NBCRNA Anesthetic Complications and Crisis Management 2 — Questions and Answers
Question 1: Intraoperative hypotension most commonly defined as MAP <65 mmHg is most rapidly treated with which initial intervention?
- IV fluid bolus and phenylephrine or ephedrine based on heart rate (Correct answer)
- Increasing volatile anesthetic concentration
- Initiating norepinephrine infusion as first line
- Dopamine infusion
Correct answer: IV fluid bolus and phenylephrine or ephedrine based on heart rate
A fluid bolus addresses hypovolemia while a vasopressor (phenylephrine for tachycardia, ephedrine for bradycardia) corrects vasodilation or reduced SVR; the choice depends on the underlying cause.
Question 2: Pulmonary embolism (PE) occurring intraoperatively presents with which characteristic hemodynamic pattern?
- Sudden hypotension, increased airway pressure, and decreased ETCO2 (Correct answer)
- Hypertension with bradycardia
- Decreased airway pressure and increased ETCO2
- Bilateral wheeze with normal hemodynamics
Correct answer: Sudden hypotension, increased airway pressure, and decreased ETCO2
Massive PE causes acute right heart obstruction, reducing pulmonary blood flow; ETCO2 drops (dead space increase), airway pressures rise (from pulmonary hypertension), and systemic BP falls.
Question 3: Venous air embolism (VAE) is detected earliest by which monitor?
- Precordial Doppler ultrasound (Correct answer)
- ETCO2 decline
- Pulmonary artery catheter
- Transesophageal echocardiography
Correct answer: Precordial Doppler ultrasound
Precordial Doppler detects as little as 0.05 mL of intracardiac air as a characteristic 'mill-wheel' murmur, earlier than any other clinical or monitoring sign.
Question 4: Postoperative cognitive dysfunction (POCD) is most strongly associated with which patient population?
- Elderly patients (>65 years) undergoing major surgery (Correct answer)
- Pediatric patients under 5 years
- Healthy young adults undergoing minor procedures
- Patients with pre-existing anxiety disorders
Correct answer: Elderly patients (>65 years) undergoing major surgery
POCD predominantly affects elderly patients; age-related neuroinflammatory vulnerability, combined with surgical stress and anesthetic exposure, leads to persistent cognitive deficits lasting weeks to months.
Question 5: Intraoperative ST-segment depression >1 mm in two contiguous leads suggests:
- Myocardial ischemia requiring immediate assessment of hemodynamics and coronary perfusion (Correct answer)
- Ventricular hypertrophy without ischemia
- Hyperkalemia
- Normal response to volatile anesthetic agents
Correct answer: Myocardial ischemia requiring immediate assessment of hemodynamics and coronary perfusion
New horizontal or down-sloping ST depression >1 mm in ≥2 contiguous leads indicates subendocardial ischemia; immediate intervention to restore coronary perfusion pressure (increase MAP, reduce heart rate) is required.
Question 6: The most common cause of intraoperative bradycardia during general anesthesia is:
- Vagal stimulation from surgical manipulation or deep inhalation anesthesia (Correct answer)
- Hypothermia below 32°C
- Beta-blocker toxicity
- Sinus node disease
Correct answer: Vagal stimulation from surgical manipulation or deep inhalation anesthesia
Vagotonic reflexes triggered by peritoneal stretch, ocular manipulation, or laryngoscopy — combined with the inherent vagotonic effect of volatile anesthetics — make vagal stimulation the most frequent cause of intraoperative bradycardia.
NBCRNA Anesthetic Complications and Crisis Management 2
Intraoperative hypotension most commonly defined as MAP <65 mmHg is most rapidly treated with which initial intervention?