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
- Patient with a large anterior mediastinal mass, develops hypoxia on induction, best management?
A Prone position
B Intubate and ventilate with IPPV
C Intubate and try to keep spontaneously breathing
D Deliver CPAP
A. Prone position
117 . Question about most common symptom associated with post-op neurological dysfunction
A Short term memory loss
B Agitation
C Hallucinations
D and E were less credible options I can’t remember
A. Short term memory loss
CEACCP 2012: Cognitive decline after anaesthesia and critical care
Postoperative cognitive decline (POCD) can be defined as impairment of cognitive functions, including memory, learning, concentration, and speed of mental processing.
Affecting surgical patients in all age groups over the short term, POCD manifests days or weeks after surgery and shows faster resolution in younger populations, although it may be permanent. Usually expressed by patients as a new inability to complete once easily attainable tasks, symptoms include difficulty staying focused on a task, inability to multitask, difficulty finding words and recalling information recently acquired. In more severe cases, POCD can cause a catastrophic loss of cognitive function, with associated increased mortality, risk of prematurely leaving work, and dependence on social welfare.
- Awareness incidence rate with GA under muscle relaxant from NAP5
A 1:1000 B 1:3000 C 1:8000 D 1:10,000 E 1:50,000
C. 1:8000
Discounting the Sedation cases, Unassessable and Unlikely reports, and the Statement Only cases (but including the Drug
Error and ICU cases) leaves 167 cases; yielding an incidence of patient reports of AAGA ~1: 17,000 (0.006%) general anaesthetics.
If drug swaps are excluded (as they are really examples of unintended paralysis rather than accidental awareness) this leaves 147 cases and an incidence of patient reports of 1:19,000 (0.005%). Both the number and the estimated incidence is remarkably close to the estimate from the Baseline Survey of 153 cases and ~1:15,000, respectively. The incidence using only Certain/probable and Possible reports is 1 in 20,000
There is a striking difference between the incidence of AAGA when no NMB is used (~ 1: 135,900) versus when an NMB is used (~1:8,200).
- Propofol infusion syndrome involves all of the following except:
A Rhabdomyolysis B Hepatomegaly C Splenomegaly D ST elevation E Acidosis
C. Splenomegaly
(LITFL)
Propofol-related Infusion Syndrome is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of:
(1) metabolic acidosis
(2) rhabdomyolysis
(3) hyperlipidaemia
(4) enlarged or fatty liver
Investigations:
Bedside
- ECG: Brugada like pattern (coved type = convex-curved ST elevation in V1-V3), RBBB, arrhythmia, heart block
- blood gas: unexplained lactic acidosis; hyperkalaemia (if rhabdomyolysis or renal failure)
Laboratory
- lipids (lipaemic serum)
- UEC (renal failure)
- CK (rhabdomyolysis)
- propofol levels or chromatography (if available)
120 Pre-operative bowel prep:
A Reduces Mortality B Reduces wound infection rates C Reduces anastamotic leak rates D Reduces re-operation rates E Facilitates colonoscopy
E. Facilitates colonoscopy
CEACCP (2009) - Fast-track surgery and anaesthesia:
Bowel preparation is traditionally administered to all patients before colorectal surgery. However, a recent meta-analysis has demonstrated that, at least for segmental resections, bowel preparation may not be necessary and may increase the risk of septic complications and aggravate preoperative dehydration.
Australian Prescriber - Bowel preparation (2005):
Complete cleaning of the large bowel is essential for colonoscopy and radiological investigation of the colon (barium enema and more recently CT colonography). Bowel preparation has also traditionally been used prior to colonic surgery although the evidence for its benefit is scant.
- AM51 How many vials of dantrolene should (according to guidelines from MH society) be kept at a remote hospital which has general anaesthesia services?
A 2 B 6 C 12 D 24 E 36
E. 36 (x 20 mg vials)
36 in remote locations, 24 in other places.
The following are the recommended contents of an MH Box:
Dantrolene
- 24 x 20 mg vials of Dantrolene
- Sterile water for injection (2000ml)clearly labelled as unsuitable for IV infusion
eg 250 ml bag from B/Braun or
100ml bottles of sterile water for parenteral injections (Pfizer)
- Drawing up needles (see above)
- 60 ml syringes 5-10
Include information on where to obtain additional dantrolene
Drugs
- 8.4% sodium bicarbonate (1mmol/ml)
- 50% dextrose 50 ml
- Lignocaine 1%
- Amiodarone 300mg
Cold Box in fridge
- 2 litres normal saline for IV use
- Actrapid insulin
Blood tubes for
- haematology, coagulation profile
- electrolytes, creatinine, urea, creatine kinase (CK)
- crossmatch
- blood gas syringes
Urine sample pot for myoglobin
Pathology forms (pre-written)
Task Cards (as described in the MH Resource kit instructions)
If space in your MH Box allows: (otherwise, have instructions on where to find) - Urinary catheter - Urinary catheter and hourly urine bag - Monitoring equipment - Arterial line equipment - Central line catheter
- Pregnant patient, progressive dyspnoea. Which would most strongly warrant further investigation?
