SAQ 2022+ Flashcards

Question 1

Q

[22A01] Describe your preoperative assessment of a patient with oesophageal cancer scheduled for an oesophagectomy and justify your strategy to optimise them before surgery. Pass rate 64.1%

Answer

A

Preoperative Assessment and Optimization for Oesophagectomy in Oesophageal Cancer
A comprehensive preoperative strategy for oesophagectomy must address physiological resilience, nutritional status, cancer staging accuracy, and risk stratification to mitigate morbidity and mortality. Key domains include cardiopulmonary fitness, nutritional repletion, and multidisciplinary risk prediction to guide tailored interventions.

Risk Stratification and Physiological Assessment
Cardiovascular Evaluation:
- Functional Testing: Assess exercise tolerance via cardiopulmonary exercise testing (CPET), with VO₂max <15 mL/kg/min indicating high risk[1][4].
- Biomarkers: NT-proBNP/BNP levels refine cardiovascular risk prediction, particularly excluding low-risk patients[4].
- Risk Scores: Composite scoring systems (e.g., cardiac, hepatic, respiratory function) reduce mortality from 9.4% to 1.6% when guiding patient selection[1].

Respiratory Optimization:
- Pulmonary Function Tests: Mandatory for baseline assessment, especially in smokers or COPD patients[1][7].
- Smoking Cessation: ≥4 weeks preoperatively reduces pulmonary complications[7].
- Prehabilitation: Respiratory muscle training improves postoperative ventilation[2][7].

Nutritional Optimization
Screening and Assessment:
- Malnutrition Screening: Use MUST score to identify high-risk patients[2][6].
- Body Composition Analysis: Measure skeletal muscle mass via CT or bioimpedance to guide protein targets (1.2–1.5 g/kg/day)[2][6].

Interventions:
- Early Supplementation: High-protein oral supplements during neoadjuvant therapy prevent catabolism[2][6].
- Synergistic Strategies: Combine protein intake with resistance training to preserve muscle mass[2].
- Preoperative Fasting: Limit fasting to 6 hours for solids and 2 hours for clear fluids[2].

Cancer Staging and Surgical Planning
Imaging Modalities:
- Endoscopic Ultrasound (EUS): Accurately stages T1–T3 tumours (85% sensitivity for T1a)[3][7].
- CT/PET-CT: Detect nodal (PET sensitivity: 82%) and distant metastases[3][7].
- Endoscopic Mucosal Resection (EMR): Gold standard for T1 staging[3].

Surgical Considerations:
- Multidisciplinary Review: Confirm resectability and neoadjuvant therapy response[3][7].
- Risk Prediction Models: 21 validated tools predict mortality, morbidity, and anastomotic leaks[4].

Prehabilitation Programs
Exercise Regimens:
- Aerobic/Resistance Training: 3–4 weeks pre-surgery improves VO₂max by 62%, reducing pneumonia (70% to 29%) and hospital stay (14 to 11 days)[2][4].
- Home-Based Protocols: Ensure adherence through structured, supervised plans[2].

Psychological Support:
- Address anxiety/depression and provide peer support to enhance compliance and recovery[2].

Multidisciplinary Coordination
- Team Involvement: Engage cardiologists, pulmonologists, dietitians, and physiotherapists to address organ-specific risks[1][4].
- Neoadjuvant Therapy Monitoring: Assess cardiotoxicity (e.g., anthracyclines) and radiation pneumonitis during chemotherapy[3][4].

Justification for Strategy
- Risk Scores and Biomarkers objectively identify high-risk patients, enabling procedure modification or intensified prehabilitation[1][4].
- Nutritional Interventions counteract cancer cachexia and chemotherapy-induced catabolism, reducing anastomotic leaks[2][6].
- Prehabilitation enhances physiological reserve, directly correlating with lower Clavien-Dindo complications[2][4].
- Accurate Staging avoids futile surgery in metastatic disease and tailors neoadjuvant regimens[3][7].

This evidence-based approach aligns with enhanced recovery pathways, optimizing outcomes for a high-risk cohort.

Citations:
[1] https://pubmed.ncbi.nlm.nih.gov/9667720/
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC6503268/
[3] https://pubmed.ncbi.nlm.nih.gov/25743465/
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC10080602/
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC8575828/
[6] https://jtd.amegroups.org/article/view/25375/html
[7] https://shc.amegroups.org/article/view/4345/html
[8] https://jtd.amegroups.org/article/view/57077/html

Answer from Perplexity: pplx.ai/share

Candidates were required to demonstrate an understanding that oesophagectomy is high risk surgery and to consider:
* Cardiovascular and respiratory complications and risks
* Other significant conditions - ex. poor nutritional status, smoking
* Assessment of risk/risk stratification
* Optimisation of these in the context of the short time available, in attempt to reduce
perioperative risk
Candidates who considered all these issues in the context of oesophageal cancer surgery and had a practical approach to assessment and optimisation achieved the higher marks.
There was a tendency for some candidates to give answers that were generic to major surgery rather than focused on oesophagectomy, lacking justification for their proposed strategy.

Question 2

Q

Question 2 Outline your management of a patient with chronic daily headache. Pass rate 79.0%

Answer

A

Management of Chronic Daily Headache
Chronic daily headache (CDH), defined as ≥15 headache days/month for ≥3 months, requires a multifaceted approach addressing underlying causes, medication overuse, and tailored prophylaxis. Key goals include reducing headache frequency, managing comorbidities, and preventing relapse.

Comprehensive Assessment
Diagnosis:
- Confirm CDH subtype (chronic migraine vs. chronic tension-type headache) using ICHD-3 criteria[3][5].
- Screen for red flags (e.g., sudden-onset headache, focal neurological deficits, fever) necessitating MRI/CT to exclude secondary causes (tumors, infections)[2][5].

Medication Overuse Evaluation:
- Identify overuse of acute medications (e.g., ≥15 days/month of NSAIDs/paracetamol or ≥10 days/month of triptans/opioids)[3][5].
- Use headache diaries to track patterns and medication intake[3].

Medication Overuse Management
Withdrawal Strategy:
- Abrupt cessation of overused medications with patient education on rebound effects[2][3].
- Bridge therapy for withdrawal symptoms:
- NSAIDs (e.g., naproxen) for inflammation.
- Short-term steroids (e.g., prednisone) in severe cases[4].
- Transition to prophylactic agents within 2 weeks[3].

Non-Pharmacological Interventions
Lifestyle Modifications:
- Regular sleep, hydration, and exercise to reduce triggers[2][4].
- Avoid alcohol, caffeine, and dietary triggers (e.g., tyramine-rich foods)[3].

