1 RAKESH

Question 1

1. A young cyclist had a road traffic accident and fractured his tibia. He is having open reduction and internal fixation. During the operation there
   is sudden loss of end tidal carbon dioxide. This was followed by fall in blood pressure. What is the most likely diagnosis?

A. Pneumothorax.
B. Haemorrhage.
C. Fat embolism.
D. Hyponatriemia.
E. Myocardial ischemia.

Answer 1

C

The fat emboli may occur by:
direct entry of depot fat globules from disrupted adipose tissue or bone marrow into the
bloodstream in areas of trauma (mechanical)
z production of toxic intermediaries of fat present in the plasma (biochemical).
Tibia fractures of marrow-containing bone have the highest incidence of fat embolism syndrome
and cause the largest-volume fat emboli. This may be because the disrupted venules in the marrow
remain tethered open by their osseous attachments, therefore the marrow contents may enter
the venous circulation with relatively little diffi culty. The tibia is a long bone and fracture requires
the intramedullary nail. During the process of inserting the intramedullary nail there is increased
pressure, which may lead to fat embolism.
Fat embolism syndrome has a classic triad:
z respiratory changes; dyspnoea, tachypnoea, and hypoxaemia are the most frequent early fi ndings
z neurological abnormalities
z petechial rash.
During fat embolism there can be hypoxia, pulmonary odema, coagulation disorder, and loss of
carbon dioxide due to sudden increase in the dead space.
Management of fat embolism syndrome involves prevention, early diagnosis, and adequate
symptomatic treatment. Supportive care requires maintenance of adequate oxygenation and
ventilation, stable haemodynamics, blood products as clinically indicated, hydration, prophylaxis of
deep venous thrombosis and stress-related gastrointestinal bleeding, and nutrition.
Mortality is estimated to be 5–15 % overall.

Question 2

2. A 72-year-old male is undergoing oesophagectomy with one lung anaesthesia. Half-way through the operation, the oxygen saturation drops from 95 %to 84 % . What will be the most appropriate step?

A. Check pipeline pressure and gas analyser, and anaesthetic flow meter.
B. Check breathing circuit for disconnection.
C. Increase the FiO 2 to 1.
D. Stop surgery and re-inflate lungs.
E. Check the position of the tube.

Answer 2

C

2. Answer: C
   Due to the various changes in lung physiology during one-lung anaesthesia, it is not uncommon
   to notice a drop in oxygen saturations. All the above steps will have to be performed. However,
   checking takes time, and interrupting surgery to re-infl ate the lungs is a last resort. The fi rst step
   is ventilation with 100 % oxygen, if not doing so already. This will allow time for the necessary

equipment checks. Further deterioration may need to be managed by stopping surgery and re-
infl ating both lungs. Inform the surgeon early before the situation gets out of control. Attention

should be paid to maintain perfusion by treating hypotension.
Management of hypoxaemia during one-lung ventilation is as follows:
z increase Fi O 2 to 100 %
z check the position and patency of the endotracheal tube
z check the rest of the circuit and the anaesthetic machine
z do a fi bre-optic bronchoscopy if the airway pressures are high
z treat hypotension and ensure adequate cardiac output
z insuffl ate oxygen to the non-ventilated lung and apply continuous positive airway pressure
(CPAP) if no improvement
z apply positive end-expiratory pressure (PEEP) to the ventilated lung
z if the above measures fail, intermittent infl ation of the collapsed lung should be performed
z clamping the pulmonary artery to remove the shunt may be necessary in some thoracic surgeries.

Question 3

3. A patient with a psychiatric disorder is scheduled for an endoscopic repair of his abdominal aortic aneurysm. He has been known to be uncontrollable, but with his medications is now well adjusted. Which of
   the following psychoactive drugs will you not continue until the day of the surgery?

A. SSRIs.
B. Lithium.
C. Benzodiazepines.
D. Prochloeperazine.
E. Risperidone.

Answer 3

B

3. Answer: B
   Most medications used in psychiatric medicine can be continued until the day of surgery. Lithium is
   the exception, as it needs to be stopped 24 h pre-operatively. Lithium can prolong neuromuscular
   blockade by reducing neurotransmitter release. It reduces anaesthetic requirements and can
   accumulate following NSAID therapy.
   The serotonin re-uptake inhibitors (SSRIs) are the most commonly used drugs in the treatment of
   depression. This is because of their effi cacy as antidepressants and preferable side-eff ect profi le. The
   primary mechanism of action is pre-synaptic serotonin re-uptake inhibition, but they also have an
   anti-cholinergic eff ect. SSRIs can be continued up until surgery, but beware the risk of serotonin crisis.
   Lithium is used in the treatment of mania and bipolar disorders. The mechanism is poorly
   understood, but mimics sodium, entering excitable cells during depolarization. This results in a
   reduction in the release of neurotransmitters in both the central nervous system (CNS) and the
   peripheral nervous system (PNS). It has a narrow therapeutic ratio and is excreted solely by the
   kidneys. Prolongation of depolarizing neuromuscular block and a reduction in the anaesthetic agent
   requirements has been reported. NSAIDs, which reduce the excretion of lithium by the kidneys,
   can result in toxic plasma levels. Toxic symptoms tend to occur with plasma levels of 1.5 mmol/L.
   Hence, it is prudent that lithium is stopped at least 24 h before surgery.
   Tricyclic antidepressants (TCAs) are used in the treatment of depression, chronic pain, and
   some forms of acute pain. Their mode of action is by the prevention of presynaptic re-uptake of
   norepinephrine and serotonin (uptake 1). They also have anti-muscarinic, antihistaminergic and
   anti-a1-adrenergic eff ects. Metabolism occurs in the liver, via the cytochrome P450 pathway, with
   signifi cant interpatient variation. TCAs should be discontinued.

Question 4

4. An 85-year-old patient with history of heart disease is undergoing a laprotomy for caecal perforation and septicaemic shock. You think he has adequately fluid resuscitated. Which of the following is the best
   indicator of adequate filling in the presence of IPPV and anaesthesia?
   A. CVP of 12 mmHg.
   B. Systolic blood pressure 120 mmHg.
   C. Heart rate <100 bpm.
   D. Systolic pressure variation less than 10 mmHg.
   E. Capillary refi ll time <3 s.

Answer 4

D

4. Answer: D
   Central venous pressure (CVP) by itself is an unreliable indicator of fl uid status, although trends in
   CVP may be more accurate. This stems from the fact that CVP readings rely heavily on intact right
   heart and pulmonary function. Blood pressure may be elevated in hypovolaemia due to sympathetic
   drive. Heart rate trends, rather than a single reading, are more important. Heart rate itself may
   be aff ected by drugs such as sedatives and β -blockers. Septic shock may produce a hypervolaemic
   circulation with warm peripheries and no lag in capillary refi ll. Variation of venous return brought
   about by intrathoracic pressure changes in intermittent positive pressure ventilation (IPPV) is wider
   in hypovolaemia. A reduced variation of venous return indicates well-fi lled ventricles.

Question 5

5. A 44-year-old woman is diagnosed with breast cancer and is scheduled for mastectomy. On pre-assessment there is no other medical issue
   and she has a mild scoliosis.

You are planning a paravertebral block for
postoperative pain relief. Regarding paravertebral block, which of the following is correct?

A. Chest deformity is a relative contraindication.
B. Opiates may help in block quality and duration.
C. Hypotension is the most common serious complication.
D. Paravertebral block, given below the umbilicus, may inhibit the stress response.
E. Additional nursing training may be required to look after the patient post operatively.

Answer 5

E

5. Answer: C
   Paravertebral block is an advanced regional anaesthesia technique. Thoracic paravertebral block
   involves injecting local anaesthetic in the vicinity of the thoracic spinal nerves.
   Chest deformity may require imaging aids to perform the block but is not a contraindication.
   There is no evidence that the opiates aff ect the quality or duration of the regional blocks, but
   they may do so in central neuraxial blockade. A block above the umbilicus may inhibit the stress
   response. Generally, ward care of patients following a regional block does not warrant any
   additional training for the staff looking after these patients, but action on the sympathetic nerve
   may result in hypotension. This potential complication needs to be monitored for and treated.

Question 6

6. You are going to anaesthetize a child with cerebral palsy for tonsillectomy. The child has a history of diffi cult intubation.
   Which of the following is the most important thing you will note?

A. There is an increased sensitivity to non-depolarizing agents.
B. Suxamethonium is not contraindicated.
C. There is a small risk of malignant hyperthermia.
D. Co-existent anticonvulsant therapy can increase resistance to volatile anaesthetics,
increasing MAC values.
E. Thiopentone is the preferred induction agent.

Answer 6

B
6. Answer: B
Cerebral palsy is associated with an alteration in neuromuscular sensitivity to muscle relaxation.
There is decreased sensitivity to non-depolarizing relaxants. They are less potent and shorter
acting, hence larger doses may be required. Depolarizing relaxants do not cause hyperkalemia,
and suxamethonium has now been shown to be safe. Anticonvulsant therapy can reduce
minimum alveolar concentration (MAC) values by increasing sensitivity to volatile agents, thus
risking awareness under anaesthesia. Propofol is preferred both as an induction agent and as an
anaesthetic, as it reduces muscle tone. However, there is no risk of malignant hyperthermia.

Question 7

7. A 20-year-old is undergoing emergency laparoscopic appendicectomy.

He had rapid sequence induction for general anaesthesia.
During the procedure the heart rate increases from 80 to 130/min,
blood pressure 120/60 to 150/80 mmHg and entidal carbon dioxide is increasing 6.5 to 8.5 while on an inhalational agent.
The patient is sweating
and his temperature is 39.5 ° C. What would be the most appropriate initial step?

A. Change the anaesthetic machine to a vapour-free machine.
B. Disconnect the vaporizer and ventilate with 100 % oxygen.
C. Intravenous Dantrolene 2 mg/kg IV to a maximum of 10 mg/kg.
D. Surgery should be stopped and the patient transferred to critical care.
E. Check for signs of compartment syndrome.

Answer 7

7. Answer: B
   Current recommendations on treating malignant hyperthermia recommend simply disconnecting
   the vaporizer to save time rather than changing the anaesthesia machine and circuit.
   Hyperventilation with 100 % oxygen is recommended. Disconnecting the vaporizer saves time.
   Dantrolene needs to be given until cardiac and respiratory systems stabilize, even if the 10 mg/kg
   dose is exceeded.
   Anaesthesia should be maintained with intravenous drugs while surgery is concluded as rapidly as
   possible. Active cooling measures should be commenced early.
   Compartment syndrome might develop later on.
   Dantrolene needs to be given till cardiac and respiratory systems stabilize, even if the 10 mg/kg
   dose is exceeded.

Question 8

8. You are about to anaesthetize a patient with a large goitre compressing the airway. During the team briefi ng which of the following equipment
   you would ask to be readily available?
   A. McCoy laryngoscope.
   B. Bougie.
   C. Fibre optic laryngoscope.
   D. Emergency tracheostomy kit.
   E. Rigid bronchoscope.

Answer 8

8. Answer: E
   A McCoy laryngoscope, bougie, fi breoptic laryngoscope, and emergency tracheotomy are aids for
   diffi cult intubation where a glottis may not be visualized. Retrosternal goitres can compress the
   trachea, making ventilation impossible. For infra-glottic obstruction and in the circumstances of
   tracheal collapse, rigid bronchoscopy is the only reliable rescue in an airway emergency.

Question 9

9. You have anaesthetized a 54-year-old male for laryngoscopy and oseophagoscopy.
   The ENT surgeon finishes the procedure within 10 min of the intubating dose of atracurium. At the end of the anaesthesia, what will be most appropriate clinical indicator for adequate neuromuscular function after reversal of non-depolarizing blockade?

