SEE Exam - Questions With Expert Verified Solutions
(A+ Accurate)
The arteria radicularis magna, or artery of Adamkiewicz, most commonly
arises from:
• T4 - T8
• T8 - L2
• L2 - L4
• L4 - S1 Right Ans - T8 - L2.
A major complication of thoracic aortic surgery is paraplegia, occurring in up
to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria
radicularis magna supplies blood to the anterior spinal artery. The arteria
radicularis magna has a variable origin from aorta, arising between T5 - T8 in
15%, between T9 - T12 in 60% and between L1 - L2 in 25% of individuals.
During fetal monitoring, Type III decelerations are thought to be related to:
• head compression
• umbilical cord compression
• uteroplacental insufficiency
• placental abruption Right Ans - umbilical cord compression
Type III, or variable, decelerations are the most common type of
decelerations. They are thought to be related to umbilical cord compression
and intermittent decreases in umbilical blood flow.
60. A 55-year-old woman with a history of congenital long QT syndrome is
undergoing a hysteroscopy for abnormal uterine bleeding. She had uneventful
induction of general anesthesia but after paracervical block with lidocaine
develops ventricular tachycardia with morphological appearance of torsades
de pointe. Which of the following medications should be AVOIDED in the
treatment of her arrhythmia?
• Amiodarone
• Calcium chloride
• Esmolol
• Magnesium sulfate Right Ans - 60. Amiodarone. Congenital long QT
syndrome may occur in conjunction with other hereditary syndromes, such as
Jervell, Lange-Nielsen or Romano-Ward syndrome, or acquired as a result of
pharmacologic or metabolic etiologies. It is an issue of cellular repolarization
,which precipitates tachyarrhythmias, most commonly polymorphic
ventricular tachycardia or torsades de pointe. There are multiple subtypes
that affect both potassium and/or sodium channels. The arrhythmias may be
precipitated by sympathetic activation, auditory stimuli or at rest. Family
history may be positive for sudden cardiac death and the ECG significant for
prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves.
Treatment includes magnesium for arrhythmias, possible permanent
pacemaker, or beta blockers for subtypes 1 and 2, but amiodarone is
considered contraindicated as it prolongs the QT interval.
59. A 76-year-old man is scheduled for a hemicolectomy. His past medical
history is significant for third degree heart block treated with a permanent
pacemaker. Problems with electrocautery use in this patient can be minimized
by:
• placing the grounding pad near the pacemaker
• using infrequent bursts of longer duration
• the use of a bipolar cautery
• reducing the surface area of the return electrode Right Ans - 59. the use
of a bipolar cautery. Electrical interference from the electrocautery can be
interpreted by the pacemaker as myocardial activity and suppress pacemaker
activity. These problems can be minimized by limiting use to short bursts,
placing the grounding pad as far from the pacemaker as possible and using a
bipolar cautery.
58. A 35-year-old woman who underwent orthotopic heart transplantation 2
years ago for nonischemic cardiomyopathy presents after a motor vehicle
accident for exploratory laparotomy under general anesthesia.
Intraoperatively, her blood pressure is 75/35 mmHg and heart rate is 90 bpm.
After the administration of phenylephrine, which of the following
hemodynamic responses do you MOST expect?
• HR decreased, BP increased
• HR decreased, BP no change
• HR no change, BP increased
• HR no change, BP no change Right Ans - 58. HR no change, BP increased.
After heart transplantation, the heart is completely denervated. The normal
resting heart rate is relatively tachycardic at 90-100 bpm due to lack of vagal
tone. Vagal bradycardic responses (to laryngoscopy, hypertension, carotid
sinus massage) will also be absent. Over time, however, many patients require
,permanent pacemaker placement for treatment of significant bradycardia.
