Ordinary physical activity does not cause undue fatigue, palpitatidyspnea, or anginal pain.

Class II: Patients with cardiac disease resulting in slight limitation of

physical activity.

They are comfortable at rest. Ordinary physical activity results infatigue, palpitation, dyspnea, or anginal pain.

Class III: Patients with cardiac disease resulting in marked limitation of

physical activity.

They are comfortable at rest. Less-than-ordinary activity causes fpalpitation, dyspnea, or anginal pain.

Class IV: Patients with cardiac disease resulting in inability to carry on

any physical activity without discomfort.

Symptoms of heart failure or the anginalsyndrome may be presenat rest. If any physical activity is undertaken, discomfort increaseTable 1-2 Objective assessment

Class A: No objective evidence of cardiovascular

disease.

No symptoms and no limitation in ordinary physical activity.

Class B: Objective evidence of minimal cardiovascular

disease.

Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.Class C: Objective evidence of moderately severe

cardiovascular disease.

Marked limitation in activity due to symptoms, even during less-than-ordinary acComfortable only at rest.

Class D: Objective evidence of severe cardiovascular

disease.

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

medication.

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

intraoperative complications.

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

of choice for this scenario.

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

any side effects. Reversal of neuromuscular blockade is achieved in a dosedependent manner and can be used in the event of failed intubation. For normal

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

16 mg/kg.

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

cardiac failure.

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

• FEV <25%

• FEV1 <2 L preoperatively or <0.8 L or <40% of predicted postoperatively

• FEV1/FVC <50% predicted

• Maximum breathing capacity <50% of predicted

• Maximum VO2 <10 mL/kg/min

98. A. Bisphosphonates are used in the treatment of osteoporosis as they inhibit

osteoclastic resorption of bone. Biphosphonates do not affect the excretion of

calcium.

99. B. Enalapril exposure during the first trimester of pregnancy has been associated

with multiple fetal defects, affecting the cardiac, pulmonary, renal, and

musculoskeletal systems.

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,

and avoidance of nephrotoxins (nonsteroidal anti-inflammatory drugs, angiotensinconverting-enzyme inhibitors, aminoglycoside antibiotics).

Airway Management

Yuriy Bronshteyn

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

cords

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

A. Hyoid bone

B. Thyroid cartilage

C. Vocal cords

D. Subglottic region

3. Airway obstruction in Pierre Robin syndrome most likely occurs

A. Between the tongue and pharyngeal wall

B. At the level of the glottis

C. In the subglottic trachea

D. At the bronchial level

4. Airway management in Klippel–Feil syndrome is most likely to be challenging

because of

A. Micrognathia

B. Macroglossia

C. Subglottic stenosis

D. Cervical spine fusion

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

intubation is

A. Arterial desaturation

B. Hypercapnia

C. Increased peak inspiratory pressures

D. Hypotension

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

step in management is

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

positive pressure

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

pressures decrease

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

C. Endotracheal reintubation

D. Administration of succinylcholine

10. In the scenario above, if the patient’s postextubation condition is left untreated, the

patient will most likely experience

A. Aspiration

B. Bronchospasm

C. Pulmonary edema

D. Croup

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

A. 3.0 mm

B. 4.0 mm

C. 5.0 mm

D. 6.0 mm

12. The superior surface of the epiglottis is innervated by the

A. Hypoglossal nerve

B. Recurrent laryngeal nerve

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

A. Trigeminal nerve

B. Facial nerve

C. Glossopharyngeal nerve

D. Hypoglossal nerve

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

A. Cranial nerve V

B. Cranial nerve VII

C. Cranial nerve IX

D. Cranial nerve XII

15. A patient who suffers acute, bilateral denervation of the external branch of the

superior laryngeal nerve will most likely present with

A. No symptoms

B. Hoarseness

C. Stridor

D. Aspiration

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,

primarily involves the

A. Internal branch of the superior laryngeal nerve

B. Hypoglossal nerve

C. Recurrent laryngeal nerve

D. Glossopharyngeal 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

A. Fully adducted vocal cords

B. Fully abducted vocal cords

C. Vocal cords in a partially adducted position with 2 to 3 mm of space between

them

D. Vocal cords oscillating between adducted and abducted position

21. Several hours after undergoing repair of an ascending aortic dissection, a 65-yearold male patient is extubated in the intensive care unit. All of the arch vessels were

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

inspiration:

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

A. Trigeminal nerve

B. Glossopharyngeal nerve

C. Superior laryngeal nerve

D. Recurrent laryngeal nerve

23. One of the following statements regarding the innervation of airway structures is

most correct:

A. The afferent limb of the gag reflex is primarily carried by fibers of the recurrent

laryngeal nerve

B. Trigeminal nerve block would facilitate awake nasotracheal intubation

C. The superior surface of the epiglottis is primarily innervated by the

glossopharyngeal nerve

D. Tactile sensation from the posterior one-third of the tongue is carried by the

hypoglossal nerve

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

anesthesia

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

management is

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

D. Cancel the case

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

exhalation to occur

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

in the following patient:

A. An obese patient with acute appendicitis who, after rapid sequence induction,

cannot be intubated

B. An elderly patient with restrictive lung disease scheduled for inguinal hernia

repair

C. An obese male patient with a hiatal hernia and GERD scheduled for umbilical

hernia repair

D. A full-term parturient brought to the OR for emergent cesarean section because

of fetal bradycardia

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

inguinal hernia repair

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:

A. Limited mouth opening

B. Thyromental distance less than 3 fingerbreadths

C. High arched palate

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

F

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A

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B

.

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.

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D

CHAPTER 2 ANSWERS

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

younger than 6 months.

 

36. C. As per ASA guidelines, it is recommended to wait at least 6 hours after

ingestion of nonhuman milk before performing an elective operation in a child.

37. C. Volatile inhalation agents and succinylcholine are considered triggers for

malignant hyperthermia (MH) reaction. MH has a genetic component, and runs in

families. Since her aunt had a severe reaction to anesthesia, further details should be

obtained from the history. If any doubt about the history, the patient should be

assumed to be prone to developing MH. Volatile agents and succinylcholine should

be avoided in this patient.

38. B. Elective surgery should be postponed for at least 6 weeks after a myocardial

infarction. Risk of reinfarction is approximately 5.5% for surgeries between 0 and 3

months, 2.5% between 3 and 6 months, and 2% after 6 months of a myocardial

infarction.

39. A. The most significant risk factor for developing pulmonary complications is the

upper abdominal or thoracic site of surgery. As such, all patients undergoing such

surgeries should be optimally prepared for the surgery. This includes pulmonary

toilet: chest physiotherapy/exercises, and postural drainage of mucus and secretions.

40. C. There is no specific value of INR before a patient is taken to the OR for

elective surgery. However, it is recommended that an INR value of 1.4 or less should

be aimed for before taking the patient to the OR for elective surgery. In case of

emergency, the INR can be normalized by infusing fresh-frozen plasma.

41. C. The paralyzed muscles due to central denervation eventually develop atrophy.

Extrajunctional receptors are then synthesized at the muscle sites, which remain

resistant to the effects of neuromuscular blockade for varying degrees. Thus, these

paralyzed muscles give an exaggerated response on direct stimulation with a nerve

stimulator. Therefore, muscle twitch monitoring should be done on the nonaffected

sites to correctly monitor the degree of neuromuscular blockade.

42. B. MAC typically is found to be lower for patients on sedatives, anxiolytics,

alcohol intoxication, hypothermia, extremes of age, moribund/sick patients, and

patients with obtunded consciousness. Chronic alcohol abuse, however, increases

MAC.

43. A. All β2 agonists are known to cause internalization of potassium (from plasma to

cell), thus causing hypokalemia. This principle is sometimes used in the treatment of

patients with hyperkalemia.

44. D. Smoking cessation for 24 hours before surgery reduces carboxyhemoglobin

(COHb) levels. Reduced levels of COHb increases levels of oxygenated Hb, which

decreases the risk of myocardial ischemia and perioperative cardiac morbidity.

Delayed benefits (cessation more than 8 weeks) are known to improve airway

immunologic and ciliary function.

45. D. Among all these tests, TEG has the highest positive predictive value for

diagnosing a bleeding tendency. Deranged values from other tests listed have not

shown to always correlate well with bleeding tendency. For example, the other tests

will be deranged in a patient with sepsis but may not show a clinically relevant

bleeding tendency.

46. D. All the other choices need evaluation/optimization prior to elective noncardiac

surgery. Uncontrolled systolic hypertension without target end-organ damage is a

minor predictor/risk factor. It can be usually controlled with intraoperative

antihypertensive medications without evidence of significant adverse outcomes.

47. C. Glycopyrrolate is a synthetic quaternary amine with antimuscarinic properties

and no central side effects like sedation. All the other choices are as a result of

direct consequence of cholinergic blockade.

48. C. Metoclopramide is a prokinetic agent that enhances gastric clearance and

increases lower esophageal sphincter tone, preventing vomiting, but may not actually

work for nausea (vomiting rather than nausea is prevented). It blocks the

dopaminergic receptors to cause parkinsonism-like extrapyramidal side effects.

