Gastrointestinal, Liver, and Renal Diseases
Thoha Pham
1. A 38-year-old woman with a history of diverticulosis is scheduled for an exploratory laparotomy for lysis of adhesions. Which of the following is the best way of maintaining core body temperature during the initial hour of general endotracheal anesthetic?
A. Providing warm and humidified inspired gases
B. Increasing ambient temperature
C. Administration of warm intravenous fluids
D. Use of warm irrigating fluids
2. Each of the following would be expected in an otherwise-healthy 125-kg (BMI 40 kg/m2) man undergoing open cholecystectomy, except
A. Decreased functional residual capacity
B. Increased intra-abdominal pressure and risk of reflux
C. Increased metabolism of volatile anesthetics
D. Decreased metabolism of atracurium
3. Which of the following has a dual effect of increasing gastric pH, and decreasing the gastric volume to minimize risks associated with aspiration?
A. Prochlorperazine
B. Ranitidine
C. Ondansetron
D. Metoclopramide
4. This finding is indicative of microatelectasis on the second postoperative day after major abdominal surgery:
A. Hypercarbia
B. Hypoxemia
C. Diffuse wheezing
D. Tactile fremitus
5. A morbidly obese 60-year-old man with a 65-pack year history of tobacco smoking is awake after an uncomplicated general anesthetic with sevoflurane for routine endoscopy and colonoscopy screening. After 45 minutes in the recovery room (PACU), while breathing 6 L/min of oxygen via nasal cannula, his pulse oximetry drops to 88%. His rest of the vital signs are stable, and the lungs are clear to auscultation. The most effective management at this point is
A. Coughing with deep breathing
B. Reintubation of the trachea
C. Intravenous administration of doxapram
D. Continuous positive-airway pressure
6. During rapid-sequence induction of anesthesia for emergent laparotomy to explore multiple stab wounds, a 45-year-old man vomits a large quantity of undigested food particles. During intubation of the trachea, food particles are noted near the cords. After instituting ventilation with 100% oxygen, the most appropriate next step in this patient’s management is
A. Place patient in Trendelenburg position
B. Ventilate with positive end–expiratory pressure of 15 cm H2O
C. Administer corticosteroids
D. Administer antibiotics
7. A 71-year-old female develops a severe case of diarrhea with multiple loose bowel movements since awakening this morning. When she arrives preoperatively for her surgery, an arterial blood gas (ABG) is obtained. The most likely finding would be
A. pH = 7.30, PaCO2 = 50, PaO2 = 60, HCO3 − = 24
B. pH = 7.35, PaCO2 = 32, PaO2 = 85, HCO3 − = 18
C. pH = 7.45, PaCO2 = 30, PaO2 = 80, HCO3 − = 28
D. pH = 7.40, PaCO2 = 45, PaO2 = 85, HCO3 − = 15
8. A 65-year-old patient is noted to have excessive bleeding during a colectomy with an activated clotting time (ACT) of 200 seconds. The most unlikely reason for this oozing is
A. Undiagnosed factor VII deficiency
B. Prior administration of heparin 5,000 U subcutaneously
C. Preoperative ingestion of aspirin and ibuprofen
D. Dilutional thrombocytopenia
9. During laparotomy, a patient has required infusion of 4 L of lactated Ringer’s and 4 U of packed red blood cells (pRBCs). As the fifth unit of pRBCs begins infusing, patient has sudden onset of tachycardia and hypotension. Within a few minutes, Foley bag reveals dark urine. The most likely cause of unexplained oozing is
A. Hemolytic transfusion reaction
B. Leukoagglutinin reaction
C. Dilutional thrombocytopenia
D. Dilutional coagulopathy
Questions 10 to 12
A 26-year-old male patient with a history of severe ulcerative colitis, unresponsive to conservative measures, presents for elective open total abdominal colectomy with end ileostomy. He has been unable to eat for the last 2 weeks and was started on total parenteral nutrition (TPN) several days prior.
10. Intraoperative effect that should be expected and monitored for is
A. Dilutional anemia
B. Hyperglycemia
C. Sepsis
D. Hyperphosphatemia
11. At the conclusion of the surgery, the patient fails to regain consciousness. The metabolic complication of TPN (Table 14-1) that is likely is
Table 14-1 Metabolic Complications of TPN.
