2011.2 Flashcards
EZ93 What is the chemical used in sodalime to indicate exhaustion?
A. ethyl violet
B. potassium permanganate
C. ?
A. Ethyl violet
Chemical reaction is;
H20 + CO2 → H2CO3
H2CO3 + 2NaOH → Na2CO3 + 2H2O
Na2CO3 + Ca(OH)2 → CaCO3 + 2NaOH
Indicators for SodasorbTM (such as ethyl violet) are colorless when fresh, and purple when exhausted, because of pH changes in the granules.
- Repeat- Main heat loss in anaesthetic for neonate
A. vasodilatation B. radiation C. convection D. conduction E. evaporative
B. Radiation
Radiation if > 28/40 PCA
Evaporation if
- Repeat- One lung ventilation- FIO2 1.0, desaturate
Management of hypoxaemia during OLV:
o Increased FiO2 to 1.0
o Confirm adequate lung isolation by talking to surgeon and checking positioning of DLT with bronchoscope
o Manually ventilate to assess compliance (?upper airway obstruction ?PTX, ?APO) - if poor compliance, suction down tube (down ventilated side) to exclude partial tube obstruction
o Ensure adequate muscle relation
o Optimise cardiac output (may need inotropes)
o Interventions to ventilated lung:
- Alveolar recruitment manoeuvre + increase PEEP (up to 10 cmH2O)
o Interventions to nonventilated lung (bearing in mind that these will interfere with surgery to varying extents)
- Alveolar recruitment manoeuvre followed by CPAP (e.g. 5-10 cmH2O) via an auxillary circuit
- Intermittent two lung ventilation
- Surgical clamping of the pulmonary artery on the operative side to decrease shunt (depending on surgery)
- Child with murmur- what would make it more likely for you to investigate if you heard the murmur
A. persist in supine position
B. louder or softer with various manouveres
??
Likely to be innocent:
- Asymptomatic
- Soft, no associated thrill
- Ejection systolic
- Lower sternal edge, does not radiate
Likely to be pathological:
- Child has chromosomal abnormality or syndrome
- Cardiac symptoms, frequent respiratory symptoms, e.g. cough, wheeze, recurrent respiratory infections
- Failure to thrive
- Family history of congenital heart diseaseInfant
- Repeat- Single lumen intubation after multiple attempts of difficult intubation, you put in a bronchoscope after and the tip is in the trachea. The structure B you see corresponds to?
??
- Repeat- CXR correspond to-
A. right side hydropneumothorax
??
- Repeat- Neonate to drug addicts found by grandmother in the house, brought into ed, mildly jaundice, slight tachycapnic. ABG PH 7.54, PaCO2 46, pO2 74, HCO 13
A. Septicaemic B. Pyloric stenosis C. Opiod overdose D. Meningitis E. Hepatitis
?? This ABG is impossible - ?incorrectly remembered
ET03 [Repeat] Jehovah’s witness refused blood- you have told him you refuse to do the surgery/anaesthesia for his own good. Ethical principle:
A. Paternalism
B. Maleficience
C. Autonomy
D. Beneficience
A. Paternalism
- Patient with aortic stenosis, the signs indicate poor prognosis
A. Palpitation
B. Radiation to carotid arteries
C. Something about characteristic of murmur
Poor prognosis:
- Angina: 5 year 50% survival
- Syncope: 3 year 50% survival
- Heart failure: 2 year 50% survival
Which is the best predictor of poor prognosis with aortic stenosis?
A. chest pain B. paroxysmal nocturnal dyspnoea C. syncope D. E.
B. Paroxysmal nocturnal dyspnoea
Poor prognosis:
- Angina: 5 year 50% survival
- Syncope: 3 year 50% survival
- Heart failure: 2 year 50% survival
- New- Patient indicated for prophylaxis of infective endocardititis
A. amoxicillin orally 2 hours prior
B. amoxicillin IV 1 hour prior
C. amoxicillin IV just before incision
D. cefazolin IV 1 hour prior
B. Amoxycillin IV 1 hour prior (best answer of the ones given)
TGA 2014
For standard prophylaxis, use:
amoxycillin 2 g (child: 50 mg/kg up to 2 g) orally, 1 hour before the procedure
OR
amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, within the 60 minutes (ideally 15 to 30 minutes) before the procedure
OR
amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IM, 30 minutes before the procedure.
- Repeat- Spontaneously breathing patient under GA, what would detect the breathing tube disconnection
Loss of anaesthetic agent waveform/decrease in end-tidal agent
(may still have capnography trace if disconnection is proximal to the sampling line)
- Repeat- Plenum and flow over vaporiser- what is not the disadvantage of flow over vaporiser
Wiki:
- Not temperature compensated (drawback)
- Not flow compensated - output concentration depends on flow
The drawover vaporizer is driven by negative pressure developed by the patient, and must therefore have a low resistance to gas flow. Its performance depends on the minute volume of the patient: its output drops with increasing minute ventilation.
