Clinical Cases in Anesthesia
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Clinical Cases in Anesthesia
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation What is the initial response to a cardiac arrest? How do chest compressions produce a cardiac output? What are the recommended rates of compression and ventilation? What are the complications of CPR? What is the optimal dose of epinephrine? What is the indication for vasopressin in CPR? What are the indications for sodium bicarbonate (NaHCO3) administration? What are the indications for calcium salt administration? What is the antidysrhythmic therapy of choice in VF/pulseless VT? What are the management strategies in bradycardias? What is the treatment of supraventricular tachydys-rhythmias? What are the indications for magnesium therapy? What are the indications for a pacemaker? Why is it important to monitor serum glucose? What are the indications for open cardiac massage? What is the management strategy for pulseless electrical activity (PEA)?Coronary Artery Disease
Coronary Artery Disease What are the determinants of myocardial oxygen supply? What are the determinants of myocardial oxygen consumption (demand)? What are the pharmacologic alternatives for treating myocardial ischemia in this patient? What is coronary steal and what agents might induce it? Should this patient receive perioperative ?-adrenergic blockade? How should this patient be monitored intraoperatively?Recent Myocardial Infarction
Recent Myocardial Infarction How do you evaluate the cardiac risk in a patient scheduled for noncardiac surgery? What is the cardiac risk in this patient? What additional investigations should be performed? What are the implications for anesthetic management when coronary revascularization is performed before noncardiac surgery? What intraoperative monitors would you use? What additional drugs would you have prepared? What anesthetic technique would you use? How would you manage this patient postoperatively?Congestive Heart Failure
Congestive Heart Failure What are possible etiologies for dilated cardio-myopathy? What is the pathophysiology of dilated cardiomyopathy? How would you monitor this patient during the perioperative period? How would you anesthetize this patient?Aortic Stenosis
Aortic Stenosis What are the symptoms and long-term prognosis of aortic stenosis? What is the etiology of aortic stenosis? How is the aortic valve area calculated? Why is it important to maintain sinus rhythm? What is the treatment for supraventricular tachy-dysrhythmias or bradydysrhythmias? How is hypotension best treated in the patient with aortic stenosis? How would you anesthetize this patient for cardiac or noncardiac surgery?Mitral Stenosis
Mitral Stenosis What is the etiology and pathophysiology of mitral stenosis? How should preload, afterload, heart rate, and contractility be managed in a patient with mitral stenosis? How would you optimize this patient’s condition preoperatively? What intraoperative monitoring would be appropriate? How would you anesthetize this patient? How should hypotension be treated in a patient with mitral stenosis? What is the treatment for perioperative right ventricular failure?Eisenmenger Syndrome Subacute Bacterial Endocarditis Prophylaxis
Eisenmenger Syndrome (Subacute Bacterial Endocarditis Prophylaxis) What are the anesthetic considerations for a patient with Eisenmenger syndrome? What is the association between bacterial endocarditis and structural heart disease? Which patients should receive endocarditis prophylaxis? What are the most likely pathogens involved in subacute bacterial endocarditis and what are the antibiotics of choice for its treatment?Hypertrophic Obstructive Cardiomyopathy
Hypertrophic Obstructive Cardiomyopathy Describe the anatomic abnormalities in HOCM What changes in preload, afterload, heart rate, and contractility will optimize hemodynamic performance in a patient with HOCM? What are the treatment options for HOCM? What monitoring would be required in HOCM patients? What considerations should be given in planning the anesthetic management of a patient with HOCM? What are the special considerations for anesthetic management of labor and delivery in a patient with HOCM?Cardiac Pacemakers and Defibrillators
Cardiac Pacemakers and Defibrillators What do the first three letters of the pacemaker code represent? What is the difference between a demand and an asynchronous pacemaker? What is the difference between ventricular (single-chamber) and dual-chamber pacemakers? Is a unipolar or bipolar pacemaker more sensitive to electrocautery interference? How is pacemaker interference by electrocautery prevented? What is pacemaker hysteresis? What causes myopotential inhibition of a pacemaker? What is an automatic implantable cardioverterdefibrillator (AICD)? How is the patient with an AICD managed in the perioperative period?Cardiac Tamponade
Cardiac Tamponade What is the pathophysiology of cardiac tamponade? What are the clinical signs and symptoms of cardiac tamponade? What is the initial management of this patient’s condition? What intraoperative monitoring techniques should be used? Describe the implications for the conduct of general anesthesia in this patientCardiomyopathy Managed With A Left Ventricular Assist Device
Cardiomyopathy Managed With A Left Ventricular Assist Device What is a cardiomyopathy? Distinguish dilated cardiomyopathy from other cardiomyopathies Explain the treatment options for dilated cardiomyopathies What is an LVAD? What are the important anesthetic considerations for patients supported by LVADs? What intra-anesthetic monitoring might be required for patients with LVADs?Noncardiac Surgery After Heart Transplantation
Noncardiac Surgery After Heart Transplantation Describe the physiology of transplanted hearts Is reinnervation of the transplanted heart a concern? Which immunosuppressive medications are typically used following cardiac transplantation? Explain the pre-anesthetic concerns for patients with a transplanted heart What anesthetic techniques are applicable to patients with cardiac transplants? What intraoperative monitors should be used in the patient with a transplanted heart? What emergency drugs are likely to be effective in the patient with a transplanted heart? For patients with a transplanted heart, is it necessary to administer anticholinergics when antagonizing neuromuscular blockade?Coronary Artery Bypass Grafting
Coronary Artery Bypass Grafting What are the major determinants of myocardial oxygen supply and demand? What types of medications are used to treat coronary artery disease? What are the pre-anesthetic concerns in the patient with coronary artery disease? What intraoperative monitoring techniques can be used for the patient undergoing cardiac surgery using cardiopulmonary bypass (CPB)? What are the common intraoperative monitors for myocardial ischemia? What are the effects of CPB on the lungs, the brain, and the kidneys? What are the effects of CPB on hemostasis?Do Not Resuscitate Order
Do-Not-Resuscitate Order What is meant by temporary revocation of do-not-resuscitate (DNR) orders in the operating room? What did you discuss with the patient prior to surgery regarding resuscitation efforts in the operating room? What options are available to the patient and clinician in order to more fully define a patient’s DNR wishes? What would you do in this case, if the patient could not be adequately ventilated with a mask? If this patient were intubated for the resuscitation but did not regain consciousness for 48 hours, is it ethical to withdraw mechanical ventilation at this time?One Lung Anesthesia
One-Lung Anesthesia Describe the anesthetic evaluation before lung resection How are ventilation and oxygenation monitored noninvasively during surgery, and how do these monitors work? What are the indications for one-lung ventilation? Describe the use of single-lumen endotracheal tubes for one-lung ventilation Which sided double-lumen endobronchial tube should be used for this patient? Describe the proper technique for placing a double-lumen endobronchial tube How is correct positioning of the double-lumen endobronchial tube assessed? What clinical problems are associated with the place-ment and use of double-lumen endobronchial tubes? What complications are related to placing the patient in the lateral decubitus position? How are pulmonary perfusion and ventilation altered during one-lung ventilation? What is the treatment for hypoxemia during one-lung anesthesia? Describe the role of a thoracostomy tube following pulmonary resection, and describe the system used for pleural drainage Describe a commonly used pleural drainage system Discuss potential post-thoracotomy complicationsThoracoscopy
Thoracoscopy What types of operations can be done with VAT? What are the advantages of performing the surgery utilizing VAT in comparison with traditional thoracotomy? What anesthetic techniques can be utilized for VAT? How can hypoxemia due to shunting during one-lung ventilation be treated? What complications can occur with VAT?Intracranial Mass Intracranial Pressure Venous Air Embolism And Autoregulation
Intracranial Mass, Intracranial Pressure, Venous Air Embolism, And Autoregulation What is cerebral autoregulation? What factors contribute to increased intracranial pressure (ICP)? How do anesthetic agents and vasoactive drugs affect cerebral blood flow (CBF) and ICP? What are the signs and symptoms of increased ICP? How is ICP monitored? How is increased ICP treated? How is venous air embolism (VAE) detected and treated? What are the contraindications to the sitting position? How would you induce and maintain anesthesia in this patient?Intracranial Aneurysms
Intracranial Aneurysms How are patients graded following subarachnoid hemorrhage from a ruptured aneurysm? What are the most serious complications following subarachnoid hemorrhage from aneurysm rupture? What are the treatment options? What monitoring is indicated for patients undergoing craniotomy for clipping of intracranial aneurysm? How is arterial blood pressure controlled? What is cerebral vasospasm, and how is it treated? How is aneurysm rupture during aneurysm clipping managed?Carotid Endarterectomy
Carotid Endarterectomy What are the indications for surgical carotid endarterectomy (CEA)? What are the alternatives to surgical CEA? What are the most serious perioperative complications? How is the patient’s neurologic status monitored? What interventions may reduce the risk of neurologic injury?Electroconvulsive Therapy
Electroconvulsive Therapy What are the physiologic effects of ECT? What are the anesthetic agents of choice for ECT? Describe the preanesthetic evaluation of ECT patients What are the anesthetic implications of psychotropic agents used in patients receiving ECT? How would you anesthetize this particular patient for ECT? What are the contraindications to ECT?Spine Surgery
Spine Surgery What are the considerations for surgery in the prone position? What monitors will you use for this case? What are somatosensory and motor evoked potentials? Describe the effects of anesthetics on somatosensory and motor evoked potentials What is a “wake-up” test? What is the bispectral index state (BIS)? Is monitoring the BIS useful in this case? Is this patient at risk for postoperative vision loss? What modalities exist for pain relief after spine surgery?Transsphenoidal Hypophysectomy
Transsphenoidal Hypophysectomy What is acromegaly? What symptoms are typical of the disease? How is the disease treated? What are the anesthetic considerations of acromegaly? How would you approach the airway management in this patient? What structures lie within the transsphenoidal surgical field? What is diabetes insipidus? What are the postoperative concerns for this patient?Depolarizing Neuromuscular Blockade
Depolarizing Neuromuscular Blockade Describe the anatomy and physiology of normal neuromuscular transmission How does succinylcholine produce muscle relaxation? What are extrajunctional receptors? How is the action of succinylcholine terminated? What factors may decrease the normal metabolism of succinylcholine? Describe a phase II block What is the treatment of phase II blockade? Describe other recognized side-effects of succinyl-choline What are the contraindications to succinylcholine administration?NonDepolarizing NeuroMuscular Blockade
NonDepolarizing NeuroMuscular Blockade Describe the mechanism by which nondepolarizing neuromuscular blockers produce neuromuscular blockade Differentiate between the commonly employed non-depolarizing muscle relaxants Briefly outline the mechanisms by which drugs other than neuromuscular muscle relaxants affect neuro-muscular blockade What effects do antibiotics have on neuromuscular blockade? How do drugs other than antibiotics affect neuro-muscular blockade? What are the metabolic factors that affect antagonism of neuromuscular blockade?Antagonism of Nondepolarizing Neuromuscular Blockade
Antagonism of Nondepolarizing Neuromuscular Blockade Describe the overall strategy for terminating the action of nondepolarizing neuromuscular blockade List the clinically relevant acetylcholinesterase inhibitors What is the mechanism of acetylcholinesterase inhibition? List the proper doses of muscle relaxant antagonists and their duration of action Explain the need for antimuscarinics used in conjunction with acetylcholinesterase inhibitors What is the onset of action for acetylcholinesterase inhibitors? Describe the mechanism of muscle relaxant antagonism by cyclodextrins Explain the clinical indices of recovery from neuro-muscular blockadeMonitoring the Neuromuscular Junction
Monitoring the Neuromuscular Junction Why is monitoring of neuromuscular function necessary in the practice of anesthesia? What is the mechanomyograph (MMG)? Describe the electromyograph (EMG) What kind of nerve stimulator is in common clinical use? Describe accelerography What is phonomyography? Explain the different patterns of nerve stimulation and the relevance of pattern choiceMyasthenia Gravis
Myasthenia Gravis What is the lesion of myasthenia gravis (MG)? How is MG diagnosed? Explain the treatment alternatives for MG Why are patients with MG sensitive to nondepolariz-ing muscle relaxants and resistant to depolarizing muscle relaxants? How are patients with MG premedicated for surgery? Describe a reasonable anesthetic technique for a patient with MG undergoing transcervical thymectomy Following emergence from anesthesia and before extubation, how is strength assessed? What is cholinergic crisis? Can preoperative evaluation predict the need for postoperative ventilation?Malignant Hyperthermia
Malignant Hyperthermia What is malignant hyperthermia (MH)? How is susceptibility to MH inherited? What is the pathophysiology of MH? What characterizes a clinical episode of MH? Outline the pharmacology of dantrolene How is MH treated? How are patients with known MH susceptibility treated? What are the recognized triggering agents? What is the significance of masseter muscle rigidity (MMR)? How is MH definitively diagnosed? Describe the neurolept malignant syndromeDiabetes Mellitus
Diabetes Mellitus Distinguish among the major types of diabetes mellitus (DM) Summarize the physiologic effects of insulin Describe the oral hypoglycemic agents and insulin preparations available to treat DM How does DM affect perioperative morbidity and mortality? What are the common causes and associated symptoms of hypoglycemia? Outline perioperative management alternatives for the diabetic patient Explain the acute complications of DM Thyroid Disease How does the thyroid affect vital organ function? How is thyroid hormone synthesized and released? How is thyroid hormone regulated? How are thyroid disorders evaluated? What other conditions are associated with thyroid disorders? What is thyroid storm and how is it treated? What are the causes of hyperthyroidism? What are the causes of hypothyroidism? What are the preoperative considerations in a patient with thyroid disease? What are appropriate preoperative tests for a patient with thyroid disease? What are the intraoperative concerns with coexisting thyroid disease? What are the postoperative concerns?Thyroid Disease
Thyroid Disease How does the thyroid affect vital organ function? How is thyroid hormone synthesized and released? How is thyroid hormone regulated? How are thyroid disorders evaluated? What other conditions are associated with thyroid disorders? What is thyroid storm and how is it treated? What are the causes of hyperthyroidism? What are the causes of hypothyroidism? What are the preoperative considerations in a patient with thyroid disease? What are appropriate preoperative tests for a patient with thyroid disease? What are the intraoperative concerns with coexisting thyroid disease? What are the postoperative concerns?Calcium Metabolism
Calcium Metabolism What is the role of calcium in the body? Where is calcium found in the body? How is calcium regulated? What are the symptoms of hypercalcemia? How is this treated? What are the symptoms of hypocalcemia? How is this treated? What are the causes of hyperparathyroidism? What are the anesthetic considerations for parathyroid resection? What are the postoperative concerns after parathyroid resection?Perioperative Corticosteroid Administration
Perioperative Corticosteroid Administration Where and what kind of steroids are naturally produced? What are the physiologic effects of glucocorticosteroids? What steroids are available for administration and what are their equivalent doses? How much cortisol is normally produced and what is Addison’s disease? What are Cushing syndrome and Cushing disease? Does this patient require “stress” dose steroids? How long after discontinuation of steroids should a patient be considered adrenally suppressed and treated accordingly? What clinical scenarios frequently require steroid administration? How is adrenal reserve evaluated? If this patient develops septic shock from a bile leak in the postanesthesia care unit (PACU), should steroids be withheld or administered?Pheochromocytoma
Pheochromocytoma What is a pheochromocytoma? Describe the clinical presentation of and diagnostic criteria for pheochromocytoma Pheochromocytoma is associated with what other syndromes? What conditions may mimic pheochromocytoma? How are patients with pheochromocytoma prepared for surgery? Describe the intraoperative management goals Outline the anesthetic choices for pheochromocytoma What are the special postoperative problems associated with resection of a pheochromocytoma? How is a previously unsuspected and undiagnosed pheochromocytoma managed following induction of anesthesia?Full Stomach
Full Stomach What are the mechanisms a conscious patient has to prevent regurgitation and pulmonary aspiration? What are the risk factors for regurgitation and pulmonary aspiration under general anesthesia? When can aspiration occur during the perioperative period? What are the problems associated with aspiration? If aspiration occurs, what are the usual course, treat-ment and prognosis? How should the nasogastric tube (NGT) be managed during induction? What pharmacologic interventions can be made to decrease the risk of aspiration? What is the reason for applying cricoid pressure during a rapid sequence induction, and what are some of the problems associated with it? What is the effect of commonly used pharmacological agents during anesthesia on lower esophageal sphincter tone? What would be an acceptable anesthetic plan for this patient?Liver Disease
