Ordinary physical activity does not cause undue fatigue, palpitatidyspnea, or anginal pain.
Class II: Patients with cardiac disease resulting in slight limitation of
Class III: Patients with cardiac disease resulting in marked limitation of
Class IV: Patients with cardiac disease resulting in inability to carry on
any physical activity without discomfort.
Class A: No objective evidence of cardiovascular
No symptoms and no limitation in ordinary physical activity.
Class B: Objective evidence of minimal cardiovascular
Class D: Objective evidence of severe cardiovascular
Severe limitations. Experiences symptoms even while at rest.
86. D. In the event of a postdural puncture headache (PDPH), 53% of headaches
resolve in 4 days, 72% in 7 days, and 85% within 6 weeks. Mild–moderate PDPH is
usually treated conservatively (fluids, caffeine drinks, analgesics). Severe PDPH
may require an epidural blood patch.
87. B. Following a rash of sudden deaths in patients taking methadone, the FDA in
2006 issued a black box warning for all practitioners, specifically detailing the high
risk of prolonged QT syndrome and sudden death in patients prescribed this
88. A. Surgery for carcinoid tumor debulking or resection may precipitate a carcinoid
crisis in the patient consisting of flushing, hypotension, bronchospasm, acidosis, and
ventricular tachycardia. Patients who received octreotide experienced no significant
89. C. Injection of large amount of local anesthetic into the vertebral artery or into the
subarachnoid or subdural space resulting in a seizure is a well-known complication
of the interscalene block. Treatment for this patient is to first establish an airway
(ABCs) and then treat the seizure.
90. B. Patients with dilated cardiomyopathy are extremely sensitive to changes in
afterload. Therefore, afterload should be minimized to maintain stroke volume.
91. C. In septic shock, both dopamine and norepinephrine can be used to treat
persistent hypotension. However, dopamine may promote further tissue acidosis in
the splanchnic circulation, whereas norepinephrine does not, thus making it the drug
92. B. The heart, because of its high oxygen requirements, is the least tolerant of
ischemia. Hyperkalemic crystalloid cardioplegia at 4°C for a maximum of 4 hours is
used to preserve the heart. Thus, reducing the ischemic time of donor hearts will
decrease morbidity and costs of cardiac transplantations.
93. D. Sugammadex reverses neuromuscular blockade by nondepolarizing muscle
relaxants by directly binding to rocuronium, vecuronium, and pancuronium, without
reversal, that is, with two twitches, the dose is 2 mg/kg. When the blockade is deeper,
the dose must be increased. When reversing following a failed intubation, a dose of 8
mg/kg of sugammadex will effectively reverse rocuronium given at 0.6 mg/kg. If the
dose of rocuronium given is 1.2 mg/kg, reversal with sugammadex requires a dose of
94. B. With prolonged periods of starvation followed by reintroduction of enteral or
parenteral nutrition, the increased release of pancreatic insulin leads to an anabolic
state and an intracellular shift of phosphate, magnesium, and potassium. Of these
derangements, hypophosphatemia leads to the most severe conditions, including
95. C. Fetal heart rate and uterine monitoring should be performed during induction,
emergence, recovery, and, if possible, during the surgery in any pregnancy of more
than 24 weeks’ gestation. The fetus becomes viable at this gestation age.
96. A. Airway management in obese patients begins first with an adequate physical
exam as these patients are more likely to be both more difficult to ventilate and to
intubate. The best predictor of difficulty is a short, thick neck (pretracheal tissue
volume) and a history of obstructive sleep apnea.
97. C. In pulmonary resections, preoperative impairment is directly related to operative
risk. Using routine pulmonary function tests, criteria have been established for highrisk patients.
• PaCO2 >45 mm Hg or PaO2 <50 mm Hg on room air
• FEV1 <2 L preoperatively or <0.8 L or <40% of predicted postoperatively
• Maximum breathing capacity <50% of predicted
98. A. Bisphosphonates are used in the treatment of osteoporosis as they inhibit
osteoclastic resorption of bone. Biphosphonates do not affect the excretion of
99. B. Enalapril exposure during the first trimester of pregnancy has been associated
with multiple fetal defects, affecting the cardiac, pulmonary, renal, and
100. C. Somatosensory-evoked potentials are usually monitored on the posterior tibial
nerves of the legs during spinal surgery and are used to assess the integrity of the
dorsal columns of the spinal cord.