The design of the drawover vaporizer is much simpler: in general it is a simple glass reservoir mounted in the breathing attachment. Drawover vaporizers may be used with any liquid volatile agent (including older agents such as diethyl ether or chloroform, although it would be dangerous to use desflurane). Because the performance of the vaporizer is so variable, accurate calibration is impossible. However, many designs have a lever which adjusts the amount of fresh gas which enters the vaporising chamber.
The drawover vaporizer may be mounted either way round, and may be used in circuits where re-breathing takes place, or inside the circle breathing attachment.
Drawover vaporizers typically have no temperature compensating features. With prolonged use, the liquid agent may cool to the point where condensation and even frost may form on the outside of the reservoir. This cooling impairs the efficiency of the vaporizer. One way of minimising this effect is to place the vaporizer in a bowl of water.
The relative inefficiency of the drawover vaporizer contributes to its safety. A more efficient design would produce too much anaesthetic vapour. The output concentration from a drawover vaporizer may greatly exceed that produced by a plenum vaporizer, especially at low flows. For safest use, the concentration of anaesthetic vapour in the breathing attachment should be continuously monitored.
PZ130 Which drugs below does not need dose adjustment in renal failure patient
A. Buprenorphine B. Morphine C. Tramadol D. ? E. ?
A. Buprenorphine
- Repeat- Child after gas induction, LMA insertion without IV cannula- desaturate to 90%. Next step of action?
A. Bag with LMA insitu
B. Bag without LMA insitu
B. Remove LMA and provide CPAP via mask
PZ128 Patient on cisapride. What drug NOT to give in recovery?
A. Tramadol
B. ?
C. ?
?? - Avoid QT prolonging drugs, also avoid serotonergic drugs
As a prokinetic agent that increases gastrointestinal motility, cisapride acts as a selective serotonin agonist in the 5-HT 4 receptor subtype. Cisapride also relieves constipation-like symptoms by indirectly stimulating the release of acetylcholine in the muscarinic receptors
Most data on cisapride interactions are derived from case reports. However, current prescribing information warns against the coadministration of cisapride and any medications known to prolong the QT interval, such as class IA or III antiarrhythmic drugs, tricyclic antidepressants, erythromycin, clarithromycin and phenothiazines.
- Repeat- Which herbal supplement reacts with tramadol?
A. Ephedra
B. St John’s wort
B. St John’s wort
Similar to more conventional antidepressants, its effects are thought to be because of the inhibition of serotonin, norepinephrine, and dopamine re-uptake by neurones.
- Repeat- Fat: blood coefficient- N2O, D, S, I
Fat:blood coefficients:
- N2O: 2.3
- Des: 27
- Iso: 45
- Sevo: 48
- Repeat- Immunology mediated heparin induced thrombocytopenia
? Answer was intravascular thrombosis
- Repeat- Half life or tirofiban?
A. 2 hours
A. 2 hours
Time to normal platelet function = 4-8 hours (can perform neuraxial block at 8 hours)
TMP-131 Repeat- Troponin can be detected for how long:
A. 5-14 days
B. ?
A. 5-14 days
- Repeat- Neonate intubation- at lips
~ 9 cm
Distance at the lips:
- There are lots of formulas, but they don’t take into account natural variation, or head position (e.g. needs to go in further if head flexed).
- Look at the child: you want the tip of the tube to be half-way between the cords and the carina - this half-way point corresponds to the heads of the clavicles in most children –> so the distance between the heads of the clavicles and the cricoid cartilage is the length of tube you want past the cords.
- Phil Ragg reckons this ‘length of tube past the cords’ also corresponds to the internal diameter of the tube (but obviously in cm, not mm)
- Another useful formula is ‘distance at the lips = 3 x ETT size (ID)’
- New - 72 year old has had hip replacement surgery and 3 days postop has a pulmonary embolus. He is fully heparinised, but still dyspnoeic, clammy, BP 80/40, pulse 120 and CVP 18. The most appropriate next step is
A. IVC filter B. Refer him for a pulmonary embolectomy C. Supportive (fluids and inotropes) D. Thrombolysis E. Warfarin
C. Supportive (fluids and inotropes) - and if this fails, then consideration of pulmonary embolectomy.
Stoelting:
Treatment options for acute pulmonary embolism include anticoagulation, thrombolytic therapy, inferior vena caval filter placement, and surgical embolectomy.
Heparin remains the cornerstone of treatment for acute pulmonary embolism.
Patients who cannot undergo anticoagulation, experience significant bleeding while being treated with anticoagulants, or have recurrent pulmonary emboli despite receiving anticoagulant therapy may require insertion of a vena cava filter to prevent lower-extremity thrombi from becoming pulmonary emboli. The use of vena cava filters should be reserved for patients with contraindications to anticoagulant treatment.
Thrombolytic therapy may be considered to hasten dissolution of pulmonary emboli, especially if there is hemodynamic instability or severe hypoxemia. Hemorrhage is the principal adverse effect of thrombolytic therapy, and so this treatment is contraindicated in patients at high risk of bleeding.
The hypotension caused by a pulmonary embolism may require treatment with inotropes such as dopamine and dobutamine or a vasoconstrictor such as norepinephrine. A pulmonary vasodilator may be needed to help control pulmonary hypertension.
Pulmonary artery embolectomy is reserved for patients who have a massive pulmonary embolism that is unresponsive to medical therapy and who cannot receive thrombolytic therapy.
- Repeat- The test to diagnose pulmonary embolism
A. CT pulmonary angiogram
B. Echocardiogram
C. Electrocardiogram
D. Ventilation-perfusion scan
A. CTPA
- Repeat- Finding on haemophilia A patient
A. Female haemarthrosis
B. Male haemarthrosis
C. Normal PT, abnormal APTT
D. Abnormal PT, normal APTT
B. Male haemarthrosis
C. Normal PT, abnormal APTT
Haemophilia A and B
- X-linked recessive
- Bleeding into weight-bearing joints (spontaneously or after trauma) - e.g. knees, ankles, elbows
- Normal PT, prolonged APTT
25.tmp11b25 New- LSCS for foetal distress, meconium stained liquor. Management of baby
A. Intrapartum suctioning B. Intrapartum suctioning and post partum tracheal suction C. Post partum tracheal suctioning D. Routine neonatal care E. Intubate
Depends on tone/respiratory effort.
If floppy/apnoeic –> intubate immediately and suction once down ETT
If vigorous, routine neonatal care
- Repeat- 36yo male with sickle cell anaemia Hct 0.3 with close foot fracture, what is true
A. Transfusion 2 pint packed cell preop
B. Spinal can be done
B. Spinal can be done
- New- An elderly lady has a closed neck of femur fracture and presents to ED. She is in chronic AF and on warfarin. INR is 2.6 and she is not bleeding. It is 9am and she is scheduled for repair the following day. According to current guidelines, how should her warfarin be reversed?
A. Prothrombinex 25IU/kg immediately and then 2 units FFP immediately prior to surgery
B. No immediate treatment then 2 units FFP immediately prior to surgery
C. Vitamin K 1mg IV immediately
D. Vitamin K 10mg IV immediately
E. Withhold warfarin
Vitamin K 3 mg IV immediately
(+ withhold warfarin… then check INR again the next day)
MJA 2013:
Check INR day before surgery: If INR 2–3, administer 3 mg vitamin K1IV
Day of surgery:
• If INR = 1.5, surgery can proceed(GPP);
If INR > 1.5, defer surgery or if urgent, dose Prothrombinex-VF according toBox 4
- Repeat- Marfan syndrome. All EXCEPT-
A. Aortic stenosis
A. Aortic stenosis
- New- Subarachnoid haemorrhage patient. What percentage rebleed in the first 24hours
A. 20%
A.
30.TMP11B30 New- Post delivery neonate did not breath post stimulation by midwife, not vigorous, heart rate drop from 140 to 90bpm. Next step of action
A. 100% oxygen B. Positive pressure ventilation C. Intubation D. CPR E. Adrenaline
B. Positive pressure ventilation
- New- The safe maximal pressure for endotracheal cuff at the lateral side of the trachea
A. 0-10 cm water B. 10-20 cm water C. 20-30 cm water D. 30-40 cm water E. 40-50 cm water
C. 20-30 cmH2O
BMC anaesthesiology:
It is thus essential to maintain cuff pressures in the range of 20–30 cm of H2O
- New- Patient with mastocytosis. Intraop would probably be:
A. Severe hypotension
A. Severe hypotension
- Repeat- Complication of celiac plexus block
A. Hypertension B. Failure of erection C. Constipation D. Paraplegia E. L3,4 lumbar pain
D. Paraplegia
- New- Post epidural and LSCS, the next day patient has persistent paraesthesia anterior thigh. What other deficits would indicate a nerve root lesion rather than a peripheral nerve injury
A. Weakness on hip flexion and thigh adduction
B. Weakness on knee flexion and plantar flexion
C. Urinary incontinence
D. Foot drop
A. Weakness of hip flexion and thigh adduction
With a femoral nerve lesion, there would be sensory loss over the anterior thigh and weakness of hip flexion, but hip adduction would be preserved (obturator nerve).
