d by
nonspe cific e ste ra se s?
A. Propofol
B. Esmolol
C. Atra curium
D. Re mife nta nil
226. Succinylcholine is contra indica te d for routine tra che a l
intuba tion in childre n be ca use of a n incre a se d incide nce of which
of the following side e ffe cts?
A. Hype rka le mia
B. Ma ligna nt hype rthe rmia
C. Ma sse te r spa sm
D. Sinus bra dyca rdia
227. From MOST to LEAST ra pid, se le ct the corre ct te mpora l
se que nce of ne uromuscula r blocka de in the a dductor of the thumb,
the orbicula ris oculi, a nd the dia phra gm a fte r a dministra tion of a n
intuba ting dose of ve curonium to a n othe rwise he a lthy pa tie nt.
A. Dia phra gm, orbicula ris oculi, thumb
B. Orbicula ris oculi, dia phra gm, thumb
C. Orbicula ris oculi, thumb, dia phra gm
D. Orbicula ris oculi sa me a s dia phra gm, thumb
228. Se le ct the T RUE sta te me nt re ga rding inte ra ction of
nonde pola rizing ne uromuscula r blocking drugs whe n dura tions of
a ction a re dissimila r.
A. If a long-a cting drug is a dministe re d a fte r a n inte rme dia te -
a cting drug, the dura tion of the long-a cting drug will be longe r
tha n norma l
B. If a long-a cting drug is a dministe re d a fte r a n inte rme dia te -
a cting drug, the dura tion of the long-a cting drug will be a bout
the sa me a s e xpe cte d
C. If a n inte rme dia te -a cting drug is a dministe re d a fte r a long-
a cting drug, the dura tion of the inte rme dia te -a cting drug will be
a bout the sa me a s e xpe cte d
D. If a n inte rme dia te -a cting drug is a dministe re d a fte r a long-
a cting drug, the dura tion of a ction of the inte rme dia te -a cting
drug will be longe r tha n e xpe cte d
229. Se le ct the corre ct sta te me nt re ga rding the e ffe cts of vola tile
a ne sthe tics on nonde pola rizing ne uromuscula r blocking drugs a nd
the re ve rsa l a ge nts.
A. Vola tile a ne sthe tics pote ntia te ne uromuscula r blocka de but
re ta rd re ve rsa l a ge nts
B. Vola tile a ne sthe tics pote ntia te both ne uromuscula r blocking
drugs a nd re ve rsa l a ge nts
C. Vola tile a ne sthe tics re ta rd both ne uromuscula r blocking drugs
a nd re ve rsa l a ge nts
D. Vola tile a ne sthe tics re ta rd ne uromuscula r blocking drugs but
pote ntia te re ve rsa l a ge nts
230. Me pe ridine is contra indica te d in pa tie nts ta king which of the
following drugs for Pa rkinson dise a se ?
A. Bromocriptine
B. Trihe xyphe nidyl (Arta ne )
C. Se le giline (Elde pryl)
D. Ama nta dine (Symme tre l)
231. Eme rge nce de lirium occurs most ofte n with
A. Se voflura ne
B. De sflura ne
C. Ke ta mine
D. Propofol
232. The most common re a son for pa tie nts to ra te a ne sthe sia with
e tomida te a s unsa tisfa ctory is
A. PONV
B. Pa in on inje ction
C. Re ca ll of intuba tion
D. Postope ra tive hiccups
233. W hich of the following muscle re la xa nts inhibits the re upta ke
of nore pine phrine by the a dre ne rgic ne rve s?
A. Pa ncuronium
B. Ve curonium
C. Rocuronium
D. Atra curium
234. The most common side e ffe ct of ora l da ntrole ne use d to
pre ve nt ma ligna nt hype rthe rmia is
A. Na use a a nd vomiting
B. Muscle we a kne ss
C. Blurre d vision
D. Ta chyca rdia
235. A 65-ye a r-old pa tie nt is a dmitte d for right uppe r qua dra nt pa in.
Acute chole cystitis is dia gnose d a nd la pa roscopic chole cyste ctomy
pla nne d. The pa tie nt ha s no ma jor me dica l proble ms othe r tha n
type 2 dia be te s, for which she ta ke s me tformin, a nd de pre ssion, for
which she ta ke s pa roxe tine (SSRI inhibitor). W hich of the following
be st de scribe s the ra tiona le for discontinua tion of me tformin 48
hours be fore surge ry?
A. Risk of me ta bolic a cidosis
B. Risk of hypoglyce mia
C. Risk of se rotonin syndrome
D. None of the a bove
236. A 37-ye a r-old ma n is brought to the ope ra ting room for re pa ir of
a broke n ma ndible susta ine d in a motor ve hicle a ccide nt. No othe r
injurie s a re significa nt. The pa tie nt ha s be e n in tre a tme nt for
a lcohol a buse a nd ta ke s disulfira m a nd na ltre xone . W hich of the
following would be the be st te chnique for ma na ge me nt of this
pa tie nt’s postope ra tive pa in?
A. Continue na ltre xone with round-the -clock low-dose
me tha done
B. Continue na ltre xone with sma ll dose s of morphine e ve ry 4
hours a s ne e de d
C. Continue na ltre xone with sma ll dose s of na lbuphine e ve ry 4
hours a s ne e de d
D. Discontinue na ltre xone a nd tre a t pa in with morphine a s
ne e de d
237. W hich of the following muscle re la xa nts is most suita ble for
ra pid intuba tion in a pa tie nt in whom succinylcholine is
contra indica te d?
A. Atra curium
B. Rocuronium
C. Ve curonium
D. Cisa tra curium
238. The ne uromuscula r e ffe cts of a n intuba tion dose of
ve curonium a re te rmina te d by
A. Diffusion from the ne uromuscula r junction ba ck into the
pla sma
B. Nonspe cific pla sma choline ste ra se s
C. The kidne ys
D. The live r
239. Re spira tory de pre ssion produce d by which of the following
a na lge sics is not re a dily re ve rse d by a dministra tion of na loxone ?
A. Me pe ridine
B. Me tha done
C. Hydromorphone
D. Bupre norphine
240. W hich of the following intra ve nous a ne sthe tic a ge nts is
a ssocia te d with the highe st incide nce of na use a a nd vomiting?
A. Mida zola m
B. Etomida te
C. Ke ta mine
D. Propofol
241. If na loxone we re a dministe re d to a pa tie nt who is re ce iving
ke torola c for postope ra tive pa in, the most like ly re sult would be
A. Bra dyca rdia
B. Hypote nsion
C. Pa in
D. None of the a bove
242. W hich drug produce s strong pulmona ry a rte ria l dila tion with
the le a st a mount of syste mic a rte ry dila tion?
A. Nitroprusside
B. Prosta gla ndin E1
C. Phe ntola mine
D. Nitric oxide
243. The a ction of succinylcholine a t the ne uromuscula r junction is
te rmina te d by which me cha nism?
A. Hydrolysis by pse udocholine ste ra se
B. Diffusion into e xtra ce llula r fluid
C. Re upta ke into ne rve tissue
D. Re upta ke into muscle tissue
244. The LEAST like ly side e ffe ct of de xme de tomidine in a he a lthy
pa tie nt is
A. Re spira tory a rre st
B. Bra dyca rdia
C. Sinus a rre st
D. Hypote nsion
245. The a dva nta ge of fospropofol (Luse dra ) ove r propofol is the
a bse nce of
A. Pa in on inje ction
B. Risk of hype rtriglyce ride mia
C. Risk of infe ction, se psis, or both
D. All of the a bove
246. W hich of the following fe a ture s of chronic morphine the ra py is
NOT subje ct to tole ra nce ?
A. Ana lge sia
B. Re spira tory de pre ssion
C. Constipa tion
D. All a re subje ct to tole ra nce
247. A 78-ye a r-old woma n with a history of re a ctive a irwa ys dise a se

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


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

A. 2 mg ve curonium followe d by succinylcholine

B. 1 mg of ve curonium, the n 2 to 4 minute s la te r, 9 mg


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

ge ne ra l a ne sthe sia ; 5 mg of mida zola m a nd 250 mg of fe nta nyl a re


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

(pla sma choline ste ra se ) ha s a dibuca ine numbe r of 57. A 1 mg/kg


dose of intra ve nous succinylcholine would like ly re sult in
A. Hype rka le mic ca rdia c a rre st
B. Pa ra lysis la sting 5 to 10 minute s
C. Pa ra lysis la sting 20 to 30 minute s
D. Pa ra lysis la sting more tha n 1 to 3 hours
261. Cya nide toxicity ma y be tre a te d with a ll of the following drugs
EXCEPT
A. Sodium nitrite
B. Hydroxocoba la min
C. Sodium thiosulfa te
D. Me thyle ne blue
262. A prolonge d ne uromuscula r block with succinylcholine ca n be
se e n in a ll of the following pa tie nts EXCEPT those
A. Chronica lly e xpose d to ma la thion
B. Tre a te d with e chothiopha te for gla ucoma
C. Tre a te d with cyclophospha mide for me ta sta tic ca nce r
D. Ha ving a C5 isoe nzyme va ria nt
263. W hich of the following sta te me nts conce rning mida zola m is
FALSE?
A. Mida zola m ha s gre a te r a mne stic tha n se da tive prope rtie s
B. Its bre a kdown is inhibite d by cime tidine
C. It produce s re trogra de a mne sia
D. It fa cilita te s the a ctions of the inhibitory ne urotra nsmitte r γ-
a minobutyric a cid (GABA) in the CNS
264. Afte r a 2-hour ve rtica l ga stric ba nding proce dure unde r
de sflura ne , oxyge n, a nd re mife nta nil a ne sthe sia , the troca r is
re move d a nd the wound is close d. Upon e me rge nce , the most
like ly sce na rio is
A. Ade qua te a na lge sia for 2 hours
B. De la ye d e me rge nce from na rcotic
C. Pa in
D. Re spira tory de pre ssion in posta ne sthe sia ca re unit (PACU)
265. An ora l surge on is a bout to pe rform a full mouth e xtra ction on
a 70-kg, 63-ye a r-old ma n unde r conscious se da tion. W ha t is the
ma ximum dose of lidoca ine with e pine phrine tha t he ca n sa fe ly
infiltra te ?

A. 200 mg

B. 300 mg

C. 400 mg

D. 500 mg
266. Posta ne sthe tic shive ring ca n be tre a te d with a ll of the
following EXCEPT
A. Na loxone
B. Physostigmine
C. Ma gne sium sulfa te
D. De xme de tomidine
267. The ma in disa dva nta ge of Suga mma de x (ORG 25969) compa re d
with ne ostigmine is
A. Re cura riza tion
B. Contra indica te d with re na l fa ilure
C. Not e ffe ctive with be nzylisoquinolinium re la xa nts
D. High incide nce of a lle rgic re a ctions
268. W hich of the biologic substa nce s liste d be low is by itse lf the
gre a te st de te rmina nt of se rum osmola lity?
A. AVP (a rginine va sopre ssin)
B. Angiote nsin I
C. Aldoste rone
D. Re na l prosta gla ndins (PGE2)
269. Above which infusion ra te doe s cya nide toxicity be come a
conce rn in a he a lthy a dult re ce iving sodium nitroprusside ?

A. 0.5 µg/kg/min

B. 2 µg/kg/min

C. 10 µg/kg/min

D. 20 µg/kg/min
270. Importa nt inte ra ctions involving chlorproma zine include a ll of
the following EXCEPT
A. Pote ntia tion of the de pre ssa nt e ffe cts of na rcotics
B. Lowe ring of the se izure thre shold
C. Prolonga tion of the QT inte rva l
D. Pote ntia tion of ne uromuscula r blocka de
271. Amrinone
A. Is a positive inotropic drug
B. Is a nta gonize d by e smolol
C. Is a va soconstrictor
D. All the a bove
272. W hich sta te me nt conce rning tricyclic a ntide pre ssa nts in
pa tie nts re ce iving ge ne ra l a ne sthe sia is T RUE?
A. The y should be discontinue d 2 we e ks be fore e le ctive
ope ra tions
B. The y ma y de cre a se the re quire me nt for vola tile a ne sthe tics
(de cre a se MAC)
C. Me pe ridine ma y produce hype rpyre xia in pa tie nts ta king
tricyclic a ntide pre ssa nts
D. The y ma y e xa gge ra te the re sponse to e phe drine
273. W hich of the following type s of insulin pre pa ra tions ha s the
fa ste st onse t of a ction if a dministe re d subcuta ne ously?
A. Gla rgine (La ntus)
B. Lispro (Huma log)
C. Re gula r (Humulin-R)
D. NPH (Humulin-N)
274. W hich of the following me cha nisms be st e xpla ins the
a nticoa gula tive prope rtie s of tirofiba n?
A. Cyclooxyge na se (COX) inhibition
B. Inte ra ction with von W ille bra nd fa ctor (vW F)
C. Inte ra ction with a ntithrombin III
D. Enha nce d a nti-Xa a ctivity
275. The dura tion of a ction of re mife nta nil is a ttributa ble to which
mode of me ta bolism?
A. Sponta ne ous de gra da tion in blood (Hofma nn e limina tion)
B. Hydrolysis by nonspe cific pla sma e ste ra se s
C. Hydrolysis by pse udocholine ste ra se
D. Ra pid me ta bolism in the la rge inte stine
276. Pa in a t the intra ve nous site is LEAST with which IV drug?
A. Dia ze pa m
B. Etomida te
C. Ke ta mine
D. Propofol
277. A 35-ye a r-old pa tie nt with a history of gra nd ma l se izure s is
a ne sthe tize d for thyroid biopsy unde r ge ne ra l a ne sthe sia consisting

of 4 mg mida zola m with infusion of propofol (150 µg/kg/min) a nd

re mife nta nil (1 µg/kg/min). The pa tie nt ta ke s phe nytoin for control

of se izure s. Afte r 30 minute s, the infusion is stoppe d a nd the


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

280. A dose of 150 mg of IV da ntrole ne is a dministe re d to a 24-ye a r-


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

DIRECT IONS (Que stions 283 through 320): Ea ch group of


que stions consists of se ve ra l numbe re d sta te me nts followe d
by le tte re d he a dings. For e a ch numbe re d sta te me nt, se le ct
the ONE le tte re d he a ding tha t is most close ly a ssocia te d with
it. Ea ch le tte re d he a ding ma y be se le cte d once , more tha n
once , or not a t a ll.

Group 283-287
283. Adre na l suppre ssion
284. Thrombosis, phle bitis, spe cific a nta gonist a va ila ble
285. Pa in on inje ction, se ve re hypote nsion in e lde rly
286. Incre a se s ICP
287. La ctic a cidosis ma y de ve lop with prolonge d use
A. Ke ta mine
B. Dia ze pa m
C. Etomida te
D. Propofol
Group 288-292
288. Re duce s MAC
289. Blocka de of a ngiote nsin re ce ptor
290. W ith high dose s ma y ca use a syste mic lupus e rythe ma tosus–
like syndrome
291. Produce s α-a dre ne rgic re ce ptor a nd β-a dre ne rgic re ce ptor
blocka de
292. Ma y re sult in se ve re re bound hype rte nsion whe n a bruptly
discontinue d
A. Clonidine
B. Hydra la zine
C. Losa rta n
D. La be ta lol
Group 293-297
293. Alte rna tive to he pa rin for ca rdiopulmona ry bypa ss
294. Glycoprote in (GP)IIb/IIIa inhibition
295. Dire ct thrombin inhibition
296. Use d a fte r a ngiopla sty ofte n for a ye a r or more to pre ve nt
re ste nosis
297. Anti-Xa a ctivity me cha nism of a ction
A. Arga troba n
B. Clopidogre l
C. Abcixima b
D. Fonda pa rinux
Group 298-301
298. Of the list, most like ly to be a ssocia te d with opioid induce d
hype ra lge sia
299. De monstra te s ce iling e ffe ct with re ga rd to re spira tory
de pre ssion
300. Anta gonism of NMDA re ce ptors
301. Nore pine phrine re upta ke inhibitor (NRI)
A. Me tha done
B. Re mife nta nil
C. Ta pe nta dol (Nucynta )
D. Butorpha nol
Group 302-305
302. Block is a nta gonize d with a nticholine ste ra se drugs
303. Block is e nha nce d with a nticholine ste ra se drugs
304. Post-te ta nic fa cilita tion occurs
305. Susta ine d re sponse to te ta nic stimulus is se e n
A. True of nonde pola rizing blocka de only
B. True of pha se I de pola rizing blocka de only
C. True of pha se II de pola rizing blocka de only
D. True of nonde pola rizing a nd pha se II de pola rizing blocka de
Group 306-315
306. Amphe ta mine s
307. α2 Agonists (clonidine , de xme de tomidine )
308. Hype rthyroidism
309. Acute e tha nol inge stion
310. Lidoca ine
311. Lithium
312. Opioids
313. Dura tion of a ne sthe sia
314. Pre gna ncy

315. Pa O2 35 mm Hg
A. No cha nge in MAC
B. Incre a se s MAC
C. De cre a se s MAC
D. Acute a dministra tion incre a se s MAC; chronic a dministra tion
de cre a se s MAC
Group 316-320
316. Le a st e ffe ctive a ntisia la gogue
317. Produce s be st se da tion
318. Ca use s gre a te st incre a se in he a rt ra te
319. Doe s not produce ce ntra l a nticholine rgic syndrome
320. Ma y produce mydria sis a nd cyclople gia whe n pla ce d topica lly
in the e ye
A. Atropine
B. Glycopyrrola te
C. Scopola mine
D. Atropine a nd scopola mine
Pharmacology and Pharmacokinetics of
Intravenous Drugs
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
169. (A) The dura tion of a ction of ne uromuscula r blocking drugs is
re la te d to the dose a dministe re d, a s we ll a s how the drug is
me ta bolize d or ha ndle d in the body. Succinylcholine norma lly is
ra pidly me ta bolize d by pla sma choline ste ra se a nd ha s a n
ultra short dura tion of a ction. The inte rme dia te -dura tion
ne uromuscula r blocke rs a tra curium a nd cisa tra curium unde rgo
che mica l bre a kdown in the pla sma (Hofma nn e limina tion), a s we ll
a s e ste r hydrolysis. Ve curonium a nd rocuronium a lso ha ve
inte rme dia te dura tion of a ctions a nd unde rgo prima rily he pa tic
me ta bolism a nd bilia ry e xcre tion with limite d re na l e xcre tion
(10%-25%). Only the long-dura tion ne uromuscula r blocke r
pa ncuronium is prima rily e xcre te d in the urine (80%). In pa tie nts
with re na l fa ilure , the dura tion of a ction of ne uromuscula r blocke rs
is not prolonge d with a tra curium or cisa tra curium; is slightly
prolonge d with ve curonium a nd rocuronium; a nd is ma rke dly
prolonge d with D-tubocura rine , pa ncuronium, doxa curium, a nd
pipe curonium. Of the long-dura tion drugs, 80% of pa ncuronium, 70%
of doxa curium, a nd 70% of pipe curonium a re re na lly e xcre te d
uncha nge d in the urine . D-tubocura rine ha s a little more live r
e xcre tion a nd a little le ss re na l e limina tion compa re d with
pa ncuronium (Miller: Miller’s Anesth esia, ed 8, pp 975–977).
COMPARATIVE PHARMACOLOGY OF NONDEPOLARIZING
NEUROMUSCULAR BLOCKING DRUGS
NA, not applicable; NS, not significant.
∗ Control twitch height (minutes).

From Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, p 151, Table 12-6.

170. (D) Pa ncre a titis ha s be e n re porte d in pa tie nts on long-te rm


propofol infusions. Be ca use of the high fa t conte nt of propofol
solutions (propofol is insoluble in a que ous solutions a nd is
ma rke te d a s a n e mulsion conta ining 10% soybe a n oil, 2.25%
glyce rol, a nd 1.2% purifie d e gg phospha tide ), pa tie nts on long-te rm
infusion should be che cke d for hype rlipide mia a nd pa tie nts
re ce iving TPN should ha ve the Intra lipid portion of the TPN
re duce d. Propofol infusion syndrome is commonly de fine d a s a n
a cute onse t of me ta bolic a cidosis a ssocia te d with ca rdia c
dysfunction (e .g., bra dyca rdia or right bundle bra nch block), a nd
one of the following: rha bdomyolysis, hype rtriglyce ride mia ,
e nla rge d live r, or re na l fa ilure . Propofol de cre a se s myoca rdia l
contra ctility a nd re duce s syste mic va scula r re sista nce but doe s not
ca use a dre na l suppre ssion. The la tte r is a fe a ture of e tomida te
a dministra tion (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 536–537; Miller: Basics of Anesth esia, ed
6, p 671).
171. (B) β-Adre ne rgic re ce ptor a nta gonists a re of thre e ge ne ra tions.
First-ge ne ra tion a nta gonists a re nonse le ctive β1 a nd β2 re ce ptor
blocke rs a nd include na dolol (Corga rd), propra nolol (Inde ra l),
sota lol (Be ta pa ce ), a nd timolol (Bloca dre n, Timoptic). Se cond-
ge ne ra tion a nta gonists a re ca rdiose le ctive β1 re ce ptor blocke rs a nd
include a ce butolol (Se ctra l), a te nolol (Te normin), bisoprolol
(Ze be ta ), e smolol (Bre vibloc), a nd me toprolol (Lopre ssor). Third-
ge ne ra tion β-a dre ne rgic a nta gonists (mixe d a nta gonists) ha ve
nonse le ctive β1 a nd β2 re ce ptor blocking a ctions a nd ha ve
a dditiona l ca rdiova scula r e ffe cts (α1-a dre ne rgic a nta gonist) a nd
include la be ta lol (Normodyne , Tra nda te ) a nd ca rve dilol (Core g).
Ca rve dilol a lso ha s some a ntioxida nt a nd a nti-infla mma tory e ffe cts
a s we ll. Ma ny of the se drugs ha ve a dditiona l tra de na me s (Brunton:
Good m an & Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12,
pp 320–330; Hem m ings; Ph arm acology and Ph y siology for Anesth esia, pp
228–229; Miller: Miller’s Anesth esia, ed 8, pp 370–371).
172. (C) Pa rkinson dise a se (pa ra lysis a gita ns or sha king pa lsy) is a
de ge ne ra tive CNS dise a se . It is ca use d by gre a te r tha n 80%
de struction of dopa mine rgic ne urons in the substa ntia nigra of the
ba sa l ga nglia . Dopa mine a cts a s a ne urotra nsmitte r to inhibit the
ra te of firing of ne urons tha t control the e xtra pyra mida l motor
syste m. The imba la nce of ne urotra nsmitte rs tha t re sults le a ds to
the e xtra pyra mida l symptoms of this dise a se . Symptoms include
bra dykine sia (slowne ss of move me nt), muscula r rigidity, re sting
tre mor (tha t le sse ns with volunta ry move me nt), a nd impa ire d
ba la nce . Drugs tha t ca n produce e xtra pyra mida l e ffe cts, such a s
the dopa mine a nta gonists drope ridol, prome tha zine , a nd
thie thylpe ra zine , a s we ll a s the dopa mine a nd se rotonin a nta gonist
me toclopra mide , a re contra indica te d. Onda nse tron, a 5-
hydroxytrypta mine type 3 (5-HT 3) re ce ptor a nta gonist, is the
pre fe rre d drug to tre a t na use a a nd vomiting for this pa tie nt (Barash :
Clinical Anesth esia, ed 7 , p 621; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 646–647).
173. (A) In orde r for de pola rizing muscle re la xa nts such a s
succinylcholine to work, the drug must inte ra ct with the re ce ptor a t
the myone ura l junction. Pa tie nts with mya sthe nia gra vis ha ve
fe we r a ce tylcholine re ce ptors on the muscle a nd a re more
re sista nt to succinylcholine but a re much more se nsitive to
nonde pola rizing muscle re la xa nts. Pa tie nts with mya sthe nic
syndrome (Ea ton-La mbe rt syndrome ) ha ve a de cre a se d re le a se of
a ce tylcholine a t the myone ura l junction; howe ve r, the numbe r of
re ce ptors is norma l. Pa tie nts with mya sthe nic syndrome a re more
se nsitive to both de pola rizing a nd nonde pola rizing muscle
re la xa nts. Huntington chore a is a de ge ne ra tive CNS dise a se tha t is
a ssocia te d with de cre a se d pla sma choline ste ra se a ctivity, a nd
prolonge d re sponse s to succinylcholine use ha ve be e n se e n. The
re sponse to de pola rizing a nd nonde pola rizing muscle re la xa nts
a ppe a rs to be uncha nge d in pa tie nts with polymyositis.
Succinylcholine is contra indica te d in pa tie nts with Duche nne
muscula r dystrophy be ca use of the risks of rha bdomyolysis,
hype rka le mia , a nd ca rdia c a rre st. Nonde pola rizing muscle
re la xa nts ha ve a norma l re sponse in pa tie nts with Duche nne
muscula r dystrophy, a lthough some pa tie nts ha ve promine nt
coe xisting ske le ta l muscle we a kne ss (Fleish er: Anesth esia and
Uncom m on Diseases, ed 6, pp 264–265, 313–316, 574; Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 247, 444, 448–452).
174. (C) Se da tion is commonly use d in the ICU to pre ve nt pa tie nt
injury, de cre a se a nxie ty, re duce pa in, re duce sympa the tic
stimula tion, a nd he lp with ve ntila tor dyssynchrony. Ma ny diffe re nt
drugs ha ve be e n use d, including ba rbitura te s, na rcotics (e .g.,
fe nta nyl, morphine ), be nzodia ze pine s (e .g., mida zola m, lora ze pa m),
e tomida te , ke ta mine , a ntipsychotics (e .g., ha lope ridol), propofol,
a nd α2-a dre ne rgic a gonists (e .g., de xme de tomidine ). Although de e p
se da tion wa s commonly use d, more re ce nt e vide nce ha s sugge ste d
tha t pa tie nts te nd to ha ve fe we r complica tions with light se da tion
a nd da ily a wa ke ning (e .g., shorte r dura tion of me cha nica l
ve ntila tion, le ss ca rdiova scula r de pre ssion, a nd shorte r ICU sta ys).
The choice of drugs de pe nds on the pa rticula r indica tions.
De xme de tomidine ha s se ve ra l de sira ble e ffe cts, e spe cia lly in the
ne urosurgica l ICU, including se da tion, a na lge sia , a nd little e ffe ct on
re spira tory drive . Its se da tive prope rtie s re se mble norma l sle e p in
tha t the se da te d pa tie nt ca n be e a sily a rouse d with stimula tion a nd
the n ra pidly fa ll ba ck to sle e p a fte r stimula tion e nds.
De xme de tomidine doe s ha ve some disa dva nta ge s, such a s cost
a nd U.S. Food a nd Drug Administra tion (FDA)-a pprove d use for
only 24 hours (Barash : Clinical Anesth esia, ed 7, pp 1584, 1599–1600;
Miller: Basics of Anesth esia, ed 6, p 672).
175. (B) Dia ze pa m (Va lium) a nd lora ze pa m a re wa te r-insoluble
be nzodia ze pine s a nd a re usua lly mixe d with propyle ne glycol to
be come soluble solutions. The se propyle ne glycol solutions a re
pa inful whe n inje cte d. Mida zola m ha s a n imida zole ring tha t a llows
the drug to be wa te r soluble in a n a cid pH (pH 3.5). W he n inje cte d
into the bloodstre a m, mida zola m is e xpose d to the highe r
physiologic pH a nd the ring cha nge s sha pe a nd the drug be come s
lipid soluble . The lipid-soluble form re a dily crosse s the blood-bra in
ba rrie r to e xe rt its pha rma cologic e ffe cts. None of the othe r drugs
cha nge form with diffe re nt pH (Hem m ings: Ph arm acology and
Ph y siology for Anesth esia, pp 144–145).
176. (C) The a mount of submucosa lly inje cte d e pine phrine re quire d
to produce ve ntricula r ca rdia c dysrhythmia s (i.e ., thre e or more
pre ma ture ve ntricula r contra ctions during or a fte r inje ction) va rie s
with the vola tile a ne sthe tic a dministe re d. Pa tie nts unde r ha lotha ne
a ne sthe sia a re pa rticula rly se nsitive to ve ntricula r a rrhythmia s,
whe re a s pa tie nts with isoflura ne , de sflura ne , a nd se voflura ne a re
le ss se nsitive to e pine phrine . Fifty pe rce nt of pa tie nts ha ve

ve ntricula r a rrhythmia s whe n a dose of 2.1 µg/kg of e pine phrine is


a dministe re d submucosa lly into pa tie nts unde r ha lotha ne
a ne sthe sia . Ve ntricula r a rrhythmia s do not se e m to occur whe n a

dose of up to 5 µg/kg of e pine phrine is inje cte d submucosa lly into


pa tie nts unde r 1.2 MAC of se voflura ne or isoflura ne in oxyge n
a ne sthe sia . Howe ve r, whe n the dose of e pine phrine is incre a se d

to be twe e n 5 a nd 15 µg/kg, the n a bout one third of pa tie nts will


e xhibit ve ntricula r e ctopy unde r se voflura ne or isoflura ne

a ne sthe sia . Thus, using the 5 µg/kg ma ximum dose , a 70-kg pa tie nt

could re ce ive up to 350 µg of e pine phrine (70 kg × 5 µg/kg) or

35 mL of this 1:100,000 solution (10 µg/mL) without ve ntricula r


a rrhythmia s (Joh nston: A com parative interaction of epineph rine with
enflurane, isoflurane and h aloth ane in m an. Anesth Analg 55:709–712,
1976; Navarro: Hum ans anesth etized with sevoflurane or isoflurane h ave
sim ilar arrh y th m ic response to epineph rine. Anesth esiology 80:545–549,
1994; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed
4, pp 54–56; Miller: Miller’s Anesth esia, ed 8, p 713).
177. (D) β-Adre ne rgic re ce ptor a nta gonists a re e ffe ctive in the
tre a tme nt of e sse ntia l hype rte nsion a nd a ngina pe ctoris. The y ca n
be use d to de cre a se morta lity in pa tie nts suffe ring myoca rdia l
infa rctions; to tre a t hype rthyroidism or hype rtrophic obstructive
ca rdiomyopa thy; a nd to pre ve nt migra ine he a da che s. Although the y
a re use ful drugs, the ir use is limite d by ma ny side e ffe cts, which
include bronchoconstriction, suppre ssion of insulin se cre tion,
blunting of the ca te chola mine re sponse to hypoglyce mia , e xce ssive
myoca rdia l de pre ssion, a triove ntricula r he a rt block, a cce ntua te d
incre a se s in pla sma conce ntra tions of pota ssium with intra ve nous
infusion of pota ssium chloride , fa tigue , a nd re bound ta chyca rdia
a ssocia te d with a brupt drug discontinua tion. An importa nt
a dva nta ge of β-a dre ne rgic re ce ptor a nta gonists use d in tre a ting
hype rte nsion is the la ck of orthosta tic hypote nsion (Brunton:
Good m an & Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 12,
pp 320–324; Miller: Basics of Anesth esia, ed 6, pp 745–775; Miller: Miller’s
Anesth esia, ed 8, pp 1217–1218).
178. (C) Anticholine rgics a re ra re ly give n with pre me dica tion toda y
unle ss a spe cific e ffe ct is ne e de d (e .g., drying of the mouth be fore
fibe roptic intuba tion, pre ve ntion of bra dyca rdia , a nd, ra re ly, a s a
mild se da tive ). Side e ffe cts a re ma ny a nd include re la xa tion or a
de cre a se of the lowe r e sopha ge a l sphincte r tone tha t ma y ma ke
pa tie nts more like ly to re gurgita te ga stric conte nts. Although the se
drugs ca n de cre a se ga stric a cid se cre tion a nd incre a se ga stric pH,
the pH e ffe cts a re sma ll a nd the dose ne e de d to a ccomplish this is
much highe r tha n clinica lly use d. The following ta ble compa re s the
e ffe cts of va rious a nticholine rgics (Hem m ings, Ph arm acology and
Ph y siology for Anesth esia, pp 229–232; Miller: Basics of Anesth esia, ed 6,
pp 75–76; Miller: Miller’s Anesth esia, ed 8, pp 377-378).
COMPARATIVE EFFECTS OF ANTICHOLINERGICS ADMINISTERED
INTRAMUSCULARLY AS PHARMACOLOGIC PREMEDICATION

From Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, p 76, Table 7-3.

179. (D) Ne ostigmine , pyridostigmine , e drophonium, a nd


physostigmine a re a nticholine ste ra se drugs. Ne ostigmine ,
pyridostigmine , a nd e drophonium a re qua te rna ry a mmonium
compounds a nd do not pa ss the blood-bra in ba rrie r. Howe ve r,
physostigmine is a te rtia ry a mine a nd doe s cross the blood-bra in
ba rrie r. This prope rty ma ke s physostigmine use ful in the tre a tme nt
for ce ntra l a nticholine rgic syndrome (a lso ca lle d postope ra tive
de lirium or a tropine toxicity) (Barash : Clinical Anesth esia, ed 7, pp 382–
383).
180. (D) W he re a s propofol, ba rbitura te s, e tomida te , a nd
be nzodia ze pine s e xe rt much, if not a ll, of the ir pha rma cologic
e ffe cts via the GABA re ce ptors, ke ta mine ha s only we a k a ctivity on
the GABA re ce ptors. Ke ta mine ’s me cha nism of a ction is comple x,
with most of the e ffe cts due to inte ra ction with NMDA re ce ptors.
Ke ta mine a lso inte ra cts with monoa mine rgic, musca rinic, a nd
opioid re ce ptors, a s we ll a s volta ge -se nsitive ca lcium ion cha nne ls
(Miller: Basics of Anesth esia, ed 6, pp 109–110).
181. (D) All of the drugs liste d a re opioids. Me pe ridine is
structura lly simila r to a tropine a nd posse sse s mild a nticholine rgic
prope rtie s. In contra st to othe r opioid-re ce ptor a gonists,
me pe ridine ra re ly ca use s bra dyca rdia but ca n incre a se he a rt ra te .
Norme pe ridine , a me ta bolite of me pe ridine with some CNS-
stimula ting prope rtie s, ma y ca use de lirium a nd se izure s if the le ve l
is high e nough. This is more like ly in pa tie nts who ha ve re na l
impa irme nt a nd a re re ce iving me pe ridine ove r se ve ra l da ys
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
102–104).
182. (D) In the Unite d Sta te s, ke ta mine is pre pa re d a s a mixture of
the two isome rs S(+) a nd R(−). In some countrie s, the S(+) isome r,
which is more pote nt a nd ha s fe we r side e ffe cts, is a va ila ble . All of
the sta te me nts a re true e xce pt for a nswe r D. Norke ta mine
(ke ta mine ’s prima ry a ctive me ta bolite ) is one fifth to one third a s
pote nt a s ke ta mine a nd ca n contribute to prolonge d e ffe cts (Barash :
Clinical Anesth esia, ed 7, pp 743–747; Miller: Basics of Anesth esia, ed 6,
pp 109–111).
183. (B) Dire ct-a cting sympa thomime tic drugs work dire ctly on the
re ce ptors. Indire ct-a cting sympa thomime tic drugs ha ve the ir e ffe cts
prima rily by e nte ring the ne urons a nd the n displa cing
nore pine phrine a nd ca using the re le a se of nore pine phrine from the
postga nglionic sympa the tic ne rve fibe rs. Ephe drine ,
me phe nte rmine , a nd me ta ra minol a re prima rily indire ct-a cting
sympa thomime tic a ge nts tha t a lso ma y ha ve some dire ct-a cting
prope rtie s. The following ta ble summa rize s the sympa thomime tic
a ge nts a nd the ir e ffe cts on the a dre ne rgic re ce ptors (Miller: Basics of
Anesth esia, ed 6, pp 72–73).
CLASSIFICATION AND COMPARATIVE PHARMACOLOGY OF
SYMPATHOMIMETICS
From Stoelting RK: Pharmacology and Physiology in Anesthetic Practice, ed 4, Philadelphia,
Lippincott Williams & Wilkins, 2006, p 293.

184. (D) Na loxone , na ltre xone , a nd na lme fe ne a re opioid re ce ptor


a nta gonists tha t ca n re ve rse the ce ntra l a nd pe riphe ra l e ffe cts of
opioids (e .g., me tha done ). Me thylna ltre xone is a qua te rna ry
a mmonium opioid re ce ptor a nta gonist tha t doe s not pe ne tra te the
CNS (i.e ., doe s not re ve rse a na lge sia ) but doe s a nta gonize
pe riphe ra l opioid re ce ptors (i.e ., blocks the GI tra ct’s opioid
re ce ptors a nd ca n tre a t opioid-induce d constipa tion). Be ca use of its
structure it is not a bsorbe d a fte r ora l a dministra tion, so it is
a dministe re d by inje ction (Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, pp 265–267; Miller: Miller’s Anesth esia, ed 8, pp 904–906).
185. (B) Pa tie nts with HIV ta ke a t le a st thre e drugs simulta ne ously
during the ir tre a tme nt. A va rie ty of a ntire trovira l drugs such a s
nucle oside re ve rse tra nscripta se inhibitors (NRTIs), non-nucle oside
re ve rse tra nscripta se inhibitors (NNRTIs), e ntry inhibitors,
inte gra se inhibitors, a nd/or prote a se inhibitors a re use d. Indina vir,
ne lfina vir, a nd ritona vir a re thre e of ma ny prote a se inhibitors
curre ntly a va ila ble . All prote a se e nzyme inhibitors ha ve me ta bolic
drug inte ra ctions. Most (e spe cia lly ritona vir in clinica l dose s)
irre ve rsibly inhibits CYP3A4 a nd this inhibition could la st for 2 to 3
da ys a fte r the drug is stoppe d.
CYP3A4 is involve d in the me ta bolism of be nzodia ze pine s (e .g.,
mida zola m) a nd ma ny opioids (e .g., fe nta nyl), a nd the se drugs
will ha ve highe r conce ntra tions a nd prolonge d e limina tion time s
whe n prote a se inhibitors a re use d. Prote a se inhibitors ca n a lso
induce the production of the CYP e nzyme s a llowing some drugs
(e .g., e stroge ns) to be me ta bolize d more quickly. In a ddition,
prote a se inhibitors ma y ca use glucose intole ra nce , disorde rs in
lipid me ta bolism, pre ma ture a the roscle rosis, a nd dia stolic
dysfunction le a ding to he a rt fa ilure , a s we ll a s a cute tubula r
ne crosis a nd ne phrolithia sis (Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, pp 1623–1660; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 484–491).
186. (C) Apre pita nt is a n NK1 a nta gonist (substa nce P a nta gonist)
with a long ha lf-life of 9 to 13 hours. It is ora lly a dministe re d for the
pre ve ntion a nd tre a tme nt of PONV, a lthough it se e ms be tte r in
pre ve nting vomiting. NK1 a nta gonists ma y a ct syne rgistica lly with 5-
HT 3 a nta gonists a nd/or de xa me tha sone . Apre pita nt is not
a ssocia te d with QTc prolonga tion. Although ma rke te d for its
a ntie me tic e ffe cts, it ha s some a nxiolytic a nd mild a ntide pre ssa nt
e ffe cts a s we ll (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, p 512; Miller: Miller’s Anesth esia, ed 8, pp 2637, 2967–2968).
187. (B) Echothiopha te is a n orga nophospha te tha t inhibits
a ce tylcholine ste ra se a s we ll a s pse udocholine ste ra se , which is
re sponsible for the me ta bolism of succinylcholine a nd e ste r-type
loca l a ne sthe tics. It doe s this by forming a phosphoryla te d comple x
with a ce tylcholine ste ra se . The topica l solution is instille d in the
e ye for tre a tme nt of re fra ctory ope n-a ngle gla ucoma . The a mount
of drug a bsorbe d ma y be sufficie nt to inhibit a ce tylcholine ste ra se
a nd ca use prolonga tion in the dura tion of a ction of succinylcholine
or miva curium. Be ca use of this, it is “re comme nde d” to wa it a t
le a st 3 we e ks a fte r the stoppa ge of e chothiopha te be fore the
a dministra tion of the se two muscle re la xa nts. One must wonde r
a bout the se “re comme nda tions” be ca use clinica l ca se s ha ve
shown tha t whe n choline ste ra se a ctivity is de cre a se d (from
e chothiopha te ) to no a ctivity, the incre a se in dura tion of
ne uromuscula r block from succinylcholine wa s le ss tha n 25
minute s (Miller: Miller’s Anesth esia, ed 8, p 379).
188. (D) Monitoring ne uromuscula r blocka de for nonde pola rizing
muscle re la xa nts ca n be done in a va rie ty of wa ys. The simple st
wa y is to me a sure the re duction or suppre ssion of a single twitch
he ight. This is commonly pe rforme d by obse rving the twitch
re sponse of the thumb’s a dductor pollicis muscle , a fte r ulna r ne rve
stimula tion. At 90% to 95% re duction of twitch he ight (i.e ., ED90 to
ED95) the re is good muscle re la xa tion for intuba tion a nd intra -
a bdomina l surge ry. Howe ve r, me a suring the re duction of twitch
he ight is not pra ctica l. Be ca use the re is good corre la tion be twe e n
re duction of twitch he ight a nd the numbe r of thumb twitche s tha t
ca n be e licite d by TOF stimula tion, TOF stimula tion is more
commonly use d whe re four twitche s a re a dministe re d ove r 2
se conds. If only one twitch of a TOF is de monstra te d, single twitch
he ight is de pre sse d a t le a st 85%; with two to four thumb twitche s,
70% to 85% de pre ssion is se e n. Note tha t the pre se nce of four
twitche s doe s not me a n tha t ne uromuscula r function ha s
comple te ly re cove re d; in fa ct, a significa nt numbe r of re ce ptors
ma y still be occupie d by the muscle re la xa nt (Barash : Clinical
Anesth esia, ed 7, p 544).
189. (C) The re a re two ma jor che mica l cla sse s of nonde pola rizing
muscle re la xa nts: the a minoste roids (-onium drugs) a nd the
be nzylisoquinolinium (-urium) drugs. In ge ne ra l, the a minoste roids
ca use no significa nt hista mine re le a se (a t the clinica l dose s of 2 to
3 × ED95), whe re a s some of the be nzylisoquinolinium drugs ca n.
The hista mine re le a se prima rily occurs with ra pid a dministra tion
of a tra curium but doe s not occur with cisa tra curium or doxa curium.
The a mount of hista mine re le a se d is ra re ly of clinica l significa nce .
The ca rdiova scula r e ffe cts of ne uromuscula r blocking drugs occur
by thre e ma in me cha nisms: (1) drug-induce d hista mine re le a se ; (2)
e ffe cts a t ca rdia c musca rinic re ce ptors; or (3) e ffe cts on nicotinic
re ce ptors a t a utonomic ga nglia . The following ta ble summa rize s
the me cha nisms for the ca rdiova scula r e ffe cts of muscle re la xa nts
(Miller: Miller’s Anesth esia, ed 7, p 882).
CLINICAL AUTONOMIC EFFECTS OF NEUROMUSCULAR
BLOCKING DRUGS

From Miller RD: Miller’s Anesthesia, ed 7, Philadelphia, Saunders, 2011, p 882, Table 29-11.

190. (A) Postga nglionic sympa the tic ne rve fibe rs re le a se


nore pine phrine from the syna ptic ve sicle s in the ne rve te rmina ls.
Eighty pe rce nt of the re le a se d nore pine phrine ra pidly unde rgoe s
re upta ke into the sympa the tic ne rve te rmina ls (upta ke 1) a nd
re e nte rs stora ge ve sicle s for future re le a se . Only a sma ll a mount of
the nore pine phrine tha t is re a bsorbe d is me ta bolize d in the
cytopla sm by MAO. Twe nty pe rce nt of the nore pine phrine is dilute d
by diffusion a wa y from the re ce ptors a nd ca n ga in a cce ss to the
circula tion. COMT, which is loca te d prima rily in the live r,
me ta bolize s this nore pine phrine (Miller: Miller’s Anesth esia, ed 8, pp
357–358; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, pp 700–701).
191. (D) Administra tion of ke ta mine ma y be a ssocia te d with visua l,
a uditory, a nd proprioce ptive ha llucina tions. The se unple a sa nt side
e ffe cts of ke ta mine occur on e me rge nce a nd ma y progre ss to
de lirium. The incide nce of e me rge nce de lirium from ke ta mine is
dose de pe nde nt a nd occurs in a pproxima te ly 5% to 30% of pa tie nts.
Eme rge nce de lirium is le ss fre que nt a fte r re pe a te d a dministra tions
of ke ta mine . The most e ffe ctive pre ve ntion for e me rge nce de lirium
is a dministra tion of a be nzodia ze pine (mida zola m be ing more
e ffe ctive tha n dia ze pa m) a bout 5 minute s be fore induction of
a ne sthe sia with ke ta mine . Atropine a nd drope ridol give n
pe riope ra tive ly ma y incre a se the incide nce of e me rge nce de lirium
(Miller: Basics of Anesth esia, ed 6, pp 110–111; Miller: Miller’s Anesth esia,
ed 8, pp 827–828).
192. (A) Extra pyra mida l side e ffe cts a re se e n most ofte n with
a ntipsychotic drugs (e .g., phe nothia zine s, thioxa nthe ne s, a nd
butyrophe none s), but the y a lso ca n be se e n with a dministra tion of
me toclopra mide . Me toclopra mide , a dopa mine a nta gonist,
incre a se s lowe r e sopha ge a l sphincte r tone a nd stimula te s ga stric
a nd uppe r inte stina l tra ct motility. Side e ffe cts a ssocia te d with
me toclopra mide use include mild se da tion, dysphoria , a gita tion,
dry mouth, a nd, in ra re insta nce s, dystonic e xtra pyra mida l
re a ctions (oculogyric crise s, trismus, torticollis). Aka thisia , or the
fe e ling of une a se a nd motor re stle ssne ss, ha s occurre d following
IV me toclopra mide , which ma y re sult in ca nce lla tion of e le ctive
surge ry (Miller: Miller’s Anesth esia, ed 8, p 2963; Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp 499–502).
193. (B) Succinylcholine is a de pola rizing muscle re la xa nt tha t
che mica lly re se mble s a ce tylcholine a nd a tta che s to the
postjunctiona l me mbra ne ion cha nne l re ce ptors. Susta ine d ope ning
of ion cha nne ls produce d by succinylcholine (a s oppose d to a
tra nsie nt ope ning with a ce tylcholine ) is a ssocia te d with le a ka ge of
pota ssium from the inte rior of ce lls sufficie nt to incre a se pla sma

conce ntra tions of pota ssium by a bout 0.5 mEq/L in norma l pa tie nts.
This slight incre a se of pota ssium le ve ls in pa tie nts with re na l
fa ilure is simila r to pa tie nts with norma l re na l function (Miller:
Miller’s Anesth esia, ed 8, p 963; Miller: Basics of Anesth esia, ed 6, p 148;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
220).
194. (A) Ma ny drugs ca n e nha nce the ne uromuscula r block
produce d by nonde pola rizing muscle re la xa nts. The se include
vola tile a ne sthe tics, a minoglycoside a ntibiotics, ma gne sium,
intra ve nous loca l a ne sthe tics, furose mide , da ntrole ne , ca lcium
cha nne l blocke rs, a nd lithium. Ca lcium doe s not e nha nce
ne uromuscula r blocka de a nd, in fa ct, a ctua lly a nta gonize s the
e ffe cts of ma gne sium. In pa tie nts with hype rpa ra thyroidism a nd
hype rca lce mia the re is a de cre a se d se nsitivity to nonde pola rizing
muscle re la xa nts a nd shorte r dura tions of a ction (Miller: Miller’s
Anesth esia, ed 8, pp 980–983).
195. (D) None of the se drugs should be a bruptly stoppe d. Clonidine
is a ce ntra lly a ctive α-a dre ne rgic a gonist tha t is use d in the
tre a tme nt of hype rte nsion. Se ve re re bound hype rte nsion ca n be
se e n be twe e n 8 a nd 36 hours a fte r the la st dose , e spe cia lly in

pa tie nts re ce iving more tha n 1.2 mg/da y. Re bound hype rte nsion, a s
we ll a s ca rdia c ische mia , ca n be se e n a fte r discontinua tion of β-
blocke r the ra py (e .g., a te nolol or me toprolol). In the pa st, it wa s
re comme nde d to stop MAOIs 2 to 3 we e ks be fore e le ctive surge ry
be ca use of the possibility of de ve loping hype rte nsive crisis during
surge ry. More re ce ntly, it ha s be come a cce pta ble to use the se drugs
up to the time of surge ry, be ca use the ir discontinua nce could pla ce
the pa tie nt a t risk for suicide . Ce rta in drug inte ra ctions ma y occur
with MAOI use , including ske le ta l muscle rigidity or hype rpyre xia
with me pe ridine , a s we ll a s a n e xa gge ra te d hype rte nsive re sponse
with the indire ct-a cting va sopre ssor e phe drine . Abrupt withdra wa l
of chronic high-dose tricyclic a ntide pre ssa nt the ra py ca n be
a ssocia te d with withdra wa l symptoms (i.e ., ma la ise , chills, coryza ,
ske le ta l muscle a ching) a nd is not re comme nde d (Miller: Basics of
Anesth esia, ed 6, pp 179–182; Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 401–407).
196. (A) About 40 ye a rs a go it wa s note d tha t kidne y re sponse
va rie s with the type of shock. In ca nine s, hypovole mic shock
re duce d re na l blood flow to 10% of controls, whe re a s ca rdioge nic
shock re duce d re na l blood flow to only 75% of controls. The ma in
diffe re nce se e me d to be re la te d to the a tria l pre ssure s (de cre a se d
in hypovole mic shock but incre a se d in ca rdioge nic shock). About 10
ye a rs la te r, a pe ptide wa s isola te d from the a trium of ra ts na me d
a tria l or A-type na triure tic pe ptide (ANP). La te r a na triure tic
pe ptide wa s isola te d from porcine bra ins a nd wa s na me d bra in or
B-type na triure tic pe ptide (BNP). In huma ns, BNP is ma inly
produce d in the ca rdia c ve ntricle s. Na triure tic pe ptide s a re
prima rily re le a se d from the a tria (ANP) a nd ve ntricle s (BNP) whe n
the cha mbe rs a re ove rdiste nde d. Thus, in the fa iling he a rt, BNP is
re le a se d. Na triure tic pe ptide s ha ve a ma in e ffe ct on the kidne ys to
e xcre te sodium a nd wa te r. The y ha ve va sodila ting prope rtie s a nd
inhibit the re le a se of re nin. Blood le ve ls of BNP a re use d a s a
ma rke r for the se ve rity of ca rdiova scula r dise a se a nd ma y ha ve a
role in pre ope ra tive ca rdia c risk a sse ssme nt. Ne siritide is a
re combina nt BNP a nd is be ing studie d for the tre a tme nt of a cute
he a rt fa ilure (Barash : Clinical Anesth esia, ed 7, p 141; Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 123–125, 131; Miller:
Miller’s Anesth esia, ed 8, p 3).
197. (B) Multiple scle rosis (MS) is a n a cquire d infla mma tory
a utoimmune dise a se in which the re is de mye lina tion of ne rve
fibe rs within the CNS. In pa tie nts with MS a nd profound ne urologic
de ficits, succinylcholine ma y ca use hype rka le mia a nd should be
a voide d, a nd nonde pola rizing muscle re la xa nts a ppe a r sa fe .
Guilla in-Ba rré syndrome is a n infla mma tory polyne uritis a ffe cting
the pe riphe ra l ne rvous syste m a nd a ssocia te d with muscle
we a kne ss. In pa tie nts with Guilla in-Ba rré , succinylcholine ma y
ca use hype rka le mia a nd should be a voide d, whe re a s
nonde pola rizing muscle re la xa nts a re not contra indica te d but a re
a voide d be ca use of incre a se d se nsitivity a nd possible prolonge d
muscle we a kne ss in the postope ra tive pe riod.
Duche nne muscula r dystrophy a nd the le ss common Be cke r
muscula r dystrophy a re both X-linke d re ce ssive dise a se s. The y
a re cha ra cte rize d by progre ssive muscle we a kne ss. In 1992 the
U.S. Food a nd Drug Administra tion issue d a wa rning with re ga rd
to the use of succinylcholine in childre n a nd a dole sce nts be ca use
succinylcholine ha s be e n a ssocia te d with se ve ra l de a ths whe n
a dministe re d to pa tie nts with unsuspe cte d muscula r dystrophy
(ma ny de ve lope d hype rka le mia a nd we re la te r dia gnose d a s
ha ving muscula r dystrophy). Nonde pola rizing muscle re la xa nts
a ppe a r sa fe , but a slowe r onse t ma y e xist.
Mya sthe nia gra vis pa tie nts ha ve fe we r postsyna ptic re ce ptors a t
the myone ura l junction, a nd, if succinylcholine is a dministe re d,
the y a ppe a r to be re sista nt. La rge r dose s a ppe a r ne e de d (1.5-

2 mg/kg) for intuba tion, a nd the re is no a ssocia te d hype rka le mic


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

succinylcholine (1 mg/kg = 2 × the ED95) will show ne uromuscula r


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

0.5 mEq/L a fte r the a dministra tion of succinylcholine . Howe ve r, in


some a cquire d conditions the pota ssium le ve l ma y incre a se 5 to

7 mEq/L a bove the ba se line pota ssium le ve l a fte r a dministra tion of


succinylcholine . This ma rke d e le va tion of pota ssium ma y le a d to
ca rdia c a rre st. The se a cquire d conditions include the following: (1)
de ne rva tion injury a s ca use d by spina l cord injury le a ding to
ske le ta l muscle a trophy; (2) ske le ta l muscle injury re sulting from
third-de gre e burns (until sca rring occurs); (3) a cute uppe r motor
ne uron injury such a s stroke ; (4) se ve re ske le ta l muscle tra uma ;
a nd (5) se ve re a bdomina l infe ctions. In the se a cquire d conditions
the pote ntia l to incre a se pota ssium le ve ls a fte r succinylcholine
usua lly ta ke s a fe w da ys to de ve lop, pe a ks 10 to 50 da ys a fte r the
initia l injury, a nd ma y pe rsist for 6 months or more . All fa ctors
conside re d, it might be prude nt to a void a dministra tion of
succinylcholine to a ny pa tie nt more tha n 24 hours a fte r the
conditions liste d he re . This vulne ra bility to hype rka le mia ma y
re fle ct a prolife ra tion of e xtra junctiona l choline rgic re ce ptors,
which provide more site s for pota ssium to le a k outwa rd a cross the
ce ll me mbra ne during de pola riza tion. Some ha ve sugge ste d tha t the
numbe r of re ce ptors is uncha nge d but tha t the re ce ptors
the mse lve s ha ve a lte re d a ffinity to a ce tylcholine or drugs. Simila r
ma rke d e le va tions of pota ssium ma y de ve lop in ca se s of
undia gnose d myopa thy (Miller: Basics of Anesth esia, ed 6, p 149–150).
202. (A) Although fluma ze nil (a spe cific be nzodia ze pine a nta gonist)
inhibits the a ctivity a t the GABA re ce ptor, it works only a t the
be nzodia ze pine re cognition site a nd ha s no e ffe ct in re ve rsing othe r
drugs tha t work on the GABA site (e .g., ba rbitura te s, e tomida te ,
propofol). It ha s a fa st onse t (within minute s), with pe a k bra in
le ve ls occurring within 6 to 10 minute s, a nd a re la tive ly short
dura tion of a ction. Fluma ze nil ca n re ve rse a ll be nzodia ze pine CNS
e ffe cts, including se da tive , a mne stic, muscle re la xa nt, a nd
a nticonvulsa nt e ffe cts. Side e ffe cts a re ra re , the most common
be ing na use a , vomiting, or both (a bout 10%). Na use a occurs more
commonly whe n fluma ze nil is give n to pa tie nts a fte r ge ne ra l
a ne sthe sia tha n a fte r conscious se da tion. Due to its short clinica l
dura tion of a ction, pa tie nts re ce iving fluma ze nil should be
monitore d for possible re se da tion a nd re spira tory de pre ssion
(Miller: Miller’s Anesth esia, ed 8, pp 843–844; Ph y sicians Desk Reference,
ed 63, 2009, pp 2646–2649; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, p 290).
203. (D) Nonste roida l a nti-infla mma tory drugs (NSAIDs) (e .g.,
a spirin, a ce ta minophe n, indome tha cin, ibuprofe n, diclofe na c, a nd
ke torola c) inhibit COX e nzyme s tha t a re involve d in the conve rsion
of a ra chidonic a cid to prosta gla ndin, thromboxa ne , a nd
prosta cyclin. COX-1 is involve d with pla te le t a ggre ga tion a nd ga stric
mucosa l prote ction; COX-2 is involve d with pa in, infla mma tion, a nd
fe ve r. TXA2 ha s prothrombotic a nd va soconstricting prope rtie s.
Prosta cyclin I2 ha s a ntithrombotic a nd va sodila ting prope rtie s.
Ke torola c is a nonse le ctive inhibitor of both COX-1 a nd COX-2
e nzyme s. Se le ctive COX-2 drugs (e .g., only ce le coxib, curre ntly
a va ila ble in the Unite d Sta te s) ca n be use d, but in ge ne ra l the se
ha ve be e n shown to ca use a sma ll incre a se in thrombotic issue s
(but fe we r e ffe cts on ga stric mucosa a nd pla te le t a ctivity). Be ca use
of a ce iling e ffe ct with re ga rd to a na lge sia , ke torola c ha s only mild-
to-mode ra te a na lge sic e ffe cts (Hem m ings: Ph arm acology and
Ph y siology for Anesth esia, pp 272–278; Miller: Basics of Anesth esia, ed 6,
pp 703–704; Miller: Miller’s Anesth esia, ed 8, pp 2978–2982).
204. (D) Acute inte rmitte nt porphyria is the most se rious form of
porphyria . This dise a se a ffe cts both the ce ntra l a nd pe riphe ra l
ne rvous syste ms. An a cute inte rmitte nt porphyria a tta ck ca n be
trigge re d by a va rie ty of conditions, including sta rva tion,
de hydra tion, stre ss, se psis, a nd some drugs, such a s e tomida te a nd
ba rbitura te s. Drugs tha t a re sa fe or probably safe include loca l
a ne sthe tics, inha le d a ne sthe tics, ne uromuscula r blocking drugs,
some intra ve nous a ne sthe tics (propofol a nd ke ta mine ), some
a na lge sics (a ce ta minophe n, a spirin, morphine , fe nta nyl,
sufe nta nil), a ntie me tics (drope ridol, H2 blocke rs, me toclopra mide ,
onda nse tron), a nd ne ostigmine a nd na loxone . Drugs tha t a re
contra indica te d include some intra ve nous a ne sthe tics
(ba rbitura te s), some a na lge sics (ke torola c, pe nta zocine ), a nd
hyda ntoin a nticonvulsa nts (Barash : Clinical Anesth esia, ed 7, pp 624–
625; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 308).
205. (A) Cytochrome P450 (CYP) e nzyme s a re involve d in the
me ta bolism of ma ny me dica tions. The re a re ma ny such isoforms
a nd the se a re furthe r cha ra cte rize d into fa milie s with a n Ara bic
numbe r a nd furthe r cha ra cte rize d into subfa milie s (ca pita l le tte r).
The clinica l a ctivity of the se e nzyme s ca n be incre a se d (induce d) or
de cre a se d (inhibite d) by a ge , ge ne tics, me dica tions, a nd some
foods. CYP2D6 is ne e de d to conve rt the ina ctive code ine to the
a ctive morphine . Simila rly, CYP2D6 a lso me ta bolize s oxycodone
into a ctive oxymorphone , a nd ina ctive hydrocodone into a ctive
hydromorphone . CYP2D6 is inhibite d by selective serotonin reuptake
inh ibitors (SSRIs) a s we ll a s with quinidine . SSRIs include fluoxe tine
(Proza c), se rtra line (Zoloft), pa roxe tine (Pa xil), fluvoxa mine (Luvox),
cita lopra m (Ce le xa ), a nd e scita lopra m (Le xa pro). Thus, pa tie nts
ta king SSRIs or quinidine will ge t a poor a na lge sic e ffe ct with
code ine , oxycodone , a nd hydrocodone (Hem m ings; Ph arm acology
and Ph y siology for Anesth esia, pp 64–65, 183–186; Miller: Basics of
Anesth esia, ed 6, p 37).
206. (D) Although e tomida te ca use s pa in on intra ve nous inje ction in
up to 80% of pa tie nts, the uninte ntiona l a dministra tion of e tomida te
into a n a rte ry doe s not re sult in de trime nta l e ffe cts to the a rte ry
(Miller: Miller’s Anesth esia, ed 8, p 852).
207. (D) Fe nta nyl is more lipid soluble tha n morphine , so it pa sse s
through the blood-bra in ba rrie r more e a sily a nd ha s a fa ste r onse t
of a ction. Fe nta nyl a lso ha s a la rge r volume of distribution, slowe r
pla sma cle a ra nce , a nd longe r e limina tion ha lf-life tha n morphine .
Howe ve r, the dura tion of a ction of fe nta nyl (whe n give n in sma ll
dose s) is much shorte r tha n tha t of morphine be ca use fe nta nyl is
ra pidly re distribute d from the bra in to ina ctive tissue site s (e .g.,
lipid site s). In la rge r dose s, the se tissue site s ca n be come
sa tura te d, a nd the pha rma cologic a ction of fe nta nyl be come s
conside ra bly prolonge d (Miller: Basics of Anesth esia, ed 7, p 115–119;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
104–105).
208. (D) This que stion illustra te s the conce pt of infusion front-e nd
kine tics. This conce pt is use ful for compa ring the kine tics of
va rious intra ve nous a ge nts use d in a ne sthe sia . Re mife nta nil
re a che s the ste a dy sta te in le ss tha n 1 hour of continuous infusion.
Approxima te ly 8 hours a re re quire d to re a ch the ste a dy sta te with
a lfe nta nil a nd sufe nta nil, whe re a s fe nta nyl a nd morphine ha ve not
a chie ve d the ste a dy sta te conce ntra tion e ve n a fte r 10 hours of
continuous infusion.
Anothe r importa nt conce pt is the time a fte r bolus to re a ch pe a k
e ffe ct: bolus front-e nd kine tics. This conce pt is more intuitive to
most a ne sthe sia provide rs. Compa ring the sa me na rcotics use d
in this que stion, a lfe nta nil a nd re mife nta nil re a ch pe a k
conce ntra tion a t ne a rly the sa me time a nd fe nta nyl only slightly
la te r (Miller: Basics of Anesth esia, ed 6, p 119).

