FU(15): Hematologic Disorders & Cancer

Question 1

A 65-year-old patient with a history of stable coronary artery disease is undergoing elective hip replacement surgery. Preoperative hemoglobin (Hb) is measured at 7.8 g/dL. During surgery, the patient experiences an estimated blood loss of 25% of total blood volume. Based on the principles of perioperative blood transfusion discussed in the TRICC trial and associated literature, what is the most appropriate next step in managing this patient’s intraoperative care?
A.) Administer crystalloid solutions exclusively, monitoring for signs of end-organ ischemia
B.) Initiate red blood cell (RBC) transfusion immediately to maintain Hb above 8 g/dL
C.) Delay RBC transfusion until Hb drops below 7 g/dL, unless signs of myocardial ischemia develop.
D.) Proceed with surgery without any transfusion, reassessing Hb levels postoperatively

Answer 1

B.) Initiate red blood cell (RBC) transfusion immediately to maintain Hb above 8 g/dL

Question 2

A patient with compensated chronic anemia scheduled for elective abdominal surgery has a preoperative Hb level of 9 g/dL. Considering the patient’s chronic condition and the need for optimizing perioperative care, when would it be most appropriate to consider blood transfusion?

A.) If intraoperative Hb level decreases to below 8 g/dL
B.) Immediately preoperatively to increase Hb above 10 g/dL
C.) Only if the patient exhibits signs of end-organ ischemia intraoperatively
D.) Postoperatively if Hb falls below 7 g/dL without signs of bleeding

Answer 2

A.) If intraoperative Hb level decreases to below 8 g/dL

Question 3

During a complex surgical procedure, a patient experiences massive blood loss, estimated at 50% of total blood volume within a few hours. Considering the principles of managing massive transfusion, which of the following strategies is most appropriate?

A.) Initiate RBC transfusion only, delaying other blood products until coagulopathy signs appear
B.) Replace blood volume exclusively with crystalloid solutions initially, assessing need for blood products sequentially
C.) Use colloid solutions to restore intravascular volume, avoiding blood products due to infection risk
D.) Administer RBC, fresh frozen plasma, and platelets in a 1:1:1 ratio immediately

Answer 3

D.) Administer RBC, fresh frozen plasma, and platelets in a 1:1:1 ratio immediately

Question 4

A 48-year-old female patient scheduled for elective abdominal surgery presents with a preoperative diagnosis of iron-deficiency anemia (IDA) with a hemoglobin (Hb) level of 9.5 g/dL. Considering the need for optimizing her anemia prior to surgery, which of the following strategies is most appropriate?

A.) Start oral ferrous iron salts, assuming elective surgery can be postponed for 6 to 8 weeks to allow for correction of the iron deficiency
B.) Delay any form of iron supplementation until postoperative period to assess natural recovery of Hb levels
C.) Administer intravenous (IV) iron preparations, as it provides a quicker replenishment of iron stores and is effective even when surgery is scheduled within a few weeks
D.) Recommend immediate erythropoietin injections without iron supplementation, focusing on stimulating endogenous erythrocyte production

Answer 4

C.) Administer intravenous (IV) iron preparations, as it provides a quicker replenishment of iron stores and is effective even when surgery is scheduled within a few weeks

Question 5

A patient with thalassemia intermedia is scheduled for splenectomy due to splenomegaly and an increasing transfusion demand. Given the patient’s condition, which of the following perioperative management strategies is most critical to reduce the risk of thromboembolic events?

A.) Prioritize maintaining hemoglobin levels above 10 g/dL with transfusion therapy alone, focusing exclusively on correcting anemia
B.) Implement aggressive perioperative thromboprophylaxis measures, including early mobilization and possibly pharmacologic intervention, due to increased thromboembolic risk, especially post-splenectomy
C.) Avoid any thromboprophylaxis, relying on the patient’s history of chronic anemia to naturally thin the blood and reduce the risk of thrombosis
D.) Schedule immediate bone marrow transplantation post-splenectomy to address the underlying cause of thalassemia and eliminate the need for further anemia management

Answer 5

B.) Implement aggressive perioperative thromboprophylaxis measures, including early mobilization and possibly pharmacologic intervention, due to increased thromboembolic risk, especially post-splenectomy

Question 6

A 30-year-old patient presents with microcytic anemia. Laboratory results show a mean corpuscular volume (MCV) of 75 fL, a hemoglobin (Hb) level of 10 g/dL, and a high red cell distribution width (RDW). The patient has a normal serum ferritin level but a decreased serum iron level and transferrin saturation. Based on these findings, which of the following is the most likely diagnosis?

A.) Thalassemia, characterized by the microcytic anemia, normal serum ferritin, and the decreased serum iron level and transferrin saturation
B.) Iron deficiency anemia (IDA), indicated by the high RDW and decreased serum iron level and transferrin saturation, despite the normal serum ferritin level
C.) Anemia of chronic disease, with normal serum ferritin reflecting adequate iron stores and decreased serum iron level as a result of inflammatory processes
D.) Sideroblastic anemia, given the microcytic anemia and a normal serum ferritin level, suggesting a defect in heme synthesis

Answer 6

C.) Anemia of chronic disease, with normal serum ferritin reflecting adequate iron stores and decreased serum iron level as a result of inflammatory processes

Question 7

A 25-year-old patient with β-thalassemia intermedia is scheduled for elective orthopedic surgery. The preoperative evaluation reveals a hemoglobin (Hb) level of 9 g/dL, with a history of transfusions but no recent therapy. Considering the patient’s condition and the upcoming surgery, which of the following preoperative management strategies is most appropriate?

A.) Proceed with surgery without preoperative transfusion, relying on the patient’s history of compensating for low Hb levels due to the chronic nature of thalassemia intermedia
B.) Administer erythropoietin alone to stimulate endogenous Hb production, avoiding transfusion-induced iron overload
C.) Recommend delaying surgery indefinitely until Hb levels can be increased through dietary modifications and oral iron supplementation
D.) Initiate transfusion therapy to increase Hb to at least 10 g/dL and implement iron chelation if indicated to address potential iron overload from previous transfusions

Answer 7

D.) Initiate transfusion therapy to increase Hb to at least 10 g/dL and implement iron chelation if indicated to address potential iron overload from previous transfusions

Question 8

A 58-year-old male patient presents with fatigue and pallor. Laboratory tests reveal a mean corpuscular volume (MCV) of 85 fL, hemoglobin (Hb) 9.8 g/dL, lactate dehydrogenase (LDH) elevated at 600 U/L, low haptoglobin, and increased indirect bilirubin. The reticulocyte count is elevated. Which of the following is the most likely diagnosis based on these findings?

A.) Hemolytic anemia, indicated by the elevated reticulocyte count, increased LDH, low haptoglobin, and increased indirect bilirubin, reflecting increased destruction of erythrocytes
B.) Aplastic anemia, characterized by normocytic anemia, but typically with a low reticulocyte count, not elevated, contrary to the patient’s presentation
C.) Anemia of chronic disease, which can present with normocytic anemia but usually does not feature elevated LDH or low haptoglobin as predominant findings
D.) Anemia of kidney disease, often associated with normocytic anemia and elevated creatinine, which is not mentioned as abnormal in this scenario

Answer 8

A.) Hemolytic anemia, indicated by the elevated reticulocyte count, increased LDH, low haptoglobin, and increased indirect bilirubin, reflecting increased destruction of erythrocytes

Question 9

Considering the management of a patient with hereditary spherocytosis undergoing elective surgery, which of the following strategies is most critical to mitigate the risk of increased hemolysis and ensure patient safety?

