A 30-year-old man receives spinal anesthesia to the level of T4. Ten minutes later, heart rate and blood pressure abruptly decrease to 30 bpm and 60/25 mmHg, respectively. The most appropriate management is administration of which of the following drugs?
A patient who is scheduled for a gastrectomy had abnormal liver function tests for four days following a prior cholecystectomy. In your consultation note, you should
(A) recommend sevoflurane anesthesia since abnormal postoperative liver function tests are unlikely with this drug
(B) recommend subarachnoid anesthesia since changes in hepatic blood flow would be less than with general anesthesia
(C) indicate that abnormal liver function tests are likely to follow this operation regardless of the anesthetic drugs used
(D) require preoperative screening for hepatitis B antigen and antibodies
(E) recommend avoiding halothane since it is more likely to produce hepatitis in patients who had previous upper abdominal surgery
A patient being mechanically ventilated in the ICU requires wound debridement twice daily. Each of the following agents would be appropriate for induction of brief general anesthesia EXCEPT
One hundred children who are to have strabismus surgery are enrolled in a research protocol. Fifty receive a new antiemetic and 50 receive a placebo preoperatively. Fifteen children in the treatment group and 37 children in the control group have nausea and vomiting postoperatively. Which of the following analyses is most appropriate for determining the statistical significance of the group differences?
A 57-year-old man with hepatocellular disease is scheduled to undergo a colectomy for colon cancer. Preoperative laboratory studies show a plasma albumin concentration of 2.4 g/dl (normal = 3.5 to 5.5 g/dl); prothrombin time is 16 sec (control 12 sec). Which of the following statements concerning the anesthetic management of this patient is true?
(A) Atracurium will have a prolonged duration of action
(B) The risk for perioperative hyperglycemia is increased
(C) Mivacurium will have a shortened duration of action
(D) The unbound fraction of thiopental will be increased
(E) Vitamin K injection will normalize the prothrombin time
A 70-kg 78-year-old man undergoing small-bowel resection during anesthesia with isoflurane in oxygen becomes hypotensive and develops frothy pink sputum in the endotracheal tube. Heart rate is 50 bpm, blood pressure is 75/60 mmHg, pulmonary artery occlusion pressure is 22 mmHg, and cardiac output is 1.7 L/min. The most appropriate initial step in management is administration of which of the following?
During general anesthesia, a patient has the acute onset of atrial fibrillation with rapid ventricular response and hypotension to 50 mmHg systolic. The most appropriate treatment is
Which of the following phenomena is primarily responsible for the decrease in core body temperature that commonly occurs during the first hour of general anesthesia?
(A) Convective heat loss from cutaneous vasodilation
(B) Decreased heat production
(C) Evaporative heat loss during skin preparation
(D) Heat loss from the respiratory tract
(E) Redistribution of core body heat to the periphery
During rapid-sequence induction prior to an emergency surgical procedure, a 20-year-old patient vomits gastric contents containing particulate matter. An endotracheal tube is easily inserted and ventilation with pure oxygen is initiated. Despite the presence of bilateral breath sounds, SpO2 is 90%. Which of the following is the most appropriate next step?
(A) Administration of broad-spectrum antibiotics
(B) Intravenous administration of high-dose methylprednisolone
A 64-year-old, 87-kg woman in good general health is undergoing a right knee arthroplasty while in the supine position with general anesthesia consisting of enflurane 2% and nitrous oxide 50% in oxygen. She is breathing spontaneously through a 7-mm endotracheal tube. During the first 30 minutes of the procedure, the arterial oxygen saturation measured by pulse oximetry decreases from 98% to 92%. The most likely cause of the desaturation is
(A) decreased functional residual capacity
(B) diffusion hypoxia
(C) hypercarbia
(D) increased airway resistance produced by the endotracheal tube
(E) inhibition of hypoxic pulmonary vasoconstriction
An obese, 35-year-old man had an episode of coughing followed by vomiting during induction of anesthesia for arthroscopy of the left knee. Intense wheezing developed bilaterally over five minutes. PaO2 is 60 mmHg, PaCO2 is 42 mmHg, and pH is 7.35. Optimal management following intubation of the trachea includes
(A) mechanical ventilation with positive end-expiratory pressure (PEEP), cancellation of surgery, and transfer to the intensive care unit
(B) saline lavage and continuation of surgery using halothane anesthesia
(C) cancellation of surgery and administration of corticosteroids and antibiotics
(D) thorough suctioning and proceeding with halothane anesthesia
(E) cancellation of surgery, vigorous mechanical ventilation, thorough suctioning, and administration of aminophylline
A 45-year-old man is scheduled for appendectomy under general anesthesia. He reports that for many years he has occasionally felt his heart "skip a beat." The ECG tracing shown was obtained one hour ago. Which of the following is the most appropriate next step?
A previously healthy, 60-kg, 17-year-old boy is undergoing emergency surgery for a gunshot wound involving the iliac vein. Ventilation is controlled with a tidal volume of 700 ml/breath, rate of 10/min, and peak inspiratory pressure of 30 cmH2O. Body temperature is normal. The most likely cause of an end-tidal carbon dioxide partial pressure of 16 mmHg is
Statistical analysis of 20 patients shows a mean cardiac output (CO) of 5 L/min with a standard deviation of 1 L/min. The distribution pattern in the sample population is normal. Which of the following is the most appropriate conclusion?
(A) Approximately 33% of the sample population would be expected to have a CO between 4 and 6 L/min
(B) Approximately 95% of the sample population would be expected to have a CO between 3 and 7 L/min
(C) Ten of the sample patients have a cardiac output greater than 5 L/min
(D) The mean and the median are both at the 50th percentile
(E) The median and the mode are the same in the sample population
A 26-year-old man who sustained multiple trauma undergoes open reduction and internal fixation of bilateral tibial-fibular fractures during anesthesia with isoflurane. nitrous oxide, and oxygen with positive pressure ventilation. During the procedure, the patient has sudden onset of hypotension, jugular venous distention, deviation of the trachea to the right, and decreased ventilatory compliance. Isoflurane is discontinued and 100% oxygen is administered. Which of the following is the most appropriate next step in management?
During laser microsurgery of the larynx using an endotracheal tube, a fire occurs in the airway. Which of the following is the most appropriate initial management?
Addition of 20 cmH2O positive end-expiratory pressure to a patient receiving controlled mechanical ventilation decreases cardiac output and left ventricular function by
An unconscious adult patient is being ventilated through an esophageal obturator airway (EOA) in the emergency department. In the absence of cervical spine injury, which of the following is appropriate?
(A) Use of the EOA for airway management until the patient regains consciousness
(B) Removal of the EOA before insertion of an endotracheal tube
(C) Placement of an endotracheal tube before removal of the EOA
(D) Removal of the EOA under fiberoptic endoscopic visualization
A 30-year-old woman is undergoing laparoscopic tubal ligation. Thirty minutes after induction of general anesthesia, arterial oxygen saturation has decreased to 89%. Arterial blood gases at an FiO2 of 1.0 are PaO2 63 mmHg and PaCO2 40 mmHg; PetCO2 is 32 mmHg. Which of the following is the most likely cause?
(A) Carbon dioxide embolus
(B) Endobronchial intubation
(C) Hypoventilation
(D) Inadvertent application of high levels of positive end-expiratory pressure
Which of the following processes is primarily responsible for the decrease in core body temperature that occurs during the first hour of general anesthesia?
(A) Decreased production of heat
(B) Convective heat loss caused by cutaneous vasodilation
(C) Evaporative heat loss during skin preparation
(D) Heat loss from the respiratory tract
(E) Redistribution of core body heat to the periphery
During induction of anesthesia, a 56-year-old man with small bowel obstruction vomits a large quantity of undigested food particles and presumably aspirates. After instituting ventilation with pure oxygen, the most appropriate management is to
(A) administer dexamethasone
(B) administer penicillin G
(C) perform bronchoscopy
(D) ventilate with positive end-expiratory pressure 15 cmH2O
(E) proceed with the anesthesia plan if the tracheal pH is greater than 2.5
A 27-year-old man with a one-month history of quadriplegia at a C6 level is given general anesthesia for cystoscopy. During the cystoscopy, blood pressure suddenly increases to 220/120 mmHg. Further evaluation is most likely to show
During induction of anesthesia in a 70-year-old man with aortic stenosis, the blood pressure decreases from 140/ 80 to 70/45 mmHg as the cardiac rhythm changes from normal sinus at 70 bpm to junctional at 120 bpm. The most appropriate initial therapy would be
An obese, 70-year-old woman with a long history of tobacco abuse is awake and semirecumbent after uneventful anesthesia with isoflurane for a ventral hernia repair. During the first hour in the recovery room while breathing 50% oxygen by face mask, her arterial oxygen saturation decreases to 90% while other vital signs remain satisfactory. Which of the following is most likely to be effective in the management of this situation?
The mortality rate of patients given drug A is 12% (8 of 66) and the mortality rate of patients given drug B is 15% (10 of 66). Which of the following tests is most appropriate to compare these mortality rates?
Ten minutes after induction of anesthesia with thiopental and isoflurane but before incision, a patient's nasopharyngeal temperature has decreased to 35.4°C. Which of the following contributed most to this decrease in temperature?
(A) Anesthesia-induced block of nonshivering thermogenesis
A 78-year-old man who is scheduled for an inguinal hernia repair has a preoperative ECG showing left bundle branch block. He has had no symptoms of cardiovascular disease. This ECG finding most likely indicates
(A) cardiac disease
(B) the need for spinal anesthesia
(C) an electrolyte disturbance
(D) the need for insertion of a temporary pacemaker
During controlled ventilation, which of the following will cause an increase in end-tidal carbon dioxide tension with a normal waveform on the capnograph?
(A) Bronchospasm
(B) Rapid blood loss
(C) Ventricular fibrillation
(D) Endobronchial migration of the endotracheal tube
A patient is undergoing exploration of a stab wound to the left side of the neck. On awake laryngoscopy, the left vocal cord is in midposition and the right vocal cord is abducted during inspiration. The most likely cause of these findings is trauma to which of the following structures on the left?
A 25-year-old man requires exploratory laparotomy following a motor vehicle accident. He is acutely intoxicated with alcohol. Which of the following is the most likely result of the alcohol ingestion?
(A) Hyperdynamic circulation
(B) Hyperglycemia
(C) Hyperthermia
(D) Increased respiratory depression from opioids
(E) Increased sensitivity to neuromuscular blocking drugs
A patient becomes flushed, dyspneic, and hypotensive during transfusion of 1 unit of packed red blood cells in the PACU. After discontinuing the transfusion, the most appropriate next step is administration of
A 28-year-old patient has severe laryngospasm after extubation of the trachea following general anesthesia. Administration of 100% oxygen using continuous positive airway pressure does not improve symptoms. SpO2 is 75%. Which of the following is the most appropriate immediate management?
The ECG strip shown is recorded as a patient with a permanent transvenous DDD pacemaker enters the operating room. These changes indicate that the pacemaker is
When evaluating a screening test, which of the following is the most appropriate term for the proportion of patients with a disease who have a positive test result?
A 60-kg, 70-year-old man requires open reduction and internal fixation of an intertrochanteric fracture sustained 24 hours ago. Serum creatinine concentration is 1 mg/dl and blood urea nitrogen concentration is 40 mg/dl. The most likely cause of these findings is
A morbidly obese patient is to undergo gastric stapling during general anesthesia. Following preoxygenation and induction, the oxygen saturation decreases after 40 seconds of laryngoscopy and attempted intubation. The rapid onset of arterial desaturation is most likely due to
Twenty minutes after thiopental induction for femoral herniorrhaphy, a 34-year-old woman is breathing spontaneously and receiving nitrous oxide-oxygen (2 liters each) and enflurane 3% by face mask. Pulse is 90 bpm, blood pressure is 80/60 mmHg, end-tidal enflurane concentration is 2%, and end-tidal carbon dioxide tension is 48 mmHg. Which of the following is most likely to occur on skin incision?
A 50-year-old man with alcoholism and jaundice is scheduled to undergo umbilical herniorrhaphy. An increase in which of the following best indicates impaired synthetic hepatic function?
The EKG rhythm shown developed during cholecystectomy in a 62-year-old man who had a myocardial infarction and is taking atenolol. The drug of choice for treating this arrhythmia is
A 40-year-old man is undergoing open reduction and internal fixation of a fractured femur. During anesthesia with fentanyl, sevoflurane, and oxygen, heart rate decreases to 20 bpm and 6 premature ventricular contractions per minute are noted. No pulse is detected. The most appropriate next step is to
A 65-year-old patient with hypertrophic cardiomyopathy has chest pain prior to induction of anesthesia. Pulse is 80 bpm and blood pressure is 130/80 mmHg. The ECG (V5) shows sinus rhythm and new ST-segment depression. The most appropriate management is administration of
A 36-year-old woman who undergoes peritoneal dialysis for chronic renal failure requires emergency surgical exploration for bowel obstruction. Serum creatinine concentration is 9.8 mg/dl and BUN concentration is 124 mg/dl. The most likely abnormality of coagulation is
(A) decreased euglobulin lysis time
(B) decreased platelet count
(C) prolonged activated partial thromboplastin time
An adult patient with atrial fibrillation develops pulseless ventricular tachycardia wfiile undergoing synchronized electirical cardioversion. Which of the following is the most appropriate management?
(A) Intravenous administration of adenosine
(B) Intravenous administration of a bolus of lidocaine followed by electrical cardioversion
(C) Immediate repeat synchronized cardioversion at the same energy level
(D) Immediate repeat synchronized cardioversion at twice the previous energy level
A 77-year-old woman is still intubated and breathing spontaneously following a total hip replacement. The muscle relaxant has been reversed. Tidal volume is 400 ml, end-tidal carbon dioxide tension is 45 mmHg, and SpO2 is 98% at an FiO2 of 1.0. On transfer from the operating table to the gurney, heart rate increases from 65 to 100 bpm and blood pressure decreases from 130/80 to 80/50 mmHg. End-tidal carbon dioxide tension is 30 mmHg and SpO2 is 94%. The most likely diagnosis is
A middle-aged, 70-kg man with a brain tumor is scheduled for an elective craniotomy. Preoperatively, he is alert but papilledema is present. Anesthesia is induced with thiopental 300 mg and succinylcholine 100 mg, followed by tracheal intubation. Immediately following intubation vigorous bucking occurs. The best immediate management would be to
(A) administer succinylcholine 100 mg intravenously
(B) administer fentanyl 500 jug intravenously
(C) hyperventilate with isoflurane 2%
(D) administer thiopental 400 mg intravenously
(E) hyperventilate and administer lidocaine 1 mg/kg intravenously
A 65-year-old man has a history of alcohol abuse. Which of the following preoperative serum concentrations would provide the best assessment of synthetic hepatic function?
Following induction of general anesthesia, mask ventilation and the initial attempt at intubation is unsuccessful. Which of the following procedures is most appropriate?
A previously healthy 46-year-old woman has severe substernal chest pain one hour after receiving morphine sulfate 10 mg intramuscularly for an elective cholecystectomy. Vital signs, SpO2, and findings on a five-lead ECG on the operating room monitor are within normal limits. Which of the following is the most appropriate next step?
A patient develops jaundice one week after undergoing laparoscopic cholecystectomy during halothane anesthesia. Laboratory studies show an increased serum alkaline phosphatase concentration, a mildly increased serum aspartate aminotransferase concentration, and a markedly increased conjugated bilirubin fraction. Which of the following is the most likely diagnosis?
Which of the following is the most likely cause of a decrease in end-tidal carbon dioxide tension during general anesthesia with a constant minute ventilation?
(A) Administration of sodium bicarbonate
(B) Intravenous administration of hypertonic glucose solution
(C) Decrease in cardiac output
(D) Decrease in fresh gas flow in a Bain circuit
(E) Malfunction of the inspiratory valve in a circle system
A 30-year-old woman undergoes thyroidectomy under general endotracheal anesthesia. Immediately after extubation while breathing spontaneously, she has laryngospasm that resolves after 60 seconds of continuous positive airway pressure applied by face mask. In the PACU, she develops shortness of breath, tachypnea, hypoxemia, and rales. Which of the following is the most likely diagnosis?
Which of the following complications is more likely to occur during cannulation of the left internal jugular vein than during cannulation of the right internal jugular vein?
A 48-year-old woman with von Willebrand's disease is scheduled for a hysterectomy. The most appropriate initial preoperative therapy to decrease bleeding is administration of
A healthy 60-kg 52-year-old woman undergoing reduction mammoplasty is anesthetized with isoflurane and oxygen, and deliberate hypotension to 80/40 mmHg is induced with nitroprusside. Urine output through an indwelling urethral catheter has been 10 mL during the past hour. You should now
(A) administer furosemide 40 mg intravenously
(B) infuse normal saline solution until urine output reaches 35 mL/hr
(C) administer dopamine at 3 mcg/kg/min
(D) expect normal urine flow with restoration of normal blood pressure
A 30-year-old man who is undergoing laparotomy and resection of a large kidney tumor has a decrease in SpO2 from 100% to 92% and an increase in peak airway pressure from 20 to 35 cm H2O. Plateau pressure is unchanged at 18 cm H2O. Which of the following is the most likely cause?
Following transfusion of packed red blood cells during general anesthesia, the patient's blood pressure decreases, heart rate and temperature increase, and hemoglobinuria and diffuse oozing are observed. Which of the following is the most appropriate first step in management?
A patient with a fasting blood glucose concentration of 100 mg/dl undergoes a four-hour operation under general anesthesia without intraoperative administration of glucose. On emergence the most likely finding will be
During a cardiac arrest with effective chest compression and positive-pressure ventilation, 50 mEq of sodium bicarbonate is administered. Which of the following is the most likely result?
A patient has severe hypotension, bronchospasm, and edema of the upper airway after injection of radiocontrast medium during cerebral angiography. The most appropriate immediate treatment is administration of
An EKG shows ventricular tachycardia in a patient with a heart rate of 160 bpm and a blood pressure of 90/60 mmHg. The best initial therapeutic maneuver prior to cardioversion is
The cardiovascular effects of an inhalational anesthetic are evaluated in 10 normal volunteers in the awake resting state and after 15 minutes of constant inspired concentration. Results were analyzed by t-test for paired data and are presented below as mean +/- standard deviation. Based on these data, which of the following conclusions is most valid?
(A) A decrease in cardiac output would have been evident if more subjects were included in the study
(B) The anesthetic decreases mean arterial pressure
(C) The anesthetic does not cause cardiac depression
(D) The anesthetic is unsafe for patients with coronary after disease
(E) There is a 95% to 100% chance that the anesthetic increases heart rate
Which of the following combinations of hemoglobin, blood gases, and cardiac output provides the greatest delivery of oxygen to tissue? (Hb, PaO2, SaO2, CO)
A 46-year-old man is scheduled for repair of an inguinal hernia. Six years ago, he had an episode of malignant hyperthermia during cholecystectomy. Which of the following is the most appropriate perioperative management?
(A) Administration of a regional anesthetic
(B) Administration of dantrolene orally for two days prior to surgery
(C) Avoidance of all inhalational anesthetics except isoflurane
(D) Avoidance of ester local anesthetics
(E) Flushing the anesthesia machine with oxygen 10 L/min for a minimum of 12 hours
A 30-year-old, 70-kg woman with mitral stenosis is scheduled for elective laparoscopic sterilization. Preoperatively she is taking digoxin and an unknown medication for chronic mental depression. The EKG demonstrates atrial fibrillation. Heart rate is 68 bpm. Anesthesia is induced with thiopental followed by nitrous oxide 50%, halothane 0.75%, and a continuous succinylcholine infusion. The ventilator is set to deliver a minute volume of 5 liters through an endotracheal tube. As the carbon dioxide is being insufflated into the abdomen, the blood pressure is noted to be elevated (150/100 mmHg) and ventricular bigeminy is present. The most appropriate therapy is to
(A) increase the halothane concentration to 1.25%
(B) discontinue the succinylcholine infusion
(C) increase minute ventilation to 7.5 L/min
(D) administer potassium 5 mEq intravenously over one minute followed by propranolol 0.25 mg
(E) measure arterial blood gas and serum electrolyte values
A 70-year-old man who underwent bilateral carotid endarterectomies two years ago is to undergo anesthesia and surgery. The denervation of the carotid bodies is likely to result in
A patient receiving mechanical ventilation with oxygen 60% postoperatively has a PaO2 of 160 mmHg and a PaCO2 of 38 mmHg. One hour later, with mechanical ventilation unchanged, the PaO2 is 150 mmHg and PaCO2 is 48 mmHg. The most likely cause of these changes is
During acute normovolemic hemodilution in an adult, which of the following compensatory mechanisms is most important in maintaining tissue oxygenation?
A 28-year-old woman undergoes total thyroidectomy. The left recurrent laryngeal nerve is transected during the procedure. Which of the following findings is most likely postoperatively?
A patient is in sinus rhythm but has no pulse during cardiopulmonary resuscitation. There is marked resistance to positive pressure ventilation and breath sounds are difficult to hear bilaterally. The endotracheal tube is clearly in the trachea. The most appropriate next step in management is to
During a reoperative total hip arthroplasty requiring transfusion of 8 units of packed red blood cells, blood begins to ooze from the operative field and intravenous catheter sites. Urine is pink. The most likely cause is
A 72-year-old man has massive venous hemorrhage during a radical prostatectomy. Blood pressure decreases from 110/60 to 75/30 mmHg and central venous pressure decreases from 12 to 4 mmHg. End-expiratory carbon dioxide tension decreases from 34 to 24 mmHg during constant minute ventilation. The most appropriate next step should be to
(A) apply positive end-expiratory pressure to the breathing circuit
(B) attempt to aspirate air from the central venous catheter
(C) expand intravascular volume
(D) place the patient in the Trendelenburg position
(E) turn the patient to the left lateral decubitus position
Which of the following findings on the left is most likely to be associated with an increased risk of complications with cannulation of the left internal jugular vein compared with cannulation of the right internal jugular vein?
(A) Longer recurrent laryngeal nerve
(B) Lower location of the cupola of the pleura
(C) More acute angle between the internal jugular and innominate veins
As part of a preoperative evaluation, a patient had a thallium scan showing a 'cold spot' over the left ventricle that occurs with moderate exercise and disappears at rest. This most likely indicates
A 68-year-old man who is scheduled for outpatient cystoscopy has non-insulin-dependent diabetes mellitus controlled with glipizide (Glucatrol) 5 mg twice daily. He has had nothing to eat since awakening this morning and has not taken glipizide today. His blood glucose level is 185 mg/dl. Before proceeding, the most appropriate management is to administer
In a patient with ventricular fibrillation refractory to repeated attempts at defibrillation and epinephrine administration, the most appropriate management is administration of