risk score Flashcards
The Glasgow Blatchford score is used to risk stratify:
a) Pulmonary haemorrhage
b) Traumatic intraperitoneal haemorrhage
c) PPH
d) SAH
e) UGI bleed
e) UGI bleed
Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management. Use for adult patients being considered for hospital admission due to upper GI bleeding.
Components: haemoglobin, BUN, initial systolic BP, heart rate > 100, melena present, recent syncope, hepatic disease history, cardiac failure present.
Med-Calc
The MELD-Na (Model for End-Stage Liver Disease-Sodium) score includes all of the following parameters EXCEPT:
a) Bilirubin
b) INR
c) Albumin
d) Creatinine
Albumin
MELD uses the following parameters:
- Bilirubin
- INR
- Creatinine
- [Hyponatraemia]
○ Part of the MELD-Na score update in 2016
○ Sodium (Na) Values < 125 are set to 125 and values >137 are set to 137
4 MELD levels are:
- >/=25 (gravely ill)
- 24-19
- 18-11
- </=10
In patients who have undergone abdominal surgery an elevated MELD score was a better predictor of poor perioperative outcome than Child-Pugh Classification
- MELD score >15 should avoid elective surgery
Calculation:
MELD =
3.8loge(serum bilirubin [mg/dL]) + 11.2loge(INR) + 9.6*loge(serum creatinine [mg/dL]) + 6.4
MELD-Na =
MELD + 1.32 * (137-Na) - [0.033*MELD * (137-Na)]
NP A 74-year-old presents for a femoral popliteal artery bypass procedure for peripheral limb ischaemia. Regarding its role in modifying their 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
REPEAT
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
Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest
POISE 2 TRIAL
23.1 According to the Fourth Consensus Guidelines for the Management of Post-operative Nausea and Vomiting (PONV) published in 2020, multimodal PONV prophylaxis should be implemented in adult patients
a. For everyone
b. 1 or more RF
c. 2 or more RF
d. 3 or more RF
e. 4 or more RF
b) 1 or more RF
22.1 The risk of a perioperative respiratory adverse event in a child is least likely to be increased by
a. Asthma
b. Infection 3 weeks ago
c. History of eczema
d. Passive smoking
History of eczema
APRICOT study
22.2 A patient with an acute subarachnoid haemorrhage arrives in the emergency department. Her Glasgow Coma Scale score is 10 and she has no motor deficit. A CT brain shows diffuse subarachnoid haemorrhage with no localised areas of blood > 1 mm thick, and no intracerebral nor intraventricular blood. Her World Federation of Neurosurgical Societies (WFNS) grade of subarachnoid haemorrhage is
a) 1
b) 2
c) 3
d) 4
e) 5
4
GCS 7-12
22.1 A risk factor for postoperative nausea and vomiting in adults is age less than
a. 20
b. 30
c. 40
d. 50
e. 60
50
4th consensus guidelines for management of PONV
21.2 Of the following, the lifestyle modification that is least effective in reducing essential
hypertension is
a) Stopping caffeine
b) Low salt diet
c) High potassium diet
d) Exercise
e) Alcohol cessation
a) Stopping caffeine
Eat a well-balanced diet that’s low in salt
Limit alcohol
Enjoy regular physical activity
Manage stress
Maintain a healthy weight
Quit smoking
Foods that are rich in potassium are important in managing high blood pressure (HBP or hypertension) because potassium lessens the effects of sodium. The more potassium you eat, the more sodium you lose through urine. Potassium also helps to ease tension in your blood vessel walls, which helps further lower blood pressure.
