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SEE Exam Questions And Answers 2023.During fetal monitoring, Type III decelerations are thought to be related to:
• head compression
• umbilical cord compression
• uteroplacental insufficiency
• placental abruption - Answer umbilical cord compression
Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in
umbilical blood flow.
The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:
• T4 - T8
• T8 - L2
• L2 - L4
• L4 - S1 - Answer T8 - L2. A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has
a variable origin from aorta, arising between T5 - T8 in 15%, between T9 - T12 in 60% and between L1 - L2 in 25% of individuals.
60. A 55-year-old woman with a history of congenital long QT syndrome is undergoing a hysteroscopy for abnormal uterine bleeding. She had uneventful induction of general anesthesia but after paracervical block with lidocaine develops ventricular tachycardia with morphological appearance of torsades de pointe. Which of the following medications should be AVOIDED in the treatment of her arrhythmia?
• Amiodarone
• Calcium chloride
• Esmolol
• Magnesium sulfate - Answer 60. Amiodarone. Congenital long QT syndrome may occur in conjunction with other hereditary syndromes, such as Jervell, Lange-Nielsen
or Romano-Ward syndrome, or acquired as a result of pharmacologic or metabolic etiologies. It is an issue of cellular repolarization which precipitates tachyarrhythmias,
most commonly polymorphic ventricular tachycardia or torsades de pointe. There are
multiple subtypes that affect both potassium and/or sodium channels. The arrhythmias may be precipitated by sympathetic activation, auditory stimuli or at rest.
Family history may be positive for sudden cardiac death and the ECG significant for prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves. Treatment includes magnesium for arrhythmias, possible permanent pacemaker, or beta blockers for subtypes 1 and 2, but amiodarone is considered contraindicated as
it prolongs the QT interval.
59. A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by:
• placing the grounding pad near the pacemaker
• using infrequent bursts of longer duration SEE Exam Questions And Answers 2023.
• the use of a bipolar cautery
• reducing the surface area of the return electrode - Answer 59. the use of a bipolar cautery. Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.
58. A 35-year-old woman who underwent orthotopic heart transplantation 2 years ago for nonischemic cardiomyopathy presents after a motor vehicle accident for exploratory laparotomy under general anesthesia. Intraoperatively, her blood pressure is 75/35 mmHg and heart rate is 90 bpm. After the administration of phenylephrine, which of the following hemodynamic responses do you MOST expect?
• HR decreased, BP increased
• HR decreased, BP no change
• HR no change, BP increased
• HR no change, BP no change - Answer 58. HR no change, BP increased. After heart transplantation, the heart is completely denervated. The normal resting heart rate is relatively tachycardic at 90-100 bpm due to lack of vagal tone. Vagal bradycardic responses (to laryngoscopy, hypertension, carotid sinus massage) will also be absent. Over time, however, many patients require permanent pacemaker placement for treatment of significant bradycardia. After heart transplant, patients are
not able to respond to demands for increased cardiac output with increased heart rate. Thus in this situation of a trauma with potentially significant blood loss, a normal
patient would have tachycardia but a heart transplant patient has no change in heart rate, only hypotension. Instead for heart transplant patients, cardiac output is augmented by increased stroke volume. For this reason it is important to maintain adequate intravascular volume. The transplanted heart is not able to respond to medications that block the parasympathetic system. Bradycardia and hypotension have to be treated with medications that have a direct effect such as epinephrine and
isoproterenol. Phenylephrine will result in increased blood pressure, but no change in heart rate. Indirect and mixed indirect/direct-acting drugs have minimal effect or have the effect of their direct components.
57. The postretrobulbar block apnea syndrome:
• is likely secondary to intravascular injection
• most commonly occurs during or immediately after injection
• is associated with unconsciousness
• carries a high morbidity and mortality - Answer 57. is associated with unconsciousness. The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.
56. A 75-year-old man is undergoing a mitral valve replacement via cardiopulmonary
bypass. The perfusionist is running bypass flows at > 2.5 liters/minute/m2. Which of SEE Exam Questions And Answers 2023.
the following is the MOST likely adverse consequence of undergoing cardiopulmonary bypass at increased flow rates?
• Increased trauma to blood elements
• Increased hypothermia
• Decreased blood flow to the brain
• Decreased myocardial blood flow - Answer 56. A. Increased trauma to blood component: Cardiopulmonary bypass (CPB) does the work of the heart and lungs in order to isolate those organs from blood flow such that surgery on the heart can occur in a relatively bloodless fashion. Thus, the CPB circuit must oxygenate and ventilate the blood and then deliver the oxygenated blood back to the body and end organs. It has long been debated whether maximal blood flow or pressure is more important in perfusion and homeostasis of the end organs during bypass. Maximizing
blood flow (generally considered to be flow at a cardiac index of > 2 liters/minute/meter2) has been shown to increase hematologic trauma, increase the magnitude of the stress or inflammatory response, cause strain on suture lines, increase shunting of blood through the pulmonary system, increase washout of cardioplegia and not necessarily lead to improved regional blood flow. The CPB machine can change total flow, but it cannot adjust regional flows to the various end organ systems. Changes in blood pressure are currently thought to be most effective
for allowing adjustments to regional flow in organ systems as the organs retain their regional vascular resistance capabilities. Thus conduct of CPB with an optimal pressure (and potentially lower flows) may allow the individual organs to regionally modulate their own flows. scheduled for ECT are routinely given anticholinergic medication preoperatively.
55. Physiologic effects of electroconvulsive therapy (ECT) include an:
• initial sympathetic response with sustained tachycardia
• initial sympathetic discharge followed by a sustained parasympathetic response
• initial parasympathetic discharge followed by a sustained sympathetic response
• initial parasympathetic response with sustained bradycardia - Answer 55. initial parasympathetic discharge followed by a sustained sympathetic response. An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased
secretions can occur, which is then followed by hypertension and tachycardia. Patient
54. A 70-year-old man with a DDD-R pacemaker for a history of symptomatic bradycardiais undergoing an anterior cervical discectomy and fusion with somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring. The pacemaker should be reprogrammed to which of the following?
• Discontinue R function
• Dual chamber asynchronous pacing
• No reprogramming
• Ventricular asynchronous pacing - Answer 54. "R" signifies rate responsiveness in the fourth position of the pacemaker designation code. Patients who are pacemaker-
dependent are limited in their ability to exercise because of fixed rate (can't get their heart rates up). "R" function allows a pacemaker to speed up to satisfy increased SEE Exam Questions And Answers 2023.
metabolic demands (via motion, minute ventilation, temperature sensors) when the patient is exercising. However, for patients who are pacemaker-dependent, rate responsiveness function may be activated by perioperative events: fasciculations from succinylcholine, myoclonus from etomidate, vigorous surgical retraction, shivering, or SSEP/MEP neuromonitoring. This can cause undesired tachycardic pacing. So in cases like the one described, it is best to turn off the rate responsiveness function. Keeping the pacemaker in DDD is otherwise acceptable as
long as a method of perfusion is assured, such as arterial blood pressure or pulse oximetry. One concern is often that the pacemaker will interpret artifact or electromagnetic inference from the bovie cautery as native heart rhythm and not initiate pacing when it is indicated, leaving the patient at risk for profound bradycardia or asystole. Placing the bovie pad away from the pacemaker generator and using bipolar cautery if needed are options to deal with that type of interference. Reprogramming to asynchronous mode risks R on T phenomenon (when the pacemaker cannot discern between artifact and native heart rhythm).
53. Correct location of the catheter tip of a central venous line is in the:
• superior vena cava
• right atrium
• riht ventricle
• pulmonary artery - Answer 53. superior vena cava. The CVP catheter tip should not
be allowed to migrate into the heart chamber to avoid arrhythmias and perforation.
52. Which of the following is NOT a potential treatment for salicylate poisoning?
• Activated charcoal
• Administration of a reversible COX-inhibitor
• Hemodialysis
• Sodium bicarbonate - Answer 52. B. Salicylic acid produces its anti-inflammatory effects via suppressing the activity of cyclooxygenase (COX). Unlike other NSAIDs, it
does this not by direct inhibition of COX, unlike most other non-steroidal anti-
inflammatory drugs (NSAIDs), but instead by suppression of the expression of the enzyme (via an un-elucidated mechanism). Salicylic acid is a non-reversible COX inhibitor. Salicylates produce epigastric pain, nausea and vomiting, hyperventilation (respiratory alkalosis), and widely ranging neurologic signs and symptoms (tinnitus, delirium, coma, seizure) as well as a primary metabolic acidosis (salicylic acid, lactic acid, and ketoacids). Treatment includes activated charcoal, alkalinization of blood and urine with IV sodium bicarbonate (pKa 3.5, thus salicylates can be "trapped" in the blood and urine, preventing movement into tissues and enhancing excretion). Hemodialysis is considered for mental status changes, severe acid-base disturbances, or serum concentrations > 100 mg/dL.
51. During pregnancy, the minimum alveolar concentration (MAC):
• decreases until the 20th week • increases until the 20th week • decreases throughout the pregnancy
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