Apex Mock Exam 2 -KAY

Which option initiates hypoxic pulmonary vasoconstriction?

alveolar hypoxia

Pulmonary hypertension is defined as PAP of at least?

25mmHg and a PAOP of no more than 15mmHg

When properly placed the distal tip of the LMA sits at the?

cricopharyngeus muscle (upper esophageal sphincter)

When properly placed, the ProSeal LMA allows a positive ventilation pressure of?

30cm H2O

In which circumstances is supplemental oxygen LEAST likely to increase arterial oxygenation?

Pulmonary edema

What are (2) examples of instrinsic restrictive lung disease?

Pulmonary edema

Aspiration pneumonia

Acute Intrinsic= caused by fluid moving into the interstitial space of the pulmonary parenchyma.

A patient received a citrated non-particulate antacid, but the case has been delayed. How long after the initial dose should a second dose be considered?

60minutes

Match the Intrinsic Laryngeal Muscle with its action on layrngeal movement?

a)Aryepiglottic

b)cricothyroid

c)posterior cricoarytenoid

d)thyroarytenoid

a)Aryepiglottic - closes glottic opening

b)cricothyroid - lengthens vocal cords

c)posterior cricoarytenoid - abducts vocal cords

d)thyroarytenoid - adducts vocal cords

Calculate expected PAO2 when the PaCO2= 80mmHg, FiO2= 28%, and A-a gradient is 35

PAO2 = (FiO2 x (Pb - PH20) - (PaCO2/RQ)

0.28 x(760-47) - (80/0.8)

200-100 = 100mmHg

100mmHg - 35(A-a gradient) = 65mmHg

Which (3) axes must be aligned to ensure the best chance for successful laryngoscopy and intubation?

Oral (OA)

Pharyngeal (PA)

Laryngeal (LA)

In a male patient, what is the next step after the tip of the double lumen ETT passes through the vocal cords?

Rotate the DLT 90 degrees in the direction of the bronchus to be intubated

When used during laparoscopic procedure, an LMA:

can be used if the procedure is less than 15minutes

Muscarinic-2 stimulation causes

Bradycardia

M2 receptor slows cardiac conduction

Dexmedetomidine (2 reactions)

Can cause HTN(central A2 stimulation causes vasodilation, sedation, and analgesia. Peripheral stimulation initiates vasoconstriction)

reduces adenylate cyclase(stimulation of G protein inhibits adenylate cyclase and reduces cAMP)

Systolic murmur heard over 5th intercostal space and MCL. What type of valvular disease would one expect?

Mitral regurgitation

Identify the vessel that will have reverse blood flow as a result of left subclavian steal syndrome?

Choose the BEST (2) NMB for the patient with hypertrophic cardiomyopathy?

Vecuronium and Rocuronium

(NOT pancuronium it increases HR, not atracurium in releases histamine)

Match each cardiac pathophysiology with its characteristic pulse waveform?

a) Aortic Stenosis -

b) Aortic Regurgitation -

c) Cardiac Tamponade -

d) Systolic left ventricular failure -

a) Aortic Stenosis - Pulsus parvus

b) Aortic Regurgitation - Bisferiens pulse

c) Cardiac Tamponade - Pulsus paradoxus

d) Systolic left ventricular failure - Pulsus alternans

Match the vasodilator with its primary site of action

a) Nitroglycerin:

b) Prazosin:

c) Nitroprusside:

a) Nitroglycerin: venules

b) Prazosin: arterioles

c) Nitroprusside: arterioles & venules

What (2) increase after placement of an infra-renal aortic cross clamp?

Mixed venous oxygen saturation

Preload

Inhaled agents chemical structures

a)Halothane

b)Isoflurane

c)Desflurane

d)Sevoflurane

a)Halothane - the only alkane, 1 Cl-, 1Br, 3Fl

b)Isoflurane- 5 Fl, 1 Cl

c)Desflurane - 6 Fl

d)Sevoflurane - 7Fl

What 2 changes in somatosensory evoked potential monitoring suggest an increased risk of nerve injury?

50% decrease in amplitude

10% INcrease in latency

A drug has a Vd of 0.5L/kg. In an 85kg patient, what loading dose must be administered to achieve a plasma concentration of 6mg/l?

255mg

Loading Dose = (Vd x desired Cp) / Bioavailability

Loading Dose = (42.5L x 6mg/L) / 1 = 255mg

Bioavailability = 1 since drug is being given IV

clearance is inversely proportional to (2)

Half-life

concentration in the central compartment

What drugs are safe to administer in the patient with a history of acute intermittent porphyria (2)?

Succinylcholine

Nitrous oxide

Avoid all barbiturates and etomidate.

When used as part of a balanced anesthetic, cardiovascular effects of nitrous oxide include (2)?

Myocardial depression

Increased BP (activates SNS, increases SVR, BP, HR)

When comparing dexmedetomidine to propofol for MAC, which statements better describe dexmedetomidine? (3)

better analgesia

inferior amnesia

longer onset

Match each drug with the enzyme or pathway that it inhibits

a) Methylene blue

b)Etomidate

c) Nitrous oxide

d) Tranexamic acid

a) Methylene blue - nitric oxide cycle guanylate monophosphate(inhibits the vasodilatory effects of NO in patients with vasoplegia)

b)Etomidate - 11 beta hydroxylase (inhibits steroid synthesis)

c) Nitrous oxide - Methionine synthase (inhibits vitamin B12 metabolism and DNA synthesis)

d) Tranexamic acid - Plasmin (inhibits fibrinolysis to reduce surgical bleeding)

Which choice is the MOST potent amnestic?

Choices:Diazepam, Midazolam, Flurazepam, Lorazepam

Lorazepam (up to 6hrs of amnesia)

Area where the nerve stimulator should be placed to elicit contraction of the adductor pollicis muscle?

Distal electrode is placed over the proximal flexor crease of the wrist and the proximal electrode is placed over the flexor carpi tendon.

(2) true statements about EMLA cream?

Adequate anesthesia is obtained in 60minutes.

It can cause methemoglobinemia

2.5% lidocaine

2.5% prilocaine

Identify substantia gelatinosa on the left side of the spinal cord?

Substantia gelatinosa resides in rexed laminae II and III in the dorsal horn.

Rank the speed of LA uptake after injection into the following sites: (1 fastest, 4 slowest)

Intrapleural, caudal, brachial plexus, intercostal

1)Intrapleural

2)Intercostal

3)Caudal

4)Brachial plexus

Which are more likely to remain in the CSF?

sufentanil, hydromorphone, meperidine, fentanyl

Hydrophillic opioid remains in the CSF and achieves a higher level of block.

Meperidine, hydromorphone,

Which measures the concentration of anesthetic by bombarding the gas sample with electrons?

mass spectrometry

What area of the EKG conicides with the "a" wave of the CVP waveform?

P wave respresents atrial depolarization.

The "a" wave on CVP represents atrial contraction

Antidromic AVNRT(widened QRS) results when

Electrical impulse travels via the accessory pathway

Describe each mode of ventilation:

a) Assist control ventilation

b) pressure control ventilation

c) intermittent mandatory ventilation

d) controlled mandatory ventilation

a) Assist control ventilation - spontaneous breaths receive full preset Vt

b) pressure control ventilation - tidal volume varies with lung compliance

c) intermittent mandatory ventilation - traditional weaning mode

d) controlled mandatory ventilation - best used for apneic patients

(2) descriptions of asynchronous pacing?

Best used for patients with no intrinsic rhythm.

Underlying ventricular activity is a risk for R on T phenomenon

Identify region of the myocardium that the lead monitors?

a) aVL

b) V3

c) II

a) aVL - Lateral LV

b) V3 - Anterior LV

c) II - RV

CRNA is using an anesthesia machine that couples fresh gas flow to the tidal volume set on the ventilator. What is the total tidal volume delivered to the patient?

Oxygen= 2L/min

Air flow= 1L/min

Bellows set at 450mL

RR = 10

I:E ratio is 1:2

550mL

Convert FGF to mL/min = 3000mL/min

Multiply FGF by fraction of inspiratory time: 3000 x (1/3) = 1000

Divide by RR: 1000 / 10 = 100mL

Add to volume set on bellows

What lead is best for diagnosing dysrhythmias?

Lead II

Side effects of levodopa

Orthostatic hypotension. Common early in therapy

Identify the area of defection that causes malignant hyperthermia

The defective ryanodine receptor (RyR1) instructs the sarcoplasmic reticulum to release excessive amount of calcium.

(2) contraindications for hypokalemic periodic paralysis?

Furosemide

Glucose infusion

Where is cerebrospinal fluid reabsorbed?

Arachnoid villi of the superior sagittal sinus.

CSF produced by choroid plexus in all 4 cerebral ventricles at a rate of ~30ml/hr

Physiologic changes that are MOST likely to occur during autonomic hyperreflexia (2)

Seizures

Pulmonary edema (acute rise in SVR can precipitate LV failure, and cause pulmonary edema)

HTN

bradycardia

Cerebral blood flow graph: which represents ICP

A-PaO2

B- PaCO2

C- CPP

D- ICP

Describe train of four monitoring for the patient with hemiparesis?

TOF monitoring on the hemiparetic limb yields a falsely elevated response(meaning false high for relaxation).

On the affected side there are extrajunctional receptors at the NMJ as well as on the sarcolema. Decreased sensitivity to Nondepolarizers.

3 diseases associated with an increased incidence of malignant hyperthermia

Central core disease

Minicore disease

King-Denborough syndrome

Region of the arm that is supplied by the median nerve

palm of hand

ventral region of thumb

Distal portions of index, middle and medial half of ring finger

Match each type of peripheral nerve to its function:

a) A alpha

b) A beta

c) A delta

d) A gamma

a) A alpha - Motor

b) A beta - pressure

c) A delta - temperature

d) A gamma - muscle tone (muscle spindles)

Which spinal level is designated by the intercristal line?

L4

A horizontal line drawn across the superior aspects of the iliac crest designates the intercristal or Tuffiers line.

After Bier block, case is completed in 10 min after injection of LA. What is the additional time you must wait before you can safely deflate the tourniquet?

10min

TQ must be inflated for a minimum of 20mins after youve injected the LA

Which lab value is prolonged in the patient with hemophilia A?

PTT only.

Factor 8 deficiency

What are (2) appropriate treatments for a patient with von willebrands disease?

Factor 8 concentrate

Desmopressin

Match each blood type with the corresponding antibody you would find in its serum:

a) A

b) AB

c) B

d) O

a) A - antiB

b) AB - none

c) B - antiA

d) O - anti A and B

Which option can be a source of coagulopathy

(VitK supplementation, increased cholecystokinin, sphichterotomy of the sphincter of Oddi, impaired bile production)

Impaired bile production

Impaired bile production reduced absorptiono f vitamin K. Vitamin K is important in producing factor 2,7, 9, 10

Effects on intacellular volume

a) D5LR

b) NS

c) D5w

a) D5LR - small dehydrated cell

b) NS - normal cell

c) D5w - swollen bloated cell

Anesthetic consideration for sickle cell anemia

SC disease (homozygous) not SC trait (heterozygous) increases risk of mortality.

pain, hypothermia, acidosis, dehydration increase sickling

What (3) reduces serum potassium

Albuterol - (B2 agonist) shifts K into cell

Insulin - Shift K into liver and skeletal muscle

Bowel prep - increases K loss in the feces

Match each event to the laboratory test that is used to monitor it

a)Coumadin

b) heparin infusion

c) fibrinolysis

d) aspirin

a)Coumadin - PT

b) heparin infusion - ACT

c) fibrinolysis - Ddimer

d) aspirin - bleeding time

What causes non-gap metabolic acidosis? (3)

Diarrhea

Renal Tubular Acidosis

Excessive chloride administration

non-gap acidosis is due to loss of HCO3- (or increased Cl-)

triad of obesity, htn, and dm2 is known as

metabolic syndrome

Hormones released by posterior pituitary (2)

ADH and oxytocin

Match each region of the adrenal gland with the primary substance it secretes

a) Zona glomerulosa

b) Zona fasciculata

c) Zona reticularis

d) Medulla

a) Zona glomerulosa - releases mineralocoritcoids (aldosterone)

b) Zona fasciculata - releases glucocorticoids (cortisol)

c) Zona reticularis - releases androgens (dehydroepiandrosterone)

d) Medulla - catecholamines (epi and norepi)

Cardiovascular complications associated with acute pancreatitis include all of the following except:

(myocardial depression, pericardial effusion, thrombophlebitis, hypervolemia)

Hypervolemia

What indices suggest a prerenal cause of oliguria (2)

Urine sodium <20mEq/L

Fractional excretion of sodium <1%

Decreased RBF causes concentrated urine (increased osmolality and low FE of sodium.

What structures reside in the adrenal medulla? (2)

Loop of Henle

Collecting ducts

Match each disease with underlying pathology

a) Addisons disease

b) Graves disease

c) Conns disease

d) Hashimotos disease

a) Addisons disease- hypoadrenalism

b) Graves disease- hyperthyroidism

c) Conns disease- hyperaldosteronism

d) Hashimotos disease- hypothyroidism

Anesthetic implications for hypothyroid patients

Hypotension

Aspiration- 2nd to decreased gastric emptying

Does NOT affect MAC, but changes in CO affect the FA/FI relationship and speed of anesthetic induction.