A. Tongue protrusion when asked.
B. Good cough.
C. Sustained head lift > 5 s.
D. Maintain sustained hand grip.
E. Inspiratory pressure − 20 cmH 2 O.

Answer 9

9. Answer: C
   Although cough, tongue protrusion, hand grip, and generation of inspiratory pressures are good
   clinical indicators of muscle power, sustained head lift is the only consistent indicator of good recovery.
   Clinical assessment:
   z sustained head lift for at least 5 s
   z generation of a vital capacity of at least 10 mL/kg
   z generation of an inspiratory pressure of at least –25 cmH 2 O.
   Tidal volume is not a reliable guide to recovery, since normal volumes can be generated with only
   20 % functional diaphragm muscle receptors.

Question 10

10. A patient is scheduled for a radical prostatectomy; he has bicuspid aortic stenosis. Which of the following options will you choose in his management?

A. Antibiotic prophylaxis.
B. Reduced afterload after a spinal anaesthetic to reduce cardiac strain.
C. Avoid tachycardia to ensure ventricular fi lling.
D. No antibiotic prophylaxis is required.
E. Promote peripheral vasoconstriction.

Answer 10

10. Answer: C
    The aortic stenosis is a fi xed outlet obstruction to left ventricular ejection. Anatomic obstruction
    to left ventricular ejection leads to concentric hypertrophy of the left ventricular heart muscle. This
    reduces the compliance of the left ventricular chamber, making it diffi cult to fi ll. Contractility and
    ejection fraction are usually maintained until late stages. Atrial contraction accounts for up to 40 %
    of ventricular fi lling.
    There is a high risk of myocardial ischemia due to increased oxygen demand and wall tension in
    the hypertrophied left ventricle. Thirty per cent of patients who have aortic stenosis with normal
    coronary arteries have angina.

Question 11

11. A 35-year-old woman with cervical spinal cord injury sustained 2 years ago is scheduled for a laprotomy.

She has large intestinal mass with associated shortness of breath.
There is history of autonomic
dysreflexia. Pick the best statement regarding her management:

A. β -blockers are indicated for autonomic dysreflexia.
B. Rapid sequence intubation is indicated for GA due to a risk of aspiration.
C. Slight head-down position promotes an improvement in FVC.
D. Fertility in aff ected females is reduced, so the abdominal mass is unlikely to be her uterus.
E. Clinically signifi cant hyperkalaemia after suxamethonium can persist until 18 months.

Answer 11

11. Answer: C
    Autonomic dysreflexia is characterized by massive disordered autonomic responses to stimulation
    below the level of the spinal lesion. It is rare in lesions lower than T 7 . Incidence increases with
    higher lesions. It may occur within 3 weeks of the original injury but is unlikely to be a problem after
    9 months. This is due to a loss of descending inhibitory control on regenerating pre-synaptic fi bres.
    Beta-blockade is only indicated in autonomic hyper-refl exia with tachycardia. Despite a theoretical
    risk of aspiration, rapid sequence induction of anaesthesia is not indicated for routine surgery.
    Slight head down or supine position promotes diaphragmatic contractility and improves forced vital
    capacity (FVC). There is risk of hyperkalaemia after suxamethonium, which usually persists until
    9 months post injury. Fertility is not aff ected in these patients.

Question 12

12. You are setting up an ENT theatre for a laser ablation of vocal-cord nodules. In order to prepare for airway fire:

A. Canvas tapes should be avoided.
B. The best airway is a modified laser tube with saline-filled cuffs.
C. The first step in an airway fire is to stop ventilating the patient.
D. Since oxygen supports combustion, gas mixtures of 21 % oxygen in nitrous oxide are suitable.
E. Protective reflective eye covers are needed.

Answer 12

12. Answer: C
    Immediate management of airway fi re:
    z stop laser or diathermy, fl ood area with 0.9 % saline
    z disconnect ETT or catheter from the breathing system
    z immediately clamp the end to reduce airfl ow to the burning area
    z withhold jet and/or mask ventilation to reduce airfl ow to the burning area
    z monitor pulse oximetry and re-ventilate when the fi re is out.

Plastic tapes are more combustible than canvas. The best means of managing the airway in this situation
is to avoid intubation and use Venturi devices. Gas mixtures of oxygen and air are better, as nitrous
oxide also supports combustion. Matt surfaces do not refl ect light and are safer than glossy surfaces.

Question 13

13. A patient suffered dural puncture during a labour epidural. She develops a headache and nausea after a day. Choose the incorrect statement
    regarding her management:

A. Prophylaxis of her headache includes bed rest.
B. ACTH can alleviate symptoms.
C. Expect her to be nauseous, as nausea accompanies headache in 60 % of patients.
D. Epidural saline infusions are dangerous as they can cause lower-limb radicular pain.
E. There is no evidence hydration reduces the incidence of headache.

