22.1 Flashcards
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
A
Repeat
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
A
c. Diuretic
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
A
RCA or LCx
4
Q
22.1 The recommended filter grade of a needle to be effective in excluding microorganisms is
A
0.20 um
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
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
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
A
= ΔP = 4v2 = 4 x 9 = 36
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
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
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
A
Nebulised Adrenaline
1mg
0.5ml/kg of 1:1000 Adrenaline nebulised
once adrenaline given consider dose of Steroid dexamethasone or hydrocortisone
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
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.
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
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.
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
A
Glossopharyngeal
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
A
Does not remove foetal red cells or vasoactive molecules (eg don’t use in pheochromocytoma surgery).
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
A
Oscillations in the tube will be diminished
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
A
Leave in situ and contact vascular surgeons
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
A
Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS
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
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.
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
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/)
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
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.
19
Q
22.1 Preperitoneal pelvic packing is a surgical treatment of haemorrhage from a/an
a) pelvic fracture
A
Haemodynamically unstable pelvic fracture
20
Q
22.1 The gauge pressure on a gas cylinder does NOT necessarily represent the contents remaining if the cylinder is filled with
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.
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
A
f) Increased SVR
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
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
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
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.
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%
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
25
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
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)
26
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
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
27
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
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.
28
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
8mg/hr
29
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
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
30
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
B. Programability
31
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
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
32
22.1 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is
80mg
Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg
33
22.1 In comparison with fresh frozen plasma, cryoprecipitate contains an increased concentration of factor
a. II
b. VII
c. XI
d. XIII
d. XIII
But Fibrinogen (I) is the most significant factor that
34
22.1 Jet ventilation for shared airway surgery is traditionally delivered at pressures in atmospheres(atm) of
a. 0-4 bar
REPEAT
3.5 ATM
35
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
a. 1-3 days
36
22.1 The sensory innervation to the larynx above the vocal cords is provided by the
a) External SLN
b) Internal SLN
c) RLN
b) Internal SLN
37
22.1 The oral morphine equivalent of tapentadol 50 mg (immediate release) is
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
38
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
b. TXA
39
22.1 A risk factor for the development of torsade de pointes is
a. hyperkalaemia
b. hypermagnasaemia
c. tachycardia
d. Female
d. Female
40
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
b. L1
41
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
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
42
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
b. 2
43
22.1 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
44
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
a. HR increases
45
22.1 In the awake term neonate the systolic arterial blood pressure is normally approximately
a. 55mmHg
b. 70mmHg
c. 80mmHg
d. 90mmHg
b. 70mmHg
46
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
b. RR >16
conjugate gaze
facial grimace
eye opening
purposeful movement
tidal volume greater than 5 ml/kg
Source: SPANZA 2019 article
47
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
Adenosine
48
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
b. OIH
49
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
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
50
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
a. Calcium gluconate
51
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
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
52
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
Endothelial damage due to ischaemia
53
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
VV ECMO
VA - bleeding (large bore arterial puncture)
54
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
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
55
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
RLN
56
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
Static compliance = Tidal volume/(Plateau pressure – Total PEEP)
Total PEEP = intrinsic PEEP (or autoPEEP) + extrinsic PEEP
57
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
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
58
22.1 Idarucizumab is used to reverse life-threatening gastrointestinal bleeding associated with
a. Warfarin
b. Rivaroxaban
c. Dabigatran
d. Heparin
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
59
22.1 When compared to the interscalene block, the supraclavicular block has the advantage that
a. Less PTX
b. Less phrenic nerve block
Less phrenic nerve block
60
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
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
61
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
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.
