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Which organ is most likely to be injured during extracorporeal shockwave lithotripsy?
The lungs
What reduces hepatic blood flow the most?
Proximity of the surgical site to the liver (60%)
By how much do volatile agents reduce hepatic blood flow?
20-30% (halothane > isoflurane)
What is the most common postoperative complication following carotid endarterectomy?
Hypertension (10-66%) from carotid baroreceptor manipulation.  Other complications include MI and CVA.
What is the most common cause of mortality following thoracic aortic surgery?
Cardiac complications
What are the cardiopulmonary consequences of peritoneal insufflation?
Reduced venous return, increased SVR, reduced CO with increased PAOP (especially in ASA III-IV patients), increased atelectasis, decreased FRC and increased intrapulmonary shunting
In what patient population is the risk of intraoperative recall and awareness the greatest?
Acute trauma (40% incidence)
What is the most common complication associated with mediastinoscopy?
Transient blindness after TURP is associated with?
Glycine irrigation
Why does acrylic bone cement cause hypotension?
Secondary to absorption of volatile methylmethacrylate monomer, embolization of air and bone marrow, lysis of cells and marrow by the exothermic reaction of the cement, and the conversion of methylmethacrylate to methacrylic acid
For right mastectomy with axillary node dissection what would you want to avoid?
Deep neuromuscular blockade (identification of the long thoracic and thoracodorsal nerves may need to be identified with stimulation)
What steps should be taken after malignant hyperthermia (MH) is diagnosed?
1.  Call for help
2.  Discontinue triggering anesthetics (volatiles & sux)
3.  Hyperventilate with O2
4.  Give IV Dantrolene (titrate to HR, ETCO2 and temp)
5.  Cooling measures (ice lavage)
6.  Treatment of metabolic derangement
During CPB, carbon dioxide elimination is controlled by
The fresh gas flow (both membrane and bubble oxygenators depend on this to eliminate CO2)
What is the single greatest risk factor for cardiac surgery?
CHF; EF < 40% is associated with increased operative risk
What are absolute indications for one-lung ventilation (OLV)?
Isolation from contamination or spillage from infection, massive pulmonary hemorrhage
What are high-priority RELATIVE indications for OLV?
Pneumonectomy, thoracoscpy
What is considered a low-priority RELATIVE indication for OLV?
Facilitation of surgical exposure
Which physiologic derangement is most associated with the anhepatic phase of orthotopic liver transplantation?
Hypocalcemia (due to unmetabolized citrate from administered blood products)
What percentage of TURP's are performed with spinal anesthesia?
What spinal level is required for TURP?
T10 (due to bladder distention)
What are the cardiovascular manifestations of TURP syndrome?
Bradycardia, hypertension, and increases in PAP, PCWP, pulse pressure, and CVP
After assessing the ABC's, what is the most appropriate treatment of VF/pulseless VT?
Immediate defibrillation
Maximal reduction of ICP with minimal risk of cerebral ischemia can be achieved at a PaCO2 of what?
30 mm Hg
Name a long wavelength laser and describe how it affects tissues
CO2 laser; absorbed by water, little tissue penetration, can cause corneal damage
Name a short wavelength laser and describe how it affects tissues
YAG and argon; react with pigmented substances such as Hgb and the retina, may cause retinal damage
What is a helium laser used for?
Used to visibly mark the point of laser contact, has no effect on tissues
What are the physiologic effects of ECT?
1.  Parasympathetic discharge (bradycardia, secretions)
2.  Sustained sympathetic discharge (tachycardia, hypertension)

Transient inceases in CBF, ICP, IOP and intragastric pressure are seen.
In decreasing order, what are the main causes of heat loss during anesthesia?
1.  Radiation (60%)
2.  Evaporation (20%)
3.  Convection (15%)
4.  Conduction (5%)
List the signs and treatment of carbon dioxide embolism
Hypotension, rise in ETCO2, hypoxemia and pulmonary edema.  Treatment consists of immediate release of the pneumoperitoneum.
What is the most sensitive measure to assess for adequate cerebral perfusion during a carotid endarterectomy under general anesthesia?
EEG monitoring
What are signs of myocardial ischemia during surgery?  What is the appropriate course of action?
ECG changes with bradycardia and hypotension; terminate the case and obtain an ECG and cardiac evaluation
What is the most common complication of ERCP?
List blood loss from greatest to least by type of hip fracture
1.  Subtrochanteric
2.  Intertrochanteric
3.  Base of the femoral neck
4.  Transcervical
5.  Subcapital       
Estimated blood loss during TURP
3-5 mL/min of resection (or 200-300 average total)
Pacemaker precautions for patients with underlying 3rd degree AVB
Place electrocautery return as far as possible from pulse generator, bipolar or ultrasonic (harmonic) electrocautery should be used in short bursts
What are the anesthetic goals for the patient with sickle cell anemia?
Avoidance of hypothermia or hyperthermia, avoidance of acidosis, avoidance of hypoxemia, hypotension or hypovolemia, and an increased FiO2.
Preservation of cerebral autoregulation during hypothermic CPB is best achieved by?
A-stat management of blood gases
What are the anesthetic management goals in the patient with aortic insufficiency?
Maintain adequate preload, mild vasodilation, modest tachycardia
Anesthesia management of the patient with carcinoid syndrome should include?
Avoidance of vasoactive substance release, blood pressure swings, catecholamine administration, histamine-releasing drugs, hypercapnea (associated with serotonin release).  Right sided valve disease and myocardial plaque are common.  Regional anesthesia is the technique of choice to reduce stress.
What are the benefits of tight intraoperative blood glucose control
Decreased incidence of wound infection, decreased metabolic abnormalities, benefits wound healing and weaning from CPB, improves fetal outcomes

(Does not alter incidence of MI or CVA)
What should the presence of tachycardia and hypertension always alert the anesthetist to?
The possibilty of hypoxia or hypercarbia

If suspected light anesthesia does not respond to opioid dosing, other more serious causes should be investigated
What are the primary advantages of controlled hypotension?
Minimization of surgical blood loss, better surgical visualization
How is controlled hypotension achieved?
Proper positioning, PPV, administration of hypotensive drugs (volatiles, sympathetic antagonists, calcium channel blockers, ACE inhibitors, peripheral vasodilators).  Sodium nitroprusside and nitroglycerin offer precise control.  High sympathetic block (epidural or spinal)
For what surgical procedures is controlled hypotension helpful?
Cerebral aneurysm, brain tumor, total hip arthroplasty, radical neck dissection, cystectomy.  Also for Jehovah's Witnesses and some plastic surgeries.
What are some relative contraindications to controlled hypotension?
Severe anemia, hypovolemia, atherosclerotic cardiovascular disease, renal or hepatic insufficiency, cerebrovascular disease, or uncontrolled glaucoma
What are the possible complications of controlled hypotension?
Cerebral thrombosis, hemiplegia, ATN, massive hepatic necrosis, MI, cardiac arrest, blindness (retinal artery thrombosis or ischemic optic neuropathy).  More likely with coexisting anemia.
What is a safe level of hypotension?
Healthy young: 50-60 mm Hg MAP
Chronic HTN: 20-30% lower than baseline
TIA hx: No decline in cerebral perfusion tolerated
What special monitoring is indicated for controlled hypotension?
A-line, ECG w/ ST segment analysis, CVP, UOP
What are techniques to reduce the risk of aspiration pneumonia in order of efficacy?
1.  Regional anesthesia with MINIMAL sedation
2.  Confirming availability of suction
3.  Intubation preceding induction (difficult airway)
What is the appropriate technique of preoxygenation in patients with normal lungs?
Four maximal breaths of 100% O2
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