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What drugs may prevent ketamine delirium?

Benzodiazepines or propofol

What do you give a cardiac transplant patient with symptomatic bradycardia?
a. Flumazenil 4 mg IV push
b. 500 mL fluid bolus
c. dopamine 200 micorg/min IV infusin
d. atropine 0.5 mg IV push

c.
Sinus node is deinnervated in transplant patient; therefore, atropine would have no effect on it.

How do you reverse a drug like dexmedetomidine or clonidine?

Atipamezole (alpha 2 antagonist)

Type II diabetic arrives for IV sedation/ EXT; he is combative & disoriented. NPO x 6 hours; took acarbose and glyburide this AM; glucose is 50. What do you do?

Give 1 mg IM glucagon
juice/ soda wouldn't work b/c of acarbose; disoriented pt. not likely to safely take PO tablets of dextrose.

What is ketamine's direct effect on the heart?

inotropic depression
it indirectly activates the sympathetic nervous system by increasing norepi by blocking its reuptake at postganglionic sympathetic neurons

Which drugs cause nerve injury/ gangrene with intra-arterial injection and trigger porphyria in susceptible individuals?

barbiturates

Which drug causes adrenal suppression lasting at least 6 hours?

etomidate

Which effect is seen with propofol?
a. elevated ICP
b. increased IOP
c. potentiate neuromuscuilar blockade
d. bronchodilation

bronchodilation

Which drug should be avoided in epilepsy?
a. propofol
b. fentanly
c. dexmedetomidine
d. methohexital

methohexital

What is acute intermitent porphyria?

autosomal dominant condition leading to a deficiency in uroporphyrinogen synthetase activity that causes an accumulation of uroporphobilogen (causing dark urine)

What are the signs/ symptoms of acute intermitent porphyria?

1. intense abdominal pain (all 4 quads)
2. muscle weakness
3. progressive confusion after several days
4. eventual darkening of urine (port wine colored)
5. hypertension
6. renal failure
7. seizures

What are the agents that can trigger acute intermitent porphyria?

1. Barbiturates (Most Common)
2. Pentazocine (analgesic)
Controversy surrounding many other drugs as possible safe or potential triggers

How do you treat acute intermitent porphyria?

1. Discontinue any known triggering agents
2. hydration
3. carbohydrate adminstration
4. Hematin 3-4 mg/kg IV over 20 min (early in attack; American Porphyria Foundation has info on how to get it quickly
5. opioids for pain control
6. antiemetics for nausea
7. beta-blockers for HTN/ tachycardia
8. Treat electrolyte abnormalities
7. benzodiazepines for seizures

30 minutes after extubating a 6 yoa asthmatic pt. you notice respiratory distress w/ high pitched coarse sounds on inspiration. What is the most likely diagnosis and treatment?

postextubation stridor
racemic epinephrine (aerosolized 2.25%): produces mucosal vasocontriction and reduces laryngeal edema

What is the first drug to administer for intraoperative bronchospasm under inhalational GA?
a. Decadron IV
b. decrease depth of anesthesia
c. Albuterol MDI through ET tube
d. Epi IV

Albuterol MDI
Save epi IV for severe bronchospasm not responsive to albuterol

What are the signs/ symptoms of thyroid storm (thyrotoxicosis factitia)?

tachycardia
severe hypotension
fever
dehydration
agitation
CHF
skeletal muscle weakness

What condition does thyroid storm potentially mimic?

malignant hyperthermia (but no muscle rigidity or rhabdomyolosis); thyroid storm more likely to occur 6-18 hours after surgery

While under anesthesia for a bone graft, the patient suddenly becomes tachycardic, hypotensive, and hypoxic; also decreasing end-tidal CO2. 12 lead EKG shows new right axis deviation, peaked T waves, and incomplete RBBB. Most likely diagnosis is?

PE

Which of the following is contraindicated in the management of malignant hyperthermia and why?
a. Procainamide 100 mg IV
b. Cardizem
c. Regular insulin and D50
d. Sodium Bicarbonate

Cardizem: Ca channel blockers contraindicated because they can cause severe myocardial depression in the presence of dantrolene.

Which of these patients would be safest to induce for GA?
a. 6 month old having 30mL formula 5 hrs ago
b. 15 yoa having 500 mL cola 2.5 hr ago
c. 46 yoa female 40 mL fresh squeezed OJ 3.5 hr ago
d. 65 yoa w/ peanut butter toast 6 hr ago

b. 15 yoa having 500 mL cola (clear liquid) 2.5 hr ago.

