SEE Exam Questions And Answers
2023-2024
During fetal monitoring, Type III decelerations are thought to be related to:
• head compression
•
... [Show More] umbilical cord compression
• uteroplacental insufficiency
• placental abruption - Correct Answer-umbilical cord compression
Type III, or variable, decelerations are the most common type of decelerations. They
are thought to be related to umbilical cord compression and intermittent decreases in
umbilical blood flow.
The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:
• T4 - T8
• T8 - L2
• L2 - L4
• L4 - S1 - Correct Answer-T8 - L2.
A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of
elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna
supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable
origin from aorta, arising between T5 - T8 in 15%, between T9 - T12 in 60% and
between L1 - L2 in 25% of individuals.
60. A 55-year-old woman with a history of congenital long QT syndrome is undergoing a
hysteroscopy for abnormal uterine bleeding. She had uneventful induction of general
anesthesia but after paracervical block with lidocaine develops ventricular tachycardia
with morphological appearance of torsades de pointe. Which of the following
medications should be AVOIDED in the treatment of her arrhythmia?
• Amiodarone
• Calcium chloride
• Esmolol
• Magnesium sulfate - Correct Answer-60. Amiodarone. Congenital long QT syndrome
may occur in conjunction with other hereditary syndromes, such as Jervell, LangeNielsen or Romano-Ward syndrome, or acquired as a result of pharmacologic or
metabolic etiologies. It is an issue of cellular repolarization which precipitates
tachyarrhythmias, most commonly polymorphic ventricular tachycardia or torsades de
pointe. There are multiple subtypes that affect both potassium and/or sodium channels.
The arrhythmias may be precipitated by sympathetic activation, auditory stimuli or at
rest. Family history may be positive for sudden cardiac death and the ECG significant
for prolonged corrected QT interval > 430ms or bizarre odd-appearing T waves.
Treatment includes magnesium for arrhythmias, possible permanent pacemaker, or
beta blockers for subtypes 1 and 2, but amiodarone is considered contraindicated as it
prolongs the QT interval.
59. A 76-year-old man is scheduled for a hemicolectomy. His past medical history is
significant for third degree heart block treated with a permanent pacemaker. Problems
with electrocautery use in this patient can be minimized by:
• placing the grounding pad near the pacemaker
• using infrequent bursts of longer duration
• the use of a bipolar cautery
• reducing the surface area of the return electrode - Correct Answer-59. the use of a
bipolar cautery. Electrical interference from the electrocautery can be interpreted by the
pacemaker as myocardial activity and suppress pacemaker activity. These problems
can be minimized by limiting use to short bursts, placing the grounding pad as far from
the pacemaker as possible and using a bipolar cautery.
58. A 35-year-old woman who underwent orthotopic heart transplantation 2 years ago
for nonischemic cardiomyopathy presents after a motor vehicle accident for exploratory
laparotomy under general anesthesia. Intraoperatively, her blood pressure is 75/35
mmHg and heart rate is 90 bpm. After the administration of phenylephrine, which of the
following hemodynamic responses do you MOST expect?
• HR decreased, BP increased
• HR decreased, BP no change
• HR no change, BP increased
• HR no change, BP no change - Correct Answer-58. HR no change, BP increased.
After heart transplantation, the heart is completely denervated. The normal resting heart
rate is relatively tachycardic at 90-100 bpm due to lack of vagal tone. Vagal bradycardic
responses (to laryngoscopy, hypertension, carotid sinus massage) will also be absent.
Over time, however, many patients require permanent pacemaker placement for
treatment of significant bradycardia. After heart transplant, patients are not able to
respond to demands for increased cardiac output with increased heart rate. Thus in this
situation of a trauma with potentially significant blood loss, a normal patient would have
tachycardia but a heart transplant patient has no change in heart rate, only hypotension.
Instead for heart transplant patients, cardiac output is augmented by increased stroke
volume. For this reason it is important to maintain adequate intravascular volume. The
transplanted heart is not able to respond to medications that block the parasympathetic
system. Bradycardia and hypotension have to be treated with medications that have a
direct effect such as epinephrine and isoproterenol. Phenylephrine will result in
increased blood pressure, but no change in heart rate. Indirect and mixed
indirect/direct-acting drugs have minimal effect or have the effect of their direct
components.
57. The postretrobulbar block apnea syndrome:
• is likely secondary to intravascular injection
• most commonly occurs during or immediately after injection
• is associated with unconsciousness
• carries a high morbidity and mortality - Correct Answer-57. is associated with
unconsciousness. The postretrobulbar block apnea syndrome is probably due to
injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The
CNS is exposed to high concentrations of local anesthetic leading to apprehension and
unconsciousness. Apnea occurs within 20 minutes and resolves within an hour.