62
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
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
63
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
Gilberts
64
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
65
22.1 The most common cause of maternal mortality in women with preeclampsia is
a. Renal failure
b. Hepatic failure
c. Intracranial haemorrhage
Intracranial haemorrhage
AHA
https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.118.11513
66
22.1 A patient with a body mass index 34 kg/m2 with no other disease has an ASA (American Society of Anesthesiologists) Physical Classification of at least
a. I
b. II
c. III
d. IV
b. II
67
22.1 Ehlers-Danlos Syndrome is associated with each of the following EXCEPT
a. Blood vessel fragility
b. LA resistance
c. Intellectual impairment
d. Glaucoma
Intellectual impairment
No solid refs
68
22.1 The effect of a drop in patient core temperature from 37 C to 34 C is to
a. Increased k time
b. Decreased viscosity
c. Decreased platelet function
c. Decreased platelet function
69
22.1 According to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis is defined as
a. SIRS criteria
b. Life threaning organ dysfunction with vasopressor requirement to maintain MAP >65 and lactate >2
c. Life threatening organ dysfunction caused by a dysregulated host response to infection
d. sBP <100, RR>22, altered mentation
Life threatening organ dysfunction caused by a dysregulated host response to infection
70
22.1 According to the 6th National Audit Project, the likelihood that a patient who reports an allergy to penicillin has a true allergy is approximately
a. 10%
b. 30%
c. 50%
d. 70%
e. 90%
10%
Nap6
71
22.1 The calculation of the initial dose of suxamethonium for a morbidly obese patient should be based upon
a. IBW
b. LBW
c. TBW
TBW
TBW (Sux and LMWH)
SOBA guidelines recommends TBW for sux and LMWH
72
22.1 A 70-year-old man undergoes a stress echocardiogram as part of his preoperative preparation before a total hip replacement. If he has clinically significant coronary artery disease, the earliest indicator during his test is most likely to be
a. Angina
b. ECG changes
c. Hypotension
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
73
22.1 Regarding the Australian and New Zealand categorisation system for prescribing medicines in pregnancy, Category C medicines are ones which
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.
74
22.1 An adult male patient has a haemoglobin level of 80 g/L and his blood film shows a reticulocyte count of 10%. These findings are compatible with
a. ALL
b. Spherocytosis
c. Aplastic anaemia
d. Pernicious anaemia
e. Anaemia of chronic disease
Hereditary spherocytosis.
Auto-haemolytic, intraplenic haemolysis. High reticulocyte count (6-20%) (normal range 0.5-2%)
75
22.1 Once a transfusion of a unit of packed red blood cells is commenced, the transfusion of that unit should be completed within
a. 1 hour
b. 2 hours
c. 4 hours
4 hrs
76
22.1 The most reliable clinical indicator of opioid-induced ventilatory impairment (OIVI) is decreased
a. Sedation
b. Respiratory rate
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.
77
22.1 A straight laryngoscope blade is likely to be more useful than the Macintosh blade when
performing direct laryngoscopy in patients with all of the following EXCEPT
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)
78
22.1 Prolonged paralysis associated with mivacurium is most appropriately managed with
a. Give FFP
b. Give pradolixime
c. Ventilate and wait for recovery
d. Sugammadex
Ventilate and wait for recovery
79
22.1 The mechanism of action of tranexamic acid is to inhibit the formation of
a. Plasminogen
b. Plasmin
c. Fibrin
d. fibrinogen
Plasmin
Primary knowledge
80
22.1 Local anaesthetics may exacerbate symptoms in patients with
MS
?repeat?
81
22.1According to the international consensus statement on uterotonic agents during caesarean section published in 2019, the suggested initial bolus dose of oxytocin to be administered after delivery of
the fetus during an elective caesarean section is
a. 1 unit
b. 3 units
c. 5 units
d. 10 units
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
82
22.1 A patient with bipolar disorder is on long-term lithium therapy. The medication that should be avoided is
a. Parecoxib
b. Gabapentin
c. Oxycodone
d. Paracetamol
e. Codeine
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
83
22.1 A 45-year-old woman is being assessed for liver transplantation. In order to determine the severity of her liver disease the Model for End-stage Liver Disease score is derived using the international normalised ratio, serum bilirubin and
a. Creatinine
b. Albumin
Creatinine
Also Na-MELD
84
22.1 The most common type of perioperative stroke is
a. Embolic
b. Hypotensive
c. Thrombotic
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.
