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Anesthesiology Continuing Education (ACE)
Joel O. Johnson, MD, PhD
Co-editor in Chief
asahq.org
2
Disclosure
- Co-editor in Chief for Anesthesiology Continuing Education
Objectives
- Understand the goals of the ACE product in furthering
education
- Appreciate the types of questions included in ACE
- Gauge the benefit that the ACE product will have on your
individual learning goals
Question writing
- Each item is researched and written by an expert
anesthesiologist
- The item is reviewed and edited by the co-editorsin-chief
- Each question and it’s content is discussed by the
ACE Editorial Board at quarterly meetings
- 100 questions are chosen for publication semiannually, after a final review for content and
educational value
Content
- “Walking Around Knowledge”
- Concise explanations
- Illustrations, Figures and Tables
- References including one textbook and at least
one published paper
Publication
- Electronic,
web-based
- Booklet
Audience Response and Participation
- Please take out your mobile device/laptop.
- Go to www.pollev.com/
- The polling questions will appear in your browser.
8
Cardiac
A patient scheduled for surgery has a preoperative
electrocardiogram (ECG)
Which of the following rhythms is MOST likely to
develop in this patient?
a) Second-degree atrioventricular
block
b) Supraventricular tachycardia
c) Pulseless electrical activity
d) Ventricular fibrillation
Delta waves in an ECG are associated with the presence of a
myocardial accessory conducting pathway. Wolff–Parkinson–
White (WPW) pattern on an ECG consists of a delta wave and
a short P-R interval due to an accessory pathway in the
conducting system of the heart. Some patients with a WPW
pattern on ECG may develop WPW syndrome, which includes
the presence of dysrhythmias, most commonly
tachydysrhythmias such as supraventricular tachycardia (SVT).
Neither second-degree atrioventricular block nor pulseless
electrical activity is commonly associated with WPW syndrome.
Although ventricular fibrillation has been reported in patients
with WPW syndrome, it is not the most common dysrhythmia in
this patient population.
Anesthesia Machine
Which of the following properties of desflurane
MOST likely necessitates the unique construction of
the agent-specific desflurane vaporizer?
a)
b)
c)
d)
Low blood–gas solubility
High boiling point
Low molecular weight
High vapor pressure.
Vapor
Pressure
(°C)
Boiling
Point
(°C)
MAC
Blood:Gas
Partition
Coefficient
Desflurane
Isoflurane
Halothane
Enflurane
664
238
243
175
22.8
48.5
50.2
56.5
6.0
1.28
0.75
1.58
0.43
1.4
2.3
1.9
Sevoflurane
157
58.5
2.05
0.68
Agent
Variable Bypass vaporizer
Desflurane vaporizer
Effects of Aging (Geriatrics)
Which of the following is MOST likely to be decreased as a
consequence of aging?
a)
b)
c)
d)
Total lung capacity
Residual volume
Vital capacity
Closing capacity
Closing capacity increases with age
Pharmacology
Which of the following statements about egg
allergies is MOST likely true?
a) Propofol contains the allergen egg white ovalbumin.
b) Parenteral nutrition with fat emulsion containing egg
lecithin is contraindicated in egg allergic patients.
c) Egg allergy is more common in the adult population than
in the pediatric population.
d) Previous anaphylaxis to eggs is considered a
contraindication to propofol.
Explanation
It is likely that rare reports of allergic reactions to
propofol are due to interactions with the propofol
molecule itself, involving the phenol ring or
isopropyl side chains.
In particular, prior exposure to cosmetic and
dermatological products containing isopropyl side
chains may have cross-sensitized the patient,
particularly in atopic individuals.
Morbid obesity
Which of the following drugs is BEST dosed on total body
weight in a morbidly obese patient?
a)
b)
c)
d)
Succinylcholine
Rocuronium
Vecuronium
Cisatracurium
Mask ventilation
Which of the following is MOST predictive of difficult mask
ventilation?
a)
b)
c)
d)
Lack of teeth
Body mass index greater than 26 kg/m2
Presence of a beard
History of snoring
Table 1. Identification of risk factors for difficult mask ventilation
with multivariate analysis (n = 1,502). Used with permission, from
Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask
ventilation. Anesthesiology. 2000;92(5):1229-1236.
