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After the first gr aft is sewn into the aorta, the arterial pressure measured from a left radial artery is 47 mm Hg and the pulmonary artery pressure is 6 mm Hg.. While on cardiopulmonar

Chapter 11 – Cardiovascular Physiology and Anesthesia

DIRECTIONS (Questions 915 through 994): Each of the questions or incomplete statements

in this section is followed by answers or by completions of the statement, respectively Select the ONE BEST answer or completion for each item

915 A 67-year-old man is to undergo a radical retropubic prostatectomy He has aortic stenosis

with a gradient of 37 mm Hg at rest He has an allergy to penicillin Which of the following

is the best regimen for subacute bacterial endocarditis (SBE) prophylaxis in this patient?

A Ampicillin and gentamicin

B Vancomycin and gentamicin

C Clindamycin and gentamicin

D Clindamycin alone

E None of the above

916 A 68-year-old patient is undergoing elective coronary revascularization Just before

cardiopulmonary bypass, the hemoglobin concentration is 8.3 g/dL and platelet count is 253,000/mm3 After cardiopulmonary bypass is initiated, the patient is cooled to 20° C and

2 units of packed red blood cells (RBCs) are transfused because of bleeding During bypass, the anesthesiologist notices that the platelet count is 10,000/mm3 and the

hemoglobin concentration is 8 g/dL The most likely cause of thrombocytopenia is

917 Which of the following is the most sensitive indicator of left ventricular myocardial

ischemia?

A Wall-motion abnormalities on the echocardiogram

B ST-segment changes in lead V5 of the electrocardiogram (ECG)

C Appearance of V waves on the pulmonary capillary wedge pressure tracing

D Elevation of the pulmonary capillary wedge pressure

E Decrease in cardiac output as measured by the thermodilution technique

918 Oxygen consumption (VO2) is measured in a 70-kg subject on a treadmill at 2500 mL per minute This corresponds to:

A 1 metabolic equivalent (MET)

B 5 METs

C 10 METs

D 15 METs

E 20 METs

919 Accidental injection of air into a peripheral vein would be LEAST likely to result in arterial

air embolism in a patient with which of the following anatomic cardiac defects?

A Patent ductus arteriosus

B Eisenmenger’s syndrome

B Left ventricular end-diastolic pressure

C Left ventricular end-diastolic volume

D Left atrial pressure

E Pulmonary artery occlusion pressure

921 The ECG rhythm strip below represents

A Atrial flutter

B Third-degree heart block

C Sinus tachycardia second-degree heart block

D Malfunctioning DDD pacemaker

E Junctional rhythm

922 A 71-year-old man is undergoing revascularization of three coronary vessels on

cardiopulmonary bypass at 28° C After the first gr aft is sewn into the aorta, the arterial pressure measured from a left radial artery is 47 mm Hg and the pulmonary artery pressure is 6 mm Hg Thirty minutes later, the arterial pressure is 52 mm Hg and pulmonary artery pressure is 31 mm Hg The most likely explanation for this is

A Malposition of the aortic cannula

B Malposition of the venous cannula

C Faulty ventricular venting

D Bypass associated sympathetic nervous system stimulation

E Pulmonary artery catheter migration

923 A78-year-old patient is anesthetized for right hemicolectomy with isoflurane and nitrous

oxide Vecuronium is administered to facilitate muscle relaxation At the end of the

operation, the neuromuscular blockade is reversed with neostigmine 4 mg and

glycopyrrolate 0.8 mg The rhythm below is noted shortly after administration of these drugs The patient’s blood pressure is 90/60 The most appropriate course of action at this point is

E Begin chest compressions

924 While on cardiopulmonary bypass during elective coronary artery revascularization, the

patient is noted to have bulging sclerae Mean arterial pressure is 50 mm Hg, temperature

is 28° C, and there is no ECG activity The most ap propriate action to take at this time is to

A Administer mannitol, 50 gm IV

B Administer furosemide, 20 mg IV

C Decrease the cardiac index

D Check the position of the aortic cannula

E Check the position of the venous return cannula

925 Which of the following correctly describes the effect of transposition of the great vessels on

the rate of induction of anesthesia?

A Inhalation induction is faster than normal; intravenous induction is slower than normal

B Inhalation induction is slower than normal; intravenous induction is faster than normal

C Both inhalation and intravenous induction are faster than normal

D Both inhalation and intravenous induction are slower than normal

E Inhalation induction is normal; intravenous induction is faster than normal

926 Anastomosis of the right atrium to the pulmonary artery (Fontan procedure) is a useful surgical treatment for each of the following congenital cardiac defects EXCEPT

A Tricuspid atresia

B Hypoplastic left heart syndrome

C Pulmonary valve stenosis

D Truncus arteriosus

E Pulmonary artery atresia

927 By what percentage is tissue metabolic rate reduced during cardiopulmonary bypass at

A Immediately after P wave on ECG

B Immediately after closure of aortic valve

C During opening of the aortic valve

D During systolic upstroke on arterial tracing

C Tetralogy of Fallot

D Congestive heart failure

E Patent ductus arteriosus

930 Administration of protamine to a patient who has not received heparin can result in

931 The primary determinants of myocardial O2 consumption, from most to least important, are

A Preload > afterload > heart rate

B Heart rate > preload > afterload

C Afterload > preload > heart rate

D Heart rate > afterload > preload

E Afterload > heart rate > preload

932 Cardiac tamponade is associated with

E 130 mm Hg

935 Hypothyroidism and hyperthyroidism could develop in patients receiving which of the

following antidysrhythmic drugs?

937 Which of the following is NOT included in tetralogy of Fallot?

A Patent ductus arteriosus

B Right ventricular hypertrophy

C Ventricular septal defect

D Overriding aorta

E Pulmonic stenosis

938 A 65-year-old female patient with sepsis is undergoing an emergency exploratory

laparotomy After induction of anesthesia and tracheal intubation, the patient’s blood pressure is noted to be 65 systolic with a heart rate of 120 beats/min Cardiac output determined by a thermodilution pulmonary artery catheter is 13 L/min Of the following

vasopressors the LEAST appropriate choice would be

939 Characteristics of ß2 stimulation include each of the following EXCEPT

A Inhibition of insulin secretion

B Glycogenolysis

C Gluconeogenesis

D Renin secretion

E Uterine relaxation

940 A 61-year-old male patient with hypertropic cardiomyopathy is scheduled for left ventricular

myectomy under general anesthesia Which of the following anesthetics would provide the most stable hemodynamics in this patient?

941 A healthy 59-year-old, 60-kg woman with a normal preoperative ECG develops wide

complex tachycardia under general anesthesia for breast biopsy Blood pressure is 81/47

mm Hg and heart rate is 220 beats/min and regular The most appropriate therapy would

942 Although ß-adrenergic receptor blockade is the best treatment for reentrant

tachydysrhythmia associated with Romano-Ward syndrome, these dysrhythmias can also

be effectively treated with

A Lidocaine

B Procainamide

C Quinidine

D Left stellate ganglion blockade

E Right stellate ganglion blockade

943 A 64-year-old patient with an axial flow left ventricular assist device (HeartMate II, Jarvik

2000) is scheduled for laparoscopic cholecystectomy under general anesthesia

Monitoring which of the following parameters is likely to be difficult in this patient?

A Blood pressure with blood pressure cuff

B Blood pressure with arterial line

C Pulmonary artery pressure with pulmonary artery (PA) catheter

D Temperature with esophageal temperature probe

E End tidal isoflurane concentration with mass spectrometer

944 In a normal person, what percentage of the cardiac output is dependent on the “atrial

kick”?

A 25%

B 35%

C 45%

E Severe diastolic dysfunction

946 A 1-year-old child with tetralogy of Fallot is to undergo elective repair of a left inguinal

hernia under general anesthesia Which of the following anesthetics would provide the most stable hemodynamics in this patient?

A Sevoflurane and N2O

B Isoflurane and N2O

C Desflurane and oxygen

E Chronic aortic insufficiency

948 A 54-year-old patient is undergoing a three-vessel coronary artery bypass graft under

general anesthesia After induction, the pulmonary capillary wedge pressure is 15 mm Hg and pulmonary artery pressures are 26/13 mm Hg Suddenly, new 30-mm Hg V waves appear on the monitor screen Systemic blood pressure is 120/70 mm Hg, heart rate is 75 beats/min, and pulmonary artery pressure is 50/35 mm Hg Which of the following drugs should be administered to the patient?

949 A 62-year-old patient scheduled for elective repair of an abdominal aortic aneurysm

develops a wide complex regular tachycardia (heart rate 150) during induction of

anesthesia Blood pressure is 110/78 Which of the following drugs would be most useful

in the management of this dysrhythmia?

A Lidocaine, 100 mg IV

B Amiodarone, 150 mg IV over 10 minutes

C Adenosine, 6 mg rapidly over 3 seconds

D Verapamil, 5 to 10 mg IV

E Esmolol, 35 mg IV

950 Under maximum stress, how much cortisol is produced per day?

951 A VVI pacemaker programmed to pace at a rate of 70 beats/min is noted on the

preoperative ECG to pace at 61 beats/min The most likely reason for this decrease in the pacing heart rate is

A Decreased atrial rate

B Third-degree heart block

C Trifascicular heart block

D Battery failure

E Normal variation

952 Calculate the cardiac output from the following data: patient weight 70 kg, hemoglobin

concentration 10 mg/dL, arterial blood gases on 100% O2: PaO2 450 mm Hg, PaCO2 32

mm Hg, pH 7.46, SaO2 99% Mixed venous blood gases are: PvO2 30 mm Hg, PaCO2 45

mm Hg, pH 7.32, SvO2 60%

A 2.5 L/min

B 3.0 L/min

C 3.5 L/min

954 A 22-year-old man with hypertrophic cardiomyopathy (HOCM) is undergoing an elective

cholecystectomy under general anesthesia Immediately after induction with thiopental, 5 mg/kg IV, the arterial blood pressure decreases from 140/82 to 70/40 mm Hg What would

be the most appropriate drug for treatment of hypotension in this patient?

955 A 65-year-old patient with moderate aortic stenosis develops a sudden increase in heart

rate during an appendectomy under general anesthesia The ventricular rate is 190 beats/min and is irregularly irregular, arterial blood pressure is 70/45 mm Hg, and there is

2 mm ST-segment depression in lead V5 of the ECG Which of the following would be the

most appropriate treatment for myocardial ischemia in this patient?

956 After emergency repair of a ruptured abdominal aortic aneurysm, a 68-year-old patient is

mechanically ventilated in the intensive care unit with 20 cm H2O of positive end-expiratory pressure (PEEP) for 3 days Sodium nitroprusside has been infused at a rate of 1.5

µg/kg/min for 48 hours to control hypertension Suddenly, the systemic blood pressure falls from 130/70 to 50 mm Hg systolic and the SaO2 drops to 75% The most likely cause of this scenario is

E Pulmonary artery catheter migration

959 Allergic reactions to protamine can occur with each of the following EXCEPT?

A Diabetes treated with NPH insulin

B Diabetes treated with regular insulin

C Diabetics treated with PZI insulin

D Previous vasectomy

E Allergy to seafood

960 A 66-year-old patient is undergoing a three-vessel coronary artery bypass operation

Anticoagulation is achieved with 20,000 units of heparin How much protamine should be administered to this patient to completely reverse the heparin after cardiopulmonary

A Ventricular end-diastolic pressure as a function of ventricular end-diastolic volume

B Stroke volume as a function of end-diastolic pressure

C Cardiac index as a function of end-diastolic pressure

D Cardiac output as a function of ventricular end-diastolic volume

E Diastolic time (as percentage of cardiac cycle) as a function of heart rate

962 A 72-year-old woman is undergoing cardiopulmonary bypass for aortic and mitral valve

replacement The surgery is uneventful; however, in the intensive care unit, blood is noted

to ooze from the pulmonary artery catheter and venous access sites Mediastinal chest tube output is 500 mL/hour A thromboelastogram is obtained and shown in the figure What is the most likely cause of profuse bleeding in this patient?

