INSTRUCTIONS

This booklet contains self-study questions of different types. Be sure you understand the directions
accompanying the questions before attempting to answer them.

All of you answers should be recorded on the separate answer sheet, which is enclosed.

The six-digit Identification Number printed in the box above the column labeled ACE ID# will be the
only means of identifying your scores. Fill in one number in each box and the corresponding circle under
each digit as shown in the SAMPLE below. Only one digit should be marked in each column. Be sure all
pencil marks are heavy and black. Marks should completely fill the circles. You need not enter your
Social Security Number.

Please note that this answer sheet has spaces for filling in more answers than are actually included in this
booklet. Ignore the part of the answer sheet after number 122.

It is requested that you answer the demographic questions (items 101-122) at the back of this booklet and
mark these answers on the answer sheet. Cumulative information gained will be used to describe the total
group of participants in the program and will help guide the development of future educational programs.

After you have submitted your answer sheet for scoring, an individualized Performance Report, which
provides a record of your answers, an evaluation of your performance, and the correct answers, will be
returned to you. It is suggested that you keep a record of your answers in this booklet as well as a record
of the Identification Number printed on your answer sheet in case you have any questions concerning the
scoring of your materials.

The completed answer sheet should be submitted for scoring in the pre-addressed postpaid envelope
provided. Scoring on this exercise will end on March 31, 2008.
DIRECTIONS FOR ITEMS 1-100: Each of the questions or incomplete statements below is followed
by four suggested answers or completions. Select the one that is best in each case and fill in the circle
containing the corresponding letter on the answer sheet.

1. A 72-year-old man is transferred to the intensive care unit after surgery to repair an abdominal
aortic aneurysm. He remains intubated and mechanically ventilated, but his muscle relaxant has
been reversed and he is starting to breathe. Tracings of the flow, volume, and airway pressure
waveforms from the mechanical ventilator are shown.

V= follow; Vt = tidal volume; Paw = airway pressure

Which of the following modes is MOST likely set on the ventilator?

(A) Spontaneous ventilation with continuous positive airway pressure (CPAP) and pressure
support
(B) Assist-control ventilation with positive end-expiratory pressure (PEEP) in the volume
preset mode
(C) Assist-control ventilation with PEEP in the pressure preset mode
(D) Airway pressure release ventilation

2. Which statement about etomidate is MOST likely true?

(A) The chemical structure is based on a steroid moiety.

(B) It may be used as an infusion for sedation in the intensive care unit.
(C) It causes pain on intravenous injection.
(D) Awakening following administration is due to hepatic metabolism.

3. Appropriate anesthetic management for a patient with epidermolysis bullosa (EB) would MOST
likely include

(A) avoidance of tracheal intubation.

(B) avoidance of tape to secure an intravenous catheter.
(C) obtaining a preoperative serum potassium level.
(D) using malignant hyperthermia precautions.

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4. A 65-year-old man is taking clopidogrel (Plavix) as part of the medical management of his
coronary artery disease. He is scheduled for right lower lobectomy to resect a squamous cell
carcinoma. He requests perioperative thoracic epidural analgesia. Which statement about this
scenario is MOST likely true?

(A) Clopidogrel inhibits platelet aggregation with a reversible mechanism.

(B) Clopidogrel is associated with pancytopenia.
(C) A single loading dose of clopidogrel may have a clinically significant effect on platelet
function.
(D) The American Society of Regional Anesthesia and Pain Medicine recommends that
clopidogrel be stopped three days before surgery.

5. Which statement about ketamine is MOST likely true?

(A) Ketamine decreases the cortical amplitude of somatosensory evoked potentials.

(B) Ketamine is associated with a decreased duration of action of nondepolarizing
neuromuscular blocking drugs.
(C) Ketamine is a direct myocardial depressant.
(D) Epidural administration produces analgesia equivalent to epidural administration of
morphine.

6. During a mediastinoscopy under general anesthesia, there is a sudden loss of the right radial
pulse. This is MOST likely to occur by compression of which major blood vessel?

(A) Descending thoracic aorta

(B) Left subclavian vein
(C) Superior vena cava
(D) Innominate artery

7. Which of the following conditions if MOST likely to occur after an episode of malignant
hyperthermia?

(A) Pericarditis
(B) Hepatitis
(C) Pleural effusion
(D) Disseminated intravascular coagulation

8. A 28-year-old parturient at 38 weeks gestation presents to the labor and delivery suite with a
cervical dilation of 2 cm and suspected early labor. She has been paraplegic with a T5 injury
since a motor vehicle accident four years ago. Which statement about her management is MOST
likely true?

(A) Labor analgesia should be initiated with epidural fentanyl.

(B) Cesarean delivery is absolutely indicated.
(C) Labor analgesia is not needed.
(D) Labor analgesia should be initiated with epidural bupivacaine.

2
9. Your patient, a 35-year-old man, requires should reconstruction secondary to an injury that
occurred while lifting weights at a local gym. You are suspicious of anabolic steroid use. Which
statement about anabolic steroid users is MOST likely true?

(A) An amateur athlete is less likely than an Olympic athlete to use anabolic steroids.
(B) Anabolic steroids increase the mg/kg dosage of nondepolarizing muscle relaxant
necessary to obtain adequate intubating conditions.
(C) Abrupt discontinuation of steroids does not produce withdrawal symptoms.
(D) The risk of deep vein thrombosis is decreased with anabolic steroid use.

10. A patient has a history of an allergic reaction to a local anesthetic but cannot recall the name.
Which of the following is MOST likely to be the cause of a true allergic reaction?

(A) Bupivacaine
(B) Lidocaine
(C) Mepivacaine
(D) Procaine

11. Which of the following is associated with the MOST rapid increase in alveolar concentration of
volatile anesthetic?

(A) Increased alveolar ventilation

(B) Increased blood:gas partition coefficient
(C) Increased cardiac output
(D) Increased volume of vessel-poor group (VPG)

12. Which statement about postdural puncture bacterial meningitis is MOST likely true?

(A) The majority of cases occur more than 48 hours after the dural puncture.
(B) Presence of fever helps differentiate meningitis from postdural puncture headache.
(C) Skin flora are the most common organisms identified in patients with meningitis.
(D) Meningitis-associated mortality has not been reported in obstetric patients.

