2014.2 Flashcards

Question 1

Q

A transdermal fentanyl patch is often used for management of cancer pain. After application, the time to reach peak plasma levels is:

A. 1hr
B. 2hrs
C. 4hrs
D. 12hrs
E: 24hrs

Answer

A

E. 24 h

ANZCA pain book 6.5.1
“The time to peak blood concentration is generally between 24 and 72 hours after initial patch application and after the patch is removed, serum fentanyl concentrations decline gradually, with a mean terminal half‐life ranging from 22 to 25 hours” (MIMS, 2008)

Question 2

Q

Pharmacological studies are undertaken in several phases. A phase 3 study involves:

A Animal studies
B Testing of drug on healthy volunteers
C Observational studies on patients with disease
D Post marketing surveillance
E Randomised controlled trials on target population

Answer

A

E. RCT on target population

Myles textbook p.137

Phase I: first administration in humans (usually healthy volunteers). Confirm/establish basic PK and toxicology data. (n=20-100)

Phase II: selected clinical investigations in target population, aimed at establishing dose-response (‘dose finding’) relationship, plus some evidence of efficacy and safety

Phase III: full scale clinical evaluation of benefits, potential risks and cost analyses

… (from australianclinicaltrials.gov.au):
Phase III studies are done to study the efficacy of an intervention in large groups of trial participants (from several hundred to several thousand) by comparing the intervention to other standard or experimental interventions (or to non-interventional standard care). Phase III studies are also used to monitor adverse effects and to collect information that will allow the intervention to be used safely.

Phase IV: post marketing surveillance (thousands of patients)

Question 3

Q

A pregnant patient 28/40 gestation is involved in a high-speed MVA. On admission to the DEM she complains of sudden onset severe chest pain. Her vital signs show HR 120, BP 160/100, SpO2 95% RA and her ECG shows ST depression. Most likely diagnosis is:

A. Cardiac contusion
B. Tension pneumothorax
C. Aortic dissection
D. Sternal fracture
E. Myocardial infarction

Answer

A

C. Aortic dissection

Blunt chest trauma and pregnancy both risk factors

Question 4

Q

A 5 year-old child with recently diagnosed Duchenne muscular dystrophy has an inhalation induction with sevoflurane for closed reduction of a distal forearm fracture. No other drugs have been given. 10 minutes later the child suffers a cardiac arrest. After a further 5 minutes a venous blood sample shows a potassium level of 8.5mmol/L. The most likely mechanism for the hyperkalaemia is:

A MH
B ARF
C Cardiomyopathy
D Rhabdomyolysis
E Crush injury

Answer

A

D. Rhabdomyolysis

CEACCP - Neuromuscular disorders and anaesthesia (2011)

“Inhalation anaesthetics have been implicated in the rhabdomyolysis seen in Duchenne muscular dystrophy patients secondary to their effects of further increasing mycoplasmic calcium. It has been difficult to elucidate whether the metabolic reaction seen is related to an anaesthesia-related rhabdomyolysis or a true malignant hyperthermia.”

Gurnaney, Pediatric Anesthesiology 2009 - ‘Malignant hyperthermia and muscular dystrophies’:

We did not find an increased risk of malignant hyperthermia susceptibility in patients with DMD or BD compared with the general population. However, dystrophic patients who are exposed to inhaled anesthetics may develop disease-related cardiac complications, or rarely, a malignant hyperthermia-like
syndrome characterized by rhabdomyolysis

Question 5

Q

A 30yr old pregnant patient develops contractions at 30/40 gestation. Which of the following can not be used for tocolysis?

A. Clonidine
B. Indomethacin
C: Magnesium
D. Salbutamol
E. Nifedipine

Answer

A

A. Clonidine (no tocolytic effect)

Indomethacin is an appropriate (first-line) tocolytic for the pregnant patient in early preterm labor (

Question 6

Q

In a patient with intraorbital haemorrhage, following local anaesthetic injection, the adequacy of occular perfusion is best assessed by:

A. Angiography
B. Indirect ophthalmoscopy
C. Direct ophthalmoscopy
D. Intra-occular pressure tonometry
E. Palpation of the globe by an experienced physician

Answer

A

B. Indirect ophthalmoscopy

Royal college of anaesthetists and opthalmologists consensus document
http://www.rcoa.ac.uk/system/files/LA-Ophthalmic-surgery-2012.pdf
Document page 26

“Indirect ophthalmoscopy should be performed to look for evidence of central retinal artery perfusion compromise”

Question 7

Q

What is the appropriate post-operative ibuprofen dosage for a one year old child tds?

A. 5mg/kg
B. 7.5mg/kg
C. 10mg/kg
D. 15mg/kg
E. 20mg/kg

Answer

A

C. 10 mg/kg

Frank Shann - Drug Doses

Question 8

Q

You are inducing a 4yr old child with Arthrogrophysis multiplex congenita. After you administer the induction agents, you find it difficult to place the laryngoscope. What is the likely complication?

A. Malignant hyperthermia
B. Neuroleptic malignant syndrome
C. TMJ rigidity
D. Opioid-induced rigidity
E. Inadequate depth of anaesthesia

Answer

A

C. TMJ rigidity

OHA p298: Arthrogryposis
Skin and SC tissue abnormalities, contracture deformities, micrognathia, cervical spine and jaw stiffness, congenital heart disease (10%), difficult airway and venous access, sensitive to thiopental, hypermetabolic response is probably not MH

Question 9

Q

What is the best measure of the anticoagulant effect of Dabigatran?

A. APTT
B. Dilute thrombin time
C. Prothrombin time
D. Bleeding time
E. TEG

Answer

A

B. Dilute thrombin time

Horlocker article.

http://www.chumontgodinne.be/files/ PradaxaPracticalquestionsFinalSept2011.pdf

In situations where an assessment of the anticoagulant activity of dabigatran is
required, the activated partial thromboplastin time (aPTT) test, which is widely available, provides an approximate indication of the anticoagulation intensity achieved with dabigatran.

If required, a more sensitive quantitative test with the diluted Thrombin Time (Hemoclot®) can be performed.

The INR is less affected by dabigatran and should therefore not be used.

