20.2 Flashcards

Question 1

Q

20.2 The breast does NOT receive sensory innervation from the

Question 2

Q

20.2 The recommended antibiotic prophylaxis for surgical termination of pregnancy is

A. Clindamycin 600 mg
B. Cephalexin 500 mg
C. Doxycycline 400 mg
D. Cephazolin 2g
E. Cephazolin 2g and metronidazole

Question 3

Q

20.2 The water capacity of an oxygen transport cylinder is 2 litres. The gauge is reading 150 bar. At an oxygen flow rate of 10 litres per minute, the number of minutes the cylinder will last is

Question 4

Q

20.2 Risk factors for chronic post-surgical pain do NOT include

a) Previous chronic pain
b) Young age
c) Higher education
d) Smoker
e) Anxiety

Question 5

Q

20.2 The anion which contributes the most to the anion gap is

a) Albumin
b) Chloride
c) Phosphate
d) HCO3
e) Urate

Answer

A

? REpeat?

a) Albumin

https://litfl.com/anion-gap/

○ albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap.

Question 6

Q

20.2 You are resuscitating a 60 kg man in cardiac arrest secondary to severe hyperkalaemia. You decide to give intravenous sodium bicarboate. Australian and New Zealand resuscitation guidelines state the initial dose of 8.4% sodium bicarbonate should be

Question 7

Q

20.2 Prothrombinex VF is a factor concentrate. It is indicated for the management of bleeding caused by

a Von Willebrand disease
b Haemophilia a
c Haemophilia b
d Haemophilia c
e Congenital fibrin deficiency

Answer

A

c Haemophilia b

Question 8

Q

20.2 A patient has a peripherally inserted central catheter (PICC) inserted. The follow-up chest X-ray shows the tip positioned in the (Chest X-Ray shown)

a) Azygos vein
b) Coronary sinus
c) SVC
d) R atrium
e) L atrium

Answer

A

a) Azygos vein

Correct positioning in image

Question 9

Q

20.2 You are called to assist with a patient in the intensive care unit who has had cardiac surgery three days ago and is now in cardiac arrest. External cardiac massage should aim for a systolic blood pressure of

a. 40
b. 60
c. 80
d. 100
e. 120

Answer

A

b. 60

BJA Article - Management of cardiac arrest following cardiac surgery - BJA Education

In the CICU, the effectiveness of ECC is confirmed by monitoring the arterial pressure trace with a target compression rate and depth to achieve a systolic impulse of > 60 mm Hg to maintain a mean perfusion pressure, preventing ventricular distension, LV wall stress, and ischaemia.

Question 10

Q

20.2 You have been asked to anaesthetise a patient with a history of severe depression that has been well controlled on moclobemide. The most appropriate medications in combination with propofol are

a Sevoflurane, morphine, phenylephrine
b Sevoflurane, pethidine, phenylephrine
c Midazolam, fentanyl, ephedrine
d Midazolam, fentanyl, metaraminol
e Sevolfurane, morphine, ephedrine

Question 11

Q

20.2 A 55-year-old patient who has undergone trans-sphenoidal hypophysectomy for a growth-hormone secreting adenoma has a urine output of one litre in the first postoperative hour. The following results are obtained. The most appropriate early management is

Na 145, Urinary osm ~200, Serum Osmolarity ~320

a) DDAVP
b) Hypertonic saline
c) Normal Saline 1 L bolus
d) 100 ml/hr of saline
e) Fluid restrict

Answer

A

a) DDAVP

Polyuria
Low urine osm
High serum osm
High Na
post transsphenoidal sx
= Central DI

Question 12

Q

20.2 The main advantage of using noradrenaline over phenylephrine for the prevention of hypotension as a result spinal anaesthesia for elective Casearean Section is

Question 13

Q

20.2 A 40 year old man suffers a hydrofluoric acid burn to 60% of his total body surface area in an industrial accident. An expected electrolyte disturbance is

a. Hypokalaemia
b. Hyponatremia
c. Hypophosphatemia
d. Hypomagnesemia
e. Hypocalcemia

Answer

A

e. Hypocalcemia

UTD:

> HF penetrates quickly through the epidermal layer into the dermis and deeper.
Fluoride ions complex with calcium and magnesium, which can lead to hypocalcemia and hypomagnesemia.
These electrolyte abnormalities and the direct cardiotoxic effects of fluoride ions contribute to the development of cardiac arrhythmias, which are the primary cause of death in HF burns.
Hypocalcemia may stimulate an efflux of potassium ions from cells resulting in hyperkalemia, and predisposing to cardiotoxicity.
QTc interval prolongation, due to hypokalemia, hypomagnesemia, and/or hypocalcemia may be seen.
Calcium salts are the mainstay of treatment of hydrofluoric acid burns; the dose and route depend upon the clinical situation

Question 14

Q

20.2 An ASA 1 28 year old male attends for inguinal hernia repair under general anaesthesia. He is administered propofol 180mg morphine 8mg rocuronium 50mg cephazolin 2g Post induction he develops an erythematous rash on his chest and arms, swelling of his lips and face, and severe hypotension. Preliminary blood results show …

Elevated tryptases (100 -> 40)
normal Ig E level
elevated morphine RAST.

The most likely diagnosis is

a) Ig E mediated morphine allergy
b) IgE mediated rocuronium allergy
c) Morphine induced histamine release
d) IgE mediated cephazolin allergy
e) Mastocytosis

Answer

A

?Repeat?

b) IgE mediated (i.e. anaphylaxis) rocuronium allergy

Morphine RAST is most sensitive (88%) and specific (100%) test for NMBD as cause of anaphylaxis (quaternary ammonium epitope)

Question 15

Q

20.2 A patient with a purely metabolic acidosis has a serum bicarbonate of 14 mmol/L and a lactate of 3.8 mmol/L. The expected PaCO2 is

Question 16

Q

20.2 A 34-year-old woman with cystic fibrosis has had a recent transthoracic echocardiogram to evaluate pulmonary pressure and suitability for lung transplantation. Below is a continuous wave Doppler trace through the tricuspid valve. Her central venous pressure is 5 mmHg. Her estimated right ventricular systolic pressure (RVSP) is (Echocardiography doppler trace shown)

Question 17

Q

20.2 In maternal cardiac arrest the most common arrhythmia is

Question 18

Q

20.2 The initial dose of IV adrenaline recommended for Grade 2 (moderate) anaphylaxis in an adult is

a) 10mcg
b) 20mcg
c) 100mcg
d) 500mcg
e) 1000mcg

Answer

A

b) 20mcg

Grade (ANZAAG)
1 - mucocutaneous only (mild)
2 - mucocutaneous and hypotension and/or bronchospasm (moderate)
3 - life threatening hypotension and/or high airway pressure (severe)
4 - arrest

For adults, put 3mg into a 50ml syringe
(or 6mg into 100mls saline; and running in mls/hr = mcg/min)
Doses:
- 20mcg = Grade 2
- 100-200mcg = Grade 3
- 1mg = Grade 4

For Paediatrics:
- put 1mg into 50ml syringe, (20mcg/ml; run @ 0.3ml/kg/hr = 0.1mcg/kg/min)
- 2mcg/kg = Grade 2 (0.1ml/kg of this dilution)
- 4-10 mcg/kg = Grade 3
- 10 mcg/kg = Grade 4 (0.1ml/kg of 1:10 000 (i.e. 100mcg/ml concentration))

IM doses are:
> 150mcg if <6 yrs
> 300mcg if 6-12yrs;

Question 19

Q

20.2 You are conducting a departmental audit and after 100 patients you have zero cases of dental damage. Your director asks you if you can estimate the risk of dental damage. You tell them that the approximate upper 95% confidence interval for the risk would be

Question 20

Q

20.2 Complications of hyperbaric oxygen therapy do NOT include

a) Myopia
b) Central retinal occlusion
c) Seizures
d) Hypoglycaemia
e) Bradycardia