13. A 79-year-old man with acute myelogenous leukemia is intubated and ventilated in the intensive
care unit. He has multiple organ failure and his leukemia has not responded to treatment. He is
comatose. Based on his previously stated wishes, his family wants to withdraw support and
provide “comfort care only.” The patient’s trachea is extubated and he breathes at a rate of 35
breaths per minute and appears to be uncomfortable and gasping for air. An infusion of fentanyl
is commenced and lorazepam is administered as required, both drugs being titrated to a
respiratory rate of 10-12 breaths per minute and to patient comfort. Two hours later, the patient
dies. One of the family members asks if the drugs were used to end the patient’s life.

In these circumstances, the MOST appropriate response would be that the specific act of sedative
and analgesic administration was based on which of the following principles?

(A) Nonabadonment
(B) Double effect
(C) Paternalism
(D) Autonomy

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14. Intravenous lidocaine is commonly used for diagnostic and therapeutic purposes for neuropathic
pain. The MOST likely primary analgesic mechanism of action of intravenous lidocaine is

(A) sodium channel blockade.

(B) calcium channel activation
(C) antagonism of the gamma-aminobutyric acid (GABA) receptor.
(D) activation of G-protein-coupled receptors.

15. A 65-year-old man undergoes placement of an epidural spinal cord stimulator for treatment of
severe pain caused by inoperable peripheral vascular disease. Following placement, he has a
marked decreased in the severity of the pain. Which of the following BEST explains this decrease
in pain?

(A) Decreased sympathetic activity

(B) Enhanced release glutamate
(C) Inhibition transmission via A-alpha fibers
(D) Direct stimulation of opioid receptors

16. Which of the following is included in the Model for End-Stage Liver Disease (MELD) score but
not the Child-Turcotte-Pugh classification of cirrhosis?

(A) Grade of encephalopathy

(B) Albumin level
(C) International normalization ratio (INR)
(D) Bilirubin level

17. Which of the following is MOST likely to occur during massive blood transfusion?

(A) Hypercalcemia
(B) Thrombocytopenia
(C) Shift of the oxygen-hemoglobin dissociation curve to the right
(D) Hyperthermia

18. In which of the following clinical situations is infective endocarditis prophylaxis MOST
appropriate?

(A) A patient with mitral valve prolapse without mitral regurgitation undergoing a
laparoscopic cholecystectomy
(B) A patient with hypertrophic cardiomyopathy scheduled for flexible bronchoscopy
(C) A patient with a previously repaired tetralogy of Fallot undergoing tonsillectomy
(D) A patient with a prosthetic aortic valve scheduled for cataract extraction

19. A new brand of tracheal tube is purchased by the hospital. Over the next month, four patients
experience unexplained tracheal tube obstruction requiring tracheal tube replacement under
difficult circumstances. After conducting a quality assurance investigation, which of the
following is MOST likely to be a required action for the anesthesia group?

(A) Report the events to the Food and Drug Administration

(B) Change back to the old brand of tracheal tube
(C) Continue to monitor the problem
(D) Call the manufacturer to complain

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20. A 63-year-old man presents in the emergency department complaining of severe pain originating
in his gluteal area and radiating down both legs. He had a spinal anesthetic two days ago for a
knee arthroscopy and denies any other neurologic symptoms. Which of the following statements
is MOST likely true?

(A) The symptoms suggest cauda equina syndrome.

(B) He needs immediate magnetic resonance imaging of the lumbar spine.
(C) The probably diagnosis is transient neurologic symptoms (TNS).
(D) These symptoms will be likely to last three months.

21. A 34-year-old, gravida 4, para 3 woman with a placenta previa presents for cesarean delivery. She
denies any recent vaginal bleeding. Her blood pressure is 124/76 mm Hg and heart rate is 84
beats/min. Her preoperative hematocrit is 32%. She has undergone two previous cesarean
deliveries. Appropriate management of this patient will MOST likely include

(A) obtaining a preoperative fibrinogen level.

(B) utilizing intraoperative blood salvage throughout surgery.
(C) preparing for massive transfusion.
(D) administering single-injection spinal anesthesia.

22. A 76-year-old woman is scheduled for a wide excision of a melanoma on her leg. She expresses
concern about “not being herself” after a prior anesthetic. Which statement about delirium or
postoperative cognitive decline (defined as changes in learning, coordination, or memory on one
or more neuropsychological test) is MOST likely true?

(A) Neuraxial anesthesia will reduce the risk of postoperative confusion.

(B) Postoperative cognitive decline is a very rare event.
(C) Compared to fentanyl, use of meperidine for postoperative analgesia is associated with a
greater risk of postoperative delirium.
(D) Age does not affect the risk of developing delirium.

23. If a patient has agitation related to scopolamine, which of the following is MOST likely to also be
present?

(A) Hypothermia
(B) Bradycardia
(C) Miosis
(D) Dry mouth

24. Which of the following medications is MOST likely to treat the manifestations of central
anticholinergic syndrome?

(A) Neostigmine
(B) Edrophonium
(C) Pyridostigmine
(D) Physostigmine

5
25. A patient who recently had an acute myocardial infarction complicated by left ventricular failure
has been receiving sodium nitroprusside for approximately 24 hours. Which of the following is
MOST likely to be an indication of cyanide toxicity?

(A) Mental status changes

(B) Metabolic alkalosis
(C) Decreased mixed venous oxygen saturation
(D) Increased vasodilation in response to a constant dose of nitroprusside

26. Which statement about the pharmacokinetics of morphine is MOST likely true?

(A) Cirrhosis is associated with a significant decrease in morphine clearance.

(B) The majority of an administered dose is metabolized to a compound that produces
respiratory depression equivalent to that of morphine itself.
(C) Decreased elimination of morphine metabolites may produce prolonged ventilatory
depression in patients with renal failure.
(D) Approximately 20% of an administered dose is excreted unchanged in the urine.

27. Which of the following is MOST likely to be associated with increased resistance to
neuromuscular blockade produced by vecuronium?

(A) Verapamil
(B) Quinidine
(C) Clindamycin
(D) Carbamazepine

28. According to the American Society for Testing and Material (ASTM) standards, which of the
following markings may be omitted from the outside of a standard, adult tracheal tube (6.0 mm or
larger)?

(A) Internal diameter in millimeters

(B) External diameter in millimeters
(C) Length markings in centimeters measured from the distal (patient) end
(D) Material from which tube is manufactured

29. An otherwise healthy 43-year-old woman is scheduled to undergo a general anesthetic for an
abdominal hysterectomy. Compared to use of a tracheal tube with a high-volume, low-pressure
cuff, the use of a tube with a low-volume, high-pressure cuff in this situation is MORE likely to

(A) result in cuff damage during intubation.

(B) be associated with a higher pressure on the lateral wall of the trachea.
(C) be associated with a higher risk of sore throat following extubation.
(D) avoid distortion of the trachea into a circular shape.

30. Which of the following changes is MOST likely to occur in the first hour after birth?

(A) Closure of the ductus arteriosus

(B) Decrease in pulmonary vascular resistance
(C) Decrease in systemic vascular resistance
(D) Left-to-right shunting through the foramen ovale

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31. According to the most recent Pediatric Advanced Life Support (PALS) Guidelines, which of the
following is the MOST likely appropriate initial intervention in the treatment of supraventricular
tachycardia in a child who is hemodynamically stable despite the dysrhythmia?

(A) Defibrillation
(B) Administration of procainamide
(C) Synchronized cardioversion
(D) Administration of amiodarone

32. A patient is scheduled for external fixator placement to the right leg after being involved in a
motor vehicle accident. The patient is intubated, ventilated, and has a chest tube in place. On
arrival in the operating room, vital signs include a blood pressure of 78/52 mm Hg and oxygen
saturation 80% with FIO2 = 1.0. Findings on chest auscultation include wheezing and decreased
breath sounds over the left axilla. The patient has the following chest radiograph:

The most appropriate treatment at this time is to

(A) administer albuterol.

(B) pull the tracheal tube back to 4 cm.
(C) perform bronchoscopy.
(D) insert a chest tube on the left.

33. An otherwise healthy 28-year-old, gravida 1, para 0 woman at 20 weeks gestation presents with
appendicitis. The surgeon plans to perform a laparoscopic appendectomy. Which statement about
the management of this patient is MOST likely true?

(A) Laparoscopic surgery is contraindicated in pregnancy.

(B) A laparoscopic insufflation pressure of 20 mm Hg or more is recommended.
(C) Minute ventilation should be adjusted to maintain an end-tidal CO 2 of approximately 32
mm Hg.
(D) The risk of fetal loss is decreased compared to an appendectomy performed via
laparotomy.

34. Which of the following is MOST likely associated with acromegaly?

(A) Sleep apnea

(B) Hypoglycemia
(C) Adenoma of the posterior pituitary gland
(D) Increased levels of adrenocorticotrophic hormone (ACTH)

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35. In a recently published paper the authors discuss the effectiveness of a new drug (compound Q)
used to prevent the development of cognitive dysfunction after cardiopulmonary bypass (CPB).
In the results section, the authors state that “the relative risk of the development of cognitive
impairment in the placebo group compared with the group administered compound Q was 1.3
(95% confidence interval 0.7 to 1.9).” Which statement about this study is MOST likely true?

(A) The study shows a statistically significant (P < 0.05) reduction in the risk of cognitive
impairment after CPB with the use of compound Q.
(B) The study was biased.
(C) Based on this study there are no differences between placebo and compound Q.
(D) The study shows a statistically significant (P < 0.05) increase in the risk of cognitive
impairment after CPB with the use of compound Q.

36. An intensive care unit nurse is concerned about venous air embolism while removing a large
hemodialysis catheter from the inguinal jugular vein. Which of the following is the MOST
appropriate advice?

(A) The patient should be in the head-up position (reverse Trendelenburg) as the central
venous catheter is removed.
(B) Performance of the Valsalva maneuver at the time of catheter withdrawal will decrease
the risk of life-threatening complications associated with catheter removal.
(C) The patient should be instructed to take in a deep breath as the catheter is removed.
(D) If the patient is intubated and undergoing positive pressure ventilation, removal of the
catheter is contraindicated.

37. A 55-year-old man in shock is being care for in the intensive care unit. In an effort to determine
the cause of the shock, a pulmonary artery catheter is placed. The following data are recorded:

Systemic blood pressure 80/60 mm Hg

Central venous pressure 18 mm Hg
Pulmonary artery pressure 32/18 mm Hg
Pulmonary artery occlusion pressure 18 mm Hg
Cardiac index 1.6 L/min/m2
Heart rate 138 beats/min

Which of the following is MOST likely etiology of his shock?

(A) Pulmonary embolism

(B) Pericardial tamponade
(C) Massive gastrointestinal hemorrhage
(D) Anaphylaxis

38. An intubated patient is being transferred from the operating room to the intensive care unit on a
different floor of the hospital with a full cylinder of oxygen. During transport, the elevator
becomes stuck. The flow setting on the cylinder is on 10 L/min oxygen. Assuming the oxygen
flow rate is unchanged, the cylinder supply will MOST likely last

(A) 90 minutes.
(B) 60 minutes.
(C) 30 minutes.
(D) 15 minutes.

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39. The shorter duration of action of remifentanil as compared to fentanyl is PRIMARILY attributed
to

(A) rapid redistribution.

(B) renal elimination.
(C) metabolism by esterases.
(D) hepatic extraction ratio.

40. Which of the following peripheral nerve blocks is MOST appropriate for rotator cuff repair?

(A) Axillary
(B) Cervical plexus
(C) Infraclavicular
(D) Interscalene

41. You are consulted for management of stump pain and phantom limb pain three months after
amputation of a patient’s right leg following a car bomb explosion. Which statement about the
evolution of stump pain and phantom limb pain is MOST likely true?

(A) Stump pain and phantom limb pain rarely occur together.
(B) Typically phantom limb pain is described as being constant.
(C) Phantom limb pain will get considerably worse over time in the majority of patients.
(D) Local pathology in the stump often is the cause of stump pain.

42. In a patient with diagnosed pheochromocytoma scheduled for laparoscopic resection, which of
the following is the BEST indication of adequate preoperative preparation?

(A) Absence of ST-T wave changes one week before surgery

(B) Absence of orthostatic hypotension
(C) No more than 10 premature ventricular contractions per minute
(D) Blood pressure of 175/95 mm Hg 18 hours prior to surgery

43. Which statement about the administration of vasopressin is MOST likely true?

(A) It is not associated with myocardial ischemia.

(B) It may be effective for management of catecholamine-resistant vasoplegia.
(C) It increases mortality associated with sepsis.
(D) It increases uterine blood flow.

44. Which statement about postdural puncture headache (PDPH) following spinal anesthesia is
MOST likely true?

(A) The incidence is related to the timing of ambulation.

(B) There is increased severity with addition of vasoconstrictors to the anesthetic.
(C) It occurs less frequently when the needle bevel of a cutting needle is perpendicular to the
direction of dural fibers.
(D) The incidence decreases with increasing age.

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45. Which statement about the treatment of postdural puncture headache is MOST likely true?

(A) Migraine medications such as sumatriptan have no role in the management of postdural
puncture headache.
(B) It is important to have the patient ambulate immediately after performing an epidural
blood patch.
(C) Treatment with an epidural blood patch is most effective if done within 24 hours of the
dural puncture.
(D) Pain relief following an epidural blood patch is often immediate.

46. Which statement about pain after laparoscopic cholecystectomy is MOST likely true?

(A) Severe pain typically lasts for seven days following surgery.
(B) Chronic pain develops in approximately 1% of patients.
(C) There are multiple nociceptive mechanisms.
(D) Shoulder pain is not described as a consequence.

47. Shortly after undergoing a C7 transforaminal epidural injection of steroid and bupivacaine under
fluoroscopic guidance for treatment of a cervical radiculopathy a previously healthy 54-year-old
man requires admission to the intensive care unit. A brainstem infarction is documented by
magnetic resonance imaging and the patient dies within 24 hours. Which of the following is the
MOST likely etiology of this problem?

(A) Allergic reaction to the local anesthetic

(B) Intrathecal injection of local anesthetic and steroid
(C) Overwhelming sepsis from a contaminated supply of steroid
(D) Injury to the vertebral artery with subsequent dissection

48. An otherwise healthy 35-year-old male is scheduled for a 12-hour reconstructive surgical
procedure. Following inadvertent rapid administration of 250 mcg of sufentanil, the patient
become apneic and positive pressure ventilation with a bag and mask is difficult. Administration
of which of the following is MOST likely to improve the ability to provide positive pressure
ventilation prior to tracheal intubation?

(A) Albuterol
(B) Ketamine
(C) Desflurane
(D) Rocuronium

49. Which statement about dexmedetomidine is MOST likely true?

(A) It has more alpha2-selectivity than clonidine.

(B) It can increase opioid-induced rigidity.
(C) It has a longer half-life than clonidine.
(D) It is not effective as an anxiolytic.

10
50. Which statement about pulse oximetry is MOST likely true?

(A) Oxyhemoglobin absorbs more light in the red band (660 nm) than does reduced
hemoglobin.
(B) Pulse oximetry is a direct measurement of arterial oxygen saturation (Sa O2).
(C) SPO2 values are most sensitive to changes in PaO2 on the steep portion of the
oxyhemoglobin curve.
(D) Calculations for the SPO2 are based on calibration curves derived from extensive animal
models of hypoxia.

51. Which of the following is MOST likely to cause a falsely low SPO2 reading on a pulse oximeter?

(A) Severe tricuspid insufficiency

(B) An increased carboxyhemoglobin concentration
(C) Ambient fluorescent light in the operating room
(D) An increased methemoglobin concentration in a hypoxic patient (PaO2 < 50 mm Hg)

52. Which statement about transurethral resection of the prostate (TURP) syndrome is MOST likely
true?

(A) Hypernatremia is common.

(B) Use of distilled water as an irrigation fluid will decrease the severity of TURP syndrome.
(C) The irrigating fluid should be at a height of at least 1.5 m to reduce the chances of
developing TURP syndrome.
(D) As the duration of resection increases, so does the chance of developing TURP
syndrome.

53. Which statement about celiac plexus block is MOST likely true?

(A) The celiac plexus lies posterior to the abdominal aorta.

(B) Hypertension is a common consequence.
(C) The procedure is usually performed in the lateral position.
(D) The celiac plexus contains both sympathetic and parasympathetic fibers.

54. Which of the following is MOST likely to precipitate an episode of myotonia in a patient with
myotonic dystrophy?

(A) Nondepolarizing muscle relaxant administration

(B) Hyperthermia
(C) Anticholinesterase administration
(D) Local anesthetic administration

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55. At 3 hours of age a term neonate born by uncomplicated spontaneous vaginal delivery is noted to
be cyanotic and with respiratory rate of 50 breaths/min. Pulse oximetry shows an SP O2 of 65% on
room air, and an arterial blood gas reveals a PaO2 of 34 mm Hg. After the neonate is placed on
100% oxygen by hood, SPO2 increases to 85% and repeat arterial blood gas shows PaO2 is 50 mm
Hg. Which of the following is the MOST likely etiology of hypoxemia in this patient?

