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UBP Question 4

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Question 4



(Short form)




A 28 Kg, 11 year old male presents for posterior repair of kyphoscoliosis. His mother states that he has Duchenne’s muscular dystrophy (DMD), has been wheelchair bound since he was 9 years old, and has experienced increasing shortness of breath over the past 6 months. Vital Signs: P = 108 b/min.; BP = 100/64 mmHg; R = 12


Pre-operative Management


1) What is the Cobb angle?

UBP Answer: Complete answer is found in the UBP Practice Set #2

2) Are you concerned about his shortness of breath?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3) What would be the primary focus of your physical exam?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4) The surgeon says he may wish to perform a “wake-up” test. He has mentioned this to the patient who is now very nervous. What would you say to this 11 year- old boy?

UBP Answer: Complete answer is found in the UBP Practice Set #2

5) Would you order any premedication?

UBP Answer: Complete answer is found in the UBP Practice Set #2


(Long Form)



A 28 Kg, 11 year old male presents for posterior repair of kyphoscoliosis.


HPI: His mother states that her son has Duchenne’s muscular dystrophy (DMD), has been wheelchair bound since he was 9 years old, and has experienced increasing shortness of breath over the past 6 months.

PSH: Tympanostomy at 2 years of age, no surgical or anesthetic complications

Medications: Prednisolone, Enalapril

Allergies: None

PE: Vital Signs: P = 108 b/min.; BP = 100/64 mmHg; R = 12

Airway: Macroglossia; Mallampati II; good neck and TMJ range of motion.

CV: Sinus tachycardia; widely split and fixed 2nd heart sound; mid-systolic click

Lungs: Clear to auscultation with diminished breath sounds bilaterally

CXR: Thoracolumbar kyphoscoliosis; Cobb angle of 70°,
ECG: RVH; right atrial enlargement; sinus tachycardia; inverted T-waves

Lab: Hgb = 15.6
ABG: pH = 7.42, pCO2 = 43, pO2 = 78
PFTs: FEV1 and FVC are both < 30% of predicted

Stress Echo: Posterobasilar hypokinesis; slow relaxation phase; right ventricular hypertrophy; pulmonary hypertension


Intra-operative Management


1) What precautions would you take in positioning the patient for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #2

2) What monitors would you utilize for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3) The surgeon wants you to place a pulmonary artery catheter. Would you agree to this?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4) Is it necessary to monitor MEPs and perform a wake-up test if you are monitoring SSEPs?

UBP Answer: Complete answer is found in the UBP Practice Set #2

5) Is monitoring of EMG’s necessary?

UBP Answer: Complete answer is found in the UBP Practice Set #2

6) Are there any risks associated with the Wake-up test?

UBP Answer: Complete answer is found in the UBP Practice Set #2

7) How would you induce this patient?

UBP Answer: Complete answer is found in the UBP Practice Set #2

8) If you were concerned about a difficult airway, could you just perform an inhalational induction?

UBP Answer: Complete answer is found in the UBP Practice Set #2

9) The surgeon requests muscle relaxation. Would you agree to this?

UBP Answer: Complete answer is found in the UBP Practice Set #2


10) You are expecting significant blood loss due to the number of vertebral levels that will be decorticated. What options do you have to minimize transfusion requirements?

UBP Answer: Complete answer is found in the UBP Practice Set #2

11) Given the risk of perioperative vision loss associated with spine surgery, would you agree to deliberate hypotension during this case?

UBP Answer: Complete answer is found in the UBP Practice Set #2

12) The surgeon asks you to employ deliberate hypotension to reduce bleeding and improve visualization in the surgical field. What technique will you use to produce hypotension?

UBP Answer: Complete answer is found in the UBP Practice Set #2

13) Two hours into the case, decreased amplitude and increased latency are noted while monitoring SSEPs. What will you do?

UBP Answer: Complete answer is found in the UBP Practice Set #2

14) Due to persistent evoked potential signal changes, you perform a wake-up test and the patient is able to appropriately move his feet and toes while squeezing your hand. Soon after reestablishing general anesthesia, his blood pressure drops to 68/30 mmHg and you notice a decrease in his end-tidal CO2. What do you think is going on?

UBP Answer: Complete answer is found in the UBP Practice Set #2

15) You hear sporadic roaring sounds from the precordial Doppler. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #2

16) Would you apply PEEP as part of your treatment?

UBP Answer: Complete answer is found in the UBP Practice Set #2


Post-operative Management


1) Would you extubate this patient at the end of the case?

UBP Answer: Complete answer is found in the UBP Practice Set #2
2) You decide to delay extubation. While transporting the patient to the ICU his oxygen saturation drops to 89%. What is your differential?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3) What are you going to do?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4) How will you manage his post-operative pain?

UBP Answer: Complete answer is found in the UBP Practice Set #2


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