AMERICAN BOARD OF ANESTHESIOLOGY AMERICAN SOCIETY OF ANESTHESIOLOGISTS IN-TRAINING EXAMINATION Book A 1993 PREPARED IN COOPERATION WITH NATIONAL BOARD OF MEDICAL EXAMINERS® Copyright© 1993 by the Joint Council on In-Training Examinations, American Board of Anesthesiology/American Society of Anesthesiologists. All rights Reserved. Reproduction of this Copyrighted Material is Prohibited. DIRECTIONS : Each of the numbered items or incomplete statements in this section is followed by answers or by comple• tions of the statement. Select the ONE lettered answer or completion that is BEST in each case and fill in the circle contain• ing the corresponding letter on the answer sheet. 1. Left ventricular subendocardial perfusion pressure is best estimated by the difference between (A) mean arterial and central venous pressures (B) diastolic arterial and pulmonary artery occlusion pressures (C) mean arterial and pulmonary artery occlusion pressures (D) systolic arterial and pulmonary artery occlusion pressures (E) diastolic arterial and central venous pressures 2. Oxygen 100 ml/min is bubbled through a vaporizer containing an anesthetic with a vapor pressure of 150 mmHg, and this mixture is added to a fresh gas flow of 5 L!min. The delivered anesthetic concentration is (A) 0.25% (B) 0.5% (C) 1% (D) 2.5% (E) 5% 3. In children with preoperative upper respiratory tract infection, which of the following is associated with the greatest risk for postoperative airway obstruction? (A) Age less than 1 year (B) Endotracheal intubation (C) Head and neck surgery (D) Inadequate airway humidification (E) Surgery for more than two hours 4. An 8-kg, 1-year-old child has a measured blood loss of 50 ml during the first two hours of a rectal pull-through opera• tion. Preoperative hematocrit was 31%. Balanced saline solution 150 ml has been administered for replacement. Urine output has been 2 ml for the last hour, heart rate is 160 bpm, and blood pressure is 40/15 mmHg. The most appropriate fluid therapy is (A) 25% albumin (B) balanced salt solution (C) balanced salt solution and mannitol (D) 5% dextrose in 0.45% saline solution (E) packed red blood cells Page2 Copyright© 1993 by the Joint Council on In-Training Examinations, American Board of Anesthesiology/American Society of Anesthesiologists. All rights Reserved Reproduction of this Copyrighted Material is Prohibited 5. A 24-year-old man who sustained multiple rib fractures in a motor vehicle accident has air leaks through bilateral chest tubes. Which of the following is most likely following initiation of high-frequency jet ventilation? (A) Airway pressure will be measured most reliably at the proximal (external) end of the endotracheal tube (B) Atelectatic areas of the lungs will re-expand (C) Changes in end-tidal carbon dioxide tension measured at the tip of the endotracheal tube will match changes in PaC02 (D) Hypercarbia will develop (E) The air leaks will be proportional to peak airway pressure 6. A 35-yea:r-old man has acute onset of low back pain, lower extremity weakness, and bladder dysfunction. He had a lumbar laminectomy two years ago. A myelogram shows disk herniation at L4-5. The most appropriate management is (A) bed rest (B) administration of a nonsteroidal anti-inflammatory agent (C) epidural administration of a corticosteroid (D) epidural administration of a local anesthetic (E) surgical decompression 7. Which of the following is more likely to occur with use of trimethaphan to induce hypotension than with use of nitro• prusside? (A) A predictable decrease in mean arterial pressure (B) Increased mixed venous P02 (C) Increased serum lactate concentration (D) Mydriasis (E) Reflex tachycardia 8. An increased initial dose and a decreased maintenance dose of pancuronium are required in patients with (A) advanced age (B) burns (C) cirrhosis (D) chronic renal failure (E) fever 9. Which of the following statements concerning variable decelerations of fetal heart rate is true? (A) It indicates compression of the umbilical cord (B) It indicates compression of the fetal head (C) It indicates prematurity (D) It is obliterated by atropine (E) It occurs normally following epidural anesthesia 10. Which of the following is a complication of glycine used for irrigation during transurethral resection of the prostate? (A) Epileptiform activity on EEG (B) Peripheral neuropathy (C) Tachycardia (D) Transient blindness (E) Transient deafness Page 3 Copyright© 1993 by the Joint Council on In-Training Examinations, American Board of Anesthesiology/American Society of Anesthesiologists. All rights Reserved. Reproduction of this Copyrighted Material is Prohibited. 