A Fibrinolysis

B Excess heparin

C Thrombocytopenia

D Factor VIII deficiency

E Poor surgical hemostasis

963 A 170-micrometer filter must be used for administration of each of the following EXCEPT

A Fresh frozen plasma

B Cryoprecipitate

C Platelets

D Packed red cells

E Albumin

964 The dose of adenosine necessary to convert paroxysmal supraventricular tachycardia to

normal sinus rhythm should be initially reduced

A In patients receiving theophylline for chronic asthma

B In patients with a history of arterial thrombotic disease taking dipyridamole

C In patients with a history of chronic renal failure

D In patients with hepatic dysfunction

E In chronic alcoholics

965 A 56-year-old male patient is anesthetized for elective coronary revascularization A

urinary catheter is placed after induction and coupled to a temperature transducer A pulmonary artery catheter is inserted, and the temperature probe on the distal portion of the catheter is also connected to a transducer The reason for measuring the temperature

of both the bladder and the blood in the pulmonary vasculature is

A Both are necessary for determining cardiac output by the thermodilution technique

B Bladder temperature is more accurate prebypass; pulmonary artery catheter

temperature is more accurate postbypass

C Pulmonary artery catheter temperature is more accurate prebypass; bladder

temperature is more accurate postbypass

D It is helpful in determining the likelihood of recooling after discontinuation of

cardiopulmonary bypass

E It is the average of these two temperatures, which is important in determining patient

body warmth

966 Which of the following would be the best intraoperative transesophageal echocardiograph

(TEE) view to monitor for myocardial ischemia?

A Mid-esophageal 4 chamber view

B Transgastric mid-papillary left ventricular short axis view

C Mid-esophageal long axis view

D Mid-esophageal 2 chamber view

E Transgastric 2 chamber view

967 Select the true statement regarding CPR and defibrillation by a health care provider in

patients experiencing sudden cardiac arrest

A Defibrillation times one should always precede CPR

B CPR should always be carried out for 2 minutes prior to defibrillation

C Two minutes of chest compressions alone (no ventilation) should be carried out prior

to first shock

D If arrest less than 1 minute (witnessed) one biphasic shock then 5 cycles of CPR

E If arrest less than 1 minute (witnessed) three biphasic shocks then 5 cycles of CPR

968 Which of the following medications blocks angiotensin at the receptor?

972 What is the minimal time after angioplasty and placement of a drug eluting stent that dual

antiplatelet therapy should be continued before considering stopping it for elective

A Heparin resistance

B Protamine allergy

C Heparin induced thrombocytopenia type I

D Heparin induced thrombocytopenia type II

E Antithrombin deficiency

974 Which of the following anatomical sites is associated with the LEAST incidence of central

line infection?

A Internal jugular vein

B External jugular vein

C Subclavian vein

D Femoral vein

E The incidence is roughly equal for all sites

975 The effects of clopidogrel (Plavix) can be reversed with

A Fresh frozen plasma

B Protamine

C Aprotinin

D Factor VIII concentrate

E None of the above

976 A disadvantage of port access coronary artery bypass surgery utilizing the da Vinci Robot

versus “standard” coronary artery revascularization with cardiopulmonary bypass is

A Need for hypothermic cardiac arrest

B Greater incidence of intraoperative hypoxia

C Greater incidence of trauma to sternum

D Increased transfusion requirements

E Increased risk of neuropsychiatric deficits

977 A right sided double lumen tube will be used to separate ventilation of the right and left

lungs for a left pneumonectomy The plan for placement is to insert the distal tube into the trachea with a laryngoscope and then to advance the distal tube into the right mainstem bronchus under bronchoscopic guidance After insertion of the tube with the laryngoscope,

CO2 is seen on mass spectrometer and the scope is passed through bronchial port until it exits the tube inside the lumen of the patient’s airway A structure is seen which appears to

be the carina The scope is then passed into the right branch and the structure in the picture below is visualized The scope is located in the

A Right mainstem bronchus

B Left mainstem bronchus

C Lingular segment

D Right upper lobe

E Left upper lobe

978 Which of the following maneuvers (after assuring proper tube placement) is LEAST likely

to raise the PaO2 during one-lung ventilation with a double lumen endotracheal tube?

A Continuous positive airway pressure (CPAP) to the non-dependent lung

B Positive end-expiratory pressure (PEEP) to the dependent lung