FMGE Anesthasia Syllabus

What reversal agent specifically encapsulates rocuronium and vecuronium, and how does it work?

Sugammadex, a modified gamma-cyclodextrin that encapsulates (chelates) aminosteroidal non-depolarizing blockers, rapidly reversing neuromuscular blockade even from deep block.

When neostigmine is used to reverse neuromuscular blockade, why must an anticholinergic be co-administered?

Neostigmine (an anticholinesterase) raises ACh at muscarinic sites causing bradycardia, salivation, and bronchospasm; glycopyrrolate or atropine is given to block these muscarinic effects.

What is the difference between spinal (subarachnoid) and epidural anesthesia?

Spinal injects a small drug volume into the CSF in the subarachnoid space (below L2 to avoid cord), giving rapid, dense block. Epidural deposits a larger volume into the epidural (potential) space, slower onset, segmental, and allows a catheter for continuous/postop analgesia.

What is Monitored Anesthesia Care (MAC)?

An anesthesia service combining local/regional anesthesia with IV sedation and analgesia while the anesthesiologist monitors vitals and is prepared to convert to general anesthesia if needed; the patient typically maintains spontaneous ventilation.

What is the most reliable confirmation of correct endotracheal tube placement?

Sustained waveform capnography (continuous detection of end-tidal CO2 over multiple breaths) confirms tracheal placement; bilateral breath sounds and chest rise are supportive.

At what vertebral/airway level does the trachea bifurcate (carina), and which mainstem bronchus is more commonly intubated if the tube is advanced too far?

The carina is at approximately T4-T5 (sternal angle). The right mainstem bronchus is more commonly intubated because it is wider, shorter, and more vertical.

What is a supraglottic airway device (e.g., LMA), and a key limitation compared with an endotracheal tube?

A device (laryngeal mask airway) placed above the glottis that seals around the laryngeal inlet for ventilation without passing through the cords. Limitation: it does not definitively protect against aspiration of gastric contents.

Define the LEMON mnemonic used to predict a difficult airway.

L: Look externally; E: Evaluate 3-3-2 rule (mouth opening 3 fingers, hyoid-mentum 3 fingers, thyroid-floor of mouth 2 fingers); M: Mallampati; O: Obstruction/Obesity; N: Neck mobility.

In the 'cannot intubate, cannot ventilate' (CICV) scenario, what is the final rescue step?

Emergency front-of-neck access — cricothyroidotomy (surgical or needle/cannula with jet ventilation).

List common causes of intraoperative hypotension under general anesthesia.

Hypovolemia/hemorrhage, anesthetic-induced vasodilation/myocardial depression, decreased preload (e.g., positive pressure ventilation, vena cava compression), arrhythmias, anaphylaxis, high spinal/neuraxial block, and pneumothorax/tamponade.

What is the most common cause of hypoxemia during anesthesia, and how is the inspired oxygen concentration handled first?

Atelectasis/V-Q mismatch and hypoventilation are common; the immediate response to hypoxemia is to increase FiO2 to 100% while identifying and correcting the cause (e.g., confirm tube position, recruit alveoli/PEEP, suction).

What triggers malignant hyperthermia, what is the underlying defect, and what is the specific treatment?

Triggered by volatile anesthetics and succinylcholine in genetically susceptible patients (ryanodine receptor RYR1 mutation causing uncontrolled sarcoplasmic Ca2+ release). Treatment: stop triggers, give dantrolene, cool the patient, and treat hyperkalemia/acidosis.

What are the earliest and most sensitive clinical signs of malignant hyperthermia?

A rapid rise in end-tidal CO2 (hypercarbia) and unexplained tachycardia are the earliest signs; masseter spasm, rigidity, and hyperthermia follow.

What is the purpose of the Post-Anesthesia Care Unit (PACU), and which scoring system assesses readiness for discharge?

The PACU provides close monitoring during emergence/recovery from anesthesia. The Modified Aldrete score (activity, respiration, circulation, consciousness, oxygen saturation) assesses discharge readiness, typically requiring ≥9.

What is the most common serious complication immediately seen in the PACU related to the airway?

Airway obstruction (often from residual anesthesia/muscle relaxation causing tongue/soft-tissue collapse or laryngospasm); other common PACU issues are nausea/vomiting, hypoxemia, and hypothermia/shivering.

Describe the WHO analgesic ladder for pain management.

Step 1: non-opioids (paracetamol/NSAIDs) ± adjuvants; Step 2: weak opioids (codeine, tramadol) ± non-opioids/adjuvants; Step 3: strong opioids (morphine) ± non-opioids/adjuvants for moderate-to-severe pain.

What is 'multimodal analgesia' and why is it preferred?

Combining analgesics with different mechanisms (e.g., paracetamol, NSAIDs, opioids, regional blocks, gabapentinoids, ketamine) to maximize pain control while minimizing the dose and side effects (especially opioids) of any single agent.

What is the formula for an uncuffed endotracheal tube internal diameter and length in children (>2 years)?

ETT internal diameter (mm) = (age/4) + 4; oral tube insertion depth (cm) = (age/2) + 12, or 3 × the ETT internal diameter.

Name key anatomical/physiological reasons children desaturate faster than adults during apnea.

Higher oxygen consumption per kg, lower functional residual capacity (FRC), and proportionally larger head/tongue with a more anterior/cephalad larynx — leading to rapid desaturation and a more difficult airway.

What physiological changes of pregnancy increase aspiration risk and make obstetric airway management hazardous?

Decreased lower esophageal sphincter tone and delayed gastric emptying (aspiration risk → all parturients treated as 'full stomach'), plus airway edema, weight gain, and reduced FRC with increased oxygen demand → rapid desaturation and difficult intubation.

What is aortocaval compression (supine hypotensive syndrome) in pregnancy and how is it prevented?

In the supine position the gravid uterus compresses the aorta and inferior vena cava, reducing venous return and causing maternal hypotension and fetal compromise; prevented by left uterine displacement (left lateral tilt of ~15 degrees).

How does MAC (anesthetic requirement) change with age in the elderly, and what does that mean for dosing?

MAC and overall anesthetic/drug requirements decrease with age (roughly 6% per decade after 40); elderly patients need lower doses and slower titration due to altered pharmacokinetics/dynamics and reduced physiologic reserve.

What is one-lung ventilation in cardiothoracic anesthesia and how is lung isolation achieved?

Ventilating only one lung (deflating the operative lung) to facilitate thoracic surgery, achieved with a double-lumen endotracheal tube or a bronchial blocker.

What is the goal of cerebral perfusion management in neurosurgical anesthesia, and what is the formula for cerebral perfusion pressure (CPP)?

Maintain adequate CPP while controlling intracranial pressure (ICP). CPP = MAP − ICP (or − CVP, whichever is greater). Hyperventilation can transiently lower ICP via cerebral vasoconstriction.

Which inhalational anesthetic property is favorable for neurosurgery regarding intracranial pressure, and which agent is often avoided?

Agents that minimally increase cerebral blood flow/ICP are preferred (low-dose volatile or total IV anesthesia with propofol, which lowers CBF/ICP). High-dose volatiles cause cerebral vasodilation and raised ICP; nitrous oxide is often avoided as it increases CBF/ICP and tension pneumocephalus.

Why are regional/neuraxial techniques particularly favored in orthopedic anesthesia, and what is bone cement implantation syndrome?

Neuraxial anesthesia reduces blood loss, thromboembolism, and provides good postop analgesia for joint/limb surgery. Bone cement implantation syndrome is hypotension, hypoxia, and possible cardiac arrest from methylmethacrylate cement during arthroplasty (embolic/vasodilatory mechanism).

What is a tourniquet used for in orthopedic surgery, and a major physiologic effect of its release?

It provides a bloodless surgical field. On deflation/release, accumulated metabolic products (lactate, potassium, CO2) wash into circulation causing transient hypotension, acidosis, and a rise in end-tidal CO2.

What are the core principles of Enhanced Recovery After Surgery (ERAS) protocols?

Multimodal, evidence-based perioperative care: preoperative counseling and carbohydrate loading, avoiding prolonged fasting, minimal/no bowel prep, opioid-sparing multimodal analgesia, normothermia, goal-directed fluids, early mobilization, and early oral feeding — to reduce stress response and speed recovery.

What is Point-of-Care Ultrasound (POCUS) and name two anesthesia applications.

Bedside, real-time ultrasound performed and interpreted by the clinician for immediate decisions. Anesthesia uses: ultrasound-guided regional nerve blocks and vascular (central/arterial line) access; also gastric content/aspiration risk assessment, FAST/lung exams, and cardiac function evaluation.

What does the FAST exam assess, and what underlying acute condition does anesthesia/trauma care use it to detect?

Focused Assessment with Sonography for Trauma evaluates the pericardial, perihepatic (Morrison's pouch), perisplenic, and pelvic spaces for free fluid (hemorrhage) and pericardial effusion/tamponade in unstable trauma patients.

What is the recommended optimization for a patient with poorly controlled hypertension or anemia before elective surgery?

Defer elective surgery to optimize: control severe hypertension (avoid cancellation for mild/moderate; treat if very high or end-organ risk) and correct/investigate significant anemia (e.g., iron, treat cause) to reduce perioperative cardiovascular and transfusion risk.