ORAL EXAMINATION, WEDNESDAY, NOVEMBER 29, 2006

Examiners, this is a type A stem. Preoperative issues are NOT discussed. All preoperative information is given below. Please allow 5 minutes at the end for feedback.

A 48-year-old, 122 Kg, 6' tall man is brought to the operating room for uvulopalatopharyngoplasty and mandibular osteotomies for obstructive sleep apnea.

HPI: Increased snoring and daytime somnolence for past year. Sleep study reveals multiple apneic episodes with arterial desaturations to 82%. Denies dyspnea on exertion and comfortably climbs 2 flights of stairs. He did not tolerate a trial of nasal CPAP.

PMH: Hypertension since age 26, treated with enalapril (ACE inhibitor) which was taken this morning. At a preoperative evaluation 2 days ago, his blood pressure was 165/83. His weight has been constant for 4 years. He does not smoke or drink alcohol. He has no allergies.

PHYS EXAM: BP 172/88, P 82, R 18, T 37C. SpO2 95% RA

HEENT: Normal mouth opening, a large tongue, a short, thick neck with limited extension and inability to view uvula or tonsils.

Cardiac and lung exam are normal. No organomegaly or peripheral edema.

XRAY: Cardiomegaly and clear lung fields.

EKG: Left ventricular hypertrophy with normal T-wave and ST segments.

LABS: Hgb is 15.5 gm/dl, BUN 22 mg/dl, creatinine 1.4 mg/dl, room air ABG - Pa02 85 mmHg, PaC02 36

mmHg, pH 7.42.

ORAL EXAMINATION, WEDNESDAY, NOVEMBER 29, 2006

Examiners, this is a type A stem. Preoperative issues are NOT discussed. All preoperative information is given below. Please allow 5 minutes at the end for feedback.

A. INTRA-OPERATIVE MANAGEMENT - 10 Minutes

1. Selection of Monitors: Your choice for blood pressure monitoring? Basis for choice? Is this patient likely to show blood pressure lability during anesthesia and surgery? Explain. Implications for management? Additional monitoring required? If so, why?

2. Management of Airway/Induction: Surgeon requests nasal intubation. Is this patient's airway likely to be difficult to secure? Why? Will you intubate before or after induction? Explain basis of choice. Is a fiberoptic technique indicated? Why/why not? Do you anticipate difficulties in performing nasal fiberoptic intubation? Explain. Can you avoid these potential difficulties in this patient? Choice of induction drugs? Why for your selection of specific drugs (hypnotics, relaxants)?

3. Hypoxemia: Sp02 falls from 98% to 93% over the hour following induction. Causes? How will you establish cause? If distal airway collapse, how will you treat? PEEP of 7 crn H20 in circuit has no effect. Why might that be? Is more PEEP indicated? N20 now off and FI02 = 97% with increase in SpO2 to 95%. Problems with high FI02 in this patient? Explain. What will you do?

B. POST-OPERATIVE CARE -10 Minutes

1. Extubation: Patient slow to emerge and remains intubated, breathing spontaneously. His jaw is wired closed. What are your criteria for extubation? Why would you leave the patient intubated? If intubated for several hours, should he be ventilated? Why/why not? If not, how will you prevent atelectasis? At time of extubation (ETT was nasotracheal) patient develops severe nosebleed. Management?

2. Severe Hypertension: After extubation, patient's blood pressure 230/115 and P 110. Causes? Your concerns about this BP? Acute management? Why? How do you decide whether to use beta-blocker versus vasodilator?

3. Pain Management after Osteotomy: Patient indicates severe pain at site of osteotomy. What can be done? Is a PCA regimen appropriate? Why/why not? Despite loading dose of morphine (15 mg) and lockout interval of 6 minutes (10 mg/hr), patient still uncomfortable. What will you do? Explain basis of management choice(s).

4. Myocardial Ischemia: 18 hours after surgery patient complains of left chest and jaw pain. How will you evaluate? EKG shows ST segment elevation in II, III, aVF. What will you do? Rationale?

C. ADDITIONAL TOPICS - 5 Minutes

1. Paraplegia and Anesthetic Management: A 26-year-old woman T4 paraplegic is scheduled to undergo debridement of an ischemic decubitus ulcer. Since she has no feeling in the operative area, the surgeon requests that the case be done under sedation. Is Monitored Anesthesia Care with IV sedation appropriate? Why/why not? Is a spinal anesthetic appropriate? Pro/con. MAC is chosen and 10 minutes into the procedure, the patient's blood pressure rises to 220/125. Why has this happened? Describe the pathophysiology of autonomic hyperreflexia. How will you treat? Why?

2. Latex Allergy: A 35-year-old woman with a history of latex allergy is scheduled for shoulder arthroscopy. How will you prepare her preoperatively? What precautions are needed perioperatively? How will you achieve them? Anesthetic plan? Why? Patient suddenly develops severe hypotension intraoperatively. Differential diagnosis? What other presentations can occur if cause is latex allergy? How will you manage? Rationale. When will you extubate? Explain.