Читать книгу Surgical Critical Care and Emergency Surgery - Группа авторов - Страница 19

Toni Manougian, MD, MBA1 and Bardiya Zangbar, MD2

1 Department of Critical Care Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, NY, USA

2 Division of Trauma and Acute Care Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA

1 Which of the following effects of epidural analgesia is correct:For patients without serious lung pathology, mid thoracic epidural analgesia has no effect on lung function.Decreased gastric secretions, peristalsis, and enhanced gastric motility results from sympathetic splanchnic blockade at the T5‐L1 level.Renal blood flow is increased and an indwelling urinary catheter is always necessary when using continuous epidural analgesia.Neuraxial analgesia (NA) has no effect on the surgical stress response. NA does not affect oxygen consumption, vasopressin, catecholamine, cortisol, or glucose levels.Thoracic epidural catheters above T4 level are safe and unlikely to cause cardiovascular effects.All of the choices are false regarding thoracic epidural catheters except choice A. Pulmonary function is unaffected by thoracic epidural analgesia in patients with normal function. However, severe pulmonary disease is a relative contraindication for brachial plexus blocks. Brachial plexus blocks such as an interscalene block affect ipsilateral hemi‐diaphragmatic excursion and reduce functional residual capacity and pulmonary function as much as 40%. Interestingly, the recurrent laryngeal nerve may also be blocked and can cause complete airway obstruction in a patient with existing vocal cord palsy. A blockade at the T5‐L1 level will increase gastric secretions, peristalsis, and enhanced gastric motility due to increased parasympathetic activity and sympathetic splanchnic blockade making choice B incorrect answer. Renal blood flow is auto‐regulated and unaffected by epidural analgesia. When thoracic epidural catheters are used, indwelling urinary catheters are not always required. Lumbar epidural analgesia however, can cause urinary retention, especially when blocking S2 to S4 spinal segments. Therefore, lumbar epidural catheters are more likely to affect bladder function than thoracic epidurals (choice C). One of the major benefits when choosing neuraxial analgesia (NA) is to blunt the sympathetic stress response. NA reduces oxygen consumption and decreases levels of vasopressin, catecholamines, cortisol, and glucose (choice D). Choice E is incorrect, because blocks at the T1‐4 level result in sympathetic blockade and profound cardiovascular effects. Blocks at T1‐T4 result in hypotension from both bradycardia and decreased cardiac contractility.Answer: AMian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M. Brachial plexus anesthesia: A review of the relevant anatomy, complications, and anatomical variations. Clin Anat. 2014; 27(2):210–21.Basse L, Werner M, Kehlet H. Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med. 2000; 25(5):498–501.

2 A 45‐year‐old man is admitted to the ICU with pneumonia, fever, agitation, and confusion. He acutely becomes increasingly agitated and is treated with haloperidol. His vital signs are respiratory rate of 18/min, oxygen saturation 94%, heart rate 92/min, blood pressure 154/78 mmHg, and temperature 38.9 °C. He is sweating, drooling with painful contractions of the neck, and is salivating. Which of the following medications is the treatment of choice? Benztropine (Cogentin)Lorazepam (Ativan)Metoclopramide (Reglan)Dantrolene (Ryanodex)Quetiapine (Seroquel)The patient is exhibiting signs of a dystonic reaction and his symptoms are best treated with benztropine. Dystonic reactions are an unwanted effect after administration of neuroleptic medications. Dystonic reactions can occur immediately, or be delayed hours to days. Classic features of dystonic reaction to medications such as haloperidol are cholinergic symptoms such as increased salivation and spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, extremities, or larynx. Dystonic reactions, while not usually life threatening, are distressing for patients and families. Benztropine, an anticholinergic agent, is used for symptomatic improvement (choice A). While some symptoms can be improved with benzodiazepines, this class of medication may worsen his confusion, blunt his respiratory drive, and contribute to ICU delirium, so choice B is not the best answer. Metoclopramide (Reglan) exerts an antiemetic effect by antagonist activity at central D2 receptors in the chemoreceptor trigger zone and may potentiate the dyskinesia symptoms, so choice C is incorrect. Dantrolene (Ryanodex) is used in reversal of malignant hyperthermia and has no primary role in treatment of dystonic reactions (choice D). While haloperidol (Haldol) is associated with neuroleptic malignant syndrome, the side effects manifested is mental status change in the form of agitated delirium with confusion or catatonic signs and mutism. Other symptoms include muscular rigidity which can be demonstrated by moving the extremities and is characterized by “lead pipe rigidity” or stable resistance through all ranges of movement. Hypothermia is common and extremely high temperatures greater than 40 °C is common. Autonomic dysfunction in the form of tachycardia with hypertension and tachypnea along with dysrhythmias may occur. In the scenarios of induced neuroleptic malignant syndrome, dantrolene can be an antidote. Quetiapine (Seroquel) is a second‐generation antipsychotic and known to be rare in causing extrapyramidal side effects and has no role in treatment of dystonic side effects (choice E).Answer: ADigby G, Jalini S, Taylor S. Medication‐induced acute dystonic reaction: the challenge of diagnosing movement disorders in the intensive care unit. BMJ Case Resp. 2015; 2015:bcr2014207215Goff DC, Arana GW, Greenblatt DJ, Dupont R, Ornsteen M, Harmatz JS, Shader RI. The effect of benztropine on haloperidol‐induced dystonia, clinical efficacy and pharmacokinetics: a prospective, double‐blind trial. J Clin Psychopharmacol 1991; 11(2):106–12.

