21.2 Flashcards

Question 1

Q

21.2 A woman experiences a post-partum haemorrhage associated with uterine atony that is
unresponsive to oxytocin and ergometrine. The recommended intramuscular dose of
carboprost (15-methyl prostaglandin F2 alpha ) to be administered is

a) 250mcg IM once
b) 250mcg IM q15mins, up to 2mg
c) 500mcg IM
d) 250mcg IV
e) 500mcg IV

Answer

A

b) 250mcg IM q15mins, up to 2mg

15-methyl-PGF2α (carboprost; Prostinfenem) which may be administered in one of two ways:
Intra-muscular injection of 0.25mg, in repeated doses as required at intervals of not less than 15
minutes to a maximum total cumulative dose of 2.0mg (ie up to 8 doses)

Source RANZCOG PPH Guideline 2021

Question 2

Q

21.2 A 74-year old man in the post-anaesthesia care unit complains of chest pain. An
electrocardiogram (ECG) is performed. The occluded coronary artery is the

Answer

A

RCA (Inferior STEMI)
- 80% RCA
- 18% LCx
- 2% rare wrap around LAD

Source LITFL

Question 3

Q

21.2 Techniques to improve the speed of onset and spread of a peribulbar block include all of the
following EXCEPT

a) Honan balloon
b) Digital pressure
c) Ocular massage
d) Hyalase

Answer

A

c) Ocular massage

Hyalase
Mixing with lignocaine
Higher concentration
Higher volume
Occular pressure (spread and IOP reduction)

Source: 2x BJA Ed articles

Question 4

Q

21.2 An adult with renal failure on regular haemodialysis has an ASA (American Society of
Anesthesiologists) physical status classification of at least

a) 1
b) 2
c) 3
d) 4
e) 5

Answer

A

ASA 3

Source: ASA Classification
https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

Question 5

Q

21.2 A derived value from an arterial blood gas sample is

Answer

A

HCO3- is derived from pCO2 and pH
Base excess is derived from pH
SaO2 is derived from oxyHb and Hb

Source LITFL

Question 6

Q

21.2 A patient presents with a serum sodium of 110 mmol/L. A feature NOT consistent with a
diagnosis of syndrome of inappropriate antiduretic hormone (SIADH) is

a) Urine osmolality <100mOsm/kg
b) Euvolaemic state
c) Urine Na >40 mmol/L
d) Increased cortisol

Answer

A

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

Source LITFL

Question 7

Q

21.2 Identified risk factors for opioid-induced ventilatory impairment DO NOT include

a) Opiate use preoperatively
b) Male gender
c) Sleep disordered breathing
d) Obesity
e) Renal impairment

Answer

A

b) Male gender

Patient-related risk factors for OIVI are

older age,
female gender,
sleep disordered breathing (SDB),
obesity,
renal impairment,
pulmonary disease (in particular chronic obstructive pulmonary disease),
cardiac disease,
diabetes,
hypertension,
neurologic disease,
two or more comorbidities,
genetic variations in opioid metabolism,
and opioid-tolerant patients.

Modifiable risk factors include:
* Coadministration of sedatives (e.g. benzodiazepines, gabapentinoids, antipsychotics and sedating antihistamines)

Simultaneous use of multiple opioid agents (this does not include verified doses of opioids taken for management of chronic pain, where the patient has developed a tolerance to and physical dependence on these medications)
Continuous infusions of opioids
Initiation of long-acting opioid preparations (including methadone)
Multiple prescribers
Inadequate nursing assessments or responses
Reliance on unidimensional pain scores alone to assess adequacy of analgesia, and chasing’ pain scores – that is, titrating opioids to pain scores alone to reduce them to a predetermined acceptable number
Using opioids for pain that is not opioid-responsive

Source ANSCA PS 41

Question 8

Q

21.2 Risks associated with robot-assisted laparoscopic prostatectomy surgery in comparison with
open prostatectomy include all of the following EXCEPT

a) CO2 embolism
b) cerebral oedema
c) corneal burns
d) major haemorrhage

Answer

A

d) major haemorrhage
- blood loss is significantly less with RALP

Up to date: RALP

Question 9

Q

21.2 The most likely complication from ultrasound guided left internal jugular central venous line insertion is

a) Arterial puncture
b) Thoracic duct injury
c) Pneumothorax
d) Haematoma

Answer

A

a) Arterial puncture
- thoracic duct injury is a risk with left sided IJ CVC insertion, but it is a rarer complication.

Question 10

Q

21.2 Regarding healthcare research, the PICO framework describes

a) Critical appraisal
b) Meta-analysis
c) Observational study
d) Systematic review

Answer

A

a) Critical appraisal

PICO is a mnemonic used to describe the four elements of a good clinical foreground question:

P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine?

I = Intervention - What main intervention, prognostic factor or exposure am I considering?

C = Comparison - Is there an alternative to compare with the intervention?

O = Outcome - What do I hope to accomplish, measure, improve or affect?

Question 11

Q

21.2 The drug of choice for the treatment of duct dependent congenital heart disease is

a) Alprostadil
b) Prostacyclin
c) Carboprost
d) Sildenafil
e) NSAID

Answer

A

a) Alprostadil

Prostin (PGE1)

Question 12

Q

21.2 A patient has blunt chest trauma. A thoracotomy is indicated if the immediate blood drainage after closed thoracostomy is greater than

a) 500mL
b) 750mL
c) 1L
d) 1.2L
e) 1.5L

Answer

A

1,500 mL immediately

OR

200 mL/hr in the first 2-4 hours

Question 13

Q

21.2 A factor that is NOT used to calculate the Child-Pugh score is

a) Albumin
b) Bilirubin
c) INR
d) Creatinine
e) Ascites

Answer

A

d) Creatinine

Albumin
Bilirubin
COAG (INR/PT)

Ascites
Encephalopathy

Question 14

Q

21.2 The relatively slower onset of action of bupivacaine with adrenaline in brachial plexus anaesthesia compared to other local anaesthetics relates to

a) lipid solubility
b) pKa
c) protein binding
d) vasoconstriction

Answer

A

b) pKa

BJA: Basic pharmacology of local anaesthetics
https://www.bjaed.org/article/S2058-5349(19)30152-0/fulltext

Local anaesthetic agents are amphipathic molecules.

They bind primarily to sodium channels but also to potassium and calcium channels, and G-protein-coupled receptors.

Structural modifications alter the physicochemical characteristics of a local anaesthetic.

Speed of onset, potency, and duration depend on the pKa, lipid solubility and protein binding, respectively.

All local anaesthetic agents carry a risk of toxicity.

Question 15

Q

21.2 You administer a dose of intravenous indocyanine green to facilitate videoangiography during
cerebral aneurysm surgery. The changes in pulse oximetry (SpO2) and cerebral oxygen
tissue saturation (SctO2) you expect to see on your monitors are

Question 16

Q

21.2 The CRASH-2 trial showed tranexamic acid administration to trauma victims results in a
reduction in

a. Decreased mortality
b. Increased mortality
c. Decreased blood product use
d. No change mortality
e. Increased bleeding

Answer

A

Death in bleeding trauma patients

Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective.

Question 17

Q

21.2 An awake patient in the post-anaesthesia care unit complains of breathlessness. The FiO2 is 0.4 via a facemask. An arterial blood gas taken at the time shows PaO2 135 mmHg, PaCO2 48 mmHg, and SpO2 100% The alveolar-arterial gradient (in mmHg) is
approximately

a) 60
b) 90
c) 120
d) 150

Answer

A

b) 90

PAO2: 0.4 (760 - 47) - 48/0.8 = 285 - 60 = 225mmHg
225 - 135 = 90mmHg.

Question 18

Q

21.2 A 69-year-old woman has a recent onset of dyspnoea and undergoes a right heart
catheterisation, with results displayed below. Her pulmonary capillary wedge pressure is 10
mmHg. The most likely diagnosis is

Answer

A

Assuming pathology is pre-lung (normal PCWP).
? Pulmonary stenosis

Question 19

Q

21.2 A ten-year-old boy (weight 30 kg) has a displaced distal forearm fracture that requires
manipulation and application of plaster. The volume of 0.5% lidocaine (lignocaine) that should be used for intravenous regional anaesthesia (Bier block) is

Answer

A

18mL

Local anaesthetic for the block:
Dilute lidocaine (lignocaine) 1% with an equal quantity of normal saline to make a 0.5% solution
Lidocaine (lignocaine) dose: 3 mg/kg (0.6 mL/kg of 0.5%; max 200 mg or 40 mL)

Source RCH Melbourne Bier’s block guideline

Question 20

Q

21.2 A five-year-old child weighing 25 kg is to be strictly nil by mouth overnight following a
laparotomy. The most appropriate fluid prescription is

Question 21

Q

21.2 Of the following, the lifestyle modification that is least effective in reducing essential
hypertension is

a) Stopping caffeine
b) Low salt diet
c) High potassium diet
d) Exercise
e) Alcohol cessation

Answer

A

A) stopping caffeine as per UTD

Eat a well-balanced diet that’s low in salt
Limit alcohol
Enjoy regular physical activity
Manage stress
Maintain a healthy weight
Quit smoking

I’m not sure which is LEAST effective. I’d have to say managing stress?

Source AHA

Question 22

Q

21.2 Sensory innervation of the cornea is by the

Answer

A

REPEAT

Corneal sensory nerves originate from the ophthalmic division of the trigeminal ganglion [3], traveling in the nasociliary nerve and its long ciliary nerve branches, and ultimately branching into nerve fibers that penetrate the cornea.

Question 23

Q

21.2 A 25-year-old male has continued post operative bleeding after an extraction of an impacted third molar tooth under a general anaesthetic. The patient mentions that his father bruises quite easily. His coagulation screen reveals: (Coagulation tests provided). The most likely diagnosis is

His coagulation screen reveals: Prolonged APTT, Normal PT.

a) Factor V Leiden
b) Haemophilia A
c) Haemophilia B
d) Von willebrand disease

Answer

A

d) Von willebrand disease
- autosomal dominant inheritance
- may have normal or prolonged APTT, PT is normal

*Haem A: X-linked recessive disorder; would expect prolonged aPTT, and normal PT
*Haem B: X-linked recessive disorder; would expect normal aPTT and normal PT

Up to date:
Inheritance patterns — Most cases of VWD are transmitted as an autosomal dominant trait; this includes types 1 and 2B, and most types 2A and 2M.

Baseline hemostasis assessment —
Most patients will have a complete blood count (CBC) with platelet count and coagulation studies during the initial evaluation for excessive bleeding or bruising.
●Individuals with VWD generally have a normal CBC and a normal platelet count, with the exception of those with type 2B VWD, most of whom will have mild thrombocytopenia (eg, platelet count 100,000 to 140,000/microL).
●Individuals with VWD may have a normal or prolonged activated partial thromboplastin time (aPTT), depending on the degree of reduction of the factor VIII level. The prothrombin time (PT) is normal in VWD.

Up to date:
●Hemophilia A – Inherited deficiency of factor VIII (factor 8 [F8]); an X-linked recessive disorder.
●Hemophilia B – Inherited deficiency of factor IX (factor 9 [F9]); also called Christmas disease; an X-linked recessive disorder.

Laboratory findings —
Hemophilia is characterized by a prolonged activated partial thromboplastin time (aPTT).
However, the aPTT may be normal in individuals with milder factor deficiencies (eg, factor activity level >15 percent), especially in hemophilia B (factor IX deficiency), where even individuals with moderate disease may have a normal aPTT.
In some individuals with hemophilia A, factor VIII levels may increase with stress, leading to a normalization of the aPTT or mis-categorization of factor levels and disease severity.
In patients with hemophilia, the aPTT corrects in mixing studies, unless an inhibitor is present, which only applies to individuals who have received factor infusions or who have an autoantibody such as a lupus anticoagulant or an acquired factor inhibitor.
Mixing studies that do not show correction of a prolonged aPTT suggest an alternative diagnosis such as an acquired factor inhibitor.
The platelet count and prothrombin time (PT) are normal in hemophilia.
Thrombocytopenia and/or prolonged PT suggest another diagnosis instead of (or in addition to) hemophilia.
Measurement of the factor activity level (factor VIII in hemophilia A; factor IX in hemophilia B) shows a reduced level compared with controls (generally <40 percent).
One exception is an individual with mild hemophilia A who undergoes testing when stressed or pregnant and has a falsely elevated factor level. If this is suspected, factor activity testing should be repeated under conditions of low stress.
The plasma von Willebrand factor antigen (VWF:Ag) is normal in hemophilia.
If VWF:Ag is reduced, this suggests the possibility of von Willebrand disease (VWD) rather than (or in addition to) hemophilia.
Urinalysis is not done routinely, but if performed it may sometimes (but not always) show microscopic or macroscopic hematuria.

Question 24

Q

21.2 The condition in which volatile anaesthesia is least appropriate is

a) Multiple sclerosis
b) Myasthenia gravis
c) Lambert-Eaton syndrome
d) Guillain-Barre syndrome
e) Muscular dystrophy

Answer

A

e) Muscular dystrophy
- rhabdomyolysis risk if given to patients with Duchenne or Becker’s muscular dystrophy
- volatiles safe in all above, and also safe in patient’s with myotonic dystrophy

Malignant hyperthermia
- high mortality uncoupling regulation of RyR1 to SR
Duschenne muscular dystrophy
- fatal rhabdo (hyperkalaemia)

Question 25

Q

21.2 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
b) 30
c) 50
d) 100

Answer

A

ANSWER: b. Ferritin <30mcg/L

Serum ferritin level < 30 μg.l−1 is the most sensitive and specific test used for the identification of absolute iron deficiency. However, in the presence of inflammation (C-reactive protein > 5 mg.l−1) and/or transferrin saturation < 20%, a serum ferritin level < 100 μg.l−1 is indicative of iron deficiency.

International consensus statement on peri-operative management of anaemia and iron deficiency

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773#:~:text=Recommendations%20for%20best%20clinical%20practice,-Physicians%20should%20consider&text=Serum%20ferritin%20level%20%3C%2030%20%CE%BCg,serum%20ferritin%20level%20%3C%20100%20%CE%BCg.

Question 26

Q

21.2 Globe perforation during eye block is more common in myopic eyes because the

Question 27

Q

21.2 A drug which is likely to slow the heart rate in a patient with a heart transplant is

Answer

A

Adenosine (effect is exagerated)

Question 28

Q

21.2 A patient requiring an elective major joint replacement has had a recent stroke. The minimum recommended duration between the stroke and surgery is

Question 29

Q

21.2 High-risk transthoracic echocardiogram findings associated with aortic dissection include all of the following EXCEPT

a) RWMA
b) Pericardial effusion
c) Dilated aortic root
d) Aortic regurgitation
e) LV hypertrophy

Answer

A

ECHO FINDINGS

intimal flap

TYPING (type A):
aortic regurgitation (acute dilatation of the aortic root, aortic leaflet prolapse, dissection flap prolapse, pre-existing disease, e.g. bicuspid valve)

pericardial effusion and/or tamponade

regional wall motion abnormality heralding coronary artery occlusion

DOPPLER
identifies true and false lumen

detect aortic branch occlusion/ dissection (absent flow)

Source LITFL

Question 30

Q

21.2 You are involved in the care of a two-year-old child who ingested a button battery within the last 4 hours. You should consider giving

Answer

A

Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval

Source QCH guidelines

Question 31

Q

21.2 Stellate ganglion block is NOT contraindicated in patients with

a) Contralateral phrenic nerve palsy
b) Glaucoma
c) Recent MI
d) Arrhythmia

Answer

A

d) Arrhythmia
- caution if conduction disease however

Contraindications are current coagulopathy (or anticoagulated), recent myocardial infarction, pathologic bradycardia, and glaucoma.

Source Radiopaedia

Contralateral stellate ganglion/phrenic nerve block/neuropathy

Question 32

Q

21.2 A four-year-old boy with a history of waddling gait, larger than normal calves and frequent falls receives a spontaneously breathing volatile-based anaesthetic with sevoflurane. One hour into the case he develops peaked T waves and then the end-tidal CO2 begins to rise.
The most appropriate immediate treatment is to

Question 33

Q

21.2 A pregnant woman requires a caesarean section delivery within 30 minutes for fetal distress.
Her body mass index (BMI) is 26 kg/m2. She has multiple sclerosis with lesions in her brain
and spinal cord and receives monthly injections of the disease-modifying drug ofatumumab.
The most appropriate plan for her delivery is

a) Spinal
b) CSE
c) Epidural
d) GA

Answer

A

a) Spinal
Makarla

Epidural and vaginal delivery
? GA

all are safe in MS
The MAN I think is to signify advanced MS

(Really there isn’t heaps of evidence)

Source World Fed Anaesthetists

https://resources.wfsahq.org/wp-content/uploads/359_english.pdf

Question 34

Q

21.2 You are examining the precordium of a patient in the preadmission clinic and hear a fourth heart sound at the apex. This finding is consistent with

a) AR
b) Athlete
c) Normal
d) Hypertension

Answer

A

) Hypertension

Talley & O’Connor CVS Exam:
S3: Physiological in pregnancy; sign of LV failure; AR & MR
S4: Never physiological, most often due to systemic hypertension

Atrial gallop - stiff LV
- hypertrophy or ischaemic ventricle

Source CV phys

Question 35

Q

21.2 A patient with an acute subarachnoid haemorrhage arrives in the emergency department. Her
Glasgow Coma Scale is 10 and she has no motor deficit. A CT brain shows diffuse
subarachnoid haemorrhage with no localised areas of blood > 1mm thick, and no
intracerebral nor intraventricular blood. Her World Federation of Neurosurgical Societies
(WFNS) grade of subarachnoid haemorrhage is

a) 1
b) 2
c) 3
d) 4
e) 5

Answer

A

d) 4
- WFNS is 4
* alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%)

Question 36

Q

21.2 Non-anaesthetist practitioners wishing to provide procedural sedation should have training in sedation and/or anaesthesia for a minimum of

Question 37

Q

21.2 In a patient with tetraplegia who develops autonomic dysreflexia, the expected haemodynamic response is

a) hypertension from splanchnic vasoconstriction above the level of the lesion
b) hypertension from splanchnic vasoconstriction below the level of the lesion
c) hypotension from uncontrolled vagal tone above the level of the lesion
d) hypotension from reduced sympathetic tone below the level of the lesion

Answer

A

b) hypertension from splanchnic vasoconstriction below the level of the lesion

ADR:
- increased SNS below
- increased PSNS above

Hypertension (>25 mmHg increase)

> 40 mmHg increase or SBP > 150 is severe

Question 38

Q

21.2 The cardiac axis of this electrocardiogram is

a) -30
b) 0
c) 45
d) -90

Answer

A

Left Axis Deviation

LITFL

Question 39

Q

21.2 The most reliable clinical indicator of opioid-induced ventilatory impairment (OIVI) is
decreased

a) level of consciousness
b) RR
c) SpO2
d) Vt

Answer

A

In any patient who is given an opioid, oversedation should be considered to indicate OIVI until proven otherwise, regardless of a patient’s respiratory rate or oxygen saturation levels.

Source ANZCA PS 41

Question 40

Q

21.2 A patient presents for endovascular clot retrieval after experiencing a right hemisensory loss and right homonymous hemianopia. The vessel most likely occluded is the left

a) ACA
b) MCA
c) PCA
d) AICA
e) PICA

Question 41

Q

21.2 The function of the bottle labelled ‘D’ in the diagram below is to protect against the
consequences of

Answer

A

DERANGED PHYSIOLOGY: CHEST DRAIN

The four-chamber pleural drain system
The major change in this system is the addition of another underwater seal, this time disconnected from the wall suction and vented to the atmosphere.
The objective is to protect the patient from pneumothorax in the event of sudden suction failure.

Question 42

Q

21.2 A trainee becomes aware that a patient they have just anaesthetised for emergency surgery is breastfeeding and seeks your advice regarding recommencement of breast feeding. You advise that breast feeding is contraindicated because during the admission today the patient
received

a) Tramadol
b) Codeine
c) Ketamine
d) Midazolam

Answer

A

Codeine

Source Appendix ANZCA PG 07

Question 43

Q

21.2 A patient undergoing robotic prostatectomy with volume-controlled ventilation has the following ventilatory measurements: (Ventilator parameters given) The static compliance is

Question 44

Q

21.2 When performing cannulation of the median cubital vein the structure that is LEAST likely to be inadvertently punctured or damaged is the

a) Ulnar artery
b) Radial nerve
c) Median nerve
d) Brachial artery
e) Ulnar nerve

Question 45

Q

21.2 A 25-year-old ASA (American Society of Anesthesiologists) physical staus classification 1
patient develops seizures five minutes after receiving a brachial plexus block with
ropivacaine. Of the following, the most suitable initial intravenous treatment is

Question 46

Q

21.2 Complications of hyperbaric oxygen therapy include all of the following EXCEPT

a) Hypoglycaemia
b) Cataract
c) Worsening CCF
d) Seizures
e) Reversible hypermetropia

Answer

A

e) Reversible hypermetropia

Question 47

Q

21.2 Analysis of variance (ANOVA) is a statistical test to determine

a) comparisons of means between two groups in normally distributed data
b) comparisons of means between two groups in non-normally distributed data
c) comparisons of means between three groups (unpaired) in normally distributed data
d) comparisons of means between three groups (unpaired) in non-normally distributed data