Glucose (hypoglycemia, hyperosmolar nonketotic coma) Protein (hyperammonemia) Hypercalcemia Hypophosphatemia Essential fatty acid deficiency Vitamin toxicity |
A. Azotemia
B. Hyperkalemia
C. Hyperosmolar ketotic hyperglycemia
D. Hyperosmolar nonketotic hyperglycemia
12. Consider that the patient opens his eyes and is extubated in the operating room. However, 15 minutes after arriving to the recovery room (PACU) he is unable to maintain adequate ventilation and oxygenation. Physical exam reveals profound global weakness with absent reflexes. The specific electrolyte abnormality that should be evaluated considering his TPN requirement is
A. Potassium
B. Phosphate
C. Sodium
D. Glucose
13. Each of the following statements about the preoperative management of an adrenal pheochromocytoma is true, except
A. Adequate blockade can be assessed by in-house blood pressures <160/90 mm Hg for 24 hours prior to surgery
B. β-Blockers should be administered only in conjunction with adequate α-blockade
C. Administration of α-blocker can decrease operative mortality
D. Nasal congestion is a sign of inadequate α-adrenergic block
14. A 40-year-old man undergoing an open resection of a pheochromocytoma under isoflurane general endotracheal anesthesia suddenly develops tachycardia, hypertension, and multifactorial ventricular ectopy. Each of the following could be considered an appropriate treatment option, except
A. Switching from isoflurane to sevoflurane
B. Intravenous vasodilator
C. Intravenous α-blocker
D. Intravenous lidocaine
15. An otherwise-healthy 38-year-old female patient is undergoing repair of a large ventral hernia under intrathecal anesthesia. A T2 sensory level is obtained with hyperbaric bupivacaine prior to incision. A false statement concerning this situation includes
A. Effective cough is preserved
B. The cardioaccelerator nerves are blocked
C. Examination of the biceps reveals full strength bilaterally
D. Bupivacaine binds to the intracellular portion of sodium channels
16. A patient with cholestasis presents for preoperative evaluation with laboratory findings revealing normal aspartate aminotransferase (serum glutamic–oxaloacetic transaminase) and prothrombin time but with a markedly elevated alkaline phosphatase. He will need a muscle relaxant for upcoming colon surgery. Which of the following anesthetic scenarios should be considered?
A. Prolonged duration of vecuronium action
B. Increase intubating dose of atracurium
C. Prolonged duration of succinylcholine action
D. Shortened duration of pancuronium action
17. An alcoholic 62-year-old male patient is noted to have jaundice one day after a laparoscopic cholecystectomy under halothane/fentanyl general endotracheal anesthesia. Bilirubin and alkaline phosphatase are elevated, but alanine aminotransferase (serum glutamic–pyruvic transaminase [SGPT]) and aspartate aminotransferase (serum glutamic–oxaloacetic transaminase [SGOT]) are within normal ranges. Of note, all values were within normal limits in this patient preoperatively. The most likely cause of his jaundice is
A. Idiopathic halothane hepatic injury
B. Worsening of underlying chronic liver dysfunction
C. Posthepatic biliary obstruction
D. Intravenous acetaminophen administration
18. An initial bolus of pancuronium was administered to a patient with end-stage liver disease with associated ascites for general anesthesia. Appropriate anesthetic considerations include all of the following, except
A. Increased sympathomimetic activity due to vagolysis
B. Intense histamine release immediately after administration
C. Larger volume of distribution requiring initial larger doses
D. Longer duration of action requiring smaller maintenance doses
19. A chronic alcoholic patient with liver cirrhosis is likely to demonstrate all of the following during administration of anesthesia, except
A. A high minimum alveolar concentration (MAC) for desflurane
B. Opioid hyperalgesia
C. Resistance to the hypnotic effects of thiopental
D. Resistance to the analgesic effects of opiates
20. A woman with long-standing alcoholic cirrhosis (Child-Turcotte-Pugh B) presents to the emergency room for chronic shortness of breath and abdominal pain. A review of her lab findings reveal a hematocrit concentration of 36% (hemoglobin 12.4 g/dL) with an arterial blood gas revealing a PaO2 of 65 mm Hg breathing a FIO2 of 0.5 via face mask. Her vitals are a blood pressure of 135/60 mm Hg and a heart rate of 88 bpm. The most likely cause of her hypoxemia is
A. Intrahepatic arteriovenous shunts
B. Intrapulmonary arteriovenous shunts
C. Anemia
D. Decreased cardiac output
21. Which of the following cardiovascular abnormalities is least likely to be present in a patient with end-stage alcoholic cirrhosis
A. Resting tachycardia
B. Widened pulse pressure
C. Increased peripheral vascular resistance
D. Increased cardiac output
A 120-kg diabetic male is scheduled for emergent pinning of his mandible after a motor vehicle accident. His wife reports that he snores loudly every night with occurrences of breathing cessation. Medical history is also significant for hypertension controlled with a diuretic. On physical examination, he has a large tongue and a wide neck with inadequate mouth opening revealing a Mallampati grade 4 view. His BMI is 38 kg/m2 with a neck circumference of 44 cm.
22. Arterial blood gas (ABG) finding that would confirm Pickwickian syndrome is
A. pH = 7.44, PaCO2 = 44, PaO2 = 90, HCO3 = 24
B. pH = 7.35, PaCO2 = 44, PaO2 = 65, HCO3 = 26
C. pH = 7.42, PaCO2 = 36, PaO2 = 80, HCO3 = 22
D. pH = 7.37, PaCO2 = 55, PaO2 = 67, HCO3 = 28
23. The dose of thiopental required for rapid-sequence induction would be increased, as compared with what would be required at his ideal body weight, because of changes in
A. Decreased basal metabolic rate
B. Increased blood volume
C. Increased muscle mass
D. Decreased liver metabolism
24. A patient with chronic liver disease is scheduled for a laparoscopic abdominal operation. The risk of mortality during surgery for this patient is assessed using
A. Mayo end-stage liver disease
B. Child-Turcotte-Pugh score
C. Ranson criteria
D. Alvarado score
25. The variable not used to calculate an MELD (model for end-stage liver disease) score to prioritize patients for liver transplantation is
A. Creatinine
B. INR (international normalized ratio)
C. Bilirubin
D. Albumin
Questions 26 to 28
A 30-year-old male patient without preoperative renal dysfunction is undergoing a primary orthotopic liver transplant (OLT) for failure due to inherited α1-antitrypsin deficiency.
26. During cross-clamping of the suprahepatic inferior vena cava (IVC), the most accurate effect created by use of venovenous bypass (VVB) is that it
A. Induces urinary retention
B. Prevents metabolic acidosis
C. Requires heparinization
D. Supports cardiac output
27. Immediately before unclamping and reperfusion of the transplanted liver, sodium bicarbonate and calcium chloride are administered intravenously to counteract
A. Coagulopathy
B. Decreased cardiac output
C. Increased systemic vascular resistance
D. Hypertension
28. At the end of the case as the drapes are taken down, diffuse microvascular bleeding is noted in this patient who required 15 U of blood during his intraoperative course. Platelet count is 40,000/mm3, prothrombin time is 18 seconds, activated partial thromboplastin time (PTT) is 54 seconds, D-dimer is 2,000 ng/mL, and serum fibrinogen concentration is 40 mg/dL. The most likely cause of bleeding is
A. Disseminated intravascular coagulation (DIC)
B. Abnormal platelet function
C. Depressed levels of factor VIII
D. Citrate toxicity
29. A patient presents for preoperative evaluation for upcoming surgery. He has a history of liver transplantation 2 years ago, otherwise feeling well. Which of the following is most likely to be present during preoperative evaluation?
A. Elevated serum creatinine concentration
B. Hypoalbuminemia
C. Prolonged partial thromboplastin time
D. Hypocalcemia
30. Following a gastric bypass procedure, a 130-kg woman is extubated and breathing spontaneously in the recovery room (PACU). She is breathing at a rate of 24 breaths/min on 10 L/min of oxygen via nasal cannula, and is complaining of continued subjective dyspnea. Arterial blood gas analysis shows PaO2 = 95 mm Hg, PaCO2 = 44 mm Hg, and pH = 7.37. The parameter most closely related to her increased alveolar–arterial oxygen-tension gradient is
A. Decreased minute volume
B. Decreased functional residual volume
C. Decreased expiratory reserve volume
D. Decreased respiratory drive
31. During laparoscopic cholecystectomy, the risk of failure to visualize contrast material entering the duodenum during intraoperative cholangiogram is highest with the administration of
A. Buprenorphine
B. Nalbuphine
C. Morphine
D. Naloxone
32. Drugs that can decrease or reduce opioid-induced biliary spasm include all of the following, except
A. Diltiazem
B. Atropine
C. Metoclopramide
D. Glucagon
33. Each of the following is associated with delayed gastric emptying, except
A. Diabetes mellitus
B. Celiac plexus block
C. Vagotomy
D. μ-Receptor agonism
Questions 34 to 39
A 33-year-old otherwise-healthy female suffering from moderately severe abdominal pain of unclear etiology is set to undergo an exploratory laparoscopy. The abdominal cavity is insufflated using carbon dioxide (CO2).
34. All of the following are correct statements regarding pathophysiologic changes associated with creation of the pneumoperitoneum, except
A. Increased risk of reflux and aspiration
B. Decreased venous return
C. Decreased systemic vascular resistance (SVR)
D. Increased intrathoracic pressures
35. Inherent risks of abdominal laparoscopy include
A. Renal failure
B. Bronchospasm
C. Gas emboli
D. Hypothermia
36. The patient is placed in a steep Trendelenburg position. Her oxygen saturation begins to gradually decline over the course of several minutes while being ventilated with 100% oxygen (FIO2 = 1.0). The initial step in the management of her hypoxemia is
A. Add positive end–expiratory pressure (PEEP)
B. Intravenous bolus of 500 mL saline
C. Reposition the patient
D. Switch to pressure support ventilation
37. The exploratory surgery progresses slowly. Over the next 3 hours, her EtCO2 begins to gradually rise, requiring increasing minute ventilation. All of the following contribute to the degree of systemic CO2 absorption, except
A. Solubility of the gas
B. Intra-abdominal pressures (IAP)
C. Duration of surgery
D. Blood pressure
38. Each of the following is hemodynamic change associated with hypercarbia, except
A. Arrhythmias
B. Bradycardia
C. High cardiac output
D. Low systemic vascular resistance (SVR)
39. The surgery continues on with a request to increase the pneumoperitoneum to 30 mm Hg to improve the surgical view. All of the following are appropriate in the differential diagnosis for hypotension during laparoscopy, except
A. Compression of the inferior vena cava
B. Increase cardiac afterload
C. Too small blood pressure cuff
D. CO2 embolism
40. This physical exam finding is inappropriately paired with the possible nerve injury resulting from ill positioning during surgery:
A. Inability to evert the foot | common peroneal nerve |
B. Inability to stand on toes | sciatic nerve |
C. Difficulty climbing stairs | femoral nerve injury |
D. Foot drop | saphenous nerve injury |
41. A 50-year-old male patient is to undergo an open nephrectomy for renal carcinoma. The patient requests an epidural for perioperative pain management, as he is strongly intolerant to μ-agonist opiate therapy with nausea and vomiting. After a T2 sensory level is obtained, the patient is induced with propofol 200 mg and rocuronium 70 mg, followed by tracheal intubation. The expected response to intubation in this patient includes
A. Hypertension
B. Tachycardia
C. Tachypnea
D. Mydriasis
42. A 24-year-old female status postrecent living-related renal transplant requires chronic immunosuppression with cyclosporine and steroids to combat organ rejection. She now presents for right-knee arthroscopic anterior cruciate ligament repair and mentions significant history of postoperative nausea and vomiting (PONV). The most appropriate next step in planning her anesthetic management is
A. Proceed with total IV anesthesia (TIVA), avoiding inhaled anesthetics
B. Avoid regional anesthesia
C. Liberally infuse intravenous fluids
D. Use metoclopramide to decrease gastric secretions
Questions 43 to 45
A 70-year-old 70-kg male with benign prostatic hypertrophy and difficulty with urination presents for a transurethral resection of his 65-g prostate (TURP). His other pertinent history includes hypertension and hyperlipidemia, both well controlled. He has a remote history of a lumbar spinal fusion with no current lumbar symptomatology. The patient requests a general anesthetic for the procedure and refuses spinal anesthesia.
43. Assuming the use of a hypotonic irrigant, these factors will contribute to the amount of fluid absorbed by the patient, except
A. Venous pressure
B. Hydrostatic pressure of the irrigation infusion
C. Lithotomy position
D. Size of prostate
44. In the recovery room, he complains of bothersome localized suprapubic pain and is requesting pain medicine. He denies pain or discomfort anywhere else. His review of systems is negative for fevers or chills. The relatively common complication of this procedure that should be ruled out at this time is
A. Hyponatremia
B. Glycine toxicity
C. Extraperitoneal perforation
D. Transient bacteremia
45. The patient is administered hydromorphone intravenously, and 20 minutes later is feeling well with minimal pain complaints. At this time, his postoperative laboratories have returned, revealing a serum sodium value of 130 mEq/L. The most appropriate next step in the management of his hyponatremia is
A. Hypertonic saline infusion
B. Fluid restriction
C. Demeclocycline administration
D. Insulin and glucose administration
46. Effects of furosemide administration in the perioperative period include
A. Hypernatremia
B. Decreased risk for acute tubular necrosis
C. Metabolic alkalosis
D. Hyperkalemia
Questions 47 to 51
A 38-year-old woman is set to undergo extracorporeal shock wave lithotripsy to disintegrate a painful stone trapped in her upper ureter. The patient is requesting an epidural anesthetic and is choosing to be otherwise awake and cooperative with her positioning and procedure.
47. The step of the epidural placement that should be avoided in this patient is
A. Loss of resistance to air
B. Loss of resistance to hanging drop
C. Test dose injection
D. Bolus dose of local anesthetics
48. Once the epidural is adequately placed and the patient is immersed sitting in the water tank, the physiologic change that should be expected is
A. Decreased central venous pressure
B. Increased vital capacity
C. Increased functional residual capacity
D. Lower extremity peripheral pooling
49. Extracorporeal shock wave lithotripsy therapy proceeds with the shock wave synchronized with what ECG phase of the cardiac cycle?
A. The P wave
B. The Q wave
C. The R wave
D. The S wave
50. Which of the following statements would be considered false with regard to extracorporeal shock wave lithotripsy (ESWL)?
A. Delivery of the shock wave is timed to coincide with the ventricular refractory phase
B. Neuraxial anesthesia up to T2 sensory level is adequate
C. If able to control ventilation, use high tidal volumes and low respiratory rate
D. Removal of the patient from the bath water can be accompanied by a decrease in the blood pressure
51. All of the following are contraindications to immersion extracorporeal shock wave lithotripsy, except
A. Harrington rod implants
B. Abdominally placed rate-responsive cardiac pacemaker
C. Positive pregnancy test
D. Large calcified abdominal aortic aneurysm
52. Which of the following is considered the most sensitive indicator of impending traumatic renal failure?
A. Decreased creatinine clearance
B. Decreased central venous pressure
C. Decreased fractional excretion of sodium
D. Increased urine osmolality
53. A 26-year-old male patient with Alport syndrome requires hemodialysis (every third day) and presents for an arteriovenous fistula creation. His last dialysis treatment was yesterday. Patient requests general anesthesia for this procedure. Which of the following drugs will have a prolonged duration of action?
A. Fentanyl
B. Neostigmine
C. Atracurium
D. Methadone
54. Each of the following is associated with acute tubular necrosis, except
A. Hyaline casts
B. Urine specific gravity <1.010
C. Muddy casts
D. Fractional excretion of sodium of 4%
Questions 55 to 56
A 75-year-old patient who is awaiting urgent laparotomy has had oliguria for the past 12 hours since the onset of his acute abdominal pain last night. His medical history includes well-controlled hypertension. Vital signs include a BP of 120/65 mm Hg and a HR of 72 bpm. His laboratory findings reveal
Urine osmolality: 550 mOsm/L
Urine specific gravity: 1.020
Urine sodium concentration: 15 mmol/L
Fractional excretion of sodium: 0.5%
Ratio of urine-to-plasma urea concentration: 10
55. The most appropriate treatment of his oliguria is
A. Fluid restriction
B. Fluid challenge
C. Renal ultrasound
D. Foley placement
56. Fluid resuscitation is done with 4 L of normal saline. The potential acid–base abnormality that can occur is
A. Hyperchloremic acidosis
B. Metabolic alkalosis
C. Hyperkalemic acidosis
D. Respiratory alkalosis
57. A 67-year-old patient with chronic renal failure presents for hip arthroscopy to address and treat his labral tears and associated hip pain. The best option for opioid therapy in this patient is
A. Meperidine
B. Codeine
C. Dextropropoxyphene
D. Fentanyl
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