After heart transplant, patients are not able to respond to demands for
increased cardiac output with increased heart rate. Thus in this situation of a
trauma with potentially significant blood loss, a normal patient would have
tachycardia but a heart transplant patient has no change in heart rate, only
hypotension. Instead for heart transplant patients, cardiac output is
augmented by increased stroke volume. For this reason it is important to
maintain adequate intravascular volume. The transplanted heart is not able to
respond to medications that block the parasympathetic system. Bradycardia
and hypotension have to be treated with medications that have a direct effect
such as epinephrine and isoproterenol. Phenylephrine will result in increased
blood pressure, but no change in heart rate. Indirect and mixed
indirect/direct-acting drugs have minimal effect or have the effect of their
direct components.
57. The postretrobulbar block apnea syndrome:
• is likely secondary to intravascular injection
• most commonly occurs during or immediately after injection
• is associated with unconsciousness
• carries a high morbidity and mortality Right Ans - 57. is associated with
unconsciousness. The postretrobulbar block apnea syndrome is probably due
to injection of local anesthetic into the optic nerve sheath, with spread into the
CSF. The CNS is exposed to high concentrations of local anesthetic leading to
apprehension and unconsciousness. Apnea occurs within 20 minutes and
resolves within an hour. Treatment is supportive.
56. A 75-year-old man is undergoing a mitral valve replacement via
cardiopulmonary bypass. The perfusionist is running bypass flows at > 2.5
liters/minute/m2. Which of the following is the MOST likely adverse
consequence of undergoing cardiopulmonary bypass at increased flow rates?
• Increased trauma to blood elements
• Increased hypothermia
• Decreased blood flow to the brain
• Decreased myocardial blood flow Right Ans - 56. A. Increased trauma to
blood component: Cardiopulmonary bypass (CPB) does the work of the heart
and lungs in order to isolate those organs from blood flow such that surgery
on the heart can occur in a relatively bloodless fashion. Thus, the CPB circuit
must oxygenate and ventilate the blood and then deliver the oxygenated blood
, back to the body and end organs. It has long been debated whether maximal
blood flow or pressure is more important in perfusion and homeostasis of the
end organs during bypass. Maximizing blood flow (generally considered to be
flow at a cardiac index of > 2 liters/minute/meter2) has been shown to
increase hematologic trauma, increase the magnitude of the stress or
inflammatory response, cause strain on suture lines, increase shunting of
blood through the pulmonary system, increase washout of cardioplegia and
not necessarily lead to improved regional blood flow. The CPB machine can
change total flow, but it cannot adjust regional flows to the various end organ
systems. Changes in blood pressure are currently thought to be most effective
for allowing adjustments to regional flow in organ systems as the organs
retain their regional vascular resistance capabilities. Thus conduct of CPB
with an optimal pressure (and potentially lower flows) may allow the
individual organs to regionally modulate their own flows. scheduled for ECT
are routinely given anticholinergic medication preoperatively.
55. Physiologic effects of electroconvulsive therapy (ECT) include an:
• initial sympathetic response with sustained tachycardia
• initial sympathetic discharge followed by a sustained parasympathetic
response
• initial parasympathetic discharge followed by a sustained sympathetic
response
• initial parasympathetic response with sustained bradycardia Right Ans -
55. initial parasympathetic discharge followed by a sustained sympathetic
response. An initial parasympathetic discharge followed by a sustained
sympathetic response is immediately seen after the induction of a seizure.
Marked bradycardia with increased secretions can occur, which is then
followed by hypertension and tachycardia. Patient
54. A 70-year-old man with a DDD-R pacemaker for a history of symptomatic
bradycardiais undergoing an anterior cervical discectomy and fusion with
somatosensory evoked potential (SSEP) and motor evoked potential (MEP)
monitoring. The pacemaker should be reprogrammed to which of the
following?
• Discontinue R function
• Dual chamber asynchronous pacing
• No reprogramming
• Ventricular asynchronous pacing Right Ans - 54. "R" signifies rate
responsiveness in the fourth position of the pacemaker designation code.