Answer

A

b) Central retinal occlusion

SE’s from HBOT:
- progressive myopia (reversible)
- seizures
- hypoglycaemia
- sinus bradycardia from stimulation of vagal activity bassociated with hyperbaric pressures

Question 21

Q

20.2 You are anaesthetising a 35 year old woman undergoing a laparoscopic appendicectomy. She uses a levonorgestrel-secreting intrauterine device (MirenaTM) for contraception and you have used sugammadex for reversal of neuromuscular blockade at the end of the procedure. Your post-operative
advice to her regarding contraception should state that

a. Barrier protection for a week
b. Barrier protection until the next period.
c. The mirena is sufficient
d. OCP for a week
e. OCP until next period

Answer

A

Repeat

a. Barrier protection for a week

In the case of non-oral hormonal contraceptives, the patient must use an additional non hormonal contraceptive method for the next 7 days

Question 22

Q

20.2 In cardiac surgery, volatile-based anaesthesia compared to total intravenous anaesthesia

Question 23

Q

20.2 Interventions that reduce the risk of agitation following electroconvulsive therapy include all of the following EXCEPT

a Low dose of propofol following the seizure
b Low dose of midazolam following the seizure
c Premedication with olanzapine
d Premedication with dexmedetomidine
e Induction with remifentanil

Question 24

Q

20.2 The structure labelled A shows (gastric ultrasound image shown)

a. Empty stomach
b. Full stomach with Solids
c. Full stomach with liquids and Air
d. Gall Bladder
e. Abdominal Aorta

Answer

A

c. Full stomach with liquids and Air

Question 25

Q

20.2 Intraoperative cell salvage is contraindicated in

Question 26

Q

20.2 The most likely diagnosis in a 45-year-old man with the above biochemistry is (liver function tests shown)

Question 27

Q

20.2 Piped oxygen supply in major hospitals is predominantly sourced from

a VIE
b Cylinders
c Pipeline off site
d Oxygen concentrator on site

Question 28

Q

20.2 Application of a pacemaker magnet to a ventricular implanted pacemaker would be expected to convert the operating mode to

a. DOO
b. VII
c. DDD
d. VVI
e. VOO

Answer

A

e. VOO

> Asynchronous mode most often the result of magnet application. In a ventricular PPM, this means VOO

> However, various sources recommend against use of magnet for PPM management due to inconsistent effects on different devices

Equipment in Anaesthesia and Critical Care:

> The use of a magnet as a solution for pacemaker problems, either in theatre or otherwise is not recommended.
The application of a magnet to the pacemaker can have unpredictable results, from causing it to change to a back-up mode such as VOO, to reverting to factory settings, to performing various self-tests, to switching off entirely.

Question 29

Q

20.2 The optimal position, under ultrasound guidance, to place a catheter tip to provide continuous erector spinae plane block for post-thoracotomy analgesia is

Question 30

Q

20.2 The maximum warm ischaemic time (in minutes) acceptable for procuring the lungs following donation after cardiac death is

a. 30
b. 60
c. 90
d. 120
e. 240

Answer

A

c. 90

Warm ischaemia time:
- Time from treatment withdrawal to the start of cold perfusion of the donated organs
- Significance is the impact on graft function
- Most important phase of WIT begins when the systolic BP is < 60mmHg
- This includes the waiting period from the absence of circulation to the declaration of death and the time before initiating the flow of cold perfusate through the cannula

Maximum WARM Ischaemia time
- Heart 30 mins
- Liver 30 mins
- Pancreas 30 mins
- Kidney 60 mins
- Lungs 90 mins

Maximum COLD Ischaemia time:
- Heart = 4 hrs
- Lungs = 6-8hrs
- Liver/Pancreas = 12hrs (DBD)/6 hrs (DCD)
- Kidneys = 18hrs (DBD)/ 12 hrs (DCD)

Question 31

Q

20.2 A 25 year old ASA 1 patient develops ongoing seizures 5 minutes after receiving a brachial plexus block with ropivacaine. Of the following, the most suitable initial intravenous treatment is

a) Midazolam
b) Intralipid
c) Propofol
d) Levetiracetam
e) Phenytoin

Question 32

Q

20.2 Hepcidin production is inhibited in response to

Question 33

Q

20.2 Compared to a normothermic patient, a patient with mild intraoperative hypothermia (35.0 oC) will have

a) More bleeding with normal INR and APTT
b) more bleeding with normal INR and raised APTT
c) More bleeding with raised INR and normal APTT
d) Unchanged bleeding and normal INR and APTT
e) Unchanged bleeding and elevated INR and APTT

Question 34

Q

20.2 Following a severe spinal cord injury, return of reflexes is usually seen after

Question 35

Q

20.2 Abuse of nitrous oxide may lead to

Question 36

Q

20.2 When using ‘Level 1 Fast Flow Fluid Warmer’ rapid fluid infuser system, of the following the device that delivers the greatest flow is a (list of intravascular cannulae)

Question 37

Q

20.2 The changes in oximetry seen after intravenous injection of indocyanine green are

Question 38

Q

20.2 A patient has prolonged surgery with a laryngeal mask airway. The following day she reports a
problem with her tongue. You examine her and see the following when she protrudes her tongue. The
most likely cause of the abnormality is (picture of a person’s face shown)

Question 39

Q

20.2 The therapy most likely to decrease mortality in neonates with congenital diaphragmatic hernia is

a) Lung protective ventilation
b) HFOV
c) Early surgical intervention - within 6 hours
d) Nitric oxide
e) thoracoscopic vs open approach?

Answer

A

BJA Education Article - Anaesthetic management of patients with a congenital diaphragmatic hernia
https://www.bjaed.org/article/S2058-5349(18)30013-1/fulltext

Question 40

Q

20.2 A 25 year old man suffers a 30% total body surface area burn. A cardiovascular physiological change expected within the first 24 hours is

Question 41

Q

20.2 Methylene blue may be used in the treatment of all of the following conditions EXCEPT

Question 42

Q

20.2 The substance that should be avoided in a patient with history of anaphylaxis to MMR vaccine is

Question 43

Q

20.2 An open Ivor-Lewis oesophagectomy is performed via a

a Laparotomy then left thoracotomy
b Laparotomy, left neck incision
c Laparotomy, Right thoracotomy
d Left thoracotomy, left neck incision
d Right thoracotomy, Laparotomy

Answer

A

c Laparotomy, Right thoracotomy

Ivor-Lewis transthoracic esophagectomy — The Ivor-Lewis transthoracic esophagectomy can be used to resect cancers in the lower third of the esophagus but is not the optimal approach for cancers located in the middle third because of the limited proximal margin that can be achieved. This procedure combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy. We prefer a minimally invasive Ivor-Lewis approach to a thoracotomy.

Transhiatal esophagectomy — A transhiatal esophagectomy (THE) can be performed to resect cervical, thoracic, and esophagogastric junction (EGJ) esophageal cancers; it is performed through an upper midline laparotomy incision and a left neck incision, typically without a thoracotomy.

Modified Ivor-Lewis transthoracic esophagectomy (left thoracoabdominal esophagogastrectomy) — A modification of the Ivor-Lewis transthoracic esophagectomy includes a left thoracoabdominal incision with a gastric pull-up and an esophagogastric anastomosis in the left chest. This approach is most useful for tumors involving the gastroesophageal junction. Only one incision is required, but disadvantages include a high incidence of complications such as postoperative reflux and limitation of the proximal esophageal margin by the aortic arch.

Tri-incisional esophagectomy — The tri-incisional esophagectomy combines the transhiatal and transthoracic approaches into a transthoracic total esophagectomy with a thoracic lymphadenectomy and cervical esophagogastric anastomosis. The three-incisional technique allows the surgeon to perform a complete two-field (mediastinal and upper abdominal) lymphadenectomy under direct vision and a cervical esophagogastric anastomosis. We prefer a thorascopic approach to the chest rather than a thoracotomy to minimize the risk of respiratory complications.