209. (C) Ble omycin is use d prima rily in the tre a tme nt of Hodgkin
lymphoma a nd te sticula r tumors. Ble omycin ca use s oxida tive
da ma ge to nucle otide s, which le a ds to bre a ks in DNA. Although
the more common side e ffe cts of ble omycin use a re
mucocuta ne ous, dose -re la te d pulmona ry toxicity is the most
se rious side e ffe ct. Ea rly signs a nd symptoms of pulmona ry toxicity
include dry cough, fine ra le s, a nd diffuse infiltra te s on x-ra y.
Approxima te ly 5% to 10% of pa tie nts will de ve lop pulmona ry
toxicity, a nd a bout 1% will die from this complica tion. Most be lie ve
tha t the risk of pulmona ry toxicity incre a se s with dose (e spe cia lly

tota l dose >250 mg), in pa tie nts olde r tha n 40 ye a rs of a ge , in

pa tie nts with a cre a tinine cle a ra nce (CrCl) of le ss tha n 80 mL/min,
a nd in pa tie nts with prior che st ra dia tion or pre e xisting pulmona ry
dise a se . Although a re la tionship a ppe a rs to e xist be twe e n the use
of ble omycin a nd the use of high conce ntra tions of oxyge n, the
de ta ils a re uncle a r. Curre ntly, it ha s be e n sugge ste d to use the
lowe st conce ntra tion of oxyge n consiste nt with pa tie nt sa fe ty with a
ca re ful e va lua tion of oxyge n sa tura tion with pulse oxime try in a ny
pa tie nt who ha s re ce ive d ble omycin (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1716–1718; Miller:
Miller’s Anesth esia, ed 8, p 1951; Stoelting: Ph arm acology and Ph y siology
in Anesth etic Practice, ed 4, pp 555–565).
210. (C) The first two le tte rs of the word “rocuronium” sta nd for
“ra pid onse t.” Of the nonde pola rizing muscle re la xa nts curre ntly
a va ila ble , rocuronium ha s the most ra pid onse t of a ction a t
clinica lly use ful dosa ge s. Rocuronium is a nonde pola rizing
ne uromuscula r re la xa nt with a n inte rme dia te dura tion of a ction
simila r to ve curonium, a tra curium, a nd cisa tra curium. At a n ED95

dose (0.3 mg/kg), the onse t time is 1.5 to 3 minute s, whe re a s with
the othe r inte rme dia te nonde pola rizing muscle re la xa nts, the onse t

time is 3 to 7 minute s. At la rge r dose s (i.e ., 2 × ED95 or 0.6 mg/kg),


onse t time ca n be re duce d to 1 to 1.5 minute s (Barash : Clinical
Anesth esia, ed 7, p 538).
211. (D) An a cute de cre a se in se rum pota ssium ca use s
hype rpola riza tion of ce ll me mbra ne s. This ca use s re sista nce to
de pola rizing ne uromuscula r blocke rs a nd a n incre a se d se nsitivity
to nonde pola rizing ne uromuscula r blocke rs (Stoelting: Ph arm acology
and Ph y siology in Anesth etic Practice, ed 4, pp 226–227).
212. (D) Awa re ne ss during ge ne ra l a ne sthe sia is the postope ra tive
re ca ll of e ve nts tha t ha ppe ne d during the a ne sthe tic. Ove ra ll
incide nce ha s de cre a se d from a bout 1% 50 ye a rs a go to a bout 0.1%
toda y (with some va ria tions from study to study). Pa tie nts a t
incre a se d risk include pa tie nts unde rgoing ca rdia c surge ry,
e ndoscopic a irwa y surge ry, ce sa re a n se ctions, a nd tra uma surge ry
(Miller: Miller’s Anesth esia, ed 8, p 1528).
213. (C) The symptoms de scribe d in this pa tie nt a re consiste nt with
choline rgic stimula tion or incre a se d le ve ls of a ce tylcholine tha t
occur with a nticholine ste ra se poisoning. Stimula tion of the
pa ra sympa the tic ne rvous syste m produce s miosis, a bdomina l
cra mping, e xce ss sa liva tion, loss of bowe l a nd bla dde r control,
bra dyca rdia , a nd bronchoconstriction. The se symptoms a re tre a te d
with a tropine . The a ce tylcholine ste ra se re a ctiva tor pra lidoxime
some time s is a dde d to tre a t the nicotinic e ffe cts of e le va tion of
a ce tylcholine a t the ne uromuscula r junction of ske le ta l muscle (i.e .,
ske le ta l muscle we a kne ss, a pne a ). CNS e ffe cts of e le va te d
a ce tylcholine le ve ls ca n include confusion, a ta xia , a nd coma . In
a ddition, supportive the ra py (the ABCs of re suscita tion [Airwa y,
Bre a thing, Circula tion, e tc.]) is provide d a s ne e de d (Miller: Miller’s
Anesth esia, ed 8, p 2495).
214. (C) Fluma ze nil is a be nzodia ze pine a nta gonist use d to
a nta gonize the be nzodia ze pine e ffe cts on the CNS. It doe s not
re ve rse the e ffe cts of ba rbitura te s, opia te s, or a lcohol. Se izure s ca n
be pre cipita te d in pa tie nts who ha ve be e n on be nzodia ze pine s for
long-te rm se da tion or pa tie nts showing signs of se rious cyclic
a ntide pre ssa nt ove rdosa ge (e .g., twitching, rigidity, wide ne d QRS
comple x, hypote nsion). Fluma ze nil ha s a shorte r e limina tion ha lf-
life (0.7-1.3 hours) compa re d with mida zola m (2-2.5 hours).
Fluma ze nil is poorly a bsorbe d ora lly (Miller: Miller’s Anesth esia, 8, p
843; Ph y sicians’ Desk Reference, ed 63, 2009, pp 2646–2649).
215. (D) Ade qua te re cove ry from ne uromuscula r blocka de is
be lie ve d to occur whe n 50% or le ss of re ce ptors a re occupie d with
muscle re la xa nts. This ca n be me a sure d with susta ine d te ta nus a t

100 Hz, but this te st is ve ry pa inful. Anothe r me thod re quire s


pa tie nt coope ra tion a nd consists of a susta ine d he a d lift for 5
se conds in the supine position. The “he a d lift” te st is the sta nda rd
te st to de te rmine a de qua te muscula r function (Miller: Basics of
Anesth esia, ed 6, p 158).
216. (B) PONV is the se cond-most common compla int re porte d in
the pe riope ra tive pe riod (pa in is the numbe r one compla int). Ma ny
drugs ha ve be e n use d to both pre ve nt (prophyla xis) a nd to tre a t
(re scue ) PONV. Antie me tics we re ofte n a dministe re d a lone , but
now combina tion the ra py of two or more drugs such a s dopa mine
a nta gonists (e .g., drope ridol, me toclopra mide ), hista mine
a nta gonists (e .g., diphe nhydra mine , proma zine ), a nticholine rgics
(e .g., scopola mine ), ste roids (e .g., de xa me tha sone ), ne urokinin
a nta gonists (e .g., a pre pita nt), a nd se rotonin a nta gonist (e .g.,
onda nse tron, dola se tron, gra nise tron, a nd pa lonose tron) a re
commonly use d. Once a se rotonin a nta gonist is give n for
prophyla xis, a dding more of a se rotonin a nta gonist in the PACU
doe s not se e m to he lp. It is be tte r to use a n a ntie me tic from
a nothe r cla ss of drugs (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 503–551; Miller: Miller’s Anesth esia, ed 8, pp 2947, 2969–
2970).
217. (A) Pa tie nts with W PW syndrome a re pre dispose d to de ve lop
supra ve ntricula r a rrhythmia s. Sympa the tic stimula tion (e .g., a nxie ty,
hypovole mia ), a s we ll a s ma ny drugs (e .g., pa ncuronium,
me pe ridine , ke ta mine , e phe drine , digoxin, ve ra pa mil), ca n induce
ta chya rrhythmia s, ofte n by e nha ncing conduction through a cce ssory
a tria l pa thwa ys. Although ve ra pa mil is use d to tre a t
supra ve ntricula r ta chya rrhythmia s be ca use of its de pre ssa nt e ffe cts
on a lve ola r noda l conduction, it a ctua lly ma y incre a se the he a rt
ra te in pa tie nts with W PW syndrome be ca use it ca n incre a se
conduction of the a cce ssory pa thwa ys. Drope ridol, in a ddition to its
a ntidopa mine rgic prope rtie s, ha s a ntidysrhythmic prope rtie s tha t
prote ct a ga inst e pine phrine -induce d dysrhythmia s. Propose d
me cha nisms include α-a dre ne rgic re ce ptor blocka de a nd mild loca l

a ne sthe tic e ffe cts. La rge dose s of drope ridol (0.2-0.6 mg/kg) ca n
re duce impulse tra nsmission via the a cce ssory pa thwa ys
re sponsible for the ta chya rrhythmia s tha t occur in pa tie nts with
W PW syndrome (Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 413–415, 766).
218. (B) Pse udocholine ste ra se (a lso ca lle d pla sma choline ste ra se )
is a n e nzyme found in pla sma a nd most othe r tissue s (e xce pt
e rythrocyte s). Pse udocholine ste ra se me ta bolize s the a ce tylcholine
re le a se d a t the ne uromuscula r junction, a s we ll a s ce rta in drugs
such a s succinylcholine , miva curium, a nd e ste r-type loca l
a ne sthe tics. It is produce d in the live r a nd ha s a ha lf-life of
a pproxima te ly 8 to 16 hours. Pse udocholine ste ra se le ve ls ma y be
re duce d in pa tie nts with a dva nce d live r dise a se . The de cre a se
must be gre a te r tha n 75% be fore significa nt prolonga tion of
ne uromuscula r blocka de occurs with succinylcholine (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 218).
219. (D) COX inhibitors a re use ful a na lge sics for mild-to-mode ra te
pa in. The re a re thre e type s of COX inhibitors: cyclooxyge na se -1
(COX-1), cyclooxyge na se -2 (COX-2), a nd cyclooxyge na se -3 (COX-3).
COX-3 is a va ria nt of COX-1, a nd the re is some controve rsy a s to its
e xiste nce in huma ns. COX inhibitors block prosta gla ndin synthe sis
in the pe riphe ry a nd in the CNS. COX-1 ha s GI mucosa l prote cting
prope rtie s a nd stimula te s pla te le t a ggre ga tion. Drugs with COX-1
inhibiting prope rtie s ca n ca use ga stric a nd duode na l ulce rs a nd ca n
inte rfe re with pla te le t a ggre ga tion. COX-2 is involve d in
infla mma tion. NSAIDs a re nonspe cific COX-1 a nd COX-2 inhibitors.
Se le ctive COX-2 inhibitors such a s ce le coxib, va lde coxib, a nd
rofe coxib a re e ffe ctive a na lge sics with a nti-infla mma tory e ffe cts.
The y ha ve a lowe r risk of GI complica tions a nd a ntipla te le t
prope rtie s tha n the nonspe cific COX-1 a nd COX-2 inhibitors.
Be ca use of a n incre a se in se rious thromboe mbolic e ve nts (i.e .,
stroke s a nd myoca rdia l infa rctions), both va lde coxib a nd rofe coxib
ha ve be e n withdra wn from the ma rke t. Curre ntly, ce le coxib is the
only se le ctive COX-2 inhibitor a va ila ble in the Unite d Sta te s. In
a ddition, both the NSAIDs a nd se le ctive COX-2 inhibitors ca n
tra nsie ntly de cre a se re na l function, e spe cia lly in pa tie nts with
pre e xisting re na l dise a se a nd in pa tie nts who a re hypovole mic.
The se re na l e ffe cts ca n le a d to hype rte nsion, e de ma , a nd a cute
re na l fa ilure (Hem m ings: Ph arm acology and Ph y siology for Anesth esia,
pp 272–277; Miller: Basics of Anesth esia, ed 6, pp 703–704; Barash :
Clinical Anesth esia, ed 7, p 437).
220. (C) The a dre na l corte x se cre te s two cla sse s of ste roids, the
corticoste roids (glucocorticoids a nd mine ra locorticoids) a nd the
a ndroge ns. The ma in glucocorticoid is hydrocortisone , a lso ca lle d
cortisol. The glucocorticoids a re use d prima rily for the ir a nti-
infla mma tory a nd immunosuppre ssive e ffe cts, but the y a lso ha ve
mine ra locorticoid a ctivity (i.e ., sodium-re ta ining e ffe cts). The se
drugs diffe r in pote ncy, a mount of mine ra locorticoid e ffe ct, a nd
dura tion of a ction. The norma l a mount of cortisol produce d da ily is

a bout 10 mg, but unde r stre ss, the le ve l ca n incre a se te nfold. The
ma in mine ra locorticoid is a ldoste rone . The norma l a mount of

a ldoste rone produce d da ily is a bout 0.125 mg. Be ca use


fludrocortisone ha s such significa nt mine ra locorticoid a ctivity, it is
use d only for this. The following ta ble compa re s se ve ra l

corticoste roids. In this ca se , 50 mg of pre dnisone is e quiva le nt in

glucocorticoid a ctivity to 7.5 mg of de xa me tha sone a nd 200 mg of


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

221. (A) The RI of ne uromuscula r blocking drugs is the time ne e de d


for sponta ne ous re cove ry of a twitch he ight from 25% to 75% of the
ba se line he ight. The e lde rly, who te nd to ha ve re duce d re na l a nd
he pa tic function, ha ve a prolonge d RI for nonde pola rizing muscle
re la xa nts tha t a re de pe nde nt upon re na l or he pa tic e limina tion
(e .g., ve curonium, D-tubocura rine , pa ncuronium, rocuronium). The
RI for a tra curium a nd cisa tra curium, which a re broke n down in the
pla sma , a re not prolonge d in the e lde rly (Miller: Miller’s Anesth esia,
ed 8, pp 975–976).
222. (B) Cyclosporine is a drug tha t se le ctive ly inhibits he lpe r T-
lymphocyte -me dia te d but not B-lymphocyte –me dia te d immune
re sponse s. It is ma inly use d a lone or in combina tion with
corticoste roids to pre ve nt or tre a t orga n re je ction. Othe r use s
include the tre a tme nt of Crohn dise a se , uve itis, psoria sis, a nd
rhe uma toid a rthritis. Side e ffe cts tha t ma y a ccompa ny the
a dministra tion of cyclosporine include ne phrotoxicity (25%-38%),
hype rte nsion, limb pa re sthe sia s (50%), he a da che s, confusion,
somnole nce , se izure s, e le va tion of live r e nzyme s, a lle rgic
re a ctions, gum hype rpla sia , hirsutism, a nd hype rglyce mia . The re
a ppe a rs to be no pulmona ry toxicity a ssocia te d with cyclosporine
the ra py (Miller: Miller’s Anesth esia, ed 8, p 580).
223. (B) Succinylcholine is ba sica lly two a ce tylcholine mole cule s
hooke d toge the r. Succinylcholine ma y e xe rt ca rdiova scula r e ffe cts
by: (1) inducing hista mine re le a se from ma st ce lls; (2) stimula ting
a utonomic ga nglia , which incre a se s ne urotra nsmission a t both the
sympa the tic a nd pa ra sympa the tic ne rvous syste ms; a nd (3) dire ctly
stimula ting postjunctiona l ca rdia c musca rinic re ce ptors. The e ffe ct
of succinylcholine on he a rt ra te is va ria ble , with both bra dyca rdia
a nd ta chyca rdia possible . The fina l he a rt ra te de pe nds upon ma ny
fa ctors, including the a mount of nicotinic stimula tion of the
sympa the tic a nd pa ra sympa the tic ga nglia , which is gre a te r for the
nondomina nt a utonomic ne rvous syste m. For e xa mple , whe n
sympa the tic ne rvous syste m tone is high (a s in childre n),
bra dyca rdia is more like ly to de ve lop whe n succinylcholine is
a dministe re d. W he n pa ra sympa the tic ne rvous syste m tone is high
(a s in ma ny a dults), ta chyca rdia , a lthough not common, is more
like ly to occur whe n succinylcholine is a dministe re d. Bra dyca rdia
is more like ly to occur whe n a se cond intra ve nous dose of
succinylcholine is a dministe re d 4 to 5 minute s a fte r the first dose ,
e spe cia lly whe n difficult la ryngoscopy (e .g., inte nse va ga l
stimula tion) is be ing pe rforme d (Miller: Basics of Anesth esia, ed 6, p
150).
224. (C) Che mica lly, succinylcholine is two a ce tylcholine mole cule s
hooke d toge the r a nd ha s ma ny e ffe cts simila r to a ce tylcholine . In
a ddition to ca using ne uromuscula r blocka de , succinylcholine
stimula te s a ll choline rgic a utonomic re ce ptors, including the
nicotinic re ce ptors of the sympa the tic a nd pa ra sympa the tic ga nglia ,
a s we ll a s the musca rinic re ce ptors in the sinus node of the he a rt.
It is this musca rinic e ffe ct tha t ca use s the bra dyca rdia tha t ca n be
se e n a fte r the a dministra tion of succinylcholine in childre n. Also
se e e xpla na tion to Que stion 223 (Miller: Miller’s Anesth esia, ed 8, p
962).
225. (A) Propofol’s che mica l structure is 2,6-diisopropylphe nol (i.e .,
is not a n e ste r) a nd thus is not me ta bolize d by e ste ra se s. Propofol
is ra pidly me ta bolize d by the live r to more wa te r-soluble
compounds tha t a re the n re na lly e xcre te d. Esmolol is a n e ste r
compound a nd is ra pidly me ta bolize d by RBC e ste ra se s (short ha lf-
life of 9-10 minute s). Atra curium a nd cisa tra curium prima rily
unde rgo Hofma nn e limina tion, which is a che mica l re a ction.
Atra curium ha s a se cond me ta bolic route : me ta bolism by
nonspe cific pla sma e ste ra se s. Inte re stingly, cisa tra curium, which is
a n isola te d form of a tra curium (1 of the 10 ste re oisome rs), doe s not
unde rgo me ta bolism by nonspe cific pla sma e ste ra se s.
The short dura tion of a ction of re mife nta nil is due to its e ste r
structure , which is me ta bolize d by blood a nd tissue nonspe cific
e ste ra se s. Be ca use of the nonspe cific me ta bolism, its dura tion of
a ction is not prolonge d in pa tie nts with pse udocholine ste ra se
de ficie ncy (Miller: Basics of Anesth esia, ed 6, pp 75, 100–101, 125, 154;
Miller: Miller’s Anesth esia. ed 8, pp 371, 824, 888–889, 977).
226. (A) Hype rka le mia , ma ligna nt hype rthe rmia , ma sse te r spa sm,
sinus bra dyca rdia , noda l rhythms, a nd mya lgia s a re side e ffe cts
tha t ca n be se e n a fte r the a dministra tion of succinylcholine . In
re ce nt ye a rs, the re ha ve be e n se ve ra l ca se re ports of intra cta ble
ca rdia c a rre st in a ppa re ntly he a lthy childre n a fte r the
a dministra tion of succinylcholine . In the se ca se s, hype rka le mia ,
rha bdomyolysis, a nd a cidosis we re docume nte d. La te r, muscle
biopsy sa mple s de monstra te d tha t ma ny of the se ca se s we re
subclinica l ca se s of Duche nne muscula r dystrophy. For this re a son
of occa siona l se ve re hype rka le mia , succinylcholine is
contra indica te d for routine tra che a l intuba tion in childre n (Barash :
Clinical Anesth esia, ed 7, p 1227; Miller: Miller’s Anesth esia, ed 8, p 983).
227. (D) To ma ke intuba tion e a sie r, it is importa nt to know whe n
the muscle s of the a irwa y a re ma xima lly re la xe d a fte r
a dministra tion of a ne uromuscula r re la xa nt. This ofte n is done with
ne uromuscula r monitoring. Howe ve r, which muscle s one monitors
is importa nt be ca use ne uromuscula r blocka de de ve lops fa ste r,
la sts a shorte r time , a nd re cove rs more quickly in the ce ntra l
muscle s of the a irwa y (i.e ., the la rynx, ja w, a nd dia phra gm) tha n in
the more pe riphe ra l a bductor muscle s of the thumb (e .g., ulna r
ne rve monitoring). Also importa nt is the obse rva tion tha t the
pa tte rn of blocka de in the orbicula ris oculi (e .g., fa cia l ne rve
monitoring) is simila r to tha t of the la rynge a l muscle s a nd the
dia phra gm. The re fore , whe n the orbicula r oculi muscle s a re
ma xima lly re la xe d, intuba tion would be optima l. W he n a dductor
function of the thumb re turns to norma l, the dia phra gm a nd
la rynge a l muscle s will ha ve re cove re d (Barash : Clinical Anesth esia,
ed 7, p 545).
228. (D) Ra re ly, it is ne ce ssa ry to cha nge from one nonde pola rizing
drug to a nothe r. A ge ne ra l rule to de te rmine the dura tion of a ction
of a drug give n a fte r a nothe r drug of diffe re nt dura tion is a ma tte r of
simple kine tics. Thre e ha lf-live s will be re quire d for a clinica l
cha nge ove r so tha t 95% of the first drug will ha ve cle a re d for the
block dura tion to be gin to ta ke on the cha ra cte ristics of the se cond
drug. For e xa mple , if a n inte rme dia te -a cting muscle re la xa nt such
a s ve curonium is give n a fte r a long-a cting a ge nt such a s
pa ncuronium, the dura tion of a ction of ve curonium is prolonge d
a fte r the first two ma inte na nce dose s of ve curonium. Afte r the third
ma inte na nce dose the dura tion of ve curonium is not prolonge d
(Miller: Miller’s Anesth esia, ed 8, pp 980–981).
229. (A) Vola tile a ne sthe tics e nha nce ne uromuscula r blocka de in a
dose -de pe nde nt fa shion. Re ce nt studie s ha ve sugge ste d tha t
a nta gonism of ne uromuscula r block is slowe d by vola tile
a ne sthe tics; thus, vola tile a ne sthe tic va por conce ntra tions should
be re duce d a s much a s possible a t the e nd of the ca se to he lp
e nsure tha t re ve rsa l will ta ke pla ce a s promptly a s possible (Miller:
Miller’s Anesth esia, ed 8, p 981).
230. (C) Se le giline is a n MAOI tha t is some time s use d in the
tre a tme nt of Pa rkinson dise a se . Me pe ridine is the origina l
phe nylpipe ridine from which a numbe r of othe r conge ne rs a re
de rive d (e .g., fe nta nyl, sufe nta nil, a lfe nta nil, re mife nta nil).
Me pe ridine is ra re ly use d a s a n a na lge sic but ra the r a s a n a nti-
shive ring drug. Me pe ridine (a s we ll a s me tha done a nd tra ma dol) is
contra indica te d in pa tie nts ta king MAOIs be ca use of the possibility
of se rotonin syndrome (e .g., a gita tion, ske le ta l muscle rigidity,
hype rpyre xia ) or de pre ssion (e .g., hypote nsion, de pre sse d
ve ntila tion, coma ) tha t ma y re sult (Miller: Miller’s Anesth esia, ed 8, pp
894–896, 909–910).
231. (A) Some childre n a wa ke n from ge ne ra l a ne sthe sia a nd
a ppe a r re stle ss a nd inconsola ble during the e a rly re cove ry pe riod
from ge ne ra l a ne sthe sia . This is ca lle d e me rge nce “e xcite me nt”
de lirium (ED), a nd more inte nsive nursing will be ne e de d to
pre ve nt such childre n from hurting the mse lve s a s we ll a s pre ve nt
the m from pulling out intra ve nous line s or surgica l dra ins. This
usua lly re solve s quickly whe n the child a wa ke ns more fully.
Although untre a te d pa in is ofte n conside re d a n instiga ting fa ctor,
ma ny childre n ca n be pa in fre e a nd still de ve lop ED. Risk fa ctors
include a ge younge r tha n 5 ye a rs (pe a k incide nce , 2-4 ye a rs of a ge ),
the use of vola tile a ne sthe tics (se voflura ne ha s the highe st
fre que ncy of ED), otola ryngologic a nd ophtha lmologic surge rie s,
a nd a nxious pa re nts. Prophyla ctic tre a tme nt with a single IV dose

of fe nta nyl (2.5 µg/kg), clonidine (2 µg/kg), ke ta mine (0.25 mg/kg),

na lbuphine (0.1 mg/kg), or de xme de tomidine (0.15 µg/kg) ca n

de cre a se the incide nce . Some ha ve use d IV propofol (1 mg/kg)


a fte r turning off se voflura ne a t the conclusion of surge ry to

de cre a se the incide nce of ED. Intra na sa l fe nta nyl (1 µg/kg) ma y be


use ful whe n the IV route is una va ila ble (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, p 391; Miller: Basics of Anesth esia, ed 6, p
558; Miller: Miller’s Anesth esia, ed 8, pp 2941–2942).
232. (A) Etomida te , a n imida zole de riva tive , is use d most ofte n for
induction of ge ne ra l a ne sthe sia , but it a lso ca n be use d for
ma inte na nce of ge ne ra l a ne sthe sia . Etomida te ha s a re la tive ly
short dura tion of a ction a nd provide s ve ry sta ble he modyna mics,
e ve n in pa tie nts with limite d ca rdiova scula r re se rve . Howe ve r, it is
a ssocia te d with se ve ra l a dve rse e ffe cts. The se a dve rse e ffe cts
include a high incide nce of na use a a nd vomiting (gre a te r tha n a fte r
thiope nta l), pa in on inje ction, thrombophle bitis, myoclonic
move me nts, a nd, some time s, hiccups. Na use a a nd vomiting
constitute the most common re a son pa tie nts ra te a ne sthe sia with
e tomida te a s unsa tisfa ctory. The a ddition of fe nta nyl to e tomida te
to de cre a se the pa in of inje ction a lso incre a se s the incide nce of
na use a a nd vomiting (Miller: Miller’s Anesth esia, ed 8, p 852).
233. (A) Pa ncuronium te nds to incre a se the he a rt ra te , me a n
a rte ria l BP, a nd ca rdia c output. This ma y be re la te d to se ve ra l
me cha nisms, including a mode ra te va golytic e ffe ct, nore pine phrine
re le a se , a nd de cre a se d re upta ke of nore pine phrine by a dre ne rgic
ne rve s. The othe r liste d drugs ra re ly ca use dire ct a dre ne rgic
stimula tion a nd do not inhibit the upta ke of nore pine phrine by
a dre ne rgic ne rve s (Miller: Miller’s Anesth esia, ed 8, p 978).
234. (B) Da ntrole ne is a muscle re la xa nt use d ora lly to he lp control
ske le ta l muscle spa sticity in pa tie nts with uppe r motor ne uron
le sions, a nd it ca n be use d a cute ly in the pre ve ntion of ma ligna nt
hype rthe rmia in pa tie nts unde rgoing a ne sthe sia . It is give n
intra ve nously in the tre a tme nt of ma ligna nt hype rthe rmia .
Da ntrole ne ha s little or no e ffe ct on smooth or ca rdia c muscle a t
clinica l dose s. Da ntrole ne works dire ctly on ske le ta l muscle by
de cre a sing the a mount of ca lcium re le a se d from the sa rcopla smic
re ticulum. This de cre a se s the e xcita tion–contra ction coupling
ne e de d for the muscle to contra ct. The most common side e ffe ct of
da ntrole ne a dministra tion is ske le ta l muscle we a kne ss. Othe r
a cute side e ffe cts include na use a , dia rrhe a , a nd blurre d vision.
W he n the drug is give n intra ve nously, a brisk diure sis occurs a nd is
re la te d to the ma nnitol a dde d to ma ke the intra ve nous solution
isotonic. W ith chronic ora l use , pa tie nts ma y ra re ly de ve lop
he pa titis a nd ple ura l e ffusions (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 596–597).
235. (D) (Ple a se a lso se e e xpla na tion to Que stion 435.) Dia be te s
me llitus is a dise a se cha ra cte rize d by a lte re d me ta bolism of
ca rbohydra te s (usua lly ma nife ste d by hype rglyce mia ), lipids, a nd
prote ins. Nine ty pe rce nt of dia be tic pa tie nts in the Unite d Sta te s
ha ve non–insulin-de pe nde nt dia be te s me llitus (NIDDM) or type 2
dia be te s a nd a re la tive de ficie ncy in circula ting insulin. Dia be tic
pa tie nts a lso ca n ha ve a de cre a se d tissue re sponse to circula ting
insulin (insulin re sista nce ). Ora l hypoglyce mic a ge nts, most
commonly of the sulfonylure a che mica l cla ss, ca n be use d in
pa tie nts with NIDDM. The se sulfonylure a drugs ha ve ma ny
me ta bolic e ffe cts, including the initia l stimula tion of the pa ncre a s to
re le a se insulin (chronica lly, insulin se cre tion is not incre a se d but
the hypoglyce mic e ffe cts a re ma inta ine d). Tolbuta mide (Orina se )
a nd chlorpropa mide (Dia bine se ) a re first-ge ne ra tion a na logs.
The bigua nide s me tformin (Glucopha ge ) a nd phe nformin work
by incre a sing the a ction of circula ting insulin on pe riphe ra l
tissue s a nd a re ca lle d a ntihype rglyce mic, not hypoglyce mic,
a ge nts. The re is no risk of hypoglyce mia with me tformin e ve n
with ove rnight fa sting.
Phe nformin wa s withdra wn from the ma rke t be ca use of a n
a ssocia tion with la ctic a cidosis. Me tformin, long thought to ca use
me ta bolic a cidosis, is now unde rstood to do so only in pa tie nts
who ha ve a bnorma l kidne y or live r function.
SSRIs a re drugs commonly use d for de pre ssion. SSRIs ha ve
se rious side e ffe cts, including hype rpyre xia . The re ha ve be e n
re ports of se rotonin syndrome with SSRI a nd me thyle ne blue , but
not with me tformin (Miller: Miller’s Anesth esia, ed 8, pp 1219–1220;
Miller: Basics of Anesth esia, ed 6, pp 182–183).
236. (D) Disulfira m a nd na ltre xone occa siona lly a re a dministe re d
ora lly in a lcoholic re ha bilita tion progra ms. Disulfira m a lte rs the
me ta bolism of a lcohol by irre ve rsibly ina ctiva ting the e nzyme
a lde hyde de hydroge na se . If the pa tie nt drinks a lcohol, the re is a
buildup of a ce ta lde hyde in the blood. This produce s the unple a sa nt
e ffe cts of flushing, he a da che , na use a , vomiting, che st pa in,
ta chyca rdia , hypote nsion, a nd confusion. The a lcohol se nsitivity
with disulfira m use ma y la st up to 2 we e ks a fte r the drug is
stoppe d. Na ltre xone is use d with disulfira m in the tre a tme nt of
a lcohol a ddiction. It a ppe a rs to block some of the re inforcing
prope rtie s of a lcohol. Pa tie nts ta king na ltre xone with disulfira m
ha ve a lowe r ra te of re la pse for a lcohol. Na ltre xone is a pure
opioid a nta gonist. Pa tie nts ta king na ltre xone a t the time of surge ry
will ha ve ma rke dly e le va te d opioid re quire me nts if opioids a re
chose n for pa in re lie f. The dura tion of a ction of na ltre xone is 24
hours, a nd the drug should be stoppe d during the hospita liza tion to
a llow be tte r pa in control with na rcotics, a s would be de sira ble in
this ma jor surgica l proce dure (Hard m an: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 10, pp 602–604; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 5, p 542; Miller:
Miller’s Anesth esia, ed 8, pp 866–868).
237. (B) Ra pid-se que nce inductions a re pe rforme d in ca se s whe re
ra pid control of the a irwa y is ne e de d. Usua lly this is pe rforme d to
se cure the a irwa y in a pa tie nt who should be e a sily intuba te d a nd
ha s a “full stoma ch.” In the se ca se s, a fte r a de qua te pre oxyge na tion
a nd suctioning of the a irwa y ca n be re a dily pe rforme d, a n
intra ve nous induction of ge ne ra l a ne sthe sia is pe rforme d with
cricoid pre ssure , a nd a muscle re la xa nt with a short-onse t time is
a dministe re d. Succinylcholine ha s the fa ste st onse t time of a ll
ne uromuscula r re la xa nts a nd is the drug of choice . Howe ve r, in
some ca se s, succinylcholine is contra indica te d a nd a nothe r
ne uromuscula r blocke r is chose n. Of the drugs liste d, rocuronium
is the be st choice be ca use of its ra pid onse t. Although the onse t
time of othe r nonde pola rizing ne uromuscula r re la xa nts ca n be spe d
up with priming (a te chnique in which 10% of the intuba ting dose is
followe d 2 to 4 minute s la te r with a n intra ve nous induction of
ge ne ra l a ne sthe sia a nd the re ma ining 90% of the re la xa nt),
rocuronium is fa st e nough without priming a nd much simple r to
use . In pa tie nts who ma y be difficult to intuba te , e ve n with
a de qua te muscle re la xa tion, a n a wa ke intuba tion should be
strongly conside re d. D-Tubocura re should ne ve r ha ve a n intuba ting
dose boluse d be ca use it ca use s significa nt hista mine re le a se , a nd
it should be give n incre me nta lly ove r se ve ra l minute s if use d to
intuba te (Miller: Miller’s Anesth esia, ed 8, p 875).
238. (A) The e ffe cts of nonde pola rizing ne uromuscula r drugs a re
ba se d on the drug be ing a t the re ce ptor. Afte r intra ve nous inje ction
of a muscle re la xa nt, pla sma drug conce ntra tion imme dia te ly sta rts
to de cre a se . To produce pa ra lysis, the drug must diffuse from the
pla sma to the ne uromuscula r junction a fte r inje ction a nd bind to
the re ce ptors. The drug e ffe ct is la te r te rmina te d by diffusion of
drug ba ck into the pla sma . Re cove ry of ne uromuscula r function
occurs whe n the muscle re la xa nt diffuse s from the ne uromuscula r
junction ba ck into the pla sma to be me ta bolize d a nd/or e limina te d
from the body (Miller: Miller’s Anesth esia, ed 8, p 871).
239. (D) Bupre norphine (Bupre ne x) is a mixe d a gonist-a nta gonist
opioid with a ve ry strong a ffinity for µ re ce ptors. Be ca use of its
strong a ffinity (33 time s gre a te r tha n morphine ) a nd slow
dissocia tion from the re ce ptors, it ha s a prolonge d dura tion of
e ffe ct (>8 hours) a nd shows re sista nce to re ve rsa l from na loxone . In
ra re ca se s of re spira tory de pre ssion, re ve rsa l ma y not be a chie ve d
with high dose s of na loxone (Miller: Miller’s Anesth esia, ed 8, p 904;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
119).
240. (B) Na use a a nd vomiting ma y be a ssocia te d with a ny of the
drugs liste d. Propofol, a nd pe rha ps mida zola m, ma y a ctua lly be
prote ctive in some pa tie nts. Of the liste d drugs in this que stion,
e tomida te ha s the highe st incide nce of na use a a nd vomiting with
some re porting a n incide nce a s high a s 40% (Barash : Clinical
Anesth esia, ed 7, p 489; Miller: Basics of Anesth esia, ed 6, pp 108–112).
241. (D) Na loxone is a pure opioid a nta gonist (a ffinity but no
intrinsic a ctivity) a t a ll opioid re ce ptors. It ma inly is use d to re ve rse
na rcotic-induce d toxicity. In la rge dose s, na loxone ma y re ve rse the
e ffe cts of e ndoge nous opioids tha t a re e le va te d in conditions of
stre ss (e .g., shock or stroke ). Na loxone ha s no e ffe ct on NSAIDs
(e .g., ke torola c) (Miller: Miller’s Anesth esia ed 8, pp 905–906).
242. (D) Nitric oxide , nitroglyce rin, nitroprusside , phe ntola mine ,
a mrinone , milrinone , a nd prosta gla ndin E a ll ha ve a va sodila tory
e ffe ct on the pulmona ry a rte ria l tre e . Howe ve r, only nitric oxide
ha s ba sica lly no e ffe ct on the syste mic circula tion. The following
ta ble compa re s the re la tive e ffica cy of va rious intra ve nous
va sodila tors (Miller: Miller’s Anesth esia, ed 8, pp 3084–3088).
RELATIVE EFFICACY OF INTRAVENOUS VASODILATORS ON
HEMODYNAMIC VARIABLES
0, none; ±, small and variable; +, mild; +++, strongest effect of that particular drug; D, decrease;
I, increase.
∗ Effect on cardiac output depends on net balance of effects on preload, afterload, and myocardial
oxygenation.
† Amrinone and milrinone are inodilators (they have inotropic plus vasodilating effects).
‡ Prostaglandin E almost always requires left atrial infusion of norepinephrine to sustain
1
adequate systemic blood pressure.
From Stoelting RK, Miller RD: Basics of Anesthesia, ed 5, Philadelphia, Churchill Livingstone,
2006, p 1794.

243. (B) Succinylcholine is ra pidly me ta bolize d in the blood by


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

dose s of 1 to 2 µg/kg/min only a mild de cre a se in tida l volume (VT)


is se e n, with no cha nge in re spira tory ra te . W ith high dose s, the
Pa CO2 ma y incre a se a bout 20% due to a de cre a se in VT a s the
re spira tory ra te incre a se s (Miller: Miller’s Anesth esia, ed 8, pp 834–
838).
245. (D) Fospropofol (Luse dra ), a pprove d in De ce mbe r 2008 for
monitore d a ne sthe sia ca re , is a prodrug of propofol tha t, a fte r IV
infusion, is ra pidly conve rte d into propofol. Be ca use it is wa te r
soluble , the proble ms a ssocia te d with a lipid ve hicle (pa in on
inje ction, risk of hype rtriglyce ride mia , risk of pulmona ry e mbolism,
risk of se psis) a re a bse nt (Eisai Corporation prod uct inform ation;
Miller: Miller’s Anesth esia, ed 8, pp 822–823).
246. (C) In a ddition to a na lge sia , re spira tory de pre ssion, na use a ,
a nd e uphoria , tole ra nce to se da tion with chronic a na lge sic the ra py
with morphine will de ve lop a fte r 2 to 3 we e ks of tre a tme nt. Miosis
a nd constipa tion occur with na rcotic a dministra tion re ga rdle ss of
le ngth of the ra py. The conce pt of tole ra nce is not a pplica ble to
the se two side e ffe cts (Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, p 195).
247. (D) H2-re ce ptor a nta gonists (e .g., cime tidine , ra nitidine ,
fa motidine , niza tidine ) ca n be use d pre ope ra tive ly to incre a se
ga stric fluid pH be fore induction of a ne sthe sia . Ele va tion of ga stric
fluid pH (a bove 2.5) is de sira ble to de cre a se the incide nce a nd
se ve rity of lung da ma ge if a spira tion of ga stric conte nts occurs. H2-
re ce ptor a nta gonists a re not uncommonly use d a s a pre me dica tion
for pa rturie nts, pa tie nts with symptoma tic ga stroe sopha ge a l re flux,
a nd obe se pa tie nts (who te nd to ha ve ve ry a cidic ga stric fluid
compa re d to nonobe se pa tie nts). H2-re ce ptor a nta gonists, in
contra st to me toclopra mide , ha ve no e ffe ct on lowe r e sopha ge a l
sphincte r tone , inte stina l motility, or ga stric e mptying. Although the
incide nce of side e ffe cts is low, side e ffe cts occa siona lly ma y
de ve lop in pa tie nts, e spe cia lly whe n the drug is a dministe re d
intra ve nously a nd whe n the drugs a re a dministe re d to the e lde rly
or to pa tie nts with he pa tic or re na l dysfunction. Bra dyca rdia ma y
de ve lop a nd ma y be re la te d to the e ffe cts on ca rdia c H2 re ce ptors.
Re ve rsible e le va tion of pla sma a minotra nsa mina se e nzyme s ma y
occur. H2-re ce ptor a nta gonists cross the blood-bra in ba rrie r a nd
ma y le a d to me nta l confusion or de la ye d a wa ke ning. Cime tidine
impa irs the me ta bolism of drugs such a s lidoca ine , propra nolol,
a nd dia ze pa m. This impa irme nt ma y be re la te d to the binding of
cime tidine to the cytochrome P-450 e nzyme s (Barash : Clinical
Anesth esia, ed 7, p 602).
248. (A) Drug se nsitivity ha s be e n re porte d in a bout 3% to 4% of
a ne sthe tic-re la te d de a ths. Alle rgic drug re a ctions ha ve be e n
re porte d to occur with most drugs a dministe re d during a ne sthe sia ,
with the e xce ption of ke ta mine a nd the be nzodia ze pine s. Although
most drug-induce d a lle rgic re a ctions occur within 5 to 10 minute s of
e xposure , re a ctions to la te x products ma y ta ke longe r tha n 30
minute s to de ve lop (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 525–529).

249. (C) Atropine is a dministe re d in dose s of 2 to 6 mg a nd is


re pe a te d e ve ry 5 to 10 minute s until se cre tions be gin to de cre a se .

In most ca se s, 2 mg e ve ry 8 hours is ne e de d. Howe ve r, dose s of 15

to 20 mg a re not uncommon a nd occa siona lly dose s ove r 1000 mg

ha ve be e n ne e de d. Pra lidoxime 600 mg re move s the


orga nophospha te compounds from a ce tylcholine ste ra se a nd is
ofte n use d in conjunction with a tropine . Be nzodia ze pine s a re ofte n
a dministe re d to counte r the e ffe cts of the ne rve ga se s on the GABA
syste m (Barash : Clinical Anesth esiology, ed 7, p 1541).
250. (A) Alfe nta nil (a fe nta nyl a na log) is le ss pote nt (1/5 to 1/10), ha s
a more ra pid onse t (within 1.5 minute s), a nd ha s a shorte r dura tion
of a ction tha n fe nta nyl. The brie f dura tion of a ction of a lfe nta nil is a
re sult of re distribution to ina ctive tissue site s a nd its ra pid he pa tic
me ta bolism (96% cle a re d within 1 hour). Re na l fa ilure doe s not
a lte r the cle a ra nce of a lfe nta nil (Miller: Basics of Anesth esia, ed 6, p
119, Figure 10-3; Miller: Miller’s Anesth esia, ed 8, p 887; Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 196).
251. (D) Asthma is a n infla mma tory illne ss a ssocia te d with
bronchia l hype r-re a ctivity a nd bronchospa sm. Me dica tions e ffe ctive
in the ma na ge me nt of a cute e xa ce rba tions of bronchia l a sthma
include the ra pid-onse t inha le d β2-a dre ne rgic re ce ptor a gonists
(e .g., a lbute rol, pirbute rol, te rbuta line ), a nticholine rgic drugs (e .g.,
inha le d ipra tropium), a nd IV corticoste roids. In a n a cute a tta ck,
ipra tropium (slowe r in onse t tha n β2-a dre ne rgic re ce ptor a gonists)
ca n be e ffe ctive whe n use d in combina tion with the ra pid-onse t β2
a gonists. W he n unre solving bronchospa sm occurs a nd is
conside re d life thre a te ning, the dia gnosis of sta tus a sthma ticus is
ma de . Although tre a tme nt ofte n sta rts with β2 a gonists (two to four
puffs e ve ry 15-20 minute s), whe n a lve ola r ve ntila tion is re duce d,
inha le d a ge nts ma y not be succe ssful. In this ca se , SQ e pine phrine

(a dult dose of 0.2 to 1 mg or 0.2 to 1 mL of 1:1000 solution) ca n be


give n. Corticoste roids e nha nce a nd prolong the re sponse to β2
a gonists, a nd, in sta tus a sthma ticus, IV corticoste roids such a s

cortisol (Solu-Corte f) 2 mg/kg IV bolus followe d by 0.5 mg/kg/hr, or

me thylpre dnisolone (Solu-Me drol) 60 to 125 mg e ve ry 6 hours, a re


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

sta rting a t a ra te of 0.1 µg/kg/min a nd incre a se d until improve me nt


is se e n or significa nt ta chyca rdia de ve lops ma y be use ful.

Ma gne sium sulfa te a t a dose of 25 to 40 mg/kg (ma ximum of 2 g)


a dministe re d ove r 20 minute s ha s be e n use d. Broa d-spe ctrum
a ntibiotics a re a lso sta rte d. In se ve re ca se s whe re fa tigue se ts in

a nd the Pa CO2 is rising (e .g., >70-80 mm Hg), ge ne ra l a ne sthe sia


with me cha nica l ve ntila tion ma y be ne e de d. The vola tile
a ne sthe tics such a s isoflura ne , ha lotha ne , or se voflura ne ca n be
use d not only to se da te but a lso to re la x the smooth muscle in the
constricte d a irwa ys. Cromolyn, howe ve r, doe s not re lie ve
bronchospa sm. Cromolyn is use d prophyla ctica lly be ca use it
inhibits a ntige n-induce d re le a se of hista mine a nd othe r a uta coids,
such a s le ukotrie ne s, from ma st ce lls. Aminophylline once wa s
wide ly use d to tre a t a cute a sthma but is ra re ly use d toda y be ca use
it a dds little to β2-a gonist a ctivity a nd ha s significa nt side e ffe cts
(Hard m an: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 10, pp 733–749; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 185–186).
252. (D) Clonidine is a n α2-a dre ne rgic a gonist. Unlike ma ny
pe riphe ra lly a cting a ntihype rte nsive drugs (e .g., gua ne thidine ,
propra nolol, ca ptopril), clonidine prima rily stimula te s ce ntra l
a dre ne rgic re ce ptors a nd de cre a se s the sympa the tic re sponse . As
with othe r drugs tha t a ffe ct the ce ntra l re le a se of ca te chola mine s,
clonidine not only re duce s a ne sthe tic re quire me nts (a s re pre se nte d
by a de cre a se in MAC) but a lso de cre a se s e xtre me s in a rte ria l BP
during a ne sthe sia . Clonidine ha s a na lge sic prope rtie s a nd re duce s
the re quire me nts for opioids. Clonidine ha s be e n give n ora lly,
intra ve nously, e pidura lly, intra the ca lly, a nd in pe riphe ra l ne rve
blocks a nd pote ntia te s the a na lge sic e ffe ct of loca l a ne sthe tics. α2-
Adre ne rgic a gonists ca n re duce the muscle rigidity se e n with the
a dministra tion of na rcotics a nd ca n be use d to de cre a se
posta ne sthe tic shive ring. Pa tie nts chronica lly ta king clonidine
should not ha ve it discontinue d be fore surge ry a nd should ke e p
ta king clonidine to pre ve nt clonidine withdra wa l a nd hype rte nsive
crisis (Miller: Miller’s Anesth esia, ed 8, pp 368, 1218, 1632).
253. (D) Chronic live r dise a se ma y inte rfe re with the me ta bolism of
drugs be ca use of the de cre a se d numbe r of e nzyme -conta ining
he pa tocyte s, de cre a se d he pa tic blood flow, or both. Prolonge d
e limina tion ha lf-time s for morphine , a lfe nta nil, dia ze pa m,
lidoca ine , pa ncuronium, a nd, to a le sse r e xte nt, ve curonium ha ve
be e n de monstra te d in pa tie nts with cirrhosis of the live r. In
a ddition, se ve re live r dise a se ma y de cre a se the production of
choline ste ra se (pse udocholine ste ra se ) e nzyme , which is ne ce ssa ry
for the hydrolysis of e ste r linka ge s in drugs such a s succinylcholine ,
a nd the e ste r loca l a ne sthe tics such a s proca ine (Miller: Basics of
Anesth esia, ed 6, p 456).
254. (D) Succinylcholine is the drug of choice (unle ss
contra indica te d) whe n ra pid-se que nce tra che a l intuba tion is
ne e de d. Although hype rka le mic ca rdia c a rre st is a complica tion of
succinylcholine a dministra tions to pa tie nts who ha ve susta ine d
burns (a s we ll a s crush injurie s, spina l cord tra uma , or othe r
de ne rva tion injurie s, chronic illne ss polyne uropa thy, a nd chronic
illne ss myopa thy), the susce ptibility for hype rka le mia a fte r a burn
injury pe a ks a t 7 to 10 da ys but ma y be gin a s e a rly a s 2 da ys a fte r
susta ining a the rma l injury. The first 24 hours a fte r the injury a re
conside re d sa fe . Adding a de fa scicula ting dose of a
nonde pola rizing ne uromuscula r blocking drug be fore
succinylcholine use to the re gime n would slow down a chie ve me nt
of pa ra lysis. Although the “priming” te chnique of giving 10% of the
intuba ting dose followe d 2 to 4 minute s la te r by the re st of the
intuba ting dose ha s be e n use d to spe e d conditions for intuba tion, it
is still slowe r tha n succinylcholine , a nd this te chnique is ra re ly
use d be ca use rocuronium (which provide s the most ra pid
intuba ting conditions a mong the nonde pola rizing ne uromuscula r
blocking drugs a nd is a close se cond be hind succinylcholine ) is
a va ila ble . An intuba ting dose of D-tubocura rine should ne ve r be
give n a s a bolus be ca use of its mode ra te hista mine re le a se (Miller:
Basics of Anesth esia, ed 6, pp 148–149).
255. (A) Clonidine , a ce ntra lly a cting α-a gonist, de cre a se s
sympa the tic ne rvous syste m outflow a nd de cre a se s pla sma
ca te chola mine conce ntra tions in norma l pa tie nts, but it ha s no
e ffe ct in pa tie nts with phe ochromocytoma s. It is use d a s a n
a ntihype rte nsive a ge nt for tre a ting e sse ntia l hype rte nsion, a n
a na lge sic whe n inje cte d e pidura lly or into the suba ra chnoid spa ce
a lone , a drug tha t prolongs the e ffe ct of re giona l loca l a ne sthe tics,

a drug tha t ca n be use d to stop shive ring (75 µg IV), a drug tha t ca n
he lp prote ct a ga inst pe riope ra tive myoca rdia l ische mia (whe n
give n pre ope ra tive ly a nd typica lly for 4 da ys a fte r surge ry), a nd a
drug tha t ca n he lp de cre a se the symptoms of na rcotic a nd a lcohol
withdra wa l (Barash : Clinical Anesth esia, ed 7, p 392; Miller: Miller’s
Anesth esia, ed 8, p 473; Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 394).
256. (C) Ske le ta l muscle spa sm, pa rticula rly of the
thora coa bdomina l muscle s (“stiff che st” syndrome ), ma y occur
whe n la rge dose s of opioids a re give n ra pidly. This ma y be
significa nt e nough to pre ve nt a de qua te ve ntila tion. Although the
a dministra tion of a muscle re la xa nt or a n opioid a nta gonist such a s
na loxone will te rmina te the ske le ta l muscle rigidity, re ve rsing the
na rcotic e ffe ct ma y not be de sira ble if surge ry is ne e de d (Miller:
Basics of Anesth esia, ed 6, p 121).
257. (B) One of the a dva nta ge s of ke ta mine is the minima l e ffe ct on

re spira tions. Afte r the intra ve nous induction dose of 2 mg/kg,


ge ne ra l a ne sthe sia is induce d within 30 to 60 se conds with, a t
most, a tra nsie nt de cre a se in re spira tions (Pa CO2 ra re ly incre a se s

more tha n 3 mm Hg). W ith unusua lly high dose s, or if opioids a re


a lso a dministe re d, a pne a ca n occur (Miller: Basics of Anesth esia, ed 6,
p 108).
258. (C) This pa tie nt ha s a pa rtia lly compe nsa te d me ta bolic
a cidosis. Me ta bolic a cidosis is commonly divide d into those with a
norma l ion ga p, a lso ca lle d hype rchlore mic me ta bolic a cidosis
(bica rbona te loss is counte rba la nce d by a n incre a se in chloride
le ve ls), a nd those with a high a nion ga p. The a nion ga p ca n be
ca lcula te d by de te rmining the diffe re nce be twe e n the sodium
conce ntra tion a nd the sum of the chloride a nd bica rbona te

conce ntra tions (i.e ., [Na +] − [Cl–] + [HCO3–]) a nd is norma lly 8 to

14 mEq/L. In this ca se , the a nion ga p is 135 − [95 + 14] = 26. This


pa tie nt, the re fore , ha s a high a nion ga p a cidosis. This que stion ha s
two forms of a cidosis tha t ha ve a high a nion ga p: dia be tic
ke toa cidosis (DKA) a nd propofol infusion syndrome , which ca use s
a la ctic a cidosis. Be ca use this pa tie nt is a type 2 (non–insulin-
de pe nde nt) dia be tic, DKA doe s not occur a nd the ca use must be
propofol infusion syndrome (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 372–373; Miller: Miller’s Anesth esia, ed 8, p
832).
259. (D) Ne urole ptic ma ligna nt syndrome (NMS) ca n be se e n in up
to 1% of pa tie nts tre a te d with a ntipsychotic drugs. The syndrome
ha s ma ny fe a ture s tha t re se mble the condition ma ligna nt
hype rthe rmia , including incre a se d me ta bolism, ta chyca rdia , muscle
rigidity, rha bdomyolysis, fe ve r, a nd a cidosis. The morta lity ra te ma y
be 20% to 30%. The re a re ma ny diffe re nce s be twe e n NMS a nd
ma ligna nt hype rthe rmia . NMS is not inhe rite d a nd usua lly ta ke s 24
to 72 hours to de ve lop a fte r the use of ne urole ptic drugs (e .g.,
phe nothia zine s, ha lope ridol), whe re a s ma ligna nt hype rthe rmia
pre se nts more a cute ly. Stopping the a ntipsychotic me dica tion is
obviously ne ce ssa ry. Be ca use dopa mine de ple tion a ppe a rs to pla y
a role in ca using NMS, the dopa mine a gonists bromocriptine a nd
a ma nta dine a ppe a r use ful in the tre a tme nt. Abrupt withdra wa l of
le vodopa ma y a lso ca use this syndrome . Succinylcholine a nd
vola tile a ne sthe tics, which a re known trigge rs for ma ligna nt
hype rthe rmia , a re not trigge rs for NMS. Da ntrole ne ha s be e n use d
to tre a t this condition (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 412–413).
260. (C) Norma l pse udocholine ste ra se is inhibite d 80% by dibuca ine
(dibuca ine numbe r of 80), whe re a s pa tie nts with a typica l
choline ste ra se show only 20% inhibition (dibuca ine numbe r of 20).
Pa tie nts who a re he te rozygous for a typica l pse udocholine ste ra se
(a s in this ca se ) ha ve inte rme dia te dibuca ine numbe rs ra nging from
50% to 60%. Succinylcholine pa ra lysis a fte r a n intuba ting dose of

1 mg/kg la sts up to 10 minute s with norma l pse udocholine ste ra se ,


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

dose s in pa re nthe sis) ca n include sodium nitrite (Na NO2—300 mg


IV ove r 10 minute s), a myl nitrite (inha la tion), sodium thiosulfa te

(12.5 g IV ove r 10 minute s), a nd hydroxocoba la min (5-10 g IV ove r


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

Hydroxocoba la min combine s with cya nide to form


cya nocoba la min or vita min B12. Me thyle ne blue is not a n a ntidote
for cya nide toxicity a nd ca n complica te the ra py by conve rting
me the moglobin ba ck to he moglobin a nd re le a sing fre e cya nide .
Although oxyge n a lone (e ve n unde r hype rba ric conditions) ha s
little be ne fit, it should be use d be ca use it dra ma tica lly
pote ntia te s the a ctivity of thiosulfa te a nd nitrite s (Barash : Clinical
Anesth esia, ed 7, pp 403–404; Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, pp 782–783, 793–796;
Miller: Miller’s Anesth esia, ed 8, pp 2501–2503).
262. (D) The dura tion of ne uromuscula r block by succinylcholine
ca n be ma rke dly prolonge d whe n the tota l a mount of pla sma
choline ste ra se is ve ry low, the a mount is norma l but of a n
a bnorma l type (i.e ., a typica l pla sma choline ste ra se ), or a n
a nticholine ste ra se drug (e .g., ne ostigmine , e chothiopha te , or the
orga nophospha te inse cticide ma la thion) is a dministe re d. To
e va lua te a prolonge d re sponse to succinylcholine , one ne e ds to
e va lua te both the tota l a mount of choline ste ra se (i.e ., qua ntita tive
te st) a nd the type of choline ste ra se (i.e ., qua lita tive te st). Atypica l
pla sma choline ste ra se is a n inhe rite d disorde r tha t occurs in
a pproxima te ly 1 of e ve ry 480 pa tie nts with he te rozygous ge nome
a nd in a pproxima te ly 1 of 3200 pa tie nts with homozygous ge nome .
The loca l a ne sthe tic dibuca ine ca n inhibit norma l pla sma
choline ste ra se e nzyme be tte r tha n a n a bnorma l e nzyme . In pa tie nts
with norma l pla sma choline ste ra se , the dibuca ine inhibition te st
re ports a numbe r a round 80 or produce s 80% inhibition.
He te rozygote s ha ve a dibuca ine numbe r of a round 50, a nd pa tie nts
who a re homozygous for the a typica l pla sma choline ste ra se ha ve a
numbe r a round 20. Tota l pla sma choline ste ra se le ve ls ca n be
re duce d with de cre a se d production, a s occurs with se ve re chronic
live r dise a se or with the use of some che mothe ra pe utic drugs (e .g.,
cyclophospha mide ). The dibuca ine numbe r is norma l whe n the
tota l pla sma choline ste ra se le ve ls a re re duce d, a s we ll a s a fte r the
use of a nticholine ste ra se drugs. Pa tie nts with a C5 isoe nzyme
va ria nt ha ve incre a se d pla sma choline ste ra se a ctivity, a more ra pid
bre a kdown of succinylcholine , a nd a shorte r dura tion of a ction
(Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, p 243; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 205–207; Miller: Basics of Anesth esia, ed 6, pp 76,
148–149; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, pp 216–220).
263. (C) Be nzodia ze pine s a re drugs tha t ha ve the che mica l structure
of a be nze ne ring a tta che d to a se ve n-me mbe r dia ze pine ring.
Mida zola m, lora ze pa m, oxa ze pa m, a nd dia ze pa m a re
be nzodia ze pine a gonists a nd fluma ze nil is a n a nta gonist.
Be nzodia ze pine a gonists a re a ll se da tive s a nd posse ss a numbe r of
fa vora ble pha rma cologic cha ra cte ristics, including production of
se da tion, a nxiolysis, a nte rogra de a mne sia (a cquisition of ne w
informa tion), a nd a nticonvulsa nt a ctivity. The a mne stic prope rtie s
a re gre a te r tha n the se da tive prope rtie s, which is why pa tie nts
some time s forge t wha t you te ll the m a fte r the be nzodia ze pine is
give n, de spite the ir ha ving wha t a ppe a rs to be a lucid discussion
with you. The y do not produce re trogra de a mne sia (store d
informa tion). The y ra re ly ca use significa nt re spira tory or
ca rdiova scula r de pre ssion a nd ra re ly a re a ssocia te d with the
de ve lopme nt of significa nt tole ra nce or physica l de pe nde nce . The
a gonist a ctions of be nzodia ze pine s most like ly re fle ct the a bility of
the se drugs to fa cilita te the inhibitory ne urotra nsmitte r GABA
a ctions in the CNS. Mida zola m a nd dia ze pa m unde rgo oxida tive
me ta bolism, a nd the ir me ta bolite s a re conjuga te d with glucuronide
be fore re na l e xcre tion. Cime tidine inhibits oxida tive me ta bolism
a nd ma y prolong the dura tion of the se drugs. Lora ze pa m a nd
oxa ze pa m prima rily unde rgo conjuga tion with glucuronic a cid,
which is not influe nce d by cime tidine usa ge or a lte ra tions in
he pa tic function (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 458–467; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 179–181; Miller: Basics of
Anesth esia, ed 6, pp 106–109; Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 140–153).
264. (C) Re mife nta nil is a n ultra short-a cting opioid most commonly
a dministe re d by a n IV infusion. Its short dura tion of a ction is due to
its e ste r linka ge , which a llows for ra pid bre a kdown by nonspe cific
pla sma a nd tissue e ste ra se s (prima rily within e rythrocyte s). Its
me ta bolism is not significa ntly influe nce d by re na l fa ilure , he pa tic
fa ilure , or pse udocholine ste ra se le ve ls (be ca use it is not
me ta bolize d to a ny significa nt e xte nt by pla sma
pse udocholine ste ra se ). The clinica l e limina tion ha lf-time is le ss

tha n 6 minute s. For monitore d a ne sthe sia ca re se da tion a fte r 2 mg

of mida zola m, a n infusion ra te of 0.05 to 0.1 µg/kg/min is use d in


he a lthy a dults. For a na lge sia during ge ne ra l a ne sthe sia with

controlle d re spira tions, a ra te of 0.1 to 1.0 µg/kg/min is commonly

use d. A loa ding dose of 1 µg/kg of re mife nta nil (or 0.5 µg/kg, if a
be nzodia ze pine wa s a lso give n) ca n be give n IV ove r 60 to 90
se conds be fore sta rting the infusion. Although it e ffe ctive ly
suppre sse s a utonomic a nd he modyna mic re sponse s to pa inful
stimuli a nd de cre a se s re spira tions a s we ll, its ra pid dissipa tion of
opioid e ffe ct produce s ra pid onse t of postope ra tive pa in (in pa inful
surgica l ope ra tions), unle ss othe r a na lge sics a re a dministe re d for
postope ra tive pa in be fore stopping the infusion (Barash : Clinical
Anesth esia, ed 7, pp 514–515, 832–834; Miller: Miller’s Anesth esia, ed 8,
pp 888–897).
265. (D) The ma ximum re comme nde d single dose of lidoca ine give n
by infiltra tion is 300 mg of lidoca ine without e pine phrine a nd

500 mg of lidoca ine with e pine phrine . Ca re ful inje ction in the
mouth is re comme nde d due to the va scula r na ture of tha t a re a
(Barash : Clinical Anesth esia, ed 7, p 572; Miller: Miller’s Anesth esia, ed 8,
p 1041).
266. (A) Postope ra tive shive ring ca n be ca use d by ma ny fa ctors,
including hypothe rmia , tra nsfusion re a ctions, a nd pa in, a s we ll a s
a ne sthe tics. It is uncomforta ble for pa tie nts a nd ca n ma ke
monitoring more difficult, but it a lso ca n le a d to significa nt
incre a se s in oxyge n consumption (up to 200%). The e xa ct e tiology in
ma ny ca se s is uncle a r, but, a fte r routine skin surfa ce wa rming,
pha rma cologic tre a tme nt ma y be ne e de d. Clonidine ,
de xme de tomidine , propofol, ke ta nse rin, tra ma dol, physostigmine ,
ma gne sium sulfa te , a nd na rcotics (e spe cia lly me pe ridine ) ha ve
be e n use d. Na loxone use ma y incre a se pa in a nd doe s not he lp
de cre a se shive ring (Barash : Clinical Anesth esia, ed 7, p 1574; Miller:
Miller’s Anesth esia, ed 8, pp 1636–1638).
267. (C) Suga mma de x is a cyclode xtrin (cyclic oligosa ccha ride )
compound tha t e nca psula te s nonde pola rizing ste roida l muscle

re la xa nts (rocuronium > ve curonium >> pa ncuronium) a nd


produce s ra pid re ve rsa l of profound block (e .g., re ve rsa l of

0.6 mg/kg rocuronium in 3 minute s). Be ca use it ha s no e ffe ct on


a ce tylcholine ste ra se , the re is no ne e d to combine it with the
a nticholine rgics a tropine or glycopyrrola te . It works only with
ste roida l muscle re la xa nts a nd ha s no e ffe ct on re ve rsing the
be nzylisoquinolinium re la xa nts (e .g., a tra curium, cisa tra curium,
doxa curium, D-tubocura rine ). The re a ppe a r to be no ca rdiova scula r
e ffe cts with suga mma de x. It is a va ila ble only outside the Unite d
Sta te s a t pre se nt (Miller: Basics of Anesth esia, ed 6, p 159; Miller:
Miller’s Anesth esia, ed 8, p 965).
268. (A) Arginine va sopre ssin (AVP), a lso ca lle d a ntidiure tic
hormone (ADH), ha s ma ny a ctions, but its prima ry role involve s
controlling se rum osmola lity by re gula ting diure sis. AVP is re le a se d
by the hypotha la mus a nd dire ctly ca use s the colle cting tubule s in
the kidne y to incre a se wa te r pe rme a bility a nd re a bsorption. This
incre a se s blood volume a nd lowe rs se rum osmola lity. Be low a

se rum osmola lity of 280 mOsm/kg, AVP is ba re ly de te cta ble ;

howe ve r, whe n the osmola lity is gre a te r tha n 290 mOsm/kg, AVP is
ma xima lly se cre te d. AVP is a lso se cre te d whe n the intra va scula r
volume is de te cte d to be low (e .g., he morrha ge , he a rt fa ilure ,
he pa tic cirrhosis, a nd a dre na l insufficie ncy). Angiote nsin I is
conve rte d to a ngiote nsin II, which is a pote nt va soconstrictor a nd
incre a se s a ldoste rone se cre tion from the a dre na l corte x.
Aldoste rone is a mine ra locorticoid a nd is involve d in sodium
re a bsorption a nd pota ssium e xcre tion in the re na l tubule s.
Aldoste rone se cre tion is stimula te d by hypovole mic sta te s. Re na l
prosta gla ndins a re re le a se d from the kidne y by sympa the tic
stimula tion or by a ngiote nsin II a nd he lp modula te the e ffe cts of
AVP (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p
738; Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, pp 671–704, 721–730; Miller: Basics of Anesth esia, ed
6, pp 449–450).
269. (B) Sodium nitroprusside (SNP) is a ra pid-a cting, dire ct-a cting
pe riphe ra l va sodila tor tha t is compose d of five cya nide moie tie s for
e ve ry NO (nitric oxide ) moie ty. Sodium nitroprusside unde rgoe s
ra pid me ta bolism to re le a se NO a s the a ctive ingre die nt. He a lthy
a dults ca n e a sily e limina te the cya nide produce d during SNP ra te s

of le ss tha n 2 µg/kg/min. Above 2 µg/kg/min a nd e spe cia lly if the

infusion ra te is gre a te r tha n 10 µg/kg/min for 10 minute s, one


should be conce rne d a bout cya nide toxicity. An e a rly sign of
cya nide toxicity is re sista nce to the hypote nsive e ffe cts of SNP
infusion, e spe cia lly whe n the ra te is le ss tha n 2 µg/kg/min. Othe r
signs include me ta bolic a cidosis a nd a n e le va tion of mixe d ve nous
P O2 va lue s (Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, p 258).
270. (D) Phe nothia zine s, such a s chlorproma zine (Thora zine ), a re
e ffe ctive a ntipsychotic (ne urole ptic) drugs tha t block D2
dopa mine rgic re ce ptors in the bra in. Extra pyra mida l e ffe cts a re not
uncommon with the se drugs. The y a lso posse ss a ntie me tic e ffe cts.
Phe nothia zine s with low pote ncy, such a s chlorproma zine , ha ve
promine nt se da tive e ffe cts, which gra dua lly de cre a se with
tre a tme nt. The e ffe cts of CNS de pre ssa nts (e .g., na rcotics a nd
ba rbitura te s) a re e nha nce d by concomita nt a dministra tion of
phe nothia zine s. Lowe ring the se izure thre shold is more common
with a lipha tic phe nothia zine s with low pote ncy (e .g.,
chlorproma zine ) compa re d with pipe ra zine phe nothia zine s. The se
drugs a re a ssocia te d with chole sta tic ja undice , impote nce ,
dystonia , a nd photose nsitivity. Ele ctroca rdiogra phic a bnorma litie s,
such a s prolonga tion of the QT or PR inte rva ls, blunting of T
wa ve s, de pre ssion of the ST se gme nt, a nd, on ra re occa sions,
pre ma ture ve ntricula r contra ctions a nd torsa de s de pointe s, a re
se e n. The a ntihype rte nsive e ffe cts of gua ne thidine a nd gua na dre l
a re blocke d by phe nothia zine s. The se drugs ha ve no e ffe ct on
ne uromuscula r blocka de (Miller: Miller’s Anesth esia, ed 8, p 1219;
Hem m ings: Ph arm acology and Ph y siology for Anesth esia, pp 189–192).
271. (A) Amrinone is a nonca te chola mine , nonglycoside ca rdia c
inotropic drug tha t works a s a se le ctive phosphodie ste ra se III (PDE
III) inhibitor. Amrinone incre a se s cyclic a de nosine monophospha te
(cAMP) le ve ls by de cre a sing cAMP bre a kdown in the myoca rdium
a nd va scula r smooth muscle . Be ca use the a ctions of PDE III
inhibitors work by a diffe re nt me cha nism tha n ca te chola mine s
(cAMP le ve ls a re incre a se d by β-a dre ne rgic re ce ptor stimula tion),
a mrinone ca n work in the pre se nce of β-blocka de a nd in ca se s
whe re pa tie nts be come re fra ctory to ca te chola mine use . The
ca te chola mine a ctions ca n be e nha nce d with PDE III inhibitors.
Amrinone produce s both positive inotropic a nd va sodila tory e ffe cts
but ha s no a ntidysrhythmic e ffe cts (Hensley : A Practical Approach to
Card iac Anesth esia, ed 5, p 277).
272. (D) Tricyclic a ntide pre ssa nts ofte n a re a dministe re d a s the
initia l tre a tme nt of me nta l de pre ssion; howe ve r, the more re ce ntly
de ve lope d SSRIs a re more fre que ntly use d be ca use of fe we r side
e ffe cts. Tricyclic a ntide pre ssa nts work by inhibiting the re upta ke of
re le a se d nore pine phrine (a nd se rotonin) into the ne rve e ndings.
Although a t one time it wa s re comme nde d to stop tricyclic
a ntide pre ssa nts be fore e le ctive surge ry, this ha s not be e n shown to
be ne ce ssa ry. Howe ve r, a lte ra tions in pa tie nt re sponse s to some
drugs should be a nticipa te d. The incre a se d a va ila bility of
ne urotra nsmitte rs in the CNS ca n re sult in incre a se d a ne sthe tic
re quire me nts (i.e ., incre a se d MAC). In a ddition, the incre a se d
a va ila bility of nore pine phrine a t postsyna ptic re ce ptors in the
pe riphe ra l sympa the tic ne rvous syste m ca n be re sponsible for a n
e xa gge ra te d BP re sponse a fte r a dministra tion of a n indire ct-a cting
va sopre ssor such a s e phe drine . If a va sopre ssor is re quire d, a
dire ct-a cting drug such a s phe nyle phrine ma y be pre fe rre d. If
hype rte nsion occurs a nd re quire s tre a tme nt, de e pe ning the
a ne sthe tic or a dding a pe riphe ra l va sodila tor such a s nitroprusside
ma y be ne e de d. The pote ntia l for a n e xa gge ra te d BP re sponse (i.e .,
hype rte nsive crisis) is gre a te st during the a cute tre a tme nt pha se
(the first 14-21 da ys). Chronic tre a tme nt is a ssocia te d with down-
re gula tion re ce ptors a nd a de cre a se d like lihood of a n e xa gge ra te d
BP re sponse a fte r a dministra tion of a sympa thomime tic. Tricyclics
ha ve significa nt a nticholine rgic side e ffe cts (e .g., dry mouth, blurre d
vision, incre a se d he a rt ra te , urina ry re te ntion) a nd ca ution is
e spe cia lly importa nt in e lde rly pa tie nts who ma y de ve lop
a nticholine rgic de lirium de spite the the ra pe utic dose s
a dministe re d. Ca ution is a dvise d with the use of me pe ridine in
pa tie nts ta king MAOIs (not tricyclic a ntide pre ssa nts) be ca use of the
possibility of inducing se izure , hype rpyre xia , or coma (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 535–536).
273. (B) In norma l nondia be tic pa tie nts, a bout 40 units of insulin a re
se cre te d e ve ry da y. The re a re ma ny SQ insulin pre pa ra tions
a va ila ble . Afte r SQ a dministra tion the onse t of a ction is ve ry ra pid
with Lispro a nd Aspa rt (15 minute s); ra pid with Re gula r (30
minute s); inte rme dia te with NPH or Le nte (1-2 hours); a nd slow
with Gla rgine (1.5 hours) a nd Ultra le nte (4-6 hours) (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 380–381).
INSULIN PREPARATIONS

From Hines RL: Stoelting’s Anesthesia and Co-Existing Disease, ed 5, Philadelphia, Saunders,
2008, p 371.

274. (B) The GPIIb/IIIa re ce ptor is spe cific for pla te le ts. Pla te le t
a ctiva tion cha nge s the sha pe of the re ce ptor a nd incre a se s its
a ffinity for fibrinoge n a nd vW F. GPIIb/IIIa re ce ptor a nta gonists (e .g.,
tirofiba n, a bcixima b, a nd e ptifiba tide ) re ve rsibly bind to the pla te le t
GPIIb/IIIa re ce ptor a nd block the binding of fibrinoge n to pla te le ts.
The y do not prolong the prothrombin time or the a ctiva te d pa rtia l
thrombopla stin time . The se drugs a re a dministe re d intra ve nously
a s a bolus a nd the n a s a continuous infusion. The pla sma ha lf-life
a fte r a bolus intra ve nous inje ction is 2 hours for tirofiba n, 2.5 hours
for e ptifiba tide , a nd only 30 minute s for a bcixima b. The biologic
ha lf-life of the se drugs is 4 to 8 hours for tirofiba n, 4 to 6 hours for
e ptifiba tide , a nd 12 to 24 hours for a bcixima b. The longe r dura tion
of a ction for a bcixima b is prima rily due to cle a ra nce by the
re ticuloe ndothe lia l syste m (tirofiba n a nd e ptifiba tide a re cle a re d by
the kidne y) a nd its stronge r a ffinity to the re ce ptor (Hem m ings:
Ph arm acology and Ph y siology for Anesth esia, pp 662–664; Miller: Basics
of Anesth esia, ed 6, p 359; Miller: Miller’s Anesth esia, ed 8, p 1873).
275. (B) Re mife nta nil is ra pidly hydrolyze d by nonspe cific pla sma
a nd tissue e ste ra se s, ma king it ide a l for a n infusion whe re pre cise
control is sought. The onse t a nd offse t of re mife nta nil is ra pid
(clinica l ha lf-time of <6 minute s). Be ca use the a ctivity of the se
nonspe cific e ste ra se s is not usua lly a ffe cte d by live r a nd re na l
fa ilure , re mife nta nil is we ll suite d for such pa tie nts (Miller: Basics of
Anesth esia, ed 6, p 125).
276. (C) Pa in with the intra ve nous inje ction is common with
dia ze pa m, e tomida te , me thohe xita l, a nd propofol. It is ve ry ra re
a fte r thiope nta l a nd ke ta mine (Miller: Basics of Anesth esia, ed 6, pp
102,109,112).
277. (D) Pa tie nts a ne sthe tize d with tota l intra ve nous a ne sthe sia
(TIVA), in this ca se consisting of mida zola m, re mife nta nil, a nd
propofol, some time s re quire a fe w minute s to re sume bre a thing
a fte r the infusions a re stoppe d. Although it ma y se e m a ppropria te
to re ve rse this pa tie nt a nd a void the ne e d for ha nd ve ntila tion,
re ve rsing be nzodia ze pine s (mida zola m) with fluma ze nil ma y
pre cipita te se izure s in e pile ptic pa tie nts, a nd, be ca use re mife nta nil
ha s such a short e limina tion ha lf-life (<6 minute s), re ve rsa l with
na loxone is not ne ce ssa ry. The pa tie nt ne e ds a brie f pe riod to
a llow the propofol to we a r off, during which ha nd or me cha nica l
ve ntila tion will be ne ce ssa ry (until the pa tie nt bre a the s
sponta ne ously). Also, muscle we a kne ss must be rule d out if a
muscle re la xa nt ha s be e n use d, a nd normoca pnia should be
a ssure d give n tha t hype rve ntila tion ma y re duce the a rte ria l CO2
be low the a pne ic thre shold (Miller: Miller’s Anesth esia, ed 8, p 897).
278. (C) Phe ntola mine , pra zosin, yohimbine , tola zoline , a nd
te ra zosin a re compe titive a nd re ve rsible α-a dre ne rgic a nta gonists.
Phe noxybe nza mine produce s a n irre ve rsible α-a dre ne rgic
blocka de . Once phe noxybe nza mine ’s α-blocka de de ve lops, e ve n
ma ssive dose s of sympa thomime tics a re ine ffe ctive until
phe noxybe nza mine ’s a ction is te rmina te d by me ta bolism.
Phe ntola mine a nd phe noxybe nza mine a re nonse le ctive α1 a nd α2
a nta gonists, pra zosin is a se le ctive α1 a nta gonist, a nd yohimbine is
a se le ctive α2 a nta gonist (Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 227–229).
279. (C) Symptoma tic bra dyca rdia a s a re sult of e xce ssive β-
a dre ne rgic re ce ptor blocka de ca n be tre a te d with a va rie ty of
drugs, a s we ll a s with a pa ce ma ke r. Tre a tme nt de pe nds upon
se ve rity of symptoms. Atropine ca n block a ny pa ra sympa the tic
ne rvous syste m contribution to the bra dyca rdia . If a tropine is not
e ffe ctive , the n a pure β-a dre ne rgic re ce ptor a gonist ca n be trie d.
For e xce ssive ca rdiose le ctive β1 blocka de , dobuta mine ca n be
use d; for a nonca rdia c se le ctive β1 a nd β2 blocka de , isoprote re nol
ca n be chose n. Dopa mine is not re comme nde d be ca use the high
dose s ne e de d to ove rcome β-a dre ne rgic re ce ptor blocka de will
ca use significa nt α-a dre ne rgic re ce ptor–induce d va soconstriction.

Gluca gon a t a n initia l dose of 1 to 10 mg intra ve nously followe d by

a n infusion of 5 mg/hr ofte n is be lie ve d to be the drug of choice for


β-a dre ne rgic blocka de ove rdosa ge . Gluca gon incre a se s myoca rdia l
contra ctility a nd he a rt ra te , prima rily by incre a sing cAMP forma tion
(not via β-a dre ne rgic re ce ptor stimula tion) a nd, to a le sse r e xte nt,
by stimula ting the re le a se of ca te chola mine s. Othe r drugs tha t ha ve
be e n use d include a minophylline a nd ca lcium chloride .
Aminophylline inhibits phosphodie ste ra se , re sulting in a n incre a se
in cAMP. Thus, like gluca gon, a minophylline incre a se s ca rdia c
output a nd he a rt ra te via a non–β-a dre ne rgic re ce ptor–me dia te d
me cha nism. Ca lcium chloride ma y prove use ful to counte ra ct a ny
de cre a se in myoca rdia l contra ctility induce d by the β-blocka de ;
howe ve r, this e ffe ct ma y be tra nsie nt (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 331–332).
280. (D) Da ntrole ne is a ske le ta l muscle re la xa nt tha t is e ffe ctive in
the tre a tme nt of ma ligna nt hype rthe rmia . Da ntrole ne is formula te d
with ma nnitol (300 mg ma nnitol/20 mg da ntrole ne ) so tha t diure sis
is promote d during da ntrole ne the ra py. Myoglobinuria from
ma ligna nt hype rthe rmia –a ssocia te d muscle bre a kdown
a ccumula te s in the re na l tubule s a nd ca n ca use kidne y fa ilure if
urine output is not ma inta ine d. Da ntrole ne works within the
muscle ce ll to re duce intra ce llula r le ve ls of ca lcium. In the usua l
clinica l dose s, da ntrole ne ha s little e ffe ct on ca rdia c muscle
contra ctility. In fulmina nt ma ligna nt hype rthe rmia , ca rdia c
dysrhythmia s ma y occur, but this is re la te d to pe rturba tions in pH
a nd e le ctrolyte s. (Ve ra pa mil should not be use d, be ca use it
inte ra cts with da ntrole ne a nd ma y produce hype rka le mia a nd
myoca rdia l de pre ssion. Lidoca ine a ppe a rs sa fe .) Some side e ffe cts
of short-te rm a dministra tion include muscle we a kne ss (which ma y
pe rsist for 24 hours a fte r da ntrole ne the ra py is discontinue d),
na use a a nd vomiting, dia rrhe a , blurre d vision, a nd phle bitis.
Hypothe rmia ma y a lso occur with ma ligna nt hype rthe rmia
tre a tme nt but is re la te d to ice pa cking, not to da ntrole ne
a dministra tion pe r se . W he n de cre a sing the fe ve r, cooling should
be stoppe d whe n core te mpe ra ture re a che s 38° C to a void
hypothe rmia . He pa totoxicity ha s be e n de monstra te d only with long-
te rm use of ora l da ntrole ne (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, p 638).
281. (C) Cisa tra curium is a ste re oisome r of a tra curium a nd a s such
ha s the sa me mole cula r we ight. Both drugs unde rgo Hofma nn
e limina tion a nd form la uda nosine . Atra curium is a lso e stima te d to
unde rgo two thirds of its me ta bolism via e ste r hydrolysis ca ta lyze d
by nonspe cific pla sma e ste ra se s (not pse udocholine ste ra se ).
Ne ithe r drug re quire s re na l or he pa tic input for its de gra da tion;
he nce , both ca n be use d with re na l or he pa tic fa ilure . Atra curium
ca use s hista mine re le a se , whe re a s cisa tra curium doe s not (Miller:
Basics of Anesth esia, ed 6, p 154).
282. (B) W ithdra wa l from opioids is ra re ly life -thre a te ning but ma y
complica te postope ra tive ca re . Opioid withdra wa l ma y
sponta ne ously sta rt within 6 to 12 hours a fte r the la st dose of a
short-a cting opioid a nd a s long a s 72 to 84 hours a fte r a long-a cting
opioid in a ddicte d pa tie nts. The dura tion of withdra wa l symptoms
a lso de pe nds on the opioid; for he roin, withdra wa l symptoms la st 5
to 10 da ys, a nd for me tha done , e ve n longe r. Opioid withdra wa l ca n
be pre cipita te d within se conds if na loxone is a dministe re d
intra ve nously to a n a ddict. (Na loxone is contra indica te d in opioid
a ddicts for this re a son.) Signs a nd symptoms of withdra wa l include
cra ving for opioids, re stle ssne ss, a nxie ty, irrita bility, na use a ,
vomiting, a bdomina l cra mps, muscle a che s, insomnia , sympa the tic
stimula tion (incre a se d he a rt ra te , incre a se d BP, mydria sis,
dia phore sis) a s we ll a s tre mors, je rking of the le gs (origin of the
te rm “kicking the ha bit”), a nd hype rthe rmia . Se izure s, howe ve r, a re
ve ry ra re a nd if se izure s occur, one should conside r tha t
withdra wa l from othe r drugs ma y a lso be occurring (e .g., from
ba rbitura te s) or tha t a n unde rlying se izure disorde r ma y a lso e xist
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 546).
For Questions 283-287: Sid e effects of each of th e intravenous ind uction
agents (th iopental, d iazepam , etom id ate, propofol, and ketam ine) occur.
Som e are uniq ue for each d rug.
283. (C) Etomida te is unique a mong the intra ve nous induction
a ge nts be ca use it ca n ca use a dre nocortica l suppre ssion by
inhibiting the conve rsion of chole ste rol to cortisol. This ca n occur
a fte r a single induction dose a nd ma y pe rsist for 4 to 8 hours. The
clinica l significa nce of this te mpora ry a dre nocortica l suppre ssion is
uncle a r. Howe ve r, in the ICU with prolonge d se da tion, clinica l
a dre na l insufficie ncy ma y de ve lop (i.e ., hypote nsion, hypona tre mia ,
a nd hype rka le mia ). He re corticoste roids should be a dministe re d in

stre ss dose s (e .g., cortisol 100 mg/da y) (Miller: Basics of Anesth esia,
ed 6, pp 111–112).
284. (B) Dia ze pa m is a be nzodia ze pine drug a nd wa s wide ly use d
intra ve nously for a ne sthe sia until mida zola m wa s de ve lope d.
Although it is a n e ffe ctive se da tive a nd a mne stic drug, dia ze pa m
ca use s significa nt pa in on inje ction a nd a t time s ve nous irrita tion
a nd thrombophle bitis. This doe s not se e m to occur with
mida zola m. Be nzodia ze pine s do not suppre ss the a dre na l gla nd.
The most significa nt proble m with be nzodia ze pine s is re spira tory
de pre ssion. Be nzodia ze pine s a re unique a mong the intra ve nous
se da tive s be ca use a spe cific be nzodia ze pine re ce ptor a nta gonist is
a va ila ble (fluma ze nil). One proble m with fluma ze nil is its re la tive ly
short dura tion of a ction (ha lf-life a bout 1 hour), which is shorte r
tha n tha t of dia ze pa m (21-37 hours) a nd mida zola m (1-4 hours)
(Miller: Basics of Anesth esia, ed 6, p 109).
285. (D) Pa in on inje ction is common with dia ze pa m, e tomida te ,
a nd propofol but ra re with thiope nta l a nd ke ta mine . Howe ve r,
he modyna mic sta bility is common with e tomida te a nd dia ze pa m,
whe re a s hypote nsion is common a fte r propofol a nd thiope nta l,
e spe cia lly in pa tie nts who a re volume -de ple te d or e lde rly.
Hype rte nsion ma y de ve lop with ke ta mine use due to its
sympa the tic ne rvous syste m stimula tion (Miller: Basics of Anesth esia,
ed 6, pp 99–102).
286. (A) ICP te nds to fa ll a fte r the a dministra tion of thiope nta l,
e tomida te , a nd propofol a nd ca n e ithe r fa ll or re ma in uncha nge d
with be nzodia ze pine s. Ke ta mine , howe ve r, ca n incre a se ICP a nd
should be a voide d in pa tie nts with intra cra nia l ma ss le sions a nd
e le va te d ICP be ca use it ca n furthe r incre a se the ICP (Miller: Basics
of Anesth esia, ed 6, pp 109–111).
287. (D) Propofol infusion syndrome (la ctic a cidosis) ma y de ve lop

whe n high-dose infusions (i.e ., >75 µg/kg/min) a re infuse d for


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

(e .g., >200 mg). The syste mic lupus e rythe ma tosus–like syndrome
will re solve once hydra la zine the ra py is discontinue d.
291. (D) La be ta lol is a n α1-a dre ne rgic re ce ptor a nd nonse le ctive β-
a dre ne rgic re ce ptor a nta gonist.
292. (A) Abrupt discontinua tion of chronica lly a dministe re d

clonidine (e spe cia lly if the dose is >1.2 mg/da y) ma y re sult in


se ve re re bound hype rte nsion within 8 to 36 hours a fte r the la st
dose .
For Question 293: Som e d rugs inh ibit coagulation and d o so th rough a
m y riad of d ifferent path way s. An und erstand ing of th ese d rugs and
th eir m ech anism s is h elpful to th e anesth esia provid er.
293. (A) Pa tie nts susce ptible to HIT-2 (he pa rin-induce d
thrombocytope nia ) should wa it 3 months for a clinica lly significa nt
de cre a se in the a ntibody tite r be fore re ce iving he pa rin. If wa iting is
not possible a nd surge ry involving ca rdiopulmona ry bypa ss ca nnot
be de la ye d, dire ct thrombin inhibitors like hirudin, biva lirudin, or
a rga troba n ca n be use d a s a nticoa gula nts for bypa ss surge ry
(Miller: Basics of Anesth esia, ed 6, pp 358–359).
294. (C) Abcixima b (Re oPro, pla sma ha lf-life 30 minute s), tirofiba n
(Aggra sta t, pla sma ha lf-life 2 hours), a nd e ptifiba tide (Inte grilin,
pla sma ha lf-life 2.5 hours) a re pote nt inhibitors of pla te le t a ctivity.
The y block the binding of vW F a nd fibrinoge n to the GPIIb/IIIa
re ce ptors on pla te le ts. The se drugs a re use d in the tre a tme nt of
a cute corona ry syndrome . If surge ry is re quire d, the ra py with
e ptifiba tide a nd tirofiba n should be stoppe d for 24 hours.
Abcixima b should be stoppe d for 72 hours be fore a n ope ra tion. All
thre e of the se drugs produce thrombocytope nia a nd a re
me ta bolize d by the kidne y, but dia lysis a s re ve rsa l is only e ffe ctive
with tirofiba n (Barash : Clinical Anesth esia, ed 7, pp 437–438, Miller:
Miller’s Anesth esia, ed 8, p 1873; Miller: Basics of Anesth esia, ed 6, pp
357–359).
295. (A) Arga troba n is a dire ct thrombin inhibitor. Ple a se se e
e xpla na tion a nd re fe re nce for Que stion 293.
296. (B) The thie nopyridine compounds, ticlopidine a nd clopidogre l,
a re P2Y12 a de nosine diphospha te (ADP) re ce ptor a nta gonists.
Binding to this ADP re ce ptor suppre sse s e xpre ssion of GPIIb/IIIa
a nd pre ve nts fibrinoge n from binding to pla te le ts. Although pla te le t
function studie s, pe r se , a re not a re lia ble wa y to te st the e ffe cts of
clopidogre l, the re is a te st to me a sure the inhibition of the
GPIIb/IIIa re ce ptor. Clopidogre l is a n ina ctive prodrug tha t must be
me ta bolize d into the a ctive form by live r oxida se s. A ge ne tic
polymorphism e xists whe re by pa tie nts a re una ble to oxidize
clopidogre l into the a ctive compound, thus ma king it the ra pe utica lly
ine ffe ctive (Barash : Clinical Anesth esia, ed 7, p 437; Miller: Basics of
Anesth esia, ed 6, pp 357–359).
297. (D) Fonda pa rinux is a n a nta gonist of fa ctor Xa . It a lso binds
with a ntithrombin III. Its principa l use is de e p ve in thrombosis
prophyla xis, a nd the re is no a ntidote for it othe r tha n stopping
the ra py a nd le tting it we a r off. Be ca use it is re na lly e limina te d,
dose must be re duce d in pa tie nts with re na l fa ilure . It is not
a pprove d for pa tie nts with history of he pa rin-induce d
thrombocytope nia (Barash : Clinical Anesth esia, ed 7, p 439).
298. (B) Both a cute tole ra nce to opioids a nd opioid-induce d
hype ra lge sia (OIH) re quire more a na lge sics to tre a t pa in. W ith
tole ra nce the pha rma cologic re sponse is le ss ove r time ; thus, more
opioids a re ne e de d to re lie ve the sa me a mount of pa in (e .g.,
chronic ba ck pa in). W ith OIH the re is a n e xa gge ra te d re sponse to
pa inful stimuli. This ca n occur unde r ce rta in situa tions such a s a n
e xa gge ra te d re sponse to pa in whe n a re mife nta nil infusion is
stoppe d (ra pid offse t of a na lge sia ). To pre ve nt this whe n using
re mife nta nil-ba se d a ne sthe sia , it is wise to a dd a longe r dura tion
opioid (e .g., morphine ) a nd/or to a dd nonopioid a na lge sics be fore
stopping a re mife nta nil infusion (if pa in is e xpe cte d in the
postope ra tive pe riod). Although the e tiology of OIH is unknown, it
ma y involve both ce ntra l a nd pe riphe ra l ne rvous syste m
a da pta tions involving the NMDA re ce ptor (Barash : Clinical
Anesth esia, ed 7, p 506; Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, pp 267–268).
299. (D) Mixe d a gonist-a nta gonist drugs, such a s butorpha nol,
na lbuphine , a nd pe nta zocine , a re pa rtia l a gonists a t the κ re ce ptor
a nd comple te compe titive a nta gonists a t the µ re ce ptor. Both the
a na lge sia a nd re spira tory de pre ssa nt e ffe cts of the se drugs
a pproa ch a ce iling e ffe ct. The y a re use d a s a na lge sics for mild-to-
mode ra te pa in. The y a re a lso use d to re ve rse e xce ssive opioid-
induce d re spira tory de pre ssion due to the ir µ a nta gonism, while
ma inta ining some a na lge sia a t the κ re ce ptor (Miller: Miller’s
Anesth esia, ed 8, pp 903–904; Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, pp 265–266).
300. (A) Although opioids a re ma inly thought to work on opioid
re ce ptors, me tha done is a lso a most pote nt NMDA re ce ptor
a nta gonist (6-18 time s tha t of morphine ). This prope rty a ppe a rs to
be use ful in re ducing the e ffe cts of opioid tole ra nce a nd
withdra wa l syndrome (Barash : Clinical Anesth esia, ed 7, p 505;
Hem m ings: Ph arm acology and Ph y siology for Anesth esia, p 264).
301. (C) Ta pe nta dol (Nucynta ) is a ne w opioid ma rke te d for fe we r
GI a nd CNS side e ffe cts. It ha s a dua l me cha nism of a ction: a s a n
a gonist for the µ re ce ptor site a nd a s a nore pine phrine re upta ke
inhibitor (NRI). It should not be use d in pa tie nts ta king MAOIs,
be ca use a n a dre ne rgic crisis ma y de ve lop. It is a lso
contra indica te d with SSRIs, be ca use it ma y le a d to se rotonin
syndrome . It is only a va ila ble ora lly (Barash : Clinical Anesth esia, ed 7,
p 505; Brunton: Good m an & Gilm an’s Th e Ph arm acological Basis of
Th erapeutics, ed 12, p 508).
For Questions 302-305: Depolarizing neurom uscular blockad e usually is
d escribed as h aving two ph ases. Ph ase I blockad e occurs with
d epolarization of th e postjunctional m em brane. Ph ase II blockad e occurs
wh en th e postjunctional m em brane h as becom e repolarized but d oes not
respond norm ally to acety lch oline (i.e., often term ed d esensitized , but
oth er factors are involved ). Th is can occur wh en th e d ose of

succiny lch oline is greater th an 2 to 4 m g/kg. Th e response of a m uscle to


electrical nerve stim ulation for a ph ase II block is sim ilar to th at for a
nond epolarizing block. Nond epolarizing neurom uscular blockad e is only
of one ty pe (Miller: Basics of Anesth esia, ed 6, pp 148–149).
302. (D) Although the me cha nisms of a nonde pola rizing a nd a pha se
II de pola rizing block like ly a re diffe re nt, the y both ca n be
a nta gonize d with a nticholine ste ra se drugs.
303. (B) Only a pha se I de pola rizing block is e nha nce d with the use
of a nticholine ste ra se drugs.
304. (D) Post-te ta nic fa cilita tion occurs whe n a single twitch tha t is
induce d a short pe riod of time a fte r te ta nic stimula tion is la rge r
tha n the a mplitude of the te ta nus. This occurs with a pha se II
de pola rizing blocka de a s we ll a s with a nonde pola rizing blocka de .
305. (B) The a mplitude of the muscle re sponse to susta ine d te ta nic
stimula tion re ma ins the sa me with pha se I de pola rizing blocka de ,
but it shows a ma rke d fa de with a pha se II de pola rizing blocka de
or a nonde pola rizing blocka de .
SUMMARY OF MUSCULAR RESPONSES TO NERVE STIMULATION
WITH DIFFERENT TYPES OF BLOCKADE
For Questions 306-315: A sim ple way to m easure th e potency of inh aled
d rugs is to m easure th eir MAC values. MAC is th e m inim um alveolar

concentration of an inh aled d rug at 1 atm osph ere (atm ) (1 atm =

760 m m Hg) wh ere 50% of patients d o not m ove in response to a


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

315. (C) Se ve re hypoxia (Pa O2 of 38 mm Hg), a s we ll a s se ve re

a ne mia (<4.3 mL/oxyge n/dL of blood), de cre a se s MAC.


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

DIRECT IONS (Que stions 321 through 377): Ea ch que stion or


incomple te sta te me nt in this se ction is followe d by a nswe rs
or by comple tions of the sta te me nt, re spe ctive ly. Se le ct the
ONE BEST a nswe r or comple tion for e a ch ite m.

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

360. If a pa tie nt we re a ne sthe tize d 90 minute s with 1.25 MAC


isoflura ne followe d by 30 minute s of 1.25 MAC se voflura ne
a ne sthe sia , wa ke -up would be
A. The sa me a s 2 hours of isoflura ne a ne sthe sia
B. The sa me a s 2 hours of se voflura ne a ne sthe sia
C. Le ss tha n 2 hours of isoflura ne a ne sthe sia , but gre a te r tha n
2 hours of se voflura ne
D. Gre a te r tha n 2 hours of isoflura ne a ne sthe sia
361. An a ne sthe sia circuit is prime d in pre pa ra tion for a n inha la tion
induction (with ope n a djusta ble pre ssure -limiting va lve ). The
a ne sthe sia hose is occlude d with a flow of 6 L/min. The a ne sthe sia
circuit (ca niste rs, hose s, ma sk, a ne sthe sia ba g) conta ins 6 L. A
ma chine ma lfunction a llows a dministra tion of 100% N2O.
Approxima te ly how much N2O would the re be in the circuit whe n
the ma lfunction is discove re d a t the 1-minute ma rk?
A. 32%
B. 48%
C. 63%
D. 86%
362. W hich of the following fa ctors lowe rs MAC for vola tile
a ne sthe tics?
A. Se rum sodium 151 mEq/L
B. Re d ha ir
C. Body te mpe ra ture 38° C
D. Acute e tha nol inge stion
363. Ea ch of the following fa ctors ca n influe nce the pa rtia l pre ssure
gra die nt ne ce ssa ry for the a chie ve me nt of a ne sthe sia EXCEPT
A. Inspire d a ne sthe tic conce ntra tion
B. Ca rdia c output
C. VA
D. Ve ntila tion of nonpe rfuse d a lve oli (de a d spa ce )
364. W hich of the following vola tile a ne sthe tics is unique in
conta ining pre se rva tive ?
A. Se voflura ne
B. De sflura ne
C. Isoflura ne
D. None of the a bove
365. If the a lve ola r-to-ve nous pa rtia l pre ssure diffe re nce of a
vola tile a ne sthe tic (P A − P V) is positive (i.e ., P A > P V) a nd the
a rte ria l-to-ve nous pa rtia l pre ssure diffe re nce (Pa − P V) is ne ga tive
(i.e ., P V > Pa ), which of the following sce na rios is MOST like ly to
be true ?
A. The va porize r ha s be e n shut off a t the e nd of the ca se
B. Induction ha s just sta rte d
C. Ste a dy sta te ha s be e n a chie ve d
D. The va porize r wa s shut off during e me rge nce , the n turne d
ba ck on
366. Ane sthe tic loss to the pla stic a nd rubbe r compone nts of the
a ne sthe tic circuit, hinde ring a chie ve me nt of a n a de qua te inspire d
conce ntra tion, is a fa ctor with which of the following a ne sthe tics?
A. De sflura ne
B. Isoflura ne
C. Se voflura ne
D. N2O
367. Fa ctors pre disposing to forma tion a nd/or re bre a thing of
compound A include e a ch of the following EXCEPT
A. Low fre sh ga s flow
B. Use of ca lcium hydroxide lime ra the r tha n soda lime
C. High a bsorbe nt te mpe ra ture s
D. Fre sh a bsorbe nt
368. The e ffe cts of a le ft-to-right shunt such a s a n a rte riove nous
fistula on inha la tion induction of a ne sthe sia is to
A. Spe e d up induction
B. Slow down induction
C. Slow down inha la tion induction only if a n intra ca rdia c (right-to-
le ft) shunt a lso e xists
D. Spe e d up inha la tion induction only if a n intra ca rdia c (right-to-
le ft) shunt a lso e xists
369. The following vola tile a ge nts a re corre ctly ma tche d with the ir
de gre e of me ta bolism (de te rmine d by me ta bolite re cove ry):
A. Se voflura ne 2%
B. Isoflura ne 0.2%
C. De sflura ne 0.02%
D. All a re corre ctly ma tche d
370. W hich of the compone nts be low is NOT conside re d in the
proce ss of “wa shin” of the a ne sthe sia circuit a t the onse t of
a dministra tion?
A. Infra re d spe ctrome te r tubing a nd re se rvoir
B. Expira tory limb
C. Ane sthe sia ba g
D. CO2 a bsorbe r
371. W hich of the following ma ne uve rs would NOT incre a se the
ra te of a n inha la tion induction?
A. Giving the pa tie nt a n inotropic infusion
B. Substituting se voflura ne for isoflura ne
C. Ove rpre ssurizing
D. Ca rrying out the induction in Sa n Die go inste a d of De nve r
372. W hich of the following a ne sthe tics would unde rgo 90%
e limina tion the most ra pidly a fte r a 6-hour W hipple proce dure
unde r 1 MAC for the dura tion of the ope ra tion?
A. Isoflura ne
B. Se voflura ne
C. De sflura ne
D. Se voflura ne a nd de sflura ne a re tie d
373. Afte r induction a nd intuba tion of a he a lthy pa tie nt a nd
institution of a ve ntila tor, the se voflura ne va porize r is se t a t 2%, a nd
fre sh ga s flow is 1 L/min (50% N2O a nd 50% O2). The inspire d
conce ntra tion on the infra re d spe ctrome te r 1 minute la te r is 1.4%.
The MAIN re a son for the diffe re nce be twe e n the dia l se tting a nd
the conce ntra tion shown on the infra re d spe ctrome te r is
A. Ra pid upta ke of se voflura ne
B. Insufficie nt fre sh ga s flow for corre ct va porize r function
C. Se cond ga s e ffe ct
D. Dilution
374. Afte r ce ssa tion of ge ne ra l a ne sthe sia tha t consiste d of a ir,
oxyge n, a nd a vola tile a ge nt only, the pa tie nt is give n 100% oxyge n.
Ea ch of the following se rve s a s a re se rvoir for vola tile a ne sthe sia
a nd ma y de la y e me rge nce EXCEPT
A. Re bre a the d e xha le d ga se s
B. The a bsorbe nt
C. The pa tie nt
D. Ga se s e me rging from the common ga s outle t
375. W hich of the following cha ra cte ristics of vola tile a ne sthe tics is
ne ce ssa ry for ca lcula tion of the time consta nt?
A. Blood/ga s pa rtition coe fficie nt
B. Bra in/blood pa rtition coe fficie nt
C. Oil/ga s pa rtition coe fficie nt
D. All of the a bove
376. The conce pt of “conte xt se nsitive ha lf-time ” e mpha size s the
importa nce of the re la tionship be twe e n ha lf time a nd
A. VA
B. Blood solubility
C. Conce ntra tion
D. Dura tion
377. Se le ct the FALSE sta te me nt re ga rding pha rma cokine tics for
vola tile a ne sthe tics. Afte r thre e time consta nts
A. 6 to 12 minute s ha ve e la pse d for “mode rn a ne sthe tics”
B. The a rte ria l-to-ve nous pa rtia l pre ssure diffe re nce (for the
vola tile ) for the bra in is ve ry sma ll
C. The e xpire d vola tile conce ntra tion will rise much le ss slowly
tha n in the pre ce ding 12 minute s
D. The ve nous blood will conta in 95% of vola tile conte nt of
a rte ria l blood

