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WorksheetsBGHMC CV Module 2025 Quiz C
Total questions: 50
Worksheet time: 50mins
A 72-year-old with insulin-dependent diabetes, CKD (eGFR 30), prior MI, and poor METs (<4) is scheduled for open aortobifemoral bypass. Resting ECG is uninterpretable (paced rhythm). The result of preop testing will change management (revascularization vs proceed). Best noninvasive test?
Exercise treadmill ECG
Coronary calcium score
Dobutamine stress echocardiography
Vasodilator stress echo
6-minute walk test
A 63-year-old with moderate AS (mean gradient 30 mmHg) and stable angina requires urgent hemicolectomy for obstruction. Which intraop hemodynamic goal is most critical?
Reduce afterload with nitroprusside
Avoid tachycardia and maintain diastolic pressure
Target low CVP to prevent edema
Hyperventilate to PaCO2 25 mmHg
Liberal PEEP to improve oxygenation
A 58-year-old with Chronic AF (rate 85) and severe MS presents for emergent laparotomy for peritonitis. Best induction plan?
Ketamine 2 mg/kg + ephedrine as needed
Etomidate/opioid blunting
High-dose propofol bolus to blunt sympathetic tone
Spinal anesthesia to avoid GA hemodynamics
Remifentanil bolus followed by nitroglycerin
A 66-year-old with NSTEMI 5 days ago (no PCI) has bowel ischemia requiring OR now. Which monitor/adjunct most improves intraop ischemia detection/management?
CVP
Arterial line plus intraop TEE
Pulmonary capillary wedge pressure
End-tidal CO2 trends
Pulse pressure variation
During carotid endarterectomy under GA, stump pressure is borderline and SSEPs fall after clamp. Best immediate intervention?
Mannitol bolus
Increase MAP ~20% above baseline
Hyperventilate to PaCO2 25
Give labetalol
Start nitroprusside
In the PACU after CEA, patient becomes drowsy and hypotensive (MAP 55) with focal neurologic deficits. Neck is soft, no hematoma. Most likely cause needing treatment now?
Cerebral hyperperfusion syndrome
Watershed ischemia from hypotension
Heparin rebound
Intracerebral hemorrhage
Embolism from clamp site
A 54-year-old with HOCM on metoprolol undergoes lap chole. Pneumoperitoneum + Trendelenburg causes hypotension and new systolic murmur. Best immediate step?
Dobutamine infusion
Phenylephrine bolus and reduce insufflation pressure
Nitroglycerin infusion
Esmolol bolus
High PEEP to increase afterload
A patient with CRT-D (not pacer-dependent) presents for mastectomy with monopolar cautery. What does placing a magnet over the device typically do?
Converts to asynchronous pacing and turns off shocks
Disables ICD tachy therapies but may not affect pacing mode
Increases pacing rate to 100 bpm
Shuts the device off completely
Has no effect if cautery is bipolar
A 68-year-old with severe AR, sinus rhythm 95, needs emergent colectomy for perforation. Suddenly BP falls to 80/40 after large phenylephrine bolus. Best next vasoactive?
More phenylephrine
Ephedrine or low-dose epinephrine
Esmolol
Vasopressin
Nitroprusside
During thoracotomy with one-lung ventilation (FiO2 0.8), SpO2 drops from 96% to 88% despite recruitment and optimal positioning. Best maneuver next?
Increase desflurane from 1.0 to 1.8 MAC
Apply CPAP to non-dependent lung or add apneic oxygenation
Add N2O
Raise PEEP on dependent lung to 15 cmH2O without recruitment
Start nitroprusside
A 76-year-old with HFpEF, severe concentric LVH, and CKD develops hypotension after induction; PPV is 6%. Which action best restores perfusion without precipitating pulmonary edema?
1-L crystalloid rapidly
Small phenylephrine doses to restore SVR
Start nitroglycerin
Esmolol infusion
High PEEP
A 62-year-old with bioprosthetic MVR (4 months ago) on aspirin presents for laparotomy. Antithrombotic plan?
Stop aspirin 7 days prior
Continue aspirin
Add warfarin 3 days preop
Bridge with heparin
Switch to clopidogrel
A 60-year-old with LVAD (continuous-flow) presents for lap hernia repair. Which statement is most correct regarding BP and preload intraop?
NIBP is reliable; MAP target is 40–50
Use Doppler for MAP 60–80 avoid hypovolemia and high PEEP
Vasodilators are first line for hypotension
Tachycardia improves LVAD flow
Treat low PI events with β-blockers
Intraop torsades occurs after ondansetron in a patient with borderline QT. Rhythm persists with MAP 65. Best first therapy?
Amiodarone bolus
Magnesium sulfate 2 g IV
Lidocaine 100 mg
Synchronized cardioversion
Atropine 0.6 mg
A 71-year-old with apical hypertrophic cardiomyopathy develops refractory hypotension during emergence after coughing. TEE: small LV cavity, mid-cavity gradient, no RWMA. Best treatment?
Phenylephrine + fluids
Dobutamine infusion
Nitroprusside infusion
Esmolol bolus then nitro
Milrinone
A 65-year-old with moderate AR and sepsis has MAP 55 despite adequate volume. Which vasopressor profile is most favorable?
Phenylephrine alone
Norepinephrine
Vasopressin alone
Dopamine at 10 μg/kg/min
Esmolol for reflex tachycardia
A 69-year-old with severe TR secondary to pulmonary HTN requires laparotomy. Which ventilator strategy best preserves RV output?
High PEEP (12–15) to reduce TR
Hypercapnia to shift Hb–O₂ curve
Avoid hypoxia/hypercarbia
Long I-time (I:E 1:1)
Large tidal volumes (10 mL/kg)
A 74-year-old with new LBBB, chest pressure, and hypotension develops during bowel resection. ST analysis unreliable. Best immediate diagnostic/management step?
Troponin now then ICU
TEE to evaluate new regional dysfunction and guide therapy
PA catheter
Stop surgery and extubate
Nitroglycerin bolus and observe
You plan neuraxial anesthesia for a hip fracture in an 80-year-old on apixaban; last dose was 24 h ago, CrCl 35 mL/min. Best course?
Proceed with spinal now
Avoid neuraxial
Reverse with vitamin K
Reverse with protamine
Give FFP then spinal
A 62-year-old with constrictive pericarditis presents for pericardiectomy. Which hemodynamic sign best distinguishes constriction from tamponade pre-incision?
Pulsus paradoxus
Kussmaul sign with prominent Y descent
Equalization with blunted Y descent
Water-hammer pulse
Cannon A waves only
A patient with stable CAD, Hb 7.8 g/dL after blood loss, HR 95, MAP 75, normal TEE wall motion, adequate oxygenation. Best next step?
Optimize hemodynamics/oxygen delivery
Transfuse to Hb ≥10
Give nitroglycerin
Start dobutamine
Hyperventilate
A 58-year-old with HFpEF and CKD has diuretic-induced metabolic alkalosis (HCO3− 34). During induction, BP falls; SVV 5%; LV small and hyperdynamic on TEE. Best cause-targeted therapy?
Phenylephrine and small fluid boluses
Dobutamine
Furosemide
Nitroprusside
Increase volatile anesthetic
A 70-year-old with carotid disease and contralateral occlusion undergoes CEA under regional. Mid-procedure patient becomes restless with contralateral weakness. Best first action?
Give fentanyl for comfort
Raise MAP and ask surgeon to shunt
Start nicardipine
Hyperventilate
Give mannitol
A 64-year-old with tachy-brady syndrome and dual-chamber pacemaker undergoes colectomy. Periodic cautery bursts coincide with asystolic pauses. Pads are on; magnet is available. Best immediate step?
