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
REPEAT
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
repeat
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
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.
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)
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: 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.
21.2 Globe perforation during eye block is more common in myopic eyes because the
REPEAT
21.2 A drug which is likely to slow the heart rate in a patient with a heart transplant is
Adenosine (effect is exagerated)
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
9 months?
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
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
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
Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval
Source QCH guidelines
21.2 Stellate ganglion block is NOT contraindicated in patients with
a) Contralateral phrenic nerve palsy
b) Glaucoma
c) Recent MI
d) Arrhythmia
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
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
REPEAT
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
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
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
) 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
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
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%)
21.2 Non-anaesthetist practitioners wishing to provide procedural sedation should have training in sedation and/or anaesthesia for a minimum of
REPEAT
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
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
21.2 The cardiac axis of this electrocardiogram is
a) -30
b) 0
c) 45
d) -90
Left Axis Deviation
LITFL
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
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
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
Left PCA
21.2 The function of the bottle labelled ‘D’ in the diagram below is to protect against the
consequences of
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.
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
Codeine
Source Appendix ANZCA PG 07
21.2 A patient undergoing robotic prostatectomy with volume-controlled ventilation has the following ventilatory measurements: (Ventilator parameters given) The static compliance is
REPEAT
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
repeat
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
repeat
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
e) Reversible hypermetropia
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
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
21.2 The oral morphine equivalent of tapentadol 50 mg (immediate release) is
a) 5mg
b) 10mg
c) 15mg
d) 20mg
e) 25mg
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
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
a) R1 side chain
UP TO DATE:
- sensitisation to R1 side chain in cephalosporins important in determining cross reactivity with penicillins.
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
repeat
21.2 Of the following, the incidence of venous air embolism is considered highest for (list of
surgical procedures given)
repeat
21.2 Intraoperative cell salvage is contraindicated in
a) LSCS
b) Revision of infected THR
c) Heparin allergy
d) Severe coagulopathy
e) Phaeochromocytoma
pheochromatoma
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
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
21.2 The anion which contributes the most to the anion gap is
a) Albumin
b) Chloride
c) Phosphate
d) Bicarbonate
Albumin -> Anion gap
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
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
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
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
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
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
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.”
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
TR
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
repeat
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
same SVP
21.2 When performing a brachial plexus block at the level of the axilla, the structure indicated by
the arrow is the
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
sarcoid
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
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.
21.2 Predictors of successful awake extubation after volatile anaesthesia in infants include
repeat
21.2 The maximum warm ischaemia time acceptable for procuring the kidney following donation
after circulatory death (DCD) is
a) 30 minutes
b) 60 minutes
c) 90 minutes
d) 120 minutes
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)
21.2 The risk of postoperative respiratory failure in myasthenia gravis is increased by the
administration of
a) Teicoplanin
b) Flucloxacillin
c) Cephazolin
d) Gentamicin
e) Vancomycin
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)
21.2 A patient with known type 3 von Willebrand disease presents with persistent epistaxis. First-
line medical therapy should include
a) DDAVP
b) Prothrombin X
c) Factor VIIa
d) Factor VIII
TXA
FVIII, vWF concentrates
- TXA as adjunct
21.2 ANZCA fasting guidelines classify all of the following as clear fluids EXCEPT
a) clear cordial
b) black coffee
c) strained broth
d) pulp free fruit juice
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”
21.2 A patient has return of spontaneous circulation (ROSC) but remains unresponsive after
cardiac arrest. ANZCOR Guidelines recommend all the following measures EXCEPT
a) Aiming SpO2 94%
b) Treating hyperglycaemia >10mmol/L
c) Normothermia
d) Cardiac catherisation
e) Amiodarone infusion
c) Normothermia
- TTM to 32-36 degrees is recommended for those that remain unresponsive
21.2 Your patient has been administered 50 mL of oral 5–aminolevulinic acid hydrochloride
(Gliolan) three hours prior to her scheduled craniotomy for resection of a glioblastoma. Care
should be taken perioperatively to avoid the adverse effect of
a) Acute kidney injury
b) Photosensitivity
c) Increased ICP
d) Hypertension
e) Hypokalaemia
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.
21.2 The most common cause of mortality in children with diabetic ketoacidosis is
cerebral oedema
21.2 An electrocardiogram (ECG) abnormality which is NOT usually associated with severe
anorexia nervosa is
resting tachycardia
ECG changes: bradycardia (AV block), TwI, prolonged QT, ST depression
21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular
aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time
before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
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.
21.2 The image below shows results from non inferiority trials. The trial labelled ‘M’ is best
described as
a) Non-inferiority is not demonstrated
b) Non-inferiority is demonstrated
c) Superiority is demonstrated
d) Inferiority is demonstrated
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.
21.2 Painless post-operative visual loss with preserved pupillary reflexes is most likely due to
a) Retinal detachment
b) Anterior ischaemic optic neuropathy
c) Corneal abrasion
d) Posterior ischaemic optic neuropathy
e) Posterior cerebral ischaemia
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.
21.2 A 50-year-old man is admitted with a stroke and undergoes cerebral angiography. The artery
marked with an ORANGE arrow on the angiogram below is the
a) Vertebral
b) Basilar
c) PICA
d) Superior cerebellar
e) Anterior cerebral
a) Vertebral
orange = vertebral
blue = basilar
purple = PCA
red arrows = AICA
yellow = pontine arteries
Circle of Willis:
21.2 The oculocardiac reflex results in
a) Hypertension
b) Apnoea
c) Junctional rhythm
d) Torsades
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.
21.2 A patient with a history of restless leg syndrome is agitated in the post-anaesthesia care unit.
After excluding other causes, the best treatment of the agitation in this patient is
a) Pethidine
b) Clonidine
c) Droperidol
d) Haloperidol
e) Midazolam
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.
21.2 With regard to the risk of postoperative surgical-site infection, 8 mg dexamethasone
administered intraoperatively has
a) No increased risk of surgical wound infection
b) Increased surgical wound infection in diabetics
c) Increased surgical wound infection in non-diabetics
d) Decreased surgical wound infection
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.
21.2 Intraoperative lung protective ventilation strategies include all of the following EXCEPT
I:E ratio 1:3
21.2 A 65 year old woman is dyspnoeic after a total hip replacement. A lung ultrasound is
performed in the post-anaesthesia care unit, with a still image shown below. The likely cause
of the dyspnoea is
PTx
21.2 Local anaesthetic-induced myotoxicity is most likely to be associated with
Adductor canal
21.2 The abnormality shown in this image is LEAST likely to be caused by an injury to the
21.2 Postdural puncture headache in obstetric anaesthesia is associated with a greater likelihood of all of the following EXCEPT
a) Postpartum depression
b) Bacterial meningitis
c) Chronic back pain
d) Cerebral vein thrombosis
e) Posterior reversible encephalopathy syndrome (PRES)
No answer provided. ?encephalitis
These are all complications of dural puncture.
Up to date: Post dural puncture headache
21.2 The most common type of perioperative stroke is
a) Thrombotic
b) Ischaemic
c) Hypotension
d) Embolic
e) Haemorrhagic
embolic
21.2 Hepcidin production is inhibited in response to
anaemia
21.2 The most common cause of cor pulmonale is
COPD
21.2 A risk factor which increases the likelihood of developing local anaesthetic systemic toxicity is
a) Hypoxia
b) Alkalaemia
c) High alpha1-acid glycoprotein
d) Hypocarbia
e) Increased carnitine levels
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.
21.2 The medical laser LEAST likely to cause eye injury is
a) CO2
b) Nd:YAG
c) Argon
d) Green light
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.
21.2 The main advantage of using noradrenaline (norepinephrine) over phenylephrine for the prevention of hypotension as a result of spinal anaesthesia for elective caesarean section is
a) Better APGAR
b) Better foetal acid-base balance
c) Less nausea & vomiting
d) Less maternal bradycardia
less bradycardia
21.2 Of the following, the LEAST likely cause of high anion gap metabolic acidosis is
a) Pancreatic fistula
b) DKA
c) Cardiac failure
d) Anti-retroviral
e) Methanol
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.