Liver Disease Describe the basic hepatic functions that are of immediate concern to anesthesiologists Explain the liver’s detoxifying and first-pass, metabolic functions Describe common extrahepatic problems associated with chronic liver failure What should a preoperative evaluation of this patient include? What effects do surgery and anesthesia have on normal liver function? What are the concerns associated with viral hepatitis? Describe acetaminophen- and halothane-associated hepatitis Is nitrous oxide, enflurane, or isoflurane hepatotoxic? List the causes of postoperative hepatic dysfunction Are some anesthetic techniques free of hepatotoxic effects? What coagulation problems are anticipated and how are they managed? What intraoperative anesthetic problems occur during liver transplantation?Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm What is the natural history of untreated abdominal aortic aneurysm (AAA)? Outline the preoperative evaluation of the patient with an AAA Which anesthetic techniques are appropriate for AAA surgery? Which monitoring devices are recommended for AAA surgery? Explain the hemodynamic consequences of aortic cross-clamping Describe the options for postoperative analgesiaEndovascular Aortic Stent Placement
Endovascular Aortic Stent Placement Explain the concept of endovascular aortic repair What are the recognized perioperative surgical com-plications associated with endovascular repairs? What are the outcomes following thoracic endovascular aortic repair? What anesthetic techniques are used for endovascular graft insertions? What problems are anticipated during proximal graft deployment? Explain the special role of transesophageal echocar-diography in endovascular stent placement Is the incidence of spinal cord ischemia different after endovascular thoracic aortic repairs compared to open repairs? What is the “post-implantation syndrome”?Transurethral Resection of the Prostate
Transurethral Resection of the Prostate Describe the TURP syndrome and its treatment What other complications can occur during a TURP? What types of irrigating fluids have been used for a TURP? What are the toxicities associated with glycine? What are the anesthetic options for a patient under-going a TURP? If a regional anesthetic is selected, what level of anesthesia is required? How would one correct the Na+ level to 135 mEq/L?Morbid Obesity
Morbid Obesity How is morbid obesity (MO) defined? Name the diseases associated with MO Describe the pathophysiology of obstructive sleep apnea How is obstructive sleep apnea diagnosed? Outline the effect of MO on functional residual capacity Is MO an indication for awake intubation? What special equipment does the anesthesiologist require to anesthetize patients for bariatric surgery? Describe an anesthetic plan for bariatric surgeryLaparoscopy
Laparoscopy What procedures are amenable to the laparoscopic technique? How is laparoscopy initiated? Why is carbon dioxide (CO2) the gas used for insufflation? What are the cardiovascular changes associated with laparoscopic surgery? What are the regional circulatory changes that occur during laparoscopy? What are the pulmonary effects associated with laparoscopic surgery? What are the benefits of laparoscopic surgery? What are the complications of laparoscopic surgery? What anesthetic techniques can be used for laparo-scopic surgery? What is the controversy regarding the use of nitrous oxide? What is the etiology and treatment of post-laparoscopy pain?Carcinoid Syndrome
Carcinoid Syndrome What are carcinoid tumors? What is carcinoid syndrome? In what locations do carcinoid tumors occur? What are the major anesthetic concerns in patients with carcinoid syndrome? What is the mechanism of action of somatostatin? What precautions are prudent for anesthetizing patients with carcinoid syndrome? How is chemoem bolization used to treat metastatic carcinoid syndrome?Kidney Transplantation
Kidney Transplantation How does diabetes affect renal transplantation? Why is timing of hemodialysis important for renal transplantation? Discuss the treatment of hyperkalemia and its associated metabolic problems What are the major anesthetic concerns for renal transplantation? What are the implications of long ischemic times during renal transplantation?Open Eye Injury And Intraocular Pressure
What is the mechanism by which intraocular pressure (IOP) is normally maintained? What pathologic conditions constitute a true ocular emergency versus a relative urgency? How does one minimize the deleterious side-effects of these agents in the presence of a rup-tured globe? What non-anesthetic agents might the ophthalmolo-gist use to maximize surgical outcome?Retinal Detachment
What are the advantages and disadvantages of general anesthesia for scleral buckle repair? Describe the oculocardiac reflex and its treatment What are the potential complications of retrobulbar anesthesia? What types of retinal detachments are amenable to elective repair? Briefly describe the series of events that occur during retinal detachment surgery Reattachment of the retina requires intraocular gasTympanomastoidectomy
Is the anxious patient a good candidate for surgery under monitored anesthesia care (MAC)? What general anesthetic techniques are most likely to minimize postopertive nausea and vomiting? Are regional anesthetics less likely to result in PONV in this patient? Why is control of blood loss important during middle ear surgery? Are long-acting neuromuscular blockers contraindi-cated in middle ear surgery? Describe the conduction of general and regional anesthesia for middle ear surgeryThe Difficult Airway
What are the predictors of difficult mask ventilation? Discuss the risk factors for difficult intubation Are the risk factors for difficult intubation reliable predictors of difficult intubation? How is the anticipated difficult intubation approached? Describe the management options for a patient who, after induction of anesthesia Following induction of anesthesia, ventilation by facemask and intubation are impossible. What maneuvers may help? How is successful tracheal intubation verified? Following a difficult intubation, how is postoperative extubation managed?Adenotonsillectomy
What are the indications and contraindications for adenotonsillectomy? Describe the essential elements of preoperative evaluation for adenotonsillectomy How is the patient premedicated for adenotonsillectomy? What anesthetic alternatives are available for patients undergoing adenotonsillectomy? What are the common postanesthesia care unit problems anticipated following adenotonsillectomy? Which patients are suitable candidates for ambulatory adenotonsillectomy? Describe the anesthetic management of a patient presenting with post-tonsillectomy hemorrhageLaser Laryngoscopy
What is a laser? Describe the most common types of lasers used in medical practice Which lasers are used in laryngeal and tracheobronchial surgery? What are the indications for laser laryngoscopy? What are the hazards of laser laryngoscopy to patients, operating room personnel, and anesthesia equipment? What anesthetic techniques are appropriate for patients undergoing laser laryngoscopy? What maneuvers are instituted to treat an airway fire? Is the risk of fire any less likely with electrocautery?Transfusion Reaction
