23.1 Flashcards

Question

23.1 A 75-year-old man has this right heart catheter trace as part of his investigation of dyspnoea. His pulmonary capillary wedge pressure is 24 mmHg. The most likely diagnosis is: A. Idiopathic Pulmonary Arterial Hypertension B. Portopulmonary Syndrome C. Left Heart Failure D. Pulmonary Embolism E. Pulmonary Fibrosis

Answer 1

C. Left heart failure causing PulmHTN Normal PAPs/d is 25/7. This would be classed as severe (55) - (if image is correct) PAWP >15 means ‘ post-capillary’ cause or combined pre- and post. This is either group 2 or 5. A PVR might help differentiate. All other options (group 1,3,4 and 5) would likely have a isolated ‘pre-capillary’ PAWP of <15 LITFL and blue book 2015 article

Answer 2

a) anterior third of the tongue

Answer 3

a) over-expansion https://www.respiratorytherapyzone.com/ventilator-waveforms/#:~:text=Note%3A%20A%20pressure%2Dvolume%20loop,hand%2C%20indicates%20increased%20lung%20compliance.

Answer 4

D. Amitriptyline Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia N.B Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the resolution of acute pain (U) (Level I) but **do not reduce** the incidence, severity and duration of postherpetic neuralgia UTD Both Gabapentinoids and TCAs are effective at TREATING postherpetic neuralgia. The former have lower risk of discontinuation due to adverse side effects. For moderate or severe pain, use gabapentinoids.

Answer 5

e) hypoglycaemia

Answer 6

A Massive bronchopleural fistula. Nick Chrimes 2022 - Journal of Anaesthesia ‘Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies’ Causes of exhaled carbon dioxide detection despite oesophageal intubation No alveolar ventilation occurring -Prior ingestion of carbonated beverages or antacids -Gastric insufflation of CO2 for upper gastrointestinal endoscopy -Prolonged ventilation with facemask or poorly positioned supraglottic airway before attempting tracheal intubation -Bystander rescue breaths Some alveolar ventilation potentially occurring -Tracheo-oesophageal fistula with tube tip proximal to fistula -Proximal oesophageal intubation with uncuffed tube in a paediatric patient

Answer 7

c. Two sets of pads, <1 second apart For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 8

e. Hypotension https://www.safetyandquality.gov.au/sites/default/files/2022-06/sepsis_clinical_care_standard_2022.pdf

Answer 9

c. inc extracellular fluid https://derangedphysiology.com/main/required-reading/electrolytes-and-fluids/Chapter%20531/hyponatremia-lazy-mans-classification

Answer 10

b. AR https://litfl.com/oesophageal-doppler/

Answer 11

E. Urine output For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation over physical examination or static parameters alone. Weak recommendation, very low-quality evidence. Remarks: Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography, where available. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx

Answer 12

a) electrical alternans Physical findings in Tamponade: - A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade - None of the findings alone are highly sensitive or specific for the diagnosis. Beck's triad 1. Low arterial blood pressure 2. Dilated neck veins 3. Muffled heart sounds - Are present in only a minority of cases of acute cardiac tamponade. Diagnosis: Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include: ●Chest pain ●Syncope or presyncope ●Dyspnea and tachypnea ●Hypotension ●Tachycardia ●Peripheral edema ●Elevated jugular venous pressure ●Pulsus paradoxus

Answer 13

a) muscolocutaneous

Answer 14

e) ensure leads securely attached https://journals.lww.com/nursing/Citation/2006/11000/Cables_and_electrodes_can_burn_patients_during_MRI.12.aspx#:~:text=The%20radiofrequency%20fields%20that%20occur,enough%20to%20require%20plastic%20surgery. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.107.187256#d1e281

Answer 15

c) 93% ANZCOR suggests against the routine administration of oxygen in persons with chest pain.13 [2015 COSTR, weak recommendation, very-low certainty evidence] For persons with heart attack, routine use of oxygen is not recommended if the oxygen saturation is >93% [National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: practice advice].9

Answer 16

e. Obstructive w/ reduced FEV1 Mucous narrowing airways = obstructive Parenchymal damage = restrictive Obstructive PFP remains the most common pulmonary function pattern in adult CF and is associated with -decrease FEV1 & FVC/FEV1 For patients with CF, an obstructive pattern is generally seen, with a decrease in forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) to FEV1 ratio. https://academic.oup.com/bjaed/article/11/6/204/263786

