Regional Anesthesia

Questions

DIRECTIONS (Questions 559-600): 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.

559. As the supervising anesthesiologist you are assigned to four operating rooms staffed by CRNA’s. Regional anesthesia is preferred in all cases; however, you are concerned about the use of regional anesthesia in the setting of anticoagulation. Of the following clinical scenarios, which patient is most likely to sustain a bleeding complication from regional anesthesia?

(A) A 46-year-old male who takes a baby aspirin daily and undergoes a spinal anesthetic for a knee arthroscopy.

(B) An elderly female with osteoporosis undergoing a total knee arthroplasty under epidural analgesia and receiving low-molecular-weight heparin once daily.

(C) A 56-year-old female who discontinued clopidogrel ten days prior to having an epidural placed for postoperative pain control following a right hemicolectomy.

(D) A 23-year-old healthy parturient who consumes daily garlic supplements undergoing an elective cesarean section.

560. As the chief of anesthesiology in your hospital, you are asked by the administration to discuss a process that is important in promoting a safe regional anesthesia practice. Which one of the following topics is the most important one to discuss?

(A) Patient care team education and awareness of limb protection and neurologic evaluation.

(B) Details regarding billing compliance.

(D) Training of medical students and residents in appropriate use of liposomal local anesthetics.

561. A 71-year-old man with osteoarthritis of the right hip is undergoing a right total hip arthroplasty. You decide to perform a spinal anesthetic. While assessing the landmarks when choosing the interspace in which to perform the lumbar puncture, you must remember that the caudal termination of the adult spinal cord is typically at

(A) T11-T12

(B) L1-L2

(D) L5-S1

(E) S2-S3

562. A 92-year-old man is undergoing total knee arthroplasty for severe painful osteoarthritis. After struggling in the placement of a lumbar spinal anesthetic, you decide to use the Taylor approach. What best characterizes the Taylor approach to performing spinal anesthesia?

(A) Uses image guidance to facilitate bony landmarks

(B) Uses a midline and steep angled approach

(D) Uses a loss of resistance technique with air

(E) Uses a paramedian approach at L5-S1

563. You are discussing a labor epidural analgesia with a 25-year-old parturient. She also happens to be a physician who is curious on what is the most popular technique for confirming correct needle location when performing an epidural block. You respond that the most popular technique is

(A) loss of resistance to either saline or air

(B) ultrasound imaging

(D) patient response

(E) block quality

564. What is the primary barrier to drug absorption from the epidural space into the CSF?

(A) Arachnoid mater

(B) Dura mater

(D) Spinous process

(E) Ligamentum flavum

565. A 68-year-old man with rheumatoid arthritis undergoes a left total knee arthroplasty. You prefer to use an isobaric solution over a hyperbaric or hypobaric solution because

(A) an isobaric solution will rise in the CSF when the patient is in the supine position

(B) a hyperbaric solution will sink in the CSF

(D) an isobaric solution will rise less than a hyperbaric solution and potentially lead to less hypotension

(E) an isobaric solution of 0.5% bupivacaine is approved by the FDA for spinal anesthesia

566. A 25-year-old football player presents for a right knee arthroscopy after sustaining a medial meniscus tear. He is frightened of general anesthesia and wants to remain awake throughout surgery. In your discussion of spinal anesthesia in the ambulatory setting, the topic of transient neurological symptoms (TNS) arises. Which local anesthetic is associated with the highest risk of sustaining TNS?

(A) Tetracaine

(B) Bupivacaine

(D) Chloroprocaine

(E) Ropivacaine

567. A patient receives a lumbar epidural block with 2% lidocaine for a vaginal hysterectomy. Three hours after surgery the patient reports a dense motor block. An MRI demonstrates a lumbar epidural hematoma. For the best neurologic outcome, it is recommended that a surgical evacuation of the hematoma occurs within

(A) 2-4 h

(B) 4-6 h

(D) 10-12 h

(E) 16-24 h

568. A 54-year-old woman with rheumatoid arthritis is scheduled for total knee replacement. The anesthesiologist plans to use 0.5% plain bupivacaine to which 25 mcg of clonidine has been added for spinal anesthesia. Intrathecal clonidine

(A) will shorten the duration of the spinal block

(B) can prolong the spinal motor block

(D) provides a reliable surgical block as a sole agent

(E) has not been approved by the FDA for epidural use

569. A 42-year-old man presents for ACL repair to your ambulatory surgery center. You decide to perform a spinal anesthetic because the patient asks to watch the surgery. You have a slow surgeon and contemplate adding 100 micrograms of epinephrine to your local anesthetic. What is the major drawback to adding epinephrine to a local anesthetic for spinal anesthesia in an ambulatory patient?

(A) Induces vomiting

(B) Does not add clinical benefit

(D) Delays return of bladder function

(E) Causes itching

570. A 27-year-old healthy female presents for a triple arthrodesis of the ankle. She prefers to have a spinal anesthetic, but recalls feeling short of breath during a previous spinal anesthetic for cesarean section. You tell her that

(A) gross pulmonary function is maintained with spinal anesthesia in healthy adults

(B) spinal anesthesia never compromises pulmonary function

(D) spinal anesthesia routinely blocks the phrenic nerve and she probably had a phrenic nerve palsy during her previous cesarean section

(E) spinal anesthesia rarely impairs pulmonary function and is the anesthetic of choice in patients with severe cystic fibrosis

571. A 25-year-old parturient presents for an elective cesarean section. After performing a spinal anesthetic with 13.5 mg of hyperbaric bupivacaine, the patient reports “feeling sick to her stomach.” Subsequently you notice the blood pressure is 62/30. The best description of the cardiovascular response to a spinal anesthetic is that

(A) no hemodynamic changes occur

(B) both arterial and venous vasodilation contribute to hypotension

(D) hypotension only occurs in patients with stenotic valvular lesions

(E) it worsens regurgitant valvular lesions

572. A 33-year-old male undergoes a subgluteal sciatic nerve block for open repair of an ankle fracture. In preparing for the block, the primary drug therapy that the anesthesiologist must consider using for local anesthetic systemic toxicity is

(A) lidocaine

(B) epinephrine

(D) phenylephrine

(E) 20% lipid emulsion

573. What was the first drug used to produce local anesthesia?

(A) Lidocaine

(B) Procaine

(D) Prilocaine

(E) Tetracaine

574. A 23-year-old parturient scheduled for an elective cesarean section undergoes a spinal anesthetic with 10.5 mg of hyperbaric bupivacaine. Ten minutes following the spinal anesthetic, she complains of nausea. Her vital signs are a BP of 75/52, pulse rate of 123 beats/min, and oxygen saturation of 98%. The best pharmacologic treatment for hypotension related to the spinal anesthetic is

(A) atropine

(B) epinephrine

(D) calcium

(E) labetalol

575. Twenty-four hours after performing a spinal anesthetic in a 27-year-old female for a vaginal hysterectomy, you are consulted to evaluate her for a presumed post-dural puncture headache. Regarding the symptoms of a post-dural puncture headache, you would expect the headache to

(A) be positional in nature with improvement when sitting

(B) be positional in nature with improvement lying down

(D) localized to one eye

(E) be associated with delayed gastric emptying

576. A 72-year-old female presents for a right thoracotomy for a right lower lobe resection for lung cancer. She consents to a thoracic epidural catheter for postoperative analgesia. She understands the risks that may result and asks about the prognosis should she develop an epidural hematoma. The statement that best characterizes the prognosis of an epidural hematoma is

(A) a spinal epidural hematoma is universally fatal

(B) a spinal epidural hematoma always results in quadriplegia

(D) a spinal epidural hematoma is not diagnosable and thus has a very poor prognosis

(E) with prompt diagnosis, treatment strategies are effective

577. A 36-year-old otherwise healthy male with Crohn disease presents for open hemicolectomy. You place a thoracic epidural catheter for postoperative analgesia. What would be considered a positive heart rate response from a test dose of 15 mcg of epinephrine?

(A) Heart rate variability changes

(B) Systolic blood pressure drops

(D) Heart rate increases by 20 beats per minute

(E) Heart rate increases by 10 beats per minute

578. A 21-year-old male presents for ACL reconstruction of the left knee. The patient prefers to have a femoral nerve block but is worried because he has been told that he has an allergy to “Novacaine”. Which statement best characterizes allergic reactions related to local anesthetics?

(A) Allergies do not occur related to local anesthetics.

(B) Reactions are usually limited to systemic hives and urticaria.

(D) Allergic reactions can be avoided by pre-treatment with diphenhydramine.

(E) Allergic reactions can effectively be treated with intravenous lipids.

579. A 50-year-old female is scheduled to undergo open repair of a distal right radius fracture. She prefers to have a supraclavicular nerve block but is concerned about nerve injury. Specifically, she is concerned about the risk of intraneural injection. Which statement best characterizes the risk of intraneural injection of local anesthetics?

(A) Ultrasound imaging suggests that it occurs frequently without leading to clinical injury.

(B) Nerve injuries do not occur by this mechanism.

(D) Intraneural injections do not occur when ultrasound is used.

(E) Intraneural injections are only a concern in peripheral nerves and not in plexi.

580. A 28-year-old female is about to undergo left hand surgery and you discuss performing a supraclavicular nerve block. She appears concerned and asks about the incidence of pneumothorax. You respond that with traditional landmark techniques, the incidence of a pneumothorax when performing a supraclavicular block has been reported to be in the range of

(A) 0.1 – 0.3%

(B) 0.2 – 1%

(D) 1 – 10%

(E) 5 – 30%

581. Maintaining the standards of care during regional anesthesia practice involves all of the following EXCEPT

(A) offering regional anesthesia to all patients

(B) informed consent

(D) appropriate and timely postoperative follow up

(E) monitoring vital signs

582. A 22-year-old parturient requests a labor epidural. During your evaluation of the patient she explains that she has an allergy to one local anesthetic but cannot remember which one. To which one of the following local anesthetics is a patient most likely to have an allergic reaction?

(A) tetracaine

(B) bupivacaine

(D) ropivacaine

(E) prilocaine

583. The rate of local anesthetic absorption from a particular injection site, from highest to lowest rate, is

(A) epidural, intercostal, brachial plexus, subcutaneous tissue, lower extremity

(B) epidural, intercostal, subcutaneous tissue, lower extremity, brachial plexus

(D) intercostal, epidural, brachial plexus, lower extremity, subcutaneous tissue

(E) subcutaneous tissue, intercostal, epidural, brachial plexus, lower extremity

584. You are providing informed consent to a patient about to undergo a popliteal sciatic block. She is concerned about the risk of long-term neurologic injury from a peripheral nerve block. You explain that the incidence of late neurologic deficits after peripheral nerve blocks is

(A) 1/10,000

(B) 4/10,000

(D) 4/100,000

(E) 4/1,000,000

585. During the performance of a left femoral nerve block utilizing traditional landmark techniques and nerve stimulation, you obtain a patellar twitch at 2.5 mA current and proceed to decrease the current while still maintaining a patellar twitch. The highest stimulating current that reliably predict intraneural needle placement is

(A) 0.2 mA

(B) 0.5 mA

(D) 1.5 mA

(E) 2.0 mA

586. You are supervising a first-year anesthesia resident during her regional anesthesia rotation. You instruct the resident to use blunt-tip needles. Blunt-tip needles

(A) are more likely to penetrate neural tissue

(B) are less disruptive to neural tissue than sharp needles

(D) have a higher incidence of successful block

(E) are only preferred when they are greater than 15 gauge

587. A 72-year-old female with painful osteoarthritis undergoes a right total knee arthroplasty. She receives an ultrasound-guided femoral nerve block. The following day, the patient reports inability to dorsiflex the right foot. The most likely reason would be

(A) a persistent motor block to the right femoral nerve

(B) neurologic injury to the right common peroneal nerve

(D) neurologic injury to the right tibial nerve

(E) neurologic injury to the superficial peroneal nerve

588. Twenty minutes after the performance of a lumbar plexus block with 40 mL of 0.5% bupivacaine for a total hip arthroplasty, the patient reports “ringing in the ears” and feeling “light headed.” The patient’s condition deteriorates and ECG monitoring shows progression to sinus bradycardia, ventricular fibrillation, and ultimately asystole. The most likely explanation for these symptoms is

(A) direct intravenous injection

(B) oversedation with midazolam

(D) profound vasodilatation

(E) vascular absorption of local anesthetic

589. Utilizing a transarterial axillary technique, a brachial plexus block is performed. After confirming negative aspiration of blood, 5 mL of 0.5% bupivacaine is administered. Suddenly the patient becomes unresponsive. Initial pharmacologic management should include the administration of

(A) 20% lipid emulsion

(B) epinephrine, 1 mg

(D) atropine, 1 mg

(E) vasopressin, 40 units

590. A 54-year-old female with adenocarcinoma of the lung presents for right thoracotomy. You plan to place a thoracic epidural catheter for postoperative analgesia. In the process of providing informed consent, the patient becomes worried about the risk of an epidural hematoma. You explain that the incidence of an epidural hematoma following the administration of a neuraxial anesthetic is estimated to be less than

(A) 1 in 10,000

(B) 1 in 50,000

(D) 1 in 400,000

(E) 1 in 1,000,000

591. A 64-year-old female presents for a right total knee arthroplasty. A spinal anesthetic was performed in the L3-L4 interspace with 0.5% isobaric bupivacaine. Five minutes after the spinal anesthetic, the patient is insensate at the level of the umbilicus. This closely approximates which one of the following dermatome levels?

(A) T4

(B) T7

(D) L1

(E) L3

592. A 42-year-old previously healthy ASA I patient undergoes an awake fiberoptic intubation with topical anesthesia for a laparoscopic appendectomy. Upon extubation she was noticed to have a saturation of 93%. While in the PACU his oxygen saturation continued to drop to 85% despite being alert, taking large tidal volumes, having a normal chest x-ray, and not improving while breathing 100% oxygen via a non-rebreather mask. You suspect methemoglobinemia. Which one of the following topical anesthetics is most associated with methemoglobinemia?

(A) Cocaine

(B) Tetracaine

(D) Lidocaine

(E) Proparacaine

593. A 39-year-old female presents for carpal tunnel release surgery. You discuss performing an IV regional block (Bier block). All of the following are important to consider EXCEPT

(A) thorough exsanguination of the extremity should take place prior to the injection of local anesthetic

(B) preservative-free lidocaine is the most frequently used local anesthetic

(D) a double tourniquet permits longer surgical time than a single tourniquet

(E) a tourniquet is more reliable when placed proximal to the elbow than at a more distal location

594. A 51-year-old patient is scheduled to undergo a right lung lower lobectomy for lung cancer. You discuss the risks and benefits of thoracic epidural analgesia. You discuss that a common medical indication for performing regional anesthesia is

(A) increased professional billing

(B) less cardiac morbidity in the previously healthy patient

(D) reduction in the administration of opioids in the immediate perioperative period.

(E) less oxygen administration

DIRECTIONS: Use the following scenario to answer Questions 595-596: You have been following a 27-year-old former nurse in your chronic pain clinic for complex regional pain syndrome of the left hand. She initially sustained a work related injury to her hand a year ago and has since experienced ongoing chronic pain. After conservative treatment with neuropathic medications she has had little relief. You decide to offer her a regional nerve block as part of a multimodal approach to treating her pain.

595. Which one of the following nerve blocks would be most appropriate?

(A) Axillary brachial plexus block

(B) Stellate ganglion block

(D) A cervical transforaminal injection

(E) An infraclavicular brachial plexus block

596. After a successful nerve block, one would expect to see all of the following signs EXCEPT

(A) miosis

(B) nasal congestion

(D) a decrease in temperature of the blocked limb by at least 1°C

(E) ptosis

DIRECTIONS (Questions 597-598): 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) Glossopharyngeal nerve

(B) Internal branch of the superior laryngeal nerve

(D) Recurrent laryngeal nerve

(E) Trigeminal nerve

(G) Anterior ethmoidal nerve

(G) Greater palatine nerve

For each patient, select the appropriate airway block.

597. A 23-year-old obese female reports having a known difficult airway. She remembered having an awake intubation the last time she presented for surgery and anesthesia. Specifically she states having had a strong “gag reflex” when the fiberoptic scope made contact with her soft palate.

598. During your performance of an awake fiberoptic intubation, you are able to advance the fiberoptic scope just above the epiglottis. Just as you are about to advance the scope through the vocal cords, it makes contact with the posterior surface of the epiglottis and the vocal cords snap shut.

DIRECTIONS (Questions 599-600): 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) C6

(B) C7

(D) T4

(E) T7

(F) T10

(G) L4

For each patient, select the vertebra described in the physical examination.

599. A 25-year-old female requests a labor epidural for analgesia. In assessing the appropriate landmarks, you palpate the anterior superior iliac spines and draw a line connecting both iliac crests.

600. A 25-year-old man presents for a right total shoulder replacement. You consent the patient for continuous cervical paravertebral blocks utilizing nerve stimulation. In assessing the appropriate topographical landmarks you palpate the most prominent spinous process in the neck.

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