DIRECT IONS (Que stions 378 through 381): Ma tch the


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

378. Ha lotha ne (1 MAC)


379. Isoflura ne (1 MAC)
380. De sflura ne (1 MAC)
381. Se voflura ne (1 MAC)
Pharmacology and Pharmacokinetics of
Volatile Anesthetics
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
321. (B) The MAC for inha la tion a ge nts va rie s with a ge . For most
vola tile a ne sthe tics, the highe st MAC va lue s a re for infa nts 1 to
6 months old. In infa nts younge r tha n 1 month or olde r tha n
6 months, the MAC is lowe r for isoflura ne , ha lotha ne , a nd
de sflura ne . Se voflura ne is diffe re nt. For se voflura ne , the MAC for
ne ona te s 0 to 30 da ys old is 3.3%, for infa nts 1 to 6 months old it is
3.2%, a nd for infa nts 6 to 12 months old it is 2.5% (Miller: Miller’s
Anesth esia, ed 8, p 2764).
322. (B) The a lve ola r pa rtia l pre ssure of a vola tile a ne sthe tic, which
ultima te ly de te rmine s the de pth of ge ne ra l a ne sthe sia , is
de te rmine d by the re la tive ra te s of input to re mova l of the
a ne sthe tic ga se s to a nd from the a lve oli. Re mova l of a ne sthe tic
ga se s from the a lve oli is a ccomplishe d by upta ke into the
pulmona ry ve nous blood, which is most de pe nde nt on a n a lve ola r
pa rtia l pre ssure diffe re nce . During the initia l mome nts of inha la tion
of a n a ne sthe tic ga s, the re is no vola tile a ne sthe tic in the a lve oli to
cre a te this pa rtia l pre ssure gra die nt. The re fore , the upta ke for a ll
vola tile a ne sthe tic ga se s will be minima l until the re sulta nt ra pid
incre a se in a lve ola r pa rtia l pre ssure e sta blishe s a sufficie nt
a lve ola r-to-ve nous pa rtia l pre ssure gra die nt to promote upta ke of
the a ne sthe tic ga s into the pulmona ry ve nous blood. This will occur
in spite of othe r fa ctors, which a re discusse d in the e xpla na tion to
Que stion 333 (Miller: Miller’s Anesth esia, ed 8, pp 648–649).
323. (D) At conce ntra tions of 1 MAC or le ss, vola tile a ne sthe tics, a s
we ll a s the inha le d a ne sthe tic N2O, will produce dose -de pe nde nt
incre a se s in the re spira tory ra te in sponta ne ously bre a thing
pa tie nts. This tre nd continue s a t conce ntra tions gre a te r tha n 1 MAC
for a ll of the inha le d a ne sthe tics e xce pt isoflura ne . W ith the
e xce ption of N2O, the e vide nce sugge sts tha t this e ffe ct is ca use d by
dire ct a ctiva tion of the re spira tory ce nte r in the CNS ra the r tha n by
stimula tion of pulmona ry stre tch re ce ptors. Additiona lly, vola tile
a ne sthe tics de cre a se VT a nd significa ntly a lte r the bre a thing
pa tte rn from the norma l a wa ke pa tte rn of inte rmitte nt de e p bre a ths
se pa ra te d by va rying time inte rva ls to one of ra pid, sha llow,
re gula r, a nd rhythmic bre a thing (Miller: Miller’s Anesth esia, ed 8, pp
691–692).
324. (D) Ba rium-conta ining a bsorbe nts tha t inte ra ct with vola tile
a ne sthe tics a nd produce ca rbon monoxide a nd compound A a re no
longe r use d in clinica l pra ctice . The y ha ve be e n re pla ce d with
ca lcium-conta ining products such a s Amsorb Plus. Conse que ntly,
a bsorbe nt gra nule s a re “consume d” by CO2 produce d by the
pa tie nt, not by the tota l flow of a ne sthe tic ga se s. On the contra ry,
with low flow te chnique s, re circula tion (re bre a thing) of e xpire d
ga se s re sults in more ra pid de ple tion of the CO2 a bsorbe nt.
Vola tile a ne sthe tics a re orga nic compounds, spe cifica lly a lka ne s
(ha lotha ne ) a nd substitute d me thyl-e thyl e the rs (de sflura ne ,
isoflura ne ) or substitute d isopropyl me thyl e the r (se voflura ne ).
The y a re ultima te ly de rive d from pe trole um source s a nd a re the n
ha loge na te d to be come substitute d orga nic compounds. The y
join a myria d of othe r orga nic ha lide s such a s ha irspra y,
prope lla nts, re frige ra nts, a nd solve nts tha t colle ctive ly contribute
to the de ple tion of the ozone la ye r in the e a rth’s a tmosphe re .
The ma in gre e nhouse ga se s a re CO2, me tha ne , a nd N2O. N2O
constitute s roughly 5% of the gre e nhouse ga se s. Anothe r
ra tiona le for the use of low-flow a ne sthe sia is the introduction of
le ss wa ste into the OR.
The disa dva nta ge of low-flow a ne sthe sia is tha t the F IO2 will
continua lly drop during the a dministra tion of a ne sthe sia (unle ss
100% oxyge n is a dministe re d), a nd vigila nce is re quire d be ca use
this drop ma y a pproa ch or e ve n re a ch the le ve l of a hypoxic
mixture (Miller: Miller’s Anesth esia, ed 8, pp 664–665).
325. (C) Although de sflura ne ha s a low blood/ga s pa rtition
coe fficie nt (0.42) a nd should produce ra pid induction of a ne sthe sia ,
its ma rke d punge ncy a nd a irwa y irrita tion ma ke inha la tion
inductions ve ry difficult. Not only do pa tie nts dislike the sce nt, but
the a irwa y irrita tion ofte n le a ds to coughing, incre a se d sa liva tion,
bre a th holding, a nd some time s la ryngospa sm (e spe cia lly if the
conce ntra tion is ra pidly incre a se d). In a ddition, with a brupt
incre a se s in conce ntra tion, pa tie nts ofte n e xpe rie nce ta chyca rdia
a nd hype rte nsion, thought to be due to incre a se d sympa the tic
discha rge (Miller: Basics of Anesth esia, ed 6, p 95).
326. (B) A va porize r ’s spe cificity is ba se d on the va por pre ssure of
the a ne sthe tic a ge nt for which it is ma de . Filling a va porize r with
a n a ge nt whose va por pre ssure is highe r re sults in a highe r
conce ntra tion in the va porize r ’s output. Simila rly, a vola tile a ge nt
with a lowe r va por pre ssure produce s a n output with a lowe r
conce ntra tion tha n tha t se e n on the dia l. The va por pre ssure of
e nflura ne , 172 mm Hg (20° C), most close ly a pproxima te s the va por
pre ssure of se voflura ne , which is 160 mm Hg (Miller: Basics of
Anesth esia, ed 6, p 81).
327. (A) W he n N2O is substitute d for a n e qua l MAC va lue of
isoflura ne , the re sulting blood pre ssure is gre a te r tha n tha t se e n
with the sa me MAC va lue a chie ve d with isoflura ne a s the sole
a ne sthe tic a ge nt. W he n a dministe re d a lone , N2O doe s not a lte r
a rte ria l blood pre ssure , stroke volume , syste mic va scula r
re sista nce , or ba rore ce ptor re fle xe s. The a dministra tion of N2O
incre a se s he a rt ra te slightly, which ma y re sult in a mild incre a se in
ca rdia c output. In vitro, N2O ha s a dose -de pe nde nt dire ct
de pre ssa nt e ffe ct on myoca rdia l contra ctility, which is proba bly
ove rcome in vivo by sympa the tic a ctiva tion (Miller: Basics of
Anesth esia, ed 6, p 93).
328. (D) All of the pre se nt-da y vola tile a ne sthe tics re duce blood
pre ssure in a dose -de pe nde nt fa shion. De sflura ne , se voflura ne ,
a nd isoflura ne ca use this prima rily through re ductions in syste mic
va scula r re sista nce . The obsole te a ge nts, ha lotha ne a nd e nflura ne ,
produce hypote nsion via dire ct myoca rdia l de pre ssion (Miller: Basics
of Anesth esia, ed 6, pp 90–91).
329. (A) The olde r a ge nt ha lotha ne te nde d to de cre a se the ca rdia c
output, whe re a s se voflura ne , de sflura ne , a nd isoflura ne te nd to
ma inta in ca rdia c output. N2O te nds to incre a se ca rdia c output
prima rily be ca use of the mild incre a se in sympa the tic tone
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
53).
330. (D) At conce ntra tions of 1 MAC, isoflura ne ma y a tte nua te
a ntige n-induce d bronchospa sm, pre suma bly by de cre a sing va ga l
tone . At simila r conce ntra tions, isoflura ne will not re duce ca rdia c
output in pa tie nts with norma l le ft ve ntricula r function. Additiona lly,
isoflura ne will de cre a se stroke volume , me a n a rte ria l pre ssure ,
a nd syste mic va scula r re sista nce in a dose -de pe nde nt ma nne r.
Ca rdia c output re ma ins uncha nge d be ca use de cre a se s in syste mic
va scula r re sista nce re sult in a re fle x incre a se in he a rt ra te tha t is
sufficie nt to offse t the de cre a se in stroke volume . Howe ve r, dose -
de pe nde nt de cre a se s in both stroke volume a nd ca rdia c inde x ca n
be se e n whe n isoflura ne is a dministe re d in conce ntra tions gre a te r
tha n 1 MAC (Miller: Basics of Anesth esia, ed 6, pp 90–95).
331. (A) De sflura ne ca n (but doe s not a lwa ys) produce incre a se d
blood pre ssure a nd he a rt ra te whe n the conce ntra tions a re ra pidly
incre a se d. This ma y be re la te d to a irwa y irrita tion a nd a
sympa the tic re sponse . This ha s a lso occurre d with isoflura ne , but
to a much le ss fre que nt a nd usua lly lowe r e xte nt. The othe r a ge nts
liste d do not ca use this sympa the tic re sponse with a ra pid incre a se
in conce ntra tion. If de sflura ne is incre a se d slowly or a prior dose
of na rcotic is give n, this incre a se in blood pre ssure a nd he a rt ra te
ma y not occur (Miller: Basics of Anesth esia, ed 6, pp 90–92).
332. (A) Of a ll the options liste d, de sflura ne ha s the lowe st
solubility consta nt, which re sults in a ve ry ra pid rise in F A/F I . The
ra te of rise is ve ry simila r to tha t se e n with N2O a nd re sults in the
most ra pid a tta inme nt of 1 MAC conce ntra tion once the ne w
vola tile a ne sthe tic ha s be e n initia te d. Isoflura ne ha s the highe st
blood/ga s solubility coe fficie nt of a ll the options, re fle cting the
la rge st qua ntity of ga s store d in the blood. This re se rvoir will re sult
in the slowe st de cline in the a lve ola r conce ntra tion of this vola tile
a ge nt upon discontinua tion. The combina tion of the se diffe re nt
solubilitie s will ultima te ly re sult in the highe st combine d MAC
whe n 1 MAC of isoflura ne is discontinue d a nd 1 MAC of de sflura ne
is introduce d (Miller: Basics of Anesth esia, ed 6, p 88; Morgan &
Mikh ail: Clinical Anesth esiology, ed 4, pp 156–157, 159).
333. (A) The a lve ola r pa rtia l pre ssure of a n a ne sthe tic is
de te rmine d by the ra te of input re la tive to re mova l of the a ne sthe tic
from the a lve oli, a s e xpla ine d in Que stion 322. During induction,
the a ne sthe tic ga s is re move d from the a lve oli by upta ke into the
pulmona ry ve nous blood. The ra te of upta ke is influe nce d by
ca rdia c output, the blood/ga s solubility coe fficie nt, a nd the a lve ola r-
to-ve nous pa rtia l pre ssure diffe re nce of the a ne sthe tic. At a lowe r
ca rdia c output, a slowe r ra te of upta ke of vola tile a ne sthe tic from
the a lve oli into the pulmona ry ve nous blood re sults in a fa ste r ra te
of incre a se in the a lve ola r conce ntra tion. This will re sult in a n
incre a se d F A/F I . Upta ke of poorly soluble a ne sthe tic ga se s from the
a lve oli is minima l, a nd the ra te of rise of F A/F I is ra pid a nd virtua lly
inde pe nde nt of ca rdia c output. Upta ke of the more soluble
a ne sthe tics, such a s isoflura ne , from the a lve oli into the pulmona ry
ve nous blood ca n be conside ra ble a nd will be re fle cte d by a
slowe r ra te of rise of the F A/F I ra tio. Ca rdioge nic shock will ha ve
the sma lle st impa ct on the most insoluble a ge nts, such a s
de sflura ne , se voflura ne , a nd N2O, whe re a s the impa ct on the ra te
of rise of F A/F I of the re la tive ly soluble a ne sthe tic ga se s, such a s
isoflura ne , will be more profound (Miller: Miller’s Anesth esia, ed 8, pp
645–646).
334. (C) The ve sse l-rich group tha t re ce ive s a pproxima te ly 75% of
the ca rdia c output is compose d of the bra in, he a rt, sple e n, live r,
sple nic be d, kidne ys, a nd e ndocrine gla nds. This group, howe ve r,
constitute s only 10% of the tota l body we ight. Be ca use of this la rge
blood flow re la tive to tissue ma ss, the se orga ns ta ke up a la rge
volume of vola tile a ne sthe tic a nd e quilibra te with the pa rtia l
pre ssure of the vola tile a ne sthe tic in the blood a nd a lve oli during
the e a rlie st mome nts of induction (Miller: Basics of Anesth esia, ed 6, p
87; Miller: Miller’s Anesth esia, ed 8, pp 647–648).
335. (D) De sflura ne is unique a mong the curre nt commonly use d
vola tile a ne sthe tics be ca use of its high va por pre ssure of
664 mm Hg. Be ca use of this, the va porize r is pre ssurize d to
1500 mm Hg a nd is e le ctrica lly he a te d to 23° C to give more
pre dica ble conce ntra tions: 664/1500 = a bout 44%. If the de sflura ne is
use d a t 1 a tm the conce ntra tion will be a bout 88% (Barash : Clinical
Anesth esia, ed 7, pp 666–668; Miller: Basics of Anesth esia, ed 6, pp 202–
203; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
60–64).
336. (B) Fre sh ga s flow = 1 L pe r minute (1000 mL/min).
F IO2 = [(100 mL/min) + (900 ×
0.21 mL/min)]/1000 mL/min = (100 + 180)/1000 = 289/1000 = 29%
Ane sthe tic flow me te rs a re de signe d to de live r ga se s ve ry
a ccura te ly (Miller: Miller’s Anesth esia, ed 8, pp 760–761).
337. (D) The situa tion de scribe d he re is a tra nspulmona ry shunt. In
pa tie nts with tra nspulmona ry shunting, blood e me rging from
unve ntila te d a lve oli conta ins no a ne sthe tic ga s. This a ne sthe tic-
de ficie nt blood mixe s with blood from a de qua te ly ve ntila te d,
a ne sthe tic-conta ining a lve oli, producing a n a rte ria l a ne sthe tic
pa rtia l pre ssure conside ra bly le ss tha n e xpe cte d. Be ca use upta ke
of a ne sthe tic ga s from the a lve oli into pulmona ry ve nous blood will
be le ss tha n norma l, tra nspulmona ry shunting a cce le ra te s the ra te
of rise in the F A/F I ra tio but re duce s the ra te of incre a se in the
a rte ria l pa rtia l pre ssure of a ll vola tile a ne sthe tics. The de gre e to
which the se cha nge s occur de pe nds on the solubility of the give n
vola tile a ne sthe tic. For poorly soluble a ne sthe tics, such a s N2O,
tra nspulmona ry shunting only slightly a cce le ra te s the ra te of rise in
the F A/F I ra tio, but it significa ntly re duce s the ra te of incre a se in
a rte ria l a ne sthe tic pa rtia l pre ssure . The opposite occurs with
highly soluble vola tile a ne sthe tics, such a s ha lotha ne a nd
isoflura ne (Miller: Miller’s Anesth esia, ed 8, pp 646–647).
338. (A) CO2 is a ve ry soluble ga s. ma king the e nd-tida l CO2 (ETCO2)
a t the le ve l of the a lve oli virtua lly ide ntica l to a rte ria l CO2 (Pa CO2).
Be ca use we me a sure ETCO2 on the tota l e xha le d ga s, the a lve ola r
CO2 is dilute d with the ga s in the de a d spa ce (e .g., a lve oli a re
ve ntila te d but a re not pe rfuse d a s we ll a s the re spira tory
pa ssa ge wa ys). A gra die nt of 2 to 5 mm Hg be twe e n Pa CO2 a nd
ETCO2 is se e n in norma l he a lthy pa tie nts. Any condition tha t
incre a se s de a d spa ce or re duce s lung pe rfusion (i.e ., incre a se s
V/Q) such a s pulmona ry e mbolism, se ve re hypote nsion, low
ca rdia c output, a nd ca rdia c a rre st will de cre a se ETCO2. ETCO2 ca n
a lso de cre a se with a n incre a se in minute ve ntila tion (incre a se d
re mova l of CO2) a nd ca n de cre a se with hypothe rmia (de cre a se d
production of CO2). Of course , ETCO2 ca n ra pidly de cre a se to ze ro
with a ny fa ilure to ve ntila te (e .g., e sopha ge a l intuba tion, circuit
disconne ction, fa ilure to turn the ve ntila tor on a fte r ma nua l
ve ntila tion is stoppe d) a s we ll a s with disruption of the sa mpling
line s. Be ca use CO2 ra pidly e quilibra te s be twe e n the bloodstre a m
a nd the a lve ola r ga s, a n e ndotra che a l tube tha t slips into a
ma inste m give s the sa me minute ve ntila tion a s a n e ndotra che a l
tube in the tra che a (a irwa y pre ssure , howe ve r, would incre a se ).
Incre a se d ETCO2 ca n ha ve ma ny ca use s, including hypove ntila tion,
re bre a thing of e xha le d ga s, incre a se d a bsorption of CO2 from the
a bdome n diste nde d with CO2 during la pa roscopy, ma ligna nt
hype rthe rmia , se psis, a nd a dministra tion of bica rbona te use d to
tre a t me ta bolic a cidosis (Barash : Clinical Anesth esia, ed 7, pp 704–705;
Miller: Basics of Anesth esia, ed 6, pp 328–329; Butterworth : Morgan and
Mikh ail’s Clinical Anesth esiology, ed 5, pp 123–127).
339. (A) Isoflura ne is unique a mong the vola tile a ge nts in tha t it
doe s not re duce ca rdia c output (ca rdia c inde x) a t conce ntra tions of
1 MAC or le ss in he a lthy volunte e rs (Miller: Basics of Anesth esia, ed 6,
pp 90–92).
340. (C) The ra te of input of vola tile a ne sthe tics from the a ne sthe sia
ma chine to the a lve oli is influe nce d by thre e fa ctors: VA, the
inspire d a ne sthe tic pa rtia l pre ssure , a nd the cha ra cte ristics of the
a ne sthe tic bre a thing syste m. Incre a se d VA will a cce le ra te the ra te
of incre a se in F A/F I for a ll vola tile a ne sthe tics. Howe ve r, the
ma gnitude of this e ffe ct is de pe nde nt on the solubility of the
inha le d a ne sthe tic. The ra te of incre a se in F A/F I de pe nds ve ry little
on VA for poorly soluble a ne sthe tics be ca use the upta ke of the se is
minima l. In contra st, the ra te of incre a se in F A/F I for highly soluble
a ne sthe tics de pe nds significa ntly on VA. Isoflura ne is the most
soluble inha le d a ne sthe tic liste d in this que stion (blood/ga s
solubility coe fficie nt 1.46). The re fore , a n incre a se in VA will
a cce le ra te the ra te of incre a se in F A/F I the most for isoflura ne .
Blood/ga s solubility coe fficie nts for the othe r vola tile a ne sthe tics
a re a s follows: ha lotha ne 2.54, e nflura ne 1.90, se voflura ne 0.69,
de sflura ne 0.42, a nd N2O 0.46 (Miller: Miller’s Anesth esia, ed 8, pp 647–
650).
341. (C) Ane sthe tic re quire me nt incre a se s from birth until
a pproxima te ly a ge 3 to 6 months. The n, with the e xce ption of a
slight incre a se a t pube rty, a ne sthe tic re quire me nt progre ssive ly
de cline s with a ging. For e xa mple , the MAC for ha lotha ne in
ne ona te s is a pproxima te ly 0.87%, in infa nts it is a pproxima te ly 1.2%,
a nd in young a dults it is a pproxima te ly 0.75%. A nota ble e xce ption
to this pa tte rn is se e n with se voflura ne , for which MAC is the
highe st with ne ona te s. If the que stion pe rta ine d only to
se voflura ne , the corre ct re sponse would ha ve be e n C. Ple a se
re vie w the a nswe r to Que stion 321 (Miller: Miller’s Anesth esia, ed 8, p
2764).
342. (B) The e xa ct me cha nism in which vola tile a ne sthe tics e xe rt
the ir e ffe cts is not fully unde rstood a nd re ma ins a topic of
conside ra ble re se a rch. The most obvious e ffe ct of ge ne ra l
a ne sthe sia , unconsciousne ss (hypnosis), is produce d a t the le ve l of
the bra in. The e nd-tida l conce ntra tion of the vola tile in que stion
re fle cts the le ve l of a ne sthe sia “se e n” by the bra in, but only once
e quilibrium ha s be e n re a che d. At e quilibrium, P alveolar = P arterial =
P CNS. Afte r thre e (95% e quilibrium) to four (99% e quilibrium) time
consta nts, the e nd-tida l conce ntra tion a nd the pa rtia l pre ssure of
the a ne sthe tic a t the bra in (a nd blood for tha t ma tte r) would be the
sa me , provide d de live ry ha s re ma ine d consta nt. A time consta nt is
de fine d a s ca pa city (of the bra in) divide d by flow (of a ne sthe tic-
la de n blood) a nd is e xpre sse d by the following e qua tion:
τ = Vλ ÷ Q
The time consta nt, τ, is a bout 3 to 4 minute s for mode rn vola tile
a ne sthe tics. Accordingly, 10 to 15 minute s must e la pse be fore
a ssuming tha t the pa rtia l pre ssure of the a ne sthe tic ha s re a che d
e quilibrium in the bra in. For this re a son, choice D is a n incorre ct
re sponse for this que stion, be ca use no me ntion is ma de of time
(Barash : Clinical Anesth esia, ed 7, pp 447–454; Miller: Basics of
Anesth esia, ed 6, p 86; Hem m ings: Ph arm acology and Ph y siology for
Anesth esia, ed 1, pp 50–51).
343. (B) Two principle s of MAC must be conside re d in this situa tion.
First, MAC is a dditive , so the fra ction of MAC of e a ch individua l ga s
must be a dde d to a rrive a t tota l MAC. The se cond is tha t a lve ola r
conce ntra tions of soluble a ge nts a re re fle cte d more a ccura te ly by
e nd-e xpira tory conce ntra tions ra the r tha n by e ithe r inspira tory
conce ntra tions or gra die nts be twe e n inspira tory a nd e xpira tory
conce ntra tions. Be ca use N2O is ve ry insoluble , it is re a sona ble to
a ssume tha t e quilibrium will be e sta blishe d e a rly. The inspira tory
conce ntra tion of N2O, a pproxima te ly 0.6 MAC, should a pproxima te
the a lve ola r conce ntra tion. Howe ve r, the e xpira tory conce ntra tions
of the more soluble vola tile a ne sthe tics should be use d to e stima te
the a lve ola r conce ntra tion. The e nd-e xpira tory isoflura ne
conce ntra tion of 0.6 re fle cts a pproxima te ly 0.5 MAC, which in
a ddition to the 0.6 MAC of N2O would be close st to a nswe r C: 1.1
MAC (Miller: Basics of Anesth esia, ed 6, pp 83–84).
344. (B) The figure shown in this que stion de picts the conce ntra tion
e ffe ct. Note tha t the inspire d a ne sthe tic conce ntra tion influe nce s
not only the ma ximum a tta ina ble a lve ola r conce ntra tion but a lso
the ra te a t which the ma ximum a lve ola r conce ntra tion ca n be
a tta ine d. The gre a te r the inha le d a ne sthe tic conce ntra tion, the
fa ste r the incre a se in F A/F I (Miller: Basics of Anesth esia, ed 6, pp 84–
85).
345. (D) The de pth of ge ne ra l a ne sthe sia is dire ctly proportiona l to
the a lve ola r a ne sthe tic pa rtia l pre ssure . The fa ste r the ra te of
incre a se in F A/F I , the fa ste r the induction of a ne sthe sia . W ith the
e xce ption of a right-to-le ft intra ca rdia c shunt (se e e xpla na tion to
Que stion 337 on e ffe ct of shunt on the ra te of incre a se in F A/F I a nd
e xpla na tion to Que stion 346 on the e ffe ct of shunt on a rte ria l
a ne sthe tic pa rtia l pre ssure a nd ra te of induction of a ne sthe sia ), a ll
of the conditions liste d in this que stion will a cce le ra te the ra te of
incre a se in F A/F I a nd thus the ra te of induction of a ne sthe sia
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
30).
346. (A) In ge ne ra l, a right-to-le ft intra ca rdia c shunt or
tra nspulmona ry shunt will slow the ra te of induction of a ne sthe sia .
This occurs be ca use of a dilutiona l e ffe ct of shunte d blood, which
conta ins no vola tile a ne sthe tic, on the a rte ria l a ne sthe tic pa rtia l
pre ssure coming from ve ntila te d a lve oli. The impa ct of a right-to-
le ft shunt on the ra te of incre a se in pulmona ry a rte ria l a ne sthe tic
pa rtia l pre ssure , a nd ultima te ly the ra te of induction of a ne sthe sia ,
is gre a te st for poorly soluble vola tile a ne sthe tics. This occurs
be ca use the upta ke of poorly soluble vola tile a ne sthe tics into
pulmona ry ve nous blood is minima l; thus, the dilutiona l e ffe ct of
the shunt on pulmona ry ve nous a ne sthe tic pa rtia l pre ssure is
e sse ntia lly unoppose d. In contra st, the upta ke of highly soluble
vola tile a ne sthe tics is sufficie nt to pa rtia lly offse t the dilutiona l
e ffe ct. Of the a ne sthe tics liste d in the que stion, de sflura ne is the
le a st soluble (Miller: Miller’s Anesth esia, ed 8, p 645).
347. (A) Both a le ft-to-right intra ca rdia c shunt a nd a le ft-to-right
tissue shunt, such a s a n a rte riove nous fistula , will re sult in a highe r
pa rtia l pre ssure of a ne sthe tic ga s in the blood re turning to the
lungs, ultima te ly re sulting in a more ra pid rise in F A/F I . Howe ve r,
this e ffe ct is minima l a nd in most ca se s is clinica lly insignifica nt
(Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p
30).
348. (D) Se voflura ne is a highly insoluble vola tile a ne sthe tic tha t
combine s with CO2 a bsorbe nts to form a vinyl e the r known a s
compound A. The blood/ga s pa rtition coe fficie nt for se voflura ne is
0.69. The va porize r ma nufa cture d by Ohme da is ca pa ble of
de live ring conce ntra tions ra nging from 0.2% to 8% a t fre sh-ga s flow
ra te s of 0.2 to 15 L/min. Its va por pre ssure is 160 mm Hg a t 20° C,
which is simila r to the va por pre ssure for the othe r vola tile
a ne sthe tics e xce pt de sflura ne (664 mm Hg a t 20° C). Ga s flows
gre a te r tha n 2 L/min pre ve nt the re bre a thing of compound A (not
the forma tion of it), thus re ducing the possibility of re na l toxicity
a ssocia te d with it (Miller: Miller’s Anesth esia, ed 8, p 662).
349. (D) Le ft-to-right shunts (e .g., PDA, a tria l se pta l de fe ct,
ve ntricula r se pta l de fe ct) a re a ssocia te d with a n incre a se in blood
flow through the lungs. W ith inha la tion induction the re is no re a l
e ffe ct on induction ra te . Re me mbe r a lso tha t a de cre a se in
syste mic va scula r re sista nce se e n with inha la tion a ge nts (e .g.,
se voflura ne ) a nd positive -pre ssure ve ntila tion te nd to de cre a se the
ma gnitude of the le ft-to-right shunt. Howe ve r, with right-to-le ft
shunts (e .g., te tra logy of Fa llot) the re is de cre a se d blood flow
through the lungs a nd a slowe r inha la tion induction. W ith a right-to-
le ft shunt, the de cre a se in syste mic va scula r re sista nce ca n
incre a se the shunt a nd le a d to a de cre a se in oxyge na tion.
Intra ve nous drugs work more ra pidly in right-to-le ft shunts.
Ha lotha ne ma y be pre fe rre d (to se voflura ne ) in right-to-le ft shunts
be ca use ha lotha ne de cre a se s contra ctility a nd be tte r ma inta ins
syste mic va scula r re sista nce (Miller: Basics of Anesth esia, ed 6, p 551).
350. (D) Vola tile a ne sthe tics produce minima l bronchodila tion
unle ss a irwa y re sista nce is incre a se d (bronchospa sm). This is
e xpla ine d by the fa ct tha t a irwa y smooth muscle tone is ordina rily
low, a nd a dditiona l bronchodila tion is difficult to de monstra te . The
irrita ting e ffe cts of de sflura ne ca n be re duce d by prior
a dministra tion of fe nta nyl or morphine (Miller: Basics of Anesth esia,
ed 6, p 95).
351. (A) Ple a se se e a lso Que stion 342 a nd its a nswe r. The
de te rmina nt of a ne sthe tic e ffe ct is pa rtia l pre ssure , ultima te ly a t
the CNS. If a pa tie nt is in a hype rba ric cha mbe r unde r 2 a tm
(1520 torr), the e ffe ctive pa rtia l pre ssure from a de sflura ne
va porize r would be double d for a ny give n dia l se tting in
compa rison with se a le ve l. A 6% se tting a t se a le ve l would be
760 × 0.06, or 45.6 mm Hg de sflura ne . The de sflura ne va porize r is
unique in tha t it is more a kin to a dua l ga s ble nde r. To a chie ve a
pa rtia l pre ssure of 45.6 mm Hg (a t 2 a tm), the dia l should be se t a t
3% (Miller: Miller’s Anesth esia, ed 8, pp 771–772).
352. (A) This cla ssic gra ph de picts the e ffe ct of switching from 21%
oxyge n a nd 79% N2O to 21% oxyge n a nd 79% nitroge n—tha t is, a ir.
W he n this occurs, la rge volume s of N2O a re re le a se d into the lungs
a nd dilute a ll ga se s, including oxyge n a nd CO2. The re duction in O2
re sults in hypoxia , a nd the re sulting fa ll in CO2 re duce s the drive to
bre a the . This combina tion occurs a t a time whe n most pa tie nts
ha ve na rcotics a nd othe r re spira tory de pre ssa nts in the body. For
this re a son, it is wise to a dministe r 100% oxyge n to pa tie nts for
se ve ra l minute s a fte r the y e me rge from ge ne ra l a ne sthe sia (Miller:
Miller’s Anesth esia, ed 8, pp 656–657).
353. (A) The ve sse l-rich group re ce ive s 75% of the ca rdia c output
a nd re pre se nts 10% of the we ight of a le a n a dult. In a se nse , the
lungs re ce ive virtua lly 100% of the ca rdia c output, but this is the
right-side d CO (the supply side for oxyge n) a nd the re fore doe s not
“count” in the cla ssic de finition. Lung pa re nchyma , ironica lly, use s
a ve ry sma ll qua ntity of oxyge n compa re d with the bra in, live r,
kidne y, a nd myoca rdium (Miller: Miller’s Anesth esia, ed 8, p 648).
354. (D) At 1 MAC conce ntra tions, isoflura ne de pre sse s me a n
a rte ria l pre ssure s prima rily by de cre a sing syste mic va scula r
re sista nce . The de cre a se in me a n a rte ria l pre ssure ma y be gre a te r
tha n tha t se e n with the a dministra tion of ha lotha ne . Howe ve r,
he a rt ra te will be incre a se d, a nd stroke volume will de cre a se to a
le sse r e xte nt tha n is se e n with the a dministra tion of 1 MAC
ha lotha ne (Miller: Miller’s Anesth esia, ed 8, p 713).
355. (B) Cha nge s in both ca rdia c output a nd VA will a ffe ct the ra te s
of rise of F A/F I, but in opposite dire ctions. An incre a se in ca rdia c
output will de cre a se the ra te of F A/F I, whe re a s a n incre a se in VA
will incre a se the ra te of F A/F I . Howe ve r, the se two opposing
options do not comple te ly offse t e a ch othe r be ca use the incre a se d
ca rdia c output a lso a cce le ra te s the e quilibrium of the a ne sthe tic
be twe e n the blood a nd the tissue s. This e quilibrium re sults in a
na rrowing of the a lve ola r-to-ve nous pa rtia l pre ssure diffe re nce a nd
a tte nua te s the impa ct of the incre a se d ca rdia c output on upta ke .
The ne t re sult will be a slight incre a se in the ra te of rise of F A/F I
(Miller: Miller’s Anesth esia, ed 8, p 646).
356. (A) Blood/ga s pa rtition coe fficie nt is the option liste d tha t most
close ly corre la te s with re cove ry from inha le d a ne sthe sia . A highe r
blood/ga s pa rtition coe fficie nt re fle cts a la rge r qua ntity of ga s
dissolve d in the blood for a give n a lve ola r conce ntra tion. Othe r
fa ctors tha t a ffe ct e me rge nce from a ne sthe sia include VA, ca rdia c
output, tissue conce ntra tions, a nd me ta bolism (Miller: Miller’s
Anesth esia, ed 8, p 654).
357. (A) N2O inte rfe re s with the e nzyme me thionine synthe ta se ,
which ca ta lyze s the conve rsion of homocyste ine to me thionine .
Chronic e xposure to N2O le a ds to a dise a se sta te simila r to vita min
B12 de ficie ncy, but with one importa nt diffe re nce : it is not a lle via te d
with vita min B12 supple me nta tion.
In he a lthy pa tie nts, me ga lobla stic cha nge s ca n be se e n in the
bone ma rrow a fte r just 12 hours of e xposure to 50% N2O (or
highe r). In pa tie nts who a re se riously ill, the se cha nge s ca n be
se e n e ve n e a rlie r. The othe r dise a se ca use d by vita min B12
de ficie ncy, suba cute combine d de ge ne ra tion of the spina l cord,
a ppe a rs only a fte r months of e xposure , a s is se e n in long-te rm
N2O a buse rs (Miller: Miller’s Anesth esia, ed 8, p 664).
358. (A) Four ma in fa ctors a ffe ct the tota l or ra te of rise of the
a lve ola r conce ntra tion of a ne sthe tic (F A) a nd he nce the inha la tion
induction of a ne sthe tics. The se fa ctors a re the inspire d
conce ntra tion of a ne sthe tic (F I ), the solubility of the a ne sthe tic, the
VA, a nd the ca rdia c output. The ra te of rise in F A/F I is fa ste r with
the le ss soluble a ne sthe tics, a s note d by the blood/ga s pa rtition
coe fficie nts. The blood/ga s pa rtition coe fficie nt me a sure d a t 37° C
is the le a st with de sflura ne (0.45), followe d close ly by N2O (0.47),
the n se voflura ne (0.65), isoflura ne (1.4), e nflura ne (1.8), a nd
ha lotha ne (2.5); it is the highe st with e the r (12). Thus, re pla cing
se voflura ne with isoflura ne would slow down induction. Incre a sing
the minute ve ntila tion a s we ll a s incre a sing the fre sh ga s flow ra te
a llows more of the a ne sthe tic to ge t into the lungs a nd offse t the
upta ke of a ne sthe tic by the blood, thus spe e ding the induction of
inha la tiona l a ne sthe sia . De cre a sing the ca rdia c output a lso
a cce le ra te s the rise of F A/F I, re sulting in fa ste r inha la tion induction
(de cre a se s the a mount of blood e xpose d to the lung a nd de cre a se s
the upta ke of a ne sthe sia ) (Miller: Miller’s Anesth esia, ed 8, pp 647–650;
Miller: Basics of Anesth esia, ed 6, pp 84–87).
359. (B) The ta ble be low conta ins a fifth column, F IO2. Choice s B
a nd D a ppe a r to be tie d a t 50%. The que stion a sks for a rte ria l
oxyge n conce ntra tion (not F IO2). During induction of ge ne ra l
a ne sthe sia , N2O is ra pidly ta ke n up into the blood, re sulting in the
so-ca lle d se cond ga s e ffe ct a nd a conce ntra ting e ffe ct.
Conce ntra tion of oxyge n in this ma nne r is te rme d “a lve ola r
hype roxyge na tion” a nd re sults in a tra nsie nt incre a se in Pa O2 of
a pproxima te ly 10% (Miller: Basics of Anesth esia, ed 6, p 85).

360. (A) The insoluble vola tile a ge nt de sflura ne ha s the a dva nta ge
of ra pid wa shout a nd the re fore ra pid re cove ry. The downside is the
highe r cost of de sflura ne compa re d with isoflura ne . A study wa s
de vise d to te st wa ke -up a fte r volunte e rs we re a ne sthe tize d with
isoflura ne for the first 75% of the a ne sthe tic a nd switche d to
se voflura ne for the la st 25%. The re sults showe d tha t the “hybrid”
la ste d a s long a s a n a ne sthe tic tha t consiste d of isoflura ne a lone
a nd prove d the futility of this stra te gy (Miller: Miller’s Anesth esia, ed 8,
pp 656–657).
361. (C) Ca lcula tion of the wa shin of N2O re quire s use of the
conce pt of time consta nt. Give n a volume of 6 L for the circle
syste m, the time consta nt is 6 L/(6 L/min) or 1 minute . The numbe rs
to re me mbe r for time consta nts a re 63%, 84%, a nd 95% for 1, 2 a nd 3
time consta nts, re spe ctive ly. A prope rly functioning a ne sthe sia
ma chine would ne ve r a llow the a dministra tion of 100% N2O, but
this nightma re sce na rio is give n pure ly for illustra tive purpose s
(Barash : Clinical Anesth esia, ed 7, p 451).
362. (D) Acute e tha nol inge stion is the only fa ctor liste d tha t will
re duce MAC. Acute a mphe ta mine inge stion ra ise s MAC, a s do
hype rna tre mia , hype rthe rmia , a nd na tura lly occurring re d ha ir.
Ge nde r, thyroid function, a nd Pa CO2 be twe e n 15 a nd 95 mm Hg a nd
Pa O2 gre a te r tha n 38 mm Hg ha ve no e ffe ct on MAC (Miller: Basics of
Anesth esia, ed 6, p 82).
363. (D) This ta ble summa rize s the fa ctors tha t influe nce the pa rtia l
pre ssure gra die nts. A right-to-le ft intra pulmona ry shunt a ffe cts the
de live ry of inha le d a ne sthe tics, but lung de a d spa ce doe s not,
be ca use the la tte r doe s not produce a dilutiona l e ffe ct on the
a rte ria l pa rtia l pre ssure of the a ne sthe tic in que stion (Miller: Basics
of Anesth esia, ed 6, pp 84–87).
FACTORS DETERMINING PARTIAL PRESSURE GRADIENTS
NECESSARY FOR ESTABLISHMENT OF ANESTHESIA

Input from Anesthesia Uptake from Alveoli to Uptake from Arterial Blood
Machine to Alveoli Pulmonary Blood to Brain
Inspired anesthetic Blood gas partition Brain/blood partition
concentration coefficient coefficient
Alveolar ventilation Cardiac output Cerebral blood flow
Characteristics of the Alveolar-to-venous partial Arterial-to-venous partial
anesthesia breathing system pressure difference pressure difference
From Stoelting RK, Miller RD: Basics of Anesthesia, ed 4, New York, Churchill Livingstone,
2000, p 26.

364. (D) Ha lotha ne wa s the only “mode rn” vola tile a ne sthe tic
(me thoxyflura ne a lso conta ine d a pre se rva tive ) tha t conta ins a
pre se rva tive , thymol. Be ca use ha lotha ne wa s a t risk for
de gra da tion into chloride , hydrochloric a cid, bromide , hydrobromic
a cid, a nd phosge ne , it wa s store d in a mbe r-colore d bottle s, a nd
thymol wa s a dde d to pre ve nt sponta ne ous oxida tion. None of the
curre ntly use d vola tile a ge nts conta ins a pre se rva tive (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 44).
365. (D) The de live ry of a ne sthe tic ga se s to a pa tie nt is a comple x
se rie s of e ve nts tha t sta rts with the a ne sthe sia ma chine a nd
culmina te s with a chie ve me nt of a n a ne sthe tic pa rtia l pre ssure in
the bra in (PBr). The pa rtia l pre ssure me a sure d in the blood for a ny
vola tile a ge nt is e ithe r rising (a t first ra pidly, the n more slowly) or
fa lling (ra pidly a t first, the n more slowly). The ve sse l-rich group
re a che s ste a dy sta te in a bout 12 minute s (for a ny dia le d le ve l of
vola tile a ge nt). The re st of the body, howe ve r, a pproa che s, but
virtua lly ne ve r re a che s, e quilibrium (e .g., the e quilibrium ha lf-time
for the fa t group is 30 hours for se voflura ne ). He nce , a true ze ro
gra die nt is ne ve r a chie ve d in the ste a dy sta te . W he n the a ne sthe tic
is discontinue d or re duce d, the re is a fa ll in the a rte ria l pa rtia l
pre ssure such tha t it is le ss tha n the ve nous pa rtia l pre ssure . In
fa ct, whe n the ve nous pa rtia l pre ssure e xce e ds the a rte ria l pa rtia l
pre ssure , it me a ns tha t the vola tile a ge nt ha s be e n re duce d (or shut
off) be ca use the lungs a re “cle a nsing” the blood a s the vola tile -
fille d blood pa sse s through the m. The ne wly “cle a nse d” blood the n
finds its wa y to the le ft ve ntricle with a ve ry low P A for the vola tile
a ge nt in que stion (Barash : Anesth esiology, ed 7, pp 450–453).
366. (B) Ane sthe tic a ge nts a re soluble in the rubbe r a nd pla stic
compone nts found in the a ne sthe sia ma chine . This fa ct ca n impe de
the de ve lopme nt of a ne sthe tic conce ntra tions of the se drugs. The
worst offe nde r is the obsole te vola tile a ge nt me thoxyflura ne .
Howe ve r, both isoflura ne a nd ha lotha ne a re soluble in rubbe r a nd
pla stic, but to a le sse r de gre e . Se voflura ne , de sflura ne , a nd N2O
ha ve little or no solubility in rubbe r or pla stic. A diffe re nt but
importa nt issue should be borne in mind re ga rding the loss of
se voflura ne . This a ge nt ca n be de stroye d in a ppre cia ble qua ntitie s
by Ba ra lyme (no longe r a va ila ble ) a nd soda lime , but not ca lcium
hydroxide lime (Amsorb) (Miller: Miller’s Anesth esia, ed 8, pp 660–661).
367. (B) Compound A is a n e the r tha t forms whe n se voflura ne
inte ra cts with a bsorbe nt gra nule s. In ra ts, compound A is a
ne phrotoxin tha t ca use s da ma ge to the proxima l re na l tubule . It is
be lie ve d tha t compound A is not ne phrotoxic in huma ns, a t le a st
not a t the conce ntra tions tha t a re a chie ve d clinica lly (e ve n with
fre sh ga s flows a s low a s 1 L/min). The fa ctors tha t le a d to
incre a se d conce ntra tions of compound A a re use of fre sh
a bsorbe nt, use of Ba ra lyme inste a d of soda lime , high a bsorbe nt
te mpe ra ture s, highe r conce ntra tions of se voflura ne in the
a ne sthe sia syste m, a nd close d-circuit or low-flow a ne sthe sia .
Ca lcium hydroxide lime (Amsorb) doe s not conta in KOH or Na OH
a nd doe s not inte ra ct with se voflura ne to produce compound A or
othe r vola tile a ge nts to produce ca rbon monoxide (Miller: Miller’s
Anesth esia, ed 8, p 790).
368. (D) A le ft-to-right pe riphe ra l shunt such a s a n a rte riove nous
fistula de live rs vola tile -conta ining ve nous blood to the lungs. This
a ction offse ts the dilutiona l e ffe ct of a right-to-le ft intra ca rdia c or
pulmona ry shunt a nd spe e ds up induction. The incre a se in the
a ne sthe tic pa rtia l pre ssure from a n a rte riove nous fistula is
de te cta ble only in the se tting of a concomita nt right-to-le ft shunt
(Miller: Basics of Anesth esia, ed 6, p 87).
369. (D) Ea ch of the vola tile a ge nts is corre ctly pa ire d with its
pe rce nta ge of re cove re d me ta bolite s. Se voflura ne is me ta bolize d
2% to 5% through oxida tive pa thwa ys using the cytochrome P-450
e nzyme pa thwa y. Like wise , the othe r vola tile a ge nts a re a ll
oxida tive ly me ta bolize d in va rying de gre e s. The obsole te a ne sthe tic
me thoxyflura ne unde rwe nt 50% me ta bolism, re sulting in high
conce ntra tions of fluoride ions a nd re sulta nt re na l fa ilure in some
pa tie nts. Ha lotha ne is unique a mong the vola tile a ge nts in tha t it
ca n unde rgo re ductive me ta bolism in the fa ce of low oxyge n
a va ila bility in the live r (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, pp 77–80).
370. (A) By de finition, the wa shin of the a ne sthe sia circuit re fe rs to
the filling of the compone nts of the circuit with a ne sthe tic ga se s.
The tota l wa shin volume s a re a round 7 L a nd bre a k down a s
follows: a ne sthe sia ba g 3 L, a ne sthe sia hose s 2 L, a nd a ne sthe sia
a bsorbe nt compa rtme nt 2 L. All of the compone nts liste d a re pa rt of
the a ne sthe sia circuit e xce pt the infra re d spe ctrome te r tubing. The
infra re d spe ctrome te r a nd ma ss spe ctrome te r ta ke a wa y (sa mple )
from incoming ga se s through a spira tion but do not dilute the m
(Miller: Miller’s Anesth esia, ed 8, pp 660–661).
371. (A) Incre a sing minute ve ntila tion is one of two me thods for
ma nipula ting ve ntila tion to incre a se the ra te of e sta blishing
a ne sthe sia . Anothe r me thod is incre a sing inspire d conce ntra tion,
which ca n be a chie ve d by turning up the dia l a bove the de sire d
ste a dy sta te conce ntra tion (ove rpre ssurizing) to re a ch ste a dy sta te
more quickly, or incre a sing fre sh ga s flow to re duce or e limina te
re bre a thing (dilution). Substituting a le ss soluble a ne sthe tic, such a s
se voflura ne for isoflura ne , a lso e sta blishe s a ne sthe sia more
ra pidly. Ca rrying out the induction in Sa n Die go inste a d of De nve r
constitute s a dministe ring the a ne sthe tic a t highe r a tmosphe ric
(ba rome tric) pre ssure , which de cre a se s the upta ke a nd he nce
incre a se s the ra te of rise of F A/F I —tha t is, a cce le ra te s the
e sta blishme nt of a ne sthe sia . The a dministra tion of a n inotropic
a ge nt incre a se s ca rdia c output, which a lso incre a se s upta ke a nd
slows the ra te of induction (Barash : Clinical Anesth esia, ed 7, pp 451–
454; Miller: Basics of Anesth esia, ed 6, pp 84–88).
372. (C) In a compa rison of the pha rma cokine tics of e limina tion for
vola tile a ne sthe tics, de sflura ne is the fa ste st. The time for a 50%
re duction (de cre me nt) in the a lve ola r pa rtia l pre ssure of the
“mode rn” a ne sthe tics is roughly the sa me : a bout 5 minute s,
re ga rdle ss of a ne sthe tic dura tion. For longe r a ne sthe tics, howe ve r,
the 80% a nd 90% de cre me nt time s be come ma rke dly diffe re nt. In
the pre se nt e xa mple , the 90% de cre me nt time for de sflura ne a fte r a
6-hour a ne sthe tic is 14 minute s. This is in sta rk contra st to
se voflura ne (65 minute s) a nd isoflura ne (86 minute s). Ple a se se e
Que stion 376 a nd its e xpla na tion (Miller: Basics of Anesth esia, ed 6, pp
88–90; Miller: Miller’s Anesth esia, ed 8, pp 654–655).
373. (D) A prope rly functioning va porize r will produce the
conce ntra tion se t on the dia l (plus or minus a sma ll tole ra nce )
provide d the fre sh ga s flow ra te is gre a te r tha n 250 mL/min a nd
le ss tha n 15 L/min. The 1 L/min ra te in this que stion is we ll within
the limits of the va porize r. The fa ct tha t re bre a thing occurs with a
circula r a ne sthe sia syste m ca use s a significa nt dilutiona l e ffe ct. It is
true tha t upta ke would e nha nce dilution, but it (upta ke ), pe r se , is
not the ma in re a son for this discre pa ncy. Upta ke is conside re d in
the discussion of the F A/F I ra tio. This que stion a ddre sse s the
cha ra cte ristics of the a ne sthe sia ma chine a nd the re la tionship
be twe e n dia l se tting a nd de live re d conce ntra tion. To a chie ve a
de sire d conce ntra tion (e .g., 2%), you must e ithe r ra ise the fre sh ga s
flow to conve rt the syste m to a nonre bre a thing syste m or se t the
va porize r to a highe r le ve l tha n is a ctua lly de sire d: the conce pt of
ove rpre ssuriza tion. In this e ra of cost conta inme nt, the la tte r is
more e conomica l (Miller: Basics of Anesth esia, ed 6, p 207).
374. (D) The a ne sthe sia circuit ca n de la y e me rge nce significa ntly if
the pa tie nt is not disconne cte d (functiona lly) from it. Ane sthe tic
ga se s be come dissolve d in the rubbe r a nd pla stic compone nts of
the bre a thing circuit. Like wise , the soda lime ca n se rve a s a
de pository for a ne sthe tics a s we ll a s the pa tie nt’s own e xha le d
ga se s. To re duce the se e ffe cts to ne a rly ze ro, the fre sh ga s flow
should be ra ise d to a t le a st 5 L/min. Fre sh ga se s e me rge via the
common ga s outle t a nd do not conta in vola tile a ge nts or N2O
be ca use the y (vola tile a ge nts a nd N2O) a re shut off during
e me rge nce (Miller: Miller’s Anesth esia, ed 8, pp 660–661).
375. (B) The time consta nt is de fine d a s ca pa city divide d by flow.
The time consta nt for a vola tile a ne sthe tic is de te rmine d by the
ca pa city of a tissue to hold the a ne sthe tic re la tive to the tissue
blood flow. The ca pa city of a tissue to hold a vola tile a ne sthe tic
de pe nds both on the size of the tissue a nd on the a ffinity of the
tissue for the a ne sthe tic. The bra in time consta nt of a vola tile
a ne sthe tic ca n be e stima te d by doubling the bra in/blood pa rtition
coe fficie nt for the vola tile a ne sthe tic. For e xa mple , the time
consta nt of ha lotha ne (bra in/blood pa rtition coe fficie nt of 2.6) for
the bra in (ma ss of a pproxima te ly 1500 g, blood flow of 750 mL/min)
is a pproxima te ly 5.2 minute s (Eger: Anesth etic Uptake and Action, ed 1,
pp 85–87; Miller: Basics of Anesth esia, ed 6, p 86).
376. (D) This conce pt highlights the fa ct tha t the diffe re nce in ha lf-
time va lue s a mong the vola tile a ne sthe tics is simila r for a ll
vola tile s if the a ne sthe tic dura tion is ve ry brie f. W ith the
a dministra tion of vola tile a ne sthe tics for longe r time s, the
diffe re nce s in re cove ry time be come more profound. For e xa mple ,
a fte r a 1-hour a ne sthe tic with de sflura ne (blood/ga s tissue
coe fficie nt 0.45), a 95% re duction in the a lve ola r conce ntra tion ca n
be re a che d in 5 minute s. W ith a n hour-long se voflura ne a ne sthe tic
(blood/ga s tissue coe fficie nt 0.65), a 95% re duction re quire s
18 minute s, a nd a n hour-long isoflura ne a ne sthe tic (blood/ga s
tissue coe fficie nt 1.4) re quire s more tha n 30 minute s to re a ch a 95%
re duction in the a lve ola r conce ntra tion (Miller: Basics of Anesth esia,
ed 6, pp 89–90; Miller: Miller’s Anesth esia, ed 8, pp 654–655).
377. (D) Afte r a pe riod of time e qua l to thre e time consta nts, the
ve nous blood e xiting the ve sse l-rich group will be a t the 95% le ve l,
but the blood a s a whole will ha ve a le ve l of le ss tha n 95%. The
ve nous blood conta ins a mixture of blood from the ve sse l-rich
group, the muscle group, the fa t group, a nd the ve sse l-poor group,
a nd a t the thre e time consta nt ma rk will be le ss tha n 95% (Miller:
Basics of Anesth esia, ed 6, pp 86–88).
378. (A)
379. (C)
380. (D)
381. (B) The informa tion for the se que stions is summa rize d in the
gra phs be low. Ha lotha ne is unique a mong the vola tile a ge nts liste d
in tha t it doe s not a ffe ct the he a rt ra te or syste mic va scula r
re sista nce in the MAC ra nge s studie d. Se voflura ne re duce s he a rt
ra te until a bout 1 MAC, a t which time it produce s a dose -de pe nde nt
incre a se in he a rt ra te (Miller: Basics of Anesth esia, ed 6, pp 90–92).
PA R T 2

Clinical Sciences
OUTLI NE

Chapter 5. Blood Products, Transfusion, and Fluid Therapy


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

DIRECT IONS (Que stions 382 through 415): Ea ch que stion or


incomple te sta te me nt in this se ction is followe d by a nswe rs
or by comple tions of the sta te me nt, re spe ctive ly. Se le ct the
ONE BEST a nswe r or comple tion for e a ch ite m.

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

DIRECT IONS (Que stions 416 a nd 417): Choose the corre ct


re sponse be low for the following que stions:

416. W hich of the following proce sse s re duce s the possibility of


tra nsmission of cytome ga lovirus (CMV) to a susce ptible re cipie nt
via tra nsfusion of RBCs?
417. W ha t is the proce ss a ime d a t re ducing gra ft-ve rsus-host
dise a se (GVHD) in tra nsfusion re cipie nts?
A. Wa shing e rythrocyte s
B. Re duction of le ukocyte s
C. Irra dia tion
D. Stora ge in Adsol
Blood Products, Transfusion, and Fluid
Therapy
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
382. (A) PT a nd a PTT a re common te sts use d to e va lua te
coa gula tion fa ctors. The PT prima rily te sts for fa ctor VII in the
e xtrinsic pa thwa y, a s we ll a s fa ctors I, II, V, a nd X of the common
pa thwa y. The a PTT prima rily te sts for fa ctors VIII a nd IX of the
intrinsic pa thwa y, a s we ll a s fa ctors I, II, V, a nd X of the common
pa thwa y. Although the PT is prolonge d with de ficie nt function of
fa ctors I, II, V, VII, or X, it is more se nsitive to de ficie ncie s of fa ctor
VII a nd le ss so with de ficie ncie s of fa ctor I or II. In fa ct, the PT is
not prolonge d until the le ve l of fibrinoge n (fa ctor I) is le ss tha n
100 mg/dL a nd ma y be prolonge d for only 2 se conds whe n the le ve l
of fa ctor II (prothrombin) is 10% of norma l. Fa ctors II, VII, IX, a nd X
a re vita min K–de pe nde nt fa ctors, a nd the ir forma tion is blocke d
with Couma din the ra py. Administe ring fa ctor VIII will not he lp a
prolonge d PT (Miller: Miller’s Anesth esia, ed 8, pp 1872–1874; Barash :
Clinical Anesth esia, ed 7, pp 415–416).
383. (C) Pla te le t conce ntra te s conta in a fa ir a mount of pla sma a nd
white blood ce lls (W BCs) but re la tive ly fe w re d blood ce lls (RBCs).
Although ABO-compa tible pla te le t tra nsfusions a re pre fe rre d
(pla te le ts survive be tte r, a nd crossma tching for subse que nt RBCs is
e a sie r), in e me rge ncie s it ha s be e n note d tha t pla te le ts ofte n give
a de qua te he mosta sis without re ga rd to ABO compa tibility. Eve n
though the re a re only sma ll qua ntitie s of RBCs in pla te le ts, the
RBCs pre se nt ca n ca use Rh immuniza tion if Rh-positive pla te le t
conce ntra te s a re inje cte d into Rh-ne ga tive pa tie nts. Thus, until
childbirth is no longe r possible , Rh-ne ga tive wome n should re ce ive
only Rh-ne ga tive pla te le ts (Miller: Miller’s Anesth esia, ed 8, p 1860;
Hoffm an: Hem atology, ed 6, p 1655).
384. (C) Coa gulopa thie s ca n be inhe rite d or a cquire d. Of the
inhe rite d coa gulopa thie s, vW D is the most common, a ffe cting 1 in
100 to 500 pe ople . Both he mophilia A (fa ctor VIII) de ficie ncy a nd
he mophilia B (fa ctor IX or Christma s dise a se ) a re X-linke d
re ce ssive disorde rs. He mophilia A occurs in 1 to 2 pe r 10,000 ma le
individua ls, a nd he mophilia B occurs in 1 pe r 100,000 ma le
individua ls. Fa ctor V, fa ctor VII, fa ctor X, a nd prothrombin (fa ctor II)
de ficie ncie s a re e xce e dingly ra re a utosoma l re ce ssive disorde rs
(Miller: Miller’s Anesth esia, ed 8, p 1872; Barash : Clinical Anesth esia, ed
7, p 432).
385. (B) Pla te le t count is incre a se d a bout 5000 to 10,000/mm3 pe r
unit of pla te le t conce ntra te in the typica l 70-kg pa tie nt. Ea ch unit
conta ins gre a te r tha n 5.5 × 1010 pla te le ts (Miller: Miller’s Anesth esia,
ed 8, pp 1840, 1860; Barash : Clinical Anesth esia, ed 7, p 421).
386. (D) This is a n e xa mple of a typica l a lle rgic re a ction. All of the
othe r choice s in this que stion ma y be involve d in he molytic
re a ctions. Alle rgic re a ctions a re a form of nonhe molytic tra nsfusion
re a ctions, which a re thought to be ca use d by fore ign prote ins in the
tra nsfuse d blood. The re a ctions occur in a bout 3% of a ll
tra nsfusions, a nd the y pre se nt with urtica ria , e rythe ma , pruritus,
fe ve r, a nd some time s re spira tory symptoms. W he n such a re a ction
occurs, the tra nsfusion is stoppe d a nd supportive the ra py, including
a ntihista mine s, is a dministe re d. If the symptoms re solve a nd the re
a re no signs of a he molytic re a ction (no fre e he moglobin in the
pla sma or urine ) or a se ve re a na phyla ctic re a ction, the tra nsfusion
ca n be re sume d (Miller: Miller’s Anesth esia, ed 8, p 1853; Barash :
Clinical Anesth esia, ed 7, p 425).
387. (C) He molytic tra nsfusion re a ctions a re ofte n the re sult of
cle rica l e rror. Thre e ma in blood compa tibility te sts ca n be
pe rforme d to re duce the cha nce of a he molytic re a ction: ABO Rh
typing, a ntibody scre e ning, a nd crossma tching. W ith corre ct ABO
a nd Rh typing, the possibility of a n incompa tible tra nsfusion is le ss
tha n 1 pe r 1000. If you a dd a type a nd scre e n, the possibility of a n
incompa tible tra nsfusion is le ss tha n 1 pe r 10,000. Optima l sa fe ty
occurs whe n crossma tching is pe rforme d (Miller: Miller’s Anesth esia,
ed 8, p 1840).
388. (D) Blood is most ofte n store d a s a liquid a t a bout 4° C but ca n
a lso be froze n for prolonge d stora ge . Be ca use of the a dde d
e xpe nse of froze n blood, it is use d prima rily for ra re blood type s
a nd for a utologous use . Blood tha t ha s a lre a dy be e n colle cte d ha s
a cryoprote ctive a ge nt (e .g., glyce rol) a dde d a nd is the n froze n a nd
store d a t a te mpe ra ture of −65° C (whe n 40% glyce rol is use d) or
−120° C (whe n 20% glyce rol is use d). Curre ntly, the U.S. Food a nd
Drug Administra tion (FDA) a llows froze n blood to be use d up to
10 ye a rs from the time of colle ction (Barash : Clinical Anesth esia, ed 7,
p 416).
389. (C) Fa ctor VII is one of the four vita min K–de pe nde nt clotting
fa ctors (fa ctors II, VII, IX, a nd X). It a lso ha s the shorte st ha lf-life of
a ll the clotting fa ctors (4-6 hours) a nd is the first fa ctor to be come
de ficie nt in pa tie nts with se ve re he pa tic fa ilure , wa rfa rin
(Couma din) a nticoa gula tion the ra py, a nd vita min K de ficie ncy. The
PT is most se nsitive to de cre a se s in fa ctor VII (Barash : Clinical
Anesth esia, ed 7, pp 411–412).
390. (C) TRALI occurs within 6 hours of blood compone nt
a dministra tion. Pa tie nts e xpe rie nce nonca rdioge nic pulmona ry
e de ma with a cute bila te ra l pulmona ry infiltra te s a nd hypoxe mia
(Pa O2/F I O2 ≤300 mm Hg or oxyge n sa tura tion ≤90% on room a ir with
no e vide nce of le ft a tria l hype rte nsion). The pa thologic cha nge s
a ssocia te d with TRALI a re comple x a nd ma y involve low-pre ssure
pulmona ry e de ma se conda ry to ne utrophil a ctiva tion a nd
se que stra tion in the lungs. Olde r tra nsfusion products (>14 da ys),
fe ma le donors (e spe cia lly multipa rous pa tie nts), a nd poole d
pla te le ts compa re d with a phe re sis pla te le ts a re a ssocia te d with a
highe r fre que ncy of this condition. Inte re stingly, a lthough le ukocyte s
ma y be pa rt of the a ctiva tion proce ss, le ukocyte re duction doe s not
se e m to significa ntly de cre a se the incide nce of TRALI but doe s
de cre a se the incide nce of fe brile re a ctions a nd the risk of CMV,
a nd it ma y de cre a se le ukocyte -induce d immunomodula tion.
Tre a tme nt for TRALI re a ctions is supportive (Barash : Clinical
Anesth esia, ed 7, pp 417–428; Miller: Basics of Anesth esia, ed 6, p 376;
Miller: Miller’s Anesth esia, ed 8, p 1859).
391. (C) Of the five blood products liste d in this que stion, pla te le ts
a re the most like ly to ca use ba cte ria l se psis. Pla te le t-re la te d se psis
is e stima te d to occur in 1 ca se pe r 12,000. The source of ba cte ria
ca n be donor blood or conta mina tion during the colle ction,
proce ssing, a nd stora ge of the blood. If pla te le ts a re coole d, the n
re wa rme d, the pla te le ts te nd not to function ve ry e ffe ctive ly.
Be ca use pla te le ts a re store d a t room te mpe ra ture of 20 to 24° C,
ba cte ria te nd to survive a nd multiply. All othe r liste d blood products
a re coole d. W hole blood a nd pa cke d RBCs a re coole d to 4° C
(unle ss the y a re froze n, which would be colde r). FFP a nd
cryopre cipita te a re froze n to be low −70° C. Albumin is he a t
ste rilize d, ma king it a ste rile pre pa ra tion tha t the n ca n be sa fe ly
store d a t room te mpe ra ture s (Miller: Miller’s Anesth esia, ed 8, pp
1859–1860; Barash : Clinical Anesth esia, ed 7, pp 423–425).
392. (C) He pa titis A tra nsmission is ve ry ra re a nd is scre e ne d for by
history a lone (not se rologica lly) be ca use the re is no ca rrie r sta te for
the virus a nd the dise a se is re la tive ly mild. A de cre a se in the
tra nsmission for va rious othe r infe ctious a ge nts ha s be e n a ttribute d
to the re ce nt a ddition of nucle ic a cid te sting (se e ta ble ). At pre se nt,
the re a re no scre e ning te sts a va ila ble for ma la ria , Cha ga s, SARS,
va ria nt Cre utzfe ldt-Ja kob dise a se , or BSE (Miller: Miller’s Anesth esia,
ed 8, pp 1856–1858; Barash : Clinical Anesth esia, ed 7, pp 415–416).
TESTS USED FOR DETECTING INFECTIOUS AGENTS IN ALL UNITS
OF BLOOD, 2008

Virus RNA Minipool Antibody To


Human immunodeficiency virus (HIV) Nucleic acid technology HIV-1, HIV-2
Hepatitis C virus (HCV) Nucleic acid technology HCV
Hepatitis B virus (HBV) HBV
Human T-cell lymphotropic virus (HTLV) HTLV-1, HTLV-2
West Nile virus Nucleic acid technology

393. (B) Blood volume de cre a se s with a ge . A pre te rm ne wborn ha s


a blood volume of 100 to 120 mL/kg, a te rm ne wborn ha s a blood
volume of a bout 90 mL/kg, a n infa nt (3-12 months) ha s a blood
volume of 80 mL/kg, a child olde r tha n 1 ye a r ha s a blood volume of
70 mL/kg, a nd a n a dult ha s a blood volume of 65 mL/kg. This 10-kg,
1-ye a r-old infa nt would ha ve a n e stima te d blood volume (EBV) of
800 mL (Barash : Clinical Anesth esia, ed 7, p 1246).
394. (B) The risk of tra nsfusion-tra nsmitte d infe ction with a unit of
scre e ne d blood in the Unite d Sta te s va rie s from study to study, but it
is ve ry infre que nt with CMV be ca use of le ukocyte -re duce d blood: 1
in 205,000 for he pa titis B, 1 in 1,935,000 for he pa titis C, 1 in 2,135,000
for HIV, 1 in 2,993,000 for HTLV-II, a nd 1 in more tha n 1,100,000 for
We st Nile virus. Thus, the most common tra nsfusiona ssocia te d
infe ction in the Unite d Sta te s is now he pa titis B. The infe ctive a ge nt
for syphilis doe s not survive a t 4° C, ma king tra nsmission unlike ly
for whole blood, pa cke d RBCs, FFP, or cryopre cipita te . It is
possible for pla te le ts (store d a t room te mpe ra ture ) to tra nsmit
syphilis (Miller: Miller’s Anesth esia, ed 8, pp 1856–1858).
395. (A) The most common type of he mophilia is he mophilia A, a n
X-linke d re ce ssive dise a se ca using a re duction in fa ctor VIII a ctivity.
The dise a se occurs with a fre que ncy of 1 in 5000 ma le individua ls.
This dise a se ca n be se ve re (<1% fa ctor VIII), mode ra te (1%-4%
fa ctor VIII), or mild (5%-30% fa ctor VIII). Pa tie nts with mild
he mophilia ra re ly ha ve sponta ne ous ble e ding. La bora tory studie s
show a norma l pla te le t count a nd norma l PT but a prolonge d
a PTT. The prima ry goa l of pre ope ra tive pre pa ra tion of pa tie nts
with he mophilia A is to incre a se pla sma fa ctor VIII a ctivity to a
le ve l tha t will e nsure a de qua te he mosta sis (i.e ., 50%-100%), the n
ma inta in a le ve l (>40% fa ctor VIII le ve ls) for 7 to 10 da ys. One unit of
fa ctor VIII is e qua l to 1 mL of 100% a ctivity of norma l pla sma . Thus,
to ca lcula te the initia l dose , first ca lcula te the pa tie nt’s blood a nd
the n the pla sma volume . The n ca lcula te the a mount of a ctivity
ne e de d to incre a se the fa ctor VIII le ve l. In this ca se , the blood
volume is 78 kg × 65 mL/kg, or a bout 5000 mL. Knowing tha t the RBC
volume is 40% (i.e ., he ma tocrit is 40) ma ke s the pla sma volume
60%. Thus, the pla sma volume is 5000 mL × 0.6, or a bout 3000 mL.
Be ca use the pa tie nt is sta rting a t 0% a ctivity a nd you wish to ra ise it
to 100% a ctivity, you will ne e d 3000 units. (If you wish to ra ise the
a ctivity by 40%, the n 3000 mL of pla sma × 0.4 for 40% a ctivity = 1200
units.) In a ddition, be ca use the ha lf-life of fa ctor VIII is a bout
12 hours, a bout 1500 units will re ma in a fte r 12 hours. An infusion of
1500 units in 12 hours, or 125 units pe r hour, will be a good sta rting
ma inte na nce infusion ra te . Fa ctor VIII ca n be a dministe re d a s
fa ctor VIII conce ntra te or cryopre cipita te (a bout 10 units/mL).
Pa tie nts with fa ctor VIII inhibitors (10%-20% of pa tie nts with
he mophilia ) re quire more fa ctor VIII. He ma tology consulta tion
should be conside re d for a ll pa tie nts with he mophilia , a nd routine
che cking of fa ctor VIII le ve ls should be pe rforme d (Marx : Rosen’s
Em ergency Med icine, ed 8, p 1614).
396. (A) Se rum ADH le ve ls incre a se during pa inful stimula tion
a ssocia te d with surge ry, a s we ll a s during positive -pre ssure
me cha nica l ve ntila tion. Sma ll dose s of furose mide (i.e ., 0.1 mg/kg)
will counte ra ct this e ffe ct during surge ry (Miller: Miller’s Anesth esia,
ed 8, p 1773; Barash : Clinical Anesth esia, ed 7, pp 344–345).
397. (B) Type O, Rh-ne ga tive blood is a lso ca lle d unive rsa l donor
blood be ca use the tra nsfuse d RBCs la ck the a ntige ns ne e de d to be
he molyze d. Be ca use the pla sma of O-ne ga tive blood conta ins a nti-A
a nd a nti-B a ntibodie s, it is pre fe ra ble to a dministe r pa cke d RBCs
(with little pla sma ) ove r whole blood (lots of pla sma ) in a n
e me rge ncy. Howe ve r, if two or more units of type O-ne ga tive ,
uncrossma tche d whole blood a re a dministe re d to a pa tie nt a nd
subse que nt blood typing re ve a ls the pa tie nt’s blood type to be A, B,
or AB, the n switching ba ck to the pa tie nt’s own blood type could
le a d to ma jor intra va scula r he molysis of the tra nsfuse d RBCs a nd,
the re fore , is not a dvise d. The use of type O-ne ga tive unive rsa l
donor whole blood, or pre fe ra bly RBCs, is re comme nde d. In the
ma le pa tie nt or the olde r fe ma le pa tie nt who will not ha ve more
childre n, type O-positive whole blood ca n be a dministe re d if fe w
type O, Rh-ne ga tive units a re a va ila ble a nd ma ssive tra nsfusion is
a nticipa te d. Only a fte r it is de te rmine d tha t the pa tie nt ha s low
e nough le ve ls of tra nsfuse d a nti-A a nd a nti-B a ntibodie s should the
corre ct type of blood be a dministe re d (Miller: Miller’s Anesth esia, ed
8, p 1840).
398. (B) The re quire me nt for blood stora ge sta te s tha t a t le a st 70%
of the e rythrocyte s must re ma in in circula tion for 24 hours a fte r a
tra nsfusion for the tra nsfusion to be succe ssful. Erythrocyte s tha t
survive longe r tha n 24 hours a fte r tra nsfusion a ppe a r to ha ve a
norma l life spa n (Miller: Miller’s Anesth esia, ed 8, p 1841).
399. (B) At a pH be low 6.0 or in cold te mpe ra ture s such a s 4° C (the
te mpe ra ture use d for blood stora ge ), pla te le ts unde rgo irre ve rsible
sha pe cha nge s. The optima l te mpe ra ture for pla te le t stora ge is 22°
C ± 2° C, or room te mpe ra ture . The re a re two ma jor proble ms with
pla te le t stora ge a t this re comme nde d te mpe ra ture . First, the pH
fa lls be ca use of pla te le t me ta bolism. Se cond, ba cte ria l growth is
possible , which could pote ntia lly le a d to se psis a nd de a th. To
minimize the se proble ms, pla te le t stora ge is limite d to 5 da ys a t 22°
C (Miller: Miller’s Anesth esia, ed 8, pp 1859–1861; Barash : Clinical
Anesth esia, ed 7, pp 417–418).
400. (A) W hole blood is ra re ly use d toda y e xce pt in e me rge ncy
ca se s whe n the ra pid infusion of blood a nd volume is ne e de d.
Store d blood conta ins citra te , a n a nticoa gula nt tha t binds ionize d
ca lcium. W he n whole blood is ra pidly tra nsfuse d (i.e .,
>50 mL/70 kg/min) the citra te binds with ca lcium, producing
tra nsie nt de cre a se s in ionize d ca lcium. The a brupt de cre a se in
ionize d ca lcium ca n le a d to prolonge d QT inte rva ls, a n incre a se in
le ft ve ntricula r e nd-dia stolic pre ssure , a nd a rte ria l hypote nsion.
W ithin 5 minute s of stopping the tra nsfusion, ionize d ca lcium le ve ls
re turn to norma l. The volume of a n a ve ra ge unit of whole blood is
500 mL. This pa tie nt re ce ive d 10 units of whole blood, or 5000 mL,
ove r 30 minute s, the n a nothe r 5 units in 15 minute s. This a ve ra ge s
to a ra te gre a te r tha n 160 mL/min (Miller: Miller’s Anesth esia, ed 8, pp
1840–1841).
401. (C) A 20-kg, 5-ye a r-old child ha s a n EBV of 70 mL/kg = 1400 mL.
The a cce pta ble blood loss ca n be de te rmine d by use of the
following formula : ma ximum a llowa ble blood loss (in
mL) = EBV × (Hcts − Hct1)/Hcts whe re EBV is the e stima te d blood
volume (in mL), Hcts is the sta rting he ma tocrit, a nd Hct1 is the
lowe st a cce pta ble he ma tocrit. For this pa tie nt, the ma xima l
a llowa ble blood loss = 1400 × (40 − 30/40) = 1400 × (10/40) = 350 mL.
This a ssume s tha t the pa tie nt is ge tting volume e xpa nsion with
crysta lloid (3 mL pe r mL of blood loss). Also se e e xpla na tion to
Que stion 393 (Barash : Clinical Anesth esia, ed 7, p 1246).
402. (B) The norma l se rum sodium conce ntra tion is 135 to
145 mEq/L. Hypona tre mia occurs whe n the se rum le ve l is le ss tha n
135 mEq/L. Clinica l symptoms corre spond not only to the le ve l of
hypona tre mia but a lso to how ra pidly sodium le ve ls a re fa lling.
Hypona tre mia is most commonly not a de ficie ncy in tota l body
sodium but ra the r is a n e xce ss of tota l body wa te r (e .g., a bsorption
of irriga ting fluids a s se e n in tra nsure thra l re se ction of the prosta te
syndrome , a nd syndrome of ina ppropria te a ntidiure tic hormone
se cre tion). It ca n a lso be ca use d by a n e xce ssive loss of sodium, a s
is se e n in se ve re swe a ting, vomiting, dia rrhe a , burns, a nd the use
of diure tics. W ith a cute fa lls in se rum sodium, ne urologic
symptoms (confusion, re stle ssne ss, drowsine ss, se izure s, coma )
re sulting from ce re bra l e de ma ca n be se e n a t se rum le ve ls be low
120 mEq/L. Ca rdia c symptoms (ve ntricula r ta chyca rdia , ve ntricula r
fibrilla tion) ca n be se e n a t le ve ls be low 100 mEq/L. The ra py for
se ve re hypona tre mia include s wa te r re striction, loop diure tics, a nd
a t time s the a dministra tion of hype rtonic sa line (3% Na Cl). The
dose of sodium ne e de d for corre ction ca n be ca lcula te d by
multiplying the tota l body wa te r (TBW = body we ight × 0.6) time s
the incre a se in sodium de sire d; tha t is,

In this pa tie nt, the ca lcula te d dose of sodium would be 100


(we ight in kg) × 0.6 × (120 mEq/L-105 mEq/L) = 900 mEq. Thre e
pe rce nt Na Cl is infuse d no fa ste r tha n 100 mL/hr. Too ra pid a
corre ction ma y le a d to ce ntra l pontine mye linolysis. Once the
le ve l re a che s 120 mEq/L, furthe r tre a tme nt usua lly consists of
wa te r re striction a nd diure tics (Miller: Miller’s Anesth esia, ed 8, p
1773).
403. (D) The intra va scula r ha lf-life of crysta lloid solution is 20 to
30 minute s, whe re a s the intra va scula r ha lf-life of colloid is 3 to
6 hours. To re store intra va scula r volume , for e a ch mL of blood lost,
3 to 4 mL of crysta lloid or 1 mL of colloid is a dministe re d. In this
ca se , though, the blood sa mple is dra wn be fore the infusion is
sta rte d, so the he moglobin dra wn should be simila r to his
he moglobin conce ntra tion imme dia te ly be fore the MVA (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 1161–1164).
404. (D) Abrupt discontinua tion of TPN tha t conta ins 10% to 20%
de xtrose ma y re sult in profound re bound hypoglyce mia .
Ta chyca rdia in this pa tie nt ma y signify hypoglyce mia . Prompt
dia gnosis a nd tre a tme nt of se ve re hypoglyce mia a re e sse ntia l if
ne urologic da ma ge is to be a voide d. W he ne ve r a ce ntra l line is
pla ce d for TPN, it should be prope rly che cke d be fore the
hype rtonic infusion is sta rte d (Miller: Miller’s Anesth esia, ed 8, p 1782).
405. (D) In a n e me rge ncy whe n ma ssive a mounts of blood a re
imme dia te ly re quire d a nd the supply of O-ne ga tive RBCs in the
blood ba nk is low, it is a cce pta ble to tra nsfuse O-positive RBCs into
ma le pa tie nts or into fe ma le pa tie nts pa st the a ge of childbirth
be fore the pa tie nt’s blood type is known. This is be ca use de la ying
blood tra nsfusion for blood typing ma y be more ha za rdous to the
pa tie nt tha n the risk of a significa nt tra nsfusion re a ction ba se d on
Rh type for the se pa tie nts. Howe ve r, for the fe ma le pa tie nt who
ha s the pote ntia l for pre gna ncy, a dministra tion of Rh-positive RBCs
is not re comme nde d (unle ss no Rh-ne ga tive RBCs a re a va ila ble ).
This is be ca use a n Rh-ne ga tive pa tie nt who re ce ive s Rh-positive
RBCs would e xpe rie nce isoimmuniza tion. For the se wome n, future
pre gna ncie s with Rh-positive fe tuse s could be a ssocia te d with
e rythrobla stosis fe ta lis. Note : RBCs a re pre fe rre d ove r whole blood
be ca use Rh-ne ga tive whole blood conta ins a la rge qua ntity of a nti-
A a nd a nti-B a ntibodie s in the pla sma (Turgeon: Clinical Hem atology,
ed 1, pp 50–51).
406. (B) He ta sta rch (hydroxye thyl sta rch) a nd de xtra n 70 (glucose
polyme rs with me a n mole cula r we ights of 70,000) a re colloid
solutions tha t a re use d for intra va scula r fluid volume e xpa nsion.
Both he ta sta rch a nd de xtra n ha ve be e n a ssocia te d with a lle rgic
re a ctions, ca n inte rfe re with coa gula tion, a nd ca n ca use
hype rvole mia . He ta sta rch, unlike de xtra n, doe s not inte rfe re with
crossma tching of blood a t the re comme nde d ma xima l da ily dose of
20 mL/kg. Ne ithe r compound ne e ds to be a dministe re d through a
filte r.
He ta sta rch a lso re duce s le ve ls of vW F significa ntly a s we ll a s
a va ila bility of glycoprote in IIb/IIIa , a nd it ca n be come dire ctly
incorpora te d into the fibrin clot (Miller: Miller’s Anesth esia, ed 8, p
1783).
407. (D) RBCs a re coole d to a bout 4° C to de cre a se ce llula r
me ta bolism. CPDA-1 is a pre se rva tive a nticoa gula nt solution ofte n
a dde d to blood. It conta ins citra te , phospha te , de xtrose , a nd
a de nine . The citra te is use d to bind ca lcium a nd a cts a s a n
a nticoa gula nt. Phospha te a cts a s a buffe r. De xtrose is a dde d a s a n
e ne rgy source for ce llula r me ta bolism on the da y of dona tion to
ra ise the blood suga r to gre a te r tha n 400 mg/dL. At 35 da ys, the
glucose le ve l drops be low 100 mg/dL. Ade nine is a dde d a s a
substra te source so tha t the ce lls ca n produce a de nosine
triphospha te . Othe r bioche mica l cha nge s include a fa ll in pH to
a bout 6.7 a nd a rise in pla sma pota ssium from a round 4 mEq/L on
the da y of dona tion to 76 mEq/L a t 35 da ys. Conce ntra tions of 2,3-
diphosphoglyce ra te fa ll be low 1 µM/mL, which ca use s a le ftwa rd
shift in the oxyhe moglobin dissocia tion curve tha t a llows for a n
incre a se d oxyge n a ffinity for the he moglobin. This le ftwa rd shift
produce s a P 50 va lue le ss (not gre a te r) tha n the norma l 26 mm Hg
(Miller: Miller’s Anesth esia, ed 8, pp 1841–1842).
408. (B) Ma ny pre se rva tion solutions a re use d for whole blood a nd
RBCs. Acid citra te de xtrose , CPD, a nd citra te phospha te double
de xtrose (CP2D) e a ch a llows blood to ha ve a she lf life of 21 da ys.
In 1978, the FDA a pprove d the a dditive a de nine to CPD. This
e xte nde d the she lf life of blood by 2 we e ks. CPDA-1 ha s a she lf life
of 35 da ys. The se solutions we re use d ma inly for whole blood.
Howe ve r, whe n compone nt the ra py be ca me more wide spre a d, it
wa s note d tha t pa cking the RBCs by re moving the pla sma a lso
re move d a significa nt a mount of a de nine a nd glucose . By use of a n
a dditive solution (which conta ins prima rily a de nine , glucose , a nd
sa line ) to the CPD or CP2D whole blood tha t ha s the pla sma
re move d, the pa cke d RBCs ca n now be store d for 42 da ys. The
thre e diffe re nt a dditive solutions curre ntly use d in the Unite d Sta te s
a re Adsol (AS-1), Nutrice l (AS-3), a nd Optisol (AS-5) (Miller: Miller’s
Anesth esia, ed 8, p 1841).
409. (D) The live r produce s most of the coa gula tion fa ctors e xce pt
for fa ctor III (tissue thrombopla stin), fa ctor IV (ca lcium), a nd fa ctor
VIII (von W ille bra nd fa ctor). The live r a lso produce s the
coa gula tion re gula tory prote in C, prote in S, a nd a ntithrombin III.
Fe ta l RBCs a re produce d e xclusive ly by the live r; in the a dult, 80%
of RBCs a re produce d by the bone ma rrow a nd only 20% a re
produce d in the live r. The de gra da tion of blood is prima rily by the
re ticuloe ndothe lia l syste m (Hem m ings: Ph arm acology and Ph y siology
for Anesth esia, ed 1, p 477; Miller: Basics of Anesth esia, ed 6, p 456).
410. (B) LMW H is produce d by the fra ctiona tion or cle a ving of
“unfra ctiona te d he pa rin (UFH)” into shorte r fra gme nts. The
a nticoa gula nt prope rtie s of UFH a nd LMW H a re comple x a nd
some wha t diffe re nt. UFH binds to a nd a ctiva te s a ntithrombin (more
e ffe ctive ly tha n LMW H) a nd ca n be monitore d e a sily with the
a PTT. At the usua l clinica l dose s of LMW H, a PTT is not prolonge d.
LMW H, on the othe r ha nd, is more e ffe ctive in ina ctiva ting fa ctor
Xa a nd ca n be monitore d by a nti-Xa le ve ls (a lthough commonly this
is not pe rforme d be ca use of the more pre dicta ble a ction of
prophyla ctic dosing of LMW H). At high dose s of LMW H, a ntifa ctor
Xa va lue s a re more commonly me a sure d. Thrombin time is a
me a sure of the a bility of thrombin to conve rt fibrinoge n to fibrin. It
is prolonge d with low a mounts of fibrinoge n, he pa rin, a nd fibrin
de gra da tion products (FDPs). A re ptila se te st is done by a dding
re ptila se to pla sma a nd wa iting for a clot to form a nd is prolonge d
in the pre se nce of lupus a nticoa gula nt, FDPs, fibrinoge n de ficie ncy,
or a bnorma l fibrinoge n. It is not prolonge d in the pre se nce of
he pa rin (Miller: Miller’s Anesth esia, ed 8, pp 1872–1874; Barash : Clinical
Anesth esia, ed 7, p 439).
411. (D) The four se le ctions to this que stion a re four of the five
ma jor he re dita ry conditions a ssocia te d with hype rcoa gula tion.
The y ca use a n incre a se d like lihood of clot forma tion by e ithe r
incre a sing prothrombotic prote ins (e .g., fa ctor V Le ide n muta tion,
prothrombin G20210A ge ne muta tion) or de cre a sing e ndoge nous
a ntithrombotic prote ins (e .g., a ntithrombin de ficie ncy, prote in C
de ficie ncy, prote in S de ficie ncy). Clot ma y a lso de ve lop if he pa rin
re sista nce occurs (usua l dose s produce le ss tha n the e xpe cte d
prolonga tion of the pa rtia l thrombopla stin time or the a ctiva te d
clotting time ) a nd is not re cognize d, a s during ca rdiopulmona ry
bypa ss. It ma y occur a s a re sult of e xce ssive binding of he pa rin to
pla sma prote ins or a n insufficie nt a mount of a ntithrombin. Be ca use
he pa rin binds to a nd pote ntia te s a ntithrombin’s a ctivity, conditions
with low a mounts of a ntithrombin show re sista nce . Tre a tme nt of
AT3 de ficie ncy is re pla ce me nt of AT3 with e ithe r spe cific AT III
conce ntra te (Thromba te III) or FFP. Re pla ce me nt of a ntithrombin to
100% a ctivity is re comme nde d be fore ca rdia c surge ry in pa tie nts
with conge nita l AT3 de ficie ncy (Miller: Miller’s Anesth esia ed 8, pp
1871–1872, 1876–1877; Young: Clinical Hem atology, ed 1, pp 1116–1118).
412. (D) vW D is the most common inhe rite d a bnorma lity a ffe cting
pla te le t function a nd is ca use d by a qua ntita tive or qua lita tive
de ficie ncy of a prote in ca lle d von W ille bra nd fa ctor (vW F). vW F is
produce d by e ndothe lia l ce lls a nd pla te le ts a nd a ppe a rs to ha ve
two ma in functions: it a cts a s a n a dhe sion prote in tha t dive rts
pla te le ts to site s of va scula r injury, a nd it he lps prote ct fa ctor VIII
from ina ctiva tion a nd cle a ra nce . Pa tie nts with vW D ha ve
prolonge d ble e ding time s a nd a re duce d a mount of fa ctor VIII.
Pa tie nts with he mophilia A a lso ha ve a de cre a se in fa ctor VIII but
norma l ble e ding time s. Type 1 vW D is the most common type
(60%-80%) a nd is a ssocia te d with a qua ntita tive de cre a se in
circula ting pla sma vW F ca use d by a de cre a se in re le a se of
a va ila ble vW F. Type 2 vW D (20%-30%) ha s se ve ra l subtype s a nd is
a ssocia te d with qua lita tive de ficie ncy of vW F. Type 3 vW D is the
le a st fre que nt (1%-5%) a nd the most se ve re form, whe re in the re is
a lmost no vW F a nd ve ry low fa ctor VIII le ve ls (3%-10% of norma l).
Tre a tme nt of vW D include s DDAVP, which incre a se s the re le a se of
a va ila ble vW F, or blood products tha t conta in vW F a nd fa ctor III
(e .g., cryopre cipita te , FFP, or fa ctor III conce ntra te s). Re combina nt
fa ctor VIII is not use d be ca use it doe s not conta in vW F (Miller:
Miller’s Anesth esia, ed 8, pp 1123, 1872; Barash : Clinical Anesth esia, ed 7,
p 433).
413. (A) Although a lle rgic re a ctions a fte r blood tra nsfusions a re
common (up to 3%), true nonhe molytic a na phyla ctic re a ctions a re
ra re . W he n a na phyla ctic re a ctions de ve lop (ofte n with only a fe w
millilite rs of blood or pla sma tra nsfuse d), the signs a nd symptoms
ma y include dyspne a , bronchospa sm, la rynge a l e de ma , che st pa in,
hypote nsion, a nd shock. The se re a ctions a re ca use d by the
tra nsfusion of “fore ign” IgA prote in to pa tie nts who ha ve he re dita ry
IgA de ficie ncy a nd ha ve forme d a nti-IgA a s a re sult of pre vious
tra nsfusions or from e a rlie r pre gna ncie s. Tre a tme nt include s
stopping the tra nsfusion a nd a dministe ring e pine phrine a nd
ste roids. If furthe r tra nsfusion is ne e de d, wa she d RBCs or RBCs
from IgA-de ficie nt donors should be use d (Miller: Miller’s Anesth esia,
ed 8, p 1853; Barash : Clinical Anesth esia, ed 7, p 426).
414. (A) For the ye a rs 2005 to 2006, 125 confirme d tra nsfusion-re la te d
fa ta litie s we re liste d by the FDA in the Unite d Sta te s. The most
common ca use wa s TRALI (51%), followe d by non-ABO he molytic
tra nsfusion re a ction (20%), microbia l infe ction (12%), ABO he molytic
tra nsfusion re a ction (7%), de a th from tra nsfusion-a ssocia te d
circula tory ove rloa d (TACO) (7%), a nd othe r (2%). Since Ma rch 2004,
whe n volunta ry ba cte ria l de te ction te sting wa s imple me nte d for
pla te le t tra nsfusions, the re ha s be e n a de cre a se in fa ta litie s
a ssocia te d with tra nsfusion of ba cte ria lly conta mina te d a phe re sis
pla te le ts. Conside ring a bout 29 million compone nts a re tra nsfuse d
e a ch ye a r (2004 ca le nda r ye a r) in the Unite d Sta te s, the re porte d
incide nce of de a th is quite sma ll
(www.fd a.gov/cber/blood /fatal/0506.h tm ; Miller: Miller’s Anesth esia, ed 8,
pp 1855–1860; Barash : Clinical Anesth esia, ed 7, pp 425–427).
TRANSFUSION-RELATED FATALITIES IN THE UNITED STATES, 2004
TO 2006
Cause of Fatality 2004-2006 Average per Year
TRALI 86 29
Other reactions (non-ABO hemolytic therapy; anaphylaxis) 67 22
Bacterial contamination 20 7
ABO hemolytic transfusion therapy 15 5
Transfusion not ruled out 31 10
TRALI, transfusion-related acute lung injury.
From Miller RD: Miller’s Anesthesia, ed 7, Philadelphia, Saunders, 2011, Table 55-6.

415. (D) The re is controve rsy not only a s to which intra ve nous fluid
is the be st but a lso how much to give . Most would sugge st tha t
isotonic crysta lloids should be the initia l re suscita tive fluids to a ny
tra uma pa tie nts, a nd the y a re ce rta inly le ss e xpe nsive tha n 5%
a lbumin, 6% hydroxye thyl sta rch, a nd de xtra n 70. Cle a r a dva nta ge s
of one fluid ove r a nothe r a re ha rd to find (Miller: Miller’s Anesth esia,
ed 8, p 1800; Barash : Clinical Anesth esia, ed 7, pp 338–339).
416. (B) Tra nsmission of CMV to pa tie nts who ha ve norma l immune
me cha nisms is be nign a nd se lf-limiting, but in pa tie nts who a re
immunocompromise d (e .g., pre ma ture ne wborns, solid orga n a nd
bone ma rrow tra nspla nt pa tie nts, a cquire d immunode ficie ncy
syndrome pa tie nts), CMV infe ction ca n be se rious a nd life
thre a te ning. Le ukocyte re duction ca n re duce CMV tra nsmission,
but re striction of blood products from se rone ga tive donors is
pre fe rre d (Miller: Miller’s Anesth esia, ed 8, pp 1857–1858; Barash :
Clinical Anesth esia, ed 7, p 424).
417. (C) GVHD is a n ofte n fa ta l condition tha t occurs in pa tie nts
who a re immunocompromise d. It occurs whe n donor lymphocyte s
(gra ft) e sta blish a n immune re sponse a ga inst the re cipie nt (host).
Blood products tha t ha ve a significa nt a mount of lymphocyte s
include RBCs a nd pla te le ts. FFP a nd cryopre cipita te a ppe a r to be
sa fe . Although dire cte d donor units from first-de gre e re la tive s a nd
le ukore duction ma y re duce the incide nce of GVHD, only irra dia te d
products (which ina ctiva te s donor lymphocyte s) ca n pre ve nt GVHD
(Miller: Miller’s Anesth esia, ed 8, p 1858; Barash : Clinical Anesth esia, ed
7, p 428).
C H AP T E R 6
General Anesthesia

DIRECT IONS (Que stions 418 through 546): Ea ch of the que stions
or incomple te sta te me nts in this se ction is followe d by
a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
Se le ct the ONE BEST a nswe r or comple tion for e a ch ite m.

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

DIRECT IONS (Que stions 547 through 566): Ea ch group of


que stions consists of se ve ra l numbe re d sta te me nts followe d
by le tte re d he a dings. For e a ch numbe re d sta te me nt, se le ct
the ONE le tte re d he a ding tha t is most close ly a ssocia te d with
it. Ea ch le tte re d he a ding ma y be se le cte d once , more tha n
once , or not a t a ll.

Questions 547-554:
547. Skin le sions a ll a ppe a r a t the sa me sta ge a nd a t the sa me time
548. Ciprofloxa cin for 60 da ys is prophyla xis for e xpose d pa tie nts
549. Not conta gious
550. Tre a tme nt ma y include stre ptomycin, ge nta micin, or
te tra cycline
551. Tre a tme nt include s triva le nt e quine a ntitoxin
552. Thre e prima ry type s: cuta ne ous, ga strointe stina l, a nd
inha la tion
553. Va ccine ma y pre ve nt or gre a tly a tte nua te symptoms if give n
within 4 da ys of e xposure
554. He morrha gic fe ve r
A. Sma llpox
B. Anthra x
C. Pla gue
D. Botulism
E. Ebola virus
Questions 555-560:
555. De cre a se d FEV1/FVC ra tio
556. De cre a se d tota l pulmona ry complia nce
557. Incre a se d TLC
558. De cre a se d FRC
559. De cre a se d FEV1, norma l FEV1/FVC ra tio
560. Incre a se d lung complia nce due to loss of e la stic re coil of the
lung
A. Pulmona ry e mphyse ma
B. Chronic bronchitis
C. Re strictive pulmona ry dise a se
D. Pulmona ry e mphyse ma a nd chronic bronchitis
E. Pulmona ry e mphyse ma a nd re strictive pulmona ry dise a se
Questions 561-566:
561. We a kne ss of a ll muscle s be low the kne e
562. Footdrop; loss of dorsa l e xte nsion of the toe s
563. We a kne ss of the muscle s tha t e xte nd the kne e
564. Ina bility to a dduct the le g; diminishe d se nsa tion ove r the
me dia l side of the thigh
565. Most commonly ca use d by pla ce me nt of pa tie nt into the
lithotomy position
566. Numbne ss ove r the la te ra l a spe ct of the thigh
A. Scia tic ne rve injury
B. Common pe rone a l ne rve injury
C. Fe mora l ne rve injury
D. Obtura tor ne rve injury
E. La te ra l fe mora l cuta ne ous ne rve injury
General Anesthesia
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
418. (B) Pa tie nts with insulin-de pe nde nt dia be te s a nd non–insulin-
de pe nde nt dia be te s re quire spe cia l conside ra tion whe n pre se nting
for surge ry. Ge ria tric a ge pa tie nts come to the OR in the fa sting
sta te a nd without ha ving ta ke n the ir morning dose of the ir ora l
dia be tic a ge nt. Chlorpropa mide is the longe st-a cting sulfonylure a
a nd ha s a dura tion of a ction up to 72 hours. Accordingly, it is
prude nt to me a sure se rum glucose be fore inducing a ne sthe sia a nd
pe riodica lly during the course of the a ne sthe tic a nd surge ry.
Re gula r insulin ha s a pe a k e ffe ct 2 to 3 hours a fte r SQ
a dministra tion a nd a dura tion of a ction a pproxima te ly 6 to 8 hours
a nd would the re fore not ca use a se rum glucose of 35 mg/dL
24 hours a fte r it wa s a dministe re d (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, pp 479, 483–484).
419. (D) Dibuca ine is a n a mide -type loca l a ne sthe tic tha t inhibits
norma l pse udocholine ste ra se by a pproxima te ly 80%. In pa tie nts
who a re he te rozygous for a typica l pse udocholine ste ra se , e nzyme
a ctivity is inhibite d by 40% to 60%. In pa tie nts who a re homozygous
for a typica l pse udocholine ste ra se , e nzyme a ctivity is inhibite d by
only 20%. The dibuca ine numbe r is a qua lita tive a sse ssme nt of
pse udocholine ste ra se . Qua ntita tive a s we ll a s qua lita tive
de te rmina tion of e nzyme a ctivity should be ca rrie d out in a ny
pa tie nt who is suspe cte d of ha ving a pse udocholine ste ra se
a bnorma lity (Miller: Basics of Anesth esia, ed 6, p 149).
420. (D) All hypote nsion ca n be broa dly broke n down into two ma in
ca te gorie s: de cre a se d ca rdia c output a nd de cre a se d syste mic
va scula r re sista nce . Flow or ca rdia c output ca n be furthe r
subdivide d into proble ms re la te d to de cre a se d he a rt ra te (i.e .,
bra dyca rdia ve rsus proble ms re la te d to de cre a se s in stroke
volume ). Norma l P O2 in mixe d ve nous blood is 40 mm Hg.
Incre a se d mixe d ve nous a rte ria l oxyge n le ve ls ca n be due to ma ny
conditions including high ca rdia c output, se psis, le ft-to-right ca rdia c
shunts, impa ire d pe riphe ra l upta ke (e .g., cya nide ), a nd de cre a se d
oxyge n consumption (e .g., hypothe rmia ), a s we ll a s sa mpling e rror.
The othe r choice s in this que stion a ll re pre se nt conditions whe re by
ca rdia c output is diminishe d a nd conse que ntly would not be
consiste nt with the da ta give n in the que stion (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 360–361).
421. (C) Tra che a l ca pilla ry a rte riola r pre ssure (25-35 mm Hg) is
importa nt to ke e p in mind in pa tie nts who a re intuba te d with
cuffe d e ndotra che a l tube s. If the e ndotra che a l tube cuff e xe rts a
pre ssure gre a te r tha n ca pilla ry a rte riola r pre ssure , tissue ische mia
ma y re sult. Pe rsiste nt ische mia ma y le a d to de struction of tra che a l
rings a nd tra che oma la cia . Endotra che a l tube s with low-pre ssure
cuffs a re re comme nde d in pa tie nts who a re to be intuba te d for
pe riods longe r tha n 48 hours be ca use this will minimize the
cha nce s for de ve lopme nt of tissue ische mia (Miller: Miller’s
Anesth esia, ed 8, pp 1665–1667).
422. (C) Enoxa pa rin, da lte pa rin, a nd a rde pa rin a re low-mole cula r-
we ight he pa rins (LMW Hs). Be ca use of the possibility of spina l a nd
e pidura l he ma toma in the a nticoa gula te d pa tie nt with ne ura xia l
blocka de , ca ution is a dvise d. The pla sma ha lf-life of LMW H is two
to four time s longe r tha n sta nda rd he pa rin. The se drugs a re
commonly use d for prophyla xis for de e p ve in thrombosis. The se
drugs a re a lso use d a t high dose s for tre a tme nt of de e p ve in
thrombosis a nd (off la be l) a s “bridge the ra py” for pa tie nts
chronica lly a nticoa gula te d with wa rfa rin (Couma din). In the se
pa tie nts who a re be ing pre pa re d for surge ry, Couma din is
discontinue d a nd LMW H sta rte d. W ith high-dose e noxa pa rin
a dministra tion (1 mg/kg twice da ily), it is re comme nde d to wa it a t
le a st 24 hours be fore a dministra tion of a single -shot spina l
a ne sthe tic (Miller: Miller’s Anesth esia, ed 8, p 1691; Barash : Clinical
Anesth esia, ed 7, p 929; Th ird Consensus Conference on Neurax ial
Anesth esia and Anticoagulation, Jan-Feb 2010;
h ttp://www.asra.com /publications-anticoagulation-3rd -ed ition-2010.ph p).
423. (A) The principa l me cha nism of pe riphe ra l ne rve injury is
ische mia ca use d by stre tching or compre ssion of the ne rve s.
Ane sthe tize d pa tie nts a re a t incre a se d risk for pe riphe ra l ne rve
injurie s be ca use the y a re unconscious a nd una ble to compla in
a bout uncomforta ble positions tha t a n a wa ke pa tie nt would not
tole ra te a nd be ca use of re duce d muscle tone tha t fa cilita te s
pla ce me nt of pa tie nts into a wkwa rd positions. The ulna r ne rve in
pa rticula r is vulne ra ble be ca use it pa sse s a round the poste rior
a spe ct of the me dia l e picondyle of the hume rus. The ulna r ne rve
ma y be come compre sse d be twe e n the me dia l e picondyle a nd the
sha rp e dge of the ope ra ting ta ble , le a ding to ische mia a nd possible
ne rve injury, which ma y be tra nsie nt or pe rma ne nt (Miller: Basics of
Anesth esia, ed 6, pp 310–312).
424. (A) The ora lly a dministe re d prodrug code ine (me thylmorphine )
must be me ta bolize d to morphine in orde r to work. About 7% to
10% of white pa tie nts ha ve a n ina ctive va ria nt of the e nzyme
CYP2D6, which is the e nzyme ne e de d to me ta bolize code ine . In
the se pa tie nts, a s we ll a s in pa tie nts who ha ve the norma l e nzyme
but the e nzyme is inhibite d (e .g., coa dministra tion of quinidine ),
code ine doe s not produce a na lge sia but morphine will produce the
e xpe cte d a na lge sia . The CYP2D6 e nzyme is a lso ne e de d to
me ta bolize oxycodone into oxymorphone a nd hydrocodone into
hydromorphone . In a ddition, some pa tie nts ha ve a polymorphism
form of CYP2D6 tha t re sults in ve ry ra pid me ta bolism of code ine
a nd ca n re sult in morphine toxicity (Miller: Miller’s Anesth esia, ed 8,
pp 574–575).
425. (D) Pa tie nts who ha ve unde rgone pe rcuta ne ous corona ry
inte rve ntion (PCI) with a nd without ste nts re quire dua l a ntipla te le t
the ra py (usua lly a spirin a nd clopidogre l) to pre ve nt re ste nosis or
a cute thrombosis a t the site of the ste nt, ofte n for the pa tie nt’s
life time . Ce ssa tion of the se drugs should be re vie we d with the
pa tie nt’s ca rdiologist. In ge ne ra l, if the e le ctive surgica l proce dure
ma y involve ble e ding, the e le ctive proce dure is de la ye d for a t le a st
2 we e ks a fte r ba lloon a ngiopla sty without a ste nt, 6 we e ks a fte r a
ba re -me ta l ste nt, a nd 12 months a fte r a drug-e luting ste nt ha s be e n
pla ce d. The n the clopidogre l is stoppe d a nd re sta rte d a s soon a s
possible a fte r the surge ry (a spirin is usua lly continue d). In a n
e me rge ncy situa tion a nd whe n the pa tie nt is ta king clopidogre l,
pla te le t tra nsfusion ma y be ne e de d (e ffe ctive ne ss of pla te le ts
de pe nds on the la st dose of clopidogre l—pla te le ts a re e ffe ctive
a fte r 4 hours but much be tte r 24 hours a fte r the la st dose of
clopidogre l) (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 13-–14; Miller: Basics of Anesth esia, ed 6, pp 168–170).
426. (C) Blood flow to the re tina ca n be de cre a se d by e ithe r a
de cre a se in me a n a rte ria l pre ssure or a n incre a se in intra ocula r
pre ssure . De cre a se d blood flow a nd sta sis a re more like ly in
pa tie nts with gla ucoma be ca use of the ir e le va te d intra ocula r
pre ssure . During pe riods of prolonge d hypote nsion, the incide nce
of re tina l a rte ry thrombosis incre a se s in the se pa tie nts (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 253-–254; Miller:
Basics of Anesth esia, ed 6, p 487).
427. (D) Na loxone (Na rca n) is a compe titive inhibitor a t a ll opioid
re ce ptors but ha s the gre a te st a ffinity for µ re ce ptors. Its dura tion of
a ction is re la tive ly short (e limina tion ha lf-life of a bout 1 hour). For
this re a son, one must be vigila nt for the possibility of
re na rcotiza tion whe n re ve rsing long-a cting na rcotics. Na ltre xone
(Re Via ) is the N-cyclopropylme thyl de riva tive of oxymorphone with
a long e limina tion ha lf-life of 8 to 12 hours. It is curre ntly a va ila ble
only a s a n ora l pre pa ra tion a nd is use d to block the e uphoric
e ffe cts of inje cte d he roin in a ddicts who ha ve be e n pre viously
de toxifie d. Na lme fe ne (Re ve x) is a nothe r opioid a nta gonist tha t ca n
be a dministe re d ora lly or pa re nte ra lly a nd ha s a n e xtre me ly long
dura tion of a ction (e limina tion te rmina l ha lf-life of 8.5 hours) (Miller:
Miller’s Anesth esia, ed 8, pp 906–907; Butterworth : Morgan & Mikh ail’s
Clinical Anesth esiology, ed 5, p 290).
428. (A) In the re cove ry room, the most common ca use of
postope ra tive hypoxe mia is a n une ve n ve ntila tion/pe rfusion
distribution ca use d by loss of lung volume re sulting from sma ll
a irwa y colla pse a nd a te le cta sis. Risk fa ctors for
ve ntila tion/pe rfusion misma tch in the postope ra tive pe riod include
old a ge , obstructive lung dise a se , obe sity, incre a se d intra -
a bdomina l pre ssure , a nd immobility. Supple me nta l oxyge n should
be a dministe re d to ke e p the Pa O2 in the 80 to 100 mm Hg ra nge ,
which is a ssocia te d with a 95% sa tura tion of he moglobin. Othe r
me a sure s ca n be ta ke n to re store lung volume , which include
re cove ring obe se pa tie nts in the sitting position, coughing, a nd
de e p bre a thing (Barash : Clinical Anesth esia, ed 7, pp 1566–1567).
429. (D) Airwa y obstruction a fte r tota l thyroide ctomy ma y be ca use d
by a postope ra tive he ma toma , compre ssion of the tra che a ,
tra che oma la cia , bila te ra l re curre nt la rynge a l ne rve da ma ge , or
hypoca lce mia re sulting from ina dve rte nt re mova l of the pa ra thyroid
gla nds. Although the a irwa y symptoms of hypoca lce mia ca n
de ve lop a s e a rly a s 1 to 3 hours a fte r surge ry, the y typica lly do not
de ve lop until 24 to 72 hours postope ra tive ly. Be ca use the la rynge a l
muscle s a re pa rticula rly se nsitive to hypoca lce mia , e a rly symptoms
ma y include inspira tory stridor, la bore d bre a thing, a nd e ve ntua l
la ryngospa sm. The ra py consists of IV a dministra tion of ca lcium
glucona te or ca lcium chloride (Miller: Basics of Anesth esia, ed 6, p 634;
Barash : Clinical Anesth esiology, ed 7, p 1330).
430. (A) Da ma ge to the ra dia l ne rve is ma nife ste d by we a kne ss in
a bduction of the thumb, ina bility to e xte nd the
me ta ca rpopha la nge a l joints, wrist drop, a nd numbne ss in the
we bbe d spa ce be twe e n the thumb a nd inde x finge rs. The ra dia l
ne rve pa sse s a round the hume rus be twe e n the middle a nd lowe r
portions in the spira l groove poste riorly. As it wra ps a round the
bone , the ra dia l ne rve ca n be come compre sse d be twe e n it a nd the
OR ta ble , re sulting in ne rve injury (Barash : Clinical Anesth esia, ed 7,
pp 808, 949).
431. (D) Bronchie cta sis is one of se ve ra l obstructive lung dise a se s
cha ra cte rize d by a diminishe d FEV1 whe n pulmona ry function is
e va lua te d. It is cha ra cte rize d by pe rma ne ntly dila te d bronchi tha t
fre que ntly conta in purule nt se cre tions. The a ffe cte d bronchi a re
ofte n highly va scula rize d, giving rise to the possibility of
he moptysis. Colla te ra l circula tion through the inte rcosta l a nd
bronchia l a rte rie s is a lso possible in the se pa tie nts. If the se ve sse ls
conne ct with the pulmona ry circula tion, pulmona ry hype rte nsion
a nd e ve ntua l cor pulmona le a re possible se que la e . Any pa tie nt
with chronic bronchia l infe ctions ma y de ve lop bronchie cta sis
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 195–196).
432. (D) Drugs tha t block dopa mine re ce ptors ma y ca use a cute
dystonic re a ctions in some pa tie nts. The incide nce with drope ridol
is a bout 1%. Tre a tme nt is the a dministra tion of a drug tha t crosse s
the blood-bra in ba rrie r with a nticholine rgic prope rtie s such a s
diphe nhydra mine or be nza tropine . Although glycopyrrola te is a n
a nticholine rgic drug, it would not be use ful in this se tting be ca use it
doe s not cross the blood-bra in ba rrie r (Miller: Miller’s Anesth esia, ed
8, p 2963; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, p 414).
433. (C) The me dia n ne rve is most fre que ntly injure d a t the
a nte cubita l fossa by e xtra va sa tion of IV drugs tha t a re toxic to
ne ura l tissue , or by dire ct injury ca use d by the ne e dle during
a tte mpts to ca nnula te the me dia l cubita l or ba silic ve ins. The
me dia n ne rve provide s se nsory inne rva tion to the pa lma r surfa ce
of the la te ra l thre e a nd one -ha lf finge rs a nd a dja ce nt pa lm, a nd
motor function to the a bductor pollicis bre vis, fle xor pollicis bre vis,
a nd oppone ns pollicis muscle s (Miller: Basics of Anesth esia, ed 6, p
313).
434. (D) Phe ochromocytoma is a n e ndocrine tumor (with re le a se of
ca te chola mine s) in which 90% of pa tie nts a re hype rte nsive , 90% of
the tumors origina te in one a dre na l me dulla , a nd 90% of a ll
phe ochromocytoma s a re be nign. This dise a se is ra re (<0.1% of
hype rte nsion in a dults), but whe n it occurs, it is ofte n se e n with a
tria d of dia phore sis, ta chyca rdia , a nd he a da che in pa tie nts with
hype rte nsion. Othe r symptoms include pa lpita tions, tre mulousne ss,
we ight loss, hype rglyce mia , hypovole mia , a nd in some ca se s
dila te d ca rdiomyopa thy a nd CHF. De a th a s a re sult of
phe ochromocytoma is due to ca rdia c conditions (e .g., myoca rdia l
infa rction, CHF) or a n intra cra nia l ble e d. In a bout 5% of ca se s,
phe ochromocytoma s show a n a utosoma l domina nt pa tte rn a nd
ma y coe xist with othe r e ndocrine dise a se s such a s me dulla ry
ca rcinoma of the thyroid a nd hype rpa ra thyroidism. This
combina tion is ca lle d multiple e ndocrine ne opla sia (MEN) type II or
IIA (Sipple syndrome ). MEN type IIB consists of phe ochromocytoma ,
me dulla ry ca rcinoma of the thyroid, a nd ne uroma s of the ora l
mucosa . The von Hippe l-Linda u dise a se consists of he ma ngioma s
of the ne rvous syste m (i.e ., re tina or ce re be llum), a nd 10% to 25% of
the se pa tie nts a lso ha ve a phe ochromocytoma . The a ve ra ge -size d
phe ochromocytoma conta ins 100 to 800 mg of nore pine phrine
(Barash : Clinical Anesth esia, ed 7, pp 1339–1340; Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 392–395).
435. (D) Ora l a ge nts tha t a re use d to he lp control hype rglyce mia in
type 2 dia be tic pa tie nts (re la tive β-ce ll insufficie ncy a nd insulin
re sista nce ) include four ma jor drug cla sse s:
1. Drugs tha t stimula te insulin se cre tion (hypoglyce mia is a risk)
a . sulfonylure a s
i. first-ge ne ra tion (chlorpropa mide , tola za mide , tolbuta mide )
ii. se cond-ge ne ra tion (glime piride , glipizide , glyburide )
b. me glitinide s (re pa glinide , na te glinide )
2. Drugs tha t de cre a se he pa tic glucone oge ne sis (hypoglyce mia not
a risk)
a . bigua nide s (me tformin)
3. Drugs tha t improve insulin se nsitivity (hypoglyce mia not a risk)
a . thia zolidine dione s (rosiglita zone , pioglita zone )
b. glita zone s
4. Drugs tha t de la y ca rbohydra te a bsorption (hypoglyce mia not a
risk)
a . α-glucosida se inhibitors (a ca rbose , miglitol)
Only drugs tha t stimula te insulin se cre tion a re a risk for producing
hypoglyce mia .
Initia l the ra py is usua lly with se cond-ge ne ra tion sulfonylure a s
(more pote nt a nd fe we r side e ffe cts tha n first-ge ne ra tion
sulfonylure a s) or with a bigua nide (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1255–1270; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 376–380;
Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, pp
481–485).
436. (C) Although e a rly mild symptoms of a lcohol withdra wa l ca n
be se e n within 6 to 8 hours a fte r a substa ntia l drop in the se rum
a lcohol le ve ls, DTs, which is se e n in a bout 5% of pa tie nts, is a life -
thre a te ning me dica l e me rge ncy tha t de ve lops 2 to 4 da ys a fte r the
ce ssa tion of a lcohol in a lcoholics. Symptoms of DTs include
ha llucina tions, comba tive ne ss, hype rthe rmia , ta chyca rdia ,
hype rte nsion or hypote nsion, a nd gra nd ma l se izure s. Tre a tme nt of
se ve re a lcohol withdra wa l consists of fluid re pla ce me nt,
e le ctrolyte re pla ce me nt, a nd IV vita min a dministra tion with
pa rticula r a tte ntion pa id to thia mine . Aggre ssive a dministra tion of
be nzodia ze pine s is indica te d to pre ve nt se izure s (5-10 mg of
dia ze pa m e ve ry 5 minute s until the pa tie nt be come s se da te d but
not unconscious). β-Blocke rs a re use d to suppre ss ove ra ctivity of
the sympa the tic ne rvous syste m, a nd lidoca ine ma y be e ffe ctive in
the tre a tme nt of ca rdia c dysrhythmia s (Hines: Stoelting’s Anesth esia
and Co-Ex isting Disease, ed 6, p 544).
437. (A) Ope ra tions on the tra che a ma y be indica te d in pa tie nts
who ha ve tra che a l tumors or pa tie nts who ha d a pre vious tra uma
to the tra che a re sulting in tra che a l ste nosis or tra che oma la cia .
Eighty pe rce nt of the ope ra tions on the tra che a involve se gme nta l
re se ction with prima ry a na stomosis, 10% involve re se ction with
prosthe tic re construction, a nd a nothe r 10% involve inse rtion of a T-
tube ste nt. The se ope ra tions fre que ntly a re ve ry complica te d a nd
re quire consta nt communica tion be twe e n the surge on a nd the
a ne sthe siologist. Pre ope ra tive pulmona ry function te sts a re
indica te d in a ll pa tie nts who a re to unde rgo e le ctive tra che a l
re se ction. Se ve re lung dise a se ne ce ssita ting postope ra tive
me cha nica l ve ntila tion is a re la tive contra indica tion for tra che a l
re se ction be ca use positive a irwa y pre ssure ma y ca use wound
de hisce nce (Miller: Miller’s Anesth esia, ed 8, pp 1987–1988).
438. (B) Hype rca lce mia is a ssocia te d with a numbe r of signs a nd
symptoms, including hype rte nsion, dysrhythmia s, shorte ning of QT
inte rva l, kidne y stone s, se izure , na use a a nd vomiting, we a kne ss,
de pre ssion, pe rsona lity cha nge s, psychosis, a nd e ve n coma .
Ge ne ra lly, pa tie nts with tota l se rum ca lcium le ve ls of 12 mg/dL or
le ss do not re quire a ny inte rve ntion, with the possible e xce ption of
re hydra tion with sa line . Highe r ca lcium le ve ls ma y be a ssocia te d
with clinica l symptoms a nd should be tre a te d be fore a ne sthe tizing
the pa tie nt. Ca ution should be ta ke n with digita lis a dministra tion to
a ny pa tie nt who is hype rca lce mic be ca use some pa tie nts ma y
e xhibit e xtre me digita lis se nsitivity (Miller: Miller’s Anesth esia, ed 8, p
1794; Barash : Clinical Anesth esia, ed 7, pp 354–355).
NORMAL CALCIUM LEVELS

Serum Calcium Serum Ionized Calcium


Conventional units (mEq/L) 4.5-5.5 mEq/L 2.1-2.6 mEq/L
Conventional units (mg/dL) 9.0-11.0 mg/dL 4.25-5.25 mg/dL
SI units (mmol/L) 2.25-2.75 mmol/L 1.05-1.30 mmol/L

439. (D) Re d-top e ye drops ca use mydria sis a nd should be use d


with ca ution in pa tie nts with close d-a ngle gla ucoma . Gre e n-top e ye
drops ca use miosis, a nd the pupilla ry constriction he lps ke e p the
dra ina ge route ope n in pa tie nts with gla ucoma a nd he lps pre ve nt
a n a cute a tta ck of gla ucoma . Cle a r or white -top e ye drops do not
cha nge pupilla ry size .
440. (D) W he n re vie wing growth curve s, the norma l 40-we e k te rm
ne wborn we ighs a bout 3.5 kg. Infa nts the n double the ir birth we ight
by 5 months a nd triple the ir we ight by 1 ye a r. The re fore , the
a ve ra ge 1-ye a r-old we ighs 10 kg (22 lb). From the a ge of 1 to
6 ye a rs, childre n ga in a bout 2 kg pe r ye a r. Thus, a n a ve ra ge 2-ye a r-
old we ighs 12 kg, 3-ye a r-old we ighs 14 kg, 4-ye a r-old we ighs 16 kg,
5-ye a r-old we ighs 18 kg, a nd 6-ye a r-old we ighs 20 kg. From a ge 6 to
10 ye a rs, childre n ga in a bout 3 kg pe r ye a r (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, pp A6-A13).
441. (A) Ca use s for a cute pa ce ma ke r ma lfunction in the OR a re
nume rous a nd include thre shold cha nge s, inhibition, ge ne ra tor
fa ilure , a nd le a d or e le ctrode dislodge me nt or bre a ka ge . A VVI
pa ce ma ke r ma y be inhibite d by myopote ntia ls. In this re ga rd,
a dministra tion of succinylcholine could a ctua lly inhibit a VVI
pa ce ma ke r. Simila rly, e le ctroca ute ry ca n inhibit a VVI pa ce ma ke r
through e le ctroma gne tic inte rfe re nce . Should this occur (in most
ca se s, de pe nding on ma nufa cture r), a ma gne t should be pla ce d
ove r the pa ce ma ke r to conve rt it into a VOO pa ce ma ke r,
e limina ting the possibility of furthe r inhibition. Pa ce ma ke rs should
be e va lua te d pre ope ra tive ly to e limina te the possibility of
ge ne ra tor fa ilure . Le a d bre a ka ge or dislodge me nt is a n unlike ly
ca use of pa ce ma ke r fa ilure unle ss the surge on is working in the
vicinity of the e le ctrode s. Acute thre shold cha nge s a re a lmost
a lwa ys a ssocia te d with cha nge s in the se rum pota ssium
conce ntra tion. In this pa rticula r pa tie nt, hype rve ntila tion ca use s a
re spira tory a lka losis tha t re sults in the intra ce llula r shifting of
se rum pota ssium. The ne t re sult is tha t the e le ctrica l thre shold for
the pa ce ma ke r is ra ise d, pre ve nting ve ntricula r ca pture (Miller:
Miller’s Anesth esia, ed 8, p 1476; Th om as: Manual of Card iac Anesth esia,
ed 2, pp 382–383).
442. (C) The ra pie s a ime d a t incre a sing functiona l re sidua l ca pa city
(FRC) of the lungs a re use ful in re ducing the incide nce of
postope ra tive pulmona ry complica tions. Force d e xpira tory
ma ne uve rs ma y le a d to a irwa y closure , which would be of no
be ne fit for this pa tie nt (Miller: Miller’s Anesth esia, ed 8, pp 447, 2932–
2934).
443. (C) The huma n bra in is a ble to ma inta in ne urona l function in
the fa ce of de cre a sing CBF be low the norma l le ve l of
50 mL/100 g/min. Be ca use O2 de live ry is dire ctly re la te d to CBF, EEG
e vide nce of ce re bra l ische mia will a ppe a r if CBF is diminishe d
sufficie ntly. The CBF re se rve , howe ve r, is substa ntia l, a nd the first
signs of ce re bra l ische mia do not a ppe a r on EEG until CBF ha s
fa lle n to a pproxima te ly 22 mL/100 g/min. W he n CBF ha s fa lle n to 15
mL/100 g/min, the EEG be come s isoe le ctric. Irre ve rsible me mbra ne
da ma ge a nd ce llula r de a th do not occur, howe ve r, until CBF fa lls to
6 mL/100 g/min. Are a s of the bra in in which CBF fa lls in the 6 to
15 mL/100 g/min ra nge a re re fe rre d to a s zone s of ische mic
pe numbra . Se ve ra l hours ma y e la pse in the se a re a s of the bra in
be fore irre ve rsible me mbra ne da ma ge occurs (Miller: Miller’s
Anesth esia, ed 8, p 410).
444. (B) Positive e nd-e xpira tory pre ssure (PEEP) is the ma inte na nce
of positive a irwa y pre ssure during the e ntire ve ntila tor cycle . The
a ddition of PEEP to the ve ntila tor cycle is ofte n re comme nde d
whe n Pa O2 is not ma inta ine d a bove 60 mm Hg, whe n bre a thing a n
F IO2 of 0.50 or gre a te r. Although not comple te ly unde rstood, PEEP is
thought to incre a se a rte ria l oxyge na tion, pulmona ry complia nce ,
a nd FRC by e xpa nding pre viously colla pse d but pe rfuse d a lve oli,
the re by de cre a sing shunt a nd improving ve ntila tion/pe rfusion
ma tching. An importa nt a dve rse e ffe ct of PEEP is a de cre a se in
a rte ria l blood pre ssure ca use d by a de cre a se in ve nous re turn, le ft
ve ntricula r filling a nd stroke volume , a nd ca rdia c output. The se
e ffe cts a re e xa gge ra te d in pa tie nts with de cre a se d intra va scula r
fluid volume . Othe r pote ntia l a dve rse e ffe cts of PEEP include
pne umothora x, pne umome dia stinum, a nd subcuta ne ous
e mphyse ma (Miller: Miller’s Anesth esia, ed 8, pp 3077–3078; Miller:
Basics of Anesth esia, ed 6, p 667).
445. (A) Pla te le ts conta in two purine rgic re ce ptors (P2Y 1 a nd P2Y 12).
Clopidogre l (Pla vix) is a prodrug a nd a n irre ve rsible inhibitor of
pla te le t P2Y 12 re ce ptors, which blocks the ADP re ce ptors a nd
inhibits pla te le t a ctiva tion, a ggre ga tion, a nd de gra nula tion. The re is
wide inte rindividua l va ria bility for clopidogre l to inhibit ADP-
induce d pla te le t a ggre ga tion, a nd some pa tie nts a re re sista nt to its
e ffe cts. Glycoprote in IIb/IIIa inhibitors block fibrinoge n binding to
pla te le t glycoprote in IIb/IIIa re ce ptors, which is the fina l common
pa thwa y of pla te le t a ggre ga tion a nd include s the intra ve nous drugs
a bcixima b (Re oPro), e ptifiba tide (Inte grilin), a nd tirofiba n
(Aggra sta t). Aspirin, na proxe n, a nd ibuprofe n inhibit pla te le t COX-1
a nd inhibit the re le a se of ADP by pla te le ts a nd pla te le t
a ggre ga tion. Se le ctive COX-2 inhibitors such a s ce le coxib,
pa re coxib, a nd va lde coxib ha ve no e ffe ct on pla te le t function
be ca use only COX-1 inhibitors a ffe ct pla te le t function. Dire ct
thrombin inhibitors suppre ss pla te le t function a nd include the
pa re nte ra l drugs hirudin, a rga troba n, le pirudin (Re fluda n),
de sirudin (Ipriva sk), biva lirudin (Angioma x), a nd drotre cogin α
(Xigris), a s we ll a s the ora l drug da biga tra n (Pra da xa , Pra da x) a nd
xime la ga tra n (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 859-871; Miller: Basics of Anesth esia, ed 6,
pp 358-359; Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 277–281, 516–518).
446. (B) As a rough a pproxima tion, if one divide s 150 by the MAC for
a ny give n vola tile a ne sthe tic, the quotie nt will be a pproxima te ly
e qua l to the oil/ga s pa rtition coe fficie nt. For e xa mple , if one we re
to divide the MAC of ha lotha ne (0.75) into 150, the quotie nt would
be 200, which is ve ry close to the a ctua l oil/ga s pa rtition coe fficie nt
for ha lotha ne (224). Simila rly, if one we re to divide the MAC of
e nflura ne (1.68) into 150, the quotie nt would be 89, which is ve ry
simila r to the oil/ga s pa rtition coe fficie nt for e nflura ne (98). The fa ct
tha t a ne sthe tics with a high oil/ga s pa rtition coe fficie nt (i.e ., lipid-
soluble a ge nts) ha ve lowe r MACs supports the Me ye r-Ove rton
the ory (critica l volume hypothe sis) (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, p 29).
447. (D) Dia be te s insipidus is cha ra cte rize d by hype rna tre mia ,
se rum hype rosmola lity, polyuria , a nd urine hypo-osmola lity.
Dia be te s insipidus ma y occur a fte r a ny intra cra nia l proce dure , but
it is pa rticula rly common in surge ry involving the pituita ry gla nd. It
ma y de ve lop intra ope ra tive ly, but it commonly de ve lops 4 to
12 hours postope ra tive ly. Intra ve nous ha lf-norma l sa line a nd
de xtrose 5% in wa te r a re sta rte d a s re pla ce me nt fluids. The
pha rma cologic tre a tme nt for dia be te s insipidus is de smopre ssin
a ce ta te (synthe tic 1-de sa mino-8-D-a rginine va sopre ssin [DDAVP])
commonly sta rte d whe n the urine output is gre a te r tha n 350 to
400 mL/hr. In a conscious pa tie nt, it is not e sse ntia l to a dministe r
DDAVP be ca use the pa tie nt ma y incre a se his ora l inta ke to
compe nsa te for polyuria . In the unconscious pa tie nt, howe ve r,
a dministra tion of DDAVP is ne ce ssa ry. De smopre ssin (DDAVP) ma y
be a dministe re d SQ, IV, or intra na sa lly. Fortuna te ly, dia be te s
insipidus re la te d to surge ry a nd he a d tra uma usua lly is tra nsie nt
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 404–405;
Barash : Clinical Anesth esia, ed 7, p 1013).
448. (B) The principa l fe a ture of Alzhe ime r dise a se is progre ssive
de me ntia . The onse t typica lly occurs a fte r a ge 60 ye a rs a nd ma y
a ffe ct a s ma ny a s 20% of pa tie nts olde r tha n a ge 80 ye a rs. In
a ddition to a ge , othe r risk fa ctors include history of se rious he a d
tra uma (e .g., boxing), Down syndrome , a nd pre se nce of the dise a se
in a pa re nt or sibling. One bioche mica l fe a ture of this dise a se is a
de cre a se in the e nzyme choline a ce tyltra nsfe ra se in the bra in.
The re is a strong corre la tion be twe e n re duce d e nzyme a ctivity a nd
de cre a se d cognitive function. Inte re stingly, a dministra tion of the
a nticholine rgic drugs scopola mine or a tropine (but not
glycopyrrola te , which doe s not cross the blood-bra in ba rrie r)
ca use s confusion simila r to tha t se e n in the e a rly sta ge s of
Alzhe ime r dise a se . Conve rse ly, a dministra tion of a nticholine ste ra se
drugs ca pa ble of pe ne tra ting the blood-bra in ba rrie r, such a s
done pe zil (Arice pt), ga la nta mine , riva stigmine (Exe lon), a nd ta crine
a re use d to tre a t pa tie nts with Alzhe ime r dise a se . Physostigmine
ma y ha ve be ne ficia l e ffe cts in some pa tie nts a s we ll. Scopola mine
is the re fore a poor choice for pre me dica tion in pa tie nts with
Alzhe ime r dise a se (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 245; Butterworth : Morgan & Mikh ail’s Clinical
Anesth esiology, ed 5, pp 619–620).
449. (C) At the e nd of a ny ge ne ra l a ne sthe tic, sponta ne ous
ve ntila tion must be re store d be fore the pa tie nt ca n be e xtuba te d.
The diffe re ntia l dia gnosis for pe rsiste nt a pne a include s muscle
re la xa nts (ina de qua te re ve rsa l or pse udocholine ste ra se
de ficie ncy), vola tile a ne sthe tics, na rcotics, hypoca rbia , da ma ge to
the phre nic ne rve s bila te ra lly, a nd the possibility of a ce ntra l
ne rvous syste m (CNS) e ve nt. Succinylcholine is hydrolyze d by
pse udocholine ste ra se to succinylmonocholine a nd choline . This is
furthe r hydrolyze d by pla sma choline ste ra se to succinic a cid a nd
choline . All of the a nticholine ste ra se a ge nts use d to re ve rse
nonde pola rizing ne uromuscula r blocka de a lso inhibit
pse udocholine ste ra se . Administra tion of succinylcholine to a ny
pa tie nt who ha s a lre a dy re ce ive d a n a nticholine ste ra se will re sult
in a prolonge d block from the succinylcholine be ca use it ca n no
longe r be e a sily hydrolyze d. In this pa tie nt, the re fore ,
succinylcholine would be by fa r the most like ly ca use of a pne a a t
the e nd of the ope ra tion (Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, p 218).
450. (A) Comple te or a lmost comple te ce ssa tion of urine flow
sugge sts a postre na l obstruction. Howe ve r, a t time s pooling of the
urine in the dome of the bla dde r should be conside re d a s a
possible ca use of oliguria in this pa tie nt in the a bse nce of
significa nt ble e ding (Miller: Miller’s Anesth esia, ed 8, pp 556–557).
451. (B) DL is de fine d a s the diffusing ca pa city of the lung. W he n a
nontoxic, low conce ntra tion of ca rbon monoxide is use d for the
me a sure me nt, it is ca lle d DLCO. The norma l va lue of DLCO is 20 to
30 mL/min/mm Hg a nd is influe nce d by the volume of blood
(he moglobin) within the pulmona ry circula tion. Thus, dise a se s
a ssocia te d with a de cre a se in pulmona ry blood volume (i.e .,
a ne mia , e mphyse ma , hypovole mia , pulmona ry hype rte nsion) will
be re fle cte d by a de cre a se in the DLCO. DLCO is a lso de cre a se d
with oxyge n toxicity a s we ll a s pulmona ry e de ma . Conditions
a ssocia te d with a n incre a se d DLCO include the supine position,
e xe rcise , obe sity, a nd le ft-to-right ca rdia c shunts (Barash : Clinical
Anesth esia, ed 7, pp 369–370, 373–374; Miller: Miller’s Anesth esia, ed 8, p
365).
452. (C) Pa tie nts unde rgoing thyroid surge ry a re a t risk for a irwa y
obstruction from a numbe r of ca use s. Postope ra tive he morrha ge
sufficie nt to ca use a la rge he ma toma could compre ss the tra che a
a nd ca use a irwa y obstruction be ca use of the close proximity of the
thyroid gla nd to the tra che a . Pe rma ne nt hypopa ra thyroidism is a
ra re complica tion tha t ma y ca use hypoca lce mia le a ding to
progre ssive stridor followe d by la ryngospa sm. The most common
ne rve injury a fte r thyroid surge ry is da ma ge to the a bductor fibe rs
of the re curre nt la rynge a l ne rve . Unila te ra lly, this is ma nife ste d a s
hoa rse ne ss. Bila te ra l re curre nt la rynge a l ne rve da ma ge , howe ve r,
ma y le a d to a irwa y obstruction during inspira tion. Se le ctive injury
of the a dductor fibe rs of the re curre nt la rynge a l ne rve is a possible
complica tion of thyroid surge ry. This injury would le a ve the voca l
cords ope n be ca use the a bductor fibe rs would be unoppose d,
pla cing the pa tie nt a t gre a t risk for a spira tion. The supe rior
la rynge a l ne rve ha s a n e xtrinsic bra nch tha t inne rva te s the
cricothyroid muscle (which te nse s the voca l cords) a nd a n inte rna l
bra nch tha t provide s se nsory inne rva tion to the pha rynx a bove the
voca l cords. Bila te ra l da ma ge to this ne rve would re sult in
hoa rse ne ss a nd would pre dispose the pa tie nt to a spira tion but
would not le a d to a irwa y obstruction pe r se (Miller: Basics of
Anesth esia, ed 6, p 469).
453. (D) MH is a clinica l syndrome tha t ma y de ve lop ra pidly or ta ke
hours to ma nife st, some time s not occurring until the pa tie nt is in
the re cove ry room. Clinica l signs include hype rte nsion, ta chyca rdia ,
re spira tory a cidosis, me ta bolic a cidosis, muscle rigidity,
myoglobinuria , a nd fe ve r. The dia gnosis of MH is unlike ly, howe ve r,
if only one of the se signs is ma nife ste d. Be ca use MH is a me ta bolic
disorde r, one of the first se nsitive signs is a n incre a se in the
production of CO2 a nd concomita nt re spira tory a cidosis. This is the
most re lia ble e a rly sign of the syndrome (Barash : Clinical Anesth esia,
ed 7, pp 612, 622–624).
454. (D) Hype rve ntila tion to Pa CO2 of 20 mm Hg or highe r for more
tha n 2 hours will re sult in a ctive tra nsport of HCO3– out of the CNS.
This re sults in sponta ne ous bre a thing a t a lowe r (not highe r)
Pa CO2. The othe r choice s should be include d in the diffe re ntia l
dia gnosis of a pne a (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 5, pp 359–361; Miller: Basics of Anesth esia, ed 6, pp 62–64,
340; Barash : Clinical Anesth esia, ed 7, pp 271–273).
455. (B) Ma ximum volunta ry ve ntila tion (MVV) is a nonspe cific
pulmona ry function te st tha t me a sure s the e ndura nce of the
ve ntila tory muscle s a nd indire ctly re fle cts the complia nce of the
lung a nd thora x a s we ll a s a irwa y re sista nce . A de cre a se d MVV
ma y be ca use d by impa irme nt to inspira tion or e xpira tion. In this
pa tie nt, FEV1 is norma l, which strongly sugge sts tha t the ve ntila tory
impa irme nt is during inspira tion. A flow-volume loop would be a
ve ry use ful confirma tory te st (Barash : Clinical Anesth esia, ed 7, pp
1033–1034).
456. (A) Guide line s for sa fe discha rge of pa tie nts from a mbula tory
surgica l ce nte rs include sta ble vita l signs, a bility to wa lk without
dizzine ss, controlle d pa in, a bse nce of na use a a nd vomiting, a nd
minima l surgica l ble e ding. The PADSS is a tool for obje ctive ly
a sse ssing a pa tie nt’s re a dine ss for discha rge from the surgica l
ce nte r a nd include s the se five crite ria . Re quire me nts to drink fluids
a nd to void be fore home discha rge a re controve rsia l a nd a re not
pa ra me te rs include d in the PADSS (Barash : Clinical Anesth esia, ed 7,
pp 1560–1561).
457. (C) Ma ligna nt hype rthe rmia (MH) is a difficult dia gnosis to
ma ke on clinica l grounds a lone . Signs of MH ma y be fulmina nt or
ve ry subtle . The y ma y occur imme dia te ly a fte r induction or ma y not
be ma nife ste d until the pa tie nt ha s re a che d the re cove ry room or
e ve n la te r. MH is a disorde r of me ta bolism a nd is a ssocia te d with
hype rte nsion, ta chyca rdia , dysrhythmia s, re spira tory a cidosis,
me ta bolic a cidosis, muscula r rigidity, rha bdomyolysis, a nd fe ve r.
Contra ry to wha t one might be lie ve ba se d on the na me of this
dise a se , fe ve r is typica lly a la te finding. Othe r dise a se s tha t ma y
mimic MH include a lcohol withdra wa l, a cute coca ine toxicity,
ba cte re mia , phe ochromocytoma , hype rthyroidism, a nd ne urole ptic
ma ligna nt syndrome . An e le va tion in te mpe ra ture a lone with
norma l blood ga se s, he a rt ra te , a nd blood pre ssure , a nd no
e vide nce of muscle bre a kdown would ve ry like ly not be due to
MH. If a pa tie nt ha d be e n pre viously subje cte d to muscle biopsy
a nd ca ffe ine -ha lotha ne contra cture te sting with ne ga tive re sults,
MH would be e xce e dingly ra re , a lthough a fa lse -ne ga tive re sult is
possible . A history of a pre vious a ne sthe tic without MH trigge ring
would be of little re a ssura nce in a pa tie nt in whom a n MH e pisode
is suspe cte d. It is not uncommon for MH-susce ptible individua ls to
not trigge r whe n a trigge ring a ne sthe tic is a dministe re d initia lly but
de ve lop fulmina nt MH with a subse que nt a ne sthe tic (Barash :
Clinical Anesth esia, ed 7, pp 622–624).
458. (D) Asthma is a n infla mma tory illne ss tha t ha s bronchia l
hype rre a ctivity a nd bronchospa sm a s a re sult. Tre a tme nt is first
dire cte d a t the infla mma tory compone nt a s the unde rlying proble m,
re se rving bronchodila tors for symptoma tic use . Be ca use
le ukotrie ne s ma y function a s infla mma tory me dia tors, the
le ukotrie ne pa thwa y inhibitors such a s zile uton a nd the le ukotrie ne
re ce ptor a nta gonist monte luka st (Singula ir) a re be ing use d for
tre a tme nt of a sthma . Zile uton a nd monte luka st a re a va ila ble only
a s ora l pre pa ra tions, whe re a s the othe r drugs liste d a re give n by
inha la tion. Flutica sone a nd tria mcinolone a re a nti-infla mma tory
corticoste roids. Ipra tropium is a qua te rna ry a mmonium compound
forme d by the introduction of a n isopropyl group to the N a tom of
a tropine a nd produce s e ffe cts simila r to those of a tropine . One
une xpe cte d finding is a re la tive la ck of e ffe ct on mucocilia ry
cle a ra nce , which ma ke s it use ful in pa tie nts with a irwa y dise a se ,
e spe cia lly if pa ra sympa the tic tone of the a irwa ys is incre a se d.
Sa lme te rol is a β2-se le ctive a dre ne rgic drug (Hard m an: Good m an &
Gilm an’s Th e Ph arm acological Basis of Th erapeutics, ed 11, pp 721–725,
730–731; Stoelting: Ph arm acology and Ph y siology in Anesth etic Practice,
ed 4, pp 271, 427).
459. (D) Acute de cre a se s in se rum sodium, due to a bsorption of
bla dde r irriga ting fluids, ra re ly ca use symptoms unle ss the sodium
le ve l drops be low 120 mEq/L. At this le ve l, tissue e de ma ma y
de ve lop a nd clinica l ne urologic signs (e .g., re stle ssne ss, na use a ,
confusion, se izure s, a nd coma ) or ECG cha nge s (e .g., wide ning of
the QRS comple x, e le va tion of the ST se gme nt, ve ntricula r
ta chyca rdia , or ve ntricula r fibrilla tion) ma y be ma nife ste d.
Tre a tme nt of mild de cre a se s in se rum sodium (i.e ., 120-135 mEq/L
with no ne urologic or ECG cha nge s) is by fluid re striction a nd/or
a dministra tion of a diure tic such a s furose mide . W he n the sodium
le ve l drops be low 120 mEq/L a nd ne urologic symptoms or cha nge s
in the ECG de ve lop, sodium chloride a dministra tion is ne e de d. To
ca lcula te the a mount ne e de d, one multiplie s the pa tie nt’s tota l
body wa te r (i.e ., 0.6 × body we ight = TBW ) by the cha nge in sodium
de sire d. In this ca se , the TBW is 60 L (0.6 × 100 kg) a nd the cha nge
of sodium is 10 mEq (120 mEq/L − 110 mEq/L), thus
60 L × 10 mEq/L = 600 mEq. Ca ution is a dvise d in a dministe ring
sodium be ca use too ra pid a dministra tion ma y le a d to
de mye lina ting CNS le sions. The re comme nde d ra te of 3% sodium
chloride (513 mEq/L) is 1 to 2 mL/kg/hr. Se rum sodium le ve ls should
be che cke d a t le a st e ve ry hour until the sodium le ve l incre a se s
a bove 120 mEq/L (Barash : Clinical Anesth esia, ed 7, pp 341–344).
460. (A) Trismus (ma sse te r spa sm) is cha ra cte rize d by rigidity of the
ja w muscle s while the limb muscle s re ma in fla ccid a fte r
a dministra tion of succinylcholine . Trismus ma y he ra ld the onse t of
MH in some pa tie nts but ma y be due to a numbe r of othe r ca use s
a nd ma y occur in norma l pa tie nts. It pre viously ha d be e n be lie ve d
tha t 50% of pa tie nts who e xpe rie nce trismus a fte r a dministra tion of
succinylcholine would go on to de ve lop MH. Re ce nt e vide nce
sugge sts, howe ve r, tha t the incide nce is le ss. If ma sse te r spa sm
occurs in a pa tie nt a fte r a dministra tion of succinylcholine , the most
conse rva tive course would be to ca nce l the ope ra tion. If
ca nce lla tion of the ope ra tion is not fe a sible , the n a nontrigge ring
a ne sthe tic should be use d, a nd the a ne sthe siologist should pa y
close a tte ntion for a ny signs of MH (Miller: Miller’s Anesth esia, ed 8, p
1296).
461. (B) Ke ta mine is unique a mong the IV induction a ge nts in tha t it
usua lly produce s ca rdia c stimula tion ma nife ste d by incre a se d he a rt
ra te , me a n a rte ria l pre ssure , a nd ca rdia c output. Ke ta mine is
be lie ve d to ha ve a ce ntra lly me dia te d sympa the tic ne rvous syste m
stimula ting e ffe ct. This e ffe ct is, howe ve r, not re la te d to dose . In
isola te d ra bbit a nd ca nine he a rts a nd in inta ct dogs, ke ta mine ha s
be e n de monstra te d to produce myoca rdia l de pre ssion. Clinica lly,
howe ve r, the myoca rdia l de pre ssa nt prope rtie s of ke ta mine a re
ove rridde n by its sympa the tic ne rvous syste m stimula ting
prope rtie s. W he n syste mic ca te chola mine s ha ve be e n de ple te d or
whe n the pa tie nt is unde r de e p a ne sthe sia , the myoca rdia l
de pre ssa nt prope rtie s of ke ta mine ma y pre domina te (Stoelting:
Ph arm acology and Ph y siology in Anesth etic Practice, ed 4, p 172).
462. (C) In the norma l muscle ce ll, de pola riza tion re sults in re le a se
of ca lcium from the sa rcopla smic re ticulum. The incre a se d
intra ce llula r ca lcium conce ntra tion re sults in muscle contra ction.
The ca lcium the n is ra pidly ta ke n up via ca lcium pumps ba ck into
the sa rcopla smic re ticulum, re sulting in re la xa tion. Both the re le a se
a nd re upta ke of ca lcium a re e ne rgy-re quiring proce sse s (i.e ., re sult
in the hydrolysis of a de nosine triphospha te [ATP]). Da ntrole ne , the
pha rma cologic tre a tme nt for MH, blocks re le a se of ca lcium from
the sa rcopla smic re ticulum without a ffe cting the re upta ke proce ss.
The de fe ct in MH is thought to be de cre a se d control of intra ce llula r
ca lcium store s pre ve nting muscle re la xa tion (Barash : Clinical
Anesth esia, ed 7, pp 622–624).
463. (D) Approxima te ly 4% of pa tie nts tre a te d with ble omycin
de ve lop pulmona ry toxicity, which ma nife sts a s se ve re pulmona ry
fibrosis a nd hypoxe mia . De a th from se ve re pulmona ry toxicity
occurs in a pproxima te ly 1% to 2% of pa tie nts tre a te d with
ble omycin. Pa tie nts who a re a t gre a te r risk for ble omycin-induce d
pulmona ry toxicity include e lde rly pa tie nts, those re ce iving more
tha n 200 to 400 mg, those with coe xisting lung dise a se , a nd those
re ce ntly e xpose d to ble omycin. In a ddition, the re is e vide nce tha t
prior ra diothe ra py a nd possibly re ce ipt of e nriche d conce ntra tions
of O2 (i.e ., inspire d oxyge n >30%) during surge ry incre a se risk of
pulmona ry toxicity. Clinica lly, pa tie nts gra dua lly de ve lop dyspne a , a
nonproductive cough, a nd hypoxe mia , a nd pulmona ry function te sts
typica lly de monstra te cha nge s in ga s flow a nd lung volume s
consiste nt with re strictive pulmona ry dise a se . If ra diogra phic
e vide nce such a s bila te ra l diffuse inte rstitia l infiltra te s a ppe a rs,
pulmona ry fibrosis usua lly is irre ve rsible (Stoelting: Ph arm acology
and Ph y siology in Anesth etic Practice, ed 4, pp 564–565).
464. (C) He a d fle xion ca n a dva nce the tube up to 1.9 cm towa rd the
ca rina a nd in some ca se s conve rt a n e ndotra che a l intuba tion into
a n e ndobronchia l intuba tion. Exte nsion of the he a d ha s the
opposite e ffe ct a nd ca n withdra w the tube up to 1.9 cm, re sulting in
e xtuba tion of some pa tie nts. Turning the he a d la te ra lly ca n move
the dista l tip of the e ndotra che a l tube a bout 0.7 cm a wa y from the
ca rina . The Tre nde le nburg position ca use s a ce pha la d shift of the
me dia stinum a nd ca n ca use the e ndotra che a l tube to migra te
dista lly a s we ll (Miller: Basics of Anesth esia, ed 6, p 242).
465. (C) Sulfur he xa fluoride is some time s inje cte d in the vitre ous in
pa tie nts with a de ta che d re tina to me cha nica lly fa cilita te
re a tta chme nt. To pre ve nt cha nge s in the size of the ga s bubble , the
pa tie nts should be give n 100% O2 15 minute s be fore inje ction of
sulfur he xa fluoride . If the se pa tie nts a re a ne sthe tize d with ge ne ra l
a ne sthe sia within 10 da ys, N2O should not be give n be ca use N2O
ca n diffuse into the ga s bubble , incre a sing intra ocula r pre ssure ,
a nd ma y re sult in blindne ss (Barash : Clinical Anesth esia, ed 7, pp
1391–1392).
466. (D) The symptoms of hypoca lce mia , which ma nife st a s
la ryngospa sm or la rynge a l stridor, usua lly de ve lop within the first
24 to 96 hours a fte r tota l thyroide ctomy. Afte r the a irwa y is
e sta blishe d a nd se cure d, the pa tie nt should be tre a te d with IV
ca lcium in the form of e ithe r ca lcium glucona te or ca lcium chloride
(Barash : Clinical Anesth esia, ed 7, pp 352–353, 1330).
467. (C) Be ca use the circula ting le ve ls of T 3 a nd T 4 re gula te TSH
re le a se from the a nte rior pituita ry gla nd by a ne ga tive fe e dba ck
me cha nism, a norma l pla sma conce ntra tion of TSH confirms a
e uthyroid sta te . The pha rma cologic tre a tme nt of choice for pa tie nts
with hypothyroidism is sodium le vothyroxine (T 4). Sodium
le vothyronine (triiodothyronine , T 3) a nd de sicca te d thyroid a re
a lte rna te the ra pe utic a ge nts (Barash : Clinical Anesth esia, ed 7, p 1328;
Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 389–390).
468. (A) La rge qua ntitie s of irriga ting fluid ca n be a bsorbe d during
tra nsure thra l re se ction of the prosta te gla nd be ca use the ope n
ve nous sinuse s in the prosta te a llow the irriga tion fluid to be
a bsorbe d. On a ve ra ge , from 10 to 30 mL of fluid pe r minute a re
a bsorbe d, a nd during long ca se s this ca n a mount to se ve ra l lite rs,
ca using hype rte nsion, re fle x bra dyca rdia , a nd pulmona ry
conge stion. Tre a tme nt consists of fluid re striction a nd a loop
diure tic (e .g., furose mide ) whe n the [Na +] le ve l is gre a te r tha n
120 mEq/L. Ra re ly doe s the a mount of fluid a bsorbe d ca use
significa nt hypona tre mia ([Na +] <120 mEq/L). In the se ca se s of
significa nt hypona tre mia , 3% sodium chloride ma y be infuse d
slowly intra ve nously (in a ddition to the loop diure tic a nd fluid
re striction) until the sodium le ve l re a che s 120 mEq/L (Barash :
Clinical Anesth esia, ed 7, pp 1428–1429).
469. (C) Pa tie nts who ha ve susta ine d the rma l injurie s a re a t risk for
ma ssive pota ssium re le a se a nd pote ntia l ca rdia c a rre st if
succinylcholine is a dministe re d 24 hours or more a fte r the y susta in
the burn, a nd the y re ma in a t risk until the burn ha s he a le d. This
incre a se d se nsitivity to succinylcholine is thought to be re la te d to
prolife ra tion of e xtra junctiona l re ce ptors. The se sa me re ce ptors
a re thought to be re la te d to the incre a se d re quire me nt for
nonde pola rizing ne uromuscula r blocking a ge nts in the se pa tie nts
(Barash : Clinical Anesth esia, ed 7, p 1523).
470. (A) The fa cia l ne rve (se ve nth cra nia l ne rve ) runs within the
substa nce of the pa rotid gla nd a nd might be come da ma ge d during
pa rotid surge ry. The fa cia l ne rve inne rva te s the la crima l,
subma ndibula r, a nd sublingua l gla nds, is se nsory to the a nte rior
two thirds of the tongue , a nd inne rva te s a ll of the muscle of fa cia l
e xpre ssion (including the orbicula ris oculi—close the e ye lids;
orbicula ris oris—purse the lips; fronta lis—ra ise the e ye brows).
The trige mina l ne rve (fifth cra nia l ne rve ) inne rva te s the muscle s of
ma stica tion (ma sse te r, te mpora lis, me dia l, a nd la te ra l
pte rygoids), which a re use d to cle nch the te e th (Miller: Basics of
Anesth esia, ed 6, p 497; Orient: Sapira’s Art and Science of Bed sid e
Diagnosis ed 4, pp 533–537).
471. (D) One gra m of he moglobin ca n combine with 1.34 mL of O2.
None of the othe r choice s in this que stion will do a s much to
incre a se the O2-ca rrying ca pa city of this pa tie nt’s blood a s a
tra nsfusion (Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, pp 787, 849).
472. (A) Ma ny of the drugs commonly a dministe re d during surge ry
a nd a ne sthe sia ha ve the pote ntia l to e voke a lle rgic re a ctions (e .g.,
morphine , propofol, loca l a ne sthe tics, a ntibiotics, a nd prota mine ,
a s we ll a s othe r ma te ria ls use d during surge ry, such a s va scula r
gra ft ma te ria l, chymopa pa in, a nd la te x). Virtua lly a ll drugs
a dministe re d IV ha ve be e n re porte d to ca use a lle rgic re a ctions.
Possible e xce ptions include be nzodia ze pine s a nd ke ta mine . An
a lle rgic re a ction should be conside re d whe n the re is a n a brupt fa ll
in blood pre ssure a ccompa nie d by incre a se s in he a rt ra te tha t
e xce e d 30% of the control va lue s. Gre a te r tha n 60% of a ll drug-
induce d a lle rgic re a ctions obse rve d during the pe riope ra tive pe riod
a re a ttributa ble to muscle re la xa nts. La te x a lle rgy is thought to be
re sponsible for 15% of a lle rgic re a ctions unde r a ne sthe sia ,
some time s including re a ctions origina lly a ttribute d to othe r
substa nce s. Pa tie nts a t risk for la te x a lle rgy include he a lth ca re
worke rs a nd pa tie nts with spina bifida . Although most drug-
induce d a lle rgic re a ctions de ve lop within 5 to 10 minute s of
e xposure , la te x signs typica lly ta ke more tha n 30 minute s to
de ve lop (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
525–529).
473. (C) De cre a se d le ve ls of pse udocholine ste ra se ha ve be e n
re porte d in pa tie nts with Huntington chore a . For this re a son, the
e ffe cts of succinylcholine ma y be prolonge d in some of the se
pa tie nts. It ha s be e n sugge ste d tha t the se nsitivity to
nonde pola rizing muscle re la xa nts is a lso incre a se d (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 247).
474. (A) Norma l intra ocula r pre ssure is 10 to 22 mm Hg. In ge ne ra l,
IV a ne sthe tics, with the possible e xce ption of ke ta mine , de cre a se
intra ocula r pre ssure . In a ddition, nonde pola rizing ne uromuscula r
blocke rs, inha le d a ne sthe tics, na rcotics, ca rbonic a nhydra se
inhibitors, osmotic diure tics, a nd hypothe rmia de cre a se intra ocula r
pre ssure . Howe ve r, e le va tion of Pa CO2 out of the physiologic ra nge ,
a s se e n with hypove ntila tion a s we ll a s a rte ria l hypoxe mia , will
incre a se intra ocula r pre ssure . De pola rizing ne uromuscula r
blocke rs, such a s succinylcholine , a lso incre a se intra ocula r
pre ssure . This incre a se in intra ocula r pre ssure occurs whe n
succinylcholine is a dministe re d IM or IV. Pre tre a tme nt with a
nonde pola rizing muscle re la xa nt be fore a dministe ring
succinylcholine ma y a tte nua te the rise in intra ocula r pre ssure . The
me cha nism for the incre a se in intra ocula r pre ssure a fte r
succinylcholine use is re la te d to drug-induce d cyclople gia ra the r
tha n contra ction of e xtra ocula r muscle s, a s this incre a se in
intra ocula r pre ssure will occur e ve n if the intra ocula r muscle s a re
cut. The gre a te st incre a se in intra ocula r pre ssure occurs with
coughing or vomiting, whe re the intra ocula r pre ssure ma y incre a se
a s much a s 35 to 50 mm Hg. The propose d me cha nism for the a cute
incre a se in intra ocula r pre ssure is a n incre a se in ve nous pre ssure .
The re doe s not a ppe a r to be a cha nge in intra ocula r pre ssure with
cha nge s within norma l physiologic ra nge s in a rte ria l blood
pre ssure or Pa CO2 (Barash : Clinical Anesth esia, ed 7, pp 1375–1376;
Miller: Basics of Anesth esia, ed 6, pp 487–488).
475. (C) The a pne a -hypopne a inde x (AHI) is use d to qua ntify the
numbe r of a pne a or hypopne a e pisode s tha t occur pe r hour. Apne a
is de fine d a s no ve ntila tion for pe riods of 10 se conds or more .
Hypopne a is de fine d a s a 50% de cre a se in a irflow or a de cre a se
sufficie nt to ca use a de cre a se in oxyge n sa tura tion of 4%. An AHI of
gre a te r tha n 30 signifie s se ve re OSA (Miller: Miller’s Anesth esia, ed 8,
p 2203; Lobato: Com plications in Anesth esiology, p 625).
476. (D) Any pa tie nt who is sche dule d for a pne umone ctomy should
unde rgo a se rie s of pre ope ra tive pulmona ry function te sts. The se
te sts a re ge ne ra lly conducte d in thre e pha se s. The te sts liste d in
this que stion pe rta in to the first ba tte ry of pulmona ry function te sts,
which a re whole -lung te sts. Re sidua l volume to TLC gre a te r tha n
50% (not <50%) is a ssocia te d with a n incre a se d ope ra tive risk. If the
re sults of a ny of the initia l whole -lung te sts a re be low the
a cce pta ble limits, a se cond pha se of te sting should be ca rrie d out
in which the function of e a ch lung is e va lua te d se pa ra te ly. The
pre dicte d postope ra tive FEV1 a fte r the se cond pha se of pulmona ry
function te sting is ca rrie d out should be gre a te r tha n 0.85 L. If the
crite ria for the se cond le ve l of pulmona ry function te sting ca nnot be
me t a nd pne umone ctomy is still de sire d, the n a third le ve l of
te sting should be ca rrie d out. During the third pha se of te sting,
postope ra tive conditions mimicking pne umone ctomy a re produce d
by occluding the pulmona ry a rte ry with a ba lloon on the side tha t is
to be re se cte d. Re sults of this te st tha t a re consiste nt with poor
outcome a fte r pne umone ctomy include me a n pulmona ry a rte ry
pre ssure gre a te r tha n 40 mm Hg, Pa CO2 gre a te r tha n 60 mm Hg, or
Pa O2 le ss tha n 45 mm Hg (Miller: Miller’s Anesth esia, ed 8, pp 1943–
1945, 1981–1982).
477. (A) Me a sure d Pa O2 should be de cre a se d a bout 6% for e a ch
de gre e Ce lsius coole r the pa tie nt’s te mpe ra ture is tha n the
e le ctrode (37° C). Be ca use the pa tie nt is 2° C coole r tha n the
e le ctrode , a 12% de cre a se (9 mm Hg) would be e xpe cte d in this
pa tie nt (77 mm Hg − 9 mm Hg = 68 mm Hg) (Miller: Basics of
Anesth esia, ed 6, p. 338).
478. (A) The two ma in ca use s of ce ntra l cya nosis a re de cre a se d
a rte ria l oxyge n sa tura tion a nd he moglobin a bnorma litie s (e .g.,
me the moglobine mia a nd sulfhe moglobine mia ). Sulfa sa la zine
(Azulfidine ) ca n ca use the forma tion of sulfhe moglobin.
Sulfhe moglobin, like me the moglobin, ma y ca use low O2 sa tura tion
in the fa ce of high Pa O2. The re is no tre a tme nt for
sulfhe moglobine mia e xce pt to wa it for the de struction of the
e rythrocyte s (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 296, 415).
479. (D) Unfra ctiona te d he pa rin is a mixture of highly sulfa te d
glycosa minoglyca ns with mole cula r we ights of 5000 to
30,000 da ltons. The onse t of a ction of unfra ctiona te d he pa rin is
imme dia te , the pla sma ha lf-life is ½ hour to 2 hours, a nd it ca n be
comple te ly re ve rse d with prota mine . Clinica lly, monitoring of
a nticoa gula tion is usua lly pe rforme d with the a PTT te st with a
ta rge t prolonga tion of 1.5 to 2 time s control. W he n unfra ctiona te d
he pa rin is use d for ca rdiopulmona ry bypa ss, the dose s a re much
highe r a nd it is monitore d with the a ctiva te d clotting time or ACT
te st (>400 se conds is usua lly conside re d sa fe for ca rdiopulmona ry
bypa ss). LMW Hs a re 4000 to 5000 da ltons in size , the onse t of a ction
is 20 to 60 minute s, the pla sma ha lf-life is 4.5 hours, a nd it ca n only
be pa rtia lly re ve rse d (65%) with prota mine . Monitoring the LMW H’s
e ffe cts is not pe rforme d, be ca use the PT a nd the a PTT te sts a re
most ofte n una ffe cte d. LMW Hs ha ve a much lowe r risk for HIT
compa re d to the unfra ctiona te d he pa rin (Miller: Basics of Anesth esia,
ed 6, pp 357–358; Miller: Miller’s Anesth esia, ed 8, pp 1872–1873).
480. (B) Se rum cre a tinine is inve rse ly proportiona l to the GFR. W ith
the incre a se in cre a tinine by a fa ctor of 4, the GFR is divide d by
four; tha t is, 120/4 = 30 mL/min (Lobato: Com plications in
Anesth esiology, p 433; Miller: Miller’s Anesth esia, ed 8, pp 558–559).
481. (A) Trisomy 21 or Down syndrome is the most common huma n
chromosoma l syndrome se e n. An incre a se d incide nce of conge nita l
hypothyroidism occurs. About one fourth of childre n with Down
syndrome a nd ma ny a dults ha ve sma lle r tra che a s tha n pre dicte d
a nd re quire a n e ndotra che a l tube tha t is one or two size s sma lle r.
One should a void unne ce ssa ry fle xion or e xte nsion of the ne ck
during intuba tion be ca use occipito-a tla ntoa xia l insta bility occurs in
a bout 15% to 20% of pa tie nts. Be ca use subluxa tion is re la tive ly
uncommon, routine ne ck ra diogra phs for a ll Down syndrome
pa tie nts a re e xce ssive . More tha n 40% of Down syndrome childre n
ha ve conge nita l he a rt dise a se (e .g., e ndoca rdia l cushion de fe cts,
ve ntricula r se pta l de fe cts, te tra logy of Fa llot, pa te nt ductus
a rte riosus). Although some childre n ha ve hypotonia , a n incre a se d
incide nce of MH ha s not be e n re porte d in the se pa tie nts (Baum :
Anesth esia for Genetic, Metabolic, and Dy sm orph ic Sy nd rom es of
Ch ild h ood , ed 2, pp 105–107; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 634–635).
482. (B) Scopola mine is a n a nticholine rgic tha t ma y produce
mydria sis a nd cyclople gia . This ca n re sult in the ina bility of a
pa tie nt’s e ye s to a ccommoda te (Stoelting: Basics of Anesth esia, ed 6, p
76).
483. (D) Ne urole ptic ma ligna nt syndrome is a pote ntia lly fa ta l
dise a se tha t a ffe cts 0.5% to 1% of a ll pa tie nts be ing tre a te d with
ne urole ptic (a ntipsychotic) drugs. The syndrome de ve lops gra dua lly
ove r 1 to 3 da ys in young ma le s a nd is cha ra cte rize d by the
following: (1) hype rthe rmia , (2) ske le ta l muscle rigidity, (3)
a utonomic insta bility ma nife ste d by cha nge s in blood pre ssure a nd
he a rt ra te , a nd (4) fluctua ting le ve ls of consciousne ss. The morta lity
from ne urole ptic ma ligna nt syndrome is 20% to 30%. Live r
tra nsa mina se s a nd cre a tine phosphokina se le ve ls a re ofte n
e le va te d in the se pa tie nts. Tre a tme nt include s supportive ca re a nd
a dministra tion of da ntrole ne . This dise a se ma y mimic MH be ca use
of its ma ny simila ritie s. One diffe re nce be twe e n ne urole ptic
ma ligna nt syndrome a nd MH is the fa ct tha t nonde pola rizing
muscle re la xa nts such a s ve curonium or cisa tra curium will ca use
fla ccid pa ra lysis in pa tie nts with ne urole ptic ma ligna nt syndrome
but not in pa tie nts with MH (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 540, 635–640).
484. (D) The cla ssic signs of fa t e mbolism include ta chyca rdia ,
dyspne a , me nta l confusion, a nd fe ve r, a nd fre que ntly the re ma y be
a pe te chia l ra sh on the uppe r pa rt of the body. Fa t e mbolism is
more common a fte r long bone fra cture s (e .g., fe mur a nd tibia ) a nd
usua lly occurs be twe e n 12 a nd 72 hours a fte r long bone fra cture s
(Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 213–214).
485. (C) Re mife nta nil is a n ultra short-a cting na rcotic. Che mica lly it
is a de riva tive of pipe ridine (like fe nta nyl), but re mife nta nil ha s a n
e ste r linka ge a nd is ra pidly broke n down by nonspe cific pla sma a s
we ll a s tissue e ste ra se s. The e limina tion ha lf-life is le ss tha n
20 minute s a nd is be st a dministe re d by a continuous infusion.
Pse udocholine ste ra se de ficie ncy or re na l or he pa tic fa ilure doe s
not a ffe ct re mife nta nil’s ra pid me ta bolism (Barash : Clinical
Anesth esia, ed 7, p 509; Stoelting: Ph arm acology and Ph y siology in
Anesth etic Practice, ed 4, p 114).
486. (D) A te rm infa nt with a strong cry a nd good muscle tone doe s
not re quire oxyge n the ra py ba se d on a 5-minute sa tura tion a lone .
The fe ta l lungs ma ke a ra pid tra nsition from a fluid-fille d orga n to
a n a ir-fille d orga n. As the zone s of a te le cta sis ope n, the sa tura tion
rise s. The ta ble be low shows a cce pta ble pre ducta l oxyge n
sa tura tion a s a function of time .

Minutes Preductal Oxygen Saturation


1 60%-65%
2 65%-70%
3 70%-75%
4 75%-80%
5 80%-85%
10 85%-95%
Data from Kattwinkel J et al: Neonatal resuscitation: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Pediatrics 126:e1400–
e1413, 2010.

487. (C) Ane sthe sia for e xtra corpore a l shock wa ve lithotripsy ma y
be a ccomplishe d with e ithe r ge ne ra l a ne sthe sia or e pidura l
a ne sthe sia . W he n a pa tie nt is subme rge d in the sta inle ss ste e l tub,
the pe riphe ra l va scula ture be come s compre sse d by the hydrosta tic
pre ssure , re sulting in a n incre a se in pre loa d. Re moving the pa tie nt
from the ta nk ha s the opposite e ffe ct. In pa tie nts who ha ve
re ce ive d e pidura l a ne sthe sia , the re is a n incre a se d incide nce of
hypote nsion ca use d by e pidura l-induce d sympa the ctomy a fte r the y
e me rge from the ba th (Miller: Basics of Anesth esia, ed 6, p 627).
488. (A) The most common re a son for une xpe cte d hospita l
a dmission a fte r outpa tie nt ge ne ra l a ne sthe sia , a s we ll a s a
prolonge d re cove ry-room sta y (for both a dults a nd childre n), is
na use a a nd vomiting. Two othe r re a sons for a prolonge d re cove ry-
room sta y a re pa in a nd drowsine ss (Barash : Clinical Anesth esia, ed 7,
pp 854, 856).
489. (A) Choline rgic crisis ca n be diffe re ntia te d from mya sthe nic
crisis by a dministe ring sma ll IV dose s of a nticholine ste ra se s. W ith
a choline rgic crisis, the re a re significa nt musca rinic e ffe cts (e .g.,
sa liva tion, bra dyca rdia , miosis) a nd a n a cce ntua te d muscle
we a kne ss. Be ca use this pa tie nt’s VT de cre a se d with the
a dministra tion of e drophonium, the dia gnosis of choline rgic crisis is
ma de . Although a tropine ma y be ne e de d to tre a t the choline rgic
symptoms, muscle we a kne ss will be worse a nd the se pa tie nts
ne e d to be intuba te d until the muscle stre ngth re turns (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 450).
490. (C) Tra ma dol, a synthe tic code ine a na log, is a ce ntra lly a cting
a na lge sic. It ca n be use d for mild to mode ra te pa in but is not a s
e ffe ctive a s morphine or me pe ridine for se ve re or chronic pa in.
One dra wba ck for tra ma dol’s pe riope ra tive use is its high
incide nce of na use a a nd vomiting. Its me cha nism of a ction for
a na lge sia is comple x. It is a we a k µ-re ce ptor a gonist, it inhibits
se rotonin a nd nore pine phrine re upta ke , a nd it e nha nce s se rotonin
re le a se . Tra ma dol-induce d a na lge sia is not e ntire ly re ve rse d with
na loxone ; howe ve r, the re spira tory de pre ssion a nd se da tion ca n be
re ve rse d. Onda nse tron, a se rotonin a nta gonist, ma y inte rfe re with
pa rt of tra ma dol’s a na lge sic a ction. Be ca use of its low µ-re ce ptor
a gonist a ctivity, it ma y be le ss like ly to produce physica l
de pe nde nce tha n othe r stronge r na rcotics. Se izure s ha ve be e n
re porte d in pa tie nts re ce iving tra ma dol a lone . The drug should be
use d with ca ution in pa tie nts ta king drugs tha t lowe r the se izure
thre shold, such a s tricyclic a ntide pre ssa nts a nd SSRIs. It ha s some
monoa mine oxida se (MAO) inhibiting a ctivity a nd should not be
use d in pa tie nts ta king MAO inhibitors. Anothe r wa rning is its use
in pa tie nts who a re de pre sse d or suicida l. Tra ma dol is not
re comme nde d in de pre sse d or suicida l pa tie nts be ca use e xce ssive
dose s, e ithe r a lone or with othe r CNS de pre ssa nts including
a lcohol, a re a ma jor ca use of drug-re la te d de a ths with fa ta litie s
re porte d within the first hour of ove rdosa ge . Pa tie nts who a re
de pre sse d or suicida l a re be tte r ma na ge d with non-na rcotic
a na lge sics (Hard m an: Good m an & Gilm an’s Th e Ph arm acological Basis
of Th erapeutics, ed 10, p 590; Ph y sicians’ Desk Reference 2009, ed 63, pp
2428–2431; Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, p 117).
491. (A) The null hypothe sis sta te s tha t the re is no diffe re nce
be twe e n two groups of da ta , while the a lte rna tive hypothe sis
sta te s the opposite or tha t the re is a diffe re nce be twe e n the
groups. The P va lue is de rive d from a te st sta tistic a nd is the
proba bility tha t we could ha ve obse rve d a diffe re nce if in re a lity
the null hypothe sis wa s true a nd the re wa s not a diffe re nce . If the
P va lue is le ss tha n a pre de te rmine d le ve l of significa nce (the α
va lue , ofte n se t a t = 0.05) the n the null hypothe sis (no diffe re nce ) is
re je cte d a nd the diffe re nce s obse rve d a re sta te d to be sta tistica lly
significa nt (P < 0.05). It ca n the n be sta te d tha t it is unlike ly
(ca lcula te d to be le ss tha n a 1 in 20 proba bility) tha t the diffe re nce s
de te cte d in the two groups occurre d by ra ndom cha nce or tha t the
null hypothe sis wa s true . W he n the P va lue is le ss tha n α but the re
a ctua lly is not a diffe re nce be twe e n the groups, it is ca lle d a type 1
e rror.
On the othe r ha nd, if no sta tistica lly significa nt diffe re nce s a re
de te cte d (P va lue > α), we a cce pt tha t the null hypothe sis (no
diffe re nce e xists) is true . If we a cce pt the null hypothe sis whe n
the a lte rna tive hypothe sis (the re is a diffe re nce ) is in fa ct true , a
type 2 e rror ha s occurre d. Type 2 e rrors a re re la te d to the powe r
of the study. Powe r is the proba bility of re je cting the null
hypothe sis (no diffe re nce ) whe n a spe cific a lte rna tive hypothe sis
(diffe re nce ) is corre ct. Powe r is re la te d to the ma gnitude of the
diffe re nce to de te ct, the va ria bility of the da ta , the α le ve l, a nd
the sa mple size . Ofte n a powe r of 0.8 is se le cte d, me a ning tha t
we a cce pt a n 80% proba bility tha t the null hypothe sis (no
diffe re nce ) is true or tha t the re is a lso a 20% cha nce tha t a
diffe re nce doe s e xist but wa s not obse rve d. La rge r sa mple size s
ma ke it e a sie r to obse rve tha t a diffe re nce e xists a nd incre a se
the powe r of a n a na lysis (Miller: Miller’s Anesth esia, ed 8, pp 3250–
3251).
492. (D) In the a bse nce of diure tics, oliguria a ssocia te d with urine
sodium conce ntra tion gre a te r tha n 40 mEq/L a nd urine osmola lity
le ss tha n 400 mOsm/L is strongly sugge stive of intrinsic re na l
dise a se (e .g., a cute tubule ne crosis), whe re a s pre re na l ca use s
ha ve urine sodium conce ntra tion le ss tha n 20 mEq/L a nd urine
osmola lity gre a te r tha n 400 mOsm/L. Furose mide , ma nnitol, a nd
dopa mine , howe ve r, obscure the a ccura te dia gnosis (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 335–338; Miller:
Basics of Anesth esia, ed 6, pp 450–452).
493. (C) In a n unconscious pa tie nt, a unila te ra l dila te d pupil would
be a ma tte r of gra ve conce rn. In a n a wa ke pa tie nt with a norma l
ne urologic e xa mina tion, howe ve r, it is le ss worrisome . An infe rior
a lve ola r ne rve block involve s inje ction of a bout 2 mL of 2%
lidoca ine a round the infe rior a lve ola r ne rve just be hind the mola rs
in the lowe r ja w. Eve n a grossly misdire cte d ne e dle proba bly could
not re a ch the ste lla te ga nglion, but we re it possible , the re sult
would be a Horne r syndrome (miosis, not mydria sis, ptosis,
a nhidrosis, a nd va sodila tion ove r the fa ce ). Blocka de of the cilia ry
ga nglion could ca use mydria sis on the ipsila te ra l side , but re a ching
the cilia ry ga nglion, loca te d be twe e n the optic ne rve a nd la te ra l
re ctus muscle a bout 1 cm from the poste rior limit of the orbit,
would be a lmost impossible with a ne e dle dire cte d towa rd the
ma ndible . Glycopyrrola te a dministe re d syste mica lly doe s not ca use
mydria sis, a s it is not ca pa ble of crossing the blood-bra in ba rrie r.
Lidoca ine instille d dire ctly into the e ye doe s not produce mydria sis,
but phe nyle phrine doe s. Ca re must be ta ke n not to spra y loca l
a ne sthe tic (with or without va soconstrictor) into the e ye s while
a pplying topica l a ne sthe sia to the na re s (Stoelting: Ph arm acology and
Ph y siology in Anesth etic Practice, ed 4, p 304).
494. (C) MAC is the minimum a lve ola r conce ntra tion of a ne sthe tic
tha t will pre ve nt move me nt of 50% of pa tie nts whe n a skin incision
is ma de a t se a le ve l (e .g., Sa n Die go). MAC × 1.3 will pre ve nt
move me nt in 95% of pa tie nts. In this que stion, tota l ga s flow is
4 L/min (1 L/min + 3 L/min). Roughly 75% of the tota l ga s is N2O. The
MAC of N2O is 104%. The pa tie nt is re ce iving a bout 0.75 MAC N2O.
The MAC for isoflura ne is 1.15. A conce ntra tion of 0.85% would
re pre se nt 0.75 MAC. Be ca use MACs a re a dditive , the tota l MAC
would be 1.5 (Barash : Clinical Anesth esia, ed 7, pp 458–459; Miller:
Basics of Anesth esia, ed 6, p 82).
495. (D) Ca rdia c output incre a se s by a bout 100 mL/min for e a ch
kilogra m of we ight ga ine d. It is e stima te d tha t e ve ry kilogra m of
a dipose tissue conta ins ne a rly 3000 m of a dditiona l blood ve sse ls.
The a dditiona l ca rdia c output is due to ve ntricula r dila tion a nd
incre a se d stroke volume , a s re sting he a rt ra te s a re not incre a se d
in obe se pa tie nts (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, p 318; Miller: Basics of Anesth esia, ed 6, pp 83–84).
496. (C) Fe noldopa m (Corlopa m) is a se le ctive dopa mine -1 re ce ptor
a gonist with significa nt va sodila ting prope rtie s. It ha s mode ra te
a ffinity for α2 re ce ptors but ha s no a ffinity for dopa mine -2, α1, β, 5-
hydroxytrypta mine type 1 (5-HT 1), or 5-HT 2 re ce ptors. It is use d for
tre a tme nt of pa tie nts with se ve re hype rte nsion (e spe cia lly with
re duce d re na l function) a nd is a dministe re d a s a n IV infusion. It
ca n be use d a s a n a lte rna tive to sodium nitroprusside a nd ha s the
a dva nta ge of no thiocya na te toxicity, re bound e ffe ct, or “corona ry
ste a l” e ffe ct, but it doe s conta in sodium bisulfite a nd is
contra indica te d in pa tie nts with a known sulfite se nsitivity.
Dope xa mine (Dopa ca rd) is a synthe tic a na log re la te d to dopa mine
with intrinsic a ctivity a t dopa mine a s we ll a s β2 re ce ptors a nd is
use d a s a n inotropic a ge nt (Miller: Miller’s Anesth esia, ed 8, pp 367–
368).
497. (B) Ide a lly, fa ctor VIII le ve ls should be ra ise d to 100% pre dicte d
be fore e le ctive surge ry to e nsure tha t the le ve ls will not fa ll be low
30% intra ope ra tive ly. Thirty pe rce nt of the norma l fa ctor VIII
conce ntra tion or gre a te r is thought to be ne ce ssa ry for a pa tie nt
who is to unde rgo ma jor surge ry. Elimina tion ha lf-time of fa ctor VIII
is 12 hours. This ma y be a ccomplishe d with fa ctor VIII conce ntra te
or cryopre cipita te . Fre sh froze n pla sma is no longe r conside re d
the ra py for he mophilia (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 421).
498. (A) He mophilia A is a ssocia te d with de cre a se d le ve ls of fa ctor
VIII. PTT te sts the intrinsic coa gula tion ca sca de a nd would be
a bnorma lly e le va te d in a ll but the most mild dise a se . A norma l
PTT is 25 to 35 se conds. Pla te le t count, PT, a nd ble e ding time s a re
norma l (se e a lso e xpla na tion to Que stion 395) (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, p 421; Barash : Clinical
Anesth esia, ed 7, pp 433–434).
499. (D) Conve ntiona l pe riphe ra l ne rve stimula tors de live r four
twitche s a t 2 Hz spa ce d 0.5 se cond a pa rt. The se de vice s we re
de signe d with the knowle dge tha t succe ssive twitche s de ple te
a ce tylcholine store s. Afte r the fourth twitch, the re is no a dditiona l
de cre me nt in twitch he ight (Miller: Basics of Anesth esia, ed 6, p 156).
500. (B) Infe rior ische mia is a ssocia te d with blocka ge or spa sm of
the right corona ry a rte ry. The right corona ry a rte ry supplie s blood to
the a triove ntricula r node in 90% of pa tie nts. Comple te he a rt block
the re fore is not une xpe cte d in pa tie nts with se ve re CAD involving
the right corona ry a rte ry (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 24–25).
501. (B) MAC is influe nce d by a va rie ty of dise a se sta te s, conditions,
drugs, a nd othe r fa ctors. Drugs tha t incre a se CNS ca te chola mine s,
such a s MAO inhibitors, tricyclic a ntide pre ssa nts, a cute
a mphe ta mine inge stion, a nd coca ine , incre a se MAC. Othe r fa ctors
tha t incre a se MAC include hype rthe rmia , hype rna tre mia , pa tie nts
with na tura l re d ha ir, a nd infa ncy. It is inte re sting tha t MAC va lue s
a re highe r for infa nts tha n for ne ona te s or olde r childre n a nd
a dults. Thyroid gla nd dysfunction including hype rthyroidism doe s
not a ffe ct the MAC. Fa ctors tha t lowe r MAC include na rcotics, IV
a ne sthe tics, loca l a ne sthe tics (e xce pt coca ine ) a nd othe r se da tive s,
a ge (6% pe r de ca de ), hypothe rmia , hypoxia , a nd se ve re a ne mia
(e .g., Hgb < 5). The following ta ble modifie d from the re fe re nce s in
this que stion summa rize s the impa ct of va rious fa ctors on MAC
(Barash : Clinical Anesth esia, ed 7, pp 458-459; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, p 164; Miller: Basics of
Anesth esia, ed 6, p 82).
IMPACT OF PHYSIOLOGIC AND PHARMACOLOGIC FACTORS ON
MINIMUM ALVEOLAR CONCENTRATION (MAC)

No Change in Increase in MAC Decrease in MAC


MAC
Duration of Drugs that increase CNS catecholamines CNS depressants
anesthesia (MAO inhibitors, tricyclic antidepressants, (narcotics, IV
Type of surgery acute amphetamine use, cocaine, anesthetics, chronic
Hyperthyroidism ephedrine) amphetamine use)
Hypothyroidism Chronic ethanol abuse Acute ethanol use
Gender Hyperthermia Hypernatremia
Hyperkalemia Hypothermia Hyponatremia
Infants Increasing age
Patients with natural red hair Pregnancy
Hypoxia
CNS, central nervous system; MAO, monoamine oxidase.

502. (B) Long-te rm lithium the ra py in pa tie nts with ma nic-de pre ssive
illne ss ma y be a ssocia te d with ne phroge nic dia be te s insipidus.
Hypothyroidism ma y de ve lop in a bout 5% of pa tie nts be ca use
lithium ca n inhibit the re le a se of thyroid hormone s. Lithium is
a lmost 100% re na lly e xcre te d. Re a bsorption occurs a t the proxima l
convolute d tubule a nd is inve rse ly re la te d to the conce ntra tion of
sodium in the glome rula r filtra te . Conse que ntly, a dministra tion of
diure tics (ma inly thia zide , but to a le sse r e xte nt loop diure tics) ma y
le a d to the de ve lopme nt of toxic lithium le ve ls. Lithium ha s
se da tive prope rtie s a nd ma y re duce the ne e d for IV a nd
inha la tiona l a ne sthe tic a ge nts. It ma y prolong the dura tion of a ction
of both pa ncuronium a nd succinylcholine , but it is not a ssocia te d
with a n e xa gge ra te d re le a se of pota ssium whe n succinylcholine is
a dministe re d (Brunton: Good m an & Gilm an’s Th e Ph arm acological
Basis of Th erapeutics, ed 12, pp 448–449; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, p 539).
503. (D) Ca rcinoid tumors ca n a rise whe re ve r e nte rochroma ffin
ce lls a re pre se nt. Most (>70%) origina te in the inte stine , a nd a bout
20% origina te in the lung. Of those tha t origina te in the
ga strointe stina l tra ct, 50% occur in the a ppe ndix, 25% in the ile um,
a nd 20% in the re ctum. The se inte re sting tumors we re ca lle d
ca rcinoid be ca use the y we re origina lly be lie ve d not to me ta sta size .
We now know this is not true . The hormone s re le a se d by the
nonme ta sta tic tumors re a ch the live r by the porta l ve in a nd a re
ra pidly ina ctiva te d. Howe ve r, once me ta sta se s re a ch the live r, the
re le a se d hormone s re a ch the syste mic circula tion a nd produce
signs a nd symptoms of the “ca rcinoid syndrome .” Symptoms
include cuta ne ous flushing, a bdomina l pa in, vomiting, dia rrhe a ,
hypote nsion or hype rte nsion, bronchospa sm, a nd hype rglyce mia .
The na tura l hormone soma tosta tin suppre sse s the re le a se of
se rotonin a nd othe r va soa ctive substa nce s from the tumor. Be ca use
the ha lf-life is a bout 3 minute s, soma tosta tin is give n by infusion.
Octre otide is a synthe tic soma tosta tin a na log with a ha lf-life of
2.5 hours a nd is give n SQ or IV for the pre ve ntion a nd tre a tme nt of
ca rcinoid symptoms (e .g., hypote nsion, hype rte nsion,
bronchospa sm). Howe ve r, the tre a tme nt of hypote nsion in pa tie nts
with ca rcinoid dise a se is diffe re nt be ca use e phe drine ,
e pine phrine , a nd nore pine phrine ca n re le a se va soa ctive hormone s
from the tumor a nd ma ke the hypote nsion worse . Hypote nsion is
be st tre a te d with fluids a nd IV octre otide or soma tosta tin.
Hype rte nsion is tre a te d with de e pe ning the a ne sthe tic a nd
a dministe ring octre otide , soma tosta tin, or la be ta lol. Bronchospa sm
is tre a te d with IV octre otide , soma tosta tin, or ne bulize d
ipra tropium. W he n giving a ne sthe sia to the se pa tie nts it is proba bly
wise to a void drugs tha t re le a se hista mine a nd othe r va soa ctive
hormone s tha t ma y pre cipita te symptoms. Propofol or e tomida te
a re good induction a ge nts, followe d by ma inte na nce a ne sthe sia
with a vola tile a ne sthe tic (e .g., isoflura ne , se voflura ne , or
de sflura ne ) a nd/or nitrous oxide with oxyge n. Ve curonium,
cisa tra curium, a nd rocuronium a ppe a r to be sa fe muscle re la xa nts.
Fe nta nyl, sufe nta nil, a lfe nta nil, re mife nta nil, a nd be nzodia ze pine s
a re a lso sa fe to use . The se rotonin a nta gonist onda nse tron is a
use ful a ntie me tic (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, pp 297–298).
504. (B) Te sticula r inne rva tion ca n be tra ce d up to the T10
de rma toma l le ve l. For this re a son, a ny ope ra tion tha t involve s
ma nipula tion or tra ction on the te sticle s must ha ve a de qua te
a ne sthe sia to pre ve nt pa in. This ca n be a chie ve d with spina l or
e pidura l a ne sthe sia , which is a ssocia te d with a T10 le ve l of
blocka de (Barash : Clinical Anesth esia, ed 7, p 916).
505. (D) The Gla sgow Coma Sca le ha s thre e ca te gorie s: e ye
ope ning, for which a ma ximum of 4 points ca n be re ce ive d; be st
ve rba l re sponse , for a ma ximum of 5 points; a nd be st motor
re sponse , for a ma ximum of 6 points. The highe r the score , the
be tte r the re sponse ; the minima l score for e a ch ca te gory is 1. Mild
he a d injury score s a re 13 to 15, mode ra te a re 9 to 12, a nd se ve re
a re 3 to 8. This se ve re he a d-injure d pa tie nt is tota lly unre sponsive
a nd would re ce ive a score of 3 (Barash : Clinical Anesth esia, ed 7, p
1018).
506. (A) Insulin me ta bolism involve s both the live r a nd kidne ys.
Re na l dysfunction, howe ve r, ha s a gre a te r impa ct on insulin
me ta bolism tha n doe s he pa tic dysfunction. In fa ct, une xpe cte d
prolonge d e ffe cts of insulin some time s a re se e n in pa tie nts with
re na l dise a se (Stoelting: Ph arm acology and Ph y siology in Anesth etic
Practice, ed 4, p 478).
507. (B) Most pulse oxime te rs illumina te tissue with two
wa ve le ngths of light: 660-nm re d light a nd 940-nm infra re d light.
Be ca use ca rboxyhe moglobin ha s a n a bsorba nce a t 660 nm, ve ry
simila r to O2 he moglobin, it produce s a fa lse ly e le va te d Sa O2 whe n
pre se nt in the blood. He moglobin F, bilirubin, a nd fluore sce in dye
ha ve no e ffe ct on pulse oxime try. Me thyle ne blue , a s we ll a s indigo
ca rmine a nd indocya nine gre e n, lowe rs the Sa O2 a s me a sure d by
pulse oxime try. Me the moglobin a bsorbs re d a nd infra re d light
e qua lly we ll a nd give s sa tura tion re a dings of 85% (Barash : Clinical
Anesth esia, ed 7, pp 702–703; Miller: Basics of Anesth esia, ed 6, p 327).
508. (D) On Ma rch 4, 1984, Libby Zion, a n 18-ye a r-old colle ge
fre shma n, wa s a dmitte d with a high fe ve r, de hydra tion, a nd chills
to a Ne w York Hospita l a nd die d within a da y. The ca use of he r
de a th wa s wide ly be lie ve d to be due to a drug inte ra ction be twe e n
phe ne lzine , which she ha d ta ke n for de pre ssion, a nd me pe ridine ,
which wa s use d to ca lm he r down. This le d to a se rotonin
syndrome a nd more a gita tion. During the night he r te mpe ra ture
rose to 107° F (42° C) a nd she suffe re d a ca rdia c a rre st a nd could
not be re suscita te d. Coca ine ha d be e n de te cte d in he r body a nd
ma y ha ve contribute d to he r de a th a s we ll. This ca se wa s use d to
e xe mplify the fa ct tha t the inte rn a nd re side nts ta king ca re of he r
we re ove rworke d, a nd this e ve ntua lly le d to Ne w York Sta te
De pa rtme nt of He a lth Code , Se ction 405, known a s the Libby Zion
La w, which limits the a mount of work for re side nts to 80 hours pe r
we e k. In 2003, the Accre dita tion Council for Gra dua te Me dica l
Educa tion (ACGME) a dopte d re gula tions for me dica l tra ining in the
Unite d Sta te s. Since the n, studie s ha ve looke d a t fa tigue a nd
clinica l pe rforma nce . A ma jor pe a k in vulne ra bility occurs be twe e n
2 AM a nd 7 AM , with a sma lle r pe a k in the mida fte rnoon. Single -
occupa nt motor ve hicle a ccide nts occur more fre que ntly in the
morning. Although pa tie nt simula tion of the e ffe cts of sle e p
de priva tion ha ve be e n studie d, psychomotor pe rforma nce a nd
mood ha ve be e n a ffe cte d, but clinica l pe rforma nce wa s not
a ffe cte d. No diffe re nce in morta lity ra te s we re se e n in the 2 ye a rs
be fore compa re d to the 2 ye a rs a fte r the 2003 guide line s we re put
into e ffe ct, a nd no diffe re nce in morta lity wa s note d whe n la rge
te a ching progra ms (thought to be the most a ffe cte d) we re compa re d
to sma lle r progra ms (Lerner: A Life-Ch anging Case for Doctors in
Training, New York Tim es, August 14, 2011; Miller: Miller’s Anesth esia, ed
8, p 3239; New York State Departm ent of Health Cod e, Section 405, known
as th e Libby Zion Law).
509. (A) Ga ba pe ntin, a n a nticonvulsa nt, wa s de ve lope d to be a
ce ntra lly a ctive γ-a minobutyric a cid (GABA) a gonist but doe s not
a ppe a r to inte ra ct with GABA re ce ptors. Its me cha nism for
producing a na lge sia is uncle a r, but it ma y involve inhibition of
volta ge -a ctiva te d ca lcium cha nne ls a s we ll a s pote ntia ting GABA
re le a se . Ca rba ma ze pine slows the re cove ry ra te of volta ge -ga te d
sodium cha nne ls, but it a lso is a n a nticonvulsa nt. Ca rba ma ze pine
is indica te d in the tre a tme nt of trige mina l ne ura lgia (Benzon:
Essentials of Pain Med icine, ed 3, pp 123–129).
510. (B) In e va lua ting this pa tie nt in he a rt fa ilure (e .g., ra le s), one
obse rve s tha t the EF is high (e .g., 80%), a fte rloa d is high (e .g.,
e le va te d systolic blood pre ssure ), a nd the he a rt ra te is high (e .g.,
120 be a ts/min). Although he ha s diffuse ra le s (ofte n a sign of high
pre loa d a nd fluid ove rloa d), this pa tie nt is a ctua lly de hydra te d from
his bowe l pre p, a nd his le ft ve ntricle doe s not fill prope rly. To
compe nsa te for the low filling volume , the he a rt ra te incre a se s.
Pa tie nts with he a rt fa ilure a nd a norma l e je ction fra ction (HFNEF),
pre viously ca lle d dia stolic he a rt fa ilure , ha ve signs of le ft-side d
he a rt fa ilure . To be tte r unde rsta nd this, think of the he a rt a s a
hydra ulic pump tha t you ne e d to not only e mpty e ffe ctive ly (during
systole ) but a lso ne e d to fill e ffe ctive ly (during dia stole ). So in this
ca se , your ma in goa ls a re to slow the he a rt ra te to a llow the le ft
ve ntricle a de qua te time to fill (e .g., with a β-blocke r such a s
e smolol) a nd to be tte r oxyge na te him (e .g., incre a se the F IO2 a nd
a dd PEEP). The diure tic furose mide would e xa ce rba te the
situa tion. Othe r conditions in which the le ft ve ntricle doe s not fill
e ffe ctive ly include le ss complia nt ve ntricula r wa lls (e .g., thick from
long-sta nding hype rte nsion or a ortic va lve ste nosis, fibrotic wa lls),
le ss room to fill (e .g., ca rdia c ta mpona de ), loss of the a tria l kick
(e .g., a tria l fibrilla tion), a nd va lvula r ste nosis (e .g., mitra l ste nosis)
(Miller: Basics of Anesth esia, ed 6, p 172; Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 419–421).
511. (B) Pe riope ra tive visua l loss a ssocia te d with nonocula r surge ry
is ra re a nd ma y re sult from corne a l tra uma , re tina l a rte ry
occlusion, re tina l ve in occlusion, optic ne rve ische mia , or cortica l
dise a se . Although ove ra ll it is a ra re proble m, it ma y de ve lop in up
to 1% of prone spina l surgica l ca se s a nd is most commonly due to
ische mic optic ne uropa thy. The ca use is unknown a nd
multifa ctoria l. Associa te d fa ctors include prolonge d intra ope ra tive
hypote nsion, a ne mia (Hgb <8), la rge intra ope ra tive blood loss,
prolonge d surge ry, a nd fa cia l e de ma . It is more common in ma le s
a nd in pa tie nts with pe riphe ra l va scula r dise a se , dia be te s me llitus,
a nd in toba cco use rs (Miller: Miller’s Anesth esia, ed 8, pp 3011–3012).
512. (D) Postope ra tive shive ring or posta ne sthe tic tre mor ca n occur
during re cove ry from a ll type s of ge ne ra l a ne sthe sia . If profound,
shive ring ca n incre a se me ta bolic ra te a nd O2 consumption (100% to
200%) with a n a ssocia te d incre a se in ca rdia c output a nd minute
ve ntila tion. Although shive ring usua lly occurs in pa tie nts with
de cre a se d body te mpe ra ture , it a lso ma y occur in pa tie nts with
norma l body te mpe ra ture a fte r a ne sthe sia . Posta ne sthe sia
shive ring is be st tre a te d by a combina tion of supple me nta l oxyge n,
re wa rming the pa tie nt, a nd/or a dministe ring IV me pe ridine . Othe r
le ss fre que ntly use d pha rma cologic tre a tme nts include clonidine ,
ma gne sium sulfa te , ca lcium chloride , chlorproma zine , drope ridol,
a nd othe r opioids (e .g., butorpha nol). Applica tion of ra dia nt he a t to
the fa ce , he a d, ne ck, che st, a nd a bdome n ha s be e n shown to
e limina te shive ring within minute s in postope ra tive pa tie nts,
de spite low core body te mpe ra ture s (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 1185, 1264; Miller: Basics of
Anesth esia, ed 6, p 643).
513. (C) The ECG signs of hype rka le mia include na rrowe d a nd
pe a ke d T wa ve s (e a rlie st ma nife sta tion of hype rka le mia ),
de cre a se in P-wa ve a mplitude , prolonge d PR inte rva l, a nd a
wide ne d QRS inte rva l. In e xtre me ca se s, the ECG ca n a ppe a r a s a
sine wa ve a s we ll a s ca rdia c a rrhythmia s (e .g., sinus a rre st,
supra ve ntricula r ta chyca rdia , a tria l fibrilla tion, pre ma ture
ve ntricula r contra ctions, ve ntricula r ta chyca rdia , a nd ve ntricula r
fibrilla tion). The se cha nge s a re pote ntia te d by hypoca lce mia , a nd
intra ve nous ca lcium ca n ra pidly corre ct some of the se ECG
cha nge s. An incre a se in U-wa ve a mplitude sugge sts hypoka le mia ,
not hype rka le mia (Miller: Miller’s Anesth esia, ed 8, pp 1205–1206).
514. (B) If the inspira tory va lve be come s stuck in the ope n position,
it will “ma lfunction” only during e xha la tion be ca use , during
inha la tion, it is suppose d to be ope n. During the e xha la tion pha se
of bre a thing, e xha le d ga se s will e xit through the e xpira tory va lve
into the e xpira tory limb of the circuit a nd be yond (prope r pa th), a s
we ll a s through the inspira tory va lve into the inspira tory limb of the
circuit (e rra nt pa th). Ga se s tra ve ling into the inspira tory limb (old
ga s) will be re turne d to the pa tie nt with ne xt bre a th. The volume of
re ce ntly e xha le d ga s is now dra wn ba ck into the pa tie nt’s lungs
a long with the “ne w” ga s tha t would be inspire d in a fully
functiona l bre a thing circuit. The ne t e ffe ct is tha t oxyge n,
se voflura ne , a nd N2O will a ll be dilute d, but the pa tie nt re bre a the s
CO2; thus, it will be the only ga s with a n incre a se d inspire d
conce ntra tion (norma l inspire d CO2 is ze ro) a s a re sult of the stuck
inspira tory va lve (Miller: Basics of Anesth esia, ed 6, p 208).
515. (D) Enla rge me nt of the tongue a nd e piglottis pre dispose s the
pa tie nt to uppe r a irwa y obstruction a nd ma ke s visua liza tion of the
voca l cords more difficult. The voca l cords a re e nla rge d, ma king
the glottic ope ning na rrowe r. In a ddition, subglottic na rrowing ma y
be pre se nt a s we ll a s tra che a l compre ssion from a n e nla rge d
thyroid (se e n in a bout 25% of a crome ga lic pa tie nts). This ofte n
ne ce ssita te s the use of a na rrowe r e ndotra che a l tube tha n one
might choose ba se d on the fa cia l e nla rge me nt. The pla ce me nt of
na sa l a irwa ys ma y be more difficult due to the e nla rge d na sa l
turbina te s. The use of CPAP is contra indica te d a fte r
tra nssphe noida l hypophyse ctomy (Barash : Clinical Anesth esia, ed 7, p
1351; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 404).
516. (A) The re a re four type s of immune -me dia te d a lle rgic
re a ctions. Ana phyla xis is a type I IgE-me dia te d re a ction tha t
involve s ma st ce lls a nd ba sophils. Ana phyla ctoid re a ctions a ppe a r
like a na phyla xis but a re not immune me dia te d. Trypta se is a
ne utra l prote a se norma lly store d in ma st ce lls but is re le a se d into
syste mic circula tion during a na phyla ctic but not a na phyla ctoid
re a ctions. Trypta se le ve ls would ne e d to be me a sure d within 1 to
2 hours of the suspe cte d a lle rgic re a ction. Pla sma hista mine le ve ls
re turn to ba se line within 30 to 60 minute s of a n a na phyla ctic
re a ction. La uda nosine is a norma l me ta bolic product of a tra curium
me ta bolism (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6,
pp 523–524; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed
5, pp 1217–1221).
517. (B) Signs of MH re fle ct the hype rme ta bolic sta te (up to 10 time s
norma l) tha t de ve lops. Clinica l signs include ta chyca rdia ,
ta chypne a , a rte ria l hypoxe mia , hype rca rbia (e .g., Pa CO2 100-
200 mm Hg), me ta bolic, a nd re spira tory a cidosis (e .g., pH 6.80-7.15),
hype rka le mia , hypote nsion, muscle rigidity, trismus a fte r
succinylcholine a dministra tion, a nd incre a se d body te mpe ra ture .
Mixe d ve nous oxyge n te nsion would be ve ry low. The clinica l
pre se nta tions a re quite va ria ble , a nd some re a ctions ma y not
de ve lop until the postope ra tive pe riod (Hines: Stoelting’s Anesth esia
and Co-Ex isting Disease, ed 6, pp 635–640).
518. (D) The SSRI fluoxe tine is one of the most pote nt inhibitors of
the cytochrome P-450 e nzyme s CYP3A4 a nd CYP2D6. CYP2D6
fa cilita te s the conve rsion of code ine to morphine , me a ning the
re sponse from a “norma l” dose would be le ss tha n e xpe cte d
be ca use of de cre a se d conve rsion. Oxycodone a nd hydrocodone
a re me ta bolize d by CYP2D6 to the ir a ctive form a s we ll, a nd a
“norma l” dose of the se would give le ss re sponse tha n e xpe cte d.
Thus, code ine , oxycodone , a nd hydrocodone would be poor
a na lge sic choice s for pa tie nts ta king SSRIs. CYP3A4 is re sponsible
for the me ta bolism of fe nta nyl, sufe nta nil, a nd a lfe nta nil.
Re mife nta nil is me ta bolize d by nonspe cific pla sma e ste ra se s
(Miller: Basics of Anesth esia, ed 6, p 37).
519. (A) Symptoms of a ma inste m or bronchia l intuba tion include
a symme tric che st e xpa nsion, unila te ra l bre a th sounds, e le va tion of
pe a k a irwa y pre ssure s, a nd ABG a bnorma litie s (e .g., hypoxe mia ).
Fre que ntly, bronchia l intuba tion is inte ntiona l (e .g., thora cic surge ry
with double -lume n e ndotra che a l tube s), but, if unde te cte d with a
single -lume n tube , a te le cta sis, hypoxia , a nd pulmona ry e de ma ma y
re sult in time . Pe a k a irwa y pre ssure s ca n a lso incre a se with ma ny
conditions such a s a irwa y obstruction (e .g., kinke d e ndotra che a l
tube , se cre tions, ove rinfla te d cuffs), bronchospa sm, incre a sing VT,
incre a se in che st wa ll muscle tone (rigid che st with na rcotics,
coughing), a nd te nsion pne umothora x. If a te nsion pne umothora x
de ve lops, a ssocia te d hypote nsion usua lly is pre se nt. Pulmona ry
e mbolism would not ca use the pe a k a irwa y pre ssure to rise a s in
this ca se (Lobato: Com plications in Anesth esiology, pp 101–102).
520. (D) Although he modyna mic insta bility ca n occur a t a ny time
during live r tra nspla nta tion, it is during the initia l pa rt of the
re pe rfusion pha se , whe n the va scula r cla mps a re re move d from
the live r gra ft, whe n ca rdiova scula r insta bility is most ma rke d. At
this time the re ca n be profound hypote nsion, re duce d ca rdia c
contra ctility, ca rdia c a rrhythmia s, a nd hype rka le mic ca rdia c a rre st.
Epine phrine , a tropine , ca lcium, a nd sodium bica rbona te should be
a va ila ble , a s we ll a s blood products, during this critica l pa rt of the
surge ry (Miller: Miller’s Anesth esia, ed 8, pp 2281–2282; Miller: Basics of
Anesth esia, ed 6, p 584).
521. (D) Me ta bolic a nd physiologic conditions a s we ll a s ce rta in
me dica tions ca n contribute to a prolonge d dura tion of a ction of
nonde pola rizing ne uromuscula r blocka de . Me ta bolic a nd
physiologic conditions include re spira tory a cidosis, mya sthe nia
syndrome s, he pa tic/re na l fa ilure , hypoca lce mia , hypothe rmia , a nd
hype rma gne se mia . Both inha le d a nd loca l a ne sthe tics a s we ll a s
corticoste roids, ma ny a ntibiotics (e .g., polymyxins,
a minoglycoside s, lincosa mine s [e .g., clinda mycin], me tronida zole
[Fla gyl]), ca lcium cha nne l blocke rs, da ntrole ne , a nd furose mide
ca n prolong nonde pola rizing ne uromuscula r blocka de (Miller: Basics
of Anesth esia, ed 6, pp 633–634).
522. (A) PONV is the se cond most common compla int from pa tie nts
a fte r surge ry (postope ra tive pa in is the numbe r one compla int). Of
the ma ny inde pe nde nt pre dictors of PONV in a dult prospe ctive
studie s, fe ma le ge nde r is the stronge st pre dictor for PONV a nd the
ne e d for postope ra tive a ntie me tic re scue tre a tme nts. It is
inte re sting to note tha t a lthough pa tie nts ofte n e xpe rie nce na use a
whe n smoking the ir first ciga re tte s, smoke rs ha ve a lowe r
incide nce of PONV compa re d to nonsmoke rs. Othe r pre dictors of
PONV include nonsmoke rs, pre vious history of PONV, history of
migra ine he a da che s, use of postope ra tive na rcotics, le ngthy
surgica l proce dure s, use of nitrous oxide , a nd the use of vola tile
a ne sthe tics (Miller: Miller’s Anesth esia, ed 8, pp 2947–2954).
523. (D) Ra re muscle dise a se s ca n ha ve dra ma tic a ne sthe tic
implica tions. MH is a mong the most importa nt ma nife sta tions of a
muscula r disorde r. MH is thought to be ca use d by a lte ra tions in
ca lcium control in muscle sa rcopla smic re ticulum in re sponse to
succinylcholine or pote nt vola tile a ne sthe tics (most like ly me dia te d
by muta tions of the rya nodine re ce ptor). Be ca use MH is a disorde r
in muscle me ta bolism, rigidity during a dministra tion of a vola tile
a ne sthe tic or a fte r succinylcholine use ma y be the pre se nting sign.
Additiona lly, a dministra tion of a ny muscle re la xa nt would not
provide muscle re la xa tion, a nd succinylcholine would be
contra indica te d. The pa tie nt doe s ha ve a re spira tory a nd me ta bolic
a cidosis a nd significa ntly incre a sing minute ve ntila tion with 100%
oxyge n, a nd the use of sodium bica rbona te would be ne e de d;
howe ve r, stopping the trigge ring a ge nt a nd a dministra tion of
da ntrole ne is most importa nt (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 635–640).
524. (D) Atropine a nd scopola mine cross the pla ce nta e a sily,
whe re a s glycopyrrola te is poorly tra nsfe rre d a cross the pla ce nta .
Although ne ostigmine crosse s the pla ce nta poorly, e nough doe s
cross the pla ce nta a nd ca n ca use fe ta l bra dyca rdia in ute ro. Tha t is
why it is be tte r to re ve rse muscle re la xa nts in pre gna nt pa tie nts for
nonde live ry surge ry with ne ostigmine a nd a tropine (Butterworth :
Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 229).
525. (A) W ith live r fa ilure , the live r ca nnot a de qua te ly de toxify
noxious che mica ls. Fifty to se ve nty pe rce nt of pa tie nts with e nd-
sta ge live r dise a se de ve lop HE. Symptoms va ry from mild
confusion, drowsine ss, a nd stupor to coma . The e tiology of HE is
comple x. Be ca use a n e le va tion in blood a mmonia le ve ls (e a sily
me a sure d) is strongly a ssocia te d with HE, tre a tme nt is a ime d a t
lowe ring the a mmonia le ve l. Othe r toxins a lso contribute to HE. To
lowe r the a mmonia le ve l, la ctulose (which de cre a se s the
a bsorption of a mmonia ) a nd ne omycin (which re duce s the
production of a mmonia by re ducing the a mmonia -producing
inte stina l flora ) a re commonly a dministe re d. Prote in re striction is
commonly done to de cre a se a mmonia production, so a mino a cid–
rich TPN is not he lpful. Fluma ze nil (a GABA re ce ptor a nta gonist)
ha s be e n shown to produce short-dura tion re ve rsa l of the
symptoms of HE in some pa tie nts a nd thus sugge sts tha t GABA
re ce ptors a re some how a ctiva te d during HE. GABA re ce ptors a re
re sponsible for inhibitory ne urotra nsmission in the CNS (Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p 280; Miller: Basics
of Anesth esia, ed 6, p 457; Miller: Miller’s Anesth esia, ed 8, p 541).
526. (C) Ke torola c is one of the fe w nonste roida l a nti-infla mma tory
drugs (NSAIDs) a pprove d for pa re nte ra l use . Although NSAIDs ha ve
a na lge sic a nd a nti-infla mma tory e ffe cts without ve ntila tory
de pre ssion, the y a lso inhibit pla te le t a ggre ga tion, ca n produce
ga stric ulce ra tion, a re a ssocia te d with re na l dysfunction, a nd ma y
impa ir bone he a ling. NSAIDs a re contra indica te d in pa tie nts
unde rgoing spina l fusion, whe re bone he a ling is e sse ntia l to a
succe ssful surgica l proce dure (Miller: Miller’s Anesth esia, ed 8, p
2982).
527. (A) Sickle ce ll a ne mia is a n inhe rite d dise a se tha t a ffe cts
a pproxima te ly 0.3% to 1% of the bla ck popula tion in the Unite d
Sta te s. Affe cte d pa tie nts a re homozygous for he moglobin S such tha t
70% to 98% of the he moglobin found in the ir RBCs is of the unsta ble
S type , re sulting in se ve re he molytic a ne mia . Fa ctors tha t fa vor the
forma tion of sickle ce lls include a rte ria l hypoxe mia , a cidosis,
de hydra tion, a nd re ductions in body te mpe ra ture . Inha le d nitric
oxide a nd othe r ne w inve stiga tiona l drugs ma y he lp re duce the
sickling proce ss a nd ma y e ve n unsickle ce lls (Butterworth : Morgan &
Mikh ail’s Clinical Anesth esiology, ed 5, pp 1177–1180; Hines: Stoeling’s
Anesth esia and Co-Ex isting Disease, ed 6, pp 411–412).
528. (A) Although ma ny books sugge st tha t obe sity is the most
common ca use of OSA, more re ce nt da ta sugge st tha t a la rge ne ck
circumfe re nce (>44 cm) re fle cts pha rynge a l fa t de position a nd is
more strongly corre la te d with OSA tha n obe sity (BMI >30). Othe r risk
fa ctors include ma le ge nde r, middle a ge , e ve ning a lcohol
consumption, or sle e p-inducing me dica tions (Hines: Stoelting’s
Anesth esia and Co-Ex isting Disease, ed 6, p 320; Miller: Miller’s
Anesth esia, ed 8, pp 2203–2204; Miller: Basics of Anesth esia, ed 6, pp 435–
436).
529. (D) The ASA close d cla ims ta sk force lists the le a ding ca use s of
ma lpra ctice cla ims a ga inst a ne sthe siologists in the 1990s to be
de a th (22%), followe d by ne rve da ma ge (21%) a nd bra in da ma ge
(10%) (Barash : Clinical Anesth esia, ed 7, pp 100–101).
530. (C) Ca rdia c re synchroniza tion the ra py (CRT) is use d in pa tie nts
with he a rt fa ilure (EF <35%) a nd ve ntricula r conductive de la y
(prolonge d QRS comple x usua lly is 120 to 150 mse c). The
conduction de la y cre a te s a me cha nica l dyssynchrony a nd worse ns
the he a rt fa ilure . CRT re quire s bive ntricula r pa cing with one le a d
in the corona ry sinus to a ctiva te the le ft ve ntricle . CRT ha s nothing
to do with bre a thing. Although CRT ha s nothing to do with a n
impla nta ble ca rdiove rte r-de fibrilla tor (ICD), ma ny pa tie nts ma y
re quire both be ca use typica lly a pa tie nt with poor le ft ve ntricle
function is a lso a t risk for sudde n de a th. Most of the se pa tie nts a lso
ha ve unde rlying CAD (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, p 129; Miller: Miller’s Anesth esia, ed 8, pp 2078–2079).
531. (D) Pa tie nts with syndrome X (a lso ca lle d me ta bolic syndrome
X) ha ve insulin re sista nce tha t le a ds to e le va te d le ve ls of insulin
a nd the me ta bolic cha nge s tha t occur with e le va te d insulin le ve ls,
e xce pt tha t hypoglyce mia doe s not de ve lop. Associa te d with it a re
low le ve ls of high-de nsity lipoprote ins, hype rte nsion, a nd incre a se d
pla sminoge n a ctiva tor inhibitor-1 le ve ls, which a re a ssocia te d with
CAD. Ma ny of the se pa tie nts a re obe se (Miller: Miller’s Anesth esia, ed
8, pp 2201–2203).
532. (C) The pa re nte ra l-to-ora l conve rsion for morphine sulfa te is
1:3; thus, 30 mg morphine pa re nte ra lly would be simila r to 30
mg × 3 = 90 mg of morphine ora lly. The pa re nte ra l-to-ora l
conve rsion for me tha done is 1:2 (Brunton: Good m an & Gilm an’s Th e
Ph arm acological Basis of Th erapeutics, ed 12, p 498).
533. (A) The VRG comprise s only 10% of the body but re ce ive s 75%
of the ca rdia c output. Equilibrium with a lve ola r pa rtia l pre ssure is
ra pid (8 to 10 minute s [4 time consta nts]). Afte r tha t point, upta ke is
a ccounte d for by the MG a nd this e quilibrium would be
a pproa che d in a time fra me on the orde r of 2 to 4 hours. The la st
compa rtme nt to re a ch e quilibrium is the VPG, which include s fa t.
This e quilibrium re quire s ma ny hours, e ve n da ys, to be a chie ve d.

W he n the va porize r is turne d off, the a lve ola r (a rte ria l) pa rtia l
pre ssure fa lls ra pidly. The pa rtia l pre ssure in the VRG would
a lso fa ll, a s would the MG. The fa t continue s to ta ke up vola tile
a ne sthe tic for hours a nd a ctua lly contribute s to re cove ry. The
pa rtia l pre ssure of ga s in the VPG a t the time the va porize r is
turne d off would be lowe r tha n the pa rtia l pre ssure in the VRG
a nd MG a nd thus would initia lly ta ke up some a ne sthe tic from
the highe r pre ssure VRG a nd MG (Miller: Miller’s Anesth esia, ed 8,
pp 639, 654–655).
534. (D) Re tinopa thy of pre ma turity (re trole nta l fibropla sia ) is a
ha za rd a ssocia te d with O2 a dministra tion to ne ona te s up to
44 we e ks (ge sta tiona l a ge + life a ge ). It is e spe cia lly a ha za rd in the
e xtre me ly pre ma ture (birth we ight <1000 g a nd ge sta tiona l a ge
<28 we e ks). Bronchopulmona ry dyspla sia is a chronic lung disorde r
tha t a fflicts infa nts who re quire d me cha nica l ve ntila tion a t birth to
tre a t re spira tory distre ss syndrome . CO2 re te ntion is a ha za rd in
pa tie nts with chronic obstructive lung dise a se . Adsorption
a te le cta sis is a pote ntia l ha za rd of oxyge n a dministra tion in a ny
pa tie nt re ce iving oxyge n conce ntra tions gre a te r tha n 50%. It re sults
from ra pid upta ke of oxyge n into the circula tion gre a te r tha n the
de live ry of oxyge n by ve ntila tion. Norma lly, the pre se nce of nitroge n
se rve s a s a n inte rna l splint, prote cting the a lve oli from colla pse .
Prolonge d high conce ntra tion of oxyge n ca n da ma ge “norma l
lungs” if give n for prolonge d pe riods of time a nd ma y le a d from
mild irrita tion to tra che obronchitis to pulmona ry inte rstitia l e de ma
to pulmona ry fibrosis (Miller: Miller’s Anesth esia, ed 8, pp 457–460,
2670; Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp
1287–1288).
535. (A) All of the ne rve s liste d in this que stion a re de rive d from the
fifth cra nia l ne rve (trige mina l ne rve ) e xce pt the gre a t a uricula r
ne rve . The ophtha lmic ne rve (V1 bra nch of trige mina l ne rve ) give s
rise to the supra trochle a r, infra trochle a r, a nd supra orbita l ne rve s.
The infra orbita l ne rve is a bra nch of V2 (ma xilla ry bra nch of the
trige mina l ne rve ). The me nta l ne rve is a bra nch of V3 (ma ndibula r
ne rve ). The gre a t a uricula r ne rve a rise s from bra nche s of C2 a nd
C3 spina l ne rve s a nd inne rva te s the skin of the oute r e a r, the
ma stoid proce ss, a nd the pa rotid gla nd (Miller: Miller’s Anesth esia, ed
8, pp 1722–1724).
536. (D) Ce re bra l va sospa sm is ofte n a ssocia te d in pa tie nts who
ha ve suffe re d a suba ra chnoid ble e d. Angiogra phic e vide nce of
va sospa sm ca n be note d in up to 70% of pa tie nts; howe ve r, clinica l
va sospa sm with de te cta ble ische mia (e .g., me nta l confusion,
le tha rgy, foca l motor, a nd spe e ch impa irme nts) is de te cte d in a bout
30% of pa tie nts. W he n clinica l va sospa sm de ve lops, it usua lly
occurs be twe e n 4 a nd 12 da ys a fte r the ble e d. Although it ma y
re solve sponta ne ously, it ma y a lso progre ss to coma a nd de a th
within a fe w hours or da ys. Re ble e ding te nds to occur e a rlie r (i.e .,
within 24 hours) (Barash : Clinical Anesth esia, ed 6, pp 1585–1586).
537. (C) Ble omycin is use d prima rily in the tre a tme nt of Hodgkin
lymphoma a nd te sticula r tumors. Ble omycin ca use s oxida tive
da ma ge to nucle otide s, which le a ds to bre a ks in DNA. Although
the more common side e ffe cts of ble omycin use a re
mucocuta ne ous, it is the dose -re la te d pulmona ry toxicity tha t is the
most se rious side e ffe ct. Ea rly signs a nd symptoms of pulmona ry
toxicity include dry cough, fine ra le s, a nd diffuse infiltra te s on
ra diogra ph. Approxima te ly 5% to 10% of pa tie nts will de ve lop
pulmona ry toxicity, a nd a bout 1% will die from this complica tion.
Most be lie ve tha t the risk of pulmona ry toxicity incre a se s with dose
(e spe cia lly tota l dose >250 mg), pa tie nts olde r tha n 40 ye a rs of a ge ,
pa tie nts with a cre a tinine cle a ra nce (CrCl) of <80 mL/min, a nd in
pa tie nts with prior che st ra dia tion or pre e xisting pulmona ry
dise a se . Although a re la tionship a ppe a rs to e xist be twe e n the use
of ble omycin a nd the use of high conce ntra tions of oxyge n, the
de ta ils a re uncle a r. Curre ntly, it ha s be e n sugge ste d to use the
lowe st conce ntra tion of oxyge n consiste nt with pa tie nt sa fe ty, with
a ca re ful e va lua tion of oxyge n sa tura tion with pulse oxime try in a ny
pa tie nt who ha s re ce ive d ble omycin (Brunton: Good m an & Gilm an’s
Th e Ph arm acological Basis of Th erapeutics, ed 12, pp 1716–1718; Miller:
Miller’s Anesth esia, ed 8, p 1943; Stoelting: Ph arm acology and Ph y siology
in Anesth etic Practice, ed 4, pp 555–565).
538. (B) The most common a dve rse ca rdia c e ve nt in the pe dia tric
popula tion is bra dyca rdia . An outcome study from the Me dica l
Colle ge of Virginia e xa mine d the incide nce of bra dyca rdia in ne a rly
8000 childre n younge r tha n 4 ye a rs old. The most common ca use s
of bra dyca rdia we re ca rdia c dise a se or surge ry a nd inha la tion
a ne sthe sia , followe d by hypoxe mia . Of those childre n who ha d
bra dyca rdia , hypote nsion occurre d in 30%, a systole or ve ntricula r
fibrilla tion in 10%, a nd de a th in 8%. Ta chyca rdia , which is common,
is not a n a dve rse e ve nt (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 1232–1236; Barash : Clinical Anesth esia, ed 7, p 1245;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, p 879).
539. (C) Ma sk ve ntila tion, one of the most ba sic a ne sthe sia
te chnique s, ca n be cha lle nging in some pa tie nts. Use of ma sk
ve ntila tion in pa tie nts who a re prone to a irwa y obstruction ca n be
more difficult be ca use of e xtra a irwa y tissue (i.e ., obe se pa tie nts
with a BMI >26), pa tie nts without te e th (i.e ., tongue is close r to the
roof of the mouth, a nd fa ce conformity ma y not fit the ma sk we ll),
a nd pa tie nts who snore (i.e ., a lre a dy ha ve re a son for a irwa y
obstruction). Ma sk ve ntila tion ca n a lso be more difficult in pa tie nts
who ha ve a be a rd (i.e ., ha rde r to ge t a good ma sk se a l), pa tie nts
whose a ge is olde r tha n 55 ye a rs, pa tie nts with fa cia l tumors, a nd
pa tie nts with fa cia l tra uma . Use of a n ora l a irwa y ma y be ne e de d
in ma ny of the se pa tie nts (Miller: Basics of Anesth esia, ed 6, p 227;
Miller: Miller’s Anesth esia, ed 8, p 1651).
540. (A) W he ne ve r pe rfusion to a n e xtre mity is ina de qua te (e .g.,
tra uma or poor pe rfusion), hypoxic e de ma de ve lops, producing
swe lling. W he n this occurs in a compa rtme nt, tissue pre ssure s
rise , de cre a sing ca pilla ry pe rfusion. Symptoms of compa rtme nt
syndrome include e xtre me pa in unre lie ve d by a na lge sics,
pa re sthe sia s, pa ra lysis, a nd pa llor. Exte nsive rha bdomyolysis ma y
de ve lop a s we ll a s pe rma ne nt ne rve a nd muscle injury in the
compa rtme nt. Be ca use the proble m is a t the tissue le ve l, pulse s
a nd ca pilla ry re fill ma y still be pre se nt. Tre a tme nt include s
fa sciotomy to re lie ve the e le va te d pre ssure (Barash : Clinical
Anesth esia, ed 7, p 1514; Miller: Miller’s Anesth esia, ed 8, p 2450).
541. (B) The a mount a nd distribution of ce re brospina l fluid (CSF) is
diffe re nt in ne ona te s compa re d with a dults. The ne ona te ha s a bout
4 mL/kg of CSF compa re d to the a dult’s 2 mL/kg. In a ddition, a lmost
ha lf of the ne ona te ’s CSF is in the spina l suba ra chnoid spa ce ,
compa re d with a bout a qua rte r of the a dult’s CSF in the spina l
suba ra chnoid spa ce . The se fa ctors he lp e xpla in why the dose is
gre a te r in ne ona te s a nd infa nts a nd of shorte r dura tion compa re d
to a dults (Miller: Miller’s Anesth esia, ed 8, pp 2727–2728).
542. (A) Endotra che a l tube size s a re me a sure d a ccording to the ID.
The y a re a va ila ble in 0.5-mm ID incre me nts (Miller: Basics of
Anesth esia, ed 6, p 230).
543. (B) MRI sca nne rs ha ve supe rconducting e le ctrica l curre nts tha t
produce la rge ma gne tic fie lds (up to 6 m) a nd a re a lwa ys “on”. The
pre se nce of a ny fe rroma gne tic obje cts in the room ma y ca use a
missile -type injury whe n the obje cts a re strongly a ttra cte d to the
sca nne r. If a pa tie nt is pinne d into the sca nne r by a ma gne tic obje ct
tha t fle w into the sca nne r, the MRI te chnicia ns ma y ha ve to turn off
the supe rconducting ma gne t. During ma gne tic shutdown (que nch)
the sca nne r will be come e xtre me ly cold (Miller: Basics of Anesth esia,
ed 6, p 621).
544. (C) Ca rbon monoxide is a colorle ss, odorle ss ga s tha t binds to
he moglobin with a n a ffinity more tha n 200 time s stronge r tha n
oxyge n. Inha la tion of CO is a ma jor ca use of morbidity a nd
morta lity in the Unite d Sta te s. A dua l-wa ve (660 nm a nd 940 nm)
pulse oxime te r is inca pa ble of distinguishing CO he moglobin from
oxyhe moglobin, but the distinction is e a sily ma de in the clinica l
la bora tory with a co-oxime te r. Significa nt qua ntitie s of
me the moglobin would re sult in a sa tura tion of 85% of the pulse
oxime te r. The slight right shift from a mild a cide mia would be
insufficie nt to a ccount for 90% sa tura tion in the fa ce of a Pa O2 of
190. Furthe rmore , the pulse oxime te r re a ding would be ne a rly the
sa me a s the co-oxime te r va lue (Miller: Miller’s Anesth esia, ed 8, pp
2679–2680; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
554–555).
545. (A) The pa thwa y for SSEP monitoring of the lowe r e xtre mity
sta rts with a stimulus of the poste rior tibia l ne rve , which ge ne ra te s
a n impulse tha t pa sse s through the dorsa l root ga nglion into the
dorsa l (poste rior) columns a nd the n to the dorsa l column nucle i.
Se cond-orde r ne rve s ca rry the impulse a cross the midline to the
tha la mus, a nd the impulse tra ve ls ove r third-orde r ne rve s to the
se nsory corte x of the bra in. Ele ctrode s in the sca lp re cord the
e le ctrica l a ctivity in the bra in. Se ve re hypote nsion or ische mia in
a ny portion of the pa thwa y a long which the induce d signa l is
conducte d ca n re sult in a re duce d e voke d pote ntia l a mplitude or
incre a se d la te ncy. Vola tile a ne sthe tic a dministra tion in MAC va lue s
gre a te r tha n 0.5 to 0.75 ca n produce a simila r e ffe ct. Ba rbitura te s,
be nzodia ze pine s, propofol, a nd othe r se da tive drugs ca n like wise
inte rfe re with SSEP monitoring. Ante rior spina l a rte ry syndrome
a ffe cts the a nte rior (motor) portion of the spina l cord a nd doe s not
inte rfe re with SSEP monitoring (Miller: Basics of Anesth esia, ed 6, pp
327–328).
546. (D) Dia be tic a utonomic ne uropa thy ca n a ffe ct the a utonomic
ne rvous syste m to such a n e xte nt tha t a tropine a nd propra nolol
would ha ve little e ffe ct (be ca use the re would be nothing to block).
Afte r he a rt tra nspla nta tion, the ne w he a rt (donor he a rt) is
de ne rva te d a nd will not re spond to a utonomic ne rvous syste m
blocking drugs. Bra in de a th by de finition is a ssocia te d with
a bse nce of a utonomic function. A high spina l would be a ssocia te d
with tota l sympa the ctomy, a nd propra nolol would ha ve no e ffe ct on
he a rt ra te , but the va gus ne rve would be una ffe cte d. Atropine
would ha ve no e ffe ct on a pa tie nt with a tria l fibrilla tion a nd
comple te he a rt block (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 26–28, 383; Miller: Basics of Anesth esia, ed 6, pp 281,
585–586).
547. (A)
548. (B)
549. (D)
550. (C)
551. (D)
552. (B)
553. (A)
554. (E)
The re a re thre e ca te gorie s of biologica l we a pons: A, B, a nd C. All
of the dise a se s in this que stion a re in the highly conta gious
Ca te gory A a ge nts.
Sma llpox is ca use d by a virus (Variola m ajor) a nd in 1980 wa s
de cla re d e xtinct by the World He a lth Orga niza tion. The
incuba tion pe riod wa s 7 to 14 da ys, a nd pa tie nts with the dise a se
pre se nte d with ma la ise , he a da che , a nd fe ve r. Two to 4 da ys la te r
a cha ra cte ristic ra sh de ve lops whe re a ll le sions a re a t the sa me
sta ge (pa pule s, ve sicle s, pustule s, a nd sca bs). Expose d pa tie nts
a nd he a lth ca re worke rs who re ce ive d a va ccina tion within
4 da ys of e xposure ha d gre a tly a tte nua te d symptoms.
Unva ccina te d pa tie nts who we re untre a te d ha d a morta lity ra te
of gre a te r tha n 30%. Pa tie nts who pre viously ha d be e n
va ccina te d ha d a lowe r morta lity ra te . Tre a tme nt include s the
drug cidofovir.
Anthra x is ca use d by a n a e robic gra m-positive spore -forming
ba cillus (Bacillus anth racis) a nd ha s thre e prima ry forms:
cuta ne ous, ga strointe stina l, a nd inha la tiona l. We a ponize d
a nthra x is ma inly a n inha la tiona l dise a se . Inha la tiona l a nthra x
symptoms occur within 1 to 7 da ys of e xposure a nd initia lly look
like vira l flu (fe ve r, chills, mya lgia , a nd a nonproductive cough).
La te r on, the pa tie nt’s me dia stina l lymph node s, whe re the
spore s ge rmina te , e nla rge , producing a wide ne d me dia stinum
tha t ca n be se e n on a che st x-ra y film. Tre a tme nt is prima rily
with ciprofloxa cin; prophyla xis to e xpose d pe rsonne l include s
60 da ys of ciprofloxa cin. Morta lity ra te for inha le d a nthra x is
gre a te r tha n 80%.
Pla gue is ca use d by a gra m-ne ga tive coccoba cillus (Yersinia pestis)
a nd ha s two forms: bubonic a nd pne umonic. W ith the more
common bubonic pla gue , the re is pa inful swe lling of the lymph
node s (buboe s), which ca n grow to 5 to 10 cm in dia me te r. The
pa tie nts de ve lop cya nosis, shock, a nd ga ngre ne in pe riphe ra l
tissue s (bla ck de a th). If the lungs be come infe cte d the n
pne umonic pla gue de ve lops, which, if untre a te d, ha s 100%
morta lity. Tre a tme nt is prima rily with stre ptomycin, a lthough
ge nta micin, te tra cycline , a nd chlora mphe nicol ha ve be e n use d.
Botulism is ca use d by the toxin from Clostrid ium botulinum . Be ca use
this dise a se is due to a ne urotoxin, it is not conta gious. The
ne urotoxin a ffe cts choline rgic ne urons a nd pre ve nts the re le a se
of a ce tylcholine . Symptoms typica lly de ve lop within 12 to 36 hours
of e xposure a nd include a cute fla ccid pa ra lysis, de cre a se d
sa liva tion, ile us, a nd urina ry re te ntion. The re a re no se nsory
de ficits. W ith a ppropria te supportive ca re a nd triva le nt e quine
a ntitoxin, the morta lity ra te is le ss tha n 5%. W ithout the use of
a ntitoxin, pa tie nts ma y ta ke 2 to 8 we e ks to re cove r. Morta lity
ra te is 5% to 10%.
The re a re more tha n 18 he morrha gic fe ve r viruse s, including Ebola
virus. The incuba tion pe riod is 2 to 21 da ys, a nd pa tie nts pre se nt
with fe ve r, mya lgia s, he a da che s, thrombocytope nia , a nd
he morrha gic complica tions (pe te chia e , e cchymosis). Untre a te d,
the morta lity ra te for Ebola virus is 90%. Tre a tme nt include s the
drug riba virin (Barash : Clinical Anesth esia, ed 7, pp 1543–1545; Miller:
Miller’s Anesth esia, ed 8, pp 2501–2502; Miller: Basics of Anesth esia, ed
6, pp 691–695).
555. (D)
556. (C)
557. (D)
558. (C)
559. (C)
560. (A)
Pulmona ry function te sts ca n be use d to cla ssify pa tie nts with
chronic pulmona ry dise a se into those with obstructive a irwa y
dise a se s (e .g., a sthma , pulmona ry e mphyse ma , a nd chronic
bronchitis) a nd those with re strictive pulmona ry dise a se s (e .g.,
pulmona ry fibrosis, scoliosis). The force d e xpira tory volume in
1 se cond or FEV1 is the a mount of a ir e xpire d in 1 se cond a nd
commonly is e xpre sse d a s a pe rce nta ge of the force d vita l
ca pa city, or FEV1/FVC. The norma l FEV1/FVC is 75% to 80%. In the
pre se nce of obstructive a irwa y dise a se , FEV1 of le ss tha n 70%
ha s mild obstruction, le ss tha n 60% ha s mode ra te obstruction,
a nd le ss tha n 50% ha s se ve re obstruction. Pa tie nts with
obstructive lung dise a se a lso ha ve a norma l (a sthma ) or incre a se
in (bronchitis, e mphyse ma ) TLC a nd FRC. In the pre se nce of
re strictive pulmona ry dise a se , FEV1 is re duce d, but be ca use FVC
is a lso re duce d, the FEV1/FVC is norma l. Pa tie nts with re strictive
dise a se ha ve a TLC, FRC, a nd tota l pulmona ry complia nce tha t
a re re duce d. In pa tie nts with pulmona ry e mphyse ma , lung
complia nce is incre a se d be ca use the e la stic re coil of the lungs is
de cre a se d (Miller: Miller’s Anesth esia, ed 8, p 1149; Miller: Basics of
Anesth esia, ed 6, pp 431-–434).
561. (A)
562. (B)
563. (C)
564. (D)
565. (B)
566. (E)
In ma ny ca se s of pe riphe ra l ne rve injurie s, the me cha nism of injury
is la rge ly unknown; howe ve r, stre tching or compre ssion of the
ne rve s ca n le a d to ne rve ische mia a nd da ma ge . In the lithotomy
position, hype rfle xion of the hips a nd/or e xte nsion of the kne e s
ca n a ggra va te stre tch of the scia tic ne rve . Also in the lithotomy
position, compre ssion of the common pe rone a l ne rve be twe e n
the he a d of the fibula a nd the me ta l supporting fra me ca n occur.
The common pe rone a l ne rve is the most common ne rve injure d
in the lithotomy position. Prope r pa dding be twe e n the me ta l le g
bra ce s a nd positioning of the le gs will limit the occurre nce of
the se injurie s. The scia tic ne rve provide s motor function for a ll
the ske le ta l muscle s be low the kne e s a nd se nsory inne rva tion
for the la te ra l ha lf of the le g a nd most of the foot. Injury to the
common pe rone a l ne rve , a bra nch of the scia tic ne rve , ca use s a
footdrop from the impa ire d a nkle dorsifle xion a nd the loss of foot
e ve rsion a nd toe e xte nsion. Injury to the fe mora l or obtura tor
ne rve s ca n occur with e xce ssive re tra ction during lowe r
a bdomina l surge ry. The obtura tor ne rve ca n a lso be injure d
during a difficult force ps va gina l de live ry or by e xce ssive fle xion
of the thigh to the groin. Injury to the fe mora l ne rve will ma nife st
a s de cre a se d e xte nsion of the kne e (pa re sis of the qua drice ps
fe moris muscle ) a nd numbne ss ove r the a nte rior a spe ct of the
thigh a nd me dia l/a nte rome dia l side of the le g. The ina bility to
a dduct the le g a nd thigh a s we ll a s numbne ss ove r the me dia l
side of the thigh a re clinica l ma nife sta tions consiste nt with
da ma ge to the obtura tor ne rve . Exce ssive fle xion of the hip on the
a bdome n ca n ca use a ne uropa thy of the la te ra l fe mora l
cuta ne ous ne rve (se nsory only) re sulting in numbne ss of the
la te ra l a spe ct of the thigh (Miller: Miller’s Anesth esia, ed 8, pp 1256–
1258; Miller: Basics of Anesth esia, ed 6, pp 304, 305, 313, 314).
C H AP T E R 7
Pediatric Physiology and
Anesthesia

DIRECT IONS (Que stions 567 through 642): Ea ch of the que stions
or incomple te sta te me nts in this se ction is followe d by
a nswe rs or by comple tions of the sta te me nt, re spe ctive ly.
Se le ct the ONE BEST a nswe r or comple tion for e a ch ite m.

567. A pre viously he a lthy 1-month-old infa nt with a strong fa mily


history of sickle ce ll a ne mia is brought to the e me rge ncy room with
a n inca rce ra te d inguina l he rnia . W hich of the following should be
ca rrie d out be fore surge ry?
A. He moglobin e le ctrophore sis
B. Pe riphe ra l sme a r
C. He ma tology consulta tion
D. None of the a bove
568. In the pre ma ture ne wborn, the glottis is a t which le ve l re la tive
to the ce rvica l spine ?
A. C3
B. C4
C. C5
D. C6
569. A 5-month-old infa nt is sche dule d for a n e le ctive ope ra tive
re duction of a right inguina l he rnia . Spina l a ne sthe sia is pe rforme d.
The first sign of a high spina l block in this pa tie nt would be
A. Hypote nsion
B. Ta chyca rdia
C. Hypoxia
D. Asystole
570. W ha t pe rce nta ge of a te rm ne wborn’s tota l body we ight
consists of wa te r?
A. 45%
B. 60%
C. 75%
D. 90%
571. W ha t is the ma ximum F IO2 tha t ca n be a dministe re d to the
mothe r without incre a sing the risk of re tinopa thy of pre ma turity
(ROP) in the fe tus in ute ro?
A. 0.35
B. 0.50
C. 0.75
D. 1.0
572. W hich of the following pa tie nts is LEAST like ly to de ve lop
ROP?
A. A te rm infa nt, 46 we e ks’ postconce ptua l a ge (PCA), e xpose d to
100% oxyge n for 6 hours
B. A pre ma ture infa nt, 29 we e ks’ PCA, e xpose d to a Pa O2 of
150 mm Hg for 1 hour
C. A pre ma ture infa nt, 28 we e ks’ PCA, ne ve r e xpose d to
supple me nta l oxyge n
D. A cya notic infa nt with te tra logy of Fa llot, 34 we e ks’ PCA,
re ce iving supple me nta l oxyge n
573. A 5-we e k-old ma le infa nt is brought to the e me rge ncy room
with proje ctile vomiting. At the time of a dmission the pa tie nt is
le tha rgic with a re spira tory ra te of 16 bre a ths/min a nd ha s ha d no
urine output in the pre ce ding 3 hours. A dia gnosis of pyloric
ste nosis is ma de , a nd the infa nt is brought e me rge ntly to the
ope ra ting room (OR) for pyloromyotomy. The MOST a ppropria te
a ne sthe tic ma na ge me nt would be
A. Awa ke intuba tion a fte r pla cing a n ora l ga stric tube
B. Inha la tion induction with se voflura ne with cricoid pre ssure
C. Awa ke sa phe nous IV ca the te r or a n intra osse ous ne e dle
pla ce me nt followe d by a ra pid-se que nce induction with
ke ta mine , a tropine , a nd rocuronium
D. Postpone surge ry
574. W hich figure of e sopha ge a l a tre sia (EA) or tra che oe sopha ge a l
fistula (TEF) is the MOST common?

575. W ha t is the ma ximum a llowa ble blood loss (MABL) for a 10-kg,
11-month-old infa nt whose sta rting he ma tocrit (Hct) is 36 a nd the
minima l a cce pta ble Hct is 25?
A. 110 mL
B. 245 mL
C. 350 mL
D. Ca nnot be ca lcula te d without a dditiona l informa tion
576. W ha t volume of pa cke d re d blood ce lls (PRBCs) with a n Hct of
60 is ne e de d to ra ise the Hct from 20 to 28 in a 10-kg, 11-month-old?
A. 55 mL
B. 105 mL
C. 155 mL
D. Ca nnot be ca lcula te d without a dditiona l informa tion
577. Re a sons for se le cting a cuffe d e ndotra che a l tube ove r a n
uncuffe d e ndotra che a l tube include a ll of the following EXCEPT
A. Fe we r intuba tions a nd e ndotra che a l tube s a re ne e de d
B. Le ss cha nce for a irwa y fire s
C. Sponta ne ous bre a thing is e a sie r
D. Aspira tion of ga stric conte nts is le ss like ly
578. An othe rwise he a lthy 4-ye a r-old ma le pa tie nt is unde rgoing
e le ctive tonsille ctomy. Be fore induction of ge ne ra l a ne sthe sia , the
pa tie nt is bre a thing a t a ra te of 20 bre a ths/min. An inha la tion
induction is be gun with se voflura ne , nitrous oxide , a nd oxyge n.
Nine ty se conds la te r, the pa tie nt is note d to bre a the a t a ra te of
40 bre a ths/min. This ra pid re spira tory ra te most like ly re pre se nts
A. Hypoxia
B. Hype rca rbia a nd e a rly de ve lopme nt of ma ligna nt hype rthe rmia
(MH)
C. The e xcite me nt sta ge of a ne sthe sia
D. Aspira tion of ga stric conte nts
579. A he a lthy 3-kg, 1-month-old ne ona te is a ne sthe tize d for a n
inguina l he rnia re pa ir. An inha la tion induction with se voflura ne is
ca rrie d out a nd the pa tie nt is intuba te d. Be fore the surgica l
incision, the systolic blood pre ssure is note d to be 65 mm Hg a nd
the he a rt ra te is 130 be a ts/min. The most a ppropria te inte rve ntion
for this pa tie nt’s blood pre ssure would be
A. Administra tion of e phe drine
B. Administra tion of phe nyle phrine
C. 50-mL fluid bolus
D. None of the a bove
580. A 5-ye a r-old boy is a ne sthe tize d for e le ctive re pa ir of a n
umbilica l he rnia . Ge ne ra l a ne sthe sia is induce d a nd ma inta ine d
with se voflura ne , nitrous oxide , a nd oxyge n via a n a ne sthe sia
ma sk. At the conclusion of the ope ra tion, the pa tie nt is ta ke n to the
re cove ry room a nd subse que ntly discha rge d to the outpa tie nt wa rd.
Be fore discha rge , the pa tie nt’s mothe r note s tha t the urine a ppe a rs
da rk brown (cola -colore d). The most a ppropria te a ction a t this time
would be
A. Discha rge the pa tie nt with instructions to re turn if urine color
doe s not norma lize
B. Discha rge the pa tie nt in 3 hours if no othe r signs or symptoms
a re ma nife ste d
C. Obta in se rum cre a tinine a nd blood ure a nitroge n (BUN) le ve ls
a nd discha rge the pa tie nt if the y a re norma l
D. Eva lua te the pa tie nt for MH
581. At wha t ma ximum inspira tory pre ssure should a n e ndotra che a l
tube le a k in a child?
A. 5 to 15 cm H2O
B. 15 to 25 cm H2O
C. 25 to 35 cm H2O
D. None of the a bove
582. A pre ma ture ne wborn de live re d a t 32 we e ks of ge sta tion is
brought to the OR for re pa ir of a le ft-side d conge nita l dia phra gma tic
he rnia (CDH). Afte r a n a wa ke tra che a l intuba tion, ge ne ra l
a ne sthe sia is ma inta ine d with se voflura ne , O2, a nd fe nta nyl.
Shortly the re a fte r, the a ne sthe siologist note s significa nt difficulty
with a de qua te ve ntila tion. The Sa O2 subse que ntly fa lls to 65%, a nd
the he a rt ra te de cre a se s to 50 be a ts/min. W ha t would be the most
a ppropria te ste p to ta ke a t this time ?
A. Pull the e ndotra che a l tube from the right ma inste m bronchus
B. Ve ntila te with positive e nd-e xpira tory pre ssure (PEEP) a nd
a dministe r furose mide
C. Pla ce a che st tube on the right side a fte r confirming a te nsion
pne umothora x
D. Pull out the e ndotra che a l tube , ma sk ve ntila te , a nd re -
intuba te the pa tie nt
583. An 8-ye a r-old boy found a t the site of a motor ve hicle a ccide nt
(MVA) ha s a rrive d in the OR for e xplora tory la pa rotomy. He ha s not
re ce ive d a ny se da tion or pa in me dica tion be ca use he a ppe a re d
“confuse d a nd did not se e m bothe re d.” He is ta chyca rdic, with
thre a dy dista l pulse s a nd cold e xtre mitie s. In spite of a 500-mL fluid
bolus, the pa tie nt ha s produce d minima l urine . W ha t is the
a pproxima te pe rce nta ge of blood volume loss in this pa tie nt?
A. <20%
B. 25%
C. 40%
D. Ca nnot de te rmine
584. In a 6-ye a r-old child, the le ngth of a n ora l e ndotra che a l tube
(from the a lve ola r ridge to the midtra che a ) most ofte n is
A. 10 cm
B. 13 cm
C. 15 cm
D. 18 cm
585. W hich of the following is the most suita ble re pla ce me nt fluid
for a 3-ye a r-old, 14-kg child unde rgoing re pa ir of clubfe e t?
A. D5W
B. D5 ½NS
C. Norma l sa line
D. La cta te d Ringe r solution
586. An othe rwise he a lthy 14-da y-old ne ona te is tra nsporte d to the
OR we ll-hydra te d for surge ry for a bowe l obstruction. A ra pid-
se que nce induction is pla nne d. Compa re d with the a dult dose , the
dose of succinylcholine a dministe re d to this pa tie nt should be
A. Diminishe d be ca use of the imma ture ne rvous syste m
B. The sa me a s the a dult dose
C. De cre a se d be ca use of de cre a se d a ce tylcholine re ce ptors
D. Incre a se d be ca use of a gre a te r volume of distribution
587. The most common ca use of ne ona ta l bra dyca rdia (he a rt ra te
<100 be a ts/min) in the de live ry room is
A. Conge nita l he a rt dise a se
B. Ma te rna l drug intoxica tion (na rcotics, a lcohol, ma gne sium,
ba rbitura te s, digitoxin)
C. Postpa rtum cold stre ss
D. Hypoxe mia
588. A 10-we e k-old infa nt born a t 31 we e ks’ ge sta tion is
a ne sthe tize d for re pa ir of a n inguina l he rnia . Ge ne ra l a ne sthe sia is
induce d by ma sk with se voflura ne , a n e ndotra che a l tube is pla ce d,
a nd a ne sthe sia is ma inta ine d with se voflura ne a nd oxyge n. W ha t
is the be st postope ra tive pa in ma na ge me nt for this pa tie nt?
A. Ca uda l block with 0.25% bupiva ca ine , 1 mL/kg, a nd a dmitte d
to a pe dia tric wa rd for ove rnight obse rva tion
B. Ca uda l block with 0.25% bupiva ca ine , 2 mL/kg, a nd a dmitte d to
a pe dia tric wa rd for ove rnight obse rva tion
C. Ora l pa in me dica tion (a ce ta minophe n) a nd discha rge d home
D. Fe nta nyl, 1 mL IV, a nd a dmitte d to a pe dia tric wa rd for
ove rnight obse rva tion
589. A 6-ye a r-old, 20-kg girl de ve lops pulse le ss ve ntricula r
ta chyca rdia a fte r induction of ge ne ra l a ne sthe sia for a
tonsille ctomy. The a ne sthe siologist intuba te s the child, a dministe rs
100% oxyge n, a nd sta rts che st compre ssions. W he n the bipha sic
de fibrilla tor quickly a rrive s in the OR a nd is a tta che d to the child,
the de fibrilla tor should be cha rge d to wha t e ne rgy le ve l for the
initia l shock?
A. 20 joule s (J)
B. 40 joule s (J)
C. 60 joule s (J)
D. 80 joule s (J)
590. The spina l cord of ne wborns e xte nds to the
A. L1 ve rte bra
B. L2-L3 ve rte bra e
C. L4-L5 ve rte bra e
D. S1 ve rte bra
591. The most common initia l symptom of EA a nd TEF is
A. Re spira tory distre ss a t de live ry (e .g., re tra ctions, ta chypne a )
B. Proje ctile vomiting
C. Hypoxia
D. Re gurgita tion during fe e ding
592. A 4-kg, 3-hour-old ne wborn with ma crosomia a nd la rge
fonta ne lle s is sche dule d for surgica l re pa ir of a n ompha loce le .
Physica l e xa mina tion re ve a ls ma croglossia but no othe r a noma lie s.
W hich of the following is like ly to occur in this pa tie nt?
A. Hype rka le mia
B. Me ta bolic a cidosis
C. Hypoxe mia
D. Hypoglyce mia
593. W hich of the following is the LEAST a ppropria te te chnique for
induction of ge ne ra l a ne sthe sia in a ne wborn for surgica l re pa ir of
TEF?
A. Awa ke tra che a l intuba tion
B. Inha la tion induction with sponta ne ous ve ntila tion a nd tra che a l
intuba tion
C. Inha la tion induction using positive -pre ssure ba g a nd ma sk
ve ntila tion a nd tra che a l intuba tion
D. Ra pid-se que nce IV induction a nd tra che a l intuba tion
594. A 3-ye a r-old with cough a nd sore throa t, but no fe ve r, is
sche dule d for tonsille ctomy. Physica l e xa mina tion re ve a ls minima l
inspira tory whe e zing. Che st x-ra y re ve a ls sma ll le ft lowe r lobe
(LLL) infiltra te . The be st course of a ction would be
A. Administe r IV ste roids a nd proce e d
B. De la y for 10 to 14 da ys a nd tre a t with ora l a ntibiotics
C. Postpone surge ry for a t le a st 1 month
D. Proce e d
595. The pre dicte d blood volume in a 4-kg ne ona te is
A. 240 mL
B. 280 mL
C. 340 mL
D. 400 mL
596. The pulmona ry va scula r re sista nce in ne wborns de cre a se s to
tha t of a dults by a ge
A. 1 to 2 da ys
B. 1 to 2 we e ks
C. 1 to 2 months
D. 1 ye a r
597. A 10-month-old infa nt is unde rgoing e le ctive re pa ir of a le ft
te sticula r hydroce le unde r ge ne ra l a ne sthe sia with isoflura ne ,
nitrous oxide , oxyge n, a nd fe nta nyl. All of the following a re
e ffe ctive a nd re a sona ble me a ns of pre ve nting hypothe rmia in this
pa tie nt EXCEPT
A. Pla ce me nt of a n infra re d he a te r ove r the ope ra ting ta ble a nd
pre wa rming the OR
B. Cove ring the OR ta ble with a he a ting bla nke t
C. Wra pping the e xtre mitie s with she e t wa dding a nd cove ring the
he a d with a cloth ca p
D. Ve ntila ting the pa tie nt with a Ma ple son D circuit a t low ga s
flows (e .g., 50 mL/kg/min)
598. Ce ntra l postope ra tive de pre ssion of ve ntila tion in a full-te rm
ne ona te is MOST like ly to occur a fte r surge ry for which of the
following?
A. Ga stroschisis
B. Ompha loce le
C. Tra che oe sopha ge a l fistula
D. Pyloric ste nosis
599. A pre ma ture ma le ne ona te born a t 34 we e ks of ge sta tion is
sche dule d to unde rgo e me rge ncy re pa ir of a le ft-side d
dia phra gma tic he rnia . W hich of the following ve sse ls could be
ca nnula te d for pre ducta l a rte ria l blood sa mpling?
A. Fe mora l a rte ry
B. Umbilica l a rte ry
C. Right ra dia l a rte ry
D. Le ft ra dia l a rte ry
600. In which of the following pa tie nts would the minimum a lve ola r
conce ntra tion (MAC) for isoflura ne be the gre a te st?
A. A pre ma ture infa nt 30 we e ks’ PCA
B. Full-te rm ne ona te
C. 3-month-old infa nt
D. 19-ye a r-old ma n with hype rthyroidism
601. A 40-kg, 10-ye a r-old child susta ins a the rma l injury to his le gs,
buttocks, a nd ba ck. The e stima te d a re a involve d is 50%. Using only
crysta lloid fluids, how much fluid should be a dministe re d during
the first 24 hours a fte r the burn?
A. 2.5 L
B. 5.5 L
C. 8.0 L
D. 10.0 L
602. An othe rwise he a lthy 3-month-old bla ck fe ma le infa nt with a
he moglobin of 19 mg/dL a t birth pre se nts for e le ctive re pa ir of a n
inguina l he rnia . He r pre ope ra tive he moglobin is 10 mg/dL. He r
fa the r ha s a history of polycystic kidne y dise a se . The most like ly
e xpla na tion for this pa tie nt’s a ne mia is
A. Sickle ce ll a ne mia
B. Iron de ficie ncy
C. Undia gnose d polycystic kidne y dise a se
D. It is a norma l finding
603. The a ne sthe siologist is ca lle d to the e me rge ncy room by the
pe dia tricia n to he lp ma na ge a 3-ye a r-old boy with a high fe ve r a nd
uppe r a irwa y obstruction. His mothe r sta te d tha t e a rlie r tha t
a fte rnoon, he compla ine d of a sore throa t a nd hoa rse ne ss. The
pa tie nt is sitting e re ct a nd le a ning forwa rd; ha s inspira tory stridor,
ta chypne a , a nd ste rna l re tra ctions; a nd is drooling. W hich of the
following is the MOST a ppropria te ma na ge me nt of a irwa y
obstruction in this pa tie nt?
A. Ae rosolize d ra ce mic e pine phrine
B. Awa ke tra che a l intuba tion in the e me rge ncy room or the OR if
time pe rmits
C. Tra nsfe r to the OR, inha la tion induction, a nd tra che a l
intuba tion
D. Tra nsfe r to the OR, IV induction, pa ra lysis with
succinylcholine , a nd tra che a l intuba tion
604. A 2-ye a r-old child with ce re bra l pa lsy a nd known se ve re
ga stroe sopha ge a l re flux (with fre que nt nightly a spira tion) a nd a
se izure disorde r is sche dule d to unde rgo iliopsoa s re le a se unde r
ge ne ra l a ne sthe sia . W hich of the following would be the pre fe rre d
te chnique for inducing ge ne ra l a ne sthe sia in this pa tie nt?
A. Inha la tion induction with se voflura ne followe d by tra che a l
intuba tion
B. IV induction with propofol followe d by la rynge a l ma sk a irwa y
C. IV induction with e tomida te a nd ve curonium followe d by
tra che a l intuba tion
D. Ra pid-se que nce induction with propofol a nd succinylcholine
followe d by tra che a l intuba tion
605. A 7-we e k-old ma le infa nt is a dmitte d to the pe dia tric inte nsive
ca re unit (ICU) with a bowe l obstruction. His la bora tory va lue s a re
sodium 120 mEq/L, chloride 85 mEq/L, glucose 85 mg/dL, a nd
pota ssium 2.0 mEq/L. Re spira tory ra te is 20 bre a ths/min, a nd
a ccording to the pa tie nt’s mothe r, urine output ha s be e n 0 for the
la st 4 hours. The most a ppropria te fluid for re suscita tion of this
pa tie nt would be
A. D2.5W with 0.45 sodium chloride a nd 20 mEq/L pota ssium
chloride
B. 0.45% sodium chloride
C. 0.9% sodium chloride with 30 mEq/L pota ssium chloride
D. 0.9% sodium chloride
606. A 12-hour-old, 1800-g ne ona te , 30 we e ks’ postge sta tiona l a ge , is
note d in the ICU to be gin ma king twitching move me nts. Blood
pre ssure is 45 mm Hg systolic, blood glucose is 50 mg/dL, a nd urine
output is 5 mL/hr. The O2 sa tura tion on pulse oxime te r is 88%. The
MOST a ppropria te course of a ction to ta ke a t this point would be
A. Administe r ca lcium glucona te (2 mL of 10% solution)
B. Glucose 10 mg IV ove r 5 minute s (2 mL of D5W )
C. Hype rve ntila te with 100% O2
D. Administe r a 20-mL bolus of 5% a lbumin
607. A Eute ctic Mixture of Loca l Ane sthe tics (EMLA) cre a m is a
mixture of which loca l a ne sthe tics?
A. Lidoca ine 2.5% a nd priloca ine 2.5%
B. Lidoca ine 2.5% a nd be nzoca ine 2.5%
C. Priloca ine 2% a nd be nzoca ine 2%
D. Lidoca ine 4%
608. Adva nta ge s of ca the te riza tion of the umbilica l a rte ry ve rsus the
umbilica l ve in in a ne wborn include a ll of the following EXCEPT
A. It a llows a sse ssme nt of oxyge na tion
B. He pa tic da ma ge from hype rtonic infusion is a voide d
C. It pe rmits a sse ssme nt of syste mic blood pre ssure
D. It is e a sie r to ca nnula te
609. The T RUE sta te me nt conce rning the rmore gula tion in ne ona te s
is which of the following?
A. A significa nt proportion of the ir he a t loss ca n be a ccounte d for
by the ir sma ll surfa ce a re a –to-we ight ra tio
B. The y compe nsa te for hypothe rmia by shive ring
C. The principa l me thod of he a t production is me ta bolism of
brown fa t
D. He a t loss through conduction ca n be re duce d by
humidifica tion of inspire d ga se s
610. Norma l va lue s for a he a lthy 6-month-old, 7-kg infa nt include
A. He moglobin 17 g/dL
B. He a rt ra te 90 be a ts/min
C. Re spira tory ra te 30 bre a ths/min
D. Systolic blood pre ssure of 60
611. A 5-ye a r-old child unde rgoing stra bismus surge ry unde r ge ne ra l
a ne sthe sia sudde nly de ve lops sinus bra dyca rdia a nd inte rmitte nt
ve ntricula r e sca pe be a ts but is he modyna mica lly sta ble . W hich
the ra py is a ppropria te for tre a ting this a rrhythmia ?
A. Te ll the surge on to stop pulling on the e ye muscle
B. Te ll the surge on to do a re trobulba r block
C. De cre a se the de pth of the vola tile a ne sthe tic
D. Administe r a tropine
612. W hich of the following re spira tory indice s is incre a se d in
ne ona te s compa re d with a dults?
A. Tida l volume (VT) (mL/kg)
B. Alve ola r ve ntila tion (mL/kg/min)
C. Functiona l re sidua l ca pa city (mL/kg)
D. Pa CO2
613. A 14-ye a r-old girl with ne urofibroma tosis is a ne sthe tize d for
re se ction of a n a coustic ne uroma . Ea ch of the following ma y
pote ntia lly complica te the a ne sthe tic ma na ge me nt of this pa tie nt
EXCEPT
A. Pre se nce of a phe ochromocytoma
B. Uppe r a irwa y obstruction from a la rynge a l ne urofibroma
C. Intra cra nia l hype rte nsion
D. Incre a se d risk for MH
614. W ith which of the following conge nita l a noma lie s is pe rsiste nt
right-to-le ft intra ca rdia c shunting of blood MOST like ly?
A. TEF
B. Ga stroschisis
C. Ompha loce le
D. CDH
615. The most re lia ble me thod of de te rmining mild de hydra tion in a
child is by the obse rva tion of
A. Dryne ss of mucous me mbra ne
B. Skin turgor a nd fonta ne lle s
C. Urine output
D. Blood pre ssure
616. Postope ra tive ble e ding following tonsille ctomy occurs most
commonly
A. By the first 6 hours
B. 6 to 24 hours a fte r surge ry
C. On the third postope ra tive da y
D. On the se ve nth postope ra tive da y
617. A 9-ye a r-old unde rgoing sinus surge ry is tre a te d with a n
unme a sure d a mount of 0.5% phe nyle phrine by the surge on, a nd the
pa tie nt de ve lops a blood pre ssure of 250/150. The most a ppropria te
tre a tme nt for this would be
A. Administe r ve ra pa mil
B. Administe r e smolol
C. Administe r la be ta lol
D. Administe r phe ntola mine
618. A 6-kg, 3-month-old ma le infa nt unde rgoe s a le ft inguina l
he rniorrha phy with a spina l a ne sthe tic. Typica lly, how long would
0.5 mL of a 0.5% bupiva ca ine solution la st?
A. Le ss tha n 30 minute s
B. 30 to 60 minute s
C. 60 to 90 minute s
D. 90 minute s to 2 hours
619. In a ddition to inspira tory stridor, which sign or symptom is
consiste nt with e piglottitis?
A. Ra pid onse t in le ss tha n 24 hours
B. Mild te mpe ra ture e le va tion (<39° C)
C. Age younge r tha n 2 ye a rs
D. Rhinorrhe a
620. W hich of the following sta te me nts re ga rding re suscita tion of
the infa nt by he a lth ca re provide rs is NOT corre ct?
A. Mouth-to-mouth or mouth-to nose ve ntila tion a t a ra te of 12 to
20 bre a ths/min is pe rforme d whe n bre a thing is ina de qua te but
a n a de qua te pulse is pre se nt
B. Sta rt che st compre ssions whe n the pulse is le ss tha n 60
be a ts/min a nd the re a re signs of poor tissue pe rfusion
C. Che st compre ssion de pth is 1/5 the a nte roposte rior dia me te r
of the che st (a bout 1 cm)
D. Compre ssion-to-ve ntila tion ra tio is 30:2 for one -pe rson a nd
15:2 for two-pe rson ca rdiopulmona ry re suscita tion (CPR)
621. All of the following a re true sta te me nts conce rning physiology
of ne wborns compa re d with tha t of a dults EXCEPT
A. Ne wborns ha ve a gre a te r pe rce nta ge of tota l body wa te r
compa re d with a dults
B. Ne wborns ha ve a highe r glome rula r filtra tion ra te (GFR) tha n
a dults
C. Ne wborns’ he a rts a re re la tive ly noncomplia nt compa re d with
a dults
D. Ne wborns’ dia phra gms ha ve a lowe r proportion of type I
muscle fibe rs (i.e ., fa tigue re sista nt, highly oxida tive fibe rs)
622. W hich of the following sta te me nts conce rning the a na tomy of
the infa nt a nd the a dult a irwa y is NOT true ?
A. An infa nt’s tongue is re la tive ly la rge in re la tion to the
oropha rynx compa re d with a n a dult’s
B. The la rynx is in a more ce pha lic position in infa nts tha n in
a dults
C. The voca l cords a re in a more horizonta l position within the
la rynx in infa nts tha n in a dults
D. The na rrowe st pa rt of the infa nt a nd a dult la rynx is a t the
le ve l of the cricoid ca rtila ge
623. W hich of the following ope ra tions would be a ssocia te d with
the LEAST incide nce of postope ra tive na use a a nd vomiting (PONV)
in a 5-ye a r-old boy?
A. Tonsille ctomy
B. Stra bismus surge ry
C. Myringotomy tube pla ce me nt
D. Orchiope xy
624. Anoma lie s a nd fe a ture s a ssocia te d with Down syndrome
include
A. Sma lle r tra che a s
B. Atla nto-occipita l insta bility
C. Thyroid hypofunction
D. All of the a bove
625. Conge nita l syndrome s fre que ntly a ssocia te d with ca rdia c
a bnorma litie s include a ll of the following EXCEPT
A. TEF
B. Me ningomye loce le
C. Ompha loce le
D. Ga stroschisis
626. Appropria te ma na ge me nt of a ne ona te born with CDH should
include
A. Inse rtion of a n oroga stric tube
B. Expa nsion of the hypopla stic lung with positive -pre ssure
ve ntila tion
C. Hype rve ntila tion to ke e p the Pa CO2 be low 40 a nd pH gre a te r
tha n 7.40
D. Ra pid tra nsport to the OR for surgica l corre ction
627. Fa ctors a ssocia te d with a n incre a se d incide nce of
la ryngospa sm include a ll of the following EXCEPT
A. Age olde r tha n 5 ye a rs
B. Pre se nce of a n a irwa y a noma ly
C. Pre se nce of a n a ctive uppe r re spira tory infe ction (URI)
D. Use of a la rynge a l ma sk a irwa y
628. W hich of the following sta te me nts re ga rding pe riope ra tive
ca rdia c a rre st in childre n is NOT corre ct?
A. Ca rdia c a rre st is more common in ne ona te s tha n infa nts or
olde r childre n
B. “Equipme nt re la te d” ca use s occur in more tha n 25% of ca rdia c
a rre sts
C. Re suscita tion is more ofte n succe ssful if the ca use is
a ne sthe sia -re la te d ra the r tha n nona ne sthe sia re la te d
D. Eme rge ncy surge ry is a ssocia te d with gre a te r tha n five time s
the cha nce of a ca rdia c a rre st
629. W hich of the following re pre se nts the gre a te st risk for
postope ra tive a pne a in a n infa nt?
A. PCA of 60 we e ks
B. He moglobin 10 g/dL
C. Re cove ry in the posta ne sthe sia ca re unit (PACU) a fte r pyloric
ste nosis re pa ir
D. 20th we ight pe rce ntile on growth cha rt
630. W hich of the following sta te me nts re ga rding the Ma ple son D
bre a thing circuit is FALSE?
A. It ha s a proxima l fre sh ga s inflow a nd a dista l ove rflow va lve
B. W ith a n inspira tory-to-e xpira tory (I:E) bre a thing ra tio of 1:2,
re bre a thing is e limina te d with sponta ne ous ve ntila tion whe n
the fre sh ga s flow is thre e time s the minute ve ntila tion
C. To e limina te re bre a thing, highe r fre sh ga s flows a re ne e de d
with controlle d ve ntila tion tha n with sponta ne ous ve ntila tion
D. The Ma ple son D circuit is the most wide ly use d of the
Ma ple son circuits for pe dia tric a ne sthe sia
631. W hich of the following is LEAST like ly to re duce the incide nce
of postope ra tive a pne a in pre te rm infa nts unde rgoing surge ry for
inguina l he rnia re pa ir?
A. De la ying ope ra tion until 60 we e ks’ postconce ptua l a ge
B. Pre ope ra tive corre ction of a ne mia
C. Ca ffe ine a dministra tion
D. Spina l a ne sthe tic with ke ta mine se da tion
632. Air should not be use d to ide ntify the e pidura l spa ce in
childre n be ca use of the risk of
A. Ve nous a ir e mbolism
B. Infe ction
C. Subcuta ne ous e mphyse ma
D. Epidura l he ma toma
633. Induction of ge ne ra l a ne sthe sia for a n e le ctive ope ra tion
should be de la ye d how ma ny hours a fte r bre a stfe e ding?
A. 2 hours
B. 4 hours
C. 6 hours
D. No fa sting ne e de d be ca use bre a st milk is OK
634. In the infa nt, hypothe rmia would LEAST like ly ma nife st a s
A. Me ta bolic a cidosis
B. Prolonge d dura tion of a ction of nonde pola rizing muscle
re la xa nts
C. Hype rglyce mia
D. Bra dyca rdia
635. Ne crotizing e nte rocolitis (NEC) ha s a ll of the following
cha ra cte ristics EXCEPT
A. Most ha ve thrombocytope nia (<70,000/mm3) a nd a prolonge d
prothrombin time (PT) a nd a ctiva te d pa rtia l thrombopla stin
time (a PTT)
B. Commonly a ssocia te d with de cre a se d ca rdia c output in the
pre se nce of fe ta l a sphyxia or postna ta l re spira tory
complica tions
C. Umbilica l a rte ry ca the te rs a re use ful to a sse ss a cid-ba se
sta tus
D. Occurs in 10% to 20% of ne wborns we ighing le ss tha n 1500 g
636. W hich of the following na rcotics ha s a shorte r ha lf-life in the
ne wborn compa re d with olde r childre n?
A. Alfe nta nil
B. Fe nta nyl
C. Re mife nta nil
D. Sufe nta nil
637. In a ne wborn, a cce ss to the ve na ca va ca n be ga ine d by
pa ssa ge of a ca the te r through the
A. Ductus a rte riosus
B. Ductus ve nosus
C. Umbilica l a rte rie s
D. Fora me n ova le
638. A 5-ye a r-old girl with he molytic-ure mic syndrome (HUS) is
brought to the OR for pla ce me nt of a dia lysis ca the te r. Me dica l
issue s typica l for this dise a se include
A. Thrombocytope nia
B. Incre a se d intra cra nia l pre ssure
C. Pa ncre a titis
D. All of the a bove
639. A 3-ye a r-old child sta tus post re se ction of W ilms tumor a t a ge
2 ye a rs is re ce iving doxorubicin (Adria mycin) a nd
cyclophospha mide for me ta sta tic dise a se . The pa tie nt is sche dule d
for pla ce me nt of a Hickma n ca the te r for continue d che mothe ra py.
Ane sthe tic conce rns re la te d to this pa tie nt’s che mothe ra pe utic
tre a tme nt include e a ch of the following EXCEPT
A. Thrombocytope nia
B. Inhibition of pla sma choline ste ra se
C. Ca rdia c de pre ssion
D. Pulmona ry fibrosis
640. Pre ope ra tive ly, hypote nsion (i.e ., de compe nsa te d shock) is
cha ra cte rize d by a systolic blood pre ssure
A. Le ss tha n 60 mm Hg for the te rm ne ona te (0-28 da ys old)
B. Le ss tha n 70 mm Hg for infa nts 1 to 12 months old
C. Le ss tha n 70 mm Hg + (2 × a ge in ye a rs) for childre n 1 to
10 ye a rs old
D. All of the a bove
641. W ha t pe rce nt of the a dult’s GFR (inde xe d to body surfa ce a re a )
doe s a 2-ye a r-old posse ss?
A. 30%
B. 50%
C. 75%
D. 100%
642. Ea ch of the following re sults in a re duction of the incide nce of
postope ra tive vomiting (POV) in childre n unde rgoing stra bismus
surge ry EXCEPT
A. IV hydra tion of 30 mL/kg/hr
B. De xa me tha sone 0.15 to 1 mg/kg IV
C. Onda nse tron 50 to 200 µg/kg IV
D. Anticholine rgics (a tropine 10-20 µg/kg or glycopyrrola te
10 µg/kg)
Pediatric Physiology and Anesthesia
Answ e rs, Re fe re nce s, a nd Ex pl a na ti ons
567. (D) At birth, the conce ntra tion of he moglobin F (fe ta l
he moglobin) is a bout 80% a nd re a che s its lowe st le ve l by 2 to
4 months of a ge . Sickle ce ll a ne mia (he moglobin SS) is a n inhe rite d
disorde r of the β-cha in of the a dult he moglobin mole cule ca use d by
a single a mino a cid substitution. It ha s a n incide nce of a bout 0.2%
in the Africa n-Ame rica n popula tion, in contra st to the re la tive ly
be nign he te rozygous condition, sickle ce ll tra it (he moglobin AS),
which a ffe cts 8% to 10% of the sa me group. Sickling ca n occur in
homozygous pa tie nts who be come hypoxic, a cidotic, hypothe rmic,
or de hydra te d. The pre domina nt he moglobin in this 1-month-old
infa nt is he moglobin F, which would te mpora rily prote ct the infa nt
from the ma nife sta tions of sickle ce ll a ne mia we re he or she
homozygous for he moglobin S. The pa tie nt should, howe ve r, be
worke d up for sickle ce ll a ne mia a t some point in e a rly life (if
he moglobin e le ctrophore sis wa s not done a s pa rt of routine
ne wborn scre e ning in a t-risk popula tions), but such a workup is not
a pre re quisite for surge ry a t 1 month of a ge (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 284, 1062, 1130; Hines:
Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 411–412; Miller:
Miller’s Anesth esia, ed 8, pp 1211–1212).
568. (A) The glottis of a pre ma ture ne wborn is a t the le ve l of C3, for
the te rm ne wborn the le ve l is C4, a nd in the a dult the glottis is a t
the C5 le ve l. The re la tive ly high glottis ma ke s intuba tion more
difficult in the pre ma ture ne wborn (i.e ., more tissue a nd le ss
dista nce ) (Barash : Clinical Anesth esia, ed 7, p 1185; Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 351; Miller: Miller’s
Anesth esia, ed 8, pp 2757–2761).
569. (C) Spina l a ne sthe sia ca n be a dministe re d sa fe ly to childre n of
a ll a ge s. Hypote nsion se conda ry to a loss of sympa the tic tone ,
common in the a dult, is ra re in the child younge r tha n 5 ye a rs of
a ge e ve n with le ve ls a s high a s T3. Be ca use of this he modyna mic
sta bility, some pe dia tric a ne sthe siologists sta rt a n IV line in the le g
a fte r the spina l a ne sthe tic is a dministe re d to the infa nt. Re spira tory
de pre ssion including a pne a a nd hypoxia with a ssocia te d
bra dyca rdia will like ly be initia l signs a ssocia te d with a tota l spina l
block in the infa nt (Barash : Clinical Anesth esia, ed 7, pp 1196–1197;
Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 463–465).
570. (C) The body compa rtme nt volume s cha nge with a ge . Muscle
conta ins a bout 75% wa te r, whe re a s a dipose tissue conta ins only
10% wa te r. Ove ra ll, tota l body wa te r de cre a se s with a ge ma inly
due to a de cre a se in e xtra ce llula r fluid, whe re a s the muscle a nd
fa t conte nt incre a se s. The fra ction of tota l body we ight tha t consists
of wa te r is 80% in pre ma ture ne wborns, 75% in te rm ne wborns,
a nd 60% in 6-month-old infa nts a nd in a dults. The se a lte ra tions in
body composition ha ve implica tions for the volume of distribution
a nd re distribution of drugs (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, p 123; Miller: Miller’s Anesth esia, ed 8, pp 2763–2764).
571. (D) The fe ta l Pa O2 doe s not incre a se a bove 60 mm Hg whe n
100% O2 is a dministe re d to the mothe r be ca use of the high O2
consumption of the pla ce nta a nd une ve n distribution of the
ma te rna l a nd fe ta l blood flow in the pla ce nta . For the se re a sons,
the F IO2 a dministe re d to the mothe r is not a fa ctor in the e tiology of
ROP in ute ro (Suresh : Sh nid er and Levinson’s Anesth esia for Obstetrics,
ed 5, p 811).
572. (A) Re tinopa thy of pre ma turity (ROP), forma lly ca lle d
re trole nta l fibropla sia , typica lly occurs in ne wborns who a re born
a t le ss tha n 35 we e ks’ ge sta tiona l a ge . It is the se cond le a ding
ca use of childhood blindne ss in the Unite d Sta te s. The risk of ROP
is inve rse ly re la te d to a ge a nd birth we ight, with a significa nt risk
occurring in infa nts we ighing le ss tha n 1500 g. ROP occurs in a bout
70% of infa nts who we igh le ss tha n 1000 g a t birth; fortuna te ly, 80%
to 90% of the se ha ve sponta ne ous re gre ssion of the re tina l cha nge s.
The risk is ne gligible a fte r 44 we e ks’ postconce ptua l a ge . The
me cha nism for ROP is comple x a nd is re la te d to the complica te d
proce ss of re tina l de ve lopme nt a nd ma tura tion. Unde r norma l
circumsta nce s, re tina l va scula ture de ve lops from the optic disk
towa rd the pe riphe ry of the re tina . This proce ss typica lly is
comple te d by 40 to 44 we e ks of ge sta tion. Hype roxia ca use s
constriction of the re tina l a rte riole s, re sulting in swe lling a nd
de ge ne ra tion of the e ndothe lium tha t disrupts norma l re tina l
de ve lopme nt. Va scula riza tion of the re tina re sume s in a n a bnorma l
fa shion whe n normoxic conditions re turn, re sulting in
ne ova scula riza tion a nd sca rring of the re tina . In the worst-ca se
sce na rio, this proce ss ca n le a d to re tina l de ta chme nt a nd
blindne ss. Conse que ntly, hype roxia should be a voide d whe n
a ne sthe tizing pre te rm infa nts. Exposure of pre te rm infa nts to Pa O2
gre a te r tha n 80 mm Hg for prolonge d pe riods of time ma y be
a ssocia te d with incre a se d incide nce a nd se ve rity of re tinopa thy of
pre ma turity. To re duce this risk, it is re comme nde d tha t the oxyge n
sa tura tion be ma inta ine d be twe e n 88% a nd 93% (a bout Pa O2 of 50-
70 mm Hg) during a ne sthe sia . On the othe r ha nd, one must ne ve r
compromise oxyge n de live ry to a ne ona te ’s bra in to prote ct the
e ye s. Although oxyge n toxicity ha s be e n strongly a ssocia te d with
ROP, othe r fa ctors a re a lso importa nt, such a s re spira tory distre ss
syndrome , me cha nica l ve ntila tion, hypoxia , hypoca rbia ,
hype rca rbia , blood tra nsfusions, se psis, conge nita l infe ctions, a nd
vita min E de ficie ncy. In fa ct, ne wborns with cya notic conge nita l
he a rt dise a se who ha ve ne ve r be e n e xpose d to supple me nta l
oxyge n the ra py ha ve a lso de ve lope d ROP (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, p 883; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 591–592; Miller: Basics of Anesth esia, ed 6, p
564).
573. (D) This pa tie nt ha s signs consiste nt with se ve re de hydra tion
a nd ne e ds re suscita tion with fluid a nd e le ctrolyte s be fore surge ry.
Surge ry should be de la ye d until the re is thorough e va lua tion a nd
tre a tme nt of the fluid a nd e le ctrolyte imba la nce s. Pyloric ste nosis
occurs in a pproxima te ly 1 in e ve ry 300 live births, ma king it one of
the most common ga strointe stina l a bnorma litie s se e n in the first
6 months of life . Pyloric ste nosis occurs a s fre que ntly in pre te rm a s
in te rm ne ona te s, a nd the re is a pre dile ction for ma le infa nts.
Pe rsiste nt vomiting usua lly ma nife sts itse lf be twe e n the se cond
a nd sixth we e ks of a ge a nd ca n re sult in de hydra tion,
hypoka le mia , hypochlore mia , a nd me ta bolic a lka losis. Fluid
re suscita tion should be initia te d with isotonic sa line . If a n IV line
ca the te r ca nnot be e sta blishe d, a n intra osse ous ne e dle should be
pla ce d. Afte r the pa tie nt voids, pota ssium the n ca n be sa fe ly a dde d
to the IV fluids. Once the re ha s be e n a de qua te hydra tion a nd
corre ction of the e le ctrolyte a nd a cid-ba se a bnorma litie s, the
pa tie nt ca n more sa fe ly unde rgo a ne sthe sia a nd surge ry. Although
se ve ra l da ys ma y be re quire d to re store norma l fluid a nd
e le ctrolyte ba la nce in some childre n, most re spond within 12 to
48 hours (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
750–751; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp
600–601).
574. (A) EA a nd TEFs re sult from fa ilure of the e sopha gus a nd the
tra che a to comple te ly se pa ra te during de ve lopme nt. Incide nce is
a pproxima te ly 1 in 4000 live births. Although e a ch of the liste d
a nswe rs is possible , Figure A re pre se nts the most common type
(86% of ca se s) ca lle d a Ty pe C TEF (EA with a dista l TEF). In the
de live ry room, one is una ble to pa ss a suction ca the te r into the
stoma ch a nd, if a n x-ra y is ta ke n, the pre se nce of a ir in the
stoma ch sugge sts a fistula be twe e n the tra che a a nd the stoma ch. If
it is not de te cte d in the de live ry room, the ne wborn te nds to ha ve
e xce ssive ora l se cre tions a nd is una ble to fe e d. In a ddition,
be ca use the fe tuse s ca nnot swa llow, the re is a highe r incide nce of
ma te rna l polyhydra mnios a nd pre ma ture de live rie s. Note : About
20% of pa tie nts with EA or TEF ha ve ma jor ca rdiova scula r
a noma lie s (e .g., a tria l se pta l de fe ct [ASD], ve ntricula r se pta l de fe ct
[VSD], te tra logy of Fa llot, a triove ntricula r [AV] ca na l, coa rcta tion of
the a orta ). Figure B (8% of ca se s) is a Ty pe A TEF (EA without a TEF).
Figure C (4% of ca se s) is a Ty pe E TEF (TEF without a n EA), a nd is
a lso ca lle d a n H-type TEF. Figure D (1% of ca se s) is a Ty pe D TEF
(EA with a proxima l a nd a dista l TEF). Type B (1% of ca se s; not
shown) is a Ty pe B TEF (EA with a proxima l TEF). Se e a lso Que stion
591 (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 574–
579; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 581–
582, 596–598; Miller: Basics of Anesth esia, ed 6, pp 561–562).
575. (B) To ca lcula te the MABL, the following formula is commonly
use d:

The e stima te d blood volume (EBV) in mL/kg for a pre ma ture infa nt
is 90 to 100 mL/kg, te rm ne wborns is 80 to 90 mL/kg, 3-month-olds
to 1-ye a r-olds is 75 to 80 mL/kg, 3-ye a r-olds to 6-ye a r-olds is 70 to
75 mL/kg, a nd olde r tha n 6 ye a rs of a ge is 65 to 70 mL/kg.
In this ca se , using 80 mL/kg, the EBV for the 10-kg 11-month-old, we
ha ve a n EBV of 800 mL.

Be fore infusing blood, the circula ting blood volume is usua lly
e xpa nde d with crysta lloids in a ra tio of 3 mL of crysta lloid for
e a ch mL of blood lost (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 384–385, 409; Miller: Miller’s Anesth esia, ed 8, pp
2784–2785).
576. (B) If blood loss e xce e ds the MABL re pla ce me nt, PRBCs a re
usua lly ne e de d. The norma l Hct of PRBCs is 60% to 80%. To
ca lcula te the volume of PRBCs to be tra nsfuse d, the following
formula is use d:
In this ca se , volume to be infuse d = 800 × (28 − 20)/60 = 106 mL
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 384–385;
Miller: Miller’s Anesth esia, ed 8, pp 2784–2785).
577. (C) Give n tha t cuffe d e ndotra che a l tube s a re ofte n chose n to be
a size sma lle r (i.e ., 0.5 mm) tha n uncuffe d e ndotra che a l tube s, the
lume n is na rrowe r a nd, the re fore , sponta ne ous bre a thing is more
difficult. Be ca use a sma lle r e ndotra che a l tube ca n be use d with a
cuff, fe we r intuba tions a re ne e de d to se le ct the corre ct tube size .
Also be ca use of the cuff, le ss ga s le a ks from the tra che a into the
pha rynx, a llowing a dministra tion of lowe r ga s flows with pote ntia l
cost sa vings a s we ll a s le ss e nvironme nta l pollution. The ga se s a re
le ss like ly to le a k into the pha rynx, a nd this should de cre a se the
cha nce of a n a irwa y fire whe n high oxyge n or nitrous oxide
conce ntra tions a re use d with ca ute ry in the ora l ca vity. To furthe r
de cre a se the cha nce of a n a irwa y fire , most a ne sthe siologists
would a void the use of nitrous oxide a nd would de cre a se the F IO2
to a round 0.30 if oxyge n sa tura tions a re a cce pta ble . The cha nce of
a spira tion of ga stric conte nts should a lso be le ss like ly (Davis:
Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 356–357; Miller:
Basics of Anesth esia, ed 6, p 554).
578. (C) Inha la tion a ge nts a re re spira tory de pre ssa nts. In ge ne ra l,
the y incre a se the re spira tory ra te a nd de cre a se the tida l volume
(VT) of re spira tions a nd a re a ssocia te d with a n incre a se in Pa CO2.
W he n inducing a child with a n inha la tion a ge nt, e spe cia lly be low
the minimum a lve ola r conce ntra tion (MAC) le ve l, the re spira tory
pa tte rn ca n va ry a nd include bre a th holding, e xce ssive
hype rve ntila tion, a nd la ryngospa sm. Although the sta ge s of
inha la tion a ne sthe sia we re cla ssica lly de scribe d with e the r, simila r
sta ge s a re se e n with the ne we r inha la tion a ge nts, but be ca use the
signs a re le ss pronounce d the y a re ra re ly de scribe d a nymore . The
cla ssic sta ge s of de pth of e the r a ne sthe sia include the first sta ge of
a ne sthe sia (a na lge sia ). Pa tie nts in the first sta ge ca n re spond to
ve rba l stimula tion, ha ve a n inta ct lid re fle x, ha ve norma l
re spira tory pa tte rns a nd inta ct a irwa y re fle xe s, a nd ha ve some
a na lge sia . The se cond sta ge of a ne sthe sia (de lirium or e xcite me nt
sta ge ) is a ssocia te d with unconsciousne ss, irre gula r a nd
unpre dicta ble re spira tory pa tte rns (including hype rve ntila tion),
nonpurpose ful muscle move me nts, a nd the risk of clinica lly
importa nt re fle x a ctivity (e .g., la ryngospa sm, vomiting, ca rdia c
a rrhythmia s). The third sta ge of a ne sthe sia (surgica l a ne sthe sia ) is
a ssocia te d with a re turn to more re gula r pe riodic re spira tions a nd
is the le ve l a ssocia te d with the a chie ve me nt of MAC. MAC is note d
by the a bse nce of move me nt (in 50% of pa tie nts) in re sponse to a
surgica l incision. As a ne sthe sia is de e pe ne d, sta ge 4 (re spira tory
pa ra lysis) is a ssocia te d with re spira tory a nd ca rdiova scula r a rre st.
In the ca se cite d in this que stion, the se cond sta ge of a ne sthe sia is
de monstra te d. Note : MH trigge re d by the sole use of vola tile
a ne sthe tics produce s a n e le va tion of ca rbon dioxide le ve ls with
ta chypne a a nd ta chyca rdia , but this is ra re during the first
20 minute s of a n a ne sthe tic. Se voflura ne a nd de sflura ne se e m to be
le ss of a trigge r tha n ha lotha ne . Mild hypothe rmia , propofol,
nonde pola rizing ne uromuscula r blocke rs, a nd tra nquilize rs ma y
de la y or pre ve nt MH from de ve loping. Succinylcholine (the only
de pola rizing ne uromuscula r blocke r in use toda y) ofte n ha ste ns the
de ve lopme nt of MH in susce ptible pa tie nts. Aspira tion of ga stric
conte nts would more like ly le a d to la ryngospa sms, whe e zing, a nd
hypoxia (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
230–231; Miller: Miller’s Anesth esia, ed 8, pp 691–692, 1294–1295;
Butterworth : Morgan & Mikh ail’s Clinical Anesth esiology, ed 5, pp 890–
891).
579. (D) The he modyna mic indice s de scribe d in this que stion a re
norma l for he a lthy 1-month-old ne ona te s (Miller: Basics of Anesth esia,
ed 6, pp 548–550).
COMPARISON OF CARDIOVASCULAR VARIABLES
Data from Miller RD: Basics of Anesthesia, ed 6, Philadelphia, Saunders, 2011, pp 548–550.

580. (D) Da rk brown or cola -colore d urine (i.e ., myoglobine mia )


ma y be ca use d by rha bdomyolysis, a possible sign of MH, a nd this
pa tie nt should be e va lua te d. More typica l signs a nd symptoms of
MH include ta chyca rdia , ta chypne a , hype rca rbia , hype rka le mia
with pe a ke d T wa ve s, a cidosis, incre a se d sympa the tic a ctivity,
irre gula r he a rtbe a t, mottle d cya notic skin, profuse swe a ting, a nd a
la te sign of incre a se d te mpe ra ture (> 1.5° C ove r 5 minute s or
te mpe ra ture >38.8° C). Supportive la bora tory te sts for MH include
e le va te d se rum cre a tine phosphokina se (CPK); myoglobin in the
se rum a nd urine ; incre a se d se rum pota ssium, ca lcium, a nd la cta te
le ve ls; a nd a me ta bolic/re spira tory a cidosis on a n a rte ria l blood
ga s. If the pre sume d dia gnosis is MH, the ra py should be initia te d
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 1186–1189;
Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 635–637).
581. (B) In infa nts a nd young childre n, the re should be a sma ll a ir
le a k a round the e ndotra che a l tube a t pe a k infla tion pre ssure s of
a pproxima te ly 15 to 25 cm H2O. The le a k te st ca n be pe rforme d by
slowly incre a sing the a irwa y pre ssure a nd liste ning with a
ste thoscope ove r the la rynx to he a r whe n a le a k de ve lops. An a ir
le a k within this pre ssure ra nge a llows for a de qua te ve ntila tion a nd
re duce s the incide nce of postintuba tion croup. The most common
ca use of postintuba tion croup is a tight-fitting e ndotra che a l tube
without a le a k a t 30 to 40 cm H2O (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 356–357, 389–390).
582. (C) A conge nita l dia phra gma tic he rnia (CDH) is the he rnia tion
of a bdomina l visce ra into the che st ca vity through a de fe ct in the
dia phra gm a nd occurs in a pproxima te ly 1 in e ve ry 3000 live births.
Most CDHs occur through a de fe ct in the le ft side of the dia phra gm
a nd produce the cla ssic tria d of dyspne a , cya nosis, a nd a ppa re nt
de xtroca rdia . Symptoms de pe nd upon the de gre e of he rnia tion a nd
the a mount of re spira tory compromise . Some ne wborns show
significa nt re spira tory compromise in the de live ry room, whe re a s
othe rs de te riora te hours la te r. If ve ntila tion is ne e de d, intuba tion is
pre fe rre d ove r ma sk ve ntila tion (ma sk ve ntila tion ma y push some
ga s into the stoma ch, incre a sing re spira tory compromise ). Usua lly,
imme dia te intuba tion of the tra che a with ge ntle re spira tory support
is ne e de d, but occa siona lly intuba tion is pe rforme d la te r in the OR.
Ora l or na soga stric tube s a re pla ce d e a rly to pre ve nt ga stric
diste ntion a nd worse ning re spira tory compromise . Be ca use CDH is
a ssocia te d with hypopla stic lungs, curre nt ve ntila tory support a ims
a t ma inta ining a pre ducta l oxyge n sa tura tion of 90% to 95%, using
low a irwa y pre ssure s a nd a llowing for mode ra te pe rmissive
hype rca rbia (Pa CO2 of 60-65 mm Hg). If the pa tie nt e xpe rie nce s
sudde n oxyge n de sa tura tion during positive -pre ssure ve ntila tion, a
te nsion pne umothora x should be suspe cte d (usua lly on the
contra la te ra l side to the CDH) a nd if confirme d, a che st tube should
be pla ce d. De spite inte nsive tre a tme nts, a bout 40% to 50% of the se
ne wborns will die in the ne wborn pe riod. At one time , the se
pa tie nts we re rushe d to the OR; now the y a re usua lly sta bilize d
(some time s for 5-15 da ys) a nd more e le ctive ly ta ke n to the OR. Also
se e e xpla na tion for Que stion 626 (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 567–574; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 594–596; Miller: Miller’s Anesth esia, ed 8, pp
2792–2793).
583. (B) Unlike a dults, childre n ma inta in sta ble he modyna mics until
re a ching a 25% to 35% loss of the ir circula ting blood volume . This is
thought to be re la te d to the ir high sympa the tic tone tha t produce s
profound pe riphe ra l va soconstriction in a n e ffort to ma inta in blood
pre ssure . The re a re , howe ve r, clinica l signs tha t he ra ld incipie nt
shock be fore blood pre ssure cha nge s. He is most like ly
a pproxima te ly 25% de ple te d a nd not in the le ss tha n 20% ra nge ,
be ca use he is confuse d a nd le tha rgic a nd not just a nxious with
norma l me nta tion (<20%). His re na l sta tus is oliguric (25% loss)
inste a d of a nuric, which would corre spond to 40% blood volume
de ple tion (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
980–981).
584. (C) The de pth of inse rtion of a n ora l e ndotra che a l tube from
the a lve ola r ridge to the midtra che a l le ve l is a pproxima te ly 7 cm for
a 1-kg ne wborn, 8 cm for a 2-kg ne wborn, 9 cm for a 3-kg ne wborn,
a nd 10 cm for a typica l 3.5-kg te rm ne wborn. The re a re ma ny wa ys
to e stima te the a ppropria te de pth of inse rtion of a n ora l
e ndotra che a l tube (in ce ntime te rs) for infa nts a nd childre n.
One me thod is using a ge (e .g., >3 ye a rs): (Age in ye a rs)/2 + 12 = tube
le ngth inse rte d
In this 6-ye a r-old child: 6/2 + 12 = 15 cm
Anothe r wa y is to multiply the inte rna l dia me te r (ID) size of the
e ndotra che a l tube by 3. For e xa mple , whe n you use a 5.0 ID size
e ndotra che a l tube , inse rt the tube a bout 15 cm. W he n using a
cuffe d e ndotra che a l tube , the cuff should be visua lize d a s just
pa ssing the voca l cords. If a n uncuffe d e ndotra che a l tube is use d,
the tube is inse rte d to the first or se cond line on the tube a t the
le ve l of the voca l cords (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, p 356).
585. (D) In e le ctive ca se s, intra ve nous fluids a re a dministe re d to
re pla ce fluid de ficits from pre ope ra tive fa sting, to ma inta in
ma inte na nce fluid re quire me nts, a nd to re pla ce ongoing fluid
losse s from the surgica l proce dure . In e me rge ncy ca se s, fluid ma y
a lso be ne e de d to re store intra va scula r volume , if hypovole mia
occurs from the e me rge ncy condition.
Ma inte na nce fluid re quire me nts follow the 4:2:1 rule , whe re
4 mL/kg is a dministe re d for the first 10 kg of we ight, 2 mL/kg for
the ne xt 10 kg of we ight, a nd 1 mL/kg for a ny we ight ove r 20 kg.
Thus, for this 14-kg child, the de ficit is ca lcula te d to be
[(4 mL × 10 kg) + (2 mL × 4 kg)] pe r hour × 10 hours = 480 mL. This
is proba bly a slight ove re stima te give n tha t the fa sting pa tie nt
conse rve s fluid. In ge ne ra l, ha lf of the fluid de ficit + the hourly
ma inte na nce fluid is a dministe re d in the first hour of a ne sthe sia ,
one fourth of the de ficit + ma inte na nce fluids for the se cond a nd
third hours, the n ma inte na nce fluids the re a fte r + re pla ce me nt
fluids for ongoing losse s.
Glucose solutions a re commonly a dministe re d to pe dia tric pa tie nts
whe n the de ve lopme nt of hypoglyce mia is gre a te st, na me ly
ne ona te s a nd a ny pa tie nt who is critica lly ill or ha s he pa tic
dysfunction. Typica lly, he a lthy childre n olde r tha n 1 ye a r of a ge
(or >10-kg we ight) do not re quire supple me nta l glucose during
surge ry, be ca use the ir glycoge n store s a re a de qua te for the stre ss
of surge ry.
The two most common isotonic solutions use d a re la cta te d Ringe r
solution a nd Pla sma Lyte A solution. Most would a void the use of
norma l sa line be ca use the re is a risk of de ve loping
hype rchlore mic me ta bolic a cidosis. Norma l sa line conta ins
154 mEq/L of Na +, which ca use s the kidne y to e xcre te
bica rbona te to pre se rve e le ctrica l ne utra lity (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 383; Miller: Basics of
Anesth esia, ed 6, pp 552–553; Miller: Miller’s Anesth esia, ed 8, pp 2783–
2784).
586. (D) Ne ona te s a nd infa nts (<2 ye a rs of a ge ) re quire more
succinylcholine pe r body we ight tha n do olde r childre n a nd a dults
to produce ne uromuscula r blocka de , be ca use the e xtra ce llula r
fluid volume is much gre a te r in ne ona te s a nd infa nts. Be ca use the
volume of distribution of succinylcholine is gre a te r, the
re comme nde d dose of succinylcholine in ne ona te s a nd infa nts to
provide optima l conditions for tra che a l intuba tion is 2 mg/kg
inste a d of the 1 mg/kg use d for a dults (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 247, 537; Miller: Miller’s Anesth esia, ed 8,
p 2771).
587. (D) He a rt ra te s le ss tha n 100 be a ts/min a re poorly tole ra te d in
the ne ona te be ca use of the re duce d ca rdia c output a nd poor tissue
pe rfusion tha t de ve lops. Conge nita l he a rt dise a se , such a s
conge nita l he a rt block or conge nita l he a rt fa ilure , is ra re a nd ca n
be dia gnose d by ne ona ta l e le ctroca rdiogra m a nd e choca rdiogra m.
Ma te rna l me dica tions during la bor a nd de live ry ra re ly ca use
bra dyca rdia ; howe ve r, fe ta l distre ss a s a re sult of hypoxia ma y
ca use it. Fe ve r a s we ll a s ma te rna l a dministra tion of β-mime tics
(e .g., te rbuta line , ritodrine ) te nd to ca use ta chyca rdia . Cold stre ss
of the ne ona te ma y le a d to hypoxe mia , which will promote
pe rsiste nce of the fe ta l circula tion, which is why a ne utra l the rma l
e nvironme nt to minimize he a t loss is importa nt. Howe ve r, the most
common ca use of ne ona ta l bra dyca rdia in the de live ry room is
re spira tory fa ilure re sulting in hypoxia a nd a cidosis. In the OR,
bra dyca rdia re sults from hypoxia , va ga l stimula tion, a nd the
de pre ssa nt e ffe cts of a ne sthe tic a ge nts (e .g., ha lotha ne ), which ca n
le a d to ca rdia c a rre st (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 513–514).
588. (A) Apne a spe lls a re de fine d a s ce ssa tion of bre a thing for a t
le a st 15 se conds a nd a re ofte n a ccompa nie d by bra dyca rdia a nd/or
cya nosis. Infa nts (e spe cia lly forme r pre ma ture ne wborns) younge r
tha n 60 we e ks’ PCA a re a t risk for a pne a a fte r ge ne ra l a ne sthe sia ,
a lthough most ca se s will occur in infa nts le ss tha n 45 we e ks’ PCA.
The se pa tie nts should be a dmitte d to the hospita l a nd ha ve a t le a st
12 a pne a -fre e hours of monitoring be fore discha rge . This child wa s
born a t 31 we e ks’ e stima te d ge sta tiona l a ge a nd is now 10 we e ks
old or is 41 we e ks’ PCA a nd ne e ds to be a dmitte d. Of the
postope ra tive a na lge sia pla ns liste d with ove rnight obse rva tion,
a nswe r A is the most a ppropria te . Answe rs B a nd D include
a na lge sic dose s tha t a re too high. Ane mia (Hct <30) a lso a ppe a rs to
incre a se the cha nce s for postope ra tive a pne ic spe lls (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, p 388; Miller: Miller’s
Anesth esia, ed 8, pp 2793–2794).
589. (B) The tre a tme nt for docume nte d ve ntricula r fibrilla tion or
pulse le ss ve ntricula r ta chyca rdia is e le ctrica l de fibrilla tion a s soon
a s possible . Ca rdiopulmona ry re suscita tion is pe rforme d until the
de fibrilla tor a rrive s a nd de fibrilla tion is a tte mpte d. W ith ma nua l
de fibrilla tors (monopha sic or bipha sic) the initia l dose should be
2 J/kg, incre a sing to 4 J/kg up to a ma ximum of 10 J/kg (or a dult
dose ). In this 20-kg child the initia l dose is 20 × 2 J/kg = 40 J.
Automa te d e xte rna l de fibrilla tors (AEDs) ca n be sa fe ly use d in
childre n 1 to 8 ye a rs of a ge . W he n using a n AED, it is be st to use
one with a pe dia tric a tte nua tor syste m, which de cre a se s the
de live re d e ne rgy to dose s a ppropria te for childre n (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 1229–1230; 2010 Am erican
Heart Association Guid elines for Card iopulm onary Resuscitation and
Em ergency Card iovascular Care, Circulation 122:S706–S719, 2010).
590. (B)

Common te a ching sta te s tha t the spina l cord of the ne wborn or


infa nt e nds a t L3 a nd the dura l sa c e nds a t S3, so lumba r
puncture should be pe rforme d in the se childre n no highe r tha n
the L4-L5 inte rspa ce . Re ce nt da ta using ultra sound sugge st tha t
the spina l cord of ne wborns e nds a t L2. For the a dult, the spina l
cord e nds a t L1 a nd the dura l sa c e nds a t S1 (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 463–464).
591. (D) EA a nd TEF ma y be suspe cte d pre na ta lly whe n the mothe r
ha s polyhydra mnios; othe rwise it is suspe cte d soon a fte r birth
whe n e xce ssive ora l se cre tions, drooling, or coughing a re note d
a nd a n ora l suction ca the te r ca nnot be pa sse d into the stoma ch.
Be ca use the pa ssa ge of a n ora l ga stric tube is not routine in ma ny
ce nte rs, the first ma nife sta tion of EA occurs whe n the ne wborn ha s
trouble bre a thing (e .g., coughing) a nd re gurgita te s with the first
fe e ding. Afte r the dia gnosis is ma de , the se pa tie nts should be
pla ce d in the he a d-up position a nd the blind uppe r pouch of the
e sopha gus should be de compre sse d with a suction tube
imme dia te ly to re duce pulmona ry a spira tion of se cre tions. Othe r
a bnorma litie s a ssocia te d with EA a nd TEF include VACTERL
(Ve rte bra l a bnorma litie s, impe rfora te Anus, Conge nita l he a rt
dise a se , Tra che oEsopha ge a l fistula , Re na l a bnorma litie s, Limb
a bnorma litie s). Se e a lso Que stion 574 (Davis: Sm ith ’s Anesth esia for
Infants and Ch ild ren, ed 8, pp 574–576; Hines: Stoelting’s Anesth esia and
Co-Ex isting Disease, ed 6, pp 596–597; Miller: Miller’s Anesth esia, ed 8, p
2792).
592. (D) Ompha loce le is the e xte rna l he rnia tion of a bdomina l
visce ra through the ba se of the umbilica l cord. It occurs in a bout 1
of 5000 births. Thirty pe rce nt of the se ne wborns will die in the
ne ona ta l pe riod, prima rily from ca rdia c de fe cts or pre ma turity.
Some of the se ne wborns with ompha loce le ha ve a syndrome
ca lle d Be ckwith-W ie de ma nn syndrome . This syndrome is
cha ra cte rize d by ompha loce le , orga nome ga ly, ma crosomia , la rge
fonta ne lle s, ma croglossia , polycythe mia , a nd hypoglyce mia . The se
pa tie nts ma y be ve ry difficult to intuba te be ca use of the ir significa nt
ma croglossia (Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed
6, p 598).
593. (C) Ane sthe sia for pa tie nts with EA a nd TEF ca n be sa fe ly
induce d with e ithe r a n intra ve nous or vola tile a ne sthe tic. Howe ve r,
positive -pre ssure ba g a nd ma sk ve ntila tion should be a voide d
be ca use it will force ga s into the stoma ch, pote ntia lly ma king
ve ntila tion of the lungs more difficult. A fre que ntly use d te chnique
to fa cilita te corre ct pla ce me nt of the e ndotra che a l tube is to
a dva nce the tube into a bronchus. W hile liste ning ove r the
stoma ch, slowly withdra w the tube until bre a th sounds a re he a rd
ove r the stoma ch. Adva nce the tube until the se sounds be come
diminishe d. Bronchoscopy is use d by some a ne sthe siologists to
ma ke sure only one fistula is pre se nt a nd to he lp position the
e ndotra che a l tube (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren,
ed 8, pp 576–577; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease,
ed 6, pp 597–598).
594. (C) This child most like ly ha s a lowe r re spira tory infe ction. The
pla nne d proce dure should be de la ye d for a pe riod of 4 to 6 we e ks.
This child ma y ha ve e a rly ma nife sta tions of pne umonia with the
LLL infiltra te a nd should be e va lua te d by a pe dia tricia n. W ithout a
physica l a sse ssme nt, simply sta rting ora l a ntibiotic the ra py would
be ill a dvise d.
The spe cific time to re sche dule surge ry for childre n with uppe r
re spira tory infe ctions (URIs) is not a bsolute . Ge ne ra lly
a cce pta ble guide line s for postpone me nt of e le ctive surge rie s for
the se pa tie nts sugge st 1 to 2 we e ks a fte r re cove ry from the a cute
illne ss. Ma nife sta tion of URI include (1) mildly sore or scra tchy
throa t; (2) cha nge in fe e ding or le ve l of a ctivity; (3) cough or
sne e zing; (4) rhinorrhe a (ne w or cha nge in consiste ncy); (5) na sa l
conge stion; (6) fe ve r highe r tha n 101° F (38.8° C); a nd (7) infla me d
throa t or hoa rse voice .
The pre se nce of the se signs a nd symptoms incre a se s the
like lihood of postope ra tive a irwa y complica tions a nd ma y
ne ce ssita te a n ove rnight a dmission. Childre n with pre e xisting
re a ctive a irwa y dise a se , re ga rdle ss of e tiology, who de ve lop URI
a re a t highe r risk of postope ra tive complica tions, a nd the
thre shold for postponing surge ry should be e ve n lowe r tha n for
simila r pa tie nts without comorbiditie s (Davis: Sm ith ’s Anesth esia
for Infants and Ch ild ren, ed 8, pp 1112–1114: Miller: Basics of
Anesth esia, ed 5, p 555).
595. (C) The e stima te d blood volume (EBV) of he a lthy full-te rm
ne ona te s is a pproxima te ly 80 to 90 mL/kg. For this 4-kg ne ona te , the
volume is 320 to 360 mL. Pre ma ture ne wborns ha ve a n EBV of 90 to
100 mL/kg, whe re a s the 3- to 12-month-old infa nt ha s a n EBV of 75
to 80 mL/kg (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, p
409).
596. (C) In the fe tus, pulmona ry va scula r re sista nce is e xtre me ly
high. In ute ro, most of the right ve ntricula r output bypa sse s the
lungs a nd flows into the de sce nding a orta through the ductus
a rte riosus. W ith the onse t of ve ntila tion a t birth the pulmona ry
va scula r re sista nce sudde nly de cre a se s, e na bling blood to flow
more e a sily through the lungs. Pulmona ry va scula r re sista nce
continue s to de cre a se a fte r birth, re a ching a dult le ve ls by 1 to
2 months of life . This is whe n pulmona ry ove rcircula tion might
occur a nd re sult in pulmona ry e de ma a nd e ve ntua l fa ilure . The
incre a se in Pa O2 not only a cts a s a pulmona ry a rte ry va sodila tor
(a long with the lowe ring of the Pa CO2) but a lso a cts a s a
va soconstrictor to the ductus a rte riosus (thus furthe r a ssisting the
cha nge from the fe ta l to the a dult circula tion) (Davis: Sm ith ’s
Anesth esia for Infants and Ch ild ren, ed 8, pp 86–87, 519).
597. (D) A compre he nsive unde rsta nding of the rmore gula tion a nd a
me ticulous a tte ntion to de ta il during the a ne sthe tic ca re of infa nts
a re both ne ce ssa ry to minimize intra ope ra tive he a t loss. In
a ne sthe tize d infa nts, he a t loss occurs through the tra nsfe r of he a t
from the pa tie nt to the e nvironme nt in one of four wa ys: ra dia tion
(tra nsfe r be twe e n obje cts not in conta ct), conduction (tra nsfe r
be twe e n obje cts in conta ct), conve ction (tra nsfe r to moving
mole cule s such a s a ir a nd fluid), a nd e va pora tion. Of the se ,
ra dia tion a nd conve ction a ccount for a bout 75% of the infa nt’s he a t
loss. For this re a son, pla ce me nt of a n infra re d he a te r ove r the OR
ta ble a nd pre wa rming the OR a tmosphe re a re the most e ffe ctive
me a ns of pre ve nting hypothe rmia in the se pa tie nts. Cove ring the
OR ta ble with a he a ting bla nke t; ve ntila ting the pa tie nt with wa rm,
humidifie d a ne sthe tic ga se s; wra pping the e xtre mitie s of the
pa tie nt with she e t wa dding; a nd cove ring the pa tie nt’s he a d with a
cloth or pla stic ca p ca n a lso re duce he a t loss a nd pre ve nt
hypothe rmia . Conve ctive force d-a ir wa rme rs ca n he lp pre ve nt a
de cre a se in body te mpe ra ture a nd a lso ha ve be e n e ffe ctive in
re wa rming hypothe rmic pa tie nts. A Ma ple son D bre a thing circuit is
not a circle syste m a nd doe s not pre se rve he a t or moisture . To
pre ve nt re bre a thing of e xpire d ga se s, sponta ne ous bre a thing flow
ra te s ne e d to be two to thre e time s the minute ve ntila tion, a nd for
controlle d ve ntila tion fre sh ga s flows ne e d to be gre a te r tha n
90 mL/kg/min. Low flows such a s 50 mL/kg/min with Ma ple son
circuits a re ina de qua te a nd will re sult in re spira tory a cidosis
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 162–165,
294–296; Miller: Miller’s Anesth esia, ed 8, pp 1627–1628).
598. (D) Although a ll of the se conditions ca n produce ve ntila tory
de pre ssion in the postope ra tive pe riod, only pyloric ste nosis
produce s ce ntra l ne rvous syste m (CNS) de pre ssion of re spira tion.
Pa tie nts with pyloric ste nosis ha ve protra cte d vomiting tha t le a ds to
de hydra tion, hypoka le mia , hypona tre mia , hypochlore mia , a nd
me ta bolic a lka losis. Postope ra tive ve ntila tory de pre ssion
fre que ntly occurs in infa nts with pyloric ste nosis, thought to be
re la te d to ce re brospina l fluid (CSF) a lka losis tha t is worse ne d by
intra ope ra tive hype rve ntila tion of the lungs. Thus, the se pa tie nts
should be fully a wa ke with a norma l ra te a nd pa tte rn of re spira tion
be fore e xtuba tion is conside re d. This is one re a son infa nts with
pyloric ste nosis should be sta bilize d a nd hydra te d be fore coming to
the OR. The othe r conditions liste d ca n le a d to me cha nica l, not
ce ntra l, ca use s of re spira tory difficulty in the postope ra tive pe riod
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 750–751;
Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, pp 600–601).
599. (C) Ne wborns with dia phra gma tic he rnia ha ve significa nt
re spira tory difficulty. In a ddition to the ir hypopla stic lungs,
pe rsiste nt pulmona ry hype rte nsion is pre se nt, producing right-to-le ft
shunting through the pa te nt ductus a rte riosus. To more
a ppropria te ly a dministe r the a ne sthe tic, a pre ducta l (ductus
a rte riosus) a rte ry should be ca nnula te d to monitor a rte ria l blood
ga se s a nd blood pre ssure . The right ra dia l or te mpora l a rte rie s
a rise from ve sse ls tha t origina te from the a orta proxima l to the
ductus a rte riosus. The oxyge n sa tura tion monitors should be
pla ce d on the right a rm a s we ll (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 595–596).
600. (C) The MAC for isoflura ne is gre a te st a t a ge 3 months. The
MAC is lowe r in pre te rm ne ona te s compa re d with te rm ne ona te s.
The low MAC in the ne wborns ma y be re la te d to the imma turity of
the CNS a nd/or re la te d to the e le va te d le ve ls of proge ste rone a nd
β-e ndorphins. The incre a se in MAC in the first fe w we e ks a fte r
birth se e ms to be re la te d to the fa lling proge ste rone le ve ls. Afte r
a ge 3 months, the MAC of the se vola tile a ne sthe tics ste a dily
de cline s with a ging e xce pt for a slight incre a se a t pube rty. For
re a sons tha t a re uncle a r, the MAC for se voflura ne is simila r in
ne ona te s a nd infa nts younge r tha n 1 ye a r (3.2%). The MAC of
se voflura ne the n de cre a se s with a ge (1 to 12 ye a rs, 2.5%; 40-ye a r-
old, 2%) (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp
190, 556; Hines: Stoelting’s Anesth esia and Co-Ex isting Disease, ed 6, p
587).
601. (C) Se ve ra l formula s (none ide a l) ha ve be e n use d a s a guide
for initia l fluid re suscita tion in burn injurie s. Intra va scula r fluid-
volume de ficits in pa tie nts with burn injurie s a re roughly
proportiona l to the e xte nt a nd de pth of the burn. The Pa rkla nd
formula , more re ce ntly re na me d the Conse nsus formula , is
pe rha ps the most commonly use d formula . This formula e stima te s
fluid ne e ds to be 4 mL/kg of crysta lloid for e a ch pe rce nt of body
surfa ce a re a burne d. Thus, in this ca se : 4 × 40 (kg) × 50
(%) = 8000 mL. Approxima te ly two thirds of this fluid should be
re pla ce d with isotonic crysta lloid solutions during the first 8 hours
a fte r the injury, the re st ove r the ne xt 16 hours. This e stima te is
modifie d clinica lly by the pa tie nt’s clinica l re sponse a s note d by the
vita l signs a nd urine output (ta rge t urine output of 0.5 mL/kg/hr)
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, pp 1017–1018;
Miller: Basics of Anesth esia, ed 6, p 685).
602. (D) The most like ly e xpla na tion for the “fa lling” he moglobin
le ve l in this pa tie nt is tha t this is a norma l physiologic finding. At
birth, a full-te rm infa nt ha s a he moglobin le ve l of a pproxima te ly 15
to 20 g/dL. A ph y siologic anem ia occurs by a ge 2 to 3 months,
re sulting in he moglobin conce ntra tions of a pproxima te ly 10 to
11 g/dL. Afte r 3 months, the re is a progre ssive incre a se in
he moglobin conce ntra tion, which re a che s le ve ls simila r to tha t of
a dults by a ge 6 to 9 months. For pre ma ture infa nts, the a ne mia is
more pronounce d (ofte n to a s low a s 8.0 g/dL), occurs e a rlie r, a nd
pe rsists longe r (Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed
8, pp 398–399).
603. (C) This history is consiste nt with a n a cute life -thre a te ning
ca use of uppe r a irwa y obstruction ca lle d e piglottitis (or more
a ppropria te ly supra glottitis be ca use othe r supra glottic structure s
a re involve d a s we ll). In the pa st, more tha n 75% of ca se s we re
ca use d by Haem oph ilus influenza type b (Hib). W ith wide spre a d
immuniza tion a ga inst H. influenzae, this condition ha s be come much
le ss fre que nt a nd the ca use s now include Haem oph ilus
parainfluenzae, group A stre ptococci, pne umococci, a nd
sta phylococci. This condition is a me dica l e me rge ncy tha t usua lly
sta rts out a s a se ve re sore throa t a nd ra pidly progre sse s to the
“four Ds” (dyspha gia , dysphonia , dyspne a , a nd drooling). It ca n
progre ss ra pidly a nd ca use de a th within 6 to 12 hours a fte r the
onse t of symptoms. The child typica lly is se e n sitting up, a ppe a rs
dyspne ic with the mouth ope n, is drooling, a nd ha s a high fe ve r
a nd ta chyca rdia . Inspira tory stridor is a la te finding a nd sugge sts
impe nding comple te uppe r a irwa y obstruction. W he n suspe cte d,
the a ne sthe siologist a nd otola ryngologist should be notifie d a nd the
child imme dia te ly tra nsfe rre d to the OR (with the pa re nt if
a ppropria te ) be fore comple te uppe r a irwa y obstruction e nsue s. In
the OR, a ne sthe sia should be induce d with se voflura ne a nd oxyge n
with the child in a sitting position. Se voflura ne is le ss like ly to
induce la ryngospa sm tha n isoflura ne or de sflura ne . IV a cce ss
should be e sta blishe d a s soon a s the child is de e ply a ne sthe tize d.
Atropine (0.02 mg/kg) should be a dministe re d to block va ga lly
me dia te d bra dyca rdia induce d by dire ct la ryngoscopy. Muscle
re la xa nts a re contra indica te d be ca use the y ca n ca use comple te
obstruction of the uppe r a irwa y in the se pa tie nts. The tra che a
should be intuba te d unde r dire ct la ryngoscopy whe n the de pth of
a ne sthe sia is sufficie nt to blunt la rynge a l re fle xe s. Also se e
e xpla na tion for Que stion 619 (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 811–813; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 614–615).
604. (D) Ce re bra l pa lsy is a CNS symptom comple x. The most
common clinica l ma nife sta tion is ske le ta l muscle spa sticity. It is
usua lly cla ssifie d a ccording to the e xtre mity a ffe cte d (e .g.,
monople gia , he miple gia , diple gia , or qua driple gia ) a nd the
cha ra cte ristics of the ne urologic dysfunction (spa stic, hypotonic,
dystonic, a the totic). Othe r ma nife sta tions include ce re be lla r a ta xia ,
se izure disorde rs, va rying de gre e s of me nta l re ta rda tion, a nd
spe e ch de ficits. Ga stroe sopha ge a l re flux is a lso common. For this
re a son, the pre fe rre d induction of ge ne ra l a ne sthe sia in the se
pa tie nts should include a ra pid-se que nce IV induction with
propofol followe d by imme dia te tra che a l intuba tion. Etomida te ,
ke ta mine , a nd me thohe xita l a re proconvulsa nts in pa tie nts with
unde rlying se izure disorde rs a nd should proba bly be a voide d. Eve n
though the se pa tie nts ha ve ske le ta l muscle spa sticity, the re ha ve
be e n no re ports of succinylcholine -induce d hype rka le mia . The
re sponse to nonde pola rizing muscle re la xa nts is norma l in most
re ports; howe ve r, some ha ve re porte d re sista nce to
nonde pola rizing muscle re la xa nts. For a ra pid-se que nce induction,
succinylcholine is fa ste r tha n ve curonium. Rocuronium could a lso
be use d due to its ra pid onse t (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 863–865; Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, p 605).
605. (D) The symptoms de scribe d in this pa tie nt a re consiste nt with
se ve re de hydra tion. Thus, the va scula r volume should be
e xpa nde d initia lly with a n isotonic sa line solution or a colloid
solution until the pa tie nt voids. W he n the urine output incre a se s,
pota ssium ca n be a dde d to the IV fluids. Although glucose
a dministra tion for long proce dure s ma y pre ve nt hypoglyce mia ,
D5W a lone or with a crysta lloid solution should not be use d to
re pla ce fluid de ficits (Davis: Sm ith ’s Anesth esia for Infants and
Ch ild ren, ed 8, pp 126–129).
606. (A) Pre te rm infa nts ha ve ve ry limite d ca lcium re se rve s a nd a re
ve ry susce ptible to hypoca lce mia . Hypoca lce mia (se rum ionize d
ca lcium le ve l <1.5 mEq/L) ma nife sts itse lf in a numbe r of
nonspe cific wa ys, including irrita bility, twitching, hypote nsion, a nd
se izure . A dose of 10 to 20 mg/kg of e le me nta l ca lcium a dministe re d
ove r 5 to 10 minute s will be a n a ppropria te sta rting dose a nd ma y
ne e d to be re pe a te d e ve ry 6 to 8 hours until the ca lcium le ve ls
sta bilize . Bra dyca rdia a nd occa siona lly a systole ca n be se e n if it is
inje cte d too ra pidly. In this infa nt of 1800 g, the sta rting dose of
1.8 kg × 10 mg/kg = 18 mg of e le me nta l ca lcium ca n be use d.
Ca lcium glucona te 10% solution conta ins a bout 9 mg/mL of
e le me nta l ca lcium so the dose is 2 mL. Some of the signs of
hypoglyce mia a re simila r to those of hypoca lce mia a nd include
se izure , irrita bility, hypote nsion, a nd some time s bra dyca rdia a nd
a pne a . In the pa tie nt de scribe d in this que stion, the glucose ha s
a lre a dy be e n me a sure d a t 50 mg/dL, which is a cce pta ble for a
pre te rm infa nt. An O2 sa tura tion of 88% is a lso a cce pta ble be ca use
the pa tie nt is a t risk for ROP (i.e ., <44 we e ks’ PCA).
Hype rve ntila tion would ca use a lka losis, which would de cre a se the
unbound fra ction of ca lcium a nd ma ke the pa tie nt more susce ptible
to se izure s. Furthe rmore , ca lcium binds to a lbumin, which would
furthe r re duce the fre e ca lcium. Be ca use the urine output is more
tha n a de qua te , it is unlike ly tha t the pa tie nt ne e ds a fluid bolus to
corre ct hypote nsion (Hines: Stoelting’s Anesth esia and Co-Ex isting
Disease, ed 6, pp 593–594).
607. (A) EMLA cre a m conta ins lidoca ine (2.5%) a nd priloca ine (2.5%).
W he n the 5% EMLA cre a m is a pplie d to dry inta ct skin a nd cove re d
with a n occlusive dre ssing for a t le a st 1 hour, topica l a ne sthe sia to
a de pth of 5 mm is obta ine d. Four pe rce nt lidoca ine (ELA-Ma x) ca n
a lso be use d a nd re quire s only 30 minute s to be come e ffe ctive
(Davis: Sm ith ’s Anesth esia for Infants and Ch ild ren, ed 8, p 441).
608. (D) Although the umbilica l ve in is la rge r a nd e a sie r to
ca nnula te tha n the umbilica l a rte ry, the umbilica l ve in will not
a llow for a de qua te a sse ssme nt of a rte ria l blood ga se s or syste mic
blood pre ssure . Additiona lly, a dministra tion of drugs or hype rtonic
solutions into the umbilica l ve in ma y be ha za rdous, be ca use the
ca the te r ca n be come we dge d in a porta l ra dicle , possibly le a ding
to he pa tic ne crosis or porta l ve in thrombosis. To pre ve nt this, the
umbilica l ve in ca the te r tip is a dva nce d only 2 to 3 cm into the
umbilica l ve in (to a point whe re blood ca n first be a spira te d).
Ca re ful pla ce me nt of a n umbilica l a rte ry ca the te r is e qua lly
importa nt. The tip of the umbilica l a rte ry ca the te r should be pla ce d
just a bove the bifurca tion of the a orta a nd be low the le ve l of the
re na l a rte rie s (L2). All intra -a rte ria l ca the te rs a re a ssocia te d with
thrombosis or e mbolism in the se ve sse ls, but fortuna te ly, se rious
injurie s a re ra re . Be ca use the re a re two a rte rie s a nd only one ve in,
difficulty with one a rte ry none the le ss offe rs a nothe r a rte ry to use
(Miller: Miller’s Anesth esia, ed 8, p 2879).
609. (C) Be ca use of the la rge surfa ce a re a –to-we ight ra tio, the thin
la ye r of insula ting subcuta ne ous fa t, a nd the limite d a bility to
compe nsa te for cold stre ss, ne ona te s a nd infa nts a re a t gre a te r risk
for intra ope ra tive hypothe rmia tha n a dults. Infa nts younge r tha n
3 months do not produce he a t by shive ring; the ir principa l me thod
of the rmoge ne sis is me ta bolism of brown fa t. He a t loss ca n occur
by ra dia tion, conduction, conve ction, a nd e va pora tion. He a t loss
through e va pora tion (not conduction) ca n be re duce d by
humidifica tion of inspire d ga se s. He a t loss by conduction (not
conve ction) is re duce d with the use of a wa rming bla nke t (Miller:
Miller’s Anesth esia, ed 8, p 2763).
610. (C) In a 6-month-old infa nt, a norma l he moglobin va lue is
a pproxima te ly 11 to 12 g/dL. The norma l he a rt ra te is a bout 100 to
140 be a ts/min, systolic blood pre ssure is 70 to 90, a nd the
re spira tory ra te is a bout 25 to 35 bre a ths/min (Miller: Basics of
Anesth esia, ed 6, pp 547–550).
611. (A) The oculoca rdia c re fle x (OCR) is commonly de fine d a s a
10% to 20% de cre a se in he a rt ra te tha t is susta ine d for more tha n
5 se conds. It ca n be induce d by tra ction on e xtra ocula r muscle s,
pre ssure on the e ye , orbita l he ma toma , ocula r tra uma , or e ye pa in.
It is commonly se e n with stra bismus ope ra tions a nd ma y produce a
wide va rie ty of ca rdia c a rrhythmia s, including sinus bra dyca rdia ,
noda l bra dyca rdia , e ctopic be a ts, ve ntricula r fibrilla tion, a nd,
ra re ly, a systole (1 in 2200 stra bismus ope ra tions). The initia l
tre a tme nt of this is to stop the stimulus (i.e ., te ll the surge on to stop
wha t he or she is doing). This re fle x quickly re sponds, a nd future
simila r stimula tion typica lly e licits le ss of a re sponse . In ma ny
ca se s no furthe r tre a tme nt is ne ce ssa ry. Incre a sing the de pth of
ge ne ra l a ne sthe sia ma y he lp to block the re fle x, a s ma y
re a sse ssing the a de qua cy of ve ntila tion (be ca use hype rca rbia a nd
hypoxe mia de cre a se the thre shold to e licit the OCR). A re trobulba r
block will pre ve nt the re fle x. Infiltra ting lidoca ine loca lly into the
re cti muscle s ma y be e ffe ctive in pre ve nting a nd tre a ting the OCR.
Atropine (0.01-0.02 mg/kg) or glycopyrrola te ca n be a dministe re d
intra ve nously if the a rrhythmia pe rsists. Some a dvoca te the
prophyla ctic use of a tropine or glycopyrrola te during stra bismus
surge ry, e spe cia lly in childre n (Davis: Sm ith ’s Anesth esia for Infants
and Ch ild ren, ed 8, pp 880–888; Miller: Basics of Anesth esia, ed 6, pp
487–488).
612. (B) The re is no diffe re nce in VT (mL/kg) be twe e n ne ona te s a nd
a dults. Ne ona te s ha ve a high O2 consumption (a bout twice tha t of
a dults). To compe nsa te for the incre a se d oxyge n de ma nd, a lve ola r
ve ntila tion is incre a se d (a lso a bout twice the a dult). The incre a se
in a lve ola r ve ntila tion e xpla ins the slightly lowe r Pa CO2. Of note ,
the pH a lso is slightly lowe r. The re duce d functiona l re sidua l
ca pa city with the incre a se d O2 consumption pla ce s the ne ona te a t
a n incre a se d risk for hypoxia during ge ne ra l a ne sthe sia if the re is
a ny difficulty with ve ntila tion (Hines: Stoelting’s Anesth esia and Co-
Ex isting Disease, ed 6, pp 584–586; Miller: Basics of Anesth esia, ed 6, pp
547–548).
PHYSIOLOGIC VARIABLES
613. (D) Ne urofibroma tosis (von Re cklingha use n dise a se ) is a n
a utosoma l domina nt ge ne tic disorde r cha ra cte rize d by multiple
ne urofibroma s involving the skin, pe riphe ra l ne rvous syste m, a nd
ce ntra l ne rvous syste m. The clinica l fe a ture s of this dise a se a re
dive rse a nd a lwa ys progre ss with time . The a ne sthe tic
ma na ge me nt of pa tie nts with ne ur