BGHMC CV Module 2025 Quiz D

An 82-year-old with symptomatic severe aortic stenosis (AVA 0.6 cm²), GI bleeding stabilized, now requires urgent right hemicolectomy. In the OR after minimal doses of etomidate and fentanyl, MAP falls to 52 mmHg, HR 86, sinus rhythm. Best immediate step?

• Titrate phenylephrine to restore diastolic pressure and coronary perfusion.

• Titrate ephedrine to improve heart rate and contractility.

• Titrate nitroglycerin to reduce wall stress and preload.

• Titrate esmolol to reduce myocardial oxygen demand.

• Titrate norepinephrine only after a 1 L crystalloid bolus.

A 68-year-old with ischemic cardiomyopathy (EF 25%), ARNI continued morning-of, becomes profoundly vasoplegic after induction. Best vasopressor plan?

• Titrate norepinephrine as first-line and add vasopressin if refractory.

• Titrate phenylephrine as first-line and add ephedrine if refractory.

• Titrate epinephrine as first-line and add milrinone if refractory.

• Titrate dopamine as first-line and add nitroprusside if refractory.

• Titrate vasopressin as sole agent throughout the case.

During thoracotomy with one-lung ventilation (FiO₂ 1.0), after recruitment and proper lateral decubitus, SpO₂ falls from 95%→86%. Best next maneuver?

• Apply CPAP 2–5 cmH₂O with oxygen to the non-dependent lung.

• Increase desflurane to deepen anesthesia and reduce oxygen consumption.

• Increase PEEP to 14 cmH₂O on the dependent lung immediately.

• Add nitroprusside to improve perfusion homogeneity.

• Add nitrous oxide to augment alveolar ventilation.

A 75-year-old with severe pulmonary hypertension (mPAP 48 mmHg), chronic sildenafil and inhaled prostacyclin, becomes hypotensive during pneumoperitoneum; PAP rises to 70/38, ETCO₂ increases from 33→45. Best integrated first step?

• Increase minute ventilation and titrate norepinephrine to maintain MAP.

• Increase PEEP to 15 cmH₂O and titrate phenylephrine to maintain MAP.

• Reduce minute ventilation and titrate vasopressin to maintain MAP.

• Increase volatile depth and titrate nitroglycerin to reduce PVR.

• Start epinephrine and tolerate permissive hypercapnia.

A pacer-dependent CRT-P patient needs major head-and-neck surgery with frequent monopolar cautery above the clavicle. Preop programming is available. Best device plan?

A 72-year-old with concentric LVH (HFpEF), CKD stage 4, develops hypotension after induction: PPV 6%, TEE shows small hyperdynamic LV, no RWMAs. Best hemodynamic move?

• Titrate phenylephrine to restore afterload before cautious fluid.

• Titrate dobutamine to increase inotropy and stroke volume.

• Titrate nitroprusside to reduce afterload and LV wall stress.

• Titrate esmolol to slow heart rate and prolong diastole.

• Titrate large crystalloid bolus to reduce PPV to <3%.

In awake carotid endarterectomy under regional anesthesia, contralateral weakness appears after cross-clamp; MAP is 140 mmHg (baseline 130 mmHg). Best action?

• Request immediate shunt placement to restore regional flow.

• Hyperventilate to reduce cerebral metabolic demand.

• Start nicardipine to maintain MAP 110 mmHg.

• Administer mannitol to reduce cerebral edema.

• Increase anesthetic depth to suppress agitation.

A patient with symptomatic severe mitral stenosis (mean gradient 15 mmHg) and chronic AF (rate 78) develops hypotension (MAP 58) and rising ETCO2 during pneumoperitoneum. Best initial step?

• Increase minute ventilation and titrate phenylephrine to maintain SVR.

• Increase PEEP and titrate nitroglycerin to reduce pulmonary pressures.

• Reduce minute ventilation and titrate ephedrine to increase heart rate.

• Increase volatile anesthetic and titrate esmolol to control demand.

• Liberalize IV fluids to raise CVP by >5 mmHg.

A 64-year-old with continuous-flow LVAD shows Doppler MAP 48 mmHg, low pulsatility index, rising lactate after positioning; ventilation is controlled with PEEP 8 cmH2O. Best correction?

• Reduce PEEP and give a fluid bolus while titrating norepinephrine.

• Increase PEEP and give nitroprusside while lowering LVAD speed.

• Maintain PEEP and give esmolol while increasing LVAD speed.

• Reduce PEEP and give furosemide while maintaining current LVAD speed.

• Maintain PEEP and give phenylephrine while lowering LVAD speed.

Beach-chair shoulder arthroscopy: arm-cuff MAP 70 mmHg; external auditory meatus is 30 cm above the transducer. Best interpretation and action?

• Cerebral perfusion is ~47 mmHg; increase systemic pressure promptly.

• Cerebral perfusion is ~70 mmHg; maintain current settings.

• Cerebral perfusion is ~60 mmHg; begin vasodilator therapy.