Anesthesia for Miscellaneous Procedures

Questions

DIRECTIONS (Questions 397-456): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

397. A 58-year-old, 5’8”, 138-kg male is brought emergently to the operating room for exploration of an open tibial fracture with vascular compromise under general anesthesia. Vital signs are BP 112/64, HR 94, RR 22, Spo₂ 96%. A rapid sequence induction with propofol, fentanyl, and succinylcholine is performed. Upon loss of consciousness, the patient desaturates precipitously, requiring positive pressure ventilation to maintain oxygenation. The LEAST effective means of preventing this desaturation would be preoxygenation with

(A) the application of positive pressure ventilation

(B) four vital capacity breaths with 100% O₂ within 30 sec

(D) placement of the patient’s head, neck, and upper body in the “ramped” position

(E) placement of the patient in the reverse Trendelenburg position

398. A 53-year-old, 5’10” 142-kg patient underwent an 8-h excision of a pancreatic cyst under combined general/epidural anesthesia. The epidural, placed at the T8 level, was dosed preoperatively with good effect. In the PACU, the patient has no incisional pain, but complains of severe bilateral buttock, upper back, and shoulder pain. On physical examination, there is tenderness to palpation of the affected areas. The most appropriate initial step in management should be to

(A) begin broad spectrum antibiotics

(B) add an anti-inflammatory to patient’s analgesic regimen

(D) seek a consult from the neurology service

(E) assure adequate volume repletion

399. You are asked to evaluate a 47-year-old male with advanced alcoholic cirrhosis, now placed on the liver transplant waiting list. In reviewing his chart, you note that he has a MELD score of 13 and is listed as a Child-Pugh class B. The criterion that is common to both classification models is

(A) serum creatinine

(B) degree of ascites

(D) serum albumin

(E) severity of encephalopathy

DIRECTIONS: Use the following scenario to answer Questions 400-401: A 28-year-old, 5’3”, 124-kg woman, who underwent Roux-en-Y gastric bypass surgery four months ago, presents to your preoperative testing unit for evaluation prior to a scheduled laparoscopic cholecystectomy. You notice her gait seems unsteady as she walks into your office, and that her handshake seems weak. On questioning, she describes a several week history of vomiting and muscle weakness that she attributes to a recent flulike illness. On exam she exhibits both a slight foot and wrist drop bilaterally. Medical history is otherwise unremarkable.

400. All of the following conditions should be part of your differential diagnosis EXCEPT

(A) Wernicke’s encephalopathy

(B) vitamin A deficiency

(D) APGARS neuropathy

(E) vitamin B₁₂ deficiency

401. The single best predictor of problematic intubation in this patient is

(A) Mallampati class 4 airway

(B) body mass index

(D) history of obstructive sleep apnea

(E) thyromental distance

DIRECTIONS: Use the following scenario to answer Questions 402-403: A 64-year-old, 5’11”, 156-kg male is brought to the operating room for an emergent laparoscopic appendectomy under general endotracheal anesthesia. Induction is performed with midazolam, sufentanil, propofol, and succinylcholine.

402. The anesthetic agent that should be dosed according to lean body weight is

(A) propofol

(B) succinylcholine

(D) midazolam

403. Anesthesia is maintained with O₂, N₂O, desflurane and sufentanil. Within 10 min of insufflation of the abdomen, the patient’s oxygen saturation has dropped slowly from 97% to 92%. The most appropriate initial step in management should be to

(A) increase tidal volume from 7 mL/kg to 10 mL/kg

(B) place the patient in reverse Trendelenburg position

(D) add 5 cm H₂O of PEEP

(E) change the ventilation mode from volume control to pressure control

404. A 52-year-old, 5’4”, 118-kg male, previously healthy, is scheduled for excision of a pancreatic cyst. Prior to surgery, he undergoes pulmonary function testing. When comparing the results of this patient’s study with those of a 5’8”, 84-kg male with a similar medical history, one would expect the greatest difference in

(A) RV

(B) FRC

(D) FVC

(E) FEV₁

405. You are called to the PACU to evaluate your patient, a previously healthy 51-year-old female who underwent an uneventful subtotal thyroidectomy for newly diagnosed papillary carcinoma that finished three hours ago, and who now appears to be in respiratory distress. On arrival, you immediately note her stridorous inspirations, her sternal retractions, and her agitation. The most likely cause of her symptoms is

(A) tracheomalacia

(B) unilateral recurrent laryngeal nerve injury

(D) incisional hemorrhage

(E) bilateral recurrent laryngeal nerve injury

DIRECTIONS: Use the following scenario to answer Questions 406-407: A 67-year-old male with a diagnosis of acute cholangitis is brought to the operating room urgently for endoscopic sphincterotomy and drainage of the gallbladder. His past medical history is significant for a recent diagnosis of Graves disease for which he was started on antithyroid therapy 2 weeks before admission. He is now febrile (38.2°C) and tachycardic (104 bpm), with oxygen saturation of 96% and a stable blood pressure. He received antibiotics one hour prior to arriving in the operating room.

406. The laboratory value that will yield the most information about the patient’s response to his antithyroid treatment is

(A) TSH

(B) free T3

(D) radioiodine uptake

(E) total T3

407. After an uneventful general anesthetic with endotracheal intubation, the patient was transferred to the PACU. Initial vital signs included a HR 108, BP 94/48, SpO₂ 98%, and T 38.4°C. You order a fluid bolus of 500 mL of crystalloid. One hour later, you are called to evaluate the patient who has just vomited and is now agitated, confused, and diaphoretic, with a temperature of 39.3°C, HR 152 bpm with ventricular ectopy, BP 86/42, SpO₂ 97%. The least appropriate medication for initial management of this patient is

(A) methimazole

(B) aspirin

(D) cholestyramine

(E) propranolol

DIRECTIONS: Use the following scenario to answer Questions 408-409: A 46-year-old male is undergoing orthotopic liver transplant for end-stage liver disease secondary to alcoholic cirrhosis.

408. Risks during graft reperfusion include all of the following EXCEPT

(A) increased systemic vascular resistance

(B) paradoxical embolus

(D) decreased coronary perfusion pressure

(E) pulmonary hypertension

409. Electrolyte disturbances commonly seen in patients undergoing liver transplantation include all of the following EXCEPT

(A) hyperkalemia

(B) hyperglycemia

(D) hypocalcemia

(E) hypoglycemia

410. 42-year-old male with end-stage renal disease secondary to a 25-year history of type I diabetes is scheduled for explant of a previously transplanted kidney followed by immediate renal transplant. The anesthetic maintenance technique that is most ideal in this situation is

(A) O₂, N₂O, desflurane, fentanyl, pancuronium

(B) O₂, N₂O, sevoflurane, fentanyl, cisatracurium

(D) O₂, air, desflurane, fentanyl, cisatracurium

(E) O₂, air, desflurane, fentanyl, rocuronium

DIRECTIONS: Use the following scenario to answer Questions 411-412: A 71-year-old female is in your ICU following emergent repair of a rupture of her descending aorta following a motor vehicle accident. She is extubated 12 h after arrival to the unit. Shortly thereafter, she begins complaining of nausea, vomiting, and severe abdominal pain. Her abdominal exam is unimpressive. Laboratory results are pending.

411. The most likely etiology of her symptoms is

(A) acute cholecystitis

(B) small bowel obstruction

(D) acute pancreatitis

(E) gastric perforation

412. Four hours later, the patient is becoming tachycardic, hypotensive, and unresponsive to fluid resuscitation. While awaiting a consult from the surgical service, pharmacologic support with which agent should be instituted?

(A) Dopamine

(B) Epinephrine

(D) Dobutamine

(E) Norepinephrine

413. You are asked to evaluate a patient in the PACU who has undergone a TURP. On arrival, you find a 76-year-old agitated man yelling that he can’t see anything. His past medical history is significant for smoking, hypertension, and coronary artery disease with recent stent placement. The most likely cause of the visual disturbance is

(A) sorbitol toxicity

(B) cortical blindness

(D) glycine toxicity

(E) hyperammonemia

414. A 74-year-old female is scheduled for ECT. Her past medical history is significant for chronic renal failure requiring dialysis three times per week. Her last dialysis was 3 d ago. You ask that a serum [K⁺] be drawn prior to induction of anesthesia. After administration of succinylcholine, her serum [K⁺] will rise approximately

(A) 0.5 mEq/L

(B) 1.5 mEq/L

(D) 0 mEq/L (no change)

(E) >3.0 mEq/L

DIRECTIONS: Use the following scenario to answer Questions 415-416: A 52-year-old male, involved in an MVA, is brought emergently to the operating room for exploratory laparotomy secondary to the presence of abdominal free air and fluid on CT scan. His past medical history is significant for alcoholic cirrhosis, Child’s class B. Preoperative coagulation studies reveal a platelet count of 82,000/mm³, prothrombin time of 18 sec (control 13 sec), and partial thromboplastin time of 62 sec (control 27 sec).

415. His apparent coagulopathy from liver disease can be reversed with a combination of all of the following EXCEPT

(A) platelets

(B) fresh frozen plasma

(D) factor VIII

(E) vitamin K

416. During induction and maintenance of general anesthesia in this patient, it is important to remember that this patient may exhibit a(n)

(A) decreased response to catecholamines

(B) decreased volume of distribution

(D) increased hepatic blood flow during surgery

(E) increased protein binding

DIRECTIONS: Use the following scenario to answer Questions 417-418: A 64-year-old female with a history of hypertension and benign ventricular arrhythmias is scheduled for extracorporeal shock wave lithotripsy (ESWL) under general anesthesia. Your recommendation to the urologist is that he use synchronized ESWL.

417. The most accurate statement about synchronized ESWL is that

(A) it generates higher intensity waves than non-synchronized ESWL

(B) shock waves should be timed 20 msec before the R wave

(D) it does not interfere with pacemakers

(E) it should be timed to correspond to the ventricular refractory period

418. You’re told that the new lithotriptor recently purchased by the hospital has not yet been approved for use. Instead, the urologist will need to use the older model Dornier lithotriptor requiring a water bath. You are now concerned about which one of the following physiologic and hemodynamic changes that may occur once the patient is positioned and the procedure is underway?

(A) Transient hypertension followed by hypotension

(B) Decrease in venous return

(D) Increased functional residual capacity

(E) Bradycardia

DIRECTIONS: Use the following scenario to answer Questions 419-420:An 82-year-old, 100-kg male with a history of hypertension and COPD is undergoing a transurethral resection of the prostate under spinal anesthesia at a T8 level. Thirty minutes into the procedure he complains that he is nauseated, and having trouble catching his breath. You note his blood pressure has increased from 100/68 mm Hg to 152/94 mm Hg, his heart rate has decreased from 74 to 56 bpm, and his ECG shows ST elevation in lead II. He is becoming restless and trying to sit up.

419. The management of this patient should include all of the following EXCEPT

(A) inform the surgeon

(B) check serum sodium, serum osmolality and hemoglobin

(D) administer intravenous furosemide

(E) stop the procedure

420. As you administer oxygen, draw blood for labs, and begin management of the patient, you note that he is becoming lethargic. His plasma [Na⁺] is 119 mEq/L. The preferred maneuver to increase the plasma [Na⁺] to 130 mEq/L is

(A) correcting his total body sodium deficit of 380 mEq

(B) infusing isotonic saline to increase [Na⁺] 1-1.5 mEq/L/h

(D) administering a potassium-sparing diuretic

DIRECTIONS: Use the following scenario to answer Questions 421-422: A 62-year-old woman with a history of severe gastroesophageal reflux is scheduled for a laparoscopic fundoplication. Past medical history is significant only for a 55 pack-year history of smoking. After an uneventful induction and intubation, she is anesthetized with isoflurane, oxygen, air, and fentanyl. After insertion of the trocar through the abdominal wall, she was placed in steep Trendelenburg position, carbon dioxide was insufflated, and the procedure begun. Three hours later, as the surgeon is preparing to remove the trocar, the patient becomes progressively more hypotensive, with a concomitant rise in peak inspiratory pressure and drop in oxygen saturation.

421. The most likely cause of the hypotension is

(A) compression of the inferior vena cava

(B) patient position

(D) pneumoperitoneum

(E) tension pneumothorax

422. After increasing inspired oxygen concentration, the priority should be to

(A) flatten the table

(B) place the patient into the left lateral position

(D) auscultate the chest

(E) ask the surgeon to decompress the pneumoperitoneum

423. An otherwise healthy 36-year-old male is scheduled for an elective excision of vocal cord polyp utilizing CO₂ laser under general anesthesia. On exam patient is 5’11”, 79 kg, with a normal airway exam. The most effective means to avoid an airway fire in this case is

(A) minimize inspired oxygen concentration

(B) wrap the endotracheal tube cuff with metal tape

(D) fill the cuff with a saline-blue dye mix

(E) add nitrous oxide

424. A 43-year-old previously healthy male presents for elective resection of a newly diagnosed pheochromocytoma. He began his phenoxybenzamine 10 d ago. All of the following statements are accurate about phenoxybenzamine EXCEPT

(A) dosing should be instituted before β-adrenoceptor blockade

(B) reversal depends on synthesis of α-adrenoceptors

(D) it causes orthostatic hypotension and reflex tachycardia

(E) it is a non-competitive, non-selective alpha blocker that covalently binds to α-adrenoceptors

425. An 82-year-old patient is scheduled to undergo hip arthroplasty with a cemented prosthesis to repair a hip fracture secondary to a mechanical fall. The patient is anesthetized with a spinal anesthetic, in addition to a propofol infusion for sedation. Shortly after insertion of the prosthesis, the patient’s blood pressure falls from 128/85 to 84/40, HR increases from 73 to 108 bpm, SpO₂ falls from 96% to 78%, and you notice a new right bundle branch block on ECG monitoring. The most likely cause of these changes is

(A) myocardial ischemia

(B) use of cement containing methylmethacrylate

(D) increased intramedullary pressure

(E) hypovolemia

426. A 43-year-old otherwise healthy male, involved in a motorcycle accident on his way to work, presents to the operating room with a posteriorly displaced open tibial fracture. He is scheduled for emergent vascular exploration of the calf wound due to diminished distal pulses, with subsequent ORIF of the fracture. The most appropriate analgesic technique is

(A) sciatic nerve block with 1.5% mepivacaine

(B) patient controlled analgesia with morphine

(D) combined sciatic and femoral nerve block with 0.5% bupivacaine

(E) sciatic nerve block with 0.75% ropivacaine

427. A 24-year-old male was brought to the operating room intubated after suffering a closed head injury from a fall while hiking. He presented for an urgent ORIF of an open comminuted distal humerus fracture. An upper extremity tourniquet was inflated continuously at 100 mm Hg above the patient’s systolic blood pressure, and remained inflated for 2.5 h during the case. The least likely effect from the use of the tourniquet is

(A) ulnar nerve palsy

(B) fibrinolysis with limb reperfusion

(D) increased preload upon tourniquet inflation

(E) decrease in core temperature after tourniquet release

428. A 38-year-old male who had required a prolonged extrication after a motor vehicle accident is brought to the operating room for exploratory laparotomy for suspected ruptured spleen as well as fixation of multiple lower extremity fractures. After induction of general anesthesia and endotracheal intubation, an esophageal temperature probe is inserted showing an initial temperature reading of 32°C. All of the following may be encountered EXCEPT

(A) metabolic acidosis

(B) impairment of the intrinsic clotting -cascade

(D) platelet dysfunction

(E) profound peripheral vasodilation

DIRECTIONS: Use the following scenario to answer Questions 429-430: A 22-year-old 5’10”, 110 kg otherwise healthy male was brought to the emergency department after being struck in the eye with a baseball. His exam revealed an open globe injury for which he is now brought emergently to the operating room. He states that he ate lunch just prior to the start of the ball game. On exam he has a large neck, 3-fingerbreadth thyromental distance, and a Mallampati Class 3 airway.

429. The safest anesthetic technique for this patient is

(A) retrobulbar block with intravenous sedation

(B) general anesthesia with laryngeal mask airway

(D) general anesthesia with awake fiberoptic intubation

(E) general anesthesia with rapid sequence induction

430. The best intubating conditions for this patient will be achieved using

(A) propofol, fentanyl, and succinylcholine 1.5 mg/kg

(B) propofol, lidocaine, and rocuronium 1.2 mg/kg

(D) propofol, fentanyl, rocuronium 0.5 mg, succinylcholine 1.5 mg/kg

431. You are asked to begin a case for your colleague. You introduce yourself to the patient, and note that he is a 63-year-old male scheduled for radical prostatectomy for prostate cancer. He is a very good historian, and tells you that his only medical problem is coronary artery disease, for which he underwent stent placement 2 years ago. His only medication is a beta blocker that he takes daily. When asked to sign the anesthesia consent, the patient informs you that he is a Jehovah’s Witness, and that he refuses all blood therapy. He tells you that the surgeon is aware, and agrees. After extensive discussion with the patient in which you discuss the various options as well as possible complications from refusal of such therapy, he still refuses. You are uncomfortable caring for this patient. Your next step should be to

(A) proceed with the case, as you are ethically obligated to care for this patient

(B) speak with his health care proxy in an effort to obtain consent from him/her

(D) refuse to care for the patient, but obtain informed refusal

(E) call the hospital attorney to get a court order to give him blood if his life is at stake

432. A 55-year-old man has undergone an uneventful knee arthroscopy under general anesthesia. His only significant preoperative medical problem is osteoarthritis. The criterion LEAST important in determining appropriateness for discharge home from the Phase II postanesthesia care unit is

(A) pain score

(B) ability to void

(D) blood pressure

(E) postoperative nausea and vomiting

433. A 78-year-old male is undergoing repair of a detached retina under general endotracheal anesthesia. The surgeon informs the anesthesiologist that he plans to inject a bubble of sulfur hexafluoride into the vitreal cavity to tamponade the retina. As the retina is re-attached, the anesthesiologist should

(A) discontinue nitrous oxide

(B) discontinue all fluorinated anesthetic gases

(D) elevate the head of the bed

(E) hyperventilate the patient

434. A 44-year-old patient underwent a 4-h operative procedure for emergency repair of a liver laceration and splenectomy following blunt abdominal trauma as a result of a motor vehicle accident. In the PACU the patient is noted to have worsening metabolic acidosis, poor urine output, and a tense and distended abdomen. The surgical team is questioning the possibility of abdominal compartment syndrome. Definitive diagnosis is made by

(A) measurement of cardiac output

(B) serial measurement of glomerular filtration rate

(D) measurement of simultaneous PCWP and CVP values

(E) serial measurements of abdominal girth

435. A 56-year-old, 84-kg patient is scheduled for outpatient knee arthroscopy for removal of loose intraarticular bodies. The patient has a 10 year history of severe obstructive sleep apnea for which he uses CPAP nightly. The single factor that would increase the safety of postoperative discharge of this patient is

(A) a surgical time of less than one hour

(B) placement of femoral nerve block to reduce postoperative pain

(D) adequate management of postoperative pain with ibuprofen

436. A 74-year-old patient is scheduled for an elective right hemicolectomy. During her preoperative evaluation, she tells your colleague that she was recently diagnosed with open angle glaucoma for which she was prescribed timolol eye drops that she uses faithfully. She will require a general anesthetic with a neuromuscular blocking agent. Your colleague’s normal practice is to reverse neuromuscular blockade with atropine and neostigmine. Given this patient’s history, your colleague should

(A) reverse with a combination of glycopyrrolate and neostigmine

(B) make no change in his practice

(D) use a short acting agent to allow spontaneous return of neuromuscular function

(E) reverse with a combination of atropine and edrophonium

437. A patient is brought to the operating room for repair of an open fracture sustained from a fall from a window during a house fire. The patient was intubated at the scene and ventilated with 100% oxygen via a bag-mask-valve device during transport to the hospital. The most reliable method for determining whether the patient has carbon monoxide poisoning while being ventilated with 100% O₂ is

(A) routine arterial blood gas analysis

(B) pulse oximetry

(D) arterial carboxyhemoglobin level

(E) capnography

438. You are asked to evaluate an 84-year-old patient scheduled for a right hemicolectomy. In comparison to a 44-year-old patient undergoing a similar procedure, you would expect to see a decrease in which one of the following physiologic parameters in the 84-year-old?

(A) Ventilation-perfusion mismatch

(B) Closing volume

(D) Alveolar dead space

(E) Residual lung volume

439. A 76-year-old female driver of a motor vehicle hit by a truck is brought to the operating room for emergent splenectomy and stabilization of a pelvic fracture. She arrives intubated, with a blood pressure of 80/40 and heart rate of 124. The patient’s past medical history is unknown. Initial labs reveal a serum potassium concentration of 7.1 mEq/L. The serum potassium concentration will NOT be decreased by

(A) an intravenous bolus of calcium chloride

(B) hyperventilation

(D) albuterol administered by nebulizer

(E) an intravenous bolus of sodium bicarbonate

440. A 62-year-old male with liver cirrhosis, currently on the liver transplant waiting list, is undergoing an emergency evacuation of subdural hematoma after a fall. The neurosurgeon is having difficulty controlling bleeding. The LEAST likely cause of the bleeding is

(A) disseminated intravascular coagulation

(B) splenic sequestration of platelets

(D) decreased synthesis of factor VIII

(E) reduced fibrinogen concentrations

441. A 68-year-old man who takes levodopa for management of Parkinson disease is scheduled to undergo an inguinal hernia repair. The patient has a history of type II diabetes as well as gastroesophageal reflux. The most appropriate perioperative anesthetic management includes

(A) droperidol as an antiemetic

(B) omission of levodopa on the morning of surgery

(D) spinal anesthesia with bupivacaine

(E) morphine for postoperative analgesia

442. A 16-year-old male, hit by a car while crossing the street, is brought emergently to the operating room for exploratory laparotomy for a presumed liver laceration, as well as extensive orthopedic injuries. You discuss with his parents the potential need to transfuse blood and blood products. When his mother asks what the greatest risk of transfusion is, you tell her

(A) mistransfusion due to human clerical error

(B) transfusion-related acute lung injury

(D) human immunodeficiency virus

(E) anaphylaxis

443. A 68-year-old woman with 40% second and third degree burns requires burn debridement twice daily. As she is being mechanically ventilated in the ICU, the surgical team has asked that the debridement be done at the bedside under general anesthesia. The LEAST appropriate agent for a brief general anesthetic in this patient is

(A) etomidate

(B) ketamine

(D) midazolam

(E) methohexital

444. A 63-year-old man with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement for management of severe portal hypertension with ascites. When lying flat he is short of breath that worsens when he sits up. He has a room air SpO₂ of 83%. The only physiologic derangement NOT seen in this patient would be

(A) impaired hypoxic pulmonary vasoconstriction

(B) elevated alveolar-arterial oxygen gradient

(D) decreased nitric oxide concentrations

445. An 88-year-old patient, who two weeks ago underwent aortic valve replacement, is noted during a postoperative clinic visit to have an unstable sternum and purulent drainage of his wound. Despite having had breakfast, he is scheduled for an emergent exploration of the wound. When planning this patient’s anesthetic management, you recall that in the elderly

(A) MAC is increased for isoflurane

(B) metoclopramide is a useful adjunct to promote gastric emptying

(D) thermoregulation is impaired

(E) glomerular filtration rate is increased

446. A 32-year-old woman sustains an injury to the left recurrent laryngeal nerve during a near total thyroidectomy. Which one of the following is the most likely postoperative finding?

(A) Adduction of the left vocal cord at rest

(B) Aphonia

(D) Stridor

(E) Paralysis of the left cricothyroid muscle

447. You are planning the anesthetic management of an 82-year-old man undergoing a carotid endarterectomy. He has a history of poorly controlled hypertension, as well as chronic renal failure requiring dialysis. The LEAST appropriate medication to manage intraoperative and postoperative hypertension would be

(A) esmolol

(B) hydralazine

(D) nitroglycerine

(E) nitroprusside

448. A 30-year-old patient presents for emergency appendectomy. He states that he was recently diagnosed with hypothyroidism but has been unable to afford the medication prescribed. The most likely manifestation of his disease in the perioperative period would be

(A) cardiac arrhythmias with ketamine administration

(B) decreased ventilatory response to hypoxia

(D) decreased sensitivity to midazolam

(E) hypotension

449. A 46-year-old male is brought to the operating room for irrigation and debridement of an open tibial fracture. He had been trapped in his car after sliding off the road and hitting a tree during an ice storm. He remained alert and hemodynamically stable at the scene during a prolonged extrication. Evaluation in the emergency department reveals only an open tibial plateau fracture as well as a “seatbelt” bruise on his anterior chest. He is hypothermic with a temperature of 34°C. All other vital signs, as well as EKG and laboratory values, were normal. MAC for isoflurane in this patient is approximately

(A) 0.8%

(B) 1%

(D) 1.5%

(E) 1.75%

DIRECTIONS: Use the following scenario to answer Questions 450-451: A 22-year-old male is brought emergently to the operating room for exploration of multiple abdominal stab wounds. He was intubated at the scene due to loss of consciousness and respiratory compromise. BP on arrival to the operating room is 70/40, HR is 130 bpm, and oxygen saturation is 92%. Blood pressure responds minimally to volume resuscitation or vasopressors. Volatile anesthetic causes severe hypotension. Oxygen saturation drops each time the FIO₂ is decreased below 1.0.

450. The most appropriate medication to prevent intraoperative recall in this patient is

(A) remifentanil

(B) scopolamine

(D) droperidol

(E) rocuronium

451. You consider utilizing a BIS monitor to measure depth of anesthesia. The only factor that does not affect the accuracy of BIS monitoring is

(A) muscle activity

(B) hypoglycemia

(D) electrical artifact

(E) ketamine

DIRECTIONS: Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Near miss

(B) Hazardous condition

(D) Latent error

(E) Preventable adverse event

For each situation, choose the appropriate patient safety concern.

452. An anesthesiologist new to the institution is asked to provide anesthesia for a 1-year-old requiring an urgent MRI. It has been several years since she has cared for a pediatric patient, and she has never before provided anesthesia in an MRI environment.

453. An 18-year-old patient was admitted to the emergency department after a bicycle accident. The Glasgow coma score at the scene was 12 that diminished to 7 in the emergency department. A CT scan of the head revealed an epidural hematoma compressing the left parietal lobe. The patient was brought emergently to the operating room for evacuation of the hematoma. Prior to induction of anesthesia, it was noted that his left pupil was now fixed and dilated. The patient was quickly prepped and draped, and a right craniotomy was performed.

(A) Plague

(B) Botulism

(D) Brucellosis

(E) Anthrax

(F) Ebola

(G) Q fever

(H) Tularemia

For each patient suspected to be a victim of biologic terrorism, select the most likely biological agent.

454. A 46-year-old man presented with fever, fatigue, and shortness of breath 5 d after suspected exposure. Chest x-ray reveals mediastinal widening and bilateral pleural effusions. The patient was admitted to a regular ICU bed, and combination therapy begun with ciprofloxacin and clindamycin.

455. Twelve days after suspected exposure, a 28-year-old man presents with recent onset of fever, vomiting, backache, and a rash, which initially began on his face and extremities. Exam reveals vesicles and pustules on his face and extremities, and a maculopapular rash on his trunk, with lesions at the same stage at each location. He is immediately placed in a negative-pressure room on strict isolation precautions until resolution and scabbing of the lesions.

456. Twenty-four hours after suspected exposure, a 56-year-old woman develops symptoms of dry mouth, double vision, difficulty speaking, and swallowing. Because the diagnosis was made early, she was given a single dose of an equine antitoxin.

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