22.1 Flashcards

Question 1

Q

22.1 A 45-year-old man presents with a history of shortness of breath and the following flow-volume loop is obtained. This is most consistent with

a) Variable intrathoracic obstruction
b) Variable extrathoracic obstruction
c) Fixed upper airway obstruction
d) Restrictive pattern
e) Normal

Question 2

Q

22.1 A 72-year-old female smoker with hypertension presents to the emergency department with a wrist fracture after a fall. She has been increasingly tired and confused over the previous week. Her serum and urine electrolytes are (supplied). The most likely diagnosis is

(Low K, low Na, Normal Ur and Cr, Ur sodium <10mmol/L)

a. SIADH
b. Addison’s
c. Diuretic

Answer

A

c. Diuretic

Question 3

Q

22.1 A 74-year old man complains of chest pain. An electrocardiograph is performed and displayed here. The occluded coronary artery could be the

a) RCA or LCx
b) RCA
c) LAD

Answer

A

RCA or LCx

Question 4

Q

22.1 The recommended filter grade of a needle to be effective in excluding microorganisms is

Question 5

Q

22.1 A patient has severe hypokalaemia and is in cardiac arrest. The Australian Resuscitation Council and the New Zealand Resuscitation Council recommend intravenous potassium should be given as

a) 5mmol bolus KCl
b) 10mmol bolus KCl
c) 5mmol KCl over 5min
d) 5mmol KCl over 10min
e) 20mmol KCl over 10min

Answer

A

5 mmol

3.6 Potassium
Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening
ventricular arrhythmias.

Consider administration for:
* Persistent VF due to documented or suspected hypokalaemia.
[Class A; Expert consensus opinion]
ANZCOR Guideline 11.5 August 2016 Page 9 of 13
Adverse effects:
* Inappropriate or excessive use will produce hyperkalaemia with bradycardia,
hypotension and possible asystole
* Extravasation may lead to tissue necrosis.

Dosage:
A bolus of 5 mmol of potassium chloride is given intravenously

Question 6

Q

22.1 A 75-year-old man has a loud ejection systolic murmur detected on clinical examination before a joint replacement. A focused transthoracic echocardiogram (TTE) detects a calcified aortic valve with a peak aortic jet velocity of 3 m/s. The peak gradient across the aortic valve is

a) 36mmHg
b) 44mmHg

Answer

A

= ΔP = 4v2 = 4 x 9 = 36

Question 7

Q

422.1 The current ANZCA guidelines for preoperative fasting of adult patients state that studies have shown that it is safe to administer

a) unlimited clear fluid 2 hours prior
b) 200ml clear fluid 2 hours prior
c) 300ml clear fluid 2 hours prior
d) 400ml clear fluid 2 hours prior

Answer

A

400mls of clear fluids pre op

Safe upper limit - definitely has not not been identified and will vary from patient to patient.

Clear fluids
Water / CHO rich fluids / pulp free fruit juice / clear cordial / black tea and coffee

Question 8

Q

22.1 A two-year-old boy with a history of respiratory tract infection one week previously has just undergone squint surgery. His airway was managed with a size 4.5 mm cuffed endotracheal tube.
The surgery was unremarkable. Twenty minutes after extubation he is awake and appears anxious, with stridor and a visible tracheal tug. His oxygen saturation is 96% on room air. The best initial management of this child is to administer

a) Dexamethasone 0.6mg/kg
b) Adrenaline nebulised 1:1000 - 0.5mL/kg
c) CPAP + T piece
d) Drugs for re-intubation

Answer

A

Nebulised Adrenaline
1mg
0.5ml/kg of 1:1000 Adrenaline nebulised
once adrenaline given consider dose of Steroid dexamethasone or hydrocortisone

Question 9

Q

22.1 You place a paravertebral catheter for postoperative analgesia at the level of T5 in an adult patient prior to a thoracotomy. Two minutes following the injection of 0.75% ropivacaine 10 mL, the patient becomes bradycardic, hypotensive and apnoeic. The most likely cause of the complication is

a) Subarachnoid injection
b) IV injection
c) LA toxicity

Answer

A

B. Intrathecal spread

c) = d) ?! possible, but respiratory function not effected until very late

ATOTW: COMPLETE SPINAL BLOCK FOLLOWING SPINAL ANAESTHESIA (2010)

CARDIO- RESPIRATORY
Hypotension*
Bradycardia*
Respiratory compromise*
Apnoea*
Reduced oxygen saturation
Difficulty speaking/coughing
Cardiac arrest (asystole)

NEUROLOGICAL
Nausea and anxiety*
Arm/hand dysaesthesia or paralysis*
High sensory level BLOCK
Cranial nerve involvement
Loss of consciousness*

CEACCP Paraveterbral Block (2009)
The overall incidence of reported complications with PVBs is between 2.6% and 5%; however, the risk of long-term morbidity is exceedingly low. No fatality directly attributable to PVBs has been reported. The failure rate in experienced hands varies between 6.8% and 10%, which is broadly comparable with epidural analgesia. Other specifically reported complications include: hypotension 4.6%, vascular puncture 3.8%, pleural puncture 1.1%, and pneumothorax 0.5%. Inadvertent pleural puncture may not be recognized, as a short but effective interpleural block will result. The actual frequency of this complication may therefore exceed 1.1%, particularly with the cranial approach. If pleural puncture is appreciated, an interpleural block can be performed intentionally and a catheter inserted to prolong analgesia. Pneumothorax only rarely follows pleural puncture but when it occurs, it is usually small and can therefore be managed conservatively. Tension pneumothorax is a potential complication in ventilated patients, but no cases have as yet been reported. Bilateral block has been reported in up to 10% of cases, which is usually due to epidural spread and less commonly to mass movement of the drug across the midline in the prevertebral plane. Epidural spread is more common with a more medial injection site and with catheter techniques, although block distribution tends to be less on the contralateral side. Ipsilateral Horner’s syndrome is a common side-effect with blocks extending to T1 and T2. Total spinal anaesthesia is very rare and has only been reported twice in the world literature. However, if the plane of approach of the needle is close to the midline, the dural cuff surrounding the intercostal nerve can be penetrated.

Question 10

Q

22.1 A patient is anaesthetised from the awake state to a state of surgical anaesthesia with propofol or a volatile anaesthetic. As the depth of anaesthesia increases, the patient’s electroencephalogram (EEG) will show oscillations that are of

Answer

A

Dominant EEG frequency decreases, and amplitude increases with increasing concentrations of anaesthetic. End result is burst suppression

https://academic.oup.com/bja/article/115/suppl_ 1/i27/234261
Figure 1 shows raw EEG waveforms during isoflurane anaesthesia.
During light anaesthesia:
-amplitude is shallow and frequency is high.
When a higher concentration is administered:
-amplitude deepens and EEG frequency slows.

