ORAL EXAMINATION: April 24, 2007

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

An 84-year-old, 76 Kg, man is admitted for emergency hip pinning following fracture of the right femoral neck after a fall. Past medical history is significant for moderate chronic obstructive pulmonary disease and hepatitis at age 37 without residual effects. He has been taking an unknown heart medication twice daily, but has not taken it for the last 2 days. His Hgb is 12.5gm/dl. Vital signs show P 108, BP 110/80, R 18 and T 36.2°C.

A. PRE-OPERATIVE EVALUATION -10 Minutes

1. COPD: How will you evaluate this patient's respiratory status? Different for emergent vs. elective surgery? Which

PFTs are helpful in planning your anesthetic? Explain. Patient has no wheezing. Are PFTs necessary? Would an ABG

be helpful? Why/why not? ABG: Pa02 50, PaC02 50. Interpret. How does this affect your anesthesia management?

Explain. Is chest x-ray necessary? Why/why not? Same patient without COPD. Is chest x-ray indicated? Why/why not?

2. Liver Disease: Does history of hepatitis concern you? Why? Would you perform any further evaluation of liver status? Why/why not? If so, what? Why?

3. Cardiac Evaluation: Are you concerned about the rapid heart rate? Why? How will you evaluate? EKG? EKG shows NSR. Will you administer a beta blocker? Why/why not? Your treatment plan? Is further cardiac workup necessary? What is necessary? Defend choice.

B. INTRA-OPERATIVE MANAGEMENT -10 Minutes

1. Monitors: Is an arterial catheter necessary? Why/why not? How will you assess blood volume status? Rationale. Is

end-tidal C02 useful in determining blood volume? Explain. Does PetC02 provide any evaluation of hemodynamic

status? Explain. Will PetC02 accurately reflect PaC02 in this patient? Why/why not?

2. Anesthetic Technique: Surgery is to be performed in lateral position. Would you favor a regional or general anesthetic technique for this patient? Why? What are the advantages of each? Disadvantages? What is the safest technique for preserving liver function? Why?

3. Regional Anesthetic: If an epidural is selected what agent would you use? Why? Would you add epinephrine?

Why/why not? How would you control sensory level? What are possible hazards of epidural? Do they differ from

SAB? How? The patient becomes confused and agitated after epidural. How will you manage? Why? If anesthesia is

inadequate, how will you proceed? Explain.

4. Respiratory Depression: Epidural is functioning well with a T6 level. After you sedate patient, oxygen saturation falls to 84%. What is the likely cause? How would you evaluate? Manage? If ventilatory support is necessary, how would you proceed?

5. Dysrhythmia: As surgeon is closing skin incision, the patient's pulse rate suddenly rises from 88 to 150. What would you do? Rhythm appears to be regular with possible flutter waves. How will you proceed? Why? Suppose blood pressure 120170. Suppose blood pressure 60/30. Rationale.

C. ADDITIONAL TOPICS - 5 Minutes

1. General Surgical Anesthesia: A 62-year-old morbidly obese woman is to undergo laparoscopic cholecystectomy. She has severe coronary artery disease and has previously refused cardiac revascularization surgery. Preop cardiac

evaluation? Why/why not? What tests? If significant myocardium at risk, how to monitor? Reasons for choices?

Induction technique; drugs? Contrast etomidate and propofol. Thoracic epidural? Why/why not? Potential complications?

2. Pain Management - Epidural Hematoma: A 57-year-old man underwent an uneventful thoracotomy with general

anesthesia and a T8/T9 thoracic epidural for post-operative pain control. On the second post-operative morning he

cannot move his legs. How determine if related to epidural analgesia? Remove the epidural catheter? Why/why not?

When would a radiographic study be indicated? CT or MRI? The MRI reveals an epidural hematoma extending from

T7 to L2. How proceed? Rationale.