How are standards for transfusion practice developed? What steps should be taken when a transfusion reaction occurs? How does the laboratory determine which direction the investigation should take? How many different types of crossmatches are there and how does the laboratory decide which should be performed? What are the immediate and delayed adverse effects of blood transfusion?Intraoperative Coagulopathies
What should be included in the preoperative evaluation? If the screening PT or aPTT are prolonged, which other laboratory tests should be ordered? What are the most common intraoperative coagulopathies? Which blood products are used to treat intraoperative coagulopathies?Blood Replacement
How is oxygen transported by the circulatory system? Describe compensatory mechanisms that take place in response to blood loss What is the minimum acceptable hemoglobin concentration (transfusion trigger)? List the potential sources of autologous blood Explain acute isovolemic hemodilution (AIHD) Outline the physiologic response to AIHD How is AIHD accomplished? Which patients are suitable candidates for AIHD? What is intraoperative cell salvage and how do modern cell salvage devices work? Outline the characteristics of blood obtained by cell salvage Describe the indications for use of intraoperative cell salvage Explain the controversies and contraindications involving intraoperative cell salvage What is preoperative autologous blood donation (PABD)? Who is eligible and what are the contraindications for PABD? Outline the disadvantages and risks of PABD Describe postoperative blood salvage Explain the advantages and disadvantages of different autologous blood sourcesThe Jehovahs Witness Patient
What is scoliosis? How is scoliosis classified? How is the curvature assessed in the patient with scoliosis? On the issue of blood, what will a JW refuse and accept? What are the medicolegal issues concerning blood transfusion in the JW who is a minor? Describe the preoperative evaluation of the patient with scoliosis Describe the intraoperative anesthetic considerations for posterior spinal fusion surgery What is the “wake-up test”? Describe the postoperative anesthetic concerns following scoliosis repair What blood substitutes are available?Hemophilia A
What is the primary deficiency in hemophilia A? How does the disease present and what are the laboratory findings? What is the role of factor VIII in the coagulation process? Describe the treatment options Discuss von Willebrand disease as another important cause of surgical bleedingTotal Hip Replacement
Briefly describe rheumatoid arthritis and its treatment What are the anesthetic considerations for the rheumatoid arthritis patient? How is the rheumatoid arthritis patient evaluated for anesthesia? Discuss the options for induction of anesthesia in a primary hip arthroplasty Several hours into the case the surgeon complains that he is operating on a moving target. How would you manage this situation? Discuss the causes and management of fat embolus syndrome Discuss thromboembolism prophylaxis and the placement of neuraxial anesthesia Discuss the options for postoperative pain control after total hip arthroplasty. Discuss the use of a lumbar plexus blockLocal Anesthetics
Describe the chemistry of local anesthetics Describe the mechanism of action of local anesthetics What factors affect the potency, onset, and duration of action of local anesthetics? Discuss the sequence of clinical anesthesia following neural blockade What are the clinical differences between the ester and amide local anesthetics? Describe the pharmacokinetics of local anesthetics How do factors such as dosage of local anesthetic, addition of vasoconstrictors, carbonation and pH adjustment Which local anesthetics are appropriate for the various regional anesthetic procedures? Describe the toxic effects of local anesthetics How is systemic local anesthetic toxicity treated? Is it prudent to use regional anesthesia in a patient who reports a Novocain allergy? What is the treatment for local anesthetic allergic reactions?Spinal Anesthesia
Other than the spinal kit, what equipment must be immediately available while performing spinal anesthesia? When arranging the spinal tray, where is the antiseptic placed in relation to the tray’s other constituents? What are the advantages of the lateral decubitus position for placing a subarachnoid block? What are the advantages of the sitting position for placing a subarachnoid block? Describe a technique for placing a spinal anesthesia Describe alternative approaches to the subarachnoid space What factors affect the spread of anesthetic within the subarachnoid space? What agents are commonly used for subarachnoid block? Besides local anesthetics, what other agents are administered in the subarachnoid space? What are the advantages of adding a vasoconstrictor to the spinal anesthetic solution? What are the recognized complications of spinal anesthesia? What are the contraindications to spinal anesthesia? Describe the advantages of spinal anesthesia over general anesthesia Explain the advantages of spinal anesthesia over epidural anesthesia Outline the advantages and disadvantages of catheter (continuous) spinal anesthesiaBrachial Plexus Anesthesia
Describe the anatomic course of the brachial plexus What are the anatomic landmarks of the axilla? What are the major approaches to blocking the brachial plexus and their indications for use? Describe the interscalene approach to blocking the brachial plexus Describe the supraclavicular approach to blocking the brachial plexus Describe the infraclavicular approach to blocking the brachial plexus Describe the axillary approach to blocking the brachial plexus What complications can arise from upper extremity blocks? What is the Bezold-Jarisch reflex? What local anesthetics are used for blocks of the brachial plexus and in what doses? Is chronic obstructive pulmonary disease (COPD) a contraindication to performing an interscalene block?Lower Extremity Anesthesia
What are the anesthetic options for this patient? What are the advantages and disadvantages of the various anesthetic options? Describe the innervation of the lower extremity Why is a sciatic nerve block necessary for adequate anesthesia for a total knee arthroplasty? How are femoral and sciatic nerve blocks performed? Which local anesthetic agents would you use? Would you sedate the patient for the performance of the femoral and sciatic nerve blocks and/or during the procedure? After performing the block and starting a propofol infusion, the patient begins to flail about upon surgical incision. Should you induce general anesthesia? Describe the use of the tourniquet in a total knee arthroplasty and its hemodynamic consequences What are the options for postoperative pain control?Labor And Delivery
What options are available to the mother for labor analgesia? Explain the advantages and disadvantages of various regional anesthetic techniques for labor and delivery What is a “walking epidural”? Describe the regional anesthetic techniques that can be employed for cesarean section Outline the treatment for postdural puncture headache What are the advantages and disadvantages of general anesthesia for cesarean section? Describe the elements of placental drug transfer What techniques can be used for post-cesarean pain relief? Outline the differential diagnosis of postpartum hemorrhage Explain the risk factors, presentation, and treatment of uterine atony Describe the presentation and treatment of retained placentaPreeclampsia
Classify the hypertensive disorders of pregnancy What are the incidence and risk factors of preeclampsia? Explain the etiology of preeclampsia Describe the pathophysiology of preeclampsia Outline the obstetric management of preeclampsia How is preeclampsia prevented from degenerating into eclampsia? Explain the management of preeclampsia-related hypertension What are the potential consequences of epidural anesthesia in the patient with preeclampsia? Describe the anesthetic options for cesarean section for the preeclamptic patient Outline the anticipated postpartum problems associated with preeclampsiaAbruptio Placenta and Placenta Previa
Summarize the major causes of third-trimester bleeding What is abruptio placenta and what are its risk factors? What are the presenting signs and symptoms of abruptio placenta and how is the diagnosis made? Describe the obstetric management of abruptio placenta Describe the effects of pregnancy on coagulation What is disseminated intravascular coagulopathy and how is it managed? How is fetal distress diagnosed? The patient is given a trial of labor, and the obstetrician requests a consult for labor analgesia. What are your concerns and how would you proceed? How would you anesthetize this patient for an emergency cesarean section? What is placenta previa? What is the clinical presentation of placenta previa and how is the diagnosis made? What is the obstetric management of placenta previa? How would you anesthetize the patient with placenta previa for cesarean section?Anesthesia For Nonobstetric Surgery During Pregnancy
What is the incidence of nonobstetric surgery in the pregnant patient? What are the anesthetic concerns when anesthetizing a pregnant patient? What are the physiologic changes during pregnancy and how do they impact on anesthesia? What is a teratogen and which anesthetic agents are known teratogens? What precautions should be taken to avoid intrauterine fetal asphyxia? How is preterm labor prevented? What monitors should be used when anesthetizing the pregnant patient? What are the special considerations for laparoscopic surgery? What general recommendations can be made when anesthetizing the pregnant patient for nonobstetric surgery?Thrombocytopenia In Pregnancy
What are the concerns when placing an epidural catheter if the platelet count is low? Who is at risk for developing an epidural hematoma? What is considered a low platelet count from the perspective of epidural catheter placement? What is the expected platelet count during pregnancy? Describe coagulation and the role that platelets play in the process What are the causes of thrombocytopenia during pregnancy? What tests are available to evaluate platelet function? Describe the bleeding time test and its limitation Describe the thromboelastogram and its limitations Describe the platelet function analyzer and its limitations What is the overall risk of epidural hematoma? Describe the known cases in the literature of epidural hematoma in the parturient What is the evidence that initiating an epidural anesthetic in a woman with a platelet count <100,000 mm?3 may be safe? How do you evaluate the patient who has a platelet count <100,000 mm?3? What are some practical recommendations regard-ing neuraxial anesthesia in the parturient who presents with a low platelet count? What is low-molecular-weight heparin (LMWH) and how does it compare with and differ from standard heparin? Why do some pregnant women take LMWH? What has been the anesthetic experience with LMWH and neuraxial anesthesia? What are some of the unique recommendations for anesthetizing the parturient taking LMWH?Neonatal Resuscitation
Describe the fetal circulation What are the physiologic changes that occur at birth? How is neonatal resuscitation managed in the delivery room? What is the Apgar score?Gastroschisis and Omphalocele
What are the differences between gastroschisis and omphalocele? How is this neonate managed preoperatively? How is the operating room prepared for this newborn? What is the anesthetic plan, and what are the intra-operative and postoperative concerns in this patient? Describe the fluid and blood product management for this neonate intraoperativelyCongenital Diaphragmatic Hernia
Describe the embryology and pathophysiology of congenital diaphragmatic hernia (CDH) What are the clinical features of CDH? How is CDH diagnosed? What is the preoperative management of CDH? What is permissive hypercapnia? What are the anesthetic considerations for the neonate with CDH? What problems may occur intraoperatively and postoperatively? Describe the techniques for fetal surgeryPyloric Stenosis
What is pyloric stenosis? What is the clinical presentation of pyloric stenosis? How is the diagnosis made? What are the metabolic derangements and how are they treated? What is the surgical treatment of pyloric stenosis? What are the anesthetic considerations?Tracheoesophageal Fistula
What is a tracheoesophageal fistula (TEF)? How does a patient with a TEF typically present? What are the preoperative concerns in a patient with TEF? How is the patient with a TEF managed intraoperatively? What are the postoperative concerns in TEF patients?Congenital Heart Disease
How are innocent and pathologic systolic murmurs differentiated? What is the incidence of congenital heart disease? What are the general anesthetic considerations for the common cardiac lesions? What should be included in the preoperative assessment? What are the anesthetic implications of intracardiac lesions with left-to-right shunting? What are the common intracardiac left-to-right shunting lesions? What are the anesthetic implications of right-to-left shunting lesions? What are the common right-to-left shunting lesions with reduced pulmonary blood flow? How are congenital heart lesions repaired? Discuss the sequelae associated with the repair of specific cardiac lesionsPreterm Infant
