1. A 42 year old female with a history of CAD presents for an emergency exploratory laparotomy. A decision is made to place a 20 g left radial a-line and transduce it at the level of the patient’s left ventricle. The entire system is zeroed at this level and the transducer is taped to the OR table. 10 minutes later, the surgeon asks to raise the table 10 cm and the a-line reads 110/70 mmHg. What is this patient’s accurate BP at this time?

A. 160/110 mm Hg
B. 117/80 mm Hg
C. 120/80 mm Hg
D 100/60 mm Hg
E. 110/70 mm Hg

(E) In this question, the system was zeroed at the transducer which is at the level of the heart, as is the standard. If the patient, along with the transducer are raised and lowered together, there should be no change in BP. If the transducer, alone, was raised and lowered, there would be an alteration of the BP. (Ehrenwerth: Anesthesia Equipment: Principles and Applications, Pages 275-278).
1. A 52-year-old female is on a nitroprusside infusion of 10 μg/kg/min after a right carotid endarterectomy. Over the next 72 hours, the SaO2 decreases from 99% to 85% with no changes in ventilator settings. Physical examination reveals no changes and chest xray is unremarkable. What is the most likely cause of this desaturation?

A. Methemoglobinemia
B. Thiocyanate toxicity
C. Cyanocobalamin toxicity
D. Cyanide toxicity
E. Inadequate PEEP

(A) When nitroprusside is metabolized, oxyhemoglobin (Fe++) is converted to methemoglobin (Fe+++). As the quantity of methemoglobin in the blood rises, the pulse oximeter erroneously registers a reading of 85%. Choice (B) is a precursor to choice (D), which leads to metabolic acidosis and tachyphylaxis, not to a reading of 85%. Thiocyanate toxicity causes nausea, mental confusion, and skeletal-muscle weakness. Choice (E) is incorrect because no changes have been made to the ventilator (Pharmacology and Physiology, 4th Edition by Stoelting. Pages 357-358)
Pediatric Anesthesia
1. A newborn infant is delivery vaginally at 38 weeks gestation without any complications. At what level would you expect to find the cricoids cartilage in this patient?

A. C4
B. C5
C. C6
D. C7
E. C8

(A) The cricoids cartilage of a newborn is at the C4 level. This is in contrast to children age 6 who have it at C5 and adults who have it at C6. Such anatomic differences must be taken into account when attempting intubation in this population. (Anesthesia, 6th Edition, Edited by R Miller. Pages 1646-1647)
OB Anesthesia
1. Which of the following will decrease uterine blood flow even if the BP remains stable?

A. Induction dose of propofol
B. Epidural infusion of local anesthetic
C. Epidural infusion of local anesthetic and opiod
D. Unintentional IV injection of a local anesthetic
E. Intrathecal injection of fentanyl

(D) All of the choices listed can cause an indirect decrease in uterine blood flow by causing hypotension. However, assuming the BP stable, none of the choices, except (D) would cause a decrease in UBF. Unintentional IV injection of a local anesthetic increases intrauterine pressure and also vasoconstricts the uterine arteries, both of which contribute to a decrease in uterine blood flow. (Obstetric Anesthesia, 3rd Edition, by Chestnut. Pages 44-45) (Anesthesia for Obstetrics, 4th Edition by Hughes. Pages 26-31, 220)
1. A 73 year old patient presents for a laparascopic hernia repair. His INR is elevated due to his chronic warfarin use. Which of the following will normalize this patient's INR the fastest?

A. Stopping Warfarin
B. oral VIT K
D. Platelets
E. recombinant factor VIII

(C) Warfarin inhibits the vit-K dependant factors (2,7,9 and 10) as well as Protein C and S. Warfarin must be stopped for several days to normalize the INR (A). Platelets do not contain the necessary factors (D) and factor VIII is not one of the factors inhibited by warfarin (E). Both vit K and FFP can be used to reverse warfarin, but oral vit K requires 24 hrs. (C) whereas FFP is much more instantaneous(Clinical Anesthesia, 5th Edition. Edited by Barash P. (2007), Lippincott. Pages 222-224, 228)
Volatile Anesthetic
1. Which property of desflurane makes it undesirable for inhalation induction?

A. Its propensity to irritate the airway
B. The low blood gas partition coefficient
C. The high MAC value
D. Its propensity to cause arrhythmias
E. The high incidence of tachycardia

(A) Desflurane is known for its propensity to cause airway irritation and therefore is not used for inhalation induction. Indeed, it is not even approved for anesthesia using an LMA for children < 6 yrs due to this risk. Desflurane's low blood gas partitiion coefficient makes it a desirable drug for general anesthesia, especially for short procedures (B). Though it has a high MAC value, this has no bearing on whether or not it should be used for inhalation (C). Both the arrhythmias (D) and the high incidence of tachycardia (E) are undesirable side effects of desflurane, but are not the reason why inhalation induction is undesirable. (Basics of Anesthesia, 5th Edition, Edited by RK Stoelting, 2007 Churchill Livingstone, Pages 93, 408)
IV Anesthetics
1. Which of the following is a side effect of atropine administration?

A. Increased lower esophageal sphincter tone
B. Hypotension
C. Salivation
D. Lacrimination
E. Mydriasis

A. Cholinergic crisis can be remembered by the pneumonic, DUMBELS, which stands for Diaphoresis/Diarrhea, Urination, Miosis (E), Bronchospasm/ Bronchorrhea/ Bradycardia, Emesis, Lacrimation (D), and Salivation (C). Atropine causes the reverse of this. Thus, choice A is the correct answer. (Basics of Anesthesia, 5th Edition, Edited by RK Stoelting, 2007 Churchill Livingstone, Page 107)
1. An investigator asks his research assistant to conduct a phone survey of every student in his class to determine which ones are cigarette smokers. The research assistant calls each of the 1,000 students, but pursues the ones in the university greek life more aggressively because he feels they will likely be more likely to smoke. Which of the following best describes the type of error associated with this study?

A. Response bias
B. Responder bias
C. Detection bias
D. Recall bias
E. Selection bias

(C) In this question, a researcher is conducting a phone survey of 1,000 students to detect how many are cigarette smokers. It is implied that he is unsuccessful in reaching all o the students initially, so decides to "pursue" those students he felt were more likely to engage in smoking (fraternity/sororities). This is a form of detection bias, where the investigator over or under pursues a subpopulation and thus the "detection" is skewed because the entire population is not surveyed accurately. Choices A, B and D are the same type of bias, most commonly known as recall bias. This form of error is seen usually when subjects are asked to recall events in the distant past (i.e. patients with heart disease asked how much exercise they did while in college). Selection bias (E) occurs when the group to be tested is not representative of the overall population. Here, the selection was the entire 1,000 students in the class. Had the selection been just the students in the fraternities/sororities, and the information was generalized for the whole class, this bias would be the source of the error. (
General Anesthesia
1. A 42 year old male with a history of acromegaly secondary to excess growth hormone secretion from a pituitary tumor presents for a left inguinal hernia repair. What characteristics of acromegalic patients is most likely to be present in this patient?

A. Renal failure
B. Prognathia
C. Increased V/Q mismatching
D. Polypoid laryngeal mass
E. Receding jaw

(C) Patients with acromegaly display an increased incidence of V/Q mismatch. Other characteristics of acromegaly include hypertension, increased risk of coronary artery disease, glucose intolerance, and osteoporosis. Airway changes include increases in the thickness and length of mandible (B) and (E). Renal failure and polypoid laryngeal masses are not a characteristic of acromegaly (A) and (B). (Anesthesia, 6th Edition, Edited by R Miller. Page 1092)