101. A. The main issue with desflurane is that it has a high saturated vapor pressure at
room temperature (669 mm Hg at 20°C). It boils at just 22.8°C compared with
sevoflurane at 58.5°C or isoflurane at 48.5°C. Therefore, the desflurane vaporizer is
heated to 39°C and pressurized at 2 atm.
102. D. The incidence of renal failure after abdominal aortic aneurysm surgery is 5.4%,
of which 0.6% requires hemodialysis. Loop diuretics (furosemide), dopamine,
mannitol, fenoldopam, and N-acetylcysteine are proposed renal protective agents;
however, there is no concrete evidence to support their use. The mainstay of renal
preservation is by reducing aortic cross-clamping time, adequate fluid resuscitation,
1. A major difference between the adult and neonatal airway is that the
A. Neonate’s larynx is located more superiorly in the neck
B. Neonate’s epiglottis is angled more superiorly
C. Narrowest segment of a neonate’s upper airway occurs at the level of the vocal
D. Neonate is at lower risk of postextubation stridor compared to the adult
2. The narrowest segment of a 14-day-old child’s upper airway is located at the
3. Airway obstruction in Pierre Robin syndrome most likely occurs
A. Between the tongue and pharyngeal wall
B. At the level of the glottis
4. Airway management in Klippel–Feil syndrome is most likely to be challenging
5. One of the following statements regarding airway management in patients with
congenital syndromes is most accurate:
A. Laryngoscopy is often challenging in Turner syndrome because of a high
frequency of laryngeal distortion
B. Airway management in Treacher Collins syndrome is complicated by a high
incidence of cervical spine instability
C. Intubation in patients with Goldenhar syndrome is often challenging due to a
high rate of subglottic stenosis
D. Airway management of patients with trisomy 21 is complicated by a high
incidence of cervical spine instability
6. A healthy 2-year-old male is scheduled to undergo a laparoscopic inguinal hernia
repair. His airway was managed uneventfully with mask ventilation followed by
direct laryngoscopy and intubation with a 4.5-mm uncuffed endotracheal tube (ETT).
Manual ventilation produces an air leak in the oropharynx beginning at a peak
pressure of 20 cm H2O. The best next step in the anesthetic management is to
A. Continue current management
B. Replace the ETT with a smaller-sized uncuffed tube
C. Replace the ETT with a larger-sized uncuffed tube
D. Replace the ETT with a 4.0-mm cuffed ETT
7. A 4-year-old patient scheduled for laparoscopic gastrostomy tube placement
undergoes induction of general anesthesia and endotracheal intubation with a 4.5-mm
cuffed endotracheal tube. The tube is taped 14 cm at the gumline, and the patient is
placed on volume-control ventilation. The most likely first sign of a right main stem
C. Increased peak inspiratory pressures
8. A 6-year-old patient scheduled for laparoscopic bilateral inguinal hernia repair
undergoes inhalational induction and intubation with a 5.0-mm cuffed endotracheal
tube. The tube is secured with the 15-cm mark at the patient’s gumline. Auscultation
reveals equal breath sounds bilaterally. Inflation of the pilot balloon results in
palpation of the inflated tube cuff just above the cricoid cartilage. A leak test reveals
leak of air into the oropharynx at a positive pressure of 20 cm H2O. The next best
A. No change in anesthetic care is indicated
B. The tube cuff should be deflated until a leak is present starting at 15 cm H2O of
C. The tube cuff should be deflated and the tube advanced until the cuff, when
inflated, is palpable below the cricoid cartilage
D. The tube cuff should be deflated and the tube withdrawn until ventilator peak
9. A 4-year-old boy with autism and failure-to-thrive undergoes a gastrostomy tube
placement. At the completion of the operation, the patient remains unresponsive but
is breathing spontaneously and has a mild gag response to oral suctioning. The
anesthesiologist extubates the patient and immediately shuts off the volatile agent.