What position due you put a patient in post aspiration?

right lateral Trendelenberg
(less aspirate likely to flow in; I think of it as what position would be most effective at using gravity to help drain it out)

Why is tracheobronchial lavage usually not indicted for aspiration?

Because the chemical damage to mucosa already occurred during the first few seconds; relative neutralization of the aspirant occurred within minutes. Lavage normally would come too late to provide any benefit.

When is exploratory bronchoscopy indicated after aspiration?

If large amounts of particulate matter are aspirated.

65 yoa female w/ CHF, Parkinsons. Pre-op vitals BP = 135/85, HR 100, resp = 15. She has taken her selegiline (selective irreversible MAO-B inhibitor), digoxin (cardiac glycoside), enalapril (ACE inhibitor), and potassium. After initiating conscious sedation using nitrous oxide/oxygen, fentanyl and midazolam, you note the following vital sign changes prior to local: BP
= 70/40, pulse = 85, respirations = 18. spO2 90. No change after administering 100% oxygen, flumazenil (Romazicon), and naloxone
(Narcan). Which next step would be the most appropriate?
A. Trendelenberg position
B. 750 ml intravenous saline fluid bolus
C. Ephedrine 2.5 mg IV
D. Phenylephrine (neosynephrine) 0.1 mg IV

D. Phenylephrine 0.1mg IV (cautiously)
no Trendelenburg or large fluid bolus due to potential to increase CVP and precipitate episode of congestive HF.
Some MAO-A inhibition w/ selegiline; therefore, ephedrine may cause hypertensive crisis

Which of the following muscle relaxants is the best choice for intubation in the atopic patient
with severe gastroesophageal reflux disease?
A. Succinylcholine
B. Mivacurium
C. Atracurium
D. Rocuronium

D. Rocuronium
Suxx may cause increased gastric pressure (through fasciculations) and increase risk of aspiration through a compromised esophageal sphincter
Mivacurium and atracurium would release histamine; bad idea in atopic patient.
Rocuronium (steroid relaxant) releases no histamine and works quickly

Which of the following medications would not require significant dosing adjustments in the
elderly patient?
A. Cisatracurium
B. Alfentanil
C. Desflurane
D. Thiopental

A. Cisatracurium (Hoffman elimination)

Why is drug clearance in the elderly compromised?

decreased renal and hepatic blood flow
decreased hepatic microsomal enzyme activity

Why does it take longer for many anesthetic agents to work on the elderly?

decreased muscle mass (highly vascularized) which is generally the first compartment

Why does it take longer for many anesthetic agents to terminate their redistribution effect in the elderly?

increase in adipose tissue which is also poorly vascularized

How does the MAC change in the elderly and why?

It decreases due to increased CNS sensitivity to anesthetic agents

A patient with a T-4 spinal injury has a 4.5 hour general anesthetic. The patient has no foley
catheter because the intended surgery was to have taken 2 hours. The patient suddenly
becomes hypertensive and bradycardic. The ECG reflects sinus bradycardia in Lead II. Flushing
is evident in the face and mucous membranes. You notice the patient sweating and exhibiting
mydriasis of both pupils. The best explanation for this complex of symptoms is:
A. myocardial infarction.
B. autonomic hyperreflexia.
C. increased intracranial pressure.
D. massive pulmonary embolism.

B. Autonomic hyperreflexia
Autonomic hyperreflexia is a syndrome of massive, disinhibited reflex sympathetic
discharge in response to cutaneous or visceral stimulation below the level of the spinal
cord lesion.

How would an MI likely present under GA?

hypotension
ST-segment changes
possibly new Q waves; V5 most sensitive

Lead II detects ishemia in which distribution?

RCA

What is the Cushing reflex?