49. B. Preoxygenation of lungs primarily acts to increase safe apnea time by

denitrogenating functional residual capacity (FRC) and increasing dissolved oxygen

content in the blood. It does not alter any physical measurements of lungs; that is, it

has no effect on FRC or on closing volume/capacity.

50. A. Halothane, especially on repeated administration, can cause two subtypes of

hepatitis (type 1 is immunogenic—mild—and type 2 is due to direct effect of

halothane on liver cells). The incidence of halothane hepatitis is around 1 in 10,000

to 1 in 35,000 halothane anesthetics.

51. C. Both halothane and sevoflurane have been used for inhalation induction in the

pediatric population. Sevoflurane has largely replaced halothane due to a better

safety profile, and has emerged as the induction agent of choice in pediatric

population.

52. D. Nitrous oxide is known to inhibit the enzyme “methionine synthase,” inhibiting

DNA synthesis and precipitating B12 deficiency, causing pernicious megaloblastic

anemia. Nitrous oxide is also known to act on NMDA receptors and also increase

pulmonary vascular resistance.

53. D. All the mechanisms have been proposed for propofol in preventing nausea and

vomiting in the postoperative period (PONV). Propofol, when used, is used in

refractory cases of PONV and in low doses.

54. C. Ketamine preserves spontaneous respiration and airway tone without causing

apnea at induction doses. Propofol and benzodiazepines are associated with

respiratory depression at induction doses and cause apnea.

55. B. Succinylcholine should not be used in patients with a history of muscular

dystrophy or patients with a history of malignant hyperthermia. Myasthenia gravis

patients may show resistance to Phase I block of succinylcholine. In patients with full

stomach, succinylcholine is used in “rapid sequence intubation” to prevent

aspiration.

56. B. Multiple studies have shown propensity of ACE inhibitors to precipitate

profound hypotension at induction of general anesthesia, especially in the geriatric

age group. Hence, ACE inhibitors should be with held on the day of the surgery,

especially in the elderly and for major surgeries.

57. D. Morbidly obese patients with OSA are often subject to persistent hypoxia,

which leads to increased pulmonary vascular resistance, eventually leading to

pulmonary artery hypertension. Obese patients are also known to have a higher

incidence of cardiac problems, including a dilated heart and heart failure.

Compression neuropathies are also common in this subpopulation. Dementia is a

central-nervous-system–related complication not associated directly with obesity.

58. D. Remifentanil preparations available in the market have glycine as the

preservative, which can cause direct neurotoxicity. Thus, it is recommended that

remifentanil preparations be not used for central neuraxial blockade.

59. D. Ondansetron exerts its antiemetic effect by acting as an antagonist on the 5-HT3

receptors. Drugs in the same category include palonosetron and granisetron. Rarely

reported side effects of these agents include QT prolongation, hypotension, and

headache.

60. C. Scopolamine is an antimuscarinic drug that can cross the blood–brain barrier

and cause sedation and confusion, especially in the elderly. It does not produce

analgesia.

61. D. Dexmedetomidine is an α2

receptor agonist, with about eight times greater

affinity for the receptor than clonidine. Continuous infusion is more likely to result in

hypotension and bradycardia.

62. C. Addisonian crisis or acute adrenal insufficiency during the perioperative period

occurs in patients with known adrenal insufficiency or in those receiving chronic

steroid therapy. The latter causes hypothalamic–pituitary axis suppression. Patients

with adrenal insufficiency may present with refractory shock with electrolyte and

glucose abnormalities. Treatment consists of administration of hydrocortisone and

correction of associated derangements.

63. B. Promethazine is commonly used as an antiemetic. It has antidopaminergic

activity, and in addition also has antihistaminic and anti–α-adrenergic activity.

64. A. Factors that are associated with an increased risk of postoperative nausea and

vomiting include previous history of postoperative nausea and vomiting, female

gender, obesity, nonsmoking, pain, eye or ear surgery, laparoscopic surgery,

anesthetic drugs, and gastric distention.

65. A. Abrupt withdrawal of TPN will most commonly result in hypoglycemia due to

the high circulating insulin levels.

66. A. Glycopyrrolate is an anticholinergic drug with a quaternary ammonium

structure, which prevents it from crossing the blood–brain barrier. Therefore, it has

no central nervous system effects (sedation). Glycopyrrolate increases the heart rate,

causes dryness of secretions, and lowers the lower esophageal sphincter tone. The

latter may predispose a patient to pulmonary aspiration of gastric contents.

67. B. Patients taking herbal medications for their alleged benefits are often unaware of

their potential side effects (bleeding tendency, platelet dysfunction, etc.). Most

medications must be stopped for at least 7 days prior to surgery.

