2015.2 Flashcards
f15B-1 Consider the following arterial blood gases. (Ref ranges in brackets) pH 7.28 PaCO2 36 Bicarbonate 18 mmol.l-1 (18-25) Base excess -7 mmol.l-1 (-4- +3) Na+ 142 mmol.l-1 (135-145) Cl- 112 mmol.l-1 (98-110)
These blood gases are consistent with
A. acute renal failure B. diabetic ketoacidosis C. ethylene glycol overdose D. intraoperative infusion of 6 litres of normal saline E. salicylate overdose
A. Acute renal failure (renal tubular acidosis)
? Could also be due to excessive administration of NaCl, although the chloride does not seem high enough to explain the acid-base derangement.
Partially compensated metabolic acidosis.
Anion gap = 142 - (112 + 18)
= 12
= normal
Causes of normal anion gap metabolic acidosis:
- excessive chloride administration
- loss of bicarb (e.g. from GIT or kidneys)
- renal tubular acidosis
- What is the most sensitive monitor for detecting a venous air embolus during neuroanaesthesia?
A transoesophageal electrocardiography (yes - it said electro) B precordial Doppler C precordial stethoscope D capnography E something else wrong
B. Praecordial Doppler
- A 34 year old primigravida collapses soon after delivery of her baby, the presumptive diagnosis is amniotic fluid embolus. Which ONE of the following supports this diagnosis?
A markedly raised serum tryptase B decreased C3-C4 levels C thrombocytosis D raised CRP E hyperfibrinogenemia
B. Decreased C3-4 levels
RH30 You are performing a peribulbar block for eye surgery. You decide to add hyalase to your local anaesthetic mix. What is the recommended concentration for hyalase?
A 25 U/ml B 50 U/ml C 100 U/ml D 150 U/ml E 1500 U/ml
A. 25 IU/mL
A lot of variation in the quoted concentrations.
Efficacy demonstrated at concentrations as low as 15 units/mL (Schulenburg, BJA 2007: Hyaluronidase reduces local anaesthetic volumes for sub-Tenon’s anaesthesia).
- (repeat PZ106) A 25 year old male presents for ECT at a free standing facility. He has a life threatening depressive illness that has not responded adequately to medication, however he is still taking tranylcypramine. The most appropriate course of action is
A cancel the procedure, cease tranylcypramine and perform the ECT in 2 weeks
B proceed with the ECT, but induce with midazolam and remifentanil
C proceed with the ECT, but pre treat with esmolol
D proceed with the ECT with caution, but with your usual drugs
E transfer the patient to a tertiary centre for their ECT
D. Proceed with the ECT with caution, but with your usual drugs
- A patient has suffered a cardiac arrest. They are intubated but there is no IV access. Which drug can be given down the ETT?
A Amiodarone B Calcium C Lignocaine D Magnesium E Sodium bicarbonate
C. Lignocaine
ARC guideline 2010 - Adrenaline, lignocaine and atropine may be given via endotracheal tube, but other cardiac arrest drugs should NOT be given endotracheally as they may cause mucosal and alveolar damage.
- (repeat SO19) A well 65 year old is having a total hip replacement under GA with sevo/nitrous/fentanyl. BP is 130/70 and stable. Before the surgeon commences reaming and cementing, the best thing to do is
A Induce hypotension B Raise BP with vasopressors C Turn off nitrous D Give steroids E Give heparin 5000u
C. Turn off nitrous
(N2O increases PVR)
CEACCP 2012 - Bone cement and the implications for anaesthesia:
‘Clinical reports and studies all demonstrate the presence of RV failure secondary to increased pulmonary artery pressure as the underlying cause of systemic hypotension and sudden cardiac arrest.’
- Pt in ICU in their 20s is diagnosed with brain death. History is that of immunosuppression for a renal transplant but otherwise well. Patient has expressed a desire to be an organ donor. All these organs can be donated except
A Bone marrow B Heart C Lung D Liver E Transplanted kidney
A. Bone marrow
Increased rate of haematological malignancy with long-term immunosuppression.
Australian Bone Marrow Donor Registry:
Exclusion criteria:
- Personal or family history of Creutzfeldt-Jakob disease (CJD), Gerstmann-Straussler-Scheinker syndrome (GSS) or Fatal Familial Insomnia (FFI)
- Thalassemia major, sickle cell disease, Fanconi anaemia or haemophilia
- Previous recipient of an organ transplant or corneal or dura mater graft
- Previous recipient of injections of human growth hormone for short stature or human pituitary hormone for infertility prior to 1986
- Previous stroke or a heart attack
- Previous cancer of any kind excluding non melanoma skin cancer (BCC/SCC) or premalignant conditions such as cervical changes
- Previous IVDU
- What is the IV loading dose of paracetamol for a 16kg child?
A 20mg/kg
15 mg/kg
…I think, although I can’t find a source.
- PL35 Local anaesthetic systemic toxicity (LAST) Intralipid initial dose in mL/kg
A 0.5 B 1 C 1.5 D 2 E 5
C. 1.5 mL/kg (of Intralipid 20%)
- 15B-29 MELD score includes INR, Creatinine and
A Albumin
B Bilirubin
C AST
D Fibrin
B. Bilirubin
- Factor V Leiden homozygote. By how much is the risk of post-operative DVT increased?
A 2x B 5x C 10x D 20x E 50x
E. 50x
(from Circulation patient information page:)
Heterozygous factor V Leiden increases the risk of developing a first DVT by 5- to 7-fold.
Homozygous factor V Leiden increases the risk of developing clots to a greater degree, about 25- to 50-fold.
Wiki:
People who inherit two copies of the mutation (homozygous), one from each parent, may have up to 80 times the usual risk of developing this type of blood clot.
- 15B-43 Kessel Blade has the blade coming off the handle at a degree of:
A 80 B 95 C 110 D 135 E 150
C. 110 degrees
LITFL
- Surgery planned under brachial plexus block performed at axilla. Pain is felt on incision at the anterolateral right forearm. Which nerve has been insufficiently blocked?
A Radial B Ulnar C Median D Musculocutaneous E Median brachial cutaneous (also remembered as axillary)
D. Musculocutaneous
- – 55M ICH, ventilated, paralysed, sedated, ICPs persistently 25mmg
A cool to
B give hypertonic saline
B. Give hypertonic saline
(but maintain serum osmolality
- – Best method to prolong apnoeic oxygen saturation in obese patient:
A position head up
B place in sniffing position
C prone
D lateral
A. Position head up
- – Neonate (born at 40 weeks, now 7 weeks old) why to reduce morphine infusion rate compared with older child
A Increased morphine crossing BBB
B Increased total body water/decreased fat
C Decreased enzymatic hepatic function
D Increased morphine-3-glucuronide (definitely M3G)
C. Decreased enzymatic hepatic function.
Sims and Johnson:
Immaturity of the blood-brain barrier was once thought to be responsible for apparent sensitivity of the neonate to drugs such as morphine, but it is now understood that pharmacokinetic differences are responsible.
(reduced protein binding with higher free morphine concentration; reduced clearance of morphine and its metabolites)
Ratio of M6G:M3G is also higher in neonates (4:10) compared to adults (1:10)
- Motor evoked potentials are used to monitor spinal cord function in scoliosis surgery. Which drugs affect them the LEAST?
A. Non-depolarising muscle relaxants B. Nitrous oxide C. Opioids D. Propofol E. Volatiles
C. Opioids
(from table in WFSA review 2015:)
Fentanyl and remifentanil: no effect Ketamine: +/- Propofol, benzodiazepines: ++ Iso, sevo, barbiturates: +++ Nitrous: ++++
- At initiation of laparoscopy/pneumoperitoneum which of the following cardiovascular parameters is LEAST likely to increase?
A. Cardiac Output B. Mean Arterial Pressure C. Heart rate D. Myocardial filling pressures E. Systemic Vascular Resistance
A. Cardiac output
Cardiac output may increase initially due to shunting of splanchnic blood into the central compartment, but after this CO will decrease due to restriction of venous return (from IVC compression) and elevated SVR.
SVR and myocardial filling pressures definitely increase.
MAP usually increases (or stays the same).
HR usually increases, although vagal reflexes can occur from peritoneal stretch.
- In order to use a 3 lead ECG setup to gain a CS5 view which of the following configurations would you use?
A. Lead I, RA lead below the clavicle, LA lead in the V5 position, LL at the hip
B. Lead I RA lead below the clavicle, LA lead at the hip LL in the V5 position
C Lead II RA lead below the clavicle, LA lead in the V5 position, LL at the hip
D Lead III RA lead below the clavicle, LA lead in the V5 position, LL at the hip
E Lead III RA lead below the clavicle, LA lead at the hip LL in the V5 position
A. Lead I; RA lead below the right clavicle, LA lead in the V5 position, LL lead at the hip
When a three-electrode ECG monitor is the only one available, it may be modified to allow approximation of stan- dard precordial lead positions. Lead I is selected, the positive exploring electrode (left arm) is located in the precordial V5 position, and the central negative electrode (right arm) may be placed in various positions on the thorax to achieve a central subclavicular (CS5), central manubrial (CM5), central chest (CC5), or central back (CB5) lead.
110 – According to NAP4 what is the rate of failure for emergency cannula cricothyroidotomy?
A 10 B 20 C 40 D 60 E 80
D. 60%
There was a high failure rate of emergency cannula cricothyroidotomy, approximately 60%. There were numerous mechanisms of failure and the root cause was not determined; equipment, training, insertion technique and ventilation technique all led to failure.
In contrast a surgical technique for emergency surgical airway was almost universally successful. The technique of cannula cricothyroidotomy needs to be taught
and performed to the highest standards to maximise the chances of success, but the possibility that it is intrinsically inferior to a surgical technique should also be considered. Anaesthetists should be trained to perform a surgical airway.
111 – Arndt bronchial blocker picture what is the straight port on the multi lumen connector for? (repeat)
A Connection of tracheal tube B Passage of nylon guide wire C Passage of fibreoptic D Passage of bronchial blocker E Connect circuit
C. Passage of fibreoptic bronchoscope
- Which would be consistent with deep partial thickness burns?
(various combinations of whether painful or not, whether blanches or not, and how it looks +/- presence of blisters)
A Pain to deep pressure only, decreased capillary refill or doesn’t blanch?
B Blanches to pressure, very painful
C Painful to air, blanches to pressure with blisters?
D Painful to deep pressure, red and weeping/wet
E No pain, no CRT
A. Pain to deep pressure only, decreased capillary refill/doesn’t blanch
vicburns.org.au - deep partial thickness:
Involves epidermis and significant part of dermis, only deeper adnexal structures intact.
Blotchy red. May blister (large blisters which rupture within hours). No capillary refill/sluggish circulation.
Decreased sensation.
- 50% burns in a patient weighing 70 kg, how much fluid to give in first 8 hours? (Repeat)
A 2.4 B 3.6 C 4.6 D 7L E 14L
Parkland:
4 x 70 x 50 = 14000 mL, 7000 mL in first 8 hours
…sounds like a lot
Modified Parkland probably more appropriate:
3 x 70 x 50 = 10500 mL, 5250 mL in first 8 hours