Esophagectomy is a technically difficult operation, and the complication rate is high due to the anatomic challenges of the procedure.

The choice of surgical approach depends upon many factors, including:
●Tumor location, length, submucosal extension, and adherence to surrounding structures
●The type or extent of lymphadenectomy desired
●The conduit to be used to restore gastrointestinal continuity
●Postoperative bile reflux
●The preference of the surgeon

Question 44

Q

20.2 The recommended maximum cuff pressure for insufflating a classic Laryngeal Mask is

a 15 cm H20
b 30 cm H20
c 40 cm H20
d 60cm H2O

Answer

A

d 60cm H2O

Question 45

Q

20.2 Of the following, the LEAST appropriate treatment in the management of severe acute respiratory distress syndrome (ARDS) is

Question 46

Q

20.2 The equipment shown in the picture is a(n) (picture of an airway device shown)

Answer

A

Arndt bronchial blocker
- use with SLT
- 9fr, loop around scope for positioning
- suction to deflate lung

Question 47

Q

20.2 International guidelines state that patients presenting for major surgery have inadequate or low iron stores if their serum ferritin level is less than

a. 20 mcg/L
b. 30 mcg/L
c. 40 mcg/L
d. 50 mcg/L
e. 100 mcg/L

Answer

A

b. 30 mcg/L

Question 48

Q

20.2 You are called to assist in the resuscitation of a 75-year-old female patient in the emergency department who is hypotensive and hypoxaemic in extremis. The image shown is of a focused transthoracic echocardiogram, parasternal short axis view. The most likely diagnosis is

a) Pulmonary embolism
b) Anterior MI
c) Cardiac tamponade
d) Pneumothorax

Answer

A

a) Pulmonary embolism

A bit about the RV in PE:

The right ventricle drapes around the LV. In response to an acute Pulmonary Embolus (PE) it first dilates. The RV can’t generate much force without training, sowhen the Pulmonary Vascular Resistance (PVR) first rises with a PE, thepulmonary arterypressures don’t actually rise substantially because the RV can’t generate largepressures.

Looking at the ventricle in short axis, the septum maybow towardstheLV which will form aD shape indiastole,producing a“volumeoverloaded right ventricle” appearance.

Only later whenthe RV has beentrainedwill it be able togenerate higher pressures. If the LV is D shaped insystole, this is a “pressureoverloaded right ventricle”.

Acute cor pulmonale with bothpressureANDvolumeoverload (D shape insystoleANDdiastole)is often absent.

Question 49

Q

20.2 The Brain Trauma Foundation guideline for management of severe head trauma recommend the treatment of intracranial pressures greater than

Question 50

Q

20.2 You are part of an international humanitarian aid mission. You have packed sevoflurane but the only local vaporiser is isoflurane specific with a maximum output of 5%. If you added sevoflurane to the isoflurane vaporiser the maximum sevoflurane output percentage would be approximately (Sevoflurane saturated vapour pressure 160mmHg, isoflurane 240mmHg)

a. 2
b. 3
c. 5
d. 7
e. 9

Answer

A

Answer: 3%.

Principle:
If Vaporizer specific for agent with low SVP (Enflurane or Sevoflurane) is misplaced with an agent that has high SVP (halothane or isoflurane) then actual output concentration will be greater than the concentration indicated by dial. (inverse is also true)

Administration of sevoflurane using other agent-specific vaporizers:

The current study investigated the concentration of sevoflurane that could be achieved when sevoflurane was administered using standard agent-specific halothane, isoflurane, and enflurane vaporizers. An artificial lung analog model was made by attaching the 3-L reservoir bag to the 15-mm end of the anesthesia circle system. The lung analog was attached and ventilated with oxygen and air at flow rates of 2 L/min each (total gas flow = 4 L/min), a tidal volume of 800 mL, a rate of 10 breaths/min, and an inspiratory-to-expiratory ratio of 1:2. The vaporizer was filled with sevoflurane and the dial turned to 1%. After a 10-minute equilibration period, the concentration of sevoflurane was measured. The vaporizer concentration was increased in 1% increments, and after a 10-minute equilibration, the sevoflurane concentration was recorded. The dial was increased from 1% to 5% for the halothane and isoflurane vaporizer and from 1% to 7% for the enflurane vaporizer. Each study was repeated five times at each incremental increase of 1% for each of the three vaporizers. The series of studies were repeated using a total gas flow of 8 L/min (oxygen 4 and air 4) instead of 4 L/min (oxygen 2 and air 2). Using the halothane or isoflurane vaporizers at the 5% setting, the maximum sevoflurane concentrations achieved were 3.0% and 3.1%, respectively. The sevoflurane concentration was a maximum of 6% using the enflurane vaporizer set at 7%. The sevoflurane concentration decreased significantly when using any of the three vaporizers at all concentrations when the gas flow was increased from 4 to 8 L/min. The current study demonstrates that clinically useful concentrations of sevoflurane can be achieved with the administration of sevoflurane through an enflurane vaporizer. Although this is not routinely recommended, in specific circumstances it may allow the use of sevoflurane in third-world countries if sevoflurane vaporizers are not available and the use of sevoflurane is clinically necessary.

Question 51

Q

20.2 A Jehovah’s Witness patient attends for a revision total hip replacement and is medically optimized. You consider she is high risk for the procedure but after extensive discussion agree to proceed, including agreeing that you will not give blood under any circumstances. Your decision can be justified on the basis of

a) Paternalism
b) Non maleficence
c) Autonomy
d) Beneficence

Answer

A

a) Autonomy
- Obligation to respect the decision-making capacities of persons.

Non-maleficence: Obligation to avoid causing harm
- If refused to proceed.

Paternalism: A set of attitudes and practices in which the health provider determines that a patient’s wishes or choices should not be honored.
- If transfused patient against their wishes

Beneficence: Obligation to provide benefits and to balance benefits against risks; obligation of physician to act for the benefit of the patient
- Controversial interpretation in this case. Both proceeding and refusing to do case may be acting for the benefit of the patient, depending on how you look at the scenario.

BJA: ‘MORAL balance’ decision-making in critical care
https://www.bjaed.org/article/S2058-5349(18)30145-8/fulltext

Question 52

Q

20.2 A 35-year-old male, three days post laparoscopic sleeve gastrectomy has ongoing nausea and vomiting. His arterial blood gas measurement is as follows: (ABG shown) The best initial therapeutic option would be

Question 53

Q

20.2 The nerve(s) that need to be blocked with local anaesthetic to achieve complete anaesthesia for amputation of the fifth toe is/are

a) Posterior tibial and sural
b) Posterior tibial and superficial peroneal
c) Sural and superficial peroneal
d) Deep and superficial peroneal
e) Sural, deep peroneal, and posterior tibial

Answer

A

b) Posterior tibial + superficial peroneal

Question 54

Q

20.2 A patient has numbness and weakness in her hand post operatively. You are trying to distinguish between an ulnar nerve lesion and a C8 / T1 radiculopathy. You can diagnose a C8 / T1 radiculopathy if she has weakness

Question 55

Q

20.2 You are asked to review a patient who underwent upper limb surgery. During the procedure the anaesthetist placed a nerve block. The patient has weakness on external shoulder rotation and atrophy of supraspinatus and infraspinatus muscles. The nerve most likely to have been injured is the

a) Axillary
b) Supraclavicular
c) Subscapular
d) Suprascapular
e) Long thoracic
f) Spinal accessory

Answer

A

d) Suprascapular

Suprascapula nerve (C5,6)
- innervates supra and infraspinatus
- comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block
- sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ

Supraclavicular nerve (C3,4)
- provides sensory to the ‘cape’ of the shoulder
- component of the cervical plexus block
- lies outside the brachial plexus
- commonly missed during supraclavicular brachial plexus blocks

Subscapular nerve:
- subscapularis
- medial rotation shoulder

Dorsal scapular nerve:
- branch of the brachial plexus
- supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle
- causes the scapula to be moved medially towards the vertebral column
- Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion

Thoracodorsal nerve:
- thoracodorsal nerve also branches from the posterior division of the brachial plexus
- this nerve innervates the latissimus dorsi muscle.

Question 56

Q

20.2 The muscle or muscle group with the greatest sensitivity to the action of non-depolarising neuromuscular blocking agents is the

a) Abdominal muscles
b) Adductor pollicus
c) Pharyngeal muscles
d) Diaphragm
e) Obbicularis occuli

Answer

A

c) Pharyngeal muscles

BJA: monitoring neuromuscular blockade

onset and offset of block is faster in central muscles with good blood supply e.g. diaphragm and larynx
peripheral muscles with relatively poor blood supply will have slower onset and a longer recovery time e.g. adductor pollicis
muscles of the upper airway and pharynx behave as central muscles at onset however they are sensitive to NMBD and recovery is slow, mirroring peripheral muscles

Induction of anaesthesia:
> Orbicularis oculi ideal muscle to monitor at this time as it is more similar to a central muscle: onset is similar to diaphragm and larynx
> single twitch or TOF is the most valuable stimulation pattern

Maintenance anaesthesia
> as diaphragm is relatively resistant, a more sensitive peripheral muscle such as adductor pollicis may not adequately reflect the degree of block required, a central muscle such as orbicularis oculi will reflect the diaphragm more closely

Reversal and recovery:
> a peripheral muscle such as adductor pollicis is the best option as resp muscles are likely to haverecovered to a greater degree, and peripheral monitoring provides a larger margin of safety

Question 57

Q

20.2 A patient with a history of paroxysmal atrial fibrillation and chronic obstructive airway disease, treated with digoxin 125mcg, salbutamol and salmeterol, develops a wheeze intraoperatively which responds to salbutamol via the endotracheal tube. The patient then develops rapid atrial fibrillation with a rate of 120 bpm, a BP of 90/60 and an ETCO2 of 40mmHg. The next most suitable treatment option is

Question 58

Q

20.2 CYP2D6 variability has NO effect on the metabolism of

Question 59

Q

20.2 The minimum macroshock current required to elicit ventricular fibrillation is

Question 60

Q

20.2 A patient undergoing robotic prostatectomy, with controlled mandatory volume ventilation, has the following measurements: plateau pressure 32 cmH2O, PEEP 8 cmH2O, autoPEEP 4 cmH2O, peak pressure 38 cmH2O, tidal volume 600mL The static compliance is

Question 61

Q

20.2 In the POISE study the use of beta blockers on the day of surgery as a cardio protective strategy in high risk patients has been associated with

a) Increased heart rate
b) Decreased hypotension
c) Increased mortality
d) Increased myocardial infarction

Answer

A

c) Increased mortality

Use of perioperative metoprolol was associated with:
* Decreased rate of myocardial infarction
* Decreased rate of revascularisation
* Decreased rate of developing new atrial fibrillation
* INCREASED rate of death
* INCREASED rate of stroke
* INCREASED rate of significant hypotension
INCREASED rate of significant bradycardia

Question 62

Q

20.2 The currently recommended antiseptic solution for skin preparation use before neuraxial blockade is

Question 63

Q

20.2 Elimination of remifentanil occurs following breakdown mainly by

a Plasma cholinesterase
b RBC esterases
c Hoffman degradation
d Hepatic Metabolism
e Plasma esterases

Answer

A

e Plasma esterases

Plasma esterases (not cholinesterase)

Esmolol metabolism is via RBC esterases.

Question 64

Q

20.2 A 69 year old woman has a right heart catheter for investigation of recent onset dyspnoea below. Her pulmonary capillary wedge pressure is 10mmHg. The most likely diagnosis is

Answer 27

A

c) Medial cord

Answer 28

A

b) Lateral cord

Answer 29

A

a) Posterior Cord

Answer 30

A

d) ECG

ECG – have AVAILABLE for every anaesthetised patient. Should be used for patients undergoing general and major regional anaesthesia AS CLINICALLY INDICATED.

Oxygen analyser – continuous operation for every patient when anaesthesia breathing system in use.

Pulse oximeter – use for every patient undergoing general anaesthesia or sedation.

Carbon dioxide monitor – use for every patient undergoing general anaesthesia, and have immediately available for sedation cases.

ET Volatile – should be in use for every patient undergoing general anaesthesia from an anaesthesia delivery system where inhalational anaesthetic agents are delivered.

Answer 31

A

Warfarin – no effect on thrombin time
Heparin - causes considerable prolongation of TT.

LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa. However LMWH in very high concentration can affect TT.

Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably.

The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.

Answer 32

A

c) Lower airway obstruction

Peripheral or lower airways obstruction: expiratory limb demonstrates concave upward, also called “scooped-out” or “coved” pattern.

Answer 33

A

d) Fixed upper Airway obstruction

Fixed upper airway obstruction (can be intrathoracic or extrathoracic): flow limitation and flattening are noted in both the inspiratory and expiratory limbs of the flow-volume loop.

Answer 34

A

a) Variable intra-thoracic obstruction

Dynamic (or variable, nonfixed) intrathoracic obstruction: flow limitation and flattening are noted on the expiratory limb of the loop.

Answer 35

A

e) Normal

Normal flow-volume loop: the expiratory portion of the flow-volume curve is characterized by a rapid rise to the peak flow rate, followed by a nearly linear fall in flow. The inspiratory curve is a relatively symmetrical, saddle-shaped curve.

Answer 36

A

Repeat

d) Sarcoidosis

Normal FEV1/FVC ratio = no obstruction
Low FVC = restrictive pattern
Low DLCO = interstitial lung disease

Asthma and emphysema would have obstructive pattern.
Myasthenia gravis would have normal DLCO
Pulmonary HTN would have normal spirometry and low DLCO.

Answer 37

A

d) Encephalitis

Complications of dural puncture include:
1. PDPH
2. hearing loss
3. pneumocephalus (if LOR to air)
4. chronic headache
5. chronic back pain
6. subdural haematoma
7. cerebral vein thrombosis
8. bacterial meningitis
9. diplopia
10. cranial nerve palsy
11. seizures

Answer 38

A

e) Left lingula

LEFT LUNG: ASIA ALPS
Apical Posterior
Superior lingula
Inferior lingula
Anterior

Anterior basal
Lateral basal
Posterior basal
Superior

RIGHT LUNG: A PALM Seed Makes Another little Palm

RUL:
Apical
Posterior
Anterior

RML:
Lateral
Medial

RLL
Superior
Medial basal
Anterior basal
Lateral basal
Posterior basal

Answer 39

A

Sartorius

Answer 40

A

Vastus Medialis

Answer 41

A

Adductor Magnus

Answer 42

A

e) Maintain SBP 140-180

Tight control of BP, preferentially with IABP
> goal of >140/90 mmHg and <180/105 mmHg.
Oxygen supplementation to maintain SpO2 >92%.
Maintenance of eucapnia to avoid cerebral vasoconstriction
> (ETCO2 35- 45 mmHg)
Temperature maintained 35-37c
Euglycaemia (BGL 70-140 mg/dL (4-8 mmol/L)) and hourly monitoring

Answer 43

A

Chemosis is NOT a sign of arterial retrobulbar haemorrhage

Signs of arterial retrobulbar haemorrhage:
1. Sudden onset proptosis
2. Raised IOP
3. Reduced acuity.

Answer 44

A

c) 1000 ml/hr

4ml/kg/hr x 30%TBSA x 100kg = 12,000mL

1/2 within the first 8hrs, remainder over the next 16 hours (starting at 6 hour mark in this stem so beware)

6,000mL/6hrs = 1000 mL/hr which is the rate you would run it over the next 6 hours.

