lower than 30 mm Hg associated with metabolic acidosis
suggests inadequate tissue perfusion. Temperature correction of PaCO2 and pH is
probably not necessary. Urine output may serve as a guide to the adequacy of renal
perfusion, with an output of 0.5 to 1 mL/kg/hr, indicating adequate renal perfusion.
72. C. Monitoring of coronary sinus pressures during retrograde administration is used
to assess proper catheter placement. The anatomical location of coronary sinus ostia
makes it very difficult for proper visualization by the surgeon. A properly placed
coronary sinus catheter will have pressure of 40 to 60 mm Hg during a 200-mL/min
infusion. 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 right atrium or in the
superior vena cava. Being up against a wall produces a very high (>100 mm Hg)
pressure. Positioning of the coronary sinus catheter should be checked with
transesophageal echocardiography and manual feel by the surgeon. If the catheter is
too deep, cardioplegia to the right ventricle will be compromised, resulting in poor
73. C. At 30°C, the heart muscle consumes oxygen at a rate of 8 to 10 mL/100 g/min,
provided it is normally contracting. Oxygen consumption in the fibrillating ventricle
at 22°C is 2 mL/100 g/min. The electromechanically quiet heart at 22°C consumes
oxygen at a rate of 0.3 mL/100 g/min.
74. A. The extra volume of crystalloid used in priming the CPB circuit may produce a
sudden dilution of circulating drug concentrations. This creates a high chance of
patient recall/ movement. Supplemental anesthetics, such as benzodiazepines or
opioids, and an additional dose of nondepolarizing muscle relaxant, may be
administered prophylactically. Volatile anesthetics delivered using vaporizers
incorporated into the CPB circuit have largely negated this problem along with the
use of BIS monitors. The effect of hemodilution on drug concentrations is likely to
be offset by a decreased need for drugs during hypothermia. On the contrary,
anesthetic requirements seem to be minimal if the patient was adequately rearmed at
the conclusion of CPB. Therefore, additional anesthesia is not routinely required
during rewarming at the termination of CPB.
75. B. Low SVR is a very common hemodynamic abnormality after CPB. This makes
weaning from CPB very difficult. SVR is usually calculated using the formula mean
arterial pressure (mm Hg) − central venous pressure (mm Hg)/pump flow (L/mi) ×
SVR should be between 1,200 and 1,400 prior to CPB separation. The units of
. SVR can be normalized with a vasoconstrictor prior to weaning
from CPB. By this, we are attempting to match the vascular input impedance to the
cardiac output impedance and optimizing energy transfer.
76. D. Acute mitral regurgitation (MR) post–CPB is often noticed as a prominent V
wave in PAOP tracing. If there is a transesophageal echocardiograph (TEE) in place,
we may be able to see a wide MR jet, with observation of an echogenic mass
attached to the mitral valve or when a mobile mass is seen to prolapse into the left
atrium during systole and to move back into the left ventricle during diastole. The
posterior papillary muscle, along with the posterior wall, is entirely perfused either
by the right coronary artery (RCA) or by the third obtuse marginal branch, usually by
a single artery unlike the anterior, which derives its blood supply from two arteries. It
is usually a complication of acute mitral infarction but maybe seen at the end of CPB
due to inadequate myocardial protection (warm blood in the adjacent descending
aorta providing inadequate protection) during CPB or air entry into the RCA. Acute
MR due to volume overload from excessive fluid administration is usually a central
MR as evidenced in TEE with a distended ventricle and can be managed by
Deppu Ushakumari and Ashish Sinha
1. Which of the following is not a characteristic feature of asthma?
A. Chronic inflammatory changes in the submucosa of the airways
B. Airway hyper responsiveness
C. Reversible expiratory airflow obstruction
D. Elastase deficiency in the airways
2. A 55-year-old male presented to you with a pulmonary function test report, which
shows an increase of FEV1 percent predicted of more than 12%, and an increase in
FEV1 of greater than 0.2 L in response to bronchodilators. Which characteristic of
his respiratory illness is depicted here?
A. Bronchial asthma—acute bronchodilator responsiveness
B. Chronic obstructive pulmonary disease (COPD)—variability in airflow
C. COPD—acute bronchodilator responsiveness
3. Which of the following techniques is associated with a lower complication rate
related to bronchospasm in the asthmatic population?
