Surgery - Intensive therapy and anesthesiology

Question 1

SUR - 11.1
We are sampling for haemoculture:
A) one day after the fever
B) at the beginning of the fever and 20 minutes later
C) one hour after the fever
D) one hour and two hours after the fever

Answer 1

ANSWER
B) at the beginning of the fever and 20 minutes later

EXPLANATION
The success of haemoculture depends on timing. Blood should be taken when the likelihood of bacteremia is the greatest, which is 40 minutes before fever develops. Fever begins with shivering, chills, which can be indicated by the patient, but if this is not feasible, it may be helpful in case of recurrent fever that fever occurs frequently at the same time. If there is absolutely no point of reference, it is advisable to take the blood sample again at any time, but not during the peak period.

Question 2

SUR - 11.2
Which neurological functions disappear in spinal anesthesia?
A) heat and pain sensation
B) pain sensation and motion
C) heat sensation and motion
D) heat and pain sensation and motion

Answer 2

ANSWER
D) heat and pain sensation and motion

EXPLANATION
The local anaesthetic drug, which is used for spinal anesthesia blocks the autonomic B-fibers, the heat-absorbing fibers, the pain-transmitting fibers and the somatic motor fibers depending on concentration in the affected spinal segments. The extent and quality of the block depends on the concentration and amount of the agent used.

Question 3

SUR - 11.3
Which of the following is not an inhalational anesthetics?
A) sevoflurane
B) isoflurane
C) propofol
D) nitrous oxide

Answer 3

ANSWER
C) propofol

EXPLANATION
The consistency of sevoflurane and isoflurane is steam, while nitrous oxide is gaseous. The inhalation of the mixture of these gases with oxygen results in narcosis. Propofol has the same effect given intravenously.

Question 4

SUR - 11.4
Major determinants of serum osmolarity, except:
A) sodium
B) glucose
C) urea
D) potassium

Answer 4

ANSWER
D) potassium

EXPLANATION
In the extracellular space the sodium, in the intracellular space the potassium are the dominant cation determining the osmotic concentration. In the extracellular space, 90% of osmolarity is related to sodium and its connected anions. In some pathological conditions, the role of the molar concentration of organic crystalloid molecules (e.g.: glucose, urea) increases

Question 5

SUR - 11.5
The most commonly used drugs for resuscitation:
A) dopamine
B) dobutamine
C) adrenaline
D) noradrenaline

Answer 5

ANSWER
C) adrenaline

EXPLANATION
Adrenaline helps to restart the heart irrespectively of the cause of cardiac arrest. Its α-sympathomimetic effect increases the perfusion pressure, thus the blood flow of the heart muscle and the brain during external heart massage. The β-mimetic effect of the drug helps to maintain the cardiac output after the spontaneous cardiac function returns. Adrenaline promotes electrical defibrillation and it is also effective in case of asystole and electromechanical dissociation.

Question 6

SUR - 11.6
Choose which of the following the most common cause of mechanical icterus is in the early postoperative period after laparoscopic cholecystectomy.
A) halothane induced hepatitis
B) not recognised Vater papilla tumor in the preoperative period
C) postoperative pancreatitis
D) clip placed on the common bile duct

Answer 6

ANSWER
D) clip placed on the common bile duct

EXPLANATION
In the early post-operative period, it is important to think of a surgical complication. During the surgical preparation, a misdiagnosed anatomical structure, e.g. the incorrectly attached clip to the ductus choledochus (common bile duct) instead of the cystic duct is able to cause mechanical icterus.

Question 7

SUR - 11.7
After strumectomy, the patient’s voice became hoarse. What do you think of first?
A) Vocal cords damaged during the intubation
B) Recurrent nerve lesion
C) Temporary laryngitis due to surgery
D) Trachea damage during surgery

Answer 7

ANSWER
B) Recurrent nerve lesion

EXPLANATION
The laryngeal recurrent nerve is behind the thyroid gland and enters the larynx, innervating the cords on each side. In case of thyroid resection, as a surgical complication, the injury of the nerve may occur, which may cause the paralysis of the cord on the same side, causing symptomatic hoarseness.

Question 8

SUR - 11.8
The thermodilution principle is used for the following measurement:
A) central venous pressure
B) capnometry
C) oxygen saturation of peripheral haemoglobin
D) determination of minute volume with PiCCO monitor

Answer 8

ANSWER
D) determination of minute volume with PiCCO monitor

EXPLANATION
For central venous pressure measurement the manometer operating on piezoelectric principle, for capnometry and the measurement of peripheral (fingernail) hemoglobin oxygen saturation a certain wavelength of infrared light is used. Percutaneous volume measurement based on the pulse countour analysis used for PiCCO monitoring is required to determine the minute volume by thermodilution technique (injection of cold, sterile, normotonic saline into the central vein, and then measurement of the temperature change of blood in the femoral artery).

Question 9

SUR - 11.9
The safest way to reduce PaCO2:
A) increase the respiratory minute ventilation
B) decrease in respiratory minute volume
C) increase in alveolar minute volume
D) the reduction of alveolar minute volume

Answer 9

ANSWER
C) increase in alveolar minute volume

EXPLANATION
The respiratory minute volume is not certain to have affect on carbon-dioxide removal. For example, if the respiratory minute volume is increased only by dead space ventilation alone (eg the respiratory frequency is doubled, but the single inspiratory volume is decreased to its 2/3 fold, the total respiratory minute volume increases, but the alveolar ventilation does not change or just decreases). Therefore, the partial pressure of carbon dioxide in the arterial blood can be achieved the best manner by the most profound (and abundant) breathing, so by increasing the alveolar minute ventilation.

Question 10

SUR - 11.10
It is not a central neuroaxial regional anesthesia
A) intravenous regional anesthesia
B) caudal blockade
C) spinal
D) peridural

Answer 10

ANSWER
A) intravenous regional anesthesia

EXPLANATION
In case of intravenous regional anesthesia, after cannulation and desangunation by a pneumatic padding, the distal part of the upper limb is filled up with the local anesthetic solution, which makes loss of sensation of the distal area of the arm after 10-15 minutes. In case of caudal blockade, the local anesthetic is introduced into the extradural space via the hiatus sacralis. During spinal anesthesia, the anesthetic solution is injected subdurally, so injected directly into the subarachnoid space. In case of peridural anesthesia, the anesthetic solution is injected directly into the epidural space.

Question 11

SUR - 11.11
The decreasing order of infection of central venous cannula:
A) internal jugular vein, subclavian vein, femoral vein
B) internal jugular vein, femoral vein, subclavian vein
C) femoral vein, internal jugular vein, subclavian vein
D) femoral vein, subclavian vein, internal jugular vein

Answer 11

ANSWER
C) femoral vein, internal jugular vein, subclavian vein

EXPLANATION
The most appropriate skin area for fixation and kept sterile easily is the area under the clavicle. This is followed by the neck on which the skin is mobile therefore the in and out sliding movement of the internal jugular vein catheter can be infected sooner than the one inserted into the subclavian vein. The skin on the inguinal region has the highest bacteria content, so the catheter inserted into the femoral vein becomes the fastest infected compared to the other two types of central venous cannulas.

Question 12

SUR - 11.13
Consequence of persistent loss of gastric juice:
1) decreased plasma hydrogen ion concentration
2) hypokalaemia
3) hypochloraemia
4) increased plasma bicarbonate level

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 12

ANSWER
E) all of the answers are correct

EXPLANATION
The gastric juice is rich in hydrochloric acid, therefore, in the event of loss of gastric acid, the loss of hydrogen ion and chloride ion is common along with the loss of water. Sodium ion concentration does not change significantly, however significant hypokalaemia will develop. This is secondary in nature, due to metabolic alkalosis. Compensatory hypoventilation may be characteristic, breathing becomes slow and superficial.

Question 13

SUR - 11.14
It may refer to hypovolaemia:
1) increase in urinary osmolarity
2) reduction of urinary osmolarity
3) reduction of urine sodium excretion
4) increased urinary sodium excretion

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 13

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Decreased volume of extracellular space in the kidney stimulates renin production and consequent angiotensin activity, which increases aldosterone secretion. As a result of aldosterone, sodium reflux is increased in kidney tubules. Increasing the concentration of sodium triggers osmoregulation, the water retention resulting from the antidiuretic hormone restores the volume of extracellular space. Hypovolaemia therefore triggers antidiuresis and antinatriuresis.

Question 14

SUR - 11.15
Preoperative urine-catheter introduction is justified:
1) for surgery near the bladder
2) in the event of significant loss of blood
3) for longer than two hours of surgery
4) before using spinal anesthesia in every case

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 14

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
When using the perioperative urinary catheter, the risk of the expected therapeutic benefit and the risk of uroinfection should be combined. For surgical interventions in the pelvis, in case of high risk of bleeding and longer operation than 2 hours, the advantage of using bladder catheter is greater than the risk. Due to spinal anesthesia, it is not recommended to use bladder catheter unless the patient’s urine is significantly obstructed during the early postoperative period.

Question 15

SUR - 11.16
Parameters used for management of patient controlled analgesia:
1) rate of continuous administration
2) bolus dose
3) lockout time
4) bolus delivery time

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 15

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
When using Patient Controlled Analgesia (PCA), 3 main parameters can be set on the syringe pump. The rate of continuous “background” administration, the amount of bolus medication given by the patient, and the duration between boluses during which the patient is in vain pressing the button, the pump does not carry out the patient’s new demand (lockout time e.g. 10 or 15 minutes) to avoid patient-induced overdose. Generally, the administration time of boluses can’t be set on the pump.

Question 16

SUR - 11.17
Proper definition for sepsis:
1) Sepsis is a life-threatening condition which is caused by the dysregulated response to infection.
2) Sepsis is suspected if the qSOFA score is >= 2.
3) In septic shock, vasopressor support is required for maintaining mean arterial blood pressure of at least 65 mmHg, and despite adequate fluid resuscitation serum lactate level is > 2.0 mmol/l.
4) Multiple organ failure is the simultaneous altered function of 3 or more organ systems.

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 16

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
The correct sepsis definition: According to the sepsis-3 definition valid from 2016, for quick diagnosis the qSOFA (quick Sepsis Related Organ Failure Assessment) score should be calculated ( 3 criteria are used: respiratory rate ≥ 22 / min, altered mental status, systolic blood pressure ≤ 100 mmHg). If the score is ≥ 2, sepsis is suspected. There is a septic shock if, despite proper fluid resuscitation, vasopressor support is required to maintain mean arterial pressure above 65 mmHg and serum lactate level is > 2 mmol / l. In multiple organ failure the function of two or more organ systems is altered, therefore intensive organ support is required to maintain homeostasis.

Question 17

SUR-11.18-11.21
Match the following:
A) isoflurane
B) vecuronium bromide
C) propofol
D) suxamethonium

SUR - 11.18 - effect can be reversed with sugammadex

SUR - 11.19 - depolarizing muscle relaxant

SUR - 11.20 - inhalational anaesthetic agent

SUR - 11.21 - intravenous anaesthetic agent

Answer 17

ANSWER
SUR - 11.18 - effect can be reversed with sugammadex - B)

SUR - 11.19 - depolarizing muscle relaxant - D)

SUR - 11.20 - inhalational anaesthetic agent - A)

SUR - 11.21 - intravenous anaesthetic agent - C)

Question 18

SUR-11.22-11.25
Match the following.
A) respiratory alkalosis
B) respiratory acidosis
C) metabolic alkalosis
D) metabolic acidosis

SUR - 11.22 - blood pH is increased, plasma bicarbonate level is increased

SUR - 11.23 - blood pH is increased, pCO2 is decreased

SUR - 11.24 - blood pH is decreased, pCO2 is increased

SUR - 11.25 - blood pH is decreased, plasma bicarbonate level is decreased

Answer 18

ANSWER
SUR - 11.22 - blood pH is increased, plasma bicarbonate level is increased - C)

SUR - 11.23 - blood pH is increased, pCO2 is decreased - A)

SUR - 11.24 - blood pH is decreased, pCO2 is increased - B)

SUR - 11.25 - blood pH is decreased, plasma bicarbonate level is decreased - D)

Question 19

SUR - 11.26
Suxamethonium is a competitive antagonist of acetylcholine, therefore the effect of suxamethonium can be reversed with acetylcholinesterase enzyme inhibitors.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 19

ANSWER
E) both the statement and the explanation are false

EXPLANATION
Suxamethonium exerts an acetylcholine agonist effect on the motor endplate and depolarises the motor endplate. Acetylcholinesterase enzyme inhibitors are able to reverse the non-depolarizing block type (based on the competitive antagonism of acetylcholine) by inhibiting the degradation of acetylcholine on the motor endplate

Question 20

SUR - 11.27
In semi-closed narcosis systems, the gas exhaled by the patient only partially returns to the system, therefore when using a semi-closed system, no carbon dioxide absorbing soda is required.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 20

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
During the use of semi-closed narcosis systems, some of the exhausted air exhaled by the patient returns to the system, then mixed with fresh gas and re-inhaled by the patient. Therefore, in the semi-closed system, it is mandatory to insert carbon dioxide absorbing soda in order to inhibit the accumulation of carbon dioxide in the inhaled gas mixture.

Question 21

SUR - 11.28
In case of mechanical ventilation, the use of positive end expiratory pressure (PEEP) enhances venous return into the heart, therefore cardiac output increases.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 21

ANSWER
E) both the statement and the explanation are false

EXPLANATION
Causes of drop in cardiac output associated with the use of PEEP (Positive End Expiratory Pressure): - decreased venous return due to increased mean intrathoracic pressure, - altered left ventricular geometry, - circulating, negative inotropic mediators. These damaging effects are less pronounced on cardiac output in case of reduced lung compliance (e.g. ARDS).

Question 22

SUR - 11.29
Hepatorenal syndrome is characterized by tubular damage of the kidneys, therefore continuous renal replacement therapy may be effective.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 22

ANSWER
D) the statement is false, but the explanation itself is true

EXPLANATION
Renal impairment in hepatorenal syndrome is mainly functional. In spite of severe renal dysfunction, morphological differences are minimal. Pathogenesis is not completely clear. It is characterised by renal hemodynamic disorders, mainly reduced cortical perfusion and intrarenal shunt formation. Also characterized by ascites, increased sodium and water retention, increased renin and aldosterone activity. Treatment of hepatorenal syndrome is adequate volume intake (albumin, fresh frozen plasma, low sodium or sodium free crysalloid solutions), diuretics and if necessary, renal replacement therapy.

Question 23

SUR - 11.30
The most common severe postoperative complication of spinal anaesthesia is the unbearable orthostatic headache because local anaesthetic agent given in the intrathecal space causes distal vasodilatation from the blocked segments.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 23

ANSWER
B) both the statement and the explanation are true but there is no causal relationship between them;

EXPLANATION
Both statements are true, but the unbearable, orthostatic headache is caused by liquor leak via the puncture site of the dura mater. In the most severe cases it can’t be reduced with medications just with local epidural injection of 10 to 15 ml of the patient’s own native venous blood.