During deep anaesthesia:
- a ‘burst and suppression’ pattern becomes apparent, characterized by extreme activity, represented by high-frequency, large-amplitude waves (bursts), alternating with flat traces (suppression).
- This pattern, excluding brain ischaemia or other factors, indicates that anaesthesia is too deep. Beyond this, flat traces become dominant and, eventually waveforms are no longer apparent.

During isoflurane, sevoflurane or propofol anaesthesia, this sequence of changes in pattern is almost identical.
The major difference in EEG between the volatile agents (isoflurane or sevoflurane) and propofol is apparent in power in the theta range.
During propofol anaesthesia, theta power remains low regardless of concentration, but during isoflurane or sevoflurane anaesthesia, it increases at surgical concentrations of anaesthesia.

Question 11

Q

22.1 A 54-year-old woman has a laryngeal mask airway inserted for a surgical procedure. The following day she complains of tongue numbness and abnormal taste over the posterior third of the tongue.
The most likely site of the nerve injury is the

a) Glossopharyngeal nerve
b) Lingual nerve
c) Facial nerve
d) Vagus nerve

Answer

A

Glossopharyngeal

Question 12

Q

22.1 The washing process of modern cell savers for intraoperative blood salvage removes all the following EXCEPT

a) Microaggregates of leucocytes
b) Platelets
c) Clotting factors
d) Fetal cells
e) Free Hb

Answer

A

Does not remove foetal red cells or vasoactive molecules (eg don’t use in pheochromocytoma surgery).

Question 13

Q

22.1 A patient with a haemopneumothorax has a chest drain in situ, which is attached to a three-bottle underwater seal drain apparatus. The system is attached to wall suction at -80 cmH20. This will cause

a) Failure of underwater seal
b) Water in suction chamber will enter drainage chamber c) Reexpansion of haemopneumothorax
d) Oscillation in tube will diminish
e) Inability for stuff to drain into first bottle

Answer

A

Oscillations in the tube will be diminished

Question 14

Q

22.1 You inadvertently place a 7.5Fr central venous catheter into the carotid artery of a patient undergoing an emergency laparotomy for peritonitis. The best course of management is to

a) Leave in, call vascular to repair at end of case
b) Heparin, remove, apply pressure

Answer

A

Leave in situ and contact vascular surgeons

Question 15

Q

22.1 A patient in atrial fibrillation with a CHA2DS2-VASc score of 2 has presented for elective hip surgery. Warfarin had been ceased for four days preoperatively and on the day before surgery the international normalized ratio (INR) was 2.1. The best course of action at this point is to

a) Postpone surgery
b) Vitamin K 3mg IV
c) Prothrombinex 25IU/kg
d) Cell saver intraop
e) Proceed with surgery

Answer

A

Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS

Question 16

Q

22.1 An anaesthetised patient is ventilated and has standard monitoring plus a central venous line. As surgery commences, the line isolation monitor alarms, indicating a potential leakage current of greater than 5 mA from one of the power circuits in use. The most appropriate action is to

a) Ignore it
b) Disconnect non-essential
equipment one by one to identify fault

Answer

A

Line isolation monitor alarms when single fault in system. If the alarm is going off, the last piece of equipment plugged in is usually suspect and should be unplugged.

Question 17

Q

22.1 The dose of hydrocortisone that has equivalent glucocorticoid effect to 8 mg dexamethasone is

a) 12mg
b) 25mg
c) 50mg
d) 100mg
e) 200mg

Answer

A

200mg Hydrocortisone or 25mg Prednisolone

Conversion
Prednisone 1mg =
Hydrocortisone 4mg =
Dexamethasone 0.15mg =
Triamcinolone 0.8mg =
Methylprednisolone 0.8mg =
Betamethasone 0.15mg =

(https://litfl.com/corticosteroids-overview/)

Question 18

Q

22.1 In the World Maternal Antifibrinolytic (WOMAN) trial, tranexamic acid administration within three hours of birth reduced the

a) Decreased all cause mortality
b) Decreased mortality due to bleeding
c) Decreased transfusion
d) Decreased use of Bakri balloons
e) Increased rate of VTE

Answer

A

b) Decreased mortality due to bleeding

TXA decreased death due to bleeding.

No difference in all cause mortality.
No difference in use of blood products. No difference in surgical interventions. No difference in thromboembolic events.

Question 19

Q

22.1 Preperitoneal pelvic packing is a surgical treatment of haemorrhage from a/an

a) pelvic fracture

Answer

A

Haemodynamically unstable pelvic fracture

Question 20

Q

22.1 The gauge pressure on a gas cylinder does NOT necessarily represent the contents remaining if the cylinder is filled with

Answer

A

Nitrous oxide

Nitrous oxide boiling point -88.6C, critical temperature +36C -> so is below critical temp at room temp, therefore exists as a vapour in equilibrium with its liquid phase and is dependent upon pressure applied to it. Pressure gauge not informative – will always read ~52 bar (the pressure at which N2O liquefies at 20C). As vapour is drawn off, N2O moves from liquid to vapour phase, maintaining the equilibrium and same vapour pressure within the cylinder.
To determine contents: cylinder must be weighed and weight of empty cylinder subtracted, then number of moles of N2O in cylinder calculated using Avogadro’s number.

Question 21

Q

22.1 Maintaining a CO2 pneumoperitoneum at a pressure of 15 mmHg is most likely to lead to

a) Lactic acidosis
b) Decreased arterial blood pressure
c) Decreased heart rate
d) Increased CVP
e) Increased renal blood flow
f) Increased SVR

Answer

A

f) Increased SVR

Question 22

Q

22.1 Of the following, the drug most likely to cause pulmonary arterial vasodilation with systemic arterial vasoconstriction when used in low doses is

a) Adrenaline
b) Noradrenaline
c) Vasopressin
d) Dopamine
e) Dobutamine

Answer

A

vasopressin

https://emcrit.org/ibcc/pressors/

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

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

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

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

Question 23

Q

22.1 When fresh frozen plasma is administered to treat hypofibrinogenaemia in a bleeding patient, the volume required to achieve an increase in plasma fibrinogen concentration of one gram per litre is

A. 5 ml/kg
B. 10 ml/kg
C. 20 ml/kg
D. 30 ml/kg
E. 50 ml/kg

Answer

A

D. 30 ml/kg

Identification and Management of Obstetric Hemorrhage
Anesthesiology Clinics - Obstetric Anesthesia (2017)
https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext

Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.