Answer

A

c) comparisons of means between three groups in normally distributed data

ANOVA (analysis of variance): comparisons of means between more than two groups or between several measurements in the same group is called analysis of variance and is frequently cited by the acronym ANOVA

Question 48

Q

21.2 The oral morphine equivalent of tapentadol 50 mg (immediate release) is

a) 5mg
b) 10mg
c) 15mg
d) 20mg
e) 25mg

Answer

A

c) 15mg

Oral Tapentadol 25mg = 8mg Oral Morphine

Oral Oxycodone 5mg = 8mg Oral Morphine

Oral Tramadol 25mg = Oral Morphine 5mg

Oral Hydromorphone 4mg = Oral Morphine 20mg

S/L Buprenorphine 200mcg = 8mg Oral Morphine

IV Oxycodone 5mg = Oral Morphine 15mg

IV Morphine 5mg = Oral Morphine 15mg

IV Hydromorphone 1mg = Oral Morphine 15mg

Question 49

Q

21.2 Allergic cross-reactivity between penicillins and cephalosporins is mediated by the

a) R1 side chain
b) R2 side chain
c) Beta lactam ring
d) Imidazole group

Answer

A

a) R1 side chain

UP TO DATE:
- sensitisation to R1 side chain in cephalosporins important in determining cross reactivity with penicillins.

Question 50

Q

21.2 A 25-year-old man suffers a burn involving 30% of his total body surface area. A
cardiovascular physiological change expected within the first twenty-four hours is

Question 51

Q

21.2 Of the following, the incidence of venous air embolism is considered highest for (list of
surgical procedures given)

Question 52

Q

21.2 Intraoperative cell salvage is contraindicated in

a) LSCS
b) Revision of infected THR
c) Heparin allergy
d) Severe coagulopathy
e) Phaeochromocytoma

Answer

A

pheochromatoma

Question 53

Q

21.2 A 76 year old woman who is spontaneously breathing through a tracheostomy tube with an
inner cannula becomes acutely breathless. Despite application of high flow oxygen, her
respiratory rate is 40 breaths per minute and her SpO2 is 82%. The next most appropriate step in her airway management is to

a) Hand ventilate
b) Suction down the tracheostomy
c) Take down the cuff
d) Remove the inner cannula
e) Remove the tracheostomy

Answer

A

remove the inner cannula

The key principles of the algorithm are:
1.Waveform capnography has a prominent role at an early stage in emergency management.
2.Oxygenation of the patient is prioritised.
3.Trials of ventilation via a potentially displaced tracheostomy tube to assess patency are avoided.
4.Suction is only attempted after removing a potentially blocked inner tube.
5.Oxygen is applied to both potential airways.
6.Simple methods to oxygenate and ventilate via the stoma are described.
7.A blocked or displaced tracheostomy tube is removed as soon as this is established and not as a ‘last resort’

BJA: Update on management of tracheostomy
https://www.bjaed.org/article/S2058-5349(19)30125-8/fulltext

Question 54

Q

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

a) Albumin
b) Chloride
c) Phosphate
d) Bicarbonate

Answer

A

albumin

ALBUMIN AND PHOSPHATE
the normal anion gap depends on serum phosphate and serum albumin
the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L)
albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap.
every 1g/L decrease in albumin will decrease anion gap by 0.25 mmoles
a normally high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis.
this is particularly relevant in ICU patients where lower albumin levels are common
Effects of albumin:
Anion gap may be underesitmated in hypoalbuminaemia, because if albumin decreased by 1g/L then the anion gap decreases by 0.25 mmol
To overcome the effects of the hypoalbuminaemia on the AG, the corrected AG can be used which is AG + (0.25 X (40-albumin) expressed in g/L

Question 55

Q

21.2 Of the following drugs, the least likely to cause pulmonary vasodilation when used at low
doses in patients with chronic pulmonary hypertension is

a) Dopamine
b) Dobutamine
c) Vasopressin
d) Milrinone

Answer

A

dopamine

least likely to cause pulmonary vasodilation (all the others do to my knowledge)
From UP TO DATE:
> At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds
> At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate.
> At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min
*clinically, the haemodynamic effects of dopamine demonstrate individual variability

Dobutamine (inodilator):
- selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances

Vasopressin:
- vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect

Milrinone (inodilator):
- the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension

Question 56

Q

21.2 A 25-year-old woman is administered two doses of aprepitant for postoperative nausea and
vomiting after a sleeve gastrectomy. She normally takes the oral contraceptive pill. You
should advise her to use alternative contraception for the next

a) 3 days
b) 7 days
c) 14 days
d) 28 days

Answer

A

28 days

Aprepitant PI:
“Alternative or “back-up” measures of contraception should be used during treatment with this medicine and for one month following the last dose of this medicine.”

Pharmacokinetics:
- aprepitant is a CYP3A4 inhibitor
- caution is also advised with warfarin and phenytoin use

Question 57

Q

21.2 A patient who usually takes oral morphine 50 mg bd develops a bowel obstruction and
experiences withdrawal symptoms. They may be described as having

a) Tolerance
b) Physical dependence
c) Psychological dependence
d) Pseudo-addiction
e) Addiction

Answer

A

physical dependance

BARASH:
Physical dependence is a “physiologic state of adaptation to a specific psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance.”

Question 58

Q

21.2 The image below on the left shows a normal central venous pressure (CVP) trace. The CVP
trace in the image below on the right is most consistent with

a) AF
b) MR
c) AR
d) TR
e) Pericardial constriction

Question 59

Q

21.2 A 26-year-old man is brought into the Emergency Department four hours after an accidental
chemical exposure during crop spraying. His clinical signs include bradycardia, vomiting,
diarrhoea, coughing, miosis and weakness. A drug which is NOT recommended during his
resuscitation and treatment is

Question 60

Q

21.2 A new volatile agent is developed. The property it shares with sevoflurane that will enable it to
be used in a sevoflurane vapouriser and deliver an accurate concentration is its

a) Blood:gas partition coefficient
b) Oil:gas partition coefficient
c) Saturated vapour pressure
d) Boiling point

Question 61

Q

21.2 When performing a brachial plexus block at the level of the axilla, the structure indicated by
the arrow is the

Question 62

Q

21.2 The diffusing capacity of the lungs for carbon monoxide (DLCO) is likely to be decreased with

a) Sarcoidosis
b) Asthma
c) Obesity
d) Pulmonary haemorrhage

Question 63

Q

21.2 The use of erythropoietin before major surgery results in
a) Less transfusion, same thrombosis
b) Less transfusion, more thrombosis
c) No change in transfusion or thrombosis
d) No change in transfusion, more thrombosis

Answer

A

a) Less transfusion, same thrombosis

●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Question 64

Q

21.2 Predictors of successful awake extubation after volatile anaesthesia in infants include

Answer 47

A

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)

Answer 48

A

d) Gentamicin

Drugs in the anaesthetic trolley that may unmask or worsen MG:
- NMBs
- gentamicin
- beta blockers (metoprolol)
- magnesium

Anaesthetic drugs to be cautious with:
- dexamethasone
- antipsychotics
- anticonvulsants
- antibiotics (vancomycin, metronidazole)

Answer 49

A

strained broth

ANZCA PS07:
“Clear fluids are regarded as water, carbohydrate rich fluids, specifically developed for perioperative use, pulp free fruit juice, clear cordial, black tea and coffee. It excludes fluids containing particulate matter, soluble fibre, milk-based drinks and jelly”

Answer 50

A

c) Normothermia
- TTM to 32-36 degrees is recommended for those that remain unresponsive

Answer 51

A

photosensitivity

Gliolan (PI):

Aminolevulinic acid hydrochloride (ALA)
Natural precurore of haeme, metabolised into fluorescent prophyrins
The fluorescence in certain tissue targets for photodynamic diagnosis
Increased fluorescent porphyrin formation by malignant glioma tissue (i.e. GBM)
After excitation with blue light (λ=400‑410 nm), PPIX is strongly fluorescent (peak at λ=635 nm) and can be visualised after appropriate modifications to a standard neurosurgical microscope.
Avoid exposure of eyes and skin to light sources afterwards (photosensivity).

