Crisis

Question 1

30yo NKDA open appendicetomy

1 min BP drops to 60, diff to vent, Vt 100mL

Question 2

CRM principles

Answer 2

1. Call for help early
2. Anticipate and plan
3. Set priorities
4. Leadership
5. Teamwork
6. Comm
7. Info
8. Attn
9. Distribute
10. Mobilse

Question 3

Anaphylaxis

Answer 3

150 microg - 7.5-20kg 5yo
300 microg - >20kg 6-12yp
500 microg - 12yo+

Community vs periop

graded approach to (2022)
volume resus
IV adrenaline

Severity grading
Mild 1- skin (46% none - NAP6)
2 - CVS comp
- 10-20mcg, 500mL
3 - severe hypotension/hypoxaemia
- sBP <60, SpO2 <90
- 50-100 microg, 1L
4 - Arrest 2L
- mostly PEA
- CPR start at sBP <50 in anaes pt

DDx

MCT
imm/ASAP, 1, 4, 24hrs

• Low output state –> worth continuing CPR

Skin testing
- provoke IgE reaction - wheal/flare
- wheal expansion = pos rxn

MR
Sux 1:2000
Roc 1:2500

1:20000 all grades anaphylaxis (CVN)

H2 extend H1 blockade

D Hill M&M

Question 4

ANAESTHETIC CRISIS / COMPLICATIONS– Anaphylaxis

[15B08] A 20 year old patient has been successfully resuscitated from suspected anaphylaxis.

Describe your immediate and longer term post crisis management. [18B02] xx (also 13A06, 05B07, 03B01)

Answer 4

ANZCA BP 2022
**IMMEDIATE mx post resus

**Post crisis mx

1. Steroids
   - 2nd mx post acute mx and pt stable
2. TRYPTASE
   - peak 15-120min post onset
   - t1/2 2hr
   - declines 3-6 hrs post onset
   - 24 hrs = reliable baseline
   - ASAP onset sx, 1, 4, 24
3. Monitor/environ
   - Grade 2-3 –> HDU/ICU
   - Grade 1/2 settled –> 6hr close mon
4. ## Referral

Repeat

Question 5

RESUSC, TRAUMA, CRISIS – Damage control resuscitation in severe trauma

[21B14] Discuss the principles of damage control resuscitation in severe trauma.

Answer 5

• maintenance of normothermia
• avoidance of excessive crystalloid administration
• permissive hypotension
• early MTP (massive transfusion protocol) and coagulation products
• early surgery and airway control
• administration of antifibrinolytic - tranexamic acid
• performance of tests to guide management including point of care (ROTEM/TEG/blood gas) and formal tests of coagulation and PLT counts.

PreHosp –> ED –> OT –> ICU

Triad
1. Permissive hypotension
2. Haemostatic resus
3. DCS

Aims
1. Cir vol
2. Cont haemorrhage
3. Correct lethal triad (hypothermia/coagulopathy/acidosis)

PHT
- Perm Hypo (sbp 80-90, map 50-60)
** bal perf and exsang **
- RESTRICT fluid (CSL>NS), pressors PRN
- blood product PAMPer

ED
- early transfusion (1:1:1)
(FFP:PLT) PROMMTT
- Antifibrinolytic (only if < 3hrs) - TXA
CRASH-2 MATTERs
- routine bloods + fibrinogen + ROTEM
- coag target
- Hb 70-90
- Fib conc 3-4g or cryo 50mL/kg
- Plt >50
- iCa 1.1-1.3
- FFP 10-15mL/kg if PT > 1.5
- Novoseven not first line
- normothermia
- AW - RSI
- - Reversal of antithrom
- –Warf –> PTX + vit K
- – dabigatran - idarucizumab + diluted TT
- – rivaroxaban / apixaban - anti-Xa, PTX
- –anti plt (PLT conc, desmopressin)

(73.1%) Discussion of the following points and the reasoning for their inclusion in resuscitation protocols for severe trauma would constitute a good answer:

• • maintenance of normothermia
• avoidance of excessive crystalloid administration
• permissive hypotension
• early MTP (massive transfusion protocol) and coagulation products
• early surgery and airway control
• administration of antifibrinolytic - tranexamic acid
• performance of tests to guide management including point of care (ROTEM/TEG/blood gas) and formal tests of coagulation and PLT counts.

The majority of candidates demonstrated an understanding of the principles of damage control resuscitation with better answers including the reasoning behind the physiological targets or goals.

There were some generic answers about the management of trauma that did not specifically address the question. These answers attracted lower marks.

Question 6

ANAESTHETIC CRISIS / COMPLICATIONS– Malignant Hyperthermia

[21A10] List the signs of malignant hyperthermia. (30%)

Outline the immediate management of a patient where malignant hyperthermia is suspected. (70%)

(also 16B08, 09A03)

Answer 6

MH
1. Early
a) EtCO2 / tachy
b) masseter spasm
c) arrhythmia

2. Developing
   a) TEMP
   b) acidosis
   c) HIGH K
3. Late
   a) Dark urine
   b) CK high
   c) Arrest

Imm Mx:
1. Dec Emergency
2. S F H
3. Delegate
4. MH box
5. Cease cause
a) off VA
b) remove vaporiser
c) change soda lime
d) hypervent

DAS - dant/anaes/supportive

DANTROLENE
2.5mg/kg q10-15min (10mg/kg max)

20mg amp + 60mL WATER

Anaesthesia
PROPOFOL TIVA

Supportive

(21A10 = 67.3%) A rare anaesthetic emergency where the early recognition and the correct immediate management can save lives. All practicing anaesthetists should be across the signs and immediate management of malignant hyperthermia.
Candidates are referred to http://malignanthyperthermia.org.au for further reading and are encouraged to familiarise themselves with their own institutions’ Malignant Hyperthermia Box locations and contents.

(16B08 = 83.6%) The borderline answer should have good coverage of the signs of MH but especially tachycardia, hypercarbia, and metabolic acidosis. Immediate management includes (a) Cessation of triggers (b) Monitoring (c) Dantrolene (d) Resource management (e) Supportive treatment eg Hyperkalemia, cooling. We feel that this question requires a high level of competence so expect discussion of the above.

Question 7

LAST

MH

drug dose

Answer 7

LAST
Intralipid
1. 1.5mL/kg
2. 15ml/kg/hr
up to 30

MH
Dantrolene
2.5mg/kg q10-15min up to 10mg/kg

Question 8

ANAESTHETIC CRISIS / COMPLICATIONS– Failure to wake

[19B15] A 16-year-old girl has failed to wake from anaesthesia following posterior instrumentation for severe idiopathic scoliosis.

Discuss the potential causes and management of her failure to wake. (also 15A09, 05A07)

Answer 8

Potential cause
Anaes/pt/surg

Mx
1. Switch off agents
2. ABCDE
3. Review hx
4. Reversal
- BZD - flumazenil 200 –> 1000microg
- Opioids - naloxone 80 –> 800

(61.8%) The examiners were looking for a systematic approach to the patient described in the question.

Those answers that did this and included the relevant and likely causes in a ** prioritised fashion** and then demonstrated a similar approach to correctly managing the situation scored well.

Candidates are reminded to answer questions in the context of the given scenario not in general terms. Answers containing factually correct information written out of context and not directly answering the question will attract poor marks.

Question 9

ANAESTHETIC CRISIS / COMPLICATIONS– OT Fire

[19B08] Your patient is midway through a laparoscopic cholecystectomy. You smell smoke and can see flames in the room adjacent to your theatre. Describe your management of this situation.

Answer 9

Triangle

1. Fuel
   - drapes/etoh sol/ETT
2. Ignition
   - Diathermy/Laser/Defib in O2
3. Oxidant
   - O2/N2O

Imm
- early recog
- comm
- remove fuel
- remove ox
- ext fire

Subs
- further pt care - bronch/burns
-failure to ext fire = RACE protocol
Rescue
Alert
Confine
Extinguish

More on fire:

PREVENTION
1. Low O2
2. Saline near site/ign source
3. TIVA
4. Laser ET

Post crisis mx:
1. Material damage
2. Burns mx
3. RCA
4. LT fu

MAK95
OHST

(39.7%) The majority of answers to this question fell short of the minimum standard required.
The question required an answer demonstrating a sensible approach to patient and staff safety.

This would include
raising the alarm,
evaluation of the immediate risk posed by the fire,
the ability of staff to fight and
contain the fire and
the assessment of the requirement for patient and staff evacuation with consideration of the ongoing surgery.

The RACE protocol is a useful tool to assist in structuring an answer to this question.

Fire safety and evacuation procedures are mandatory staff training in hospitals and it is expected that candidates are familiar with procedures that may be required in their daily working environment, particularly if this type of emergency occurs mid- surgery.

Question 10

ANAESTHETIC CRISIS / COMPLICATIONS– Anaphylaxis

[15B08] A 20 year old patient has been successfully resuscitated from suspected anaphylaxis.

Describe your immediate and longer term post crisis management. [18B02] xx (also 13A06, 05B07, 03B01)

[13A06] A fit 37-year-old female presents for laparoscopic appendicectomy. She reports a “severe allergic reaction” during her a laparoscopy 5 years ago. There were no tests performed and the records are not available.

a. Outline your strategy for managing this case. (70%)

b. List the investigations that are recommended following any suspected anaphylaxis and when they should be performed. (30%)
(also 18B02, 05B07, 03B01)

Answer 10

Imm mx post resus of anaphylaxis
1. early ix
2. Monitor at ICU - biphasic rxn
3. Discussion with pt

TRYPTASE (via SST)
1. Imm
2. 1
3. 4
4. 24

LT mx
- referral to allergy testing/letter to GP/M&M / bracelet

Suspected anaphylaxis

cardiac arrest rhythm = PEA

GL: ANZCA ANZAAG 2022

(82.6%) The borderline standard needed to include:
- Appropriate blood investigations – serial Tryptase – demonstrates knowledge of correct time frames and trends - Mention of an ongoing appropriate environment and monitoring.
- Referral for allergy testing – demonstrates and understands time frame, etc
- Communication for patient eg. interim letter to GP pre-discharge, updated final letter, etc

(37.1%) Key components of an answer for this question related to
1. demonstration of a logical approach including: History of previous episode; allergic risk/tendency; discuss with surgeon; inform
patient of likely risks; make low risk plan for this case including drug choice’s; monitoring and contingency plans if problems.
2. serum levels of reaction / anaphylaxis markers [histamine; tryptase]; skin testing and timing of all.

Question 11

ANAESTHETIC CRISIS / COMPLICATIONS– Residual NMB

[17B07] A patient in the post anaesthesia care unit is suspected of having residual neuromuscular blockade.

a) List ways to assess this patient for the presence of residual neuromuscular blockade. (30%)

b) Discuss methods to reduce the risk of residual neuromuscular blockade. (70%)

Answer 11

A)
Assess NMB
1. Clinical
2. PN stimulation
a) TOF
b) DBS
c) Single twith
d) PTC

The above measured by:
MADE - mechano/accelero/direct/EMG

B)
Reduce risk
1. NMBA choice
2. Intraop PNS
3. Reversal
4. Comm w surgeon
5. Avoid NMBA

(74.8%) Most candidates answered this well. A borderline answer needed to mention ways to assess residual blockade including clinical and neuromuscular transmission stimulators/monitors as well as an appropriate strategy regarding muscle relaxants used, monitoring of relaxation, and reversal agents.

(55%) Key components of a response to this question included:
Part (a) Part (b)
- complications such as airway obstruction/hypoxia and its
- causes/aspiration/increased length of stay in PACU/hospital
- clinical tests (head lift/grip strength/tidal volumes) and their reliability - tactile/mechanical methods: levels of discrimination and limitations
- objective monitors – accelerometers/force transducers
- sensitivity of various methods

Question 12

ANAESTHETIC CRISIS / COMPLICATIONS– Frothy secretions in PACU

[16B04] A 55-year-old male is in the post-anaesthetic care unit after nasal surgery. He is conscious, dyspnoeic and is coughing up frothy secretions.

List your differential diagnosis and

how this would direct subsequent management.

Answer 12

Frothy secretions = ** APO + Obstruction**

APO: Hx/Ex/Ix
Hx - CCF
Ex - CVS
Ix - CXR, ECG, TTE

Obstruction: Hx/Ex/Ix
throat pack, blood clots
ENT ex

(44.7%) Borderline answer includes:
- Most likely causes: pulmonary oedema, obstruction (e.g. throat pack, clots)
- Subsequent management: appropriately recognises and manages** APO and obstruction**

Question 13

ANAESTHETIC CRISIS / COMPLICATIONS– Intra-arterial injection

[15B07] A drug has been unintentionally administered through a radial arterial line in an awake patient.

Describe your management of this situation.

Answer 13

IA injection –> substance –> spasm –> ischaemia and thrombosis

Mx
1. ID drug - thio is the WORST
2. Perfusion distal to injury
3. Useful of IAL
4. Analgesia
5. Other
-Consideration/ mx/ f/u

Bad drugs IA:
1. Ketamine = necrosis
2. Atrac/amio/roc = ischaemia
3. Phenytoin/thio = all the bad stuff
4. PPF = hyperaemia, distal blanching

(50.3%) A borderline answer was expected to consider the need to identify drug and potential for damage and to recognise the usefulness of maintaining the intra-arterial catheter.
Some recognition of immediate and long term clinical features/complications/disease process was also looked for. A structured approach to management including 1. maintaining perfusion, 2. considering anticoagulation and 3. use of analgesia was expected.

Question 14

ANAESTHETIC CRISIS / COMPLICATIONS– Awareness

[15B05] A 61 year old woman is scheduled for total laparoscopic hysterectomy. She has had an episode of awareness under anaesthesia during previous laparoscopic surgery.

a) What are the risk factors for awareness? (30%)

b) How would you minimise this patient’s risk of awareness during her operation? (70%)

Answer 14

RF for awareness
Pt/Surg/Anaes

Pt
1. Younger adults
2. Obesity
3. Diff AW
4. Previous AAGA

Surg
1. Emergency
2. Obs / NROS / cardiac / thoracic
3. Time of day - evening / night

Anaes
- NMBA use
- Junior anaes

(80.1%) Comment:
- In Part A the borderline candidate was expected to recognise the most common risk factors for awareness e.g. neuromuscular blockade,
specific surgical procedures, total intravenous anaesthesia and previous episodes of awareness.
- In Part B, the borderline standard expected was for candidates to show some consideration of the previous episode and potential factors
involved and to address key risk factors.

Question 15

Awareness 2 - cause and evidence

[12B15] Classify the possible causes for patient awareness under general anaesthesia. (70%)

Evaluate the evidence for the use of Bispectral Index monitoring in reducing the risk of awareness. (30%)

Answer 15

Causes of awareness
1. Pt
2. Human
3. Equip

BIS trials
1. 2014 metanalysis
- BIS dec awareness by 75% in high risk pts

2. 2015 BJA Sculler
   R: BIS to 44 after NMB in 10 fully awake volunteers

(50.3%) Key components of a response to this question related to:
1) Classification of causes
- patient factors (inability to tolerate adequate anaesthesia, increased requirements due to altered PK or PD)
- human factors (errors of omission, programming, distraction, inattention)
- equipment related (calibration, malfunction, disconnection, misuse)-case or context related (emergency, instability)
2) Evaluation of BIS
- evidence basis for this monitor compared with others (for total intravenous anaesthesia and for inhalational anaesthesia) - evidence for the monitor in high risk cases
- evidence for the monitor in combination with others.

Question 16

ANAESTHETIC CRISIS / COMPLICATIONS– PONV

[15A02] a) List the risk factors for postoperative nausea and vomiting (PONV) (30%)

b) Evaluate methods to minimise PONV (70%)

Answer 16

PONV def
N/Retch/V 24-48hr post op inpt

30 - 80%

Issues
1. Pt dissat 2. Delay PACU d/c
3. Risk of suture dehis/asp/rupture/electrolyte dist

RF - pt/surg/anaes

pt - female/previous PONV/age
anaes surg - VA/N2O, periop opioid

PONV RF (apfel)
Baseline risk 20%
1. Female
2. Non-smoker
3. Postop opioids
4. Previous PONV

1. ID 2. Prevent 3. Treat
2. ID - apfel
3. PRevent by risk strat
   - mod - 1-2 rx
   - high - 2+ intervention
   multifactorial = multimodal

Anaes
- non VA - IMPACT study –> dec PONV risk by 25% TIVA > VA

+ hydration + multimodal analgesia

3. Treat
   - ANTIEMESIS - as prevention

(58.5%) Candidates needed to include the following points
- A. List most of the RFs that have positive overall evidence . If items that are disproved are listed, candidates were marked down
- B. Understand role of risk stratification to ̄PONV (choosing appropriate methods) and considers/evaluate more than just antiemetics.
Background:

Question 17

ANAESTHETIC CRISIS / COMPLICATIONS– AMI in PACU

[14A06] A patient is complaining of central chest pain in PACU following femoro-popliteal artery bypass surgery. a) Outline the diagnostic criteria for acute myocardial ischaemia on an ECG? (30%)
b) Describe your management of acute myocardial ischaemia in PACU in this patient. (70%)

[11B14] A 70-year-old man has undergone radical prostatectomy under GA. On emergence he has crushing central chest pain, is restless, and has cold, clammy skin. His blood pressure is 90/50 mm Hg, pulse rate 110/minute and SpO2 is 95% on oxygen via a Hudson mask.
A twelve-lead ECG shows widespread ST segment elevation across the anterior chest leads.
a) Describe your immediate management. (50%)
b) What are the treatment priorities for this patient? (50%) (also 04A01)

Answer 17

ECG Dx AM Ischaemia (not infarct)
1. STE
2. TWI (1mm, 2 contig leads)
3. Q waves

Mx
1. Confirm via
a) 12 lead ECG
b) trops/Hb

2. OPTIMISE O2 supply/dmd

M - IV analgesia
O - spo2 > 95%
A - aspirin load
N - GTN if BP allow

(57.1%) Key components of an answer for this question related to:
- a description of ECG changes of ischaemia and NOT infarction
- a description of immediate “standard management” of infarction as well as managing issues specific to this pt [setting of vascular surgery, heparinisation, “normal” BP etc]

(39%) Key components of a response to this question included:
- Management should aim to treat the cause and minimise damage. The ECG and symptoms are diagnostic of myocardial ischaemia; consideration should also be given to
other causes of hypotension.
- Immediate management
o address myocardial oxygen supply and demand (oxygen delivery, coronary vasodilators, analgesia, antiplatelet agents, management of blood pressure), haemoglobin o confirm diagnosis: serial ECGs, serial blood tests (cardiac ensymes), CXR, echo
o monitoring, patient disposal
- Treatment priorities
o immediate management as above
o invasive evaluation
o reperfusion/revascularisation strategies; anticoagulation issues in the postoperative period

Question 18

ANAESTHETIC CRISIS / COMPLICATIONS– LAST

[13A14] You perform multiple intercostal blocks using 300mg ropivacaine for flail chest

a. What features would make you suspect systemic local anaesthetic toxicity? (50%)

b. How would you manage the situation? (50%) (also 06A09, 03B07)

Answer 18

IC > caudal/epi > TAP > BP > sci > s/cut

ADRENALINE
1mcg/kg NOT 1mg

3 reasons:
1. worsens acidosis (lower seizure threshold, impair cardiac contractility)

2. potentially that can worsen the local anesthetic moving into set to the cell (ion trapping)
3. proarrhythmogenic

LAST mx
1. GENERAL
ABC
Seizure - BZD (PPF/Thio negative ino)
Treat - hypotension/brady/tachy

2. SPECIFIC
   - intralipid 20%
   1.5mL/kg bolus
   15mL/kg/hr up to 30

• ECMO
• CPB

(67.3%) Key components of an answer for this question are: a. recognizing that this clinical scenario is a high risk for LA toxicity; acknowledging the potential for relative or absolute overdose; outlining symptoms/signs consistent with toxicity. b. general and specific therapy/supportive management for toxicity – intralipid use and willingness to support circulation for prolonged period [ECMO CPB] important.

Question 19

ANAESTHETIC CRISIS / COMPLICATIONS– ALS / Cardiac arrest

[11A06] A 60-year-old man is booked for plating of a fractured ankle. He arrests on induction. His ECG shows ventricular fibrillation. Outline the immediate management of his cardiac arrest with particular reference to current resuscitation guidelines. (also 07A13)

Answer 19

(55%) The current (2010) Australian or New Zealand resuscitation guidelines for this situation formed the basis for the answer to this question. A high standard was expected from Fellowship candidates. A flow diagram that simplified the presentation of information for this question was used by some candidates.

Question 20

ANAESTHETIC CRISIS / COMPLICATIONS– Cricothyroidotomy

[11A08]

(a) Describe the anatomy, including surface landmarks, relevant to performing cricothyroidotomy. (50%)

(b) What are the complications of this procedure? (50%)

Answer 20

Anatomy

Superior: thyroid
cartilaage

(55%) Key components included:
Part (a)
o description of the cricothyroid membrane: borders/dimensions
o thyroid cartilage/thyroid notch
o identification of the cricoid cartilage below the thyroid cartilage and the cricothyroid membrane in between o relevant anatomy: vocal cords/superior thyroid artery/cricothyroid arteries
o safe site and extension of the incision
Part (b)
o trauma to (nominated) blood vessels: arteries and veins
o vocal cord injury
o subglottic stenosis
o false passage (and sequelae; mediastinal emphysema/pneumothorax/airway obstruction)
o oesophageal perforation

Question 21

ANAESTHETIC CRISIS / COMPLICATIONS– Anaesthetic machine failure

[00B12] Half way during 2 level posterior spine fusion in a 75yo man with stable angina, the electronic anaesthetic machine diagnoses that it has an internal fault and without warning shuts all functions off including gas delivery, ventilation and monitoring. How will you manage this situation?

Answer 21

Issues:
1. Prone - limited access
2. Mid procedure - cant wake
3. Stable angina - corPP –> BP / ECG

(85%) Crisis management was usually satisfactorily managed, with the exception of explicit ‘finger on the pulse’ clinical monitoring when the instrument monitoring fails. No candidates suggested they could monitor intra-arterial pressure temporarily without an electronic monitor, by connecting the catheter to an aneroid manometer and displaying a mean pressure. Some candidates suggested they were unable to complete anaesthesia by relying on intravenous drugs without a gas delivery machine.