Medication Flashcards
22.2 The diabetic medication that, as part of its therapeutic effect, significantly prolongs gastric emptying is
a) dulaglutide
b) sitagliptin
c) metformin
d) gliclazide
e) acarbose
a) dulaglutide
The primary mechanism of action of dulaglutide, as an incretin mimetic hormone or an analogue of human glucagon-like peptide-1, is to increase insulin secretion when glucose levels are elevated, decrease glucagon secretion, and delay gastric emptying in an effort to lower postprandial glucose level.
Acarbose:
Acarbose is a complex oligosaccharide that acts as a competitive, reversible inhibitor of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase.
Pancreatic alpha-amylase hydrolyzes complex carbohydrates to oligosaccharides in the small intestine
By delaying the digestion of carbohydrates, acarbose slows glucose absorption, resulting in a reduction of postprandial glucose blood concentrations.
-> causes delayed gastric emptying but is not necessarily a part of its therapeutic effect
20.1 Prolonged block post mivacurium
A)Sugammadex 4mg/kg
B)Neostigmine 100microg/kg
C)FFP 20ml/kg
D)Pralidoxime
E)Wait for it to wear off
E)Wait for it to wear off
> Neostigmine inhibits plasma cholinesterases (that could slow mivacurium metabolism), but effects are less than the inhibition of acetylcholinesterases, resulting in a “net” reversal of nondepolarizing block. Dose in stem inappropriate though.
> Administration of whole blood or FFP is not recommended unless there is another primary indication for the transfusion.
> In patients with homozygous pseudocholinesterase deficiency, will result in prolonged NMB; monitor and await.
22.1 A 74-year-old man presents for a femoral popliteal artery bypass procedure for peripheral limb ischaemia. Regarding its role in modifying his perioperative cardiovascular risk, clonidine
a. Increased stroke
b. No change in complications
c. Increased death
d. Increased non fatal MI
e. Increased risk of non fatal cardiac arrest
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
22.2 The medication most strongly associated with an acute primary hypotensive reaction following transfusion of blood products is
a. aspirin
b. celecoxib
c. hydralazine
d. metoprolol
e. labetalol
f. perindopril
f. perindopril
Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement.
Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).
22.2 A 45-year-old male received a heart transplant one month ago. He develops a new supraventricular tachyarrhythmia without hypotension during a gastroscopy. The most appropriate therapy is
a) Adenosine
b) Amiodarone
c) Digoxin
d) Esmolol
e) Verapamil
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.
23.1 The glucagon-like peptide-1 receptor (GLP-1) agonist semaglutide is associated with
A. delayed gastric emptying
B. hypoglycaemia
C. hyperlactataemia
a) delayed gastric emptying
22.1 A drug which does NOT increase the defibrillation threshold in a patient with an implanted cardioverter defibrillator is
a. Amiodarone
b. Atropine
c. B-blocker
d. Flecainide
e. Sotalol
e. Sotalol
Drugs that INCREASE defibrillation threshold:
+ Amiodarone (Chronic)
+ Atropine
+ lignocaine
+ Diltiazem
+ Flecainide
+ Verapamil
+ Venlafaxine
+ Anaesthetic agents.
Drugs that DECREASE defibrillation threshold:
- Sotalol
- Amiodarone (acute)
- Nifekalant
Drugs with No Change in DFT
= B- blocker
= Disopyramide
= Procainamide
= Propafenone
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304797/
22.1 The mechanism of action of tranexamic acid is to inhibit the formation of
a. Plasminogen
b. Plasmin
c. Fibrin
d. fibrinogen
b. Plasmin
Plasminogen activation results in increased conversion of plasminogen to plasmin, the latter an enzyme that breakdowns the fibrinogen in blood clots.
Tranexamic acid is a synthetic derivative of lysine that exerts antifibrinolytic effects by blocking lysine binding sites on plasminogen molecules, inhibiting the interaction of plasminogen with formed plasmin and fibrin.
As a result, inhibition of plasminogen activation results in stabilization of the preformed fibrin meshwork produced by secondary hemostasis.
23.1 In subarachnoid block for caesarean section, hyperbaric local anaesthetic compared to regular local anaesthetic has been shown to reduce the
a. Risk of total spinal
b. Analgesic properties
c. Onset of anaesthetic
d. Offset of anaesthetic
e. Chance of inadequate anaesthetic
reduce onset time
c) faster onset of anaesthetic
https://pubmed.ncbi.nlm.nih.gov/28708665/ agrees with faster onset but for non obstetric surgery
UTD
hyperbaric bupivacaine because of its rapid onset and the option to modify the spinal level by changing the position of the operating table. Plain bupivacaine (ie, slightly hypobaric, prepared in saline) may also be used for spinal anesthesia for CD. The literature comparing safety and efficacy of hyperbaric with isobaric bupivacaine for CD is inconclusive
20.1 IgE-related penicillin anaphylaxis crossover rate with cephazolin
a. 0.1%
b. 1%
c. 5%
d. 10%
1%
BJA ED
20.2 Idarucizumab reverses the anticoagulant effect of
a) Clopidogrel
b) Rivaroxaban
c) Dabigatran
d) Apixaban
e) Rivaroxaban
c) Dabigatran
Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran
Dabigatran bleeding may be treated with:
- idarucizumab
- haemodialysis
- TXA will decrease fibrinolysis and has some effect
- FFP also has some effect
Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding
- 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration)
- Limited data support administration of an additional 5 g
Dosage Modifications
Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required
Hepatic impairment: Not studied
Dosing Considerations
This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study
22.2 When used for prolonged analgesia in a healthy adult, the recommended maximum dose of ropivacaine via continuous infusion or bolus dosing in a 24-hour period is
a) 450mg
b) 600mg
c) 770mg
d) 1200mg
c) 770mg
Product info: Fresenius-Kabi
When prolonged epidural blocks are used, either by continuous infusion or repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses of up to 800 mg ropivacaine for surgery and postoperative analgesiaadministered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours.
product info: pfizer
When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Experience to date indicates that a cumulative dose of up to 770 mg ropivacaine hydrochloride administered over 24 hours is well tolerated in adults when used for postoperative pain management: i.e., 2016 mg. Caution should be exercised when administering ropivacaine for prolonged periods of time, e.g., > 70 hours in debilitated patients
21.2 Of the following drugs, the least likely to cause pulmonary vasodilation when used at low
doses in patients with chronic pulmonary hypertension is
a) Dopamine
b) Dobutamine
c) Vasopressin
d) Milrinone
dopamine
- least likely to cause pulmonary vasodilation (all the others do to my knowledge)
- From UP TO DATE:
> At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds
> At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate.
> At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min
*clinically, the haemodynamic effects of dopamine demonstrate individual variability
Dobutamine (inodilator):
- selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances
Vasopressin:
- vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect
Milrinone (inodilator):
- the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension
22.1 A 30-year-old parturient presents in labour. She has a history of Addison’s disease from autoimmune adrenalitis and has been taking prednisolone 6 mg daily for ten years. On presentation the patient is given hydrocortisone 100 mg intravenously. The most appropriate steroid replacement regimen the patient should receive during labour is
a. 25mg TDS hydrocortisone
b. 8mg/hr hydrocortisone
c. 6mg PO prednisone
8mg/hr
Guidelines for mx of glucocorticoids during the perioperative period for patients with adrenal insufficiency
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14963
23.1 The next patient on your endoscopy list is a 50-year-old woman who has been scheduled for gastroscopy and colonoscopy under sedation, after unsatisfactory
proceduralist-supervised midazolam and fentanyl sedation in the past. She states that she has egg anaphylaxis and carries an adrenaline (epinephrine) auto-injector.
The most appropriate agent to use for her sedation is
A. Propofol
B. Ketamine
C. Remifentanil
D. Sevofluarane
A
The situation in adults is straightforward: there is convincing evidence that propofol is safe in patients who are allergic to peanut and/or soy and/or egg.
BJA Ed
https://academic.oup.com/bja/article/116/1/11/2566111
21.2 The oral morphine equivalent of tapentadol 50 mg (immediate release) is
a) 5mg
b) 10mg
c) 15mg
d) 20mg
e) 25mg
c) 15mg
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
20.1 The substance that should be avoided in a patient with history of anaphylaxis to MMR vaccine is
a) Protamine
b) Penicillin
c) Sulphonamides
d) Gelofusine
gelofusin
Anaphylaxis after vaccination is probably due to anaphylactic sensitivity to gelatin or neomycin, not an egg allergy
22.2 A patient presents for endoscopic retrograde cholangiopancreatography (ERCP) with a history of previous post-ERCP pancreatitis. The management most likely to reduce the likelihood of pancreatitis is
a) Gentamicin
b) PR indomethacin
c) Creon post op
d) Preop smoking cessation
b) PR indomethacin
APMSE 5th edition 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. Epidural > PCA for severe acute pancreatitis
A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis
https://www.nejm.org/doi/full/10.1056/NEJMoa1111103
Nonsteroidal antiinflammatory drugs (NSAIDs) are potent inhibitors of phospholipase A2, cyclooxygenase, and neutrophil–endothelial interactions, all believed to play an important role in the pathogenesis of acute pancreatitis. NSAIDs are inexpensive and easily administered and have a favorable risk profile when given as a single dose, making them an attractive option in the prevention of post-ERCP pancreatitis. Preliminary studies evaluating the protective effects of single-dose rectal indomethacin or diclofenac in post-ERCP pancreatitis have been conducted, and a meta-analysis suggests benefit.
