2014.2 Flashcards
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
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)
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
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)
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
A
C. Aortic dissection
Blunt chest trauma and pregnancy both risk factors
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
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
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
A
A. Clonidine (no tocolytic effect)
Indomethacin is an appropriate (first-line) tocolytic for the pregnant patient in early preterm labor (
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
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”
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
A
C. 10 mg/kg
Frank Shann - Drug Doses
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
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
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
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.
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
A
A. 3:1
ARC neonatal resus guidelines
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
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
12
Q
61.Tumour lysis syndrome causes all of the following biochemical abnormalities EXCEPT:
- A. Hyperkalaemia
- B. Hypernatraemia
- C. Hyperphosphataemia
- D. Hyperuricaemia
- E. Hypocalcaemia
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)
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
A
B. Posterior
Stimulating phrenic nerve (anterior)
Therefore redirect posteriorly
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
A
A. Rapid respiratory rate
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
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
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
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…
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%
A
C. 32%
Rule of 9’s:
Half of upper limb: 4.5
All of lower limb: 18
Anterior surface abdomen: 9
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
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)
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
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.
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
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
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
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’.
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
A
B. Gas sample line leak (not sure what the trace looked like but this is always the answer!)
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
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
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
A
A. CTPA
25
100. 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
A. 4L
Parkland: 4 x 80 x 25 = 8L
1/2 over first 8 hr = 4L
26
101. 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
C. 3 mcg/l
Normal range for ferritin 12-200 mcg/l (OHA p1273)
27
102. 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
A. Autonomy
28
103. 100% Saturated air @ 20 degrees is what relative humidity @ 37 degrees
* A. 20%
* B. 30%
* C. 40%
* D. 50%
* E. 60%
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%
29
104. Maximum cumulative dose of intralipid (ml/kg)
* A. 10
* B. 12
* C. 15
* D. 20
B. 12 mL/kg
30
105. 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
E. NaCl infusion
Normal anion gap metab acidosis (therefore not ketones, uraemia, lactic, toxins - incl methanol)
31
106. 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
A. Uteroplacental insufficiency
32
107. 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. ?
A. Cohort
- Prospective
- pick groups and follow forwards to look for outcomes
33
110. 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
B. Isolated factor VII deficiency
PROTHROMBINEX-VF contains concentrated factor IX, factor II, factor X and low level of factor VII.
34
111. 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
C. Cease N2O
| Oxford handbook
35
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
A. Lateral aspect of forearm
| musculocutaneous nerve - gives off lateral cutaneous nerve of forearm
36
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
Something either side of horizontal fissure.
37
12 year-old with idiopathic scoliosis, most likely have associated
* A Phaeochromocytoma
* B Renal artery stenosis
* C Mitral valve prolapse
* D Diabetes insipidus
* E
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
38
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
B. Laryngomalacia
Laryngomalacia - most common cause of chronic pediatric stridor causing approximately 60% of stridor seen in newborns.
39
A picture of an echo 4 chambers view
* A Anterior mitral valve leaflet
* B Posterior mitral valve leaflet
* C
* D
* E
Leaflet closest to RV is anterior
40
Cryoprecipate, once thawed must use within
* A 30 minutes
* B 2 hours
* C 4 hours
* D 6 hours
* E 12 hours
C. or D. Should be used within 4-6 hours
| transfusion.com.au fact sheet
41
Glycine 1.5% used for TURP, osmolality is
* A 200
* B
* C
* D 300
* E 320
A. 200
CEACCP - Anaesthesia for transurethral resection of the prostate (2009)
42
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. ?
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)
43
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
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.
44
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
C. Dorsum of hand
45
Blue urticaria is a complication of
* A
* B Methylene blue
* C Patent blue something
* D
* E
C. Patent blue V
Anaphylaxis and blue urticaria associated with Patent Blue V injection
http://www.respond2articles.com/ ANA/forums/1182/ShowThread.aspx
46
Intraosseous sampling - least accurate on
* A Albumin
* B Urea
* C Haemoglobin
* D Chloride
* E Calcium
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
47
Subtenon's block - muscle most likely to have inadequate block
* A Medial rectus
* B Lateral
* C Superior
* D Superior oblique
* E Inferior
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'
48
EVAR, best method to reduce risk of renal impairment
* A Sodium bicarbonate
* B N-acetylcysteine
* C Normal saline
* D
* E
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
49
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
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.
50
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
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.
51
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
D. Obturator nerve
52
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
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).