Question 10

Q

What is the ratio of compression to breaths for neonatal resuscitation?

A. 3:1
B. 15:1
C. 30:1
D. 15:2
E. 30:2

Answer

A

A. 3:1

ARC neonatal resus guidelines

Question 11

Q

In patients with refractory elevated ICP, bilateral decompressive craniectomy is associated with reduction in ICP and also results in:

A. Reduced duration of ventilation
B. Reduced duration of hospitalisation
C. Improved overall mortality
D. Worse long-term neurological outcome
E. Unchanged long-term neurological outcome

Answer

A

D. Worse long-term neurological outcome

CEACCP - Traumatic brain injury: an evidence-based review of management (2013)

‘For intracranial hypertension refractory to medical therapy, decompressive craniotomy can be used. A section of skull vault is removed, allowing the brain to expand and ICP decrease. However, there is little consensus on its use. Results from the DECRA study did not resolve this uncertainty. Contrary to expectations, outcome was significantly poorer for patients randomly assigned to receive decompressive craniotomy compared with those who received standard care. Consequently, decompressive craniotomy is currently reserved for when other methods of ICP control have failed. It is hoped that the RESCUEicp trial, now ongoing, will provide further evidence.’

Cochrane review:
http://www.ncbi.nlm.nih.gov/pubmed/16437469
“There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome.”

DECRA trial (NEJM 2011) - decreased ICP, decreased days of ventilation and ICU stay, but worse outcome at 6 months.

RESCUE study - worse functionally but no difference in mortality.

2014 article:
http://www.ncbi.nlm.nih.gov/pubmed/24662856

Question 12

Q

61.Tumour lysis syndrome causes all of the following biochemical abnormalities EXCEPT:

A. Hyperkalaemia
B. Hypernatraemia
C. Hyperphosphataemia
D. Hyperuricaemia
E. Hypocalcaemia

Answer

A

B. Hypernatraemia

Medscape:
http://emedicine.medscape.com/article/282171-overview#showall
Clinically, the syndrome is characterized by rapid development of hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and acute renal failure.

CEACCP - Intensive care management of patients with haematological malignancy (2010)

Question 13

Q

You are performing an interscalene nerve block using a nerve stimulator when your patient begins to hiccough. You should aim to position the tip of your needle more

A) Anterior
B) Posterior
C) Cephalad
D) Caudal
E) Superficial

Answer

A

B. Posterior

Stimulating phrenic nerve (anterior)
Therefore redirect posteriorly

Question 14

Q

The characteristic respiratory pattern in a patient with an acute C5 spinal cord injury is

A. Rapid respiratory rate
B. Arterial hypoxaemia
C. Chest wall immobility
D. Preserved cough
E. Preserved inspiratory force

Answer

A

A. Rapid respiratory rate

Question 15

Q

Tavi vs max medical therapy nonoperable aortic stenosis reduction in risk at 30 days of

A. AMI
B. AKI
C. Death
D. Atrial fibrillation
E. Stroke

Answer

A

???

In the PARTNER trial (see below), TAVI had significantly increased incidence of stroke, vascular complications and major bleeding at 30 days, compared with standard therapy. No difference at 30 days for any of the other outcomes, including death, AMI, AKI, or AF. Reduction in death and cardiac symptoms (NYHA III or IV) at 1 year with TAVI.

PARTNER trial - Leon et al, NEJM (2010): ‘Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery’

Results: A total of 358 patients with aortic stenosis who were not considered to be suitable can- didates for surgery underwent randomization at 21 centers (17 in the United States). At 1 year, the rate of death from any cause (Kaplan–Meier analysis) was 30.7% with TAVI, as compared with 50.7% with standard therapy (hazard ratio with TAVI, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P

Question 16

Q

Medial peribulbar block tip max distance (in mm) past equator for minimal vein injury

A. 5
B. 10
C. 15
D. 20
E. 25

Answer

A

A. 5 mm

NYSORA - Local and regional anesthesia for eye surgery:

‘Medial canthus approach: The needle is introduced at the medial junction of the lids, nasal to the lacrimal caruncle, in a strictly posterior direction to a depth of 15 mm or less. At this level, the space between the orbital wall and the globe is similar in size to that of the inferior and temporal approach and is free from blood vessels.’

If average axial length is 23-34 mm, then 15 mm or less is definitely no more than 5 mm past the equator…

Question 17

Q

A patient has suffered flash burns to half of the left upper limb, all of the left lower limb and the anterior surface of the abdomen. The approximate percentage of the body surface which has been burnt is:

A. 18%
B. 23%
C. 32%
D. 41%
E. 48%

Answer

A

C. 32%

Rule of 9’s:
Half of upper limb: 4.5
All of lower limb: 18
Anterior surface abdomen: 9

Question 18

Q

You are anaesthetising an ASA 1 woman for a laparoscopic gynaecological procedure. How long does it take for the PaCO2 to peak?
* A. 90min

Answer

A

B. 15-30 mins

During uneventful CO2 -pneumoperitoneum, PaCO2 progressively increases to reach a plateau 15 to 30 minutes after the beginning of CO2 insufflation in patients under controlled mechanical ventilation during gynecologic laparoscopy in the Trendelenburg position.

(some online textbook)

Question 19

Q

Anaemia post partial gastrectomy is most likely due to:

A folate deficiency secondary to steatorrhea
B ongoing haemorrhage from stomal ulcer ‘(yes Stomal not stomach)’
C malabsorption of iron
D Vit B deficiency due to loss of intrinsic factor
E folate deficiency due to lack of appetite

Answer

A

D. B12 deficiency due to loss of intrinsic factor.

Iron absorbed in duodenum
Folate in jejunum
B12 in terminal ileum (but needs intrinsic factor, secreted by stomach)

Shouldn’t have steatorrhea with gastrectomy - pancreatic enzymes still secreted.

