24.1 Flashcards

Question

The intrinsic muscles of the larynx do NOT include: a) Cricothyroid b) Suprahyoid c) Transverse arytenoid d) Cricoarytenoid

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

d) CT British Heart Rhythm Societies guidelines

Answer 6

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

Answer 7

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)

Answer 8

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

Answer 9

a) 40 40; if 50 was there the answer would be 50 NAP 6 says CPR if SBP<50mmHg ANZAAG says 50mmHg

Answer 10

A - Adductor Pollicis - Usual site for NMT Correct on ASA website

Answer 11

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

Answer 12

Add picture of peng block (can’t from my account) a) Psoas Tendon (This)

Answer 13

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)

Answer 14

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

Answer 15

a) Blue/ White Blue and white shoulder White bottle Pre 2004 made cylinder is blue

Answer 16

C Neoresus 10-30mcg/kg

Answer 17

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

Answer 18

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)

Answer 19

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

Answer 20

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 (either vastus medialis or vastus lateralis), 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.

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

Greater occipital

Answer 26

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

Answer 27

20-30 mins ANZCA PG43a

Answer 28

Atrac - histamine release is bad. more Mastocytosis Info would be good

Answer 29

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

Answer 30

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

Answer 31

c) Erector spinae

Answer 32

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

Answer 33

b) Intravascular Volume Common Adverse Effects - genital infections (eg vulvovaginal candidiasis, balanitis) - polyuria - dysuria - UTI - dyslipidaemia - hypoglycaemia (when used with a sulfonylurea or insulin) - increased haematocrit - constipation - nausea - thirst - renal impairment, eg increased serum creatinine (related to volume depletion, generally occurs early in treatment and is reversible) Australian Medicines Handbook

Answer 34

NAOMI 72 hours ANZCA Blue Book 2023 Oral naltrexone should be stopped at least 24 hours and ideally 72 hours prior to elective surgery. And there is a lack of instruction re Contrave- so best to stop 72 hours prior. And limited evidence re low dose naltrexone for chronic pain - so for consistency blue book says 72 hours. Caution increased opioid sensitivity in patients using perioperative naltrexone.

Answer 35

B Thiopentone BJA article 2018 Propofol infusions have been associated with a brugada like ECG. https://www.brugadadrugs.org/avoid/

Answer 36

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

Answer 37

c) Low BSL, hyperkaelamia, hyponatraemia Adrenal crisis is a medical emergency and should be considered in any patient presenting with one or more of the following symptoms: * altered consciousness * circulatory collapse * hypoglycaemia * hyponatraemia * hyperkalaemia * seizures * history of steroid use/withdrawal * any clinical features of Addison disease Adrenal crisis may be precipitated by stress, sepsis, dehydration or trauma; clinical features may be modified accordingly. In patients with known adrenal insufficiency, nonadherence with therapy, inappropriate cortisol dose reduction or lack of stress related cortisol dose adjustment can cause adrenal crisis. Aus Family Physician - RACGP

Answer 38

Bupivicaine Avoid - Lignocaine/lidocaine - Prilocaine Considering the specificity of patients with G6PD deficiency, attention should be given to the choice of local anesthetic, because for instance lidocaine and prilocaine are not recommended, while bupivacaine is shown to be safe to use. Management of Anesthesia and Perioperative Procedures in a Child with Glucose-6-Phosphate Dehydrogenase Deficiency J Clin Med. 2022 Nov Also avoid methylene blue (prev Q) Could only find - don't give lignocaine - can give bupivacaine Also found don't give articaine, prilocaine or benzocaine https://cdho.org/factsheets/glucose-6-phosphate-dehydrogenase/#:~:text=Local%20anaesthetic%20agents%20(e.g.%2C%20prilocaine,9%20in%20G6PD%20deficient%20persons.

Answer 39

a) its 50ml/kg bolus Resistant Hypotension * Additional IV fluid bolus 50 mL/kg * Continue Adrenaline Infusion * Add second vasopressor * Consider CVC * TOE/TTE * Cardiac bypass/ECMO if available Adult Recommendations - Additional IV fluid bolus 50 mL/kg - Noradrenaline Infusion 3 – 40 mcg/min (0.05 - 0.5 microg/kg/min) and/or - Vasopressin bolus 1– 2 units then 2 units per hour - If neither available use either Metaraminol or Phenylephrine - Infusion Glucagon 1– 2 mg IV every 5 min until response: draw up and administer IV (Counteract β blockers) Anaphylaxis during Anaesthesia Refractory Management ANZAAG-ANZCA guideline Also useful; resistant bronchospasm * Consider: - Oesophageal intubation - Circuit malfunction - Airway device malfunction - Tension pneumothorax * Continue Adrenaline Infusion * Add alternative bronchodilators Adult Recommendations Salbutamol * Metered Dose Inhaler 12 puffs (1200 microg) * IV bolus 100-200microg +/- infusion 5-25microg/min Magnesium 2 g (8 mmol) over 20 minutes Consider Inhalational Anaesthetics and Ketamine

Answer 40

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)

Answer 41

d) Supreme Classic has the internal bands that need cutting ? iGel clearly used for direct intubation. I can't see anything about "direct intubation" with the supreme but can find via bougie and aintree exchange. Auragain allows: The Ambu® AuraGain™ (Ambu A/S, Ballerup, Denmark) is a new anatomically curved, single-use supraglottic airway device launched in June 2014, that features an integrated gastric access port and direct intubation capability using a standard endotracheal tube ideally guided by a flexible videoscope. Proseal can't find anything Supraglottic airway devices as conduits for tracheal intubation There are a number of SGAs that allow direct passage of an adult-sized ETT, including the LMA Fastrach™, the LMA Classic Excel™, the LMA cTrach™ (LMA™ North America, Inc., San Diego, CA, USA), the Air-Q™ (Mercury Medical®, Clearwater, FL, USA), the Ambu® Aura-i™, the Ambu® AuraOnce™ (Ambu Inc. Glen Burnie, MD, USA), the i-gel™ (Intersurgical Ltd., Liverpool, NY, USA), and the Elisha airway device (Elisha Medical Technologies, Ltd., Katzrin, Israel).4-9 An adult ETT can be placed directly into the trachea via these SGAs, either blindly or with bronchoscopic guidance. However, these SGAs designed for intubation may not be readily available in the operating room,10 and many anesthesiologists are not familiar with using them as stand-alone airways or intubating devices. https://link.springer.com/article/10.1007/s12630-012-9714-8 (its old from 2012 but lists classic as a no. There are other SGAs in which passage of an adult full-sized ETT into the trachea may be problematic, including the LMA Classic™, the LMA-Unique™, the double lumen SGAs (i.e., the LMA ProSeal™ and LMA Supreme™), and other SGAs. While they do not permit direct ETT intubation, these SGAs are readily available in the operating room and are commonly used as a stand-alone airway device. The small internal diameter (ID) of the airway lumen in these SGAs prevents an adult full-sized ETT (7.0 mm or larger) from passing through. In addition, the length of the ETT may be too short to reach mid-trachea (Fig. 1). This increases the risk of vocal cord compression and dislodging when the SGA is removed.1-3,11,12 In this case, the use of introducers or catheters is necessary to achieve tracheal intubation. In this article, we review the use of the following devices: 1) an Aintree Intubation Catheter, 2) a guidewire catheter, 3) a gum elastic bougie, and 4) a small ETT. Many extraglottic airway devices allow the direct passage of an adult-sized tracheal tube, but this is not possible with the LMA-Supreme(TM) . We evaluated the feasibility of using the LMA-Supreme(TM) as a conduit for intubation in patients with known difficult airways. CJA 2012 - supreme requires use of guidewire/AIC/fibrescope

Answer 42

Albumin MELD uses the following parameters: - Bilirubin - INR - Creatinine - [Hyponatraemia] ○ Part of the MELD-Na score update in 2016 ○ Sodium (Na) Values < 125 are set to 125 and values >137 are set to 137 4 MELD levels are: - >/=25 (gravely ill) - 24-19 - 18-11 - 15 should avoid elective surgery Calculation: MELD = 3.8*loge(serum bilirubin [mg/dL]) + 11.2*loge(INR) + 9.6*loge(serum creatinine [mg/dL]) + 6.4 MELD-Na = MELD + 1.32 * (137-Na) - [0.033*MELD * (137-Na)]

Answer 43

repeat: Sheehans https://www.uptodate.com/contents/post-dural-puncture-headache Complications of PDPH 1. Chronic Back pain 2. Hearing loss 3. Acute onset headache consider pneumopcephalus headache 4. Persistent headache 5. Increased risk of subdural haematoma 6. postpartum depression 7. bacterial meningitis 8. Reversible cerebral vasoconstriction syndrome (RCVS) 9. Posterior reversible encephalopathy syndrome (PRES)

Answer 44

REPEAT with slightly reworded answers A is safest answer. Previous iterations of this Q have been controversial. NSAIDs technically safe in first trimester, but not in third (post 32 weeks) as can cause premature duct closure. a. Not safe or 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 45

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

Answer 46

Fetal bradycardia No idea - commonest sign is pv bleeding and fetal brady (non specific) and both answers are there! Mentioned on MELB course that foetal Brady

Answer 47

D do spine imaging if CSF leak present do lumbar blood patch

Answer 48

STEPH a) Anterior spinal artery syndrome Anterior spinal artery syndrome usually includes tracts in the anterior two-thirds of the spinal cord, which include the CSTs, the spinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control. CST involvements produce weakness and reflex changes. A spinothalamic tract deficit produces the bilateral loss of pain and temperature sensation. Tactile, position, and vibratory sensation are normal. Urinary incontinence is usually present. Dorsal cord syndrome results from the bilateral involvement of the dorsal columns, the corticospinal tracts, and descending central autonomic tracts to bladder control centers in the sacral cor. Dorsal column symptoms include gait ataxia and paresthesias. CST dysfunction produces weakness that, if acute, is accompanied by muscle flaccidity and hyporeflexia and, if chronic, by muscle hypertonia and hyperreflexia. Extensor plantar responses and urinary incontinence may be present. A single anterior and two posterior spinal arteries supply the spinal cord. The anterior spinal artery supplies the anterior two-thirds of the cord. The posterior spinal arteries primarily supply the dorsal columns. The anterior and posterior spinal arteries arise from the vertebral arteries in the neck and descend from the base of the skull. Various radicular arteries branch off the thoracic and abdominal aorta to provide additional blood supply to the spinal arteries.The largest and most consistently present of these radicular branches is the great ventral radicular artery or the artery of Adamkiewicz, which supplies the anterior spinal artery. Up To Date

Answer 49

STEPH b) 0.9% Normal Saline Hypernatraemia is classified as: Mild (146-149 mmol/L) Moderate (150-169 mmol/L) Severe (≥170 mmol/L) --> stem not hypernatraemia Head Injury - Isotonic fluids (eg NaCl 0.9% recommended) IV Fluids Glucose 5% should be given in maintenance fluids for children with no other source of glucose --> likely enteral fed in this setting **Also note: do not give hypotonic fluid - Do NOT give glucose 4% with sodium chloride 0.18% - Sodium chloride 0.45% solutions are only rarely indicated RCH Guidelines - Hypernatraemia - Head Injury - IV fluids

Answer 50

D) increase expiratory time Reworded repeat, but prev options don't directly align with these Low respiratory rates - Short inspiratory time, long expiratory time (decreases time in which there is a high intrathoracic pressure) - Low PEEP - Tidal volumes: 5-6mL/kg --> allows adequate pulmonary blood flow, normocarbia, low PVR Avoid CHAOS (hypercarbia, hypothermia, acidosis, hypoxia, SVR drop) Ideally spontaneous ventilation Patients who have undergone the Fontan procedure depend on blood flow through the pulmonary circulation without the assistance of the right ventricle. The difference between central venous pressure and systemic ventricular end-diastolic pressure (termed the “transpulmonary gradient”) is the primary force promoting pulmonary blood flow and, more importantly, cardiac output. Circulation in the Fontan patient is promoted by low pulmonary vascular resistance. Positive-pressure ventilation with increased tidal volumes, as described above, can result in excessive intrathoracic pressures, leading to decreased venous return to the heart and increased pulmonary vascular resistance. In periods of low oxygen saturation, 100% inspiratory oxygen is appropriate. The addition of PEEP will increase intrathoracic pressure, reducing venous return. Trendelenberg positioning would increase CVP and therefore bloodflow through pulmonary circulation. BJA: fontan circulation: For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure. https://academic.oup.com/bjaed/article/8/1/26/277637

Answer 51

STEPH c) Ask surgeon to release gag Summary of Management of Lost Ventilation During Pediatric Tonsillectomy * Manual ventilation with 100% oxygen, assessing compliance and leaks * Ask surgeon to release mouth gag * Bolus of propofol 2–3 mg/kg * Consider LMA malposition, bronchospasm, circuit or filter problem, laryngospasm * If no other cause apparent, assume laryngospasm and give suxamethonium 1–2 mg/kg as soon as SaO2 falls * Lung recruitment breaths as SaO2 improves * Deepen anesthesia, continue surgery SIMS A Guide to Paediatric Anaesthesia

Answer 52

REPEAT b. 60 BJA Article - Management of cardiac arrest following cardiac surgery - BJA Education In the CICU, the effectiveness of ECC is confirmed by monitoring the arterial pressure trace with a target compression rate and depth to achieve a systolic impulse of > 60 mm Hg to maintain a mean perfusion pressure, preventing ventricular distension, LV wall stress, and ischaemia.

Answer 53

c) Ventilate and wean bypass *Failure of oxygenation I think wean bypass and ventilate - thoughts? Asked about this at the Melbourne course - indicates failure of the oxygenator so agree ventilate and wean bypass, replace oxygenator. Steph.

Answer 54

A) Nasopharyngeal Proximity to brain Consistent correlation with core and brain temperature changes Accessibility Oxygenator blood temp represents temp of blood leaving circuit and doesnt reflect blood perfusing the brain Clinical Techniques in Cardiovascular and Thoracic Surgery: This textbook discusses the monitoring of cerebral temperature during CPB and often cites nasopharyngeal temperature as a standard method due to its proximity to the brain. Reference: Sabik, Joseph F., et al. "Temperature management and monitoring during cardiopulmonary bypass." In: Clinical Techniques in Cardiovascular and Thoracic Surgery, edited by Little Brown and Company, 1998. Perfusion: This journal article discusses various techniques for monitoring cerebral temperature during CPB, emphasizing the use of nasopharyngeal temperature probes. Reference: Zollinger, Andreas, et al. "Temperature Management and Monitoring During Cardiopulmonary Bypass." Perfusion, vol. 18, no. 1, 2003, pp. 3-9. doi:10.1191/0267659103pf582oa.

Answer 55

A) Anterior mitral leaflet RV is an anterior structure hence anterior leaflet

Answer 56

REPEAT c) Cease clopidogrel for 5 days, continue aspirin - prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis - For clopidogrel, we stop five days before surgery - Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting - suggest that surgery be performed in centers with 24-hour interventional cardiology coverage UP TO DATE: Noncardiac surgery after PCI Nonemergency noncardiac surgery — For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we prefer to defer planned nonemergency, nonurgent noncardiac surgery until at least six months after stent implantation. The risks of noncardiac surgery before six months are increased after both BMS and DES. For patients whose surgery requires cessation of one or both antiplatelet agents and cannot wait six months, and where the risks of delaying surgery outweigh the benefits, our recommended minimal duration of DAPT is four to six weeks, depending on the urgency of surgery and risk of thrombotic complication. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES. Although we prefer to wait at least six weeks when possible, in patients for whom earlier surgery is in their best interest after weighing risks and benefits, we sometimes refer patients as early as four weeks after stent placement. The proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT and regardless of stent type during this early period after stenting. We believe this risk to be higher prior to the minimum duration of DAPT recommended above, but the final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and patient has taken place. In many cases, DAPT can be continued in the perioperative period, although for some surgeries, such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis. In these patients who undergo noncardiac surgery before the recommended minimum duration of DAPT, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. The rationale to continue aspirin comes in part from the POISE-2 trial (PCI subgroup analysis), which is discussed separately. However, as many neurosurgical patients, for whom bleeding might be life threatening or lead to severe adverse outcomes, were not enrolled in POISE-2, the optimal strategy is not known. ●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy. ●With regard to stopping P2Y12 inhibitor prior to noncardiac surgery, we generally follow recommendations found in the manufacturer's package insert for each drug. - For clopidogrel, we stop five days before surgery; that is, the last dose is taken on the sixth day before surgery. - For prasugrel, we stop seven days before surgery. - For ticagrelor, we stop three to five days before surgery. - Some experts are willing to recommend shorter discontinuation periods for procedures less likely to be associated with major bleeding. ●Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting. ●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage

Answer 57

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.

Answer 58

REPEAT e. 1:136,000 https://www.bjanaesthesia.org/article/S0007-0912%2817%2930746-8/fulltext 1/670 E-LSCS 1/8000 with muscle relaxation 1/8600 CTS 1/8200 Volatile + neuromuscular blocking Overall 1:19000

Answer 59

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

Answer 60

REPEAT c) Normal Lung Normal lung = A lines (pleura) + batwing appearance + sliding

Answer 61

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

Answer 62

REPEAT c) Allow the eye to proptose Orbital Compartment Syndrome The orbital compartment is a fixed space with limited capacity for expansion. If something like blood fills part of that space the pressure increases and may result in ischaemia of the optic nerve or the retina. A lateral canthotomy is a way of releasing this pressure. You have up to approximately 2 hours before irreversible visual loss occurs. It may occur in less than 2 hours however, so speed is of the essence. use local anesthetic but warn the patient that they may feel pain Perform the canthotomy: place the scissors across the lateral canthus and incise the canthus full thickness Perform cantholysis: Grasp the lateral lower eyelid with toothed forcepsPull the lower eyelid anteriorlyPoint the scissors toward the patient’s nose, place the blades either side of the lateral canthal tendon, and cut. By cutting the canthal tendon,the counter pressure of the eyelid on the is relieved and the eye is allowed to proptose and pressure is relieved. LITFL Goal of procedure: to release pressure on the globe & to decrease intraocular pressure enough to reinstitute retinal artery blood flow. The canthotomy allows trhe eye to move forward and open up the space, reducing pressure. The globe itself should not swell.

Answer 63

B) Metoprolol Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) recommend beta-blockers as a first-line therapy for rate control in atrial fibrillation. Reference: January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019;140(2)

Answer 64

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.

Answer 65

d) Proceed ANZCA PG07 appendix 1 - Chewing gum and boiled sweets should be discarded prior to inducing anaesthesia to avoid them being Inhaled as a foreign body but do not constitute an indication for delaying any procedure unless they have been ingested. Therefore D

Answer 66

REPEAT b) transfuse for Hb >100 Emergency fixation means there is no time for an exchange transfusion perioperative goals: - planning and optimisation - ensuring adequate O2 delivery - hydration - analgesia - performed at a centre with a multidisciplinary sickle cell team Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD. Exchange transfusion vs. top-up transfusion Exchange Transfusion: - slowly removing the person’s blood and replacing with fresh donor blood or plasma - Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body - in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30% - Exchange transfusion removes HbS and increases HBA Top-up transfusion: - standard transfusion process of giving donor blood - advantages of simple top-up include: 1. Increase oxygen carrying capacity 2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA) 3. Prevent or reverse complications of vast-occlusion 4. Can be given acutely - disadvantages include: 1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l) 2. HbS is not removed, only diluted

Answer 67

c) L5-S1 https://www.nysora.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia/chapter34-spinal-anesthesia-preview/

Answer 68

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

Answer 69

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

Answer 70

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

Answer 71

4 x 15 = 60mg

Answer 72

REPEAT c) Reduced due to increased volume of distribution and clearance 2010 Paper on major burns The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution. BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns. Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized. https://pubmed.ncbi.nlm.nih.gov/20510522/

Answer 73

REPEAT 1,500 mL immediately OR 200 mL/hr in the first 2-4 hours

Answer 74

D) pneumothorax From BJA 2016 lung US article The features of a pneumothorax are abolished sliding, absence of B lines, absence of the lung pulse, and presence of the lung point Extra info from BJA The US feature of Intersititial syndrome is B lines. These are artifacts generated by the juxtaposition of alveolar air and septal thickening (from fluid or fibrosis). Their characteristics are Occasional B lines can be seen in normal lungs (especially at the bases). Up to two between two adjacent ribs can be considered normal. Three or more between rib spaces (or close together in a transverse image) are pathological

Answer 75

AT - 1 hour 1.2.3 Time of lumbar drain placement to systemic intravenous heparinization should be greater than 60 minutes Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains Guidelines from the Society for Neuroscience in Anesthesiology and Critical Care ASRA: 1 hour Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted. Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits. NYSORA: Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Answer 76

REPEAT e. Increased risk of non fatal cardiac arrest POISE II * clonidine 200mcg per day - did not reduce the rate of composite outcome of death or nonfatal MI - but it increased the risk of clinically important hypotension and nonfatal cardiac arrest * aspirin initiation or continuation – no significant effect on rate of composite of death or non fatal MI but increased risk of major bleeding Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest POISE 2 TRIAL

Answer 77

A) esmolol They get anti impulse therapy which usually starts off with beta blockade before alpha blockade. Up to date: Patients often present with severe hypertension and are initially stabilized with fast-acting, intravenous beta blockers (eg, esmolol or labetalol) or calcium channel blockers. Anti-impulse therapy lowers blood pressure

Answer 78

KATE Catastrophizing Page 24 APMSE In children 8-18 yrs old "parent pain catastrophising" was main risk factor for development of CPSP Significance of each risk factor varies with operation but pre existing psych factors (high state anxiety and pain magnification as a component of catastrophising) increases the risk across two types of surgery (TKR+Breast CA surgery)

Answer 79

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: 1. TCAs (amitriptyline) NNT: 3.6, NNH: 9 2. Strong opioids NNT 4.3 NNH 11.7 3. Tramadol NNT: 4.7, NNH 12.6 4. SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 5. Gabapentin NNT: 7.2 NNH 25.6 6. Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: * First line: pregabalin, gabapentin and amitriptyline; * Second line: tramadol and lamotrigine (in incomplete SCI); * Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; * Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 80

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

Answer 81

Nikki: B) Opioid induced hyperalgesia; The key features are long case with Remi running, as well as increased pain following additional opioids. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.13602

Answer 82

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

Answer 83

B) prothrombinex. Prothrombinex product information states don’t give if hx of HITS PROTHROMBINEX CONTAINS HEPARIN

Answer 84

REPEAT d) Reduced time to resumption of oral intake The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy https://pubmed.ncbi.nlm.nih.gov/15979735/ Conclusion: Preoperative dexamethasone use significantly reduces early posttonsillectomy pain, improves oral intake and facilitates meeting the discharge criteria while using standard anesthesia technique and sharp dissection tonsillectomy without any significant side effects.

Answer 85

REPEAT b) 250mcg IM q15mins, up to 2mg 15-methyl-PGF2α (carboprost; Prostinfenem) which may be administered in one of two ways: Intra-muscular injection of 0.25mg, in repeated doses as required at intervals of not less than 15 minutes to a maximum total cumulative dose of 2.0mg (ie up to 8 doses) Source RANZCOG PPH Guideline 2021

Answer 86

B) 15mg 50mg x0.3 Tapentadol Conversion at 0.3 Tramadol conversion at 0.2 Oxycodone 1.5 Hydromorphone 5 Buprenorphine patch mcg/hr@2 Fentanyl patch mcg/hr @3 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 87

REPEAT AT - Rocuronium Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 by Sadleir et al (This paper was referenced in NAP 6 "Cross-sensitivity, based on skin testing and specific IgE, is common, with suxamethonium being the most commonly crossreacting drug (Sadleir 2013).") Fig 4 shows Rates of cross-reactivity for patients diagnosed with anaphylaxis according to the triggering NMBD. - for sux anaphylaxis: highest cross-reactivity was roc (24%), then interestingly vec and cis were both tied at 12%, as were panc and atrac at 6% PREVIOUS NOTES: BJA Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 https://academic.oup.com/bja/article/110/6/981/245571 Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium. Anaphylaxis rates (highest to lowest) Primary anaphylaxis: rocuronium > atracurium > vecuronium > pancuronium = cisatracurium Cross-reactivity: suxamethonium > rocuronium > vecuronium > pancuronium > atracurium > cisatracurium

Answer 88

REPEAT b. serum separating tube (gold top tube or red) Potassium EDTA (purple) -> FBC sodium citrate (blue) -> clotting screen/Rotem sodium oxalate (green) -> heavy metals (lead copper zinc)

Answer 89

REPEAT 4 hours As per Lifeblood Start the transfusion as soon as possible after removing the blood component from approved temperature-controlled storage. Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. Redcross: "Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. " Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously) FFP: Once FFP is thawed, must use within 24 hours. Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org) Cryoprecipitate Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused. Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.

Answer 90

AT a) TRALI Both TACO and TRALI are characterised by: - hypoxia - acute dyspnoea - diffuse bilateral infiltrates However, presence of fever is more in keeping with TRALI. Reference: Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Skeatea and Ted Eastlund

Answer 91

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).

Answer 92

AT REPEAT C. 30cmH2O (c.f. 60cmH20 for same question but for LMA cuff pressure) References (a bit old now): "Guidelines1,2 recommend a cuff pressure of 20 to 30 cm H2O. Inflation of the cuff in excess of 30 cm H2O damages the tracheal mucosa by compromising capillary perfusion. When pressures are greater than 50 cm H2O, total obstruction of tracheal blood flow occurs.3 In rare instances, massive overinflation of the cuff may lead to acute complications such as tracheal bleeding or rupture.4 " - from Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation by Lizy et al 2014 Whereby: 1 American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171(4):388–416. 2 Lorente L, Blot S, Rello J. Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J. 2007;30(6):1193–1207. https://link.springer.com/article/10.1007/s10877-020-00501-2

Answer 93

AT - REPEAT a. Electromyography of internal laryngeal muscles True - the NIM-EMG tube tests RLN function via EMG of the muscles wiki: Notably, the only muscle capable of separating the vocal cords for normal breathing is the posterior cricoarytenoid. If this muscle is incapacitated on both sides, the inability to pull the vocal folds apart (abduct) will cause difficulty breathing. Bilateral injury to the recurrent laryngeal nerve would cause this condition. It is also worth noting that all muscles are innervated by the recurrent laryngeal branch of the vagus except the cricothyroid muscle, which is innervated by the external laryngeal branch of the superior laryngeal nerve (a branch of the vagus). Anaesthesia: Nerve Integrity Monitor tubes for thyroid surgery (2014) Recurrent laryngeal nerve function should be monitored during thyroid surgery [1], either by direct observation of vocal cord function during surgery [2], which can be difficult, or by electromyography (EMG), during which electrodes are placed adjacent to the vocal cords to detect motion when the laryngeal nerves are stimulated. Electrodes can be secured to the outside of a tracheal tube so that they come into contact with the vocal cords during intubation [3]. Indeed, electrodes have been embedded into the material of the tracheal tube (Medtronic Nerve Integrity Monitor (NIM) Standard Reinforced EMG Endotracheal Tube, Medtronic Xomed Inc., Jacksonville, FL, USA), albeit leading to an increase in bulk and external diameter in comparison with equivalent internal diameter tubes (Fig. 2). The size and rigidity of the NIM tubes mandate oral tracheal intubation rather than nasal intubation, which itself is further inhibited by the positioning of cable attachments for the electrodes along the tube's length. http://smpp.northwestern.edu/bmec66/weightlifting/emgback.html An electromyography (EMG) is a measurement of the electrical activity in muscles as a by product of contraction. An EMG is the summation of action potentials from the muscle fibers under the electrodes placed on the skin. The more muscles that fire, the greater the amount of action potentials recorded and the greater the EMG reading. http://www.shanahq.com/main/content/reliable-technique-make-nim-tube-work-preview The specialized endotracheal tubes (ETT), such as Xomed and TriVantage Nerve Integrity Monitoring (NIM) ETTs (Medtronic Xomed Inc., Jacksonville, FL USA) allow for RLN identification through continuous intraoperative EMG monitoring of the laryngeal muscles. https://www.aana.com/newsandjournal/Documents/jcourse1_0410_p151-160_rev2.pdf The Medtronic NIM electromyographic (EMG) endotracheal tube (Medtronic Xomed) is constructed of a flexible silicone elastomer and has a distal inflatable cuff. The tube is fitted with 4 stainless steel wire electrodes (2 pairs) that are embedded in the silicone of the main shaft distance, slightly superior to the cuff. The electrodes are designed to make contact with the patient’s vocal cords to facilitate EMG monitoring of the RLN when connected to a multichannel EMG monitoring device. If monitoring correctly, the EMG monitor should show a consistent sound signal and an action potential tracing. J Anaesthesiol Clin Pharmacol: The neural integrity monitor electromyogram tracheal tube: Anesthetic considerations (2013) When attempting to identify LNs, a stimulating electrical current of 0.5-2.0 mA is used by the surgeon. This current is administered via a sterile probe, which is placed directly on the anatomical site in question. Additionally, return electrodes are positioned in the skin above the sternum. When a LN is located, an electrical signal is subsequently generated by the motion of the vocal cords. An audibly recognizable “machine gun click” is then produced from the device's associated monitor. This sound has a set frequency of 4 times/s (4 Hz). Simultaneously, an oscilloscope-like screen displays an identifiable sinusoidal response.

Answer 94

AT - Two sets of pads, <1 second apart (OR - Two sets of pads, <5 seconds apart) Following 3 standard shocks for refractory VF Two defibrillators are used to provide sequential defibrillation with pads oriented in anterio-lateral and anterior posterior The shocks are delivered near-simultaneously - Anteriolateral first - Then Anterioposterior DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial DSED: For paramedic services randomized to DSED, paramedics will apply a second set of defibrillation pads in the anterior-posterior configuration (Fig. 1) Application of the second set of defibrillation pads for the second defibrillator will occur during the 2-min cycle of CPR following the third defibrillation attempt, minimizing any interruptions in CPR. All subsequent defibrillation attempts will be carried out by sequential defibrillation shocks provided by two defibrillators. To ensure that shocks are not administered at the exact same moment, we will employ a short (less than 1 s) delay to provision of the second defibrillator shock. This will be accomplished by having a single paramedic pressing the “shock” button on each defibrillator in rapid succession as opposed to simultaneously. This technique will be performed across all sites when randomized to the DSED arm to maintain consistency in application within the trial. NOTES ON PREVIOUS QUESTION 23.1 For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 95

Nikki A) cold saline irrigation Intraoperative seizures have a higher incidence of transient motor deterioration and longer hospital stays.[10] First-line treatment should be irrigation of the brain with sterile iced saline. Propofol bolus (10 to 20 mg IV) or midazolam (1 to 2 mg IV) should be administered to terminate the seizure if iced saline is ineffective. https://www.ncbi.nlm.nih.gov/books/NBK572053/

Answer 96

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

Answer 97

AT REPEAT b) Hypoxia Hypoxia Local anaesthetics are bases with pKa above physiological pH. The more alkalaemic the environment the more unionionised (B) form there is – which will speed diffusion across plasma membrane = can exert Na+ channel blockade. https://www.bjanaesthesia.org/article/S0007-0912(17)38238-7/pdf https://academic.oup.com/bjaed/article/15/3/136/279390 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087022/ Hypoxia – metabolic acidosis = ion trapping = increased toxicity Alkalaemia = prevents ion trapping in tissues (intralipid can work) = reduced toxicity High a1GP = reduced free fraction (a1gp high affinity, low capacity) = reduced toxicity Low CO2 = alkalosis = prevents ion trapping in tissues (intralipid can work) = reduced toxicity Carnitine deficiency = increased toxicity, therefore increased carnitine will reduce toxicity https://pubmed.ncbi.nlm.nih.gov/19849674/ a. Hypoxia - Yes b. Alkalemia - No - acidosis causes increased ionised fraction due to its weak base properties c. High α1-acid glycoprotein - No, normally bound to alpha-1 acid glycoprotein d. Hypocarbia < (decreased seizure threshold) - No - hypercarbia increases CNS blood flow and increases risk of seizures due to more LA delivered to CNS e. Increased carnitine levels -s - Never heard of it

Answer 98

a) Non inferiority graph (line crossed the 0 line but not non-inferior dotted line) NIKKI

Answer 99

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/

Answer 100

REPEAT B) analyse the difference between the means of more than two groups

Answer 101

Draw please

Answer 102

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'

Answer 103

REPEAT D. Adductor Canal unclear phenomonenon prolonged exposure and high concentrations of local anaesthetic

Answer 104

REPEAT a) Critical appraisal PICO is a mnemonic used to describe the four elements of a good clinical foreground question: P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine? I = Intervention - What main intervention, prognostic factor or exposure am I considering? C = Comparison - Is there an alternative to compare with the intervention? O = Outcome - What do I hope to accomplish, measure, improve or affect?

Answer 105

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/

Answer 106

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

Answer 107

REPEAT b. Unstable angina UTD: Unstable angina (UA) and acute non-ST elevation myocardial infarction (NSTEMI) differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins): ●UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischemia (eg, ST segment depression or transient elevation or new T wave inversion). ●NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present. MINS: Myocardial injury after non-cardiac surgery (up to 30 days post-op): 1. Elevated postop troponin 2. Resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), not requiring an ischaemic feature (i.e. no chest pain, no ECG change) VISION studies (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) demonstrated that severity of MINS strongly associated with 30-day mortality after NCS. hs-cTnT <20ng/L ~ 0.5% 30 day mortality 20-64ng/L ~3% 30 day mortality 65-999 ng/L ~9% 30 day mortality >1000ng/L ~30% 30 day mortality Whilst VISION trial identified MINS in at risk patients, the question now becomes what interventions are available to prevent this complication?

Answer 108

VICTORIA B https://litfl.com/super-axis-man-sam/

Answer 109

VICTORIA Surviving Sepsis 2021 guidelines D

Answer 110

REPEAT b. Octreotide 50mcg bolus Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small. It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 111

A) vasoplegia Vasoplegia is characterized by a normal or augmented cardiac output with low systemic vascular resistance (SVR) causing organ hypoperfusion. The exact definition has varied but typically is considered when shock occurs within 24 h of CPB in the setting of a cardiac index (CI) is greater than 2.2 L/kg/m2 and SVR less than 800 dyne s/cm5

Answer 112

REPEAT B) 02 consumptiom at rest One metabolic equivalent (MET) is the amount of oxygen consumed while sitting at rest, equal to 3.5 mL O2 per kg body weight × min

Answer 113

A) 8cm ANZCOR: In patients with an ICD or a permanent pacemaker the defibrillator pad/paddle is placed on the chest wall ideally at least 8 cm from the generator position

Answer 114

REPEAT C) Increased PVR Initial - may lead to burns shock Increased SVR (by 200%) Increased PVR Increased capillary permeability- loss of intravascular volume/Increased interstitial oedema Reduced CO SIRS By day 5 hyperdynamic circulation Tachycardia Increased CO (remains for at least 2 years maybe longer)

Answer 115

MAYANK - found some options for you! Steph ? Options c) Desaturation Total spinal anesthesia has been reported in neonates. It is most commonly manifested by apnea with no change in systemic blood pressure or heart rate, although should pronounced bradycardia occur, a reduction in cardiac output is likely and should be treated aggressively. It can occur after a dose of as little as 0.6 mg/kg of tetracaine. Alteration in position, particularly by raising the lower body above the level of the head or thorax, may be the most common cause of a high spinal block. Although the rate of administration of the local anesthetic does not appear to affect the level of spinal anesthesia in adults, similar studies have not been conducted in neonates or infants. It is possible that factors, such as the use of a relatively large-bore needle (22-gauge) and a tuberculin syringe providing the means for injecting with high pressure, along with the small distance between vertebrae, combines to make the rate of injection an important consideration in neonates and infants by producing unintended barbotage. We have observed this complication with rapid drug administration. Management consists of assisted or controlled ventilation until the return of spontaneous respiratory function. Cote. Practice of Anesthesia for Infants and Children, A, Seventh Edition - confirmed by QCH consultant **I initially thought b) Decreased BP Significant changes in blood pressure are uncommon in pediatric patients after the accurate administration of epidural analgesia. A high sympathetic single-injection caudal block to T6 has been found to evoke no significant changes in heart rate, cardiac index, or blood pressure in children. Even when thoracic epidural block is combined with general anesthesia, cardiovacular stability is usually maintained in otherwise healthy pediatric patients. Therefore, hypotension should raise the suspicion of total spinal anesthesia and/or an intravascular injection leading to local anesthetic toxicity. After these complications are ruled out, other causes, such as hydration status, intravascular filling pressure, and inotropic state, and the depth of anesthesia should be assessed. NYSORA

Answer 116

REPEAT Hypoglossal (deviates to the affected side) Nerve injuries : (pressure neuropraxia) Lingual nerve injury (most common) RLN (most serious) Hypoglossal Glossopharyngeal Inferior alveolar Infra orbital Usually self resolve except for RLN

Answer 117

REPEAT Axillary Nerve

Answer 118

Hypovolaemia Normal for end diastole is 3.5 to 5.6cm Image https://thoracickey.com/cardiac-chambers/ PSAX End diastolic AREA: Hypovolemia <8cm2 Normal 8-14cm 2 Hypervolemia > 14cm2 IVSd and IVSs – Interventricular septal end diastole and end systole. The normal range is 0.6-1.1 cm. LVIDd and LVIDs – Left ventricular internal diameter end diastole and end systole. The normal range for LVIDd is 3.5-5.6 cm, and the normal range for LVIDs is 2.0-4.0 cm. LVPWd and LVPWs – Left ventricular posterior wall end diastole and end systole. The normal range is 0.6-1.1 cm. RVDd – Right ventricular end diastole. The normal range is 0.7-2.3 cm. Ao Root Diam – Aortic root diameter. The normal range is 2.0-4.0 cm. LA Diameter – Left atrium diameter. The normal range is 2.0-4.0 cm. The IVSd and IVPWd measurements are used to determine left ventricular hypertrophy, which is the thickening of the muscle of the left ventricle. LV hypertrophy is a marker for heart disease. In general, a measurement of 1.1-1.3 cm indicates mild hypertrophy, 1.4-1.6 cm indicates moderate hypertrophy, and 1.7 cm or more indicates severe hypertrophy. Hypovolaemia Normal for end diastole is 3.5 to 5.6cm

Answer 119

Pplat-PEEP driving pressure is defined as distending pressure above the applied Peep Required to generate Vt - key variable for optimisation when performing mechanical ventilation in ARDS - also Vt/CRS (Ratio of Tidal volume to static resp system compliance)