Knee flexion is L5/S1
Ankle plantar flexion is S1/2
Ankle dorsiflexion (or lack of dorsiflexion with foot drop) = L4/5
Urinary incontinence = sacral nerve roots
- Repeat- Nerve supply to the upper eyelid-
A. ophthalmic branch of trigeminal and sympathetic from superior collicus ganglion
A. Ophthalmic branch of trigeminal and sympathetic from superior colliculus
- Repeat- Post LSCS foot drop-
A. Common peroneal nerve
??
- Repeat- Post op cervical- patient complaint arm weakness. Differentiate C8, T1 versus ulnar nerve injuries
A. Abductor pollicis brevis
Weakness of abductor policies braves would indicate a C8/T1 lesion rather than an ulnar nerve lesion, as this muscle is innervated by the median nerve (from C8/T1 roots)
- Repeat-Absent of Q waves-
A. Digitalis toxicity
A. Digitalis toxicity
- Repeat- What can prolong QT interval except-
A. Magnesium
A. Magnesium
used to treat torsades so definitely wouldn’t prolong it
- Repeat- Post carotidenderactomy in the ward, patient seizure. Noted patient operation side is more severe stenosis and post op difficult to control blood pressure. What would prevent seizure most
A. Add on antihypertensive
B. Start anti convulsant
A. Add antihypertensive
- Repeat- Post local anaesthetic block in difficult intubate patient- patient seizure. What would you give?
A. Midazolam 5mg
B. thiopentone
C. propofol
D. Suxamethonium
A. Midazolam 5 mg
- Repeat- Carcinoid patient intraop hypotension-
A. octreotide
A. Octreotide
- Repeat- Allergic question, which is true
A. Collect tryptase 8hours
B. RAST test most sensitive/ specific
C. Absent of trytase exclude anaphylactic
D. Skin and intradermal test- sensitivity, specificity
Collect tryptase immediately after resuscitation, at 1 hour, 4 hours and 24 hours. Normal result does not exclude anaphylaxis.
RAST is highly specific but has poor sensitivity.
Skin testing:
- Comprises skin prick testing and intradermal test
- Skin prick testing highly sensitive for NMBAs and gelatins, but insensitive for barbiturates, benzos and opioids
- Intradermal testing is indicated if there is clinical suspicion but negative SPT. The AAGBI suggests that IDT is more sensitive but less specific than SPT (some drugs, e.g. morphine, have a direct histamine-releasing action, and may lead to false positives with IDT)
- Skin prick testing is safe, but intradermal injections may rarely precipitate systemic reactions
- Repeat- What more likely to cause TRALI?
A. FFP
A. FFP
- New- After transfusion of 5 unit of FFP what is least likely to occur
A. Haemolytic reaction
B. Hypocalcaemia
C. Infection
D. Hyperkalaemia
D. Hyperkalaemia
- Severe asthmatic- tachycapnia, HR120, speaking in words, pH 7.45, pCO2 46, pO2 96, HCO3 24. Then given nebulised salbutamol continuously, nebulised ipratropium bromide, and hydrocortisone- The next step:
A. ?
B. ?
IV magnesium 50 mg/kg over 20 mins, followed by 30 mg/kg/h
- Repeat- Most common cause of awareness-
A. human error
A. Human error
- New- There is evidence to avoid BIS
C. Increased post-op mortality
Monitoring with BIS and absence of BIS values 5 min were associated
with improved survival and reduced morbidity in patients enrolled in the B-Aware Trial
- New- Most common cause of paediatric post anaesthesia cardiac arrest
A. Drug error
B. Respiratory cause
C. Multifactorial
D. Cardiac problem (?)
B. Respiratory cause
- New- Post cervical spine op, there is bulging noted under the incision site. Patient desaturated, combative, keep pulling off the oxygen facemask. Next course of action
A. Rapid sequence induction
B. Gas induction
C. Needle aspiration of the bulge at the neck
B. Gas induction
- New- What drug known to cause prolong QT and risk of Torsades de pointes
A. Metoclopramide
B. Droperidol
C. Tranexamic acid
B. Droperidol (probably only at high doses, e.g. 5-10 mg)
- New- During cardiac catheterisation (?) patient become BP 80/60, HR 110, CVP 16. What is the next most important investigation
A. Echocardiogram
B. CXR
C. Electrocardiogram
A. Echo - to exclude tamponade
- Intraop hyperfibrinolysis- how to diagnose (euglobulin lysis time NOT an option in the answer)
A. TEG
B. PT
C. APTT
A. TEG
- New- 75yo patient seen for femoral bypass surgery, no significant cardiac risk factor. He will be admitted 3 days prior to operation. You decided NOT to start on beta blocker and you are justified because:
A. There is increase mortality and morbidity
B. There is not enough time to safely start beta blocker
C. The beta blocker may make the patient claudication worst
D. ?
A. Increased mortality and morbidity
POISE - fewer MIs, but more stroke/death/bradycardia