Treatment is supportive.
56. A 75-year-old man is undergoing a mitral valve replacement via cardiopulmonary
bypass. The perfusionist is running bypass flows at > 2.5 liters/minute/m2. Which of the
following is the MOST likely adverse consequence of undergoing cardiopulmonary
bypass at increased flow rates?
• Increased trauma to blood elements
• Increased hypothermia
• Decreased blood flow to the brain
• Decreased myocardial blood flow - Correct Answer-56. A. Increased trauma to blood
component: Cardiopulmonary bypass (CPB) does the work of the heart and lungs in
order to isolate those organs from blood flow such that surgery on the heart can occur in
a relatively bloodless fashion. Thus, the CPB circuit must oxygenate and ventilate the
blood and then deliver the oxygenated blood back to the body and end organs. It has
long been debated whether maximal blood flow or pressure is more important in
perfusion and homeostasis of the end organs during bypass. Maximizing blood flow
(generally considered to be flow at a cardiac index of > 2 liters/minute/meter2) has been
shown to increase hematologic trauma, increase the magnitude of the stress or
inflammatory response, cause strain on suture lines, increase shunting of blood through
the pulmonary system, increase washout of cardioplegia and not necessarily lead to
improved regional blood flow. The CPB machine can change total flow, but it cannot
adjust regional flows to the various end organ systems. Changes in blood pressure are
currently thought to be most effective for allowing adjustments to regional flow in organ
systems as the organs retain their regional vascular resistance capabilities. Thus
conduct of CPB with an optimal pressure (and potentially lower flows) may allow the
individual organs to regionally modulate their own flows. scheduled for ECT are
routinely given anticholinergic medication preoperatively.
55. Physiologic effects of electroconvulsive therapy (ECT) include an:
• initial sympathetic response with sustained tachycardia
• initial sympathetic discharge followed by a sustained parasympathetic response
• initial parasympathetic discharge followed by a sustained sympathetic response
• initial parasympathetic response with sustained bradycardia - Correct Answer-55.
initial parasympathetic discharge followed by a sustained sympathetic response. An
initial parasympathetic discharge followed by a sustained sympathetic response is
immediately seen after the induction of a seizure. Marked bradycardia with increased
secretions can occur, which is then followed by hypertension and tachycardia. Patient
54. A 70-year-old man with a DDD-R pacemaker for a history of symptomatic
bradycardiais undergoing an anterior cervical discectomy and fusion with
somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring.
The pacemaker should be reprogrammed to which of the following?
• Discontinue R function
• Dual chamber asynchronous pacing
• No reprogramming
• Ventricular asynchronous pacing - Correct Answer-54. "R" signifies rate
responsiveness in the fourth position of the pacemaker designation code. Patients who
are pacemaker-dependent are limited in their ability to exercise because of fixed rate
(can't get their heart rates up). "R" function allows a pacemaker to speed up to satisfy
increased metabolic demands (via motion, minute ventilation, temperature sensors)
when the patient is exercising. However, for patients who are pacemaker-dependent,
rate responsiveness function may be activated by perioperative events: fasciculations
from succinylcholine, myoclonus from etomidate, vigorous surgical retraction, shivering,
or SSEP/MEP neuromonitoring. This can cause undesired tachycardic pacing. So in
cases like the one described, it is best to turn off the rate responsiveness function.
Keeping the pacemaker in DDD is otherwise acceptable as long as a method of
perfusion is assured, such as arterial blood pressure or pulse oximetry. One concern is
often that the pacemaker will interpret artifact or electromagnetic inference from the
bovie cautery as native heart rhythm and not initiate pacing when it is indicated, leaving
the patient at risk for profound bradycardia or asystole. Placing the bovie pad away from
the pacemaker generator and using bipolar cautery if needed are options to deal with
that type of interference. Reprogramming to asynchronous mode risks R on T
phenomenon (when the pacemaker cannot discern between artifact and native heart
rhythm).
53. Correct location of the catheter tip of a central venous line is in the:
• superior vena cava
• right atrium
• riht ventricle
• pulmonary artery - Correct Answer-53. superior vena cava. The CVP catheter tip
should not be allowed to migrate into the heart chamber to avoid arrhythmias and
perforation.
52. Which of the following is NOT a potential treatment for salicylate poisoning?
• Activated charcoal
• Administration of a reversible COX-inhibitor
• Hemodialysis
• Sodium bicarbonate - Correct Answer-52. B. Salicylic acid produces its antiinflammatory effects via suppressing the activity of cyclooxygenase (COX). Unlike other
NSAIDs, it does this not by direct inhibition of COX, unlike most other non-steroidal antiinflammatory drugs (NSAIDs), but instead by suppression of the expression of the
enzyme (via an un-elucidated mechanism). Salicylic acid is a non-reversible COX
inhibitor. Salicylates produce epigastric pain, nausea and vomiting, hyperventilation
(respiratory alkalosis), and widely ranging neurologic signs and symptoms (tinnitus,
delirium, coma, seizure) as well as a primary metabolic acidosis (salicylic acid, lactic
acid, and ketoacids). Treatment includes activated charcoal, alkalinization of blood and
urine with IV sodium bicarbonate (pKa 3.5, thus salicylates can be "trapped" in the
blood and urine, preventing movement into tissues and enhancing excretion).
Hemodialysis is considered for mental status changes, severe acid-base disturbances,
or serum concentrations > 100 mg/dL.
51. During pregnancy, the minimum alveolar concentration (MAC):
• decreases until the 20th week
• increases until the 20th week
• decreases throughout the pregnancy
• increases throughout the pregnancy - Correct Answer-51. Decreases throughout
pregnancy. The MAC progressively decreases during pregnancy, at term by as much as
40%. MAC returns to normal by the third day after delivery.
50. During pregnancy, the minimum alveolar concentration (MAC):
• decreases until the 20th week
• increases until the 20th week
• decreases throughout the pregnancy
• increases throughout the pregnancy - Correct Answer-50. A. There were 100,000
reported exposures to acetaminophen in 2005, 333 of which were fatal and 3310
considered significant. Acetaminophen is a central COX-2 and prostaglandin synthase
inhibitor and is responsible for 51% of all acute hepatic failure in the US. 90% of
ingested acetaminophen is conjugated with glucuronide or sulfate, 5-15% is oxidized to
NAPQI (by cytochrome P450) which is toxic and is detoxified by glutathione, and 5%
eliminated unchanged in urine. If sulfate becomes saturated, NAPQI can no longer be
detoxified by glutathione and it reaches toxic levels in the liver. Stage I acetaminophen
toxicity: asymptomatic Stage II acetaminophen toxicity: hepatitis-like findings (AST/ALT,
INR) Stage III acetaminophen toxicity: peak hepatotoxicity at 72-96 hours Stage IV
acetaminophen toxicity: hepatic recovery (does not always occur) N-acetylcysteine
(augments glutathione reserves) @ 140 mg/kg loading dose PO or 150 mg/kg IV
(preferable) followed by repeated (smaller) doses every 4 hours. Because NAC is so
effective, charcoal is not needed unless co-ingestion is suspected.
49. Which of the following is MOST true regarding acetaminophen poisoning?
• 5% of acetaminophen is excreted in the urine
• Acetaminophen is responsible for at least 90% of acute hepatic failure in the US
• Acetaminophen is a central COX-1 inhibitor
• The majority of acetaminophen is oxidized by NAPQI (which is detoxified by
glutathione) - Correct Answer-49. Topically applied ophthalmic medications are
absorbed: more quickly than subcutaneous administration. Topically applied ophthalmic
medications are absorbed at a rate intermediate between intravenous and
subcutaneous injection. Children and the elderly are at particular risk for the toxic
effects of topically applied medications.
48. Which of the following is NOT a contraindication to activated charcoal in the setting
of suspected aspirin poisoning?
• Bowel obstruction
• Bowel perforation
• Inability to protect airway
• Two hours since ingestion - Correct Answer-two hours since ingestion
47. The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
(Enter numerical answer in box below. Click 'Next' when completed.) - Correct Answer47. The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
(Enter numerical answer in box below. Click 'Next' when completed.) 15-25%. Passive
flow accounts for about 75 - 85% of ventricular filling. The remaining 15 - 25% occurs as
a result of atrial contraction, which is lost during atrial fibrillation.
46. A 74-year-old man with a past medical history significant for hypertension and
coronary artery disease is scheduled for a right thoracotomy for right upper lobectomy.
His current medications include aspirin, clopidogrel, lisinopril, and atenolol. A T5-6
thoracic epidural is planned or preoperative analgesia. What is the MINIMUM amount of
time the patient should be off his aspirin and clopidogrel prior to having an epidural
placed?
• 5 days
• 7 days
• 10 days
• 14 days
• Does not need to hold prior to epidural placement - Correct Answer-46. 7 days. The
current recommendations from the American Society of Regional Anesthesia are to wait
7 days after the last dose of clopidogrel prior to neuraxial block placement to avoid the
potential for epidural hematoma development due to the potent anti-platelet effect of this
thienopyridine agent. Ticlopidine, another thienopyridine anti-platelet agent similar to
clopidogrel, should be held for 14 days prior to epidural placement. NSAIDs, COX-2
inhibitors, and aspirin are not contraindicated with neuraxial blockade when used by
themselves.
45. The age group with the highest minimum alveolar concentration (MAC) of
desflurane is:
• 2 - 3 months
• 1 - 2 years
• 25 - 30 years
• greater than 75 years - Correct Answer-45. 2 - 3 months. The two-to-three-months-ofage group represents the highest MAC requirement. MAC subsequently decreases with
advancing age.
During cardiopulmonary bypass, the amount of drainage to the bypass reservoir is
dependent on which of the following?
• Central venous pressure and the height differential between the heart and the venous
reservoir canister
• Central venous pressure, height differential between the heart and the venous
reservoir canister, and flow of the bypass circuit
• Central venous pressure, height differential between the venous cannula and the
arterial cannula
• None of the above are correct - Correct Answer-44. A. Venous blood (venous
drainage) enters the cardiopulmonary bypass circuit by gravity or siphonage into a
venous reservoir placed 40 to 70 cm below the level of the heart. The amount of
drainage is determined by central venous pressure; the height differential between the
heart and the venous reservoir canister; resistance in cannulas, tubing, and connectors;
and absence of air within the system. Central venous pressure is determined by
intravascular volume and venous compliance, which is influenced by medications,
sympathetic tone, and anesthesia. "Chattering" or "fluttering" of the venous cannula
results when compliant venous or atrial walls collapse against the cannular intake
opening. This collapse results from inadequate blood volume or excessive siphon
pressure. This phenomenon is corrected by adding volume to the patient.
A decrease in cerebral blood flow is seen after the administration of:
• isoflurane
• propofol
• desflurane
• ketamine - Correct Answer-43. A decrease in cerebral blood flow is seen after the
administration of: propofol. The inhaled anesthetic agents and ketamine all increase
cerebral blood flow (CBF). Benzodiazepines, etomidate, propofol and barbiturates all
decrease CBF.
Which of the following cardiac valvular abnormalities is MOST frequently observed
during the acute embolization of fat, air or thrombus?
Aortic regurgitation
• Mitral regurgitation
• Pulmonic regurgitation
• Tricuspid regurgitation - Correct Answer-42. D- tricuspid regurg. Classically with
embolization of fat, air or thrombus to the heart and pulmonary vasculature, pulmonary
vascular resistance increases and causes right ventricular dilation and dysfunction
which may progress to right ventricular failure. Tricuspid regurgitation is often seen on
TEE as a result of tricuspid annular dilation due to right ventricular dilation and the
increased pulmonary vascular resistance.
A 65-year-old woman with severe mitral regurgitation presents for mitral valve repair.
She develops hypotension after the induction of general anesthesia. Vital signs include
BP 78/40 mmHg, HR 84 bpm, and SpO2 98%. Which of the following drugs will MOST
effectively treat her hypotension without worsening her mitral regurgitation?
• Ephedrine
• Atropine
• Vasopressin
• Phenylephrine - Correct Answer-40. Ephedrine. Hemodynamic goals for patients with
mitral regurgitation include maintenance of sinus rhythm and a relative tachycardia in
order to minimize regurgitation. Interventions that increase left ventricular afterload
should be avoided in order to promote forward systemic cardiac output and reduce
mitral regurgitation. Preload should be judiciously maintained but arbitrary fluid boluses
should be avoided as excessive volume administration can worsen ventricular distention
and mitral regurgitation. Left ventricular contractility should be maintained. Mitral
regurgitation may occur as a result of chronic coronary artery disease and ischemia of
the left ventricle, in addition to papillary muscle dysfunction due to ischemia. There are
two papillary muscles in the left ventricle that connect the left ventricular walls to the
mitral valve apparatus via the chordae tendinae. The posterior papillary muscle derives
its blood supply from the posterior descending artery and the anterior papillary muscle
receives blood supply from both the left anterior descending artery and the circumflex
coronary artery. Thus, the posterior papillary muscle is most vulnerable to ischemia.
With ischemia of the inferior left ventricular wall due to occlusion of the posterior
descending artery, the posterior papillary muscle becomes dysfunctional. If the ischemia
continues, the posterior papillary muscle may rupture, ultimately leading to acute mitral
regurgitation.
Anesthetic implications of multiple sclerosis include:
• exacerbation induced by spinal anesthesia
• exacerbation induced by epidural anesthesia
• exacerbation of symptoms secondary to hypothermia
• the presence of significant peripheral neuropathy causing severe hyperkalemia after
succinylcholine administration - Correct Answer-39. Exacerbation induced spinal
anesthesia. Spinal anesthesia has been reported to cause exacerbation of the disease.
Epidural and other regional techniques appear to have no adverse effect, especially in
obstetrics; however a lower concentration of local anesthetic should be used.
Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is
usually improved by mild hypothermia.
38. Which of the following is NOT a side effect of mild hypothermia?
• Coagulopathy
• Diuresis
• Seizures
• Ventricular arrhythmias - Correct Answer-38. Coagulaopathy. Hypothermia is
classified as mild (core temperature 32-35°C), moderate (28-32°C), and severe (<
28°C), and leads to multiple physiologic derangements, including in the CNS (fatigue,
ataxia, reduced gag reflex, coma, decreased EEG activity), cardiovascular system
(hypovolemia [secondary to diuresis], arrhythmias [including asystole]), pulmonary
system (respiratory depression, apnea, pulmonary edema), kidneys ("cold diuresis"),
and immune system (immunosuppression). Most anesthesiologists are aware of the
adverse effects associated with mild hypothermia in the perioperative period (e.g.
increased risk of wound infection, cardiac morbidity, and PACU stay). However, in the
ICU population, some of whom are exposed to environmental extremes, the
manifestations of hypothermia become more numerous.
37. The National Institute for Occupational Safety (NIOSH) recommends limiting the
operating room concentration of nitrous oxide to:
• 0.5 ppm
• 5 ppm
• 25 ppm
• 50 ppm - Correct Answer-37. The National Institute for Occupational Safety (NIOSH)
recommends limiting the operating room concentration of nitrous oxide to: 25 ppm.
NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and
halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used).
36. Correct statements concerning the use of benzodiazepines in the elderly include:
• volume of distribution is increased
• reduced pharmacodynamic sensitivity is observed
• the elimination half-life of diazepam, but not midazolam, is increased
• all of the above - Correct Answer-36. A. Increased Volume of distrubution. Aging
increases the volume of distribution for all benzodiazepines, effectively prolonging their
elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The
elimination half-lives of both diazepam and midazolam are increased.
35. Magnesium sulfate therapy is the gold standard for seizure prophylaxis in the setting
of preeclampsia. Which of the following is the MOST likely side effect of magnesium?
• Decreased motor endplate sensitivity to acetylcholine
• Development of coagulopathy
• Increased systemic vascular resistance
• Inhibition of acetylcholinesterase - Correct Answer-35. A. Magnesium is a divalent
cation that competes with calcium and inhibits many calcium-dependent processes.
With regard to muscle relaxation, it is known to: (1) antagonize calcium either at the
motor end plate or cell membrane, reducing calcium influx into the myocyte; (2)
Compete with calcium for low-affinity calcium binding sites on the outside of the SR
membrane and prevent the rise in free intracellular calcium concentration; and (3)
Attenuate the: release of acetylcholine at neuromuscular junction, sensitivity of the
motor endplate to acetylcholine, and excitability of the muscle membrane. Implications
for and potential interactions with anesthesia care are many. Magnesium may increase
the likelihood of hypotension with epidural use (studies with gravid ewes demonstrated
reduced maternal MAP, but not uterine blood flow or fetal oxygenation during epidural).
Magnesium can potentiate the effects of both depolarizing and non-depolarizing muscle
relaxants (probably not as much with depolarizing), increasing potency and duration
(clinically it is still advised to use the same intubating dose as potentiation can be
variable; and smaller maintenance doses). Magnesium can trigger hypotension,
especially with concurrent use calcium entry-blocking agents (nifedipine). Sedation is
very commonplace with therapeutic levels of serum magnesium; a 20% decrease in
MAC can be seen with serum magnesium levels 7-11 mg/dL Magnesium can
hypothetically affect any calcium-dependent process, but inhibition of coagulation due
specifically to isolated magnesium use is not thought to be clinically significant.
34. In the midesophageal long axis view at approximately 110-130 degree multiplane
angle, which of the left ventricular walls can be BEST assessed for function and
regional wall motion abnormalities? [Show Less]