Intubation
In the properly executed ramped or head-elevated
laryngoscopy position (HELP), which of the following is
MOST likely true?
a) The cervical spine is in an extended position with respect to
the thoracic spine.
b) The head is in a flexed position with respect to the cervical
spine.
c) The external auditory meatus is in the same plane as the
sternal notch.
d) The oral axis is perpendicular to the pharyngeal axis.
Sniffing position
HELP (head elevated)
Intraoperative Complications
The reported risk of perioperative venous gas
embolism (VGE) is HIGHEST during which of the
following procedures?
a)
b)
c)
d)
Cesarean delivery
Central line placement
Stereotactic brain biopsy
Laparoscopy
Procedure
Hysteroscopy
Cesarean delivery
Reported Risk
85%‒98%
30%‒97%
Craniofacial procedures
66%‒83%
Sitting craniotomy
Uterine myomectomy
10%‒80%
40%‒70%
Hepatic resection/surgery
44%‒68%
Total hip arthroplasty
57%
Operative hysteroscopy
10%‒50%
Stereotactic brain biopsy
8%‒14%
Deep brain stimulator implant
4.5%
Laparoscopy
Central line placement
<0.6%
0.2%‒1%
Rare (case reports) of VGE
Procedure
Mechanism
Intestinal endoscopy
Air/CO2 under pressure
Vitrectomy
Entrainment through the central retinal vein
Spine surgery
Venous entrainment when the operative site is
≥ 5 cm above the level of the right ventricle
Shoulder arthroscopy
Entrainment of residual air in saline irrigation bags
Gravity driven or pressurized venous entry of air
Infusions
Endoscopic retrograde
cholangiopancreatography
Transurethral resection of the prostate
Contrast injector in imaging studies
Intravenous infusion bags
Forced air via the endoscope after a Kasai
procedure
Risk
The HIGHEST risk of seroconversion from a needlestick injury
is from a patient infected with which of the following?
a) Rabies
b) Human immunodeficiency virus (HIV)
c) Hepatitis C
d) Hepatitis B
Pediatrics
Postextubation croup in pediatric patients is
MOST likely to be associated with:
a) an audible leak at a peak inspiratory
pressure of 20 cm H2O.
b) supine position.
c) patient age of 5 or 6 years.
d) a recent history of croup
Summary
The benefits associated with the Anesthesiology Continuing
Education product are:
• Refreshes the participants knowledge
• Introduces new concepts that are built on existing
knowledge
• Provides continuing education that translates into useful
clinical information
A 40-year-old patient in the postanesthesia care unit after
laparoscopic cholecystectomy develops new-onset atrial fibrillation
(AF). Vital signs include a heart rate of 135 beats/min and
noninvasive blood pressure of 140/66. The patient is awake and
oriented. What is the recommended initial next step?
(A)
(B)
(C)
(D)
Heart rate control
Echocardiogram
Electrical cardioversion
Anticoagulation
Which of the following is MOST likely to be associated with an
increased risk of postoperative nausea and vomiting (PONV)?
(A)
(B)
(C)
(D)
Age greater than 75 years
History of smoking cigarettes
Male sex
Longer duration of anesthesia
A 52-year-old woman with mitral valve stenosis presents for
a cholecystectomy. Her preoperative electrocardiogram
reveals normal sinus rhythm at 90 beats/min. Which of the
following represents the BEST perioperative management
strategy?
(A) β-Receptor blockade
(B) Infective endocarditis prophylaxis
(C) Anticoagulation
(D) Nitroglycerin
Exposure to which of the following is MOST likely to
deactivate the color indicator in soda lime absorbent?
(A)Fluorescent lights
(B)Compound A
(C)Water
(D)Heat
Each of the following medications is capable of causing
burst suppression on the electroencephalogram (EEG)
EXCEPT
(A) midazolam.
(B) pentobarbital.
(C) sevoflurane.
(D) sufentanil.
If an E-cylinder is providing 4 L/min flow of oxygen and
the cylinder pressure gauge reads 600 psig, the
cylinder will MOST likely become empty in
(A) 90 minutes.
(B) 60 minutes.
(C) 45 minutes.
(D) 15 minutes.
Which of the following estimates of the total blood volume
for a 1.8-kg premature neonate is MOST accurate?
(A) 125 mL
(B) 150 mL
(C) 175 mL
(D) 240 mL
Questions?