Place magnet and continue
Stop cautery
Increase volatile to deepen anesthesia
Start epinephrine infusion
Use bipolar cautery without other changes
During EVAR with iliac limb deployment, the patient develops bradycardia and hypotension with ST depression. No bleeding. This is most consistent with:
A. Atheroembolism
B. Reflexes from baroreceptor and ischemia
C. Pulmonary embolism
D. Protamine reaction
E. Tension pneumothorax
A 52-year-old with WPW develops orthodromic AVRT intraop (narrow-complex SVT) at 190 bpm; BP 90/60, perfusing. Best therapy?
A. Adenosine 6 mg IV
B. Diltiazem 20 mg IV
C. Amiodarone 150 mg
D. Esmolol infusion
E. Procainamide 10 mg/kg
A 79-year-old with moderate aortic stenosis is scheduled for hip arthroplasty. Which nerve block plan is most consistent with hemodynamic goals?
High thoracic epidural with rapid initiation
Peripheral nerve blocks + GA
Spinal with hyperbaric bupivacaine 3 mL
Continuous epidural with bolus 15 mL 0.5% bupivacaine
Bier block
In a patient with severe MR undergoing laparoscopic colectomy, insufflation increases SVR and causes pulmonary edema. Best integrated management?
Increase PEEP to 15
Reduce insufflation pressure
Phenylephrine boluses
Esmolol bolus
Large fluid bolus
A 67-year-old with restrictive cardiomyopathy from amyloidosis presents for ORIF. Which induction approach best avoids decompensation?
Ketamine 2 mg/kg and ephedrine
Etomidate/low-dose opioid with gentle titration
High-dose propofol
Spinal anesthesia
Deep volatile mask induction
A 73-year-old with descending aortic dissection arrives hypertensive and tachycardic. Best sequence of IV therapy?
Nicardipine then esmolol
Esmolol then add vasodilator
Nitroprusside alone
Labetalol only
Hydralazine then esmolol
During OLV for left VATS, SpO2 falls despite CPAP to non-dependent lung. Blood gas shows PaO2 52 on FiO2 1.0. Best next strategy?
Intermittent reinflation of non-dependent lung and ensure dependent lung recruitment
Increase desflurane to 2 MAC
Add N2O
Increase PEEP blindly
Start nitroprusside
A 65-year-old with MI 3 weeks ago treated medically (no PCI) needs urgent colectomy for bleeding cancer. Antiplatelet: aspirin 81 mg daily. Best periop strategy?
Stop aspirin 7 days before
Continue aspirin
Start clopidogrel today
Stop aspirin morning-of only
Replace with LMWH
A 59-year-old with moderate MR and normal coronaries becomes hypotensive during beach-chair shoulder surgery. Arm MAP is 70; brain is 30 cm above transducer. Best interpretation/step?
CPP adequate
Cerebral MAP ≈ ~47
Decrease FiO2 to augment HPV
Lower head position worsens regurgitation
Give nitroprusside
A 66-year-old with saccular AAA undergoes open repair. Immediately after aortic cross-clamp, BP rises to 190/90 and ST depression appears. Best treatment pairing?
Large fluid bolus + phenylephrine
Increase anesthetic depth and add short-acting vasodilator while maintaining CPP
Esmolol only
Mannitol
High PEEP
A 72-year-old with CRT-P is pacer-dependent. You anticipate heavy unipolar cautery above the umbilicus. Best preop device plan?
Magnet during case
Program asynchronous pacing
Turn device off and use external pads only
Nothing—risk minimal
Change to VVI-40
A 61-year-old with pulmonary HTN on sildenafil and inhaled treprostinil becomes hypotensive (MAP 50) after induction. PAP 60/30. SpO2 96%. Best pressor choice?
Phenylephrine infusion
Norepinephrine infusion
Epinephrine boluses
Esmolol infusion
Nitroprusside infusion
A 74-year-old with recent TIA on clopidogrel presents for urgent hemicolectomy within 24 h of last dose. Platelet function testing shows significant inhibition. Which step most increases hemostatic capacity now?
Desmopressin only
Platelet transfusion timed near incision
Vitamin K
PCC
Tranexamic acid alone
A 65-year-old with HFrEF, EF 25% requires major abdominal surgery. Despite NE 0.1 µg/kg/min, MAP is 60 with lactate rising; TEE shows global LV depression, full IVC, no obstruction. Best next drug strategy?
Add phenylephrine
Add low-dose inodilator while maintaining MAP with NE
Start nitroprusside
Esmolol infusion
Increase volatile depth
A 69-year-old with tamponade needs pericardial window. Pre-incision, which action is most harmful?
Ketamine induction
Fluids
Positive-pressure ventilation with high PEEP
Phenylephrine
Maintaining spontaneous ventilation
A 68-year-old with CKD and resistant HTN becomes severely hypertensive on emergence (MAP 125), euvolemic, no pain. Best titrable IV agent?
Hydralazine
Nicardipine infusion
Nitroprusside as first line
Esmolol boluses only
Labetalol large bolus
A 73-year-old with orthostatic hypotension and severe AS presents for hip fracture repair. Which spinal technique, if any, best balances risk?
Standard single-shot spinal
Carefully titrated incremental epidural or peripheral blocks with GA—avoid single-shot sympathectomy
Combined spinal-epidural with full intrathecal dose
Spinal with isobaric bupivacaine 3 mL
No regional technique is ever acceptable
A 60-year-old with stable CAD on β-blocker and statin has postoperative troponin elevation (MINS) without symptoms. ECG is unchanged, hemodynamically stable. Best early management strategy?
Ignore since asymptomatic
Optimize oxygen balance and hemodynamics
Routine thrombolysis
Emergent cath for all MINS
Start dual antiplatelet therapy immediately
A 55-year-old with severe MR (flail P2) is in the prone position for spine surgery. Sudden hypotension occurs after high PEEP is applied. Best explanation and step?
PEEP reduced preload and increased regurgitant fraction
Increased LV afterload improves forward flow
Bradycardia from PEEP is beneficial
Give phenylephrine
Give esmolol
A 64-year-old with Mobitz II AV block (no pacer) requires urgent laparotomy. Best safety plan before induction?
Atropine on the table
Transcutaneous pads placed and transvenous pacing immediately available
Esmolol for rate control
Phenylephrine infusion
Proceed without pacing due to urgency
A 71-year-old with CABG (LIMA–LAD patent) develops ischemic ST changes during sternotomy for noncardiac thoracic surgery. MAP is 55, HR 102. First, most effective combined maneuver?
Nitroglycerin infusion alone
Reduce HR and restore MAP
Increase sevo to 2 MAC
Fluid bolus 1 L
Start dobutamine
A patient with prosthetic aortic valve (mechanical) on warfarin (goal INR 2.5) and no risk factors is scheduled for elective hernia repair. Neuraxial is planned. Best anticoagulation plan?
Continue warfarin
Hold warfarin 5 days
Bridge with therapeutic heparin regardless
Stop 2 days before only
Switch to DOAC
A 70-year-old with amyloid restrictive cardiomyopathy becomes hypotensive after modest blood loss. TEE: normal LV size, preserved EF, collapsible IVC. Which action best restores CO?
Careful volume repletion; avoid tachycardia
Nitroprusside
Esmolol
Milrinone first
High PEEP
A 63-year-old with primary pulmonary HTN is maintained on IV epoprostenol via dedicated pump/line. Intraop the pump fails. First priority?
Clamp line to prevent air
Resume epoprostenol immediately and support MAP with NE
Increase PEEP
Give nitroglycerin
Start labetalol
A 59-year-old with ischemic cardiomyopathy (EF 30%) and moderate functional MR becomes progressively hypotensive with rising filling pressures. TEE shows global hypokinesis, no LVOT obstruction, full IVC. Best drug pairing?
Phenylephrine only
NE to maintain MAP + low-dose dobutamine/milrinone to augment forward flow
Esmolol
Nitroprusside only
Vasopressin only
In a patient with severe AS under GA, which rhythm change is most dangerous and requires aggressive prevention/treatment?
Sinus bradycardia to 55
New-onset AF
First-degree AV block
Junctional rhythm at 60
Sinus tachycardia to 100