Source AHA
21.1 The modified Aldrete scoring system uses all of the following EXCEPT
a) BP
b) Pain score
c) Resp rate
d) sedation level
pain score
20.2 You are seeing a 48 year-old woman in your pre-operative clinic for assessment for laparoscopic sleeve gastrectomy. Her co-morbidities include obesity (BMI is 65 kg/m2), hypertension, type 2 diabetes mellitus and polycystic ovary syndrome. Her neck circumference is 38 cm. Her husband states that she snores loudly, but he has never observed her having any apnoeic episodes and she reports no excessive tiredness during the day. Her score using the STOP-BANG questionnaire is
a. 3
b. 4
c. 5
d. 6
e. 7
a. 3 (snoring, BMI, Htn)
Snoring loudly
Tiredness during day time
Observed Apnoea
Pressure: Htn
BMI > 35
Age > 50
Neck circumference >40cm (43cms male)
Gender: Male
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
22.1 A risk factor for the development of torsade de pointes is
a. hyperkalaemia
b. hypermagnasaemia
c. tachycardia
d. Female
d. Female
20.1 IgE-related penicillin anaphylaxis crossover rate with cephazolin
a. 0.1%
b. 1%
c. 5%
d. 10%
1%
BJA ED
20.2, 22.2 The modified Aldrete scoring system is used for determining the
a) Predicts difficulty of bag mask ventilation
b) Safety of day surgery
c) Discharge from recovery
d) Modification of recovery criteria
e) Discharge from hospital
c) Discharge from recovery
Aldrete score, which includes five elements (activity, respiration, circulation, consciousness, oxygen saturation) [16].
The original scoring system was developed before the invention of pulse oximetry and used the patient’s colouration as a surrogate marker of their oxygenation status. A modified Aldrete scoring system was described in 1995 which replaces the assessment of skin colouration with the use of pulse oximetry to measure SpO2.
The Modified Aldrete system includes five additional elements that are particularly useful during the Phase II recovery period prior to discharge to home (dressing, pain, ambulation, feeding, urine output)
21.1 The implemention of comprehensive multidisciplinary geriatric assessments in the peri-operative period has been shown to
a) Reduce mortality
b) Reduce AKI
c) Reduce periop risk of MACE
d) Reduce length of stay
e) Increase cancellation for surgery
d) Reduce length of stay
less time in aged care and reduced mortality
Blue book 2019:
“A referral to a geriatrician for further assessment and management may also be warranted in the preoperative period.
Indeed, a meta-analysis of perioperative interventions to reduce delirium found that a geriatrics consultation before surgery was one of only two perioperative interventions that were associated with a reduction in delirium.”
Association of anaesthetists: The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review
- reduced medical complications
> reduced postop delirium,
> reduced pneumonia
> reduced pressure sores - fewer cancellations
- reduced length of stay
22.2 Predictors of difficult sedation (agitation or inability to complete the procedure) of patients undergoing gastroscopy do NOT include
Unknown options but…
Factors associated WITH difficulty during Gastroscopy were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during COLONOSCOPY were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use
22.1 Following the initial subarachnoid haemorrhage from a ruptured aneurysm, the patient is at greatest risk of rebleeding during the following
a. 1-3 days
b. 3-5 days
c. 5-7 days
d. 7-10 days
a. 1-3 days
21.1 The risk of a perioperative respiratory adverse event in a child is least likely to be increased by
A. Asthma
B. infection 3 weeks ago,
C. history of eczema,
D. passive smoking
history of eczema
22.1 Created by the Global Initiative for Chronic Obstructive Lung Disease, the alphabetical GOLD groups A to D are tools for the assessment of chronic obstructive pulmonary disease. These classes are based on
a. Symptoms and exacerbations
b. FEV1
c. FEV1 and exacerbations
d. FEV1/FVC and exacerbations
e. FEV1 and symptoms
Sx and exacerbations
FEV1
GOLD ABE assessment tool
21.2 A factor that is NOT used to calculate the Child-Pugh score is
a) Albumin
b) Bilirubin
c) INR
d) Creatinine
e) Ascites
d) Creatinine
- Originally devised to predict outcomes in Cirrhotic patients undergoing portosystemic Surgery
- Assess perioperative risk for patients with liver disease who undergo hepatic or non-hepatic surgery
- Factors include:
o Encepahlopathy
§ None +1
§ Mild to moerate + 2
§ Severe +3
o Ascites
§ None +1
§ Mild to moderate (diuretic responsive) +2
§ Severe (diuretic refractory) +3
o Bilirubin
§ <2 mg/dl +1
§ 2-3mg/dl +2
§ >3 mg/dl +3
o Albumin
§ >3.5g/dl +1
§ 2.8-3.5g/dl +2
§ <2.8g/dl +3
o INR
§ <1.7 +1
§ 1.7-2.3 +2
§ >2.3 +3 - Class A 5-6 points
o 1-5yr survival rate 95% - Class B 7-9 points
o 1-5 year survival rate 75% - Class C 10-15 points
1-5 yr survival rate 50%
Original study Mortality rates in patients who undergo abdominal surgeries:
- Class A 10%
- Class B 82%
- Class C 82%
Newer Study mortality rates after surgery:
- Class A 2%
- Class B 12%
- Class C 12%
Drawbacks:
- Subjective measurement of:
o ascites
o encephalopathy
- Does not consider
o Pre-op infection
o Aetiology of cirrhosis
o Surgery type
23.1 In children, severe sleep apnoea is suggested by an apnoea-hypopnoea index
greater than
a. 10
b. 15
c. 20
d. 30
e. 40
a) 10
22.2 The 2012 Berlin definition of the acute respiratory distress syndrome (ARDS) defines moderate disease as one with a PaO2 / FiO2 ratio (in mmHg) of
a) 50-100
b) 100-200
c) 200-300
d) 300-400
a) 100-200
2012 BERLIN DEFINITION OF ARDS
ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.
Key components
- acute, meaning onset over 1 week or less
- bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph
- PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
- “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.
Severity
- ARDS is categorized as being mild, moderate, or severe:
23.1 The Sequential Organ Failure Assessment (SOFA) score is used in intensive care for the assessment of sepsis. This score does NOT include the
a. Bilirubin
b. Platelets
c. PaO2/FiO2
d. GCS
e. Hypoglycaemia
e) hypoglycaemia
21.2 An adult with renal failure on regular haemodialysis has an ASA (American Society of
Anesthesiologists) physical status classification of at least
a) 1
b) 2
c) 3
d) 4
e) 5
ASA 3
Source: ASA Classification
https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
21.1, 22.2 Intraoperative lung protective ventilation strategies include all of the following EXCEPT
A. Vt 6-8ml/kg
B. Patient titrated PEEP
C. Recruitment manoeuvre
D. I:E ratio 1:3
I:E ration 1:3
BJA Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations:
An expert consensus was reached for 22 recommendations and four statements.
The following are the highlights:
(i) a dedicated score should be used for preoperative pulmonary risk evaluation; and
(ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs.
The ventilator should initially be set to a tidal volume of 6–8 ml kg−1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O.
PEEP should be individualised thereafter.
When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used.
Inspiratory/expiratory ratio:
Several studies have compared prolonged inspiratory-to-expiratory (I:E) ratios to the 1:2 ratio commonly used during mechanical ventilation.
An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage.
Prolonged I:E ratio increases mean airway pressure and concomitantly reduces peak airway pressure.
Studies using prolonged inspiratory times have described beneficial effects, including increased CRS and PaO2, lower alveolar–arterial gradient, and reduced inflammatory markers.
Given the lack of evidence for a clear benefit of a specific I:E ratio, no recommendation was offered by the panel.
However, the panel noted that optimisation of inspiratory time for individual patients can be achieved by monitoring parameters, such as oxygenation, CRS, and ΔP.
Intraoperative FIO2
Increased FIO2 during mechanical ventilation is administered to prevent or correct hypoxaemia, but may result in hyperoxia.
The negative effects of hyperoxia are not clear, but it has been suggested that it may increase oxidative stress, peripheral vascular and coronary artery vasoconstriction, decrease cardiac output, increase resorption atelectasis, and increase the rate of PPCs.
Recommendations for optimal use of oxygen and current evidence regarding the association between hyperoxaemia and clinically relevant outcomes during intraoperative mechanical ventilation are lacking.
Few studies have revealed a protective effect of hyperoxaemia, some report an association with mortality, whilst others show no association with clinically relevant outcomes.
Therefore, in the absence of evidence, the most prudent course of action during mechanical ventilation is to maintain normoxaemia.
SpO2 monitoring can assist in the detection of hypoxaemia, but during oxygen therapy SpO2 cannot detect hyperoxia.
Whilst SpO2 monitoring reduces the incidence of hypoxaemia, it does not improve the overall patient outcomes and does not reduce morbidity and mortality.
Therefore, once the airway is secured, FIO2 should be set to ≤0.4 with the goal of using the lowest possible FIO2 to achieve normoxia (or SpO2 ≥94%)
Unnecessarily high FIO2 should be avoided.
Administering lower FIO2 will not only decrease the risk of hyperoxia, but will also reduce the masking effect of oxygen therapy and allow for earlier diagnosis of gas-exchange impairment.
22.1 A patient with a body mass index 34 kg/m2 with no other disease has an ASA (American Society of Anesthesiologists) Physical Classification of at least
a. I
b. II
c. III
d. IV
b. II
21.2 A man with atrial fibrillation has no valvular heart disease. According to joint American Heart Association (AHA), American College of Cardiology (ACC) and Heart Rhythm Society (HRS) guidelines, oral anticoagulants are definitely recommended if his CHA2DS2-VASc score is greater than or equal to
a) 1
b) 2
c) 3
d) 4
e) 5
b) 2
- 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
22.1 Moderate obstructive sleep apnoea in children is diagnosed by an apnoea-hypopnoea index of
a. 5-10
b. 10-15
c. 15-20
d. 20-25
e. 25-30
a. 5-10
21.1 Severe obstructive sleep apnoea in a 6-year-old child is confirmed if during polysomnography the
apnoea/hypopnea index (AHI) is greater than or equal to
A >5
B >10
C >15
D >20
E >30
> 10
22.1 According to the ‘Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (PONV)’ published in 2020, multimodal PONV prophylaxis should be implemented in adult patients
a. For everyone
b. 1 or more RF
c. 2 or more RF
d. 3 or more RF
e. 4 or more RF
b. 1 or more RF
In this iteration of the PONV guideline, one of the major changes is that we now recommend the use of multimodal prophylaxis in patients with one or more risk factors. This decision was made due to the concern over inadequate prophylaxis as well as the availability of antiemetic safety data.
21.2 International guidelines state that patients presenting for major surgery have inadequate or low iron stores if their serum ferritin level is less than
a) 20
b) 30
c) 50
d) 100
ANSWER: d. Ferritin <100mcg/L
Serum ferritin level < 30 μg.l−1 is the most sensitive and specific test used for the identification of absolute iron deficiency. However, in the presence of inflammation (C-reactive protein > 5 mg.l−1) and/or transferrin saturation < 20%, a serum ferritin level < 100 μg.l−1 is indicative of iron deficiency.
International consensus statement on peri-operative management of anaemia and iron deficiency
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773#:~:text=Recommendations%20for%20best%20clinical%20practice,-Physicians%20should%20consider&text=Serum%20ferritin%20level%20%3C%2030%20%CE%BCg,serum%20ferritin%20level%20%3C%20100%20%CE%BCg.
The Sequential Organ Failure Assessment (SOFA) score is used in intensive care for the
assesment of sepsis. This score does NOT include the:
a) MAP
b) FiO2/PaO2
c) INR
d) GCS
e) Plts
Previous Q (23.1) with different options.
ANSWER C (INR)
The modified Aldrete scoring system uses all of the following EXCEPT the
a) BP
b) Pain score
c) Resp rate
d) sedation level
b) Pain score
Aldrete score, which includes five elements (activity, respiration, circulation, consciousness, oxygen saturation) [16].
The original scoring system was developed before the invention of pulse oximetry and used the patient’s colouration as a surrogate marker of their oxygenation status. A modified Aldrete scoring system was described in 1995 which replaces the assessment of skin colouration with the use of pulse oximetry to measure SpO2.
The Modified Aldrete system includes five additional elements that are particularly useful during the Phase II recovery period prior to discharge to home (dressing, pain, ambulation, feeding, urine output)