The anesthesiologist then inserts an appropriately sized oropharyngeal airway and
places a face mask connected to the ventilator circuit over the patient’s face,
allowing the patient to breathe 100% oxygen. Despite providing a chin lift, jaw
thrust, and positive-pressure breaths, the anesthesiologist notes that the ventilator
shows no end-tidal carbon dioxide. Auscultation over the sternal notch reveals no air
movement. The pulse oximeter reading then rapidly drops to 70% from 100%. The
next best step in management is
A. Administration of albuterol
B. Insertion of a nasal trumpet
D. Administration of succinylcholine
10. In the scenario above, if the patient’s postextubation condition is left untreated, the
patient will most likely experience
11. A 2-year-old child weighing 13 kg is scheduled for inguinal hernia repair. She is at
the 55th percentile for height for her age. An appropriately-sized cuffed endotracheal
tube for this patient will have an internal diameter of
12. The superior surface of the epiglottis is innervated by the
C. Internal branch of the superior laryngeal nerve
D. External branch of the superior laryngeal nerve
13. Tactile sensation from the anterior third of the tongue is carried by fibers of the
14. A 48-year-old female patient with temporomandibular joint dysfunction and
associated limited mouth opening is scheduled for a thyroidectomy for goiter. Due to
concern for challenging laryngoscopy, the anesthesiologist elects to perform an
awake fiberoptic intubation. In order to anesthetize the posterior third of the tongue,
the anesthesiologist should perform a nerve block of the
15. A patient who suffers acute, bilateral denervation of the external branch of the
superior laryngeal nerve will most likely present with
16. To anesthetize the supraglottic laryngeal mucosa, the local anesthetic should be
injected into one of the following areas:
A. The base of the anterior tonsillar pillar
B. Medial to the lesser cornu of the hyoid bone
C. Superior to the superior cornu of the thyroid cartilage
D. Through the cricothyroid membrane
17. The efferent limb of the glottic closure reflex, which is involved in laryngospasm,
A. Internal branch of the superior laryngeal nerve
18. A 65-year-old woman undergoes a thyroidectomy for papillary thyroid cancer.
Immediately after emergence and extubation, she is aphonic and has minimal chest
movement, despite spontaneously moving her limbs and head. Auscultation reveals
lack of breath sounds over the chest. There is no evidence of a surgical site
hematoma. The anesthesiologist provides a jaw thrust and positive-pressure breaths,
which slightly improve the patient’s oxygenation and ventilation. The surgeon
suggests a bilateral block of both the internal and external branches of the patient’s
superior laryngeal nerve. If performed this block would likely result in
A. Worsening of the patient’s respiratory distress and no change in her aphonia
B. Improvement of the patient’s respiratory distress and no change in her aphonia
C. No change in the patient’s respiratory distress and improvement of her aphonia
D. No change in the patient’s respiratory distress and no change in her aphonia
19. A 48-year-old woman with temporomandibular joint dysfunction and limited mouth
opening is scheduled for thyroidectomy for goiter. Due to concern for a difficult
laryngoscopy, the anesthesiologist elects to perform an awake oral fiberoptic
intubation. To reliably blunt the afferent limb of the cough reflex, the
anesthesiologist should perform a bilateral block of the
A. Superior laryngeal nerve and the recurrent laryngeal nerve
B. Glossopharyngeal nerve and internal branch of the superior laryngeal nerve
C. Glossopharyngeal nerve and external branch of the superior laryngeal nerve
D. Internal and external branches of the superior laryngeal nerve
20. If an adult patient were to suffer an acute, bilateral transection of cranial nerve X,
awake laryngoscopy would most likely reveal
C. Vocal cords in a partially adducted position with 2 to 3 mm of space between
D. Vocal cords oscillating between adducted and abducted position
preserved during the operation. After extubation, the patient’s voice is noted to be
hoarse. Awake fiberoptic laryngoscopy would most likely show the following during
A. Vocal cords in a fully abducted position
B. Vocal cords in a fully adducted position
C. Left vocal cord in an adducted position and right vocal cord fully abducted
D. Left vocal cord in an abducted position and right vocal cord fully adducted
22. An awake tracheostomy would be facilitated by a regional block of the
23. One of the following statements regarding the innervation of airway structures is
A. The afferent limb of the gag reflex is primarily carried by fibers of the recurrent
B. Trigeminal nerve block would facilitate awake nasotracheal intubation
C. The superior surface of the epiglottis is primarily innervated by the
D. Tactile sensation from the posterior one-third of the tongue is carried by the
24. A nasal trumpet would be most appropriate for management of anesthetic-induced
upper airway obstruction in one of the following patients:
A. A 25-year-old passenger ejected out of a motorcycle now with Glasgow Coma
