ORAL EXAMINATION: Tuesday, November 28, 2006

Examiners please note: This is a type B examination. Preoperative topics ARE discussed. Please leave 5 minutes at the conclusion for feedback

A 23-year-old, 130 kg, 5’10” man was involved in a motor vehicle accident 2 hours ago sustaining a femoral fracture. He is scheduled for insertion of an intramedullary rod. He complains of pain in the posterior cervical area and is slightly dyspneic. He has a history of hypertension treated with captopril (ACE-inhibitor) for 2 years. P 120, BP 90/60 mmHg, R 28, T 37°C. Hgb is 10.5 gm/dL.

A. PRE-OPERATIVE EVALUATION - 10 Minutes

1. Hemodynamic assessment: What impression do you have concerning the patient’s hemodynamic state from the above vital signs? Why? Do you need more information to assess hemodynamic status? If so, what? Why?

2. Dyspnea - assessment, implications: Why is patient dyspneic? How will you evaluate further? Is a pulmonary contusion likely? How will you confirm or rule out? Why is it important to diagnose if present? Is fat embolic disease likely? What is it? How do you diagnose? Treat? Explain.

3. Cervical pain - implications: The patient has had no evaluation of neck pain. Is this of concern? Why? What would you consider to be minimally acceptable for evaluation of C-spine? Explain.

B. INTRA-OPERATIVE MANAGEMENT – 10 Minutes

1. Monitoring: How will end-tidal CO2 assist your anesthetic mgmt? Does the history of hypertension and/or the presence of obesity impact your monitoring plans? How? Explain?

2. General vs. regional anesthesia: Surgeon inquires if regional anesthesia appropriate for procedure. Your response? Explain. Benefits vs. risks of general anesthesia? Assume general anesthetic chosen.

3. Induction and airway management: Assume you were able to visualize uvula preop. Does this influence your approach to general anesthesia? How? Explain. Should patient be intubated awake? Why/why not? Assume awake intubation not indicated. Is ketamine indicated for induction? Why/why not? Your choice of induction agent(s) and reasons.

4. Anesthetic maintenance - choices: What anesthetic agent(s) will you select for maintenance? Why? Will you need a muscle relaxant for the procedure? Why/why not? Will you use N2O? Discuss reasons for decision.

5. Oliguria - causes, management: One hour into this procedure you note only 60 ml of urine. Discuss your evaluation, likely causes and mgmt of patient’s low urine output.

6. Blood loss, transfusion: During rodding the patient loses 1500 ml of blood. Will you transfuse? Why/why not? If not, how do you determine need for transfusion? Is cell saver indicated? Why/why not?

C. ADDITIONAL TOPICS – 5 Minutes

1. Pediatrics - ventriculo-peritoneal shunt: A 10-month-old presents for emergency V-P shunt. Anterior fontanelle is bulging and child is irritable. Pt drank milk 2 hours ago. BP is 110/60, HR 80. Anesthetize using inhalation technique? Why/why not? Different if apple juice? Use a pediatric circle system? Why/why not? If not, what system? Explain. How to maintain anesthesia? Why? Muscle relaxant? If so, how monitor?

3. Myasthenia gravis: A 45-year-old woman with well-controlled myasthenia gravis is scheduled for

cholecystectomy. Her only medication is pyridostigmine 60mg q 6h. How does Dx influence your anesthetic mgmt? If surgery scheduled for 11 am? Regional or general? Assume general. Administer a muscle relaxant? Why/why not? If so, which? Why? Assume atracurium given but one hour later, after 5 mg neostigmine, trainof-four remains absent. How proceed? How differentiate myasthenic vs. cholinergic crisis?