2014.1 Flashcards
- Given the following diagram, what does X represent? (diagram of underwater seal drain apparatus)
A. Amount of drainage since system was connected to patient
B. Level of resistance to drainage of pleural cavity
C. Level of underwater seal applied to pleural cavity
D. Maximum pressure ?in/against pleural cavity on expiration
E. Maximum suction that can be applied to pleural cavity
?
- Retrobulbar block. Sign of brainstem spread
A. Atonic pupil B. Unilateral blindness in blocked eye C. Contralateral blindness D. Diplopia- past papers remembered this as dysphagia E. Nystagmus
C. Contralateral blindness
Caused by back-spread of LA to the optic chiasm
Drowsiness/Vomiting/Convulsions/Respiratory Depression/Arrest
http://bja.oxfordjournals.org/content/75/1/93.full.pdf
- Otherwise healthy 20 yo male undergoes surgery for an ORIF tibia for open tib fracture. The limb is exanguinated and the tourniquet correctly applied at 250mmHg. His SBP is 120. When the surgeons go to start there is a small amount of bleeding. Do you..
A. Accept that a small amount of bleeding may occur with a tourniquet
B. Reinflate at a higher pressure
C. Check coags
D. Take tourniquet down, rexanguinate and reinflate
E. Something else
A. Accept a small amount of bleeding
- This was the CXR showing a widened mediastinum with an otherwise normal CXR, there was an electronic circuit thing at the bottom right but nothing else obvious. Aortic dissection was the answer (at least I think!)
Aortic dissection
- Fatigue during night shifts can be minimized by:
A. Avoiding daylight B. not sleeping during day C short naps during shift D use of caffeine or stimulants E. using benzodiazepines for sleep during the day
C
CEACCP - fatigue and the anaesthetist (2013)
6.Patient with Acute Intermittent Porphyria presents to hospital with abdominal pain and requires a general anaesthetic. Which drug for PONV would you avoid?
A. Metoclopramide B. Prochlorperazine C. Tropisetron D. Ondansetron E. Droperidol
A. Metoclopramide
Oxford handbook
- A 65 year old man having a total hip placement under general anaesthetic has continued to take his moclobemide. He becomes hypotensive shortly after induction. The best treatment would be judicious use of
A. adrenaline B. dobutamine C. ephedrine D. metaraminol E. phenylephrine
E. Phenylephrine
Moclobemide- reversible MAOI
Most dangerous - indirect sympathomimetics (Ephedrine/Metaraminol/Amphetamine/Cocaine)
Direct sympathomimetics - exaggerated effect
Serotonin Syndrome - Pethidine/Tramadol
Pancuronium - releases stored NA
Oxford Handbook
- The following capnography trace was observed in an intubated and ventilated patient (low/false plateau, then true plateau just prior to inspiration). The most likely explanation for this respiratory pattern is
A. endobronchial intubation B. endotracheal cuff leak C. gas sampling line leak D. obstructive airways disease E. spontaneous ventilatory effort
C. Gas sampling line leak
- When topping up a labour ward epidural to an epidural for lower segment caesarean section, the optimum level of block when assessed for light touch is to:
A. T2 B. T4 C. T6 D. T8 E. T10
B. T4
- You are in the pre-admission clinic assessing a 60 year old male who is due to undergo total knee replacement in 10 days time. He is taking dabigatran 150mg BD for chronic atrial fibrillation. He has no other past medical history and normal renal function. He is planned for a spinal anaesthetic. The most appropriate management for his anticoagulation is:
A. Cease dabigatran 7 days prior
B. Cease dabigatran 3 days prior
C. Cease dabigatran 3 days prior and give bridging anticoagulation
D. Cease dabigatran 24 hours prior and measure INR on day of surgery
E. Continue dabigatran and withhold on day of surgery
B. Cease dabigatran 3 days, prior. No bridging required (low risk for thromboembolism).
Darbigatran - factor Xa inhibitor
At least 48 hours for spinal
MIMS
- A 15 yo girl with newly diagnosed mediastinal mass presents for supraclavicular lymph node biopsy under GA. The most important investigation to perform preoperatively
A. CXR B. CT chest C. MRI chest D. PET scan E. TOE
CT or MRI to determine presence/extent of airway compression. ?MRI better for 15 year-old to minimise radiation.