B. General anesthesia—laryngeal mask airway (LMA)
C. General anesthesia—endotracheal tube (ETT)
D. Combined general and neuraxial anesthesia
4. A 22-year-old patient with a history of moderate persistent asthma on medium-dose
inhaled corticosteroids and long-acting inhaled β-agonist presents for an emergency
appendectomy. On clinical examination, he is actively wheezing, but maintaining an
oxygen saturation of 99% on room air. Which of the following statements about this
clinical scenario is most appropriate?
A. Presence of wheezing on physical examination indicates that he is having a
B. Volatile anesthetics cause bronchodilation through catecholamine-independent
C. Increased airway resistance that occurs intraoperatively is usually due to acute
D. A laryngeal mask airway (LMA) is more stimulating to the airway than an
endotracheal tube, and should be avoided in asthmatics
5. During the above case, the end-tidal sevoflurane concentration reads 3.5, but the
anesthesia ventilator is alarming because of high peak airway pressures. Which of
the following is the most likely cause?
B. Anaphylactic reaction to intravenous muscle relaxant that you just administered
C. Mechanical causes of obstruction
D. Inadequate depth of anesthesia
6. At the end of the above case, the surgeon requests you to extubate the patient fully
awake because he found extensive intestinal adhesions and is afraid of retained
gastric contents in the stomach. Which of the following will be your most likely plan
A. Insert an orogastric tube, empty the stomach as much as you can, and proceed
with a deep extubation to avoid bronchospasm
B. Administer intravenous lidocaine to decrease the likelihood of airway
stimulation and wait till the patient is fully awake before extubation
C. Shut off the inhalational agent and use intravenous propofol to avoid
transitioning through a rocky stage-2 wake up
D. Transition to a laryngeal mask airway (LMA) under sevoflurane anesthesia and
let the patient wake up with an LMA
7. Which of the following is true regarding administering general anesthesia to a
chronic obstructive pulmonary disease (COPD) patient?
A. Nitrous oxide + opioid technique is ideal
C. Use lower breathing rates to permit more exhalation time
D. Correct the hypercapnia intraoperatively to help extubate early
8. Anesthetic considerations for a patient with severe pulmonary hypertension include
A. Right heart catheterization is the gold standard for diagnosis
B. Mortality in pregnant patients undergoing vaginal delivery is very small as
C. Minimize tachycardia, hypoxemia, and hypercapnia during anesthetic
D. Cardiac output from a failing right ventricle depends on filling pressure from
venous return and pulmonary pressure
9. Which of the following is not a part of the “STOP BANG” screening questionnaire
for obstructive sleep apnea (OSA)?
10. Risk factors associated with increased perioperative morbidity and mortality in
thoracic surgery patients include all the following, except
C. Experience of the operating surgeon
11. The following is not necessarily a part of prethoracotomy respiratory assessment
A. Pulmonary capillary wedge pressure >18 mm Hg
B. Predicted postoperative FEV1 >40%
D. Predicted postoperative diffusing capacity for carbon monoxide (DLCO) >40%
12. Which of the following is one of the benefits regarding cessation of smoking 12 to 24
A. Shift of oxyhemoglobin dissociation curve to the right
B. Improvement in mucociliary transport
C. Decrease in sputum production
D. Improved small-airway function
13. In surgical cases requiring lung isolation
A. Measurement of tracheal width from a posteroanterior chest radiograph is of no
use in selecting the size of a double-lumen tube (DLT)
B. More frequent use of left-sided DLT is based on the anatomy of
C. Uniform ventilation to all lobes is most likely achieved by a right-sided DLT
because it has a ventilation slot in the bronchial tube
D. Fiber–optic confirmation of correct DLT placement is not required if you have
14. A 59-year-old lady is intubated with a 37 left-sided double-lumen tube (DLT) for
wedge resection of left lower lobe nodule. After intubation, you inflate the bronchial
cuff and ventilate the left lung through the bronchial lumen without any difficulty.
Then you proceed to inflate the tracheal cuff and ventilate through the tracheal
lumen. You notice a very high resistance to air flow. Which of the following events
is most unlikely with the said clinical picture?
