ORAL EXAM, Wednesday, April 25 #2

RESIDENTS AND FACULTY: This is a type A stem. Preoperative topics are NOT discussed. The exam begins with the arrival of the patient in the operating room.

A 44-year-old, 90 Kg, 5'6" tall, non-English speaking woman is brought to the operating room for a total left knee replacement.

HPI: She has severe rheumatoid arthritis involving multiple joints. She leads a sedentary existence due to limited mobility. Her medications include a non-steroidal anti-inflammatory drug, methotrexate and prednisone 5 mg daily.

PMH: Intravenous heroin use between ages 18-20. Is positive for hepatitis B antigen.

She had a right knee synovectomy under general anesthesia 3 years ago in another country and no records are available. She has no allergies, does not drink alcohol and does not smoke.

PHYS EXAM: P 92, BP 110/60, R 16, T 37°C

Mild restriction of jaw and neck mobility with partial view of uvula.

Lung and heart exam is normal. Painful swollen joints

Chest XRAY: Normal

LABS: Hgb 10.5 gms/dl, glucose 112 mg/dl, coagulation studies, electrolytes and liver function tests are normal.

The patient states concern over post-op nausea and claims a low pain tolerance. She has been cleared in the pre-admission unit for general or regional anesthesia.

ORAL EXAM, Wednesday, April 25 #2

FACULTY: This is a type A stem. Preoperative topics are NOT discussed. The exam begins with the arrival of the patient in the operating room. Please leave 5 minutes at the end for feedback.

A. INTRA-OPERATIVE MANAGEMENT -10 Minutes

1. Anesthetic Technique: Would you consider a regional anesthetic in this patient? Why/why not? Interpreter cannot gain consent for regional. How would you proceed? How would you secure airway? Discuss advantages/disadvantages of awake intubation, inhalation induction with spontaneous ventilation or fiberoptic techniques. If inhalation induction, which agent? Why?

2. Intra-operative Ventilation: Following a difficult intubation using a fiberoptic laryngoscope, the airway pressure rises to 50 em H20. How would you evaluate to determine cause? If mucous plug suspected, how would you proceed? If suction does not improve status, what would you do? Why? Patient develops wheezing. What would you do now? Explain.

3. Dysrhythmia: HR suddenly increases from 90 to 160 and BP falls from 130170 to 80/50. How proceed? Explain. Assume SVT. Administer adenosine? Why/why not? Alternatives? When is cardioversion indicated?

4. Intra-operative Hypotension: The tourniquet on her left lower extremity is now released after 90 minutes of inflation. Her BP rapidly falls to 70/40. Why? How would you manage? Why? Sp02 decreases to 88% while receiving oxygen and nitrous oxide (FI02 .30). DDx? Differentiate? Rx? Rationale. Would increase or decrease in ETC02 help to make diagnosis? Explain.

B. POST-OPERATIVE CARE - 10 Minutes

1. Post-operative Ventilation: At end of surgery, patient breathes spontaneously with a rate of 30 with an end-tidal C02 of 58 mmHg. Discuss further evaluation. Treatment? Why?

2. Pain: How will you manage severe pain in knee? PCA with morphine exacerbates nausea and vomiting. What other alternatives exist? Which would you choose? Why?

3. Post-op Jaundice: 3 days post-op the patient has a bilirubin of 7 mg/dl and appears jaundiced. You are called due to suspicion that this is anesthetic related. Discuss your evaluation and impression.

4. Sepsis: On the fourth post-op day the patient's temperature is 39°C and her BP falls to 75/50 over 2 hours. She is disoriented and tachypneic with a room air Sp02 of 88%. How would you proceed? You suspect sepsis. 2 liters of crystalloid fail to raise blood pressure and ABG on 50% mask 02 is Pa02 80, PaC02 28, pH 7.19. Interpret. Discuss further management. Would you desire specialized monitoring? If so, what? Why? How will it help management?

C. ADDITIONAL TOPICS - 5 Minutes

1. (CA-3 only) Regional anesthesia - obstetrics: A healthy 28-year-old woman is receivmg an epidural anesthetic for an elective Cesarean section. After identifying the epidural space, how will you avoid unintentional intravascular or subarachnoid injection of the anesthetic? Despite your test, she has a grand mal seizure after injection. How treat? Why? Intubate? Why/why not? Peripheral pulse unobtainable with chest compressions. Any special steps required? What? Why? With uterine displacement, BP returns to 95/50, but fetal heart rate now 85. Indication for urgent Cesarean delivery? Why/why not?

2. (CA-1, 2, or 3) Carboxyhemoglobin: A 65-year-old woman with a long history of depression presents to the OR for repair of a lacerated radial artery and multiple tendons following a suicide attempt. She was found locked in her garage with a car engine running, unconscious and unresponsive. She was volume resuscitated and brought to your hospital. She is now awake but confused and agitated. Her BP is 1701110 and her pulse is 125. Her Sp02 is reading 100%. What further information do you need before anesthetizing her? What does the Sp02 value mean? What are the anesthetic implications of carboxyhemoglobin?