3 A 75‐year‐old woman underwent a cholecystectomy for a gangrenous gallbladder. Postoperatively, the patient appears calm and you would like to extubate the patient in the next 24 hours. Which of the following represents the best stepwise approach to pain and sedation?Short‐acting narcotic infusion with fentanyl and propofol.Standing IV acetaminophen (Ofirmev), low‐dose ketamine (Ketalar) infusion, and PRN hydromorphone (Dilaudid) IV push.Short‐acting narcotic infusion with fentanyl, plus dexmedetomidine (Precedex) drip plus gabapentin (Neurontin) PO.Short‐acting remifentanil and propofol infusions.Propofol infusion and dexmedetomidine (Precedex).Narcotic first regimens are common but undesirable because their adverse effects include ileus, delayed extubation, tolerance, and opioid‐induced hyperalgesia. Narcotics also place patients at risk for withdrawal. For most patients, especially those you plan to extubate soon or those at risk for complications, narcotic infusions are not the first choice. A stepwise approach including multimodal analgesia with acetaminophen, intermittently dosed narcotics and ketamine (0.5 mg/kg IVP × 1 followed by 1–2 mcg/kg/min infusion) is recommended. The goal is to minimize opioid therapy when managing postsurgical adult patients in the ICU (conditional recommendation, very low quality of evidence) and ketamine can be used as an IV adjunct. Gabapentin is also available as part of stepwise approach. Acetaminophen and pain‐dose ketamine infusions are excellent analgesics and can be added to an intermittently dosed narcotic plan as needed, making choice B the best answer. Choices A, C, and D are also incorrect because they rely on opioid infusions and do not represent the best stepwise approach. It is especially important to avoid continuous narcotic infusions in patients at high risk for opioid toxicity, such as those with sleep apnea or at patients at risk for ileus. Although dexmedetomidine (Precedex) has some pain effects as an alpha 2 agonist, its primary effect is sedation and would not be the best choice for pain in combination with propofol. The patient is calm and does not need two sedative agents, so choice (E) is also incorrect.Answer: BDevlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825–73.

4 A 67‐year‐old woman is in the ICU on postoperative day 2 after laparotomy. Current medications include clonidine, quetiapine, hydromorphone, melatonin, and metoprolol. Her sleep pattern is altered and she shows signs of agitated delirium. Which of her medications increases her risk for aspiration?ClonidineDexmedetomidine (Precedex)Quetiapine (Seroquel)Hydromorphone (Dilaudid)Melatonin (N‐acetyl‐5‐hydroxytryptamine)Antipsychotic medications such as haloperidol and quetiapine are used to manage delirium. These medications can increase the QTC interval but also antagonize dopamine signaling, which affects the swallow mechanism and increases the risk of aspiration. Therefore, choice C is correct.Both clonidine (choice A) and dexmedetomidine (choice B) are useful adjuncts in pain management because of their effects at central α2 receptors. Clonidine blocks sympathetic outflow, reduces arterial blood pressure, and ameliorates symptoms of alcohol and opiate withdrawal but does not increase aspiration risk. When used in epidural pain catheters, clonidine produces analgesia at the presynaptic and post junctional alpha 2 receptors. Dexmedetomidine (Precedex) produces centrally mediated sympatholytic sedation, anxiolysis, and analgesia. A transient increase in blood pressure during the loading dose of dexmedetomidine may occur, followed by hypotension which may be concerning for patients needing strict blood pressure control. A valuable characteristic of dexmedetomidine is the ability to produce sedation without respiratory depression. In some critically ill patients, night time sleep patterns are enhanced when patients are lightly sedated with dexmedetomidine. When compared to GABA agonists, dexmedetomidine resembles natural non‐REM‐type sleep.Postsynaptic activation of α2 receptors inhibits sympathetic activity, decreasing blood pressure and heart rate, having no effect on dopamine receptors or aspiration. According to the FDA, dexmedetomidine is indicated for initial sedation for the first 24 hours. Although not contraindicated, prolonged use of dexmedetomidine can lead to withdrawal effects like rebound hypertension, especially in higher doses. Hydromorphone (choice D) is an opioid receptor agonist used for severe pain. Hydromorphone is about 8–9 times more potent than morphine. Side effects of hydromorphone are pruritus, sedation, constipation, nausea, and vomiting. Adverse effects are more pronounced with excessive dosages and include respiratory and cardiovascular depression, dependency, and ileus. An overdose of hydromorphone resulting in loss of consciousness could result in aspiration, but it does not contribute to aspiration in usual therapeutic doses.Melatonin (N‐acetyl‐5‐hydroxytryptamine) is a mild hypnotic and generally well tolerated and regarded as safe with few adverse effects. It is synthesized in the pineal gland and its release helps regulate sleep and circadian rhythms. The anterior hypothalamus regulates melatonin which has its effects at MT2 and MT1 receptors. Melatonin (M) receptors are ubiquitous, found in the brain, retina, throughout the cardiovascular system, in the liver, gallbladder, colon, and skin. The MT1 receptor agonism is related to sleep onset. The most frequently reported adverse effects are daytime sleepiness, headache, dizziness, and hypothermia. Aspiration is not among reported adverse effects of melatonin, so choice E is incorrect.Answer: CAlexopoulou C, Kondili E, Diamantaki E, Psarologakis C, Kokkini S, Bolaki M, Georgopoulos D . Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study. Anesthesiology. 2014; 121(4):801–7.Besag FMC, Vasey MJ, Lao KSJ, Wong ICK . Adverse events associated with melatonin for the treatment of primary or secondary sleep disorders: a systematic review. CNS Drugs 2019; 33(12):1167–86.Herzig SJ, LaSalvia MT, Naidus E, Rothberg MB, Zhou W, Gurwitz JH, Marcantonio ER. Antipsychotics and the risk of aspiration pneumonia in individuals hospitalized for nonpsychiatric conditions: a cohort study. J Am Geriatr Soc 2017; 65(12):2580–6.DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care. 2015; 30(1): 40–8.Longnecker D ; Brown DL, Newman MF, Zapol W. Anesthesiology , Second Edition. New York: McGraw‐Hill Professional; 2012. 1748 p. p.

5 Which commonly prescribed medications in the intensive care unit is most likely to cause an unstable arrhythmia and sudden death?Fentanyl, opioid analgesicMeperidine (Demerol), opioid analgesicHaloperidol (Haldol), typical antipsychoticDexmedetomidine (Precedex), alpha 2 agonistPropofol, short‐acting lipophilic intravenous general anestheticHaldol (choice C) has a proven association with torsade de pointe and sudden death. Prolonged QT intervals can be congenital or acquired as in a patient receiving haldol, methadone, atypical antipsychotics, or antidepressants. Long QT associated with polymorphic ventricular tachycardia (PMVT) is called torsade de pointes. Factors that increase the QT and risk for torsades are rapid administration of QT prolonging drugs, coexisting myocardial ischemia, older age, recent dysrhythmia, hypomagnesemia, or hypokalemia. The first‐line treatment of acquired QT prolongation with torsade de pointes is 2–4 gm intravenous magnesium followed by infusion 1 gm/h, replacement of potassium if needed, cardioversion or isoproterenol for bradycardia or pauses. PMVT without long QT can also be seen in acute coronary syndromes.Fentanyl infusions typically in the range of 50–200 mcg/h are used for sedation and pain control. Adverse effects of fentanyl include tolerance, constipation, hyperalgesia, and dependence. Fentanyl can cause hypotension; however, it is not associated with life‐threatening arrhythmias (choice A). Similarly, meperidine (Demerol) is an opioid analgesic. Adverse effects of meperidine include respiratory and circulatory depression, lightheadedness, constipation, nausea, vomiting, and dependence. Meperidine does not have a known association with life‐threatening arrhythmias (choice B).Common side effects of the sedative‐anxiolytic dexmedetomidine (Precedex) are sinus bradycardia and hypotension. Dexmedetomidine also provides some analgesic effects. It is a centrally acting sympatholytic alpha 2 agonist but it does not prolong the QT interval (choice D).Propofol (choice E) is a hypnotic agent for induction of anesthesia or for sedation. It produces sedation through GABA potentiation. Some of the more serious adverse effects or propofol are hypotension from reduced systemic vascular resistance or direct myocardial depression and propofol infusion syndrome (PRIS). PRIS is a metabolic derangement manifested by metabolic acidosis, renal injury, and rhabdomyolysis. However, propofol is not usually associated with life‐threatening arrhythmias or sudden death.Answer: CRay WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med. 2009; 360(3):225–35.Huffman JC, Stern TA. QTc prolongation and the use of antipsychotics: a case discussion. Prim Care Companion J Clin Psychiatry. 2003; 5(6):278–81.Milbrandt EB, Kersten A, Kong L, Weissfeld LA, Clermont G, Fink MP, Angus DC. Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients. Crit Care Med. 2005; 33(1):226–9; discussion 263‐5.Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, Stiles RA, Dittus RS, Bernard GR, Ely EW. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007; 298(22):2644–53.Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG ; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301(5):489–99.Biesenbach P, Mårtensson J, Lucchetta L, Bangia R, Fairley J, Jansen I, Matalanis G, Bellomo R. Pharmacokinetics of magnesium bolus therapy in cardiothoracic surgery. J Cardiothorac Vasc Anesth. 2018; 32(3):1289–94.Ling X, Zhou H, Ni Y, Wu C, Zhang C, Zhu Z . Does dexmedetomidine have an antiarrhythmic effect on cardiac patients? A meta‐analysis of randomized controlled trials. PLoS One 2018; 13(3):e0193303.

6 A 120 kg 82‐year‐old man with a past medical history of colon cancer, diabetes, and renal insufficiency is admitted to the ICU after a colectomy. Postoperatively, he had bilateral transversus abdominis (TAP) blocks placed. His creatinine clearance is estimated to be 52 mL/min. Which of the following factors increase his risk for local anesthetic toxicity?Renal insufficiencyAdvanced ageMale sexObesityDiabetesLocal anesthetic toxicity (LAST) is a life‐threatening event resulting from inadvertent intravascular administration or excessively dosed local anesthetic medications. The underlying mechanisms of LAST are multifactorial, but primarily manifest with cardiovascular and neurologic deterioration. The risk factors for LAST are extremes of age (choice B), pregnancy, low body weight, and pre‐existing cardiovascular disease. The anesthetic medications should be based on ideal body weight. Renal insufficiency (choice A), gender (choice C), and diabetes (choice E) do not affect the likelihood of LAST. Obesity (choice D) could contribute if the dosage was based on actual rather than ideal body weight.Answer: BEl‐Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anes. 2018; 11:35–44.Neal JM, Barrington, MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, Rubin DS, Weinberg G The third American society of regional anesthesia and pain medicine practice advisory on local anesthetic toxicity: executive summary 2017. Regional Anesth. Pain Med. 2018; 43(2):113–23.

7 A 112 kg patient with a history of anxiety disorder has been admitted to the ICU. He is intubated and he is on multimodal sedation including a hydromorphone drip 3 mg/h for 7 days. To manage his ongoing sedation and acute pain needs, in addition to the current medications, including IV Tylenol, what is your next best action?Start a ketamine drip to provide dissociative analgesia, 5 mcg/kg/min.Start low‐dose ketamine drip at 1–2 mcg/kg/min after a bolus and start to decrease hydromorphone (Dilaudid) by 20%.Increase the hydromorphone (Dilaudid) drip to 4 mg/h to provide both sedation and analgesia.Add lorazepam (Ativan) drip and increase the hydromorphone (Dilaudid) to 4 mg/h.Start a propofol infusion, switch hydromorphone (Dilaudid) to equianalgesic fentanyl.Higher doses of ketamine infusions contribute to the unwanted side effects including agitation, hallucinations, and somnolence. These psycho‐mimetic effects are particularly worrisome in a patient who may be unable to communicate these effects. For this reason, choice A is incorrect. Sub‐anesthetic doses of ketamine when added to a multimodal pain approach are opioid sparing and may attenuate unwanted side effects of ketamine (choice B). It is not appropriate to use narcotics as a single agent to control both pain and sedition (choice C) because tolerance develops, so increasing doses will be needed. Benzodiazepines are associated with ICU delirium and may contribute to delayed weaning from mechanical ventilation, so choice D is not the best choice. There is no indication to change from dilaudid to fentanyl (choice E).Answer: BDevlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825–73.Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018; 43(5):456–66.Radvansky BM, Shah K, Parikh A, Sifonios AN, Le V, Eloy JD. Role of ketamine in acute postoperative pain management: a narrative review. Biomed Res Int. 2015; 2015:749837.