(A+ Accurate)
The arteria radicularis magna, or artery of Adamkiewicz, most commonly
arises from:
• T4 - T8
• T8 - L2
• L2 - L4
• L4 - S1 Right Ans - T8 - L2.
A major complication of thoracic aortic surgery is paraplegia, occurring in up
to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria
radicularis magna supplies blood to the anterior spinal artery. The arteria
radicularis magna has a variable origin from aorta, arising between T5 - T8 in
15%, between T9 - T12 in 60% and between L1 - L2 in 25% of individuals.
During fetal monitoring, Type III decelerations are thought to be related to:
• head compression
• umbilical cord compression
• uteroplacental insufficiency
• placental abruption Right Ans - umbilical cord compression
Type III, or variable, decelerations are the most common type of
decelerations. They are thought to be related to umbilical cord compression
and intermittent decreases in umbilical blood flow.
60. A 55-year-old woman with a history of congenital long QT syndrome is
undergoing a hysteroscopy for abnormal uterine bleeding. She had uneventful
induction of general anesthesia but after paracervical block with lidocaine
develops ventricular tachycardia with morphological appearance of torsades
de pointe. Which of the following medications should be AVOIDED in the
treatment of her arrhythmia?
• Amiodarone
• Calcium chloride
• Esmolol
• Magnesium sulfate Right Ans - 60. Amiodarone. Congenital long QT
syndrome may occur in conjunction with other hereditary syndromes, such as
Jervell, Lange-Nielsen or Romano-Ward syndrome, or acquired as a result of
pharmacologic or metabolic etiologies. It is an issue of cellular repolarization
,which precipitates tachyarrhythmias, most commonly polymorphic
ventricular tachycardia or torsades de pointe. There are multiple subtypes
that affect both potassium and/or sodium channels. The arrhythmias may be
precipitated by sympathetic activation, auditory stimuli or at rest. Family
history may be positive for sudden cardiac death and the ECG significant for
prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves.
Treatment includes magnesium for arrhythmias, possible permanent
pacemaker, or beta blockers for subtypes 1 and 2, but amiodarone is
considered contraindicated as it prolongs the QT interval.
59. A 76-year-old man is scheduled for a hemicolectomy. His past medical
history is significant for third degree heart block treated with a permanent
pacemaker. Problems with electrocautery use in this patient can be minimized
by:
• placing the grounding pad near the pacemaker
• using infrequent bursts of longer duration
• the use of a bipolar cautery
• reducing the surface area of the return electrode Right Ans - 59. the use
of a bipolar cautery. Electrical interference from the electrocautery can be
interpreted by the pacemaker as myocardial activity and suppress pacemaker
activity. These problems can be minimized by limiting use to short bursts,
placing the grounding pad as far from the pacemaker as possible and using a
bipolar cautery.
58. A 35-year-old woman who underwent orthotopic heart transplantation 2
years ago for nonischemic cardiomyopathy presents after a motor vehicle
accident for exploratory laparotomy under general anesthesia.
Intraoperatively, her blood pressure is 75/35 mmHg and heart rate is 90 bpm.
After the administration of phenylephrine, which of the following
hemodynamic responses do you MOST expect?
• HR decreased, BP increased
• HR decreased, BP no change
• HR no change, BP increased
• HR no change, BP no change Right Ans - 58. HR no change, BP increased.
After heart transplantation, the heart is completely denervated. The normal
resting heart rate is relatively tachycardic at 90-100 bpm due to lack of vagal
tone. Vagal bradycardic responses (to laryngoscopy, hypertension, carotid
sinus massage) will also be absent. Over time, however, many patients require
,permanent pacemaker placement for treatment of significant bradycardia.