If she could tolerate it, would do this procedure under LA (if any concerns about airway compression or SVC syndrome).
- A CTG recording with late prolonged decelerations. Cause:
A. GA B. Head compression C. Uteroplacental insufficiency D. Acute asphyxia E. Umbilical cord compression.
C. Uteroplacental insufficiency
Late decelerations begin at peak of uterine contraction and recover when the contraction ends.
Caused by:
Maternal Hypotension
Pre-Eclampsia
Uterine Hyperstimulation
Head compression- Early deceleration
Umbilical cord compression- Variable deceleration
http: //geekymedics.com/2011/05/29/how-to-read-a-ctg/
http: //ceaccp.oxfordjournals.org/content/3/2/38.full.pdf+html
- A new antiemetic decreases the incidence of PONV by 33% compared with conventional treatment. 8% who receive the new treatment still experience PONV. The number of patients who must receive the new treatment instead of the conventional before 1 extra patient will benefit is
A. 3 B. 4 C. 8 D. 25 E. 33
D. 25
1/ARR
1/Probability (with intervention)-Probablity (Control)
1/0.12-0.08=1/0.04 = 25
- You are anaethetising a lady for elective laparoscopic cholecystectomy, who apparently had an anaphylactic reaction to rocuronium in her last anaesthetic. There has not been sufficient time for her to undergo cross-reactivity testing. What would be the most appropriate drug to use:
A. vecuronium B. cisatracurium C. pancuronium D. atracurium E. suxamethonium
B Cisatracurium
60-70% of all anaphylaxis
Anaphylaxis to suxamethonium - 60% to all others NMBD
Benzylisoquinolonium
Less potential for histamine release
Cisatracurium less histamine release
Peck + Hill
…If it’s elective, the safest thing to do is to defer the case until she has had allergy testing.
- Increase in period bleeding EXCEPT
A. Gingko B. Garlic C. Ginger D. Fish Oil E. Echinacea
E. Echinacea
- Post op hip ORIF, commonest periop complication
A. UTI B. PE C. Delirium D. AMI E. Pneumonia
C. Delirium
Anaesthesia UK - tutorial of the week: neck of femur fracture; perioperative management (2013)
- You are anaesthetizing a 50 year old man who is undergoing liver resection for removal of metastatic carcinoid tumour. He has persistent intraoperative hypotension despite fluid resuscitation and intravenous octreotide 50 ug. The treatment most likely to be effective in correcting the hypotension is:
A. Adrenaline B. Dobutamine C. Levosimenden D. Milrinone E. Vasopressin
E. Vasopressin
CEACCP - carcinoid: the disease and its implications for anaesthesia (2011):
A significant proportion of the surgery related to carcinoid will be for the removal of metastases by hepatic resection. Here, the need to try to maintain a relatively low CVP, during clamping of the hepatic artery and portal vein to avoid backflow into the liver and venous bleeding, will further exacerbate the risk of hypotension. The response to inotropic and vasopressor agents is unpredictable and, in general, drugs such as norepinephrine and epinephrine can be hazardous in carcinoid patients. Norepinephrine has been shown to activate kallikrein in the tumour and can even lead to the syn- thesis and release of bradykinin resulting paradoxically in further vasodilatation and worsening hypotension, although exaggerated hypertensive responses may be seen. Indeed, any pharmacological stimulation of the autonomic nervous system has the potential to provoke further problems with vasoactive hormone release. In practice, cautious administration of small doses of phenylephrine has been found helpful in some patients.
Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20 – 50 mg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasocon- strictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small.
It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instabil- ity rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy. Monitoring of fluid losses, especially bleeding, is very important in these patients.
- 80 year old female for open reduction and internal fixation of a fractured neck of femur. Fit and well. You notice a systolic murmur on examination. Blood pressure normal. On transthoracic echo, she has a calcified aortic valve, with aortic stenosis with a mean gradient of 40mmHg. How do you manage her:
A. Instigate low dose beta blockade
B. Defer, and refer to a cardiologist
C. Perform a transoesophageal echo to get a better look at the valve
D. Proceed to surgery with no further investigation
E. Perform a dobutamine stress echo
D. Crack on
CEACCP - anaesthetic management of patients with hip fractures: an update (2013):
No study has so far shown that ‘preoptimization’ improves outcome among hip fracture patients, whereas two large meta-analyses of 275,000 patients have shown that delay to surgery beyond 48 h is associated with increased 30 day post- operative mortality, complications, and length of inpatient stay…
…The management of patients with hip fracture in whom a systolic murmur [indicating aortic stenosis (AS)] is heard remains conten- tious. Traditionally, anaesthetists have been reluctant to administer anaesthesia without additional echocardiographic information con- cerning aortic valve area, transvalvular gradient, and left ventricular contractility (indicated by ejection fraction), for fear of producing cerebral and coronary hypotension and ischaemia through arteriolar relaxation in patients with a relatively fixed, stenotic cardiac output, consequent to spinal (and general ) anaesthesia.
Guidelines have consistently stated that echocardiography is indicated if it has not been performed recently. However, despite the prevalence of AS being higher in the population with hip frac- ture (20–40% vs 3% in the over 75s, possibly contributing to the aetiology of the fall), several studies have found that early postoperative mortality among patients with AS undergoing hip fracture is similar to hip fracture patients without AS, although higher mortality has been noted in other studies. Insistence on pre- operative echocardiography has declined in recent years; however, as this can delay surgery, and the information yielded rarely changes management, which should be to treat patients with an audible ejection systolic murmur as if they had at least moderate AS, and administer anaesthesia accordingly, that is: using invasive arterial pressure monitoring and vasopressors to maintain coronary and cerebral perfusion pressure, and delivering anaesthesia sympa- thetically to the patients age and co-morbidities.
19 (Repeat) Electrocardiogram in the Cs5 configuration. What are you looking at when monitoring lead I.
A. anterior ischaemia B. atrial C. inferior D. lateral E. septal
D. Lateral
- (Repeat) Pringles procedure for life threatening liver haemorrhage includes clamping of:
A. Aorta B. Hepatic artery C. Hepatic vein D. Portal pedicle E. Splenic Artery
D. Portal pedicle
both hepatic artery and portal vein
- A 60 y.o. diabetic man has below knee amputation for ischaemic leg. His neuropathic pain is treated with oxycodone 40mg BD and paracetamol 1g QID. He is also on omeprazole 20mg BD for reflux. You decide to start him on gabapentin. Before choosing a dosing regime and starting treatment it is most important that you:
A. cease his omeprazole B. check his hepatic transaminase level C. check his renal function D. CHeck his QT interval on a resting ECG E. Decrease his oxycodone
C. Check his renal function
- The anterior and posterior borders of the ‘triangle of safety’, the preferred insertion site for an intercostal catheter, are pec major and:
A. Coracobrachialis B. Deltiod C. Lat Dorsi D. Serratius Anterior E. Trapezius
C. Lat dorsi
- A 39 yo male brought into ED with a compound fracture of his forearm. Has a history of schizophrenia and depression with nucertain medication compliance. He is confused and agitated wuth generalised rigidity but no hyperreflexi:A. Obs - HR 120, BP 160/90, RR 18, Sats 98 Temp 38.8 Likely Dx?
A. Heat stress from anticholinergics B. Hypoxic ischaemic encephalopathy C. Neuroleptic malignant syndrome D. Serotonin syndrome E. Pain from fracture
C. Neuroleptic malignant syndrome
- CO2 laser penetrates surface tissue so well with little damage to underlying tissue because
A) Well absorbed by Hb B) Poorly absorbed by H20 C) Widely disseminated in tissue D) Long infrared wavelength E) Short infrared wavelength
D. Long infrared wavelength
- (NEW) An 80yo man is having a transuretheral bladder resection, the surgeon is using diathermy close to the lateral bladder wall which results in patient thigh adduction. The nerve involved is:
A. Inferior gluteal B. Obturator C. Pudendal D. Scaitic E. Superior gluteal
B. Obturator
Obturator - adductor muscles of the hip
Inferior gluteal - gluteus maximus
Pudendal - sensation to genitals + anal canal, pelvic floor muscles, sphincters
Sciatic - posterior thigh and leg
- (New) You are involved in research and as part of data collection you collect ASA scores. This type of data is:
A. Ratio B. Nominal C. Non-parametric D. Numerical E. Ordinal
E. Ordinal
- An otherwise healthy man presents with anaemia. The test that most reliably indicates iron deficiency is decreased:
A. MCV B. serum ferritin C. serum iron D. serum transferrin E. total iron binding capacity
B. serum ferritin
Iron deficiency anaemia:
MCV Low Ferritin Low Serum Iron Low Transferrin Low Total Iron Binding Capacity High
Ferritin intracellular protein - stores and releases iron
- The maximal allowable atmospheric concentration of nitrous oxide in Australian and New Zealand operating theatres (in parts per million) is
A. 5 B. 25 C. 50 D. 100 E. 200
B. 25
- What is associated with down regulation of nicotinic acetylcholine receptors:
A. Guillain-Barre syndrome B. Organophospate overdose C. Spinal cord injury D. Stroke E. Prolonged neuromuscular blockade
B. Organophosphate overdose
nAchR Down-regulation:
- Myasthenia Gravis
- Anticholinesterase poisoning
- Organophosphate poisoning
nAchR Up-Regulation:
- Spinal cord injury
- Stroke
- Burns
- Prolonged immobility
- Prolonged exposure to NMD
- Multiple Sclerosis
- Guillain Barre
Miller page 900 (table 29-1)
- A reduction in DLCO can be caused by:
A. Asthma B. Emphysema C. Left to right shunt D. Pulmonary haemorrhage E. Bronchitis
B. Emphysema
Increased DLCO (120-140% predicted):
- Asthma
- Pulmonary haemorrhage
- Polycythaemia
- Left to Right shunt
Rate of Diffusion = A (C1-C2)/D
- A healthy 25 year old woman is 18 weeks pregnant. Her paternal uncle has had a confirmed episode of malignant hyperthermia. She has never had susceptibility testing. Her father and siblings have not been tested either. The best test to exclude malignant hyperthermia susceptibility before she delivers is
A. Genetic test father B. Genetic test woman C. Muscle biopsy sibling D. Muscle biopsy father E. Muscle biopsy woman
E. Muscle biopsy woman
If you want the best test to exclude MH for this patient, you have to muscle biopsy her.
In real life though, a better approach might be to muscle biopsy her father (and not expose her to the risks of GA, including fetal loss). If he is negative, she will almost certainly be negative (unless there is MH on her mother’s side).
- (New) The size (in French gauge) of the largest suction catheter which can be passed through a size 8 endotracheal tube which will take up not greater than half the internal diameter is size:
A. 6 B. 8 C. 10 D. 12 E. 14
D. 12
French size is the circumference in mm
Diameter of suction catheter must be = 4
Circ = 2 x pi x r, = pi x diam, = 3.14 x 4, = 12
- (Repeat) Pneumoperitoneum causes a decrease in cardiac output at what pressure (or possibly ABOVE what pressure)
A. 10mmHg B. 20mmHg C. 30mmHg D. 40mmHg E. 50mmHg
A. 10 mmHg
Miller says >10
CEACCP - Laparascopic abdominal surgery (2004)
20 mmHg - decreased VR, decreased CO, decreased MAP.