Answer 13

13. Answer: A

Bed rest does not prevent headache, and can promote venous thrombosis instead.
There are a number of theories regarding the cause of post-dural puncture headache (PDPH).
The most commonly held belief is that it is due to the CSF leaking through the dural puncture site,
leading to intracranial hypotension. This causes settling of the brain and stretching of intracranial
nerves, meninges, and blood vessels.
Incidence of PDPH is estimated to be between 30 and 50 % following diagnostic or therapeutic
lumbar puncture, 0–5 % following spinal anaesthesia and up to 81 % following accidental dural
puncture during epidural insertion in the pregnant woman. It commonly occurs at a rate of
about 1 % following epidural placement.
The classic features of the headache caused by dural puncture are:
z often frontal-occipital: most headaches do not develop immediately after dural puncture but
24–48 h after the procedure, with 90 % of headaches presenting within 3 days; the headache is
worse in the upright position and eases when supine
z pressure over the abdomen with the woman in the upright position may give transient relief
to the headache by raising intracranial pressure secondary to a rise in intra-abdominal pressure
(Gutsche sign).
Other associated symptoms that may be present include nausea, vomiting, neck stiff ness,
photophobia, tinnitus, visual disturbance, and cranial nerve palsies.
Management of PDPH
Conservative:
z bed rest
z encourage oral fl uids and/or intravenous hydration
z reassurance.
A recent Cochrane review concluded that routine bed rest after dural puncture is not benefi cial and
should be abandoned.
Pharmacological:
z caff eine, either intravenous (e.g. 500 mg caff eine in 1 L of saline) or orally
z synacthen (synthetic adrenocorticotropic hormone (ACTH)
z regular analgesia: paracetamol, diclofenac etc.
Other drugs with insuffi cient evidence in the literature are 5HT agonists (e.g. sumatriptan),
gabapentin, desmopressin (DDAVP), theophyline, and hydrocortisone.
Interventional:
z immediate:
insertion of long-term intrathecal catheter placement (15 % ) and epidural saline bolus (13 % )
epidural morphine.
z epidural blood patch, which involves injecting approximately 20 mL of the patient’s own fresh
blood (taken in a strict sterile fashion) into the epidural space near the site of the suspected
puncture.

Question 14

14. A 27-year-old man has made a complaint to the hospital regarding ulnar neuropathy.

He says he developed ulnar nerve injury due to inadequate care during his long anaesthetic for a lower-limb free flap. The operation was conducted under a combine spinal–epidural, and you think he was comfortable during the operation. Pick the best statement regarding his condition:

A. This condition is more common in female patients due to fat compressing nerve in the ulnar groove.
B. 85 % of cases occur under general anaesthetic.
C. Prevention includes additional padding and abduction of neutral arm as it reduces ulnar
compression.
D. Common in young patients due to increased muscle bulk.
E. A difference in nerve conduction from the contralateral unaffected arm is diagnostic.

Answer 14

B

14. Answer: B
    Ulnar nerve injury is more common in males (3:1) because of reduced fat padding and a smaller
    carpal tunnel. Fifteen per cent of cases can occur with the patient awake. Additional padding may
    not make a diff erence, and although abduction of neutral arm reduces ulnar compression, it can
    strain the brachial plexus. The injury is more common in older patients, and may be accompanied
    by reduced nerve conduction in the unaff ected arm, indicating pre-operative sub-optimal nerve
    dysfunction.

Question 15

15. A medical registrar has referred an 18-year-old patient with bilateral progressive leg weakness.
    The leg weakness followed flu-like symptoms
    a week ago. Which of the following management approaches is most appropriate for the patient?

A. Diagnosis is Guillain–Barré syndrome; requires ICU admission and physiotherapy.

B. Diagnosis is Guillain–Barré syndrome; requires ICU admission for non-invasive ventilation.

C. Diagnosis is Guillain–Barré syndrome; requires ICU admission and corticosteroid therapy.

D. Diagnosis is Guillain–Barré syndrome; requires ICU admission and CSF filtration.

E. Diagnosis is Guillain–Barré syndrome; requires ICU admission and immunoglobin therapy.

Answer 15

E

15. Answer: E
    Guillain–Barré syndrome is an acute ascending immune-mediated demyelinating polyneuropathy.
    It is the most common cause of generalized paralysis. Fifty per cent of cases follow a viral illness.
    Incidence is 1–2 per 100 000 and the male-to-female ratio is 1.5:1. Incidence follows a bimodal
    distribution, with peaks in age ranges of 15–35 years and 50–75 years.
    The major symptom is rapidly progressive paralysis, which, unlike polio, is symmetrical. Paralysis
    of the lower extremities is followed by paralysis of the upper extremities, and both proximal and
    distal muscle groups are involved. Deep tendon refl exes are initially reduced and later are absent.
    One-third of patients require mechanical ventilation.
    Management is the ABC approach. The patient requires airway protection (intubation) and
    respiratory support, such as non-invasive ventilation or tracheostomy, should be considered
    earlier rather than later because prolonged respiratory support is likely. Patient may need IV fl uids,
    inotropes, and invasive haemodynamic monitoring. After initial management, an attempt should
    be made to reach a defi nitive diagnosis (since the initial diagnosis of Guillain–Barré syndrome is
    clinical). Lumbar puncture and CSF analysis often shows increased CSF protein levels. A neurologist
    should be consulted if any uncertainty exists as to the diagnosis.
    Intravenous immunoglobulins or exchange plasmaphoresis are the disease-modifying treatment. The
    role of corticosteroids for anti-infl ammatory action has no evidence to support it. Other measures
    are mainly supportive:
    z physiotherapy
    z prophylaxis against DVT (due to limited mobility for a long time)
    z pressure area care
    z nutritional support (preferably enteral)
    z treatment of infections depending on culture and sensitivity reports.
    The best treatment option for Guillain–Barré syndrome is to mange the patient in the critical
    care unit; providing supportive and immunoglobin therapy has been shown to modify the disease
    process.

Question 16

16. A 38-year-old man has been retrieved from a house fir with 30 %burns.

He was admitted to the high-dependency unit 24 h ago.

He is stable, with normal blood gases, and is on patient-controlled morphine.

The nurse responsible for his care requests you to review the patient and possibly discharge him to the ward. What is the most appropriate explanation to keep him in HDU?

A. Burn patients require multiple surgical procedures.
B. Patients with partial thickness burns have higher analgesic requirements.
C. Burn patients with > 25 % BSA require monitoring of COHb and cyanide levels.
D. Burns patients with > 25 % BSA produce systemic infl ammatory responses.
E. Fluid resuscitation is still required.

Answer 16

16. Answer: C
    Carbon monoxide poisoning is treated with oxygen even after clinical improvement beyond 1
    day because of the second peak of CO after 24 h. Full-thickness burns can be equally as painful
    as partial thickness burns, largely due to painful surrounding skin. Lichtenberg fl owers appear in
    lightning strikes. Fluid resuscitation time begins from the initial time of injury.
    In carbon monoxide poisoning, when carboxyhaemoglobin (COHb) is > 20 % , arterial blood gas will
    appear normal, and SaO 2 will appear normal because both COHb and oxyhaemoglobin absorb at
    940 nm. Bench co-oximetry utilizes an additional wavelength of red light, allowing diff erentiation.
    The clinical course of CO poisoning is directly related to the degree and duration of exposure.
    In the majority of cases those with a COHb level in the blood of less than 10 % will have no
    symptoms, whereas in those with a level of 50 % or greater are likely to suff er from coma, cardiac
    depression, or cardiac arrest. Myocardial injury is common and a predictor of mortality. Some
    patients may also develop rhabdomyolysis and renal failure.
    The classical cherry-pink discolouration of the skin caused by large amounts of COHb is in practice
    rarely seen. Skin pallor and cyanosis are more usual. Skin blisters may occur as a result of tissue
    hypoxia.

Question 17

17. A patient with a heart–lung transplant is scheduled for elective inguinal hernia repair. With respect to anaesthetic management, which of the
    following statements is appropriate?

A. The resting heart rate is 100–110/min due to sympathetic upregulation following denervation.

B. Nitric oxide responsiveness and coronary blood flow are increased.

C. Patients are susceptible to pulmonary oedema due to a high risk of diastolic dysfunction.

D. Regional anaesthesia will be best in view of the altered physiology of the heart.

E. Due to immunosuppression, denervation, and a high risk of pulmonary dysfunction, patients with heart–lung transplants should ideally be intubated.

Answer 17

C

17. Answer: D
    Heart and lung transplant patients have altered physiology:
    z the heart is denervated, with the resting heart rate usually around 85–95 bpm; some patients
    will be bradycardic and may have a permanent pacemaker
    z the autonomic system responses are obtunded.
    Contractility remains the same for the heart , unless rejection is developing.
    The heart should be considered as permanently denervated, and hence there will be poor tolerance
    to acute hypovolaemia.
    For pharmacological intervention, direct-acting agents should be used:
    z atropine has no eff ect on the denervated heart
    z the eff ect of ephedrine is reduced and unpredictable

z hydralazine and phenylephrine produce no refl ex tachycardia or bradycardia in response to
their primary action
z adrenaline, noradrenaline, isoprenaline, and β -blockers act as predicted.
Pulmonary edema can occur due to disrupted pulmonary lymphatics.
Heart–lung transplants should be managed without intubation if possible because of the risk of
disruption of the tracheal anastomosis.

Question 18

18. A 56-year-old man with acute bowel obstruction is on the emergency list for laparotomy. He has a significant history of hypertension and depression. He is on bendroflumethiazide, enalapril, and phenelzine.

During the operation his blood pressure went down to 65/30 from 140/90 and his heart rate was 120/min.

Fluid resuscitation continued, but the blood pressure rose to 70/40. What would be the most appropriate
treatment at this stage?

A. Intravenous bolus of ephedrine 6 mg/ml, monitoring the response.

B. Intravenous bolus of metaraminol 500 mcg/ml, monitoring the response.

C. Noradrenaline infusion with arterial monitoring.

D. Vasopressin infusion with arterial monitoring.

E. Phenylephrine bolus.

Answer 18

E

18. Answer: E
    The patient is on MAOIs. These work by inhibition of the enzyme monoamine oxidase, which is
    present on external mitochondrial membranes and inactivates monoamine neurotransmitters in
    both the central and peripheral nervous systems. MAOIs cause an increase in the level of amine
    neurotransmitters. Monoamine oxidase exists as two isoenzymes, A and B, which have diff erent
    properties. MAO-A acts mainly on serotonin, noradrenaline, and adrenaline. It is the main form
    of MAO found in the human brain. MAO-B preferentially metabolizes non-polar aromatic amines
    such as phenylethylamine and methylhistamine, and is responsible for 75 % of MAO activity,
    predominating in the gastrointestinal tract, platelets, and most other non-neural cells. Tyramine
    (a precursor of noradrenaline that is found in cheese and other foods) and dopamine are substrates
    for both A and B. There are now two generations of MAOIs: the original drugs, which inhibit both
    forms of MAO non-selectively and irreversibly, and the newer generation, which reversibly inhibit
    MAO-A. Selegiline, the anti-Parkinsonism drug, is an MAO-B inhibitor.
    MAOIs are used as follows:
    z non-specifi c and type A-specifi c MAOIs (e.g. phenelzine, isocarboxazid, and tranylcypromine)
    are used for treatment of depression in patients who may not tolerate other modes of
    therapy (tricyclic antidepressants, SSRIs, or electroconvulsive therapy)
    z type B-specifi c MAOIs (e.g. selegiline) are used as anti-Parkinsonism drugs.
    Hypertensive crisis may occur with amphetamines, methyldopa, levodopa, dopamine, epinephrine,
    norepinephrine, guanethidine, or indirectly acting vasoconstrictors. Hence drugs that have
    indirect sympathomimetic action are contraindicated in the presence of MAOIs. Direct-acting
    sympathomimetics (adrenaline, noradrenaline, and phenylephrine) should be titrated to eff ect in
    patients on MAOIs, as they may have an enhanced eff ect due to receptor hypersensitivity.
    A bolus of phenylephrine would be the appropriate fi rst line of action with such hypotension.

Question 19

19. You are assessing a 10-year-old boy with Down’s syndrome for a laproscopic appendectomy. He has a pansystolic murmur, high lymphocytic count, and is septic.

Which of the following statements
would you consider inappropriate?