Question 24

Q

22.1 You review a patient before major bowel surgery. Using the American Heart Association/American College of Cardiology consensus guidelines, you assess him as being at intermediate risk of a perioperative adverse cardiac event. When explaining this to the patient, this best translates to a numerical risk in the range of

a) 1-5%
b) 5-10%
c) 10-15%
d) 15-20%

Answer

A

Based on patient factors alone, adults can be categorized into low (<5%), borderline (5 to <7.5%), intermediate (≥7.5 to <20%), or high (≥20%) 10-year CVD risk. Source: ACC/AHA Guideline 2019

https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention

https://www.jacc.org/doi/epdf/10.1016/j.jacc.2019.03.010

Question 25

Q

22.1 Postdural puncture headache in obstetric anaesthesia is associated with a greater likelihood of all of the following EXCEPT

a. Sheehan syndrome
b. Depression
c. Chronic back pain
d. Bacterial meningitis

Answer

A

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

Encephalitis most likely answer

https://www.uptodate.com/contents/post-dural-puncture-headache

Complications of PDPH
1. Chronic Back pain
2. Hearing loss
3. Acute onset headache consider pneumopcephalus headache
4. Persistent headache
5. Increased risk of subdural haematoma
6. postpartum depression
7. bnacterial meningitis
8. Reversible cerebral vasoconstriction syndrome (RCVS)
9. Posterior reversible encephalopathy syndrome (PRES)

Question 26

Q

22.1 A woman with atrial fibrillation has no valvular heart disease. According to AHA guidelines, oral anticoagulants are definitely recommended if her CHA2DS2-VASc score is greater than or equal to

a. 2
b. 3
c. 4
d. 5
e. 6

Answer

A

REPC. 3

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

Up to date:

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

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

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

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

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

Question 27

Q

22.1 When using cardioversion to revert a patient in atrial fibrillation to sinus rhythm, the direct current shock is synchronised with the ECG to coincide with the

a. Start of R wave
b. Start of Q wave
c. Middle of T wave
d. peak of R wave

Answer

A

d) Peak of R wave

The appropriate energy level is then selected, and the discharge/shock button is pressed and held. The defibrillator does not release the shock immediately. Instead, it waits for the next R-wave to appear and delivers the shock at the time of the R-wave. This allows the shock to be provided safely away from the T wave, avoiding the R-on-T phenomenon.

Question 28

Q

22.1 A 30-year-old parturient presents in labour. She has a history of Addison’s disease from autoimmune adrenalitis and has been taking prednisolone 6 mg daily for ten years. On presentation the patient is given hydrocortisone 100 mg intravenously. The most appropriate steroid replacement regimen the patient should receive during labour is

a. 25mg TDS hydrocortisone
b. 8mg/hr hydrocortisone
c. 6mg PO prednisone

Question 29

Q

22.1 Abnormal Q waves are NOT a feature of the electrocardiogram in

A. Digitalis toxicity
B. LBBB
C. Recent transmural MI
D. Wolff-Parkinson-White
E. Previous MI

Answer

A

A. Digitalis toxicity

Miller’s
The ECG made easy
http://lifeinthefastlane.com/ecg-library/pmi/

Normal Q waves
- Due to depolarisation of the interventricular septum from left to right
- Seen in the left-sided leads (I, aVL, V5, V6)

Pathological Q waves
- > 1 mm depth
- > 1 mm (= 40 ms) across

Digoxin ECG changes
- Therapeutic: prolonged PR interval (AV nodal delay), shortened QTC intervals (rapid ventricular repolarisation), ST depression (↓ slope of phase 3), T wave inversion
- Toxic: atrial or ventricular arrhythmias (↑ automaticity), prolonged PR interval → heart block, SA node inhibition → sinus arrest
- Atrial tachycardia with block = most common arrhythmia attributed to digoxin toxicity
- VF = most frequent cause of death
- QRS = normal!

Q waves in MI
- Occur with transmural infarctions, and are less likely with subendocardial infarctions
- Develops days after the onset of AMI, and is usually permanent
- Indicates the part of the heart that has been damaged

LBBB ECG changes
- Wide QRS
- Wide QS complex in lead V1
- Wide R wave in lead V6 with slight notching at the peak and TWI
- The axis is highly variable: can be normal or deviated to the left or right

Wolff-Parkinson-White syndrome
- Due to the presence of an accessory bundle between the atrium and ventricle, which has no AV node to delay conduction
- Short PR interval
- Early slurred upstroke of the QRS complex due to delta wave

Question 30

Q

22.1 The fourth position of the international pacemaker (NBG) code represents the

A. Pacing
B. Programability
C. Sensing
D. Anti-dyrhythmic functions
E: Inhibition

Answer

A

B. Programability

Question 31

Q

22.1 In a 5-year-old child with severe life-threatening anaphylaxis and no intravenous access, the recommended initial dose of intramuscular adrenaline is

a. 100mcg
b. 150mcg
c. 300mcg
d. 500mcg
e. 600mcg

Answer

A

150mcg IM

Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min

Refractory management:
Additional IV fluid 20-40ml/kg,
Noradrenaline infusion 0.1- 2mcg/kg/min
Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Question 32

Q

22.1 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is

Answer

A

80mg

Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg

Question 33

Q

22.1 In comparison with fresh frozen plasma, cryoprecipitate contains an increased concentration of factor

a. II
b. VII
c. XI
d. XIII

Answer

A

d. XIII

But Fibrinogen (I) is the most significant factor that

Question 34

Q

22.1 Jet ventilation for shared airway surgery is traditionally delivered at pressures in atmospheres(atm) of

a. 0-4 bar

Answer

A

REPEAT

3.5 ATM

Question 35

Q

22.1 Following the initial subarachnoid haemorrhage from a ruptured aneurysm, the patient is at greatest risk of rebleeding during the following

a. 1-3 days
b. 3-5 days
c. 5-7 days
d. 7-10 days

Answer

A

a. 1-3 days

Question 36

Q

22.1 The sensory innervation to the larynx above the vocal cords is provided by the

a) External SLN
b) Internal SLN
c) RLN

Answer

A

b) Internal SLN

Question 37

Q

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

Answer

A

c) 15mg

Oral Tapentadol 25mg = 8mg Oral Morphine

Oral Oxycodone 5mg = 8mg Oral Morphine

Oral Tramadol 25mg = Oral Morphine 5mg

Oral Hydromorphone 4mg = Oral Morphine 20mg

S/L Buprenorphine 200mcg = 8mg Oral Morphine

IV Oxycodone 5mg = Oral Morphine 15mg

IV Morphine 5mg = Oral Morphine 15mg

IV Hydromorphone 1mg = Oral Morphine 15mg

Question 38

Q

22.1 The EXTEM plot from a ROTEM sample is shown. The most appropriate treatment for this bleeding patient is

(EXTEM graph with low amplitude and hyperfibrinolysis)

a. Platelets
b. TXA
c. Fibrinogen
d. Coagulation factors

Question 39

Q

22.1 A risk factor for the development of torsade de pointes is

a. hyperkalaemia
b. hypermagnasaemia
c. tachycardia
d. Female

Answer

A

d. Female

Question 40

Q

22.1 In adults the spinal cord usually extends from the brainstem to the level of the inferior margin of the

a. T12
b. L1
c. L2
d. L3

Question 41

Q

22.1 A 60-year-old woman presents for thrombectomy with left lower leg ischaemia. She has not received any medications since presentation, and takes none at home. The sole abnormality on laboratory testing is an activated partial thromboplastin time (APTT) of 52 seconds. The most likely cause of the raised APTT is

a. Lupus anticoagulant
b. Erroneous reading
c. Cold agglutinins
d. Factor VII deficiency
e. Haemophilia A

Answer

A

a. Lupus anticoagulant

Factor VII
-> prolonged PT but not APTT

Cold Agglutinins
-> prolonged PT and APTT
-> “sole abnormality”

Haemophilia A
-> isolated prolonged APTT
-> associated with bleeding and not clotting

Lupus Anticoagulation
-> increased risk of clotting
-> prolonged APTT and normal PT

Question 42

Q

22.1 The manufacturer’s instructions for use of the i-gel supraglottic airway device recommend a minimum patient weight of

a. 1
b. 2
c. 3
d. 5
e. 10

Question 43

Q

22.1 A derived value from an arterial blood gas sample is

Answer

A

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

Source LITFL

Question 44

Q

22.1 The most clinically useful indicator of effective ventilation during neonatal resuscitation is an improvement in

a. HR increases
b. Grimace
c. Resp rate

Answer

A

a. HR increases

Question 45

Q

22.1 In the awake term neonate the systolic arterial blood pressure is normally approximately

a. 55mmHg
b. 70mmHg
c. 80mmHg
d. 90mmHg

Answer

A

b. 70mmHg

Question 46

Q

22.1 Predictors of successful awake extubation after volatile anaesthesia in infants do NOT include

a. Grimace
b. RR >16
c. TV >5ml/kg
d. Conjugate gaze
e. Eye opening

Answer

A

b. RR >16
conjugate gaze
facial grimace
eye opening
purposeful movement
tidal volume greater than 5 ml/kg

Source: SPANZA 2019 article

Question 47

Q

22.1 A man underwent a heart transplant 12 months ago. A drug or therapy which is likely to result in an exaggerated effect in him is

Answer

A

Adenosine

Question 48

Q

22.1 A 30-year-old woman has had a free flap operation of eight hours duration. She received an intraoperative remifentanil infusion and was given 10 mg morphine 30 minutes before the end of the operation. In recovery her pain score has increased from 6/10 on arrival in recovery to 9/10 in spite of a further 10 mg of intravenous morphine. The most likely diagnosis is

a. Acute behavioural change
b. OIH
c. Inadequate analgesia
D. Physical dependence

Question 49

Q

22.1 Propofol infusion syndrome is characterised by all of the following EXCEPT

a. Splenomegaly
b. ST elevation
c. Hepatomegaly
d. Rhabdomyolysis
e. Metabolic acidosis

Answer

A

a. Splenomegaly

Associated with high doses >4mg/kg/hr and prolonged use (>48hrs)
Safe doses of propofol infusion for sedation in ICU are considered to be 1-4mg/kg/hr
-> fatal Cases pf PRIS have been reported after infusion doses as low as 1.9-2.6mg/kg/hr

Risk factors:
i. Young age
ii. Critical illness
iii. High fat and low Carbohydrate intake
iv. Inborn errors of mitochondrial fatty acid oxidation
v. Catecholamine infusion/ High catecholamine and glucocorticoid levels
vi. Steroid therapy
vii. Severe head injuries

Characteristics:
i. Bradycardia
ii. Severe metabolic acidosis
iii. Cardiovascular collapse
iv. Rhabdomyolysis
v. Hyperlipidaemia
vi. Renal failure
vii. Hepatomegaly

Management:
- Routine monitoring of CK and triglycerides should be performed for the at risk population
○ Daily CK and triglyceridees after 48hrs of propofol infusion
○ Increasing CK in the absence of other pathology triggers suspiscion of PRIS
- Propofol immediately stopped and alternative (midazolam and alfentanil) are used
- PRIS is difficult to treat once it occurs
- CVS support provided as needed
- Renal replacement therapy may be required to treat lactic acidosis, clear propofol and its metabolites from the patient rapidly
- Catecholamine resistant shock has been reported
- Pacing has been used with limited success
ECMO has been reported and successfully used in the CVS support of PRIS

Question 50

Q

22.1 Of the following, the drug with the LEAST effect on serum potassium is

a. Calcium gluconate
b. NaHCO3
c. Resonium
d. Salbutamol
e. Frusemide

Answer

A

a. Calcium gluconate

Question 51

Q

22.1 The risk of a perioperative respiratory adverse event in a child is least likely to be increased by

a. Asthma
b. Infection 3 weeks ago
c. History of eczema
d. Passive smoking

Answer

A

History of eczema

APRICOT study
The presence of one of the main risk factors for perioperative respiratory events (asthma, wheezing, upper respiratory tract infection, snoring and passive smoking) revealed an increased risk for bronchospasm for tracheal tubes and SGA and stridor for tracheal tubes

Question 52

Q

22.1 The underlying trigger for the development of acute traumatic coagulopathy is

a. Acidosis
b. Hypothermia
c. Endothelial damage from ischaemia
d. Dilution of coagulation factors from resuscitation
e. Activation of fibrinolysis

Answer

A

Endothelial damage due to ischaemia

Question 53

Q

22.1 Differential hypoxia is a syndrome characterised by lower arterial oxygen saturation in the upper body. It is a complication specific to the use of

a. VA ECMO
b. VV ECMO
c. ECCO2 device
d. Haemodialysis
e. Peritoneal dialysis

Answer

A

VV ECMO

VA - bleeding (large bore arterial puncture)

Question 54

Q

22.1 Under the NEXUS criteria, requirements to clear the cervical spine of trauma patients without radiographic imaging include all of the following EXCEPT

a. No midline tenderness
b. No distracting injury
c. No altered level of consciousness
d. Able to turn head 45 deg
e. No focal neurological deficit

Answer

A

d. Able to turn head 45 deg

NEXUS criteria:

One easy mnemonic for these criteria is NSAID:

Neuro Deficit
Spinal Tenderness (Midline)
Altered Mental Status/Level of Consciousness
Intoxication
Distracting Injury

Question 55

Q

22.1 A 54-year-old woman had a laryngeal mask airway inserted during anaesthesia. The next day she reports hoarseness. On indirect laryngoscopy the right vocal cord is in a paramedian position and is lower than the left vocal cord. The most likely site of the nerve injury is the right

a. SLN
b. RLN
c. Lingual
d. Hypoglossal

Question 56

Q

22.1 A patient undergoing robotic prostatectomy with volume-controlled ventilation has the following
ventilatory measurements (supplied). The static compliance is

a. 20ml/cmH2O
b. 23ml/cmH2O
c. 25ml/cmH2O
d. 30ml/cmH2O
e. 38ml/cmH2O

Answer

A

Static compliance = Tidal volume/(Plateau pressure – Total PEEP)

Total PEEP = intrinsic PEEP (or autoPEEP) + extrinsic PEEP

Question 57

Q

22.1 A patient presents for endoscopic retrograde cholangiopancreatography (ERCP) with a history of previous post-ERCP pancreatitis. The management most likely to reduce the likelihood of pancreatitis is

a. Gentamicin
b. PR indomethacin
c. Creon post op
d. Preop smoking cessation

Answer

A

Rectal indomethacin

APMSE 5th edition 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. Epidural > PCA for severe acute pancreatitis

Question 58

Q

22.1 Idarucizumab is used to reverse life-threatening gastrointestinal bleeding associated with

a. Warfarin
b. Rivaroxaban
c. Dabigatran
d. Heparin

Answer

A

c) Dabigatran

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran

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

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

Dosage Modifications

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

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

Question 59

Q

22.1 When compared to the interscalene block, the supraclavicular block has the advantage that

a. Less PTX
b. Less phrenic nerve block

Answer

A

Less phrenic nerve block

Question 60

Q

22.1 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 Support Australia (APLS) guidelines the next drug treatment should be intravenous

a. IV midazolam
b. Phenytoin
c. Levetiracetam

Answer

A

a) Midazolam 0.15mg/kg

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

Question 61

Q

22.1 In long-term use of nonsteroidal anti-inflammatory drugs, the risk of thromboembolic complications is lowest with

a. Ibuprofen
b. Celecoxib
c. Diclofenac
d. Naproxen

Answer

A

b. Celecoxib

The ANZCA pain booklet also references this study:

Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data

With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.

The ANZCA pain booklet also references this study

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281031/
Naproxen OR 1, Celecoxib OR 1.3, Ibuprofen OR 1.49, Diclofenac OR 1.63 in UK study 2016 investigating NSAID use in knee OA.

Question 62

Q

22.1 A 74-year-old man presents for a femoral popliteal artery bypass procedure for peripheral limb ischaemia. Regarding its role in modifying his perioperative cardiovascular risk, clonidine

a. Increased stroke
b. No change in complications
c. Increased death
d. Increased non fatal MI

Answer

A

Increased non fatal MI

POISE II
* clonidine 200mcg per day - did not reduce the rate of composite outcome of death or nonfatal MI - but it increased the risk of clinically important hypotension and nonfatal cardiac arrest
* aspirin initiation or continuation – no significant effect on rate of composite of death or non fatal MI but increased risk of major bleeding

Question 63

Q

22.1 A 45-year-old man presents on the day of surgery for an elective inguinal hernia repair. He is well
but is noted to be mildly jaundiced. He takes simvastatin for hyperlipidaemia and has no other medical history. He consumes about three standard drinks of alcohol per day and does not smoke. He briefly experimented with illicit drugs more than ten years ago. His laboratory results show: (supplied) The most likely diagnosis is

a. Gilbert’s
b. ETOH
c. Cirrhosis

Question 64

Q

22.1 A 50-year-old man is admitted with a stroke and undergoes cerebral angiography. The artery
marked by the arrow on the angiogram is the

a. Vertebral
b. Basilar
c. PCA
d. PICA
e. Anterior cerebral artery

Answer 55

A

Intracranial haemorrhage

AHA
https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.118.11513

Answer 56

A

Intellectual impairment

No solid refs

Answer 57

A

c. Decreased platelet function

Answer 58

A

Life threatening organ dysfunction caused by a dysregulated host response to infection

Answer 59

A

TBW

TBW (Sux and LMWH)
SOBA guidelines recommends TBW for sux and LMWH

Answer 60

A

Start exercise
Decreased perfusion resulting in onset of ischemia
RWMA–> ECG changes–> angina

Echocardiographic images recorded during ischemia show abnormalities of wall motion, thus allowing for the detection of significant coronary artery disease
https://www.sciencedirect.com/topics/nursing-and-health-professions/stress-echocardiography

Answer 61

A

c= Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.

Answer 62

A

Hereditary spherocytosis.

Auto-haemolytic, intraplenic haemolysis. High reticulocyte count (6-20%) (normal range 0.5-2%)

Answer 63

A

SS /GCS

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.

Answer 64

A

https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PS56BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper

Straight laryngoscope blades
These may be considered for patients with anterior column problems including
prominent maxillary incisors, retrognathia, large tongue and large floppy
epiglottis 74. The Miller straight blade with its low profile produces a higher
pressure on the submandibular tissues with the same force (pressure =
force/area), and can be used to lift the epiglottis directly 75 to facilitate intubation.
There is evidence to support better success rates with straight blades as a rescue
device when the Macintosh blade has failed 76, 77. However, comparative studies of
straight blades and videolaryngoscopy are lacking. As the paraglossal technique
for straight laryngoscope blades is different from Macintosh blades, training and
ongoing volume of practice is recommended for optimal use. It should be
recognised that while straight blades provide better laryngoscopic views, the
incidence of difficult intubation due to the narrower field of vision is increased 78.
* Corazelli, London,

McCoy (CLM) laryngoscope blades
When “McCoy” laryngoscope blades are in their flexed position, they apply pressure
at the base of the tongue lifting the epiglottis anteriorly and are therefore, suitable for
posterior column problems (e.g. manual inline stabilisation of head and neck 79, 80)
where the mandible and submandibular tissues are normal. However, the effect of
this levering action of McCoy blades has not been shown to consistently improve
laryngeal view 81, 82. When compared to Glidescope TM videolaryngoscopes, McCoy
laryngoscope blades resulted in longer tracheal intubation times in bariatric
patients 83.

Recommendations concerning Straight and McCoy laryngoscope blades
Page 15 PG56(A)BP Difficult airway equipment BP 2021
Advanced equipment, such as videolaryngoscopy and the common availability
of flexible bronchoscopes and intubation guides/bougies, may prove to be better
alternatives to difficult airway management. While evidence is currently lacking,
it is recommended that Straight and McCoy laryngoscope blades are not
required in DATs unless operators have been trained in their use and have
ongoing volume of practice (Weak recommendation for, level of evidence
moderate quality)

Answer 65

A

Ventilate and wait for recovery

Answer 66

A

Plasmin

Primary knowledge

Answer 67

A

MS

?repeat?

Answer 68

A

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h (0.04–0.125 IU.min)

EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h (0.125–0.25 IU.min).

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.147571 unit

Repeat

Answer 69

A

b) diclofenac

LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery

NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2

BJA: perioperative advice for psychotropic drugs

Answer 70

A

Creatinine

Also Na-MELD

Answer 71

A

c) Embolic

Blue Book 2017
Perioperative Stroke

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

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

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

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

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

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

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

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

Answer 72

A

50

4th consensus guidelines for management of PONV

Answer 73

A

Cephazolin

Answer 74

A

Aortic stenosis

Answer 75

A

d

a. Accessory nerve (Trapezius paralysis, causing lateral winging)
b. Long thoracic N- (Serratus anterior paralysis, causing medial winging)
c. Dorsal scapular N (Rhomboids paralysis, causing lateral winging)
d. Suprascapular nerve (Infra and supraspinatus – doesn’t affect scapula)

Answer 76

A

Elevated IGF1 with GH non suppression

Repeat

Answer 77

A

Hypoasthesia - Veldman criteria

Pain distal to primary injury – Not mentioned specifically in Budapest criteria, but in Veldman

Hypoaesthesia = reduced sensation to pain

Answer 78

A

e. Defer and refer to haematology for further Ix

Answer 79

A

6.5mm

Aintree 4.7mm ID, 6.5mm ED (will accept a 42mm FOB and size 7 ETT)

repeat

Answer 80

A

5 days

Previous MCQ2015A – cryoprecipitate once thawed must use within 4 hours.

Previous MCQ2015B – FFP must be transfused within 4 hours once thawed, or stored at 2-6 degrees for 5 days.

Answer 81

A

Sx and exacerbations

GOLD ABCD assessment tool

Answer 82

A

Mast cell degranulation - anaphylactic reaction

Answer 83

A

Tell surgeon to deflate / remove pneumoperitoneum

?endobronchial intubation caused by pneumoperitoneum-> loss of lung sliding but continual lung pulse?

Lung pulse:
Cardiac contraction is sufficiently forceful as to move the lung in synchrony with the cardiac cycle. This movement is readily detected as cardiophasic movement of the pleural line. It has the same implication as detection of respirophasic movement of the pleural line which termed lung sliding (ie, there is no pneumothorax at the site of probe application on the chest wall).

Answer 84

A

HOCM: pathopneumonic

A person who has syncope during exertion is more likely to have an obstruction to blood flow (aortic stenosis or hypertrophic cardiomyopathy) or ventricular tachycardia as a cause. On the other hand, syncope after completion of exercise is more likely of reflex origin, such as the common faint.

https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics#:~:text=A%20person%20who%20has%20syncope,such%20as%20the%20common%20faint

Answer 85

A

No change in outcomes

repeat

Answer 86

A

RUL

APALM
APIS APAL

Answer 87

A

ION
Post - spinal
Ant - cardiac

repeat

Answer 88

A

100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O

https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3

Answer 89

A

Ischaemic optic neuropathy (ant)

https://www.researchgate.net/figure/Top-Funduscopic-examination-revealed-pale-and-swollen-discs-with-small-hemorrhages-on_fig2_6759964

Answer 90

A

a. Proceed with lobectomy or pneumonectomy

FEV1 surgical suitability:
- >80% or >2l pneumonectomy
○ no further testing required
- >80% or >1.5l lobectomy
○ no further testing required
- <80% or <2l for pneumonectomy
○ -> calculate ppoFEV1
- <80% or <1.5l for lobectomy
○ -> perform DLCO and express as % of predicted DLCO
○ Saturations on air
- ppoFEV1 < 40% and DLCO <40% = High Risk
-> check VO2 Max <15ml/o2/min-> advised not to proceed
- ppoFEV1 >40% and DLCO >40% and SaO2 >90% = Average risk (no further testing)

Answer 91

A

a. Electrical alternans

Beck’s Triad
- Muffled heart sounds
- Engorged veins
- Widened pulse pressure (hypotension)

IVC shouldn’t collapse in tamponade due to raised ra pressure
Electrical alternans is seen in tamponade/pericardial effusion
REPEAT

Answer 92

A

hydroxycobalamin

Answer 93

A

HYPERCa2+

Answer 94

A

Maximum P-wave corresponds to placement in the Cavo-atrial Junction (CAJ)

Benefits of CAJ placement
- furthest distance from “high risk” areas
- Largest vein diameter
- highest blood flow capacity
- minimal risk for catheter migration and looping

Too short placement:
Increased risk of:
- DVT
- Phlebitis

Too long placement:
Increased risk of:
- arrhythmias
- tricuspid valve dysfunction
atrial dysfunction

ECG and corresponding anatomy:

Normal P-wave = upper vasculature prior to CAJ
Max P-wav= CAJ
Initial negative P-wave deflection = Right Atrium
Biphasic P-wave = Right Atrium
Inverted P-wave = Right Ventricle

Answer 95

A

a. Saphenous

sensory only

rapid onset more suggestive or direct injury to nerve, later onset suggestive of ischaemia relating to oedema
mulscular injury related to tourniquet results in swelling/pain/weakness of affected muscle
post tourniquet syndrome - swollen, pale, stiff, weakness but not paralysis
L5 radiculopathy would affect knee flexion, but would have presented immediately post op if spinal related

Answer 96

A

c. 30cmH2O
Paeds 20cmH20

Answer 97

A

e. Sotalol

Drugs that INCREASE defibrillation threshold:
+ Amiodarone (Chronic)
+ Atropine
+ lignocaine
+ Diltiazem
+ Flecainide
+ Verapamil
+ Venlafaxine
+ Anaesthetic agents.

Drugs that DECREASE defibrillation threshold:
- Sotalol
- Amiodarone (acute)
- Nifekalant

Drugs with No Change in DFT
= B- blocker
= Disopyramide
= Procainamide
= Propafenone

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304797/

Answer 98

A

Extensive Brachial plexus anatomy questions produced in 2022.2 paper on Brainscape

Answer 99

A

a. 1%

i.e. what is the positive predictive value (PPV) for this test

PPV= TP/ TP +FP
Negative Predictive Value = TN / TN + FN

Prevalence of 1/1000
Sensitivity of 100%
Specificity of 90%

Of patients that are disease positive in population of 1000
TP = 1
FN = 0
-> 100% sensitivity

Of patients that are disease negative in population of 1000
FP = 99
TN = 900
-> 90% Specificity

PPV= 1/ 1 + 99
= 1/100
=1%

NPV= 900/ 900 + 0
= 1/1
= 100%

Answer 100

A

REPphotosensitivity

Gliolan (PI):

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

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

Answer 101

A

Reduced Myoglobinaemia

Repeat but its not myoglobinuria it was myoglobinaemia

There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria)
There IS less increase in ETCO2
There IS less muscle rigidity

Answer 102

A

Qincreased SVR

EMSB handbook
CO is reduced after Burn injury 2ry to:
- myocardial depressant mediators
- decreased blood volume
- reduced venous return
- increased pulmonary and systemic vascular resistance due to increased levels of catecholamines

