Week 4 HF/trauma/vascular

Question 1

A 65-year-old male with a history of hypertension and smoking presents with a thoracic aortic aneurysm measuring 5.5 cm. What is the most likely pathophysiological mechanism contributing to the development of this patient’s aortic aneurysm?

Answer 1

degenerative changes in the aortic wall d/t HTN and atherosclerosis

Question 2

2. Question: A patient presents with acute tearing chest pain radiating to the back and a blood pressure differential between arms. Which pathophysiological event is most likely occurring?

Answer 2

aortic dissection (rupture p/w severe hypotension)

Question 3

3. Question: A 30-year-old patient with Marfan syndrome is evaluated for elective surgery. What should be the primary anesthetic concern regarding the patient’s vascular system?

Answer 3

propensity for rapid aortic dilation and risk of dissection

Question 4

4. Question: In preoperative evaluation for aortic surgery, which factor is the most critical predictor of postoperative renal failure?

Answer 4

The presence of preoperative renal dysfunction
- Avoidance of hypovolemia, hypotension, low CO, and nephrotoxic drugs are important to decrease the likelihood of postoperative renal failure

Question 5

5. Question: In a patient undergoing surgery for a descending thoracic aortic aneurysm, what is the primary anesthetic goal regarding blood pressure management?

Answer 5

keeping BP elevated to ensure adequate spinal cord perfusion

Question 6

6. Question: Which complication is most critical to monitor for immediately after thoracic aortic surgery?

Answer 6

paraplegia

Question 7

7. Question:For a patient with Marfan syndrome undergoing elective non-cardiac surgery, what is the most important anesthetic consideration related to the aorta?

Answer 7

careful monitoring and control of BP to prevent dissection

Question 8

8. Question: A patient with a descending thoracic aneurysm is undergoing preoperative evaluation. Which aspect is most critical to assess preoperatively for anesthesia planning?

Answer 8

Presence of coexisting pulmonary disease

Question 9

9. Question: During the surgical repair of a thoracic aortic aneurysm, what is the most effective strategy to protect renal function?

Answer 9

use of mannitol before aortic clamping
-Renal protection is achieved by direct instillation of renal preservation fluid (4℃ lactated Ringer solution with 25g mannitol/L and 1 g methylprednisolone/L) and can be administered directly by the surgeon into the renal artery

Question 10

10. Question: In a patient with systemic hypertension undergoing surgery, which of the following intraoperative findings is most indicative of hypertensive heart disease-related left ventricular hypertrophy?

Answer 10

Diastolic dysfunction and elevated filling pressures

Question 11

11. Question: In distinguishing between aortic dissection and aneurysm, which clinical feature is more indicative of an aortic dissection?

Answer 11

Acute onset of tearing chest pain

Question 12

12. Question: A patient with untreated systemic hypertension is at increased risk for perioperative morbidity and mortality primarily due to:

Answer 12

endothelial dysfunction and associated vasculopathy

Question 13

13. Question: A patient with an aortic aneurysm is undergoing surgery. The nurse anesthesiologist notices an increase in blood pressure during the procedure. What is the most likely cause of hypertension in this scenario?

Answer 13

compensation for decreased aortic compliance

Question 14

14. Question: A 60-year-old male patient with untreated hypertension is scheduled for an abdominal surgery. His blood pressure is consistently above the target despite multiple antihypertensive medications. This is an example of:

Answer 14

refractory HTN

Question 15

15. Question: A patient with a known aortic dissection is found to have elevated serum creatinine levels. What is the most likely pathophysiological mechanism for this renal impairment?

Answer 15

Direct renal artery involvement in dissection

Question 16

16. Question: A patient with chronic heart failure (CHF) is scheduled for elective surgery. Preoperative evaluation indicates elevated jugular venous pressure and peripheral edema. What is the most likely mechanism for these findings?

Answer 16

Increased preload d/t fluid retention

Question 17

17. Question: During thoracic aortic aneurysm repair, the nurse anesthesiologist must be vigilant for signs of spinal cord ischemia. Which monitoring technique is most effective for detecting early signs of spinal cord ischemia?

Answer 17

SSEP

Question 18

18. Question: A patient with dilated cardiomyopathy (DCM) is undergoing non-cardiac surgery. Which anesthetic strategy is most appropriate to minimize myocardial stress?

Answer 18

maintenance of normovolemia and careful use of vasodilators

Question 19

19. Question: A 70-year-old patient undergoing vascular surgery has a history of chronic hypertension. What is the most appropriate intraoperative hemodynamic goal for this patient?

Answer 19

slightly elevated BP to ensure organ perfusion

Question 20

20. Question: A 55-year-old male patient with hypertrophic cardiomyopathy (HCM) is scheduled for elective non-cardiac surgery. What anesthetic approach is most appropriate to reduce the risk of exacerbating his condition?

Answer 20

maintaining a normal to slightly elevated preload

Question 21

21. Question: During thoracoabdominal aortic aneurysm repair, the nurse anesthesiologist must be aware of the potential for ischemic injury to the spinal cord. The great radicular artery of Adamkiewicz plays a key role in this. What specific function does this artery serve that is crucial during this surgery?

Answer 21

supplies anterior spinal artery ensuring blood flow to lower 2/3 of spinal cord

Question 22

22. Question: A patient with dilated cardiomyopathy (DCM) undergoing surgery exhibits signs of acute heart failure intra-operatively. Which intervention is most appropriate?

Answer 22

cautious fluid management and potential use of diuretics

Question 23

23. Question: In a patient undergoing aortic aneurysm repair with a supraceliac aortic cross-clamp, which hemodynamic change is most commonly observed immediately after clamping?

Answer 23

increased SVR and systemic BP

Question 24

24. Question: A patient with acute heart failure is undergoing emergency surgery. Which of the following strategies is most appropriate to optimize cardiac output?

Answer 24

balancing fluid administration w/ inotropic support as needed

Question 25

25. Question: In the case of infrarenal aortic cross-clamping, which of the following is the most expected hemodynamic response?

Answer 25

Minimal change in systemic BP

Question 26

26. Question: A patient with advanced HFpEF (Heart failure with preserved ejection fraction) is scheduled for a major abdominal surgery. What is the most appropriate anesthetic management to prevent exacerbation of heart failure symptoms in this patient?

Answer 26

maintaining a balanced intravascular volume and avoiding rapid rhythm changes

Question 27

27. Question: When managing a patient with thoracic aortic cross-clamping, which pharmacologic strategy is most appropriate to mitigate the hemodynamic effects?

Answer 27

utilizing vasodilators to manage increased BP

Question 28

28. Question: A patient with a history of left ventricular assist device (LVAD) implantation is undergoing non-cardiac surgery. What is the most crucial aspect of anesthesia management for this patient?

Answer 28

maintaining adequate preload to prevent suction events

Question 29

29. Question: During aortic cross-clamping above the renal arteries, what immediate hemodynamic change is most expected?

Question 30

30. Question: A patient with restrictive cardiomyopathy is scheduled for elective surgery. Which of the following is the most appropriate anesthetic management strategy?

Answer 30

maintaining SR to avoid significant bradycardia

Question 31

31. Question: What is the primary renal concern during aortic surgery involving cross-clamping near the renal arteries?

Answer 31

Decrease in renal blood flow, increase in renal vascular resistance, ischemia-reperfusion insult to kidneys leading to renal failure

Question 32

32. Question: A patient with HFpEF (heart failure with preserved ejection fraction) is undergoing major surgery. What is the primary focus for anesthesia management in this patient?

Answer 32

avoiding rapid changes in HR and rhythm

Question 33

33. Question: What is the primary cardiovascular response seen with thoracic aortic cross-clamping?

Answer 33

increased SVR

Question 34

34. Question: In a patient with HFrEF (heart failure with reduced ejection fraction) undergoing vascular surgery, which of the following strategies is most crucial to optimize perioperative outcomes?

Answer 34

Judicious use of inotropic support and strict control of fluid balance

Question 35

35. Question: In thoracoabdominal aortic surgery, what factor most significantly contributes to the risk of spinal cord ischemia?

Answer 35

duration of aortic cross-clamping

Question 36

36. Question: In a patient with heart failure with preserved ejection fraction (HFpEF) undergoing non-cardiac surgery, which of the following is the most crucial for preventing perioperative heart failure exacerbation?

Answer 36

careful fluid management and avoidance of tachycardia

Question 37

37. Question: During thoracic aortic aneurysm repair, which monitoring technique is most effective in assessing real-time spinal cord perfusion?

Answer 37

SSEP

Question 38

38. Question: During a surgical procedure, a patient with heart failure with preserved ejection fraction (HFpEF) develops acute pulmonary edema. What is the most appropriate initial treatment?

Answer 38

furosemide or other loop diuretics reduce LV filling pressures, decrease pulmonary venous congestion and improve clinical symptoms

Question 39

39. Question: What is a primary anesthetic challenge in thoracic aortic aneurysm repair?

Answer 39

managing rapid fluid shifts and blood loss

Question 40

40. Question: A 68-year-old patient with advanced heart failure with preserved ejection fraction (HFpEF) and a history of pulmonary hypertension is undergoing an urgent non-cardiac surgery. Midway through the surgery, the patient develops marked systemic hypotension and signs of right heart failure. What is the most appropriate management strategy?

Answer 40

administration of PDE inhibitors and careful fluid management

Question 41

41. Question: A 70-year-old male patient with a history of hypertension and smoking is scheduled for a carotid endarterectomy. During the procedure, which of the following monitoring techniques is most crucial for detecting cerebral ischemia during cross-clamping of the carotid artery?

Answer 41

transcranial doppler U/S allows continuous monitoring OR neuro assessment if they are awake

Question 42

42. Question: During a major vascular surgery, a patient with dilated cardiomyopathy (DCM) and severe systolic dysfunction exhibits a sudden decrease in cardiac output. Echocardiography reveals worsening left ventricular function without significant valvular pathology. Which intervention should be prioritized?

Answer 42

incremental use of an inotrope w/ vasodilator properties

Question 43

43. Question: A 68-year-old male with a history of hypertension and smoking is scheduled for a carotid endarterectomy due to significant carotid artery stenosis. During surgery, the patient’s blood pressure drops suddenly. What is the most likely cause of the sudden drop in blood pressure in this patient?

Answer 43

surgical stimulation of carotid sinus

Question 44

44. Question: A patient with hypertrophic obstructive cardiomyopathy (HOCM) undergoing an elective orthopedic procedure develops sudden hypotension and pulmonary edema. The most likely cause is dynamic left ventricular outflow tract obstruction. What is the optimal management strategy?

Answer 44

infusion of a short-acting beta-blocker and cautious fluid administration

Question 45

45. Question: A 30-year-old female presents with episodic bilateral finger pallor and cyanosis, triggered by cold exposure. What could this be?

Answer 45

neurogenic vasospasm, an episodic vasospastic ischemia of the digits. Raynaud’s phenomenon-vasospastic ischemia

Question 46

46. Question: A patient undergoing surgery has a history of pericarditis with occasional pericardial effusions. Which anesthetic approach is most appropriate to prevent exacerbation of pericarditis?

Answer 46

cautious fluid management and low PP ventilation

Question 47

47. Question: A 68-year-old patient undergoing carotid endarterectomy develops sudden hypertension during cross-clamping of the carotid artery. What is the most likely pathophysiological mechanism behind this observation?

Answer 47

increased SVR

Question 48

48. Question: During a thoracic surgery, a patient with a history of blunt cardiac trauma presents with new-onset hemodynamic instability. What is the most likely cause?

Answer 48

ventricular rupture or tamponade

Question 49

49. Question: During carotid endarterectomy, which of the following is the best indicator of adequate cerebral perfusion in the absence of invasive monitoring techniques?

Answer 49

Transcranial doppler if asleep, neuro assessment if awake

Question 50

50. Question: A patient with constrictive pericarditis is undergoing an elective non-cardiac procedure. Which of the following anesthetic strategies is most appropriate?

Answer 50

maintain adequate venous return by avoiding hypovolemia

Question 51

51. Question: During an emergency abdominal surgery, a patient with a history of constrictive pericarditis develops acute hypotension and decreased cardiac output. What is the most likely cause, and how should it be managed?

Answer 51

reduced ventricular filling; cautious fluid resuscitation and inotropic support

Question 52

52. Question: A patient with cardiac tamponade due to penetrating chest trauma is undergoing emergency surgery. Which anesthetic management strategy is most critical?

Answer 52

immediate surgical decompression of the tamponade

Question 53

53. Question: A patient undergoing elective surgery has a history of acute pericarditis. Which anesthetic management approach is most appropriate to mitigate the risk of exacerbating pericarditis?

Answer 53

cautious fluid management and low positive pressure ventilation

Question 54

54. Question: During an elective procedure, a patient with a known pericardial cyst experiences sudden cardiac arrest. What is the most likely cause, and how should it be managed?

Answer 54

cardiac tamponade; urgent surgical exploration

Question 55

55. Question: A young athlete experiences commotio cordis during a sports event and is brought to the hospital. Despite successful resuscitation, he remains hemodynamically unstable. What is the most appropriate anesthetic management during emergency surgery?

Answer 55

careful fluid management and readiness for defibrillation

Question 56

56. Question: A patient presents with a blunt chest trauma from a motor vehicle collision. Imaging reveals an aortic injury near the isthmus. What is the most critical consideration for anesthesia management during surgical repair?

Answer 56

strict BP control to reduce shear stress on aorta