Neurointensive & Perioperative care

Question 1

1. Which one of the following statements regarding cerebral blood flow is LEAST accurate?
   a. Cerebral blood flow to white matter is
   approximately 25 ml/100 g/min
   b. Total cerebral blood flow is approximately 750 ml/min in adults
   c. Regional cerebral blood flow tends to
   track cerebral metabolic rate of oxygen
   consumption rather than cerebral metabolic rate of glucose consumption
   d. Cerebral blood flow to gray matter is
   approximately 80 ml/100 g/min
   e. Brain tissue accounts for 20% of basal
   oxygen consumption and 25% of basal
   glucose consumption

Answer 1

c—Regional cerebral blood flow tends to track cerebral metabolic rate of oxygen consumption rather than cerebral metabolic rate
of glucose consumption

Question 2

2. Which one of the following statements
   regarding intracranial compliance is LEAST
   accurate?
   a. Increase in the volume of one intracranial
   compartment will lead to a rise in ICP
   unless it is matched by an equal reduction
   in the volume of another compartment
   b. Cerebral compliance is equal to intracranial volume displaced divided by the resultant change in intracranial pressure
   c. CSF and CBV compartments normally
   represent a volume of approximately
   1400 ml
   d. Additional intracranial volume is initially
   accommodated with little or no change
   in ICP
   e. Once craniospinal buffering capacity is
   exhausted further small increases in intracranial volume lead to substantial rises
   in ICP

Answer 2

c—CSF and CBV compartments normally represent a volume of approximately 1400 ml

Question 3

3. Which one of the following statements
   regarding the intracranial pressure pulse
   waveform is most accurate?
   a. Percussion wave, which reflects the ejection of blood from the heart transmitted
   through the choroid plexus in the
   ventricles
   b. Third arterial wave is the percussion wave
   c. First wave is the tidal wave which reflects
   brain compliance
   d. Second wave is the dicrotic wave that
   reflects aortic valve closure
   e. Intracranial hypertension increase in the
   peak of the tidal and dicrotic waves

Answer 3

e—Intracranial hypertension increase in the peak of the tidal and dicrotic waves

Question 4

4. Regarding cerebral autoregulation in adults,
   which one of the following statements is
   LEAST accurate?
   a. Increasing hypoxia results in increasing
   cerebral blood flow
   b. Cerebral blood flow is relatively constant
   over a range of cerebral perfusion pressures from 50 to 150 mmHg
   c. Cerebral blood flow is directly proportional to cerebral perfusion pressure
   (CPP) when CPP is greater than
   150 mmHg or less than 50 mmHg
   d. A pCO2 of 4.0 kPa (30 mmHg) is associated with an average cerebral blood flow
   of approximately 50 ml/100 g/min
   e. Cerebral blood flow¼cerebral perfusion
   pressure/cerebral vascular resistance

Answer 4

d—A pCO2 of 4.0 kPa (30 mmHg) is associated with an average cerebral blood flow of approximately 50 ml/100 g/min (see graph)

Question 5

5. Which one of the following statements
   regarding control of cerebral vascular tone
   is LEAST accurate?
   a. CO2 causes vasoconstriction at low tensions in the blood, and vasodilatation at
   higher tensions
   b. Alpha2 and beta-1 adrenergic stimulation
   cause vasodilatation
   c. Prostaglandins PGE2 and PGI2 are
   vasodilators
   d. Increase in perivascular K+ causes
   vasodilatation
   e. Thromboxane A2 is a potent
   vasoconstrictor
   185

Answer 5

b—Alpha2 and beta-1 adrenergic stimulation
cause vasodilatation

Question 6

6. Maintenance of which one of the following
   requires the highest proportion of energy
   expenditure in the brain?
   a. Transmembrane electrical and ionic
   gradients
   b. Membrane structure and integrity
   c. Synthesis and release of neurotransmitters
   d. Neurogenesis
   e. Axonal transport

Answer 6

a—Transmembrane electrical and ionic
gradients

Question 7

7. Immediately below which one of the following regional cerebral blood flow values does
   the onset of infarction occur if sustained for
   more than 2-3 h?
   a. Less than 50 ml/100 g/min
   b. Less than 23 ml/100 g/min
   c. Less than 17 ml/100 g/min
   d. Less than 10 ml/100 g/min
   e. Less than 5 ml/100 g/min

Answer 7

c—Less than 17 ml/100 g/min

Question 8

8. Which one of the following statements regarding neuroprotection during anesthesia is LEAST accurate?
   a. Burst suppression must be achieved before any neuroprotective effects are seen with barbiturates
   b. Hyperglycemia exacerbates ischemic injury
   c. Mild hypothermia for low-grade aneurysm clipping and for head injury may not be of benefit
   d. Hyperthermia should be treated
   e. Volatile anesthetics reduce the vulnerability of the brain to ischemic injury

Answer 8

a—Burst suppression must be achieved
before any neuroprotective effects are seen
with barbiturates

Question 9

9. Which one of the following statements
   regarding successful strategies for cerebral
   protection during cerebrovascular surgery is
   LEAST accurate?
   a. For a given total vessel occlusion time,
   brief-repetitive occlusions rather than a
   longer-single occlusion where possible
   should be the goal
   b. Collateral blood flow can be increased by
   inducing hypertension (e.g. target MAP
   150 mmHg)
   c. Preoperative perfusion imaging to help
   identify patients who have low cerebrovascular reserve and may be at higher risk
   for iatrogenic ischemia
   d. Intraoperatively, vessel or graft patency
   can be confirmed by
   e. IHAST2 trial showed improvement in
   outcome for clipped ruptured aneurysms
   (WFNS1 and 2) given mild hypothermia
   compared to normothermia

Answer 9

e—IHAST2 trial showed improvement in
outcome for clipped ruptured aneurysms
(WFNS1 and 2) given mild hypothermia
compared to normothermia

Question 10

10. Which one of the following statements
    regarding the role of hypothermia in the
    management of traumatic brain injury is
    LEAST accurate?
    a. Eurotherm trial showed a significant
    increase in odds of unfavorable outcome
    but not death at 6 months in the mild
    hypothermia group
    b. Two trials of hypothermia therapy in children with TBI have shown no improvement in neurologic or other outcomes
    one pediatric trial showed a nonsignificant
    increase in mortality
    c. Eurotherm trial RCT included patients
    with TBI last 10 days and hypothermia
    was induced if the ICP climbed above
    20 mmHg for 5 min refractory to tier 1
    management
    d. Statistically significant increase in the odds
    of an unfavorable outcome in the group
    allocated to therapeutic hypothermia
    e. Statistically significant increase in the odds
    of death at 6 months (HR 1.45 (1.01-2.10))
    hence discontinued due to futility

Answer 10

a—Eurotherm trial showed a significant
increase in odds of unfavorable outcome
but not death at 6 months in the mild
hypothermia group

Question 11

11. A patient in the emergency department has
    been intubated and ventilated. CT head has
    shown a rightEDHwith significantmass effect.
    His right pupil is larger than the left and the
    anesthetist is concerned about hemodynamic
    instability. What ASA grade is this patient?
    a. 1
    b. 2
    c. 3
    d. 4
    e. 5
    f. 6

Answer 11

e—ASA 5

Question 12

12. A 27-year-old man undergoes general anesthesia for a hernia repair. As the anesthesia
    begins, his jaw muscles tense and he becomes
    generally rigid. He becomes febrile, tachycardic, and tachypneic. Which one of the following treatments is most appropriate?
    a. Atropine
    b. Procyclidine
    c. Succinylcholine
    d. Dantrolene
    e. Thiopental

Answer 12

d—Dantrolene

Question 13

13. Which one of the following is LEAST likely to
    be associated with massive blood transfusion?
    a. Iron overload
    b. Hyperkalemia
    c. Hypocalcemia
    d. Hypothermia
    e. Coagulopathy

Answer 13

a—Iron overload

Question 14

14. Which one of the following statements
    regarding intraoperative blood loss management techniques applied in patients refusing
    blood product transfusion is LEAST
    accurate?
    a. Meticulous attention to hemostasis and
    technical blood losses during surgery are
    not usually important
    b. Phlebotomy should be rationalized
    c. Jehovah’s witnesses generally accept prothrombin complex concentrate
    d. Intraoperative cell saver use should be
    considered if appropriate
    e. DDAVP (vasopressin) can be used as a
    procoagulant

Answer 14

c—Jehovah’s witnesses generally accept prothrombin complex concentrate

Question 15

15. Which one of the following statements
    regarding the oxygen-dissociation curve is
    LEAST accurate?
    a. It is sigmoidal due to cooperative binding
    of oxygen to hemoglobin
    b. The Bohr effect is a shift of the dissociation curve to the left
    c. Reducing pH shifts the oxygendissociation curve to the left
    d. The fetal oxygen-dissociation curve is
    shifted to the left reflecting the increased
    oxygen affinity of fetal hemoglobin caused
    by the presence of the gamma subunit of
    hemoglobin
    e. Increased temperature shifts the oxygendissociation curve to the left

Answer 15

b—The Bohr effect is a shift of the dissociation curve to the lef

Question 16

16. Which one of the following statements
    regarding mechanical ventilation is LEAST
    accurate?
    a. PEEP and CPAP aim to keep alveoli open
    during inspiration
    b. Delivery of machine breaths may be triggered by time or start of a patients spontaneous breath
    c. SIMV allows patients to breath spontaneously between machine breaths
    d. Patients with sufficient spontaneous
    respiratory drive can be managed with
    pressure support ventilation alone
    e. Tidal volume is usually calculated as
    6-8 ml/kg of ideal body weight

Answer 16

a—PEEP and CPAP aim to keep alveoli
open during inspiration

Question 17

17. A 70 kg man has lost 1.7 l of blood from a stab
    wound. Which one of the following is the
    LEAST likely to be showing?
    a. Respiratory rate 20-30
    b. Narrow pulse pressure
    c. Urine output 5-15 ml/h
    d. Confusion
    e. Pulse rate 120-140 bpm

Answer 17

a—Respiratory rate 20-30

Question 18

18. Which one of the following statements regarding shock is LEAST accurate?
    a. Cardiac tamponade is a cause of
    obstructive shock
    b. Sepsis can cause a distributive shock
    c. Spinal shock can cause bradycardia and
    hypotension
    d. Hypovolemic shock is managed with restoration of the circulating volume
    e. Neurogenic shock is due to peripheral
    vasoconstriction

Answer 18

e—Neurogenic shock is due to peripheral
vascoconstriction

Question 19

19. Which one of the following is the most
    appropriate approximate blood volume for
    a term neonate?
    a. 90-105 ml/kg
    b. 80-90 ml/kg
    c. 70-80 ml/kg
    d. 70 ml/kg
    e. 65 ml/kg

Answer 19

b—80-90 ml/kg

Question 20

20. A 44-year-old male sustains a major trauma
    and is found with vomitus in his airway at
    scene with a GCS on E2V2M4. Primary survey suggests isolated head injury and is admitted to intensive care for medical management
    of intracranial pressure. ICP is 19 mmHg
    therefore he is kept sedated and ventilated.
    On day 2 he starts to desaturate and CXR is
    performed. PaO2/FiO2 ratio is 113 mmHg
    (15 kPa). TTE is normal and there is no evidence of peripheral edema. Which one of the
    following is the most likely diagnosis?
    a. Lower respiratory tract infection
    b. ARDS
    c. ALI
    d. Congestive cardiac failure
    e. Hemopneumothorax

Answer 20

b—ARDS

Question 21

39. Anesthetic agents in NICU:
    a. Etomidate
    b. Halothane
    c. Isoflurane
    d. Ketamine
    e. Midazolam
    f. Opiates
    g. Propofol
    h. Sevoflurane
    i. Succinylcholine
    j. Vancuronium

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. Avoided in head injury patients due to rise
in CMRO2, CBF and ICP
2. Causes a decrease in CMRO2, CBF
and ICP
3. Anticonvulsant effect but no effect on
CMRO2, CBF and ICP

Answer 21

1—d, Ketamine, 2—g, Propofol; 3—e, Midazolam

Question 22

40. Bleeding diatheses:
    a. Antiplatelets
    b. Disseminated intravascular coagulation
    c. Factor V deficiency
    d. Glanzmann’s thrombasthenia
    e. Hemophilia
    f. Liver failure
    g. Thrombocytopenia
    h. Uremia
    i. Von Willebrand’s disease
    j. Warfarin or vitamin K deficiency

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. Normal PT, raised APTT, normal bleeding time, normal platelet count
2. Prolonged PT, prolonged APTT, prolonged bleeding time, reduced platelets
3. Normal PT, Normal APTT, prolonged
bleeding time, reduced platelets

Answer 22

1—e, Hemophilia, 2—b, Disseminated intravascular coagulation, 3—g, Thrombocytopenia

Question 23

41. Coagulation assays:
    a. APTT
    b. Bleeding time
    c. Dilute Russell’s viper venom time
    (aRVVT)
    d. Factor V Leiden
    e. Factor VII assay
    f. Factor VIII assay
    g. INR
    h. Mixing (50:50) test
    i. Platelet function assay
    j. Thrombin clotting time

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. Used to assess fibrinogen deficiency
2. Has largely been replaced by platelet function assays
3. Helpful to determine if prolonged PT or
aPTT is due to patient clotting factor deficiency or due to presence of clotting
inhibitors
4. Test for lupus anticoagulant

Answer 23

1—j, Thrombin clotting time, 2—b, Bleeding time, 3—h, 50:50 mixing study, 4—c, Dilute Russell’s
viper venom time

Question 24

42. Acid-base balance:
    a. Acute metabolic acidosis
    b. Acute metabolic alkalosis
    c. Acute respiratory acidosis
    d. Acute respiratory alkalosis
    e. Compensated metabolic acidosis
    f. Compensated respiratory acidosis
    g. Partially compensated metabolic acidosis
    h. Partially compensated metabolic alkalosis
    i. Partially compensated respiratory acidosis
    j. Partially compensated respiratory alkalosis

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. pH 7.21, pO2 108 mmHg (14.3 kPa), pCO2
15 mmHg (1.99 kPa), HCO3 15 mmol/l,
Base Excess 10 mmol/l
2. pH 7.55, pO2 113 mmHg (15.1 kPa), pCO2
25 mmHg (3.3 kPa), HCO3 22 mmol/l,
Base Excess +7 mmol/l
3. pH 7.18, pO2 67 mmHg (8.9 kPa), pCO2
74 mmHg (9.8 kPa), HCO3 11 mmol/l,
Base Excess 12 mmol/l
4. pH 7.35, pO2 76 mmHg (10.1 kPa), pCO2
55 mmHg (7.33 kPa), HCO3 29 mmol/l,
Base Excess 1 mmol/l

Answer 24

1—a, Acute metabolic acidosis, 2—d, Acute respiratory alkalosis, 3—i, Partially compensated respiratory acidosis (Type 2 respiratory failure), 4—f, Compensated respiratory acidosis

Question 25

43. Electrolyte disturbance:
    a. Hypernatremia
    b. Hyponatremia
    c. Hyperkalemia
    d. Hypokalemia
    e. Hypocalcemia
    f. Hypermagnesemia
    g. Hypomagnesemia
    h. Hypophosphatemia
    i. Hyperphosphatemia

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. Tall T waves progressing to widened QRS
complexes
2. U wave
3. Prolonged QT interval

Answer 25

1—c, Hyperkalemia, 2—d, Hypokalemia, 3—e, Hypocalcemia

Question 26

44. Arrhythmia:
    a. Amiodarone
    b. Atropine
    c. Bisoprolol
    d. Digoxin
    e. Electrical cardioversion
    f. Flecainide
    g. Furosemide
    h. Lidocaine
    i. Pacemaker
    j. Vagal maneuver plus adenosine
    k. Verapamil

For each of the following descriptions, select the
most appropriate answers from the list above.
Each answer may be used once, more than once,
or not at all.
1. First line for stable ventricular tachycardia
2. First line for narrow complex tachycardia
3. First line for persistent bradyarrhythmia
causing symptoms
4. Third degree heart block

Answer 26

1—a, Amiodarone, 2—j, Vagal maneuver
plus adenosine, 3—b, Atropine, 4—i,
Pacemaker