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Oral case 1

Created: 11/1/2005

A 2-year-old 12 kg boy is scheduled for a posterior fossa craniotomy for a mass lesion. He had been active until 48 hours ago, when his parents noted him to be lethargic, listless and eating poorly. Vital signs are as follows: Blood pressure 90/50 mmHg, heart rate 100, and hemoglobin 13 g/dl.

 Preoperative evaluation

An anesthesiologist shall be responsible for determining the medical status of the patient, developing a plan of anesthesia care, and acquainting the patient or the responsible adult with the proposed plan. The development of an appropriate plan of anesthesia care is based upon reviewing the medical record, interviewing and examining the patient to discuss the medical history, previous anesthetic experiences, and drug therapy, assessing those aspects of the physical condition that might affect decisions regarding perioperative risk and management, obtaining and/or reviewing tests and consultations necessary to the conduct of anesthesia, and determining the appropriate prescription of preoperative medications as necessary to the conduct of anesthesia.

 Intracranial pressure

1. What would your neurologic examination of this patient entail?

2. What is the anesthetic relevance?

3. How will you assess him for elevated intracranial pressure?

4. Is a CAT scan necessary?

5. How will your finding affect premedication?

 Fluid status

1. How will you assess his fluid status?

2. What laboratory studies will be helpful?

3. If needed, what fluids will you administer?

4. Should glucose be avoided if this is the day before surgery?


1. The mother strongly requests that he receives no shots prior to being put to sleep. What is your response?

This patient is lethargic and not fully responsive, scheduled for emergency surgery. While it is usually hard to prepare children for the operating room, this child should have no difficulty separating from his parents, and he may not be entirely reactive to the placement of needles.

2. Are other alternatives acceptable?

 Intraoperative course

I. Monitoring

1. What monitoring is essential for his case?

2. How will patient positioning affect your choices?

3. If central venous pressure is desired, how would you initiate it? What would be your timing and approach?

4. Is a precordial Doppler indicated?

 Anesthesia induction

1. If he is drowsy, would you consider a halothane induction? Why or why not?

2. Would you intubate with a relaxant? Why or why not?

3. Which relaxant would you use?

 Maintenance of anesthesia

1. What anesthetic circuit would you use?

2. Could an adult circle be used? Why or why not?

3. Would you use humidification? Explain.

4. Discuss your choice of anesthetic agents for maintenance.

 Controlled hypotension

1. The surgeon encounters bleeding and requests an immediate reduction in blood pressure. What is your response?

2. How will you proceed? Discuss agents and monitoring.

3. How will you decide what the lowest blood pressure is?

 Air embolism

1. Thirty-minutes into the resection, the blood pressure suddenly drops to 30/0 mm Hg, and his oxygen saturation decreases to 85%. What may be the cause?

2. What additional data might you quickly attain to help with the diagnosis?

3. If end-tidal CO2 has fallen, what would you do? Why?

 Postoperative care

I. Hypothermia:

1. The child's temperature in the recovery room is 35 degrees C rectally. Why?

2. Is this a concern? Why?

3. What would you do? Explain.


1. When would you extubate this child? Why?

2. What are your criteria? Explain.

3. After extubation, the child is agitated and stridorous. What is happening?

4. What would you do? Discuss evaluation and management.

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