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Flashcards in Cardiac Deck (75):
1

The normal resting potential of the ventricular cell is largely the result of the?

extracellular movement of potassium

The movement of K+ out of the cell and down its concentration gradient results in a net loss of positive charge from inside the cell. An electrical potential is established across the membrane with the inside of the cell being negative because anions do not accompany the K+.

pg. 414
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

2

A group of left ventricular pressure-volume loops is shown. By dragging & reordering the selections in yellow, match the pressure-volume loop with the corresponding cardiac pathology.

-Mitral Stenosis
-Atrial Stenosis
-Mitral Regurgitation
-Atrial Regurgitation

Know the shapes:

pp. 478-479
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

3

After perfusing the myocardium, most of the blood returns to the right atrium via the:

coronary sinus

After perfusing the myocardium, most of the blood returns to the right atrium via the coronary sinus. Lesser amounts of blood also return via the anterior cardiac veins and the Thebesian veins.

pg. 223
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

4

In the normal patient, the orifice of the mitral valve is approximately:

4 - 6 cm2

pg. 467
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

5

A 65-year-old male is undergoing a TURP under general anesthesia. During the procedure a CVP catheter is placed to facilitate fluid management and the tracing below is obtained. This tracing is consistent with:

tricuspid regurgitation



Incompetence of the tricuspid valve abolishes the x descent resulting in a prominent cv wave.

pg. 420
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 40
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

6

A 32-year-old female, with a history of mitral regurgitation is scheduled for a uterine myomectomy. Management of this patient's anesthetic should include:

afterload reduction with a nitroprusside infusion

The anesthetic goal is to improve forward left ventricular stroke volume and decrease the regurgitant fraction. Maintenance of a normal to slightly increased heart rate is recommended. Afterload reduction with a vasodilator drug, such as nitroprusside, will improve left ventricular function.

pg. 35
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

7

The area of the myocardium most vulnerable to ischemia is the:

left subendocardium

Because it is subjected to the greatest intramural pressures during systole, the endocardium tends to be most vulnerable to ischemia during decreases in coronary perfusion pressure.

pg. 432
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

8

The Bainbridge Reflex: (Select 2)

s elicited as a result of an increased volume of blood in the heart, causes a decrease in ADH secretion

The Bainbridge reflex (atrial stretch reflex) is elicited as a result of an increased volume of blood in the heart. This process can increase heart rate by 10 - 15%. This reflex helps to prevent sequestration of blood in veins, atria and pulmonary circulation. Antidiuretic hormone secretion is decreased and atrial natriuretic peptide release is increased.

pg. 480
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

9

An 84-year-old man with a history of severe aortic stenosis is scheduled for a cystoscopy to evaluate his hematuria. The most appropriate anesthetic technique in this patient would be:

a local anesthetic with narcotic/benzodiazepine sedation

Spinal and epidural anesthesia are contraindicated in patients with severe aortic stenosis. If general anesthesia is necessary, an opioid-based anesthetic with a suitable nonopioid induction agent such as etomidate is required to maintain afterload. Local anesthesia with sedation is also a preferred technique.

pg. 474
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 498
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

10

During depolarization of the ventricular cell, activation of the slow calcium channels occurs during phase:

2

During phase 2, the plateau phase, there is activation of the slow calcium channels.

pg. 220
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

11

During repair of a perforated colonic diverticula, the following hemodynamic parameters were obtained: mean arterial pressure = 92 mmHg, central venous pressure = 2 mmHg and cardiac output = 7.5 L/min. From this, the systemic vascular resistance can be calculated to be:

960 dyn sec / cm5

Systemic vascular resistance is calculated with the following equation:

SVR = 80 x (MAP - CVP) / CO

The normal range of SVR is 900 - 1500 dyn . sec cm-5.

pg. 165, 706
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

12

The ECG strip below is consistent with:

first degree block

Rhythm Strip

This strip demonstrates regular sinus rhythm with a PR interval greater than 20 msec, consistent with first degree block.

pg. 1580
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

13

Auscultatory findings associated with mitral valve prolapse include a: (Select 2)

mid-systolic click, late systolic murmur

Mitral valve prolapse is the most common form of valvular heart disease. It is more common in young women and can be associated with Marfan syndrome, rheumatic carditis, myocarditis, thyrotoxicosis and systemic lupus erythematosus. Auscultatory finding associated with MVP include a mid-systolic click and a late systolic murmur.

pg. 35
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

14

During cardiopulmonary bypass, roller pumps:

maintain output regardless of the systemic resistance encountered

The constant speed of the rollers pumps blood regardless of the resistance encountered and produces a continuous nonpulsatile flow.

pg. 1087
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

15

Electrophysiologic effects of verapamil are the result of:

binding to the slow L-type calcium channels

Calcium channel blockers are organic compounds that block calcium influx through the L-type, but not T-type channels. Verapamil preferentially binds the channel in its depolarized state and thus produces a use-dependent block.

pg. 417
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pp. 101, 361-364
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

16

The rhythm strip below is consistent with:

an intraventricular conduction delay

Rhythm Strip

This ECG strip indicates regular sinus rhythm with widened QRS complexes (greater than 0.12 msec). This occurs as a result of an intraventricular conduction delay. Since only a rhythm strip is available, localization to either the right or left bundles is not possible.

pg. 1582
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

17

The incidence of cardiac complications in surgical patients 50 years of age and older having non-cardiac surgery is approximately:

1 - 10%

Coronary artery disease is responsible for over one-third of all deaths in Western societies and is a major cause of perioperative morbidity and mortality. The overall incidence of CAD in surgical patients is estimated to be between 5 and 10%. The incidence of cardiac complications in patients greater than 50 years of age is between 1 and 10% and can be predicted by the number of independent predictors present (Goldman Cardiac Risk Index).

pg. 452
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 573
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

18

A potent endothelial-derived vasodilator that has also been shown to inhibit platelet aggregation is:

nitric oxide

Nitric oxide is synthesized from arginine by nitric oxide synthetase. Nitric oxide is a potent vasodilator and inhibits platelet aggregation.

pg. 428
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 398
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

19

In the figure below, ECG lead III corresponds to lead:

In accordance with Einthoven's triangle, limb lead III corresponds to the line connecting points B to D.

pg. 1579
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

20

Anatomically, the sinoatrial node is located:

in the right atrium at the junction of the superior vena cava

The SA node is a group of specialized pacemaker cells in the sulcus terminalis, located posteriorly at the junction of the right atrium and the superior vena cava.

pg. 470
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

21

In the normal patient, the major determinant of left ventricular preload is:

pulmonary venous return

In the absence of significant valvular dysfunction, venous return is the major determinant of both right and left ventricular preload.

pg. 423
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 213
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

22

The hexaxial reference system is often used to show the vector of depolarization or axis of the electrocardiogram. (Click here to show hexaxial diagram). By dragging & reordering the selections in yellow, match the electrocardiographic lead with the corresponding vector.

Kravitz, L. "Hexaxial reference system"
URL: http://www.unm.edu/~lkravitz/EKG/hexaxial.html

23

Most of the perfusion of the left ventricle occurs:

upon the closing of the aortic valve

As a result of the high intramural pressures that occur during the contraction of the left ventricle, perfusion mostly occurs during diastole, after closure of the aortic valve.

pg. 224
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

24

The ECG findings below have been associated with:

procainamide administration

Rhythm Strip

This ECG strip is consistent with torsades de points. This arrhythmia has been associated with the use of type IA and type III antiarrhythmics as well as hypomagnesemia and hypokalemia. Torsades has also been associated with congenital long QT syndrome (Romano-Ward syndrome).

pg. 1584
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

25

Contraction of the cardiac myocyte occurs when intracellular calcium levels rise and the calcium binds to:

troponin C

A 100-fold increase in intracellular calcium concentration promotes contraction as calcium ions bind to the troponin C subunit of troponin.

pp. 214-215
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

26

The pulmonary artery tracing below is most consistent with:

mitral regurgitation

Wedge Trace

This PCWP trace indicates a large (canon) v wave consistent with mitral regurgitation.

pp. 707,1076
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

27

Compensatory mechanisms generally present in patients with congestive heart failure include:

increased catecholamine production, increased ADH secretion

Major compensatory mechanisms generally present in patients with heart failure include increased preload, increased sympathetic tone, activation of the renin-angiotensin-aldosterone system, release of ADH and ventricular hypertrophy.

pg. 107
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

28

A 28-year-old female is scheduled for a laparoscopic cholecystectomy. Her past medical history is significant for fainting episodes and her ECG shows prolongation of the QT interval. Anesthetic management of this patient should include: (Select 2)

premedication to reduce preoperative anxiety, the administration of beta-blockers

Events known to further prolong the QT interval should be avoided, such as abrupt increases in sympathetic stimulation associated with preoperative anxiety and noxious stimulation interoperatively, acute hypokalemia due to iatrogenic hyperventilation and the administration of drugs known to prolong the QTc, such as droperidol. Consideration should be given to establishing beta-blockade prior to induction as this has been shown to offer a considerable reduction in the incidence of cardiac events.

pg. 73
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

29

The greatest degree of volume overload of the left ventricle is seen in patients with:

aortic regurgitation

Regardless of the cause, aortic regurgitation produces volume overload of the left ventricle. Patients with severe aortic regurgitation have the largest end-diastolic volumes of any heart disease.

pp. 38-39
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

30

Anatomically, the atrioventricular node is located:

in the septal wall of the right atrium anterior to the opening of the coronary sinus

The AV node is located in the septal wall of the right atrium, just anterior to the opening of the coronary sinus and above the insertion of the septal leaflet of the tricuspid valve.

pg. 415
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

31

According to LaPlace's law, ventricular wall tension can be decreased by:

increasing wall thickness

According to LaPlace's law, the larger the ventricular radius, the greater the wall tension. Conversely, an increase in wall thickness reduces ventricular wall tension.

pg. 424
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pp. 225,236
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

32

The ST segment changes below are likely to be seen in a patient with:

hypothermia

Rhythm Strip

The ST changes shown are known as Osborn waves or J-point waves and are associated with hypothermia.

"Osborn wave." URL: http://en.wikipedia.org/wiki/Osborn_wave

33

Arterial pulse pressure is inversely proportional to the:

compliance of the arterial tree

Arterial pulse pressure is directly related to stroke volume, but is inversely proportional to the compliance of the arterial tree.

pg. 429
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

34

During cardiopulmonary bypass, reduction of the core temperature to 28o C results in a reduction of oxygen consumption of approximately:

50%

For each degree Centigrade reduction in temperature, there is an 8% reduction in metabolic rate, so that at 28oC there is an approximate reduction in metabolic rate of 50%.

pg. 1089
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

35

Volatile anesthetic agents: (depress or increase) the entry of calcium into the myocardial cells

depress the entry of calcium into the myocardial cells

Studies suggest that all volatile anesthetics depress cardiac contractility by decreasing the entry of calcium ions into cells during depolarization, altering the kinetics of its release and decreasing the sensitivity of contractile proteins to calcium.

pg. 418
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 101
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

36

The rhythm strip below is consistent with:

Mobitz I block

Rhythm Strip

This rhythm strip demonstrates an increasing PR interval with a subsequent dropped QRS complex consistent with a Mobitz I block also known as a Wenkebach block.

pg. 1580
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

37

Unstable angina is defined as:

chronic angina that becomes more frequent, angina at rest, new onset angina

Unstable angina is defined as (1) an abrupt increase in severity, frequency (more than three episodes per day), or duration of anginal attacks (crescendo angina), (2) angina at rest, or (3) new onset angina (within the past 2 months).

pp. 2,7
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

38

Blood flow through the systemic capillaries is: non-pulsatile or pulsatile?

non-pulsatile

Systemic blood flow is pulsatile in large arteries because of the heart's cyclic activity; by the time blood reaches the systemic capillaries, flow is continuous and laminar.

pg. 429
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

39

During initiation of cardiopulmonary bypass in the adult patient, pump flow is gradually increased to:

2.0 - 2.5 L/min/m2

With the initiation of cardiopulmonary bypass, the systemic arterial pressure is closely monitored as pump flow is gradually increased to 2 - 2.5 L/min/m2 (50 - 60 L/kg/min).

pg. 1095
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

40

Heart rate is normally controlled by which node?

