ITE March 2009

Panacea Financial Contract Review
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onyX

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Firstly... this shouldn't be breaking any rules of the test if things are generically talked about...

What the F*** was that test?😱 Seemed like each year this gets to be more into the Board exam for Medicine instead of Anesthesiology? And yes... I know we are supposed to "know everything", but I want to feel like the test I'm taking is related to the field I'm in. For example... all the patients with post-op day 3... 30... problems, when do we ever see them (especially when these issues would not show up in the OR or the ICU setting)??? Or treat them??? Seems like those were Surgery boards ?'s.

To be fair... I thought the CT questions were pertinent as related to pharmacology. Solid 2 questions about intubations... But where were the questions about "how much oxygen do I have left?" for transport. And the EABL?

anyone feel my pain...
 
The innominate is (potentially) compressed during mediastinoscopy.

-copro
 
Some random thoughts...

Sux and epidurals can be used in MS patients, so wtf?

Post-op blindness can be caused by ischemic neuropathy, retinal artery occlusion and venous obstruction, so wtf?
 
My personal favorites were several EMR related questions, for which a couple of the "correct" answers on the exam were inconsistent with the EMRs that I've actually used. Those were just bad questions, and I hope/suspect that the newness of the topic means they were unscored research questions.

Surprisingly less pediatrics, cardiac, physics, equipment (other than the EMR), this year. Seemed like there was a lot of endocrine, plenty of OB. Quite a few ABG questions.

Not many pictures ... one utterly bizarre V/Q graph that I had to spend a few minutes deciphering before I could answer the question.
 
Etomidate said:
Some random thoughts...

Sux and epidurals can be used in MS patients, so wtf?

Post-op blindness can be caused by ischemic neuropathy, retinal artery occlusion and venous obstruction, so wtf?
Click to expand...


The literature out there including the ASA advisory on postoperative visual loss put out by the Univ. of Washington team showed that central retinal artery occlusion is more common during surgeries where thromboembolic phenomenon occur such as vascular/cardiac surgery. Ischemic neuropathy has been linked to instrumentation of the spine with large blood loss (2L or more) and surgeries lasting more than 6 hours.

The newest papers on this complication and the last I recall reading from the UW alluded to a possible compartment syndrome secondary to increased use of intraoperative fluids. They used the porcine model to attempt to recreate this complication. However, they were not able to do so as the porcine optic's copartment is known to be more distensible in comparison to humans. Combine that with the known increase in intraocular pressure d/t prone positioning and the answer that made most sense to me was ION (ischemic optic neuropathy).
 
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Im glad I was not the only one lost on the V/Q graft all I could see was that the perfusion graft wasnt linked with the ventilation graft.
 
At least there weren't 10 questions on ankle blocks, like last year. I was surprised they didn't have any TEE questions.

Yeah, what was that VQ chart? Usually, when I see something like that I can at least recalling seeing something like it in the past, I might not alway remember all the detail about it (PV loops, Flow volume loops, labor curve, etc). That thing was way out there.

I was happy to see minimal reference to the seldom used volatile agents, I think one halothane question, everything else was nitrous, iso, des and sevo.

Overall, I thought it was a better test than prior versions. Agreed not great, definitely better.
 
MTGas2B said:
Yeah, what was that VQ chart?
Click to expand...

I spent a good 30 minutes today flipping through textbooks and doing Google image searches for v/q graphs and never found anything even slightly resembling it.

There were (of course) questions where I thought "oh yeah, I should know this, shouldn't have blown off review for this thing" ... but that was the only one that totally, completely, WTF-level blindsided me. That graph is etched into my brain and even now with the benefit of books, the internet, and time I'm still not sure what the answer was supposed to be.

MTGas2B said:
I was happy to see minimal reference to the seldom used volatile agents, I think one halothane question, everything else was nitrous, iso, des and sevo.
Click to expand...

That was encouraging. I'm now going to officially flush everything I know about methoxyflurane and enflurane out of my brain.

:need a flush emoticon:
 
ProRealDoc said:
The literature out there including the ASA advisory on postoperative visual loss put out by the Univ. of Washington team showed that central retinal artery occlusion is more common during surgeries where thromboembolic phenomenon occur such as vascular/cardiac surgery. Ischemic neuropathy has been linked to instrumentation of the spine with large blood loss (2L or more) and surgeries lasting more than 6 hours.

The newest papers on this complication and the last I recall reading from the UW alluded to a possible compartment syndrome secondary to increased use of intraoperative fluids. They used the porcine model to attempt to recreate this complication. However, they were not able to do so as the porcine optic's copartment is known to be more distensible in comparison to humans. Combine that with the known increase in intraocular pressure d/t prone positioning and the answer that made most sense to me was ION (optic ischemic neuropathy).
Click to expand...


I guess the problem I had on that one was the stem had the pt there for 4 hrs... and I don't recall how much blood they lost, but the stem is always just a little "off" of the studies. Less straightforward, if that makes sense, so then I sit there wasting time second-guessing the issue.

I picked ION too, but would have been slightly more confident if the stem fit the research studies. (Although, patients do crazy things, and never are "textbook".)
 
pgg said:
That was encouraging. I'm now going to officially flush everything I know about methoxyflurane and enflurane out of my brain.

:need a flush emoticon:
Click to expand...

Just remember enflurane is the only volatile agent FDA approved for vaginal delivery. 😀
 
got that one wrong but at least I learned from that link. (the uptodate PACER question)
 
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onyX said:
Seemed like each year this gets to be more into the Board exam for Medicine instead of Anesthesiology? And yes... I know we are supposed to "know everything", but I want to feel like the test I'm taking is related to the field I'm in.
Click to expand...

The way I look at it, we are physicians first and anesthesiologists second. While I struggled with some of these medicine type questions on this years test, I did not feel like they were particularly unfair.

I hope that the test writers continue to push us to stay fresh in the non-OR based aspects of our knowledge since that is largely what differentiates us from anesthetists.

- pod
 
My favorite thing was that there was a series of questions with a common set of potential answers labeled A-F. Unfortunately, I only had A-E available to me to select on my answer sheet. 😕
 
The V/Q chart and explaination can be found on pages 19-21 of the answer key for the 2008 (issue 5b) Anesthesia Continuing Education (ACE) project. They are offered by the ASA as CME credits and my program just happened to give these to all the CA3's this year for the first time. They were very helpful.

-B



pgg said:
I spent a good 30 minutes today flipping through textbooks and doing Google image searches for v/q graphs and never found anything even slightly resembling it.

There were (of course) questions where I thought "oh yeah, I should know this, shouldn't have blown off review for this thing" ... but that was the only one that totally, completely, WTF-level blindsided me. That graph is etched into my brain and even now with the benefit of books, the internet, and time I'm still not sure what the answer was supposed to be.



That was encouraging. I'm now going to officially flush everything I know about methoxyflurane and enflurane out of my brain.

:need a flush emoticon:
Click to expand...
 
bthings said:
The V/Q chart and explaination can be found on pages 19-21 of the answer key for the 2008 (issue 5b) Anesthesia Continuing Education (ACE) project. They are offered by the ASA as CME credits and my program just happened to give these to all the CA3's this year for the first time. They were very helpful.

-B
Click to expand...

Interesting, I'll have to look for those.

Just found the V/Q graph on page 1443 of Miller 6th ed ... still think it's an odd way to present data, but if it's in Miller, it's fair game.
 
periopdoc said:
The way I look at it, we are physicians first and anesthesiologists second. While I struggled with some of these medicine type questions on this years test, I did not feel like they were particularly unfair.

I hope that the test writers continue to push us to stay fresh in the non-OR based aspects of our knowledge since that is largely what differentiates us from anesthetists.

- pod
Click to expand...

Agreed.


FWIW, I've enjoyed Stoelting's Anesthesia & Coexisting. It does a good job explaining (at our level) many of the diseases we rarely encounter, and appropriate anesthetic mgmt. Looking over it today, it seems like many of the questions were pulled directly from it. Autonomic hyperreflexia, even the Pierre-Robin glossoptosis. :wtf:
 
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succ should not be used in MS patients. may exacerbate.
same with spinal anesthesia.
epidural anesthesia is ok.

Etomidate said:
Some random thoughts...

Sux and epidurals can be used in MS patients, so wtf?

Post-op blindness can be caused by ischemic neuropathy, retinal artery occlusion and venous obstruction, so wtf?
Click to expand...
 
Bertelman said:
Agreed.


FWIW, I've enjoyed Stoelting's Anesthesia & Coexisting. It does a good job explaining (at our level) many of the diseases we rarely encounter, and appropriate anesthetic mgmt. Looking over it today, it seems like many of the questions were pulled directly from it. Autonomic hyperreflexia, even the Pierre-Robin glossoptosis. :wtf:
Click to expand...


that was also in big blue (peds section).
 
narcusprince said:
Im glad I was not the only one lost on the V/Q graft all I could see was that the perfusion graft wasnt linked with the ventilation graft.
Click to expand...

yup , I've never seen a graph like that before either. I think I went with whichever d x fit the mismatch.
 
ProRealDoc said:
The literature out there including the ASA advisory on postoperative visual loss put out by the Univ. of Washington team showed that central retinal artery occlusion is more common during surgeries where thromboembolic phenomenon occur such as vascular/cardiac surgery. Ischemic neuropathy has been linked to instrumentation of the spine with large blood loss (2L or more) and surgeries lasting more than 6 hours.

The newest papers on this complication and the last I recall reading from the UW alluded to a possible compartment syndrome secondary to increased use of intraoperative fluids. They used the porcine model to attempt to recreate this complication. However, they were not able to do so as the porcine optic's copartment is known to be more distensible in comparison to humans. Combine that with the known increase in intraocular pressure d/t prone positioning and the answer that made most sense to me was ION (ischemic optic neuropathy).
Click to expand...

What about the prone guy with bradycardia and hypotension ?
 
dr2323 said:
yup , I've never seen a graph like that before either. I think I went with whichever d x fit the mismatch.
Click to expand...

Hey I think I read the graph a bit differently. I thought since the graph showed an average mean of adequete perfusion with inadequete ventilation. I could be wrong but I thought it showed DEAD space ventilation.
 
Ha... anybody pissed at the community service question or the doped guys?
 
Agreeing with the above poster, I think the graph was trying to show a mis match which included an increase in dead space. There was only one answer choice with an increase in dead space...65 yo with emphysema.

I showed 4 of staff that graph today and none of them had ever seen it before.

The epiglottitis questions... It had to be the induction with sevo, but what about the important parts of that induction..sitting up, ENT in the room, done in the OR, not the ER.

The peds was easy.

Why were there 10-12 questions about CO and CN toxicity and which drug treats both (i said O2)

Cubs
 
although hyperbaric o2 is useful in the treatment of carboxyhemoglobinemia, it is useless in for CN poisoning (the whole issue is that you can't use o2). thiosulfate may be used for both.

cubs3canes said:
Agreeing with the above poster, I think the graph was trying to show a mis match which included an increase in dead space. There was only one answer choice with an increase in dead space...65 yo with emphysema.

I showed 4 of staff that graph today and none of them had ever seen it before.

The epiglottitis questions... It had to be the induction with sevo, but what about the important parts of that induction..sitting up, ENT in the room, done in the OR, not the ER.

The peds was easy.

Why were there 10-12 questions about CO and CN toxicity and which drug treats both (i said O2)

Cubs
Click to expand...
 
CARBON MONOXIDE POISONING COMPLICATED BY CYANIDE POISONING

See treatment indications at Carbon Monoxide Poisoning and Smoke Inhalation.

RATIONALE: Carbon monoxide and cyanide poisoning frequently occur simultaneously in victims of smoke inhalation. These two agents in combination exhibit synergistic toxicity. HBO2 may have a direct effect in reducing the toxicity of cyanide and augmenting the benefit of antidote treatment. The traditional antidote for cyanide poisoning is the infusion of sodium nitrate, which creates the formation of methemoglobin. This carries the potential to impair the oxygen-carrying capacity of hemoglobin. HBO2 increase in plasma dissolved oxygen content may offer a direct benefit.

Source: Hyperbaric Oxygen Therapy: A Committee Report. Undersea and Hyperbaric Medical Society. 1996 Revision.
 
Jeff05 said:
although hyperbaric o2 is useful in the treatment of carboxyhemoglobinemia, it is useless in for CN poisoning (the whole issue is that you can't use o2). thiosulfate may be used for both.
Click to expand...

Hyperbaric oxygen isn't useless; it does have benefits in CN poisoning, even though CN's mechanism is blocking the electron transport chain rendering mitochondria unable to use oxygen (so one wouldn't think extra high PO2 would help). But there are a number of references on the 1st page of Google's results for "hyperbaric oxygen cyanide" ...

You're right though, thiosulfate is the better single agent treatment. A Google books search produced this explanation:
Manual of clinical problems in pulmonary medicine said:
Treatment of cyanide poisoning in fire victims with significant carboxyhemoglobin levels can be complicated because nitrites induce the formation of methemoglobin, further compromising oxygen delivery. In these situations, carboxyhemoglobin and methemoglobin levels should be monitored closely during treatment, or sodium thiosulfate as a sole agent for treatment should be considered.
Click to expand...

cubs3canes said:
I showed 4 of staff that graph today and none of them had ever seen it before.
Click to expand...

The exact graph is in Big Miller; obscure maybe, but fair game.


Finally ... I think this thread is getting awfully close to crossing the line in regards to discussing specific ABA questions from Saturday's exam. Let's discuss topics, not questions, lest we get squished.
 
proman said:
CARBON MONOXIDE POISONING COMPLICATED BY CYANIDE POISONING

See treatment indications at Carbon Monoxide Poisoning and Smoke Inhalation.

RATIONALE: Carbon monoxide and cyanide poisoning frequently occur simultaneously in victims of smoke inhalation. These two agents in combination exhibit synergistic toxicity. HBO2 may have a direct effect in reducing the toxicity of cyanide and augmenting the benefit of antidote treatment. The traditional antidote for cyanide poisoning is the infusion of sodium nitrate, which creates the formation of methemoglobin. This carries the potential to impair the oxygen-carrying capacity of hemoglobin. HBO2 increase in plasma dissolved oxygen content may offer a direct benefit.

Source: Hyperbaric Oxygen Therapy: A Committee Report. Undersea and Hyperbaric Medical Society. 1996 Revision.
Click to expand...


Wasn't it amyl nitrite? I

t induces the formation of methemoglobin, which sequesters cyanide as non-toxic cyanomethemoglobin
 
i agree with the wtf? to the v/q question...i guessed emphysema too -- same thought process about dead space ventilation.... never saw a v/q graph like that anywhere before.... oh well, on to step 3...
 
Hard to say what the CN CO treatment is. Gotta love questions with multiple right answers!

from emedicine:

Hyperbaric oxygen use may be considered for patients with cyanide poisoning refractory to other antidotes; it is especially effective when concomitant carbon monoxide toxicity exists

Sodium thiosulfate (Tinver)
Acts as donor of sulfur, which is used as substrate by rhodanese and other sulfurtransferases for detoxification of cyanide to thiocyanate; DOC for treating cyanide toxicity with concomitant carbon monoxide poisoning.
 
Proper dilution of lidocaine to 0.1% or less (500 to 1000 mg lidocaine per liter solvent), and adding 1 mg fresh epinephrine to each liter, are of the essence.

International Journal of Cosmetic Surgery and Aesthetic Dermatology
Tumescent Anesthesia: Lidocaine Dosing Dichotomy
To cite this paper:
Rudolph H. De Jong. International Journal of Cosmetic Surgery and Aesthetic Dermatology. March 2002, 4(1): 3-7. doi:10.1089/153082002320007412.

We also need to know the maximum dose for tumescent anesthesia (different than for IV or SQ etc)
 
UMMS FMD said:
My favorite thing was that there was a series of questions with a common set of potential answers labeled A-F. Unfortunately, I only had A-E available to me to select on my answer sheet. 😕
Click to expand...

Yes, definitely a work in progress.

I also agree that the V/Q graph was a big WTF.
 
is this exam always on the first saturday of march?
 
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most likely to relapse if there is a coexisting psychiatric disorder is the correct answer.

The other question pertaining to Sub Abuse the correct answer was abstinence from alcohol and drugs.
 
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