FU(11): Abnormalities of Conduction & pHTN

Question 1

In a patient with pulmonary arterial hypertension (PAH), which factor is most crucial to maintain during anesthesia?

A.) Maintained RV preload and reduced RV afterload
B.) Reduced cardiac preload
C.) Increased cardiac afterload
D.) Decreased systemic vascular resistance

Answer 1

A.) Maintained RV preload and reduced RV afterload

Question 2

In a patient with pulmonary hypertension, what is the most significant risk associated with general anesthesia?

A.) Hypertensive crisis
B.) Excessive bleeding
C.) Renal impairment
D.) Right ventricular failure

Answer 2

D.) Right ventricular failure

Question 3

A patient with poorly controlled hypertension is undergoing a major abdominal surgery. Which intraoperative complication is this patient most at risk for?

A.) Hypotension
B.) Myocardial ischemia
C.) Bradycardia
D.) Excessive bleeding

Answer 3

B.) Myocardial ischemia

Question 4

A patient with a history of pulmonary arterial hypertension (PAH) is scheduled for non-cardiac surgery. Which of the following is the most appropriate perioperative management?

A.) Avoidance of nitrous oxide
B.) Avoidance of nitrous oxide
C.) Maintenance of normocarbia
D.) Use of high-dose inotropic agents

Answer 4

C.) Maintenance of normocarbia

Question 5

A patient with a history of pulmonary arterial hypertension (PAH) is scheduled for elective surgery. Which anesthetic technique is most appropriate?

A.) High-dose volatile anesthetics
B.) Total intravenous anesthesia TIVA
C.) Regional anesthesia with minimal sedation
D.) General anesthesia with controlled ventilation

Answer 5

B.) Total intravenous anesthesia TIVA

Question 6

During surgery, a patient with a history of pulmonary arterial hypertension (PAH) and right ventricular (RV) failure develops acute hypotension. What is the most appropriate immediate intervention?

A.) Administration of a high-dose inotropic agent
B.) Rapid volume expansion with crystalloids
C.) Initiation of nitric oxide inhalation therapy
D.) Increase in positive end-expiratory pressure (PEEP)

Answer 6

C.) Initiation of nitric oxide inhalation therapy

Question 7

A patient with systemic hypertension and left ventricular hypertrophy (LVH) is undergoing major surgery. Which of the following is the primary concern regarding anesthesia management?

A.) Risk of hypotension and decreased coronary perfusion
B.) Excessive bleeding due to hypertension
C.) Increased risk of malignant hyperthermia
D.) Ventilatory complications due to LVH

Answer 7

A.) Risk of hypotension and decreased coronary perfusion

Question 8

A 65-year-old male with a history of systemic hypertension is scheduled for elective surgery. Preoperative assessment reveals well-controlled blood pressure with ACE inhibitors. During surgery, the patient exhibits significant intraoperative blood pressure variability. What is the most likely underlying pathophysiological mechanism for this intraoperative hemodynamic instability?

A.) Reduced baroreceptor sensitivity due to chronic hypertension
B.) Acute withdrawal of ACE inhibitors
C.) Development of secondary hypertension
D.) Exacerbation of underlying ischemic heart disease

Answer 8

A.) Reduced baroreceptor sensitivity due to chronic hypertension

Question 9

A patient with a history of pulmonary arterial hypertension (PAH) is undergoing non-cardiac surgery. Which of the following anesthetic considerations is most critical due to the pathophysiology of PAH?

A.) Avoidance of nitrous oxide to prevent increase in pulmonary vascular resistance
B.) Strict maintenance of normocarbia to avoid hypoxic pulmonary vasoconstriction
C.) Use of high-dose opioid techniques to blunt sympathetic response
D.) Liberal fluid administration to maintain preload and cardiac output

Answer 9

B.) Strict maintenance of normocarbia to avoid hypoxic pulmonary vasoconstriction

Question 10

A 55-year-old patient with a history of myocardial infarction is undergoing elective surgery. During anesthesia, the ECG shows a new onset of Left Bundle Branch Block (LBBB). Which of the following is the most likely cause of this finding?

A.) Hypocalcemia
B.) Hypervolemia
C.) Pulmonary embolism
D.) Myocardial ischemia

Answer 10

D.) Myocardial ischemia

Question 11

A patient presents with symptomatic bradycardia. ECG shows a regular rhythm with a heart rate of 45 bpm and a narrow QRS complex. Which of the following is the most likely diagnosis?

A.) Sinus bradycardia
B.) Third-degree AV block
C.) Junctional rhythm
D.) Ventricular tachycardia

Answer 11

C.) Junctional rhythm

Question 12

A patient with chronic renal failure undergoing surgery exhibits a prolonged QT interval. Which drug should be used with caution?

A.) Propofol
B.) Isoflurane
C.) Amiodarone
D.) Lidocaine

Answer 12

C.) Amiodarone

Question 13

A patient with Wolff-Parkinson-White (WPW) syndrome develops a tachyarrhythmia. Which of the following drugs is contraindicated?

A.) Procainamide
B.) Digoxin
C.) Verapamil
D.) Adenosine

Answer 13

B.) Digoxin

Question 14

In a patient with a history of myocardial infarction, which ECG finding would most strongly suggest ischemia?

A.) Peaked T waves
B.) Prolonged QT interval
C.) First-degree AV block
D.) ST-segment elevation

Answer 14

D.) ST-segment elevation

Question 15

In a patient with Wolff-Parkinson-White Syndrome, what ECG finding is typically observed?

A.) Delta wave
B.) Prolonged QT interval
C.) Elevated ST segment
D.) Second-degree AV block

Answer 15

A.) Delta wave

Question 16

What is the primary mechanism of arrhythmia in Torsades de Pointes?

A.) Triggered activity
B.) Reentry
C.) Conduction block
D.) Increased automaticity

Answer 16

A.) Triggered activity

Question 17

A patient with an inferior myocardial infarction is at increased risk for which of the following conduction disturbances?

A.) Paroxysmal atrial tachycardia
B.) Wolff-Parkinson-White syndrome
C.) Atrioventricular (AV) block
D.) Right bundle branch block (RBBB)

Answer 17

C.) Atrioventricular (AV) block

Question 18

A 55-year-old patient presents with signs of myocardial ischemia. An ECG shows ST elevation in leads II, III, and aVF. What is the most likely cause?

A.) Anterior wall ischemia
B.) Inferior wall ischemia
C.) Lateral wall ischemia
D.) Septal ischemia

Answer 18

B.) Inferior wall ischemia

Question 19

A 65-year-old patient with a history of hypertension and diabetes is scheduled for elective surgery. Preoperative ECG shows a left bundle branch block (LBBB). During the operation, you notice ST-segment elevation in leads V1 to V3. What is the most likely cause of this ECG finding?

A.) Normal variant due to pre-existing LBBB
B.) Acute myocardial infarction
C.) Digitalis toxicity
D.) Hyperkalemia

Answer 19

A.) Normal variant due to pre-existing LBBB

Question 20

During a complex cardiothoracic surgery, a patient with a history of ischemic heart disease and recent myocardial infarction (MI) suddenly develops a new left bundle branch block (LBBB) on the intraoperative ECG, accompanied by hypotension and tachypnea. What is the most appropriate initial management step?

A.) Immediate administration of intravenous nitroglycerin
B.) Initiation of inotropic support with dobutamine
C.) Urgent echocardiographic assessment
D.) Administration of supplemental oxygen and diuretics

Answer 20

C.) Urgent echocardiographic assessment

Question 21

A patient undergoing a neurosurgical procedure with a history of Brugada syndrome exhibits wide-complex tachycardia resembling ventricular tachycardia (VT), but remains asymptomatic and hemodynamically stable. What is the most appropriate management strategy?

A.) Observation and continuous ECG monitoring
B.) Administration of IV procainamide
C.) Placement of an ICD (Implantable Cardioverter-Defibrillator) if not already in place
D.) Urgent catheter ablation

Answer 21

B.) Administration of IV procainamide

Question 22

During a high-risk cardiac surgery, a patient with known hypertrophic cardiomyopathy (HCM) and recurrent nonsustained ventricular tachycardia (NSVT) suddenly develops sustained ventricular tachycardia (VT) with hemodynamic instability. The patient is already on appropriate beta-blocker therapy. What is the most appropriate immediate management step?

A.) Immediate synchronized cardioversion
B.) Intravenous administration of amiodarone
C.) Administration of intravenous lidocaine
D.) Urgent ICD (Implantable Cardioverter-Defibrillator) placement

Answer 22

A.) Immediate synchronized cardioversion

Question 23

A 55-year-old male with a history of obesity and chronic stress presents with a blood pressure of 155/95 mm Hg. He has a strong family history of hypertension. His physical examination is notable for bilateral carotid bruits and a BMI of 32 kg/m^2. Laboratory studies show no evidence of secondary causes of hypertension. How does chronic sympathetic nervous system overactivity contribute to this patient’s primary hypertension?

A.) It directly leads to vasodilation and decreased peripheral resistance
B.) It reduces heart rate and cardiac output
C.) It increases renal sodium and water reabsorption leading to volume expansion
D.) It enhances baroreceptor sensitivity, leading to decreased blood pressure

Answer 23

C.) It increases renal sodium and water reabsorption leading to volume expansion

Question 24

A 60-year-old female is diagnosed with primary hypertension. She has a moderate intake of dietary sodium and a sedentary lifestyle. Her blood work indicates increased levels of plasma renin activity. What role does dysregulation of the renin-angiotensin-aldosterone system play in the pathogenesis of this patient’s hypertension?

A.) Decreased renin levels reduce aldosterone secretion, causing hypotension
B.) Activation of angiotensin II leads to vasoconstriction and sodium retention
C.) Excessive aldosterone promotes potassium retention and sodium excretion
D.) Angiotensin II promotes bradykinin accumulation, which reduces blood pressure

Answer 24

B.) Activation of angiotensin II leads to vasoconstriction and sodium retention

Question 25

A 45-year-old woman with primary hypertension is noted to have impaired endothelium-dependent vasodilation. She has no history of cardiovascular disease but has high-normal cholesterol levels. What is the implication of endothelial dysfunction in the pathogenesis of this patient’s hypertension?

A.) Enhanced production of nitric oxide leading to persistent hypotension.
B.) Endothelial dysfunction typically results in decreased, not increased, production of EDHF
C.) Decreased vascular smooth muscle cell proliferation
D.) Reduced synthesis or availability of endothelium-derived vasodilators like nitric oxide

Answer 25

D.) Reduced synthesis or availability of endothelium-derived vasodilators like nitric oxide

Question 26

A 58-year-old male is scheduled for elective hernia repair. He has a history of hypertension, currently controlled with a thiazide diuretic and an ACE inhibitor, which he was instructed to hold on the morning of surgery. In the preoperative area, his blood pressure is recorded at 160/100 mm Hg. Why is it generally acceptable to proceed with surgery in this patient despite preoperative blood pressure elevation?

A.) Single blood pressure readings may not accurately represent chronic blood pressure control, and asymptomatic patients without end-organ damage are at low risk for perioperative complications from hypertension
B.) Elevated blood pressure in the preoperative setting always indicates well-controlled chronic hypertension, requiring no further management
C.) The patient’s chronic use of an ACE inhibitor ensures that his blood pressure will self-correct intraoperatively
D.) Preoperative hypertension is best managed by immediate administration of antihypertensive medications to reduce blood pressure before surgery

Answer 26

A.) Single blood pressure readings may not accurately represent chronic blood pressure control, and asymptomatic patients without end-organ damage are at low risk for perioperative complications from hypertensionv

Question 27

A 65-year-old female with a history of poorly controlled hypertension presents for elective cholecystectomy. Her echocardiogram shows left ventricular hypertrophy with diastolic dysfunction. Her blood pressure on the day of surgery is 178/92 mm Hg. Considering her left ventricular hypertrophy and diastolic dysfunction, why is meticulous blood pressure control important in this patient?

A.) Diastolic dysfunction in patients with left ventricular hypertrophy is typically a sign of reduced systemic vascular resistance, which can be managed with increased fluid administration
B.) Poorly controlled hypertension leads to a decreased risk of intraoperative arrhythmias, which are beneficial for patients with diastolic dysfunction
C.) Left ventricular hypertrophy decreases chamber compliance, making the heart particularly sensitive to volume changes and requiring careful management of blood pressure to prevent end-organ ischemia
D.) Left ventricular hypertrophy is associated with enhanced baroreceptor reflexes, leading to increased stability in blood pressure during surgery

Answer 27

C.) Left ventricular hypertrophy decreases chamber compliance, making the heart particularly sensitive to volume changes and requiring careful management of blood pressure to prevent end-organ ischemia

Question 28

A 32-year-old man is scheduled for outpatient arthroscopic knee surgery. He has no prior history of hypertension but presents with a preoperative blood pressure of 190/110 mm Hg and reports occasional headaches and palpitations. Why might this patient’s surgery be delayed for further evaluation of his hypertension?

A.) The patient’s symptoms and severe hypertension without a prior diagnosis suggest a secondary cause, such as pheochromocytoma, which requires preoperative optimization to prevent intraoperative hypertensive crises
B.) Secondary hypertension is less severe than primary hypertension and does not require any special considerations for elective surgery
C.) The patient’s symptoms indicate white-coat hypertension, which is best managed by reassurance and proceeding with surgery
D.) Palpitations and headaches are typical manifestations of essential hypertension and do not warrant further investigation

Answer 28

A.) The patient’s symptoms and severe hypertension without a prior diagnosis suggest a secondary cause, such as pheochromocytoma, which requires preoperative optimization to prevent intraoperative hypertensive crises

Question 29

A 70-year-old woman with chronic hypertension controlled with an ACE inhibitor and a β-blocker is scheduled for a total hip replacement. Her preoperative blood pressure is 145/85 mm Hg. Why is the continuation of her β-blocker recommended on the day of surgery?

A.) β-blockers are known to significantly lower blood pressure intraoperatively, thus preventing any hypertensive episodes
B.) The patient’s ACE inhibitor is sufficient to control blood pressure intraoperatively, making the β-blocker redundant
C.) Abrupt withdrawal of β-blockers can lead to rebound hypertension and tachycardia, which can increase perioperative cardiovascular risk
D.) β-blockers increase the risk of perioperative bleeding and should be discontinued several days before surgery

Answer 29

C.) Abrupt withdrawal of β-blockers can lead to rebound hypertension and tachycardia, which can increase perioperative cardiovascular risk

Question 30

A 62-year-old male with a history of refractory hypertension on five antihypertensive medications is undergoing vascular surgery for an aortic aneurysm. His preoperative blood pressure is controlled at 138/82 mm Hg. In managing a patient with refractory hypertension, why is it crucial to maintain a slightly elevated systemic vascular resistance intraoperatively?

A.) Lower systemic vascular resistance is preferred to reduce afterload and decrease myocardial oxygen demand
B.) Elevated systemic vascular resistance is an indicator of successful hypertension management and should be used as a therapeutic goal
C.) High systemic vascular resistance is necessary to compensate for the reduced volume status typically seen in patients with refractory hypertension
D.) Maintaining slightly elevated systemic vascular resistance helps ensure adequate perfusion pressure across vital organs, considering the patient’s reduced functional reserve from chronic hypertensive end-organ damage

Answer 30

D.) Maintaining slightly elevated systemic vascular resistance helps ensure adequate perfusion pressure across vital organs, considering the patient’s reduced functional reserve from chronic hypertensive end-organ damage

Question 31

A 68-year-old woman with a history of chronic kidney disease and hypertension presents with a blood pressure of 210/120 mm Hg and headache but no signs of end-organ damage. She is scheduled for an urgent hysterectomy due to heavy bleeding. Why should blood pressure management be titrated slowly in this patient’s urgent hypertensive crisis without end-organ damage?

A.) Rapid reduction in blood pressure can lead to hypoperfusion and ischemia, particularly in patients with chronic hypertension and compromised organ perfusion
B.) Lowering blood pressure too quickly can exacerbate the headache and potentially increase bleeding risks
C.) Chronic kidney disease patients require higher blood pressure to maintain glomerular filtration, which should not be rapidly altered
D.) Slow titration is not necessary; immediate normalization of blood pressure is the primary goal in all hypertensive crises

Answer 31

A.) Rapid reduction in blood pressure can lead to hypoperfusion and ischemia, particularly in patients with chronic hypertension and compromised organ perfusion

Question 32

A patient with a known history of hypertension presents to the emergency department with a blood pressure of 220/130 mm Hg and severe chest pain radiating to his back. A CT scan confirms an acute aortic dissection. In the management of a hypertensive crisis with aortic dissection, why is the addition of a β-blocker such as esmolol to arteriolar dilator therapy particularly desirable?

A.) The primary goal is to lower blood pressure quickly, and β-blockers are the fastest acting antihypertensive agents
B.) β-blockers reduce shear forces on the aortic wall by decreasing heart rate and contractility, which is vital in reducing the progression of aortic dissection
C.) Arteriolar dilators alone are sufficient to manage hypertension in aortic dissection, and β-blockers are not recommended
D.) β-blockers can increase blood pressure, providing a counter-regulatory effect to arteriolar dilators

Answer 32

B.) β-blockers reduce shear forces on the aortic wall by decreasing heart rate and contractility, which is vital in reducing the progression of aortic dissection

Question 33

A 60-year-old patient presents with labile blood pressures, ranging from 170/100 mm Hg to 250/120 mm Hg, accompanied by episodes of severe headaches, palpitations, and diaphoresis. Biochemical testing reveals elevated catecholamine levels, and an MRI shows an adrenal mass suggestive of pheochromocytoma. Why is controlled blood pressure reduction crucial in patients with pheochromocytoma presenting with a hypertensive crisis?

A.) The main goal is to eliminate the headache and diaphoresis symptoms rapidly by decreasing blood pressure
B.) Patients with pheochromocytoma are at risk of catecholamine-induced cardiomyopathy and arrhythmias, which can be exacerbated by abrupt changes in blood pressure
C.) Immediate blood pressure reduction is needed to prevent the adrenal mass from growing further
D.) In pheochromocytoma, hypertension is transient and self-limiting, so aggressive management is not typically required

Answer 33

B.) Patients with pheochromocytoma are at risk of catecholamine-induced cardiomyopathy and arrhythmias, which can be exacerbated by abrupt changes in blood pressure

Question 34

A patient with a history of hypertension treated with clonidine is scheduled for major abdominal surgery. Clonidine was stopped 24 hours before surgery due to concerns about perioperative hypotension. In the PACU, the patient exhibits markedly elevated blood pressure and heart rate. Why may dexmedetomidine be considered in the management of a patient with clonidine withdrawal syndrome?

A.) Dexmedetomidine causes rapid vasodilation and is the primary treatment for hypertension
B.) The primary goal is to continue clonidine therapy; dexmedetomidine has no role in clonidine withdrawal syndrome
C.) Dexmedetomidine is a rapid-acting α2-adrenergic agonist that can mitigate the excessive sympathetic activity resulting from clonidine withdrawal
D.) Dexmedetomidine is a long-acting agent appropriate for managing chronic hypertension, not acute withdrawal

Answer 34

C.) Dexmedetomidine is a rapid-acting α2-adrenergic agonist that can mitigate the excessive sympathetic activity resulting from clonidine withdrawal

Question 35

A 55-year-old woman with PAH, characterized by a mean pulmonary artery pressure (mPAP) of 35 mm Hg and pulmonary vascular resistance (PVR) of 4 Wood Units (WU), is undergoing elective cholecystectomy. She is currently treated with an endothelin receptor antagonist. In the perioperative management of this patient with PAH, why is it crucial to maintain a stable cardiac output (CO) and avoid increases in PVR?

A.) Because an increase in PVR or decrease in CO could exacerbate right ventricular strain and lead to right heart failure
B.) Because a higher CO would reduce PVR and alleviate symptoms of PAH
C.) Because PAH is primarily treated with volume loading, which increases CO
D.) Because increased CO is the primary goal in the management of PAH during surgery

Answer 35

A.) Because an increase in PVR or decrease in CO could exacerbate right ventricular strain and lead to right heart failure

Question 36

A 60-year-old man with moderate PAH (mPAP of 32 mm Hg) is experiencing an intraoperative hypertensive crisis during a total hip replacement. He is on combination therapy with a PDE-5 inhibitor and an endothelin receptor antagonist. In managing this intraoperative PAH crisis, which intervention is most appropriate to prevent further pulmonary vascular constriction and potential right ventricular failure?

Answer 36

Administer IV vasodilators that selectively reduce PVR w/o significantly affecting SVR

Question 37

A 45-year-old woman with PAH is scheduled for an elective laparoscopic cholecystectomy. She is currently managed with sildenafil and periodic inhaled nitric oxide therapy. Why is maintaining a stable nitric oxide level crucial during surgery for a patient with PAH?

A.) To enhance renal perfusion and prevent acute kidney injury
B.) To reduce the systemic vascular resistance and improve cardiac output
C.) To ensure consistent pulmonary vasodilation and prevent sudden spikes in pulmonary artery pressure
D.) To increase the efficiency of oxygen delivery to tissues

Answer 37

C.) To ensure consistent pulmonary vasodilation and prevent sudden spikes in pulmonary artery pressure

Question 38

A 68-year-old patient with a history of PAH functional class III is scheduled for elective knee replacement surgery. The patient has been on tadalafil and is scheduled for preoperative right heart catheterization. Why is preoperative right heart catheterization crucial in this patient with PAH before knee replacement surgery?

A.)
B.)
C.)
D.)

Answer 38

Provides accurate HD data to assess the severity of PAH and guide peri-op management, including anesthesia

During joint replacements, there is a risk for embolic showers that acutely increase RV afterload. During right heart catheterizations, they perform studies with inhaled nitric oxide to determine responsiveness to vasodilator therapy and can indicate the effectiveness of Ca Channel blockers as well. Understanding this can help guide preoperative therapy to optimize their status before entering surgery. It can also guide therapy choices intraoperatively for acute RV afterload increases in the case of an embolic shower.

Question 39

A patient with PAH presents for abdominal surgery. The patient experiences dyspnea on minimal exertion and reports a decrease in exercise tolerance over the past few months. In a PAH patient with worsening exercise tolerance, what is the primary anesthesia consideration during abdominal surgery?

A.)
B.)
C.)
D.)

Answer 39

Maintain PVR and RV function to prevent intra-op and post-op decompensation

Primary goal with PAH pts is maintaining optimal “mechanical coupling” between RV and pulmonary circulation to promote adequate left-sided filling and systemic perfusion. This can be achieved by reduced PVR to reduce the workload of RV but maintain preload

Question 40

A 55-year-old patient with PAH is scheduled for a laparoscopic cholecystectomy. The patient is taking sildenafil and reports occasional chest discomfort with exertion. An echocardiogram has shown RV hypertrophy and reduced RV compliance. For the patient with PAH and RV hypertrophy undergoing laparoscopic cholecystectomy, why is careful management of intraoperative ventilatory settings essential?

A.)
B.)
C.)
D.)

Answer 40

to avoid increases in RV afterload from PPV and hypercarbia, which can lead to RV failure

Question 41

A patient with idiopathic PAH, on combination therapy including a prostanoid, is admitted for an emergency appendectomy. The patient has had a recent syncope episode and is classified as NYHA functional class III. Why is the continuation of prostanoid therapy critical in a PAH patient undergoing emergency appendectomy?

A.) Prostanoids reduce PVR and inhibit platelet aggregation, which is crucial for maintaining RV function during acute surgical stress
B.) They provide sedative properties that can reduce perioperative anxiety and stress
C.) Prostanoids have analgesic effects that will benefit postoperative pain management
D.) They are necessary to prevent postoperative deep vein thrombosis

Answer 41

A.) Prostanoids reduce PVR and inhibit platelet aggregation, which is crucial for maintaining RV function during acute surgical stress

Question 42

A 70-year-old patient with PAH is scheduled for elective hernia repair. The patient has marked RV dilation and significant tricuspid regurgitation on echocardiography. What is the primary anesthetic concern for a patient with PAH, RV dilation, and tricuspid regurgitation during hernia repair?

A.) To use regional anesthesia to completely avoid the cardiovascular effects of general anesthesia
B.) To monitor urinary output meticulously as an indirect measure of cardiac output
C.) To avoid perioperative factors that could further increase RV afterload and exacerbate tricuspid regurgitation
D.) To prioritize rapid postoperative mobilization to reduce the risk of RV failure

Answer 42

C.) To avoid perioperative factors that could further increase RV afterload and exacerbate tricuspid regurgitation

Question 43

A 68-year-old patient with idiopathic PAH is scheduled for a total knee arthroplasty. The patient is currently managed on oral endothelin receptor antagonists and reports shortness of breath with minimal exertion. Why should embolic phenomena be a particular concern during total knee arthroplasty in a patient with idiopathic PAH?

A.) To prevent postoperative deep vein thrombosis and pulmonary embolism common in orthopedic surgeries
B.) Because bone marrow emboli can lead to long bone fractures during arthroplasty
C.) To avoid the risk of fat embolism syndrome which is more common in patients without PAH
D.) Because intraoperative embolic events can acutely increase right ventricular afterload and precipitate right heart failure

Answer 43

D.) Because intraoperative embolic events can acutely increase right ventricular afterload and precipitate right heart failure.

Question 44

A 59-year-old patient with moderate PAH is scheduled for laparoscopic abdominal surgery. The patient’s PAH is managed with a combination of a prostanoid and a PDE5 inhibitor. In a patient with moderate PAH undergoing laparoscopic surgery, why is the management of carbon dioxide insufflation critical?

A.) Because CO2 insufflation can increase right ventricular afterload and impede ventricular filling, exacerbating PAH
B.) To prevent postoperative shoulder pain associated with the CO2 insufflation.
C.) Because CO2 insufflation is known to cause postoperative cognitive dysfunction.
D.) To reduce the risk of venous gas embolism during laparoscopic procedures.

Answer 44

A.) Because CO2 insufflation can increase right ventricular afterload and impede ventricular filling, exacerbating PAH

Question 45

A 73-year-old patient with severe PAH requiring continuous intravenous prostanoid therapy is undergoing a thoracoscopic lobectomy for lung cancer. For a patient with severe PAH on continuous intravenous prostanoid therapy, why is the administration of inhaled pulmonary vasodilators recommended during thoracoscopic surgery?

A.) To enhance systemic oxygenation and prevent hypoxemia during one-lung ventilation
B.) Because inhaled anesthetics can lead to bronchodilation and improve operative lung re-expansion
C.) To selectively reduce pulmonary artery pressures and limit inhibition of HPV, thereby optimizing right ventricular function
D.) To reduce the risk of postoperative pulmonary complications, such as pneumonia

Answer 45

C.) To selectively reduce pulmonary artery pressures and limit inhibition of HPV, thereby optimizing right ventricular function

Question 46

A 35-year-old patient with PAH is undergoing a non-emergent cesarean section. The patient has been managed on a regimen of oral ERA and a diuretic. There is a noted NYHA functional class II status. What is the primary anesthetic consideration for a patient with PAH undergoing a cesarean section?

A.) To prevent the risk of postpartum hemorrhage, which is increased in patients with PAH
B.) The anesthetic plan should aim to minimize any increase in right ventricular afterload while ensuring adequate uteroplacental perfusion
C.) Because regional anesthesia is contraindicated in patients with PAH due to the risk of severe hypotension
D.) To avoid the use of oxytocin which can exacerbate PAH by causing systemic vasodilation

Answer 46

B.) The anesthetic plan should aim to minimize any increase in right ventricular afterload while ensuring adequate uteroplacental perfusion