Rakesh 5 Flashcards
- A 54-year-old man with a history of COPD undergoes left shoulder
arthroscopic surgery under interscalene brachial plexus block. The operation
was uneventful. In recovery after 30 min the nurse looking after the patient
noticed he was looking pale, with heart rate of 110, BP of 110/70 mmHg,
respiratory rate of 25/min, and saturation of 90 % on room air. On auscultation
there was no wheeze and air entry on left base was reduced. The chest X-ray
in recovery appears normal. What is the most likely cause of his symptoms?
A. Local anaesthetic toxicity.
B. Left phrenic nerve block/palsy.
C. Exacerbation of COPD.
D. Horner’s syndrome.
E. Recurrent laryngeal nerve block.
B
- Answer: B
Local anaesthetic toxicity is less likely considering the duration of the operation. Phrenic nerve palsy
is the most likely cause for all the symptoms and signs. The chest X-ray needs to be in inspiratory
phase to show the raised diaphragm of left side. Recurrent laryngeal nerve block is a well-known
complication after interscalene block, which can cause hoarseness of voice due to ipsilateral
paralysis of the vocal cords. The other mentioned complications are possible but are unlikely
- A 54-year-old patient is having retinal detachment surgery under
general anaesthetic. During the surgery the patient became bradycardic
with heart rate of 40 beats per minute and blood pressure of 75/40.
What is the fi rst thing would you do?
A. Reduce the inspired inhalation concentration of isofl urane.
B. Give intravenous glycopyrolate 200 mcg.
C. Give intravenous atropine 600 mcg.
D. Stop the surgeon operating and release the muscles of the globe.
E. Give intravenous ephedrine 6–12 mg.
D
- Answer: D
The oculo-cardiac refl ex (OCR) can occur secondary to traction on the eye and ocular muscles,
resulting in bradycardia. Occasionally it can cause junctional rhythm or asystole. The aff erent
pathway is ciliary ganglion to ophthalmic division of trigeminal nerve to gasserian ganglion to main
trigeminal sensory nucleus fourth ventricle. The eff erent pathway is the vagus nerve.
The fi rst step in managing OCR is to releasing the traction on the eye. Persistent bradycardia
should be treated with anticholinergic drugs. Intravenous atropine sulphate blocks the peripheral
muscarinic receptors at the heart, and release of traction blocks the conduction at ciliary ganglion
on the aff erent limb of OCR. Atropine or glycopyrrolate can be used to treat this refl ex and it can
be given prophylactically. Hypoxia, hypercarbia, and light anaesthesia potentiate this refl ex and
should be avoided. Retrobulbar block does not guarantee attenuation of this refl ex.
- A 65-year-old lady with BMI of 38 had a total knee replacement
under general anaesthesia. Femoral nerve block was performed using
ultrasound. She suff ers from mild asthma and hypertension. The total
tourniquet time was 1 h 40 min. Twenty-four hours postoperative, the
patient complained of paraesthesia in the right foot and is found to have
foot drop. Which of the following is the most likely cause?
A. Pressure injury from the long duration of operation.
B. Ischaemic injury to the calf muscle.
C. Deep vein thrombosis in the calf muscle.
D. Compression injury to the sciatic nerve.
E. Compartment syndrome in the thigh.
D
- Answer: D
Foot drop can be defi ned as a signifi cant weakness of ankle and toe. The foot and ankle dorsifl exors include the tibialis anterior, extensor hallucis longus, and extensor digitorum longus. These muscles are supplied by the sciatic nerve. The paresis of sciatic nerve is more like to be due to the insult secondary to the prolonged application of the tourniquet. Pressure injury, ischaemic injury, and DVT are less likely.
- An 8-year-old child is rescued 20 min after near-drowning and has a
core temperature of 30 ° C and fi xed dilated pupils. Along with the
resuscitation what would be the appropriate treatment:
A. Intravenous barbiturate infusion.
B. Rapid re-warming to 32–34 ° C.
C. Intravenous steroid therapy.
D. Hypoventilation.
E. Intravenous sodium bicarbonate.
B
4. Answer: B
Accidental hypothermia exists when the body’s core temperature unintentionally drops below
35 ° C. Hypothermia can be classifi ed arbitrarily as mild (35–32 ° C), moderate (32–28 ° C), or severe
(<28 ° C). In a hypothermic patient, the absence of signs of life alone is unreliable for declaring death.
- A 65-year-old male patient had open prostatectomy under general
anaesthesia. The surgical procedure was complicated, with prolonged
anaesthesia for 5 h, and there was a total blood loss of about 2.5 L. Intraoperatively
he received 6 units of packed cells and he was transferred
to the intensive care unit. In the intensive care unit, the patient was
tachycardic and hypotensive. The peak airway pressure was about
30–35 cm H 2 O. On chest examination there were bilateral lung
crepitations. The most likely cause of his condition is:
A. Cardiogenic shock.
B. Acute myocardial infarction.
C. Sepsis.
D. Transfusion-related reaction.
E. Transfusion-related acute lung injury.
E
- Answer: E
The clinical condition presented here is following the transfusion of packed cells. Hence the most
likely diagnosis is transfusion-related acute lung injury (TRALI). TRALI is defi ned as new acute
lung injury occurring during or within 6 h after a transfusion, with a clear temporal relationship to
the transfusion. Another important concept is that acute lung injuries temporally associated with
multiple transfusions can be TRALI because each unit of blood or blood component can carry one
or more of the possible causative agents: anti-leukocyte antibody, biologically active substances,
and other yet unidentifi ed agents.
- A 35-year-old male is listed for electroconvulsive therapy. He is
medically fi t but has a family history of allergy to suxamethonium.
You are advised by the consultant to use rocuronium and sugammadex.
Which of the following statements is true regarding sugammadex?
A. Most of the drug is metabolized and excreted by kidney.
B. Sugammadex binds with rocuronium at the neuromuscular junction.
C. The drug forms complex with the rocuronium with a ratio of 1:3.
D. The free plasma concentration of rocuronium increases following complex formation with
sugammadex.
E. It is a modifi ed γ -cyclodextrin with eight side chains and a negatively charged carboxyl
group.
E
- Answer: E
Sugammadex is the fi rst selective relaxant binding agent to reverse neuromuscular blockade. It is
a γ -cyclodextrin that forms a tight (1:1) one-to-one complex with rocuronium (vecuronium to a
lesser extent), reducing the plasma concentration of the neuromuscular blocking agents and rapidly
reversing their eff ects. It is a modifi ed γ -cyclodextrin with eight side chains and negatively charged
carboxyl group to increase the affi nity.
- As a universal precaution there is a recommendation to use a heat
and moisture-exchange fi lter with each patient. A heat and moistureexchange
fi lter incorporates a high-effi ciency particulate air fi lter of
small size. Which of the following pathogens will pass through the
heat and moisture-exchange fi lter?
A. Pseudomonas aeruginosa .
B. Mycoplasma pneumonia .
C. Mycobacterium tuberculosis .
D. Staphylococcus aureus .
E. Legionella pneumophilia.
a
- Answer: C
A standard heat and moisture exchange fi lter is tested to 0.3 μm pore size.
The sizes of the organisms are:
Pseudomonas aeruginosa : 1–3 μm
Mycoplasma pneumoniae : 0.15 μm is the smallest.
Mycobacterium tuberculosis : 2–4 μm length, 0.2–0.4 μm wide
Staphylococcus aureus : 0.6 μm diameter
Legionella pneumophilia : 1–3 μm long, 0.5–1.0 μm wide
- A 70-year-old woman is referred to the pain clinic with severe shooting
pains in the upper half of the left side of her face. These are made worse
by eating. Physical examination and all investigations are normal. Simple
analgesics have not provided eff ective pain relief. Which of the following
would be the initial treatment?
A. Carbamazepine.
B. Topical capsaicin ointment.
C. Oral morphine.
D. Transcutaneous nerve stimulation (TENS).
E. Fluoxetine.
A
8. Answer: A
Trigeminal neuralgia is an intermittent, usually unilateral, severe neuropathic pain, which can come
on spontaneously or by stimulation of the trigger zone. There is an abnormality in the trigeminal
sensory system. There is signifi cant female preponderance (2:1). Magnetic resonance imaging is
recommended in these patients.
Classifi cation
Type 1 is primary or idiopathic.
Type 2 is secondary to irritation or compression of the trigeminal nerve by tumour or disease,
including multiple sclerosis.
Medical treatment
Response to carbamazepine is almost diagnostic of this condition. Gabapentine, baclofen, and
sodium valproate have also been used.
- A 70-year-old patient, who had a hip replacement 2 weeks ago, now
has dislocated the hip. The patient is on ramipril, simvastatin, aspirin,
and dabigatran. Which of the following statements is correct regarding
dabigatran?
A. The drug is licensed for venous thromboembolism (VTE) prophylaxis in AF patients.
B. The drug is in its active form.
C. The drug needs routine coagulation monitoring.
D. The drug is a direct thrombin inhibitor.
E. The drug is metabolized in liver and excreted by kidney in inactive form.
e
- Answer: D
Dabigatran is a new oral anticoagulant for prevention of venous thromboembolism. This drug is a specific, competitive, and reversible thrombin inhibitor.
Mechanism of action
Dabigatran is a direct thrombin inhibitor and is used in the form of a pro-drug, dabigatran etexilate.
This is metabolized by plasma esterases into active drug, dabigatran. It prolongs APTT, PT, and TT.
The real advantage of the drug is it does not need routine coagulation monitoring. It does not have
a specifi c antidote
- An 88-year-old male patient is admitted with fracture of neck of femur
for left hip hemiarthroplasty. The patient is a known hypertensive, on
atenolol 50 mg and ramipril 5 mg. Following spinal anaesthesia the
blood pressure drops to 60/35 mmHg and his heart rate drops from
80 to 60/min. He has received 1.5 L of Hartman’s solution. The next
step is:
A. To transfuse 500 mL crystalloid and recheck the blood pressure every 1–2 min.
B. To give incremental bolus of 6 mg ephedrine along with the crystalloid.
C. To position the patient’s head downwards and infuse 500 ml crystalloid.
D. To give 250 ml of gelofusion along with the bolus of 6 mg of ephedrine.
E. To give 500 mcg metaraminol as bolus, along with the rest of the crystalloid and recheck
the blood pressure.
e
- Answer: E
Central neuraxial block causes reduction of sympathetic outfl ow, which results in reduction of
the sympathetic tone and reduction of the systemic vascular resistance. This is compensated by
increase in heart rate and stroke volume; in a group of geriatric patients these are less eff ective.
Furthermore, this patient is on β -blockers and ACE inhibitors, which, along with less compliant
ventricles, further compounds the problem for the patient. In the elderly patient hypotension
should be treated with cautious use of fl uids and vasopressors. Ephedrine is likely to be ineff ecti
- A 50-year-old man with metastatic cancer is listed for intramedullary
nailing of a pathological femoral fracture. For the last 3 months he has
been on 300 mg/day of oral morphine for cancer-related pain control.
What is the most appropriate way to manage his postoperative pain?
A. The patient’s morphine should be temporarily discontinued during the perioperative
period.
B. This patient has reached the upper limit of opioid and should be reduced before the surgery.
C. This patient will be tolerant to opioid analgesia — increasing opioid load would lead to
addiction and should be avoided.
D. Routine postoperative patient-controlled morphine would be adequate.
E. A combination of femoral nerve block and fentanyl patient-controlled analgesia with
shorter lock-out and higher bolus would be appropriate.
e
- Answer: E
The principles of acute pain management in the patient who is dependent on high-dose opioids
represent challenges, as it is diffi cult to diff erentiate addiction from dependence and to avoid opioid
withdrawal symptoms. It is also diffi cult to achieve adequate pain management, as tolerance to the
eff ect of postoperative opioids must also be considered.
The aim is to bring acute pain under control. Opioid use in the context of pain/analgesia is unlikely
to lead to addiction. Reducing high background opioid doses acutely may precipitate withdrawal.
Standard postoperative opioid regimes are unlikely to be adequate for opioid-tolerant patients,
who are also less likely to suff er side eff ects such as respiratory depression. Involvement of a
multidisciplinary team will often be necessary to manage behavioural, psychological, psychiatric, and
medical problems encountered in this group of patients.
- Twenty-four hours following a normal vaginal delivery a 34-year-old
woman is looking drowsy on routine examination. Her heart rate is
110/min and blood pressure is 85/40 mmHg. Her temperature is noted
to be 38.9 ° C. She is treated with 1 L of crystalloid and oral amoxicillin.
The midwife is concerned and has asked for an anaesthetic review of
the patient. What would be the most appropriate step to follow?
A. Keep giving fl uid until the tachycardia settles.
B. Insert a central venous line to monitor fl uids on the ward.
C. Arrange early transfer to an HDU facility.
D. Ask the midwife to do hourly MEWS on the ward.
E. Advise the obstetrician to refer her to the medical team.
c
- Answer: C
During the 2006–2008 triennium, sepsis was the leading cause of direct maternal death, accounting
for 26 direct deaths and with a further 3 deaths classifi ed as ‘late direct’, particularly those
associated with Group A streptococcal infection (GAS).
Most of the deaths occurred in the postpartum period; more than half following lower segment
caesarean section. Seven women died from sepsis that developed after vaginal delivery, illustrating
- A 56-year-old male presents for day-case knee arthroscopy. On the day
unit he seems to be slightly confused. Patient is a known alcoholic and
had a few admissions to the hospital with upper gastrointestinal bleeding.
The last hospital letter shows he was diagnosed with end-stage liver
failure. What would be the most appropriate anaesthetic management?
A. Cancel the case and rearrange as an inpatient procedure.
B. Cancel the patient, as anaesthesia carries high risk and this is not a life-threatening
situation.
C. Call the bed manager, arrange an inpatient bed and do the case.
D. Patient would need to be intubated as he is at high risk of aspiration.
E. After the procedure he should be followed up by an alcohol-awareness team.
a
- Answer: B
Patients with end-stage liver disease are at signifi cant risk of mobility and mortality after anaesthesia
and surgery. Medical and surgical intervention may exacerbate liver dysfunction and result in
life-threatening hepatic failure. End-stage liver disease should constitute a relative contraindication
to surgical intervention except for life-threatening situations. Death from liver disease and
alcoholism increases by 7 % a year
- A 70-year-old man is brought to A&E following a collapse at home. The
paramedics gave him 1000 mL of crystalloid and noticed a pulsating
swelling in the abdomen. On arrival in A&E his BP is 100/60 mmHg,
heart rate is 110/min, and GCS 15/15. The FAST scan was positive
and CT scan showed leaking aneurysm. Which of the following is not
appropriate management?
A. Check NIBP in both arms.
B. Good preoperative assessment.
C. Administer IV fl uids to restore the BP.
D. Administer IV fl uids to aim for a MAP of 90 mmHg.
E. Get blood products as soon as possible.
d
- Answer: C
Ruptured AAA is a surgical emergency and a rapid preoperative evaluation is required. The fi rst
response of many anaesthetists confronted with a patient with a ruptured AAA is to administer
intravenous fl uids to rapidly restore blood pressure to near-normal levels. However, excessive
administration of fl uids prior to clamping of the aorta will increase bleeding through thrombus
dislodgement and dilution of clotting factors. A brief and targeted preoperative assessment should
be made. Most patients will have extensive atherosclerotic and smoking-related diseases. Many
patients have signifi cant coronary artery disease, which is not always obvious from history and
examination. Diabetes, hypertension, and renal impairment are also common. Blood pressure
should be checked non-invasively in both arms as there may be brachiocephalic and subclavian
artery stenosis. If there is a diff erence in readings, the higher reading should be use.
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- You are asked to review a 32-year-old woman in the post-delivery ward.
Twenty-four hours post forceps delivery, she is complaining of left foot
drop. She had a labour epidural for pain relief, which worked very well.
On examination she has good power in both legs and there are no other
neurological issues. What is the most likely cause?
A. Epidural haematoma.
B. Dense block from the top up.
C. Epidural abscess.
D. Neuropraxia of the common peroneal nerve from forceps delivery.
E. Spinal cord compression.
D
- Answer: D
Postpartum foot drop is caused by damage to the lumbosacral nerve trunk or, less frequently, the
common peroneal nerve. The lumbosacral trunk (L4 and L5) is compressed between the ala of
the sacrum and the descending foetal head. It may also occur during a forceps delivery. Typically, it
occurs in a mother of short stature with a large baby. The result is a unilateral foot drop, with loss
of sensation and/or paraesthesia along the lateral calf and foot. Common peroneal nerve damage
may occur due to improper or prolonged positioning during lithotomy, and sensory defi cit may be
limited to the dorsum of the foot. Nerve-conduction studies are required to identify the site of
neural damage with any certainty.