85
22.1 A risk factor for postoperative nausea and vomiting in adults is age less than
a. 20
b. 30
c. 40
d. 50
e. 60
50
4th consensus guidelines for management of PONV
86
22.1 A patient has a known IgE-mediated allergy to penicillin. The cephalosporin with the lowest risk of allergic cross-reactivity is
a. Ceftazidime
b. Cefoxitin
c. Cephazolin
Cephazolin
87
22.1 A 68-year-old woman presents with a loud systolic murmur in the anaesthesia room before total
hip joint arthroplasty. A transthoracic echocardiogram is performed (image provided) and shows
a. AS
b. LVOT
c. MR
MR
88
22.1 A 78-year-old man is undergoing left heart catheter angiography. A graph displaying pressures in the aorta (Ao) and left ventricle (LV) as well as electrocardiography trace over time is demonstrated below. These pressure recordings are characteristic of
a. MR
b. MS
c. AR
d. AS
e. TR
Aortic stenosis
89
22.1 The abnormality shown in this image (image of shoulder shown) is LEAST likely to be caused by
an injury to the
a. Accessory nerve N
b. Long thoracic N
c. Dorsal scapular N
d. Suprascapular N
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)
90
22.1 The biochemical diagnosis of a growth hormone (GH)-secreting tumour such as in acromegaly is
based on oral glucose tolerance test demonstrating
a. Elevated GH with IGF-1 non suppression
b. Elevated IGF1 with GH suppression
c. Elevated IGF1 with GH non suppression
d. Elevated GH with IGF 1 suppression
e. Elevated GH and IGF1
Elevated IGF1 with GH non suppression
Repeat
91
22.1 Complex regional pain syndrome is NOT characterised by
a. Vasomotor
b. Sudomotor
c. Pain distal to primary injury –
d. Hypoaesthesia
e. Edema
Hypoasthesia - Veldman criteria
Pain distal to primary injury – Not mentioned specifically in Budapest criteria, but in Veldman
Hypoaesthesia = reduced sensation to pain
92
22.1 A 45-year-old woman is reviewed in the preadmission clinic. She is scheduled to undergo a microwave endometrial ablation for menorrhagia in one week’s time. Her preoperative laboratory investigations include the following blood results (full blood examination and iron studies shown).
The most appropriate course of action would be to
a. Proceed
b. Iron IV then proceed
c. Transfuse 2 RBC intraop
d. Use cell saver intraop
e. Defer and refer to haematology for further Ix
e. Defer and refer to haematology for further Ix
93
22.1 The outer diameter of an Aintree Intubation Catheter is
a. 4.8mm
b. 6.5mm
c. 7mm
6.5mm
Aintree 4.7mm ID, 6.5mm ED (will accept a 42mm FOB and size 7 ETT)
repeat
94
22.1 Extended life plasma is thawed fresh frozen plasma which can be stored at 2 to 6 C for a
maximum period of
a. 2 days
b. 3 days
c. 5 days
d. 7 days
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.
95
22.1 Created by the Global Initiative for Chronic Obstructive Lung Disease, the alphabetical GOLD groups A to D are tools for the assessment of chronic obstructive pulmonary disease. These classes are based on
a. Symptoms and exacerbations
b. FEV1
c. FEV1 and exacerbations
d. FEV1/FVC and exacerbations
e. FEV1 and symptoms
Sx and exacerbations
GOLD ABCD assessment tool
96
22.1 Red man syndrome as a consequence of vancomycin administration is caused by
a. Type II hypersensitivity reaction
b. IgE sensitivity
c. Vasodilation of vessels
d. Mast cell degranulation
Mast cell degranulation - anaphylactic reaction
97
22.1 A 35-year-old patient is undergoing a diagnostic laparoscopy. Three minutes after insufflation of CO2 her oxygen saturation falls to 85%. You note decreased air entry on the left side of her chest.
Lung ultrasound on the left reveals lung pulse and no lung sliding. The best first action is to
a. Tell surgeon to deflate
b. Needle decompression
c. Chest drain
d. Pigtail drain
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).
98
22.1 A 26-year-old patient presents with exertional syncope. The most likely diagnosis is
a. HOCM
b. Long QT syndrome
c. CCF
d. IHD
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
99
22.1 Bowel preparation prior to elective colorectal surgery is associated with
a. No change
b. Decreased risk of surgical site infection
c. Decreased risk of anastomotic breakdown
d. Something about mortality/morbidity
No change in outcomes
repeat
100
22.1 The part of the lung that is typically divided into apical, anterior and posterior segments is the
a. RUL
b. RML
c. RLL
d. LUL
e. LLL
RUL
APALM
APIS APAL
101
22.1 The most common cause of bilateral blindness following spinal surgery and anaesthesia is
a. Ischaemic optic neuropathy
b. Retinal artery occlusion
c. Retinal detachment
d. Cortical stroke
ION
Post - spinal
Ant - cardiac
repeat
102
22.1 The 2012 Berlin definition of the Acute Respiratory Distress Syndrome (ARDS) defines moderate disease as one with a PaO2 / FiO2 ratio (in mmHg) of
100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O
https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3
103
22.1 This image is an apical four chamber view obtained by transthoracic echocardiography. The artery that supplies the area indicated by the arrow is the
a. RCA
b. LAD
c. CCx
104
22.1 A patient has undergone a multilevel cervical spine fusion and upon emergence from anaesthesia reports complete visual loss. Fundoscopic examination shows a pale optic disc with haemorrhages. This supports a diagnosis of
a. CRAO
b. AION
c. PION
Ischaemic optic neuropathy (ant)
https://www.researchgate.net/figure/Top-Funduscopic-examination-revealed-pale-and-swollen-discs-with-small-hemorrhages-on_fig2_6759964
105
22.1 An asymptomatic 65-year-old male with squamous cell carcinoma of the left lung has been referred for assessment of suitability for lung resection. There is no evidence of spread on computerised tomography scanning. PaCO2, electrocardiogram, full blood count and electrolytes are normal. His SpO2 on room air is 95%. His forced expiratory volume in one second is 2.3 litres (predicted 3.3 litres) and forced vital capacity is 3.4 litres (predicted 4.4 litres). The most appropriate course of action is to
a. Proceed with lobectomy or pneumonectomy
b. Proceed with lobectomy only
c. DLCO testing
d. Lung V/Q scan
e. CPET
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)
106
22.1 Findings associated with massive pericardial tamponade include
a. Electrical alternans
b. Exaggerated collapsible IVC on ECHO during respiratory cycle
c. Pulses alternans
d. Kussmaul breathing
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
107
22.1 The first-line drug recommended by both the Australian Resuscitation Council and the New Zealand Resuscitation Council to treat severe cyanide poisoning is
a. Methylene blue
b. Hydroxycobalamine
c. Sodium thiosulfate
hydroxycobalamin
108
22.1 Complications of severe anorexia nervosa (body weight < 40% ideal) include all of the following EXCEPT
a. HypoK
b. Cl abnormality
c. Delayed gastric emptying
d. Hypercalcaemia
e. Cardiomyopathy
HYPERCa2+
109
22.1 A patient requires a peripherally inserted central venous catheter. Electrocardiographic (ECG)-aided tip localisation is used to site the tip of the catheter. The initial ECG from the catheter is shown.
The ECG when the catheter is placed appropriately will be
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
110
22.1 You are asked to review a patient two days after a surgically difficult total knee replacement that was undertaken under tourniquet. The anaesthesia and analgesia technique used was spinal anaesthesia in combination with an ultrasound-guided adductor canal block and high-volume local anaesthetic infiltration by the surgeon. The patient complains of a new onset of leg weakness on the operative side. The nerve LEAST likely to be involved in this weakness is the
a. Saphenous
b. Femoral
c. Sciatic
d. Deep peroneal
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
111
22.1 When using an endotracheal tube in an adult, the highest recommended cuff pressure to avoid mucosal ischaemia is
a. 10cmH2O
b. 20
c. 30
d. 40
e. 50
c. 30cmH2O
Paeds 20cmH20
112
22.1 A drug which does NOT increase the defibrillation threshold in a patient with an implanted cardioverter defibrillator is
a. Amiodarone
b. Atropine
c. B-blocker
d. Flecainide
e. Sotalol
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/
113
22.1 The nerve labelled by the arrow in the diagram (image of brachial plexus given) is the
a. Median nerve
b. MC nerve
c. Radial nerve
d. Ulnar nerve
Extensive Brachial plexus anatomy questions produced in 2022.2 paper on Brainscape
114
22.1 A test for a condition which has a prevalence of 1 in 1000 has a sensitivity of 100% and a
specificity of 90%. The probability of a patient who receives a positive result actually having the
condition is
a. 1%
b. 10%
c. 50%
d. 100%
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%
115
22.1 This posteroanterior chest X-ray shows enlargement of the
(everyone seems to be unsure of answer, no image supplied)
a. Aorta
b. RA
c. RV
d. LA
e. LV
116
22.1Your 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
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.
117
22.1 Anaesthesia-induced rhabdomyolysis differs from malignant hyperthermia in that it is NOT
a. Reduced myoglobinuria
b. Less increase in ETCO2
c. Less muscle rigidity
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
118
22.1 You are planning to perform a peribulbar block and wish to check the axial length of the eye prior to proceeding. The average axial length of the globe in adults as measured by ultrasound is
a. 20mm
b. 23mm
c. 26mm
d. 29mm
e. 32mm
B 23mm
119
22.1 A 25-year-old man suffers a 30% total body surface area burn. A physiological change expected within the first 24 hours is
a. Increased PVR
b. Decreased SVR
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
120
22.1 Of the following clinical conditions, difficult intubation is LEAST likely to be associated with
a. Apert syndrome
b. Hurler
c. Pierre Robin
d. Down
e. Treacher collins
a. Apert syndrome
REPEAT
121
22.1 Somatosensory evoked potentials (SSEPs) are used to monitor spinal cord function during
scoliosis surgery. They are LEAST affected by
a. Opioids
b. Volatiles
c. Muscle relaxant
REAPEAT
Muscle relaxants
SSEPS - opioids
122
22.1 Suxamethonium may be safely given to patients with
a. Becker muscular dystrophy
b. Cerebral palsy
c. Guillain Barre
d. Frederich’s ataxia
e. Duchenne muscular dystrophy
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
123
22.1 A 65-year-old man presents to the preadmission clinic two weeks prior to his total knee replacement. His blood results include haemoglobin 100 g/L, ferritin 20 μg/L and normal C-reactive protein. The best course of action is to
a. Proceed
b. EPO and iron
c. Iron tablet and delay 3 months
d. Iron transfusion and proceed
e. PRBC
Postpone 3 months and give oral iron
124
22.1 A patient’s glomerular filtration rate is estimated at 35 mL/min/1.73m2. The patient’s chronic kidney disease can be classified as Stage
a. 5
b. 4
c. 3a
d. 3b
e. 2
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
125
22.1 To allow cardiopulmonary bypass in a patient with heparin resistance, fresh frozen plasma may be administered in order to increase the level of
ATIII
126
22.1 The image shows results from noninferiority trials. The trial labelled N is best described as
(the confidence interval crosses midline of no effect and margin of non-inferiority)
a. Inferior
b. Non-inferior
c. Inconclusive
Inconclusive
127
22.1 The radial artery pressure trace shown below is from a patient who has an intra-aortic balloon pump in situ. The device has been switched to 1:2 augmentation to assess the timing. The trace shows an augmented beat followed by a nonaugmented beat. With respect to the augmentation, the trace shows
a. Early deflation
b. Late deflation
c. Late inflation
d. Early inflation
e. No change
128
22.1 A patient is undergoing treatment for a malignant hyperthermia crisis. Active cooling should be ceased when the patient’s core temperature has dropped to
a. 35
b. 36
c. 37
d. 38
38
129
22.1A 63-year-old woman is to undergo an elective total hip replacement. Her past medical history includes hypertension, stroke, type 2 diabetes mellitus, chronic atrial fibrillation and chronic renal impairment with an estimated creatinine clearance of 46 mL/min. Her medications include dabigatran 150 mg bd for stroke prevention. Perioperatively, her dabigatran therapy should
a. Be withheld 2 days
b. Withhold 3 days
c. Withhold 5 days
d. Withhold 6 days
e. Continue
5d
ANZCA - CrCl >80 (3D) 80-50 (4D) <50 (5D)
130
22.1 A 50-year-old man with carcinoid syndrome having a resection of a peripheral hepatic metastasis develops a sudden fall in BP from 110/70 mmHg to 85/50 mmHg without significant bleeding. The most appropriate management is
a. Normal saline bolus
b. Octreotide 50mcg bolus
c. Metaraminol 0.5mg
d. Noradrenaline 5mcg bolus
e. Calcium 6.8mmol
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
131
22.1 The nerve(s) that need to be blocked with local anaesthetic to achieve complete anaesthesia for amputation of the fifth toe is/are
a. Posterior tibial
b. Sural
c. Deep and superficial peroneal
d. Superficial peroneal and tibial
e. Superior peroneal, tibial, sural
d. Superficial peroneal and tibial
REPEAT
Sural nerve would also need blocked for skin surface - see anso
132
22.1 A man has symptomatic carbon monoxide poisoning. His pulse oximetry (SpO2) and arterial blood gas (PaO2) would be expected to show
a. Normal SpO2, Normal PaO2
b. Normal SpO2, reduced PaO2
c. Reduced SpO2, normal PaO2
d. Reduced SpO2, reduced PaO2
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/
133
22.1 Venous air embolism during frontal craniotomy is most likely to arise from the
a. Transverse sinus
b. Sigmoid sinus
c. Superior sagittal
d. Straight
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/
134
22.1 St. John’s wort (herbal medicine Hypericum perforatum) will reduce the effects of
a. Aspirin
b. Clopidogrel
c. Warfarin
d. Heparin
e. NOAC
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
135
22.1 You are about to anaesthetise a 25-year-old man for an open appendicectomy. He has a history of tricuspid atresia for which he has had a Fontan procedure. An important goal in managing his ventilation under anaesthesia is to ensure
a. Long I time, low pressures
b. Long I time, PEEP
c. Long E time
d. Spontaneous ventilation
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
136
22.1 According to the ‘Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (PONV)’ published in 2020, multimodal PONV prophylaxis should be implemented in adult patients
a. For everyone
b. 1 or more RF
c. 2 or more RF
d. 3 or more RF
e. 4 or more RF
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.
137
22.1 When using ROTEM thromboelastometry, the APTEM test is used to assess
a. Fibrinolysis
b. Platelet function
c. Coagulation factors
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).
138
22.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is
a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone
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
139
22.1 You are anaesthetising a patient for implantation of an automated implantable cardioverter defibrillator. The patient is a 48-year-old with dilated cardiomyopathy and pulmonary hypertension.
The preoperative echocardiogram report states that the estimated pulmonary artery systolic pressure is 55 mmHg, and that there is mild right ventricular systolic dysfunction. To avoid
worsening right ventricular function during induction, it would be best to consider using
a. Milrinone
b. Dopamine
c. Dobutamine
d. Adrenaline
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)
140
22.1 Regarding healthcare research, the PICO framework describes
a. Forming a research question and literature review
b. Framework to conduct systematic review
Forming a research question and literature review
REPEAT
141
22.1 A 36-year-old man complains of left calf pain for two weeks. His pain is worse on walking but not completely relieved by sitting or lying down. On examination, he has mild weakness of left big toe extension. The most likely finding on MRI would be
a. L4/5 central disc bulge with facet joint pathology
b. L4/5 disc prolapse with compression of interveterbral foramina pathology
c. L5/S1 central disc bulge with facet joint degeneration
d. L5/S1 disc prolapse with compression of interveterbral foramina pathology
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.
142
22.1 A normal sized six-year-old girl has a haemoglobin of 70 g/L following surgery. The volume of packed red blood cells that you would plan to infuse to raise her haemoglobin to 80 g/L is
a. 80ml
b. 100ml
c. 120ml
d. 180ml
e. 200ml
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
143
22.1 A 57-year-old female smoker presents for a laparotomy with the following pulmonary function tests
(normal FEV1 FVC, low RV and FRC only, normal DLCO)
They are consistent with a diagnosis of
a. Obesity
b. PE
c. Pulmonary fibrosis
d. COPD
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.
144
22.1 A 24-year-old man with Wolff-Parkinson-White syndrome is having anaesthesia for a knee arthroscopy. During the procedure he develops the following rhythm. His blood pressure is 100/65mmHg.
The most appropriate treatment is
a. Adenosine
b. Procainamide
c. Verapamil
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
145
22.1 The train-of-four (TOF) ratio above which the majority of anaesthetists will NOT be able to visually detect fade on TOF stimulation is
a. 0.2
b. 0.4
c. 0.6
d. 0.7
e. 0.9
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).
146
22.1A high mixed venous oxygen saturation (SvO2) is most likely to be associated with
a. COPD
b. PE / Tamponade
c. Acute MI
d. Severe liver failure
e. Sepsis
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.
147
22.1 You have anaesthetised a 25-year-old woman for a sleeve gastrectomy. She normally takes the oral contraceptive pill. You used rocuronium and at the end of the case reversed it with 4 mg/kg of sugammadex. Prior to discharge you should advise her to use non-hormonal contraception for the next
a. 1 day
b. 3 days
c. 5 days
d. 7 days
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
148
22.1 Moderate obstructive sleep apnoea in children is diagnosed by an apnoea-hypopnoea index of
a. 5-10
b. 10-15
c. 15-20
d. 20-25
e. 25-30
a. 5-10