What is the average amount of irrigation that is systemically absorbed during TURP?

10-30mL/min

Blood loss = 2-5mL/min

Match each hormone to its primary physiologic effect:

a) Secretin

b) Motilin

c) Cholecytokinin

d) Gastrin

a) Secretin- stimulates bile flow

b) Motilin- stimulates upper GI motility

c) Cholecytokinin- stimulates gallbladder contraction

d) Gastrin- stimulates pepsinogen secretion

Which is expected to decrease in the elderly?

PaO2

polyhydraminos should raise suspicion for?

Tracheosophageal Fistula

TEF is the letter "T" in the VATER and VACTREL associations

Select (2) best agents for the neonate with necrotizing enterocolitis

Fentanyl

Ketamine

Better options than VA and propofol

All of the following are anesthetic considerations for the patient with a tonsilar bleed except

(LMA, requires RSI, volume restricted before induction, hemorrhage most commonly occurs within 24hours of surgery)

LMA

LMA is actually contraindicated

Do water soluble drugs require a larger dose in neonatal pharmacokinetics?

Yes.

They have a larger Vd

Compared to the adult, which is higher in the newborn (2)

Vd for water soluble drugs

Extracellular fluid volume

All are associated with apoptosis in the developing brain except

(ketamine, fentanyl, midazolam, sevoflurane)

Fentanyl

What is the MAC of isoflurane in the full term parturient (pregnant)?

0.6%

in FT pregnant pt MAC is reduced 40%

What lung volumes increase in the pregnant patient? (2)

Tidal volume (30%)

Inspiratory reserve volume

What should be avoided in the patient with myelomeningocele?

(lateral, desflurane, succs, latex)

latex

Elderly characteristic associated with greatest risk of 30day mortality?

(unplanned ICU admission, emergent surgery, asa 4, acute renal impairment)

ASA 4 status = 12.4% 30day mortality

Convert 38.3C to farenheight

100.9

F = (C x 1.8) + 32

Gay-Lussac's Law

the pressure of a gas is directly proportional to the Kelvin temperature if the volume is constant

Poiseuille's Law equation=

If you triple the radius it will cause flow to increase by a factor of=

Flow = (pir^4change in P) / (8nl)

Flow = (3.14 x Radius^4 x pressure difference / 8 x viscosity x length

by a factor of 81

Ketorolac should be avoided in all except:

(samters triad, PUD, renal insufficiency, chroncic bronchitis)

Chronic bronchitis

Best antiemetic for patient with prolonged QT interval

(droperidol and transdermal scop, ondansetron and droperidol, ondansetron and dexamethasone, scop and dexamethasone)

Dexamethasone and transdermal scopolamine

Patient has remained in ankles crossed position for several hours following induction of anesthesia. Which nerves are at the highest risk of injury? (2)

Sural

Superficial peroneal

Describe the managment of gout (2)

Patients should be liberally hydrate

Sodium bicarb enhances uric acid excretion

Treatment for tetanus includes all of the following except:

(antitoxin, debridement of the infected area, phenylephrine, intubation)

Phenylephrine

Diagonstic criteria for type 2, but not type 1, complex regional pain syndrome include:

previous nerve injury

Following retinal detachment surgery, how long should nitrous oxide be avoided?

a)silicone oil

b)air bubble

c)sulfur hexafluoride

a)silicone oil - 0days

b)air bubble- 5days

c)sulfur hexafluoride- 10days

Match each twitch to its corresponding nerve:

a) Plantar flexion

b) Patellar twitch

c) Adductor twitch

d) Dorsiflexion

a) Plantar flexion- tibial nerve

b) Patellar twitch- femoral nerve

c) Adductor twitch- obturator nerve

d) Dorsiflexion- peroneal nerve

What increases as a result of pneumoperitoneum during laparoscopic surgery (3)

ICP+CPP

A-a gradient - as a function of decreased FRC and V/Q mismatch

MAP- due to hypercarbia, the neuroendocrine respone(catecholamines, vasopressin, cortisol) and increased afterload

Match each immunosuppressive drug to its best description:

a) Tacrolimus

b) Antithymocyte globulin

c) Cyclosporine

d) Azathioprine

a) Tacrolimus- macrolide antibiotic

b) Antithymocyte globulin- polyclonal IgG

c) Cyclosporine- 11 aminoacid cyclic peptide

d) Azathioprine- prodrug that converts to 6 mercaptopurine