Answer 17

b) 4yo 4 yo = wong baker faces score 3-18. 8 yo = Visual analogue scale. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/ APMSE 5 also

Answer 18

c. 200mg hydrocortisone 200mg Hydrocortisone or 25mg Prednisolone Conversion Prednisone 1mg = Hydrocortisone 4mg = Dexamethasone 0.15mg = Triamcinolone 0.8mg = Methylprednisolone 0.8mg = Betamethasone 0.15mg = (https://litfl.com/corticosteroids-overview/)

Answer 19

a) inhalational anaesthesia https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/

Answer 20

c) 0, 1, 4, 24 Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours. https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf

Answer 21

a) saphenous

Answer 22

d. Augments Cardiac output in patients with LV failure Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation. Brief releases at a lower pressure facilitate carbon dioxide clearance. The terminology and methods of initiation, titration, and weaning are distinct from other modes of mechanical ventilation. The use of APRV is increasing in the UK despite a current paucity of high-quality evidence high intrathoracic pressure decreases the transmural left ventricular pressure, reducing the work of contraction and increasing cardiac output. In the context of hypoxaemia, a mode of mechanical ventilation that improves arterial oxygenation will improve myocardial oxygen delivery, myocardial function and cardiac output. As APRV is a spontaneous breathing mode, in addition to the benefits of spontaneous ventilation, reduced doses of sedative drugs can often be used, with subsequent reduction of requirement for vasoactive drugs and improvement in haemodynamic state. Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation https://www.bjaed.org/article/S2058-5349(19)30178-7/fulltext https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20518/airway-pressure-release-ventilation-aprv-ards

Answer 23

c) DOO The pacing mode will be DOO when the programmed pacing mode is a dual chamber mode or an MVP mode (AAIR<=>DDDR, AAI<=>DDD), VOO when the programmed pacing mode is a single chamber ventricular mode, and AOO when the programmed pacing mode is a single chamber atrial mode.

Answer 24

a) methylene blue Drugs to avoid: Antibiotics Sulphonamides (check with your doctor) Co-trimoxazole (Bactrim, Septrin) Dapsone Chloramphenicol Nitrofurantoin Nalidixic acid Antimalarials Chloroquine Hydroxychloroquine Primaquine Quinine Mepacrine Chemicals Moth balls (naphthalene) Methylene blue Foods Fava beans (also called broad beans) Other drugs Sulphasalazine Methyldopa Large doses of vitamin C Hydralazine Procainamide Quinidine Some anti-cancer drugs

Answer 25

(base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50 or 1 divided by risk reduction population risk = 10/100 patients get PONV population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug) RR= 0.10-0.08=0.02 NNT= 1/RR =1/0.02 =50

Answer 26

a) case control https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html

Answer 27

a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication) https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy

Answer 28

c. Decreased amplitude, increased latency

Answer 29

a) Cold Saline Irrigation

Answer 30

b) severe dermatographia

Answer 31

a) turn left lateral UTD: Cardiac herniation is usually seen within three days of surgery, presenting as sudden onset of hypotension and shock, cyanosis, chest pain, and superior vena cava syndrome. The acute event is usually preceded immediately by coughing, moving the patient, vomiting, or extubation. Treatment involves emergent surgery to reposition the heart and close the pericardial defect to prevent recurrence. ?bleeding Rapid filling of the PPS with blood can occur within 24 hours of surgery. This complication is more common after pleuropneumonectomy or pneumonectomy for suppurative lung disease. The clinical presentation may be with hypotension and shock due to the loss of intravascular blood volume. The mainstay of treatment is surgical reexploration and control of bleeding sources.

Answer 32

b) vasoplegia

Answer 33

b) flaccid paralysis Guillain–Barré syndrome (GBS) is an inflammatory disease of the PNS and is the most common cause of acute flaccid paralysis

Answer 34

a. Dysaesthesia Chronic pain that may involve itchiness, burning, electric shock, or a general tightening in any part of the body. Allodynia Pain from stimuli which are not normally painful. The pain may occur other than in the area stimulated. Hyperalgesia is an abnormally increased sensitivity to pain Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense https://www.iasp-pain.org/resources/terminology/#:~:text=DYSESTHESIA,sen

Answer 35

d. 65 to 85 per hundred Risk of acquiring CMV through a leucodepleted blood product is estimated at around 1 in 13,575,000. This compares to a community acquired risk where 85% of Australian adults are infected by the age of 40. 85% of australians are CMV positive by the age of 40 https://www.blood.gov.au/system/files/documents/cmv-blood-components.pdf

Answer 36

d) diltiazem Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673 Should also avoid sotolol

Answer 37

a) Accurate delivery of volatile concentration from vaporiser PS31 Level two check should be performed at the start of each anaesthetic list. 4.2.3.2 Inhalational anaesthesia delivery devices (vapouriser) 4.2.3.2.1 Ensure electricity is connected to vapourisers that require it. 4.2.3.2.2 Check the anaesthetic liquid level is within marked limits. 4.2.3.2.3 Ensure all filling ports are sealed. 4.2.3.2.4 Check correct seating, locking and interlocking of detachable vapourisers or casettes. 4.2.3.2.5 Test for circuit leaks with a cassette installed or for each vapouriser in the “on” and “off” state. 4.2.3.3 Check for machine leaks upstream from the common gas outlet or breathing system, using a protocol appropriate for the anaesthesia delivery system.

Answer 38

b) diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs

Answer 39

a. <110ml leak with cuff deflated approach is to use 110 mL or 10% of tidal volume as the cut-off https://litfl.com/cuff-leak-test/

Answer 40

b) no limitation in neck movement One of the most commonly used mnemonics is “NSAID” which stands for: N eurological deficit S pinal tenderness A ltered mental status I ntoxication D istracting injury

Answer 41

e) haloperidol Bluebook - suggest antipsychotics with caution

Answer 42

d) loss of pain and temperature

Answer 43

A. Pecs 1 or Pecs 2 https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/thorax/pectoralis-serratus-plane-blocks/ PECs 2 may be adequate in analgesia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141978/ so answer could be pecs 1

Answer 44

C. 3 Subject repeat but different stem

Answer 45

Category GFR ml/min/1.73 m2 Terms G1 ≥90 Normal or high G2 60-89 Mildly decreased* G3a 45-59 Mildly to moderately decreased G3b 30-44 Moderately to severely decreased G4 15-29 Severely decreased G5 <15 Kidney failure Assign Albuminuria category as follows: Albuminuria categories in CKD Category ACR (mg/g) Terms A1 <30 Normal to mildly increased A2 30-300 Moderately increased* A3 >300 Severely increased** Abbreviations: ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease. *Relative to young adult level. **Including nephrotic syndrome (albumin excretion ACR >2220 mg/g) **Collectively referred to as “CGA Staging” REPEAT

Answer 46

E. distance from anterior surface of dens to posterior surface of anterior arch of atlas The atlantodental interval is used in the diagnosis of atlanto-occipital dissociation injuries and injuries of the atlas and axis. The anterior atlantodental interval is the horizontal distance between the posterior cortex of the anterior arch of the atlas (C1) and the anterior cortex of the dens in the median (midsagittal) plane Normal values for anterior atlantodental interval are: radiographs: adults: males: <3 mm females: <2.5 mm 1 (although most authors describe <3 mm ref) children: <5 mm ref CT: adults: <2 mm

Answer 47

A. Move medial

Answer 48

d) myasthenia gravis or d) Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia if responses remembered incorrectly but of this list CP is probably the answer a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis 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 REPEAT

Answer 49

B. 7.32 https://emj.bmj.com/content/18/5/340 The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of −0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being −0.11 to +0.04 units. https://litfl.com/vbg-versus-abg/ pH - Good correlation - pooled mean difference: +0.035 pH units

Answer 50

D. Substance P Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting (2011) https://www.ncbi.nlm.nih.gov/pubmed/21434941 Aprepitant acts centrally at NK-1 receptors in vomiting centres within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy. REPEAT

