safety and quality in anaesthetic practice Flashcards
The rank of volatile anaesthetic agents from highest to lowest derived global
warming potential over 100 years (GWP100) is:
a) Nitrous, des, iso, sevo
b) Des, iso, nitrous, sevo
c) Des, nitrous, iso, sevo
d) Nitrous, des, sevo, iso
B
Desflurane (Des): GWP100 around 2,500-3,000
Isoflurane (Iso): GWP100 around 1,000-1,100
Nitrous oxide (Nitrous): GWP100 around 298
Sevoflurane (Sevo): GWP100 around 130-210
Organ procurement after circulatory death is generally stood down if the time from
cessation of cardiorespiratory support to circulatory death extends beyond:
a) 60min
b) 90min
c) 120min
90 mins
30mins
Liver
Pancreas
Heart
60mins
Kidneys
90mins
Lungs
Page 35 ANZICS statement 2.4.3 Warm ischemia time
Donate life
The most appropriate order of blood products transfused sequentially through the
same blood administration set is:
A) RBC - plasma - plts
B) RBC - plts - plasma
C) Plasma - RBC - plts
D) Plts- RBC -plasma
D) Plts- RBC -plasma
according to Lifeblood guidelines, platelets MUST be given before RBC if in the same line, as red cell debris will trap platelets; platelets and plasma can be sequential through the same set; as platelets take a long time to transfuse, it makes sense to first transfuse plasma (fast), then platelets, then red cells
The muscle recommended for neuromuscular monitoring by the 2023 American
Society of Anesthesiologists practice guidelines is the:
a) Adductor Pollicis
b) Flexor pollicis longus
c) Flexor hallucis brevis
d) Corrugator supercilii
e) Orbicularis oculi
A - Adductor Pollicis - Usual site for NMT
Correct on ASA website
In the event of an electrical fire in the operating room, the correct fire extinguisher
type to use is:
a) Dry powder
b) Wet
c) Chemical
d) CO2
CO2
Pull/Aim/Squeeze/Sweep
Don’t use fire blankets - concentrated heat on patient
Saline or water for body cavity fire
Dry powder and chemical can leave residues that could damage equipment
According to the ISO colour code for medical gas cylinders, Entonox is indicated by
a) Blue/ White
b) Yellow
c) Black
d) Grey
a) Blue/ White
Blue and white shoulder
White bottle
Pre 2004 made cylinder is blue
The minimum age in years for in vitro contracture testing for suspected malignant
hyperthermia is
a) 6
b) 8
c) 10
d) 12
10
All current Australian and New Zealand laboratories follow the guidelines of the European Malignant Hyperthermia Group for In Vitro Contracture Testing.
The EMHG guidelines are summarised as follows:
Age and Weight
The minimum weight limit for Australian and New Zealand laboratories is 30 kg and the minimum age for IVCT is 10 years.
(Emhg actually says min age for muscle biopsy is 4 yrs but lab’s should not test children under 10 yrs without relevant control data)
IVCT details
The biopsy should be performed on the quadriceps muscle (eithervastus medialisorvastuslateralis), using local (avoiding local anaesthetic infiltration of muscle tissue), regional, or trigger-free general anaesthetic techniques.
The muscle samples can be dissected in vivo or removed as a block for dissection in the laboratory within 15 minutes.
The time from biopsy to completion of the tests should not exceed 5 hours.
Muscle specimens should measure 20-25 mm in length and at least four tests should be performed each one using a fresh specimen.
The tests should include a static cumulative caffeine test and a dynamic or static halothane test.
The results should be reported as the threshold concentration, which is the lowest concentration of caffeine or halothane that produces a sustained increase of at least 2 mN (0.2 grams) in baseline force from the lowest force reached.
In Australia and New Zealand, a return to practice program is recommended after an absence from consultant anaesthetic practice for more than:
a) 3 months
b) 6 months
c) 9 months
d) 12 months
12 months
A drug which is unlikely to interfere with skin testing is oral:
a) Diphenhydramine
b) Amitriptyline
c) Prednisolone
d) Risperidone
e) Ranitidine
MAYANK Risperidone
Avoid antihistamines and steroids
TCAs known to interfere
Mayo clinic website
See allergy.org.au - risp mentioned in appendix b as a med that may need held
According to the ANZCA guideline on fatigue risk management in anaesthesia practice the duration of an ideal nap is:
a) 10-20
b) 20-30
c) 40-50
MAYANK 20-30 mins
ANZCA PG43a
The clinical laser type with the greatest tissue penetration is:
a) Argon
b) Nd:yag
c) Some other yag
d) Co2
e) Holmium
b) Nd:yag
Modified Question: this question asks Greatest, old asks least
Least = CO2
Most = Nd:Yag
CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm.