Results
A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03).
Conclusions
Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition.
The amount of intravenous potassium chloride required to raise the plasma potassium level from 2.8 mmol/L to 3.8 mmol/L in a normal adult is approximately
a. 10mmol
b. 20mmol
c. 30mmol
d. 100mmol
e. 200mmol
e. 200mmol
K+ < 3.0 mmol/L: 200-400 mmol of potassium are required to raise it by 1 mmol/L
K+ > 3.0 mmol/L: 100-200 mmol of potassium are required to raise it by 1 mmol/L
Hypokalaemia P. GLOVER
https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Publications/CCR Journal/Previous Editions/September 1999/05-Sept_1999_Hypokalaemia.pdf
If the serum potassium level is greater than 3 mmol/L, 100-200 mmol of potassium are required to raise it by 1 mmol/L; 200 - 400 mmol are required to raise the serum potassium level by 1 mmol/L when the potassium concentration is less than 3mmol/L, assuming a normal distribution between cells and the intracellular space, and a linear relationship between plasma potassium and body deficit (which has been described, i.e. 0.27 mmol/L/100 mmol deficit/70 kg), exists. The rate of administration of potassium will be influenced by the presence and seriousness of the pathophysiological changes caused by hypokalaemia. The underlying disorder should also be treated simultaneously.
22.2 A 48-year-old man is day two post-laparoscopic high anterior resection. He has used 42 mg of intravenous morphine in the past 24 hours. You wish to start him on oral tapentadol immediate release. The most appropriate equianalgesic dosage would be
a) 50mg six times a day
b) 100mg six times a day
c) 200mg six times a day
d) 300 mg six times a day
a) 50mg six times a day
42mg IV Morphine = 126mg Oral Morphine
126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)
Option 50mg 6 times a day = 300mg
As direct OME to tapentadol conversion is 400mg, a 300mg dose represents a 25% dose reduction, which is line with a 25-50% dose reduction due to incomplete cross-tolerance during opioid rotation.
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
23.1 The bioavailability of an oral dose of ketamine is approximately
A. 10%
B. 20%
C. 40%
D. 70%
E. 80%
B. 20%
25% (a few studies have higher ranges but typically around 20-25%)
https://doi.org/10.1192/bjp.bp.115.165498
20.1 The anti-emetic action of aprepitant is via receptors for
A. Serotonin
B. Neurokinin-A
C. Dopamine
D. Substance P
E. Glycine
D. Substance P
Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting (2011)
https://www.ncbi.nlm.nih.gov/pubmed/21434941
Aprepitant acts centrally at NK-1 receptors in vomiting centres within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy.
23.1 Of the following drugs, the LEAST suitable for managing atrial arrhythmias in a patient with a left ventricular assist device is
A. Metoprolol
B. Amiodarone
C. Digoxin
D. Diltiazem
d) diltiazem
Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673
Should also avoid sotolol
21.1 The main advantage of using norepinephrine (noradrenaline) over phenylephrine for the prevention of
hypotension as a result of spinal anaesthesia for elective caesarean section is
A. Better APGAR
B. Better foetal acid/base
C. Less nausea/vomiting
D. Less maternal bradycardia
less maternal bradycardia
21.1 The muscle or muscle group with the greatest sensitivity to the action of non-depolarising neuromuscular blocking agents is/are the
a. Abdominal muscles
b. Adductor pollicis
c. Pharyngeal muscles
d. Diaphragm
c. Pharyngeal muscles
Millers Anaesthesia:
Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and
An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.
20.2 A 46-year old man collapses unexpectedly and fractures his femur. He is booked for acute theatre. A pre-operative electrocardiogram is performed. Of the following, the most appropriate peri-operative medical management is (ECG shown)
ECG = WPW
a) Flecainide
b) Aspirin
c) Digoxin
d) Magnesium
e) Verapamil
a) Flecanide
WPW ECG = short PR, wide QRS, delta wave at start of QRS
If WPW, need to prolong refractor period of accessory pathway with agents such as procainamide/flecainide/amiodarone/sotalol.
Avoid verapamil (increases ventricular rate).
Avoid beta blockers (don’t affect accessory pathway).
https://litfl.com/wolff-parkinson-white-syndrome-ccc/
21.1 A 30-year-old woman, gravida 2, parity 1, undergoes an elective lower segment caesarean section for breech presentation. The international consensus statement on the use of uterotonic agents recommends that the first line uterotonic management is
a) 1unit
b) 1 unit followed by infusion 2.5-7.5 Units/hr
c) 3 units
d) 3 units followed by infusion
Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h (0.04–0.125 IU.min)
EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h (0.125–0.25 IU.min).
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14757
22.1 The first-line drug recommended by both the Australian Resuscitation Council and the New Zealand Resuscitation Council to treat severe cyanide poisoning is
a. Methylene blue
b. Hydroxycobalamine
c. Sodium thiosulfate
hydroxycobalamin
21.1 A patient with C6 tetraplegia is undergoing removal of bladder stones under general anaesthesia. The blood pressure rises to 166/88 mmHg. The appropriate response is to
a. Clonidine
b. Hydralazine
c. Decompress the bladder
d. Fentanyl
e. Deepen your anaesthetic
decompress the bladder
Autonomic Dysreflexia:
- medical emergency characterised by severe hypertension,
- brought on by stimulation below the level of the lesion
Factors affecting the development of ADR:
1. Level of spinal injury
2. Duration of injury
3. Whether injury is complete or incomplete
Pathology:
Stimuli arise from caudal roots below the level of the lesion leading to uncontrolled sympathetic activation below the level of the lesion
○ 80% being due to bladder distension
○ Other triggers include
§ bowel distension
§ acute abdo pathology
§ activation of pain fibres
§ sexual activity
§ uterine contractions
23.1 According to the categorisation system used in Australia and New Zealand for prescribing medicines safely in pregnancy, category X denotes drugs which are
a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication)
b. Untested drugs in pregnancy
c. Drugs safe in pregnancy
a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication)
https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy
22.2 The most likely side effect observed in the post anaesthetic care unit after the use of dexmedetomidine is
a. Bradycardia
b. hypotension
c. shivering
d. cough
e. sedation
b. hypotension
The use of dexmedetomidine did not increase the duration of PACU LOS but was associated with reduced emergence agitation, cough, pain, postoperative nausea and vomiting, and shivering in PACU. There was an increased incidence of hypotension but not residual sedation or bradycardia in PACU.
https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU
23.1 The success rate of stopping smoking before surgery is NOT improved by
a) Bupropion
b) Clonidine
c) Nortroptyline
d) Varencicline
e) SSRI
E - SSRIs
ANZCA PG12 Background Paper
21.1 The atmospheric lifetime of nitrous oxide (in years) is approximately
A. 1yr
B. 10 yr
C. 50 yrs
D. 100years
100 years
Desflurane: 10yrs
Sevoflurane 1yr
23.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is
A. Inhalational anesthesia
B. Remifentanil at end of case
C. Dexamethasone
D. Intranasal ketamine
or
a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone
A. Inhalational anesthesia
or
b. Clonidine
Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy.
PROSPECT
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.
23.1 In a patient with glucose-6-phosphate dehydrogenase deficiency (G6PD), the
intravenous agent that should be avoided is
a. Methylene blue
b. Indocyanine green (ICG)
c. Iodine
d. Dextrose
a) methylene blue
Drugs to avoid:
Antibiotics
Sulphonamides (check with your doctor)
Co-trimoxazole (Bactrim, Septrin)
Dapsone
Chloramphenicol
Nitrofurantoin
Nalidixic acid
Antimalarials
Chloroquine
Hydroxychloroquine
Primaquine
Quinine
Mepacrine
Chemicals
Moth balls (naphthalene)
Methylene blue
Foods
Fava beans (also called broad beans)
Other drugs
Sulphasalazine
Methyldopa
Large doses of vitamin C
Hydralazine
Procainamide
Quinidine
Some anti-cancer drugs
21.2 A patient with a history of restless leg syndrome is agitated in the post-anaesthesia care unit.
After excluding other causes, the best treatment of the agitation in this patient is
a) Pethidine
b) Clonidine
c) Droperidol
d) Haloperidol
e) Midazolam
midazolam
- Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms.
Perioperative treatment of symptoms
If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible.
If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day.
If oral intake is feasible, a patient’s usual oral medication may be given.
Levodopa (a dopamine agonist) may be administered by nasogastric tube.
Alternatively, parenteral apomorphine or a rotigotine patch may be used.
Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis.
Nausea is a common side effect so it may need to be given with an antiemetic.
Rotigotine patches may be used every 24 hours.
Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms.
Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.
21.1 Of the following, allergy based on cross reaction to penicillin sensitivity is most likely with
A) Cephazolin
B) ceftriaxone
C) cefapime
D) cefaclor
E) cefoxatin
D) Cefaclor
- Cephalexin? More so than Cephazolin (no B-lactam)
- Cefaclor
Source: UpToDate
22.2 1 MAC of sevoflurane affects the sensory evoked potential signal for spinal surgery by
a) increased latency, increased conduction speed, increased amplitude
b) increased latency, decreased conduction speed, decreased amplitude
c) decrease latency, increased conduction speed, decreased amplitude
d) increased latency, increased conduction speed, decreased aptitude
Increased latency, decreased conduction speed, decreased amplitude
21.2 Methylene blue may be used in the treatment of all of the following conditions EXCEPT
a) Methemoglobinemia
b) Priapism
c) Hepatopulmonary syndrome
d) G6PD deficiency
e) Sepsis
d) G6PD deficiency
(contraindicated)
Methylene blue PI:
PROVEBLUE® is indicated:
* for the treatment of drug-induced methaemoglobinaemia (e.g. prilocaine)
* for the treatment of idiopathic methaemoglobinaemia (in which structural abnormality of haemoglobin is not present)
* as a bacteriological stain
* as a dye in diagnostic procedures such as fistula detection
* for the delineation of certain body tissues during surgery.
Contraindications:
PROVEBLUE® is contraindicated in the following circumstances:
* known hypersensitivity to the drug or any other thiazide dyes
* patients with severe renal impairment
* patients with glucose-6-phosphate dehydrogenase deficiency
* methaemoglobinaemia due to chlorate poisoning
* methaemoglobinaemia during treatment of cyanide poisoning
Intrathecal and subcutaneous injection of methylene blue are also contraindicated as they can result in neural damage (intrathecal administration) and necrotic abscess (subcutaneous administration).
Precautions:
Methylene blue is a potent monoamine oxidase inhibitor.
Serotonin syndrome.
Dose:
Adults and children: In the treatment of methaemoglobinaemia, methylene blue is administered intravenously as the 0.5 % solution in doses of 1 to 2 mg per kg bodyweight injected over a period of 5 minutes.
A repeat dose may be given after one hour if required.
A maximum dose of 7mg/kg bodyweight is recommended.
The use of methylene blue is not recommended in infants under 4 months of age.
STAT PEARLS :Methylene blue
https://www.ncbi.nlm.nih.gov/books/NBK557593/
“Methylene blue is a safe drug at a therapeutic dose of <2 mg/kg; however, when levels are >7 mg/kg, many of the adverse effects it exhibits will occur. Serotonin syndrome has been found to occur when combining serotonergic agents with methylene blue at a dose of 5 mg/kg.”
Methylene blue: caution serotonin syndrome, G6PD deficiency
Indications: vasoplegic syndrome, plasmodium falciparum, methaemoglobinaemia, diagnostic purposes.
Safe at doses <2mg/kg. (used in vasoplegic syndrome on CPB at 3mg/kg - Up to date)
Serotonin syndrome at >5m/kg
Other adverse effects at >7mg/kg.
21.1 The risk of major bleeding in patients taking direct oral anticoagulants (DOACs) is NOT significantly increased by commencing administration of
a) Atorvastatin
b) Amiodarone
c) Digoxin
d) Diltiazem
e) Fluconazole
1st a) Atorvastatin
2nd c) Digoxin
source of Atorvastatin > Digoxin
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818856/
All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels
Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp)
Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp
There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding
It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered
Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme.
The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4
23.1 Rotational thromboelastometry (ROTEM) is performed on a bleeding patient with the
following series of graphs produced. The most appropriate therapy to be
administered is
a. TXA
b. Fibrinogen
c. Cryo
d. FFP
a) TXA
Hyperfibrinolysis
https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter%201.2.0.1/intepretation-abnormal-rotem-data
21.2 With regard to the risk of postoperative surgical-site infection, 8 mg dexamethasone administered intraoperatively has
a) No increased risk of surgical wound infection
b) Increased surgical wound infection in diabetics
c) Increased surgical wound infection in non-diabetics
d) Decreased surgical wound infection
a) No increased risk of surgical wound infection
- Now, the Perioperative Administration of Dexamethasone and Infection Trial (PADDI), led by Professor Tomás Corcoran, Director of Research in the Department of Anaesthesia and Pain Medicine, Royal Perth Hospital has found that administering a low-dose of dexamethasone during anaesthesia for surgical operations does not increase the risk of surgical wound infections.
21.1, 20.1 The drug which has the LEAST impact on somatosensory evoked potentials (SSEPs) monitored in a 15-year-old patient undergoing scoliosis surgery is
A) propofol
B) fentanyl
C) desflurane
D) Midazolam
E) sevoflurane
B) fentanyl
Drugs which have the least impact on SSEPs
1. Ketamine
2. Opioids
3. Dexmedetomidine
Article in Anaesthesiology
https://pubs.asahq.org/anesthesiology/article/99/3/716/40407/Pharmacologic-and-Physiologic-Influences-Affecting
o SSEPs = small amplitude potentials measured over the sensory cortex or via epidural electrodes from stimuli applied to the posterior tibial nerves. SSEPs are transmitted via the posterior columns of the spinal cord in the territory of the posterior spinal arteries which supply the posterior 1/3 of the cord. As they are low amplitude they are affected by basal muscle tremor and the signal-to-noise ratio is improved by increasing the depth of muscle relaxation. Their use is not significantly affected by therapeutic concentrations of anaesthetic vapours
o MEPs = series of short-duration constant current stimuli of 300-700 V applied to the motor cortex and measured via needle electrodes inserted into tibialis anterior, abductor halluces and vastus medialis muscles along with selected small muscles of the hands for reference. MEPs rely on corticospinal tract integrity which lies in the territory of the anterior spinal artery. MEPs therefore complement SSEPs in their assessment of spinal cord function. MEPs are large amplitude potentials and are incompatible with profound muscle relaxation. Neuromuscular blocking agents are therefore best avoided or given by infusion and dose optomised with discussion with the technicians (or just give remi).
o All anaesthetic vapours reduce MEP amplitude in a dose-dependent manner, and more than 0.5 MAC are not compatible with reliable monitoring. Thus Propofol TIVA is preferred.
- Remifentanil is commonly used due to low context sensitive half life and negligible effect on intraop evoked responses
20.1 Abuse of nitrous oxide may lead to
a. Anaemia due to decreased erythropoietin
b. Anaemia due to glutathione deficiency
c. Neurological damage due to methionine deficit
d. Pulmonary HTN
C
Methionine Synthetase Inhibitor
22.1 A patient in atrial fibrillation with a CHA2DS2-VASc score of 2 has presented for elective hip surgery. Warfarin had been ceased for four days preoperatively and on the day before surgery the international normalized ratio (INR) was 2.1. The best course of action at this point is to
a) Postpone surgery
b) Vitamin K 3mg IV
c) Prothrombinex 25IU/kg
d) Cell saver intraop
e) Proceed with surgery
Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS
21.2 Cryoprecipitate contains all of the following EXCEPT
a) Factor I
b) Factor VII
c) Factor VIII
d) VWF
e) Fibronectin
b) Factor VII
Redcross:
Cryoprecipitate contains most of the following found in fresh frozen plasma:
1. factor VIII
2. fibrinogen
3. factor XIII
4. von Willebrand factor
5. fibronectin
Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains:
Factors:
II
IX
X
small amount of factor VII.
Also contains:
plasma proteins (human)
Antithrombin III (human)
Heparin sodium (porcine)
Sodium
Phosphate
Citrate
Chloride
20.2 During the 21st century, the dominant ozone-depleting substance emitted as a result of medical usage to date has been
a) Desflurane
b) Nitrous oxide
c) CO2
d) Isoflurane
e) CFCs
Nitrous oxide
Halothane & isoflurane cause catalytic destruction of ozone, but halothane hardly used and isoflurane has short atmospheric lifetime.
Desflurane + sevoflurane don’t cause ozone depletion.
20.2 During the 21st century, the dominant ozone-depleting substance emitted as a result of medical usage to date has been
a) Desflurane
b) Nitrous oxide
c) CO2
d) Isoflurane
e) CFCs
Nitrous oxide
Halothane & isoflurane cause catalytic destruction of ozone, but halothane hardly used and isoflurane has short atmospheric lifetime.