A. Left DLT too deep with the tracheal outlet into the left main-stem bronchus
B. Left DLT displaced with the bronchial cuff herniated at carina
C. Left DLT entered the right bronchus with the tracheal outlet in the right main
D. DLT too far out with the bronchial lumen sitting just above the carina
15. What would you do if you have the following situation with a bronchial blocker for
A. Appropriate positioning for this surgery
B. Withdraw the bronchial blocker a couple of centimeters
C. Insert the bronchial blocker a few centimeters farther down
D. Remove the bronchial blocker and reinsert it into the left side
16. In which of the following situations is applying continuous positive-airway pressure
(CPAP) to the nondependent lung most ideal for improving oxygenation?
C. Massive pulmonary hemorrhage
17. Which of the following statements is false regarding ventilation/perfusion
relationship in a lateral decubitus position during spontaneous ventilation?
A. The ventilation/perfusion matching is preserved
B. Contraction of dependent hemi diaphragm is more efficient
C. Dependent lung is on a more favorable part of the compliance curve
D. The lower lung receives less ventilation and more perfusion than the upper lung
18. In an open pneumothorax, the major effect of mediastinal shift is to
A. Decrease the contribution of dependent lung to the tidal volume
B. Move air to and fro between the dependent and the nondependent lung
C. Decrease the perfusion to the dependent lung
D. Compress the big veins and decrease cardiac preload
19. Factors known to inhibit hypoxic pulmonary vasoconstriction (HPV) and thus worsen
the alveolar–arterial oxygen gradient include all of the following, except
20. A 64-year-old female is undergoing a left video-assisted thoracoscopy for a
suspicious pulmonary nodule. Immediately after positioning the patient laterally,
which of the following alarms indicates a malposition of the double-lumen tube
D. Unable to drive bellows alarm
21. A bronchial blocker is useful in all of the following clinical situations, except
A. Patient to be left intubated post operatively
B. Anatomical abnormality precluding the placement of a double-lumen tube
C. Tamponading bronchial bleeding in adult patients
D. To attain better collapse of the nondependent lung
22. Which of the following statements about lung resection surgery is false?
A. Mortality rate for pneumonectomy is 5% to 7%
B. Mortality rate for lobectomy is 2% to 3%
C. Mortality is higher for left-sided pneumonectomy
D. Most postoperative deaths result from cardiac issues
23. Regarding lung resection surgery, which of the following statements is false?
A. Perioperative arrhythmias are common
B. Supraventricular tachycardias (SVTs) are thought to result from surgical
manipulation or distension of the right atrium
C. Incidence of arrhythmia decreases with age due to the ageing of cardiac
D. Postoperative hypoxemia and acidosis due to atelectasis and shallow breathing
24. Which of the following has the least effect on hypoxic pulmonary vasoconstriction
25. Which of the following statements is not true regarding “lower lung syndrome”?
A. It is caused by excessive fluid administration in a lateral decubitus position
B. It increases intrapulmonary shunting
C. It is gravity-dependent transudation of fluid into the dependent lung
D. It is due to volutrauma caused during one-lung ventilation
26. The first step recommended to improve oxygenation if a patient is exhibiting drop in
oxygen saturation during one-lung ventilation is
A. Apply continuous positive-airway pressure (CPAP) to the collapsed lung
B. Apply positive end–expiratory pressure (PEEP) to the dependent lung
C. Periodic inflation of the collapsed lung
D. Continuous inflation of oxygen into collapsed lung
27. During apneic oxygenation,
A. Adequate oxygenation can be maintained only for short periods of time
rises 3 to 4 mm Hg in the first minute
rises 1 to 2 mm Hg each subsequent minute after the first minute
D. Progressive respiratory acidosis limits the use of this technique to 10 to 20
28. A 68-year-old male patient with a lung nodule underwent a right upper lobectomy.
On postoperative day 4, the patient develops a sudden large air leak from the chest
tube associated with increasing pneumothorax and partial lung collapse. The most
A. Bronchopleural fistula on the right from necrosis of suture line
B. Bronchopleural fistula on the right from inadequate surgical closure of the
C. Atelectasis causing shifting of the mediastinum to the left
29. An 80-year-old female underwent a left lower lobectomy. In the ICU on
postoperative day 2, she develops hemoptysis. The vital signs are stable, but on the
chest X-ray a homogenous density is seen in the left lower lung area. After
subsequent bronchoscopy, the left upper lobar orifice is closed. The most likely
A. Acute herniation of the heart into the left lower lobe area
B. It is a normal finding and the homogenous opacity is due to accumulation of
fluid in the left lower lobe area
C. Torsion of the left upper lobe as the left upper lobe expanded to occupy the left
D. Reexpansion edema of the left upper lobe
30. A 45-year-old recent immigrant from Vietnam is admitted to the emergency
department with massive hemoptysis (>600 mL in the last 24 hours). You are called
to evaluate the patient for a possible bronchial artery embolization or a rigid
bronchoscopy. In your discussion with the patient, which of the following statements
is not appropriate about his clinical condition?
A. Operative mortality exceeds 20%
B. It can be done as a semi-elective procedure, and there is no need to do it
C. The most common cause of death is asphyxia secondary to blood in the airway
D. Medical management has a lower mortality rate than operative management
31. An 81-year-old chronic smoker, with a history of 60 pack year smoking, is admitted
with progressive dyspnea and a huge right-sided pulmonary cyst. The cyst is
compressing her remaining right lung, and she is brought to the OR for an emergency
pulmonary cystectomy. Which of the following is right regarding anesthetic
A. The greatest risk of rupture of the cavity is during preoxygenation just prior to
B. These cavities allow to and fro movement of air and have a very low chance to
C. Maintenance of spontaneous ventilation is desirable until a double-lumen tube
D. Assisted ventilation is not necessary immediately after induction and can be
32. A 66-year-old patient with a history of severe tracheal stenosis is presenting for a
tracheal resection. The most unlikely clinical finding is
B. Wheezing evident on exertion
C. Dyspnea worse on sitting up and leaning forward
D. Patient may have a history of blunt/penetrating tracheal trauma
33. In the anesthetic management of the above patient, which of the following statements
A. Flow–volume loops aid the clinician in evaluating the severity of the lesion
B. Right radial artery blood pressure monitoring is preferred over the left side for
C. Slow-inhalation induction is not advisable and a rapid-sequence induction
D. Early extubation is not advisable at the end of the procedure for risk of
34. Complications associated with mediastinoscopy include all the following, except
A. Vagally mediated reflex bradycardia
35. Anesthetic considerations for bronchoalveolar lavage include all the following,
A. It is performed for patients who make excess quantities of surfactant and fail to
B. It is performed under general anesthesia with lung isolation
C. It is usually performed in the supine position
D. It involves positioning the patient in a lateral position to aid active suctioning of
36. Considerations for lung transplantation include all the following, except
A. Cor pulmonale does not necessarily require combined heart–lung transplantation
B. Patients with diminished left-ventricular function can be transplanted as long as
they have normal right-ventricular function
C. Patients with Eisenmenger syndrome require combined heart–lung
D. Organ selection is based on size and ABO compatibility
37. After a double-lung transplantation
A. Loss of lymphatic drainage predisposes to pulmonary edema
B. Respiratory pattern changes to a slow deep respiration
C. Cough reflex is abolished above the carina
D. Hypoxic pulmonary vasoconstriction is abolished
38. Anesthetic considerations for esophageal surgery include
A. Very low risk of pulmonary aspiration
B. Mandatory pulmonary artery catheter monitoring
C. Diaphragmatic retractors interfering with cardiac function
D. Always performed with a double-lumen tube (DLT)
39. Lung-volume-reduction surgery (LVRS)
A. Has been demonstrated to have very good efficacy by the National Emphysema
B. Necessitates limiting of peak inspiratory pressure to 30 cm H2O following
C. A prolonged inspiratory time is recommended for facilitating exposure of the
D. Patients have a better outcome if kept intubated at the end of the surgery
40. Which of the following flow–volume loops will be expected in a child with variable
41. A 12-year-old boy with suspected lymphoma presents to you for a lymph node
biopsy. When you go to visit the patient, you notice that he has venous engorgement
and edema of the head, neck, and arms. He refuses to lie down, and is tachycardiac
and tachypneic. The preferred management for this boy would be
A. Safest thing will be to secure the airway immediately by using rapid-sequence
B. Preferably biopsy the lymph node under local anesthesia so that the patient can
be sent for radiotherapy immediately after a tissue diagnosis
C. Empiric treatment with steroids and surgery under general anesthesia only after
the airway compromise is alleviated
D. Get a chest X-ray and rule out mediastinal compression prior to any active
1. D. Asthma is a type of reactive airway disease characterized by hyperresponsive
airways, reversible expiratory airflow obstruction, and chronic inflammation. Sudden
bronchospasm in response to external/internal stimuli and response to bronchodilators
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