1. Patients should take prescribed b-blockers on the day of surgery and continue them
perioperatively. Because the receptors are up-regulated, withdrawal may precipitate
hypertension, tachycardia, and myocardial ischemia. Clonidine should also be continued
perioperatively because of concerns for rebound hypertension.
2. Under most circumstances peri-induction hypotension responds best to administration of
intravenous fluids and the use of direct-acting sympathomimetics such as phenylephrine.
3. To determine the etiology of hypoxemia, calculate the A-a gradient to narrow the
differential diagnosis.
4. Calculating the anion gap (Naþ [HCO
3
þ Cl ]) in the presence of a metabolic acidosis
helps narrow the differential diagnosis.
5. Estimating volume status requires gathering as much clinical information as possible
because any single variable may mislead. Always look for supporting information.
6. Rapid correction of electrolyte disturbances may be as dangerous as the underlying
electrolyte disturbance.
7. When other causes have been ruled out, persistent and refractory hypotension in trauma
or other critically ill patients may be caused by hypocalcemia or hypomagnesemia.
8. There is no set hemoglobin/hematocrit level at which transfusion is required. The decision
should be individualized to the clinical situation, taking into consideration the patient’s
health status.
9. An outpatient with a bleeding diathesis can usually be identified through history (including
medications) and physical examination. Preoperative coagulation studies in asymptomatic
patients are of little value.
10. Thorough airway examination and identification of the patient with a potentially difficult
airway are of paramount importance. The “difficult-to-ventilate, difficult-to-intubate”
scenario must be avoided if possible. An organized approach, as reflected in the American
Society of Anesthesiologists’ Difficult Airway Algorithm, is necessary and facilitates highquality
care for patients with airway management difficulties.
11. No single pulmonary function test result absolutely contraindicates surgery. Factors
such as physical examination, arterial blood gases, and coexisting medical problems also
must be considered in determining suitability for surgery.
12. Speed of onset of volatile anesthetics is increased by increasing the delivered
concentration of anesthetic, increasing the fresh gas flow, increasing alveolar ventilation,
and using nonlipid-soluble anesthetics.
13. Opioids depress the carbon dioxide–associated drive to breathe, resulting in
hypoventilation. Because of the active metabolites, patients with renal failure may
experience an exaggerated reaction to morphine.
14. Appropriate dosing of intravenous anesthetics requires considering intravascular volume
status, comorbidities, age, and medications.
15. Termination of effect of intravenous anesthetics is by redistribution, not biotransformation
and breakdown.
16. Although succinylcholine is the usual relaxant used for rapid sequence induction, agents
that chelate nondepolarizing relaxant molecule may alter this paradigm in the future.
17. Leave clinically weak patients intubated and support respirations until the patient can
demonstrate return of strength.
18. Lipid solubility, pKa, and protein binding of the local anesthetics determine their potency,
onset, and duration of action, respectively.
19. Local anesthetic-induced central nervous system toxicity manifests as excitation, followed
by seizures, and then loss of consciousness. Hypotension, conduction blockade, and
cardiac arrest are signs of local anesthetic cardiovascular toxicity.
20. There is sound scientific evidence that low-dose dopamine is ineffective for prevention and
treatment of acute renal injury and protection of the gut.
21. A preoperative visit by an informative and reassuring anesthesiologist provides useful
psychologic preparation and calms the patient’s fears and anxiety before administration of
anesthesia.
22. The risk of clinically significant aspiration pneumonitis in healthy patients having elective
surgery is very low. Routine use of pharmacologic agents to alter the volume or pH of
gastric contents is unnecessary.
23. The most important information obtained in a preanesthetic evaluation comes from a
thorough, accurate, and focused history and physical examination.
24. When compressed, some gases condense into a liquid (N2O and CO2) and some do not
(O2 and N2). These properties define the relationship between tank volume and pressure.
25. The semiclosed circuit using a circle system is the most commonly used anesthesia
circuit. Components include an inspiratory limb, expiratory limb, unidirectional valves, a
CO2 absorber, a gas reservoir bag, and a pop-off valve on the expiratory limb.
26. Every patient ventilated with an ascending bellows anesthesia ventilator receives
approximately 2.5 to 3 cm H2O of positive end-expiratory pressure (PEEP) because of the
weight of the bellows.
27. The output of traditional vaporizers depends on the proportion of fresh gas that bypasses
the vaporizing chamber compared with the proportion that passes through the vaporizing
chamber.
28. A conscientious approach to positioning is required to facilitate the surgical procedure,
prevent physiologic embarrassment, and prevent neuropathy and injury to other aspects of
the patient’s anatomy.
29. The first step in the care of the hypoxic patient fighting the ventilator is to ventilate the
patient manually with 100% oxygen.
30. Risk factors for auto-PEEP include high minute ventilation, small endotracheal tube,
chronic obstructive pulmonary disease, and asthma.
31. When determining whether an abnormal electrocardiogram (ECG) signal may be an artifact,
look to see if the native rhythm is superimposed on (marching through) the abnormal tracing.
32. A patient with new ST-segment depression or T-wave inversion may have suffered a non–
ST-elevation myocardial infarction.
33. Pulse oximetry measures arterial oxygenation using different wavelengths of light shone
through a pulsatile vascular bed. Pulse oximetry can detect hypoxemia earlier, providing
an early warning sign of potential organ damage.
34. Below a hemoglobin saturation of 90%, a small decrease in saturation corresponds to a
large drop in PaO2.
35. Except for visualization with bronchoscopy, CO2 detection is the best method of verifying
endotracheal tube location.
36. Analysis of the capnographic waveform provides supportive evidence for numerous
clinical conditions, including decreasing cardiac output; altered metabolic activity; acute
and chronic pulmonary disease; and ventilator, circuit, and endotracheal tube malfunction.
37. Trends in central venous pressures are more valuable than isolated values and should
always be evaluated in the context of the patient’s scenario.
38. Pulmonary catheterization has not been shown to improve outcome in all patient subsets.
39. The risks of central venous catheterization and pulmonary artery (PA) insertion are many
and serious, and the benefits should be identified before initiation of these procedures to
justify their use.
40. To improve accuracy in interpretation of PA catheter data, always consider the timing of
the waveforms with the ECG cycle.
41. Ipsilateral ulnar arterial catheterization should not be attempted after multiple failed
attempts at radial artery catheterization.
42. With the exception of antagonists of the renin-angiotensin system and possibly diuretics,
antihypertensive therapy should be given up to and including the day of surgery.
43. Symptoms of awareness may be very nonspecific, especially when muscle relaxants are used.
44. When a patient with structural heart disease develops a wide-complex tachycardia,
assume that the rhythm is ventricular tachycardia until proven otherwise. When a patient
develops tachycardia and becomes hemodynamically unstable, prepare for cardioversion
(unless the rhythm is clearly sinus!).
45. When a patient develops transient slowing of the sinoatrial node along with transient
atrioventricular block, consider increased vagal tone, a medication effect, or both.
46. Even mild hypothermia has a negative influence on patient outcome, increasing rates of
wound infection, delaying healing, increasing blood loss, and increasing cardiac morbidity
threefold.
47. If a patient’s exercise capacity is excellent, even in the presence of ischemic heart disease,
the chances are good that the patient will be able to tolerate the stresses of surgery. The
ability to climb two or three flights of stairs without significant symptoms (e.g., angina,
dyspnea, syncope) is usually an indication of adequate cardiac reserve.
48. Patients with decreased myocardial reserve are more sensitive to the cardiovascular
depressant effects caused by anesthetic agents, but careful administration with close
monitoring of hemodynamic responses can be accomplished with most agents.
49. For elective procedures, the most current fasting guidelines are as follows:
Clear liquids (water, clear juices) 2 hours
Nonclear liquids (Jello, breast milk) 4 hours
Light meal or snack (crackers, toast, liquid) 6 hours
Full meal (fat containing, meat) 8 hours
50. “All that wheezes is not asthma.” Also consider mechanical airway obstruction, congestive
failure, allergic reaction, pulmonary embolus, pneumothorax, aspiration, and
endobronchial intubation.
51. Patients with significant reactive airway disease require thorough preoperative preparation,
including inhaled b-agonist therapy and possibly steroids, methylxanthines, or other
agents.
52. The necessary criteria for acute lung injury/acute respiratory distress syndrome (ALI/
ARDS) include:
(1) Acute onset
(2) PaO2/FiO2 ratio of 300 for ALI
(3) PaO2/FiO2 ratio of 200 for ARDS
(4) Chest radiograph with diffuse infiltrates
(5) Pulmonary capillary wedge pressure of 18 mm Hg
53. Mechanical ventilation settings for patients with ARDS or ALI include tidal volume of at
6 to 8 ml/kg of ideal body weight while limiting plateau pressures to <30 cm H2O. PEEP
should be adjusted to prevent end-expiratory collapse. FiO2 should be adjusted to maintain
oxygen saturations between 88% and 92%.
54. Acute intraoperative increases in PA pressure may respond to optimizing oxygenation and
ventilation, correcting acid-base status, establishing normothermia, decreasing the
autonomic stress response by deepening the anesthetic, and administering vasodilator
therapy.
55. The best way to maintain renal function during surgery is to ensure an adequate
intravascular volume, maintain cardiac output, and avoid drugs known to decrease renal
perfusion.
56. Measures to acutely decrease intracranial pressure (ICP) include elevation of the head
of the bed; hyperventilation (PaCO2 25 to 30 mm Hg); diuresis (mannitol and/or
furosemide); and minimized intravenous fluid. In the setting of elevated ICP, avoid
ketamine and nitrous oxide.
57. Airway comes first in every algorithm; thus succinylcholine is the agent of choice for a
rapid-sequence induction for the full-stomach, head-injured patient, despite the
transient rise in ICP seen with succinylcholine. Succinylcholine must be avoided in
children with muscular dystrophy and should be avoided except in airway emergencies
in young males.
58. Malignant hyperthermia (MH) is an inherited disorder that presents in the perioperative
period after exposure to inhalational agents and/or succinylcholine. The disease may be
fatal if the diagnosis is delayed and dantrolene is not administered. The sine qua non of
MH is an unexplained rise in end-tidal carbon dioxide with a simultaneous increase in
minute ventilation in the setting of an unexplained tachycardia.
59. Patients with Alzheimer’s disease may become more confused and disoriented with
preoperative sedation.
60. In patients with multiple sclerosis spinal anesthesia should be used with caution and only
in situations in which the benefits of spinal anesthesia over general anesthesia are clear.
61. Patients with diabetes have a high incidence of coronary artery disease with an atypical or
silent presentation. Maintaining perfusion pressure, controlling heart rate, continuous ECG
observation, and a high index of suspicion during periods of refractory hypotension are
key considerations.
62. The inability to touch the palmar aspects of the index fingers when palms touch (the
prayer sign) can indicate a difficult oral intubation in patients with diabetes.
63. Thyroid storm may mimic MH. It is confirmed by an increased serum tetraiodothyronine
(T4) level and is treated initially with b-blockade followed by antithyroid therapy.
64. Perioperative glucocorticoid supplementation should be considered for patients receiving
exogenous steroids.
65. Obese patients may be difficult to ventilate and difficult to intubate. Backup strategies
should always be considered and readily available before airway management begins.
66. A patient with a Glasgow Coma Scale of 8 is sufficiently depressed that endotracheal
intubation is indicated.
67. The initial goal of burn resuscitation is to correct hypovolemia. Burns cause a generalized
increase in capillary permeability with loss of significant fluid and protein into interstitial tissue.
68. From about 24 hours after injury until the burn has healed, succinylcholine may cause
hyperkalemia because of proliferation of extrajunctional neuromuscular receptors. Burned
patients tend to be resistant to the effects of nondepolarizing muscle relaxants and may
need two to five times the normal dose.
69. Abrupt oxygen desaturation while transporting an intubated pediatric patient is probably
the result of main stem intubation.
70. Because children have stiff ventricles and rely on heart rate for cardiac output, maintain
heart rate at all costs by avoiding hypoxemia and administering anticholinergic agents
when appropriate.
71. Infants may be difficult to intubate because they have a more anterior larynx, relatively
large tongues, and a floppy epiglottis. The narrowest part of the larynx is below the vocal
cords at the cricoid cartilage.
72. Hyperventilation with 100% oxygen is the best first step in treating a pulmonary
hypertensive event.
73. If a child with tetralogy of Fallot has a hypercyanotic spell during induction of anesthesia,
gentle external compression of the abdominal aorta can reverse the right-to-left shunt
while pharmacologic treatments are being prepared.
74. The patient with a ventricular obstructive cardiac lesion is at high risk for perioperative
cardiac failure or arrest because of ventricular hypertrophy, ischemia, and loss of
contractile tissue.
75. Pregnant patients can pose airway management problems because of airway edema, large
breasts that make laryngoscopy difficult, full stomachs rendering them prone to aspiration,
and rapid oxygen desaturation caused by decreased functional residual capacity.
76. In preeclampsia hypertension should be treated, but blood pressure should not be
normalized. Spinal anesthesia may be preferable to general anesthesia when the
preeclamptic patient does not have an existing epidural catheter or there is insufficient
time because of nonreassuring fetal heart rate tracing.
77. Intrauterine fetal resuscitation and maternal airway management are of overriding
importance in patients with eclamptic seizures.
78. Basal function of most organ systems is relatively unchanged by the aging process per se,
but the functional reserve and ability to compensate for physiologic stress are reduced.
79. In general, anesthetic requirements are decreased in geriatric patients. There is an
increased potential for a wide variety of postoperative complications in the elderly, and
postoperative cognitive dysfunction is arguably the most common.
80. Anesthesiologists increasingly are asked to administer anesthesia in nontraditional
settings. Regardless of where an anesthetic is administered, the same standards apply for
safety, monitors, equipment, and personnel.
81. O-negative blood is the universal donor for packed red blood cells; for plasma it is AB positive.
82. If a patient is pacemaker dependent, the interference by electrocautery may be interpreted
by the device as intrinsic cardiac activity, leading to profound inhibition of pacing and
possible asystole. Devices should be programmed to the asynchronous mode before
surgery.
83. Pacemaker-mediated tachycardia is an endless-loop tachycardia caused by retrograde
atrial activation up the conduction system, with subsequent tracking of this atrial signal
and then pacing in the ventricle. It can be terminated by application of a magnet that
prevents tracking.
84. Loss of afferent sensory and motor stimulation renders a patient sensitive to sedative
medications secondary to deafferentiation. For the same reason neuraxial anesthesia
decreases the minimum alveolar concentration of volatile anesthetics.
85. Patients with sympathectomies from regional anesthesia require aggressive resuscitation,
perhaps with unusually large doses of pressors, to reestablish myocardial perfusion after
cardiac arrest.
86. Although patients with end-stage liver disease have a hyperdynamic circulation characterized
by increased cardiac index and decreased systemic vascular resistance, impaired myocardial
function, coronary artery disease, and pulmonary hypertension are common.
87. Patients with liver disease commonly have an increased volume of distribution,
necessitating an increase in initial dose requirements. However, because the drug
metabolism may be reduced, smaller doses are subsequently administered at longer
intervals.
88. There is no best anesthetic technique during cardiopulmonary bypass. Patients with
decreased ejection fraction will not tolerate propofol infusions or volatile anesthesia as
well as patients with preserved stroke volume and will probably require an opioid-based
technique.
89. Always reassess optimal positioning of any lung-isolation device after repositioning the
patient. A malpositioned tube is suggested by acute increases in ventilatory pressures and
decreases in oxygen saturation.
90. Methods to improve oxygenation during one-lung ventilation include increasing FiO2,
adding PEEP to the dependent lung, adding continuous positive airway pressure to the
nondependent lung, adjusting tidal volumes, and clamping the blood supply to the
nonventilated lung.
91. To decrease airway pressures, always use the largest double-lumen endotracheal tube
available.
92. If ICP is high, as evidenced by profound changes in mental status or radiologic evidence of
cerebral swelling, avoid volatile anesthetics and opt instead for a total intravenous
anesthetic technique.
93. If PaCO2 significantly increases after 30 minutes of pneumoperitoneum, search for another
cause of hypercapnia such as capnothorax, subcutaneous PaCO2, CO2 embolism, or
endobronchial intubation.
94. Pulmonary arterial occlusion pressure is an unreliable indicator of cardiac filling pressures
during pneumoperitoneum.
95. Postoperative nausea and vomiting are common after laparoscopic surgery; they should
be anticipated and treated prophylactically.
96. Methohexital should be considered the drug of choice for the induction of anesthesia for
electroconvulsive therapy (ECT). ECT causes pronounced sympathetic activity, which may
result in myocardial ischemia or even infarction in patients with coronary artery disease.
97. To perform ECT safely it is necessary to complete a preoperative history and physical
examination, use standard monitors, have readily available equipment and medications
appropriate for full cardiopulmonary resuscitation, use an induction agent (e.g.,
methohexital) and muscle relaxant (e.g., succinylcholine), and have a b-blocker readily
available (e.g., esmolol).
98. Doses of morphine differ by a factor of 10 between intravenous, epidural, and intrathecal
routes.
99. Chronic pain is best treated by using multiple therapeutic modalities, including physical
therapy, psychologic support, pharmacologic management, and rational use of more
invasive procedures such as nerve blocks and implantable technologies.
100. Neuropathic pain is usually less responsive to opioids than pain originating from
nociceptors.
perioperatively. Because the receptors are up-regulated, withdrawal may precipitate
hypertension, tachycardia, and myocardial ischemia. Clonidine should also be continued
perioperatively because of concerns for rebound hypertension.
2. Under most circumstances peri-induction hypotension responds best to administration of
intravenous fluids and the use of direct-acting sympathomimetics such as phenylephrine.
3. To determine the etiology of hypoxemia, calculate the A-a gradient to narrow the
differential diagnosis.
4. Calculating the anion gap (Naþ [HCO
3
þ Cl ]) in the presence of a metabolic acidosis
helps narrow the differential diagnosis.
5. Estimating volume status requires gathering as much clinical information as possible
because any single variable may mislead. Always look for supporting information.
6. Rapid correction of electrolyte disturbances may be as dangerous as the underlying
electrolyte disturbance.
7. When other causes have been ruled out, persistent and refractory hypotension in trauma
or other critically ill patients may be caused by hypocalcemia or hypomagnesemia.
8. There is no set hemoglobin/hematocrit level at which transfusion is required. The decision
should be individualized to the clinical situation, taking into consideration the patient’s
health status.
9. An outpatient with a bleeding diathesis can usually be identified through history (including
medications) and physical examination. Preoperative coagulation studies in asymptomatic
patients are of little value.
10. Thorough airway examination and identification of the patient with a potentially difficult
airway are of paramount importance. The “difficult-to-ventilate, difficult-to-intubate”
scenario must be avoided if possible. An organized approach, as reflected in the American
Society of Anesthesiologists’ Difficult Airway Algorithm, is necessary and facilitates highquality
care for patients with airway management difficulties.
11. No single pulmonary function test result absolutely contraindicates surgery. Factors
such as physical examination, arterial blood gases, and coexisting medical problems also
must be considered in determining suitability for surgery.
12. Speed of onset of volatile anesthetics is increased by increasing the delivered
concentration of anesthetic, increasing the fresh gas flow, increasing alveolar ventilation,
and using nonlipid-soluble anesthetics.
13. Opioids depress the carbon dioxide–associated drive to breathe, resulting in
hypoventilation. Because of the active metabolites, patients with renal failure may
experience an exaggerated reaction to morphine.
14. Appropriate dosing of intravenous anesthetics requires considering intravascular volume
status, comorbidities, age, and medications.
15. Termination of effect of intravenous anesthetics is by redistribution, not biotransformation
and breakdown.
16. Although succinylcholine is the usual relaxant used for rapid sequence induction, agents
that chelate nondepolarizing relaxant molecule may alter this paradigm in the future.
17. Leave clinically weak patients intubated and support respirations until the patient can
demonstrate return of strength.
18. Lipid solubility, pKa, and protein binding of the local anesthetics determine their potency,
onset, and duration of action, respectively.
19. Local anesthetic-induced central nervous system toxicity manifests as excitation, followed
by seizures, and then loss of consciousness. Hypotension, conduction blockade, and
cardiac arrest are signs of local anesthetic cardiovascular toxicity.
20. There is sound scientific evidence that low-dose dopamine is ineffective for prevention and
treatment of acute renal injury and protection of the gut.
21. A preoperative visit by an informative and reassuring anesthesiologist provides useful
psychologic preparation and calms the patient’s fears and anxiety before administration of
anesthesia.
22. The risk of clinically significant aspiration pneumonitis in healthy patients having elective
surgery is very low. Routine use of pharmacologic agents to alter the volume or pH of
gastric contents is unnecessary.
23. The most important information obtained in a preanesthetic evaluation comes from a
thorough, accurate, and focused history and physical examination.
24. When compressed, some gases condense into a liquid (N2O and CO2) and some do not
(O2 and N2). These properties define the relationship between tank volume and pressure.
25. The semiclosed circuit using a circle system is the most commonly used anesthesia
circuit. Components include an inspiratory limb, expiratory limb, unidirectional valves, a
CO2 absorber, a gas reservoir bag, and a pop-off valve on the expiratory limb.
26. Every patient ventilated with an ascending bellows anesthesia ventilator receives
approximately 2.5 to 3 cm H2O of positive end-expiratory pressure (PEEP) because of the
weight of the bellows.
27. The output of traditional vaporizers depends on the proportion of fresh gas that bypasses
the vaporizing chamber compared with the proportion that passes through the vaporizing
chamber.
28. A conscientious approach to positioning is required to facilitate the surgical procedure,
prevent physiologic embarrassment, and prevent neuropathy and injury to other aspects of
the patient’s anatomy.
29. The first step in the care of the hypoxic patient fighting the ventilator is to ventilate the
patient manually with 100% oxygen.
30. Risk factors for auto-PEEP include high minute ventilation, small endotracheal tube,
chronic obstructive pulmonary disease, and asthma.
31. When determining whether an abnormal electrocardiogram (ECG) signal may be an artifact,
look to see if the native rhythm is superimposed on (marching through) the abnormal tracing.
32. A patient with new ST-segment depression or T-wave inversion may have suffered a non–
ST-elevation myocardial infarction.
33. Pulse oximetry measures arterial oxygenation using different wavelengths of light shone
through a pulsatile vascular bed. Pulse oximetry can detect hypoxemia earlier, providing
an early warning sign of potential organ damage.
34. Below a hemoglobin saturation of 90%, a small decrease in saturation corresponds to a
large drop in PaO2.
35. Except for visualization with bronchoscopy, CO2 detection is the best method of verifying
endotracheal tube location.
36. Analysis of the capnographic waveform provides supportive evidence for numerous
clinical conditions, including decreasing cardiac output; altered metabolic activity; acute
and chronic pulmonary disease; and ventilator, circuit, and endotracheal tube malfunction.
37. Trends in central venous pressures are more valuable than isolated values and should
always be evaluated in the context of the patient’s scenario.
38. Pulmonary catheterization has not been shown to improve outcome in all patient subsets.
39. The risks of central venous catheterization and pulmonary artery (PA) insertion are many
and serious, and the benefits should be identified before initiation of these procedures to
justify their use.
40. To improve accuracy in interpretation of PA catheter data, always consider the timing of
the waveforms with the ECG cycle.
41. Ipsilateral ulnar arterial catheterization should not be attempted after multiple failed
attempts at radial artery catheterization.
42. With the exception of antagonists of the renin-angiotensin system and possibly diuretics,
antihypertensive therapy should be given up to and including the day of surgery.
43. Symptoms of awareness may be very nonspecific, especially when muscle relaxants are used.
44. When a patient with structural heart disease develops a wide-complex tachycardia,
assume that the rhythm is ventricular tachycardia until proven otherwise. When a patient
develops tachycardia and becomes hemodynamically unstable, prepare for cardioversion
(unless the rhythm is clearly sinus!).
45. When a patient develops transient slowing of the sinoatrial node along with transient
atrioventricular block, consider increased vagal tone, a medication effect, or both.
46. Even mild hypothermia has a negative influence on patient outcome, increasing rates of
wound infection, delaying healing, increasing blood loss, and increasing cardiac morbidity
threefold.
47. If a patient’s exercise capacity is excellent, even in the presence of ischemic heart disease,
the chances are good that the patient will be able to tolerate the stresses of surgery. The
ability to climb two or three flights of stairs without significant symptoms (e.g., angina,
dyspnea, syncope) is usually an indication of adequate cardiac reserve.
48. Patients with decreased myocardial reserve are more sensitive to the cardiovascular
depressant effects caused by anesthetic agents, but careful administration with close
monitoring of hemodynamic responses can be accomplished with most agents.
49. For elective procedures, the most current fasting guidelines are as follows:
Clear liquids (water, clear juices) 2 hours
Nonclear liquids (Jello, breast milk) 4 hours
Light meal or snack (crackers, toast, liquid) 6 hours
Full meal (fat containing, meat) 8 hours
50. “All that wheezes is not asthma.” Also consider mechanical airway obstruction, congestive
failure, allergic reaction, pulmonary embolus, pneumothorax, aspiration, and
endobronchial intubation.
51. Patients with significant reactive airway disease require thorough preoperative preparation,
including inhaled b-agonist therapy and possibly steroids, methylxanthines, or other
agents.
52. The necessary criteria for acute lung injury/acute respiratory distress syndrome (ALI/
ARDS) include:
(1) Acute onset
(2) PaO2/FiO2 ratio of 300 for ALI
(3) PaO2/FiO2 ratio of 200 for ARDS
(4) Chest radiograph with diffuse infiltrates
(5) Pulmonary capillary wedge pressure of 18 mm Hg
53. Mechanical ventilation settings for patients with ARDS or ALI include tidal volume of at
6 to 8 ml/kg of ideal body weight while limiting plateau pressures to <30 cm H2O. PEEP
should be adjusted to prevent end-expiratory collapse. FiO2 should be adjusted to maintain
oxygen saturations between 88% and 92%.
54. Acute intraoperative increases in PA pressure may respond to optimizing oxygenation and
ventilation, correcting acid-base status, establishing normothermia, decreasing the
autonomic stress response by deepening the anesthetic, and administering vasodilator
therapy.
55. The best way to maintain renal function during surgery is to ensure an adequate
intravascular volume, maintain cardiac output, and avoid drugs known to decrease renal
perfusion.
56. Measures to acutely decrease intracranial pressure (ICP) include elevation of the head
of the bed; hyperventilation (PaCO2 25 to 30 mm Hg); diuresis (mannitol and/or
furosemide); and minimized intravenous fluid. In the setting of elevated ICP, avoid
ketamine and nitrous oxide.
57. Airway comes first in every algorithm; thus succinylcholine is the agent of choice for a
rapid-sequence induction for the full-stomach, head-injured patient, despite the
transient rise in ICP seen with succinylcholine. Succinylcholine must be avoided in
children with muscular dystrophy and should be avoided except in airway emergencies
in young males.
58. Malignant hyperthermia (MH) is an inherited disorder that presents in the perioperative
period after exposure to inhalational agents and/or succinylcholine. The disease may be
fatal if the diagnosis is delayed and dantrolene is not administered. The sine qua non of
MH is an unexplained rise in end-tidal carbon dioxide with a simultaneous increase in
minute ventilation in the setting of an unexplained tachycardia.
59. Patients with Alzheimer’s disease may become more confused and disoriented with
preoperative sedation.
60. In patients with multiple sclerosis spinal anesthesia should be used with caution and only
in situations in which the benefits of spinal anesthesia over general anesthesia are clear.
61. Patients with diabetes have a high incidence of coronary artery disease with an atypical or
silent presentation. Maintaining perfusion pressure, controlling heart rate, continuous ECG
observation, and a high index of suspicion during periods of refractory hypotension are
key considerations.
62. The inability to touch the palmar aspects of the index fingers when palms touch (the
prayer sign) can indicate a difficult oral intubation in patients with diabetes.
63. Thyroid storm may mimic MH. It is confirmed by an increased serum tetraiodothyronine
(T4) level and is treated initially with b-blockade followed by antithyroid therapy.
64. Perioperative glucocorticoid supplementation should be considered for patients receiving
exogenous steroids.
65. Obese patients may be difficult to ventilate and difficult to intubate. Backup strategies
should always be considered and readily available before airway management begins.
66. A patient with a Glasgow Coma Scale of 8 is sufficiently depressed that endotracheal
intubation is indicated.
67. The initial goal of burn resuscitation is to correct hypovolemia. Burns cause a generalized
increase in capillary permeability with loss of significant fluid and protein into interstitial tissue.
68. From about 24 hours after injury until the burn has healed, succinylcholine may cause
hyperkalemia because of proliferation of extrajunctional neuromuscular receptors. Burned
patients tend to be resistant to the effects of nondepolarizing muscle relaxants and may
need two to five times the normal dose.
69. Abrupt oxygen desaturation while transporting an intubated pediatric patient is probably
the result of main stem intubation.
70. Because children have stiff ventricles and rely on heart rate for cardiac output, maintain
heart rate at all costs by avoiding hypoxemia and administering anticholinergic agents
when appropriate.
71. Infants may be difficult to intubate because they have a more anterior larynx, relatively
large tongues, and a floppy epiglottis. The narrowest part of the larynx is below the vocal
cords at the cricoid cartilage.
72. Hyperventilation with 100% oxygen is the best first step in treating a pulmonary
hypertensive event.
73. If a child with tetralogy of Fallot has a hypercyanotic spell during induction of anesthesia,
gentle external compression of the abdominal aorta can reverse the right-to-left shunt
while pharmacologic treatments are being prepared.
74. The patient with a ventricular obstructive cardiac lesion is at high risk for perioperative
cardiac failure or arrest because of ventricular hypertrophy, ischemia, and loss of
contractile tissue.
75. Pregnant patients can pose airway management problems because of airway edema, large
breasts that make laryngoscopy difficult, full stomachs rendering them prone to aspiration,
and rapid oxygen desaturation caused by decreased functional residual capacity.
76. In preeclampsia hypertension should be treated, but blood pressure should not be
normalized. Spinal anesthesia may be preferable to general anesthesia when the
preeclamptic patient does not have an existing epidural catheter or there is insufficient
time because of nonreassuring fetal heart rate tracing.
77. Intrauterine fetal resuscitation and maternal airway management are of overriding
importance in patients with eclamptic seizures.
78. Basal function of most organ systems is relatively unchanged by the aging process per se,
but the functional reserve and ability to compensate for physiologic stress are reduced.
79. In general, anesthetic requirements are decreased in geriatric patients. There is an
increased potential for a wide variety of postoperative complications in the elderly, and
postoperative cognitive dysfunction is arguably the most common.
80. Anesthesiologists increasingly are asked to administer anesthesia in nontraditional
settings. Regardless of where an anesthetic is administered, the same standards apply for
safety, monitors, equipment, and personnel.
81. O-negative blood is the universal donor for packed red blood cells; for plasma it is AB positive.
82. If a patient is pacemaker dependent, the interference by electrocautery may be interpreted
by the device as intrinsic cardiac activity, leading to profound inhibition of pacing and
possible asystole. Devices should be programmed to the asynchronous mode before
surgery.
83. Pacemaker-mediated tachycardia is an endless-loop tachycardia caused by retrograde
atrial activation up the conduction system, with subsequent tracking of this atrial signal
and then pacing in the ventricle. It can be terminated by application of a magnet that
prevents tracking.
84. Loss of afferent sensory and motor stimulation renders a patient sensitive to sedative
medications secondary to deafferentiation. For the same reason neuraxial anesthesia
decreases the minimum alveolar concentration of volatile anesthetics.
85. Patients with sympathectomies from regional anesthesia require aggressive resuscitation,
perhaps with unusually large doses of pressors, to reestablish myocardial perfusion after
cardiac arrest.
86. Although patients with end-stage liver disease have a hyperdynamic circulation characterized
by increased cardiac index and decreased systemic vascular resistance, impaired myocardial
function, coronary artery disease, and pulmonary hypertension are common.
87. Patients with liver disease commonly have an increased volume of distribution,
necessitating an increase in initial dose requirements. However, because the drug
metabolism may be reduced, smaller doses are subsequently administered at longer
intervals.
88. There is no best anesthetic technique during cardiopulmonary bypass. Patients with
decreased ejection fraction will not tolerate propofol infusions or volatile anesthesia as
well as patients with preserved stroke volume and will probably require an opioid-based
technique.
89. Always reassess optimal positioning of any lung-isolation device after repositioning the
patient. A malpositioned tube is suggested by acute increases in ventilatory pressures and
decreases in oxygen saturation.
90. Methods to improve oxygenation during one-lung ventilation include increasing FiO2,
adding PEEP to the dependent lung, adding continuous positive airway pressure to the
nondependent lung, adjusting tidal volumes, and clamping the blood supply to the
nonventilated lung.
91. To decrease airway pressures, always use the largest double-lumen endotracheal tube
available.
92. If ICP is high, as evidenced by profound changes in mental status or radiologic evidence of
cerebral swelling, avoid volatile anesthetics and opt instead for a total intravenous
anesthetic technique.
93. If PaCO2 significantly increases after 30 minutes of pneumoperitoneum, search for another
cause of hypercapnia such as capnothorax, subcutaneous PaCO2, CO2 embolism, or
endobronchial intubation.
94. Pulmonary arterial occlusion pressure is an unreliable indicator of cardiac filling pressures
during pneumoperitoneum.
95. Postoperative nausea and vomiting are common after laparoscopic surgery; they should
be anticipated and treated prophylactically.
96. Methohexital should be considered the drug of choice for the induction of anesthesia for
electroconvulsive therapy (ECT). ECT causes pronounced sympathetic activity, which may
result in myocardial ischemia or even infarction in patients with coronary artery disease.
97. To perform ECT safely it is necessary to complete a preoperative history and physical
examination, use standard monitors, have readily available equipment and medications
appropriate for full cardiopulmonary resuscitation, use an induction agent (e.g.,
methohexital) and muscle relaxant (e.g., succinylcholine), and have a b-blocker readily
available (e.g., esmolol).
98. Doses of morphine differ by a factor of 10 between intravenous, epidural, and intrathecal
routes.
99. Chronic pain is best treated by using multiple therapeutic modalities, including physical
therapy, psychologic support, pharmacologic management, and rational use of more
invasive procedures such as nerve blocks and implantable technologies.
100. Neuropathic pain is usually less responsive to opioids than pain originating from
nociceptors.
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