11. While checking an anesthesia machine, opening the oxygen flow-control valve yields no oxygen flow, although the wall-mounted oxygen pipeline supply gauge reads 50 psig. Opening the backup oxygen cylinder results in normal oxygen flow. The most likely cause is (A) failure of the oxygen pipeline supply (B) failure of the second-stage oxygen pressure regulator (C) a malfunctioning check valve in the oxygen pipeline supply inlet (D) a malfunctioning fail-safe valve (E) a malfunctioning oxygen flow-control valve 12. Which of the following statements concerning banked blood is true? (A) Red blood cells preserved with CPDA-1 have a shelf life of approximately 21 days (B) Packed red blood cells deliver oxygen normally immediately after administration (C) Packed red blood cells contain most of the leukocytes present in the donated unit (D) Citrate is used as a source of energy for whole blood (E) Stored whole blood contains all coagulation factors except II and VIII 13. With long-term administration, which of the following drugs produces the most prolonged sedative effect of diazepam? (A) Cimetidine (B) Famotidine (C) Metoclopramide (D) Ranitidine (E) Warfarin 14. The effect of neomycin at the neuromuscular junction is (A) decreased by depolarizing relaxants (B) partially reversed by calcium (C) potentiated by anticholinesterases (D) prevented by pretreatment with magnesium (E) primarily prejunctional 15. Compared with diazepam, midazolam (A) is more lipid soluble (B) has a longer elimination half-life (C) has a larger volume of distribution (D) has a greater clearance (E) undergoes slower hepatic metabolism 16. A 73-year-old woman with a preoperative serum creatinine concentration of 2.1 mgI dl develops oliguria during enflu• rane anesthesia. Urine sodium concentration is 10 mEq/L and urine osmolality is 450 mOsm/L. The most likely cause of these findings is (A) acute renal failure (B) chronic renal insufficiency (C) decreased renal perfusion (D) fluoride nephrotoxicity (E) intraoperative administration of furosemide Page 4 Copyright© 1993 by the Joint Council on In-Training Examinations, American Board of Anesthesiology/American Society of Anesthesiologists. All rights Reserved. Reproduction of this Copyrighted Material is Prohibited. 17. The odor of isoflurane is noted during isoflurane anesthesia with an endotracheal tube and mechanical ventilation. Mean airway pressure is unchanged. A scavenging system with an open interface and an active disposal system is being used. The most likely cause of the isoflurane odor is (A) a leak in the inspiratory limb of the anesthesia circuit (B) application of excessive negative pressure to the scavenging interface (C) malfunction of the pop-off valve of the anesthesia machine (D) obstruction of the gas disposal tubing leading from the scavenging interface (E) obstruction of the transfer tubing to the scavenging interface 18. During active labor, 10 ml of bupivacaine 0.5% with epinephrine 1:200,000 is administered epidurally. Fifteen minutes later, maternal blood pressure is 70/50 mmHg and heart rate is 70 bpm; fetal heart rate is 90 bpm for 45 seconds, with loss of beat-to-beat variability. The most likely explanation for the fetal vital signs is (A) fetal bupivacaine cardiotoxicity (B) maternal bupivacaine cardiotoxicity (C) maternal hypotension (D) uterine artery vasoconstriction (E) umbilical cord compression 19. A 2500-g, 12-hour-old infant is tracheally intubated and mechanically ventilated at a rate of 20/min with an FI02 of 0.4 and peak inspiratory pressure of 25 cmH20. At birth, amniotic fluid was meconium stained and Apgar scores were 2 and 7. The most recent arterial blood gas levels are Pa02 50 mmHg, PaC02 55 mmHg, and pH 7.20. The most appro• priate management is to (A) administer sodium bicarbonate (B) begin intravenous infusion of prostaglandin E1 (C) increase FI02 (D) increase ventilation (E) perform bronchial lavage 20. During insufflation of the peritoneal cavity with carbon dioxide at the start of laparoscopy, heart rate increases to 140 bpm, blood pressure decreases to 70/40 mmHg, and a loud murmur is heard through the esophageal stethoscope. The most appropriate immediate step is to (A) administer a vasoconstrictor (B) infuse crystalloid solution rapidly (C) discontinue the inhaled anesthetic (D) insert a central venous catheter (E) deflate the abdomen 21. Thirty-six hours after primary repair of meningomyelocele, a term newborn has frequent periods of apnea lasting 25 sec onds and associated with oxygen desaturation to 80%. The most likely explanation is (A) hyperglycemia (B) loss of cerebrospinal fluid (C) obstructive hydrocephalus (D) residual anesthetic effect (E) normal postoperative events Page 5 Copyright© 1993 by the Joint Council on In-Training Examinations, American Board of Anesthesiology/American Society of Anesthesiologists. All rights Reserved. Reproduction of this Copyrighted Material is Prohibited. 22. The hemodynamic profile below is from a 62-year-old man in the ICU after coronary artery bypass grafting. Entering ICU +30 Minutes Heart rate (bpm) 90 120 Blood pressure (mmHg) 125/75 80/30 PADP (mmHg) 12 25 PAOP (mmHg) 10 25 CVP (mmHg) 6 8 Which of the following is the most likely cause of the changes occurring after 30 minutes? (A) Anaphylactic reaction (B) Left ventricular ischemia (C) Pericardia} tamponade (D) Pulmonary embolism (E) Septic shock 23. Myofascial pain is an example of (A) a central pain state (B) neuropathic pain (C) psychogenic pain (D) somatic pain (E) visceral pain 24.