Subspecialty Anesthesia
What the exam tests
Subspecialty items test the one or two decisions that distinguish the case: OLV, CPB, ICP, obstetric airway, pediatric dosing, ambulatory discharge, and burn resuscitation.
Core rules
- Cardiac: anticipate hemodynamic effects of induction, maintain coronary perfusion, and use TEE for valve and major cases.
- Thoracic: verify double-lumen tube position with bronchoscopy; for OLV hypoxemia check position, suction, apply CPAP to the nondependent lung and PEEP to the dependent lung.
- Neuro: cerebral perfusion pressure = MAP − ICP; avoid hypotension and hypoxia; hyperventilation is temporary for herniation.
- Obstetric: failed intubation is a leading cause of maternal death; aspiration prophylaxis and left uterine displacement are routine.
- Pediatric: uncuffed tubes may be used with a leak; weight-based doses; maintenance fluids with isotonic solution.
- Outpatient: PONV prophylaxis and discharge criteria matter as much as anesthesia.
- Trauma and burns: secure the airway early; burns need titrated fluid resuscitation, not edema.
Worked example
During right thoracotomy with OLV, SpO2 falls to 88%. Check tube position with bronchoscopy, suction secretions, ensure the operative lung is isolated, apply CPAP 5 cmH2O to the nondependent lung, PEEP to the dependent lung, and optimize cardiac output. Reasoning: hypoxemia is usually shunt from the nonventilated lung; recruitment and CPAP reduce it. Do not simply increase inspired oxygen without checking position.
Traps
Assuming all thoracic cases need a double-lumen tube; hyperventilating a head-injured patient indefinitely; giving a laboring patient an epidural without an airway plan; using adult fluid formulas in children.