24.1 Flashcards
A medication that would be acceptable to a patient who refuses all products derived
from human plasma is:
a) Prothrombinex
b) Activated factor 7
c) Fibrinogen concentrate
d) Albumin
e) anti-d
Factor 7 - Recombinant, made from baby hamster kidney cells
Albumin - Alburex® 5 AU (Human Albumin 50 g/L) is an Australian manufactured albumin product
Fib con - Lyophilised precipitate. manufactired from cryoprecipitate.
PCC - Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors containing factors II, IX and X and a small amount of factor VII.
Red cross lifeblood.
Correct answer is rVIIa
An adult patient undergoing cardiac surgery exhibits excessive bleeding following
cardiopulmonary bypass. A thromboelastogram performed on their blood is shown
below. The most likely cause of the bleeding is
(ROTEM with low Extem A10 and normal Fibtem A10)
a) Platelets
b)Fibrinogen
c) FFP
d) TXA
Plateltes
Fibrinogen if low Fibtem
TXA if curves tail off early
FFP if MCF low
A term neonate is undergoing closure of gastroschisis under general anaesthesia with pressure control ventilation via an endotracheal tube. The estimated blood loss is 10 mL. Fluid therapy has been 4% albumin 40 mL/kg in addition to maintenance 10% dextrose 4 mL/kg/h. During closure of the defect, the oxygen saturation falls to 80%. The most likely cause of the desaturation is:
a) Pulmonary oedema/excessive fluids
b) Reduced Lung compliance
c) Undiagnosed congenital heart disease
4) Return to foetal circulation
b) Reduced Lung compliance
- Closure of abdominal wall post gastroschisis repair leads to significantly increased abdominal compartment pressures and can splint diaphragm. May need staged closure.
Term neonate = ~3.5 kg
40ml/kg = ~140mls in
Normal blood volume 90 x 3.5 = 315ml
10ml blood loss + added environmental losses from exposed bowel
The key is the timing with closure, and to be aware that staged closures are frequently done. Most likely answer is lung complicance, and PCV which would result in a reduction in volumes on closing.
Phaeochromocytoma commonly presents with all of the following EXCEPT:
a) RV Hypertrophy
b) Pulmonary HTN
c) long QT
d) ST changes
e) Cardiomyopathy
b) Pulmonary HTN
Long QT + ST changes common
Cardiomyopathy less common but well documented
RVH possible, although more commonly LVH
REview Duchenne muscular dystrophy is NOT associated with:
a) Increased CK
b) Cardiomyopathy in female carriers
c) decreased Sensitivity to non-depolarising NMBs
Alternative remembered answers:
a) Reisistant to NDNMB
b) Premature death
c) Aspiration
d) Conduction abnomality in females
Increased sensitivity to non depolarisers
Ck -> Anaesthesia induced rhabdo
Cardio- All at-risk females, regardless of their carrier status, should be monitored for development of cardiomyopathy
When administered in combination with tramadol, the agent considered highest risk
for the development of serotonin syndrome is:
a) Moclobemide
b) Escitalopram
c) Desvenlafaxine
d) Tapentadol
Moclobemide
- Reversible MAOI
SSRIs and SNRIs are lower risk
Tapentadol - no serotonin effect
Tranylcypromine or phenylzine are irreversible blockers and would be the highest risk
The action of methylene blue in treating vasoplegia is mediated by:
a) Inhibits inducible NO
b) Inhibits constitutive NO
c) Inhibits guanylate cyclase
d) Agonises angiotensin II receptors
e) Something about V1 Receptors?
c) Inhibits guanylate cyclase
Methylene Blue acts by inhibiting guanylate cyclase, thus decreasing C-GMP and vascular smooth muscle relaxation
A stellate ganglion block is NOT indicated in the management of:
a) AV block
b) Resistant ventricular arrhythmia
c) PTSD
d) Scleroderma
e) Hyperhidrosis
AV block
CI in
- cardiac conduction block
- Glaucoma
- Anticoagulation
Indications
Complex regional pain syndrome of the head and upper limbs
Peripheral vascular disease
Upper extremity embolism
Postherpetic neuralgia
Chronic post-surgical pain
Hyperhidrosis
Raynaud disease
Scleroderma
Orofacial pain
Phantom limb
Atypical chest pain
A cluster or a vascular headache
Post-traumatic stress disorder
Meniere syndrome
Intractable angina
Refractory cardiac arrhythmias
Obstructive sleep apnoea in children is diagnosed with an apnoea-hypopnoea index
(AHI) of at least:
a) >1
b) >5
c) >10
a) >1
0 normal
Mild/mod/severe
1-5
5-10
>10
Neostigmine should be avoided in patients with:
a) Familial periodic paralysis
b) Myotonia congenita
c) Duchennes
d) Beckers
e) Friedrichs ataxia
b) Myotonia congenita
Myotonia congenita is a condition characterized by delayed relaxation of the muscles after voluntary contraction. Neostigmine can exacerbate this delayed relaxation, potentially worsening symptoms
A transjugular intrahepatic portosystemic shunt procedure is contraindicated in
patients with:
a) Hepatorenal syndrome
b) Refractory ascites
c) Severe TR
d) Variceal bleeding
e) Budd chiari
c) Severe tricuspid regurgitation (TR)
Severe TR can lead to increased right atrial pressure, which may impede the proper function of the TIPS and worsen outcomes.
Contraindications:
Severe Hepatic encephalopathy
Severe Pulmonary Htn
Severe TR
Multiple Hepatic Cysts
Coagulopathy (relative contraindication)
When confirming correct placement of an endotracheal tube, verifying the presence
of sustained exhaled carbon dioxide requires all the following EXCEPT:
a) CO2 rises with expiration and falls with inspiration
b) Consistent square waveform
c) Consistent or increasing amplitude of the capnogram over 7 breaths
d) Peak amplitude more than 7.5mmHg above baseline
e) Capnogram is clinically appropriate
Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies
Suggests b) is most correct answer
Verifying the presence of sustained exhaled carbon dioxide requires all the following criteria to be met (Fig. 2; [93]):
- Amplitude rises during exhalation and falls during inspiration.
- Consistent or increasing amplitude over at least seven breaths [74, 91].
- Peak amplitude more than 1 kPa (7.5 mmHg) above baseline [74, 94].
- Reading is clinically appropriate.
The dataset that was used to create the Eleveld TCI model did NOT include
patients who are / have:
a) Neonates
b) Elderly
c) Cirrhotic liver disease
d) End stage renal disease
Neonates. Eleveld designed for a wide patient pop, but not neonates.
The blood product that contains the highest concentration of citrate is:
a) FFP
b) RBCs
c) Platelets
d) Cryoprecipitate
e) Fibrinogen concentrate
a) FFP
FFP - 20mmol/l (associated with highest rate of Citrate toxicity)
- cannot find a great reference but is quoted in Citrate Toxicity During CRRT After Massive Transfusion (they then reference 1992 guidelines from Transfusion Med, 1994 article about plasma exchage, and Miller’s 2009)
Lifeblood - additive for plasmapheresis is highest concentration of 4%
- could also argue that even if derived from whole blood donation, most of the citrate likely to be in the plasma anyway and when cellular components separated from plasma it will remain (no evidence for that)
These numbers unclear source material
Platelets - 15-20mmol/L
Plasma - 13-15mmol/L
Red cells 5-7.5mm/L
Cryo 13-15mmol/L
Fib conc - nil
During a new pandemic, an anaesthetist refuses to provide sedation for an elective
operation due to concern that the procedure may hasten community spread of the
disease. This is the ethical principle of:
a) Beneficence
b) Non-maleficence
c) Justice
d) Conscientious objection
e) Professional autonomy
Primum non nocere: First, do no harm - Non maleficence
The anaesthetic technique associated with the highest rate of postprocedure
patency of a newly-created arteriovenous fistula is
a) Propofol TIVA
b) Brachial plexus block
c) Sedation + LA
d) Volatile
Regional -ie Brachial plexus
Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study protocol : a randomised controlled trial comparing primary unassisted patency at 1 year of primary arteriovenous fistulae created under regional compared to local anaesthesia
supraclavicular or Axillary block
The image below shows the arterial pressure (red, upper line) and balloon pressure
(blue, lower line) from an intra-aortic balloon pump set at 1:2 augmentation. The
point of the waveform indicated by the large green arrow is called:
a) Assisted end diastolic
b) Assisted systolic
c) Unassisted end diastolic
d) Assisted systolic
Assisted end diastolic
A patient’s true arterial oxygen saturation will be lower than a pulse oximeter
reading in the presence of:
a) Carboxy Hb
b) Sickle cell
c) Methylene blue
CarboxyHb
- Probe cannot differentiate between HbO and COHb
The others cause false readings
Organ procurement after circulatory death is generally stood down if the time from
cessation of cardiorespiratory support to circulatory death extends beyond:
a) 60min
b) 90min
c) 120min
90 mins
30mins
Liver
Pancreas
Heart
60mins
Kidneys
90mins
Lungs
Page 35 ANZICS statement 2.4.3 Warm ischemia time
Donate life
The rank of volatile anaesthetic agents from highest to lowest derived global
warming potential over 100 years (GWP100) is:
a) Nitrous, des, iso, sevo
b) Des, iso, nitrous, sevo
c) Des, nitrous, iso, sevo
d) Nitrous, des, sevo, iso
B
Desflurane (Des): GWP100 around 2,500-3,000
Isoflurane (Iso): GWP100 around 1,000-1,100
Nitrous oxide (Nitrous): GWP100 around 298
Sevoflurane (Sevo): GWP100 around 130-210
A characteristic feature of postoperative visual loss due to posterior ischaemic optic
neuropathy is:
a) Painful
b) Normal light reflexes
c) Normal fundoscopy
d) Visual inattention
c) Normal fundoscopy
The bipolar leads of a 12-lead electrocardiogram are:
a) All
b) V1-V6
c) aVL, aVR, aVF
d) I, II, III
e) None
D) I, II, III
3-electrode system
- Uses 3 electrodes (RA, LA and LL)
- Monitor displays the bipolar leads (I, II and III)
Life in the Fast Lane
The local anaesthetic with the lowest CCCNS ratio (ratio of the drug dose required
to cause cardiac collapse to the drug dose required to cause seizure) is:
a) Levobupivacaine
b) Bupivacaine
c) Lignocaine
d) Ropivacaine
B) Bupivacaine
CC/CNS Ratio: the ratio of the dose required to cause CVS collapse and the dose required to cause CNS toxicity (indicates the CNS is more vulnerable than CVS)
Lignocaine: 7.1
Ropivacaine: 5.0
Bupivacaine: 3.7
Levobupivacaine: **not listed
Petkov
Ropivacaine and levobupivacaine, for example, have higher CC/CNS ratios than racemic bupivacaine; therefore, it seems logical to preferentially use these drugs when long-acting LAs are desired.
Pubmed
The time for reversal of therapeutic dabigatran after administration of
idarucizumab 5 g is:
a) 5 mins
b) 15 mins
c) 30 mins
d) 60 mins
e) 120 mins
5 mins
- Essentially one circulation time
Intravenously administer the dose of 5 g (2 vials, each contains 2.5 g) as
o Two consecutive infusions or
o Bolus injection by injecting both vials consecutively one after another via syringe
Idarucizumab was administered as one 5 g intravenous infusion over five minutes
Among the 90 patients with available data, the median maximum reversal of the pharmacodynamic anticoagulant effect of dabigatran as measured by ECT or dTT in the first 4 hours after administration of 5 g idarucizumab was 100%, with most patients (>89%) achieving complete reversal. Reversal of the pharmacodynamics effects was evident immediately after administration.
FDA Product Guide
See blue book article
The intrinsic muscles of the larynx do NOT include:
a) Cricothyroid
b) Suprahyoid
c) Transverse arytenoid
d) Cricoarytenoid
b) Suprahyoid
Suprahyoid muscles are extrinsic muscles of the larynx that attach outside the laryngeal framework and assist in swallowing and other movements. Not in anatomy for anaesthetists!
The intrinsic muscles of the larynx have a threefold func-
tion: they open the cords in inspiration, they close the cords and the laryngeal inlet during deglutition, and they alter the tension of the cords during speech.
They comprise the posterior and lateral cricoarytenoids,
the interarytenoids and the aryepiglottic, the thyroarytenoid, the thyroepiglottic, the vocalis and the cricothyroid muscles.
Anatomy for Anaesthetists
When interpreting an arterial blood gas, a high serum anion gap is consistent with:
a) lithium toxicity
b) Salicylate toxiticy
c) Hypercholeraemia
d) Hypoalbuminaemia
e) Hypercalcaemia
b) Salicylate toxicity
Salicylate toxicity can cause an elevated serum anion gap due to the production of organic acids (salicylic acid and its metabolites) that are not measured by the standard anion gap calculation. This leads to an increased anion gap metabolic acidosis.
HAGMA results from accumulation of organic acids or impaired H+ excretion
Causes (LTKR)
Lactate
Toxins
Ketones
Renal
Causes (CATMUDPILES)
CO, CN
Alcoholic ketoacidosis and starvation ketoacidosis
Toluene
Metformin, Methanol
Uremia
DKA
Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde
Iron, Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
NAGMA results from loss of HCO3- from ECF
Causes (CAGE)
Chloride excess
Acetazolamide/Addisons
GI causes – diarrhea/vomiting, fistulae (pancreatic, ureters, billary, small bowel, ileostomy)
Extra – RTA
Causes (ABCD)
Addisons (adrenal insufficiency)
Bicarbonate loss (GI or Renal)
Chloride excess
Diuretics (Acetazolamide)
LITFL
The Glasgow Blatchford score is used to risk stratify:
a) Pulmonary haemorrhage
b) Traumatic intraperitoneal haemorrhage
c) PPH
d) SAH
e) UGI bleed
e) UGI bleed
Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management. Use for adult patients being considered for hospital admission due to upper GI bleeding.
Components: haemoglobin, BUN, initial systolic BP, heart rate > 100, melena present, recent syncope, hepatic disease history, cardiac failure present.
Med-Calc
In a male patient with quadriplegia undergoing a rigid cystoscopy, the optimal
choice of anaesthesia to prevent autonomic dysreflexia is
a) Spinal
b) Epidural
c) GA with volatile at 1 MAC
d) Topical only
a) Spinal
Elective surgery.Urological. Recurrent urinary tract infections and long-term catheterization increase the risk of bladder cancer. Cystoscopy is a common procedure as is insertion of suprapubic catheters and botox injections for the management of neuro- pathic bladders.
Spinal anaesthesia is safe in patients with CSCI and is an effect- ive way of abolishing ADR15 and spasms. Spinal anaesthesia is becoming a widely accepted technique in patients with pre-exist- ing spinal cord pathology and is routinely used in Stoke Mande- ville Hospital, with a low dose (1.5–2 ml) hyperbaric bupivacaine 0.5%, for most procedures. Spinals can be challenging to site because of poor positioning as a result of spasms and contractures, the presence of spinal metal work, and bony deformities.
The effectiveness and the level of the block are difficult to ascertain. The loss of the Babinski reflex and a change in tone from spasticity to flaccid paralysis indicate an established block; although the height of the block remains difficult to assess. The anaesthetist must be vigilant for the signs and symptoms of a total spinal block.
Epidural anaesthesia has been demonstrated to be effective in reducing ADR in labouring women; however, it is less reliable for general and urological surgical procedures.
I asked a boss about this - he said if previous autonomic dysreflexia definitely needs an anaesthetic!
Perioperative management for patients with a chronic spinal cord injury. BJA 2015
Interference with pacemaker function can result from all of the following EXCEPT:
a) RF ablation
b) High volume ventilation
c) Peripheral nerve stimulator
d) CT
e) Diathermy
d) CT
British Heart Rhythm Societies guidelines
A neonate with a postmenstrual age of 34 weeks (born at 26 weeks) and weighing
2 kg is undergoing retinal laser therapy under general anaesthesia. The oxygen
saturation is 92% on the following ventilator settings: FiO2 0.4; inspiratory pressure
15 cmH2O; PEEP 5 cmH2O; rate 24 breaths per minute. The most appropriate
course of action is to:
a) Increase FiO2 to 100
b) Suction tube
c) Increase PEEP to 7
d) Recruitment breath at 30cmh2o
e) Do nothing
E: Do nothing
Targets for premature babies:
* Volume-targeted or pressure-limited mode targeting tidal volumes of 5 ml kg1
* Ventilatory frequency: 30-60 bpm
* PEEP: 6-8 cmH2O
* Titrate above to maintain normocapnia or mild hypercapnia
* Titrate FIO2 to achieve SpO2 90-95%.
RCH guidelines
When auscultating the heart the Valsalva manoeuvre will increase the murmur
intensity of:
a) AS
b) MS
c) MR
d) MVP
e) VSD
Mitral valve prolapse
Valsalva increases the strength of murmurs due to hypertrophic obstructive cardiomyopathy and mitral valve prolapse. It decreases the intensity of aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, and ventricular septal defects.
OPPOSITE IS TRUE FOR SQUATTING (Increases preload)
The most appropriate order of blood products transfused sequentially through the
same blood administration set is:
A) RBC - plasma - plts
B) RBC - plts - plasma
C) Plasma - RBC - plts
D) Plts- RBC -plasma
D) Plts- RBC -plasma
according to Lifeblood guidelines, platelets MUST be given before RBC if in the same line, as red cell debris will trap platelets; platelets and plasma can be sequential through the same set; as platelets take a long time to transfuse, it makes sense to first transfuse plasma (fast), then platelets, then red cells
The breathing system shown in the accompanying picture is an example of
Mapleson:
a) A
b) B
c) C
d) D
e) F
c
In an anaesthetised patient with anaphylaxis, cardiac compression should be
initiated at a systolic blood pressure of less than:
a) 40
b) 60
c) 80
d) 100
e) 120
a) 40
40; if 50 was there the answer would be 50
NAP 6 says CPR if SBP<50mmHg
ANZAAG says 50mmHg
The muscle recommended for neuromuscular monitoring by the 2023 American
Society of Anesthesiologists practice guidelines is the:
a) Adductor Pollicis
b) Flexor pollicis longus
c) Flexor hallucis brevis
d) Corrugator supercilii
e) Orbicularis oculi
A - Adductor Pollicis - Usual site for NMT
Correct on ASA website
A single intraoperative dose of 8 mg dexamethasone compared to 4 mg results in:
a) No difference in analgesia
b) No difference in PONV
c) No difference in BSL
d) Increased surgical site infection
B is the answer
Check 4th consensus guidelines
Does show better analgesia
PADDI Trial (Monash and ANZCA) 2021
No difference in infection with dex 8 vs placebo
Anaesthesiology Nov 2021, Vol 135, issue 5 - article by Aus anaesthesiologists
A higher dose
- Will cause more hyperglycaemia in DM patients but not clinically/statiscally significant
- Will improve PONV for 72 hours = possibly
- Some studies show this can improve analgesia - ortho, ent cases particularly
8mg dose recommended
Was the question related to addition of dex in block - Korean study compared 4vs8 in 2018
You are undertaking an ultrasound guided pericapsular nerve group (PENG) block
for hip surgery. In the accompanying image, the structure labelled with the arrow is
the:
a) Psoas Tendon (This)
b) Iliacus
c) Sartorius
Add picture of peng block (can’t from my account)
a) Psoas Tendon (This)
The tooth most commonly damaged during direct laryngoscopy is the:
a) Right maxillary central incisor
b) Left maxillary lateral incisor
c) Left maxillary Central incisor
d) Right maxillary lateral incisor
c) Left maxillary Central incisor
BJA education article - 2016 and Aagbi
Left max central incisor most common from blade (fulcrum) 32%
Right max central - 19%
Right third molar if posterior injury
Periodontitis and cvs risk link
Reminder to link poor dentition with other risk factors - meth/smoking/poor diet/autoimmune conditions and their anaesthetic impact
1:4500 risk (Rcoa)
In the event of an electrical fire in the operating room, the correct fire extinguisher
type to use is:
a) Dry powder
b) Wet
c) Chemical
d) CO2
CO2
Pull/Aim/Squeeze/Sweep
Don’t use fire blankets - concentrated heat on patient
Saline or water for body cavity fire
Dry powder and chemical can leave residues that could damage equipment
According to the ISO colour code for medical gas cylinders, Entonox is indicated by
a) Blue/ White
b) Yellow
c) Black
d) Grey
a) Blue/ White
Blue and white shoulder
White bottle
Pre 2004 made cylinder is blue
During resuscitation of a newborn, the heart rate is noted to be 50 beats per minute
despite optimal ventilation and chest compressions. The next step in management
is to give intravenous adrenaline:
a) 0.1-0.3ml/kg 1:1000
b) 0.5-1ml/kg 1:10000
c) 0.1-0.3ml/kg 1:10000
d) 0.1-0.3ml/kg 1:100000
C
Neoresus
10-30mcg/kg
An adult weighing 80 kg has sustained full-thickness burns to 40% of their body.
The recommended volume of fluid resuscitation in the first 24:
a) 9600ml
b) 16000ml
c) 6400ml
Actual exam options gave 3ml/kg/bsa to 4ml/kg/bsa range
3 * 40 * 80 = 9600
4 * 40 * 80 = 12800
Parkland seems to be trending toward 3ml these days rather than 4
Deranged physiology key points
Urine output as end goal - risk of fluid creep with same
Albumin reduces total volume of resus but not difference to survival
Hypertonic fluids - increased mortality and AKI
Other formula
Brooke
Evan’s
Monafo
Shriner’s -paeds
Galvestons - paeds
In a can’t intubate, can’t oxygenate (CICO) scenario when using a 14G cannula
and a Rapid-O2 oxygen delivery device, the initial rescue breath should be:
a) 2 seconds, 10L O2
b) 4 seconds, 10L O2
c) 2 secs 15L
d) 4 secs 15L
d) 4 secs 15L
Initial breath 4 seconds @ 15L (rate is 250ml/s i.e. total delivered in 4 seconds = 1L)
If no improvement in SpO2 after 30 seconds give another 2 second breath
Subsequent breaths once sats fall by 5% from maximum Spo2 achieved with initial jet ventilation breath = 2 secs (I.e. 500ml)
The maximum recommended cumulative dose of Intralipid 20% for the treatment of
local anaesthesia systemic toxicity is:
a) 8ml/kg
b) 9ml/kg
c) 12ml/kg
c) 12ml/kg
Intralipid 20% treatment
Initial bolus 1.5ml/kg (repeat up to Max 3 times 5 mins apart
Infusion 15ml/kg /hr
Max cumulative dose = 12 ml/kg
The minimum age in years for in vitro contracture testing for suspected malignant
hyperthermia is
a) 6
b) 8
c) 10
d) 12
10
All current Australian and New Zealand laboratories follow the guidelines of the European Malignant Hyperthermia Group for In Vitro Contracture Testing.
The EMHG guidelines are summarised as follows:
Age and Weight
The minimum weight limit for Australian and New Zealand laboratories is 30 kg and the minimum age for IVCT is 10 years.
(Emhg actually says min age for muscle biopsy is 4 yrs but lab’s should not test children under 10 yrs without relevant control data)
IVCT details
The biopsy should be performed on the quadriceps muscle (eithervastus medialisorvastuslateralis), using local (avoiding local anaesthetic infiltration of muscle tissue), regional, or trigger-free general anaesthetic techniques.
The muscle samples can be dissected in vivo or removed as a block for dissection in the laboratory within 15 minutes.
The time from biopsy to completion of the tests should not exceed 5 hours.
Muscle specimens should measure 20-25 mm in length and at least four tests should be performed each one using a fresh specimen.
The tests should include a static cumulative caffeine test and a dynamic or static halothane test.
The results should be reported as the threshold concentration, which is the lowest concentration of caffeine or halothane that produces a sustained increase of at least 2 mN (0.2 grams) in baseline force from the lowest force reached.
A medication that should be avoided in a patient with thyroid storm is:
a) Aspirin
b) Propranolol
c) Potassium Iodide
d) PTU
NSAIDS/aspirin should be avoided as it displaces thyroxine from protein and subsequently increases free T3 and T4 levels.
Thyroid storm
General measures
Cooling
IVF +/- glucose
Paracetamol
Propranolol
Specific
Hydrocortisone 200 mg QID IV
PTU
after PTU sodium iodide/lugols iodine
A patient with a perioperative troponin rise above normal, chest pain, left ventricular
anterior regional wall motion abnormality, and atheroma without thrombus
occluding 70% of the left anterior descending coronary artery has had a/an
NSTEMI
STEMI
Unstable angina
Acute myocardial injury
Chronic myocardial injury
Type 1 MI
Type 2 MI
NSTEMI
MINS: MI/ischemic myocardial injury that doesn’t fulfill MI defn
MI: Myocardial injury with rise/fall cTn above 99th percentile of upper ref limit within 30 days post op plus at least one of:
Ischemic symptoms
New ischemic ECG changes
New path Q waves on ECG
Imaging evidence of myocardial ischemia
Angiographic/autopsy evidence of coronary thrombus
Regarding sex differences in the incidence of connected consciousness (ability to
respond to command during general anaesthesia) in adults after tracheal intubation
as measured by the isolated forearm technique:
a) Higher in females due to lower propofol ml/kg dose
b) Higher in females despite same dose propofol
c) Higher in males due to lower propofol ml/kg dose
d) Higher in males despite same propofol dose
e) No sex difference
B) higher in females despite same dose propofol
BJA Feb 2023
https://www.bjanaesthesia.org/article/S0007-0912(22)00192-1/fulltext
Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1–7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy
*supplementary table shows dosing between female and male responders vs non responders and dosing is the same
A patient who underwent a thoracotomy six months ago reports shooting pain on
the chest wall occurring without any trigger. This is known as:
Post thoracotomy pain syndrome
IASP Post-thoracotomy pain syndrome:
“Pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure” in general it is burning or stabbing pain with dysesthesia thus shares many features of neuropathic pain.
Dysesthesia: unpleasant abnormal sensation spontaneous or evoked
In Australia and New Zealand, a return to practice program is recommended after an absence from consultant anaesthetic practice for more than:
a) 3 months
b) 6 months
c) 9 months
d) 12 months
12 months
In this ultrasound image, the cricothyroid membrane is at the position marked
A
B
C
D
E
C
A superficial cervical plexus block will block all of the following nerves EXCEPT the:
a) Lesser occipital
b) Greater occipital
c) Greater auricular
d) Transverse cervical
e) Supraclavicular
Greater occipital
A drug which is unlikely to interfere with skin testing is oral:
a) Diphenhydramine
b) Amitriptyline
c) Prednisolone
d) Risperidone
e) Ranitidine
Risperidone
Avoid antihistamines and steroids
TCAs known to interfere
Mayo clinic website
See allergy.org.au - risp mentioned in appendix b as a med that may need held
According to the ANZCA guideline on fatigue risk management in anaesthesia practice the duration of an ideal nap is:
a) 10-20
b) 20-30
c) 30-40
d) 40-50
20-30 mins
ANZCA PG43a
A 39-year-old requires anaesthesia for a laparoscopic cholecystectomy. They have a history of mastocytosis and have never had an anaesthetic in the past. The non-depolarising muscle relaxant to avoid using is:
a) Atracurium
b) Cisatracurium
c) Pancuronium
d) Rocuronium
e) Vecuronium
Atrac - histamine release is bad.
more Mastocytosis Info would be good
A healthy woman with an uncomplicated pregnancy has an American Society of Anesthesiologists (ASA) Physical Status classification of:
a) 1
b) 2
c) 3
d) 4
2
NP: The antibiotic considered safest to be administered to a patient with myasthenia gravis in the perioperative period is:
a) Vancomycin
b) Gentamycin
c) Erythromycin
d) Flucloxacillin
e) Ciprofloxacin
d) Flucloxacillin
Black box warning for fluoroquinolones (ciprofloxacin)
Probably also avoid
Aminoglycosides (Amikacins/gentamicin/streptomycin) and tobramycin although TOBRAMYCIN probably least problematic of these.
Macrolides (erythromycin)
These antibiotics have not been shown to cause many problems for MG patients
Tetracycline (doxycycline, minocycline) – this may worsen MG
Sulfonamides (Bactrim), Penicillin – causes rare cases, usually not a problem for majority of MG patients
https://myastheniagravis.org/mg-and-drug-interactions/#:~:text=These%20antibiotics%20have%20black%20box,Ketek%20(telithromycin)
https://myasthenia.org/Portals/0/Cautionary%20Drugs.pdf
The clinical laser type with the greatest tissue penetration is:
a) Argon
b) Nd:yag
c) Er:yag
d) Co2
e) Holmium
b) Nd:yag
Modified Question: this question asks Greatest, old asks least
Least = Er:yag
Most = Nd:Yag
Er:yag (Erbrium-Yag) used in dermatology which is the least penetrative
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.
Argon penetration of 0.5mm
The accompanying image is obtained while doing an ultrasound guided erector spinae plane block at the level of the transverse process of the fourth thoracic vertebra. The muscle marked by the arrow is the:
a) Traps
b) Rhomboids
c) Erector spinae
d) Latissimus Dorsi
c) Erector spinae
Risk factors for delirium after hip fracture surgery include all EXCEPT
a) Frailty
b) Age
c) GA vs Neuraxial technique
d) Male Sex
c) GA vs Neuraxial
Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis:
This meta-analysis did not find any statistically significant difference in POD incidence between NA and GA groups or in any subgroup analyses. There was no difference in delirium incidence regardless of inclusion or exclusion of patients with pre-existing dementia or preoperative delirium
a) Frailty, b) Age -> risk factors
Most notably, neck of femur fracture repair is associated with up to 70% risk of postoperative delirium. There are several explanations: a neck of femur fracture is commonly associated with frail older patients; perioperative pain is a significant issue; and the surgery is usually done in an emergency setting with limited opportunity for preoperative optimisation
BJA
d) Male sex -> risk factor
Male sex associated with increased risk of delirium, multiple studies on Google
Borders of the anterior triangle of the neck DO NOT include the:
a) Inferior angle of mandible
b) Middle third of clavicle
c) Sternocleidomastoid muscle
d) Midline neck
b) Middle third of clavicle
Anterior triangle contains IJ
Superiorly: inferior border of the mandible.
Laterally: anterior border of the sternocleidomastoid.
Medially: sagittal line down the midline of the neck.
Posterior triangle contains EJ
Anterior: posterior border SCM
Posterior: anterior border trapezius
Inferior: middle third clavicle
StatPearls
Anatomy, Head and Neck, Neck Triangle
The abnormalities seen in the electrocardiogram below are consistent with:
a) Hypercalcaemia
b) Hypermagnasaemia
c) Hyperphosphataemia
d) Hypokalaemia
e) Hyperkalaemia
NAOMI
ECG features of hypokalemia:
Increased P wave amplitude
Prolongation of PR interval
Widespread ST depression and T wave flattening/inversion
Prominent U waves (best seen in the precordial leads V2-V3)
Apparent long QT interval due to fusion of T and U waves (= long QU interval)
A 50-year-old has had a headache for the last month which is relieved by lying flat. They have had no medical procedure to their spine such as epidural, spinal or lumbar puncture. Their brain magnetic resonance (MR) imaging scan shows diffuse meningeal enhancement and brain sagging. The neurologist suspects spontaneous intracranial hypotension and asks you to do an epidural blood patch. No spinal imaging has been performed to confirm a cerebrospinal fluid (CSF) leak. You should
A do LP to measure pressure if low do lumbar patch
B do blood patch at lumbar level with no further investigation
C do spine imaging if CSF leak present do blood patch at level
D do spine imaging if CSF leak present do lumbar blood patch
E refuse to do blood patch
D do spine imaging if CSF leak present do lumbar blood patch
The image below is from the transoesophageal echocardiogram of an adult patient who is about to undergo cardiac surgery. The structure labelled with the arrow is the:
TOE image - four chamber, with arrow pointing to leaflet closest to septum
A) Anterior mitral leaflet
B) Posterior mitral leaflet
C) Tricuspid septal leaflet
D) Tricuspud anterior leaflet
E) Tricuspid posterior leaflet
A) Anterior mitral leaflet
RV is an anterior structure hence anterior leaflet
A 45-year-old received a heart transplant one month ago. They develop a new supraventricular tachyarrhythmia without hypotension during gastroscopy. The most appropriate therapy is:
a) Adenosine
b) Amiodarone
c) Esmolol
d) Verapamil
e) Digoxin
REPEAT
d) Esmolol
Management of Arrhythmias After Heart Transplant
https://www.ahajournals.org/doi/10.1161/CIRCEP.120.007954
In asymptomatic patients, additional cardiac monitoring such as 24-Holter or an event monitor can be useful to assess the SVT burden, and a trial of atrioventricular nodal blockers (β-blockers preferably) can be attempted with caution in view of potential risk of bradycardia. Calcium channel blockers such as diltiazem and verapamil are contraindicated in patients taking immunosuppression such as tacrolimus and cyclosporine as it can impair the metabolism CYP3A, which increases the levels of these drugs potentially causing renal toxicity.
The use of adenosine in the management of SVT has remained a subject of controversy for over a quarter century. In the past, adenosine was contraindicated in patients post-OHT due to its supersensitivity and presumed risk of prolonged atrioventricular block.
Thus, based on the aforementioned data, in patients with OHT, adenosine is feasible and safe at reduced doses (starting at 1.5 mg for patients ≥60 kg) as long as patients are closely monitored, with dose escalation as needed. Furthermore, the 2010 American Heart Association guidelines on advanced cardiovascular life support also recommended lowering the initial dose of adenosine to 3 mg for the acute management of SVT in patients with OHT.
An open Ivor-Lewis oesophagectomy is performed via a:
a Laparotomy then left thoracotomy
b Laparotomy, left neck incision
c Laparotomy, Right thoracotomy
d Left thoracotomy, left neck incision
REPEAT
C
Transhiatal - laparotomy & cervical anastomosis
Ivor-Lewis - laparotomy & R thoracotomy (tumour upper ⅔)
Thoracoabdominal - L throacotomy crossing costal margin & diaphragm (tumour lower ⅔)
Minimally invasive - thorascopic oesophageal mobilisation, laparoscopic gastric mobilisation & cervical
anastomosis
A 69-year-old patient is dyspnoeic and complains of right shoulder tip pain while in the post-anaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents:
a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung
REPEAT
c) Normal Lung
Normal lung = A lines (pleura) + batwing appearance + sliding
A ten-year-old boy (weight 30 kg) has a displaced distal forearm fracture that requires manipulation and application of plaster. The volume of 0.5% lidocaine that should be used for intravenous regional anaesthesia (Bier block) is:
a) 9ml
b) 12ml
c) 15ml
d) 18ml
e) 36ml
REPEAT
0.5% lidocaine = 5mg/ml
Max dose - 3mg/kg
30kg = 90mg max dose for this pt.
90/5=18mls of 0.5% solution
Therefore D.
In neonates, an imaginary line joining the most superior points of the iliac crests will cross the spinal interspace of:
a) L3-4
b) L4-5
c) L5-S1
d) S1-S2
c) L5-S1
https://www.nysora.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia/chapter34-spinal-anesthesia-preview/
A normal systolic arterial blood pressure in the awake term neonate is approximately:
a) 60
b) 70
c) 85
d) 90
REPEAT
70
Term 1 hr - 70
Term 12 hr - 66
Day 1 asleep - 70
Day 1 awake - 71
Week 2 - 78
Week 4 - 85
According to RCH term 3.5kg SBP normal range is 60-95.
https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/blood-pressure-disorders#goto-noninvasive-bp-measuring
A 10-year-old child (weight 30 kg) presents to the emergency department in status epilepticus. They have received one dose of 15 mg midazolam buccally prior to arrival to hospital. According to Advanced Paediatric Life Support Australia guidelines the next drug treatment should be intravenous:
a) Ketamine 15mg IV
b) Midazolam 4.5mg IV
c) Propofol RSI and burst suppression
d) Levetiracetam 1.2g IV
REPEAT
b) Midazolam 4.5mg IV
Status epilepticus is defined as:
- Continuous seizure activity for 5 minutes or more without return of consciousness,
- recurrent seizures (2 or more) without an intervening period of neurological recovery
So needs urgent treatment.
APLS (in order)
Midaz dose is 0.15/kg IV/IM or 0.3mg buccal/IN
After first dose, if still seizing, repeat midaz, IV/IO
Levetiracetam of phenytoin
Lev = 40-60mg/kg, phen = 20mg/kg)
RSI
1st line: Midazolam IV/IO/IM –> 0.15mg/kg
2nd line: Midazolam IV/IO/IM –> 0.15mg/kg
3rd line: Keppra 40mg/kg (max 3g)
4th line: Phenytoin 20mg/kg or phenobarbitone
5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone
A 5-year-old child with severe life-threatening anaphylaxis and no intravenous access, the recommended initial dose of intramuscular adrenaline is:
a. 100mcg
b. 150mcg
c. 300mcg
d. 500mcg
e. 600mcg
Repeat
b. 150mcg
Up to 6 years 150 IM
Over 6 years 300 IM
(ideally 10microg/kg)
Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min
Refractory management:
Additional IV fluid 20-40ml/kg,
Noradrenaline infusion 0.1- 2mcg/kg/min
Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV
The analgesic drug with the most favourable Number Needed to Treat (NNT) for neuropathic pain is:
a) Amitriptyline
b) Gabapentin
c) Tramadol
d) Pregabalin
e) Carbamazepine
REPEAT reconsidered as Amitriptyline
a) Amitriptyline
https://www.bjaed.org/article/S2058-5349(18)30073-8/fulltext#tbl1
APMSE 5th edition:
Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8)
Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain.
At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7)
Pregabalin
Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732);
* Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015);
* Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367);
* Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562).
Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6))
Amitriptyline
By order of favourable NNT:
- TCAs (amitriptyline) NNT: 3.6, NNH: 9
- Strong opioids NNT 4.3 NNH 11.7
- Tramadol NNT: 4.7, NNH 12.6
- SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
- Gabapentin NNT: 7.2 NNH 25.6
- Pregabalin NNT:7.7, NNH 13.9
ANZCA Pain book
Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:
- First line: pregabalin, gabapentin and amitriptyline;
- Second line: tramadol and lamotrigine (in incomplete SCI);
- Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
- Fourth line: TENS, oxycodone and dorsal root entry zone lesions.
The main difference between a size 5 microlaryngeal tube (MLT) and a standard size 5 endotracheal tube is that the size 5 MLT:
A. Smaller cuff
B. Longer length
C. Larger external diameter
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).
A new antiemetic reduces the risk of post-operative vomiting by 20%. In a population with a baseline risk of post-operative vomiting of 10%, the number needed to treat is:
a. 2
b. 5
c. 10
d. 20
e. 50
AT
REPEAT
(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
A 30-year-old athlete undergoing a knee arthroscopy under general anaesthesia
develops intraoperative tachycardia. A 12-lead electrocardiogram is obtained and
shown below. The most likely diagnosis is:
a) AF
b) Flutter
c) AVNRT
d) Multifocal atrial tachycardia
AT
Repeat
Delta waves present, therefore WPW = AVRT
WPW + delta wave = AVRT → anatomical re-entry circuit (Bundle of Kent)
AVNRT is a functional re-entry circuit within the AV node
ECG features of AVNRT
● Regular tachycardia ~140-280 bpm
● Narrow QRS complexes (< 120ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
● P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF. They may be buried within, visible after, or very rarely visible before the QRS complex
https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
Analysis of variance (ANOVA) is a statistical test to determine:
a) The validity between an expected and observed outcome in a population
b) The difference between the means of more than two populations
c) The difference between two populations with non-parametric data
d) The degree of similarity of the median between two or more populations
e) If the variance within a population is likely to be abnormally or normally distributed
REPEAT
B) analyse the difference between the means of more than two groups
When performing a brachial plexus block at the level of the axilla, the structure indicated by the arrow is the:
a) Musculocutaneous
b) Radial
c) Ulnar
REPEAT
A third heart sound at the apex may be heard in:
a) Healthy people aged less than 40
b) Mitral prolapse
c) HTN
23.1 OPTIONS:
a) pulmonary stenosis
b) pulmonary hypertension
c) pericarditis
d) pregnancy
AT
Repeat
Can occur in healthy young people
The third heart sound is mainly created by the early-diastolic rapid distension of the left ventricle that accompanies rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow
S3 may be normal in people under 40 years of age and some trained athletes but should disappear before middle age. Re-emergence of this sound late in life is abnormal[5] and may indicate serious problems such as heart failure.
‘Sounds like Ken-tu-cky’
In pulmonary function testing the presence of airflow limitation is defined by a post- bronchodilator FEV1/FVC ratio less than:
a) 0.5
b) 0.6
c) 0.7
d) 0.8
c) 0.7
The 12-lead electrocardiogram shown is most consistent with acute total occlusion
of the:
a) LAD
b) PDA
c) OM
d) RCA
a) LAD
Am I missing something? I can’t see total occlusion of anything here.
Wellens syndrome- Lad
https://litfl.com/wellens-syndrome-ecg-library/
A 70-year-old patient booked for a revision total hip replacement is reviewed in preadmission clinic ten days before surgery. The following blood test results are
noted:
haemoglobin 110 g/L
ferritin 51 mcg/L
CRP (c-reactive protein) 10 mg/L
The most appropriate management for this patient should be to:
a Transfuse 2u pRBC
b Give oral iron therapy and continue with surgery
c Give oral iron therapy and defer surgery for 6 weeks
d Give IV iron
e Do nothing
c Give oral iron therapy and defer surgery for 6 weeks
IV Iron is probably best, however all in agreement that surgery should be delayed making C the correc t choice based on guidlines accepting the flaws in oral iron therapy
https://www.blood.gov.au/module-2-perioperative-patient-blood-management-guidelines
Iron therapy
Oral iron in divided daily doses. Evaluate response
after 1 month. Provide patient information
material.
IV iron if oral iron contraindicated, is not tolerated
or effective; and consider if rapid iron repletion
is clinically important (e.g. <2 months to non
deferrable surgery).
NOTE: 1 mcg/L of ferritin is equivalent to 8–10 mg
of storage iron. It will take approximately 165 mg of
storage iron to reconstitute 10 g/L of Hb in a 70 kg
adult. If preoperative ferritin is <100 mcg/L, blood
loss resulting in a postoperative Hb drop of ≥30 g/L
would deplete iron stores.
In patients not receiving preoperative iron therapy,
if unanticipated blood loss is encountered,
150 mg IV iron per 10g/L Hb drop may be given
to compensate for bleeding related iron loss
(1 ml blood contains ~0.5 mg elemental iron
Footnotes
1 Anaemia may be multifactorial, especially in the elderly or in those with chronic disease, renal impairment,
nutritional deficiencies or malabsorption.
2 In an anaemic adult, a ferritin level <15 mcg/L is diagnostic of iron deficiency, and levels between
15–30 mcg/L are highly suggestive. However, ferritin is elevated in inflammation, infection, liver disease and
malignancy. This can result in misleadingly elevated ferritin levels in iron-deficient patients with coexisting
systemic illness. In the elderly or in patients with inflammation, iron deficiency may still be present with
ferritin values up to 60–100 mcg/L.
3 Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal
women) should be evaluated by gastroscopy/colonoscopy to exclude a source of GI bleeding, particularly a
malignant lesion. Determine possible causes based on history and examination; initiate iron therapy; screen
for coeliac disease; discuss timing of scopes with a gastroenterologist.
4 CRP may be normal in the presence of chronic disease and inflammation.
5 Consider thalassaemia if MCH or MCV is low and not explained by iron deficiency, or if long standing.
Check B12/folate if macrocytic or if there are risk factors for deficiency (e.g. decreased intake or absorption),
or if anaemia is unexplained. Consider blood loss or haemolysis if reticulocyte count is increased. Seek
haematology advice or, in presence of chronic kidney disease, nephrology advice
The QRS axis of the attached electrocardiograph is closest to:
a) -90
b) -45
c) +45
d) +90
VICTORIA
B
https://litfl.com/super-axis-man-sam/
In septic shock, the recommended target mean arterial pressure in an adult is:
a) 50 mmHg
b) 55 mmHg
c) 60 mmHg
d) 65 mmHg
VICTORIA
Surviving Sepsis 2021 guidelines
D
Kate The nerve marked by the arrow is the:
REPEAT
Axillary Nerve
