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UBP Question 3

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Question 3



(Short form)



A 68 year old, 72 Kg, woman with a history of recurrent unilateral transient ischemic attacks (TIAs) over the past week, presents to the operating room for urgent left carotid endarterectomy. Her medical history is significant for a myocardial infarction one year ago and poorly controlled chronic hypertension. Additionally, she continues to experience orthopnea and occasional exertional angina. Her medications include digoxin, furosemide, nifedipine, aspirin, and NTG as needed.

Pre-operative Management


1) What are your concerns for this patient?

UBP Answer: Complete answer is found in the UBP Practice Set #1

2) How would you evaluate her cardiac status?

UBP Answer: Complete answer is found in the UBP Practice Set #1

3) What testing would you recommend to assess her risk for cardiac ischemia?

UBP Answer: Complete answer is found in the UBP Practice Set #1

4) When would cardiac revascularization be indicated prior to CEA?

UBP Answer: Complete answer is found in the UBP Practice Set #1

5) What anesthetic technique would you use for this case?
Is RA or GA better for CEA?

UBP Answer: Complete answer is found in the UBP Practice Set #1

6) Which monitors would you place for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #1

7) If you were planning a general anesthetic, would you monitor neurological function intra-operatively?

UBP Answer: Complete answer is found in the UBP Practice Set #1

8) Let’s assume that TEE was not available, and you place central venous and pulmonary artery catheters. What options are available for neurologic monitoring?

UBP Answer: Complete answer is found in the UBP Practice Set #1

9) What is the significance of a digoxin level of 2.2?

UBP Answer: Complete answer is found in the UBP Practice Set #1

10) Would you administer any premedications for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #1


(Long Form)



A 68 year old, 72 Kg, woman presents to the operating room for urgent left carotid endarterectomy. She has experienced multiple unilateral transient ischemic attacks over the past week.


Meds: Digoxin, furosemide, nifedipine, aspirin, NTG prn

Allergies: NKDA

PMH: Her past medical history includes poorly controlled HTN and an MI that occurred one year ago with subsequent moderate CHF. She underwent cardiac catheterization eight months ago with PCA to the RCA. Her ejection fraction is 30%, and she experiences occasional exertional angina and orthopnea

PE: Vital Signs: P = 68, BP = 170/95 mmHg, RR = 22, T = 37 °C, weight = 80kg
Airway: Mallampati II, TMD > 60cm, Edentulous
Neck: Left carotid bruit
Lungs: Rales heard in both lung bases

CXR: Prominent vascular markings and cardiomegaly

EKG: NSR, LVH, Q waves V1-V4, nonspecific ST changes

Lab: Hgb = 11.5 gm/dL, Na+ = 134mEq/L, K+ = 3.1 mEq/L; digoxin level = 2.2


Intra-operative Management


1) How would you provide regional anesthesia for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #1

2) What are the complications of deep and superficial cervical plexus blocks?

UBP Answer: Complete answer is found in the UBP Practice Set #1

3) Do you need to perform a deep cervical plexus block to provide adequate analgesia?

UBP Answer: Complete answer is found in the UBP Practice Set #1

4) The patient refuses regional anesthesia. How would you induce general anesthesia?

UBP Answer: Complete answer is found in the UBP Practice Set #1

5) Would Ketamine be acceptable? Why/ why not?

UBP Answer: Complete answer is found in the UBP Practice Set #1

6) How would you maintain anesthesia? Is isoflurane the best volatile anesthetic for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #1

7) What is pharmacologic preconditioning? Does it apply in this case?

UBP Answer: Complete answer is found in the UBP Practice Set #1

8) During dissection, the patient’s heart rate drops to 48 beats per minute and her blood pressure falls to 88/40 mm Hg. Are you concerned? What is your differential diagnosis?

UBP Answer: Complete answer is found in the UBP Practice Set #1

9) What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #1


10) Shortly after placement of the carotid cross clamp, ipsilateral EEG slowing is noted. What is the significance of this change in the EEG?

UBP Answer: Complete answer is found in the UBP Practice Set #1

11) Despite these interventions, the EEG tracing continues to show ipsilateral slowing and the surgeon wants you to raise the SBP to 180 mm Hg. Would you agree to do this? What is the highest blood pressure you would allow?

UBP Answer: Complete answer is found in the UBP Practice Set #1

12) As you raise the BP you notice new onset ST segment depression.
What would you do? Would you give NTG? Why?

UBP Answer: Complete answer is found in the UBP Practice Set #1



Post-operative Management


1) The patient does not follow commands at the end of anesthetic. What do think is going on?

UBP Answer: Complete answer is found in the UBP Practice Set #1

2) How will you rule out intracranial pathology?

UBP Answer: Complete answer is found in the UBP Practice Set #1

3) Following the administration of flumazenil, the patient becomes more alert and her neurologic exam is unremarkable. Thirty minutes later, the PACU nurse calls to report that her respiratory rate is 24 breaths per minute and her SPO2 is 92% on 10 L/min of oxygen via face mask. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #1

4) When you examine the patient there is notable inspiratory stridor and she is now complaining of pressure in her neck underneath the dressing. Are you going to intubate her?

UBP Answer: Complete answer is found in the UBP Practice Set #1

5) Would you open the wound prior to transporting her to the operating room?

UBP Answer: Complete answer is found in the UBP Practice Set #1
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