68. A. Gentamicin is an aminoglycoside antibiotic that blocks acetylcholine release

from the presynaptic terminals and reduces postsynaptic responsiveness. This may

prolong neuromuscular blockade associated with nondepolarizing muscle relaxants.

69. B. Estrogen intake can lead to a hypercoagulable state, predisposing women to

thromboembolic events. Other risk factors for thromboembolism include major

surgery, multiple trauma (hip fracture), lower extremity paralysis, increasing age,

cardiac or respiratory failure, prolonged immobility, presence of central venous lines,

and a wide variety of hematologic conditions (inherited or acquired).

70. C. Because of its narrow therapeutic index, lithium dosing requires constant

surveillance with monitoring of levels and dosage adjustment. Three types of lithium

intoxication can occur—acute, acute or chronic, and chronic. Chronic lithium

intoxication occurs in those patients on long-term lithium therapy.

• Mild toxicity: manifests as lethargy, drowsiness, coarse hand tremor, muscle

weakness, nausea, vomiting, and diarrhea

• Moderate toxicity: manifests as confusion, dysarthria, nystagmus, ataxia,

myoclonic twitches, and flat or inverted T-waves on ECG

• Severe toxicity: may be life-threatening. It may present with grossly impaired

consciousness, increased deep tendon reflexes, seizures, syncope, renal

insufficiency, coma, and death.

71. A. Patients under treatment with MAOIs have an increased availability of

endogenous norepinephrine. Therefore, treatment with an indirect-acting drug such as

ephedrine can lead to an exaggerated response. Hypotension in these patients is

better managed with a direct-acting drug such as phenylephrine.

72. B. Patients taking oral hypoglycemic agents may experience delayed hypoglycemia

in the absence of caloric intake in the intraoperative and postoperative periods.

Hence, patients should be advised not to take oral hypoglycemic agents the morning

of the surgery. In addition, metformin should be stopped at least 48 hours before

surgery as it may precipitate the development of lactic acidosis during surgery.

Patients on an insulin pump should continue the insulin at the basal rate.

73. B. Digoxin is an inotrope that blocks the Na

+

/K

+ ATPase pump on the myocardial

cell. It causes calcium ions to enter the cells, but causes a net K

+

loss from the cell.

Thus, hypokalemia, more so than hypercalcemia, will exacerbate digitalis toxicity.

Signs and symptoms of digoxin toxicity include drowsiness or confusion,

nausea/vomiting, loss of appetite, diarrhea, disturbed color vision (yellow or green

halos around objects), agitation, and cardiac dysrhythmias. Characteristic EKG

changes include bradycardia, a prolonged PR interval, or an accelerated junctional

rhythm.

74. C. During central line insertion, the guide wire or the tip of the catheter enters the

right atrium and may result in an arrhythmia, which returns to sinus rhythm when the

guide wire/catheter tip is withdrawn out of the heart.

75. C. Antibiotic allergies may result in an anaphylactic or anaphylactoid reaction.

Based on the patient’s presentation, anaphylactic shock is the most consistent

diagnosis and needs to be treated with epinephrine first, which reverses most of the

manifestations of anaphylaxis.

76. D. The ulnar nerve is frequently spared with an interscalene block. Complications

of an interscalene block include stellate ganglion block, phrenic nerve block,

recurrent laryngeal nerve block, Horner syndrome, vertebral artery injection,

epidural/subarachnoid/subdural injection, and pneumothorax.

77. A. An axillary nerve block produces blockade of the median, ulnar, and the radial

nerves. Sensation to the lateral aspect of the forearm is provided by the

musculocutaneous nerve, which must be blocked separately (deep injection into the

coracobrachialis muscle).

78. D. The femoral nerve lies lateral to the femoral artery, which is lateral to the

femoral vein (VAN—vein, artery, nerve; medial to lateral).

79. D. The ankle block blocks the deep peroneal nerve, the saphenous nerve, the

posterior tibial nerve, the sural nerve, and the superficial peroneal nerve.

80. A. Laryngopharyngitis is more common after an endotracheal intubation than when

using a laryngeal mask airway. The incidence of sore throat can vary from 15% to

40%, and depends on operator experience (less trauma). Use of smaller endotracheal

tubes, smaller cuff sizes (less area of contact with tracheal mucosa), and low

pressure in the tracheal cuff decrease the incidence of postoperative sore throat.

Using lidocaine jelly to lubricate the endotracheal tube (rather than lubricating jelly)

increases the incidence of sore throat. Most cases of sore throat resolve

spontaneously.

81. B. In HOCM, obstruction of the ventricular outflow tract can occur from systolic

anterior motion of the mitral valve against the hypertrophied septum. In patients with

a severe HOCM, myocardial depression is beneficial, which can be obtained by

using β-blockers (metoprolol) or calcium channel blockers.

82. D. St. John wort is a commonly used herbal medication that is a CYP2C19- and

CYP3A4 inducer. As clopidogrel is activated by the cytochrome P450 system, St.

John wort may be used to increase the effect of clopidogrel in hyporesponders. It

reduces the effect of warfarin and heparin, with little effect on aspirin.

83. C. Advanced age is the most important predictor of atrial fibrillation not only in

patients following cardiac surgery but also in the general population.

84. C. Parkinson disease is characterized by a loss of dopamine in the nigrostriatum,

resulting in bradykinesia, rigidity, postural instability, and pill-rolling resting tremor.

Metoclopramide (and droperidol) has significant antidopaminergic properties and

should be avoided in these patients in the treatment of nausea and vomiting.

85. B. The New York Heart Association classification for heart failure is based on

both a functional and objective assessment of the patient’s capabilities and

symptoms. This patient is asymptomatic at rest and can go about his activities of

daily living without issues. However, with more strenuous activity, he becomes

dyspneic. His classification would, therefore, be 2 (Tables 1-1 and 1-2).

Table 1-1 Functional capacity: How a patient with cardiac disease feels during physical activity

Class I: Patients with cardiac disease but resulting in no limitation of

physical activity.

 

70. A 42-year-old patient is scheduled for a hernia repair under general anesthesia. His

medications include fluoxetine, alprazolam, and lithium for bipolar disorder. In the

preoperative area, he appears confused, has tremors, and is ataxic. Your next step

would be to

A. Cancel the case

B. Proceed with the case

C. Order a lithium blood level

D. Consult a psychiatrist

71. A 34-year-old patient is to undergo an appendectomy under general anesthesia. He

is taking a monoamine oxidase inhibitor (MAOI) for depression. Intraoperatively, his

blood pressure drops to 72/36 mm Hg and a medication is administered. His blood

pressure suddenly increases to 220/120 mm Hg. The most likely medicine that was

administered is

A. Ephedrine

B. Meperidine

C. Phenylephrine

D. Norepinephrine

72. All of the following are true about diabetic patients, except

A. Patients should take half or one-third of their insulin dose the morning of the

surgery

B. Patients should continue their oral hypoglycemic agents the morning of the

surgery

C. Finger-stick blood glucose should be tested before taking the patient to the

operating room

D. Patient with an insulin pump should continue the insulin at their basal rate

73. Digoxin toxicity is most likely exacerbated by

A. Hyperkalemia

B. Hypokalemia

C. Hypercalcemia

D. Hypocalcemia

74. The most common complication of inserting a central venous catheter is

A. Carotid artery puncture

B. Thrombosis

C. Cardiac arrhythmias

D. Air embolism

75. A patient is administered cephalexin preoperatively. Within 5 minutes of starting the

antibiotic, the patient starts to wheeze and develops tachycardia, and the blood

pressure drops to 78/42 mm Hg. Your next step would be to administer

A. Ephedrine

B. Phenylephrine

C. Epinephrine

D. Oxygen

76. All of the following may occur with an interscalene block, except

A. Subarachnoid injection

B. Radial nerve blockade

C. Median nerve blockade

D. Ulnar nerve blockade

77. An axillary nerve block would not produce loss of sensation of the

A. Lateral aspect of the forearm

B. Medial aspect of the forearm

C. The entire forearm

D. None of the above

78. The femoral nerve lies

A. Medial to the femoral artery

B. Anterior to the femoral artery

C. Posterior to the femoral artery

D. Lateral to the femoral artery

79. All of the following nerves are blocked by an ankle block, except

A. Sural

B. Superficial peroneal

C. Deep peroneal

D. Anterior tibial

80. Sore throat is

A. More common after using an endotracheal tube

B. More common after using a laryngeal mask airway

C. Similar incidence with either endotracheal tube or a laryngeal mask airway

D. More common after using an oral airway

81. A patient with hypertrophic obstructive cardiomyopathy (HOCM) presents with

dyspnea and angina on exertion. Which of the following is the best agent to treat

these symptoms?

