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Sign in via Shibboleth. Clinical Sports Medicine Collection. Search Advanced search allows to you precisely focus your query. Search within a content type, and even narrow to one or more resources. You can also find results for a single author or contributor. Home Books Schwartz's Principles of Surgery: Brunicardi F, Andersen D. Charles Brunicardi, et al. Schwartz's Principles of Surgery: Accessed December 18, Jump to a Section Chapter Anesthesia for the Surgical Patient. Please enter User Name. View All Subscription Options. Pop-up div Successfully Displayed This div only appears when the trigger link is hovered over.
At the end of surgery, a train of 4 revealed no twitches. Which one of the following medications could potentiate the neuromuscular blocking effect of rocuronium? Magnesium Magnesium enhances neuromuscular blockade produced by nondepolarizing neuromuscular-blocking drugs and, to a lesser extent, enhances neuromuscular blockade produced by succinylcholine. Patients treated chronically with anticonvulsants phenytoin, carbamazepine are relatively resistant to some pancuronium, vecuronium, rocuronium, cisatracurium, pipecuronium, doxacurium.
Antibiotics devoid of neuromuscular-blocking effects are the penicillins and cephalosporins. Nifedipine and remifentanil have not been shown to have any interactions with neuromuscular blocking agents. A 3-year-old healthy child is undergoing strabismus repair surgery under general anesthesia with a laryngeal mask airway. Ten minutes into the surgery, the surgeon applies traction to the medial rectus muscle; asystole ensues and a code blue was called.
Traction was stopped immediately and there was an abrupt return of spontaneous rhythm. Which of the 2 cranial nerves are most likely responsible for the intraoperative asystole? V and X Traction on the extraocular muscles or pressure on the globe causes bradycardia, atrioventricular block, ventricular ectopy, or asystole. Miller's Anesthesia 7th edition, page A G8P4 parturient with known placenta previa is undergoing her fourth repeat cesarean delivery under combined spinal-epidural anesthesia.
Soon after delivery of the fetus, an occult placenta accreta was diagnosed. Approximately 3 L of blood were lost rapidly from the uterus over 10 minutes and a decision was made to proceed with a hysterectomy. A total of 8 units of packed red blood cells and 8 units of fresh frozen plasma were rapidly transfused. Surgical bleeding was controlled with clamping of the uterine arteries but an ongoing oozing of blood was noted from the incision sites. Laboratory investigation revealed a hematocrit of 0.
Free Anesthesiology Basic & Advanced Practice Questions
Which one of the following steps would be the most appropriate next step in the management of this patient? Administer platelets and apply forced air warmer. Administer platelets and cryoprecipitate This is an example of disseminated intravascular coagulopathy DIC from massive transfusion. Miller's Anesthesia 7th edition, pages An emergent page is received to come to the post-anesthesia recovery unit to see a year-old woman status post-hysterectomy under general anesthesia for endometrial adenomyosis.
She had a history of insulin-dependent diabetes, unstable angina and IgA deficiency. She had an intraoperative blood loss of 2 L and was just starting to receive blood transfusion when the patient complained of chest pain, dyspnea, severe itching and dizziness. The transfusion was stopped and epinephrine and hydrocortisone were administered to the patient with resolution of the symptoms.
Transfuse 4 units of cross-matched blood immediately. Request 4 units of leukoreduced packed red cells. Request 4 units of cytomegalovirus CMV negative packed. Hold transfusion and administer IV fluids, mannitol and lasix to force diuresis. Request 4 units of washed packed red cells This is an anaphylactic reaction caused by the transfusion of IgA to a patient who is IgA deficient and has formed anti-IgA.
A year-old woman with history of acute intermittent porphyria is scheduled to undergo a bilateral tubal ligation under general anesthesia. Which one of the following medications should be avoided in this patient? Thiopental Acute intermittent porphyria is a rare disorder of heme synthesis in which the precursors to heme synthesis, porphyrins, accumulate and lead to neurological manifestations.
You have not finished your quiz. If you leave this page, your progress will be lost. A year-old man undergoes total knee arthroplasty under epidural anesthesia. He complains of persistent back pain at the epidural site that begins on postoperative day 3 and continues to worsen. The pain was initially localized, but now radiates down his right thigh to his knee, stopping there. He does not complain of any sensory deficits or have any bladder or bowel incontinence. Which one of the following diagnoses is the most probable? Direct neurotoxic effect of local anesthetic.
Epidural abscess The clinical scenario described in the stem is most suggestive of an epidural abscess. This is a rare but dreaded complication of epidural anesthesia that usually manifests as localized back pain that worsens and develops radicular changes. Epidural abscesses have a median onset of days. The patient goes on to develop sensory and motor deficits and eventually paralysis if untreated.
Direct neurotoxic effect of local anesthetics is less often seen with conventional concentrations of local anesthetics and does not follow this timeline. Epidural hematoma proceeds more rapidly to produce sensory and motor deficits within hours. Anterior spinal artery syndrome is predominantly characterized by motor changes. There is no associated pain. A year-old female is undergoing repair of a laceration of the third toe under ankle block.
Which one of the following anatomic landmarks is appropriate for performing an ankle block? It can be blocked by subcutaneous infiltration of local anesthetic between the medial malleolus and the extensor hallucis longus tendon.
Anesthesiology Basic Practice Questions | The Pass Machine
The posterior tibial nerve is blocked by deep infiltration of local anesthetic between the posterior tibial artery and the medial malleolus, not between the lateral malleolus and the tendocalcaneus. This nerve does not supply the web space between the first and second digits or the lateral fifth digit. It can be blocked by subcutaneous infiltration of local anesthetic between the lateral malleolus and the extensor digitorum longus or anterior border of the medial malleolus , not between the tendons of the anterior tibial and extensor hallucis longus muscle.
The nerve is blocked by identifying the groove between the extensor hallucis longus and the extensor digitorum longus tendons, 2 cm distal to the intermalleolar line, and infiltrating the local anesthetic, just lateral to the dorsalis pedis artery pulse. The nerve is blocked by local anesthetic infiltration between the lateral malleolus and the tendocalcaneus, not between medial malleolus and tendocalcaneus.
In essence, the ankle block can be achieved by local anesthetic infiltration in a ring- n like fashion at the ankle level. A 4-year-old boy must undergo surgery for repair of an open eye injury secondary to globe laceration. He ate 2 hours prior to his accident. General anesthesia is required for repair. Which one of the following anesthetic techniques is appropriate for securing the airway? Intubation after deep inhalational induction.
Slow, controlled intravenous IV induction with propofol and vecuronium. Rapid, sequence IV induction with propofol and succinylcholine. Rapid, sequence IV induction with propofol and rocuronium.
Anesthesiology ADVANCED Practice Questions
Rapid, sequence IV induction with propofol and rocuronium The child has a full stomach and is at risk for aspiration. Succinylcholine is the drug of choice to use for rapid sequence induction in the setting where aspiration is a risk as succinylcholine facilitates tracheal intubation within 30 seconds as compared to other muscle relaxants.
Succinylcholine use is a relative contraindication in this case since this is an open globe injury. There is a risk of expulsion of the contents of the globe secondary to an increase in the intraocular pressure caused by succinylcholine induced muscle fasciculations.
The safer approach is to perform rapid sequence induction with propofol and a large-dose of rocuronium which provides optimal intubating conditions within 60 to 90 seconds without the risk of expulsion of the contents of the globe. In addition, the FDA has published a warning for the risk of cardiac arrest from hyperkalemic rhabdomyolysis in children administered succinylcholine, especially males, 8 years of age or younger. These were healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy.
Awake intubation with topical anesthesia of the airway is optimal and safe in an adult, but a 4-year-old child would not be as cooperative enough for this approach. Deep inhalational anesthesia and slow, controlled IV induction with vecuronium are techniques with a high risk for aspiration. A year-old patient is scheduled for hand surgery under intravenous regional anesthesia IVRA. Forty ml of 0. At the same moment, the surgeon is called away for an emergency. Which one of the following options is the safest management approach for this patient?
Deflate the tourniquet and transfer the patient to PACU. Continue tourniquet inflation and wait for the surgeon to return. Wait for one hour and then deflate the tourniquet. Wait for 20 minutes and then, deflate, inflate, and deflate the tourniquet intermittently. Wait for 20 minutes and then, deflate, inflate, and deflate the tourniquet intermittently IVRA provides intense surgical anesthesia for short surgical procedures less than 45 to 60 min on the forearm, hand, and the leg.
A double tourniquet is applied on the upper arm or lower leg and the upper cuff is inflated after the arm is exsanguinated using an Esmarch elastic bandage. The patient usually complains of tourniquet pain after 20 to 30 minutes. The lower cuff is then inflated over the already anesthetized area, and the upper cuff is deflated.
In this case scenario, the surgery was postponed since the surgeon was called away right after the injection. The safest approach is to wait for at least 20 minutes and release the tourniquet intermittently to prevent rapid, intravenous bolusing of the local anesthetic which may cause seizures and other systemic toxicity. Tourniquet pain limits the use of IVRA to approximately 60 minutes of block time. A year-old man with a history of depression treated with amitriptyline is undergoing hemiarthroplasty of his left hip.
Following surgery, his neuromuscular blockade is reversed with neostigmine and atropine. In the recovery room, he is noted to be flushed and febrile with dilated pupils and dry skin. He also has persistent confusion; however, vital signs are normal. His serum creatine kinase and arterial blood gases are normal. Which one of the following diagnoses is the most likely for this patient? Anticholinergic syndrome Concurrent use of amitriptyline tricyclic antidepressant and atropine anticholinergic may result in additive anticholinergic adverse effects. Complications include hyperthermia, hypertension and tachycardia.
Serotonin syndrome is usually characterized by increased sweating, while neurolept malignant syndrome is characterized by bradykinesia and increased serum creatine kinase. Autonomic hyperreflexia usually occurs only in paraplegic patients. Pain causes increased sympathetic discharge and sweating. Malignant hyperthermia would cause tachypnea due to hypercarbia before hyperthermia sets in. A year-old woman with multiple sclerosis presents for a knee arthroscopy.
Which one of the following statements regarding perioperative considerations for this patient is most likely true? There is an increased risk of malignant hyperthermia. There may be an increased risk of aspiration. Exacerbations are unlikely to occur following surgery if general anesthesia and neuraxial blockade are both avoided. Volatile anesthetics increase the risk of exacerbations.
There may be an increased risk of aspiration Multiple sclerosis MS is characterized by remissions and exacerbations. In the literature, psychological stress and exposure to high ambient temperatures have been proposed as relapse triggers for MS. There may be an increased risk of aspiration due to cranial nerve involvement causing dysphagia. As such, the leading cause of death in MS is bronchial pneumonia. Volatile anesthetics have been used without complications in such patients.
There is no association with malignant hyperthermia. According to the National Multiple Sclerosis Society, most MS patients can tolerate standard anesthesia without undue risk. All forms of anesthesia are considered safe for patients with MS. Special consideration may have to be made for those with severe advanced disease with evidence of muscle weakness or those having respiratory problems.
Infection or fever, however, may tend to aggravate symptoms of MS. There is no evidence that the stress of surgery will exacerbate MS. Which one of the following opioid receptors is responsible for chest wall rigidity when opioids are administered? Each receptor is responsible for certain side effects seen when opioids are administered. Fentanyl is often cited as the opioid most likely to induce chest wall rigidity and this can make it difficult or impossible to ventilate the patient. A mother calls to inquire when she should stop breastfeeding her 4 month old before her scheduled hernia repair.
According to the ASA practice guidelines, infants should fast from ingesting breast milk for how many hours? All ASA 3 patients should have preoperative testing based on their medical conditions. A pregnancy test is recommended before providing anesthesia in a woman of child bearing age. A patient history and physical examination is the minimum recommendation by the ASA. A preoperative evaluation by an anesthesiologist must be done within 48 hrs of each anesthetic.
Schwartz’s Principles of Surgery ABSITE and Board Review, 9e
A preoperative evaluation by an anesthesiologist must be done within 48 hrs of each anesthetic Option D is correct because this is a Centers for Medicare and Medicaid CMS requirement for billing. Option A is incorrect because the ASA guidelines recommend against performing "routine" tests but rather testing based on medical conditions, type of surgery and only if results will change management. Option B is incorrect because the ASA states that women of child-bearing age "may be offered a pregnancy test".
Option C is incorrect because the ASA recommends a review of pertinent medical records in addition to the patient history and physical examination as the minimum preoperative evaluation. Your second case of the day has a history of glaucoma. Which medication is contraindicated?
Scopolamine Scopolamine is correct because scopolamine is an anticholinergic and can dilate the pupils and increase intraocular pressure IOP. The rest are incorrect because these drugs have no effect on IOP. Patients with glaucoma may have elevated IOP at baseline.