53
A printout of 12-lead ECG
* A Atrial fibrillation with BBB
* B Sinus tachycardia with BBB
* C Torsades de pointes
* D VT
* E VF
?
54
(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
A. Maximal suction applied to system
55
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
C. Hypoglossal nerve
56
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
?
57
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
A. Fat embolism
Triad of pulmonary, neurologic and skin changes.
58
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
B. AFE
59
Treatment for patients with congenital long QT syndrome
* A Pacemaker/defibrillator
* B Accessory pathway abalation
* C Beta blocker
* D Calcium channel blocker
* E
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.
60
18 month old child with VF arrest, shock with
* A 10J
* B 30J
* C 50J
* D 100J
* E
C. 50J
DC shock in paeds 4J/kg
Average 1 yo 10 kg, 2 yo 12 kg
61
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
B. Rupture of aneurysm
Oxford handbook of anaesthetic emergencies:
Detected by HTN, extravasation of contrast
62
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
C. Serotonin syndrome
63
Best drug to reduce both gastric acidity and volume
* A Ranitidine
* B PPI
* C Sodium citrate
* D
* E
A. Ranitidine
H2 antagonists more effective than PPIs when given on the day of surgery
64
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
E. Phenylephrine
| adrenaline and noradrenaline are also direct acting, but you are not going to use these as first line
65
Patient with hyperthyroidism - proceed with elective surgery only if normal level of these hormones is seen
* A TSH
* B T4
* C T3
* D T3 & T4
* E
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
66
In pregnant women the dural sac ends at
* A
* B L3
* C L5
* D S1
* E S3
D. S1
| NYSORA
67
Full size C oxygen cylinder providing 10L/min of oxygen flow to a patient during transport. How long will this cylinder last?
* A
* B
* C 45 minutes
* D
* E
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
68
```
Patient awaiting renal transplant. Why would you ask them to stop Echinacia?
A. Hepatotoxic
B. Nephrotoxic
C. Coagulopathy
D. Immune suppression
E. ?
```
D. Immune suppression
Chronic echinacea use suppresses immune function.
69
Red-man syndrome secondary to vancomycin is due to
* A Type II hypersensitivity reaction
* B Vasodilation
* C Mast cell degranulation
* D IgE immediated response
* E Serotonin release
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)
70
A 40 y.o. female newly diagnosed ITP. Retinal detachment for surgery in 2 days. Platelets 40 and blood group A+. Management of her ITP:
* A Administer Anti-D antibodies 6 hrs pre op
* B Admister desmopressin one hour pre op
* C Administer methylpred and IVIG 2 days pre op
* D Recheck platelet count morning of surgery and if not dropped continue
* E Platelet transfusion morning of surgery
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
71
Absolute contraindication to ECT
* A Cochlear implants
* B Epilepsy
* C Pregnancy
* D Raised intracranial pressure
* E Myocardial infarction
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.
72
Repeat Stellate ganglion block. Needle entry next to SCM muscle at C6. Which direction to advance needle ?
* A. C3
* B. C4
* C. C5
* D. C6
* E. C7
D. C6
WFSA ATOTW - Stellate ganglion block (2012)
Enter at C6
Hit C6 transverse process, then angle down.
73
Repeat CTG with early decelerations
* A. GA
* B. Fetal head compression
* C. Uteroplacental insufficiency
* D. Acute asphyxia
* E. Umbilical cord compression
B. Fetal head compression
74
Repeat Endocarditis prophylaxis
* A Bicuspid valve
* B Congenital repair > 12 months ago
* C Rheumatic heart valve
* D Uncorrected cyanotic heart disease
* E MVP
D. Uncorrected cyanotic heart disease
Patient indications
1. Prosthetic heart valve
2. Congenital heart disease, only if:
- unrepaired cyanotic (incl palliative shunts/conduits)
- prosthetic materials in repair (first 6 mths)
- repaired defects with residual defect
3. Heart transplant
4. Previous IE
5. Rh heart disease (indigenous only)
75
Repeat CVL relatively contraindicated in:
* A. LBBB
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'
76
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
77
(Repeat) You’re anaesthetizing an otherwise well 40 yo male for a craniotomy. Propofol and remifentanil TIVA. Using entropy. The MAP is 70 mmHg, heart rate is 70 bpm, Sats are 98%, state entropy is 50 and the response entropy 70. Most appropriate next step is
* A. give 0.5 mg metaraminol iv
* B. use NMT to assess train of four ratio
* C. change to volatile anaesthetic
* D. do nothing
* E. increase propofol TCI concentration by 0.5
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
78
Repeat What proportion of the population are heterozygous for pseudocholinesterase deficiency, i.e. have a dibucaine number 30-70?
