22.2 Flashcards

Question 1

Q

**

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

a) 6 weeks
b) 3 months
c) 6 months
d) 12 months

Answer

A

b) 3 months

ANZCA PS09 2014

NB: PG09 was updated in 2022 and no longer states a minimum timeframe, so this is unlikley to return as an MCQ

Question 2

Q

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

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

Answer

A

b) 250mcg IM q15mins, up to 2mg

QLD maternity guidelines
Carpoprost 250mcg IM
Repeat every 15-90min as r

Question 3

Q

22.2 A 25-year-old male has continued postoperative bleeding after an extraction of an impacted third molar tooth under a general anaesthetic. The patient mentions that his father bruises quite easily. His coagulation screen reveals: (provided). The most likely diagnosis is
(APTT raised, PT normal?)

a. Factor V leiden
b. haemophilia A
C. Von willebrand’s disease
D. Haemophilia B

Answer

A

b. von willebrand’s disease

autosomal dominant inheritance
may have normal or prolonged APTT, PT is normal

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

REPEAT

vWD can have prolonged APTT or normal APTT. Haemophilias are X-linked

Question 4

Q

22.2 The nerve labelled by the arrow marked H in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Median Nerve

Question 5

Q

22.2 Adverse effects of the use of sodium-glucose co-transporter 2 inhibitors in the perioperative period do NOT include

a) UTI
b) Hyperglycaemic DKA
c) Hypovolaemia
d) Hypercalcaemia

Answer

A

Hypercalcaemia

SGLT2 inhibitors are relatively new and have several side effects that warrant caution, including the unique risks of diabetic ketoacidosis (DKA), mycotic genital infections and possibly lower limb amputations. Also polyuria, volume depletion, hypoT

Hypoglycaemia
As the glucose-lowering mechanism of SGLT2 inhibitors is glycaemia-dependent, hypoglycaemia risk is low. However, hypoglycaemia may occur when SGLT2 inhibitors are used in conjunction with sulphonylurea or insulin therapy.

https://www1.racgp.org.au/ajgp/2021/april/use-of-sodium-glucose-co-transporter-2-inhibitors#:~:text=Safety%20and%20tolerability,and%20possibly%20lower%20limb%20amputations.

Question 6

Q

22.2 A drug that is contraindicated for a patient with a history of heparin-induced thrombocytopaenia is

a) Bivalirudin
b) Danaparoid
c) Prothrombinex
d) Fib conc

Answer

A

c) Prothrombinex

Has factors 2, 9, 10, heparin, ATIII

Question 7

Q

22.2 The nerve labelled by the arrow marked F in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Axillary Nerve

Question 8

Q

22.2 The antiemetic that interferes with the effectiveness of oral hormonal contraception is
a) Aprepitant
b) Ondansetron
c) Metoclopramide

Answer

A

28 days

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

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

Question 9

Q

22.2 During an infraclavicular approach to the brachial plexus, the tip of the needle is positioned closest to the
a. roots
b. trunks
c. divisions
d. cords
e. branches

Question 10

Q

22.2 A 72-year-old patient is undergoing resection of an anterior skull based tumour using a combined endoscopic and frontal craniotomy approach. Seven hours into the procedure she has a large diuresis of pale urine and you suspect she may have developed diabetes insipidus. The most appropriate test result to confirm your diagnosis in this setting is a

a. Low serum ADH levels
b. Sequentially increasing Na levels
c. Serum osmolality <260
d. Urine Na >40
e. Urine specific gravity > something

Answer

A

b. Sequentially increasing Na levels

Question 11

Q

22.2 A 54-year-old woman has a laryngeal mask airway (LMA) inserted for a surgical procedure. The following day she complains of tongue numbness and abnormal taste over the anterior two-thirds 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
e) Hypoglossal nerve

Answer

A

b) Lingual nerve

general sensation to the anterior two-thirds of the tongue is by innervation from the lingual nerve, a branch of the mandibular branch of the trigeminal nerve (CN V3)

Has fibres from both mandibular branch of CN V3 and CN VII

Question 12

Q

22.2 The modified Aldrete scoring system is used for determining the

a. Predicts difficulty of bag mask ventilation
b. Safety of day surgery
c. Discharge from recovery
d. Discharge from hospital

Answer

A

c. Discharge from hospital

Aldrete score, which includes five elements (activity, respiration, circulation, consciousness, oxygen saturation) [16]. The Modified Aldrete system includes five additional elements that are particularly useful during the Phase II recovery period prior to discharge to home (dressing, pain, ambulation, feeding, urine output)

UTD

Question 13

Q

22.2 A 72-year-old woman on aspirin presents to her ophthalmologist for follow-up three days after you performed a transconjunctival peribulbar block for cataract surgery on her left eye. She complains of painless periorbital swelling, erythema, and mild chemosis which started the day after surgery but is improving. She had a peribulbar block three weeks ago for surgery on the other eye. The most likely diagnosis is

a. Retrobulbar bleeding?
b. Residual swelling from peribulbar block
c. Infection
d. hyalase reaction/allergy

Answer

A

?hyalase reaction

Question 14

Q

22.2 A 47-year-old man is anaesthetised for an elective laparoscopic cholecystectomy. Three minutes after induction, he is noted to have a heart rate of 130 bpm and systolic blood pressure of 60 mmHg. The most appropriate initial dose of adrenaline is
a) 100mcg IM Adr
b) 200mcg IM Adr
c) 20mcg Adr IV
d) 100mcg Adr IV
e) 50mcg Adr IV

Answer

A

e) 50mcg Adr IV

ANZCA
Grade 1: no adrenaline required.
Grade 2: 10-20mcg IV adrenaline. Escalate to 50mcg if insufficient response to initial dose. Consider initial IM adrenaline as a safe and effective alternative.
Grade 3: 50-100mcg IV adrenaline. Escalate to 200mcg if insufficient response to initial dose.
Grade 4: As discussed earlier, in PEA arrest 1000mcg (1mg) IV adrenaline immediately and then repeated every 1-2 minutes. For shockable rhythms follow ALS guidelines.

ANZAAG use Ring and Mesmer scale for anaphylactic reactions as a base for classifying anaphylaxis grade (see image)

From sunny coast QH document
With PAGS ‘Life Threatening Anaphylaxis’ can be distinguished from
‘Moderate Anaphylaxis’ in an adult by the presence of any
one of these signs:
* systolic blood pressure of <60 mmHg
* life-threatening tachy- or bradyarrhythmia
* oxygen saturation <90%
* inspiratory pressures of >40 cmH2

Life-threatening anaphylaxis

Question 15

Q

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

a) 40mg
b) 80mg
c) 120mg

Answer

A

80mg

16kg x 5mg/kg = 80mg

Question 16

Q

22.2 Large doses of sugammadex can potentially lead to
a) hypoglycaemia
b) hyperglycaemia
c) bradycardia
d) Prolonged QT

Answer

A

c) bradycardia

from PI

Question 17

Q

22.2 The nerve labelled by the arrow marked E in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Musculocutaneous Nerve

Question 18

Q

22.2 You are involved in the care of a two-year-old child who has ingested a button battery in the last four hours. You would consider giving

a) Milk
b) Bicarbonate
c) Chewing gum
d) Activated charcoal
e) Sucralfate

Answer

A

e) Sucralfate
administration of two teaspoons (10 mL) of honey or sucralfate at 10-minute intervals (up to six doses) if fewer than 12 hours have passed since ingestion; this may reduce severity of injury. Sucralfate in Australia is currently available as a tablet form only. It can be crushed with 10–20 mL of water for 1–2 minutes to be dispersed and is preferred for children aged <12 months as honey can carry the risk of botulism

https://www1.racgp.org.au/ajgp/2022/july/button-battery-injury

Question 19

Q

22.2 A patient presents with sepsis-induced hypoperfusion or septic shock. The minimum suggested volume of intravenous crystalloid to be administered over the first three hours as outlined in the Surviving Sepsis Guideline is

a) 10ml/kg
b) 20ml/kg
c) 30ml/kg
d) 40ml/kg
e) 50ml/kg

Answer

A

30ml/kg

For patients with sepsis-induced hypoperfusion or septic shock, we suggest that at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours of resuscitation.
Quality of evidence: Low

Question 20

Q

22.2 Of the following, all are useful for the treatment of status epilepticus EXCEPT

a. Calcium
b. isoflurane
c. ketamine
d. propofol
e. phenytoin

Answer

A

a. Calcium
(unless hyppocalcaemia is causing your seizures)

Deranged Physiology:
First line agents
- Benzodiazepines: boluses every 2-5 minutes
- Phenytoin: 20mg/kg loading dose
Phenytoin on its own is useless. Or rather, it is inferior to benzodiazepines as a solitary agent. Always, both must be used simultaneously.

Second line agents
- Midazolam infusion
- Phenytoin (well, rather, the American study recommends fosphenytoin)
- Phenobarbital and levetiracetam are also in this second line of attack

Third line agents: for refractory status epilepticus
- Propofol infusion, or midazolam infusion, or thiopentone infusion.
- At this stage, continuous EEG monitoring becomes mandatory
- The role of traditional antiepileptic drugs is also exhausted at this stage, as there will probably be no benefit from adding them into a situation where a constantly observed burst suppression is already achieved by high dose anaesthetic infusion.