Helium-Neon laser also has very little penetration.
Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm.
According to the 5th National Audit Project (NAP5), the incidence of awareness during general anaesthesia using a non-relaxant technique with a volatile agent is approximately:
a. 1:700
b. 1:8000
c. 1:10000
d. 1:19000
e. 1:136,000
REPEAT
e. 1:136,000
https://www.bjanaesthesia.org/article/S0007-0912%2817%2930746-8/fulltext
1/670 E-LSCS
1/8000 with muscle relaxation
1/8600 CTS
1/8200 Volatile + neuromuscular blocking
Overall 1:19000
According to the RELIEF study, in major abdominal surgery a liberal fluid strategy
(10 mL/kg of crystalloid at induction followed by 8 mL/kg/hour during the case)
compared to a restrictive fluid strategy, results in:
A. Increased bowel anastomosis breakdown
B. Increased mortality
C. Decreased mortality
D. No difference in wound infection
E. Decreased acute kidney injury
REPEAT
E. Decreased acute kidney injury
Restrictive had more AKI
Otherwise no outcome significant statistically
https://www.thebottomline.org.uk/summaries/relief/
A patient with known suxamethonium allergy is most likely to demonstrate cross reactivity with:
a. Mivacurium
b. Cisatracurium
c. Atracurium
d. Rocuronium
e. Cephazolin
REPEAT
AT - Rocuronium
Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 by Sadleir et al
(This paper was referenced in NAP 6 “Cross-sensitivity, based on skin testing and specific IgE, is common, with suxamethonium being the most commonly crossreacting drug (Sadleir 2013).”)
Fig 4 shows Rates of cross-reactivity for patients diagnosed with anaphylaxis according to the triggering NMBD.
- for sux anaphylaxis: highest cross-reactivity was roc (24%), then interestingly vec and cis were both tied at 12%, as were panc and atrac at 6%
PREVIOUS NOTES:
BJA Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011
https://academic.oup.com/bja/article/110/6/981/245571
Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important.
Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium.
Anaphylaxis rates (highest to lowest)
Primary anaphylaxis: rocuronium > atracurium > vecuronium > pancuronium = cisatracurium
Cross-reactivity: suxamethonium > rocuronium > vecuronium > pancuronium > atracurium > cisatracurium
The image below shows results from non-inferiority trials. The trial labelled ‘M’ is best described as:
a) Non inferiority graph (line crossed the 0 line but not non-inferior dotted line)
NIKKI
Analysis of variance (ANOVA) is a statistical test to determine:
a) The validity between an expected and observed outcome in a population
b) The difference between the means of more than two populations
c) The difference between two populations with non-parametric data
d) The degree of similarity of the median between two or more populations
e) If the variance within a population is likely to be abnormally or normally distributed
REPEAT
B) analyse the difference between the means of more than two groups
In pulmonary function testing the presence of airflow limitation is defined by a post- bronchodilator FEV1/FVC ratio less than:
a) 0.5
b) 0.6
c) 0.7
d) 0.8
c) 0.7
Local anaesthetic-induced myotoxicity is most likely to be associated with:
A. Biers
B. Interscalene
C. Sciatic
D. Adductor Canal
REPEAT
D. Adductor Canal
unclear phenomonenon
prolonged exposure and high concentrations of local anaesthetic
Regarding healthcare research, the PICO framework describes:
a) Critical appraisal
b) Meta-analysis
c) Observational study
d) Systematic review
REPEAT
a) Critical appraisal
PICO is a mnemonic used to describe the four elements of a good clinical foreground question:
P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine?
I = Intervention - What main intervention, prognostic factor or exposure am I considering?
C = Comparison - Is there an alternative to compare with the intervention?
O = Outcome - What do I hope to accomplish, measure, improve or affect?
Kate According to the Australian and New Zealand Committee on Resuscitation guidelines, the minimum distance a defibrillation pad should be placed away from a pacemaker or implantable cardiac defibrillator generator is:
a) 8cm
b) 12cm
c) 16cm
A) 8cm
ANZCOR:
In patients with an ICD or a permanent pacemakerthe defibrillator pad/paddle is placed on the chest wall ideally at least 8 cm from the generator position
Kate For driving pressure guided ventilation, driving pressure is the:
a) Pplat-peep
b) Peak pressure-peep
c) Other formulas
Pplat-PEEP
driving pressure is defined as distending pressure above the applied Peep Required to generate Vt
- key variable for optimisation when performing mechanical ventilation in ARDS
- also Vt/CRS (Ratio of Tidal volume to static resp system compliance)
23.1 You are planning to extubate a patient following airway surgery. The patient has FAILED the cuff-leak test when
a. <110ml leak with cuff deflated
b. >110ml leak with cuff deflated
c. Audible leak with cuff deflated
d. No audible leak with cuff deflated
e. No audible leak with cuff pressure <30cm H2O
a. <110ml leak with cuff deflated
approach is to use 110 mL or 10% of tidal volume as the cut-off
https://litfl.com/cuff-leak-test/
21.1 Infection control management of patients with carbapenemase-producing Enterobacteriaceae (CPE)
infection should include all of the following EXCEPT
a) isolation
b) contact precautions
c) droplet precautions
d) screening at risk patients with rectal swab and urine mcs
c) droplet precautions
https://www.safetyandquality.gov.au/sites/default/files/migrated/Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceae.pdf