(A) Surfactant deficiency

(B) Sepsis
(C) Transient tachypnea of the newborn
(D) Cyanotic congenital heart disease

56. A patient undergoing general anesthesia initially received intravenous (IV) succinylcholine (100
mg) to facilitate tracheal intubation. Vecuronium was administered after the patient exhibited
signs of recovery from succinylcholine. Towards the end of the procedure, neuromuscular
blockade was reversed with neostigmine (5 mg IV) and glycopyrrolate (1 mg IV). However, prior
to skin closure the patient began to move, and succinylcholine (20 mg IV) was administered. The
patient subsequently experiences a prolonged weakness. Which of the following is the MOST
likely cause of the prolonged weakness?

(A) Inhibition of succinylcholine metabolism by neostigmine

(B) Recurarization
(C) Low serum levels of normal plasma cholinesterase
(D) Aytpical plasma cholinesterase

57. A patient with a history of egg allergy receives a standard induction dose of generic propofol.
Which of the following side effects is MOST likely to occur?

(A) Adrenal suppression

(B) Metabolic acidosis
(C) Anaphylaxis
(D) Bronchospasm

58. Which of the following is MOST likely to occur when the Bainbridge reflex is elicited?

(A) Hypertension
(B) Bradycardia
(C) Hypotension
(D) Tachycardia

59. Which of the following is MOST likely indicated in the initial treatment of a cardiovascular
collapse associated with an intravascular injection of a toxic dose of bupivacaine?

(A) Administration of calcium channel blockers

(B) Administration of bretylium
(C) Cardiopulmonary bypass
(D) Prevention of acidosis

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60. In patients with acute lung injury and acute respiratory distress syndrome, mechanical ventilation
with which of the following tidal volumes, calculated on the basis of ideal body weight, is MOST
likely to reduce mortality?

(A) 6 mL/kg
(B) 10 mL/kg
(C) 12 mL/kg
(D) 15 mL/kg

61. Which of the following is MOST likely to be a contraindication to drotrecogin alfa (Xigris)
administration in patients with severe sepsis?

(A) Hypotension despite fluid resuscitation

(B) Hypoxemia after application of positive end-expiratory pressure
(C) Massive ongoing gastrointestinal hemorrhage
(D) Oliguria resistant to loop diuretic administration

62. A 46-year-old male is admitted to the neurosurgical intensive care unit following successful
surgical clipping of a ruptured intracranial aneurysm. On postoperative day six, transcranial
Doppler ultrasonography is suggestive of cerebral vasospasm. Which of the following is the
MOST appropriate initial therapy prior to angiography?

(A) Diuresis
(B) Hypertension
(C) Transfusion
(D) Hyperventilation

63. Which of the following medications would be the MOST appropriate therapy to treat
symptomatic bradycardia two months following cardiac transplantation?

(A) Atropine
(B) Glycopyrrolate
(C) Isoproterenol
(D) Phenylephrine

64. Which of the following interventions is MOST likely to reduce the incidence of ventilator-
associated pneumonia?

(A) Stress-ulcer prophylaxis with sucralfate

(B) Daily ventilator circuit changes
(C) Supine position
(D) Continuous subglottic suction

13
65. A 28-year-old, gravida 2, para 1 woman in active labor requests epidural analgesia. After an
epidural catheter is placed successfully, her cervix is found to be 9 cm dilated. Lidocatine 1%
with 1:200,000 epinephrine is administered epidurally to achieve rapid analgesia. Which
statement about the addition of epinephrine to the local anesthetic is MOST likely true?

(A) Uteroplacental perfusion will be decreased.

(B) Umbilical vascular resistance will be decreased.
(C) The concentration of local anesthetic required for labor analgesia will be decreased.
(D) Uterine activity will be increased.

66. Eighteen hours following routine coronary artery bypass grafting with cardiopulmonary bypass
the patient’s serum troponin is 9 ng/mL. Which statement about troponin concentrations is MOST
likely true?

(A) Elevations of troponin following cardiopulmonary bypass do not reflect significant

myocardial damage.
(B) Troponin values peak four to six hours following myocardial injury.
(C) Elevated troponin values provide information as to the mechanism of cardiac injury.
(D) The degree of elevation in troponin concentrations provides prognostic information.

67. Which statement about propofol infusion syndrome is MOST likely true?

(A) It occurs only in children.

(B) Rhabdomyolysis frequently occurs.
(C) Liver failure frequently occurs.
(D) It has only been reported in patients receiving propofol for long-term sedation.

68. In considering flow through an intravenous catheter, doubling which of the following is MOST
likely to result in the greatest increase in flow?

(A) Viscosity of fluid

(B) Length of catheter
(C) Pressure differential between proximal and distal ends of the catheter
(D) Radius of catheter

69. Which statement about heliox (helium/oxygen mixtures) is MOST likely true?

(A) The maximum available oxygen concentration is 80%.

(B) The mixture is less dense than oxygen alone.
(C) Heliox may not be administered to patients on mechanical ventilators.
(D) The generation of reactive metabolites by helium is a significant problem.

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70. Which of the following represents a Mapleson D circuit? (Note that the arrow represents the
location from which fresh gas is introduced into the system.)

71. Which of the following is MOST likely to increase pulmonary vascular resistance?

(A) Inhaled nitric oxide

(B) Hypercapnia
(C) Administration of 100% oxygen
(D) Alkalemia

72. Which of the following therapies is the ONLY one derived from human blood?

(A) Aprotinin
(B) Desmopressin
(C) Recombinant activated factor VII
(D) Tissue sealant (eg, Tisseel or Hemaseel)

73. Human recombinant antithrombin III is MOST useful in the management of which of the
following conditions?

(A) Heparin-induced thrombocytopenia

(B) Von Willebrand disease
(C) Heparin resistance
(D) Platelet dysfunction

74. Which of the following is MOST likely to predict a difficult intubation in a patient with normal
appearance?

(A) Mallampati class

(B) Thyromental distance
(C) Sternomental distance
(D) A combination of Mallampati class and thyromental distance

15
75. The decrease in postoperative ileus observed with perioperative use of a thoracic epidural
infusing local anesthetic is MOST likely due to

(A) increased release of met-enkephalins.

(B) blockade of parasympathetic visceral fibers.
(C) blockade of sympathetic visceral fibers.
(D) decreased release of acetylcholine for myenteric plexus.

76. Which statement comparing peribulbar and retrobulbar blocks is MOST likely true?

(A) More local anesthetic is used during the retrobulbar block.

(B) Peribulbar block produces a more rapid onset of anesthesia.
(C) Peribulbar block has a lower risk of myotoxicity to the inferior rectus muscle.
(D) The retrobulbar block involves entering the muscle cone.

77. Almost immediately after a retrobulbar block with 0.5% bupivacaine and 1:400,000 epinephrine
is performed, the patient convulses and cardiopulmonary arrest occurs. The MOST likely cause of
this event is

(A) retrobulbar hemorrhage.

(B) oculocardiac reflex.
(C) subdural injection.
(D) ophthalmic artery injection.

78. A patient develops an acute herpes zoster outbreak (shingles). Which statement about this c
condition is MOST likely true?

(A) Thoracic distribution is the most common site for shingles.

(B) The pain associated with shingles commonly persists for more than three months.
(C) The rash appears prior to the development of pain.
(D) Antiviral agents are not effective in shortening the duration of pain.

79. Which statement about postherpetic neuralgia is MOST likely true?

(A) Complications of herpes zoster in the distribution of the ophthalmic nerve are limited to
chronic pain.
(B) When initiated within three days following the development of a rash, antiviral therapy is
completely effective in preventing the development of postherpetic neuralgia.
(C) Pain associated with postherpetic neuralgia is most commonly described as dull or aching
pain.
(D) Advanced age is a risk factor for the development of postherpetic neuralgia.

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INSTRUCTIONS FOR ITEMS 80 AND 81: This series of items refers to the diagnosis, treatment
or management of a single patient.

80. A 27-year-old, gravida 1, para 0 woman presents for initial prenatal care. An ultrasound
examination confirms a viable 18-week pregnancy. The patient denies any symptoms or problems
since becoming pregnant but has previously been diagnosed with Marfan syndrome. Which of the
following is MOST appropriate to include in her initial prenatal evaluation?

(A) Counseling that she is at high risk for maternal mortality

(B) Performance of an echocardiogram
(C) Performance of liver function tests
(D) Counseling that cesarean delivery will be necessary

81. On echocardiogram (shown below), the patient has an aortic root diameter of 4.6 cm, which has
remained stable throughout pregnancy.

She presents for an elective cesarean delivery. The MOST appropriate anesthetic management
includes

(A) general anesthetic.

(B) single-injection spinal anesthesia.
(C) combined spinal-epidural (CSE) anesthesia.
(D) continuous epidural anesthesia.

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INSTRUCTIONS FOR ITEMS 82 AND 83: This series of items refers to the diagnosis, treatment
or management of a single patient.

82. A patient presents to the preoperative clinic with hypertension. Which statement about
hypertension is MOST likely true?

(A) A pulse pressure (systolic minus diastolic blood pressure) of more than 65 mm Hg
increases the risk of stroke.
(B) Pulse pressure greater than 65 mm Hg is caused by increased elastic recoil of the major
conducting vessels (eg, aorta).
(C) Isolated systolic hypertension is usually first diagnosed in patients less than 50 years of
age.
(D) Isolated diastolic hypertension is the most common form of hypertension in patients over
50 years old.

83. After an initial blood pressure determination of 195/65 mm Hg, repeat determinations are 175/55
mm Hg and 180/50 mm Hg. There is no other preoperative information available. The patient
asks if there are any additional perioperative risks of proceeding with elective surgery. Which of
the following assessments of her status is MOST accurate?

(A) Elective surgery should be canceled when systolic blood pressure is consistently above
170 mm Hg.
(B) Diabetes mellitus is associated with pulse pressure hypertension.
(C) Postoperative renal injury is not influenced by the presence of pulse pressure
hypertension.
(D) Perioperative mortality is lowest in ambulatory patients with a diastolic blood pressure
below 70 mm Hg.

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INSTRUCTIONS FOR ITEMS 84 THROUGH 86: This series of items refers to the diagnosis,
treatment or management of a single patient.

84. A 71-year-old Jehovah’s Witness is to undergo a three-level (L3-S1) anterior-posterior spinal

fusion with removal and replacement of hardware. The surgeon consults you to help develop a
perioperative plan that allows the surgery without transfusion. The MOST appropriate initial step
is to

(A) set up a program of blood self-donation.

(B) establish with the patient what drugs and intravenous fluids can be administered.
(C) administer recombinant human erythropoietin the night before surgery.
(D) administer recombinant interleukin-11 daily for the week prior to surgery.

85. On the day of surgery, previously discussed plans to manage intraoperative blood loss are
reaffirmed. Which of the following is MOST likely to be included in the plan?

(A) Discontinuing surgery when the target hemoglobin is reached

(B) Use of directed donor blood from other Jehovah’s Witnesses
(C) Elective intraoperative hypothermia
(D) Administration of recombinant factor VIIa prior to incision.

86. At the end of the procedure, the patient’s hemoglobin is 5.5 gm/dL. The MOST appropriate
immediate course of action would be to

(A) administer aprotinin.

(B) keep the patient paralyzed and ventilated in the intensive care unit.
(C) administer recombinant human erythropoietin.
(D) administer synthetic hemoglobin.

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INSTRUCTIONS FOR ITEMS 87 AND 88: This series of items refers to the diagnosis, treatment
or management of a single patient.

