A 55-kg, 70-year-old woman with mild chronic renal failure is unresponsive 20 hours after an uneventful coronary artery bypass grafting procedure. Anesthetic drugs included fentanyl 3000 mcg, diazepam 35 mg, and pancuronium 20 mg. Which of the following is the most appropriate next step in management?
Physiologically, coronary blood flow relates most directly 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
Which of the following is most likely to result in oxygen desaturation in a patient with Eisenmenger's syndrome who is scheduled for cesarean delivery?
Which of the following is the most appropriate management of decreased cardiac output in patients with isolated aortic insufficiency?
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
Which of the following statements concerning use of temperature-corrected blood gas measurement (pH-stat) during hypothermic cardiopulmonary bypass is true?
Which of the following effects of catecholamine results in the greatest increase in preload?
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 5-month-old infant with tetralogy of Fallot is scheduled for elective inguinal herniorrhaphy. Which of the following would require the operation to be postponed?
During uncomplicated mask induction with halothane and 50% nitrous oxide in oxygen in a 6-month-old infant with a large ventricular septal defect and valvular pulmonic stenosis, SpO2 decreases from 85% (room air) to 60%; heart rate is 100 bpm and blood pressure is 62/40 mmHg. The most appropriate management is to
A 60-year-old obese man who has an antithrombin III deficiency is scheduled for radical prostatectomy. Prior to the operation this patient should receive
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?
During protamine administration following separation from cardiopulmonary bypass, blood pressure decreases from 100/70 to 60/30 mmHg and peak inspiratory pressure increases from 26 to 60 cm H2O. The most appropriate next step in management is administration of
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?
Which of the following pre-existing conditions predisposes to new-onset third-degree heart block during pulmonary artery catheterization?
A 1100-g, 10-day-old infant is to undergo ligation of a patent ductus arteriosus after unsuccessful medical treatment. Within three minutes of intravenous administration of atropine 20 mcg, fentanyl 20 mcg, and pancuronium 0.1 mg, systemic blood pressure decreases from 80 to 30 mmHg, heart rate from 180 to 140 bpm, and arterial oxygen saturation from 90% to 80%. The most appropriate management is to
Which of the following statements concerning isolated mitral stenosis is true?
The tracing indicates that the pacemaker generator is
Increasing preload, systemic vascular resistance and heart rate will best maintain hemodynamic stability in patients with
If a patient with excessive bleeding during exploratory laparotomy has a normal activated clotting time, the LEAST likely cause of the bleeding is
Hemodilution is used during profound hypothermic cardiopulmonary bypass primarily because it
Each of the following is a physiologic effect of intra-aortic balloon pump therapy EXCEPT
Pulmonary artery diastolic pressure increases acutely from 10 to 20 mmHg in a 28-year-old man undergoing cervical laminectomy in the sitting position. The most appropriate first step in the management of this patient is to
In the absence of coronary artery disease, isoflurane-induced vasodilation and tachycardia are beneficial hemodynamic goals for which of the following cardiac diseases?
Pulsus paradoxus is commonly seen during anesthesia in patients with each of the following conditions EXCEPT
An atrioventricular sequential demand pacemaker is placed in a patient who has abnormal atrioventricular conduction. Each of the following statements about this situation is true EXCEPT:
A 62-year-old man is undergoing elective coronary artery bypass grafting and aortic valve replacement for three-vessel coronary artery disease and aortic stenosis. Shortly after intubation, heart rate increases from 75 to 100 bpm and blood pressure decreases from 130/70 to 70/40 mmHg with acute, severe ST-segment depression in lead V5. Which of the following is the most appropriate management?
Each of the following conditions can be accurately evaluated with transesophageal echocardiography EXCEPT
An 18-month-old child with tetralogy of Fallot is anesthetized with halothane and nitrous oxide. Following intubation, oxygen saturation decreases abruptly from 85% to 45%. The most effective treatment is
Which of the following is the primary factor regulating normal coronary blood flow?
After weaning from cardiopulmonary bypass following mitral valve replacement, a patient's cardiac output is reported to be 3.7 L/min measured by thermodilution technique using 5% dextrose in water 10 ml at room temperature as injec-tate. This value could be falsely high if
A 70-kg, 47-year-old man is undergoing a repeat coronary artery bypass graft. Following sternotomy, administration of heparin 300 units/kg for anticoagulation increases the activated coagulation time from a baseline of 135 sec to 210 sec. This finding is compatible with
Each of the following changes is expected with deliberate hypothermia EXCEPT
After termination of cardiopulmonary bypass, a patient who is chronically digitalized receives digoxin 0.5 mg in error. An ECG shows sinus bradycardia with intermittent sinus arrest; blood pressure is 90/60 mmHg. Which of the following drugs is contraiindicated in this patient?