Question 20

Q

65year old for video assisted thoracoscopic lower lobe wedge resection. Surgeon requests lung isolation and one lung ventilation.
Predictors of intraoperative hypoxia are:

A central rather than peripheral lesion
B left sided lesion
C low Aa Oxygen gradient when ventilating both lungs
D right sided lesion
E supine rather than lateral position

Answer

A

A,D and E all predictors of intraop hypoxia.
?Poor recall (possibly all except…)

CEACCP - Hypoxaemia during one-lung anaesthesia (2010)

Factors predictive of hypoxaemia during OLV include: ventilation of the left rather than the right lung, low oxygen partial pressure on two lungs, absence of reduction of perfusion to areas of lung pathology, and supine position rather than the lateral decubitus position

Question 21

Q

Small air bubbles in the arterial line system will reduce:

A. Dampening coefficient
B. ?Extrinsic Coefficient
C. Measured systolic pressure
D. Measured MAP
E. Resonant frequency

Answer

A

C and E

CEACCP - Blood pressure measurement (2007):

Some damping is inherent in any system and acts to slow down the rate of change of signal between the patient and pressure transducer. This can be caused by occlusion of the arterial system, a bubble interrupting the saline column, or using a soft cannula and tubing. Some damping is useful, however, as it reduces the resonant frequency of the pressure transducing system. The amount of damping in a system is indicated by the ‘damping factor’.

Question 22

Q

Q95: RPT. Capnograph trace form a patient that is intubated and ventilated. What does it indicate?

A. Endotracheal intubation
B. Gas sample line leak
C. ETT cuff leak
D. Obstructive disease
E. Spontaneous breaths

Answer

A

B. Gas sample line leak (not sure what the trace looked like but this is always the answer!)

Question 23

Q

98.’You extubate a young woman after a dental procedure under GA. She has a history of hereditary angioedema and in recovery she develops airway oedema. Best treatment

A. FFP
B. IV Adrenaline
C. IV corticosteroids
D. IV promethazine
E. Nebulized adrenaline

Answer

A

A. FFP

UpToDate - Hereditary angioedema: treatment of acute attacks.

adrenaline, corticosteroids, antihistamines no use
1st line C1 esterase inhibitors
if not available, use FFP

Question 24

Q

A previously well 65 year old female develops acute shortness of breath 3 days post hip replacement. The most appropriate investigations to confirm PE is

A. CTPA
B. D-dimer
C. Echo
D. Ecg
E. V/Q scan

Question 25

Q

20 year old female with 25% burns to her body. She weighs 80 kg. How much replacement fluid should she be given over the next 8 hours?

A. 4L
B. 4.8L
C. 5L
D. 6L
E. 8L

Answer

A

A. 4L

Parkland: 4 x 80 x 25 = 8L
1/2 over first 8 hr = 4L

Question 26

Q

50 y.o female with a history of mennohhragia is having a hysterectomy. Her pre-operative Hb is 95. What serum ferritin would confirm iron deficiency anaemia?

A. 30 mcg/L
B. 3 mg/L
C. 3 mcg/L
D. 0.3 mg/L
E. 3000 mcg/L

Answer

A

C. 3 mcg/l

Normal range for ferritin 12-200 mcg/l (OHA p1273)

Question 27

Q

An Adult Jehovah’s Witness requires a redo hip replacement for a peritrochanteric fracture. They request that no blood products are given. The anaesthetists decision to PROCEED is best given by:

A. Autonomy
B. Beneficence
C. Justice
D. Nonmaleficence
E. Paternalism

Answer

A

A. Autonomy

Question 28

Q

100% Saturated air @ 20 degrees is what relative humidity @ 37 degrees

A. 20%
B. 30%
C. 40%
D. 50%
E. 60%

Answer

A

C. 40%

At 20 deg, 100% sat 20 mmHg
At 37 deg, 100% sat 47 mmHg

At 37 deg, the same amount of water vapour will give a relative humidity of 20 / 47 = 0.42 = 42%

Question 29

Q

Maximum cumulative dose of intralipid (ml/kg)

A. 10
B. 12
C. 15
D. 20

Answer

A

B. 12 mL/kg

Question 30

Q

60yo alcoholic with HTN, has abdominal pain. No findings at laparotomy. 12 hrs later: Na140 k5 cl115 HCO3 18. What is the most likely diagnosis?

A. ARF
B. Diabetic ketosis
C. Lactic acidosis
D. Methanol
E. NaCl infusion

Answer

A

E. NaCl infusion

Normal anion gap metab acidosis (therefore not ketones, uraemia, lactic, toxins - incl methanol)

Question 31

Q

Diagram of a CTG (showing late decelerations). Causes:

A. Uteroplacental insufficiency
B. Foetal head compression
C. Foetal asphyxia
D. Umbilical cord compression
E. General anaesthesia

Answer

A

A. Uteroplacental insufficiency

Question 32

Q

In a clinical trial, researchers looked at 2 groups - smokers vs. non-smokers and followed then up for a period of time. This type of study is a

A. Cohort
B. Case study
C. Observational
D. RCT
E. ?

Answer

A

A. Cohort

Prospective
pick groups and follow forwards to look for outcomes

Question 33

Q

Prothrombinex VF is useful in the perioperative period to correct the coagulopathic defect of all of the following except

A. Isolated factor II deficiency
B. Isolated factor VII deficiency
C. Isolated factor IX deficiency
D. Isolated factor X deficiency
E. Warfarin

Answer

A

B. Isolated factor VII deficiency

PROTHROMBINEX-VF contains concentrated factor IX, factor II, factor X and low level of factor VII.

Question 34

Q

A 65 year old man otherwise fit and healthy is having a TKR under GA (O2, N2O, sevoflurane and fentanyl). His blood pressure has been stable through-out the case at 130/80. Before the orthopaedic surgeons start reaming and bone cemetation you should

A. Give heparin 5000 iu
B. Give a corticosteroid
C. Cease N2O
D. Induce hypotension
E. Give a vasopressor to increase blood pressure

Answer

A

C. Cease N2O

Oxford handbook

Question 35

Q

Photograph and Ultrasound picture of regional block. probe held transverse against posterolateral aspect of distal humerus over triceps. shows triangular nerve in close proximity to humerus. After infiltration of 5mls of 0.75% ropivacine Numbess in:

A lateral aspect of forearm
B ring dorsum??
C medial??
D palmar aspect and distal dorsal aspect of little finger and medial half of ring finger
E palmar aspect and distal dorsal aspect of thumb, index and medial fingers and lateral half od ring finger

Answer

A

A. Lateral aspect of forearm

musculocutaneous nerve - gives off lateral cutaneous nerve of forearm

Question 36

Q

Lateral CXR given. Can see lower half of thorax and vertebrae but upper half is all black with clear demarcation

A ?
B Artifact caused by patient’s arm
C Left lower lobe consolidation
D Right middle lobe consolidation
E Right lower lobe consolidation

Answer

A

Something either side of horizontal fissure.

