23.2 Flashcards

Question

The risk of developing postherpetic neuralgia may be reduced by treating acute herpes zoster (shingles) with A. Ibuprofen B. Gabapentin C. Aciclovir D. Amitriptyline E. Oxycodone

Answer 1

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 2

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran Dabigatran bleeding may be treated with: - idarucizumab - haemodialysis -PCC 25-50IU/kg - TXA will decrease fibrinolysis and has some effect - FFP also has some effect Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding - very high affinity for dabigatran (300x vs affinity for thrombin) - 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration) - RE-VERSE-AD trial: undetectable levels <20ng/ml within minutes and for 24 hours - Limited data support administration of an additional 5 g depending on clinical situation Dosage Modifications Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required Hepatic impairment: Dosing Considerations This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 3

c. Pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 4

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 5

e Plasma esterases Plasma esterases (not cholinesterase) Esmolol metabolism is via RBC esterases.

Answer 6

Check ANZCA documents

Answer 7

C- Multifocal Atrial Tachycardia Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias. - https://emedicine.medscape.com/article/155825-overview#a10 DCCV is indicated for 1. Any haemodynamically unstable narrow or wide QRS complex tachycardia 2. AF <48hrs 3. AF >48hrs with adequate anticoag/TOE to exclude thrombus 4. SVTs and monomorphic TVs not responding to trial of IV medical therapy DCCV is CONTRAindicated in: a. Digitalis toxicity and associated tachycardia b. AF >48hrs without adequate anticoagulation/TOE -BJAEducation 2017 https://academic.oup.com/bjaed/article/17/5/166/2669966

Answer 8

REPEAT 23.1 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 9

A - GLP1 receptor agonist (rest of options made up) “Dulaglutide binds to glucagon-like peptide 1 receptors, slowing gastric emptying and increases insulin secretion by pancreatic Beta cells. Simultaneously the compound reduces the elevated glucagon secretion by inhibiting alpha cells of the pancreas, as glucagon is known to be inappropriately elevated in diabetic patients. GLP-1 is normally secreted by L cells of the gastrointestinal mucosa in response to a meal” - Wikipedia, Dulaglutide - Once weekly injection, “trulicity” https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

Answer 10

c) 2 minutes

Answer 11

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

Answer 12

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 13

d) Atropine Blue book 2019

Answer 14

d) Hypotension The commonest presenting feature of perioperative anaphylaxis by far was hypotension (accounting for 46%), followed by bronchospasm/high airway pressure (18%), tachycardia (9.8%), flushing/non-urticarial rash 6.6% and cyanosis/oxygen desaturation (4.7%).

Answer 15

https://www.anztadc.net/Publications/Images/ANZCA/Unintended%20Intraarterial%20injection%20WebAIRS%20news%20ANZCA%20Bulletin%20September%202019.pdf

Answer 16

a) Deepen with propofol and insert LMA Nasal continuous positive airway pressure (CPAP) is contraindicated after transsphenoidal surgery due to the risk of tension pneumocephalous. The level of consciousness, eye movements, visual fields, and acuity should be tested frequently and any deterioration discussed with the surgeon, and radiological investigation and/or re-exploration considered. https://academic.oup.com/bjaed/article/11/4/133/266875#3195876

Answer 17

New question Measures to avoid venous air embolism when inserting an internal jugular central venous catheter in an awake patient include all of the following EXCEPT c) Insert during inspiration Negative pressure generated by inspiration in an AWAKE patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126790/

Answer 18

d) Pulmonary haemorrhage Rewording of 21.2 Question Won't increase in Myasthenia Gravis Causes of HIGH value include: Asthma Left-right intracardiac shunt polycythaemia Pulmonary haemorrhage Obesity - Dlco will increase but kco will not

Answer 19

b) 30mcg Moderate = 2mcg/kg Life threatening = 4-10mcg/kg file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf

Answer 20

Repeat 22.2 Serotonin syndrome Hyperreflexia differentiates Usually has hypertension and hyperthermia

Answer 21

Repeat SSRI Clonidine has limited efficacy ANZCA PG12 Background Paper ANZCA PERIOP CESSATION OF SMOKING GUIDELINE: "Effective pharmacotherapy options include nicotine replacement therapy, nicotine partial agonists such as varenicline (Champix), bupropion (Zyban), nortryptilline and clonidine" Up to Date Pharmacotherapy for Smoking Cessation in Adults - First-line pharmacotherapies for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion - Clonidine: despite promising initial studies, clonidine is now generally regarded as having limited efficacy for smoking cessation. - Selective serotonin reuptake inhibitors/anxiolytics – Selective serotonin reuptake inhibitors (SSRIs) and anxiolytic drugs generally have not been shown to be effective for smoking cessation

Answer 22

d) Vastus Lateralis Anteromedial: sartorius Lateral: vastus medialis Posterior: adductor longest and magnus

Answer 23

Repeat e) Ulnar nerve The cubital fossa is triangular in shape and consists of three borders, a roof, and a floor: Lateral border – medial border of the brachioradialis muscle. Medial border – lateral border of the pronator teres muscle. Superior border – horizontal line drawn between the epicondyles of the humerus. Roof – bicipital aponeurosis, fascia, subcutaneous fat and skin. Floor – brachialis (proximally) and supinator (distally). Contents: - radial nerve - biceps tendon - brachial artery - median nerve Mnemonic for contents of the cubital fossa: Really Need (radial nerve) Beer To (biceps tendon) Be At (brachial artery) My Nicest (median nerve).

Answer 24

REPEAT a) 5mmol bolus KCl https://www.anzcor.org/home/adult-advanced-life-support/guideline-11-5-medications-in-adult-cardiac-arrest/ Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening ventricular arrhythmias. Consider administration for: Persistent VF due to documented or suspected hypokalaemia. [Class A; Expert consensus opinion] Adverse effects: Inappropriate or excessive use will produce hyperkalaemia with bradycardia, hypotension and possible asystole Extravasation may lead to tissue necrosis. Dosage: A bolus of 5 mmol of potassium chloride is given intravenously.

Answer 25

REPEAT c) Increased mortality Use of perioperative metoprolol was associated with: * Decreased rate of myocardial infarction * Decreased rate of revascularisation * Decreased rate of developing new atrial fibrillation * INCREASED rate of death * INCREASED rate of stroke * INCREASED rate of significant hypotension INCREASED rate of significant bradycardia

Answer 26

d) 24hrs Extrajunctional receptors are not found in normal active muscle but appear very rapidly whenever muscle activity has ended or after injury has been sustained. They can appear within 18 h of injury and an altered response to neuromuscu- lar blocking drugs can be detected within 24 h of the insult. They disappear when muscle activity returns to normal.

Answer 27

REPEAT increased SVR EMSB handbook CO is reduced after Burn injury 2ry to: - myocardial depressant mediators - decreased blood volume - reduced venous return - increased pulmonary and systemic vascular resistance due to increased levels of catecholamines In the first 24hrs reduced cardiac output persists even after restoration of blood volume Between 24-48hrs post burn a hyperdynamic state develops with reduced peripheral resistance, increased oxygen consumption and increased cardiac output

Answer 28

b) Stop/stop antibiotics For adults with suspected sepsis or septic shock, we suggest AGAINST using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. Weak, very low quality of evidence For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. Weak, low quality of evidence

Answer 29

10mins PG18

Answer 30

b. Myaesthenia gravis or b. Cerebral palsy ED95 is 0.8mg/kg in a MG patient b. Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia 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

Answer 31

REPEAT Increases NIRS , decreases peripheral spo2 SctO2 up, SpO2 down. Source: Korean Journal Anaesthesia https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Answer 32

REPEAT CO2 Laser danger is proportional to penetration. Penetration inversely proportional to the laser wavelength. CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm. Helium-Neon laser also has very little penetration. Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm.

Answer 33

Size 7.0 The Tube The endotracheal tube has a length and diameter. The endotracheal tubes size (“give me a 6.0 tube”) refers to its internal diameter in millimeters (mm). The ETT will typically list both the inner diameter and outer diameter on the tube (for example, a 6.0 endotracheal tube will list both the internal diameter, ID 6.0, and outer diameter, OD 8.8).

Answer 34

Repeat c. Anterior to erector spinae and posterior to transverse process 5th rib Midpoint between T5-6 (Usual Incision T4-5, ICC T6)

Answer 35

NNT = 6 to 7 NNT=1/ARR. (Absolute Risk Reduction) ARR = 0.2-0.05 = 0.15 1/0.15 = 6.66 With respect to previous variation of this question: (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 36

a) Torsades 2ry to prolonged QT leading to R on T PETKOV

Answer 37

See combined deck for multiple Qs on lung ultrasound

Answer 38

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride https://litfl.com/cryoprecipitate/ Fractionated plasma product consisting of Fibrinogen (Factor I), von Willebrand Factor, Factor VIII, and small amounts of Factor XIII and Fibronectin https://www.anzca.edu.au/getattachment/9ec71c61-8a66-4f81-b0f8-c87d65e36298/Australasian-Anaesthesia-2023

Answer 39

Warm ischaemia time: - Time from treatment withdrawal to the start of cold perfusion of the donated organs - Significance is the impact on graft function - Most important phase of WIT begins when the systolic BP is < 60mmHg - This includes the waiting period from the absence of circulation to the declaration of death and the time before initiating the flow of cold perfusate through the cannula Maximum WARM Ischaemia time - Heart 30 mins - Liver 30 mins - Pancreas 30 mins - Kidney 60 mins - Lungs 90 mins Maximum COLD Ischaemia time: - Heart = 4 hrs - Lungs = 6-8hrs - Liver/Pancreas = 12hrs (DBD)/6 hrs (DCD) - Kidneys = 18hrs (DBD)/ 12 hrs (DCD)

Answer 40

c. No need to bridge See ETG recommendations https://www.ahajournals.org/doi/full/10.1161/JAHA.120.017559

Answer 41

a) C1-esterase inhibitor Treatment options: Plasma derived C1-esterase inhibitor = Berinert/Cinryze, Androgens = Danazol B2 Bradykinin Receptor antagonist = Icatibant FFP. Danazol (an androgen) is recommended as first line PROPHYLAXIS for planned procedures (need to give for 5-10 days prior and 2-5 days post) For emergency or high risk procedures C1 esterase inhibitor concentrate (Berinert or Cinryze) is recommended - give 1 hour before procedure - more effective than danazol but more expensive Berinert: - 20units/kg IV over 10 min - Symptoms usually stabilise in 30 mins - 2nd dose uncommon, but may be given 30mins to 2hrs after 1st dose Icatibant: - 30mg slow subcut infusion in abdominal area Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation Short answer: - if you have days before surgery increase danazole, if complex surgery increase danazole and give C1Inh - If you have acute emergency surgery give C1Inh Concentrate (Berinert/Cinryze) before and after - if you have an acute attack use C1Inh or Bradykinin antagonist (Icatibant) - If C1 Inh and Bradykinin antagonoist are not available then use FFP but this may worsen the attack due to the presence of C4 in the FFP - Has Cetirizine been misremembered instead of Cinryze as an option in this question? No it wasn't -> adrenaline, steroids, antihistamines have no role in treatment of HAE acute attack

Answer 42

Depth of tube in water in bottle 3

Answer 43

b. FFP REPEAT

Answer 44

24hrs Oxford handbook

Answer 45

A) Type 1 MI Clinical classification based on the assumed proximate cause of the MI: - Type 1 ○ MI caused by atherothrombotic coronary artery disease ○ And usually precipitated by atherosclerotic plaque disruption ( rupture or erosion) - Type 2 ○ MI consequent to a mismatch between oxygen supply and demand ○ Multiple potentional mechanisms: § Coronary dissection § Vasospasm § Emboli § Microvascular dysfunction § Increases in demand without underlying coronary artery disease - Type 3 ○ Patient with typical presentation of MI (ECG changes or VF) with unexpected death before blood samples for biomarkers could be drawn - Type 4a ○ MI associated with Percutaneous Coronary intervion (PCI) - Type 4b ○ Subcategory of PCI related MI related to stent/scaffold thrombosis - Type 5 CABG related MI

Answer 46

d) continue to avoid cognitive decline post-op Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function https://www.ukcpa-periophandbook.co.uk/medicine-monographs/donepezil

Answer 47

a. Not safe or c. safe only in 1st trimester 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 48

a) renal failure '...phosphate containing laxatives can lead to acute phosphate nephropathy' https://academic.oup.com/bjaed/article/16/9/305/1743822#35669023 - BJA Ed article Phosphate binds to calcium leading to crystal calcium phosphate deposition in tubules. Old repeat 2020 https://academic.oup.com/bjaed/article/16/9/305/1743822#35669023

Answer 49

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 50

c) falsly low SpO2 Effects of hihg dose hydroxycobalamin: - red urine - thrombocytosis - leukopenia

Answer 51

D> Myocardial ischaemia An inverted U wave may represent myocardial ischemia (and especially appears to have a high positive predictive accuracy for left anterior descending coronary artery disease[7] ) or left ventricular volume overload. ^Wikipedia -------- U-wave inversion is abnormal (in leads with upright T waves) A negative U wave is highly specific for the presence of heart disease Common causes of inverted U waves Coronary artery disease Hypertension Valvular heart disease Congenital heart disease Cardiomyopathy Hyperthyroidism In patients presenting with chest pain, inverted U waves: Are a very specific sign of myocardial ischaemia May be the earliest marker of unstable angina and evolving myocardial infarction Have been shown to predict a ≥ 75% stenosis of the LAD / LMCA and the presence of left ventricular dysfunction ^LITFL: https://litfl.com/u-wave-ecg-library/

Answer 52

D) Mitral Stenosis (Rheumatic, moderate to severe) DOAC use is contraindicated in certain clinical conditions, notably, in patients who have a mechanical heart valve and those with rheumatic mitral stenosis. Moderate to severe renal impairment or significant hepatic disease is also a contraindication to DOAC treatment Bioprosthetic valves are less thrombogenic thus DOAC use is acceptable. https://www.ahajournals.org/doi/epdf/10.1161/JAHA.120.017559

Answer 53

8mg/hr Guidelines for mx of glucocorticoids during the perioperative period for patients with adrenal insufficiency https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14963

Answer 54

b) O2 consumption when sitting One metabolic equivalent (MET) is defined as the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml O2 per kg body weight x min.

Answer 55

C:3 (Pt is GCS 14 E4V4M6, with motor deficit) The WFNS scale: Grade 1: GCS 15, no motor deficit. Grade 2: GCS 13-14 without deficit Grade 3: GCS 13-14 with focal neurological deficit Grade 4: GCS 7-12, with or without deficit. Grade 5: GCS <7 , with or without deficit. (BJA Education, Deranged Physiology)

Answer 56

e) Liver transplantation - Oxygen therapy for symptom relief - Liver transplant provides long term survival benefit - All other therapies tried but no conclusive evidence of benefit/nil are FDA approved Hepatopulmonary Syndrome Article https://www.ncbi.nlm.nih.gov/books/NBK562169/ Hepatopulmonary syndrome (BJA) - Prevalence up to 20% (end stage liver disease) - Characterised by: disordered pulmonary capillary vasodilation and VQ mismatch - Present with hypoxia, ortheodeoxia (decrease in PaO2 when standing) - Diagnosis w/bubble echocardiography - Risk factor for early post-transplant mortality - If transplant successful, will resolve over time

Answer 57

a) neostigmine infusion 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

Answer 58

d) Ibuprofen 400mg - Ibuprofen (I think, because of the single oral dose statement) APMSE 5th edition Acute pain after third molar extraction is the most extensively studied model for testing postoperative analgesics in single-dose investigations. Nonselective NSAIDs or coxibs are recommended as “first-line” analgesics following third molar extraction (Derry 2011 Level I, 155 RCTs, n=16,104), however paracetamol is also safe and effective with a dose of 1,000 mg providing better pain relief than lower doses (Weil 2007 Level I [Cochrane], 21 RCTs, n=1,968). The best available evidence suggests the use of NSAIDs either with or without paracetamol is effective and well-tolerated (Moore 2018 Level I, 5 SRs, n unspecified). Nonselective NSAIDs are more effective than paracetamol or codeine (either alone or in combination) (Ahmad 1997 Level I, 33 RCTs, n=5,171). Ibuprofen (200–512 mg) specifically is superior to paracetamol (600–1,000 mg) in this setting and combining these two drugs improves analgesia further (Bailey 2014 Level I [Cochrane], 7 RCTs, n=2,241)

Answer 59

d 60cm H2O

Answer 60

e. peak of R wave https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%20634/normal-iabp-waveform https://litfl.com/intra-aortic-balloon-pump-trouble-shooting/

Answer 61

b) Hypoglycaemia Stoelting: Prader-Willi syndrome is a rare genetic disorder characterized by hypothalamic-pituitary abnormalities with severe hypotonia during the neonatal period and during the first two years of life, hyperphagia with a risk of morbid obesity during infancy and adulthood, learning difficulties and behavioural problems or severe psychiatric problems. The disease affects 1/25,000 births. https://www.orphananesthesia.eu/en/rare-diseases/published-guidelines/prader-willi-syndrome/1339-prader-willi-syndrome-2/file.html Prader-Willi syndrome is a rare genetic disorder characterized by hypothalamic-pituitary abnormalities with severe hypotonia during the neonatal period and during the first two years of life, hyperphagia with a risk of morbid obesity during infancy and adulthood, learning difficulties and behavioural problems or severe psychiatric problems. The disease affects 1/25,000 births.

Answer 62

e) decreased afterload https://academic.oup.com/bjaed/article/13/6/208/246828#2904603 Aortic cross-clamping and physiological considerations The physiological effect of aortic cross-clamping during surgery varies with the level of the clamp in relation to the main aortic branches. Perfusion to the lower half of the body is therefore dependent on collateral circulation while the clamp is applied. Clamp application increases the afterload of the heart and a sudden increase in arterial pressure proximal to the clamp; this can be attenuated with vasodilators [e.g. glyceryl trinitrate (GTN), sodium nitroprusside], opioids, or deepening of anaesthesia. These measures may also allow fluid loading in preparation for clamp release; however, the effect of vasoactive drugs is unpredictable; they may change haemodynamics without improving cardiac output and tissue perfusion due to blood redistribution.10 Increased afterload and left ventricular end-diastolic volume both increase myocardial contractility and oxygen demand. This increase in myocardial oxygen demand is usually met by an increase in coronary blood flow and oxygen supply, but can cause myocardial ischaemia. After aortic cross-clamp release, peripheral vascular resistance decreases by 70–80%, causing a decrease in arterial pressure. Hypotension can also be caused by blood sequestration in the lower half of the body, ischaemia–reperfusion injury, and the washout of anaerobic metabolites causing metabolic (lactic) acidosis. This can cause direct myocardial suppression and profound peripheral vasodilatation. Coronary blood flow and left ventricular end-diastolic volume also decrease (almost 50% from pre-clamp levels) after clamp release. Strategies to manage hypotension after aortic cross-clamp release include gradual release of the clamp, volume loading, vasoconstrictors, or positive inotropic drugs (e.g. ephedrine, meteraminol, phenylephrine, epinephrine, and norepinephrine). It is important to be aware that vasoactive drugs should only be used after adequate volume repletion.10 Management of aortic cross-clamp application and release requires excellent communication with the surgeon in order to anticipate and manage the physiological effects.

Answer 63

Most likely answer will be related to hypophosphataemia Refeeding syndrome is a constellation of biochemical abnormalities which occurs when normal intake is resumed after a period of starvation. Its characteristic features are **low levels of phosphate, potassium, magnesium and sodium**. Its major complications include **cardiac arrhythmias, heart failure (due to hypophosphataemia), muscle weakness, rhabdomyolysis, seizures and an altered sensorium.** The major risk factors are calorie malnutrition of any cause, alcohol or drug use, low BMI (18-16) and starvation for 5-10 days. Pathophysiology With the restoration of glucose as a substrate, insulin levels rise and cause cellular uptake of these ions. **Depletion of adenosine triphosphate (ATP) and 2,3-diphosphoglyceric acid (2,3-DPG)** results in **tissue hypoxia** and **failure of cellular energy metabolism.** This may manifest as **cardiac and respiratory failure**, with **paraesthesiae** and **seizures** also reported. Thiamine deficiency may also play a part. - Exogenous sources of phosphate are inadequate to supplement the daily phosphate requirements - Intracellular phosphate stores are used to synthesise ATP (using protein and fat as fuel) - Homeostatic mechanisms maintain serum concentrations of these ions at the expense of intracellular stores Reference: https://derangedphysiology.com/main/required-reading/endocrinology-metabolism-and-nutrition/Chapter%20315/refeeding-syndrome "

Answer 64

****D. 20 mins **The time taken to reduce K+ with insulin/dextrose ranges from ~15-30 mins depending on source ** https://www.uptodate.com/contents/treatment-and-prevention-of-hyperkalemia-in-adults Treatment approach to hyperkalemic emergencies — Patients with a hyperkalemic emergency should receive (table 1): Intravenous calcium and insulin are rapidly acting treatments that provide time for the initiation of therapies that remove the excess potassium from the body. ●Intravenous calcium to antagonize the membrane actions of hyperkalemia ●Intravenous insulin (typically given with intravenous glucose) to drive extracellular potassium into cells ●Therapy to rapidly remove excess potassium from the body (ie, loop or thiazide diuretics if renal function is not severely impaired, a gastrointestinal cation exchanger, and/or dialysis [preferably hemodialysis] if renal function is severely impaired) ●Treatment of reversible causes of hyperkalemia, such as correcting hypovolemia and discontinuing drugs that increase the serum potassium (eg, nonsteroidal anti-inflammatory drugs, inhibitors of the renin-angiotensin-aldosterone system) RCH: http://www.rch.org.au/clinicalguide/guideline_index/Hyperkalaemia/ Insulin/glucose to be given at the same time If severe hyperkalaemia: - Dextrose 10% : 5ml/kg IV bolus (if no hyponatremia) - Insulin short action: 0.1 U/kg IV bolus (Max 10 units) Then followed by infusion insulin/glucose (see below) -If moderate hyperkalaemia: - Dextrose 10% IV at maintenance with 0.9% sodium chloride (normal saline) - Insulin short action infusion : 0.1 U/kg/h IV Note: Close monitoring of glucose every 30-60 minutes Onset of Action: 15 minutes, should reduce intravascular K+, reduction of 0.5-1.5mmol/L Duration: peak 60 minutes, 2-3hours American College of Emergency Physicians: Nebulized albuterol by face mask begins to take measurable effect after 15 to 20 minutes and lowers the serum potassium level by up to 1 mEq/L, depending on the dose. β-Agonists are safe despite the side effect of tachycardia. **Insulin, given intravenously in combination with glucose, also results in a similar fall in the potassium level after 20 to 30 minutes **and also lowers levels by up to 1 mEq/L. The combination of nebulized albuterol and intravenous insulin with glucose appears to be additive, lowering serum potassium by a mean of 1.21 mEq/L or more.11 Adult hyperkalemic patients who have ECG changes should receive continuous nebulized albuterol and 50 grams of intravenous dextrose plus 10 units of intravenous regular insulin. Emergency Medicine Journal J Accid Emerg Med. 2000 May; 17(3): 188–191. The management of hyperkalaemia in the emergency department INSULIN WITH GLUCOSE Insulin binds to specific membrane receptors and via an unknown second messenger, stimulates the sodium-potassium (Na-K) adenosine triphosphatase (ATP) pump resulting in intracellular uptake of K.5 This effect is independent of its hypoglycaemic action. Uraemia attenuates the hypoglycaemic response to insulin but does not affect its hypokalaemic action. Insulin has been the traditional temporising treatment against which newer treatments are compared. It is indicated in every case of hyperkalaemia that needs emergency treatment. Ten units (in adults) soluble insulin is given with 40–60 g glucose intravenously as a bolus. In children, a glucose load of 0.5 g/kg/h (2.5 ml/kg/h) should be given. This is because many of these patients increase their endogenous insulin production with the administration of a glucose load. If the blood glucose rises above 10 mml/l, insulin should be added at 0.05 u/kg/h.24 These studies show that the onset of hypokalaemic action is within 15 minutes and lasts for at least 60 minutes. The reduction in K observed is 0.65–1.0 mmol/l.5, 10 Delayed (30–60 minutes post insulin) hypoglycaemia is common (up to 75% of patients10) if less than 30 g glucose is given. LITFL: Treatment of hyperkalaemia involves stabilizing the myocardium to prevent arrhythmias, shifting potassium back into the intracellular space and removing excess potassium from the body. Drive Potassium into the Cell: Insulin & Glucose - Dose: IV fast acting insulin (actrapid) 10-20 units and glucose/dextrose 50g 25-50ml - Insulin drives potassium into cells and administering glucose prevents hypoglycaemia. - Begins to work in 20-30mins reduces potassium by 1mmol/L and ECG changes within the first hour Ca gluconate - should be part of initial treatment but it does not lower either total body or serum potassium, it acts as a membrane stabiliser LITFL: Correct Serious Conduction Abnormalities (Calcium) - Calcium is a very useful agent. It does not lower the serum potassium level, but instead is used to stabilise the myocardium, as a temporising measure. Calcium is indicated if there is widening of QRS, sine wave pattern (when S and T waves merge together), or in hyperkalaemic cardiac arrest. - The ‘cardiac membrane stabilising effects’ take about 15-30mins. Calcium Chloride - Dose: Calcium Chloride 10% 5-10mL = 6.8 mmol - 3 x more potent than Calcium Gluconate - Complication: severe thrombophlebitis - Calcium Gluconate: - Dose: Calcium Gluconate 10% 5-10mL = 2.2 mmol - Less potent, less irritating to veins - Potential Complications of Calcium administration - Bradycardia, hypotension and peripheral vasodilation - Generally these occur if administered too quickly - Avoid in digoxin toxicity (use magnesium as alternative) - salbutamol Drive Potassium into the Cell: Salbutamol - Dose: 10-20mg via nebulizer - Beta 2 agonist therapy lower K via either IV or nebulizer route. - Salbutamol can lower potassium level 1mmol/L in about 30 minutes, and maintain it for up to 2 hours. - Very effective in renal patients that are fluid overloaded - Drive Potassium into the Cell: Sodium Bicarbonate - Dose: 50- 200mmol of 8.4% Sodium Bicarbonate - Bicarbonate is only effective at driving Potassium intracellullarly if the patient is acidotic - Begins working in 30-60 minutes and continues to work for several hours. Eliminate Potassium From the Body: Calcium Resonium - Dose: 15-45g orally or rectally, mixed with sorbitol or lactulose - Calcium polystyrene sulfonate is a large insoluble molecule that binds potassium in the large intestine, where it is excreted in faeces - Effects take 2-3 hours M&M 2016: An intravenous infusion of glucose and insulin (30–50 g of glucose with 10 units of insulin) is also effective in promoting cellular uptake of potassium and lowering plasma [K+], but may take up to 1 h for peak effect

Answer 65

c) Staphyloma https://eyewiki.aao.org/Ocular_Anesthesia#cite_note-:2-3 **Contraindications** **Absolute** Confirmed allergy to a necessary anesthetic, and nystagmus. Other contraindications are just those of the particular surgery that is to be performed. **Relative** Long eye (in the anterior to posterior axis, evidenced by high myopia), staphyloma (abnormal protrusion at a weak spot in the wall of the eye), enophthalmos (posteriorly or deep set eyes), and extended surgery duration are relative contraindications to retrobulbar and peribulbar anesthesia. In an uncooperative patient, patients deemed to be unable to follow commands during surgery, children and those with uncontrollable neurological movements, general anesthesia may be considered.

Answer 66

700ml 50% of blood volume in 3 hours S Blaine. BJAE Paediatric massive transfusion

Answer 67

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15291 The 2011 guidelines list seven ‘acceptable’ reasons for delaying surgery: 1 Haemoglobin < 80 g.l−1 2 Plasma sodium concentration < 120 or > 150 mmol.l−1 and potassium concentration < 2.8 or > 6.0 mmol−1 3 Uncontrolled diabetes 4 Uncontrolled or acute onset left ventricular failure. 5 Correctable cardiac arrhythmia with a ventricular rate > 120.min−1 6 Chest infection with sepsis 7 Reversible coagulopathy

Answer 68

All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. - biceps brachii: forearm flexion and supination. Accessory shoulder flexor - coracobrachialis: shoulder flexion, arm adduction. - Brachialis: forearm flexion The musculocutaneous nerve innervates skin on the anterolateral side of the forearm.

Answer 69

b) crescendo TIA symptoms https://academic.oup.com/bja/article/99/1/119/269458 Ideally, patients presenting with a suspected TIA should have undergone investigation and, if appropriate, surgery within 2 weeks of presentation.

Answer 70

b) Central retinal occlusion SE's from HBOT: - progressive myopia (reversible) - seizures - hypoglycaemia - sinus bradycardia from stimulation of vagal activity bassociated with hyperbaric pressures

Answer 71

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

Answer 72

e) stop 2 weeks before, start moclobemide and omit Moclobemide day of surgery -> probably in discussion with the patients psychiatrist Tranylcypromine, sold under the brand name Parnate among others, is a monoamine oxidase inhibitor. More specifically, tranylcypromine acts as nonselective and irreversible inhibitor of the enzyme monoamine oxidase. In the elective setting, there is some debate regarding the management of patients on MAOI. Although the risks associated with anaesthesia in those taking this group of drugs are significant, abrupt withdrawal may precipitate serious psychiatric relapse. Traditionally, irreversible MAOIs have been stopped 2 weeks before operation; however, omitting the dose of moclobemide on the day of surgery is acceptable. It has been suggested that in the elective situation, patients could be switched from an irreversible MAOI to moclobemide to avoid a prolonged period of discontinuation.

Answer 73

28 days Aprepitant PI: "Alternative or "back-up" measures of contraception should be used during treatment with this medicine and for one month following the last dose of this medicine." Pharmacokinetics: - aprepitant is a CYP3A4 inhibitor - caution is also advised with warfarin and phenytoin use

Answer 74

d. Stop volatile, calcium ?Duchenne muscular dystrophy? This patient most likely has Anaesthesia Induced Rhabdomyolysis (AIR) given the peaked Twaves and slow rise in ETCO2 Immediate MH Management: Stop administering Sevo, flush machine (or new), charcoal filters. Dantrolene.

Answer 75

b) 2 ATM https://academic.oup.com/bjaed/article/7/1/2/509371 **A typical parameter-set for HFJV via a subglottic catheter is DP, 2 atm; f, 150 min−1; Fio2, 1.0; I-time, 50%. ** Driving pressure 1-2 atm (250-500ml/s) RR 8-10 Automated jet ventilator – typical starting jet pressure for an adult is 1.5 bar (~1.5 atm). Manual jet ventilators deliver up to 3.5-4 bar.

Answer 76

a) Iron transfusion Iron infusion (ferric carboxymaltose) – can cause renal wasting of phosphate resulting in severe hypophosphataemia Vitamin D deficiency and hyperparathyroidism can also cause hypophosphataemia. Vitamin D deficiency would result in low calcium whereas hyperparathyroidism would result in hypercalcaemia. Fanconi syndrome: rare defect of proximal tubule leading to decreased reabsorption -> results in hypokalaemia, hypophosphataemia, hyperchloraemic metabolic acidosis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689119/

Answer 77

No change in Mortality, no change in POD No evidence was found that mortality or serious complication were modified by targeting either a BIS of 50 or 35 A broad range of anaesthetic depth can be delivered safely when using volatile anaesthetic agents and processed electroencephalographic monitoring https://www.thebottomline.org.uk/summaries/pom/balance/

Answer 78

a) Tamponade Oesophageal fistula more likely in left atrial ablation Cardiac tamponade occurs ~1%. Can usually be managed with reversal of anticoagulation and percutaneous drainage. Vascular complications most common followed by tamponade. https://www.ahajournals.org/doi/10.1161/circep.113.000768 https://academic.oup.com/bjaed/article/12/5/230/289246#3659733

Answer 79

b) 1 or more RF

Answer 80

serum free metanephrines and nor-metanephrines https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230088/ ## Footnote https://www1.racgp.org.au/ajgp/2021/january-february/adrenal-disease-an-update

Answer 81

D. Withdraw PAC 2 cm and insert DLT LITFL: Pulmonary haemorrhage after PAOP measurement a life threatening time-critical emergency pulmonary artery rupture caused by inflation of the pulmonary artery catheter (PAC) balloon during ‘wedging’ (measurement of the pulmonary artery occlusion pressure) some experts advise against measuring PAWP because of the risk of pulmonary artery rupture 0.2% risk, 30% mortality RISK FACTORS pulmonary hypertension mitral valve disease anticoagulants age >60 years MANAGEMENT Goals prevent further pulmonary haemorrhage stop bleeding resuscitate Call for help ICU consultant anaesthetist/ OT cardiothoracic surgeon interventional radiology Resuscitation A may have to be emergently intubated if not already B FiO2 1.0 controlled ventilation if able to recognize which lung is haemorrhaging may be able to perform lung isolation (insert single lumen tube into unaffected side, exchange for a double lumen tube or use bronchial blocker with bronchoscopic assistance) apply PEEP to tamponade wound C large bore IV cannulae, fluids, blood products, inotropes Specific therapy Lay the patient ruptured side down withdraw pulmonary catheter 2-3 cm with balloon down then refloat PAC with balloon inflated to occlude pulmonary artery (to try to tamponade bleeding) stop antiplatelet agents and anticoagulants give reversal agents: — protamine for heparin — platelets for anti-platelet agents give blood products as indicated by FBC, coags and clinical state interventions — angiogram or bronchoscopy to isolate pulmonary vessel involved — if bleeding doesn’t settle will require lobectomy

Answer 82

Alprostadil (PGE1) From Paediatric BASIC on CHD: - Resuscitation of an infant or newborn in shock should follow a standard approach regardless of the aetiology. - Any patient with a duct dependent lesion either for pulmonary blood flow, or systemic output, will require PGE1. The problem is that whether or not a duct dependent lesion is present is unclear in most cases. If CHD has been diagnosed antenatally, PGE1 should be started. - The cyanosed neonate presenting with severe cyanosis (O2 <75) and/or in extremis should be started on PGE1; the assumption being that the duct has closed and needs to be reopened.

Answer 83

a. Decreased mortality Death in bleeding trauma patients Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. - Reduced death due to bleeding x 0.85 - Equivocal blood transfusion - Equivocal thromboembolism

Answer 84

c) T6 LITFL: https://litfl.com/trauma-spinal-injury/ **Neurogenic shock** is classically characterised by hypotension, bradycardia and peripheral vasodilatation. Neurogenic shock is due to loss of sympathetic vascular tone and happens only after a significant proportion of the sympathetic nervous system has been damaged – as may occur with lesions at the T6 level or higher. **Spinal shock** is not a true form of shock. It refers to the flaccid areflexia that may occur after spinal cord injury, and may last hours to weeks. It may be thought of as ‘concussion’ of the spinal cord and resolves as soft tissue swelling improves. Priapism may be present.

Answer 85

C. 3 - if male CHA2DS2-VASc score ≥2 to be recommended chronic OAC (Grade 1A). - if female CHA2DS2-VASc score ≥3 to be recommended chronic OAC (Grade 1A). * non-sex risk factor also holds bearing: - For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Up to date: Our approach to deciding whether to prescribe anticoagulant therapy for patients with AF (excluding those with rheumatic mitral stenosis that is severe or clinically significant [mitral valve area ≤1.5 cm2], a bioprosthetic valve [surgical or bioprosthetic] within the first three to six months after implantation, or a mechanical heart valve) is as follows: *For a CHA2DS2-VASc score ≥2 in males or ≥3 in females, we recommend chronic OAC (Grade 1A). *For a CHA2DS2-VASc score of 1 in males and 2 in females: -For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Age 65 to 74 years is a stronger risk factor than the other factors conferring one CHA2DS2-VASc score point. -For patients with other risk factors, the decision to anticoagulate is based upon the specific nonsex risk factor and the burden of AF. For patients with very low burden of AF (eg, AF that is well documented as limited to an isolated episode that may have been due to a reversible cause such as recent surgery, heavy alcohol ingestion, or sleep deprivation), it may be reasonable to forgo chronic OAC and institute close surveillance for recurrent AF, although it may not be possible to reliably estimate AF burden from surveying symptoms or infrequent monitoring. The frequency and duration of AF episodes vary widely over time, and episodes are often asymptomatic. *For patients with a CHA2DS2-VASc of 0 in males or 1 in females, we suggest against OAC (Grade 2C). Patient values and preferences may impact the decision. For example, a patient who is particularly stroke averse and is not at increased risk for bleeding may reasonably choose anticoagulation, particularly if the patient is a candidate for treatment with a direct oral anticoagulant (DOAC). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline

Answer 86

d) Dexamethasone The ECG shows LONG QT https://litfl.com/qt-interval-ecg-library/

Answer 87

b) 3rd nerve palsy https://derangedphysiology.com/main/required-reading/neurology-and-neurosurgery/Chapter%204631/lesions-oculomotor-nerve-cn-iii This is the "down and out" eye syndrome. It is characterised by ptosis, a down-and-out pupil, mydriasis, absent light reflex with intact consensual constriction of the opposite eye, and failure of accommodation. Classically, this is the lesion which develops during uncal herneation, due to an ipsilateral cerebral injury. Causes of unilateral CN III lesions: - Uncal herneation: Pressure from herniating uncus on nerve - Fracture involving ipsilateral cavernous sinus - Cavernous sinus thrombosis (ipsilateral) - Aneurysm (ipsilateral) - Midbrain lesion (see Question 26.2 from the second paper of 2011) Causes of bilateral CN III lesions: - Cavernous sinus thrombosis - Aneurysm - Contralateral brainstem lesion (midbrain) Exclusion of a 4th nerve lesion - Tilt the head to the same side as the lesion - The affected eye will intort if the fourth nerve is intact.

Answer 88

c) Larger bolus lower infusion rate https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13345 https://journals.lww.com/anesthesia-analgesia/fulltext/2014/06000/a_general_purpose_pharmacokinetic_model_for.12.aspx

Answer 89

d) Von willebrand disease - autosomal dominant inheritance - may have normal or prolonged APTT, PT is normal *Haem A: X-linked recessive disorder; would expect prolonged aPTT, and normal PT *Haem B: X-linked recessive disorder; would expect normal aPTT and normal PT Up to date: Inheritance patterns — Most cases of VWD are transmitted as an autosomal dominant trait; this includes types 1 and 2B, and most types 2A and 2M. Baseline hemostasis assessment — Most patients will have a complete blood count (CBC) with platelet count and coagulation studies during the initial evaluation for excessive bleeding or bruising. ●Individuals with VWD generally have a normal CBC and a normal platelet count, with the exception of those with type 2B VWD, most of whom will have mild thrombocytopenia (eg, platelet count 100,000 to 140,000/microL). ●Individuals with VWD may have a normal or prolonged activated partial thromboplastin time (aPTT), depending on the degree of reduction of the factor VIII level. The prothrombin time (PT) is normal in VWD. Up to date: ●Hemophilia A – Inherited deficiency of factor VIII (factor 8 [F8]); an X-linked recessive disorder. ●Hemophilia B – Inherited deficiency of factor IX (factor 9 [F9]); also called Christmas disease; an X-linked recessive disorder. Laboratory findings — Hemophilia is characterized by a prolonged activated partial thromboplastin time (aPTT). However, the aPTT may be normal in individuals with milder factor deficiencies (eg, factor activity level >15 percent), especially in hemophilia B (factor IX deficiency), where even individuals with moderate disease may have a normal aPTT. In some individuals with hemophilia A, factor VIII levels may increase with stress, leading to a normalization of the aPTT or mis-categorization of factor levels and disease severity. In patients with hemophilia, the aPTT corrects in mixing studies, unless an inhibitor is present, which only applies to individuals who have received factor infusions or who have an autoantibody such as a lupus anticoagulant or an acquired factor inhibitor. Mixing studies that do not show correction of a prolonged aPTT suggest an alternative diagnosis such as an acquired factor inhibitor. The platelet count and prothrombin time (PT) are normal in hemophilia. Thrombocytopenia and/or prolonged PT suggest another diagnosis instead of (or in addition to) hemophilia. Measurement of the factor activity level (factor VIII in hemophilia A; factor IX in hemophilia B) shows a reduced level compared with controls (generally <40 percent). One exception is an individual with mild hemophilia A who undergoes testing when stressed or pregnant and has a falsely elevated factor level. If this is suspected, factor activity testing should be repeated under conditions of low stress. The plasma von Willebrand factor antigen (VWF:Ag) is normal in hemophilia. If VWF:Ag is reduced, this suggests the possibility of von Willebrand disease (VWD) rather than (or in addition to) hemophilia. Urinalysis is not done routinely, but if performed it may sometimes (but not always) show microscopic or macroscopic hematuria.

Answer 90

All People Kick My Cat Atm> PSI > KPA > mmHg > cmH2O 1ATM = 14.69 PSI = 101.325 kPa = 760mmHg = 1033 cmH20

Answer 91

c. Hypercarbia Single-lung ventilation leads to a **right-to-left intrapulmonary shunt** as the nondependent lung continues to undergo perfusion with no ventilation, leading to a widened alveolar-to-arterial (A-a) oxygen gradient, which may contribute further to **hypoxemia**. Factors leading to decreased blood flow to the ventilated lung also lead to hypoxemia. Such factors include: Low Fio2 leads to **hypoxic pulmonary vasoconstriction** in the dependent ventilated lung High mean airway pressures in the dependent ventilated lung Vasoconstrictor agents Intrinsic PEEP The lateral decubitus position under anesthesia: Under anesthesia, there is a decrease in functional residual capacity. The upper lobe moves under anesthesia to a more favorable portion of the compliance curve versus the lower lung, which lies now on a less favorable portion of the compliance curve. Neuromuscular blockade contributes to abdominal contents pressing against the dependent hemidiaphragm, thereby restricting ventilation. Open non-dependent lung leads to variation in compliance and thus **worsens ventilation-perfusion (V/Q) mismatch** - thereby leading to hypoxemia. **Carbon dioxide elimination is usually unaffected **in using single-lung ventilation with adequate maintenance of minute ventilation. Both lungs may be affected independently by single-lung ventilation. The ventilated-dependent lung is prone to ventilator-induced lung injury due to higher tidal volumes used. The nondependent nonventilated lung is prone to injury by surgical trauma and ischemia-reperfusion injuries. Considering these physiological changes in single-lung ventilation is vital to safely performing the anesthetic technique and airway management. Reference: StatPearls Single-Lung Ventilation https://www.ncbi.nlm.nih.gov/books/NBK538314/"

Answer 92

e) Remove vaporiser https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline%20Malignant%20hyperthermia%202020.pdf?ver=2021-01-13-144236-793 as per guidelines, see link and attached image As per anaesthetic crisis manual 1. Call for help, communicate and delegate 2. Stop any volatile and remove vaporiser 3. Allocated task cards 4. Give dantrolene 5. Hyperventilate with 100% high flow oxygen 6. Use activated charcoal filters on both limbs 7. Maintain anaesthesia with TIVA 8. Insert IAL +/- CVC 9. Actively cool if temperature > 38.5 10. Treat associated hyperkalaemia, acidosis, arrhythmias

Answer 93

b) Subclinical Hyperthyoirdism Subclinical hyperthyroidism: low TSH, normal T3 + T4 Clinical hyperthyroidism: low TSH, high T3, high/normal T4 Subclinical hypothyroidism: high TSH, normal T3 + T4 Clinical hypothyroidism: high TSH, low/normal T3, i T4 Amiodarone: high/normal TSH, low T3 (2o to inhibition of pituitary T4 to T3 conversion) Sick euthyroid: low TSH, low T3 Hypophysectomy (central hypothyroidism): low/normal TSH/T3/T4 Compliant on thyroxine: normal TSH, high/normal T3, low T4 Non-compliant w thyroxine (pt taking several tabs prior to Dr’s appointment): high TSH, normal T4

Answer 94

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

Answer 95

a) propofol

Answer 96

REPEAT c. sinus tachy with prolonged QRS

Answer 97

c) pelvic splanchnic -> visceral not somativ nerve

Answer 98

a. PECS I (PECS II Covers SA and will extend to the sternum) https://www.youtube.com/watch?v=0g_PGLYy0gw

Answer 99

REPEAT 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 100

e) Propofol https://www.bjanaesthesia.org/article/S0007-0912(20)30547-X/pdf

Answer 101

d) Dopamine Dobutamine (β1 and β2), dopexamine (DA1, some β2) and low-dose dopamine (DA1 and DA2, β1 and β2, α1 in high dose) all have vasodilatory effects on the splanchnic circulation, and have been shown to improve markers of perfusion. For many years, low-dose infusions of dopamine were used as a prophylactic and therapy for acute renal failure, using the logic that DA1- and DA2-mediated vasodilation in renal and splanchnic beds would be protective. https://pubmed.ncbi.nlm.nih.gov/12794401/

Answer 102

REPEAT 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 103

Repeat Depends on resource read and the indication for the line/expected duration/site on insertion

Answer 104

Answers could also possibly be COPD, Acute stroke or Neonates c) Bleomycin toxicity Bleomycin is a particularly important chemotherapy drug for the anaesthetist to be aware of. Bleomycin is often used to treat germ cell tumours and Hodgkin's disease in a curative setting. The major limitation of bleomycin therapy is the potential for subacute pulmonary damage that can progress to life-threatening pulmonary fibrosis. Pulmonary toxicity occurs in 6–10% patients and can be fatal.2 Exposure to high-inspired concentration oxygen therapy, even for short periods, as experienced during anaesthesia, is often implicated in causing rapidly progressive pulmonary toxicity in patients previously treated with bleomycin.3 These claims have been considered controversial by some, but it is the authors' recommendation that any patient previously exposed to bleomycin therapy should be treated as high risk, and summary guidance regarding oxygen therapy is shown in Table 4. Summary guidance—oxygen therapy for patients who have received bleomycin > Patients have a life-long risk of bleomycin-induced lung injury > Oxygen therapy should be avoided if at all possible > Clinical procedures (and leisure activities) involving a high should be avoided If a patient is hypoxic > O2 therapy should be minimized to maintain O2 saturation of 88–92% > High oxygen concentrations should be used with extreme caution for immediate life-saving indications only (to maintain O2 saturation of 88–92%)

Answer 105

90mg PO morphine 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 106

midazolam - Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Perioperative treatment of symptoms If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible. If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day. If oral intake is feasible, a patient’s usual oral medication may be given. Levodopa (a dopamine agonist) may be administered by nasogastric tube. Alternatively, parenteral apomorphine or a rotigotine patch may be used. Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis. Nausea is a common side effect so it may need to be given with an antiemetic. Rotigotine patches may be used every 24 hours. Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.

Answer 107

New question. a) Postoperative myocardial injury was associated with an increased risk of death. Twenty-seven of the 315 patients (8.6%; 95% CI, 6.0–12.2%) with myocardial injury died within 30 days compared with 29 of the 1312 patients (2.2%; 95% CI, 1.5–3.2%) with normal troponin I levels (P<0.01) Reference: Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality (Circulation 2013)

Answer 108

REPEAT f) Increased SVR

Answer 109

d) diplopia Bilateral visual loss associated with insufficiency to posterior circulation so: parieto-occipital ischaemia, signs of stroke, visual agnosia, ophthalmoplegia or diplopia.

Answer 110

e) VVI with intermittent failure to sense

Answer 111

b) Diuretics Grade 1: moderate hypoxia (Spo2<94%) or hypotension [fall in systolic blood pressure (SBP) >20%]. Grade 2: severe hypoxia (Spo2<88%) or hypotension (fall in SBP >40%) or unexpected loss of consciousness. Grade 3: cardiovascular collapse requiring CPR. Patient Risk factors: 1. old age 2. poor pre-existing physical reserve 3. impaired cardiopulmonary function -> NYHA 3 or 4 4. pre-existing pulmonary htn 5. Male Sex 6. Diuretics 7. ASA grade 3 or 4 8. osteoporosis 9. bony metastases 10. concomitant hip fractures (particularly pathological and intertrochanteric) (latter due to abnormal vascular channels through which marrow contents can enter the circulation) Surgical Risk factors 1. patients with previously un-instrumented femoral canal > revision surgery 2. Use of long-stem femoral component Anaesthetic Risk reduction: - discussion between surgeons and anaesthetists over uncemented vs. cemented based on patient Hx particularly if lon-stem prosthesis, femoral fracture or patients with cardiorespiratory disease - no clear evidence regarding the impact of anaesthetic technique - increase inspired O2 considered in all patients at time of cementation - avoid intravascular volume depletion - Higher level of haemodynamic monitoring in high risk patients Factors NOT predictive of severe BCIS include: Arteriosclerosis Angina pectoris Congestive heart failure Beta-blockers Angiotensin-converting enzyme inhibitors.

Answer 112

repeat 23.1 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.