A. Endocardial cushion and ventricular septal defects are common cardiac problems.

B. High risk of atlantioaxial instability necessitates screening lateral radiographs.

C. No abnormal responsiveness to anaesthetics is documented.

D. Incidence of leukaemia and polycythemia is common.

E. Eisenmenger’s syndrome may complicate obstructive sleep apnea.

Answer 19

19. Answer: B
    Down’s syndrome is one of the most common chromosomal disorders. Invariably anaesthetists
    will encounter patients with this syndrome for a variety of procedures.
    Screening lateral radiographs in the asymptomatic patients are not indicated. There may be
    accompanying cardiac defects and leukaemia. Obstructive sleep apnoea and Eisenmenger’s
    syndrome can both increase the chances of pulmonary hypertension and aggravate it.
    Down’s syndrome is characterized by:
    z trisomy of chromosome 21 due to non-dysjunction of chromosomes during germ cell
    formation; it is the most common congenital anomaly, carrying an incidence of 1.6 per
    1000 births

Question 20

20. A 55-year-old male is on an elective list for removal of the thymus gland.

He has recently been diagnosed with myasthenia gravis, and is on cholinesterase inhibitors and prednisolone.
He denies any respiratory
problems but suffers from chronic fatigue syndrome.

His preoperative investigations are all normal. The best anaesthetic management for this
patient would be:

A. RSI using suxamethonium.
B. A reduced dose of non-depolarizing neuromuscular blocking agents should be used for intubation.
C. Neuromuscular block must be reversed using cholinesterase inhibitors.
D. Postoperative ventilation.
E. An intensive care bed postoperatively.

Answer 20

B

20. Answer: B
    Myasthenia gravis is an autoimmune disease in which IgG auto-antibodies are produced against the
    nicotinic ACh receptors within the neuromuscular junction. The auto-antibodies lead to destruction
    of the receptors. Symptoms include a fatigable weakness, which can be localized to specifi c
    muscle groups (ocular, bulbar, and respiratory) or become widespread. Treatment may involve
    cholinesterase inhibitors, plasma exchange, immunosuppressants, and IV immunoglobulins.
    Myasthenia gravis patients exhibit a relative resistance to depolarizing neuromuscular blocking

agents and the dose used may need to be increased. Conversely, patients show sensitivity to non-
depolarizing neuromuscular blocking agents, requiring only 10 % of normal dose. Cholinesterase

inhibitors should be avoided as they can not only prolong the duration of a depolarizing
neuromuscular blocking agents block, but also precipitate a cholinergic crisis. Drugs that interfere
with neuromuscular transmission should be avoided. Postoperative ventilation may be necessary.

Question 21

21. A 95-year-old ASA 2 is scheduled to have his hip fracture fixed.
    You discuss the anaesthetic options with the patient and decide to avoid a general anaesthetic and offer the patient spinal anaesthesia.
    Which of the following reasons would you give?

A. Spinal anaesthesia for hip surgery reduces one-month mortality.

B. There is reduced autoregulation in the brain and kidneys.

C. Due to a smaller muscle mass, a moderate increase in serum creatinine is indicative of severe renal impairment.

D. FVC, FEV1, FRC,VC, and CC are all reduced.

E. Reduced total body water and plasma proteins.

Answer 21

D

21. Answer: D
    Geriatric changes increase mortality and morbidity. There is impaired autoregulation, with
    impaired renal function. There are reduced plasma proteins and body water, aff ecting drug
    delivery and metabolism.
    There are also respiratory system changes in elderly patients:
    z Functional residual capacity (FRC) is unchanged, but closing capacity falls with age, causing lung
    collapse. Loss of elastic recoil increases pulmonary compliance, but chest wall compliance falls
    due to degenerative changes in joints. Loss of septa increases alveolar dead space. Closing
    volume increases to exceed functional residual capacity in the upright posture at 66 years old,
    resulting in venous admixture. Thus normal P aO 2 falls steadily: (13.3 – age/30) kPa, or
    (100 – age/4) mmHg and ventilatory reserve declines with age.
    z Ventilatory response to hypoxia and hypercapnia declines with risk of postoperative apnoea.
    z O 2 consumption and CO 2 production fall by 10–15 % by the seventh decade. Patients are
    able to tolerate a longer period of apnoea following preoxygenation and minute volume
    requirement is reduced.
    z Airway protective refl exes decline, increasing the risk of postoperative pulmonary aspiration.
    z In edentulous patients, maintenance of a patent airway and face mask seal may be diffi cult.
    Leaving false teeth in situ may help.

Question 22

22. A 23-year-old Afro-Caribbean patient has an open tibial fracture and is on the emergency list for open reduction and internal fixation of tibia. The surgeon is concerned about the compartment pressure. The
    normal pressure in the lower limb muscle compartment is:
    A. 10–12 mmHg.
    B. 6–12 mmHg.
    C. 10–20 mmHg.
    D. 0–5 mmHg.
    E. 15–20 mmHg.

Answer 22

B
22. Answer: A
Compartment syndrome is a painful condition that occurs when pressure within the muscles
builds to dangerous levels. This pressure can decrease blood fl ow, which prevents nourishment
and oxygen from reaching nerve and muscle cells.
Muscles are contained in compartments or thick fi brous bands of tissue or fascia. Because of
injury, pressure can increase within the compartment, leading to swelling (fl uid accumulation) or
bleeding. In non-contracting muscle, the compartment pressure is normally about 0–15 mmHg.
If the pressure within the compartment increases (usually greater than about 30–45 mmHg; other
clinicians use other pressure values that are within 30 mm of the diastolic BP), most individuals
develop compartment syndrome. When these high compartment pressures are present,
blood cannot circulate to the muscles and nerves to supply them with oxygen and nutrients.
Compartment syndrome symptoms such as pain and swelling will then occur.
Muscle compartment measurements via a catheter connected to transducers are important after
trauma, particularly in comatose or sedated patients who are otherwise unable to complain of any
symptoms.

Question 23

23. A young university student slipped on an icy road and suffered a humeral bone fracture.

As the fracture is open it requires an emergency
procedure for open reduction and internal fixation. She has a very low pain threshold and morphine makes her very sick. She is happy to have
a nerve block. Which nerve block is most suitable for her?
A. Axillary brachial plexus block.
B. Axillary brachial plexus block with fentanyl PCA.
C. Interscalene brachial plexus block.
D. Supraclavicular brachial plexus block.
E. Infraclavicular brachial plexus block.

Answer 23

D

23. Answer: D
    The brachial plexus is formed by ventral rami of C5 to C8, with contributions from C4 and T2 in
    some. It provides nerve supply to the upper limb.
    It is composed of:
    z roots: C5–C8 and T1 (ventral rami)
    z trunks: upper , middle, and lower
    z division: anterior and posterior
    z cords: medial/lateral/posterior.
    At the supra-clavicular region the brachial plexus is in a compact form. The block at this level
    has the highest probability of blocking all the branches of the plexus. There is increased risk of
    pneumothorax, but this can be avoided by using ultrasound guidance or avoiding the medial aspect
    for needle insertion.
    Interscalene brachial plexus block could be used, but the area supplied by the C8 and T1 nerve
    roots may be missed. This may innervate the humeral area.

Question 24

24. A 65-year-old woman with community-acquired pneumonia is admitted with a chest infection. She has fever, tachyardia, hypotension, and hypoxia. A provisional diagnosis of septicemic shock is made and she is admitted to the HDU for critical care.

When you resuscitate her,
which of the following is not a clinical target for goal-directed therapy for severe sepsis?

A. Central venous pressure ≥ 12 mmHg in ventilated patients.
B. Mean arterial pressure 65–90 mmHg.
C. Urine output ≥ 0.5 mL/kg/h.
D. Haemoglobin ≥ 8 g/dL.
E. Central venous oxygen saturation ≥ 70 mmHg.

Answer 24

24. Answer: D
    Severe sepsis, a syndrome characterized by systemic infl ammation and acute organ dysfunction in
    response to infection, is a major healthcare problem aff ecting all age groups throughout the world.
    It is crucial to administer appropriate intravenous antimicrobial therapy in the care of patients with
    severe sepsis who may require surgery to control the source of sepsis. Preoperative resuscitation,
    aimed at optimizing major organ perfusion, is based on the judicious use of fl uids, vasopressors, and
    inotropes.

Question 25

25. A 60-year-old man underwent a scheduled Hartmann’s procedure for a gastrointestinal tract malignancy.

Postoperative pain was well controlled
using an epidural infusion containing 0.1 %bupivacaine with 2 mcg/ mL of fentanyl.

Twenty-four hours after the operation, he developed a
temperature of 39.5 ° C, severe backache, and heaviness and weakness of the right leg for the previous 2 h. The most appropriate step in this case
would be:

A. Stop the epidural infusion and observe for recovery of motor power.
B. Withdraw the epidural catheter by 1 cm and monitor for return of motor power.
C. Remove the epidural catheter and send the tip for culture.
D. Discontinue the epidural, do a full septic screen, and start broad-spectrum antibiotics
pending culture results.
E. Perform an urgent MRI and refer to a neurosurgeon.

Answer 25

E

25. Answer: E
    Complication of neuraxial blockade includes arachnoiditis, meningitis, and abscess, but serious
    infection following spinal or epidural anaesthesia is rare. Staphylococcus is the most common
    organism associated with epidural abscess.
    The classical triad of fever, backache, and neurological defi cit is suggestive of an epidural abscess,
    but all three features are only present in 13 % of cases at the time of diagnosis. It is a time-limited
    emergency and prognosis in terms of neurological recovery is poor if symptoms are present for
    longer than 24 h. Delay in diagnosis is associated with increased morbidity and mortality. An urgent
    MRI to confi rm the diagnosis and referral to a neurosurgeon for decompression is indicated.
    The catheter tip should be sent for culture and broad-spectrum antibiotics should be instituted, but
    there should be no delay in decompression once the diagnosis is confi rmed.

Question 26

26. A 75-year-old woman presents to the pain clinic with an 8-week history of severe pain in the right eye.

This pain is continuous with a burning sensation. She was treated with intermittent steroids for a painful rash
which she developed a few weeks ago. The most likely cause for her pain is:

A. Atypical facial pain.
B. Late signs and symptoms of polymyalgia rheumatica.
C. Post-herpetic neuralgia.

D. Trigeminal neuralgia.

E. Atypical presentation of trigeminal neuralgia.

Answer 26

B

26. Answer: C
    Herpes zoster results from reactivation of the varicella zoster virus. Herpes zoster is a sporadic
    disease, with an estimated lifetime incidence of 10–20 % . The incidence of herpes zoster increases
    sharply with advancing age, roughly doubling in each decade past the age of 50 years.
    Varicella zoster virus is a highly contagious DNA virus. Varicella represents the primary infection
    in the non-immune or incompletely immune person. During the primary infection, the virus gains
    entry into the sensory dorsal root ganglia. Reactivation of the virus occurs following a decrease
    in virus-specifi c cell-mediated immunity. The reactivated virus travels down the sensory nerve and
    is the cause for the dermatomal distribution of pain and skin lesions. Patients with disease states
    that aff ect cell-mediated immunity, such as HIV infection and certain malignancies, are also at
    increased risk.
    Herpes zoster typically presents with a prodrome consisting of hyperaesthesia, paraesthesias,
    burning dysaesthesias, or pruritus along the aff ected dermatome(s). The prodrome generally lasts
    1–2 days but may precede the appearance of skin lesions by up to 3 weeks. Some patients may
    have prodromal symptoms without developing the characteristic rash.
    Pain is the most common complaint for which patients with herpes zoster seek medical care.
    The pain may be described as ‘burning’ or ‘stinging’ and is generally unrelenting. Some patients
    may have insomnia because of the severe pain.

Question 27

27. A 55-year-old patient is on your list for elective thyroidectomy for a large goitre. She is on medications for hypertension. During preoperative assessment she informs you that over the last couple of weeks she has noticed that on extending her neck, her arms feel weak and slightly numb. She has not mentioned this to her doctors earlier. The next appropriate step in planning her airway management during anaesthesia would be:

A. Plan a careful conventional laryngoscopy and intubation, taking care to minimize neck
movement.
B. Plan the use of a flexible laryngeal mask airway and intermittent positive pressure ventilation.
C. Plan an awake fibreoptic technique for intubation.
D. Obtain an MRI of the neck to look for posterior atlanto-axial subluxation.
E. Plan an elective tracheostomy prior to induction of anaesthesia.

Answer 27

D

27. Answer: D
    Rheumatoid arthritis is associated with various problems with the airway:
    z fi xed neck deformity
    z narrowing of cricoarytenoid joint
    z involvement of the temporomandibular joint
    z atlanto-axial subluxation (AAS).
    AAS can be anterior (80 % ), posterior (5 % ), vertical (10–20 % ), or lateral. Anterior AAS will produce
    symptoms on neck fl exion while posterior AAS worsens on neck extension with implications for
    conventional laryngoscopy.
    This patient’s symptoms are suggestive of posterior AAS and need imaging to diagnose or exclude
    it. She also has an enlarged thyroid, which may in itself compromise her airway. It would not be
    appropriate to proceed without further imaging. The patency of the trachea would be important in
    view of tracheacheal collapse.

Question 28

28. A 30-year-old man underwent a nailing of the tibia following a compound fracture sustained in a road traffic accident. Postoperatively he was comfortable on PCA morphine. Six hours postoperatively you are
    called by the nurse to review the patient as he is complaining of severe pain in the leg and paraesthesia. Examination reveals a tense, swollen
    leg, with reduced sensation and severe pain on passive stretching of the calf muscle, and with distal pulse palpable. The most appropriate
    management would be:
    A. A bolus of 5 mg intravenous morphine followed by PCA morphine.

B. Urgent referral to the trauma surgeon for suspected compartment syndrome.

C. A postoperative femoral nerve block to augment the eff ect of morphine analgesia.

D. Arrange postoperative placement of epidural catheter with a continuous epidural infusion,
as the PCA is not adequately controlling the pain.

E. Full septic screen to check inflammatory markers and start antibiotics for suspected
postoperative sepsis.

Answer 28

B

28. Answer: B
    Compartment syndrome is commonly seen after traumatic fractures in an osseofacial compartment
    of leg and forearm, but can occur in thigh, upper arm, and foot. Compartment syndrome requires
    prompt diagnosis and treatment by decompression, otherwise it leads to neurological defi cit,
    muscle necrosis, amputation, and death. Pain is a cardinal feature and regional anaesthesia may
    mask this and delay diagnosis. The other features are paraesthesia, tense, painful compartment,
    pain on passive stretch of muscle, and sensory loss. Pulselessness is not common and is a very
    late feature.

Question 29

29. A 40-year-old patient has sustained a fall from height and has broken his right femoral shaft. He undergoes a femoral nailing the next day but develops confusion and becomes hypoxic in the recovery. You suspect fat embolism. Which of the following is a major Gurd’s criteria for the diagnosis of fat embolism?

A. Fat in urine and sputum.
B. Emboli in the retina on fundoscopy.
C. Axillary petechiae.
D. Tachypnoea.
E. P aO 2 < 8.0 kPa on room air.

Answer 29

29. Answer: C
    Explanation: fat embolism presents typically 24–72 h after initial trauma, which is usually a long bone
    fracture. The presentation consists of a classic triad of neurological abnormalities, petechial rash,
    and respiratory changes. However, these signs are not always reliable and a high index of suspicion
    is needed. Gurd’s criteria (see Table 1.3 ) are most commonly used to aid diagnosis and have three
    major and a number of minor criteria described. You need at least one major and four minor
    criteria for the diagnosis of fat embolism.

Question 30

30. A 77-year-old lady is admitted to A&E following a fall at home.
    She is brought to the department by ambulance technicians without spinal immobilization.

She has bilateral head of humerus fractures, a nasal
fracture, and multiple lacerations to her face. She suffers from severe rheumatoid arthritis. What should be done urgently before she is referred to the orthopedic team?

A. Call the maxillo-facial team to suture the lacerations.
B. Spinal immobilization and CT scan of the cervical spine.
C. Reduce displaced humeral fracture.
D. Give her antibiotics.
E. Tetanus vaccination.

Answer 30

B

30. Answer: B
    Rheumatoid arthritis is a multisystem disorder mainly involving joints. Approximately 25 % of
    patients with severe rheumatoid arthritis have atlanto-axial subluxation, but of these only 25 % will
    have neurological signs or symptoms. It is important to know about tingling of hands or feet, and
    neck pain, and to assess the range of neck movement. Excessive movement during anaesthesia can
    lead to cervical cord compression.
    Cervical spine radiographs: the role of preoperative cervical spine fl exion/extension views is
    controversial and interpretation is diffi cult.
    Flexion/extension views are mandatory in all patients with neurological symptoms or signs, and
    also in those with persistent neck pain. Preoperative cervical spine radiographs may help determine
    management in some patients with severe disease. Specialist radiological advice may be required.
    All rheumatoid patients should be treated as having an unstable spine. This may involve awake
    fi breoptic intubation or manual in-line stabilization when undertaking direct laryngoscopy, laryngeal
    mask airway (LMA) insertion, or moving the patient. MRI and CT may be useful in assessing cord
    compression.
    This patient has suff ered a signifi cant trauma to the head, so cervical spinal fracture or further
    displacement of undiagnosed atlanto-axial subluxation has to be excluded.

Question 31

Wrong in Exam 1

Answer 31

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