- 60yo male had total knee replacement. 7 days post-operatively diagnosed with deep venous thrombosis on ultrasound. Was on LMWH. PLT dropped from 300 immediately post-op and now 150x10^9/L. All the following are acceptable treatments EXCEPT
A. Argabotran B. Lepirudin C. Fondaparinax D. Danaparoid E. Warfarin
C. Fondaparinux
Synthetic Xa inhibitor, chemically related to low molecular weight heparins (Wiki)
- [Repeat] Maximum dose (with low risk of toxicity) of lignocaine (with adrenaline 1:100000) for liposuction with tumescence technique:
A. 3 mg/kg B. 7 mg/kg C. 15 mg/kg D. 25 mg/kg E. 35 mg/kg
E. 35 mg/kg
CEACCP - Novel techniques of local anaesthetic infiltration (2011)
Another method to increase the effectiveness and duration of local anaesthetics at the site of infiltration is a technique known as tumescent analgesia. A high volume but low concentration of a local anaesthetic (lidocaine 0.05 – 0.1%) together with dilute epi- nephrine is infiltrated at the site of incision, causing the tissues to become firm. Analgesia and anaesthesia are thought to be pro- longed by the increase in hydrostatic pressure in the tumescent tissues causing blood vessel compression and therefore reduction in local anaesthetic removal from the site of injection. The local anaesthetic effect is also prolonged by both the presence of epi- nephrine, which causes vasoconstriction, and sequestration of the local anaesthetic in fat due to its lipophilicity. The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22–57 mg kg21 of lidocaine7 – 9 have been used in the context of tumescent techniques and have been shown to have safe plasma concentration profiles.
- Drug to facilitate clip placement during cerebral aneurysm surgery
A. nimodipine B. mannitol C. adenosine D. hypertonic saline E. thiopentone
C. Adenosine
- Which drug should be avoided both intra- and post operatively in a woman having surgery who is breast feeding a 6 week old baby?
A. codeine B. morphine C. paracetamol D. parecoxib E. tramadol
A. Codeine
Mothers may be ultra-rapid metabolisers, leading to higher than normal morphine concentrations (which then appear in breast milk).
Another version of this question has pethidine as an option - pethidine is also bad, as neonates excrete norpethidine slowly and so are more vulnerable to toxicity.
- A three year old girl for an elective hernia repair is seen immediately prior to surgery. It is revealed she had 100mL of apple juice 2 hours ago. The best course of action is to:
A. Postpone surgery for 2 hours B. Postpone surgery for 4 hours C. Postpone surgery for 6 hours D. Cancel surgery E. Continue with surgery
E. Crack onski
Apple juice = clear fluid
- In accordance with their belief that blood transfusion is wrong, a Jehovah’s Witness may consent to all of the following except:
A. Cryoprecipitate B. Immunoglubulins C. Fresh Frozen Plasma D. Factor VIIa E. Prothrombinex
C. FFP
Unacceptable:
- Pre-op autologous blood donation
- Transfusion of the ‘primary components’ of blood, namely whole blood, packed red cells, plasma, platelets and white cells.
May be acceptable (not banned by the church, up to the patient):
- Fractions of all the primary components (incl. albumin, cry, clotting factors, immunoglobulins, recombinant human EPO, interferon, interleukins, haemoglobin-based blood substitutes or oxygen carriers).
- 80 year old lady with fractured NOF needing ORIF. On examination had a systolic murmur. Arranged TTE which showed a calcific aortic valve with peak velocity of 4 m/s. Using the simplified Bernoulli equation, what is the peak pressure gradient across the valve:
A. 16 mmHg B. 32 mmHg C. 48 mmHg D. 64 mmHg E. 80 mmHg
D. 64 mmHg
Bernoulli principle - an increase in the flow velocity of an ideal fluid will be accompanied by a simultaneous reduction in its pressure
Simplified equation:
P1 - P2 = 4V^2
- You have developed a new cardiac output monitor called WaCCO. You want to compare the readings with the gold standard, a pulmonary artery catheter. What is the best statistical method to present the data/results:
A. Funnel plot B. Bland-Altman plot C. Forest plot D. Galbraith plot E. Partial regression plot
B. Bland-Altman plot
CEACCP - Minimally invasive cardiac output monitors 2011
‘The accuracy of these devices has been researched in a number of different settings. The most consistently used method of assessing their accuracy has been to measure their mean bias in comparison with another method of cardiac output measurement using the Bland-Altman method.’
- A 60 year old, triple vessel disease normal LV. Hypotensive post CABG, ST elevation in II and avF, CVP 15 PCWP 25. Normal SVR
A. Early diastolic mitral inflow dynamic with atrial systole B. Left inferior hypokinesis C. Left ventricle collapse in systole D. Right ventricle dilation and TR E. Severe Mitral Regurg
B. ST elevation in II and aVF indicates inferior infarct. Elevation of both CVP and PCWP suggests hypokinesis of both RV and LV.
- Maximum amplitude from TEG or ROTEM decreased give
A. Cryoprecipitate B. FFP C. Platelets D. Prothrombinex E. Tranexamimic acid
C. Platelets
see video on lifeinthefastlane, TEG
- Young male, previous IVDU, now on 100mg Methadone per day has a laparotomy with an effective epidural. Amount of IV Morphine needed per HOUR:
A. 1mg B. 2mg C. 4mg D. 8mg E. 16mg
B. 2 mg/h
Using the conversion ratios from the CJA article below, 100 mg oral methadone –> 2.78 mg/h IV morphine. 2 mg/h may be underdosing, but is the more conservative option, out of 2 mg/h and 4 mg/h.
Review article: perioperative pain management of patients on methadone (CJA 2005)
When converting methadone to other opioids in the postoperative period, two issues need to be con- sidered. The first is the incomplete tolerance between opioids, the second is that the conversion ratio between opioids is not bi-directional. Conversion of methadone to other opioids appears to be more problematic and is associated with worsening pain and dysphoria. Since there is no uniformly accepted conversion ratio for substituting methadone with another opioid, a conservative approach should be adopted. In the authors’ experience, a conservative methadone to morphine ratio (4 or 5:1) is used. For instance, a patient previously on 30 mg methadone per day will be equivalent to roughly 120 mg oral morphine per day. Factoring the oral bioavailability (33%) and a 50% cross-tolerance, the hourly morphine requirement is approximately 1 mg·hr–1 intravenously.
On the first day, the maximum background infusion rate of morphine should not exceed 3 mg·hr–1 due to the highly unpredictable nature of the equianalgesic conversion. A PCA device is used separate from the iv infusion if there is an underlying pain condition. After the patient is loaded with adequate amounts of mor- phine, reassessments of pain, sedation and respiratory rate are made at least once every two hours as the patient approaches a steady state with the morphine and as the methadone continues to clear from their system. The ward nurses and clinicians looking after the patient are informed of the patient’s unique requirements.
- Fluoroscopy in the operating theatre increases the exposure of theatre personnel to ionising radiation. Best method to minimise one’s exposure to such radiation is to
A. have dosimeter checked at least 6-monthly
B. limit exposure time to radiation
C. maximal distance from radiation source
D. stand behind transmitter of C arm
E. wear protective garments
C. Maximal distance from radiation source
Intensity of radiation = 1/distance sqaured
At least 3 feet from source
6 feet or air provides 9 inches of concrete or 2.5mm lead
CEACCP - Radiation safety for anaesthetists (2012)
- Ibuprofen dose for one year old child tds regular post-op dose
A. 5mg/kg B. 10 C. 15 D. 20 E. 25
B. 10 mg/kg
5-10 mg/kg (MIMS)
10 mg/kg (RCH)