* A. 0.04%
* B. 0.4%
* C. 4%
* D. 14%
* E. 40%
C. 4%
| ref: Peck and Hill table, ch 4
79
Repeat CO2 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
A & B wrong. (well absorbed by water).
C. ?widely disseminated (dissipates in tissue, doesn't really penetrate)
D. correct (long infrared wavelength)
E. wrong
80
Repeat With regards to ROTEM: decreased maximal clot firmness (decreased MA: maximal amplitude on TEG) correlates best with needing to give:
* A. FFP
* B. Cryoprecipitate
* C. Platelets
* D. Prothrombinex
* E. Tranexamimic acid
C. Platelets
81
Repeat The MELD score is calculated using INR, Bilirubin & what?
* A. Creatinine
* B. Albumin
* C. Urea
* D. AST
* E. Ammonia
A. Creatinine
MELD:
- INR
- bilirubin
- creatinine
- aetiology
82
Which of the following attributes of a scientific publication is most likely to be be protective against fraudulent research?
```
A. Published in a peer review journal
B. Multiple authors
C. Departmental director sole author
D. Research findings similar to other published studies
E. Backing of a major research institute
```
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.
83
Repeat An 80 year old man undergoes a unilateral lumbar sympathectic blockade. The most likely side effect that he experiences is:
* A. Genitofemoral neuralgia
* B. Haematuria
* C. Postural hypotension
* D. Lumbar radiculopathy
* E. Psoas haematoma
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.
84
Repeat The most important effect of Lugol's iodine administration before thyroid surgery is
* A. reduce incidence of thyroid storm
* B. reduce incidence of vocal cord palsy
* C. increase likelihood to identify and preserve parathyroid glands
* D. pigmentation of thyroid gland to help identify thyroid gland
* E. reduce vascularity of thyroid gland
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]
85
To exclude raised ICP in an awake patient the most reliable finding is what ?
* A. No headache
* B. No diplopia
* C. No vomiting
* D. Pulsatile retinal vein
* E. No papilloedema
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.
86
Repeat (march 2011). What percentage of patients with SAH are troponin positive?
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%)
87
(Repeat) Best way to determine a neonate's heart rate
A. Auscultate the chest.
A. Auscultate the chest
88
```
(Repeat) Optimal fluid management during laparotomy
A. Pulse pressure variation
B. EF on a TOE
C. CVP
D. BP
E. HR
```
A. Pulse pressure variation
89
133. A 50 year old male is having an aortic valve replacement for aortic stenosis. He is stable on bypass initially but after the first dose of cardioplegia his MAP falls to 25mmHg, CVP 1 and his mixed venous oxygen saturation is 80%. What is the best management in this situation.
```
A. Metaraminol bolus
B. Commence an adrenaline infusion
C. Increase oxygen flow rate
D. Increase pump flow rate
E. IV crystalloid bolus
```
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
90
(Repeat) Maximum recommended time for an adult tourniquet
```
A. 90 min
B. 120 min
C. ?
D. ?
E. ?
```
Aim for
91
63. Repeat- The most effective method for cerebral protection in aortic arch aneurysm repair
```
A. Systemic hypothermia 20degrees
B. Antegrade perfusion to carotid arteries
C. Retrograde perfusion to jugular veins
D. Thiopentone
E. Steroid (?)
```
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.
92
Repeat: Post (R) pneumonectomy on the ward becomes acutely unwell, hypotensive, raised CVP. What do you do?
A. Turn left lateral.
A. Turn left lateral
| pneumonectomy side dependent
93
Repeat: Venous air embolism. How to position the patient?
a. Head up + R) up
b. Head up + L) up
c. Head down + R) up
d. Head down + L) up
C. Head down, right side up
| displace air from RVOT
94
```
Repeat: TBI - What fluid NOT to give?
A. Synthetic colloids
B. saline
C. albumin
D. FFP
E. Plasmalyte
```
E. Albumin
| SAFE study
95
Which population is more susceptible to CNS damage from hyponatraemia?
* A. Children
* B. Young males
* C. Young females
* D. Old males
* E. Old females
A. Children
96
Hb 86 post TKJR in an asymptomatic patient with stable angina.
a. Transfuse to 120
b. transfuse to 100
c. observe overnight and repeat mane
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
97
Health care worker. HBV exposure. Known to have immunisation titres. What do you do?