Question 37

Q

12 year-old with idiopathic scoliosis, most likely have associated

A Phaeochromocytoma
B Renal artery stenosis
C Mitral valve prolapse
D Diabetes insipidus
E

Answer

A

C. Mitral valve prolapse

CEACCP - Scoliosis surgery in children (2006)

Approximately 25% patients with idiopathic scoliosis have mitral valve prolapse, but this is rarely of clinical significance and antibiotic cover is given

Question 38

Q

Term neonate, noted to have intermittent stridor few days after birth, then parents also notice stridor during feeding and sleep. Otherwise normal and healthy. Most likely condition is

A Cri-du-chat syndrome
B Laryngomalacia
C Tracheomalacia
D
E

Answer

A

B. Laryngomalacia

Laryngomalacia - most common cause of chronic pediatric stridor causing approximately 60% of stridor seen in newborns.

Question 39

Q

A picture of an echo 4 chambers view

A Anterior mitral valve leaflet
B Posterior mitral valve leaflet
C
D
E

Answer

A

Leaflet closest to RV is anterior

Question 40

Q

Cryoprecipate, once thawed must use within

A 30 minutes
B 2 hours
C 4 hours
D 6 hours
E 12 hours

Answer

A

C. or D. Should be used within 4-6 hours

transfusion.com.au fact sheet

Question 41

Q

Glycine 1.5% used for TURP, osmolality is

A 200
B
C
D 300
E 320

Answer

A

A. 200

CEACCP - Anaesthesia for transurethral resection of the prostate (2009)

Question 42

Q

Sick ICU patient with moderate to severe ARDS PaO2/FIO2 ratio of 200, cardiac index 1.7. Decided to have ECMO, best mode is

A AV
B VA
C VV
D. ?

Answer

A

C. Veno-venous

CEACCP - Extracorporeal membrane oxygenation in adults (2011)

Veno-venous ECMO is designed to provide gas exchange, while veno-arterial ECMO provides both gas exchange and haemodynamic support.

(This patient’s cardiac function is not too bad)

Question 43

Q

Middle age women c/o pain in hands when hanging out washing. Also found to have muscle wasting on one of the hand associated with weaker radial pulse.

A CRPS
B Lateral medullary syndrome
C Thoracic outlet syndrome
D Paraneoplastic syndrome
E

Answer

A

C. Thoracic outlet syndrome

CEACCP - Anaesthesia for vascular surgery
of the upper limb (2013)

Thoracic outlet syndrome (TOS) refers to a cluster of symptoms caused by compression of the neurovascular structures of the upper limb as they pass between the first rib and clavicle en route to the axilla. Symptoms depend on the component affected—the brachial plexus, subclavian artery or subclavian vein—giving rise to neurogenic, arterial or venous TOS, respectively.

The clinical features of TOS depend on the structures affected. Neurogenic TOS refers to compression of the brachial plexus and accounts for the majority of cases of TOS. Symptoms reflect the nerve roots involved. Symptoms do not follow a dermatomal distribution, distinguishing TOS from radicular nerve pathology. Ninety per cent of cases involve the C8 and T1 nerve roots causing pain and paraesthesia in an ulnar nerve distribution and wasting of abductor pollicis brevis, the hypothenar eminence, and interosseii. Involvement of C5, C6, and C7 causes pain referred to the upper chest, neck, ear, and outer arm. Radial nerve symptoms can also be present.

Question 44

Q

Same radial nerve question with photos of a probe over postero-lateral upper arm and ultrasound image that show a triangular shape nerve, most likely the radial nerve. Injecting 5 ml of 0.75% [[ropivacaine] will produce sensory block over

A Medial forearm
B Lateral forearm
C Dorsum part of hand
D Plantar surface of ring and little finger
E Plantar surface of middle and ring finger

Answer

A

C. Dorsum of hand

Question 45

Q

Blue urticaria is a complication of

A
B Methylene blue
C Patent blue something
D
E

Answer

A

C. Patent blue V

Anaphylaxis and blue urticaria associated with Patent Blue V injection

http://www.respond2articles.com/ ANA/forums/1182/ShowThread.aspx

Question 46

Q

Intraosseous sampling - least accurate on

A Albumin
B Urea
C Haemoglobin
D Chloride
E Calcium

Answer

A

E. Calcium

Miller LJ, Arch Pathol Lab Med (2010) - A new study of intraosseous blood for laboratory analysis.

There was a significant correlation between intravenous and IO samples for red blood cell counts and hemoglobin and hematocrit levels but not for white blood cell counts and platelet counts. There was a significant correlation between intravenous and IO samples for glucose, blood urea nitrogen, creatinine, chloride, total protein, and albumin concentrations but NOT for sodium, potassium, CO(2), and calcium levels

Question 47

Q

Subtenon’s block - muscle most likely to have inadequate block

A Medial rectus
B Lateral
C Superior
D Superior oblique
E Inferior

Answer

A

D. Superior oblique

Entry point is inferonasal, so it makes sense that the muscle that inserts furthest away from this point would be most likely to be blocked inadequately.

Ophthalmic Regional Block
(Chandra M Kumar):

‘Most patients develop akinesia with 4 to 5mL of local anaesthetic agent but the superior oblique and eyelid muscles may remain active’

Question 48

Q

EVAR, best method to reduce risk of renal impairment

A Sodium bicarbonate
B N-acetylcysteine
C Normal saline
D
E

Answer

A

C. Normal saline

CEACCP - Complex endovascular aortic aneurysm repair (2012)

Because the EVAR procedure involves the liberal use of contrast media to assist placement and deployment of the graft to ensure proper exclusion of the aneurysmal sac, it is worthwhile ensuring that the patients are well hydrated to prevent postoperative renal impairment. There is no current evidence to support routine use of diuretic agents during EVAR

Question 49

Q

EVAR is preferred over open AAA repair because

A Lower cost
B Lower mortality
C Less follow up
D Less re-intervention
E Less need for critical care

Answer

A

E. Less need for critical care

Definitely not B, C or D. Not sure about A. The overall cost of EVAR is likely to be significant, given the more intensive follow-up and greater need for re-intervention compared with open repair.

CEACCP - Complex endovascular aortic aneurysm repair (2012)

The advantages of endovascular techniques over the equivalent open repair include a reduction in blood loss and avoidance of the associated complications of laparotomy and aortic cross clamping. Although the long-term benefits are still under investigation, many vascular specialists believe that, due to rapidly advancing technology and increasing worldwide experience, it is likely that endovascular techniques will become a routine treatment option for patients with complex aneurysms

WFSA ATOTW - Anaesthesia for endovascular aortic aneurysm repair (2014)

EVAR vs Open surgery

Potential benefits of EVAR over the conventional open surgical procedure are: less physiological disturbance, reduced blood loss, less pain, reduced length of ICU and hospital stay. For infra-renal aneurysms additional benefits include reduced procedural time and avoidance of general anaesthesia. Disadvantages of EVAR include potential conversion to GA in a patient deemed unfit for GA, increased long-term complications such as endoleak and graft migration and the requirement of lifelong yearly surveillance by CT scan or duplex ultrasound.

Two UK multicentre studies looked at outcomes between open and endovascular AAA repair from 1999 to 2003.
The EVAR 1 study showed that EVAR reduces the operative mortality (30 day mortality) compared to open surgery by a third and medium term aneurysm-related mortality, but offered no decrease in long- term all-cause mortality at 4 years. EVAR is also associated with increased re-interventions and complications but has the same health related quality of life as open procedures.
The EVAR 2 study concluded there was no long-term survival benefit of EVAR versus surveillance in patients deemed unfit for open repair and showed that there was considerable 30 day operative mortality with EVAR in these patients (9% mortality). The study recommended focusing on increasing patients’ physiological fitness. A number of patients in the surveillance group however, crossed over into EVAR group so potentially skewing results. The most recent NICE guidelines state that there is uncertain benefit of EVAR over surveillance in patients who are unfit for open repair.

Since these studies, increasingly complex aneurysms are being treated with EVAR and in patients who would otherwise be deemed unfit for open surgery. Also, technological improvements in stent design and operator experience have increased so studies and longer term follow-up is required to determine the long-term risks and benefits of EVAR.

Question 50

Q

Laser flex tube with double cuffs - how to inflate cuff(s)?

A Inflate proximal then distal
B Inflate distal then proximal
C
D Inflate distal only
E Inflate proximal only

Answer

A

A. Inflate proximal then distal.

? reference

The idea of having two cuffs is that the distal one still provides a seal if the proximal one is perforated by the laser.

Question 51

Q

Forceps delivery. Loss of sensation medial thigh with loss of adduction at hip joint - resulted from injury to

A Sciatic nerve
B lumbosacral plexus
C Lateral cutaneous nerve of thigh
D Obturator nerve
E

Answer

A

D. Obturator nerve

Question 52

Q

Called to cath lab because patient became agitated. Unstable angina having PCI,difficult right coronary stenting. Patient was hypotensive 80/40, HR 80/min in SR. What is the next best management step?

A Transfer to operating theater immediately
B Sedate and intubate
C ?crack on
D Transthoracic echocardiography

Answer

A

D. TTE (to exclude tamponade)

D. TTE to exclude tamponade
(stem sounds like possible complication - “became agitated”, “difficult RCA stenting”)

Likely management stay and stabilise… (therefore B or D)
Probably not A (doesn’t sound like need to move immediately) or C (needs to be stabilised first).

Question 53

Q

A printout of 12-lead ECG

A Atrial fibrillation with BBB
B Sinus tachycardia with BBB
C Torsades de pointes
D VT
E VF

Question 54

Q

(Repeat) Diagram of 3-chamber chest drain system with underwater seal. The height of the fluid level in the pressure regulating chamber indicates

A Maximal suction applied to the system
B
C
D
E

Answer

A

A. Maximal suction applied to system

Question 55

Q

Photo of a patient with tongue deviation post cervical spinal fusion. Which nerve is damaged?

A Glossopharyngeal nerve
B Vagus nerve
C Hypoglossal nerve
D Accessory nerve
E

Answer

A

C. Hypoglossal nerve

Question 56

Q

Post cardiac surgery. Rhythm strip to assess pacing on AOO. What is the diagnosis?

A Pacing spikes with loss of capture
B
C
D
E

Question 57

Q

Young male with MVA + femur # on traction. More than 24 hours. Became confused and drowsy, BP normal, crackles both lung fields with worsening O2 saturation despite increasing oxygen flow. Diagnosis?

A Fat embolism
B Compartment syndrome
C Pulmonary embolism
D
E

Answer

A

A. Fat embolism

Triad of pulmonary, neurologic and skin changes.

Question 58

Q

G5P5 in third stage labour. Found to be unresponsive, cyanosed, faint pulse. On oxytocin induction and epidural infusion 10ml/hour. Also oozing from previous IV or blood sampling sites. Diagnosis?

A High spinal
B AFE
C PE
D
E Massive haemorrhage

Question 59

Q

Treatment for patients with congenital long QT syndrome

A Pacemaker/defibrillator
B Accessory pathway abalation
C Beta blocker
D Calcium channel blocker
E

Answer

A

C. Beta blocker

(also overdrive pacing/AICD)

CEACCP - Long QT syndrome (2008)

β-blockers, administered at the maximum tolerated dose, are the mainstay of treatment, although other options should be considered in high-risk patients. In those intolerant of β-blockers, left cardiac sympathetic denervation has been shown to reduce the risk of malignant arrhythmias. Cardiac pacing, by increasing the heart rate and shortening QTC, has also been shown to be efficacious in high-risk subjects. In those with difficult to control symptoms or survivors of a cardiac arrest, an implantable cardiovertor defibrillator (ICD) should be strongly considered.

Question 60

Q

18 month old child with VF arrest, shock with

A 10J
B 30J
C 50J
D 100J
E

Answer

A

C. 50J

DC shock in paeds 4J/kg

Average 1 yo 10 kg, 2 yo 12 kg

Question 61

Q

Endovascular coiling of cerebral aneurysm under GA, patient suddenly develop hypertension. What is the most likely cause?

A Acute hydrocephalus
B Rupture of aneurysm
C Contrast reaction
D Cerebral embolism
E

Answer

A

B. Rupture of aneurysm

Oxford handbook of anaesthetic emergencies:

Detected by HTN, extravasation of contrast

Question 62

Q

A patient on citalopram. Post-op in PACU given tramadol. Developed fever, tremor, restlessness, confusion, hyperreflexia. Diagnosis is

A Neuroleptic malignant syndrome
B MH
C Serotonin syndrome
D
E

Answer

A

C. Serotonin syndrome

Question 63

Q

Best drug to reduce both gastric acidity and volume

A Ranitidine
B PPI
C Sodium citrate
D
E

Answer

A

A. Ranitidine

H2 antagonists more effective than PPIs when given on the day of surgery

Question 64

Q

Patient on moclobemide came in for surgery. In view of the use of vasopressor to treat hypotension one will give judicious amount of

A
B Metaraminol
C Adrenaline
D Noradrenaline
E Phenylephrine

Answer

A

E. Phenylephrine

adrenaline and noradrenaline are also direct acting, but you are not going to use these as first line

Answer 61

A

D. T3 and T4 (TSH will improve later)

Langley RW, Endocrinol Metab Clin North Am (2003) - Perioperative management of the thyrotoxic patient

Ideally, thyrotoxic patients should be as close as possible to clinical and
biochemical euthyroidism before going to surgery. It is common for TSH
values to remain suppressed as a consequence of prolonged hyperthyroidism
in patients who have otherwise normalized their T4 and T3 values on
therapy [31]. The TSH level in this case will eventually increase, and should
not be considered a contraindication to surgery

Answer 62

A

D. S1

NYSORA

Answer 63

A

C. 45 mins

(from BOC healthcare website)

Size C cylinder lasts:

81 mins at 6 L/min
49 mins at 10 L/min
32 mins at 15 L/min

Answer 64

A

D. Immune suppression

Chronic echinacea use suppresses immune function.

Answer 65

A

C and B both correct

(Mast cell degranulation leading to histamine release and subsequent histamine-induced vasodilation)

Red man syndrome - anaphylactoid reaction (mast cell degran but not IgE mediated)

Answer 66

A

C. Administer methylpred and IVIG 2 days pre-op

Acc to UTD-
For management of life-threatening bleeding, treatment options include:

■Platelet transfusions
■IVIG (1 g/kg, repeated the following day if the platelet count remains

Answer 67

A

D. Raised ICP

With the exception of raised intracranial pressure, there are no absolute contraindications to ECT although there are a number of clinical situations in which extra caution is required.

Answer 68

A

D. C6

WFSA ATOTW - Stellate ganglion block (2012)

Enter at C6
Hit C6 transverse process, then angle down.

Answer 69

A

B. Fetal head compression

Answer 70

A

D. Uncorrected cyanotic heart disease

Patient indications

Prosthetic heart valve
Congenital heart disease, only if:
- unrepaired cyanotic (incl palliative shunts/conduits)
- prosthetic materials in repair (first 6 mths)
- repaired defects with residual defect
Heart transplant
Previous IE
Rh heart disease (indigenous only)

Answer 71

A

A. LBBB

(risk complete heart block if you cause injury to the right bundle branch)

Kumar S, International Journal of Case Reports and Images (2011) ‘Complete atrioventricular block during central venous catheter placement with pre-existing left bundle branch block: Preparedness guidelines’

Answer 72

A

E. 35 mg/kg

Answer 73

A

B. Assess train of four

(from forum on gasexchange.com)

The 2 numbers provided by the Entropy monitor are the State Entropy (SE) and Response Entropy (RE). SE is calculated over frequencies from 0.8 to 32 Hz while RE is calculated over frequencies from 0.8 to 47 Hz. The significance of this difference is that frequencies below 32 Hz are dominated by the EEG signal while EMG signal from facial muscles dominate above 32 Hz. In theory, SE reflects the cortical state of the patient (and hence depth of anaesthesia) while RE additionally incorporates facial muscle EMG signals. The idea is that if there is a significant difference between SE and RE, this reflects inadequate analgesia (which increases facial muscle tone – apparently).

Just like with BIS, the manufacturer recommends increasing depth of anaesthesia if the SE is above 60 as this represents a possibility of awareness. Unlike BIS, they also recommend giving additional analgesia if the RE is more than 5-10 above the SE.

There are several papers comparing BIS and Entropy and the short answer seems to be that the BIS and the SE correlate reasonably well with only occasional disagreement. None of these trials are large enough to demonstrate a difference in the ability of either monitor to detect awareness (and quite frankly, the jury is still out on whether BIS is useful for this – awareness is just too rare an event to study easily). I am not aware of any trials demonstrating the usefulness of the RE for guiding analgesic administration.

reference: Bein B. Entropy. Best Pract Res Clin Anaesthesiol. 2006 Mar;20(1):101-9

Answer 74

A

C. 4%

ref: Peck and Hill table, ch 4

Answer 75

A

D. Long infrared wavelength

A & B wrong. (well absorbed by water).
C. ?widely disseminated (dissipates in tissue, doesn’t really penetrate)
D. correct (long infrared wavelength)
E. wrong

Answer 76

A

C. Platelets

Answer 77

A

A. Creatinine

MELD:

INR
bilirubin
creatinine
aetiology

Answer 78

A

D. Research findings similar to other published studies.

(From Waldron R, ‘Researchers behaving badly’, ANZCA Bulletin Sept 2012)

So, as an ordinary anaesthetist working in clinical practice, how do I decide which papers to rely on to guide and improve
my clinical practice? Can I rely on articles from highly reputable, peer-review journals? History would suggest no, not always. The Lancet, Nature, Science, Anaesthesia & Analgesia and European Journal of Anaesthesia all have retracted papers.

Can I always rely on articles whose authors or co-authors include professors and department heads? Again the answer is not always. Boldt, Reuben, Poldermans, and Das were heads of departments.

Can I rely on articles emanating from reputable institutions? No, not always. In 1983, the Journal of the American Medical Association mentions Boston Medical Center, Massachusetts General Hospital, Mount Sinai School of Medicine, Yale University School of Medicine, Sloan- Kettering Memorial Cancer Center and Harvard Medical School28 as institutions at which research fraud has occurred.

Finally, as Steve Shafer mentioned at the 2008 Sydney ANZCA annual scientific meeting, another element in good research is the ability to reproduce results at another institution.

Answer 79

A

A. Genitofemoral neuralgia

Ch 39.
Cousins & Bridenbaugh’s
Common complications of neurolytic lumbar sympathetic blockade include puncture of major vessel or renal pelvis, subarachnoid injection, neuralgia—genitofemoral nerve (5% to 10% pain in the groin), somatic nerve damage—neuralgia (1%), perforation of a disk, stricture of the ureter after phenol or alcohol injection, infection from catheter technique (extremely rare), ejaculatory failure (bilateral block in young males), and chronic back pain.

Answer 80

A

E. Reduce vascularity of thyroid gland

(Wiki)

Preoperative administration of Lugol’s solution decreases intraoperative blood loss during thyroidectomy in patients with Grave’s disease.[3] However, it appears ineffective in patients who are already euthyroid on anti-thyroid drugs and levothyroxine.[4]

Answer 81

A

E. No papilloedema

(although pailloedema is a late sign of raised ICP).

Headache, diplopia and vomiting are all nonspecific signs and their absence would be associated with low negative predictive value.

Retinal vein is not pulsatile.

Answer 82

A

C. 40-60%

CEACCP - Cardiovascular complications after brain injury (2011)

Elevation of cardiac troponin I (cTnI) has been reported in 20–68% of patients after SAH (mean incidence 36%)

Answer 83

A

A. Auscultate the chest

Answer 84

A

A. Pulse pressure variation

Answer 85

A

A. Metaraminol bolus

Cardioplegia induces transient hypotension secondary to K-related vasodilation, best managed with alpha agonist.

Miller 7th ed pg 1916 - “Initiation of CPB is often associated with a period of hypotension, which can be managed with the administration of an alpha-agonist into the venous reservoir of the ECC circuit. Any hypotension and hypertension that occur despite adequate flow and SvO2 can be treated by adjusting the patient’s SVR with vasoconstrictors or vasodilators”

Should be on full flows so D is incorrect

Answer 86

A

B. Antegrade perfusion to carotid arteries.

Di Bartolomeo R, Multimedia Manual of Cardio-Thoracic Surgery (2011) - ‘Cerebral protection during surgery of the aortic arch’

Anterior selective cerebral perfusion (ASCP) provides the surgeon prolonged safe periods of circulatory arrest which are often required to perform complex arch reconstructions in patients with acute dissections or extensive disease of the thoracic aorta.

ASCP may be safely used with moderate hypothermia (26 °C) with substantial reduction of CPB and deep hypothermia related complications.

In our experience ASCP and moderate hypothermia represented an effective and reliable method of brain protection allowing us to obtain favorable results in terms of mortality and neurological outcome.

Answer 87

A

A. Turn left lateral

pneumonectomy side dependent

Answer 88

A

C. Head down, right side up

displace air from RVOT

Answer 89

A

E. Albumin

SAFE study

Answer 90

A

A. Children

Answer 91

A

C. Observe overnight and repeat mane

Patient blood management guidelines:

RBC transfusion should not be dictated by a haemoglobin ‘trigger’ alone, but should be based on assessment of the patient’s clinical
status. In the absence of acute myocardial or cerebrovascular ischaemia, postoperative transfusion may be inappropriate for patients with a haemoglobin level of >80 g/L

Answer 92

A

E. Do nothing

(from Australian Prescriber)

The source patient should be tested for hepatitis B surface antigen (HBsAg) as soon as possible. No further action is required if the test is negative. If the injured person has not been immunised and the result is likely to be delayed, a dose of HBV vaccine is given immediately, with subsequent doses at one and six months. A single dose (400 IU) of hepatitis B immunoglobulin should also be given as soon as possible (preferably within 72 hours).

If the injured person has been vaccinated against HBV and seroconversion has been documented, then no further action is required. When seroconversion has not been documented, a booster dose of hepatitis B vaccine should be given immediately and, if surface antibodies cannot be measured within 72 hours, a dose of HBIG given.

Answer 93

A

A. 0.3%

1:313 (Australian Prescriber)

Answer 94

A

CPP = 70 - CVP

Answer 95

A

A. Increased myocardial O2 extraction

high O2 extraction at rest from heart

Answer 96

A

MH ABG:

mixed resp and metabolic acidosis (low bicarb, negative BE)
CO2 elevated

Answer 97

A

A. Direct laryngoscopy and intubation after inhalation induction with sevoflurane

Answer 98

A

C. Ask surgeon to release gag

Answer 99

A

D. IV magnesium

Answer 100

A

ANZCA guidelines:

6 wks: clear fluids 2 hr, breast 4 hr, formula/solid 6 hr

RCH guidelines:

6 months: clear fluids 1 hr, everything else 6 hr

Answer 101

A

A. Insulin 0.15 units/kg + glucose 50% 0.5 mL/kg

Answer 102

A

14 mL/kg/min

1 MET is 3.5 mL/kg/min

Answer 103

A

E. Ventilate in the prone position

Answer 104

A

E. Ordinal

Answer 105

A

A. 10 mmHg

IAP 10-20 mmHg

Answer 106

A

C. Oral hygiene

Answer 107

A

A. Codeine

Answer 108

A

D. Systemic release of tissue factor
(if you had to pick one)

Trauma-induced coagulopathy arises quickly after severe injury, and is probably initially due to a combination of materials released from tissue injury (tissue factor, coagulation factors, and inflammatory mediators), and hypoperfusion.

Platelet dysfunction, fibrinogen consumption and hyperfibrinolysis all contribute to the coagulopathy, and environmental hypothermia and acidosis (as a result of tissue hypoperfusion) exacerbate it.

(After 1 L of Hartmann’s, there is unlikely to be significant dilution of clotting factors)

Answer 109

A

B. Transient bradycardia followed by tachycardia and hypertension

Answer 110

A

A. Deflate trache cuff, insert one-way valve, insert fenestrated piece

(see life in the fast lane, fenestrated tracheostomy tube)

Answer 111

A

B. Arterial line

Answer 112

A

E. Alteration in gene expression

Answer 113

A

A. Desflurane

Sherman J, Anesth Analg (2012) - ‘Life cycle greenhouse gas emissions of anesthetic drugs’

BACKGROUND:
Anesthesiologists must consider the entire life cycle of drugs in order to include environmental impacts into clinical decisions. In the present study we used life cycle assessment to examine the climate change impacts of 5 anesthetic drugs: sevoflurane, desflurane, isoflurane, nitrous oxide, and propofol.

METHODS:
A full cradle-to-grave approach was used, encompassing resource extraction, drug manufacturing, transport to health care facilities, drug delivery to the patient, and disposal or emission to the environment. At each stage of the life cycle, energy, material inputs, and emissions were considered, as well as use-specific impacts of each drug. The 4 inhalation anesthetics are greenhouse gases (GHGs), and so life cycle GHG emissions include waste anesthetic gases vented to the atmosphere and emissions (largely carbon dioxide) that arise from other life cycle stages.

RESULTS:
Desflurane accounts for the largest life cycle GHG impact among the anesthetic drugs considered here: 15 times that of isoflurane and 20 times that of sevoflurane on a per MAC-hour basis when administered in an O(2)/air admixture. GHG emissions increase significantly for all drugs when administered in an N(2)O/O(2) admixture. For all of the inhalation anesthetics, GHG impacts are dominated by uncontrolled emissions of waste anesthetic gases. GHG impacts of propofol are comparatively quite small, nearly 4 orders of magnitude lower than those of desflurane or nitrous oxide. Unlike the inhaled drugs, the GHG impacts of propofol primarily stem from the electricity required for the syringe pump and not from drug production or direct release to the environment.

DISCUSSION:
Our results reiterate previous published data on the GHG effects of these inhaled drugs, while providing a life cycle context. There are several practical environmental impact mitigation strategies. Desflurane and nitrous oxide should be restricted to cases where they may reduce morbidity and mortality over alternative drugs. Clinicians should avoid unnecessarily high fresh gas flow rates for all inhaled drugs. There are waste anesthetic gas capturing systems, and even in advance of reprocessed gas applications, strong consideration should be given to their use. From our results it appears likely that techniques other than inhalation anesthetics, such as total i.v. anesthesia, neuraxial, or peripheral nerve blocks, would be least harmful to the environment.

Answer 114

A

E. Absence of breathing

Indications: not responsive and not breathing normally

Answer 115

A

D. The provision of significant information

While this is a cornerstone of informed consent, it is not affect competence - i.e. it’s not a ‘patient factor’

Answer 116

A

D. C1 inhibitor concentrate

1st line = C1 inhibitor concentrate

If not available -> FFP

Adrenaline, steroids, anti-hist not effective

Answer 117

A

B. Sequentially remove non-essential monitors from the circuit until fault is identified

(Sydney Uni website):

Isolating Transformers and Line Isolation Monitors.

These are the more expensive alternative to RCD’s and are widely used in operating theatres because they do not disconnect the power when a fault is detected, yet provide safety should such a fault exist.

The first component is a large transformer (the Isolating Transformer) mounted in the wall cavity which converts the earth-referenced mains supply to a “floating” supply. The floating supply provides 240V between two active wires, but because the supply is not earth-referenced, the presence of an earth circuit through the patient or anyone else is perfectly safe and no current will flow. All the circuit to earth does is to reference the floating supply to earth; no current actually flows through the earth connection.

The Line Isolation Monitor continually checks that the floating supply is not earth-referenced, and indicates on a dial how much current could flow to earth if there was an earth connection. If the potential earth current would be more than 5mA an alarm will sound, alerting the anaesthetist to the presence of a loss of the “floating” nature of the supply. It does this by intermittently connecting one of the two active wires to ground through a very large resistance. If the other wire is connected to ground a circuit will be formed and current will flow, and this indicates how much current would flow through the circuit if either of the two active wires are connected to ground.

As with an RCD the device will not alarm under 5mA, so microshock may still occur unnoticed, however macroshock is very unlikely; only current flowing through the patient from between the active wires will no be detected.

(RCH - electrical safety):

Line Isolation overload Monitors (LIMs)
In critical life support applications where loss of power supply cannot be tolerated, special power outlets powered by isolation transformers are installed.

Line Isolation Monitors are installed to continually monitor electrical leakage in the power supply system. If an electrical fault develops in a medical device connected to an isolated power outlet, the LIM will detect the leakage current. The LIM will alarm and indicate the level of leakage current, but will not shut off the electric supply.

The faulty equipment can be identified by un-plugging one item of equipment at a time from the supply until the alarm stops sounding. Equipment that is not faulty may be reconnected. Faulty equipment should be appropriately labelled and sent to Biomedical Engineering for repair.

The LIM also monitors how much power is being used by the equpiment connected to it. If too much power is being used, the LIM will alarm and indicate that there is an overload. The power used must be reduced immediately by moving some equipment to another circuit as soon as possible until the alarm stops sounding. Failure to reduce the load on the LIM will result in the circuit breaker tripping and loss of power to the circuit.

Answer 118

A

A. rFVIIa

Answer 119

A

A. Suction (if flat)

Answer 120

A

C. grade 2

Grade 1
asymptomatic or minimal headache and slight neck stiffness
70% survival

Grade 2
moderate to severe headache; neck stiffness; no neurologic deficit except cranial nerve palsy
60% survival

Grade 3
drowsy; minimal neurologic deficit
50% survival

Grade 4
stuporous; moderate to severe hemiparesis; possibly early decerebrate rigidity and vegetative disturbances
20% survival

Grade 5
deep coma; decerebrate rigidity; moribund
10% survival

Answer 121

A

E. cardiac output > 20% higher

? reference

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