A. Hydrochlorothiazide

B. Metoprolol

C. Morphine

D. Nitroglycerin

82. St. John wort (Hypericum perforatum) potentiates the effects of

A. Heparin

B. Warfarin

C. Aspirin

D. Clopidogrel

83. The most powerful predictor of atrial fibrillation post–cardiac surgery is

A. History of diabetes

B. History of hypertension

C. Age

D. Time on bypass

84. A patient with Parkinson disease undergoes a general anesthetic. Your plan to treat

his nausea would include all of the following, except

A. Dexamethasone

B. Scopolamine patch

C. Metoclopramide

D. Ondansetron

85. A 65-year-old patient is being treated for congestive cardiac failure. He is able to

take a shower but gets dyspneic on mowing the lawn. His New York Heart

Association classification is

A. Class 1

B. Class 2

C. Class 3a

D. Class 3b

86. The percentage of postdural puncture headaches that would resolve spontaneously

by 1 week is approximately

A. 30%

B. 50%

C. 50%

D. 70%

87. A 46-year-old lady is seen at the preoperative assessment clinic. She is taking 180

mg/day methadone. The most likely change to be found in her preoperative ECG is

A. Prolonged PR interval

B. Prolonged QTc

C. U wave

D. Tented T-waves

88. You are about to anesthetize a 55-year-old man who is undergoing liver resection for

removal of metastatic carcinoid tumor. The drug of choice to treat intraoperative

hypotension is

A. Octreotide

B. Dobutamine

C. Milrinone

D. Vasopressin

89. You are performing an interscalene brachial plexus block on an awake 40-year-old

patient who is healthy with no significant medical history. Soon after injecting 20 mL

of 0.25% bupivacaine the patient becomes agitated, has a seizure, and loses

consciousness. Your first step in management is

A. Administer intralipid

B. Administer midazolam or propofol to control the seizure

C. Establish airway and give 100% O2 via a face mask

D. Administer epinephrine

90. Patients with dilated cardiomyopathy exhibit all of the following, except

A. Decreased myocardial contractility

B. Afterload should be maximized

C. Increased preload

D. Left ventricular hypertrophy

91. A septic patient has a central venous pressure of 10 mm Hg, a blood pressure of

80/40 mm Hg, and a pulse rate of 96 beats/min. The best agent to treat the

hypotension is

A. Dopamine

B. Dobutamine

C. Noradrenaline

D. Epinephrine

92. Which of the following organs is least tolerant of ischemia for removal for

transplantation?

A. Cornea

B. Heart

D. Kidney

E. Pancreas

93. You have administered a patient 1.2 mg/kg of rocuronium to do an intubation. You

are unable to intubate or ventilate the patient and decide to reverse the patient’s

paralysis with sugammadex. The dosage you would use is

A. 2 mg/kg

B. 4 mg/kg

C. 8 mg/kg

D. 16 mg/kg

94. A young female patient with anorexia nervosa has just started eating again. After 4

days, she develops dyspnea and is found to have cardiac failure. Which of the

following is most important to correct?

A. Potassium

B. Phosphate

C. Glucose

D. Sodium

95. A pregnant lady is to undergo general anesthesia for acute appendicitis. At what

gestational age should you monitor fetal heart rate?

A. 16 weeks

B. 18 weeks

C. 24 weeks

D. 28 weeks

96. Which of the following is the best predictor of a difficult intubation in a morbidly

obese patient?

A. Pretracheal tissue volume

B. Body mass index

C. Mallampati score

D. Thyromental distance

97. A patient with a history of chronic obstructive pulmonary disease presents for lung

volume–reduction surgery. Which of the following is a contraindication for surgery?

A. Age >60 years

B. Chronic asthma

C. FEV <25%

D. Evidence of bullous disease

98. All of the following help increase the excretion of calcium, except

A. Bisphosphonates

B. Calcitonin

C. Furosemide

D. IV crystalloids

99. Which of the following is contraindicated to use during pregnancy?

A. Aspirin

B. Enalapril

C. Metoprolol

D. Hydralazine

100. During scoliosis surgery, monitoring of somatosensory-evoked potentials indicates

monitoring of

A. Anterior horn

B. Anterior corticospinal tract

C. Dorsal column

D. Spinothalamic tract

101. The desflurane vaporizer is heated because of desflurane’s

A. High vapor pressure

B. High boiling point

C. High minimum alveolar concentration

D. High volatility

102. Which of the following is the most effective way to reduce renal failure in a patient

having an abdominal aortic aneurysm repair?

A. Fluid bolus prior to aortic clamping

B. Fluid bolus after aortic clamp release

C. Administration of mannitol

D. Minimization of cross-clamp time

CHAPTER 1 ANSWERS

1. D. Scopolamine, an anticholinergic drug, is often applied as a transdermal patch

preoperatively for the prevention of postoperative nausea and vomiting. However,

like atropine, and unlike glycopyrrolate, scopolamine passes through the blood–brain

barrier and can cause confusion, especially in the elderly. Hence, application of

scopolamine patch should be avoided in the elderly. Treatment of scopolamineinduced confusion may require administration of physostigmine.

2. D. Metoclopramide is a prokinetic agent and helps to increase gastric motility. The

ASA does not recommend preoperative administration of metoclopramide for

prevention of postoperative nausea and vomiting. All the other agents have proven

benefit in preventing postoperative nausea and vomiting.

3. B. Famotidine is known to cause thrombocytopenia (both quantitative and

qualitative platelet dysfunction). Patients with ITP already have low platelets; thus,

such premedication should be avoided. Warfarin does not affect platelet function or

number, thus has no relation to perioperative bleeding due to platelet pathology;

however, it is an independent risk factor for bleeding.

4. B. Aprepitant is an NK1

receptor antagonist that antagonizes the action of

substance P in the central nervous system to prevent nausea and vomiting.

Palonosetron is a 5-HT3 antagonist, metoclopramide is an antidopaminergic agent,

and prochlorperazine is a dopamine (D2

) receptor antagonist (antipsychotic drug)

with additional antiemetic activity.

5. C. The Apfel score can be used to predict patients with a high risk for

perioperative nausea and vomiting (PONV). It includes four factors: female gender,

nonsmoking, postoperative use of opioids, and previous PONV or motion sickness in

the patients’ history. Surgeries like laparoscopy, middle-ear surgery, and strabismus

surgery are associated with a higher risk of PONV.

6. C. Etomidate administration can cause an increase in the incidence of perioperative

nausea and vomiting (PONV). Promethazine, haloperidol, and propofol all are used in

the treatment of PONV. The latter two are usually used for the treatment of

refractory PONV.

7. C. β-Lactam antibiotics must be given within 60 minutes prior to incision.

Vancomycin and fluoroquinolones require administration within 120 minutes prior to

incision.

8. D. Vancomycin and fluoroquinolones require administration within 120 minutes

prior to incision. β-Lactam antibiotics must be given within 60 minutes prior to

incision.

9. D. Effort tolerance of around 4 METs (metabolic equivalent of tasks) or more is

suggested to be a good predictor for postoperative cardiopulmonary outcome. These

activities are classified as per physical strain involved.

10. C. One metabolic equivalent is defined as the amount of oxygen consumed at rest,

and is equal to 3.5 mL O2

/kg/min. The energy cost of any activity can be determined

by multiplying 3.5 to the oxygen consumption (mL O2

/kg/min). METs can be

assessed as follows:

• 1 MET—can take care of self (eating, dressing, toilet)

• 4 METs—can walk up a flight of steps or a hill

• 4 to 10 METs—can do heavy household work (scrubbing floors, lifting heavy

furniture)

• >10 METs—can participate in strenuous sports (swimming, tennis, basketball,

skiing)

11. B. As per ASRA guidelines 2010, heparin infusion should be stopped at least 2 to

4 hours before placing an epidural. This is to prevent the potential formation of an

epidural hematoma.

12. A. As per the AHA/ACC Scientific Statement, reversal of warfarin can be

achieved by using all, except choice D. However, for emergent surgery the fastest

method is the administration of fresh-frozen plasma. Peak action of injectable vitamin

K takes up to 6 to 12 hours.

13. C. As per ASRA guidelines (2010), aspirin intake by the patient is no more

considered as a contraindication to performing a neuraxial block.

14. D. The assessment of preoperative predictability for obstructive sleep apnea can

be done by using the “STOP-BANG” questionnaire. In this scoring, male gender, and

not female gender, is classified as a risk factor (S, snoring; T, tired during daytime;

O, observed for apnea during sleep; P, high blood pressure; B, BMI >35 kg/m2

; A,

age >50 years; N, neck circumference >40 cm; G, male gender). In addition to the

questionnaire, upper airway anatomical abnormalities that increase the likelihood of

obstruction are tonsillar hypertrophy, tumors of the upper airway, or facio maxillary

abnormalities.

15. D. All, except choice D, are signs of diabetic autonomic neuropathy. Urinary

retention at this age is more likely due to prostate hypertrophy.

16. B. Weight loss due to dialysis is attributed to actual volume (ultrafiltrate) removed

from the body. Thus, a high weight loss can predict higher circulatory volume lost,

which can lead to poor compensation of hypotension in patients undergoing surgery.

17. A. Ketamine causes the least respiratory depression among the intravenous

induction agents. Therefore, it may be beneficial as an induction agent in patients

with severe asthma. However, ketamine causes an increase in secretions, and may

produce emergence delirium (vivid dreams). Pretreatment with glycopyrrolate and

midazolam alleviates these effects of ketamine. The other induction agents cause

dose-dependent respiratory depression.

18. B. Droperidol can cause a significant prolongation of the QT interval on the ECG.

Patients should have a preoperative ECG, and ECG monitoring should be continued

postoperatively for at least 2 hours, before discharging the patient.

19. D. At present, no conventional test (PT, PTT) can be used to quantify the clinical

effects of LMWH on the coagulation system. Anti–Factor Xa estimation may be used

in specific patients to monitor the coagulative effects of LMWH.

20. B. As these drugs act on different receptors, their effects are generally considered

to be synergistic. Patients receiving both these drugs may be prone to greater

sedation and respiratory depression than when receiving the drug alone.

21. D. Preoperative evaluation in fact includes a battery of tests and adds additional

costs to the total perioperative costs. However, preoperative evaluation is vital, as it

recognizes patient comorbidities, which can worsen perioperatively and cause

increased patient morbidity. Preoperative evaluation eventually lowers indirect costs

that may be incurred to treat the worsening aliment, postoperatively. During

preoperative interaction, patient anxiety is usually lowered as the risks and procedure

are explained to the patient.

22. B. An anesthesia consent should be obtained during preanesthetic evaluation,

whenever possible. This is one of the prime aims that need to be fulfilled as a

component of preoperative anesthetic evaluation.

23. D. The goals of preanesthetic evaluation include all those listed in the question. In

addition, other targets of preanesthetic evaluation include education of patients and

families about anesthesia and the anesthesiologist’s role, obtaining informed consent,

motivation of patients to stop smoking and lose weight, or commit to other preventive

care.

24. D. ASA classification does not include the nature of procedure in predicting

perioperative morbidity and mortality. It only includes patient-based morbidity rather

than type of surgery.

25. B. Healthy pregnant patients in labor are classified as an ASA II. Patients with

controlled diabetes or essential hypertension are still classified as an ASA II.

Presence of preeclampsia will step up the classification to an ASA III.

26. C. Sedatives typically alleviate anxiety in hypertensive patients (preventing blood

pressure elevations due to surgery-related anxiety), in patients with chronic alcohol

abuse, and in children to maintain cooperation for induction of anesthesia. In

neurosurgical patients, sedatives can lead to depression of respiratory drive, which

can cause hypercarbia and an increase in intracranial pressure.

27. A. As per ASRA guidelines, warfarin must be stopped at least 5 days prior and

clopidogrel 7 to 10 days prior to elective surgery. Low-molecular-weight heparin in

therapeutic doses must be stopped at least 24 hours prior, and when being used in

prophylactic doses, it must be stopped at least 12 hours prior to an elective surgery

requiring central neuraxial blockade. Aspirin use is no more considered as a

contraindication to performing a neuraxial block.

28. B. ASA classifies any medical comorbidity without functional limitation (i.e.,

hypertensive without coronary artery disease or angina) as an ASA II. Once the

patient’s activity is limited due to the disease, the patient is then categorized as an

ASA III.

29. D. By definition, such patients are categorized as ASA Class VI.

30. C. By definition, these patients require surgery despite being really sick. Most

often, the surgical correction of the underlying pathology (that may have led to

multiorgan involvement) may be the only option of improving their chances of

survival. A hemodynamically unstable patient secondary to perforation peritonitis,

with an acute kidney injury, would be an example. Although the patient may be

extremely sick, until the perforation peritonitis is surgically treated, the chances of

survival may not improve.

31. B. ASA III is a patient with severe systemic disease that is a constant threat to life

(functionality incapacitated).

32. C. Warfarin should be stopped at least 5 days prior to surgery. On the day of the

surgery, the prothrombin time (international normalized ratio or INR) is checked. An

INR of 1.4 or less is desirable to perform the surgery.

33. A. Before any rate/rhythm control in patients likely to have AF for more than 48

hours, left-atrial clots must be ruled out. An undiagnosed clot can lead to

catastrophic embolic consequences.

34. D. For a drug-eluting stent, it is advised to avoid elective surgery for a year (to

continue dual antiplatelet medication), and for a bare-metallic stent, it is advised to

avoid elective surgery for about 4 weeks. Performing laparoscopic surgery post–

CABG surgery is highly risky. So when surgery needs to be planned in the near

future, the patient should be advised to undergo balloon dilatation and then delay the

elective procedure for 2 to 3 weeks thereafter.

35. C. Renal failure can induce platelet dysfunction, and therefore, central neuraxial

blockade is still debated in these patients. They also have coagulation factor

abnormalities that may predispose them to deep vein thrombosis. Anemia is a result

of decreased erythropoietin production and is often labeled as “anemia of chronic

disease.”