Which of the following is the most likely cause of the coronary steal phenomenon?
Pulmonary artery diastolic pressure is an unreliable indicator of left ventricular end-diastolic pressure in patients with
Three hours after undergoing coronary artery bypass grafting, an elderly man develops severe hypotension after intravenous administration of morphine 4 mg. Pulmonary artery occlusion pressure is 27 mmHg and central venous pressure is 30 mmHg. Transesophageal echocardiography shows decreased end-diastolic ventricular volumes. Which of the following is the most likely diagnosis?
Which of the following results in the greatest increase in right-to-left shunting in an infant with cyanotic heart disease?
During cardiopulmonary bypass at a nasopharyngeal temperature of 28°C and a hematocrit of 20%, temperature-corrected PaCO2 is 50 mmHg and uncorrected PaCO2 is 60 mmHg. The most appropriate management is to
Compared with dopamine, dobutamine
Each of the following statements concerning the activated clotting time (ACT) is true EXCEPT:
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 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
Hypomagnesemia is associated with
An arterial blood sample is obtained from a patient undergoing hypothermic cardiopulmonary bypass at 28 C. Analysis at 37 C shows a pH of 7.40 and PaCO2 of 40 mmHg. Which of the following values are most likely if the analysis is corrected to 28 C?
In patients who have undergone cardiopulmonary bypass, administration of milrinone is most likely to result in an increase in which of the following?
Intraoperatively, the occurrence of prominent "a" waves on the central venous pressure waveform can be explained by each of the following EXCEPT
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
Following protamine administration, profound pulmonary hypertension is most likely initiated by release of
In the diagram, point "X" represents a patient with severe left ventricular dysfunction. The points labeled 1, 2, and 3 each represent the results of a different therapeutic intervention. Which of the following represents the most likely intervention at each point?
Spinal anesthesia at a T6 sensory level is most likely to improve cardiac output in patients with
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-kg, 57-year-old man has an initial activated clotting time (ACT) of 122 seconds prior to elective cardiopulmonary bypass. Five minutes after administration of heparin 200 mg, ACT increases to 154 seconds. After two additional doses of 200 mg each from different lots, ACT increases to 240 seconds. The most appropriate next step is to
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?
The tracing indicates that the pacemaker generator is
A 14-month-old child has tetralogy of Fallot with dynamic obstruction to right ventricular outflow. Which of the following is most likely to decrease cyanosis in this child?
A 50-year-old man with severe coronary artery disease undergoes coronary artery bypass grafting. Five minutes after successful termination of cardiopulmonary bypass, ST-segment elevation is noted in lead II of the ECG, and the following findings are noted: BP 70/40, Pulse 80, CVP 16 cmH2O, PAp 25/10. Appropriate management is to
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 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?
During total cardiopulmonary bypass, metabolic acidosis and decreasing mixed venous oxygen saturation are noted. The most likely cause is
A 62-year-old man, who had a myocardial infarction three years ago, complicated by congestive heart failure and renal failure, is undergoing a colectomy. A pulmonary artery catheter demonstrates a cardiac output higher than measurements recorded during a cardiac catheterization two months after the infarction. Which of the following most likely contributes to the increased cardiac output?
In a patient with surgically significant aortic insufficiency, cardiac output measured by thermodilution will
Addition of 20 cm H2O positive end-expiratory pressure to a patient receiving controlled mechanical ventilation decreases cardiac output and left ventricular function by
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?
Which of the following time concentration curves would be expected in arterial blood following intravenous injection of indocyanine green dye in a 3-year-old child with a small ventricular septal defect?
A 67-kg, 52-year-old man is undergoing heart transplantation. After implantation of the donor heart and discontinuation of cardiopulmonary bypass, isoproterenol is administered intravenously to maintain heart rate greater than 100 bpm. During the next 10 minutes, blood pressure decreases from 105/55 mmHg to 75/40 mmHg. Heart rate is 102 bpm and cardiac output is 5.8 L/min. The most appropriate management is administration of
A patient has a heart rate of 110 bpm one year after heart transplantation. His tachycardia is most likely the result of
Which of the following findings is most likely in patients receiving intravenous milrinone?
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?
Cardiac output measured by thermodilution with a pulmonary artery catheter most accurately reflects systemic blood flow in a patient with
During repair for coarctation of the aorta in a healthy 13-year-old patient, right radial artery pressure increases from 100/60 to 105/70 mmHg after the aorta is cross clamped. This most likely indicates that
A 70-kg 58-year-old man with unstable angina is scheduled to undergo coronary artery bypass grafting. Intravenous heparin and nitroglycerin are administered for four days before surgery. Before initiating cardiopulmonary bypass, 21,000 units of heparin are administered through the central venous catheter; five minutes later, activated clotting time is 280 seconds. Which of the following is the most appropriate next step in management?
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 following hemodynamic values are obtained two hours after coronary artery bypass surgery: Cardiac index 1.7 L/min/m2; Pulm Art. Occ. Pressure 22 mmHg; MAP 60 mmHg; Urine volume 0.2 ml/kg/hr. The most appropriate management is
Left ventricular end-diastolic volume is most likely to be underestimated by pulmonary artery occlusion pressure in patients with
Left ventricular end-diastolic volume is most likely to be underestimated by pulmonary artery occlusion pressure in patients with
A 66-year-old man with aortic regurgitation is brought to the operating room for aortic valve replacement after having received morphine, scopolamine premedication. PO2 is 40 mmHg in a sample of pulmonary artery blood drawn 10 minutes after the patient started breathing pure oxygen. This finding is compatible with
A 35-year-old patient with asymmetric septal hypertrophy (IHSS) is undergoing bladder suspension with sevoflurane 1%, nitrous oxide 50%, and oxygen 50%. Immediately after skin incision, blood pressure decreases to 90/60 mmHg and junctional tachycardia of 150 bpm is noted on the ECG. Which of the following is the most appropriate management?
Nitroprusside therapy for hypertension should be discontinued in the presence of
Which of the following findings would be considered normal in the EEG of an adult?
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 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?
In a patient with ventricular fibrillation refractory to repeated attempts at defibrillation and epinephrine administration, the most appropriate management is administration of
Which of the following findings necessitates the preoperative insertion of a ventricular pacemaker in a 48-year-old man scheduled to undergo cholecystectomy?
A 75-year-old man with a left bundle branch block is undergoing placement of a pulmonary artery catheter through the right internal jugular vein. He becomes pale and his heart rate decreases to 40 bpm when the catheter tip enters the right ventricle. The most likely cause is
Pulmonary artery occlusion pressure
Following cardiopulmonary bypass, right ventricular distention is noted after infusion of protamine 40 mg. Pulmonary artery pressure has increased from 25/18 to 50/30 mmHg and systemic arterial pressure has decreased from 110/65 to 0 mmHg. Which of the following is the most appropriate treatment?
Following blunt trauma to the chest, a patient has tachycardia, hypotension, and markedly distended neck veins. Each of the following is expected EXCEPT
Following hypothermic cardiopulmonary bypass, adequacy of total body rewarming is best indicated by normothermia recorded from the
A patient receiving propranolol and nifedipine is scheduled for elective coronary artery bypass surgery. During induction with fentanyl and oxygen, heart rate decreases from 52 to 36 bpm and blood pressure decreases from 130/85 to 80/50 mmHg. Administration of atropine 2 mg intravenously has no effect. The most appropriate treatment at this time is administration of
Which of the following best describes cardiomyopathy following therapy with doxorubicin (Adriamycin)?
Which of the following is the best method of pacing to improve cardiac output in a patient with third-degree heart block?
Which of the following is the most appropriate drug to treat hypotension in patients with asymmetric septal hypertrophy (IHSS)?
Two hours after coronary artery bypass grafting, a 60-year-old man has a heart rate of 140 bpm and blood pressure of 80/60 mmHg. Cardiac index is 1.5 L/min/m2. Central venous pressure is 23 mmHg with large a-waves in the right atrial pressure tracing. A pulsus paradoxus of 6 mmHg is noted. Which of the following is the most likely diagnosis?
Addition of 20 cmH2O positive end-expiratory pressure to a patient receiving controlled mechanical ventilation decreases cardiac output and left ventricular function by
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 patient who is receiving ventilatory support after coronary artery bypass grafting has a PaO2 of 132 mmHg, a PaCO2 of 19 mmHg, and a pH of 7.57. Which of the following is most likely to result from this level of hypocarbia?
During cardiopulmonary bypass, the perfusionist notes that the mixed venous oxygen saturation has decreased from to 55%. Which of the following is the most likely cause?
A 46-year-old patient who abuses intravenous drugs develops acute aortic valvular insufficiency from bacterial endocarditis. Which of the following statements concerning pressures measured through a pulmonary artery catheter is true?