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ASIPP Critical Care Questions Flashcards

1
Q 
1825. A patient with a score of 4 on the Riker Sedation – Agitation
scale can be best described as:
A. Very agitated
B. Very sedated
C. Unarousable
D. Sedated
E. Calm and cooperative
A
  1. Answer: E

Source: Day MR, Board Review 2005

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2
Q
  1. All of the following are true regarding the use of opioids
    in patients with altered hepatic function except:
    A. Smaller clearance of the opioid
    B. Volume of distribution is increased
    C. Prolonged elimination half-time
    D. Relatively normal initial distribution
    E. Accumulation of drug will occur
A
  1. Answer: B
    Explanation:
    Ref: Murphy. Chapter 16. Opioids. In: Clinical
    Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
    Lippincott, 1992, pg 431
    Source: Day MR, Board Review 2003
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3
Q
  1. What is the mode of action of cocaine in the central
    nervous system?
    A. increasing the reuptake of norepinephrine
    B. blocking dopamine receptors
    C. activating GABA receptors
    D. mediating its rewarding effect through dopamine cells
    in the ventral tegmentum area that projects to the
    basal ganglia
    E. inhibiting acetylcholine esterase in the central nervous
    system
A
  1. Answer: D
    Explanation:
    Cocaine acts by blocking reuptake of neurotransmitters
    (norepinephrine, dopamine, and serotonin) at the synaptic
    junctions, resulting in increased neurotransmitter
    concentrations. Because norepinephrine is the primary
    neurotransmitter of the sympathetic nervous system,
    sympathetic stimulation results and leads to
    vasoconstriction, tachycardia, mydriasis, and
    hyperthermia. Central nervous system stimulation may
    appear as increased alertness energy talkativeness,
    repetitive behavior, diminished appetite, and increased
    libido. Psychological stimulation by cocaine produces an
    intense euphoria that is often compared to orgasm.
    Pleasure and reward sensations in the brain have been
    correlated with increased neurotransmission in the
    mesolimbic or mesocortical dopaminergic tracts (or
    both). Cocaine increases the functional release of
    dopamine, which activates the ventral tegmental-nucleus
    accumbens pathway, which seems to be major component
    of the brain reward system. Activation of this pathway is
    essential for the reinforcing actions of psychomotor
    stimulants
    Source: Laxmaiah Manchikanti, MD
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4
Q
  1. Which of the following is true regarding the use of Midazolam
    for ICU sedation?
    A. Rapid onset
    B. Long duration of action
    C. No tolerance of CNS effects after prolonged infusion
    D. Will not cause hypotension even with high doses
    E. Metabolites are inactive
A
  1. Answer: A