A soft 2/6 systolic ejection murmur B elevated JVP C third heart sound D orthopnoea E peripheral oedema at ankles
B. Elevated JVP
?orthopnoea
Mothers who develop incipient cardiac disease in late pregnancy are difficult to diagnose as symptoms are similar to the later stages of pregnancy i.e. shortness of breath, swollen ankles, fatigue, reduction in exercise capacity, murmurs, third heart sound and arrhythmias. Loud 4th heart sound, diastolic murmur, grade 3/6 systolic murmur, fixed splitting of second heart sound or opening snap should raise suspicion and appropriate investigations including ECG and echocardiography should be performed.
Peripheral oedema and orthopnoea are common in pregnancy, and do not necessarily indicate cardiac disease.
3rd heart sound can be normal, especially in young people and especially in people with hyper dynamic circulations (represents rapid ventricular filling)
- How before return to normal platelet function in chronic diclofenac use.
A 12hrs B 1-2d C 4d D 7d E 10d
? B. 1-2 days
Hard to find a definitive reference, but the one below would suggest 1-2 days is a good guess.
Schafer, J Clin Pharmacol 1995 - Effects of Nonsteroidal Antiinflammatory Drugs on Platelet Function and Systemic Hemostasis:
Unlike aspirin, the effect of nonaspirin NSAIDs on platelets is reversible. Because these drugs reversibly inhibit platelet cyclooxygenase, function of the enzyme is restored as the drugs are cleared from circulation. Therefore, normal platelet function returns more rapidly after discontinuation of NSAIDs with shorter half-lives.
A study comparing ten commercially available NSAIDs administered to healthy human volunteers demonstrated considerable variability in extent and duration of their inhibitory effects on ex vivo platelet aggregation. As predicted, a single oral dose of aspirin abolished the second wave of aggregation in response to ADP and epinephrine, and it produced a long-lasting effect that persisted for 5 to 8 days. Additionally, piroxicam, naproxen, diclofenac, and indomethacin blocked ADP- or epinephrine-induced second-wave aggregation, and the abnormality persisted 3 days after piroxicam was discontinued and 2 days after naproxen, diclofenac, and indomethacin were discontinued. Ibuprofen and diflunisal produced a weaker but definite effect, which normalized within 24 hours of ingestion.
- How long after starting a unit of FFP does it have to be completed
A 2hrs B 4 C 6 D 8 E 10hrs
B. 4 hours
All blood component transfusions should be completed within 4 hours of starting
- You arrive to a code blue for a 5 year old child 16kg in a shockable rhythm. CPR has commenced, he has had TWO shocks already. What is the next step:
A Adrenaline B Amiodarone C Iv fluid bolus D Shock 50j E Shock 100j
A. Adrenaline 10 mcg/kg
- FAST scan includes
A Pelvis, pericardium, perihepatic, perisplenic
B Pelvis, pericardium, perihepatic, paracolic
C Lung, pericardium, perihepatic, perisplenic
D More combinations of above
A. Pelvis, pericardium, perihepatic, perisplenic
RUQ - Morison’s pouch (between liver and R. kidney)
LUQ - between spleen an L. kidney
Suprapubic - between posterior bladder and vagina (Pouch of Douglas) or between bladder and rectum in males
Pericardium
- You arrive in the emergency department to treat a man with an attempted hanging. He has a LMA in situ, it is easy to ventilate (or something like that) Sa 98% HR 120, BP 130/80 GCS 5 initially. What is the next single most important thing to do.
A Apply rigid collar with manual inline stabilisation B Check subcutaneous emphysema C Fibre optic examination of airway D Lateral c-spine xray E Remove LMA and intubate
A. Apply rigid collar with manual inline stabilisation
- You are supplying oxygen from the variable flow meter on the wall at 6L/min. The tubing becomes obstructed. What is the pressure reached in the tubing
A 1atm (100kPa) B 2atm (200kPa) C 3atm (300kPa) D 4atm (400kPa) E 5atm (500kPa)
D. 4 atm (400 kPa)
- The adverse event that leads to the most medico legal claims against anaesthetists is:
A Dental damage from airway management B Eye injury C Non-obstetric epidural complications D Obstetric epidural complications E Peripheral nerve injury
A. Dental damage from airway management
CEACCP (2006) - Injury during anaesthesia:
Oral injury occurs during 1 in 20 general anaesthetics (5%). Oral (especially dental) injury is the most frequent cause for complaint and litigation against anaesthetists.
Dental injury occurs during 1% of general anaesthetics. It is most commonly sustained during laryngoscopy and requires intervention in only 2% of cases. The teeth most likely to be injured are the upper incisors, most commonly in patients aged 50–70 yr.
- 65 year old lady with osteoarthritis, for TKR in 2 weeks time. She has Fe deficiency anaemia, with Hb 105, Ferritin 30mcg/l. The best management would be:
A Oral Fe tablets until surgery
B Oral Multivitamin containing Fe until surgery
C IV Fe infusion
D Blood transfusion
E Check Hb on day of surgery and don’t proceed if
C. IV iron infusion
Not enough time for oral iron to work.
See ‘Intravenous Iron in Surgery and Obstetrics’, blue book 2011.
- What is the expected rise in platelets from one unit of pooled leucodepleted platelets in a 70kg patient?
A 10-20 B 21-40 C 40-60 D 60-80 E 80-100
B. 21-40
transfusion.com.au:
One unit (one standard adult dose) of Platelets Apheresis or Pooled Leucocyte Depleted would be expected to increase the platelet count of a 70 kg adult by 20–40 x 10^9 /L. The usual dose in an adult patient is 1 unit (apheresis) or 1 pool (pooled).
One unit of Platelets Paediatric Apheresis Leucocyte Depleted would be expected to increase the platelet count of an 18 kg child by 20 x 10^9 /L.
- [Repeat] You are assessing a patient for intubation. MP3 and thyromental distance 6cm. Compared with MP, TMD is? (repeat)
Various combinations of mallampati being more/less sensitive and specific compared to thyromental distance
Thyromental distance is less sensitive but more specific for difficult intubation than Mallampati score.
- You are about the anaesthetise a patient BMI 38 for bariatric surgery. Plan to give 1m/kg of sux. Compared with Ideal body weight, total body weight dosing results in:
A shorter onset, shorter duration B shorter onset, similar duration C shorter onset, longer duration D similar onset, shorter duration E similar onset, longer duration
E. Similar onset, longer duration (and better intubating conditions)
Lemmens, Anes Analg 2006 - The dose of succinylcholine in morbid obesity:
Optimal succinylcholine dosing for morbidly obese individuals (BMI > 4) was evaluated by randomized controlled trial with outcomes being onset of maximum neuromuscular blockade, intubating conditions, and duration of action of neuromuscular blockade. Groups received 1 mg/kg comparing dosing based on ideal body weight (IBW), lean body weight (LBW), or total body weight (TBW).
Results: Onset of neuromuscular blockade did not differ between groups. Intubating conditions* were significantly better in the group dosed by TBW. Duration of action of neuromuscular blockade differed between groups, TBW > LBW > IBW.
Ingrande, BJA 2010 - Dose adjustments of anaesthetics in the morbidly obese:
In MO subjects, the amount of pseudocholinesterase is increased. In addition, the amount of extracellular fluid is increased. As both of these factors determine the duration of action of succinylcholine, administration should be based on TBW. When compared with administration based on 1 mg kg−1 IBW or LBW, 1 mg kg−1 TBW administration results in a more profound block and better tracheal intubating conditions, with clinically insignificant postoperative myalgia.
X1 – man undergoing transcatheter aortic valve replacement, ECG shown with regular p waves approx. rate of 100, two broad QRS complexes with no relation to p waves. i.e. Complete heart block. What is the best way of managing this? (CPR was NOT an option)
A Atropine B Transcutaneous pacing C Adreline D Isoprenaline E Transvenous pacing
??
B. Transcutaneous pacing (initially)
E. Transvenous pacing (as soon as feasible)
(Probably transcutaneous pacing initially until transvenous pacing can be established - will have arterial sheaths in for TAVI but nothing in femoral vein)
X2 - A patient presents for THR with a febrile illness, but wishes to proceed despite the risks. You can justify your decision to defer the case based on:
A Automony B Beneficence C Non-maleficence D Paternalism E Utilitarianism
C. Non-maleficence
X3 - You collect ropivacaine levels post-operatively. This type of data is:
A Continuous B Numerical C Ordinal D Nominal E Categorical
A. Continuous