23.1 Therapeutic privilege is defined as
A. Withholding information to obtain consent
B. Getting presents and money for treating someone.
C. Not telling pt info because of their religious or cultural beliefs.
D. Withholding information to the patient if you think it will cause harm
D. Withholding information to the patient if you think it will cause harm
https://www.sciencedirect.com/topics/medicine-and-dentistry/therapeutic-privilege
“Therapeutic privilege,” also known as “therapeutic nondisclosure,” is defined as the withholding of relevant health information from the patient if nondisclosure is believed to be in the best interests of the patient (President’s Commission, 1982; Berger, 2005). The two most common justifications for such nondisclosure are that the disclosure would create incapacitating emotional distress and that disclosure would violate a patient’s personal, cultural, or other social requirements (Crawley et al., 2001; Berger, 2005).
20.2 A Jehovah’s Witness patient attends for a revision total hip replacement and is medically optimized. You consider she is high risk for the procedure but after extensive discussion agree to proceed, including agreeing that you will not give blood under any circumstances. Your decision can be justified on the basis of
a) Paternalism
b) Non maleficence
c) Autonomy
d) Beneficence
a) Autonomy
- Obligation to respect the decision-making capacities of persons.
Non-maleficence: Obligation to avoid causing harm
- If refused to proceed.
Paternalism: A set of attitudes and practices in which the health provider determines that a patient’s wishes or choices should not be honored.
- If transfused patient against their wishes
Beneficence: Obligation to provide benefits and to balance benefits against risks; obligation of physician to act for the benefit of the patient
- Controversial interpretation in this case. Both proceeding and refusing to do case may be acting for the benefit of the patient, depending on how you look at the scenario.
BJA: ‘MORAL balance’ decision-making in critical care
https://www.bjaed.org/article/S2058-5349(18)30145-8/fulltext
21.1 An 84-year-old woman with dementia presents for surgery for a breast lump. She lives in a care facility and is accompanied by the nurse manager from the facility and her son. Neither have a written legal authority to act on her behalf. Regarding consent for her surgery
a) Anaesthetic consent is implied in surgical consent
b) Son can’t consent
c) Legal guardian can’t consent
d) Not required if 2 Doctors are in agreement about the need for surgery
e) nil consent required if would be in patients interest/not against wishes
a) anaesthetic consent implied in surgical consent
or
e) nil consent required if would be in patients interest/ not against wishes
https://journals.sagepub.com/doi/pdf/10.1177/0310057X1003800504
The anaesthetist should give the parent or relative the same kind of information as a patient and recommend the appropriate procedure. The consent of a parent or relative is lawful authority to proceed. If the parent or relative does not wish to take this role, it may be necessary for a court or a guardianship body to appoint someone else to make the decision. This may take some time, and if the procedure is medically necessary and cannot be deferred, then reasonable treatment may be administered without consent (this is a principle of the common law and, in some jurisdictions, is also in legislation: for example, in New South Wales, the Guardianship Act 1987 (NSW) s 37; and in Victoria
22.2 Regarding cardiopulmonary exercise testing before major surgery, oxygen pulse is the
a. Arterial oxygen content at peak HR
b. Arterial oxygen saturation at mean HR?
c. Arterial oxygen saturation at peak HR
d. PaO2 at peak HR
e. Oxygen consumption/min divided by HR
e. Oxygen consumption/min divided by HR
VO2/HR: oxygen consumption divided by HR, known as the ‘oxygen pulse’ (ml beat–1)
https://www.bjaed.org/article/S2058-5349(19)30021-6/fulltext
The objective of CPET is to determine functional capacity in an individual.
Deficiencies in CPET-derived variables—specifically:
1. ventilatory anaerobic threshold (AT)
2. peak O2 consumption (VO2peak)
3. ventilatory efficiency for carbon dioxide (VE/VCO2)
—are associated with poor postoperative outcomes (mortality, morbidity, admission to intensive care, and length of hospital stay) after intra-abdominal surgery.
- Does the oxygen pulse increase with exercise?
The oxygen pulse is the VO2 divided by HR, and represents the product of the stroke volume and the arterial-venous oxygen difference. It can be seen in panel 2 and can be viewed as a surrogate for stroke volume, and as such should increase at the start of exercise before slowly reaching a plateau at its highest predicted value.
22.2 An absolute contraindication to transoesophageal echocardiography is
A. Dysphagia
B. GORD
C. Oesophageal stricture
D. oesophageal webbing
E. oesophageal varices
C. Oesophageal stricture
https://www.asecho.org/wp-content/uploads/2014/05/2013_Performing-Comprehensive-TEE.pdf
23.1 According to National Audit Project (NAP) 5, the incidence of awareness during general anaesthesia for lower segment caesarean section should be quoted as
a) 1:700
b) 1:3,000
c) 1:8,000
d) 1:19,000
e) 1:36,000
a) 1:670 (or 1:700)
22.2 The prevention of microbial contamination of living tissues or sterile materials is known as
a. disinfection
b. antisepsis
c. decontamination
d. asepsis
e. sterilisation
d. asepsis
Asepsis: the prevention of microbial contamination of living tissues or sterile materials.
Disinfection: the inactivation of non-sporing organisms using either thermal or chemical means.
Sterilisation: complete destruction of all micro-organisms, including spores.
https://www.anzca.edu.au/getattachment/e4e601e6-d344-42ce-9849-7ae9bfa19f15/PG28(A)-Guideline-on-infection-control-in-anaesthesia
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
23.1 Application of a pacemaker magnet to a dual-chamber implanted pacemaker would be expected to convert the operating mode to
a. AOO
b. VOO
c. DOO
d. AAI
c) DOO
The pacing mode will be DOO when the programmed pacing mode is a dual chamber mode or an MVP mode (AAIR<=>DDDR, AAI<=>DDD), VOO when the programmed pacing mode is a single chamber ventricular mode, and AOO when the programmed pacing mode is a single chamber atrial mode.
21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
1 hour
ASRA: 1 hour
Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.
Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.
NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.
21.1, 23.1 In patients without other co-morbidities, bariatric weight loss surgery is indicated when the body mass index (kg/m2) is greater than
a. 35
Major updates (2022) to 1991 National Institutes of Health guidelines for bariatric surgery
Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) 35 kg/m2 , regardless of presence, absence, or severity of co-morbidities.
MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2
BMI thresholds should be adjusted in the Asian population such that a BMI 25 kg/m2 suggests clinical obesity, and individuals with BMI 27.5 kg/m2 should be offered MBS.
Long-term results of MBS consistently demonstrate safety and efficacy.
Appropriately selected children and adolescents should be considered for MBS.
https://www.soard.org/article/S1550-7289(22)00641-4/fulltext#:~:text=The%201991%20NIH%20Consensus%20Statement,surgery%20that%20is%20applied%20universally
Contraindications:
- Inflammatory disease of GI tract (ulcers, oesophagitis, Crohn’s)
- Upper GI bleeding
- Portal Htn
- Liver Cirrhosis
- Chronic Pancreatitis
- Laparascopic surgery may be technically difficult in patients weighing >180kg and may be considered a relative contraindication
23.1 Diagnostic criteria for adult systemic inflammatory response syndrome include all of
the following EXCEPT
a. Leukopenia
b. Hypothermia
c. Tachycardia
d. Tachypnoea
e. Hypotension
e. Hypotension
https://www.safetyandquality.gov.au/sites/default/files/2022-06/sepsis_clinical_care_standard_2022.pdf
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
21.1 A neonate born by emergency caesarean section is limp, pale, has a weak grimace and weak cry, and a heart rate of 60 beats per minute. The Apgar Score is
A. 3
B. 4
C. 5
D. 6
E. 7
3
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 The recommended filter grade of a needle to be effective in excluding microorganisms is
0.20 um
22.2 For a 70-year-old patient on rivaroxaban with normal renal function a major guideline recommends proceeding with hip fracture surgery after two half-lives of the drug. This equates to
a. 12 hours
b. 24 hours
c. 48 hours
d. 72 hours
e.
b. 24 hours
ASA guidelines
-If creatinine clearance >/=30 ml.min-1 (Cockcroft-Gault), proceed with surgery after two half lives (24 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)
- If creatinine clearance < 30 ml.min-1, proceed with surgery after four half lives (48 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)
22.1 The gauge pressure on a gas cylinder does NOT necessarily represent the contents remaining if the cylinder is filled with
Nitrous oxide
Nitrous oxide boiling point -88.6C, critical temperature +36C -> so is below critical temp at room temp, therefore exists as a vapour in equilibrium with its liquid phase and is dependent upon pressure applied to it. Pressure gauge not informative – will always read ~52 bar (the pressure at which N2O liquefies at 20C). As vapour is drawn off, N2O moves from liquid to vapour phase, maintaining the equilibrium and same vapour pressure within the cylinder.
To determine contents: cylinder must be weighed and weight of empty cylinder subtracted, then number of moles of N2O in cylinder calculated using Avogadro’s number.
21.2 Regarding healthcare research, the PICO framework describes
a) Critical appraisal
b) Meta-analysis
c) Observational study
d) Systematic review
a) Critical appraisal
PICO is a mnemonic used to describe the four elements of a good clinical foreground question:
P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine?
I = Intervention - What main intervention, prognostic factor or exposure am I considering?
C = Comparison - Is there an alternative to compare with the intervention?
O = Outcome - What do I hope to accomplish, measure, improve or affect?
22.2 A patient presents with sepsis-induced hypoperfusion or septic shock. The minimum suggested volume of intravenous crystalloid to be administered over the first three hours as outlined in the Surviving Sepsis Guideline is
a) 10ml/kg
b) 20ml/kg
c) 30ml/kg
d) 40ml/kg
e) 50ml/kg
30ml/kg
https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Executive_Summary__Surviving_Sepsis_Campaign_.14.aspx
20.2 According to National Audit Project (NAP) 5, the incidence of awareness during general anaesthesia for cardiac surgery is
a) 1:400
b) 1:800
c) 1:8000
d) 1: 12000
e) 1:20000
c) 1:8000
Awareness rates
GA with no muscle relaxant = 1:136,000
GA with muscle relaxation = 1/8,000
CTS 1/8,600
E-LSCS = 1/670
Overall 1:19,000
22.2 According to the ANZICS Statement on Death and Organ Donation 2021, circulatory determination of death in the context of organ donation requires the absence of evidence of circulation for at least
a. 2min
b. 3min
c. 5 min
d. 10 min
c. 5 min
Circulatory determination of death in the context of organ donation
12 Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination.
13 For the purposes of organ donation, circulatory determination of death should be documented using a specific form (see Appendix E) to demonstrate explicitly that all criteria set out in this Statement are met. The same criteria should be listed in local hospital forms
20.2 Repeated unreasonable behaviour directed towards a person or group that creates a risk to health and safety is best defined as
a. Bullying
b. Harassment
c. Percipience
d. Discrimination
e. Antagonism
a. Bullying
Bullying is unreasonable behaviour that creates a risk to health and safety. It is behaviour that is repeated over time or occurs as part of a pattern of behaviour. “Unreasonable behaviour” is behaviour that a reasonable person, having regard to all the circumstances, would expect to victimise, humiliate, undermine or threaten the person to whom the behaviour is directed.
- Direct bullying – behaviour that is overt and usually involves conduct directed at a person to belittle or demean them. Examples include:
> Aggressive and intimidating behaviour.
> Belittling, degrading or humiliating comments.
> Spreading misinformation or malicious rumours.
> Interfering with a person’s property or work equipment.
> Displaying offensive material (for example pornography). - Indirect bullying – behaviour that excludes or removes benefits from a person. Examples include:
> Assigning meaningless tasks unrelated to the job.
> Setting tasks that are unreasonably below or beyond a person’s skill level.
> Deliberately changing work rosters to inconvenience particular employees.
> Deliberately withholding information that is vital for effective work performance.
Harassment is any type of unwanted behaviour that offends, humiliates or intimidates a person, and targets them on the basis of a characteristic covered by anti-discrimination law, for example gender, race, ethnicity or disability, etc. In general, harassment is any behaviour that is:
Unwelcome, not asked for and not returned.
Likely to humiliate (put someone down), seriously embarrass, offend or intimidate (threaten or scare) someone.
Based on a personal characteristic (or family or friend’s characteristic) protected by law.
Discrimination means treating a person with an identified attribute or personal characteristic as set out in legislation less favourably than a person who does not have the attribute or personal characteristic.
> Gender.
Transgender, gender history and trans-sexual status.
Pregnancy and potential pregnancy.
Childbirth or breastfeeding.
Marital status.
Sexual orientation.
Lawful sexual activity.
Disability or impairment.
Race (including colour, nationality, descent and origin).
Physical features.
Age.
Carer status and family responsibilities.
Religious belief or activity.
Political belief or activity.
Trade union membership and industrial activity.
Associated with a person who is identified by reference to any of these attributes
Sexual Harassment
Sexual harassment is against the law. Sexual harassment is unwelcome sexual behaviour, which could be expected to make a person feel offended, humiliated or intimidated. It can be physical, verbal or written.
Victimisation
Victimisation is unlawful. Victimisation occurs when a person is treated unfairly due to that person having made a complaint of sexual harassment. Victimisation is behaviour that makes a person suffer a detriment including feeling uncomfortable, isolated, insecure or
intimidated.
https://www.anzca.edu.au/resources/corporate-documents/anzca-policy-on-bullying-discrimination-and-harass.pdf
20.1According to the ANZCA PS 50 “Recommendation on Practice Re-entry for a Specialist Anaesthetist” it is recommended that after an absence of more than 12 month from practicing clinical anaesthesia a re-entry program should be offered. The duration of the program for every year of absence would usually be at least
A) 2 weeks per year off
B) 3 weeks per year off
C) 4 weeks per year off
D) 6 weeks per year off
E) 8 weeks per year off
c) 4 weeks
ANZCA PS
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
20.1 The Brain Trauma Foundation guideline for management of severe head trauma recommend the treatment of intracranial pressures greater than
a. 5mmHg
b. 10
c. 15
d. 22
e. 25
22
21.2 Analysis of variance (ANOVA) is a statistical test to determine
a) comparisons of means between two groups in normally distributed data
b) comparisons of means between two groups in non-normally distributed data
c) comparisons of means between three groups (unpaired) in normally distributed data
d) comparisons of means between three groups (unpaired) in non-normally distributed data
c) comparisons of means between three groups in normally distributed data
ANOVA (analysis of variance): comparisons of means between more than two groups or between several measurements in the same group is called analysis of variance and is frequently cited by the acronym ANOVA
21.2 The Vortex Approach to airway management does all of the following EXCEPT
a) At least 1 attempt by the most experienced clinician
b) Maximum 3 attempts at each lifeline (unless gamechanger)
c) CICO status escalates with unsuccessful best effort at any lifeline
d) Trigger for initiating CICO Rescue is SpO2 <90%
d) Trigger for initiating CICO Rescue is SpO2 <90%
- According to the Vortex Approach the trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines.
Trigger for Initiating CICO Rescue VORTEX APPROACH
The trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines.
Note that this trigger is independent of the oxygen saturations since, even in the unusual situation where the oxygen saturations remain high following best efforts at all three lifelines, the inability to confirm alveolar oxygen delivery means that eventual desaturation is inevitable.
Rather than being a deterrent to its performance, recognition of the need for CICO Rescue while the oxygen saturations remain high should be viewed as advantageous – providing increased time to perform this confronting procedure in a more controlled manner, thereby increasing the chance of success.
Conversely, a critically low oxygen saturation is not in itself a trigger to initiate CICO Rescue if best efforts at all three lifelines have not yet been completed.
While legitimate opportunities to enter the Green Zone in a timely fashion via the familiar upper airway lifelines remain, these should be given priority, as they are more likely to be successful than resorting to an unfamiliar and more traumatic technique.
Oxygen saturations are therefore not a relevant consideration in deciding the trigger for CICO Rescue – this is always “the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines”.
They are, however, a relevant consideration in making the context dependent decision of what constitutes a best effort at each lifeline in a particular situation.
This is because the oxygen saturations impact on how much time it is reasonable to invest in optimising each of the upper airway lifelines before declaring a best effort.
When the oxygen saturations are critically low it might be reasonable to have only one attempt at each lifeline before declaring a best effort, even though this means leaving some potential optimisation interventions untried.
This is because the incremental benefit of repeated attempts to optimise a lifeline that has already failed is typically low relative to untried alternative lifelines.
Thus the time expended on such low yield interventions cannot be justified when the patient is already critically hypoxaemic and alternatives (including CICO Rescue) with a substantially higher likelihood of success remain.
22.1 A test for a condition which has a prevalence of 1 in 1000 has a sensitivity of 100% and a specificity of 90%.
The probability of a patient who receives a positive result actually having the condition is
a. 1%
b. 10%
c. 50%
d. 100%
a. 1%
i.e. what is the positive predictive value (PPV) for this test
PPV= TP/ TP +FP
Negative Predictive Value = TN / TN + FN
Prevalence of 1/1000
Sensitivity of 100%
Specificity of 90%
Of patients that are disease positive in population of 1000
TP = 1
FN = 0
-> 100% sensitivity
Of patients that are disease negative in population of 1000
FP = 99
TN = 900
-> 90% Specificity
PPV= 1/ 1 + 99
= 1/100
=1%
NPV= 900/ 900 + 0
= 1/1
= 100%
21.1, 22.2 Regarding healthcare research, the SQUIRE guidelines describe
a) Standards for RCTs
b) Standards for meta-analysis
c) Standards for observational studies
d) Standards for systematic reviews
e) Standards of quality improvement
e) Standards of quality improvement
Quality Improvement
(Standards for QUality Imporvement and Reporting Excellence)
CONSORT: randomised trials
PRISMA: systematic reviews and meta-analysis (Preferred Reporting Items for Systematic reviews and meta-analysis).
STROBE: observational studies
23.1 During standard diagnostic nocturnal polysomnography for investigation of obstructive sleep apnoea, apnoea is defined as cessation of airflow for
A. 10 sec
B. 20 sec
C. 30 sec
D. 10 sec with 3% desat
E. 20 sec with 3 % desat
A
Apnea is defined as the cessation of airflow for ten or more seconds.
Hypopnea is defined as a recognizable, transient reduction, but not a complete cessation of, breathing for ten or more seconds.
Hypopnea requires a 4% fall in SpO2
https://www.ncbi.nlm.nih.gov/books/NBK441909/#:~:text=Obstructive%20Sleep%20Apnea%20(OSA)%2C,for%20ten%20or%20more%20seconds.
23.1 According to the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) guidelines for the investigation of a suspected anaphylactic reaction, serum tryptase should be measured at
a. 0, 4, 12
b. 0, 2, 4, 24
c. 0, 1, 4, 24
d. 0, 4 , 6, 24
e. 1, 6, 24
c) 0, 1, 4, 24
Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours.
https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf
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)
21.2 The image below shows results from non inferiority trials. The trial labelled ‘B’ is best
described as
a) Non-inferiority is not demonstrated
b) Non-inferiority is demonstrated
c) Superiority is demonstrated
d) Inferiority is demonstrated
a) Non-inferiority is not demonstrated
Possible outcomes in a non-inferiority trial.
In A (blue), non-inferiority is demonstrated.
In B (green), non-inferiority is not demonstrated, and the trial is inconclusive.
In C (red), the new treatment is inferior.
23.1 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 greater than 1mm thick, and no intracerebral or intraventricular blood. Her World Federation of Neurosurgical Societies (WFNS) grade of subarachnoid haemorrhage is
A. 1
B. 2
C. 3
D. 4
E. 5
D. 4
- alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%)
Note the new modified Fischer scale.
G0 No SAH or IVH (0%)
G1 Focal or diffuse thin SAH but no IVH (6-24%)
G2 Focal or diffuse thin SAH with IVH (15-33%)
G3 Thick SAH no IVH (33-35%)
G4 Thicc SAH with IVH (34-40%)
The main differences between the Fisher scale and modified Fisher scale are:
1) Fisher scale, no SAH is grade 1, but 0 in modified Fisher scale
2) Fisher scale, thin SAH & no IVH is grade 2, but 1 in modified Fisher scale
3) Fisher scale, thick SAH with no IVH is grade 3 and the same 3 in modified Fisher scale
4) Fisher scale, any IVH is grade 4, irrespective of the presence of SAH but in modified Fisher scale it is either 2 if thin or no SAH, or grade 4 if thick SAH
Modified Fisher Scale:
grade 0
- no subarachnoid hemorrhage (SAH)
- no intraventricular hemorrhage (IVH)
- incidence of symptomatic vasospasm: 0% 3
grade 1
- focal or diffuse, thin SAH
- no IVH
- the incidence of symptomatic vasospasm: 24%
grade 2
- focal or diffuse, thin SAH
- IVH present
- the incidence of symptomatic vasospasm: 33%
grade 3
- thick SAH
- no IVH
- the incidence of symptomatic vasospasm: 33%
grade 4
- thick SAH
- IVH present
- the incidence of symptomatic vasospasm: 40%
Note: the original study did not include a specified measurement or criteria to define thick vs thin hemorrhage.
REPEAT
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
22.1 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
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:
22.2 Analysis of variance (ANOVA) is a statistical test to determine
a) The validity between an expected and observed outcome in a population
b) The difference between the means of more than two populations
c) The difference between two populations with non-parametric data
d) The degree of similarity of the median between two or more populations
e) If the variance within a population is likely to be abnormally or normally distributed
B) analyse the difference between the means of more than two groups
23.1 A new antiemetic reduces the risk of postoperative vomiting by 20%. In a population with a baseline risk of postoperative vomiting of 10%, the number needed to treat is
a. 2
b. 5
c. 10
d. 20
e. 50
(base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50
or 1 divided by risk reduction
population risk = 10/100 patients get PONV
population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug)
RR= 0.10-0.08=0.02
NNT= 1/RR
=1/0.02
=50
The commonest primary cause of death from anaesthesia airway events in the NAP4 report was
A. Barotrauma
B. Aspiration
C. Tracheostomy dislodged
D. Bleeding post-trache insertion
B. Aspiration
Aspiration was the single commonest cause of death in anaesthesia events.
Poor judgement was the likely root cause in many cases which included elements of poor assessment of risk (patient and operation) and failure to use airway devices or techniques that would offer increased protection against aspiration. Several major events occurred when there were clear indications for a rapid sequence induction but this was not performed.
21.2 The domains described in the Edmonton Frail Scale do NOT include
A) Cognition
B) Mental illness
C) Weight
D) Age
E) Functional assessment
D) Age
Can Grandma Functionally Support Medication Nutrition Mood Continence Self
i.e.
C (cognition)
G (general health)
F (functional independence)
S (social support)
M (medication use)
N (nutritional status)
M (mood, presence of mental illness)
C (continence)
S (self reported performance)
22.1 The 2012 Berlin definition of the Acute Respiratory Distress Syndrome (ARDS) defines moderate disease as one with a PaO2 / FiO2 ratio (in mmHg) of
100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O
https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3
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 A forest plot is a commonly used tool in meta-analysis. It presents
a) A qualitative analysis of pooled data from multiple studies
b) A number needed to treat vs number needed to harm
c) The non-inferiority of a study
d) The pooled data from all of the studies
d) The pooled data from all of the studies
Forest plots or blobbograms are used in order to show graphically the studies which have been included in the meta-analysis.
They demonstrate the differences between studies and provide an estimate of the overall result.
22.1 Under the NEXUS criteria, requirements to clear the cervical spine of trauma patients without radiographic imaging include all of the following EXCEPT
a. No midline tenderness
b. No distracting injury
c. No altered level of consciousness
d. Able to turn head 45 deg
e. No focal neurological deficit
d. Able to turn head 45 deg
NEXUS criteria:
One easy mnemonic for these criteria is NSAID:
Neuro Deficit Spinal Tenderness (Midline) Altered Mental Status/Level of Consciousness Intoxication Distracting Injury
23.1 According to the Revised Cardiac Risk Index, a 72-year-old male scheduled for a laparoscopic cholecystectomy with a history of hypertension, 20 pack-year history of smoking, type 2 diabetes requiring insulin and a previous stroke has a score of
A. 1
B. 2
C. 3
D. 4
E. 5
B. 2
( CVA, Insulin use)
UTD
CHF
Renal impairment
Insulin use
Stroke
Ischaemic heart
Surgically high risk
20.2 The ANZCA Choosing Wisely recommendations advise avoiding all of the following EXCEPT
A. Offering an epidural on a patient who is labouring spontaneously with a normal pregnancy and no comorbidities, upon request
B. Giving blood transfusion on a healthy 20yo male with Hb > 70g/L, except when severe and symptomatic
C. Giving an anaesthetic to a high-risk patient with severe comorbidities without risk stratifying them and taking an anaesthetic history and assessment
D. Ordering cardiac stress testing for a patient undergoing high risk non-cardiac surgery.
A. Offering an epidural on a patient who is labouring spontaneously with a normal pregnancy and no comorbidities, upon request
22.2 All patients over 70 years of age having received either spinal or general anaesthesia at Hospital X are reviewed 3 years later to assess cognitive function. The aim of the study is to determine whether exposure to general anaesthesia or spinal anaesthesia impacts cognitive function. This trial design is best described as a
a) RCT
b) cohort study
c) case-control study
d) case series
e) cross-sectional study
b) cohort study
What is a Cohort Study design?
- Cohort studies are longitudinal, observational studies, which investigate predictive risk factors and health outcomes.
- They differ from clinical trials, in that no intervention, treatment, or exposure is administered to the participants.
- The factors of interest to researchers already exist in the study group under investigation.
- Study participants are observed over a period of time. The incidence of disease in the exposed group is compared with the incidence of disease in the unexposed group.
- Because of the observational nature of cohort studies they can only find correlation between a risk factor and disease rather than the cause.
Cohort studies are useful if:
- There is a persuasive hypothesis linking an exposure to an outcome.
- The time between exposure and outcome is not too long (adding to the study costs and increasing the risk of participant attrition).
- The outcome is not too rare.
22.1 The image shows results from noninferiority trials. The trial labelled N is best described as
(the confidence interval crosses midline of no effect and margin of non-inferiority)
a. Inferiority demonstrated
b. Non-inferiority demonstrated
c. Superiority demonstrated
d. Non-inferiority not demonstrated/Inconclusive
Inconclusive/Noninf not demonstrated
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
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.
23.1 A 58-year-old man with alcohol-related cirrhosis is booked to undergo a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The calculation of his MELD-Na score to estimate his mortality risk requires all of the following EXCEPT
A. Sodium
B. INR
C. Cr
D. Albumin
E. Bilirubin
D. Albumin
https://www.tamingthesru.com/blog/r1-diagnostics/labs-in-hepatic-failure
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.
