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1. A 58-year-old patient has severe shortness of breath and "wheezing." On examination, it is found that the patient has inspiratory and expiratory stridor. Further evaluation reveals marked extrinsic compression of the midtrachea by a tumor. The type of airflow at the point of obstruction within the trachea is
A. Laminar flow
B. Orifice flow
C. Undulant flow
D. Stenotic flow
E. None of the above

1. (B) Orifice flow occurs when gas flows through a region of severe constriction such as described in this question. Laminar flow occurs when gas flows down parallel-sided tubes at a rate less than critical velocity. When the gas flow exceeds the critical velocity, it becomes turbulent (Miller: Anesthesia, ed 6, pp 690-691; Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 224-225).

2. Concerning the patient in question 1, administration of 70% helium in O2 instead of 100% O2 will decrease the resistance to airflow through the stenotic region within the trachea because
A. Helium decreases the viscosity of the gas mixture
B. Helium decreases the friction coefficient of the gas mixture
C. Helium decreases the density of the gas mixture
D. Helium increases the Reynolds number of the gas mixture
E. None of the above

2. (C) During orifice flow, the resistance to gas flow is directly proportional to the density of the gas mixture. Substituting helium for nitrogen will decrease the density of the gas mixture, thereby decreasing the resistance to gas flow (as much as threefold) through the region of constriction (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 224-225; Miller: Anesthesia, ed 6, pp 690-691, 2539).

3. A 56-year-old patient is brought to the operating room (OR) for elective replacement of a stenotic aortic valve. An awake 20-gauge arterial catheter is placed into the right radial artery and is then connected to a transducer located at the same level as the patient's left ventricle. The entire system is zeroed at the transducer. Several seconds later, the patient raises both arms into the air such that his right wrist is 20 cm above his heart. As he is doing this, the blood pressure (BP) on the monitor reads 120/80. What would this patient's true BP be at this time?
A. 140/100 mm Hg
B. 135/95 mm Hg
C. 120/80 mm Hg
D. 105/65 mm Hg
E. 100/60 mm Hg

3. (C) Modern electronic blood pressure (BP) monitors are designed to interface with electromechanical transducer systems. These systems do not require extensive technical skill on the part of the anesthesia provider for accurate usage. A static zeroing of the system is built into most modern electronic monitors. Thus, after the zeroing procedure is accomplished, the system is ready for operation. The system should be zeroed with the reference point of the transducer at the approximate level of the aortic root, eliminating the effect of the fluid column of the system on arterial BP readings (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 275-278).

4. An admixture of room air in the waste gas disposal system during an appendectomy in a paralyzed, mechanically ventilated patient under general volatile anesthesia can best be explained by which mechanism of entry?
A. Venous air embolism
B. Positive pressure relief valve
C. Negative pressure relief valve
D. Soda lime canister
E. Ventilator bellows

4. (C) Waste gas disposal systems, also called scavenging systems, are designed to decrease pollution of the OR by anesthetic gases. These scavenging systems can be passive (waste gases flow from the anesthesia machine to a ventilation system on their own) or active (anesthesia machine connected to a vacuum system then to the ventilation system). The amount of air from a venous gas embolism would not be enough to be detected in the disposal system. Positive pressure relief valves open if there is an obstruction between the anesthesia machine and the disposal system, which would then leak the gas into the OR. A leak in the soda lime canisters would also vent to the OR. Since most ventilator bellows are powered by oxygen, a leak in the bellows would not add air to the evacuation system. The negative pressure relief valve is used in active systems and will entrap room air if the pressure in the system is less than -0.5 cm H2O. (Miller: Anesthesia, 6th ed. pp 303-307; Stoelting: Basics of Anesthesia, ed 5, pp 198-199).

5. The relationship between intra-alveolar pressure, surface tension, and the radius of an alveolus is described by
A. Graham's law
B. Beer's law
C. Newton's law
D. Laplace's law
E. Bernoulli's law

5. (D) The relationship between intra-alveolar pressure, surface tension, and the radius of alveoli is described by Laplace's law for a sphere, which states that the surface tension of the sphere is directly proportional to the radius of the sphere and pressure within the sphere. With regard to pulmonary alveoli, the mathematical expression of Laplace's law is as follows:

where T is the surface tension, P is the intra-alveolar pressure, and R is the radius of the alveolus. In pulmonary alveoli, surface tension is produced by a liquid film lining the alveoli. This occurs because the attractive forces between the molecules of the liquid film are much greater than the attractive forces between the liquid film and gas. Thus, the surface area of the liquid tends to become as small as possible, which could collapse the alveoli (Miller: Anesthesia, ed 6, pp 689-690).

6. A size "E" compressed-gas cylinder completely filled with N2O contains how many liters?
A. 1160 L
B. 1470 L
C. 1590 L
D. 1640 L
E. 1750 L

6. (C) The World Health Organization requires that compressed-gas cylinders containing N2O for medical use be painted blue. Size "E" compressed-gas cylinders completely filled with N2O contain approximately 1590 L of gas (Stoelting: Basics of Anesthesia, ed 5, p 188).

7. Which of the following methods can be used to detect all leaks in the low-pressure circuit of any contemporary anesthesia machine?
A. Oxygen flush test
B. Common gas outlet occlusion test
C. Traditional positive-pressure leak test
D. Negative-pressure leak test
E. No test can verify the integrity of all contemporary anesthesia machines

7. (D) Many anesthesia machines have a check valve downstream from the rotameters and vaporizers but upstream from the oxygen flush valve. When the oxygen flush valve button is depressed and the Y-piece (which would be connected to the endotracheal tube [ETT] or the anesthesia mask) is occluded, the circuit will be filled and the needle on the airway pressure gauge will indicate positive pressure. The positive pressure reading will not fall, however, even in the presence of a leak in the low-pressure circuit of the anesthesia machine. If a check valve is present on the common gas outlet, the positive-pressure leak test can be dangerous and misleading. In 1993, the United States Food and Drug Administration (FDA) established the FDA Universal Negative Pressure Leak Test. With the machine master switch, the flow control valves and the vaporizers turned off, a suction bulb is attached to the common gas outlet and compressed until it is fully collapsed. If a leak is present the suction bulb will inflate. It was so named because it can be used to check all anesthesia machines regardless of whether they contain a check valve in the fresh gas outlet (Miller: Anesthesia, ed 6, pp 309-310).

8. Which of the following valves prevents transfilling between compressed-gas cylinders?
A. Fail-safe valve
B. Pop-off valve
C. Pressure-sensor shutoff valve
D. Adjustable pressure-limiting valve
E. Check valve

8. (E) Check valves permit only unidirectional flow of gases. These valves prevent retrograde flow of gases from the anesthesia machine or the transfer of gas from a compressed-gas cylinder at high pressure into a container at a lower pressure. Thus, these unidirectional valves will allow an empty compressed-gas cylinder to be exchanged for a full one during operation of the anesthesia machine with minimal loss of gas. The adjustable pressure-limiting valve is a synonym for a pop-off valve. A fail-safe valve is a synonym for a pressure-sensor shutoff valve. The purpose of a fail-safe valve is to discontinue the flow of N2O if the O2 pressure within the anesthesia machine falls below 25 psi (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 46-47; Miller: Anesthesia, ed 6, p 276.)

9. The expression that for a fixed mass of gas at constant temperature, the product of pressure and volume is constant is known as
A. Graham's law
B. Bernoulli's law
C. Boyle's law
D. Dalton's law
E. Charles' law

9. (C) Boyle's law states that for a fixed mass of gas at constant temperature, the product of pressure and volume is constant. This concept can be used to estimate the volume of gas remaining in a compressed-gas cylinder by measuring the pressure within the cylinder (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 224).

10. The pressure gauge on a size "E" compressed-gas cylinder containing O2 reads 1600 psi. How long could O2 be delivered from this cylinder at a rate of 2 L/min?
A. 90 minutes
B. 140 minutes
C. 250 minutes
D. 320 minutes
E. Cannot be calculated

10. (C) United States manufacturers require that all compressed-gas cylinders containing O2 for medical use be painted green. A compressed-gas cylinder completely filled with O2 has a pressure of approximately 2000 psi and contains approximately 625 L of gas. According to Boyle's law (see explanation to question 9) the volume of gas remaining in a closed container can be estimated by measuring the pressure within the container. Therefore, when the pressure gauge on a compressed-gas cylinder containing O2 shows a pressure of 1600 psi, the cylinder contains 500 L of O2. At a gas flow of 2 L/min, O2 could be delivered from the cylinder for approximately 250 minutes (Stoelting: Basics of Anesthesia ed 5, p 188).
CHARACTERISTICS OF COMPRESSED GASES STORED IN "E" SIZE CYLINDERS THAT MAY BE ATTACHED TO THE ANESTHESIA MACHINE
Characteristics O2 N2O CO2 Air
Cylinder color Green Blue Gray Yellow
Physical state Gas L/G L/G Gas
contents (L) 625 1590 1590 625
weight empty (kg) 5.90 5.90 5.90 5.90
weight full (kg) 6.76 8.80 8.90
pressure full (psi) 2000 750 838 1800
(Stoelting: Basics of Anesthesia, ed 5, p 188.)

11. A 25-year-old healthy patient is anesthetized for a femoral hernia repair. Anesthesia is maintained with isoflurane and N2O 50% in O2 and the patient's lungs are mechanically ventilated. Suddenly, the "low-arterial saturation" warning signal on the pulse oximeter alarms. After the patient is disconnected from the anesthesia machine, he is ventilated with an Ambu bag with 100% O2 without difficulty and the arterial saturation quickly improves. During inspection of your anesthesia equipment, you notice that the bobbin in the O2 rotameter is not rotating. This most likely indicates
A. The flow of N2O through the O2 rotameter
B. No flow of O2 through the O2 rotameter
C. A flow of O2 through the O2 rotameter that is markedly lower than indicated
D. A leak in the O2 rotameter above the bobbin
E. A leak in the O2 rotameter below the bobbin

11. (B) All of the choices listed in this question can potentially result in inadequate flow of O2 to the patient; however, given the description of the problem, no flow of O2 through the O2 rotameter is the correct choice. In a normally functioning rotameter, gas flows between the rim of the bobbin and the wall of the Thorpe tube, causing the bobbin to rotate. If the bobbin is rotating you can be certain that gas is flowing through the rotameter and that the bobbin is not stuck (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 40-42).

12. The O2 pressure-sensor shutoff valve requires what O2 pressure to remain open and allow N2O to flow into the N2O rotameter?
A. 10 psi
B. 25 psi
C. 50 psi
D. 100 psi
E. 600 psi

12. (B) Fail-safe valve is a synonym for pressure-sensor shutoff valve. The purpose of the fail-safe valve is to prevent delivery of hypoxic gas mixtures from the anesthesia machine to the patient due to failure of the O2 supply. When the O2 pressure within the anesthesia machine decreases below 25 psi, this valve discontinues the flow of N2O or proportionally decreases the flow of all gases. It is important to realize that this valve will not prevent delivery of hypoxic gas mixtures or pure N2O when the O2 rotameter is off, but the O2 pressure within the circuits of the anesthesia machine is maintained by an open O2 compressed-gas cylinder or central supply source. Under these circumstances, an O2 analyzer would be needed to detect delivery of a hypoxic gas mixture (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 37-38).

13. A 78-year-old patient is anesthetized for resection of a liver tumor. After induction and tracheal intubation, a 20-gauge arterial line is placed and connected to a transducer that is located 20 cm below the level of the heart. The system is zeroed at the stopcock located at the wrist while the patient's arm is stretched out on an arm board. How will the arterial line pressure compare with the true BP?
A. It will be 20 mm Hg higher
B. It will be 15 mm Hg higher
C. It will be the same
D. It will be 15 mm Hg lower
E. It will be 20 mm Hg lower

13. (C) It is important to zero the electromechanical transducer system with the reference point at the approximate level of the heart. This will eliminate the effect of the fluid column of the transducer system on the arterial BP reading of the system. In this question, the system was zeroed at the stopcock, which was located at the patient's wrist (approximate level of the ventricle). Blood pressure expressed by the arterial line will, therefore, be accurate, provided the distance between the patient's wrist and the stopcock remains 20 cm. Also see explanation to question 3 (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 276).

14. The second-stage O2 pressure regulator delivers a constant O2 pressure to the rotameters of
A. 4 psi
B. 8 psi
C. 16 psi
D. 32 psi
E. 64 psi

14. (C) O2 and N2O enter the anesthesia machine from a central supply source or compressed-gas cylinders at pressures as high as 2200 psi (oxygen) and 750 psi (N2O). First-stage pressure regulators reduce these pressures to approximately 45 psi. Before entering the rotameters, second-stage O2 pressure regulators further reduce the pressure to approximately 14 to 16 psi (see figure with answer to question 12) (Miller: Anesthesia, ed 6, pp 274-275).

15. The highest trace concentration of N2O allowed in the OR atmosphere by the National Institute for Occupational Safety and Health (NIOSH) is
A. 1 part per million (ppm)
B. 5 ppm
C. 25 ppm
D. 50 ppm
E. 100 ppm

15. (C) NIOSH sets guidelines and issues recommendations concerning the control of waste anesthetic gases. NIOSH mandates that the highest trace concentration of N2O contamination of the OR atmosphere should be less than 25 ppm. In dental facilities where N2O is used without volatile anesthetics, NIOSH permits up to 50 ppm (Miller: Anesthesia, ed 6, pp 303-304).

16. A sevoflurane vaporizer will deliver an accurate concentration of an unknown volatile anesthetic if the latter shares which property with sevoflurane?
A. Molecular weight
B. Viscosity
C. Vapor pressure
D. Blood/gas partition coefficient
E. Oil/gas partition coefficient

16. (C) Agent-specific vaporizers, such as the Sevotec (sevoflurane) vaporizer, are designed for each volatile anesthetic. However, volatile anesthetics with identical saturated vapor pressures could be used interchangeably with accurate delivery of the volatile anesthetic.
VAPOR PRESSURES
Agent Vapor Pressure mm Hg at 20° C
Halothane 243
Enflurane 172
Sevoflurane 160
Isoflurane 240
Desflurane 669
(Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 60-63; Stoelting: Basics of Anesthesia, ed 5, p 79.)

17. The portion of the ventilator (Ohmeda 7000, 7810, and 7900) on the anesthesia machine that compresses the bellows is driven by
A. Compressed oxygen
B. Compressed air
C. Electricity alone
D. Electricity and compressed oxygen
E. Electricity and compressed air

17. (A) The control mechanism of standard anesthesia ventilators, such as the Ohmeda 7000, uses compressed oxygen (100%) to compress the ventilator bellows and electrical power for the timing circuits (Miller: Anesthesia, ed 6, p 298).

18. Which of the following rotameter flow indicators is read in the middle of the dial?
A. Bobbin
B. "H" float
C. Ball float
D. Skirted float
E. Nonrotating float

18. (C) Five types of rotameter indicators are commonly used to indicate the flow of gases delivered from the anesthesia machine. As with all anesthesia equipment, proper understanding of their function is necessary for safe and proper use. All rotameter flow indicators should be read at the upper rim except ball floats, which should be read in the middle (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 40-43).

19. When the pressure gauge on a size "E" compressed-gas cylinder containing N2O begins to fall from its previous constant pressure of 750 psi, approximately how many liters of gas will remain in the cylinder?
A. 200 L
B. 400 L
C. 600 L
D. 800 L
E. Cannot be calculated

19. (B) The pressure gauge on a size "E" compressed-gas cylinder containing N2O shows 750 psi when it is full and will continue to register 750 psi until approximately three-fourths of the gas has left the cylinder. A full cylinder of N2O contains 1590 L. Therefore, when 400 L of gas remain in the cylinder, the pressure within the cylinder will begin to fall (Stoelting: Basics of Anesthesia, ed 5, p 188).

20. A 3-year-old child with severe congenital facial anomalies is anesthetized for extensive facial reconstruction. After inhalation induction with sevoflurane and oral tracheal intubation, a 22-gauge arterial line is placed in the right radial artery. The arterial cannula is then connected to a transducer that is located 10 cm below the patient's heart. After zeroing the arterial line at the transducer, how will the given pressure compare with the true arterial pressure?
A. It will be 10 mm Hg higher
B. It will be 7.5 mm Hg higher
C. It will be the same
D. It will be 7.5 mm Hg lower
E. It will be 10 mm Hg lower

20. (B) In this question the reference point is the transducer, which is located 10 cm below the level of the patient's heart. Thus, there is an approximate 10 cm H2O fluid column from the level of the patient's heart to the transducer. This will cause the pressure reading from the transducer system to read approximately 7.5 mm Hg higher than a true arterial pressure of the patient. A 20-cm column of H2O will exert a pressure equal to 14.7 mm Hg. Also see explanations to questions 3 and 13 (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 275).

21. If the internal diameter of an intravenous catheter were doubled, flow through the catheter would be
A. Decreased by a factor of 2
B. Decreased by a factor of 4
C. Increased by a factor of 8
D. Increased by a factor of 16
E. Increased by a factor of 32

21. (D) Factors that influence the rate of laminar flow of a substance through a tube is described by the Hagen-Poiseuille law of friction. The mathematical expression of the Hagen-Poiseuille law of friction is as follows:

where is the flow of the substance, r is the radius of the tube, ∆P is the pressure gradient down the tube, L is the length of the tube, and μ is the viscosity of the substance. Note that the rate of laminar flow is proportional to the radius of the tube to the fourth power. If the diameter of an intravenous catheter is doubled, flow would increase by a factor of 2 raised to the fourth power (i.e., a factor of 16) (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 225).

22. Of the following statements concerning the safe storage of compressed-gas cylinders, choose the one that is FALSE.
A. Should not be handled with oily hands
B. Should not be stored near flammable material
C. Should not be stored in extreme heat or cold
D. Paper or plastic covers should not be removed from the cylinders before storage
E. All of the above statements are true

22. (D) The safe storage and handling of compressed-gas cylinders is of vital importance. Compressed-gas cylinders should not be stored in extremes of heat or cold, and they should be unwrapped when stored or when in use. Flames should not be used to detect the presence of a gas. Oily hands can lead to difficulty in handling of the cylinder, which can result in dropping the cylinder. This can cause damage to or rupture of the cylinder, which can lead to an explosion (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 8-11).

23. For any given concentration of volatile anesthetic, the splitting ratio is dependent on which of the following characteristics of that volatile anesthetic?
A. Vapor pressure
B. Barometric pressure
C. Molecular weight
D. Specific heat
E. Minimum alveolar concentration (MAC) at 1 atmosphere

23. (A) Vaporizers can be categorized into variable-bypass and measured-flow vaporizers. Measured-flow vaporizers (nonconcentration calibrated vaporizers) include the copper kettle and Vernitrol vaporizer. With measured-flow vaporizers, the flow of oxygen is selected on a separate flowmeter to pass into the vaporizing chamber from which the anesthetic vapor emerges at its saturated vapor pressure. By contrast, in variable-bypass vaporizers, the total gas flow is split between a variable bypass and the vaporizer chamber containing the anesthetic agent. The ratio of these two flows is called the splitting ratio. The splitting ratio depends on the anesthetic agent, temperature, the chosen vapor concentration set to be delivered to the patient, and the saturated vapor pressure of the anesthetic (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 63).

24. A mechanical ventilator (e.g., Ohmeda 7000) is set to deliver a tidal volume (Vt) of 500 mL at a rate of 10 breaths/min and an inspiratory-to-expiratory (I:E) ratio of 1:2. The fresh gas flow into the breathing circuit is 6 L/min. In a patient with normal total pulmonary compliance, the actual Vt delivered to the patient would be
A. 400 mL
B. 500 mL
C. 600 mL
D. 700 mL
E. 800 mL

24. (D) The contribution of the fresh gas flow from the anesthesia machine to the patient's Vt should be considered when setting the Vt of a mechanical ventilator. Because the ventilator pressure-relief valve is closed during inspiration, both the gas from the ventilator bellows and the fresh gas flow will be delivered to the patient breathing circuit. In this question, the fresh gas flow is 6 L/min or 100 mL/sec (6000 mL/60). Each breath lasts 6 sec (60 sec/10 breaths) with inspiration lasting 2 sec (I:E ratio = 1:2). Under these conditions, the Vt delivered to the patient by the mechanical ventilator will be augmented by approximately 200 mL. In some ventilators, such as the Ohmeda 7900, Vt is controlled for the fresh gas flow rate such that the delivered Vt is always the same as the dial setting (Morgan: Clinical Anesthesia ed 4, pp 82-84).

25. In reference to question 24, if the ventilator rate were decreased from 10 to 6 breaths/min, the approximate Vt delivered to the patient would be
A. 600 mL
B. 700 mL
C. 800 mL
D. 900 mL
E. 1000 mL

25. (C) Also see explanation to question 24. The ventilator rate is decreased from 10 to 6 breaths/min. Thus, each breath will last 10 seconds (60 sec/6 breaths) with inspiration lasting approximately 3.3 sec (I:E ratio = 1:2), i.e., 3.3 seconds times 100 mL/second. Under these conditions, the actual Vt delivered to the patient by the mechanical ventilator will be 830 mL (500 mL + 330 mL) (Morgan: Clinical Anesthesia, ed 4, pp 82-84).

26. Vaporizers for which of the following volatile anesthetics could be used interchangeably with accurate delivery of the concentration of anesthetic set on the vaporizer dial?
A. Halothane, sevoflurane, and isoflurane
B. Sevoflurane and isoflurane
C. Halothane and sevoflurane
D. Halothane and isoflurane
E. Sevoflurane and desflurane

26. (D) The saturated vapor pressures of halothane and isoflurane are very similar (approximately 240 mm Hg at room temperature) and therefore could be used interchangeably in agent-specific vaporizers (see explanation and table in explanation for question 16) (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 60-63; Stoelting: Basics of Anesthesia, ed 5, p 79).

27. If the anesthesia machine is discovered Monday morning having run with 5 L/min of oxygen all weekend long, the most reasonable course of action to take before administering the next anesthetic would be
A. Turn machine off for 30 minutes before induction
B. Place humidifier in line with the expiratory limb
C. Avoid use of sevoflurane
D. Change the CO2 absorbent
E. Administer 100% oxygen for the first hour of the next case

27. (D) Clinically significant concentrations of carbon monoxide can result from the interaction of desiccated absorbent, both soda lime and Baralyme. The resulting carboxyhemoglobin level can be as high as 30%. Many of the reported occurrences of carbon monoxide poisoning have been observed on Monday mornings. This is thought to be the case because the absorbent granules are the driest after disuse for two days, particularly if the oxygen flow has not been turned off completely. There are several factors that appear to predispose to the production of carbon monoxide: (1) degree of absorbent dryness (completely desiccated granules produce more carbon monoxide than hydrated granules); (2) use of Baralyme versus soda lime (provided that the water content is the same in both); (3) high concentrations of volatile anesthetic (more carbon monoxide is generated at higher volatile concentrations); (4) high temperatures (more carbon monoxide is generated at higher temperatures); and (5) type of volatile used:

28. According to NIOSH regulations, the highest concentration of volatile anesthetic contamination allowed in the OR atmosphere when administered in conjunction with N2O is
A. 0.5 ppm
B. 2 ppm
C. 5 ppm
D. 25 ppm
E. 50 ppm

28. (A) NIOSH mandates that the highest trace concentration of volatile anesthetic contamination of the OR atmosphere when administered in conjunction with N2O is 0.5 ppm (Miller: Anesthesia, 6 ed, pp 303-304).

29. The device on anesthesia machines that most reliably detects delivery of hypoxic gas mixtures is the
A. Fail-safe valve
B. O2 analyzer
C. Second-stage O2 pressure regulator
D. Proportion-limiting control system
E. Diameter-index safety system

29. (B) The O2 analyzer is the last line of defense against inadvertent delivery of hypoxic gas mixtures. It should be located in the inspiratory (not expiratory) limb of the patient breathing circuit to provide maximum safety. Because the O2 concentration in the fresh-gas supply line may be different from that of the patient breathing circuit, the O2 analyzer should not be located in the fresh-gas supply line (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 216-220).

30. A ventilator pressure-relief valve stuck in the closed position can result in
A. Barotrauma
B. Hypoventilation
C. Hypoxia
D. Hyperventilation
E. Low breathing circuit pressure

30. (A) The ventilator pressure-relief valve (also called the spill valve) is pressure controlled via pilot tubing that communicates with the ventilator bellows chamber. As pressure within the bellows chamber increases during the inspiratory phase of the ventilator cycle, the pressure is transmitted via the pilot tubing to close the pressure-relief valve, thus making the patient breathing circuit "gastight." This valve should open during the expiratory phase of the ventilator cycle to allow the release of excess gas from the patient breathing circuit into the waste-gas scavenging circuit after the bellows has fully expanded. If the ventilator pressure-relief valve were to stick in the closed position, there would be a rapid buildup of pressure within the circle system that would be readily transmitted to the patient. Barotrauma to the patient's lungs would result if this situation were to continue unrecognized (Eisenkraft: Potential for barotrauma or hypoventilation with the Drager AV-E ventilator. J Clin Anesth, 1:452-456, 1989; Morgan: Clinical Anesthesia, ed 4, pp 81-82).

31. A mixture of 1% isoflurane, 70% N2O, and 30% O2 is administered to a patient for 30 minutes. The expired isoflurane concentration measured is 1%. N2O is shut off and a mixture of 30% O2, 70% N2 with 1% isoflurane is administered. The expired isoflurane concentration measured one minute after the start of this new mixture is 2.3%. The best explanation for this observation is
A. Intermittent back pressure (pumping effect)
B. Diffusion hypoxia
C. Concentration effect
D. Effect of N2O solubility in isoflurane
E. Effect of similar mass-to-charge ratios of N2O and CO2

31. (D) Vaporizer output can be affected by the composition of the carrier gas used to vaporize the volatile agent in the vaporizing chamber, especially when nitrous oxide is either initiated or discontinued. This observation can be explained by the solubility of nitrous oxide in the volatile agent. When nitrous oxide and oxygen enter the vaporizing chamber, a portion of the nitrous oxide dissolves in the liquid agent. Thus, the vaporizer output transiently decreases. Conversely, when nitrous oxide is withdrawn as part of the carrier gas, the nitrous oxide dissolved in the volatile agent comes out of solution, thereby transiently increases the vaporizer output (Miller: Anesthesia, ed 6, pp 286-288).

32. The mass spectrometer waveform above represents which of the following situations?
A. Cardiac oscillations
B. Kinked endotracheal tube
C. Bronchospasm
D. Incompetent inspiratory valve
E. Incompetent expiratory valve

32. (E) The capnogram can provide a variety of information, such as verification of the presence of exhaled CO2 after tracheal intubation, estimation of the difference in Paco2 and Petco2, abnormalities of ventilation, and the presence of hypercapnia or hypocapnia. The four phases of the capnogram are inspiratory baseline, expiratory upstroke, expiratory plateau, and inspiratory downstroke. The shape of the capnogram can be used to recognize and diagnose a variety of potentially adverse circumstances. Under normal conditions, the inspiratory baseline should be 0, indicating that there is no rebreathing of CO2 with a normal functioning circle breathing system. If the inspiratory baseline is elevated above 0, there is rebreathing of CO2. If this occurs, the differential diagnosis should include an incompetent expiratory valve, exhausted CO2 absorbent, or gas channeling through the CO2 absorbent. However, the inspiratory baseline may be elevated when the inspiratory valve is incompetent (e.g., there may be a slanted inspiratory downstroke). The expiratory upstroke occurs when the fresh gas from the anatomic dead space is quickly replaced by CO2-rich alveolar gas. Under normal conditions the upstroke should be steep; however, it may become slanted during partial airway obstruction, if a sidestream analyzer is sampling gas too slowly, or if the response time of the capnograph is too slow for the patient's respiratory rate. Partial obstruction may be the result of an obstruction in the breathing system (e.g., by a kinked endotracheal tube) or in the patient's airway (e.g., the presence of chronic obstructive pulmonary disease or acute bronchospasm). The expiratory plateau is normally characterized by a slow but shallow progressive increase in CO2 concentration. This occurs because of imperfect matching of ventilation and perfusion in all lung units. Partial obstruction of gas flow either in the breathing system or in the patient's airways may cause a prolonged increase in the slope of the expiratory plateau, which may continue rising until the next inspiratory downstroke begins. The inspiratory downstroke is caused by the rapid influx of fresh gas, which washes the CO2 away from the CO2 sensing or sampling site. Under normal conditions the inspiratory downstroke is very steep. Causes of a slanted or blunted inspiratory downstroke include an incompetent inspiratory valve, slow mechanical inspiration, slow gas sampling, and partial CO2 rebreathing (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 240).

33. Select the FALSE statement.
A. If a Magill forceps is used for a nasotracheal intubation, the right nares is preferable for insertion of the nasotracheal tube.
B. Extension of the neck can convert an endotracheal intubation to an endobronchial intubation.
C. Bucking signifies the return of the coughing reflex.
D. Postintubation pharyngitis is more likely to occur in females.
E. Stenosis becomes symptomatic when the adult tracheal lumen is reduced to less than 5 mm.

33. (B) Complications of tracheal intubation can be divided into those associated with direct laryngoscopy and intubation of the trachea, tracheal tube placement, and extubation of the trachea. The most frequent complication associated with direct laryngoscopy and tracheal intubation is dental trauma. If a tooth is dislodged and not found, radiographs of the chest and abdomen should be taken to determine whether the tooth has passed through the glottic opening into the lungs. Should dental trauma occur, immediate consultation with a dentist is indicated. Other complications of direct laryngoscopy and tracheal intubation include hypertension, tachycardia, cardiac dysrhythmias, and aspiration of gastric contents. The most common complication that occurs while the ETT is in place is inadvertent endobronchial intubation. Flexion, not extension, of the neck or change from the supine to the head-down position can shift the carina upward, which may convert a mid-tracheal tube placement into a bronchial intubation. Extension of the neck can cause cephalad displacement of the tube into the pharynx. Lateral rotation of the head can displace the distal end of the ETT approximately 0.7 cm away from the carina. Complications associated with extubation of the trachea can be immediate or delayed. The two most serious immediate complications associated with extubation of the trachea are laryngospasm and aspiration of gastric contents. Laryngospasm is most likely to occur in patients who are lightly anesthetized at the time of extubation. If laryngospasm occurs, positive-pressure mask-bag ventilation with 100% O2 and forward displacement of the mandible may be sufficient treatment. However, if laryngospasm persists, succinylcholine should be administered intravenously or intramuscularly. Pharyngitis is another frequent complication after extubation of the trachea. This complication occurs most commonly in females, presumably because of the thinner mucosal covering over the posterior vocal cords compared with males. This complication usually does not require treatment and spontaneously resolves in 48 to 72 hours. Delayed complications associated with extubation of the trachea include laryngeal ulcerations, tracheitis, tracheal stenosis, vocal cord paralysis, and arytenoid cartilage dislocation (Stoelting: Basics of Anesthesia, ed 5, pp 231-232).

34. Gas from an N2O compressed-gas cylinder enters the anesthesia machine through a pressure regulator that reduces the pressure to
A. 60 psi
B. 45 psi
C. 30 psi
D. 15 psi
E. 10 psi

34. (B) Gas leaving a compressed-gas cylinder is directed through a pressure-reducing valve, which lowers the pressure within the metal tubing of the anesthesia machine to 45 to 55 psi (Miller: Anesthesia, ed 6, p 276).

35. Which of the following factors is LEAST responsible for killing bacteria in anesthesia machines?
A. Metallic ions
B. High O2 concentration
C. Anesthetic gases (at clinical concentrations)
D. Shifts in humidity
E. Shifts in temperature

35. (C) There is considerable controversy regarding the role of bacterial contamination of anesthesia machines and equipment in cross-infection between patients. The incidence of postoperative pulmonary infection is not reduced by the use of sterile disposable anesthetic breathing circuits (as compared with the use of reusable circuits that are cleaned with basic hygienic techniques). Furthermore, inclusion of a bacterial filter in the anesthesia breathing circuit has no effect on the incidence of cross-infection. Clinically relevant concentrations of volatile anesthetics have no bacteriocidal or bacteriostatic effects. Low concentrations of volatile anesthetics, however, may inhibit viral replication. Shifts in humidity and temperature in the anesthesia breathing and scavenging circuits are the most important factors responsible for killing bacteria. In addition, high O2 concentration and metallic ions present in the anesthesia machine and other equipment have a significant lethal effect on bacteria. Acid-fast bacilli are the most resistant bacterial form to destruction. Nevertheless, there has been no case documenting transmission of tuberculosis via a contaminated anesthetic machine from one patient to another. When managing patients who can potentially cause cross-infection of other patients (e.g., patients with tuberculosis, pneumonia, or known viral infections, such as acquired immune deficiency syndrome [AIDS]) a disposable anesthetic breathing circuit should be used and nondisposable equipment should be disinfected with glutaraldehyde (Cidex). Sodium hypochlorite (bleach), which destroys the human immunodeficiency virus, should be used to disinfect nondisposable equipment, including laryngoscope blades, if patients with AIDS require anesthesia (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 100).

36. Which of the following systems prevents attachment of gas-administering equipment to the wrong type of gas line?
A. Pin-index safety system
B. Diameter-index safety system
C. Fail-safe system
D. Proportion-limiting control system
E. None of the above

36. (B) The diameter-index safety system prevents incorrect connections of medical gas lines. This system consists of two concentric and specific bores in the body of one connection, which correspond to two concentric and specific shoulders on the nipple of the other connection (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 21, 30, 37).

37. A volatile anesthetic has a saturated vapor pressure of 360 mm Hg at room temperature. At what flow would this agent be delivered from a bubble-through vaporizer if the carrier-gas flow through the vaporizing chamber is 100 mL/min?
A. 30 mL/min
B. 60 mL/min
C. 90 mL/min
D. 120 mL/min
E. 150 mL/min

37. (C) The amount of anesthetic vapor (mL) in effluent gas from a vaporizing chamber can be calculated using the following equation:

where VO is the vapor output (mL) of effluent gas from the vaporizer, CG is the carrier gas flow (mL/min) into the vaporizing chamber, SVPanes is the saturated vapor pressure (mm Hg) of the anesthetic gas at room temperature, and Pb is the barometric pressure (mm Hg). In this question, fresh gas flow is 100 ml/min. 100 ml/min × 0.9=90 mL/min (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 61).

38. The dial of an isoflurane-specific, variable bypass, temperature-compensated, flowover, out-of-circuit vaporizer (i.e., modern vaporizer) is set on 2% and the mass spectrometer measures 2% isoflurane vapor from the common gas outlet. The flowmeter is set at a rate of 700 mL/min during this measurement. The output measurements are repeated with the flowmeter set at 100 mL/min and 15 L/min (vapor dial still set on 2%). How will these two measurements compare with the first measurement taken?
A. Output will be less than 2% in both cases
B. Output will be greater than 2% in both cases
C. Output will be 2% at 100 mL/min O2 flow and less than 2% at 15 L/min flow
D. Output will be 2% in both cases
E. Output will be less than 2% at 100 mL/min and 2% at 15 L/min

38. (A) The output of the vaporizer will be lower at flow rates less than 250 mL/min because there is insufficient pressure to advance the molecules of the volatile agent upward. At extremely high carrier gas flow rates (>15 L/ min) there is insufficient mixing in the vaporizing chamber (Miller: Anesthesia, ed 6, p 286).

39. Which of the following would result in the greatest decrease in the arterial hemoglobin saturation (Spo2) value measured by the dual-wavelength pulse oximeter?
A. Intravenous injection of indigo carmine
B. Intravenous injection of indocyanine green
C. Intravenous injection of methylene blue
D. Presence of elevated bilirubin
E. Presence of fetal hemoglobin

39. (C) Pulse oximeters estimate arterial hemoglobin saturation (Sao2) by measuring the amount of light transmitted through a pulsatile vascular tissue bed. Pulse oximeters measure the alternating current (AC) component of light absorbance at each of two wavelengths (660 and 940 nm) and then divide this measurement by the corresponding direct current component. Then the ratio (R) of the two absorbance measurements is determined by the following equation:

Using an empirical calibration curve that relates arterial hemoglobin saturation to R, the actual arterial hemoglobin saturation is calculated. Based on the physical principles outlined above, the sources of error in Spo2 readings can be easily predicted. Pulse oximeters can function accurately when only two hemoglobin species, oxyhemoglobin and reduced hemoglobin, are present. If any light-absorbing species other than oxyhemoglobin and reduced hemoglobin are present, the pulse oximeter measurements will be inaccurate. Fetal hemoglobin has minimal effect on the accuracy of pulse oximetry, because the extinction coefficients for fetal hemoglobin at the two wavelengths used by pulse oximetry are very similar to the corresponding values for adult hemoglobin. In addition to abnormal hemoglobins, any substance present in the blood that absorbs light at either 660 or 940 nm, such as intravenous dyes used for diagnostic purposes, will affect the value of R, making accurate measurements of the pulse oximeter impossible. These dyes include methylene blue and indigo carmine. Methylene blue has the greatest effect on Sao2 measurements because the extinction coefficient is so similar to that of oxyhemoglobin (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 254-255).

40. A 75-year-old patient with chronic obstructive pulmonary disease is ventilated with a mixture of 50% oxygen with 50% helium. Isoflurane 2% is added to this mixture. What effect will helium have on the mass spectrometer reading of the isoflurane concentration?
A. The mass spectrometer will give a slightly increased false value
B. The mass spectrometer will give a false value equal to double the isoflurane concentration
C. The mass spectrometer will give the correct value
D. The mass spectrometer will give a wrong value equal to half the isoflurane concentration
E. The mass spectrometer will give an erroneous value slightly less than the correct value of isoflurane

40. (B) The mass spectrometer functions by separating the components of a stream of charged particles into a spectrum based on their mass-to-charge ratio. The amount of each ion at specific mass-to-charge ratios is then determined and expressed as the fractional composition of the original gas mixture. The charged particles are created and manipulated in a high vacuum to avoid interference by outside air and minimize random collisions among the ions and residual gases. An erroneous reading will be displayed by the mass spectrometer when a gas that is not detected by the collector plate system is present in the gas mixture to be analyzed. Helium, which has a mass charge ratio of 4, is not detected by standard mass spectrometers. Consequently, the standard gases (i.e., halothane, enflurane, isoflurane, oxygen, nitrous oxide, nitrogen, and carbon dioxide) will be summed to 100% as if helium were not present. All readings would be approximately twice their real values in the original gas mixture in the presence of 50% helium (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 203-205).

41. Which of the following combinations would result in delivery of a higher-than-expected concentration of volatile anesthetic to the patient?
A. Halothane vaporizer filled with sevoflurane
B. Halothane vaporizer filled with isoflurane
C. Isoflurane vaporizer filled with halothane
D. Isoflurane vaporizer filled with sevoflurane
E. Sevoflurane vaporizer filled with halothane

41. (E) Because halothane and isoflurane have similar saturated vapor pressures, the vaporizers for these volatile anesthetics could be used interchangeably with accurate delivery of the anesthetic concentration set by the vaporizer dial. If a sevoflurane vaporizer were filled with a volatile anesthetic that has a greater saturated vapor pressure than sevoflurane (e.g., halothane or isoflurane), a higher-than-expected concentration would be delivered from the vaporizer. If a halothane or isoflurane vaporizer were filled with a volatile anesthetic that had a lower saturated vapor pressure than halothane or isoflurane (e.g., sevoflurane, enflurane, or methoxyflurane), a lower-than-expected concentration would be delivered from the vaporizer (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 66-67).
VAPOR PRESSURE AND MAC
Halo En Sevo Iso Des Metho
VP 20° C 243 172 160 240 669 23
MAC 30-55y/o 0.75 1.63 1.8 1.17 6.6 0.16

42. At high altitudes, the flow of a gas through a rotameter will be
A. Greater than expected
B. Less than expected
C. Greater than expected at high flows but less than expected at low flows
D. Less than expected at high flows but greater than expected at low flows
E. Greater than expected at high flows but accurate at low flows

42. (E) Gas density decreases with increasing altitude (i.e., the density of a gas is directly proportional to atmospheric pressure). Atmospheric pressure will influence the function of rotameters because the accurate function of rotameters is influenced by the physical properties of the gas, such as density and viscosity. The magnitude of this influence, however, depends on the rate of gas flow. At low gas flows, the pattern of gas flow is laminar. Atmospheric pressure will have little effect on the accurate function of rotameters at low gas flows because laminar gas flow is influenced by gas viscosity (which is minimally affected by atmospheric pressure) and not gas density. However, at high gas flows, the gas flow pattern is turbulent and is influenced by gas density (see explanation to question 2). At high altitudes (i.e., low atmospheric pressure), the gas flow through the rotameter will be greater than expected at high flows but accurate at low flows (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 38-43, 224-225).

43. A patient presents for knee arthroscopy and tells his anesthesiologist that he has a VDD pacemaker. Select the true statement regarding this pacemaker.
A. It senses only the ventricle
B. It paces only the ventricle
C. Its response to a sensed event is always inhibition
D.Its response to a sensed event is always a triggered pulse
E. It is not useful in a patient with AV nodal block

43. (B) Pacemakers have a three to five letter code that describes the pacemaker type and function. Since the purpose of the pacemaker is to send electrical current to the heart, the first letter identifies the chamber(s) paced; A for atrial, V for ventricle and D for dual chamber (A+V). The second letter identifies the chamber where endogenous current is sensed; A,V, D, and O for none sensed. The third letter describes the response to sensing; O for none, I for inhibited, T for triggered and D for dual (I+T). The fourth letter describes programmability or rate modulation; O for none and R for rate modulation (i.e., faster heart rate with exercise). The fifth letter describes multisite pacing (more important in dilated heart chambers); A, V or D (A+V) or O. A VDD pacemaker is used for patients with AV node dysfunction but intact sinus node activity. (Miller: Anesthesia, ed 6, pp 1416-1418).

44. All of the following would result in less trace gas pollution of the OR atmosphere EXCEPT
A. Using a high gas flow in a circular system
B. Tight mask seal during mask induction
C. Use of a scavenging system
D. Periodic maintenance of the anesthesia machine
E. Allow patient to breath 100% O2 as long as possible before extubation

44. (A) Although controversial, it is thought that chronic exposure to low concentrations of volatile anesthetics may constitute a health hazard to OR personnel. Therefore, removal of trace concentrations of volatile anesthetic gases from the OR atmosphere with a scavenging system and steps to reduce and control gas leakage into the environment are required. High-pressure system leakage of volatile anesthetic gases into the OR atmosphere occurs when gas escapes from compressed-gas cylinders attached to the anesthetic machine (e.g., faulty yokes) or from tubing delivering these gases to the anesthesia machine from a central supply source. The most common cause of low-pressure leakage of anesthetic gases into the OR atmosphere is the escape of gases from sites located between the flowmeters of the anesthesia machine and the patient, such as a poor mask seal. The use of high gas flows in a circle system will not reduce trace gas contamination of the OR atmosphere. In fact, this could contribute to the contamination if there is a leak in the circle system (Miller: Anesthesia, ed 6, pp 3151-3153).

45. The greatest source for contamination of the OR atmosphere is leakage of volatile anesthetics
A. Around the anesthesia mask
B. At the vaporizer
C. At the rotameter
D. At the CO2 absorber
E. At the endotracheal tube

45. (A) Although all of the choices in this question can contribute as sources of contamination, leakage around the anesthesia face mask poses the greatest threat (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 128-129; Miller: Anesthesia, ed 6, pp 3151-3153).

46. Uptake of sevoflurane from the lungs during the first minute of general anesthesia is 50 mL. How much sevoflurane would be taken up from the lungs between the 16th and 36th minutes?
A. 25 mL
B. 50 mL
C. 100 mL
D. 200 mL
E. 500 mL

46. (C) The amount of volatile anesthetic taken up by the patient in the first minute is equal to that amount taken up between the squares of any two consecutive minutes. Accordingly, 50 mL would be taken up between the 16th (4 × 4) and 25th (5 × 5) minute, and another 50 mL would be taken up between the 25th and 36th (6 × 6) minute (Miller: Anesthesia, ed 5, p 87).

47. Which of the drugs below would have the LEAST impact on somatosensory evoked potentials (SSEP) monitoring in a 15-year-old patient undergoing scoliosis surgery?
A. Midazolam
B. Fentanyl
C. Thiopental
D. Isoflurane
E. Vecuronium

47. (E) In evaluating SSEPs, one looks at both the amplitude or voltage of the recorded response wave as well as the latency (time measured from the stimulus to the onset or peak of the response wave). A decrease in amplitude (>50%) and/or an increase in latency (>10%) is usually clinically significant. These changes may reflect hypoperfusion, neural ischemia, temperature changes, or drug effects. All of the volatile anesthetics as well as barbiturates cause a decrease in amplitude as well as an increase in latency. Etomidate causes an increase in latency and an increase in amplitude. Midazolam decreases the amplitude but has little effect on latency. Opioids cause small and not clinically significant increases in latency and decrease in amplitude of the SSEPs. Muscle relaxants have no effect of the SSEP (Miller: Anesthesia, ed 6, pp 1525-1537; Stoelting: Basics of Anesthesia, ed 5, pp 312-314).

48. Select the FALSE statement regarding iatrogenic bacterial infections from anesthetic equipment.
A. Even low concentrations of O2 are lethal to airborne bacteria
B. Bacteria released from the airway during violent exhalation originate almost exclusively from the anterior oropharynx
C. Of all the bacterial forms, acid-fast bacteria are the most resistant to destruction
D. Shifts in temperature and humidity are probably the most important factors responsible for bacterial killing
E. Bacterial filters in the anesthesia breathing system lower the incidence of postoperative pulmonary infections

48. (E) Also see explanation to question 35. There is no evidence that the incidence of postoperative pulmonary infection is altered by the use of sterile disposable anesthesia breathing systems (compared with the use of reusable systems that are cleaned with basic hygienic techniques) or by the inclusion of a bacterial filter in the anesthesia breathing system (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 100).

49. Frost develops on the outside of an N2O compressed-gas cylinder during general anesthesia. This phenomenon indicates that
A. The saturated vapor pressure of N2O within the cylinder is rapidly increasing
B. The cylinder is almost empty
C. There is a rapid transfer of heat to the cylinder
D. The flow of N2O from the cylinder into the anesthesia machine is rapid
E. None of the above

49. (D) Vaporization of a liquid requires the transfer of heat from the objects in contact with the liquid (e.g., the metal cylinder and surrounding atmosphere). For this reason, at high gas flows, atmospheric water will condense as frost on the outside of compressed-gas cylinders (Stoelting: Basics of Anesthesia, ed 5, p 188).

50. The LEAST reliable site for central temperature monitoring is the
A. Pulmonary artery
B. Skin on forehead
C. Distal third of the esophagus
D. Nasopharynx
E. Tympanic membrane

50. (B) Pulmonary artery, esophageal, axillary, nasopharyngeal, and tympanic membrane temperature measurements correlate with central temperature in patients undergoing noncardiac surgery. Skin temperature does not reflect central temperature and does not warn adequately of malignant hyperthermia or excessive hypothermia (Miller: Anesthesia, ed 6, p 1591).

51. Each of the following statements concerning rotameters is true EXCEPT
A. Rotation of the bobbin within the Thorpe tube is important for accurate function
B. The Thorpe tube increases in diameter from bottom to top
C. Its accuracy is affected by changes in temperature and atmospheric pressure
D. The rotameter for N2O and CO2 are interchangeable
E. The rotameter for O2 should be the last in the series

51. (D) Rotameters consist of a vertically positioned tapered tube that is smallest in diameter at the bottom (Thorpe tube). Gas enters at the bottom of the Thorpe tube and elevates a bobbin or float, which comes to rest when gravity on the float is balanced by the fall in pressure across the float. The rate of gas flow through the tube depends on the pressure drop along the length of the tube, the resistance to gas flow through the tube, and the physical properties (density and viscosity) of the gas. Because few gases have the same density and viscosity, rotameters cannot be used interchangeably (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 38-43).

52. The reason a 40:60 mixture of helium and O2 is more desirable than a 40:60 mixture of nitrogen and O2 for a spontaneously breathing patient with tracheal stenosis is
A. Helium has a lower density than nitrogen
B. Helium is a smaller molecule than O2
C. Absorption atelectasis decreased
D. Helium has a lower critical velocity for turbulent flow than does O2
E. Helium is toxic to most microorganisms

52. (A) The critical velocity for helium is greater than that for nitrogen. For this reason, there is less work of breathing when helium is substituted for nitrogen (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 224-225; Miller: Anesthesia, ed 6, pp 690-691).

53. The maximum Fio2 that can be delivered by a nasal cannula is
A. 0.25
B. 0.30
C. 0.35
D. 0.40
E. 0.45

53. (E) The Fio2 delivered to patients from low-flow systems (e.g., nasal prongs) is determined by the size of the O2 reservoir, the O2 flow, and the patient's breathing pattern. As a rule of thumb, assuming a normal breathing pattern, the Fio2 delivered by nasal prongs increases by approximately 0.04 for each L/min increase in O2 flow up to a maximal Fio2 of approximately 0.45 (at an O2 flow of 6 L/min). In general, the larger the patient's Vt or faster the respiratory rate, the lower the Fio2 for a given O2 flow (Miller: Anesthesia, ed 6, pp 2812-2813).

54. General anesthesia is administered to an otherwise healthy 38-year-old patient undergoing repair of a right inguinal hernia. During mechanical ventilation, the anesthesiologist notices that the scavenging system reservoir bag is distended during inspiration. The most likely cause of this is
A. An incompetent pressure-relief valve in the mechanical ventilator
B. An incompetent pressure-relief valve in the patient breathing circuit
C. An incompetent inspiratory unidirectional valve in the patient breathing circuit
D. An incompetent expiratory unidirectional valve in the patient breathing circuit
E. None of the above; the scavenging system reservoir bag is supposed to distend during inspiration

54. (A) In a closed scavenging system interface, the reservoir bag should expand during expiration and contract during inspiration. During the inspiratory phase of mechanical ventilation the ventilator pressure-relief valve closes, thereby directing the gas inside the ventilator bellows into the patient breathing circuit. If the ventilator pressure-relief valve is incompetent, there will be a direct communication between the patient breathing circuit and scavenging circuit. This would result in delivery of part of the mechanical ventilator Vt directly to the scavenging circuit, causing the reservoir bag to inflate during the inspiratory phase of the ventilator cycle (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 128).

55. Which color of nail polish would have the greatest effect on the accuracy of dual-wavelength pulse oximeters?
A. Red
B. Yellow
C. Blue
D. Green
E. White

55. (C) The accurate function of dual-wavelength pulse oximeters is altered by nail polish. Because blue nail polish has a peak absorbance similar to that of adult deoxygenated hemoglobin (near 660 nm), blue nail polish has the greatest effect on the Spo2 reading. Nail polish causes an artifactual and fixed decrease in the Spo2 reading by these devices. Turning the finger probe 90 degrees and having the light shining sidewise through the finger is useful when there is nail polish on the patient's fingernails (Miller: Anesthesia, ed 6, pp 1448-1452).

56. The minimum macroshock current required to elicit ventricular fibrillation is
A. 1 mA
B. 10 mA
C. 100 mA
D. 500 mA
E. 5000 mA

56. (C) The minimum macroshock current required to elicit ventricular fibrillation is 50 to 100 mA (Brunner: Electricity, Safety, and the Patient, ed 1, pp 22-23; Miller: Anesthesia, ed 6, pp 3145-3146).

57. The line isolation monitor
A. Prevents microshock
B. Prevents macroshock
C. Provides electrical isolation in the OR
D. Sounds an alarm when grounding occurs in the OR
E. Provides a safe electrical ground

57. (D) The line isolation monitor alarms when grounding occurs in the OR or when the maximum current that a short circuit could cause exceeds 2 to 5 mA. The line isolation monitor is purely a monitor and does interrupt electrical current. Therefore, the line isolation monitor will not prevent microshock or macroshock (Brunner: Electricity, Safety, and the Patient, ed 1, p 304; Miller: Anesthesia, ed 6, pp 3140-3141).

58. Kinking or occlusion of the transfer tubing from the patient breathing circuit to the closed scavenging system interface can result in
A. Barotrauma
B. Hypoventilation
C. Hypoxia
D. Hyperventilation
E. None of the above

58. (A) A scavenging system with a closed interface is one in which there is communication with the atmosphere through positive- and negative-pressure relief valves. The positive-pressure relief valve will prevent transmission of excessive pressure buildup to the patient breathing circuit, even if there is an obstruction distal to the interface or if the system is not connected to wall suction. However, obstruction of the transfer tubing from the patient breathing circuit to the scavenging circuit is proximal to the interface. This will isolate the patient breathing circuit from the positive-pressure relief valve of the scavenging system interface. Should this occur, barotrauma to the patient's lungs can result (Ehrenwerth: Anesthesia Equipment: Principles and Applications, pp 127-128).

59. If the isoflurane vaporizer dial of an older (non- pressure compensating) machine is set to deliver 1.15% in Denver, Colo. (barometric pressure 630 mm Hg), how many MAC will the patient receive?
A. About 20% more than 1 MAC
B. About 10% more than 1 MAC
C. One MAC
D. About 10% less than 1 MAC
E. About 20% less than 1 MAC

59. (B) MAC for isoflurane is 1.15% of 1 atmosphere or 8.7 mm Hg. An isoflurane vaporizer set for 1.15% will use a splitting ratio of 1:39. For purposes of illustration, imagine 100 mL of oxygen passes through the vaporizing chamber and 3900 mL through bypass chamber.
100 mL × 240/(760 - 240) = 46.1 mL of isoflurane vapor (plus 100 mL oxygen)
46.1/(3900 + 100) = 46.1/4000 = 1.15%
1.15% × 760 mm Hg = 8.7 mm Hg (1 MAC)
Consider now the same splitting ratio applied in Denver:
100 mL × 240/(630 - 240) = 61.5 mL of isoflurane vapor (plus 100 mL oxygen)
61.5/(3900 + 100) = 61.5/4000 = 1.53%
1.53% × 630 mm Hg = 9.7 mm Hg (roughly 1.1 MAC)
Older vaporizers are not compensated for changes in barometric pressure. As a general rule, the higher the altitude (lower the barometric pressure), the greater the vaporizer output. Conversely, the higher the barometric pressure (i.e., hyperbaric chamber), the lower the output. The graph above depicts the relationship between "dialed" MAC versus delivered MAC as a function of barometric pressure expressed in atmospheres (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 70).

60. Select the FALSE statement regarding noninvasive arterial BP monitoring devices.
A. If the width of the BP cuff is too narrow, the measured BP will be falsely lowered
B. The width of the BP cuff should be 40% of the circumference of the patient's arm
C. If the BP cuff is wrapped around the arm too loosely, the measured BP will be falsely elevated
D. Oscillometric BP measurements are accurate in neonates
E. Frequent cycling of automated BP monitoring devices can result in edema distal to the cuff

60. (A) Automated noninvasive blood pressure (ANIBP) devices provide consistent and reliable arterial BP measurements. Variations in the cuff pressure resulting from arterial pulsations during cuff deflation are sensed by the device and are used to calculate mean arterial pressure. Then, values for systolic and diastolic pressures are derived from formulas that use the rate of change of the arterial pressure pulsations and the mean arterial pressure (oscillometric principle). This methodology provides accurate measurements of arterial BP in neonates, infants, children, and adults. The main advantage of ANIBP devices is that they free the anesthesia provider to perform other duties required for optimal anesthesia care. Additionally, these devices provide alarm systems to draw attention to extreme BP values and have the capacity to transfer data to automated trending devices or recorders. Improper use of these devices can lead to erroneous measurements and complications. The width of the BP cuff should be approximately 40% of the circumference of the patient's arm. If the width of the BP cuff is too narrow or if the BP cuff is wrapped too loosely around the arm, the BP measurement by the device will be falsely elevated. Frequent BP measurements can result in edema of the extremity distal to the cuff. For this reason, cycling of these devices should not be more frequent than every 1 to 3 minutes. Other complications associated with improper use of ANIBP devices include ulnar nerve paresthesia, superficial thrombophlebitis, and compartment syndrome. Fortunately, these complications are rare occurrences (Miller: Anesthesia, ed 6, pp 1269-1271; Stoelting: Basics of Anesthesia, ed 5, p 307).

61. An incompetent ventilator pressure-relief valve can result in
A. Hypoxia
B. Barotrauma
C. A low-circuit-pressure signal
D. Hypoventilation
E. Hyperventilation

61. (D) If the ventilator pressure-relief valve were to become incompetent, there would be a direct communication between the patient breathing circuit and the scavenging system circuit. This would result in delivery of part of the Vt during the inspiratory phase of the ventilator cycle directly to the scavenging system reservoir bag. Therefore, adequate positive-pressure ventilation may not be achieved and hypoventilation of the patient's lungs may result. Also see explanation to question 54 and accompanying figure (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 120).

62. The pressure gauge of a size "E" compressed-gas cylinder containing air shows a pressure of 1000 psi. Approximately how long could air be delivered from this cylinder at the rate of 10 L/min?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 40 minutes
E. 50 minutes

62. (C) A size "E" compressed-gas cylinder completely filled with air contains 625 L and would show a pressure gauge reading of 2000 psi. Therefore, a cylinder with a pressure gauge reading of 1000 psi would be half-full, containing approximately 325 L of air. A half-full size "E" compressed-gas cylinder containing air could be used for approximately 30 minutes at a flow rate of 10 L/min (see definition of Boyle's law in explanation to question 9 and explanation and table from question 10) (Stoelting: Basics of Anesthesia, ed 5, p 188).

63. The most frequent cause of mechanical failure of the anesthesia delivery system to deliver adequate O2 to the patient is
A. Attachment of the wrong compressed-gas cylinder to the O2 yoke
B. Crossing of pipelines during construction of the OR
C. Improperly assembled O2 rotameter
D. Fresh-gas line disconnection from the anesthesia machine to the in-line hosing
E. Disconnection of the O2 supply system from the patient

63. (E) Failure to oxygenate patients adequately is the leading cause of anesthesia-related morbidity and mortality. All of the choices listed in this question are potential causes of inadequate delivery of O2 to the patient; however, the most frequent cause is inadvertent disconnection of the O2 supply system from the patient (e.g., disconnection of the patient breathing circuit from the endotracheal tube) (Miller: Anesthesia, ed 6, p 300).

64. The esophageal detector device
A. Uses a negative pressure bulb
B. Is especially useful in children younger than 1 year of age
C. Requires a cardiac output to function appropriately
D. Is reliable in morbidly obese patients and parturients
E. Is contraindicated if there is blood in the airway

64. (A) The esophageal detector device (EDD) is essentially a bulb that is first compressed then attached to the ETT after the tube is inserted into the patient. The pressure generated is about negative 40 cm of water. If the ETT is placed in the esophagus, then the negative pressure will collapse the esophagus and the bulb will not inflate. If the ETT is in the trachea, then the air from the lung will enable the bulb to inflate (usually in a few seconds but at times may take more than 30 seconds). A syringe that has a negative pressure applied to it has also been used. Although initial studies were very positive about its use, more recent studies show that up to 30% of correctly placed ETTs in adults may be removed because the EDD suggested esophageal placement. Misleading results have been noted in patients with morbid obesity, late pregnancy, status asthmatics and when there is copious endotracheal secretion, where the trachea tends to collapse. Its use in children younger than 1 year of age showed poor sensitivity as well as poor specificity. Although a cardiac output is needed to get CO2 to the lungs for a CO2 gas analyzer to function, a cardiac output is not needed for an EDD (American Heart Association—Guidelines for CPR and ECC. Circulation Volume 112, Issue 24, pp IV-54, IV-150, IV-169, 2005; Miller: Anesthesia, ed 6, p 1648).

65. The reason CO2 measured by capnometer is less than the arterial Paco2 value measure simultaneously is?
A. Use of ion specific electrode for blood gas determination
B. Alveolar capillary gradient
C. One way values
D. Alveolar dead space
E. Intrapulmonary shunt

65. (D) The capnometer measures the CO2 concentration of respiratory gases. Today this is most commonly performed by infrared absorption using a sidestream gas sample. The sampling tube should be connected as close to the patient's airway as possible. The difference between the end-tidal CO2 (Etco2) and the arterial CO2 (Paco2) is typically 5-10 mm Hg and is due to alveolar dead space ventilation. Because non-perfused alveoli do not contribute to gas exchange, any condition that increases alveolar dead space ventilation (i.e., reduces pulmonary blood flow such as a pulmonary embolism or cardiac arrest) will increase dead space ventilation and the Etco2 to Paco2 difference. Conditions that increase pulmonary shunt result in minimal changes in the Paco2-Etco2 gradient. CO2 diffuses rapidly across the capillary-alveolar membrane (Barash: Clinical Anesthesia, ed 5, pp 670-671; Miller: Anesthesia, ed 6, pp 1455-1462).

66. Which of the following arrangements of rotameters on the anesthesia machine manifold is safest with left to right gas flow?
A. O2, CO2, N2O, air
B. CO2, O2, N2O, air
C. N2O, O2, CO2, air
D. Air, CO2, O2, N2O
E. Air, CO2, N2O, O2

66. (E) The last gas added to a gas mixture should always be O2. This arrangement is the safest because it assures that leaks proximal to the O2 inflow cannot result in delivery of a hypoxic gas mixture to the patient. With this arrangement (O2 added last), leaks distal to the O2 inflow will result in a decreased volume of gas, but the Fio2 of Anesthesia will not be reduced (Stoelting: Basics of Anesthesia, ed 5, pp 188-189).

67. A Datex Ohmeda Sevotec 5 vaporizer is tipped over while being attached to the anesthesia machine, but is placed upright and installed. The soonest it can be safely used is
A. After 30 minutes of flushing with dial set to "off"
B. After 6 hours of flushing with dial to "off"
C. After 24 hours of flushing with dial set to "off"
D. After 30 minutes with dial set at low concentration
E. After 12 hours with dial set to low concentration

67. (D) Most modern Datex-Ohmeda Tec or North American Dräger Vapor vaporizers (except desflurane) are variable-bypass, flow-over vaporizers. This means that the gas that flows through the vaporizers is split into two parts depending upon the concentration selected. The gas either goes through the bypass chamber on the top of the vaporizer or the vaporizing chamber on the bottom of the vaporizer. If the vaporizer is "tipped" which might happen when a filled vaporizer is "switched out" or moved from one machine to another machine, part of the anesthetic liquid in the vaporizing chamber may get into the bypass chamber. This could result in a much higher concentration of gas than dialed. With the Datex-Ohmeda Tec 4 or the North American Drager Vapor 19.1 series it is recommended to flush the vaporizer at high flows with the vaporizer set at a low concentration until the output shows no excessive agent (this usually takes 20-30 minutes). The Drager Vapor 2000 series has a transport (T) dial setting. This setting isolates the bypass from the vaporizer chamber. The Aladin cassette vaporizer does not have a bypass flow chamber and has no "tipping" hazard (Miller: Anesthesia ed 6, pp 285-288).

68 In the event of misfilling, what percent sevoflurane would be delivered from an isoflurane vaporizer set at 1%?
A. 0.6%
B. 0.8%
C. 1.0%
D. 1.2%
E. 1.4%

68. (A) The table above shows the calculation (fraction) that when multiplied by the quantity of fresh gas traversing the vaporizing chamber (affluent fresh gas in mL/min) will yield the output (mL/min) of anesthetic vapor in the effluent gas. When this fraction is multiplied by 100 it equals the splitting ratio for 1% for the given volatile. For example, when the isoflurane vaporizer is set to deliver 1% isoflurane, one part of fresh gas passed through the vaporizing chamber while 47 parts travel through the bypass chamber. One can determine on inspection that when a less soluble volatile like sevoflurane (or enflurane for the sake of example) is placed into an isoflurane (or halothane) vaporizer, the output in volume percent will be less than expected. How much less can be determined by simply comparing their splitting ratios 27/47 or 0.6. Halothane and enflurane are no longer used in the United States, but old halothane and enflurane vaporizers can be (and are) used elsewhere in the world to accurately deliver isoflurane and sevoflurane respectively (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 67).

69. How long would a vaporizer (filled with 150 mL volatile) deliver 2% isoflurane if total flow set at 4.0 L/minute?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
E. 10 hours

69. (C) Two percent of 4 L/min would be 80 mL of isoflurane per minute. VAPOR PRESSURE PER ML OF LIQUID
Halo En Iso Sevo Des
vapor per liquid 226 196 195 182 207
(Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 60)
Since 1 mL of vapor produces 195 mL of gas or making the simplistic calculation of 195 × 150 mL = 29,250. It follows that 29,250/80 = 365 minutes or about 6 hours.
Note that each mL of most volatiles will yield 200 mL vapor at 20° C. Thus 150 min × 200 mL/min = 30,000 min. It follows that 30,000 min/80 mL/min = 375 minutes or ≈ 6 hours. (Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 60).

70. Raising the frequency of an ultrasound transducer used for line placement or regional anesthesia, e.g., from 3 MHz to 10 MHz, will result in
A. Higher penetration of tissue with lower resolution
B. Higher penetration of tissue with higher resolution
C. Lower penetration of tissue with higher resolution
D. Higher resolution with no change in tissue penetration
E. Higher penetration with no change in resolution

70. (C) The human ear can perceive sound in the range of 20 Hz to 20 kHz. Frequencies above 20 kHz, inaudible to humans, are ultrasonic frequencies (ultra = Latin for "beyond" or "on the far side of"). In regional anesthesia, ultrasound is used for imaging in the frequency range of 2.5 to 10 MHz. Wavelength is inversely proportional to frequency, i.e., λ = C/f (λ = wavelength, C = velocity of sound through tissue or 1540 m/sec, f = frequency). Wavelength in millimeters can be calculated by dividing 1.54 by the Doppler frequency in megahertz. Penetration into tissue is 200 to 400 times wavelength and resolution is twice the wavelength. Therefore, a frequency of 3 MHz (wavelength .51 mm) would have a resolution of 1 mm and a penetration of up to 100 - 200 mm (10-20 cm) whereas 10 MHz (wavelength 0.15 mm) corresponds to a resolution of 0.3 mm, but penetration depth of no more than 60-120 mm (6-12 cm) (Miller: Anesthesia, ed 6, p 1364).

71. The fundamental difference between microshock and macroshock is related to
A. Location of shock
B. Duration
C. Voltage
D. Capacitance
E. Lethality

71. (A) Microshock refers to electric shock in or near the heart. A current as low as 50 μA passing through the heart can produce ventricular fibrillation. Use of pacemaker electrodes, central venous catheters, pulmonary artery catheters and other devices in the heart make are necessary prerequisites for microshock. Because the line isolation monitor has a 2 milliamps (2000 μA) threshold for alarming, it will not protect against microshock (Miller Anesthesia, ed 6, page 3145).

72. Intraoperative awareness under general anesthesia can be eliminated by closely monitoring
A. EEG
B. BP/heart rate
C. Bispectral index (BIS)
D. End tidal volatile
E. None of the above

72. (E) Intraoperative awareness or recall during general anesthesia is rare (overall incidence is 0.2%, for obstetrics 0.4%, for cardiac 1-1.5%) except for major trauma which has a reported incidence up to 43%. With the EEG, trends can be identified with changes in the depth of anesthesia, however the sensitivity and specificity of the available trends are such that none serve as a sole indicator of anesthesia depth. Although using the BIS monitor may reduce the risk of recall, it, like the other listed signs as well as patient movement, does not totally eliminate recall (Miller: Anesthesia, ed 6, pp 1230-1259).

73. A mechanically ventilated patient is transported from the OR to the intensive care unit (ICU) using a portable ventilator that consumes 2 L/min of oxygen to run the mechanically controlled valves and drive the ventilator. The transport cart is equipped with an "E" cylinder with a gauge pressure of 2000 psi. The patient receives a VT of 500 mL at a rate of 10 breaths/minute. If the ventilator requires 200 psi to operate, how long could the patient be mechanically ventilated?
A. 20 min
B. 40 min
C. 60 min
D. 80 min
E. 100 min

73. (D) The minute ventilation is five liters (0.5 L per breath at 10 breaths per minute) and 2 liters per minute to drive the ventilator for a total O2 consumption of 7 liters per minute. A full oxygen "E" cylinder contains 625 liters. Ninety percent of the volume of the cylinder (≈ 560 L) can be delivered before the ventilator can no longer be driven. At a rate of 7 L/min, this supply would last about 80 minutes (Stoelting: Basics of Anesthesia, ed 5, page 188).

74. A 135 Kg man is ventilated at a rate of 14 breaths/minute with a Vt of 600 mL and positive end-expiratory pressure (PEEP) of 5 cm H2O during a laparoscopic banding procedure. Peak airway pressure is 50 cm H2O and the patient is fully relaxed with a non-depolarizing neuromuscular blocking agent. How can peak airway pressure be reduced without a loss of alveolar ventilation?
A. Increase the inspiratory flow rate
B. Take off PEEP
C. Reduce the I:E ratio (e.g., change from 1:3 to 1:2)
D. Decrease Vt to 300 and increase rate to 28
E. None of the above

74. (C) After eliminating reversible causes of high peak airway pressures such as occlusion of the endotracheal tube, mainstem intubation, bronchospasm, etc., adjusting the ventilator can reduce the peak airway pressure. Increasing the inspiratory flow rate would cause the airway pressures to go up faster and would produce higher peak airway pressures. Taking the PEEP off would have no significant effect. Changing the I:E ratio from 1:3 to 1:2 will permit 8% (25% inspiratory time to 33% inspiratory time) more time for the Vt to be administered and would result in lower airway pressures. Decreasing the Vt to 300 and increasing the rate to 28 would give the same minute ventilation, but not the same alveolar ventilation. Recall that alveolar ventilation equals (frequency) times (Vt minus dead space); and since dead space is the same (about 2 mL/kg ideal weight) alveolar ventilation would be reduced, in this case to a dangerously low level. Another option is to change from volume cycled to pressure cycled ventilation, which produces a more constant pressure over time instead of the peaked pressures seen with fixed Vt ventilation. (Barash: Clinical Anesthesia, ed 5, pp 1484-1485; Miller: Anesthesia, ed 6, pp 2820-2822).