Source: Day MR, Board Review 2005

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5
Q 
1829. The heart rate response to the infusion of a moderate
dose of phenylephrine in conscious patients is not
blocked by
A. Atropine
B. Hexamethonium
C. Phenoxybenzamine
D. Reserpine
E. Scopolamine
A
  1. Answer: D
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6
Q
  1. Which of the medical community, active euthanasia is
    best defi ned as:
    A. The withdrawal of life-sustaining measures
    B. The provision by a physician of the means by which
    patients can end their own lives
    C. The intentional termination of a patient’s life by a
    physician
    D. The withholding of life-sustaining measures
    E. The act of ending a patients life by a health care professional
A
  1. Answer: C
    Explanation:
    Ref: Breitbant, Possik, Rosenfeld. Chapter 46. Cancer,
    Mind, and Spirit. In: Textbook of Pain, 4th Edition. Wall
    and Melzack, Churchill Livingstone, 1999, pg 1082
    Source: Day MR, Board Review 2003
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7
Q 
1831. Intravenous administration of norepinephrine in a patient
already taking an effective dose of atropine will
often
A. Increase heart rate
B. Decrease total peripheral resistance
C. Decrease blood sugar
D. Increase skin temperature
E. Reduce pupil size
A
  1. Answer: A
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8
Q
  1. A patient in the coronary care unit has been receiving
    warfarin for 2 weeks. As a result of this therapy, the
    patient will probably have
    A. Reduced plasma factor II activity
    B. Reduced plasma factor VIII activity
    C. Reduced plasma plasminogen activity
    D. Increased tissue plasminogen activator
    E. Increased platelet adenosine stores
A
  1. Answer: A
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9
Q
  1. True statements regarding the apnea test used to diagnose
    brain death include all of the following except:
    A. Absence of spontaneous breathing during disconnection
    from the ventilator
    B. Arterial pH below 7.30 at the end of the test
    C. PaCO2 > 60 torr at the end of the test
    D. Core body temperature higher than or equal to 35 degrees
    Celcius at the start of the test
    E. PaO2
A
  1. Answer: D
    Explanation:
    Ref: Grenick. Chapter 111. Brain Death and Permanently
    Lost Consciousness. In: Textbook of Critical Care.
    Shoemaker, Thompson, Holbrook; W.B. Sanders, 1984, pg
    969
    Source: Day MR, Board Review 2003
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10
Q
  1. A patient is admitted to the emergency room 2 hours
    after taking an overdose of phenobarbital. The plasma
    level of the drug at time of admission is 100 mg/L, and
    the apparent volume of distribution, half-life, and
    clearance of phenobarbital are 35 L, 4 days, and 6.1 L/d,
    respectively. The ingested dose was approximately
    A. 1 g
    B. 3.5 g
    C. 6.1 g
    D. 40 g
    E. 70 g
A
  1. Answer: B
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11
Q
  1. Following a very large overdose of a benzodiazepine, a
    patient is admitted to hospital. Which one of the following
    is not likely to be of therapeutic value in the
    management of this patient?
    A. Administration of naloxone
    B. Gastric lavage if an endotracheal tube is in place
    C. Intravenous fl umazenil
    D. Protection of the airway
    E. Ventilatory support
A
  1. Answer: A
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12
Q
  1. Which of the following is not true regarding continuous
    epidural infusion of medication versus intermittent
    bolus technique?
    A. Easier to titrate medication via a continuous infusion
    B. There are fewer fl uctuations in cerebral spinal fl uid
    concentrations of drug with a continuous infusion
    C. Tachyphylaxis is less common with the intermittent
    bolus technique
    D. Continuous epidural infusion provides better analgesia
    than intermittent bolus
    E. Higher risk for respiratory depression with the intermittent
    bolus technique
A
  1. Answer: C
    Explanation:
    Ref: Anderson. Chapter 16. Continuous Regional
    Analgesia. In: Textbook of Regional Anesthesia. Raj et al,
    Churchill Livingstone, 2002, pg 239
    Source: Day MR, Board Review 2003
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13
Q
  1. A patient is admitted to the emergency department for
    treatment of a drug overdose. The identity of the drug
    is unknown, but it is observed that when the urine pH
    is acidic, the renal clearance of the drug is less than the
    glomerular fi ltration rate and that when the urine pH
    is alkaline, the clearance is greater than the glomerular
    fi ltration rate. The drug is probably a
    A. Strong acid
    B. Weak acid
    C. Nonelectrolyte
    D. Weak base
    E. Strong base
A
  1. Answer: B
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14
Q 
1838. Which of the following opioids do not evoke the release
of histamine?
1. Sufentanil
2. Alfentanil
3. Fentanyl
4. Meperidine
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Murphy. Chapter 16. Opioids. In: Clinical
    Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
    Lippincott, 1992, pg 416
    Source: Day MR, Board Review 2003
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15
Q
  1. A post-op patient with intraabdominal bypass presents
    with new complaints of back pain with bilateral leg
    weakness, altered refl exes: knee left 1+, right 2+. The
    patient is on heparin and Plavix with epidural catheter.
    Next step in management of this patient is:
  2. To stop infusion and reassess after 4 hours
  3. To obtain surgical consult
  4. To increase infusion
  5. Order MRI of thoracic & lumbar spine
A
  1. Answer: D (4 Only)
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16
Q
  1. Which of the following criteria can be used to support
    the diagnosis of brain death in the intensive care unit?
  2. Light-fi xed pupils
  3. An isoelectric electroencephalogram recorded in part
    at full gain
  4. No evidence of decerebrate or decorticate posturing
    or shivering
  5. Heart rate increase of less than 5 beats per minute after
    intravenous atropine 0.04 mg/kg
A
  1. Answer: E (All)
    Explanation:
    (Shoemaker, pp 968-969.)
    The defi nition of brain death is the permanent loss of all
    integrated brain functions. The patient is not experiencing
    pain or suffering. As such, it is extremely important to
    elimate all medications and correct hemodynamic
    variables that may be contributing to the comatose
    conditions before one declares the patient brain dead. The
    patient should have adequate blood pressure and
    temperature above 34°C ( 93.2°F) and be free of alcohol,
    toxins, and medications that could depress brain function.
    A detailed and thoroughly documented clinical
    examination should be performed and then repeated no
    sooner than 2 h after the initial examination. Body
    temperature, blood ethanol level, and toxicology screens
    should be documented. In the absence of muscle relaxants,
    there should be no spontaneous movement and no
    evidence of decerebrate to decorticate posturing or
    shivering and there should be no spontaneous breathing
    for 3 min ( at Paco2 > 60 torr at the end of the test).
    If the patient has pulmonary disease, the Pao2 must be
    less than 50 torr at the end of the test. The patient must
    have light-fi xed pupils and the absence of corneal
    refl exes, response to painful stimuli, response to upper
    and lower airway stimulation, ocular response to head
    turning, and ocular response to ear irrigation
    with 50 mL of ice water. Intravenous atropine
    0.04 mg/kg should fail to increase the heart rate by more
    than 5 beats per minute. An isoelectric
    electroencephalogram recorded in part at full gain should
    also be obtained. The ultimate criterion of brain death is
    the complete absence of cerebral blood fl ow, which can be
    documented by bilateral internal carotid and vertebral
    anteriography or by radionuclide cerebral imaging.
    Source: Kahn and Desio
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17
Q
  1. The pharmacokinetics of which the following drug/s
    is/are not changed in the presence of hepatic or renal
    diseases:
  2. Dexmetetomidine
  3. Etomidate
  4. Thiopental
  5. Propofol
A
  1. Answer: D (4 only)

Source: Day MR, Board Review 2005

18
Q
  1. True statements regarding delirium tremens includes:
  2. Can be treated with Haloperidol
  3. Benzodiazepine are the preferred sedatives
  4. Rarely fatal if untreated
  5. Clonidine can be used to treat hypertension associated
    with withdrawal
A
  1. Answer: C (2 & 4)

Source: Day MR, Board Review 2005

19
Q
  1. True statements regarding the use of ketamine in trauma
    patients include:
  2. It may be used as the sole agent for trauma surgery
  3. It possesses sympathomimetic action
  4. At lower doses it is an analgesic
  5. It can be used in trauma patients with head injuries
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Ketamine produces a profound analgesia and may be used
    in high doses as the sole agent for emergency and trauma
    surgery.
    This agent possesses sympathomimetic action, which may
    be benefi cial in injured patients with a depressed
    cardiovascular system because of sharp.
    At lower doses, it can be used as an analgesic.
    Ketamine increases intracranial pressure, however, and is
    contraindicated in head injuries.
20
Q
  1. In patients with carbon monoxide (CO) poisoning,
  2. Carboxyhemoglobin (COHb) is greater than 20%
  3. pulse oximetry is a reliable measure of COHb
  4. the half-life of COHb in room air is 5 h
  5. hyperbaric O2 is the treatment of choice
A
  1. Answer: B (1 & 3)
    Explanation:
    (Miller, 4/e. pp 2431-2432.)
    Carbon monoxide is normally present and bound at about
    1 percent of oxygen binding sites in hemoglobin. When a
    person is exposed to smoke, CO concentrations can rise
    dramatically; 20% defi nes poisoning. Because CO has 200
    times greater affi nity for hemoglobin than oxygen and is
    slow to be released, hypoxia can result. COHb and
    hemoglobin have similar absorption characteristics.
    Therefore, pulse oximetry will not give a reliable measure
    of COHb, overestimating the amount of hemoglobin
    available to tissues. The half-life of CO in room air is
    about 5 h. The treatment of choice is 100% O2, which
    reduces the half-life to 1 h. Hyperbaric O2 can speed this
    process but is not necessary.
    Source: Curry S.
21
Q
  1. The following statements regarding hydration in terminal
    situation are true?
  2. Hydration is always helpful in terminal patients
  3. Hydration can help to reduce delirium and opioid
    side-effects
  4. Hydration improves fatigue
  5. Some patients can die comfortably without hydration
A
  1. Answer: C (2 & 4)

Source: Reddy et al. Pain Practice: Dec 2001, March 2002

22
Q
  1. Carbon monoxide (CO) may be characterized by which
    of the following statements?
  2. Poisoning results in increased minute ventilation
  3. CO has twice the affi nity for hemoglobin that oxygen
    has
  4. CO shifts the oxyhemoglobin dissociation curve to
    the right
  5. CO produces carboxyhemoglobin that absorbs the
    same frequency of light as oxyhemoglobin
A
  1. Answer: D (4 Only)
    Explanation:
    (Stoelting, Anesthesia and Co-Existing Disease, 3/e. p
    536.)
    Carotid and aortic bodies increase minute ventilation in
    response to a decreased PaO2 , not decreased
    hemoglobin saturation. Carbon monoxide has over 200
    times the affi nity for hemoglobin that oxygen has.
    Carboxyhemoglobin shifts the oxyhemoglobin
    dissociation curve to the left. Because carboxyhemoglobin
    absorbs the same frequency of light as oxyhemoglobin,
    oxyhemoglobin saturation may be overestimated in the
    presence of CO poisoning.
    Source: Curry S.
23
Q
  1. True statements in relation to patients with transplanted
    hearts include
  2. atherosclerosis of the donated heart is a frequent complication
  3. hepatic toxicity, usually manifested by elevated levels
    of transaminase, is the most common organs toxicity
    associated with use of cyclosporine
  4. azathioprine (Imuran) often causes leukopenia
  5. newer immunosuppressants, which have become the
    standard of care in these patients, have made opportunistic
    infections rare
A
  1. Answer: B (1 & 3)
    Explanation:
    (Stoelting, Pharmacology, 2/e. p 233.)
    Up to 50 percent of these patients develop atherosclerosis
    within 5 years of transplantation regardless of the age of
    the transplanted heart. Angina is rare because of
    denervation of the heart. Renal toxicity is the most common side effect of cyclosporine. These patients are
    markedly immunocompromised, and strict sterile
    technique should be observed for every invasive
    procedure.
    Source: Curry S.
24
Q
  1. Factors contributing to delirium include:
  2. Extremes of aging
  3. Underlying psychotic or neurotic disorder
  4. Central nervous system disease
  5. Alkalosis
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Dull. Chapter 8. Recovery Management of the
    Healthy Patient. In: Principles and Practice of
    Anesthesiology. Rogers et al, Mosly, 1993, pg 136
    Source: Day MR, Board Review 2003
25
Q
  1. Advantages of propofol over the other sedative –hypnotics
    is/are:
  2. Short duration of effect
  3. Short recovery period
  4. Minimal side effects
  5. No tolerance with prolonged administration
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Hemelrijck, Gonzales, White, Chapter 53.
    Pharmacology of Intravenous Anesthetic Agents. In:
    Principles and Practice of Anesthesiology. Rogers et al,
    Mosly, 1993, pg 1147
    Source: Day MR, Board Review 2003
26
Q
  1. Intermittent epidural morphine injections for hospitalized
    in patients are acceptable because
  2. Respiratory depression is extremely rare, predictable,
    and easily treated
  3. The incidence of urinary retention is not higher than
    intermittent intramuscular (IM) injections
  4. Nurses do not mind giving epidural injections
  5. There is low incidence of respiratory depression, and
    catheter-related problems are minimal
A
  1. Answer: D (4 Only)
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
27
Q
  1. Drugs known to increase digoxin levels include
  2. Quinidine
  3. Hydrochlorothiazide
  4. Amiodarone
  5. propranolol
A
  1. Answer: B (1 & 3)
    Explanation:
    (Stoelting, Pharmacology, 2/e. pp 291-292, 350-351.)
    Quinidine and amiodarone both increase serum digoxin
    levels, which may lead to toxicity. Hydrochlorothiazide
    may lead to dig toxicity by reducing potassium levels but
    not by raising digoxin levels. Propranolol has no effect on
    dig levels.
    Source: Curry S.
28
Q
  1. Which of the following statements is true regarding the
    use of opioids in the mechanically ventilated patient?
  2. Depression of the cough refl ex increases tolerance of
    the endotracheal tube
  3. Depression of the ventilation helps prevent the patient
    from “fi ghting the ventilator”
  4. Sedation decreases anxiety
  5. Analgesia increases patient comfort
A
  1. Answer: E (All)
    Explanation:
    Ref: Murphy. Chapter 16. Opioids. In: Clinical
    Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
    Lippincott, 1992, pg 432
    Source: Day MR, Board Review 2003
29
Q 
1853. Which of the following are useful for control of burn
pain in a pediatric patient?
1. Epidural local anesthetic
2. Epidural morphine
3. Fentanyl intravenous
4. Propofol infusion
A
  1. Answer: A (1,2, & 3)
30
Q
  1. True statements regarding the withdrawal of life support
    include:
  2. A distinction has to be made between a competent and
    a noncompetent patient
  3. Recent cases have based the right to withdraw life support
    on the Fifth Amendment to the United States
    Constitution and Bill of Rights which guarantees the
    right to liberty and self-determination
  4. An incompetent patient who had expressed a desire
    while competent not to be maintained on life support
    should be treated as a competent individual
  5. Our judicial system encourages the use of judicial review
    for all termination of life-support issues
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Benesch. Chapter 112. Legal Aspects of Brain Death
    Certifi cation and Withdrawal of Life Support. In:
    Textbook of Critical Care. Shoemaker, Thompson,
    Holbrook; W.B. Sanders, 1984, p 979
    Source: Day MR, Board Review 2003
31
Q
  1. Clinical signs to confi rm brain death include the following:
  2. Pupils non-reactive to light stimulation
  3. Isoelectric electroencephalogram recorded at full gain
  4. Absent ocular response to head turning (no eye movement)
  5. Presence of decorticate posturing
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Grenick. Chapter 111. Brain Death and Permanently
    Lost Consciousness. In: Textbook of Critical Care.
    Shoemaker, Thompson, Holbrook; W.B. Sanders, 1984, pg
    968B
    Source: Day MR, Board Review 2003
32
Q
  1. True statements regarding nonsteroidal anti-infl ammatory
    drugs are:
  2. Slowly absorbed after oral administration
  3. Tissue distribution is extensive
  4. Signifi cantly dependent on renal elimination
  5. Low clearances
A
  1. Answer: D (4 Only)
    Explanation:
    Ref: Katz. Chapter 33. Nonsteroidal Anti-infl ammatory
    Analgesics. In: Practical Management of Pain, 3rd
    Edition. Raj et al, Mosby, 2000, pg 480
    Source: Day MR, Board Review 2003
33
Q
  1. A patient with a fl ail chest and lower-extremity fractures
    is consulted by the trauma team to provide pain management.
    The most appropriate plan would be
  2. Small IV doses of opiates
  3. Lumbar epidural with a hydrophilic opiate to promote
    cephalad distribution to thoracic dermatomes
  4. Thoracic epidural with opiate and local anesthetic
  5. Thoracic epidural with local anesthetic alone and
    systemic PCA
A
  1. Answer: D (4 Only)
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
34
Q
  1. Important considerations for patients with serious burn
    injuries include which of the following?
  2. In the fi rst 24 h after the burn, patients should be given
    fl uid at approximately 8 mL/kg per hour for each
    percent of body area burned
  3. Patients are resistant to nondepolarizing muscle relaxants
    primarily because the volume of distribution for
    these drugs is vastly increased
  4. Patients have a decreased requirement for opioids
  5. Patients do not respond normally to succinylcholine
    and may suffer cardiac arrest
A
  1. Answer: D (4 Only)
    Explanation:
    (Barash, 3/e. pp 1188-1190, 1196.)
    Fluid needs are great, but the recommended amount is
    2 to 4 mL/kg per hour for each percent of body
    burned. Follow vital signs and urine output as fi nal
    monitors. Evaporative losses, high metabolism, and
    exposure tend to lead to hypothermia in burn patients.
    Burn patients receiving succinylcholine can have an
    abnormally high release of potassium, leading to cardiac
    arrest. Resistance to nondepolarizing muscle relaxants is
    due to the proliferation of extrajunctional receptors,
    which are less responsive to these drugs. These patients
    have severe pain and require high doses of narcotics.
    Source: Curry S.
35
Q
  1. A patient in the intensive care unit is in a persistent
    vegetative state and has total loss of cortical layers
    demonstrated on CT scan of the brain. The patient is
    able to breathe spontaneously. Which of the following
    interventions would be appropriate in the care of this
    patient?
  2. New infusions of vasopressors to maintain hemodynamics
  3. Mechanical ventilation if spontaneous respiration
    deteriorates
  4. Insertion of an intraaortic balloon pump to augment
    cardiac function
  5. Continued nutrition via a nasogastric tube
A
  1. Answer: D (4 Only)
    Explanation:
    (shoemaker, p 969-972.)
    A patient who is not brain dead but had permanently
    lost consciousness can be describedas one whose
    personality, memory, interaction with others, and
    emotional states are gone, but whose physical
    vegetative functions and refl exes persist. If cerebral
    arteriography and modifi ed CT scanning of the brain
    demonstrate total loss of cortical layers, the irreversibility
    of the patient’s unconscious state can be verifi ed. At that
    point, it is justifi able to proceed on the premise that lifesustaining
    therapies will no longer benefi t the patient and
    are therefore not indicated. A patient on ventilator may be
    weaned in spite of deteriorating vital signs and blood
    gases. Even nutrition may be withheld, through commonly
    it will be continued while new therapies, ventilation, antibiotics, and pressor support are withheld.
    Source: Kahn and Desio
36
Q
  1. Advantages of patient-controlled epidural analgesia
    over conventional epidural continuous infusion is/are:
  2. Increased effi ciency
  3. Higher satisfaction
  4. Decreased sedation
  5. Reduced opioid use
A
  1. Answer: E (All)
    Explanation:
    Ref: Anderson. Chapter 16. Continuous Regional
    Analgesia. In: Textbook of Regional Anesthesia. Raj et al,
    Churchill Livingstone, 2002, pg 243
    Source: Day MR, Board Review 2003
37
Q
  1. Which of the following implantable drug-delivery
    systems would be appropriate for a patient with a life
    expectancy of a few days to several weeks?
  2. Simple epidural catheter
  3. Reservoir/port
  4. Tunneled epidural catheter
  5. Implantable continuous infusion
A
  1. Answer: B (1 & 3)
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
38
Q
  1. Which of the following is/are goals of ICU sedation?
  2. Reduce fears
  3. Reduce anxiety
  4. Reduce agitation
  5. Alleviate pain
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Ref: Ebert. Current Strategies in ICU Sedation. In:
    Anesthesiology News Special Report. March 2001
    Source: Day MR, Board Review 2003
39
Q
  1. A terminal patient is experiencing intractable cancer
    pain that is well localized to one side of the pelvis.
    Which of the following invasive procedures would be
    most appropriate for treating the pain?
  2. Percutaneous cordotomy
  3. Midline myelotomy
  4. Epidural block
  5. Subarachnoid phenol saddle block
A
  1. Answer: E (All)
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
40
Q
  1. A patient with multi-organ failure in the intensive case
    unit complains of back pain. Vitals signs include low
    blood pressure (90/60), and tachycardia, and decreased
    urine output. The most appropriate analgesic(s) for
    this patient is/are:
  2. Ketoralac
  3. Morphine
  4. Meperidine
  5. Fentanyl
A
  1. Answer: D (4 Only)
    Explanation:
    The nsaid, meperidine and morphine are contraindicated
    with renal insuffi ciency. Fentanyl is the best choice.
41
Q
  1. Cardiac transplantation is accurately characterized by
    which of the following statements?
  2. Atropine, in usual doses, is the initial drug of choice
    in a cardiac transplant patient who becomes bradycardic
    intraoperatively
  3. Vagal stimulation has more profound on heart rate in a
    cardiac transplant patient than in a normal patient
  4. The peak vasopressor effect of ephedrine is more
    rapid in a cardiac transplant patient than in normal
    patients
  5. Usual doses of antimuscarinic agents, such as atropine
    or glycopyrrolate, should be given to these patients
    when muscle relaxants are reverses with neostigmine
    or edrophonium
A
  1. Answer: D (4 Only)
    Explanation:
    (Barash, 3/e. pp 1271-1272. Stoelting, Pharmacology, 2/e,
    p 233.)
    The vagus is not connected to the transplanted heart;
    therefore, vagal tone does not affect heart rate, nor does
    atropine. Elevated heart rates can be achieved via beta
    agonists such as isoproterenol. Drugs with primarily
    indirect effects, such as ephedrine, take longer to act
    because of sympathetic denervation of the heart.
    Vasopresssor effects require release of norepinephrine
    from intact sympathetic nerve endings followed by
    transport via the circulation of the heart, where direct
    alpha and beta agonism can take place. Although cardiac
    muscarinic effects are unlikely with anticholinesterase
    drugs in a patient with a transplanted heart, pulmonary
    and gastrointestinal muscarinic effects do occur and
    should be blocked with antimuscarinic agents.
    Source: Curry S.

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