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 β-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 patient

Cardiomyopathy 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 complications

Thoracoscopy


=> 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 blockade

Monitoring 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 choice

Myasthenia 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 syndrome

Diabetes 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 analgesia

Endovascular 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 surgery

Laparoscopy


=> 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 gas

Tympanomastoidectomy


=> 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 surgery

The 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 hemorrhage

Laser 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 sources

The 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 bleeding

Total 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 block

Local 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 anesthesia

Brachial 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 placenta

Preeclampsia


=> 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 preeclampsia

Abruptio 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 intraoperatively

Congenital 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 surgery

Pyloric 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 lesions

Preterm 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 MRI

Acute 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 wounds

Asthma


=> 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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