Fourth line agents: for these, there is little evidence.
- Volatile anaesthetic agents
- Desflurane and Isoflurane
- Ketamine
- Lignocaine
- Magnesium
- Pyridoxine

Fifth line therapies:
- Hypothermia
- Ketogenic diet
- Deep brain stimulation
- Surgical management

Question 21

Q

22.2 The nerve labelled by the arrow marked A in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Dorsal Scapular Nerve

Question 22

Q

22.2 A 25-year-old ASA (American Society of Anesthesiologists) physical status classification I patient develops seizures five minutes after receiving a brachial plexus block with ropivacaine. Of the following, the most suitable initial intravenous treatment is
a) phenytoin
b) levetiracetam
c) propofol
d) intralipid

Answer

A

c) propofol

https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_final.pdf?ver=2018-07-11-163755-240&ver=2018-07-11-163755-240

Question 23

Q

22.2 A 45-year-old man is ventilated in the intensive care unit and is in a critical state. His pulmonary artery wedge pressure is 26 mmHg, cardiac index is 1.7 L/minute/m2 and his PaO2/FiO2 ratio is 200 mmHg. A decision is made to place him on extracorporeal membrane oxygenation. The most appropriate mode is

a) VV ECMO
b) VA ECMO
c) Atrio-aorto ECMO
d) Ventriculo-atrial ECMO

Answer

A

b) VA ECMO

PaO2/FiO2 ratio
Mild: 200-300 = mortality 27%
Moderate = 100-200 mortality 32%
Severe < 100 = Mortality 45%

Cardiac Index
Normal: 2.5-4.2l/min

PAWP:
Normal 4-12mmHg

CI is low, PaO2/FiO2 ratio is mild, PAWP is high

Question 24

Q

22.2 A patient is bleeding and her ROTEM displays a Fibtem A5 of 2 mm (normal > 4 mm). The most appropriate treatment is

a. FFP
b. fib conc
c. cryoprecipitate
d. TXA

Answer

A

b) fibrinogen concentrate

bleeding and low fib = concentrate
not bleding and low = cryo

Question 25

Q

22.2 The piece of airway equipment shown is a

a. bullard laryngoscope
b. CMAC video stylet
c. lightwand
d. flexible bougie

Answer

A

CMAC video stylet

Question 26

Q

22.2 The curve labelled ‘b’ is most likely to represent the flow–volume loop of a patient with (looked like a fixed obstruction but away from normal curve)

a) Asthma
b) Post lung transplant
c) Pulmonary fibrosis
d) Tracheal stenosis
e) VC palsy

Answer

A

Tracheal stenosis

Question 27

Q

22.2 You are performing femoral venous cannulation in an obese man under ultrasound guidance. The image quality is suboptimal as the vein is deep. The best way to improve the image quality is to

a. Increase USS speed of transmission
b. Decrease USS speed of transmission
c. Use higher frequency probe
d. Use lower frequency probe
e. Increase wavelength

Answer

A

d. Use lower frequency probe

Question 28

Q

22.2 Of the following, the procedure that is most commonly associated with chronic pain after surgery is
a) Amputation
b) Mastectomy
c) Thoracotomy
d) TKR
e) Hernia repair

Answer

A

a) Amputation

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

Question 29

Q

22.2 Suxamethonium may be safely given to patients with (list of neuromuscular diseases given)

a. Becker muscular dystrophy
b. Myaesthenia gravis (new option)
c. Guillain Barre
d. Hypokalaemic periodic paralysis (new option)
e. Duchenne muscular dystrophy

Answer

A

b. Myaesthenia gravis

In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug.

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

ED95 is 0.8mg/kg in a MG patient

Question 30

Q

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

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

Answer

A

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

Note the new modified Fischer scale.
G0 No SAH or IVH (0%)
G1 Focal or diffuse thin SAH but no IVH (6-24%)
G2 Focal or diffuse thin SAH with IVH (15-33%)
G3 Thick SAH no IVH (33-35%)
G4 Thicc SAH with IVH (34-40%)

The main differences between the Fisher scale and modified Fisher scale are:
1) Fisher scale, no SAH is grade 1, but 0 in modified Fisher scale
2) Fisher scale, thin SAH & no IVH is grade 2, but 1 in modified Fisher scale
3) Fisher scale, thick SAH with no IVH is grade 3 and the same 3 in modified Fisher scale
4) Fisher scale, any IVH is grade 4, irrespective of the presence of SAH but in modified Fisher scale it is either 2 if thin or no SAH, or grade 4 if thick SAH

GCS 7-12

Question 31

Q

22.2 A 60-year-old man remains unconscious after an isolated head injury. The systolic blood pressure (in mmHg) should be kept above

a) 90
b) 100
c) 110
d) 120
e) 140

Answer

A

b) 100

Brain trauma foundation
Level III recommendation.
To decrease mortality and improve outcomes:

Maintain SBP at >100mmHg for patients 50 - 69
Maintain SBP at >110 for patients 15 - 49
Maintain SBP at >110 for patients 70 or older

Question 32

Q

22.2 Which is least likely to cause inaccuracies in pulse oximetry
a) Anaemia
b) Vasoconstriction
c) AF
d) Methaemoglobin
e) Carboxyhaemoglobin

Answer

A

Anaemia

Causes of inaccuracies:
- nail polish
- Indocyanin green
- AF
- Methaemoglobin

etc

Question 33

Q

22.2 AFE incidence highest in
a)
b) LSCS
c) Instrumental delivery
d) Preeclampsia
e)

Question 34

Q

22.2 A 56-year-old patient presents with exertional syncope. The most likely diagnosis is
(previously this was a 26yo)

a) HOCM
b) Aortic stenosis
c) Long QT syndrome

Answer

A

AS - given age

MOST COMMON unknown 39%
aha has a table of prevalence for syncope

arrhythmias and vasovagal 14%
orthostatic hypotension 11% - neurological being the main (7%; meds 3% psychiatric 1%)
others (carotid sinus syncope, hypoglycemia, hyperventilation)
situation and organic heart disease 3%

for exersional syncope

Syncope after exercise may be due to left ventricular outflow tract obstruction from aortic stenosis or hypertrophic obstructive cardiomyopathy but can also suggest the diagnosis of postexercise hypotension in which an abnormality in autonomic regulation of vascular tone or heart rate results in vasodilation or bradycardia after moderate-intensity aerobic activity.

https://www.ahajournals.org/doi/full/10.1161/01.CIR.0000031168.96232.BA#

Question 35

Q

22.2 The normal axial length of the globe of an adult eye is
a. 20mm
b. 23mm
c. 26mm
d. 29mm
e. 32mm

Question 36

Q

22.2 Cyclooxygenase type 2 inhibitors (COX-2) in pregnancy are considered

a. Not safe
b. safe
c. safe only in 1st trimester
d. safe only in 1st and 3rd trimester
e. not safe for 3rd trimester and 48 hours post delivery

Answer

A

While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32

APMSE

Question 37

Q

22.2 Predictors of difficult sedation (agitation or inability to complete the procedure) of patients undergoing gastroscopy do NOT include

Answer

A

Unknown options but…

Factors associated WITH difficulty during Gastroscopy were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during COLONOSCOPY were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use

Question 38

Q

22.2 You are reviewing a primigravida at 32 weeks gestation with a Fontan circulation in the anaesthetic preassessment clinic. Peripartum care should avoid the use of

a. Terbutaline
b. Nitrous oxide
c. Ergometrine
d. Lignocaine 2% with adrenaline 1:200 000
e.

Answer

A

Ergometrin increases PVR and SVR

Question 39

Q

22.2 The nerve labelled by the arrow marked J in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Medial Cutaneous nerve of the forearm

Question 40

Q

22.2 The smallest recommended endotracheal tube that should be railroaded over an Aintree catheter has an internal diameter of
a) 4.0 mm
b) 5.0 mm
c) 6.0 mm
c) 7.0 mm
e) 8.0mm

Answer

A

c) 7.0 mm

Question 41

Q

22.2 You are giving IPPV via a mapleson D (bain) circuit. Minimum FGF to maintain normocapnia is
a) 50ml/kg/min
b) 70ml/kg/min
c) 100ml/kg/min
d) 150ml/kg/min
e) 200ml/kg/min

Answer

A

70-80ml/ kg/ min
Controlled ventilation

https://www.frca.co.uk/article.aspx?articleid=100141
A fresh gas flow of only 70 ml/kg is required to produce normocarbia.

Bain and Spoerel have recommended the following:

2 L/min fresh gas flow in patients <10 kg
3.5 L/min fresh gas flow in patients 10-50 kg
70 ml/kg fresh gas flow in patients >60 kg

The recommended tidal volume is 10 ml/kg and respiratory rate is 12-16 breaths/minute.

Question 42

Q

22.2 1 MAC of sevoflurane affects the sensory evoked potential signal for spinal surgery by

a) increased latency, increased conduction speed, increased amplitude
b) increased latency, decreased conduction speed, decreased amplitude
c) other variations of above

Answer

A

Increased latency, decreased conduction speed, decreased amplitude

Question 43

Q

22.2 Based on this ECG tracing, the mode in which this pacemaker is operating is

a) VAI with intermittent failure to capture
b) AAI with intermittent failure to sense
c) DDD
d) VVI with intermittent failure to capture
e) VVI with intermittent failure to sense

Question 44

Q

22.2 You have diagnosed anaphylaxis in an eight-year-old girl having an appendicectomy. She weighs 20 kg and has refractory bronchospasm despite an adrenaline (epinephrine) infusion running at 15 mcg/min. The recommended initial dose of salbutamol (100 mcg/puff) via metered dose inhaler is

a) 1 puff
b) 3 puffs
c) 6 puffs
d) 10 puffs
e) 12 puffs

Answer

A

12 puffs
6puffs< 6yrs
12 puffs> 6 yrs

Question 45

Q

22.2 For a skewed distribution of data the best measure of dispersion of data is the

a) range
b) mode
c) standard deviation
d) variance
e) Interquartile Range
f) median

Answer

A

e) Interquartile Range

Unlike range and interquartile range, variance is a measure of dispersion that takes into account the spread of all data points in a data set. It’s the measure of dispersion the most often used, along with the standard deviation, which is simply the square root of the variance. The variance is mean squared difference between each data point and the centre of the distribution measured by the mean.

Standard deviation (SD) is the most commonly used measure of dispersion. It is a measure of spread of data about the mean. SD is the square root of sum of squared deviation from the mean divided by the number of observations.

The other advantage of SD is that along with mean it can be used to detect skewness. The disadvantage of SD is that it is an inappropriate measure of dispersion for skewed data.

SD is used as a measure of dispersion when mean is used as measure of central tendency (ie, for symmetric numerical data).

For ordinal data or skewed numerical data, median and interquartile range are used

Question 46

Q

22.2 A 21-year-old patient with a history of schizophrenia on quetiapine develops tremor, restlessness, hyperreflexia, nausea and vomiting in the post-anaesthesia care unit following an emergency laparoscopic cholecystectomy. Her heart rate is 80 / minute, blood pressure 130/90 mmHg, and her temperature is 37.0°C. The most likely diagnosis is

a. MH
b. NMS
c. serotonin syndrome
d. rhabdomyolysis
e. anticholinergic crisis

Answer

A

Serotonin Syndrome
Hyper reflexia
Usually has hypertension and hyperthermia

https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png

Question 47

Q

22.2 During spinal surgery, the anaesthetic agent that is least likely to decrease motor evoked potentials is

a Ketamine
b Precedex
c Propofol
d Volatiles
e Remifentanil

Answer

A

Remifentanil
A. Non-depolarising muscle relaxants - false - NMBDs abolish MEPs
B. Nitrous oxide - false - N2O can completely abolish MEPs
D. Propofol - false - PPF has less of an effect than volatiles, but still affects MEPs
E. Volatiles - false - volatiles are the most likely

NMBDs > volatiles > N2O > PPF > opioids

https://www.uptodate.com/contents/anesthesia-for-elective-spine-surgery-in-adults
While neurologic injury can cause changes in recorded potentials, other factors can interfere with interpretation. Confounding factors that can occur during surgery include inhalational anesthetics, hypothermia, hypotension, hypoxia, anemia, and preexisting neurologic lesions. Inhaled anesthetics such as isoflurane, sevoflurane, and nitrous oxide can reduce the amplitude and prolong the latency of SSEP and can completely abolish MEP. Neuromuscular blocking agents (NMBAs) also abolish motor evoked potentials and cannot be used when monitoring. Intravenous anesthetics such as propofol, barbiturates, and opioids have less of an effect on monitoring, though very deep anesthesia, even with propofol, can affect waveforms.

https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia
Evoked potentials — Evoked potential monitoring is used to assess the integrity of the tested neural pathway. Somatosensory, visual, and brainstem auditory evoked potentials monitor neurologic structures between peripheral sites where specific stimulations are applied, and responses are recorded from central locations. Motor evoked potentials monitor such structures by stimulating the motor cortex and recording from the epidural space (D-wave) or, more commonly, from distal muscles. Changes in evoked responses can result from technical, positional, pharmacologic, physiologic, or surgical causes.

For spine surgery, both MEPs and SSEPs are used to monitor spinal cord function to increase sensitivity. Motor and sensory tracts are anatomically distinct and have different vascular supply in areas of the cortex, brainstem, and spinal cord.

Motor evoked potentials (MEPs) – MEP responses are affected by even very low concentrations of volatile anesthetic agents. In general, total intravenous anesthesia (TIVA) facilitates MEP monitoring. However, inhalation agents at 0.5 MAC or less can be used in many patients, especially during intracranial surgery

Opioids – IV opioids cause small, dose-dependent depression of SSEP and MEP responses, though even at very high doses of opioids, evoked potentials can be recorded [76-78]. Infusions of remifentanil, fentanyl, or sufentanil are commonly used as part of TIVA during neuromonitoring. Opioids tend to produce high-amplitude slow waves in the EEG.

Balanced anesthetic approach — When SSEPs and MEPs are monitored, a balanced anesthetic using both a low-dose inhalation anesthetic (up to 0.5-MAC isoflurane, sevoflurane, or desflurane) and low- to medium-dose propofol (eg, propofol, 40 to 75 mcg/kg/min IV) with a relatively high-dose opioid (eg, remifentanil 0.1 to 0.4 mcg/kg/min) offers several advantages:

●Movement with motor stimulation is reduced, which is particularly important during intracranial aneurysm surgery.
●The addition of a 0.3 to 0.5 MAC inhalation agent may reduce the chance of awareness under anesthesia.
●Compared with TIVA, the addition of a 0.5 MAC inhalation agent allows reduction of the dose of propofol infusion, facilitating more rapid wakeup and earlier neurologic examination.
●Compared with TIVA, the chance of accidental interruption of the anesthetic for mechanical reasons (ie, kinked or infiltrated IV catheter or tubing such that IV agents no longer infuse) is reduced.

Question 48

Q

22.2 The nerve labelled by the arrow marked G in the diagram is the

Ulnar Nerve
Axillary Nerve
Median Nerve
Medial Cutaneous nerve of the forearm
Long Thoracic Nerve
Dorsal Scapular Nerve
Radial Nerve
Suprascapular nerve
Musculocutaneous Nerve

Answer

A

Radial Nerve

Question 49

Q

22.2 Drug classes demonstrated to reduce mortality in chronic heart failure with reduced ejection fraction include all of the following EXCEPT

A. ACE inhibitors
B. Beta blockers
C. Angiotensin receptor blockers
D. Spironolactone
E. Digoxin

Question 50

Q

22.2 This ultrasound image is acquired in preparation for a thoracic erector spinae plane block. The structure indicated by the arrow is the

Question 51

Q

22.2 Anterior spinal artery syndrome would NOT result in

a. Motor
b. Proprioception
c. Pain sensation
d. Temperature

Answer

A

Proprioception

OHA (5th) p305

Question 52

Q

22.2 This lung ultrasound image is consistent with

a. pulmonary oedema
b. pneumonia
c. pneumothorax
d. pleural effusion
e. Normal lung

Answer

A

c. pneumothorax

Question 53

Q

22.2 A 50-year-old man is admitted with a stroke and undergoes cerebral angiography. The artery marked on angiography with the arrow is the (left AICA)

Question 54

Q

22.2 A patient has return of spontaneous circulation (ROSC) but remains unresponsive after cardiac arrest. ANZCOR Guidelines recommend all the following measures EXCEPT

a) Titrating FiO2 for SpO2 94-98%
b) Treating hyperglycaemia >10mmol/L
c) Targeted temp management at 32-36 degrees
d) Maintaining MAP >70

Answer

A

d) Maintaining MAP >70

Recommends maintaining equal or greater than pts usual, or at least a SBP> 100mmHg

https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.7-Jan16.pdf

Question 55

Q

22.2 You have been managing a case of malignant hyperthermia in an 80 kg man and have given a total of 400 mg of dantrolene (Dantrium). The amount of mannitol you have also administered is

a. None
b. 1.6g
c. 12g
d. 40g
e. 60g

Answer

A

e. 60g

Each 20mg dantrolene contains 3g mannitol

Question 56

Q

22.2 A woman is diagnosed with preeclampsia and fetal growth restriction at 30 weeks gestation. Her haemodynamics are most likely to show
a) Increased CO, Decreased SVR
b) Decreased CO, Decreased SVR
c) Decreased CO, Increased SVR
d) No change CO, Increased SVR

Answer

A

c) Decreased CO, Increased SVR

It is plausible that a case of pre-eclampsia that occurs earlier in gestation and is associated with fetal growth restriction is related to low cardiac output and high peripheral vascular resistance with a much similar profile as observed in women with fetal growth restriction without HDP. In cases of later and term gestation pre-eclampsia, babies tend to be larger and there is a predominantly high cardiac output, low peripheral vascular resistance and raised intravascular volume state. Certainly, the clinical phenotype of a very ‘dry’, intravascularly depleted woman at 26 weeks with a growth restricted baby and conversely of a well-perfused oedematous woman with a bounding pulse and large baby at 38 weeks rings true: both have hypertension, but the mechanisms may be diametrically opposite.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569150/

Our findings of a relatively hypodynamic circulation with a lower CO and higher TPR in women who develop preeclampsia/FGR lend credence to reports of hemodynamic dysfunction observed in the subclinical and clinical stage of preeclampsia and FGR.
https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.118.11092#d1e1667

Question 57

Q

22.2 A 6-year-old patient (140 cm, 24 kg, BSA 0.97m2) is on hydrocortisone 15 mg/day. Perioperative glucocorticoid supplementation is (considered if)

a.
b. Taking >1week
c. Taking >1 month
d. Taking >2 months
e. Taking >4 months

Answer

A

Taking > 1 month

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963

Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra-articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency

All children who have known glucocorticoid deficiency (primary or secondary), or who are at risk of glucocorticoid deficiency (on significant exogenous dose of glucocorticoid >10–15 mg.m-2 per day) 38, should receive an i.v. dose of hydrocortisone at induction (2 mg.kg−1 for minor or major surgery under general anaesthesia).

Question 58

Q

22.2 Recirculation is a cannula position complication specific to the use of

a) ECCO2R
b) VV ECMO
c) VA ECMO
d) dialysis
e) AV ECVO

Answer

A

b) VV ECMO

VV ECMO Disadvantages
- no cardiac support
- local recirculation though oxygenator at high flows
- reverse gas exchange in lung if FiO2 low
- limited power to create high systemic arterial oxygen tension

Question 59

Q

22.2 A 50-year-old man has the following pulmonary function test result: (provided). The most consistent diagnosis is
FEV1 68%, FVC 68%, DLCO 91%

a. Pulmonary hypertension
b. pulmonary fibrosis
c. myasthenia gravis
d. sarcoidosis

Answer

A

c. myasthenia gravis

Question 60

Q

22.2 A thoracic regional technique that will NOT provide analgesia for sternal fractures is a
a. PECS I
b. PECS II
c. Parasternal intercostal nerve block?
d. Transfascial muscle block (can’t remember wording)
e. transverse thoracic plane block

Answer

A

b. PECS I
(PECS II Covers SA and will extend to the sternum)

Question 61

Q

22.2 For a 70-year-old patient on rivaroxaban with normal renal function a major guideline recommends proceeding with hip fracture surgery after two half-lives of the drug. This equates to

a. 12 hours
b. 24 hours
c. 48 hours
d. 72 hours
e.

Answer

A

b. 24 hours

ASA guidelines

-If creatinine clearance >=30 ml.min-1 (Cockcroft-Gault), proceed with surgery after two half lives (24 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)
- If creatinine clearance < 30 ml.min-1, proceed with surgery after four half lives (48 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)

Question 62

Q

22.2 A patient in ICU 1 hour post CABG is in VF. What is the least suitable management
a) Atropine
b) Adrenaline
c)
d) Amiodarone
e) 3 stacked shocks

Answer

A

B

Repeat

NEVER GIVE ADRENALINE
ANZ CALS guideline

Question 63

Q

22.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is

a. codeine
b. morphine
c. fentanyl
d. tramadol
e. oxycodone

Answer

A

A codeine

Oxycodone B
Morphine C
Tramadol C
Fentanyl C

Question 64

Q

22.2 An absolute contraindication to transoesophageal echocardiography is
A. Dysphagia
B. GORD
C. Oesophageal stricture
D. oesophageal webbing
E. oesophageal varices

Answer

A

C. Oesophageal stricture

https://www.asecho.org/wp-content/uploads/2014/05/2013_Performing-Comprehensive-TEE.pdf

Answer 58

A

PAPi goes down in acute RVF
- actually designed to prognosticate in acute MI

E is the answer

https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.121.009085#:~:text=The%20pulmonary%20artery%20pulsatility%20index,left%20ventricular%20assist%20device%20implantation.

Answer 59

A

A . Cardiac tamponade

Deranged physiology

In summary
The CVP is raised
All CVP waveform components are elevated
a and v waves are tall
x descent is steep
y descent is (usually) absent

Answer 60

A

ALTERED 22.1 QUESTION

D Spirometry FEV1 only

GOLD 1 > 80% Pred
GOLD 2 50-79% Pred
GOLD 3 30-49% Pred
GOLD 4 < 30% Pred

Answer 61

A

C

https://academic.oup.com/bjaed/article/17/2/68/2907833

Answer 62

A

e. AAA

Osteoarthritis
nerve compression syndrome due to bony overgrowth, and carpal tunnel syndrome
Hypertension
Diabetes mellitus
Cardiomyopathy/HF
Colorectal cancer
Sleep Apnea
Thyroid nodules and thyroid cancer
Hypogonadism
Compression of the optic chiasm

Source: BJA

Answer 63

A

D Inhalational anaesthetic

https://academic.oup.com/bja/article/118/3/335/2999642?login=false

Answer 64

A

C 3L/min

LVOT area x VTI = SV
3cm2 x 10cm = 30ml

SV x HR = CO
30 x 100 = 3000

Answer 65

A

a) 100-200

2012 BERLIN DEFINITION OF ARDS

ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.

Key components
- acute, meaning onset over 1 week or less
- bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph
- PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
- “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.

Severity
- ARDS is categorized as being mild, moderate, or severe:

Answer 66

A

d. autoimmune disease (with potential vascular complications)

RANZCOG

Maternal characteristics that are associated with an increased likelihood of pre-eclampsia include:
- previous pre-eclampsia, particularly when more serious or early onset before 34 weeks
- pre-existing medical conditions (including chronic hypertension, underlying renal disease, or pre-gestational diabetes mellitus),
- underlying antiphospholipid antibody syndrome,
- multiple pregnancy

UTD: Preeclampsia: Prevention
https://www.uptodate.com/contents/preeclampsia-prevention

Based on the available data (see ‘Evidence of efficacy’ above), we recommend low-dose aspirin prophylaxis for women at high risk for preeclampsia. There is no consensus on the exact criteria that confer high risk. It is reasonable to use the US Preventive Services Task Force (USPSTF) high-risk criteria, which are also endorsed by the American College of Obstetricians and Gynecologists (ACOG).

The incidence of preeclampsia is estimated to be at least 8 percent for pregnant women with any one of these high risk factors:
●Previous pregnancy with preeclampsia, especially early onset and with an adverse outcome
●Multifetal gestation
●Chronic hypertension
●Type 1 or 2 diabetes mellitus
●Chronic kidney disease
●Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus)

Answer 67

A

C Reduced due to increased volume of distribution and clearance

2010 Paper on major burns

The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution.

BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns.

Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized.

https://pubmed.ncbi.nlm.nih.gov/20510522/

Answer 68

A

C. Increased minute ventilation

Cerebral blood flow
Cardiac output
Acid–base status
Major haemorrhage
Arterial inflow/venous outflow obstruction

Oxygen content
Haemoglobin concentration
Haemoglobin saturation
Pulmonary function
Inspired oxygen concentration
Inspired oxygen concentration

Answer 69

A

REPEAT
c) 9 months

Answer 70

A

B peak of T wave

Triggering of the IABP is usually set according to the patient’s ECG tracing.
When an R wave is detected the balloon is triggered to automatically start inflating in the middle of the T wave.
Triggering can be impaired if the patient develops an arrhythmia, is paced or has a poor ECG trace.

LITFL

Answer 71

A

D Na 154, 308 mOsm/L

Answer 72

A

b. hypotension

The use of dexmedetomidine did not increase the duration of PACU LOS but was associated with reduced emergence agitation, cough, pain, postoperative nausea and vomiting, and shivering in PACU. There was an increased incidence of hypotension but not residual sedation or bradycardia in PACU.

https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU

Answer 73

A

b) Adrenaline

-You do not use full dose adrenaline (rather, give smaller doses)
-You do three “stacked shocks”
-You try pacing (rate of 90, DDD) in asystole if pacing wires are available
-If they are already paced and in PEA, you turn off the pacing to “unmask” VF.
-These shocks and attempted pacing are all measures you take before starting CPR, which is a departure from the ACLS norms.
-If you can’t control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles.
-Amiodarone is the only drug in the protocol, which makes it easy to remember.
-After five minutes of unsuccessful resuscitation the chest should be re-opened. -External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest.
-Non-surgical staff are encouraged to re-open the chest in an emergency

https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-arrest-following-cardiac-surgery

Answer 74

A

e) 1.5L

or >200ml/hr over the next 2-4hrs

Answer 75

A

B) analyse the difference between the means of more than two groupsc) comparisons of means between three groups in normally distributed data

Answer 76

A

B II

ASA II Paediatric examples: Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations

Answer 77

A

b. 4/3/1 (<6mo) or c.

6/4/1 (>6mo)

i. For adults having an elective procedure, limited solid food may be taken up to six hours prior to
anaesthesia and clear fluids may be taken up to two hours prior to anaesthesia.

ii. For children over six months of age having an elective procedure, limited solid food or formula may be
given up to six hours, breast milk up to four hours and clear fluids (no more than 3ml/kg/hr) up to one
hour prior to anaesthesia.

iii. For infants under six months of age having an elective procedure, formula may be given up to four
hours, breast milk up to three hours and clear fluids (no more than 3ml/kg/hr) up to one hour prior to
anaesthesia.

iv. Prescribed medications may be taken with a sip of water less than two hours prior to anaesthesia
unless otherwise directed (for example oral hypoglycaemics and anticoagulants).

v. An H2-antagonist, proton pump inhibitor or other agent that decreases gastric secretion and acidity
should be considered for patients with an increased risk of gastric regurgitation.

Answer 78

A

B 6 hours

20 x 25 x 4 = 2000 L
(Parklands)

In first 8 hours 50%
1 L in 8 hours FROM TIME OF BURN

So in 6 hours.

Answer 79

A

B Morphine

Histamine-releasing

Answer 80

A

C Neostigmine

Consider this Ogilve’s Syndrome

Psuedo-obstruction.

If > 9cm dilation, would need surgical management.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168359/#!po=17.5000

UTD refers to diameters over 12cm as being cut off

Answer 81

A

c) Decreased clearance – same dose

The dose recommendations for mild and moderate renal impairment (creatinine clearance between 30 and 80 mL/min) are the same as for adults without renal impairment.

Sugammadex is not recommended for use in patients with severe renal impairment (including patients requiring dialyses)

8.6 Renal Impairment
This drug is known to be substantially excreted by the kidney. Effect of mild or moderate renal impairment on sugammadex PK and PD was obtained from a study in elderly patients [see Use in Specific Populations (8.5)]. Although clearance of drug decreased in elderly subjects with mild and moderate renal impairment, there was no significant difference in the ability of sugammadex to reverse the pharmacodynamic effect of rocuronium. Hence, no dosage adjustment is necessary for mild and moderate renal impairment. BRIDION is not recommended for use in patients with severe renal impairment due to insufficient safety information combined with the prolonged and increased overall exposure in these patients [see Warnings and Precautions (5.11), Clinical Pharmacology (12.3)].

PI

Answer 82

A

E. Decreased acute kidney injury

Restrictive had more AKI
Otherwise no outcome significant statistically

https://www.thebottomline.org.uk/summaries/relief/

Answer 83

A

c) 30ml/kg

After a dose of 10 to 15 mL/kg of FFP, plasma clotting factors rise about 15%, and the fibrinogen level rises by 40 mg/dL (0.4g/l)

https://www.sciencedirect.com/topics/medicine-and-dentistry/fresh-frozen-plasma

1g/0.4g= 2.5
2.5 x 10ml/kg= 25ml/kg
2.5 x 15ml/kg= 37.5ml/kg
30ml/kg best answer

For cryoprecipitate:

One unit of Cryo is 15-20 mL in volume and contains 150-250 mg of fibrinogen. Cryo is generally transfused in pools of 10 units, which should increase an adult recipient’s fibrinogen level by 50-100 mg/dL. (0.5-1g/l)

10 units of cryo= 200-300ml
200ml/70kg= 2.8ml/kg
200ml/70kg= 4.2ml/kg

Typically 1 bag of whole blood cryoprecipitate given per 5–10 kg body weight would be expected to
increase the patient’s fibrinogen concentration by 0.5–1.0 g/L.1
Typically 1 bag of cryoprecipitate apheresis given per 10–20 kg body weight would be expected to
increase the patient’s fibrinogen concentration by 0.5–1.0 g/L.1
A standard adult dose of cryoprecipitate (3-4g of fibrinogen for a 70kg adult) is equivalent to:
y 10 bags of whole blood cryoprecipitate or
y 5 bags of apheresis cryoprecipitate

Paediatric dosing is not established however common practise is 5mL/kg or 1-2 whole blood
cryoprecipitate units per 10kg.

Answer 84

A

e. Spinal level of drain

According to AANN2 and SNACC4 Guidelines:
* Patient positioning and leveling is crucial to prevent complications from lumbar drainage
* The head of the bed, height of drainage chamber, and changes in patient positioning must be monitored
closely to prevent sudden overdrainage
* While making changes to the patient’s positioning, the lumbar drainage device should be clamped so that
overdrainage does not occur

https://www.integralife.com/file/general/1604065981.pdf
(manufacturer’s instructions)

Answer 85

A

d. transverse cervical

Supraclavicular nerve block. An initial injection of 3 mL local anesthetic is deposited at the midpoint of the sternocleidomastoid muscle, followed by 7 mL injected subcutaneously in a caudad and cephalad direction along the posterior border of the muscle.

complications:
1.Infection
2.Hematoma
3.Phrenic nerve block
4.Local anesthetic toxicity
5.Nerve injury

https://www.nysora.com/techniques/head-and-neck-blocks/cervical/cervical-plexus-block/

Answer 86

A

e. haloperidol

Clonidine-> no mention in the evidence
dexmedetomidine-> as an infusion seems to reduce risk of post-op delerium and could be used to treat but not necessarily practical in combative patient
Propofol-> not mentioned
Midazolam-> avoid benzos as can worsen delerium

If pharmacological approaches are required to reduce
risk of harm to the person with agitated delirium, then
haloperidol can be administered in incremental 0.5-mg
doses. Benzodiazepines should be used for people with
alcohol-related cognitive disorders or in people with
Parkinsonian dementia. There is no evidence to support the
use of prophylactic pharmacological measures
(cholinesterase inhibitors, antipsychotics, melatonin) in
routine peri-operative care for patients at risk of POD

https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_Perioperative_care_of_people_with_dementia_2019.pdf?ver=2019-02-11-121238-777&timestamp=1549888049165&ver=2019-02-11-121238-777&timestamp=1549888049165

Duan and colleagues conducted a meta-analysis of 18 clinical trials and found that intraoperative and postoperative dexmedetomidine administration significantly reduces the risk postoperative delirium (odds ratio 0.35).
->
https://www.bjanaesthesia.org/article/S0007-0912(20)30566-3/fulltext

Answer 87

A

b) Rocuronium based on LBW

Answer 88

A

C. Elevated ICP

No Absolute contraindications
Relative contraindications
1. Raised ICP or space occupying lesion
2. MI within the last 3 months
3. Severe arterial hypertension
4. Acute Glacoma
5. Changes in the cerebral arteries e.g. aneurysm

Pregnancy and Pacemakers are not contraindications to ECT

Indications:
1. Depression (most common)
2. MDD with psychotic features
3. Schizoaffective disorder
4. Schizophrenia with catatonia
5. Highly suicidal or depressed pregnant patients (not first line)
6. Bipolar affective disorder
7. Neuroleptic malignant syndrome

Answer 89

A

Ulnar Nerve

Answer 90

A

d) 1:19000

repeat

The estimated incidence of patient reports of AAGA was ~1:19,000 anaesthetics.

However, this incidence varied considerably in different settings.
The incidence was
~1:8,000 when neuromuscular blockade was used and
~1:136,000 without it.

Two high risk surgical specialties were
Cardiothoracic anaesthesia (1:8,600) and
Caesarean section (~1:670).

Answer 91

A

Tramadol

APMSE 5th edition:

Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8)

Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain.
At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7)

Pregabalin
Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732);
* Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015);
* Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367);
* Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562).

Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6))

A) Amitriptyline

repeat 20.1

By order of favourable NNT:

TCAs (amitriptyline) NNT: 3.6, NNH: 9
Strong opioids NNT 4.3 NNH 11.7
Tramadol NNT: 4.7, NNH 12.6
SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
Gabapentin NNT: 7.2 NNH 25.6
Pregabalin NNT:7.7, NNH 13.9

ANZCA Pain book

Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:

First line: pregabalin, gabapentin and amitriptyline;
Second line: tramadol and lamotrigine (in incomplete SCI);
Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 92

A

b. Exchange transfusion for HbSS <30%
c. transfuse for Hb >100
emergency fixation = no time for exahnge transfusion

perioperative goals:
- planning and optimisation
- ensuring adequate O2 delivery
- hydration
- analgesia
- performed at a centre with a multidisciplinary sickle cell team

Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD.
Exchange transfusion vs. top-up transfusion
Exchange Transfusion:
- slowly removing the person’s blood and replacing with fresh donor blood or plasma
- Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body
- in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30%
- Exchange transfusion removes HbS and increases HBA

Top-up transfusion:
- standard transfusion process of giving donor blood
- advantages of simple top-up include:
1. Increase oxygen carrying capacity
2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA)
3. Prevent or reverse complications of vast-occlusion
4. Can be given acutely
- disadvantages include:
1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l)
2. HbS is not removed, only diluted
3. Prevent or reverse complications of vast-occlusion
4. Can be given acutely
- disadvantages include:
1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l)
2. HbS is not removed, only diluted

Answer 93

A

c) 770mg

Product info: Fresenius-Kabi

When prolonged epidural blocks are used, either by continuous infusion or repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses of up to 800 mg ropivacaine for surgery and postoperative analgesiaadministered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours.

product info: pfizer

When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Experience to date indicates that a cumulative dose of up to 770 mg ropivacaine hydrochloride administered over 24 hours is well tolerated in adults when used for postoperative pain management: i.e., 2016 mg. Caution should be exercised when administering ropivacaine for prolonged periods of time, e.g., > 70 hours in debilitated patients

Answer 94

A

b. Cold saline irrigation of brain

Seizures, either focal or generalized, are most likely to occur during cortical mapping. They are treated by irrigating the brain tissue with ice-cold saline. They usually cease with this treatment alone, but occasionally benzodiazepines, anti-epileptic drugs, or re-sedation with airway control are required.

An emergency plan for airway control has to be in place at all times and this can be challenging as the patient’s head is fixed in head pins and often away from the ventilator. The options include the insertion of an LMA which may be easier than oro-tracheal intubation.

Awake craniotomy is generally a well-tolerated procedure with a low rate of conversion to general anaesthesia and a low rate of complications. One of the most frequent complications is patient intolerance of the procedure, often because of the urinary catheter or prolonged positioning and intra-operative seizures.

Answer 95

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.

Answer 96

A

c) Continuation leads to increased risk of major bleeding

Aspirin in patients undergoing non cardiac surgery
https://www.nejm.org/doi/full/10.1056/nejmoa1401105

Conclusions

Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number

Answer 97

A

d. asepsis

Asepsis: the prevention of microbial contamination of living tissues or sterile materials.
Disinfection: the inactivation of non-sporing organisms using either thermal or chemical means.
Sterilisation: complete destruction of all micro-organisms, including spores.

https://www.anzca.edu.au/getattachment/e4e601e6-d344-42ce-9849-7ae9bfa19f15/PG28(A)-Guideline-on-infection-control-in-anaesthesia

Answer 98

A

b) cohort study

What is a Cohort Study design?
- Cohort studies are longitudinal, observational studies, which investigate predictive risk factors and health outcomes.
- They differ from clinical trials, in that no intervention, treatment, or exposure is administered to the participants.
- The factors of interest to researchers already exist in the study group under investigation.
- Study participants are observed over a period of time. The incidence of disease in the exposed group is compared with the incidence of disease in the unexposed group.
- Because of the observational nature of cohort studies they can only find correlation between a risk factor and disease rather than the cause.

Cohort studies are useful if:
- There is a persuasive hypothesis linking an exposure to an outcome.
- The time between exposure and outcome is not too long (adding to the study costs and increasing the risk of participant attrition).
- The outcome is not too rare.

Answer 99

A

e) Standards of quality improvement

Quality Improvement

(Standards for QUality Imporvement and Reporting Excellence)

CONSORT: randomised trials
PRISMA: systematic reviews and meta-analysis (Preferred Reporting Items for Systematic reviews and meta-analysis).
STROBE: observational studies

Answer 100

A

a) 30 min

If the anaesthesia machine requires electrical power for normal operation, a backup power supply must be a part of the machine and permit normal operation for at least 30 minutes after a mains power supply failure. An alarm must be activated at the time of the mains failure and the state of the reserve power supply must be indicated while it is in use.

https://www.anzca.edu.au/getattachment/f05e02ec-2023-4c50-b57f-9549ea0c4183/PS54(A)-Position-statement-on-the-minimum-safety-requirements-for-anaesthesia-machines-and-workstations-for-clinical-practice-2021#page=

Answer 101

A

e. 200mmol

K+ < 3.0 mmol/L: 200-400 mmol of potassium are required to raise it by 1 mmol/L
K+ > 3.0 mmol/L: 100-200 mmol of potassium are required to raise it by 1 mmol/L

Hypokalaemia P. GLOVER
https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Publications/CCR Journal/Previous Editions/September 1999/05-Sept_1999_Hypokalaemia.pdf

If the serum potassium level is greater than 3 mmol/L, 100-200 mmol of potassium are required to raise it by 1 mmol/L; 200 - 400 mmol are required to raise the serum potassium level by 1 mmol/L when the potassium concentration is less than 3mmol/L, assuming a normal distribution between cells and the intracellular space, and a linear relationship between plasma potassium and body deficit (which has been described, i.e. 0.27 mmol/L/100 mmol deficit/70 kg), exists. The rate of administration of potassium will be influenced by the presence and seriousness of the pathophysiological changes caused by hypokalaemia. The underlying disorder should also be treated simultaneously.

Answer 102

A

d. acetazolamide

acetazolamdie has been known to cause lactic acidosis but is less common than the other drugs listed unless there is a 5th option not remembered

Answer 103

A

b. increased bleeding and normal aptt and inr

Bleeding because cold = we know this

Haemtology analyzer in labs warms blood to 37.2 degrees (fixes hypothermia on sample)

Answer 104

A

e. Oxygen consumption/min divided by HR

VO2/HR: oxygen consumption divided by HR, known as the ‘oxygen pulse’ (ml beat–1)

https://www.bjaed.org/article/S2058-5349(19)30021-6/fulltext

The objective of CPET is to determine functional capacity in an individual.
Deficiencies in CPET-derived variables—specifically:
1. ventilatory anaerobic threshold (AT)
2. peak O2 consumption (VO2peak)
3. ventilatory efficiency for carbon dioxide (VE/VCO2)
—are associated with poor postoperative outcomes (mortality, morbidity, admission to intensive care, and length of hospital stay) after intra-abdominal surgery.

Does the oxygen pulse increase with exercise?
The oxygen pulse is the VO2 divided by HR, and represents the product of the stroke volume and the arterial-venous oxygen difference. It can be seen in panel 2 and can be viewed as a surrogate for stroke volume, and as such should increase at the start of exercise before slowly reaching a plateau at its highest predicted value.

Answer 105

A

c) 8

E=2
V=2
M=4
Total= 8

Answer 106

A

a. Electromyography of internal laryngeal muscles

Answer 107

A

Long Thoracic Nerve

Answer 108

A

d) No difference

Repeat

Conclusions

In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746. opens in new tab.)

https://www.nejm.org/doi/full/10.1056/NEJMoa1811687

Answer 109

A

d) Esmolol

Management of Arrhythmias After Heart Transplant
https://www.ahajournals.org/doi/10.1161/CIRCEP.120.007954

In asymptomatic patients, additional cardiac monitoring such as 24-Holter or an event monitor can be useful to assess the SVT burden, and a trial of atrioventricular nodal blockers (β-blockers preferably) can be attempted with caution in view of potential risk of bradycardia. Calcium channel blockers such as diltiazem and verapamil are contraindicated in patients taking immunosuppression such as tacrolimus and cyclosporine as it can impair the metabolism CYP3A, which increases the levels of these drugs potentially causing renal toxicity.

The use of adenosine in the management of SVT has remained a subject of controversy for over a quarter century. In the past, adenosine was contraindicated in patients post-OHT due to its supersensitivity and presumed risk of prolonged atrioventricular block.

Thus, based on the aforementioned data, in patients with OHT, adenosine is feasible and safe at reduced doses (starting at 1.5 mg for patients ≥60 kg) as long as patients are closely monitored, with dose escalation as needed. Furthermore, the 2010 American Heart Association guidelines on advanced cardiovascular life support also recommended lowering the initial dose of adenosine to 3 mg for the acute management of SVT in patients with OHT.

Answer 110

A

Thrombin

rivaroxiban 10
dabigatran thrombin

Answer 111

A

REPEAT

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= TP/ TP + FP
= 1/ 1 + 99
= 1/100
=1%

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

Answer 112

A

d) Alprostadil

https://www.rch.org.au/piper/neonatal_medication_guidelines/Alprostadil_(Prostin_VR)%E2%80%93(Prostaglandin_E1)/

Alprostadil (PROSTAGLANDIN E1) is a synthetic prostaglandin used to relax the ductus arteriosus in early post-natal life, where a patent ductus is critical for survival, including Tetralogy of Fallot, pulmonary atresia, pulmonary stenosis, tricuspid atresia and transposition of the great arteries.

Dose
To open a closed ductus arteriosus:
0.1 micrograms/kg/minute (100 nanograms/kg/min). An effect is usually seen within 30-60 minutes. Reduce the dose once an effect is seen or as directed by a Consultant.1

Doses > 0.1 micrograms/kg/minute are rarely more effective and may cause serious adverse effects.3

To maintain patency of ductus arteriosus:
0.01 to 0.02 micrograms/kg/minute (10-20 nanograms/kg/min).1, 2

For persistent pulmonary hypertension of the newborn (PPHN):
0.01 to 0.05 micrograms/kg/minute (10-50 nanograms/kg/min).2

Answer 113

A

a) Pupillary constriction and reaction to light

Stellate ganglion block causes ipsilateral Horner’s Syndrome:
Ptosis (eyelid droop)
Miosis (constricted pupils)
Anhydrosis (loss of sweating)
Enophthalmos (sinking of eyeball into the bony cavity that protects the eye)
*Pupillary constriction in response to light is controlled by the Edinger-Westphal nucleus of CN3, which will remain intact.

Answer 114

A

d. Withdraw PAC 2cm and insert DLT
Pulmonary rupture

Miller:
- Position pt with bleeding lung dependent
- Perform endotracheal intubation, oxygenation, airway toilet
- Isolate lung by endobronchial DLT or SLT or bronchial blocker
- Withdraw PAC several centimetres, leaving it in the main PA. Do not inflate the balloon (except with fluoroscopic guidance)
- Position pt with isolated bleeding lung nondependent. Administer PEEP to the bleeding lung if possible
- Transport the patient to medical imaging for diagnosis and embolisation if feasible

Answer 115

A

REPEAT 20.2

b. Unstable angina

UTD:

Unstable angina (UA) and acute non-ST elevation myocardial infarction (NSTEMI) differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins):

●UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischemia (eg, ST segment depression or transient elevation or new T wave inversion).

●NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present.

MINS: Myocardial injury after non-cardiac surgery (up to 30 days post-op):
1. Elevated postop troponin
2. Resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), not requiring an ischaemic feature (i.e. no chest pain, no ECG change)

VISION studies (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) demonstrated that severity of MINS strongly associated with 30-day mortality after NCS.

hs-cTnT
<20ng/L ~ 0.5% 30 day mortality
20-64ng/L ~3% 30 day mortality
65-999 ng/L ~9% 30 day mortality
>1000ng/L ~30% 30 day mortality

Whilst VISION trial identified MINS in at risk patients, the question now becomes what interventions are available to prevent this complication?

Answer 116

A

c) Normal 23 DPG

https://www.bjaed.org/article/S2058-5349(20)30157-8/fulltext

Advantages of Cell salvage:
1. reduction in need for donor blood transfusion

no restrictive transfusion triggers
superior oxygen delivery compared to donor blood
-> red cells retain elliptical profiles and retain deformability
-> increased concentrations of 2,3 DPG and ATP
-> evidence supports early transfusion as oxygen carriage and deformability degrade over time
lack of adverse immunolgical effects
-> no sensitisation to antigens; Kell, duffy or Lutheran
-> donor blood transfusion causes dose-dependant transfusion related immunosupression (TRIM) this can lead to increased risk of post-op infection and posible increased risk of tumour growth in patients undergoing cancer surgery
Fulfills criteria for certain cultural groups to receive blood transfusion (JW)
Financial benefits despite equipment and staffing costs

Disadvantages:
1. The salvaged blood contains clinically insignificant concentrations of clotting factors and platelets, and when large volumes of blood are processed, the use of clotting factors, platelets, and calcium may be necessary.

High initial cost of equipment and training
Processing of blood requires a few minutes, blood may not be immediately available in time critical scenariois
REinfusion hypotension can occur and can be very marked requiring vasopressors
More labor intensive than donor blood, increased diligence required when collecting blood
May not be appropriate for all situations of operative blood loss
->Malignancy: use is controversial but supported in some instances (cystectomy radical prostatectomy, nephrectomy)
->Sepsis: not absolute contraindication but colume of contaminated material and pus must be limited
->Haemaglobonpathy: relative contraindication in sickle cell trait/disease and thalassaemia due to red cell fragility and potential for haemolysis

Answer 117

A

b. low frequency high amplitude

Changes in the electroencephalogram during anaesthesia and their physiological basis
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.

Answer 118

A

Suprascapular nerve

Answer 119

A

c. I:E ratio 1:3

BJA Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations:

An expert consensus was reached for 22 recommendations and four statements.

The following are the highlights:
(i) a dedicated score should be used for preoperative pulmonary risk evaluation; and
(ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs.

The ventilator should initially be set to a tidal volume of 6–8 ml kg−1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O.

PEEP should be individualised thereafter.

When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used.

Inspiratory/expiratory ratio:
Several studies have compared prolonged inspiratory-to-expiratory (I:E) ratios to the 1:2 ratio commonly used during mechanical ventilation.

An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage.
Prolonged I:E ratio increases mean airway pressure and concomitantly reduces peak airway pressure.

Studies using prolonged inspiratory times have described beneficial effects, including increased CRS and PaO2, lower alveolar–arterial gradient, and reduced inflammatory markers.

Given the lack of evidence for a clear benefit of a specific I:E ratio, no recommendation was offered by the panel.

However, the panel noted that optimisation of inspiratory time for individual patients can be achieved by monitoring parameters, such as oxygenation, CRS, and ΔP.

Intraoperative FIO2

Increased FIO2 during mechanical ventilation is administered to prevent or correct hypoxaemia, but may result in hyperoxia.

The negative effects of hyperoxia are not clear, but it has been suggested that it may increase oxidative stress, peripheral vascular and coronary artery vasoconstriction, decrease cardiac output, increase resorption atelectasis, and increase the rate of PPCs.

Recommendations for optimal use of oxygen and current evidence regarding the association between hyperoxaemia and clinically relevant outcomes during intraoperative mechanical ventilation are lacking.

Few studies have revealed a protective effect of hyperoxaemia, some report an association with mortality, whilst others show no association with clinically relevant outcomes.

Therefore, in the absence of evidence, the most prudent course of action during mechanical ventilation is to maintain normoxaemia.

SpO2 monitoring can assist in the detection of hypoxaemia, but during oxygen therapy SpO2 cannot detect hyperoxia.

Whilst SpO2 monitoring reduces the incidence of hypoxaemia, it does not improve the overall patient outcomes and does not reduce morbidity and mortality.

Therefore, once the airway is secured, FIO2 should be set to ≤0.4 with the goal of using the lowest possible FIO2 to achieve normoxia (or SpO2 ≥94%)

Unnecessarily high FIO2 should be avoided.

Administering lower FIO2 will not only decrease the risk of hyperoxia, but will also reduce the masking effect of oxygen therapy and allow for earlier diagnosis of gas-exchange impairment.

Answer 120

A

b. Rocuronium 1.2mg/kg

Cis not appropriate for intubation

Sux with K 6.3 is risky. (I’ve never heard of reduced dose)

Answer 121

A

d. 65 to 85 per hundred

85% of australians are CMV positive by the age of 40

https://www.blood.gov.au/system/files/documents/cmv-blood-components.pdf

Answer 122

A

a) 50mg six times a day

42mg IV Morphine = 126mg Oral Morphine

126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)

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

Answer 123

A

a) dulaglutide

The primary mechanism of action of dulaglutide, as an incretin mimetic hormone or an analogue of human glucagon-like peptide-1, is to increase insulin secretion when glucose levels are elevated, decrease glucagon secretion, and delay gastric emptying in an effort to lower postprandial glucose level.

Acarbose:
Acarbose is a complex oligosaccharide that acts as a competitive, reversible inhibitor of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase.

Pancreatic alpha-amylase hydrolyzes complex carbohydrates to oligosaccharides in the small intestine

By delaying the digestion of carbohydrates, acarbose slows glucose absorption, resulting in a reduction of postprandial glucose blood concentrations.
-> causes delayed gastric emptying but is not necessarily a part of its therapeutic effect

Answer 124

A

d) Trendelenberg c) Supine

Moving from upright to supine affects the respiratory function of the tetraplegic and high paraplegic individual differently to the able-bodied person.

The increase in abdominal girth when sitting in tetraplegia is secondary to decreased abdominal muscle strength and the associated increased abdominal wall compliance.

In the seated position, the abdominal contents are less supported by the decreased abdominal wall muscle tone and fall forward, increasing the waist size and lowering the diaphragm.

In able-bodied subjects, the FVC is reduced in the supine position, whereas in tetraplegia it is increased.

Postural changes are associated with symptoms; patients with an acute, high SCI report less breathlessness when supine compared to sitting.

In the supine position, the weight of the abdominal contents forces the diaphragm to a higher resting level so that contraction produces greater absolute excursion of the diaphragm; an effect that can be increased when the person with tetraplegia is tipped 15° head down from supine such that the vital capacity rises by a further 6%

Answer 125

A

a. Bleeding

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

Blue book 2017

Answer 126

A

d) >6

Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers

Answer 127

A

b. serum separating tube (gold top tube or red)

Potassium EDTA (purple)
-> FBC

sodium citrate (blue)
-> clotting screen/Rotem

sodium oxalate (green)
-> heavy metals (lead copper zinc)

Answer 128

A

c. 30cmH2O
paeds 20 cmH2O

Answer 129

A

c. 5 min

Circulatory determination of death in the context of organ donation

12 Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination.

13 For the purposes of organ donation, circulatory determination of death should be documented using a specific form (see Appendix E) to demonstrate explicitly that all criteria set out in this Statement are met. The same criteria should be listed in local hospital forms

Answer 130

A

d. Asthma

What are the causes of an elevated DL CO ?

The causes of an elevated DLCO are numerous, but is most commonly caused by asthma and obesity (increased pulmonary blood flow). Pulmonary hemorrhage is an additional important cause.

https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201605-355CC

Answer 131

A

f. perindopril

Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement.

Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).

Answer 132

A

d) 6 months

ANZCA PS 12 perioperative smoking
https://www.anzca.edu.au/getattachment/5deb6800-e8f9-453f-b9a6-a151a9323249/PG12(POM)-Guideline-on-smoking-as-related-to-the-perioperative-period-(PS12)

Effects of quitting
1 day
- Reduced HbCO3-> increased O2 content
- Reduced nicotine/ SNS stimulation

3 weeks
- Increased wound healing

6-8 weeks
- Reduced sputum volume
- Increased lung function

6 months
- Increased immune function

Answer 133

A

a) Smaller bolus smaller total dose

Marsh = more, Schnider = sparing
Marsh based on mass alone = MMA
Schnider includes senescence, sex = SSS

Answer 134

A

b. Suprascapular nerve

Suprascapula nerve (C5,6)
- innervates supra and infraspinatus
- comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block
- sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ

Supraclavicular nerve (C3,4)
- provides sensory to the ‘cape’ of the shoulder
- component of the cervical plexus block
- lies outside the brachial plexus
- commonly missed during supraclavicular brachial plexus blocks

Subscapular nerve:
- subscapularis
- medial rotation shoulder

Dorsal scapular nerve:
- branch of the brachial plexus
- supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle
- causes the scapula to be moved medially towards the vertebral column
- Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion

Thoracodorsal nerve:
- thoracodorsal nerve also branches from the posterior division of the brachial plexus
- this nerve innervates the latissimus dorsi muscle.

https://resources.wfsahq.org/atotw/the-shoulder-block/

Answer 135

A

d) Reduced time to resumption of oral intake

Intraoperative dexamethasone administration reduces postoperative pain, nausea and
vomiting and time to resumption of oral intake after tonsillectomy (S) (Level I [Cochrane
Review]), with no increase in adverse effects (U) (Level I [Cochrane Review]).

https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf

Answer 136

A

b. sinus tachy with BBB

The most correct answer would be Trifasicular block:
RBBB with LAD (RBBB with left anterior hemiblock) and 1st degree heart block

Barash 8E 2017:
The term bifascicular block often refers to block in the right bundle and one of the two major fascicles of the left bundle. RBBB with left anterior hemiblock is present when the ECG shows an RBBB with a left axis deviation (usually greater than −60 degrees) in the absence of an inferior myocardial infarction. Complete RBBB with right axis deviation (greater than 90 degrees) is indicative of RBBB and left posterior hemiblock in the absence of a lateral myocardial infarction or evidence of right-sided heart failure. The term trifascicular block is used to describe first-degree AV block in the presence of bifascicular block.

Is it necessary to insert a temporary pacemaker before general anesthesia for an asymptomatic patient with bifascicular or trifascicular block?
The risk for progression to complete heart block in asymptomatic patients with bifascicular block is low. Further, no clinical characteristics have been identified that accurately predict the risk of development of complete heart block. Therefore, routine PPM implantation in patients with asymptomatic bifascicular block is not recommended. Observations made in the perioperative period have suggested that development of complete heart block during general anesthesia is also rare; therefore, it is generally not recommended that patients undergo temporary pacemaker insertion before general anesthesia. However, it is advisable to have an external pacemaker available in the operating room.

Answer 137

A

c. Hypocalcaemia

Laryngospasm is a rare, but serious and potentially lethal, complication of hypocalcemia in adults. In every adult presenting with acute dyspnea and stridor, the possibility of hypocalcemia should be considered. Hypocalcemia should be treated promptly.

Answer 138

A

d. Noradrenaline

Supportive Management of Massive PE

Coexisting left ventricular systolic dysfunction and diastolic dysfunction complicate the management of heart failure patients with massive PE. Although a common strategy in response to systemic arterial hypotension is to prescribe a fluid bolus, volume loading may worsen biventricular failure, pulmonary edema, and hypoxemia. An initial trial of volume expansion, limited to 250 to 500 mL, may be attempted in those heart failure patients without evidence of increased right-sided filling pressures or pulmonary edema.6

Although non–heart failure patients generally respond well to pure vasopressors for hemodynamic support in massive PE, many heart failure patients will not tolerate the isolated increase in systemic vascular resistance. PE patients with heart failure may require an agent with mixed vasopressor and inotropic properties such as norepinephrine, epinephrine, or dopamine. Whereas LV function often becomes hyperdynamic to compensate for RV failure, the presence of underlying LV systolic dysfunction in heart failure patients may limit the patient’s ability to maintain normal systemic cardiac output and may necessitate the addition of inotropes.

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.803965

Answer 139

A

A. Magnesium TdP

For all patients with congenital LQTS and a history of syncope, seizures, or resuscitated SCA, we recommend treatment with a beta blocker [8]. In general, we suggest propranolol or nadolol, given their superior efficacy in this patient population. The use of atenolol and metoprolol has been associated with an increased rate of recurrences [25]. In addition, if the symptom was resuscitated SCA, then an ICD as secondary prevention is indicated as well in most circumstances

double check UTD bb

https://www.uptodate.com/contents/congenital-long-qt-syndrome-treatment

Statpearls

Acute - mag
Long term prevention of TDP - BB

Treatment / Management
The goal of management is the prevention of lethal arrhythmias such as torsade de pointes (TdP). As described earlier, the longer the QT interval, the higher the risk is for torsade de pointes. A patient who is hemodynamically unstable should receive non-synchronized electrical defibrillation. Also, first-line treatment is magnesium sulfate, and the benefit is seen independent of serum magnesium level. In those who do not respond to magnesium sulfate, temporary transvenous overdrive pacing should be considered. Isoproterenol and Class IB antiarrhythmic drugs, such as lidocaine and phenytoin may also be used. [5][11][12][13]

For long-term management in congenital Long QT syndrome, beta-blockers are the first line choice, and they help prevent ventricular arrhythmias by stabilizing ventricular action potential and helping block sympathetic surges associated with arrhythmias. An implantable cardioverter defibrillator (ICD) is recommended in patients with Long QT syndrome who were resuscitated from a cardiac arrest. It is also indicated in those whom have beta-blocker resistant symptoms or have contraindications to beta-blockers. It also may be indicated in asymptomatic individuals who are suspected to be at high risk for ventricular arrhythmias.

Answer 140

A

d. Age >3

Answer 141

A

b. pneumonia

Air bronchogram

Answer 142

A

c. Doxycycline 400mg

Insertion of Mirena-> no antibiotics
exception is acute PID-> clindamycin

https://ranzcog.edu.au/wp-content/uploads/2022/05/Prophylactic-Antibiotics-in-Obstetrics-and-Gynaecology.pdf

Answer 143

A

b) 2,5

Air: 1, 5
Oxygen: 2, 5
N2O: 3,5
CO2: 2, 6
He: 2, 4

Cyclopropane 3, 6
Entonox 7

Answer 144

A

POSTERIOR CUTANOUS NERVE OF THE THIGH

lat / int and medial cutaneous of the thigh
femoral nerve (posterior division)
saphenous
obturator (post branch)
tibial nerve - articulates to the knee
sciatic (common perineal nerve)
L3/4 = extensors of knee
L5/S1 = flexors of the knee

Anatomy for Anaesthetists

Answer 145

A

b) PR indomethacin

A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis

https://www.nejm.org/doi/full/10.1056/NEJMoa1111103

Nonsteroidal antiinflammatory drugs (NSAIDs) are potent inhibitors of phospholipase A2, cyclooxygenase, and neutrophil–endothelial interactions, all believed to play an important role in the pathogenesis of acute pancreatitis. NSAIDs are inexpensive and easily administered and have a favorable risk profile when given as a single dose, making them an attractive option in the prevention of post-ERCP pancreatitis. Preliminary studies evaluating the protective effects of single-dose rectal indomethacin or diclofenac in post-ERCP pancreatitis have been conducted, and a meta-analysis suggests benefit.

Results
A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03).

Conclusions
Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition.

Answer 146

A

Hypoplastic mandible (micrognathia) – difficult intubation
§ Pierre Robin sequence
§ Treacher Collins
§ Hemifacial microsomia (Goldenhar syndrome)

Midface hypoplasia – difficult bag-mask ventilation
§ Apert syndrome
§ Crouzon syndrome
§ Pfeiffer syndrome
§ Saethre-Chotzen syndrome

Macroglossia – difficult bag-mask ventilation AND difficult intubation
§ Hurler’s/Hunter’s syndrome (mucopolysaccharidoses)
§ Beckwith-Wiedemann syndrome
§ Down’s syndrome

https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai

Mucopolysaccharidoses, Down syndrome, muscular dystrophies, and other neurologic disorders have been associated with obstructive sleep apnea

Prevalence of OSAS.
Genetic Disorder Prevalence of OSAS
Neuromuscular diseases 69.2%
Prader–Willi syndrome 94.7%
Arnold–Chiari syndrome 80%
Achondroplasia 100%
Crouzon syndrome 100%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156845/

https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai

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