Answer 45

A

b) Propofol

BJA: No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut

“No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered.”

Answer 46

A

c) Dabigatran

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran

Dabigatran bleeding may be treated with:
- idarucizumab
- haemodialysis
- TXA will decrease fibrinolysis and has some effect
- FFP also has some effect

Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding
- 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration)
- Limited data support administration of an additional 5 g

Dosage Modifications

Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required
Hepatic impairment: Not studied
Dosing Considerations

This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 47

A

Nitrous oxide

Halothane & isoflurane cause catalytic destruction of ozone, but halothane hardly used and isoflurane has short atmospheric lifetime.

Desflurane + sevoflurane don’t cause ozone depletion.

Answer 48

A

Answer: a) Codeine
TGA Pregnancy categories https://www.tga.gov.au/prescribing-medicines-pregnancy-database

Category A
■ Codeine
Category C
■ Methadone
■ Tramadol
■ Oxycodone
■ Morphine

Answer 49

A

C. Opioids

A. Non-depolarising muscle relaxants - false - NMBDs abolish MEPs
B. Nitrous oxide - false - N2O can completely abolish MEPs
D. Propofol - false - PPF has less of an effect than volatiles, but still affects MEPs
E. Volatiles - false - volatiles are the most likely

NMBDs > volatiles > N2O > PPF > opioids

https://www.uptodate.com/contents/anesthesia-for-elective-spine-surgery-in-adults
While neurologic injury can cause changes in recorded potentials, other factors can interfere with interpretation. Confounding factors that can occur during surgery include inhalational anesthetics, hypothermia, hypotension, hypoxia, anemia, and preexisting neurologic lesions. Inhaled anesthetics such as isoflurane, sevoflurane, and nitrous oxide can reduce the amplitude and prolong the latency of SSEP and can completely abolish MEP. Neuromuscular blocking agents (NMBAs) also abolish motor evoked potentials and cannot be used when monitoring. Intravenous anesthetics such as propofol, barbiturates, and opioids have less of an effect on monitoring, though very deep anesthesia, even with propofol, can affect waveforms.

https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia
Evoked potentials — Evoked potential monitoring is used to assess the integrity of the tested neural pathway. Somatosensory, visual, and brainstem auditory evoked potentials monitor neurologic structures between peripheral sites where specific stimulations are applied, and responses are recorded from central locations. Motor evoked potentials monitor such structures by stimulating the motor cortex and recording from the epidural space (D-wave) or, more commonly, from distal muscles. Changes in evoked responses can result from technical, positional, pharmacologic, physiologic, or surgical causes.

For spine surgery, both MEPs and SSEPs are used to monitor spinal cord function to increase sensitivity. Motor and sensory tracts are anatomically distinct and have different vascular supply in areas of the cortex, brainstem, and spinal cord.

Motor evoked potentials (MEPs) – MEP responses are affected by even very low concentrations of volatile anesthetic agents. In general, total intravenous anesthesia (TIVA) facilitates MEP monitoring. However, inhalation agents at 0.5 MAC or less can be used in many patients, especially during intracranial surgery

Opioids – IV opioids cause small, dose-dependent depression of SSEP and MEP responses, though even at very high doses of opioids, evoked potentials can be recorded [76-78]. Infusions of remifentanil, fentanyl, or sufentanil are commonly used as part of TIVA during neuromonitoring. Opioids tend to produce high-amplitude slow waves in the EEG.

Balanced anesthetic approach — When SSEPs and MEPs are monitored, a balanced anesthetic using both a low-dose inhalation anesthetic (up to 0.5-MAC isoflurane, sevoflurane, or desflurane) and low- to medium-dose propofol (eg, propofol, 40 to 75 mcg/kg/min IV) with a relatively high-dose opioid (eg, remifentanil 0.1 to 0.4 mcg/kg/min) offers several advantages:

●Movement with motor stimulation is reduced, which is particularly important during intracranial aneurysm surgery.
●The addition of a 0.3 to 0.5 MAC inhalation agent may reduce the chance of awareness under anesthesia.
●Compared with TIVA, the addition of a 0.5 MAC inhalation agent allows reduction of the dose of propofol infusion, facilitating more rapid wakeup and earlier neurologic examination.
●Compared with TIVA, the chance of accidental interruption of the anesthetic for mechanical reasons (ie, kinked or infiltrated IV catheter or tubing such that IV agents no longer infuse) is reduced.

Answer 50

A

a) Lean body weight

FROM SOBA:

LBW exceeds IBW in obese and plateaus at ~100kg in men and ~70kg in females
IBW used to calculate the adjusted body weight for maintenance infusion of propofol (IBW +40%).
IBW calculated using Broca formula (Ht in cm - 100; Ht in cm =105; as optimal weights for men and women respectively in kg)

Answer 51

A

A. Not offering an epidural on a patient who is labouring spontaneously with a normal pregnancy and no comorbidities, upon request

Answer 52

A

Answer: a) Bernoulli equation using tricuspid peak + RAP
i.e. RVSP = 4v2 + RAP (~PAP in absence of RVOTO)

Answer 53

A

c) 420 ms
i.e. RR interval = 60 / HR; therefore RR interval is 60/60 = 1
420 / square root of 1 is 420ms

From LITFL:
The corrected QT interval (QTc) estimates the QT interval at a standard heart rate of 60 bpm
QT:
Time from the start of the Q wave to the end of the T wave
Represents time taken for ventricular depolarisation and repolarisation, effectively the period of ventricular systole from ventricular isovolumetric contraction to isovolumetric relaxation
The QT interval is inversely proportional to heart rate:
The QT interval shortens at faster heart rates
The QT interval lengthens at slower heart rates
An abnormally prolonged QT is associated with an increased risk of ventricular arrhythmias, especially Torsades de Pointes

Corrected QT interval (QTc)
The corrected QT interval (QTc) estimates the QT interval at a standard heart rate of 60 bpm
This allows comparison of QT values over time at different heart rates and improves detection of patients at increased risk of arrhythmias
Bazett formula: QTC = QT / √ RR

Note: The RR interval is given in seconds (RR interval = 60 / heart rate).

Answer 54

A

e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0

Answer 55

A

Answer: Hypocalcaemia
● AMH
○ Increased risk of adverse effects related to volume depletion(e.g. hypotension, fainting)
○ UTI

Answer 56

A

a) Greater auricular

Answer 57

A

repeat

c. 7

Answer 58

A

Repeat

c) Breast milk 3 hours, clear fluids 1 hour to max 3ml/kg

Infants <6 months having elective procedure
* 4 hours for formula
* 3 hours for breast milk
* 1 hour for clear fluids (≤3 ml/kg/hr)

Children > 6 months having elective procedure
* 6 hours for limited solid food or formula
* 4 hours for breast milk
* 1 hour for clear fluids (≤ 3ml/kg/hr)

Answer 59

A

Amitriptyline

By order of favourable NNT:

TCAs (amitriptyline) NNT: 3.6, NNH: 9
Strong opioids NNT 4.3 NNH 11.7
Tramadol NNT: 4.7, NNH 12.6
SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
Gabapentin NNT: 7.2 NNH 25.6
Pregabalin NNT:7.7, NNH 13.9

By order of favourable NNH:

Gabapentin NNT: 7.2 NNH 25.6
Pregabalin NNT:7.7, NNH 13.9
Tramadol NNT: 4.7, NNH 12.6
SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
Strong opioids NNT 4.3 NNH 11.7
TCAs (amitriptyline) NNT: 3.6, NNH: 9

ANZCA Pain book

Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:

First line: pregabalin, gabapentin and amitriptyline;
Second line: tramadol and lamotrigine (in incomplete SCI);
Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 60

A

Repeat

E. Pulmonary Stenosis

Answer 61

A

a) Ischaemic optic neuropathy

Postoperative visual loss (POVL) occurs in 1/60 000–1/125 000 operations. Spinal surgery has the highest incidence of POVL.

American Society of Anesthesiologists (ASA) Post Operative Visual Loss Registry, spinal surgery accounted for 93/131 (70%) of all cases of visual loss after non-ophthalmic surgery.
Of these:
> 83 were attributable to ischaemic optic atrophy (ION)
> 10 were caused by central retinal artery occlusion (CRAO).

CRAO
- caused by direct pressure on the globe causing raised intraocular pressure and compromising retinal perfusion.
- visual loss is usually unilateral and associated with other signs of pressure (e.g. ophthalmoplegia, ptosis, or altered sensation in the territory of the supraorbital nerve).
- Initial careful positioning of the head and regular checks throughout the procedure in case of movement minimizes the risk
- documentation of eye checks should occur every 30mins and horseshoe shaped head rests should be avoided in prone patients

ION
> associated with:
- male gender
- obesity
- increasing blood loss
- operative procedures >6 hrs in length.
- The use of the Wilson frame has also been implicated.
> final common pathway is thought to be hypoperfusion of the optic nerve, there is no clear association with either intraoperative systemic hypotension or with the presence of peripheral vascular disease or diabetes.
> recently updated ASA practice advisory for POVL associated with spinal surgery recommends regular intraoperative testing of haemoglobin concentration. However, it was unable to suggest a transfusion threshold that would prevent POVL.

Other possible causes of POVL:
1. Cortical ischaemia
2. Haemorrhage into a cerebral tumour.

In high-risk cases, assessment of vision should be performed as soon as possible in PACU and an early ophthalmic opinion sought if there is a suggestion of visual compromise.

Initial management
1. optimization of arterial pressure
2. oxygenation
3. correction of anaemia.

Treatment with agents such as acetazolamide has not been beneficial and there is rarely any useful improvement in vision with either injury, so attention should be focused on preventative measures:
1. Careful positioning with the head at the same level as the heart
2. Meticulous haemostasis,
3. Possibly staging prolonged procedures should be considered.

Because of the devastating nature of this complication, patients should be informed of an increased incidence of visual loss after spinal operations that are expected to be of prolonged duration and associated with significant blood loss.

Answer 62

A

b. Unstable angina

Not a Repeat, no Tropnin rise in this question making the answer unstable angina as opposed to NSTEMI

UTD:

Unstable angina (UA) and acute non-ST elevation myocardial infarction (NSTEMI) differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins):

●UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischemia (eg, ST segment depression or transient elevation or new T wave inversion).

●NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present.

MINS: Myocardial injury after non-cardiac surgery (up to 30 days post-op):
1. Elevated postop troponin
2. Resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), not requiring an ischaemic feature (i.e. no chest pain, no ECG change)

VISION studies (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) demonstrated that severity of MINS strongly associated with 30-day mortality after NCS.

hs-cTnT
<20ng/L ~ 0.5% 30 day mortality
20-64ng/L ~3% 30 day mortality
65-999 ng/L ~9% 30 day mortality
>1000ng/L ~30% 30 day mortality

Whilst VISION trial identified MINS in at risk patients, the question now becomes what interventions are available to prevent this complication?

Answer 63

A

c) LAD

LIFL: Myocardial Ischaemia
https://litfl.com/myocardial-ischaemia-ecg-library/

More Myocardial Ischaemia ECG Examples: Example 1

Subendocardial ischaemia:
The most striking abnormality is the widespread ST depression, seen in leads I, II and V5-6. This is consistent with widespread subendocardial ischaemia.
There is also some subtle ST elevation in V1-2 and aVR with small Q waves in V1-2, suggesting that the cause of the widespread ischaemia is a proximal LAD occlusion.

Answer 64

A

a. Bullying

Bullying is unreasonable behaviour that creates a risk to health and safety. It is behaviour that is repeated over time or occurs as part of a pattern of behaviour. “Unreasonable behaviour” is behaviour that a reasonable person, having regard to all the circumstances, would expect to victimise, humiliate, undermine or threaten the person to whom the behaviour is directed.

Direct bullying – behaviour that is overt and usually involves conduct directed at a person to belittle or demean them. Examples include:
> Aggressive and intimidating behaviour.
> Belittling, degrading or humiliating comments.
> Spreading misinformation or malicious rumours.
> Interfering with a person’s property or work equipment.
> Displaying offensive material (for example pornography).
Indirect bullying – behaviour that excludes or removes benefits from a person. Examples include:
> Assigning meaningless tasks unrelated to the job.
> Setting tasks that are unreasonably below or beyond a person’s skill level.
> Deliberately changing work rosters to inconvenience particular employees.
> Deliberately withholding information that is vital for effective work performance.

Harassment is any type of unwanted behaviour that offends, humiliates or intimidates a person, and targets them on the basis of a characteristic covered by anti-discrimination law, for example gender, race, ethnicity or disability, etc. In general, harassment is any behaviour that is:
Unwelcome, not asked for and not returned.
Likely to humiliate (put someone down), seriously embarrass, offend or intimidate (threaten or scare) someone.
Based on a personal characteristic (or family or friend’s characteristic) protected by law.
Discrimination means treating a person with an identified attribute or personal characteristic as set out in legislation less favourably than a person who does not have the attribute or personal characteristic.

> Gender.
Transgender, gender history and trans-sexual status.
Pregnancy and potential pregnancy.
Childbirth or breastfeeding.
Marital status.
Sexual orientation.
Lawful sexual activity.
Disability or impairment.
Race (including colour, nationality, descent and origin).
Physical features.
Age.
Carer status and family responsibilities.
Religious belief or activity.
Political belief or activity.
Trade union membership and industrial activity.
Associated with a person who is identified by reference to any of these attributes

Sexual Harassment
Sexual harassment is against the law. Sexual harassment is unwelcome sexual behaviour, which could be expected to make a person feel offended, humiliated or intimidated. It can be physical, verbal or written.

Victimisation
Victimisation is unlawful. Victimisation occurs when a person is treated unfairly due to that person having made a complaint of sexual harassment. Victimisation is behaviour that makes a person suffer a detriment including feeling uncomfortable, isolated, insecure or
intimidated.

https://www.anzca.edu.au/resources/corporate-documents/anzca-policy-on-bullying-discrimination-and-harass.pdf

Answer 65

A

Repeat

a. A+

Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B

[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies. 

Answer 66

A

b) Pulmonary odema

B-lines

> Vertical echogenic short path reverberation artefacts originating at the pleural line and extending to the deepest part of the ultrasound image.
They interrupt any horizontal A-lines.
Occasional B-lines are considered normal.
More than 3 B-lines in any single view is considered pathological.
Where there are numerous B-lines in close proximity they become confluent.
B-lines move with lung movement.
They are caused by ultrasound energy reverberating in a fluid filled focus that is surrounded by air. These foci may be interstitial or alveolar.
Cardiogenic and noncardiogenic oedema may have very similar appearances.
Interstitial thickening due to fibrosis or lymphangitis can also create the sonographic appearance of diffuse B-lines.

Answer 67

A

a) Normal lungs

Probe selection

Linear probe (8–12 MHz)

These high-frequency probes give good resolution of superficial structures. As the anterior pleura is relatively superficial, excellent images of the pleura and lung sliding can be obtained. The poor penetration of high-frequency US and the narrow sector width mean deeper structures are poorly imaged.
Curvilinear probe (3–5 MHz)

This is the best all-round probe for LU. Lung sliding can be easily visualized as can IS. Effusions, consolidated lung, and the diaphragm are also well imaged because of the good penetration and large sector width. The large footprint of the probe means some angulation is needed to avoid the ribs when scanning postero-laterally.
Phased array (3–4.5 MHz)

These probes have a useful footprint for getting in between the ribs. They can be used to demonstrate all the signs of LU but the clarity of the images is not as good.
General points

The clearest images are obtained by having the image as shallow as possible with the focus point at the level of interest. The frequency can be adjusted to enhance the image, depending on the depth. Increasing the frequency on a curvilinear probe will improve the appearance of lung sliding whilst worsening the appearance of a consolidated lung base.

Answer 68

A

a) Normal lungs

M-mode image demonstrating seashore sign seen with normal lung sliding.

Answer 69

A

e) Pneumonia

Signs of Pneumonia on lung ultrasound:
> Early Pneumonia
- B-lines and areas of sub pleural consolidation
- Fluid filled alveoli surrounded by air-filled lungs cause a short path reverberation anbd B-lines can be seen
- loalised patches of numerous nB-lines indicate sub-pleural consolidation

> Hepatization: solid appearing consolidated lung
- inflammatoy and ppurulent fluid filled alveoli makes the lung appear solid, with homogenous relatively fine echotexture similar to liver
- Atelectasis can also cause solid non-aerated lung and it can be difficult to distinguish the two conditions

> Shred sign: irregular consolidation/ air interface
- consolidated areas adjacent to aerated areas where the consolidated areas will be linear and well defined

> Air bronchograms and dnamic air bronchograms
- Air within consolidated area may remain in small aeratedpatches of lung or more commonly air remains within small bronchi, small airbubbles all lined up within a bronchus are known as sonographic air bronchograms
- when air bubbles are seen to bubble in and out with each breath the term “dynamic air bronchogram” is used

> Colour doppler interrogation: flow remains
- pulmonary arterial and venous vasculature are well demonstrated in areas of consolidation

Associated pleural effusion or empyema
- small hyperechoic parapneumonic effusion are frequently demonstrated
- echogenic debris within the effusion suggest empyema

Answer 70

A

Repeat

b. GA

Grade 1: moderate hypoxia (Spo2<94%) or hypotension [fall in systolic blood pressure (SBP) >20%].

Grade 2: severe hypoxia (Spo2<88%) or hypotension (fall in SBP >40%) or unexpected loss of consciousness.

Grade 3: cardiovascular collapse requiring CPR.

Patient Risk factors:
1. old age
2. poor pre-existing physical reserve
3. impaired cardiopulmonary function
-> NYHA 3 or 4
4. pre-existing pulmonary htn
5. Male Sex
6. Diuretics
7. ASA grade 3 or 4
8. osteoporosis
9. bony metastases
10. concomitant hip fractures (particularly pathological and intertrochanteric)
(latter due to abnormal vascular channels through which marrow contents can enter the circulation)

Surgical Risk factors
1. patients with previously un-instrumented femoral canal > revision surgery
2. Use of long-stem femoral component

Anaesthetic Risk reduction:
- discussion between surgeons and anaesthetists over uncemented vs. cemented based on patient Hx particularly if lon-stem prosthesis, femoral fracture or patients with cardiorespiratory disease
- no clear evidence regarding the impact of anaesthetic technique
- increase inspired O2 considered in all patients at time of cementation
- avoid intravascular volume depletion
- Higher level of haemodynamic monitoring in high risk patients

Factors NOT predictive of severe BCIS include:

Arteriosclerosis
Angina pectoris
Congestive heart failure
Beta-blockers
Angiotensin-converting enzyme inhibitors.

Answer 71

A

b) 4% albumin

SAFE study (2004) showed increased mortality at 24 months when albumin used as resuscitation fluid cf normal saline.
Also caused higher ICP at 1 week post injury.
4% albumin (274 mOsm/L & 266 mOsm/kg) is hypotonic and hypoosmolar.

Answer 72

A

c) 1:8000

Awareness rates
GA with no muscle relaxant = 1:136,000
GA with muscle relaxation = 1/8,000
CTS 1/8,600
E-LSCS = 1/670
Overall 1:19,000

Answer 73

A

Decreased SVR

Hyperthyroidism:
increases HR
increases cardiac contractility.
increases LVEF
increases diastolic relaxation
increases CO

SVR decreases
>T3 induces systemic vasodilation.

Answer 74

A

B. Initially decreases then normalises

Oral glucose tolerance test — The most specific dynamic test for establishing the diagnosis of acromegaly is an OGTT. When performing the test, we measure serum GH before and two hours after glucose administration; the criterion for the diagnosis of acromegaly is a GH concentration greater than 1 ng/mL. In normal subjects, serum GH concentrations fall to 1 ng/mL or less within two hours after ingestion of 75 g glucose. In contrast, the post-glucose values are greater than 2 ng/mL in over 85 percent of patients with acromegaly.

Following oral glucose administration in humans, a transient suppression of plasma GH levels for 2–3 h is observed followed by a delayed rise occurring at 3–5 h post glucose ingestion. This initial suppression seems to be related to a glucose-mediated increase in hypothalamic somatostatin release. Evidence supporting this hypothesis emerges from the findings that in healthy individuals, GH secretion in response to GHRH or GH secretagogue is diminished after an oral glucose loa]. Furthermore, the inhibitory effect of glucose is reversed with the acetylcholinesterase inhibitor pyridostigmine, a substance thought to suppress somatostatin release from the hypothalamus. These findings support the hypothesis that oral glucose load is associated with a somatostatin release into the hypophyseal portal blood suppressing GH levels. The delayed GH rise would result from a decrease in somatostatinergic tone and hence an increase in GHRH. Subsequently, the available pituitary stores of GH are released leading to a rebound rise in GH.

Answer 75

A

Raised ICP
*also associated with a difficult airway (Difficult BMV Ventilation)

Apert syndrome:
Autosomal dominant abnormality of first branchial arch causing premature closure of cranial sutures, midface hypoplasia, choanal atresia, cleft palate, fusion of cervical spine (mainly C5-C6) and syndactyly.

May have associated cardiac and renal abnormalities as well as intellectual impairment due to megalocephaly, hypoplasia of white matter and agenesis of the corpus callosum.

Obstructive sleep apnea is present in 50% and there may be an increased incidence of upper airway obstruction at induction, which is mostly overcome by routine maneuvers.

Classically, craniosynostosis release with fronto-orbital advancement is completed at 6 to 12 months of age if intracranial pressure (ICP) is normal [24-26]. However, elevated ICP may occur in up to 43 percent of cases. In this event, prompt surgical advancement and potentially ventriculoperitoneal shunt placement is required

Answer 76

A

a. Teicoplanin

Answer 77

A

c) Discharge from recovery

This score assesses five parameters:
1. level of activity
2. respiration
3. circulation
4. consciousness
5. Oxygen saturation

Each parameter is scored 0, 1, or 2, and patients scoring 9 or greater are eligible to be transferred from the high-dependency PACU to the ASU.

Limitations:
> It does not provide an assessment for home-readiness
> Does not address some of the common side effects seen in the PACU, such as: - pain
- nausea and vomiting
- bleeding at the incision site.

Answer 78

A

Repeat

a) Midazolam

Blue Book 2019

RLS Definition
-Common neurological sensorimotor disorder characterised by the urge to move ones legs
-It is associated with unpleasnat paraesthesias deep within the legs during periods of rest or inactivity, whihc are relieved by movement

Pathophysiology
> RLS can be primary (idiopathic) or secondary
> patients with secondary RLS develop symptoms secondary to another disease process or drug
> causes of 2ry RLS include Iron deficiency, pregnancy, kidney disease, rheumatic disease and medications
> 1ry RLS Pathophysiology is partially known and includes genteic component along with theories of dopamine and brain iron dysregulation

Anaesthetic implications
- RLS may worsen recur or present perioperatively
- Common triggers include sleep deprivation and immobilisation
- Drug therapy for RLS shopuld be continued perioperatively where possible
- interuptions to treatment should be for the shortest time possible to prevent rebound effects
- if imobilised for a long period of time, dopamine agonists such as rotigotone may be required
- premedication with benzodiazepines or pregabalin may be useful
- prolonged medical imaging procedures or procedures under local anaesthetic alone may not be possible.
- post-op agitation 2ry to akathisia may be misinterpretted as delerium and treated with dopamine antagonists such as haloperidol which will worsen symptoms, Benzodiazepines should be used instead.