8 A 30 year old patient with a history of substance abuse is admitted after a motor vehicle accident with left 3 rd , 4 th and 5 th rib fractures and proximal tibia fracture. He takes buprenorphine 8 mg daily. What is the appropriate management of acute pain for a patient taking 8 mg buprenorphine daily?Always stop buprenorphine because it competes with opioid receptors.Continue buprenorphine in the same dose and order patient‐controlled analgesia with dilaudid without basal rate.Request a femoral nerve block, avoid narcotics, and stop buprenorphine.Start dilaudid PCA with a basal rate and a demand dose of 0.5 mg every 10 minutes.Increase the dose of buprenorphine by 50% and start dilaudid 0.5 mg q4h prn.Buprenorphine is a lipophilic, semisynthetic opioid with partial agonist activity and high affinity for the mu receptor. Patients on buprenorphine maintenance therapy are frequently encountered in the ICU. In certain doses (more than 12 mg daily), buprenorphine can block the ability to use other opioids for breakthrough pain which does not occur at lower doses of buprenorphine (less than 8–12 mg daily sublingual dose). At low doses, there may be synergistic analgesia between buprenorphine and other opioids. Current opinion favors continuation of low‐dose buprenorphine (either at full or reduced dose), so choice B is the correct answer. Patients on buprenorphine maintenance may have severe postoperative pain and experience buprenorphine‐induced hyperalgesia. It may not be appropriate to stop buprenorphine at this dose (choices A and C). While regional anesthesia is ideal for this patient, given his type of injury, a femoral nerve block will mask symptoms of compartment syndrome that may result from tibial plateau fractures (choice C), so he may not be a candidate for regional anesthetic. Patient controlled analgesia (PCA) is another good choice but basal rates are not recommended due to risk of apnea, even in patients with tolerance (choice D). Basal rates increase both the overall amount of drug delivered and adverse effects without improving analgesia. There is no indication to increase the dose of buprenorphine (choice E).Answer: BBuresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating perioperative and acute pain in patients on buprenorphine: narrative literature review and practice recommendations. J Gen Intern Med. 2020; 35(12):3635–43. doi: 10.1007/s11606‐020‐06115‐3. Epub 2020 Aug 21.Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St‐Jean M, Rashiq S, Van Camp K, Flamer D, Satok‐Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019; 123(2):e333–e342. doi: 10.1016/j.bja.2019.03.044. Epub 2019 May 29. PMID: 31153631; PMCID: PMC6676043.Leighton BL, Crock LW. Case series of successful postoperative pain management in buprenorphine maintenance therapy patients. Anesth Analg. 2017; 125(5):1779–83.Chen KY, Chen L, Mao J. Buprenorphine‐naloxone therapy in pain management. Anesthesiology. 2014; 120(5):1262–74.

9 A 62‐year‐old patient with chronic pain is admitted after Hartmann's procedure for diverticulitis. His chronic pain was controlled with 40 mg Oxycodone every 8 hours. He is intubated and you want to start a fentanyl drip post op in equianalgesic dose. What is the closest basal fentanyl dose?50 mcg/hr100 mcg/hr150 mcg/hr200 mcg/hr250 mcg/hrThe first step in this calculation is to estimate the total daily narcotic dose and then convert this dose to an equivalent dose of oral morphine. Morphine is the reference point to convert between different narcotics to obtain the starting point for conversion. Each 20 mg of PO Oxycodone is equivalent to 30 mg PO Morphine. And IV to PO conversion rate of Morphine is 1 to 3. IV equianalgesic parenteral dose of Fentanyl to Morphine is 0.1–0.2 mg fentanyl per 10 mg morphine. This patient is taking 120 mg of oxycodone which converts to 180 mg of PO Morphine. 180 mg of PO morphine would be equal to 60 mg of IV morphine, and equianalgesic parenteral fentanyl dose would be 0.6–1.2 mg of Fentanyl daily (600–1200 mcg). Therefore, the hourly drip dose would be closest to 25–50 mcg/hr. Additionally, using higher than necessary continuous infusion rates (choices B through E) can cause opioid‐induced hyperalgesia. Continuous opioid infusions at inappropriately high doses contribute to oversedation and delayed extubation. In context, a simple rule is that fentanyl is 100 x more potent than morphine. An infusion of 100 μg/h fentanyl is equivalent to 10 mg of morphine per hour.Answer: AHurley RW, Hurley NM, Elkassabany and Wu CL. Acute Postoperative Pain. In: Miller RD, ed. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier Saunders.MedicationEquianalgesic dose IV/IMEquianalgesic dose POTypical adult starting dose IVTypical adult starting dose POMorphine10 mg30 mg5–10 mg q3‐4h15–30 mg q3‐4hOxycodone20 mg5–10 mg q4‐6hFentanyl100 mcg (not patch)25 mcg/h transdermal (patch) equivalent PO morphine dose 45–75 mg50 mcg/h patch approx equal 1 mg/h morphine infusionMethadone10 mg20 mg5–10 mg q12hCodeine200 mg30–60 mg q3‐4hHydromorphone (Dilaudid)1.5 mg7.5 mg1–2 mg q3‐4h4–8 mg q3‐4h

10 An 18‐year‐old boy is emergently intubated and exhibits masseter muscle spasm after induction with succinylcholine. He is in the OR for emergency surgery for a ruptured appendix. Which of the following additional symptoms would give you a heightened suspicion for malignant hyperthermia (MH)?BradycardiaEnd‐tidal CO2 of 35 mmHGRigidity of skeletal muscles of the limbsErythemaDiaphoresisThe onset of malignant hyperthermia can be heralded by tachycardia, trismus or masseter muscle spasm, and arrhythmias. Although concerning, as few as 20% of patients with masseter spasm progress to malignant hyperthermia. Triggers for MH include succinylcholine and inhalation anesthetic gases such as desflurane. This susceptibility to these triggers is due to genetic mutations with the most common one being the RYR1 gene or dihydropyridine (DHP) receptors located within the t‐tubule membrane. Monitoring for signs of MH such as increasing temperature, end‐tidal CO2, and rigidity of skeletal muscles is key to prompt recognition. MH can be rapidly fatal and treatment with Dantrolene must be started immediately. Dantrolene is a direct skeletal muscle relaxant that blocks calcium release by antagonistic effect at the ryanodine receptor (RYR1). Metabolism is increased in malignant hyperthermia resulting in hypercarbia (choice B), hyperthermia, and tachycardia (choice A). In this scenario, masseter muscle spasm in combination with rigidity of other muscle groups makes the diagnosis of malignant hyperthermia likely (choice C). Erythema (choice D) or diaphoresis (choice E) is not specific for malignant hyperthermia.Answer: CBandschapp O, Girard T. Malignant hyperthermia. Swiss Med Wkly. 2012; 142:w13652.Denborough M. Malignant hyperthermia. Lancet. 1998; 352(9134):1131–6.Sessler DI. Temperature Regulation and Monitoring. In: Miller RD, ed. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders.

11 Which of the following medications is best reversed with Sugammadex (Bridon)?Succinylcholine (Anectine)Cisatracurium (Nimbex)Midazolam (Versed)Ropivacaine (Naropin)Rocuronium (Zemuron)Sugammadex (Bridon) is a dextran compound that surrounds and encapsulates the nondepolarizing aminosteroid muscle relaxant rocuronium, allowing for reversal of its effects. It cannot reverse succinylcholine (Anectine), a depolarizing muscle relaxant which makes choice A incorrect. While sugammadex can reverse some other nondepolarizing medications, it has a lower affinity for the other aminosteroid paralytics such as vecuronium (Norcuron). Therefore, the quality of reversal depends on the class, amount of muscle recovery, and class of paralytic agent used. Choice B is incorrect because Sugammadex cannot reverse benzylisoquinolinium relaxants such as cisatracurium (Nimbex). Choice E is the correct answer here. Dosages to reverse rocuronium (Zemuron) are based on actual body weight and recovery at the motor end plate. For example, if two or more twitch responses to stimulation are present, 2 mg/kg of actual body weight is given. A higher dose, 4 mg/kg is needed if post tetanic stimulation is needed to produce a twitch response. For immediate reversal of rocuronium, 16 mg/kg is recommended. Train of four (TOF) monitoring is used to assess recovery from and depth of neuromuscular blockade. When using paralytic agents in the ICU, TOF monitoring should be used. Choice C, midazolam (Versed) is a benzodiazepine and can be reversed with flumazenil (Romazicon). Choice D, Ropivacaine (Naropin) is a local anesthetic and can be reversed with lipid emulsions in case of systemic toxicity.Answer: EDuvaldestin P, Kuizenga K, Saldien V, Claudius C, Servin F, Klein J, Debaene B, Heeringa M. A randomized, dose‐response study of sugammadex given for the reversal of deep rocuronium‐ or vecuronium‐induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg. 2010; 110(1):74–82.Hunter JM. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation. Br J Anaesth. 2017; 119(suppl_1):i53–i62.

12 A 75‐year‐old woman is admitted to the ICU after axillary to bifemoral bypass. Patient complains of pain from anterior thigh to her toes and a quadratus lumborum block is performed. What is the most serious complication of this procedure?HypertensionPostdural puncture headacheHyperemia of the legNumbness of the lumbar dermatomesRetroperitoneal hematomaBecause the quadratus lumborum block (QL) is a deep block, complications to watch out for include direct injury to the kidney, lumbar arteries, leading to retroperitoneal hematoma and pleural penetration leading to pneumothorax (choice E). A prolonged motor block may result from anesthetic distribution to the lumbar plexus. Hypotension, which can result from the spread of local anesthetic to the paravertebral space, has also been described (choice A). Local anesthetic toxicity (LAST) is always a potential risk of any peripheral or neuraxial technique. Rupture of the dura mater causing postdural puncture headache is a complication of an epidural catheter placement (wet tap) and not a complication of QL block (choice B). Numbness of the lumbar dermatomes (choice D) is the desired effect and hyperemia of the leg is transient and not a complication (choice C) (Figure 12.1).Figure 12.1 Quadratus lumborum block. QL: quadratus lumborum; EO: external oblique; IO: internal oblique; TA: transverse abdominis; K: kidney; P: psoas major; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: EElsharkawy H, El‐Boghdadly K, Barrington M. Quadratus lumborum block: anatomical concepts, mechanisms, and techniques. Anesthesiology. 2019; 130(2):322–335.Krohg A, Ullensvang K, Rosseland LA, Langesæter E, Sauter AR. The analgesic effect of ultrasound‐guided quadratus lumborum block after cesarean delivery: a randomized clinical trial. Anesth Analg 2018; 126(2):559–565.Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015; 32(11):812–8.

13 A 60‐year‐old morbidly obese man with a difficult airway and obstructive sleep apnea was taken for emergent laparotomy for peritonitis. After awake fiberoptic intubation with benzocaine and induction of anesthesia, the oxygen saturation reads and remains 85% with good signal quality. His lips appear cyanotic, and he has bilateral breath sounds. Which of the following is the most likely cause?CarboxyhemoglobinemiaMethemoglobinemiaCyanide toxicityMain stem intubationHgb A1c level greater than 10%Acquired methemoglobinemia is potentially threatening and must be immediately recognized. The most common cause of methemoglobinemia is exposure to oxidizing agents such as benzocaine and nitroglycerine (choice B). When iron is ferrous oxidized to its ferric state, oxygen binding to hemoglobin is prevented which shifts the oxygen hemoglobin dissociation curve to the left. Excess methemoglobin leads to hypoxia, cyanosis, impaired aerobic respiration, and metabolic acidosis. Other etiologies are genetic deficiencies of cytochrome‐b5 and cytochrome‐b5 reductase. Unfortunately, pulse oximetry and arterial blood gases can be misleading in patients with methemoglobinemia. Co‐oximetry is the gold standard. Treatment options for methemoglobinemia include supportive measures, methylene blue, and vitamin C which are potent reducing agents. Methylene blue is contraindicated in G6PD deficiency.There are no triggering agents to cause Carboxyhemoglobinemia (i.e., Smoke inhalation with CO) and Cyanide toxicity (i.e., Smoke inhalation, Sodium Nitroprusside, Poisons) in this case which makes choices A and C unlikely. The patient is intubated fiber‐optically and has bilateral breath sounds which makes choice D unlikely. Choice E indicates untreated diabetes mellitus and is therefore incorrect.Answer: BGuay J . Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009; 108(3):837.Anderson CM, Woodside KJ, Spencer TA, Hunter GC. Methemoglobinemia: An unusual cause of postoperative cyanosis. J Vasc Surg. 2004; 39(3):P686–690.

14 Patient is a 70 kg, 60‐year‐old man undergoing paravertebral nerve block due to multiple rib fractures in the ICU. Patient is hemodynamically stable before the block; however, becomes hypotensive and tachycardic 15 minute after the procedure is finished. You are suspecting local anesthetics toxicity. What would be the most appropriate treatment at this time? Vasopressin bolus followed by infusionDiltiazem (Cardizem) 5 mg bolus followed by infusionLipid emulsion 20% 100 mL follow by infusionPropofol 100 mgLorazepam (Ativan) 2 mgLocal anesthetic systemic toxicity (LAST) can occur after inadvertent intravascular injection or increased vascular uptake of a local anesthetic (LA) agent. The mechanisms for the clinical responses seen are multifactorial, mostly affecting the central nervous and cardiovascular systems. Neurologic manifestations such as tinnitus, seizures, or confusion are most common but the cardiovascular effects can be devastating. LA medications accumulate in mitochondria and cardiac tissue with greater affinity relative to plasma and can manifest with profound shock and cardiac instability.LA exerts its action at voltage‐gated sodium channels, blocks calcium channels, and at higher concentrations inhibits other channels, enzymes, and receptors including the carnitine‐acylcarnitine translocase receptor in mitochondria. This is the basis for treatment of LAST with lipid emulsion. Bupivacaine is more likely to cause cardiovascular collapse because it is more lipophilic and has a greater affinity for the voltage‐gated sodium channels. Factors that increase the likelihood of toxicity are extremes of age, comorbidities, higher total dose of LA medication, and site of injection. The highest incidence of LAST is with paravertebral blocks.Treatment of LAST includes 20% lipid emulsion which acts as a “lipid sink.” Recommended dose is 100 mL over 2–3 minutes for patients at least 70 kg (1.5 mL/kg), followed by infusion of 250 mL over 20 minutes. The bolus can be repeated, and the infusion rate doubled if clinically not improved (choice C).Further care includes supportive measures such benzodiazepines for treatment of seizures. Lorazepam (Ativan) can be administered if the patient is showing signs of seizure activity (choice E). Beta‐blockers, calcium channel blockers (diltiazem), and vasopressin should be avoided (choices A and B). Epinephrine if needed should be administered at lower doses (less than 1 mg/kg). Propofol is not the best choice and can exacerbate hypotension (choice D).Answer: CNeal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version. Reg Anesth Pain Med. 2020:rapm‐2020‐101986. doi: 10.1136/rapm‐2020‐101986. Epub ahead of print.El‐Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018; 11:35–44.

15 A 65‐year‐old polytrauma patient in the ICU with blunt cerebrovascular injury and rib fractures has severe pain which affects patient's respiratory efforts. Patient has a new lower extremity venous thromboembolic event. You place a pain consult for possible epidural anesthesia. Considering your plan for a neuraxial block, which of the following therapies should be avoided?Ketorolac (Toradol) and subcutaneous heparinASAEnoxaparin (Lovenox)Heparin infusionAcetaminophen IV (Ofirmev)Because neuraxial techniques are increasingly used to manage pain in the ICU, intensivists need to understand the guidelines for management of anticoagulation as it affects the placement of epidural catheters. Serious complications associated with neuraxial anesthesia are epidural hematomas, epidural abscess, and nerve injuries. Absolute contraindications include patient refusal and severe coagulopathy. Relative contraindications are sepsis, thrombocytopenia, pre‐existing nerve injury, placement in anesthetized adults, and anticoagulation. While none of the above medications alone are absolutely contraindicated (choices B, C, D, and E), a patient receiving more than one antithrombotic medication should not receive an epidural or spinal anesthetic technique (choice A). Non‐steroidal anti‐inflammatory medications are not contraindicated if used alone.Answer: AHorlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence‐Based Guidelines (fourth edition). Reg Anesth Pain Med. 2018; 43(3):263–309.

16 Patient is a 65‐year‐old woman admitted to the ICU for TBI with past medical history of mitochondrial disease and lupus. Patient has been on long‐term steroids. Patient is agitated and you suspect she has increased ICP. You are about to intubate the patient for airway protection. What would be the best choice for induction and intubation?PropofolEtomidate (Amidate)Lorazepam (Ativan)FentanylNo induction, topicalize with benzocaine and plan for awake fiberoptic intubationCritically ill patients are often intubated emergently, and a rapid sequence technique is preferred if clinically deteriorating. Typically, clinicians combine sedative and paralytic agents although judgment is needed before deciding to use either class of drug. Fentanyl will provide a stable induction and can be used with succinylcholine for a rapid sequence intubation (choice D). Propofol lowers ICP and is also acceptable in traumatic brain injured patients. But in the setting of mitochondrial disease, it should be avoided as propofol infusion syndrome is thought to result from inhibition of mitochondrial enzymes in mitochondria and on mitochondrial membranes (choice A). A single low dose of propofol may be acceptable; however, it can cause vasodilation and hypotension and is not the best choice here. Etomidate, a sedative‐hypnotic, is often used because it has relative cardiac stability when compared with propofol. Caution should be used with even a single dose of etomidate (Amidate) because it can cause adrenal insufficiency by inhibition of 11β‐hydroxylase (choice B). Long‐acting benzodiazepines such as lorazepam (Ativan) can delay a post intubation neurovascular exam and its use should be avoided (choice C). Awake fiberoptic intubation is unlikely to be tolerated in an agitated patient (choice E).Answer: DNiezgoda J, Morgan PG. Anesthetic considerations in patients with mitochondrial defects. Paediatr Anaesth. 2013; 23(9):785–93.Footitt EJ, Sinha MD, Raiman JA, Dhawan A, Moganasundram S, Champion MP. Mitochondrial disorders and general anaesthesia: a case series and review. Br J Anaesth. 2008; 100(4):436–41.

17 About 5 hours ago, a 35‐year‐old woman with a history of depression and anxiety, ingested an unknown amount of alcohol (ethanol), 20 tabs of alprazolam (Xanax), and methocarbamol (Robaxin). She is arousable to sternal rub. Blood pressure is 100/60 mmHg, heart rate is 68/min, respiratory rate is 8/min, and temperature is 36 °C. Which is the most appropriate intervention?IntubationGastric lavageFlumazenil (Anexate)Fomepizole (Antizol)Activated charcoalSince the patient ingested several medications, the best intervention is intubation and supportive care (choice A). Activated charcoal is not likely to be effective since the presentation is delayed, so activated charcoal and gastric lavage are not indicated (choices B, E). Flumazenil (Anexate) is an antidote for benzodiazepines but is contraindicated in a patient with chronic use of alprazolam. Flumazenil may precipitate withdrawal seizures in this case. It would be difficult to treat subsequent seizures after flumazenil since benzodiazepine receptors would be blocked (choice C). Benzodiazepine overdose may cause respiratory depression but risks of reversing benzodiazepines in chronic use outweigh potential benefits as it may precipitate seizure. Fomepizole (4‐methylpyrazole, Antizol) competitively inhibits the first enzyme in the metabolism of ethylene glycol and methanol (alcohol dehydrogenase) which prevents their metabolism to toxic acids. The slower rate of metabolite production allows the liver to process and excrete the metabolites as they are produced; however, it is not indicated in acute ethanol toxicity. Do not give fomepizole in acute alcohol intoxication because fomepizole will compete for alcohol dehydrogenase (choice D) and impair metabolism. Methocarbamol (Robaxin) is a muscle relaxant.Answer: ABrent J, McMartin K, Phillips S, Aaron C, Kulig K ; Methylpyrazole for Toxic Alcohols Study Group. Fomepizole for the treatment of methanol poisoning. N Engl J Med. 2001; 344(6):424–9.Seger DL. Flumazenil‐‐treatment or toxin. J Toxicol Clin Toxicol 2004; 42(2):209–16.Chyka PA, Seger D, Krenzelok EP, Vale JA ; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: single‐dose activated charcoal. Clin Toxicol (Phila). 2005; 43(2):61–87.

18 Which of the following is a true statement regarding flumazenil (Anexate)?It exerts a clinical effect by competitive antagonism at mu receptor.It is a competitive inhibitor at GABA A receptors.Flumazenil does not contribute to seizure activity in benzodiazepine tolerant patients.It is a relatively long‐acting medication.Flumazenil consistently reverses respiratory depression caused by benzodiazepine overdose.Mu receptors are specific transmembrane neurotransmitter receptors that couple G proteins and are activated by opioids and are not affected in the presence of flumazenil (choice A). Naltrexone (Vivitrol) is a competitive antagonist to mu receptors. Flumazenil (Anexate) is structurally similar to midazolam and is a nonspecific competitive antagonist of the benzodiazepine receptor (GABAA) in the central nervous system (CNS) (choice B). Flumazenil has a limited role in the management of benzodiazepine overdose, purportedly to avoid the need for procedure (i.e., intubation), and is contraindicated in the presence of a known seizure disorder or benzodiazepine dependence. It can reverse the effect of benzodiazepines in the CNS and precipitate seizures making choice C incorrect. Flumazenil rapidly undergoes hepatic metabolism to inactive metabolites and its half‐life is not long, about 40–80 minutes, thus the duration of effect of a long‐acting benzodiazepine or a large benzodiazepine dose can exceed that of flumazenil making choices D and E incorrect. However, in the right scenario, flumazenil as a reversal and rescue medication can be lifesaving. The recommended initial dose in adults is 0.2 mg IV given by slow push over 1–2 minutes. Doses can be repeated 0.2 mg, but one must watch for a maximum dose of 2 mg.Answer: BKreshak AA, Cantrell FL, Clark RF, Tomaszewski CA. A poison center's ten‐year experience with flumazenil administration to acutely poisoned adults. J Emerg Med. 2012; 43(4):677–82.Weinbroum AA, Flaishon R, Sorkine P, Szold O, Rudick V. A risk‐benefit assessment of flumazenil in the management of benzodiazepine overdose. Drug Saf 1997; 17(3):181–96.Shalansky SJ, Naumann TL, Englander FA. Effect of flumazenil on benzodiazepine‐induced respiratory depression. Clin Pharm 1993; 12(7):483–7.Seger DL. Flumazenil‐‐treatment or toxin. J Toxicol Clin Toxicol 2004; 42(2):209–16.Murray L Little M Pascu O Hoggett KA. Toxicology Handbook. 3rd Edition. eBook ISBN: 9780729584951.

19 A 40‐year‐old man with a history of depression is admitted to the ICU after laparotomy and lysis of adhesions. He was using a fentanyl PCA but developed autonomic dysfunction, confusion, and muscular rigidity. The PCA was stopped because it was suspected that he was exhibiting serotonin syndrome . When stable, you will need to rethink the pain management plan. What is the best course of action?Stop fentanyl PCA and order tramadol (Ultram)Continue fentanyl PCA and add methadone (Dolophine)Stop fentanyl PCA and order meperidine (Demerol)Stop the fentanyl PCA and order a morphine PCAStop the fentanyl PCA and order oxycodoneSome opioids including fentanyl, methadone, and demerol act as serotonergic agents that contribute to the development of serotonin syndrome. Medications in this class of opioids are the synthetic and semisynthetic opioids. Serotonin syndrome results from over‐dosage or coadministration of narcotics with serotonin reuptake inhibitor antidepressants (SSRIs). Synthetic piperidine opioids are pro‐serotonergic in their own right and can act as serotonin reuptake inhibitors. This class of narcotics includes fentanyl, methadone, oxycodone, meperidine (Demerol), and tramadol (choices B, C, and E). Morphine is not in this class and does not inhibit serotonin reuptake (choice D) and is the correct answer. Clinical manifestations of serotonin syndrome results from increased postsynaptic stimulation of 5‐hydroxytryptamine, 2A and 1A serotonin receptors in the central and peripheral nervous system. Since this patient has a history of depression and is receiving a synthetic opioid, serotonin syndrome is suspected.Answer: Dvan Ewijk CE, Jacobs GE, Girbes ARJ. Unsuspected serotonin toxicity in the ICU. Ann Intensive Care. 2016; 6(1):85.Pathan H, Williams J. Basic opioid pharmacology: an update. Br J Pain. 2012; 6(1):11–16.Pedavally S, Fugate JE, Rabinstein AA. Serotonin syndrome in the intensive care unit: clinical presentations and precipitating medications. Neurocrit Care. 2014; 21(1):108–13.

20 A 130 kg, 70‐year‐old man fell 2 weeks ago during a hiking trip and sustained a femur fracture and cervical spine injury. He has a history of heavy snoring and has a BMI of 38. His course was complicated by acute kidney injury but his GFR is now 35 and recovering. He is cooperative and comfortable on a PCA with hydromorphone (Dilaudid) 0.2 mg every 10 minutes. You prefer to do an awake bronchoscopy without intubation to evaluate his recent fever and infiltrate seen on the chest x‐ray. Which of the following techniques is the best option for this procedure?Give a hydromorphone (Dilaudid) bolus and start a propofol infusion while maintaining spontaneous respirations.Topicalization is contraindicated; prepare to intubate for bronchoscopy using rocuronium and propofol.Topicalization of the recurrent and superior laryngeal nerves to anesthetize the tongue, epiglottis, vocal cords, and trachea.Topicalization of the hypoglossal nerve to anesthetize the base of the tongue and arytenoids and aryepiglottic folds.Bilateral superficial cervical plexus block.Different techniques are used to sedate and anesthetize the airway for an awake bronchoscopy using a variety of medications such as benzodiazepines, short‐acting opioids (fentanyl, remifentanil), propofol, ketamine, or dexmedetomidine. In cooperative patients at risk for airway obstruction or difficult intubation, topicalization may be a good choice and should be considered. This can be achieved by anesthetizing the airway with regional techniques with or without sedation or in combination with inhaled anesthetic agents such as viscous lidocaine.Sensation to the oropharynx, and larynx and trachea must be blocked to perform an awake fiberoptic bronchoscopy or intubation. There are several ways to achieve the necessary analgesia, but the sensory nerves should be anesthetized. The superior laryngeal nerve supplies sensory innervation to the base of the tongue, epiglottis and aryepiglottic folds, and arytenoids. It also supplies motor innervation to the external branch of the cricothyroid muscle. The recurrent laryngeal nerve supplies sensory innervation to the vocal cords and trachea (choice C).The combination of narcotic bolus (Dilaudid) and propofol infusion is likely to result in apnea that would require intubation. Since this patient could have a difficult intubation (presence of cervical spine injury and a BMI of 38), this is not the best plan (choice A). Topicalization is not contraindicated in this patient and should be considered before intubation (choice A). The hypoglossal nerve is purely motor and does not need to be blocked (choice D). A superficial cervical plexus block provides anesthesia to the skin of the anterolateral neck and auricular areas and skin inferior to the clavicle. This block can be used in thyroid or clavicular surgery but would not anesthetize the airway or facilitate an awake bronchoscopy (choice E).Answer: CElmaddawy AEA, Mazy AE. Ultrasound‐guided bilateral superficial cervical plexus block for thyroid surgery: The effect of dexmedetomidine addition to bupivacaine‐epinephrine. Saudi J Anaesth. 2018; 12(3):412–8.Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002; 27(2):180–92.

21 An 89‐year‐old man fell off a ladder and fractured ribs 3, 4, 5, and 6 on the left side. He is a smoker and has a history of chronic obstructive pulmonary disease (COPD). His pain score is 9/10 and he is taking shallow breaths. He takes antiplatelet medications for atrial fibrillation but cannot remember his last dose. His SpO 2 reads 92% on a 30% face mask. His vital signs are stable. What intervention do you want to recommend to control his pain?Lidocaine patchOxycodoneHydromorphone (Dilaudid) PCAErector spinae block (ESP) plus hydromorphone (Dilaudid) PCA and gabapentinIntercostal nerve block (ICNB)Given his age and pre‐existing COPD, this patient is at risk for pulmonary complications of thoracic trauma. He is in significant pain and appears to be splinting with hypoventilation. The side effects of narcotics such as increased risk for ICU delirium, constipation, and nausea also make these agents a less attractive option when used alone (choices B and C). Erector spinae (ESP) blocks work through a combination of different mechanisms, particularly anesthetic spread to the thoracic paravertebral space. There is evidence to suggest that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal procedures including in the management of rib fractures. Intercostal nerve blocks (ICNB) for multiple rib fractures require multiple injections of local anesthetics increasing the risk of toxicity. Choice E, ICNB alone is not the best choice as multimodal approach is recommended to control pain in patients with blunt thoracic trauma. Moreover, being on antiplatelet therapy increases the risk of bleeding for intercostal nerve block (choice E). Choice A, lidocaine patch would not provide sufficient pain relief and continued splinting with shallow breathing may contribute to atelectasis. The patch may cause some numbness to the skin but because of its superficial site of action, it does not decrease fracture pain. Erector spinae blocks in combination with narcotics and gabapentin would establish a multimodal pain control regimen and is conditionally recommended by latest EAST guidelines (choice D) (Figure 12.2).Figure 12.2 Erector spinae plane block. ES: erector spinae; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: DGalvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, Fox AD, Alley DE, Ditillo M, Joseph BA, Robinson BR, Haut ER. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016; 81(5):936–51.Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2020; 68:110063.

22 Considering the appropriateness of nerves blocked to the procedure performed, which patient's pain is more likely to be adequately controlled?Abdominal wall reconstruction with bilateral TAP indwelling catheter.Large bowel resection with bilateral TAP block injection.Cervical fusion with erector spinae block single injection.Esophageal reconstruction with a neurolytic celiac plexus block.Shoulder surgery with axillary nerve block.Transverse Abdominis Plane (TAP) nerve blocks with indwelling catheters provide adequate somatic analgesia for abdominal wall surgery (choice A). In contrast, quadratus lumborum (QL) nerve blocks provide visceral in addition to somatic analgesia for the abdominal wall and the lower thoracic wall segments. This is because QL nerve blocks spread to the paravertebral space and sometimes achieve epidural spread. In large bowel resection, bilateral TAP block injections will not provide adequate analgesia for deep visceral pain (choice B). Erector spinae (ESP) block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal procedures including in the management of rib fractures. It does not relieve somatic pain for cervical fusion (choice C). Choice D, celiac plexus block places the either a local anesthetic or neurolytic solution directly on the celiac ganglion anterolateral to the aorta. When used, for example, to manage pain in terminal pancreatic cancer, a neurolytic agent is chosen. Choice E is incorrect since the axillary nerve block will not provide adequate coverage for the shoulder joint surgery. Axillary nerve block will provide adequate analgesia from the mid upper arm extending to the hand (Figure 12.3).Figure 12.3 Transverse abdominis plane block. QL: quadratus lumborum; EO: external oblique; IO: internal oblique; TA: transverse abdominis; K: kidney; P: psoas major; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: ATsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, Tai YT, Lin JA, Chen KY. Transversus abdominis plane block: an updated review of anatomy and techniques. Biomed Res Int. 2017; 2017:8284363.Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2020; 68:110063.