ANESTHESIA ORAL BOARDS EXAM
QUESTIONS AND ANSWERS
How is OSA different from Obstruction Sleep Hypopnea - Correct Answers -OSA
complete cessation of airflow for greater 10 seconds, 5 times per hour. OSH is
decrease in airflow greater than 50% for more than 10 seconds, 15x more per hour.
They both have a 4% decrease in O2 sat.
How is the definitive diagnosis of OSA made - Correct Answers -A formal sleep study
What are the systemic manifestations of OSA - Correct Answers -Neuro: Hyper
somnolence, increased sensitivity to anesthetic agents.
Cardiac: Htn, LVH, pulmonary HTN
Pulmonary: Increase V/Q mismatch from decrease FRC and atelectasis. This usually
due to the comorbidities that accompany it.
GI: Usually upward displacement of stomach due to abdominal pressure -> GERD
Renal: htn nephropathy
How is OSA distinguished from Pickwickian Syndrome - Correct Answers -OSA is
complete stop of airway, while Pickwickian is chronic hypoventilation that worsens
during sleep. This results in elevated PaCO2 levels.
How to diagnose pickwickian syndrome - Correct Answers -BMI > 30, PaCO2 > 44, no
alternate explanation for hypoventilation. Pts often have co-existing OSA but they don't
go together.
Pickwickian Sequelae - Correct Answers -Polycythemia, cor pulmonale, somnolence,
reduced lung volumes, increased closing capacity, decreased FRC, V/Q mismatch, RV
failure, chronic CO2 retention.
How does OSA effect anesthetic management - Correct Answers -Pre-op: assess for
comorbordities. Pre-op thorough airway exam because most are a difficult airway.
Intra-op: minimize sedatives because they have an increased sensitivity to CNS
depressants so minimal to no versed. Thorough pre-oxygenation due to low FRC,
difficult airway cart in the room and consider an awake intubation if away was non-
reassuring. During surgery use multi-modal pain regimen to minimal opioids including
regional, and local wound infiltration.
,Post-op: extubate in head up position to improve pulmonary mechanics and extubate
after fully awake. CPAP machine in the pacu and monitor closely for episodes of apnea
and desaturation.
What monitors will you use for an OSA pt - Correct Answers -Standard ASA, twitch
monitor, second IV, foley
Name the 5 ASA monitors - Correct Answers -temp, capno, blood pressure, pulse ox, 5
lead ECG
What premedications would you give to an OSA patient - Correct Answers -verbal
reassurance, then maybe small dose of ketamine or versed and some reglan.
How would you perform a superior laryngeal nerve block for an awake intubation? and
translaryngeal nerve block - Correct Answers -2ml of 2% lidocaine just anterior to the
cornu of the hyoid bone and a trans-tracheal recurrent laryngeal nerve block. A
recurrent nerve block is never performed because it can lead to vocal cord paralysis
and obstruction so we do a translaryngeal block to target just the sensory fibers. Go
through the cricothyroid membrane with 5 cc of 4% lidocaine with a 22 gauge needle.
What is your awake intubation technique - Correct Answers -5cc of 4% lidocaine via
atomizer, if they have a limited mouth opening then use a nebulizer with 5cc of 4% for
30 minutes
What anesthetic gas would you use with an OSA pt and why - Correct Answers -
Desflurane, insoluble in fat, rapid wake up, fast return of reflexes, reduce amount of
post op sedation.
How would you extubate an OSA patient - Correct Answers -Assuming no adverse
intraoperative events or significant volume shifts, i would extubate with emergency
airway equipment on standby, patient in the sitting position to optimize pulmonary
mechanics, adequate reversal, and have the patient spontaneously breating with normal
tidal volumes and respiratory rate. Once the patient is responding to commands and
protecting the airway I'll extubate.
What are your respiratory parameters for extubation - Correct Answers -RR 10-30
breaths per minute, sat greater than 95% with FIO2 > 40%, VC greater than 10ml/kg of
ideal body weight, and TV >5 ml/kg of ideal body weight.
What is controlling glucose in the OR important - Correct Answers -1. Impaired immune
response
2. Increased risk of infection
3. Impaired wound healing
4. Dehydration secondary to osmotic diuresis
5. Risk of fatal nonketotic hyperosmolar coma
,What is your plan for post operative pain control in an OSA patient - Correct Answers -
1. Tylenol and NSAIDS
2. Surgeon local anesthesia around wound
3. PCA, relief without overdosing in a monitored setting
4. Regional
What are some benefits post op PCA vs regional techniques - Correct Answers -Less
opioid use resulting in less side effects such as respiratory complications like chest wall
rigidity.
What your ddx for post op disorientation - Correct Answers -1. Hypoxia, hypercarbia,
hypotension, malignant arrhythmia
2. Anesthesia causes: gas, opioids, paralytics, reactions
3. Withdraw or intoxication from substance abuse
4. Metabolic changes: electrolytes, temperature, thyroid
5. Neurologic: post ictal, edema, stroke
Delay emergence/disorientation work up - Correct Answers -1. Go to bed side, make
sure patient is oxygenating, ventilating and vital signs are stable.
2. Next a focused H&P, review OR and PACU notes. What meds and when symptoms
began, perform focused neuro physical.
3. Stat labs: cbc, abg, electrolytes, glucose
4. Stat head CT if suspect stroke and neuro consult.
5. Order my delay emergence panel: twitch monitor, neuro exam, glucose, temperature,
abg, electrolytes, cbc, reverse meds, CT scan.
MEN 1, MEN2A, MEN2B - Correct Answers -MEN1: pit adenoma, parathyroid
hyperplasia, pancreatic tumors
MEN2A: Parathy hyperplasia, medullary thyroid cancer, pheochromocytoma
MEN2B: Medullary thyroid CA, pheochromocytoma
One lung ventilation indications - Correct Answers -1. Lung isolation to prevent damage
or contamination of the healthy lung.
2. Isolation of ventilation ie bronchopleural fistula
3. Single lung lavage
4. Helps with lung drainage and improves operative field
5. Surgical exposure for : thoracotomy, pneumonectomy, esophagectomy
How to place and confirm DLT? - Correct Answers -1. Check both balloons
2. Lubricate the inside and outside of the tube and place stylet down bronchial lumen
3. Place through the cords and rotate 90 degrees to the left.
4. Look down the tracheal lumen and see the carina and the bronchial balloon.
5. The right upper lung should display 3 orifices (right upper/middle/lower bronchi), and
the left upper and lower bronchi.
6. Inflate tracheal balloon and verify b/l lung inflation
, 7. Inflate bronchial balloon and connect both to the circuit and inflate to verify the
endobronchial balloon is not obstructing the carina.
8. Clamp each tracheal lumen and verify unilateral lung movement.
Name some malpositioning errors with double lumen tubes - Correct Answers -1.
Endobronchial cuff too deep which makes diminshed breath sounds.
2. Position into the opposite bronchus which may make the opposite lung collapse.
3. Underinsertion of the DLT where the endobronchial cuff is at the carina
Contraindication to a DLT left side - Correct Answers -A mass in the left main bronchi
Troubleshooting hypoxia in a double lumen tube - Correct Answers -First step is to
increase FIO2 and to grab your bronchoscope and verify placement. Too far can
obstruct the left upper lobe. Suction out mucus, verify no kinks in the tube. Peep to the
ventilated lung. CPAP to surgical lung. Resume two lung ventilation. Clamping of the
pulmonary ARTERY, only really helps with pneumonectomy. Last resort is putting
patient on bypass.
A patient has elevated bilirubin and jaundice after losing 2L of blood acutely, why? -
Correct Answers -Shock liver has likely occurred. You need to call this ischemic
hepatitis.
What is the acute treatment for MI - Correct Answers -Morphine, oxygen, aspirin,
nitrates if pressure allows, and beta blockers if heart rate allows.
Ddx for increased mediastinal drain output post CABG - Correct Answers -CABG Graft
dysfunction which includes graft clotting, suture rupture, kink, tamponade.
Would you exchange a double lumen tube in the ICU? why or why not? - Correct
Answers -Yes
1. Easier to suction through.
2. ICU team is more familiar
3. Lower airway pressures with the same tidal volume
What are the advantages and disadvantages of bronchial blockers - Correct Answers -
1. They can dislodge easily.
2. Difficult to place
3. Cost more than DLT
4. They can be placed next to single lumen and not through it.
5. No tube exchange, better for long cases.
6. Better for difficult airways
7. Can be used to isolate individual lobes
What is your dose for a thoracic epidural for rib fractures - Correct Answers -Bupivicaine
1/8th percent 8-10cc/hr
QUESTIONS AND ANSWERS
How is OSA different from Obstruction Sleep Hypopnea - Correct Answers -OSA
complete cessation of airflow for greater 10 seconds, 5 times per hour. OSH is
decrease in airflow greater than 50% for more than 10 seconds, 15x more per hour.
They both have a 4% decrease in O2 sat.
How is the definitive diagnosis of OSA made - Correct Answers -A formal sleep study
What are the systemic manifestations of OSA - Correct Answers -Neuro: Hyper
somnolence, increased sensitivity to anesthetic agents.
Cardiac: Htn, LVH, pulmonary HTN
Pulmonary: Increase V/Q mismatch from decrease FRC and atelectasis. This usually
due to the comorbidities that accompany it.
GI: Usually upward displacement of stomach due to abdominal pressure -> GERD
Renal: htn nephropathy
How is OSA distinguished from Pickwickian Syndrome - Correct Answers -OSA is
complete stop of airway, while Pickwickian is chronic hypoventilation that worsens
during sleep. This results in elevated PaCO2 levels.
How to diagnose pickwickian syndrome - Correct Answers -BMI > 30, PaCO2 > 44, no
alternate explanation for hypoventilation. Pts often have co-existing OSA but they don't
go together.
Pickwickian Sequelae - Correct Answers -Polycythemia, cor pulmonale, somnolence,
reduced lung volumes, increased closing capacity, decreased FRC, V/Q mismatch, RV
failure, chronic CO2 retention.
How does OSA effect anesthetic management - Correct Answers -Pre-op: assess for
comorbordities. Pre-op thorough airway exam because most are a difficult airway.
Intra-op: minimize sedatives because they have an increased sensitivity to CNS
depressants so minimal to no versed. Thorough pre-oxygenation due to low FRC,
difficult airway cart in the room and consider an awake intubation if away was non-
reassuring. During surgery use multi-modal pain regimen to minimal opioids including
regional, and local wound infiltration.
,Post-op: extubate in head up position to improve pulmonary mechanics and extubate
after fully awake. CPAP machine in the pacu and monitor closely for episodes of apnea
and desaturation.
What monitors will you use for an OSA pt - Correct Answers -Standard ASA, twitch
monitor, second IV, foley
Name the 5 ASA monitors - Correct Answers -temp, capno, blood pressure, pulse ox, 5
lead ECG
What premedications would you give to an OSA patient - Correct Answers -verbal
reassurance, then maybe small dose of ketamine or versed and some reglan.
How would you perform a superior laryngeal nerve block for an awake intubation? and
translaryngeal nerve block - Correct Answers -2ml of 2% lidocaine just anterior to the
cornu of the hyoid bone and a trans-tracheal recurrent laryngeal nerve block. A
recurrent nerve block is never performed because it can lead to vocal cord paralysis
and obstruction so we do a translaryngeal block to target just the sensory fibers. Go
through the cricothyroid membrane with 5 cc of 4% lidocaine with a 22 gauge needle.
What is your awake intubation technique - Correct Answers -5cc of 4% lidocaine via
atomizer, if they have a limited mouth opening then use a nebulizer with 5cc of 4% for
30 minutes
What anesthetic gas would you use with an OSA pt and why - Correct Answers -
Desflurane, insoluble in fat, rapid wake up, fast return of reflexes, reduce amount of
post op sedation.
How would you extubate an OSA patient - Correct Answers -Assuming no adverse
intraoperative events or significant volume shifts, i would extubate with emergency
airway equipment on standby, patient in the sitting position to optimize pulmonary
mechanics, adequate reversal, and have the patient spontaneously breating with normal
tidal volumes and respiratory rate. Once the patient is responding to commands and
protecting the airway I'll extubate.
What are your respiratory parameters for extubation - Correct Answers -RR 10-30
breaths per minute, sat greater than 95% with FIO2 > 40%, VC greater than 10ml/kg of
ideal body weight, and TV >5 ml/kg of ideal body weight.
What is controlling glucose in the OR important - Correct Answers -1. Impaired immune
response
2. Increased risk of infection
3. Impaired wound healing
4. Dehydration secondary to osmotic diuresis
5. Risk of fatal nonketotic hyperosmolar coma
,What is your plan for post operative pain control in an OSA patient - Correct Answers -
1. Tylenol and NSAIDS
2. Surgeon local anesthesia around wound
3. PCA, relief without overdosing in a monitored setting
4. Regional
What are some benefits post op PCA vs regional techniques - Correct Answers -Less
opioid use resulting in less side effects such as respiratory complications like chest wall
rigidity.
What your ddx for post op disorientation - Correct Answers -1. Hypoxia, hypercarbia,
hypotension, malignant arrhythmia
2. Anesthesia causes: gas, opioids, paralytics, reactions
3. Withdraw or intoxication from substance abuse
4. Metabolic changes: electrolytes, temperature, thyroid
5. Neurologic: post ictal, edema, stroke
Delay emergence/disorientation work up - Correct Answers -1. Go to bed side, make
sure patient is oxygenating, ventilating and vital signs are stable.
2. Next a focused H&P, review OR and PACU notes. What meds and when symptoms
began, perform focused neuro physical.
3. Stat labs: cbc, abg, electrolytes, glucose
4. Stat head CT if suspect stroke and neuro consult.
5. Order my delay emergence panel: twitch monitor, neuro exam, glucose, temperature,
abg, electrolytes, cbc, reverse meds, CT scan.
MEN 1, MEN2A, MEN2B - Correct Answers -MEN1: pit adenoma, parathyroid
hyperplasia, pancreatic tumors
MEN2A: Parathy hyperplasia, medullary thyroid cancer, pheochromocytoma
MEN2B: Medullary thyroid CA, pheochromocytoma
One lung ventilation indications - Correct Answers -1. Lung isolation to prevent damage
or contamination of the healthy lung.
2. Isolation of ventilation ie bronchopleural fistula
3. Single lung lavage
4. Helps with lung drainage and improves operative field
5. Surgical exposure for : thoracotomy, pneumonectomy, esophagectomy
How to place and confirm DLT? - Correct Answers -1. Check both balloons
2. Lubricate the inside and outside of the tube and place stylet down bronchial lumen
3. Place through the cords and rotate 90 degrees to the left.
4. Look down the tracheal lumen and see the carina and the bronchial balloon.
5. The right upper lung should display 3 orifices (right upper/middle/lower bronchi), and
the left upper and lower bronchi.
6. Inflate tracheal balloon and verify b/l lung inflation
, 7. Inflate bronchial balloon and connect both to the circuit and inflate to verify the
endobronchial balloon is not obstructing the carina.
8. Clamp each tracheal lumen and verify unilateral lung movement.
Name some malpositioning errors with double lumen tubes - Correct Answers -1.
Endobronchial cuff too deep which makes diminshed breath sounds.
2. Position into the opposite bronchus which may make the opposite lung collapse.
3. Underinsertion of the DLT where the endobronchial cuff is at the carina
Contraindication to a DLT left side - Correct Answers -A mass in the left main bronchi
Troubleshooting hypoxia in a double lumen tube - Correct Answers -First step is to
increase FIO2 and to grab your bronchoscope and verify placement. Too far can
obstruct the left upper lobe. Suction out mucus, verify no kinks in the tube. Peep to the
ventilated lung. CPAP to surgical lung. Resume two lung ventilation. Clamping of the
pulmonary ARTERY, only really helps with pneumonectomy. Last resort is putting
patient on bypass.
A patient has elevated bilirubin and jaundice after losing 2L of blood acutely, why? -
Correct Answers -Shock liver has likely occurred. You need to call this ischemic
hepatitis.
What is the acute treatment for MI - Correct Answers -Morphine, oxygen, aspirin,
nitrates if pressure allows, and beta blockers if heart rate allows.
Ddx for increased mediastinal drain output post CABG - Correct Answers -CABG Graft
dysfunction which includes graft clotting, suture rupture, kink, tamponade.
Would you exchange a double lumen tube in the ICU? why or why not? - Correct
Answers -Yes
1. Easier to suction through.
2. ICU team is more familiar
3. Lower airway pressures with the same tidal volume
What are the advantages and disadvantages of bronchial blockers - Correct Answers -
1. They can dislodge easily.
2. Difficult to place
3. Cost more than DLT
4. They can be placed next to single lumen and not through it.
5. No tube exchange, better for long cases.
6. Better for difficult airways
7. Can be used to isolate individual lobes
What is your dose for a thoracic epidural for rib fractures - Correct Answers -Bupivicaine
1/8th percent 8-10cc/hr