SA node

The cardiac impulse normally originates in the sinoatrial (SA) node, a group of specialized pacemaker cells.

pg. 217
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

41

In the normal patient, loss of atrial contraction will reduce ventricular filling by approximately:

15 - 30%

Absent (atrial fibrillation), ineffective (atrial flutter) or altered timing of atrial contraction (low atrial or junctional rhythms) can reduce ventricular filling by 15 - 30%.

pg. 423
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 878
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

42

Causes of secondary hypertension include: (Select 2)

hypercortisolism, renal artery stenosis

Common causes of secondary hypertension include renovascular disease, hyperaldosteronism, aortic coarctation, pheochromocytoma, Cushing's syndrome (hypercortisolism), renal parenchymal disease and pregnancy-induced hypertension.

pg. 89
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

43

Most of the changes in coronary arterial blood flow are the result of:

local metabolic demand

Under normal conditions, changes in coronary blood flow are entirely due to variations in arterial tone in response to metabolic demand.

pg. 225
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

44

Normal aortic valve orifice area in the adult is approximately:

2.5 - 3.5 cm2

Normal aortic valve orifice area is 2.5 - 3.5 cm2. Critical aortic stenosis is said to exist when the aortic valve orifice is reduced to less than 0.7 cm2.

pg. 473
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

45

Patients with a sinus arrhythmia experience an increase in heart rate during?

during inspiration

Sinus arrhythmia is a cyclic variation in heart rate that corresponds to respiration (increasing with inspiration and decreasing during expiration); it is due to cyclic changes in vagal tone.

pg. 64
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

46

The majority of myocardial oxygen demand occurs during:

isovolumic contraction

The heart normally extracts between 75 and 80% of arterial oxygen content, by far the greatest oxygen extraction of all organs. The majority of oxygen demand is derived from the development of LV pressure during isovolumic contraction.

pg. 225
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

47

In the figure below, isovolumic relaxation corresponds to:

pp. 478-479
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

Klabunde, RE. "Cardiovascular Physiology Concepts." Dec, 2009
URL: http://www.cvphysiology.com/Cardiac%20Function/CF024.htm

48

Pharmacologic agents that reduce the conversion of plasminogen to plasmin and interfere with plasmin degradation of fibrin include:

aminocaproic acid

Both aminocaproic acid and tranexamic acid bind to produce a structural change in both plasminogen and plasmin. The structural change prevents the conversion of plasminogen to plasmin and also prevents plasmin from degrading fibrinogen and fibrin. Both agents have been shown to be effective in reducing blood loss (and replacement therapy) in cardiac surgical patients.

pg. 405
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

49

A 24-year-old man with a history of severe hypertrophic cardiomyopathy is scheduled for a staging laparoscopy to evaluate Hodgkin's lymphoma. Anesthetic considerations in this patient include the use of:

phenylephrine as a vasopressor as needed

Phenylephrine and other pure α-adrenergic agonists are ideal vasopressors in these patients because they do not augment contractility but increase SVR.

pp. 118-119
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

50

In the heart, the fastest conduction velocities are found in the:

His-Purkinje system

The His-Purkinje fibers have the fast conduction velocities in the heart, resulting in nearly simultaneous depolarization of the entire endocardium of both ventricles (normally within 0.03 s).

pg. 415
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 217
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

51

From the pressure-volume loop below, the ejection fraction is approximately:

58%

PV Loop

The EF can be calculated by the following equation:



Normal EF is approximately 67% + 8%.

pg. 212
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

pg. 479
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

52

In the healthy adult at rest, the coronary blood flow is approximately:

225 mL/min

In the average adult man, coronary blood flow is approximately 225 ml/min at rest. The myocardium regulates its own blood flow closely between perfusion pressures of 50 - 120 mmHg.

pg. 475
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

53

During cardiopulmonary bypass, carbon dioxide elimination is dependent on:

total gas flow to the oxygenator

Arterial carbon dioxide tension during CPB is dependent on total gas flow, whereas arterial oxygenation is generally inversely related to the thickness of the blood film in contact with the membrane and the oxygen concentration.

pg. 1087
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

54

Initiation of cardiopulmonary bypass is associated with a decrease in:

platelet glycoprotein receptors

CPB alters and depletes glycoprotein receptors on the surface of platelets resulting in platelet dysfunction. CPB is associated with an elevation in the levels of catecholamines, cortisol, vasopressin and angiotensin.

pg. 496
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

55

Cardiac sympathetic fibers originate from:

T1 - T4

Cardiac sympathetic fibers originate in the thoracic spinal cord (T1 - T4) and travel to the heart initially through the cervical ganglia (stellate) and then as the cardiac nerves.

pg. 420
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pp. 328, 330
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

56

The rhythm strip below is consistent with:

ventricular pacing

Rhythm Strip

This strip demonstrates a pacemaker spike followed by a prolonged QRS complex consistent with ventricular pacing.

pg. 1588
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

57

Slowly climbing a single flight of stairs corresponds to approximately:

4 metabolic equivalents (METs)

The ability to do light work at home or climb one flight of stairs slowly corresponds to about 4 metabolic equivalents (METs) and is one of the important criteria in determining the need for noninvasive cardiac testing.

pg. 456
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

58

During cardiopulmonary bypass, hypertension is said to exist if the mean systemic pressure exceeds:

100 mmHg

High systemic arterial pressures on CPB (> 150 mmHg) have been associated with aortic dissection and cerebral hemorrhage. Generally, when mean arterial pressure exceeds 100 mmHg, hypertension is said to exist.

pg. 512
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

59

During initiation of cardiopulmonary bypass in the adult patient, mean systemic pressures fall as a result of:

a decrease in blood viscosity

At the onset of CPB, systemic arterial pressure usually decreases abruptly. This decrease is attributed to abrupt hemodilution, which reduces blood viscosity and effectively lowers SVR.

pg. 1095
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

60

Local anesthetics depress cardiac conduction by:

binding to fast sodium channels

Local anesthetics have important electrophysiologic effects on the heart at blood concentrations that are generally associated with toxicity. At high blood concentration, local anesthetics depress conduction by binding to fast sodium channels.

pg. 417
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

61

The primary determinant of systemic vascular resistance in the normal patient is:

arteriolar tone

Because viscoelastic properties are generally fixed in any patient, arteriolar tone is the primary determinant of SVR.

pg. 424
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

62

Pulmonary hypertension is defined as:

sustained pulmonary mean pressure greater than 25

The pulmonary arteries normally have a systolic pressure of 18 - 25 mmHg, a diastolic pressure of 6 - 10 mmHg and a mean pressure of 12 - 16 mmHg. Pulmonary hypertension is defined as a mean pulmonary artery pressure higher than 25 mmHg at rest or higher than 30 mmHg with exercise.

pg. 97
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. New York and Philadelphia: Churchill Livingstone, 2008.

63

Under normal conditions, the oxygen saturation of the blood in the coronary sinus is approximately:

25%

The heart normally extracts between 75 - 80% of arterial oxygen content, by far the greatest oxygen extraction of all organs. This results in a saturation of 20 - 25% in the coronary sinus.

pg. 225
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

64

Signs and symptoms consistent with cardiac tamponade include: (Select 2)

jugular venous distention, muffled heart sounds

Specific signs of cardiac tamponade include hypotension, jugular venous distention and distant muffled heart sounds. Another common finding is pulsus paradoxus. The ECG usually demonstrates a decrease in voltage across all leads. The use of a PA catheter may reveal equilibration of right and left atrial and ventricular end-diastolic pressures at approximately 20 mmHg.

pp. 491-492
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

65

On the CVP tracing below, ventricular contraction corresponds best with:

B

Three waves can generally be identified on atrial pressure tracings. The a wave (A) is due to atrial systole. The c wave (B) coincides with ventricular contraction. The v wave (C) is the result of pressure buildup from the venous return before the AV valve opens.

pg. 705
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

66

A 5' 10", 175 lb patient is undergoing coronary artery bypass grafting. During the procedure the cardiac output is measured at 4.5 L/min. From this information, the cardiac index is calculated to be:

2.27 L/min/m2

The cardiac index is defined as the cardiac output divided by the body surface area (BSA). The BSA can be calculated from the formula:

BSA Calculation

This patient has a BSA of 1.98 m2, resulting in a cardiac index of 2.27 L/min/m2.

pg. 706
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

Mosteller RD: Simplified Calculation of Body Surface Area. N Engl J Med 1987 Oct 22;317(17):1098 (letter)

67

The two most important preoperative cardiac risk factors are unstable angina and:

evidence of congestive heart failure

Identifying patients at greatest risk allows appropriate measures to be taken that may facilitate a favorable outcome. The two most important risk factors are unstable coronary syndrome and evidence of CHF.

pg. 443
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 223
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

68

A 73-year-old man is brought to the operating room for repair of multiple lacerations and reduction of bilateral femur fractures. His past medical history includes atrial fibrillation and he is receiving coumadin daily. The most rapid reversal of the anticoagulation effects of coumadin can be achieved with:

fresh frozen plasma

The most rapid replacement of vitamin K dependent coagulation factors can be achieved by the administration of fresh frozen plasma.

pg. 851
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

69

The transplanted heart: has a normal Starling relationship between?

preload and cardiac output

Because the Starling relationship between end-diastolic volume and cardiac output is normal, the transplanted heart is often said to be preload dependent.

pg. 484
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 1414
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

70

In the absence of anemia or hypoxia, the best determinant of the adequacy of cardiac output is:

mixed venous oxygen saturation

A decrease in mixed venous oxygen saturation in response to increased demand usually reflects inadequate tissue perfusion. Thus, in the absence of hypoxia or severe anemia, measurement of mixed venous oxygen tension (or saturation) offers the best determination of the adequacy of cardiac output.

pg. 420
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

71

Normally, the largest fraction of the total blood volume is found in the:

venous system

With normal distribution of blood volume, 64% resides in the venous system.

pg. 428
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

72

The rhythm strip below is consistent with: complete heart block

This rhythm strip demonstrates a regular atrial rate, a regular ventricular rate, but no relationship between the P wave and QRS complex. If the ventricular rate exceeds the atrial rate, this rhythm is sometimes referred to as AV dissociation.

pp. 1581-1582
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

73

During cardiopulmonary bypass, centrifugal pumps:

cause less trauma to the blood cells than roller pumps

In contrast to roller pumps, centrifugal pumps experience reduced flow with increased SVR and are unable to provide pulsatile flow. However, centrifugal pumps have been shown to cause less blood cell trauma.

pg. 493
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

pg. 1087
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

pg. 512
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

74

Prior to initiation of cardiopulmonary bypass, activated clotting time (ACT) should exceed:

400 seconds

Anticoagulation must be established prior to CPB to prevent acute disseminated intravascular coagulation. The adequacy of anticoagulation must be confirmed with determination of ACT. An ACT longer than 400 - 480 seconds is considered safe at most centers.

pg. 514
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.

pg. 1088
Barash, PG, Cullen, BF, Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

75

In the CVP tracing below, the increase in pressure resulting from venous return entering the atrium before the tricuspid valve opens is best represented by:

C

CVP Trace

Three waves can generally be identified on atrial pressure tracings. The a wave (A) is due to atrial systole. The c wave (B) coincides with ventricular contraction. The v wave (C) is the result of pressure buildup from the venous return before the AV valve opens.

pg. 316
Nagelhout, JJ, and Zaglaniczny, KL. Nurse Anesthesia. St. Louis: Elsevier, 2010.