Quick Phrases

Question 1

Describe your induction technique for a patient with severe aortic stenosis

Answer 1

My goals for this induction is to maintain preload, after load, and sinus rhythm.

I will achieve this by running a GA.
- Prior to induction, I will site art line, run fluid to maintain euvolaemia, and commence metaraminol infusion.

• I will use high dose fentanyl and a slow titrated, low-dose propofol infusion, in order to prevent hypotension, and blunt the sympathetic response to laryngoscopy. I will then give 100mg of rocuronium for intubation.

Question 2

You are called to ICU to intubate a morbidly obese, hypoxic patient. What are your priorities?

Answer 2

This is likely going to be a difficult airway.

My priorities are to
1) optimise oxygenation
2) prepare thoroughly for a difficult airway with safe rescue strategies.
3) minimising aspiration risk
4) ensure adequate resource for airway management in a remote location.

Question 3

How are you going to intubate a morbidly obese, hypoxic patient in ICU?

Answer 3

Preparation:
- Difficult airway trolley + experienced airway assistant.
- Ramp patient, then pre-oxygenate upright with NIV.
- Ensure adequate IV access, arterial line, and end-tidal monitoring.

Induction:
- Perform RSI with alfentnail, propofol, rocuronium, then lie patient flat.
- Intubate with videolaryngoscope as plan A, and confirm placement with EtCO2.

Question 4

How would you modify your induction for a patient with raised intracranial pressure?

Answer 4

My goals for this induction is to:
1) Maintain cerebral perfusion and oxygenation.
2) Prevent rise in ICP.
3) Acknowledge risk of aspiration.

Preparation:
- Temporise with mannitol and head up position.
- Ensure adequate IV access, arterial line, and infusions.

Induction:
- Slow uptitration of propofol and remifentanil, with metaraminol to maintain a MAP of 80 to 90.
- Once unresponsive, give 100mg rocuronium.
- Gentle laryngoscopy to secure airway.

Question 5

You have a patient with ongoing massive haemorrhage in theatre needing urgent anaesthesia. How would you induce this patient?

Answer 5

My goals are:
- Rapid onset anaesthesia.
- Maintain sympathetic drive and permission hypotension.
- Minimise risk of aspiration.

To achieve this, I will perform a GA with RSI.
- Ensure well working IV access and art line if time permits.
- Induce with 1mg/kg ketamine, 100mg rocuronium, apply cricoid, then secure the airway with a video laryngoscope and a size 8 ETT.

I will ensure that massive transfusion protocol is ongoing, and maintain SBP of 80-100 throughout.

Question 6

You are asked to anaesthetise a patient with severe pulmonary hypertension for an elective laparoscopic cholecystectomy. How would you approach induction?

Answer 6

My goals are:
1. Prevent further rise in PVR
2. Maintain perfusion and function of the right heart.

To achieve this, I will
- Ensure adequate IV access, arterial line, CVC prior to induction. Vasopressor and pulmonary vasodilators ready.
- Arrange for second anaesthetist with TOE expertise.
- Adequate pre-oxygenation for EtO2 of >0.9.
- I will perform a modified RSI with 2mg midaz, 300microg fentanyl, 40mg propofol, and 100mg rocuronium, and secure airway with a videolaryngoscope.

• Actively avoid hypoxia, hypercapnia, acidosis, and excessive sympathetic stimulation. Maintain MAP of 65 at all time.

Question 7

What vasopressor, inotropes, and pulmonary vasodilators will you use for a patient with severe pHTN?

Answer 7

Vasopressors:
- Noradrenaline at 1-10microg/min.
- Vasopressin at 1-3 units/hr

Pulmonary vasodilators:
- Inhaled NO at 20-50ppm.
- Milranone at 0.25microg/kg/min. Can also use nebulise dose at 5mg.

Inotropes
- Dobutamine 1-5 mic/kg/min

Question 8

You are asked to anaesthetise a child with active post-tonsillectomy bleeding for surgical control. What are your priorities?

Answer 8

My priorities are:
1) Volume resuscitation with crystalloid and blood products.
2) Rapidly secure the airway to minimise aspiration risk.
3) Prepare for difficult airway due to anatomical distortion and active bleeding.

Question 9

How will you induce this child with active post-tonsillectomy bleed?

Answer 9

I will achieve my priorities by:
- Team briefing on difficult airway plan, with adequate rescue management including a ENT surgeon on standby.
- Ensure adequate IV access and ongoing volume resuscitation.
- Prepare 2x functioning suctions, bottle of saline, adequate lighting, videolaryngoscope.

• Attempt pre-oxygenation with child upright. Induce with 3mg/kg propofol and 1mg/kg of sux. Cricoid on once child lied flat.
• Intubate with videolaryngoscope and an appropriately sized ETT. Limit amount of attempts and progress through pre-planned rescue techniques.