Answer 51

c) 110 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 52

A. AION Answer is more likely ‘A - Anterior Ischaemic Optic Neuropathy, because: 1. Most common 2. One or two days post - up to 12 3. Optic disc oedema (CRAO - fundoscopic appearance is that retina appears pale with cherry red central spot). PION fundoscopy is normal at first but has late developing oedema. It is less common than AION. https://eyewiki.aao.org/Non-Arteritic_Anterior_Ischemic_Optic_Neuropathy_(NAION) As mentioned earlier, optic disc edema is always present in the acute phase of NAION (the reason will be discussed in the section under Pathophysiology) and comes in two varieties, diffuse or segmental. Posterior ischemic optic neuropathy (PION) encompasses those conditions that result in ischemia to any portion of the optic nerve posterior to the optic disc. By definition, PION will not cause disc edema. Symptoms: The classic description of patients with NAION presenting with acute, painless unilateral vision loss that is often described as a blurring or cloudiness of vision, often inferiorly, has been expanded. Although the majority of patients do not have accompanying pain, headache or periocular pain is reported in 8-12% of patients, which can make it difficult to differentiate from optic neuritis

Answer 53

c. 9 AHA guidelines 12 Months But 12 weeks minimum Although the evidence between surgical timing and stroke risk is limited to only these 2 studies, we suggest that elective noncardiac surgery be deferred at least 6 months after a prior stroke, and possibly as long as 9 months to reduce the risk of perioperative stroke in patients undergoing noncardiac surgery. Alternatively, patients who stand to gain significant improvements in quality of life with elective surgery may consider waiting only 6 months after a prior stroke REPEAT

Answer 54

C. Between lowest renal artery to bifurcation of aorta https://litfl.com/reboa-in-resuscitation/ Anatomy: The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals) Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male) Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long) Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long) REBOA location based on injury: >suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or >blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or >patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or common femoral vessels) (Zone III REBOA) Simplistic rendering of aorta. Zone 1 (from left subclavian artery to the upper border of the celiac trunk), Zone 2 (the upper border of the celiac trunk to the lower border of the distal take-off of the renal arteries), and Zone 3 (from the lower border of the lower renal artery to the aortic bifurcation). Zone 1 is occluded in the case of cardiac arrest or life-threatening intra-abdominal hemorrhage; Zone 2 has no current indication; and Zone 3 is occluded in the case of life-threatening pelvic or lower limb haemorrhage7. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta.

Answer 55

D. Withholding information to the patient if you think it will cause harm https://www.sciencedirect.com/topics/medicine-and-dentistry/therapeutic-privilege “Therapeutic privilege,” also known as “therapeutic nondisclosure,” is defined as the withholding of relevant health information from the patient if nondisclosure is believed to be in the best interests of the patient (President’s Commission, 1982; Berger, 2005). The two most common justifications for such nondisclosure are that the disclosure would create incapacitating emotional distress and that disclosure would violate a patient’s personal, cultural, or other social requirements (Crawley et al., 2001; Berger, 2005).

Answer 56

a) Open repair Flow chart from Blue book https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862

Answer 57

a) delayed gastric emptying

Answer 58

e. 45ml/hr 0.9% NS 5% dextrose REPEAT

Answer 59

B. Cardiac hernation https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.896829

Answer 60

a) day of and 2 days prior

Answer 61

d) Supraclavicular Axillary nerve innervates skin to inferior deltoid (regimental badge)+ motor to terres minor and deltoid. Lateral pectoral nerve innervates the anterosuperior part of the glenohumeral joint. Subscapular nerves - upper subscapular nerve serves the upper portion of the subscapularis muscle; the middle subscapular nerve (thoracodorsal nerve) innervates latissiumus dorsi; lower subscapular nerve innervates subscapularis and terres major. Supraclavicular nerve - sensory only and innervates skin across entire shoulder and trapezius in a ‘cape-like’ fashion - sometimes missed in interscalene block. Suprascapular nerve sensory innervation to glenohumeral joint and acromiovlavicular joint + motor to supraspinatus/infraspinatous (rotator cuff) https://pubmed.ncbi.nlm.nih.gov/32712453/

Answer 62

A. Aspirin 150mg daily (option was definitely 150mg not 100mg) or D. Ca Aspirin should be given at a dose between 75 and 150 mg per day, started preferably before 16 weeks, possibly taken at night, and continued until delivery; https://www.somanz.org/content/uploads/2023/06/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf Calcium supplementation (1.5g/day) should therefore be offered to women with moderate to high risk of preeclampsia, particularly those with a low dietary calcium intake (247)

Answer 63

c) Foetal RBC All others removed with leukodepletion filter

Answer 64

b. Insufficient fludrocortisone replacement In Primary Adrenal Insufficency, cortisol deficiency results in decreased feedback to the HPA axis, leading to increased secretion of ACTH to stimulate the adrenal cortex. Simultaneously, MCs deficiency causes increased release of renin by the juxtaglomerular apparatus of the kidneys.

Answer 65

Sartorius repeat

Answer 66

c. Pain at site 1 month prior to surgery Pain itself is a risk factor: the strongest predictors of CPSP are chronic preoperative pain and the severity of acute postoperative pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741327/#:~:text=Pain%20its

Answer 67

b) 1 or more RF

Answer 68

D. 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 REPEAT

Answer 69

d. 7 weeks UPDATE: 2-3 weeks PG68(A) https://www.anzca.edu.au/getattachment/af1fb728-5e87-413a-b006-c54cecf282b1/PG68(A)-Guideline-surgical-patient-safety-SARS-CoV-2 For most patients, it is safe to proceed with surgery TWO TO THREE WEEKS post SARS-CoV-2 infection provided no ongoing symptoms are present. For high-risk patients, it is recommended to perform an individualised risk assessment and utilise Shared Decision Making to determine optimal timing of surgery post SARS-CoV-2 infection. Patients who are asymptomatic, have returned back to baseline, are vaccinated, aged <70 years and without comorbidity can proceed with non-urgent elective minor surgery (day case) and endoscopy procedures without delay beyond the infectious period (timeframe as per local guideline and expertise ALL patient with ongoing symptoms, especially those who have not returned to baseline function and those patients with a history of moderate or more severe25 SARS-CoV-2 infection: recommended delay for non-urgent elective surgery is still 7 weeks

Answer 70

c. sinus tachy with prolonged QRS

Answer 71

a) NT ProBNP Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume. In contrast, in comparison with enalapril, patients receiving LCZ696 had consistently lower levels of NTproBNP (reflecting reduced cardiac wall stress) and troponin (reflecting reduced cardiac injury) throughout the trial. ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.013748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Answer 72

c. dobutamine ## Footnote UTD

Answer 73

a. Normal - Normal A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin, owing to their similar absorbances. The blood gas PO2 will also be normal in these cases (despite the presence of tissue hypoxia). ## Footnote file:///Users/newuser/Downloads/BTS%20Guideline%20for%20oxygen%20use%20in%20adults%20in%20healthcare%20and%20emergency%20settings.pdf

Answer 74

A. Lupus anticoagulant (normal PT, raised APTT) Lupus anticoagulant (more likely to be associated with thrombosis than bleeding) ## Footnote https://www.uptodate.com/contents/image?imageKey=HEME%2F79969

Answer 75

b. high HDL-C ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.105.169405

Answer 76

a. medial cutanous brachial nerve C8/T1 roots are often missed. Therefore, interscalene blocks tend to fail on the ulnar side of the arm Medial brachial cutaneous nerve (C8-T1, arises from the medial cord of the brachial plexus): upper medial arm ## Footnote NYSORA

Answer 77

D. Albumin ## Footnote https://www.tamingthesru.com/blog/r1-diagnostics/labs-in-hepatic-failure

Answer 78

c) lateral antebrachial https://anatomytool.org/content/radiopaedia-drawing-contents-superficial-cubital-fossa-english-labels ## Footnote double check - no reference

Answer 79

Dopamine - least likely to cause pulmonary vasodilation (all the others do to my knowledge) - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension ## Footnote https://pubs.asahq.org/anesthesiology/article/121/5/914/13855/VasopressinThe-Perioperative-Gift-that-Keeps-on

Answer 80

B. 2 (CVA, Insulin use) ## Footnote UTD

Answer 81

C. Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF ## Footnote https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Answer 82

a) 15 mins 50UI/kg, Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors. ## Footnote https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Answer 83

Longer length Different cuff size/ length: The MLT® has a cuff size/ length that would be typical for an adult-sized 'standard' ETT. A 'standard' pediatric 5.0 enndotracheal tube has a smaller cuff made for a pediatric-sized trachea (see picture below). Distance of cuff from tube tip: In an MLT® the cuff is further away from the tube tip which is acceptable as the adult trachea is obviously longer than the pediatric one (see picture below). ## Footnote https://aam.ucsf.edu/microlaryngoscopy-tube-mlt%C2%AE

Answer 84

d. pregnancy

Answer 85

d. 54 Ex-preterm infants at risk of post-operative apnoea should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 54 weeks. Term infants should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 46 weeks.d) 54 weeks ## Footnote https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60

Answer 86

B. Aphasia ## Footnote UTD

Answer 87

c) 20mmHg Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction. Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg. ## Footnote https://academic.oup.com/bjaed/article/12/3/110/258792

Answer 88

B. distal to LSCA The appropriate performance of the IABP is dependent on proper position. Ideally, the tip of the balloon should be positioned 2–3 cm distal to the origin of the left subclavian artery (LSCA) ## Footnote https://academic.oup.com/bja/article/110/2/316/228037

Answer 89

E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding ## Footnote https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Answer 90

c) inf alveolar The conventional inferior alveolar nerve block is the most commonly used nerve block technique in dentistry The nerves anesthetized are the inferior alveolar, incisor, mental, and lingual nerves. The mandibular teeth to the midline, the body of the mandible, the lower part of the mandibular ramus, buccal periosteum and mucous membrane to the premolars, anterior 2/3 of the tongue, oral floor, lingual soft tissue, and the periosteum are all anesthetized ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218392/

Answer 91

c) 30j In internal defibrillation, an initial dose of 20 joules is recommended to avoid burn-like injury to the myocardium. Care should be taken to avoid coronary vessels to prevent vessel damage. Subsequent doses can be increased to a maximum of 40 joules. Sterile internal pads must be used for internal defibrillation and should be readily available during any thoracotomy procedures ## Footnote https://www.ncbi.nlm.nih.gov/books/NBK499899/

Answer 92

Pre-ductal -> right

Answer 93

A A - Alcohol is a common cause of macrocytosis and macrocytic anemia. (UpToDate) B - No - normally nomrocytic chronic disease anaemia C - No - microcytic D - I can't find anything on macrocytosis with thyrotoxicosis, but hypothyroidism definitely does E - Possibly.... https://hemonc.mhmedical.com/content.aspx?bookid=1783§ionid=121720217

Answer 94

B - prevention of electrocution. BJA Education

Answer 95

A The situation in adults is straightforward: there is convincing evidence that propofol is safe in patients who are allergic to peanut and/or soy and/or egg. BJA Ed https://academic.oup.com/bja/article/116/1/11/2566111

Answer 96

A Apnea is defined as the cessation of airflow for ten or more seconds. Hypopnea is defined as a recognizable, transient reduction, but not a complete cessation of, breathing for ten or more seconds. Hypopnea requires a 4% fall in SpO2 https://www.ncbi.nlm.nih.gov/books/NBK441909/#:~:text=Obstructive%20Sleep%20Apnea%20(OSA)%2C,for%20ten%20or%20more%20seconds.

Answer 97

C. Foetal neuroprotection https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.

Answer 98

Poorly remembered options Definitely do not give Painstop as contains codeine Opioids should be PRN only c or d -go with D - tramadol versus oxycodone re OSA paracetamol 15mg/kg (360mg) QID ibuprofen 10mg/kg (240mg) TDS tramadol 1mg/kg (24mg) QID oxycodone 0.1-0.2mg/kg (2.4-4.8mg) 4hourly Codeine should not be used. Deaths. Ultrafast metabolisers --> high levels of morphine. Nonselective NSAIDs may increase the risk of any bleeding-related outcome after tonsillectomy in adults (U) (Level I); however, not in paediatric patients Prospect advice: The basic analgesic regimen should include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) administered pre-operatively or intra-operatively and continued postoperatively. A single dose of intravenous (i.v.) dexamethasone is recommended for its analgesic and anti-emetic effects. Pre-operative gabapentinoids, intra-operative ketamine (only in children) and dexmedetomidine are recommended in patients with contra-indications to the basic analgesic regimen. Analgesic adjuncts such as intra-operative and postoperative acupuncture and postoperative honey are recommended. Opioids should be reserved as rescue analgesics in the postoperative period

Answer 99

B. 20% 25% (a few studies have higher ranges but typically around 20-25%) https://doi.org/10.1192/bjp.bp.115.165498

Answer 100

C) Cease clopidogrel for 5 days, continue aspirin WFSA update document https://resources.wfsahq.org/wp-content/uploads/uia29-Perioperative-management-of-patients-with-coronary-stents-for-non-cardiac-surgery.pdf 2014 AHA/ACC guidelines on perioperative medicine don't give a firm answer except: > 180 days since insertion = proceed (Level II b evidence)

Answer 101

A. Inhalational anesthesia or b. Clonidine Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy. PROSPECT https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.

Answer 102

d. Hyalase/hyaluronidase reaction/allergy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850816/

Answer 103

E Can't remember if this was the exact ECG but it had LAD

Answer 104

D - AB Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply.

Answer 105

E - SSRIs ANZCA PG12 Background Paper

Answer 106

Cefazolin A first-generation cephalosporin is recommended, such as 2g intravenous cefazolin. The dose should be increased to 3g for women weighing over 120kg. Consideration should also be given to a repeat dose if the procedure is prolonged (over 3 hours). * For women with a history of immediate or delayed nonsevere hypersensitivity to penicillins, cefazolin, as above, remains appropriate. * For women with a history of immediate or delayed severe hypersensitivity to penicillins, use Clindamycin 600mg iv plus Gentamicin 2mg/kg iv. * For women colonised with Methicillin-resistant Staphylococcus aureas (MRSA) or at increased risk of being colonised with MRSA, add Vancomycin 15mg/kg iv. * Azithromycin may be considered at caesarean sections performed during labour or at least four hours after rupture of membranes (2). Administration of azithromycin 500mg has been shown to reduce a composite outcome of endometritis, wound infection or other infection (3). However, a strong recommendation in favour of routine use is not yet warranted given the concerns around the external validity of the paper, inducing resistance to azithromycin and possible effects on the establishment of the indigenous microbiome.

Answer 107

A. cesarean section rate. B. Instrumental delivery. Unscheduled anaesthetic interventions (6 RCTs): significantly fewer patients required clinician top-ups with PCEA compared with CEI. The RD was 27% (95% CI: 18, 36, p<0.00001). Similar findings were obtained when only studies with a quality score of 3 or more were analysed (RD 35%, 95% CI: 19, 51, p<0.0001). No heterogeneity was detected (p=0.36). Amount of local anaesthetic (8 RCTs): different regimens were used and significant heterogeneity was detected (p<0.0001). All studies found that higher local anaesthetic doses were used with CEI than with PCEA. Motor block (4 RCTs): significantly fewer patients had 'no motor weakness' with PCEA than with CEI; the RD was 18% (95% CI: 6, 31, p=0.003). Analgesia: there was no difference in the visual analogue scores between the treatments in the 7 RCTs that used them. There was no significant difference between PCEA and CEI for: patient satisfaction (5 RCTs); total duration of first and second stage of labour (3 RCTs); incidence of Caesarean section or instrumental delivery (9 RCTs); incidence of low Apgar scores at 1 and 5 minutes after birth (6 RCTs); hypotension (6 RCTs); high block (3 RCTs); pruritus (2 RCTs); shivering (1 RCT) or nausea (1 RCT). The results for all of these outcomes were reported in the review. Both PCEA and CEI appear to be safe for the mother and the neonate. Patients who receive PCEA are less likely to require anaesthetic intervention, require lower doses of local anaesthetic and have less motor block than those who receive CEI. https://www.ncbi.nlm.nih.gov/books/NBK69143/

Answer 108

repeat a) Less transfusion, same thrombosis ●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Answer 109

a. Reduced Myoglobinaemia Repeat but its not myoglobinuria it was myoglobinaemia - There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria) - There IS less increase in ETCO2 - There IS less muscle rigidity

Answer 110

B. Diazepam UTD Discontinuation of all serotonergic agents ●Supportive care aimed at normalization of vital signs ●Sedation with benzodiazepines ●Administration of serotonin antagonists ●Assessment of the need to resume use of causative serotonergic agents after resolution of symptoms

Answer 111

A. High frequency

Answer 112

D. perindopril Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension