NBCRNA Anesthetic Complications and Crisis Management 1 — Questions and Answers
Question 1: Intraoperative anaphylaxis most commonly presents with which cardiovascular sign?
- Severe hypotension and tachycardia (Correct answer)
- Hypertension and bradycardia
- Bradycardia with normal blood pressure
- Atrial fibrillation
Correct answer: Severe hypotension and tachycardia
Anaphylaxis causes massive histamine release leading to vasodilation, increased capillary permeability, and reduced venous return, producing severe distributive hypotension with compensatory tachycardia.
Question 2: The first-line treatment for intraoperative anaphylaxis is:
- Epinephrine 0.01 mg/kg IV (10–100 mcg) titrated to response (Correct answer)
- Diphenhydramine IV first, followed by corticosteroids
- Ephedrine 10 mg IV bolus
- Norepinephrine infusion
Correct answer: Epinephrine 0.01 mg/kg IV (10–100 mcg) titrated to response
Epinephrine is the only first-line treatment for anaphylaxis; it counteracts vasodilation (alpha-1), supports heart rate and contractility (beta-1), and reverses bronchospasm (beta-2).
Question 3: Intraoperative bronchospasm during general anesthesia is most commonly caused by what?
- Airway manipulation (intubation, suctioning) in an inadequately anesthetized patient (Correct answer)
- Volatile anesthetic overdose
- Excessive PEEP causing air trapping
- Pulmonary embolism
Correct answer: Airway manipulation (intubation, suctioning) in an inadequately anesthetized patient
Stimulation of the reactive airway by endotracheal tube placement or suctioning when the depth of anesthesia is inadequate triggers reflex bronchospasm through vagal airway reflexes.
Question 4: Which intraoperative sign is the earliest indicator of malignant hyperthermia (MH)?
- Unexplained increase in end-tidal CO2 (Correct answer)
- Rising core temperature
- Muscle rigidity
- Tachycardia with ST changes
Correct answer: Unexplained increase in end-tidal CO2
Increased metabolic rate from uncontrolled skeletal muscle calcium release produces excess CO2 before core temperature rises significantly, making elevated ETCO2 the most sensitive early MH sign.
Question 5: The immediate management of an accidental intravenous injection of local anesthetic (LAST) begins with:
- Stop injection, call for help, secure airway, and prepare lipid emulsion (Correct answer)
- Immediately administer epinephrine 1 mg IV
- Perform chest compressions as first action
- Administer sodium bicarbonate to alkalinize the blood
Correct answer: Stop injection, call for help, secure airway, and prepare lipid emulsion
The ASRA LAST management protocol prioritizes stopping the injection, calling for help, maintaining oxygenation and airway, controlling seizures with benzodiazepines, and preparing lipid emulsion for cardiovascular collapse.
Question 6: During cardiac arrest under general anesthesia, which drug is given with caution (or avoided) when epinephrine is being used to treat LAST?
- High-dose vasopressin and calcium channel blockers (Correct answer)
- Beta-blockers
- Amiodarone
- Lidocaine
Correct answer: High-dose vasopressin and calcium channel blockers
High-dose vasopressin can worsen lipid emulsion therapy outcomes; beta-blockers can exacerbate the myocardial depression; ASRA recommends smaller epinephrine doses (<1 mcg/kg) rather than standard ACLS doses during LAST resuscitation.
NBCRNA Anesthetic Complications and Crisis Management 1
Intraoperative anaphylaxis most commonly presents with which cardiovascular sign?