22.2 Flashcards

Question

22.2 The piece of airway equipment shown is a a. bullard laryngoscope b. CMAC video stylet c. lightwand d. flexible bougie

Answer 1

CMAC video stylet

Answer 2

Tracheal stenosis

Answer 3

d. Use lower frequency probe

Answer 4

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%

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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#

Answer 10

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

Answer 11

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

Answer 12

Ergometrin increases PVR and SVR

Answer 13

4. Medial Cutaneous nerve of the forearm

Answer 14

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.

Answer 15

Increased latency, decreased conduction speed, decreased amplitude

Answer 16

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

Answer 17

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

Answer 18

Serotonin Syndrome Hyper reflexia Usually has hypertension and hyperthermia https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png

Answer 19

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.

Answer 20

7. Radial Nerve

Answer 21

Proprioception OHA (5th) p305

Answer 22

c. pneumothorax

Answer 23

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

Answer 24

e. 60g Each 20mg dantrolene contains 3g mannitol

Answer 25

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

Answer 26

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).

Answer 27

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

Answer 28

c. myasthenia gravis

Answer 29

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

Answer 30

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)

Answer 31

B Repeat NEVER GIVE ADRENALINE ANZ CALS guideline

Answer 32

A codeine Oxycodone B Morphine C Tramadol C Fentanyl C

Answer 33

C. Oesophageal stricture ## Footnote https://www.asecho.org/wp-content/uploads/2014/05/2013_Performing-Comprehensive-TEE.pdf

Answer 34

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 35

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 36

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 37

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

Answer 38

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 39

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

Answer 40

C 3L/min LVOT area x VTI = SV 3cm2 x 10cm = 30ml SV x HR = CO 30 x 100 = 3000

Answer 41

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 42

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 43

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 44

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 45

REPEAT c) 9 months

Answer 46

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 47

D Na 154, 308 mOsm/L

Answer 48

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 49

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

Answer 50

e) 1.5L or >200ml/hr over the next 2-4hrs

Answer 51

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

Answer 52

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 53

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 54

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 55

B Morphine Histamine-releasing

Answer 56

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 57

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)]. ## Footnote PI

Answer 58

E. Decreased acute kidney injury Restrictive had more AKI Otherwise no outcome significant statistically https://www.thebottomline.org.uk/summaries/relief/

Answer 59

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 60

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 61

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 62

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×tamp=1549888049165&ver=2019-02-11-121238-777×tamp=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 63

b) Rocuronium based on LBW

Answer 64

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 65

1. Ulnar Nerve

Answer 66

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 67

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: 1. TCAs (amitriptyline) NNT: 3.6, NNH: 9 2. Strong opioids NNT 4.3 NNH 11.7 3. Tramadol NNT: 4.7, NNH 12.6 4. SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 5. Gabapentin NNT: 7.2 NNH 25.6 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 68

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 69

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 70

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 71

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 72

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 73

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 74

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 75

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 76

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 77

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 78

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 79

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 80

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. 7. 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 81

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

Answer 82

a. Electromyography of internal laryngeal muscles

Answer 83

5. Long Thoracic Nerve

Answer 84

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 85

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 86

Thrombin rivaroxiban 10 dabigatran thrombin

Answer 87

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 88

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 89

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 90

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 91

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 92

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 2. no restrictive transfusion triggers 3. 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 4. 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 5. Fulfills criteria for certain cultural groups to receive blood transfusion (JW) 6. 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. 2. High initial cost of equipment and training 3. Processing of blood requires a few minutes, blood may not be immediately available in time critical scenariois 4. REinfusion hypotension can occur and can be very marked requiring vasopressors 5. More labor intensive than donor blood, increased diligence required when collecting blood 6. 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 93

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 94

8. Suprascapular nerve

Answer 95

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 96

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 97

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 98

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 99

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 100

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 101

a. Bleeding ECMO complications: - patient complications: bleeding & coagulopathy most common - mechanical complications: access insufficiency common Blue book 2017

Answer 102

d) >6 Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers

Answer 103

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 104

c. 30cmH2O paeds 20 cmH2O

Answer 105

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 106

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 107

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 108

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 109

a) Smaller bolus smaller total dose Marsh = more, Schnider = sparing Marsh based on mass alone = MMA Schnider includes senescence, sex = SSS

Answer 110

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

Answer 111

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 112

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 113

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 114

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 115

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 ## Footnote 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 116

b. pneumonia Air bronchogram

Answer 117

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 118

b) 2,5 Air: 1, 5 Oxygen: 2, 5 N2O: 3,5 CO2: 2, 6 He: 2, 4 Cyclopropane 3, 6 Entonox 7

Answer 119

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 ## Footnote Anatomy for Anaesthetists

Answer 120

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.

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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