Deppu Ushakumari and Ashish Sinha
1. Which of the following is responsible for the plateau phase of cardiac action potential?
A. Slow movement of potassium out of the cell
B. Slow movement of calcium into the cell
C. Slow movement of calcium out of the cell
D. Both A and C
2. A 2-year-old boy is induced with halothane-inhalation induction. The patient suddenly gets bradycardic, and you decide to administer atropine 0.4 mg intravenously. Immediately thereafter, you notice that the patient is having a junctional tachycardia. Which of the following most accurately describes the sequence of events?
A. Sinoatrial (SA) node suppression by halothane followed by anticholinergic action of atropine
B. Atrioventricular (AV) node suppression by halothane followed by anticholinergic action of atropine
C. SA node and AV node suppression by halothane followed by anticholinergic action of atropine
D. SA node and AV node suppression by halothane followed by paroxysmal tachycardic action of atropine
3. Significant intravenous absorption/inadvertent intravenous injection of bupivacaine can cause profound bradycardia and sinus node arrest. Which of the following best describes the mechanism of cardiac toxicity of bupivacaine?
A. Bupivacaine binds inactivated fast sodium channels and dissociates from them slowly
B. Bupivacaine binds activated fast sodium channels and dissociates from them slowly
C. Bupivacaine binds inactivated slow sodium channels and dissociates from them slowly
D. Bupivacaine binds activated slow sodium channels and dissociates from them slowly
4. The mechanisms of depression of cardiac contractility by volatile anesthetics include all the following, except
A. They decrease the entry of calcium into cells during depolarization
B. They affect only L-type calcium channels
C. They alter kinetics of calcium release
D. They decrease the sensitivity of contractile proteins to calcium
5. The mechanism of “x” descent (descent between C and V waves) in the following right atrial tracing (Fig 11-1) is
A. Downward movement of the atrioventricular (AV) valve cusps after ventricular contraction
B. Pulling down of the atrium by ventricular contraction
C. Relaxation of atrium after atrial systole
D. Decline in atrial pressure as the AV valves open
6. A 38-year-old healthy male volunteer is undergoing cardiac function tests as part of a physiology experiment. His vital signs are HR = 62 bpm, BP = 124/74 mm Hg, respiratory rate = 12 breaths/min, SpO2 = 100% on room air, and Hb = 14 g/dL. Which of the following is the best determination of the adequacy of his cardiac output?
A. Cardiac index 4.0 L/min/m2
B. Cardiac output 8.1 L/min by thermodilution technique
C. Cardiac output 8.1 L/min by Fick method
D. SvO2 of 75% from a pulmonary artery (PA) catheter
7. Which of the following patients will be affected the most from loss of atrial contribution to preload?
A. A 65-year-old patient with severe aortic regurgitation who went into recent onset atrial fibrillation
B. A 35-year-old patient with mitral-valve area of 1.0 cm2 who went into recent onset atrial fibrillation
C. An 80-year-old patient with severe aortic stenosis who went into recent onset atrial fibrillation
D. A 55-year-old patient with acute right-ventricular myocardial infarction
8. Which of the following formulae explains the hypertrophy of heart in response to pressure or volume loads (P, intraventricular pressure; R, ventricular radius; t, wall thickness; T, circumferential stress)?