What are the anatomic and physiologic differences between the infant and the adult? What is the definition of prematurity? Do the pharmacokinetics and pharmacodynamics of anesthetic drugs differ in this population as compared with adults? What are the nil per os (NPO) guidelines for this case? What anesthetic options are available and what are the concerns regarding each option? If a general anesthetic is planned, what are the induction options? What are the appropriate monitors for this case? What are the options for postoperative pain control? When can this infant be discharged home? Could this procedure have been done as an outpatient after discharge?MRI and the Down Syndrome Child
What is magnetic resonance imaging (MRI)? What are the magnetic field problems associated with MRI? What are the specific problems encountered with physiologic monitors and equipment in the MRI suite? What are possible patient problems encountered in the MRI scanner? What are the clinical manifestations of Down syndrome? Describe the pre-anesthetic evaluation of the child with Down syndrome What anesthetic alternatives are available for the child with Down syndrome undergoing MRI? Describe the postanesthetic concerns in the child with Down syndrome after MRIAcute Postoperative Pain
Why has postoperative pain been undertreated in the past? Which factors in this patient’s history may impact on postoperative pain management? Which organ systems are affected by postoperative pain? Outline the major afferent pain pathways What are the primary chemical mediators of pain? What are the advantages and disadvantages of intramuscular opioid therapy? List alternative postoperative analgesic modalities for this patient What is patient-controlled analgesia (PCA)? What are typical dosage schedules for intravenous PCA-administered opioids? Compare the advantages and disadvantages of PCA opioids with those of intramuscular opioids Describe the regional analgesic techniques available for postoperative pain relief. Which are applicable to this patient? By what mechanism does neuraxial (epidural and subarachnoid) opioid administration produce analgesia? Outline the potential side-effects of neuraxial opioids and their treatment Describe the advantages and disadvantages of subarachnoid and epidural opioids Which opioids and adjuvants are commonly used in the subarachnoid and epidural spaces? What is preemptive analgesia? Can it reliably be performed in this patient?Low Back Pain
What is the incidence of low back pain? List the differential diagnosis of low back pain Describe the classic presentation of a patient with a herniated nucleus pulposus Differentiate the clinical presentation of a herniated nucleus pulposus from spinal stenosis Describe the pathogenesis and treatment of myofascial syndrome (trigger points) What are the signs and symptoms of sacroiliac disease and how is it treated? What are the facet joints and how does pathology in them manifest? What is the mechanism of action by which epidural steroid injections work? What are the pathogenesis, diagnosis, and treatment of internal disc disruption (IDD)? Which oral medications are prescribed for low back pain? What is failed back syndrome (FBS) and how is it managed?Postherpetic Neuralgia
What is the pathogenesis of an acute herpes zoster infection? How does an acute herpes zoster infection manifest itself? What is postherpetic neuralgia (PHN)? Which patients are at risk for the development of PHN? How does PHN present? What medications can be used for treatment of PHN? What is the mechanism of action of these medications? What invasive procedures can be used for the treatment of PHN? Can PHN be prevented?Complex Regional Pain Syndrome
Define complex regional pain syndrome (CRPS) type 1 and type 2 What are the pathophysiologic theories leading to CRPS? Delineate the different stages of CRPS What are the signs and symptoms of CRPS? How is the diagnosis of CRPS made? What different nerve blocks can be used for diagnosis and treatment of CRPS? What other modalities can be used to treat CRPS?Cancer Pain Management
What is the prevalence of cancer pain? What is the prevalence of cancer pain by organ system? What are the different causes of pain in a cancer patient? What is the WHO ladder? What guidelines can be followed in devising a chronic analgesic regimen for treating cancer pain? What are the advantages of set-dose extended-duration opioid management? Describe the anatomy of the celiac plexus What are the indications for performing a celiac plexus block? How is a celiac plexus block performed and what complications can occur? What are the differences between alcohol and phenol neurolysis? When would one use intrathecal versus epidural analgesia for cancer pain management?Ambulatory Surgery
Are there advantages to performing surgery on an ambulatory basis? Which patients are considered acceptable candidates for ambulatory surgery? Are there any patients who should never have surgery on an ambulatory basis? Are diabetic patients suitable candidates for ambulatory surgery? What types of surgical procedures are appropriate for ambulatory surgery? What is the appropriate fasting time before ambulatory surgery that necessitates an anesthetic? Should drugs be administered to empty the stomach or change gastric acidity or volume before the administration of an anesthetic? How can patients be appropriately screened for anesthesia when ambulatory surgery is planned? What preoperative laboratory studies should be obtained before surgery? Should an internist evaluate each patient before ambulatory surgery? Is anxiolytic premedication advisable before ambulatory surgery, and what agents are appropriate? What are the reasons for last-minute cancellation or postponement of surgery? What is the ideal anesthetic for ambulatory surgery? Are there relative or absolute contraindications to the administration of a general anesthetic in the ambulatory setting? What are the advantages and disadvantages to performing a conduction anesthetic in the ambulatory patient? What are the advantages and disadvantages of selecting a nerve block technique for the ambulatory patient? Describe the intravenous regional anesthetic technique (Bier block) for surgery on the extremities What sedatives can be administered to supplement a regional anesthetic? What complications of nerve block anesthesia are of special