* A. Booster dose of his immunisation
* B. HBV immunoglobulins
* C. Pegylated Interferon
* D. Aciclovir
* E. Do nothing
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.
98
HIV seroconversion post needlestick injury:
a. 0.3%
b. 3%
c. 30%..
A. 0.3%
1:313 (Australian Prescriber)
99
Repeat: Craniotomy, MAP 80, transducer 13cm below, CVP given, what's the CPP?
CPP = 70 - CVP
100
Repeat: Unremakable finding on a laparotomy. Has been given 3L cystalloid and minimal EBL. Physiological response to such haemodilution includes ALL EXCEPT:
a. Increased myocardial O2 extraction.
b. Increased tissue O2 extraction.
c. Increased tissue flow due to decrease viscosity.
d. Increased tissue flow due to vasodilatation.
A. Increased myocardial O2 extraction
| high O2 extraction at rest from heart
101
Features suggestive of MH on ABG: Acidosis/alkalosis, hyper/hypocapnia, Zero BE vs. -9 BE.
MH ABG:
- mixed resp and metabolic acidosis (low bicarb, negative BE)
- CO2 elevated
102
A 50 year old male in recovery after an anterior cervical spinal fusion, developing increasing respiratory distress, bulge under original incision, combative, repeatedly removing oxygen mask, spO2 96%. What is the most appropriate management ?
* A. Direct laryngoscopy and intubation after inhalational induction with sevoflurane
* B. Awake tracheostomy by surgeons
* C. Awake fibreoptic intubation using minimal sedation
* D. Direct laryngoscopy and intubation with propofol and sux
* E. Retrograde intubation
A. Direct laryngoscopy and intubation after inhalation induction with sevoflurane
103
Asthmatic paediatric patient, tonsillectomy. Desaturates and stiff to bag. First thing to do?
* A. Salbutamol
* B. Suction
* C. Ask surgeon to release gag
* D. Paralysis
* E. ? reintubate
C. Ask surgeon to release gag
104
Balloon pump trace 2:1
* A. Early inflation
* B. Late inflation
* C. Early deflation
* D. Late deflation
* E. ? No problem
?
105
Repeat A 40 yo woman for laparotomy to remove phaeochromocytoma under combined epidural and general anaesthesia. Pre-operatively treated with phenoxybenzamine and metoprolol. Intra-operatively, blood pressure is 250/130 despite high dose phentolamine and SNP. HR is 70/min and SaO2 are 98%. The next most appropriate treatment is:
* A. Epidural Lignocaine
* B. IV Esmolol
* C. IV Hydralazine
* D. IV Magnesium
* E. IV Propofol
D. IV magnesium
106
Fasting time for a 6 week old...
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
107
AAI paced ECG:
1) Failure to capture
2) CHB
3) 2nd degree HB
4) AF
?
108
Hyperkalaemia of 7 or 8.
Most appropriate immediate (or was it most "effective") therapy:
a. Insulin + Glucose
b. Bicarb
c. Salbutamol
d. Resin
e. Something else
A. Insulin 0.15 units/kg + glucose 50% 0.5 mL/kg
109
Correct INR range for a patient with a mechanical valve
2.5-3.5
110
Flow volume loop diagram
* A. Variable intra-thoracic obstruction
* B. Variable extra-thoracic obstruction
* C. Restrictive pattern
* D. Obstructive pattern
* E. Fixed obstruction
?
111
4 METS is how many ml O2 / min
14 mL/kg/min
| 1 MET is 3.5 mL/kg/min
112
A 30 year old multi trauma patient one week post injury has severe ARDS. He is currently ventilated at 6ml/kg tidal volume, PEEP of 15cm H20 and pa02/Fi02 is less than 150. The next step to improve oxygenation is:
* A. increase PEEP to 20cmH20
* B. increase tidal volume to 10mls/kg
* C. initiate nitrous oxide therapy
* D. commence high flow oscillatory ventilation
* E. ventilate in the prone position
E. Ventilate in the prone position
113
Repeat 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. T11
B. T4
114
Repeat You are involved in research and as part of data collection you collect ASA scores. This type of data is:
* A. Categorical
* B. Nominal
* C. Non-parametric
* D. Numerical
* E. Ordinal
E. Ordinal
115
Repeat During a pneumoperitoneum, at what level of intra-abdominal pressure does cardiac output fall?
* A. 10 mmHg
* B. 20 mmHg
* C. 30 mmHg
* D. 40 mmHg
* E. 50 mmHg
A. 10 mmHg
| IAP 10-20 mmHg
116
Repeat Best option to reduce risk of ventilator induced pneumonia?
* A. Nurse in supine position
* B. Early spontaneous ventilation through ETT
* C. Oral hygiene
* D. Use antacids
* E. Regularly change breathing circle
C. Oral hygiene
117
Repeat 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
118
Repeat A patient is in Class 4 haemorrhagic shock, secondary to a gunshot wound to the abdomen. He is clinically coagulopathic 30 minutes later. He has received intravenous Hartmann's 1L. The coagulopathy is likely related to:
* A. acidosis
* B. dilution of clotting factors
* C. hypothermia
* D. systemic release of tissue factor
* E. tissue hypoperfusion
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)
119
Repeat The normal physiological response following ECT is
* A. transient tachycardia followed by bradycardia and hypotension
* B. transient bradycardia followed by tachycardia and hypertension
* C. unpredictable
* D. transient tachycardia followed by bradycardia and hypertension
* E. tachycardia and hypotension
B. Transient bradycardia followed by tachycardia and hypertension
120
Repeat In preadmission clinic with patient with a tracheostomy. To enable patient to talk you would
* A. Deflate tracheostomy cuff, insert one-way valve, insert fenestrated piece
* B. Deflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
* C. Inflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
* D. Inflate tracheostomy cuff, insert one-way valve, insert fenestrated piece
* E. ?
A. Deflate trache cuff, insert one-way valve, insert fenestrated piece
(see life in the fast lane, fenestrated tracheostomy tube)
121
Repeat What is NOT a contraindication to MRI?
* A. Pulmonary artery catheter
* B. Arterial line
* C. Scissors
* D. Coiled ECG cable
* E. Laryngoscope
B. Arterial line
122
Repeat What is the mechanism of central sensitisation?
* A. Increased intracellular magnesium
* B. Antagonism of the NMDA receptor
* C. Glycine is the major neurotransmitter involved
* D. Recurrent a-delta fibre activation
* E. Alteration in gene expression
E. Alteration in gene expression
123
Repeat Which volatile contributes most to greenhouse gases / environmental pollutant ?
* A Desflurane
* B N2O
* C Sevoflurane
* D Isoflurane
* E Halothane
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.
124
Repeat The clinical sign that a lay person should use to decide whether to start CPR is:
* A. Absent central pulse
* B. Absent peripheral pulse
* C. Loss of consciousness
* D. Obvious airway obstruction
* E. Absence of breathing
E. Absence of breathing
Indications: not responsive and not breathing normally
125
Repeat A patient's competence to give informed consent is determined by all the following except:
* A. Ability to communicate a choice
* B. Ability to apply reasoning
* C. Ability to understand consequences
* D. The provision of significant information
* E. ?
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'
126
First line treatment for acute attack of hereditary angioedema
* A FFP
* B Adrenaline
* C Steroids
* D C1 inhibitor concentrate
* E anti-histamine
D. C1 inhibitor concentrate
1st line = C1 inhibitor concentrate
If not available -> FFP
Adrenaline, steroids, anti-hist not effective
127
Repeat Adult male who is intubated and ventilated, with CVL in situ. Just before surgeon starts the Line Isolation Monitor alarms about a leak at 5mA. What do you do?
* A. stop procedure and move to a safe location
* B. sequentially remove non essential monitors from the circuit until fault is identified
* C. unplug the CVL to electrically isolate it until fault is identified
* D. ensure the patient is earthed
* E. Check the diathermy pad
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.
128
Repeat Patient with Haemophilia A with known high titres of inhibitors to factor 8. What would you give to prevent bleeding in the patient for OT
* a. FVIIa
* b. High dose FVIII concentrate
* c. FFP
* d. Cryo
* e. Platelets
A. rFVIIa
129
Mec stained liquor post LSCS Did not state if infant flat or vigorous
* A. Suction
* B. Routine care
A. Suction (if flat)
130
55 year old subarachnoid haemorrhage secondary to aneurysm. Patient is confused with a oculomotor (3rd cranial nerve) palsy, complains of a severe headache. This patient is in Hunt and Hess class:
* A 0
* B 1
* C 2
* D 3
* E 4
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
131
Repeat In a 140kg obese patient, compared to a 70 kg person
* A. cardiac output >20% lower
* B. cardiac output 10% lower
* C. cardiac output no different
* D. cardiac output 10% higher
* E. cardiac output >20% higher
E. cardiac output > 20% higher
? reference