Contraindications:
- hypersensitivity
- porphyria
- pregnancy

Precautions:
- After administration of Gliolan, exposure of eyes and skin to strong light sources (e.g. operating illumination, direct sunlight or brightly focused indoor light) should be avoided for 24 hours.
- Co-administration with other potentially phototoxic substances (e.g. tetracyclines, sulfonamides, fluoroquinolones, hypericin extracts) should be avoided
- Within 24 hours after administration, other potentially hepatotoxic medicinal products should be avoided.
- In patients with pre-existing cardiovascular disease, Gliolan should be used with caution since literature reports have shown decreased systolic and diastolic blood pressures, pulmonary artery systolic and diastolic pressure as well as pulmonary vascular resistance.

Answer 52

A

cerebral oedema

Answer 53

A

resting tachycardia

Answer 54

A

1 hour

ASRA: 1 hour

Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.

Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.

NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Answer 55

A

a) Non-inferiority is not demonstrated

Possible outcomes in a non-inferiority trial.
In A (blue), non-inferiority is demonstrated.
In B (green), non-inferiority is not demonstrated, and the trial is inconclusive.
In C (red), the new treatment is inferior.

Answer 56

A

PCA

e) Posterior cerebral ischaemia

UTD: Postoperative visual loss after anaesthesia for nonocular surgery

Pupillary light reflexes*
Unilateral central retinal artery occlusion, ischemic optic neuropathy, and retrobulbar hematoma result in a poor or absent pupillary response to light (“direct” response) with a normal response when light is directed to the other pupil (“indirect” response); this “relative afferent pupillary defect” is revealed when tested with the swinging flashlight maneuver; if these processes are bilateral, there will be poor or absent direct pupillary responses and a relative afferent pupillary defect only if asymmetric.
Mid-dilated and nonreactive pupils are consistent with acute angle-closure glaucoma, while sluggish to fixed and dilated pupils are seen with glycine-induced visual loss.
Pupillary light reflexes are normal in cases of corneal abrasion, cerebral or cortical visual loss, and in cases of PRES. Examination of pupils is discussed more fully separately.

Answer 57

A

a) Vertebral
orange = vertebral
blue = basilar
purple = PCA
red arrows = AICA
yellow = pontine arteries

Circle of Willis:

Answer 58

A

c) Junctional rhythm

Up to date: Anaesthesia for elective eye surgery

Oculocardiac reflex manifestations —
Manifestations of the oculocardiac reflex commonly occur when pressure is applied to extraocular muscles.
These include bradycardia (a decrease of 10 to 20 percent in the basal heart rate), junctional rhythms, hypotension, and, rarely, asystole.
This reflex can occur during injection of local anesthesia or during the surgical procedure itself.
Management includes stopping the stimulus (eg, release of traction or manipulation of the extraocular muscles).
If this is ineffective, an anticholinergic medication (eg, atropine or glycopyrrolate) is administered.
The risk of inducing this reflex may be reduced by an effective regional anesthetic block or general anesthesia with adequate depth.

Answer 59

A

midazolam

Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms.

Perioperative treatment of symptoms
If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible.
If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day.
If oral intake is feasible, a patient’s usual oral medication may be given.
Levodopa (a dopamine agonist) may be administered by nasogastric tube.
Alternatively, parenteral apomorphine or a rotigotine patch may be used.
Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis.
Nausea is a common side effect so it may need to be given with an antiemetic.
Rotigotine patches may be used every 24 hours.
Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms.
Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.

Answer 60

A

a) No increased risk of surgical wound infection

Now, the Perioperative Administration of Dexamethasone and Infection Trial (PADDI), led by Professor Tomás Corcoran, Director of Research in the Department of Anaesthesia and Pain Medicine, Royal Perth Hospital has found that administering a low-dose of dexamethasone during anaesthesia for surgical operations does not increase the risk of surgical wound infections.

Answer 61

A

I:E ratio 1:3

Answer 62

A

Adductor canal

Answer 63

A

No answer provided. ?encephalitis
These are all complications of dural puncture.

Up to date: Post dural puncture headache

Answer 64

A

hypoxia

NYSORA: LAST

NYSORA Tips
There is a greater likelihood for LA systemic toxicity in petite patients (small muscle mass), those at the extremes of age, and patients with preexisting heart disease or carnitine deficiency.
Roughly half the cases of LAST are atypical, with no seizures (other CNS symptoms), only CV toxicity or delayed onset.
The incidence of toxicity increases with injections near richly vascular areas. It is highest with paravertebral injections, followed by upper and lower extremity PNBs.
Prevention of LAST-related morbidity requires optimizing a complete system for regional anesthesia: patient selection, nerve block choice, drug and dose, complete monitoring and use of USGRA when possible, and preparing for LAST by having a kit available and practicing with simulation.
Prevention also includes raising awareness and educating our non-anesthesiology colleagues about proper use of LAs and risks, including management of LAST.

Answer 65

A

CO2

Laser danger is proportional to penetration.
Penetration inversely proportional to the laser wavelength.

CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm.
Helium-Neon laser also has very little penetration.

Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm.

Answer 66

A

less bradycardia

Answer 67

A

pancreatic fistula

-> should cause NAGMA

HAGMA:
Lactate
Toxins
Ketones
Renal failure

NAGMA
Chloride
Addison’s, adrenal insuffiency, acetazolamide
GI loss (pancreatic fistula)
Extra: RTA

Anion gap:
- Anion Gap = Na+ – (Cl- + HCO3-)
- The Anion Gap (AG) is a derived variable primarily used for the evaluation of metabolic acidosis to determine the presence of unmeasured anions
- The normal anion gap is assumed to be 12, and the normal HCO3 is assumed to be 24

Delta ratio:
- can check delta ratio in the presence of a high anion gap metabolic acidosis (HAGMA) to determine if it is a ‘pure’ HAGMA or if there is coexistant normal anion gap metabolic acidosis (NAGMA) or metabolic alkalosis.

Answer 68

A

a) Bleeding

ECMO complications:
- patient complications: bleeding & coagulopathy most common
- mechanical complications: access insufficiency common

Blue book 2017

Answer 69

A

b) 4

Right lung:
RUL: APA
RML: LM
RLL: SMALP

Left lung:
LUL: ASIA (S&I form the lingular lobe)
LLL: ALPS

Subsegments (total of 42)
Left: 10 + 10
Right: 6 + 4 + 12

Answer 70

A

e) Decreased SVR
- increased CO, increased SBP and decreased DBP with widened PP

UP TO DATE: Cardiovascular effects of hyperthyroidism:

Thyroid hormone has important effects on cardiac muscle, the peripheral circulation, and the sympathetic nervous system that alter cardiovascular hemodynamics in a predictable way in patients with hyperthyroidism.
The main changes are :
●Increases in heart rate, cardiac contractility, systolic and mean pulmonary artery pressure, cardiac output, diastolic relaxation, and myocardial oxygen consumption
●Reductions in systemic vascular resistance and diastolic pressure

Answer 71

A

c) Lowest FiO2 possible

Bleomycin

Bleomycin is a particularly important chemotherapy drug for the anaesthetist to be aware of.
Bleomycin is often used to treat germ cell tumours and Hodgkin’s disease in a curative setting.
The major limitation of bleomycin therapy is the potential for subacute pulmonary damage that can progress to life-threatening pulmonary fibrosis.
Pulmonary toxicity occurs in 6–10% patients and can be fatal.
Exposure to high-inspired concentration oxygen therapy, even for short periods, as experienced during anaesthesia, is often implicated in causing rapidly progressive pulmonary toxicity in patients previously treated with bleomycin.
These claims have been considered controversial by some, but it is the authors’ recommendation that any patient previously exposed to bleomycin therapy should be treated as high risk, and summary guidance regarding oxygen therapy is shown:

Answer 72

A

b) Diaphragm

Answer 73

A

c) Cease clopidogrel for 5 days, continue aspirin
- prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis
- For clopidogrel, we stop five days before surgery
- Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting
- suggest that surgery be performed in centers with 24-hour interventional cardiology coverage

UP TO DATE: Noncardiac surgery after PCI

Nonemergency noncardiac surgery — For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we prefer to defer planned nonemergency, nonurgent noncardiac surgery until at least six months after stent implantation. The risks of noncardiac surgery before six months are increased after both BMS and DES.
For patients whose surgery requires cessation of one or both antiplatelet agents and cannot wait six months, and where the risks of delaying surgery outweigh the benefits, our recommended minimal duration of DAPT is four to six weeks, depending on the urgency of surgery and risk of thrombotic complication. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES. Although we prefer to wait at least six weeks when possible, in patients for whom earlier surgery is in their best interest after weighing risks and benefits, we sometimes refer patients as early as four weeks after stent placement.

The proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT and regardless of stent type during this early period after stenting. We believe this risk to be higher prior to the minimum duration of DAPT recommended above, but the final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and patient has taken place. In many cases, DAPT can be continued in the perioperative period, although for some surgeries, such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis.

In these patients who undergo noncardiac surgery before the recommended minimum duration of DAPT, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. The rationale to continue aspirin comes in part from the POISE-2 trial (PCI subgroup analysis), which is discussed separately. However, as many neurosurgical patients, for whom bleeding might be life threatening or lead to severe adverse outcomes, were not enrolled in POISE-2, the optimal strategy is not known.

●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy.
●With regard to stopping P2Y12 inhibitor prior to noncardiac surgery, we generally follow recommendations found in the manufacturer’s package insert for each drug.
- For clopidogrel, we stop five days before surgery; that is, the last dose is taken on the sixth day before surgery.
- For prasugrel, we stop seven days before surgery.
- For ticagrelor, we stop three to five days before surgery.
- Some experts are willing to recommend shorter discontinuation periods for procedures less likely to be associated with major bleeding.
●Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting.
●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage

Answer 74

A

a) Midazolam 0.15mg/kg

1st line: Midazolam IV/IO/IM –> 0.15mg/kg
2nd line: Midazolam IV/IO/IM –> 0.15mg/kg
3rd line: Keppra 40mg/kg (max 3g)
4th line: Phenytoin 20mg/kg or phenobarbitone
5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Answer 75

A

c) Alcohol 70%
- only suitable for short-term cannulation (<24 hours)

Answer 76

A

d) WPW
Type B pattern

LITFL:
ECG features of WPW in sinus rhythm
-> PR interval < 120ms
-> Delta wave: slurring slow rise of initial portion of the QRS
-> QRS prolongation > 110ms
-> Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
-> Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction

Can be left-sided (Type A) or right-sided (Type B), and ECG features will vary depending on this:

Left-sided AP:
produces a positive delta wave in all precordial leads, with R/S > 1 in V1.
(Dominant R Wave in V1)
Sometimes referred to as a type A WPW pattern

Right-sided AP:
produces a negative delta wave in leads V1 and V2.
Sometimes referred to as a type B WPW pattern

Tachyarrhythmias in WPW

There are only two main forms of tachyarrhythmias that occur in patients with WPW

Atrial fibrillation or flutter.
-> Due to direct conduction from atria to ventricles via an AP, bypassing the AV node
Atrioventricular re-entry tachycardia (AVRT).
-> Due to formation of a re-entry circuit involving the AP

Breakdown of Type A example:
- Sinus rhythm with a very short PR interval (< 120 ms)
- Broad QRS complexes with a slurred upstroke to the QRS complex — the delta wave
- Dominant R wave in V1 suggests a left-sided AP, and is sometimes referred to as “Type A” WPW
- Tall R waves and inverted T waves in V1-3 mimicking right ventricular hypertrophy (RVH) — these changes are due to WPW and do not indicate underlying RVH
- Negative delta wave in aVL simulating the Q waves of lateral infarction — this is referred to as the “pseudo-infarction” pattern

Answer 77

A

b) Alcoholic liver disease
- AST>ALT

In hepatitis and paracetamol toxicity would expect ALT>AST.

In cholecystitis, would expect a cholestatic picture with raised conjugated bilirubin and raised GGT/ALP.

LITFL: Overall analysis of Liver Function Tests (LFT)

Transaminitis: Aminotransferases (AST, ALT)
- Generally associated with hepatocellular damage
- Generally not associated with cholestasis

Ratio of AST and ALT can be useful in differential
ALT is more specific for liver damage than AST

AST: ALT =1
-> Associated with ischaemia (CCF and ischaemic necrosis and hepatitis)

AST: ALT >2.5
-> Associated with Alcoholic hepatitis
-> Alcohol induced deficiency of pyridoxal phosphate
AST: ALT <1
-> High rise in ALT specific for Hepatocellular damage
-> Paracetamol OD with hepatocellular necrosis
-> Viral hepatitis, ischaemic necrosis, toxic hepatitis
-> Elevation with cholestasis (ALP, GGT)

ALP – primarily associated with cholestasis and malignant hepatic infiltration
Marker of rapid bone turnover and extensive bony metastasis

GGT – sensitive to alcohol ingestion
Marker of hepatocellular damage but non-specific
Sharpest rise associated with biliary and hepatic obstruction

Answer 78

A

d) Trigger for initiating CICO Rescue is SpO2 <90%

According to the Vortex Approach the trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines.

Trigger for Initiating CICO Rescue VORTEX APPROACH
The trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines.

Note that this trigger is independent of the oxygen saturations since, even in the unusual situation where the oxygen saturations remain high following best efforts at all three lifelines, the inability to confirm alveolar oxygen delivery means that eventual desaturation is inevitable.

Rather than being a deterrent to its performance, recognition of the need for CICO Rescue while the oxygen saturations remain high should be viewed as advantageous – providing increased time to perform this confronting procedure in a more controlled manner, thereby increasing the chance of success.

Conversely, a critically low oxygen saturation is not in itself a trigger to initiate CICO Rescue if best efforts at all three lifelines have not yet been completed.

While legitimate opportunities to enter the Green Zone in a timely fashion via the familiar upper airway lifelines remain, these should be given priority, as they are more likely to be successful than resorting to an unfamiliar and more traumatic technique.

Oxygen saturations are therefore not a relevant consideration in deciding the trigger for CICO Rescue – this is always “the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines”.

They are, however, a relevant consideration in making the context dependent decision of what constitutes a best effort at each lifeline in a particular situation.

This is because the oxygen saturations impact on how much time it is reasonable to invest in optimising each of the upper airway lifelines before declaring a best effort.

When the oxygen saturations are critically low it might be reasonable to have only one attempt at each lifeline before declaring a best effort, even though this means leaving some potential optimisation interventions untried.

This is because the incremental benefit of repeated attempts to optimise a lifeline that has already failed is typically low relative to untried alternative lifelines.

Thus the time expended on such low yield interventions cannot be justified when the patient is already critically hypoxaemic and alternatives (including CICO Rescue) with a substantially higher likelihood of success remain.

Answer 79

A

d) The pooled data from all of the studies

Forest plots or blobbograms are used in order to show graphically the studies which have been included in the meta-analysis.
They demonstrate the differences between studies and provide an estimate of the overall result.

Answer 80

A

a) Amputation

Top 10 Rank order:
1. Amputation 30-85%
2. Thoracotomy 5-67%
3. Mastectomy 11-57%
4. Inguinal hernia repair 0-63%
5. Sternotomy 28-56%
6. Cholecystectomy 3-56%
7. Knee arthroplasty 19-43%
8. Breast Augmentation 13-38%
9. Vasectomy 0-37%
10. Radical prostatectomy 35%

Answer 81

A

a) Greater occipital

Answer 82

A

d) 10 minutes
- best answer; one of those shit questions that depends on your source.

Morgan & Mikhail’s (chapter 36: anaesthesia for ophthalmic surgery):
“ Succinylcholine increases IOP by 5-10mmHg for 5-10 minutes”.
- due to prolonged contracture of the EOM

BARASH:
Succinylcholine increases IOP 7 to 10 mmHg reaching a peak pressure 1 to 2 minutes after IV administration and returns to the baseline in 5 to 7 minutes. This increase may be attenuated by pretreatment with anesthetics, although none completely eliminates the increase in IOP. In the presence of a lacerated globe, this increase in IOP may increase the extrusion of intraocular contents although greater increases in IOP may occur during crying and coughing.

Yao & Artusio’s:
- also quotes same information: increases IOP 7 to 10mmHg, returning to baseline in 5 - 7 minutes.

Stoelting’s:
Intraoccular pressure peaks at 2-4 minutes after administration and returns to normal by 6 minutes

Answer 83

A

a) Pulsus paradoxus

Physical findings in Tamponade:
- A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade
- None of the findings alone are highly sensitive or specific for the diagnosis.

Beck’s triad
1. Low arterial blood pressure
2. Dilated neck veins
3. Muffled heart sounds
- Are present in only a minority of cases of acute cardiac tamponade.

Physical findings of sinus tachycardia and the absence of frank hypotension
may indicate significant hemodynamic compromise from cardiac tamponade and serve as an indication for immediate pericardiocentesis.

In contrast, Kussmaul sign (the absence of an inspiratory decline in jugular venous pressure) is not usually seen in cardiac tamponade.

Tachycardia and hypotension
- Sinus tachycardia is seen in almost all patients, in an attempt to maintain cardiac output
- Hypotension is somewhat more variably present
- One exception is when the underlying disease is associated with bradycardia, as with a pericardial effusion and subacute cardiac tamponade associated with hypothyroidism.
- Tachycardia also may not be seen in patients with early cardiac tamponade even though they have signs of a hemodynamically significant effusion, such as an elevated jugular venous pressure.

Elevated jugular venous pressure
- The JVP is almost always elevated in cardiac tamponade and may be associated with venous distension in the forehead and scalp.
- CVP wave form:
->x descent is preserved
->y descent is attenuated or absent
(due to the limited or absent late diastolic filling of the ventricle)

Pulsus paradoxus
-defined as: abnormally large decrease in systolic blood pressure (>10 mmHg) on inspiration
- common finding in moderate to severe cardiac tamponade and is the direct consequence of ventricular interdependence.
- not all patients with cardiac tamponade have pulsus paradoxus (eg, those with chronic hypertension leading to elevated ventricular diastolic pressures or those with a co-existent atrial septal defect).

Pericardial rub — A pericardial rub may be heard in patients with cardiac tamponade due to inflammatory pericarditis.

Electrocardiography
- ECG in cardiac tamponade typically shows sinus tachycardia and may also show low voltage.
- If pericarditis is present, the ECG findings typical of that disorder are also seen.
- Electrical alternans is characterized by beat-to-beat alterations in the QRS complex and, in some cases, other electrocardiographic waves that reflect the swinging of the heart in the pericardial fluid.
- Electrical alternans is relatively specific but not very sensitive for cardiac tamponade; rarely, this phenomenon is seen with very large pericardial effusions alone.

Diagnosis:
Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include:
●Chest pain
●Syncope or presyncope
●Dyspnea and tachypnea
●Hypotension
●Tachycardia
●Peripheral edema
●Elevated jugular venous pressure
●Pulsus paradoxus

Presence of a pericardial effusion on echocardiography with evidence of cardiac chamber collapse, flow variation, or dilation of the inferior vena cava is consistent with, and highly suggestive of, cardiac tamponade.

However, the diagnosis of cardiac tamponade can only be confirmed by the hemodynamic and clinical response to pericardial fluid drainage.

Answer 84

A

a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours

UP TO DATE: Arrhythmias in COPD
For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C).

Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3).

Answer 85

A

b) 2

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

Answer 86

A

e) Low resistance

Answer 87

A

b) Pulmonary hypertension

Up to date: Overview of pulmonary function testing in adults

Diffusing capacity — Measurement of the single-breath diffusing capacity for carbon monoxide (DLCO; also known as transfer factor or TLCO) is quick, safe, and useful in the evaluation of restrictive and obstructive lung disease, as well as pulmonary vascular disease. The technique and interpretation are discussed separately.

In the setting of restrictive disease, the diffusing capacity helps distinguish between intrinsic lung disease, in which DLCO is usually reduced, and other causes of restriction, in which DLCO is usually normal.

In the setting of obstructive disease, the DLCO helps distinguish between emphysema, in which it is usually reduced, and other causes of chronic airway obstruction, like asthma or chronic bronchitis, where it is usually normal.

The DLCO is also used in the assessment of pulmonary vascular disease (eg, thromboembolic disease, pulmonary hypertension), which typically causes a reduction in DLCO in the absence of significant restriction or obstruction

Answer 88

A

a) face, legs, activity, cry, consolability

Answer 89

A

d) Knee extension weakness
- this is femoral innervation

BJA: Perioperative peripheral nerve injuries
https://academic.oup.com/bjaed/article/12/1/38/260058

Lower limb peripheral nerve injuries

Sciatic nerve injury (L4–S3)

Mechanism of injury
Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component.

Clinical presentation
Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 90

A

Methylene blue PI:

PROVEBLUE® is indicated:
* for the treatment of drug-induced methaemoglobinaemia (e.g. prilocaine)
* for the treatment of idiopathic methaemoglobinaemia (in which structural abnormality of haemoglobin is not present)
* as a bacteriological stain
* as a dye in diagnostic procedures such as fistula detection
* for the delineation of certain body tissues during surgery.

Contraindications:
PROVEBLUE® is contraindicated in the following circumstances:
* known hypersensitivity to the drug or any other thiazide dyes
* patients with severe renal impairment
* patients with glucose-6-phosphate dehydrogenase deficiency
* methaemoglobinaemia due to chlorate poisoning
* methaemoglobinaemia during treatment of cyanide poisoning

Intrathecal and subcutaneous injection of methylene blue are also contraindicated as they can result in neural damage (intrathecal administration) and necrotic abscess (subcutaneous administration).

Precautions:
Methylene blue is a potent monoamine oxidase inhibitor.
Serotonin syndrome.

Dose:

Adults and children: In the treatment of methaemoglobinaemia, methylene blue is administered intravenously as the 0.5 % solution in doses of 1 to 2 mg per kg bodyweight injected over a period of 5 minutes.
A repeat dose may be given after one hour if required.
A maximum dose of 7mg/kg bodyweight is recommended.
The use of methylene blue is not recommended in infants under 4 months of age.

STAT PEARLS :Methylene blue
https://www.ncbi.nlm.nih.gov/books/NBK557593/

“Methylene blue is a safe drug at a therapeutic dose of <2 mg/kg; however, when levels are >7 mg/kg, many of the adverse effects it exhibits will occur. Serotonin syndrome has been found to occur when combining serotonergic agents with methylene blue at a dose of 5 mg/kg.”

Methylene blue: caution serotonin syndrome, G6PD deficiency
Indications: vasoplegic syndrome, plasmodium falciparum, methaemoglobinaemia, diagnostic purposes.

Safe at doses <2mg/kg. (used in vasoplegic syndrome on CPB at 3mg/kg - Up to date)
Serotonin syndrome at >5m/kg
Other adverse effects at >7mg/kg.

Answer 91

A

d) Reduced RR

BJA: HFNP oxygen therapy
https://www.bjanaesthesia.org/article/S0007-0912(17)53999-9/fulltext
- reduced RR
- increased MV
- reduced WOB, reduced Vd, reduced AWR
- provides CPAP 3-7 cmH20 (mouth closed)

Answer 92

A

e) Protamine

The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin.

https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data

Answer 93

A

b) Factor VII

Redcross:
Cryoprecipitate contains most of the following found in fresh frozen plasma:
1. factor VIII
2. fibrinogen
3. factor XIII
4. von Willebrand factor
5. fibronectin

Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains:

Factors:
II
IX
X
small amount of factor VII.

Also contains:
plasma proteins (human)
Antithrombin III (human)
Heparin sodium (porcine)
Sodium
Phosphate
Citrate
Chloride

Answer 94

A

d) 7500mls

Compared with the blood volume (65 to 70 mL/kg) in nonpregnant women, the blood volume in pregnant women at term is increased to 100 mL/kg

Answer 95

A

c) Genitofemoral

Answer 96

A

b) Suprahyoid

Extrinsic Muscles of the larynx:
1. Sternothyroid muscle
2. Thyrohyoid muscle
3. Inferior constrictor of the pahrynx

Indirect elevators of the larynx:
1. Mylohyoid
2. Stylohyoid
3. geniohyoid

Indirect depressors of the larynx:
1. Sternohyoid
2. Omohyoid

Intrinsic Muscles of the larynx:
1. Posterior Cricoarytenoid
2. Lateral Cricoarytenoid
3. Interarytenoid
4. Thyroarytenoid
5. Vocalis
6. Cricothyroid

actions of intrinsic laryngeal muscles
1. Abductor of the cords: posterior cricoarytenoids
2. Adductors of the cords: lateral cricoarytenoids, interarytenoids
3. Sphincter to the vestibule: aryepiglottics (interarytenoid), thyroepiglotics
4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 97

A

d) Knee extension weakness
- most correct based on answers remembered
- this is femoral innervation

Superficial peroneal nerve injury (L4–5 S1–2)

Mechanism of injury
Lithotomy and the lateral position are the common risk factors as the nerve is potentially compressed at the fibular head. Length of time in lithotomy has not been associated with an increased risk of developing a PPNI.

Clinical presentation
There is loss of dorsiflexion and eversion of the foot (equinovarus deformity). Sensory manifestations are described along the anterolateral border of the leg and the dorsum of the digits except those supplied by saphenous and sural nerves.

Orthobullets:
Common peroneal nerve
- superficial & deep branches

Deep peroneal
- motor: extensor digitorum longus, extensor hallucis longus (dorsiflexion)
- sensory: 1st dorsal webspace

Superficial peroneal
- motor: peroneus longus and brevis (eversion)
- sensory: dorsum foot (except for 1st dorsal webspace & 5th toe)

Lower limb peripheral nerve injuries

Sciatic nerve injury (L4–S3)

Mechanism of injury
Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component.

Clinical presentation
Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 98

A

Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy

flexor pollicis brevis
abductor pollicis brevis
opponens pollicis
lateral lumbricals

AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 99

A

D) Age

Can Grandma Functionally Support Medication Nutrition Mood Continence Self

i.e.
C (cognition)
G (general health)
F (functional independence)
S (social support)
M (medication use)
N (nutritional status)
M (mood, presence of mental illness)
C (continence)
S (self reported performance)

Answer 100

A

d. Ferritin

ANZCA blue book:

ACD caused primarily by inflammation

Mechanism:
1. Iron
- Inflammation reduces Iron availabilty as a protective mechanism whereby Iron is sequestered and stored in macrophages to limit availability to microbial pathogens
- Hepcidin expression is increased, this prevents the release of Iron by reticuloendothelial system resulting in “functional iron deficiency” with reduced tissue availability of iron, despite apparently normal total body iron stores. (hence increased Ferritin)

Response to erythropoietin
- mechanism not clear suspect blunting of response to erythropoietin
Therapeutic agents
chemotherapies that impair bone marrow response to erythropoiesis
65% of patients with lung and gynae cancer treated with platinum based drug develop anaemia

RCPA advice on interpretation of Soluble Transferrin Receptor:

Soluble transferrin receptor levels in plasma are elevated if there is increased iron demand due to Iron deficiency, increased erythropoiesis (eg, Haemolysis) or dyserythropoiesis (eg, Megaloblastic anaemia), regardless of other, coexistent states.

Thus, it can be used to demonstrate iron deficiency in patients who also have an acute phase response and it can distinguish Iron deficiency from the Anaemia of chronic disease.

Patients with an acute phase response have reduced plasma iron and transferrin with elevation of Ferritin, making these usual indicators unreliable.