21.2 Flashcards
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
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
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
RCA (Inferior STEMI)
- 80% RCA
- 18% LCx
- 2% rare wrap around LAD
Source LITFL
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
c) Ocular massage
Hyalase
Mixing with lignocaine
Higher concentration
Higher volume
Occular pressure (spread and IOP reduction)
Source: 2x BJA Ed articles
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
ASA 3
Source: ASA Classification
https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
21.2 A derived value from an arterial blood gas sample is
HCO3- is derived from pCO2 and pH
Base excess is derived from pH
SaO2 is derived from oxyHb and Hb
Source LITFL
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
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
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
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
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
d) major haemorrhage
- blood loss is significantly less with RALP
Up to date: RALP
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
a) Arterial puncture
- thoracic duct injury is a risk with left sided IJ CVC insertion, but it is a rarer complication.
21.2 Regarding healthcare research, the PICO framework describes
a) Critical appraisal
b) Meta-analysis
c) Observational study
d) Systematic review
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?
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
a) Alprostadil
Prostin (PGE1)
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
1,500 mL immediately
OR
200 mL/hr in the first 2-4 hours
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
d) Creatinine
Albumin
Bilirubin
COAG (INR/PT)
Ascites
Encephalopathy
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
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.
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
Higher SctO2
Lower SpO2
In patients given ICG for videoangiography, a 25 mg bolus results in a greater and more prolonged increase in SctO2 and a greater reduction in SpO2
https://pmc.ncbi.nlm.nih.gov/articles/PMC4384398/
21.2 The CRASH-2 trial showed tranexamic acid administration to trauma victims results in a
reduction in
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.
a. Decreased mortality
b. Increased mortality
c. Decreased blood product use
d. No change mortality
e. Increased bleeding
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
b) 90
PAO2: 0.4 (760 - 47) - 48/0.8 = 285 - 60 = 225mmHg
225 - 135 = 90mmHg.
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
Assuming pathology is pre-lung (normal PCWP).
? Pulmonary stenosis
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
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
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
a. 65ml/hr N Saline
b. 45ml/hr N saline w 5% dex
c. 45ml/hr N Saline w 2.5% dex
d. 65ml/hr .45% saline w 2.5% dex
e. 65ml/hr .45% saline w 5% dex
45ml/hr 0.9% NS 5% dextrose
maintenanicne fluid = 4,2,1 rule = 65ml/hr
in unwell children (acute CNS/ post op/ trauma/ pulmonary conditions) - 2/3 maintenaince rate due to ^ADH secretion.
preferred maintenaince fluid type 0.9% NS + 5% glucose +/- potassium
most sick children will retain water and need less than full maintenaince fluid
https://www.rch.org.au/clinicalguide/guideline_index/intravenous_fluids/
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
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
21.2 Sensory innervation of the cornea is by the
a. Nasociliary
b.Optic
c.Trigeminal
d.Frontal
a. Nasociliary.
It is a branch of the Trigeminal nerve. https://academic.oup.com/bjaed/article/17/7/221/3800526
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.
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
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.
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
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)