A.) Avoid mechanical heart valves and closely monitor the patient if undergoing cardiopulmonary bypass due to the risk of exacerbating hemolysis and causing end-organ damage
B.) Focus primarily on preoperative splenectomy regardless of the presence of gallstones, to reduce the risk of hemolytic crises during surgery
C.) Implement aggressive iron supplementation preoperatively to compensate for the expected increase in hemolysis during surgery
D.) Prioritize the administration of eculizumab preoperatively to prevent complement activation and subsequent intravascular hemolysis

Answer 9

A.) Avoid mechanical heart valves and closely monitor the patient if undergoing cardiopulmonary bypass due to the risk of exacerbating hemolysis and causing end-organ damage

Question 10

In managing anesthesia for a patient with paroxysmal nocturnal hemoglobinuria (PNH) undergoing non-cardiac surgery, which of the following considerations is most important to prevent exacerbation of hemolytic anemia?

A.) Administer eculizumab intraoperatively to directly inhibit complement factor C5, thus preventing membrane attack complex formation on erythrocytes
B.) Ensure aggressive hydration and alkalization to prevent hemosiderinuria and subsequent renal insufficiency from hemoglobin release
C.) Minimize exposure to inhalational anesthetic agents and use propofol to avoid complement-activated anaphylactoid reactions associated with some anesthetics
D.) Focus exclusively on perioperative transfusion with washed RBCs to minimize the risk of triggering a hemolytic reaction through complement activation

Answer 10

C.) Minimize exposure to inhalational anesthetic agents and use propofol to avoid complement-activated anaphylactoid reactions associated with some anesthetics

Question 11

A patient with a known history of Glucose-6-phosphate dehydrogenase (G6PD) deficiency, classified as Class III (10–60% G6PD activity), is scheduled for elective surgery under general anesthesia. Considering the risk of oxidative stress-induced hemolysis, which of the following anesthesia plans is most appropriate?

A.) Prefer the use of isoflurane or sevoflurane for maintenance of anesthesia, as they are known to be safe in patients with G6PD deficiency
B.) Utilize benzodiazepines for preoperative anxiolysis and avoid isoflurane and sevoflurane during maintenance of anesthesia due to their potential to depress G6PD activity
C.) Administer methylene blue preoperatively as prophylaxis against potential oxidative stress-induced hemolysis during surgery
D.) Focus on the perioperative use of antibiotics and vitamin K to prevent infection and bleeding complications, regardless of their effect on G6PD activity

Answer 11

B.) Utilize benzodiazepines for preoperative anxiolysis and avoid isoflurane and sevoflurane during maintenance of anesthesia due to their potential to depress G6PD activity

Question 12

A pediatric patient with severe pyruvate kinase (PK) deficiency is undergoing splenectomy to decrease the rate of red blood cell (RBC) destruction. In planning for perioperative care, which of the following considerations is most crucial to minimize the risk of exacerbated hemolysis and ensure stability?

A.) Ensure adequate transfusion support with packed RBCs preoperatively to optimize hemoglobin levels and monitor for signs of hemolysis postoperatively
B.) Administer high-dose vitamin K preoperatively to enhance coagulation pathways and reduce the risk of bleeding, despite PK deficiency’s primary impact on RBCs
C.) Focus on the use of methylene blue during surgery to prevent the risk of methemoglobinemia associated with PK deficiency
D.) Prioritize aggressive phosphate supplementation preoperatively to counteract the reduced 2,3-DPG production in PK deficiency

Answer 12

A.) Ensure adequate transfusion support with packed RBCs preoperatively to optimize hemoglobin levels and monitor for signs of hemolysis postoperatively

Question 13

A 40-year-old patient with sickle cell anemia (HbSS) is scheduled for elective hip replacement surgery. Given the high-risk nature of the procedure and the patient’s condition, which of the following perioperative management strategies is most appropriate to minimize the risk of vasoocclusive crises and acute chest syndrome?

A.) Maintain hemoglobin levels above 12 g/dL using simple transfusions and restrict fluid intake to avoid overhydration during surgery.
B.) Delay transfusions until signs of vasoocclusive crisis appear postoperatively, and manage with standard analgesia and oxygen therapy as needed
C.) Aim to maintain preoperative hemoglobin S (HbS) levels below 30% with exchange transfusion if necessary, and ensure aggressive hydration, analgesia, and warming to prevent hypothermia
D.) Focus primarily on avoiding hyperoxia by limiting oxygen therapy and minimize the use of opioids to reduce the risk of respiratory depression

Answer 13

C.) Aim to maintain preoperative hemoglobin S (HbS) levels below 30% with exchange transfusion if necessary, and ensure aggressive hydration, analgesia, and warming to prevent hypothermia

Question 14

A patient with a history of hemolytic anemia due to unstable hemoglobin is scheduled for elective surgery. Considering the potential for hemolysis, which of the following is the most critical aspect of perioperative management for this patient?

A.) Administration of corticosteroids preoperatively to stabilize red blood cell membranes and prevent hemolysis during surgery
B.) Avoidance of oxidizing drugs and careful monitoring for signs of hemolysis, with transfusion support ready if severe hemolysis occurs
C.) Routine preoperative exchange transfusion to replace unstable hemoglobin with normal hemoglobin to prevent hemolysis
D.) Using hypertonic solutions for hydration to maintain high osmotic pressure and reduce red blood cell breakdown during surgery

Answer 14

B.) Avoidance of oxidizing drugs and careful monitoring for signs of hemolysis, with transfusion support ready if severe hemolysis occurs

Question 15

A patient with sickle cell trait (HbAS) requires anesthesia for a minor outpatient procedure. Regarding the perioperative anesthetic management and risk of sickling events, which of the following statements is most accurate?

A.) Patients with sickle cell trait should receive exchange transfusions preoperatively to reduce HbS levels below 30% to prevent sickling events
B.) Sickle cell trait significantly increases the risk of perioperative vasoocclusive crises, necessitating aggressive hydration, oxygenation, and warming measures
C.) Sickle cell trait (HbAS) does not significantly increase perioperative morbidity or mortality, and standard anesthesia protocols can be safely applied without additional sickling-related precautions
D.) General anesthesia is contraindicated for patients with sickle cell trait due to a high risk of severe sickling complications; regional anesthesia is the only safe option

Answer 15

C.) Sickle cell trait (HbAS) does not significantly increase perioperative morbidity or mortality, and standard anesthesia protocols can be safely applied without additional sickling-related precautions

Question 16

A patient with a history of lupus, diagnosed with warm autoimmune hemolytic anemia (WAHA), is scheduled for elective surgery. Given the autoimmune nature of the anemia, which of the following is the most appropriate perioperative management strategy?

A.) Perform preoperative exchange transfusion to replace all autoantibody-coated red blood cells with donor cells to prevent hemolysis
B.) Continue supportive management with corticosteroids and closely monitor for signs of hemolysis, adjusting the therapy as needed to maintain stable hemoglobin levels
C.) Discontinue all immunosuppressive therapy 48 hours before surgery to reduce the risk of infection, regardless of hemolysis status
D.) Perform preoperative exchange transfusion to replace all autoantibody-coated red blood cells with donor cells to prevent hemolysis

Answer 16

B.) Continue supportive management with corticosteroids and closely monitor for signs of hemolysis, adjusting the therapy as needed to maintain stable hemoglobin levels

Question 17

A patient with a diagnosis of macrocytic anemia due to folate deficiency is scheduled for non-urgent abdominal surgery. Considering the anemia’s impact on the patient’s overall health and the potential for perioperative complications, which of the following management strategies is most appropriate?

A.) Delay surgery until hemoglobin levels reach 12 g/dL, achieved through repeated red cell transfusions without folate supplementation
B.) Administer vitamin B12 injections instead of folate, as vitamin B12 deficiency is the most common cause of macrocytic anemia
C.) Avoid supplementation or transfusion and proceed with surgery to prevent delays, as macrocytic anemia does not significantly impact surgical outcomes
D.) Administer folate supplementation orally or parenterally, depending on the severity of the deficiency, and consider red cell transfusion if hemoglobin levels are critically low (<8 g/dL) to prepare the patient for surgery

Answer 17

D.) Administer folate supplementation orally or parenterally, depending on the severity of the deficiency, and consider red cell transfusion if hemoglobin levels are critically low (<8 g/dL) to prepare the patient for surgery

Question 18

A patient with rheumatoid arthritis, diagnosed with anemia of chronic disease (ACD), is preparing for orthopedic surgery. Considering the hypoproliferative nature of ACD, which of the following preoperative interventions is most appropriate?

A.) If erythropoietin levels are low, administer erythropoiesis-stimulating drugs in conjunction with iron therapy, tailoring the dose to minimize thromboembolic risks
B.) Preoperatively administer high-dose corticosteroids to correct anemia by suppressing the inflammatory response that causes ACD
C.) Perform routine red blood cell transfusions to correct anemia, regardless of hemoglobin levels or erythropoietin status
D.) Delay surgery until hemoglobin levels spontaneously improve, as ACD typically resolves without intervention once inflammation subsides

Answer 18

A.) If erythropoietin levels are low, administer erythropoiesis-stimulating drugs in conjunction with iron therapy, tailoring the dose to minimize thromboembolic risks

Question 19

A patient with confirmed vitamin B12 deficiency anemia, presenting with neurologic symptoms, is undergoing surgery that typically involves the use of nitrous oxide. Given the impact of nitrous oxide on vitamin B12 activity, which of the following is the most appropriate approach to anesthesia in this case?

A.) Use nitrous oxide cautiously during surgery, as it does not have a significant impact on vitamin B12 metabolism when administered for short periods
B.) Administer a high dose of vitamin B12 preoperatively to counteract the effects of nitrous oxide on methionine synthesis
C.) Avoid the use of nitrous oxide due to its potential to exacerbate vitamin B12 deficiency and neurologic symptoms by further impairing methionine synthesis and S-adenosylmethionine synthesis
D.) Switch to regional anesthesia to avoid systemic anesthetics, as vitamin B12 deficiency does not impact neurologic function with this approach

Answer 19

C.) Avoid the use of nitrous oxide due to its potential to exacerbate vitamin B12 deficiency and neurologic symptoms by further impairing methionine synthesis and S-adenosylmethionine synthesis

Question 20

A 45-year-old patient with a history of acquired aplastic anemia, attributed to long-term exposure to tricyclic antidepressants, is scheduled for elective surgery. Given the condition’s impact on bone marrow function, which of the following is the most appropriate preoperative evaluation and management strategy?

A.) Administer erythropoiesis-stimulating agents (ESAs) alone to address pancytopenia, as they are effective in all cases of bone marrow suppression
B.) Avoid antibiotic prophylaxis to reduce the risk of antibiotic resistance, regardless of neutropenia severity
C.) Discontinue all transfusions and rely on corticosteroids to boost bone marrow function preoperatively
D.) Assess the severity of anemia and thrombocytopenia to determine the need for transfusion support and antibiotic coverage, and consider the use of granulocyte colony-stimulating factor (G-CSF) to increase neutrophil counts if severe neutropenia is present

Answer 20

D.) Assess the severity of anemia and thrombocytopenia to determine the need for transfusion support and antibiotic coverage, and consider the use of granulocyte colony-stimulating factor (G-CSF) to increase neutrophil counts if severe neutropenia is present

Question 21

A pediatric patient with type II congenital methemoglobinemia, characterized by a systemic deficiency of cytochrome b5 reductase, is scheduled for a minor surgical procedure. Given the nature of the methemoglobinemia, which of the following treatment approaches is most appropriate for managing this condition in the perioperative period?

A.) Administer methylene blue intravenously to reduce high levels of methemoglobin, utilizing the methemoglobin reductase system, and monitor for effectiveness with an intraarterial catheter measuring arterial blood gases and methemoglobin levels
B.) Do not administer methylene blue intravenously as the primary treatment, as it does not reduce methemoglobin levels regardless of enzyme deficiencies
C.) Use high-dose ascorbic acid as a rapid and definitive treatment for methemoglobinemia in place of methylene blue
D.) Avoid monitoring methemoglobin levels perioperatively, as clinical signs are sufficient to gauge the severity of methemoglobinemia

Answer 21

A.) Administer methylene blue intravenously to reduce high levels of methemoglobin, utilizing the methemoglobin reductase system, and monitor for effectiveness with an intraarterial catheter measuring arterial blood gases and methemoglobin levels

Question 22

An adult patient with acquired methemoglobinemia due to exposure to oxidizing agents is undergoing an elective procedure. With methemoglobin levels reported at 15%, and the patient showing mild symptoms of hypoxia, which of the following is the most appropriate management plan to ensure patient safety during anesthesia?

A.) Use methylene blue prophylactically in all patients undergoing elective procedures, regardless of methemoglobin levels
B.) Manage hypoxia by increasing the fraction of inspired oxygen (FiO2) alone, as methemoglobinemia does not require specific interventions
C.) Correct any acidosis, avoid exposure to known oxidizing agents such as local anesthetics like benzocaine and prilocaine, and closely monitor the electrocardiogram for signs of ischemia
D.) Administer benzocaine spray to manage airway irritation, as its local effect does not contribute to systemic methemoglobinemia

Answer 22

C.) Correct any acidosis, avoid exposure to known oxidizing agents such as local anesthetics like benzocaine and prilocaine, and closely monitor the electrocardiogram for signs of ischemia

Question 23

A 65-year-old patient with a diagnosis of polycythemia vera (PV), who has a history of thrombosis, is scheduled for major abdominal surgery. Considering the risks associated with PV, which of the following preoperative management strategies is most appropriate to minimize the risk of perioperative thrombosis and hemorrhage?

A.) Perform exchange transfusion preoperatively to replace red blood cells with plasma to reduce blood viscosity
B.) Conduct phlebotomy to reduce hematocrit (Hct) to below 45% and manage thrombocytosis, if present, to decrease platelet count to below 400,000/mm3. Continue low-dose aspirin therapy unless there is a specific contraindication due to high bleeding risk
C.) Avoid phlebotomy to prevent anemia and withhold all antiplatelet medications regardless of thrombosis history
D.) Focus solely on managing thrombocytosis and allow hematocrit levels to remain elevated to avoid delaying surgery

Answer 23

B.) Conduct phlebotomy to reduce hematocrit (Hct) to below 45% and manage thrombocytosis, if present, to decrease platelet count to below 400,000/mm3. Continue low-dose aspirin therapy unless there is a specific contraindication due to high bleeding risk

Question 24

A patient with secondary polycythemia due to chronic obstructive pulmonary disease (COPD) is undergoing a minor elective procedure. The patient’s hematocrit (Hct) is significantly elevated. What is the most appropriate anesthetic management plan for this patient to reduce the risk of perioperative complications?

A.) Evaluate the need for preoperative phlebotomy to reduce Hct and ensure optimal hydration to decrease blood viscosity and the potential for thrombotic and hemorrhagic complications
B.) Avoid preoperative hydration to prevent hemodilution, which could worsen tissue oxygen delivery during surgery
C.) Administer erythropoiesis-stimulating agents (ESAs) preoperatively to stabilize red blood cell production
D.) Delay surgery until hematocrit normalizes without intervention, as secondary polycythemia typically resolves quickly with rest

Answer 24

A.) Evaluate the need for preoperative phlebotomy to reduce Hct and ensure optimal hydration to decrease blood viscosity and the potential for thrombotic and hemorrhagic complications

Question 25

A patient with hemophilia, characterized by a deficiency in factor VIII, is scheduled for a minor surgical procedure. Understanding the hemostatic importance of the propagation phase, which the patient lacks, what is the most targeted approach to minimize bleeding risk during surgery?

A.) Administer factor IX concentrate to support coagulation, as factor IX can compensate for factor VIII deficiency
B.) Administer factor VIII concentrate to correct the specific deficiency and achieve adequate levels for surgery, supplemented by close monitoring of factor levels and bleeding signs postoperatively
C.) Rely on desmopressin (DDAVP) alone to manage Factor VIII deficiency, regardless of the severity of the hemophilia
D.) Use antifibrinolytic agents (e.g., tranexamic acid) without Factor VIII replacement, as they are sufficient to manage bleeding in hemophilia A

Answer 25

B.) Administer factor VIII concentrate to correct the specific deficiency and achieve adequate levels for surgery, supplemented by close monitoring of factor levels and bleeding signs postoperatively

Question 26

A clinical research team is evaluating the relevance of the traditional cascade model versus the new coagulation model for developing improved guidelines for managing coagulation disorders. Given the distinct perspectives offered by the cascade and new coagulation models, which of the following research objectives is most appropriate for directly contrasting these models in the context of patient care?

A.) Compare patient outcomes using platelet function tests alone, as platelet activity fully represents the initiation and propagation phases of coagulation
B.) Evaluate the role of genetic testing in diagnosing coagulation disorders without considering the functional assessments emphasized by the new coagulation model
C.) Focus solely on PT and aPTT for all coagulation assessments, as these tests are sufficient for evaluating the propagation phase and overall thrombin generation
D.) Assess patient outcomes using traditional PT and aPTT monitoring to guide anticoagulant therapy, as suggested by the cascade model, versus a comprehensive coagulation assessment including thrombin generation assays, to reflect the new model’s emphasis on the propagation phase

Answer 26

D.) Assess patient outcomes using traditional PT and aPTT monitoring to guide anticoagulant therapy, as suggested by the cascade model, versus a comprehensive coagulation assessment including thrombin generation assays, to reflect the new model’s emphasis on the propagation phase

Question 27

A patient with a known severe deficiency of factor X is scheduled for an elective orthopedic surgery that carries a significant risk of blood loss. Considering the available treatment options and the goal of optimizing coagulation status preoperatively, which of the following approaches is most appropriate?

A.) Administer fresh frozen plasma (FFP) alone to correct factor X deficiency, as it is the safest and most effective way to achieve high factor X levels
B.) Administer factor X concentrate preoperatively to achieve factor levels of 50% or more, monitoring closely for potential thrombotic complications associated with concentrate use
C.) Use desmopressin (DDAVP) to increase endogenous factor X levels preoperatively, as it is effective for severe factor X deficiency
D.) Delay surgery until the patient’s factor X levels normalize spontaneously, as factor X deficiency rarely causes significant surgical bleeding

Answer 27

B.) Administer factor X concentrate preoperatively to achieve factor levels of 50% or more, monitoring closely for potential thrombotic complications associated with concentrate use

Question 28

A patient with a severe factor V deficiency is scheduled for a procedure known to have a moderate risk of bleeding. Given the absence of specific factor V concentrates and the patient’s coagulation disorder, which of the following management plans is most suitable to ensure hemostatic stability during and after the surgery?

A.) Administer cryoprecipitate preoperatively, as it is the most concentrated source of factor V and minimizes the risk of volume overload
B.) Use recombinant factor V concentrate to raise factor V levels, as it is the safest and most effective way to correct the deficiency
C.) Administer fresh frozen plasma (FFP) at a dose of 15 to 20 mL/kg to achieve a 20% to 30% increase in factor V levels, with close moni- toring for signs of volume overload and repeated infusions as needed based on the half-life of factor V
D.) Avoid prophylactic treatment and monitor for bleeding during the procedure, intervening with factor V replacement only if significant bleeding occurs

Answer 28

C.) Administer fresh frozen plasma (FFP) at a dose of 15 to 20 mL/kg to achieve a 20% to 30% increase in factor V levels, with close moni- toring for signs of volume overload and repeated infusions as needed based on the half-life of factor V

Question 29

A patient with factor XI deficiency and a history of mild bleeding episodes is scheduled for an extensive dental surgery. Considering the potential for bleeding associated with factor XI deficiency, which of the following approaches is the most appropriate to minimize the risk of perioperative bleeding?

A.) Avoid antifibrinolytic agents due to their limited role in managing bleeding risk for dental procedures in patients with factor XI deficiency
B.) Use desmopressin (DDAVP) as a first-line treatment for all patients with factor XI deficiency, as it universally raises factor XI levels
C.) Administer fresh frozen plasma (FFP) routinely for all patients with factor XI deficiency, regardless of severity or bleeding history
D.) Administer antifibrinolytic agents, such as tranexamic acid or μ-aminocaproic acid (EACA), prior to the procedure, and reserve factor XI concentrates for patients with severe deficiency or history of major bleeding

Answer 29

D.) Administer antifibrinolytic agents, such as tranexamic acid or μ-aminocaproic acid (EACA), prior to the procedure, and reserve factor XI concentrates for patients with severe deficiency or history of major bleeding

Question 30

A patient with severe hemophilia A and high-titer inhibitors is scheduled for major orthopedic surgery. Given the presence of inhibitors that render factor VIII concentrates ineffective, which of the following management strategies is most appropriate to ensure hemostasis during and after the procedure?

A.) Administer high-dose factor VIII concentrates preoperatively, as higher doses can overcome the inhibitory effect of high-titer inhibitors
B.) Use desmopressin (DDAVP) to boost endogenous factor VIII levels, as it is effective in severe hemophilia A with inhibitors
C.) Use recombinant factor VIIa (NovoSeven) or activated pro- thrombin complex concentrates (FEIBA) preoperatively to bypass the inhibited coagulation factor pathway, monitoring closely for efficacy and potential thrombotic complications
D.) Use antifibrinolytic agents like tranexamic acid to control bleeding, as bypassing agents are unnecessary for major surgery

Answer 30

C.) Use recombinant factor VIIa (NovoSeven) or activated pro- thrombin complex concentrates (FEIBA) preoperatively to bypass the inhibited coagulation factor pathway, monitoring closely for efficacy and potential thrombotic complications

Question 31

A patient with mild hemophilia B, characterized by factor IX levels between 5% and 40%, is scheduled for a minor outpatient procedure. Given the specific nature of hemophilia B and the planned surgical intervention, which of the following anesthesia management strategies is the most suitable to ensure patient safety and minimize bleeding risk?

A.) Rely solely on desmopressin (DDAVP) to increase Factor IX levels preoperatively, as it effectively boosts clotting factors in hemophilia B patients
B.) Administer a low dose of recombinant factor IX product or purified factor IX concentrate preoperatively to increase factor IX levels above 50% for the procedure, with post- operative monitoring of factor IX levels to guide further administration if necessary
C.) Avoid administering Factor IX preoperatively and instead monitor for bleeding during the procedure, providing transfusions only if bleeding occurs
D.) Use fresh frozen plasma (FFP) instead of Factor IX concentrate, as it provides sufficient levels of Factor IX and avoids the need for specific factor replacement

Answer 31

B.) Administer a low dose of recombinant factor IX product or purified factor IX concentrate preoperatively to increase factor IX levels above 50% for the procedure, with post- operative monitoring of factor IX levels to guide further administration if necessary

Question 32

A patient with thrombocytopenia due to a chronic bone marrow disorder is scheduled for elective neurosurgery. Given the risks associated with the specific type of surgery and the patient’s hematologic condition, which of the following platelet transfusion thresholds is most appropriate to minimize the risk of perioperative hemorrhage?

A.) Increase the platelet count to 20,000/mm³ preoperatively, as this threshold sufficiently reduces the risk of spontaneous bleeding in most surgical cases
B.) Avoid platelet transfusions preoperatively, as chronic bone marrow disorders will cause rapid consumption of transfused platelets
C.) Maintain a platelet count of 50,000/mm³ preoperatively, as this level is adequate for all types of surgical procedures, including neurosurgery
D.) Increase the platelet count to approximately 100,000/mm3 preoperatively to mitigate the risk of bleeding into a closed space such as the cranium, adhering to the higher threshold recommended for neurosurgical procedures

Answer 32

D.) Increase the platelet count to approximately 100,000/mm3 preoperatively to mitigate the risk of bleeding into a closed space such as the cranium, adhering to the higher threshold recommended for neurosurgical procedures

Question 33

A pediatric patient diagnosed with Hemolytic Uremic Syndrome (HUS) secondary to an Escherichia coli infection is scheduled for an urgent surgical intervention due to complications related to HUS. With the patient exhibiting thrombocytopenia and acute renal failure, what is the most appropriate perioperative management strategy to address the thrombocytopenia?

A.) Administer supportive treatment, including fluids and potentially platelet transfusions if thrombocytopenia is severe, while carefully monitoring renal function and avoiding procedures that may exacerbate renal injury
B.) Use anticoagulant therapy to prevent microthrombi formation, as thrombocytopenia in HUS is primarily due to excessive clotting
C.) Delay all surgical interventions until platelet counts normalize, as thrombocytopenia contraindicates any form of surgery in HUS patients
D.) Administer high-dose corticosteroids to address thrombocytopenia and renal failure, as they are effective in managing HUS complications

Answer 33

A.) Administer supportive treatment, including fluids and potentially platelet transfusions if thrombocytopenia is severe, while carefully monitoring renal function and avoiding procedures that may exacerbate renal injury

Question 34

A pregnant patient presenting with HELLP syndrome, characterized by hemolysis, elevated liver enzymes, and a low platelet count, requires an emergency cesarean section. Considering the unique challenges posed by HELLP syndrome in the perioperative period, which of the following anesthetic management strategies is most suitable to ensure maternal and fetal safety during the procedure?

A.) Always opt for general anesthesia to avoid the risk of bleeding complications associated with regional anesthesia, regardless of platelet count or coagulation status.
B.) Delay the cesarean section until the platelet count normalizes with transfusions, as immediate delivery is not necessary in HELLP syndrome
C.) Use regional anesthesia without evaluating coagulation parameters, as regional techniques are safer for both mother and baby in all cases of HELLP syndrome.
D.) Employ an assessment of the patient’s coagulation status, including platelet count and liver function tests, to guide the choice between regional and general anesthesia, with a preference for regional anesthesia if the patient’s condition allows

Answer 34

D.) Employ an assessment of the patient’s coagulation status, including platelet count and liver function tests, to guide the choice between regional and general anesthesia, with a preference for regional anesthesia if the patient’s condition allows

Question 35

A patient scheduled for elective surgery is diagnosed with HIT type 2 after developing thrombocytopenia and a positive anti-platelet factor 4–heparin antibody test during heparin therapy. Given the implications of HIT type 2 on perioperative management, which of the following is the most appropriate approach to minimize the risk of thrombosis while managing thrombocytopenia?

A.) Switch to low-molecular-weight heparin (LMWH) for anticoagulation, as LMWH has a lower risk of causing HIT compared to unfractionated heparin.
B.) Discontinue all forms of heparin immediately and initiate anticoagulation with a direct thrombin inhibitor or a factor Xa inhibitor while closely monitoring the platelet count and adjusting the anticoagulation regimen based on the patient’s recovery and surgical timing
C.) Delay all anticoagulation until the platelet count returns to normal, to avoid the risk of bleeding during surgery
D.) Administer high-dose corticosteroids to rapidly increase platelet counts and manage thrombosis risk associated with HIT type 2

Answer 35

B.) Discontinue all forms of heparin immediately and initiate anticoagulation with a direct thrombin inhibitor or a factor Xa inhibitor while closely monitoring the platelet count and adjusting the anticoagulation regimen based on the patient’s recovery and surgical timing

Question 36

A patient with a history of HIT type 2, now in remission with no detectable HIT antibodies, is scheduled for an urgent coronary artery bypass graft (CABG) surgery. Considering the patient’s history and the urgency of the surgery, which of the following management plans is most appropriate to ensure safe anticoagulation during cardiopulmonary bypass?

A.) Use argatroban for anticoagulation during cardiopulmonary bypass, as it provides long-lasting inhibition of thrombin and is primarily cleared by the kidneys, making it suitable for patients with impaired liver function
B.) Rely on warfarin therapy initiated preoperatively to manage anticoagulation during CPB, as it prevents thrombin generation effectively
C.) Use bivalirudin for anticoagulation during cardiopulmonary bypass, as it directly inhibits thrombin without the risk of activating HIT antibodies, ensuring a safer alternative for patients with a history of HIT type 2
D.) Administer low-molecular-weight heparin (LMWH) for anticoagulation, as it carries a lower risk of HIT reactivation compared to unfractionated heparin

Answer 36

C.) Use bivalirudin for anticoagulation during cardiopulmonary bypass, as it directly inhibits thrombin without the risk of activating HIT antibodies, ensuring a safer alternative for patients with a history of HIT type 2

Question 37

A patient with type 1 vWD scheduled for a dental extraction has baseline vWF and factor VIII levels of 15 IU/dL. Considering the type of vWD and the planned minor surgical procedure, which of the following management strategies is most suitable to ensure adequate hemostasis?

A.) Administer desmopressin (DDAVP) intravenously at a dose of 0.3 g/kg to stimulate the release of endogenous vWF and factor VIII, improving platelet function and minimizing bleeding risks associated with the dental extraction
B.) Administer factor VIII concentrate alone, as factor VIII replacement fully addresses the bleeding risk associated with type 1 vWD
C.) Rely solely on antifibrinolytic therapy with tranexamic acid, as it is sufficient to control bleeding without the need for vWF replacement
D.) Use fresh frozen plasma (FFP) to replace clotting factors, as it contains adequate amounts of vWF and eliminates the need for DDAVP

Answer 37

A.) Administer desmopressin (DDAVP) intravenously at a dose of 0.3 g/kg to stimulate the release of endogenous vWF and factor VIII, improving platelet function and minimizing bleeding risks associated with the dental extraction

Question 38

For a patient with type 3 vWD experiencing severe bleeding and scheduled for major orthopedic surgery, which of the following approaches is most appropriate to manage the bleeding and ensure hemostatic stability during and after the operation?

A.) Administer desmopressin (DDAVP) preoperatively and postoperatively, as it effectively releases endogenous vWF and factor VIII stores to manage severe bleeding in type 3 vWD patients
B.) Use antifibrinolytic agents like tranexamic acid alone to manage bleeding, since clot stabilization is sufficient for patients with complete vWF deficiency undergoing major surgery
C.) Administer vWF concentrates to provide the missing vWF and factor VIII, ensuring adequate levels of these crucial clotting factors for the surgery and the postoperative period, with close monitoring of response and adjustment of doses as needed
D.) Rely solely on fresh frozen plasma (FFP) to replace clotting factors during surgery, as it contains all necessary factors and avoids the need for specific vWF concentrates

Answer 38

C.) Administer vWF concentrates to provide the missing vWF and factor VIII, ensuring adequate levels of these crucial clotting factors for the surgery and the postoperative period, with close monitoring of response and adjustment of doses as needed

Question 39

A patient with type 2A vWD is undergoing elective abdominal surgery. Given the qualitative defect in plasma vWF characteristic of type 2A vWD, which involves a reduction in the number of large vWF multimers, what is the optimal preoperative preparation to manage the patient’s bleeding risk?

A.) Administer desmopressin (DDAVP) alone to increase endogenous vWF levels, regardless of the patient’s subtype
B.) Utilize vWF concentrates that contain both vWF and factor VIII to ensure the presence of functional vWF multimers and adequate factor VIII levels, tailored to the patient’s specific vWD subtype and severity of the defect
C.) Use factor VIII concentrate alone, as factor VIII replacement is sufficient to address the bleeding risk associated with vWD
D.) Rely on antifibrinolytic agents (e.g., tranexamic acid) without vWF replacement, as they can fully manage bleeding risk in type 2A vWD

Answer 39

B.) Utilize vWF concentrates that contain both vWF and factor VIII to ensure the presence of functional vWF multimers and adequate factor VIII levels, tailored to the patient’s specific vWD subtype and severity of the defect

Question 40

In a patient with hereditary antithrombin (AT) III deficiency undergoing surgery, which of the following strategies is critical to minimizing the risk of venous thromboembolism (VTE) while ensuring hemostasis is maintained throughout the perioperative period?

A.) Rely on mechanical VTE prophylaxis measures, such as sequential compression devices, avoiding the use of AT III concentrates because hereditary AT III deficiency does not significantly impact the risk of perioperative thrombosis
B.) Implement aggressive fluid hydration as the primary strategy for thrombosis prevention
C.) Initiate high-dose unfractionated heparin without AT III supplementation, recognizing that standard anticoagulation alone is sufficient to manage the thrombotic risk associated with hereditary AT III deficiency
D.) Administer AT III concentrates to maintain AT III levels above 80% until 5 days after surgery, alongside standard VTE prophylaxis measures, due to the patient’s significantly elevated risk of thrombosis related to hereditary AT III deficiency

Answer 40

D.) Administer AT III concentrates to maintain AT III levels above 80% until 5 days after surgery, alongside standard VTE prophylaxis measures, due to the patient’s significantly elevated risk of thrombosis related to hereditary AT III deficiency

Question 41

In a patient heterozygous for Factor V Leiden undergoing elective orthopedic surgery, which of the following perioperative anticoagulation strategies is most appropriate to mitigate the increased risk of VTE associated with this genetic condition?

A.) Use aspirin alone for VTE prophylaxis, as it provides sufficient protection for patients with Factor V Leiden
B.) Delay initiating anticoagulation until postoperative day 3 to avoid interfering with surgical hemostasisC.) Rely solely on mechanical prophylaxis with compression stockings, as pharmacologic prophylaxis is unnecessary for heterozygous Factor V Leiden
D.) Initiate prophylactic anticoagulation with low-molecular-weight heparin (LMWH) preoperatively and continue postoperatively, considering the patient’s 5- to 7-fold increased risk of VTE due to heterozygous Factor V Leiden mutation

Answer 41

D.) Initiate prophylactic anticoagulation with low-molecular-weight heparin (LMWH) preoperatively and continue postoperatively, considering the patient’s 5- to 7-fold increased risk of VTE due to heterozygous Factor V Leiden mutation

Question 42

For a patient with a prothrombin gene mutation scheduled for a major abdominal surgery, which of the following is the most appropriate perioperative management plan to address the elevated thrombotic risk associated with this condition?

A.) Use aspirin alone for VTE prophylaxis, as it is sufficient to address thrombotic risk associated with prothrombin gene mutation.
B.) Delay initiation of VTE prophylaxis until postoperative day 3 to avoid interference with surgical hemostasis
C.) Ensure rigorous VTE prophylaxis using LMWH initiated preoperatively and extended postoperatively, due to the elevated levels of prothrombin and resultant increased thrombotic risk from the prothrombin gene mutation
D.) Avoid LMWH to minimize bleeding risk and rely solely on mechanical prophylaxis with compression stockings

Answer 42

C.) Ensure rigorous VTE prophylaxis using LMWH initiated preoperatively and extended postoperatively, due to the elevated levels of prothrombin and resultant increased thrombotic risk from the prothrombin gene mutation

Question 43

In the perioperative management of a patient with essential thrombocythemia undergoing hip replacement surgery, which of the following approaches best addresses the risk of both thrombotic and hemorrhagic complications inherent to this myeloproliferative disorder?

A.) Perform preoperative platelet transfusion to stabilize platelet function and reduce bleeding risk during surgery
B.) Use of LMWH and close monitoring for signs of hemorrhage, due to the elevated thrombotic risk from essential thrombocythemia and the potential for an acquired von Willebrand syndrome causing bleeding
C.) Rely solely on aspirin therapy for thromboprophylaxis, regardless of the patient’s platelet count or thrombotic history
D.) Discontinue all anticoagulation to avoid bleeding, as the risk of hemorrhage outweighs thrombotic concerns in essential thrombocythemia

Answer 43

B.) Use of LMWH and close monitoring for signs of hemorrhage, due to the elevated thrombotic risk from essential thrombocythemia and the potential for an acquired von Willebrand syndrome causing bleeding

Question 44

Considering the prothrombotic tendency associated with antiphospholipid antibody syndrome, which of the following is the most appropriate management strategy for a patient with this condition requiring lower limb surgery under regional anesthesia?

A.) Forego regional anesthesia entirely, based on the data showing that antiphospholipid antibody syndrome categorically contraindicates the use of any form of neuraxial block due to a significant risk of spinal hematoma
B.) Utilize regional anesthesia without any modification to existing anticoagulation therapy, this highlights the importance of anticoagulant timing to prevent both thrombotic events and potential complications from the neuraxial block
C.) Proceed with regional anesthesia, ensuring that anticoagulation therapy is appropriately managed in the perioperative period to mitigate the risk of thrombosis, while adhering to guidelines on the timing of anticoagulant cessation and resumption in relation to neuraxial block placement and removal
D.) Opt for general anesthesia, recognizing the potential risks and lack of feasibility of regional anesthesia in patients with antiphospholipid antibody syndrome

Answer 44

C.) Proceed with regional anesthesia, ensuring that anticoagulation therapy is appropriately managed in the perioperative period to mitigate the risk of thrombosis, while adhering to guidelines on the timing of anticoagulant cessation and resumption in relation to neuraxial block placement and removal

Question 45

For a patient with a history of treatment with doxorubicin presenting for elective non-cardiac surgery, what is the most prudent approach to manage the risk of anthracycline-induced cardiotoxicity?

A.) Obtain a preoperative echocardiogram to assess left ventricular function, given the patient’s history of exposure to anthracyclines and the potential for both acute and chronic cardiotoxicity, ensuring that any cardiac dysfunction is identified and managed appropriately before proceeding with surgery
B.) Proceed with surgery without any preoperative cardiac assessment due to the lack of current cardiac symptoms which negates the risk of anthracycline-induced cardiac complications
C.) Focus solely on monitoring for acute dysrhythmias intraoperatively, not the potential for chronic cardiotoxicity and left ventricular dysfunction which does not manifest immediately
D.) Prescribe prophylactic dexrazoxane immediately before surgery, misunderstanding its role as a preoperative prophylactic measure for patients with past anthracycline exposure

Answer 45

A.) Obtain a preoperative echocardiogram to assess left ventricular function, given the patient’s history of exposure to anthracyclines and the potential for both acute and chronic cardiotoxicity, ensuring that any cardiac dysfunction is identified and managed appropriately before proceeding with surgery

Question 46

In planning anesthesia for a patient with a diagnosed solid tumor, how does the use of the TNM staging system influence perioperative care?

A.) Relying exclusively on the patient’s physical symptoms to determine the anesthesia plan, disregarding the TNM stage as it is considered irrelevant to perioperative management and focuses only on postoperative oncological treatment
B.) Assuming all solid tumors present with the same perioperative risks regardless of their TNM stage, thereby simplifying the anesthesia plan to a one-size-fits-all approach without individualized consideration for tumor spread or prognosis
C.) Utilizing the TNM staging system allows for a detailed assessment of the tumor’s size, lymph node involvement, and presence of metastases, aiding in the development of a nuanced anesthesia plan that accounts for potential complications related to tumor invasiveness and metastatic spread
D.) Treating the TNM staging as a static assessment that does not require reevaluation, underestimating the dynamic nature of cancer progression and the potential impact of changing tumor characteristics on anesthesia management

Answer 46

C.) Utilizing the TNM staging system allows for a detailed assessment of the tumor’s size, lymph node involvement, and presence of metastases, aiding in the development of a nuanced anesthesia plan that accounts for potential complications related to tumor invasiveness and metastatic spread

Question 47

When planning regional anesthesia for a patient who has received cisplatin chemotherapy, what is the most critical factor to consider for minimizing the risk of exacerbating neurotoxicity?

A.) Recognizing all patients treated with cisplatin are at an equal risk of severe immediate neurotoxic reactions to local anesthetics, regardless of their individual clinical presentations or the time elapsed since their last chemotherapy treatment
B.) Recognizing that subclinical neurotoxicity may be present in patients treated with cisplatin, thus necessitating a cautious approach to regional anesthesia to avoid further nerve damage
C.) Prioritizing the use of high-dose local anesthetics in all patients who have undergone chemotherapy with cisplatin, recognizing that higher doses are required to achieve effective nerve blockade in the presence of chemotherapy-induced peripheral neuropathy
D.) Recognizing the patient’s chemotherapy history when selecting anesthetic techniques, including the choice and dose of local anesthetic, as chemotherapy-induced changes are known to have minimal impact on the efficacy or safety of regional anesthesia

Answer 47

B.) Recognizing that subclinical neurotoxicity may be present in patients treated with cisplatin, thus necessitating a cautious approach to regional anesthesia to avoid further nerve damage

Question 48

In planning anesthesia for a patient who has undergone treatment with chemotherapeutic agents known for pulmonary toxicity, such as bleomycin, what factor is most crucial to consider for minimizing perioperative pulmonary complications?

A.) Minimizing the inspired oxygen concentration to maintain oxygen saturation between 90% and 92% is crucial due to the heightened risk of exacerbating preexisting bleomycin-induced lung injury
B.) Prioritizing high concentrations of inspired oxygen because of a patient’s history of bleomycin therapy, as the potential benefits of oxygen therapy decrease the risks of exacerbating pulmonary toxicity in the perioperative setting
C.) Focusing exclusively on mechanical ventilation parameters with no consideration for the patient’s chemotherapeutic history, as previous treatments have negligible impact on perioperative lung function
D.) Recognizing that all patients with a history of chemotherapy require invasive ventilation during surgery, regardless of their current pulmonary function or specific history with bleomycin and other pulmonary toxic agents

Answer 48

A.) Minimizing the inspired oxygen concentration to maintain oxygen saturation between 90% and 92% is crucial due to the heightened risk of exacerbating preexisting bleomycin-induced lung injury

Question 49

A 16-year-old patient with recently diagnosed acute lymphoblastic leukemia presents for emergent surgery due to a bowel obstruction. They received their first cycle of chemotherapy two days ago. Preoperatively, the patient is noted to be lethargic with an irregular pulse. Lab results show potassium of 6.5 mEq/L, calcium of 7.2 mg/dL, phosphorus elevated, and uric acid of 12 mg/dL. The patient’s creatinine is also elevated from baseline. In the context of this clinical scenario, what is the most likely complication the patient is experiencing?

A.) Acute renal failure of unknown etiology, with secondary electrolyte imbalances that are not related to the patient’s recent chemotherapy or underlying leukemia diagnosis
B.) Primary hyperparathyroidism, characterized by hypercalcemia leading to downstream effects on potassium and uric acid levels
C.) A typical response to chemotherapy, where electrolyte imbalances are expected and transient, requiring minimal intervention beyond standard hydration and supportive care
D.) Tumor lysis syndrome, evidenced by hyperkalemia, hypocalcemia, hyperphosphatemia, elevated uric acid, and acute renal failure, likely triggered by recent chemotherapy administration

Answer 49

D.) Tumor lysis syndrome, evidenced by hyperkalemia, hypocalcemia, hyperphosphatemia, elevated uric acid, and acute renal failure, likely triggered by recent chemotherapy administration

Question 50

A 58-year-old patient with a history of lung cancer presents to the emergency department with facial and upper extremity edema, distended neck veins, and dyspnea. The patient reports experiencing worsening symptoms over the past week. Upon examination, increased intracranial pressure is suspected due to the patient’s nausea and altered level of consciousness. The patient’s history and symptoms suggest a specific complication related to their cancer. What is the most likely diagnosis?

A.) Central venous thrombosis, with symptoms including localized swelling, pain in the affected area, and possible dyspnea
B.) Acute heart failure, which can present with dyspnea, edema, and fatigue
C.) Lymphatic obstruction, which might cause localized or generalized edema
D.) Superior vena cava syndrome, characterized by obstruction of the superior vena cava, leading to venous congestion in the upper body

Answer 50

D.) Superior vena cava syndrome, characterized by obstruction of the superior vena cava, leading to venous congestion in the upper body

Question 51

A 65-year-old patient with a known history of prostate cancer reports severe back pain, progressive weakness in the legs, and difficulty urinating. The patient mentions that the symptoms have gradually worsened over the past month. On physical examination, there is noticeable weakness in the lower extremities, reduced sensation below the waist, and hyperreflexia. Given the patient’s cancer history and current symptoms, what is the most likely diagnosis?

A.) Acute lumbar disc herniation, which can cause back pain and sciatica, typically presenting with unilateral leg pain and possible motor weakness
B.) Spinal cord compression, likely due to metastatic lesions in the epidural space from the patient’s prostate cancer
C.) Multiple sclerosis, a chronic autoimmune condition that affects the central nervous system, leading to symptoms like muscle weakness, sensory changes, and autonomic dysfunction
D.) Peripheral neuropathy, which involves damage to the peripheral nerves and can cause weakness, numbness, and pain, usually in the hands and feet

Answer 51

B.) Spinal cord compression, likely due to metastatic lesions in the epidural space from the patient’s prostate cancer

Question 52

Considering the immunomodulatory properties of anesthetics in a patient undergoing surgery for breast cancer, which anesthetic technique would be MOST appropriate to potentially reduce the risk of tumor progression?

A.) General anesthesia with volatile agents
B.) High-dose opioid-based anesthesia without regional techniques
C.) Regional anesthesia supplemented with minimal opioid analgesia
D.) Exclusive use of nitrous oxide for analgesia and sedation

Answer 52

C.) Regional anesthesia supplemented with minimal opioid analgesia

Question 53

A patient with a recent diagnosis of small cell lung cancer presents for preoperative evaluation before undergoing lung resection. They report muscle weakness that improves with use. Given the suspicion of a paraneoplastic syndrome, which of the following assessments is MOST critical to accurately distinguish between Lambert-Eaton myasthenic syndrome (LEMS) and myasthenia gravis (MG) for tailored anesthesia management?

A.) Serum acetylcholine receptor (AChR) antibodies to distinguish between LEMS and myasthenia gravis (MG)
B.) Chest CT scan to check for a thymoma or lung mass
C.) Edrophonium (Tensilon) test to diagnose MG
D.) Electromyography (EMG) with repetitive nerve stimulation testing

Answer 53

D.) Electromyography (EMG) with repetitive nerve stimulation testing

Question 54

A patient scheduled for major abdominal surgery has been on 10 mg of prednisone daily for 4 months due to a chronic inflammatory condition. Considering the risk of adrenal suppression, which preoperative intervention is MOST appropriate?

A.) Administer hydrocortisone 50 mg IV at induction, followed by 25 mg IV every 8 hours for 24 hours
B.) Administer hydrocortisone 100 mg IV at induction of anesthesia only
C.) Administer hydrocortisone 100 mg IV at induction followed by 100 mg IV every 8 hours for the first 24 hours
D.) No additional steroid supplementation is needed due to the low dose of prednisone

Answer 54

C.) Administer hydrocortisone 100 mg IV at induction followed by 100 mg IV every 8 hours for the first 24 hours

Question 55

In evaluating a lung cancer patient’s readiness for lobectomy, which assessment provides the MOST critical insight into postoperative respiratory risk?

A.) Diffusing capacity of the lungs for carbon monoxide (DLCO) to assess gas exchange
B.) Preoperative spirometry to measure Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 second (FEV1)
C.) Arterial blood gas (ABG) analysis to evaluate oxygenation and acid-base status
D.) Complete pulmonary function tests (PFTs), including lung volumes and airway resistance

Answer 55

B.) Preoperative spirometry to measure Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 second (FEV1)

Question 56

A patient with colorectal cancer and moderate anemia is scheduled for surgical resection. To minimize perioperative risk, which management strategy is MOST appropriate?

A.) Administer intraoperative blood transfusions as needed based on real-time hemodynamic monitoring
B.) Proceed with surgery without preoperative intervention, relying on postoperative transfusion to correct anemia
C.) Utilize cell salvage and minimize intraoperative blood loss to reduce the need for transfusion
D.) Optimize hemoglobin levels preoperatively through iron supplementation or erythropoiesis-stimulating agents (ESAs), if indicated, based on the cause of anemia

Answer 56

D.) Optimize hemoglobin levels preoperatively through iron supplementation or erythropoiesis-stimulating agents (ESAs), if indicated, based on the cause of anemia

Question 57

A patient with medullary thyroid cancer, potentially associated with multiple endocrine neoplasia type 2, is scheduled for total thyroidectomy. Given the increased risk of pheochromocytoma, which preoperative evaluation and anesthetic plan is MOST critical to ensure patient safety?

A.) Routine preoperative evaluation without specific screening for pheochromocytoma, with an emphasis on rapid sequence induction to prevent aspiration
B.) A primary focus on minimizing the use of neuromuscular blocking agents to avoid exacerbating potential hypercalcemia related to medullary thyroid cancer
C.) Comprehensive preoperative screening for pheochromocytoma with plasma-free metanephrines or 24-hour urinary metanephrines, followed by an anesthetic plan that includes preparations for managing hypertensive crises
D.) Prioritization of thyroid hormone levels adjustment over pheochromocytoma screening, with standard anesthetic care

Answer 57

C.) Comprehensive preoperative screening for pheochromocytoma with plasma-free metanephrines or 24-hour urinary metanephrines, followed by an anesthetic plan that includes preparations for managing hypertensive crises

Question 58

A patient with newly diagnosed Hodgkin lymphoma presents with a large anterior mediastinal mass for biopsy. Given the risk of airway and cardiovascular compression, which anesthetic approach is MOST appropriate?

A.) Awake fiberoptic intubation with the patient in a semi-upright position, maintaining spontaneous ventilation throughout the procedure
B.) General anesthesia with muscle relaxation and positive pressure ventilation, initiated after securing the airway with a rapid sequence induction
C.) Sedation and local anesthesia, assuming minimal risk of airway compromise due to the patient’s lack of respiratory symptoms
D.) Induction of general anesthesia in the supine position, using a volatile agent and assisted ventilation to ensure oxygenation

Answer 58

A.) Awake fiberoptic intubation with the patient in a semi-upright position, maintaining spontaneous ventilation throughout the procedure

Question 59

A patient with chronic myeloid leukemia in the accelerated phase is scheduled for splenectomy due to symptomatic splenomegaly. Which anesthetic management consideration is MOST crucial?

A.) Preparation for immediate postoperative mechanical ventilation, anticipating severe leukostasis affecting pulmonary function
B.) Exclusive use of regional anesthesia to avoid exacerbation of leukocyte count associated with general anesthesia
C.) Vigilant intraoperative management of potential massive blood loss due to hypersplenism and splenic sequestration
D.) Aggressive preoperative hydration to prevent tumor lysis syndrome, assuming it as the primary risk during splenectomy

Answer 59

C.) Vigilant intraoperative management of potential massive blood loss due to hypersplenism and splenic sequestration

Question 60

A patient who received allogeneic HSCT for acute lymphoblastic leukemia (ALL) presents with acute graft-versus-host disease affecting the skin and gastrointestinal tract, scheduled for endoscopic evaluation. Which anesthetic management strategy is MOST crucial?

A.) Exclusive focus on preventing skin breakdown during patient positioning, given the skin involvement in GVHD
B.) Comprehensive management of fluid and electrolyte imbalances due to gastrointestinal involvement of GVHD, ensuring hemodynamic stability during the procedure
C.) Use of high-dose corticosteroids intraoperatively to immediately address the inflammatory response associated with GVHD
D.) Implementation of a no-touch isolation technique to minimize the risk of infection transmission during anesthesia administration

Answer 60

B.) Comprehensive management of fluid and electrolyte imbalances due to gastrointestinal involvement of GVHD, ensuring hemodynamic stability during the procedure

Question 61

A pediatric patient with acute lymphoblastic leukemia and spinal cord compression is scheduled for emergency decompression surgery. Given the patient’s condition, which anesthetic consideration is MOST crucial?

A.) Aggressive management of potential intraoperative bleeding due to thrombocytopenia, including preoperative platelet transfusion to maintain platelet counts above a safe threshold
B.) Liberal use of crystalloid solutions to address dehydration, with minimal focus on coagulation status
C.) Primary focus on rapid sequence induction to prevent aspiration, with less emphasis on the hematologic status
D.) Emphasis on maintaining normothermia as the primary anesthetic goal, assuming it will minimize metabolic demands and improve outcomes

Answer 61

A.) Aggressive management of potential intraoperative bleeding due to thrombocytopenia, including preoperative platelet transfusion to maintain platelet counts above a safe threshold

Question 62

A patient with chronic myeloid leukemia (CML) in blast crisis with significant hyperleukocytosis is scheduled for leukapheresis. Considering the risk of leukostasis and pulmonary complications, which anesthetic approach is MOST appropriate?

A.) Prioritizing the use of regional anesthesia to avoid systemic effects of general anesthetics that might worsen leukostasis
B.) Focusing on aggressive diuresis preoperatively to reduce total leukocyte count before leukapheresis
C.) Emphasizing strict avoidance of any sedation that might depress respiratory effort, considering only local anesthetic techniques for vascular access
D.) Ensuring meticulous respiratory management, including the use of lung-protective ventilation strategies and readiness to manage pulmonary complications associated with hyperleukocytosis.

Answer 62

D.) Ensuring meticulous respiratory management, including the use of lung-protective ventilation strategies and readiness to manage pulmonary complications associated with hyperleukocytosis.

Question 63

A patient with chronic myeloid leukemia in blast crisis requires emergency abdominal surgery. Given the patient’s leukostasis and potential for tumor lysis syndrome, which anesthetic management is MOST crucial?

A.) Primary focus on leukapheresis before surgery to reduce leukocyte count, delaying surgical intervention until leukostasis is resolved
B.) Implementation of a strict low-potassium diet in the immediate preoperative period to preemptively manage hyperkalemia associated with tumor lysis syndrome
C.) Exclusive reliance on total intravenous anesthesia (TIVA) to avoid the potential exacerbation of blast crisis by volatile anesthetics
D.) Aggressive management of potential tumor lysis syndrome with hydration and allopurinol preoperatively, coupled with vigilant monitoring for metabolic derangements intraoperatively

Answer 63

D.) Aggressive management of potential tumor lysis syndrome with hydration and allopurinol preoperatively, coupled with vigilant monitoring for metabolic derangements intraoperatively