Scale of 13 and some periorbital bruising
B. A 32-year-old term parturient, otherwise healthy except for gestational
thrombocytopenia, who requires emergent cesarean section under general
C. A 45-year-old female with temporomandibular joint syndrome and breast cancer
scheduled for bilateral mastectomy
D. A 65-year-old male with a mechanical mitral valve on therapeutic
anticoagulation undergoing emergent coronary catheterization for unstable angina
25. A 55-year-old woman with severe anxiety and rheumatoid arthritis is scheduled for
thyroidectomy for medullary thyroid cancer. Her airway exam in the upright position
is notable for a nonvisible uvula with the tongue protruded, a 2 fingerbreadth mouth
opening, a thyromental distance of 2.5 fingerbreadths, and neck range-of-motion at
the atlanto-occipital joint of about 70 degrees. Examination of her neck reveals an
enlarged, fixed, and nonmobile mass that appears to be contiguous with the thyroid
gland when the patient swallows. The trachea cannot be palpated. The patient is
highly anxious and tells you that under no circumstance will she let you insert a
“breathing tube inside my airway while I’m awake.” The next best step in anesthetic
A. Induction of general anesthesia followed by fiberoptic bronchoscopy
B. Induction of general anesthesia followed by rigid bronchoscopy
C. Induction of general anesthesia followed by laryngeal mask airway placement
26. After rapid sequence induction of general anesthesia, a patient is unable to be
intubated. Subsequent attempts at ventilation by face mask and a supraglottic airway
device are also unsuccessful. One of the following statements regarding transtracheal
jet ventilation and surgical cricothyrotomy in this situation is most correct:
A. Transtracheal jet ventilation does not require a patent natural airway
B. Ventilation through a surgical cricothyrotomy allows both inhalation and
C. The development of laryngospasm during ventilation through a cricothyrotomy
would rapidly cause pulmonary overinflation and barotrauma
D. Transtracheal jet ventilation can be continued for a longer period of time than
can ventilation via a cricothyrotomy
27. Use of a laryngeal mask airway would be most appropriate for airway management
A. An obese patient with acute appendicitis who, after rapid sequence induction,
B. An elderly patient with restrictive lung disease scheduled for inguinal hernia
C. An obese male patient with a hiatal hernia and GERD scheduled for umbilical
D. A full-term parturient brought to the OR for emergent cesarean section because
28. After undergoing an uneventful operation, one of the following patients would be the
best candidate for “deep extubation”:
A. A 23-year-old woman with asthma who has just undergone an exploratory
laparotomy for small bowel obstruction
B. A 65-year-old man with gastroesophageal reflux who has just undergone an
C. An 18-year-old patient with scoliosis who has just undergone a 6-hour posterior
thoracolumbar spinal instrumentation and fusion
D. A 64-year-old female with coronary artery disease who has just undergone a
total hip arthroplasty under general anesthesia
29. One of the following is a primary risk factor for difficult mask ventilation:
B. Thyromental distance less than 3 fingerbreadths
D. Inability to bring mandibular incisors anterior to the maxillary incisors
30. An otherwise healthy patient with a history of daytime sleepiness and snoring from
laryngeal papillomatosis undergoes polysomnography and spirometry, which shows
dynamic inspiratory obstruction. The flow–volume loop that would be most
consistent with this patient’s condition is
1. A. The neonate’s larynx is located more superiorly in the neck than the adult’s.
The location of the adult’s larynx is at C4–C5 level of the spine, while the neonate’s
is at C3–C4 level. The neonate’s epiglottis is relatively longer, stiffer, and angled
more posteriorly compared to the adult’s, which is one of the reasons why straight
blades are more popular among pediatric anesthesiologists. The narrowest part of the
upper airway is at the level of the cricoid cartilage in neonates, and at the level of the
vocal cords in adults. The child’s airway takes on adult characteristics between the
ages of 5 and 10 years. The neonate is at greater risk of postextubation stridor
compared to the adult. Resistance through a cylindrical tube (such as the trachea) is
inversely proportional to the radius raised to the fourth power (Poiseuille law). Thus,
a 1-mm reduction in tracheal diameter due to edema results in a marked rise in
airway resistance in small children, which may be inconsequential in adults.
2. D. According to classical teaching, the narrowest portion of a child’s upper airway
is at the level of the cricoid cartilage, whereas the narrowest portion of an adult’s
upper airway is at the level of the vocal cords. However, a more recent
bronchoscopic study of airway dimensions in children found that between the ages of
6 months and 13 years, the glottis, not the cricoid cartilage, is the narrowest portion
of the child’s airway. This study did not measure airway dimensions in children
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