Oral Examination – November 2006 #1

Examiners and Examinees please note – this is a type B stem. Preoperative issues are discussed. Please leave 5 minutes at the end of the examination for feedback.

An 11-year-old 65 kg boy is scheduled for urgent ORIF of an open fractured olecranon sustained in motor vehicle accident 90 minutes ago. He has a history of asthma treated with cromolyn sodium and an albuterol inhaler. He required hospitalization and prednisone for status asthmaticus 6 weeks ago. He ate a full lunch before the accident. Bilateral diffuse expiratory wheezes are noted. BP 125/80 mmHg, P 104, R 22, T 36.8^o C.

A. PRE-OPERATIVE EVALUATION - 5 Minutes

1. Implications of obesity: Anesthetic implications of obesity? Does obesity alter the amount of anesthetic drugs required? Explain. Does obesity increase incidence of difficult intubation? Explain.

2. Pulmonary assessment: How will you assess status of asthma? Does child require ABGs before surgery? Why/why not? Does presence of bilateral wheezing contraindicate anticipated ORIF? Why/why not? Assume neurovascular compromise and surgery proceeding.

3. Preop meds (steroid, bronchodilator, gastrokinetic, etc.: Is steroid rx indicated? Purpose(s)? Can you empty stomach preop? Why/why not? Role of metoclopramide? Child is in moderate pain. Is it appropriate to give an intravenous opioid? Why/why not?

B. INTRA-OPERATIVE MANAGEMENT – 10 Minutes

1. Regional vs. general anesthesia: If child cooperative and calm, would you consider upper extremity block? Why/why not? If so, axillary vs. interscalene? Explain. Presume parents and patient request general anesthetic. Your priorities for patient as you plan for GA?

2. Assume general - induction, airway mgmt: Colleague suggests inhalation induction because of asthma. Agree? Why/why not? Is thiopental a reasonable choice for induction? Why/why not? If not, your choice. Explain. Is succinylcholine appropriate for paralysis? Why/why not? Is use of laryngotracheal lidocaine by an LTA kit contraindicated given recent lunch? What benefit does it offer? How does it prevent bronchospasm?

3. Severe bronchospasm after intubation: Assume lidocaine via LTA kit not used. Ventilation is very difficult following intubation. Airway pressures are high. What will you do? What drugs will you give? Epinephrine? Why/why not? Does pattern of ventilation during bronchospasm make a difference? How?

4. Anesthetic maintenance - choices: Bronchospasm improved. Is halothane your choice for maintenance? Why/why not? Colleague states halothane contraindicated because of obesity. Agree/disagree? Your choice and reason(s). Does patient require muscle relaxant during procedure? Why/why not?

5. Vomiting at emergence, extubation - mgmt: Patient opens eyes and vomits with ETT still in place. What will you do? Is patient at risk for aspiration? Why? How will you prevent?

C. ADDITIONAL TOPICS – 5 Minutes

1. Transplant anesthesia: A 55-year-old woman requires anesthesia for a cadaveric kidney transplant for chronic renal failure. How to evaluate cardiac function, coagulation? K+ is 5.6mEq/L. Treat? Why/why not? Regional vs. general? Why? Assume general. Choice of agents for maintenance? Why? Choice of relaxant(s)? Why?

2. Emergent burn management: A 71-year-old male fell asleep while smoking in bed brought to ER with third degree burns over his face, neck and upper trunk. He is obtunded, stridorous with face and neck swelling. He has O2 saturation of 91% while receiving 40% oxygen by mask, and stable vital signs (BP 140/80, P 95). How to assess airway? Why? Respiration? How might a 30% carboxyhemoglobin level be relevant? How could this be consistent with the SpO2? Mgmt of his airway?