10. D. Thyroid storm is a medical emergency and if untreated, often fatal. Supportive
treatment includes cooling, hydration, and β-blockers to control heart rate.
Propranolol has the additional benefit of inhibiting the peripheral conversion of T4–
T3. Propylthiouracil and methimazole inhibit the synthesis of T4 by blocking the
organification of tyrosine residues. Iodide blocks the release of preformed thyroid
hormones, but it should be given only after the loading dose of antithyroid medication
to prevent the utilization of iodine in the synthesis of new thyroid hormones.
Administration of cortisol is also recommended to prevent complications from
potential coexisting adrenal insufficiency.
11. A. Hypoparathyroidism resulting from the unintentional removal of the parathyroid
glands is a potential complication of thyroidectomy. Low blood calcium levels
interfere with normal muscle contraction and nerve conduction, and can result in
muscle cramps, weakness, tetany, laryngospasm, and stridor. Treatment consists of
normalizing the serum calcium level with intravenous calcium. While a neck
hematoma can cause airway compromise due to compression, it is unlikely to cause
muscle cramps. Stridor due to bilateral vocal cord paralysis is evident immediately
on extubation and would require reintubation to establish a patent airway. Sodium
bicarbonate would cause a metabolic alkalosis and potentially worsen symptoms of
hypocalcemia by decreasing ionized calcium levels.
12. C. Patients with OSA may have an increased likelihood of difficult intubation,
since the upper airway abnormalities associated with OSA (increased neck
circumference, large tongue, decreased cross-sectional area of the upper airway) may
also predispose to difficult intubation. Hypercapnia associated with severe OSA can
lead to right-heart failure. OSA is associated with increased perioperative
complications including cardiac arrhythmias, hypertension, myocardial ischemia,
respiratory failure, and stroke. Supine positioning and sedative agents make the
upper airway even more prone to obstruction. Thus, patients with OSA may require
CPAP in the immediate postoperative period.
13. B. Preoperative preparation is essential for caring for the obese patient.
Perioperative concerns include difficult intravenous access, possible need for arterial
blood pressure monitoring, positioning, difficult endotracheal intubation, and
appropriate dosing of medications. Nondiabetic obese patients are not at increased
risk of aspiration of gastric contents, as they may have smaller gastric fluid volumes
at higher pH than do lean nondiabetic patients. However, obesity may increase the
risk of a difficult laryngeal intubation, especially in males and patients with a higher
Mallampati score. Placement of the patient in the reverse Trendelenburg position
during intubation is advantageous because it reduces atelectasis, increases time to
oxygen desaturation after preoxygenation, and moves the chest and abdominal tissue
caudally to allow easier access to the mouth for endotracheal intubation. Obese
patients have a smaller volume of distribution for water-soluble drugs. Thus, dosing
of these drugs should be based on ideal body weight to avoid overdosing. Larger fat
will be slower because of the larger volume of distribution, and thus, maintenance
doses should be administered less frequently.
14. D. Refeeding syndrome can occur in malnourished patients who are acutely fed
(either enterally or parenterally). It is caused by increased adenosine triphosphate
production and metabolic rate. Hypophosphatemia is the hallmark biochemical
feature of refeeding syndrome. Other metabolic and electrolyte disturbances may
include abnormal sodium and fluid balance; hypokalemia; hypomagnesemia; thiamine
deficiency; and changes in glucose, protein, and fat metabolism. Refeeding syndrome
can be avoided by slowly increasing the nutritional intake toward caloric goals.
15. C. Cricoid pressure can be associated with several complications. These
complications are more likely in the elderly, children, pregnant women, patients with
cervical injury, patients with difficult airways, and when there is difficulty palpating
the cricoid cartilage. The technique involves the application of backward pressure on
the cricoid cartilage to occlude the esophagus and thus prevents the aspiration of
gastric contents during induction of anesthesia. However, strong downward pressure
can also displace an unstable cervical spine and worsen visualization of the airway
by occluding the glottis. In contrast, parturients may need more pressure to
effectively occlude the esophagus.
16. A. The primary goal of intraoperative blood sugar management is to avoid
hypoglycemia. The most common perioperative management regimen consists of
giving the patient a fraction (usually half) of the morning intermediate-acting insulin
their short duration of action. Metformin has a duration of action of 6 to 24 hours (up
to 48 hours with the extended release formulation). While it was previously
recommended that metformin be discontinued 48 hours preoperatively to avoid risk
of fatal lactic acidosis, more recent data suggest that this risk is low. The optimal
level of glucose control in the perioperative setting remains controversial. The
American Association of Clinical Endocrinologists (AACE) and the American
Diabetes Association (ADA) recommend keeping blood glucose between 140 and
180 mg/dL in critically ill patients. For noncritically ill patients treated with insulin,
premeal glucose targets should generally be <140 mg/dL and random blood glucose
values should be <180 mg/dL. The NICE-SUGAR trial in critically ill patients
showed an increased mortality and increased incidence of severe hypoglycemia in
patients randomized to intensive glucose control (target glucose range 81–108
17. D. Carcinoid tumors are slow-growing tumors that secrete serotonin, kallikrein, and
histamine. Excess serotonin secretion can result in carcinoid syndrome, which is
characterized by diarrhea, flushing, palpitations, and bronchoconstriction. However,
most patients with carcinoid tumors are not symptomatic because the liver detoxifies
the excess serotonin. Patients are symptomatic if they have tumors arising outside of
the hepatic portal venous system or when liver metastatic disease has compromised
hepatic synthetic function. The sclerosing effect of serotonin on the tricuspid and
pulmonary valves can result in right-heart failure. The left heart is generally not
affected because of lung metabolism of serotonin. Preoperative echocardiography
should be considered in patients with carcinoid syndrome.
18. A. Patients with a serum calcium >14 mg/dL should be managed with saline and
diuresis to decrease their calcium level. Neuromuscular-blocking agents should be
titrated carefully as severe hypercalcemia can result in muscle weakness. Prolonged
hypercalcemia can result in osteoporosis and risk of vertebral compression fractures
with laryngoscopy and bone fractures during transport. Hypoventilation should be
avoided as acidosis increases ionized calcium levels.
19. C. Hypersecretion of aldosterone results in increased sodium reabsorption in the
distal renal tubule in exchange for potassium and hydrogen ions. This results in fluid
retention, hypertension, metabolic alkalosis, hypokalemia, and muscle weakness.
20. B. Adults normally secrete 20 to 30 mg of cortisol daily. This may increase to
over 300 mg under conditions of stress.
21. C. Patients who have received the equivalent of 5 mg of prednisone or more for a
period of more than 2 weeks within the previous 3 months may not be able to
respond appropriately to surgical stress due to adrenal suppression. These patients
should receive perioperative steroid replacement therapy. The dose of steroids
needed is controversial though. One recommended approach is to give a dose
between 1 and 5 times the daily cortisol production (no more than 100 to 150 mg of
cortisol equivalent) per day, beginning at the time of surgery and taper the
replacement over 48 to 72 hours.
22. A. Cushing syndrome is characterized by muscle weakness/wasting, glucose
intolerance, hypertension, hypokalemia, weight gain, hypercoagulability, and
23. D. Intraoperative management of pheochromocytoma resection includes avoidance
of drugs (e.g., ketamine, ephedrine) or techniques that may stimulate the sympathetic
nervous system. Intubation should be performed after a deep level of anesthesia is
also be useful because it blocks α-adrenergic receptors. Magnesium infusions have
been shown useful in managing hypertension by inhibiting catecholamine release and
by altering adrenergic receptor response. Patients with pheochromocytomas are often
24. B. While all of the above may cause hypotension on induction of anesthesia, the
most likely cause in this patient is diabetic autonomic neuropathy. Diabetic patients
with hypertension, longstanding diabetes, coronary artery disease, and old age are
more likely to have autonomic dysfunction. Patients with autonomic neuropathy are
unable to compensate for intravascular volume changes with an increased heart rate,
and thus are more likely to have hemodynamic instability and even sudden cardiac
25. C. Limited joint mobility syndrome is due to glycosylation of tissue proteins due to
chronic hyperglycemia. It is characterized by hand stiffness, though other joints
(wrists, elbows, feet, spine) may be involved. Involvement of the temporomandibular
joint and the cervical spine can result in difficult endotracheal intubation.
Ophthalmic, Ear, Nose, and Throat Surgery
1. The most accurate statement regarding absorption of topically administered
ophthalmic drugs is that they are absorbed
A. Slower than subcutaneous absorption
B. Faster that intravenous absorption
D. Slower than intravenous absorption
2. Drainage of aqueous humor occurs at all of these sites, except
3. The normal intraocular pressure (IOP) is _______ (mm Hg):
4. Correct consequence of respiratory variables on intraocular pressure (IOP) is
A. Decrease in PaO2 will decrease IOP
B. Increase in PaO2 will decrease IOP
C. Decrease in PaCO2 will increase IOP
D. Increase in PaCO2 will increase IOP
5. All of the following will serve to decrease intraocular pressure (IOP), except
6. Increases in intraocular pressure (IOP) following succinylcholine administration for
tracheal intubation can be minimized by all of the following, except
C. Detachment of extraocular muscles from the globe
7. The ocular effects of ketamine includes
C. Decrease in intraocular pressure
8. An 82-year-old female patient who resides in a nursing home facility presents for
breast biopsy. She states that she uses eye drops to treat glaucoma, but does not
know exact names. Patient denies other medical issues, however states that she
frequently has acid reflux. Potential anesthetic considerations as a result of eye
drops include all of the following, except
A. Hyperchloremic metabolic acidosis
B. Hypokalemic metabolic acidosis
C. Prolonged neuromuscular block with succinylcholine
D. Atropine-resistant bradycardia
9. An air bubble is injected into the posterior chamber at the conclusion of retinal
surgery (pneumatic retinopexy) to facilitate anatomically correct healing. The most
appropriate anesthetic management, before the air bubble is injected, is
A. Increase depth of anesthesia
B. Discontinue nitrous oxide (N2O)
C. Ensure adequate muscle relaxation
10. Compared with air, sulfur hexafluoride (SF6
) bubble injected following vitreous
A. Has a longer duration of action
B. Is more soluble in blood than nitrogen
C. Is inert and will not expand
D. Is contraindicated in outpatient surgery
A 22-month-old 14.5-kg “preemie” is undergoing strabismus repair under general
endotracheal anesthetic (GETA). Following an uneventful inhaled induction with
sevoflurane, peripheral IV was obtained, and by oversight, patient was given 20 mg of
succinylcholine prior to intubation. Masseter spasm was noted moments later.
11. What parameter is considered the earliest sign and symptom of an ensuing
hypermetabolic state following succinylcholine administration?
12. Midway through the surgery, when surgical traction in the operative field is applied,
patient’s heart rate plummets from 110 bpm down to 55 bpm. The pairing that
accurately reflects the afferent and efferent limbs, respectively, of this reflex is
A. Trigeminal nerve vagus nerve
C. Vagus nerve trigeminal nerve
D. Trochlear Nerve optic nerve
13. The most appropriate first step in the management of this hemodynamic instability is
14. At the conclusion of the surgery, postoperative nausea and vomiting should be
anticipated and can be minimized by all of the following, except
15. The true statement regarding an oculocardiac reflex is
A. It does not occur in enucleated patients
B. Incidence is increased in the setting of hypercarbia
C. Intensity increases with repeated stimulation
D. Suppressed by general anesthesia
16. All of the following anatomic structures may participate in triggering an acute and
abrupt bradycardia during ophthalmic surgery, except
17. Appropriate anesthetic management for ophthalmic surgery requires tight control of
intraocular pressure (IOP) before, during, and after the procedure. The accurate
effect of an anesthetic drug or maneuver on IOP is
A. Decreased by glycopyrrolate
B. Increased by hyperventilation
D. Increased by nondepolarizing muscle relaxants
18. All these nerves can be disrupted by injection of local anesthetics into the
19. The eye movement that is preserved, or unaffected, following a retrobulbar block
20. Possible complications of a retrobulbar block include all the following, except
A. Central retinal artery occlusion
A patient is given propofol 20 mg intravenously just before placement of a retrobulbar
block (0.5% bupivacaine—3 mL) to provide ocular akinesia for ocular surgery.
21. As the surgeon attempts to place a lid speculum, the patient squints, preventing
adequate placement. Additional blockade of which muscle can provide additional
22. Moments later, apnea occurs followed by complete loss of consciousness. The most
likely etiology to explain this event is
A. Subarachnoid injection of local anesthetic
D. Intravenous injection of local anesthetic
A 57-year-old otherwise-healthy male was leaving a dinner party when he was involved in
a rollover car accident during which a foreign object became lodged into his right eye. He
is taken to the OR for emergent surgical repair of a penetrating wound to his right globe.
23. The most appropriate anesthetic plan to consider is
A. Retrobulbar block followed by monitored anesthesia care (MAC)
B. IV induction of general anesthesia avoiding muscle relaxants
C. Rapid-sequence induction of anesthesia using large dose rocuronium
D. Secure the airway with an awake fiberoptic intubation
24. Anesthetic strategies that can minimize intraocular pressure (IOP) increase and
lessen his risk of ocular extrusion include all of the following, except
C. Inhaled volatile agent, 2.0 MAC
25. Fifteen minutes after the start of surgery, while the surgeon is retracting the medial
rectus muscle, the patient becomes hypotensive and bradycardic. The first-line
therapy to address this cardiovascular derangement is
26. The patient’s vital signs normalize and anesthesia is maintained with desflurane and
nitrous oxide. Later in the case, conjunctival instillation of a phenylephrine (10%)
solution results in immediate escalation of blood pressure from 105/70 to 220/115
mm Hg, while his pulse falls from 86 to 35 bpm. The ECG reveals new onset of
ectopic ventricular complexes. The most appropriate treatment option at this time is
27. At the conclusion of the surgery, patient is extubated and brought to the recovery
room (PACU) in a stable condition. Thirty minutes later, when he is more awake, he
notes unilateral eye discomfort in the nonsurgical eye. He has associated tearing,
conjunctivitis, photophobia, and pain, which is worsened with blinking. These eye
symptoms are most likely caused by
28. True statement regarding laryngospasm is
A. Associated risk of pulmonary edema
B. The false vocal cords do not spasm
C. Mediated through the recurrent laryngeal nerve
D. Increased risk of aspiration
29. A patient in the intensive care unit (ICU) with pulmonary failure requires tracheal
intubation. Compared with nasotracheal intubation, oral tracheal intubation carries a
30. When compared to an adult, the airway anatomy of a 6-week-old infant reveals
A. Tongue is smaller and floppy
B. Airway is narrowest at the glottic opening
C. Position of the larynx is more anterior in the neck
D. Epiglottis is flat and firm
A 3-year-old patient arrives for rescheduled tonsillectomy and adenoidectomy with another
acute upper respiratory tract infection (URI). Her initial surgery was postponed 3 weeks
31. Postponement of surgery will reduce the risk of
32. Surgery proceeded without incident; however, 2 hours later in the recovery room
(PACU), she vomits a large blood clot followed by ongoing bleeding. She appears
pale and anxious. Vitals reveal heart rate = 130 bpm, respiratory rate = 25 bpm, and
blood pressure = 77/35 mm Hg. Her capillary refill time is 4 seconds. The most
appropriate next step in management at this time is
A. Insertion of orogastric tube to empty the stomach of blood
B. Emergent return to the operating room
C. Administer anxiolysis medication
D. Provide liberal fluid resuscitation
A 65-year-old male requires transoral laser microsurgery to address his laryngeal webs.
His medical history reveals remote tobacco smoking and recreational drug use in college.
33. Minimizing airway fire hazards associated with laser surgery can be accomplished
by use of all of the following, except
A. Intermittent mode laser emissions
B. An air/oxygen anesthetic technique
C. A polyvinylchloride (PVC) endotracheal tube
D. Saline-soaked sponges over exposed tissues
34. Ten minutes later, the surgeon yells “FIRE!” The most appropriate next step is to
C. Instill saline down the endotracheal tube lumen
D. Remove the endotracheal tube
35. One hour later while recovering in the PACU, the patient is noted to have stridor and
difficulty breathing. At this time, the most appropriate next step in his airway
A. Administration of aerosolized epinephrine
C. Administration of helium and oxygen
D. Intravenous injection of dexamethasone
36. A 10-year-old girl with hoarseness presents for laser microsurgery to address
laryngeal papillomas. She is otherwise healthy. The surgeon is requesting a general
endotracheal anesthetic (GETA). The gas mixture least likely to support combustion
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