A. P = 2Tt/R
B. T = 2P/Rt
C. T = 2R/Pt
D. PT = Rt
9. Dose of heparin (U/kg) administered for cardiopulmonary bypass is (approximately)
A. 100 to 200
B. 200 to 300
C. 300 to 400
D. 400 to 500
10. The sinoatrial and the atrioventricular (AV) nodes are supplied in majority of the individuals by
A. Left anterior descending artery
B. Right coronary artery
C. Circumflex artery
D. Posterior descending artery
11. Baroreceptor reflex is ineffective for long-term blood pressure (BP) control because
A. Renin angiotensin aldosterone system takes over the control
B. Renal regulation of BP is more powerful
C. Of adaptation to changes in BP over 1 to 2 days
D. All of the above
12. Which of the following portions of myocardium has a dual blood supply?
A. Bundle of His
B. Atrioventricular node
C. Posterior papillary muscle
D. Sinoatrial node
13. Which of the following types of myocardial work needs the highest oxygen requirement?
A. Electrical activity
B. Volume work
C. Pressure work
D. Basal requirement
14. Which of the following inhalational agents causes the least coronary vasodilation?
A. Halothane
B. Isoflurane
C. Desflurane
D. Sevoflurane
15. Which of the following surgeries carries the highest cardiovascular risk?
A. Emergency appendectomy
B. Carotid endarterectomy
C. Femoral–popliteal bypass surgery
D. Inguinal hernia repair
16. A 67-year-old patient with uncontrolled hypertension presents for an elective dialysis access creation. Which of the following techniques is not suited for attenuating the hypertensive response to intubation?
A. Administering 3 μg/kg of fentanyl intravenously
B. Administering topical airway anesthesia
C. Administering lidocaine 0.5 mg/kg intravenously
D. Administering esmolol 1 mg/kg intravenously
17. The patient mentioned above develops severe hypotension immediately after intubation. Which of the following agents is most suited to bring the blood pressure back to normal values?
A. Ephedrine
B. Phenylephrine
C. Epinephrine
D. Dopamine
18. Which of the following antianginal agents has the highest coronary vasodilating potential?
A. Nitrates
B. Verapamil
C. Dihydropyridines
D. β-Blockers
19. Which of the following statements about calcium channel blockers (CCBs) is not true?
A. CCBs potentiate both depolarizing and nondepolarizing neuromuscular blockers
B. CCBs potentiate the circulatory effects of volatile anesthetic agents
C. Verapamil may decrease anesthetic requirements
D. Verapamil has no effect on cardiac contractility; it acts only on the atrioventricular (AV) node
20. Which of the following β-blockers is most suited for a patient with bronchospastic disease?
A. Propranolol
B. Metoprolol
C. Acebutolol
D. Bisoprolol
21. A 24-year-old female patient with a preoperative QTc interval of 550 ms is undergoing breast surgery under general anesthesia. Droperidol is administered to the patient for prevention of postoperative nausea, following which the patient goes into polymorphic-ventricular tachycardia. Which of the following drugs/therapies is best for the patient at this point?
A. Amiodarone
B. Lidocaine
C. Pacing
D. Diltiazem
22. Which of the following factors is not associated with severe multivessel disease during exercise electrocardiography?
A. Sustained decrease (≥10 mm Hg) in systolic blood pressure during exercise
B. Failure to reach a maximum heart rate greater than 70% of predicted
C. Persistence of ST-segment depression after exercising for 5 minutes or longer
D. A 1-mm upsloping of ST segment
23. Surgical electrocautery may cause a problem with an automated implantable cardioverter defibrillator (AICD) by all the following mechanisms, except
A. AICD interpreting a cautery current as ventricular fibrillation
B. Inhibition of pacemaker function due to cautery artifact
C. Increased pacing rate due to activation of a rate-responsive sensor
D. Cautery current generating too much heat at the location of AICD and causing burns
24. Which of the following ECG leads is most sensitive to detect an anterior-wall myocardial ischemia?
A. V5
B. V4
C. II
D. V2
25. Which of the following is not true about systemic hypothermia during cardiopulmonary bypass (CPB)?
A. Intentional hypothermia is always used following the initiation of CPB
B. Core body temperature is usually reduced to 20 to 32°C
C. Metabolic oxygen requirements are usually halved for every of 10°C reduction in temperature
D. Profound hypothermia to temperatures of 15 to 18°C allows total circulatory arrest for up to 60 minutes
26. Adverse effects of hypothermia include all the following, except
A. Platelet dysfunction
B. Irreversible coagulopathy
C. Potentiation of citrate toxicity
D. Depression of myocardial contractility
27. Coronary perfusion pressure is
A. Arterial diastolic pressure | left-ventricular end diastolic pressure |
B. Arterial diastolic pressure | left-ventricular end systolic pressure |
C. Arterial systolic pressure | left-ventricular end diastolic pressure |
D. Arterial systolic pressure | left-ventricular end systolic pressure |
28. Which of the following views of transesophageal echocardiograph (TEE) is most suited to visualize blood supply of all the segments of the heart?
A. Midesophageal fourth-chamber view
B. Midesophageal second-chamber view
C. Transgastric midshort axis view
D. Midesophageal third-chamber view
29. Disadvantages of high-dose opioid induction include all the following, except
A. Prolonged postoperative respiratory depression
B. High incidence of recall during surgery
C. Possible impairment of immune response
D. Myocardial depression
30. A 66-year-old male is undergoing coronary artery bypass grafting (CABG). After the chest is opened, a progressive decline in cardiac output is noticed. The most accurate statement regarding the change is
A. It is normal in deeply anesthetized patients
B. Intravenous fluid administration will not help correct this change
C. It implies imminent risk of death, and you should ask for blood to be transfused
D. It is caused by surgeon lifting the heart, especially if it is not accompanied by a drop in blood pressure
31. Aprotinin therapy should be considered for all of the following patients, except
A. Jehovah witnesses
B. Redo surgeries
C. Patients who had prior exposure to aprotinin
D. Patients on combined clopidogrel (Plavix) and aspirin therapy
32. Which of the following statements is false regarding placement of venous cannulas for cardiopulmonary bypass (CPB)?
A. Venous cannulas are inserted before aortic cannula placement
B. Venous cannula insertion frequently precipitates atrial or ventricular arrhythmias
C. Venous cannulas can impede venous return to the heart
D. Venous cannulas can cause superior vena cava syndrome
33. Following initiation of cardiopulmonary bypass (CPB) for aortic valve replacement, you notice the mean arterial pressure (MAP) consistently above 100 mm Hg. The most appropriate next step is
A. It is normal, and no action is needed
B. Pump flow should be decreased to decrease the blood pressure
C. It is usually caused by an air lock in the arterial cannula
D. Administer midazolam to prevent awareness
34. Which of the following is not an indication of low flow rates under cardiopulmonary bypass (CPB)?
A. SvO2 >80%
B. Progressive metabolic alkalosis
C. Low urine output
D. Hypoxemia noticed on an in-line venous oxygen saturation monitor
35. Discontinuing ventilation prematurely before full flow is achieved on cardiopulmonary bypass (CPB) causes
A. A right-to-left shunt leading to hypoxemia
B. Increased dead space
C. Helps to increase venous return via the venous outflow cannula
D. Aids the surgeon to visualize and cannulate the coronary sinus
36. Which of the following is the most sensitive to detect air bubbles at the termination of cardiopulmonary bypass (CPB)?
A. Transesophageal echocardiography (TEE)
B. Doppler ultrasonography
C. Manual visualization
D. Epiaortic echocardiography
37. Sweating during the rewarming phase of termination of cardiopulmonary bypass (CPB)
A. Implies light anesthesia
B. Is a hypothalamic response to perfusion with blood that is often at 39°C
C. Necessitates cooling the operating room
D. Can be prevented by using a forced air-warming device during the surgery
38. Use of corrected gas tensions during hypothermia
A. Is called pH-stat management
B. Preserves cerebral autoregulation
C. Improves myocardial preservation
D. Is done by adding sodium bicarbonate to the venous reservoir
39. Infusion of nitroglycerin at the termination of cardiopulmonary bypass (CPB)
A. Dilates the coronary vessels and helps improve coronary flow
B. Speeds the rewarming process and decreases large temperature gradients
C. Is an old technique that produces unnecessary hemodynamic changes
D. Improves renal blood flow
40. General guidelines for separation from cardiopulmonary bypass (CPB) include all the following, except
A. Core body temperature of at least 34°C
B. Stable heart rhythm or pacer rhythm
C. Heart rate around 80 to 100 bpm
D. Adequate ventilation with 100% O2
41. Timing of inflation of an intra-aortic balloon pump (IABP) should be
A. Just before the dicrotic notch
B. Just after the dicrotic notch
C. As soon as the downward slope of aortic pulse begins
D. Synchronized with the rise of aortic pulse
42. A 68-year-old patient with an infected prosthetic aortic valve underwent a valve replacement. Post–cardiopulmonary bypass (CPB), his central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance (SVR) are low, while the cardiac output (CO) is high. The next step in management of this patient is
A. Adding an inotrope
B. Adding intra-aortic balloon pump (IABP)
C. Adding a pulmonary vasodilator
D. Increasing the hematocrit
43. After neutralizing heparin, which of the following is the fate of the heparin–protamine reaction product?
A. The only product remaining will be water since it is an acid–base reaction
B. It is removed by the reticuloendothelial system
C. It is removed by the kidneys
D. It is excreted unchanged via gastrointestinal (GI) tract
44. Heparin rebound after termination of cardiopulmonary bypass (CPB) is due to
A. Redistribution of protamine to peripheral compartments
B. Redistribution of heparin to central compartment
C. Both A and B are true
D. Both A and B are false; it is due to inadequate protamine dosing
45. DDAVP (desmopressin) administration can increase the activity of all the following factors, except
A. Factor VII
B. Factor VIII
C. Factor XII
D. von Willebrand factor
46. In the first few postoperative hours after an open heart surgery, the emphasis is on
A. Monitoring for excessive postoperative bleeding
B. Maintaining adequate urine output
C. Trying for an early extubation
D. Maintaining euthermia
47. Inhaled nitric oxide (NO) at 60 ppm has all of the following effects, except
A. Drop in systemic vascular resistance (SVR)
B. Drop in pulmonary vascular resistance (PVR)
C. Improvement in cardiac output
D. Better right coronary perfusion
48. Donor–recipient compatibility in cardiac transplantation is based on all, except
A. Heart size
B. ABO blood–group typing
C. Cytomegalovirus serology
D. Tissue crossmatching
49. The central venous pressure (CVP) waveform in cardiac tamponade is characterized by
A. Abolition of X descent
B. Abolition of Y descent
C. CV waveform
D. Tall C waves
50. In constrictive pericarditis,
A. Increased diastolic filling does not occur, in contrast to acute tamponade
B. The Y descent is absent in CVP waveform
C. Pulsus paradoxus is uncommon
D. Diffuse T-wave abnormalities are a rare sign
51. A 25-year-old male with a family history of sudden cardiac deaths is undergoing a laparoscopic appendectomy. Immediately after induction and intubation, you notice a heart rate of 120 bpm and blood pressure of 60/40 mm Hg, with a normal capnogram. You suspect the patient has idiopathic hypertrophic subaortic stenosis. Which of the following maneuvers is most likely to help this patient’s hemodynamics?
A. Lowering the head end of the bed and administering 10 mg of ephedrine IV
B. Administering a bolus of 1 L of normal saline and esmolol 10 mg IV
C. Administering verapamil 5 mg IV immediately
D. Administering a bolus of normal saline and phenylephrine 100 μg IV
52. Pulmonary capillary wedge pressure (PCWP) does not correspond to the left-ventricular end diastolic pressure (LVEDP) in all of the following situations, except
A. Mitral stenosis
B. Tricuspid regurgitation
C. Very high positive end–expiratory pressure (PEEP)
D. Left-atrial myxoma
53. Normal mixed venous oxygen tension is ______ (mm Hg):
A. 75
B. 40
C. 45
D. 560
54. The only clinically proven method to reduce the risk of perioperative myocardial infarction (MI) and associated death is
A. Perioperative β-blocker therapy
B. Perioperative clonidine therapy
C. Both A and B
D. Use of esmolol boluses intraoperatively to keep the heart rate <80 bpm
55. Which of the following statements is false regarding perioperative myocardial infarction (MI)?
A. Most perioperative MIs occur in the first 48 to 72 hours postoperatively
B. A 1-minute episode of 1-mm ST-segment elevation or depression on the ECG increases the risk for cardiac events by 10-fold
C. Perioperative risk reduction with β-blockers and clonidine is inferior to risk stratification with invasive testing, angioplasty, and coronary artery bypass grafting (CABG)
D. Tachycardia (>105 bpm) for 5 minutes in the postoperative period can increase the risk of death by 10-fold
56. Which of the following is the most effective means of predicting a perioperative cardiac event?
A. Echocardiography wall-motion abnormalities
B. Echocardiography ejection fraction
C. Dipyridamole–thallium scintigraphy
D. Careful preoperative evaluation
57. Which of the following is most effective method of preventing the hemodynamic changes associated with intubation?
A. Brief laryngoscopy (<15 seconds)
B. Esmolol 1 mg/kg IV before intubation
C. Lidocaine 2 mg/kg before intubation
D. Deepen the anesthesia with propofol 1 mg/kg
58. Which of the following events is not likely to adversely affect hemodynamics in a patient with mitral-valve prolapse?
A. Sympathetic stimulation
B. Decreased systemic vascular resistance
C. Head-up position of the patient
D. Increased pulmonary vascular resistance
59. Anesthetic considerations in a patient with mitral regurgitation include all the following, except
A. Avoid sudden decreases in heart rate
B. Avoid sudden decreases in systemic vascular resistance (SVR)
C. Minimize drug-induced myocardial depression
D. Monitor the magnitude of the C wave of CVP as a reflection of mitral-regurgitant flow
60. Treatment of patients with prolonged QT interval include all, except
A. β-Blockers
B. Right stellate ganglion block
C. Avoidance of drugs that prolong the QT interval
D. Availability of electrical cardioversion while the patients are undergoing surgical procedures
61. Anesthetic considerations in patients with aortic stenosis include all, except
A. Intra-arterial blood pressure monitoring
B. Prophylactic administration of intravenous vasoconstrictor phenylephrine
C. Avoidance of extreme bradycardia or tachycardia
D. Avoidance of sudden increases in systemic vascular resistance (SVR)
62. Ventricular premature beats (VPCs) can be treated with lidocaine (1–2 mg/kg IV) when they
A. Are frequent (more than six premature beats/min)
B. Are multifocal
C. Take place during the ascending limb of the T wave (R-on-T phenomenon)
D. All of the above
63. Which of the following drugs needs not be avoided in the anesthetic management of a patient with Wolff–Parkinson–White (WPW) syndrome?
A. Ketamine
B. Pancuronium
C. Succinylcholine
D. Digitalis
64. Which of the following statements is false regarding management of a patient with an automated implantable cardioverter defibrillator (AICD)?
A. The “magnet mode” is always safe
B. The ground plate should be placed as far as possible from the pulse generator
C. Bipolar electrocautery may be used over unipolar electrocautery to reduce interference between electrosurgical cautery and the pacemaker
D. The magnet mode may produce asynchronous pacing at 99 bpm
65. Cardiac tamponade is characterized by
A. Increase in diastolic filling of the ventricles
B. Decrease in stroke volume
C. Increase in systemic blood pressure due to increased intrapericardial pressure from accumulation of fluid in the pericardial space
D. Systolic dysfunction, and not diastolic dysfunction, is the primary problem
66. An 81-year-old patient with a history of moderate aortic regurgitation is undergoing a coronary artery bypass grafting (CABG). The surgeon decides not to vent the left ventricle. You think this is a wrong decision, and your arguments include all the following, except
A. Venting can be done through a drain placed from the right superior pulmonary vein into the left ventricle
B. Venting can be done through a pulmonary venous drain
C. Retrograde flow through the aortic valve could cause left-ventricular distension
D. Venting done by aspirating from the antegrade cardioplegia line placed in the proximal ascending aorta will not be helpful
67. Centrifugal pumps are superior to roller pumps because of all, except
A. They are less traumatic to blood cells
B. They do not pump air bubbles secondary to air being less dense than blood
C. They are afterload-dependent, and avoid the risk of line rupture with clamping of the arterial inflow circuit
D. Roller pumps compress the fluid-filled tubing between the roller and curved metal back plate and hence avoid air
68. During cardiopulmonary bypass (CPB), the nasopharyngeal temperature is 28°C, the hematocrit is 20%, the temperature corrected PaCO2 is 50 mm Hg, and the uncorrected PaCO2 is 60 mm Hg. The most appropriate management is to
A. Administer additional opioid
B. Administer packed red blood cells to increase hematocrit to 25%
C. Further decrease the patient’s temperature
D. Increase fresh-gas flow to the oxygenator
69. Two days after coronary artery bypass grafting, a 62-year-old man remains sedated, endotracheally intubated, and mechanically ventilated. Over the next 3 hours, PaO2 decreases from 90 to 70 mm Hg at an FIO2 of 0.7, peak inspiratory pressure measured proximally in the ventilator circuit increases from 40 to 66 cm H2O, and plateau pressure remains unchanged at 30 cm H2O. Which of the following is the most likely case of these changes?
A. Adult respiratory distress syndrome (ARDS)
B. Bronchial mucus plugging
C. Left-ventricular failure
D. Tension pneumothorax
70. Regarding the maintenance of blood pressure during cardiopulmonary bypass (CPB), which of the following is false?
A. Lower blood pressures may reduce cerebral blood flow and reduce emboli load to the brain, while higher pressures may improve cerebral blood flow but cause more emboli
B. Pressures less than 40 mm Hg are avoided if possible in adults
C. Pressures higher than 90 mm Hg are used during rewarming
D. Pressures up to 90 mm Hg may be used in patients with cerebral vascular disease
71. During total cardiopulmonary bypass, metabolic acidosis and decreasing mixed venous oxygen saturation are noted. The most likely cause is
A. Hypothermia
B. Hypoperfusion
C. Rewarming
D. Light anesthesia
72. While monitoring coronary sinus pressure during retrograde cardioplegia,
A. If the pressure at the distal tip of the coronary sinus catheter during cardioplegia administration at 200 mL/min is equal to central venous pressure, the catheter is not in the coronary sinus but is most likely in the pulmonary artery
B. If the pressure is very high (>100 mm Hg), the coronary sinus catheter is in the left ventricle
C. If the pressure in the coronary sinus catheter is 40 to 60 mm Hg during a 200-mL/min infusion, the catheter is correctly positioned
D. If the catheter is placed too distally, delivery of cardioplegia to the left ventricle will be compromised and result in left-ventricular dysfunction
73. The electromechanically quiet heart at 22°C consumes oxygen at a rate of
A. 2 mL/100 g/min
B. 8 mL/100 g/min
C. 0.3 mL/100 g/min
D. 0.1 mL/100 g/min
74. Additional supplemental anesthetics and muscle relaxants should be administered
A. At institution of cardiopulmonary bypass (CPB)
B. At rewarming
C. Both A and B
D. In the early period after conclusion of CPB
75. The most common hemodynamic abnormality after cardiopulmonary bypass (CPB) is
A. Low cardiac output
B. Low systemic vascular resistance (SVR)
C. High pulmonary vascular resistance
D. Low heart rate
76. A 57-year-old male is undergoing coronary artery bypass grafting (left internal mammary artery to left anterior descending artery). After termination of cardiopulmonary bypass (CPB), you notice a prominent V wave in the pulmonary artery occlusion pressure (PAOP) tracing. The most likely reason for the finding is
A. Left-ventricular dysfunction
B. Right-ventricular dysfunction
C. Cardiac tamponade
D. Posterior papillary muscle dysfunction
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