concern to the ambulatory patient? Should patients having ambulatory surgery be tracheally intubated? What is the role of propofol in ambulatory surgery? What is total intravenous anesthesia (TIVA), and what are its advantages and disadvantages? What is moderate sedation, when is it employed, and what advantages does it offer? When tracheal intubation is required for a short procedure, can one avoid the myalgias associated with succinylcholine? Can a relative overdose of benzodiazepines be safely antagonized? Do the newer volatile agents offer advantages over older agents such as enflurane and isoflurane? What are the etiologies of nausea and vomiting, and what measures can be taken to decrease their incidence and severity? How is pain best controlled in the ambulatory patient in the PACU? What discharge criteria must be met before a patient may leave the ambulatory surgery center? What are the causes of unexpected hospitalization following ambulatory surgery? When may patients operate a motor vehicle after receiving a general anesthetic? What is the role of aftercare centers for the ambulatory surgery patient? Are quality assurance and continuous quality improvement possible for ambulatory surgery?Office Based Anesthesia
Why have office-based procedures and anesthesia services grown so rapidly? What do you need to consider before providing office-based anesthesia (OBA)? What equipment is necessary to provide safe OBA? Is it the same as for the hospital setting? Are there any differences in record keeping or documentation as compared with the hospital setting? Does the history of malignant hyperthermia preclude an office-based procedure and anesthesia? Are there any limitations set for types of patients/ procedures for office-based surgery? What method/technique would you choose to provide anesthesia? How will you treat postoperative nausea and vomiting (PONV)? How will you determine when the patient is ready to be discharged?Thoracic Trauma
What are the consequences of thoracic trauma? How are traumatic pneumothorax and/or hemothorax managed in a patient undergoing laparotomy for splenic injury? What are the mechanisms of morbidity and mortality from flail chest? What are the management options for flail chest and pulmonary contusion? What are the perioperative management options for traumatic hemopericardium? What are the clinical implications of blunt cardiac trauma? When should traumatic thoracic aortic injury be suspected and how is the diagnosis made? In blunt trauma patients with multiple injuries that include thoracic aortic injury, how is surgery prioritized? What are the perioperative clinical and anesthetic pitfalls Describe the clinical management of transmediastinal gunshot woundsAsthma
What is asthma? How is asthma classified? How would you distinguish obstructive from restrictive lung disease, and asthma from chronic obstructive pulmonary disease (COPD) Briefly describe the pharmacology of medications available to treat asthma. What are the indications for mechanical ventilation in severe asthma (status asthmaticus)? What preoperative evaluation and preparation would you order for this patient? Would you choose general anesthesia (with endotra-cheal intubation, with a laryngeal mask airway) or a neuraxial block for this patient? What are the signs and causes of perioperative bronchospasm? The patient refused to have “a needle stuck in her back”Shock
What are the determinants of blood pressure? How should postoperative hypotension be approached? What is the definition of shock? What are the different types of shock and the basics of treatment for each type? What would you do for this patient? A pulmonary artery catheter (PAC) was inserted What is the classification of hemorrhage according to the American College of Surgeons? The heart rate suddenly goes up to 170 beats per minute with wide QRS complexes and the blood pressure drops further. What are the diagnostic possibilities? What are the treatment options for each of the discussed dysrhythmias? What would you do for this patient?Bradycardia and Hypertension
What is the differential diagnosis of bradycardia? What is the treatment for the different types of bradycardia? What is the differential diagnosis of postoperative hypertension? What intravenous agents may be administered to treat hypertension?Hypothermia
How is hypothermia defined and graded? What mechanisms lead to hypothermia in a patient under general anesthesia in the operating room? What are the physiologic responses to hypothermia? What are the physiologic consequences of hypothermia? Are there any benefits to mild intraoperative hypothermia? What are the different sites at which temperature can be monitored? What are the modalities to prevent and treat perioperative hypothermia? Is prevention of hypothermia warranted in a patient who received a central neuraxial block?Postanesthesia Care Unit Discharge Criteria
What is the cause of nausea and vomiting? What are the risk factors for postoperative nausea and vomiting (PONV)? What is the incidence and importance of nausea and vomiting after anesthesia and surgery? What are the treatment options available for PONV? What are the main complications occurring in the postanesthesia care unit (PACU)? What are the discharge criteria for discharge from the PACU?Respiratory Failure
How is postoperative respiratory failure defined? What are the two main types of acute respiratory failure? What are the four primary causes of hypoxemia and how are they distin-guished? Which is most likely in this patient, and how would you treat it? how would this ABG be interpreted? What treatment should be prescribed? How would you manage this patient? Briefly describe the most common ventilatory modes What criteria are used to determine whether extubation will be successful?Delayed Emergence Coma and Brain Death
What are the possible causes, investigation, and treatment for delayed emergence from anesthesia? How would you manage this patient in the intensive care unit? What is your response? What are the criteria for brain death?Anaphylaxis
What is the mechanism of anaphylaxis? What is the difference between anaphylactic and anaphylactoid reactions? What treatment should be administered to this patient? What else should be checked on physical examination? What are the medications most often implicated in anaphylaxis? In anaphylactoid reactions? What is the percentage of patients allergic to penicillin who will have a reaction when challenged with a cephalosporin? Should surgery be allowed to proceed or should the case be cancelled? What will you tell the patient postoperatively?
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