A 26-year-old patient with multiple trauma is admitted to the intensive care unit postoperatively. The early development of polyuria, hypotension, low urine sodium excretion, high serum osmolality, and normal serum creatinine concentration is best explained by
A 25-year-old woman undergoes a difficult open cholecystectomy during anesthesia with isoflurane, nitrous oxide, fentanyl, and vecuronium. Five units of blood are administered intraoperatively. Two days later, the patient has mildly increased serum transaminase concentrations and markedly increased alkaline phosphatase and direct bilirubin concentrations. Which of the following is the most likely cause?
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
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?
In a patient undergoing liver transplantation, sodium bicarbonate and calcium chloride are administered immediately before reperfusion of the transplanted liver to counteract
During right upper lobectomy and one-lung ventilation with a double-lumen endotracheal tube, the PaO2 decreases to 40 mmHg. The PaCO2 is 39 mmHg. Which of the following is most appropriate?
(A) Confirm position of the tube with bronchoscopy
(B) Apply 5 cmH20 continuous positive airway pressure to the nondependent lung
(C) Apply 5 cmH20 positive end-expiratory pressure to the dependent lung
(D) Resume two-lung ventilation
(E) Clamp the pulmonary artery of the nondependent lung
A man with alcoholic cirrhosis and a hemoglobin concentration of 10 g/dl has an intraoperative PaO2 of 75 mmHg at an FiO2 of 0.5. Which of the following is the most likely cause of the low PaO2?
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. PetC02 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
A 15-year-old previously healthy boy is scheduled for a celiotomy to relieve an acute intestinal obstruction. A rapid sequence induction is used. Anesthesia is maintained with a balanced technique including nitrous oxide and oxygen (5L:2L), meperidine, and pancuronium. Because of abdominal distention and the high pressure required for inflation of the lungs, a nasogastric tube is inserted. The abdomen remains distended, but compliance improves dramatically. At this time the patient is cyanotic, PaO2 is 48 mmHg, PaCO2 is 52 mmHg, and pH is 7.29. Nitrous oxide is discontinued. The most important therapeutic measure is to
(A) remove the nasogastric tube
(B) insert a chest tube on the right side
(C) withdraw the endotracheal tube 1 cm
(D) deflate the cuff on the endotracheal tube
(E) replace the endotracheal tube with one of larger internal diameter
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 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
During cardiopulmonary resuscitation (CPR) in an adult, external chest compression is being performed at the rate of 90/min with 2 inches of sternal depression and a compression-relaxation ratio of 20:80. The most appropriate action is to
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?
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?
Four days after mitral valve replacement, a 49-year-old, 70-kg woman who has had oliguric renal failure since the operation requires insertion of a Schribner shunt for hemodialysis. Her BUN concentration is 104 mg/dl, serum creatinine is 9.3 mg/dl, serum sodium is 130 mEq/L, and serum potassium is 6.7 mEq/L. During the operation under local anesthesia, diazepam 7.5 mg and morphine 10 mg are administered intravenously to control agitation. Five minutes later while she is sleeping quietly, unifocal premature ventricular contractions appear at a rate of 10 per minute on the ECG monitor. The most appropriate therapy is to
(A) administer calcium gluconate 250 mg intravenously
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
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?
You are called to anesthetize a patient for an emergency pericardial window for a large pericardial effusion. Which of the following drugs is most appropriate for initiation of anesthesia?
A patient undergoes thoracotomy in the lateral decubitus position. Which of the following maneuvers is most likely to increase PaO2 during one-lung ventilation?
(A) Applying continuous positive airway pressure to the nondependent lung
(B) Applying positive end-expiratory pressure to the dependent lung
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
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 68-year-old man has a permanent DVI pacemaker that has been functioning appropriately. Which of the following is most likely to cause conversion to VOO pacing?
(A) Electroconvulsive therapy
(B) Insertion of a pulmonary artery catheter
(C) Placement of a magnet over the pulse generator
A 76-year-old man has a leaking abdominal aortic aneurysm. His blood pressure and pulse have remained stable for 15 minutes at 90/60 mmHg and 130 bpm, respectively. His hemoglobin concentration is 11 g/dl, and the EKG shows a left bundle branch block. Induction of anesthesia should proceed
(A) after a pulmonary artery catheter has been inserted and the pulmonary artery occlusion pressure is greater than 7 mmHg
(B) when the pulse has decreased below 130 bpm from the rapid transfusion of blood
(C) when systolic blood pressure has increased to more than 120 mmHg from the rapid infusion of lactated Ringer's solution
(D) immediately on arrival in the operating room
(E) when circulatory signs deteriorate or cease to improve with rapid volume expansion
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 120-kg 56-year-old man undergoing gastrectomy during anesthesia with fentanyl and isoflurane has a PetCO2 of 35 mmHg and a PaCO2 of 50 mmHg. His FEV,/FVC ratio is 80% of predicted. Heart rate is 120 bpm and arterial blood pressure is 80/40 mmHg. Which of the following is the most likely cause of the difference in PaCO2 and PetCO2?
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 50-year-old man who takes aspirin and nifedipine is scheduled for thoracotomy with one-lung ventilation. Which of the following is associated with the greatest risk for intraoperative hypoxemia?
(A) Preoperative withdrawal of nifedipine therapy
(B) Intraoperative mild respiratory acidosis
(C) Intraoperative administration of isoflurane
(D) Intraoperative administration of nitroglycerin
A previously healthy 28-year-old woman scheduled for laparoscopic tubal ligation becomes, agitated and refuses to undergo the procedure after being brought to the operating room. This behavior most likely resulted from preoperative administration of
A 45-year-old patient with chronic alcoholism develops jaundice four days after a cholecystectomy under halothane/morphine general anesthesia. Bilirubin and alkaline phosphatase are elevated, but ALT is only slightly above normal. All values were within normal limits preoperatively. The most likely cause of jaundice is
(A) opioid-induced spasm of the sphincter of Oddi
(B) hepatic dysfunction secondary to halothane exposure
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
A 56-year-old woman with pulmonary fibrosis is scheduled for pneumonectomy. Which of the following parameters best predicts potential postoperative functional impairment?
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?
Six hours after coronary artery bypass grafting, a pulmonary artery catheter oximeter shows a mixed venous hemoglobin oxygen saturation of 50%. This value may result from each of the following EXCEPT
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 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 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 70-year-old man undergoes cross clamping of the aorta for repair of an abdominal aneurysm. Which of the following methods is most appropriate for decreasing hypotension associated with removal of the cross clamp?
(A) Administration of a phenylephrine bolus when the cross clamp is removed
(B) Correction of any base deficit with sodium bicarbonate during clamping
(C) Decrease of anesthetic to allow blood pressure to increase to 20% above preclamp levels
(D) Volume loading to increase pulmonary artery occlusion pressure prior to removal
(E) Infusion of dopamine 10 minutes prior to removal
An endobronchial Robertshaw tube is inserted for resection of a midesophageal tumor under isoflurane, oxygen, pancuronium anesthesia. Forty minutes into a planned two-hour resection, arterial blood gas values are reported as PO2 45 mmHg, PCO2 45 mmHg, and pH 7.33. Ten minutes earlier, the values were PO2 210 mmHg, PCO2, 41 mmHg, and pH 7.39. The first action should be to
(A) reposition the Robertshaw tube
(B) apply positive end-expiratory pressure to the ventilated lung
(C) reinflate and ventilate the non ventilated lung
An elderly man has an acute dissection of the descending thoracic aorta. Which of the following antihypertensive therapies is most likely to extend the dissection?
(A) Esmolol infusion
(B) Nitroglycerin infusion
(C) Nitroprusside infusion
(D) Nitroprusside infusion combined with a beta-adrenergic blocker
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?
A patient with alcoholic cirrhosis, ascites, and gastrointestinal bleeding receives 4 units of red blood cells prior to anesthesia with isoflurane in oxygen for emergency exploratory laparotomy. After the peritoneum is opened and the fluid is drained, blood pressure decreases to 60/40 mmHg and SpO2 decreases to 90%. The most likely cause of the hypoxemia is
(A) acute myocardial ischemia
(B) decreased 2,3-diphosphoglycerate in transfused blood
A 75-year-old man with aortic stenosis and coronary artery disease has a preinduction heart rate of 68 bpm and blood pressure of 125/70 mmHg. After induction of anesthesia with fentanyl, midazolam, and pancuronium, heart rate is 90 bpm and blood pressure is 85/45 mmHg. ECG shows a new ST-segment elevation in lead II. Which of the following is the most appropriate initial management?
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 patient who is paraplegic secondary to spinal cord transection at T3 develops bradycardia and facial flushing during a nephrectomy under general anesthesia with nitrous oxide, fentanyl, and atracurium. The most likely cause of this response 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 23-year-old man who is receiving his first anesthetic has not resumed spontaneous ventilation two hours after receiving succinylcholine. The train-of-four monitor shows no twitch response. Which of the following is the most likely cholinesterase genotype in this patient?
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 40-year-old woman with Graves' disease is undergoing thyroidectomy with 1% isoflurane, 60% nitrous oxide, and oxygen. During surgical manipulation of the thyroid, temperature increases to 38.5°C, heart rate to 160 bpm, and blood pressure to 150/100 mmHg. The most appropriate initial treatment is to
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
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
Two hours after sustaining extensive burns of the head, neck and chest in a house fire, a patient has stridor and difficulty breathing. The most appropriate management is
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 is the most appropriate initial therapy for acute pulmonary hypertension with right ventricular dysfunction and severe systemic hypotension that occurs during anesthesia?
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 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 19-year-old man is undergoing inguinal herniorrhaphy. He is anesthetized with a spinal block supplemented with midazolam and fentanyl. During the procedure, he has sudden loss of consciousness, profound hypotension, and bradycardia; systolic pressure is 40 mmHg and heart rate is 30 bpm. Cardiopulmonary resuscitation is started. The most appropriate next step is administration of
A 50-year-old patient undergoes subtotal thyroidectomy for Graves' disease. In the immediate postoperative period, he has marked hoarseness but no stridor. The most likely cause of the hoarseness is trauma to the
(A) external branch of the superior laryngeal nerve
(B) internal branch of the superior laryngeal nerve
A 35-year-old woman with systemic lupus erythematosus is admitted to the critical care unit following sudden onset of severe chest pain. Examination shows tachycardia, hypotension, pulmonary edema, and a blowing systolic murmur in the left parasternal region. The most appropriate management is
(A) aerosol administration of terbutaline
(B) intravenous infusion of phenylephrine and nitroglycerin
(C) intravenous infusion of esmolol
(D) intravenous infusion of epinephrine and nitroprusside
(E) volume loading with lactated Ringer's solution
A 67-year-old man is undergoing total hip replacement under general anesthesia. He had a permanent endocardial VVI pacemaker placed two years ago for complete heart block, and since arrival in the operating room has been paced continuously. Use of the electrocautery causes the pacemaker to malfunction intermittently. The most appropriate management is to
(A) tape a magnet over the pacemaker generator and convert to asynchronous mode
(B) do nothing since the pacemaker is programmed to deal with this circumstance
(C) stop the surgeon from using the electrocautery
(D) limit the surgeon to 10 sec/min electrocautery bursts
(E) place the electrocautery indifferent lead as close as possible to the pacemaker
A 70-kg man with ischemic heart disease is undergoing abdominal aortic aneurysm resection. At the time of infrarenal cross-clamping, 0.2-mV ST-segment depression appears on lead V5 of the ECG. Hemodynamic changes occurring at the same time are shown below. Systemic blood pressure 90/50 --> 150/90; Heart rate 80 --> 95; PAp 20/10 --> 45/24; Mean pulmonary artery occlusion pressure (mmHg) 10 --> 23; Cardiac output (L/min) 4.5 --> 3.2. Ischemia would be decreased by restoring the pre-clamp level of each of the following EXCEPT
Following pneumonectomy, a paralyzed patient being mechanically ventilated has the following arterial blood gas values: PaO2 71 mmHg, PaCO2 55 mmHg, pH 7.29. SvO2 is 45%. The most likely explanation for this SvO2 is
Two months ago a 68-year-old man with insulin-dependent diabetes mellitus had a transurethral resection of the prostate under spinal anesthesia with tetracaine plus epinephrine. He now has numbness and tingling in both feet and disturbance of gait. Physical examination demonstrates stocking-type hypesthesia of both feet and ankles. The most likely diagnosis is
(A) anterior spinal artery syndrome
(B) diabetic neuropathy
(C) adhesive arachnoiditis
(D) cauda equina syndrome
(E) peripheral nerve injury from the lithotomy position
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
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
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
A 75-year-old man is confused, restless and disoriented two days after an aortic aneurysm repair. Serum sodium concentration is 112 mEq/L, serum osmolality is low, and urine is hypertonic. The most appropriate treatment is
(A) restriction of fluid intake
(B) administration of isotonic saline solution
(C) administration of hypertonic (3%) saline solution
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 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
A 63-year-old man with a history of congestive heart failure and left ventricular dilation is scheduled for carotid endarterectomy. During carotid cross-clamping, the surgeon requests that systolic blood pressure be increased from 100 to 160 mmHg. Compared with an identical patient with normal left ventricular size, what is the effect of this change in blood pressure on this patient's myocardial oxygen consumption?
A patient is bleeding excessively after routine transurethral resection of the prostate. Re-exploration discloses diffuse oozing. The most appropriate management is administration of
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
In a patient with ventricular fibrillation refractory to repeated attempts at defibrillation and epinephrine administration, the most appropriate management is administration of
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?
A 33-year-old woman is scheduled for emergency appendectomy under general anesthesia. She has hypertrophic cardiomyopathy and has had two episodes of syncope in the past year. Which of the following statements concerning anesthetic management is true?
(A) Spinal anesthesia is preferred to general anesthesia
(B) Deep levels of isoflurane anesthesia are appropriate
(C) Fluid administration should be restricted
(D) Phenylephrine is preferred to ephedrine to treat hypotension
(E) Positive end-expiratory pressure will decrease left ventricular outflow obstruction
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
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
A patient with chronic paraplegia (T4 level) is undergoing cystoscopy and removal of bladder calculi without anesthesia. After 10 minutes, blood pressure is 240/100 mmHg and pulse is 50 bpm. The most appropriate management is administration of
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?
A 75-year-old, 60-kg man with moderately disabling heart failure secondary to ischemic heart disease is undergoing a transurethral prostatic resection under halothane-nitrous oxide anesthesia. Resection time is 30 minutes, and fluid replacement has been lactated Ringer's solution 500 mL. Although heart rate is unchanged, the arterial pressure monitor used because of his cardiac condition has changed from A to B over the last 15 minutes. The most appropriate management is to
(A) discontinue halothane
(B) adminster ephedrine 10 mg intravenously
(C) administer digoxin one half of his daily dose intravenously
A healthy 57-year-old man with a ureteral calculus is scheduled for immersion extracorporeal shock wave lithotripsy. Which of the following statements is true?
(A) Delivery of the shock wave is timed by the R wave of the ECG
(B) Continuous epidural anesthesia is contraindicated because of the risk for infection
(C) If a regional technique is used, a T10 sensory level is required for adequate anesthesia
(D) If general anesthesia is used, high tidal volumes and low respiratory rate are preferred
(E) Removal of the patient from the bath is accompanied by an increase in blood pressure
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 patient is undergoing thoracotomy in the lateral position. Five minutes after initiation of one-lung ventilation using a double-lumen tube and 100% oxygen, SpO2 decreases from 100% to 65%. Which of the following is the most appropriate initial step in management?
(A) Adding continuous positive airway pressure to the nondependent lung
(B) Adding positive end-expiratory pressure to the dependent lung
(C) Increasing the tidal volume to the dependent lung
(D) Resuming two-lung ventilation
(E) Verifying the position of the double-lumen tube
Following a right lower lobectomy, a patient develops a bronchopleural fistula and becomes hypoxic. He is orally intubated and mechanically ventilated with pure oxygen. PaO2 is 65 mmHg, PaCO2 is 70 mmHg, and pH is 7.25. Which of the following will produce the most favorable change in the blood gases?
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
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
You are called to a witnessed cardiac arrest where cardiopulmonary resuscitation is being performed. After successful intubation, arterial blood gas values are PaO2 86 mmHg, PaCO2 63 mmHg, and pH 7.25 at an FiO2 of 1.0. The most appropriate management at this time is to
(A) repeat arterial blood gas analysis using a new specimen
(B) administer sodium bicarbonate
(C) administer fluid challenge with 500 ml of normal saline solution
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
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 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
A 90-kg, 59-year-old man with chronic obstructive pulmonary disease is undergoing laparotomy. Mechanical ventilation is being carried out with a fresh gas flow of 2 L/min at a rate of 16/min and tidal volume of 900 ml; I:E ratio is 1:2.5. PaCO2 remains greater than 50 mmHg. Preoperative PaCO2, was normal. Which of the following is the most appropriate next step?
(A) Adding 10 cmH20 of positive end-expiratory pressure
A 38-year-old woman with hyperthyroidism is undergoing open reduction and internal fixation of a fractured humerus with isoflurane anesthesia. Intraoperatively her heart rate increases to 120 bpm with occasional premature ventricular contractions. The most appropriate therapy at this time is to
A patient is scheduled for right pneumonectomy. A left-sided double-lumen endobronchial tube is inserted. After the endobronchial side is clamped and both cuffs are inflated, breath sounds are heard only on the left. Which of the following is the most likely cause?
(A) Herniation of the endobronchial cuff over the carina
(B) Occlusion of the right upper lobe bronchus
(C) Placement of the endobronchial lumen in the left mainstem bronchus
(D) Placement of the endobronchial lumen in the right mainstem bronchus
(E) Placement of the endobronchial lumen in the trachea
During acute normovolemic hemodilution in an adult, which of the following compensatory mechanisms is most important in maintaining tissue oxygenation?
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?
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
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 70-year-old man with mild hypertension and aortoiliac occlusive disease is undergoing aortofemoral bypass grafting. Which of the following interventions is most effective in maintaining renal perfusion during infrarenal aortic clamping?
A patient who had liver transplantation two years ago now requires general anesthesia for ENT surgery. Minimal rejection has occurred on a regimen of cyclosporine and prednisone. Which of the following is most likely?
Addition of 20 cmH2O positive end-expiratory pressure to a patient receiving controlled mechanical ventilation decreases cardiac output and left ventricular function by
Following blunt trauma to the chest, a patient has tachycardia, hypotension, and markedly distended neck veins. Each of the following is expected EXCEPT
(A) cardiac output of 2.1 L/min
(B) mixed venous oxygen saturation of 75%
(C) pulmonary artery occlusion pressure of 25 mmHg
(D) pulmonary artery diastolic pressure of 25 mmHg
A 69-year-old woman with mitral stenosis and atrial fibrillation is scheduled for mitral valve replacement and removal of a left atrial thrombus. After administration of pancuronium, heart rate increases to 140 bpm and blood pressure decreases to 70/40 mmHg. Which of the following is the LEAST appropriate treatment?
A 65-year-old man with essential hypertension well controlled around 140/90 mmHg with hydrochlorothiazide is scheduled for right colectomy for carcinoma. Preoperative EKG and all laboratory values are normal except for a hematocrit of 29% and serum potassium level of 3.2 mEq/L. Central venous pressure (CVP) measured from an internal jugular catheter inserted before induction of anesthesia is 7 mmHg. Ten minutes after induction with thiopental 200 mg followed by enflurane 3% in nitrous oxide and oxygen (50% each), blood pressure decreases suddenly from 110/70 to 80/50 mmHg with heart rate unchanged at 78 bpm. CVP is now 20 mmHg and the EKG demonstrates a midjunctional rhythm. After discontinuing the enflurane, the most appropriate action would be to
(A) administer furosemide 20 mg intravenously
(B) verify proper placement of the CVP catheter
(C) administer atropine 0.4 mg intravenously
(D) administer packed erythrocytes 1 unit
(E) administer potassium 20 mEq in 250 ml of intravenous fluid over 15 minutes
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
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 39-year-old patient with insulin-dependent diabetes mellitus receives thiopental 250 mg and succinylcholine 80 mg and is ventilated with 0.75% isoflurane in oxygen. Arterial pressure decreases abruptly from 140/100 to 80/50 mmHg while heart rate remains unchanged at 70 bpm. Failure of heart rate to increase most likely results from
(A) acute hypoglycemia
(B) autonomic neuropathy
(C) depression of sinus node function by thiopental
(D) depression of the baroreflex response by isoflurane
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?
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
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 19-year-old college student is brought to the emergency department cyanotic and incoherent. Respiratory rate is 48/min, pulse is 140 bpm, and blood pressure is 140/85 mmHg. The only history obtainable is that he was at a party and suddenly felt sick. Cyanosis persists despite administration of pure oxygen by mask. A venous blood sample is chocolate-brown. The action most beneficial to the patient is to
(A) intubate the trachea and control ventilation
(B) perform bronchoscopy to treat foreign body aspiration
(C) obtain a pulmonary ventilation-perfusion scan
(D) administer methylene blue intravenously
(E) administer thiosulfate in normal saline solution 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?
After the first 70 minutes of a transurethral resection of the prostate, a 70-year-old man becomes confused and has tachycardia, hypertension, and shortness of breath. Serum sodium concentration is 116 mEq/L. After informing the surgeon that the procedure should be terminated as soon as possible, the most appropriate next step would be to
(A) administer furosemide
(B) administer labetalol
(C) administer 3% sodium chloride
(D) change the irrigating solution to normal saline
During insufflation of the peritoneal cavity with carbon dioxide at the start of laparoscopy, heart rate increases to 140 bpm, blood pressure decreases to 70/40 mmHg, and a loud murmur is heard through the esophageal stethoscope. The most appropriate immediate step is to
During transurethral resection of the prostate under spinal anesthesia with a sensory level to T10, a patient has sudden onset of sharp upper abdominal pain and nausea. Arterial blood pressure increases from 120/80 to 150/90 mmHg; the patient becomes diaphoretic. Which of the following is the most likely diagnosis?
A patient with moderate hypothyroidism and unstable angina requires urgent coronary artery bypass grafting. Which of the following is most appropriate before proceeding with the operation?
(A) Initiation of epinephrine infusion
(B) Intramuscular administration of a barbiturate
(C) Intravenous administration of triiodothyronine (T3)
A 20-year-old woman with poorly controlled diabetes mellitus is scheduled for urgent drainage of an abdominal abscess. She received an initial dose of regular insulin 10 units followed by regular insulin 5 units/hr for the past five hours. Laboratory studies show serum sodium concentration 128 mEq/L, potassium 5.4 mEq/L, chloride 80 mEq/L, and glucose 750 mg/dl. The most appropriate perioperative management is
(A) addition of subcutaneous NPH insulin
(B) administration of sodium bicarbonate to correct metabolic acidosis
(C) administration of normal saline solution to correct the presumed hypovolemia
(D) administration of furosemide to correct hyponatremia
(E) infusion of 5% dextrose in 0.2% saline solution to prevent hypoglycemia
During induction of general anesthesia in a patient with a supraglottic tumor, both intubation and subsequent ventilation via a face mask are impossible. A cricothyroidotomy is performed with a 16-gauge intravenous catheter. Which of the following statements is true?
(A) Application of pressures greater than 35 cmH2O to the catheter will increase the risk for pulmonary barotrauma
(B) PaC02 can be maintained at a normal level using a standard circle system attached to the catheter
(C) PaO2 greater than 100 mmHg can be maintained indefinitely using transtracheal jet ventilation with pure oxygen through the catheter
(D) Emergency surgical tracheostomy would have improved the likelihood of survival
(E) The presence of this tumor contraindicates jet ventilation via cricothyroidotomy
Following extubation after nasotracheal intubation for seven days, a 35-year-old man has fever, facial pain, nasal stuffiness, and purulent nasal secretions. The most likely cause is
During laser excision of vocal cord polyps in a 5-year-old boy, dark smoke suddenly appears in the surgical field. The trachea is intubated and anesthesia is being maintained with halothane, nitrous oxide, and oxygen. The most appropriate initial step is to
A 70-year-old patient is shivering and has chest pain in the PACU following a cholecystectomy. Heart rate is 120 bpm, and blood pressure is 220/120 mmHg. SpO2 is 97% at an FiO2 of 0.4. An ECG shows ST-T wave changes, which are not affected by intravenous administration of nitroglycerin. Which of the following is the most appropriate next step?
A 70-kg, 77-year-old man Is undergoing left nephrectomy with nitrous oxide, oxygen, fentanyl, and midazolam anesthesia. He has a 90 pack-year history of cigarette smoking and has chronic obstructive pulmonary disease. One hour after incision, expiratory wheezing occurs and peak Inspiratory pressure increases from 35 to 65 cmH20; end-tidal PCO2 is unchanged, but SpO2 decreases from 97% to 88%. The most likely cause is
A 70-kg, 50-year-old man is scheduled for muscle flap closure of a decubitus ulcer over the sacrum. He has been quadriplegic at the level of C6-7 for six years. Which of the following is most likely to result from subarachnoid anesthesia with tetracaine 10 mg for this procedure?
In patients with head trauma, which of the following factors results in a return of arterial pH toward normal levels after two days of mechanical hyperventilation?
(A) Decreased renal absorption of hydrogen ions
(B) Decreased renal blood flow
(C) Increased PaCO2 with constant minute ventilation
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
A 68-year-old man has signs of a coagulopathy after receiving 10 units of packed erythrocytes during emergency repair of a leaking abdominal aortic aneurysm. The most likely cause is
A 55-year-old man who is scheduled to undergo carotid endarterectomy (CEA) has a persistent myocardial filling defect at three hours on a dipyridamole-thallium scan. Which of the following statements is correct?
(A) Coronary autoregulation is effective in this segment
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 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
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
During isoflurane anesthesia, a 45-year-old patient with chronic asthma has wheezing, prolonged expiration, sinus tachycardia of 120 bpm, and premature ventricular contractions. Preoperative medication included cromolyn and theophylline. The most appropriate treatment is to administer
A 57-year-old man has back pain, a heart rate of 90 bpm, decreased pulse in the left arm, and blood pressure of 200/110 mmHg. During infusion of nitroprusside, heart rate increases to 115 bpm and blood pressure decreases to 140/80 mmHg. The most appropriate management at this time is administration of
A 58-year-old man with a history of angina is undergoing resection of an abdominal aortic aneurysm under morphine, nitrous oxide, d-tubocurarine anesthesia. Just before removal of the aortic cross-clamp, heart rate is 74 bpm, blood pressure is 115/70 mmHg, and pulmonary artery occlusion pressure is 7 mmHg. Immediately after removal of the cross-clamp, heart rate increases to 120 bpm, blood pressure decreases to 80/55 mmHg, and pulmonary artery occlusion pressure decreases to 3 mmHg. The V5 lead on the EKG demonstrates sudden ST-segment depression and T-wave inversion. Initial therapy should be
(A) reapplication of the aortic cross-clamp
(B) intravenous administration of sodium bicarbonate
(C) initiation of a phenylephrine infusion
(D) rapid expansion of blood volume by transfusion
In the absence of coronary artery disease, isoflurane-induced vasodilation and tachycardia are beneficial hemodynamic goals for which of the following cardiac diseases?
A 70-year-old man who has just undergone an abdominal aortic aneurysm repair under halothane anesthesia develops hypertension, dyspnea, and cyanosis shortly after awakening in the recovery room. Administration of furosemide 20 mg intravenously improves the cyanosis within 10 minutes. This immediate effect of furosemide is best explained by
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
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
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
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
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
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?
A 35-year-old woman undergoes a one-hour abdominal liposuction procedure under general anesthesia. During the procedure, 2000 ml of crystalloid is administered and 800 ml of fatty tissue is extracted. Thirty minutes postoperatively, blood pressure is 75/40 mmHg and heart rate is 100 bpm; SpO2 is 94% on room air. Which of the following is the most likely cause of these findings?
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 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?
Five minutes after initiating one-lung ventilation using a double-lumen endobronchial tube, a 70-year-old patient has a decrease in Sp02 from 99% to 90%. Tidal volume and respiratory rate are unchanged. Fiberoptic bronchoscopy verifies appropriate positioning of the tube. Which of the following is the most likely cause of the desaturation?
(A) Blood flow to the nondependent lung
(B) Failure of hypoxic pulmonary vasoconstriction in the dependent lung
(C) Inadequate filling of the bronchial cuff
(D) Inadequate minute ventilation
(E) Surgical manipulation of the nondependent lung
A patient has a decrease in heart rate from 80 to 50 bpm and a decrease in blood pressure from 140/90 to 60/40 mmHg while in the recovery room after adrenalectomy for pheochromocytoma. The most appropriate treatment is administration of
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
During a right lower lobe resection, SpO2 decreases from 99% to 70% after institution of one-lung ventilation. FiO2 is 1.0. The most appropriate management is to
(A) administer an inhaled bronchodilator
(B) apply continuous positive airway pressure to the right lung
(C) apply positive end-expiratory pressure to the left lung
A 72-year-old woman is somnolent one day after left carotid endarterectomy. She has smoked 2 packs of cigarettes daily for 50 years. Six weeks ago, she underwent right carotid endarterectomy. At this time, arterial blood gases while breathing room air are PO2, 45 mmHg, PCO2, 60 mmHg, and pH 7.30. Which of the following is the most likely cause of the increased PCO2?
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?
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 who is scheduled for emergency laparotomy for bowel obstruction has had oliguria for three hours. She has had hypertension for 10 years. Which of the following laboratory findings would indicate preoperative fluid challenge?
(A) Urine osmolality: 300 mOsm/L
(B) Urine specific gravity: 1.015
(C) Urine sodium concentration: 35 mmol/L
(D) Fractional excretion of sodium: 0.5
(E) Ratio of urine-to-plasma creatinine concentrations: 8
Two days after total abdominal hysterectomy, a 54-year-old woman develops lethargy followed by seizures and coma. Laboratory studies show a serum sodium concentration of 108 mEq/L and serum osmolality of 225 mOsm/kg. The most appropriate next step in management is administration of which of the following?
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
A 30-year-old man is brought to the emergency department after being rescued from a house fire. With the trachea intubated and FiO2 at 1.0, arterial blood gas values are PaO2 495 mmHg, PaCO2 28 mmHg, and pH 7.28. Hemoglobin saturation measured by co-oximeter is 50%. The most appropriate next step is to
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?
During enflurane anesthesia for colectomy in a 75-year-old man with sepsis, urine output decreases to 10 ml/hr. Heart rate is 120 bpm, blood pressure is 100/50 mmHg, central venous pressure is 10 mmHg, and pulmonary artery occlusion pressure is 15 mmHg. The most appropriate management at this time is to
A 70-kg 61-year-old patient undergoes a four-hour resection of an abdominal aortic aneurysm during anesthesia with fentanyl and enflurane. Infrarenal clamping is required during the procedure. Twelve hours after the procedure, urine output is 15 ml/hr with a fractional sodium excretion of 6%. Which of the following is the most likely cause?
A 50-year-old woman develops stridor 10 hours after undergoing thyroidectomy. The most appropriate management is administration of which of the following drugs?
A 65-year-old man is disoriented and has a headache and nausea in the recovery room 30 minutes after transurethral resection of the prostate with glycine irrigation performed under spinal anesthesia. Heart rate is 50 bpm and blood pressure is 180/110 mmHg. Which of the following is LEAST likely?
Which of the following statements concerning carbon monoxide poisoning is true? A 38-year-old woman with a large goiter has undergone subtotal thyroidectomy. Airway obstruction is noted immediately after extubation despite normal vocal cord function on laryngoscopy. Which of the following is the most likely explanation?
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 64-year-old patient with chronic obstructive pulmonary disease sustained fractures of ribs 4 through 8 on the left one hour ago. Examination shows agitation, heart rate of 120 bpm, respiratory rate of 30/min, and blood pressure of 180/100 mmHg. PaO2 is 70 mmHg and PaCO2 is 35 mmHg on room air. Radiographs of the chest show no abnormalities. Which of the following is the most appropriate immediate management?
(A) Continuous epidural analgesia using local anesthetics
(B) Mechanical ventilation
(C) Infusion of midazolam
(D) Patient-controlled analgesia with morphine sulfate
An 80-kg, 70-year-old woman is scheduled for a mastectomy. She has a history of congestive heart failure treated with digoxin 0.25 mg daily. Preoperative examination shows a sinus rhythm at 80 bpm and blood pressure of 110/70 mmHg. Laboratory studies show a serum potassium concentration of 4.2 mEq/L and a serum digoxin concentration of 1.5 mcg/ml. Five minutes after induction of general anesthesia, ventricular bigeminy is noted; blood pressure is 85/65 mmHg, SpO2 is 97%, and PetCO2, is 20 mmHg. Which of the following is the most appropriate management?
A 64-year-old man with diabetes mellitus well controlled with NPH insulin undergoes lower extremity revascularization. Following administration of protamine 10 mg, the patient has facial flushing and blood pressure of 60/30 mmHg. The most appropriate initial step in management is administration of which of the following drugs?
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?
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
Following induction of general anesthesia, mask ventilation and the initial attempt at intubation is unsuccessful. Which of the following procedures is most appropriate?
A 57-year-old man has back pain, a heart rate of 90 bpm, decreased pulse in the left arm, and blood pressure of 200/110 mmHg. During infusion of nitroprusside, heart rate increases to 115 bpm and blood pressure decreases to 140/80 mmHg. The most appropriate management at this time is administration of
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 40-year-old patient has pain following injection of 8 ml of thiopental 2.5% through a right radial artery catheter. His hand remains pink. Which of the following is the most appropriate next step?
(A) Injection of lidocaine through the catheter
(B) Injection of nitroglycerin through the catheter
A 32-year-old man is scheduled for hernia repair. He underwent heart transplantation for cardiomyopathy five years ago. Which of the following findings is most likely?
(A) Absence of coronary atherosclerosis
(B) Biventricular hypokinesis on echocardiography
(C) Down-regulation of cardiac beta-adrenergic receptors