After heart transplant, patients are not able to respond to demands for
increased cardiac output with increased heart rate. Thus in this situation of a
trauma with potentially significant blood loss, a normal patient would have
tachycardia but a heart transplant patient has no change in heart rate, only
hypotension. Instead for heart transplant patients, cardiac output is
augmented by increased stroke volume. For this reason it is important to
maintain adequate intravascular volume. The transplanted heart is not able to
respond to medications that block the parasympathetic system. Bradycardia
and hypotension have to be treated with medications that have a direct effect
such as epinephrine and isoproterenol. Phenylephrine will result in increased
blood pressure, but no change in heart rate. Indirect and mixed
indirect/direct-acting drugs have minimal effect or have the effect of their
direct components.
57. The postretrobulbar block apnea syndrome:
• is likely secondary to intravascular injection
• most commonly occurs during or immediately after injection
• is associated with unconsciousness
• carries a high morbidity and mortality Right Ans - 57. is associated with
unconsciousness. The postretrobulbar block apnea syndrome is probably due
to injection of local anesthetic into the optic nerve sheath, with spread into the
CSF. The CNS is exposed to high concentrations of local anesthetic leading to
apprehension and unconsciousness. Apnea occurs within 20 minutes and
resolves within an hour. Treatment is supportive.
56. A 75-year-old man is undergoing a mitral valve replacement via
cardiopulmonary bypass. The perfusionist is running bypass flows at > 2.5
liters/minute/m2. Which of the following is the MOST likely adverse
consequence of undergoing cardiopulmonary bypass at increased flow rates?
• Increased trauma to blood elements
• Increased hypothermia
• Decreased blood flow to the brain
• Decreased myocardial blood flow Right Ans - 56. A. Increased trauma to
blood component: Cardiopulmonary bypass (CPB) does the work of the heart
and lungs in order to isolate those organs from blood flow such that surgery
on the heart can occur in a relatively bloodless fashion. Thus, the CPB circuit
must oxygenate and ventilate the blood and then deliver the oxygenated blood
, back to the body and end organs. It has long been debated whether maximal
blood flow or pressure is more important in perfusion and homeostasis of the
end organs during bypass. Maximizing blood flow (generally considered to be
flow at a cardiac index of > 2 liters/minute/meter2) has been shown to
increase hematologic trauma, increase the magnitude of the stress or
inflammatory response, cause strain on suture lines, increase shunting of
blood through the pulmonary system, increase washout of cardioplegia and
not necessarily lead to improved regional blood flow. The CPB machine can
change total flow, but it cannot adjust regional flows to the various end organ
systems. Changes in blood pressure are currently thought to be most effective
for allowing adjustments to regional flow in organ systems as the organs
retain their regional vascular resistance capabilities. Thus conduct of CPB
with an optimal pressure (and potentially lower flows) may allow the
individual organs to regionally modulate their own flows. scheduled for ECT
are routinely given anticholinergic medication preoperatively.
55. Physiologic effects of electroconvulsive therapy (ECT) include an:
• initial sympathetic response with sustained tachycardia
• initial sympathetic discharge followed by a sustained parasympathetic
response
• initial parasympathetic discharge followed by a sustained sympathetic
response
• initial parasympathetic response with sustained bradycardia Right Ans -
55. initial parasympathetic discharge followed by a sustained sympathetic
response. An initial parasympathetic discharge followed by a sustained
sympathetic response is immediately seen after the induction of a seizure.
Marked bradycardia with increased secretions can occur, which is then
followed by hypertension and tachycardia. Patient
54. A 70-year-old man with a DDD-R pacemaker for a history of symptomatic
bradycardiais undergoing an anterior cervical discectomy and fusion with
somatosensory evoked potential (SSEP) and motor evoked potential (MEP)
monitoring. The pacemaker should be reprogrammed to which of the
following?
• Discontinue R function
• Dual chamber asynchronous pacing
• No reprogramming
• Ventricular asynchronous pacing Right Ans - 54. "R" signifies rate
responsiveness in the fourth position of the pacemaker designation code.