87. A 38-year-old male presents to the preoperative anesthesia clinic for evaluation prior to elective
ankle surgery. He has a seizure disorder that is well controlled with phenytoin. He also takes the
herbal remedies echinacea and ginseng on a regular basis. During his visit to the clinic he
complains of diplopia. On physical examination, nystagmus is noted in addition to obtaining a
serum phenytoin determination, the MOST appropriate initial management of this patient would
include

(A) increasing the phenytoin dose.

(B) discontinuing the ginseng.
(C) discontinuing the echinacea.
(D) obtaining an ophthalmology consult.

88. After appropriate treatment, the patient’s diplopia and nystagmus resolve. He presents for his
ankle surgery. He has continued to take ginseng on a regular basis and recently began taking
ginger. Which statement about his anesthetic management is MOST likely true?

(A) Neuraxial anesthesia is contraindicated.

(B) He is at increased risk for postoperative nausea.
(C) The herbal remedies should be discontinued 24 hours before surgery.
(D) He is at increased risk for hypoglycemia.

INSTRUCTIONS FOR ITEMS 89 AND 90: This series of items refers to the diagnosis, treatment
or management of a single patient.

89. As opposed to a smaller prophylaxis dose, a patient is receiving a dose of 1 mg/kg enoxaparin
every 12 hours for treatment of a deep venous thrombosis. The patient is scheduled for surgery
under neuraxial anesthesia. The MOST appropriate time to proceed with the surgery would be

(A) 24 hours from the last dose.

(B) when the prothrombin time is normal.
(C) 12 hours from the last dose.
(D) when an activated partial thromboplastin time is normal.

90. During placement of the epidural in this patient some blood is noted in the epidural catheter. The
blood is cleared and does not reappear. In managing this situation, which of the following is
MOST appropriate?

(A) Keep the anti-factor Xa level less than 0.2 U/mL for 24 hours after surgery.
(B) Postpone surgery for 24 hours and then perform a general anesthetic.
(C) Delay the next enoxaparin dose until 24 hours after surgery.
(D) Advise the surgeon this patient is not at increased risk of spinal hematoma.

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INSTRUCTIONS FOR ITEMS 91 AND 92: This series of items refers to the diagnosis, treatment
or management of a single patient.

91. A 75-year-old female with a cardiac rhythm management device (CRMD) with defibrillation
capabilities presents for an elective abdominal hysterectomy. Which of the following statements
about her preoperative management is MOST likely true?

(A) The pacing rate should be reduced.

(B) Preoperative interrogation is not indicated if bipolar electrocautery is used.
(C) All antitachycardia therapy should be disabled.
(D) Minute ventilation responsiveness, if present, should be enabled.

92. A magnet is placed over the generator of the cardiac rhythm management device (CRMD).
Which statement about the consequences of this action is MOST likely true?

(A) All devices will automatically convert to an asynchronous pacing mode.

(B) Antitachycardia therapy may be disabled by the magnet.
(C) Placement of a magnet will not have any effect on the function of a CRMD with
defibrillation capabilities (an ICD).
(D) Programming will always return to the original mode when the magnet is removed.

21
INSTRUCTIONS FOR ITEMS 93 AND 94: This series of items refers to the diagnosis, treatment
or management of a single patient.

93. A 73-year-old male is undergoing general anesthesia for coronary artery revascularization.
Shortly after induction, the monitor reveals a change in his electrocardiogram from normal sinus
rhythm to the following:

This cardiac rhythm is BEST described as

(A) first-degree atrioventricular (AV) block.

(B) second-degree Mobitz type I AV block.
(C) second-degree Mobitz type II AV block.
(D) third-degree heart block.

94. The rhythm persists and after sternotomy, the patient’s blood pressure decreases to 70/40 mm Hg.
Which of the following therapeutic maneuvers would be MOST appropriate?

(A) Administration of atropine

(B) Synchronized cardioversion
(C) Administration of amiodarone
(D) Placement of epicardial pacing wires

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INSTRUCTIONS FOR ITEMS 95 THROUGH 97: This series of items refers to the diagnosis,
treatment or management of a single patient.

95. A 67-year-old, 81 kg woman with a history of asthma and hypertension has undergone a vaginal
hysterectomy under general anesthesia. Induction was performed with fentanyl, propofol, and
vecuronium (single 6 mg dose); sevoflurane was used for maintenance of anesthesia. Antibiotic
prophylaxis was provided with clindamycin. No other drugs were administered. At the end of the
90-minute procedure train-of-four (TOF) ulnar nerve stimulation produces four observed twitches
without fade. Which of the following statements is MOST likely true?

(A) Her measured TOF ratio (fourth twitch:first twitch) will be greater than 0.9.
(B) She does not need reversal of the nondepolarizing muscle relaxant.
(C) Sevoflurane delays the recovery of TOF after neuromuscular reversal.
(D) She will have a strong hand grip.

96. Reversal drugs are administered and the patient extubated. Immediately prior to extubation a
small amount of fade was evident on train-of-four (TOF) stimulation. In the postanesthesia care
unit (PACU), she is tachypneic and complains of difficulty breathing and swallowing. Which of
the following statements is MOST likely true?

(A) She will be able to maintain her normal tidal volume.

(B) Her ability to manage her oral secretions has returned to normal.
(C) Her risk of hypoxic episode is less than 1%.
(D) She will be able to speak clearly.

97. Over the next 90 minutes, the patients experiences several desaturation episodes. On a chest
radiograph she has bilateral atelectasis. Her arterial blood gas analysis is Pa O2 85 mm Hg, PaCO2
29 mm Hg, pHa 7.51, with an FIO2 of 0.4. You arrange for an intensive care unit bed. She
complains of feeling weak and having difficulty swallowing. Which of the following statements
is MOST likely true?

(A) She aspirated gastric contents during the surgical procedure.

(B) She should be evaluated for myasthenia gravis.
(C) Clindamycin could not have contributed to her muscle weakness.
(D) Abnormal serum cholinesterase will increase the duration of action of nondepolarizing
muscle relaxants.

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INSTRUCTIONS FOR ITEMS 98 THROUGH 100: This series of items refers to the diagnosis,
treatment or management of a single patient.

98. A 70-year-old man with normal ventricular function undergoes uneventful coronary artery bypass
surgery to the left anterior descending artery and the obtuse marginal artery. While still intubated
in the intensive care unit (ICU), his central venous pressure increases from 7 mm Hg on arrival to
18 mm Hg over four hours. This is accompanied by decreases in his cardiac index and systemic
blood pressure. There has been no significant chest tube output since the patient arrived in the
ICU. Which of the following BEST explains these findings?

(A) Right ventricular failure

(B) Pericardial tamponade
(C) Hypovolemia
(D) Myocardial ischemia

99. Which of the following would be the BEST way to confirm the diagnosis in this patient?

(A) Twelve-lead electrocardiogram (ECG)

(B) Chest radiography
(C) Serum troponin concentration determination
(D) Echocardiography

100. The patient has become increasingly tachycardic to 120 beats/min with further decline in cardiac
index. Before returning to the operating room, the MOST effective medical management to
increase the patient’s cardiac index would be to

(A) administer esmolol.

(B) start a diltiazem infusion.
(C) administer a diuretic.
(D) administer intravenous fluid bolus.

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ACE PROGRAM EVALUATION
We are interested in your feedback and comments. Please take five minutes to answer the following
questions. Your responses will be used in our continuing efforts to improve the program and meet the
needs of our members. All responses will remain confidential and anonymous. Your responses will be
aggregated with those of all other subscribers. Cumulative information thus gained will be used to
describe the demographics of ACE Program subscribers and will help guide the development of future
ASA educational programs. Written comments may be sent by email to Edwin A. Bowe, MD, Editor-in-
Chief, at [email protected].

ABOUT YOURSELF

One Answer Only 101. I am an ASA

(A) member.
(B) nonmember.
(C) resident member.

One Answer Only 102. My professional status is

(A) resident or fellow in anesthesiology.

(B) practicing anesthesiologist.
(C) retired anesthesiologist.
(D) CRNA.
(E) other.

One Answer Only 103. The medical school from which I obtained my degree is located in

(A) United States

(B) another country
(C) I am not a physician (if you are not a physician, please skip to
Question 106)

One Answer Only 104. I completed anesthesiology residency training

(A) prior to 1970.

(B) between 1970 and 1979.
(C) between 1980 and 1989.
(D) between 1990 and 1999.
(E) in 2000 or later.

One Answer Only 105. I have been in active anesthesia practice

(A) less than 1 year.

(B) 1 to 3 years.
(C) 4 to 7 years.
(D) 8 to 15 years.
(E) over 15 years.

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One Answer Only 106. My primary practice location is

(A) academic/teaching medical center.

(B) community hospital (less than four residency training programs
in facility
(C) city/county hospital
(D) government/military.
(E) other.

Multiple Answers 107. My professional board certification includes

(A) anesthesiology.
(B) pain medicine.
(C) critical care medicine.
(D) other specialty.
(E) no certification.

One Answer Only 108. I am a faculty member in a medical school/university

(A) Yes
(B) No

One Answer Only 109. The country in which I practice is

(A) United States

(B) another country.

Multiple Answers 110. I have attended or used the following continuing medical education
(CME) programs during the past year:

(A) ASA annual meeting

(B) ASA workshop
(C) ASA Self-Education and Evaluation (SEE) Program
(D) A journal-based CME program
(E) Other

ABOUT YOUR EXPERIENCE

Multiple Answers 111. My motivation for participating in the ACE Program is

(A) self-education or assessment.

(B) preparation for primary certification.
(C) fulfillment of continuing medical education requirement.
(D) preparation for ABA recertification examination.
(E) other.

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Multiple Answers 112. I expect the ACE Program to expose me to

(A) basic science and research in anesthesia literature.

(B) clinical anesthesia publications.
(C) general medical literature.
(D) new clinical knowledge and current research.
(E) other.

One Answer Only 113. The ACE Program

(A) exceeded my expectations.

(B) met my expectations.
(C) did not meet my expectations.

Multiple Answers 114. I would recommend the ACE Program to

(A) residents or fellows.

(B) faculty members.
(C) clinical practitioners.
(D) CRNAs.
(E) physician assistants.

One Answer Only 115. The ACE Program is relevant to my clinical practice of anesthesia.

(A) Strongly agree

(B) Agree
(C) Not sure
(D) Disagree
(E) Strongly disagree

One Answer Only 116. I gained knowledge from ACE that I can apply to my practice

(A) immediately.
(B) within the year.
(C) not at all.

Multiple Answers 117. Where did you use the ACE Program?

(A) Office/hospital
(B) Home
(C) While traveling

YOUR SUGGESTIONS

One Answer Only 118. Doe you use the ABA Joint Council on In-Training Examinations
taxonomic codes?

(A) Yes
(B) No

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Multiple Answers 119. I would like to see ACE provide

(A) in-depth subspecialty coverage on a rotating basis (eg, 25

additional items [questions, answers, discussions] on pediatric
anesthesia in one issue; 25 additional items on obstetric
anesthesia in the next issue; 25 additional items on cardiac
anesthesia in the third issue, etc).
(B) a Knowledge Gap Analysis (a body of questions and answers,
without discussions or references) that I could take at a single
sitting and which would provide feedback regarding my
performance in each subspecialty area.
(C) both.
(D) neither.

One Answer Only 120. I find the references following the Discussion section

(A) useful.
(B) not useful.

One Answer Only 121. Are you using or planning to subscribe to an electronic version of the
ACE Program?

(A) Yes
(B) No

One Answer Only 122. If you are using or planning to use an electronic version of the ACE
Program, would you prefer a CD-ROM or a Web-based version?

(A) CD-ROM
(B) Web-based
(C) Not interested in either electronic version

Thank you for your participation. We appreciate your continuing interest and participation in
important ASA activities such as this survey.

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