Desflurane + sevoflurane don’t cause ozone depletion.
21.2 The risk of postoperative respiratory failure in myasthenia gravis is increased by the
administration of
a) Teicoplanin
b) Flucloxacillin
c) Cephazolin
d) Gentamicin
e) Vancomycin
d) Gentamicin
Drugs in the anaesthetic trolley that may unmask or worsen MG:
- NMBs
- gentamicin
- beta blockers (metoprolol)
- magnesium
Anaesthetic drugs to be cautious with:
- dexamethasone
- antipsychotics
- anticonvulsants
- antibiotics (vancomycin, metronidazole)
23.1 Cryoprecipitate contains coagulation factors
A. 2, 8, 13, von willebrands
B. 1, 7, 13 , von willebrands.
C. 1, 8, 13, von willebrands.
D. 2, 7, 13, von willebrands.
C.
Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF
https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate
22.1 When fresh frozen plasma is administered to treat hypofibrinogenaemia in a bleeding patient, the volume required to achieve an increase in plasma fibrinogen concentration of one gram per litre is
A. 5 ml/kg
B. 10 ml/kg
C. 20 ml/kg
D. 30 ml/kg
E. 50 ml/kg
D. 30 ml/kg
Identification and Management of Obstetric Hemorrhage
Anesthesiology Clinics - Obstetric Anesthesia (2017)
https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext
Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.
22.2 Normal (0.9%) saline has the physical properties of
a. Na 140, 280 mOsm/L
b. Na 148, 296 mOsm/L
c. Na 150, 300 mOsm/L
d. Na 154, 308 mOsm/L
D Na 154, 308 mOsm/L
20.2 Elimination of remifentanil occurs following breakdown mainly by
a Plasma cholinesterase
b RBC esterases
c Hoffman degradation
d Hepatic Metabolism
e Plasma esterases
e Plasma esterases
Plasma esterases (not cholinesterase)
Esmolol metabolism is via RBC esterases.
21.1 The composition of blood returned to the patient from intraoperative cell salvage shows
A. No evidence of haemolysis
B. Normal 2,3 DPG
C. Nil evidence of bone cement or some embolism type
D. Normal levels of coagulation factors
B. Normal 2,3 DPG
higher Hct-60%
No immunimodulation
require reinfusion within 6hrs
pause with sement, caution metal fragments
21.1 Toxicity of methylene blue is likely to be seen after single bolus dose (in mg/kg) greater than
a. 1mg/kg
b. 2mg/kg
c. 5mg/kg
d. 0.5mg/kg
e. 0.1mg/kg
c. 5mg/kg
Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg.
Source: STAT PEARLS - Methylene blue https://www.ncbi.nlm.nih.gov/books/NBK557593/
20.2 Of the following, the agent that causes the LEAST prolongation of the Thrombin Clotting Time (or Thrombin Time) is
a) Heparin
b) LMWH
c) Bivalirudin
d) Warfarin
e) Dabigatran
d) Warfarin
Warfarin – no effect on thrombin time
Heparin - causes considerable prolongation of TT.
LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa.
-> However LMWH in very high concentration can affect TT.
Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably.
The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.
22.2 In a previously normal patient with cardiac failure secondary to acute pulmonary embolism, the best choice of vasoactive agent for initial treatment is
a. Dobutamine
b. Milrinone
c. Isoprenaline
d. Noradrenaline
d. Noradrenaline
Supportive Management of Massive PE
Coexisting left ventricular systolic dysfunction and diastolic dysfunction complicate the management of heart failure patients with massive PE. Although a common strategy in response to systemic arterial hypotension is to prescribe a fluid bolus, volume loading may worsen biventricular failure, pulmonary edema, and hypoxemia. An initial trial of volume expansion, limited to 250 to 500 mL, may be attempted in those heart failure patients without evidence of increased right-sided filling pressures or pulmonary edema.6
Although non–heart failure patients generally respond well to pure vasopressors for hemodynamic support in massive PE, many heart failure patients will not tolerate the isolated increase in systemic vascular resistance. PE patients with heart failure may require an agent with mixed vasopressor and inotropic properties such as norepinephrine, epinephrine, or dopamine. Whereas LV function often becomes hyperdynamic to compensate for RV failure, the presence of underlying LV systolic dysfunction in heart failure patients may limit the patient’s ability to maintain normal systemic cardiac output and may necessitate the addition of inotropes.
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.803965
22.2 A 76-year-old man requires an emergency thoracotomy to treat an expanding haemothorax. He is mildly hypotensive and is not fasted. His plasma electrolytes and haemoglobin are below. The most appropriate strategy to employ to intubate him with a double lumen endotracheal tube is to (use)
K 6.3 Ur 7-ish Cr 174
a. Cisatracurium 0.5mg/kg
b. Rocuronium 1.2mg/kg
c. Suxamethonium 1mg/kg
d. Suxamethonium 0.5mg/kg (?was this an option)
b. Rocuronium 1.2mg/kg
Cis not appropriate for intubation
Sux with K 6.3 is risky. (I’ve never heard of reduced dose)
21.1 You have been asked to anaesthetise a patient with a history of severe depression which has been
well controlled on moclobemide. The most appropriate medications in combination with propofol are
a. Sevoflurane, morphine, phenylephrine
b. Sevoflurane, pethidine, phenylephrine
c. Midazolam, fentanyl, ephedrine
d. sevoflurane, oxycodone, ephedrine
a. Sevoflurane, morphine, phenylephrine
Moclobemide = MAOi
23.1 Desufflation after surgical pneumoperitoneum is NOT associated with an increase in
a) SVR
b) CI
c) EF
d) preload
e) LV work
a) SVR
21.2 A bleeding patient has ROTEM results including (results displayed) . The most appropriate treatment is
a) Cryoprecipitate
b) FFP
c) Platelets
d) TXA
e) Protamine
e) Protamine
The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin.
https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data
22.1 Of the following, the drug most likely to cause pulmonary arterial vasodilation with systemic arterial vasoconstriction when used in low doses is
a) Adrenaline
b) Noradrenaline
c) Vasopressin
d) Dopamine
e) Dobutamine
c) Vasopressin
https://emcrit.org/ibcc/pressors/
- From UP TO DATE:
> At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds
> At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate.
> At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min
*clinically, the haemodynamic effects of dopamine demonstrate individual variability
Dobutamine (inodilator):
- selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances
Vasopressin:
- vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect
Milrinone (inodilator):
- the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension
22.2 Suxamethonium may be safely given to patients with (list of neuromuscular diseases given)
a. Becker muscular dystrophy
b. Myaesthenia gravis (new option)
c. Guillain Barre
d. Hypokalaemic periodic paralysis (new option)
e. Duchenne muscular dystrophy
b. Myaesthenia gravis
ED95 is 0.8mg/kg in a MG patient
21.1 A common electrolyte disturbance following the administration of ferric carboxymaltose is
a. hypophosphatemia
b. hypocalicaemia
c. hypokalaemia
d. hypercalicaemia
e. hypernatraemia
Hypophosphataemia
Ferric carboxymaltose (Ferinject) for iron-deficiency anaemia
https://www.nps.org.au/radar/articles/ferric-carboxymaltose-ferinject-for-iron-deficiency-anaemia
In this set of patients administered FCM (n = 5799), treatment-related side effects that occurred in more than 1% of the group included:
- nausea (3.1%)
- hypophosphataemia (1.9%)
- injection-site reactions (1.6%)
- headache (1.4%)
- hypertension (1.3%)
- dizziness (1.2%)
22.2 You will anaesthetise a 39-year-old woman for a laparoscopic cholecystectomy. She has a history of mastocytosis and has never had an anaesthetic in the past. A drug which you should avoid is
a. fentanyl
b. morphine
c. remifentanil
d. tramadol
B Morphine
Histamine-releasing
22.1 A patient presents for endoscopic retrograde cholangiopancreatography (ERCP) with a history of previous post-ERCP pancreatitis. The management most likely to reduce the likelihood of pancreatitis is
a. Gentamicin
b. PR indomethacin
c. Creon post op
d. Preop smoking cessation
Rectal indomethacin
APMSE 5th edition 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. Epidural > PCA for severe acute pancreatitis
22.2 Of the following, all are useful for the treatment of status epilepticus EXCEPT
a. Calcium
b. isoflurane
c. ketamine
d. propofol
e. phenytoin
a. Calcium
(unless hyppocalcaemia is causing your seizures)
Deranged Physiology:
First line agents
- Benzodiazepines: boluses every 2-5 minutes
- Phenytoin: 20mg/kg loading dose
Phenytoin on its own is useless. Or rather, it is inferior to benzodiazepines as a solitary agent. Always, both must be used simultaneously.
Second line agents
- Midazolam infusion
- Phenytoin (well, rather, the American study recommends fosphenytoin)
- Phenobarbital and levetiracetam are also in this second line of attack
Third line agents: for refractory status epilepticus
- Propofol infusion, or midazolam infusion, or thiopentone infusion.
- At this stage, continuous EEG monitoring becomes mandatory
- The role of traditional antiepileptic drugs is also exhausted at this stage, as there will probably be no benefit from adding them into a situation where a constantly observed burst suppression is already achieved by high dose anaesthetic infusion.
Fourth line agents: for these, there is little evidence.
- Volatile anaesthetic agents
- Desflurane and Isoflurane
- Ketamine
- Lignocaine
- Magnesium
- Pyridoxine
Fifth line therapies:
- Hypothermia
- Ketogenic diet
- Deep brain stimulation
- Surgical management
20.1 A 22-year-old patient is scheduled for resection of a large extra-adrenal paraganglionoma. The tumour is secreting metanephrine. The most likely therapy to be commenced at the preassessment clinic prior to surgery is
a) Prazocin
b) Phentolamine
c) Magnesium
d) Phenoxybenzamine
e) Ca channel blocker
Phenoxybenzamine
UpToDate
Phenoxybenzamine is the preferred drug for preoperative preparation to control blood pressure and arrhythmia in most centers in the United States. It is an irreversible, long-acting, nonspecific alpha-adrenergic blocking agent.
With their more favorable side-effect profiles and lower financial cost, selective alpha-1-adrenergic blocking agents (eg, prazosin, t erazosin, or d oxazosin) are utilized in many centers or are preferred to phenoxybenzamine when long-term pharmacologic treatment is indicated (eg, for metastatic pheochromocytoma).
20.1 Which drug not metabolised by CYP2D6?
a) Oxycodone
b) Tramadol
c) Amitryptiline
d) Codeine
e) Hydromorphone
e) Hydromorphone
20.2 The next patient on your anaesthetist-supported endoscopy list is a fifty-year old woman who has been scheduled for gastroscopy and colonoscopy under sedation, having failed with proceduralist- supervised midazolam and fentanyl sedation in the past. She states that she has egg anaphylaxis, and carries an EpiPen. The most appropriate agent to use for her sedation is
a) Ketamine
b) Propofol
c) Remifentanil
d) Sevoflurane
e) Thiopentone
b) Propofol
BJA: No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut
“No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered.”
21.1, 21.2 You give a dose of intravenous indocyanine green to facilitate videoangiography during cerebral aneurysm surgery. The displayed pulse oximetry (SpO2) and cerebral oxygen tissue saturation (SctO2) changes you expect to see are
a. Increases NIRS , decreases peripheral
b. Decreases NIRS, decreases peripheral
c. No change NIRS, decreases peripheral
d. Increases NIRS and peripheral
e. Decreases NIRS, increases peripheral
a. Increases NIRS , decreases peripheral
SctO2 up, SpO2 down.
Source: Korean Journal Anaesthesia
https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings
22.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is
a. codeine
b. morphine
c. fentanyl
d. tramadol
e. oxycodone
a. codeine
Oxycodone B
Morphine C
Tramadol C
Fentanyl C
21.1 A 48 year old male is day two post-laparoscopic high anterior resection. He has used 42 mg of intravenous morphine in the past 24 hours. You wish to start him on oral tapentadol immediate release. The most appropriate equianalgesic dosage would be
a. 50 QID
b. 100 QID
c. 150 QID
d. 200 QID
b. 100mg QID
42mg IV Morphine = 126mg Oral Morphine
126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)
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
20.2, 22.2 The analgesic drug with the most favourable Number Needed to Treat (NNT) for neuropathic pain is
a) Amitriptyline
b) Gabapentin
c) Tramadol
d) Pregabalin
e) Carbamazepine
Tramadol
APMSE 5th edition:
Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8)
Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain.
At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7)
Pregabalin
Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732);
* Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015);
* Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367);
* Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562).
Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6))
Amitriptyline
By order of favourable NNT:
- TCAs (amitriptyline) NNT: 3.6, NNH: 9
- Strong opioids NNT 4.3 NNH 11.7
- Tramadol NNT: 4.7, NNH 12.6
- SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
- Gabapentin NNT: 7.2 NNH 25.6
- Pregabalin NNT:7.7, NNH 13.9
ANZCA Pain book
Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:
- First line: pregabalin, gabapentin and amitriptyline;
- Second line: tramadol and lamotrigine (in incomplete SCI);
- Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
- Fourth line: TENS, oxycodone and dorsal root entry zone lesions.
21.1 A 30-year-old professional athlete who underwent a knee arthroscopy under general anaesthesia becomes tachycardic in the recovery room. His non-invasive systolic blood pressure is 90 mmHg. A 12-lead ECG is obtained. The most appropriate therapy is
a. Adenosine 6mg (or 60mg remembered by other cohort)
b. valsalva
c. 50J
d. 200J
b. valsalva
Fluid and magnesium - fixes all.
But could also be conscious VT or something stupid….
22.1 Suxamethonium may be safely given to patients with
a. Becker muscular dystrophy
b. Cerebral palsy
c. Guillain Barre
d. Frederich’s ataxia
e. Duchenne muscular dystrophy
CP
b. Cerebral palsy
->sux and volatiles are not contraindicated
-> presence of extrajunctional receptors may cause hyperkalaemia
a. Becker muscular dystrophy
-> essentially milder Duchenne’s (see duchenne response to Sux)
b. Cerebral palsy
-> Sux and volatiles not contraindicated
-> reduced MAC requirement
-> increased sensitivity to muscle relaxants
c. Guillain Barre
-> sux contraindicated due to risk of hyperkalaemia
-> increased sensitivity to Non depolarising NB
d. Frederich’s ataxia
-> sux should be avoided due to risk of hyperkalaemia
e. Duchenne muscular dystrophy
-> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis
22.2 The use of intraoperative dexamethasone for tonsillectomy
a) Increased oedema
b) Increased post tonsillectomy bleed
c) Increased Analgesic requirement
d) Reduced time to resumption of oral intake
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.
23.1 Tranexamic acid is NOT useful for managing
A. Post cardiac bypass
B. Neurotrauma
C. PPH
D. Trauma
E. Upper GI bleed
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
https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/
21.1 Suxamethonium may be safely given to patients with
a) chronic spinal cord injury
b) Hypokalaemic periodic paralysis
c) muscular dystrophy
d) myasthenia gravis
e) multiple sclerosis
d) myasthenia gravis
In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug.
Sux is not recommended in patients with neuromuscular disease due to:
1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis
2. fasiculations causing temperomandibular muscle spasm preventing intubation
Suxamethonium is
contraindicated in patients with recent burns or
spinal cord trauma causing paraplegia (can be given
immediately after the injury, but should be avoided
from approximately day 10 to day 100 after the injury),
ED95 is 0.8mg/kg in a MG patient
20.1 Of the following agents, haemodialysis is most effective in clearing (list of anticoagulant drugs given)
a. Warfarin
b. Clopidogrel
c. Apixaban
d. Dabigatran
e. Rivaroxaban
Dabigatran definitely, almost entirely renal clearance
Warfarin no
Rivaroxaban no
Clopidogrel yes (renal excretion)
Apixaban yes
21.1 Effective pharmacotherapy options to support smoking cessation in the perioperative period include all of the following EXCEPT
a) bupropion
b) clonidine
c) nortoptyline
d) Varenicicline
e) fluoxetine
Fluoxetine
23.1 A drug that is NOT useful for the treatment of vasoplegic shock is
A. Hydroxycobalamin
B. Methylene blue
C. Dobutamine
D. vasopressin
E. Dopamine
c. dobutamine
UTD
Indications for the use of hyperbaric oxygen therapy in the treatment of acute carbon monoxide toxicity include all of the following EXCEPT
a. Pregnancy
b. COHb level 10%
c. Difficult to examine patient as likely concomitant drug overdose
d. Myocardial ischaemia
e. Reduced GCS
b. COHb level 10%
21.1 In elderly patients without diabetes mellitus the use of aspirin in primary prevention of disease
a. Reduced cardiovascular mortality
b. Increased incidence of major bleeding
c. Increased cancer related death
d. Lower all cause mortality
e. Reduced thromboembolic events
increased incidence of major bleeding
21.2 Your patient has been administered 50 mL of oral 5–aminolevulinic acid hydrochloride
(Gliolan) three hours prior to her scheduled craniotomy for resection of a glioblastoma. Care
should be taken perioperatively to avoid the adverse effect of
a) Acute kidney injury
b) Photosensitivity
c) Increased ICP
d) Hypertension
e) Hypokalaemia
photosensitivity
Gliolan (PI):
- Aminolevulinic acid hydrochloride (ALA)
- Natural precurore of haeme, metabolised into fluorescent prophyrins
- The fluorescence in certain tissue targets for photodynamic diagnosis
- Increased fluorescent porphyrin formation by malignant glioma tissue (i.e. GBM)
- After excitation with blue light (λ=400‑410 nm), PPIX is strongly fluorescent (peak at λ=635 nm) and can be visualised after appropriate modifications to a standard neurosurgical microscope.
- Avoid exposure of eyes and skin to light sources afterwards (photosensivity).
Contraindications:
- hypersensitivity
- porphyria
- pregnancy
Precautions:
- After administration of Gliolan, exposure of eyes and skin to strong light sources (e.g. operating illumination, direct sunlight or brightly focused indoor light) should be avoided for 24 hours.
- Co-administration with other potentially phototoxic substances (e.g. tetracyclines, sulfonamides, fluoroquinolones, hypericin extracts) should be avoided
- Within 24 hours after administration, other potentially hepatotoxic medicinal products should be avoided.
- In patients with pre-existing cardiovascular disease, Gliolan should be used with caution since literature reports have shown decreased systolic and diastolic blood pressures, pulmonary artery systolic and diastolic pressure as well as pulmonary vascular resistance.
22.2 A drug that is contraindicated for a patient with a history of heparin-induced thrombocytopaenia is
a) Bivalirudin
b) Danaparoid
c) Prothrombinex
d) Fib conc
c) Prothrombinex
Has factors 2, 9, 10, heparin, ATIII
21.1, 22.2 IIn critically ill patients undergoing mechanical ventilation, energy dense enteral nutrition (1.5 kcal/mL/kg) compared to routine (1 kcal/mL/kg) enteral feeding provides
a) Higher incidence of VAP
b) Lower incidence of AKI
c) Lower all cause 90-day mortality
d) No difference
d) No difference
Repeat
Conclusions
In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746. opens in new tab.)
https://www.nejm.org/doi/full/10.1056/NEJMoa1811687
22.2 The recommended antibiotic prophylaxis for surgical termination of pregnancy is
a. Clindamycin 600 mg
b. Cephalexin 500 mg
c. Doxycycline 400 mg
d. Cephazolin 2g
e. Cephazolin 2g and metronidazole
c. Doxycycline 400mg
Insertion of Mirena-> no antibiotics
exception is acute PID-> clindamycin
https://ranzcog.edu.au/wp-content/uploads/2022/05/Prophylactic-Antibiotics-in-Obstetrics-and-Gynaecology.pdf
Of the following, the agent that has the greatest capacity to absorb infrared radiation in the atmosphere is
a) CO2
b) desflurane
c) sevoflurane
d) nitrous
e) isoflurane
b) Desflurane
Atmospheric heat absorbed by a substance compared with CO2 is its GWP
GWP CO2 = 1
GWP N20 = 265 (atmospheric lifetime of 114yrs)
GWP sevo = 130 (atmospheric lifetime of 1.1yrs)
GWP desflurane = 2540 (atmospheric lifetime of 14yrs)
A fasted patient with type 2 diabetes mellitus presents for elective surgery. She has omitted one dose of a sodium-glucose co-transporter-2 (SGLT2) inhibitor. The lowest pinprick ketone level that would support a diagnosis of euglycaemic ketoacidosis is
a) 0.3
b) 0.6
c) 1.0
d) 3.0
c) 1.0
Clinicians should consider DKA/euDKA in patients taking SGLT2i who have one or more of:
- symptoms of abdo pain, nausea, vomiting, fatigue or metabolic acidosis
(a normal or only modestedly elevated plasma glucose level does not exclude diagnosis)
- finger prick capillary blood ketone ( or blood beta-hydroxybutyrate) level >1/0mmol/l with or without hyperglycaemia
- Low (negative) Base Excess <-5mmol/l indicating metabolic acidosis on arterial or venous blood gasses
If the blood ketone leve is >1.0mmol/l in an unwell patient on SGLT2i, take arterial or venous blood gases to measure the BE.
If ketones >1.0mmol/l and BE <-5mmol/l the patient has presumed DKA
If the BSL is <14mmol/l it is presumed euDKA
> for a ward patient a MET team should be activated or ICU contacted for review in collaboration with endocrinology services
> management priorities include:
1. Rehydration
2. IV insulin with added dextrose if BSL <15mmol/l
3. hourly monitoring of blood glucose, ketones and blood gases
4. All should be reviewed by an endocrinologist or on-call physician and critical care specialist
23.1 A woman who is to undergo a caesarean section reports that she is allergic to amoxicillin. The reaction is limited to a rash. For surgical antimicrobial prophylaxis, you should administer
A. Cefoxitin
B. Cefazolin
C. Doxycycline
D. Clindamycin
Cefazolin
A first-generation cephalosporin is recommended, such as 2g intravenous cefazolin. The dose should be increased to 3g for women weighing over 120kg. Consideration should also be given to a repeat dose if the procedure is prolonged (over 3 hours).
- For women with a history of immediate or delayed nonsevere hypersensitivity to
penicillins, cefazolin, as above, remains appropriate. - For women with a history of immediate or delayed severe hypersensitivity to penicillins, use Clindamycin 600mg iv plus Gentamicin 2mg/kg iv.
- For women colonised with Methicillin-resistant Staphylococcus aureas (MRSA) or at increased risk of being colonised with MRSA, add Vancomycin 15mg/kg iv.
- Azithromycin may be considered at caesarean sections performed during labour or at least four hours after rupture of membranes (2). Administration of azithromycin 500mg has been shown to reduce a composite outcome of endometritis, wound infection or other infection (3). However, a strong recommendation in favour of routine use is not yet warranted given the concerns around the external validity of the paper, inducing resistance to azithromycin and possible effects on the establishment of the indigenous microbiome.
23.1 A 30-year-old woman has her bipolar disorder well controlled with lithium therapy. The analgesic agent LEAST suitable for her is
a. Tramadol
b. Diclofenac
c. Oxycodone
d. Methadone
b) diclofenac
LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery
NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2
BJA: perioperative advice for psychotropic drugs
22.1 A 24-year-old man with Wolff-Parkinson-White syndrome is having anaesthesia for a knee arthroscopy. During the procedure he develops the following rhythm. His blood pressure is 100/65mmHg.
The most appropriate treatment is
a. Adenosine
b. Procainamide
c. Verapamil
b. Procainamide
BJA: Perioperative cardiac arrhythmias
https://academic.oup.com/bja/article/93/1/86/265716
- Paroxysmal SVT (PSVT) due to re‐entrant circuits that involve accessory pathways (congenital electrical connections between the atrium and ventricle that bypass the AV node, such as Wolff–Parkinson–White Syndrome) pose caveats in the management of SVT.
- It should be noted that patients with accessory pathways, in addition to PSVT, may also develop atrial fibrillation, and in the latter situation are at increased risk for developing ventricular fibrillation (VF) upon exposure to classic AV‐nodal blocking agents (digoxin, calcium channel blockers, beta blockers, adenosine) because these agents reduce the accessory bundle refractory period.
- In such cases, i.v. procainamide, which slows conduction over the accessory bundle, is an acceptable option. Flecainide and amiodarone should also be considered, and cardiology consultation may be helpful.2
22.2 A 25-year-old ASA (American Society of Anesthesiologists) physical status classification I patient develops seizures five minutes after receiving a brachial plexus block with ropivacaine. Of the following, the most suitable initial intravenous treatment is
a) phenytoin
b) levetiracetam
c) propofol
d) intralipid
c) propofol
https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_final.pdf?ver=2018-07-11-163755-240&ver=2018-07-11-163755-240
21.1 21.2 Benztropine ameliorates the side effects of drugs that antagonize
a) Dopamine receptor
b) Nicotinic Ach receptor
c) Muscarinic Ach receptor
d) Serotonin
e) Noradrenaline
a) Dopamine receptor
MOA: central acting anticholinergic
22.2 In preschool-aged children having tonsillectomy under general anaesthesia, delirium is more likely with the use of
a) Remifentanil at end of case
b) Dexamethasone
c) IN something? ketamine?
d) Inhalational anaesthetic
D Inhalational anaesthetic
https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/
21.1 Chronic recreational use of nitrous oxide may lead to
a. Anaemia due to decreased EPO
b. Anaemia from glutathione deficiency
c. Neurological damage due to methionine deficit
d. Pulmonary hypertension
neurological damage due to methionine deficit
20.2 The muscle or muscle group with the greatest sensitivity to the action of non-depolarising neuromuscular blocking agents is the
a) Abdominal muscles
b) Adductor pollicus
c) Pharyngeal muscles
d) Diaphragm
e) Obbicularis occuli
c) pharyngeal muscles
Millers Anaesthesia:
Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and
An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.
20.2 In the POISE study the use of beta blockers on the day of surgery as a cardio protective strategy in high risk patients has been associated with
a) Increased heart rate
b) Decreased hypotension
c) Increased mortality
d) Increased myocardial infarction
c) Increased mortality
Use of perioperative metoprolol was associated with:
* Decreased rate of myocardial infarction
* Decreased rate of revascularisation
* Decreased rate of developing new atrial fibrillation
* INCREASED rate of death
* INCREASED rate of stroke
* INCREASED rate of significant hypotension
INCREASED rate of significant bradycardia
Of the following, the side-effect LEAST likely to be caused by adenosine administration is
A. chest pain
B. bronchospasm
C. GI upset
D. Flushing
E. Dyspnoea
B. bronchospasm
Blue book 2017 article (see image)
CLASS
short acting anti-arrhythmic
naturally occurring purine nucleoside
MECHANISM OF ACTION
depression of SA & AV nodal activity
antagonises cAMP-mediated catecholamine stimulation of ventricular muscle
-> negative chronotropy & dromotropy
direct agonist at specific cell membrane receptors (A1 & A2) A1 = coupled to K+ channels by a guanine nucleotide-binding protein in supraventricular tissue.
PHARMACEUTICS
clear, colourless
3mg/mL
in saline
DOSE
rapid IV bolus followed by saline flush
3mg -> 6mg -> 12mg (adult)
0.04 to 0.25mg/kg (children)
INDICATIONS
diagnosis and treatment of paroxysmal SVT
ADVERSE EFFECTS
bronchospasm
flushing
SOB
Chest pain
CONTRAINDICATIONS
second and third degree AV block
allergy
care with asthma and COPD
PHARMACOKINETICS
Onset – 10 seconds
Duration – 10 seconds
Absorption – must be given IV
Distribution
Metabolism – absorbed by RBC’s and endothelium
Elimination – t ½ = 10 seconds
20.2 Prothrombinex VF is a factor concentrate. It is indicated for the management of bleeding caused by
a Von Willebrand disease
b Haemophilia a
c Haemophilia b
d Haemophilia c
e Congenital fibrin deficiency
c Haemophilia b
21.2 A 30-year-old man with morbid obesity (body mass index [BMI] 55 kg/m2) presents for middle ear surgery. The most appropriate bolus dose of propofol for induction should be based on
a) IBW
b) TBW
c) ABW
d) LBW
e) PBW
d) LBW
22.1 St. John’s wort (herbal medicine Hypericum perforatum) will reduce the effects of
a. Aspirin
b. Clopidogrel
c. Warfarin
d. Heparin
e. NOAC
c. Warfarin
It is also a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, midazolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs
23.1 Despite two separate 300 IU/kg doses of heparin, you have failed to attain yourtarget activated clotting time prior to instituting cardiopulmonary bypass. An appropriate option now would be to give
a. More heparin
b. FFP
c. Dalteparin
d. bivalirudin
b. FFP
20.2, 23.2 Complications of hyperbaric oxygen therapy do NOT include
a) Myopia
b) Central retinal occlusion
c) Seizures
d) Hypoglycaemia
e) Bradycardia
b) Central retinal occlusion
SE’s from HBOT:
- progressive myopia (reversible)
- seizures
- hypoglycaemia
- sinus bradycardia from stimulation of vagal activity bassociated with hyperbaric pressures
22.2 A 6-year-old patient (140 cm, 24 kg, BSA 0.97m2) is on hydrocortisone 15 mg/day. Perioperative glucocorticoid supplementation is (considered if)
a.
b. Taking >1week
c. Taking >1 month
d. Taking >2 months
e. Taking >4 months
Taking > 1 month
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963
Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra-articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency
All children who have known glucocorticoid deficiency (primary or secondary), or who are at risk of glucocorticoid deficiency (on significant exogenous dose of glucocorticoid >10–15 mg.m-2 per day) 38, should receive an i.v. dose of hydrocortisone at induction (2 mg.kg−1 for minor or major surgery under general anaesthesia).
22.2 Drug classes demonstrated to reduce mortality in chronic heart failure with reduced ejection fraction include all of the following EXCEPT
A. ACE inhibitors
B. Beta blockers
C. Angiotensin receptor blockers
D. Spironolactone
E. Digoxin
Digoxin
23.1 Sacubitril use reduces the plasma levels of
A. NT proBNP
B. Angiotensin II
C. BNP
D. Neprolysin
E. Bradykinin
a) NT ProBNP
Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume.
In contrast, in comparison with enalapril, patients receiving LCZ696 had consistently lower levels of NTproBNP (reflecting reduced cardiac wall stress) and troponin (reflecting reduced cardiac injury) throughout the trial.
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.013748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
21.2 The drug of choice for the treatment of duct dependent congenital heart disease is
a) Alprostadil
b) Prostacyclin
c) Carboprost
d) Sildenafil
e) NSAID
a) Alprostadil
Prostin (PGE1)
21.2 Complications of hyperbaric oxygen therapy include all of the following EXCEPT
a) Hypoglycaemia
b) Cataract
c) Worsening CCF
d) Seizures
e) Reversible hypermetropia
e) Reversible hypermetropia
22.2 Of the following, the substance LEAST likely to cause lactic acidosis is
a. methanol
b. propofol
c. metformin
d. acetazolamide
d. acetazolamide
acetazolamdie has been known to cause lactic acidosis but is less common than the other drugs listed unless there is a 5th option not remembered
21.2 A peripheral intravenous cannula is being inserted in the forearm of a man having a hemicolectomy. The skin asepsis preparation NOT suitable for this procedure is
a) Povidone iodine
b) Chlorhexidine 2%
c) Alcohol 70%
d) Chlorhexidine 0.5% with alcohol
e) Tincture of iodine
c) Alcohol 70%
- only suitable for short-term cannulation (<24 hours)
Prior to neuraxial block in a patient with normal renal function, apixaban should be ceased for
a. 1 day
b. 2 days
c. 3 days
d. 5 days
e. 7 days
c. 3 days
20.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is
a) Codeine
b) Methadone
c) Tramadol
d) Oxycodone
e) Morphine
Answer: a) Codeine
TGA Pregnancy categories https://www.tga.gov.au/prescribing-medicines-pregnancy-database
Category A
■ Codeine
Category C
■ Methadone
■ Tramadol
■ Oxycodone
■ Morphine
20.2 In the morbidly obese the induction dose of propofol should be calculated based on
a) Lean body weight
b) Total body weight
c) Ideal body weight
d) Ideal body weight + 70%
e) Adjusted body weight
a) Lean body weight
FROM SOBA:
LBW exceeds IBW in obese and plateaus at ~100kg in men and ~70kg in females
IBW used to calculate the adjusted body weight for maintenance infusion of propofol (IBW +40%).
IBW calculated using Broca formula (Ht in cm - 100; Ht in cm =105; as optimal weights for men and women respectively in kg)
20.1, 21.2 A patient with a history of paroxysmal atrial fibrillation and chronic obstructive airways disease develops a wheeze intraoperatively which resolves with administration of salbutamol via the endotracheal tube.
Soon after, he develops rapid atrial fibrillation with a ventricular rate of 120 beats per minute, a BP of 90/60 and an ETCO2 of 40mmHg. His regular medications are
inhaled salbutamol, inhaled salmeterol and digoxin 125mcg daily. The next most suitable treatment is
a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours
b) Esmolol 500mcg/kg and infusion
c) Direct cardioversion with 50J
d) Metoprolol 2.5mg IV up to 3 doses
a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours
UP TO DATE: Arrhythmias in COPD
For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C).
Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3).
Addition of Digoxin in this answer stem could be prefered over Amiodarone
22.2 A 34-year-old for a diagnostic laparoscopy has a height of 158 cm and a weight of 120 kg (BMI 48 kg/m2). For induction of anaesthesia, appropriate drug dosing includes
a) Fentanyl based on TBW
b) Rocuronium based on LBW
c) Propofol induction based on ABW
d) Propofol infusion based on LBW
e) Suxamethonium based on IBW
b) Rocuronium based on LBW
21.2, 22.2 The estimated proportion of human induced climate change attributable to nitrous oxide is
a) 0.01
b) 0.06
c) 1
d) >6
d) >6
Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers
20.1 A 55-year-old man is found to be in atrial fibrillation. He has no previous medical history. Physical examination, blood pressure and fasting blood glucose are normal. Appropriate long-term management is
A. Aspirin
B. Dabigatran
C. No anticoagulation
D. Warfarin
E. Rivaroxaban
C. No Anticoagulation
- if male CHA2DS2-VASc score ≥2 to be recommended chronic OAC (Grade 1A).
- if female CHA2DS2-VASc score ≥3 to be recommended chronic OAC (Grade 1A).
- non-sex risk factor also holds bearing:
- For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A).
Up to date:
Our approach to deciding whether to prescribe anticoagulant therapy for patients with AF (excluding those with rheumatic mitral stenosis that is severe or clinically significant [mitral valve area ≤1.5 cm2], a bioprosthetic valve [surgical or bioprosthetic] within the first three to six months after implantation, or a mechanical heart valve) is as follows:
*For a CHA2DS2-VASc score ≥2 in males or ≥3 in females, we recommend chronic OAC (Grade 1A).
*For a CHA2DS2-VASc score of 1 in males and 2 in females:
-For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Age 65 to 74 years is a stronger risk factor than the other factors conferring one CHA2DS2-VASc score point.
-For patients with other risk factors, the decision to anticoagulate is based upon the specific nonsex risk factor and the burden of AF. For patients with very low burden of AF (eg, AF that is well documented as limited to an isolated episode that may have been due to a reversible cause such as recent surgery, heavy alcohol ingestion, or sleep deprivation), it may be reasonable to forgo chronic OAC and institute close surveillance for recurrent AF, although it may not be possible to reliably estimate AF burden from surveying symptoms or infrequent monitoring. The frequency and duration of AF episodes vary widely over time, and episodes are often asymptomatic.
*For patients with a CHA2DS2-VASc of 0 in males or 1 in females, we suggest against OAC (Grade 2C). Patient values and preferences may impact the decision. For example, a patient who is particularly stroke averse and is not at increased risk for bleeding may reasonably choose anticoagulation, particularly if the patient is a candidate for treatment with a direct oral anticoagulant (DOAC).
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline
21.2 A drug which is likely to slow the heart rate in a patient with a heart transplant is
a. Phenylephrine
b. Digoxin
c. Metaraminol
d. Adenosine
Adenosine (effect is exagerated)
21.1 A patient has bipolar disorder and is on long term lithium therapy. An analgesic which should be avoided is
a. Diclofenac
b. Tramadol
c. Oxycodone
d. Methadone
a. Diclofenac
LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery
NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2
BJA: perioperative advice for psychotropic drugs
In the management of anaphylaxis in a 5-year-old with no intravenous or intra-osseous access, the correct dose of intramuscular adrenaline is
A. 20mcg
B. 50mcg
C. 100mcg
D. 150mcg
E. 300mcg
D. 150mcg
23.1 A 35-year-old woman is brought to the emergency department following a suspected amitriptyline overdose. She has a Glasgow Coma Scale score of 6 and her blood pressure is 90/46 mmHg. Her electrocardiogram is most likely to show
A. AF
B. CHB
C. Sinus tachy with prolonged QRS
D. Sinus brady with prolonged QRS
E. VT
c. sinus tachy with prolonged QRS
22.2 A 21-year-old patient with a history of schizophrenia on quetiapine develops tremor, restlessness, hyperreflexia, nausea and vomiting in the post-anaesthesia care unit following an emergency laparoscopic cholecystectomy. Her heart rate is 80 / minute, blood pressure 130/90 mmHg, and her temperature is 37.0°C. The most likely diagnosis is
a. MH
b. NMS
c. serotonin syndrome
d. rhabdomyolysis
e. anticholinergic crisis
Serotonin Syndrome
Hyper reflexia
Usually has hypertension and hyperthermia
https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png
20.1 In planning the induction of anaesthesia in a morbidly obese patient, the total body weight should be used to calculate the dose of
A Suxamethonium
B Propofol
C Thiopentone
D Rocuronium
a) Suxamethonium
21.1 A patient with a history of hereditary angioedema requires an appendectomy for acute appendicitis.
The most effective therapy for the prevention of an acute attack in the perioperative period is
a) FFP
b) Icatibant
c) Hydrocortisone
d) Danazole
e) cetirizine
d) Danazol
https://www.allergy.org.au/hp/papers/hereditary-angioedema
Treatment options:
Plasma derived C1-esterase inhibitor = Berinert/Cinryze,
Androgens = Danazol
B2 Bradykinin REceptor antagonist = Icatibant
FFP.
Danazol (an androgen) is recommended as first line PROPHYLAXIS for planned procedures (need to give for 5-10 days prior and 2-5 days post)
For emergency or high risk procedures C1 esterase inhibitor concentrate (Berinert or Cinryze) is recommended
- give 1 hour before procedure
- more effective than danazol but more expensive
Berinert:
- 20units/kg IV over 10 min
- Symptoms usually stabilise in 30 mins
- 2nd dose uncommon, but may be given 30mins to 2hrs after 1st dose
Icatibant:
- 30mg slow subcut infusion in abdominal area
Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation
Short answer:
- if you have days before surgery increase danazole, if complex surgery increase danazole and give C1Inh
- If you have acute emergency surgery give C1Inh Concentrate (Berinert/Cinryze) before and after
- if you have an acute attack use C1Inh or Bradykinin antagonist (Icatibant)
- If C1 Inh and Bradykinin antagonoist are not available then use FFP but this may worsen the attack due to the presence of C4 in the FFP
- Has Cetirizine been misremembered instead of Cinryze as an option in this question? No it wasn’t
-> adrenaline, steroids, antihistamines have no role in treatment of HAE acute attack
A bleeding patient has ROTEM results including (ROTEM results shown). The most
appropriate treatment is
a) Plts
b) FFP
c) Cryo
d) TXA
c) Cryo
Cryo or TXA,
TXA first line treatment however patient has low fibrinogen and requires fibrinogen replacement.
The recommended dose of IV adrenaline in a 15 kg, 5 year old child with grade 2 (moderate) perioperative anaphylaxis is
a) 15mcg
b) 30mcg
c) 50mcg
d) 100mcg
e) 150mcg
b) 30mcg
Moderate = 2mcg/kg
Life threatening = 4-10mcg/kg
file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf
The drug that is LEAST likely to decrease blood flow to the splanchnic circulation is:
a) Noradrenaline
b) Adrenaline
c) Vasopressin
d) Dopamine
e) Phenylephrine
d) Dopamine
Dobutamine (β1 and β2), dopexamine (DA1, some β2) and low-dose dopamine (DA1 and DA2, β1 and β2, α1 in high dose) all have vasodilatory effects on the splanchnic circulation, and have been shown to improve markers of perfusion. For many years, low-dose infusions of dopamine were used as a prophylactic and therapy for acute renal failure, using the logic that DA1- and DA2-mediated vasodilation in renal and splanchnic beds would be protective.
https://pubmed.ncbi.nlm.nih.gov/12794401/
When commencing treatment of proximal deep vein thrombosis or pulmonary embolus, factor Xa inhibitors (apixaban, rivaroxaban) are preferred to dabigatran or warfarin because they do not require
a. A need to dose reduce in pregnancy
b. No need to dose reduce in renal failure
c. No need to bridge
d. Need for monitoring
e. Once daily dosing
c. No need to bridge
See ETG recommendations
https://www.ahajournals.org/doi/full/10.1161/JAHA.120.017559
A patient taking tranylcypromine, a monoamine oxidase inhibitor, requires elective surgery.
The best management is to
(made up answers)
a) Cease 1 month before surgery
b) Do not Cease
c) Cease day of surgery
d) Cease 2 weeks before surgery
e) stop 2 weeks before, start moclobemide and omit Moclobemide day of surgery
e) stop 2 weeks before, start moclobemide and omit Moclobemide day of surgery
-> probably in discussion with the patients psychiatrist
Tranylcypromine, sold under the brand name Parnate among others, is a monoamine oxidase inhibitor. More specifically, tranylcypromine acts as nonselective and irreversible inhibitor of the enzyme monoamine oxidase.
In the elective setting, there is some debate regarding the management of patients on MAOI. Although the risks associated with anaesthesia in those taking this group of drugs are significant, abrupt withdrawal may precipitate serious psychiatric relapse. Traditionally, irreversible MAOIs have been stopped 2 weeks before operation; however, omitting the dose of moclobemide on the day of surgery is acceptable. It has been suggested that in the elective situation, patients could be switched from an irreversible MAOI to moclobemide to avoid a prolonged period of discontinuation.
The antiemetic least likely to precipitate an arrhythmia in a patient with this ECG is
a) Droperidol
b) Metoclopramide
c) Promethazine
d) Dexamethasone
e) Ondansetron
d) Dexamethasone
The ECG shows LONG QT
https://litfl.com/qt-interval-ecg-library/
20.2 The composition of Plasma-Lyte 148 (in mmol/l) includes
a Na 140 Mg 1.0 K 5.0 acetate 27 lactate 0
b Na 140 Mg 1.5 K 5.0 acetate 0 lactate 27
c Na 140 Mg 1.0 K 4.0 acetate 24 lactate 0
d Na 140 Mg 1.0 K 4.0 acetate 0 lactate 24
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