When elevated ICP approaches systemic arterial pressure causing:
1. Hypertension
2. Bradycardia

How will a PE likely present under GA? (4)

1. tachycardia
2. hypotension
3. hypoxia
4. right-axis deviation on EKG

Which of the following drugs should be avoided for induction of general anesthesia in the severe
coronary artery disease patient?
A. Propofol
B. Fentanyl
C. Sevoflurane
D. Ketamine

D. Ketamine

You are extracting teeth on a morbidly obese man who is a heavy smoker and has obstructive
sleep apnea. The patient receives 100 mcg of fentanyl and 5 mg of midazolam prior to local
anesthetic injection. After a few minutes you note that the patient's ventilation has decreased
and he appears clinically cyanotic. However, the pulse oximeter reads 96% (SpO2). What is the
most likely explanation for this phenomenon?
A. Motion artifact due to patient movement
B. High levels of carboxyhemoglobin
C. Elevated hemoglobin and hematocrit
D. Supplemental oxygen by nasal cannula

B. High levels of carboxyhemoglobin

An 18 year-old healthy male patient in your office was given 10 mg of midazolam, 50 mcg of
fentanyl and 30 mg of propofol during a long extraction case. The patient has prolonged
emergence from anesthesia and decreased ventilations. The pulse oximeter reads 89%
oxygenation on 4 L nasal cannula oxygen. The patient is administered flumazenil 0.2 mg and
naloxone 0.2 mg. His mental status and ventilations improve. Forty minutes later in your
recovery room he appears drowsy and is non-responsive to commands. The pulse oximeter
reads 91%. Shallow unobstructed respirations are approximately 12 per minute. How should
you proceed?
A. Administer flumazenil
B. Administer supplemental oxygen
C. Support the patient's airway
D. Administer naloxone

A. flumazenil

What is the onset, time to peak effect, and duration of Flumazenil?

onset: 1-2 min
peak: 2-10 min
duration: 45-90 min

What is the onset, time to peak effect, and duration of naloxone?

onset: 1-2 min
peak: 5-15 min
duration: 60-240 min

The OMS team is treating an orbital floor blow-out fracture in a 47 year-old man who has a
history of hypertension and is a smoker. During elevation of the orbital contents the patient is
noted to become hypotensive (SBP = 65) and bradycardic (45). The most appropriate initial
pharmacologic treatment for this clinical situation is?
A. Ephedrine 20 mg IV
B. Transcutaneous pacing
C. Epinephrine 1.0 mg IV
D. Atropine 0.5 mg IV

D. Atropine 0.5 mg IV

The patient you are treating is a spinal cord injured dialysis patient with end stage renal disease
(ESRD). He exhibits a serum potassium of 5.1. Which of the following muscle relaxants is the
agent of choice with this patient?
A. Rocuronium
B. Vecuronium
C. Atracurium
D. Succinylcholine

C. Atracurium
no suxx due to cord injury --> extrajunctional receptor upregulation potential for severe hyperkalemia

Which of the following best supports the discontinuation of pyridostigmine (Mestinon -
cholinesterase inhibitor) during the anesthetic management of the patient with myasthenia
gravis?
A. Continuation would increase risk of cholinergic crisis
B. Continuation would increase risk of respiratory muscle weakness
C. Discontinuation decreases sensitivity to respiratory depression associated with opioids
D. Continuation results in resistance to succinylcholine and shortened duration

A. Continuation would increase risk of cholinergic crisis

What is myasthenia gravis?

an autoimmune disease of the motor endplate. They only have about 20-30% of the normal number of Ach motor-endplate receptors; About 25% are required for functional neuromuscular transmission.

How is myasthenia gravis treated?

anticholinesterase therapy
the goal is to increase the amount of Ach to overcome the lack of Ach receptors resulting in an increase in neuromuscular function.

What are the 4 common anticholinesterase agents that can treat myasthenia gravis?

1. edrophonium
2. neostigmine
3. pyridostigmine (most common)
4. ambedonium

How do you assess the respiratory function of a patient with myasthenia gravis pre-op?

PFTs

Which common anesthetic drugs must be used sparingly in patients with myasthenia gravis?

narcotics
due to depressing an already comprimised respiratory reserve

What is the problem with continuing anticholinesterase therapy in myasthenia gravis patients for GA?

1. antagonizes non-depolarizing relaxants and prolongs succinylcholine effects
2. has the potential risk of resulting in cholinergic crisis

What is the problem with stopping anticholinesterase therapy in myasthenia gravis patients for GA?

1. Results in muscle weakness and compromised respiratory function
2. If relaxant still needed, it will cause resistance to succinylcholine (and prolong its effects) and increase sensitivity to nondepolarizing relaxants.

a depolarizing neuromuscular agents?
A. A lack of fade in response to train of four (TOF)
B. Increase in post-tetanic stimulation
C. Tetanus is associated with fade in muscle response
D. Fourth twitch of TOF disappears with 60-70% receptor occupancy

A. A lack of fade in response to train of four (TOF)

A 37 year-old female presents for emergent surgery. She has been recently diagnosed with
Graves' disease but has yet to start any treatment. She also has hypertension and arthritis. Her
only medication is Lasix (furosemide), which she takes sporadically. What would be the most
appropriate medication to administer pre-operatively to avoid anesthetic complications in this
emergent situation?
A. Propylthiouracil
B. Decadron
C. Iodide
D. Propranolol

D. Propanolol

What is Graves disease?

An autoimmune disease where autoantibodies are generated that trigger the TSH receptor. This results in gland enlargement and overt hyperthyroidism

Does thyroid storm exhibit hypertension or hypotension?

hypertension with wide pulse pressure early on;
later hypotension (shock) ensures

What are the common types of anti-thyroid medications? How long do they take to act?

1. Propylthiouracil
2. Methimazole
inhibits thyroid hormone production and peripheral conversion of T4 --> T3
takes 6-8 weeks to become euthyroid

What do iodide containing solutions do?

inhibit T3/T4 release for a period of time.
Pre-op preparation for hyperthyroid/ Graves patients may take 7-14 days ideally

How do corticosteroids like decadron affect patients in thyroid storm?

reduce thyroid hormone secretion
reduce peripheral conversion of T4 --> T3

22 yoa female for 3rds. normal pre-op vitals; anesthetic w/ 3.5 mg midazolam, 50 mcg fentanly, 50 mg ketamine, 50 mg propofol. 144mg lido w/ 72 mcg epi. HR after induction 95. 45 min later pt. is slightly confused, palpitations, feels warm. bp 150/60; HR 145 irregular; RR 22; end-tidal CO2 43. What is best diagnosis/ treatment?
A. secondary to combination of ketamine and epinephrine. In a healthy individual would observe for another 30 minutes.
B. secondary to combination of ketamine and epinephrine and possible pain. Warrants
pharmacologic intervention.
C. Tachycardia, and hypercapnea must alert the practitioner to consider a diagnosis of
malignant hyperthermia and initiate dantrolene therapy.
D. The clinical presentation is that of a hypermetabolic state. Would consider a diagnosis of hyperthyroidism and initially manage with esmolol 20 - 30 mgs.

D. The clinical presentation is that of a hypermetabolic state. Would consider a diagnosis of hyperthyroidism and initially manage with esmolol 20 - 30 mgs.

A 27 year-old female with a previously unknown medical history arrives in the PACU after repair
of a facial laceration under general anesthesia. She has not had a significant blood loss.
Shortly after arrival, she is noted to have a heart rate of 150, a temperature of 39o C, a
respiratory rate of 30, oxygen saturation of 99 %, and a blood pressure of 92/65. A blood gas
reveals a pH of 7.4, PaO2 of 80, PaCO2 of 38, and a bicarbonate of 24. She is agitated and
confused. What is the most likely diagnosis?
A. Thyrotoxicosis
B. Malignant Hyperthermia
C. Pheochromocytoma
D. Postoperative pain

A. Thyrotoxicosis

26 yoa 60 kg female sedated w/ 3.5 mg midazolam, 100 mcg fentanyl, 0.4 mg atropine, 30 mg ketamine, 60 mg propofol bolus, then continuous infusion (total 375 mg) Patent airway, spontaneous resp. bp 110/65, HR 72 regular. 5 min after has what appeared to be brief self-limiting seizure. 2nd one occurred 5 min later. EEG normal. What is most consistent?
A. Myoclonic activity associated with opioid compounded by hypoxia
B. Emergence reaction associated with ketamine
C. Dysphoric reaction associated with atropine(tertiary amine)
D. Idiopathic reaction associated with propofol; etiology unknown

D. idiopathic reaction associated w/ propofol; etiology unknown

Can you get seizure-like activity from opioids?

High dose opioids can cause myoclonus which may sometimes resemble seizures. Muscle rigidity and myoclonus most often observed on induction in practice, but have been observed post-operatively

What may be responsible for this constellation of signs/ symptoms?
Central manifestations like:
1. disorientation
2. agitation
3. hallucinations
4. ataxia
5. seizures.
Peripheral manifestations like:
1. tachycardia
2. mydriasis
3. facial flushing
4. hyperpyrexia
5. urinary retention
6. decreased sweating

Central anticholinergic syndrome

What anesthesia drugs may precipitate central anticholinergic syndrome?

antichoinergics that cross the blood-brain barrier
1. atropine
2. hyoscyamine
3. scopolamine
NOT glycopyrolate since quaternary amine doesn't cross barrier

How do you treat central anticholinergic syndrome?

1 mg physostigmine

A 56 year-old male was admitted at after sustaining a fractured mandible. The patient
undergoes general anesthesia for open reduction of a mandible fracture 15 hours later. He has
a history of hypertension, cigarette smoking, daily alcohol consumption, and cocaine use. He
last used cocaine two days ago. While awakening in the recovery room, he becomes
progressively more confused, tremulous, and agitated. The patient does not complain of pain.
Monitoring shows heart rate - 115; BP 180/98; RR - 22; oxygen saturation - 92%; ECG - sinus
tachycardia. Which medication would you administer initially to manage this situation?
A. Morphine sulfate
B. Labetalol (Trandate)
C. Haloperidol (Haldol)
D. Lorazepam (Ativan)

D. Lorazepam
Alchohol withdrawal

Name 6 possible causes of post-surgery delirium

1. cerbral hypoperfusion, hypotension, hypoxia, anemia
2. hyperthermia
3. fluid, electrolyte, or acid-base abnormalities
4. Pain
5. anticholinergic syndrome
6. Withdrawal from: benzodiazepines, opioids, alcohol

A healthy 22 year-old female who is 5 foot 2 inches, 170 pounds presents for extraction of 1
tooth. Oxygen at 4 liters/minute is administered via nasal cannula. Five minutes after oxygen
administration is initiated the patient is induced with propofol 140 mgs. The patient becomes
apneic. Pulse oximeter reads 100%. The surgeon proceeds with extracting the tooth and does
not take immediate intervention to provide airway support and positive pressure ventilation.
Which of the following either justifies or counters the surgeon's actions?
A. Preoxygenation with the 36% oxygen mixture for 5 minutes will maintain the oxygen
saturation at or above 90% for at least 3 minutes in this individual
B. The surgeon should initiate positive pressure ventilation as obese patients desaturate
approximately twice as rapidly as individuals with lean body mass.
C. Preoxygenation with an FiO2 of 0.36 will produce a PAO2 of 160 mm Hg which does not
provide ample reserve for the surgeon to complete a 30 second procedure
D. The administration of propofol will not result in prolonged apnea and continuous
insufflation of oxygen will sustain an oxyhemoglobin saturation > 90%.

B.

A 68 year-old male with a history of emphysema is anesthetized for management of a panfacial
fracture. Intraoperative medications administered include sevoflurane, propofol, succinylcholine,
and morphine. The patient is orally intubated with difficulty. Two hours into the surgery the
anesthesiologist comments that the patient has been developing increased airway pressures.
Auscultation of the chest is difficult with distant sounds. Oxygen saturation is 90%. The patient
is also noted to be hypotensive despite fluid replacement for the blood loss. Which of the
following interventions should be considered?
A. Reposition the endotracheal tube
B. Needle decompression of the chest
C. Administer four puffs of albuterol
D. Administer phenylephrine

B. Needle decompression of the chest.
Poor question. spO2 not as low as expected for tension pneumo, actual BP not given. Bilateral distant sounds very unlikely he developed bilateral tension pneumo at same time.

What action would you take in regards to the ventilation of an intubated anesthetized patient
who is in bronchospasm?
A. Increase expiratory time by decreasing ventilator rate
B. Decrease inspiratory flow rates to decrease inspiratory time
C. Apply PEEP (positive end expiratory pressure)
D. Increase minute volume

Answer: A
Rationale:
The objective in managing a patient who is having a bronchospastic episode is to minimize lung hyperinflation. Lung hyperinflation occurs when there is diminished
expiratory flow which results in gas trapping in the alveoli and small airways. Lung hyperinflation can be prevented by increasing the expiratory to inspiratory ratio. A slow breathing rate should be used to allow for adequate ventilation and adequate time for exhalation. This should be coupled with an increase in inspiratory flow rate which will
decrease inspiratory time. PEEP should not be used because it impairs exhalation and increases the likelihood of distal air trapping. A decrease in minute ventilation (tidal
volumes less than 10 mg/kg) will allow controlled hypoventilation and should be used also to allow for adequate ventilation and exhalation.

An 18 year-old 65 kg male with sickle cell anemia is involved in a motor vehicle accident
sustaining a mandibular fracture. He is admitted to the hospital and goes to the operating room
10 hours after admission. On admission the patient is started on 0.9% NS with 20 mEq
potassium at 110 mL/hr. The patient's HCT is 30% at the start of surgery. During surgery blood
loss is approximately 75 cc. The patient receives 500 cc of Lactated Ringer's solution
intraoperatively. On arrival to the PACU the patient is shivering and complaining of feeling cold
with a body temperature of (96F). Demerol (maperidine) 25 mg IV is administered for the
shivering. Shortly thereafter the patient complains of dyspnea and extremity pain. Respiratory
rate is 20. An ABG is taken and the results are pH 7.38, PaO2 of 80, PaCO2 of 42, and a
bicarbonate of 22. What factor could be contributory to the patient's presentation?
A. Hypothermia
B. Dehydration
C. Anemia
D. Demerol

A. Hypothermia

Hypothermia may cause peripheral
vasoconstriction promoting vascular stasis and hyperthermia accelerates hemoglobin S
polymerization.

Levonordefrin in the local anesthetic agent causes a decrease in which of the following
cardiovascular affects?
A. Mean arterial pressure
B. Heart rate
C. Diastolic blood pressure
D. Systemic vascular resistance

Answer: B
Rationale:
Levonordefrin lacks significant beta-2 activity. The vasoconstricting activity associated
with alpha agonism raised the mean arterial pressure. A compensatory vagal reflex is
initiated by the baroreceptors in the aortic arch and carotid sinuses and the heart rate is
decreased. Epineprhine is the vasoconstrictor most appropriate for hypertensive patients
and levonordefrin is the vasoconstrictor most appropriate for patients with tachycardic
conditions.

Which local anesthetic has the greatest risk of cardiotoxicity?
A. Articaine
B. Bupivicaine
C. Ropivicaine
D. Prilocaine

B. Bupivicaine

Which drug is more likely to cause respiratory collapse if overdosed?
A. Articaine
B. Bupivicaine
C. Ropivicaine
D. Etidocaine

A. Articaine
When the more potent lipid soluble drugs are overdosed there is a greater likelihood that the patient will develop ventricular dysrhythmias resulting in cardiovascular collapse in contrast to hypotension, bradycardia and hypoxia that follows an overdose of the other less potent local anesthetics, such as lidocaine, articaine, mepivicaine, and prilocaine.

Which of the following drugs decreases lower esophageal sphincter tone?
A. Neostigmine
B. Glycopyrrolate
C. Metoclopramide
D. Succinylcholine

B. Glycopyrrolate
Also atropine and TCAs though this has not been proven to be of clinical significance

In a patient homozygous for atypical pseudocholinesterase, which of the following best explains
the prolonged action of succinylcholine?
A. Increased proportion of drug at neuromuscular junction
B. Slowed diffusion away from the neuromuscular junction
C. Development of a "dual" or phase I block
D. Unopposed prejunctional activity

A. Increased proportion of drug at NMJ
Most of the succinylcholine administered to a patient is metabolized by pseudocholinesterase in the bloodstream to succinylmonocholine, a metabolite with minimal neuromuscular blocking properties. Only five percent of the injected drug ever reaches the neuromuscular junction. Neuromuscular blockade ends when succinylcholine diffuses into the extracellular space. Prolonged blockade occurs in individuals who are homozygous for atypical pseudocholinesterase, which has 1/100 the
affinity of the normal enzyme for succinylcholine. As a consequence, more succinylcholine reaches the neuromuscular junction. In these individuals, urinary
excretion and protein binding contribute to the clearance of the drug.

Which drugs combination balances out the potential adverse hemodynamic properties of each
agent?
A. Propofol and remifentanil
B. Ketamine and propofol
C. Etomidate and midazolam
D. Midazolam and propofol

B. Ketamine and propofol

46 yoa male w/ BMI 32 & controlled asthma is sedated, becomes apneic, unable to mask or intubate. Classic LMA placed w/ PPV. Inspiratory pressure required w/ 30 cmH2O for 2.5 hr surgery. Which satement is most accurate?
A. The use of a classic LMA for an obese, asthmatic patient was inappropriate
B. Surgery length exceeds manufacturers recommendation for classic LMA
C. The inspiratory pressure used in this case was higher than suggested
D. Supine position increases the risk of gastric insufflation and aspiration

C. The inspiratory pressure used in this case was higher than suggested
Should not exceed 20 cmH2O

What are 3 drugs with low hepatic extraction ratios?

1. thiopental
2. diazepam
3. lorazepam

What are 2 drugs with intermediate hepatic extraction ratios?

1. methohexital (Brevital)
2. midazolam

What are 3 drugs with high hepatic extraction ratios?

1. propofol
2. ketamine
3. etomidate

Decreased hepatic blood flow (due to aging or volatile anesthetics) affects which type of drugs most?
A. Low hepatic extraction rates (thiopental, diazepam, lorazepam)
B. Intermediate hepatic extraction rates (methohexital, midazolam)
C. High hepatic extraction rates (propofol, ketamine, etomidate)

C. High hepatic extraction rates (propofol, ketamine, etomidate)

The elimination and clearance of which anesthetic agent is least affected by the coadministration
of a potent inhalational agent?
A. Ketamine
B. Methohexital
C. Midazolam
D. Diazepam

D. Diazepam
due to low hepatic extraction rate; less affected by decreased hepatic blood flow caused by inhalation agent

Which anesthetic agent can produce adverse cardiovascular effects when administered to a
patient taking tricyclic antidepressants?
A. Dexmedetomidine
B. Ketamine
C. Etomidate
D. Desflurane

Answer: B
Tricyclic antidepressants block catecholamine reuptake. Increasing concentrations of circulating catecholamines can lead to tachycardia and hypertension. Ketamine has
sympathomimetic effects and can potentiate the cardiovascular effects of tricyclic antidepressants. Of the inhalational agents halothane should be avoided as it may result in ventricular arrhythmias. There is no drug interaction causing cardiovascular effects with any of the other agents.

Which of the following describes the effect of desflurane on the cardiovascular system?
A. Maintaining positive pressure ventilation with desflurane minimizes the potential for
cardiovascular collapse
B. Of the potent anesthetic agents, desflurane promotes an abnormal collateral blood flow
redistribution (coronary steal) that causes myocardial ischemia
C. Airway pungency associated with desflurane causes a reflex tachycardia not seen with
sevoflurane
D. The concomitant administration of fentanyl with desflurane potentiates the sympatholytic
effect of fentanyl resulting in a decrease in heart rate

C. Airway pungency associated with desflurane causes a reflex tachycardia not seen with
sevoflurane

What actions can optimize a mask induction with sevoflurane in the patient with a difficult
airway?
A. Priming the system with 1 MAC sevoflurane
B. Pretreatment with an opioid
C. Pretreatment with a benzodiazepine
D. Pretreatment with an antisialogogue

C. Pretreatment with a benzodiazepine
Should not contribute to apnea and will help patient maintain spontaneous respirations

Prior to administering general anesthesia to a 1 year-old born at 32 weeks, one should be
concerned with:
A. bronchopulmonary dysplasia.
B. intracranial hemorrhage.
C. oxygen-induced retinopathy.
D. Sudden Infant Death Syndrome.

A. bronchopulmonary dysplasia
BPD is a chronic pulmonary disorder that typically afflicts premature infants who required increased concentrations of oxygen and mechanical ventilation at birth to treat respiratory
distress syndrome. This results in increased airway reactivity, decreased arterial oxygenation due to ventilation-to-perfusion mismatch.

Administration of dry anesthetic gases and oxygen at room temperature via an anesthetic
breathing system that bypasses the nose may lead to:
A. Atelectasis
B. Alveolar-arterial shunting
C. Heat Loss
D. Hypertension

C. Heat Loss
The most important reason to provide heated humidification during general anesthesia is to decrease heat loss and associated decrease in body temperature. may lead to
cytologic damage of the respiratory epithelium, drying of secretions, and water and heat loss from the patient. This is particularly important in infants and children who are
rendered poikilothermic with general anesthesia.

A 63 year-old male with a past medical history of hypertension, coronary artery disease, and
gout has the following vital signs in the PACU. BP = 200/120, P = 84, RR = 18, T = 99.1, oxygen
saturation is 98%. What medication is most appropriate?
A. Labetalol 20 mg
B. Hydralazine 10 mg
C. Phentolamine 5 mg
D. Esmolol 30 mg

A. Labetalol 20 mg
Labetalol is an alpha, and beta-1 blocker, and would be a good choice in terms reducing blood pressure without untoward effects on the heart. It preferentially has greater 
alpha blocking effects to beta blocking effects by a ratio of approximately 4 to 1. Its onset occurs in 5 - 10 minutes

Dexmedetomidine (Precedex®) acts on which receptor?
A. gamma-aminobutyric (GABA)
B. Mu-1
C. alpha 2 adrenergic
D. beta2 adrenergic

C. alpha 2 adrenergic
it is an agonist like clonidine

Question: Administration of which of the following drugs does not produce active metabolites?
A. Diazepam
B. Meperidine
C. Morphine
D. Lorazepam

D. Lorazepam

What are the 2 active metabolites of diazepam?

desmethyldiazepam and oxazepam

What is the active metabolite of meperidine (Demerol)? What side effect might it have?

normeperidine which has half the potency of
meperidine and may have CNS side effects (CNS excitability - seizures). Normeperidine is eliminated by the kidneys.

What is the most potent metabolite of morphine?

morphine-6-glucuronide, which is more potent than morphine itself

Your postoperative patient is in the recovery room and has been treated for nausea and
vomiting. Two hours after this treatment, the patient begins to experience torticollis and
blepahrospasm. Which of the following agents was most likely used to treat this patient's
nausea and vomiting?
A. Prochlorperazine (Compazine)
B. Ondansetron (Zofran)
C. Dexamethasone (Decadron)
D. Scopolamine (Transderm - Scop)

A. Prochlorperazine (Compazine)
This patient is experiencing extrapyramidal symptoms as a result of an anti-emetic medication. Of these medications, prochlorperazine, is the only one which can causes
the extrapyramidal effects, occurring due to its anti-dopaminergic effects. Treatment of the extrapyramidal symptoms can be with either the antihistamine diphenhydramine (Benadryl) or the anticholinergic benzatropine (Cogentin.)

How do you treat extrapyramidal symptoms resulting from an anti-emetic medication?

Treatment of the extrapyramidal symptoms can be with either:
1. antihistamine diphenhydramine(Benadryl)
2. anticholinergic benzatropine (Cogentin.)

In which of the following situations should the use of flumazenil be avoided?
A. Diazepam overdose
B. Pre-existing ischemic heart disease
C. Head injury
D. Concomitant opioid/benzodiazepine use

C. Head injury
Flumazenil can increase intracranial pressure, and its use in head injury patients should be avoided.

Which of the following antihypertensive medications should be held preoperatively?
A. Atenolol (β-1 selective blocker)
B. Clonidine (alpha-2 adrenergic agonist)
C. Lisinopril (ACE inhibitor)
D. Minoxidil (vasodilator)

C. Lisinopril (ACE inhibitor)
While there is no universal agreement, many believe that ACE inhibitors and angiotensin receptor antagonists should be held the day of surgery.

Why do many like ACE inhibitors and ARBs to be held on day of surgery?

Peri-induction hypotension can result from the loss of sympathetic tone associated with anesthesia induction
superimposed upon renin-angiotensin system (RAS) blockade. The vasopressin system is the only intact system left to maintain BP, and vasopressin release is not a fastresponse system compared to the sympathetic nervous system. The usual pressors used intraoperatively (ephedrine and phenylephrine) might be insufficient with RAS blockade as well as sympathetic tone loss associated with anesthesia induction.

Why are pediatric patients more susceptible to airway compromise when they are supinely
positioned?
A. The rostrally positioned epiglottis will narrow the airway when patient supine.
B. Diaphragmatic breathing is compromised with supination.
C. Relatively vertical rib position decreases ventilatory efficiency.
D. Airway compliance increases in the supine position.

B. Diaphragmatic breathing is compromised with supination.
The pediatric patient is more dependent on diaphragmatic breathing because of the relatively horizontally angled ribs and the less developed accessory muscles. The tongue is positioned higher in the oral cavity impinging on the soft palate secondary to the rostrally positioned larynx. Supine
positioning may compromise the airway secondary to tongue, and not epiglottal obstruction.

Which of the following is the least likely to unmask the negative inotropic effects of ketamine?
A. Uncompensated shock
B. Chronic beta-blocker therapy
C. Cocaine use
D. Excessive volume resuscitation

D. Excessive volume resuscitation
The negative inotropic effects may be unmasked with depletion of endogenous catecholamine stores (cocaine use, chronic beta-blocker therapy) or when the sympathetic compensatory mechanism is overwhelmed
as occurs when patients are in shock or are critically ill.

What is the onset of the cardiovascular effects of ketamine and their usual duration?

Onset 3-5 min (IV)
20 min (IV)

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