MCQ 2 Flashcards
- The likely complications of laparoscopy include:
A. pneumothorax
B. shoulder pain
C. gas embolism
D. aspiration
E. left bundle branch block
A. true B. true C. true D. true E. false The problems associated with laparoscopy are caused by: • Intra-peritoneal insufflation • Absorption of carbon dioxide • Positioning • The surgical procedure Respiratory effects These effects are due to the: • Pneumo-peritoneum • Use of carbon dioxide as the insufflation gas • Position of the patient The lung volumes are reduced, especially the functional residual capacity (FRC) due to displacement of the diaphragm cephalad, reduced chest wall dimensions and muscle tone with a reduced intrathoracic blood volume. These changes lead to atelectasis, pulmonary shunting and hypoxaemia. Increased airway pressures may result in: • Barotrauma and pneumothorax • Increased physiological dead space • Reduced lung compliance • Hypercarbia as carbon dioxide is absorbed • Endobronchial intubation as the carina moves cephalad Cardiovascular effects Secondary to pneumo-peritoneum, the effects of the GA and positioning are: • Increased systemic vascular resistance • Increased mean arterial pressure • Decreased pre-load leading to reduced cardiac output • Ischaemia due to alterations in supply and demand• Arrhythmias – These may be ventricular due to rise in carbon dioxide tension or vagally mediated due to peritoneal traction • Cardiac failure Additional problems are: • Acid aspiration and regurgitation • Deep vein thrombosis • Trocar injuries to bowel and bladder • Bleeding • Postoperative nausea and vomiting • Venous gas embolism • Burns and explosions
The likely results in an elderly, dehydrated man, breathing
room air with prolonged bowel obstruction include:
A. respiratory alkalosis
B. metabolic acidosis
C. hypoxaemia
D. uraemia
E. anaemia
A. true B. true C. true D. true E. false Bowel obstruction The clinical features of prolonged bowel obstruction include: • Vomiting, colicky abdominal pain, abdominal distension, absolute constipation (i.e. neither flatus nor faeces) • Dehydration and loss of skin turgor • Hypotension and tachycardia • Abdominal distension and increased bowel sounds • Empty rectum on digital examination • Tenderness or rebound indicates peritonitis
The following are observed in a patient with acute
tubular necrosis:
A. normal blood creatinine and high blood urea
B. excretion of small amounts of highly concentrated urine
C. hyperkalaemia
D. progressive increase in central venous pressure
E. casts in the urine
A. false B. false C. true D. true E. true
Acute tubular necrosis Acute tubular necrosis (ATN) accounts for 85% of the intrinsic causes of acute renal failure (ARF).
Causes • 50% are due to ischaemia • 35% are due to toxins – inflammatory mediators, aminoglycosides, paracetamol, heavy metals and myoglobin The thick ascending limb (TAL) of the Loop of Henle is particularly predisposed to ischaemia for two reasons. 1. Although total blood flow to the kidneys is very high (25% of cardiac output) the majority is directed to the renal cortex. Medullary blood flow is limited so that the concentration gradient of osmolarity is preserved. 2. Active ion pumps in the TAL are high oxygen consumersThe combination of poor blood supply and high oxygen demand leaves this section of the tubule very vulnerable to ischaemia. Plasma biochemistry • Rising urea and creatinine • A metabolic acidosis, with or without hyperkalaemia Urinary analysis Loss or tubular concentrating ability in intrinsic ARF results in urine and plasma that are iso-osmolar. Typical findings: • Oliguria 30ml/h of dilute urine • Urine osmolarity 350mosmol/l • Urine sodium 20mmol/l • Urine urea 150mmol/l • Urine specific gravity 1,010 • Ratio of urine to plasma osmolarity 1:2 • Ratio of urine:plasma creatinine 20 • Pigmented casts in urine
Platelet concentrates:
A. are viable for 2 weeks
B. must be filtered when administered
C. may cause significant histamine release
D. must be cross-matched
E. contain citrate
A. false B. true C. true D. false E. false ABO compatible platelet transfusions are desirable but not essential. Platelet concentrates contain small numbers of RBCs and leukocytes. They can be stored at 22C to 24C for 5 days but platelet function deteriorates after 48h. They are administered through a special filter, do not require cross matching, contain citrate as an anticoagulant and do not result in significant release of histamine.
- Dopaminergic receptor blockers:
A. decrease gastric emptying
B. decrease renal blood flow
C. relieve motion sickness
D. are used as anti-arrhythmics
E. are used to treat Parkinson’s disease
A. true B. true C. false D. false E. false
The following types of agents have been used:
• Phenothiazines – a group of anti-psychotic (neuroleptic) drugs have a limited role in the treatment of vomiting
• Butyrophenones – effective in the prevention and treatment, of postoperative nausea and vomiting
• Benzamides
• Metoclopramide used as an antiemetic and prokinetic drug
• Antagonism of peripheral D1 receptors resulting in vasoconstriction of renal and mesenteric vasculature
Injections of vitamin B12 are appropriate for patients
with anaemia due to:
A. Chron’s disease
B. a Vegan’s diet
C. epileptics on phenytoin
D. pregnancy
E. a gastrectomy
A. true B. true C. false D. false E. true Vitamin B12 is indicated in the following conditions:
• Individuals with pernicious anaemia
• Individuals with gastro intestinal disorders– Sprue, coeliac disease, regional enteritis, localised inflammation of the stomach or small intestine
• Partial and total gastrectomy when the antrum and intrinsic factor is lost
• Vegetarians who do not eat meat, fish, eggs, milk or milk products
The following are associated with aortic incompetence:
A. rheumatic arthritis
B. syphilis
C. Ankylosing spondylitis
D. Marfan’s syndrome
E. AIDS
A. true B. true C. true D. true E. false
Causes and associations of aortic regurgitation are:
○ Acute regurgitation causes
• Acute rheumatic fever
• Infective endocarditis
• Dissection of the aorta
• Ruptured sinus Valsalva aneurysm
• Failure of a prosthetic valve
○ Chronic aortic regurgitation
• Rheumatic heart disease
• Syphilis
• Arthritides: Reiter’s syndrome, ankylosing spondylitis and rheumatoid arthritis
• Severe hypertension
• Marfans’ syndrome
• Bicuspid aortic valve
• Osteogenesis imperfecta
Concerning fat embolism syndrome:
A. A petechial rash is essential for a certain diagnosis
B. A fall in haematocrit is characteristic
C. Mental changes may be due to hypoxia
D. There may be a pyrexia
E. It occurs more commonly in tibial fractures than femoral
fractures
- A. false B. false C. true D. true E. false
Fat embolism is most closely associated with fractures of the pelvis and long bones of the lower extremity.
○ Although injury is the main triggering factor leading to fat embolism syndrome, orthopaedic procedures such as hip arthroplasty and intra-medullary nailing for lower limb fractures may lead to the release of marrow fat into the circulation. Fat embolism may develop in any condition where there is potential for fat to be release into the circulation such as muscle injury and burns.
Of those patients who develop clinically evident fat embolism syndrome 20% show a fulminating course with mortality approaching 50%. The condition may occur at any age but it is most commonly seen in young males who are most at risk from serious trauma.
Clinical diagnosis
•PaO28kPa (60mmHg)
• Petechial rash
• Unexpected neurological signs Supportive changes
• Associated hypovolaemia and tachycardia
• Hypothermia
• Pyrexia
• Sudden reduction in haemoglobin
• Sudden onset of thrombocytopenia
• Increased erythrocyte sedimentation rate
• Fat globules in urine and sputum
• Retinal changes
Intraocular pressure is normally:
A. 1.0 to 2.0 kPa above atmospheric pressure
B. increased by hypercarbia
C. reduced by non-depolarising neuromuscular blocking drugs
D. reduced by enflurane
E. reduced by trimetaphan
A. true B. true C. true D. true E. true Normal pressure is 15 to 25mmHg. Once the eye is opened intra-ocular pressure (IOP) is equal to atmospheric pressure. IOP is increased by hypoxia, hypercarbia, coughing and vomiting. All volatile agents cause a dose related decrease on IOP due to decreased extra-ocular muscle tone and increased aqueous humour outflow. Etomidate and propofol reduce IOP and thiopentone reduces it but to a lesser degree. Ketamine increases IOP and causes blephorospasm and nystagmus. All non-depolarising drugs lower IOP. Suxamethonium increases IOP possibly by contraction of the orbital smooth muscle. A peak increase occurs at about 4min returning to normal by 6min
Pulmonary surfactant:
A. can be made synthetically
B. is found in amniotic fluid at full term
C. prevents alveolar collapse at low pressure
D. is made by type 1 pneumocytes
E. is a glycoprotein
- A. true B. true C. true D. false E. false Surfactant is a lipid surface tension lowering agent. Composition • Dipalmityl phosphatidyl choline 60%
• Phosphatidyl glycine 5%
•
Other phospholipids 10%
• Neutral lipoids 13%
• Proteins 8%
• Carbohydrates 2% Synthesis It is produced by type II alveolar epithelial cells (these are cuboid cells with large nuclei). Functions
• It lowers the surface tension in the alveoli, so increasing the compliance of the lungs and reduces the work of breathing
• Promotes alveolar stability
• Helps to keep the alveoli dry
A maxillary nerve block in the pterygopalatine fossa
gives anaesthesia of the:
A. upper molars
B. upper incisors
C. soft palate
D. anterior two-thirds of the tongue
E. anterior part of the nasal septum
A. true B. true C. true D. false E. true
The maxillary nerve passes through the foramen rotundum into the pterygopalatine fossa and via the fissure into the infra-temporal fossa and continues as the infra temporal nerve.
The maxillary nerve gives off numerous branches:
• Meningeal branches within the cranium (dura mater)
• Ganglionic branches within the pterygopalatine fossa (to the pterygopalatine ganglion
• Zygomatic branches within the pterygopalatine fossa divide into two branches – facial and temporal – to the cheek and temple
• Posterior superior alveolar nerve divides into branches within the pterygopalatine fossa which supply the maxillary sinus, maxillary molar teeth, cheek and gums
• Middle superior alveolar nerve – from the infra orbital nerve to the maxillary sinus and upper premolar teeth
• Anterior superior alveolar nerve from the infra orbital nerve to the maxillary sinus and canine and incisor teeth
• Intraorbital nerve divides into palpebral, nasal and superior labial branches
The following may contribute to acute renal failure
following abdominal surgery:
A. pre-existing upper respiratory tract infection
B. an induction dose of gentamycin
C. massive blood transfusion
D. endotoxaemia
E. obstructive jaundice
- A. false B. false C. true D. true E. true The possible causes of renal failure during the postoperative period are: Pre-renal • Hypovolaemia, inadequate pre-operative correction of third spaces losses, e.g. septicaemia, pancreatitis. These causesecretion of antidiuretic hormone (ADH), rennin and aldosterone and afferent arterial vaso-constriction • Low cardiac output • Hepato-renal failure associated with jaundice Renal • Old age • Pre-existing renal impairment • Renal ischaemia – thrombus or embolism • Hypoxia • Nephrotoxic drugs – NSAIDs, contrast media, gentamicin • Rhabdomyolysis • Hypercalcaemia, hyponatraemia Post renal • Ureteric obstruction by myoglobin, ligatures, fibrosis, tumours • Catheter – blocked
Air embolism is especially dangerous in the presence of:
A. atrial septal defect (ASD)
B. ventricular septal defect (VSD)
C. tetralogy of Fallot
D. aortic stenosis
E. coarctation of the aorta
- A. true B. true C. true D. false E. false The rise in pulmonary pressures associated with venous air embolism may predispose to a right to left shunting in any condition in which a communication exists between the systemic and the pulmonary circulations. This will result in a systemic air embolism. Such conditions are an ASD, VSD, PDA and a patent foramen ovale, which may be present in up to 35% of all individuals in autopsy studies and other complex cardiac anomalies.
Air embolism is especially dangerous in the presence of:
A. atrial septal defect (ASD)
B. ventricular septal defect (VSD)
C. tetralogy of Fallot
D. aortic stenosis
E. coarctation of the aorta
- A. true B. true C. true D. false E. false The rise in pulmonary pressures associated with venous air embolism may predispose to a right to left shunting in any condition in which a communication exists between the systemic and the pulmonary circulations. This will result in a systemic air embolism. Such conditions are an ASD, VSD, PDA and a patent foramen ovale, which may be present in up to 35% of all individuals in autopsy studies and other complex cardiac anomalies.
Bilateral hilar lymphadenopathy is a recognised
feature of:
A. pulmonary tuberculosis
B. Hodgkin’s disease
C. erythema multiformis
D. systemic lupus erythematosus (SLE)
E. pneumoconiosis
- A. true B. true C. false D. false E. false The differential diagnosis of bilateral lymphadenopathy includes – lymphoma, pulmonary tuberculosis, carcinoma of the bronchus and sarcoidosis (erythema nodosum).
The following can be derived from the blood gas analyser:
A. base excess
B. pH
C. PCO2
D. standard bicarbonate
E. actual bicarbonate
- A. true B. false C. false D. true E. true Blood gas analysers report a wide range of results, but the only parameters measured directly are: • The partial pressure of oxygen PO2 • The partial pressure of carbon dioxide PCO2 • Blood pHThe haemoglobin oxygen saturation (HbO2%) is calculated from the PO2 using the oxygen dissociation curve and assumes a normal P50 and that there are no abnormal forms of haemoglobin present. The actual bicarbonate, standard bicarbonate and base excess are calculated from the pH and PCO2 using the Siggard–Anderson nomogram. This normogram is derived from a series of in vitro experiments relating pH, PCO2 and bicarbonate. Anaesthesia and Intensive Care Medicine December 2002; 3: 474
In a patient with a healthy heart transplant undergoing
elective non-cardiac surgery:
A. a resting heart rate of 50 beats/min is normal
B. the cardiovascular response to laryngoscopy is absent
C. atropine will cause a tachycardia
D. isoprenaline is the chronotrope of choice
E. anti-rejection therapy should be stopped preoperatively
- A. false B. false C. false D. true E. false The heart is denervated and will therefore only respond to circulating catecholamine. If there is no extra adrenaline stimulus the heart rate will be about 60bpm. In the presence of adrenaline there will be a high resting rate, in the absence of a vagal inhibition. Typically 100 to 120bpm. A slowing heartbeat is a sign of rejection. The cardiovascular responses to laryngoscopy are still evident via the adrenal axis but they are often delayed. There is no vagal tone in the transplanted heart therefore atropine is ineffective as a chronotope. Isoprenaline is the drug of choice in a bradycardia. Anti-rejection therapy should be monitored. BJA 1990; 67: 772–778
Low molecular weight heparin:
A. activity is effectively measured by activated partial
thromboplastin time (APTT)
B. strongly binds to plasma proteins
C. has a longer plasma half-life than a standard heparin
D. has its effect reversed by an equivalent dose of protamine
E. has a prolonged plasma clearance in patients with renal failure
- A. false B. false C. true D. false E. true Low molecular weight heparins are derived from the depolymerisation of heparin by either chemical or enzymatic degradation. Compared to unfractionated heparin, low molecular weight heparins are more effective at inhibiting factor Xa and less effective at promoting the formation of the inactive “anti-thrombin – thrombin” complex. Advantages • Single daily dose due to a longer half-life • Less effective on platelets • Reduced affinity for von Willebrand factor• Reduced risk of heparin induced thrombocytopenia • Reduced need for monitoring coagulation Protamine is not fully effective in reversing the effects of low molecular weight heparin.
Kinetics • Administered subcutaneously once a day (bioavailability is 90% from the subcutaneous route)
• The half-life is 12h, which is 2 to 4 times longer than standard heparin
• Less protein bound than standard heparin
• Renal elimination and the t1/2 increases with renal failure
Low molecular weight heparin:
A. activity is effectively measured by activated partial
thromboplastin time (APTT)
B. strongly binds to plasma proteins
C. has a longer plasma half-life than a standard heparin
D. has its effect reversed by an equivalent dose of protamine
E. has a prolonged plasma clearance in patients with renal failure
Intrinsic (auto) positive end expiratory pressure (PEEP):
A. can be achieved by reversing the I:E ratio
B. does not result in air trapping when compared to
extrinsic PEEP
C. can be easily monitored in ITU patients
D. has the same effect as extrinsic PEEP on haemodynamic
values
E. requires an extra work of breathing to initiate a
spontaneous breath
- A. true B. false C. true D. true E. true Auto PEEPi (intrinsic PEEPi) is the difference between the alveolar pressure and the airway pressure at the end of expiration. It exists when expiration continues right up to inspiration (i.e. there is no expiratory pause). PEEPi occurs when there is: • An obstruction to expiratory flow – asthma, chronic obstructive ariway disease (COAD) • When the expiratory time is too short – rapid respiratory rate, prolonged inspiratory time Newer ventilators usually have a means of checking the PEEPi level. It is important to note that the value on the pressure dial of ventilators during expiration does not reflect the level of PEEPi in the lung. When beneficial, PEEP increases FRC by alveolar recruitment. This reduces pulmonary venous admixture and increases PaCO2 at any given FIO2. However PEEP may produce unpredictable effects especially if lung compliance is dyshomogeneous, as in pneumonia or volume-controlled ventilation. PEEP will increase peak airway pressure and may cause over distension of lung units, hence: • Barotrauma is a risk • Compression of vessels around distended alveoli may divert blood to underventilated regions, hence:– Increased physiological dead space– Worsen the shunt fraction– Increased pulmonary vascular resistance (PVR)
The effects of ecstasy (3,4-methylene
dioxymethamphetamine):
A. are dose related
B. include hyperpyrexia, hypercalcaemia and hyperkalaemiaC. are due to inhibition of 5-hydroxytryptamine (5-HT)
D. are due to drinking large amounts of water
E. include renal failure due to rhabdomyolysis
- A. false B. true C. false D. false E. true Ecstasy (3,4 methylenedioxymethamphetamine – MDMA) is an amphetamine derivative. MDMA causes the release of 5-HT, one of the neurotransmitters Paper 1 Answers 150 implicated in the control of mood. In primates it causes irreversible loss of serotonergic nerve fibres. 5-HT is a neurotransmitter triggering the thermoregulatory centre in the hypothalamus to increase body temperature. Acute effects include: • Empathy • Heightened alertness • Acute psychosis • Trismus • Tachycardia Positive effects tend to lessen with regular use while negative effects increase. The main problems in the management of these patients are: Acute toxicity Hyperthermia, muscle rigidity, obtunded consciousness and fitting. There appears to be no relationship between effects and the dose. A syndrome similar to malignant hyperpyrexia can occur with rhabdomyolysis, DIC and MOF. Rapid cooling and the use of dantrolene have been recommended if the core temperature is 40C. Drinking large amounts of water at raves to prevent dehydration causes dilutional hyponatraemia and cerebral oedema. Acute liver failure may occur due to either a reaction to ecstasy itself or a reaction to a contaminant. Hall. Ecstasy and Anaesthesia. BJA 1997 [Editorial]
The following arrest the heart in diastole:
A. hypercalcaemia
B. hyperkalaemia
C. acidosis
D. hypothermia
E. digitalis overdose
- A. false B. true C. false D. true E. false
Exposure to nitrous oxide 20% in oxygen for a
prolonged time causes:
A. sedation
B. respiratory depression
C. abdominal distension
D. leukopenia
E. vitamin B12 deficiency
- A. false B. false C. true D. true E. false Nitrous oxide affects vitamin B12 synthesis by inhibiting the enzyme methionine synthetase. This effect is of importance if the duration of the nitrous oxide anaesthesia exceeds 8h.Nitrous oxide also interferes with folic acid metabolism and impairs the synthesis of DNA. Prolonged exposure may cause agranulocytosis and bone marrow aplasia. Exposure of patients to nitrous oxide for 6h or longer may result in megaloblastic anaemia.
Occupational exposure to nitrous oxide may result in a myeloneuropathy. This condition is similar to sub acute combined degeneration of the spinal cord and has been reported in some dentist and in individuals addicted to the inhalation of nitrous oxide.
A pregnant lady who had an accidental dural tap
and presented with headache, photophobia and
hyperaesthesia of both lower limbs would be most
appropriately treated with:
A. reassurance and review in 2 h
B. neurosurgical consultation
C. emergency CT scan
D. epidural saline
E. epidural blood patch