Drugs that may exacerbate RLS
1. Classic neuroleptics
- Haloperidol, prochlorperazine, promethazine
2. Atypical antipsychotics
- clozapine, olanzapine, quetiapine
3. Antidepressants
- amitriptyline, citalopram, lithium
4. Antihistamines
- promethazine
5. Dopamine antagonist anti-emetics
- metoclopramide
6. opioids
- Tramadol (serotonin), naloxone/naltrexone (antagonists)

> Opioids, oxycodone, fentanyl, morphine etc generally have a beneficial effect

> IV anaesthetics, Inhalational anaesthetics, muscle relaxants, local anaesthetics, NSAIDs, Antiemetics have no effect

Goals:
1. Prevent RLS exacerbation
- avoid drug triggers
- premedicate with benzos
- use benzos for sedation
- continue treatment for RLS
- consider topical dopamine agonists when oral route unavailable

Alleviate post-op exacerbations
- use parenteral opioids
- Apomorphine
- mobilise patient ASAP
Alleviate long-term exacerbation of RLS after surgery
- monitor ferritin levels
- If ferritin level < 75mcg/ml treat with oral or IV iron replacement
- transiently increase dopamine agonist dose to TDS or QID if unable to leave bed

Answer 79

A

c) Embolic

Blue Book 2017
Perioperative Stroke

Epidemiology
A perioperative stroke is defined as one that occurs either intra-operatively or in the post-operative period within 30 days70. Perioperative strokes are associated with an increased length of stay and a six-fold increased mortality. Any combination of surgery and anaesthesia is associated with an increased risk of stroke irrespective of the type of surgery. This may relate to coagulation changes

The most common type of perioperative stroke is ischaemic stroke of embolic origin (heart or aorta). Hypotension is rarely the cause of perioperative stroke. Haemorrhagic stroke is uncommon which probably reflects the fact that severe hypertension during anaesthesia is a rare event, and anticoagulants have typically been withheld.

The risk of perioperative stroke varies depending on the type of the surgery and patients’ risk factors.

Procedural risk
Urgent surgery is associated with an increased risk of stroke when compared to elective surger.

Cardiac, vascular and brain surgeries are defined as “high-risk” as these have an increased risk of stroke when compared to other types of surgery. Valvular and aortic repair surgeries have a stroke risk as high as 8 to 10 per cent.

Perioperative strokes in non-high-risk surgery are relatively rare and are estimated to have an incidence of about 1/1000 cases80.

Patients’ risk factors
>Age
>history of previous stroke or transient ischaemic attack
>renal failure
>atrial fibrillation
>history of cardiovascular diseases
are identified risk factors for perioperative stroke.

Atrial fibrillation is associated with a two-fold increase in the risk of death and stroke after carotid endarterectomy.

Answer 80

A

d. Urine osmolarity <100

DIAGNOSTIC CRITERIA
>hypotonic hyponatraemia
>urine osmolality > plasma osmolality (<275mOsm/kg) (i.e. concentrated urine despite hypotonic blood)
>urinary Na+ > 20mmol/L
>normal renal, hepatic, cardiac, pituitary, adrenal and thyroid function
>euvolaemia (absence of hypotension, hypovolaemia, and oedema)
correction by water restriction

CAUSES (MAD CHOP)

Major Surgery
>abdominal
>thoracic
>transsphenoidal pituitary surgery (6-7 days post op)

ADH production by tumours (Ectopic)
>small cell bronchogenic carcinoma
>adenocarcinoma of pancreas/duodenum
>leukaemia
>lymphoma
>thymoma

Drugs
>antidepressants (e.g. SSRI, TCAs, MAOIs)
>psychotropics (e.g. haloperidol, chlorpromazine), carbamazepine, Na+ valproate)
>anaesthetic drugs (barbiturates, inhalational agents, oxytocin, opioids)
>ADH analogues (vasopressin, DDAVP)
>chemotherapy (e.g.Vinca alkaloids, Melphalan, Methotrexate and cyclophosphamide)
>others (e.g. NSAIDs, amiodarone, ciprofloxacin, morphine, MDMA, proton pump inhibitors)

CNS Disorders
>cerebral trauma
>brain tumour (primary or metastases)
>meningitis/encephalitis
>brain abscess
>SAH
>acute intermittent porphyria
>SLE

Hormone deficiency
>hypothyroidism
>adrenal insufficiency

Others
>Guillain-Barre Syndrome
>HIV infection (early symptomatic or AIDS)
>hereditary SIADH
>giant cell arteritis
>idiopathic (occult small cell or olfactory neuroblastoma)

Pulmonary Disorders
>pneumonia (viral, fungal, bacterial)
>TB
>lung abscess

MANAGEMENT
1. see hyponatraemia
2. fluid restrict
3. incremental increase in Na+ if indicated to avoid central pontine myelinolysis
4. medications to decrease ADH secretion
>Demeclocycline
>Tolvaptan / Conivaptan

Answer 81

A

Labetalol

RANZCOG
first line drugs are
> methyldopa
> labetalol
> oxprenolol.

Second line agents are:
- hydralazine
- nifedipine
- prazosin.

Acute Rx:
Labetalol: 20-40mg IV q10min
Nifedipine 10-20mg PO Q45min
Hydralazine 5-10mg IV q20min

Answer 82

A

C: 120ml/min

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO.

humeral flow rates were significantly faster using a pressure bag (153 mL/min) compared with humeral those achieved without pressure bag (84 mL/min)
tibial flow rates to be significantly faster using a pressure bag (165 mL/min) compared with those achieved without a pressure bag (73 mL/min)

Answer 83

A

a. 3

Snoring loudly
Tiredness during day time
Observed Apnoea
Pressure: Htn

BMI > 35
Age > 50
Neck circumference >40cm (43cms male)
Gender: Male

Answer 84

A

C. 3

if male CHA2DS2-VASc score ≥2 to be recommended chronic OAC (Grade 1A).
if female CHA2DS2-VASc score ≥3 to be recommended chronic OAC (Grade 1A).
non-sex risk factor also holds bearing:
For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A).

Up to date:

Our approach to deciding whether to prescribe anticoagulant therapy for patients with AF (excluding those with rheumatic mitral stenosis that is severe or clinically significant [mitral valve area ≤1.5 cm2], a bioprosthetic valve [surgical or bioprosthetic] within the first three to six months after implantation, or a mechanical heart valve) is as follows:

*For a CHA2DS2-VASc score ≥2 in males or ≥3 in females, we recommend chronic OAC (Grade 1A).

*For a CHA2DS2-VASc score of 1 in males and 2 in females:
-For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Age 65 to 74 years is a stronger risk factor than the other factors conferring one CHA2DS2-VASc score point.
-For patients with other risk factors, the decision to anticoagulate is based upon the specific nonsex risk factor and the burden of AF. For patients with very low burden of AF (eg, AF that is well documented as limited to an isolated episode that may have been due to a reversible cause such as recent surgery, heavy alcohol ingestion, or sleep deprivation), it may be reasonable to forgo chronic OAC and institute close surveillance for recurrent AF, although it may not be possible to reliably estimate AF burden from surveying symptoms or infrequent monitoring. The frequency and duration of AF episodes vary widely over time, and episodes are often asymptomatic.

*For patients with a CHA2DS2-VASc of 0 in males or 1 in females, we suggest against OAC (Grade 2C). Patient values and preferences may impact the decision. For example, a patient who is particularly stroke averse and is not at increased risk for bleeding may reasonably choose anticoagulation, particularly if the patient is a candidate for treatment with a direct oral anticoagulant (DOAC).

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline