25. Which of the following is not true about systemic hypothermia during
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
D. Profound hypothermia to temperatures of 15 to 18°C allows total circulatory
26. Adverse effects of hypothermia include all the following, except
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. Arterialsystolic pressure left-ventricular end diastolic pressure
D. Arterialsystolic 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
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
31. Aprotinin therapy should be considered for all of the following patients, except
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
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
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
B. Progressive metabolic alkalosis
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
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)
37. Sweating during the rewarming phase of termination of cardiopulmonary bypass
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
40. General guidelines for separation from cardiopulmonary bypass (CPB) include all
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
B. Adding intra-aortic balloon pump (IABP)
C. Adding a pulmonary vasodilator
43. After neutralizing heparin, which of the following is the fate of the heparin–protamine
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
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
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
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
49. The central venous pressure (CVP) waveform in cardiac tamponade is characterized
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
C. Very high positive end–expiratory pressure (PEEP)
53. Normal mixed venous oxygen tension is ______ (mm Hg):
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
D. Use of esmolol boluses intraoperatively to keep the heart rate <80 bpm
55. Which of the following statements is false regarding perioperative myocardial
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
D. Tachycardia (>105 bpm) for 5 minutes in the postoperative period can increase
56. Which of the following is the most effective means of predicting a perioperative
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?
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
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 mitralregurgitant flow
60. Treatment of patients with prolonged QT interval include all, except
B. Right stellate ganglion block
C. Avoidance of drugs that prolong the QT interval
D. Availability of electrical cardioversion while the patients are undergoing
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)
A. Are frequent (more than six premature beats/min)
C. Take place during the ascending limb of the T wave (R-on-T phenomenon)
63. Which of the following drugs needs not be avoided in the anesthetic management of
a patient with Wolff–Parkinson–White (WPW) syndrome?
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
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
A. Venting can be done through a drain placed from the right superior pulmonary
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 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)
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
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
71. During total cardiopulmonary bypass, metabolic acidosis and decreasing mixed
venous oxygen saturation are noted. The most likely cause is
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
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
74. Additional supplemental anesthetics and muscle relaxants should be administered
A. At institution of cardiopulmonary bypass (CPB)
D. In the early period after conclusion of CPB
75. The most common hemodynamic abnormality after cardiopulmonary bypass (CPB)
B. Low systemic vascular resistance (SVR)
C. High pulmonary vascular resistance
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
D. Posterior papillary muscle dysfunction
1. B. The normal ventricular cell–resting membrane potential is −80 to −90 mV. Na–
K ATPase bound to the membrane is responsible for concentrating K
and in exchange for Na and maintaining this resting-membrane potential. Action
potential (depolarization) occurs when cell membrane becomes less negative and
crosses a threshold value. This depolarization raises the membrane potential of the
myocardial cell, sometimes as high as +20 mv. The cardiac action potential is
slightly different from neuronal action potential in that it has a characteristic spike
and plateau appearance. The spike portion of this action potential is produced by
opening of fast sodium channels along with a decreased permeability to potassium
and the plateau portion (0.2–0.3 seconds) is due to opening of slower calcium
channels. After depolarization, the sodium and calcium channels close and the
membrane permeability to potassium is restored. This restores the resting-membrane
potential to its baseline. Spontaneously depolarizing cells, responsible for the
myocardial rhythm, do so primarily by intrinsic slow leakage of calcium into cells
aided by leaky Na channels moving Na
ACTION POTENTIAL PHASE NAME NET ION MOVEMENT
in (relative impermeability to K
1 Early rapid repolarization K
+ out (increased permeability to K
transi2 Plateau (a part of repolarization) Ca
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