75. The pressure and volume per minute delivered from the central hospital oxygen supply are:
A. 2100 psi and 650 L/minute
B. 1600 psi and 100 L/minute
C. 75 psi and 100 L/minute
D. 50 psi and 50 L/minute
E. 30 psi and 25 L/minute

75. (D) The central hospital oxygen supply to the operating rooms is designed to give enough pressure and oxygen flow to run the three oxygen components of the anesthesia machine (patient fresh gas flow, the anesthesia ventilator and the oxygen flush valve). The oxygen flowmeter on the anesthesia machine is designed to run at an oxygen pressure of 50 psi and for emergency purposes the oxygen flush valve delivers 35 to 75 L/min of oxygen (Stoelting: Basics of Anesthesia, ed 5, pp 187-189).

76. During normal laminar airflow, resistance is dependent upon which characteristic of oxygen?
A. Density
B. Viscosity
C. Molecular weight
D. Vapor pressure
E. Temperature

76. (B) Within the respiratory system both laminar and turbulent flows exist. At low flow rates, the respiratory flow tends to be laminar, like a series of concentric tubes that slide over one another with the center tubes flowing faster than the more peripheral tubes. Laminar flow is usually inaudible and is dependent on gas viscosity. Turbulent flow tends to be faster flow, is audible and is dependent upon gas density. Gas density can be decreased by using a mixture of helium with oxygen. (Barash: Clinical Anesthesia, ed 5, pp 794-795, Miller: Anesthesia, ed 6, p 2539).

77. If the oxygen cylinder is being used as the source of oxygen at a remote anesthetizing location and the oxygen flush valve on an anesthesia machine were pressed and held down, as during an emergency situation, each of the items below would be bypassed during 100% oxygen delivery EXCEPT:
A. O2 flowmeter
B. First stage regulator
C. Vaporizer check valve
D. Vaporizers
E. Second stage regulator

77. (B) Anesthesia machines have a high, intermediate and low pressure circuits. The high pressure circuit is from the oxygen cylinder to the oxygen pressure regulator (first stage regulator) which takes the oxygen pressure from a high of 2200 psi to 45 psi. The intermediate pressure circuit consists of the pipeline pressure of about 50 to 55 psi and goes to the second stage regulator, which then lowers the pressure to 14 to 26 psi (depending upon the machine). The low pressure circuit then consists of the flow tubes, vaporizer manifold, vaporizers and vaporizer check valve to the common gas outlet. The oxygen flush valve is in the intermediate pressure circuit and bypasses the low pressure circuit (Stoelting: Basics of Anesthesia, ed 5, p 187; Miller: Anesthesia, ed 6, pp 274-276).

78. After induction and intubation with confirmation of tracheal placement, the O2 saturation begins to fall. The O2 analyzer as well as mass spectrometer show 4% inspired oxygen. The oxygen line pressure is 65 psi. The O2 tank on the back of anesthesia machine has a pressure of 2100 psi and is turned on. The oxygen saturation continues to fall. The next step should be
A. Exchange the tank
B. Switch the O2 line with N2O line
C. Disconnect the O2 line from hospital source
D. Extubate and start mask ventilation
E. Replace pulse oximeter probe

78. (C) Two major problems should be noted in this case. The first obvious problem is the inspired oxygen concentration of 4%, a concentration that is not possible if the gases going to the machine are appropriate unless the oxygen analyzer is faulty. In this case, where both the oxygen analyzer and the mass spectrometer read 4%, the pipeline gas line supplying "oxygen" most likely contains something other than oxygen. Second, the oxygen line pressure is 65 psi. The pipeline pressures are normally around 50 to 55 psi, whereas the pressure from the oxygen cylinder, if the cylinder is turned on, is reduced to 45 psi. For the oxygen tank to deliver oxygen to the patient, the pipeline pressure needs to be less than 45 psi, which in this case would occur only when the pipeline is disconnected. Although we rarely think of problems with hospital gas lines, a survey of more than 200 hospitals showed about 33% had problems with the pipelines. Most common pipeline problems were low pressure, followed by high pressure and, very rarely, crossed gas lines. (Barash: Clinical Anesthesia, ed 5, pp 563-564, Miller: Anesthesia, ed 6, pp 274-276).

79. The correct location for placement of the V5 lead is
A. Midclavicular line third intercostal space
B. Anterior axillary line fourth intercostal space
C. Midclavicular line fifth intercostal space
D. Anterior axillary line fifth intercostal space.
E. Any position on precordium

79. (D) There are many ways to monitor the electrical activity of the heart. The five-electrode system using one lead for each limb and the fifth lead for the precordium is commonly used in the operating suite. The precordial lead placed in the V5 position (anterior axillary line in the fifth intercostal space) gives the V5 tracing, which combined with the standard lead II are most common tracings used to look for myocardial ischemia (Barash: Clinical Anesthesia, ed 5, pp 889, 1539; Miller: Anesthesia, ed 6, pp 1392-1393).

80. The Diameter Index Safety System (DISS) refers to the interface between
A. Pipeline source and anesthesia machine
B. Gas cylinders and anesthesia machine
C. Vaporizers and refilling connectors attached to bottles of volatile anesthetics
D. Float and tapered flow tube on machine manifold
E. Both pipeline and gas cylinders interfaces with anesthesia machine

80. (A) The DISS provides threaded, non-interchangeable connections for medical gas pipelines through the hospital as well as to the anesthesia machine. The Pin Index Safety System (PISS) has two metal pins located in different arrangements around the yoke on the back of anesthesia machines, with each arrangement for a specific gas cylinder. Vaporizers often have keyed fillers that attach to the bottle of anesthetic and the vaporizer. Vaporizers not equipped with keyed fillers occasionally have been misfilled with the wrong anesthetic liquid (Barash: Clinical Anesthesia, ed 5, p 563; Miller: Anesthesia, ed 6, pp 276 and 288).

81. Each of the following is cited as an advantage of calcium hydroxide lime (Amsorb Plus, Drägersorb) over soda lime EXCEPT:
A. Compound A is not formed
B. Carbon monoxide is not formed
C. More absorptive capacity per 100 g of granules
D. Indicator dye once changed does not revert to normal
E. It does not contain NaOH or KOH

81. (C) Calcium hydroxide lime does not contain the monovalent hydroxide bases that are present in soda lime (namely NaOH and KOH). Sevoflurane in the presence of NaOH or KOH is degraded to trace amounts of Compound A, which is nephrotoxic to rats at high concentrations. Soda lime normally contains about 13% to 15% water, but if the soda lime is desiccated (water content < 5% — which has occurred if the machine is not used for a while and the fresh gas flow is left on) and exposed to current volatile anesthetics (isoflurane, sevoflurane and especially desflurane), carbon monoxide can be produced. Neither Compound A nor carbon monoxide are formed when calcium hydroxide lime is used. With soda lime and calcium hydroxide lime the indicator dye changes from white to purple as the granules become exhausted; however, over time, exhausted soda may revert back to white. With calcium hydroxide lime the dye once changed does not revert to normal. The two major disadvantages of calcium hydroxide lime are the expense and the fact that its absorptive capacity is about half of soda lime (10.2 L of CO2/100 g of calcium hydroxide lime versus 26 L of CO2/100 g of soda lime) (Barash: Clinical Anesthesia, ed 5, pp 411-413; Miller: Anesthesia, ed 6, pp 296-298; Stoelting: Basics of Anesthesia, ed 5, pp 200-202).

82. The arrows in the figure above indicate
A. Respiratory variation
B. An underdamped signal
C. An overdamped signal
D. Atrial fibrillation
E. Aortic regurgitation

82. (B) The aim of direct invasive monitoring is to give continuous arterial BPs that are similar to the intermittent noninvasive arterial BPs from a cuff, as well as to give a port for arterial blood samples. The displayed signal reflects the actual pressure as well as distortions from the measuring system (i.e., the catheter, tubing, stopcocks, amplifier). Although most of the time the signal is accurate, at times we see an underdamped or an overdamped signal. In an underdamped signal, as in this case, exaggerated readings are noted (widened pulse pressure). In an overdamped signal, readings are diminished (narrowed pulse pressure). Note however the mean BP tends to be accurate in both underdamped and overdamped signals (Miller: Anesthesia, ed 6, pp 1272-1279).

83. During a laparoscopic cholecystectomy exhaled CO2 is 6%, but inhaled CO2 is 1%. Which explanation could NOT account for rebreathing CO2?
A. Channeling through soda lime
B. Faulty expiratory valve
C. Exhausted soda lime
D. Faulty inspiratory valve
E. Absorption of CO2 through peritoneum

83. (E) Rebreathing of expired gases (e.g., stuck open expiratory or inspiratory valves), faulty removal of CO2 from the carbon dioxide absorber (e.g., exhausted CO2 absorber, channeling through a CO2 absorber or having the CO2 absorber bypassed — an option in some older anesthetic machines), or adding CO2 from a gas supply (rarely done with current anesthetic machines) can all increase inspired CO2. Absorption of CO2 during laparoscopic surgery when CO2 is used as the abdominal distending gas would increase absorption of CO2 but would not cause an increase in inspired CO2 (Miller: Anesthesia, ed 6, pp 1458-1461; Stoelting: Basics of Anesthesia, ed 5, pp 199-201, 314).

84. Helium
A. Black
B. Brown
C. Blue
D. Gray
E. Orange

84. (B)

85. Nitrogen
A. Black
B. Brown
C. Blue
D. Gray
E. Orange

85. (A)

86. Carbon dioxide
A. Black
B. Brown
C. Blue
D. Gray
E. Orange

84. (B) 85. (A) 86. (D) Medical gas cylinders are color coded but may differ from one country to another. If there is a combination of two gases, the tank would have both corresponding colors, for example, a tank containing oxygen and helium would be green and brown. The only exception to the mixed gas color scheme is O2 and N2 in the proportion of 19.5% to 23.5% mixed with N2, which is solid yellow (air).
GAS COLOR CODES
Gas United States International
Air Yellow White and Black
Carbon Dioxide Gray Gray
Helium Brown Brown
Nitrogen Black Black
Nitrous Oxide Blue Blue
Oxygen Green White
(Ehrenwerth: Anesthesia Equipment: Principles and Applications, p 7.)

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