In the first 24hrs reduced cardiac output persists even after restoration of blood volume

Between 24-48hrs post burn a hyperdynamic state develops with reduced peripheral resistance, increased oxygen consumption and increased cardiac outputuestion 6
Discuss the implications of anticoagulation as well as an appropriate
anticoagulant management strategy for a 25-year-old with a mechanical aortic
valve for the duration of pregnancy, delivery and the postpartum period.
Pass Rate 43.9%
This question required candidates to demonstrate an adequate understanding of
anticoagulation principles for a mechanical valve prosthesis and extrapolate these
principles and their implications to gestation and the peripartum period.
The discussion requirements for a pass to this question were as follows:
* Continuation of anticoagulation up until close to delivery
* Potential effects of anticoagulation on the fetus, including teratogenicity and
fetal loss risks due to haemorrhage
* Implications for neuraxial techniques
* Risk of major bleeding
There were many who overlooked key components to the question and focused on
only one or two facets of the question, which was inadequate to gain a pass. Some
candidates appeared to have been short of time given the brevity of some of the
answers.
Better answers also included a discussion that these are high risk pregnancies, with
death and thromboembolic complications possible in the mother, and the place of
other therapeutic options pre- and post-delivery such as low molecular weight
heparin

Answer 103

A

a. Apert syndrome

REPEAT

Answer 104

A

REAPEAT

Muscle relaxants

SSEPS - opioids

Answer 105

A

cerebral palsy

Suxamethonium is
contraindicated in patients with recent burns or
spinal cord trauma causing paraplegia (can be given
immediately after the injury, but should be avoided
from approximately day 10 to day 100 after the injury)

Sux is not recommended in patients with neuromuscular disease due to:
1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis
2. fasiculations causing temperomandibular muscle spasm preventing intubation

Answer 106

A

Postpone 3 months and give oral iron

Answer 107

A

3b
Category GFR
ml/min/1.73 m2 Terms
G1 ≥90 Normal or high
G2 60-89 Mildly decreased*
G3a 45-59 Mildly to moderately decreased
G3b 30-44 Moderately to severely decreased
G4 15-29 Severely decreased
G5 <15 Kidney failure

Answer 108

A

Inconclusive

Answer 109

A

5d

ANZCA - CrCl >80 (3D) 80-50 (4D) <50 (5D)

Answer 110

A

b. Octreotide 50mcg bolus

Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small.

It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy

https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 111

A

d. Superficial peroneal and tibial

REPEAT

Sural nerve would also need blocked for skin surface - see anso

Answer 112

A

a. Normal SpO2, Normal PaO2

ABG

HbCO (elevated levels are significant, but low levels do not rule out exposure)
lactate (tissue hypoxia)
PaO2 should be normal, SpO2 only accurate if measured (not calculated from PaO2)
MetHb (exclude)

https://litfl.com/carbon-monoxide-poisoning/

Answer 113

A

c. Superior sagittal

Risk factors for venous air embolism include sitting craniotomy, posterior fossa surgery and procedures near the superior sagittal sinus. In these situations, the surgical site is often above the level of the right atrium and hence venous air entrainment is facilitated, or there is a large risk of venous exposure through which air may be entrained. Depending on the volume of air entrained, reduced end-tidal carbon dioxide, arrhythmias or right heart failure and cardiovascular collapse are all possible. However, changes in clinical parameters often occur late and are nonspecific for small volumes of entrainment. Specific monitoring for detection of venous air embolism includes non-invasive means such as end-tidal nitrogen, precordial Doppler or stethoscope and transcranial Doppler. Invasive methods include transoesophageal echocardiography, oesophageal stethoscope, pulmonary artery catheter and central venous pressure monitoring.

https://resources.wfsahq.org/atotw/anaesthesia-for-craniotomy-and-brain-tumour-resection/

Answer 114

A

c. Warfarin

It is also a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, midazolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs

Answer 115

A

c. Long E time

Spont vent not appropriate for this surgery as will require RSI so spont vent can’t be ensured

BJA: fontan circulation:
For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure.

https://academic.oup.com/bjaed/article/8/1/26/277637

Answer 116

A

b. 1 or more RF

In this iteration of the PONV guideline, one of the major changes is that we now recommend the use of multimodal prophylaxis in patients with one or more risk factors. This decision was made due to the concern over inadequate prophylaxis as well as the availability of antiemetic safety data.

Answer 117

A

Fibrinolysis

In APTEM, coagulation is also activated as in EXTEM. By the addition of aprotinin or tranexamic acid in the reagent, fibrinolytic processes are inhibited in vitro.

The comparison of EXTEM and APTEM allows for a rapid detection of fibrinolysis. Furthermore, APTEM enables the estimation if an antifibrinolytic therapy alone normalises the coagulation or if additional measures have to be taken (e.g. administration of fibrinogen).

Answer 118

A

b. Clonidine
PROSPECT 2021
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299

Pre-operative and intra-operative interventions that improved postoperative pain were:
- paracetamol;
- non-steroidal anti-inflammatory drugs;
- intravenous dexamethasone;
- ketamine (only assessed in children);
- gabapentinoids;
- dexmedetomidine;
- honey;
- acupuncture.

Inconsistent evidence was found for:
- local anaesthetic infiltration;
- antibiotics;
- magnesium sulphate.
Limited evidence was found for
- clonidine.

The analgesic regimen for tonsillectomy should include:
1. paracetamol;
2. non-steroidal anti-inflammatory drugs; and
3. intravenous dexamethasone,
4. with opioids as rescue analgesics.

Analgesic adjuncts such as:
1. intra-operative and postoperative acupuncture as well as
2. postoperative honey are also recommended.
3. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated

Answer 119

A

c. Dobutamine

In 2017 a similar questions was asked and an option for metaraminol was given, metaraminol could be a better answer as it will increase syutemic pressure and reduce heart rate maintaining RCA perfusion at induction. Dobutamine and milrinone can cause systemic vasodilation leading to reduction in systemic blood pressure and RCA perfusion pressure, Both adrenaline and Dopamine do not cause pulmonary vasodilation and can lead to tachyarhythmias

Pulmonary hypertension and its management in patients undergoing non-cardiac surgery
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.12831

Vasoconstrictors, inotropes and inodilators

Maintaining the gradient between aorta and right ventricle is achieved by using sympathomimetic and non-sympathomimetic vasopressors. Noradrenaline and vasopressin improve perfusion of the right coronary artery, reduce the pulmonary/systemic vascular resistance ratio, enhance right ventricular performance and marginally improve cardiac output

However, the evidence of their impact on mortality related to right heart failure is weak. Inotropes that enhance right ventricular performance, such as adrenaline, dobutamine and levosimendan are effective in treating right-sided heart failure.

The use of inotropes has a modest impact in reducing the overall mortality related to PH, and their wide availability and ease of administration make this group of drugs very attractive for use in the peri-operative setting.

Inodilators, such as the phosphodiesterase-3 inhibitors milrinone and enoximone, have been shown to be beneficial when compared with conventional inotropic support only. It appears that the influence of phosphodiesterase-3 inhibitors on reducing pulmonary vascular resistance is more pronounced than the reduction in systemic vascular resistance. However, reduction in systemic vascular resistance can compromise right coronary artery blood flow in patients with severe PH and therefore they should be administered cautiously.

Treatment of pulmonary hypertensive crisis:

General principles
- Avoid hypoxic pulmonary vasoconstriction
- Avoid hypercarbia, acidosis and hypothermia
- Avoid high airway pressures
- Optimise right ventricular preload
- Reduce right ventricular afterload
- Maintain coronary blood flow
- Maintain sinus rhythm
- Maintain arterial blood pressure and cardiac output

Vasopressors– noradrenaline; vasopressin

Inotropes– adrenaline; dobutamine

Inodilators– milrinone; enoximone

Intravenous vasodilators (caution if low systolic blood pressure)
- Milrinone (25–50 μg.kg−1 bolus, followed by 0.5–0.75 μg.kg−1.min−1 continuous infusion)
- Prostacyclin (4–10 ng.kg−1.min−1 continuous infusion)
- Iloprost (1–3 ng.kg−1.min−1 continuous infusion)
- Sildenafil (10 mg bolus three times a day)

Selective pulmonary vasodilation
- Iloprost (5–10 μg diluted in 10 ml saline, nebulised over 10 min, repeated every 2–4 h)
- Prostacyclin (25–50 μg diluted in 50 ml saline, nebulised over 15 min, repeated every hour)
- Nitric oxide (5–40 ppm continuously)

Answer 120

A

Forming a research question and literature review

REPEAT

Answer 121

A

d. L5/S1 disc prolapse with compression of interveterbral foramina pathology

BJA: Chronic BAck Pain
https://academic.oup.com/bjaed/article/6/4/152/387156?itm_medium=sidebar&itm_source=trendmd-widget&itm_campaign=BJA_Education&itm_content=BJA_Education_0

Neurological examination may reveal sensory, motor and reflex abnormalities. Nerve root pain can be caused by disc herniation, spinal stenosis and epidural adhesions. The nerve roots leave the spinal canal via the intervertebral foramina.

Answer 122

A

b. 100ml
4mg/kg blood will raise Hb by 10g/L
Paediatric weight estimation:
Luscombe: Weight (kg) = (age x 3) + 7
RCH: Weight (kg) = (age + 4) x 2

Formula for calculating transfusion volume (mL)
Children <20 kg:
PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor)

Children >20 kg: 1 unit PRBC

Example:
6 + 4 x 2 = 20kg

20kg x 10g/l x 0.5 = 100ml

Answer 123

A

a. Obesity

Obesity and pulmonary function testing
https://www.jacionline.org/article/S0091-6749(05)00164-8/fulltext

Full pulmonary function tests are often necessary to better characterize the spirometric abnormalities seen in the obese patient
The most sensitive indicator of obesity is a low expiratory reserve volume (ERV) and functional residual capacity
Restriction is seen in more severe obesity, with reductions in TLC and FVC.
However, residual volume is often preserved because of the relative high closing volume in relation to ERV.

Answer 124

A

b. Procainamide
BJA: Perioperative cardiac arrhythmias
https://academic.oup.com/bja/article/93/1/86/265716

Paroxysmal SVT (PSVT) due to re‐entrant circuits that involve accessory pathways (congenital electrical connections between the atrium and ventricle that bypass the AV node, such as Wolff–Parkinson–White Syndrome) pose caveats in the management of SVT.
It should be noted that patients with accessory pathways, in addition to PSVT, may also develop atrial fibrillation, and in the latter situation are at increased risk for developing ventricular fibrillation (VF) upon exposure to classic AV‐nodal blocking agents (digoxin, calcium channel blockers, beta blockers, adenosine) because these agents reduce the accessory bundle refractory period.
In such cases, i.v. procainamide, which slows conduction over the accessory bundle, is an acceptable option. Flecainide and amiodarone should also be considered, and cardiology consultation may be helpful.2

Answer 125

A

b. 0.4

BJA: Monitoring of neuromuscular block
https://academic.oup.com/bjaed/article/6/1/7/347026

When neuromuscular monitoring is used, visual or tactile evaluation of the degree of neuromuscular block is unreliable.

Even experienced anaesthetists are unable to detect fade when the TOF ratio is >0.4.

It is now thought that significant residual curarization is still present if the TOF ratio is <0.97 (not 0.7 as previously suggested8).

Answer 126

A

d. Severe liver failure
but could also be
e. Sepsis

LIFTL:

INTERPRETATION

High SvO2
- increased O2 delivery (increased FiO2, hyperoxia, hyperbaric oxygen)
- decreased O2 demand (hypothermia, anaesthesia, neuromuscular blockade)
- high flow states: sepsis, hyperthyroidism, severe liver disease

Low SvO2
- decreased O2 delivery:
1. decreased Hb (anaemia, haemorrhage, dilution)
2. decreased SaO2 (hypoxaemia)
3. decreased Q (any form of shock, arrhythmia)

increased O2 demand (hyperthermia, shivering, pain, seizures)
Causes of High SvO2 despite evidence of End-organ Hypoxia:
1. microvascular shunting (e.g. sepsis)
2. histotoxic hypoxia (e.g. cyanide poisoning)
3. abnormalities in distribution of blood flow

Anesthesia Monitoring Of Mixed Venous Saturation:
https://www.ncbi.nlm.nih.gov/books/NBK539835/

In sepsis, ScvO2 less than 70% or SvO2 lower than 65% correlate with poor prognosis.[2] In application, certain studies have shown that maintaining a goal ScvO2 greater than 70% leads to reduced mortality.[11] Therefore, ScvO2 is used to guide treatment algorithms in the Surviving Sepsis Campaign (SSC).

Studies have shown that normal to higher levels of mixed venous oxygen saturation in patients with clinically worsening sepsis do not rule out tissue hypoxia due to the inability to utilize O2.[11][7] Therefore, several studies support the conclusion that abnormally low or high ScvO2 correlates with higher mortality in patients with septic shock.

Answer 127

A

d. 7 days

A bolus dose of sugammadex is thought to have the following consequences:
(i) the equivalent of missing one daily dose of oral contraceptives, and
(ii) reduced efficacy of other hormonal contraceptives (e.g. implant, vaginal ring, or intrauterine system) requiring additional non-hormonal contraception be used for 7 days.

https://www.bjanaesthesia.org/article/S0007-0912(18)30198-3/fulltext

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