1) In what order would you administer the following induction medications?
A: Rocuronium → Fentanyl → Propofol → Midazolam
B: Fentanyl → Midazolam → Rocuronium → Propofol
C: Propofol → Fentanyl → Midazolam → Rocuronium
D: Midazolam → Fentanyl → Propofol → Rocuronium
1) D
The order of induction medications is:
Medication for pain (fentanyl) → Medication to sedate the patient/make them "fall asleep" (propofol) → Medication for paralysis (rocuronium)
Midazolam is often administered prior to propofol, while the patient is still awake, to relieve anxiety and supplement sedation.
2) Select all of the following medications that would, when administered, help the patient lose consciousness (loss of Awareness):
A: Midazolam
B: Propofol
C: Remifentanil
D: Dexmedetomidine
E: Succinylcholine
F: Ketamine
G: Sevoflurane
H: Phenylephrine
2) A, B, C, D, F, G
Propofol, ketamine, and dexmedetomidine have strong sedative-hypnotic effects and are used as the primary sedative agent during the induction phase.
Midazolam and remifentanil, amongst other effects, have sedative properties, and are used to supplement the primary sedative agent. This allows one to reduce the dose of the primary sedative agent and reduce side effects associated with it.
Sevoflurane is a volatile agent used as the primary sedative agent during the maintenance phase.
3) Which drug(s) are used to facilitate laryngoscopy and endotracheal intubation?
A: Ephedrine
B: Succinylcholine
C: Midazolam
D: Fentanyl
3) B, D
Succinylcholine (NMB) is used to paralyze the skeletal muscle, including the muscles used for breathing. This prevents the patient from coughing and gagging.
Opioids, including fentanyl, have the same effect, as they reduce airway reflexes (coughing, bronchospasm) and autonomic response to painful stimuli during intubation.
4) Which of the following medications provide neuromuscular block (i.e., paralysis)? Select all that apply.
A: Midazolam
B: Rocuronium
C: Dexamethasone
D: Succinylcholine
4) B, D
Succinylcholine is a depolarizing neuromuscular block. Rocuronium is a non-depolarizing neuromuscular block.
5) The patient has an allergy to sevoflurane, a maintenance agent. The patient is still able to be anesthetized and have surgery.
A: True
B: False
5) A
Some patients have an allergy to volatile anesthetics, including sevoflurane, and will develop malignant hyperthermia. In that case, total intravenous anesthesia can be used. This is when an IV sedative agent is used during the maintenance phase.
6) You performed CPR on a patient and would like to ensure that they do not remember the experience. What would you administer to provide anterograde amnesia?
A: Midazolam
B: Ephedrine
C: Propofol
D: Fentanyl
6) A
While propofol and midazolam both have amnesic properties, midazolam has more profound amnesic effects and is ideal for this situation.
7) What is the antidote to an opioid overdose?
A: Atropine
B: Sugammadex
C: Flumazenil
D: Naloxone
7) D
Naloxone is the most commonly used antidote for an opioid overdose.
8) What is the clinical presentation of an opioid overdose? Select all that apply.
A: Dilated pupils
B: Pinpoint pupils
C: Increased RR
D: Decreased RR
E: Cool, clammy skin
F: Warm, flushed skin
G: Alert, hyperactive
H: Drowsiness, confusion
8) B, D, E, H
These are the hallmark clinical signs and symptoms of an opioid overdose.
9) What is the antidote to a benzodiazepine overdose?
A: Atropine
B: Sugammadex
C: Flumazenil
D: Naloxone
9) C
Flumazenil is a benzodiazepine antagonist.
10) What is the clinical presentation of a benzodiazepine overdose? Select all that apply.
A: Dilated pupils
B: Slurred speech
C: Increased RR
D: Decreased RR
E: Alert, hyperactive
F: Drowsiness, confusion
10) B, F
Overdose classically presents as CNS depression, slurred speech, and normal vitals.
Unlike with opioid overdose, respiratory depression is uncommon with an isolated benzodiazepine overdose. However, benzodiazepine overdose is often concurrent with co-ingestion of another depressant, such as alcohol or opioids, which can cause potentially fatal respiratory depression.
11) A patient with normal vitals was prepped in the operating room. A primary IV induction agent is given to sedate the patient and the anesthesia monitor shows the following within the first minute of administering the drug. What is the most likely agent that was given?
A: Propofol
B: Dexmedetomidine
C: Ketamine
11) A
The most likely agent is propofol, given the decrease in blood pressure, relatively stable heart rate (within normal range), and decreased respiratory rate. Ketamine provides stable or increased blood pressure. Dexmedetomidine provides stable respiratory rate.
Another clue is the fast onset (propofol takes ~30 sec to take effect, which is the fastest onset compared to the other options).