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Category: Critical Care Medicine-Surgery, Trauma, and Transplantation--->Cardiothoracic and Vascular Surgery
Page: 2

Question 6# Print Question

A 72-year-old female is admitted to the ICU following a right upper lobectomy for squamous cell carcinoma that was found incidentally on workup of a thoracic vertebral compression fracture. Her past medical history is significant for 35 pack-year smoking history. She underwent preoperative PFTs that showed no evidence of significant pulmonary disease with a normal FEV1 and DLCO. Otherwise, she has an old compression fracture at T10, osteoarthritis, and mild peripheral vascular disease. She arrived to the ICU extubated, painfree with epidural analgesia, and on 10 L oxygen delivered via facemask with an oxygen saturation of 88%. An arterial blood gas is drawn, which reveals:

  • a pH of 7.34
  • pCO2 of 48
  • a pO2 of 64

Given her age, smoking history, and right upper lobectomy, you are concerned about postoperative respiratory failure.

Which of the following is the best method during operative one lung ventilation to decrease the incidence of post-op acute lung injury?

A. Ensure tidal volume of 8 to 10 mL/kg ideal body weight (IBW) to prevent atelectasis in the ventilated lung and to ensure adequate oxygenation
B. Maintain 100% FiO2 throughout one lung ventilation to avoid hypoxia and hypoxic vasoconstriction
C. Avoid the use of PEEP in the ventilated lung to allow the use of higher tidal volume ventilation while reducing the risk of barotrauma
D. Ensure tidal volume of 4 to 6 mL/kg IBW combined with 5 to 10 cm H2O PEEP to reduce overdistention of the ventilated single lung and maintain adequate oxygenation


Question 7# Print Question

A 29-year-old male with a history of two spontaneous pneumothoraces in the past year, and mild exercise-induced asthma, is admitted to the ICU for monitoring after a video assisted thoracoscopic surgery for resection of a 6 × 10 cm bleb in the right lower lobe. The procedure was uncomplicated and the patient was extubated without difficulty in the operating room before transport to the ICU. 

Per the anesthesiologist’s note, to facilitate surgical exposure on the operative lung, the patient was intubated with a left-sided DLT after induction of anesthesia. Single lung ventilation (of the nonoperative lung) was then initiated following conformation of proper position of the DLT using a flexible fiberoptic bronchoscope.

Which of the following is an advantage of a DLT over a bronchial blocker (BB)?

A. DLT is preferred in patients who require postoperative mechanical ventilation
B. Selective lobar isolation can only be achieved using a DLT
C. Bronchial suctioning of the nonventilated lung is only possible when using a DLT
D. DLT is the preferred method to isolate the lung in a tracheostomized patient who has had a laryngectomy


Question 8# Print Question

A 46-year-old previously healthy male who was recently diagnosed with lymphoma is transferred to your ICU from an outside hospital in septic shock due to presumed pneumonia. On arrival he is developing worsening hypoxemic, hypercarbic respiratory failure, and will need to be intubated. A CXR is significant for bilateral, patchy opacities, and a widened superior mediastinum.

Which of the following tests would be most helpful in determining the patient’s risk for airway compromise during induction of general anesthesia (GA) and intubation?

A. Normal, recent pulmonary function tests
B. Ability to lie supine without orthopnea or cough
C. Lung and airway auscultation
D. Echocardiogram


Question 9# Print Question

A 46-year-old female with a history of atrial fibrillation presents with a left atrial appendage clot, despite being on oral anticoagulation therapy. She was admitted to the ICU from the electrophysiology laboratory following left atrial appendage isolation with the LARIAT procedure. She received 5000 units of heparin before trans-septal puncture. Following successful left atrial appendage exclusion, she received protamine and all procedural catheters were removed. Over the course of her first hour in the ICU she has become progressively more hypotensive and tachycardic, and she remains in atrial fibrillation. On physical examination she is tachypneic with jugular venous distension and muffled heart sounds.

What is the next best step in confirming her diagnosis?

A. Assessing for the presence of pulsus paradoxus
B. Cardiac MRI
C. Echocardiogram
D. Cardiac catheterization


Question 10# Print Question

A 68-year-old male with a thoracic aortic aneurysm underwent thoracic endovascular aortic stent graft repair (TEVAR). A lumbar spinal drain was placed at the start of the case for spinal cord protection and cerebral spinal fluid (CSF) pressure was maintained at less than 15 mm Hg by intermittent CSF drainage as needed throughout the case. The procedure went well and lasted approximately 6 hours. At the end of the case, the patient was extubated and was admitted to the ICU for post-op management.

The spinal drain was kept in place, and the CSF pressure was maintained in the 10 to 12 mm Hg range for the first 24 hours with intermittent CSF drainage as needed. On postoperative day #2, the patient remained neurologically intact and the drain was clamped. The following day, he was noted to have bilateral lower extremity weakness. The ICU team was called urgently to evaluate him. He was hemodynamically stable with a heart rate of 65, blood pressure of 110/55 with a MAP of 73, respiratory rate of 12 on room air with an oxygen saturation of 98%. Laboratory test results revealed a white blood cell count of 10, hemoglobin of 8, and platelets of 220. Physical examination was remarkable only for symmetric bilateral lower extremity weakness of 2/5.

Which of the following interventions would be the least helpful to restore neurologic function in the patient?

A. Reopen the spinal drain and drain off CSF to a pressure of approximately 10 mm Hg. Do not exceed 10 to 15 mL of CSF drainage per hour
B. Increase MAP to 90 mm Hg or greater using vasopressors as needed
C. Transfuse patient to a hemoglobin of 10 or greater
D. Reopen the spinal drain and immediately drain 30 mL CSF per hour as needed to restore neurologic function and achieve a CSF pressure of less than 10 mm Hg




Category: Critical Care Medicine-Surgery, Trauma, and Transplantation--->Cardiothoracic and Vascular Surgery
Page: 2 of 3