Behavioral Therapies:
- Cognitive-behavioral therapy (CBT) for stress management[2].
- Relaxation techniques (biofeedback, mindfulness) to lower headache frequency[2][4].
- Physical therapy for cervicogenic contributors[5].

Pharmacological Prophylaxis
First-Line Agents:
| Headache Type | Medication | Dosing | Evidence |
|——————–|———————-|—————————–|—————————|
| Chronic Migraine | Topiramate | 25–100 mg/day | 50% reduction in days[3] |
| | Amitriptyline | 10–75 mg nocte | Improved quality of life[4] |
| Chronic TTH | Propranolol | 40–160 mg/day | Reduced frequency[4] |
| | Botulinum toxin A | 155–195 U q12wks (migraine) | FDA-approved for CM[5] |

Second-Line Options:
- Gabapentin (300–1800 mg/day) for comorbid neuropathic pain[2].
- CGRP monoclonal antibodies (e.g., erenumab) for refractory cases[3].

Acute Attack Management
Stepwise Therapy:
Mild-moderate attacks: NSAIDs (ibuprofen 400 mg) + antiemetic (metoclopramide 10 mg)[4][5].
Severe attacks: Triptans (sumatriptan 50–100 mg) or dihydroergotamine[5].
Refractory cases: Sedative-dose propofol (1 mg/kg IV) in ED settings reduces LOS by 50%[1].

Avoid: Opioids and barbiturates due to dependency risk[3].

Referral Criteria
- Neurology consultation if:
- Failed ≥2 prophylactic agents after 8–12 weeks.
- Diagnostic uncertainty (e.g., trigeminal autonomic cephalalgias)[3][5].
- Comorbid psychiatric conditions (e.g., anxiety/depression) requiring specialist input[2].

Rationale for Strategy
- Medication withdrawal resolves rebound headaches in 50–70% of cases within 2 months[3].
- Prophylaxis reduces headache days by ≥50% in 40–60% of patients, with topiramate showing the highest efficacy[3][4].
- Multimodal care combining behavioral and pharmacological interventions improves adherence and long-term outcomes[2][5].

This approach aligns with guidelines from the Australian and New Zealand Headache Society, emphasizing patient-centered care and prevention of chronification.

Citations:
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3876315/
[2] https://pubmed.ncbi.nlm.nih.gov/24784123/
[3] https://www1.racgp.org.au/ajgp/2021/december/the-state-of-migrain
[4] https://www.racgp.org.au/afp/2014/march/chronic-headache
[5] https://academic.oup.com/bjaed/article/8/4/138/294149

Answer from Perplexity: pplx.ai/share

Pass rate 79.0%
Candidates were required to include the following in their answer to this question:
* A reasonable history about the headache (onset, severity, type of pain etc).
* Exclusion of intracranial pathology - ex. haemorrhage, tumour, trauma.
* Appreciation of the fact that medication may help but unlikely to be a cure so
multidisciplinary support/assessment/treatment will be required.
* Avoidance of full mu agonists when considering medications.

Question 3

Q

[22A03]
The following are the arterial blood gas (ABG) results of a patient with chronic liver disease:
Reference ranges
pH 7.49 7.36 - 7.44
PaCO2 25 mmHg (3.3 kPa) 36 - 44 mmHg (4.8 - 5.9 kPa)
PaO2 55 mmHg (7.3 kPa) 85 - 100 mmHg (11.3 - 13.3 kPa)
HCO3 24.8 mmol/L 22 - 28 mmol/L
SpO2 88%
FiO2 0.21
Interpret this ABG.
List the causes of hypoxia in patients with chronic liver disease.
Describe how you would differentiate between the causes of hypoxia in patients with chronic liver disease.
Pass rate 31.3%

Answer

A

ABG Interpretation
The arterial blood gas (ABG) results indicate:
1. Respiratory Alkalosis (pH 7.49, ↓PaCO₂ 25 mmHg)
2. Severe Hypoxemia (PaO₂ 55 mmHg, SpO₂ 88% on room air)
3. Normal Bicarbonate (HCO₃⁻ 24.8 mmol/L)

This pattern suggests acute respiratory alkalosis (uncompensated) with significant hypoxia. The low PaCO₂ reflects hyperventilation, while the normal HCO₃⁻ rules out chronic compensation or a mixed metabolic disorder.

Differentiation Between Causes
Step 1: Clinical Assessment
- HPS: Platypnea, orthodeoxia (SpO₂ ↓ ≥5% when upright), clubbing[5][8].
- PoPH: Loud P2 heart sound, TR murmur, signs of right heart failure (JVD, edema)[7][8].
- Ascites/Hydrothorax: Abdominal distension, ↓breath sounds on imaging[1][2].

Citations:
[1] https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-acid-base-abnormalities-liver-dysfunction-S1665268122000175
[2] https://jmisr.researchcommons.org/home/vol5/iss3/23/
[3] https://pubmed.ncbi.nlm.nih.gov/28684104/
[4] https://www.msdmanuals.com/professional/pulmonary-disorders/pulmonary-hypertension/hepatopulmonary-syndrome
[5] https://my.clevelandclinic.org/health/diseases/24190-hepatopulmonary-syndrome
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC7473417/
[7] https://pmc.ncbi.nlm.nih.gov/articles/PMC4081678/
[8] https://www.atsjournals.org/doi/full/10.1164/rccm.201209-1583ci

Answer from Perplexity: pplx.ai/share

This question was poorly answered.
While most candidates correctly interpreted the ABG, when attempted, many struggled to correctly calculate the A-a gradient. The list of causes of hypoxia in these patients was often incomplete.
The list was required to include
1. Hepatopulmonary syndrome
2. Portopulmonary hypertension
3. Mechanical – ascites, hepatic hydrothorax, massive hepatomegaly
In the third part of the question candidates were required to demonstrate an understanding of how chronic liver disease may impact on gas exchange and have an approach that would help identify the specific cause through history, examination, and investigation.

Question 4

Q

[22A04] Describe the factors that ensure the safety and quality of a ward-based postoperative epidural analgesia service.
Pass rate 45.6%

Answer

A

Ensuring Safety and Quality in Ward-Based Postoperative Epidural Analgesia
A safe and effective epidural service requires standardized protocols, multidisciplinary coordination, and rigorous monitoring to mitigate risks such as infection, haematoma, and inadequate analgesia. Key factors span clinical governance, staff training, and infrastructure readiness.

Multidisciplinary Protocols and Guidelines
- Standardized procedures for catheter insertion, maintenance, and removal, including anticoagulation management (e.g., stopping LMWH 12–24 hours pre-insertion)[1][5].
- Checklists for prescription verification, pump programming, and catheter labelling to prevent drug errors[2][3].
- Complication protocols:
- Inadequate analgesia: Bolus dosing (± 5–10 mL local anaesthetic) and rate adjustments after assessing sensory block[1][2].
- Hemi-block: Repositioning the patient to gravity-dependent side[1].
- Hypotension: Fluid resuscitation and vasopressors (e.g., ephedrine)[4].

Staff Training and Competency
- Mandatory education for nurses on:
- Epidural pump operation, sensory block assessment (e.g., ice test), and motor block grading (Bromage score)[2][5].
- Recognising red flags (e.g., sudden back pain, limb weakness) indicating spinal haematoma/abscess[2][4].
- Anaesthetist expertise: Epidurals inserted by experienced clinicians, with senior support for difficult cases[5].

Patient Selection and Education
- Exclusion criteria: Coagulopathy, sepsis, or refusal[1][5].
- Preoperative counselling on expected numbness, pruritus, and the need for frequent monitoring[5].
- Informed consent covering risks (e.g., 1:10,000 haematoma risk) and benefits[5].

Medication Safety
| Strategy | Purpose | Evidence |
|—————————-|———————————————-|———————-|
| Pre-loaded infusion bags | Reduce dosing errors |[1][3] |
| Dedicated epidural lines | Prevent accidental IV administration |[1][5] |
| Standardised concentrations | Simplify prescriptions (e.g., 0.1% bupivacaine + 2–4 µg/mL fentanyl) |[2][5] |

Monitoring and Documentation
- Vital signs: BP, SpO₂, and sedation scores every 2 hours[2][4].
- Block assessment:
- Sensory level: Ice/Ethyl Chloride testing every 4 hours[2].
- Motor block: Bromage score (0–3) to detect excessive spread[2].
- Pain scoring: Visual analogue scale (VAS) at rest and movement[5].

Infrastructure and Emergency Readiness
- Ward requirements:
- High-dependency bed areas for close observation[4].
- Immediate access to naloxone, lipid emulsion (Intralipid® 20%), and vasopressors[1][4].
- 24/7 anaesthetic coverage for complication management (e.g., suspected haematoma requiring MRI/neurosurgery)[4][5].

Catheter Management
- Securement: Catheter taped over the shoulder with Tegaderm® to prevent disconnection[5].
- Aseptic technique: Chlorhexidine skin prep and sterile dressing changes[5].
- Removal: Coagulation status rechecked; delayed if anticoagulants resumed post-op[1].

Quality Assurance
- Audits of pain scores, complication rates, and protocol adherence[2][3].
- Incident reporting for near-misses (e.g., pump programming errors) to refine safety protocols[3].

Key Outcomes
- Reduced complications: Structured programs lower pneumonia risk by 40% and haematoma incidence to <0.01%[1][3].
- Improved analgesia: 85% of patients report VAS <3/10 with protocol adherence[2][5].

This framework aligns with ANZCA guidelines, prioritising patient safety through systematic risk mitigation and interdisciplinary collaboration.

Citations:
[1] https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/epianalg16.pdf
[2] https://rightdecisions.scot.nhs.uk/media/v32f2spi/protocol-for-postoperative-epidural-analgesia-2.pdf
[3] https://pharmaceutical-journal.com/article/research/improving-the-safety-of-epidural-analgesia
[4] https://fpm.ac.uk/media/2576
[5] https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Epidural%20Analgesia%20Post%20Operative%20Ward%20Based%20for%20Non%20Obstetric%20Patients%20UHL%20Anaesthesia%20Policy.pdf

Answer from Perplexity: pplx.ai/share

This question required candidates to demonstrate an adequate understanding of service design by considering the following issues:
* Monitoring of the patient - physiological variables and epidural site
* Dedicated equipment - pump and programme, connections/lines, medications
* Acute Pain Service input - daily review/24-hour access for help/advice
* Education and in service training for nursing staff and RMOs
* Protocols for managing problems - ex nausea, itch, inadequate analgesia, hypotension
* Continuous audit process

Question 5

Q

[22A05] Describe a technique for front of neck access to the airway in a ‘Can’t Intubate, Can’t Oxygenate’ situation. (50%)
Outline the potential complications and limitations of this technique. (50%)
Pass rate 86.7%

Answer

A

Front of Neck Access in CICO: ANZCA PS61-Aligned Technique, Complications, and Limitations

Technique for Front of Neck Access (50%)
Per ANZCA guidelines (PS61), the scalpel-bougie-tube technique is the preferred method for emergency front-of-neck access (eFONA) in a “Can’t Intubate, Can’t Oxygenate” (CICO) scenario.

Step-by-Step Procedure:
1. Preparation and Positioning:
- Call for help and ensure emergency equipment (scalpel, bougie, size 6.0–7.0 cuffed tracheal tube) is immediately available.
- Neutral neck position (avoid hyperextension if cervical spine injury is suspected).

Identify the Cricothyroid Membrane (CTM):
- Palpate the thyroid cartilage → slide caudally to the CTM (soft depression between thyroid and cricoid cartilages).
- If landmarks are unclear, use a 4 cm vertical midline incision to expose the CTM.
Incision and Airway Entry:
- Vertical skin incision (3–4 cm) over the CTM, followed by blunt dissection with fingers to separate tissues.
- Horizontal stab incision (1 cm) through the CTM.
Bougie Insertion:
- Insert a bougie through the CTM incision, directing it caudally into the trachea.
- Rotate 90° to confirm tracheal placement (distinct “clicks” against tracheal rings).
Tube Placement:
- Rail-road a cuffed tracheal tube (ID 6.0–7.0 mm) over the bougie to 4–5 cm depth.
- Inflate the cuff and secure the tube with ties/tape.
Confirmation:
- Capnography (end-tidal CO₂ >2 kPa) and bilateral chest rise.
- Avoid auscultation initially to minimize delays.

Limitations
1. Anatomical Challenges:
- Obesity, neck masses, or trauma may obscure the CTM, increasing failure rates.
- Landmark identification fails in 30% of cases without prior neck palpation (NAP4 data).

Pediatric Contraindication:
- Not recommended for children 90% success rates in trained hands.

Citations:
[1] https://libguides.anzca.edu.au/cpd/emergency/cico
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC7807984/

Answer from Perplexity: pplx.ai/share

Pass rate 86.7%
The overwhelming majority of candidates were able to describe a recognised technique with no critical step omitted. Most noted the importance of the cricothyroid membrane in their description with better candidates going on to describe the surface anatomy and the surrounding structures used to identify it.
In the second part of the question the potential complications and limitations of the chosen technique were adequately covered by most candidates. Better candidates expanded their answer to include the context of a patient in an emergency with comorbidities that could impact on the success of the technique.
Some candidates also acknowledged the advantages of protocols for CICO, annual simulation training and familiarisation with, and ready availability of, pre-prepared standardised CICO equipment.

Question 6

Q

[22A06]
A patient with primary pulmonary hypertension is scheduled for laparoscopic bowel resection.
Their current medication is bosentan PO 125mg bd.
Discuss how their condition influences your perioperative management.
Pass rate 54.9%

Answer

A

Perioperative Management of Primary Pulmonary Hypertension (PAH) for Laparoscopic Bowel Resection
Patients with PAH face significant perioperative risks due to right ventricular (RV) dysfunction and increased pulmonary vascular resistance (PVR). Laparoscopic surgery introduces additional challenges from pneumoperitoneum and positioning. Key strategies focus on maintaining RV-pulmonary circulation coupling, avoiding PVR triggers, and ensuring continuity of PAH therapies.

Preoperative Optimization
1. Risk Stratification:
- Assess RV function via echocardiography (TAPSE 65 mmHg** (RV coronary perfusion depends on systemic pressure).
- Avoid factors ↑PVR: hypoxia, hypercapnia, acidosis, hypothermia.

Anesthetic Technique:
- Balanced anesthesia: Combine low-dose propofol/volatile (e.g., sevoflurane) with epidural analgesia to blunt catecholamine surges.
- Ventilation:
- Tidal volume 6–8 mL/kg, PEEP 5–8 cmH₂O to prevent atelectasis.
- Target PaCO₂ 30–35 mmHg (prevents acidosis-driven PVR ↑).

Monitoring:
- Arterial line (beat-to-beat BP), CVP (target 8–12 mmHg), and TEE (assess RV strain).
- EtCO₂ (↑ levels may indicate CO₂ embolism from laparoscopy).

Laparoscopic Considerations:
- Trendelenburg positioning: Limit to 3× ULN requires dose reduction).
- Avoid CYP3A4 inhibitors (e.g., erythromycin) post-op.

Outcome Improvement Strategies
- Prehabilitation: 2–4 weeks of inspiratory muscle training pre-op improves RV function.
- Early mobilization: Reduces venous thromboembolism risk (incidence 15–20% in PAH).

This approach aligns with AHA/ESC guidelines, reducing mortality from 15% to <5% in expert centers.

Citations:
[1] https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136
[2] https://resources.wfsahq.org/atotw/perioperative-management-of-patients-with-pulmonary-hypertension-and-right-ventricular-dysfunction/
[3] https://journals.lww.com/hhmi/fulltext/2024/08020/anesthesia_and_pulmonary_hypertension__a_narrative.2.aspx
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC10038649/
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC8519362/

Answer from Perplexity: pplx.ai/share

Question 7

Q

[22A07] An 80-year-old man is in the post anaesthesia care unit (PACU) following a transurethral resection of prostate under spinal anaesthesia.
He is restless, saturating poorly on air and refusing to keep an oxygen mask on.
List the likely differential diagnoses and describe your management.
Pass rate 37.9%

Answer

A

Differential Diagnoses and Management of Hypoxia and Restlessness in PACU Post-TURP

Likely Differential Diagnoses
1. Hypoventilation
- Residual sedation/opioid effects: Even with spinal anesthesia, systemic opioids or sedatives (e.g., midazolam) may cause respiratory depression.
- High spinal block: Rare but possible diaphragmatic impairment (sensory level above T4).

Atelectasis
- Reduced lung expansion due to immobility or splinting from pain.
Pulmonary Edema
- Fluid overload from TURP irrigation (1.5% glycine absorption) or IV fluids.
Pulmonary Embolism (PE)
- Immobility-related deep vein thrombosis post-surgery.
Acute Coronary Syndrome (ACS)
- Silent myocardial ischemia in elderly patients, presenting as restlessness and hypoxia.
Delirium
- Postoperative delirium (hypoactive/hyperactive subtype) due to hypoxia, medications, or metabolic derangements.
Aspiration Pneumonia
- Impaired airway reflexes during sedation for spinal anesthesia.
COPD/Chronic Lung Disease Exacerbation
- Stress of surgery or retained secretions.

Immediate Management

Oxygen Delivery and Airway
- Alternative oxygenation: Switch to high-flow nasal cannula (HFNC) at 40–60 L/min with FiO₂ 0.3–0.6. Better tolerated than masks.
- Positioning: Elevate head to 45° to improve ventilation.
- Monitor: Continuous SpO₂, RR, and EtCO₂ if available.
Assess and Treat Underlying Cause
| Diagnosis | Intervention |
|———————–|———————————————————————————-|
| Hypoventilation | Administer naloxone 40–80 µg IV if opioid-induced. Repeat every 2–3 mins. |
| Atelectasis | Incentive spirometry, deep breathing exercises, CPAP if severe. |
| Pulmonary Edema | IV furosemide 20–40 mg; restrict fluids. |
| PE | Start therapeutic LMWH (e.g., enoxaparin 1.5 mg/kg) after CT pulmonary angiogram. |
| ACS | ECG, troponin, and sublingual nitroglycerin (if SBP >110 mmHg). |
| Delirium | Dexmedetomidine 0.1–0.7 µg/kg/hr IV (avoids respiratory depression). |
| Aspiration | Ceftriaxone 1 g IV + azithromycin 500 mg IV. |
Investigations
- ABG: Confirm hypoxia (PaO₂ <60 mmHg) and assess for hypercapnia.
- CXR: Rule out pulmonary edema, consolidation, or pneumothorax.
- ECG: ST changes for ACS, right heart strain for PE.
- Labs: CBC (anemia), electrolytes (hyponatremia from TURP syndrome), troponin.
Delirium Management
- Non-pharmacological: Reorient patient, ensure glasses/hearing aids, involve family.
- Pharmacological: Haloperidol 0.5–1 mg IV for severe agitation.

Key Considerations
- Hypoxia-driven agitation: Treating hypoxia may resolve restlessness.
- Avoid restraints: Escalates agitation; use 1:1 nursing supervision instead.
- Fluid balance: Monitor for TURP syndrome (hyponatremia <125 mmol/L: treat with 3% saline).

Outcome: Early intervention reduces ICU admissions (↓30%) and mortality (↓15%) in elderly PACU patients[3][6].

Citations:
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC4456822/
[2] https://www.archbronconeumol.org/en-adverse-respiratory-events-in-post-anesthesia-articulo-S1579212914003747
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC10540998/
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC7556934/
[5] https://opentextbc.ca/clinicalskills/chapter/5-5-management-of-hypoxemia/
[6] https://journals.lww.com/anesthesia-analgesia/fulltext/1995/12000/oxygen_therapy_in_the_postanesthesia_care_unit.36.aspx

Answer from Perplexity: pplx.ai/share

Candidates were required to consider the following issues and their management:
* Hypoxia/hypotension
* TURP syndrome/Hyponatraemia
* Cardiac ischaemia/myocardial infarction
* Delirium – drug/stress response related
Common reasons for failure to achieve a pass mark were omitting to consider perioperative cardiac events or delirium, or demonstrating a poor understanding of the management of hyponatraemia.

Question 8

Q

[22A08]
Identify the points labelled A to F on this intra-aortic balloon pump (IABP) pressure-time trace at the commencement of 1:2 augmentation. (30%)
Outline the aims of IABP placement and discuss the underlying physiological principles. (70%)
Pass rate 49.7%

Answer

A

Identification of Points on the IABP Pressure-Time Trace (30%)

Aims of IABP Placement and Physiological Principles (70%)

Aims of IABP Placement
The intra-aortic balloon pump (IABP) is a mechanical device used to support left ventricular function by improving myocardial oxygen supply-demand balance and optimizing hemodynamics. The primary aims include:

Augment Coronary Perfusion:
- Increase diastolic pressure to enhance coronary blood flow during diastole, especially in ischemic myocardium.
Reduce Left Ventricular Afterload:
- Decrease systolic aortic pressure via balloon deflation, reducing myocardial oxygen consumption and workload.
Improve Cardiac Output:
- By reducing afterload and enhancing stroke volume, cardiac output increases by 0.5–1 L/min.
Bridge to Definitive Therapy:
- Stabilize patients with cardiogenic shock or severe ischemia for revascularization, surgery, or ventricular assist device implantation.

Physiological Principles
The IABP operates based on the principle of counterpulsation, which involves synchronized inflation and deflation of the balloon during specific phases of the cardiac cycle.

Timing of Balloon Inflation
- Balloon inflation occurs at the dicrotic notch, immediately after aortic valve closure during early diastole.
- Inflated balloon displaces blood retrograde toward the coronary arteries and forward into systemic circulation, increasing diastolic pressure and coronary perfusion.
Timing of Balloon Deflation
- Deflation occurs just before isovolumetric contraction during late diastole.
- This creates a vacuum effect in the aorta, reducing aortic pressure and afterload, thereby facilitating LV ejection.
Hemodynamic Effects
| Parameter | Effect | Clinical Impact |
|————————|—————————————————————————–|———————————————————-|
| Coronary Blood Flow | ↑ 30–40% during diastole | Improves myocardial oxygenation and reverses ischemia. |
| Afterload Reduction | ↓ 15–20% | Reduces LV workload and myocardial oxygen consumption. |
| Stroke Volume | ↑ 10–20% | Improves cardiac output and systemic perfusion. |
| Pulmonary Capillary Wedge Pressure (PCWP) | ↓ 20% | Alleviates pulmonary congestion in heart failure. |

Key Features of Optimal IABP Function
- Balloon inflation produces a sharp “V” shape at augmented diastolic pressure (D) exceeding unassisted systolic pressure (A).
- Assisted systolic pressure (E) is lower than unassisted systolic pressure (A) due to reduced afterload.
- Assisted end-diastolic pressure (F) is lower than unassisted end-diastolic pressure (B) by 10–15 mmHg.

Clinical Applications
IABP is indicated for conditions such as:
- Cardiogenic shock following myocardial infarction (MI).
- Refractory angina or acute coronary syndrome with pump failure.
- Low cardiac output states post-cardiac surgery or mechanical complications of MI (e.g., ventricular septal defect).

Limitations
1. Requires intact systemic circulation; ineffective in severe peripheral vascular disease or aortic regurgitation.
2. Contraindicated in patients with irreversible cardiac failure or coagulopathy.
3. Limited long-term use; typically serves as a bridge to definitive therapy.

This approach aligns with ANZCA guidelines emphasizing precision timing for optimal hemodynamic support and improved clinical outcomes in critically ill cardiac patients.

Citations:
[1] https://pplx-res.cloudinary.com/image/upload/v1741395283/user_uploads/LTFpFvrIIArbrNZ/IABP-unlabelled.jpg
[2] https://litfl.com/intra-aortic-balloon-pump-trouble-shooting/
[3] https://www.vumc.org/cvicu/sites/default/files/2020-02/IABP_Timing_Guidelines.pdf
[4] https://www.portsmouthicu.com/resources/2016-06-16-IABP-v2-Joined-FINAL.pdf
[5] https://journals.lww.com/nursing/fulltext/2009/02001/interpreting_intra_aortic_balloon_pump_waveforms.4.aspx

Answer from Perplexity: pplx.ai/share

Label | Description | Physiological Significance |
|———–|———————————————————————————|———————————————————————————————–|
| A | Unassisted Peak Systolic Pressure | Represents the peak systolic pressure during unassisted cardiac output (baseline LV contractility). |
| B | Unassisted End-Diastolic Pressure | The lowest pressure in the aorta before the next systole, reflecting preload and LV relaxation. |
| C | Dicrotic Notch (timing marker for balloon inflation) | Indicates closure of the aortic valve; balloon inflation begins here to augment diastolic perfusion. |
| D | Augmented Diastolic Pressure (balloon inflation peak) | Balloon inflation displaces blood retrograde, increasing coronary and systemic perfusion during diastole. |
| E | Assisted Peak Systolic Pressure (post-deflation) | Reduced afterload due to balloon deflation, lowering LV workload and myocardial oxygen demand. |
| F | Assisted End-Diastolic Pressure (post-balloon deflation) | Lower end-diastolic pressure due to reduced preload and afterload, improving cardiac efficiency. |

Question 9

Q

[22A09]
Discuss how pregnancy influences your perioperative management of a patient at 25 weeks gestation scheduled for laparoscopic appendicectomy.
Pass rate 49.7%

Answer

A

Perioperative management of a pregnant patient at 25 weeks gestation requiring laparoscopic appendicectomy demands meticulous attention to maternal physiological changes, fetal wellbeing, and surgical-specific risks. Key considerations span pre-, intra-, and postoperative phases, integrating obstetric, surgical, and anaesthetic priorities.

Maternal and Fetal Assessment
1. Sepsis evaluation
- Screen for infection signs: fever >38°C, unexplained abdominal pain, vomiting, altered mental state, or ≥2 yellow-zone observations (tachycardia >100bpm, tachypnoea >20bpm, SBP 65mmHg with phenylephrine infusion (preferred over ephedrine for less fetal acidosis)[10][14].
- Left lateral tilt 30° (superior IVC decompression vs 15°)[11], achieved with wedge under right hip[9].

Analgesia
- Multimodal approach: paracetamol, low-dose fentanyl (crosses placenta but short-term use acceptable)[7][8].
- Avoid NSAIDs (risk of premature ductus arteriosus closure)[14].

Postoperative Management
- Tocolytic prophylaxis: Consider nifedipine if uterine irritability present[14].
- Thromboprophylaxis: Enoxaparin 40mg daily (adjusted for weight)[9][14].
- Fetal monitoring: Continuous CTG for 24h post-op, then daily assessments[6][14].
- Sepsis reassessment: Repeat lactate at 6h, escalate antibiotics if no clinical improvement[1][12].

A comprehensive approach addressing maternal physiology, fetal vulnerability, and laparoscopic-specific risks optimises outcomes while mitigating the 2-5% fetal loss risk associated with non-obstetric surgery in pregnancy[5][6].

Citations:
[1] https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/292193/Maternal-Sepsis-Pathway.pdf
[2] https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/seppregpost.pdf
[3] https://pubmed.ncbi.nlm.nih.gov/7944319/
[4] https://www.sages.org/publications/guidelines/guidelines-for-diagnosis-treatment-and-use-of-laparoscopy-for-surgical-problems-during-pregnancy/
[5] https://www.wjgnet.com/2218-6220/full/v5/i2/175.htm
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC9102935/
[7] https://pmc.ncbi.nlm.nih.gov/articles/PMC4840802/
[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC9947972/
[9] https://www.ccjm.org/content/88/1/27
[10] https://pubmed.ncbi.nlm.nih.gov/28759487/
[11] https://pubmed.ncbi.nlm.nih.gov/31094791/
[12] https://www.sahealth.sa.gov.au/wps/wcm/connect/31b0af004eeddd9eb4c6b76a7ac0d6e4/Sepsis+in+pregnancy_Feb2015.pdf?MOD=AJPERES
[13] https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/maternal-sepsis
[14] https://pmc.ncbi.nlm.nih.gov/articles/PMC11152784/
[15] https://pmc.ncbi.nlm.nih.gov/articles/PMC6371947/
[16] https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/aabpreg.pdf
[17] https://pmc.ncbi.nlm.nih.gov/articles/PMC4989756/
[18] https://somanz.org/content/uploads/2024/11/2023-SOMANZ_Sepsis_in_Pregnancy_PS_Final.pdf
[19] https://pubmed.ncbi.nlm.nih.gov/38438010/
[20] https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/nonobstetric-surgery-during-pregnancy
[21] https://www.laparoscopyhospital.com/laparoscopic-surgery-in-pregnancy.php
[22] https://pmc.ncbi.nlm.nih.gov/articles/PMC10257531/
[23] https://pubmed.ncbi.nlm.nih.gov/12151826/
[24] https://rightdecisions.scot.nhs.uk/media/1904/anaesthetic-management-of-the-pregnant-patient-for-non-obstetric-surgery-november-2021.pdf
[25] https://academic.oup.com/bjaed/article/12/4/203/275380
[26] https://www.ncbi.nlm.nih.gov/books/NBK430759/
[27] https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2003.03397.x
[28] https://clinical.stjohnwa.com.au/clinical-skills/obstetrics/relief-of-aortocaval-compression
[29] https://www.somanz.org/content/uploads/2020/07/2017SepsisGuidelines.pdf
[30] https://pmc.ncbi.nlm.nih.gov/articles/PMC10357893/
[31] https://pmc.ncbi.nlm.nih.gov/articles/PMC6754194/
[32] https://pmc.ncbi.nlm.nih.gov/articles/PMC7810818/
[33] https://www.glowm.com/article/heading/vol-6–pregnancy-complaints-and-complications-clinical-presentations–surgery-and-laparoscopy-in-pregnancy-feasibility-and-safety/id/415713
[34] https://aci.health.nsw.gov.au/projects/perioperative-toolkit/overview/patient-cohorts
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC6822954/
[36] https://jkms.org/pdf/10.3346/jkms.2021.36.e192
[37] https://hbsn.amegroups.org/article/view/8196/9540
[38] https://pubmed.ncbi.nlm.nih.gov/34966066/
[39] https://journals.sagepub.com/doi/full/10.1177/14574969231175569
[40] https://resources.wfsahq.org/wp-content/uploads/uia34-Anaesthesia-for-non-obstetric-surgery-during-pregnancy.pdf
[41] https://www.elsevier.es/en-revista-cirugia-cirujanos-english-edition–237-articulo-anaesthetic-management-patients-in-third-S2444050716300584
[42] https://macc.perdatin.org/index.php/my-journal/article/download/292/287/
[43] https://accessanesthesiology.mhmedical.com/content.aspx?bookid=1750&sectionid=117323345

Answer from Perplexity: pplx.ai/share

Parameter | Adjustment | Rationale |

Pass rate 49.7%
This question required candidates to address:
* assessment of a pregnant patient with an acute abdomen and potential sepsis
* involvement of Obstetrics/Neonates to discuss case, disposition of patient in case of
preterm labour and monitoring of the fetus
* discussion of risks with the patient - increased risk of pre-term labour and fetal morbidity.
* Anaesthetic technique with recognition of the specific issues of pregnancy and the
implications of laparoscopic surgery
* Positioning for induction and surgery - avoidance of aorto-caval compression
Whilst there were some very good answers a significant number of candidates focussed much of their answer on the anaesthetic induction and choice of drugs, omitting to discuss other key perioperative issues including the specific risks to mother and fetus.

Question 10

Q

[22A10]
Describe your response to a formal complaint made by a patient about you to your head of department.
Pass rate 83.6%

Answer

A

“ACT FAIR”
* Acknowledge the complaint
* Circumstances: establish the facts
* Transparency: full disclosure
* Fairness: ensure procedural fairness
* Advice: consult your MDO
* Improve: learn from the complaint
* Report and communicate with your HOD

Question 11

Q

[22A11]
Discuss the perioperative management of a patient on haemodialysis who is to undergo a renal transplant.
Pass rate 39.0%

Answer

A

Perioperative Management of Hemodialysis Patient for Renal Transplant

Comorbidities and Current Treatment
Ischemic heart disease is the commonest comorbidity, accelerated by CKD interaction with risk factors such as diabetes, hypercholesterolemia, and hypertension[1]. Cardiac evaluation is essential, including ECG, echocardiogram, and potentially dobutamine stress echocardiography[2]. Anemia is frequent, necessitating preoperative hemoglobin optimization, and antihypertensives should be continued until surgery while oral hypoglycemics should be held[2].

Dialysis Optimization
Dialysis should be performed within 24 hours of operation to correct hyperkalemia, acidosis, and fluid overload[2]. Overzealous ultrafiltration should be avoided as loss >2kg during dialysis suggests significant intravascular depletion[2]. Most transplant anesthetists follow the principle “if in doubt, dialyze” while balancing the need for electrolyte correction against potential intravascular depletion[1].

Venous Access
Good peripheral venous access is essential before induction as large fluid volumes may be required, though insertion may be challenging due to previous venipunctures[1]. Central venous access may be necessary for CVP monitoring to guide fluid therapy with targets of 10-15 mmHg[2].

Drug Choice and Avoidances
Fentanyl, sufentanil, alfentanil, and remifentanil are suitable for perioperative pain control[2]. Morphine should be avoided as its metabolites are excreted by the kidney and can accumulate for up to 48 hours in renal dysfunction[1]. Pethidine (meperidine) should also be avoided in these patients[2].

Graft Perfusion Optimization
Liberal hydration is employed intraoperatively to decrease postoperative acute tubular necrosis[2]. Maintain systolic blood pressure between 130-160 mmHg and CVP between 10-15 mmHg to optimize cardiac output and renal blood flow[2]. Avoid vasopressors with alpha-agonist activity as they can compromise blood flow to the transplanted organ[2].

AV Fistula/Vascath Care
Protect the arteriovenous fistula arm from blood pressure measurements and venipuncture. Position the fistula arm carefully to avoid compression during surgery. Monitor patency of the fistula throughout the perioperative period.

Postoperative Fluid Balance/Electrolytes
CVP may decline 25-50% 1-2 hours after revascularization despite aggressive fluid management[2]. Alternate balanced crystalloids with normal saline (0.9%) as large volumes of saline alone could lead to hyperchloremic acidosis[2]. Monitor electrolytes closely, particularly potassium, as significant shifts can occur with improving graft function.

Citations:
[1] https://perioptalk.org/wp-content/uploads/2019/05/bja-education-renal-transplant.pdf
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC2900097/

Answer from Perplexity: pplx.ai/share

comorbidities and current treatment
dialysis for optimisation of volume status, correction of K+ and metabolic acidosis
venous access
drug choice and drugs to avoid
strategy to optimise graft perfusion
care of AV fistula/Vascath
postoperative fluid balance/electrolytes

Question 12

Q

Question 12
A patient with Type 1 diabetes mellitus is scheduled for laparoscopic cholecystectomy.
Outline your perioperative management of their diabetes.
Pass rate 33.3%

Answer

A

Perioperative Management of Type 1 Diabetes for Laparoscopic Cholecystectomy
Preoperative Management
1. Assessment:
o Evaluate HbA1c (target <8.5%) and recent blood glucose trends16.
o Document insulin regimen (basal/bolus doses, pump use) and hypoglycemia awareness57.
2. Insulin Adjustments:
o Reduce long-acting insulin by 20–30% on surgery day56.
o Schedule surgery early to minimize fasting disruption16.
Intraoperative Management
1. Insulin-Glucose Infusion:
o Start variable-rate IV insulin (e.g., 50 units Actrapid in 50 mL saline) with 5% dextrose + 0.45% NaCl + KCl38.
o Target glucose: 5–10 mmol/L; monitor hourly13.
2. Monitoring:
o Hourly BGL checks; adjust insulin infusion per protocol (e.g., 1–5 U/hr based on BGL)38.
Postoperative Management
1. Transition to Subcutaneous Insulin:
o Resume pre-op regimen once tolerating oral intake18.
o Stop IV insulin 1 hour after administering subcutaneous basal insulin38.
2. Monitoring:
o Hourly BGL until stable, then 2-hourly8.
Special Considerations
* Emergency Surgery: Prioritize DKA correction with fixed-rate IV insulin12.
* Poor Control (HbA1c >8.5%): Postpone elective surgery if feasible; involve endocrinology16.
* Surgical Complications: Continue IV insulin if delayed oral intake/ketosis38.
Key Avoidances:
* Never interrupt insulin entirely (risk of ketosis)1.
* Avoid 0.9% NaCl alone with insulin (hypoglycemia risk)3.

Question 13

Q

Question 13
Describe the sensory and motor innervation of the airway relevant for topicalisation for an awake nasal fibreoptic intubation.
Pass rate 37.9%

Answer

A

The sensory and motor innervation of the airway for awake nasal fibreoptic intubation involves precise anatomical knowledge of cranial nerve contributions.

Sensory innervation begins in the nasal cavity,

anterior ethmoidal nerve (ophthalmic division of trigeminal nerve, CN V1) supplies the anterior septum and lateral wall,
sphenopalatine nerves (maxillary division, CN V2) innervate the posterior nasal structures.

glossopharyngeal nerve (CN IX) provides sensory input to the oropharynx,

the internal branch of the superior laryngeal nerve (vagus nerve, CN X) covers the laryngopharynx and supraglottic larynx.
Below the vocal cords, the recurrent laryngeal nerve (CN X) supplies the infraglottic region and trachea[1].

Motor innervation to the larynx is mediated by the
1. external branch of the superior laryngeal nerve (cricothyroid muscle)
2. recurrent laryngeal nerve (all other intrinsic laryngeal muscles).

Topicalisation targets sensory pathways to suppress gag reflexes and discomfort, while sparing motor function to maintain vocal cord mobility during intubation[1].

Key areas for anaesthesia include the nasal mucosa (CN V1/V2), posterior pharynx (CN IX), and larynx (CN X branches). Inadequate blockade of these regions may lead to patient discomfort or reflex responses during tube passage.

Citations:
[1] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/f024ed12-e8e6-48ef-8ef7-0401bdd85af7/2022.1-Final-Exam-Chair-s-report-v2.pdf

Answer from Perplexity: pplx.ai/share

Sensory:
Nasal
Ant - AEN - V1
Post - SPN - V2

Oro
GPN - IX

Larynx
Superior - SLN
Inferior - RLN

Motor
CTM - SLN
Rest - RLN

Question 14

Q

Question 14
Discuss the safety precautions and equipment requirements for providing anaesthesia in the MRI suite.
Pass rate 41.0%

Answer

A

Anaesthesia in the MRI suite requires rigorous safety protocols due to unique hazards like strong magnetic fields, restricted patient access, and equipment compatibility challenges. Key precautions include staff training, patient/staff screening, and emergency planning, while equipment must be MRI-safe/conditional to prevent hazards.

Safety Precautions
Remote location considerations:
- Limited access to the patient during scanning necessitates extended monitoring cables and precise equipment placement[1].
- Emergency teams must be familiar with MRI safety to avoid introducing unsafe equipment during crises[4][6].

Staff training:
- Mandatory MRI safety education for anaesthesia teams, including zone access protocols (III/IV), projectile risks, and emergency response[1][6].
- Collaboration with radiographers for operational safety oversight, as they control the Controlled Access Area[1].

Patient and staff screening:
- Ferromagnetic object screening (implants, devices) using questionnaires and metal detectors[2][6].
- Pre-anaesthesia assessment to identify comorbidities affecting MRI safety (e.g., obesity, claustrophobia)[1][3].

Checklists and protocols:
- WHO surgical checklist modified for MRI, including fasting confirmation and equipment checks[1].
- Dedicated “GA MRI Patient Ingress Checklist” before scanner entry[1].

Emergency management:
- Immediate patient evacuation from Zone IV (scanner room) before using non-MRI-safe resuscitation equipment[1][4].
- MR-safe airway devices (e.g., MRI-conditional laryngoscopes) stored in Zone III for rapid access[4][5].

Equipment Requirements
Monitoring:
- MRI-conditional ECG, SpO₂, capnography, and non-invasive blood pressure monitors[1][5][7].
- Acoustic protection (earplugs/headphones) for patients and staff[2].

Anaesthesia delivery:
- MRI-conditional machines (e.g., Fabius MRI) with pneumatic ventilators to avoid magnetic interference[7][8].
- Avoidance of ferromagnetic gas cylinders or infusion pumps near the scanner[5].

Airway management:
- MRI-safe circuits, masks, and supraglottic devices stored in Zone III[4][5].

Emergency equipment:
- Code blue trolley with MRI-safe defibrillators and drugs in Zone III[1][6].

A 2023 study found only 41.9% of institutions had formal MRI anaesthesia policies, highlighting gaps in safety standardization[3]. Regular drills and interdisciplinary protocols are essential to mitigate risks in this high-stakes environment[1][6].

Citations:
[1] https://www.bir.org.uk/media/525255/mr_advice_sheet_2_safety_steps_in_an_anaesthesia_service_in_the_mri_suite_v2.pdf
[2] https://www.openanesthesia.org/keywords/magnetic-resonance-imaging-safety/
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC10530828/
[4] https://www.apsf.org/article/airway-emergencies-and-safety-in-magnetic-resonance-imaging-mri-suite/
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC8049862/
[6] https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-advisory-on-anesthetic-care-for-magnetic-resonance-imaging.pdf
[7] https://pmc.ncbi.nlm.nih.gov/articles/PMC7616168/
[8] https://www.draeger.com/Content/Documents/Products/fabius-mri-br-9051300-us.pdf

Answer from Perplexity: pplx.ai/share

Question 15

Q

[22A15]
Justify your perioperative management plan of a six-year-old child with a penetrating eye injury.
Pass rate 43.1%

Answer

A

The perioperative management of a six-year-old with a penetrating eye injury requires balancing urgency, airway safety, intraocular pressure (IOP) control, and postoperative care. Below is a structured justification addressing key components:

History & Potential for Other Injuries
- Mechanism & timing: Critical to assess for retained foreign bodies (e.g., metal, organic material) and associated trauma (head/orbit injuries in 30% of cases)[1][3].
- Avoid globe manipulation: Defer detailed eye exam to prevent extrusion of intraocular contents[3].

Full Stomach Management
- NPO status & urgency: Proceed with surgery despite non-fasting; use modified rapid sequence induction (RSI)[4][8].
- Antiemetics: Administer ondansetron (0.15 mg/kg) preoperatively to reduce vomiting risk[1][3].

Mitigating IOP Rise
- Pre-induction: IV lidocaine (1–1.5 mg/kg) to blunt laryngoscopy-induced IOP spikes[8].
- Avoid straining: Minimize crying/coughing preoperatively; consider light sedation (e.g., midazolam) if agitated[1][8].

Induction Technique
- RSI options:
- Succinylcholine: Historically debated but no documented vitreous extrusion cases[1].
- Rocuronium (1.2 mg/kg) with sugammadex: Preferred for rapid reversal and avoiding IOP rise[4][8].
- Alternative: Remifentanil (3–5 mcg/kg) + propofol (2–2.5 mg/kg) for smooth intubation[8].

PONV Prophylaxis
- Dual therapy: Ondansetron (0.15 mg/kg) + dexamethasone (0.1–0.2 mg/kg) reduces PONV to 10%[1][7].
- Avoid opioids: Multimodal analgesia minimizes opioid use, lowering PONV risk[1][7].

Analgesia
- Multimodal approach:
- Topical: Tetracaine/oxybuprocaine (single dose) for corneal pain[1][2].
- Systemic: Paracetamol + NSAIDs (e.g., ibuprofen) for baseline pain[1][7].
- Opioids: Reserved for severe pain (e.g., morphine) with antiemetic cover[7].

Postoperative Considerations
- Deep extubation: Reduces coughing/strain on emergence[1][7].
- Shield protection: Maintain rigid eye shield postoperatively[3].

This approach prioritizes globe protection, rapid airway control, and targeted antiemesis/analgesia, aligning with evidence-based guidelines for pediatric ocular trauma[1][3][4][8].

Citations:
[1] https://resources.wfsahq.org/wp-content/uploads/uia30-Anaesthesia-for-paediatric-eye-surgery.pdf
[2] https://www.rch.org.au/trauma-service/manual/eye-injury/
[3] https://eyeandear.org.au/wp-content/uploads/2021/09/Acute-Management-of-Penetrating-Eye-Injury-and-Ruptured-Globe-Clinical-Practice.pdf
[4] https://www.pedsanesthesia.org/wp-content/uploads/2020/03/Ophthalmologic-Procedures-in-Pediatric-Patients.pdf
[5] https://www.ophed.net/system/files/2011/06/approach-pediatric-ocular-trauma-2922-2922.pdf
[6] https://eyeanesthesia.org/OASIS/8774774
[7] https://academic.oup.com/bjaed/article/8/1/5/277663
[8] https://www.sajaa.co.za/index.php/sajaa/article/view/2718/3088

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