21.2 The most common complication of extracorporeal membrane oxygenation (ECMO) in adults is
a) Bleeding
b) Vascular damage
c) Embolism
d) Inadvertently decannulate
a) Bleeding
ECMO complications:
- patient complications: bleeding & coagulopathy most common
- mechanical complications: access insufficiency common
Blue book 2017
21.2 The power board on the back of the anaesthesia machine has caught fire during an elective case. This should be extinguished with
a) CO2
b) Fire blanket
c) Wet chemical powder
d) Foam
e) Water
a) CO2
21.2 The most common presenting rhythm associated with maternal cardiac arrest is
Repeat
21.2 The number of segments in the lower lobe of the left lung is
a) 3
b) 4
c) 5
d) 10
e) 12
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
21.2 Cardiovascular effects of hyperthyroidism include
a) Increased DBP
b) Narrow pulse pressure
c) Reduced diastolic relaxation
d) Decreased CO
e) Decreased SVR
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
21.2 The coagulopathy that can result from intrahepatic cholestasis of pregnancy is due to
Vitamin K deficiency
21.2 A man who had successful treatment of a germ cell tumour ten years ago presents for laparoscopic appendectomy. Your intraoperative management should consider
a) Lung protective ventilation
b) Oncoanaesthesia
c) Lowest FiO2 possible
d) MAP 60
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:
21.2 The muscle or muscle group with the greatest resistance to the action of non-depolarising neuromuscular blocking agents is the
a) Adductor pollicis
b) Diaphragm
c) Orbicularis oculi
d) Pharyngeal
b) Diaphragm
21.2 A patient presents for a trans-urethral resection of the prostate (TURP). He had a single drug-eluting coronary stent for angina pectoris inserted six months ago and is taking clopidogrel and aspirin. The most appropriate preoperative management of his medications is to
a) Cease aspirin, continue clopidogrel
b) Cease aspirin for 10 days, cease clopidogrel for 5 days
c) Cease clopidogrel for 5 days, continue aspirin
d) Cease clopidogrel for 10 days, continue aspirin
e) Continue both aspirin and clopidogrel
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
21.2 A ten year old child (weight 30 kg) presents to the emergency department in status epilepticus. He has received one dose of 15 mg midazolam buccally prior to his arrival. According to Advanced Paediatric Life Supprt, Australia (APLS) guidelines the next drug treatment should be intravenous
a) Midazolam
b) Propofol
c) Levetiracetam
d) Phenytoin
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
21.2 A peripheral intravenous cannula is being inserted in the forearm of a man having a hemicolectomy. The skin asepsis preparation NOT suitable for this procedure is
a) Povidone iodine
b) Chlorhexidine 2%
c) Alcohol 70%
d) Chlorhexidine 0.5% with alcohol
e) Tincture of iodine
c) Alcohol 70%
- only suitable for short-term cannulation (<24 hours)
21.2 In pulmonary function testing the presence of airflow limitation is defined by a post- bronchodilator FEV1/FVC ratio less than
a) 0.5
b) 0.6
c) 0.7
d) 0.8
c) 0.7
21.2 A 30-year-old man with morbid obesity (body mass index [BMI] 55 kg/m2) presents for middle ear surgery. The most appropriate bolus dose of propofol for induction should be based on
a) IBW
b) TBW
c) ABW
d) LBW
e) PBW
d) LBW
21.2 A 30 year old athlete undergoing a knee arthroscopy under general anaesthesia becomes tachycardic intraoperatively. A 12-lead electrocardiogram (ECG) is obtained. The most likely diagnosis is
a) Atrial fibrillation
b) Atrial flutter
c) Sinus tachycardia
d) WPW
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
21.2 A 45-year-old man has the following results on his blood biochemistry testing: The most likely diagnosis is
- Bili 30*
- AST 1000*
- ALT 500*
- Albumin 30*
*These blood results are not the original stem.
The most likely diagnosis is:
a) Hepatitis
b) Alcoholic liver disease
c) Paracetamol toxicity
d) Cholecystitis
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
21.2 The Vortex Approach to airway management does all of the following EXCEPT
a) At least 1 attempt by the most experienced clinician
b) Maximum 3 attempts at each lifeline (unless gamechanger)
c) CICO status escalates with unsuccessful best effort at any lifeline
d) Trigger for initiating CICO Rescue is SpO2 <90%
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.
21.2 A structure that is NOT clamped during a Pringle manoeuvre is the
Repeat
21.2 A forest plot is a commonly used tool in meta-analysis. It presents
a) A qualitative analysis of pooled data from multiple studies
b) A number needed to treat vs number needed to harm
c) The non-inferiority of a study
d) The pooled data from all of the studies
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.
21.2 Of the following, the procedure that is most commonly associated with chronic pain after surgery is
a) Amputation
b) Mastectomy
c) Thoracotomy
d) TKR
e) Hernia repair
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%
21.2 Performing a superficial cervical plexus block will block all of the following nerves EXCEPT the
a) Greater occipital
b) Greater auricular
c) Lesser occipital
d) Supraclavicular
e) Transverse cervical
a) Greater occipital
21.2 Suxamethonium causes a sustained contraction of the extraocular muscles for up to
a) 2 minutes
b) 3 minutes
c) 5 minutes
d) 10 minutes
e) 20 minutes
C) 5 mins
- 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
21.2 Findings associated with massive pericardial tamponade include
a) Pulsus paradoxus
b) Electrical alternans
c) Kussmaul sign
d) Pericardial rub
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.
21.2 A 59-year-old lady presents for elective coronary artery graft surgery. She has a pulmonary artery catheter inserted with the waveforms displayed below. Her cardiac output is 4.5 L/min.
Her mean pulmonary artery pressure is 33 mmHg. The most likely explanation for the waveforms seen is that she has
21.2 A patient with a history of paroxysmal atrial fibrillation and chronic obstructive airways disease develops a wheeze intraoperatively which resolves with administration of salbutamol via the endotracheal tube.
Soon after, he develops rapid atrial fibrillation with a ventricular rate of 120 beats per minute, a BP of 90/60 and an ETCO2 of 40mmHg. His regular medications are
inhaled salbutamol, inhaled salmeterol and digoxin 125mcg daily. The next most suitable treatment is
a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours
b) Esmolol 500mcg/kg and infusion
c) Direct cardioversion with 50J
d) Metoprolol 2.5mg IV up to 3 doses
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).
21.2 A man with atrial fibrillation has no valvular heart disease. According to joint American Heart Association (AHA), American College of Cardiology (ACC) and Heart Rhythm Society (HRS) guidelines, oral anticoagulants are definitely recommended if his CHA2DS2-VASc score is greater than or equal to
a) 1
b) 2
c) 3
d) 4
e) 5
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
21.2 The advantage of the Mapleson E circuit in paediatric anaesthesia is due to its
a) Use with low FGF
b) Ability to assess compliance
c) Ability to assess tidal volume
d) Ability to rapidly change levels of CPAP
e) Low resistance
e) Low resistance
21.2 A 50 year old man has the following pulmonary function test result:
FEV1 98% predicted
FVC 95% predicted
DLCO 43% predicted
The diagnosis is most consistent with:
a) Pulmonary fibrosis
b) Pulmonary hypertension
c) COPD
d) Obesity
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
21.2 When performing a paediatric pain assessment, the five elements assessed to obtain the FLACC score are
a) face, legs, activity, cry, consolability
b) face, legs, arms, cry, consolability
c) function, legs, arms, cry, crossed legs
d) frown, legs, activity, cry, crossed arms
a) face, legs, activity, cry, consolability
21.2 Local anaesthetic blockade of the sciatic nerve results in loss of function of all of the following EXCEPT
a) Weak dorsiflexion
b) Dorsal foot sensation loss
c) Knee flexion weakness
d) Knee extension weakness
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.
21.2 Methylene blue may be used in the treatment of all of the following conditions EXCEPT
a) Methemoglobinemia
b) Priapism
c) Hepatopulmonary syndrome
d) G6PD deficiency
e) Sepsis
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.
21.2 A respiratory effect of high flow nasal oxygen therapy is
a) Increased deadspace
b) Reduced MV
c) Increased work of breathing
d) Reduced RR
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)
21.2 A bleeding patient has ROTEM results including (results displayed) . The most appropriate treatment is
a) Cryoprecipitate
b) FFP
c) Platelets
d) TXA
e) Protamine
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
21.2 Cryoprecipitate contains all of the following EXCEPT
a) Factor I
b) Factor VII
c) Factor VIII
d) VWF
e) Fibronectin
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
21.2 The size 5 i-gel® supraglottic airway is recommended for patients who weigh over
a) 50kg
b) 60kg
c) 70kg
d) 80kg
e) 90kg
e) 90kg
21.2 A normal 75 kg term parturient may be expected to have a total blood volume of
a) 5250mls
b) 6000mls
c) 6750mls
d) 7500mls
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
21.2 The nerve labelled by the arrow in the diagram below is the
a) Obturator
b) Accessory obturator
c) Genitofemoral
d) Ilioinguinal
e) Iliohypogastric
c) Genitofemoral
21.2 The intrinsic muscles of the larynx do NOT include
a) Cricothyroid
b) Suprahyoid
c) Thyroarytenoid
d) Transverse arytenoid
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)
21.2 Of the following, the deficit that DOES NOT result from damage to the common peroneal nerve is
a) Weak dorsiflexion
b) Dorsal foot sensation loss
c) Knee flexion weakness
d) Knee extension weakness
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.
21.2 A patient has numbness and weakness in her hand postoperatively. 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
A. Parasthesia in little finger
B. Parasthesia in the distribution of the interscalene nerve
C. Weakness in adductor digiti minimi
D. Weakness in abductor pollicis brevis
E. Weakness in lateral interosseus
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
21.2 The domains described in the Edmonton Frail Scale do NOT include
A) Cognition
B) Mental illness
C) Weight
D) Age
E) Functional assessment
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)
21.2 In a patient with anaemia of chronic disease, of the following the most likely to be elevated is
a. MCV
b. transferrin saturation
c. Increased soluble Transferrin Receptor
d. Ferritin
e. Total iron binding capacity
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.
21.2 The apical four–chamber view of a transthoracic echocardiogram below shows
Dilated RA and RV
21.2 The equipment shown in the picture below is a
NIM tube: Neural Integrity Monitor Electromyogram Tracheal Tube
21.2 The estimated proportion of human induced climate change attributable to nitrous oxide is
a) 0.01
b) 0.06
c) 1
d) >6
d) >6
Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers
