Анестезиология

[Tsiklinskiy]

1. 2
2."В"

[Евгений Хоменко]

1. - 4, т.к. ригидность грудной клетки при индукции может возникать и при весьма небольших дозах фентанила, далеких от высоких доз.
2. - А. т.к. любой инотропный препарат при его введении и увеличении дозы будет создавать дополнительное увеличение концентрации Са2++ в кардиомиоцитах, что неминуемо вызовет увеличение потребности в кислороде, для закачки Са обратно во внутриклеточные депо. Этого эффекта не лишен даже ЛЕВОЗИМЕНДАН, сенситизатор Са.

[Alexey Dyachkov]

Вот, наконец, и ответы. С этого момента буду публиковать на английском.

№1 Correct Answer: C. High-dose opioid-based anesthetic techniques, particularly those utilizing synthetic opioids (such as fentanyl), initially gained popularity due to the reliable hemodynamic stability that is achieved, while producing minimal cardiovascular depression. In addition, hormonal responses to surgical stimuli are significantly blunted with such a regimen. Notable disadvantages include prolonged respiratory depression, a high incidence of clinically significant muscle rigidity on induction, and frequent reports of intraoperative awareness and recall in those instances where opioids are utilized as the sole anesthetic agent.

№2 Correct Answer: B. Milrinone and amrinone are within a class of drugs called "inodilators." Their mechanism of action involves increasing intracellular calcium through the inhibition of the phosphodiesterase III enzyme. As a result, these medications act like catecholamines but bypass the catecholamine receptors on the surface of the cell. The effect of the increase of intracellular calcium results in increased inotropy with systemic and pulmonary vasodilation. Milrinone does not increase myocardial oxygen demand, as its increased inotropy is counterbalanced by an oxygen sparing decrease in systemic vascular resistance and pulmonary vascular resistance. Milrinone is devoid of the platelet effects, whereas amrinone can have thrombogenic effects.


New

#1 Which of the following statements regarding the effect of epinephrine on the cardiovascular system is/are TRUE?
1. It lengthens the systolic phase of the cardiac cycle.
2. It increases heart rate.
3. It reduces myocardial oxygen demand.
4. Receptor (i.e., alpha or beta ) predominance is affected by the dose administered.

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.

#2 What alterations are seen in the arterial waveform measurement as one moves from the aorta to a distal artery?
1. Later occurrence of the dicrotic notch
2. Increase in diastolic pressure
3. Increase systolic pressure
4. Reduced slope of the initial systolic upstroke

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; E if all.

[Tsiklinskiy]

1."C"
2."B"

[Alexey Dyachkov]

Прошу прощения за задержку. Вдохновлённый Игорем Булатовым продолжаю.

#1 Correct Answer: C. Epinephrine is a powerful catecholamine that affects both beta and alpha receptors. The degree to which the receptor is predominantly affected is dose dependent. At low doses, beta-effects predominate with increased heart rate, increased contractility, increased cardiac output, and some peripheral dilation. At an intermediate doses, the improvement in cardiac performance is also associated with alpha-stimulation, which results in vasoconstriction and an increase in mean arterial pressure. With high doses, alpha-effects predominate with extreme vasoconstriction and hypertension. Tachycardia, dysrhythmias, and vasoconstrictive side effects typically limit administration of epinephrine.

#2 Correct Answer: B. As one moves from the large central arteries to the peripheral arteries, the arterial waveform changes. This occurs because of the narrowing of the vascular tree, which results in different impedance and harmonic resonances compared to the larger arteries. This results in the phenomena called distal pulse amplification. This amplification manifests itself in higher systolic but lower diastolic blood pressure readings, widened pulse pressure, steeper systolic upstroke, and a later occurrence of the dicrotic notch. MAP is just slightly lower in a peripheral artery when compared to the aorta.

______________________________________________________

#1. Which of the following monitors is the most accurate indicator of ventricular preload?

A. Central venous pressure (CVP) trends
B. Pulmonary capillary wedge pressure (PCWP)
C. Transesophageal echocardiogram (TEE)
D. Mixed venous saturation
E. Urine output

#2. Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
A preoperative ECG should be ordered and evaluated in which of the following patient populations?
1. Patient with a prior myocardial infarction
2. Patient with a history of hypertension, diabetes mellitus, or peripheral vascular disease
3. Males >60 years
4. Females >70 years

[Евгений Хоменко]

#1. Which of the following monitors is the most accurate indicator of ventricular preload?

A. Central venous pressure (CVP) trends
B. Pulmonary capillary wedge pressure (PCWP)
C. Transesophageal echocardiogram (TEE) correct
D. Mixed venous saturation
E. Urine output

#2. Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
A preoperative ECG should be ordered and evaluated in which of the following patient populations?
1. Patient with a prior myocardial infarction
2. Patient with a history of hypertension, diabetes mellitus, or peripheral vascular disease
3. Males >60 years
4. Females >70 years

[Tsiklinskiy]

1. "С"
2. "Е"

[Alexey Dyachkov]

№1 Correct Answer: C. The most accurate preload indicator for the left ventricle is the TEE probe, as it can assess actual intracardiac chamber size and thus preload. Urine output is also a very accurate method of detecting adequacy of LV preload; however, in healthy people with inadequate LV preload, urine output may be maintained. Conversely, there are numerous conditions in which there will be inadequate urine output despite adequate LV preload. CVP trends can be altered by abnormalities within the right ventricle, pulmonary circulation, and the left side of the heart. PCWP is only accurate if there are no complicating matters within the lungs (excessive positive end-expiratory pressure), left atrial abnormalities (mitral stenosis), and LV abnormalities (ischemia). Mixed venous oxygen saturation is an accurate indicator of total body O2 balance but does not directly measure LV preload; it may be normal despite inadequate LV preload if the heart rate is increased to maintain cardiac output.

№2 Correct Answer: E. The preoperative 12-lead ECG can provide important information on the status of the patient's myocardium and coronary circulation. Abnormal Q waves in high-risk patients are highly suggestive of a past myocardial infarction. Patients with Q-wave infarctions are known to be at increased risk of a perioperative cardiac event and have a worse long-term prognosis. Patients who exhibit LVH or ST-segment changes on a preoperative ECG also are at an increased risk of a perioperative cardiac event. Reasonable recommendations for a preoperative ECG include patients with systemic cardiovascular disease, diabetes mellitus, males >60 years, and females >70 years.

NEW:

#1. An advantage of membrane over bubble oxygenators in cardiopulmonary bypass circuits is:

A. The uptake of inhaled anesthetics is more predictable with membrane oxygenators.
B. There is less trauma to blood constituents.
C. Pulsatile flow is possible with the use of a membrane oxygenator.
D. Membrane oxygenators offer a cost advantage over bubble oxygenators.
E. Carbon dioxide exchange is significantly more effective.

#2. Mediastinoscopy:

A. commonly occludes the left radial pulse
B. may be associated with right hemiparesis
C. may cause injury to the superior laryngeal nerve
D. is a procedure with potential for life-threatening hemorrhage
E. must be accompanied by general anesthesia

[Tsiklinskiy]

Алексей, отвечаю с большой неуверенностью в правильности:

1."В"
2."Е"

[Евгений Хоменко]

Алексей у нас прям полиграф какой-то. Держит всех в страхе и неуверенности.
Поддерживаю Святослава в правильности его неуверенности.
1. мембранные оксигенаторы дороже, пульсовой поток делает Pump, кровь травмируется и там и там, так что ответ Е, т.к. основное преимущество мембран - возможность сепаративно регулировать оксигенацию и газообмен.
С практической точки зрения вопрос не ясен, т.к. пузыри нигде не пользуют. У нас же не "своя игра" и не "чо, где когда".

2. ответ Е, т.к. пульс м. пропадать справа, ларингуес не представляю как можно достать, гемипарез тоже с трудом, кровотечение как правило легко контролируется даже из ствола ЛА при его непреднамеренной биопсии.

[Alexey Dyachkov]

Поздравляю всех с наступающими и прошедшими праздниками!
Надеюсь, что в Н.Г. отвечающих на вопросы станет больше (как минимум, на одного человека, по имени Юрий)
Женя, безусловно, у нас не "своя игра", однако, если задаваться целью сдавать какие-то тесты (европейские или другие), надо знать врагов в лицо. То есть, относиться к тестам как к тестам, где нужно выбрать один правильный ответ.
Кроме этого, я решил немного ускориться и увеличить количество вопросов.

Ответы:

#1. Correct Answer: B. Studies comparing the two types of oxygenators reveal less trauma to blood constituents with membrane oxygenators. Hemolysis and the resultant release of red cell debris is a potential problem associated with bubble oxygenators. Likewise, a decrease in platelet activity—resulting from platelet destruction, increased aggregation, and adherence to the oxygenator—may lead to impairment of postoperative hemostasis.

#2. Correct Answer: D. Mediastinoscopy is a means for assessing spread of lung carcinoma. Hemorrhage is a real risk and may be life threatening. Pressure on the innominate artery by the mediastinoscope has been thought to cause transient left hemiparesis; therefore, it is recommended that blood pressure be monitored in the left arm and that the right radial pulse be monitored continuously. A decrease in the right radial pulse would be an indication for repositioning the mediastinoscope. Recurrent laryngeal nerve injury may occur either secondary to damage by the mediastinoscope or involvement by the tumor. If both recurrent laryngeal nerves are damaged, upper airway obstruction may result. Mediastinoscopy may be performed under local anesthesia.

New:

#1. Which of the following may be effective therapy for the patient with severe, irreversible pulmonary hypertension?
1. Heterotopic heart transplant
2. Orthotopic heart transplant
3. Heart-lung transplant
4. Left ventricular assist device

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
_________________________

#2. Which of the following statements is/are TRUE?
1. Parasympathetic stimulation to the heart decreases heart rate via muscarinic receptors, decreasing adrenergic receptor activation through G-protein–mediated pathways.
2. Sympathetic stimulation occurs via alpha-1, beta-1, and beta-22 receptors through G-protein–mediated pathways.
3. Chronotropic and inotropic effects of beta-1 activation results from increased numbers of calcium channels available for activation.
4. Sympathetic stimulation to the heart is via the stellate ganglia, with the right stellate having more chronotropic effect and the left stellate having more inotropic effect.

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
_______________________

#3. Which of the following statements regarding bronchial blockers is/are TRUE?
1. They are effective in maintaining lung isolation despite surgical manipulation.
2. A Univent tube is useful for bilateral lung transplant cases.
3. Placement of an embolectomy catheter into the bronchus should be performed blindly.
4. Bronchial blockers may be used in children younger than 12 years.

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
______________________

#4. Relatively strong indications for the perioperative placement of a pulmonary artery catheter in the patient undergoing cardiac surgery include:
1. procedures in which continuous retrograde cardioplegia is to be employed during cardiopulmonary bypass
2. a patient with moderate to severe pulmonary hypertension
3. access to central circulation for the infusion of vasoactive drugs
4. assistance in the management of the patient with impaired left ventricular function

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
______________________

#5. In the lateral decubitus position:

A. Blood flow to the nondependent lung is significantly greater than it is to the dependent lung.
B. The distribution of blood flow is turned by 180 degrees compared to the supine position.
C. In the awake, spontaneously breathing patient, there is poor ventilation/perfusion matching in the dependent lung.
D. Controlled ventilation is required to ensure gas exchange and ventilation when a thoracotomy is performed.
E. The nondependent hemidiaphragm is pushed higher into the chest.

[Gusev Juriy]

Предполагаемые ответы: 1. В 2. А 3. не знаю 4. я предполагаю, что С 5. Е

[Евгений Хоменко]

1. B т.к. гетеротопная транплантация - будет работать как right heart assist device, трансплант сердце-легкие радикальное решение проблемы.
2. Я бы ответил Е, т.к. не вижу очевидных противоречий ни в одном из вариантов, распределение ганглионарных предпочтений соответствует анатомии.
3. D т.к. блокеры могут смещаться при манипцляциях, вслепую заводить катетер фогарти это ай-яй-яй, а юнивент не подходит для билатеральной последовательной трансплантации, т.к. надо манипулировать с бронхами, детям вообще двухпросветные трубкине лезут.
4. С. все понятно.
5. D, т.к. если знать, что dependant lung это то которое внизу, то можно понять, что кровоток в нем больше, распределение меняется все-таки наверное на 90 градусов, спонтанное дыхание дает лучшее соотношение вентиляции и перфузии, т.к. оно больше вентилируется, ни и диафрагма может смещаться вследствие давления из брюшной полости

[Tsiklinskiy]

1."В"
2."Е"
3."С"
4."С"
5."D"

[Alexey Dyachkov]

Вот и ответы:

#1. Correct Answer: B. Severe, irreversible pulmonary hypertension remains one of the few absolute contraindications to orthotopic heart transplantation. The right ventricle of a healthy donor heart is unable to cope acutely with a markedly elevated, fixed, pulmonary vascular resistance. In such cases, heart-lung transplantation or heterotopic heart transplantation of the donor heart into the right chest (with anastomosis of the major donor and native vessels, without removing the native heart) may be effective.

#2. Correct Answer: E. Parasympathetic stimulation to the heart decreases heart rate via muscarinic receptors, decreasing adrenergic receptor activation through G-protein–mediated pathways. Sympathetic stimulation occurs via alpha-1, beta-1, and beta-22receptors through G-protein–mediated pathways. Chronotropic and inotropic effects of beta-1 activation results from increased numbers of calcium channels available for activation. Sympathetic stimulation to the heart is via the stellate ganglia, with the right stellate having more chronotropic effect and the left stellate having more inotropic effect.

#3. Correct Answer: C. The Univent tube may be helpful for cases in which changing the double-lumen tube to a single lumen tube may be difficult (e.g., following bilateral lung transplant). It is a single lumen endotracheal tube with a movable endobronchial blocker. The bronchial blocker technique can be useful in achieving selective ventilation in adults and in children younger than 12 years, and it should be placed via bronchoscopic guidance. These tubes are not used very commonly because they are easily displaced.

#4. Correct Answer: C. Although indications for the placement of a pulmonary catheter vary among institutions, those conditions in which left ventricular filling pressures cannot be reliably predicted by transduced right atrial pressures generally predicate pulmonary artery catheter placement. These conditions include pulmonary hypertension, left ventricular dysfunction or decreased compliance, and valvular dysfunction. Other indications include operations requiring prolonged operative time or combined procedures (valve replacement plus coronary grafting).

#5. Correct Answer: D. Controlled positive-pressure ventilation is the only way to provide adequate ventilation and to guarantee gas exchange during a thoracotomy. In the lateral decubitus position, the distribution of blood flow and ventilation is similar to that in the upright position, but turned by 90 degrees. Good ventilation/perfusion matching at the level of the dependent lung results in adequate oxygenation in the awake, spontaneously breathing patient. The dependent hemidiaphragm is pushed higher into the chest by the abdominal contents than is the nondependent diaphragm.


New:

#1. Which of the following statements about post–cardiac transplant patients is/are TRUE?
1. They are better able to increase heart rate than stroke volume.
2. Their resting stroke volume tends to be 50–60% of normal volume.
3. They are insensitive to circulating catecholamines.
4. They are preload dependent.

Choose A if 1, 2, and 3 are correct; B if 1 and 3; C if 2 and 4; D if 4; and E if all.
__________

#2. Regarding lung volume reduction surgery, all of the following are true EXCEPT:
A. This procedure is necessary in patients with end-stage emphysema.
B. Ventilation can usually be decreased after the chest is open.
C. Nitrous oxide should be avoided.
D. Pneumothorax may be difficult to diagnose.
E. Patients have a greater amount of functional lung tissue after surgery.
__________


#3. In patients presenting for vascular surgery, the incidence of significant coronary artery disease (stenosis >70%) detected by angiography in patients without any clinical symptoms of coronary stenosis is:
A. <1%
B. 11%
C. 37%
D. 78%
E. nearly universal
_________

#4. For patients undergoing vascular surgery, when is myocardial ischemia most likely to occur?
A. Preoperatively
B. During the induction of anesthesia
C. Intraoperatively, prior to revascularization
D. In the immediate postoperative period
E. 48–72 Hours postoperatively
___________

#5. Coronary sinus drainage includes all of the following EXCEPT:
A. great cardiac vein
B. middle cardiac vein
C. thebesian veins
D. posterior left ventricular vein
E. oblique vein of Marshall

Sincerely,
Alexey.